Chakravarthy Murali
Department of Anesthesia, Critical Care and Pain Relief, Fortis Hospitals, Bengaluru, Karnataka, India.
Ann Card Anaesth. 2017 Apr-Jun;20(2):226-233. doi: 10.4103/aca.ACA_20_17.
Challenging times are here for cardiac surgical and anesthesia team. The interventional cardiologist seem to have closed the flow of 'good cases' coming up for any of the surgery,; successful percutaneous interventions seem to be offering reasonable results in these patients, who therefore do not knock on the doors of the surgeons any more . It is a common experience among the cardiac anesthesiologists and surgeons that the type of the cases that come by now are high risk. That may be presence of comorbidities, ongoing medical therapies, unstable angina, uncontrolled heart failure and rhythm disturbances; and in patients with ischemic heart disease, the target coronaries are far from ideal. Several activities such as institution of preoperative supportive circulatory, ventilatory, and systemic disease control maneuvers seem to have helped improving the outcome of these 'high risk ' patients. This review attempts to look at various interventions and the resulting improvement in outcomes. Several changes have happened in the realm of cardiac surgery and several more are en route. At times, for want of evidence, maximal optimization may not take place and the patient may encounter unfavorable outcomes.. This review is an attempt to bring the focus of the members of the cardiac surgical team on the value of preoperative optimization of risks to improve the outcome. The cardiac surgical patients may broadly be divided into adults undergoing coronary artery bypass graft surgery, valve surgery and pediatric patients undergoing repair/ palliation of congenital heart ailments. Optimization of risks appear to be different in each genre of patients. This review also brings less often discussed issues such as anemia, nutritional issues and endocrine problems. The review is an attempt to data on ameliorating modifiable risk factors and altering non modifiable ones.
心脏外科和麻醉团队正面临着充满挑战的时期。介入心脏病专家似乎阻断了原本会流向任何心脏手术的“优质病例”；成功的经皮介入治疗似乎在这些患者身上取得了不错的效果，因此他们不再寻求外科医生的帮助。心脏麻醉医生和外科医生都有一个共同的经历，即现在送来的病例类型风险很高。这可能表现为存在合并症、正在进行的药物治疗、不稳定型心绞痛、未控制的心力衰竭和心律失常；对于缺血性心脏病患者，目标冠状动脉也远不理想。诸如开展术前支持性循环、通气和全身性疾病控制措施等多项活动，似乎有助于改善这些“高风险”患者的治疗效果。本综述试图探讨各种干预措施及其对治疗效果的改善情况。心脏外科领域已经发生了一些变化，还有更多变化正在到来。有时，由于缺乏证据，可能无法实现最大程度的优化，患者可能会遭遇不良后果。本综述旨在让心脏外科团队成员关注术前风险优化对改善治疗效果的价值。心脏外科患者大致可分为接受冠状动脉搭桥手术的成人、瓣膜手术患者以及接受先天性心脏病修复/姑息治疗的儿科患者。各类患者的风险优化似乎有所不同。本综述还探讨了一些较少被讨论的问题，如贫血、营养问题和内分泌问题。本综述旨在收集有关改善可改变风险因素和改变不可改变风险因素的数据。
