Case Study: Anesthesia Management for a Complex Cardiac Surgery

Patient Information:
– Name: Mr. Smith
– Age: 62
– Gender: Male
– Medical history: Mr. Smith has a history of coronary artery disease (CAD) and severe aortic stenosis. He has undergone percutaneous coronary intervention (PCI) in the past and has been managed with medical therapy. He is now scheduled for a complex cardiac surgery, which includes aortic valve replacement (AVR) and coronary artery bypass grafting (CABG).

Preoperative Assessment:
– Mr. Smith underwent a comprehensive preoperative assessment, including a detailed medical history, physical examination, laboratory tests, and diagnostic imaging.
– His echocardiogram showed severe aortic stenosis with an aortic valve area of 0.8 cm² and a mean gradient of 45 mmHg. There was also evidence of left ventricular hypertrophy.
– Coronary angiography revealed significant stenosis (>70%) in the left anterior descending artery and circumflex artery, indicating the need for CABG in addition to AVR.
– Pulmonary function tests demonstrated normal lung function, and renal function tests were within normal limits.
– The patient was considered high risk due to his comorbidities and the complexity of the surgery.

Anesthetic Management:
– A multidisciplinary team, including cardiac surgeons, anesthesiologists, and perfusionists, discussed the case and formulated an anesthetic plan.
– The patient was advised to discontinue antiplatelet therapy (aspirin and clopidogrel) one week prior to surgery to minimize bleeding risk.
– On the day of surgery, standard monitors, including electrocardiogram (ECG), non-invasive blood pressure (NIBP), pulse oximetry, and end-tidal carbon dioxide (EtCO2) were applied.
– An arterial line was inserted for invasive blood pressure monitoring, and a central venous catheter was placed to guide fluid management.
– Anesthesia was induced with a combination of intravenous (IV) medications, including a short-acting opioid (e.g., fentanyl) and a hypnotic agent (e.g., propofol).
– After endotracheal intubation, mechanical ventilation was initiated with a lung-protective strategy, aiming for low tidal volumes and limited plateau pressure.
– Anesthesia was maintained with a balanced technique using volatile agents (e.g., sevoflurane) and continuous IV infusion of opioids (e.g., remifentanil) to ensure analgesia and hemodynamic stability.
– Intraoperatively, invasive blood pressure, central venous pressure, cardiac output, and mixed venous oxygen saturation were closely monitored.
– To ensure adequate myocardial protection, cold cardioplegia solution was administered intermittently to achieve cardiac arrest during aortic cross-clamping.
– The surgery involved aortic valve replacement with a bioprosthetic valve and triple coronary artery bypass grafting using saphenous vein grafts.
– Hemostasis was carefully managed throughout the procedure, and blood products were transfused as needed to maintain appropriate coagulation parameters.
– At the end of the surgery, the patient was gradually weaned off cardiopulmonary bypass (CPB) with meticulous attention to hemodynamics and fluid balance.
– Once stable, the patient was transferred to the intensive care unit (ICU) for postoperative monitoring and management.

Postoperative Course:
– In the ICU, the patient was closely monitored for hemodynamic stability, respiratory function, and pain control.
– Mechanical ventilation was continued until the patient demonstrated adequate respiratory effort and met extubation criteria.
– Pain management included a multimodal approach, combining opioids, non-opioid analgesics.


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