Oxygen Saturation In Patients Research Articles

The Effect of Plasma Exchange on Recovery of Patients with Coronavirus Disease 2019 (COVID-19) Admitted to the Intensive Care Unit

Introduction: To evaluate the efficacy and safety of Plasma Exchange (PE) in Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) positive pneumonia patients. Method: This study was a case series conducted at a referral hospital. Twenty SARS-CoV-2-positive patients had an oxygen saturation of 80-90%, and the respiratory rate above 30 per minute. These symptoms started 1 week after the onset of the disease. All patients had less than 90% oxygen saturation and needed respiratory support (oxygen therapy) treated with plasma exchange on 3-5 consecutive days during hospitalization. We followed the amount of oxygen saturation, which was in the form of increasing the patient's oxygen saturation above 90% without oxygen supply and above 92% without oxygen, improving shortness of breath and improving patients' clinical symptoms. Results: Our study included a total of 20 COVID-19 patients with an overall mean age of 48.9 ± 12.1 years (range: 39–58 years); 60% (n=12) were males, 34.5% of whom benefited from TPE sessions. On the third day after the treatment, shortness of breath improved in these patients. Oxygen saturation of any twenty patients increased before the procedure of plasma exchange. Clinical symptoms of all patients were decreasing shortness of breath and improving patients' clinical symptoms after the procedure. Conclusion: According to our observations, plasma exchange could not show a significant therapeutic effect in COVID-19 patients with severe lung involvement.

Successful use of extracorporeal membrane oxygenation for life‐threatening macrophage activation syndrome after treatment with tocilizumab in an systemic juvenile idiopathic arthritis patient

AbstractMacrophage activation syndrome (MAS) is a rare, potentially life‐threatening condition in rheumatic diseases. The primary treatments consist of high‐dose corticosteroids and immunosuppressive drugs, although more recently, cytokine inhibitors like anakinra or tocilizumab (TCZ) have been reported. We present a case of a child with systemic juvenile idiopathic arthritis (sJIA). After receiving a single infusion of TCZ, the child developed progressive hypoxia and was subsequently transferred to the pediatric intensive care unit (PICU) after 4 days. An immediate postintubation chest X‐ray revealed a diffuse exudative lesion. Despite continuous efforts to provide mechanical ventilation and respiratory support, the patient's oxygen saturation continued to decline. Moreover, the patient developed hemodynamic compromise, necessitating the administration of norepinephrine. Eventually, vasopressin and dopamine were added to maintain stable hemodynamics. After an intensive but ineffective treatment, extracorporeal membrane oxygenation (ECMO) was initiated in the PICU after 16 h. The patient successfully recovered and was weaned off ECMO support after 60 h. Following discharge from the PICU, given the severe refractory clinical features, we made an attempt to readminister TCZ treatment. However, within half an hour of TCZ infusion, the patient experienced anaphylaxis characterized by palpitations and chest tightness, leading to the discontinuation of TCZ. TCZ, as a biological agent, is commonly used in the treatment of sJIA. Nonetheless, the occurrence of MAS and anaphylaxis following TCZ administration for sJIA may be more prevalent than previously recognized. Pediatric rheumatologists should exercise caution when initiating TCZ for active sJIA. Furthermore, we want to underscore the importance of life‐saving techniques such as ECMO for sJIA patients in emergency situations.

Addressing desaturation in a tracheal stenosis patient using the transnasal humidified rapid-insufflation ventilatory exchange technique during tracheostomy: A case report.

Transnasal humidified rapid-insufflation ventilatory exchange (THRIVE) is used in tracheostomy but not in cases of airway obstruction. This case report explores the use of THRIVE for managing airway obstruction during tracheostomy in patients with subglottic and tracheal stenosis, thereby addressing the current knowledge gap and exploring its potential for airway management. A 63-year-old female with subglottic and tracheal stenoses underwent tracheostomy. Multiple attempts to establish a patent airway were unsuccessful, and oxygen saturation dropped to 56%. Endotracheal tube was directed toward the tracheal wall, causing airway obstruction. THRIVE was administered to the patient. Subsequently, the tube position was adjusted to enhance ventilation. The patient's oxygen saturation increased to 99%. The postoperative complications, including subcutaneous emphysema, pneumothorax, pneumomediastinum and pneumopericardium, resolved. The patient was discharged on postoperative day 9. THRIVE could be considered a temporary measure to enhance oxygenation before initiating a definitive treatment strategy.

Spontaneous bilateral pneumothorax and pneumomediastinum independent of mechanical ventilation as complications of COVID-19 pneumonia: A case report.

Since the beginning of the COVID-19 pandemic, several infected patients have suffered from unusual and severe complications. Among these rare complications, pneumothorax and pneumomediastinum have attracted clinical attention. Such complications might be challenging to diagnose immediately because of the atypical presentation in some cases. Accurate diagnosis is essential to ensure effective treatment. Here, we present the case of a 62-year-old male who presented with symptoms of COVID-19 acute respiratory distress. There was diffuse subcutaneous emphysema in the face, neck, shoulder, and chest wall on clinical examination. The patient was started on oxygenation via a non-rebreather mask. On further evaluation, his chest X-ray revealed bilateral peripheral opacities in the lung fields, bilateral pneumothorax, and subcutaneous emphysema, after which intercostal drainage tubes were inserted. The patient's oxygen saturation was not satisfactory, and he was switched to a high-flow nasal cannula. However, his condition deteriorated, and he was put on mechanical ventilation and inotropic support. Despite our best efforts, the patient succumbed to the disease. We want to emphasize the importance of this adverse event despite his nonsmoking history and the exclusion of positive pressure ventilation. Although benign, early diagnosis of this condition is vital, as the condition could lead to worse morbidity if left unrecognized.

Simultaneous occurrence of knee septic arthritis and coronavirus disease 2019 (COVID-19): A case report

BackgroundCoronavirus disease 2019 (COVID-19) pandemic is increasingly recognized as a serious, worldwide public health concern. Most of the patients with COVID-19 are asymptomatic or show mild symptoms. It is important to identify the unusual manifestations and their long-term complication. Case presentationA case of COVID-19 in 45 years old man with septic arthritis due to Staphylococcus aureus is presented. COVID-19 was diagnosed using real-time polymerase chain reaction without obvious clinical manifestation. The patient had no history of trauma or inflammatory arthritis and had progressive left knee pain and limitation of movement. Knee X-ray was normal. Aspiration of the knee joint fluid showed a cloudy and purulent appearance. The patient was admitted to hospital and immediately treated with vancomycin 1gr/12 hr. A polymerized chain reaction (PCR) test for COVID-19 was performed, which was positive 24 h after hospitalization. Staphylococcus aureus was reported in synovial fluid culture which was sensitive to vancomycin and ciprofloxacin, thus vancomycin was continued. On the 4th day of hospitalization the patient had cough, therefore underwent CT scan lungs and ground-glass opacities (GGO) characteristic of COVID-19 were noticed. Favipiravir and interferon were started. Patient’s knee aspiration was performed for 5 consecutive days. On the 6th day of hospitalization, joint fluid markedly decreased and the patient's oxygen saturation was 96%. One week after hospitalization, the patient was discharged and a month later knee examination was completely normal. ConclusionsSeptic arthritis should be considered in the manifestations or co-morbidity of COVID-19 patients with joint pain, swelling or redness.

Case Report: Successful Treatment of COVID-19 ARDS with Transcutaneous Vagus Nerve Stimulation

We report two individuals who successfully recovered from COVID-19-induced ARDS after being treated with transcutaneous auricular vagus nerve stimulation (taVNS). In the first case, taVNS was started after eleven hospital days of continual deterioration despite mechanical ventilation along with supportive therapy of steroids, antibiotics, and immunoglobulins. On the twelfth day of hospitalization, taVNS was begun four times daily, resulting in sudden improvement in oxygenation. There was a concomitant reduction of c-reactive protein from 109.6 μg/mL to 10 μg/mL. After nine days of taVNS therapy, the patient's improved respiratory function improved enough that she was able to be extubated. No additional treatments had been added or changed during this time. After twenty-seven days of hospitalization, the patient was discharged to home without supplemental oxygen. The second case involves taVNS therapy in the home setting. After nineteen days of progressive deterioration, the patient's oxygen saturation declined to 90% on room air before taVNS treatment was instituted. After tens days of taVNS treatment three times daily, his oxygen saturation had climbed to 97%, and by day 25 of VNS therapy, the patient felt he was fully recovered. taVNS is capable of improving regulation of the inflammatory response in other clinical conditions such as autoimmune disorders in humans and septic shock in animal models. We suggest that transcutaneous auricular vagus nerve stimulation is potent enough to improve the clinical course of COVID-19 associated ARDS because of its potential to minimize the clinical deterioration associated with the immunological surge known as the cytokine storm. taVNS is a safe and potentially efficacious treatment for COVID-19 ARDS.

Survival Rate Prediction of Head Injury Patients with Peripheral Oxygen Saturation

Good management of head injuries can improve patient survival. Examination of peripheral oxygen saturation (SpO2) is a procedure performed at the primary survey. This study aims to predict the survival rate of head injury patients with the SpO2 value. The method used was a prospective study with a cohort design. Samples were head injury patients who came to the ER without comorbidities. The instruments used were the Revised Trauma Score (RTS) and Oximetry. Patients who arrived at the ER were measured for their SpO2 levels, treated according to SOP, and 6 hours later, the survival rates were assessed. The sampling technique used was purposive sampling. The statistical test used is Somers’d Correlation Test. The sample consisted of 46 head injury patients with SpO2 in a good category of 30 (65.2%) and good survival of 32 (69.6%). SpO2 had a strong correlation with survival (p = 0.00; r = 0.846; RR = 8.16). Patients with good SpO2 were 8.16 times more survive than others. Low SpO2 can be used as an early indicator of tissue hypoxia and related to mortality. The ER nurse should be concerned about the patient's oxygen saturation and ensure that the SpO2 level is in the 95% -100% range.

COVID-19 with pulmonary embolism: Case report

A 20-years-old female patient presented to the emergency service due to complaints of sudden onset of severe shortness of breath; by a 3-day history of fever and a 1-day history of dry cough. After the patient evaluation, the presence of SARS-COV-2 infection together with the acute pulmonary embolism was detected. After the low molecular weight heparin was applied to the patient, the considerable increase was detected in the patient's oxygen saturation level. The acute pulmonary embolism can be seen after viral pneumonia.1 SARS-COV-2 pneumonia in comparison to the normal healtly population has much more embolism complication. In the evaluation stage, the request of contrast-enhanced tomography is crucial for the patients who have a high level of D-dimer and severe shortness of breath. The low molecular weight heparin that we use for treatment is given prophylactically in high-risk patients.3 In the reduction of anti-inflammatory response besides the protective effect of heparin; It is also known that IL-6 has binding properties at recent publications.4 In our case, We evaluated micro-thrombosis and large-vessel thrombosis may coexist in SARS-Cov-2 pneumonia and the effect of heparin.

Giant Retroperitoneal Hematoma During Extracorporeal Membrane Oxygenation in a Patient With Coronavirus Disease-2019 Pneumonia

A 71-YEAR-OLD man was admitted to the intensive care unit because of severe bilateral pneumonia resulting from coronavirus disease-2019. His chief complaints were persistent fever, cough, and shortness of breath. Thoracic computed tomography showed bilateral multiple ground-glass opacities. An arterial blood gas analysis demonstrated a low oxygenation index. The patient received high-flow oxygen therapy via a nasal cannula to maintain his oxygen saturation >90%. After receiving supportive care for 2 days, the patient's respiratory function deteriorated further. Endotracheal intubation was performed, but the patient's oxygen saturation remained approximately 70% despite mechanical ventilation with 100% oxygen. Therefore, percutaneous venovenous extracorporeal membrane oxygenation (ECMO) was initiated. Activated partial thromboplastin time was targeted to 60 seconds using a heparin infusion. Progressive hypotension without apparent cause developed 7 days after ECMO was begun. What is the diagnosis? Acute respiratory distress syndrome and profound hypoxemia are the main causes of death in coronavirus disease-2019 pneumonia.1Ruan Q. Yang K. Wang W. et al.Clinical predictors of mortality due to COVID-19 based on an analysis of data of 150 patients from Wuhan.China. Intensive Care Med. 2020; 46: 846-848Crossref PubMed Scopus (2899) Google Scholar Despite the wide use of mechanical ventilation with low-volume, low-pressure, and prone position ventilation strategies, the mortality is still as high as 60% in severe cases.2Yang X. Yu Y. Xu J. et al.Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: A single-centered, retrospective, observational study.Lancet Respir Med. 2020; 8: 475-481Abstract Full Text Full Text PDF PubMed Scopus (5946) Google Scholar In such situations, ECMO might be a life-saving measure, but it also is associated with hemorrhagic complications.3Henry B.M. COVID-19, ECMO, and lymphopenia: A word of caution.Lancet Respir Med. 2020; 8: e24Abstract Full Text Full Text PDF PubMed Scopus (172) Google Scholar,4Augoustides J.G. Extracorporeal membrane oxygenation – crucial considerations during the coronavirus crisis.J Cardiothorac Vasc Anesth. 2020; 34: 1720-1722Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar In addition, because of a relatively complex management, various complications may occur during ECMO support.5Keller S.P. Contemporary approaches in the use of extracorporeal membrane oxygenation to support patients waiting for lung transplantation.Ann Cardiothorac Surg. 2020; 9: 29-41Crossref PubMed Google Scholar,6Hoyler M.M. Flynn B. Iannacone E.M. et al.Clinical management of venoarterial extracorporeal membrane oxygenation.J Cardiothorac Vasc Anesth. 2020; 34: 2776-2792Abstract Full Text Full Text PDF Scopus (14) Google Scholar Abdominal computed tomography revealed a large cystic retroperitoneal mass, with extravasation of contrast consistent with a retroperitoneal hematoma. The patient remained hypotensive despite volume resuscitation with crystalloid and packed red blood cell transfusion. An intravenous infusion of norepinephrine was required to temporize the hypotension, but the serum lactate concentration continued to increase. The right internal iliac artery was occluded successfully in the angiography suite, and his hemodynamics stabilized. After the procedure, he was returned to the intensive care unit. The patient eventually was weaned from mechanical ventilation and was discharged from hospital 76 days after the procedure. Figure 1 The authors have no conflicts of interest to disclose.

Perubahan Kadar Saturasi Oksigen pada Pasien Dewasa yang Dilakukan Tindakan Suction Endotrakeal Tube di Ruang ICU RSUD Ulin Banjarmasin

Handling for airway obstruction due to excessive accumulation of secretions can be done with suction, suction is done by inserting suction catheter tube into endotracheal tube or tracheostomy which aims to liberate airway. Endotracheal suction in critically ill patients can cause increased intracranial pressure, brain swelling and systemic hypoxemia may even lead to death. The easiest way to find out hypoxemia is by looking at the patient's oxygen saturation of peripheral oxygen saturation is a presentation of hemoglobin binds with oxygen in the arteries with normal values between 95-100%.This research aims to analyze changes in oxygen saturation levels of patients before, during and after the suction endotracheal tube performed in Intensive Care Unit Ulin Banjarmasin Hospital. This research method is quantitative with comparative design. The population in this research are all patients who had endotracheal tube and suction was done, the sample in the research are 25 respondents with Probability sampling technique, analyzed by paired T test.The results of this research at the time of 1 "-3" average oxygen saturation change of 0-1%, while 4"- 6" on average by 2-3% and at 7 "-10" on average by 2-5% . Paired T-test results showed there was a change in oxygen saturation level in adult patients performed endotracheal tube suction in Intensive Care Unit Ulin Banjarmasin Hospital.

A comparison of two designs for earcons conveying pulse oximetry information

We performed a randomised controlled trial comparing two kinds of earcons that could provide intermittent pulse oximetry information about a patient's oxygen saturation (SpO2) and heart rate (HR). Timbre-earcons represented SpO2 levels with different levels of timbre, and pitch-earcons with different levels of pitch. Both kinds of earcons represented HR with tremolo. Participants using pitch-earcons identified SpO2 levels alone, and both SpO2 plus HR levels, significantly better than participants using timbre-earcons: p < .001 in both cases. However, there was no difference between earcon conditions in how effectively HR was identified, p = .422. For both kinds of earcons, identification of SpO2 levels was more compromised by simultaneous changes in HR than identification of HR levels was compromised by simultaneous changes in SpO2, suggesting asymmetric integrality. Overall, pitch-earcons may provide a better intermittent auditory pulse oximetry display than timbre-earcons, especially for clinical contexts when quiet is needed.

Pulmonary Complication following Drug-Eluting Bead Hepatic Chemoembolization

A 70-year-old man with a history of essential hypertension presented to his gastroenterologist with a 6-month history of unintentional weight loss. After an unremarkable colonoscopy, a computed tomographic (CT) scan of the abdomen was performed demonstrating a 6.2-cm arterially enhancing hepatic mass with delayed washout and extension into the hepatic vein ([Fig. 1a], [b]). The patient was found to have no associated liver disease or serologic evidence of viral hepatitis. A biopsy of the mass was performed demonstrating poorly differentiated hepatocellular carcinoma (HCC), and the patient was referred to interventional radiology for locoregional therapy. Prior to liver-directed therapy, imaging demonstrated a small pleural effusion felt to be related to venous invasion and narrowing of inferior vena cava (IVC). The drug-eluting beads transarterial chemoembolization (DEB-TACE) was performed with 100- to 300-µm drug-eluting beads loaded with 75 mg of doxorubicin (LC Beads, BTG, West Conshohocken, PA) followed by 300 to 500 µm “bland” particle (Embosphere; Merit Medical, Salt Lake City, UT) embolization. An angiographic endpoint of 5-beat stasis was reported. No angiographic images were stored demonstrating arteriovenous shunting; however, in retrospect, shunting could have been suspected based on attenuation of caval blood surrounding the tumor on arterial phase imaging on both CT and angiography ([Fig. 1c], [d]). Approximately 48 hours after discharge, the patient presented to his primary care physician with fevers and mild dyspnea. This was attributed to an increased right pleural effusion following DEB-TACE, which was managed conservatively without thoracentesis. The patient's oxygen saturation was incidentally noted to be decreased at 92%; however, patient was judged not to be symptomatic enough to require treatment and as such was discharged from medical care with instructions to follow up if symptoms worsened. The patient improved over the course of the next month, but follow-up imaging demonstrated a minimal response of the treated HCC. After discussion with the patient, repeat DEB-TACE was performed.

The Role of Chest X-Ray and Bedside Ultrasound in Diagnosing Pulmonary Bleb versus Pneumothorax

History of present illness: A 48-year-old male with chronic obstructive pulmonary disease (COPD) presented to the emergency department with stabbing chest pain to the right lower rib region along the axillary line. On examination, patient had no visible trauma, but was in mild respiratory distress with absent breath sounds on the right side. The patient's oxygen saturation ranged in the 90s on room air during his encounter, but otherwise had unremarkable vital signs. Significant findings: The patient was evaluated with bedside ultrasound for concern of possible pneumothorax. Imaging of the left lung with M-mode demonstrated a “sea shore” sign showing a wavy pattern below the pleural line caused by lung sliding as well as “comet tail” artifact caused by from the deep pleura. However, there was no lung sliding on the right shown by a lack of “comet tail” artifact and a “bar code” sign where M-mode shows straight lines throughout the image, this is caused by lack of motion below the pleura. This lack of lung sliding is consistent with possible pneumothorax or bleb. A two-view chest X-ray (CXR) revealed absent lung parenchyma in the right lung similar to a large pneumothorax (see red outline). Electronic medical record chart review revealed previous CXRs with similar findings. This patient was determined to have an acute COPD exacerbation with chronic blebs, but no pneumothorax. Discussion: Pulmonary blebs are collections of air in the alveolar layer of the pleura formed by a rupture of the alveolar wall.1 They can leak air into chest cavity leading to a high rate of recurrent spontaneous pneumothorax.2 Chest X-rays (CXR) are the current gold standard in diagnosing pneumothorax. A recent study among 192 critically ill patients showed CXR has high diagnostic accuracy and positive predictive value, at 90.6% and 95.0%, respectively.3 Visible visceral pleural lines on CXR seen without distal lung markings is usually diagnostic of pneumothorax.4 In this case however, the patient’s CXR and lung ultrasound findings were similar to standard pneumothorax findings, however chart review demonstrated the patient had a known large pulmonary bleb. The treatment for pneumothorax is chest tube insertion. To avoid unnecessary chest tube placement, emergency physicians must consider pulmonary blebs as a diagnosis in patients with mild respiratory distress who have a large area of absent lung parenchyma and visible visceral pleural lines on CXR. If a clinician is unsure and does not have access to previous imaging, a computed tomography scan of the chest can be used to clarify the diagnosis.5 This patient was conservatively managed with oral prednisone, intravenous morphine sulfate, combination albuterol-ipratropium nebulizer treatment, and later discharged for pulmonology follow up.6 The patient did not require any further imaging during this visit. In recurrent disease or severe dyspnea, bullectomy may be indicated. Topics: Ultrasound, X-ray, pulmonary blebs, pneumothorax.

Thyrotoxic hypokalemic periodic paralysis

Hypokalemia is a serious and life-threatening clinical condition. We present a case of a 45-year-old male, with known hyperthyroidism presenting with profound tremor, irritability, quadriparesis, and labored breathing since morning, on the day of admission. Arterial blood gas analysis showed severe hypokalemia. Patient's vital was stabilized and patient's oxygen saturation was maintained on oxygen inhalation. Intravenous potassium chloride infusion was administered with regular monitoring of vitals and electrolytes. Patient's symptoms improved. Thyroid function testing showed high free T3 (tri-iodothyronine) and free T4 (thyroxine) with low thyroid-stimulating hormone concentration in the serum, indicating thyrotoxic hypokalemic periodic paralysis. Treatment with antithyroid drug carbimazole resulted in an improvement during the follow-up visit. Hypokalemia is believed to be a consequence of a massive shift due to increased sodium–potassium–adenosine triphosphatase (Na+K+ATPase) pump activity in the presence of elevated thyroid hormones.

59-Year-Old Woman With Fatigue, Dyspnea, and Lower Extremity Edema

59-Year-Old Woman With Fatigue, Dyspnea, and Lower Extremity Edema

Trigeminocardiac reflex and haemodynamic changes during Le Fort I osteotomy

The Le Fort I osteotomy is performed under general anaesthesia and specific haemodynamic conditions, i.e. hypotensive general anaesthesia. This study assessed the incidence of the trigeminocardiac reflex (TCR) during the different stages of the Le Fort I osteotomy. Forty-seven patients requiring a Le Fort I osteotomy were included. General anaesthesia was induced. In terms of haemodynamic changes, each patient's oxygen saturation (SpO2), mean arterial pressure (MAP), heart rate (HR), and electrocardiogram (ECG) were monitored by SADAAT Monitoring System and recorded during the different stages of osteotomy: before the induction of anaesthesia, before osteotomy cuts, after finishing the right pterygoid plate osteotomy, after finishing the left pterygoid plate osteotomy, and after performing down-fracture of the maxilla. No significant alteration in haemodynamic values was seen at the different stages of Le Fort I osteotomy. One patient showed arrhythmia with non-sinus junction rhythm after sinus bradycardia and two premature atrial contractions in the down-fracture stage, which led to the abrupt cessation of the procedure by the surgeon. This study showed no significant alterations in haemodynamic values during the different stages of Le Fort I osteotomy. Halting the procedure momentarily was sufficient to allow spontaneous normalization of the HR, blood pressure, and dysrhythmia.

An Incidental Finding of Severe Hypoxia in an Asymptomatic Patient Caused by Pulmonary Arteriovenous Malformations

SESSION TITLE: Pulmonary Vascular Disease Cases I SESSION TYPE: Affiliate Case Report Slide PRESENTED ON: Monday, October 26, 2015 at 11:00 AM - 12:00 PM INTRODUCTION: Pulmonary arteriovenous malformations (AVMs) are a rare clinical entity, especially when found in isolation with no underlying etiology. Literature review suggest that pulmonary AVMs are symptomatic in 91% of cases, with dyspnea in 82% and cyanosis in 79% of patients. Furthermore, 70% are also associated with Osler Weber Rendu Syndrome. We report a case of severe asymptomatic hypoxia, discovered incidentally on routine pre-operative evaluation, found to have isolated multiple large pulmonary AVMs. Workup failed to show any underlying etiology. CASE PRESENTATION: The patient is a 54 year old female, with a history of COPD and severe aortic valve insufficiency, diagnosed via an echocardiogram at another facility, referred to cardiovascular surgery at our hospital. During pre-surgical evaluation, she was found to be hypoxic, with oxygen saturation in the 80%s on 2L of oxygen by nasal cannula and was admitted. Upon admission, her oxygen saturation was at 85% on a non re-breather mask. She denied any symptoms. Physical examination was unremarkable. Laboratory values showed hemoglobin of 17.3g/L and hematocrit of 48.9%. Chest X-Ray revealed a mass like density in the right lower lobe (RLL). CT scan of the thorax with contrast was negative for pulmonary embolus but 4 AVMs in RLL and 2 in right upper lobe were identified. Further questioning and workup was negative for Osler-Weber-Rendu syndrome or other underlying etiology. Resting echo showed an EF of 70% and a Bubble Echocardiogram revealed extensive right to left shunting. Bubbles entered from the pulmonary venous drainage into the left atrium consistent with AVMs. She had a pulmonary angiogram and AVMs of the RLL were embolizedx2 and an amplatzer vascular occlusion plug was deployedx2. After embolization, the patient's oxygen saturation was at 95% on 6L of oxygen. A Transesophageal Echo showed moderate aortic insufficiency and she decided to forego cardiac surgery. DISCUSSION: Studies show most cases of pulmonary AVMs have an underlying etiology and are symptomatic in 91% of patients. Our case represents a patient with large asymptomatic pulmonary AVMs with no underlying etiology. CONCLUSIONS: It shows that in patients presenting with hypoxia with no clear underlying cause, pulmonary AVMs can be considered as a cause and that pulmonary angiogram and embolization of AVMS is the cornerstone of treatment of pulmonary AVMs. Reference #1: Faughnan ME, LUI YW, Wirth JA, et al. Diffuse Pulmonary arteriovenous malformations: characteristics and prognosis. Chest 2000; 117:31 DISCLOSURE: The following authors have nothing to disclose: Asad Omar No Product/Research Disclosure Information

Endoscopic management of congenital anterior glottic stenosis

IntroductionCongenital anterior glottic stenosis (web) is a rare condition usually presenting with airway obstruction, stridor or dysphonia. Symptomatic infants may require tracheotomy to bridge the neonatal period. Early open surgical reconstruction may have significant risks and failure may still result in tracheotomy. We introduce an endoscopic surgical approach with balloon dilation for primary management of congenital anterior glottic stenosis. MethodsWe present three cases of congenital anterior glottic stenosis in children 7, 14, and 90 days old presenting with stridor, dyspnea, and dysphonia. The larynx was exposed by suspension microlaryngoscopy. The glottic stenosis was incised from a posterior to anterior direction using a laryngeal sickle knife. Subsequently, an airway balloon was guided through the stenotic lumen. Once the balloon was inflated, the balloon pressure was maintained for 30s or until the patient's oxygen saturation dropped below 92%. The dilation was repeated two or three times. The patients were kept intubated with an uncuffed endotracheal tube and monitored in the pediatric intensive care unit following surgery. ResultsAll three patients were extubated within 72h without complications. One patient failed the first extubation attempt and was reintubated and successfully extubated 24h later. Patients were re-evaluated with direct microlaryngoscopy within two weeks. All patients had symptomatic relief and did not require further surgical intervention. ConclusionEndoscopic balloon dilation laryngoplasty may be a safe and effective primary procedure for pediatric patients with congenital anterior glottic stenosis. It is technically simple and obviates the potential morbidities associated with an open surgical procedure or tracheotomy.

Anaesthetic management of intraoperative airway obstruction by ruptured hydatid cyst of right lung and barotrauma induced pneumothorax of the contralateral lung.

Sir, We present a case of anaesthetic complications of ruptured hydatid cyst of lung causing obstruction of double lumen tube (DLT) by daughter cysts on the operative side as well as on the healthy side. A 22-year-old female was posted for cystectomy of the right sided hydatid cyst. Besides routine monitoring, invasive blood pressure was also measured. Anaesthesia was induced with intravenous fentanyl (100 μg), propofol (100 mg) and vecuronium (6 mg). The patient was intubated with 37 FG left sided, DLT in a semi-sitting position. The position of the tube was confirmed with a fibreoptic bronchoscope (FOB) in the supine position as well as in lateral decubitus position. Intraoperatively cyst was found ruptured, and during its handling, we found that hundreds of daughter cysts blocked the tracheal lumen. So we clamped the tracheal end of DLT and one-lung ventilation (OLV) was provided with 5-6 ml/kg of tidal volume and 100% oxygen and subsequently suctioned out hundreds of daughter cysts from the tracheal lumen. About 45 min after starting OLV, we found bronchial lumen also being obstructed by the daughter cysts; there was difficulty to ventilate with rapid onset of hypoxia and peak airway pressure rose up to 50 cm H2O. We suctioned the cysts immediately. After cystectomy and capitonnage were being performed, we replaced DLT with appropriate sized single lumen tube. FOB revealed that left bronchial lumen was circumferentially compressed by bronchial mucosa, and there were no changes in bronchial dimensions during positive pressure ventilation. After extubation, there was a drop in oxygen saturation. Chest X-ray showed a left sided pneumothorax and chest drain was inserted which improved patient's oxygen saturation to 100%. The clinical presentation, pre-operative and post-operative complications associated with pulmonary hydatid cysts depends on whether the cyst is intact or ruptured.[1] OLV does not guarantee a safe operation if either DLT is malpositioned intraoperatively, or contralateral lung is involved pre-operatively. In our case, cyst handling during surgery caused the escape of hundreds of daughter cysts causing obstruction of both the lumens of DLT and patient suffered from repetitive episodes of desaturation. This obstruction of major airways made ventilation difficult and led to increased airway resistance and pressures causing barotrauma of the ventilated lung. During surgery, it was not evident due to open chest cavity, but after closure it manifested as pneumothorax of the ventilated lung leading to intercostal drain insertion. Barotrauma from excessive tidal volume and high airway pressure may occur if left sided, DLT is positioned distally such that the entire tidal volume is directed to only one lobe.[2] Nevertheless, peak airway pressures were not excessive in our case during initiation of OLV and FOB showed the tube to be in a good position. During the surgery, the malposition of DLT could not prevent the dependent lung against contamination of cyst contents and tube obstruction by hydatid cyst caused an excessive increase in airway pressure leading to barotrauma of the ventilated lung. It did not convert into tension pneumothorax due to open chest cavity at the time of surgery.[3] Patients undergoing thoracic surgery are at risk of increased airway resistance of dependent lung secondary to secretions and soft tissue obstruction. This produces potential for a ball valve effect, with limitation during expiration resulting in the overinflation of the lung.[4] We extubated the patient, which averted tension pneumothorax after chest closure. Spillage of laminated membrane could probably take place at any stage of anaesthesia, causing airway obstruction and further hypoxemia and asphyxia.[5] Hence, we conclude that one should be vigilant about post-operative pneumothorax in complicated ruptured hydatid cyst of the lung.

Percutaneous embolization of a giant collateral vessel originating from the azygos vein via the inferior vena cava

We present the case of a 45-year-old man with univentricular heart, small outlet chamber, and L-transposition of the great vessels. As an infant, the patient underwent multiple palliative surgical interventions. He presented with worsening dyspnea and fatigue and was found to have systemic oxygen saturation of 85% on 2 L of oxygen by nasal cannula, whereas he had chronically remained between 90 and 95% throughout most of adulthood. There was no evidence of significant valvular regurgitation or stenosis, nor was there an overt intracardiac shunt by echocardiography. Cardiac CT and cardiac MRI revealed a large serpiginous systemic to pulmonary venovenous collateral located behind the left atrium. The collateral drained into the lower right pulmonary vein as it entered the left atrium. The tributary veins to the "giant" collateral were determined by these images modalities. The patient underwent a percutaneous embolization of this giant venovenous collateral via a remnant supracardinal vein originating from the infrarenal inferior vena cava using two Amplatzer Vascular Plug II. Immediately after the procedure the patient's oxygen saturation increased to 90% on room air at rest. At 2 months follow-up the patient had a marked clinical improvement with oxygen saturation as high as 95% on room air while walking. Our case illustrates a successful embolization of a giant collateral via an embryological venous remnant connecting the IVC to the azygos system.