Cardiovascular collapse after labetalol for hypertensive crisis in an undiagnosed pheochromocytoma during cesarean section.

Pheochromocytoma is a catecholamine-producing tumor but rarely delayingly diagnosed until during pregnancy. We reported a pregnant woman who underwent emergent cesarean section because of intrauterine growth retardation, oligohydramnios, and hypertension. The existence of an undiagnosed pheochromocytoma was suspected by the unusual hemodynamic response to spinal anesthesia, abdominal compressions, and operative stimulus. Hypertensive crisis occurred during the operation and she was sent to the intensive care unit for postoperative care. In the intensive care unit, cardiovascular collapse occurred after nonselective ß-adrenergic blockade. Unexpected hypertensive crisis during the perioperative period should alert clinicians to the possibility of a pheochromocytoma. For the treatment of choice, nonselective ß-adrenergic blockade should not be used before the α-blockade.

An analysis of patient variables that influence intravenous patient-controlled analgesic use of morphine with quantile regression.

BACKGROUND: Previous studies using linear regression analysis have shown that age, weight, gender, and the site of operation affect intravenous patient-controlled analgesia (IVPCA) narcotic use. However, there are inconsistent observations in the literature. The authors postulate that patient variables could have different effects at various doses of narcotics. To test this hypothesis, the authors analyzed the effect of patient variables on increasing doses of IVPCA narcotic with quantile regression. METHODS: The authors collected retrospective data from 1,782 patients who received IVPCA for a minimum of 3 days after surgery. The authors used stepwise linear regression model to identify variables that significantly affected the total IVPCA requirements. Quantile regression model was further applied to assess the effects of selected variables on the ascending percentile of IVPCA narcotic use. RESULTS: Gender, age, body weight, cancer, and surgical site were identified as significant predictors for IVPCA demand. Body weight had the most and cancer had the least significant effects on total IVPCA demands. The results of quantile regression model revealed that the determinants under consideration varied with different percentiles of IVPCA demand. The patient variables correlated with IVPCA narcotic use differently when the dose exceeded the seventieth to eightieth percentiles compared with other percentiles of narcotic use. CONCLUSIONS: The authors' findings highlight the heterogeneous postoperative pain requirements among patients and the consequent complex process of efficiently managing postoperative pain.

Thoracic epidural anesthesia for a polymyositis patient undergoing awake mini-thoracotomy and unroofing of a huge pulmonary bulla.

General anesthesia with one-lung ventilation is a conventional anesthetic strategy for most chest surgery, including resection of pulmonary bullae. However, this anesthetic management may cause alveolar barotrauma, hemodynamic instability, pulmonary atelectasis and long-term ventilator dependency. Here, we report a 64-year-old female with polymyositis and bronchiolitis obliterans organizing pneumonia who was scheduled for surgical intervention for a huge pulmonary bulla over the right upper lung. Under thoracic epidural anesthesia, with the patient maintaining clear consciousness and spontaneous breathing, a mini-thoracotomy was accomplished to unroof and partially resect the bulla. There were no perioperative complications, and the patient was satisfied with the anesthetic care. Pulmonary function tests and daily physical performance also improved postoperatively.