Anaesthetic Management and Cardiopulmonary Bypass
All patients receive their cardiac medications until the morning of surgery. Oral intake is usually stopped 6 hours before LVAD implantation. With glucose check-up every 2 hours and subcutaneous insulin injections as needed, diabetic adult patients receive intravenous fluids according to their body weight, starting at the initiation of preoperative fasting (2,3). Sublingual lorazepam (2 mg) is administered 2 hours before surgery to decrease anxiety. Anesthesia is induced with either Ketamine iv bolus, Etomidate iv, Fentanyl iv and Esmeron iv. After intubation, all patients were ventilated with 100% oxygen. All invasive procedures are performed while the patients are under deep anesthesia. Arterial blood pressure, central venous pressure, electrocardiogram, saturation with pulse oximetry and rectal temperature are routinely monitored during and after surgery (4). Anesthesia is maintained in these cases with Sevoflurane, Propofol iv, Fentanyl iv and Ketamine iv until the patients are fully awake in the postoperative period. Ultra–fast-track anesthetic (5) management is not performed in any of the patients, and all patients were transferred to the intensive care unit while still under full sedation. Patients are extubated when optimal cognitive, hemodynamic, and respiratory functions were achieved. For postoperative pain management, paracetamol is usually administered. Tranexamic acid (50 mg/kg) is used routinely to prevent bleeding complications (4,5,6). Perioperative changes in temperature, hemodynamics, and respiratory and metabolic parameters are recorded. Alterations in hemoglobin and hematocrit, blood loss, and transfusion requirement are monitored and documented. Standard hemoglobin electrophoresis is performed to detect the concentrations of HbS and HbA. By local protocol, all patients undergo LVAD implantation on central extra-corporeal circulation support.