Right-to-Left Shunt During Transseptal Mitral Valve-in-Valve Replacement: A Case Report.

The following case report details an 88-year-old woman with severe mitral stenosis and moderate mitral regurgitation who presented with worsening dyspnea on exertion. The patient had undergone 4-vessel coronary artery bypass graft and mitral valve replacement 14 years before and was deemed high risk for redo sternotomy. A transseptal mitral valve-in-valve replacement was performed which resulted in intraoperative hypoxia and hypotension after atrial septal defect creation for valve deployment. A right-to-left shunt had developed due to the patient's underlying pulmonary hypertension. Successful atrial septal defect closure resolved the hypoxia and hypotension. The patient had a brief and uncomplicated postoperative course.

Opiate-Free Tricuspid Valve Replacement: Case Report.

The utility of opioid pain medications for perioperative analgesia is well described. However, opioids have many dangerous side effects including respiratory depression, acute tolerance, hyperalgesia, and chronic opioid dependence. Multimodal approaches continue to be used in more invasive and complex surgical procedures for enhanced recovery and decreased postoperative complications from opioid administration. The current case report centers on a 30-year-old male recovering from opioid addiction presenting with severe tricuspid regurgitation scheduled to undergo a tricuspid valve replacement. The patient requested an opioid-free procedure, and a multimodal plan was developed for intraoperative and postprocedure management. This case represents a completely opioid-free valve replacement surgery and recovery.

Tailoring the Blood Ordering Process for Cardiac Surgical Cases Using an Institution-Specific Version of the Maximum Surgical Blood Order Schedule.

BACKGROUND: Excess ordering of blood products for surgical cases is expensive and wasteful. Evidence has shown that institution-specific versions of the Maximum Surgical Blood Order Schedule (MSBOS) lead to better ordering practices. Most MSBOSs recommend a crossmatch for a minimum of 2 units of packed red blood cells (PRBCs) for cardiac surgical cases; however, studies have shown that >50% of these patients receive no transfusions. Our aim was to create a blood order algorithm for cardiac surgical cases that would decrease unnecessary crossmatching. METHODS: Retrospective data was collected for 264 patients from January 2011 through April 2012. The crossmatch-to-transfusion ratio (C:tx), transfusion probability (%T), and transfusion index (TI) were calculated for each type of procedure. RESULTS: All 264 patients were crossmatched and 98 patients were transfused, resulting in an overall transfusion probability (%T) of 37.12% (95% confidence interval 31.52-43.09). A total of 1175 units of blood were crossmatched, but only 370 units of blood were transfused, resulting in a C:tx of 3.17 (95% confidence interval 2.61-4.03). The average number of units transfused per procedure (transfusion index) was 1.40. C:tx was highest and TI was lowest for CABG, where approximately 11 units of blood were ordered for every 1 unit transfused (C:tx =11.70 ± 3.04), and the TI was 0.32. CONCLUSIONS: Using the gold standard C:tx of >2:1 as an indicator of inappropriate blood utilization, our analysis confirmed that excessive crossmatching occurred for several procedures. Now a subset of cardiac surgical cases only requires a type and screen order prior to surgery.

Successful epidural blood patch after dural tear.

Current literature reports a 3.1% incidence of durotomy with spine surgery, and this number increases to 15.9% with revision spine surgery. With the use of a blood patch to treat a dural tear, the anesthesia team was able to prevent a second reoperation. This treatment option offers anesthesiologists the opportunity to minimize further patient harm and increased cost associated with dural tears.

Spinal cord ischemia resulting in paraplegia following extrapleural pneumonectomy.

A patient undergoing radical extrapleural pneumonectomy for epithelioid malignant mesothelioma developed acute paraplegia postoperatively related to long-segment spinal cord ischemia. The usual area of concern for this complication is the T9 to T12 area where the artery of Adamkiewicz is most likely to originate. In this patient, there was ligation of only upper thoracic, ipsilateral segmental arteries from the T3 to T6 level, yet he still developed paraplegia. Our hypothesis is variant mid-thoracic vascular anatomy. Previously unreported, to our knowledge, this should be understood as a rare complication of this surgery.