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*الواقعة:(83- 87)*

" فَلَوْلَا إِذَا بَلَغَتِ الْحُلْقُومَ (83) وَأَنْتُمْ حِينَئِذٍ تَنْظُرُونَ (84) وَنَحْنُ أَقْرَبُ إِلَيْهِ مِنْكُمْ ولكن لَا تُبْصِرُونَ (85) فَلَوْلَا إِنْ كُنْتُمْ غَيْرَ مَدِينِينَ (86) تَرْجِعُونَهَا إِنْ كُنْتُمْ صَادِقِينَ (87)". صدق الله العظيم. *الواقعة:(83- 87)*.

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*الواقعة:(83- 87)*

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  1. " فَلَوْلَا إِذَا بَلَغَتِ الْحُلْقُومَ (83) وَأَنْتُمْ حِينَئِذٍ تَنْظُرُونَ (84) وَنَحْنُ أَقْرَبُ إِلَيْهِ مِنْكُمْ ولكن لَا تُبْصِرُونَ (85) فَلَوْلَا إِنْ كُنْتُمْ غَيْرَ مَدِينِينَ (86) تَرْجِعُونَهَا إِنْ كُنْتُمْ صَادِقِينَ (87)" صدق الله العظيم *الواقعة:(83- 87)* Egypt, Sunset

  2. NO and APRV for the Treatment of Myocardial Stunning Complicated with ARDS after Cardiac Surgery: Case Report & Review of Literature Mohamed R. El-Tahan, M.D. Assistant Professor of Anaesthesia & Surgical ICU, University of Dammam, Dammam, Saudi Arabia,Member of the Association of Cardiothoracic Anaesthetists of UK,Member of the European Association of Cardio-Thoracic Anesthetists,Member of the Association of Anaesthetists of Great Britain and Ireland,Associate Professor of Cardiothoracic Anaesthesia & Surgical ICU,Mansoura University, Mansoura, Egypt,Instructor for ALS & EPLS, European Resuscitation Council.

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  4. N O

  5. N O

  6. N O

  7. N O

  8. Myocardial stunning is an uncommon post-ischemic reversible contractile dysfunction after cardiac surgery.

  9. Myocardial stunningoften defined as the need for prolonged inotropic therapy or IABP, which is frequently observed 4-6hrs. after the use of CPB for CABG surgery.

  10. Myocardial stunning usually resolves around 24hrs.postoperatively.

  11. Nitric oxide (NO) inhalation may represent a novel therapy for myocardial stunning by improving LV function after ischemia and reperfusion.

  12. Effect of iNO on myocardial infarct size. representative midventricular slice from a mouse breathing room air without iNO

  13. Serial changes in %baseline of slope of LV end-systolic pressure-volume relationship. †P<0.05 vs. baseline.

  14. History A 49-yrs-old (56kg, 156cm) gentleman with a history of hypertension, diabetes and coronary artery disease, presented for bypass grafting for the left-anterior descending (LAD) and right coronary (RCA) arteries.

  15. History Preoperative medications included atenolol and nitrates. Baseline cardiac troponin I (cTnI) was 0.04µg/L.

  16. TTE TTE findings showed an EFof 58%, apical-inferior wall hypokinesia, trivial mitral and tricuspid regurgitation, MPAPof 24mm Hg, and normal RV diameters.

  17. Cardiac Cath. Cardiac catheterization showed two-vessel disease (LAD and RCA) with good global LV function.

  18. Anesthesia Standardized balanced propofol, sufentanil, and cisatracuriumanesthesia was used with the maintenance of stable hemodynamics.

  19. Surgery Two vessels were grafted; internal mammary artery to the LAD and saphenous vein to the RCA.

  20. Surgery The cross-clamp time was 100 minand the CPB time was 160 min.

  21. Surgery Discontinuation of CPB was accomplished with withepinephrine(4µg/min).

  22. Postoperative Management The patient was shifted to the ICU while he was sedated and ventilated using SIMV/PSV mode with a FiO2of 0.45, VTof 450mL, frequency of 12/min, I: E ratio of 1:2, PEEPof 5cm H2Oand PSV of 20cm H2O.

  23. Postoperative Management

  24. Postoperative Management

  25. Postoperative Management Excessive mediastinal bleeding (900 mL)was notedthroughoutthe first 2postoperative hours.

  26. Postoperative Management Hemoglobin was 5.5g/dL. PT was 29.0s. INR was 2.3. aPTT was 98.5s. Platelet count was 15 103/mL. Fibrinogen was 72 mg/dL.

  27. Postoperative Management 5UPRBCs, 4 UFFP, 8Ucryoprecipitate was transfused, protamine sulfate (1mg/kg) was given, metabolic acidosis was corrected and normothermia was optimized. Unfortunately, hemorrhage persisted through the drainage tubes.

  28. Postoperative Management TEEshowed EFof 55%, normal RV diameters and wall motions, and ruled out of the pericardial collection.

  29. Postoperative Management The use of recombinant activated factor VII in a dose of 20μg/kgsucceeded in controlling of bleeding.

  30. Postoperative Management On the POD 2, ECGexcluded new ischemia and cTnI was 5.7µg/L.

  31. Postoperative Management Epinephrine infusion and ventilatory support were successfully discontinued.

  32. Postoperative Management Tracheal extubation was performed uneventfully.

  33. Postoperative Management The patient had developed cardiogenic pulmonary edemawith rising cTnI to 84µg/L.

  34. Postoperative Management ECGexcluded new onset myocardial ischemia. TEE showed EF of 32%, diffuse LV hypokinesis, normal RV function and absence of pericardial collection.

  35. Postoperative Management The patient was re-intubated and ventilated using SIMV/PSV mode using a FiO2 of 1.0, VT of 330mL, frequency of 16/min, I: E ratio of 1:2, PEEP of 5cmH2O and PSV of 20cmH2O.

  36. Postoperative Management For circulatory support, epinephrine (14µg/min), dopamine(15µg/kg/min) and IABP were necessary.

  37. Postoperative Management Coronary angiography confirmed the patency of the two bypass grafts and revealed global LV hypokinesis.

  38. Postoperative Management After 6 hrs. the patient developed progressive tachypnea>40/min, Paw≥42cm H2Oand refractory hypoxemiadespite of increasing the levels of PEEP to 15cm H2O.

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