Regional anesthesia in cardiac surgery: a friend or a foe?

Escalating costs and change in the profile of patients presenting for cardiac surgery requires modification of perioperative management strategies. Regional anesthesia has played an integral part of many fast-track anesthesia protocols across North America and Europe. This review suggests that for patients undergoing coronary artery bypass graft surgery, the risk-to-benefit ratio is in favor of epidural and spinal anesthesia, provided there are no specific contraindications and the guidelines for the use of regional techniques in cardiac surgery are followed. Patients managed with regional techniques seem to benefit from superior postoperative analgesia, shorter postoperative ventilation, reduced incidence of supraventricular arrhythmia, and lower rates of perioperative myocardial infarction. The results of this analysis suggest that for each episode of neurologic complication, 20 myocardial infarctions and 76 episodes of atrial fibrillation would be prevented, thus, we would consider the regional anesthesia and analgesia to be an effective strategy that improves perioperative morbidity. However, other treatment modalities such as the addition of calcium channel blockers, aspirin, and beating heart surgery, are also suggested to be beneficial in cardiac surgical patients and may impose less risk than the use of regional techniques. We believe that the results presented in this review are encouraging enough to permit continued investigation. A prospective, randomized, controlled multicenter trial needs to be adequately powered to answer important clinical questions and allow for a long-term follow-up.     

Inflammatory myofibroblastic tumor of the pancreas: a case report of 2 pediatric cases—steroids or surgery?

Inflammatory pseudotumors also termed inflammatory myofibroblastic tumors (IMTs) are rare, benign, solid lesions of unclear etiology more usually found in the lung and very rarely in the pancreas. We report 2 cases and outline our management for each. The first case was treated surgically, whereas the second was treated with high-dose steroids. This represents the first reported case whereby steroid treatment has been successful in pancreatic IMT.     

Massive hemorrhage in a patient with intestinal Behçet's disease: report of a case

Major gastrointestinal bleeding is a rare manifestation of intestinal Behçet's disease. We report herein the case of a 64-year-old man with intestinal Behçet's disease complicated by myelodysplastic syndrome who suffered massive hemorrhage. Colonoscopy demonstrated ulceration of the entire colon from the cecum to the rectum, characterized by punched-out ulcers. Angiography demonstrated apparent extravasation of contrast material in the terminal ileum, and embolization was not successful. Continued and massive bleeding necessitated surgical resection of the involved segment of ileum; however, massive bleeding recurred. Re-endoscopy showed oozing hemorrhage from the multiple colon ulcerations. Intra-arterial prednisolone injection therapy was given, following which the melena gradually subsided and completely stopped within a few days.     

Cataract surgery: regional anesthesia or monitored anesthesia care?]

BACKGROUND: Retrospective study in patients undergoing cataract surgery by facoemulsification in order to evaluate the incidence of regional peribulbar anaesthesia compared with MAC (Monitored Anesthesia Care). METHODS: Between January 1999 and December 2000, 1902 patients were studied. Peribulbar anaesthesia was performed by using a double or single inferior-lateral injection with a mixture of Lidocaine 2% and Bupivacaine 0.5% or, as a single agent, of Ropivacaine 0.75%. Jaluronydase 10 UI/ml was added to either agents. RESULTS: Only in 8% of patients intravenous drugs were added during surgery to correct bradycardia in 3%, hypertension 3% and for sedation in 2%. CONCLUSIONS: Regional anesthesia represents the most suitable anesthesia technique in patients undergoing cataract surgery by facoemulsification. Only in 8% of patients MAC was suitable, due to excessive anxiety or cardiovascular imbalance. Compared to other anesthesia techniques, regional anaesthesia is significantly safer. The utility of preoperative tests in reducing the morbidity associated with surgery, is also discussed.     

Delayed massive hemorrhage after pancreatic and biliary surgery: embolization or surgery?

OBJECTIVE: To analyze the management of delayed massive hemorrhage (DMH) after major pancreatic and biliary surgery. SUMMARY BACKGROUND DATA: Despite a decreased mortality rate for pancreatic and biliary surgery, DMH is still an important cause of postoperative mortality. The aim of the present study was to analyze the management of DMH after pancreatic and biliary surgery, and specifically to assess the role of embolization and surgical intervention. METHODS: The study group (SG) consisted of 1010 patients from 1994 to 2002 who underwent pancreatic or biliary surgery (cholecystectomy excluded). Patients from a previous study (1983-1993, n = 686) were used as a historical control group (HCG). RESULTS: The incidence of DMH (SG 2.3% vs. HCG 3.2%) declined somewhat but did not differ significantly between both periods. The number of patients with a septic complication (SG 74% vs. HCG 50%) and a sentinel bleed (SG 78% vs. HCG 100%) before the onset of DMH did not differ significantly. Embolization (SG 2 of 2 patients vs. HCG 0 of 2 patients) was not used frequently. Successful outcome after surgical intervention (SG 14 of 16 patients vs. HCG 8 of 14 patients) and the surgical procedures performed to obtain hemostasis were comparable and overall mortality (SG 22% vs. HCG 29%) was comparable. CONCLUSIONS: The incidence of DMH declined somewhat from 3.2% to 2.3% over the past years. Most patients present with septic complications and a sentinel bleed before onset of DMH. Despite general acceptance of embolization in our unit, it was used infrequently in patients with DMH. Aggressive surgical intervention was the treatment of choice in patients with DMH after pancreatic or biliary surgery.     

Extensive gluteal hematoma following InterStim® implant: a case report

Major bleeding complications following sacral nerve stimulation (SNS, InterStim®) are exceptionally rare and have not been reported in the literature. We report a case of extensive gluteal hematoma following SNS procedure in a woman with a known history of thrombophilia.     

Idiopathic asymptomatic main pulmonary artery aneurysm: surgery or conservative management? A case report

Idiopathic main pulmonary artery aneurysm is a very rare entity and there are no clear guidelines for optimal treatment. Operative treatment is recommended for patients with a risk of rupture, which is not well defined. We present an unusual case of a 53-year-old woman with an idiopathic main pulmonary artery aneurysm. Our case is asymptomatic, without a causative cardiac lesion and/or pulmonary hypertension; therefore, we did not operate on our patient and she was stable at 22-month follow-up.     

A case report of anesthesia for a child with Hajdu–Cheney syndrome

Hajdu–Cheney syndrome is an extremely rare disorder characterized by progressive skeletal acro-osteolysis, which results in extremity fractures and scoliosis often requiring surgical treatment from childhood. A unique facial structure and deformity of the cervical spine is associated with a difficult airway. We report here a 10-year-old girl with Hajdu–Cheney syndrome who developed progressive basilar impression and medullary compression for which foramen magnum decompression was performed. After slow induction of anesthesia, we were able to perform fiberoptic orotracheal intubation via a VBM bronchoscope airway. This case report contributes to the accumulation of knowledge about anesthesia for this rare syndrome.     

Swan-Ganz entrapment during cardiac surgery – a case report

Inability to withdraw a Swan-Ganz catheter as a result of its intracardiac entrapment is a rare but serious complication. In a normal intracardiac course, the catheter tends to rest against the antero-lateral wall of the right atrium where the catheter may be caught by the suture during cannulation for Cardiopulmonary Bypass (CPB). Entrapment of a Swan-Ganz catheter by the left atriotomy suture is described in this case report.     

Rostral basilar artery syndrome following transsphenoidal surgery—a report of four cases

Vascular complications can arise from transsphenoidal surgery (TSS) and have a high incidence of mortality and serious morbidity. Though haemorrhage from the injury to internal carotid is well know, ischaemic complication after TSS is rare. We report a series of four patients who remained unconscious after TSS, and on postoperative imaging infarcts were seen distributed in the rostral basilar artery. The possible mechanism of this complication is described.     

Unusual case of abdominal pain following liver transplant: causality or casualty?

This is an unusual case of chronic abdominal pain following two liver transplants with at least three potential causes: traumatic neuroma, intussusception of the small bowel of the Roux loop and biliary cast. Surgical removal of the latter two factors led to resolution of the pain. The management of the clinical case is discussed.     

Biliary atresia splenic malformation syndrome--is it a result of embryonically midline rotational defects? A case report

The authors present a case of biliary atresia splenic malformation (BASM) syndrome in a 34-week gestational age boy who died shortly after birth. Autopsy results showed polysplenia, short pancreas, extrahepatic biliary atresia, heterotaxy of liver, tracheoesophageal and duodenal atresia, right lung hypoplasia, cardiac defects with tetralogy of Fallot, axial skeletal defects, and minor genitourinary disorders. Additional histopathologic findings were congenital hepatic fibrosis and bronchopulmonary dysplasia. The authors consider that the abnormalities of this case are possibly a unique combination. Midline defects, which are the most notable features of the presented case, may be closely related to pathogenesis of BASM syndrome.     

Day surgery: a problem of economics or financial management?

Day surgery is often cited as a means of reducing expenditure on health care or increasing surgical activity within a given budget, whilst at the same time maintaining or improving the quality of care offered to patients. The aims of this paper are to explore the validity of this claim and to look at the issues involved in putting it into practice. The main conclusions are that day surgery is much better value for money than inpatient surgery, but there is no guarantee that savings will be made in every case. The main problem is one of sound financial management of change rather than economics. It is necessary to: (i) agree clear targets with surgeons and monitor them; (ii) ensure that the potential for day surgery is being maximized by monitoring the characteristics of patients having inpatient surgical procedures which are suitable for day surgery; and (iii) give surgeons greater control over their own budgets so that they can see the benefits of improved efficiency.     

Does pancuronium or cisatracurium delay the rate of arousal following remifentanil-based anesthesia?

STUDY OBJECTIVE: The present report investigates the rate of arousal following remifentanil-based anesthesia associated with the coadministration of pancuronium, which inhibits butyrylcholinesterase, or cisatracurium, which is partially metabolized by nonspecific esterases, versus vecuronium that is eliminated independently of ester hydrolysis. DESIGN, SETTING AND PATIENTS: Sixty patients, ASA I-II, scheduled for elective abdominal surgeries were enrolled in a double-blinded prospective study. In fact, patients were equally divided into three Groups with each Group receiving remifentanil and either one of the following three muscle relaxants: pancuronium, vecuronium or cisatracurium. MEASUREMENTS: The rate of arousal following discontinuation of anesthesia was assessed by Modified Aldrete Score. Time to eye opening on verbal command, tracheal extubation, Modified Aldrete Score >9, and time to discharge from the recovery room were recorded. MAIN RESULTS: Time to eye opening on verbal command, tracheal extubation, Modified Aldrete Score >9, and time to discharge from the recovery room were not significantly different between the three groups. CONCLUSION: The results suggest that recovery following remifentanil-based anesthesia is not delayed by the coadministration of pancuronium, cisatracurium versus vecuronium; and by the use of neostigmine for reversal of neuromuscular blockade.