Adult Cardiac Anesthesiology
22 cases on induction and hemodynamic management in structural and coronary disease, coagulation and blood-product decisions after bypass, vasoplegia and inotrope selection, perioperative antiplatelet and anticoagulant timing, and postoperative rhythm, sedation, and glycemic management — choose a case below to open its full multi-voice debate.
A 79-year-old woman with critical aortic stenosis needs induction for urgent aortic valve replacement. The disagreement isn't about which drug looks best on paper — it's about whether her own chronic beta-blockade quietly disqualifies the agent that looks best on paper.
A 68-year-old man on long-term glyburide is scheduled for a redo coronary artery bypass. The argument for volatile anesthesia's own cardioprotective mechanism runs straight into a drug already sitting in his system that may have switched that mechanism off years before he ever reached the operating room.
A 52-year-old woman with hypertrophic obstructive cardiomyopathy is hypotensive coming off bypass after septal myectomy. Every vasopressor in the cart works by a different mechanism, and only one of those mechanisms is guaranteed not to recreate the exact obstruction the surgery just relieved.
Two patients, two competing reasons to move the TXA dose in opposite directions. One's redo sternotomy on dual antiplatelet therapy argues for going higher; the other's chronic kidney disease argues for going lower — and dose is the one variable both arguments are actually fighting over.
A 58-year-old woman facing a redo triple-valve repair carries the kind of bleeding risk aprotinin was once reserved for. The drug that might help her most isn't sold in this country anymore — and the argument for chasing it hinges on how much trust the room still puts in the trial that took it off the market.
A 70-year-old man on a preoperative heparin infusion bridge won't clot down after a standard heparin dose. Three ways exist to fix the same antithrombin problem, and each one trades a different risk for the others.
A 66-year-old man with twenty years of NPH insulin exposure needs his heparin reversed at the end of bypass. The only reversal agent available carries a real reaction risk in exactly his history — and the argument over how to give it turns on a distinction the team can't actually confirm until it's already happening.
A 61-year-old man on ticagrelor for a five-day-old NSTEMI is bleeding after bypass with a confirmed platelet-function defect on point-of-care testing. Desmopressin could plausibly help — the argument is over whether "plausibly" is worth reaching for before the more direct fix already sitting in the blood bank.
A viscoelastic assay off bypass points squarely at fibrinogen as the driver of a 45-year-old woman's oozing. Naming the deficiency turned out to be the easy part — which product actually corrects it is where the room splits.
A 67-year-old man on chronic lisinopril develops refractory vasoplegia after a long bypass run. The drug most likely to help him works through the same pathway his home medication has spent years suppressing.
Two patients come off bypass in low cardiac output syndrome needing inotropic support. One's borderline kidneys argue against a renally cleared drug; the other's recent ventricular arrhythmia argues against a catecholamine — and between them, neither inotrope is the safe default.
A 70-year-old man with an ejection fraction of 22% is scheduled for high-risk reoperative valve surgery. The drug with the most promising early signal for exactly his risk profile isn't approved in this country — and the trial that was supposed to settle the question came back negative for almost everyone.
A 59-year-old woman with longstanding pulmonary hypertension develops acute right heart failure after mitral valve surgery. The drug that most precisely targets her pulmonary vasculature isn't the only reasonable answer once her low cardiac output is added to the picture.
A 57-year-old man with critical left main disease is three days into his ticagrelor washout when his angina recurs at rest. The guideline window that was supposed to make this decision simple is exactly what's now being weighed against the risk of waiting it out.
A 44-year-old woman with infective endocarditis on apixaban needs valve surgery today, not after a normal washout. The fastest reversal agent for her factor Xa inhibitor carries a real, documented cost that shows up later — on the bypass circuit itself.
A 71-year-old man with a dilated left atrium and borderline kidneys is due for CABG tomorrow morning. His statin is either protecting him from the atrial fibrillation he's otherwise likely to develop after surgery, or setting up a myopathy his kidneys may not be equipped to clear.
A 76-year-old woman with a heavily calcified aortic valve is off bypass after AVR, and her home metoprolol is due. Resuming it protects against the arrhythmia her abrupt withdrawal would otherwise risk — and could also mask or worsen a conduction injury nobody has confirmed is absent yet.
A 69-year-old man with moderate COPD faces real elevated risk for atrial fibrillation after his CABG. The single most effective prophylactic drug for that exact outcome carries a rare but genuine pulmonary toxicity risk in the one organ system he can least afford to gamble with.
A 68-year-old man is paced through new complete heart block after his CABG and needs ICU sedation. The drug with dexmedetomidine's reputation for preventing delirium also slows the heart — and the largest trial actually built to test that reputation in cardiac surgery didn't confirm it.
A 61-year-old man facing a hemiarch replacement with circulatory arrest is looking at one of the longest bypass exposures the team will run all year. The two largest trials of prophylactic steroids in cardiac surgery both came back negative — and the question is whether his case is different enough to matter.
A 63-year-old man with diabetes is about to start his CABG, and his glucose target for the case is still unsettled. The trial that once made tight control the standard for cardiac surgery patients specifically was later contradicted by a larger one — and the room hasn't fully agreed on which one should govern an anesthetized patient who can't report his own hypoglycemia.
A 54-year-old man is on the ERAS fast-track pathway for his CABG, and intraoperative methadone is the anesthetic team's usual way of getting there. His baseline QT interval, borderline before anyone gives him a single milligram, is exactly the detail that pathway wasn't built around.