Anesthesia For Noncardiac Surgery Research Articles

Anaesthesia for non-cardiac surgery in children and young adults with Fontan physiology.

Patients with Fontan physiology require non-cardiac surgery. Our objectives were to characterise perioperative outcomes of patients with Fontan physiology undergoing non-cardiac surgery and to identify characteristics which predict discharge on the same day. Children and young adults with Fontan physiology who underwent a non-cardiac surgery or an imaging study under anaesthesia between 2013 and 2019 at a single-centre academic children's hospital were reviewed in a retrospective observational study. Continuous variables were compared using the Wilcoxon rank sum test, and categorical variables were analysed using the Chi-square test or Fisher's exact test. Multivariable logistic regression analysis results are presented by adjusted odds ratios with 95% confidence intervals and p values. 182 patients underwent 344 non-cardiac procedures with anaesthesia. The median age was 11 years (IQR 5.2-18), 56.4% were male. General anaesthesia was administered in 289 (84%). 125 patients (36.3%) were discharged on the same day. On multivariable analysis, independent predictors that reduced the odds of same-day discharge included the chronic condition index (OR 0.91 per additional chronic condition, 95% CI 0.76-0.98, p = 0.022), undergoing a major surgical procedure (OR 0.17, 95% CI 0.05-0.64, p = 0.009), the use of intraoperative inotropes (OR 0.48, 95% CI 0.25-0.94, p = 0.031), and preoperative admission (OR = 0.24, 95% CI: 0.1-0.57, p = 0.001). In a contemporary cohort of paediatric and young adults with Fontan physiology, 36.3% were able to be discharged on the same day of their non-cardiac procedure. Well selected patients with Fontan physiology can undergo anaesthesia without complications and be discharged same day.

Shamrock Lumbar Plexus Block for Hip Hemiarthroplasty in a High Risk Elderly Patient with Hip Fracture.

Hip fractures in the geriatric population are associated with high morbidity and mortality rate. Early surgical fixation is of major importance, as it is one of the factors that contribute to patient optimization. However, these patients usually present a high burden of comorbidities, including aortic stenosis that could affect their treatment. Despite major advances in anesthetic and surgical techniques, severe aortic stenosis remains an independent, important risk factor for patients undergoing anesthesia for noncardiac surgery. In these patients, general and/or neuraxial anesthesia should be avoided; peripheral nerve blockade is a viable option. This article presents a 96-year-old hip fracture patient with severe aortic stenosis and aspiration pneumonia that successfully underwent hip hemiarthroplasty under peripheral nerve blockade as sole anesthesia.

P4580The effect of anesthetic techniques on cardiac troponin-T after non-cardiac surgery

Abstract Background The effects of anesthetics on cardiac protection and clinical outcomes have shown conflicting results in patients undergoing non-cardiac surgery. Unlike cardiac surgeries in which cardio-protective effects of anesthetic techniques have been reported, it lacks evidence and reproducibility in non-cardiac surgery. A current generation high-sensitivity cardiac troponin (hs-cTnI) is known to detect perioperative myocardial injury in non-cardiac surgery which is closely related to clinical outcomes. In this study, we hypothesized that balanced anesthesia using both remifentanil and volatile agents is the most effective in reducing postoperative myocardial injury, and compared the incidence of postoperative myocardial injury among different types of general anesthesia. Methods We analyzed the data of 3555 patients who underwent general anesthesia for non-cardiac surgery in our hospital between February 2010 and December 2016. In all patients, hs-cTnI was detected in preoperative period and postoperative period within 48 hours. Major exclusion criteria was troponin elevation before surgery. Patients were stratified into three groups; 661 patients who were received propofol-remifentanil total intravenous anesthesia (TIVA group), 1279 patients who were received volatile anesthesia without remifentanil (Volatile group) and 1622 patients who were received volatile anesthesia with remifentanil (Balanced group). The Primary outcome was troponin elevation [hs-cTnI≥0.04 ng/mL] within post-operative within 48 hours, and the incidence of postoperative complications such as postoperative acute kidney injury, new-onset atrial fibrillation and in-hospital mortality were also compared. Results The occurrence of myocaridial injury were significant difference between three groups. The occurrence of myocardial injury was significantly lower in the Balanced group than in Volatile group after adjustment (Odds ratio (OR) = 0.727; 95% confidence interval (CI) = 0.59–0.89; P-value = 0.002). Balanced group and TIVA group showed comparable results in risk of postoperative troponin elevation after adjustment (OR 1.131; 95% CI 0.96–1.33; P-value = 0.133). The incidence of troponin elevation was significantly higher in Volatile group than TIVA group after adjustment (OR 1.6; 95% CI 0.52–0.96; P-value = 0.005). The incidence of AKI was significantly lower in Balanced group than Volatile group after adjustment (OR 0.637; 95% CI 0.49–0.81; P-value <0.001). Conclusion The remifentanil combination during general anesthesia may be associated with myocardial protection effect in patients undergoing non-cardiac surgery. Whether this impact leads to adverse long-term outcome remains unclear, and requires further investigation.

Risk associated with anesthesia for noncardiac surgery in children with congenital heart disease.

Database analysis has indicated that perioperative cardiac arrest occurs with increased frequency in children with congenital heart disease. Several case series and large datasets from ACS NSQIP have identified subgroups at the highest risk. Consistently, patients with single ventricle physiology (especially prior to cavopulmonary anastomosis), severe/supra-systemic pulmonary hypertension, complex lesions, and cardiomyopathy with significantly reduced ventricular function have been shown to be at increased risk for adverse events. Based on these results, algorithms for assessing risk have been proposed. How hospitals and health care systems apply these guidelines to provide safe care for these challenging patient groups requires the application of modern quality improvement techniques. Each institution should develop a system which reflects local expertise and resources.

Williams Syndrome and Anesthesia for Non-cardiac Surgery: High Risk Can Be Mitigated with Appropriate Planning.

Patients with Williams syndrome are considered at high risk for anesthesia-related adverse events. At our institution, all William syndrome patients undergoing cardiac surgical, cardiac catheterization/interventional procedures, and cardiac imaging studies are cared for by cardiac anesthesiologists. All William syndrome patients undergoing non-cardiac surgical, interventional, or imaging studies are cared for by main operating room pediatric anesthesiologists with consultative input from a cardiac anesthesiologist. We reviewed our experience with 75 patients undergoing 202 separate anesthetics for 95 non-cardiac procedures and 107 cardiac procedures from 2012 to 2016. The mean age was 7.5 ± 7.0years and the mean weight was 22.3 ± 17.0kg. One hundred and eighty-seven patients had a general anesthetic (92.6%). Medications used included etomidate in 26.2%, propofol in 37.6%, isoflurane in 47.5%, and sevoflurane in 68.3%. Vasopressors and inotropes were required including calcium (22.8%), dopamine (10.4%), norepinephrine (17.3%), phenylephrine (35.1%), vasopressin (0.5%), and ephedrine (5.4%). The median length of stay after anesthesia was 2.8days (range 0-32). No adverse events occurred in 89.6% of anesthetics. There were two cases of cardiac arrest, one of which required extracorporeal life support for resuscitation. Of the non-cardiac surgical procedures, 95.7% did not have a cardiovascular adverse event. Patients with Williams syndrome are at high risk for anesthesia, especially when undergoing cardiac procedures. The risk can be mitigated with appropriate planning and adherence to the hemodynamic goals for non-cardiac surgical procedures.

Anesthesia for a Patient on Monoamine Oxidase Inhibitors

ABSTRACT Monoamine oxidase (MAO) inhibitors are frequently used for multidrug-resistant major depression, which is emerging as an epidemic in the modern era. Anesthesia during chronic use of MAO inhibitors is a matter of debate because of increased risk of drug interactions with various anesthetic drugs. Cardiac disorders contribute to perioperative and postoperative complications. Recent studies illustrate the safety of anesthesia without discontinuation of MAO inhibitors if sympathetic homeostasis is maintained and known drug interactions are avoided. In this case study, a 72-year-old male psychiatric patient on permanent treatment with tranylcypromine (30 mg/day) was admitted for bipolar hemiarthroplasty. After complete aseptic precautions, spinal anesthesia was achieved by 12.5 mg 0.5% heavy bupivacaine and 30 μg clonidine intrathecally. The anesthetic effect was adequate, but surgery was not completed timely and the effect of spinal anesthesia was weaned off, so general anesthesia was given and surgery was completed. There was no perioperative or postoperative complication. In conclusion, general or regional anesthesia for noncardiac surgery without discontinuation of MAO inhibitors may be safe after careful preoperative evaluation of the patient. How to cite this article Krishan G, Singh RP, Agrawal M, Agrawal R. Anesthesia for a Patient on Monoamine Oxidase Inhibitors. Int J Adv Integ Med Sci 2016;1(2):81-83.

Controversies in anaesthesia for noncardiac surgery in older adults

As the population of the world is rapidly ageing, the amount of surgery being performed in older patients is also increasing. Special attention is required for the anaesthetic and perioperative management of these patients. The clinical and non-clinical issues specific to older surgical patients are reviewed, with a special emphasis on areas of debate related to anaesthesia care in this group. These issues include the role of frailty and disability in preoperative assessment, choice of anaesthesia technique for hip fracture, postoperative delirium, and approaches to shared decision-making before surgical procedures.

Utility of TEE in Anesthesia for Non Cardiac Surgery: A Practical Review

Two dimensional echocardiography of the heart gives the accurate dimensions of cardiac anatomical structures. In addition, Doppler effect by virtue of measuring blood velocity gives critical information regarding functioning of the heart (cardiac output and flow across cardiac valves). Trans-esophageal echocardiography (TEE) has revolutionized surgical and anesthetic management in patients undergoing cardiac surgery ever since its introduction in 1980s, but its intraoperative utility in non-cardiac surgery is a new emergent dimension. We review here, the nascent and lesser studied use of TEE in patients undergoing non-cardiac surgery, concentrating on five basic views which can be rapidly viewed even by lesser trained anesthesiologists in the learning curve to provide valuable information requisite for non cardiac surgery.

Management of Anesthesia for Noncardiac Surgery in Pediatric Patient with Isolated Persistent Patent Ductus Arteriosus

Management of Anesthesia for Noncardiac Surgery in Pediatric Patient with Isolated Persistent Patent Ductus Arteriosus

Case series: Dexmedetomidine and ketamine for anesthesia in patients with uncorrected congenital cyanotic heart disease presenting for non-cardiac surgery

The number of patients with uncorrected congenital cyanotic heart disease is less but at times some may present for non-cardiac surgery with a high anesthetic risk. Some of these may even be adults with compromised cardiopulmonary physiology posing greater challenges to the anesthesiologist. The authors have used a combination of dexmedetomidine and ketamine for anesthesia for non cardiac surgery in five patients with cyanotic heart disease and right to left shunt (3-Eisenmenger's syndrome, 2-Tetralogy of Fallot). The sympathoinhibitory effects of dexmedetomidine were balanced with the cardiostimulatory effects of ketamine, thereby maintaining good cardiovascular stability. The analgesia was good and there was no postoperative agitation. This drug combination was effective and safe for patients with cyanotic heart disease for non cardiac surgeries.

Anaesthesia for non-cardiac surgery in a cardiac transplant recipient

Anaesthesia for non-cardiac surgery in a cardiac transplant recipient

Anaesthesia for non-cardiac surgery in a cardiac transplant recipient

Cardiac transplantation has become the standard therapy for idiopathic dilated cardiomyopathy and end-stage ischaemic heart disease. With the introduction of newer immunosuppressants, together with better patient selection, improved perioperative monitoring and care, the overall survival of recipients has improved. An increasing number of patients who received a transplant present for either elective or emergency non-cardiac surgery. We hereby discuss the perioperative management of such a patient who came to our set-up for bipolar haemiarthroplasty.

Anaesthesia for noncardiac surgery in children with congenital heart disease

Children with Congenital Heart Disease (CHD) presenting for non-cardiac surgery have various physiological and functional abnormalities and thus pose great challenges to the anaesthesiologist. The principles of anaesthesia are to minimize pathophysiological changes which may upset the complex interaction between systemic and pulmonary vascular resistance. Knowledge of the specific cardiac anatomy, familiarity with the modifications of the cardiorespiratory physiology, the awareness of the potential risks of complications for each individual case are mandatory for the choice of the anaesthesia strategy for each patient. During the preoperative assessment, the risk-benefit ratio should be estimated and preoperative plan established in order to optimize the preoperative status. An anaesthesiologist must also understand pharmacology of drugs being used and should tailor anaesthetic management to the type of surgery. An interdisciplinary team approach is the cornerstone for the safe delivery of anaesthesia to this paediatric patient population. The team should comprise an anesthesiologist, a paediatric cardiologist, a surgeon, a cardio-surgeon and a neonatologist. This review is meant to explain the classification of congenital heart diseases and to equip the anaesthesiologist with the necessary information about preoperative assessment, anaesthesiology management, monitoring tools important for the safe non-cardiac surgery procedures as well as therapeutic strategies during the postoperative period.

Neuroadaptive output feedback control for nonlinear nonnegative dynamical systems with actuator amplitude and integral constraints

A neuroadaptive output feedback control architecture for nonlinear nonnegative dynamical systems with input amplitude and integral constraints is developed. Specifically, the neuroadaptive controller guarantees that the control amplitude as well as the integral of the control input over a given time interval are constrained, and the physical system states remain in the nonnegative orthant of the state space. The proposed approach is used to control the infusion of the anesthetic drug propofol for maintaining a desired constant level of depth of anesthesia for noncardiac surgery in the face of infusion rate constraints and an integral drug dosing constraint over a specified time period. Copyright © 2010 John Wiley & Sons, Ltd.

A Practice of Anesthesia for Infants and Children, 4th Edition.

A Practice of Anesthesia for Infants and Children, 4th Edition.

Anesthesia for noncardiac surgery in infant with undiagnosed single ventricle

Anesthesia for noncardiac surgery in infant with undiagnosed single ventricle

Anesthesia for Noncardiac Surgery in Adults with Congenital Heart Disease

Anesthesia for Noncardiac Surgery in Adults with Congenital Heart Disease

Anaesthesia for noncardiac surgery in the heart transplant recipient

Anaesthetizing a patient who benefited from a heart transplant will undoubtedly fascinate any anaesthetist. Basic principles need to be adhered to in order to ensure that no unnecessary harm is caused to these patients. Furthermore, the conscientious anaesthetist will want to remain abreast of the advances in the understanding of physiological changes occurring over the years after transplantation and the continuous innovations in the field of immunosuppression. Understanding of the mechanisms surrounding cardiac allograft vasculopathy and insight into the possibility of reinnervation are continuously evolving; but changes in therapeutic regimens in an attempt to lower side effects have probably a greater impact on day-to-day clinical practice. Understanding how to administer fluids adequately to a transplant patient; how to use direct vasoactive agents; how to manage the infectious risk; and the need to be aware of the multiple side effects of immunosuppressive regimens are essential to recognize, prevent or treat possible perioperative complications.

Anesthesia for non-cardiac surgery in children with congenital heart disease

It has been estimated that 0.8% of children born in the United States will be diagnosed to have some form of congenital heart disease. (CHD) Many of these children will require surgery for noncardiac conditions that are commonly encountered during childhood (e.g. inguinal hernia, dental caries, or chronic tonsillitis). Moreover, many children with CHD have other associated noncardiac (e.g. orthopedic or genitourinary) congenital anomalies that require surgical repair. Many of these procedures are performed in general hospitals by noncardiac anesthesiologists. It is therefore essential that the anesthesiologist be knowledgeable, not only of the basics of pediatric anesthesia, but also of the pathophysiology of the cardiac lesions. Knowledge of the physiological consequences of shunting or obstruction is essential to understanding the hemodynamic consequences of any congenital heart deformity. Application of these physiologic concepts permits the anesthesiologist to design a rational management plan for the child with CHD.

Anesthesia for noncardiac surgery in a neonate with interrupted aortic arch - A case report -

Interrupted aortic arch (IAA) is a rare congenital cardiovascular anomaly in which there is no direct continuity between the aortic arch and the descending aorta. A patent ductus arteriosus (PDA) usually feeds the descending aorta. But, as ductus constricts, IAA is lethal in nearly 100% of the cases, if untreated. The cause of death is a combination of greatly increased left to right shunt with increased pulmonary blood flow, which results in heart failure, pulmonary edema, and sequelae of the reduced perfusion of all structures distal to the interruption. During the noncardiac surgery in such patients, adequate managements with prostaglandin infusion, careful manipulation of the pulmonary-systemic blood flow ratio, inotropic support, and aggressive treatment of acidosis should be provided to ensure optimal outcomes of subsequent surgical reconstruction. We present the anesthetic experience of abdominal surgery in a neonate with a type A IAA combined with PDA and ventricular septal defect. (Korean J Anesthesiol 2008; 55: 358～62)