Intraoperative Anesthetic and Surgical Concerns for Robotic Thoracic Surgery
Robotic thoracic surgery continues to gain momentum and is emerging as the optimal method for minimally invasive thoracic surgery. As a rapidly advancing field, continued review of the surgical and anesthetic concerns unique to robotic thoracic operations is necessary to maintain safe and efficient practice. In this review, we discuss the intraoperative concerns as they pertain to pulmonary, esophageal, and mediastinal thoracic robotic operations.
Operational and Institutional Recommendations and Requirements for TAVR: A Review of Expert Consensus and the Impact on Health Care Policy
When transcatheter aortic valve replacement (TAVR) was first approved for use in the United States in 2012, multiple leading surgical and cardiology societies were tasked with creating recommendations and requirements for operators and institutions starting and maintaining TAVR programs. Creation of this consensus document was challenging due to limited experience with this new technology, and a lack of robust centralized data that could be used to validate outcome measures and create benchmarks for self-assessment and improvement. Despite these limitations, this document provided government agencies a framework for regulation that ultimately determined requirements for Medicare payment for TAVR and therefore greatly determined how and where care was delivered for patients with aortic stenosis. After the proliferation of TAVR institutions throughout the US and with data from more than 100,000 cases in the STS/ACC Transcatheter Valve Therapies TM Registry, leaders of the same societies reconvened in 2018 to update their consensus document. The new recommendations include suggested personnel, facilities, training, and assessment of outcomes and competencies required to run a safe and efficient TAVR program. This article seeks to detail the changes from the original consensus document with a particular focus on issues relevant to cardiac anesthesiologists as well as important healthcare policy ramifications for patients and providers in the United States.
Do special measures-such as postoperative CPAP, a prolonged PACU stay, and PACU EtCO2 monitoring-improve the outcome in a patient with obstructive sleep apnea?
A Prospective Randomized Study of Paravertebral Blockade in Patients Undergoing Robotic Mitral Valve Repair
OBJECTIVE: The aim of this study was to evaluate the addition of paravertebral blockade to general anesthesia in patients undergoing robotic mitral valve repair. DESIGN: A randomized, prospective trial. SETTING: A single tertiary referral academic medical center. PARTICIPANTS: 60 patients undergoing robotic mitral valve surgery. INTERVENTIONS: Patients were randomized to receive 4-level paravertebral blockade with 0.5% bupivicaine before induction of general anesthesia. All patients were given a fentanyl patient-controlled analgesia upon arrival to the intensive care unit, and visual analog scale pain scores were queried for 24 hours. On postoperative day 2, patients were given an anesthesia satisfaction survey. MEASUREMENTS AND MAIN RESULTS: After obtaining institutional review board approval, surgical and anesthetic data were recorded perioperatively and compared between groups. Compared to general anesthesia alone, patients receiving paravertebral blockade and general anesthesia reported significantly less postoperative pain and required fewer narcotics intraoperatively and postoperatively. Patients receiving paravertebral blockade also reported significantly higher satisfaction with anesthesia. Successful extubation in the operating room at the conclusion of surgery was 90% and similar in both groups. Hospital length of stay also was similar. No adverse reactions were reported. CONCLUSIONS: The addition of paravertebral blockade to general anesthesia appears safe and can reduce postoperative pain and narcotic usage in patients undergoing minimally invasive cardiac surgery. These findings were similar to previous studies of patients undergoing thoracic procedures. Paravertebral blockade alone likely does not reduce hospital length of stay. This may be more closely related to early extubation, which is possible with or without paravertebral blockade.
Does Paravertebral Blockade Facilitate Immediate Extubation After Totally Endoscopic Robotic Mitral Valve Repair Surgery?
OBJECTIVE: Immediate extubation of select patients in the operating room after cardiac surgery has been shown to be safe and may result in improved hemodynamics and decreased cost perioperatively. The aim of this study was to evaluate whether the addition of paravertebral blockade (PVB) to general anesthesia facilitates extubation in the operating room in patients undergoing totally endoscopic robotic mitral valve repair (TERMR). METHODS: A review of 65 consecutive patients who underwent TERMR between January 2012 and June 2013 at a single institution was conducted. Patients were divided into two groups, one group that received PVB and general anesthesia and a second group that received general anesthesia alone. The data analyzed included quantities of anesthetic administered during surgery and the location of extubation after surgery. RESULTS: A total of 34 patients received PVB and general anesthesia, whereas 31 received general anesthesia alone. The two groups had similar demographic and surgical data. Patients in the PVB and general anesthesia group were more likely to be extubated in the operating room (67.6%, n = 23 vs 41.9%, n = 13, P = 0.048) and required less intraoperative fentanyl (3.41 mug/kg vs 4.90 mug/kg, P = 0.006). There were no adverse perioperative events in either group related to PVB or extubation. CONCLUSIONS: The addition of PVB to general anesthesia for perioperative pain control facilitated extubation in the operating room in patients undergoing TERMR. Paravertebral blockade allowed for lower intraoperative fentanyl dosing, which may account for the increased incidence of immediate extubation. A detailed prospective study is warranted.
Preoperative localization in primary hyperparathyroidism
OBJECTIVE: To determine the most effective preoperative localization techniques for patients with primary hyperparathyroidism to facilitate the surgical procedure, decrease patient morbidity, and decrease the number of repeat surgeries owing to inability to locate the abnormal parathyroid gland. METHODS: This was a retrospective study in which 53 patients with primary hyperparathyroidism underwent preoperative sestamibi scanning and ultrasonography. If the two tests failed to agree on the precise location of the abnormal gland, a third imaging technique, magnetic resonance imaging (MRI), was used to confirm the precise location of the gland. Patients with secondary, tertiary, and recurrent hyperparathyroidism and patients with thyroid carcinoma were excluded from this study. Twenty males and 33 females were involved in the study. The mean age was 59.8 years (range 34-84 years). The preoperative results were compared with findings in surgery. A successful surgery was defined as parathyroid hormone and corrected calcium values in the normal range following the operative procedure. RESULTS: There was concurrence between ultrasound and sestamibi scanning in 70% (37 of 53) of the patients. When both agreed, the identified location of the abnormal parathyroid gland was correct 97% (36 of 37) of the time. The ultrasound and sestamibi scanning did not coincide in 30% of the patients (16 of 53). In this scenario, MRI was performed. When the MRI agreed with either of the two previous imaging techniques, the abnormal gland was accurately localized 100% of the time. In six cases (11%), there was no definitive agreement between all three tests that were performed. CONCLUSION: The combination of preoperative ultrasonography and sestamibi scanning is effective in predicting the location of parathyroid adenomas in patients with primary hyperparathyroidism. When both tests conflict, MRI is an effective tool to localize the abnormal glands. This study describes an algorithm for the preoperative localization of parathyroid gland abnormalities, in particular parathyroid adenomas. Second, it allows patients to undergo unilateral neck exploration, as opposed to bilateral neck exploration, where operative times, duration of hospitalization, and patient morbidity are potentially decreased