Anaesthetic Management of Pheochromocytoma with Atrial Fibrillation - A Case Report

An elderly female aged 65 years weighing 69 Kgs presented to the Pre-Anaesthetic Clinic (PAC) for transurethral resection of bladder carcinoma. As part of the evaluation of bladder carcinoma, Contrast Enhanced Computed Tomography (CECT) abdomen done showed a left adrenal lesion. She was a known case of hypertension since the last 10 years and was on telmisartan tablets 40 mg once daily (OD) since then. She had a history of palpitations 3 years back, which when evaluated was diagnosed as atrial fibrillation. She was started on metoprolol tablets 25 mg OD and warfarin 2 mg OD. In view of her history and positive findings on CECT abdomen, it was decided in the PAC to screen her for pheochromocytoma. There was no definite history of classic triad of headache, palpitation and sweating. No history of headache, weight loss, fatigue, syncopal attacks, hypo / hyperthyroidism were reported. Physical examination showed Heart Rate (HR) of 96 beats per minute (bpm), irregular in rhythm, Respiratory Rate (RR) of 16 breaths per minute and Blood Pressures (BP) of 146 / 98 mmHg and 140 / 90 mmHg in the supine and sitting positions respectively. Biochemical test results showed 24-hour urine metanephrine 0.452 mg / l which is 1.45 mg / 24 hrs. (normally < 1 mg / 24 hrs.) and urine vanillylmandelic acid 8.1 mg / gm creatinine (2 – 7 mg / gm). Electrocardiography (ECG) showed right bundle branch block and AF (Atrial Fibrillation) with controlled ventricular rate. Echocardiography showed mild aortic stenosis, aortic regurgitation and ejection fraction of 68 % with no evidence of clots / thrombus. In terms of clinical imaging, the CECT showed a well-defined lesion in the left adrenal measuring 19 x 12 mm with a relative washout of 21 % and a faint subtle hyperdense lesion in the base of left lateral wall of the urinary bladder measuring approximately 20 x 19 mm. Other blood investigations like Hb, haematocrit, urea, creatinine and blood sugars were within normal limits.

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Thyroid Storm Treated With Nonconventional Therapy

Journal of the Endocrine Society ◽

10.1210/jendso/bvab048.1967 ◽

2021 ◽

Vol 5 (Supplement_1) ◽

pp. A962-A962

Author(s):

Caroline Tashdjian ◽

Paul Shiu ◽

Tarandeep Kaur

Keyword(s):

Atrial Fibrillation ◽

Critically Ill ◽

Liver Enzymes ◽

Normal Liver ◽

Ventricular Rate ◽

Thyroid Storm ◽

Free T4 ◽

History Of ◽

Chest X Ray ◽

Iodine Treatment

Abstract Background: Thyroid storm is a rare sequela of thyrotoxicosis with mortality rate of 10-30%. Management of thyroid storm is heavily dependent on thionamides. Cholestyramine and potassium iodide (SSKI) are used as adjunctive therapy and not as the sole treatment for storm. We present a case of thyroid storm treated with cholestyramine and SSKI. Clinical Case: A 45 year old male with past medical history of atrial fibrillation, congestive heart failure, hypertension, substance abuse and grave’s disease presented to the emergency department (ED) for diarrhea. During the course of ED, patient went into atrial fibrillation with rapid ventricular rate. Chest X-ray showed pulmonary edema. Labs were: TSH <0.0025 mIU/L (0.35-4.94 mIU/L) and free T4 3.52 ng/dl (0.7-1.40 ng/dl). Patient was noncompliant with methimazole. Upon admit, ACLS was initiated due to hypoxia and transferred to ICU for ventilator and pressor support. Wartofsky score was 60, suggestive of thyroid storm. Management included methimazole 20mg every 4hours, hydrocortisone 100mg every 8 hours, cholestyramine 4mg every 6 hours, and SSKI 250mg every 6 hours for thyrotoxicosis and amiodarone infusion for afib. Despite normal liver enzymes on admit, day 3 AST increased to 2740 U/L (5-34) and ALT 2684 U/L (0-55). Methimazole was stopped due to potential hepatotoxicity. Day 3 free T4 remained high at 4.16 ng/dl and patient remained critically ill. Plasmapheresis was offered as methimazole was stopped and patient was hemodynamically unstable to undergo surgery. However, family declined this intervention; SSKI and cholestyramine were continued. Free T4 was monitored over the course of treatment; by day 5 free T4 trended down to 1.93 ng/dl. SSKI was eventually stopped on day 8 of treatment as free T4 had normalized and cholestyramine reduced to 4mg twice daily. By day 15, free T4 was 0.8 ng/dl, so cholestyramine was stopped. Due to clinical improvement, patient was weaned off the ventilator and pressor support along with hydrocortisone. Liver enzymes normalized by Day 17. Patient was restarted on methimazole 5mg daily before discharge. Discussion: Thyroid storm is associated with varying degree of liver dysfunction, which can pose a challenge to treatment. In our case, acute fulminant liver failure was multifactorial in the setting of shock, thyroid storm and potential drug toxicity. Thus, thionamides were contraindicated. Radioactive iodine treatment was contraindicated due to use of amiodarone. Plasmapheresis and emergent thyroidectomy could not be done. Thus, nonconventional therapy was used and patient responded well to treatment. This case emphasizes the use of cholestyramine along with SSKI as an effective treatment in patients who are critically ill the setting of a thyroid storm, especially when thionamides are contraindicated and other avenues of treatment are limited.

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Atrial fibrillation following low voltage electrical injury

BMJ Case Reports ◽

10.1136/bcr-2020-239306 ◽

2021 ◽

Vol 14 (1) ◽

pp. e239306

Author(s):

Shrestha Ghosh ◽

Atanu Chandra ◽

Sourav Sen ◽

Sukanta Dutta

Keyword(s):

Atrial Fibrillation ◽

Cardiac Involvement ◽

Low Voltage ◽

Ventricular Rate ◽

Prior History ◽

Electrical Injury ◽

Bundle Branch Block ◽

History Of ◽

Premature Beats ◽

Irregular Pulse

Electrical injuries can have myriad presentations, including significant cardiac involvement. Arrhythmias are the most frequently experienced cardiac affliction, of which sinus tachycardia or bradycardia, ventricular fibrillation, atrial or ventricular premature beats and bundle branch block are most commonly reported. A 50-year-old man, with no prior history of cardiac disease, presented with palpitations following low voltage electrical injury. On examination, he was tachycardic with an irregularly irregular pulse. An ECG confirmed atrial fibrillation with rapid ventricular rate. Chemical cardioversion was attempted successfully, following which the patient reverted to sinus rhythm. Atrial fibrillation following electrical injury has been rarely described in the literature, and is rarer so without associated high voltage electrical exposure or pre-existing cardiac ailment.

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Surgical management of perineal laceration in a cow affected with cervico vaginal prolapse

Indian Journal of Animal Research ◽

10.18805/ijar.b-3308 ◽

2017 ◽

Author(s):

U. Lakshmikantan ◽

M. Murugan ◽

A. Ganesan ◽

T. Sathiamoorthy

Keyword(s):

Suture Material ◽

Lateral Wall ◽

Vaginal Prolapse ◽

Absorbable Suture ◽

Perineal Laceration ◽

Perineal Repair ◽

Second Stage ◽

Interrupted Suture ◽

Left Lateral Wall ◽

History Of

A five year old cow was brought with the history of delivering the calf without untying Buhner’s suture which was applied to retain the recurrent cervico vaginal prolapse, resulting in rare occurrence of extensive laceration of perineum accompanied with cervico vaginal prolapse. Examination of perineum revealed two tears on the left lateral wall of the vagina. Absorbable suture material, poly glycolic acid (PGA) was used to appose the vaginal tears. Vulval labium was applied with simple interrupted suture using silk. Perineal repair was helpful in reconstructing the vagina and vulva. In conclusion, proper surgical apposition would restore the normal conformation of reproductive passage in cows affected with perineal laceration and Buhner’s suture should essentially be removed to avoid extensive damage to the perineum at the time of second stage parturition.

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The effect of mitral valve replacement on atrial fibrillation behaviour

International Surgery Journal ◽

10.18203/2349-2902.isj20191054 ◽

2019 ◽

Vol 6 (4) ◽

pp. 1159

Author(s):

Megavath Motilal ◽

Vijaya Rama Raju Nadakuditi ◽

Alla Gopala Krishna Gokhale ◽

Sudhakar Koneru ◽

Manoj Kumar Moharana ◽

...

Keyword(s):

Atrial Fibrillation ◽

Mitral Valve ◽

Valve Replacement ◽

Mitral Valve Replacement ◽

Mitral Valve Surgery ◽

Ventricular Rate ◽

History Of ◽

Atrial Rhythm

Background: Atrial fibrillation (AF) persisting after mitral valve surgery reduces survival due to heart failure and thrombo-embolisms and impairs quality of life. Restoration of the sinus rhythm might lead to a lower incidence of thrombo-embolism and valve-related complications in the postoperative period.Methods: This non-randomized prospective study was carried out between period April 2015 to December 2018 in the Department of Cardiothoracic and Vascular Surgery, Government General hospital, Guntur, Andhra Pradesh, India. A total of 80 patients underwent mitral valve replacement during the study period. 50 patients out of these were with atrial fibrillation and were part of this study, who underwent mitral valve replacement.Results: All fifty patients were in atrial fibrillation based on clinical examination and the echocardiogram. 13 patients preoperatively were in atrial fibrillation with fast ventricular rate. These patients were placed on antiarrhythmic drugs to control the ventricular rate prior to mitral valve replacement. After surgery twenty out of fifty (40%) patients reverted to NSR and maintained the same rhythm till the 6 months of follow-up. Twenty-nine (58%) patients continued in atrial fibrillation after surgery.Conclusions: The results of the present study showed that preoperative atrial rhythm strongly determines postoperative rhythm. In view of the promising results of combined mitral valve and anti-atrial fibrillation surgery, the inescapable conclusion is that the anti-arrhythmic procedure should be offered routinely to all patients with a history of preoperative AF.

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Shared decision making in athletes with cardiovascular disease: what we can learn from a masters athlete

BMJ Case Reports ◽

10.1136/bcr-2021-245822 ◽

2021 ◽

Vol 14 (12) ◽

pp. e245822

Author(s):

Roshan Patel ◽

Susil Pallikadavath ◽

Matthew P M Graham-Brown ◽

Anvesha Singh

Keyword(s):

Atrial Fibrillation ◽

Decision Making ◽

Shared Decision Making ◽

Sinus Bradycardia ◽

Ventricular Rate ◽

Shared Decision ◽

Patient Request ◽

Masters Athlete ◽

History Of

A 75-year-old male cyclist began suffering from palpitations on exertion. Symptoms terminated spontaneously with cessation of physical activity. The episodes caused significant distress with an impact on physical performance and quality of life. An echocardiogram showed a dilated left atrium, and an exercise ECG demonstrated that episodes of atrial fibrillation developed when his ventricular rate was above 140 beats per minute. Rate control could not be offered due to a history of sinus bradycardia nor rhythm control due to low likelihood of success. Anticoagulant therapy was commenced but discontinued at patient request as he considered risks to outweigh benefits given his desire to continue cycling. Management of athletes with atrial fibrillation is based on guidelines for the general population; however, treatment goals for athletes may differ. Shared decision making is essential to allow patients to make informed decisions about their care, accepting that individuals view treatment risks and benefits differently.

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The Incidence of Atrial Fibrillation Among Patients with AL Amyloidosis Undergoing High Dose Melphalan and Stem Cell Transplantation (HDM/SCT): Experience at a Single Institution

Blood ◽

10.1182/blood.v126.23.5490.5490 ◽

2015 ◽

Vol 126 (23) ◽

pp. 5490-5490 ◽

Cited By ~ 1

Author(s):

Dina Brauneis ◽

Monica Arun ◽

Frederick L Ruberg ◽

Anthony C Shelton ◽

John Mark Sloan ◽

...

Keyword(s):

Atrial Fibrillation ◽

Stem Cell ◽

Patient Characteristics ◽

Ventricular Rate ◽

High Dose ◽

Al Amyloidosis ◽

Hemodynamic Stability ◽

Atrial Size ◽

History Of ◽

High Dose Melphalan

Abstract Background High dose melphalan and autologous stem cell transplantation (HDM/SCT) can induce hematologic responses and prolong survival in selected patients with AL amyloidosis. However, cardiac toxicity associated with HDM/SCT remains an ongoing concern in patients with AL amyloidosis. Atrial fibrillation (AF) may complicate SCT 4-10% of the time (Olivieri et al. 1998, Hidalgo et al. 2004). The development of AF in the SCT period can be challenging to manage. Studies identifying risk factors for the development of AF in amyloidosis are limited (Abhishek et al. 2013). Objective We sought to determine the incidence of atrial fibrillation in patients with AL amyloidosis undergoing SCT. Patients and methods We retrospectively analyzed charts of 91 consecutive patients undergoing HDM/SCT for AL amyloidosis between January 2011 and May 2015. The peri-transplant period was defined from the first day of stem cell mobilization until the time to engraftment. For all patients, medical records were reviewed for age, gender, prior history of AF, baseline troponin I, brain natriuretic peptide (BNP), baseline echocardiography, dose of Melphalan, ventricular rate at the time of AF event, hemodynamic stability (based on blood pressure), AF management and the return to normal sinus rhythm (NSR). Results Ninety-one patients with AL Amyloidosis underwent HDM/SCT from January 2011 to May 2015. Overall, twelve patients (13.1%) developed AF during SCT period, at a median of D+9 (range, D-10 to D+21). Baseline characteristics of these patients are listed in Table 1. Patient characteristics and AF management are listed in Table 2. Of note, there were three patients who had a history of PAF who did not develop AF during the peri-transplant period. Conclusion AF occurred in 13.1% of patients with AL amyloidosis undergoing HDM/SCT in the peri-transplant period, a rate higher than previously reported in other patient populations. Four of seven patients with a history of supraventricular tachyarrhythmia (SVT) developed AF during the peri-transplant period, making prior SVT a potential risk factor. The presence of cardiac amyloidosis, even in early stages, in combination with high dose Melphalan, may also predispose this group of patients to supraventricular arrhythmias. The identification of risk factors for developing AF in patients with AL amyloidosis may enable the use of preventative action in the future. Table 1. Patient Characteristics at Baseline N = 12 (%) Median Age, years (range) 59.5 (40-68) Gender Male Female 6 (50) 6 (50) Organ Involvement Cardiac only Renal only Pulmonary only Cardiac and renal 3 (25.0) 4 (33.3) 1 (8.3) 4 (33.3) History of AfibPrior anticoagulation Prior rate control 4 (33.3) 2/4 (50.0) 4/4 (100.0) Median BNP, pg/mL (range) 59.5 (17-558) Median Troponin, ng/mL (range) 0.0385 (0.006 - 0.446) Median TSH*, IU/mL (range) 1.56 ( 0.24-5.39) Cardiac Echo IVSD**, mm (range) Presence of diastolic dysfunction Diastolic Dysfunction, grade (range) LVEF***, % (range) Left atrial size****, mm (range) 11.5 ( 8.0-17.0)8 (66.6) 1.0 ( 0.0-3.0)61.6 ( 44-71)36.5 ( 23-43) Median PR interval on EKG in ms, (range) 183 (132-230) Dose of Melphalan140mg/m2 200mg/m2 4(33.3) 8(66.6) *TSH: Thyroid stimulating hormone **IVSD: Interventricular septal diastolic thickness (normal < 10mm for women and < 11mm for men) ***LVEF: Left ventricular ejection fraction **** Left atrial size in parasternal long axis view (normal < 40mm) Table 2. Patient Characteristics at Time of AF Event N = 12 (%) Median Day to event as it relates to stem cell infusion, (range) D+9 (D-10 to D+21) Median Ventricular Rate, beats per minute (range) 130 (83-159) Hemodynamic Stability Stable Unstable 5(41.6) 7(58.3) Treatment of rate/rhythm Beta blocker alone Calcium channel blocker Amiodarone and beta blocker No specific intervention 5(41.7) 0 (0.0) 3(33.3) 4(33.3) Anticoagulation Yes No 3(33.3) 9(75.0) Disclosures No relevant conflicts of interest to declare.

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Arrhythmia Secondary to Cold Water Submersion during Helicopter Underwater Escape Training

Prehospital and Disaster Medicine ◽

10.1017/s1049023x15005464 ◽

2016 ◽

Vol 31 (1) ◽

pp. 108-110 ◽

Cited By ~ 1

Author(s):

Paven P. Kaur ◽

Sarah E. Drummond ◽

Jeremy Furyk

Keyword(s):

Atrial Fibrillation ◽

Sinus Rhythm ◽

Cold Water ◽

Escape Training ◽

Publication Type ◽

Normal Limits ◽

History Of ◽

Chest X Ray ◽

Electrocardiogram Ecg ◽

Irregular Pulse

AbstractA 32-year-old, fit and healthy, Caucasian male presented with a less than 24-hour history of palpitations with the onset following participation in helicopter underwater escape training (HUET). He reported no chest pain, shortness of breath, syncope, or pre-syncope symptoms. On examination, an irregularly irregular pulse was noted at a rate of 120 beats per minute with a blood pressure of 132/84. There was no evidence of congestive cardiac failure. The electrocardiogram (ECG) demonstrated atrial fibrillation at 97 beats per minute with a normal axis, normal QRS complexes, and a QTc of 399 ms. Bloods were all within normal limits and a chest x-ray showed no abnormality. The patient was loaded with amiodarone and reverted to sinus rhythm with a normal post-reversion ECG. Five years on, following further HUET, the patient presented with an identical presentation. His ECG showed fast atrial fibrillation at a rate of 115 beats per minute. On this occasion, he was sedated and Direct Current cardioverted with reversal to sinus rhythm after one shock. It was felt that the precipitating factor for this patient’s atrial fibrillation, in both cases, was HUET. The case discussed describes a previously fit and well subject who developed a sustained arrhythmia secondary to cold water submersion. Evidence suggests water submersion can provoke cardiac arrhythmias via the suggested theory of “autonomic conflict.” It has been proposed that a number of unexplained deaths related to water submersion may be secondary to arrhythmogenic syncope.KaurPP, DrummondSE, FurykJ. Arrhythmia secondary to cold water submersion during helicopter underwater escape training. Prehosp Disaster Med. 2016;31(1):108–110.

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Mature Nasopharyngeal Teratoma in a Child

Case Reports in Otolaryngology ◽

10.1155/2015/515474 ◽

2015 ◽

Vol 2015 ◽

pp. 1-3 ◽

Cited By ~ 1

Author(s):

Ramesh Parajuli ◽

Suman Thapa ◽

Sushna Maharjan

Keyword(s):

Mature Teratoma ◽

Neck Region ◽

Lateral Wall ◽

Cystic Mass ◽

Nasal Discharge ◽

Fatty Tissue ◽

Head And Neck Region ◽

Left Lateral Wall ◽

Nasopharyngeal Mass ◽

History Of

Teratomas are neoplasms derived from the germ cell with components of all the three embryonic layers. These are rare neoplasms in head and neck region which can occur in any age group but are more prevalent in children. The present case is an 11-year-old girl who was brought with history of painless and progressive swelling in the oropharynx for 3 years with the associated left sided nasal blockage and nasal discharge. CT scan was suggestive of benign nasopharyngeal mass highly suspicious for lipoma. Excision of the mass was done under general anaesthesia. Peroperatively, it was a smooth, pedunculated mass arising from the left lateral wall in the nasopharynx. On cut section, it was solid to cystic mass similar to fatty tissue. Her HPE report came out to be mature teratoma of nasopharynx.

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Spontaneous urinary bladder perforation: An unusual presentation of well-differentiated papillary peritoneum mesothelioma

Urologia Journal ◽

10.1177/03915603211001181 ◽

2021 ◽

pp. 039156032110011

Author(s):

Armando Serao ◽

Francesca Ambrosini ◽

Barbara Cavallone ◽

Tiziana Borra ◽

Andrea Di Stasio

Keyword(s):

Histopathological Examination ◽

Lateral Wall ◽

Exploratory Laparotomy ◽

Bladder Rupture ◽

Free Fluid ◽

Case Presentation ◽

Left Lateral Wall ◽

Intraperitoneal Bladder Rupture ◽

History Of ◽

Well Differentiated

Introduction: Well-differentiated papillary mesothelioma (WDPM) is a very rare neoplasm. Most of WDPM are asymptomatic and are often incidentally detected during surgery. This report describes a case of WDPM of the peritoneum unexpectedly diagnosed in a male with a spontaneous intraperitoneal bladder rupture. Case presentation: A 65-year-old male presented to our Emergency Department in November 2019 with a two-day history of anuria, abdominal pain, distention, and sepsis. The CT scan reported a large amount of extra and intraperitoneal free fluid. The CT cystogram showed bladder perforations on the dome and on the left lateral wall which was repaired through exploratory laparotomy. Intraoperatively, we encountered extensive suppurative peritonitis with large fibrino-purulent exudation. The purulent perivesical peritoneum was dissected and sent for histopathological examination which unexpectedly resulted in WDPM of the peritoneum. Conclusion: Although we can’t affirm with certainty, this case would seem to suggest that WDPM had played a role in patient’s clinical presentation. However, further research is necessary to draw stronger conclusion.

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Canada-wide mixed methods analysis evaluating the reasons for inappropriate emergency department presentation in patients with a history of atrial fibrillation: the multicentre AF-ED trial

BMJ Open ◽

10.1136/bmjopen-2019-033482 ◽

2020 ◽

Vol 10 (4) ◽

pp. e033482

Author(s):

Kathryn Lauren Hong ◽

Corinne Babiolakis ◽

Brigita Zile ◽

Milena Bullen ◽

Sohaib Haseeb ◽

...

Keyword(s):

Atrial Fibrillation ◽

Emergency Department ◽

Logistic Regression ◽

Content Analysis ◽

Random Effects ◽

Qualitative Content Analysis ◽

Primary Objective ◽

Urgent Care ◽

Ventricular Rate ◽

History Of

ObjectivesThe primary objective of this study was to ascertain the reasons for emergency department (ED) attendance among patients with a history of atrial fibrillation (AF).DesignAppropriate ED attendance was defined by the requirement for an electrical or chemical cardioversion and/or an attendance resulting in hospitalisation or administration of intravenous medications for ventricular rate control. Quantitative and qualitative responses were recorded and analysed using descriptive statistics and content analysis, respectively. Random effects logistic regression was performed to estimate the OR of inappropriate ED attendance based on clinically relevant patient characteristics.ParticipantsParticipants ≥18 years with a documented history of AF were approached in one of eight centres partaking in the study across Canada (Ontario, Nova Scotia, Alberta and British Columbia).ResultsOf the 356 patients enrolled (67±13, 45% female), the majority (271/356, 76%) had inappropriate reasons for presentation and did not require urgent ED treatment. Approximately 50% of patients(172/356, 48%) were driven to the ED due to symptoms, while the remainder presented on the basis of general fear or anxiety (67/356, 19%) or prior medical advice (117/356, 33%). Random effects logistic regression analysis showed that patients with a history of congestive heart failure were significantly more likely to seek urgent care for appropriate reasons (p=0.03). Likewise, symptom-related concerns for ED presentation were significantly less likely to result in inappropriate visitation (p=0.02). When patients were surveyed on alternatives to ED care, the highest proportion of responses among both groups was in favour of specialised rapid assessment outpatient clinics (186/356, 52%). Qualitative content analysis confirmed these results.ConclusionsImproved education focused on symptom management and alleviating disease-related anxiety as well as the institution of rapid access arrhythmias clinics may reduce the need for unnecessary healthcare utilisation in the ED and subsequent hospitalisation.Trial registration numberNCT03127085

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