Partial hepatic resections for metastatic neuroendocrine tumors: perioperative outcomes.

STUDY OBJECTIVE: Partial hepatic resection reduces tumor burden in patients with metastatic neuroendocrine tumors, thereby improving quality and length of life. These procedures can be challenging as well as life-threatening. Our aim was to evaluate our patients' perioperative outcomes and propose a definition for an intraoperative carcinoid crisis relevant to this surgery, given its unique surgical considerations. DESIGN: Retrospective study. SETTING: Mayo Clinic, Rochester, Minnesota. PATIENTS: One hundred sixty-nine patients undergoing partial hepatic resection for metastatic neuroendocrine tumors between 1997 and 2015 were identified retrospectively from a surgical database at Mayo Clinic Rochester. INTERVENTIONS: None. MEASUREMENTS: Intraoperative carcinoid crisis for patients undergoing hepatic resection of neuroendocrine tumors was defined. Patients' medical records were reviewed and data were abstracted describing patient and procedural characteristics and perioperative outcomes. MAIN RESULTS: There were no documented cases of carcinoid crisis (0.0%, 95% C.I. 0.0% to 2.2%). One patient developed clinical findings of an emerging carcinoid crisis, but was successfully treated with doses of octreotide and findings resolved in <10 min. Prophylactically 500 µg octreotide was given subcutaneously in 77% (130/169) of patients preoperatively. CONCLUSIONS: There were no documented cases of carcinoid crisis (0.0%, 95% C.I. 0.0% to 2.2%). Adverse events were infrequent.

Increased Risk of Postthoracotomy Pain Syndrome in Patients with Prolonged Hospitalization and Increased Postoperative Opioid Use.

Background. Postthoracotomy pain syndrome (PTPS) is unfortunately very common following thoracotomy and results in decreased quality of life. The purpose of this retrospective study was to determine perioperative patient, surgical, and analgesic characteristics associated with the development of PTPS. Methods. Sixty-six patients who presented to the Mayo Clinic Rochester Pain Clinic were diagnosed with PTPS 2 months or more after thoracotomy with postoperative epidural analgesia. These patients were matched with sixty-six control patients who underwent thoracotomy with postoperative epidural analgesia and were never diagnosed with PTPS. Results. Median (IQR) hospital stay was significantly different between control patients (5 days (4, 6)) compared with PTPS patients (6 days (5, 8)), P < 0.02. The total opioid equivalent utilized in oral morphine equivalents in milligrams for the first three days postoperatively was significantly different between control patients and PTPS patients. The median (IQR) total opioid equivalent utilized was 237 (73, 508) for controls and 366 (116, 874) for PTPS patients (P < 0.005). Conclusion. Patients with a prolonged hospital stay after thoracotomy were at an increased risk of developing PTPS, and this is a novel finding. Patients who utilize higher oral morphine equivalents for the first 3 days were also at increased risk for PTPS.

Refractory hypotension during spinal anesthesia for Cesarean delivery due to undiagnosed pheochromocytoma.

Profound hypotension and resistance to conventional vasopressor therapy following administration of spinal anesthesia for Cesarean delivery occurred in a multiparous parturient. Postpartum evaluation for secondary hypertension showed a diagnosis of pheochromocytoma. Pheochromocytoma was mistaken for preeclampsia with significant vasopressor requirement to treat hypotension from spinal anesthesia. If pheochromocytoma is diagnosed during pregnancy and Cesarean delivery is required, spinal anesthesia may not be the optimal choice of anesthesia.

Emergency bedside cesarean delivery: lessons learned in teamwork and patient safety.

BACKGROUND: Maternal cardiovascular and pulmonary events during labor and delivery may result in adverse maternal and fetal outcome. Potential etiologies include primary cardiac events, pulmonary embolism, eclampsia, maternal hemorrhage, and adverse medication events. Remifentanil patient-controlled analgesia is an alternative when conventional neuraxial analgesia for labor is contraindicated. Although remifentanil is a commonly used analgesic, its use for labor analgesia is not clearly defined. CASE PRESENTATION: We present an unexpected and unique case of remifentanil toxicity resulting in the need for an emergent bedside cesarean delivery. A 30-year-old G3P2 woman receiving subcutaneous heparin anticoagulation due to a recent deep vein thrombosis developed cardiopulmonary arrest during labor induction due to remifentanil toxicity. CONCLUSION: A rapid discussion among the attending obstetric, anesthesia, and nursing teams resulted in consensus to perform an emergent bedside cesarean delivery resulting in an excellent fetal outcome. During maternal cardiopulmonary arrest, a prompt decision to perform a bedside cesarean delivery is essential to avoid significant maternal and fetal morbidity. Under these conditions, rapid collaboration among obstetric, anesthesia, and nursing personnel, and an extensive multi-layered safety process are integral components to optimize maternal and fetal outcomes.

Chronic postthoracotomy pain and health-related quality of life.

BACKGROUND: Pain after thoracotomy is common. The objective of this study was to assess whether pain 3 months postthoracotomy negatively impacts quality of life. METHODS: One hundred ten patients were prospectively assessed using the Medical Outcomes Study 36-Item Short Form Health Survey before and 3 months after elective thoracotomy. Pain and medication use were evaluated by questionnaire. Patients experiencing pain at 3 months were compared with patients who did not have postthoracotomy pain. RESULTS: Seventy-five patients (68%) had pain 3 months postthoracotomy; 12 patients (11%) rated their average pain greater than 3 (out of 10). Eighteen (16%) patients required opioid analgesics. The pain group reported lower SF-36 scores in physical functioning (p = 0.049), bodily pain (p = 0.0002), and vitality (p = 0.044). There were no other significant differences in any SF-36 scale between the pain and non-pain groups. CONCLUSIONS: Pain is commonly reported at 3 months after elective thoracotomy but is generally mild, shows improvement with time, and does not usually require opioid analgesics. Patients who experience postthoracotomy pain at 3 months are at risk for significantly decreased physical functioning and vitality, but are not at risk for significantly decreased social, emotional, or mental health functioning compared with patients who do not experience postthoracotomy pain at 3 months.

Preoperative gabapentin for acute post-thoracotomy analgesia: a randomized, double-blinded, active placebo-controlled study.

BACKGROUND: The role of preoperative gabapentin in postoperative pain management is not clear, particularly in patients receiving regional blockade. Patients undergoing thoracotomy benefit from epidural analgesia but still may experience significant postoperative pain. We examined the effect of preoperative gabapentin in thoracotomy patients. METHODS: Adults undergoing elective thoracotomy were enrolled in this prospective, randomized, double-blinded, placebo-controlled study, and randomly assigned to receive 600 mg gabapentin or active placebo (12.5 mg diphenhydramine) orally within 2 hours preoperatively. Standardized management included thoracic epidural infusion, intravenous patient-controlled opioid analgesia, acetaminophen and ketorolac. Pain scores, opioid use and side effects were recorded for 48 hours. Pain was also assessed at 3 months. RESULTS: One hundred twenty patients (63 placebo and 57 gabapentin) were studied. Pain scores did not significantly differ at any time point (P = 0.53). Parenteral and oral opioid consumption was not significantly different between groups on postoperative day 1 or 2 (P > 0.05 in both cases). The frequency of side effects such as nausea and vomiting or respiratory depression was not significantly different between groups, but gabapentin was associated with decreased frequency of pruritus requiring nalbuphine (14% gabapentin vs. 43% control group, P < 0.001). The frequency of patients experiencing pain at 3 months post-thoracotomy was also comparable between groups (70% gabapentin vs. 66% placebo group, P = 0.72). CONCLUSIONS: A single preoperative oral dose of gabapentin (600 mg) did not reduce pain scores or opioid consumption following elective thoracotomy, and did not confer any analgesic benefit in the setting of effective multimodal analgesia that included thoracic epidural infusion.

Conversion from intrathecal morphine to oral methadone.

BACKGROUND AND OBJECTIVES: Methadone is an inexpensive and highly effective analgesic when titrated appropriately. Its equianalgesic ratio with other opioids is variable, however. We present a case of conversion from high-dose intrathecal (IT) morphine to oral methadone. CASE REPORT: A 37-year-old man was admitted to the orthopedic service due to increased lower back pain. He had a history of recurrent L5 plasmacytoma, an L5 corpectomy, and L3-S1 fusion with instrumentation. An implanted neuraxial drug delivery device had been placed at another institution for back pain. Evaluation suggested infection involving the hardware. The patient underwent hardware removal, debridement of osteomyelitis, and removal of the IT catheter. The patient's analgesia was converted from IT to intravenous morphine and then to oral methadone. CONCLUSIONS: The conversion from high-dose IT morphine to oral methadone has not been previously described. The case presents higher IT morphine to oral methadone conversion ratio than might be expected based upon conventionally used equianalgesic tables.

Opioid-free analgesia following total knee arthroplasty--a multimodal approach using continuous lumbar plexus (psoas compartment) block, acetaminophen, and ketorolac.

BACKGROUND AND OBJECTIVES: Traditionally, postoperative analgesia following total knee arthroplasty (TKA) has been provided by neuraxial or peripheral regional techniques with supplemental administration of opioids. We report an alternative method of postoperative pain management for patients undergoing TKA in whom the use of systemic or neuraxial opioids may result in significant side effects. CASE REPORT: A 74-year-old woman with a history of protracted nausea and vomiting after systemic and neuraxial opioid administration presented for left total knee arthroplasty. A spinal anesthetic with postoperative continuous lumbar plexus (psoas) analgesia was planned. A quadriceps motor response was elicited and a 20-gauge catheter was advanced through an 18-gauge insulated Tuohy needle into the psoas sheath. After 30 mL of bupivacaine 0.5% with 100 microg clonidine was administered through the psoas catheter, a spinal anesthetic (2 mL 0.5% bupivacaine at the L2-3 interspace) was performed. A continuous psoas infusion of 0.2% bupivacaine with 2 microg/mL clonidine at 8 mL/h was initiated in the recovery room. The psoas infusion was subsequently changed to 0.2% bupivacaine without clonidine and the rate increased to 10 mL/h. Supplemental analgesia with oral acetaminophen 1 g every 4 to 6 hours alternating with intravenous ketorolac 15 mg every 6 hours provided satisfactory analgesia, with visual analog scale (VAS) scores of 0 to 2 at rest and 3 to 4 with movement. The psoas catheter was removed 48 hours postoperatively because of prolongation of the prothrombin time. VAS scores remained 0 to 3 throughout the remainder of her hospitalization. CONCLUSION: A multimodal approach consisting of continuous lumbar plexus (psoas) block and nonopioid analgesics successfully provided postoperative pain relief in our patient and facilitated her physical rehabilitation after total knee arthroplasty.