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Chapter 99: Anesthesia and the Patient with Cardiovascular Disease

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The effects of intraoperative neuraxial block and postoperative epidural analgesia on major cardiovascular outcomes after noncardiac surgery remain controversial. In a propensity-weighted study of 10,010 high-risk noncardiac surgical patients, neuraxial block was associated with a reduction in which of the following complications?

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A. Composite death, myocardial infarction, or stroke

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B. Death

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C. Myocardial infarction

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D. Clinically important hypotension

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E. None of the above

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The answer is E. (Hurst’s The Heart, 14th Edition, Chap. 99) There is little scientific evidence that any particular anesthetic approach is superior to its reasonable alternatives.1-7 In this substudy from the POISE-2 trial, neither neuraxial block nor postoperative epidural analgesia were associated with a statistically significant effect on death (option B), myocardial infarction (option C), stroke, hypotension (option D), or the composite end point (option A). In another study of 98,290 elective colectomies,8 neuraxial technique was associated with a decreased risk of thromboembolism and cerebrovascular events, but it was associated with an increased risk of myocardial infarction, urinary tract infection, postoperative ileus, and blood transfusions.

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In general, there are no definite recommendations for choosing a particular anesthetic to decrease the risk of perioperative cardiac events. In which of the following surgical procedures may a neuraxial technique be advantageous to enable early recognition of complications?

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A. Transurethral resection of prostate

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B. Mastectomy

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C. Colectomy

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D. Small bowel resection

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E. Nephrectomy

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The answer is A. (Hurst’s The Heart, 14th Edition, Chap. 99) In certain defined surgical procedures such as transurethral resection of prostate (option A), a neuraxial technique may be advantageous in enabling early recognition of complications. This is not applicable in all circumstances (options B, C, D, E), and clinical judgment must be exercised to make the best choices in individual circumstances. Regional anesthetics and monitored anesthesia care are not infrequently converted to general anesthetics intraoperatively as a result of unexpectedly long surgery, patient discomfort, or changes in the surgical plan. No practitioner can be certain that a particular technique will be adequate for the surgical procedure, given the unpredictability of the situation, and the anesthesiologist must have flexibility to alter the technique as needed.

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Although there is limited evidence to guide the safe use of neuraxial anesthesia in patients receiving novel anticoagulant drugs, this is not an absolute contraindication. Which of the following statements about best practice recommendations ...

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