Evaluation of Palm Print Sign and Prayer Sign in Prediction of Difficult Laryngoscopy in Diabetic Patients.

Background: Laryngoscopy or endotracheal intubation in diabetic patients due to impaired mobility of the Atlanto-occipital joint owing to non-enzymatic glycosylation in connective tissue has always been a problem. A difficult laryngoscopy can disrupt the intubation process; therefore, it is valuable to predict difficult laryngoscopy using some anatomical criteria before general anesthesia. Objectives: The present study discussed the diagnostic value of two tests, palm print sign and prayer sign, in the prediction of laryngoscopy difficulty. Methods: Design: A diagnostic test and cross-sectional analytical design were used in this study. Setting: The study population included 200 patients with type 2 diabetes who were candidates for surgery under general anesthesia. Before surgery, the patients were examined regarding the airway status, Mallampati classification, head extension rate, thyromental distance, body mass index, upper lip biting test, and two palm print sign and prayer sign tests. All the diagnostic tests were compared to the Cormack test result for difficult airways regarding their sensitivity and specificity in difficult laryngoscopy. Results: The highest sensitivity was related to the Mallampati test, prayer sign test, and palm print sign test (100%). Furthermore, the mouth-opening test had the highest specificity (100%). The highest accuracy was reported for Mallampati, palm print sign, and prayer sign tests (> 86%). Conclusions: Among the tests studied to predict difficulty in laryngoscopy in diabetic patients, Mallampati and palm print sign tests have good sensitivity, specificity, and accuracy. Studies with a larger sample size are suggested to obtain more accurate results.

Evaluation of the effect of crocin on prevention of atrial fibrillation after coronary artery bypass grafting or heart valve replacement: A double-blind, randomized, placebo-controlled trial.

Objective: The aim of this study was to evaluate the effect of crocin on the prevention of atrial fibrillation after coronary artery bypass grafting (CABG) and heart valve replacement. Materials and Methods: 100 patients who were scheduled for CABG or heart valve replacement surgeries were randomly assigned into two groups of treatment and placebo. In the treatment group, patients received crocin tablets from three days prior to surgery and on the first three postoperative days (for a total of six days). During the first three days after surgery, postoperative atrial fibrillation (POAF) was assessed by electrocardiogram monitoring. Prooxidant-antioxidant balance (PAB) and c-reactive protein (CRP) levels were also assessed. Results: POAF developed in 7 patients in the treatment group versus 18 patients in the control (p=0.02). PAB levels were significantly lower in the crocin group (p<0.001), while differences in CRP levels were insignificant (p=0.39). Conclusion: It seems that prophylactic use of crocin is effective in reducing the incidence of POAF in patients undergoing heart surgeries.

Launching Awake Craniotomy Technique in a Resource-Limited Center: New Insights into the Patient Experience, Costs, and Long-Term Outcomes and a Narrative Review of the Literature.

BACKGROUND: Awake craniotomy (AC) with brain mapping is a standard surgical technique for the excision of lesions located in eloquent areas. We aimed to assess the clinical challenges, patient experience, costs, and long-term outcomes of AC in a resource-limited setting. METHODS: In this cross-sectional study, electronic documents of 12 patients who underwent AC with functional brain mapping were prospectively collected from August 2017 to October 2020. Patient characteristics, surgical specifications, hospitalization period, intraoperative and postoperative events, functional outcome, patients' satisfaction, costs, and survivals were collected and analyzed. RESULTS: Twelve patients with a median age of 42.5 (interquartile range, 13.5) were enrolled, of whom 8 were male (66.7%), and 9 (75%) were harboring grade 2 glioma. Of the patients, 8.34%, 33.34%, and 58.33% had partial, subtotal, and gross total excision of the tumors, respectively. The intraoperative seizure was the only complication and occurred in 2 cases (16.67%). At 1 year follow-up, none of the patients experienced any neurologic deficit. Eleven patients (91.6%) had a satisfactory opinion about reappearing in the AC. At 38 months follow-up, mortality was 8% for AC group and 25% among the historically matched controls who had surgery under general anesthesia (P = 0.27). Most costs belonged to the neurosurgery team (43%), and the overall expenses were reduced by 13% compared with a putatively well-equipped setting in our country. CONCLUSIONS: In carefully selected individuals, AC with brain mapping for excision of gliomas could be a safe, effective, and affordable strategy in a resource-limited setting and can be successfully performed with satisfactory outcomes.

Hypericum perforatum in the treatment of psychiatric and neurodegenerative disorders: Current evidence and potential mechanisms of action.

BACKGROUND: Psychiatric disorders are substantially associated with reduced quality of life and increased mortality. Depression and anxiety are two of the most common psychiatric disorders that often co-occur with each other as well as with other mental health conditions. Because of the limitations of currently available antidepressant therapies, there is a need for agents with improved efficacy and less adverse effects. Hypericum perforatum, widely known as St. John's wort, is a perennial herbaceous plant most well known for its antidepressant properties. METHODS: We reviewed the available in vitro, in vivo, and clinical evidence on the efficacy, safety, and mechanisms of action of St. John's wort and its active constituents in the treatment of psychiatric and neurodegenerative disorders. RESULTS: Several interesting data have been reported about the antidepressant properties of H. perforatum in clinical trials with different designs. In particular, a number of antidepressant-controlled trials demonstrated that H. perforatum and its active ingredients, hypericin and hyperforin, possess antidepressant properties similar to those of tricyclic antidepressants and selective serotonin reuptake inhibitors but with fewer and milder side effects. CONCLUSION: St. John's wort may exert potent antidepressant effects and represents an efficacious and safe treatment. However, the current clinical evidence regarding the efficacy of H. perforatum in other psychiatric and neurodegenerative disorders is not sufficient to draw a robust conclusion.

Effect of the Aortic Root Infusion of Sufentanil on Ischemia-Reperfusion Injury in Patients Undergoing Coronary Artery Bypass Grafting: A Randomized Clinical Trial.

Background: Ischemic postconditioning is a novel strategy for attaining cardioprotection. Remarkable evidence from various in vitro and in vivo animal and human studies have shown significant opioid-induced cardioprotection against myocardial ischemia/reperfusion (I/R) injury. The purpose of this study was to assess the cardioprotective effect of sufentanil against I/R injury after on-pump coronary artery bypass grafting (CABG). Methods: Between June 2016 and July 2017, 80 consecutive patients with triple-vessel disease undergoing on-pump CABG were enrolled in this prospective randomized study. The patients assigned to the sufentanil group received a single dose of sufentanil (0.2 µg/kg diluted with 50 cc of saline) 5 minutes before the removal of the aorta cross-clamp, with the sufentanil injected via a cardioplegia needle into the aortic root. In the control group, the same volume of normal saline was injected as a placebo. Cardiac enzymes, the inotrope score, and the outcome data were compared between the 2 groups. Results: The mean age of the patients was 60.48±7.50 years (range=41-69 y), and men comprised 65.0% of the study population. The levels of CK-MB and cardiac troponin I were significantly lower in the sufentanil group (P<0.001). The amount of inotrope use (P<0.001), the incidence of atrial fibrillation (P=0.014), electrical shock (P=0.007), and the mechanical ventilation time (P<0.001) decreased in the sufentanil group compared with the control group. However, the use of intra-aortic balloon pumps (P=0.247) and the ICU length of stay (P=0.867) were not significantly different between the 2 groups. Conclusion: The injection of a single dose of sufentanil into the aortic root prior to aorta cross-clamp removal diminished cardiac injury during on-pump CABG in our patients.

Effects of dexmedetomidine on heart arrhythmia prevention in off-pump coronary artery bypass surgery: A randomized clinical trial.

BACKGROUND: Arrhythmia occurring during and after surgery is one of the major complications in open-heart surgery. Dexmedetomidine is an intravenous alpha-2 agonist and very specific short-acting drug to protect the various organs against ischemic injuries and blood reflow. However, the effect of dexmedetomidine for preventing intraoperative heart arrhythmias has not been recognized. OBJECTIVE: This study aimed to determine the effect of dexmedetomidine on the incidence rate of heart arrhythmias and anesthetic required in off-pump coronary artery bypass surgery. METHODS: This randomized clinical trial was conducted on patients who were candidates for off-pump coronary artery bypass referring to Imam Reza Hospital of Mashhad, Iran, from July 2016 through January 2017. The patients were randomly assigned to two groups of intervention (infusion of 0.5 mcg/kg/h dexmedetomidine together with induction followed by infusion of 0.5 mcg/kg/h by the end of the surgery) or control (saline infusion). Mean arterial pressure (MAP) and heart rate (HR) were measured before induction, during surgery operation and ICU admission. Data were analyzed by SPSS version 18 using Chi Square and independent-samples t-test. RESULTS: A total of 76 patients with a mean age of 59.8 ± 8.2 years (in two groups of 38) were studied. The two groups had no statistically significant difference in terms of background variables. The MAP and HR values before induction, during surgery and ICU admission were significantly higher in the control group than in the intervention group (p=0.001). Out of the studied arrhythmias, the values of PAC (55.2% vs. 15.7%), PVC (81.5% vs. 21.0%), AF (26.3% vs. 7.8%), VTAC (21.0% vs. 2.6%) were significantly lower in dexmedetomidine group (p=0.001). CONCLUSION: It seems that dexmedetomidine administration during induction and surgery can cause significant reduction in most of the common arrhythmias in off-pump coronary bypass surgery. The use of dexmedetomidine maintains MAP and HR at significantly lower values, and changes compared to the control group as well as reduces the need for anesthetic compounds. TRIAL REGISTRATION: The present study has been registered at the Iranian Registry of Clinical Trials (www.IRCT.IR) with a code of IRCT2016072413159N9 before starting the study. FOUNDING: This study was fully sponsored by the Research Deputy at Mashhad University of Medical Sciences, Iran (grant number 941413).

Risk Factors and Outcome of Acute Kidney Injury after Congenital Heart Surgery: A Prospective Observational Study.

BACKGROUNDS AND AIMS: Acute kidney injury (AKI) is a frequent event after congenital heart surgery with increased mortality and morbidity. We investigated frequency, risk factors, and associated morbidity and mortality of AKI after pediatric cardiac surgery at a single institution. METHODS: Children undergoing congenital heart surgery from March 2013 to February 2016 were assessed for development of AKI based on modified pediatric Risk, Injury, Failure, Loss, and End-stage renal disease criteria. They were also investigated for predictive risk factors, associated mortality, and morbidity including duration of mechanical ventilation, Intensive Care Unit (ICU), and hospital length of stay. RESULTS: Five hundred and nineteen patients were recruited during the study period including 259 (49.9%) males and 260 (50.1%) females. AKI was seen in 150 (28.9%) patients including 101 (67.3%), 42 (28%), and 7 (4.7%) cases with risk, injury, and failure stages, respectively. Patients with AKI had longer ventilation time (P = 0.002), ICU (P = 0.05), and hospital (P = 0.56) stay. Mortality was seen in 31 (2.7%) and 44 (11.9%) patients with and without AKI, respectively (P = 0.01). After multivariable logistic regression, there was an association between AKI and preoperative abnormal levels of creatinine (adjusted odds ratio [aOR] = 0.47, 95% confidence interval [CI] 0.22-1.01; P = 0.05), presence of cyanotic heart disease (aOR = 1.97, 95% CI = 1.15-3.2; P = 0.01), duration of surgery (aOR = 1.05/10 min, 95% CI = 1.01-1.08; P = 0.007), and elevated lactate level (aOR = 1.14, 95% CI = 1.03-1.3; P = 0.01). CONCLUSION: The presence of cyanotic heart disease, duration of surgery, elevated postoperative lactate level, and likely preoperative creatinine level were independent risk factors for the development of AKI after congenital heart surgery.

Effect of Intravenous Acetaminophen (Paracetamol) on Hemodynamic Parameters Following Endotracheal Tube Intubation and Postoperative Pain in Caesarian Section Surgeries.

BACKGROUND: Use of analgesics, especially opioids, before delivery during cesarean section for preventing hemodynamic changes after endotracheal intubation and postoperative analgesia is limited due to their adverse effects on the neonate. OBJECTIVES: The aim of this study was to investigate the effect of intravenous acetaminophen (paracetamol) in blunting hemodynamic responses to endotracheal intubation and postoperative pain in parturient undergoing cesarean section by general anesthesia. PATIENTS AND METHODS: Eighty parturients undergoing cesarean section by general anesthesia were randomly divided to receive either 15 mg/kg intravenous paracetamol (n = 40) or normal saline (n = 40) fifteen minutes before endotracheal intubation. Mean arterial blood pressure (MAP) and pulse rates were compared at baseline and after intubation at one minute interval for five minutes between the two groups. The patients were also compared for postoperative pain intensity and analgesic requirement. RESULTS: Patients in the saline group experienced more pain in the recovery room (VAS 7.0 ± 1.24 vs. 6.15 ± 2.27; P value = 0.041) and required more fentanyl intraoperatively (150 µg vs. 87.7 ± 75; P value < 0.01) and meperidine postoperatively (12.88 ± 20.84 mg vs. 1.35 ± 5.73; P value = 0.002) than the paracetamol group. Mean arterial pressure (MAP) changes were similar after intubation in the both groups (P value = 0.71), however, pulse rates showed greater changes following intubation in the saline group (P value = 0.01). CONCLUSIONS: Intravenous acetaminophen administered before caesarean section reduced tachycardia after intubation, narcotic drugs administration during and after the operation and reduced pain in PACU.

Comparison of Intravenous Morphine with Sublingual Buprenorphine in Management of Postoperative Pain after Closed Reduction Orthopedic Surgery.

BACKGROUND: Postoperative pain is a common side effect following surgery that can significantly reduce surgical quality and patient's satisfaction. Treatment options are morphine and buprenorphine. We aimed to compare the efficacy of a single dose of intravenous morphine with sublingual buprenorphine in postoperative pain control following closed reduction surgery. METHODS: This triple blind clinical trial was conducted on 90 patients referred for closed reduction orthopedic surgery. They were older than 18 years and in classes I and II of the American Society of Anesthesiologists (ASA) with an operation time of 30-90 minutes. Patients were divided into two groups of buprenorphine (4.5µg/kg sublingually) and morphine (0.2mg/kg intravenously). Baseline characteristics, vital signs, pain score, level of sedation and pharmacological side effects were recorded in the recovery room (at 0 and 30 minutes), and in the ward (at 3, 6 and 12 hours). SPSS version 19 software was used for data analysis and the significance level was set at P<0.05. RESULTS: Ninety patients were studied, 60 males and 30 females with a mean age of 37.7±16.2 years. There was no significant difference between the two groups in terms of baseline characteristics. Pain score in the morphine group was significantly higher than the buprenorphine group with an average score of 2.5 (P<0.001). Postoperative mean heart rate in the buprenorphine group was four beats lower than the morphine group (P<0.001). Also, in the buprenorphine 48.6% and in the morphine group 86.7% of cases were conscious in recovery (P=0.001) with a higher rate of pruritus in the latter group (P=0.001). CONCLUSION: Sublingual buprenorphine administration before anesthesia induction in closed reduction surgery can lead to better postoperative pain control in comparison to intravenous morphine. Due to simple usage and longer postoperative sedation, sublingual buprenorphine is recommended as a suitable drug in closed reduction surgery.

Right Atrium Myxoma After Lung Adenocarcinoma.

INTRODUCTION: Heart secondary tumors are much more common than primary tumors. These two types of tumors differ not only by their source but also by their symptoms and location in heart chambers. CASE PRESENTATION: This report presents a 66-year-old heavy smoker female with a history of pulmonary lobectomy due to lung adenocarcinoma, hysterectomy due to myoma, and lumpectomy due to benign breast mass, who had symptoms of right heart failure for months. Physical examinations followed by imaging showed a mass in her right atrium, which was most likely, a myxoma. After a successful surgical excision, histopathological findings confirmed the diagnosis. More studies are needed to evaluate a possible combination between these soft tissue masses. CONCLUSIONS: A right atrium myxoma in a patient with a history of multiple soft tissue tumors has been limited to only a few cases. This may suggest a genomic affinity or similarity; if so, those with multiple different type soft tissue masses should be screened for a heart mass before the mass becomes complicated.

Evaluating the incidence of cognitive disorder following off-pump coronary artery bypasses surgery and its predisposing factors.

BACKGROUND: Cognitive disorder is a fluctuating cognitive destruction and a common problem for hospitalized patients, which leads to loss of consciousness. It is usually accompanied with increased mortality, prolonged hospital stay, and decreased rehabilitation. OBJECTIVES: The purpose of this study was to determine risk factors associated with cognitive disorder after open-heart surgery. PATIENTS AND METHODS: In total, 171 patients who had undergone off-pump open-heart surgery and lacked any history of psychiatric disorders were enrolled. Samples were selected according to a purposive sampling method. The Mini-Mental State Examination questionnaire was used for these patients to assess the incidence of cognitive disorder 24 hours after the operation in ICU and to compare creatinine level, ESR, extubation time and patients' age in the two groups, one with postoperative cognitive disorder and the other without it. Independent T-test was used to compare the two groups regarding any history of diseases such as diabetes, hypertension and hyperlipidemia, Chi square test was used. RESULTS: In total, 75% of patients had postoperative cognitive disorder. There was a significant association between the history of high blood pressure, C-reactive protein and preoperative creatinine levels in both cognitive disorder and control groups. CONCLUSIONS: Given the significant prevalence of postoperative cognitive disorder and significant associatio n between the history of high blood pressure, C-reactive protein and preoperative creatinine and cognitive disorder, detection of patient's clinical symptoms may improve diagnosis, treatment and prevention of this disorder.

Factors affecting on serum lactate after cardiac surgery.

BACKGROUND: The relation between elevated blood lactate level and mortality and morbidity rates after coronary bypass surgery is a proven subject. One of the factors that seems to affect directly the blood lactate level is the storage duration of packed red blood cells. OBJECTIVES: This study aimed to evaluate the effect of storage duration of transfused blood on serum lactate during cardiac surgery and up to 24 hours after that in the ICU. PATIENTS AND METHODS: In a cross-sectional study, 228 patients referred to three hospitals of Mashhad University of Medical Sciences for open cardiac surgery, was enrolled using systematic random sampling method. Immediately after accessing arterial line, the first sample of arterial blood gas (ABG) was obtained. For evaluation of lactate levels, the next samples were obtained at the end of surgery and after 24 hours of staying ICU. RESULTS: Among 5 factors which affected lactate level during surgery, diabetes and higher ejection fraction (EF) reduced changes of the lactate level. On the other hand, the number of infused blood units, duration of on-pump time, and the mean storage duration of blood units were associated with elevated serum lactate during surgery. A significant relationship was found between blood storage duration and serum lactate levels 24 hours after surgery. CONCLUSIONS: Comparing the serum lactate level before operation and 24 hours after the operation showed that the number of received blood units had a significant effect on serum lactate. We found no significant effect for blood storage duration; however, the number of given blood units was more significant.

Comparison of Effectiveness of Betamethasone gel Applied to the Tracheal Tube and IV Dexamethasone on Postoperative Sore Throat: A Randomized Controlled Trial.

INTRODUCTION: Postoperative sore throat is a common complaint in patients with endotracheal intubation and has potentially dangerous complications. This randomized controlled trial study investigated the incidence of postoperative sore throat after general anesthesia when betamethasone gel is applied to a tracheal tube compared with when IV dexamethasone is prescribed. MATERIALS AND METHODS: Two hundred and twenty five American Society of Anesthesiologist (ASA)-class I and II patients undergoing elective abdominal surgery with tracheal intubation were randomly divided into three groups: betamethasone gel, intravenous (IV) dexamethasone, and control groups. In the post-anesthesia care unit, a blinded anesthesiologist interviewed all patients regarding postoperative sore throat at 1,6, and 24 hours after surgery. RESULTS: The incidence of sore throat was significantly lower in the betamethasone gel group compared with the IV dexamethasone and control groups, 1, 6, and 24 hours after surgery. In the first day after surgery 10.7% of the betamethasone group had sore throat whereas 26.7% of the IV dexamethasone group and 30.7% of the control group had sore throat. Bucking before extubation was observed in 14(18.4%), 8(10.4%), and 9(12.2%) patients, in the IV dexamethasone, betamethasone gel, and control group, respectively. CONCLUSION: We concluded that wide spread application of betamethasone gel over tracheal tubes effectively mitigates postoperative sore throat, compared with IV dexamethasone application.

Comparing the effect of preoperative administration of methylprednisolone and its administration before and during surgery on the clinical outcome in pediatric open heart surgeries.

BACKGROUND: Cardiac surgery under Cardiopulmonary bypass causes a systemic inflammatory response with a multifactorial etiology including direct tissue damage, ischemia and stimulation of immune system induced by cardiopulmonary bypass. This study was designed due to the high prevalence and complications of this stimulated immune system in mortality, morbidity, length of ICU stay, and mechanical ventilation. OBJECTIVES: This study was aimed to compare preoperative and intraoperative methylprednisolone (MP) to intraoperative MP alone with respect to postbypass inflammation and clinical outcome. PATIENTS AND METHODS: Sixty pediatric patients (age < 5years) undergoing cardiopulmonary bypass surgery between September 2011-2012 at Imam Reza hospital-Mashhad were randomly assigned to receive preoperative and intraoperative MP (group 1: 30 mg/kg, 4 hours before bypass and in bypass prime, n = 30) or intraoperative MP only (group 2: 30 mg/kg, n = 30). Postoperative temperature (peak temperature and average temperature during the first 24 hours), amount of inotropic, duration of mechanical ventilation, ICU stay, WBC, BUN, creatinine, and CRP were recorded and compared in both groups. Data were analyzed with SPSS version 13 by T-test, Mann-Whitney test if necessary, and Chi-squared distribution. RESULTS: Patient characteristics including age, weight, gender, and duration of bypass were almost similar in both groups (P > 0.05). No significant difference in amount of inotropic medications used for hemodynamic supports, duration of mechanical ventilation, peak and average temperature and length of ICU stay was observed. Among the laboratory tests (WBC, BUN, creatinine, CRP) only WBC counts raised more in group 2 when compared to group 1(P < 0.05). CONCLUSIONS: There was no difference in clinical outcome after cardiac surgery when we administered an additional dose of methylprednisolone compared to a single dose of methylprednisolone.

Comparison between preoperative administration of methylprednisolone with its administration before and during congenital heart surgery on serum levels of IL-6 and IL-10.

BACKGROUND: Steroid administration during cardiopulmonary bypass is considered to improve cardiopulmonary function by modulating inflammations caused by bypass. OBJECTIVES: This study was performed to compare effectiveness of preoperative and intraoperative methylprednisolone (MP) to preoperative methylprednisolone alone in post bypass inflammatory (IL-6) and anti-inflammatory (IL-10) factors. PATIENTS AND METHODS: Fifty pediatric patients undergoing cardiopulmonary bypass surgery from August 2011 to 2012 in the cardiac surgery department of Imam Reza Hospital, the major center for CPB, in Mashhad, Iran were randomly assigned to receive preoperative and intraoperative MP (30 mg/kg, 4 hours before bypass and in bypass prime, number 25) or preoperative MP only (30 mg/kg, number 25). Before and after bypass, four and 24 hours after bypass, serum IL-6 and IL-10 were measured by ELISA. RESULTS: In both groups, no significant difference with variation of expression for IL-6 (inflammatory factor) and IL-10 (anti-inflammatory factor) in different times after bypass was observed. CONCLUSIONS: No significant difference in reducing post bypass inflammation between preoperative steroid treatment and combined preoperative and intraoperative steroid administration reported and they had the same effects.

Video-assisted thoracoscopic patent ductus arteriosus closure in 2,000 patients.

Video-assisted thoracoscopic surgery has proved to be a safe and effective method with low complication and high success rates. From 1997 to 2008, 2,000 consecutive patients with patent ductus arteriosus underwent closure of the ductus with 2 titanium clips via a video-assisted thoracoscopic technique. Complete closure was confirmed using our handmade intraesophageal stethoscope. The mean age was 5.2 years, and mean weight was 9.8 kg. One death was reported 1 month after surgery, due to sepsis during hospitalization for chylothorax treatment. The procedure was converted to an emergency thoracotomy in one case, due to ductal wall rupture. There were 4 late residual shunts treated via thoracotomy. We observed transient laryngeal nerve dysfunction in 14 patients. All patients were reassessed by postoperative echocardiography. The mean procedure (skin-to-skin) time was 10 ± 2 min, and hospitalization was 21 h. This study indicates that video-assisted thoracoscopic closure of patent ductus arteriosus is a safe, simple, and cost-effective method with low complication and high success rates. Furthermore, the cosmetic benefits make it appropriate as an out-patient procedure.

Inadvertent intrathecal injection of atracurium.

This report relates how tracurium was given by mistake, intrathecally, during spinal anesthesia, to a 38-year-old woman, who was a candidate for abdominal hysterectomy. When no analgesia was observed, the mistake in giving the injection was understood. She was evaluated postoperatively by train of four ratio, measuring her breathing rate, eye opening, and protruding of tongue at one, two, twenty-four, and forty-eight hours, and then at one and two weeks, with the final evaluation the following month. The patient had normal timings during the operation and postoperation periods, and no abnormal findings were observed through the first month. This finding was contrary to several studies, which described adverse reactions due to accidental intrathecal injection of neuromuscular blocking drugs.

A large saphenous vein graft aneurysm one year after coronary artery bypass graft surgery presenting as a left lung mass.

Aneurysm of a saphenous vein graft (SVG) is a rare but fatal complication of coronary artery bypass graft (CABG) surgery. The development of SVG aneurysms appears usually about 10-20 years after the operation at an estimated rate of <1%. A 68-year-old male was referred to the emergency department after frequent episodes of dyspnea, chest pain and hemoptysis. He previously had CABG surgery one year before. The physical examination was normal. Chest radiogram showed a left pulmonary midzone mass. CT-angiogram demonstrated a large aortic pseudoaneurysm (6.36 x 6.06 cm) in the middle part of the ascending aorta. After sternotomy, the ascending aorta above sinotubular junction near the origin of brachiocephalic artery was resected and replaced with a tube graft. The patient was transferred to ICU with stable hemodynamic status. SVG aneurysm should be considered while encountering mediastinal mass or undiagnosed cardiopulmonary symptoms in patients with a previous history of CABG because of its rarity and overlap of symptoms with other thoracic, pulmonary, and cardiac diseases. Surgery seems to be the treatment of choice to reduce the risk of rupture and embolism.