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Arterial lines are routinely used for hemodynamic monitoring and blood sampling in the operating room and in cardiac surgery intensive care unit. The complications related to arterial line insertion are very low; the knowledge of the relevant artery anatomy, skills and the experience of the operator and selection of a right size cannula plays a vital role in reducing morbidity related to arterial line insertion. We describe extensive superficial and deep necrosis of lower limb following arterial cannula insertion in a preterm neonate undergoing arterial switch procedure and discuss measures to prevent such a complication.

Electroconvulsive therapy (ECT) is a safe and effective treatment for many psychiatric disorders. The passage of electrical current lead to hemodynamic alterations which may be detrimental to patients suffering from severe coronary artery disease. We describe perioperative anesthetic management of a patient having severe left main coronary artery stenosis (LMCAS) with severe triple vessel coronary artery disease (TVD).

Background : Significant proportion of congenital heart surgery (CHS) children exhibit sepsis, but have negative blood culture and defined “culture negative sepsis (CNS).” Aims and Objectives : Retrospective analysis of CNS patients undergoing CHS. Material and Methods : 437 consecutive CHS children grouped as controls (antibiotic prophylaxis), CNS, and culture positive sepsis (CPS). Results : Incidences of CNS and CPS were 16% and 7%. Median mechanical ventilation (MV) in hours among CPS, CNS, and control was 116 (45–271), 63 (23–112), and 18 (6–28) (P < 0.001), respectively. Multivariable linear regression identified CPS (median ratio: 3.1 [2.3–4.1], P < 0.001), CNS (median ratio: 5.6 [3.7–8.4], P < 0.001), and weight (kg) (median ratio: 0.98 [0.96–0.99], P = 0.009) as associations of MV. Intensive care unit (ICU) stay (hours) was 192 (120–288) in CNS, 288 (156–444) in CPS, and 72 (48–120) in controls (P < 0.0001). Multivariable linear regression showed CNS (median ratio: 2.4 [2.0–2.9], P< 0.001) CPS (median ratio: 3.3 [2.5–4.4], P < 0.001), and weight (median ratio: 0.98 [0.97–0.99], P = 0.001) prolonging ICU stay. Mortality was 10.7%, 2.9% and 1.2% in CPS, CNS, and control (P = 0.03). Multivariable regression identified CPS an independent predictor of mortality with odds ratio 8.6 (1.7–44.9; P = 0.010). 11.26% patients in CNS and 79.3% in CPS received antibiotics for more than 10 d ays. Conclusion : Incidence of CNS was 16%; duration of MV and ICU stay and mortality was significantly less in CNS than CPS patients.

Central venous access is useful for monitoring central venous pressure, inserting pulmonary artery catheter and administering vasoactive drugs in hemodynamically unstable patients. Central venous catheter (CVC) insertion through internal jugular vein may cause major vessel injury, inadvertent arterial catheterization, brachial plexus injury, phrenic nerve injury, pneumothorax, and haemothorax. We describe unusual presentation of hemothorax following CVC placement in a patient undergoing vestibular schwannoma excision. The patients' trachea intubated after several attempts during which thiopentone up to 600 mg administered. Thereafter, under ultrasound guidance, an 18G introducer needle placed in the right internal jugular vein but guide-wire did not advance. Meanwhile, the patient became hemodynamically unstable and a CVC placed in right subclavian vein and norepinephrine infused at 0.05 μg/kg/min; simultaneously, 1000 ml normal saline administered through CVC. The hemodynamic instability attributed to thiopentone administered during endotracheal intubation. The surgical procedure cancelled, and the patient shifted to critical care unit (CCU). Mechanical ventilation continued. In CCU, hemodynamic parameters further deteriorated and 0.1 μg/kg/min epinephrine started. Bedside lung ultrasound showed a large collection in pleural space on the right side. Chest radiograph showed a homogenous opacity obliterating costophrenic angle on the right side. A possibility of hemothorax considered, chest tube inserted and 1000 ml sanguineous fluid drained. Blood sample drawn through CVC showed air from proximal and middle lumen but distal lumen drained blood. Another CVC placed in the femoral vein and subclavian vein CVC removed. The vasoactive drug infusion transferred to CVC in femoral vein and 2 units pRBCs transfused. Hemodynamic parameters gradually stabilized and the patient recovered completely.

Perioperative management of severe pulmonary hypertension (PH) is challenging. Anaesthesiologists come across perioperative management of such cases during incidental surgeries, surgery for various congenital heart diseases and valvular heart diseases and for caesarean section or painless labour in pregnant patient with Eisenmenger syndrome. Knowledge of pathophysiology of PH and novel drugs acting through different mechanisms is paramount in managing such patients. This review will help understanding pathophysiology of PH, anaesthetising patients with PH, use of novel drugs for PH and use of new mechanical devices for rescue of failing right ventricle.

The results of mitral valve surgery have improved steadily. The current operative mortality rates for mitral valve surgery are reported to be in the region of 1.5% for mitral valve repair and 5.5% for mitral valve replacement. To ensure good perioperative patient outcome, it is imperative to follow management techniques based on sound scientific principles. In this review article, the authors describe anesthetic management, complexities of cardiopulmonary bypass and weaning from cardiopulmonary bypass in patients of varying severity of mitral stenosis.

The mitral valve (MV) is a sophisticated natural engineering marvel. The MV requires coordinated action of all its interrelated anatomical components: The MV leaflets, the annulus, the left atrium, the tendinous chords and the papillary muscles with its surrounding left ventricular wall for an effective closure of its orifice. Mitral valve regurgitation (MR) is frequently found in patients undergoing cardiac surgery with cardiopulmonary bypass. MR can be secondary to a structural or a functional defect of one or several components of the MV. The mechanism(s) of functional MR is the most complex. A precise understanding of the pathophysiology of MR helps resolving the cardiac status of a patient and choice of therapy for a particular patient. Transesophageal echocardiography can define the underlying mechanism(s) of MR; a thorough understanding of the mechanism(s) helps deciding the surgical procedure needed to repair the MR. In this article, the author reviews the mechanisms and pathophysiology of MR.

Hypertrophic cardiomyopathy (HCM) is the most common genetic cardiovascular disease with many genotype and phenotype variations. Earlier terminologies, hypertrophic obstructive cardiomyopathy and idiopathic hypertrophic sub-aortic stenosis are no longer used to describe this entity. Patients present with or without left ventricular outflow tract (LVOT) obstruction. Resting or provocative LVOT obstruction occurs in 70% of patients and is the most common cause of heart failure. The pathology and pathophysiology of HCM includes hypertrophy of the left ventricle with or without right ventricular hypertrophy, systolic anterior motion of mitral valve, dynamic and mechanical LVOT obstruction, mitral regurgitation, diastolic dysfunction, myocardial ischemia, and fibrosis. Thorough understanding of pathology and pathophysiology is important for anesthetic and surgical management.

Severe mitral regurgitation (MR) following balloon mitral valvotomy (BMV) needing emergent mitral valve replacement is a rare complication. The unrelieved mitral stenosis is compounded by severe MR leading to acute rise in pulmonary hypertension and right ventricular afterload, decreased coronary perfusion, ischemia and right ventricular failure. Associated septal shift and falling left ventricular preload leads to a vicious cycle of myocardial ischemia and hemodynamic collapse and needs to be addressed emergently before the onset of end organ damage. In this report, we describe the pathophysiology of hemodynamic collapse and peri-operative management issues in a case of mitral valve replacement for acute severe MR following BMV.

Hypertrophic cardiomyopathy (HCM) poses many unique challenges regarding the conduct of anesthesia and surgery. Adequate preload, control of sympathetic stimulation, heart rate, and increased afterload are required to decrease the left ventricular outflow tract obstruction. Comprehensive intraoperative transesophageal echocardiography (TEE) examination confirms the diagnosis, elucidates the pathophysiology, and identifies the various anomalies of mitral valve apparatus and allows assessment of the adequacy of surgery. In this review, we focus on the preoperative assessment, conduct of anesthesia and comprehensive TEE examination of patients presenting for surgery with HCM. The various surgical options are extended myectomy and resection, plication and release.

Polytrauma remains the leading cause of death and disability in children and young adults. Systematic organized team effort is essential for improving the survival in trauma victims. Initial assessment includes preparation, triage, rapid primary survey and resuscitation, secondary survey and definitive care. ABCDE of primary survey includes airway maintenance with cervical spine control, breathing and ventilation. Circulation and hemorrhage control, disability and exposure with prevention of hypothermia. Secondary survey includes head to toe examination of the trauma patient including a complete history and physical examination and reassessment of all vital signs. Definitive care may involve shifting the patient to radiology/operating room/intensive care unit.