Jaume Fontanals

Helium and Carbon Dioxide Pneumoperitoneum in Patients with Pheochromocytoma Undergoing Laparoscopic Adrenalectomy

Insufflation with helium is used to prevent respiratory acidosis, hypercapnia, and cardiovascular instability associated with carbon dioxide (CO2) pneumoperitoneum. The aim of this prospective study was to compare CO2 with helium pneumoperitoneum with special reference to respiratory and hemodynamic changes at different times during the operation. Altogether 22 pheochromocytoma patients undergoing laparoscopic adrenalectomy (LpA) were included using CO2 in 11 patients (CO2LpA) and helium in 11 patients (HeLpA). The insufflation pressure was 12 mmHg. The two groups were comparable with regard to demographic data and preoperative management. CO2 and helium insufflation were associated with similar catecholamine increase. The most striking significant increase compared with the baseline was observed during tumor isolation: The mean plasma epinephrine (EPI) and norepinephrine (NE) levels increased 32.86-fold and 25.92-fold, respectively, in the CO2LpA patients and 27.43-fold and 18.46-fold, respectively, in the HeLpA patients. HeLpA did not result in significant hypercarbia or acidosis at any measured intraoperative point; this was without any alteration in minute ventilation to maintain these normal PaCO2, excess base (EB), and pH values. Significant increases of mean arterial pressure, pulmonary arterial pressure, pulmonary vascular resistance index, PaCO2, EB, and acidosis were seen in the CO2LpA patients at the time of tumor isolation and tumor removal compared with those in HeLpA patients. No patient required conversion to open surgery. There were no significant differences between CO2LpA and HeLpA regarding mean operative time (117.50 ± 93.68 vs. 106.87 ± 16.60 minutes), mean blood loss (168.54 ± 78.63 vs. 142.02 ± 109.26 ml), hospital stay (4 days), the need for analgesics, or mean time required to return to normal activity (12 days). There was one wound infection in the HeLpA group and one wound hematoma and one case of atelectasis in the CO2LpA group. Helium may be the agent of choice for abdominal insufflation in patients undergoing LpA for pheochromocytoma, eliminating the adverse hemodynamic and respiratory changes associated with CO2 insufflation.

Hypothermia in acute coronary syndrome: brain salvage versus stent thrombosis?

To the Editor: Mild hypothermia therapy (HT), defined as body temperature between 33°C and 34°C, is associated with improvement in neurological outcome after cardiac arrest. HT reduces cerebral metabolism of glucose and oxygen consumption with ensuing neuroprotection. In 2002, randomized clinical

Monitoring in resuscitation: Comparison of cardiac output measurement between pulmonary artery catheter and NICO

AIM The cardiac output and coronary perfusion pressure generated from chest compressions during resuscitation manoeuvres can predict effectiveness and successful outcome. Until now, there is no good method for haemodynamic monitoring during resuscitation. Noninvasive partial carbon dioxide rebreathing system (NICO, Novametrix Medical Systems, Inc., Wallingford, CT, USA) is a relatively new non-invasive alternative to thermodilution for measuring cardiac output. The accuracy of the NICO system has not been evaluated during resuscitation. The aim of this study is to compare thermodilution cardiac output method with NICO system and to assess the utility of NICO during resuscitation. METHODS AND DESIGN Experimental study in 24 Yorkshire pigs. Paired measurements of cardiac output were determined during resuscitation (before ventricular fibrillation and after 5, 15, 30 and 45 min of resuscitation) in the supine position. The average of 3 consecutive thermodilution cardiac output measurements (10 ml 20 degrees C saline) was compared with the corresponding NICO measurement. RESULTS Bland and Altman plot and Lins concordance coefficient showed a high correlation between NICO and thermodilution cardiac output measurements although NICO has a tendency to underestimate cardiac output when compared to thermodilution at normal values of cardiac output. CONCLUSIONS There is a high degree of agreement between cardiac output measurements obtained with NICO and thermodilution cardiac output during resuscitation. The present study suggests that the NICO system may be useful to measure cardiac output generated during cardiopulmonary resuscitation.

Mechanical thrombectomy in acute basilar artery occlusion: A safety and efficacy single centre study.

Objectives The objective of this study was to add more evidence about the efficacy and safety of mechanical thrombectomy in patients with basilar artery occlusion and secondarily to identify prognostic factors. Methods Twenty-two consecutive patients (mean age 60.5 years, 15 men) with basilar artery occlusion treated with mechanical thrombectomy were included. Clinical, procedure and radiological data were collected. Primary outcomes were the modified Rankin scale score with a good outcome defined by a modified Rankin scale score of 0–2 and mortality rate at three months. Results The median National Institutes of Health stroke scale at admission was 24 (interquartile range 11.5–31.25). Twelve patients (54.5%) required tracheal intubation due to a decreased level of consciousness. Successful recanalisation (modified treatment in cerebral ischaemia scale 2b–3) was achieved in 20 patients (90.9%). A favourable clinical outcome (modified Rankin scale score 0–2) was observed in nine patients (40.9%) and the overall mortality rate was 40.9% (nine patients). Haemorrhagic events were observed in three patients (13.63%). A decreased level of consciousness requiring intubation in the acute setting was more frequent in patients with poor outcomes (84.6%) than in patients with favourable outcomes (11.1%), and in patients who died (100%) compared with those who survived (23.1%), with a statistically significant difference (P = 0.002 and P = 0.001, respectively). Conclusion Mechanical thrombectomy is feasible and effective in patients with acute basilar artery occlusion. A decreased level of consciousness requiring tracheal intubation seems to be a prognostic factor and is associated with a poor clinical outcome and higher mortality rate. These initial results must be confirmed by further prospective studies with a larger number of patients.