Implications and considerations during pheochromocytoma resection: A challenge to the anesthesiologist

Pheochromocytoma is a rare catecholamine secreting tumor arising commonly from adrenal medulla. It has got multidimensional challenging aspects in spite of our improved understanding of its physiological and clinical behavior during surgical resection. This neuroendocrine tumor is associated with a most unpredictable and fluctuating clinical course during anesthesia and surgical intervention. The clinical difficulties and challenges increase manifold in patients with undiagnosed or accidental diagnosis of pheochromocytoma who present to the hospital for the treatment of some other disease or emergency. The most common manifestations of this clinical spectrum include hypertension, headache, palpitations, episodic sweating, and feeling of doom. The definite and only treatment for this rare tumor is surgical resection which itself is very challenging for an anesthesiologist. This article reviews the pre-operative evaluation, pharmacological preparation, intraoperative and post-operative management of patients with pheochromocytoma especially from anesthesiologist's perspectives

Anesthesia and Intensive care implications for pituitary surgery: Recent trends and advancements

The advancements in neuro-endocrine surgical interventions have been well supported by similar advancements in anesthesiology and intensive care. Surgery of the pituitary tumor poses unique challenges to the anesthesiologists and the intensivists as it involves the principles and practices of both endocrine and neurosurgical management. A multidisciplinary approach involving the endocrine surgeon, neurosurgeon, anesthesiologist, endocrinologist and intensivist is mandatory for a successful surgical outcome. The focus of pre-anesthetic checkup is mainly directed at the endocrinological manifestations of pituitary hypo or hyper-secretion as it secretes a variety of essential hormones, and also any pathological state that can cause imbalance of pituitary secretions. The pathophysiological aspects associated with pituitary tumors mandate a thorough airway, cardiovascular, neurologic and endocrinological assessment. A meticulous preoperative preparation and definite plans for the intra-operative period are the important clinical components of the anesthetic strategy. Various anesthetic modalities and drugs can be useful to provide a smooth intra-operative period by countering any complication and thus providing an uneventful recovery period

Care of Terminally ill Cancer Patients: An Intensivist’s Dilemma

Background and Context: Treatment of terminally ill cancer patients always poses great challenges especially when these critical patients are admitted in intensive care unit (ICU). The severity of their diseases throws a clinical and ethical dilemma to the treating intensivist. Aims and Objectives: To evaluate the benefits of intensive care treatment in terminally ill cancer patients and also to find out whether optimal utilization of critical care resources has got any positive financial, psychological and clinical outcome. Materials and Methods: A retrospective evaluation of 53 terminally ill cancer patients, who got admitted to ICU of our department, was carried out. Majority of these patients presented with terminal phase of illness involving multi-organ pathologies with diverse range of symptoms. These patients were provided ventilatory, symptomatic and supportive treatment on patient-to-patient basis. Strict and vigilant monitoring of all vital parameters was carried out. At the end of study, all the data was compiled systematically and was subjected to statistical analysis using non parametric tests. Results: The demographic profile of such patients was highly variable with regard to educational, social and financial status (P<0.05). The most common group of cancer was hematological malignancies (24.53%) followed by lung cancer (18.87%), uteri-ovarian (15.09), colorectal (13.2%) and others. Significant number (P<0.05) of patients (64.15%) required mechanical ventilation and ionotropic support (79.24%). Mortality increased with increasing number of organ system involvement and reaching up to 100% with involvement of 5 or more organ systems. Conclusions: ICU care is the best form of treatment for terminally ill but resources should be used optimally so that a young deserving patient should not be sacrificed for the scarcity of resources

Delivering obstetrical critical care in developing nations

Obstetrical critical care has not been able to achieve the same level of peaks in developing nations like India, as in the western countries. Numerous factors, including clinical and economical, have played a major role in widening the gap of quality care delivery in severely ill obstetric patients, between the two extreme worlds. Moreover, this wide gap can be, to a large extent, attributable to the lower literacy rates, paucity of research in obstetrical critical care, poverty, lack of awareness, and the sociocultural and behavioral factors prevalent in these developing nations. The most common indication for Intensive Care Unit (ICU) admission of such patients throughout the world is hemorrhage, both antepartum and postpartum. Hypertensive disorders, pre-eclampsia, and its related complications are also major contributory factors for such admissions. The pattern of the disease necessitating such admissions influences maternal mortality to a great extent. The present article reviews the most common indications of obstetrical admissions to the ICU, the challenges and obstacles in the treatment of severely ill obstetric patients, their possible outcome in the developing nations, room for improvement, and the need for a change in the system for better delivery of critical care obstetrical services

Is intensive care the only answer for high risk pregnancies in developing nations?

Background : Management of high risk obstetric patients. Aim : The present study was conducted to evaluate the primary causes of the admission of obstetric patients to Intensive Care Unit (ICU), the presence of co-morbid diseases, outcome of such patients, their survival rate as well as the factors which contribute to the maternal mortality. Settings and Design : A retrospective study was conducted in the Department of Obstetrics and Gynaecology and Anaesthesiology/ICU of our Institute. Materials and Methods : Sixty-one obstetric patients, who were admitted to ICU between 20 December 2006 and 31 January 2010, were evaluated for various factors responsible for their admission as well as their outcome. Statistical Analysis : At the end of study, the data were arranged systematically and subjected to statistical analysis using nonparametric tests and P value &lt;0.05 was considered significant. Results : Majority of the 61 patients admitted in ICU were referred from the peripheral health centers, smaller nursing homes/hospitals and some even without proper primary care and mainly comprising uneducated and rural population. Hemorrhage, pregnancy induced hypertension, cardiac diseases, respiratory insufficiency and sepsis were the main causes for admission. A total of 18 patients among 61 died during their ICU stay in the hospital. Conclusions : In the developing countries, high risk pregnancy should be managed at peripheral centers with proper facilities, antenatal visits and timely referral. The intensive care help should be reserved for very high risk pregnancies with co-morbid diseases

Anesthesia implications in emergency oncologic surgery in a case of untreated Parkinsonism

Oncologic surgery has made tremendous advancements in the last two decades. The prognosis of once thought to be irreversible and incurable diseases has improved dramatically with these advancements, which have given a fresh lease of hope to the general population. But there are certain factors that are still unfavorable for achieving improved outcome of surgery in various cancers. The associated comorbid diseases do determine to a large extent the actual outcome of all the interventions to treat oncologic disease. The untreated coexisting disease makes the task of the attending anesthesiologist very challenging as numerous complications are anticipated, especially during emergency surgery. We are describing a case of a patient with endometrial carcinoma who presented with unstoppable bleeding per-vaginum and was suffering from Parkinson disease since 1½ years, for which no treatment was ever sought. Vaginal hysterectomy was performed under graded epidural anesthesia; and after a smooth and uneventful postoperative period of 8 days, she was referred to radiotherapy unit for further management

Clinical and critical care concerns in severely ill obese patient

The incidence of obesity has acquired an epidemic proportion throughout the globe. As a result, increasing number of obese patients is being presented to critical care units for various indications. The attending intensivist has to face numerous challenges during management of such patients. Almost all the organ systems are affected by the impact of obesity either directly or indirectly. The degree of obesity and its prolong duration are the main factors which determine the harmful effect of obesity on human body. The present article reviews few of the important clinical and critical care concerns in critically ill obese patients