Section on Anesthesiology. (Abstracts of Scientific Posters).

AN1-E. RADICAL CHANGE IN SURGICAL PLAN BASED ON UNEXPECTED INTRAOPERATIVE TEE FINDINGS IN A PATIENT WITH A HYPERCOAGUABLE STATE AND AORTIC THROMBUS. Amy Yeatman, DO, Douglas Yeatman, MD, and Cathy Cooper, MD. Department of Anesthesiology, Virginia Commonwealth University, Medical College of Virginia, Charlottesville, VA.

Transesophageal echocardiography (TEE) is a diagnostic modality used frequently during surgical procedures. It provides invaluable real-time information about fluctuating anatomic and physiologic states. A 41-year-old man presented to the emergency department with complaints of severe right leg pain. His medical history was significant for paroxysmal chest pain, bilateral lower extremity numbness and tingling, hypertension, congestive heart failure, multiple transient ischemic attacks, syncope, and acute aortic dissection. The patient had an extensive radiologic work-up, and was diagnosed with an ascending aortic graft thrombus (by computed tomography) that was thought to be transiently embolizing pieces of the clot to the lower extremity. A sternotomy with aortic thrombectomy was planned with the usual intraoperative monitoring, which includes TEE at our institution. In the case presented, the information provided by TEE radically altered the entire surgical course. The planned thrombectomy for removal of th e symptomatic ascending aortic graft thrombus was drastically changed when, after surgical manipulation, TEE failed to show the continued presence of the previously identified thrombus. At this time, the right lower extremity pulses were noted to be absent. An extensive examination with the TEE followed and demonstrated a previously undiagnosed clot in the descending aorta. An intra-arterial descending aortic thrombectomy via the right femoral artery was attempted without success. Upon cannulation of the right femoral artery, a large thrombus was identified and evacuated, thereby restoring pulses to the affected extremity. A descending aortic angioplasty was then performed through the right femoral artery, with visual restoration of aortic patency by TEE. TEE provided a unique look at an intraoperative embolic event as it occurred. As the thrombus was the nidus for the surgical plan, the embolization of the thrombus caused not only a new significant problem, but also negated the need for the originally planne d surgery. The real-time information provided by TEE was invaluable for accurate diagnosis and subsequent surgical treatment of the patient's fluctuating disease process.

AN2-E. FAST-TRACK CARDIAC ANESTHESIA. Mohanad Shukry, MD. Department of Anesthesiology, Tulane University Hospital and Clinic, New Orleans, LA.

Prolonged controlled ventilation in cardiac surgical patients is standard practice up to the present day, although early tracheal extubation in these patients is not a new concept. We looked at the literature and tried to find why cardiac surgical patients had to go through prolonged controlled ventilation, despite the fact that there were attempts to push for early extubation in these patients as early as 1970s. In the 1970s, Prakash et al showed that it is possible, based on a halothane anesthetic, to extubate the trachea of cardiac surgical patients less than an hour after surgery. At that time, postoperative cardiorespiratory complications were common because of poor myocardial protection and surgical techniques. As halothane was well known to be a myocardial depressant, opioid-based anesthetics began to gain popularity for patients undergoing cardiac surgery. Thus, continuation of ventilatory support became a necessity in the 12 to 24 hours following the surgery, particularly after administration of high -dose opioid anesthetics that were considered to provide a "stress-free" environment. Inhalation-based anesthetic techniques had been shown to be a key for early extubation in cardiac surgical patients, but the use of inhalation anesthetics in patients with coronary artery disease was questioned as isoflurane was proclaimed to be a powerful coronary vasodilator causing coronary steal. In the 1990s, the interest in early extubation for cardiac patients increased with the increasing pressure to maximize cost efficiency in health care. Early extubation became feasible because of improvements in anesthesia management, as large outcome studies demonstrated the safety of different anesthetic techniques , coupled with the advancement in surgical techniques, myocardial protection, and postoperative hemostasis. Also, inhalation anesthetics, such as isoflurane, were shown not to cause clinically significant coronary steal. Medications such as propofol were found to provide shorter postoperative sedation and decreased t ime to extubation with lower incidence of hypertension. By selecting suitable fast-track candidates, utilizing appropriate anesthetic techniques, and coordinating perioperative care, early tracheal extubation following cardiac surgery can be safe and reliable. Patient safety is important and cannot be sacrificed in pursuit of early tracheal extubation. In addition, the costs involved in the treatment of complications following cardiac surgery exceed the savings achieved by early tracheal extubation. Recent evidence has shown that "fast- track" extubation of the trachea and discharge from the ICU can be safely achieved in cardiac surgery.