Annals of Cardiac Anaesthesia最新文献

Introduction: Effective pain management during paediatric cardiac surgery is essential to prevent complications such as metabolic, neuroendocrine, and immunological disturbances. Thoracic epidural anesthesia (TEA) offers significant benefits in terms of pain relief and postoperative recovery. However, its application in children is challenging due to the risk of dural puncture and nerve injury. This study compares the efficacy of two techniques: direct thoracic space insertion and caudal-to-thoracic space catheter placement for TEA in pediatric cardiac surgery.

Materials and methods: This prospective, randomized study was conducted at a tertiary center with 40 children undergoing elective cardiac surgery. Participants were randomized into two groups: Group A (Direct Thoracic Space) and Group B (Caudal-to-Thoracic Space). Epidural catheter insertion was followed by a bolus of bupivacaine and morphine, and continuous infusion for postoperative pain control. Hemodynamic parameters, Face, Legs, Activity, Cry, Consolability (FLACC) scores for pain, and analgesic requirements were monitored.

Results: Both groups exhibited similar hemodynamic responses, with statistically significant differences in systolic blood pressure at 60 and 72 h (P < 0.05) favoring the Direct Thoracic group. Postoperative pain control, assessed using FLACC scores, was marginally better in Group A, but differences were not statistically significant. No major complications were observed.

Discussion: While both methods provided comparable analgesia and hemodynamic stability, the direct thoracic approach was slightly more effective in pain management. The caudal to thoracic method remains technically simpler and more accessible, making it a viable alternative.

Conclusion: Both techniques provide effective analgesia, with no major complications. The caudal to thoracic approach offers a safer, simpler alternative to direct thoracic catheter placement in pediatric cardiac surgery.

End-stage heart failure remains without a definitive solution other than transplantation, despite significant medical and technological advancements. This chapter delves into the preoperative evaluation of this complex patient group, offering practical and individualized approaches to clinical management. It outlines personalized anesthetic strategies and transesophageal echocardiography (TEE) techniques that have revolutionized intraoperative management and surgical outcomes across various procedures in real time. The chapter integrates best practice recommendations and guidelines from leading medical and scientific societies in heart failure, cardiovascular anesthesia, cardiothoracic surgery, and echocardiography. Topics covered include perioperative evaluation of patients with end-stage heart failure, understanding and managing their clinical condition before undergoing surgery or complex procedures, anesthetic plans, and intraoperative echocardiography protocols tailored to the type of intervention and patient pathophysiology, as well as alternative procedures for managing end-stage heart failure. This review is particularly valuable for cardiovascular anesthesiologists and surgeons working in resource-limited settings, where access to advanced techniques, procedures, and technologies is not always available to address the medical and surgical challenges of these patients.

Point-of-care ultrasound (POCUS) plays an integral role in diagnosing and optimizing the care of patients in a wide variety of clinical settings, ranging from the operating room to the intensive care unit, emergency department, and office-based practices. Low-cost handheld ultrasound systems that connect to mobile phones or tablets have become widely available and are being used by clinicians at the bedside to complement their physical exam and guide their decision making. The capabilities of these portable ultrasound systems have evolved over time, including implementation of biplane imaging (also referred to as X-plane imaging), that allows simultaneous imaging the heart in two orthogonal planes. This "GPS of cardiac imaging" was previously only available for needle guidance and vascular access. We detail the first reported use of biplane imaging for cardiac imaging using an inexpensive portable ultrasound probe based on advanced semiconductor technology (also known as "ultrasound on a chip") in a healthy volunteer for demonstrative purposes and describe its potential clinical applications.

Abstract: Complex aortic aneurysms, including thoracoabdominal, juxtarenal, and pararenal aneurysms, pose significant challenges due to their involvement with vital branch vessels. Fenestrated endografts have emerged as a promising alternative to traditional open surgery. These devices are available in two types: custom-made and off-the-shelf. Custom fenestrated endografts are tailored to individual anatomy, offering precision but requiring longer preparation times and higher costs. Off-the-shelf fenestrated endografts provide a standardized approach with shorter deployment times and lower costs but may not suit highly complex cases. The aim of this review is to assess the role of custom and off-the-shelf fenestrated endografts in treating complex aortic aneurysms, focusing on clinical outcomes, complications, cost-effectiveness, and advancements in technology. We conducted a systematic search of PubMed, Scopus, and Google Scholar for studies published between 2000 and 2024 using keywords such as "complex aortic aneurysms," "fenestrated endograft," "custom endograft," and "off-the-shelf endograft." Data on outcomes, complications, and technological advancements were extracted and analyzed. This review seeks to provide insights into the advantages and challenges of both approaches, guiding clinicians in optimizing treatment strategies for complex aortic aneurysm patients.

Introduction: Robotic-assisted thoracic surgery (RATS), due to its multiple advantages, has revolutionized the medical field in recent years. Yet, its implementation has been slower compared to other surgical fields. More data on the benefits of RATS regarding patient outcomes are required to justify the high costs of equipment. This study aimed to expand our understanding of anesthetic management of RATS and to analyze the postoperative patient outcomes.

Materials and methods: The r-retrospective descriptive study of the clinical history of 50 patients who underwent RATS using Da Vinci dVX® between 2018 and 2021 in the Thoracic Surgery Department of a single-center university teaching hospital. Statistical analyses of the clinical-demographic variables and those related to airway management, mechanical ventilation, intraoperative hemodynamics, and postoperative outcomes were carried out. Subgroup analysis of patient cases was performed based on the date of surgical intervention to compare the operating time, length of hospital stay, and postoperative complications as surrogates of the learning curve.

Results: 92% of patients were easily intubated with double-lumen tubes (76% were VivaSight-DL and 12% standard double-lumen tubes) following the usual protocol, while in 8% of patients, a difficult airway was detected and lung isolation using bronchial blockers was performed. During the one-lung ventilation (OLV) period, 24.4% of patients suffered arterial hypotension and 19.5% required intravenous vasoconstrictors probably due to the capnothorax. The mean duration of the interventions was 135.4 minutes. The average hospital stay was 5.4 days on average, and the mean number of complications was 0.48% per person. No statistically significant difference was found between early and late patient subgroups in terms of operating time, length of hospital stay, and postoperative complications.

Conclusions: RATS is a safe intervention which is well managed anesthetically by the use of double-lumen tubes with embedded camera. The use of protective ventilation strategy, including optimal PEEP and lung recruitment maneuver, during one-lung ventilation is effective and hemodynamically well-tolerated in the majority of the patients (80%). The RATS approach is associated with short hospital stay and low postoperative complication incidence. Further studies are warranted to explore new anesthetic management techniques and compare the benefit of robot-assisted thoracic surgery with conventional surgical approaches.

Abstract: WATCHMAN (Boston Scientific, Plymouth, MN, USA) is the most commonly utilized left atrial appendage occlusion device. Although increased operator experience has led to a significant decline in reported complications, serious and potentially fatal events can still occur. We present a case of WATCHMAN device embolization that was identified using transesophageal echocardiography shortly after device deployment, along with the subsequent management and retrieval of the device.