RESUMEN
Elective joint arthroplasty is a commonly performed procedure with postoperative cardiovascular complications occurring in up to 3% of elderly patients. Preoperative cardiac evaluation, including transthoracic echocardiography, may improve risk stratification and optimise perioperative outcomes in patients having non-cardiac surgery.This study aimed to investigate the frequency, indications, appropriateness and consequences of preoperative transthoracic echocardiography in elective joint arthroplasty patients. A one-year retrospective audit was conducted for patients who had elective joint arthroplasties performed at St Vincent's Hospital Melbourne. Patient demographics, transthoracic echocardiography indication, time between transthoracic echocardiography being ordered, performed and its impact on date of surgery were obtained via database and manual chart review. Appropriateness of transthoracic echocardiography was determined in accordance with international guidelines. This study analysed 609 elective joint arthroplasties. Of these, 116 (19%) already had a recent transthoracic echocardiography. Of the remaining 493 patients, 192 (39%) received a resting transthoracic echocardiography. Only 92 (48%) of the transthoracic echocardiography's ordered were deemed appropriate. Transthoracic echocardiography resulted in a significant delay of 31 days in time to surgery.This study indicates that almost 40% of elective joint arthroplasty patients with no recent echocardiogram are having a resting transthoracic echocardiography as part of their preoperative assessment. In 52% of cases, these are not clearly appropriate and result in delays to surgery.
Asunto(s)
Ecocardiografía , Procedimientos Quirúrgicos Electivos , Anciano , Artroplastia , Ecocardiografía/métodos , Procedimientos Quirúrgicos Electivos/métodos , Humanos , Cuidados Preoperatorios , Estudios RetrospectivosRESUMEN
Intravenous fluids are commonly administered for patients having colonoscopy despite relatively little data to support this practice. It is unclear what, if any, effect crystalloid administration has on stroke volume and cardiac output in patients who are fasting and have had bowel preparation agents. We aimed to assess the physiological effect of 10 ml/kg of crystalloid administration in colonoscopy patients on haemodynamic parameters including stroke volume, stroke volume variation and cardiac output, as measured with transthoracic echocardiography. Our secondary aims were to determine whether stroke volume variation predicted fluid responsiveness in gastrointestinal endoscopy patients and whether these haemodynamic measures are different in fasting patients with bowel preparation (colonoscopy patients) compared to fasting patients alone (gastroscopy patients). We recruited 54 patients having elective gastrointestinal endoscopy (25 colonoscopy, 29 gastroscopy). All patients had stroke volume, cardiac output and stroke volume variation measured with transthoracic echocardiography at baseline. In colonoscopy patients, stroke volume, cardiac output and stroke volume variation were remeasured after 10 ml/kg of intravenous crystalloid. Administration of 10 ml/kg of crystalloid increases stroke volume by 19.6 ml ( p < 0.00005) and cardiac output by 0.81 l/min ( p < 0.001). Stroke volume variation reduced from 23% to 14% after fluid administration ( p < 0.0011). The optimum threshold of stroke volume variation to predict fluid responsiveness was 21% with a sensitivity of 77.8% and specificity of 62.5%. Administration of 10 ml/kg of crystalloid increases stroke volume and cardiac output, and reduces stroke volume variation in fasting elective colonoscopy patients.
Asunto(s)
Soluciones Cristaloides , Endoscopía , Fluidoterapia , Gasto Cardíaco , Soluciones Cristaloides/uso terapéutico , Humanos , Volumen SistólicoRESUMEN
Patients with severe pulmonary hypertension (PHT) represent a high-risk population when undergoing noncardiac surgery. During thoracic surgery with 1-lung ventilation, atelectasis of the operative lung, and frequently associated hypoxemia, is likely to exacerbate PHT and precipitate acute right ventricular failure. We present a patient with previously undiagnosed PHT who suffered 2 cardiac arrests during emergent thoracic surgery for empyema. After successful resuscitation in the operating room, she subsequently required prolonged venoarterial extracorporeal membrane oxygenation. Focused transthoracic echocardiography to evaluate cardiac function was critical in the diagnosis of PHT and subsequent treatment with sildenafil and nifedipine when discharged from the hospital.