Seminars in cardiothoracic and vascular anesthesia
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Semin Cardiothorac Vasc Anesth · Sep 2013
ReviewCurrent concepts in diagnosis and perioperative management of carcinoid heart disease.
Carcinoid tumors are neuroendocrine tumors with a very unpredictable clinical behavior. In the setting of hepatic metastases, the tumor's release of bioactive substances into the systemic circulation results in carcinoid syndrome: a constellation of symptoms among which cutaneous flushing, gastrointestinal hypermotility, and cardiac involvement are the most prominent. Cardiac manifestations, also known as carcinoid heart disease, are secondary to a severe fibrotic reaction which frequently involves the right-sided valves and may extend towards the subvalvular apparatus leading to valve thickening and retraction. ⋯ Carcinoid heart disease poses two distinct challenges for the anesthesiologist: carcinoid crisis and low cardiac output syndrome secondary to right ventricular failure. Carcinoid crisis, characterized by flushing, hypotension, and bronchospasm, may be precipitated by catecholamines and histamine releasing drugs used routinely in patients undergoing valve surgery. Although a broader utilization of octreotide have significantly simplified the anesthetic and perioperative management of these patients, a very balanced anesthetic technique is required to identify and manage low cardiac output syndrome.
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Vascular surgical patients are a diverse group of patients who tend to be elderly, with multiple comorbidities, while vascular procedures may involve significant blood loss and ischemia of tissues beyond the arterial obstruction. Regional anesthesia techniques may offer benefits to patients undergoing vascular surgery because of their cardiorespiratory comorbidities. However, this group of patients is commonly receiving multiple medications, including anticoagulants, so regional techniques are not without risks. This review will discuss this topic based around 3 fundamental revascularization procedures, carotid, abdominal aortic aneurysm repair, and infrainguinal surgery, discussing the clinical applications of regional techniques relevant to each key area.
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Semin Cardiothorac Vasc Anesth · Jun 2013
Case ReportsOne-lung ventilation for surgical repair of thoracic aortic aneurysm.
Advances in the surgical approach to thoracic aortic aneurysm repairs have led to the increasing use of one-lung ventilation. Today's practice of cardiothoracic and vascular anesthesia requires a clear understanding of the techniques available for lung separation and the technical skills necessary to employ them. In this article, we discuss and evaluate the options for one-lung ventilation in thoracic aortic aneurysm repair with regard to preoperative, intraoperative, and postoperative management.
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Semin Cardiothorac Vasc Anesth · Jun 2013
Case ReportsTreatment of acute silicoproteinosis by whole-lung lavage.
Acute silicoproteinosis is a rare disease that occurs following a heavy inhalational exposure to silica dusts. Clinically, it resembles pulmonary alveolar proteinosis (PAP); silica exposure is thought to be a cause of secondary PAP. ⋯ Without clinical improvement despite antibiotic and steroid treatment, the patient was scheduled for whole-lung lavage under general anesthesia. Anesthetic challenges included double-lumen tube placement and single-lung ventilation in a hypoxic patient, facilitating lung lavage, and protecting the contralateral lung from catastrophic spillage.
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Semin Cardiothorac Vasc Anesth · Mar 2013
The impact of dexmedetomidine infusion in sparing morphine consumption in off-pump coronary artery bypass grafting.
Recovery from off-pump coronary artery bypass (OPCAB) has been reported to be more advantageous than conventional coronary artery bypass grafting with regard to both hospital and intensive care unit length of stay. Dexmedetomidine is a selective α-2 agonist that has been used successfully as an adjunct to narcotics in adult and pediatric cardiac surgery. The aim of this study was to assess the effect of dexmedetomidine on the recovery, total narcotic consumption, and total hospital and intensive care unit length of stay in patients undergoing OPCAB. ⋯ Our study showed that dexmedetomidine might be an effective adjuvant in reducing both total hospital and intensive care unit length of stay in patients undergoing OPCAB. Dexmedetomidine might play a role in reducing total morphine and fentanyl consumption in OPCAB.