D. Daly

A Systematic Review of the Safety and Effectiveness of Fast-track Cardiac Anesthesia

COST containment and efficient resource use have forced anesthesiologists to rethink their management strategies for cardiac surgery. In the late 1970s, when anesthetic practice predominantly involved inhalational anesthesia, it was possible to extubate cardiac surgical patients within a few hours after surgery. However, there was no economic pressure or incentive to practice cost-effective medicine at that time. An opioid-based anesthetic regimen gained popularity in the 1980s, when studies confirmed its ability to allow hemodynamic stability, even in patients with marginal cardiac reserve. This necessitated continuation of postoperative ventilatory support for 12–24 h in cardiac surgical patients. The growing need for intensive cardiovascular and ventilatory support during the immediate postoperative period in these patients required an expansion of intensive care unit (ICU) bed availability. Until recently, this need for postoperative ICU nursing care and length of stay had continued unchecked. The aims of “fast-tracking” cardiac surgical patients include early tracheal extubation and decreased length of ICU and hospital stay with subsequent cost reduction. Fast-track cardiac anesthesia (FTCA) techniques include the use of short-acting hypnotic drugs, reduced doses of opioids, or the use of ultrashort-acting opioids, and, in some cases, the use of antifibrinolytic drugs or drugs to prevent atrial fibrillation. There are purported benefits of early tracheal extubation and reduced duration of mechanical ventilation. Several randomized trials have found that early tracheal extubation can be safely achieved, and it may lead to reduced ICU stay and costs. Despite these findings, there are residual concerns regarding early tracheal extubation and FTCA. Studies to date have not included a sufficient number of patients to detect a clinically important effect on serious morbidity or mortality. The primary objective of this systematic review was to determine whether FTCA is as safe as traditional cardiac anesthesia (TCA) based on the administration of high doses of opioids. The hypothesis tested was that there is not an increased risk of mortality or major morbidity associated with FTCA compared with TCA.

Update on the role of paravertebral blocks for thoracic surgery: are they worth it?

Purpose of review To consider optimal analgesic strategies for thoracic surgical patients. Recent findings Recent studies have consistently suggested analgesic equivalence between paravertebral and thoracic epidural analgesia. Complications appear to be significantly less common with paravertebral analgesia. Summary There is good evidence that paravertebral block can provide acceptable pain relief compared with thoracic epidural analgesia for thoracotomy. Important side-effects such as hypotension, urinary retention, nausea, and vomiting appear to be less frequent with paravertebral block than with thoracic epidural analgesia. Paravertebral block is associated with better pulmonary function and fewer pulmonary complications than thoracic epidural analgesia. Importantly, contraindications to thoracic epidural analgesia do not preclude paravertebral block, which can also be safely performed in anesthetized patients without an apparent increased risk of neurological injury. The place of paravertebral block in video-assisted thoracoscopic surgery is less clear.

Prediction of Neurological Outcome Using Bispectral Index Monitoring in Patients with Severe Ischemic-Hypoxic Brain Injury Undergoing Emergency Surgery

Background:Predicting outcome from ischemic-hypoxic brain injury can be difficult in patients rushed to the operating room for time-critical emergency surgery. The authors chose to evaluate the prognostic ability of bispectral index (BIS) in this setting. Methods:Twenty-five critically ill, unconscious patients with ischemic-hypoxic brain injury undergoing emergency surgery were prospectively studied. Clinical evaluation, laboratory investigations, BIS, and burst suppression ratio were recorded before and during surgery. Neurologic outcome of the patients was measured according to the Glasgow outcome scale at 30 days after injury, with poor neurologic outcome defined as severe disability or death. Results:The incidence of poor neurologic outcome was 68%. Neither clinical judgment (P = 0.40) nor pupillary responses (P = 0.21) were predictive of neurologic outcome after surgery. An abnormal BIS trace was strongly associated with poor neurologic outcome, positive likelihood ratio 6.6 (95% CI 1.7–36.4; exact test P = 0.002). Some BIS values were significantly different when comparing patients with and without poor outcome: c-statistics for the average BIS and maximal electroencephalographic burst-suppression were 0.80 (95% CI 0.62–0.98; P = 0.017) and 0.84 (95% CI 0.68–0.99; P = 0.007), respectively. A normal BIS (P < 0.0005) but not clinical judgment (P = 0.16) could identify a group of patients more likely to survive with a good neurologic outcome. Conclusions:BIS, when compared with clinical judgment and routine laboratory tests, provides useful information that may identify patients with a good chance of recovery after ischemic-hypoxic brain injury requiring emergency surgery.