Regional anesthesia, consisting of spinal, caudal, and epidural blocks, was first utilized for surgical procedures at the turn of the twentieth century. Initially deemed unsafe due to reports of permanent neurologic injury, a large-scale study in the 1950s proved complications were rare when blocks were performed skillfully and with attention to sterile technique, combined with the improved safety profile of injected medications. Initial work showing improved pain management in cancer patients has expanded spinal opioids for postoperative pain management. (Katz, 1981; Cunningham, 1983; Vanstrum, 1988).Spinal anesthesia now has a long track record of safety. In some circumstances, it is the anesthetic of choice and, at times, even the safest option. While local anesthetics are used to provide surgical anesthesia, they are often combined with intrathecal (IT) opioids to supplement intraoperative analgesia and provide postoperative analgesia once the local anesthetic has worn off. Spinal opioids are also used to manage chronic pain, sometimes as single injections, but more often via implantable infusion pumps.
Aims & Objectives: Chylothorax occurs in 2.8-3.9% of children post-cardiac surgery and is associated with increased length of stay and mortality. The median time to diagnosis is reported as 4-8.5 days postoperatively. We hypothesize that early diagnosis without dependence on initiation of enteral feeds will lead to earlier resolution. We propose a predictive chylothorax model for earlier detection than traditional pleural fluid testing (PFT). Methods: A prospective cohort of 405 patients <18 years old (415 encounters) post-cardiac surgery at a single tertiary-care academic center between 2016 and 2019 was studied. Exclusion criteria were mechanical circulatory support and chylothorax diagnosis within post-chest closure day (PCD) 1. Multivariate regression models optimized AUC and selected from postoperative chest tube output (CTO), age, race, genetic syndrome, surgical weight, STAT category, single/two ventricle repair with/without arch reconstruction, operative times, prior surgery, and delayed sternal closure (DSC). Results: PFT confirmed chylothorax in 37 encounters (9.2%). The final model included DSC and identified CTO of 15.7 mL/kg on PCD1 as having important predictive value with AUC 0.65. Patients with CTO >15.7 mL/kg on PCD1 were more likely to have chylothorax with a model sensitivity of 85%, specificity of 68%, positive predictive value of 31% and accuracy of 84%. The negative predictive value of CTO <15.7 mL/kg on PCD1 was 96%. DSC was a significant risk factor (Table).Conclusions: Chest tube output on PCD1 may be an early predictor of chylothorax allowing for diagnosis prior to the initiation of enteral feeds. Early diagnosis has potential to decrease duration of chylothorax and improve related outcomes.
This article focuses on new findings leading to improved understanding of the pathophysiology and mechanisms of potential drug interactions between anesthetic drugs or techniques and cardiovascular medications in patients scheduled for surgery. Only the most frequently used drugs are reviewed. Elective surgery provides the luxury to consider these risks and alter therapy accordingly. Under urgent circumstances, however, the increased risks associated with these agents should be anticipated with the goal to minimize adverse effects while maintaining optimal cardiovascular function in the perioperative period.
When performing left-sided catheter ablation, anticoagulation is used to prevent formation of thrombi that might embolize. After heparin administration, appropriate anticoagulation is confirmed by measuring Activated Coagulation Time (ACT). We report a case during which ACT results were erroneous, and review alternatives to the ACT under such circumstances.
