Perioperative management of phaeochromocytoma.

Phaeochromocytoma is a rare catecholamine producing tumour, feared for its life threatening cardiovascular disturbances during anaesthesia. Improved medical and anesthetic management resulted in reduction of perioperative phaeochromocytoma resection mortality from about 50% in the pioneer period to near 0% nowadays. Cardiomyopathy is usually reversible if managed properly. Stress related or (inverted) Tako Tsubo cardiomyopathy is a recent finding, deserving our attention. Preoperative alpha blockade should be performed to achieve cardiovascular stability and decrease uncontrolled intraoperative surges in blood pressure. During anaesthesia, additional antihypertensive (also mainly alpha blocking) agents are essential to prevent and overcome hypertensive crises. Magnesium sulphate is a safe and promising agent in improving cardiovascular stability and should have a place in standard therapy. A careful selection of anaesthetic drugs and techniques that cause the least hypertension is most important. Preoperative and intraoperative beta-blockade can only be used as adjuvant therapy, mainly to control tachycardia and other rhythm disturbances. Postoperatively, the patient is transferred to the intensive care unit where adequate management of haemodynamic and metabolic complications takes place.

[Primary peritonitis combined with streptococcal toxic shock syndrome following an upper respiratory tract infection caused by Streptococcus pyogenes]. / Primaire peritonitis in samenhang met streptokokken-toxischeshocksyndroom na bovensteluchtweginfectie door Streptococcus pyogenes.

A 52-year-old woman with no previous history of major health problems presented with an acute abdomen and symptoms of shock. Three days earlier she had been diagnosed as having acute laryngitis which was treated with steroids. On admission she was suffering from hypotension, renal failure, liver failure and coagulopathy. Emergency laparotomy revealed purulent fluid spread diffusely throughout the abdominal cavity. Streptococcus pyogenes was grown in culture from this fluid, enabling a diagnosis of streptococcal toxic shock syndrome (STSS) with primary peritonitis to be made. This combination is rare, and has been described only a few times. Only one other patient is known in whom this combination was preceded by respiratory symptoms. The treatment consists of abdominal lavage, intravenous administration of antibiotics and immunoglobulins, and support for renal function, liver function, respiration and coagulation.

First trimester anesthesia exposure and fetal outcome. A review.

Approximately 0.5-2% of all pregnant women undergo nonobstetric surgery during their pregnancy. This percentage does not include patients who are in the early phase of gestation and are not aware of it at the time of surgery. When pregnancy is diagnosed, the concern raises whether surgery and anesthesia during early gestation pose hazard to the developing fetus, by increasing the risk of congenital anomalies and spontaneous abortion. Literature review suggests that there is no increase in congenital anomalies at birth in women who underwent anesthesia during pregnancy. However, first trimester anesthesia exposure does increase the risk of spontaneous abortion and lower birth weight. This is more likely due to surgical manipulation and the medical condition that necessitates surgery than to the exposure to anesthesia.

Clinical use of etomidate.

Etomidate and methohexital were administered for induction of anesthesia in 45 patients who had to undergo open heart surgery. The anesthesia technique was otherwise standardised. Measurements of blood pressure and heart rate were obtained during a period of ten minutes after injection of the induction agent, and in a selected group of 16 patients cardiac index and stroke volume index were obtained by impedance cardiography. In the group of 45 patients, blood pressure one minute after induction was unchanged with Etomidate, but decreased (-6%) with methohexital. During intubation, important variations of systolic blood pressure occurred, specially with Etomidate (+ 36%) and less with methohexital (+ 21%). Heart rate increased in both groups during intubation (+ 41%) and returned towards starting value after ten minutes. In the group of 16 patients, cardiac index varied with Etomidate, decreasing during intubation (- 21%), increasing to + 32% and then returning to starting value afterwards. Heart rate increased with intubation (+ 39%) and was still somewhat elevated at ten minutes. Stroke volume index decreased with intubation (- 36%) and was still lower than the initial value at ten minutes (- 14%). With methohexital, cardiac index variations were less pronounced (+ 11%). Cardiac index was lower than the initial value at ten minutes (- 14%). Stroke volume index decreased with intubation (- 36%) and was still lower than the initial value at ten minutes (- 14%). This was compensated by an increase in heart rate. These measurements made during induction reflect the complex interaction of drug administration and technical manipulations. Blood pressure lowering one minute after the injection of methohexital can be ascribed to vasodilatation and myocardial depression. The important blood pressure and cardiac index variations observed with Etomidate are probably due to the short action and the lack of analgesic properties of this agent.