Difficult anesthetic management during pheochromocytoma surgery.

The anesthetic management of two middle-aged patients having surgical removal of large pheochromocytomas is described. The same team of physicians was involved in the care of the patients, including an endocrinologist, who supervised their preoperative care. Although the preoperative care included pharmacologic adrenergic receptor blockade and fluid administration, guidelines for surgical readiness did not follow those recommended in our literature. Both patients experienced severe intraoperative hypotension after complete interruption of the tumors' venous drainage, and one patient suffered a cardiac arrest. Explanations for the occurrence of these problems are discussed, including factors relating to the complexity of the disease process. However, it is conceivable that appropriate input from the anesthesiologist during the preoperative preparation of these patients may have ameliorated, if not prevented, the encountered difficulties.

Carbon dioxide dynamics during apneic oxygenation: the effects of preceding hypocapnia.

STUDY OBJECTIVE: To compare the rate of increase of arterial carbon dioxide tension (PaCO2) during apneic oxygenation preceded by acute respiratory hypocapnia with that during apnea preceded by respiratory eucapnia. DESIGN: Randomized, prospective, single crossover study. SETTING: Operating room at a teaching hospital. PATIENTS: 19 ASA physical status I, II, and III patients requiring general endotracheal anesthesia and invasive monitoring for elective surgery. INTERVENTIONS: Two ventilatory states preceding apneic oxygenation were studied in each patient. The first respiratory state was established using controlled mechanical ventilation in the stable, anesthetized patient, followed by a 5-minute period of apneic oxygenation. Arterial and mixed central venous blood gas samples were obtained simultaneously prior to and at 1-minute intervals during apnea. Ventilatory parameters were then changed to establish the second respiratory state. During the subsequent period of apnea, the study was repeated as above. MEASUREMENTS AND MAIN RESULTS: Arterial and mixed central venous partial pressure of carbon dioxide (pCO2) levels were measured. A greater increase in PaCO2 was found during the first minute of apneic oxygenation in the hypocapneic group compared with the eucapneic group. The venoarterial gradient of pCO2 was also greater in the hypocapneic group prior to apnea. CONCLUSIONS: Acute hypocapnia compared with eucapnia prior to apneic oxygenation is associated with a greater rise in PaCO2 in the anesthetized patient. This finding may be due in part to widening of the venoarterial gradient of pCO2.

Rheumatic symptoms following adjuvant therapy for breast cancer.

Twenty-three women with a diagnosis of breast cancer who subsequently developed new nonmetastatic rheumatic symptoms, and/or had a history of rheumatic symptoms prior to their diagnosis of breast cancer, were identified from the oncology and rheumatology practices of a 400-bed tertiary-care teaching hospital. For each patient a structured telephone interview and detailed chart review were conducted. Of eight women with no previous rheumatic history (Group I), four developed polyarthritis (1 seropositive), three fibromyalgia, and one spondylosis after the diagnosis of breast cancer, which in four cases occurred during or shortly after cyclophosphamide-based combination chemotherapy, in two cases during tamoxifen therapy, and in one case after radiotherapy only. Of 15 women who had previous rheumatic symptoms (Group II), 12 developed worse and/or new symptoms, five after chemotherapy and seven on tamoxifen. In both groups the symptoms had a significant negative impact on functional status, and in some cases resolution was only partial even after many years of followup. Prospective studies are needed to determine the incidence, risk factors, and optimal management of nondestructive polyarthropathy or fibromyalgia in women who receive systemic adjuvant therapy for breast cancer.

Cardiovascular effects of different infusion rates of sufentanil in patients undergoing coronary surgery.

OBJECTIVE: Pharmacokinetics and haemodynamic effects of a total dose of 15 micrograms.kg-1 sufentanil, an opioid anaesthetic agent, were studied in patients undergoing aortocoronary bypass surgery at three infusion rates of 30 (group I), 5 (group II), and 2 (group III) micrograms.kg-1.min-1, respectively. RESULTS: Plasma concentrations of sufentanil could be optimally characterized by a linear biexponential pharmacokinetic model. Non-compartmental analyses indicated that there was no significant difference in the values of clearance (11.6, 13.3, 14.3 ml.min-1.kg-1), steady-state volume of distribution (0.220, 0.255 and 0.331 l.kg-1) and mean residence time (18.8, 13.3 and 14.3 min) among the groups. The observed mean Cmax values of 421 (group I), 125 (group II), and 53 (group III) ng.ml-1 and observed mean AUC values from 0 to 3 min were all consistent with the dosing regimens. There were large inter-individual variations in haemo-dynamic response. Compared to plasma data, a delay in haemodynamic effects was found. Times to reach peak haemodynamic effect ranged from 4.3 to 4.9 min for group I, from 4.6 to 6.1 min for group II, and from 9.9 to 11.3 for group III. Except heart rate, peak haemodynamic effects in these study patients generally ranged from 20.9% to 35.2%. Significant reductions in the area under the effect-time profiles of mean arterial blood pressure and systemic vascular resistance were observed in group II and group III, but not in group I. Significant reductions in the area under the effect-time profiles of left ventricular stroke work index were observed in group III only. No effect on heart rate was found in any group. CONCLUSION: Our findings suggested that a slower infusion rate of sufentanil at a dose of 15 micrograms.kg-1 tends to give a greater reduction in mean arterial blood pressure, systemic vascular resistance, and left ventricular stroke work index than does a faster infusion rate.

Aortic dissection in giant-cell arteritis.

Twenty-three cases of aortic dissection in patients with giant-cell arteritis are reviewed and an additional case is reported. Forty-six percent presented catastrophically with aortic dissection and no prior history of giant cell arteritis. Eighty percent died within 2 weeks of the event; four patients had successful surgical grafts. There was diffuse involvement of the aorta with giant cells in 89%, but dissecting tears occurred primarily in the proximal aorta in 85% of cases. The majority of cases with a preceding history of giant cell arteritis were on low doses of steroid or on no treatment at the time of dissection, and the median erythrocyte sedimentation rate of these patients was 62 mm/h (range 21-98). Evidence of some form of hypertension, whether acute or chronic, mild or severe, was found in 77% of patients. Inadequate treatment of giant-cell arteritis and underlying hypertension (treated or untreated) are potential factors leading to aortic dissection in these patients.

In vitro effect of fresh frozen plasma on the activated coagulation time in patients undergoing cardiopulmonary bypass.

The in vitro effect of fresh frozen plasma (FFP) on the whole blood activated coagulation time (ACT) was examined in 18 patients undergoing cardiopulmonary bypass (CPB) during coronary artery bypass graft surgery. The addition of FFP to whole blood in vitro, after systemic heparinization, significantly prolonged the ACT from 451 +/- 21 seconds (mean +/- SE) to 572 +/- 41 seconds (P less than 0.05). There was no significant correlation between the plasma antithrombin III activity and the prolongation in ACT after systemic heparinization, with or without addition of FFP. The addition of FFP to whole blood in three of the six patients who exhibited heparin resistance (ACT less than 400 seconds after administration of 350 unit/kg heparin) did not prolong the ACT to greater than 400 seconds. These observations suggest that infusion of FFP will further prolong the ACT after heparin administration in most patients including some with initial heparin resistance.

Intraarticular methylprednisolone therapy in hemophilic arthropathy.

This small pilot study examined the use of intraarticular methylprednisolone in hemophilic synovitis. Nineteen joints in ten adult hemophiliacs were studied. There was subjective improvement at 24 hr following injection in 79% of joints injected, and the improvement persisted up to 8 wk in 58%. The number of hemarthroses decreased following intraarticular steroids (mean of 7.7 bleeds in the 8 wk prior to injection versus a mean of 1.9 bleeds in the 8 wk following injection). Similarly the amount of clotting factor used for the injected target joint decreased from a mean of 7,616 units to 2,315 units postinjection (p less than .001). Improvement correlated with presence of synovitis but not with radiologic stage of the joint. Aspirated synovial fluids were analyzed and showed characteristics consistent with low-grade inflammation. These preliminary observations suggest that intraarticular corticosteroid injection may be a useful therapeutic tool in the medical management of hemophilic arthropathy.

Comparison between high-dose sufentanil-oxygen and high-dose fentanyl-oxygen for neuroanaesthesia.

The cardiovascular responses to anaesthesia, neurosurgery and the postoperative administration of naloxone were studied in 20 patients. Ten patients were anaesthetized with sufentanil 20 micrograms kg-1 and 10 with fentanyl 100 micrograms kg-1, and oxygen. At 30-min intervals, sufentanil 50 micrograms or fentanyl 250 micrograms was given to maintain anaesthesia. Mean arterial pressure and heart rate did not increase following intubation, incision of the scalp or infusion of naloxone. Because of inadequate anaesthesia, thiopentone was administered at the end of surgery to one patient who had received sufentanil and seven patients who received fentanyl. Apart from one patient in each group the tracheal tubes were removed within 1 h of the start of the administration of naloxone. Recall of tracheal intubation or surgery was not reported by any patient. High-dose sufentanil-oxygen anaesthesia, like high-dose fentanyl-oxygen anaesthesia, was satisfactory for use in neurosurgery. However, high-dose narcotic anaesthesia, followed by the postoperative administration of naloxone, requires that skilled nursing care be available for many hours after surgery.

High dose fentanyl-oxygen anesthesia for intracranial mycotic aneurysm surgery: a clinical report.

The resection of a mycotic aneurysm in a patient with concurrent cardiac valvular disease was carried out successfully using high dose fentanyl-oxygen anesthesia followed by immediate postoperative naloxone reversal. The technique and benefits of this type of anesthesia in neurosurgical procedures are discussed.

Avascular necrosis of bone with rheumatoid vasculitis.

A 76-year-old woman with classical rheumatoid arthritis presented with a left groin mass associated with radiologic erosion of the adjacent bony public ramus. The hip joint was not involved. Computerized tomography showed an encapsulated cyst of the pubic ramus that was surgically excised and measured about 6 x 8 cm. Histologic examination of the cystic mass and adjacent bone showed marked avascular necrosis, surrounded by an acute necrotizing vasculitis with fibrinoid necrosis. We postulate that, in this case, rheumatoid vasculitis caused an avascular necrosis of the pubic ramus.

Neuroarthropathy (Charcot joints) in familial amyloid polyneuropathy.

Two patients with familial amyloid polyneuropathy (FAP) of Andrade type developed neuroarthropathy (Charcot joints). In 1 patient both knees were affected and in the other patient both ankles. This complication added markedly to the already severe disability and limitation of movement caused by the underlying illness. To the best of our knowledge this is the first description of Charcot joints in FAP. Neuroarthropathy in FAP is probably more common than previously suspected and should be sought in any case of FAP with joint disease.