Management of Unrepaired Tetralogy of Fallot in an 86-Year-Old Patient Undergoing Transcatheter Aortic Valve Replacement.

Tetralogy of Fallot (TOF) is the most common cyanotic congenital heart defect, typically requiring early treatment in infancy. Untreated TOF is associated with poor survival, with most uncorrected patients not surviving beyond the third decade. Here, we present a unique case of an 86-year-old female with uncorrected TOF who underwent a transcatheter aortic valve replacement (TAVR) procedure due to severe aortic stenosis (AS). The patient's TOF was identified during infancy, and she was categorized as an acyanotic "pink baby." Notably, the first palliative surgery for TOF was performed in 1944, when the patient was seven years old. The patient never underwent corrective surgery for TOF and continued to lead a symptom-free life until she developed severe AS later in life. The TAVR procedure significantly improved her symptoms, illustrating the importance of considering alternative etiologies for symptoms in elderly patients with uncorrected TOF and AS. In addition, we underscore the anesthetic management during TAVR, specifically highlighting the challenges addressed, such as the utilization of general anesthesia with transesophageal echocardiography (TEE) and the placement of a pulmonary artery (PA) catheter.

Carbon Dioxide Elimination After Sodium Bicarbonate Administration as a Novel Method to Assess Cardiac Output: A Pilot Study.

Introduction Cardiac output/pulmonary blood flow measurement is an important way to assess patients during the perioperative period, as well as patients who are critically ill. Current methods of assessing cardiac output have limitations. One indicator of cardiac output may be the expired carbon dioxide (CO2) partial pressure response to intravenous sodium bicarbonate (IVSB), which is rapidly converted to CO2. Methods We conducted an initial evaluation of the relationship between expired CO2 partial pressure and blood flow after a bolus of IVSB. To assess this relationship, we used a cardiopulmonary bypass circuit with predetermined blood flows in a laboratory trial and then assessed 18 patients undergoing surgery requiring cardiopulmonary bypass. Results For the laboratory portion of this pilot study, higher peak expired CO2, faster time to reach peak, higher area under the curve, and greater kurtosis of peak were observed at higher cardiac output flow rates, and higher mean expired CO2 was significantly associated with higher flow rates (p < 0.001). In the human study, higher mean (p = 0.023) and peak expired CO2 (p = 0.028) were both significantly associated with higher cardiac output flow rates. Conclusions This technique may be a way to intermittently assess cardiac output or improve accuracy when used in conjunction with other continuous output monitors.

Osteopetrosis-Anesthetic Considerations for Total Knee Arthroplasty: A Case Report.

Autosomal dominant or benign osteopetrosis is a rare genetic disorder of osteoclasts that results in dense but brittle bone structures. Patients with osteopetrosis may be scheduled for total knee arthroplasty to treat painful and functionally limiting osteoarthrosis. A search of the published literature produced no citation concerning anesthesia for patients with autosomal dominant osteopetrosis undergoing total knee arthroplasty. We present a case report detailing our experience and discuss considerations for the care of future patients with autosomal dominant osteopetrosis.

Brachial plexus injury: treatment options and outcomes.

The brachial plexus is a series of nerves formed by roots of cervical segments 5 to 8 (C5-C8) as well as the first thoracic nerve (T1). It functions to provide sensation and motor innervation to the skin and muscles of the chest and upper limb. It does so through different segments: roots, trunks, divisions, and cords. Injuries to the brachial plexus occur relatively frequently and are due mainly to traumatic accidents that lead to traction or compression of the nerve roots. When considering the etiology and treatment of such injuries, it is important to make a distinction between adult versus obstetric brachial plexus injury. Although several surgical treatment options are described and used for patients with brachial plexus injury, no perfect remedy currently exists. Prevention and safety should be the focus. At the same time, high-quality studies and new technology and techniques are needed to determine more effective treatments for this group.

The current format and ongoing advances of medical education in the United States.

The objective of this study was to examine the current system of medical education along with the advances that are being made to support the demands of a changing health care system. American medical education must reform to anticipate the future needs of a changing health care system. Since the dramatic transformations to medical education that followed the publication of the Flexner report in 1910, medical education in the United States has largely remained unaltered. Today, the education of future physicians is undergoing modifications at all levels: premedical education, medical school, and residency training. Advances are being made with respect to curriculum design and content, standardized testing, and accreditation milestones. Fields such as plastic surgery are taking strides toward improving resident training as the next accreditation system is established. To promote more efficacious medical education, the American Medical Association has provided grants for innovations in education. Likewise, the Accreditation Council for Graduate Medical Education outlined 6 core competencies to standardize the educational goals of residency training. Such efforts are likely to improve the education of future physicians so that they are able to meet the future needs of American health care.