Left ventricular assist devices (LVADs) provide mechanical support for left ventricular ejection in the failing heart. We describe the anaesthetic management of a patient with an LVAD requiring laparoscopic cholecystectomy. A 51-yr-old female patient with severe heart disease had a Heartmate II LVAD implanted 4 months before this proposed elective surgery. Maintaining haemodynamic stability in the perioperative period is essential in such patients. The case was managed successfully using invasive monitoring and anaesthesia with sevoflurane and remifentanil. The potential problems in management of patients with LVADs are highlighted and discussed. A team approach is essential.
To determine the incidence of laparoscopic cholecystectomy (LC) and open cholecystectomy (OC) and some of their possible outcomes (complications, mortality, 30-day readmission) in the general population of senior citizens, we examined Medicare claims data for beneficiaries 65 years and older in eight states. Billing data for all cholecystectomies (ICD9-CM 51.22, 51.23) performed on an inpatient basis in those states on Medicare beneficiaries age 65 and older during fiscal year 1992 were examined. The incidence of LC in each state ranged from 2.1 to 3.2/1,000, whereas the incidence of OC ranged from 2.2 to 3.5/1,000. Eleven and one-half percent of LC patients suffered at least one perioperative complications, as did 21.5% of OC patients. There was considerable interstate variation in complication rates. In-hospital mortality was about five times greater of OC (4.5%) than for LC (0.9%). Patients who underwent OC were more likely (9.2%) to be readmitted within 30 days than were LC patients (7.0%). LC seems to be at least as safe as OC in the elderly population. Analyzing Medicare claims data can be useful in uncovering geographic variations in cholecystectomy practice.
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