Analgesia with epidural bupivacaine, sufentanil or the combination was studied in 50 patients who had undergone thoracotomy. During operation all patients received an initial dose of bupivacaine 0.5% with adrenaline 5 micrograms.ml-1 (5-10 ml) by thoracic epidural catheter. One hour later the patients were divided into three groups: the bupivacaine group (bupivacaine 0.125%), the sufentanil group (50 micrograms sufentanil in 60 ml normal saline) and the combination group (50 micrograms sufentanil in 60 ml bupivacaine 0.125%). Analgesia in the three groups was provided by a continuous epidural infusion (5-10 ml.h-1) for 3 days. The mean dose of bupivacaine was significantly higher (P less than 0.05) in the bupivacaine group (12.07 mg.h-1 (s.e.mean 0.97 mg.h-1)), compared with the combination group (9.82 mg.h-1 (s.e.mean 0.43 mg.h-1)). The mean dose of sufentanil in the sufentanil group was similar to the combination group (6.37 micrograms.h-1 (s.e.mean 0.23 micrograms.h-1) and 6.52 micrograms.h-1 (s.e.mean 0.28 micrograms.h-1), respectively. The pain scores on the inverse visual analogue scale of most patients in the bupivacaine group were unacceptably low. The sufentanil group had much better pain scores, but on exercise these patients experienced more pain than the combination group. The combination group had, overall, better pain scores. In the combination group, there were better respiratory results.
SummaryA patient sufering from phaeochromocytoma and coronary artery stenoses needed coronary artery bypass grafting before adrenalectomy. High thoracic epidural analgesia (T,-TJ with bupivacaine and sufentanil in combination with general anaesthesia was used. Plasma adrenaline and noradrenaline concentrations decreased during the period before bypass grafting compared to the baseline value and no important haemodynamic changes were seen during this period. Thoracic epidural analgesia failed to suppress the release of catecholamine during the bypass period. After the operation, the plasma catecholamine concentrations returned to the baseline value. Excellent analgesia (visual analogue scale = 1-2) was achieved with a postoperative epidural, but the plasma catecholamine concentration increased considerably. Key wordsAnaesthetic techniques, regional; epidural. Surgery; phaeochromocytoma, cardiovascular.In patients with phaeochromocytoma, producing adrenaline and noradrenaline, haemodynamic instability during adrenalectomy is frequent despite pretreatment with a-and b-blocking drugs. Release of catecholamines due to stress or manipulation of the adrenal glands causes hypertension and tachyarrythmias. In patients with angina at rest, the risk of myocardial infarction during adrenalectomy must be assumed to be high. A case is reported in which a patient with phaeochromocytoma and unstable angina (NYHA IV) underwent coronary artery bypass grafting, followed by adrenalectomy 6 weeks later. Case historyA 73-year-old 85-kg man, height 184 cm, suffering from hypertension, coronary artery disease and hyperlipidaemia type IV, was admitted to hospital with unstable angina. Several times a week he suffered from periods of profuse sweating accompanied by headaches, dizziness and palpitations. The angina reduced and the ECG became normal with P-blocking drugs, nitrates and calcium antagonists. Further investigation revealed a high level of vanilyl mandelic acid (VMA) in the urine and a very high concentration of adrenaline and noradrenaline (1.1 nmol/litre and 4.7 nmol/litre) in plasma. The normal value for adrenaline is 0.06-0.30 nmol/litre and for noradrenaline 0.6-2.3 nmol/litre. MIBG-and CT-scan showed bilateral hyperplasia of the adrenal glands, and phaeochromocytoma was suspected. A low total circulating volume was found using the radioactive labelled erythrocytes method.A 70% stenosis of the left anterior descending coronary artery (LAD), two consecutive segments of 80% stenosis of the circumflex coronary artery and a 75% stenosis of the right coronary artery (RCA) were demonstrated by coronary angiography. Ventriculography showed normal kinesis of the ventricular wall. The cardiac index was 3.4 litres/minute/sq m.In view of the severe coronary artery pathology, the risk of myocardial infarction during adrenalectomy was considered to be high. For this reason it was decided to revascularise the myocardium first, followed by adrenalectomy 6 weeks later. Anaesthetic managementOne week before coronary artery bypass grafting ...
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