The Changing Face of Vascular Surgery Anesthesiology Practice

Youn-Hoa Jung^*
*Correspondence: Youn-Hoa Jung, Department of Anaesthesiology and Critical Care Medicine, University School of Medicine, 1800 Orleans St., Baltimore, MD 21287, USA, Email:

Keywords

Vascular surgery anaesthesiology • Anaesthesiologists • Cardiac surgery

Introduction

Patients undergoing heart surgery are frequently at high risk, with various concomitant illnesses such as pulmonary, cardiac, renal, endocrine, and systemic problems. The anaesthetic care of such individuals necessitates extensive knowledge and commitment. During surgery, handling the heart and lungs may cause severe physiologic disruption. The anaesthetic approach was changed from a high-dose narcotic to a balanced technique that included moderate-dose opioids, shorter-acting muscle relaxants, and volatile anaesthetics. Patient outcomes improved as the specialisation matured. Cardiac surgeries reach expanded tremendously, and it was available throughout the developing globe by the end of the twentieth century. Thoracic surgery evolved more slowly. For a long period, the surgical profile was limited to standard lobectomies and pneumonectomies. In the last two to three decades, several novel therapeutic techniques have arisen [1].

Several new therapeutic modalities for difficult lung cancer, oesophageal cancer, mediastina mass excision, tracheal surgery, and thoracic trauma surgical techniques have arisen in the previous two to three decades. The introduction of video-assisted thoracoscopic surgery increased the field's popularity and established it as a distinct speciality. The surgical and anaesthetic needs of thoracic surgery differed greatly from those of heart surgery. This advancement resulted in the separation of thoracic anaesthesia from cardiothoracic anaesthesia. Thoracic anaesthesiology is currently a selfcontained specialty. Cardiovascular anaesthesiology is no longer practised by thoracic anaesthesiologists. New lung separation technologies are making thoracic anaesthesia safer. In this issue, discuss the advantages of VivaSight double-lumen tubes [2].

Postoperative neurocognitive problems arise from the intricate combination of a patient's baseline vulnerability and other risk factors. Age, weakened higher-level cognitive skills, operation characteristics such as invasiveness, duration, and urgency, and postoperative admission to an intensive care unit are all commonly recognised no modifiable risk factors for PNDs. The presence of these risk factors should prompt a thorough evaluation of the patient as well as an in-depth discussion with the patient, their family or carers, and the perioperative team. Before performing elective surgery on a patient, doctors should conduct a complete health assessment to address and maximise modifiable risk factors for PNDs. Preoperative modifiable risk factors cover a spectrum of risks that are frequently related with but not always causal of PNDs. Adopting preoperative healthy lifestyle advice, such as World Health Organization guidelines for risk reduction of cognitive decline and dementia, is a realistic technique for boosting patients' resilience to the pressures of surgery and anaesthesia [3].

Discussion

The strongest recommendations are for physical exercise, tobacco cessation, nutrition, and hypertension and diabetes treatment. In a 2019 study, three general protocols (orientation, cognitive stimulation, and mobilisation) were administered with customised protocols based on each patient's particular risk factors. This personalised, family-involved approach reduced postoperative complications in 281 individuals over the age of 70. This personalised, family-involved programme reduced postoperative delirium in 281 patients over the age of 70, with rates of 19.4% in the control group versus 2.6% in the intervention group. Furthermore, at 30 days following discharge, physical and cognitive function improved in the intervention group compared to the control group. Another targeted rehabilitation study in which 699 older adult participants (60 years) used preoperative cognitive exercises targeting memory, speed, attention, flexibility, and problem-solving functions resulted in a lower incidence of delirium, with rates of 13.2% in the intervention group vs 23.0% in the control group. Several organisations, including the American College of Surgeons National Surgical Quality Improvement Program, the American Geriatrics Society, and the European Society of Anaesthesiology and Intensive Care, have published guidelines that recommend specific practises for perioperative care of older adults. Despite the data supporting these suggestions, there remains a gap in their incorporation into patient care pathways. Preoperative screening for frailty and dementia, preoperative geriatric consultation, and postoperative screening for delirium were reported for less than 10% of surgical cases in a survey of 1737 US anaesthesiologists [4].

A feasibility study of 61 older patients (60 years) discovered that when a cognitive rehabilitation programme was administered, only 17% of the patients finished the training; they reported "feeling depressed." Studies have failed to demonstrate a relevant difference between regional and general anaesthesia in the context of a direct link between anaesthesia and brain health. Furthermore, when comparing anaesthetic agents, there is no compelling data to imply that a certain anaesthetic agent is indicated or should be avoided in terms of cognitive outcomes after general anaesthesia. The use of a processed electroencephalogram (EEG) monitor to reduce anaesthetic dose during surgery is one point of contention. Although various studies have been conducted, the literature does not provide a clear response as to whether anaesthetic titrated to an EEG measure affects the incidence of postoperative neurocognitive impairment. In a 2018 meta-analysis8, MacKenzie et al determined that the use of EEG-guided anaesthetic depth "was not effective." More research is needed, but one prevalent notion is that there is a population of cognitively weak patients who are unusually vulnerable to the deleterious consequences of an anaesthetic overdose and could benefit from EEG-guided anaesthetic depth [5].

Conclusion

Cardiac anaesthesiologists quickly rose to positions of leadership in academic anaesthesiology. Their outgoing personalities and proclivity for research, education, and therapeutic expertise may have contributed to their impressive growth. With the rising complexity of procedures, cardiac anaesthesiologists took over the cardiac intensive care sector. Their knowledge of cardio-respiratory physiology aided in the improvement of outcomes in complex surgeries such as an arterial switch, serious congenital heart disease, heart/lung transplant, and major vascular surgeries. The possibility presented by freshly developed TEE probes and their miniaturisation was grabbed by anaesthesiologists. Cardiologists were hesitant to limit their clinical and interventional practise by spending valuable time in the operating room. Anaesthesiologists learned echocardiography quickly and quickly excelled at TEE. TEE machines become ubiquitous in cardiac care.

The paradigm change to shorter-acting medications sparked renewed interest in patient rehabilitation. Multimodal analgesia, which included regional blocks, intrathecal morphine, and no steroidal anti-inflammatory medications, became popular. The traditional intensive care approach was upset by new weaning techniques and extensive surveillance. Patients were quickly intubated in the recovery area and sent to specialised post cardiac surgery recovery centres. Fast-track cardiac anaesthesia is now the standard form of care in most parts of the world. With the popularity of fast-tracking and its revenue advantage, conventional high-dose narcotic anaesthesia is now limited to a few very high-risk instances.

Acknowledgement

None.

Conflict of Interest

None.

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