Preoperative risk factors of hemodynamic instability during laparoscopic adrenalectomy for pheochromocytoma.

BACKGROUND: Adrenalectomy for pheochromocytoma is considered to be a challenging procedure because of the risk of hemodynamic instability (HI), which is poorly defined and unpredictable. The objective of this retrospective study from a prospectively maintained database was to determine the predictive factors for perioperative HI, which is defined as a morbidity-related variable, in patients undergoing unilateral laparoscopic adrenalectomy (LA) for pheochromocytoma. METHODS: A total of 149 patients with unilateral pheochromocytoma undergoing LA were included. First, HI was defined using independent hemodynamic variables associated with perioperative morbidity. Next, a multivariable logistic regression analysis was performed to determine the independent preoperative risk factors for HI. RESULTS: There was no postoperative mortality, and the overall morbidity rate was 10.7 %. The use of a cumulative dose of norepinephrine >5 mg was the only independent hemodynamic predictive factor for postoperative complications; thus, this variable was used to define HI. A multivariate analysis revealed that a symptomatic high preoperative blood pressure (p = 0.003) and a ten-fold increase in urinary metanephrine and/or normetanephrine levels (p < 0.0001) were significant predictors of HI. When no predictive factors were present, the risk of HI and the postoperative morbidity were 1.5 and 4.3 %, respectively. However, when two predictive factors were present, the HI risk and the postoperative morbidity were 53.8 and 30.8 %, respectively. CONCLUSION: Perioperative HI, defined as the need for a cumulative dose of norepinephrine >5 mg, is significantly associated with postoperative morbidity and can be predicted by symptomatic preoperative high blood pressure and above a ten-fold increase in urinary metanephrine and/or normetanephrine levels.

Assessment of haemostasis in patients with cirrhosis: Relevance of the ROTEM tests?: A prospective, cross-sectional study.

BACKGROUND: In patients with cirrhosis, decreased rotational thromboelastometry (ROTEM) parameters suggest hypocoagulability secondary to liver dysfunction. However, observed normal or increased thrombin generation suggests preserved haemostasis and/or a procoagulant state. The correlated levels of both coagulation factors and inhibitors also support preserved haemostasis. OBJECTIVE: The objective of this study is to investigate the correlation between three specific approaches of haemostasis (ROTEM, thrombin generation and coagulation factors/inhibitors) on the same plasma sample from patients with cirrhosis. DESIGN: A prospective, observational study. SETTING: Single university hospital. PARTICIPANTS: Forty patients with cirrhosis. INTERVENTION: Measurement of the following factors: model for end-stage liver disease (MELD) scores; ROTEM maximum clot firmness (ROTEM-MCF) in EXTEM, INTEM, FIBTEM assays; fibrinogen; factors V and VIII; von Willebrand factor; protein C; protein S; antithrombin; and the thrombin generation test (TGT) enabling the calculation of endogenous thrombin potential without and with thrombomodulin, and the ratio of endogenous thrombin potential with-to-without thrombomodulin (regarded as an index of hypercoagulability). RESULTS: ROTEM-MCF values were distributed within the normal and hypocoagulation ranges; were correlated to variations in factor V, fibrinogen, protein C and S and antithrombin; and were inversely correlated to MELD scores (ρ > 0.5; P < 0.05). Levels of von Willebrand factor were above normal and were not correlated with any other factor levels. After addition of thrombomodulin, endogenous thrombin potential values were distributed within or above normal values. Factor V variation was correlated to the ratio of endogenous thrombin potential with-to-without thrombomodulin. CONCLUSION: ROTEM indicated hypocoagulability correlated to liver dysfunction. In contrast, the TGT indicated a preserved or even increased coagulation profile (which was supported by the correlation between coagulant factors and inhibitors) and a potential for hypercoagulability inversely correlated to the degree of liver dysfunction. ROTEM may not be appropriate for haemostasis assessment in patients with liver cirrhosis and could lead to the unnecessary transfusion of fresh frozen plasma. TRIAL REGISTRATION: S.C. 3024 - ID RCB: 2012-A01728-35.

Central sensory-motor deficit after uneventful single-dose spinal morphine administration in a patient with preexisting migraine headaches.

Hemiplegic migraine is a condition associated with vascular alteration of the central nervous system and transient neurologic deficits. Permanent morphine-induced motor dysfunction has been reported after spinal ischemia. We report a persisting central neurological deficit after single-dose spinal administration of 400 microg of morphine in a patient with no previous neurological condition. Hemiplegic migraine was thought to be present when the patient emerged from anesthesia. Weakness in the left quadriceps and saddle anesthesia of the perineum and urinary retention of central origin remained present 3 yr later. Over the 3 postoperative years, the patient was admitted to a neurological unit 5 times because of acute headache associated with complete left-sided hemiplegia. These symptoms resolved within 24 h of onset. Hemiplegic migraine was thought to be the most likely diagnosis of these recurrent attacks. We hypothesize that the patient's persistent deficits were caused by a combination of spinal morphine and spinal cord vascular dysfunction associated with hemiplegic migraine.

Compatibility and stability of binary mixtures of acetaminophen, nefopam, ketoprofen and ketamine in infusion solutions.

BACKGROUND AND OBJECTIVE: Administering various combinations of acetaminophen, ketoprofen, nefopam and ketamine, though sometimes discussed, is expected to provide superior pain relief and reduce opioid analgesic-related side effects. However, some studies have indicated that multimodal analgesia has limited efficacy. We studied the stability of various binary combinations of these four drugs. PATIENTS AND METHODS: The drugs were studied at 25 degrees C. Binary mixtures of acetaminophen, ketoprofen, nefopam and ketamine were produced. Each drug concentration was assessed using a specific high-performance liquid chromatographic technique. Measurements were carried out at T0, +1, +2, +4, +6 and +24 h. A 5% loss of initial concentration was considered to be significant. The changes with time of the concentrations were analysed using linear regression analysis. A P value of less than 0.05 was significant. RESULTS: The four drugs tested in the binary mixtures were stable, showing neither loss of concentration nor degradation products (P > or = 0.05). CONCLUSION: Physicochemical negative interaction is not likely to account for the limited clinical efficacy sometimes reported with binary combinations of these drugs. Coadministration of binary mixtures of acetaminophen, nefopam, ketoprofen and ketamine from the same bottle or infusion bag using the same venous line is demonstrated to be feasible.

No Proof Found of Anesthesia Involvement in Medical Misconduct During the Nazi Period. Investigation of the Alleged Purchase of 150 Inmates From Auschwitz Concentration Camp by Bayer to Test a New Narcotic.

A comprehensive investigation was undertaken to find evidence of the frequently reported, but never authenticated, "purchase of 150 inmates" from Auschwitz concentration camp by Bayer to test a new narcotic, resulting in the death of all investigated inmates. The archives of Auschwitz camp, Bayer, and the so-called former Soviet Union, where evidence of this alleged misconduct could have been saved, were investigated, but no evidence was found. Many records concerning concentration camp experiments on humans had been destroyed, but given the Nazis' meticulous record-keeping, the death of 150 inmates should have been recorded somewhere. Unethical medical research was indeed undertaken by physicians in concentration camps in many medical specialties, but no records regarding anesthesia-related medical misconduct during the Nazi period were found despite the allegations to the contrary that have been investigated here.

Opioid-induced sedation in the postanesthesia care unit does not insure adequate pain relief: a case-control study.

BACKGROUND: Sedation can occur during intravenous titration of morphine for acute pain control in the postanesthesia care unit (PACU). We designed this case-control study to evaluate the relationship between opioid-induced sedation in the PACU and adequacy of early postoperative analgesia. METHODS: Intravenous morphine was titrated in 2 mg (body weight < or =60 kg) or 3 mg (body weight >60 kg) boluses every 5 min to treat moderate-to-severe pain in the PACU. Pain was assessed using a 11-point verbal rating scale (VRS) with scores > or =3 representing moderate-to-severe pain. The 6-point Ramsay score was used to assess the level of sedation with scores >3 representing clinically significant sedation. Twenty-six patients, with a Ramsay sedation score >3 and a pain VRS > or =3 at discharge from the PACU, were evaluated 24 h after surgery to assess (a) the recall of early postoperative pain in the PACU, (b) quality of sleep on the first night after surgery, (c) pain on the 24th postoperative hour, and (d) satisfaction with pain management at 24 h after surgery. Two patients discharged from the PACU with VRS pain scores <3 were matched to each of the patients with pain scores > or =3 and Ramsay score >3, as part of a 52 patient control group. RESULTS: Patients with Ramsay scores >3 and pain scores > or =3 more frequently reported moderate-to-severe pain in the PACU (severe/moderate/no pain: 18%/25%/57% vs 58%/16%/26%, P = 0006, for the control and the sedated group, respectively), poorer quality of sleep the night after surgery (well/moderate/bad: 48%/42%/10% vs 23%/23%/54%, P = 0.001, for the control and the sedated group, respectively), and higher pain scores at the 24th hour after surgery (severe/moderate/no pain: 6%/44%/50% vs 50%/42%/8%, P < 0.0001, for the control and the sedated group, respectively). In addition, their overall satisfaction with pain control during the first 24 postoperative hours was lower (satisfied/moderately satisfied/not satisfied: 96%/2%/2% vs 50%/30%/20%, P < 0.0001, for the control and the sedated group, respectively). CONCLUSION: Clinically significant opioid-induced sedation in the PACU does not insure adequate self-reported pain relief.

Early postoperative tako-tsubo-like left ventricular dysfunction: transient left ventricular apical ballooning syndrome.

We diagnosed transient left ventricular apical wall motion abnormalities after surgery in a patient presenting with a clinical and electrocardiographic picture of acute myocardial infarction in the absence of significant coronary disease. These angiographic, clinical, and electrocardiographic features satisfied the criteria of the recently described tako-tsubo-like left ventricular dysfunction.

Adducted vocal cords relieved by neuromuscular blocking drug: a cause of impaired mechanical ventilation when using a laryngeal mask airway: two photographically documented cases.

Two cases of vocal cord closure, which was responsible for acute intraoperative impairment of mechanical ventilation in two patients with entropy-controlled depth of anesthesia, are reported. Administration of low-dose neuromuscular blocking drug was associated with immediate vocal cord relaxation and restoration of efficient mechanical ventilation.

Point of controversy: perioperative care of patients undergoing pheochromocytoma removal-time for a reappraisal?

Adrenalectomy for pheochromocytoma is reported with a mortality close to zero in recent studies. The dogma of preoperative fluid and hypotensive drug administrations is widely applied in patients scheduled for pheochromocytoma removal and is assumed to have a beneficial effect on operative outcomes. This paradigm is only based on historical studies of non-standardized practices and criteria for efficacy, with no control group. Pre- and intraoperative hypovolemia have never been demonstrated in patients scheduled for pheochromocytoma removal. Recent improvements in outcome of patients undergoing adrenalectomy for pheochromocytoma could also be the result of improvement in surgical techniques and refinement in anesthetic practices. Whether better knowledge of the disease, efficiency of available intravenous short-acting vasoactive drugs, and careful intraoperative handling of the tumor make it possible to omit preoperative preparation in most patients scheduled for pheochromocytoma removal is presently questionable. We reviewed available literature in this respect.