Co-axial Endotracheal Tube Technique for Achieving One Lung Ventilation in a Toddler With a Space Occupying Malignant Tumor of the Right Lung

Achieving one-lung ventilation in pediatrics is often challenging. In caring for these patients, the anesthesiologist must consider the child's age and size, underlying tracheobronchial anatomy, equipment availability, urgency of procedure, and as well as the experience level of the anesthesiologist. This report describes a "tube-inside-tube" technique that was adopted for providing one-lung ventilation in a toddler. The method described here involved railroading a smaller endotracheal tube over a flexible intubation video endoscope into the left mainstem bronchus coaxially through a larger endotracheal tube placed in the trachea. The technique achieved effective left-lung ventilation and isolation of the operative right lung during surgical resection of a malignant mesenchymal tumor. On completion of the procedure, double-lung ventilation could be established through the endotracheal tube in the trachea after the retraction of the video endobronchial tube.

Troubleshooting During Temporary Epicardial Lead Implantation in a Child with an Erosive Twiddler's Syndrome and Multiple Sternotomies: A case report

Temporary epicardial cardiac pacing in patients with bradyarrhythmias may be used as a bridge to implantation of a permanent pacemaker. The temporary epicardial lead placement may sometimes necessitate a sternotomy that may pose a challenge in patients who have had multiple earlier sternotomies. The difficulty in accessing the epicardium for urgent implantation of temporary epicardial pacing leads depends on the extent of adhesions in such patients. We report an 8-year-8-month-old girl with a pacemaker with an extruded pulse generator and difficult myocardial access due to 5 prior transsternal procedures. The child presented to a tertiary care hospital in Muscat, Oman, in 2021. A trouble-shooting technique was adopted to achieve temporary epicardial pacing to provide time for a course of antibiotic therapy administration. A permanent transvenous pulse generator system was implanted after 7 days of temporary pacing.

Surgical repair of interrupted right sided cervical aortic arch with hypoplasia of the descending thoracic aorta in a child with PHACE syndrome

Obstruction of a right cervical aortic arch in association with hypoplasia of the descending aorta is a rare congenital cardiac malformation. We report the case of a 6-month-old boy with PHACE (posterior fossa anomalies, hemangioma, arterial anomalies, cardiac anomalies, and eye anomalies) syndrome and interruption of a right sided cervical aortic arch. The descending thoracic aorta in the child had a long hypoplastic segment and the patient also had small ventricular septal defect and pulmonary valve stenosis. The surgical technique of reconstruction of the aortic arch and the descending thoracic aorta through a median sternotomy is described.

Aortic root abscess and anomalous aortic origin of right coronary artery in a 5-year-old child

BACKGROUND

Aortic root abscess is a rare complication of infective endocarditis in children.

CASE REPORT

A 5-year-old boy with infective endocarditis of aortic valve and an anterior aortic root abscess was found to have anomalous aortic origin of right coronary artery from the left coronary sinus on computed tomography scan with contrast.

RESULT

He was managed surgically by "patch and prosthesis" approach and required aortic root enlargement. Since anomalous aortic origin of right coronary artery is a relative contraindication for a Konno-Rastan aortic root enlargement, a Manouguian procedure was performed.

CONCLUSION

Anterior aortic root abscesses are rare, the co-existence of anomalous aortic origin of right coronary artery is rarer still and such cases requiring aortic root enlargement are possibly best served by a Manouguian procedure.

Large aortopulmonary collateral artery exclusively supplying the lower lobe of left lung in an infant with common arterial trunk with aortic dominance with confluent pulmonary arteries

INTRODUCTION

Common arterial trunk with aortic dominance has well-developed bilateral pulmonary arterial arborization without any essential major aortopulmonary collateral arteries (MAPCAs), whereas "solitary" arterial trunk is characterized by collateral arterial supply to all bronchopulmonary segments and absent pulmonary arteries.

CASE REPORT

We report a term female neonate with common arterial trunk with aortic dominance with confluent pulmonary arteries with a large MAPCA as the sole blood supply to the lower lobe of the left lung.

RESULTS

Initial diagnostic workup missed this MAPCA from the descending thoracic aorta. It was suspected during surgery due to massive left atrial return and confirmed by cardiac catheterization study in the early postoperative period and treated successfully by unifocalization.

DISCUSSION

A large essential MAPCA supplying an entire lobe in the common arterial trunk with aortic dominance has not been described. It can present as heart failure and inability to wean off the ventilator in the early postoperative period following intracardiac repair.

CONCLUSION

This is a case hitherto undescribed and possibly falling outside the well-entrenched classifications of the common arterial trunk and a large MAPCA could be an addition to the list of lesion modifiers. Our experience with this case underlines the importance of a thorough and open-minded approach to the initial imaging assessment of even well-described conditions.

Double outlet right atrium-A "bridge" across the bridging leaflets

INTRODUCTION

Mal-alignment between the inter-atrial septum (IAS) and the inter-ventricular septum (IVS) during cardiac embryogenesis results in abnormal atrioventricular (AV) connections ranging from doubleoulet left atrium (DOLA) to double outlet right atrium (DORA)1.

CASE REPORT

We report DORA resulting from partial override of the interatrial septum (IAS) across the cleft between the bridging leaflets of the left atrioventricular (AV) valve.

RESULTS

Successful surgical management with preservation of the orifice is described, leading to an unusual type of double orifice left AV valve.

DISCUSSION

The mal-alignment of the interatrial septum, resulting in it bridging the bridging leaflets, leads to an additional orifice between the RA and the LV and a unique form of right to left shunt. DORA can cause cyanosis depending on the size of the shunt and the compliance of the ventricles. Our patient was acyanotic, possibly due to the small size of the orifice and low LV compliance secondary to hypertrophy of the LV.

CONCLUSION

our case adds to the spectrum of atrial septal mal-alignment variant of DORA in the setting of AVSD without atrial and ventricular components, with RA to LV communication occurring via the smaller orifice of a left atrioventricular valve divided by the abnormal insertion of a partially overriding, mal-aligned atrial septum; a mechanism not described previously - the 'bridge' across the bridging leaflets!

Coarctation of the aorta, known yet can be missed

The clinical presentation of coarctation of aorta (CoA) is well known; however, it is the most common congenital heart disease in the newborn period to be missed, with significant mortality and morbidity associated with missing the diagnosis. We report a 20-day-old newborn boy who presented with congestive heart failure and weak femoral pulses. Chest X-ray (CXR) showed cardiomegaly and pulmonary edema and electrocardiography (ECG) showed extreme right axis deviation and absent left ventricular forces in the left precordial leads. Based on these, clinical suspicion of coarctation of aorta was made and confirmed by echocardiography. After initial stabilization with prostaglandin E2 infusion, child underwent urgent coarctation of aorta repair with uneventful post-operative course. High index of suspicion for coarctation of aorta in a newborn with such presentation is required and urgent referral to Pediatric Cardiology and cardiac surgery center is mandatory to reduce the morbidity and mortality associated with missing the diagnosis.

Novel anaesthetic approach for surgical access and haemodynamic management during off-pump coronary artery bypass through a left thoracotomy

For myocardial revascularization on a beating heart through a thoracotomy, a properly deployed endobronchial blocker (EBB) provides ideal conditions for surgical access. In addition, adequate volume replacement to achieve optimal cardiac performance is a primary goal of haemodynamic management in patients undergoing off-pump coronary artery bypass grafting. To achieve both these ends, this case report describes the combined use of a left-sided EBB along with a volumetric pulmonary artery catheter in a patient who underwent a successful off-pump coronary artery bypass surgery through an anterolateral thoracotomy.

Coronary artery grafting in infants

BACKGROUND

Coronary artery bypass grafting (CABG) with cardiac vale repair is an uncommon surgery in infants. CABG is technically demanding in infants due to the small size not only of the coronary arteries but also the potential graft arteries. The short and long-term outcome of surgery is not known and thus has largely been avoided.

RESULTS

We report the case histories of two infants in whom CABG was undertaken successfully as a life-saving measure. Case 1: This infant needed an arterial switch operation after which the right coronary artery (RCA) was stenosed resulting in low cardiac output. After the right internal mammary artery (RIMA) was used to anastamose the RCA, the hemodynamic status improved drastically. Case 2: This infant underwent surgical correction for Anomalous Left Coronary Artery from Pulmonary Artery (ALCAPA). Postoperatively, she was in low cardiac output. She was found to have an occluded left coronary artery and mitral regurgitation (MR). After she underwent left internal mammary artery (LIMA) to Left Anterior Descending (LAD) anastamosis and mitral valve repair, the clinical condition improved dramatically.

CONCLUSION

CABG is an uncommon operation in infants. This surgery is technically difficult. The long term results are not known and there are very few reports for the same. Though such an operation is best avoided, it can be used as a desperate life saving measure.

Arterial Switch Operation: Troponin T Does Not Predict Ventilation Requirements

The aim of this study was to assess whether postoperative cardiac troponin T levels could predict ventilation requirements in infants undergoing the arterial switch operation. Cardiac troponin T was measured 6 hours after aortic cross clamping and prior to tracheal extubation in 20 consecutive patients; 10 had simple and 10 had complex (with ventricular septal defect) transposition of the great arteries. The mean plasma troponin T level prior to extubation did not differ significantly in patients who were re-intubated and those who were successfully extubated. The initial cardiac troponin T levels in the complex defect group was significantly higher than in the simple transposition group. There was no correlation between initial cardiac troponin T levels and the duration of mechanical ventilation. There was no difference in mean duration of ventilation between the 2 groups. It was concluded that the postoperative cardiac troponin T level is not a predictor of successful extubation or prolonged artificial ventilation in this subset.

Selection of Monitoring Site and Outcome after Neonatal Coarctation Repair

To assess whether simultaneous invasive arterial pressure monitoring of right upper and lower limbs in neonatal aortic coarctation with or without arch hypoplasia has an impact on surgical decision-making and outcome, data of 140 newborns who underwent emergency surgical repair over 15 years were analyzed retrospectively. The 36 who had simultaneous right arm and lower limb arterial pressure monitored intraoperatively were assigned to group 1. The other 104 who had blood pressure monitored invasively at a single site (either upper or lower limb) were allocated to group 2. In group 1, a residual gradient across the repaired segment was detected intraoperatively in 13% of patients, and corrected at the same sitting. In group 2, 6% needed subsequent balloon angioplasty. In all babies with arch hypoplasia in group 1, the proximal aortic cross clamp was readjusted at least once to avoid compromise of carotid blood flow. Simultaneous right upper and lower limb invasive pressure monitoring has an impact on the overall outcome in these sick neonates.

Myocardial protection during neonatal cardiac surgery

Myocardial protection is of major concern in neonatal cardiac surgery where coronary ostial transfer is required as part of the surgical procedure. Retrograde coronary sinus perfusion (RCSP) of cold cardioplegic solution was evaluated in infants undergoing arterial switch operations. Hemodynamic measurements and postoperative cardiac troponin I (cTnI) levels were estimated in addition to transthoracic echocardiography to assess the extent of myocardial injury. The results were compared with a similar cohort of patients where ante grade selective coronary artery perfusion (ASCP) was used during coronary ostial transfer. Our experience suggests that RCSP is a useful option in this subset of patients.

First-trimester pregnancy loss and active Chlamydia trachomatis infection: correlation and ultrastructural evidence

The incidence of Chlamydia trachomatis (Ct) infection and the possible correlation between couples presenting with first-trimester spontaneous abortions and active Ct infection was assessed. Additionally, the ability of Ct to infect zona-free hamster oocytes was explored by incubating the oocytes with spermatozoa from infected patients. A total of 961 women and 750 men consulting our reproductive medicine centre were screened for Ct using direct immunofluorescence. The general incidence of Ct infection was 9.4% in females (90 of 961) and 13.9% in males (104 of 750). In women with spontaneous abortions the incidence of Ct was 21.0% (14 of 66) compared with 8.9% (23 of 59) for women without spontaneous abortions and term pregnancies (chi-square, P < 0.05). When both partners of the couples were considered (one or both partners infected), the incidence rose to 68.8% (22 of 32) (chi-square, P < 0.001). In vitro studies using electron microscopy demonstrated the presence of Ct on the surface of and inside the oocyte. These results indicate a correlation between an active Ct infection and spontaneous abortion. Electron microscopy studies suggested the possibility of direct oocyte infection by Ct. Two models are proposed for the pathogenesis of Ct-related early abortions: (i) direct zygote infection, and (ii) immune response to heat shock proteins expressed by the zygote and triggered by previous Ct infections.

[Exploratory analysis of risk factors of acute inner ear dysfunctions]

Aside from the clinical picture, the frequent occurrence of vascular risk factors favors a vascular pathogenesis of acute sensorineural hearing loss. However, the data on the association of vascular risk factors with sensorineural hearing loss are controversial. Achieving a sufficient number of patients and establishing a suitable control group is difficult. We analyzed the data of 393 patients suffering from acute sensorineural hearing loss. Risk factors, general, audiological, and laboratory parameters were investigated. Mean hearing loss and remission during 10 days of hospital treatment were calculated. The patient group was divided into patients with a certain risk factor and those without this risk factor, and mean remission and hearing loss were compared. Patients suffering from hyperlipidemia or hypotension had substantial and significantly higher mean hearing losses than patients not suffering from these diseases. Thrombosis, embolism, and hypertension were associated with a significantly worse remission of hearing loss. Repeated episodes of sensorineural hearing loss showed a significant worse remission, but less mean hearing loss before therapy. Smoking, diabetes mellitus, infections of the upper airways, and allergies had no influence on remission and mean hearing loss.

Serum S100beta release after coronary artery bypass grafting: roller versus centrifugal pump

BACKGROUND

Microemboli generated during cardiopulmonary bypass (CPB) are implicated in the cerebral injury seen after coronary artery bypass grafting. Centrifugal pumps generate fewer microemboli than roller pumps. Increased S100beta levels have been reported after coronary artery bypass grafting, with levels greater than 1 ng/mL resulting in poorer neuropsychologic outcome. This study investigated the potential neurologic benefits of centrifugal pumps, by using S100beta as a marker for cerebral injury.

METHODS

Thirty-two patients who had coronary artery bypass grafting were randomly assigned to two groups. Serial blood samples (preoperative, end of bypass, 30 minutes, and 2 and 24 hours after cardiopulmonary bypass) were taken and the serum analyzed for S100beta using a new immunoluminometric assay.

RESULTS

Both groups were matched for age, number of grafts, and cardiopulmonary bypass and cross-clamp times. Postoperative serum S100beta levels were significantly higher in both groups than preoperative levels. Peak S100beta levels did not correlate with cardiopulmonary bypass time; however, 24-hour S100beta levels correlated with intubation time r = 0.40, p = 0.04). Th ere was no significant difference in S100beta levels between the groups at any of the time points.

CONCLUSIONS

S100beta levels increased after coronary artery bypass grafting. Centrifugal pumps do not significantly decrease S100beta release. Persistently increased S100beta levels are associated with longer intubation times.

Drawing with the non-dominant hand: implications for the study of construction

BACKGROUND

Constructional impairment following left vs. right hemisphere damage has been extensively studied drawing tasks. A confounding factor in these studies is that right-handed patients with left hemisphere damage (LHD) are often forced by weakness to use their non-dominant (left) hand or hemiparetic dominant hand. Qualitative differences in the drawing characteristics of left and right hand drawings by normal subjects have not previously been characterized. The present study was undertaken to determine the qualitative differences between left and right hand drawings of normal subjects.

METHODS

Thirty right-handed, elderly subjects without a history of neurological disease were asked to draw, from memory, seven objects using the right and left hand. Half of the subjects were randomly assigned to draw with the left hand first, and half the right hand first. Right and left hand drawings were compared using a standardized scoring system utilized in several previous studies of drawing in focal and diffuse neurological disease. Each drawing was scored on eighteen criteria. Right and left hand drawing scores were then compared using the t-test for paired samples or the Wilcoxon matched-pairs test.

RESULTS

Drawings made using the left hand were found to be significantly simpler, more tremulous and of poorer overall quality than drawings made by the same subjects using the right hand.

CONCLUSIONS

The deficits found in left versus right hand drawings of normals are similar to those found in patients with LHD, suggesting that much of the drawing impairment seen following LDH is due to an elementary motor disturbance related to use of the non-dominant hand.

Development of an alcohol withdrawal clinical pathway: an interdisciplinary process

Studies show that as many as 40 percent of all patients in general hospitals are admitted because of complications related to alcoholism. However, the literature has little in specific clinical pathways, treatment protocols, or guidelines for the interdisciplinary care of these patients in the acute care setting. Furthermore, the little information that is published shows a lack of consistency in recommended treatment regimes. This article reviews a coordinated, interdisciplinary effort in developing and implementing a clinical pathway for alcohol withdrawal.

Integrating nursing education into a trauma outreach program

A level 1 trauma center is challenged to provide optimal trauma care to patients in the region it serves. One approach is to increase the knowledge and clinical skills of all trauma care providers, especially those who work outside urban areas. This article describes one trauma center's experience of integrating rural nursing education into an existing medical trauma outreach program. The educational strategies, example of course content, and organizational aspects of the program are described, along with marketing strategies used to promote the program.

New insights on the mode of action of intrauterine contraceptive devices in women

To gain a better understanding of the mechanism of action of intrauterine devices (IUDs), a search was made for ova in the genital tracts of 115 women using no contraception and of 56 women using IUDs, all of whom volunteered for study in conjunction with surgical sterilization. Ova were recovered from tubal flushings between 48 and 120 hours after the midcycle peak of luteinizing hormone in 39% of the IUD users compared with 56% of women in the control group (0.05 less than P less than 0.10). This suggests an action of the IUD before the ovum reaches the uterus. Eggs with a microscopic appearance consistent with fertilization were recovered from the fallopian tubes of half of the women using no contraception who had intercourse within the fertile period of the reproductive cycle and from whom ova were recovered. In contrast (P less than 0.01), no eggs with this appearance were recovered in IUD users who had intercourse within the fertile period. No ova were recovered from the body of the uterus of any of the IUD users. Fertilized ova are less likely to reach the uterine cavity containing an IUD. Thus, the principal mode of IUDs is by a method other than destruction of live embryos.

Treatment of leiomyomata uteri with D-Trp6-luteinizing hormone-releasing hormone

Suppression of the secretion of gonadal steroids by chronic administration of a superactive agonist of luteinizing hormone-releasing hormone (LH-RH) was used for treatment of leiomyomata uteri. Ten menstruating women, presenting with a total of 20 uterine leiomyomas, were treated for 3 months with daily subcutaneous injections of D-Trp6-LH-RH. Serum estradiol (E2) levels were suppressed rapidly in five patients and were decreased in other patients. At the end of therapy, leiomyomas regressed completely in three patients, while five patients showed a decrease of more than 40% in the volume of leiomyomas. The reduction in tumor size was correlated with the rapidity of the fall in serum E2 levels. In one patient, the leiomyomata increased in size during treatment, and one woman had a poor clinical response. The agonist was well tolerated and few side effects were observed. Therapy with LH-RH agonists offers an alternative in the management of some uterine leiomyomas.

Return of fertility in lactating and non-lactating women

The return of fertility post-partum and the incidence of pregnancy were studied in 74 mothers who chose not to breast-feed and who wanted another pregnancy promptly (Group I) and 143 mothers who practised exclusive lactation and decided not to use contraceptives (Group II). Women who breast-fed had much lower pregnancy rates than those who did not. During the first 6 months of the study, there were 53 (72%) pregnancies among the Group I women and no pregnancies among Group II mothers. Only sixteen (11%) women in Group II discontinued the study because of inadequate milk secretion. The low rate of pregnancy and the low rates of inadequate milk secretion in Group II appear related to the special efforts made to promote breast-feeding and give proper instruction to the mothers in this group. The successful lactation is attributed to a high suckling frequency, night feedings, ample mother and child skin-to-skin contact, avoidance of bottle feeding for as long as possible, and the clinical staff's regular emotional support and encouragement to the nursing mother.

Effects of hormonal and nonhormonal contraceptives on lactation and incidence of pregnancy

From June 1974 to June 1976, 665 women who had given birth to full-term infants and who were willing to nurse the infant were admitted to this study. At three to six weeks postpartum, subjects chose which of four study groups to join. One-hundred-forty-three mothers chose Group I, exclusive lactation with no contraception; 109 chose Group II, lactation and intrauterine contraception (IUD); 228 chose Group III, lactation and an intramuscular injection of 150 mg medroxyprogesterone acetate (Depo-Provera Sterile Aqueous Suspension, DMPA) given every three months; and 185 chose Group IV, lactation and one tablet of 0.6 mg Clogestone Acetate given daily. Mother and child were examined monthly until the child's spontaneous weaning, the mother's dropout, or the study's close in 1979. Mothers from Group I (exclusive lactation) were dropped from study when they requested and were prescribed a contraceptive. During the first six months of study, the percent of mothers who dropped out of Groups I, II, III, and IV for personal or medical reasons was 28.0, 16.5, 11.4, and 27.1, respectively. Pregnancies began to occur in the sixth month postpartum. Overall, pregnancies occurred in 6% of mothers in exclusive lactation, 3% of mothers protected by an IUD, and 8% of mothers protected by Clogestone. No pregnancies occurred in the 228 women receiving DMPA. Some mothers in the Clogestone or DMPA groups were still breast-feeding their children two or three times a day at the study's close, at which time the child was three or more years of age. No ill effects were observed in growth and development of these children during the study. The DMPA group had the most mothers who were breast-feeding for more than 20 months.

Hormonal and morphologic effects of bromocriptine on normal rat pituitary and GH3 tumor cells

Bromocriptine in concentrations up to 5 X 10(-4) mol/L was studied for any deleterious effects upon normal rat pituitary cells, as well as on the rat GH3 cell line. Normal rat pituitary glands were obtained by decapitation from 50-day-old female Wistar rats and dispersed with 0.25% trypsin. The cells (10(5) per plate) were then incubated in 60 by 15 mm plates (Falcon) that contained 3 ml of Dulbecco's modified Eagle's medium with 10% fetal calf serum. GH3 cells were plated in a similar fashion. Bromocriptine was added in concentrations of 5 X 10(-4) to 5 X 10(-9) mol/L, and aliquots of medium were obtained at 6, 24, and 48 hours for the determination of growth hormone and prolactin. Cell counts were performed at 24 and 48 hours. A significant reduction in concentrations of growth hormone and prolactin was observed with concentrations of bromocriptine of 5 X 10(-5) and 5 X 10(-4) mol/L at 24 and 48 hours (p less than 001). Although no significant changes in cell counts were observed in the normal rat pituitary cells, the GH3 cells showed complete disruption at 48 hours only in the plates that contained the highest concentrations of bromocriptine. Electron microscopy of normal rat cells and GH3 demonstrated selective cytotoxic effects only on the GH3 cells. In conclusion, bromocriptine has been demonstrated to have a direct effect on hormone release and on the morphologic characteristics of tumor cells but not normal pituitary cells.