A 60-year-old male had the symptoms of dyspnea, orthopnea, swelling in hands and feet, and cyanosis in lips and tongue for two months. He was admitted to a health-center and diagnosed with SVCS due to substernal goiter. After 2 days, his condition deteriorated, and he was admitted to emergency department of our hospital. On physical examination, excessive edema and cyanosis in upper chest wall and head-neck area were found out. His neck was short and thick with restricted movements. As he had developed dyspnea and arrhythmia, he was transferred to surgical intensive care unit. According to medical records, he had unsatisfactory sleep quality, excessive daytime sleepiness, severe snoring, and sleep apnea since 2 months ago. His body mass index (BMI) was 39 kg/m2, indicating obesity. Thyroid function tests revealed euthyroidism. His chest X-ray showed bilateral upper mediastinal enlargement and deviation of trachea (). Thorax computerized tomography (CT) revealed the deviation of trachea without obstruction, and compression of superior vena cava by the right lobe of thyroid gland. Previous polysomnography findings were obtained. Apnea-hypopnea index (AHI) was calculated as 26.7 episodes/h and nocturnal oxygen desaturation was documented as 65%. OSAS was diagnosed with the aid of polysomnography.\nAn urgent endotracheal intubation and mechanical ventilation were planned because of severe respiratory acidosis and hypercapnia (pH: 7.192, PaCO2: 145 mmHg, PaO2: 60 mmHg with 8 L/min nasal oxygen supplement). Following preoxygenation with 100% O2 via face mask, light anesthesia was induced with propofol, and laryngoscopy was applied without muscle relaxant. Spontaneous respiration was preserved after the administration of propofol. In the laryngoscopic assessment, Cormack and Lehane grade was considered as 4. The laryngeal Mask Airway (LMA) was placed promptly after failed endotracheal intubation. Mechanical ventilation was initiated through LMA and tracheostomy was performed uneventfully. The patient with SVCS was given antiedemal (steroid and diuretic), empiric antibiotic, and bronchodilator treatment in intensive care unit. Hence, his upper extremity and face-neck edema were reduced evidently. The steroid treatment was stopped, when nosocomial pneumonia was diagnosed on the 12th day. After the treatment of pneumonia, steroid treatment was restarted. The ventilatory mode was changed from synchronized intermittent mandatory ventilation (SIMV) to continuous positive airway pressure (CPAP) when arterial blood gas analysis revealed acceptable values (pH: 7.494, PaCO2 37.1 mmHg, PaO2 64.9 mmHg, HCO3 27.9 using FiO2 0.35) on the 35th day of mechanical ventilation. CPAP ventilation was applied for one week. Follow up T connector with oxygen supply was put on the tracheostomy cannula. Weaning was performed successfully on the 45th day.\nTracheal compression resulting from the enlargement of thyroid gland extending to substernal archus was detected in control CT after weaning (). The case was referred to thoracic surgeon, and he decided to perform thyroidectomy. The patient lost weight rapidly and thyroid function test indicated hyperthyroidism, which was attributed to the radiopaque agent used for CT. As soon as the result of thyroid function test returned to normal range, total thyroidectomy was performed successfully through collar incision and median sternotomy in elective conditions. Histopathological examination revealed a benign multinodular goiter. He was recovered and discharged from the hospital on the 14th postoperative day.
Case 7 involved an 8-year-old girl with a diagnosis of ventricular septal defect. She presented to the ICU as intubated after ventricular septal defect (VSD) closure. She was on 7.4mcg/kg/min dopamine, 8mcg/kg/hr dobutamine, and 0.08mcg/kg/min adrenalin support postoperatively. She received a 1mg/hr midazolam infusion for 14 hours and a 0.15mg/kg/hr tramadol infusion for 23 hours. After 24 hours, her pupils were dilated and an epidural hemorrhage and shift were detected in her cranial computational tomography (CT) scan, after which the epidural hemorrhage was extracted. Despite the lack of sedative administration for the first 96 postoperative hours, she was sedated and the conditions of her pupils did not change. A reverse flow was detected in her carotid Doppler scan but no intracerebral hemorrhage was detected in her cerebral angiogram. At 98 postoperative hours, she performed the standard apnea test and her ApneaLink™ recordings were made simultaneously. Due to the desaturation occurring at the end of the apnea test that lasted 4 minutes and 38 seconds, continuous positive airway pressure (CPAP) treatment was applied. Her PaCO2 value increased from 45 to 75mmHg and the ApneaLink™ showed that there was no respiratory effort present. This demonstrated that the presence of apnea can be seen and recorded by ApneaLink™ during the apnea test.