Administration of Protamine Through Radial Arterial Access: A Prospective Observational Study.

Protamine is mainly used to reverse the anticoagulant effect of heparin after cardiopulmonary bypass (CPB). Unfortunately, it is associated with adverse clinical reactions ranging from minor cardiopulmonary instability to fatal cardiovascular collapse. In the present prospective observational study, effects of protamine administration through peripheral intra-arterial route, i.e., radial artery, were investigated.

Congenital giant right coronary artery.

Giant coronary artery aneurysms are exceptionally uncommon with an incidence of 0.02%. The natural history and prognosis of giant coronary artery aneurysm are still not well known.

An intriguing case of post-operative respiratory failure from an occult diaphragmatic hernia- be aware of the masquerader.

Though respiratory complications after cardiac surgery for congenital heart disease are common, and malformations of the diaphragm can be expected in these patients, the presence of an occult diaphragmatic defect unrecognisible preoperatively and complicating the post operative course is very rare and need a high index of suspicion for diagnosis in the setting of post operative respiratory failure. We present here a case of post operative respiratory failure from a delayed presenting diaphragmatic hernia in a 2-month-old boy who underwent corrective surgery for Taussig bing anomaly and hypoplastic aortic arch. Surgical repair of the diaphragmatic defect and reduction of the bowel loops to the abdomen resulted in rapid weaning from ventilation and recovery with subsequent discharge from hospital.

Unusual left ventricle to left atrial fistula.

Left ventricular to left atrial fi stula is a very uncommon finding. Most of the cases are secondary to surgical procedures or paravalvular infectious process. The present case depicted an unusual regurgitation (apart from transmitral MR) through LV-LA fistula causing deterioration of the patient's symptoms.

Sudden, new-onset aortic regurgitation during off pump coronary bypass surgery.

During off pump coronary artery bypass grafting surgery, it is common to observe mitral or tricuspid regurgitation due to heart displacement. But it's very unusual to notice new onset aortic regurgitation in OPCABG.

Perioperative implications of Coronary-cameral fistula.

Coronary-cameral fistulas (CCFs) are mostly congenital in origin and rarely acquired. Clinical symptoms are decided by the hemodynamic significance of the coronary fistula. Even in asymptomatic patients, it is essential to know about coronary CCF particularly if the patient is to undergo cardiac surgery with cardioplegic cardiac arrest. Incidental finding of coronary CCF should never be ignored. Intraoperative myocardial protection and methods used are significantly influenced by such fistula.

Ipsilateral foot drop after aortobifemoral bypass.

Peripheral nerves can be injured by a direct result of the anesthetic technique of regional anesthesia or it can be contributed/compounded by poor perioperative positioning and padding, tourniquets, and the nature of surgery and diseases affecting the microvasculature of nerves. We present a case of perioperative peripheral nerve injuries which could not be explained by anesthesia technique nor surgery per se.

Perioperative management in a patient with panhypopituitarism - evidence based approach: a case report.

BACKGROUND: Hypopituitarism is characterized by partial or complete deficiency of vital endocrinological hormones such as steroid and thyroid hormones. Generally, normal individual can exhibit 2- to 10-folds rise in serum cortisol levels during stressful period. But patients with panhypopituitarism are more prone to develop metabolic and haemodynamic instability particularly during stressful perioperative period. This can potentially increase significant morbidity and mortality. CASE SUMMARY: A 62-year-old female patient presented with breathlessness on exertion. Her coronary angiography revealed critical triple vessel coronary artery disease, and she was scheduled for coronary artery bypass grafting surgery. She had been diagnosed with Sheehan's syndrome (postpartum hypopituitarism) since 20 years. She was taking steroid and thyroxine regularly. After uneventful off-pump coronary artery bypass grafting surgery, patient had severe haemodynamic compromise with Addisonian crisis in the post-operative phase. Left ventricular dysfunction was refractory to maximal inotropic therapy. Addisonian crisis was treated with higher 'Stress doses' of intravenous hydrocortisone and routine oral thyroxin. DISCUSSION: Acute Addisonian crisis after stressful surgery is a life-threatening complication. Evidence-based approach plays an important role in appropriate biochemical assessments and specific therapeutic decisions regarding hormonal over-replacement or under-replacement in the perioperative period.

Sudden appearance of new clot.

A patient having mitral stenosis with chronic atrial fibrillation, large left atrium, and spontaneous echo contrast is expected to have clot in LA or LAA. TEE is more sensitive to detect thrombus in LA and LAA than transthoracic echocardiography. However, false-negative results can still occur due to multilobed LAA, and a thrombus can be potentially missed.

Massive subcutaneous emphysema after off-pump coronary bypass surgery.

Subcutaneous emphysema is a condition when air gets accumulated into the tissues under the skin and in the soft tissues of the chest wall or neck but can also spread to other parts of the body. It generally causes minimal symptoms and nonlethal; sometimes, it may be severe and life-threatening if deeper tissues of the thoracic outlet and chest are involved. It is essential to know the mechanisms of subcutaneous emphysema after cardiac surgery.

Guillain-Barré syndrome after cardiac surgery: diagnostic dilemma.

Guillain-Barré Syndrome after cardiac surgery is very uncommon. Mechanism remains elusive although immunological reaction post surgery has been postulated. This disease can potentially increase the morbidity of the postoperative patients and generally cannot be explained by the cardiac disease or interventions. It is very much essential to diagnose the condition as appropriate management can substantially and profoundly change the course of treatment.

Aortic regurgitation after chemoport catheter insertion: Diagnostic dilemma.

Catheter insertion in central vein can potentially cause accidental arterial injury. However it is very unusual to see such catheter in aorta causing aortic regurgitation. Pressure monitoring and Ultrasound guidance can reliably prevent accidental arterial puncture.

A curious case of raised gradient across mitral bioprosthetic valve.

High Doppler valve gradient is generally suggestive of valve thrombosis. However, it should be corroborated with the finding of restricted leaflet movement to confirm the diagnosis. In the present case, abnormally high gradient was not associated with limited leaflet movements or any valve thrombus.

Superior vena cava clamping during thoracic surgery: Implications for the anesthesiologist.

Resection and reconstruction of the SVC is a challenging Intraoperative situation owing to the potential complications after clamping a patent vessel. Hemodynamic imbalance and neurological effects of SVC clamping can be life threatening. These complications can be prevented by careful intraoperative monitoring and management. Anaesthesiologist must be aware of different options to manage such challenging situations.