Dragana Unic-Stojanovic

General versus regional anesthesia for carotid endarterectomy.

t G p c c THE FIRST CAROTID ENDARTERECTOMY (CEA) was performed at St Mary Hospital, London, England, in 1954.1 This is a surgical procedure performed to reduce the ncidences of embolic and thrombotic stroke. The incidence of erioperative stroke during CEA is approximately 2.3%.2 The ncidence of perioperative myocardial infarction (MI), which is efined by Q-wave criteria on an electrocardiogram, in patients ndergoing CEA is 2%.3 The overall mortality for CEA was eported to be 1.3% to 1.8% in 2 large systematic reviews in hich the highest rate was 15%.4,5 To reduce the incidences of morbidity and mortality, there is a constant search for optimal anesthetic and surgical techniques.

Anesthetics and cerebral protection in patients undergoing carotid endarterectomy.

EREBRAL ISCHEMIA/HYPOXIA may occur in a vari-ety of perioperative circumstances. The main pathophy-siologic aspects involved in cerebral ischemia/reperfusion arecaused by adenosine triphosphate (ATP) consumption, theexcitotoxic actions of glutamate, changes in ionic homeostasis,and formation of free radicals (Fig 1). Outcomes from suchevents range from subclinical neurocognitive deficits to cata-strophic neurologic morbidity or death.

Preoperative Insight Into the Quality of Radial Artery Grafts.

We investigated the impact of preoperative ultrasonography of the forearm circulation on radial artery conduit selection. Preoperative ultrasound of the forearm circulation was performed routinely in 536 patients planned for radial artery harvesting. The safety assessment of the harvest included the following algorithm of tests: the ultrasound, the Allen test, and pulse oximetry. The quality criteria that were used to exclude a radial artery from harvesting were small size of the artery, diffuse atherosclerosis, calcifications, and severe neointimal hyperplasia. The overall rejection rate due to safety reasons was 16.4%. Seventy-one (13.2%) radial arteries did not fulfill the conduit quality criteria and consequently these arteries were not harvested. In 13.4% of radial arteries, localized arterial wall disease was found in the distal third of the artery. The distal part of the artery was discarded and the rest was used as a conduit. Our results indicate that the ultrasound provides an accurate preoperative insight into the radial artery morphology, enabling selection of the arteries with favorable morphological features.

Consecutive Observational Study to Validate EuroSCORE II Performances on a Single-Center, Contemporary Cardiac Surgical Cohort

OBJECTIVE To compare and validate the original EuroSCORE risk stratification models with the renewed EuroSCORE II model in a contemporary cardiac surgical practice. DESIGN A consecutive observational study to validate EuroSCORE II performances, conducted as retrospective analysis of prospectively collected data. SETTING A tertiary university institute for cardiovascular diseases. PARTICIPANTS Adult patients undergoing cardiac surgery between January and December 2012. METHODS One thousand eight hundred sixty-four consecutive patients were scored preoperatively using additive and logistic EuroSCORE as well as EuroSCORE II. The discriminative power of the EuroSCORE models was tested by calculating the area under the receiver operating characteristic curve (AUC). The calibration of the models was assessed by Hosmer-Lemeshow statistics and with observed-to-expected mortality ratio. MEASUREMENTS AND MAIN RESULTS The in-hospital overall mortality was 3.65%, with predicted mortalities according to additive EuroSCORE, logistic EuroSCORE, and EuroSCORE II of 5.14%, 6.60%, and 3.51%, respectively. The observed-to-expected (O/E) mortality ratio confirmed good calibration for the entire cohort only for EuroSCORE II (1.05, 95% confidence interval 0.81 - 1.29). Hosmer-Lemeshow test confirmed overall good calibration only for additive EuroSCORE (p = 0.129). The EuroSCORE II confirmed very good discriminatory power for a prolonged intensive care unit (ICU) stay of>2 days and>5 days (AUCs>0.75). Acceptable discriminatory power was confirmed for a prolonged postoperative stay of>7 days and>12 days (AUCs>0.70). CONCLUSION EuroSCORE II confirmed very good discriminatory capacity, good calibration ability (O/E mortality ratio), and good capability to predict prolonged ICU and postoperative stays in a contemporary patient cohort undergoing cardiac surgery.

The current role of surgery in treating adult patients with patent ductus arteriosus.

OBJECTIVE Surgical closure of patent ductus arteriosus (PDA) is still required in selected adult patients. We analyzed the morphology of the anomaly and coexisting pathological findings in adult patients who were recently referred to our institute for surgical PDA repair. PATIENTS AND INTERVENTIONS Six adult PDA patients who were not considered candidates for percutaneous closure underwent surgical PDA correction. In three patients with isolated PDA, computed tomographic scan revealed short, wide, and distorted ductus. In the remainder three patients, concomitant heart or aortic disease was found. Transpulmonary approach under total cardiopulmonary bypass or hypothermic circulatory arrest was performed. RESULTS In all patients, a Dacron patch was used to close the duct. The balloon occlusion technique with normothermic cardiopulmonary bypass was performed in four patients. In one of these patients, the balloon occlusion was not feasible because of unfavorable ductal anatomy, and PDA was closed in short hypothermic circulatory arrest. In two patients with aortic aneurysm, PDA closure and aortic reconstruction were performed in deep hypothermic circulatory arrest. No significant complications occurred during postoperative course. After the mean follow-up period of 48 months, neither ductal reopening nor aneurysmal degeneration of remnant ductal tissue was found. CONCLUSION Surgical PDA closure in adults remains the treatment of choice in wide, deformed PDAs unsuitable for percutaneous closure and PDAs associated with surgical aortic or heart disease.

Anesthesia for transcatheter aortic valve implantation: A case report (anesthesia for TAVI)

Uvod: Transkateterska implantacija aortne valvule (TAVI) je manje invazivna tehnika koja je postala alternativni terapijski pristup kod bolesnika sa visokim perioperativnim rizikom. Glavni cilj anestezije tokom TAVI je postizanje i održavanje hemodinamske stabilnosti. Mogu se koristiti lokalna ili opšta anestezija zavisno od zdravstvenog statusa bolesnika i karakteristika same procedure. Prikaz slučaja: Prikazujemo slučaj bolesnice stare 80 godina koja je primljena u našu bolnicu zbog pogoršanja dispneje uzrokovane teškom stenozom aortnog ušća. Urađen je TAVI pod lokalnom anestezijom i laganom sedacijom, koja je protekla bez komplikacija. Zaključak: Za uspešno izvođenje TAVI neophodan je multidisciplinarni timski rad u kome kardio-anesteziolog predstavlja značajnu kariku.

Suspected hepatotoxicity effect of amiodarone (amiodarone and liver)

Uvod: Akutni hepatotoksični efekat je retka, ali potencijalno fatalna komplikacija primene amiodarona. Prikazaću slučaj suspektnog akutnog oštećenja jetre posle intravenske primene amiodarona, kod bolesnika sa poremećajem srčanog ritma po tipu atrijalne fibrilacije, nakon kardiohirurške procedure. Prikaz slučaja: Bolesnik star 62 godine je primljen u naš Institut pod dijagnozom akutne disekcije aneurizme ascedentne aorte, zbog čega je hitno operisan. Operacija i neposredni postoperativni tok su protekli uobičajeno, bez komplikacija. Trećeg postoperativnog dana, nastaje poremećaj srčanog ritma po tipu atrijalne fibrilacije, zbog čega je započeta terapija intravenskom primenom amiodarona. Zbog nastanka hipotenzije, posle oko 12 h trajanja aritmije, ordinirana je terapija fenilefrinom i noradrenalinom. U biohemijskim analizama, pokazane su povišene vrednosti koncentracije laktata do 3,8 mmol/L, INR 3,12, alanin aminotransferaza 4401 IU/L, aspartat aminotransferaza 7355 IU/L, laktat dehidrogenaza 30043 IJ/L, a koncentracija kreatinina se povećala od 96 do 190 μg/l. Razvila se oliguria. Isključena je terapija amiodaronom. Petog postoperativnog dana, uspostavljen je sinusni ritam. Nakon primenjene terapije, nastalo je poboljšanje i pad vrednosti aminotransferaza i drugih parametara. Trinaestog postoperativnog dana, pacijent je otpušten iz bolnice u rehabilitacioni centar. Zaključak: Amiodaron je antiaritmik izbora u slučaju teških i životno ugrožavajućih aritmija kod bolesnika sa akutnom dekompenzovanom srčanom insuficijencijom. U prisustvu hepatičke kongestije, intravenska primena amiodarona može da uzrokuje akutnu hepatičku insuficijenciju, pa bi hepatička funkcija trebalo da bude redovno kontrolisana kod kritično obolelih.

Perioperative management of postdural puncture headache: Postdural puncture headache

Introduction: Postdural puncture headache (PDPH) is a complication of puncture of the dura mater. It is a common side effect of spinal anesthesia, lumbar puncture and occasionally, may accidentally occur in epidural anesthesia. The headache is defined as a bilateral headache that develops within 7 days after lumbar puncture and disappears within 14 days. It has been described in some cases that headaches can last from a few mounts to even years. Factors that increase the risk of PDPH is young age, female sex and pregnancy. Incidence is strongly related to the needle size and type. Case Report: We report a case of a 49-year-old man who was admitted to our Institute for elective veins surgery. We choose spinal anesthesia for this operation and use 25 gauged spinal needle. Patient was hemodynamically stable during the whole surgery without headache and he was discharged home at 1st post operative day. However, after two days, patient came to the hospital complaining of severe headache in frontal and occipital areas, followed by neck stiffness. Our first approach in treatment was conservative therapy. Recumbent positioning, oral and intravenous fluid, 500 mg coffeine iv. bid and morphine 4 qid. The headache persisted for the next 2 days, despite conservative therapy. Our next approach was epidural blood patch like effective treatment for PDPH. First we placed patient in the lateral position and inserted epidural needle at the level L3 - L4. Then we injected 15 ml of autologes blood into epidural space. His headache resolved within one hour of procedure, he denied any further headache one month after discharge. Conclusion: In our case, it was shown that lumbar puncture is an important cause of iatrogenic morbidity in the form of postdural puncture headache. Incidence of headache can be resolved by using thinner needle. When the headache does not respond to conservative therapy, epidural blood patch is a reasonable and effective treatment. Surgical closure is the last option.

Acute aortic dissection in patient with suspected pheochromocytoma

Introduction: Aortic dissection is one of the most fatal vascular emergencies. Almost 40% of the patients do not reach hospital in time while more than quarter die in the first 24 hours after the dissection begins. Case Report: A 37-year old man was admitted to our hospital with severe anterior chest pain which had lasted for over a week. Suspected aortic dissection was rapidly confirmed using imaging modalities - MDCT chest scan and TTE, followed by an urgent surgical management - Bentall procedure. MDCT chest scan also discovered adrenal incidentaloma defined as malignant, pheochromocytoma like mass. Due to the critical state of the patient, there was not enough time for further endocrinologic testing. Discussion and conclusion: When treating patients with pheochromocytoma and acute aortic disection, it is crucial to obtain a stable hemodynamic state before the surgery, since they can trigger a severe hypertensive crisis due to high levels of cathecholamines induced chronic vasoconctriction. The most vulnerable periods are the induction of anesthesia and perioperative hemodynamic oscillations, so treating patients with short acting alpha- 1 adrenergic blocking agents preoperatively has proven to be helpful - Phentolamine. Both dissection of aorta and pheochromocytoma present challenges for anesthesiologists and early recognition of symptoms is essential in establishing the diagnosis and reducing the mortality rate.

An epidural catheter removal after recent percutaneous coronary intervention and coronary artery stenting: Epidural catheter and antiaggregation therapy

Introduction: Anticoagulation and antiplatelet therapy in the presence of the epidural catheter is still controversial. It is well known that dual antiplatelet therapy is indicated for 12 months after the placement of drug-eluting stents (DES). Removal of an epidural catheter during that period is related to an increased risk of stent occlusion in case of discontinuation of platelet function inhibitors or, on the other hand, increased risk of epidural hematoma associated with neurological deficit if suppressed platelet function is still present. Case Report: Here we present a case of a 63-year-old man who was admitted to Institute for Cardiovascular Diseases Dedinje for elective aortic surgery. Before the induction, an epidural catheter was inserted at the Th10-Th11 epidural space. Uneventful surgery was performed under the combined epidural and general anesthesia. On the 2nd postoperative day, the patient sustained a ST depression myocardial infarction treated with percutaneous coronary intervention with DES placement, while epidural catheter was still in place. Dual antiplatelet therapy with 600mg of clopidogrel, 100 mg of acetilsalicylic acid (ASA) and low molecular weight heparin (LMWH) were started during the procedure. The next day, clopidogrel (75 mg) and ASA (100 mg) were continued as well as LMWH. The decision to remove the epidural catheter was made on the 9th postoperative day, after platelet aggregation assays were performed. Six hours after catheter removal the patient again received clopidogrel, ASA and LMWH. There were no signs of epidural hematoma. Conclusion: This case shows that point-of-care testing with platelet aggregation assays may be useful in increasing the margin of safety for epidural catheter removal during dual antiplatelet therapy.