Mas de feocromocitoma / More on pheochromocytoma

Julio 6, 2017. No. 2741

Alfa bloqueo selectivo versus no selectivo antes de adrenalectomía laparoscópica Selective Versus Non-selective α-Blockade Prior to Laparoscopic Adrenalectomy for Pheochromocytoma. Randle RW1, Balentine CJ2, Pitt SC2, Schneider DF2, Sippel RS2. Ann Surg Oncol. 2017 Jan;24(1):244-250. doi: 10.1245/s10434-016-5514-7. Epub 2016 Aug 25. Abstract BACKGROUND: The optimal preoperative α-blockade strategy is debated for patients undergoing laparoscopic adrenalectomy for pheochromocytomas. We evaluated the impact of selective versus non-selective α-blockade on intraoperative hemodynamics and postoperative outcomes. METHODS: We identified patients having laparoscopic adrenalectomy for pheochromocytomas from 2001 to 2015. As a marker of overall intraoperative hemodynamics, we combined systolic blood pressure (SBP) > 200, SBP < 80, SBP < 80 and >200, pulse > 120, vasopressor infusion, and vasodilator infusion into a single variable. Similarly, the combination of vasopressor infusion in the post-anesthesia care unit (PACU) and the need for intensive care unit (ICU) admission provided an overview of postoperative support. RESULTS: We identified 52 patients undergoing unilateral laparoscopic adrenalectomy for pheochromocytoma. Selective α-blockade (i.e. doxazosin) was performed in 35 % (n = 18) of patients, and non-selective blockade with phenoxybenzamine was performed in 65 % (n = 34) of patients. Demographics and tumor characteristics were similar between groups. Patients blocked selectively were more likely to have an SBP < 80 (67 %) than those blocked with phenoxybenzamine (35 %) (p = 0.03), but we found no significant difference in overall intraoperative hemodynamics between patients blocked selectively and non-selectively (p = 0.09). However, postoperatively, patients blocked selectively were more likely to require additional support with vasopressor infusions in the PACU or ICU admission (p = 0.02). Hospital stay and complication rates were similar. CONCLUSION: Laparoscopic adrenalectomy for pheochromocytoma is safe regardless of the preoperative α-blockade strategy employed, but patients blocked selectively may have a higher incidence of transient hypotension during surgery and a greater need for postoperative support. These differences did not result in longer hospital stay or increased complications. PDF Manejo perioperatorio actual de los feocromocitomas Current perioperative management of pheochromocytomas. Ramachandran R1, Rewari V1. Indian J Urol. 2017 Jan-Mar;33(1):19-25. doi: 10.4103/0970-1591.194781. Abstract Neuroendocrine tumors which have the potential to secrete catecholamines are either associated with sympathetic adrenal (pheochromocytoma) or nonadrenal (paraganglioma) tissue. Surgical removal of these tumors is always indicated to cure and prevent cardiovascular and other organ system complications associated with catecholamine excess. Some of these tumors have malignant potential as well. The diagnosis, localization and anatomical delineation of these tumors involve measurement of catecholamines and their metabolic end products in plasma and urine, 123I-metaiodobenzylguanidine scintigraphy, computed tomography, and/or magnetic resonance imaging. Before surgical removal of the tumors, the optimization of blood pressure, as well as intravascular volume, is an important measure to avoid and suppress perioperative adverse hemodynamic events. Preoperative preparation includes the use of alpha-adrenergic antagonists, beta-adrenergic antagonists with or without other antihypertensive agents, fluid therapy as well as insulin therapy for hyperglycemia if required. Due attention should be given to type and dose of alpha-receptor antagonists to be used and the duration of this therapy to achieve an optimal level of preoperative "alpha-blockade." Despite this preoperative preparation, many patients will have hypertensive crises intraoperatively which need to be promptly and carefully managed by the anesthesia team which requires intensive and advanced monitoring techniques. The most common complication after tumor removal is hypotension which may require fluid therapy and vasopressor support for a few hours. With advancement in surgical and anesthetic techniques, the incidence of severe morbidity and mortality associated with the surgery is low in high volume centers. HTLM XIV Congreso Virtual Mexicano de Anestesiología 2017 Octubre 1-Diciembre 31, 2017 Información / Information

Anestesiología y Medicina del Dolor 52 664 6848905 vwhizar@anestesia-dolor.org anestesia-dolor.org

Anestesia, diabetes y corazon / Anesthesia, diabetes and hearth

Julio 10, 2017. No. 2745

Diabetes, isquemia perioperatoria y anestésicos volátiles: consecuencias de trastornos en el metabolismo del sustrato miocárdico. Diabetes, perioperative ischaemia and volatile anaesthetics: consequences of derangements in myocardial substrate metabolism. van den Brom CE1, Bulte CS, Loer SA, Bouwman RA, Boer C. Author information Cardiovasc Diabetol. 2013 Mar 4;12:42. doi: 10.1186/1475-2840-12-42. Abstract Volatile anaesthetics exert protective effects on the heart against perioperative ischaemic injury. However, there is growing evidence that these cardioprotective properties are reduced in case of type 2 diabetes mellitus. A strong predictor of postoperative cardiac function is myocardial substrate metabolism. In the type 2 diabetic heart, substrate metabolism is shifted from glucose utilisation to fatty acid oxidation, resulting in metabolic inflexibility and cardiac dysfunction. The ischaemic heart also loses its metabolic flexibility and can switch to glucose or fatty acid oxidation as its preferential state, which may deteriorate cardiac function even further in case of type 2 diabetes mellitus.Recent experimental studies suggest that the cardioprotective properties of volatile anaesthetics partly rely on changing myocardial substrate metabolism. Interventions that target at restoration of metabolic derangements, like lifestyle and pharmacological interventions, may therefore be an interesting candidate to reduce perioperative complications. This review will focus on the current knowledge regarding myocardial substrate metabolism during volatile anaesthesia in the obese and type 2 diabetic heart during perioperative ischaemia. PDF El preacondicionamiento inducido por isoflurano es atenuado por la diabetes. Isoflurane-induced preconditioning is attenuated by diabetes. Tanaka K1, Kehl F, Gu W, Krolikowski JG, Pagel PS, Warltier DC, Kersten JR. Am J Physiol Heart Circ Physiol. 2002 Jun;282(6):H2018-23. Abstract Volatile anesthetics stimulate, but hyperglycemia attenuates, the activity of mitochondrial ATP-regulated K(+) channels. We tested the hypothesis that diabetes mellitus interferes with isoflurane-induced preconditioning. Acutely instrumented, barbiturate-anesthetized dogs were randomly assigned to receive 0, 0.32, or 0.64% end-tidal concentrations of isoflurane in the absence or presence of diabetes (3 wk after administration of alloxan and streptozotocin) in six experimental groups. All dogs were subjected to a 60-min left anterior descending coronary artery occlusion followed by 3 h of reperfusion. Myocardial infarct size (triphenyltetrazolium staining) was 29 +/- 3% (n = 8) of the left ventricular area at risk in control experiments. Isoflurane reduced infarct size (15 +/- 2 and 13 +/- 1% during 0.32 and 0.64% concentrations; n = 8 and 7 dogs, respectively). Diabetes alone did not alter infarct size (30 +/- 3%; n = 8) but blocked the protective effects of 0.32% (27 +/- 2%; n = 7) and not 0.64% isoflurane (18 +/- 3%; n = 7). Infarct size was directly related to blood glucose concentrations in diabetic dogs, but this relationship was abolished by higher concentrations of isoflurane. The results indicate that blood glucose and end-tidal isoflurane concentrations are important determinants of infarct size during anesthetic-induced preconditioning. PDF  Anestésicos como cardioprotectores: traducibilidad y mecanismo. Anaesthetics as cardioprotectants: translatability and mechanism. Kikuchi C1, Dosenovic S, Bienengraeber M. Br J Pharmacol. 2015 Apr;172(8):2051-61. doi: 10.1111/bph.12981. Epub 2015 Jan 12. Abstract The pharmacological conditioning of the heart with anaesthetics, such as volatile anaesthetics or opioids, is a phenomenon whereby a transient exposure to an anaesthetic agent protects the heart from the harmful consequences of myocardial ischaemia and reperfusion injury. The cellular and molecular mechanisms of anaesthetic conditioning appear largely to mimic those of ischaemic pre- and post-conditioning. Progress has been made on the understanding of the underlying mechanisms although the order of events and the specific targets of anaesthetics that trigger protection are not always clear. In the laboratory, the protection afforded by certain anaesthetics against cardiac ischaemia and reperfusion injury is powerful and reproducible but this has not necessarily translated into similarly robust clinical benefits. Indeed, clinical studies and meta-analyses delivered variable results when comparing in the laboratory setting protective and non-protective anaesthetics. Reasons for this include underlying conditions such as age, obesity and diabetes. Animal models for disease or ageing, human cardiomyocytes derived from stem cells of patients and further clinical studies are employed to better understand the underlying causes that prevent a more robust protection in patients PDF XIV Congreso Virtual Mexicano de Anestesiología 2017 Octubre 1-Diciembre 31, 2017 Información / Information Encuentro Internacional de Manejo de la Vía Aérea Bariloche. Argentina. Nov 30-Dic 2, 20l7 Información / Information

Anestesiología y Medicina del Dolor 52 664 6848905 vwhizar@anestesia-dolor.org anestesia-dolor.org

Diabetes en el paciente grave / Diabetes in the critically ill patient

Julio 11, 2017. No. 2746

Estos días se ha enviado información sobre endocrinopatías diversas. Si duda la diabetes es la patología endocrina más frecuente por lo que se harán varios envíos con este tema apasionante. Después seguiremos con tiroides, alteraciones pituitarias y otras endocrinopatías de interés capital en la medicina perioperatoria, medicina crítica y del dolor. Disfrute su lectura Information on endocrinopathies has been sent to you in these days. Diabetes in the most common endocrine pathology, so we will make several submissions with this exciting topic. Later we will continue with thyroid, pituitary alterations and other endocrinopathies of capital interest in perioperative medicine, critical medicine and pain. Enjoy your reading Manejo del diabético grave Management of critically ill patients with diabetes. Silva-Perez LJ1, Benitez-Lopez MA1, Varon J1, Surani S1. World J Diabetes. 2017 Mar 15;8(3):89-96. doi: 10.4239/wjd.v8.i3.89. Abstract Disorders of glucose homeostasis, such as stress-induced hypoglycemia and hyperglycemia, are common complications in patients in the intensive care unit. Patients with preexisting diabetes mellitus (DM) are more susceptible to hyperglycemia, as well as a higher risk from glucose overcorrection, that may results in severe hypoglycemia. In critically ill patients with DM, it is recommended to maintain a blood glucose range between 140-180 mg/dL. In neurological patients and surgical patients, tighter glycemic control (i.e., 110-140 mg/d) is recommended if hypoglycemia can be properly avoided. There is limited evidence that shows that critically ill diabetic patients with a glycosylated hemoglobin levels above 7% may benefit from looser glycemic control, in order to reduce the risk of hypoglycemia and significant glycemic variability. KEYWORDS: Critical care; Diabetes mellitus; Glycemic control; Hypoglycemia; Intensive care unit; Stress hyperglycemia PDF Manejo del paciente grave con diabetes tipo 2. La necesidad de terapia personalizada Management of critically ill patients with type 2 diabetes: The need for personalised therapy. Kar P1, Jones KL1, Horowitz M1, Deane AM1. World J Diabetes. 2015 Jun 10;6(5):693-706. doi: 10.4239/wjd.v6.i5.693. Abstract Critical illness in patients with pre-existing diabetes frequently causes deterioration in glycaemic control. Despite the prevalence of diabetes in patients admitted to hospital and intensive care units, the ideal management of hyperglycaemia in these groups is uncertain. There are data that suggest that acute hyperglycaemia in critically ill patients without diabetes is associated with increased mortality and morbidity. Exogenous insulin to keep blood glucose concentrations < 10 mmol/L is accepted as standard of care in this group. However, preliminary data have recently been reported that suggest that chronic hyperglycaemia may result in conditioning, which protects these patients against damage mediated by acute hyperglycaemia. Furthermore, acute glucose-lowering to < 10 mmol/L in patients with diabetes with inadequate glycaemic control prior to their critical illness appears to have the capacity to cause harm. This review focuses on glycaemic control in critically ill patients with type 2 diabetes, the potential for harm from glucose-lowering and the rationale for personalised therapy. KEYWORDS: Critically ill; Diabetes; Intensive care; Management; Personalised therapy PDF Control de la glucosa en la UCI: Una historia continua. Glucose Control in the ICU: A Continuing Story. Preiser JC1, Chase JG2, Hovorka R3, Joseph JI4, Krinsley JS5, De Block C6, Desaive T7, Foubert L8, Kalfon P9, Pielmeier U10, Van Herpe T11, Wernerman J12. J Diabetes Sci Technol. 2016 Nov 1;10(6):1372-1381. Print 2016 Nov. Abstract In the present era of near-continuous glucose monitoring (CGM) and automated therapeutic closed-loop systems, measures of accuracy and of quality of glucose control need to be standardized for licensing authorities and to enable comparisons across studies and devices. Adequately powered, good quality, randomized, controlled studies are needed to assess the impact of different CGM devices on the quality of glucose control, workload, and costs. The additional effects of continuing glucose control on the general floor after the ICU stay also need to be investigated. Current algorithms need to be adapted and validated for CGM, including effects on glucose variability and workload. Improved collaboration within the industry needs to be encouraged because no single company produces all the necessary components for an automated closed-loop system. Combining glucose measurement with measurement of other variables in 1 sensor may help make this approach more financially viable. KEYWORDS: continuous glucose control; diabetes; intensive care; time in band PDF Año de revisión 2013: Cuidados Críticos - metabolismo. Year in review 2013: Critical Care--metabolism. Lheureux O, Preiser JC. Crit Care. 2014 Oct 27;18(5):571. doi: 10.1186/s13054-014-0571-4. Abstract Novel insights into the metabolic alterations of critical illness, including new findings on association between blood glucose at admission and poor outcome, were published in Critical Care in 2013. The role of diabetic status in the relation of the three domains of glycemic control (hyperglycemia, hypoglycemia, and glycemic variability) was clarified: the association between mean glucose, high glucose variability, and ICU mortality was stronger in the non-diabetic than in diabetic patients. Improvements in the understanding of pathophysiological mechanisms of stress hyperglycemia were presented. Novel developments for the management of glucose control included automated closed-loop algorithms based on subcutaneous glucose measurements and microdialysis techniques. In the field of obesity, some new hypotheses that could explain the 'obesity paradox' were released, and a role of adipose tissue in the response to stress was suggested by the time course of adipocyte fatty-acid binding protein concentrations. In the field of nutrition, beneficial immunological effects have been associated with early enteral nutrition. Early enteral nutrition was significantly associated with potential beneficial effects on the phenotype of lymphocytes. Uncertainties regarding the potential benefits of small intestine feeding compared with gastric feeding were further investigated. No significant differences were observed between the nasogastric and nasojejunal feeding groups in the incidence of mortality, tracheal aspiration, or exacerbation of pain. The major risk factors to develop diarrhea in the ICU were described. Finally, the understanding of disorders associated with trauma and potential benefits of blood acidification was improved by new experimental findings. PDF XIV Congreso Virtual Mexicano de Anestesiología 2017 Octubre 1-Diciembre 31, 2017 Información / Information

Anestesiología y Medicina del Dolor 52 664 6848905 vwhizar@anestesia-dolor.org anestesia-dolor.org