Seminars in Cardiothoracic and Vascular Anesthesia最新文献

{"title":"Unanticipated Profound Paralysis and Sugammadex Dosing Implications After Videoscopic Thoracic Surgery.","authors":"Melissa L McKittrick,&nbsp;Frederick W Lombard","doi":"10.1177/10892532211059885","DOIUrl":"https://doi.org/10.1177/10892532211059885","url":null,"abstract":"<p><p>A bedridden patient with empyema presented for thoracoscopic decortication. During the procedure, despite a post-tetanic count (PTC) of 0 via calibrated quantitative neuromuscular monitoring, persistent diaphragmatic movement impaired operating conditions, so rocuronium was re-dosed. After surgery, the patient had 0 PTC. Sugammadex was titrated to achieve baseline neuromuscular strength, monitoring the effect of each 200-mg dose. Ultimately, 1200 mg was required to achieve baseline strength. We describe monitor troubleshooting, considerations with unexpectedly deep neuromuscular blockade, the importance of routine quantitative neuromuscular monitoring, and one strategy for sugammadex reversal in patients with profound paralysis outside of the standard dosing guidelines.</p>","PeriodicalId":46500,"journal":{"name":"Seminars in Cardiothoracic and Vascular Anesthesia","volume":"26 1","pages":"86-89"},"PeriodicalIF":1.4,"publicationDate":"2022-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"39800998","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Is It Time for Paradigm Shift in Pain Management for Cardiac Surgery Patients?","authors":"Kathirvel Subramaniam,&nbsp;Ibrahim Sultan,&nbsp;Nathaen Weitzel,&nbsp;Miklos D Kertai","doi":"10.1177/10892532211058494","DOIUrl":"https://doi.org/10.1177/10892532211058494","url":null,"abstract":"Opioids are reliable and effective analgesics for treating acute postoperative pain following any surgical procedure, including cardiac surgery. Recent concerns about persistent opioid use after discharge from the hospital have triggered changes in the way patients’ pain is managed during their perioperative period. This has led to the widespread use of various regional analgesic techniques, as well as anesthesia techniques based on non-narcotic analgesics for cardiac surgery. Multi-modal analgesia has been an accepted component of enhanced recovery after surgery (ERAS) protocols and implementation of ERAS in cardiac surgery has been shown to decrease opioid consumption, duration of mechanical ventilation, and length of intensive care unit and hospital stay. Seminars in Cardiothoracic and Vascular Anesthesia (SCVA) invited submissions related to painmanagement after cardiac surgery and published a series of impressive articles dedicated to this important topic for the December issue. Devarajan et al explored evidence behind the use of various neuraxial and non-neuraxial regional analgesic techniques in a two-part review. It is clear that epidural blocks will not be re-entering the cardiac surgical arena because of concerns over epidural hematoma, despite their advantages. However, spinal opioids are making a comeback, with renewed interest in their clinical use and research for ERAS protocols. Tissue plane blocks (erector spinae block, pecto-intercostal block, and transverse thoracic plane block) are becoming popular, as they can be administered easily with ultrasound guidance and have been found to be safe compared to central neuraxial blocks in cardiac surgery. In this issue of SCVA, two original articles are published on the use of these tissue plane blocks in cardiothoracic surgery. Cardinale et al studied transverse thoracic plane blocks in elective cardiac surgery along with multimodal analgesia. The authors reported increased early extubations and shortened length of intensive care unit and hospital stay. Dunham et al published on the utility of intercostal nerve blocks with standard and liposomal bupivacaine in thoracic surgical patients. While these studies add evidence to support the incorporation of these blocks into clinical practice, there is a need for large, well-controlled, and randomized clinical studies with meaningful patient outcomes before perioperative physicians can declare victory and adopt them into a new standard of care. The use of various non–opioid-based analgesics (ketamine, dexmedetomidine, lidocaine, acetaminophen, ketorolac, and gabapentin) in cardiac surgery is another topic of debate. Nazarnia et al reviewed and reported the evidence behind the use of non–opioid-based analgesics in cardiac surgery practice. While the cardiac anesthesia community has widely adopted the use of these medications as alternatives to opioids, the review pointed out the lack of clear evidence supporting the efficacy and safety of many ","PeriodicalId":46500,"journal":{"name":"Seminars in Cardiothoracic and Vascular Anesthesia","volume":"25 4","pages":"249-251"},"PeriodicalIF":1.4,"publicationDate":"2021-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"39721110","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Regional Analgesia for Cardiac Surgery Part 1. Current status of neuraxial and paravertebral blocks for adult cardiac surgery.","authors":"Jagan Devarajan,&nbsp;Sennaraj Balasubramanian,&nbsp;Soheyla Nazarnia,&nbsp;Charles Lin,&nbsp;Kathirvel Subramaniam","doi":"10.1177/10892532211023337","DOIUrl":"https://doi.org/10.1177/10892532211023337","url":null,"abstract":"<p><p>Cardiac surgeries are known to produce moderate to severe pain. Pain management has traditionally been based on intravenous opioids. Poorly controlled pain can result in increased incidence of respiratory complications such as atelectasis and pneumonia leading to prolonged intubation and intensive care unit length of stay and subsequent prolonged hospital stay. Adequate perioperative analgesia improves hemodynamics and immunologic responses, which would result in better outcomes after cardiac surgery. Opioid sparing \"Enhanced Recovery After Surgery\" protocols are increasingly being incorporated into cardiac surgeries. This will reduce opioid requirements and opioid-related side effects and facilitate fast-tracking of patients. Regional analgesia can be provided by neuraxial blocks, fascial plane blocks, peripheral nerve blocks, or simply by the infiltration of the wound with local anesthetics for cardiac surgery. Neuraxial analgesia is provided through epidural, spinal, and paravertebral routes. Though they are being replaced by peripheral fascial plane blocks, epidural and spinal analgesia are still being used in some centers. In this article, neuraxial forms of analgesia are focused. We sought to review epidural analgesia and its impact in suppressing hemodynamic stress response, reducing pulmonary complications, and development of chronic pain. The relationship between intraoperative heparinization and potential neuraxial hematoma is discussed. Other neuraxial options such as spinal and paravertebral analgesia and their usefulness, benefits, and limitations are also reviewed.</p>","PeriodicalId":46500,"journal":{"name":"Seminars in Cardiothoracic and Vascular Anesthesia","volume":"25 4","pages":"252-264"},"PeriodicalIF":1.4,"publicationDate":"2021-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1177/10892532211023337","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"39119214","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Persistent Pain After Cardiac Surgery: Prevention and Management.","authors":"James C Krakowski,&nbsp;Matthew J Hallman,&nbsp;Alan M Smeltz","doi":"10.1177/10892532211041320","DOIUrl":"https://doi.org/10.1177/10892532211041320","url":null,"abstract":"<p><p>Persistent postoperative pain (PPP) after cardiac surgery is a significant complication that negatively affects patient quality of life and increases health care system burden. However, there are no standards or guidelines to inform how to mitigate these effects. Therefore, in this review, we will discuss strategies to prevent and manage PPP after cardiac surgery. Adequate perioperative analgesia may prove instrumental in the prevention of PPP. Although opioids have historically been the primary analgesic approach to cardiac surgery, an opioid-sparing strategy may prove advantageous in reducing side effects, avoiding secondary hyperalgesia, and decreasing risk of PPP. Implementing a multimodal analgesic plan using alternative medications and regional anesthetic techniques may offer superior efficacy while reducing adverse effects.</p>","PeriodicalId":46500,"journal":{"name":"Seminars in Cardiothoracic and Vascular Anesthesia","volume":"25 4","pages":"289-300"},"PeriodicalIF":1.4,"publicationDate":"2021-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8669213/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"39330455","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Incorporation of the Transverse Thoracic Plane Block Into a Multimodal Early Extubation Protocol for Cardiac Surgical Patients.","authors":"Jeffrey P Cardinale,&nbsp;Ryan Latimer,&nbsp;Candace Curtis,&nbsp;Yana Bukovskaya,&nbsp;Logan Kosarek,&nbsp;Jason Falterman,&nbsp;Danielle M Tatum,&nbsp;Jay Trusheim","doi":"10.1177/1089253220957484","DOIUrl":"https://doi.org/10.1177/1089253220957484","url":null,"abstract":"<p><strong>Background: </strong>The aim for early extubation remains an important goal in cardiac surgical patients. Therefore, employment of a multimodal approach to pain management that includes a transverse thoracic plane block was retrospectively examined at a single-center tertiary care hospital on the effects of time to extubation, opioid consumption, and length of stay in patients undergoing cardiac surgery via median sternotomy.</p><p><strong>Methods: </strong>Blocks were performed on all cardiac surgical patients except for those undergoing left ventricular assist device placement, thoracic transplant, emergent surgery, or redo sternotomy. Following additional exclusions for intra- and postoperative complications unrelated to anesthesia, final analysis was conducted on 75 patients per group. Multimodal pain management included intravenous analgesics and transverse thoracic plane block where patients received 15 mL 0.5% bupivacaine + epinephrine bilaterally under ultrasound guidance prior to incision.</p><p><strong>Results: </strong>Following transverse thoracic plane block and multimodal analgesics, 50.6% of patients were extubated in the operation room versus 8.6% in the control group. Intraoperative opioids were decreased, and intensive care unit and total length of stay were reduced by 5 hours and 1 day, respectively, in block patients as compared with controls. Postoperative opioids were not significantly different. There were no reported complications directly attributed to the block.</p><p><strong>Conclusions: </strong>The transverse thoracic plane block and multimodal regimen for patients undergoing median sternotomy resulted in a significant number of patients extubated in the operation room without an increase in postoperative re-intubations. Moreover, the block appears to be a quick and safe procedure to utilize on cardiac surgery patients.</p>","PeriodicalId":46500,"journal":{"name":"Seminars in Cardiothoracic and Vascular Anesthesia","volume":"25 4","pages":"301-309"},"PeriodicalIF":1.4,"publicationDate":"2021-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1177/1089253220957484","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"38361082","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Corrigendum to \"Current Status of Neuraxial and Paravertebral Blocks for Adult Cardiac Surgery\".","authors":"","doi":"10.1177/10892532211065082","DOIUrl":"https://doi.org/10.1177/10892532211065082","url":null,"abstract":"","PeriodicalId":46500,"journal":{"name":"Seminars in Cardiothoracic and Vascular Anesthesia","volume":"25 4","pages":"324"},"PeriodicalIF":1.4,"publicationDate":"2021-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"39577810","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Effect of Regional Analgesia Techniques on Opioid Consumption and Length of Stay After Thoracic Surgery.","authors":"Wills C Dunham,&nbsp;Frederick W Lombard,&nbsp;David A Edwards,&nbsp;Yaping Shi,&nbsp;Matthew S Shotwell,&nbsp;Kara Siegrist,&nbsp;Susan S Eagle,&nbsp;Mias Pretorius,&nbsp;Matthew D McEvoy,&nbsp;Erin A Gillaspie,&nbsp;Jonathan C Nesbitt,&nbsp;Jonathan P Wanderer,&nbsp;Miklos D Kertai","doi":"10.1177/1089253220949434","DOIUrl":"https://doi.org/10.1177/1089253220949434","url":null,"abstract":"<p><strong>Background: </strong>We examined how intercostal nerve block (ICNB) with standard bupivacaine and ICNB with extended-release liposomal bupivacaine, compared with thoracic epidural analgesia (TEA), were associated with postoperative opioid pain medication consumption and hospital length of stay (LOS) after thoracic surgery.</p><p><strong>Methods: </strong>We studied 1935 patients who underwent thoracic surgery between January 1, 2010, and November 30, 2017, at a tertiary academic center. Primary and secondary outcomes were postoperative opioid consumption expressed as morphine milligram equivalents (MMEs) at 24, 48, and 72 hours after surgery, the LOS, and total MME consumption from surgery to discharge.</p><p><strong>Results: </strong>Of these patients, 888 (45.9%) received TEA, 730 (37.7%) ICNB with standard bupivacaine, 127 (6.6%) ICNB with liposomal bupivacaine, and 190 (9.8%) no regional analgesia. Compared with epidural analgesia, in 2017, ICNB liposomal bupivacaine provided similar pain control in terms of MME consumption at 24 and 72 hours, but decreased MME consumption at 48 hours (odds ratio [OR] = 0.33; confidence interval [CI] = 0.14-0.81) and at discharge (OR = 0.28; CI = 0.12-0.68) and was associated with a higher likelihood for a shorter LOS (hazard ratio = 3.46; CI = 2.42-4.96). Compared with TEA, ICNB with standard bupivacaine and no regional analgesia use showed varying impact on MME consumption between 24 and 72 hours after surgery, and their use was not associated with a significantly reduced MME consumption at discharge but with a shorter hospital LOS.</p><p><strong>Conclusions: </strong>Multimodal analgesia involving regional anesthetic alternatives to TEA could help manage postoperative pain in thoracic surgery patients.</p>","PeriodicalId":46500,"journal":{"name":"Seminars in Cardiothoracic and Vascular Anesthesia","volume":"25 4","pages":"310-323"},"PeriodicalIF":1.4,"publicationDate":"2021-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1177/1089253220949434","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"38489764","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Regional Analgesia for Cardiac Surgery. Part 2: Peripheral Regional Analgesia for Cardiac Surgery.","authors":"Jagan Devarajan,&nbsp;Sennaraj Balasubramanian,&nbsp;Ali N Shariat,&nbsp;Himani V Bhatt","doi":"10.1177/10892532211002382","DOIUrl":"https://doi.org/10.1177/10892532211002382","url":null,"abstract":"<p><p>The introduction of regional analgesia in the past decades have revolutionized postoperative pain management for various types of surgery, particularly orthopedic surgery. Nowadays, they are being constantly introduced into other types of surgeries including cardiac surgeries. Neuraxial and paravertebral plexus blocks for cardiac surgery are considered as deep blocks and have the risk of hematoma formation in the setting of anticoagulation associated with cardiac surgeries. Moreover, hemodynamic compromise resulting from sympathectomy in patients with limited cardiac reserve further limits the use of neuraxial techniques. A multitude of fascial plane blocks involving chest wall have been developed, which have been shown the potential to be included in the regional analgesia armamentarium for cardiac surgery. In myofascial plane blocks, the local anesthetic spreads passively and targets the intermediate and terminal branches of intercostal nerves. They are useful as important adjuncts for providing analgesia and are likely to be included in \"Enhanced Recovery after Cardiac Surgery (ERACS)\" protocols. There are several small studies and case reports that have shown efficacy of the regional blocks in reducing opioid requirements and improving patient satisfaction. This review article discusses the anatomy of various fascial plane blocks, mechanism of their efficacy, and available evidence on outcomes after cardiac surgery.</p>","PeriodicalId":46500,"journal":{"name":"Seminars in Cardiothoracic and Vascular Anesthesia","volume":"25 4","pages":"265-279"},"PeriodicalIF":1.4,"publicationDate":"2021-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1177/10892532211002382","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"25567747","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Nonopioid Analgesics in Postoperative Pain Management After Cardiac Surgery.","authors":"Soheyla Nazarnia,&nbsp;Kathirvel Subramaniam","doi":"10.1177/1089253221998552","DOIUrl":"https://doi.org/10.1177/1089253221998552","url":null,"abstract":"<p><p>Opioid analgesia is still considered the standard of practice for cardiac surgery. In recent years, combinations of several nonnarcotic analgesics and regional analgesia have shown promise in restricting opioid use during and after cardiac surgery. Ketamine infusion, dexmedetomidine infusion, acetaminophen, ketorolac, and gabapentin are useful adjuvants in cardiac anesthesia practice and have opioid-sparing properties. The beneficial effects of nonnarcotic multimodal analgesia on intraoperative stress response, recovery profile, postoperative pain, and persistent opioid use after cardiac surgery are yet to be established, and further randomized clinical trials are required.</p>","PeriodicalId":46500,"journal":{"name":"Seminars in Cardiothoracic and Vascular Anesthesia","volume":"25 4","pages":"280-288"},"PeriodicalIF":1.4,"publicationDate":"2021-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1177/1089253221998552","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"38908772","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Combined Liver Kidney Transplant in Adult Patient With Alagille Syndrome and Pulmonary Hypertension.","authors":"Rose K McGahan,&nbsp;Jonathan E Tang,&nbsp;Manoj H Iyer,&nbsp;Antolin S Flores,&nbsp;Leonid A Gorelik","doi":"10.1177/10892532211008742","DOIUrl":"https://doi.org/10.1177/10892532211008742","url":null,"abstract":"<p><p>In this article, we describe a case of a 33-year-old female with Alagille syndrome complicated by bilateral branch pulmonary artery stenosis resulting in moderate pulmonary hypertension, end-stage liver disease complicated by portal hypertension, and chronic renal disease who presented for combined liver-kidney transplant. Alagille syndrome is an autosomal dominant disease affecting the liver, heart, and kidneys. Multidisciplinary preoperative evaluation was performed with a team consisting of a congenital heart disease cardiologist, a cardiac anesthesiologist, a nephrologist, and a transplant surgeon. We describe Alagille syndrome and our intraoperative management. To our knowledge, this is the first description of a combined liver-kidney transplant in an adult patient with Alagille syndrome.</p>","PeriodicalId":46500,"journal":{"name":"Seminars in Cardiothoracic and Vascular Anesthesia","volume":"25 3","pages":"191-195"},"PeriodicalIF":1.4,"publicationDate":"2021-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1177/10892532211008742","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"25608817","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}