Slide tracheoplasty with pericardial patch augmentation for reconstruction of severe congenital tracheal stenosis involving carina : A case report.

Objective: Slide tracheoplasty seems to be the most efficient surgical procedure for correcting long-segment funnel-shaped congenital tracheal stenosis. However, in cases of extremely long-segment or those involve carina, slide tracheoplasty when operated alone has certain degree of limitations which often need additional operative procedure. The authors report a technique of slide tracheoplasty in combination with pericardial patch augmentation in a child with congenital tracheal stenosis involving the carina. Methods: A 3-month-old girl, previously diagnosed with Tetralogy of Fallot and congenital tracheal stenosis, presented with severe cyanosis and serious major airway obstruction after a few days of upper respiratory tract infection (URI). Because of the failure to maintain her ventilation with a high positive pressure ventilator, an emergency slide tracheoplasty with a modified right Blalock’s Taussig shunt was performed under a cardiopulmonary bypass. The intraoperative finding revealed a complete tracheal ring stenosis involving the lower half of the trachea and carina. It was transected at the middle and a vertical incision was made at the posterior wall of the upper trachea and anterior wall of the lower and extended into orifices of the main bronchus. The upper and lower tracheal flaps were slid together and sutured with interrupted Proline 5-0. Consequently, she still had significant obstruction of the main bronchi postoperatively and needed a re-operation two days later. Under cardiopulmonary bypass support, the lower anastomotic sutures were removed and an additional bronchial incision was made into the main bronchus. The anterior upper tracheal flap was separated into two, and each equal flap was pulled down and sutured to the main bronchus. Then an autologous pericardial patch was used to cover all the airway defects. Intraoperative fiberoptic bronchoscopy demonstrated adequate tracheo-bronchial lumen. Results: The child had postoperative hyperactive airway reaction and needed prolonged ventilator support and tracheostomy for tracheal toileting. Repeated postoperative bronchoscopy found moderated granulation tissue which was easily removed by catheter suction. Unfortunately, the patient expired six months after the surgery due to uncontrolled sepsis. However, a bronchoscopic finding before the patient’s death revealed adequate major airway patency. Conclusion: Combined slide tracheoplasty with pericardial patch augmentation made reconstruction of the complex congenital tracheal stenosis involving carina or tracheal bronchus possible and minimized the result of unflavoric excessive granulation tissue forming caused by pericardial tracheoplasty alone.

Hypothermic circulatory arrest and retrograde cerebral perfusion for aortic surgery at Siriraj Hospital: a preliminary review of anesthetic management.

OBJECTIVE: To evaluate the anesthetic management in patients undergoing aortic surgery cerebral perfusion; with particular emphasis on under hypothemic circulatory arrest and retrograde intraoperative brain protection, blood salvage and postoperative outcomes. MATERIAL AND METHOD: Retrospective case series. Data on medical conditions, anesthesia, surgery and postoperative care from patients who underwent operation between June 1993 and December 1999 were analyzed. RESULTS: There were 53 patients involved in this study. They all received general balanced anesthesia; 70.6 per cent had single-lumen endotracheal intubation, while the remaining required double-lumen endotracheal intubation. The duration of the anesthetic procedure, aortic cross-clamping and circulatory arrest, were 365.58 +/- 89.21, 126.35 +/- 34.64 and 48.35 +/- 19.47 min respectively. The lowest nasopharyngeal and rectal temperature were 17.42 +/- 1.40 degrees C and 21.26 +/- 2.80 degrees C respectively. Thiopental 804.68 +/- 353.93 mg and dexamethasone 14.41 +/- 7.88 mg were administered for brain protection, in addition to retrograde cerebral perfusion; 82.35 per cent received 785.71 +/- 273.86 mg of tranexamic acid and only 23.52 per cent received aprotinin in order to reduce blood loss. However, massive blood replacement therapy was always necessary. In the postoperative period, the patients were ventilated for 39.18 +/- 59.53 h, the length of hospital stay was 14.58 +/- 5.83 d, and the mortality was 13.2 per cent. CONCLUSION: This preliminary data indicate that hypothermic circulatory arrest in aortic surgery is associated with a high mortality rate, despite attempts to provide adequate cerebral protection as well as intraoperative blood salvage.

Slide tracheoplasty for severe congenital long segment tracheal stenosis in infants: surgical and anesthetic management.

Congenital long segment tracheal stenosis is the rare occurrence of an intrinsic narrowing of the trachea due to a complete cartilagenous ring. It is difficult to manage and can be life threatening especially when these patients who are usually neonates or infants have the pathological pattern of a long segment and have to come for surgical correction. Despite many technical reports on how to correct this anormaly, currently, the technique of "slide tracheoplasty" is claimed to be the most successful with the good immediate and long-term outcomes. But because of the rare and life threatening disease, so we were encouraged and write this report about the disease and its management. These are the case series reports of 4 infants with a history and diagnosis of severe long segment congenital tracheal stenosis who needed a difinite surgical repair. The authors decided to use the surgical technique of "slide tracheoplasty" with successful outcome. In two of the cases, patients needed cardioplumonary bypass support during the surgical repair. All of these patients did well after the operation except one patient with a history of congenital heart disease (tetralogy of Fallot) who needed an emergency surgical repair and was reoperated upon with pericardial patch. In this reports the authors did not find any benefit from tracheostomy. Also, details of surgical and anesthetic procedure were discussed with the conclusion that the surgical technique of slide tracheoplasty should be the surgical of choice for the management of congenital long segment tracheal stenosis.

Factors influencing the ambient operating room temperature.

Objective: With an effort to decrease the incidence of core hypothermia in the preoperative period and ambient operating room temperature is a well known predictor of intraoperative core hypothermia. This prospective study was done with the primary purpose to find any possible influential factors associated with the ambient operating room temperature especially the function of thermostat. The secondary purpose was to survey the attitude and knowledge of operating room personnel concerning the relationship between an ambient operating room temperature and patient's intraoperative core hypothermia including measures to prevent preoperative core hypothermia and any obstacles. Methods: We surveyed thermostat function and measured the real ambient operating room temperature both in the operating rooms where the thermostats were functioning (TFR) and those where they weren't (TNFR) in the Siammitra building, Siriraj hospital during the period of December 2000 and January 2001. Also, 200 questionnaires were used to survey operating room personnel regarding their knowledge and attitude concerning the relationship between an ambient operating room temperature and patient's intraoperative core hypothermia including measures to prevent preoperative core hypothermia and any obstacles. Results: 40% (20 out of 46) of the thermostats were non functioning (most of these were in the orthopedics and ophthalmic operating rooms) and the mean ambient temperature in these rooms (TNFR) was 19.2 ฑ 1.57 ฐC which was significantly lower than that in the rooms where the thermostat was functioning (TFR). 90% of the mean operating room temperature in the TNFR were lower than 21ฐC. However, the lowest temperature (12ฐC) was found in a TFR and still more than half of the mean ambient temperatures in the TFR were lower than 21ฐC. More than half of the operating room personnel believed that increasing the ambient temperature could help prevent intraoperative core hypothermia. Non functioning of the thermostats was the main reason of the cold operating room given by the scrub nurses while intolerance of the surgical team to a warm environment was the main reason given by the anesthesia team. The staff anesthesiologists asked for more attention and concern be given to hypothermia and warming process. Conclusion: Non functioning of the thermostat is probably the important influential factor determining the ambient temperature in orthopedics and ophthalmic operating rooms. While the ambient temperatures in some of the rooms where the thermostat were functioning (non cardiopulmonary bypass room) were still very low. More information about core hypothermia and optimal operating room temperature, information about patient\\\'s temperature during the operation and access to control the ambient temperature should be the way to improve the quality of care and prevent the risk of core hypothermia to our patient during operation.

A young woman with inevitable limb loss.

We report a pitfall in the management of a young 43-year-old female who presented with a history of claudication and threaten limb loss. Inappropriate axillobifemoral bypass graft surgery was performed, resulting in perioperative graft failure with progressive inevitable gangrene of the left leg. Rescue surgery was performed to salvage the right limb but she developed perioperative myocardial infarction. Delayed amputation was justified, pre-operative cardiac evaluation and aggressive percutaneous coronary intervention was performed followed by an uneventful definitive below-knee amputation of left leg. The patient was discharged and was referred for a left leg prosthesis.

Transcatheter closure of atrial septal defects by amplatzerTM septal occluder instead of open heart surgery.

Although surgical repair of secundum atrial septal defect (ASD) is a safe, widely accepted procedure with negligible mortality, it is associated with morbidity, discomfort and a thoracotomy scar. As an alternative to surgery, a variety of devices for transcatheter closure of ASD have been developed. Large delivery sheath, difficult implantation technique, inability to capture, and structural failure are some of the limitations of previous devices. Objective: This study reports our clinical experience with transcatheter closure of ASD using the AmplatzerTM Septal Occluder , a new occlusion device. Methods: Patients with ASD met established two-dimensional echocardiographic criteria for transcatheter closure. ASD size was measured by transesophageal echocardiogram (TEE) and balloon occlusion catheter (stretched diameter). The AmplatzerTM ’s size was chosen to be equal to stretched dia-meter (+ 1 mm). The device was advanced transvenously into a guiding sheath and deployed under fluoroscopic and TEE guidance. Once its position was optimal, it was released. Right atrial atriogram and TEE were undertaken to demonstrate the residual shunt. Results: There were 5 patients with mean age of 9.6+8.4 years and mean weight of 24.7 + 14.9 kg. The mean ASD diameter measured by TEE was 16.1+ 2 mm and by stretched diameter was 18.5 + 3.5 mm. The mean device diameter was 19.2 + 4 mm (range 15 to 24 mm). Immediately after the deployment, a tiny residual shunt was observed at the core of the device in each case. However, at 24 hours only one patient who had a 24 mm device placed had a small (<2 mm) residual shunt. No complication was encountered during the procedure. Conclusion: The AmplatzerTM Septal Occluder is a prosthesis that can be easily deployed in patients with secundum ASD. The result of closure was excellent. This device could be used to close large ASD (particularly with diameter > 20 mm) safely in our patients.

Pain management in Siriraj Hospital (Data from doctors and nurses).

A survey was carried out among housestaffs and nurses involved with postoperative patient cares to assess their attitudes toward postoperative analgesic care and their knowledge of analgesics. Only 37 percent of the respondents prescribed analgesics for complete pain relief, The most common prescribed drugs were paracetamol, pethidine, morphine, sosegon, baralgan and aspirin, but morphine would be in the second order in the nurses opinion. Doctors had more knowledge in the routes of pain relief such as intermittent intravenous injection, local infiltration or gases inhalation. The respondents knew many intramuscular routes, but did not know about their dangers and toxicitis.56.8 percent of the respondents were satisfied with their treatments. This study demonstrates the need for better and more comprehensive training of housestaff and nurses in analgesic case.

Pain management in siriraj hospital: Data from patients.

The objectives of the study are to evaluate the significance of pain problem in Siriraj Hospital, success rate and mothods of pain relief being given to the patients. We questioned 440 patients in whom 53.7% had pain as one of the main symptoms that brought them to the hospital and 53.3% had asked for pain relief drugs during their admission, these showed that pain is a common problem and a challenge to all doctors. By using Linear Analogue Scale we found that the success rate of pain relief were excellent 26.6%, good 25.9, bad 34.3% and there was no effect in 13.2% Factors affecting success are sites of pain, sex, age and duration after operation. 71.8% of all patients had received analgesic drug prescription but only 44.1% were recorded to have the drugs. The most commonly used drugs are paracetamol, morphine and pethidine. Oral and intramuscular routes are most common administrative routes.