The last 10 years advances
Fawzeya Aboul Fetouh Professor of Anesthesia Cairo University fawziafetouh@yahoo.com
6th Assiut Anesthesia Conference Hurghada 3-7 Dec 2012 12/7/2012
Discuss lessons learned from SCA annual meeting, Bullitin October 2012, ECTAS ,Cairo Feb 2012, EACTA June Amesterdam 2012 aimed to introduce update in cardiac anesthesia and to Evaluate controversial issues
Update in biomedical technology Surgical techniques update Cardiac anesthesia update Update in CPB and Perfusion techniques Post operative strategy update
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Innovative diagnostic and interventional techniques Coronary angioplasty Balloon valvoplasty Hybrid valve surgery mitral and aorta
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UPDATE IN MONITORING Regression of the of pulmonary artery Cather Introduction of Non invasive cardiac output monitoring with wide range of accuracy Increase awareness of splanchnic circulation introduction of gastric tonometry ,and TEE imaging of the portal circulation Cerebral Oximetry which made revolution of the neurocognitive outcome in eldrly cardiac patient Bed side monitoring of Hb and Meth, Carboxy Hb Mathews JP et al: ASE / SCA Recommendations and Guidelines for CQI in Perioperative Echo. JASE + Anesth Analg 2009. 12/7/2012
Innovative use of 3D TEE , minimization , More resolution
Live 3D Clinicallyproven 3D technology
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Miniaturization + Next generation micro-beam forming
Pure Wave Crystal Exceptional image quality
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MV
AV
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Establishment of Off-pump coronary artery bypass (OPCAB) and Total arterial grafting Transmyocardial laser revascularization Stem cell therapy Robotic surgery Ballon valvoplasty Transcatheter valve surgery 12/7/2012
1) 2) 3) 4) 5)
one lung ventilation during TMR, hemodynamic monitoring guided by transesophageal echocardiography, hemodynamic support by pharmacological and mechanical interventions, such as catecholamines and intra-aortic balloon pump, for myocardial dysfunction during and following TMR, potential risk of bleeding from the perforation following TMR and this risk should be more emphasized if systemic anticoagulation is required early recovery and epidural anesthesia for postoperative analgesia when the operation is performed without cardiopulmonary bypass
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1. It is fast-track anesthesia protocol. 2. Rapid ventricular pacing and cessation of mechanical ventilation interrupts cardiac ejection and minimizes heart translocation 3. Vasopressor administration before pacing and cardioversion may restore adequate hemodynamics 4. Transesophageal echocardiography is used to assess valve size and for hemodynamic monitoring. 5. Mostly off pump procedure with CPB machine backup 12/7/2012
Anesthesia- have evolved with improvements in surgical/radiological technique. Low incidence conversion to open repair Types: local anesthesia + sedation / regional / combined regional/GA or GA alone AAA- std ASA monitors, art line, 2 PIVs TAA- add CSF drain, IOTEE May need to ↓ BP during stent deployment: ◦ SNP, NTG, adenosine, rapid pacing Michael Andritsos. Anesthesia and the endovascular stenting 12/7/2012 patient
Robot can accomplish surgery via smaller portal than with conventional minimally invasive techniques Further reduction in size of incision May ultimately provide opportunity for “telesurgery” where operator could be at long distance from patient
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Introduction of TEE in pediatric patient more complicated anomalies is now makes an intraoperative challenge for the pediatric cardiac anesthesiologist Early surgical interference more young age Progressive interventional Minimally invasive palliative procedures in the cath lab as Ballon valvoplasty , closusure of ASD , VSD and PD puts a load on the pediatric cardiac anesthiologists
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Warm , or tepid cardioplegia Ultrafiltration as routine use in CPB Portable modular CPB
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(1) Bruckenberger E: Herzbericht 2006
(2) Tebbe U et al: Rückgang der Krankenhaus-Sterblichkeit…, Dtsch Med Wochenschr 2007; 132: 1559 –1556 (3)ESC: Euro Heart Survey –Cardiovascular Diseases in Europe 2006 (4)Heller Günther: Sterblichkeitsrisiko von Frauen und Männern nach Myokardinfarkt, Dtsch Arztebl 2008; 105(15):279-85
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Introduction of concept of cardioprotection , brain protection Introduction of the concept of ischemic preconditioning Introduction of newer concept of intropic agents
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Based on TEE assessment of the cardiac output, LV function after separation from CPB No “unnecessary” Preemptive inotropes
More awareness to afterload reduction and hemodynamic parameters modulation
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Cardiac glycosides Calcium sensitizers Liothyronine (T3)
Binds to troponin C [Cai] –dependently, does not impair diastolic relaxation Effects continue 24 hours after drug stopped in CHF patients; active metabolite? Small trials in cardiac surgery patients using 8-36 μg/kg load ± 0.2-0.3 μg/kg/min infusion (↑CO, ↓SVR and ↓PVR) Kivikko. Circulation 2003;107:81-86 Follath. Lancet 2002;360:196-202 12/7/2012
9F-Catheter blood outlet blood inlet
IABP • IABP (Intra-aortic balloon pump): coronary perfusion with inotropes to activate oxygen deprived cells. 1 Mortality with 3 inotropes= 80% • Mortality with multi-organ failure, two organs = 80% 2
pigtail
•Impella unloads left ventricle •Increases flow to heart and organs without inotropes & reduces workload 3 1. Publication: Samuels LE & al , J Card Surg. 1999 Jul-Aug;14(4):288-93. 100% Post-CS 1996-1999 2. PAMI-II Stone et al, J Am Coll Cardiol 29:1459, 1997 3. M.Valgimigli et al.,Catheterization & Cardiovascular Interventions 65:263– 267 (2005)
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Introduction of recombinant factor VIIa in intractable medical bleeding and in Dissecting AA Regression of aprotinin Wide spread use of tranexemic acid Cell saver tchnology Use of ROTEM to assess coagulopathy and use target therapy
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Cardiac function, temperature, bleeding, respiratory function, and mental status are deciding factors Requires committed Critical Care Nursing and clear protocol for early Extubation
Fast-Track Anesthesia and Cardiac Surgery: A Retrospective Cohort Study of 7989 Patients ANESTHESIA & ANALGESIA Vol. 108, No. 3, March 2009
Thank you
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