After evaluating the extension and pattern of sensory blockade in high, mid, and low thoracic epidural analgesia, the authors suggest that it is safe to use similar dosage regimens in all three regions, and that in high thoracic epidural analgesia, it is important to insert the epidural catheter at the level of the intended cranial border of blockade.
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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