oxygen, 1% sevoflurane, and fentanyl 2-4 g/kg. No patients responded when the abdominal incision was made. However, four patients had transient increases in heart rate and six patients had transient increases in arterial blood pressure during the intraabdominal procedure. The abdominal wall was relaxed without muscular relaxants.No patients complained of postoperative pain immediately after awakening from anesthesia. Postoperative pain management consisted of a continuous IV infusion of fentanyl (20 g/h) for the first day, supplemented with flurbiprofen on the second day in three patients. The averages of visual analog scale (VAS) scores on each day were 23, 49, and 31 on the first, second, and third postoperative days, respectively.The clinical course in these patients suggests that the intercostal nerves were effectively blocked by this technique. The bilateral rectus abdominis muscles were relaxed, no patients showed signs of poor analgesia on the abdominal incision, and VAS scores on the first postoperative day suggested reasonable levels of analgesia. We suggest that this technique may merit further evaluation in clinical trials.
Life-threatening hemoptysis is one the most challenging condition encountered in critical care. Bronchial artery embolization (BAE) has become an established procedure, in the management of massive and recurrent hemoptysis. Bronchial arteries have variable anatomy. The reported prevalence of bronchial arteries with an anomalous origin ranges from 8.5-35%. We are describing two patients who presented with hemoptysis and were effectively managed with bronchial artery embolization. Both these patients had anomalous origin of bronchial artery from the internal mammary artery, one from the Right Internal Mammary Artery (RIMA) and one from the Left Internal Mammary Artery (LIMA). The procedures were performed under general anesthesia. In the fi rst case a double lumen endobronchial tube was used while in the second case, the patient was managed without tracheal intubation. The fi rst patient was dyspnoeic; saturation was poor and was unable to maintain her airway probably due to profuse blood in her airways. We used a double lumen tube in her to isolate the diseased lung from the healthier lung. We gave her muscle relaxants and mechanical ventilation so that a stable lung fi eld could be provided during embolization. The second patient was quite stable and comfortable while breathing room air. We decided not to interfere with his airway. A backup plan and preparation for urgent airway control and lung isolation was done inside the catheterization laboratory. From the management point of view, an unstable patient with life-threatening hemorrhage needs airway control and lung isolation. A stable patient with minimum to moderate bleeding may be managed safely under general anesthesia with the patient spontaneously breathing.
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