Radiologically Inserted Gastrostomy Tube Placement Guided by the Assessment and Primary Palliative Care Provided by an Amyotrophic Lateral Sclerosis Multidisciplinary Clinic: A Single-Arm Retrospective Clinical Study.

Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disease with a median survival of about 3 years. An ALS multidisciplinary team can provide primary palliative care and improve outcomes and quality of life for patients. Feeding tube insertion may be considered for patients with significant weight loss, or respiratory insufficiency. While radiologically inserted gastrostomy (RIG) tube placement may be an option, further studies are required to determine its best timing and appropriateness. This study's objectives were to evaluate the feasibility and outcomes of RIG tube placement in ALS patients over a 90-day follow-up period through the assessment and primary palliative care provided by the multidisciplinary team. This retrospective study reviewed the placement of 16 or 18 French RIG-tube without intubation or endoscopy for 36 ALS patients at a single center between April 2019 and December 2021. Measures included ALS Functional Rating Scale-Revised (ALSFRS-R) scores to determine the ALS stage. Demographic, clinical, procedural, and follow-up data were reviewed. Results showed that the RIG tube placement had a low rate of minor adverse events (11%) and no major procedure-related adverse events. The mean ALSFRS-R score at the time of procedure in subjects who died within 90 days was lower than of those alive beyond 90 days (P = .04). This study found that RIG-tube placement is a safe and effective way to manage dysphagia in ALS patients and highlights the importance of educating members of the multidisciplinary clinic in palliative care principles to determine the appropriateness of RIG tube placement.

Percutaneous Image Guided Cryoablation of Adrenal Metastases From Renal Cell Carcinoma: A Single Institution Review.

OBJECTIVES: To assess the safety, technical success, disease progression, and survival associated with percutaneous image-guided cryoablation of renal cell carcinoma metastasis (mRCC) in the adrenal gland. METHODS: Retrospective, single-institution review of adult patients undergoing percutaneous cryoablation for adrenal mRCC between the years of 2007-2021. Technical parameters, technical success, safety, and survival were analyzed according to standard criteria. RESULTS: Forty-six patients (39 male; mean age 66 ± 8.8 years) with 57 tumors ablated over 51 sessions with a median hospital length of stay of 1 day (range 0-3 days). Forty-four (96%) had primary of clear cell histology. Aim of ablation was curative intent in 39 of 57 tumors (72%) with local tumor control in the remainder. There were 2 (4%) technical failures and technique efficacy was achieved in 52 out of the remaining 55 (95%). There were no Common Terminology Criteria for Adverse Events' immediate complications and 4 of 51 (8%) delayed complications. Twenty-five of 57 (44%) had disease progression anywhere, away from ablation site. One-, 3-, and 5-year recurrence free survival rates were 100%, 89%, and 89% and overall survival was 98%, 85%, and 71%. Fifty-one of 57 (89%) underwent preprocedural alpha blockade with hypertensive crisis in 27 of 56 (54%) available records, of which there were no adverse outcomes. CONCLUSION: Percutaneous cryoablation of mRCC to the adrenal glands is safe with robust local control, leading to advocacy for its ongoing use in this patient population. Multi-disciplinary management is recommended for successful treatment.

Hemodynamic course during ablation and selective hepatic artery embolization for metastatic liver carcinoid: a retrospective observational study.

BACKGROUND: Manipulation of carcinoid tumors during ablation or selective hepatic artery embolization (transarterial embolization, TAE) can release vasoactive mediators inducing hemodynamic instability. The main aim of our study was to review hemodynamics and complications related to minimally invasive treatments of liver carcinoids with TAE or ablation. METHODS: Electronic medical records of all patients with metastatic liver carcinoid undergoing ablation or TAE from 2003 to 2019 were abstracted. Noted were severe hypotension (mean arterial pressure [MAP] ..± 55.ßmmHg), severe hypertension (systolic blood pressure ... 180.ßmmHg), and perioperative complications. Associations of procedure type and pre-procedure octreotide use with intraprocedural hemodynamics were assessed using linear regression. A robust covariance approach using generalized estimating equation method was used to account for multiple observations. RESULTS: A total of 161 patients underwent 98 ablations and 207 TAEs. Severe hypertension was observed in 24 (24.5%) vs. 15 (7.3%), severe hypotension in 56 (57.1%) vs. 6 (2.9%), and cutaneous flushing observed in 2 (2.0%) vs. 48 (23.2%) ablations and TAEs, respectively. After adjusting for preprocedural MAP, ablation was associated with lower intraprocedural MAP compared to TAE (estimate -27.ßmmHg, 95%CI -30 to -24.ßmmHg, p.ß<.ß0.001). Intraprocedural declines in MAP were not affected by preprocedural use of octreotide (p.ß=.ß0.7 for TAE and p.ß=.ß0.4 for ablation). CONCLUSIONS: Ablation of liver carcinoids was associated with substantial hemodynamic instability, especially hypotension. In contrast, a higher number of TAE patients had cutaneous flushing. Preprocedural use of octreotide was not associated with attenuation of intraprocedural hypotension.

Hemodynamic course during ablation and selective hepatic artery embolization for metastatic liver carcinoid: a retrospective observational study

Abstract Background: Manipulation of carcinoid tumors during ablation or selective hepatic artery embolization (transarterial embolization, TAE) can release vasoactive mediators inducing hemodynamic instability. The main aim of our study was to review hemodynamics and complications related to minimally invasive treatments of liver carcinoids with TAE or ablation. Methods: Electronic medical records of all patients with metastatic liver carcinoid undergoing ablation or TAE from 2003 to 2019 were abstracted. Noted were severe hypotension (mean arterial pressure [MAP] ≤ 55 mmHg), severe hypertension (systolic blood pressure ≥ 180 mmHg), and perioperative complications. Associations of procedure type and pre-procedure octreotide use with intraprocedural hemodynamics were assessed using linear regression. A robust covariance approach using generalized estimating equation method was used to account for multiple observations. Results: A total of 161 patients underwent 98 ablations and 207 TAEs. Severe hypertension was observed in 24 (24.5%) vs. 15 (7.3%), severe hypotension in 56 (57.1%) vs. 6 (2.9%), and cutaneous flushing observed in 2 (2.0%) vs. 48 (23.2%) ablations and TAEs, respectively. After adjusting for preprocedural MAP, ablation was associated with lower intraprocedural MAP compared to TAE (estimate −27 mmHg, 95%CI −30 to −24 mmHg, p < 0.001). Intraprocedural declines in MAP were not affected by preprocedural use of octreotide (p = 0.7 for TAE and p = 0.4 for ablation). Conclusions: Ablation of liver carcinoids was associated with substantial hemodynamic instability, especially hypotension. In contrast, a higher number of TAE patients had cutaneous flushing. Preprocedural use of octreotide was not associated with attenuation of intraprocedural hypotension.

Beware: Sialadenitis as a Rare Post Neurosurgical Complication: A Single-Institution Clinical Case Series.

OBJECTIVE: Acute postoperative sialadenitis is a potentially life-threatening complication of cranial neurosurgery characterized by swelling of the face and neck due to obstruction of salivary ducts by either mechanical obstruction or, potentially, pharmacologic stasis or gland obstruction. Given the paucity of literature surrounding this rare phenomenon, we sought to report our experience with acute sialadenitis after cranial neurosurgery. METHODS: Retrospective review of patients with acute sialadenitis after neurosurgical craniotomy or craniectomy from a single institution from January 1, 2011, through December 31, 2021. RESULTS: Seven patients (median age: 27 years; 6 female) identified meeting our inclusion criteria out of 10,014 patients who underwent craniotomy and/or craniectomy procedures during last 11 years (∼0.006%), 5 of these cases were considered skull base procedures. Five (71%) patients required emergent airway management either via intubation or tracheostomy and 5 (71%) were treated with steroids. Additional supportive care included sialagogues, warm compress, massage, analgesics, and intravenous hydration for all 7 patients. Three patients (43%) developed concomitant transient focal neurologic deficits attributable to the sialadenitis. No mortalities occurred as a result of this complication. CONCLUSIONS: Acute post-neurosurgical sialadenitis spans a range of severity, with some patients requiring emergent airway management and prolonged ventilator support whereas other patients only require conservative supportive care. Early recognition of acute sialadenitis after cranial neurosurgery can prevent fatal outcomes and provide complete recovery from this condition. Therefore, all neurosurgeons, anesthesiologists, and intensivists should be aware of this rare, but potentially life-threatening, complication.

Feasibility and safety of percutaneous image-guided cryoablation of abdominal wall endometriosis.

PURPOSE: To evaluate the feasibility and safety of percutaneous image-guided cryoablation of abdominal wall endometriosis (AWE). MATERIALS AND METHODS: A retrospective review of percutaneous cryoablation (CT or MR) of AWE was performed from January 2018 to December 2020. Eighteen patients were identified from an internal percutaneous ablation database. Technical success, complications, and outcomes were analyzed according to standard nomenclature. RESULTS: Patients comprised 18 females (mean age 36.9 years) who underwent 18 cryoablation procedures to treat 23 AWE deposits. Three of the 18 cases were performed under MR guidance, while the remaining 15 employed CT guidance. Technical success was achieved in all 18 cases (100%). Fifteen of 18 patients (83%) had biopsy proven AWE deposits prior to treatment. Hydrodisplacement was used to displace adjacent bowel, bladder, or neurovascular structures in 13/18 cases (72%). The mean number of probes used per case was 3. Sixteen of 23 (70%) of AWE deposits had imaging follow-up (median 85 days). Of the 16 lesions with imaging follow-up, 15 (94%) demonstrated no residual enhancement or T1 hyperintensity at the treatment site and 1 lesion (6%) demonstrated residual/progressive disease. At clinical follow-up, 13 of 14 (93%) patients reported improvement in AWE-related symptoms. Eleven patients had clinically documented pain scores before and after ablation and all demonstrated substantial symptomatic improvement. No society of interventional radiology (SIR) major complications were observed. CONCLUSIONS: Percutaneous cryoablation of AWE is feasible with a favorable safety profile. Further longitudinal studies are needed to document durable response over time.

Percutaneous Image-Guided Core Needle Biopsy of Neuroendocrine Tumors: How Common Is Intraprocedural Carcinoid Crisis?

PURPOSE: To retrospectively evaluate the incidence of carcinoid crisis, other complications, and physiologic disturbances during percutaneous image-guided core needle biopsy of neuroendocrine tumors (NETs) in the lung and the liver. MATERIALS AND METHODS: Between January 2010 and January 2020, 106 computed tomography (CT) or ultrasound (US)-guided core needle biopsies of lung and liver NETs were performed in 95 consecutive adult patients. The mean age was 64 ± 13 years, and 48% were female. The small bowel was the most common primary site (33%, 31/95), and 32 (34%) patients had pre-existing symptoms of carcinoid syndrome. The mean tumor size was 3.2 ± 2.6 cm, and mean number of passes was 3.4 ± 1.6. A 17/18-gauge needle was used in 91% (96/106) of the biopsies. Thirteen (12%) patients received either outpatient or prophylactic octreotide. RESULTS: No patients experienced carcinoid crisis or needed octreotide, inotropes, vasopressors, or resuscitation. A single biopsy procedure (0.9%, 1/106) was complicated by bleeding that required angiographic hepatic artery embolization. Changes in pre-biopsy- versus post-biopsy systolic blood pressure and heart rate were -1.6 mm Hg (P = .390) and 0.6 beat/min (P = .431), respectively. Tumor functional status, overall tumor burden, and the elevation of neuroendocrine markers were not associated with intraprocedural physiologic disturbances. There were 4 minor complications (0.4%, 4/106) associated with the biopsy procedure that were not attributed to hormone excretion from tumor manipulation. CONCLUSIONS: Percutaneous image-guided core biopsy of NETs is safe, with low complication rate and no definite carcinoid crisis in the current cohort.

Anesthesia During Positive-pressure Myelogram: A New Role for Cerebral Oximetry.

BACKGROUND: Positive-pressure myelogram (PPM) is an emerging radiologic study used to localize spinal dural defects. During PPM, cerebrospinal fluid pressure (CSFp) is increased by injecting saline with contrast into the cerebrospinal fluid. This has the potential to increase intracranial pressure and compromise cerebral perfusion. METHODS: We performed a retrospective chart review and analysis of 11 patients. The aim was to describe the periprocedural anesthetic management of patients undergoing PPM. RESULTS: All patients underwent PPM with general anesthesia and intra-arterial blood pressure and near-infrared spectroscopy monitoring of regional cerebral tissue oxygen saturation. Mean±SD maximum lumbar CSFp was 58±12 mm Hg. Upon intrathecal injection, mean systolic blood pressure increased from 115±21 to 142±32 mm Hg (P<0.001), diastolic blood pressure from 68±12 to 80±20 mm Hg (P≤0.001), and mean blood pressure from 87±10 to 98±14 mm Hg (P=0.02). Ten of 11 patients received blood pressure augmentation with phenylephrine to minimize the risk of reduced cerebral perfusion secondary to increased CSFp after intrathecal injection. The mean heart rate before and following injection was similar (68±15 vs. 70±15 bpm, respectively; P=0.16). There was a decrease in regional cerebral oxygen saturation after positioning from supine to prone position (79±10% to 74±9%, P=0.02) and a further decrease upon intrathecal injection (75±10% to 69±9%, P≤0.01). CONCLUSIONS: Systemic blood pressure increased following intrathecal injection during PPM, possibly due to a physiologic response to intracranial hypertension/reduced cerebral perfusion or administration of phenylephrine. Regional cerebral oxygen saturation decreased with the change to prone position and further decreased upon intrathecal injection. Cerebral near-infrared spectroscopy has a potential role to monitor the adequacy of cerebral perfusion and guide adjustment of systemic blood pressure during PPM.

Percutaneous cryoablation of abdominal wall endometriosis: the Mayo Clinic approach.

Abdominal wall endometriosis (AWE) is a rare form of endometriosis that often results in substantial pain and debility. The current treatment algorithm for AWE is not well established. The purpose of this review is to describe the Mayo Clinic experience with thermal ablation of symptomatic AWE as well as to review current imaging and interventional literature regarding the diagnosis and treatment of AWE.

Safety and Efficacy of Percutaneous Image-guided Cryoablation of Completely Endophytic Renal Masses.

OBJECTIVE: To evaluate the safety, efficacy, and oncologic control of percutaneous image-guided cryoablation in the treatment of completely endophytic renal masses. Percutaneous image-guided cryoablation is a minimally invasive and effective treatment for small renal masses. Image-guided cryoablation is an attractive treatment for completely endophytic tumors given the challenge in visualization of such lesions during surgical extirpation. MATERIALS AND METHODS: A retrospective study evaluating percutaneous cryoablation of completely endophytic renal masses with normal overlying renal cortex was performed. From January 2003 to December 2015, 200 endophytic renal masses (RENAL score 3 - endophytic/exophytic) were identified from an internal renal ablation database. After imaging review, 49 tumors with completely intact overlying renal cortex in 47 patients were included in the study. Outcomes, including complications and oncologic efficacy were evaluated according to standard nomenclature. RESULTS: Patients comprised 37 men and 10 women (mean age 64.0 years) who underwent 48 cryoablation procedures to treat 49 renal masses. Mean tumor size was 2.5 ± 0.5 cm. Major complications occurred following 5 of the 48 (10%) procedures. Forty of 46 (87%) tumors with imaging follow-up were recurrence-free at a mean of 56 months. Five of six local recurrences were successfully retreated with cryoablatoin. CONCLUSION: Percutaneous thermal ablation of completely endophytic renal masses is a relatively safe procedure associated with acceptable complication and local tumor control rates. Given the complexities associated with partial nephrectomy, percutaneous cryoablation may be considered an alternative treatment for these select patients. Long-term follow-up studies are necessary to determine the durable efficacy of this treatment.

Hydraulic stimulation of carotid artery baroreceptors as a likely cause of transient asystolic cardiac arrest during diagnostic angiography or surgical endarterectomy.

We describe two patients-both who underwent general anesthesia-in whom we theorize that hydraulic pressure on carotid artery baroreceptors resulted in transient asystolic cardiac arrest (TACA) during diagnostic or therapeutic procedures. Patient #1 was a 58-year-old female who experienced TACA in response to rapid injection of radiocontrast material into the carotid artery during diagnostic cerebral angiography. Her history was remarkable for aneurysmal subarachnoid hemorrhage at least 13 hr prior to angiography, radiographic evidence of intracranial hypertension, and baseline bradycardia, collectively suggestive of increases in baseline vagal tone. Potentially contributing to TACA, the patient had a 90° curve in the internal carotid artery, just distal to the carotid bifurcation and tip of the angiography catheter, that likely diminished runoff of injected contrast solution and, in turn, would have exacerbated any intracarotid pressure increases in response to injection. There was no evidence of increased baseline vagal tone in Patient #2, a 79-year-old female having carotid endarterectomy surgery. She experienced TACA immediately after full release of an occlusive clamp on the common carotid artery proximal to the now closed carotid arteriotomy, but while the internal carotid was still occluded. Of note, the carotid artery baroreceptors were not treated with local anesthetic in these patients, thus they should have retained much of their normal function. We describe the possible pathomechanisms involved in TACA in these patients, measures to diminish the likelihood of the phenomenon occurring in future patients, and methods for treating the asystole.

Anesthetic challenges and outcomes for procedures in the intraoperative magnetic resonance imaging suite: A systematic review.

BACKGROUND AND OBJECTIVE: Hybrid operating room suites with intraoperative magnetic resonance imaging enable image guided surgery in a fully functional operating room environment. While this environment creates challenges to anesthetic care, the effects on anesthetic adverse events and outcomes are largely unknown. This systematic scoping review aims to map the existing knowledge about anesthetic care in advanced imaging hybrid operating rooms. METHODS: A broad-based literature search was performed using the PubMed (Medline), Embase, Cochrane Library, Web of Science, and Google Scholar databases. References published in English between January 1994 and August 2017 were included. Quality of evidence was assessed using the GRADE guidelines. RESULTS: Forty-seven manuscripts were eligible for data collection. Adverse events were heterogeneously defined across 17 manuscripts and occurred in 0 to 100% (quality of evidence mostly very low). Monitoring difficulty was reported in 4 manuscripts of very low data quality. Interference between the magnet and the electrocardiogram was investigated in 2 manuscripts (quality of evidence low and very low, respectively). None of the reported events appeared to result in long-term patient harm. Author recommendations or a narrative review of the literature were provided in 40 manuscripts. Common safety concerns included lower equipment reliability, inaccessibility of the patient and airway, and the relative isolation of the suite (in relationship to other anesthesia care areas). Most authors also emphasized the importance of safety checklists, protocols, and provider training. DISCUSSION: While intraoperative magnetic resonance imaging hybrid operating rooms are increasingly utilized, the existing literature does not allow estimating adverse event rates in this location. Prospective studies quantifying the effect of the environment on anesthesia outcomes are lacking. Despite this, there is a broad consensus regarding the anesthetic and safety concerns. More research is needed to inform practice standards and training requirements for this challenging environment.

Anesthesia-Related Outcomes for Endovascular Stroke Revascularization: A Systematic Review and Meta-Analysis.

BACKGROUND AND PURPOSE: There is currently controversy on the ideal anesthesia strategy during mechanical thrombectomy for acute ischemic stroke. We performed a systematic review and meta-analysis of studies comparing clinical and angiographic outcomes of patients undergoing general anesthesia (GA group) and those receiving either local anesthesia or conscious sedation (non-GA group). METHODS: A literature search on anesthesia and endovascular treatment of acute ischemic stroke was performed. Using random-effects meta-analysis, we evaluated the following outcomes: recanalization rate, good functional outcome at 90 days (modified Rankin Score≤2), symptomatic intracranial hemorrhage, death, vascular complications, respiratory complications, procedure time, and time to groin puncture. RESULTS: Twenty-two studies (3 randomized controlled trials and 19 observational studies), including 4716 patients (1819 GA and 2897 non-GA) were included. In the nonadjusted analysis, patients in the GA group had higher odds of death (odds ratio [OR], 2.02; 95% confidence interval [CI], 1.66-2.45) and respiratory complications (OR, 1.70; 95% CI, 1.22-2.37) and lower odds of good functional outcome (OR, 0.58; 95% CI, 0.48-0.64) compared with the non-GA group. There was no difference in procedure time between the 2 primary comparison groups. When adjusting for baseline National Institutes of Health Stroke Scale, GA was still associated with lower odds of good functional outcome (OR, 0.59; 95% CI, 0.29-0.94). When considering studies performed in the stent-retriever/aspiration era, there was no significant difference in good neurological outcome rates (OR, 0.84; 95% CI, 0.67-1.06). CONCLUSIONS: Acute ischemic stroke patients undergoing intra-arterial therapy may have worse outcomes when treated with GA as compared with conscious sedation/local anesthesia. However, major limitations of current evidence (ie, retrospective studies and selection bias) indicate a need for adequately powered, multicenter randomized controlled trials to answer this question.

Real-Time Cineangiography Visualization of Cerebral Aneurysm Rupture in an Awake Patient: Anatomic, Physiological, and Functional Correlates.

Intracranial aneurysms are common and, on a population-based perspective, are a major cause of morbidity and mortality as a result of mass effect or rupture. Cerebral angiography is the primary technique used for the diagnosis of cerebral aneurysms, and the imaging data have additional utility for planning medical, endovascular, or surgical treatments. An extremely rare periprocedural complication of cerebral angiography is rupture of the aneurysm, either as a chance phenomenon or as a result of some physiologic change or mechanical effect. We report on a single awake, alert patient who experienced intraprocedural aneurysm rupture that was recorded in real time during diagnostic cerebral angiography and subsequently proved fatal. Rupture occurred shortly after the completion of contrast material injection into a semi-open vascular bed and appeared to be temporally unrelated to any supranormal change in systemic physiology. No therapeutic endovascular procedure was planned or attempted. From the high-quality sequential, frame-by-frame images, and electronic sedation and anesthesiology records, plus our own real-time observations (G.L., W.L.L.), we were able (for educational purposes) to reconstruct the time course of rupture of the aneurysm, the velocity and pattern of blood escaping the aneurysm and entering the subarachnoid space, and other physiologic and functional correlates (blood pressure changes, alterations in consciousness) that may be critical to our understanding of the mechanism and consequences of aneurysm rupture.

IMAGE-GUIDED THERMAL ABLATION OF ADRENAL METASTASES: HEMODYNAMIC AND ENDOCRINE OUTCOMES.

OBJECTIVE: Image-guided thermal ablation of adrenal metastases has been increasingly used for local tumor control. This procedure has been associated with hypertensive urgency; however, endocrine complications have not been clearly described. Our objective was to assess the hemodynamic behavior and risk for adrenal insufficiency related to adrenal ablation. Additionally, we sought to understand the utility of preprocedural α-blockade to prevent periprocedural hemodynamic complications. METHODS: This was a retrospective study of patients undergoing image-guided ablation of adrenal metastases between 2003 and 2015 at our institution. We reviewed electronic medical records to obtain clinical information, including α-blockade preparation, periprocedural hemodynamic parameters, interventions, and postablation adrenal function. RESULTS: Thermal ablation was performed in 58 patients (46 men [79%]; median age, 66 years) with 60 adrenal metastases ablated in 62 sessions. Alpha-blockade was used pre-ablation in 49 (79%) sessions; it was associated with less hypertensive urgency (23 [47%] for α-blockade vs. 10 [77%] for no α-blockade; P = .048) but higher need for vasopressors (22 [45%] for α-blockade vs. 1 [8%] for no α-blockade; P = .02) during ablation. Adrenal insufficiency occurred in 13 (22%) patients, of whom 10 had history of contralateral adrenalectomy or metastases, and only 3 of 13 had a normal-appearing contralateral adrenal gland. CONCLUSION: Hemodynamic changes during ablation of adrenal metastases are common. Pre-ablation α-blockade decreases the severity of the hypertensive episode, at the expense of higher need for vasopressors periprocedurally. Adrenal function should be assessed after adrenal metastasis ablation, as adrenal insufficiency may occur after such treatment. ABBREVIATIONS: ACTH = adrenocorticotropic hormone BP = blood pressure CT = computed tomography DBP = diastolic blood pressure HR = heart rate IQR = interquartile range IV = intravenous MAP = mean arterial pressure MWA = microwave ablation RFA = radiofrequency ablation SBP = systolic blood pressure.

Preoperative Levels of Catecholamines and Metanephrines and Intraoperative Hemodynamics of Patients Undergoing Pheochromocytoma and Paraganglioma Resection.

OBJECTIVE: To determine whether, despite pharmacologic adrenergic receptor blockade, higher preoperative levels of catecholamines and metanephrines (adrenergic activity) are associated with increased intraoperative complications. MATERIALS AND METHODS: Records of patients undergoing paraganglioma and pheochromocytoma (PGL-PCC) resection from January 1, 2000, to June 30, 2015, were reviewed for preoperative levels of adrenergic activity, intraoperative variability in blood pressure and heart rate (range), and postoperative outcomes (hypotension requiring treatment). Patients were categorized by maximum preoperative adrenergic activity by greater degree of abnormality, categorized as normal (≤100%) or 101%-200%, 201%-500%, 501%-1000%, and ≥1001% of upper limit of normal. RESULTS: In total, 258 patients underwent intrathoracic or intra-abdominal PGL-PCC resection, of whom 240 received pretreatment with nonselective α1,2-blockers and 7 received pretreatment with selective α1-blockers. Intraoperative hemodynamic variability was greater with higher preoperative levels of adrenergic activity (P <.001). However, substantial variability was observed even with adrenergic activity levels within the normal range: systolic blood pressure (median [interquartile range], 75 [63-83] mm Hg) and heart rate (34 [26-43] beats per minute). Among patients with preoperative levels of adrenergic activity ≤500% vs ≥501% of the upper limit of normal, higher levels were associated with greater likelihood of postoperative diagnosis of volume overload (8% vs 2%, P = .04) and greater requirement for vasopressor infusions for hypotension (5% vs 1%, P = .01). CONCLUSION: Substantial intraoperative hemodynamic instability was encountered in patients with PGL-PCC resection, regardless of preoperative hormonal activity level; therefore, universal preoperative adrenergic receptor blockade should be recommended. Postoperative hypotension was rare and more prevalent in those with higher preoperative hormonal activity.

The Perception of Female Smokers with Fibromyalgia on the Effects of Smoking on Fibromyalgia Symptoms.

OBJECTIVE: Smokers with fibromyalgia have greater pain intensity and function impairment compared to nonsmokers. Patients' perceptions of interactions between smoking and fibromyalgia symptoms have not been described. The primary aim of this study was to report the perceptions of female smokers with fibromyalgia on how smoking affects symptoms. METHODS: Forty-eight daily smokers with fibromyalgia enrolled in the Mayo Clinic Fibromyalgia Treatment Center completed the Fibromyalgia Impact Questionnaire, Fagerstrom Test for Nicotine Dependence, Patient Health Questionnaire-9, General Anxiety Disorder-7 and a Fibromyalgia Symptoms and Smoking Survey which queried how smoking directly affected fibromyalgia symptoms (eg, pain, tiredness/fatigue, stiffness, nervousness/anxiety, depression/blueness, irritability, concentration, and overall) or indirectly as a coping mechanism. RESULTS: The majority of subjects reported smoking had no direct effect on fibromyalgia physical symptoms (pain [60% reported no effect], fatigue [56%], stiffness [81%]) but direct improvement of emotional symptoms (anxiety [62% reported improvement], irritability [64%]). The majority of subjects used smoking to cope with pain (69%) via distraction (83%) and relaxation (77%), lessening emotional distress by reducing a sense of frustration (83%) or sadness (54%) because of pain, and as a justification for resting vis-à-vis "smoke breaks" (69%). Thirty-one smokers were mildly and 17 moderately/severely dependent on tobacco, and no difference in fibromyalgia impact score (P = 0.70), pain (P = 0.39), depression (P = 0.20), and anxiety (P = 0.64) scores were detected, but more moderately/severely dependent subjects reported smoking improved pain (50% vs. 17%, P = 0.04). DISCUSSION: Smokers with fibromyalgia reported smoking helped to cope with fibromyalgia pain but generally did not directly ameliorate fibromyalgia physical symptoms.

Anesthetic management of patients undergoing resection of carcinoid metastasis to the brain.

BACKGROUND: Carcinoid tumors are derived from enterochromaffin cells and may release physiologically active compounds into the systemic circulation, leading to the development of carcinoid syndrome. Occasionally, these tumors metastasize to the brain, warranting biopsy or resection. In these surgical patients, the perioperative implications for anesthetic management are not heretofore defined in the indexed literature. METHODS: Patients who had craniotomy for biopsy or resection of intracranial carcinoid tumors were retrospectively identified at a single medical center. Patient demographics, perioperative anesthetic management, adverse events, and outcome were summarized in this case series. RESULTS: Eleven patients were identified; median age was 60 years (range = 42-78 years), and 45% were male. Immediately before surgery, 4 patients (36%) were receiving a somatostatin analog drug, and no patient had unchecked carcinoid syndrome. All patients received general anesthesia that included inhaled isoflurane and nitrous oxide, and all had invasive arterial blood pressure monitoring. One patient developed sustained hypotension after induction of anesthesia, likely related to hypovolemia and anesthetic drugs, but the possibility of carcinoid mediator release cannot be excluded. There were no other signs or symptoms of carcinoid syndrome in this or any other patient. Of all 11 patients, 10 (91%) experienced either significant disease progression (n = 2; 18%) or death (n = 8; 73%) from carcinoid disease, its sequelae, or an undetermined cause within 3 years after surgery. Of note, 3 of the deaths occurred shortly after surgery, on postoperative days 3, 7, and 8. CONCLUSIONS: In our experience, carcinoid tumor metastasis to the brain-whether because of tumor makeup or prior treatment-is unlikely to produce symptoms of new-onset carcinoid syndrome intraoperatively; however, the risk cannot be completely excluded. Postsurgical prognosis was poor, both within the hospital and after hospital discharge.

Safety of lumbar spine radiofrequency procedures in the presence of posterior pedicle screws: technical report of a cadaver study.

OBJECTIVE: To determine whether the thermal energy associated with lumbar spine radiofrequency neurotomy (RFN) performed near titanium and stainless steel pedicle screws is conducted to the pedicle screws or adjacent tissues, or both, thus introducing potential for thermal damage to those tissues. DESIGN: Cadaver study. SETTING: Cadaver laboratory equipped with fluoroscopy, surgical spine implements, and radiofrequency generator. SUBJECTS: No live human subject; a fresh frozen (and thawed) cadaver torso was used for the study. METHODS: Titanium and stainless steel pedicle screws were placed in the lumbar spine of a fresh frozen cadaver torso with real-time fluoroscopic guidance. Conventional RFN cannula placement was performed at the level of pedicle screws and a control (nonsurgically altered) lumbar level. Neurotomy was performed with conventional radiofrequency lesioning parameters. Temperatures were recorded at multiple sites through thermistor probes. RESULTS: Direct contact of the radiofrequency cannula with the pedicle screws during conventional RFN produced a substantial increase in temperature in the surrounding soft tissues. A small increase in temperature occurred at the same sites at the control level. CONCLUSIONS: Titanium and stainless steel pedicle screws are capable of sustaining large increases in temperature when the radiofrequency probe comes in contact with the screw. These results are suggestive that pedicle screws could serve as a possible source of tissue heating and thermal injury during RFN.

Anesthesia and cor triatriatum.

AIMS AND OBJECTIVES: Cor triatriatum sinistrum (CTS) and cor triatriatum dextrum (CTD) are rare congenital anomalies characterized by the presence of a perforated septum which divides the respective atrium into a proximal and distal chamber. This report reviews the perioperative course of patients with uncorrected cor triatriatum (CT) undergoing procedures requiring anesthesia. In addition, we performed a literature search that examines the experience of others regarding the peri-operative course of patients with CT. MATERIALS AND METHODS: A computerized search of a medical record database was conducted to identify patients with a clinical diagnosis of uncorrected CTD and CTS undergoing surgical procedures. Descriptive statistics were used. RESULTS: We identified 12 adult patients with asymptomatic CTS (n = 7) and CTD (n = 5) who underwent 23 anesthetics. There were no perioperative complications which could be attributed directly to the anatomy of CT. CONCLUSIONS: Our observation and review of the literature suggest that patients with asymptomatic CT typically tolerate anesthesia and surgical procedures well.