Correlation Between Changes in End-Tidal Carbon Dioxide Concentration and Cardiac Output During Inferior Vena Cava Clamping and Unclamping in Living-donor Liver Transplantation

BACKGROUND

To test the hypothesis that low end-tidal carbon dioxide tension encountered during anhepatic phase in liver transplantation is related to hemodynamic status rather than ventilatory status, and can be used to predict the change in cardiac output during anhepatic phase.

METHODS

We retrospectively analyzed and compared data, included end-tidal carbon dioxide tension (ETCO2), arterial blood pressure, heart rate, central venous pressure, cardiac output, cardiac index, and stroke volume, before and after inferior vena cava clamping, and 0, 5, 10, 30 minutes during the anhepatic, and 5 minutes after the release of IVC cross clamp during the reperfusion phase, with paired Student t test, repeated measurement, and linear regression. P < .05 was regarded as significant.

RESULTS

The cardiac output and ETCO2 decrease significantly after clamping the inferior vena cava and increase concomitantly after unclamping. There is a positive correlation between the changes in % in cardiac output and ETCO2 (Pearson coefficient r = 0.741).

CONCLUSION

The changes in ETCO2 can be used to predict the changes of the cardiac output in % when cardiac output monitoring is not available. Before unclamping of the IVC, mild hyperventilation is suggested to prevent excessive increase in PaCO2.

Review of critical incidents in a university department of anaesthesia

In 2011, our hospital started a new system of 100% procedural audit of anaesthesia work, in which we incorporated the reporting of critical incidents. This monitoring of critical incidents has enabled identification of the spectrum of incidents and risk factors and helped in the education of trainees and specialists. In this review, we analyse 379 incidents that had been reported among 44,915 anaesthetics administered in a two-year period. The risk of incidents was higher in patients of lower American Society of Anesthesiologists physical status, anaesthesia of long duration and anaesthesia carried out after-hours. The most common incidents were airway problems and drug administration problems. Fifty-nine percent of incidents were evaluated to be preventable and adverse outcomes occurred in 48% of cases. Human factors were the major contributors to incidents. We suggest that incorporating critical incident reporting as part of a 100% procedural audit facilitated, rather than discouraged, the reporting of critical incidents, even though reporting was not anonymous. The rate of incident reporting increased from 0.37% to 0.84%.

P2-18-05: Cardiotoxicity Risks of Adjuvant Trastuzumab in Asian Breast Cancer Patients

Background: Adjuvant trastuzumab (T)-based chemotherapy reduces relapse and improves overall survival in early breast cancer. However, T-associated cardiotoxicity potentially limits its use. Our study aims to report the incidence, severity and reversibility of cardiotoxicity amongst Asian breast cancer patients.

Methods: This is a retrospective review of patients who have received adjuvant T from June 2005 to March 2011 at our centre. CT was defined as a drop in left ventricular ejection fraction (LVEF) to less than 50% and / or reduction of ≥ 10% of baseline. Cardiovascular (CVS) risk factors were defined as having at least one of the following factors: family or previous history of CAD, hypertension, diabetes mellitus, hyperlipidemia and smoking. One-way repeated measures ANOVA was used to evaluate the mean LVEF change and Chi-square test to evaluate the association of demographics and CT.

Results: A total of 314 female patients were reviewed. CT was reported in 124 (39.5%), of whom 96 had asymptomatic decline in LVEF and 28 were symptomatic. T was withheld (n=53) due to asymptomatic decline in LVEF (n=40), symptomatic heart failure (n=3) and both (n=10). Forty-three patients with resolution of CHF (n=11) or LVEF recovery (n=32) were rechallenged. Cardiotoxicity recurred in 14 - asymptomatic decline in LVEF (n=10), recurrent CHF (n=1) and both (n=3). Overall, there were no cardiac-related deaths. Factors that predicted for CT included low normal pre-trastuzumab LVEF (&lt;60%) (p=0.01), prior anthracyclines (p=0.011), decline in LVEF pre-anthracycline and before T (p=0.022) and BMI ≥ 23kg/m2 (p=0.018). Three-monthly LVEF showed statistically significant decline against baseline over the time points (p=0.005). As expected, the decline in LVEF demonstrated significant interaction with CT groups and non CT group (p&lt;0.001).

A case of metastatic squamous cell carcinoma of the hypopharynx manifesting as acute abdomen

INTRODUCTION

Squamous cell head and neck cancers are usually confined to local and regional sites but occasionally, patients may present with rare manifestations of distant metastases.

CLINICAL PICTURE

A 23-year-old female was treated with concurrent chemo-radiotherapy for stage IVA post-cricoid squamous cell carcinoma. A month later, she presented with acute abdomen and was found to have extensive peritoneal nodules at laparotomy. Intestinal obstruction soon followed.

TREATMENT

She was managed conservatively for the intestinal obstruction and given weekly paclitaxel.

OUTCOME

She continued to deteriorate and succumbed shortly after the diagnosis of carcinomatosis peritoneii.

CONCLUSION

This rare and aggressive presentation reminds us to be cognizant of relapsed head and neck cancers manifesting atypically, and the need for more aggressive search of distant disease in at least some subgroups of head and neck cancer.

Ethnicity, obstructive sleep apnoea and ischaemic heart disease

We studied the relationship between different ethnic groups, obstructive sleep apnoea (OSA) and ischaemic heart disease. Four hundred and thirty-two inpatients from the medical wards were interviewed. Limited overnight sleep studies were done in 129 of those who had habitual snoring, daytime sleepiness based on an Epworth sleepiness scale of 8 or more, or a large neck size of 40 cm or more. There were 315 Chinese (72.9%), 67 Malays (15.5%), 43 Indians (10%) and 3 from other races (1.4%). The prevalence of OSA was 19.7%, 30% and 12% among the Chinese, Malays and Indians, respectively. The prevalence ratio for OSA was 1.52 in Malays using Chinese patients as the baseline (P = 0.07). The median neck circumference was 37 cm in both racial groups. The median body mass index was 22.7 kg/m2 in Chinese compared to 23.6 kg/m2 in Malays. The median apnoea-hypopnoea index was 22.7, 19.0 and 26.9 events/hour among the Chinese, Malays and Indians, respectively. OSA was independently associated with the prevalence of IHD (adjusted prevalence ratio 1.68; 95% CI: 1.15, 2.46; P = 0.009). The prevalence of ischaemic heart disease (IHD) was 31%, 24% and 28% in Chinese, Malays and Indians, respectively. The prevalence ratio for IHD in Malays compared to Chinese was 0.77. After adjusting for OSA, there was an even greater reduction in the risk of IHD (adjusted prevalence ratio 0.70). This suggests that OSA is a confounder in the relationship between race and ischaemic heart disease.

A case report of a patient with bronchial carcinoid tumour and late presentation of Cushing's syndrome

Bronchial carcinoid tumour with ectopic adrenocorticotrophin (ACTH) production is an uncommon cause of Cushing's syndrome. In most instances, the patient presents with clinical hyperglucocorticolism and a search for its underlying pathology leads to the discovery of an inconspicuous bronchial carcinoid tumour, if at all. Often the tumour is not immediately detectable. We report a patient who presented in the reverse order--she initially had a large asymptomatic bronchial carcinoid tumour that subsequently manifested as clinical Cushing's syndrome after remaining quiescent for four years.