ABSTRACT
Patients with coronary stents undergoing non-cardiac surgery are at increased risk of major adverse cardiovascular events perioperatively. Impeccable patient care and communication between all members of the healthcare team will minimize this risk. The dominant risk factor for stent thrombosis and major adverse cardiovascular events is the interruption of dual antiplatelet therapy (e.g. aspirin and clopidogrel). If clopidogrel therapy has to be interrupted due to increased risk of bleeding, continuation of aspirin is strongly recommended to reduce the risk of stent thrombosis. The interval between percutaneous coronary interventions and operation is the next major risk factor for stent thrombosis. The incidence of major adverse cardiovascular events is inversely related to this interval, with the highest mortality rate occurring <30 days after stent implantation. Ideally, for patients with drug-eluting stents, elective surgery should be delayed for at least 1 yr and for patients with bare-metal stents, the recommended minimum period is 6 weeks. The use of a neuraxial anaesthetic technique must be carefully considered due to the risk of an epidural haematoma. Perioperative monitoring should focus on early recognition of myocardial ischaemia, infarction, or both. If stent thrombosis is present, rapid triage to an interventional catheterization laboratory is essential for restoration of coronary blood flow.
Subject(s)
Cardiovascular Diseases/etiology , Intraoperative Complications , Postoperative Complications , Stents/adverse effects , Anesthesia/methods , Coronary Disease/therapy , Drug-Eluting Stents/adverse effects , Humans , Monitoring, Physiologic/methods , Perioperative Care/methods , Platelet Aggregation Inhibitors/administration & dosage , Platelet Aggregation Inhibitors/adverse effects , Risk Factors , Thrombosis/etiologySubject(s)
Cardiopulmonary Bypass , Hemorrhage/etiology , Intraoperative Complications/etiology , Tracheal Diseases/etiology , Adult , Aortic Valve Stenosis/surgery , Coronary Disease/surgery , Fatal Outcome , Female , Hemorrhage/therapy , Humans , Intraoperative Complications/therapy , Male , Middle AgedSubject(s)
Anticoagulants , Catheterization, Swan-Ganz/adverse effects , Coated Materials, Biocompatible/adverse effects , Heparin , Thrombosis/etiology , Catheterization, Swan-Ganz/instrumentation , Coated Materials, Biocompatible/analysis , Humans , Microscopy, Electron, Scanning , Thrombosis/prevention & controlSubject(s)
Databases as Topic , Government Programs , Hospital Information Systems , Outcome Assessment, Health Care , Blood Pressure/physiology , Coronary Artery Bypass/mortality , Coronary Artery Bypass/statistics & numerical data , Heart Rate/physiology , Hemodynamics/physiology , Humans , Myocardial Ischemia/epidemiology , Process Assessment, Health Care , Quality Assurance, Health Care , Risk Adjustment , Risk FactorsSubject(s)
Anesthesiology/classification , Coronary Artery Bypass/classification , Severity of Illness Index , Cardiovascular Diseases/complications , Cardiovascular Diseases/physiopathology , Cardiovascular Diseases/surgery , Coronary Artery Bypass/adverse effects , Disease/classification , Elective Surgical Procedures/classification , Humans , Risk Factors , Survival RateABSTRACT
The use of both clinical medical and administrative databases is discussed in the context of an academic anesthesiology's transition from the tenets of quality assurance to those of continuous quality improvements. A historical framework is presented. The basic and aggregate models are introduced, and examples are used to illustrate the composite system.
Subject(s)
Anesthesiology/standards , Models, Organizational , Quality Assurance, Health Care , Total Quality Management , Anesthesiology/education , Anesthesiology/organization & administration , Databases, Factual , Humans , Professional Review OrganizationsSubject(s)
Aorta, Thoracic/diagnostic imaging , Echocardiography, Transesophageal , Female , Humans , Middle AgedABSTRACT
Nitrates are commonly used for rapid relief of ischemia in the initial management of unstable angina. However, their optimal dosage, route of administration, and therapeutic goals have not been fully established. This study was conducted to determine the optimal dosage and mode of administration (intravenous bolus versus sublingual spray) of nitrates and the therapeutic goals of their use in the immediate management of unstable angina. In a single-center prospective trial, 72 consecutive patients with unstable angina accompanied by typical ST-segment depression on electrocardiogram were randomly assigned to receive isosorbide dinitrate either as repeated intravenous boluses or as sublingual sprays while being delivered to the hospital by a mobile intensive care unit. Optimal nitrate dosage was tailored to pain relief while monitoring mean blood pressure reduction to an optimal range (5% to 20%) without dosage restriction. The mean nitrate dosage needed for ischemia control during the first hour of treatment was 7.8 +/- 3.8 mg. Optimal blood pressure reduction was achieved by significantly more intravenously treated patients than sublingually treated patients (68% v 41%, P = .037). Intravenously treated patients also experienced a more pronounced therapeutic effect, as assessed by reduction in chest pain score (67% v 39%, P = .0004) and decrease in ST-segment depressions (57% v 27%, P = .004). These results show that higher doses of nitrates than previously recommended are required for ischemia control during the initial management of unstable angina. The use of repeated intravenous boluses is safe and more easily controlled and, therefore, more efficacious than sublingual sprays in inducing the maximal anti-ischemic effect while avoiding significant hypotension.
Subject(s)
Angina, Unstable/drug therapy , Emergency Treatment , Isosorbide Dinitrate/administration & dosage , Myocardial Ischemia/drug therapy , Vasodilator Agents/administration & dosage , Administration, Sublingual , Aged , Aged, 80 and over , Female , Humans , Injections, Intravenous , Male , Middle Aged , Prospective Studies , Treatment OutcomeSubject(s)
Aorta/injuries , Aortic Valve/surgery , Echocardiography, Transesophageal , Aged , Female , HumansABSTRACT
Transesophageal echocardiography (TEE) is an integral part of decision-making and monitoring in the perioperative period for patients undergoing valvular heart surgery. Multiplanar probes with improved pre- and intraoperative evaluation, eg, improved accuracy of estimation of mitral regurgitation jet size, have led to a more precise surgical approach. In the intensive care unit, TEE is proving invaluable in diagnosing occult causes of clinical instability that are usually surgically correctable. Advances in imaging technology with three- and four-dimensional TEE will facilitate preoperative decision-making, determine intraoperative approaches to valvular surgery, and provide earlier recognition of complications in the intensive care unit.
Subject(s)
Echocardiography, Transesophageal , Heart Valve Diseases/diagnostic imaging , Preoperative Care/methods , Aortic Valve/diagnostic imaging , Aortic Valve/surgery , Decision Making , Echocardiography, Transesophageal/methods , Heart Valve Diseases/surgery , Humans , Intensive Care Units , Intraoperative Period , Mitral Valve/diagnostic imaging , Mitral Valve/surgery , Postoperative CareABSTRACT
Three cases of successful prehospital resuscitation of blunt trauma patients sustaining cardiac arrest resulting from ventricular fibrillation are reported. Although probably uncommon, ventricular fibrillation not caused by severe hypovolemia, exsanguination, or severe hypoxia in the setting of blunt trauma might be a treatable cause of cardiac arrest. Early electrocardiographic monitoring of patients with blunt trauma, including those with cardiac arrest, can detect this small, yet easily salvageable group of patients.