Whole lung lavage of nine children with pulmonary alveolar proteinosis: experience in a tertiary lung center

Pulmonary alveolar proteinosis [PAP] is a rare disease in children, characterized by intra-alveolar accumulation of large amounts of surfactant proteins, which severely reduce gas exchange. Whole lung lavage [WLL] is the preferred technique for the treatment of severe PAP. This report presents nine pediatric cases with advanced PAP who underwent WLL under general anesthesia during a 9 year period. One patient was treated with multiple unilateral WLL without employing cardiopulmonary bypass [CPB] and eight cases were treated by simultaneous lavage of both lungs using partial CPB. Our experience suggested that partial CPB was useful to support oxygenation during WLL in small children with severe PAP in whom lung separation and selective lavaging of each lung were impracticable

Acute respiratory failure as a rare complication of celiac plexus block in a patient with adenocarcinoma of the Ampulla of Vater

Celiac and splanchnic plexus blocks are considered as terminal approaches for pain control in end stage pancreatic cancer. It may be done temporarily [using local anesthetics] or as a permanent act [using alcohol and/or phenol]. Like every other interventional procedure, celiac plexus block has its own potential complications and hazards among them pneumothorax and ARDS are very rare. In this case report we present an end stage patient with adenocarcinoma of ampulla of Vater with involvement of both abdomen and thorax who presented with severe intractable abdominal pain. Bilateral celiac plexus block in this patient resulted in left side pneumothorax and subsequent development of ARDS. We discuss the rare complications of celiac plexus block as well

efficacy of a single dose of pethidine, fentanyl and morphine in treating postanesthesia shivering

Postanesthesia shivering is an undesirable event that may induce a variety of adverse consequences including patient discomfort, increased oxygen consumption and wound pain. Thus, its pharmacological treatment should be regarded. The purpose of this study was to compare the efficacy of morphine, fentanyl and pethidine for the treatment of postanesthesia shivering. Fifty patients who developed shivering were treated in a randomized double blinded manner with an intravenous bolus dose of 2 or 4 mg morphine, 25 or 50 mg pethidine, and 50 microg fentanyl. Then, they were monitored for 30 minutes and the shivering suppression grade, the time taken to stop shivering, the shivering cessation time, recurrence of shivering and opioid side effects were evaluated. Core body temperature was measured immediately before, and at 15 and 30 minute after administering the drug. The groups did not differ significantly regarding shivering suppression grade, shivering cessation time, and recurrence of shivering. There was a significant difference in the time taken to stop shivering between groups. Following injection of the drugs, the core temperatures increased in the five groups with statistical difference. All opioids were effective in treating postanesthesia shivering in a similar extent

Simultaneous pancreas and kidney transplantation: first report from Shahid Beheshti University of Medical Sciences and review of anesthesia considerations

We report a 33 year-old woman presented with signs and symptoms of severe uncontrolled diabetes mellitus and chronic renal failure [diabetic nephropathy]. She was prepared for emergency simultaneous pancreas and kidney transplantation [SPK] using hemodialysis and after compensating for the acid - base abnormality. She was discharged from the hospital about 3 week after the surgery with good renal and pancreatic function. A 2-month follow-up revealed no complication and a good renal and pancreatic function. Due to the importance of this kind of treatment and several anesthetic considerations of SPK we present this case report along with some pearls about related anesthetic view points

Comparison of sedative and hemodynamic effects of remifentanil and propofol in patients with pulmonary disease requiring mechanical ventilation in intensive care unit

ICU hospitalized patients usually need sedation. Common sedatives include benzodiazepines, opioids, barbiturates and etc. This study was conducted to compare the sedative, hemodynamic and respiratory effects of propofol and remifentanil in pulmonary disease patients requiring intubation and mechanical ventilation in intensive care unit of Masih Daneshvari Hospital during the years 2005-2007. This study was conducted as a randomized controlled clinical trial. All patients with pulmonary disease requiring mechanical ventilation in the ICU were randomly divided into two groups. The first group was given an initial 10 micro g /kg/min infusion of propofol and the second group received an infusion of remifentanil starting with 0.05 micro g /kg and the doses sequentially increased to reach a sedation state of 3-4 according to Ramsay sedation scale. The regimen was continued for 48 hours, during which blood pressure, heart rate, and respiratory rate were monitored every 3 hours. Data was analyzed using SPSS version 11 software. A total of 40 patients with a mean age of 58.67 +/- 18.57yrs [range 21-85 yrs] including 27 [67.5%] males and 13 [32.5%] females entered the study. The mean time to optimal sedation was 17.9 +/- 13.9 min and 20.16 +/- 16.11 min for remifentanil and propofol groups, respectively [p=0.09]. The mean systolic and diastolic blood pressures of each group showed a small decrease after initiation of infusion but this decrease was not statistically significant [p=0.26 for remifentanil and p=0.12 for propofol group]. The heart rate and respiratory rate showed no dramatic change during the infusion period. Both remifentanil and propofol are suitable drugs for sedating patients with pulmonary disease and neither of them induces dramatic hemodynamic changes. Therefore, using each of them is effective for optimal sedation of patients

Fracture and aspiration of tracheostomy tube

Methods of opening the airways like tracheostomy are used to provide appropriate ventilation for patients with upper airway problems. Tracheostomy may be accompanied by some complications. In the present study, we reported a 41- year-old man with progressive dyspnea and cyanosis induced by fracture of tracheostomy tube. He referred to our center and a chest x-ray was obtained showing fracture of tracheostomy tube within trachea. He underwent surgery and fractured tracheostomy was removed/ extracted. A plastic tracheostomy tube was placed for him and he discharged the day after. Fracture and aspiration of tracheostomy tube is a rare complication which requires a prompt and precise management. Patient education regarding the maintenance of tracheostomy tube for prevention of this complication is highly recommended

Clinical analysis of EEG parameters in prediction of the depth of anesthesia in different stages: a comparative study

Evaluation of depth of anesthesia is especially important in adequate and efficient management of patients. Clinical assessment of EEG in the operating room is one of the major difficulties in this field. This study aims to find the most valuable EEG parameters in prediction of the depth of anesthesia in different stages. EEG data of 30 patients with same anesthesia protocol [total intravenous anesthesia] were recorded in all anesthetic stages in Shohada-e-Tajrish Hospital. Quantitative EEG characteristics are classified into 4 categories of time, frequency, bispectral and entropy-based characteristics. Their sensitivity, specificity and accuracy in determination of depth of anesthesia were yielded by comparing them with the recorded reference signals in awake, light anesthesia, deep anesthesia and brain dead patients. Time parameters had low accuracy in prediction of the depth of anesthesia. The accuracy rate was 75% for burst suppression response. This value was higher for frequency- based characteristics and the best results were obtained in beta spectral power [accuracy: 88.9%]. The accuracy rate was 89.9% for synch fast slow bispectral characteristics. The best results were obtained from entropy-based characteristics with the accuracy of 99.8%. Analysis of the entropy-based characteristics had a great value in predicting the depth of anesthesia. Generally, due to the low accuracy of each single parameter in prediction of the depth of anesthesia, we recommend multiple characteristics analysis with greater focus on entropy-based characteristics

Comparison between CT-scan and trans-abdominal sonography in celiac and splanchnic plexus blocks in patients with advanced pancreatic head cancer

Malignant diseases are usually associated with severe pain during their course especially at the end stages. Pancreatic head cancer is one of these diseases which can be associated with severe intolerable pains in the end stages. Sometimes, these pains are extremely severe and interfere with patient's normal life. There are various techniques to control the pain out of which, celiac and splanchnic plexus blocks [temporary and permanent] are widely accepted procedures especially in severe cases and can control the pain efficiently. There are different approaches for performing this block which are all acceptable technically but are different in case of efficacy, accuracy and potential complications. Two groups were studied prospectively in 3 academic centers to evaluate different techniques of celiac plexus block in terms of feasibility and complications. For this purpose, 61 patients with a confirmed pancreatic head cancer who experienced severe pains were divided into two groups. CT- and sonographically-guided celiac and splanchnic plexus blocks were evaluated in group 1 [n=32] and group 2 [n=29], respectively. This study showed that the pain control and patients' satisfaction were greater in the CT-scan group [group A, p=0.18]. The success rate of performing a ganglion block was higher in the ultrasound group [group B, p=0.000]. The need for a re-block was also higher in the latter group. But, the quality of life improved more in the first group [CT-scan group]. However, no statistically significant difference was found between the two groups regarding these two variables. Pain relief started earlier and lasted longer in the CT-scan group. No complication was detected except for one case of abdominal infection in the sonography group and in some cases a mild pain [score<3] was reported which was not significant. Considering the limited number of cases, it seems that although there was no significant difference in the outcome of plexus block or related complications between the two above-mentioned procedures, the suggested imaging technique for celiac plexus block is CT-scan because of its feasibility, accuracy and lower number of trials to achieve a favorable result. More complementary assessments are recommended to obtain more precise results

Familiarity of physicians with the aims of pre-operative anesthesia evaluation clinics

The role of the anaesthesiologist in the quality of care rendered to patients during the pre-operative period is well known. The role of pre-operative anesthesia clinics in providing better conditions for patients undergoing anesthesia is now well documented. This study was performed to evaluate the familiarity of Iranian physicians with the aims of anesthesia clinics 10 years after the establishment of such clinics in Iran. Materials and All physicians working in 2 university medical centers were selected. A questionnaire was given to them and answers were analyzed and interpreted by statistical methods. Three-hundred forty-four Iranian physicians were questioned about their knowledge regarding anesthesia clinics out of which, 38% were faculty members, about half of them had working experience more than 10 yrs., 57.3% of them were surgeons, 27.6% of them were non-surgical clinical physicians, 6.4% were paraclinicians and the remaining were general practitioners. Forty-one percent of physicians were familiar with the aims of anesthesia clinics. Only 34% of physicians had referred patients to such clinics. The most important goals of establishment of these clinics from the physicians' point of view were to prepare the patients for operation [71%], reduce the complications of surgery [54%], reduce the time required for preparing patients for surgery [36%] and reducing the costs [34%]. Considering the results, it seems that a great majority of Iranian physicians are still unfamiliar with the aims of anesthesia clinics. Direct communication between anaesthesiologists and medical staff and stressing the benefits of establishing such clinics in medical congresses are beneficial and highly recommended by the authors

Anesthesia management in a pregnant woman with severe sub-glottic stenosis

Tracheal stenosis is extremely rare during pregnancy and is frequently mistaken for and treated as asthma. We describe the management of anesthesia in a pregnant patient with severe subglottic stenosis requiring rigid bronchoscopy for dilation and laser treatment of the stenotic area.

Acquaintance of patients with the aims of pre-operative anesthesia evaluation clinics

Anesthesia is peri-operative medicine. The role of anesthesiologist in the quality of care rendered to patients during the pre-operative period is well known. The role of pre-operative anesthesia clinics in providing better conditions for patients undergoing anesthesia is now well documented. This study was performed to evaluate the familiarity of Iranian patients with the aims of anesthesia clinics 10 years after the establishment of such clinics in Iran. All patients referred to anesthesia clinics in two university medical centers were evaluated during a 2-week period. A questionnaire was given to them and answers were analyzed and interpreted by statistical methods. Of the 286 patients who participated in this study, 56% were males and 44% were females; 43% of them were familiar with the goals of pre-op anesthesia, 83% of the patients mentioned that pre-op evaluation was the reason of their referral and 67% gave a positive feed-back on the clinic. The need for creating more motivation in patients and physicians was mentioned by 83% of the patients. Considering the statistical results, it seems that there is a great need to familiarize patients with the goals of these clinics and to create some motivation in them. By doing so, we can hope to offer better services to patients and reduce the anesthesia complications and anxiety

Efficacy of pethidine and buprenorphine for prevention and treatment of postanesthetic shivering

Postanesthetic shivering is a distressing postoperative complication. Pharmacological control is an effective method for treatment and prevention of postoperative shivering. Pethidine prevents or manages shivering far better than equianalgesic doses of other opioids. However, buprenorphine is an opioid with a similar structure to morphine but approximately 33 times more potent. This study aimed to assess and compare the effects of these two opioids in preventing post-anesthetic shivering. This randomized double- blind clinical trial was designed to compare the efficacy of buprenorphine and pethidine in prevention of post anesthetic shivering. Sixty ASA grade I-II patients undergoing general anesthesia for elective Cesarean section entered the study. Patients received either buprenorphine 3microg/kg [n=30] or pethidine 0.5 mg/kg [n=30] intravenously 30 min before the end of surgery. Heart rate and blood pressure were measured 15 min after the injection. Occurrence of shivering was evaluated for one hour in the recovery room. Also, pain intensity was assessed by using a visual analog scale [VAS; 0-5]. Shivering was significantly reduced in the pethidine group [5 of 30 versus 13 of 30, p < 0.05]. Visual pain scores were similar in both groups. There was no difference between the two groups regarding hemodynamics. Despite similar in pain control, pethidine is more effective than buprenorphine in prevention of post anesthetic shivering

Ventilation with proSeal laryngeal mask airway during short-term elective gynecologic surgery

The laryngeal mask airway [LMA] is a supraglottic airway device that can be used as a substitute for the standard endotracheal tube in emergency and difficult airway managements. However, the use of LMA for elective surgical procedures is still controversial. In most published studies, ETCO2 and SPO2 monitoring was applied to assess the adequacy of LMA placement. However, the most reliable method for evaluating ventilation and oxygenation is the measurement of arterial oxygen partial pressure [PaO2] and arterial carbon dioxide partial pressure [PaCO2] directly from an arterial blood sample. The purpose of this descriptive cross-sectional study was to evaluate ventilation and oxygenation with ProSeal laryngeal mask airway [PLMA] during short-term elective gynecologic surgery in paralyzed anesthetized patients. Fifteen ASA [American Society of Anesthesiologists] class I-II women undergoing short-term elective gynecologic operations under general anesthesia were included in the study. After induction of standard general anesthesia an appropriate size ProSeal LMA was inserted and controlled ventilation was established. Position of LMA was detected via auscultation of the lungs and epigastric area. Before the end of surgery, an arterial blood sample was withdrawn for blood gas analysis. First attempted insertion of PLMA was successful in all patients. The position of PLMA was good in 11, acceptable in 2 and suspected in 2 patients. PaO2, PaCO2 and SaO2 were within the normal limits in all situations. Duration of anesthesia [> 30 min and < 30 min] had no effect on PaO2. We concluded that ventilation and oxygenation can be maintained through a PLMA during short-term elective gynecologic surgery under general anesthesia

Pain relief methods after thoracotomy

Thoracotomy is one of the surgical operations which causes severe pain. In fact, this pain is one of the most excruciating pains caused by surgical operations. Different procedures are performed to decrease this pain which is associated with significant physiologic, mental and pathologic complications. Each of these procedures has its own advantage and disadvantages. In many centers, the most common treatment method used, is considered as the first choice. In this study, common methods of analgesia after thoracotomy were compared. During this meta-analysis, "Visual Analogue Scale" [VAS] of patients in epidural group was compared with those in four groups of systemic opioids, intercostal block, para- vertebral block and intrapleural infusion in the first 24 hours after surgery. Data obtained from 28 randomized clinical trials [RCT] which compared the procedures in 1697 patients after thoracotomy were gathered using random effect model, effect size index and the standardized difference average. Statistical values were evaluated and the results obtained using standard error, 5% maximum confidence limit and 5% minimum confidence limit. The obtained data were evaluated using studies performed between 1987 and 2005. After evaluating 314 titles and 185 abstracts, 28 articles were entered in the meta- analysis considering inclusion criteria. Four groups of epidural with systemic opioids, epidural with para-vertebral, epidural with intercostal and epidural with intrapleural analgesia were studied. It was noticed that the epidural method in total 24 hours with 95% CI= -0.9802 to -0.3844 was a better procedure compared with systemic opioids. Epidural method did not show any difference with intercostal method in 24 hours mean with 95% CI= -0.2171 to +0.5906. Epidural method was also better than intrapleural in 24 hours mean with 95% CI= -1.1166 to -0.0106. When comparing epidural with para-vertebral, epidural was better with 95% CI= +0.1744 to -0.4527. According to the evaluations performed, epidural method is recommended as the method of choice to reduce pain after thoracotomy

Nd-YAG laser in management of endobronchial lesions, a five - year report

Background: Nd-YAG laser is a relatively safe and effective procedure in the management of various types of endobronchial lesions including tracheobronchial tumors. It has been used in treatment of benign tumors and as a palliative therapy in obstructive airway lesions due to non-operable lung cancers

Materials and Methods: In this study, patients who underwent laser therapy because of their endobronchial lesions that admitted during 1994-99 in our hospital were investigated. A total number of 210 patients including 14 with benign tumors, 77 with malignant tumors, 11 with metastatic lesions, 14 with undefined prognosis tumor, and 94 with other lesions who seek laser therapy were investigated. The most common signs and symptoms among these patients were cough, dyspnea, hemoptysis, and obstructive pneumonitis. Improvement in airway obstruction following the application of laser therapy was assessed based on clinical signs and symptoms, arterial blood gas indices and spirometric results

Results: After performing laser therapy, cough in 95.1% of patients, dyspnea in 97.7%, hemoptysis in 89.4% and obstructive pneumonitis in all of these patients showed a significant improvement. Obstruction was relieved in more than 95% of the patients; however, this rate reached to 100% in lesions of trachea and main airways. 98% of 263 obstruction sites were relieved immediately after procedure, and 34.6 % of these cases were completely treated by laser therapy. Complications of laser therapy were observed only in 2 of these patients, that resulted in death in one case

Conclusion: The results of our study were consistent with the previous studies regarding the efficacy and safety of Nd-YAG laser therapy in endobronchial lesions

Whole lung lavage under general anesthesia in a child with pulmonary alveolar proteinosis [a case report]

Pulmonary alveolar proteinosis [PAP] is a rare disease in which surfactant accumulates abnormally in the pulmonary alveolar walls and causes respiratory symptoms. The only known effective treatment for PAP is pulmonary lavage. We have reported an 11- year-old girl with pulmonary alveolar proteinosis who underwent pulmonary lavage with normal saline under general anesthesia by a new method [using an univent tube for pulmonary blockage, ventilating one lung, and concurrently passing a catheter from out of the tube for lavage]. The general condition and vital signs of the patient were normal during lavage and in follow up. Three weeks later, her opposite lung was lavaged too. The results were favorable