Seminars in Cardiothoracic and Vascular Anesthesia最新文献

Introduction: Serum albumin's association with liver transplant outcomes has been investigated with mixed findings. This study aimed to evaluate perioperative albumin level, independently and as part of the albumin-bilirubin (ALBI) grade, as a predictor of post-liver transplant hospital and intensive care unit (ICU) length of stay (LOS).

Methods: Adult liver-only transplant recipients at our institution from September 2011 to May 2019 were included in this retrospective study. Repeat transplants were excluded. Demographic, laboratory, and hospital course data were extracted from an institutional data warehouse. Negative binomial regression was used to assess the association of LOS with ALBI grade, age, BMI, ASA score, Elixhauser comorbidity index, MELD-Na, warm ischemia time, units of platelets and cryoprecipitate transfused, and preoperative serum albumin.

Results: Six hundred and sixty-three liver transplant recipients met inclusion criteria. The median preoperative serum albumin was 3.1 [2.6-3.6] g/dL. The median postoperative ICU and hospital LOS were 3.8 [2.4-6.8] and 12 [8-20] days, respectively. Preoperative serum albumin predicted hospital but not ICU LOS (ratio .9 [95% confidence interval (CI) .84-.99], P = .03, hospital LOS vs ratio .92 [95% CI 0.84-1.02], P = .10, ICU LOS). For patients with MELD-Na ≤ 20, ALBI grade-3 predicted longer hospital and ICU LOS (ratio 1.40 [95% CI 1.18-1.66], P < .001, hospital LOS vs ratio 1.62 [95% CI 1.32-1.99], P < .001, ICU LOS). These associations were not significant for patients with MELD-Na > 20.

Conclusions: Serum albumin predicted post-liver transplant hospital LOS. ALBI grade-3 predicted increased hospital and ICU LOS in low MELD-Na recipients.

Introduction. Thoracic interfascial plane blocks are increasingly used for pain management after minimally invasive thoracotomy for valve repair and replacement procedures. We hypothesized that the addition of these blocks to the intercostal nerve block injected by the surgeon would further reduce pain scores and opioid utilization. Methods. In this retrospective cohort study, 400 consecutive patients who underwent minimally invasive thoracotomy for mitral or aortic valve replacement and were extubated within 2 hours of surgery were enrolled. The maximum pain score and opioid utilization on the day of surgery and other outcome variables were compared between patients who received interfascial plane blocks and those who did not. Results.193 (48%) received at least one interfascial plane block while 207 (52%) received no interfascial plane block. Patients who received a thoracic interfascial plane block had a maximum VAS score on the day of surgery (mean 7.4 ± 2.5) after the block was administered which was significantly lower than patients in the control group who did not receive the block (mean 7.9 ± 2.2) (P = .02). Opioid consumption in the interfascial plane block group on the day of surgery was not significantly different from the control group. Conclusion. Compared to intercostal blocks alone, the addition of thoracic interfascial plane blocks was associated with a modest reduction in maximum VAS score on the day of surgery. However, no difference in opioid consumption was noted. Patients who received interfascial plane blocks also had decreased blood transfusion requirements and a shorter hospital length of stay.

Neurocognitive changes are the most common complication after cardiac surgery, ranging from acute postoperative delirium to prolonged postoperative neurocognitive disorder. Changes in cognition are distressing to patients and families and associated with worse outcomes overall. This review outlines definitions and diagnostic criteria, risk factors for, and mechanisms of Perioperative Neurocognitive Disorders and offers strategies for preoperative screening and perioperative prevention and management of neurocognitive complications.

Central airway obstruction due to tracheal tumors presents unique challenges to the anesthesiologist. We present the case of a 44-year-old male taken to the OR for biopsy and resection of an undiagnosed tracheal mass. Intraoperative management was complicated by bleeding and significant hemodynamic instability, necessitating rapid surgical and anesthetic intervention. This ultimately led to abortion of surgical resection. Pathologic examination revealed a primary tracheal plasmacytoma, a rare type of tracheal tumor. Here, we describe anesthetic and hemodynamic considerations for a tracheal plasmacytoma. We discuss the approach to airway management in variable intrathoracic tracheal obstruction and the unpredictability of tracheal tumors.

Lung transplantation (LTx) historically was performed with cardiopulmonary bypass (CPB) or Off-pump. Recent data suggest an increased interest in extracorporeal membrane oxygenation (ECMO) as perioperative circulatory support by many lung transplantation centers worldwide. However, there are no established guidelines for anesthetic management for LTx. We present a patient with a history of systemic sclerosis and interstitial lung disease complicated by acute onset of systemic pulmonary hypertension and right heart failure undergoing LTx. We aim to discuss perioperative circulatory support, including ECMO bridge to LTx, and how best to consider the varied intraoperative strategies of CPB vs ECMO vs off-pump during LTx, intraoperative maintenance, and coagulation management.

Preoperative cardiac evaluation is a cornerstone of the practice of anesthesiology. This consists of a thorough history and physical attempting to elucidate signs and symptoms of heart failure, angina or anginal equivalents, and valvular heart disease. Current guidelines rarely recommend preoperative echocardiography in the setting of an adequate functional capacity. Many patients may have poor functional capacity and/or have medical history such that echocardiographic data is available for review. Much focus is often placed on evaluating major valvular abnormalities and systolic function as measured by ejection fraction, but a key impactful component is often overlooked-diastolic function. A diagnosis of diastolic heart failure is an independent predictor of mortality and is not uncommon in patients with normal systolic function. This narrative review addresses the clinical relevance and management of diastolic dysfunction in the perioperative setting.

The management of children with a borderline ventricle has been debated for many years. The pursuit of a biventricular repair in these children aims to avoid the long-term sequelae of single ventricle palliation. There is a lack of anesthesia literature relating to the care of this complex heterogenous patient population. Anesthesiologists caring for these patients should have an understanding on the many different forms of physiology and the impact on provision of anesthesia and hemodynamic parameters, the goals of biventricular staging and completion as well as the pre-operative, intra-operative, and post-operative considerations relating to this high-risk group of patients.

Transesophageal echocardiography (TEE) for liver transplant has historically been avoided due to concern it may cause bleeding from esophageal varices. However, several recent studies, as well as increasing clinical experience, have indicated that it may be safe in many circumstances. We performed a systematic review of the literature to identify and summarize studies reporting complications in patients having TEE during liver transplant. Studies were identified by searching relevant key terms on PubMed as well as citation searching in relevant reviews. We identified 6 studies between 1996 and 2015 which evaluated complications of TEE during liver transplant. They reported an overall bleeding complication rate between .3% and 2.8% and a major bleeding complication rate between .0% and .8%. Most of the major bleeds had identifiable high-risk features such as recent variceal bleeding or banding. Review of the literature suggests that TEE may be safely used in patients undergoing liver transplantation, even with known varices, with a complication rate similar to that of all patients undergoing TEE. However, the risks of TEE may outweigh the potential benefits among patients undergoing liver transplant with particular high-risk features.

Background. Intubations, especially in emergent settings, carry a high risk of hemodynamic instability with potentially catastrophic outcomes. Weight-based dosing of induction drugs can be inappropriately high for elective or emergent intubations and lead to hemodynamic instability. We hypothesized that monitoring the patient state index of SEDLine monitors (Masimo, Irvine, CA) would decrease the dose of induction drugs in the operating room during elective intubations.Methods. In this randomized study, SEDLine monitoring was provided to the intervention group but not to the control group during the induction of anesthesia in the operating room. Anesthesia providers in the intervention group were advised to titrate induction drugs to a Patient State Index of <50 before proceeding with intubation. The primary outcome was the induction dose of propofol and etomidate per kilogram normalized to propofol dose equivalents. Secondary outcomes included supplemental doses of ketamine, midazolam, fentanyl, phenylephrine, and ephedrine per kg, time from induction to intubation, administration of additional propofol or vasopressors after induction, mean arterial pressure ≥ or <65 mmHg, and lowest mean arterial pressure post-induction.Results. We found no significant difference in propofol equivalents between groups (P = .41). Using a SEDLine decreased the odds that a patient would require vasopressors during induction (odds ratio of .39 [95% confidence interval, .15-.98]).Conclusion. SEDLine monitoring during induction did not decrease dosing of the induction drugs etomidate and propofol but decreased the odds of receiving vasopressors. Further studies are warranted to assess the utility of processed electroencephalography in emergent intubations outside of the operating room.