Anesthetic considerations in a patient with mitral valve disease for posterior fossa surgery

Mitral valve disease in patients undergoing posterior fossa surgery enhances the inherent risk of the procedure and can complicate the anesthetic management. A great challenge for the anesthesiologist is to choose the most appropriate perioperative technique that balances the specific anesthetic considerations of both the cardiac and the neurologic diseases. The authors describe the anesthetic management of a patient with a meningioma in the posterior fossa requiring craniectomy and tumor decompression. She was also diagnosed with severe mitral regurgitation and moderate mitral stenosis.     

Anesthetic considerations in myofibrillar myopathy

Myofibrillar myopathy (MFM) is a relatively newly recognized genetic disease that leads to progressive muscle deterioration. MFM has a varied phenotypic presentation and impacts cardiac, skeletal, and smooth muscles. Affected individuals are at increased risk of respiratory failure, significant cardiac conduction abnormalities, cardiomyopathy, and sudden cardiac death. In addition, significant skeletal muscle involvement is common, which may lead to contractures, respiratory insufficiency, and airway compromise as the disease progresses. This study is the first report of anesthetic management of a patient with MFM. We report multiple anesthetic encounters of a child with genetically confirmed BAG3‐myopathy, a subtype of MFM with severe childhood disease onset. A review of the anesthetic implications of the disease is provided, with specific exploration of possible susceptibility to malignant hyperthermia, rhabdomyolysis, and sensitivity to other anesthetic agents.     

Understanding cardiac shunts

Most patients with congenital heart disease have a cardiac shunt whose direction and magnitude can have a major impact on cardiorespiratory physiology and function. The dynamics of the shunt can be significantly altered by anesthetic management and must be understood in order to provide optimal anesthetic care. Given that there are now more adults than children with congenital heart disease and that the majority of nonpediatric patients are cared for in centers without special expertise in congenital heart disease, it is imperative that all anesthesia providers have a general understanding of the subject. This educational review describes a technique to explain this complex subject using simple pictorial diagrams.     

Combined spinal epidural anesthesia with epidural volume extension technique for hysterectomy in patient with unpalliated cyanotic heart disease--a case-report

Adults with unrepaired cyanotic heart disease scheduled for a non-cardiac surgery present serious concerns for the anesthesiologists. Both general and regional anesthetic techniques have been safely reported in Eisenmenger's syndrome and adults with Tetralogy of Fallot (TOF) for non-cardiac surgery. The safety of low-dose sequential combined spinal epidural (CSE) technique in high-risk cardiac cases has recently been emphasized in obstetric anesthetic practice but to our knowledge, this technique has not been reported for hysterectomy in cyanotic heart disease patients in anesthetic literature. We report the successful management of hysterectomy in a patient with ventricular septal defect and pulmonary atresia (VSD-PA) using CSE anesthesia with epidural volume extension (EVE) technique.     

Children with heart disease: Risk stratification for non-cardiac surgery

Study objectiveChildren with congenital or acquired heart disease have an increased risk of anesthesia related morbidity and mortality. The child's anesthetic risk is related to the severity of their underlying cardiac disease, associated comorbidities, and surgical procedure. The goal of this project was to determine the ease of use of a preoperative risk stratification tool for assigning pediatric cardiac staff and to determine the relative frequency that children with low, moderate, and high risk cardiac disease present for non-cardiac surgery at a tertiary pediatric hospital.DesignA risk-stratification tool was prospectively applied to children with congenital heart disease who presented for non-cardiac surgery.SettingPerioperative.PatientsWe identified a subset of 100 children with congenital heart disease out of 2200 children who required general anesthesia for surgical or radiological procedures over a 6 week period.InterventionsA risk stratification tool was utilized to place the patient into low, moderate, or high risk categories to help predict anticipated anesthetic risk. Each grouping specified assignment of staff caring for the patient, clarified preoperative expectations for cardiac assessment, and determined if patient care could be performed at our freestanding ambulatory surgical center.MeasurementsElectronic perioperative records were reviewed to obtain demographic information, the underlying heart disease, prior cardiac surgery, associated conditions, anesthetic management, complications, and provider type.Main resultsApproximately 4.5% of children presented with cardiac disease over a 6 week period. In 100 consecutive children with cardiac disease, 23 of the children were classified as low risk, 66 patients were classified as moderate risk, and 11 of the patients were classified as high risk. Pediatric cardiac anesthesiologists provided care to all high risk patients. There were no serious adverse events.ConclusionsWe found this risk stratification method an effective method to differentiate children into low, moderate, and high risk categories for anesthesia planning and management.     

Manejo anestésico en neurocirugía de paciente con síndrome de Eisenmenger y síndrome de Down. Reporte de un caso

Adults patients with congenital heart disease increasingly present for non cardiac surgery. The anesthetic management this type of patients in neurosurgery requires a meticulous surgical anesthetic planning. The need for urgent intervention, with the presence of a congenital heart disease evolved to Eisenmenger Syndrome, associated to a difficult airway, is a challenge for the anesthesiologist. The use of dexmedetomidine may be a valid alternative. We present the case of a patient with Down syndrome, and Eisenmenger syndrome who underwent drainage of brain abscess from the emergency department and was subsequently scheduled for reintervention. We compare the different anesthetic techniques used in both procedures, analyzing the implications they had on the main physiopathological alterations presented by the patient.     

Anesthetic management for patients with compromised left ventricular function due to coronary artery disease in non-cardiac surgery

BACKGROUND : As the number of patients suffering from coronary artery disease (CAD) increases, anesthetic management for these patients become more common than the past. But no established management strategies have been proven beneficial. METHODS : We reviewed all anesthetic management records of seven patients with compromised LV function (EF<30% or FS<30%) for CAD in our hospital, who had undergone non-cardiac operations. RESULTS : Three cases were brain surgeries and four cases were abdominal surgeries. In all cases, central venous catheters were placed before induction of general anesthesia. After inotropic agents were started through central venous catheters, patients went through induction with midazolam, fentanyl and propofol without any trouble. In three cases of abdominal surgeries, pulmonary artery catheters were placed. And in five cases, artery catheters were placed in the femoral arteries, so that, in case of cardiac shock, we could start IABP without delay. In one case, we experienced shock during operation, but without IABP, the patient recovered with pharmacological support. No patient died of cardiac cause during the hospital stay for the procedure. CONCLUSIONS : We reported anesthetic management of seven patients with compromised left ventricular function for CAD in non-cardiac surgery. However, as the reports of anesthetic management in patients with compromised left ventricular function in non-cardiac surgery is few, further study will be required.     

Manejo anestésico de neonatos submetidos a cateterismo cardíaco diagnóstico e terapêutico: uma revisão sistemática da literatura

BackgroundSeveral interventional cardiology procedures are required in neonates with congenital heart disease. Interventional cardiology procedures have a higher risk of cardiac arrest compared to other interventions. At present, there is great heterogeneity in the perioperative management of congenital heart disease neonates undergoing diagnostic cardiac catheterization or therapeutic cardiac catheterization.Study objectivesPrimary aim: Provide a systematic review of the most effective and/or safe anesthetic and perioperative management in neonates with congenital heart disease who undergo diagnostic cardiac catheterization or therapeutic cardiac catheterization. Secondary aim: Identify the medications, monitoring parameters and airway management used in the same population.DesignSystematic literature review.SettingCatheterization laboratory.MethodsLiterature was searched (December 2017) in electronic databases Medline, EMBASE, ScienceDirect, BIREME‐Lilacs‐Biblioteca Virtual de la Salud, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects and Health Technology Assessment Database.Main resultsFrom 130 records identified, four studies met inclusion criteria and quality assessment. None of the studies were relevant to the primary objective. Regarding the secondary objectives, one study compared the efficacy and adverse effects of racemic ketamine and its S(+) ketamine enantiomer, one study reported the efficacy of subarachnoid anesthesia for high‐risk children undergoing diagnostic cardiac catheterization, one study identified the factors associated to high severity adverse events related to sedation, anesthesia and airway, and one study retrospectively analyzed cardiac catheterization procedures in neonates weighing less than 2.5 kg.ConclusionThere are no evidence‐based recommendations available for congenital heart disease neonates undergoing cardiac catheterization. More studies are required to evaluate the ideal anesthetic and perioperative management in this population.     

Anesthesia for patients with congenital long QT syndrome

Long QT syndrome is a malfunction of cardiac ion channels resulting in impaired ventricular repolarization that can lead to a characteristic polymorphic ventricular tachycardia known as torsades de pointes. Stressors, by increasing sympathetic tone, and drugs can provoke torsade de pointes, leading to syncope, seizures, or sudden cardiac death in these patients. Beta blockade, implantation of cardioverter defibrillators, and left cardiac sympathetic denervation are used in the treatment of these patients. However, these treatment modalities do not guarantee the prevention of sudden cardiac death. Certain drugs, including anesthetic agents, are known to contribute to QT prolongation. After reviewing the literature the authors give recommendations for the anesthetic management of these patients in the perioperative period.     

Cardiac arrest at induction of anesthesia in a child with undiagnosed right-ventricular dependent coronary circulation: a case report

Pediatric perioperative cardiac arrest occurs in 1.4 per 10,000 anesthetics, with an overall mortality rate of 26%. The etiology of the arrest is identifiable in the majority of these patients. We report the case of a child with a complex congenital heart defect, who sustained a cardiac arrest at induction of anesthesia, secondary to right-ventricular dependent coronary circulation. We discuss the incidence, risks, anesthetic management and outcomes of pediatric cardiac arrest in the perioperative period especially in patients with complex congenital heart disease.     

Successful anesthetic management of three patients with cardiac dysfunction for non-cardiac surgery using olprinone hydrochloride

Non-cardiac surgery presents significant risks to patients with cardiac dysfunction. The relative safety of different anesthetic techniques has been studied without mentioning any clear indication. The depression of myocardial contractility by anesthetic agents limits their use in patients with cardiac dysfunction, especially for induction of anesthesia. We used olprinone hydrochloride perioperatively in the anesthetic management of three patients. In all cases, anesthetic induction, intraoperative course and the postoperative period proceeded uneventfully. We consider that perioperative use of continuous olprinone hydrochloride infusion may be suitable for patients with cardiac dysfunction for non-cardiac surgery.     

Postural orthostatic tachycardia syndrome: anesthetic implications in the obstetric patient

We report the anesthetic management of a parturient with postural orthostatic tachycardia syndrome. This syndrome is associated with hemodynamic instability, which can be worsened by the physiology of labor and delivery. We discuss anesthetic concerns with this disease in the parturient and suggest approaches for management of this disease.     

直立性心动过速综合征：产科麻醉处理的思考

我们报道一例患有直立性心动过速综合征产妇的麻醉处理，这种综合征表现为血流动力学不稳定，并可能随产程及分娩生理的变化而恶化。我们讨论对患有此类疾病产妇的麻醉相关问题，并提出麻醉处理的方法。     

Anesthesia and postoperative care for cardiac operations.

Almost three decades have passed since the establishment of open-heart surgery, and in such a short life span the specialty has established itself scientifically and reached a certain maturity. New techniques, better understanding of the pathophysiology of cardiac problems, and the effective use of new drugs constantly improve the results of operation. Greater experience in anesthetic management and improved postoperative care will contribute much to the success of this youngest surgical specialty. This review outlines the current principles of anesthesia and postoperative care of patients undergoing cardiac operations. Preanesthetic evaluation provides guidance for anesthetic management, supportive techniques, and postoperative care. During operations, light anesthesia is usually sufficient for patients with cardiac disease and minimizes myocardial depression. Monitoring must provide data on the physiological changes that are taking place from moment to moment during and after operations. Perfusion produces a highly abnormal state, and the severity of complications varies with its duration. Introduction of new drugs has also facilitated hemodynamic management during and after operations. Postoperative care is based on careful observation of the patient and early detection of trends, both of which lead to preventive rather than curative treatment wheneven possible.     

Anesthesia and cardiac electrophysiology (Part I)

Cardiac arrhythmias are a common complication of surgery and anesthesia. They are more likely to occur in patients with heart disease and the presence of a transitory imbalance can supply the underlying substrate for reentry, triggered activity, or abnormal automaticity. The physiologic impact of a given arrhythmia depends on its duration, on ventricular response, and on the underlying cardiac disease. Optimal management of arrhythmias in the anesthetized patient will depend on knowledge of the trigger mechanisms, the effects of anesthetic drugs on cardiac electrophysiology, and situations that favor arrhythmias. The anesthesiologist must cope with a plethora of problems related to the patient's clinical state and the trauma of surgical manipulation. Experience with electrocardiography and the application of various devices (pacemakers, cardioverters, implantable defibrillators) and knowledge of the pharmacodynamics and pharmacokinetics of new intravenous drugs will be essential for patient management. The purpose of the present review is to provide the anesthesiologist with an overview of current views on the diagnosis and management of arrhythmias during anesthesia.     

Cardiac anesthesia and surgery in geriatric patients

The average age of US population is steadily increasing, with more than 15 million people aged 80 and older. Coronary artery disease and degenerative cardiovascular diseases are particularly prevalent in this population. Consequently, an increasing number of elderly patients are referred for surgical intervention. Advanced age is associated with decreased physiologic reserve and significant comorbidity. Thorough preoperative assessment, identification of the risk factors for perioperative morbidity and mortality, and optimal preparation are critical in these patients. Age-related changes in comorbidities and altered pharmacokinetics and pharmacodynamics impacts anesthetic management, perioperative monitoring, postoperative care, and outcome. This article updates the age-related changes in organ subsystems relevant to cardiac anesthesia, perioperative issues, and intraoperative management. Early and late operative outcome in octogenarians undergoing cardiac surgery are reviewed. The data clearly indicate that no patient group is "too old" for cardiac surgery and that excellent outcomes can be achieved in selected group of elderly patients.     

Anesthetic management for patients with Brugada syndrome

Brugada syndrome should not be neglected in terms of anesthetic management because its perioperative autonomic imbalance may cause ventricular fibrillation and sudden cardiac arrest. Diagnosis of Brugada syndrome is easily made by unique electrocardiographic pattern of right bundle branch block and ST segment elevation in the right precordial leads. Thus the number of patients with Brugada syndrome for anesthetic management tends to increase. We review current concept of anesthetic management for patients with Brugada syndrome including fourteen cases in our institution, two out of which developed VF during operation.     

The use of cervical paravertebral block as the sole anesthetic for shoulder surgery in a morbid patient: a case report

OBJECTIVES: The purpose of this case report is to describe the use of the cervical paravertebral block as the sole anesthetic for shoulder surgery in a patient unable to tolerate general anesthesia. Recent literature describes the continuous cervical paravertebral block as an effective alternative to the interscalene block for the management of postoperative pain after shoulder surgery. CASE REPORT: An 85-year-old man with severe respiratory and cardiac disease presented for major shoulder surgery. The patient's complex medical history required an anesthetic technique that would avoid general anesthesia and preserve phrenic nerve function. This case report describes, to our knowledge, the first successful use of the continuous cervical paravertebral block as the sole anesthetic for shoulder surgery. CONCLUSIONS: Continuous cervical paravertebral block provided excellent surgical conditions and postoperative pain relief for this patient and allowed gradual and intermittent dosing of the catheter and continuous assessment of the anesthetic impact on respiratory function.     

Kidney transplantation in valvular heart disease and pulmonary hypertension: Consensus in waiting

Kidney transplantation induces a lesser anesthetic, surgical, and physiological alterations than other solid organ transplantation. Concomitant valvular pathologies expose these patients to poor postoperative outcome. There is a critical gap in knowledge and lack of coherence in the guidelines related to the management in patients with end‐stage renal disease with valvular heart disease. The individualized diagnostic and management plan should be based on the assessment of perioperative outcomes. Similarly, pulmonary hypertension in end‐stage renal disease poses a unique challenge, it can manifest in isolation or may be associated with other cardiac lesions, namely left‐sided valvular heart disease and left ventricular systolic and diastolic dysfunction. Quantification and stratification according to etiology are needed in pulmonary hypertension to ensure an adequate management plan to minimize the adverse perioperative outcomes. Lack of randomized controlled trials has imposed hindrance in proposing a unified approach to clinical decision‐making in these scenarios. In this review, we have described the magnitude of the problems, pathophysiologic interactions, impact on clinical outcomes and have also proposed a management algorithm for both the scenarios.     

Future directions in cardiac and vascular anesthesia: unanswered questions regarding variables controllable by anesthetic management

The influence of anesthetic choices and techniques upon outcomes in cardiac surgery is difficult to ascertain because of the low incidence of morbid and fatal outcomes that are attributable to anesthetic management. This discussion summarizes several areas that have been addressed in clinical trials, including temperature management, intraoperative hemodynamics, and glucose control.