Seminars in cardiothoracic and vascular anesthesia
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Ventricular assist devices (VADs) have revolutionized long-term care for patients with congestive heart failure. These patients represent about 1% of the adults in the United States, considering that heart failure is a contributing factor in more than 250,000 deaths annually. ⋯ At least four assist devices are clinically available, and two other devices are being investigated. Because cardiopulmonary by-pass is required for implantation of these devices, anesthetizing these critically compromised patients requires extensive monitoring, skillful anesthetic management, and expert postoperative care.
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One-lung ventilation is used during a variety of cardiac, thoracic, and major vascular procedures. Endobronchial tubes, bronchial blockers, and occasionally, single-lumen tubes are used to isolate the lungs. ⋯ Finally, intraoperative hypoxia and hypercarbia in patients with intrinsic lung disease frequently complicate one-lung anesthesia. The concepts and controversies in lung isolation techniques are discussed.
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Lung transplantation is the only therapeutic option for more than 3,000 individuals in the United States with end-stage lung disease. Innovations in anesthetic and surgical techniques have expanded the indications for lung transplantation. Presently, the major limiting factor in the number of lung transplantations that are performed is the availability of suitable donor organs. ⋯ Transesophageal echocardiography is commonly used to evaluate intraoperative ventricular function. Continuous cardiac output, mixed venous oxygen saturation, continuous arterial blood gas monitoring, and the bispectral index have also been used to monitor the patient during lung transplantation. Anesthetic management of lung transplantation requires a thorough understanding of end-stage lung disease and pharmacologic and technical considerations that may not be applicable in any other part of anesthetic practice.