Purpose Pericardial diseases present unique perioperative considerations for the anesthesiologist. The purpose of this review is to provide a summary of the pertinent issues related to the etiology, diagnosis, pathophysiology, and perioperative management of patients presenting for operative treatment of pericardial disease. Source A selective search of the anesthesia, cardiology, and cardiothoracic surgical literature was carried out with particular emphasis on acute pericarditis, effusion, tamponade, and constrictive pericarditis Principal findings The anesthesiologist needs to be well versed in the etiology (i.e., differential diagnosis), pathophysiology, and diagnostic modalities in order to best prepare the patient for surgery. Diagnosis and guidance of management requires a working knowledge of the specific associated hemodynamic consequences, particularly of the impaired diastolic function that can occur. Echocardiography is essential in the diagnosis and management of these patients. Conclusions Patients with acute and chronic pericardial diseases often require the need for surgical intervention. Several unique features of acute tamponade and constrictive pericarditis require careful perioperative consideration. With proper preparation and pre-anesthetic optimization, patients with a variety of pericardial diseases can be safely managed before, during, and after their surgical intervention.

Objective Resolution of the acute respiratory distress syndrome (ARDS) requires clearance of pulmonary edema. Biologically variable ventilation (BVV) strategies that improve gas exchange, lung mechanics, and inflammatory mediators in ARDS may be beneficial in this regard. We used quantitative computed tomography (CT), a single indicator thermodilution system (PiCCOÒ) to determine extravascular lung water (EVLW), and the change in edema protein concentration over time to compare edema clearance with BVV vs conventional mechanical ventilation (CMV) in a porcine ARDS model. Methods Sixteen pigs with oleic acid lung injury were randomized to four hours of ventilation with either CMV (n = 8) or BVV (n = 8) at identical low tidal volume and minute ventilation over time. Hemodynamic variables, gas exchange, lung mechanics, and PiCCO derived EVLW were determined hourly. Computed tomography images and edema fluid samples were obtained at baseline lung injury and after four hours of ventilation. Wet and dry lung weights were determined postmortem.Results At four hours with BVV, peak airway pressure was decreased significantly and lung compliance improved compared with CMV (P = 0.003; P \ 0.001, respectively). Hemodynamic variables and gas exchange were not different between groups. Also at four hours, computed tomography revealed an increase in total gas volume (P = 0.001) and a decrease in total lung weight and global lung density (P = 0.005; P = 0.04 respectively) with BVV. These findings were associated with a significant increase in the gas volume of normally aerated lung regions (P \ 0.001) and a decrease in the poorly and non-aerated lung regions (P = 0.001). No change in any CT parameter occurred with CMV. The lung weights derived from computed tomography correlated well with postmortem wet weights (R 2 = 0.79; P \ 0.01). The decrease in PiCCO derived EVLW from injury to four hours did not differ significantly between BVV and CMV. Extravascular lung water showed no correlation with postmortem wet weights and significantly underestimated lung water. Average alveolar fluid clearance rates were positive (1.4%Áhr -1 (3%)) with BVV and negative with CMV (-2.0%Áhr -1 (4%)). Conclusions In a comparison between BVV and CMV, computed tomography evidence suggests that BVV facilitates enhanced clearance and/or redistribution of edema fluid with improved recruitment of atelectatic and poorly aerated lung regions; no such evidence was seen with either single thermodilution measurement of EVLW or edema clearance rates. The results of computed tomography provide further evidence of the benefit of BVV over conventional ventilation in ARDS. RésuméObjectif La re´solution d'un syndrome de de´tresse respiratoire aigue¨(SDRA) ne´cessite l'e´limination de

In a cohort of patients who had echocardiography and BNP measurements before undergoing major thoracic surgery, this study showed that when evaluated together greater preoperative left atrial diastolic volume index and transmitral flow deceleration time but not BNP levels were independent predictors for POAF.

Purpose The ability to assess the brain-at-risk during carotid endarterectomy (CEA) under general anesthesia remains a major clinical problem. Point-of-care monitoring can potentially dictate changes to management intraoperatively. In this observational study, we examined the correlation between a series of point-of-care monitors and lactate flux during CEA. Methods Both neurosurgeons and vascular surgeons participated in the study. The patients underwent arterialjugular venous blood sampling for oxygen, carbon dioxide, glucose, and lactate, n = 26; bispectral index (BIS) monitoring ipsilateral to side of surgery, n = 26; raw and processed electroencephalogram (EEG), n = 22; and bi-frontal cerebral oximetry using the Fore-Sight monitor, n = 20. Results One patient experienced a new neurological deficit when assessed at 24 hr following surgery. Lactate flux into the brain was correlated with the greatest decrease in cerebral oximetry with carotid cross-clamping; lactate efflux was correlated with the least. The most noticeable changes in processed EEG (density spectral analysis) were also seen with lactate influx, but at a slower time resolution than cerebral oximetry. Loss of autoregulatory behaviour was demonstrated with lactate influx; however, no correlation was seen between lactate flux and BIS monitoring. Conclusion There was a correlation between cerebral oximetry and lactate flux during carotid cross-clamping. The Fore-Sight monitor may be of value as a point-of-care monitor during CEA under general anesthesia. A novel finding of this study is lactate flux into the brain in the presence of a large difference in cerebral oxygenation during cross-clamping of the carotid artery. Registered at clinicaltrials.gov: NCT000737334. RésuméObjectif La capacite´d'e´valuer le cerveau a`risque pendant une endarte´riectomie carotidienne (EC) sous anesthe´sie ge´ne´rale demeure un proble`me clinique important. Le monitorage au chevet pourrait potentiellement conduire ad es modifications de la prise en charge perope´ratoire. Dans cette e´tude observationnelle, nous avons explore´la corre´lation entre une se´rie de moniteurs au chevet et le flux de lactate pendant une EC. Méthode Des neurochirurgiens et des chirurgiens vasculaires ont pris part a`cette e´tude. Les patients ont subi un e´chantillonnage du sang veineux arte´riel jugulaire pour de´tecter les concentrations d'oxyge`ne, de dioxyde de carbone, de glucose et de lactate, n = 26; monitorage par index bispectral (BIS) ipsilate´ral au côte´de la chirurgie, n = 26; e´lectroence´phalogramme (EEG) brut et apre`s

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