Editor,The preoperative assessment of the likelihood of a postoperative cardiac event is complex. 1 The Revised Cardiac Risk Index (RCRI) is a commonly used scoring system for the stratification of cardiac risk of patients undergoing major non-cardiac surgery. 2 The RCRI scores patients according to six clinical categories: high-risk surgery (thoracic, abdominal and supra-inguinal vascular surgery); history of ischaemic heart disease (IHD); history of congestive heart failure; cerebrovascular disease; insulin-dependent diabetes; and renal failure. Since the publication of the original article in 1999, the RCRI has become a widely used stratification tool for cardiac risk. A recent meta-analysis has examined the predictive value of the RCRI in these studies. 3 It concluded that the RCRI performed moderately well at discriminating between low and high perioperative risk. However, the authors felt that it performed poorly in vascular cohorts, and that the studies included were of variable quality. This report highlights the need for further studies evaluating the RCRI.We report the results of a single centre observational study of consecutive patients undergoing major vascular surgery (aortic surgery, infra-inguinal bypass surgery, amputation). Ethical approval for this study [REC reference number 04/193(1)] was provided by the West of Scotland Research Ethics Committee (Chairperson Dr A Binning) on 2 March 2004. All patients gave written consent to the study. The patients were preoperatively scored according to the RCRI criteria. 2 The presence of other risk factors was obtained from the patient's history and medical records. Operations were recorded as elective or expedited (within 3 weeks of initial presentation). Patients operated as an emergency, within 24 h of an unplanned admission, were excluded. Postoperative screening for cardiac events was performed by daily clinical assessment, serial ECGs and troponin I measurement. The primary outcomes were major adverse cardiac event (MACE) (non-fatal myocardial infarction and cardiac mortality) and all-cause mortality. Patients were followed-up for 6 weeks following surgery. Statistical analysis was performed using SPSS (Version 15) statistical software package (SPSS, Chicago, IL). Categorical variables are presented with totals and percentages, and analysed with Chi-square, Fisher's exact test or Mann-Whitney test as appropriate. Receiver operating characteristic (ROC) curves were plotted to model the efficacy of the RCRI. The area under the curve (AUC) was calculated.A total of 252 patients were included in the study: aortic surgery 25.8%; bypass surgery 39.7%; and lower limb amputation 34.5%. Thirty-nine patients (15.5%) had a postoperative MACE, and 20 patients (7.9%) died within the postoperative 6-week period. Applying the RCRI to the cohort as a whole, the rate of MACE for RCRI class 1, 2, 3 and 4 was 13.4, 14.9, 18.6 and 16.7%, respectively (P ¼ 0.858) (Table 1). Similarly, the rate of perioperative mortality for these groups was 7.3, 9.2, 6.8 and 8.3%, r...
IntroductionSimilar to pheochromocytomas, paragangliomas can secrete catecholamines, although they are usually non-functional and clinical presentation is non-specific. We present a case of accidental, intra-operatively diagnosed neuroendocrine-active sympathetic paraganglioma, which was suspected and confirmed during elective retroperitoneal tumor removal.Case presentationA 25-year-old Caucasian Croatian man, American Society of Anesthesiologists status 1, underwent elective surgery for retroperitoneal tumor removal. The tumor had been discovered by chance during a routine examination and was suspected to be a sarcoma. Our patient had no history of previous medical conditions nor did he have symptoms characteristic of a neuroendocrine secreting tumor. The results of ultrasound and magnetic resonance imaging studies showed a large, well demarcated retroperitoneal tumor mass in his upper abdomen localized between the aorta and vena cava, measuring approximately 9×6×4.5cm. In the operating room an epidural catheter was inserted at the T7 to T8 level prior to induction of general anesthesia. Epidural analgesia was maintained by an infusion pump with local anesthetic and opiate mixture. During the surgical excision of the tumor, hemodynamic changes occurred, with hypertension (205/110mmHg) and tachycardia (up to 120 beats/minute). In spite of the fact that the surgical field of work did not include adrenal glands whose direct manipulation could explain this occurrence, there was a high degree of suspicion for the presence of a neurosecreting tumor. His clinical symptoms were relieved after administration of urapidil, esmolol and magnesium sulfate. After tumor excision, our patient developed severe hypotension. Hemodynamic stability was reinstated with aggressive volume replacement, with crystalloids and colloids, vasopressors and hydrocortisone. His post-operative course was unremarkable and on the eighth post-operative day our patient was discharged from hospital, with no consequences or symptoms on follow-up two years after surgery.ConclusionsOur patient’s case emphasizes the need to consider the presence of extra-adrenal paragangliomas in the differential diagnosis of retroperitoneal tumors, despite their rare occurrence. In our patient’s case, invasive hemodynamic monitoring during combined general anesthesia and epidural analgesia and early recognition of catechol-induced symptoms raised suspicion of the existence of a paraganglioma, and this led to an adequate therapeutic approach and favorable outcome of the surgery. Pre-operative recognition of paragangliomas could lead to better pre-operative preparation, but even high clinical suspicion in undiagnosed forms during surgery and the availability of rapid and short-acting vasodilatators, α-blockers and β-blockers might favor good outcome.
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