Anesthetic management of robot-assisted thoracoscopic thymectomy.

Myasthenia gravis (MG) is a rare disorder involving neuromuscular junction. In conjunction with medical therapy, thymectomy is a known modality of treatment of MG and has shown to increase the probability of remission and overall symptomatic improvement. For minimally invasive thymectomy, video-.assisted thoracoscopic surgery has been the preferred surgical approach till recently. The robotic surgical procedure must necessarily bring new challenges to the anesthesiologists to effectively meet the specific requirements of the technique. At present, there is a paucity of literature regarding the anesthetic concerns of robotic assisted thymectomy, patient in question specifically posed a challenge since different maneuvers and techniques had to be tried to obtain optimum surgical conditions with stable ventilatory and hemodynamic parameters. Concerns of patient positioning and hemodynamic monitoring have also been discussed.

Successful double lumen tube insertion in a patient with unanticipated laryngeal and tracheal web.

A 45-year-old female patient admitted for surgical management of carcinoma esophagus, presented with difficulty in insertion of left-sided 37 F and 35 F double lumen tube (Mallinckrodt® Broncho-Cath). Fiberoptic bronchoscopy revealed a subglottic web in the larynx just below the vocal cords and a tracheal web just above the carina. Differential lung ventilation could be achieved with a 35 F internal diameter double lumen tube (Portex® Blueline® Endobronchial tube).

Myocardial protection with isoflurane during off-pump coronary artery bypass grafting: a randomized trial.

OBJECTIVES: To analyze the hemodynamic effects and myocardial injury using troponin-T and creatine phosphokinase (CPK-MB) with isoflurane and compare it with a control group in patients undergoing off-pump coronary artery bypass (OPCAB) surgery. DESIGN: This prospective, randomized study was performed in patients scheduled for elective OPCAB surgery during February 2007 to February 2009. SETTING: Tertiary care, university teaching hospital. PARTICIPANTS: Forty-five patients undergoing elective OPCAB surgery. INTERVENTIONS: Patients were randomly allotted to receive either isoflurane (inspired concentration between 1.0% and 2.5%) or propofol (1.5 to 3.5 mg/kg/h) during OPCAB surgery. The concentration of these agents was titrated such that the BIS value was maintained between 50 and 60. MEASUREMENTS AND MAIN RESULTS: The hemodynamic data were measured and recorded after induction of anesthesia (baseline), during the distal anastomosis of each coronary artery, and 5 and 30 minutes after giving protamine. In addition, blood samples for troponin-T and CPK-MB were obtained after induction (baseline), after 6 hours and 24 hours postoperatively. The cardiac index was significantly higher in the isoflurane group at all stages, except during distal anastomosis of the diagonal branch of the left anterior descending artery (p < 0.05). There was a significant increase in troponin-T levels at 6 and 24 hours after surgery in the propofol group (from 0.037 ± 0.013 ng/mL to 0.098 ± 0.045 ng/mL and 0.081 ± 0.025 ng/mL, respectively, p < 0.05). Significant increases in the troponin-T levels were observed at 6 hours (from 0.033 ± 0.011 ng/mL to 0.052 ± 0.025 ng/mL, (p < 0.05) in the isoflurane group, and the levels in the propofol group were significantly higher than the isoflurane group at 6 and 24 hours after surgery (p < 0.05). The CPK-MB levels increased in both groups, but were not statistically different. CONCLUSIONS: Isoflurane provides protection against myocardial damage in a clinically used dosage as documented by lower levels of troponin-T in patients undergoing OPCAB surgery.

Anesthetic management of patient with myasthenia gravis and uncontrolled hyperthyroidism for thymectomy.

The relationship between myasthenia gravis (MG) and other autoimmune disorders like hyperthyroidism is well known. It may manifest earlier, concurrently or after the appearance of MG. The effect of treatment of hyperthyroidism on the control of MG is variable. There may be resolution or conversely, deterioration of the symptoms also. We present a patient who was diagnosed to be hyperthyroid two and half years before the appearance of myasthenic symptoms. Pharmacotherapy for three months neither improved the myasthenic symptoms nor the thyroid function tests. Thymectomy resulted in control of MG as well as hyperthyroidism. In conclusion, effective control of hyperthyroidism in the presence of MG may be difficult. The authors opine that careful peri-operative management of thymectomy is possible in a hyperthyroid state.

Left atrial thrombus formation immediately after mitral valve replacement: a case report.

Mechanical dysfunction from valve thrombosis is a dreaded complication of valve replacement surgery, usually presenting months to years after the procedure. Here we report acute deterioration of prosthetic valve function due to intraoperative obstruction by a thrombus.

Microorganisms present in discharging otitis media in a group of patients in Kathmandu.

Discharge from the ear is one of the commonest symptoms of infections of the ear. To study the major strains of bacteria encountered in ear discharges, this study was conducted from July 1999, to June 2001 in the microbiology laboratory of Om Hospital. A total of 115 patients, of 6-35 years of age clinically diagnosed as discharging otitis media were studied. In 60.9% single organism and in 26.08% two organisms were isolated. Results revealed that, Staphylococcus aureus (34.3%), Klebsiella pneumoniae (24.3%), Pseudomons aeruginosa (22.8%), Enterobacter sps (7.1%), Esch coli (4.3%), Citrobacter sps (1.4%), Proteus sps (1.4%), Acinetobacter sps (1.4%) and Pneumococci (1.4%) were the common organisms in the discharge. Candida albicans (2.8%) was the pathogen in two cases. In 27.8% of cases the causative agent was not demonstrated. About sixty percent (65.9%), 64.8% and 56.0% of the isolates were sensitive to amikacin, ciprofloxacin and gentamycin respectively.