Steven Konstadt

Intraoperative Transesophageal Echocardiography During Noncardiac Surgery

OBJECTIVEnTo investigate the use and impact of transesophageal echocardiography (TEE) during noncardiac surgery.nnnDESIGNnRetrospective study.nnnSETTINGnA university teaching hospital.nnnPARTICIPANTS AND INTERVENTIONSnThe medical records and the videotapes of 123 intraoperative TEE examinations were reviewed.nnnMEASUREMENTS AND MAIN RESULTSnTEE was used for non-consultative indications in 68 patients and in consultation in 55 patients. Information that would not have been detected intraoperatively by other means included intracardiac defects, valvular and aortic pathology, the presence or absence of ventricular dysfunction or intracardiac thrombi, and embolization during surgery. Findings during the initial TEE examination and the TEE evaluation of intraoperative events resulted in a major impact on patient management in 15% of patients. The majority of patients in whom TEE had any impact (the sum of major, minor, and limited impact groups) were classified as American Society of Anesthesiologists (ASA) class 3 or 4. Patients in whom TEE had any impact were significantly older than patients in whom TEE had no impact (66.5 +/- 13.4 years v 58.1 +/- 16.2 years; p < 0.05). No patient experienced a complication related to intraoperative TEE.nnnCONCLUSIONnIt appears that TEE in patients undergoing noncardiac surgery is efficacious in rapidly disclosing new findings and information during periods of hemodynamic instability. It may have a significant impact on intraoperative patient management and may be beneficial in patients older than 66 years of age.

Intraoperative transesophageal echocardiography during liver transplantation

OBJECTIVEnTo investigate the safety, value, and impact of transesophageal echocardiography during liver transplantation.nnnDESIGNnRetrospective.nnnSETTINGnUniversity teaching hospital.nnnPARTICIPANTS AND INTERVENTIONSnThe medical records of 346 patients and the videotapes of 100 intraoperative transesophageal echocardiography examinations were reviewed.nnnMEASUREMENTS AND MAIN RESULTSnTransesophageal echocardiography was indicated for intraoperative monitoring in 62 patients, 41 of whom had pertinent findings, and for diagnostic purposes in 38 patients, 14 of whom had the expected diagnosis verified. Thirty-one patients had no intraoperative findings. Information that would not have been detected intraoperatively by other means included intracardiac defects, the potential for transpulmonary air passage, valvular regurgitation, the presence or absence of ventricular dysfunction, and embolization occurring at allograft reperfusion. Unanticipated findings during the initial transesophageal echocardiography examination as well as evaluation of intraoperative events resulted in a major impact on patient management in 11% of patients. Preoperatively, 64 patients had a prothrombin time greater than 14 seconds; 56 had a platelet count less than 100,000/mm3; and 23 had esophageal varices, 7 of whom had not had variceal sclerotherapy. Two patients had a complication possibly caused by transesophageal echocardiography (sinus bradycardia and upper gastrointestinal bleeding). No patient experienced documented variceal hemorrhage, esophageal or gastric perforation, and/or oropharyngeal trauma.nnnCONCLUSIONSnIt appears that transesophageal echocardiography can be performed safely in patients undergoing liver transplantation, is efficacious in rapidly disclosing new information and monitoring during periods of hemodynamic instability, and may have a significant impact on intraoperative patient management during liver transplantation.

Comparison of the cardiovascular effects of cisatracurium and vecuronium in patients with coronary artery disease

PurposeCisatracurium besylate (Nimbex® Injection, Glaxo Wellcome Inc., Research Triangle Park, NC) is an intermediate-acting bis-benzylisoquinolinium neuromuscular blocking drug that is one of the stereoisomers of atracurium. At doses ≤. 8 × ED95, it caused no clinically important cardiovascular side effects or histamine release in healthy patients. The purpose of the present study was to investigate the haemodynamic effects of high doses of cisatracurium in patients with coronary artery disease.MethodsOne hundred patients undergoing myocardial revascularization participated in a pilot study (seven patients) and a double-blinded, randomized, controlled trial comparing the haemodynamic effects of cisatracurium with vecuronium at three centres. The patients were anaesthetized using oxygen 100%, with etomidate, fentanyl and a benzodiazepine, and tracheal intubation was facilitated using succinylcholine. After baseline haemodynamic measurements, the study drug was administered over 5–10 sec according to group assignment: Group A (pilot) cisatracurium, 0.20 mg·kg−1 (4 × ED95), (n = 7); Group B-cisatracurium, 0.30 mg·kg−1 (6 × ED95), (n = 31); Group C-vecuronium, 0.30 mg·kg−1 (6 × ED95), (n = 31); Group D cisatracurium, 0.40 mg·kg−1 (8 × ED95), (n = 21); Group E-vecuronium, 0.30 mg·kg−1 (6 × ED95), (n = 10). The haemodynamic measurements were repeated at 2, 5, and 10 min after cisatracurium or vecuronium.ResultsTwo patients in Group D had > 20% decreases in MAR but only one required therapy for hypotension. The haemodynamic changes from pre-to post-injection in the cisatracurium patients were minimal and similar to patients receiving vecuronium.ConclusionsIn patients with coronary artery disease, rapid cisatracurium (4-8×ED95) boluses and vecuronium (6×ED95) result in minor, clinically insignificant haemodynamic side effects.RésuméObjectif Le bésylate de cisatracurium (Nimbex® Injection, Glaxo Wellcome Inc., Research Triangle Park, NC) est un myorelaxant di-benzylisoquinolinium à action intermédiaire qui est un des stéréo-isomères de l’atracurium. En doses de ≤ 8 × ED 95 , il ne cause pas d’effets secondaires cardiovasculaires importants ou de libération d’histamine chez les patients en santé. L’objectif de la présente étude était d’examiner les effets hémodynamiques de fortes doses de cisatracurium chez des patients souffrant d’insuffisance coronarienne.MéthodesCent patients devant subir une revascularisation myocardique ont participé à une étude pilote (sept pa tients), et à un essai contrôlé en double insu et randomisé, où ont été comparés les effets hémodynamiques du cisatracurium et du vécuronium dans trois centres. Les patients ont reçu une anesthésie avec de l’oxygène 100 %, avec étomidate, fentanyl et une benzodiazépine; on a utilisé de la succinylcholine pour faciliter l’intubation endotrachéale. Après les mesures hémodynamiques de départ, le médicament à l’étude a été administré pendant 5 à 10 secondes selon l’attribution du groupe: Groupe A (pilote) cisatracurium, 0,20 mg·kg−1 (4 × ED95), (n = 7); Groupe B-cisatracurium, 0,30 mg·kg−1 (6 × ED95), (n = 31); Groupe C-vécuronium, 0,30 mg·kg−1 (6 x ED95), (n = 31); Groupe D cisatracurium, 0,40 mg·kg−1 (8 × ED95), (n = 21); Groupe E-vécuronium, 0,30 mg·kg−1 (6 × ED95), (n = 10). Les mesures hémodynamiques ont été reprises 2, 5 et 10 min après l’administration de cisatracurium ou de vécuronium.RésultatsDeux patients du Groupe D ont présenté une baisse > 20% de la TAM, mais aucune thérapie pour l’hypotension n’a été nécessaire. Les changements hémodynamiques survenus entre la préinjection et la postinjection ont été minimes et semblables chez les patients ayant reçu le cisatracurium ou le vécuronium.ConclusionChez les patients souffrant d’insuffisance coronarienne, l’administration rapide de bolus de cisatracurium (4-8 × ED95) et de vécuronium (6 × ED65) n’a produit que des effets secondaires hémodynamiques mineurs, peu significatifs sur le plan dinique.

ST segment depression following intubation

A 61-YEAR-OLD, 85kg woman presented for removal of an infected right breast implant. Five years earlier, she had undergone bilateral mastectomy with implant insertion without complication. Because her physical examination was normal and she had no evidence of cardiac disease, she received a course of Adriamycin (doxorubicin, Adria Laboratories, Columbus, OH). Follow-up radionuelide angiography was normal and the patient had no cardiacsymptoms. At the time of surgery, the patient had no cardiac symptoms and, apart from slight erythema over the breast scar, the physical examination, chest x-ray, and blood chemistries were unremarkable. The admission ECG showed normal sinus rhythm at a rate of 60 beats/min and nonspecific T wave abnormalities in leads Vz-Vs. Previous ECGs were not available, and in the absence of cardiac symptoms, it was decided to proceed with general anesthesia. Following the application of all routine monitors, general anesthesia was induced with midazolam, 2 mg, fentanyl, 100 kg, thiopental, 200 mg, and 100 mg of succinylcholine. Intubation was easily performed, and it was accompanied by an increase in the heart rate from 57 to 73 beats/min, and a fall in the blood pressure from 122/45 (68) to 103/45 (64) mmHg. At this point, 3 mm of ST segment depression was noted (Fig 1). What is your diagnosis?

8 Echocardiography in aortic disease

Transoesophageal echocardiography has rapidly become an important diagnostic modality for patients with aortic atherosclerosis or aortic dissection. Use of this modality can help direct patients to proper therapeutic modalities. This paper will review the role of transoesophageal echocardiography in these disease processes.