Diagnosis of cardiac tamponade with transesophageal echocardiography following the induction of anesthesia for suspected testicular torsion.

Transesophageal echocardiography (TEE) is a valuable tool for evaluating hemodynamic instability in patients under general anesthesia. We present the case of a 28‑year‑old man who presented with complaints of testicular pain concerning for testicular torsion. After induction of general anesthesia for scrotal exploration and possible orchiopexy, the patient developed severe and persistent hypotension. Using intraoperative TEE, the diagnosis of pericardial tamponade was made, and an emergent pericardial window was performed.

Effect of etomidate and propofol induction on hemodynamic and endocrine response in patients undergoing coronary artery bypass grafting/mitral valve and aortic valve replacement surgery on cardiopulmonary bypass.

Introduction: The concerns for induction of anaesthesia in patients undergoing cardiac surgery include hemodynamic stability, attenuation of stress response and maintenance of balance between myocardial oxygen demand and supply. Various Intravenous anaesthetic agents like Thiopentone, Etomidate, Propofol, Midazolam, and Ketamine have been used for anesthetizing patients for cardiac surgeries. However, many authors have expressed concerns regarding induction with thiopentone, midazolam and ketamine. Hence, Propofol and Etomidate are preferred for induction in these patients. However, these two drugs have different characteristics. Etomidate is preferred for patients with poor left ventricular (LV) function as it provides stable cardiovascular profile. But there are concerns about reduction in adrenal suppression and serum cortisol levels. Propofol, on the other hand may cause a reduction in systemic vascular resistance and subsequent hypotension. Thus, this study was conducted to compare induction with these two agents in cardiac surgeries. Methods: Baseline categorical and continuous variables were compared using Fisher’s exact test and student’s t test respectively. Hemodynamic variables were compared using student’s t test for independent samples. The primary outcome (serum cortisol and blood sugar) of the study was compared using Wilcoxon Rank Sum test. The P value less than 0.05 was considered significant. Results: Etomidate provides more stable hemodynamic parameters as compared to Propofol. Propofol causes vasodilation and may result in drop of systematic BP. Etomidate can therefore be safely used for induction in patients with good LV function for CABG/MVR/AVR on CPB without serious cortisol suppression lasting more than twenty-four hours.

Anesthetic issues for robotic cardiac surgery.

As innovative technology continues to be developed and is implemented into the realm of cardiac surgery, surgical teams, cardiothoracic anesthesiologists, and health centers are constantly looking for methods to improve patient outcomes and satisfaction. One of the more recent developments in cardiac surgical practice is minimally invasive robotic surgery. Its use has been documented in numerous publications, and its use has proliferated significantly over the past 15 years. The anesthesiology team must continue to develop and perfect special techniques to manage these patients perioperatively including lung isolation techniques and transesophageal echocardiography (TEE). This review article of recent scientific data and personal experience serves to explain some of the challenges, which the anesthetic team must manage, including patient and procedural factors, complications from one‑lung ventilation (OLV) including hypoxia and hypercapnia, capnothorax, percutaneous cannulation for cardiopulmonary bypass, TEE guidance, as well as methods of intraoperative monitoring and analgesia. As existing minimally invasive techniques are perfected, and newer innovations are demonstrated, it is imperative that the cardiothoracic anesthesiologist must improve and maintain skills to guide these patients safely through the robotic procedure.

Use of nitric oxide in thoracic surgery for a high risk cardiac patient.

Nitric oxide (NO) is a selective pulmonary vasodilator especially in the presence of pulmonary artery hypertension. With right ventricle (RV) dysfunction, inhaled NO may increase RV ejection fraction and cardiac output. The main advantage of NO over intravenous therapy is its inability to decrease systemic pressure thereby maintaining the coronary perfusion pressure and the myocardial perfusion. In this case report, we discuss the use of NO in a routine thoracic surgery patient suffering with severe left ventricular dysfunction and a potential candidate for a very high cardiac risk.

Postoperative Takotsubo cardiomyopathy.

Takotsubo cardiomyopathy also known as transient apical ballooning syndrome or stress induced reversible cardiomyopathy is an increasingly reported syndrome generally characterized by transient systolic dysfunction of the apical and/or mid segment of the left ventricle. It is frequently precipitated by severe stress and clinically mimics an acute ST‑elevation myocardial infarction, with angiographically normal coronary arteries. A high index of suspicion is needed to diagnose this syndrome. We describe a patient who developed Takotsubo cardiomyopathy in the post‑operative period following vaginal hysterectomy.

Anesthesia and cor triatriatum.

Aims and Objectives: Cor triatriatum sinistrum (CTS) and cor triatriatum dextrum (CTD) are rare congenital anomalies characterized by the presence of a perforated septum which divides the respective atrium into a proximal and distal chamber. This report reviews the perioperative course of patients with uncorrected cor triatriatum (CT) undergoing procedures requiring anesthesia. In addition, we performed a literature search that examines the experience of others regarding the peri‑operative course of patients with CT. Materials and Methods: A computerized search of a medical record database was conducted to identify patients with a clinical diagnosis of uncorrected CTD and CTS undergoing surgical procedures. Descriptive statistics were used. Results: We identified 12 adult patients with asymptomatic CTS (n = 7) and CTD (n = 5) who underwent 23 anesthetics. There were no perioperative complications which could be attributed directly to the anatomy of CT. Conclusions: Our observation and review of the literature suggest that patients with asymptomatic CT typically tolerate anesthesia and surgical procedures well.

Myocardial protection during off pump coronary artery bypass surgery: A comparison of inhalational anesthesia with sevoflurane or desflurane and total intravenous anesthesia.

Aims and Objectives: The objective of the study was to evaluate the myocardial protective effect of volatile agents-sevoflurane and desflurane versus total intravenous anesthesia (TIVA) with propofol in offpump coronary artery bypass surgery (OPCAB) by measuring cardiac troponin-T (cTnT) as a marker of myocardial cell death. Materials and Methods: The study was conducted on 139 patients scheduled to undergo elective OPCAB surgery. The patients were randomly allocated to receive anesthesia with sevoflurane, desflurane or TIVA with propofol. The cTnT levels were measured preoperatively, at arrival in postoperative intensive care unit, at 8, 24, 48 and 96 hours thereafter. Results: The changes in cTnT levels at all time intervals were comparable in the three groups. Conclusion: The study did not reveal any difference in myocardial protection after OPCAB with either sevoflurane or desflurane or TIVA using propofol as assessed by measuring serial cTnT values.

Induction characteristics of two different concentrations of propofol in children undergoing eye surgeries

To compare the induction characteristics of two different concentrations of propofol [i.e. 1% and 2%] in children undergoing eye surgeries. This cross-sectional comparative study was conducted at LV Prasad Eye Institute Hyderabad India. Hundred consecutlve patients of American soclety of Anaesthesiologist [ASA] status I and II coming for elective eye surgeries were enrolled in the study. Patients were divided into two groups of 50 each. Group A were given propofol 1% while patients in Group B were given propofol 2% for induction of anaesthesia and were maintained with 1% isoflurane and 60% nitrous oxide in oxygen. Induction characteristics were assessed and compared in two groups. Student's t test and chi- square test were applied. Loss of consciousness was more rapid with propofol 2% compared with propofol 1% [40s Vs 48s; P = 0.02]. Pain on injection occurred in 5 patients [10%] and 10 patients [20%], P = 0.09 after propofol 1% and 2% respectively. Spontaneous movements during induction occurred in 8 patients [16%] and 12 patients [24%, P=0.18]. Satisfactory intubation was done in 40 patients [80%] and 45 patients [90%, P=0.19], while spasm just after intubation was noticed in 1 patient [2%] and 3 patients [6%] receiving propofol 1% and 2% respectively. Hemodynamic changes were not different in the two groups. Propofol 1% and propofol 2% are equally effective and safe for induction of anaesthesia in children undergoing eye surgeries

Anaesthetic challenges in surgical excision of phaeochromocytoma

Background: Phaeochromocytoma is a rare tumour; which is benign but metabolically active; with a potential for malignancy. This tumour of adrenal or extra adrenal origin usually presents as hypertension; which can be sustained or paroxysmal and with lethal complications. Aim: To present an anaesthetic experience during the surgical resection of a phaeochromocytoma. Method: A 26-year old woman with phaeochromocytoma of the right adrenal gland is presented. The tumour was excised under general anaesthesia. The anaesthesia involved the use of continuous infusion of esmolol (an ultra short-acting intravenous cardioselective beta-antagonist) and propofol. The resected tumour was sent for histopathological examination. Results: The tumour was completely excised under general anaesthesia. The haemodynamic changes that occurred during tumour handling were controlled with fentany1;propofol/esmolol infusion. Histopathological findings confirmed phaeochromocytoma. Conclusion: Although; the anaesthetic and surgical management of a phaeochromocytoma could be an uphill task; it is possible in an environment with limit laboratory and intensive care facilities

effect of piracetam on the anaesthetic recovery in geriatric patients

Piracetam is a nootropic agent claimed to possess a protective effect on cerebral nerve cells against hypoxia. The present study included 80 geriatric patients undergoing suprapubic prostatectomy under general anaesthesia. They were divided into two equal groups: test and control. Patients of the test group received piracetam, 15 gm. added to 500 ml lactated Ringer solution - as an I.V. infusion at the start of surgery. The anaesthetic technique was standardized and the study conducted on a double-blind basis. Subjective as well as objective assessment of the state of consciousness cortical activity and neurovegetative stability was carried out in the post-anaesthetic period. Piracetam administration was found to reduce the post-anaesthetic recovery time. Recovery was rapid, smooth, lucid and free of neuropsychic complications