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Arrhythmias and conduction disturbances after coronary artery bypass graft surgery: Epidemiology, management, and prognosis
778
Dehmer GJ, Fisher M, Tate DA, e t al: Reversal of heparin anticoagulation by recombinant platelet factor 4 i n humans. Circulation 9 1 : 2 1 8 8 - 2 1 9 4 , 1995 Eighteen patients having cardiac catheterization and heparin anticoagulatlon received recombinant platelet factor 4 (rPF 4) 0.5, 1.0, 2.5, or 5.0 mg/kg in a phase 1, open-label trial. There were no significant hemodynamic effects or side effects in any patient despite transient rPF 4 levels as high as 14,870 ng/mL in patients receiving 5.0 mg/kg Doses of 2.5 and 5.0 mg/kg were uniformly effective In reversing the anticoagulant (ACT > 300 seconds) effect of heparin; lower doses were effective in most One patient receiving 2 5 rng/kg had a slight transient increase in liver enzymes
LITERATURE REVIEW
adult who could not be weaned from ventllatory support owing to tracheomalacla After anesthetic induction and succlnylcholine, the endotracheal tube was changed to a laryngeal mask airway (LMA) and manual positive-pressure ventilation with oxygen was maintained until spontaneous ventilation resumed. Fiberoptic bronchoscopy via the suction port of a catheter mount attached to the LMA was used to guide the apphcator sheath containing the stent Into satisfactory subglottlc position After stent placement, the patient was relntubated for 24 hours and then weaned without problem.
Soni AK, Conacher
I D , W a l l e r D A , et a h V i d e o -
thoracoscopic placement of paravertebral catheters: A technique for postoperative analgesia for bilateral thoracoscopic surgery. B r J A n a e s t h 7 2 : 4 6 2 assisted
Hornick PI, Harris P, Cousins C, et ah Assessment of the value of the immediate postoperative chest radiograph after cardiac operation. Ann Thorac Surg 5 9 : 1 1 5 0 - 1 1 5 4 , 1995 In a prospective analysis of 100 consecutive adult cardiac surgical patients, the immediate postoperative radiograph was of value in 11 patients when necessary to clarify or confirm clinical findings or to check lntraaortlc balloon catheter position One of 89 chest radiographs deemed unnecessary was found to be of clinical value. The authors call into question the practice of obtaining routine immediate postoperative chest radiographs in the absence of clinical indications.
S p o t n i t z W D , S a n d e r s R P , H a n k s J B , e t a h General surgical complications can be predicted after cardiopulmonary bypass. Ann Surg 2 2 1 : 4 8 9 - 4 9 7 , 1995 A retrospective review of 1,831 patients undergoing cardlopulmonary bypass surgery in a 3-year period was performed Factors associated with an increased risk of general surgical complications included use of the intraaortIc balloon pump and inotroplc agents, prolonged cardiopulmonary bypass, intensive care unit stay and ventilator support; treatment with steroids, and occurrence of arrhythmlas Surprise, surprise!
C o n t i J B , Belardinelli L, Curtis AB: Usefulness of adenosine in diagnosis of tachyarrhythmias. A m J Cardiol 7 5 : 9 5 2 - 9 5 5 , 1995 Twenty medical house officers were asked to diagnose the tachyarrhythmias in 12 hemodynamieally stable patients before and after administration of adenosine. Diagnostic accuracy (compared with an electrophysiologist expert) increased significantly after adenosine-induced slowing of atrlovenmcular conduction when atrioventricular nodal reentrant taehycardla, ventricular tachycardaa, and orthodromic reciprocating tachyeardaa in WolffParkinson-White syndrome were present The incidence of correct diagnosis of atrial fibrillation and flutter has not improved further by induction of transient atrioventrlcular block with adenosine Adenosine administration impaired the accurate diagnosis of sinus tachycardia; blocked sinus beats were confused with flutter waves
Van de Putte P, Martens P: Anaesthetic management for placement of a stent for high tracheal stenosis. Anaesth Intens Care 2 2 : 6 1 9 - 6 2 1 , 1 9 9 4 This case report describes the anesthetic management for placement of a self-expandable endotracheal Glanturco stent in an
464, 1994 Although pain after thoracoscoplc surgery IS less than after thoracotomy, the postoperative pain associated with pleural stripping after thoracoscoplc surgery for recurrent pneumothorax can be a problem This article describes the technique of percutaneous placement of intercostal catheters with direct thoracoscoplc guidance at the time of surgery A 16G Tuohy needle was inserted percutaneously in the posterior axillary line into the fifth intercostal space with direct internal surveillance by the thoracoscope. Normal saline was injected to develop an Intercostal plane and a 19G catheter was then passed via the Tuohy needle until it lay In the paravertebral gutter. Buplvacaine, 0.125% 10 mL bolus plus 4 mL/h infusion, was administered through each catheter for 48 hours postoperatwely This provided satisfactory analgesia without side effects in combination with patient-controlled morphine analgesia. Thoracoscoplc placement of paravertebral catheters may be a useful alternative technique for postthoracoscopy analgesia when epidural or spinal analgesia is not indicated
REVIEW ARTICLES
Pinski SL, Trohman RG: Implantable cardioverterdefibrillators: Implications for the nonelectrophysiologist. Ann Int Med 1 2 2 : 7 7 0 - 7 7 7 , 1995 Although implanted defibrillators resist most forms of electromagnetic radiation, a conservatwe approach in dealing with these devices during surgery, radiotherapy, hthotrlpsy, and electroconvulsive therapy is recommended Basic strategies for the safe management of the patient with an implanted defibrillator undergoing surgery are described; preoperatwe deactivation of the device is encouraged Standard basic life support and advanced cardiac life support resuscitation tactics are used when indicated, the presence of eplcardlal defibrillation patches may increase the energy requirement for external defibrillation
Pires LA, Wagshal AB, Lancey R, et ah Arrhythmias and conduction disturbances after coronary artery bypass graft surgery: Epidemiology, management, and prognosis. Am Heart J 1 2 9 : 7 9 9 - 8 0 8 , 1995 This elementary review discusses the epldemlologlc features and pathogenesis, diagnosis and management, and prognosis of postoperatwe arrhythmias and conduction disturbances in coronary artery surgery patients Prophylactic administration of beta-
LITERATURE REVIEW
779
ACKNOWLEDGMENT
of Cardtology, Anaesthesia and Intenstve Care, Annals of Internal Medtcme. Annals of Surgery, Annals of Thoraczc Surgery, Bnttsh Journal of Anaesthesia, Clrculatton, Journal of Thoracic and Cardtovascular Surgery.
Papers revmwed in this issue were selected from those published in the following journals:American Heart Journal, American Journal
Contributions to this literature review were made by Peter Slmger, MD, Montreal, Canada.
adrenerglc antagonists has demonstrated efficacy m the reduction of atrial tachyarrhythmlas but has not become widely used.
Dehmer GJ, Fisher M, Tate DA, e t al: Reversal of heparin anticoagulation by recombinant platelet factor 4 i n humans. Circulation 9 1 : 2 1 8 8 - 2 1 9 4 , 1995 Eighteen patients having cardiac catheterization and heparin anticoagulatlon received recombinant platelet factor 4 (rPF 4) 0.5, 1.0, 2.5, or 5.0 mg/kg in a phase 1, open-label trial. There were no significant hemodynamic effects or side effects in any patient despite transient rPF 4 levels as high as 14,870 ng/mL in patients receiving 5.0 mg/kg Doses of 2.5 and 5.0 mg/kg were uniformly effective In reversing the anticoagulant (ACT > 300 seconds) effect of heparin; lower doses were effective in most One patient receiving 2 5 rng/kg had a slight transient increase in liver enzymes
LITERATURE REVIEW
adult who could not be weaned from ventllatory support owing to tracheomalacla After anesthetic induction and succlnylcholine, the endotracheal tube was changed to a laryngeal mask airway (LMA) and manual positive-pressure ventilation with oxygen was maintained until spontaneous ventilation resumed. Fiberoptic bronchoscopy via the suction port of a catheter mount attached to the LMA was used to guide the apphcator sheath containing the stent Into satisfactory subglottlc position After stent placement, the patient was relntubated for 24 hours and then weaned without problem.
Soni AK, Conacher
I D , W a l l e r D A , et a h V i d e o -
thoracoscopic placement of paravertebral catheters: A technique for postoperative analgesia for bilateral thoracoscopic surgery. B r J A n a e s t h 7 2 : 4 6 2 assisted
Hornick PI, Harris P, Cousins C, et ah Assessment of the value of the immediate postoperative chest radiograph after cardiac operation. Ann Thorac Surg 5 9 : 1 1 5 0 - 1 1 5 4 , 1995 In a prospective analysis of 100 consecutive adult cardiac surgical patients, the immediate postoperative radiograph was of value in 11 patients when necessary to clarify or confirm clinical findings or to check lntraaortlc balloon catheter position One of 89 chest radiographs deemed unnecessary was found to be of clinical value. The authors call into question the practice of obtaining routine immediate postoperative chest radiographs in the absence of clinical indications.
S p o t n i t z W D , S a n d e r s R P , H a n k s J B , e t a h General surgical complications can be predicted after cardiopulmonary bypass. Ann Surg 2 2 1 : 4 8 9 - 4 9 7 , 1995 A retrospective review of 1,831 patients undergoing cardlopulmonary bypass surgery in a 3-year period was performed Factors associated with an increased risk of general surgical complications included use of the intraaortIc balloon pump and inotroplc agents, prolonged cardiopulmonary bypass, intensive care unit stay and ventilator support; treatment with steroids, and occurrence of arrhythmlas Surprise, surprise!
C o n t i J B , Belardinelli L, Curtis AB: Usefulness of adenosine in diagnosis of tachyarrhythmias. A m J Cardiol 7 5 : 9 5 2 - 9 5 5 , 1995 Twenty medical house officers were asked to diagnose the tachyarrhythmias in 12 hemodynamieally stable patients before and after administration of adenosine. Diagnostic accuracy (compared with an electrophysiologist expert) increased significantly after adenosine-induced slowing of atrlovenmcular conduction when atrioventricular nodal reentrant taehycardla, ventricular tachycardaa, and orthodromic reciprocating tachyeardaa in WolffParkinson-White syndrome were present The incidence of correct diagnosis of atrial fibrillation and flutter has not improved further by induction of transient atrioventrlcular block with adenosine Adenosine administration impaired the accurate diagnosis of sinus tachycardia; blocked sinus beats were confused with flutter waves
Van de Putte P, Martens P: Anaesthetic management for placement of a stent for high tracheal stenosis. Anaesth Intens Care 2 2 : 6 1 9 - 6 2 1 , 1 9 9 4 This case report describes the anesthetic management for placement of a self-expandable endotracheal Glanturco stent in an
464, 1994 Although pain after thoracoscoplc surgery IS less than after thoracotomy, the postoperative pain associated with pleural stripping after thoracoscoplc surgery for recurrent pneumothorax can be a problem This article describes the technique of percutaneous placement of intercostal catheters with direct thoracoscoplc guidance at the time of surgery A 16G Tuohy needle was inserted percutaneously in the posterior axillary line into the fifth intercostal space with direct internal surveillance by the thoracoscope. Normal saline was injected to develop an Intercostal plane and a 19G catheter was then passed via the Tuohy needle until it lay In the paravertebral gutter. Buplvacaine, 0.125% 10 mL bolus plus 4 mL/h infusion, was administered through each catheter for 48 hours postoperatwely This provided satisfactory analgesia without side effects in combination with patient-controlled morphine analgesia. Thoracoscoplc placement of paravertebral catheters may be a useful alternative technique for postthoracoscopy analgesia when epidural or spinal analgesia is not indicated
REVIEW ARTICLES
Pinski SL, Trohman RG: Implantable cardioverterdefibrillators: Implications for the nonelectrophysiologist. Ann Int Med 1 2 2 : 7 7 0 - 7 7 7 , 1995 Although implanted defibrillators resist most forms of electromagnetic radiation, a conservatwe approach in dealing with these devices during surgery, radiotherapy, hthotrlpsy, and electroconvulsive therapy is recommended Basic strategies for the safe management of the patient with an implanted defibrillator undergoing surgery are described; preoperatwe deactivation of the device is encouraged Standard basic life support and advanced cardiac life support resuscitation tactics are used when indicated, the presence of eplcardlal defibrillation patches may increase the energy requirement for external defibrillation
Pires LA, Wagshal AB, Lancey R, et ah Arrhythmias and conduction disturbances after coronary artery bypass graft surgery: Epidemiology, management, and prognosis. Am Heart J 1 2 9 : 7 9 9 - 8 0 8 , 1995 This elementary review discusses the epldemlologlc features and pathogenesis, diagnosis and management, and prognosis of postoperatwe arrhythmias and conduction disturbances in coronary artery surgery patients Prophylactic administration of beta-
LITERATURE REVIEW
779
ACKNOWLEDGMENT
of Cardtology, Anaesthesia and Intenstve Care, Annals of Internal Medtcme. Annals of Surgery, Annals of Thoraczc Surgery, Bnttsh Journal of Anaesthesia, Clrculatton, Journal of Thoracic and Cardtovascular Surgery.
Papers revmwed in this issue were selected from those published in the following journals:American Heart Journal, American Journal
Contributions to this literature review were made by Peter Slmger, MD, Montreal, Canada.
adrenerglc antagonists has demonstrated efficacy m the reduction of atrial tachyarrhythmlas but has not become widely used.