Spontaneous rapture with consequent retroperitoneal hemorrhage (Wunderlich’s syndrome) is the complication mostly feared from large renal angiomyolipomas (RAMLs). In hemodynamic stable patients, minimal invasive therapies have superseded open surgery as the mainstay of treatment, with contemporary cases mostly treated by selective arterial embolization. Robotic-assisted laparoscopic partial nephrectomy (RALPN) is an established minimal access treatment that has been used in the past for benign and malignant lesions of the kidney in the elective setting, but rarely in urgent situations as primary treatment. We present a case of a ruptured RAML in a young female treated effectively by RALPN.

BACKGROUND:The aim of this study was to identify Greek anesthesiologists' difficult airway management practices, as well as the availability of equipment and familiarity with different airway management techniques.METHODS:A questionnaire containing 21 questions was posted to the vast majority of specialist anesthesiologists practicing in Greece (N.=849). Filled copies of the questionnaire were returned anonymously.RESULTS:Response rate was 42% (360/849). Preoperative evaluation was performed by 95% of the respondents, with senior anesthesiologists relying mostly on subjective estimation of the airway. Ninety percent of the respondents had direct access to a difficult airway cart. Laryngeal masks were available in most anesthesia Departments (86%), but expertise was still unsatisfactory, especially in hospitals with a lower workload. Spreading and familiarity with newer airway adjuncts was insufficient, especially in smaller anesthesia Departments. Only 39% of the respondents had a flexible fibrescope readily available. Sixty percent could be considered skilled with laryngeal masks and 11% with fibrescopes. When the occasion for fibrescope use did occur, less senior anesthesiologists opted for laryngeal masks and were clearly less inclined towards surgical intervention. However, for the more senior anesthesiologists surveyed, the application of a face mask with a ''two hands'' technique and more traditional supraglottic airway devices were found to be more common.CONCLUSION:There are shortfalls in various areas of airway management in Greece, in particular with the availability of modern airway devices and training in fibrescopic intubation.

We report on the successful mangement of airway obstruction, immediately after tracheal intubation for elective operation, in a patient with concealed tracheomalacia. We discuss the issues posed in patients with mild or undiagnosed chronic obstructive pulmonary disease (COPD) that are relevant to tracheomalacia. We underline the link between tracheomalacia and COPD and emphasize the high level of awareness needed, in order to avoid or manage promptly adverse events during airway management for anesthesia in these patients.

Zero flow pressure is the arterial pressure at which blood flow ceases in the cerebral circulation and may represent the effective downstream pressure of this system. We used a bench model of pulsatile fluid flow to determine whether simulated changes in downstream pressure may be detected by estimation of zero flow pressure. A Doppler probe was used to record flow velocity and a pressure transducer was used to measure driving pressure. Eight different configurations of the circuit were produced, and at each configuration the external pressure around a collapsible segment of the circuit was changed in order to simulate intracranial pressure. Perfusion pressure and zero flow pressure were estimated for each configuration and each level of external pressure. The sensitivity of the model in predicting the change in external pressure from the change in zero flow pressure was 94%. This indicates that estimation of zero flow pressure by this method is a sensitive way of monitoring trends in changes in downstream pressure.

Voyagis, G.; Charissi, N.; Athanassiou, L.; Iatrou, C.; Dimitriou, V. Author Information

Voyagis, G.; Athanassiou, L.; Douma, A.; latrou, C.; Charissi, N.; Simopoulos, C.; Dimitriou, V. Author Information

Douma, A.; Voyagis, G.; Athanassiou, L.; latrou, C.; Simopoulos, C.; Dimitriou, V. Author Information

Athanassiou, L.; Voyagis, G.; Douma, A.; latrou, C.; Simopoulos, C.; Dimitriou, V. Author Information

latrou, C.; Voyagis, G.; Athanassiou, L.; Skouteli, E.; Dimitriou, V. Author Information

UNLABELLED:Zero flow pressure (ZFP) in the cerebral circulation is defined as the arterial pressure at which flow ceases. Noninvasive methods of estimating cerebral perfusion pressure (CPP) and ZFP using transcranial Doppler ultrasonography have been described. There is a paucity of normal physiological data related to changes in estimated CPP (eCPP) and ZFP induced by changes in carbon dioxide (CO(2)). We studied the effects of CO(2) on eCPP and ZFP in 17 healthy volunteers. After baseline measurements of middle cerebral artery blood-flow velocity and blood pressure, subjects voluntarily hyperventilated to decrease their end-tidal CO(2) (PE'CO(2)) by approximately 7.5 mm Hg, and then they increased their PE'CO(2) by approximately 7.5 mm Hg by breathing through a Mapleson D circuit. Blood-flow velocity and blood pressure were recorded at each stage. The eCPP and ZFP were calculated by using established formulas, and the results were analyzed with analysis of variance. With increasing PE'CO(2), eCPP increased from 50.67 mm Hg (8.33 mm Hg) (mean [SD]) to 60.87 mm Hg (9.28 mm Hg) (20% increase; P < 0.001), with a corresponding decrease in ZFP (P = 0.017); hypocapnia resulted in the opposite effects on eCPP and ZFP. These results indicate physiological changes in eCPP and ZFP that can be expected from changes in CO(2) in subjects without any neurological disorder. IMPLICATIONS:Increasing end-tidal CO(2) increases the estimated cerebral perfusion pressure and vice versa. These results are opposite to those expected from the known effects of CO(2) on intracranial pressure. Thus, we support the suggestion that, in the absence of intracranial hypertension, vascular tone remains a major determinant of effective downstream pressure and cerebral perfusion.

Electromagnetic interference in the operating theatre can be a hazard for patients. Understanding of the phenomena that can lead to it is of paramount importance. I highlight a form of interference that to my knowledge has not been reported before and which posed a risk of injury to the patient. A 61-year-old male patient with non-insulin-dependent diabetes mellitus was anaesthetised for evacuation of a right chronic subdural haematoma. There was no focal deterioration and the Glasgow Coma Scale (GCS) was 14–15. The anaesthetic technique consisted of induction with propofol, fentanyl and atracurium and maintenance of anaesthesia with a mixture of nitrous oxide and isoflurane in oxygen. Neuromuscular blockade was maintained with incremental doses of atracurium, as indicated by monitoring of the neuromuscular junction. The peripheral nerve stimulator used was a Dakmed 750 Digital, attached just below the lateral aspect of the right knee, over the common peroneal nerve. Train-of-four (TOF) stimulation was applied on demand for the assessment of neuromuscular blockade. During the intervals between testing, the stimulator was switched on but idle. The diathermy device used was a Valleylab Force 2 CEM Electrosurgical Generator. The indifferent electrode paddle was sited at the left thigh. During the course of the anaesthetic, it was noticed that the right foot was jerking vigorously and the peripheral nerve stimulator was discharging in an erratic way. Just prior to that, TOF stimulation had shown clinical recovery of only the first twitch and no additional muscle relaxant was used, because the operation was nearing an end. Triggering of chaotic peripheral nerve stimulator activation coincided with activation of the monopolar diathermy. On closer observation, it was noticed that the cable of the monopolar probe of the diathermy was lying behind the stimulator, almost in contact with it. Activation of the diathermy after the diathermy cable was moved away from the stimulator did not affect the stimulator or cause jerking of the foot; the malfunction of the stimulator and movements of the foot recurred if the cable was returned to its original position. Interference between diathermy equipment and almost any electronic device in use in the theatre environment has been described before. There is extensive literature on the effects and safety of pacemakers and implantable cardioverter-defibrillators when diathermy is used [1]. Interference between a peripheral nerve stimulator and pacemaker that led to cardiac arrest has been described [2]. In this case, the unintentional proximity of the cable of the monopolar diathermy with the peripheral nerve stimulator caused uncontrolled discharge from the stimulator. The vigorous jerking of the foot may have several explanations, one of which is post-tetanic potentiation. I am not able to say if the voltage output of the stimulator was also increased during the incident (transformer-like inductive coupling effect could explain such a phenomenon). The fact that neuromuscular function was recovering facilitated the diagnosis; however, we do not know if harmful current was applied over the peroneal nerve during earlier phases of the operation. Prolonged application of an excessive voltage over a nerve could result in transient or permanent nerve damage. The diathermy device uses frequencies of 0.5–10 MHz, well above the 100 Hz tetanic stimulus used by a peripheral nerve stimulator. This frequency could be applied indirectly by inductive coupling to the nerve stimulator and then directly to the nerve through the stimulator leads. We do not know what are the effects of prolonged application of such frequencies to human nerves. Clinical examination revealed no damage to the patient's peroneal nerve. Nerve conduction studies were not performed. This incident is an example of a potentially harmful event in the operating theatre environment. Electromagnetic interference is ‘invisible’ even to an otherwise experienced eye and can have catastrophic results [3]. Diathermy cables should always be kept well separated from any other electronic equipment. Separation criteria should be followed for all electronic devices [4]. Special care should be taken in the presence of implantable electronic devices. At present, health workers are not trained to be aware of problems arising due to electromagnetic interference. Standards on electromagnetic compatibility and interference prevention of electronic devices exist, i.e. the European standard EN55011 [5], but more attention needs to be given in healthcare practice and planning to minimise risks.

s and Programme: European Society of Anaesthesiologists; 9th Annual Meeting with the Swedish Society of Anaesthesiology; Gothenburg, Sweden, 7-10 April 2001: Clinical and Experimental Circulation

S-35 (Saturation of haemoglobin at PO2 = 35mmHg) is a new concept in monitoring systemic oxygenation that includes the effect of changes in oxyhaemoglobin dissociation curve (ODC) on oxygen delivery. This study was designed to evaluate any possible alterations in oxyhaemoglobin dissociation curve and in S-35 of critical intrabdominal organs (small bowel, liver and kidney) in an experimental liver transplantation model. Ten pigs of mean body weight of 25-30kg underwent OLTx under homogenous anaesthesiological and technical procedures. Five of them were healthy (Group B) while the other five (Group C) were in fulminant hepatic failure (FHF) which had been surgically induced. Five healthy pigs underwent general anaesthesia and were used as a control group (Group A). Venous blood gas analysis was performed in superior mesenteric, hepatic and renal veins at well-defined timepoints during the course of OLTx. Regarding Group C, there has been a statistically significant decrease of S-35 after reperfusion in small bowel, in comparison to base-line values (implying a rightwards shift of ODC). This may be attributed to an attempt to meet increased metabolic needs of an organ which seems to be mostly involved. In opposite, the ODC seems to remain unaffected in both liver and kidney, probably due to temporarily limited metabolic activity.

The increasing incidence of fulminant-viral and toxic-hepatic failure (F.H.F.) and the severe shortage of cadaveric liver donors in Greece have stressed the need for the development of liver support systems, which will be used as temporary metabolic support of F.H.F. patients until the host liver regenerates or a suitable graft is provided. The aim of the present study was to evaluate an extracorporeal liver support system (E.L.S.SY.) based on an isolated pig liver graft as a means of temporary metabolic support in a surgically induced acute liver failure (ALF) model in pigs. E.L.S.SY. application for a 6-hour period of observation showed worsening of haemodynamic condition probably due to big extracorporeal volume or circulating toxins or mediators delivered from the ischaemic hepatic tissue. However, there is evidence of: metabolic support provided by the E.L.S.SY. which could be more obvious if treatment had been instituted at an earlier stage or porcine hepatocytes substitute the isolated graft (currently under investigation).