Perioperative concerns of recurrent urinary bladder phaeochromocytoma with skeletal metastasis.

We report the perioperative management of a 61-year-old man diagnosed with recurrent urinary bladder phaeochromocytoma with vertebral and rib metastasis following partial cystectomy and nephrectomy. His blood pressure was controlled with antihypertensive agents. Epidural analgesia was avoided in view of vertebral metastasis; instead, analgesia was provided with fentanyl infusion. Intraoperative hypertensive episodes were managed with nitroglycerine, sodium nitroprusside and esmalol. However, after surgery, the patient required inotropic support and was moved to the intensive care unit. Analgesia was maintained with fentanyl infusion, and inotropic support was gradually weaned off. Nuclear ablative therapy was planned for bony metastasis. We recommend that recurrences of extra-adrenal phaeochromocytoma be investigated for bony metastasis and cautiously managed in the perioperative period so as to avoid neurological complications.

Low- versus high-dose combination of midazolam-ketamine for oral premedication in children for ophthalmologic surgeries.

INTRODUCTION: Midazolam and ketamine are useful for oral premedication in children to allay anxiety. We compared the effects of midazolam with a combination of high- and low-dose ketaminemidazolam as an oral premedication. METHODS: This is a randomised, controlled prospective study conducted in 87 children who were scheduled for ophthalmologic surgeries. Group M received oral midazolam 0.5 mg/kg, Group MKL received oral midazolam 0.25 mg/kg and ketamine 3 mg/kg, and Group MKH received midazolam 0.5 mg/kg and ketamine 6 mg/kg. Standard general anaesthesia technique was used. Sedation levels and ease of parental separation were noted. RESULTS: A linear increasing trend in sedation was seen in the preoperative sedation scores of all the three groups. At 30 minutes, 23 children in Group MKH had good sedation scores as opposed to 20 in Group MKL and 12 in Group M. The best parental separation time was much shorter in the combination groups. There were no statistically significant differences in the parental separation scores, mean response to induction and mask acceptance. The time to reach Aldrete score of 10 was shorter in Group MKL (22 +/- 5 min) and Group M (36 +/- 1 min) compared to Group MKH (52 +/- 2 min). Group MKH had a higher incidence of excessive salivation compared to the other groups. CONCLUSION: A combination of low-dose midazolam and ketamine is as effective as high-dose midazolam and ketamine for achieving optimum anxiolysis and a faster recovery, with a lower incidence of excessive salivation in children undergoing ophthalmic surgery.

Perianesthetic management of the first robotic partial cystectomy in bladder pheochromocytoma. A case report.

The authors report the perianesthetic considerations of a rare case of pheochromocytoma of the urinary bladder for which the first reported robotic partial cystectomy and ureteric reimplantation were performed. A 59-year-old male patient, known to be hypertensive, was posted for transurethral resection of a bladder tumor. In the operation room, after attaching the monitors, a subarachnoid block was given. Upon manipulation of the tumor, the blood pressure and heart rate increased markedly. A pheochromocytoma was suspected and was later confirmed by raised urine catecholamine levels and meta-iodobenzyl-guanidine scan. The patient was started on tablet prazosin and atenolol. After optimization, a robotic partial cystectomy was planned. In the operating room, an epidural catheter and a radial artery cannula were inserted. After the induction of anesthesia and the securing of the airway, surgery was started. After the insertion of the verres needle, pneumoperitoneum was created very slowly, and then the patient was positioned in 40 degrees Trendelenburg. Surges in arterial blood pressure (ABP) were managed with titrated doses of sodium nitroprusside and nitroglycerine and boluses of esmolol and labetalol. ABP drops postoperatively were managed with fluid and dopamine infusion. Robotic surgery is a safe alternative to the open technique for pheochromocytoma of the urinary bladder. Care should be taken during the positioning of the patient for robot placement and during pneumoperitoneum creation.

Unpredicted neurological complications after robotic laparoscopic radical cystectomy and ileal conduit formation in steep trendelenburg position: two case reports.

Robotic surgery is becoming popular for minimally invasive surgical evolution as robotic devices allow unprecedented control and precision in minimally invasive procedures. Two cases of robotic radical cystectomy with ileal conduit urinary diversion surgeries having perioperative neurologic complications related to prolonged surgery in steep head down position are presented. In these patients, neurological deterioration occurred after extubation probably due to cerebral edema. We suggest the duration and positioning should be optimized for such prolonged surgery in steep head down position and some recommendations should be made. Moreover, in such surgeries a great vigilance has to be observed in the perioperative period.

Passage of peritoneal fluid into lumbar epidural catheter during pelvic exenteration.

Migration of an epidural catheter into either paravertebral tissues or pleural cavity has already been described. Up to now, no case of passage of peritoneal fluid into the epidural space has been reported. Here we report such an event in a patient submitted to pelvic exenteration, and discuss its diagnosis and management.

Case report: Airway management of a patient with popping pedunculated subglottic laryngeal polyp.

Management of airway is a great challenge to anesthesiologists. Sometimes though airway is apparently normal but lesion around it may give a concern for securing airway. Patient, 52 years, ASA grade I presented to otolaryngology clinic with important complaints of stridor and dyspnoea. There was no comorbidity. Routine investigations were normal. Indirect laryngoscopic examination revealed pedunculated mass (polyp) arising from subglottic region, with a size of 0.7 x 0.5 cm and its pedicle was around 1.5 cm long delicate structure. This polyp was not visible during inspiration but it popped out of the vocal cords during expiration. Microlaryngeal surgery was planned to remove this polyp. Intubation of trachea was a great challenge as polyp was visible only during expiration. Tracheal intubation under controlled ventilation and neuromuscular blockade might have caused rupture of polyp pedicle or dislodgement of polyp in the trachea (as its pedicle was quite thin and delicate) which would have resulted in respiratory obstruction in the patient. Fiberoptic guided awake intubation was planned during expiratory phase of spontaneous respiration in order to avoid any injury or damage to the polyp or its pedicle.

Tramadol for postoperative shivering: a double-blind comparison with pethidine.

In most operating and recovery rooms, shivering is controlled by the use of humidifiers, warming blankets, and inhalation of humidified heated oxygen. However, pharmacological control is an effective alternate treatment modality. This randomized, double-blind trial, conducted in 30 ASA Grade 1 or 2 patients, was designed to explore the efficacy of tramadol and pethidine in the treatment of post-anaesthetic shivering. Tramadol is an inhibitor of the re-uptake of serotonin (5-hydroxytryptamine) and norepinephrine in the spinal cord. This facilitates 5-hydroxytryptamine release, which influences thermoregulatory control. We compared the efficacy of tramadol with that of pethidine, presently a widely used drug for the control of shivering. Patients received either tramadol 1 mg/kg or pethidine 0.5 mg/kg intravenously and the grade of shivering, pulse rate, blood pressure and respiratory rate were observed every 10 minutes after injection for one hour Shivering was significantly more likely to have ceased in the tramadol group (12 of 15 versus 4 of 15 cases, P<0.05) at 10 minutes after drug administration and this control was better sustained. No patients receiving tramadol had a recurrence of shivering. It is concluded that intravenous tramadol 1 mg/kg is more effective for the treatment of postoperative shivering than pethidine 0.5 mg/kg.