The unexpected diagnosis of phaeochromocytoma in the anaesthetic room

A 77-year-old man was admitted for aortic valve replacement and combined coronary bypass grafting. Grossly, labile arterial pressures were demonstrated on anesthetic induction prompting cancellation and Intensive Care Unit transfer. Urine analysis identified high normetadrenaline/creatinine ratio, plasma metanephrine, and plasma normetanephrine. A left adrenal lesion on computed tomography scan collectively indicated pheochromocytoma. Laparoscopic adrenalectomy was prioritized at multidisciplinary team before cardiac surgery. Vague symptoms of pheochromocytoma pose a diagnostic problem, being often attributed to common/co-existing pathology. The blood pressure instability on anesthetic required precise control, multidisciplinary input, and awareness of possible diagnosis as a routine intervention for hypotension may have been fatal in view of underlying cardiac pathology.

A comparative study between propofol and etomidate in patients under general anesthesia / Estudo comparativo entre propofol e etomidato em pacientes sob anestesia geral

ABSTRACT BACKGROUND AND OBJECTIVES: Induction of anesthesia is a critical part of anesthesia practice. Sudden hypotension, arrhythmias, and cardiovascular collapse are threatening complications following injection of induction agent in hemodynamically unstable patients. It is desirable to use a safe agent with fewer adverse effects for this purpose. Present prospective randomized study is designed to compare propofol and etomidate for their effect on hemodynamics and various adverse effects on patients in general anesthesia. METHODS: Hundred ASA I and II patients of age group 18-60 years scheduled for elective surgical procedure under general anesthesia were randomly divided into two groups of 50 each receiving propofol (2 mg/kg) and etomidate (0.3 mg/kg) as an induction agent. Vital parameters at induction, laryngoscopy and thereafter recorded for comparison. Adverse effect viz. pain on injection, apnea and myoclonus were carefully watched. RESULTS: Demographic variables were comparable in both the groups. Patients in etomidate group showed little change in mean arterial pressure (MAP) and heart rate (HR) compared to propofol (p > 0.05) from baseline value. Pain on injection was more in propofol group while myoclonus activity was higher in etomidate group. CONCLUSIONS: This study concludes that etomidate is a better agent for induction than propofol in view of hemodynamic stability and less pain on injection.

RESUMO JUSTIFICATIVA E OBJETIVOS: A indução é uma parte crítica da prática de anestesia. Hipotensão súbita, arritmias e colapso cardiovascular são complicações ameaçadoras após a injeção de agente de indução em pacientes hemodinamicamente instáveis. É aconselhável o uso de um agente seguro com menos efeitos adversos para esse propósito. O presente estudo prospectivo, randômico, teve como objetivo comparar propofol e etomidato quanto a seus efeitos sobre a hemodinâmica e aos vários efeitos adversos em pacientes sob anestesia geral. MÉTODOS: Cem pacientes ASA I e II, entre 18-60 anos, programados para procedimento cirúrgico eletivo sob anestesia geral, foram divididos aleatoriamente em dois grupos de 50 cada para receber propofol (2 mg/kg) e etomidato (0,3 mg/kg) como um agente de indução. Os parâmetros vitais na indução, laringoscopia e posteriormente foram registrados para comparação. Efeitos adversos como dor à injeção, apneia e mioclonia foram cuidadosamente monitorados. RESULTADOS: As variáveis demográficas foram comparáveis em ambos os grupos. Os pacientes do grupo etomidato apresentaram pouca alteração da pressão arterial média (PAM) e da frequência cardíaca (FC) em comparação com o grupo propofol (p < 0,05) a partir do valor basal. Houve mais dor à injeção no grupo propofol, enquanto houve mais atividade mioclônica no grupo etomidato. CONCLUSÕES: Este estudo conclui que etomidato é um agente melhor para a indução do que o propofol em relação à estabilidade hemodinâmica e menos dor à injeção.

Effect of protective lung ventilation strategy applied from anesthesia induction period on lung compliance and oxygenation in patients undergoing gynecological laparoscopic surgery / 临床麻醉学杂志

Objective To explore the effects of protective lung ventilation strategy applied from anesthesia induction period on lung compliance and oxygenation in patients undergoing gyneco-logical laparoscopic surgery.Methods A total of 60 female patients underwent gynecological laparo-scopic surgery were randomly divided into protective lung ventilation strategy beginning from induction group (group A),protective lung ventilation strategy beginning after intubation group (group B),conventional ventilation group (group C).All the three groups received intermittent posi-tive ventilation.The oxygen concentration was 100% and oxygen flow rate was 2 L/min,the inhalation and exhalation ratio was 1∶2.Group A was given low tidal volume+low PEEP+lung recruitment ma-neuver (from induction,i.e.after the disappearance of spontaneous breathing,take mask ventilation lasted for 5 minutes with a tidal volume of 6 ml/kg,respiratory rate was 1 6 times/min,PEEP was 5 cm H 2 O,which was applied every 30 min);group B was given low tidal volume+low PEEP+lung recruitment maneuver (before intubation:tidal volume was 10 ml/kg,respiratory rate was 10 times/min;after intubation:tidal volume was 6 ml/kg,respiratory rate was 1 6 times/min,PEEP was 5 cm H 2 O,which was applied every 30 min);group C:tidal volume was 10 ml/kg,respiratory rate was 10 times/min.Ppeak,Pmean,CL were recorded at induction (T0 ),after intubation (T1 ),30 min (T2 ),60 min (T3 )during operation,release of pneumoperitoneum (T4 ).The arterial blood gas analysis was performed at T0 ,T1 ,T3 and after extubation (T5 ).Then the oxygenation index (OI)and pulmonary shunt fraction (Qs/Qt)was calculated.Results The Ppeak and Pmean were significantly higher among the three groups after pneumoperitoneum (T1 ,T2 ,T3 ,T4 )compared with T0 (P <0.05),Ppeak of group C was significantly higher compared with that of group A and group B and Pmean at T2 increased significantly (P < 0.05 );The CL of three groups decreased obviously after pneumoperitoneu (P <0.05),CL of group C was lower significantly than that of group A and group B at T3 ,T4 (P <0.05)while the difference between group A and group B were not significant.The OI of the three groups decreased significantly after exthbation (P <0.05)and the difference among the three groups was not significant.Qs/Qt of three groups increased obviously at T3 and decreased at T5 (P <0.05),Qs/Qt of group C was higher significantly than that of group A and group B at T3 (P <0.05).Only one patient in group C got pulmonary infection.Conclusion Compared with conventional ventilation,the protective lung ventilation strategy can significantly improve the lung compliance and oxygenation function in the patients undergoing gynecological laparoscopic surgery.

The effects of hemodynamics for elderly patients on different ways to induce the sevoflurane / 中国基层医药

Objective To observe the effects of hemodynamics for elderly patients on different ways to induce the sevoflurane .Methods 42 cases of elderly patients were selected and divided into A ,B and C groups with simple random method,14 cases respectively In A,B,C group.Patients were treated with drugs in different concentra-tions of sevoflurane inhalation induction of anesthesia .The patient's heart rate ,loss of consciousness awake to the time were observed and recorded .Results After treatment,A,B,C group disappearance time of awareness were (64.10 ± 6.49)s,(64.00 ±6.97)s and (83.20 ±13.28)s,A and B groups after a comparative analysis ,the difference was not statistically significant (t=0.323,P>0.05),group C and group A,B after a comparative analysis,the difference was statistically significant (t=5.328,P 0.05).Conclusion Elderly patients after sevoflu-rane induction ,the effect is significant ,stable circulation .

The development of ventricular fibrillation due to etomidate for anesthetic induction: a very rare side effect, case report / Desenvolvimento de fibrilação ventricular por causa de etomidato para indução anestésica: um efeito colateral muito raro, relato de caso / Desarrollo de fibrilación ventricular debido al etomidato para la inducción anestésica: un efecto colateral muy raro, relato de caso

Background and objectives: Ventricular fibrillation occurring in a patient can result in unexpected complications. Here, our aim is to present a case of ventricular fibrillation occurring immediately after anesthesia induction with etomidate administration. Case report: A fifty-six-year-old female patient with a pre-diagnosis of gallstones was admitted to the operating room for laparoscopic cholecystectomy. The induction was performed by etomidate with a bolus dose of 0.3 mg/kg. Severe and fast adduction appeared in the patient's arms immediately after induction. A tachycardia with wide QRS and ventricular rate 188 beat/min was detected on the monitor. The rhythm turned to VF during the preparation of cardioversion. Immediately we performed defibrillation to the patient. Sinus rhythm was obtained. It was decided to postpone the operation due to the patient's unstable condition. Conclusion: In addition to other known side effects of etomidate, very rarely, ventricular tachycardia and fibrillation can be also seen. To the best of our knowledge, this is the first case regarding etomidate causing VF in the literature. .

Justificativa e objetivos: A ocorrência de fibrilação ventricular em um paciente pode resultar em complicações inesperadas. Nosso objetivo é apresentar um caso de fibrilação ventricular que ocorreu após a indução anestésica com administração de etomidato. Relato de caso: Paciente do sexo feminino, 56 anos, com pré-diagnóstico de cálculos biliares, foi admitida na sala de cirurgia para colecistectomia laparoscópica. A anestesia foi induzida com a administração de etomidato com uma dose em bolus de 0,3 mg/kg. A paciente apresentou uma grave e rápida adução dos braços logo após a indução. Taquicardia com QRS largo e frequência ventricular de 188 bpm foram detectadas no monitor. O ritmo converteu-se em fibrilação ventricular (FV) durante a preparação para a cardioversão. A paciente foi imediatamente submetida a desfibrilação. O ritmo sinusal foi obtido. Decidimos adiar a cirurgia por causa da condição de instabilidade da paciente. Conclusão: Além dos efeitos secundários conhecidos de etomidato, taquicardia ventricular e fibrilação, embora muito raramente, também podem ser observadas. Até onde sabemos, esse é o primeiro caso na literatura de FV causado por etomidato. .

Justificación y objetivos: La aparición de fibrilación ventricular en un paciente puede originar complicaciones inesperadas. Nuestro objetivo es presentar un caso de fibrilación ventricular que ocurrió después de la inducción anestésica con administración de etomidato. Caso clínico: Paciente del sexo femenino, 56 años, con prediagnóstico de cálculos biliares que entró en quirófano para colecistectomía laparoscópica. La inducción de la anestesia fue realizada con administración de etomidato con una dosis en bolo de 0,3 mg/kg. La paciente presentó una grave y rápida aducción de los brazos inmediatamente después de la inducción. En el monitor se detectó taquicardia con QRS ancho y frecuencia ventricular de 188lpm. El ritmo se convirtió en fibrilación ventricular durante la preparación para la cardioversión. La pacientefue inmediatamente sometida a la desfibrilación. Se logró el ritmo sinusal. Decidimos postergar la cirugía debido a la condición de inestabilidad del paciente. Conclusión: Además de los efectos secundarios conocidos del etomidato también se pueden observar taquicardia ventricular y fibrilación (aunque sea algo muy raro). Hasta donde sabemos, este es el primer caso de fibrilación ventricular causado por etomidato en la literatura. .

Effects of pentazocine on intubation stress response during slow induction of anesthesia / 实用医学杂志

Objective To investigate the effect of pentazocine combined with midazolam on intubation stress response in slow induction of anesthesia. Mtheods Forty ASAⅠ~Ⅱpatients were divided into two groups. Anesthesia was induced with midazolam 0.03 mg/kg in both groups,and pentazocine 0.8 mg/kg (i.v.) was given in pentazocine group or fentanyl 2 μg/kg (i.v.) in fentanyl group. Five minutes later, 2 mL of 1% decicaine was administered by cricothyroid membrane puncture to facilitate the intubation.The SpO2, circulatory indexes (HR, SBP, DBP, BIS) and sedation level were measured at T0, T1, T2, T3, T4, T5, T6. Results Both pentazocine and fentanyl can inhibit stress responses to tracheal intubation effectively,but pentazocine group is better than fentanyl group on the cardiovascular stability during slow induction of anesthesia. Conclusion Pentazocine 0.8 mg/kg can inhibit stress responses to tracheal intubation effectively with a low incidence of adverse reactions in the slow induction of anesthesia.

Effects of sulfentanyl or fentanyl combined with midazolam on respiratory function during slow induction of anesthesia / 解放军医学杂志

Objective To compare the influences of sulfentanyl or fentanyl combined with midazolam on respiratory function in slow induction of anesthesia.Methods Forty ASA Ⅰ-Ⅱ patients were divided into two groups.Anesthesia was induced with midazolam 0.03mg/kg in both groups,and fentanyl 2?g/kg(i.v.)was given in fentanyl group or sulfentanyl 0.2?g/kg(i.v.)in sulfentanyl group.Five minutes later,2ml of 1% decicaine was administered by cricothyroid membrane puncture to facilitate the intubation.Respiratory indexes(respiratory frequency,VT,MVV,PETCO2,SPO2),circulatory indexes(MAP,HR)and sedation level were measured before and 1,2,3,4,5 minute(s)after injection of drugs,at cricothyroid membrane puncture,and pre-and post-intubation.Results Patients showed respiratory depression(respiratory frequency was reduced)in both groups 2 minutes after injection of drugs.However,respiratory frequency was decreased more markedly in fentanyl group than that in sulfentanyl group.Ten out of 20 patients were obliged to receive breathing intervention in fentanyl group,but two in sulfentanyl group.Conclusion In combination with midazolam,sedative effect of sulfentanyl is stronger than that of fentanyl in equivalent analgesic dose,but with less respiratory depression.Sulfentanyl may be more suitable for slow induction of anesthesia.