Current opinion in anaesthesiology
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Spinal cord ischemia remains an important complication of open surgical and endovascular stent graft repair of thoracic and thoracoabdominal aortic aneurysm despite advances in operative technique. Identification of risk factors and interventions to prevent and treat spinal cord ischemia has the potential to prevent spinal cord infarction and the morbidity and mortality associated with paraplegia. ⋯ Permanent paraplegia after thoracic and thoracoabdominal aortic aneurysm repair can be prevented in many high-risk patients by early detection and immediate treatment of spinal cord ischemia before it evolves to infarction. The mortality and morbidity associated with permanent paraplegia justifies the risks and uncertainties associated with established therapeutic interventions.
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The article reviews the epidemiology of airway injuries, airway anatomy, techniques for airway management, helpful pharmacologic adjuncts and finally alternatives to airway manipulation. ⋯ Trauma to the airway, either blunt or penetrating or iatrogenic, can result in significant patient morbidity and mortality. Although, relatively rare, if we practice long enough, each of us will encounter such a patient. The anesthesiologist must be familiar with airway anatomy and the location of injury for successful treatment. Along with airway injuries, associated injuries are common and often complicate definitive airway treatment. Modern anesthetic medications such as dexmedetomidine and proven techniques such as awake fiberoptic intubation can be used to safely treat these difficult patients. Alternative therapies such as cricothyroidotomy and cardiopulmonary bypass should be available if first-line therapies fail to secure an injured airway.
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Minimally invasive surgery involving the thoracic cavity continues to increase. With the introduction of robotic systems, particularly the da Vinci robot system more than 10 years ago, thoracic operations have been performed with some provocative results and limited, defined advantages. The present review provides an overview of common thoracic surgical procedures performed with the robotic system and discusses the anesthetic implications. ⋯ Anesthesiologists must be familiar with lung isolation techniques and flexible fiberoptic bronchoscopy while participating in thoracic surgical cases that require robotic systems. In addition, prevention and recognition of potential complications, such as crushing injuries or nerve damage, must be sought. Because the potential for converting to an open thoracotomy exists, all measures must be taken to manage patients accordingly if the situation arises.
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Curr Opin Anaesthesiol · Feb 2010
ReviewCerebral monitoring to optimize outcomes after cardiac surgery.
Although significant achievements have been made in the perioperative care of patients undergoing cardiac surgery, adverse cerebral outcomes remain an ongoing concern. Multiple approaches have been utilized to address neurologic complications, though definitive therapeutic strategies are lacking. This review focuses on the various cerebral monitoring options that can be used in cardiac surgery to improve perioperative outcomes. ⋯ The use of a comprehensive cerebral monitoring strategy can optimize cerebral outcomes after cardiac surgery.
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Heparin-induced thrombocytopenia (HIT) is an important, increasingly recognized antibody-mediated complication of heparin therapy occurring in approximately 0.5-5% of patients receiving heparin for at least 5 days. HIT is a prothrombotic disorder that typically presents with a 50% platelet count drop, thrombotic event manifesting usually 5-14 days after starting heparin, or both. HIT antibodies usually decrease to negative titers/levels within 3 months. When there is clinical suspicion of HIT, heparin should be discontinued and alternative anticoagulation should be considered, as well as laboratory evaluation for HIT. ⋯ For patients with HIT, alternative anticoagulation is available, but for cardiovascular surgery, if the operation cannot be delayed until HIT antibodies have become negative, alternative anticoagulation strategies are recommended, although patients with HIT are at a greater risk for adverse outcomes.