Thoracic epidural analgesia in a patient with multiple comorbidities for subxiphoid incisional hernia repair

Anesthetic preparation before non-cardiac surgery deserves particular attention in patients with cardiac disease as these are prone to develop hemodynamic instability and myocardial ischemia. Risk of complications is not only related to individual patient characteristics, but also to surgery related factors. In this report we present our experience regarding anesthetic management of a patient with multiple comorbidities including advanced chronic obstructive pulmonary disease, severely impaired left ventricular systolic function and occluded by pass grafts. We chose thoracic epidural analgesia for his subxiphoid incisional hernia repair. The operative and postoperative course was uneventful

comparison of APACHE II and APACHE IV scoring systems in predicting outcome in patients admitted with stroke to an intensive care unit

Stroke is the second major cause of death worldwide. APACHE IV is a successful scoring system assessing severity of illness and prognosis of ICU patients. The objective of this study was to compare APACHE IV scoring system for patients admitted with stroke with APACHE II scoring system. We included all patients with the diagnosis of stroke, who were admitted to intensive care unit of our hospital for tracheal intubation and mechanical ventilation, between 1 January 2008 and 1 February 2009 from prospectively collected ICU database. Observed mortality rates were compared with predicted mortality rates for both the APACHE IV and APACHE II scoring systems, SMR, sensitivity and specificity were determined. The mortality percentages were predicted using the APACHE IV system and were compared with the observed data. The statistical analysis was carried out using SPSS for Windows version 15.0. The qualitative variables were compared to a _2 [chi-squared] test. Fifty five patients were included in the study, with an average age of 76.5 +/- 11.5 years for male patients and 72 +/- 5 years for females. The overall mortality observed was 34.54% in all the patients [19/55 patients]. Apache IV predicted mortality rate sensititivity and specificity were 94.7% and 94.4% respectively, SMR of 0.95 and diagnostics value was 94.5%. Apache II predicted mortality rate sensitivity and specificity were 100% and 86.1% respectively, SMR of 0.79 and diagnostics value was 90.9%. Predicting outcome in stroke patients is difficult due to variability in etiology, presentation and underlying patho-physiology. We conclude that APACHE IV scoring system is better than the APACHE II system in predicting mortality rate in ICU stroke patients. APACHE IV [score of >84] gives probably a more reliable prediction of high risk of death in patients with stroke than APACHE II [score >24]