55 research outputs found
Intraoperacijski TEE i anestezioloÅ”ko lijeÄenje bolesnika s mehaniÄkom potporom srca
A ventricular assist device (VAD) is inserted to provide mechanical circulatory support. A VAD can rest the myocardium and allow it to recover from stunning or hibernation, while maintaining vital organ perfusion (bridge-to-recovery). If myocardial recovery cannot occur, the goal is to support the patient to transplantation (bridge-to-transplantation), or, if the patient is not a transplant candidate, to enhance the quality of life for a limited period of time (destination therapy). Perioperative transesophageal echocardiography is a major component of patient management, and it is important for surgical and anesthetic decision-making. In addition to the standard examination, device-specific pre-, intra-, and postoperative considerations are essential to the echocardiographic evaluation. These include: (a) the pre-VAD insertion examination of the heart and large vessels, in order to exclude significant aortic regurgitation, tricuspid regurgitation, mitral stenosis, patent foramen ovale or other cardiac abnormality that could lead to right-to-left shunt after the left VAD placement, intracardiac thrombi, ventricular scars, pulmonic regurgitation, pulmonary hypertension, pulmonary embolism and atherosclerotic disease in the ascending aorta; and to assess the right ventricular function; and (b) the post-VAD insertion examination of the device and reassessment of the heart and large vessels. The examination of the device aims to confirm the completeness of the device and heart deairing, cannulas alignment and patency, and the competency of the device valves using two-dimensional, and color, continuous and pulsed wave Doppler modalities. The goal of the heart examination after the implantation should be to exclude the aortic regurgitation or an uncovered rightto- left shunt, and to assess the right ventricular function, the left ventricular unloading, and the effect of the device settings on the global heart function.UreÄaj za mehaniÄku potporu srcu (eng. VAD) se ugraÄuje radi pružanja mehaniÄke potpore srcu i cirkulaciji. Njime se osigurava oporavak miokarda nakon stunninga i hibernacije, i u isto vrijeme održava perfuzija vitalnih organa (eng. bridge-to-recovery). Ukoliko se miokard ne može oporaviti od oÅ”teÄenja tada je cilj ovakve terapije pružiti potporu bolesniku do trenutka transplantacije srca (eng. bridge-to-transplantation), ili ukoliko bolesnik nije pogodan za transplantaciju, poboljÅ”ati mu kvalitetu života u ograniÄenom vremenu (ciljna terapija). Perioperacijski TEE je glavna metoda u lijeÄenju i nadziranju takvih bolesnika koja pruža brojne informacije i kirurgu i anesteziologu, olakÅ”avajuÄi pri tom donoÅ”enje važnih terapijskih odluka. Uz osnovni standardni pregled, za ehokardiografsku procjenu su važni i za ureÄaj specifiÄni pre-, intra- i postoperacijski ehokardiografski pregled. To ukljuÄuje: (a) pregled srca i velikih krvnih žila prije postavljanja VAD ureÄaja, kako bi se iskljuÄila znaÄajnija aortna regurgitacija, trikuspidna regurgitacija, mitralna stenoza, otvoreni foramen ovale i druge abnormalnosti koje bi mogle dovesti do D-L shunt-a nakon postavljanja VAD-a, stvaranja intrakardijalnih tromba, ventrikulskih ožiljaka, pluÄne regurgitacije i hipertenzije, pluÄne embolije i aterosklerotske bolesti u uzlaznoj aorti. Važno je i procijeniti funkciju desnog ventrikula, i (b) pregled ureÄaja nakon postavljanja VAD-a i ponovna procjena srca i velikih krvnih žila. Cilj pregleda ureÄaja je potvrditi ispravnost ureÄaja, izvrÅ”enog srÄanog odzraÄivanja; potvrditi ispravan položaj kanila i njihovu prohodnost, kompetentnost valvula i to uporabom dvodimenzionalnog, obojenog, kontinuiranog i pulsnog doplera. Cilj pregleda srca nakon implantacije je iskljuÄiti aortnu regurgitaciju ili neprepoznati D-L shunt, i procijeniti funkciju desnog ventrikla, odtereÄenost lijevog ventrikla i opÄenito uÄinak razliÄitih podeÅ”avanja ureÄaja na globalnu srÄanu funkciju
Intraoperacijski TEE i anestezioloÅ”ko lijeÄenje bolesnika s mehaniÄkom potporom srca
A ventricular assist device (VAD) is inserted to provide mechanical circulatory support. A VAD can rest the myocardium and allow it to recover from stunning or hibernation, while maintaining vital organ perfusion (bridge-to-recovery). If myocardial recovery cannot occur, the goal is to support the patient to transplantation (bridge-to-transplantation), or, if the patient is not a transplant candidate, to enhance the quality of life for a limited period of time (destination therapy). Perioperative transesophageal echocardiography is a major component of patient management, and it is important for surgical and anesthetic decision-making. In addition to the standard examination, device-specific pre-, intra-, and postoperative considerations are essential to the echocardiographic evaluation. These include: (a) the pre-VAD insertion examination of the heart and large vessels, in order to exclude significant aortic regurgitation, tricuspid regurgitation, mitral stenosis, patent foramen ovale or other cardiac abnormality that could lead to right-to-left shunt after the left VAD placement, intracardiac thrombi, ventricular scars, pulmonic regurgitation, pulmonary hypertension, pulmonary embolism and atherosclerotic disease in the ascending aorta; and to assess the right ventricular function; and (b) the post-VAD insertion examination of the device and reassessment of the heart and large vessels. The examination of the device aims to confirm the completeness of the device and heart deairing, cannulas alignment and patency, and the competency of the device valves using two-dimensional, and color, continuous and pulsed wave Doppler modalities. The goal of the heart examination after the implantation should be to exclude the aortic regurgitation or an uncovered rightto- left shunt, and to assess the right ventricular function, the left ventricular unloading, and the effect of the device settings on the global heart function.UreÄaj za mehaniÄku potporu srcu (eng. VAD) se ugraÄuje radi pružanja mehaniÄke potpore srcu i cirkulaciji. Njime se osigurava oporavak miokarda nakon stunninga i hibernacije, i u isto vrijeme održava perfuzija vitalnih organa (eng. bridge-to-recovery). Ukoliko se miokard ne može oporaviti od oÅ”teÄenja tada je cilj ovakve terapije pružiti potporu bolesniku do trenutka transplantacije srca (eng. bridge-to-transplantation), ili ukoliko bolesnik nije pogodan za transplantaciju, poboljÅ”ati mu kvalitetu života u ograniÄenom vremenu (ciljna terapija). Perioperacijski TEE je glavna metoda u lijeÄenju i nadziranju takvih bolesnika koja pruža brojne informacije i kirurgu i anesteziologu, olakÅ”avajuÄi pri tom donoÅ”enje važnih terapijskih odluka. Uz osnovni standardni pregled, za ehokardiografsku procjenu su važni i za ureÄaj specifiÄni pre-, intra- i postoperacijski ehokardiografski pregled. To ukljuÄuje: (a) pregled srca i velikih krvnih žila prije postavljanja VAD ureÄaja, kako bi se iskljuÄila znaÄajnija aortna regurgitacija, trikuspidna regurgitacija, mitralna stenoza, otvoreni foramen ovale i druge abnormalnosti koje bi mogle dovesti do D-L shunt-a nakon postavljanja VAD-a, stvaranja intrakardijalnih tromba, ventrikulskih ožiljaka, pluÄne regurgitacije i hipertenzije, pluÄne embolije i aterosklerotske bolesti u uzlaznoj aorti. Važno je i procijeniti funkciju desnog ventrikula, i (b) pregled ureÄaja nakon postavljanja VAD-a i ponovna procjena srca i velikih krvnih žila. Cilj pregleda ureÄaja je potvrditi ispravnost ureÄaja, izvrÅ”enog srÄanog odzraÄivanja; potvrditi ispravan položaj kanila i njihovu prohodnost, kompetentnost valvula i to uporabom dvodimenzionalnog, obojenog, kontinuiranog i pulsnog doplera. Cilj pregleda srca nakon implantacije je iskljuÄiti aortnu regurgitaciju ili neprepoznati D-L shunt, i procijeniti funkciju desnog ventrikla, odtereÄenost lijevog ventrikla i opÄenito uÄinak razliÄitih podeÅ”avanja ureÄaja na globalnu srÄanu funkciju
Kardioprotektivni uÄinak sevoflurana s obzirom na vrijeme primjene pri operacijama aortokoronarnoga premoÅ”tavanja [Cardioprotective effect of sevoflurane with regard to time of application in patients undergoing coronary artery bypass grafting]
Background: Sevoflurane is a volatile anaesthetic which belongs to the group of general
anaesthetics. Its cardioprotective effect has been proved in experimental and clinical studies.
However, it still hasn't been studied whether this effect on the myocardium differs depending
on the time of the administration. The aim of this study was to determine whether the
cardioprotective effect of sevoflurane was more expressed when administered before the onset
of myocardial ischaemia (during preconditioning phase of coronary bypass grafting
operations) compared to its administration after the period of ischaemia (during
postconditioning).
Methods: Seventy-two patients scheduled for elective coronary artery bypass graft surgery
were randomly assigned to one of three groups: a group of patients who were anaesthetised by
sevoflurane administered before the onset of ischaemia (SEVO pre; n=24), a group of patients
who were anaesthetised by sevoflurane administered after the ischaemic period (SEVO post;
n=24) and a control group who were anaesthetised only by midazolam and fentanyl (Control;
n=24). The effect on myocardium was assessed by successive measurements of cardiac
biomarkers in the perioperative period: troponin I (cTnI), creatine kinase (CK), CK-MB
isoenzyme and lactate dehydrogenase (LD). The degree of myocardial injury was estimated
quantitatively on the basis of the summary values of the cardiac biomarkers and categorically
on the basis of the distribution of peak troponin I concentrations in the perioperative period.
The following summary variables were: peak value, time to reach the peak value, difference
between the peak and the first measured value, percent difference between the peak and the
first measured value, difference between the last and the first measured values, percent
difference between the last and the first measured values, the area under the curve of the
measured values through the period. The categorical assessment of periprocedural myocardial
injury was done on the basis of peak troponin I at 2, 4, 8 and 12 Ī¼g/L. Results: Quantitatively the estimated degree of perioperative myocardial injury did not differ
significantly between the groups for any of the monitored parameters. The only difference
found was a significantly lower value of CK-MB difference between the peak and the first
measured value in the group SEVO pre in comparison to the SEVO post group (p = 0.010).
This may speak in favour of smaller periprocedural myocardial injury in the SEVO pre group.
Based on peak troponin I concentrations, the number of patients who had perioperative
myocardial injury did not differ significantly between the groups, although there was a trend
of the smallest number of such patients in the SEVO pre group for all monitored peak
concentrations of troponin I. In a univariate analysis of predictor variables for the
development of periprocedural myocardial injury (peak troponin I > 2 Ī¼g/L), lower body
surface area (p = 0.010) was found the only significant variable. In a multivariate analysis
model for the same outcome, in which the body surface area and administration mode of
anaesthetic were included, the body surface area (OR = 0.020; 95% CI = 0.001 ā 0.401, p =
0.011), and SEVO pre group compared to SEVO post group (OR = 0.277; 95% CI = 0.078 ā
0.977, p = 0.046) were found as significant favourable predictors. Within patients that were
operated in CABG method and also within those operated in OPCAB method, the
quantitatively and categoricaly estimated degree of perioperative myocardial injury, did not
differ significantly between the groups for any of the monitored parameters.
Conclusion: This research did not unequivocally establish the cardioprotective effect of
sevoflurane when administered before the onset of ischaemia compared to midazolam and
fentanyl, nor did it establish the cardioprotective effect when compared to sevoflurane
administered after the ischaemic period. Some of our results may suggest possible
cardioprotective effect of sevoflurane when administered before ischaemia compared to
sevoflurane administered after ischaemia in terms of a minor periprocedural myocardial
injury. However, further randomized controlled trials are necessary to confirm this result
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