Successful management of unsuspected retroperitoneal paraganglioma via the use of combined epidural and general anesthesia: a case report.

INTRODUCTION: Similar to pheochromocytomas, paragangliomas can secrete catecholamines, although they are usually non-functional and clinical presentation is non-specific. We present a case of accidental, intra-operatively diagnosed neuroendocrine-active sympathetic paraganglioma, which was suspected and confirmed during elective retroperitoneal tumor removal. CASE PRESENTATION: A 25-year-old Caucasian Croatian man, American Society of Anesthesiologists status 1, underwent elective surgery for retroperitoneal tumor removal. The tumor had been discovered by chance during a routine examination and was suspected to be a sarcoma. Our patient had no history of previous medical conditions nor did he have symptoms characteristic of a neuroendocrine secreting tumor. The results of ultrasound and magnetic resonance imaging studies showed a large, well demarcated retroperitoneal tumor mass in his upper abdomen localized between the aorta and vena cava, measuring approximately 9×6×4.5cm. In the operating room an epidural catheter was inserted at the T7 to T8 level prior to induction of general anesthesia. Epidural analgesia was maintained by an infusion pump with local anesthetic and opiate mixture. During the surgical excision of the tumor, hemodynamic changes occurred, with hypertension (205/110mmHg) and tachycardia (up to 120 beats/minute). In spite of the fact that the surgical field of work did not include adrenal glands whose direct manipulation could explain this occurrence, there was a high degree of suspicion for the presence of a neurosecreting tumor. His clinical symptoms were relieved after administration of urapidil, esmolol and magnesium sulfate. After tumor excision, our patient developed severe hypotension. Hemodynamic stability was reinstated with aggressive volume replacement, with crystalloids and colloids, vasopressors and hydrocortisone. His post-operative course was unremarkable and on the eighth post-operative day our patient was discharged from hospital, with no consequences or symptoms on follow-up two years after surgery. CONCLUSIONS: Our patient's case emphasizes the need to consider the presence of extra-adrenal paragangliomas in the differential diagnosis of retroperitoneal tumors, despite their rare occurrence. In our patient's case, invasive hemodynamic monitoring during combined general anesthesia and epidural analgesia and early recognition of catechol-induced symptoms raised suspicion of the existence of a paraganglioma, and this led to an adequate therapeutic approach and favorable outcome of the surgery. Pre-operative recognition of paragangliomas could lead to better pre-operative preparation, but even high clinical suspicion in undiagnosed forms during surgery and the availability of rapid and short-acting vasodilatators, α-blockers and ß-blockers might favor good outcome.

Spinal anesthesia at the L2-3 and L3-4 levels: comparison of analgesia and hemodynamic response.

Aim of this study was to evaluate level of analgesia and hemodynamic response to spinal anesthesia obtained by administering 15 mg 0.5% isobaric bupivacaine at L2-3 vs. L3-4 interspace for inguinal herniorrhaphy, since studies comparing analgesia and hemodynamic response at the L2-3 vs. L3-4 interspaces are lacking. In a prospective, randomized clinical study that encountered 72 patients undergoing elective inguinal herniorrhaphy randomly allocated in to two equal groups L2-3 (N = 36) and L3-4 (N = 36) according to lumbar interspace where intrathecal injection of bupivacaine was administered. Analgesia was evaluated by intraoperative "rescue" fentanyl requirements, the absence of pain and the maximal visual analogue scale (VAS) scores reached per patient during the operation. The severity of intraoperative pain was quantified by a 10 cm VAS scale (VAS 0: no pain to 10: worst pain imaginable) every 5 minutes after skin incision until the end of the operation. VAS > 3 was treated with intravenous fentanyl 25 microg. Hemodynamic response was monitored and evaluated, heart rate was continuously monitored as well as, baseline systolic, diastolic and mean arterial pressure prior to induction and every 5 minute after applying spinal anesthesia until surgical completion. Intraoperative fentanyl requirements were significantly higher in group L3-4 (L2-3 0%, 97.5% confidence interval [CI] 0.0-0.11 vs. L3-4 17%, 95% CI 0.07-0.32, p = 0.025). Absence of pain was significantly higher in L2-3 group at the beginning of the operation (L2-3 89%, 95% CI 0.74-0.96 vs. L3-4 67%, 95% CI 0.50-0.79, p = 0.047). The maximal VAS scores reached per patient during the operation in L2-3 group were lower then in L3-4 group (L2-3 median [M] 0, range [R] 0-3, L3-4 M 0, R 0-8, p = 0.014). There were no significant differences (p > 0.05) in the incidence of hypotension (L2-3 19%, 95% CI 0.09-0.35 vs. L3-4 17%, 95% CI 0.07-0.32) and bradycardia (L2-3 19%, 95% CI 0.09-0.35 vs. L3-4 8%, 95% CI 0.02-0.23). Spinal anesthesia with isobaric bupivacaine administered in L2-3 interspace for inguinal herniorrhaphy provides superior analgesia and equal hemodynamic stability as compared to neuroaxial anesthesia administered in the L3-4 interspace.

Duration and variability of speech segments in fluent speech of children with and without stuttering.

The purpose of this study was to compare the duration and variability of speech segments of children who stutter with those of children who do not stutter and to identify changes in duration and variability of speech segments due to the effect of utterance length. Eighteen children participated (ranging from 6.3 to 7.9 years of age). The experimental task required the children to repeat a single word in isolation and the same word embedded in a sentence. Durations of speech segments and Coefficients of variation (Cv) were defined to assess temporal parameters of speech. Significant differences were found in the variability of speech segments on the sentence level, but not in duration. The findings supported the assumption that linguistic factors pose direct demands on the speech motor system and that the extra duration of speech segments observed in the speech of stuttering adults may be a kind of compensation strategy.