Structural Heart Issues in Dextrocardia: Situs Type Matters.

Background: Patients who are diagnosed with dextrocardia, a rare congenital heart condition in which the heart points toward the right side of the chest, need their specific situs classification (eg, solitus, inversus, ambiguus) ascertained to optimize their care and outcomes. In this report, we discuss the perioperative anesthetic management of a patient presenting with dextrocardia. Case Report: A 44-year-old African American female with a history of hypertension, hyperlipidemia, gastroesophageal reflux disease, and diabetes mellitus type 2 was admitted for shortness of breath, dyspnea on exertion, orthopnea, and paroxysmal nocturnal dyspnea. The patient had been diagnosed with dextrocardia in 2003 at an outside hospital and was asymptomatic prior to this presentation. Chest x-ray revealed bilateral perihilar vascular congestion with bibasilar atelectasis and suspected small bilateral pleural effusions consistent with new-onset congestive heart failure. Preoperative 2-dimensional transthoracic echocardiography revealed an ostium secundum-type atrial septal defect (ASD) with mild left-to-right atrial shunting. The patient's ASD was repaired using a pericardial patch. Conclusion: The anesthetic management of patients presenting with dextrocardia is complex. Preoperative cardiac transthoracic echocardiography can identify cardiac lesions or aberrant anatomy associated with dextrocardia. Proper placement of electrocardiogram electrodes is necessary to avoid false-positive results for perioperative ischemia. Central line access must be adjusted to anatomic variations. Clinicians should have high suspicion for associated pulmonary hypertension and should limit sedatives preoperatively to minimize the cardiovascular effects of hypoxia and/or hypercarbia on the pulmonary vasculature. Finally, high clinical suspicion for respiratory complications should be maintained, as dextrocardia has been associated with respiratory complications secondary to primary ciliary dyskinesia in approximately 25% of patients.

Does promethazine shorten the length of stay in the post anesthesia care unit?

The combination of promethazine and opioids is known to have an opioid-sparing effect, thereby facilitating a reduction in total patient opioid consumption. In recent years, this practice has fallen out of favor in many healthcare facilities, except primarily in the post anesthesia care unit (PACU). The goal of this study was to highlight the potential of promethazine as a direct or indirect adjuvant medication in acute pain management. The present investigation was undertaken with a case series of adult female patients who underwent open total abdominal hysterectomies. Data from the PACU was reviewed with patients being separated into two groups. Group 1 received only intravenous opioids for acute pain management. Group 2 received a combination of intravenous opioids for acute pain management and intravenous promethazine for nausea and/or vomiting. Patients were discharged from the PACU with a modified Aldrete score of 9 or 10. The study showed that patients who received promethazine in addition to opioids were discharged from the PACU an average of 19.2 minutes earlier than those patients who received only opioids (p=0.003). The time to achieve modified Aldrete score of 9 or higher was more quickly achieved when open abdominal hysterectomy patients received promethazine in addition to opioids in the PACU. The study concluded that promethazine, in combination with opioids, could potentially decrease PACU stay postoperatively. Based on the present investigation, the prospect of using promethazine in other facets of pain management are intriguing and warrant future studies. Specifically, it may be worth investigating whether promethazine is truly an adjunct in combination with opioids and to determine if there are any other antihistamines or neuroleptics which may have similar clinical effects to promethazine.

Perioperative implications and management of dextrocardia.

Dextrocardia, a term used to describe all varieties of developmental malformations resulting in the positioning of the heart in the right hemithorax, is linked to a number of highly significant cardiac disorders. Current estimates vary tremendously in the literature. Only about 10 % of patients with diagnosed dextroversion show no substantial cardiac pathology; however, the incidence of congenital heart defects associated with dextrocardia is close to 100 %. The majority of studies previously reported include dextrocardia associated with situs inversus and cases of Kartagener syndrome. There is complex embryology and pathogenesis that results in dextrocardia. Physical examinations of the heart, such as percussion and palpation during routine exams, are vitally important initial diagnostic instruments. X-ray, CT scan, echocardiography (ECHO), and MRI are all invaluable imaging modalities to confirm and classify the diagnosis of dextrocardia. In summary, heart malposition is a group of complex pathologic associations within the human body, rather than just a single congenital defect. Clinicians such as anesthesiologists have unique challenges managing patients with dextrocardia. An appreciation of associated pathogenesis, appropriate diagnosis, and management is paramount in ensuring the best outcome for these patients perioperatively.

Development of accurate models for individualized prediction of survival after cytoreductive nephrectomy for metastatic renal cell carcinoma.

BACKGROUND: There is limited evidence to guide patient selection for cytoreductive nephrectomy (CN) following the diagnosis of metastatic renal cell carcinoma (mRCC). OBJECTIVE: Given the significant variability in oncologic outcomes following surgery, we sought to develop clinically relevant, individualized, multivariable models for the prediction of cancer-specific survival at 6 and 12 mo after CN. The development of this nomogram will better help clinicians select patients for cytoreductive surgery. DESIGN, SETTING, AND PARTICIPANTS: We identified 601 consecutive patients who underwent CN for kidney cancer at a single tertiary cancer center. INTERVENTION: CN for mRCC. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The development cohort was used to select predictive variables from a large group of candidate predictors. The discrimination, calibration, and decision curves were corrected for overfit using 10-fold crossvalidation that included stepwise variable selection. RESULTS AND LIMITATIONS: With a median follow-up of 65 mo (range: 6-199) for the entire cohort, 110 and 215 patients died from kidney cancer at 6 and 12 mo after surgery, respectively. For the preoperative model, serum albumin and serum lactate dehydrogenase were included. Final pathologic primary tumor stage, nodal stage, and receipt of blood transfusion were added to the previously mentioned parameters for the postoperative model. Preoperative and postoperative nomograms demonstrated good discrimination of 0.76 and 0.74, respectively, when applied to the validation data set. Both models demonstrated excellent calibration and a good net benefit over large ranges of threshold probabilities. The retrospective study design is the major limitation of this study. CONCLUSIONS: We have developed models for accurate prediction of cancer-specific survival after CN, using either preoperative or postoperative variables. While these tools need validation in independent cohorts, our results suggest that the models are informative and can be used to aid in clinical decision making.

Risk prediction in the management of small renal masses.

PURPOSE OF REVIEW: Small renal masses (SRMs) are frequently encountered due to the ubiquitous use of abdominal cross-sectional imaging. Enhanced risk prediction in the management of SRMs would allow for a more informed decision of which, if any, patients would benefit from the available intervention modalities. RECENT FINDINGS: Data suggest that a substantial proportion of SRMs are benign and that a significant proportion demonstrate indolent clinical behavior, leading to increased implementation of active surveillance strategies. Extirpative treatment of SRMs may be associated with worse outcomes, particularly in the elderly and infirm. Patient characteristics, including advanced age and comorbidity, and tumor anatomy are being increasingly recognized as having significant prognostic importance in terms of which type of treatment to offer. Further, a recent renewed interest in renal mass biopsy for risk stratification in SRMs has occurred as tumor size, radiographic characteristics, and growth kinetics are limited in their predictive capacity. SUMMARY: Within the last decade, the reference standard treatment of SRMs evolved from radical nephrectomy to nephron-sparing approaches. This evolution continues, as we learn more about the complex interplay between patient and tumor characteristics and, as outcomes data mature, to ablative therapies and active surveillance.