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Signa Vitae

Journal of Intensive Care and Emergency Medicine

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Sevoflurane vs propofol in high risk cardiac surgery: design of the randomized trial “Sevo-Aifa”

Abstract

Objective. Recent evidence indicates that volatile anesthetics improve post-ischemic recovery. In a meta-analysis of 22 randomized studies, the use of volatile anesthetics was associated with significant reduction in myocardial infarction and mortality. All the studies in this meta-analysis included low risk patients undergoing isolated procedures (mostly isolated coronary artery bypass grafting). We want to confirm the cardioprotective effects of volatile anesthetics, in cardiac surgery, as indicated by a reduced intensive care unit stay and/or death in a high risk population of patients, undergoing combined valvular and coronary procedures.
Methods. Four centres will randomize 200 patients to receive either total intravenous anesthesia with propofol or anesthesia with sevoflurane. All patients will receive a standard average dose of opiates. Perioperative management will be otherwise identical and standardized. Transfer out of the intensive care unit will follow standard criteria.
Results. Reduced cardiac damage will probably translate into better tissue perfusion and faster recovery, as documented by a reduced intensive care unit stay. The study is powered to detect a reduction in the composite end point of prolonged intensive care unit stay (>2days) and/or death from 60% to 40%.
Conclusions. This will be the first multicentre randomized controlled trial comparing the effects of volatile anesthetics and total intravenous anesthesia in high risk patients undergoing cardiac procedures. Our trial should help clarify whether or not volatile agents should be recommended in high risk patients undergoing cardiac surgery.

Key words: anesthetic gases, cardiac surgical procedures, myocardium protection, sevoflurane, cardiac anesthesia, intensive care, volatile agents

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Usage of central venous catheter for delayed traumatic pneumothorax

Abstract

Pneumothorax, whether spontaneous, iatrogenic or traumatic, frequently requires drainage, especially in the face of positive pressure ventilation or general anesthesia. The traditional approach with large-bore, rigid chest tube is associated with significant pain and various complications. Recently, less invasive modalities such as pigtail catheter or fine-needle aspiration have been used in selected patients. We report a case of delay-onset pneumothorax after trauma and the patient was treated successfully with the easily available central venous catheter for drainage.

Key words: thoracic injury, delayed traumatic pneumothorax, central venous catheter, thoracotomy

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Transient, unilateral, complete, oculomotor palsy in an adult patient with idiopathic intracranial hypertension

Abstract

Idiopathic intracranial hypertension (IIH) is a well recognized condition of elevated intracranial pressure of unknown cause. Many etiologies have been proposed, but few- besides a high body mass index, hypervitaminosis A, steroid withdrawal, exposure to tetracyclines and female gender- have been proven. The main morbidity in this condition is visual loss and is often reversed if recognized early and treated promptly with weight- reduction, a low-sodium diet and acetazolamide.

Key words: idiopathic intracranial hypertension, oculomotor palsy, headache, adult

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Jaundice, occult blood and acute cholecystitis: hemobilia as the initial presentation of acute cholecystitis complicated by a pseudoaneurysm

Abstract

Identifying the presence of hemobilia can be clinically important since it might change the therapeutic approach to patient management. Here, we report a 56-year-old man with clinical symptoms of acute cholecystitis. Multidetector-row computed tomography of the abdomen showed a ruptured pseudoaneurysm arising from the right hepatic artery. Angiography, with transarterial coil embolization of the pseudoaneurysm, was performed before surgery to reduce the risk of hemostatic complications.

Key words: pseudoaneurysm, hepatic artery, hemobilia, multidetector-row computed tomography, transarterial embolization

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Platypnea-orthodeoxia-like syndrome in a septic newborn with late appearance of right congenital diaphragmatic hernia

Abstract

Introduction. Cyanosis and dyspnoea with interatrial shunting of blood occurring without change in body position are termed platypnea-orthodeoxia-like syndrome.
Case presentation. We describe a female newborn with sepsis, who developed cyanosis. Two weeks after the initial appearance of cyanosis she presented with a right-sided diaphragmatic hernia, which was not seen on the initial X-rays. The hernia was surgically repaired. Her postoperative course was uneventful.
Conclusions. In our case, interatrial shunting of blood was presumably caused by disturbed intrathoracic pressures. Positive pressure ventilation and sepsis may also contribute to the development of such a syndrome.

Key words: cyanosis, right-to-left shunt, infant, sepsis, congenital diaphragmatic hernia

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