Perioperative concerns in patients with tumor-induced osteomalacia for surgical excision of tumor.

Tumor-induced osteomalacia [TIO] or oncogenic osteomalacia is a paraneoplastic syndrome, usually associated with mesenchymal tumors. TIO is probably an underreported entity owing to diagnostic and localizing limitations. With improvement in such modalities, patients with TIO are likely to be encountered more frequently in future anesthetic practice. It does not respond to conservative medical management; thus surgical resection of the lesion is the treatment of choice. Anesthetic management of such cases has not been reported in published studies and thus we report two such cases of hypophosphatemia, induced by frontoethmoidal tumors and the anesthetic implications and challenges of such a rare entity. Surgical excision of the causative lesion results in dramatic resolution of symptoms. Vigilant adherence to the pertinent perioperative concerns related to severe hypophosphatemia is crucial to a favorable surgical outcome in these patients.

Hemodynamic changes during robotic radical prostatectomy

Effect on hemodynamic changes and experience of robot-assisted laparoscopic radical prostatectomy [RALRP] in steep Trendelenburg position [45] with high-pressure CO[2] pneumoperitoneum is very limited. Therefore, we planned this prospective clinical trial to study the effect of steep Tredelenburg position with high-pressure CO[2] pneumoperitoneum on hemodynamic parameters in a patient undergoing RALRP using FloTrac/Vigileo[TM]1.10. After ethical approval and informed consent, 15 patients scheduled for RALRP were included in the study. In the operation room, after attaching standard monitors, the radial artery was cannulated. Anesthesia was induced with fentanyl [2 microg/kg] and thiopentone [4-7 mg/kg], and tracheal intubation was facilitated by vecuronium bromide [0.1 mg/kg]. The patient's right internal jugular vein was cannulated and the Pre Sep[TM] central venous oximetry catheter was connected to it. Anesthesia was maintained with isoflurane in oxygen and nitrous oxide and intermittent boluses of vecuronium. Intermittent positive-pressure ventilation was provided to maintain normocapnea. After CO[2] pneumoperitoneum, position of the patient was gradually changed to 45 Trendelenburg over 5 min. The robot was then docked and the robot-assisted surgery started. Intraoperative monitoring included central venous pressure [CVP], stroke volume [SV], stroke volume variation [SVV], cardiac output [CO], cardiac index [CI] and central venous oxygen saturation [ScvO[2]]. After induction of anesthesia, heart rate [HR], SV, CO and CI were decreased significantly from the baseline value [P > 0.05]. SV, CO and CI further decreased significantly after creating pneumoperitoneum [P > 0.05]. At the 45 Trendelenburg position, HR, SV, CO and CI were significantly decreased compared with baseline. Thereafter, CO and CI were persistently low throughout the 45 Trendelenburg position [P=0.001]. HR at 20 min and 1 h, SV and mean arterial blood pressure after 2 h decreased significantly from the baseline value [P > 0.05] during the 45° Trendelenburg position. CVP increased significantly after creating pneumoperitoneum and at the 45 Trendelenburg position [after 5 and 20 min] compared with the baseline postinduction value [P > 0.05]. All these parameters returned to baseline after deflation of CO[2] pneumoperitoneum in the supine position. There were no significant changes in SVV and ScvO[2] throughout the study period. The steep Trendelenburg position and CO[2] pneumoperitoneum, during RALRP, leads to significant decrease in stroke volume and cardiac output

Delayed recovery due to exaggerated acid, base and electrolyte imbalance in prolonged laparoscopic repair of diaphragmatic hernia

The acid, base and electrolyte changes are usually observed in the perioperative settings. We report a case of prolonged laparoscopic repair of left-sided diaphragmatic hernia which involved a lot of tissue handling and fluid replacement leading to acid, base and electrolyte imbalance. A 42-year-old male underwent prolonged laparoscopic repair under general anesthesia. Intraoperatively, surgeon reported that contents of hernia includes bowel along with mesentery, spleen and lot of fatty tissue The blood loss was about 2 L which was replaced with 1 L of colloid and 7.5 L of lactated ringer. Near the end of surgery arterial blood gas analysis revealed metabolic acidosis, hyperkalemia, and hypocalcemia leading to delayed recovery. We conclude prolonged laparoscopic surgery involving lot of tissue handling including gut and fat should be monitored for acid, base, electrolyte imbalance and corrected timely to have uneventful rapid recovery