Management Of Cardiac Patients Research Articles

An introduction to transoesophageal echocardiography: I. Basic principles.

The purpose of this review is to introduce the uninitiated to transoesophageal echocardiography (TEE): how it works, and what it can do. Sufficient detail is provided to serve as a reference guide to anaesthetists already using TEE in clinical practice. A Medline search of English language literature up to and including August 1995 was conducted using the key words echocardiography and TEE. Reference echocardiography textbooks were also utilized in the preparation of this review. All information available from TEE is derived from either cardiac imaging or analysis of blood flow velocity using various Doppler modes. To understand the diagnostic capabilities of TEE we review clinically useful views of the heart as well as modes of cardiac imaging. Sufficient basic physics is presented to allow proper use of adjustment features on the echocardiography machine so that cardiac imaging can be optimized. Available Doppler modes are explained along with an overview of their clinical applications. Figures illustrating clinically useful views obtainable with omniplane TEE are included along with colour prints demonstrating clinical applications of colour flow Doppler. TEE is becoming increasingly important in the management of cardiac patients for cardiac and non-cardiac surgery. An understanding of the capabilities of the technology as well as the underlying physics allows the anaesthetist to glean the most information from this valuable technique, both quantitatively and qualitatively.

Pro: Early extubation after cardiac surgery decreases intensive care unit stay and cost

The recurrent or new trends of early extubation after cardiac surgery are here to stay in the 1990s. The preoperative status does not necessarily predict the postoperative course and prolonged mechanical ventilation following cardiac surgery should not be uncritically considered as routine. All patients should be assessed for tracheal extubation at the earliest opportunity when the criteria are met in the ICU. Early extubation post-cardiac surgery does reduce ICU and hospital length of stay and costs. It also allows early ICU discharge and reduces case cancellations without any increase in postoperative complications and readmission. These studies have emphasized that the change in the process of care to early extubation can affect patient outcome as well as costs in cardiac patient care. The substantial difference in cost savings per cardiac case between "criteria discharge" and "actual discharge" points out the importance of the organization of the process of care being delivered. To achieve maximum cost benefit from early extubation in cardiac patients, the organization of the perioperative management of these patients must be optimized. This process of care includes intraoperative anesthetic modification; organization of ICU and staff expertise; postoperative early extubation and management; acute pain service; ICU discharge policy; utilization of step-down unit and surgical ward; and communication among cardiac patient management teams (cardiovascular surgeon, cardiac anesthesiologist, ICU staff, nurses, respiratory therapists, physiotherapists, and social workers), which are all vital to the success of such a program.

Preoperative and Perioperative Management of Cardiac Patients Undergoing Noncardiac Surgery

Cardiac diseases, particularly coronary artery disease and its risk factors, are associated with the majority of perioperative complications in patients undergoing major noncardiac surgery. Risks are remarkably low overall, yet for selected patients undergoing high-risk procedures, the chances of complications remain reasonably high. The literature has focused largely on identifying patients in whom complications are most likely to occur, using clinical assessment, including RFI, specialized cardiac testing, and perioperative monitoring. Characteristics of the patient and the surgery both influence outcomes. Current practices may have swung toward excessive testing, especially in patients whose surgical risks are low or moderate. Surprisingly little attention has been devoted to the evaluation of preoperative interventions for reducing perioperative risk. Some observations support the feasibility of performing noncardiac surgery in some high-risk groups using support devices or temporizing techniques. The general application of percutaneous or surgical revascularization as a means of reducing perioperative risk has not been assessed and to date represents an expensive and perhaps risky strategy. In patients who satisfy the usual symptomatic or prognostic criteria for coronary revascularization, its timing should depend on the urgency and risk of the noncardiac procedure. Finally, patients with cardiac devices--pacemakers, prosthetic valves, implantable debrillators, and antitachycardia devices--and survivors of congenital and transplant surgery have specific needs that require careful attention, going beyond the usual vigilance required in the perioperative period.

Efficacy of capnometry in ventilatory management of cardiac patients

The ability of capnometry to prevent hypercarbia and to safely help in weaning post-cardiac surgery patients was investigated. The first group, 60 patients, had arterial blood gases (ABG) determined after each new ventilator setting. The corresponding end-tidal C0 2 (P ETCO 2) was recorded and PaCO 2-P ETCO 2 gradients were established at each ABG determination. The initial gradient was maintained during ventilation in the patient. A later gradient, determined when the patient was waking, was used to wean. The next 50 patients, the second group, had responses to ventilator changes determined solely by capnometry. ABG were routinely drawn only to establish the maintenance and weaning PaCO 2-P ETCO 2 gradients. The initial gradients of 8.43 ± 3.45 (mean ± SD) and 7.65 ± 2.24 mmHg, in the first and second groups, narrowed to 1.27 ± 3.79 and 2.21 ± 3.96 mmHg, respectively, when the patients were ready to wean. All patients in both groups were safely weaned. Patients in the second group had fewer ABG. determinations, 3.78 ± 1.30 v 5.40 ± 1.97, a decrease of 1.62 (95% confidence interval 1.54 to 1.70). No patient was hypercarbic. The study shows that capnometry can be used to safely wean patients, decrease the number of ABG, and prevent hypercarbia.

The challenges of OMT in postsurgical management of cardiac patients

The challenges of OMT in postsurgical management of cardiac patients

The Role of Diet, Exercise, and Medication in Blood Lipid Management of Cardiac Patients.

In brief: Results of clinical investigations clearly indicate that aggressive management of blood lipids and lipoproteins can significantly benefit cardiovascular health. This finding is particularly important for patients with diagnosed coronary heart disease and those at risk for developing it. Therapy comprises reduction of excess body fat, a diet low in cholesterol and saturated fats, endurance exercise, and medication. Drugs that affect blood lipid levels include beta-blockers, bile acid binding resins, fibric acid derivatives, hydroxymethylglutaryl-coenzyme A reductase inhibitors, nicotinic acid, and probucol. These can be used singly or in combination to bring about the desired lipid profile.

Cardiovascular Effects of Morphine in Patients with Coronary Arterial Disease

Large doses of morphine sulfate have been reported to cause myocardial lactate production and reduction in coronary blood flow in animals. Similar effects with clinical doses in man would significantly alter the management of cardiac patients. Eleven adult patients with significant coronary arterial disease and normal left ventricular ejection fraction were studied before and 30 minutes after infusion of morphine (0.25 mg/kg IV). Evaluation of myocardial metabolism showed an increase in coronary sinus oxygen content (p less than 0.001) and a reduction in myocardial oxygen consumption. Myocardial lactate extraction was not altered. No change in coronary sinus blood flow was seen. It is concluded that infusion of morphine sulfate, 0.25 mg/kg IV, does not produce global myocardial ischemia in patients with coronary artery disease and normal ventricular function.

Rehabilitation of the cardiac patient. Program phases and rationale.

Management of cardiac patients has clearly changed, with increasing encouragement of early activity. The four-part rehabilitation program described here begins in the coronary care unit and continues well past discharge from hospital.

Cardiovascular Effects of Morphine in Patients with Coronary Arterial Disease

Large doses of morphine sulfate have been reported to cause myocardial lactate production and reduction in coronary blood flow in animals. Similar effects with clinical doses in man would significantly alter the management of cardiac patients. Eleven adult patients with significant coronary arterial disease and normal left ventricular ejection fraction were studied before and 30 minutes after infusion of morphine (0.25 mg/kg IV). Evaluation of myocardial metabolism showed an increase in coronary sinus oxygen content (p < 0.001) and a reduction in myocardial oxygen consumption. Myocardial lactate extraction was not altered. No change in coronary sinus blood flow was seen. It is concluded that infusion of morphine sulfate, 0.25 mg/kg IV, does not produce global myocardial ischemia in patients with coronary artery disease and normal ventricular function.

Application of medical engineering for exercise tests and management on ischemic heart disease--check-alarm-training system.

In the management of Ischemic Heart Disease (IHD) patients the exercise tests are indispensable for the evaluation of severity, coronary reserve capacity or their functional capacities. In the case of cardiac rehabilitation, it is very important to gain the data about patients' cardiac activities (H.R., ECG, workload, etc) not only in the laboratory testing process but also in their daily lives directly. The latter is also the exercise test in the broad sense, and the need for such a test has been recognized by clinicians. We have been utilizing the H.R. value refering to ST, T changes on the exercise test to evaluate and control the IHD patients. Fortunately, by the aid of recent advances of the electronics, we have become able to devise so compact an apparatus as can be carried in their daily lives without worries. These are H.R. Alarm, H.R. Memo. and ECG Memo. In addition to them, the ergometer with a computer for treating the fundamental data in the rehabilitation program has been devised.The Check-Alarm-Training system (CATS) is composed of these apparatuses and considered to be very useful for the management of cardiac patients in their daily lives.

Post-Operative Cardiac Care.

The extraordinary advances in cardiac surgery have widened possibility of improvement for an ever increasing number of patients. The purpose of this volume is to inform those responsible for postoperative management of these patients of special problems that must be identified and treated to achieve a successful outcome. The 143 pages comprise 12 chapters that include following subjects: design and management of an intensive care unit, blood balance, water and electrolyte balance, blood gas and acid base changes, and hematological disorders. Separate chapters deal with postoperative problems of cardiovascular system, respiratory failure, cerebral damage, cardiac arrest, and special problems of infancy. The book does not deal with postoperative management of cardiac patients undergoing noncardiac operations. Some aspects of relevant special pathologic physiology underlying each problem are discussed very briefly in each chapter. Primarily, the book is designed as a practical

Rehabilitation of the patient with acute myocardial infarction

Rehabilitation of the patient with acute myocardial infarction

COMBINED EFFECT OF SODIUM WARFARIN AND PHENYLBUTAZONE.

IN THE COURSE of long-term ambulatory management of cardiac patients with an anticoagulant, sodium warfarin, five individuals also received phenylbutazone for various arthritic manifestations. In all patients a significant dramatic increase in the prothrombin time was observed, at times accompanied by hemorrhagic episodes. In each case, the unexpected effects occurred rapidly at the end of the usual course of treatment with 200 to 300 mg of phenylbutazone daily for five to seven days. A relationship of phenylbutazone to some factors of the coagulation mechanism has been suggested by several investigators, though the available reports do not support consistently positive ideas. For example, Humble 1 stated that the clotting of blood was diminished by phenylbutazone alone, but that the prothrombin time was also lengthened in 30% of the patients receiving this drug. In two individuals it was prolonged as much as two minutes. These findings have not been duplicated by other

The management of cardiac patients in relation to surgery.

Skillful anesthesia and surgical operations do not significantly increase the demands upon the heart for work. Patients who have organic heart disease but who have been able to carry on normal daily activities without symptoms referable to the heart tolerate anesthesia and operation without difficulty provided that anoxia, hemorrhage and shock are avoided. Hypertension, cardiac enlargement, valvular disease other than advanced aortic stenosis, and electrocardiographic abnormalities, per se, do not increase surgical mortality or postoperative morbidity. When symptomatic myocardial insufficiency or evidence of congestive heart failure is present, a period of preoperativre treatment with rest, digitalis, sodium restriction and mercurial diuretics is advisable. Treatment should be as thorough as possible during the interval in which the operation can be safely delayed. With adequate management, patients who have had myocardial failure can be expected to tolerate aniesthesia and surgery satisfactorily. Postoperative complications, such as pneumonia, atelectasis, thromboembolic accidents and abdominal distention, are not well borne, however, and may be responsible for a return of cardiac decompensation. Patients who have auricular fibrillation or auricular flutter should be digitalized before operation even though there have been no symptoms of impaired myocardial reserve and regardless of the ventricular rate. Surgery should be avoided if possible in persons who have severe coronary disease, aortic stenosis, coronary ostial steniosis due to syphilitic aortitis, and high grade or complete auriculoventricular block complicated by the Stokes-Adams syndrome. Spinal anesthesia should not be employed in the presence of these conditions. The decision as to the exact type of operation to be performed is seldom influenced by the existence of organic heart disease. The presence of organic heart disease is only occasionally of more than secondary importance in determining the choice of the anesthetic agent to be given by inhalation. Cyclopropane, however, should not be used. Although unimportant disturbances of cardiac rhythm occur frequently during anesthesia and operation, serious complications such as ventricular tachycardia, standstill of the heart and ventricular fibrillation are uncommon. The treatment of these conditions has been discussed. Postoperative cardiac complications are not common and are seldom responsible for death of the patient. The greatest incidence occurs in patientswhohaveseverecoronaryarterydisease. The intravenous administration of fluids which contain sodium should be avoided during operation and the postoperative period unless their use is specifically indicated.