Seema Prasad

Minimal effective dose of magnesium sulfate for attenuation of intubation response in hypertensive patients

STUDY OBJECTIVE To study the minimal effective dose of magnesium sulfate to control blood pressure (BP) during intubation in hypertensive patients. DESIGN Prospective, randomized, double-blind study. SETTING Operating room of an academic medical center. PATIENTS 80 adult, ASA physical status 1 and 2, controlled hypertensive patients undergoing elective surgery under general anesthesia and requiring endotracheal intubation. INTERVENTIONS Patients were randomized to 4 groups. Patients in study groups received a magnesium sulfate infusion at a dose of 30 (Group I), 40 (Group II), or 50 mg/kg (Group III) before induction of anesthesia, while patients in control group (Group IV) received a 1.5 mg/kg lidocaine bolus 90 seconds before intubation. Anesthesia was induced and maintained with a propofol infusion. Laryngoscopy and intubation were performed 4 minutes after administration of vecuronium. MEASUREMENTS Heart rate (HR) and BP were recorded before, during, and after endotracheal intubation for 10 minutes. Measures to manage hemodynamic instability were recorded. Serum magnesium levels were also recorded. MAIN RESULTS The changes in HR were comparable among groups. Mean arterial pressure (MAP) was maintained within normal limits in Group I patients while Groups II and III patients showed a significant decrease in MAP (P = 0.01) compared with baseline. A total of 6 patients (30%) in Group II and 10 patients (50%) in Group III required interventions (P = 0.001). No patient in Group I and only one patient (5%) in Group IV required intervention. CONCLUSIONS Magnesium 30 mg/kg is the optimum dose to control BP during intubation in hypertensive patients. A further increase in the dose of magnesium may cause significant hypotension.

Rare Adrenal Gland Emergencies: A Case Series of Giant Myelolipoma Presenting With Massive Hemorrhage and Abscess

Introduction: Adrenal Myelolipoma is a rare benign neoplasm, which contains mature adipose tissue and variable amounts of haematopoietic elements. Most lesions are small and asymptomatic, discovered incidentally during autopsy or imaging studies performed for other reasons. Case Presentation: Here we reported a series of two cases of giant myelolipomas of the adrenal gland; first one the largest tumor reported so far presented with massive hemorrhage and the second case introduced with its rare unreported presentation of adrenal myelolipomas i.e. a large abscess. Discussion: Adrenal myelolipoma is a rare and asymptomatic tumor usually discovered incidentally in less than 1% of population on autopsy or imaging performed for other reasons. There is an increasing incidence of large adrenal myelolipoma (> 10 cm) presenting with life threatening and recurrent retroperitoneal hemorrhage along with other complications as abscess. To avoid such a life-threatening situation, authors recommend close monitoring and consideration of urgent surgical intervention for tumors larger than 4 cm at presentation or increase in size or change in appearance during follow-up.

Large pelvic masses of obscure origin: urologist's perspective.

Background: Large pelvic masses pose unique diagnostic and therapeutic challenges due to varied aetiology, paucity of characteristic imaging features, lack of therapeutic algorithms and surgical difficulties in resection inside the narrow confines of the pelvis with close proximity of vital structures. Methods: Records of 22 patients with large pelvic masses in the last six years were analysed. Their demographic and clinical features were noted, along with imaging features, preoperative biopsy, surgical procedure, intraoperative difficulties, complications, adjuvant therapy and outcome. Results: There were 14 men and 8 women with a median age of 45 years. Presenting symptoms were abdominal mass, pain, lower urinary tract symptoms, urinary retention and constipation. Imaging was mostly unable to determine the organ of origin of the tumour. Histopathology revealed pelvic fibromatosis (2), chondrosarcoma (1), liposarcoma (1), haemangioendothelioma (1), lymphangioma (2), fibroleiomyoma (1), leiomyosarcoma (3), schwannoma (4), malignant nerve sheath tumour (1), rectal gastrointestinal stromal tumour (1), retrovesical hydatid cysts (3), sacral chordoma (1) and Ewing’s sarcoma (1). In 5 patients complete excision was not possible because of extension into vital structures. Fifteen patients were alive at 1–5 years of follow-up. Conclusions: Urologists, being the ‘gatekeepers of the pelvis’, are usually involved in the management of large pelvic masses. Good outcome can be achieved with careful surgical planning.

A Randomized Controlled Trial Comparing Combined Spongiosum Block and Intraurethral Lignocaine with Intraurethral Lignocaine Alone in Optical Internal Urethrotomy for Urethral Stricture

BACKGROUND AND PURPOSE Optical internal urethrotomy is the most commonly performed procedure for the management of anterior urethral stricture. This study was performed to compare the safety and efficacy of spongiosum block along with intraurethral lignocaine with intraurethral lignocaine alone for optical internal urethrotomy. PATIENTS AND METHODS Fifty patients with anterior urethral stricture were prospectively randomized to undergo optical internal urethrotomy under spongiosum block along with intraurethral lignocaine (group 1=25 patients) and intraurethral lignocaine only (group 2=25 patients). The procedure-related pain was noted using the visual analogue scale. Postprocedure evaluation was performed by uroflowmetry and urethral calibration. Retrograde urethrography and micturating cystourethrography were performed as needed. RESULTS Optical internal urethrotomy was successfully completed in all patients. The mean visual analogue score for pain in group 1 (1.5 ± 1.4) was significantly lower than the score in group 2 (2.7 ± 1.8) (P=0.006). At 6 months follow-up, recurrent strictures developed in three patients in group 1 and five patients in group 2. CONCLUSIONS Spongiosum block with intraurethral lignocaine has a better anesthetic effect than intraurethral lignocaine alone for performing optical internal urethrotomy. Spongiosum block with intraurethral lignocaine is a viable alternative for regional and general anesthesia in the management of anterior urethral stricture with optical internal urethrotomy.

Unusual causes of Hematuria in dialysis patients: Diagnostic dilemma, risks and management

Two male patients with end-stage renal disease (ESRD) developed a spontaneous hemorrhage of one of their native kidneys and were referred to our institution. Symptoms included sudden onset abdominal pain, hematuria and shock. Symptoms were associated with a hemoglobin decrease. Computerized tomography (CT) was done and nephrectomy undertaken in both the cases. Histologic findings confirmed bleeding and there was no abnormality other than those related to renal insufficiency (cysts and atrophy). In chronic hemodialysis (HD) patients with hematuria, if other common causes are not identified spontaneous subcapsular or renal cyst rupture should be kept in mind. Surgery is our preferred treatment because of the diagnostic dilemma of tumors and the potential mortality of massive hematomas in morbid patients.

Pelvic Pheochromocytoma: A Rare Lethal Tumor Initially Presenting as Tuboovarian Mass to Gynaecologist

Extra-adrenal pheochromocytomas are rare, but potentially lethal, tumors which may initially present to gynecologists masquerading as a tuboovarian mass leading to a potentially dangerous exploration in an unprepared patient. We present a case of a large extra-adrenal pheochromocytoma which was diagnosed intraoperatively because of sudden hypertension.

Laparoscopic single-site synchronous bilateral cortex-preserving adrenalectomy using conventional trocars and instruments for large bilateral adrenal pheochromocytomas

Laparoendoscopic single‐site surgery is being adapted for widespread indications because it offers minimal invasiveness. Herein, we report a case of synchronous bilateral cortex‐preserving adrenalectomy for bilateral large adrenal pheochromocytomas. We used conventional laparoscopic instruments and trocars through a single‐port site. The total operative time was 110 min. There were no perioperative complications. Single‐incision multiport laparoendoscopic surgery, also known as SIMPLE surgery, can be safely used for bilateral adrenalectomy. This modification holds promise with its minimally invasive nature and reduced cost.

Ocular ischemic syndrome: A rare cause of postoperative visual loss following coronary artery bypass graft (CABG) surgery

Ocular ischemic syndrome is a chronic insufficiency of ocular blood supply due to carotid artery or ophthalmic artery occlusion. It is a consequential squeal of severe atherosclerosis,1 hypertension, diabetes,2 carotid artery dissection,3 or inflammatory conditions of carotid artery4 or emboli.5 The patient shows varied presentation as asymptomatic initially; gradually there is blurring, which may be transient or even may manifest as abrupt visual loss. The condition may present with many posterior segment changes. In addition, if not detected early or followed periodically, it may present with anterior segment complications, such as inflammation, neovascularization, or secondary neovascular glaucoma (NVG). An early detection of this rare manifestation of chronic carotid insufficiency is very important, as the condition may herald life threatening thrombotic conditions of brain or myocardium. Though NVG can be a cause of an abrupt as well as gradual visual loss in many systemic conditions, it has never found its place as a cause of visual disturbances and postop visual loss presenting immediate to postop or during periop period of nonophthalmic surgeries. The cause of perioperative visual loss (POVL) has suggested involvement of any structure of visual system, from cornea to occipital lobe, but among various vascular causes of POVL, ocular ischemic syndrome has never been implicated. The appearance or onset of the disease during postop or periop period in coronary arterial bypass graft (CABG) surgery has not yet been reported. The rarity of the case qualifies the need for reporting, which may emphasize multidisciplinary approach, follow-up, and intervention in such cases.

Spectrum of retroperitoneal and genitourinary paraganglioma: Experience at a North Indian tertiary care center

Introduction Genitourinary and retroperitoneal paragangliomas are infrequent tumors with bizarre presentation. A high index of suspicion is required to make a diagnosis in young hypertensive individuals. Our aim is to study the varied clinical presentations and management of these paragangliomas. Herein, we share our experience of clinical presentation, diagnosis, and management of these paragangliomas. Material and methods Seventeen consecutive patients who underwent surgery for paraganglioma at our institute from August 2009 to July 2014 were included. Demographic, peri-operative, surgical, and follow up data were collected and analyzed. Results Mean age of presentation was 34.8 years with female predominance. The majority of the tumors were located in the retroperitoneum and urinary bladder. Most of them presented with classical symptoms of catecholamine excess and hypertension. Complete surgical resection could be performed in 13 cases. At a median follow up of two years, cases with R0 resection (no microscopic malignant cells) did not show recurrence. Among patients on chemotherapy, one died, another had partial response, and yet another had progressive disease. Conclusions Genitourinary and retroperitoneal paragangliomas are a disease of a young age group with variable clinical features at presentation. Appropriate pre-operative optimization and complete surgical resection provide the best chance of cure.

Malignant Pelvic Pheochromocytoma Presenting as NonFunctioning Kidney and Accelerated Hypertension: A Rare Presentation

Paragangliomas are neuroendocrine tumors that arise from sympathetic nerve ganglia. They can develop anywhere from the neck to the pelvis, but are most commonly found in the abdomen, particularly at the aortic bifurcation or in the periaortic region. Malignant paragangliomas account for 29–40% of cases. We report a case of 36-year hypertensive female presented with and right flank pain and accelerated hypertension. On evaluation she was diagnosed to have non unctioning kidney due to malignant pelvic paraganglioma with right ureteric encasement. We believe our case is one of the first reported in literature as rare presentation of malignant paraganglioma presenting as nonfunctioning kidney and accelerated hypertension.