Perioperative Considerations Research Articles

Indications, algorithms, and outcomes for coronary artery bypass surgery in patients with acute coronary syndromes.

For patients with a non-ST-segment elevation acute coronary syndrome (NSTE-ACS), guideline recommendations and treatment pathways focus on revascularization for definitive treatment if the patient is an appropriate candidate. Despite the widespread use of revascularization for NSTE-ACS, most patients undergo a percutaneous coronary intervention, whereas a minority of patients undergo coronary artery bypass grafting. Focusing specifically on the USA, the contemporary utilization, preoperative and perioperative considerations, and outcomes of NSTE-ACS patients undergoing coronary artery bypass grafting have not been comprehensively reviewed.

Perioperative considerations in children with autism spectrum disorder.

Children with autism often present a challenge to the anesthesiologist. This review summarizes the current experiences and recommendations for the perioperative management of this unique group of patients. Autism is the fastest growing neurodevelopmental disorder in the world. Increased recognition and public awareness of the disease is driven largely by the advances in research. A large body of evidence exists that identifies the role of genetic, environmental, biological, and developmental factors in the origin of autism. The anesthesia literature consists mostly of case reports. Recent publications are reporting management strategies and evaluation of this patient population's perioperative experiences. Patients with autism spectrum disorder are a heterogeneous group and often need general anesthesia for different procedures and studies. Familiarity with each patient's behavioral specifics and efforts to alleviate stress is of paramount importance for a smooth perioperative course with minimal adverse events.

Perioperative Considerations in Crohn Disease and Ulcerative Colitis.

The management of inflammatory bowel disease (IBD) is medically and surgically complex. Numerous patient- and disease-oriented factors must be considered in treating patients with IBD, including nutritional replenishment/support, effect of immunosuppressive medications, extent of resection, and use of proximal diversion. Perioperative planning and optimization of the patient is imperative to ensuring favorable outcomes and limiting morbidity. These perioperative considerations in Crohn disease and ulcerative colitis are reviewed here.

Consideraciones perioperatorias en pacientes consumidores de drogas ilícitas de uso frecuente

Due to the significant increase of illicit or recreational drugs in our society, it is increasingly likely that we find patients using them in the surgical context. It is important to understand the main effects of illegal substances most commonly used by patients undergoing surgery, such as cocaine, marijuana, cocaine paste and psychostimulants, as the most significant effects that can be produced by combining these recreational drugs with related substances of surgery and anesthesia. It is also relevant to consider the major perioperative considerations (surgical and anesthetic) in consumer patients of these illicit drugs.Cocaine alters the cardiovascular, respiratory, central nervous, gastrointestinal and renal systems, addicted patients taking higher risk of acute myocardial infarction, arrhythmias and arterial hypertensive crisis. Marijuana inhibits muscarinic acetylcholine receptors, primarily affecting the cardiovascular, respiratory and neuropsychiatric systems, and has an important role in intra and postoperative analgesic management. The cocaine base paste causes transient increase in dopaminergic neurotransmission, being similar to cocaine so a similar perioperative management is recommended. The psychostimulant drugs are sympathomimetic effect, essentially affecting the cardiovascular and metabolic systems.This review summarizes the current medical evidence on the subject, in order to unify criteria and management guidelines suggest these patients during the perioperative period, where the effects of these illicit drugs are likely to be more significant, potentially leading to serious complications and endangering the patient's life.

Right and left ventricular assist devices support and liver dysfunction: prognostic and therapeutic implications.

Advanced heart failure is a chronic, systemic disease, which affects other organs in ways that are incompletely understood. Patients with advanced heart failure commonly develop congestive hepatopathy, which may lead to progressive hepatic injury and fibrosis. Because the independent adverse effects of hepatic dysfunction on early and late outcomes after continuous flow left ventricular assist devices have also not been entirely demonstrated, we review its impact on this patient population. Although early mortality is increased in patients with significantly elevated total bilirubin before implant, early improvement in hepatic function is consistently observed following left ventricular assist device (LVAD) implantation, and this early improvement remains stable during late follow-up. Furthermore, a growing experience with expanded application of LVAD therapy in special patient populations, such as those with restrictive cardiomyopathy or congenital heart disease, demonstrates improved outcomes with LVAD compared with continued medical therapy. Although these outcomes are encouraging in the context of hepatic dysfunction not being considered a precluding factor in isolation, careful patient selection and preoperative optimization should be employed to ensure acceptable risk and a durable outcome. Significant preoperative hepatic dysfunction can increase early mortality in patients undergoing LVAD implant, but long-term outcomes in early survivors demonstrate improvement in measures of hepatic function, which is maintained during follow-up. Numerous perioperative considerations are imperative to optimize to ensure a durable outcome with LVAD in these patients.

Becker's Muscular Dystrophy and Orthotopic Heart Transplantation: Perioperative Considerations

Patients with Becker's and Duchenne's muscular dystrophy occasionally have myocardial involvement leading to end-stage heart failure. Heart transplantation is established as an effective therapy. Achieving successful outcomes in this challenging group requires special consideration during the perioperative period to limit preoperative deconditioning, minimize anesthesia complications, and rapidly institute rehabilitation with appropriate precautions. We reviewed our recent experience with Becker's muscular dystrophy patients and discuss the management of perioperative issues specific to this patient group.

The Patient with an LVAD Presenting for Non-cardiac Surgery: Perioperative Considerations

Heart failure refractory to medical therapy may be treated by heart transplantation. Given that the need for organs outpaces supply, ventricular assist devices (VADs) were developed to support hemodynamics in the patient with end-stage heart failure. Initially approved only in those patients awaiting transplantation, VADs are now implanted for long-term therapy in patients ineligible for transplantation. Many of these patients may subsequently present for non-cardiac surgery, possibly in a non-transplant center. General anesthesiologists may therefore be expected to care for these patients, especially in an emergency. This review presents an overview of current VADs as well as their unique preoperative and intraoperative anesthetic considerations.

Ventricular assist devices and non-cardiac surgery.

The use of ventricular assist devices has expanded significantly since their approval by the Food and Drug Administration in the United States in 1994. In addition to this, the prevalence of heart failure continues to increase. We aim to provide an overview of perioperative considerations and management of these patients for non-cardiac surgery. We performed a Medline search for the words “ventricular assist device,” “Heartmate” and “HeartWare” to gain an overview of the literature surrounding these devices, and chose studies with relevance to the stated aims of this review. Patients with ventricular assist devices are presenting more frequently for surgery not related to their cardiac pathology. As the mechanically supported population grows, general anesthesiologists will be faced with managing these patients, possibly outside of the tertiary care setting. The unique challenges of this patient population can best be addressed by a thorough understanding of ventricular assist device physiology and a multidisciplinary approach to care.

Implications of Rheumatic Disease and Biological Response-Modifying Agents in Plastic Surgery.

The preoperative evaluation for any reconstructive or aesthetic procedure requires a detailed history of existing medical conditions and current home medications. The prevalence of rheumatic diseases such as rheumatoid arthritis, gout, and psoriasis is high, but the impact of these chronic illnesses on surgical outcome and the side effects of the powerful medications used for treatment are often underappreciated. In this review, the authors highlight key perioperative considerations specific to rheumatologic diseases and their associated pharmacologic therapies. In particular, the authors discuss the perioperative management of biological response-modifying agents, which have largely become the new standard of therapy for many rheumatic diseases. The literature reveals three key perioperative concerns with biological therapy for rheumatic disease: infection, wound healing delays, and disease flare. However, data on specific perioperative complications are lacking, and it remains controversial whether withholding biological therapy before surgery is of benefit. The risk of these adverse events is influenced by several factors: age, sex, class of biological agent, duration of exposure, dosage, onset and severity of disease, and type of surgical procedure. Overall, it remains best to develop an individualized plan. In younger patients with recent onset of biological therapy, it is reasonable to withhold therapy based on 3 to 5 half-lives of the specific agent. In older patients with a substantial history of rheumatic disease, the decision to discontinue therapy must be weighed and decided carefully in conjunction with the rheumatologist.

Airway Management via Laryngeal Mask in Laryngotracheal Resection.

We present a case of impassable subglottic stenosis scheduled for tracheal resection and reconstruction managed by establishing a supraglottic airway. Despite careful preoperative evaluation, the stenosis was localized higher than anticipated, rendering conventional intubation impossible. Laryngeal mask bridging to cross-field ventilation was feasible and jet ventilation and cardiopulmonary bypass were available as emergency strategies. Surgery and emergence went uneventful. Perioperative considerations are discussed in this report.

Perioperative considerations in adult mitochondrial disease: A case series and a review of 111 cases

Mitochondrial disease has been uncommon conditions, still results in death during childhood in many cases. The ideal anesthetic pharmacological management strategy for adult patients with mitochondrial disease is currently unclear. In this study, we presented features of the anesthesia methods employed and the perioperative complications of patients in our institution and in previously published case reports. We report the use of general anesthesia 7 times in 6 adult patients with mitochondrial disease during 2004–2014. All cases were performed with maintained intravenous anesthesia. One case was reintubated on the day after surgery, but the cause of death was not directly related to anesthesia. One hundred and eleven general anesthesia cases in 97 adult patients with mitochondrial disease were described in 83 the literature. Although several severe perioperative complications and deaths have been reported, malignant hyperthermia had not been reported in adult cases, and metabolic disorder called propofol infusion syndrome had also not been reported in adult patients undergone total intravenous anesthesia. Perioperative complications of lactic acidosis were reported more in inhalation anesthesia than intravenous anesthesia. Therefore we recommended intravenous anesthesia rather than inhalation anesthesia for adult mitochondrial disease.

Anesthetic Implications in Rubinstein-Taybi Syndrome

Rubinstein-Taybi syndrome (RTS), also known as broad thumb-hallux syndrome or Rubinstein syndrome, is an autosomal dominant condition characterized by short stature, moderate to severe learning difficulties, distinctive facial features, and broad thumbs and first toes. Given the associated anatomical features of the disorder, anesthetic care may be required during surgical procedures to correct the end-organ effects of the disorder. We present a 5-year-old boy with RTS that required anesthetic care for an adenotonsillectomy. Previous reports of anesthetic care for patients with RTS are reviewed and the perioperative considerations of these patients are discussed. J Med Cases. 2015;6(11):534-536 doi: http://dx.doi.org/10.14740/jmc2344w

Perioperative Management of a Patient With Giant Axonal Neuropathy

Giant axonal neuropathy (GAN) is a rare, autosomal recessive, progressive neurodegenerative disorder affecting both the central and peripheral nervous systems. The aberrant accumulation of cytoskeletal-associated proteins causes neurodegeneration resulting in both motor and sensory dysfunction. Given the invariable and progressive involvement of the neuromuscular system, anesthetic care is frequently needed to correct the orthopedic sequelae of the disorder. We present a 12-year-old girl with GAN who required anesthetic care for posterior spinal fusion to treat scoliosis. Previous reports of anesthetic care for patients with GAN are reviewed, and the perioperative considerations of these patients are discussed. J Med Cases. 2015;6(11):512-516 doi: http://dx.doi.org/10.14740/jmc2346w

Reconstructive surgery and patients with spinal cord injury: Perioperative considerations for the plastic surgeon

Background: Patients with spinal cord injury (SCI) requiring reconstructive surgery, particularly for pressure ulcers, are ubiquitous in Plastic and Reconstructive Surgery practices. Much of the current literature focuses on operative techniques, antibiotic indications, sitting protocols, and dressing and bedding choices. Methods: This paper reviews normal neuroanatomy, outlines changes in neurophysiology observed in spinal cord injury, and addresses concepts related to perioperative care that are highly relevant but often under-emphasised. Results: Vascular disturbances such as autonomic dysreflexia and orthostatic hypotension are dangerous phenomena occurring in this patient population that, if not properly recognised and treated, may result in complications such as haematoma, flap loss, inadequate tissue perfusion, and death. The management of spasticity, deep venous thrombosis, and perioperative pain are also relevant and discussed in this paper. Conclusion: A basic understanding of these concepts is essential for the Plastic Surgeon involved in the care of patients with SCI and pressure ulcers, particularly before and after debridement or reconstruction.

A Literature Review of Total Hip Arthroplasty in Patients with Ankylosing Spondylitis: Perioperative Considerations and Outcome

Ankylosing spondylitis is a spondyloarthropathy affecting the sacro-iliac joints with subsequent progression to the spine and the hip joints. The hip joints are affected by synovitis, enthesial inflammation, involvement of medullary bone, progressive degeneration and secondary osteoarthritis. Clinical presentation is usually in the form of pain and stiffness progressing to disabling fixed flexion contractures and in some instances, complete ankylosis. Hip arthroplasty should be considered for hip pain, postural and functional disability, or pain in adjacent joints due to hip stiffness. We conducted a literature review to determine peri-operative considerations and outcome in ankylosing spondylitis patients undergoing hip arthroplasty. In this review, we have discussed pre-operative surgical planning, thromboprophylaxis, anaesthetic considerations and heterotopic ossification. Outcomes of arthroplasty include range of movement, pain relief, survivorship and complications.

Perioperative Considerations for Children With Right Ventricular Dysfunction and Failing Fontan

The survival of patients with congenital heart diseases (CHD) has increased in the past decades, resulting in the identification of new characteristics of chronic comorbidities observed in pediatric and adults with CHD. Patients with CHD can present with a broad clinical spectrum of manifestations of congestive heart failure (CHF) at any point throughout their lives that may be related to anatomical or surgical variables. This article focuses on the perioperative assessment of patients with CHD and CHF, with an emphasis on pathophysiologic, diagnostic, and therapeutic alternatives in patients with right ventricular failure and failing Fontan circulation. We also provide descriptions of the effects of sedatives and anesthetics commonly used in this population in diagnostic or invasive procedures.

Case Report: Perioperative management of a pregnant poly trauma patient for spine fixation surgery

Trauma is estimated to complicate approximately one in twelve pregnancies, and is currently a leading non-obstetric cause of maternal death. Pregnant trauma patients requiring non-obstetric surgery pose a number of challenges for anesthesiologists. Here we present the successful perioperative management of a pregnant trauma patient with multiple injuries including occult pneumothorax who underwent T9 to L1 fusion in prone position, and address the pertinent perioperative anesthetic considerations and management.

Anesthetic Pharmacology and Perioperative Considerations for Heart Transplantation

From uncertain beginnings over four decades ago, heart transplantation is now the definitive therapy for end-stage heart failure. This review will attempt to comprehensively cover the broad gamut of anesthetic, hemodynamic, antimicrobial, immunosuppressive and hemostatic agents used by the cardiothoracic anesthesiologist in the perioperative management of patients with endstage heart disease.

Anesthetic Pharmacology and Perioperative Considerations for the End Stage Liver Disease Patient

The number of patients with end stage liver disease is growing worldwide. This is likely a result of advances in medical science that have allowed these patients to lead longer lives since the incidence of diseases such as alcoholic cirrhosis and viral hepatitis have remained stable or even decreased in recent years, at least in more developed nations. Many of these patients will require anesthetic care at some point. The understanding and application of basic principles of pharmacokinetics is paramount to the practice of anesthesia. An understanding of pharmacokinetic principles provides the anesthesiologist with a scientific foundation for achieving therapeutic objectives associated with the use of any drug; however, pathologic conditions often alter the expected kinetic profile of many drugs. Anesthesia providers caring for these patients must be aware of the altered pharmacokinetics that may occur in these patients. We review normal liver physiology, pathophysiology of liver disease in general, and how liver failure affects the pharmacokinetics and pharmacodynamics of anesthetic agents; providing some specific examples.

Anesthetic Pharmacology for Kidney Transplantation

Kidney transplants are routinely performed at medical centers around the world. Concurrent with improved surgical techniques, a better understanding of the pharmacology involved in the perioperative anesthetic management has led to improved outcomes in these patients. This chapter reviews the perioperative pharmacologic considerations surrounding kidney transplant patients from the viewpoint of the transplant anesthesiologist.