: At our institution, we recognized a need for a standardized, efficient approach to safely evaluate, prepare, and transport patients in need of emergent surgery. With the establishment of an Emergency Surgery Transport and Assessment Team, we were able to substantially reduce our median transport time to the OR. We believe other institutions can establish an efficient team using existing resources to expedite care of the emergent surgical patient.
Successful deliveries from patients supported by axial flow left ventricular devices have been previously reported. We present the first case of a successful pregnancy and birth in a patient with a centrifugal-flow left ventricular assist device. A 24-year-old female with methamphetamine-induced cardiomyopathy and end-stage congestive heart failure supported by a HeartWare™ ventricular assist device (Medtronic) presented two years after device implantation with an unplanned pregnancy at 11-weeks of gestation. Following a multidisciplinary evaluation by experts in advanced heart failure, maternal fetal medicine, cardiothoracic surgery, anesthesia, ethics, psychiatry, and palliative care, an advanced plan of care was established. An elective induction of labor was scheduled for the 34th week of gestation. Given poor labor progression despite maximal induction efforts, the patient was transferred to a cardiothoracic operating room where she delivered a healthy baby boy via Cesarean section under close hemodynamic monitoring by advanced heart failure and cardiothoracic surgery teams.
This chapter explains that the interpretation of acid–base abnormalities is an essential skill required when caring for critically ill patients. The differential causes of respiratory acidosis include central nervous system depression, upper and lower airway obstruction, and hypermetabolic states with increased production of CO2, such as malignant hyperthermia and thyroid storm. The treatment for hypoxic and hypercarbic respiratory failure involves reversing the offending agents if applicable, treatment of the underlying cause, and mechanical ventilation. The 2 commonly used strategies for mechanical ventilation are non-invasive ventilation with a mask and endotracheal intubation. The selection of ventilation strategy is dependent on numerous patient factors. Clinicians must set respiratory rate, tidal volume, positive end-expiratory pressure, inspiratory flow, fraction of inspired oxygen, mode (volume versus pressure control), and the amount of assistance per breath. All need to be tailored toward each patient’s specific goals. In patients with severe acidosis, there may be a temptation to hyperventilate in order to treat the hypercarbia and hypoxia as quickly as possible. This can be deleterious as high tidal volumes may lead to ventilator-induced lung injury due to volutrauma, cytotrauma, and barotrauma.
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