Bronchial rupture following endobronchial blocker placement: a case report of a rare, unfortunate complication.

BACKGROUND: Lung separation may be achieved through the use of double lumen tubes or endobronchial blockers. The use of lung separation techniques carries the risk of airway injuries which range from minor complications like postoperative hoarseness and sore throat to rare and potentially devastating tracheobronchial mucosal injuries like bronchus perforation or rupture. With few case reports to date, bronchial rupture with the use of endobronchial blockers is indeed an overlooked complication. CASE PRESENTATION: A 78-year-old male patient with a left upper lobe lung adenocarcinoma underwent a left upper lobectomy with a Fuji Uniblocker® as the lung separation device. Despite an atraumatic insertion and endobronchial blocker balloon volume within manufacturer specifications, an intraoperative air leak developed, and the patient was found to have sustained a left mainstem bronchus rupture which was successfully repaired and the patient extubated uneventfully. Unfortunately, the patient passed on in-hospital from sepsis and other complications. CONCLUSION: Bronchial rupture is a serious complication of endobronchial blocker use that can carry significant morbidity, and due care should be exercised in its use and placement. Bronchoscopy should be used during insertion, and the volume and pressure of the balloon kept to the minimum required to prevent air leak. Bronchial injury should be considered as a differential in the presence of an unexplained air leak.

Cardiac sarcoma attached to pacemaker lead.

BACKGROUND AND AIM: Cardiac sarcoma is a rare condition and may mimic atrial myxoma. We present a case report of a man with a cardiac sarcoma. METHOD: Case report presentation. RESULTS: A 68-year-old man with a permanent pacemaker presented to us with a 4-month history of breathlessness. Echocardiography revealed a large right atrial mass adherent to the pacemaker lead and a provisional diagnosis of atrial myxoma was made based on echocardiographic appearance. A 60 x 30 x 30 mm irregular lobulated tumour was surgically resected from the right atrium. Upon histopathologic examination, the tumour was consistent with an undifferentiated pleomorphic sarcoma. CONCLUSION: Cardiac sarcomas have an extremely poor prognosis and more unfortunately this man developed a surgical site infection and died of acute mediastinitis. We discuss the presentation, imaging and current surgical approaches to cardiac sarcoma. Curative treatment is currently limited for this disease.

Ideal Sequence of Didactic Lectures and Simulation in Teaching Transesophageal Echocardiography Among Anesthesiologists.

OBJECTIVE: Performing a basic perioperative transesophageal echocardiography (TEE) requires 3-dimensional knowledge of cardiac anatomy, psychomotor skills, and image interpretation. Commonly, lectures followed by simulation sequence is used for teaching TEE. Differences may occur among learners when this sequencing of instructional components is altered. The authors investigated the ideal sequence of lectures and simulation in teaching basic perioperative TEE. DESIGN: Prospective randomized comparative study. SETTING: Simulation room in a large academy tertiary care center. PARTICIPANTS: Noncardiac anesthesiologists in Singapore with no prior knowledge of TEE. INTERVENTION: Comparison of acquisition and retention of knowledge and skills between the lecture followed by simulation group (LS) and the simulation followed by lecture (SL) group. MEASUREMENTS AND MAIN RESULTS: Knowledge was assessed using multiple-choice questions (MCQs) and skills using a skill test. The primary outcome measured was the MCQ scores (post-course and retest) and the skill test scores (post-course and retest). Of the 43 anesthesiologists who were recruited, 22 were randomized into the LS group and 21 to the SL group. All participants took pre-course and post-course MCQs and post-course skill tests. Post-tests were repeated 1 month after the course to assess retention. There was no significant difference in the post-course MCQ (85.87% v 81.82%) and skill test scores (85.78% v 81.55%) between the SL and LS groups, respectively. The SL group demonstrated significantly better retention of knowledge at 1 month (MCQ score 83.5% v 72.73%; p = 0.003) and skills (skill test score 85.32% v 1.90%; p = 0.016) than the other. CONCLUSION: This study showed that, for retention (at 1 month) of both knowledge and skills, it is preferable to teach practical skills followed by theoretical knowledge to anesthesiologists who are complete novices to TEE.

Echocardiography for Intraoperative Decision Making in Mitral Valve Surgery-A Pilot Simulation-Based Training Module.

Echocardiographic assessment of the repaired or replaced mitral valve intraoperatively involves making a high-impact joint decision with the surgeon, in a time-sensitive manner, in a dynamic clinical situation. These decisions have to take into account the degree of imperfection if any, the likelihood of obtaining a better result, the underlying condition of the patient, and the impact of a longer cardiopulmonary bypass period if the decision is made to reintervene. Traditional echocardiography teaching is limited in its ability to provide this training. The authors report the development and implementation of a training module simulating the dynamic clinical environment of a mitral valve surgery in progress and the critical echo-based intraoperative decision making involved in the assessment of the acceptability of the surgical result.