Higher hematocrit level associated with higher 5-aminolevulinic acid-induced perioperative blood pressure change.

BACKGROUND: 5-aminolevulinic acid (5-ALA) is used for photodynamic diagnosis-assisted surgeries. Hypotension is among 5-ALA-related adverse effects. 5-ALA metabolism requires iron. The red cell life span is 120 days and heme iron is daily recycled. Higher hematocrit is likely to correlate with higher recycled iron. We previously reported 5-ALA-induced hemodynamics in urological surgery. This analysis aimed to determine the association between 5-ALA-induced perioperative systolic blood pressure (SBP) changes and the hematocrit. METHODS: This retrospective study enrolled consecutive patients who underwent transurethral resection of bladder tumor from August 2018 to December 2020. The patients were classified into the 5-ALA-pretreated patients (5-ALA group; n = 26) and non-pretreated patients (control group; n = 97). We evaluated the correlation between SBP change rates and hematocrit levels. The primary analyses included the difference in correlations between the two groups. Subsequently, the correlations were analyzed in the 5-ALA group and control group, respectively. RESULTS: The correlations significantly differed between the two groups preoperatively (P<0.001), during surgery (P = 0.014), postoperatively (P = 0.001), and on the following morning (P = 0.002). The correlations between SBP changes and the hematocrit in the 5-ALA group were significant before patients entered the operation room (Spearman's rank correlation coefficient [rS]=-0.449, P = 0.024), before anesthesia induction (rS=-0.584, P = 0.002), during surgery (rS=-0.401, P = 0.047), after operation (rS=-0.658, P<0.001), and on the following morning (rS=-0.547, P = 0.004). Those in the control group were not significant. CONCLUSIONS: The hematocrit levels were significantly correlated with perioperative 5-ALA-induced SBP changes. The association was again observed the next day. Higher hematocrit may be a factor for 5-ALA-induced hemodynamic changes.

Differences in 5-Aminolevulinic Acid-Induced Hemodynamic Changes between Patients Undergoing Neurosurgery and Urological Surgery.

INTRODUCTION: Oral 5-aminolevulinic acid (5-ALA) is often used for photodynamic diagnosis-assisted glioma or bladder tumor surgery. 5-ALA affects blood pressure (BP). In fact, hypotension is a well-known adverse effect of 5-ALA in urology. However, information regarding 5-ALA-induced hemodynamic changes in neurosurgery remains limited. Furthermore, the duration of hypotension and how 5-ALA affects the heart rate (HR) are yet to be determined. Thus, in this study, we aimed to elucidate 5-ALA-induced perioperative hemodynamic changes in neurosurgery and urological surgery by examining real-world data. METHODS: Consecutive patients who underwent neurosurgery (neurosurgery patients; 5-ALA-pretreated vs. non-pretreated [17 vs. 16], from January 2014 to March 2021) and urological surgery (urological surgery patients; 5-ALA-pretreated vs. non-pretreated [26 vs. 101], from August 2018 to September 2020) were enrolled. Differences in hemodynamics were evaluated using the linear mixed model. BP and HR in 5-ALA-pretreated patients were compared with those in non-pretreated patients. Differences in 5-ALA-induced preoperative BP changes were compared between the neurosurgery patients and urological surgery patients. RESULTS: 5-ALA scarcely affected the hemodynamics in neurosurgery patients, whereas 5-ALA-induced hemodynamic changes were clearly observed in urological surgery patients. Hemodynamic parameters were found to be not significantly different between 5-ALA-pretreated and non-pretreated neurosurgery patients. The preoperative, intraoperative, and postoperative BP in 5-ALA-pretreated urological surgery patients were significantly lower than those in the non-pretreated patients. Preoperatively, two 5-ALA-pretreated urological surgery patients had severe postural hypotension (systolic BP <50 mmHg), and one of them did not continue with the surgery because of prolonged severe hypotension. The BP in 5-ALA-pretreated urological surgery patients tended to be persistently lower for 9 h after 5-ALA pretreatment. The preoperative and postoperative HR values were higher in 5-ALA-pretreated urological surgery patients. Cumulative incidences of BP reduction and HR elevation were significantly higher in 5-ALA-pretreated urological surgery patients. The preoperative BP reduction in 5-ALA-pretreated urological surgery patients was significantly larger than that in neurosurgery patients. CONCLUSIONS: 5-ALA-induced hemodynamics may differ between neurosurgery patients and urological surgery patients. 5-ALA may affect BP for at least 9 h.

Spinal myoclonus following neuraxial anesthesia: a literature review.

Spinal myoclonus (SM) is a rare neurologic movement disorder following neuraxial anesthesia (NA). SM following NA (SM-NA) has insufficient clinical information and its pathogenesis remains to be elucidated. The aim of this review article was to summarize the past cases and consider SM-NA pathophysiology. Based on our PubMed search, it was revealed that SM-NA develops within several hours after neuraxial local anesthetic (LA) administration and resolves in a day without leaving neurologic compilations. It occurs primarily in the lower extremities, but can sometimes spread upward and affect the upper extremities and trunk. Although statistical adjustments are indispensable, analysis of the previous cases provided important facts that seem to be related with the mechanism of SM-NA. The frequently used LAs for spinal anesthesia were hyperbaric. SM-NA occurrence was more frequent in women. After initiation of spinal anesthesia, intrathecal hyperbaric LA distributes cephalad. In the LA elimination process, the large concentration differences in intrathecal LA may induce the partially functioning spinal neurons, resulting in myoclonus generation. The morphological features of the lumbar spine in women can predispose to a higher LA concentration difference. SM-NA is an unpredictable and rare neural complication following NA and should be confirmed by basic experiments and large-scale researches.

Preanesthetic severe postural hypotension following 5-aminolevulinic acid pretreatment in patients for photodynamic diagnosis-assisted urological surgery.

BACKGROUND: 5-Aminolevulinic acid (5-ALA) is utilized for photodynamic diagnosis-assisted (PDD) surgery. However, it has been associated with vasodilation, hence, occasional hypotension. CASE PRESENTATION: We encountered two patients who had severe postural hypotension following 5-ALA pretreatment prior to an operation. They were scheduled for urological PDD surgery, but upon standing to walk to the operation room, they felt sick because of severe hypotension. One of them underwent the surgery after recovery, but the other surgery was canceled due to a prolonged hypotension that lasted for more than a day. CONCLUSIONS: Severe postural hypotension may develop as a result of the high concentration of porphyrin precursors, which may affect the nervous system. Severe postural hypotension may be due to 5-ALA-induced autonomic dysfunction as well as vasodilative action of 5-ALA. These observations suggest that in addition to the careful monitoring of patients' vital signs, standing should be avoided following 5-ALA pretreatment.

A case of spinal myoclonus in a patient with elective cesarean section.

BACKGROUND: Transient myoclonic involuntary movements, typically referred to as spinal myoclonus (SM), rarely develop in the extremities following neuraxial anesthesia (NA). NA indications in patients with history of SM following NA (SM-NA) are unknown. CASE PRESENTATION: A 33-year-old woman developed SM-NA after elective cesarean section (CS). Approximately 130 min after spinal anesthesia induction, she began exhibiting involuntary movements, which became most severe after approximately 3 h. The involuntary movements gradually decreased without treatments and disappeared after approximately 5 h. The patient underwent CS on three occasions. The first CS (age, 29 years) was under a combination of spinal and epidural anesthesia. The third CS (age, 35 years) was completed using only spinal anesthesia. There were no neurological events during the postoperative courses for the first and third CS. CONCLUSIONS: SM-NA can unexpectedly occur, and history of SM-NA may not be contraindicative for repeated NA.

Severe Dextran-Induced Anaphylactic Shock during Induction of Hypertension-Hypervolemia-Hemodilution Therapy following Subarachnoid Hemorrhage.

Dextran is a colloid effective for volume expansion; however, a possible side effect of its use is anaphylaxis. Dextran-induced anaphylactoid reaction (DIAR) is a rare but severe complication, with a small dose of dextran solution sufficient to induce anaphylaxis. An 86-year-old female who underwent clipping for a ruptured cerebral aneurysm was admitted to the intensive care unit. Prophylactic hypertension-hypervolemia-hemodilution therapy was induced for cerebral vasospasm following a subarachnoid hemorrhage. The patient went into severe shock after administration of dextran for volume expansion, and dextran administration was immediately discontinued. The volume administered at that time was only 0.8 mL at the most. After fluid resuscitation with a crystalloid solution, circulatory status began to recover. However, cerebral vasospasm occurred and the patient's neurological condition deteriorated. Five weeks after the shock, she was diagnosed with hypersensitivity to dextran by a skin test. When severe hypotension occurs after dextran administration, appropriate treatments for shock should be performed immediately with discontinuation of dextran solution. Although colloid administration is recommended in some guidelines and researches, it is necessary to consider concerning the indication for volume expansion as well as the risk of colloid administration.

Anaesthetic management of a patient with the intracardiac extension of Wilms' tumour.

Summary Wilms' tumour (nephroblastoma) is known to invade the inferior vena cava and extend to the intracardiac chambers. We describe the treatment and surgical removal of the intracardiac extension of a Wilms' tumour using cardiopulmonary bypass in a 4-year-old girl. Techniques to avoid paradoxical embolism in the presence of a patent foramen ovale and to deal with excessive hepatic venous blood flow using the Pringle manoevre (hepatic inflour occlusion) are described. Good communication between anaesthesiologists, surgeons and perfusionists was indispensable. The anaesthesiologist is an important member of the team during performance of a complicated procedure.