Phaeochromocytoma crisis: two cases of undiagnosed phaeochromocytoma presenting after elective nonrelated surgical procedures.

Phaeochromocytoma is a catecholamine producing tumour and an uncommon cause of hypertension. We present two cases of relatively asymptomatic individuals, in which previously undiagnosed phaeochromocytoma was unmasked by elective nonadrenal surgical procedures, manifesting as postoperative hypertensive crisis and subsequent cardiogenic shock. The initial management in intensive care is discussed, in addition to the clinical and biochemical diagnostic challenges present. Successful adrenalectomy was performed in each case.

Laparoscopic adrenalectomy versus open adrenalectomy: results from a retrospective comparative study.

The relatively new operation of laparoscopic adrenalectomy has now become the procedure of choice for the management of most benign adrenal tumours. We have reviewed the data relating to the first 25 patients on whom we performed laparoscopic adrenalectomy and have made comparison with a group of 25 diagnosis-matched individuals on whom we had previously carried out open adrenalectomy. The patients who underwent laparoscopic adrenalectomy had a significantly shorter hospital stay and experienced significantly less postoperative morbidity than those who had an open operation, but the operation time was significantly longer for the laparoscopic group of patients. There is now good potential and sound evidence base for extending the indications for laparoscopic adrenalectomy.

Survey of arrangements for anaesthesia for interventional neuroradiology for aneurysmal subarachnoid haemorrhage.

The management of patients with subarachnoid haemorrhage following rupture of an intracranial aneurysm is changing. The recent introduction of endovascular occlusion of the aneurysm using detachable coils offers an alternative to craniotomy and clipping of the aneurysm for the prevention of recurrent aneurysmal haemorrhage. The aim of this survey was to evaluate the current provision of peri-operative care for patients with an aneurysmal subarachnoid haemorrhage in the United Kingdom and Republic of Ireland. A survey was conducted of the 34 neuroscience centres which provide an adult neurosurgery service in the United Kingdom and Republic of Ireland. Most centres reported an increasing role for coiling, and a decreasing role for clipping in the management of aneurysmal subarachnoid haemorrhage. The provision of peri-operative care for patients undergoing interventional neuroradiology procedures varied greatly between centres. Neurovascular services in the UK are being reorganised and adequate staff and facilities should be available for the peri-operative care of patients undergoing interventional neuroradiology procedures.

Remifentanil and anaesthesia for carcinoid syndrome.

Carcinoid syndrome creates many challenges during anaesthesia, including hypertension, hypotension and bronchospasm. These challenges are less common and less severe after the routine use of octreotide. We describe the use of remifentanil as part of the anaesthetic management of a 67-yr-old man undergoing resection of a carcinoid tumour of the terminal ileum. The combination of perioperative octreotide administration, intraoperative remifentanil infusion and sevoflurane anaesthesia, with postoperative epidural analgesia proved satisfactory. We review the recent literature and suggest that remifentanil is a useful addition to the armamentarium of the anaesthetist in the management of a patient with carcinoid syndrome.

Anticipation and planning for anaesthesia provision within MR units in the UK.

We surveyed 33 UK MR units that have been developed by New Opportunity Funding (NOF) with reference to planning for and provision of anaesthetic services. The likely clinical and resource implications were documented. Units were developed predominantly in acute general hospitals with paediatric, critically ill and neuroscience patients represented. It may be predicted that up to 50% of newly built units will require anaesthetic provision and this should be anticipated at the planning stage. A senior anaesthetist should be involved in the planning process.

The use of remifentanil in the anaesthetic management of patients undergoing adrenalectomy: a report of three cases.

The use of remifentanil has been recommended because of its ability to minimise the hypertensive response to tracheal intubation and surgical stimulation in various types of surgery. We describe the use of remifentanil in the anaesthetic management of three cases of open adrenalectomy, two for removal of a phaeochromocytoma and one for removal of an adrenal cortical tumour. Although the use of remifentanil was associated with no adverse events in the patient undergoing resection of the adrenal cortical tumour, its administration was associated with significant hypotension and bradycardia in the two phaeochromocytoma patients, who had both been given alpha- and beta-adrenergic receptor blocking drugs before surgery. It did not prevent the increases in blood pressure or plasma catecholamine levels associated with tumour manipulation in these patients. Remifentanil should therefore be used with caution in patients receiving alpha- and beta-adrenergic receptor blocking drugs. The use of potent vasodilators may still be necessary during tumour manipulation even if remifentanil is being infused.

The neuroanaesthesia workforce in Great Britain and Ireland.

A survey of the 36 units that provide a neuroanaesthesia service in Great Britain and Ireland was conducted. It shows the variation in the type of hospital, the number of whole-time equivalent neuroanaesthetists, the number of operating sessions and the number of neurosurgical beds per million of the catchment population of each unit. On-call commitment and arrangements for managing long cases are described. Current problems pertaining to neuroanaesthetic practice are mentioned. This survey will provide a basis for the planning of future neuroanaesthetic services, as the potential of expansion of neurosurgery and neuroradiology is realised. However, it is difficult to make accurate projections and hence advise on future workforce requirements in a climate of changing service delivery. Attention should be given to a number of workforce issues highlighted in this survey if recruitment into neuroanaesthesia is to be encouraged.

Thyroid disease.

In summary, disease of the thyroid gland is common. Anaesthetists will be required to manage patients with hypothyroidism and hyperthyroidism and those requiring thyroidectomy. Since anaesthesia for thyroidectomy provides many challenges of airway management, the anaesthetist should pay particular attention to preoperative assessment of the airway and should be able to deal with acute airway complications in the perioperative phase.