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• W2920587077 abstract "We thank Cakir and associates [1Cakir H. Donmez K. Yurekli I. Kestelli M. Cakir P. What are the first-line anesthetic agents in cases of propofol and remifentanil allergy? (letter).Ann Thorac Surg. 2019; 108: 312Abstract Full Text Full Text PDF Scopus (1) Google Scholar] for their comments on our article [2Kanda H. Kamiya H. Sugawara A. et al.Minimally invasive awake mitral valve surgery and cardiopulmonary bypass without general anesthesia.Ann Thorac Surg. 2019; 107: e247-e248Abstract Full Text Full Text PDF Scopus (5) Google Scholar] about indications for minimally invasive awake mitral surgery in patients with propofol and remifentanil allergies. As they have pointed out, theoretically, general anesthesia could be induced in patients with propofol and remifentanil allergies using midazolam plus fentanyl or inhalational anesthetic agents under strict monitoring and life support care. Nevertheless, it is uncertain whether general anesthesia or regional anesthesia is more appropriate in a patient who has twice experienced cardiac arrest during induction of general anesthesia. The patient’s preoperative ejection fraction recovered to around 50% to 60% on the day before surgery; it decreased to around 20% with new-onset heart failure and in the postresuscitation period. In fact, the patient’s heart function was not the most important concern for performing this awake surgery. In other words, we believe that both general anesthesia and epidural analgesia can be carried out safely in patients with reduced cardiac function under effective care and monitoring. In the present case, the most pressing concern was that general anesthesia could cause fatal allergy. Ho and colleagues [3Ho A.M. Chung D.C. Joynt G.M. Neuraxial blockade and hematoma in cardiac surgery: estimating the risk of a rare adverse event that has not (yet) occurred.Chest. 2000; 117: 551-555Abstract Full Text Full Text PDF PubMed Scopus (211) Google Scholar] mathematically estimated that the risk of spinal injury from an epidural catheter-induced hematoma during cardiac surgery using cardiopulmonary bypass and heparin ranged from 1 in 150,000 to 1 in 1,500. Therefore, epidural anesthesia is a reliable and acceptable analgesic strategy even in cardiac surgery with cardiopulmonary bypass, as long as epidural catheterization is performed 1 day before surgery and the catheter is withdrawn after coagulation parameters are normalized. Enhanced recovery after surgery was recently recommended as a means of achieving early recovery, and it includes oral nutrition and rehabilitation that facilitates shorter hospital stays and earlier social reintegration. The context-sensitive half-time of midazolam is longer than that of propofol, potentiating arousal delay. Therefore, we prefer to refrain from using midazolam given due consideration of enhanced recovery after surgery. Notably, skin prick and intradermal tests in recipients of inhalation anesthetic agents (sevoflurane and desflurane) were impossible at our institution. The perioperative state of consciousness was a primary concern for medical staff including the surgeon, anesthesiologist, and perfusionist because the patient had experienced cardiac arrest twice and been rescued by venoarterial extracorporeal membrane oxygenation. A conscious patient can serve as the cerebral function monitor during surgery. Consciousness was a most useful and appropriate neuromonitor in this patient. In conclusion, we believe that minimally invasive awake mitral valve surgery with epidural anesthesia without general anesthesia was the most appropriate and safe procedure in the case in question. What Are the First-Line Anesthetic Agents in Case of Propofol and Remifentanyl Allergy?The Annals of Thoracic SurgeryVol. 108Issue 1PreviewWe congratulate Kanda and colleagues for their work [1]. In the study, a patient with propofol and remifentanyl allergies was successfully treated with thoracic epidural anesthesia. The patient's preoperative ejection fraction was not reported to be impaired. Therefore, we believe that thoracic epidural application should not be the first choice because cardiopulmonary bypass method is used, even if the patient has a successful epidural application. There are successful results with thoracic epidural anesthesia patients treated with off-pump surgery. Full-Text PDF" @default.
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• W2920587077 doi "https://doi.org/10.1016/j.athoracsur.2019.01.051" @default.
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