ContextActivation of the coagulation system and depletion of endogenous anticoagulants
are frequently found in patients with severe sepsis and septic shock. Diffuse
microthrombus formation may induce organ dysfunction and lead to excess mortality
in septic shock. Antithrombin III may provide protection from multiorgan failure
and improve survival in severely ill patients.ObjectiveTo determine if high-dose antithrombin III (administered within 6 hours
of onset) would provide a survival advantage in patients with severe sepsis
and septic shock.Design and SettingDouble-blind, placebo-controlled, multicenter phase 3 clinical trial
in patients with severe sepsis (the KyberSept Trial) was conducted from March
1997 through January 2000.PatientsA total of 2314 adult patients were randomized into 2 equal groups of
1157 to receive either intravenous antithrombin III (30 000 IU in total
over 4 days) or a placebo (1% human albumin).Main Outcome MeasureAll-cause mortality 28 days after initiation of study medication.ResultsOverall mortality at 28 days in the antithrombin III treatment group
was 38.9% vs 38.7% in the placebo group (P = .94).
Secondary end points, including mortality at 56 and 90 days and survival time
in the intensive care unit, did not differ between the antithrombin III and
placebo groups. In the subgroup of patients who did not receive concomitant
heparin during the 4-day treatment phase (n = 698), the 28-day mortality was
nonsignificantly lower in the antithrombin III group (37.8%) than in the placebo
group (43.6%) (P = .08). This trend became significant
after 90 days (n = 686; 44.9% for antithrombin III group vs 52.5% for placebo
group; P = .03). In patients receiving antithrombin
III and concomitant heparin, a significantly increased bleeding incidence
was observed (23.8% for antithrombin III group vs 13.5% for placebo group; P<.001).ConclusionsHigh-dose antithrombin III therapy had no effect on 28-day all-cause
mortality in adult patients with severe sepsis and septic shock when administered
within 6 hours after the onset. High-dose antithrombin III was associated
with an increased risk of hemorrhage when administered with heparin. There
was some evidence to suggest a treatment benefit of antithrombin III in the
subgroup of patients not receiving concomitant heparin.

https://jamanetwork.com/journals/jama/articlepdf/194284/JCE10000.pdf

High-Dose Antithrombin III in Severe Sepsis: A Randomized Controlled Trial

The role of the endothelium in severe sepsis and multiple organ dysfunction syndrome

Clinically inapparent adrenal masses are incidentally detected after imaging studies conducted for reasons other than the evaluation of the adrenal glands. They have frequently been referred to as adrenal incidentalomas. In preparation for a National Institutes of Health State-of-the-Science Conference on this topic, extensive literature research, including Medline, BIOSIS, and Embase between 1966 and July 2002, as well as references of published metaanalyses and selected review articles identified more than 5400 citations. Based on 699 articles that were retrieved for further examination, we provide a comprehensive update of the diagnostic and therapeutic approaches focusing on endocrine and radiological features as well as surgical options. In addition, we present recent developments in the discovery of tumor markers, endocrine testing for subclinical disease including autonomous glucocorticoid hypersecretion and silent pheochromocytoma, novel imaging techniques, and minimally invasive surgery. Based on the statements of the conference, the available literature, and ongoing studies, our aim is to provide practical recommendations for the management of this common entity and to highlight areas for future studies and research.

/pdf/the-clinically-inapparent-adrenal-mass-update-in-diagnosis-2azu2oiru3.pdf

The Clinically Inapparent Adrenal Mass: Update in Diagnosis and Management

BACKGROUND:Regional anesthesia (RA) provides excellent anesthesia and analgesia for many surgical procedures. Anesthesiologists and patients must understand the risks in addition to the benefits of RA to make an informed choice of anesthetic technique. Many studies that have investigated neurologica

Neurological complications after regional anesthesia: contemporary estimates of risk.

American Association of Clinical Endocrinologists and American Association of Endocrine Surgeons Medical Guidelines for the Management of Adrenal Incidentalomas

BackgroundDue to potential neurologic sequelae, the risk:benefit ratio of thoracic epidural analgesia is controversial. Surprisingly, however, few available data address neurologic complications. The incidence of neurologic complications occurring after thoracic epidural catheterization was studied

Incidence of Neurologic Complications Related to Thoracic Epidural Catheterization

Posterior retroperitoneoscopic adrenalectomy is a new mini- mally invasive method. It represents an alternative to conventional open procedures and laparoscopic techniques. Between July 1994 and Novem- ber 1995 a total of 30 retroperitoneoscopic adrenalectomies were per- formed on 27 patients. In 24 patients, unilateral tumors were seen (size 1-7 cm): seven Cushing adenomas,five Conn adenomas, seven pheochro- mocytomas, four hormonally inactive tumors, one cyst. Three patients suffered from Cushing syndrome with bilateral adrenal gland hyperpla- sias (two inoperable pituitary gland tumors, one bronchial carcinoid with ACTHsecretion).Theoperationswerecarriedoutinproneposition.After balloon dilatation of the retroperitoneum and creation of a pneumoperi- toneum the preparation of the adrenal gland was performed via three trocar sites positioned below the 12th rib. Twenty-five adrenalectomies were completed endoscopically, and five times (among four patients) conversion to the conventional posterior technique was necessary. The average operating time of complete endoscopic adrenalectomies was 124 minutes (45-225 minutes); blood loss was 10 to 120 ml. With minimal need for postoperative analgesia (average dosage 7.9 mg of piritramide), mobilization and adequate food uptake were possible on the day of operation. The posterior retroperitoneoscopic adrenalectomy is a rela- tively fast, safe method, with the advantages of the posterior open approach and minimally invasive surgery. It therefore represents an important addition to adrenal gland surgery.

Posterior Retroperitoneoscopy as a New Minimally Invasive Approach for Adrenalectomy: Results of 30 Adrenalectomies in 27 Patients

Posterior retroperitoneoscopic adrenalectomy is one of the new endoscopic methods in endocrine surgery In a prospective clinical study 142 posterior retroperitoneoscopic adrenalectomies (72 right, 70 left) were performed in 130 patients (52 males, 78 females, age 491 ± 149 years) Indications were primary adrenal tumors (unilateral, n= 118; bilateral, n= 2), adrenal metastases (n= 2), and bilateral ACTH-dependent hyperplasias (n= 10) Tumor size ranged from 05 to 70 cm (mean 27 ± 14 cm) Partial adrenalectomies were performed in 39 patients Conversion to open posterior adrenalectomy was necessary in five patients and seven procedures (5%) Intraoperative and postoperative complications were minor and occurred in 5% and 13%, respectively Mortality was zero Operating time was 101 ± 39 minutes (range 35–285 minutes) and depended on tumor type (pheochromocytoma versus others; p < 001), tumor size (< 3 vs ≥ 3 cm; p < 005), gender (p < 005), and extent of resection (partial versus complete, p < 005 Twenty-three adrenalectomies (17%) were performed within 1 hour or less Blood loss was 54 ± 72 ml Consumption of analgesics was low (mean 6 mg piritramide postoperatively) Median duration of hospitalization was 3 days Posterior retroperitoneoscopic adrenalectomy is a safe method that has become a standard procedure in endocrine surgery

Posterior Retroperitoneoscopic Adrenalectomy: Lessons Learned within Five Years

Arterialization of the portal vein in orthotopic and auxiliary liver transplantation. A report of three cases.

p > 0.05) from that seen with complete extirpation (46 patients operated during the same period). All patients with Conn adenomas and pheochromocytomas were biochemically and clinically cured (follow-up 11 months; range 1–31 months). The four patients with Cushing adenoma currently require decreasing cortisol substitution. In the two MEN-II patients adrenal gland cortical function could be maintained; one patient is on low-dose steroid supplementation and the other on none. No local recurrence of tumors has been observed. In selected cases the retroperitoneoscopically performed subtotal adrenal gland resection is a safe procedure that can potentially maintain the function of the adrenal gland cortex.

Reiner M. Giebler

Papers

Incidence of Neurologic Complications Related to Thoracic Epidural Catheterization

Posterior Retroperitoneoscopy as a New Minimally Invasive Approach for Adrenalectomy: Results of 30 Adrenalectomies in 27 Patients

Posterior Retroperitoneoscopic Adrenalectomy: Lessons Learned within Five Years

Arterialization of the portal vein in orthotopic and auxiliary liver transplantation. A report of three cases.

Subtotal adrenalectomy by the posterior retroperitoneoscopic approach