[Hyperlactemia during undiagnosed pheochromocytoma resection under laparoscopy].

A 51-year-old man was scheduled to undergo adrenal tumor resection. Because his general physical findings and labolatory tests were not particular, and his serum concentrations of noradrenaline and adrenaline were within normal limit, the tumor was diagnosed as nonfunctional adrenal tumor. Anesthesia was induced with propofol, fentanyl and maintained with oxygen, air, propofol and remifentanil. When the surgeons started to work around the tumor, his blood pressure and heart rate increased suddenly. We decided to deal with the tumor as pheochromocytoma and started administering landiolol and prostaglandin E1. After the administration of the drugs, hemodynamic changes became stabilized; however, the increasing serum concentration of lactate continued until ligation of the adrenal vein. There were no clinical manifestations of circulatory failure and his liver function was within normal limits from his blood test. After the operation, we found his plasma concentration of adrenaline extremely high during the operation. Adrenaline increases blood lactate concentration due to metabolic effects. Hyperlactemia should be considered as one of the typical symptoms of pheochromocytoma.

[Anesthetic management for laparoscopic resection of adrenal pheochromocytoma in a woman with chronic renal failure].

A 52-year-old woman, undergoing hemodialysis for chronic renal failure over thirty years, developed pheochromocytoma. Her serum concentrations of noradrenaline (NA) and adrenaline were 5,330 pg x ml(-1) and 212 pg x ml(-1), respectively. She had often developed hypertensive crisis and also hypotensive crisis during hemodialysis, and quite often she had to give up continuing hemodialysis before its end. Anesthesia was induced by propofol, remifentanil and maintained with oxygen, air, propofol and remifentanil. Before starting operation, continuous hemodiafiltration (CHDF) was performed without any water removal. Although hypotension occurred temporarily after CHDF, severe hemodynamic changes were not observed during operation owing to NA substitution and infusion of 5% plasma protein fraction, and the operation was finished uneventfully. The molecular weight of NA is 169.18, and it can be filtered by CHDF. Because of removal of excessive NA by CHDF, we can avoid severe hemodynamic changes often observed in other case reports. CHDF was useful for anesthetic management of a patient with adrenal pheochromocytoma.

An unusual case of airway obstruction at the tip of an endotracheal tube caused by insertion of a nasogastric tube.

We report an unusual case of ventilatory impediment caused by the obstruction of an endotracheal tube (ETT) by a nasogastric (NG) tube. A 72-year-old woman with bronchial asthma was scheduled for colostomy closure. An ETT of 7.5-mm internal diameter (ID) could not be advanced, and finally a 5.0-mm ID ETT was placed, because she had post-intubation tracheal stenosis. When an NG tube was inserted after endotracheal intubation, ventilation suddenly became nearly impossible. She was treated for an asthmatic attack, but her respiratory condition did not recover. We then exchanged the ETT for a laryngeal mask airway (LMA) and removed the NG tube. It was suspected that the cause of the airway obstruction was that the NG tube in the esophagus compressed the membranous portion of the stenotic trachea and the tip of the ETT was obstructed.