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We report an incident of detection of a free-floating thrombus in the left ventricle (LV) using intraoperative two-dimensional (2D) and three-dimensional (3D) transesophageal echocardiography (TEE) during proximal coronary artery bypass graft anastomosis. A 58-year-old man presented to us with a 6-month history of chest pain without any history suggestive of myocardial infarction or transient ischemic attacks. His preoperative echocardiography revealed the systolic dysfunction of LV, mild hypokinesia of basal and mid-anterior wall, and the absence of an aneurysm. He was scheduled for on-pump coronary artery bypass surgery. On intraoperative TEE before establishing cardiopulmonary bypass (CPB), a small immobile mass was found attached to LV apical area. After completion of distal coronary artery grafting, when the aortic cross-clamp was removed, the heart was filled partially and beating spontaneously. TEE examination using 2D mode revealed a free-floating mass in the LV, which was suspected to be a thrombus. Additional navigation using biplane and 3D modes confirmed the presence of the thrombus and distinguished it from papillary muscles and artifact. The surgeon opened the left atrium after re-establishing electromechanical quiescence and removed a thrombus measuring 1.5 cm Χ 1 cm from the LV. The LV mass in the apical region was no longer seen after discontinuation of CPB. Accurate TEE-detection and timely removal of the thrombus averted disastrous embolic complications. Intraoperative 2D and recent biplane and 3D echocardiography modes are useful monitoring tools during the conduct of CPB.

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INTRODUCTION: Patients of lung volume reduction surgery (LVRS) having an ASA status III or more are likely to be further downgraded by surgery to critical levels of pulmonary function. AIM: To compare the efficacy of thoracic epidural block with (0.125%) bupivacaine, fentanyl combination and (0.125%) bupivacaine, fentanyl combination with adjunctive intravenous magnesium infusion for the relief of postoperative pain in patients undergoing LVRS. METHODS: Patients were operated under general anesthesia. Thirty minutes before the anticipated completion of skin closure in both groups, (Group A and Group B) 7 ml of (0.125%) bupivacaine calculated as 1.5 ml/thoracic segment space for achieving analgesia in dermatomes of T4, T5, T6, T7, and T8 segments, along with fentanyl 50 µg (0.5 ml), was administered through the catheter, activating the epidural block, and the time was noted. Thereafter, in patients of Group A, magnesium sulfate injection 30 mg/kg i.v. bolus was followed by infusion of magnesium sulfate at 10 mg/kg/hr and continued up to 24 hours. Group B was treated as control. RESULTS AND ANALYSIS: A significant increase in the mean and maximum duration of analgesia in Group A in comparison with Group B (P<0.05) was observed. Total epidural dose of fentanyl and bupivacaine required in Group A was significantly lower in comparison with Group B in 24 hours. DISCUSSION: Requirement of total doses of local anesthetics along with opioids could be minimized by magnesium infusion; therefore, the further downgradation of patients of LVRS may be prevented. CONCLUSION: Intravenous magnesium can prolong opioid-induced analgesia while minimizing nausea, pruritus, and somnolence.

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BACKGROUND: To avert nausea and vomiting the 5-Hydroxytryptamine3 (5-HT3) antagonists have become the first line of treatment ifassociated with cardiovascular effects andappear to cause QT prolongation. OBJECTIVE: Evaluate the effect of 1 mg, 4 mg, and 8 mg bolus doses of intravenous Ondansetron, relative to placebo, in prevention of postoperative nausea and vomiting (PONV) and to find out the changes of QT interval corrected for heart rate (QTc). MATERIALS AND METHODS: This prospective randomized, placebo-controlled, double-blind study was carried out among 136 adult participants of both sexes in a tertiary care postgraduate teaching institute at Kolkata. mg, 4 mg or 8 mg inj. Ondansetron was diluted to 10 ml with normal saline, was infused 30 min before extubation in relation with a control group. Time to first rescue antiemetic medication and in QTc interval at different time intervals, in each group was noted in different in the various surgical operation theaters (OTs). RESULTS: Requirement of the first rescue antiemetic in the postoperative period between 60 to 120 min in the mg, 4 mg or 8 mg Ondansetron groups was in 28%, 24% and 7% participants respectively; between 120 to 240 min in 63%, 72% and 57% respectively; and within 360 min in 9%, 4% and 36% respectively. Significant and maximal QTc prolongation was observed in the participants with mg or 8 mg Ondansetron 3 and 5 min of drug administration. CONCLUSIONS: One mg Ondansetron in healthy adult participants can effectively prevent PONV causing no or insignificant prolongation of QTc interval.