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How would you anesthetize this patient?
Phenylpiperidine opioids (fentanyl, sufentanil, remifen-tanil and alfentanil), benzodiazepines, and etomidate are all reasonable choices for anesthetic induction in patients with mitral stenosis (Table 6.2). Opioids also have the advantage of increasing vagal tone and slowing the heart rate, usually without associated hypotension. Short-acting barbiturates produce undesirable venodilation and myo-cardial depression. Ketamine is contraindicated on the basis of its tachycardic effects. Volatile agents produce both myocardial depression and vasodilation and should be used cautiously in low concentrations.
Theoretically, the most suitable neuromuscular blocking agents for mitral stenosis are succinylcholine, vecuronium, rocuronium and cisatracurium. For long cardiothoracic procedures continuous intravenous infusions are a good choice to maintain an adequate level of neuromuscular blockade, which decreases oxygen consumption during cardiopulmonary bypass. Pancuronium is relatively contra-indicated since it produces tachycardia.
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