RESUMEN
In 2017 the American College of Cardiology issued an Expert Consensus Decision Pathway dedicated specifically to the management of bleeding in patients on anticoagulants. The consensus document is both timely and important as indications for more novel anticoagulants expand rapidly. The document reviews in detail recommendations for interruption, management and re-initiation of anticoagulation in bleeding scenarios. Numerous points within the document are relevant to perioperative physicians managing patients on anticoagulation with either bleeding complications or undergoing surgical procedures. The intent of this narrative review is to highlight the salient points within the expert consensus for perioperative physicians.
Asunto(s)
Anticoagulantes/administración & dosificación , Cardiología/normas , Consenso , Toma de Decisiones , Hemorragia/terapia , Atención Perioperativa/métodos , Médicos , Administración Oral , Hemorragia/inducido químicamente , Humanos , Tromboembolia/prevención & control , Terapia Trombolítica/normas , Estados UnidosRESUMEN
BACKGROUND: Steep Trendelenburg during surgery has been associated with many position-related injuries. The American Society of Anesthesiology practice advisory recommends documentation, frequent position checks, avoiding shoulder braces, and limiting abduction of upper extremities to avoid brachial plexopathy. We conducted a web-based survey to assess anesthesiologists' practices, institutional policies, and complications encountered when using steep Trendelenburg. METHODS: Two thousand fifty randomly selected active members of the American Society of Anesthesiology were invited via email to participate in a 9-item web-based survey. Results are reported as absolute numbers and proportions with 95% confidence interval (CI). RESULTS: Survey response rate was 290 of 2050 (14.1%). 44.6% (95% CI, 38.9-50.3) of the respondents documented anesthesia start and finish, 73.9% (95% CI, 68.8-79) frequently checked positioning during surgery, 30.8% (95% CI, 25.4-36.2) reported using shoulder braces, 66.9% (95% CI, 61.5-72.3) tucked patients' arms to the side, 54.0% (95% CI, 48.2-59.8) limited fluid administration, and more than two-thirds did not limit the duration or inclination angle. Notably, 63/290 (21.7%) reported a complication and only 6/289 (2.1%) had an institutional policy. The most common complication was airway and face edema, second was brachial plexus injury, and third was corneal abrasions. Most institutional policies, when present, focused on limiting duration of steep Trendelenburg and communication with surgical team. Only 1/6 policies required avoiding use of shoulder braces. CONCLUSION: Based on survey results, practices related to steep Trendelenburg varied among USA anesthesiologists. Differences included protective measures, documentation, positioning techniques, fluid management, and institutional guidelines. The singular commonality found among all respondents was lack of institutional policies. Survey results highlighted the need for institutional policies and more education.
Asunto(s)
Anestesiólogos/psicología , Adhesión a Directriz/estadística & datos numéricos , Inclinación de Cabeza/efectos adversos , Humanos , Política Organizacional , Guías de Práctica Clínica como Asunto , Encuestas y Cuestionarios , Estados UnidosRESUMEN
OBJECTIVE: To compare monitored anesthesia care (MAC) and general anesthesia (GA) for transcatheter aortic valve implantation (TAVI). DESIGN: Retrospective, case-control study. SETTING: A large university-affiliated hospital system. PARTICIPANTS: The study comprised patients who underwent TAVI with the Medtronic CoreValve (Medtronic, Minneapolis, MN) between 2011 and 2015. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: MAC (n = 44) and GA (n = 21) were compared in 65 patients who underwent TAVI. Baseline characteristics/demographics, hospital stay, intraoperative conditions, and intensive care unit (ICU)/hospital stays were compared using the chi-square test, unpaired t-test, or binomial regression where appropriate. There were no significant differences between patient populations with regard to 30-day mortality, ICU/hospital stay, and complication rates. The GA group used more blood product. The rate of ICU readmission was greater in the GA group but did not reach statistical significance. CONCLUSIONS: GA provides no significant advantages over MAC during TAVI.
Asunto(s)
Analgésicos/administración & dosificación , Anestesia General/métodos , Anestésicos por Inhalación/administración & dosificación , Anestésicos Intravenosos/administración & dosificación , Anestésicos Locales/administración & dosificación , Monitoreo Intraoperatorio/métodos , Reemplazo de la Válvula Aórtica Transcatéter/métodos , Anciano , Anciano de 80 o más Años , Estudios de Casos y Controles , Dexmedetomidina , Ecocardiografía , Etomidato , Femenino , Fentanilo , Humanos , Tiempo de Internación/estadística & datos numéricos , Lidocaína , Masculino , Éteres Metílicos , Estudios Retrospectivos , Medición de Riesgo , Sevoflurano , Resultado del TratamientoRESUMEN
BACKGROUND: Extubation in the operating room (OR) after cardiac surgery remains controversial due to safety concerns. Its feasibility had been suggested in select patients after off-pump surgery. AIM: To review the outcomes of patients extubated in the OR after on-pump cardiac valve surgery (cohort of interest) in comparison with patients extubated conventionally in the intensive care unit (ICU) (control). We hypothesized that the timing of extubation was not associated with postoperative complications. METHODS: Retrospective review of 272 consecutive patients who had undergone cardiac valve surgery at Jackson Memorial Hospital, Miami, Florida between January 1, 2009 and December 30, 2013. RESULTS: Compared with the control group, patients extubated in the OR had shorter cardiopulmonary bypass (CPB) (87 vs. 113 min, p < 0.0001) and aortic cross-clamp times (60 vs. 78 min, p < 0.0001), lower transfusion requirements (41.38% vs. 57.01%, p = 0.0342), shorter ICU (four vs. five days, p = 0.0002), and hospital stays (7.8 vs. 10 days, p = 0.0151). Mortality, overall rates of complications in all categories, ICU readmissions, and reintubations were similar in both groups. Each additional minute of CPB decreased the odds of extubation in the OR by a factor of 0.988 (odds ratio = 0.988; 95%CI: 0.980, 0.997). Pulmonary perfusion and ventilation during CPB increased the likelihood of extubation in the OR by a factor of 2.45 (odds ratio = 2.453; 95%CI: 1.247, 4.824). CONCLUSIONS: In select patients, extubation in the OR after on-pump valve surgery is safe. It is facilitated by shorter duration of CPB and pulmonary perfusion and ventilation during CPB. doi: 10.1111/jocs.12736 (J Card Surg 2016;31:274-281).
Asunto(s)
Extubación Traqueal/métodos , Procedimientos Quirúrgicos Cardíacos/métodos , Válvulas Cardíacas/cirugía , Complicaciones Posoperatorias/epidemiología , Femenino , Florida/epidemiología , Estudios de Seguimiento , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Oportunidad Relativa , Quirófanos , Periodo Posoperatorio , Estudios Retrospectivos , Factores de TiempoAsunto(s)
Ecocardiografía Transesofágica/normas , Insuficiencia de la Válvula Mitral/diagnóstico por imagen , Guías de Práctica Clínica como Asunto/normas , Sociedades Médicas/normas , Ecocardiografía Transesofágica/métodos , Humanos , Insuficiencia de la Válvula Mitral/epidemiología , Estados Unidos/epidemiologíaAsunto(s)
Puente Cardiopulmonar/métodos , Manejo de la Enfermedad , Trasplante de Corazón , Heparina/efectos adversos , Hirudinas/administración & dosificación , Trasplante de Riñón , Fragmentos de Péptidos/administración & dosificación , Trombocitopenia/inducido químicamente , Anticoagulantes/administración & dosificación , Antitrombinas/administración & dosificación , Pruebas de Coagulación Sanguínea , Cardiomiopatías/complicaciones , Cardiomiopatías/cirugía , Femenino , Fibrinolíticos/efectos adversos , Humanos , Persona de Mediana Edad , Proteínas Recombinantes/administración & dosificación , Insuficiencia Renal Crónica/complicaciones , Insuficiencia Renal Crónica/cirugía , Trombocitopenia/diagnóstico , Trombocitopenia/terapia , Trombosis/prevención & controlRESUMEN
BACKGROUND: Extubation in the operating room (OR) after cardiac surgery is hampered by safety concerns, psychological reluctance, and uncertain economic benefit. We have studied the factors affecting the feasibility of extubation in the OR after cardiac surgery and its safety. METHODS: The outcomes of 78 patients extubated in the OR after open heart surgery were retrospectively compared to a matched control group of 80 patients with similar demographics, co-morbidities, and operative procedures, that were performed over the same time period, but extubated in the intensive care unit (ICU) following a standard weaning protocol. Variables collected included the incidence of subsequent unplanned tracheal reintubation in the ICU, postoperative complications, need for mediastinal re-exploration, surgical and OR times, and ICU and hospital lengths of stay. RESULTS: Out of a total of 372 cardiac procedures performed during the designated time frame, 78 (21%) resulted in extubation in the OR, mostly after off-pump coronary revascularization (41%) and aortic valve replacement (19.4%). Preoperative hypertension, EF ≥30%, off-bypass revascularization and shorter surgical times increased the likelihood of extubation in the OR. Extubation in the OR did not increase perioperative morbidity and mortality rates, but decreased the length of ICU and hospital stays. The incidence of unanticipated subsequent tracheal intubation in the ICU was comparable to noncardiac high-risk procedures (2.5%). CONCLUSIONS: Extubation in the OR can be safely performed in a select group of cardiac surgery patients without any increase in postoperative morbidity or mortality. The proposed mathematical model performed reasonably well in predicting a successful extubation in the OR.
Asunto(s)
Extubación Traqueal/métodos , Procedimientos Quirúrgicos Cardíacos , Cuidados Posoperatorios/métodos , Adulto , Anciano , Anciano de 80 o más Años , Procedimientos Quirúrgicos Cardíacos/mortalidad , Técnicas de Apoyo para la Decisión , Femenino , Humanos , Unidades de Cuidados Intensivos , Tiempo de Internación/estadística & datos numéricos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Quirófanos , Complicaciones Posoperatorias/epidemiología , Estudios RetrospectivosAsunto(s)
Dolor Postoperatorio/terapia , Toracotomía , Agonistas de Receptores Adrenérgicos alfa 2/uso terapéutico , Analgesia Epidural , Anestesia Intravenosa , Antiinflamatorios no Esteroideos/uso terapéutico , Crioanestesia , Humanos , Ketamina/uso terapéutico , Bloqueo Nervioso , Estimulación Eléctrica Transcutánea del NervioAsunto(s)
Cuerpos Extraños/diagnóstico por imagen , Cuerpos Extraños/etiología , Pericardio , Tapones Quirúrgicos de Gaza/efectos adversos , Adulto , Procedimientos Quirúrgicos Cardíacos/métodos , Ecocardiografía , Femenino , Cuerpos Extraños/cirugía , Defectos del Tabique Interventricular/cirugía , Ventrículos Cardíacos , Humanos , Imagen por Resonancia Magnética , Toracotomía/métodos , Tomografía Computarizada por Rayos X , Resultado del TratamientoRESUMEN
A very loud systolic murmur was identified during a pre-operative evaluation of a 51-year-old woman for an elective hysterectomy. The TTE showed a 4.7 cm intracardiac mass obstructing the RVOT. The patient was scheduled instead for resection of the mass. Before anesthesia induction, the surgical team and perfusionist were prepared to initiate CPB in case of circulatory collapse. After induction of general anesthesia, the patient became hypotensive, requiring vasopressor support. She recovered and was then successfully placed on CPB. The mass was removed without incident, and a TEE confirmed resolution of the RVOT obstruction. The patient did well post-operatively.
Asunto(s)
Leiomioma , Obstrucción del Flujo Ventricular Externo , Femenino , Ventrículos Cardíacos , Humanos , Persona de Mediana Edad , Obstrucción del Flujo Ventricular Externo/diagnóstico por imagen , Obstrucción del Flujo Ventricular Externo/etiología , Obstrucción del Flujo Ventricular Externo/cirugíaRESUMEN
A 58-year-old male presented with a hemodynamically significant pulmonary embolism. Computed tomography angiogram revealed a saddle embolus in the main pulmonary artery with extensive clot burden affecting all lobes and right heart strain. Transthoracic echocardiogram displayed a dilated right ventricle with reduced systolic function. The patient was scheduled for pulmonary embolectomy. The intraoperative transesophageal echocardiogram (TEE) demonstrated a mobile left atrial thrombus that was missed on previous imaging. After removal of the thrombi, TEE showed a patent foramen ovale (PFO). The left atrial thrombus passed across the PFO secondary to increased right heart and pulmonary pressures.
Asunto(s)
Trombosis Coronaria/complicaciones , Trombosis Coronaria/diagnóstico por imagen , Ecocardiografía Transesofágica/métodos , Hallazgos Incidentales , Embolia Pulmonar/complicaciones , Embolia Pulmonar/cirugía , Trombosis Coronaria/cirugía , Atrios Cardíacos/diagnóstico por imagen , Atrios Cardíacos/cirugía , Humanos , Masculino , Persona de Mediana EdadRESUMEN
It has been demonstrated that smoking is associated with an increase in postoperative and chronic pain. The changes in the pain-related neural pathways responsible for these effects are unknown. Additionally, the effects of nicotine withdrawal, resulting from smoking abstinence preoperatively, has not been evaluated in terms of its impact on pain sensation. In this study, an animal model has been used to assess these effects. A rat model of long-term nicotine exposure was used. Von Frey mechanical sensory tests were performed. Western Blot and immunohistological analysis were conducted on spinal cord samples. Mechanical sensory thresholds increased in the initial period (1-3 weeks), indicating hyposensitivity. Long-term (410 weeks) and under nicotine withdrawal, the mechanical sensory thresholds decreased, indicating hyperalgesia. During short-term nicotine exposure, glutamate decarboxylase 67 (GAD67), GAD65, and µ-opioid receptors (MOR) up-regulated. Beta-endorphins down-regulated. Increased γ -aminobutyric acid (GABA) and MOR appear responsible for the hyposensitivity since the GABA receptor antagonist, bicuculline and opioid receptor antagonist, naloxone decreased the mechanical thresholds of nicotine-induced hyposensitivity. In long-term nicotine exposure, the expression of GAD67, MOR, and GABA decreased. Baclofen, a derivative of GABA, reversed the hyperalgesia seen with nicotine withdrawal. Therefore, nicotine acts as an analgesic when used acutely or short-term. Long-term exposure or nicotine withdrawal (similar to smoking cessation) results in hyperalgesia. Nicotine appears to alter pain sensitivity by affecting the expression of GAD65, GAD67, MOR, endorphins, and GABA. This may partially explain the increased pain and opioid use seen in chronic smokers in the postoperative period.
Asunto(s)
Nicotina/farmacología , Percepción del Dolor/efectos de los fármacos , Umbral del Dolor/efectos de los fármacos , Síndrome de Abstinencia a Sustancias/psicología , Animales , Baclofeno/farmacología , Bicuculina/farmacología , Modelos Animales de Enfermedad , Regulación hacia Abajo/efectos de los fármacos , Endorfinas/metabolismo , Glutamato Descarboxilasa/metabolismo , Hiperalgesia/inducido químicamente , Masculino , Naloxona/farmacología , Ratas , Receptores Opioides mu/metabolismo , Médula Espinal/metabolismo , Factores de Tiempo , Regulación hacia Arriba/efectos de los fármacos , Ácido gamma-Aminobutírico/metabolismoRESUMEN
STUDY OBJECTIVE: To determine the incidence burden and associated risk factors of residual neuromuscular block (rNMB) during routine U.S. hospital care. DESIGN: Blinded multicenter cohort study. SETTING: Operating and recovery rooms of ten community and academic U.S. hospitals. PATIENTS: Two-hundred fifty-five adults, ASA PS 1-3, underwent elective abdominal surgery with general anesthesia and ≥1 dose of non-depolarizing neuromuscular blocking agent (NMBA) for endotracheal intubation and/or maintenance of NMB between August 2012 and April 2013. INTERVENTIONS: TOF measurements using acceleromyography were performed on patients already receiving routine anesthetic care for elective open or laparoscopic abdominal surgery. Measurements allowed assessment of the presence of residual neuromuscular block (rNMB), defined as a train-of-four (TOF) ratio <0.9 at tracheal extubation. We recorded patient and procedural characteristics and assessed TOF ratios (T4/T1) at various times throughout the procedure and at tracheal extubation. Differences in patient and clinical characteristics were compared using Fisher's exact test for categorical variables and t-test for continuous variables. Multivariate logistic regression assessed risk factors associated with rNMB at extubation. MAIN RESULTS: Most of the study population, 64.7% (nâ¯=â¯165) had rNMB (TOF ratioâ¯<â¯0.9), among them, 31.0% with TOF ratio <0.6. Among those receiving neostigmine and/or qualitative peripheral nerve stimulation per clinical decision, 65.0% had rNMB. After controlling for confounders, we observed male gender (odds ratio: 2.60, Pâ¯=â¯0.008), higher BMI (odds ratio: 1.04/unit, Pâ¯=â¯0.043), and surgery at a community hospital (odds ratio: 3.15, Pâ¯=â¯0.006) to be independently associated with increased odds of rNMB. CONCLUSIONS: Assessing TOF ratios blinded to the care team, we found that the majority of patients (64.7%) in this study had rNMB at tracheal extubation, despite neostigmine administration and qualitative peripheral nerve stimulation used for routine clinical care. Qualitative neuromuscular monitoring and clinical judgement often fails to detect rNMB after neostigmine reversal with potential severe consequences to the patient. Our data suggests that clinical care could be improved by considering quantitative neuromuscular monitoring for routine care.
Asunto(s)
Anestesia General/efectos adversos , Retraso en el Despertar Posanestésico/epidemiología , Procedimientos Quirúrgicos Electivos/efectos adversos , Bloqueo Neuromuscular/efectos adversos , Fármacos Neuromusculares no Despolarizantes/efectos adversos , Adulto , Anciano , Anciano de 80 o más Años , Anestesia General/métodos , Índice de Masa Corporal , Inhibidores de la Colinesterasa/administración & dosificación , Retraso en el Despertar Posanestésico/complicaciones , Retraso en el Despertar Posanestésico/diagnóstico , Retraso en el Despertar Posanestésico/prevención & control , Femenino , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Neostigmina/administración & dosificación , Neostigmina/efectos adversos , Neostigmina/antagonistas & inhibidores , Bloqueo Neuromuscular/métodos , Monitoreo Neuromuscular , Fármacos Neuromusculares no Despolarizantes/administración & dosificación , Fármacos Neuromusculares no Despolarizantes/antagonistas & inhibidores , Estudios Prospectivos , Factores de Riesgo , Factores Sexuales , Estados Unidos , Adulto JovenRESUMEN
AIM: The aim of this study was to describe our institutional experience, primarily with general anesthesiologists consulting with cardiac anesthesiologists, caring for left ventricular assist device (LVAD) patients undergoing noncardiac surgery. MATERIALS AND METHODS: This is a retrospective review of the population of patients with LVADs at a single institution undergoing noncardiac procedures between 2009 and 2014. Demographic, perioperative, and procedural data collected included the type of procedure performed, anesthetic technique, vasopressor requirements, invasive monitors used, anesthesia provider type, blood product management, need for postoperative intubation, postoperative disposition and length of stay, and perioperative complications including mortality. STATISTICAL ANALYSIS: Descriptive statistics for categorical variables are presented as frequency distributions and percentages. Continuous variables are expressed as mean ± standard deviation and range when applicable. RESULTS: During the study, 31 patients with LVADs underwent a total of 74 procedures. Each patient underwent an average of 2.4 procedures. Of the total number of procedures, 48 (65%) were upper or lower endoscopies. Considering all procedures, 81% were performed under monitored anesthesia care (MAC). Perioperative care was provided by faculty outside of the division of cardiac anesthesia in 62% of procedures. Invasive blood pressure monitoring was used in 27 (36%) procedures, and a central line, peripherally inserted central catheter or midline was in place preoperatively and used intraoperatively for 38 (51%) procedures. Vasopressors were not required in the majority (65; 88%) of procedures. There was one inhospital mortality secondary to multiorgan failure; 97% of patients survived to discharge after their procedure. CONCLUSION: At our institution, LVAD patients undergoing noncardiac procedures most frequently require endoscopy. These procedures can frequently be done safely under MAC, with or without consultation by a cardiac anesthesiologist.
Asunto(s)
Anestesia/métodos , Corazón Auxiliar , Atención Perioperativa/métodos , Procedimientos Quirúrgicos Operativos , Anciano , Femenino , Humanos , Tiempo de Internación/estadística & datos numéricos , Masculino , Monitoreo Fisiológico/métodos , Complicaciones Posoperatorias/prevención & control , Estudios RetrospectivosRESUMEN
A growing number of patients are undergoing prolonged management of advanced heart failure with the use of continuous flow left ventricular assist devices (LVADs). Subsequently, an increasing number of patients are presenting with complications associated with these devices. Based on an analysis of three major LVAD institutions, the number of patients developing LVAD pump thrombosis may be much higher than originally projected. [1],[2] The management of this highly feared complication continues to be challenging, as the population of LVAD patients is very heterogeneous and heavily burdened with comorbidities. The standard protocol of increasing anticoagulation may fail to achieve successful resolution of thrombus. Difficulty and poor prognosis may make reoperation less than desirable. Here, we present a case of successful thrombolysis following intravenous administration of tissue plasminogen activator in the Intensive Care Unit setting.
Asunto(s)
Corazón Auxiliar/efectos adversos , Terapia Trombolítica/métodos , Trombosis/etiología , Trombosis/prevención & control , Ecocardiografía , Insuficiencia Cardíaca/diagnóstico por imagen , Insuficiencia Cardíaca/etiología , Insuficiencia Cardíaca/terapia , Trasplante de Corazón , Humanos , Masculino , Complicaciones Posoperatorias/prevención & control , Complicaciones Posoperatorias/terapia , Reoperación , Trombosis/diagnóstico por imagen , Adulto JovenRESUMEN
OBJECTIVES: Clinical trials of either pulmonary perfusion or ventilation during cardiopulmonary bypass (CBP) are equivocal. We hypothesized that to achieve significant improvement in outcomes both interventions had to be concurrent. DESIGN: Retrospective case-control study. SETTINGS: Major academic tertiary referral medical center. PARTICIPANTS: Two hundred seventy-four consecutive patients who underwent open heart surgery with CBP 2009-2013. INTERVENTIONS: The outcomes of 86 patients who received pulmonary perfusion and ventilation during CBP were retrospectively compared to the control group of 188 patients. MEASUREMENTS AND MAIN RESULTS: Respiratory complications rates were similar in both groups (33.7 vs. 33.5%), as were the rates of postoperative pneumonia (4.7 vs. 4.3%), pleural effusions (13.9 vs. 12.2%), and re-intubations (9.3 vs. 9.1%). Rates of adverse postoperative cardiac events including ventricular tachycardia (9.3 vs. 8.5%) and atrial fibrillation (33.7 vs. 28.2%) were equivalent in both groups. Incidence of sepsis (8.1 vs. 5.3%), postoperative stroke (2.3 vs. 2.1%), acute kidney injury (2.3 vs. 3.7%), and renal failure (5.8 vs. 3.7%) was likewise comparable. Despite similar transfusion requirements, coagulopathy (12.8 vs. 5.3%, p = 0.031) and the need for mediastinal re-exploration (17.4 vs. 9.6%, p = 0.0633) were observed more frequently in the pulmonary perfusion and ventilation group, but the difference did not reach the statistical significance. Intensive care unit (ICU) and hospital stays, and the ICU readmission rates (7.0 vs. 8.0%) were similar in both groups. CONCLUSION: Simultaneous pulmonary perfusion and ventilation during CBP were not associated with improved clinical outcomes.