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Vitamine K Antagonist and Colonoscopy: Proposal to Get out of a Dilemma
Mohamed Karim Abdessalem,
Sophie Dufraisse,
Julie Demas,
Martine Beurdeley,
Hélène Ribier
Issue:
Volume 11, Issue 1, June 2023
Pages:
1-4
Received:
4 November 2022
Accepted:
18 November 2022
Published:
31 January 2023
Abstract: The management of anticoagulants in patients requiring digestive endoscopy, and particularly VKA, is not always easy. There is indeed often a discrepancy between the recommendations of leaned societies and practice in the conduct of VKA treatment before a screening colonoscopy. The recommendations take into account the haemorrhagic risk of the endoscopic procedure and the nature and importance of the thrombotic risk for which the patient is under treatment. A colonoscopy with or without a biopsy is considered a low bleeding risk procedure for which it is recommended not to stop VKA treatment. If the examination reveals a lesion, the resection gesture will be programmed in a second time after stopping the AVK which will possibly be substituted by a Low molecular weight heparin according to a very precise schedule. In practice, this recommendation is poorly followed, because the continuation of VKA does not allow to carry out simultaneously a diagnostic and therapeutic gesture and sometimes imposes an overload of work. Its systematic stopping is also not the right solution, because it often consists of unnecessary thromboembolic risk taking. To resolve this dilemma, we propose to decide whether to discontinue VKA treatment based on the level of risk of adenoma and colorectal cancer.
Abstract: The management of anticoagulants in patients requiring digestive endoscopy, and particularly VKA, is not always easy. There is indeed often a discrepancy between the recommendations of leaned societies and practice in the conduct of VKA treatment before a screening colonoscopy. The recommendations take into account the haemorrhagic risk of the endo...
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Anesthesiological Management of Acute Generalized Peritonitis at Chu Kara
Essohanam Tabana Mouzou,
Sarakawabalo Assenouwe,
Pikabalo Tchetike,
Eyram Yoan Makafui Amekoudi
Issue:
Volume 11, Issue 1, June 2023
Pages:
5-13
Received:
24 December 2022
Accepted:
11 January 2023
Published:
31 January 2023
Abstract: The aim of our work was to make an inventory of the anesthesiological management of acute generalized peritonitis at the CHU-Kara. To determine the frequency of acute generalized peritonitis; to describe their treatment in pre, per and postoperative; to analyze the postoperative follow-up. This work was a retrospective descriptive study carried out on the files of patients operated for acute generalized peritonitis from November 1, 2019 to October 31, 2020. The study was performed in the surgical resuscitation department and in the operating room. Fifty-eight cases of generalized peritonitis were selected for the study. Peritonitis represented 27.8% of abdominal surgical emergencies. The patients were male dominated with a mean age of 29.6 years. The average consultation time was 3.5 days. Fever was the predominant clinical sign on admission (72.4%). The average duration of preoperative resuscitation was 17 hours and 18 minutes. The combination of Ceftriaxone and Metronidazole was the most used antibiotic therapy. General anesthesia was standard. Spinal anaesthesia was the second technique used. Preoxygenation was systematic for general anesthesia. Pancuronium (72.2%) was the most used curare. The average duration of anesthesia was 105 minutes. Laparotomy, peritoneal cleansing and drainage were performed in all patients, followed by excision-suture of the stomach (43.1%). Peritonitis due to peptic ulcer perforation predominated (43.1%) followed by typhoid perforation of the small intestine (24.1%). The morbidity rate was 41.4%, dominated by parietal suppurations (15.5%). The mortality rate was 8.6%. The average length of stay in intensive care was 8.7 days. The anesthesiological management of acute peritonitis remains a real challenge for anesthesiologists, given the major volume disturbances, the delay in diagnosis with its corollary of septic shock, and the lack of qualified personnel with which they are faced. Peritonitis is a real public health problem because of its still very high mortality. It was carried out with insufficiencies related to the poverty of the population, the inexistence of universal health insurance, the insufficiency of the technical platform and the insufficiency of organization.
Abstract: The aim of our work was to make an inventory of the anesthesiological management of acute generalized peritonitis at the CHU-Kara. To determine the frequency of acute generalized peritonitis; to describe their treatment in pre, per and postoperative; to analyze the postoperative follow-up. This work was a retrospective descriptive study carried out...
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Research Article
Pre-Anesthetic Consultation at the University Clinics of Kinshasa: Patient Profile, Type of Surgery, Anesthetic Protocol
Berthe Barhayiga,
Raïs N’sinabau*,
Gibency Mfulani,
Adonis Ntoka,
Odon Tshibangu,
Gédéon Mpuramana,
Eriksson Landu,
Arthur Isamba,
Carl Lemba,
Joël Cimbila,
Franchout Diakiese,
Patrick Mukuna,
Yves Mboloko,
Philippe Azika,
Wilfrid Mbombo
Issue:
Volume 11, Issue 1, June 2023
Pages:
14-18
Received:
8 January 2023
Accepted:
1 February 2023
Published:
9 March 2023
DOI:
10.11648/j.ijacm.20231101.13
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Abstract: Introduction: PAC is an element of anesthetic safety that makes it possible to collect information about the patient (history, physical examination), to assess the operative risk, to choose the technique of anesthesia and perioperative care best suited to the clinical condition of the patient. General objective was to describe the practice of PAC at the University Clinics of Kinshasa. Methods: This is a cross-sectional descriptive study carried out in Kinshasa from 1 January to 31 December 2021 (12 months), at the Department of Anesthesia and Resuscitation (ARD) of the University Clinics of Kinshasa. It involved all patients who had been consulted as part of a scheduled surgery, i.e. 443 patients. Results: The average age was 36.6 years with extremes of 7 days and 91 years. The female sex was predominant with 55.3%. Hypertension was the most found medical history in 13.5%. Gyneco-obstetric surgery (22.3%), otolaryngological surgery (13.8%) and neurosurgery (10.2%) were the most common of the surgical types. ASA I and ASA II patients were the most common (85.3%). General anesthesia accounted for 59% with Sevoflurane offered in 91% of general anesthesia. Spinal anesthesia accounted for 35.7%. Conclusion: The PAC is regularly performed in our environment in case of scheduled surgery and concerns all available surgical specialties.
Abstract: Introduction: PAC is an element of anesthetic safety that makes it possible to collect information about the patient (history, physical examination), to assess the operative risk, to choose the technique of anesthesia and perioperative care best suited to the clinical condition of the patient. General objective was to describe the practice of PAC a...
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Anesthesia for Extraction of a Bronchial Foreign Body in a Three-Year-Old Child About a Case at the CHU Ignace Deen in Conakry
Abdoulaye Touré,
Amadou Yalla Camara,
Nze Obiang Pascal Christian,
Almamy Bangoura,
M'mah Lamine Camara,
Donamou Joseph
Issue:
Volume 11, Issue 1, June 2023
Pages:
19-22
Received:
21 February 2023
Accepted:
20 March 2023
Published:
31 March 2023
Abstract: Introduction: Foreign body inhalation (FB) is a medical-surgical emergency and a frequent cause of respiratory distress in children. Multidisciplinary management combining ENT surgeon and anesthetist-resuscitator. Rigid or flexible bronchoscopy under general anesthesia in total or inhaled intravenous allows the diagnosis and the extraction of the foreign body. The rarity and seriousness of the inhalations seem to us to justify their publication. We report the journey of a case of inhalation of a foreign body consisting of a 6 centimeter point, the extraction of which was only possible thanks to a bronchoscope associated with a Quick air. Observation: this is a child of three in a particular ATCD from 132 km from the capital for inhalation of a foreign body for several days, after passing through two health structures for extraction without success for lack of a specialist. The child is admitted to the CHU Ignace Deen. The clinical, radiographic examination of the thorax revealed a rectilinear opacity of approximately 6 cm next to the right main bronchus. The indication for extraction under general anesthesia was raised. The first attempt at D12 inhalation with a rigid bronchoscope ended in failure. The second attempt two weeks later under inhalation anesthesia with halothane using a rigid bronchoscope associated with Quick air enabled the successful extraction of a tip of approximately 6cm. The immediate evolution was simple. Conclusion: the anesthesia of the child for inhalation of foreign body is a real challenge for the anesthesiologist-resuscitator. The choice of induction technique can be intravenous or inhalation with preservation of spontaneous ventilation. The rigid bronchoscope associated with the Quick air allowed the extraction.
Abstract: Introduction: Foreign body inhalation (FB) is a medical-surgical emergency and a frequent cause of respiratory distress in children. Multidisciplinary management combining ENT surgeon and anesthetist-resuscitator. Rigid or flexible bronchoscopy under general anesthesia in total or inhaled intravenous allows the diagnosis and the extraction of the f...
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A Case of Kounis Syndrome Caused by Anaphylaxis During Surgery
Issue:
Volume 11, Issue 1, June 2023
Pages:
23-27
Received:
28 February 2023
Accepted:
28 March 2023
Published:
11 April 2023
Abstract: Kounis syndrome is a hypersensitivity coronary disorder associated with several triggers, such as drugs, foods, environmental, coronary stents and other factors. It was originally proposed by the Greek cardiologist Nicholas Kounis in 1991. Kounis syndrome is a life-threatening and challenging emergency disease, which is constantly being recognized and studied. It is a disease that is constantly being recognized and Kounis syndrome can be classified into three types, involving coronary artery spasm, plaque rupture or stent thrombosis respectively. Most patients with coronary artery spasm caused by allergies can recover completely after active treatment, and the prognosis is good. If not, it may cause severe myocardial damage and even myocardial infarction, which threatens the patient's life. In our case, a 56-year-old female patient was scheduled to undergo right pelvic resection. A few minutes after the start of intravenous succinylated gelatin infusion, she was experienced a decrease in heart rate, blood pressure, oxygen saturation and ST elevation on 2-lead. An anaphylactic reaction was suspected after rapid differential diagnosis and gradually recovered with treatment. In this context, a rapid differential diagnosis and a highly suspicious become essential, because the management of Kounis syndrome is different from the traditional acute coronary syndrome. Kounis syndrome requires simultaneous diagnosis and treatment of both allergic reaction and acute coronary syndrome based on their manifestations and risk factors. This case describes the onset, development, and recovery of Kounis syndrome in this patient in detail, and illustrates the classification, pathophysiology, and treatment of Kounis syndrome. It is hoped that through the management of this case, the occurrence of Kounis syndrome can be rapidly identified and treated accordingly so that avoiding disaster for patients.
Abstract: Kounis syndrome is a hypersensitivity coronary disorder associated with several triggers, such as drugs, foods, environmental, coronary stents and other factors. It was originally proposed by the Greek cardiologist Nicholas Kounis in 1991. Kounis syndrome is a life-threatening and challenging emergency disease, which is constantly being recognized ...
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A Roadmap for Early Management of Trauma Patients
Rashid Khan,
Aziz Haris,
Naresh Kaul,
Abdullah Al-Jadidi
Issue:
Volume 11, Issue 1, June 2023
Pages:
28-31
Received:
3 December 2022
Accepted:
7 March 2023
Published:
15 April 2023
Abstract: Trauma is primarily a health hazard of the young and results in loss of precious productive years. It is the leading cause of death in young adults. Most of the health care workers are faced with management of these patients on a regular basis. The concept of ‘Platinum 10 minutes’ or an extended Platinum time of 20 minutes should be strictly adhered to optimize survival. The team of well trained first responders at the accident team should ensure that the patient receives resuscitative care during the early phase of trauma management To enhance trauma care, management has been revolutionized over the past few decades by adopting evidence based recommendations that has led to improved outcome following trauma. The main issues in the acute phase of trauma management includes securing the airway and providing optimal ventilation, fluid and blood product management, control of body temperature and intracranial pressure. A well structured trauma resuscitation approach in a step-wise manner is essential to address all issues that contribute to reduction in mortality and functional disability. An optimal pre-hospital care at the site of the trauma with efficient transfer of the patients to designated trauma centres and maintaining continuity of care has been outlined in this article without daunting the reader with intricacies of trauma care.
Abstract: Trauma is primarily a health hazard of the young and results in loss of precious productive years. It is the leading cause of death in young adults. Most of the health care workers are faced with management of these patients on a regular basis. The concept of ‘Platinum 10 minutes’ or an extended Platinum time of 20 minutes should be strictly adhere...
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Research Article
A Patient with Extremely Severe Constrictive Pericarditis Underwent Emergency Pericardiectomy Without Cardiopulmonary Bypass
Issue:
Volume 11, Issue 1, June 2023
Pages:
32-34
Received:
23 March 2023
Accepted:
10 April 2023
Published:
15 April 2023
DOI:
10.11648/j.ijacm.20231101.17
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Abstract: We report a case of a 58-year-old man admitted to hospital with severe constrictive pericarditis. An emergency pericardiectomy was planned due to the patient's orthopnea associated with hemodynamic instability. The patient performed pericardiectomy without cardiopulmonary bypass. The patient was found to be orthopnea and began to experience disturbance of consciousness after entering the operating room. Non-invasive blood pressure was 100/54 mmHg, accompanied by atrial fibrillation, the ventricular rate was 158 beats/min, and arterial oxygen saturation was 90% with air inhalation. After intubation, the ventricular rate rose to 187 beats/min, the blood pressure dropped to 65/45 mmHg, and vasopressors were urgently administered to maintain circulatory stability. At the same time, the internal jugular vein cannula was placed ultrasound-guided. During the operation, the central venous pressure (CVP) increased to 41.2 cmH2O, and cerebral oxygen saturation dropped to 47.6%. Although the patient with severe constrictive pericarditis, we still performed pericardiectomy without cardiopulmonary bypass. The operation time was about 3 hours, and the patient was successfully transferred to the Intensive Care Unit (ICU) to continue monitoring and treatment, and the tracheal intubation was removed 48 hours after the operation and he was discharged 19 days after the operation. Real-time transesophageal echocardiography (TEE) monitoring played a crucial role in intraoperative management.
Abstract: We report a case of a 58-year-old man admitted to hospital with severe constrictive pericarditis. An emergency pericardiectomy was planned due to the patient's orthopnea associated with hemodynamic instability. The patient performed pericardiectomy without cardiopulmonary bypass. The patient was found to be orthopnea and began to experience disturb...
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Hyperventilation Syndrome After Strabismus Surgery - A Case Report
Issue:
Volume 11, Issue 1, June 2023
Pages:
35-37
Received:
23 April 2023
Accepted:
10 May 2023
Published:
17 May 2023
Abstract: Hyperventilation syndrome (HVS) mainly occurs in patients under anxiety and stress and is marked by rapid, excessive breathing, resulting in respiratory alkalosis and subsequent hypocalcemia and hypokalemia, causing various physical symptoms, like numbness or tingling sensation, overactive reflexes, muscle cramps, twitches, and in severe cases, acute myocardial infarction or even death, requiring immediate diagnosis and medical intervention. We report a rare case of HVS after strabismus surgery under local anesthesia. The patient is a healthy 31-year-old woman with no psychiatric or other diseases in the past medical history. At the end of the procedure, as soon as the surgeon uncovered the sheet, the patient complained about numbness in the lower limbs, spasm in the upper limbs, muscle rigidity, and double vision. At that time, the electrocardiogram monitoring showed normal blood pressure, heart rate, pulse oxygen saturation, and breathing rate. However, the patient was awake and extremely nervous. Emergency arterial blood gas analysis (ABG) was performed immediately and revealed respiratory alkalosis with significantly reduced PaCO2 and secondary hypocalcemia and hypokalemia. Verbal reassurance, closed-mask inhalation, and electrolyte supplement were administered. HVS gradually subsided. In this context, a prompt differential diagnosis and a high degree of suspicion are essential. Monitoring end-tidal carbon dioxide may also aid in the early detection of HVS, as changes in breathing rate and pattern may be observed before definite signs and symptoms manifest in patients with HVS. However, since surgical drapes and trays cover the torso, detecting any changes in breathing rate and pattern during the surgery may be challenging. This article describes a case of HVS after strabismus surgery under local anesthesia and provides a summary of the occurrence, manifestation, diagnosis, and treatment of HVS. It is hoped that this article will facilitate the prompt identification and appropriate treatment of HVS, thereby preventing any potential negative outcomes for the patients. Additionally, HVS is a rare complication during the perioperative period and has only been reported in a small number of case reports. Therefore, further research is needed to confirm the effectiveness of measures for prevention and treatment mentioned in the text.
Abstract: Hyperventilation syndrome (HVS) mainly occurs in patients under anxiety and stress and is marked by rapid, excessive breathing, resulting in respiratory alkalosis and subsequent hypocalcemia and hypokalemia, causing various physical symptoms, like numbness or tingling sensation, overactive reflexes, muscle cramps, twitches, and in severe cases, acu...
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Evaluation of Endotracheal Cuff Pressure and Volume of Air for Inflation of CUFF Following Intubation After General Anaesthesia for Elective Surgery
Issue:
Volume 11, Issue 1, June 2023
Pages:
38-43
Received:
2 May 2023
Accepted:
18 May 2023
Published:
6 June 2023
Abstract: Background: Endotracheal intubation is part of general anesthesia. The endotracheal cuff situated near the end of the tube is inflated following successful intubation (above the carina) to secure the airway. A critical function of the endotracheal tube (ETT) cuff during general anesthesia is to seal the airway thus preventing aspiration of pharyngeal contents into the trachea and leaks during positive pressure ventilation. From the literature, we know that excessive cuff pressure decreases tracheal capillary perfusion which has the potential to lead to endothelial necrosis, while insufficient cuff pressure leads to pulmonary aspiration of oro-pharyngeal contents and leads to ventilator-associated pneumonia and pulmonary pneumonitis. Methodology: All the patients above the age of 18 years who presented to The Aga Khan University Hospital, Nairobi for elective surgical procedures under general anesthesia and requiring endotracheal intubation for the surgical procedure were included in the audit. Patients were induced and intubated according to routine practice by the attending anesthesiologist and the cuff was subsequently inflated by the anesthetic assistant, anesthesia resident, instructor, or consultant anesthesiologist. Patients were maintained with volatile anesthetic agents or total intravenous anesthesia in a mixture of oxygen and air according to the anesthesiologist’s choice. The volume of the air used to inflate the cuff was recorded and the intra-cuff pressure was measured by one of the investigators after securing the endotracheal tube (before positioning the patient) with an aneroid manometer connected to the pilot balloon of the ETT cuff. Results: The volume of air used to inflate the endotracheal cuff was in the range of 3ml and 15ml with the mean volume being 7.64 ml, median of 8ml, and mode of 10ml. The resultant cuff pressure ranged between 10 cmH2O to 110 cmH2O with a median of 40 ml and mode of 22 ml. Overall 14% of the total patients had intra-cuff pressure of less than normal which is below 20 cmH2O, 23% of patients had normal cuff pressure between 20 to 30 cmH2O, and 63% had more than normal pressure which was more than 30 cmH2O. Conclusion: The average volume of air inflated for the endotracheal cuff was 7.64 ml and the cuff pressure was 46.71 cmH2O. Recommendations: The endotracheal tube cuff is inflated under the guidance of a manometer to a target pressure of 20-30 cmH2O.
Abstract: Background: Endotracheal intubation is part of general anesthesia. The endotracheal cuff situated near the end of the tube is inflated following successful intubation (above the carina) to secure the airway. A critical function of the endotracheal tube (ETT) cuff during general anesthesia is to seal the airway thus preventing aspiration of pharynge...
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Anesthesia Management of Trachea Reconstruction in a Patient with Traumatic Neck Closed Tracheal Complete Rupture
Jiaqi Yang,
Yang Chen,
Yu Li
Issue:
Volume 11, Issue 1, June 2023
Pages:
44-48
Received:
13 May 2023
Accepted:
1 June 2023
Published:
10 June 2023
Abstract: Closed cervical tracheal rupture caused by trauma is a rare clinical emergency severe disease. We report the anesthesia experience of a 37-year-old male patient undergoing emergency tracheal reconstruction surgery due to a traumatic neck closed tracheal complete rupture. The patient was conscious and hoarse when entering the operation room, complained of dyspnea during inspirations, maxillofacial neck swelling, obvious subcutaneous crepitus of neck by palpation, and limited mouth opening. Mallampati grade III, neck movement was limited due to pain, and difficulty in intubation was considered in combination with the patient's neck, chest computed tomography (CT) and airway evaluation. Failure of intubation after the administration of muscle relaxants may result in rapid difficulty in establishing a surgical airway. Intubation under the guidance of awake bronchoscopy may fail to reach the distal tracheal end, and may lead to increased airway injury and inability to maintain ventilation. In order to ensure the safety of patient, it was decided to explore the neck incision under local anesthesia, find the broken end of the trachea, insert the endotracheal tube at the distal end, and then perform general anesthesia to control the airway. Intraoperative vital signs were stable of the patient. After the operation, the tracheostomy tube was changed and transferred the patient to ICU for further treatment. Patients with cervical tracheal rupture, establishing airway under local anesthesia with preserve the patient's spontaneous breathing combined sedation is a selection of security technology.
Abstract: Closed cervical tracheal rupture caused by trauma is a rare clinical emergency severe disease. We report the anesthesia experience of a 37-year-old male patient undergoing emergency tracheal reconstruction surgery due to a traumatic neck closed tracheal complete rupture. The patient was conscious and hoarse when entering the operation room, complai...
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Impact of Comorbidities on Cancellation of Surgery in Patients Previously Reviewed: A Prospective Observational Study
Issue:
Volume 11, Issue 1, June 2023
Pages:
49-57
Received:
19 May 2023
Accepted:
7 June 2023
Published:
15 June 2023
Abstract: Globally patients with inter-current medical diseases are common place and are likely to present for anaesthesia and surgery at some point in their life. Surgical patients with inter-current medical diseases pose a great challenge to the anaesthetist; optimal perioperative care has to be provided to prevent adverse events, and thus reduce morbidity and mortality. Where preoperative optimization of the disease is not optimal, cancellation with its attendant consequencies becomes inevitable. This prospective observational study was carried out at the University of Abuja Teaching Hospital, Gwagwalada, Abuja between February 2018 and July 2018. All patients presenting for surgery at our general modular operating rooms formed the subjects of this study. A standardized questionnaire was used to document patient demographics, the presence and type of comorbidity, level of control of comorbidity, facility where care was being assessed for the inter-current illness, surgical diagnosis, nature of surgery and the decision or otherwise to proceed with the planned surgery. Questionnaires were administered pre induction on arrival at the Reception. A total of 215 (21%) patients had comorbidities. The cardiovascular system was the most affected, 55.8% and Hypertension (51.6%) was the most common comorbidity. There were a total of 10 (4.7%) cancellations. Cancellation was highest among the adult age group 70%, the female 80% and the Obstetric population 30%. Comorbidity is common among patients presenting for surgery. Cancellation of surgery on the day of surgery as a result of comorbidity despite preoperative review a day before surgery is possible though with a low incidence. Good preoperative review and optimization of the comorbidity will minimize this day of surgery cancellation.
Abstract: Globally patients with inter-current medical diseases are common place and are likely to present for anaesthesia and surgery at some point in their life. Surgical patients with inter-current medical diseases pose a great challenge to the anaesthetist; optimal perioperative care has to be provided to prevent adverse events, and thus reduce morbidity...
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Acute Normovolemic Hemodilution in a Patient with Severe Peripheral Arterial Disease: A Rare Case Report
Issue:
Volume 11, Issue 1, June 2023
Pages:
58-61
Received:
17 May 2023
Accepted:
6 June 2023
Published:
21 June 2023
Abstract: Acute normovolemic hemodilution (ANH) is a blood conservation technique that involves withdrawing blood from a patient before surgery and replacing it with a combination of crystalloid and/or colloid solutions, prior to any surgical bleeding. The withdrawn blood can be re-infused during or after the surgical procedure to reduce the need for allogeneic blood transfusions. Patients with high levels of hemoglobin (Hb) and hematocrit (Hct) are at an increased risk of thromboembolic events due to the higher whole blood viscosity (WBV). By reducing blood cell concentration and blood viscosity, ANH can decrease the thromboembolic events during and after surgery in patients with elevated Hb and Hct levels. This article specifically describes the application of ANH in a patient with critical limb ischemia who underwent lower limb thrombectomy and presented with high Hb and Hct levels. ANH presents a promising new approach to reducing the need for allogeneic blood transfusion, while also potentially decreasing the rate of thromboembolic events perioperatively. However, further research is needed to determine the optimal target Hct for patients with polycythemia undergoing ANH, which will help to establish a goal directed ANH. Additionally, the safety and efficacy of ANH should be evaluated in larger populations to ensure its effectiveness and safety. Despite these limitations, ANH remains a compelling and exciting new approach to minimizing the risk of thromboembolic events during and after surgery, and may represent an important tool for improving patient outcomes in the future.
Abstract: Acute normovolemic hemodilution (ANH) is a blood conservation technique that involves withdrawing blood from a patient before surgery and replacing it with a combination of crystalloid and/or colloid solutions, prior to any surgical bleeding. The withdrawn blood can be re-infused during or after the surgical procedure to reduce the need for allogen...
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