Perioperative Issues Research Articles

Perioperative Management Issues of Direct Oral Anticoagulants

The treatment repertoire of oral anticoagulation has changed dramatically over the past few years from one class of vitamin K1 antagonists to an increasing number of direct oral anticoagulants (DOACs). Clinicians are confronted with the problem of managing patients on novel agents in the critical setting before, during, and after surgery, where the risk of bleeding and thrombosis are increased simultaneously. Randomized clinical data are insufficient to date, but clinical exposure enlarges the body of experience. The following review considers perioperative management issues in various categories, including minor elective surgery, major elective surgery, and acute surgery. This review is a credo to personalized medicine where the patient's underlying thromboembolic risk status, the potential bleeding risk, or actual hemorrhagic manifestation determine the selection of multi-modal targeted management strategies.

Circulation : Clinical Summaries

<i>Circulation</i> : Clinical Summaries

Emergency mitral valve replacement for acute severe mitral regurgitation following balloon mitral valvotomy: Pathophysiology of hemodynamic collapse and peri-operative management issues

Severe mitral regurgitation (MR) following balloon mitral valvotomy (BMV) needing emergent mitral valve replacement is a rare complication. The unrelieved mitral stenosis is compounded by severe MR leading to acute rise in pulmonary hypertension and right ventricular afterload, decreased coronary perfusion, ischemia and right ventricular failure. Associated septal shift and falling left ventricular preload leads to a vicious cycle of myocardial ischemia and hemodynamic collapse and needs to be addressed emergently before the onset of end organ damage. In this report, we describe the pathophysiology of hemodynamic collapse and peri-operative management issues in a case of mitral valve replacement for acute severe MR following BMV.

Common congenital heart defects and perioperative issues in management

Common congenital heart defects and perioperative issues in management

Handbook of Neuroanesthesia, Fifth Edition. Edited by Philippa Newfield, James E. Cottrell. Philadelphia, Lippincott Williams &amp; Wilkins, 2012. Pages: 480. Price: $60.84.

A “handbook” in medicine is almost like the “middle child” in a family: never taken too seriously but still expected to abide by the rules, never gets the spotlight but still ends up being the most successful and useful of the bunch, always by your side at times of crisis but does not get the respect it truly deserves. The fifth edition of Handbook of Neuroanesthesia, edited by Newfield and Cottrell, almost fits that bill. This book is a perfect example of what you can do right with a difficult and super-specialized subject, limited available real estate, and economy on your mind. I am not an author by any stretch of the imagination, but I can almost feel the pain of the authors while they were planning, editing, and executing this book: what to include and what to leave out!This book is structured like a typical handbook in medicine. Smaller in dimensions than a regular textbook, it has 28 chapters and approximately 500 pages. The chapters are neatly divided into logical sections dealing with general considerations, anesthetic management, and postanesthesia and intensive care. The section on general considerations deals with basic topics, such as physiology, metabolism, effects of anesthesia, improving neurologic recovery from cerebral ischemia, and pain management in neurosurgical patients. There is also a nicely written chapter by a neurosurgeon on the team approach to patient management and the importance of interdisciplinary communication. The second section deals with wide-ranging topics on modern neuroanesthetic management, including head trauma, tumors, aneurysms, strokes, pediatric cases, awake craniotomies, interventional neuroradiological diagnostic and therapeutic procedures, pregnant patients with neurosurgical conditions, positron emission tomography scan, deep brain stimulators, gamma knife, and stereotactic procedures, and many more. The third section has chapters dedicated to traditional postoperative and intensive care topics such as systemic supportive care, fluids and electrolytes, nutrition, and brain death. At the end, there are two additional chapters under the appendices section dedicated to accessing and exchanging information technology and American Society of Anesthesiologists practice guidelines on preventing postoperative visual loss and neuropathies.A unique feature of this book is that all the chapters have an illustrative clinical case description highlighting the relevant clinical points right at the beginning. This is followed by chapter highlights in all (and a summary in many) of the chapters. This early summary really helps to keep focus on the intended topic from the beginning and makes for an easy review later. At the end of every chapter, there is a list of suggested readings. Interestingly enough, many of the chapters actually have a list of suggested Internet references as well, which is sure to satisfy many of us who are hungry for more!The contents of the chapters are logical, up to date, practical, informative, and very easy to read. The authors have taken a comprehensive approach to clinical information presentation and managed to include a wide range of relevant multidisciplinary scientific information about a particular topic without losing sight of the overall goal of perioperative patient care. Almost every topic has not only discussion of perioperative issues and concerns, such as monitoring, medications, induction and maintenance, outcome, and many more but also useful information on pathophysiology, anatomy, pharmacology, diagnostic modalities, treatment and management options, and outcome and preventative data. All of this makes for a very satisfying read and makes this book feel really comprehensive yet convenient, a rare combination indeed. There is also a treasure trove of useful tables in the book, and several easy-to-understand diagrams and figures have been thrown in for good measure. In keeping up with the times, the authors have paid special attention to issues such as interdisciplinary teamwork, communication, and information technology. The chapter on online medical resources and search modalities available for clinical scientists made for an interesting read.Any shortcomings in this book? Nah!! In my humble opinion, considering the target audience and the set objectives of this text, the authors have achieved in this book what many authors hope to achieve and what most prospective authors should aspire to achieve….simplicity, balance, and objectivity. One could nitpick about lack of glossy pages and a paucity of color plates, but in today’s day and age, keeping overhead costs low is a key ingredient to success. Color, especially if zealously overdone, can be a distraction in scientific texts. Does the small print bother me? Not yet, but my days are probably numbered and hey, remember this is a handbook. Neuroanesthesiology was probably never a superstar subspecialty, but if this wonderful handbook manages to make a few converts and motivate a few uninitiated to pursue the specialty, that would be its biggest achievement. This book has that capability and then some.

Anesthetic considerations in parturients with liver transplant

Advances in the surgical technique, safer anesthetic agents, improved hemodynamic monitoring, better pre-operative optimization of cirrhotic patients and postoperative critical care facilities have led to drastic improvement in the outcomes following orthotopic liver transplantation (OLT). Reproductive dysfunction in patients with end-stage liver disease can be corrected within months of successful orthotopic liver transplantation. Consequently, there is a worldwide increase in the number of women of childbearing potential after orthotopic liver transplantation. Successful pregnancies are now increasingly being reported in these patients. These are high-risk pregnancies as increased medical and obstetric complications and adverse maternal and fetal effects of immunosuppressant medications are likely to be encountered in these patients following liver transplantation. Optimal antenatal and perioperative management in these parturients warrant a multidisciplinary approach and meticulous planning. There is little evidence available regarding anesthetic concerns in this high-risk pregnant population. This review is aimed at addressing important perioperative issues in parturients, who have undergone a successful liver transplantation.

Pharmacists take prominent role at the International Society of Heart and Lung Transplant 33rd annual meeting and scientific sessions in Montreal

There was a real buzz after the pharmacy symposium at the International Society of Heart and Lung Transplant (ISHLT) annual conference this year in Montreal, with the audience and speakers...

Long-term outcomes after heart transplantation in adult patients with cardiac congenital heart disease: impact of initial defect and repair: a collaboratve study on 97 patients

Purpose: An increasing number of children with complex congenital heart disease reach adulthood because of the advances in pediatric cardiology and surgery. Residual abnormalities in cardiac structure and function predispose adults with congenital heart disease (ACHD) to late-onset heart failure and its complications. Heart transplantation (HTx) often remains the only option. But ACHD represent a heterogeneous population. We thought to compare outcomes in different defects and in different physiopathological models of repair i.e. univentricular (1V) or biventricular (2V) status. Methods: Out of a multi-institutional (3 centers) series of 2257 HTx from 1988 and 2012, 100 (4.4%) were performed in 97 ACHD aged ≥16 years at the time of operation (65 men). We evaluated clinical data, etiology, surgical history, perioperative issues and outcomes. Results: The mean age at the time of HTx was 29.8±10.5 years (range 16-58). Forty-three patients (44%) had 1V physiology including 16.5% Fontan-type circulation and 54 (56%) had 2V physiology including 26% with a systemic right ventricle. Primary diagnosis included single ventricle (27%), D-transposition of the great arteries (20%), tricuspid atresia (13%), tetralogy of Fallot (12%), congenital valvular heart diseases (11%), corrected transposition of the great arteries (7%), and other anomalies (9%). Eighty-seven patients (90%) had undergone ≥1 prior cardiac surgery before HTx.An additional surgical procedure during the HTx, like pulmonary artery reconstruction, was performed in 22% patients. Twenty-four patients (25%) required reintervention for post-operative hemorrhage. In-hospital mortality was high (34%). Multivariable factors associated with increased in-hospital mortality included female gender of the donor and tricuspid atresia. The 1V patients were more often younger (26.9 vs 32.1 years, p=0.014), had undergone more surgeries (2.9 vs 1.9 prior surgeries, p=0.002), had a lower requirement for ventricular assist device implantation before HTx (4.7% vs 20.4%, p=0.02), and had longer ischemic (229 vs 182min, p<0.001) and cardiopulmonary bypass times (240 vs 163min, p<0.001). Long-term survival was significantly higher in 2V patients (p=0.023). Conclusion: HTx of ACHD poses several surgical challenges due to complex anatomy, specific physiology and prior surgical interventions. 1V physiology is associated with higher in-hospital and long-term mortality, in comparison to 2V physiology. Further studies are warranted to identify whether earlier HTx of these patients may improve these outcomes.

Teaching and Sustainably Implementing Awake Craniotomy in Resource-Poor Settings

Awake craniotomy for brain tumor resection has the benefit of avoiding a general anesthetic and decreasing associated costs (e.g., intensive care unit beds and intravenous line insertion). In low- and middle-income countries, significant resource limitations for the system and individual make awake craniotomy an ideal tool, yet it is infrequently used. We sought to determine if awake craniotomy could be effectively taught and implemented safely and sustainably in low- and middle-income countries. A neurosurgeon experienced in the procedure taught awake craniotomy to colleagues in China, Indonesia, Ghana, and Nigeria during the period 2007-2012. Patients were selected on the basis of suspected intraaxial tumor, absence of major dysphasia or confusion, and ability to tolerate the positioning. Data were recorded by the local surgeons and included preoperative imaging, length of hospital admission, final pathology, postoperative morbidity, and mortality. Awake craniotomy was performed for 38 cases of suspected brain tumor; most procedures were completed independently. All patients underwent preoperative computed tomography or magnetic resonance imaging. In 64% of cases, patients remained in the hospital <10 days. The most common pathology was high-grade glioma, followed by meningioma, low-grade glioma, and metastasis. No deaths occurred, and no case required urgent intubation. The most common perioperative and postoperative issue was seizure, with 1 case of permanent postoperative deficit. Awake craniotomy was successfully taught and implemented in 6 neurosurgical centers in China, Indonesia, Ghana, and Nigeria. Awake craniotomy is safe, resource-sparing, and sustainable. The data suggest awake craniotomy has the potential to significantly improve access to neurosurgical care in resource-challenged settings.

Understanding and managing medication in elderly people

Ageing alters drug handling by the body (pharmacokinetics) and response to medications (pharmacodynamics). Multiple comorbidities increase the risk of adverse drug reactions and medication burden, with increased potential for drug interactions. Elderly people are seldom included in clinical trials, so underestimation of benefits and overestimation of risk may lead to under-treatment. Cognitive and functional changes associated with ageing may make it difficult for elderly people to adhere to treatment regimens. In this review, we consider these issues, with particular reference to drugs prescribed for gynaecology patients (the 'gynaecology formulary'). It will focus on key areas of gynaecological practice, including prescribing anticholinergic drugs, hormone treatments and anticancer drugs, and perioperative issues relating to anaesthesia, analgesia and anticoagulation. Implications of common comorbidities, including osteoporosis, diabetes mellitus and cardiovascular disease, for prescribing in gynaecological patients will also be considered.

High Le Fort I and Bilateral Split Sagittal Osteotomy in Crouzon Syndrome

Crouzon syndrome is a rare, autosomal dominant disease from a fibroblast growth factor receptor 2 gene mutation, characterized by premature craniosynostosis, hypertelorism, orbital proptosis, psittichorina, hypoplastic maxilla, and mandibular prognathism. We present an adult 32-year-old Crouzon syndrome patient who underwent an elective High Le Fort I and bilateral split sagittal osteotomy for midface advancement with a background of jaw malocclusion and obstructive respiratory symptoms. The operation features a potential dynamic movement of the secured airway in the surgical field and close proximity to exposed ocular structures. Permissive hypotensive anesthesia was employed to improve the surgical field and reduce intraoperative blood loss and dose of long-acting opioids. He was extubated at the end of an uneventful surgery and was monitored in the high dependency overnight before he was discharged to the general ward. Perioperative issues include potential difficult airway management; ocular, auditory, and neurological injury prevention; surgery-specific anesthetic technique; and postoperative analgesia. Understanding the multisystemic issues facilitates the dynamic anesthetic management during surgery. Good communication among the multidisciplinary team is essential to ensure a successful operation and uneventful recovery.

Orthopedic trauma surgery in the morbidly obese patient

The treatment of morbidly obese patients in orthopedic trauma differs in many ways compared to injured patients with normal body mass indices. This paper highlights key differences and ways to overcome obstacles. We present specific tips, as well as considerations for initial planning, positioning for surgery, intra-operative strategies, and a discussion on both anesthesia and imaging. Several treatment strategies have been shown to have better results in morbidly obese patients. Pre-operative planning is necessary for minimizing risk to the patient. The prevalence of morbid obesity has increased in the USA in the past quarter century. Treatment for orthopedic injuries in morbidly obese patients requires a multidisciplinary approach that addresses not only their orthopedic injuries, but also medical co-morbidities. A team of medicine doctors, anesthesiologists, X-ray technicians, physical and occupational therapists, respiratory therapists, and social workers is needed in addition to the orthopedic surgeon. Modifications in both pre-operative planning and intra-operative strategies may be necessary in order to accommodate the patient. This paper presents numerous technical tips that can aid in providing stable fixation for fractures, as well as addressing peri-operative issues specific to the morbidly obese.

Perioperative treatment for children with hemophilia

Hemophilia is a common pediatric hereditary bleeding disorder,including hemophilia A (FⅧ deficiency) and hemophilia B (FⅨ deficiency).Children with hemophilia tend to spontaneous bleeding or bleeding after minor injuries or surgery.In this review,we briefly discussed the preoperative diagnosis and classification of hemophilia,dynamic monitoring of FⅧ or FⅨ,dose of clotting factor and duration of treatment and some other perioperative issues when surgery is needed,to guide hemophilia children's surgery and postoperative rehabilitation. Key words: Hemophilia; Children; Perioperative period; Treatment

Repeated Respiratory Failure and Failed Extubation Following Intraoperative Advanced Airway Device Endotracheal Intubation

Intraoperative airway management by anesthesiology providers has evolved over the years to include many specialized devices and techniques that can have tremendous impact on the care of the perioperative critically ill patient. When perioperative patient care issues arise, anesthesiologists and perioperative critical care specialists should both be actively involved in a dialogue regarding many the relevant patient care issues, including any airway and respiratory function problems. Additionally, critical care specialists should be familiar with the use and potential complications of the increasingly diverse airway (and non-airway) tools and devices used by anesthesiologists in the operating room. The authors present a case report of a 66-year-old man who suffered repeated postoperative respiratory failure following an uncomplicated upper extremity orthopedic procedure. The patient developed unexplained, repeated postoperative respiratory failure that necessitated reintubation related to the accidental and unrecognized retention of a plastic tip extender from a Bullard fiber-optic laryngoscope. After transfer to the ICU, the patient continued to have significant respiratory distress requiring aggressive post-extubation noninvasive mechanical ventilation. The cause of this complication was not diagnosed by the anesthesiologist or the intensive care team throughout the course of this patient’s respiratory failure. Ultimately, the patient spontaneously expectorated the tip extender with rapid improvement in his respiratory function. This case highlights the importance of the dialogue that should occur between anesthesiologists and critical care specialists when unexpected and/or unexplained perioperative complications occur.

Priority Patient Safety Issues Identified by Perioperative Nurses

Much of the work done by perioperative nurses focuses on patient safety. Perioperative nurses are aware that unreported near misses occur every day, and they use that knowledge to prioritize activities to protect the patient. The purpose of this study was to identify the highest priority patient safety issues reported by perioperative RNs. We sent a link to an anonymous electronic survey to all AORN members who had e-mail addresses in AORN’s member database. The survey asked respondents to identify top perioperative patient safety issues. We received 3,137 usable responses and identified the 10 highest priority safety issues, including wrong site/procedure/patient surgery, retained surgical items, medication errors, failures in instrument reprocessing, pressure injuries, specimen management errors, surgical fires, perioperative hypothermia, burns from energy devices, and difficult intubation/airway emergencies. Differences were found among practice settings. The information from this study can be used to inform the development of educational programs and the allocation of resources to enhance safe perioperative patient care.

Severe intraoperative hypertension after induction of anesthesia in a child with a neuroblastoma

Neuroblastomas are the most common, non-central nervous system tumor of childhood. Similar to pheochromocytomas, they are derived from neural crest cells and therefore retain the potential to synthesize catecholamines. Unlike pheochromocytomas, however, perioperative issues related to blood pressure instability with hypertension are uncommon. We report details of a 3-year-old child with a neuroblastoma who developed severe hypertension and end-organ effects after induction of anesthesia. The association of such problems with neuroblastoma is reviewed and options for perioperative care presented.

Pulmonary Hypertension Roundtable: Pulmonary Roundtable – Bariatric Surgery and the PAH Patient

As guest editor of this issue on perioperative issues in PAH patients, Sean Studer, MD, MSc, convened a group of experts to discuss the implications of bariatric surgery for the pulmonary hypertension patient. Given the prevalence of obesity and its sequelae related to PH patients, it's not an uncommon topic. The approach to patient counseling, minimizing surgical risks, and working with the interdisciplinary team were addressed among the wide range of topics by clinicians on the front lines. Taking part in the conversation were Michael Mathier, MD, Assistant Professor of Medicine, Director, Pulmonary Hypertension Program, and Associate Director, Cardiovascular Fellowship Program of the University of Pittsburgh Medical Center; Dana P. McGlothlin, MD, Medical Director of Combined Heart-Lung Transplantation and Mechanical Circulatory Support, Medical Director of the Cardiac Intensive Care Unit, and Associate Director of the Pulmonary Hypertension Program at the University of California, San Francisco; Ramesh C. Ramanathan, MD, is a surgeon specializing at the University of Pittsburgh Medical Center. Deborah J. Levine, MD, Associate Professor, Pulmonary Disease and Critical Care Medicine, Director, Pulmonary Hypertension Clinic, University of Texas Health Science Center, San Antonio, added comments from the pulmonary perspective to the transcript of the discussion.

Low-dose spinal anesthesia for urgent laparotomy in severe myasthenia gravis

Myasthenia gravis (MG) is an autoimmune disease with an incidence of 2-10/100,000 cases per year, characterized by muscle weakness secondary to destruction of postsynaptic acetylcholine receptors. In these patients, important perioperative issues remain unresolved, namely, optimal administration of cholinesterase inhibitors, risks of regional anesthesia, and prediction of need of postoperative mechanical ventilation. We describe the use of a low-dose spinal anesthesia in a patient with MG who was submitted for emergence exploratory laparotomy. The utilization of low-dose spinal anesthesia allowed us to perform surgery with no adverse respiratory or cardiovascular events in this patient.

Robot-Assisted Intracorporeal Formation of the Ileal Neobladder

We are celebrating the 10th anniversary of robot-assisted laparoscopic radical cystectomy (RARC) with urinary diversion (UD), and it seems that this operation is successfully following the footsteps of robot-assisted laparoscopic radical prostatectomy. Until now, approximately 1000 RARCs have been recorded; of them, only 102 were performed totally intracorporeally with a formation of an ileal neobladder. Despite the small numbers, morbidity and functional outcomes seem to be acceptable, when compared with the gold standard-the open procedure. It is imperative that in a challenging procedure such as this, the console surgeon follow a standardized protocol of all surgical steps to ensure the optimal results. In this article, we are sharing Karolinska's experience and discuss all perioperative issues along with ways of dealing with tricky cases.

A formula for implant volume choice in breast reconstruction after nipple sparing mastectomy

Implant choice after Nipple Sparing Mastectomy (NSM) is a problematic perioperative issue. In this retrospective study, the authors searched for a correlation between mastectomy weight and implant volume choice after NSM. A mathematical expression of this correlation was found that might help surgeons decide implant volume after NSM.