Perioperative management of a double valve replacement and coronary artery bypass graft in a patient with carcinoid syndrome; a case report and literature review

INTRODUCTION

Carcinoid tumors are rare neuroendocrine tumors; about 5% of patients develop the carcinoid syndrome. We present the case of a patient with carcinoid syndrome undergoing cardiac surgery.

CASE REPORT

A 74-year-old patient with carcinoid heart disease and hepatic metastases underwent double valve replacement and CABG. The patient was on octreotide therapy and antihypertensive medication. An octreotide infusion was commenced perioperatively. Pharmaceutical agents that could potentially precipitate histamine release or exacerbate catecholamine secretion and carcinoid crises were avoided. Postoperatively, recovery was complicated by atrial fibrillation, chest infection, pleural effusions, acute kidney injury and delirium.

DISCUSSION

Hepatic metastases cause systemic hormones' secretion, which cause a carcinoid crisis. Perioperative administration of octreotide is used, while vigilance is required to differentiate between hemodynamic effects related to the operation or disease specific factors.

CONCLUSION

No carcinoid crisis was evident perioperatively. High vigilance with appropriate monitoring, aggressive management combined with meticulous choice of pharmaceutical agents led to this outcome.

Post-Operative Thoracic Epidural Analgesia and Incidence of Major Complications according to Specific Safety Standardized Documentation: A Large Retrospective Dual Center Experience

(1) Background: Thoracic epidural analgesia is considered the gold standard in post-operative pain management following thoracic surgery. This study was designed to explore the safety of thoracic epidural analgesia and to quantify the incidence of its post-operative complications and side effects in patients undergoing thoracotomy for major surgery, such as resection of lung malignancies and lung transplantation. (2) Methods: This is a retrospective, dual-center observational study including patients that underwent major thoracic surgery including lung transplantation and received concurrent placement of thoracic epidural catheters for post-operative analgesia. An electronic system of referral and documentation of complications was used, and information was retrieved from our electronic critical care charting system. (3) Results: In total, 1145 patients were included in the study. None of the patients suffered any major complication, including hematoma, abscess, or permanent nerve damage. (4) Conclusions: the present study showed that in experienced centers, post-operative epidural analgesia in patients with thoracotomy is a safe technique, manifesting minimal, none-serious complications.

Monitoring the Cerebral Oximetry Index Along With In-line Cardiopulmonary Bypass Parameters in a High-Risk Patient Undergoing Cardiac Surgery: A Case Report

The quest to minimize the morbidity and mortality of patients undergoing cardiac surgery is ongoing. Impaired cerebral autoregulation and tissue malperfusion are linked with neurological complications. The cerebral oximetry index (COx) has been introduced as an index of cerebral autoregulation, while in-line monitoring enables the detection and prevention of metabolic disturbances during cardiopulmonary bypass (CPB). This report presents the case of a 58-year-old female patient scheduled for aortic valve replacement under minimally invasive extracorporeal circulation (MiECC). Her medical history consisted of epilepsy, multiple ischemic strokes, heavy smoking, and brachiocephalic artery stenosis. We sought to investigate the limits of autoregulation and the role of metabolic indices of perfusion on COx. Mean arterial blood pressure (ABP), cerebral oximetry (rSO₂), and in-line perfusion data during CPB were recorded at 10s intervals. The lower limit of autoregulation was 44mmHg on both sides and the upper limit was 98mmHg on the right and 107mmHg on the left side. A multiple linear regression analysis was performed to identify any potential predictors of COx values. Hemoglobin (Hb), PCO₂, flow, DO₂ index (DO₂i), Ο₂ extraction ratio (O₂ER), and perfusion ratio (PR) were included in the analysis. Significant equations were found on both sides. Predicted COx left was equal to 5.8 - 11.04O₂ER - 0.04Hb (p=0.001, R²= 0.15). Predicted COx right was equal to 3.06 - 0.3flow - 6.8O₂ER -0.03Hb + 0.02PCO₂ + 0.004DO₂i(p=0.03, R²=0.13). Targeting physiological perfusion and monitoring perfusion during CPB may have an additional impact on cerebral autoregulation and should be studied further.

Chronic pain treatment with pregabalin in end stage respiratory failure patients awaiting lung transplantation on ambulatory veno-venous extra corporeal membrane oxygenator support; a series of nine cases

Background

End-stage respiratory failure is non-treatable with mechanical ventilation and can be treated with veno-venous extracorporeal membrane oxygenators (VV-ECMO). It can also be used as a bridge to lung transplantation or recovery of lung function. This patient group can suffer from chronic pain, which is further exacerbated by painful procedures required as part of treatment. Pregabalin is licensed for chronic neuropathic pain and generalized anxiety disorder. Thus far, it has not been tried in routine analgesia protocols for pain relief of patients on VV-ECMO.

Case Series

We included nine patients aged 17-54 years on VV-ECMO awaiting lung transplantation. Exclusion criteria were acute kidney injury and chronic kidney disease. All patients had morphine patient-control analgesia. In addition, pregabalin 50 mg twice daily was initiated in all patients with dose escalation as required. Pain scores and quality of sleep were evaluated daily. All patients experienced significant pain relief, demonstrated by reduced pain scores after treatment commencement. The mean visual analogue scale score was reduced significantly from 6 ± 2 to 3 ± 1. A significant increase in good-quality sleep duration was recorded from 5 ± 1.7 hours per day before to 8 ± 2.1 hours per day after pregabalin treatment. All patients except for two reported reduced anxiety levels of at least 2 ± 1 scale improvement (p <0.05).

Conclusions

Pregabalin is an efficient analgesic with accompanying anxiolytic effects in this group of patients with unique characteristics such as high analgesia requirements and exacerbated psychological and emotional stress. HIPPOKRATIA 2023, 27 (1):22-24.

Intravenous parecoxib and continuous femoral block for postoperative analgesia after total knee arthroplasty. A randomized, double-blind, prospective trial

BACKGROUND

Up until now, the optimal strategy for postoperative pain management after total knee arthroplasty (TKA) remains to be elucidated.

OBJECTIVE

The current investigation aimed to examine the analgesic efficacy and the opioid sparing effects of intravenous parecoxib in combination with continuous femoral blockade.

STUDY DESIGN

Randomized, double-blind, prospective trial.

SETTING

University hospital in the United Kingdom.

METHODS

In total, 90 patients underwent TKA under subarachnoid anesthesia and received continuous femoral block initially as a bolus with 20 mL of ropivacaine 0.75%. Infusion of 0.2% on 10 mL/h followed. Patients were randomized into 2 groups. Group D and Group P received parecoxib and placebo, respectively at 12 hour time intervals. Visual analog scale (VAS) pain scores were obtained at different time intervals including 4, 8, 12, 24 and 36 hours. The pain scores were measured with patients in a resting position. Morphine could also be administered with a patient controlled analgesia (PCA) pump if the specified analgesia was deemed inadequate (VAS > 5).

RESULTS

None of the patients were withdrawn from the study. Parecoxib provided greater relief than placebo following TKA. The VAS pain scores measured at rest were statistically significantly lower in parecoxib-treated patients compared to the placebo group (P = 0.007) at 4 (P = 0.044), 12 (P = 0.001), and 24 hours (P = 0.012), postoperatively. Patients receiving parecoxib consumed less morphine at all time intervals than patients receiving placebo, with borderline statistical significance (P = 0.054). In each time period, all patients receiving continuous femoral block irrespectively of the treatment group, required low morphine doses.

LIMITATIONS

Current protocol did not answer question as to functional recovery.

CONCLUSION

According to our findings intravenous parecoxib in combination with continuous femoral block provided superior analgesic efficacy and opioid sparing effects in patients undergoing TKA.