By C. Narin
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Additional resources for Perioperative Considerations in Cardiac Surgery
TEE is recommended for high-risk patients for myocardial ischemia with a category II indication (TEE may be helpful in improving clinical outcomes) by ASA. This indication is strenghtened when ECG cannot be used for detection of ischemia in situations such as the existence of LBBB, extensive Q waves or ST-T segment changes on baseline ECG. However, it is weakened when there are wall motion abnormalities due to fibrotic, calcified or aneurysmal myocardium at the baseline (London et al,2008). Category I indications (TEE is useful in improving clinical outcomes) for the usage of TEE includes, suspected thoracal aortic aneurysm-dissection or disruption in unstable patients Anesthesia in Cardiac Surgery 19 in the preoperative period; life-threatening hemodynamic disturbance, valve repair, congenital heart surgery, hypertrophic obstructive cardiomyopathy repair, endocarditis, aortic valve function in aortic dissection repair, evaluation of pericardial window procedures intraoperatively and unexplained hemodynamic disturbances in ICU setting.
The signalling throughout the cell during anesthetic preconditioning include protein kinase C (PKC), protein tirozin kinase (PTK), mitogenactivated protein kinases (MAPK), protein kinase-B, mitochodria and ion channels (sarcolemmal and mitochodrial ATP-dependent potassium channels) (Figure 1) (Lorsomradee et al,2008). In pharmacological preconditioning, activators of protein kinases, agonists of adenosine receptors, scavengers of free radicals, opioids, ethyl alcohol, acetylcholine, bradykinin, angiotensin II, noradrenalin, platelet-activating factor were all used, but most of them can not be used for their protective effects because of their side effects or insufficient data of their clinical efficacy (Lango&Mrozinski,2010).
Prophylactic atrial pacing has been shown to reduce the development of POAF. Bi-atrial pacing revealed more significant reduction in POAF vs left or right atrial pacing or no pacing (Fan et al, 2000). It has also been shown to be as effective as the pharmacological measures (Crystal et al,2004;Burgers et al,2006). 2 Treatment of postoperative atrial fibrillation POAF is a self-terminating but recurrent tachyarrhythmia that usually subsides in 6-8 weeks after cardiac surgery. It should be kept in mind that the adrenergic response in the postoperative period will reduce the effectiveness of any therapy that does not include betablokers (Nair,2010).