Due to the increase in average life expectancy and the higher incidence of cardiovascular disease with advancing age, more elderly patients present for cardiac surgery nowadays. Advances in pre- and postoperative care have led to the possibility that an increasing number of elderly patients can be operated on safely and with a satisfactory outcome. Currently, coronary artery bypass surgery, aortic and mitral valve surgery, and major surgery of the aorta are performed in elderly patients. The data available show that most cardiac surgical procedures can be performed in elderly patients with a satisfactory outcome. Nevertheless, the risk for these patients is only acceptable in the absence of comorbidities. In particular, renal dysfunction, cerebrovascular disease, and poor clinical state are associated with a worse outcome in elderly patients. Careful patient selection, flawless surgery, meticulous hemostasis, perfect anesthesia, and adequate myocardial protection are basic requirements for the success of cardiac surgery in elderly patients. The care of elderly cardiac surgical patients can be improved only through the strict collaboration of geriatricians, anesthesiologists, cardiologists, and cardiac surgeons, in order to obtain a tailored treatment for each individual patient.
Vascular access used in the treatment of patients involves central and peripheral vein accesses and arterial accesses. Catheterization of central veins is widely used in clinical practice; it is a necessary part of the treatment of patients in various settings. The most commonly involved vessels are the internal jugular, subclavian, and femoral veins. The mechanical, infectious, and thrombotic complications of central venous catheterization are markedly reduced when the procedure is performed with real-time ultrasound guidance or (to a slightly lesser extent) ultrasound assistance. Ultrasound guidance is also used to create peripheral venous accesses, for catheterization of peripheral veins and for peripheral insertion of central venous catheters. In this setting, it increases the catheterization success rate, especially during difficult procedures (e.g., obese patients, children) and reduces complications such as catheter-related infections and venous thrombosis. Arterial cannulation is used for invasive monitoring of arterial pressure and for access during diagnostic or therapeutic procedures. Ultrasound guidance reduces the risk of catheterization failure and complications. It is especially useful for arterial catheterization procedures performed in the absence of a palpable pulse (e.g., patient in shock, ECMO). Imaging support is being used increasingly to facilitate the creation of vascular accesses under difficult conditions, in part because of the growing use of ultrasonography as a bedside procedure. In clinical settings where patients are becoming increasingly vulnerable as a result of advanced age and/or complex disease, the possibility to reduce the risks associated with these invasive procedures should motivate clinicians to acquire the technical skills needed for routine use of sonographic support during vascular access procedures.
Keywords Vascular access Á UltrasoundRiassunto Gli accessi vascolari utilizzati nella cura dei pazienti comprendono gli accessi venosi centrali e periferici e gli accessi arteriosi. L'incannulamento di accessi venosi centrali è manovra largamente diffusa nella pratica clinica e si rende necessaria per la cura dei pazienti in molteplici contesti. I vasi centrali che usualmente vengono incannulati sono la vena giugulare interna, la vena succlavia e la vena femorale. Nell'incannulamento venoso centrale sia l'eco-assistenza che l'eco-guida real time, pur con una leggera superiorità di quest'ultima, riducono drasticamente le complicanze meccaniche, infettive e trombotiche. La guida ecografica viene utilizzata anche per l'accesso venoso periferico, per l'incannulamento di vasi periferici e di vasi centrali a inserzione periferica (PICC). In questo contesto la guida ecografica aumenta il successo della manovra di incannulamento soprattutto in condizioni di difficoltà, come avviene nei pazienti obesi o nei bambini, e diminuisce le complicanze quali le infezioni catetere correlate e le trombosi venose. L'incannulamento arterioso viene utilizzato per il monitoraggio cruent...
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