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Patients at highest risk for paraplegia have had focal neurological deficit, uncal herniation, or preexisting intracranial hypertension 567. New guidelines (American College of Cardiology and the American Heart Association, 2007) for perioperative management in high-risk patients include (Text BOX 8 ) recommendations on fluid management, blood pressure control, neurological monitoring, and other factors. Patients who require preoperative care due to other causes (severe acute respiratory or sepsis, recent open abdominal or pelvic trauma, and occult bleeding) should be managed according to accepted standards of critical care. Because of the inherent problems with use of the brainstem reflexes in guiding fluid replacement, patients who are being monitored with central lines in place should have continuous CSF flow during hemodilution to preserve neurologic function and prevent increased intracranial pressure. Placement of a lumbar puncture needle in the morning and removal in the evening may prevent the development of spinal epidural hematomas, 811 as in spinal puncture for diagnostic paracentesis in the setting of coma. In addition, blood transfusion may also prevent the development of subdural hematomas. Patients with active spinal hematomas should have spinal drainage. Hydroxyethyl starch solutions have been used as a “diluent” for red blood cells in the anesthesiology literature but have not been studied for this purpose. 64 Recovery is slower than after other types of cardiac surgery, particularly coronary artery bypass surgery, and the mortality rate is higher. The median hospital stay is about 7 days. Longer hospitalizations may be due to prolonged recovery or operative bleeding or both. Mild lower limb paraparesis without concomitant bladder disturbance is a common problem during the first few weeks after surgery; this is usually transient and resolves completely within 6 months. Shoulder pain, weakness, and limited range of motion are common, particularly after aortic dissection repair. Bladder incontinence is usually not present after the first month postoperatively but may occur late. Infection is an important problem postoperatively. Aortic grafts may migrate distally, which may cause spinal cord ischemia. Most patients will have some degree of late aortic insufficiency, which is usually of moderate severity. 728 5ec8ef588b


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