Anesthesia and laparoscopic adrenalectomy for primary aldosteronism.

Adrenalectomy is the curative treatment of primary aldosteronism or Conn's syndrome. Laparoscopic adrenalectomy, a new method, should result in less pain and shorter hospitalization. We reported 25 patients who received anesthesia and laparoscopic adrenalectomy from 1995-1999. There were 17 females and 8 males. The mean age was 41.9 years (range 25-59). Ninety-six per cent had hypertension, 76 per cent had weakness of the extremities. When these patients sought medical care, their serum potassium and bicarbonate were 2.4 and 30.9 mEq/l respectively. Before operation, after treatment with spinorolactone, they were 4.3 and 24.4 mEq/l respectively. Associated diseases and cardiovascular abnormalities were reported. General anesthesia was the anesthetic technique of choice. Laparoscopic adrenalectomy was described in detail. Sixteen patients had adenomas on the left adrenal gland, 9 were on the right. Twenty-four patients had unilateral adrenalectomy, one had enucleation of the tumor. The size of the adenoma was 1.8 cm (range 1-3). There was no morbidity or mortality. All patients were discharged on the third postoperative day.

Surgery and anesthesia for pheochromocytoma--a series of 40 operations.

Pheochromocytoma is a catecholamine-producing tumor which can be life-threatening. A series of 40 operations in 39 pheochromocytoma patients at a tertiary hospital in Thailand from 1976 to 1997 was reported. The patients were 30 females and 9 males; aged 7-73 years. One man had 2 operations 5 years apart. The most common symptoms and signs were palpitation, headache and hypertension. Preoperative management consisted of control of blood pressure and restoration of intravascular volume by using prazosin, an alpha adrenergic blocker. New imaging techniques have improved the ability to localize the tumors; 20 were found in the right adrenal glands, 14 in the left, 1 patient had bilateral tumors, 4 in Organs of Zuckerkandl and 1 patient had metastatic liver nodules. The operative procedures were 39 laparotomies and 1 laparoscopic surgery. The surgical and anaesthetic procedures were presented, and nitroprusside was used to control intraoperative blood pressure. Removal of tumors was successful in all cases except for 1 mortality due to injury of the liver and massive blood loss. Other complications were postoperative pulmonary edema and renal vein thrombosis. One patient had MEN type 2 and five cases were malignant. Pheochromocytoma can be cured by surgery, but cooperation among surgeons, anesthesiologists and internists is very important.

Hemodynamic responses to captopril during splenectomy in thalassemic children.

Splenectomy in beta-thalassemic children is frequently accompanied by perioperative hypertension which occasionally is followed by convulsion. The efficacy of captopril in attenuating the hypertensive response to splenectomy was investigated in 82 thalassemic children. The control group, consisting of 40 patients, received intravenous furosemide (1 mg/kg) preoperatively; whereas, 42 children were randomly allocated into 2 groups to receive oral captopril (0.7 mg/kg) or a combination of captopril (0.7 mg/kg) and furosemide (1 mg/kg) before the operation. Before anesthetic induction, both systolic and diastolic arterial pressures in the captopril and the combined groups were significantly lower than the furosemide group (P < 0.001), whereas, the heart rates in all groups were comparable. Changes in arterial pressure in response to the operation were significantly smaller in the combined group when compared with the other two groups (P < 0.001). Immediate postoperative hypertension requiring additional management occurred in 20 per cent of the furosemide group, and 14.3 per cent in the other two groups. One patient in the combined group had a convulsion in association with hypertension. The authors conclude that captopril combined with furosemide effectively controls intraoperative hypertension in thalassemic children undergoing splenectomy; however, postoperative hypertension remains common, and needs appropriate treatment immediately.

Factors influencing CPR outcome in Siriraj Hospital.

This prospective study of cardiopulmonary resuscitation was surveyed in Siriraj Hospital from 1 March 1996 to 31 May 1996. In a 3-month-period, 94 resuscitated patients were reported with initial survivors 31 cases (33%) and 3 patients (3%) were alive until discharged from the hospital. Most of the resuscitated patients belonged to the emergency department (47%) with the lowest survival rate (23%). The common causes of cardiac arrest were heart diseases (31%) and respiratory failure (21%). All survivors who were able to be discharged from the hospital had suffered cardiac arrest from heart diseases. After resuscitation, only half of the initial survivors received postarrest care in the intensive care units, the rest remained in general wards and outpatient department. By using logistic regression for multivariate analysis, the survival rate was correlated with locations of CPR, duration of CPR and duration of attempt endotracheal intubation. The initial survival outcome of CPR was not related to sex, age, time of day of CPR, duration of hospitalization before CPR, types of arrhythmia, delay in doctors' arrival and performers of CPR.

APACHE II in a postoperative intensive care unit in Thailand.

In order to evaluate the effectiveness of an intensive care unit (ICU), the case-mix has to be considered. This was a cohort study. By using Acute Physiology and Chronic Health Evaluation scores (APACHE II score), we evaluated the case-mix and mortality rate of 282 patients who were treated in our postoperative ICU. The overall mortality rate was 10.6 per cent. Higher Acute physiology scores and emergency surgery in the presence of chronic health status were related to higher mortality, but age was not. However, the original APACHE II model could not precisely predict the mortality of Thai patients. We used stepwise logistic regression to determine the predictors of death and found the prediction model to be -7.24 + 0.37 (APACHE II score) + 1.46 (postemergency surgery). The actual mortality for patients with APACHE II score > 15 in our ICU was higher than that predicted by the original APACHE II model. The causes of this difference might be difference in methodology, characteristics of ICU and the quality of care.