Isaac Yeung

Patients with heart failure require special considerations in the perioperative setting given the challenges caused by heart failure pathophysiology. This pathophysiology is complex and involves several mechanisms that contribute to both disease progression and the clinical syndrome, including cardiac remodeling, neurohormonal activation, and resultant hemodynamic derangements. Anesthetic management of these patients requires diligence at all stages of care. Preoperative assessment includes risk stratification, management of comorbid conditions, and heart failure medication management. Anesthetic agents have differing effects on hemodynamics and selection of these agents must be aimed at preventing hemodynamic collapse in patients with heart failure. In addition, the increased risk of intraoperative complications among these patients often necessitates means of invasive hemodynamic monitoring and use of vasopressor or inotropic support. Finally, the postoperative care of heart failure patients requires attention to the volume status of these patients, as well as considerations for pain management and modulation of the surgical stress response. In this review article, we aim to review how the pathophysiologic mechanisms and changes that occur with heart failure impact anesthetic management and patient-centered perioperative care.

Pheochromocytoma, a rare catecholamine-secreting tumor, poses significant perioperative challenges due to its potential for severe hemodynamic instability. Careful management of patients with pheochromocytoma is critical for patient safety and favorable outcomes. The diagnostic workup focuses on biochemical analysis of plasma or urinary metanephrines, followed by imaging for tumor localization and genetic testing to identify hereditary syndromes. Preoperative management emphasizes adequate alpha-adrenergic blockade followed by beta-blockade to stabilize cardiovascular function. Anesthetic planning requires meticulous attention to volume status, cardiovascular optimization, and intraoperative monitoring to mitigate the risks of hypertensive crises and hypotension. Postoperative care must account for ongoing hemodynamic and metabolic fluctuations. A multidisciplinary, protocol-driven approach is essential to improve outcomes in patients undergoing pheochromocytoma resection. This paper provides a comprehensive overview of the genetic, biochemical, clinical, and anesthetic considerations involved in the diagnosis and perioperative management of pheochromocytoma.

Postoperative delirium (POD) represents a perioperative neurocognitive disorder that has dreaded ramifications on a patient’s recovery from surgery. Dexmedetomidine displays multiple mechanisms of neuroprotection to assist in preventing POD as a part of a comprehensive anesthetic care plan. This review will cover dexmedetomidine’s pharmacological overlap with the current etiological theories behind POD along with pre-clinical and clinical studies on POD prevention with dexmedetomidine. While the body of evidence surrounding the use of dexmedetomidine for POD prevention still requires further development, promising evidence exists for the use of dexmedetomidine in select dosing and circumstances to enhance recovery from surgery.