Case Reports

This case report focuses on the anesthetic management of a patient with Myasthenia Gravis who underwent left-sided colectomy, due to the presence of a tumor on the left colic (splenic) flexure. Myasthenia gravis is a chronic autoimmune neuromuscular disease which is characterized by differ-ent degrees of weakness of skeletal muscles. The anesthetic management and treatment of every patient with myasthenia gravis should be performed carefully, due to the fact that many periopera-tive complications may occur. In our case anesthetic technique included the combination of general anesthesia, with the use of neuromuscular agent and thoracic epidural blockade with the use of a catheter, which permitted intermittent boluses doses and continuous infusion of local anesthetics and opioids. Neuromuscular blockade was reversed with the use of sugammadex. Patient’s periop-erative management was effective and uneventful.

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The deficiency of the natural heart pacemaker, the conduction disturbances and the appearance of arrhythmias are common complications after cardiac surgery. Placement of epicardiac electrodes (ventricular, atrial, or both) during cardiac surgery remains common practice, even though few patients will actually need some kind of temporary epicardiac pacing for various periods of time. Temporary epicardiac pacing may be ventricular, atrial or atrioventricular, depending on the specific features of each patient and it aims at preserving the cardiac rhythm, securing the desired heart rate and achieving an acceptable cardiac output. Temporary epicardiac pacing is not without danger, since, under specific circumstances, it may have a negative impact on the hemodynamics of the patient, to the point of circulatory collapse. It may also cause ventricular tachycardia (R on T phenomenon) and cardiac arrhythmias (if pacing is not synchronized to the heart’s natural pacemaker). Ventricular Pacing and Sensing (VVI) is accomplished by the placement of electrodes only on the ventricles, which a priori means a certain degree of hemodynamic compromise, due to the loss of atrial contribution in preserving cardiac output. In certain occasions, this impact may be even more significant. This case report concerns  a patient who underwent Coronary Artery Bypass Grafting (CABG) and after placement of the electrodes of temporary epicardiac ventricular pacing he presented significant decrease in systemic arterial pressure and the appearance of cannon A waves on central venous pressure (CVP) tracing every time the pacemaker was triggered. These phenomena, which receded after the disconnection of the pacemaker, consists a case of Pacemaker Syndrome.This problem was solved by adjusting the pacemaker’s frequency at a rate lower than that of the patient’s natural pacemaker.

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Noonan syndrome (NS) is an autosomal dominant disorder characterized by anatomic and pathophysiologic abnormalities.Anesthetic management in these cases has many challenges regarding airway management and cardiovascular stability.We present a case report of a 11-year-old male child who was scheduled for maxillofacial surgery under general anesthesia.

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We report a case of persistent bronchospasm after anesthesia induction. The case refers to an elective surgery of an ulcerous formation in the intergluteal cleft. Bronchospasm is not an unusual event in the immediate intubation period, especially in patients with respiratory disease, but in most cases resolves uneventfully. In this patient, despite thorough treatment in the operation room, ausculatory findings remained unchanged, with progressive worsening of arterial blood gases. After this event, the surgery was postponed and the patient was transferred to the ICU for further management. In this article we describe the steps that were taken in order to manage this adverse event and ensure patient’s safety and successful outcome.

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Evaluation of monitoring readings, taking into account each patient’s pathology as well as the impact of every medical intervention can guide us to make optimal clinical decisions in the periopeative setting. We present three cases in which clinical decisions concerning the management of acute perioperative pulmonary hypertension were based both on haemodynamic monitoring readings and on each patient’s specific pathology. First case: After anesthesia induction in a patient with severe aortic valve insufficiency, an increase in pulmonary artery pressure was recorded. Infusion of isoprenaline, which has a positive chronotropic effect, decreased diastolic time, diastolic blood flow into the left ventricle and also pulmonary artery pressure. Second case: A patient with severe aortic valve stenosis was found with increased pulmonary artery pressure. Intravenous administration of atenolol (1+1mg) reduced the heart rate and the pulmonary artery pressure. Third case: A 15 year old patient with aortic isthmus rupture underwent open surgical repair with graft interposition. After establishment of one lung ventilation and left thoracotomy, pulmonary artery pressure increased. Pulmonary hypertension was managed successfully by oxygen insufflation to the non-ventilated left lung. In our first patient, heart rate increase reduced diastolic time, which decreased the amount of retrograde blood flow into the left ventricle through the regurgitant aortic valve. In the second patient, the heart rate reduction decreased blood flow velocity through the stenotic aortic valve as well as the pressure gradient between left ventricular chamber and aorta. In both patients, enhanced left ventricular function resulted in a reduction in pulmonary artery pressure. Decrease of the alveolar partial pressure of oxygen (PAO2) is the most important parameter that stimulates hypoxic pulmonary vasoconstriction. Oxygen insufflation increased PAO2, resulting in a decrease in pulmonary artery pressure .Clinical decisions based on haemodynamic monitoring readings resulted in effective management of pulmonary hypertension and in a good patient outcome.

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Scoliosis is a musculoskeletal disorder, in which there is a sideways curvature of the spine. Surgical correction of scoliosis is a long-lasting high-risk procedure, which can lead to serious complications such as pulmonary embolism and substantial haemorrhage. In our case a 20 year-old male with idiopathic scoliosis curve of 82o underwent a reconstructive spinal surgery. Tranexamic acid (TXA) i.v infusionwas used intraoperatively to reduce the blood loss. The operation took 8h to complete and proceeded well without complications. Afterwards the patient was then transferred to ICU. The third postoperative day he was admitted back to the orthopedic ward. 7h after admission he presented clinical symptoms of pulmonary embolism (PE). The suspicion of a pulmonary embolism was confirmed by an emergency CT pulmonary angiogram. Consequently, the patient was again admitted to the ICU and was treated with LMWH in a therapeutic dose. Three days later he returned back to the orthopedic ward clinically stabilized and with normal ABGs. In this case report the cause and origin of pulmonary embolism was not clear. The patient was treated with chemical thromboprophylaxis (LMWH) from the first postoperative day and yet PE was not prevented.This event contradicts the supposed rarity of PE after correction of AIS surgery. It also results in a controversy over the efficacy of LMWH on reducing the incidence of VTE and over the safety and proper dosing of TXA.

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This case report describes the rare occurrence of tetraplegia, caused by conversion disorder, in a patient who received spinal anesthesia for arthroscopic surgery. A 35-year-old female with a history of migraine headaches received spinal anesthesia for arthroscopic left knee surgery. On sensory block examination, she was noted to have a T10 level of blockade. During surgery and45 min after performing spinal anesthesia, patient reported bilateral loss of both sensation and motor function of her upper limbs. Patient was hemodynamic stable with absence of respiratory depression or any alteration of consciousness level. Physical signs and symptoms did not correlate with any known anatomical or neurological patterns. MRI imaging revealed no abnormalities. Psychiatric consultation was performed wherein familial stressor circumstances were identified, leading to diagnosis of conversion disorder.

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Amiodarone-induced thyrotoxicosis is a rare but serious complication of amiodarone use, especially in patients with severe cardiac disease. We discuss the anaesthetic considerations and management of patients with severe cardiac disease who require lifesaving thyroidectomy. We present a patient who developed amiodarone-induced thyrotoxicosis, following administration of amiodarone and hepatotoxicity due to thiamazole. Patient’s life depended upon surgery as soon as possible. Total thyroidectomy was performed under general anaesthesia with precautions related to hyperthyroidism and cardiac stability. Complete cardiac rehabilitation was achieved two weeks after surgery. Total thyroidectomy is, in selected cases, the only treatment option and should not be delayed based on the hypothesis that pre-operative medical preparation will optimize the patient’s condition (endocrine and cardiac).

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Placenta previais anobstetriccomplication in which theplacentais inserted partially or wholly in the lower uterine segment. It is a leading cause ofantepartum haemorrhage. We report a case of 31-year-old woman presented in Obstetric and Gynecological clinic with signs and symptoms of Placenta previa. One day after admission, patient gave birth by caesarean section to a healthy baby. Yet, two hours later, the patient's condition was deteriorated due to postpartum hemorrhage (PPH). The diagnosis of Placenta previa was based on symptoms and sign as continuous bleeding ‘ex utero’, clots in vagina, uterine atony and distended bladder. Blood loss was approximately >1000 ml and was accompanied by clinically apparent shock. Using a conservative treatment such as the application of uterotonic drugs and uterine massage, we managed uterus to be saved.

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We report a rare case of a young woman with anti-N-Methyl-D-Aspartate receptor (NMDAR) encephalitis, who developed psychiatric symptoms, dyskinesias, hypoventilation, hypersalivation and seizures. Serial analysis of antibodies to NR1/NR2B heteromers of the NMDAR was positive on the patient's serum and cerebrospinal fluid (CSF). Removal of an ovarian teratoma after intravenous immunoglobulin and corticosteroid therapy resulted in a prompt neurological response.

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