Seminars in cardiothoracic and vascular anesthesia
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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.
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Semin Cardiothorac Vasc Anesth · Jun 2005
ReviewCognitive dysfunction after cardiac surgery: revisiting etiology.
Cognitive dysfunction remains a frequent complication of cardiac surgery. Despite many years of research, few preventive strategies and no definitive therapeutic options exist for the management of this troublesome clinical problem. ⋯ The etiology of cognitive dysfunction after cardiac surgery is multifactorial and includes cerebral microembolization, global cerebral hypoperfusion, systemic and cerebral inflammation, cerebral temperature perturbations, cerebral edema, and possible blood-brain barrier dysfunction, all superimposed on genetic differences in patients that may make them more susceptible to injury or unable to repair from injury once it has occurred. This review expands on these potential etiologies in detailing the evidence for their existence.
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Macro and microemboli can both cause significant neurologic dysfunction. The traditional belief in cardiac surgery was that the damage perpetrated by an embolus was caused by the occlusion of an arterial branch, resulting in an ischemic event and subsequent infarction. However, ongoing research has demonstrated that the mere passage of a deformable embolus (air, lipid, or semi-solid clot) will disrupt the endothelium as it is extruded through the vessel. ⋯ A significant breakdown of the blood-brain barrier causes marked brain swelling, increased intracranial hypertension, and a possible increase in the size of the lesions associated with larger occlusive emboli. Gaseous microemboli are also a well-documented endothelial irritant and can cause significant brain dysfunction. It is important to avoid delivering emboli of any size or composition to the cerebral vasculature in order to reduce the impact of cardiac surgery on the brain.
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Semin Cardiothorac Vasc Anesth · Jun 2005
ReviewA systematic approach to the understanding and redesigning of cardiopulmonary bypass.
Cardiopulmonary bypass (CPB) is a highly complex process. We developed a system to capture and study detailed information during cardiac surgery that serves as a framework for understanding variation that occurs during CPB. The system allows the surgical team to link unwanted variation (ie, hypotension) and unwanted events (ie, the production of microemboli) to the processes of care. ⋯ Periods of embolic activity and cerebral desaturation could be related to surgical and CPB processes of care. We have identified increased emboli counts in the CPB circuit and in the middle cerebral arteries related to the method of venous drainage, manipulation of the aorta, and anastomotic techniques. se of this model provides the surgical team detailed information about these precursors to neurologic injury. This system provides a systematic approach to the understanding and redesigning of CPB.
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Semin Cardiothorac Vasc Anesth · Jun 2005
ReviewReducing cerebral emboli during cardiopulmonary bypass.
Neurologic injury is a common complication of cardiac surgery and is associated with significant morbidity, mortality, and resource utilization. The incidence varies widely according to the definition used, patient age, and complexity of surgery. The manifestations of neurologic injury are broad, ranging from subtle neurocognitive dysfunction to frank stroke. ⋯ In the current paper, we discuss the pathophysiology of neurologic injury after cardiac surgery and methods of reducing cerebral embolization. Reducing emboli and neurologic injury during CPB requires a multidisciplinary approach that includes several simple diagnostic and therapeutic strategies. Reducing cerebral emboli should be a major goal for future research in the fields of cardiac anesthesia, surgery and perfusion.