Genetics of coagulation: considerations for cardiac surgery

Genetic variants in the coagulation system have been known since antiquity. Today, because of modern improvements in diagnosis and medical management, the clinician is likely to encounter a spectrum of coagulation factor deficiencies and identified polymorphic variants in the surgical population. Because perioperative hemorrhagic and thrombotic complications are potentially serious, it is important to understand the role that these defects and variants may play in predicting risk and optimizing patient management. The implications of coagulation genetics on the perioperative management of the cardiac surgery patient are reviewed.     

Intraoperative considerations during minimal-access cardiac surgery.

The range of minimal-access cardiac surgery approaches has many implications in intraoperative management. A modified anesthetic regimen is required to deal with the type of surgical exposure, hemodynamic instability, whether cardiopulmonary bypass is used, and early extubation. Intraoperative considerations include hemodynamic monitoring, one-lung ventilation, pharmacological stabilization of the myocardium, pacing, hypothermia, bleeding, and rapid emergence with a minimum of postoperative mechanical ventilation. As a result, anesthetic methods and intraoperative management were modified to meet these specific needs of minimally invasive cardiac procedures.     

Robotic-assisted cardiac surgery: anesthetic and postoperative considerations

OBJECTIVE: To assess the feasibility of endoscopic telemanipulated cardiac surgery and describe the anesthetic, postoperative, and surgical implications of minimally invasive robotic-assisted cardiac surgery. DESIGN: Prospective study. SETTING: Cardiovascular and transplant center, university hospital. PARTICIPANTS: Twenty patients (13 men, 7 women) scheduled for either coronary artery bypass graft surgery or valve surgery. Mean age was 53 +/- 5 years (range, 31 to 75 years) and mean New York Heart Association class was 2.4. Three patients (6 %) were having redo procedures, and 1 patient had bacterial endocarditis. INTERVENTIONS: Surgery was done with the aid of the daVinci surgical robot (Intuitive Surgical, Mountain View, CA). Induction and maintenance of anesthesia consisted of a target-controlled infusion of remifentanil and propofol. In 11 cases (55%), cardiopulmonary bypass was performed with Port-Access technology (Heartport, Redwood City, CA), and in the remaining 9 cases (45%), conventional femorofemoral bypass was used. MEASUREMENTS AND MAIN RESULTS: Fifteen patients (75 %) were extubated within 6 hours and discharged from the cardiac surgery intensive care unit on postoperative day 1. Two patients (10%) were reexplored in the immediate postoperative period. Two conversions to thoracotomy were reported. One reoperation at 6 months and 1 late death occurred. At 1-year follow-up, excellent functional results were observed in 18 cases. CONCLUSION: Caution should be used when assessing innovative medical-surgical techniques. Despite technical difficulties and lengthy procedures, results were satisfactory. The feasibility of robotic-assisted surgery for coronary artery bypass graft and valve procedures is intuitively appealing.     

Unique considerations for the spinal cord injured patient undergoing cardiac surgery utilizing cardiopulmonary bypass

A 37-year-old male with mitral valve regurgitation presented for mitral valve replacement. He has been a C5 quadriplegic for 13 years. The patient had been discharged 2 months before to this admission after a complicated hospital course for Staphylococcus aureus infection of the left hip. His course was complicated by adult respiratory distress syndrome (ARDS) requiring prolonged intubation, acute renal failure (ARF) requiring dialysis, 10-day coma, and bacterial endocarditis now requiring mitral valve replacement. After initial stabilization with antibiotics and gradual improvement of the multiorgan system failure, the patient presented for valve replacement and worsening congestive heart failure (CHF). Para- and quadriplegic patients rarely undergo cardiac surgery requiring cardiopulmonary bypass (CPB). The explanation for this low incidence of heart surgery in this patient population ranges from physiologic changes from the spinal cord injury to their relatively short life span. Therefore, there is no vast knowledge of how these patients with spinal cord injury will physiologically respond to CPB. Chronic paraplegia presents unique anesthetic and perfusion challenges. General anesthesia for a patient with prolonged spinal cord damage can be difficult because of dysreflexia, muscle wasting, and potassium changes with depolarizing muscle relaxants. For the perfusionist, chronic paraplegia also accentuates hemodynamic responses to nonpulsatile flow with low peripheral vascular resistance common and difficult to treat. Dramatic increases in circulating catecholamine levels are a secondary result of the initiation of CPB that can cause a hypo- and hypertensive state. Depending on the level of spinal cord injury, one might expect acute hypo- or hypertension with the various phases of open-heart surgery and CPB. A viscous circle may occur because the hypertensive state is exaggerated because of inhibitory signals not passed below the spinal cord lesion and, therefore, the vasoconstrictive reflex continues unabated. The attack usually occurs abruptly and can lead to cerebrovascular hemorrhage and death if not controlled. Fortunately, we found this patient did not develop mass autonomic dysreflexia and was not difficult to wean from CPB. The problems associated with spinal cord injury present potential complications to this patient population. Numerous triggering mechanisms may lead to a variety of clinical complications. Consideration of a response/ treatment management plan for potential problems must be exercised by the surgical team.     

Anaesthetic considerations for hysteroscopic surgery

Use of the hysteroscope in modern gynaecological practice continues to develop as a diagnostic and management tool for intrauterine disease. Operative hysteroscopy (OH) is now an accepted alternative to hysterectomy for women with menorrhagia. The advantages of OH are associated with its short operating time, rapid post-operative recovery and low morbidity. However, there are concerns about the potential serious complications which can occur during and following OH, and it is important that both surgeons and anaesthetists are aware of these--especially as many procedures take place as day-cases. Much has been written in the urological literature concerning complications of endoscopic surgery. Information gathered from patients with post-transurethral resection of the prostate (TURP) syndrome has been useful in the treatment of gynaecology patients. However, the techniques used in TURP are not entirely comparable to hysteroscopic surgery as the uterus has a very thick wall, which requires higher distension pressures. The main complications of OH are fluid overload, hyponatraemia, hypo-osmolality, haemorrhage, uterine perforation and, rarely, gas or air embolism. Fluid overload with hyponatraemia and hypo-osmolality occurs in up to 6% of cases and it can be fatal. Therefore, all possible measures should be taken to prevent it or to detect it and treat it early. There are no controlled studies comparing different anaesthetic techniques for OH. Regional anaesthesia may offer an advantage over general anaesthesia because it enables early detection of fluid overload. Great care should be taken when positioning the patient to prevent peripheral neuropathy.     

Anesthetic considerations for pediatric podiatric surgery

The author reviews anesthetic considerations for the pediatric patient requiring foot and lower leg surgery. He initially describes the physiologic and psychologic differences from adults. Preoperative, intraoperative, and postoperative factors are then evaluated.     

Anesthetic considerations in surgery for gastrointestinal disease

We have attempted to present a brief overview of current considerations in anesthesia for surgery of gastrointestinal disease as practiced at our institution. Many considerations remain unexplored owing to limitations of space. We have deliberately concentrated upon antecedent and concurrent therapy encountered in the treatment of the surgical patient. The potent drugs introduced in the past decade have produced infinite potential for drug interactions--some serious, some not so serious, and some which are desirable. We hope we have generated further reader interest in this mushrooming problem of modern medicine confronting the anesthesiologist and surgeon in the perioperative period.     

Anaesthetic considerations for non-obstetric surgery during pregnancy

Surgery during pregnancy is complicated by the need to balance the requirements of two patients. Under usual circumstances, surgery is only conducted during pregnancy when it is absolutely necessary for the wellbeing of the mother, fetus, or both. Even so, the outcome is generally favourable for both the mother and the fetus. All general anaesthetic drugs cross the placenta and there is no optimal general anaesthetic technique. Neither is there convincing evidence that any particular anaesthetic drug is toxic in humans. There is weak evidence that nitrous oxide should be avoided in early pregnancy due to a potential association with pregnancy loss with high exposure. There is evidence in animal models that many general anaesthetic techniques cause inappropriate neuronal apoptosis and behavioural deficits in later life. It is not known whether these considerations affect the human fetus but studies are underway. Given the general considerations of avoiding fetal exposure to unnecessary medication and potential protection of the maternal airway, regional anaesthesia is usually preferred in pregnancy when it is practical for the medical and surgical condition. When surgery is indicated during pregnancy maintenance of maternal oxygenation, perfusion and homeostasis with the least extensive anaesthetic that is practical will assure the best outcome for the fetus.     

Anesthesia considerations for lung volume reduction surgery

Patient selection is of crucial importance for outcome after lung volume reduction surgery. The anesthesiologist should be involved actively in patient selection, because he or she is in charge of the treatment during the critical perioperative period. Patient history and status and results from chest radiographs, high-resolution CT scans, and catheterization of the right heart should be taken carefully into account in the patient selection process. Promising new results involving functional parameters may predict outcome objectively after lung volume reduction surgery in the future. Careful selection and preoperative preparation of patients also are important to avoid complications and keep the success rate high. The anesthesiologist's understanding of the principles involved is important for the successful conduct of lung volume reduction surgery. It is unclear if lung volume reduction surgery is superior to conventional therapy in the long run because the decline in lung function is progressive after the procedure. A multicenter trial comparing patients undergoing lung volume reduction surgery with patients with emphysema who are treated conventionally hopefully will clarify this important question in the future.     

Positioning considerations for lateral lumbar interbody surgery

Lateral Lumbar Interbody fusion has gained popularity as a minimally invasive approach to the thoracolumbar spine which provides indirect neurological decompression, increased fusion mass surface area, and provides coronal and sagittal plane correction of spinal deformity. The Lateral Lumbar Interbody Fusion is traditionally performed in the lateral decubitus position, however, concomitant pathologies in the spine often require ancillary procedures. The purpose of this paper is to describe standard Lateral Lumbar Interbody Fusion positioning considerations as well as to explore multi-position and single position surgeries when two separate approaches are required.     

机器人辅助心脏手术的麻醉

机器人辅助心脏手术本身的特点与要求,使其麻醉具有一定的特殊性。现将机器人辅助心脏手术的特点、麻醉方法及其麻醉管理要点作一介绍。