Tehran University Medical Journal

---

Background: During general anesthesia in patients with mediastinal mass compression effect on the heart, great intra thoracic vessels, or tracheal tree can lead to decrease venous return, cardiovascular collapse or tracheal obstruction. These complications may be worsened after induction of general anesthesia or prescribing muscle relaxants.
Case report: A twenty one years old female with huge anterior mediastinal mass was a candidate for right sided thoracotomy. Compression effect on the adjacent structures has been reported in chest CT scan and in echocardiography. Awake oro-tracheal intubation was performed in sitting position. Then patient positioned to left lateral decubitus for thoracotomy During surgery asystole occured. We changed the position to remove compression effect on the heart and great vessels. Fortunately these maneuvers changed asystole to sinus rhythm.
Conclusion: Decreased thoracic muscular tone and removed spontaneous ventilation after muscle relaxant may threaten patient’s life. Change of patient’s position can remove the compression effect.

---

Background: We report a case with apparent resistance to local anesthetics. While regional anesthetics failure are often attributed to technical failure, the clinical presentation and medical history of this patient suggests a true resistance to local anesthetics.
Case report: A 28 years old man was scheduled for elective orthopedic surgery for right sided tibial bone fracture, and decision of spinal anesthesia was made. There was a questionable history of multiple prior episodes of local anesthetic unresponsiveness (Interscalan block, local infiltration for lipoma resection and dental surgery). Spinal anesthesia was performed and sensory or motor blockade was not obtained despite any evidence of technical problems. The surgical procedure performed under general anesthesia and skin analgesia (local infiltration of lidocaine 2% and bupivacaine 0.5% to forearm), did not achieve, the day after surgery.
Conclusion: While the failure rate of spinal anesthesia has been shown range from 4 to 13% and is often attributed to technical failure, this particular case showed a true resistance to local anesthetics.

---

Background: Acupuncture is one of the most effective methods of alleviating pain in different situations including chronic and acute pain management. The aim of this study was to evaluate the effectiveness of acupuncture in the reduction of post-operative pain after hernia repair.

Methods: In this placebo-controlled, double-blinded clinical trial, we enrolled 60 male patients aged 30 to 60 years old with an ASA physical status of I or II undergoing elective inguinal hernia repair under general anesthesia in Imam Khomeini Hospital, Tehran, Iran. All patients experienced standard anesthetic and surgical procedures. After completion of the operation and while the patients were still under general anesthesia, they were randomly assigned to two groups: acupuncture (with stimulation of GV2, GV4 and SP6 points with sterile acupuncture needles), and control (with sham acupuncture stimulation). After termination of anesthesia, during the first six hours, the pain intensity was evaluated hourly. Pethidine (25 mg) was administered for the patients when necessary. Pain intensity and pethidine use were recorded and compared between the two groups.

Results: The mean age of two groups did not differ. Pain intensity was significantly lower in the acupuncture group between the second and fifth postoperative hours. Moreover, pethidine use was significantly lower in the acupuncture group versus the control group during the first six hours after surgery (12.07±7.5 mg vs. 12.91±6.5 mg, respectively p=0.0001).

Conclusion: The application of acupuncture in patients is associated with a marked decrease in pain after inguinal hernia repair and does not have any serious complications. Acupuncture is strongly recommended for all post-operative patients.

---

Background: Cardiac herniation is a fatal post pneumonectomy complication. We report the signs, clinical findings, diagnosis and management of a patient with post pneumonectomy cardiac herniation.

Case report: A 34-year-old man with lung cancer underwent left pneumonectomy with partial pericardiectomy in the right lateral decubitus position. At the end of the surgery, cardiovascular collapse, severe bradycardia, desaturation and elevated airway pressure occurred just after repositioning the patient to the supine position. This patient survived as we returned him to the right lateral decubitus position and avoided the use of positive pressure ventilation.

Conclusions: Attention to the acute complications of pneumonectomy, diagnosis and rapid therapeutic interventions is essential in post pneumonectomy care.