Evaluation of the use of the fourth version FloTrac system in cardiac output measurement before and after cardiopulmonary bypass.

The FloTrac system is a system for cardiac output (CO) measurement that is less invasive than the pulmonary artery catheter (PAC). The purposes of this study were to (1) compare the level of agreement and trending abilities of CO values measured using the fourth version of the FloTrac system (CCO-FloTrac) and PAC-originated continuous thermodilution (CCO-PAC) and (2) analyze the inadequate CO-discriminating ability of the FloTrac system before and after cardiopulmonary bypass (CPB). Fifty patients were included. After exclusion, 32 patients undergoing cardiac surgery with CPB were analyzed. All patients were monitored with a PAC and radial artery catheter connected to the FloTrac system. CO was assessed at 10 timing points during the surgery. In the Bland-Altman analysis, the percentage errors (bias, the limits of agreement) of the CCO-FloTrac were 61.82% (0.16, - 2.15 to 2.47 L min) and 51.80% (0.48, - 1.97 to 2.94 L min) before and after CPB, respectively, compared with CCO-PAC. The concordance rates in the four-quadrant plot were 64.10 and 62.16% and the angular concordance rates (angular mean bias, the radial limits of agreement) in the polar-plot analysis were 30.00% (17.62°, - 70.69° to 105.93°) and 38.63% (- 10.04°, - 96.73° to 76.30°) before and after CPB, respectively. The area under the receiver operating characteristic curve for CCO-FloTrac was 0.56, 0.52, 0.52, and 0.72 for all, ≥ ± 5, ≥ ± 10, and ≥ ± 15% CO changes (ΔCO) of CCO-PAC before CPB, respectively, and 0.59, 0.55, 0.49, and 0.46 for all, ≥ ± 5, ≥ ± 10, and ≥ ± 15% ΔCO of CCO-PAC after CPB, respectively. When CO < 4 L/min was considered inadequate, the Cohen κ coefficient was 0.355 and 0.373 before and after CPB, respectively. The accuracy, trending ability, and inadequate CO-discriminating ability of the fourth version of the FloTrac system in CO monitoring are not statistically acceptable in cardiac surgery.

Comparison of right ventricular measurements by perioperative transesophageal echocardiography as a predictor of hemodynamic instability following cardiac surgery.

BACKGROUND: The relationship between perioperative right ventricular (RV) performance and hemodynamic instability after cardiac surgery seemed less portrayed. Therefore, we sought to elucidate this relationship and compare the accuracy of different RV systolic indices in predicting outcome of cardiac surgery. METHODS: This study enrolled consecutive patients referred for cardiac surgeries. Exclusion criteria were non-sinus rhythm or contraindications to transesophageal echocardiography (TEE). TEE exam and simultaneous pulmonary hemodynamics were recorded in two stages: after induction of anesthesia and before sternotomy (stage 1), and after sternal closure (stage 2). RV measurements performed offline included fractional area change (RVFAC), tricuspid annular plane systolic excursion (TAPSE), peak systolic tricuspid annular velocity (RVS'), myocardial performance index (RVMPI), and global longitudinal strain (RVGLS). The end point was defined as prolonged use (>24 h) of postoperative inotropic agent in the intensive care unit (ICU). RESULTS: The study population included 68 patients (mean age 61 ± 11 y; 49 men). Twenty-two of these patients (32%) were administered inotropic agents for a prolonged period with a mean duration of 63.9 ± 5.3 h, accompanied with significantly longer ventilator use (p = 0.006) and longer ICU stay (p = 0.001) than patients without a prolonged inotropic agent use. Multivariable analysis demonstrated that only RVGLS in either stage 1 (odds ratio [OR] 1.11, p = 0.048) or stage 2 (OR 1.15, p = 0.018) was significantly associated with the outcome, especially a RVGLS > -13.5% in stage 2 demonstrating high risk of prolonged inotropic agent use after cardiac surgery (OR 7.37, p = 0.016). CONCLUSION: RVGLSs performed using perioperative TEE are reliably associated with hemodynamic instability following cardiac surgery. This finding adds substantial information to postoperative critical care.

An analysis of surgical outcomes in patients aged 80 years and older.

OBJECTIVES: Elderly patients (aged ≥ 80 years) undergo an increasing number of operations. Elderly patients undergoing operations usually develop more postoperative complications and have poorer outcomes. The aim of this study is to identify the relative importance between preoperative and intraoperative variables to predict adverse postoperative outcomes in these patients. METHODS: We retrospectively analyzed the records of 404 patients (aged ≥ 80 years and underwent a noncardiac surgery) collected from the quality assurance database in our department. We reviewed the patients' preoperative and intraoperative variables as well as postoperative complications and outcomes. Odds ratios of risk factors were then calculated by univariate and multivariate analyses. In addition, hazard ratios of incidence of discharge and mortality rates were analyzed. RESULTS: Overall, 26.4% of patients developed one or more postoperative complications, and the in-hospital mortality rate was 6.7%. The majority of these patients had pre-existing cardiovascular disorders such as hypertension (47.5%). Respiratory complication was the most common postoperative complication (12.9%). Multivariate analysis showed male sex, anesthesia method, and colloid infusion were risk factors for increased respiratory complication. Our results showed that patients who developed different kinds of postoperative complications had a different level of risks associated with prolonged hospital stay and mortality. CONCLUSION: Patients over the age of 80 years, of male sex, under general anesthesia, and receiving colloid infusion were at a higher risk of developing respiratory complications. Postoperative respiratory complications occurred in most of the geriatric surgical patients. Efforts to improve the surgical outcomes must include measures to minimize in-hospital complications. Detailed evaluation and better communicating the aforementioned risk factors to these patients are suggested for improving anesthesia quality and surgical outcomes.

Predictive risk index and prognosis of postoperative reintubation after planned extubation during general anesthesia: a single-center retrospective case-controlled study in Taiwan from 2005 to 2009.

OBJECTIVES: Postoperative reintubation after planned extubation (RAP) following general anesthesia is a major anesthetic morbidity. A previous study on RAP identified the various risk factors for RAP, including chronic obstructive pulmonary disease (COPD), pneumonia, systemic inflammatory response syndrome (SIRS), and airway surgery. However, the prognosis and predictive risk index of RAP were not investigated. METHODS: Data on surgical patients who were reintubated after planned extubation at the end of surgery between January 1, 2005 and December 31, 2009 were retrospectively sorted out from the quality assurance database of the Department of Anesthesiology, Chang Gung Memorial Hospital. Risk factors and prognosis of RAP cases were compared with the control group (successful planned extubation) using descriptive statistics and logistic regression. The RAP predictive risk index was developed from multivariate logistic regression and the predictive accuracy was evaluated by goodness-of-fit test. RESULTS: Of the 227,876 patients who were subjected to endotracheal intubation for general anesthesia, 130 (0.06%) sustained postoperative RAP. The control group consisted of 390 patients who were randomly selected from those who underwent endotracheal intubation without RAP. A total of 30 variables, including demographic, operative, anesthetic data, and prognosis were analyzed. We found that significant risk factors for RAP included COPD (odds ratio: 4.30), pneumonia (odds ratio: 6.60), ascites (odds ratio: 4.86), SIRS (odds ratio: 7.52), hypothermia (body temperature <35°C; odds ratio: 2.45), rocuronium as muscle relaxant (odds ratio: 1.90), inexperienced anesthetic service (odds ratio: 3.44), and airway surgery (odds ratio: 4.34). An RAP predictive risk index was developed and the predictive accuracy was confirmed by goodness-of-fit test as excellent discrimination (c statistic: 0.873). RAP significantly increased postoperative stay in hospital (odds ratio: 2.46) and intensive care unit, as well as tracheostomy and mortality (odds ratio: 58.52). CONCLUSION: The RAP predictive risk index included higher American Society of Anesthesiologists classification, conscious disturbance, COPD, pneumonia, SIRS, room air SpO2 <95%, hypothermia, airway surgery, and head and neck surgeries. The RAP predictive risk index provides us an opportunity to take preventive measures including renewal of risk-reduction protocols for high-risk patients.

Operation cancellation at Chang Gung Memorial Hospital.

BACKGROUND: Roughly 60,000 operations are performed at our medical center every year, so making efficient use of operating rooms (OR) is an important issue. Decreasing the cancellation rate of surgery is one method that could increase efficiency. We reviewed all OR cancellations in 2007 to survey the cancellation rates and causes. METHODS: The present study was retrospective. Data were collected from the Department of Anesthesiology Quality Assurance Database of Chang Gung Memorial Hospital. We analyzed medical records for cancellations from January 1 to December 31, 2007. Data were analyzed using SPSS 16.0, employing descriptive measures and logistic regression. RESULTS: There were 61855 operations scheduled during this period; 229 were cancelled (0.37%). The mean age of patients in the cancelled group was significantly higher than that in the the non-cancelled group. We found a positive correlation between the cancellation rate and American Society of Anesthesiologists physical status. Cancellations for outpatient surgery were most frequent, as were those in the ophthalmology department. Forty-seven cases were cancelled because of cardiovascular problems; 136 operations were done later after the original cancellation issues were addressed while 11 were done under local anesthesia. CONCLUSIONS: Of all causes of cancellation of surgery, 54.1% were avoidable. Medical teams must communicate better with patients and relatives, identify and treat relevant comorbidities, and make adequate preparations for surgery.

An analysis of perioperative eye injuries after nonocular surgery.

OBJECTIVE: Perioperative eye injuries, although rare, often lead to great discomfort and anxiety for patients. The purpose of this study was to explore the incidence and related risk factors of perioperative eye injuries. METHODS: We retrospectively analyzed the records of inpatients who underwent nonocular surgery under general anesthesia with intubation between October 2006 and December 2008. Incidents of eye injuries were extracted from the Department of Anesthesiology Quality Assurance Database of Chang Gung Memorial Hospital. Univariate analysis and logistic regression modeling were used to assess the risk factors. RESULTS: A total of 75,120 cases were included in the study, of whom 17 (0.023%) were identified to have sustained perioperative eye injury. Corneal abrasion was the most common form of eye injury (10 patients; 59%). Patients who had been operated on in the prone position [odds ratio (OR), 10.8; 95% confidence interval (CI), 2.4-48.8] or lateral position (OR, 7.1; 95% CI, 1.2-43.2), those who had undergone head and neck surgery (OR, 9.3; 95% CI, 2.3-38.0), sustained intraoperative deliberate hypotension (OR, 8.7; 95% CI, 2.4-31.8), or who had preoperative anemia (OR, 5.3; 95% CI, 1.8-15.4) were more susceptible to eye injuries. The duration of anesthesia was not an independent risk factor (OR per hour, 0.9; 95% CI, 0.8-1.7). CONCLUSION: In addition to head and neck surgery, operations in the lateral or prone position, preoperative anemia and intraoperative deliberate hypotension are also precipitating factors for perioperative eye injuries. For patients who are at high risk or for procedures that are apt to cause injury, preoperative recognition and intraoperative caution are of paramount importance.

Quantification of urinary 8-iso-prostaglandin F2alpha using liquid chromatography-tandem mass spectrometry during cardiac valve surgery.

Oxidative stress is an unavoidable event during many complex surgical procedures. 8-iso-prostaglandin F(2alpha) (8-iso-PGF(2alpha)) is a reliable biomarker for the evaluation of oxidative stress in vivo. The aim of this study is to develop simple and accurate liquid chromatography-tandem mass spectrometry (LC-MS/MS) methods for the detection of urinary 8-iso-PGF(2alpha) in samples collected from patients who received a cardiopulmonary bypass (CPB) during cardiac valve surgery. Urine samples of 14 patients with cardiac valve diseases were collected before, during, and after CPB. The level of 8-iso-PGF(2alpha) was detected via selected-reaction monitoring triple quadrupole MS/MS and the result was compared with 12 healthy volunteers. The method's detection limit (3S/N) was 0.25 pg for 8-iso-PGF(2alpha), with a linear working range of 0.25-20 ng/ml. For patients with cardiac valve disease, the 8-iso-PGF(2alpha) levels before the bypasses were the same as those of healthy individuals (P>0.05) and the 8-iso-PGF(2alpha) levels during and after CPB were significantly higher than those before the bypasses (P<0.05). In conclusion, we present a simple and specific protocol for LC-MS/MS quantification of urinary 8-iso-PGF(2alpha) collected during CPB. Using this technique, it would be feasible to assess the levels of oxidative stress during cardiac surgery and thereby helpful for the management of oxidative injury.

Postoperative reintubation after planned extubation: a review of 137,866 general anesthetics from 2005 to 2007 in a Medical Center of Taiwan.

BACKGROUND: regarding general anesthesia, postoperative reintubation after planned extubation (RAP) is needed when circumstances compel us to do so, irrespective of prolongation of hospital stay and increase of medical expenditure. We describe here our implementation of a case-controlled model to identify the risk factors of RAP. METHODS: patients who saw RAP in the space from January 1, 2005 to December 31, 2007 were retrospectively sorted out from the Quality Assurance (QA) database of the Department of Anesthesiology. We compared RAP cases with the control group and analyzed the factors using descriptive statistics and logistic regression. Reintubation was defined as intubation after the extubation for the initial endotracheal intubation, for general anesthesia, at the time period before departure from the post-anesthesia care unit. RESULTS: of the 137,866 patients who underwent endotracheal intubation for general anesthesia, 83 (0.06%) sustained RAP. The control group included 249 patients randomly selected for endotracheal intubation without RAP. Twenty-two variables, including demographic, operative and anesthetic data, were analyzed. We found that patients with preoperative COPD (odds ratio: 7.17, 95% CI: 1.98-26.00), pneumonia (odds ratio: 7.94, 95% CI: 1.93-32.78), ascites (odds ratio: 13.76, 95% CI: 1.08-174.74) and systemic inflammatory response syndrome (SIRS) (odds ratio: 11.90, 95% CI: 2.63-53.86) were more likely to be subjected to RAP. Airway surgery and head-neck surgery also predisposed patients to reintubation. However, administration of both an extra dose of opioid and neuromuscular blocker at the end of surgery proved irrelevant to RAP. CONCLUSIONS: risk factors for RAP are clear and unambiguous. This study will prompt further studies on preventative measures or evaluation of how to improve outcome.

Neurological impairment following myocardial ischemia associated with postoperative epidural analgesia.

Although epidural analgesia reduces the postoperative stress response and provides good pain relief for patients, potential complications associated with the technique may decrease its acceptability for some patients. We describe a 76-year-old female who underwent surgery for carcinoma of the urinary tract. Postoperative epidural analgesia was performed at the postanesthesia care unit. Neither a repeat attempt nor accidental dural puncture was encountered during the procedure. Unfortunately, she sustained neurological impairment of the bilateral lower limbs following an episode of myocardial ischemia during the early postoperative period. When the neurological deficit was recognized following epidural anesthesia, poor puncture technique was the first to be blamed. In fact, a high level of sensory blockade could markedly decrease blood pressure and heart rate, particularly in the presence of hypovolemia, which might lead to impairment of coronary perfusion and result in myocardial ischemia. Severe systemic hypotension might further lead to hypoperfusion of the spinal cord, most possibly in the mid-thoracic region (T4 to T8) due largely to its relative hypovascularity. Therefore, we recommend that maintaining sufficient circulatory volume of the patient, evaluating and recording the neurological function of the patient and determining the possible risk factors associated with coronary arterial disease are imperative prior to performing an epidural procedure.

Labetalol pretreatment reduces blood pressure instability during surgical resection of pheochromocytoma.

BACKGROUND: To evaluate the effect of pretreatment with the mixed alpha- and beta-adrenergic blocker, labetalol, on blood pressure instability during surgical resection of pheochromocytoma. METHODS: Blood pressure stability and surgical results were compared between patients in the saline (n = 11) and labetalol (n = 15) groups. Anesthesia was induced with fentanyl, sodium thiopental and atracurium, and maintained with isoflurane in a 50% oxygen/nitrous oxide mixture. Intravenous labetalol was administered in the labetalol group before surgical incision, with the maximal dose being 1.2 mg/kg, while normal saline was administered to patients in the control, saline, group. Supplemental intravenous sodium nitroprusside (SNP) infusion was administered whenever systolic blood pressure exceeded 180 mmHg. The number of patients with intraoperative hypertension or hypotension, dosage of SNP administered, number of intraoperative hypertension episodes, use of fluid and blood transfusion, and heart rate (defined as the mean of heart rate every 5 minutes throughout the operation) were compared between these two groups. RESULTS: The number of patients with intraoperative hypertension, number of patients receiving SNP, dose of SNP administered, and number of hypertension episodes were significantly lower in patients who received labetalol pretreatment than in control patients. CONCLUSION: This study has demonstrated that labetalol pretreatment (1.2 mg/kg) with supplemental SNP provides more favorable blood pressure control during surgical resection of pheochromocytoma than with SNP alone.

The effects of continuous axillary brachial plexus block with ropivacaine infusion on skin temperature and survival of crushed fingers after microsurgical replantation.

BACKGROUND: Continuous axillary brachial plexus block with local anesthetic has been shown to improve tissue perfusion after replantation surgery of the extremity. The present study aimed to investigate whether continuous axillary brachial plexus block with ropivacaine infusion can improve the survival of the reconstructive fingers secondary to an increase in its skin temperature in patients receiving replantation surgery of the crushed fingers. METHODS: Under general anesthesia, 18 patients received replantation or toe-to-hand transplantation of their crushed digits. They were randomly divided into two groups. Under ultrasound guidance, continuous axillary brachial plexus analgesia was effected by a loading dose of 10 ml 0.75% ropivacaine, followed by an infusion of 4-5 ml per hour for up to three days (Group A). Patients who did not receive continuous analgesia postoperatively served as a control (Group B). An infrared thermometer was used to hourly assess the skin temperature of the surgical and non-surgical sites in both groups for 24 h after the surgery. In addition, the survival (the rate of re-operation or amputation) of the reconstructive digits was also evaluated in both groups. RESULTS: The skin temperature of the digits (T1) on both groups did not show any significant difference at any point of time after the surgery albeit there was a trend of increased skin temperature on the reconstructive digits in patients receiving continuous axillary brachial plexus block (Group A) as compared to those without receiving the block (Group B). Also, the difference in skin temperature (dT) differed slightly at 0, 9 and 21 hours postoperatively in Group A in comparison with Group B (0.75 +/- 0.65 vs. -2.33 +/- 1.24, 0.53 +/- 0.34 vs. -3.02 +/- 1.27, -0.125 +/- 0.55 vs. -2.33 +/- 0.91, p < 0.05). However, no patients in both groups received a second operation or amputation of the graft. CONCLUSIONS: The result of this study demonstrated that axillary brachial plexus block with continuous infusion of 0.75% ropivacaine can increase the skin temperature, an index of tissue perfusion, of the reconstructive digits for 24 h after microvascular surgery of the crushed fingers. However, graft survival was good in both groups.

Use of the Arndt wire-guided endobronchial blocker via nasal for one-lung ventilation in patient with anticipated restricted mouth opening for esophagectomy.

Functional separation of the lungs may be accomplished by several methods. Patient with restricted mouth opening has limited options for one-lung ventilation. We report the use of wire-guided endobronchial blockade, a new tool for achieving one-lung ventilation in a patient with restricted mouth opening requiring nasotracheal, fiberoptic intubation for esophagectomy and reconstruction with gastric tube substitution.

Use of the Arndt wire-guided endobronchial blocker to facilitate one-lung ventilation for pediatric empyema during video-assisted thoracoscopy.

BACKGROUND: Video-assisted thoracoscopic surgery (VATS) has emerged as an innovative and popular procedure for the management of postpneumonic empyema in children refractory to a medical response. One-lung ventilation is required during VATS. In this study, we evaluated the efficacy of intraoperative wire-guided endobronchial blockade (WEB) for achieving 1-lung ventilation during a thoracoscopic procedure for pediatric empyema. METHODS: Eighteen patients undergoing a VATS approach for evacuation of an empyema cavity were studied. We used a new device, a bronchial blocker tube, to establish 1-lung ventilation. Intraoperative oxygenation, ventilation, and hemodynamics, as well as the duration of the operation during 1-lung ventilation were recorded. The number of unsuccessful placement attempts, number of malpositionings of the device, and the number of secondary dislodgements of the device after turning the patient into the lateral position were also counted. The quality of lung deflation and inflation was rated by the surgeon under direct visualization as either excellent, fair, or poor. RESULTS: The mean operative time was 80+/-10.8 (range, 50 approximately 120) min. The mean peak inspiratory pressure under 1-lung ventilation was 28.7+/-3.6 cm H2O, and no desaturation was noted. A number of unsuccessful placement attempts were required in 1 patient (1/18) for left-sided VATS. No malpositioning or secondary dislodgement of the device was noted. The quality of lung deflation was judged as being excellent in all patients. CONCLUSIONS: VATS can safely and effectively be performed in children with a proper anesthetic technique. With the development and clinical use of this new device, the bronchial blocker tube proved to be effective and easy to use for establishing 1-lung ventilation in a pediatric population.

Usefulness of transesophageal echocardiography for transcatheter closure of ostium secundum atrial septum defect with the amplatzer septal occluder.

BACKGROUND: Transcatheter closure of ostium secundum atrial septum defect (ASDII) using the new self-centering occluder, Amplatzer Septal Occluder (ASO), has been well developed in recent years. We describe the importance and role of transesophageal echocardiography (TEE) in the selection and closure of such defects. METHODS: Thirty patients referred for transcatheter closure of ASDII by ASO were enrolled in this study. During catheterization, two-dimensional TEE was performed on all patients during and after transcatheter closure. ASD size and morphology were assessed by TEE before catheterization. The ASD stretched diameter was also measured by TEE and fluoroscopy. RESULTS: With the aid of TEE, transcatheter closure of an ASD was successfully, safely and effectively performed on 29 patients. The mean ASD diameter determined by TEE was 17.4 +/- 4.8 mm. The mean stretched diameters measured by TEE and fluoroscopy were 18.7 +/- 5.6 mm and 17.9 +/- 5.5 mm, respectively. The mean device diameter was 19 +/- 5.6 mm. Immediate complete closure was documented by color Doppler TEE in 29 patients. Complications were encountered in one patient, with the device becoming dislodged into the main pulmonary artery. The device was retrieved by surgery and the defect was repaired in the operating room. CONCLUSIONS: Transcatheter closure of ASDs using an Amplatzer device is feasible, safe and effective. Two-dimensional TEE can provide useful information before, during and after transcatheter closure of ASDs.

Usefulness of intraoperative transesophageal echocardiography in the assessment of surgical repair of pediatric ventricular septal defects with video-assisted endoscopic techniques in children.

BACKGROUND: Mini cardiac operative procedures with video-assisted endoscopic techniques for closure of ventricular septal defects (VSDs) in pediatric patients have become quite popular for cardiac surgery. A precise diagnosis is very important for determining the surgical approach, and evaluation by intraoperative transesophageal echocardiography (TEE) plays a major role in confirmation of the preoperative diagnosis, residual defects, and the need to return to the bypass after repair. METHODS: Sixty-five patients (30 boys and 35 girls; aged 8.7 +/- 5.3 years) who were undergoing minimally invasive closure of VSDs were monitored with a Hewlett-Packard color Doppler pediatric TEE throughout the procedure. RESULTS: Closure of the defect was successfully performed in all patients. Sixty-two patients showed neither residual shunt nor aortic regurgitation after the repair. Residual leaks were detected intraoperatively in 3 patients after the repair. One patient required a return to the bypass with an immediate reoperation due to a residual color jet diameter of > 3 mm. One patient was changed from video-assisted endoscopic techniques to a surgical approach for closure of the VSD from a conventional median sternotomy after identification by TEE of an outlet-type perimembranous VSD with 2 additional muscular VSDs. CONCLUSIONS: Our study showed that, with refinement of surgical closure of VSD via video-assisted endoscopic techniques, intraoperative TEE provides valuable and accurate information for decision-making in surgical management, provides immediate assessment of surgical repairs, and prevents reintervention and the morbidity associated with residual flow.

Folding of the epiglottis - an unusual complication to be recognized after laryngoscopic endotracheal intubation.

We report a case of folding of the epiglottis during endotracheal intubation, an unusual complication of intubation. A 36-year-old female patient underwent laryngeal microsurgery for a vocal polyp. Following anesthesia induction, an endotracheal tube (ID = 6.0 mm, cuffed) was advanced through an intubating laryngoscope via the oropharyngeal route. At the beginning of the surgery, the otolaryngologist noted that the patient's epiglottis was folded under the view of the surgical laryngoscopy. The endotracheal tube was adjusted immediately by withdrawing it 0.5 cm with the cuff deflated. Slight edema of the upper ridge of the epiglottis was noted. There were no sequelae such as laryngeal spasm or vocal cord palsy after the surgery. The "peardrop" phenomenon is suggested as a possible cause of this event. Potential adverse outcomes of this unusual occurrence are reviewed.

A two-center survey of cardiac events and peri-operative managements of cardiac patients undergoing non-cardiac surgery in Taiwanese population.

BACKGROUND: The risk of cardiac patients undergoing noncardiac surgery is relatively high. Successful preoperative evaluation and perioperative anesthetic management of a patient require a good communication among the patient, the anesthesiologist and the surgeon as well as excellent cooperation between the surgeon and anesthesiologist with a tacit understanding of the peri-operative risks. Peri-operative risk factors have been readily investigated in Caucasians or Westerners. As different ethnic populations may have different risk factors for a same disease entity, understanding the uniqueness in this respect in Taiwanese is mandatory. The purpose of this study is to examine the risk factors, perioperative cardiac events and the qualities of preoperative preparation and post-operative intensive care in Taiwanese cardiac patients undergoing noncardiac surgery. METHODS: Two medical centers in Taiwan worked out a set of prospective questionnaire to evaluate the preoperative preparation, intraoperative events, and postoperative care of cardiac patients undergoing noncardiac surgery in these hospitals. RESULTS: Between March 2002 and May 2002, there were 196 cardiac patients undergoing noncardiac surgery out of a total of 10,129 anesthetized surgical patients in two medical centers. The risk factors of these patients included coronary artery disease, hypertension, diabetes mellitus, congestive heart failure, arrhythmia, and renal function impairment. In these 196 cases, only 26.5% (52) and 16.8% (33) had been preoperatively evaluated by cardiologist and anesthesiologist respectively through consultation. The number of pre-operation specific cardiac tests totaled 34, and 41 patients (20.9%) required post-operative intensive care. There were two peri-operative fatalities and fourteen peri-operative cardiac events. CONCLUSIONS: The quality of care for preoperative evaluation and quality assurance need to be improved in Taiwan.

Stroke after intraaortic balloon counterpulsation associated with mobile atheroma in thoracic aorta diagnosed using transesophageal echocardiography.

We describe a patient who developed embolic stroke after coronary artery bypass grafting (CABG) associated with intraaortic balloon pump (IABP) insertion. Intraoperative transesophageal echocardiography (TEE) revealed marked irregular mass and disruption of the intimal surface of the thoracic aorta with overlying shaggy echogenic material on the intimal surface of the descending thoracic aortic lumen. This case of stroke after IABP insertion suggested that the balloon inflation fragmented some mobile components on the inner surface of the aorta, and this floating debris entered the systemic circulation. TEE might be able to predict the risk of stroke in such a patient.