Propofol-Based Versus Dexmedetomidine-Based Sedation in Cardiac Surgery Patients

Weaning-associated interventions for ventilated intensive care patients: A scoping review

BACKGROUND

Mechanical ventilation is a core intervention in critical care, but may also lead to negative consequences. Therefore, ventilator weaning is crucial for patient recovery. Numerous weaning interventions have been investigated, but an overview of interventions to evaluate different foci on weaning research is still missing.

AIM

To provide an overview of interventions associated with ventilator weaning.

STUDY DESIGN

We conducted a scoping review. A systematic search of the Medline, CINAHL and Cochrane Library databases was carried out in May 2023. Interventions from studies or reviews that aimed to extubate or decannulate mechanically ventilated patients in intensive care units were included. Studies concerning children, outpatients or non-invasive ventilation were excluded. Screening and data extraction were conducted independently by three reviewers. Identified interventions were thematically analysed and clustered.

RESULTS

Of the 7175 records identified, 193 studies were included. A total of six clusters were formed: entitled enteral nutrition (three studies), tracheostomy (17 studies), physical treatment (13 studies), ventilation modes and settings (47 studies), intervention bundles (42 studies), and pharmacological interventions including analgesic agents (8 studies), sedative agents (53 studies) and other agents (15 studies).

CONCLUSIONS

Ventilator weaning is widely researched with a special focus on ventilation modes and pharmacological agents. Some aspects remain poorly researched or unaddressed (e.g. nutrition, delirium treatment, sleep promotion).

RELEVANCE TO CLINICAL PRACTICE

This review compiles studies on ventilator weaning interventions in thematic clusters, highlighting the need for multidisciplinary care and consideration of various interventions. Future research should combine different interventions and investigate their interconnection.

Methadone in combination with magnesium, ketamine, lidocaine, and dexmedetomidine improves postoperative outcomes after coronary artery bypass grafting: an observational multicentre study

BACKGROUND

An optimal pharmacological strategy for fast-track cardiac anesthesia (FTCA) is unclear. This study evaluated the effectiveness and safety of an FTCA program using methadone and non-opioid adjuvant infusions (magnesium, ketamine, lidocaine, and dexmedetomidine) in patients undergoing coronary artery bypass grafting.

METHODS

This retrospective, multicenter observational study was conducted across private and public teaching sectors. We studied patients managed by a fast-track protocol or via usual care according to clinician preference. The primary outcome was the total mechanical ventilation time in hours adjusted for hospital, body mass index, category of surgical urgency, cardiopulmonary bypass time and EuroSCORE II. Secondary outcomes included successful extubation within four postoperative hours, postoperative pain scores, postoperative opioid requirements, and the development of postoperative complications.

RESULTS

We included 87 patients in the fast-track group and 88 patients in the usual care group. Fast-track patients had a 35% reduction in total ventilation hours compared with usual care patients (p = 0.007). Thirty-five (40.2%) fast-track patients were extubated within four hours compared to 10 (11.4%) usual-care patients (odds ratio: 5.2 [95% CI: 2.39-11.08; p < 0.001]). Over 24 h, fast-track patients had less severe pain (p < 0.001) and required less intravenous morphine equivalent (22.00 mg [15.75:32.50] vs. 38.75 mg [20.50:81.75]; p < 0.001). There were no significant differences observed in postoperative complications or length of hospital stay between the groups.

CONCLUSION

Implementing an FTCA protocol using methadone, dexmedetomidine, magnesium, ketamine, lignocaine, and remifentanil together with protocolized weaning from a mechanical ventilation protocol is associated with significantly reduced time to tracheal extubation, improved postoperative analgesia, and reduced opioid use without any adverse safety events. A prospective randomized trial is warranted to further investigate the combined effects of these medications in reducing complications and length of stay in FTCA.

TRIALS REGISTRATION

The study protocol was registered in the Australian New Zealand Clinical Trials Registry ( https://www.anzctr.org.au/ACTRN12623000060640.aspx , retrospectively registered on 17/01/2023).

Dexmedetomidine Sedation Combined With Remifentanil in MitraClip Procedures is Feasible and Improves Hemodynamics

OBJECTIVES

The objective of the study was to compare the overall feasibility, respiratory and hemodynamic stability, as well as process times of a dexmedetomidine-based sedative regimen compared with general anesthesia among patients undergoing MitraClip procedures.

DESIGN

A retrospective cohort study.

SETTING

A single tertiary care university center.

PARTICIPANTS

The study included 79 patients.

INTERVENTIONS

Dexmedetomidine sedation versus general anesthesia.

MEASUREMENTS AND MAIN RESULTS

Seventy-nine MitraClip procedures in dexmedetomidine/remifentanil conscious sedation (DCS, n = 26) or general anesthesia (GA, n = 53), performed between 2018 and 2020 at Charité - Universitätsmedizin Berlin, were analyzed retrospectively. Patients' median age was 81 years in both groups without differences in preinterventional EuroScore I (DCS 6 [5; 8], GA 7 [6; 8]) or systolic function (left ventricular ejection fraction: DCS 50% [32; 60] v. GA 50% [36; 60]; tricuspid annular plane systolic excursion: DCS 19 mm [16; 22] v GA 19 mm [15; 22]). During MitraClip procedures, respiratory parameters revealed no differences between groups, whereas patients under DCS showed higher mean arterial pressures (DCS 64 mmHg [59; 74] v GA 58 mmHg [53; 66]) and needed less norepinephrine (DCS 0.0µg/kg/min [0.0; 0.2] v GA 0.08 µg/kg/min [0.05; 0.15]). Emergence from both anesthesia regimens to readiness for intensive care unit transfer was faster in DCS (8 min [4; 18] v GA 16 min [11; 23]); however, total process time was comparable between groups (DCS 128 min [104; 155] v GA 142 min [117; 190]). Two patients required a switch from DCS to GA due to oral bleeding or prolonged procedure time. Both were excluded from the analysis. There was no switch to open surgery and no differences in postoperative complications between DCS and GA.

CONCLUSION

Dexmedetomidine/remifentanil sedation appears to be feasible and a safe option for MitraClip procedures, and provides better hemodynamic stability with faster emergence times compared with general anesthesia.

Comparison of the efficacy and safety of sedation protocols with the use of dexmedetomidine-remifentanil and propofol-remifentanil during percutaneous closure of atrial septal defects: a randomized clinical trial

Background

The study was aimed to compare the efficacy and safety of different sedation protocols of dexmedetomidine–remifentanil and propofol–remifentanil for percutaneous closure of atrial septal defects (ASD) under transthoracic echocardiography (TTE) guidance.

Material and methods

From March 2020 to January 2021, of 114 patients screened, 59 ASD patients scheduled for percutaneous closure under TTE guidance were randomly allocated into the dexmedetomidine–remifentanil (D–R) group (n = 29) and the propofol–remifentanil (P–R) group (n = 30). The incidence of hemodynamic and respiratory adverse events, arterial blood gas analysis, induction and recovery time, pain score, infusion rate of remifentanil, satisfaction of the surgeon and patient, additional sedatives were collected for analysis and comparison.

Results

The induction time was longer in the D–R group than that in the P–R group (17.66 ± 2.65 min vs 11.43 ± 1.48 min; difference, 6.22 min; 95% CI 5.10 to 7.35; P < 0.001). No differences were observed in the 2 groups in terms of the additional sedatives, infusion rate of remifentanil, pain score, recovery time (P > 0.05). There was no difference between the two groups regarding the incidence of cardiovascular adverse events (6 [20.7%] vs 4 [13.3%]; difference, 7.4%; 95% CI − 11.7 to 26.5%; P = 0.506). Respiratory adverse events occurred in 1 patient (3.4%) in the D–R group, and 8 patients (26.7%) in the P–R group (difference, 23.3%; 95% CI 6.2 to 40.5%; P = 0.026). The incidence of hypercapnia was significantly lower in the D–R group (4 [13.8%]) than in the P–R group (13 [43.3%]; difference, 29.5%; 95% CI 7.8 to 51.2%; P = 0.012).

Conclusions

Except for more rapid the induction time and higher the surgeon satisfaction score in the propofol–remifentanil protocol, the efficacy was similar between two sedation protocols. The hemodynamic stability was comparable, the dexmedetomidine–remifentanil protocol had superior airway security due to fewer hypercapnia and respiratory adverse events.

Post-operative management of hypertrophic obstructive cardiomyopathy

Hypertrophic obstructive cardiomyopathy patients are at increased risk of sudden cardiac arrest due to dynamic left ventricular outflow tract obstruction, myocardial ischaemia and arrhythmias. Septal myectomy remains the gold standard therapy for patients with hypertrophic obstructive cardiomyopathy (HOCM) refractory to other therapy. This review comprehensively focuses on the post-operative management and complications of HOCM patients undergoing surgical correction. Although these patients are at risk of various perioperative complications from anaesthesia and surgery due to the underlying complexity of their disease, surgical myectomy is associated with excellent long-term outcomes if carried out in experienced centers.

Cardiovascular Safety of Clonidine and Dexmedetomidine in Critically Ill Patients after Cardiac Surgery

Purpose

The aim of this retrospective study was to assess the haemodynamic adverse effects of clonidine and dexmedetomidine in critically ill patients after cardiac surgery.

Methods

2769 patients were screened during the 30-month study period. Heart rate (HR), mean arterial pressure (MAP), and norepinephrine requirements were assessed 3-hourly during the first 12 hours of the continuous drug infusion. Results are given as median (interquartile range) or numbers (percentages).

Results

Patients receiving clonidine (n = 193) were younger (66 (57-73) vs 70 (63-77) years, p=0.003) and had a lower SAPS II (35 (27-48) vs 41 (31-54), p=0.008) compared with patients receiving dexmedetomidine (n = 141). At the start of the drug infusion, HR (90 (75-100) vs 90 (80-105) bpm, p=0.028), MAP (70 (65-80) vs 70 (65-75) mmHg, p=0.093), and norepinephrine (0.05 (0.00-0.11) vs 0.12 (0.03-0.19) mcg/kg/min, p < 0.001) were recorded in patients with clonidine and dexmedetomidine. Bradycardia (HR < 60 bpm) developed in 7.8% with clonidine and 5.7% with dexmedetomidine (p=0.51). Between baseline and 12 hours, norepinephrine remained stable in the clonidine group (0.00 (-0.04-0.02) mcg/kg/min) and decreased in the dexmedetomidine group (-0.03 (-0.10-0.02) mcg/kg/min, p=0.007).

Conclusions

Dexmedetomidine and the low-cost drug clonidine can both be used safely in selected patients after cardiac surgery.

Dexmedetomidine in Adult Patients in Cardiac Surgery Critical Care: An Evidence-Based Review

Although several options are available for postoperative sedation in the intensive care unit, the selective α2-adrenoceptor agonist dexmedetomidine may offer advantages for patients after cardiac surgery. The author conducted a review of the literature on the use of dexmedetomidine in the cardiac surgery population to determine possible advantages and disadvantages in this patient population. Although the use of dexmedetomidine has not been conclusively shown to change overall morbidity and mortality and may be associated with higher drug cost, its other demonstrated effects offer advantages for postoperative cardiac surgery patients that other forms of sedation cannot match.

Dexmedetomidine implementation in pain management in the immediate postoperative period of cardiac surgery

BACKGROUND

This study arose from the need to improve all tasks related to monitoring pain in post cardiac surgery patients.

OBJECTIVES

Checking and quantifying the pain suffered by patients undergoing cardiac surgery in the first 24hours of their stay in the intensive care unit (ICU), treated with Dexmedetomidine (Dex) as analgesic adjuvant, as well as their degree of sedation and the need for opiates such as rescue analgesia.

MATERIAL AND METHODS

Unicentric study, observational, descriptive, from April 2016 to September 2017. Both genders, all adult, undergoing cardiac surgery, operating theatre-extubated and Dex continuous infusion carriers. Pain degree level was evaluated by the Visual analogue Scale of Pain (VAS), from immediately post-surgery until 24hours from ICU entry and sedation degree, by the Richmond Sedation Agitation Scale (RASS), only while the Dex infusion lasted.

RESULTS

109 patients were included. The results obtained showed that the average pain suffered by patients during the first 24hours was .47 with standard deviation (SD) of 1.25; the average maximum pain experienced was 3.58 with a range of 0 to 8 and the RASS average was -.68 (SD: 0,80). In addition, 44.04% of the patients needed rescue opiates, although only 7.32% showed severe pain greater than 6.

CONCLUSIONS

The Dex infusion patients showed mild levels of pain, however, a small percentage, who must be taken into account, suffered severe pain.

Psychotropic drug therapy in patients in the intensive care unit - usage, adverse effects, and drug interactions: a review

Managing psychological problems in patients admitted to intensive care unit (ICU) is a big challenge, requiring pharmacological interventions. On the other hand, these patients are more prone to side effects and drug interactions associated with psychotropic drugs use. Benzodiazepines (BZDs), antidepressants, and antipsychotics are commonly used in critically ill patients. Therefore, their therapeutic effects and adverse events are discussed in this study. Different studies have shown that non-BZD drugs are preferred to BZDs for agitation and pain management, but antipsychotic agents are not recommended. Also, it is better not to start antidepressants until the patient has fully recovered. However, further investigations are required for the use of psychotropic drugs in ICUs.

Effects of dexmedetomidine on postoperative cognitive function in patients undergoing coronary artery bypass grafting

Effects of dexmedetomidine on postoperative cognitive function in patients undergoing coronary artery bypass grafting were investigated. Eighty patients undergoing systemic anesthesia with extracorporeal coronary artery bypass grafting in The People's Hospital of Guangxi Zhuang Autonomous Region from January 2015 to August 2017 were selected and randomly divided into the observation group (n=40) and control group (n=40). The two groups were treated with dexmedetomidine and equal volume of normal saline, respectively. Moreover, safety indexes including EEG bispectral index (BIS) at 30 min before induction of anesthesia (T0), immediately after intubation (T1), when incision was made (T2), when chest was closed (T3), when operation was completed (T4) and at 6 h after operation (T5), intraoperative circulatory system-related complications, cortisol, epinephrine and norepinephrine levels at the end of surgery as well as anesthesia recovery time and postoperative mechanical ventilation time were recorded and compared. All the patients were followed up for 1 week. Mini-mental state examination (MMSE) and Montreal cognitive assessment (MoCA) were administered at 1, 3 and 7 days after operation, and the incidence of intraoperative awareness and postoperative cognitive dysfunction was recorded. BIS value in the observation group was lower than that in the control group (P<0.05) at T1-T4 time points, and the BIS value in the observation group was higher than that in the control group (P<0.05) at T5. Incidence rates of intraoperative arrhythmia, hypertension and hypotension in the observation group was significantly lower than those in the control group (P<0.05). At the end of operation, levels of cortisol, epinephrine and norepinephrine in the observation group were significantly lower than those in the control group (P<0.05). Anesthesia recovery time and postoperative mechanical ventilation time in the observation group was significantly shorter than the time in the control group (P<0.05). MMSE and MoCA scores of the observation group were better than those of the control group (P<0.05). The incidence of cognitive impairment and postoperative cognitive impairment in the observation group was significantly lower than those in the control group (P<0.05). Therefore, it is concluded that dexmedetomidine can effectively reduce the incidence of postoperative cognitive impairment in patients undergoing coronary artery bypass grafting, and it is of high safety for circulatory function.

Perioperative Sedation in Mechanically Ventilated Cardiac Surgery Patients With Dexmedetomidine-Based Versus Propofol-Based Regimens

BACKGROUND

Sedative agents used during cardiac surgery can influence the patient's time to extubation, intensive care unit (ICU) and hospital length of stay, and incidence of delirium.

OBJECTIVE

This study evaluates the effects of the intraoperative and postoperative use of dexmedetomidine versus propofol infusions.

METHODS

This 19-month retrospective observational study at an academic medical center included 278 patients 18 years of age or older who underwent coronary artery bypass grafting (CABG), valve replacement surgery, or combined CABG plus valve surgery, who received either a dexmedetomidine or propofol infusion in addition to general anesthesia intraoperatively. The primary outcome was time to extubation. The secondary outcomes were ICU and hospital length of stay and incidence of delirium.

RESULTS

Use of dexmedetomidine (n = 69) as an intraoperative and postoperative sedative as opposed to propofol (n = 209) was significantly associated with increased likelihood of extubation (ie, shorter time to extubation; hazard ratio = 1.63, 95% CI = 1.21-2.19, P = 0.001). There was no significant association between use of dexmedetomidine and ICU discharge ( P = 0.99), hospital discharge ( P = 0.52), and incidence of delirium ( P = 0.27) after adjusting for other covariates. Conclusion and Relevance: Dexmedetomidine increased the likelihood of extubation when compared with propofol, with no increase in ICU or hospital length of stay or incidence of delirium. Our study is unique in that there was no crossover between patients who received dexmedetomidine and propofol infusions intraoperatively and postoperatively Dexmedetomidine-based regimens could serve as a suitable alternative to propofol-based regimens for fast-track extubation.

A comparison between dexmedetomidine and propofol on extubation times in postoperative adult cardiac surgery patients: a systematic review protocol

REVIEW QUESTION/OBJECTIVE

The objective of this systematic review is to synthesize the best available evidence regarding the effects of dexmedetomidine compared to propofol on time to extubation, intensive care unit (ICU) length of stay (LOS), hospital LOS and mortality in postoperative adult cardiac surgery patients.The specific review question is as follows:What is the effectiveness of dexmedetomidine compared to propofol on times to extubation, ICU LOS, hospital LOS and mortality in postoperative adults undergoing cardiac surgery?

Safety and efficacy of ketamine-dexmedetomidine versus ketamine-propofol combinations for sedation in patients after coronary artery bypass graft surgery

Background and Aims:

Prolonged mechanical ventilation after cardiac surgery is associated with serious complications that increase morbidity and mortality. The present study was designed to compare ketamine-propofol (KP) and ketamine-dexmedetomidine (KD) combinations for sedation and analgesia in patients after coronary artery bypass graft (CABG) surgery as regards hemodynamics, total fentanyl dose, time of weaning from mechanical ventilation, time of extubation, and any adverse outcome.

Materials and Methods:

Seventy post-CABG patients were sedated using ketamine 1 mg/kg IV then 0.25 mg/kg/h infusion combined with either dexmedetomidine or propofol to maintain Ramsay sedation score ≥4 during assisted ventilation. Group KP received ketamine + propofol 1 mg/kg bolus followed by 25–50 μg/kg/min. Group KD received ketamine + dexmedetomidine 1.0 μg/kg over 20 min and then 0.2–0.7 μg/kg/h. Total dose of fentanyl in the first 24 h, time of weaning, time of extubation, mean arterial blood pressure, heart rate, and Intensive Care Unit (ICU) stay time were recorded.

Statistics:

Sample size of 35 patients was calculated for 90% power, α = 0.05, β = 0.1, and anticipated effect size = 0.40 using sample size software (G*Power version 3.00.10, Germany). Analytic statistics was performed on IBM compatible computer using SPSS version 11.5 (IBM, New York, United States) software package under Windows XP operating system. All results presented in the form of mean ± standard deviation. Data compared using unpaired Student's t-test, P < 0.05 was considered as statistically significant.

Results:

Group KD showed a significant decrease in mean time of weaning and extubation in group KD in comparison with group KP (374.05 ± 20.25 min vs. 445.23 ± 21.7 min, respectively, P < 0.001) (432.4 ± 19.4 min and 504 ± 28.7 min, respectively, P < 0.0001). Fentanyl consumption showed a significant decrease in group KD in comparison with group KP (41.94 ± 20.43 μg and 152.8 ± 51.2 μg, respectively, with P < 0.0001). There were insignificant difference between both groups as regards hemodynamic stability and length of ICU stay.

Conclusion:

Using KD combination for sedation, post-CABG surgery provided short duration of mechanical ventilation with less fentanyl dose requirement in comparison with KP with insignificant difference in both groups as regards hemodynamic stability and length of the ICU stay.

Sedation After Cardiac Surgery: Is One Drug Better Than Another?

The classic high-dose narcotic-based cardiac anesthetic has been modified to facilitate a fast-track, rapid recovery in the intensive care unit (ICU). Postoperative sedation is consequently now an essential component in recovery of the patient undergoing cardiac surgery. It must facilitate the patient's unawareness of the environment as well as reduce the discomfort and anxiety caused by surgery, intubation, mechanical ventilation, suction, and physiotherapy. Benzodiazepines seem well suited for this role, but propofol, opioids, and dexmedetomidine are among other agents commonly used for sedation in the ICU. However, what is an ideal sedative for this application? When compared with benzodiazepine-based sedation regimens, nonbenzodiazepines have been associated with shorter duration of mechanical ventilation and ICU length of stay. Current sedation guidelines recommend avoiding benzodiazepine use in the ICU. However, there are no recommendations on which alternatives should be used. In postcardiac surgery patients, inotropes and vasoactive medications are often required because of the poor cardiac function. This makes sedation after cardiac surgery unique in comparison with the requirements for most other ICU patient populations. We reviewed the current literature to try to determine if 1 sedative regimen might be better than others; in particular, we compare outcomes of propofol and dexmedetomidine in postoperative sedation in the cardiac surgical ICU.

Experienced Use of Dexmedetomidine in the Intensive Care Unit: A Report of a Structured Consensus

Objective

Management of pain, agitation and delirium (PAD) remains to be a true challenge in critically ill patients. The pharmacological proprieties of dexmedetomidine (DEX) make it an ideal candidate drug for light and cooperative sedation, but many practical questions remain unanswered. This structured consensus from 17 intensivists well experienced on PAD management and DEX use provides indications for the appropriate use of DEX in clinical practice.

Methods

A modified RAND/UCLA appropriateness method was used. In four predefined patient populations, the clinical scenarios do not properly cope by the current recommended pharmacological strategies (except DEX), and the possible advantages of DEX use were identified and voted for agreement, after reviewing literature data.

Results

Three scenarios in medical patients, five scenarios in patients with acute respiratory failure undergoing non-invasive ventilation, three scenarios in patients with cardiac surgery in the early postoperative period and three scenarios in patients with overt delirium were identified as challenging with the current PAD strategies. In these scenarios, the use of DEX was voted as potentially useful by most of the panellists owing to its specific pharmacological characteristics, such as conservation of cognitive function, lack of effects on the respiratory drive, low induction of delirium and analgesia effects.

Conclusion

DEX might be considered as a first-line sedative in different scenarios even though conclusive data on its benefits are still lacking.

The Effect of Dexmedetomidine on Outcomes of Cardiac Surgery in Elderly Patients

OBJECTIVE

The goal of this retrospective study was to investigate the effects of perioperative use of dexmedetomidine (Dex) on outcomes for older patients undergoing cardiac surgery.

DESIGN

Retrospective investigation.

SETTING

Patients from a single tertiary medical center.

PARTICIPANTS

A total of 505 patients (≥65 years old) who underwent coronary artery bypass graft (CABG) or valve surgery. CABG and/or valve surgery plus other procedures were divided into 2 groups: 283 received intravenous Dex infusion (Dex group) and 222 did not (Non-Dex group).

INTERVENTIONS

Perioperative Dex intravenous infusion (0.24 to 0.6 μg/kg/h) initiated after cardiopulmonary bypass and continued for<24 hours postoperatively in the ICU.

MEASUREMENTS AND MAIN RESULTS

Data were risk adjusted, propensity score weighted, and multivariate logistic regression was used. The primary outcome was mortality. Secondary outcomes included postoperative stroke, coma, myocardial infarction, heart block, cardiac arrest, delirium, renal failure, and sepsis. Perioperative Dex infusion significantly decreased in-hospital mortality (0.90% v 2.83%; adjusted odds ratio (OR), 0.099; 95% confidence interval (CI), 0.030-0.324; p = 0.004) and operative mortality (1.35% v 3.18%; adjusted OR, 0.251; 95% CI, 0.077-0.813; p = 0.021). Perioperative Dex treatment also reduced the risk of stroke (0.90% v 1.77%; adjusted OR, 0.15; 95% CI, 0.038-0.590; p = 0.007), and delirium (7.21% v 10.95%; adjusted OR, 0.35; 95% CI, 0.212-0.578; p < 0.0001).

CONCLUSIONS

Results from this study (ClinicalTrials.gov identifier: NCT01683448) suggested perioperative use of dexmedetomidine was associated with decreases in in-hospital and operative mortality in elderly patients following cardiac surgery. It also reduced incidences of postoperative stroke and delirium in elderly patients.

Postoperative Critical Care of the Adult Cardiac Surgical Patient. Part I: Routine Postoperative Care

OBJECTIVES

Cardiac surgery, including coronary artery bypass, cardiac valve, and aortic procedures, is among the most common surgical procedures performed in the United States. Successful outcomes after cardiac surgery depend on optimum postoperative critical care. The cardiac intensivist must have a comprehensive understanding of cardiopulmonary physiology and the sequelae of cardiopulmonary bypass. In this concise review, targeted at intensivists and surgeons, we discuss the routine management of the postoperative cardiac surgical patient.

DATA SOURCE AND SYNTHESIS

Narrative review of relevant English-language peer-reviewed medical literature.

CONCLUSIONS

Critical care of the cardiac surgical patient is a complex and dynamic endeavor. Adequate fluid resuscitation, appropriate inotropic support, attention to rewarming, and ventilator management are key components. Patient safety is enhanced by experienced personnel, a structured handover between the operating room and ICU teams, and appropriate transfusion strategies.

Pectoral nerves (PECS) and intercostal nerve block for cardiac resynchronization therapy device implantation

A 71-year-old man was scheduled to undergo cardiac resynchronization therapy device (CRTD) implantation. He was combined with severe chronic heart failure due to ischemic heart disease. NYHA class was 3 to 4 and electrocardiogram showed non-sustained ventricular. Ejection fraction was about 20% revealed by transthoracic echocardiogram. He was also on several anticoagulation medications. We planned to implant the device under the greater pectoral muscle. As general anesthesia was considered risky, monitored anesthesia care utilizing peripheral nerve block and slight sedation was scheduled. Pectoral nerves (PECS) block and intercostal block was performed under ultrasonography with ropivacaine. For sedation during the procedure, continuous infusion of dexmedetomidine without a loading dose was performed. The procedure lasted about 3 hours, but the patient showed no pain or restlessness. Combination of PECS block and intercostal block may provide effective analgesia for CRTD implantation.

Dexmedetomidine: a review of applications for cardiac surgery during perioperative period

Cardiac surgery is associated with a high incidence of cardiovascular and other complications during the perioperative period that translate into increased mortality and prolonged hospital stays. Safe comprehensive perioperative management is required to eliminate these adverse events. Dexmedetomidine is a selective α2-adrenoreceptor agonist that has been described as an ideal medication in the perioperative period of cardiac surgery. The major clinical effects of dexmedetomidine in this perioperative period can be summarized as attenuating the hemodynamic response, cardioprotective effects, antiarrhythmic effects, sedation in the ICU setting, treatment of delirium, and procedural sedation. Although there are some side effects of dexmedetomidine, it is emerging as an effective therapeutic agent in the management of a wide range of clinical conditions with an efficacious, safe profile. The present review serves as an overview update in the diverse applications of dexmedetomidine for cardiac surgery during the perioperative period.

Dexmedetomidine: a review of applications for cardiac surgery during perioperative period

Cardiac surgery is associated with a high incidence of cardiovascular and other complications during the perioperative period that translate into increased mortality and prolonged hospital stays. Safe comprehensive perioperative management is required to eliminate these adverse events. Dexmedetomidine is a selective α2-adrenoreceptor agonist that has been described as an ideal medication in the perioperative period of cardiac surgery. The major clinical effects of dexmedetomidine in this perioperative period can be summarized as attenuating the hemodynamic response, cardioprotective effects, antiarrhythmic effects, sedation in the ICU setting, treatment of delirium, and procedural sedation. Although there are some side effects of dexmedetomidine, it is emerging as an effective therapeutic agent in the management of a wide range of clinical conditions with an efficacious, safe profile. The present review serves as an overview update in the diverse applications of dexmedetomidine for cardiac surgery during the perioperative period.

The Year in Review

Congenital cardiac anesthesiology is a young and rapidly growing subspecialty. It embraces a large spectrum of congenital and acquired heart diseases, which now affect the entire life span of patients from “cradle to grave.” One of the challenges faced by congenital cardiac anesthesiologists is reading the large amount of relevant literature from the fields of cardiology, cardiac surgery, intensive care medicine, and anesthesiology. This review highlights some of the current themes in the literature during the past year.