Background: Endotracheal intubation is the prominent cause of airway mucosal injury which results in postoperative sore throat (POST), with an incidence of 21%–65%. Although this complication is minor, if left unresolved, it produces significant agony and annoyance to the patient. This study was conducted to evaluate the efficacy of nebulized ketamine in decreasing POST. Materials and Methods: After written informed consent, 96 patients of the American Society of Anesthesiologists physical status (PS) 1–2 between 18 and 60 years, of either sex undergoing general anesthesia (GA) with tracheal intubation were enrolled in this prospective, randomized, placebo-control, and double-blind controlled trial. Patients were randomized into two groups; Group 1 received ketamine 50 mg (1.0 ml) with 4.0 ml of saline nebulization, while Group 2 received saline nebulization 5.0 ml for 15 min. GA was administered 15 min after completing nebulization. On reaching postanesthesia care unit, POST monitoring was done at 0, 2, 4, 6, 12, and 24 h after extubation. POST was graded on a four-point scale (0–3). Results: The overall incidence of POST in this study was 25%: POST was experienced by 7 patients (14.6%) in ketamine and 17 patients (35.4%) in saline group (Fisher's exact P = 0.018). There was statistically significant reduction in the incidence of POST in ketamine group when compared to saline, at 2, 4, 6,12, and 24 h postoperatively (P < 0.05*). Severity of sore throat was also higher in saline group when compared to ketamine at 4 h (P = 0.030*) and 6 h (P = 0.016*) postextubation. Conclusion: Preoperative ketamine nebulization effectively reduced the incidence and severity of POST, with no adverse effects.

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Purpose: The purpose of the study was to review and summarize current literature concerning the validation and application of lung ultrasound (LUS) in critically ill patients with acute respiratory distress syndrome (ARDS). Materials and Methods: An extensive literature search was conducted using PubMed, Cochrane Review, Google Scholar, and Ohio State University Link based on the question if LUS should be considered a reliable investigational technique for ARDS diagnosis, treatment, and prognosis in pediatric and adult population. Results: LUS has been successfully validated for facilitating early diagnosis and diagnosis of simultaneous lung conditions, predicting lung recruitment treatment effect, and evaluating the prognosis in ARDS patients. Whether lung US is a useful tool in the prediction of prone position and oxygenation response in patients with ARDS is conflicting. Conclusions: LUS is a noninvasive, radiation-free, cheap, and easy to perform tool for critically ill patients with ARDS and might be a promising technique used in the Intensive Care Unit for ARDS management.

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Background and Objectives: Pain assessment of nonverbal, critically ill patients continues to present a challenge in Intensive Care Unit (ICU). The Critical-Care Pain Observation Tool (CPOT) rates critically ill patients' pain based on clinical observation. In the present study, the accuracy of CPOT was compared with physiological indicators of pain in mechanically ventilated, critically ill patients. Methods: This quantitative prospective observational study was conducted to assess pain in the critically ill, mechanically ventilated patients in comparison to physiologic indicators such as blood pressure and heart rate. A repeated measures design was chosen, and a sample size of 180 was taken from 60 patients with sepsis, acute exacerbations of chronic obstructive pulmonary disease, community-acquired pneumonia, and postsurgical patients in the ICU. The two painful procedures chosen were tracheal suction and patient positioning. The data were collected at rest, at tracheal suctioning, 20 min later at positioning of the patient, and final reading 20 min later. Three testing periods, each including 4 assessments for a total of 12 pain assessments with sixty patients, were completed during each patient's ICU course. A total of six assessments were done with the patient at rest and three each with pain stimulus of tracheal suctioning and patient positioning. Results: There was a significant increase in both hemodynamic variables (systolic blood pressure and diastolic blood pressure) during painful procedures except for the heart rate during positioning. The correlation between the CPOT and Ramsay scale was negative and significant. Conclusions: The present study provides evidence that the CPOT has good psychometric properties. It might prove useful for pain assessment in uncommunicative critically ill patients.

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Background and Aims: Intraperitoneal local anesthetic is an effective analgesic approach in laparoscopic appendectomy in adults. The aim of the study was to compare the postoperative pain when intraperitoneal bupivacaine is administered alone versus the addition of dexmedetomidine to it in children undergoing a laparoscopic appendectomy. Methods: In this prospective randomized trial, 52 children were randomly allocated to Group B who received intraperitoneal bupivacaine 0.25% (2 mg/kg) or Group BD who received intraperitoneal bupivacaine 0.25% (2 mg/kg) plus dexmedetomidine (1 mcg/kg) for postoperative analgesia in children undergoing laparoscopic appendectomy. Postoperative pethidine consumption at day 1 was recorded and considered the primary outcome of the study. Patients were evaluated for pain scores at 0, 2, 4, 6, 12, and 24 h, time to first request of pethidine, sedation scores at 0, 2, 4, and 6 h, length of hospital stay, and parents' satisfaction. Chi-square, Fisher's exact, Student's t-test, and Mann–Whitney U-tests were used for analysis. Results: Postoperative visual analog scale scores were lower in Group BD at 2, 4, and 6 h (mean = 3, 3, 3, respectively) compared with Group B (mean = 4, 5, 4, respectively) (P < 0.05). Patients in Group BD had more sedation scores at 0, 2, and 4 h (P < 0.05), longer time to first rescue analgesia (P = 0.03), lesser rescue analgesic consumption (P = 0.02), shorter length of hospital stay (P = 0.02), and higher parents' satisfaction (P = 0.01). Conclusion: Adding dexmedetomidine to intraperitoneal bupivacaine provides adequate postoperative analgesia in children undergoing laparoscopic appendectomy.

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Background: The thyroid gland surgery is a common and painful procedure demanding analgesia. Many regional techniques are applied for anterior neck surgeries mostly assigned in relation to the involved cervical fascia. Dexmedetomidine (Precedex) is a selective alpha 2 adrenoceptor agonist which prolongs the sensory blockade duration of local anesthetics. Our study hypothesis is that ultrasound (US)-guided bilateral superficial cervical plexus block (BSCPB) may provide longer analgesia when adding dexmedetomidine to bupivacaine-epinephrine. Purpose: The aim of this study is to evaluate the analgesic efficacy and possible side effects of US-guided BSCPB and the effect of dexmedetomidine addition to bupivacaine-epinephrine in patients undergoing thyroid surgery. Methods: This prospective, double-blind, randomized study was performed on 42 patients randomized into two equal groups each of 21; bupivacaine Group B and dexmedetomidine Group D. Patients with contraindications to regional anesthesia or uncontrolled comorbidities were excluded from the study. Total pethidine consumption in 24 h is the primary outcome. The visual analog scale, timing of the first opioid request, and hemodynamics are the secondary outcomes. Results: In Group D, there was a longer time to the first request of opioid postoperatively, a lower total pethidine consumption and pain score postoperatively, and lower fentanyl requirements intraoperatively. Conclusions: Sonographic-guided bilateral SCPB using a combination of bupivacaine, dexmedetomidine, and epinephrine was superior to bupivacaine for prolonged analgesia with less intra- and postoperative opioid consumption and lower side effect profile during thyroid surgery.

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Objectives: The aim of the study was to compare time to intubation and glottic visualization between Macintosh, McCoy, and Glidescope video laryngoscope (GVL) in morbidly obese patients. Methodology: Forty-five American Society of Anesthesiologists I–III morbidly obese patients were randomized into three groups of 15 each and time to intubation, Cormack–Lehane grading, and Intubation Difficulty Score (IDS) were compared. Results: GVL took more time to intubate (TTI) compared to Macintosh and McCoy laryngoscope (P = 0.0001). Overall IDS were similar between the groups. Conclusion: To conclude, GVL takes longer TTI with no added advantage in IDS and hemodynamic response to intubation in morbidly obese patients. McCoy is only as effective as Macintosh and hence Macintosh laryngoscope should be laryngoscope of choice due to its widespread availability and familiarity.

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Introduction: Mental health issues, especially depression, are common in chronic pain patients. Depression affects these patients negatively and could lead to poor control of their pain. Some risk factors for both chronic pain and depression are known and need to be targeted as part of the management in a multidisciplinary approach. This study was conducted to estimate the prevalence of depression among chronic pain patients attending a pain clinic and to explore the association between depression in chronic pain patients and other factors such as sociodemographic features, number of pain sites, severity of pain, and types of pain. Methods: This is a cross-sectional study that carried out in a chronic pain clinic in a tertiary care hospital in Riyadh, Saudi Arabia (King Faisal Specialist Hospital and Research Centre). All chronic pain patients including cancer-related pain, apart from acute pain patients and children, were eligible to participate in the study. Association between depression and sociodemographic factors was assessed with univariate and multivariate methods. Main outcome measures were the prevalence of depression in chronic pain patients using the Patient Health Questionnaire-9 (PHQ-9) and the association with sociodemographic factors. Results: A total of 200 chronic pain patients (128 females [64%]) participated in the study. The prevalence of depression was 71% (95% confidence interval: 64.7–77.3) based on the PHQ-9 diagnostic criteria using a cutoff point of >5. Among those patients who were depressed, 9 (4.5%) had severe depression as compared to 31 (15.5%), 41 (20.5%), and 61 (30.5%) who had moderately severe, moderate, and mild depression, respectively. Depression (scored at the cutoff point of 5) in chronic pain patients was significantly associated with age, financial status, medical history of depression, and pain severity. Conclusion: Depression is common among chronic pain patients with several risk factors aggravating its presentation. Due to their increased risk of depression, psychiatric counseling that offers mental health assistance should be prioritized and made available as a multidisciplinary approach for the treatment of chronic pain patients.

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The postoperative pain management in open thoracotomy is very crucial as the effective analgesia can prevent respiratory and thrombotic complications and lead to early mobilization and discharge. The thoracic epidural analgesia is the gold standard in such surgeries; however, there are few adverse effects such as hypotension, dural puncture, and contralateral block that always warrants safer alternative. Recently, with the advent of ultrasound, the regional anesthetic techniques are getting more popular to avoid such complications. Erector spinae plane (ESP) block is one of the novel techniques that has been described as a safe thoracic paravertebral block. We are reporting here the continuous ESP block as a primary mode of postoperative analgesia which was continued for 48 h. The intraoperative opioid requirement was very less, and the maximum NRS score in postoperative period was 4 at 12 h, which was well managed with multimodal analgesic regimen along with rescue doses of opioid.

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Massive blood loss has been a dreaded complication of liver transplantation, and the accompanying transfusion is associated with adverse outcomes in the form of decreased patient and graft survival. With advances in both surgical techniques and anesthetic management during transplantation, blood and blood products requirements reduced significantly. However, transfusion practices vary among different centers. The altered coagulation parameters in patients with liver cirrhosis results in a state of “rebalanced hemostasis” and patients are just as likely to clot as they are to bleed. Commonly used coagulation tests do not always reflect this new state and can, therefore, be misleading. Transfusion of blood products solely to correct abnormal parameters may worsen the coagulation status, thus adversely affecting patient outcome. Point-of-care tests such as thromboelastometry more reliably predict the risk of bleeding in these patients and in addition may provide quicker turnaround times compared to routine tests. Perioperative management should also include the possibility of thrombosis in these patients, and the use of low-molecular-weight heparin correlates with better patient survival. This review article aims to highlight the concept of rebalanced hemostasis, limitation of routine coagulation tests, and harmful effect of empiric transfusion of blood products.

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Context: The South Asian region is comprised of eight countries, i.e., Pakistan, India, Bangladesh, Sri Lanka, Afghanistan, Bhutan, Nepal, and Maldives. There is dearth of literature documenting anesthesia research in this region. Aim: The aim of this audit was to look at research productivity in the region by examining the volume and the type of anesthesia publication in five high-index anesthesia journals. Settings and Design: The study design was a survey of literature in the top five high-impact anesthesiology journals carried out at a tertiary care hospital. Materials and Methods: The journal citation report 2016 was accessed to identify the top five anesthesia journals based on their impact factor. We identified articles published in these journals between January 2000 and December 2015. Statistical Analysis: Microsoft Excel 2003 worksheet was used for data collection from extracted articles. Results: The highest number of publications came from India (n = 487) 95.9%; 58.5% of these were correspondence, 21% were original articles, 12.8% were case reports and case series, 1.2% reviews, and 1% editorials. Fourteen articles were published from Pakistan, with 1.2% original articles, 0.8% letter to editor, 0.6% audits, and 0.2% case reports. Nepal and Sri Lanka contributed seven publications. There were no publications in these journals from authors from Bangladesh, Afghanistan, Bhutan, and Maldives in the reviewed journals. The highest number of publications was equally distributed between two journals, i.e., “Anesthesia and Analgesia” (29.5%) and “Anesthesia” (28.9%). Conclusion: We found that scientific contributions from the South Asian region in terms of original anesthesiology research in five high index anesthesiology journals was suboptimal and has not shown an increasing trend over the last 16 years.

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Background: Severe musculoskeletal trauma can trigger an inflammatory response, and an excessive inflammatory response can lead to systemic inflammatory response syndrome and multiorgan failure. High-mobility group box 1 (HMGB1) is an early mediator pro-inflammatory cytokine in sterile injuries and a late cytokine mediator in infection and sepsis. Previous research has shown that administration of systemic lidocaine can inhibit HMGB1 expression in macrophages of septic rats. The aim of this study was to demonstrate the efficacy of systemic lidocaine to inhibit HMGB1 mRNA and protein in a BALB/c mouse model of sterile inflammation due to closed fracture musculoskeletal injury. Materials and Methods: Twenty adult male BALB/c mice were divided into lidocaine and control groups. The closed fracture musculoskeletal injury was performed by breaking the left thigh bone of the mice. Four hours after undergoing the closed fracture, the lidocaine group was treated with lidocaine intravenous (2 mg/kg). The same volume of distilled water was injected into the control group instead of lidocaine. HMGB1 mRNA expression was examined with real-time polymerase chain reaction, and HMGB1 protein level was determined with enzyme-linked immunosorbent assay. Results: The expression of HMGB1 mRNA and protein levels in mice that sustained inflammation due to a closed fracture musculoskeletal injury was significantly decreased in the lidocaine group (P < 0.00 and P < 0.00 for mRNA and protein, respectively). Conclusions: Intravenous administration of lidocaine effectively inhibited the inflammatory process in BALB/c mice that underwent closed fracture musculoskeletal injury by suppressing HMGB1 mRNA transcription and HMGB1 protein translation.

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Background: Toward improving the reporting quality of clinical case reports in the Saudi Journal of Anaesthesia, we conducted this audit. The aim of this paper is to provide an overview of the different objectives for clinical case reports and to identify those subordinate items which seem most relevant from the CAse REport (CARE) checklist. Methods: We performed this pilot study on clinical case reports published in the Saudi Journal of Anaesthesia (SJA) in the past 5 years from 2013 to 2017. The journal publishes 4 issues/year that means 20 issues were studied. We used one online source to gather the clinical case reports which is the SJA website. A total of 84 case reports were studied. We have applied the 13^th items in the CARE checklist on the case reports to determine their representations. Two reviewers abstracted data from all included papers to determine the adaptation of the CARE checklist. Data are presented as percentages of different subordinate items of the CARE guidelines. Results: None of the 84 case reports met all subordinate items of CARE guidelines, and only 5 subordinate items were reported fully met (100%). Patient perspective subordinate item was not mentioned in our series due to lack of data in the studied case reports. Therefore, only 12 subordinate items were included. We reported those adaptation percentages of the 12^th subordinate items of the CARE checklist as follows: (a) title, keywords, abstract patient's biodata, and conclusion 100%; (b) main symptoms of the patients 97.6%; (c) timeline 78.5%; (d) diagnosis 94.0%; (e) treatment 97.6%; (f) strengths 85.7%; (g) literature review 94.0%; and (h) patient consent 33.4%. Conclusion: We believe that the CAse REport guidelines can provide an international framework for the authors to follow in writing their case reports and for the editors to use to ensure the completeness and readiness of the peer-reviewed case reports for publication. For the SJA, we have to apply the CARE checklist and to ensure all subordinate items are adapted including the patient's perspective subordinate item and to make sure that the consent form obtained and accompanied each submitted case reports.

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Background and Objectives: The present study was designed to explore the utility of ultrasound-guided diaphragmatic thickness in the preoperative period in healthy controls scheduled for live-related donor hepatectomy and patients suffering from chronic liver disease scheduled for liver transplantation (LT) and its use as a predictor of postoperative weaning failure. Materials and Methods: This prospective observational study was conducted in a tertiary health care center and 65 adult (18–70 years) participants (30 healthy liver donors and 35 liver transplant recipients) were enrolled for this study. Right diaphragmatic thickness of both donors and recipients was measured by B-mode ultrasound using a 10 MHz linear array transducer in the supine position in the operation theater just before induction of anesthesia. For subgroup analysis of the recipients, we further divided them into two groups – Group 1 (diaphragmatic thickness < 2 mm) and Group 2 (diaphragmatic thickness > 2 mm), and comparison was done for duration of mechanical ventilation. Intergroup comparison was made for duration of mechanical ventilation and various other parameters. Results: The sonographic measurement of diaphragm revealed that its thickness is decreased in patients with chronic liver disease patients (2.12 ± 0.54 mm) as compared to healthy donors (3.70 ± 0. 58 mm). On multiple logistic regression, higher duration of mechanical ventilation was associated with diaphragmatic thickness < 2 mm (Group 1 of recipients) (adjusted odds ratio 0.86; 95% confidence interval: 0.75–0.99; P = 0.013) after adjusting for age, gender, and body mass index. Conclusions: Diaphragmatic thickness is decreased in patients with chronic liver disease as compared to healthy liver donors. Preoperative measurement of ultrasound-guided right hemidiaphragm thickness can be used to predict weaning failure in patients undergoing LT. Other studies are needed to confirm these finding on different group of patients.

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Background and Aims: The critically ill patients with liver disease are vulnerable to infections in both community and hospital settings. The nosocomial infections are often caused by multidrug-resistant (MDR) bacteria. The present observational study was conducted to describe the epidemiology, course, and outcome of MDR bacterial infection and identify the risk factors of such infection in critically ill patients with liver disease. Materials and Methods: A retrospective observational study was conducted on 106 consecutive critically patients with liver disease admitted in the Intensive Care Unit between March 2015 and February 2017. The MDR and non-MDR (non-MDR) groups were compared and the risk factors identified by multivariate analysis. Results: Out of the 106 patients enrolled in the study, 23 patients had infections caused by MDR bacteria. The MDR-infected patients had severe liver disease (Child–Pugh score 11 ± 2.3 vs. 7 ± 3.9; P = 0.04), longer duration of antibiotic usage (6 ± 2.7 days vs. 2 ± 1.5 days; P = 0.04), greater use of total parenteral nutrition (TPN) (73.9% vs. 62.6%; P = 0.04), and more concurrent antifungal administration (60.8% vs. 38.5%; P = 0.04). The mortality was higher in MDR group (hazard ratio = 1.86; P < 0.05). The independent predictors of MDR bacterial infection were Child–Pugh score >10, prior carbapenem use, antibiotic use for more than 10 days, TPN use, and concurrent antifungal administration. Conclusion: The study demonstrated a high prevalence of MDR bacterial infection in critically ill patients with a higher mortality over non-MDR bacterial infection and also identified the independent predictors of such infections.

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Parasitic twin is a rare form of conjoined twins with an incidence ranging from 1 in 50,000 to 1,00,000 live births. In thoracopagus type, both hearts are joined together and often are associated with underlying congenital cardiac malformations. The separation surgery is a challenging task for both the surgeon as well as anesthetist due to the complexity of the procedure and long duration of surgery, carrying mortality close to 100% in case of significant cardiac fusion. Here, we are sharing anesthetic management of successful separation of a rare type of parasitic male conjoined twins who had connected hearts and common liver.

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Background: Psoas sciatic block (Pso/Sci) is a modern anesthetic technique for lower extremities surgery. The use of this technique can avoid the adverse effects of the general anesthesia or the central neuroaxial blockade, especially in patients with multiple comorbidities. Purpose: The purpose of this study is to compare the efficacy of combined Pso/sci as a sole anesthetic technique with conventional combined spinal epidural (CSE) anesthesia for patients undergoing total knee arthroplasty. Methods: Eighty patients scheduled for total knee replacement were included in the study. Patients were divided into two equal groups: Pso/sci group received ultrasound guided with the use of nerve locator continuous Pso/sci and the second group (CSE) received CSE anesthesia. Onset of sensory and motor block time, hemodynamic changes, contralateral spread, first-time need for analgesia, incidence of complications, and patient and surgeon satisfactions were recorded. Results: The block time was significantly higher in the (Pso/Sci) group. Two patients in (Pso/Sci) had contralateral spread. Sensory and motor block onsets were delayed significantly in (Pso/Sci). Hemodynamic changes occurred in the CSE; however, it was insignificant compared to Pso/sci group. The first analgesic request was significantly later in (Pso/Sci) compared to the CSE group. There were no differences found in both groups as regard complications, early mobilization, and patients and surgeons satisfaction. Conclusions: Psoas sciatic block is an alternative safe and successful anesthetic technique, which can provide an adequate anesthesia for total knee surgery with less hemodynamic changes.

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The prevalence of pulmonary artery catheter (PAC) entrapment in open-heart surgery is scarce with a prevalence rate of 0.065%. Challenges in managing such cases lie particularly in choosing the modalities (chest roentgenogram, fluoroscopy, and transesophageal echocardiography) to accurately identify the anatomic location and cause of entrapment. In this case, we report a 42-year-old man who underwent mitral valve replacement with PAC entrapment discovered on postoperative day 2 and subsequently underwent retrieval after re-sternotomy. This case also highlights the usefulness of transesophageal echocardiography by the cardiac anesthetist in aiding the surgeons to locate the anatomic location where the catheter was entrapped.

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We report a case of a 32-year-old male patient who developed unilateral lower-limb compartment syndrome following a long surgical procedure during which intermittent pneumatic compression was used as deep-venous thrombosis prophylaxis. This complication of surgery is associated with significant morbidity. Previously published reports have suggested the possible risk factors and a way to reach a diagnosis at an early stage. The possible risk factors we present are the long operative time and the use of intermittent pneumatic compression as deep-vein thrombosis prophylaxis. These findings could be used to raise awareness in early diagnosis and treatment.

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Obstructive sleep apnea (OSA) is prevalent and presents perioperative challenges. There are guidelines regarding perioperative care of OSA, but analgesia management of OSA patients is inconsistent or inadequate. This is a study of the United Kingdom anesthesiologists' postoperative analgesia preferences for OSA patients. Overall, the 1^st choice of main analgesia was continuous epidural local anesthetic (LA) without opioid, at 30% rate; P = 0.001. The 2^nd choice was continuous epidural LA plus fentanyl, at 21% rate; P = 0.001. The 3^rd choice was intrathecal diamorphine, at 19% rate; P = 0.001. The 4^th choice was nerve block catheter LA infusion, at 13% rate; P = 0.001. The 5^th choice was wound infiltration with LA ± epinephrine, at 8% rate; P = 0.001. The 6^th choice was systemic opioid, at 7% rate; P = 0.007. The 7^th choice was systemic nonsteroidal anti-inflammatory drugs, at 2% rate; P = 0.001. The hospital setting or anesthesiologists' experience did not significantly impact analgesia choice: P =0.411. This study shows that current practice by anesthesiologists has a preference for regional or opioid-sparing analgesia for OSA patients. This safe approach conforms to guidelines and should be encouraged.

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The vertical infraclavicular block (VIB) of the brachial plexus is commonly used to provide local anesthesia (LA) of the upper limb. The original method involves LA injection at the mid-point of an infraclavicular line between acromion and jugular fossa. However, this method is ineffective in adult patients with variant anatomy. Two modified VIB methods have been previously suggested. This prospective observational, clinical study compared both modified VIB approaches. The study showed that modified VIB is easy, efficacious, and applicable to all adult patients; including those with small stature, extreme tallness, or variant anatomy.

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Spinal anesthesia (SA) is utilized as an effective means of anesthesia and has an impressive safety record but it is not devoid of complications, and sometimes, the complications are as fatal as cardiac arrest. Although many factors are involved in etiology of cardiac arrest under SA, the vagal responses to the decreased preload are the most common culprits. We report two cases of cardiac arrest under SA; which happened despite our patient being adequately preloaded utilizing the ultrasonography-guided targeted volume therapy. The patients were successfully resuscitated with no neurological deficit.

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A left lung mass after induction and tracheal intubation, which partially was obstructing the left main bronchus, was accidentally discovered in a 56-year-old female scheduled to undergo elective total thyroidectomy. Her preoperative chest X-ray showed a right-sided shift of the trachea. She did not have stridor or shortness of breath or superior vena cava obstructive syndrome. Induction and tracheal intubation were performed uneventfully. Fiberoptic bronchoscopy performed and showed complete obstruction on the left main bronchus. Excision biopsy suggested mucoepidermoid carcinoma (MEC). MEC is one of the very rare neoplasms of the lungs. Most lesions are low grade and overall prognosis may be more favorable than other forms of lung cancer.

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Abnormalities of the coronary vascular branches and cardiac hemangiomas represent together unusual clinical entities, with an incidence difficult to establish for the former as the vast majority of the patients with these anomalous vascular connections are usually asymptomatic and 2.8% for the latter. Symptomatic patients may develop dyspnea on exertion or chest pain secondary to a “coronary steal” phenomenon as part of the underlying pathophysiology of the disease. The authors report a case of a patient with concomitant cardiac capillary hemangioma with multiple coronary to pulmonary artery fistula connections that was successfully treated with surgical resection of the tumor and ligation of the fistula tracts. A comprehensive and balanced anesthesia management aimed to preserve tight hemodynamic stability to avoid increased myocardial demand and worsening of the coronary steal becomes essential in these patients.

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