Anaesthetic management of extra-pleural pneumonectomy and hyperthermic intrathoracic chemotherapy procedure.

Malignant pleural mesothelioma is a rare tumour with survival of 9-17 months after diagnosis. Radical surgical resection by extra-pleural pneumonectomy combined with hyperthermic intrathoracic chemotherapy has shown to improve patient survival and better microscopic tumour control. Anaesthetic management of this procedure is challenging due to the complex pathophysiological changes associated with prolonged duration of surgery, one- lung ventilation, haemodynamic instability due to major blood loss, temperature variations including heat loss during pneumonectomy and rapid rise in temperature during hyperthermic chemotherapy, cardiac arrhythmias due to exposure to heated chemotherapeutics, cisplatin toxicity and acid-base changes. Intra-operative management involves protective ventilation, regulation of temperature and haemodynamics along with prevention of complications associated with 'heated chemotherapeutics'. Thorough pre-operative assessment and preparation, advanced intra-operative monitoring with prompt corrective interventions, will help in improved patient outcome in the immediate post-operative period. We present one such case done for the 1(st) time in India.

Implications of ICU stay after brain death: the Saudi experience.

OBJECTIVE: The interval from brain death (BD) to organ harvesting is critical to the success of transplantation. We evaluated the time from BD onset to harvesting and analyzed sources of delay. MATERIALS AND METHODS: This retrospective study was conducted from January 1999 to December 2003. Time intervals analyzed to determine the causes of delay were: time of admission to the intensive care unit (ICU), to the report to the Saudi Center for Organ Transplantation (SCOT), to the documentation of BD, to organ retrieval and/or cardiocirculatory cessation without organ retrieval. RESULTS: During the 5-year analysis, 1834 people were reported to the SCOT. Of those, more than 1511 (80%) were reported during their first week of treatment in the ICU, and BD was documented in 1099 (59.9%). The mean interval from ICU admission to organ retrieval or cardiac arrest was 10.3 days and that from admission to the report to the SCOT was 5.6 days. In the consensual group, the mean interval from the documentation of BD until harvesting was 2 days, and that from documentation until cardiocirculatory cessation without organ retrieval in the nonconsensual group was 5 days. All subjects demonstrated a significant decrease in systolic blood pressure and a significant increase in plasma sodium and serum creatinine levels. The body temperature, serum plasma levels of sodium, and kidney function (measured by the serum creatinine level) of potential donors were compared, and patients with hypothermia, hypernatremia, or renal failure had a shorter stay in the ICU. CONCLUSIONS: Fewer than 30% of the patients could be maintained on mechanical support for more than 1 week after the declaration BD. It is crucial that we increase hospital-staff awareness about the importance of organ donation and transplantation, improve the identification of BD candidates, and enable the early reporting and documentation of BD.