Seminars in cardiothoracic and vascular anesthesia
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The demographics of cardiac surgical patients are changing. The average age at operation has risen 10 years since 1980, and the risk of surgery related to severe atherosclerosis of the aorta and its branches is increasing. Although cardiac risk is increasing, operative techniques to minimize cardiac risk have placed the emphasis on comorbid conditions. Patients with preexisting unstable cerebral, vascular, renal, and hepatic disease are at a markedly increased risk and should be carefully evaluated preoperatively.
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Semin Cardiothorac Vasc Anesth · Mar 2004
ReviewTreatment of inoperable coronary disease and refractory angina: spinal stimulators, epidurals, gene therapy, transmyocardial laser, and counterpulsation.
Intractable angina from refractory coronary disease is a severe form of myocardial ischemia for which revascularization provides no prognostic benefit. Inoperable coronary disease is also accompanied by a "vicious cycle" of myocardial dystrophy from a chronic alteration of the cardiac sympathetic tone and sensitization of damaged cardiac tissues. Several adjunctive treatments have demonstrated efficacy when revascularization is either unsuccessful or contraindicated. ⋯ Epidurals are easy to perform and often available for outpatient or inpatient use. The rapid anti-ischemic effect may complement therapeutic angiogenesis or other interventions with delayed onset to clinical benefit. A new era for interventional and implant cardiology is beginning to emerge as more clinicians, including cardiologists, gradually learn new procedures to safely provide more therapeutic options for patients suffering refractory angina.
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Semin Cardiothorac Vasc Anesth · Mar 2004
Intraoperative echocardiography: support for decision making in cardiac surgery.
Intraoperative echocardiography (including transesophageal echocardiography, epiaortic ultrasound and epicardial echocardiography) is commonly performed in North American hospitals during cardiac anesthesia. Several authors have reported on the positive impact of intraoperative echocardiography on patients' outcomes. ⋯ Intraoperative echocardiography can also detect complications associated with the performed procedure and can be an excellent hemodynamic monitor in unstable patients. In this paper different scenarios where intraoperative echocardiography is useful are reviewed, some clinical cases are shown to illustrate, and a review of related literature is reported.
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Semin Cardiothorac Vasc Anesth · Mar 2004
Perioperative detection of brain oxygenation and clinical outcomes in cardiac surgery.
Awareness of the high incidence of subtle central nervous system dysfunction after cardiopulmonary bypass, when it leads to increased vigilance in monitoring and diagnosis, remains the most important factor in the detection of postoperative injury. Preliminary data from an ongoing prospective study indicates that the use of noninvasive cerebral oximetry may be associated with a decreased length of stay in patients who have had coronary artery bypass grafting.
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The bispectral index is an electroencephalogram-based monitoring tool to help anesthesiologists determine depth of anesthesia. The bispectral index indicates both the potential for awareness and of relative hypnotic overdose, but it does not predict movement or hemodynamic responses to stimulation, and it cannot predict the exact moment consciousness returns. ⋯ It is also being used in intensive care units to help quantify the level of sedation in patients and as an outcome predictor in patients with brain injuries. Low values of the bispectral index often occur during catastrophic, ischemic, events but the use of this technology for the routine monitoring of such events is unproven.