Anaesthesia and Intensive Care Medicine最新文献

Transplantation is a definitive treatment of choice in suitable patients with end-stage organ failure. Approximately 5000 heart transplants and 4000 lung transplants are performed globally every year. Survival after heart transplant is almost twice in comparison to lung transplant. Due to deficiency in donor pool, number of patients on waiting list are increasing every year. Recipient selection should be done carefully as it massively impacts the outcome. Anaesthesia management for heart and lung transplant is quite demanding. In this article, we will review the various challenges encountered by an anaesthetist during the pre-, intra-, and postoperative period. The postoperative complications and its management will also be discussed briefly.

Off-pump coronary artery bypass grafting (OPCABG) surgery allows surgical revascularization of the heart whilst avoiding the inherent risks of cardiopulmonary bypass (CPB). Advances in technologies and techniques have improved operating conditions and have led to an increase in popularity of OPCABG. However, surgical manipulation of a beating heart and clamping of perfusing coronary arteries can cause significant haemodynamic consequences which must be anticipated and carefully managed. The anaesthetist must therefore assimilate information from multiple sources and remain vigilant to any changes intraoperatively.

Postoperative care of the cardiac surgical patient requires a multidisciplinary approach. A brief period of sedation and ventilation is followed by protocol-guided recovery with some patients going on to require more complex care. Specific complications need to be recognized and managed, including bleeding, cardiac tamponade, arrhythmias, renal failure and gastrointestinal complications. Prompt diagnosis and treatment can be life saving and requires effective communication and teamwork. An array of bedside tests is available to aid decision-making, including point of care coagulation tests, lung ultrasound and echocardiography. Advanced life support necessitates a unique approach requiring the provision of resuscitation and anaesthesia for prompt surgical re-exploration. Pharmacological and mechanical assistance is readily available to treat cardiovascular instability as well as the ability for invasive cardiac output monitoring. Analgesia is an important aspect of postoperative care as well as active recognition of delirium.

Continued advances in the understanding and management of congenital heart disease (CHD) mean that over 90% of children born with CHD now survive to adulthood. This in turn results in greater numbers of adult patients presenting for medical and surgical care at non-specialist centres. A simple classification of adult congenital heart disease (ACHD) according to complexity can help clinicians to understand the implications of the specific cardiac anomaly encountered. Issues relating to the conduct of anaesthesia in ACHD patients include careful attention to euvolaemia, the preservation of sinus rhythm and cardiac output, and in complex patients, manipulating the balance between systemic and pulmonary blood flows. Additionally, effective antibiotic prophylaxis and the prevention of either excessive bleeding or thromboembolism are vitally important. It should not be forgotten that although many patients with simple or repaired cardiac lesions may be very well managed in a non-specialist unit, those with Eisenmenger’s syndrome or severe pulmonary hypertension have an extremely high risk of death in the perioperative period, and in all but life-threatening situations should always be managed within specialist centres.

Anaesthetists play a key role in the management of patients in the cardiac catheterization laboratory (cath lab), both for elective and emergency procedures. Safe and effective provision of anaesthesia relies on a thorough appreciation of the setup of the cath lab and an understanding of the ever-increasing range of procedures carried out in the angiography suite. This article provides an overview of general considerations for working in this challenging environment within the hospital, as well as outlining key cardiology subspecialties and their requisites for the anaesthetist: electrophysiology, structural, interventional, devices and mechanical circulatory support.

Hybrid approaches involving staged open surgical and percutaneous endovascular procedures are rapidly emerging in the panorama of major aortic disease. The most recent guidelines support progressive expansion and adoption of this approach especially for patients who might not tolerate major aortic surgery.

The multidisciplinary context in which these hybrid procedures arise require more comprehensive and integrated anaesthesiology involvement in the in their planning and execution.

This review will summarize the key concepts in aortic disease management, the current status of hybrid aortic procedures and focus on the anaesthetic management of thoracic aortic endovascular and hybrid procedures. As utilization of endovascular arch stents is expected to rise, it is crucial that cardiac anaesthesiologists are familiar with their inherent complexities, anaesthetic considerations, and potential complications.

The electrocardiogram (ECG) is an integral part of the diagnostic process for a wide variety of cardiac conditions. It consists of six limb and six precordial leads which record the electrical activity of the heart in the frontal and horizontal planes respectively. The standard ECG waves include the P wave which represents atrial depolarization, the QRS complex generated by depolarization of the ventricular myocardium and the T wave which reflects ventricular repolarization. According to the site of origin, cardiac arrhythmias can be classified as supraventricular or ventricular tachycardias. The most common supraventricular tachycardias are sinus tachycardia, atrial tachycardia, atrioventricular nodal re-entrant tachycardia, atrioventricular re-entrant tachycardia, atrial flutter and atrial fibrillation. Ventricular tachycardias originate in the ventricles and can be potentially life-threatening.

The purpose of cardiopulmonary bypass is to maintain perfusion and oxygenation of the vital organs in the absence of heart and lung function, usually to facilitate surgery on the heart, but occasionally in other situations. Although the intricacies of the modern extracorporeal circuit and the conduct of cardiopulmonary bypass are the domain of the clinical perfusion scientist (‘perfusionist’), safe surgery mandates a good understanding of some fundamentals by the anaesthetist and the surgeon. This review is aimed at the anaesthetist. First, we will systematically examine the main components of the extracorporeal circuit, travelling in the direction that blood travels, from the venous cannula to the arterial cannula. Then we will describe the process of preparing for bypass, ‘going on’, conducting a bypass run, and weaning and separation from bypass. It is crucial to have clear communication between the surgeon, perfusionist and anaesthetist. This can be difficult for the novice because a quite specific language has evolved in cardiac operating theatres to signal key events in the cardiopulmonary bypass sequence. As we go through this article, we will highlight commonly used terminology and expressions used.