AN EVENT OF UNDIAGNOSED INTRAOPERATIVE HYPERTENSION - STILL A NIGHTMARE - SUSPENSE CONTINUES …A CASE REPORT

Intraoperative events are not uncommon to any anesthesiologist. For every case inside the operating room, some major or minor events always occur related to patient, surgery, or anesthesia. Managing such events depends on the skill and experience of the anesthesiologist. When it becomes unmanageable due to undiagnosed and unanticipated conditions, it creates a “tug of war” situation inside the operating room. So, screening of such unidentied undiagnosed conditions is an essential aspect of the pre-anesthesia checkup. Unfortunately, sometimes due to asymptomatic presentations in non-stress conditions, it becomes difcult to screen them before surgery.We describe such an event of an intraoperative hypertensive crisis that remained undiagnosed before and after surgery leading to continuing suspense.

Using of urapidil for correction of arterial hypertension in cataract surgery

Purpose. Comparative analysis of clinical efficacy of urapidil and droperidol for relief of arterial hypertension (AH) during cataract surgery. Material and methods. The study included 30 patients who underwent relief of intraoperative hypertension with urapidil or droperidol in combination with sedation. According to method of treatment of hypertension, 3 groups of patients were distinguished: 1st group – 10 patients whom were injected only with urapidil, 2nd group – 10 patients whom were injected urapidil against the background of sedation; 3rd group – 10 patients whom received droperidol against the background of sedation. Results. We relieved intraoperative rise in blood pressure and avoided complications associated with it, in all 3 groups. Using of urapidil did not cause side effects from cardiovascular, respiratory and nervous systems. The dose of urapidil was reduced when used in conjunction with sedatives. Droperidol has been shown to be effective in patients with cognitive impairment with signs of arousal. Conclusion. The applied methods of relief of intraoperative AH were effective in all patients. Urapidil for correction of AH in outpatients is justified due to its effectiveness and safety. Droperidol for treatment of AH is preferable for patients with unstable psychoemotional status, agitation. Such patients should be monitored in hospital. Key words: urapidil, ebrantil, droperidol, intraoperative arterial hypertension, ophthalmosurgery.

Deliberate Compensated Vasoplegia - a Novel Pharmacological Regimen for Controlling Arterial Blood Pressure During Surgery for Pheochromocytoma

Background: Intraoperative hemodynamic fluctuations are the most dreaded phenomenon associated with the treatment of pheochromocytoma. Preoperative alpha-adrenergic blockade protocols aimed at abating these fluctuations have achieved controversial results. No study to date has evaluated the use of intraoperative treatment protocols during surgery for pheochromocytoma. Deliberate compensated vasoplegia (DCV) is a novel pharmacological regimen developed at our institution intended to decrease severe hypertensive events. The aim of this study is to compare outcomes of pheochromocytoma resection with and without the DCV protocol. Methods: A retrospective analysis of all pheochromocytoma resections between the years 2012 and 2020 was performed. Resections performed with and without the DCV protocol were compared. The primary outcome measured was the incidence of severe intraoperative hypertension (mean arterial pressure ≥ 150 mmHg). Secondary outcomes included other abnormal blood pressure measurements as well as perioperative data and complications. Results: A total of 41 pheochromocytoma resections were included: 21 performed using standard practice and 20 with the DCV protocol. Analysis demonstrated no significant difference in preoperative parameters including tumor size, catecholamine levels, or alpha-blockade protocol. The use of the DCV protocol resulted in a significant decrease in the incidence of severe hypertensive episodes from 1.95±3.6 to 0.03±0.13 events/hour (p=0.008). The DCV protocol was not associated with any adverse events. Conclusions: This study demonstrates that DCV anesthesia protocol significantly decreases the incidence of severe hypertensive episodes during pheochromocytoma resection. This is the first study describing a highly effective protocol for controlling intraoperative hypertension and hemodynamic instability in pheochromocytoma patients.

Administration of Tumescence in Pediatric Burn Patients Causes Significant Hypertension

The effects of injecting tumescence containing phenylephrine in pediatric burn patients are unknown, but anecdotally our clinicians note a high incidence of hypertension requiring treatment. This study sought to determine whether tumescence with phenylephrine was associated with hypertension requiring treatment in our pediatric burn patients. This was a retrospective cohort study of pediatric burn patients who underwent tangential excision with split-thickness autografting, excision alone, or autografting alone from 2013 to 2017. Records were reviewed for hypertensive episodes, defined as ≥2 consecutive blood pressure readings that were >2 SD above normal. Published intraoperative age- and sex-adjusted standards were used to define reference values. Parametric and nonparametric tests were used when appropriate. In total, 258 operations were evaluated. Mean patient age was 7.6 ± 5.2 years, and 64.7% were male. Patients were predominately white (69.8%). Overall, there was a 62.8% incidence of hypertension. On univariate logistic regression analysis, duration of operation, estimated blood loss, treated TBSA, and weight-adjusted volume of tumescence were significant predictors of intraoperative hypertension (P < .01). On multivariate analysis, weight-adjusted volume of tumescence alone was significantly associated with the presence of hypertension with an odds ratio of 2.0 (95% confidence interval: 1.33–3.04). Of the 162 operations which exhibited at least one episode of significant hypertension, 128 cases (79%) were treated. Intraoperative administration of phenylephrine-containing tumescence in pediatric burn patients is associated with clinically significant hypertension requiring treatment. This practice should be conducted with caution in pediatric burn operations until its clinical implications are defined.

A Case Report of Thalamic Infarction after Lumbar Drain: A Unique Cause of Perioperative Stroke?

In the case presented, a patient has an unexplained episode of hypertension during aneurysm clipping. Following the procedure, the patient was discovered to have bilateral thalamic infarctions unrelated to the vascular location of the aneurysm. After a review of the case, it becomes apparent that intracranial hypotension caused by lumbar over drainage of cerebrospinal fluid (CSF) is the likely cause of both the episode of intraoperative hypertension and the thalamic infarcts. It is often presumed that having an open dura protects against intracranial hypotension and subsequent herniation. We present this case to suggest that opening the dura might not be protective in all cases and anesthesiologists must pay particular attention to the rate of CSF drainage. Lumbar CSF drainage is a technique frequently employed during neurological surgery and it is important for anesthesiologists to understand the signs, symptoms, and potential consequences of intracranial hypotension from rapid drainage.

A Comparison of Labetalol and Nitroglycerin for The Management of Intraoperative Hypertension in Ambulatory Surgical Patients Who Underwent Cataract Surgery

Background: This is a prospective randomized blinded clinical trial comparing the efficacy and safety of labetalol and nitroglycerin for the management of intraoperative hypertension in ambulatory surgical patients who underwent cataract surgery. Methods: A total of 80 hypertensive patients (systolic blood pressure> 200 mmHg or diastolic blood pressure>100 mmHg) who had increased blood pressure during cataract surgery under topical anesthesia were reviewed. Patients were randomized to receive nitroglycerin (group N, n=40) or labetalol (group L, n=40). The initial dose of nitroglycerin was a bolus of 2 µg/kg and repeat dose of 1ug/kg intravenously every 5 minutes. Labetalol was administered as a bolus of 5 mg followed by 5 mg intravenously as needed every five minutes up to maximum dose of 1 mg/kg. Results: Systolic blood pressure decreased from 21.4±8.6 mm Hg (200 to 260 mm Hg) to 18.8±6.4 mm Hg with administration of nitroglycerin. Labetalol reduced systolic blood pressure from 21.4±6.7 mm Hg (201 to 258 mm Hg) to 17.6±11.6 (p=0.02). Nitroglycerin increased baseline heart rate from 68±8 beats/min to 82±6 beats/min (p=0.04), however, in the labetalol group heart rate reduced from control 72±6 to 64±9 beats/min (P<0.05). The hypotension episode was 18 (45%) cases in the nitroglycerin group and 2 (5%) cases in the labetalol group respectively (p<0.05). The mean of systolic blood pressure during their stay in the recovery room in nitroglycerin group was 20.7±9.6 mm Hg and in labetalol group was 18.5±10.2 mm Hg (p<0.05). Conclusion: Nitroglycerin may produce reflex tachycardia and episode of hypotension especially in elderly patients intraoperatively. Labetalol is a safe and effective antihypertensive agent for management of increased blood pressure during cataract surgery with topical anesthesia.