Ahmet Mahli

Cardiac operations during pregnancy: review of factors influencing fetal outcome

Women with underlying rheumatic heart disease, even if well compensated, can easily be affected by acute heart failure caused by out-of-the-ordinary cardiorespiratory requirements during pregnancy. In such cases, medical therapy is not always sufficient to drive a heart, and open heart operation might be necessary. Many factors associated with cardiac operations requiring cardiopulmonary bypass, such as hypothermia, can adversely affect both the mother and the fetus, but the morbidity and mortality rates are higher for the fetus than the mother. Because fetal heart tones were lost during cardiopulmonary bypass and were reheard in the intensive care unit in our case presentation, we have presumed that the loss of fetal heart tones should not always indicate fetal death and have discussed harmful factors in relation with the fetal morbidity and mortality in light of the literature.

Aetiology of convulsions due to stellate ganglion block: a review and report of two cases

Stellate ganglion block is a selective sympathetic block that affects the ipsilateral head, neck, upper extremity and upper part of the thorax. Convulsions are a recognized complication of intra-arterial injection during stellate ganglion block. As central nervous system toxicity depends ultimately on the concentration of the local anaesthetics presented to the brain, the likely causative factors are discussed as well as the types of toxic symptoms and their onset times. The paper considers the aetiological factors of such convulsions resulting from stellate ganglion block in two patients.

Pulmonary microvascular injury following general anaesthesia with volatile anaesthetics - halothane and isoflurane: a comparative clinical and experimental study

Pulmonary microvascular injury has become a recently studied phenomenon that may be responsible for most of the complications associated with the lungs. Thirty patients undergoing partial hemilaminectomy or discectomy due to hernia of nucleus pulposus underwent Tc-99m HMPAO lung clearance as well as Tc-99m pertechnetate lung scintigraphy pre-operatively, and following general anaesthesia with halothane and isoflurane (third, fourth and tenth post-operative days). The results were compared with conventional techniques and haemodynamic parameters during the peri-operative period. In order to demonstrate acute phase changes under general anaesthesia and to perform pathological examinations, 21 New Zealand rabbits underwent radionuclide studies with Tc-99m HMPAO or Tc-99m pertechnetate. Lung biopsies were also performed. Despite no significant differences in any of the conventional diagnostic techniques, Tc-99m pertechnetate lung scintigraphy was performed for both the halothane and isoflurane groups, and Tc-99m HMPAO lung clearance was performed for the isoflurane group pre- or post-operatively. Tc-99m HMPAO lung clearance was impaired significantly in the halothane group on the third post-operative day (half time: 6.4 +/- 1.6 pre-operative and 13.76 +/- 3.3 s, P < 0.001) decreasing to pre-operative levels on the tenth post-operative day. Acute phase exposure to halothane was characterized with extremely abnormal Tc-99m HMPAO lung clearance in rabbits with respect to isoflurane, diminishing to control levels on the third day (half time: 8.7 +/- 86 control and 28.65 +/- 4.6, P < 0.001). Pathological examinations also demonstrated endothelial damage on acute exposure in the halothane group. General anaesthesia with halothane may give rise to alveolar microvascular injury, which generally seems to be underdiagnosed and may lead to serious post-operative complications.

Clinical approach to graft hepatic artery thrombosis following living related liver transplantation

Abstract: Hepatic artery thrombosis (HAT) has an occurrence rate of 1.7–26% following living donor liver transplantation (LDLT) and is one of the most common reasons for graft loss and mortality in this population. There is a higher incidence of HAT in pediatric recipients. The aim of this case report is to discuss clinical approaches for the treatment of HAT occurring in the early post‐operative period after LDLT. An 11‐month‐old, 7.8‐kg female with cirrhosis secondary to biliary atresia underwent LDLT at Gazi University Hospital in Ankara. The graft was a left lateral segment from her father with a left hepatic artery (HA) of 2 mm diameter and a graft weight/recipient body weight ratio of 2.0%. After an uneventful early post‐operative period, HAT was diagnosed by Doppler ultrasonography (USG) on the fifth post‐operative day. Following angiographic evaluation, immediate exploration and reanastomosis was performed using an operation microscope. Post‐operatively, the HA was patented by Doppler USG and graft function returned to normal. Now, 42 months later, the patient continues to do well with normal graft function, using a regimen of tacrolimus monotherapy for immunosuppression. In countries which have very limited resources for urgent re‐transplantation, given their serious donor shortage, graft salvage may be the only option for patient survival when HAT occurs. In these circumstances, early diagnosis and immediate revascularization may be the only method for graft salvage. A daily routine of Doppler USG examination in the early post‐operative period may provide a method for the early diagnosis of HAT, before liver enzymes are elevated and hepatic necrosis has begun.

Anesthetic management of caesarean section of a pregnant woman with cerebral arteriovenous malformation: a case report

IntroductionThe choice of anesthetic technique for Caesarean section of a pregnant woman with cerebral arteriovenous malformation (AVM) is made to maintain a stable cardiovascular system, but due to the rarity of this condition, no definitive guidelines exist.Case PresentationWe report the case of anesthetic management of Caesarean section of a pregnant woman with cerebral AVM (grade V). After the diagnosis, the radiologists decided to perform angiography and endovascular operation for treatment after the termination of pregnancy. The patient refused to undergo this procedure and with the beginning of the contractions of uterus, she was admitted to hospital urgently at the 40th week of gestational age and Caesarean section under general anesthesia was performed successfully.ConclusionWe concluded that in case of emergency, general anesthesia can be used satisfactorily for Caesarean section of a pregnant woman with cerebral AVM. Ensuring optimal maternal and fetal well-being, we are of the opinion that it is also possible to control the arterial blood pressure of patients with general anesthesia.

Anaesthesia for caesarean section in the presence of multivalvular heart disease and severe pulmonary hypertension: a case report

IntroductionPulmonary hypertension is a rare condition and in combination with pregnancy, it can result in high maternal mortality. Mitral stenosis is one of the complicated cardiac diseases that may occur during pregnancy. In this report, we describe our management of such a case, which was even more difficult in combination with pulmonary hypertension, mitral stenosis, and aortic and tricuspid valve insufficiency requiring emergency caesarean section under general anaesthesia.Case presentationA 29-year-old primiparae was presented to the anaesthetic department for an urgent caesarean section with a diagnosis of severe pulmonary hypertension in combination with mitral stenosis. The patient was hospitalized prepartum and received oxygen therapy and anticoagulation with heparin. The patient was monitored during labour and delivery with oximetry and arterial and central venous pressure line. Pulmonary arterial lines were not used due to an increased risk and questionable usefulness. Echocardiography revealed a systolic pulmonary arterial pressure of 75 mmHg, and mitral stenosis, aortic and tricuspid valve insufficiency.We decided to proceed under general anaesthesia. Anaesthesia was induced with etomidate, and succinylcholine. Dopamine and nitroglycerin infusion was preoperatively started and infusion was also preoperatively continued. Hemodynamic parameters were stable during delivery. Neonatal weight and apgar score were satisfactory. After the delivery of a healthy baby, oxytocin was administered. Surgery was completed uneventfully. During the postoperative period, the patient received furosemide and morphine. As the arterial blood gas analyses were stable and the chest-ray was normal, the patient was extubated postoperatively in the second hour in ICU.ConclusionPatients with significant multivalvular heart disease require careful preoperative, multidisciplinary assessment and anesthetic planning before delivery in order to optimize cardiac function during the peripartum period and make informed decisions regarding the mode of delivery and anaesthetic technique.

The Extent of Blockade Following Axillary and Infraclavicular Approaches of Brachial Plexus Block in Uremic Patients

Introduction This study was aimed to compare the axillary approach performed through multiple injection method and vertical infraclavicular approach performed through single injection method in terms of the sensory and motor block onset, quality, and extent of blocks of brachial plexus in uremic patients who underwent arteriovenous fistula surgery. Methods Forty patients scheduled for creation of arteriovenous fistula with axillary brachial plexus block (group AX, n = 20) or infraclavicular brachial plexus block (IC group, n = 20) were examined. The median, radial, ulnar, and musculocutaneous nerves were selectively localized by nerve stimulation. The volume of the local anesthetics was calculated based on the height of each patient, and the volume determined was prepared by mixing 2% lidocaine and 0.5% bupivacaine in equal proportions. Sensory and motor block were assessed at 3, 6, 9, 12, 15, 18, and 30th min and their durations were measured. Results While the adequate sensory and motor block rate with axillary approach was 100% in musculocutaneous, median, radial, ulnar and medial antebrachial cutaneous nerves, it was 65% in axillary nerve, 80% in intercostobrachial nerve and 95% in medial brachial cutaneous nerve. This rate was found to be 100% for all the nerves with infraclavicular approach. Conclusion For arteriovenous fistula surgeries in uremic patients, both axillary approach performed through multiple injection method and vertical infraclavicular approach performed through single injection method can be used successfully; however, for the short performance of the procedure, infraclavicular block may be preferred. Keywords Brachial plexus block; Axillary; Infraclavicular; Uremic patients

Malposition of subclavian vein catheter inserted through indirect technique in a pediatric liver transplantation: a case report

IntroductionClinicians use either direct or indirect (Seldinger) techniques for internal juguler or subclavian vein catheterization. This report aims to point out that the success rate of the direct technique where the catheter is inserted directly through the cannula may be higher particularly in catheterization of pediatric cases.Case presentationA 7.5-month-old female infant weighing 7200 gm was operated on for liver transplantation. The patient suffered jaundice at one month of age and was diagnosed with neonatal colestatic hepatitis. After routine monitoring, via indirect technique, central catheterization was attempted through internal jugular vein. However, the attempt failed. Therefore, again via indirect technique, catheterization was achieved through the right subclavian vein and fixed at 8 cm. After the operation started, fluid replacement and central venous pressure monitoring were performed with this catheter. Immediately after the operation, a control postero-anterior chest radiograph of the patient was obtained. This graph revealed that the tip of the catheter was fixed in the right internal jugular vein. Since the vital symptoms of the patient were not stable, the catheter was not removed and fluid replacement was performed via this technique. The catheter was removed on the postoperative 2nd day.ConclusionThe J wire advanced via the indirect technique advances anatomically following the upper wall of subclavian vein. Because of the smaller vessel dimensions and sharper, more angulated routes the subclavian and internal jugular veins make in infants, the rigid J wire may advance in the cephalic direction. However, in the technique where the catheter (Cavafix ® catheter) is inserted directly through the cannula, this probability is less since J wire is not used and the catheter employed is flexible. We concluded that especially in pediatric cases, employment of the technique where the catheter is inserted directly through the cannula would be more convenient in order to decrease the catheter malpositioning probability.

Anesthesia for Pregnant Patients with Eisenmenger Syndrome

The Eisenmenger syndrome is a form of cyanotic congenital heart disease that does not usually respond to corrective surgery, and its occurrence is very rare in pregnant women. There are ongoing debates regarding the management of Eisenmenger syndrome in this particular population, and the prognosis is not certain with regard to maternal, fetal, and neonatal outcomes. Eisenmenger syndrome develops in patients who have left-to-right shunts resulting in right heart volume overload. Although any intracardiac defect resulting in left-to-right shunting of blood can lead to volume and pressure overload, the shunt is most generally because of atrial septal or ventricular septal defects. Increased pulmonary vascular resistance is among the consequences of this volume overload, and it results in right ventricular enlargement, pulmonary hypertension, and reversal of the left-to-right shunt into a bidirectional or right-to-left fixed shunt. The skill and experience of the anesthesiologist on common potential intraoperative problems as well as the ability to respond to hemodynamic disturbances as quickly as possible bear much more importance than the specific technique or agent that is used. Regional anesthesia should be established with low dose of local anesthetic along with an opioid. The epidural should be induced slowly in order to avoid acute episodes of hypotension. In the case of a requirement for general anesthesia, rapid sequence induction is the standard technique.

Anesthesia for Pregnant Patient with Cardiac Disease

Management of pregnant women with heart disease has always been challenging. However, owing to recent novelties in cardiac surgery and correction of cardiac anomalies as well as the successful performance of heart transplants, it is possible that cardiac diseases will coexist with pregnancy and the frequency will increase in future. Using proper approach with respect to the suitable use of analgesics and anesthetics, in addition to both the pathophysiology and pharmacological therapy regarding the parturient, how these interact with anesthetic care should be considered meticulously. Although the conditions of cardiac pathology such as congenital or acquired, functional or structural, cyanotic or noncyanotic, and endocardial, myocardial, or pericardial defects may not have shown symptoms during non-pregnancy state, they become evident during mid-to-late pregnancy as an outcome of developing physiologic hemodynamic stresses. When the pregnant patient is encountered by the anesthetist, different structural lesions might be uncorrected, fully corrected, or partially corrected. Most of the time, since a single approach to the management of cardiac lesions is not present, a concurrence on the optimal anesthetic technique does not exist.