Adverse Clinical Effects Associated With Non-catecholamine Pharmacologic Agents for Treatment of Vasoplegic Syndrome in Adult Cardiac Surgery.

Vasoplegic syndrome is a relatively common complication that can happen during and after major adult cardiac surgery. It is associated with a higher rate of complications, including postoperative renal failure, longer duration of mechanical ventilation, and intensive care unit stay, as well as increased mortality. The underlying pathophysiology of vasoplegic syndrome is that of profound vascular hyporesponsiveness, and involves a complex interplay among inflammatory cytokines, cellular surface receptors, and nitric oxide (NO) production. The pharmacotherapy approaches for the treatment of vasoplegia include medications that increase vascular smooth muscle contraction via increasing cytosolic calcium in myocytes, reduce the vascular effects of NO and inflammation, and increase the biosynthesis of and vascular response to norepinephrine. Clinical trials have demonstrated the clinical efficacy of non-catecholamine pharmacologic agents in the treatment of vasoplegic syndrome. With an increase in their use today, it is important for clinicians to understand the adverse clinical outcomes and patient risk profiles associated with these agents, which will allow better-tailored medical therapy.

Perioperative Glycemic Management in Cardiac Surgery: A Narrative Review.

Diabetes and hyperglycemic events in cardiac surgical patients are associated with postoperative morbidity and mortality. The causes of dysglycemia, the abnormal fluctuations in blood glucose concentrations, in the perioperative period include surgical stress, surgical techniques, medications administered perioperatively, and patient factors. Both hyperglycemia and hypoglycemia lead to poor outcomes after cardiac surgery. While trying to control blood glucose concentration tightly for better postoperative outcomes, hypoglycemia is the main adverse event. Currently, there is no definite consensus on the optimum perioperative blood glucose concentration to be maintained in cardiac surgical patients. This review provides an overview of perioperative glucose homeostasis, the pathophysiology of dysglycemia, factors that affect glycemic control in cardiac surgery, and current practices for glycemic control in cardiac surgery.

Anesthesia for Nonintubated Video-Assisted Thoracoscopic Surgery.

With the growing adoption of Enhanced Recovery After Surgery protocols across all surgical groups, including thoracic surgery, coupled with improved video-assisted thoracoscopic surgery (VATS) equipment and techniques, nonintubated thoracoscopic surgery has gained significant popularity in recent years. Avoiding tracheal intubation with an endotracheal or double-lumen tube and general anesthesia may reduce or eliminate the risks associated with traditional mechanical ventilation, one-lung ventilation, and general anesthesia. Studies have shown a trend toward better preservation of postoperative respiratory function and improved postoperative lengths of hospital stay, morbidity, and mortality; however, these have not been conclusively proven. This review article discusses the advantages of nonintubated VATS, the types of thoracic surgery in which this technique has been described, patient selection, appropriate anesthetic techniques, surgical concerns, potential complications relevant to the anesthesiologist during the conduct of nonintubated VATS surgery, and suggested management of these complications.

Review of Postoperative Care for Heart Transplant Recipients.

The early postoperative management strategies after heart transplantation include optimizing the function of the denervated heart, correcting the causes of hemodynamic instability, and initiating and maintaining immunosuppressive therapy, allograft rejection surveillance, and prophylaxis against infections caused by immunosuppression. The course of postoperative support is influenced by the quality of allograft myocardial protection prior to implantation and reperfusion, donor-recipient heart size matching, surgical technique of orthotopic heart transplantation, and patient factors (eg, preoperative condition, immunologic compatibility, postoperative vasomotor tone, severity and reversibility of pulmonary vascular hypertension, pulmonary function, mediastinal blood loss, and end-organ perfusion). This review provides an overview of the early postoperative care of recipients and includes a brief description of the surgical techniques for orthotopic heart transplantation.

Total intravenous anesthesia for liver resections: anesthetic implications and safety.

Inhalational anesthetics have been the default agents for general anesthesia maintenance for several decades. However, with advances in total intravenous anesthesia (TIVA) and a growing body of evidence on the potential benefits of TIVA, anesthesiologists need to question this paradigm. Some of the benefits of propofol-based TIVA, such as its antiemetic properties and patients' smooth emergence, are widely acknowledged. A growing body of evidence suggests that TIVA may potentially benefit the immune system and cancer outcomes. From an existential health perspective, there is evidence that inhalational agents have a materially higher global warming potential than propofol-based TIVA. Despite the compelling potential benefits of propofol-based TIVA, there are barriers to its widespread adoption. To examine the applicability of TIVA as a mainstay agent more rigorously, we discuss the safety and applicability of propofol-based TIVA in the context of complex major abdominal surgery, specifically, liver resection surgery. We also discuss the use of propofol-based TIVA in liver resection surgery with a broad, integrated approach, addressing general and specific clinical considerations, economic factors, and operating room turnover.

Infection Control for Perioperative Ultrasonography and Echocardiography.

Ultrasound technology has revolutionized point-of-care diagnostics, decision-making, and the guidance of interventional procedures in Anesthesiology and Perioperative Medicine. Recent literature has highlighted important infection control considerations when performing transesophageal or transthoracic echocardiography, point-of-care ultrasound, and ultrasound-guided procedures. This narrative review focuses on operator precautions and disinfection methods and summarizes key recommendations from the international Echocardiography and Radiology Societies.

Heparin Resistance During Cardiopulmonary Bypass in Adult Cardiac Surgery.

The use of heparin for anticoagulation has changed the face of cardiac surgery by allowing a bloodless and motionless surgical field throughout the introduction of cardiopulmonary bypass (CPB). However, heparin is a drug with complex pharmacologic properties that can cause significant interpatient differences in terms of responsiveness. Heparin resistance during CPB is a weighty issue due to the catastrophic consequences stemming from inadequate anticoagulation, and the treatment of it necessitates a rationalized stepwise approach due to the multifactorial contributions toward this entity. The widespread use of activated clotting time (ACT) as a measurement of anticoagulation during CPB is examined, as it may be a false indicator of heparin resistance. Heparin resistance also has been repeatedly reported in patients infected with COVID-19, which deserves further exploration in this pandemic era. This review aims to examine the variability in heparin potency, underlying mechanisms, and limitations of using ACT for monitoring, as well as provide a framework towards the current management of heparin resistance.

Preoperative Evaluation and Care of Heart Transplant Candidates.

Heart transplantation is recommended for patients with advanced heart failure refractory to medical and device therapy, and who do not have absolute contraindications. When patients become eligible for heart transplantation, they undergo comprehensive evaluation and preparation to optimize their posttransplantation outcomes. This review provides an overview of the processes that are employed to enable the candidates to be transplant-ready when donor hearts are available.

Pulmonary thromboendarterectomy and pulmonary haemorrhage.

Pulmonary thromboendarterectomy surgery is the recommended treatment for patients with chronic thromboembolic pulmonary hypertension. Massive intraoperative pulmonary haemorrhage with bleeding into the airway is a rare complication, and it typically presents as cardiopulmonary bypass flow is reduced and blood begins to flow through the pulmonary circulation. Immediate management includes maintaining extracorporeal circulation to reduce blood flow through the pulmonary circulation, isolation of the affected lung, while the surgeon identifies and repairs the site of haemorrhage.

Diagnosis of bone cement implantation syndrome using point of care ultrasound examination.

Once regarded as a rare complication, the potentially fatal bone cement implantation syndrome (BCIS) has been increasingly reported. BCIS can present as transient desaturation, hypotension, cardiac dysrhythmias, and cardiovascular collapse. Diagnosis of BCIS is often clinical and confirmed with computed tomography (CT) imaging postoperatively. However, point of care ultrasound (POCUS) examination could be a helpful and timely tool to clinch the diagnosis in a sudden cardiovascular collapse. We present a case of Grade 3 BCIS where POCUS examination revealed a massive clot in the right atrium, which supports the diagnosis.