Variable hemodynamic fluctuations during resection of multicentric extraadrenal pheochromocytomas

PURPOSE: To report the perioperative management and the serious hemodynamic fluctuations during manipulation of an organ of Zuckerkandl tumour in a patient undergoing resection of multicentric extraadrenal pheochromocytomas. CLINICAL FINDINGS: A 28-yr-old man who had undergone at age 12 a laparotomy for excision of an extraadrenal pheochromocytoma complained of paroxysmal headache, occasional sweating and palpitations. The arterial blood pressure (BP) was 200/100 mmHg. A 24-hr-urine collection showed catecholamines 5076 microg x 24 hr(-1) (normal < 25 microg x 24 hr(-1)). Computed tomography of the abdomen revealed two retroperitoneal masses, one adjacent to the lower pole of the right kidney and a second larger mass located at the aortic bifurcation in the region of the organ of Zuckerkandl. The patient was scheduled for excision of multiple extraadrenal pheochromocytomas. He was prepared preoperatively for two weeks with prazosin 1 mg po q six hours and propranolol 10 mg tid. Manipulation of the infrarenal tumour was uneventful but manipulation of the Zuckerkandl tumour resulted in severe hypertensive episodes with BP ranging from 200/100 to 320/120 mmHg. Surgery was interrupted temporarily; the hypertensive crisis was controlled by the infusion of sodium nitroprusside and by iv phentolamine and esmolol. CONCLUSION: In a patient undergoing resection of recurrent multicentric extraadrenal pheochromoctyomas, severe hypertensive episodes occurred during manipulation of one tumour but not during manipulation of the other. This may be attributed to inadequate preparation of the patient, difficult surgical dissection of the large Zuckerkandl pheochromocytoma, and/or secondary to an excessive and different pattern of release of catecholamines during manipulation of the Zuckerkandl tumour.     

Unusual case of difficult double-lumen endotracheal tube removal

A reusable Robertshaw red rubber double-lumen endotracheal tube (DLT) was placed to facilitate lung isolation for thoracoscopy in a 49-year-old atopic patient. In spite of its smooth insertion, it was then not possible to remove the DLT. Direct laryngoscopy showed severe laryngeal edema. After 48 hours of medical treatment with steroids, the trachea was extubated. The laryngeal edema could have been the result of physical and chemical irritation by the reusable rubber DLT itself, or from the substances formed during repeated cleaning and sterilization of the DLT. Atopic patients who are prone to developing latex allergy are also more liable to develop severe reactions to chemical, mechanical, and physical irritation from reusable red rubber DLTs or from the chemical solution used for its cleaning and sterilization.     

Congenital diaphragmatic hernia and eventration

A review of 52 consecutive cases of congenital diaphragmatic hernia composed of 36 cases of Bochdalek hernia (B.H.) 13 of diaphragmatic eventration (D.E.), and 3 of diaphragmatic agenesis (D.A.) is reviewed critically. The operative mortality rate in Bochdalek hernia was 8.3% but became 20% with reference to the 15 infants with B.H. operated in the first 24 hrs. of life and 31.5% with reference to all 19 infants requiring repair of the diaphragmatic defect during the first day after birth. The operative mortality in D.A. was 100% and was nil in D.E. The mortality appeared related directly to prematurity, early age at operation, preoperative hypoxemia (PaO2 less than or equal to 60), hypercarbia, (PaCO2 greater than or equal to 60), and acidosis (pH less than or equal to 7.0), association with life-threatening anomalies affecting the lungs and its vessels, the heart, the size of the diaphragmatic defect and of the celomic cavity, the postoperative development of NEC and of obstructing intestinal adhesions. Eight of the 33 survivors (24%) with B.H. developed intestinal obstruction secondary to adhesions 2 months to 14 years after operation, of whom 7 required surgical intervention, and 3 bowel resections. The total mortality rate in B.H. was 14% and the rate in this series of combined defects was 15%.     

A comparison of epidural tramadol and epidural morphine for postoperative analgesia

The present study compared epidural tramadol with epidural morphine for postoperative analgesia in 20 patients undergoing major abdominal surgery. Intraoperatively, the patients were anaesthetized by a balanced technique of general anaesthesia combined with lumbar epidural lidocaine. In ten of the patients 100 mg tramadol diluted in 10 ml normal saline was also injected epidurally, while 4 mg epidural morphine was used in the other ten patients. In all patients, the visual analogue pain score, PaO₂, PaCO₂ and respiratory rate were monitored every hour for the first 24 hr postoperatively. In both the tramadol and morphine groups, the mean hourly pain scores ranged from 0.2 ± 0.6 to 1.4 ± 2.5 throughout the period of observations. However, the mean PaO₂ was decreased postoperatively in the epidural morphine group, while no change was observed in the epidural tramadol group. The maximal decrease of PaO₂ in the epidural morphine group was observed at the tenth hour postoperatively, when it decreased to 72.8 ± 10.3 mm Hg. This was not associated with any increase in PaCO₂ or a decrease of respiratory rate, suggesting that hypoxaemia rather than hypercarbia or decreased respiratory rate may be an earlier indicator of respiratory depression in patients breathing room air without oxygen supplementation. The absence of clinically relevant respiratory depression following epidural tramadol compared with epidural morphine may be attributed to the different mechanisms of their analgesic action. The results suggest that epidural tramadol can be used to provide prolonged postoperative analgesia without serious side effects.