We report anesthesia for pheochromocytoma resection in a 15-year-old boy. He had panhypopituitarism due to surgical removal of primitive neuroectodermal tumor in the brain and postoperative chemotherapy at 9 months of age, and has been receiving desmopressin for diabetes insipidus. A diagnosis of pheochromocytoma was made based on an elevated urinary excretion of catecholamines and their metabolites as well as a mass lesion in the adrenal gland detected by computed tomography, and surgical removal was scheduled. Preoperatively blood pressure was controlled by doxazocine, an α1-adenoreceptor antagonist and desmopressin was replaced with continuous infusion of vasopressin, which was continued during anesthesia. Total intravenous anesthesia with propofol, fentanyl and remifentanil was performed. Besides increasing the dose of remifentanil, phentolamine, nicardipine and landiolol were administered for controlling hypertension and tachycardia in response to surgical stimuli. Hypotension after adrenalectomy was restored by noradrenaline and by increasing the infusion rate of vasopressin. Surgery completed uneventfully, urine output was remained constant during anesthesia.
Background: Hemorrhage shock following penetrating abdominal aortic injury leads to high mortality during the perioperative period. Case: A 32-year old woman was admitted for severe hemorrhagic shock due to a self-inflicted knife wound that penetrated her right upper abdominal quadrant and was visible on ultrasound examination as a massive zone 1 hematoma. Her vitals upon admission were as follows: an unreadable systolic blood pressure(extremely low), a pulse rate of 139 beats per minute, respiratory rate of 40 breaths per minute, and peripheral oxygen saturation of 81% of room air. An emergency transperitoneal operation was performed. Massive bleeding occurred from a retroperitoneal hematoma, followed by bradycardia. Pringle maneuver and thoracic aortic cross-clamping procedures were performed simultaneously, followed by diaphragmatic aortic compression. Total estimated blood loss amounted to 10,000 mL, which warranted an infusion of 30,000 mL of fluids. The patient was diagnosed with duodenal, liver, superior mesenteric vein, and abdominal aortic penetrating injuries, which were repaired under direct vision. The patient's postoperative recovery was successful and uneventful. Conclusion: The Pringle maneuver and thoracic aortic cross-clamping procedures followed by diaphragmatic aortic compression were effective on active hemorrhage and ruptured the hematoma.
Blunt trauma to the upper extremity sometimes causes a brachial artery pseudoaneurysm. However, venous injuries from blunt trauma may also result in a pseudoaneurysm in patients with an arteriovenous(AV) fistula for hemodialysis. A 62-year-old man presented because of aggravating swelling and resting pain in his upper extremity 3 weeks after a traffic accident. Computed tomographic angiography demonstrated a pseudoaneurysm of the cephalic vein close to the anastomosis of the brachiocephalic AV fistula. An aneurysmectomy was successfully performed. Attention has to be given to the risk of venous pseudoaneurysm caused by venous injuries from blunt trauma in patients with an AV fistula.