Propofol TCI Reductions Do Not Attenuate Significant Falls in Cardiac Output Associated With Anesthesia Induction and Knee-Chest Positioning in Spinal Surgery

Background: Induction of anesthesia and the knee-chest position are associated with hemodynamic changes that may impact patient outcomes. The aim of this study was to assess whether planned reductions in target-controlled infusion propofol concentrations attenuate the hemodynamic changes associated with anesthesia induction and knee-chest position. Materilas and Methods: A total of 20 patients scheduled for elective lumbar spinal surgery in the knee-chest position were included. In addition to standard anesthesia monitoring, bispectral index and noninvasive cardiac output (CO) monitoring were undertaken. The study was carried out in 2 parts. In phase 1, target-controlled infusion propofol anesthesia was adjusted to maintain BIS 40 to 60. In phase 2, there were 2 planned reductions in propofol target concentration: (1) immediately after loss of consciousness—reduction calculated using a predefined formula, and (2) before positioning—reduction equal to the average percentage decrease in CO after knee-chest position in phase 1. Changes from baseline in CO and other hemodynamic variables following induction of anesthesia and knee-chest positioning were compared. Results: Induction of anesthesia led to decreases of 25.6% and 19.8% in CO from baseline in phases 1 and 2, respectively (P

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Journal Club

No abstract available

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Cognitive Prehabilitation: Supercharged Mind or Wishful Thinking?

No abstract available

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Role of Frailty and Comorbidity in Determination of Operability for Patients With Oral and Oropharyngeal Squamous Cell Carcinoma

Abstract

Purpose of Review

To review the role of frailty and comorbidities in determining operability and associated outcomes in patients with oral and oropharyngeal squamous cell carcinoma.

Recent Findings

Frailty and comorbidity have been linked to multiple adverse outcome measures including risk of mortality, surgical complications, length of stay, intensity of care needs, discharge disposition, risk of readmission, and cost of healthcare delivery. There are diverse objective and validated measures of comorbidity and frailty. Addition of comorbidity and objective frailty measurements has been demonstrated to improve predictive power of nomograms and clinical staging systems for patients with oral and oropharyngeal squamous cell carcinoma. The use of predictive tools that assess frailty may contribute to shared decision making, realistic expectations, and facilitation of appropriate level of care. While emerging literature supports the role of prehabilitation, there is paucity of data in support of such interventions for patients afflicted by oral and oropharyngeal cancer.

Summary

Frailty assesses operability beyond anatomic resectability and incorporates key determinants of physical, nutritional, and cognitive well-being. Objective measurements of frailty predict meaningful outcomes following surgery for cancers of the oral cavity and oropharynx. This paper suggests that clinicians should objectively and routinely assess frailty, which may facilitate patient counseling, improved risk stratification, informed decision making, and further research to elucidate relationship of frailty with outcomes in head and neck specific populations.

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Hypokalaemic metabolic alkalosis, hypertension and diabetes: what is the link

Two years after diagnosis of a metastatic neuroendocrine gastrin-secreting tumour and after several cycles of chemotherapy and peptide receptor radionuclide therapy, a 56-year-old woman presented with hypokalaemic metabolic alkalosis, hypertension, leg oedema and new-onset diabetes mellitus. Further investigations revealed renal potassium loss confirmed by a transtubular potassium gradient of 16, fully suppressed serum aldosterone, but instead highly elevated blood levels of morning cortisol and adrenocorticotropic hormone as well as increased urinary excretion of glucocorticoid and mineralocorticoid metabolites. Ruling out other causes, paraneoplastic hypercortisolism was diagnosed. Pharmacological inhibition of the steroid 11β-hydroxylase with metyrapone resulted in complete resolution of metabolic alkalosis, hypokalaemia, hypertension, hyperglycaemia and leg oedema within 1 week.

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Oncocytic cyst of the larynx: a rare finding

A 75-year-old woman presented with an 18-month history of severe, slowly worsening dysphonia. She was a smoker and known to have multiple benign cystic thyroid lesions. She reported no associated symptoms and other medical and social history was unremarkable. Fibreoptic nasendoscopy revealed a right-sided supraglottic cyst appearing to arise from the right false vocal cord. Further bedside examination was unremarkable. She underwent microlaryngoscopy and biopsy which showed a cyst originating from the right anterior ventricle, successfully removed without rupture using cold steel. Formal histopathology revealed a 14x10x7 mm unilocular, completely excised cyst lined by oncocytic epithelium and composed of columnar cells with darkly stained nuclei and abundant granular, eosinophilic cytoplasm. Three weeks postoperatively the patient's voice had returned to normal. To date, 11 months postoperatively, there is no evidence of recurrence, and she will continue long-term follow-up.

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Inguinal hernia containing a native orthotopic kidney

We report a rare case of an inguinal hernia containing part of a native kidney and present a review of the literature with regard to urological findings in patients with inguinal hernias. This case involves an elderly man with known bilateral inguinal hernias with an incidental radiographic finding of a large right inguinal hernia containing the inferior pole of the right kidney. The patient was not symptomatic from the hernia and given his overall frailty, no surgical intervention was offered.

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