ABSTRACT
The authors thank thank the editors for this opportunity to review the recent literature on vascular surgery and anesthesia and provide this clinical update. The last in a series of updates on this topic was published in 2019.1 This review explores evolving discussions and current trends related to vascular surgery and anesthesia that have been published since then. The focus is on the major points discussed in the recent literature in the following areas: carotid artery surgery, infrarenal aortic surgery, peripheral vascular surgery, and the preoperative evaluation of vascular surgical patients.
Subject(s)
Coronary Vessel Anomalies , Perioperative Care , Humans , Aorta, Thoracic/abnormalities , Aorta, Thoracic/surgery , Aorta, Thoracic/diagnostic imaging , Coronary Vessel Anomalies/surgery , Coronary Vessel Anomalies/diagnostic imaging , Coronary Vessels/surgery , Coronary Vessels/diagnostic imaging , Perioperative Care/methodsABSTRACT
This article reviews research highlights in the field of thoracic anesthesia. The highlights of this year included new developments in the preoperative assessment and prehabilitation of patients requiring thoracic surgery, updates on the use of devices for one-lung ventilation (OLV) in adults and children, updates on the anesthetic and postoperative management of these patients, including protective OLV ventilation, the use of opioid-sparing techniques and regional anesthesia, and outcomes using enhanced recovery after surgery, as well as the use of expanding indications for extracorporeal membrane oxygenation, specialized anesthetic techniques for airway surgery, and nonintubated video-assisted thoracic surgery.
Subject(s)
Anesthesia, Conduction , Anesthesiology , Anesthetics , One-Lung Ventilation , Adult , Child , Humans , One-Lung Ventilation/methods , Analgesics, Opioid , Thoracic Surgery, Video-Assisted/methodsSubject(s)
Aortic Valve Stenosis , Heart Valve Prosthesis Implantation , Pulmonary Disease, Chronic Obstructive , Transcatheter Aortic Valve Replacement , Humans , Aortic Valve/diagnostic imaging , Aortic Valve/surgery , Pulmonary Disease, Chronic Obstructive/complications , Pulmonary Disease, Chronic Obstructive/surgery , Aortic Valve Stenosis/complications , Aortic Valve Stenosis/diagnostic imaging , Aortic Valve Stenosis/surgery , Treatment Outcome , Retrospective StudiesSubject(s)
Coronary Vessel Anomalies , Coronary Vessels , Humans , Adult , Infant , Coronary Vessels/diagnostic imaging , Coronary Vessels/surgery , Pulmonary Artery/diagnostic imaging , Pulmonary Artery/surgery , Pulmonary Artery/abnormalities , Coronary Vessel Anomalies/diagnostic imaging , Coronary Vessel Anomalies/surgery , Treatment Outcome , ReplantationSubject(s)
Extracorporeal Membrane Oxygenation , Respiration Disorders , Humans , Hypoxia/therapy , ObesityABSTRACT
TACROLIMUS, a mainstay of immunosuppression after orthotopic heart transplantation (OHT), is associated with a broad range of side effects. Vasoconstriction caused by tacrolimus has been proposed as a mechanism underlying common side effects such as hypertension and renal injury. Neurologic side effects attributed to tacrolimus include headaches, posterior reversible encephalopathy syndrome (PRES), or reversible cerebral vasospasm syndrome (RCVS). Six case reports have been published describing RCVS in the setting of tacrolimus administration after OHT. The authors report a case of perfusion-dependent focal neurologic deficits attributed to tacrolimus-induced RCVS in an OHT recipient.
Subject(s)
Heart Transplantation , Posterior Leukoencephalopathy Syndrome , Vasospasm, Intracranial , Humans , Tacrolimus/adverse effects , Vasospasm, Intracranial/chemically induced , Vasospasm, Intracranial/diagnostic imaging , Posterior Leukoencephalopathy Syndrome/chemically induced , Posterior Leukoencephalopathy Syndrome/diagnostic imaging , Critical Illness , Perfusion/adverse effects , Heart Transplantation/adverse effectsSubject(s)
Aortic Valve Stenosis , Heart Valve Prosthesis , Stenosis, Pulmonary Vein , Humans , Aortic Valve/diagnostic imaging , Aortic Valve/surgery , Stenosis, Pulmonary Vein/diagnostic imaging , Stenosis, Pulmonary Vein/etiology , Stenosis, Pulmonary Vein/surgery , Aortic Valve Stenosis/diagnostic imaging , Aortic Valve Stenosis/surgery , Echocardiography , Echocardiography, TransesophagealSubject(s)
Anesthesia , Anesthesiology , One-Lung Ventilation , Thoracic Surgical Procedures , HumansABSTRACT
Background Methohexital and propofol can both be used as sedation for direct current cardioversion (DCCV). However, there are limited data comparing these medications in this setting. We hypothesized that patients receiving methohexital for elective DCCV would be sedated more quickly, recover from sedation faster, and experience less adverse effects. Methods and Results This was a prospective, blinded randomized controlled trial conducted at a single academic medical center. Eligible participants were randomly assigned to receive either methohexital (0.5 mg/kg) or propofol (0.8 mg/kg) as a bolus for elective DCCV. The times from bolus of the medication to achieving a Ramsay Sedation Scale score of 5 to 6, first shock, eyes opening on command, and when the patient could state their age and name were obtained. The need for additional medication dosing, airway intervention, vital signs, and medication side effects were also recorded. Seventy patients who were randomized to receive methohexital (n=37) or propofol (n=33) were included for analysis. The average doses of methohexital and propofol were 0.51 mg/kg and 0.84 mg/kg, respectively. There were no significant differences between methohexital and propofol in the time from end of injection to loss of conscious (1.4±1.8 versus 1.1±0.5 minutes; P=0.33) or the time to first shock (1.7±1.9 versus 1.4±0.5 minutes; P=0.31). Time intervals were significantly lower for methohexital compared with propofol in the time to eyes opening on command (5.1±2.5 versus 7.8±3.7 minutes; P=0.0005) as well as at the time to the ability to answer simple questions of age and name (6.0±2.6 versus 8.6±4.0 minutes; P=0.001). The methohexital group experienced less hypotension (8.1% versus 42.4%; P<0.001) and less hypoxemia (0.0% versus 15.2%; P=0.005), had lower need for jaw thrust/chin lift (16.2% versus 42.4%; P=0.015), and had less pain on injection compared with propofol using the visual analog scale (7.2±9.7 versus 22.4±28.1; P=0.003). Conclusions In this model of fixed bolus dosing, methohexital was associated with faster recovery, more stable hemodynamics, and less hypoxemia after elective DCCV compared with propofol. It can be considered as a preferred agent for sedation for DCCV. Registration URL: https://www.clinicaltrials.gov/ct; Unique identifier: NCT04187196.
Subject(s)
Methohexital , Propofol , Electric Countershock/adverse effects , Humans , Hypoxia , Propofol/adverse effects , Prospective StudiesABSTRACT
This clinical challenge discusses a case in which a patient was referred for aortic valve repair or replacement due to severe aortic regurgitation from infective endocarditis. In addition to discovering a previously unknown tricuspid valve vegetation, the intraoperative echocardiographic evaluation was instrumental in revealing an undiagnosed Gerbode defect. The flow through this Gerbode defect was previously mistaken for tricuspid regurgitation, and the patient was misdiagnosed as exhibiting severe pulmonary hypertension. This case highlights the importance of reviewing preoperative echocardiographic imaging, as well as diligence in completing a thorough intraoperative transesophageal echocardiographic exam prior to cardiopulmonary bypass. In addition, while flow typically occurs in Gerbode defects during systole, this case demonstrates that flow can also occur during diastole, which was most likely due to the severe aortic regurgitation. Fortunately, the patient was able to undergo successful treatment for the unexpected sequalae of the infective endocarditis, including repair of the Gerbode defect, tricuspid valve repair, and aortic valve and root replacement. Importantly, the incorrect diagnosis of severe pulmonary hypertension was removed.
Subject(s)
Aortic Valve Insufficiency , Endocarditis, Bacterial , Endocarditis , Heart Septal Defects, Ventricular , Hypertension, Pulmonary , Aortic Valve/diagnostic imaging , Aortic Valve/surgery , Aortic Valve Insufficiency/diagnostic imaging , Aortic Valve Insufficiency/surgery , Echocardiography, Transesophageal , Endocarditis/complications , Endocarditis/diagnostic imaging , Endocarditis/surgery , Endocarditis, Bacterial/complications , Endocarditis, Bacterial/diagnostic imaging , Endocarditis, Bacterial/surgery , Heart Septal Defects, Ventricular/surgery , HumansABSTRACT
Perioperative management of implantable cardioverter-defibrillators is an important part of anesthetic care. Society recommendations and expert consensus statements exist to aid clinicians, and they have identified the umbilicus as an important landmark in decision-making. Implantable cardioverter-defibrillator antitachycardia therapy may not need to be deactivated for infraumbilical surgery because electromagnetic interference is unlikely to occur. The authors present two cases in which inappropriate antitachycardia therapy occurred intraoperatively with use of an underbody dispersive electrode, even though both surgeries were infraumbilical. The authors also present two cadaver models to demonstrate how monopolar electrosurgery below the umbilicus is sensed using both traditional and underbody dispersive electrosurgical return electrodes.