Anesthesiology
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Case Reports
Case Scenario: Perioperative Management of a Young Woman with Fontan Repair for Major Gynecologic Surgery.
Effective treatment for many congenital heart diseases diagnosed before birth has become available since the last three decades. Continuous improvements in surgical knowledge and techniques have allowed patients born with severe heart defects to survive through adulthood. However, palliative surgery often implies profound modifications of classical circulatory physiology, which must be taken into account particularly when general anesthesia is needed for major noncardiac surgery. ⋯ In this case scenario, the authors report the perioperative management of a young woman who underwent major gynecologic surgery, who was managed using a transpulmonary thermodilution technique that was deemed more accurate than noncalibrated pulse-contour method and also able to provide more information regarding preload status. The authors adopted an integrated approach merging together hemodynamic and functional data (ScvO2 and venoarterial CO2 difference) to assess the appropriateness of hemodynamic management. The authors describe also pathophysiologic changes during such condition and also potential drawbacks of chosen technique.
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It is well recognized that increased transfusion volumes are associated with increased morbidity and mortality, but dose-response relations between high- and very-high-dose transfusion and clinical outcomes have not been described previously. In this study, the authors assessed (1) the dose-response relation over a wide range of transfusion volumes for morbidity and mortality and (2) other clinical predictors of adverse outcomes. ⋯ Patients receiving high- or very-high-dose transfusion are at especially high risk for hospital-acquired infections and thrombotic events. Mortality increased linearly over the entire dose range and exceeded 50% after 50 erythrocyte units.
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Historical Article
An Anesthesiologist's Perspective on the History of Basic Airway Management: The "Preanesthetic" Era-1700 to 1846.
Basic airway management modern history starts in the early 18th century in the context of resuscitation of the apparently dead. History saw the rise and fall of the mouth-to-mouth and then of the instrumental positive-pressure ventilation generated by bellows. Pulmonary ventilation had a secondary role to external and internal organ stimulation in resuscitation of the apparently dead. ⋯ Although the techniques had been described at the time, very few physicians practiced glottic (intubation) and subglottic (tracheotomy) techniques. Before the anesthetic era, positive-pressure ventilation was discredited and replaced by manual negative-pressure techniques. In the middle of the 19th century, physicians who would soon administer anesthetic gases were unfamiliar with the positive-pressure ventilation concept.