Successful anesthetic management in axillo-axillary bypass surgery.

Axillo-axillary bypass grafting is considered the operation of choice for patients with subclavian steal syndrome. Anesthetic management of high-risk patients with coronary-subclavian steal syndrome presents safety and technical challenges. Presently described is case of chronic obstructive lung disease and coronary artery disease in a 52-year-old man who required axillo-axillary bypass surgery to treat stenosis at the origin of left subclavian artery. Successful anesthetic management was achieved for patient undergoing axillary-axillary bypass surgery using a cervical epidural technique.

The effect of tramadol plus paracetamol on consumption of morphine after coronary artery bypass grafting.

STUDY OF OBJECTIVE: To compare the effects of oral tramadol+paracetamol combination on morphine consumption following coronary artery bypass grafting (CABG) in the patient-controlled analgesia (PCA) protocol. DESIGN: A prospective, double-blind, randomized, clinical study. SETTING: Single-institution, tertiary hospital. PATIENTS: Fifty cardiac surgical patients undergoing primary CABG surgery. INTERVENTIONS: After surgery, the patients were allocated to 1 of 2 groups. Both groups received morphine according to the PCA protocol after arrival to the coronary intensive care unit (bolus 1 mg, lockout time 15 minutes). In addition to morphine administration 2 hours before operation and postoperative 2nd, 6th, 12th, 18th, 24th, 30th, 36th, 42th, and 48th hours, group T received tramadol+paracetamol (Zaldiar; 325 mg paracetamol, 37.5 mg tramadol) and group P received placebo. Sedation levels were measured with the Ramsay Sedation Scale, whereas pain was assessed with the Pain Intensity Score during mechanical ventilation and with the Numeric Rating Scale after extubation. If the Numeric Rating Scale score was ≥3 and Pain Intensity Score was ≥3, 0.05 mg/kg morphine was administered additionally. MEASUREMENTS: Preoperative patient characteristics, risk assessment, and intraoperative data were similar between the groups. MAIN RESULTS: Cumulative morphine consumption, number of PCA demand, and boluses were higher in group P (P<.01). The amount of total morphine (in mg) used as a rescue analgesia was also higher in group P (5.06±1.0), compared with group T (2.37±0.52; P<.001). The patients who received rescue doses of morphine were 8 (32%) in group T and 18 (72%) in group P (P<.001). Duration of mechanical ventilation in group P was longer than group T (P<.01). CONCLUSION: Tramadol+paracetamol combination along with PCA morphine improves analgesia and reduces morphine requirement up to 50% after CABG, compared with morphine PCA alone.

Ultrasound guided continuous paravertebral block in a patient with coronary heart disease and sleep apnea syndrome.

The case of a 77-year-old patient with severe coronary heart disease who underwent radical mastectomy with axillary lymph node dissection by ultrasound-guided continuous paravertebral block (CPVB) is described in the present report. Radical mastectomy with axillary dissection is a surgical procedure that necessitates endotracheal intubation and is usually performed under general anesthesia, which carries heightened risk for patients with coronary heart disease (CHD) and sleep apnea syndrome (SAS). Ultrasound-guided CPVB is a simple and safe alternative technique that allows for the use of anesthesia and postoperative analgesia with minimal side effects.

Multiple Brain Abscesses Due to Phialemonium in a Renal Transplant Recipient: First Case Report in the Literature.

Fungal brain abscesses are a rare but serious complication in transplant recipients. Phialemonium organisms are rare causes of invasive mold infections. Here, we present the first case of a renal transplant recipient with multiple brain abscesses caused by Phialemonium infection A. A 51-year-old female kidney transplant recipient was admitted with pneumonia of an unknown cause and treated with empiric intravenous antibiotics. Her treatment was uneventful, and she was discharged 1010 days later. After 5 days, she was readmitted with fever, cerebral palsy, and speech disorder. The patient had undergone living-donor renal transplant 7 months earlier. A cranial computed tomography and magnetic resonance imaging were performed for a possible cerebrovascular pathology. The magnetic resonance imaging scan showed multiple brain abscesses located at the left parietal, frontal and occipital lobes; right parietal and occipital lobes; right basal ganglia; and left cerebellum. The patient received meropenem, linezolid, sulfamethoxazole and trimethoprim, and AmBisome for probable pathogenic infection, and immunosuppressive agents dosage was reduced increasingly immunosuppressed. We identified Phialemonium in cerebrospinal fluid culture. The patient received voriconazole 200 mg twice daily. Lesions could not be drained due to lack of capsula formation. The patient died on the 30th day of antifungal therapy. Phialemonium organisms, although a rare cause of fungal infections, are associated with a high mortality rate in immunocompromised patients. To our knowledge, this is the first case report in the literature describing multiple brain abscesses due to Phialemonium in a transplant recipient. Clinicians recipient should be alert about these rare opportunistic fungi in the differential diagnosis of brain abscess, and bronchoscopy and bronchoalveolar lavage are recommended for transplant patients when they are admitted with pneumonia exclude fungal infections.

Massive Alimentary Tract Bleeding due to Cytomegalovirus Infection in an Elderly Patient.

In recent years, cytomegalovirus (CMV) has been recognized as an important common pathogen in immunocompromized patients. This is due to the increasing number of immunosuppressive medications, intensive cancer chemotherapy use, recurrent transplantations, progressively aging population, and the higher number of human immunodeficiency virus infections. Cytomegalovirus infection especially interests the gastrointestinal tract, anywhere, from the mouth to the anus. Namely, the most commonly affected area is the colon, followed by duodenum, stomach, esophagus and small intestine. The most frequent manifestations of CMV colitis are: diarrhea, fever, gastrointestinal bleeding and abdominal pain. We report here the case of an 82-year-old woman, who was treated for non-Hodgkin lymphoma; she was admitted to the emergency department for abdominal pain and diffuse arthralgia, following massive upper- and lower- gastrointestinal bleeding, due to duodenal and colonic ulcers related to CMV infection.

The effects of different ventilator modes on cerebral tissue oxygen saturation in patients with bidirectional superior cavopulmonary connection.

AIMS AND OBJECTIVES: We used near-infrared spectroscopy to document changes in cerebral tissue oxygen saturation (SctO2) in response to ventilation mode alterations after bidirectional Glenn (BDG; superior cavopulmonary connection) procedure. We also determined whether spontaneous ventilation have a beneficial effect on hemodynamic status, lactate and SctO2 when compared with other ventilation modes. MATERIALS AND METHODS: 20 consecutive patients undergoing BDG were included. We measured SctO 2 during three ventilator modes (intermittent positive-pressure ventilation [IPPV]; synchronized intermittent mandatory ventilation [SIMV]; and continuous positive airway pressure + pressure support ventilation [CPAP + PSV]). We, also, measured mean airway pressure (AWP), arterial blood gases, lactate and systolic arterial pressures (SAP). RESULTS: There was no change in SctO2 in IPPV and SIMV modes; the SctO2 measured during CPAP + PSV and after extubation increased significantly (60.5 ± 11, 61 ± 10, 65 ± 10, 66 ± 11 respectively) (P < 0.05). The differences in the SAP measured during IPPV and SIMV modes was insignificant; the SAP increased significantly during CPAP + PSV mode and after extubation compared with IPPV and SIMV (109 ± 11, 110 ± 12, 95 ± 17, 99 ± 13 mmHg, respectively) (P < 0.05). Mean AWP did not change during IPPV and SIMV modes, mean AWP decreased significantly during CPAP + PSV mode (14 ± 4, 14 ± 3, 10 ± 1 mmHg, respectively) (P < 0.01). CONCLUSIONS: The SctO2 was higher during CPAP + PSV ventilation and after extubation compared to IPPV and SIMV modes of ventilation. The mean AWP was lower during CPAP + PSV ventilation compared to IPPV and SIMV modes of ventilation.