Physical Address

304 North Cardinal St.
Dorchester Center, MA 02124

Cardiovascular Monitoring in Noncardiac Surgery

Key Points 1. Excellent cardiac and hemodynamic management is essential to achieving good outcomes in patients with cardiovascular disease, particularly those undergoing high-risk noncardiac surgery. 2. Much cardiovascular information can be obtained from the standard American Society of Anesthesiologists monitors, including those usually associated with evaluation of respiratory function (pulse oximetry, capnography). The pulse oximeter plethysmograph can be used to assess adequacy of the peripheral circulation;…

Adult Congenital Heart Disease in Noncardiac Surgery

Key Points 1. Because of successes in treating congenital cardiac lesions, there are currently as many as or more adults than children with congenital heart disease (CHD). 2. Noncardiac anesthesiologists see these patients for a vast array of ailments and injuries requiring surgery. 3. If at all possible, noncardiac surgery on adult patients with moderate to complex CHD should be performed at an adult congenital heart…

Pulmonary Hypertension in Noncardiac Surgical Patients

Key Points 1. Pulmonary hypertension (PH) is a rare disease with a high degree of morbidity and mortality for patients undergoing noncardiac surgery. 2. PH, although having several classification schemes, can be largely divided into high pulmonary venous pressure (typically from left-sided heart disease) and normal pulmonary venous pressure (typically from lung, embolic, or intrinsic disease). 3. The morbidity and mortality from PH rest on the…

Anesthesia for Noncardiac Surgery After Heart Transplant

Key Points 1. Cardiac transplant is the definitive treatment of advanced heart failure and has demonstrated improving outcomes and long-term survival. 2. The transplanted heart receives no neural modulatory signal in the posttransplant period and is dependent on filling and humoral catecholamines. 3. Mild restrictive physiology is the norm even with well-functioning grafts, and peak exercise capacity is reduced under even optimal circumstances. 4. The risk…

Left Ventricular Assist Device–Supported Patient Presenting for Noncardiac Surgery

Key Points 1. Regardless of the level of complexity or invasiveness of the planned procedure, the perioperative considerations and the anesthetic approach to left ventricular assist device (LVAD)–supported patients are the same because the removal of sympathetic tone by sedation or induction of general anesthesia should be expected to initially exert the same effect on the physiology of ventricular assist device (VAD)-supported patients regardless of the…

Cardiovascular Implantable Electronic Device Management in Noncardiac Surgery

Key Points 1. Active fixation leads can penetrate through structures (e.g., the thin-walled right atrium) during placement and present as pain, pneumomediastinum, or effusions. 2. Active rate modulation in cardiac implantable electrical devices (CIEDs) may result in heart rate changes intraoperatively related to changes in monitored parameters such as ventilation. 3. Mode switching allows for the identification of atrial tachyarrhythmias and the automatic conversion of pacemaker…

Care of the Patient With Coronary Stents Undergoing Noncardiac Surgery

Key Points 1. Percutaneous coronary intervention (PCI) with stent placement is frequently performed, with a substantial number of patients requiring subsequent noncardiac surgery (NCS). 2. Three types of stents are currently available for clinical use: bare metal stents (BMSs), drug-eluting stents (DESs), and bioresorbable stents (BRSs). 3. The two main stent-related complications are restenosis and thrombosis. 4. The risk of restenosis peaks within the first year…

Perioperative Approach to the High-Risk Cardiac Patient

Key Points 1. Perioperative triage should determine whether cardiac patients receive outpatient surgery, routine inpatient care, or critical care services. 2. Advanced hemodynamic monitoring may be required in high-risk patients with cardiac disease undergoing noncardiac surgery, including direct arterial pressure measurements, filling pressures, echocardiography, and cardiac outputs. 3. Patients with stable or unstable coronary artery disease (CAD) are commonly seen for noncardiac surgery. The unstable patients…

Perioperative Cardiovascular Evaluation and Management for Noncardiac Surgery

Key Points 1. Preoperative assessment of the cardiac patient undergoing noncardiac surgery includes risk assessment for major adverse cardiac events (MACEs). 2. Categorizing risk for MACEs is dependent on patient risk factors, including the noncardiac procedure, patient age, emergent status of the procedure, preexisting organ dysfunction, and independence in daily activities. 3. Cardiac risk model calculators exist to facilitate quantification of risk and aid the perioperative…

Postoperative Pain Management for the Cardiac Patient

Key Points 1. Inadequate postoperative analgesia and/or an uninhibited perioperative surgical stress response has the potential to initiate pathophysiologic changes in all major organ systems, which may lead to substantial postoperative morbidity. Adequate postoperative analgesia prevents unnecessary patient discomfort, may decrease morbidity, hospital lengths of stay, and thus may decrease costs. 2. Pain after cardiac surgery may be intense and originates from many sources, including the…

Long-Term Complications and Management

Key Points 1. Cardiac surgical patients are at significant risk from preventable adverse events. These events occur through human error, by either faulty decision making (diagnosis, decision for treatment) or faulty actions (failure to implement the plan correctly). 2. Human error is ubiquitous and cannot be prevented or eliminated by trying harder or by eliminating the one who errs. Reduction in human error requires system changes…

Central Nervous System Dysfunction After Cardiopulmonary Bypass

Key Points 1. Despite a progressive decrease in cardiac surgical mortality, the incidence of postoperative neurologic complications has remained relatively unchanged over the decades. 2. The risk for stroke in patients undergoing coronary artery surgery increases progressively with increasing age, ranging from 0.5% for patients younger than 55 years to 2.3% for those older than 75 years. 3. Neurologic events in cardiac surgical patients are associated…

Postoperative Cardiovascular Management

Key Points 1. Maintaining oxygen transport and oxygen delivery appropriately to meet the tissue metabolic needs is the goal of postoperative circulatory control. 2. Cardiac function worsens after cardiac surgical procedures. Therapeutic approaches to reverse this dysfunction are important and often can be discontinued in the first few postoperative days. 3. Myocardial ischemia often occurs postoperatively, and it is associated with adverse cardiac outcomes. Multiple strategies…

Postoperative Respiratory Care

Key Points 1. Cardiac anesthesia has fundamentally shifted from a high-dose narcotic technique to a more balanced approach using moderate-dose narcotics, shorter-acting muscle relaxants, and volatile anesthetic agents. 2. This new paradigm has also led to renewed interest in perioperative pain management involving multimodal techniques that facilitate rapid tracheal extubation such as regional blocks, intrathecal morphine, and supplementary nonsteroidal antiinflammatory drugs. 3. This approach has prompted…

Discontinuing Cardiopulmonary Bypass

Key Points 1. The key to successful weaning from cardiopulmonary bypass (CPB) is proper preparation. 2. After rewarming the patient, correcting any abnormal blood gases, and inflating the lungs, make sure to turn on the ventilator. 3. To prepare the heart for discontinuing CPB, optimize the cardiac rate, rhythm, preload, myocardial contractility, and afterload. 4. The worse the heart's condition, the more gradually CPB should be…

Transfusion Medicine and Coagulation Disorders

Key Points 1. It is easiest to think of coagulation as a wave of biologic activity occurring at the site of tissue injury, consisting of initiation, acceleration, control, and lysis. 2. Hemostasis is part of a larger body system: inflammation. The protein reactions in coagulation have important roles in signaling inflammation. 3. Thrombin is the most important coagulation modulator, interacting with multiple coagulation factors, platelets, tissue…

Extracorporeal Devices Including Extracorporeal Membrane Oxygenation

Key Points 1. Two predominant methods of blood propulsion are used: positive displacement roller pumps and constrained vortex centrifugal-type pumps. 2. Modern heart-lung machines are equipped with a number of alarm systems and redundant backup systems to overcome primary system failures. 3. Blood gas exchange devices have improved over time in terms of reduced blood-surface interface, improved efficiency, and improved blood device-related inflammatory response. 4. Gaseous…

Cardiopulmonary Bypass Management and Organ Protection

Key Points 1. Cardiopulmonary bypass (CPB) is associated with a number of profound physiologic perturbations. The central nervous system, kidneys, gut, and heart are especially vulnerable to ischemic events associated with extracorporeal circulation. 2. Advanced age is the most important risk factor for stroke and neurocognitive dysfunction after CPB. 3. Acute renal injury from CPB can contribute directly to poor outcomes. 4. Drugs such as dopamine…

Patient Safety in the Cardiac Operating Room

Key Points 1. Cardiac surgical patients are at significant risk from preventable adverse events. These events occur through human error, by either faulty decision making (diagnosis, decision for treatment) or faulty actions (failure to implement the plan correctly). 2. Human error is ubiquitous and cannot be prevented or eliminated by trying harder or by eliminating the one who errs. Reduction in human error requires system changes…

Reoperative Cardiac Surgery

Key Points 1. Reoperative cardiac surgery presents greater risk than first-time surgery because patients are usually older, have more comorbidity, and have more advanced cardiovascular disease. Also, resternotomy can be hazardous due to adhesions of cardiac structures to the sternum. Bypass conduits may not be available owing to prior use, and the frequency of valve replacement versus valve repair is higher. 2. A thorough history, clinical…