Pheochromocytoma, Fulminant Heart Failure, and a Phenylephrine Challenge. the Perioperative Management of Adrenalectomy in a Jehovah's Witness Patient: a Case Report.

Perioperative management of pheochromocytoma in the setting of catecholamine-induced heart failure requires careful consideration of hemodynamic optimization and possible mechanical circulatory support. A Jehovah's Witness patient with catecholamine-induced acutely decompensated heart failure required dependable afterload reduction for a cardio-protective strategy. This was emphasized due to the relative contraindication to perioperative anticoagulation required for mechanical circulatory support. A phenylephrine challenge clearly demonstrated adequate alpha blockade after only 24 hours of phenoxybenzamine treatment. This resulted in advancement of the surgery date. This case also highlights management of beta blockade, volume and salt loading, autologous blood transfusion, and profound post-operative vasoplegia in the setting of cardiogenic shock. Careful attention to hemodynamic optimization and cardio-protective strategies ultimately resulted in positive outcome for this challenging clinical scenario.

Avoid suboptimal perioperative analgesia during major surgery by enhancing thoracic epidural catheter placement and hemodynamic performance.

Thoracic epidural analgesia (TEA) is an established gold standard for postoperative pain control especially following laparotomy and thoracotomy. The safety and efficacy of TEA is well known when the attention to patient selection is upheld. Recently, the use of fascial plane blocks (FPBs) has evolved as an alternative to TEA most likely because these blocks avoid problems such as neurological comorbidity, coagulation disorders, epidural catheter failure and hypotension due to sympathetic denervation. However, if an FPB is performed, postoperative monitoring and adjuvant treatments are still necessary. Also, the true efficacy of FPBs is questioned. Thus, should we prioritize less efficient analgesic regimens with FPBs when preventive treatment strategies for epidural catheter failure and hypotension exist for TEA? It is time to promote and underscore the benefits of TEA provided to patients undergoing major open surgical procedures. In our mind, FPBs and landmark-guided techniques should be limited to less extensive surgery and when either neuraxial blockade is contraindicated or resources for optimal epidural catheter placement and maintenance are not available.

Thoracic caudal epidural catheter localization using ultrasound guidance.

Caudal epidural catheters provide exceptional analgesia while avoiding or minimizing opioids. Historically, the catheter tip location (dermatomal level) was estimated or verified via epidurogram. According to the Pediatric Regional Anesthesia Database, the majority of caudal-to-thoracic epidural catheters are placed without imaging guidance or verification of the position of the catheter tip. Ponde et al demonstrated that catheter insertion depth was longer when using ultrasound guidance than when estimated by external measurement. We report a simple yet novel ultrasound approach for catheter localization.