Problems in anesthesia : cardiothoracic surgery

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Nonetheless, this doctor plays many important roles in your care before, during, and after your surgery or procedure, and is an essential member of the cardiac team. Specifically, your cardiac anesthesiologist: Ensures your comfort during surgery or a cardiac procedure with the use of anesthetics tailored to your specific medical condition and existing health issues Continually monitors your vital functions such as breathing, heart rate and rhythm, blood pressure, body temperature, oxygen saturation, and fluid and blood needs throughout and immediately following surgery or a procedure, making medical decisions on your behalf as necessary Manages your care, including any pre-existing medical conditions, throughout surgery and the immediate post-operative period Manages your pain during the immediate post-operative period to make you as comfortable as possible Provides expert consultation on many issues pertaining to your care, including pain management, anticoagulation, and airway management What type of anesthesia will I have?

There are four basic types of anesthesia: General anesthesia Regional anesthesia Local anesthesia Sedation If you are having cardiac surgery, you must have general anesthesia, which renders you unconscious, immobile, and unable to experience pain or other sensations.

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Why is there a preoperative interview and what does it consist of? The preoperative interview has two important purposes. One is to provide your cardiac anesthesiologist with essential information about your health history and habits so he or she can properly plan and manage your anesthesia and care during and following your surgery or procedure. If, for example, you have a chronic medical condition, such as allergies or asthma, your cardiac anesthesiologist must know this information in order to tailor your anesthesia to your specific situation.

In addition, your cardiac anesthesiologist will ask about your use of cigarettes, alcohol, and prescribed or illicit drugs, as these affect how your body responds to anesthesia. The other important purpose of the preoperative interview is to give you an opportunity to ask questions and voice any concerns you may have. Will I be asleep during my entire operation? If you are having general anesthesia, you will not be conscious aware during your entire operation. You will not experience pain or other sensations and cannot be aroused until and unless the cardiac anesthesiologist chooses to wake you.

Be assured that throughout your entire operation, your cardiac anesthesiologist continually monitors and adjusts your level of anesthesia so that you are always adequately anesthetized. Typically we place one pad on the back, to the left of the spine. The second pad is near the apex of the heart at the left anterior axillary line.

The presence of a capnothorax further complicates the situation, since CO 2 acts as an electrical insulator, further hampering defibrillation efforts.


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If initial external defibrillation efforts prove unsuccessful, consideration should be given to resuming two-lung ventilation to reduce electrical impedance through the chest 1 , 5 , 8 , Fortunately, we rarely encounter patients who are resistant to more than three or four defibrillation attempts when using the aforementioned pad position together with a biphasic defibrillator and energy levels of to Joules.

Intravenous amiodarone is typically given if one or two defibrillation attempts are unsuccessful. Placement of epicardial pacing wire is difficult during robotic mitral surgery and we rarely place epicardial or transvenous pacing wires in these cases. Nonetheless different CPB cannulation strategies may be employed, particularly for the venous return lines.

Similarly, different strategies for cardioplegia delivery may be selected based on surgeon preference or patient characteristics. Anesthesiologists may be tasked with placing lines that will be used for venous drainage or cardioplegia administration. The location and number of such lines may, in turn, influence the selection of additional lines used for pressure monitoring, fluid administration, or drug delivery. The primary method of venous drainage for CPB is placement of a cannula via the femoral vein that is typically advanced into the right atrium RA or superior vena cava SVC.

In addition, supplementary venous drainage may be accomplished by means of a 15 to 18 French cannula introduced into the right internal jugular RIJ vein and advanced into the SVC under TEE guidance. This SVC cannula may be placed entirely by the anesthesiologist with tubing passed around the surgical drapes to the CPB machine.

Alternatively, as is our practice, a 5 French single-lumen cannula is inserted by the anesthesiologist into the RIJ, close to the clavicle Figure 2. This line is flushed, capped and prepped into the surgical field. Later, under TEE guidance, the surgeon uses this 5 French cannula to introduce a guidewire, followed by dilators, and finally the wire-reinforced venous cannula. Supplementary venous drainage may also be provided by a commercially-available endo-pulmonary vent. This balloon tipped catheter has a design similar to a short pulmonary artery catheter and is inserted into the RIJ by mean of an introducer sheath.

Module 2 Overview of Cardiac Anesthesia

The tip of the 9 French, endo-pulmonary vent is advanced with TEE guidance to a position in the main pulmonary artery, within one to two centimeters of the pulmonary artery bifurcation and then connected by vacuum-assisted drainage into the CPB circuit. It is our clinical impression that the latter system provides better venous drainage at a lower cost than the endo-pulmonary vent.

In addition to the 5 French introducer that is prepped into the surgical field, we typically place a second line into the RIJ at a position that allows placement of surgical drapes between the two. Typically an 8. We do not use a pulmonary artery catheter for robotic MVR cases. If an endo-pulmonary vent is used, pulmonary artery pressures can be transduced prior to CPB. Once protamine is given, the endo-pulmonary vent is generally removed.

The RIJ may also be used to place a percutaneous coronary sinus catheter for retrograde cardioplegia delivery. Retrograde cardioplegia may be chosen as the sole method of cardiac arrest by choice or because of patient factors significant aortic regurgitation. We have used a percutaneous coronary sinus catheter for retrograde cardioplegia delivery in a limited number of cases. In these cases we used a both TEE and fluoroscopy with contrast administration to confirm correct catheter position in the coronary sinus.

If the catheter moves toward the tricuspid valve or right atrial appendage, it is rotated counterclockwise and reinserted. Should the catheter be directed toward the inferior vena cava, it is rotated clockwise prior to additional attempts. Arterial pressure monitoring is accomplished by means of a left radial artery catheter. Should a right radial arterial line become damped or otherwise nonfunctional during the operation, it would be considerably more difficult to troubleshoot. However, if endo-aortic balloon occlusion of the ascending aorta with antegrade cardioplegia is planned, then bilateral radial arterial catheters are placed.

Under these circumstances, damping of the right radial arterial pressure waveform is presumed to represent migration of the endoaortic balloon with innominate artery occlusion. Intraoperative cerebral oximetry has also been suggested as a means to detect endo-aortic balloon migration 5.

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A decline in right-sided cerebral oximeter readings should prompt TEE confirmation of aortic balloon position. Our own surgical practice has never included the endo-aortic balloon clamping and cardioplegia delivery system. Instead, our surgeons favor a long transthoracic, or Chitwood, clamp together with antegrade cardioplegia that is administered by a cannula placed into the ascending aorta via a small port incision located to the right of the sternum Figure 2.

Blood-based crystalloid cardioplegia is given. We have infrequently used retrograde cardioplegia administered via a percutaneously-placed coronary sinus catheter. In addition to precise delineation of mitral pathology and evaluation of the surgical repair, TEE is used to detect additional findings that may impact the conduct of the operation.

Procedures

The presence of more than mild aortic regurgitation may necessitate the administration of retrograde cardioplegia. Atrial level shunts may complicate passage of femoral venous guidewires and cannulae. However, the need for real-time guidance during placement of guidewires and cannulae represents a unique role for TEE during robotic and minimally-invasive cardiac surgery.

[Full text] Assessment and pathophysiology of pain in cardiac surgery | JPR

During cannulation of the femoral artery, continuous TEE imaging ensures that guidewire passage into the descending aorta has been successful. The way we deliver care to patients within our state-of the-art Carl J. Our cardiac and thoracic anesthesia services provide perioperative care to thousands of surgical patients each year. This provides our residents and fellows with a comprehensive patient care experience in the full spectrum of health problems related to cardiovascular and thoracic disorders requiring surgical intervention.

General surgery anesthesia encompasses the entire span of intra-abdominal procedures, including colorectal, oncological, gynecologic, endocrine, hepatic, bariatric, urological, plastic and more. Our anesthesiologists specialize in providing evidence-based anesthesia solutions for highly complex surgeries. Among our specialty areas is anesthesia for robotic surgery, a growing field that offers great promise. Other areas of focus include enhanced regional anesthesia techniques to help patients recover faster, and reduced narcotics to support normal intestinal function after surgery.

We also are investigating ways to improve anesthesia for elderly patients, to reduce the impact on their cognitive function and deliria after surgery. The Neuroanesthesia Service offers many of the newest techniques in this rapidly evolving subspecialty. The Service manages anesthesia for real-time intraoperative magnetic resonance imaging, awake craniotomies for speech, motor, and seizure mapping, plus the latest in neural monitoring.

With a caseload exceeding 1, per year, the Neuroanesthesia Service has its own staff of monitoring technicians, as well as experts in both raw and processed EEG monitoring, burst suppression techniques, somatosensory, auditory, visual, and brainstem and motor-evoked potentials, and facial nerve monitoring. Orthopedic surgery takes many forms, from torn ligament repairs to full joint replacements of the knee and hip.

The use of epidural anesthesia as an alternative to general anesthesia is associated with improved outcomes, shortened hospital stays and lower healthcare costs for patients undergoing hip and knee replacement surgery. We work with patients and their surgeons to determine the best type of anesthesia for their particular circumstance.