Veno-Arterial Extracorporeal Membrane Oxygenation Rescue in a Patient With Pulmonary Hypertension Presenting for Revision Total Hip Arthroplasty: A Case Report and Narrative Review.

Patients with pulmonary hypertension (PH) are at an increased risk of perioperative morbidity and mortality when undergoing non-cardiac surgery. We present a case of a 57-year-old patient with severe PH, who developed cardiac arrest as the result of right heart failure, undergoing a revision total hip arthroplasty under combined spinal epidural anesthesia. Emergent veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) was undertaken as rescue therapy during the pulmonary hypertensive crisis and a temporizing measure to provide circulatory support in an intensive care unit (ICU). We present a narrative review on perioperative management for patients with PH undergoing non-cardiac surgery. The review goes through the updated hemodynamic definition, clinical classification of PH, perioperative morbidity, and mortality associated with PH in non-cardiac surgery. Pre-operative assessment evaluates the type of surgery, the severity of PH, and comorbidities. General anesthesia (GA) is discussed in detail for patients with PH regarding the benefits of and unsubstantiated arguments against GA in non-cardiac surgery. The literature on risks and benefits of regional anesthesia (RA) in terms of neuraxial, deep plexus, and peripheral nerve block with or without sedation in patients with PH undergoing non-cardiac surgery is reviewed. The choice of anesthesia technique depends on the type of surgery, right ventricle (RV) function, pulmonary artery (PA) pressure, and comorbidities. Given the differences in pathophysiology and mechanical circulatory support (MCS) between the RV and left ventricle (LV), the indications, goals, and contraindications of VA-ECMO as a rescue in cardiopulmonary arrest and pulmonary hypertensive crisis in patients with PH are discussed. Given the significant morbidity and mortality associated with PH, multidisciplinary teams including anesthesiologists, surgeons, cardiologists, pulmonologists, and psychological and social worker support should provide perioperative management.

The Answer to the Silent "Super Spreader": An Innovative Way to Manage Chest Drains on Coronavirus Patients With Active Air Leaks.

The risk of aerosol transmission has been a key factor for the rapid dissemination of the coronavirus pandemic. Transportation of coronavirus disease 2019 (COVID-19)-infected patients with active air leaks could expose unprotected health care personnel and other patients to aerosolized viral particles. We devised a way to avoid aerosolization while the chest tube drain is on water seal. It involves placing an Ultipor100 viral filter on the suction port of the drain system as well as sealing off the safety valve. This mechanism allows positive pressure from an air leak to escape while on water seal while trapping viral particles.

An Innovative Way to Achieve Safe Lung Deflation During One-Lung Ventilation in a Potential Coronavirus Disease 2019 Patient: A Case Report.

A novel coronavirus pandemic may be particularly hazardous to health care workers. Airway management is an aerosol-producing high-risk procedure. To minimize the production of airborne droplets, including pathogens such as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), from the endotracheal tube during procedures requiring lung deflation, we devised a technique to mitigate the risk of infection transmission to health care personnel.

Anesthetic management during bronchoscopy of patients with pulmonary hypertension.

This article is intended to provide an overview of the anesthetic management for bronchoscopic procedures in patients with pulmonary hypertension (PH). This includes the classifications of PH, diagnosis with severity, and treatment modalities as detailed knowledge of this condition is imperative for proper anesthetic management. Preoperative evaluation and optimization of the patient is discussed as well. Bronchoscopic procedures require airway manipulation and compromise ventilation for lengths of time. As hypoxemia and hypercarbia trigger decompensation in PH, this may lead to a downward spiral if control is lost. Therefore a discussion of the intraoperative anesthetic management and the critical concerns are detailed in this article, as well as treatment modalities and management for said concerns.

Hybrid Stage I Procedure as Initial Palliation for Neonate With Hypoplastic Left Heart Syndrome and Right Congenital Diaphragmatic Hernia.

During the past decade, a hybrid procedure has emerged and dramatically evolved as an alternative stage I palliation to the conventional Norwood procedure in neonates with hypoplastic left heart syndrome (HLHS). The hybrid approach avoids the need for cardiopulmonary bypass (CPB) utilizing stenting of the arterial duct and bilateral pulmonary artery banding. Cerebral and coronary perfusion pressure is maintained, and the pulmonary vasculature is protected from higher systemic pressure. Elimination of risks associated with CPB gains vital time to stabilize the patient and correct coexisting noncardiac anomalies and allows growth in preparation for the later stages of the Fontan pathway. The association of HLHS with right congenital diaphragmatic hernia (CDH) is rare. We report performing a successful hybrid stage I palliation on a neonate with HLHS and severe right CDH.

Quadruple Vessel Coronary Artery Bypass Grafting in a 14-Year-Old Child With Plasminogen Activator Inhibitor-1 4G/4G Gene Polymorphism.

Myocardial ischemia due to coronary artery disease is an extremely rare condition in childhood and adolescence. Absence of obvious serious risk factors remains a challenge to modern cardiology. We present the case of a 14-year-old boy who underwent quadruple-vessel coronary artery bypass grafting with bilateral pedicled internal mammary artery and bilateral radial artery grafting. We try to highlight a rare but important 4G variant PAI-1 (SERPINE 1) gene mutation as the etiology of severe coronary artery disease in our patient. To the best of our knowledge, he is one of the youngest patients who underwent coronary artery bypass surgery with 4 arterial grafts.

Successful one-lung ventilation in a patient with the Fontan circulation undergoing thoracoscopic procedure.

Over the course of the past 4 decades, the survival of patients with the Fontan circulation has improved and today they often present for noncardiac surgery anesthesia care. In patients with the Fontan circulation, pulmonary blood flow is passive and anesthetic management is directed at reducing pulmonary vascular resistance and maintaining adequate cardiac output. One-lung ventilation can have unfavorable effects on the Fontan circulation due to hypoxia, hypercarbia, and increased airway pressure. We present a case of successful one-lung ventilation in a patient with the Fontan circulation and describe the perioperative anesthetic management.