Use of EMLA cream for skin anesthesia and epidural insertion in the patients with cesarean delivery: A prospective double-blind randomized clinical trial.

Background: Pain relief of epidural anesthesia in cesarean delivery is difficult. EMLA, a eutectic mixture of lidocaine and prilocaine, is effective for pain reduction during venipuncture and superficial surgery. However, its effectiveness during epidural insertion is not well elucidated. The aim of this randomized, double-blind study was to evaluate the efficacy of EMLA for epidural insertion in elective cesarean delivery. Methods: With Institutional Review Board approval and written patients' informed consent, forty-two ASA physical status 2 patients (aged 23-45) scheduled for elective cesarean section were included in this study. The patients were randomized to applied ELMA (EMLA group) or placebo cream (Placebo group) about one hour prior to anesthesia. Pain during skin infiltration with 1% mepivacaine and subsequent insertion of Tuohy needle was assessed immediately after each procedure. The presence of patient's response with physical withdrawal on both procedures was recorded. Statistical analysis was performed using Mann-Whitney U test and Fisher's exact test. A value of P < 0.05 was considered significant. Results: Median VAS values on skin infiltration and on insertion of Tuohy needle did not differ between groups. The incidence of patient's response with physical withdrawal on skin infiltration was not different between groups. However, that on insertion of Tuohy needle was significantly lower in EMLA group than in Placebo group (0%, 21%). Conclusions: EMLA cream could not reduce the pain during epidural insertion.

Anesthetic management with remimazolam for a pediatric patient with Duchenne muscular dystrophy.

RATIONALE: With Duchenne muscular dystrophy (DMD) being the most common and most severe type of muscular dystrophy, DMD patients are at risk for complications from general anesthesia due to impaired cardiac and respiratory functions as the pathological condition progresses. In recent years, advances in multidisciplinary treatment have improved the prognosis of DMD patients, and the number of patients requiring surgery has increased. Remimazolam is a benzodiazepine derivative similar to midazolam. Its circulatory stability and the fact that it has an antagonist make it superior to propofol.There are no reports of pediatric patients with DMD undergoing total intravenous anesthesia with remimazolam. PATIENT CONCERNS: A 4-year boy was scheduled for single-incision laparoscopic percutaneous extraperitoneal closure for inguinal hernia under general anesthesia, but the surgery was postponed because his serum creatine phosphokinase level was extremely high. DIAGNOSIS: He was diagnosed with DMD. According to the results of the genetic test, exon deletion of the DMD gene was detected using multiplex ligation-dependent probe amplification, although he had no symptoms of DMD except for elevated serum levels of creatine phosphokinase, etc. INTERVENTION: He was admitted for the same surgical purpose. Anesthesia was induced with 3 mg of intravenously administered remimazolam. He lost the ability to respond to verbal commands. After the intravenous administration of 100 µg of fentanyl, a continuous infusion of remifentanil (1.0 µg/kg/min) and remimazolam (15 mg/h) was started, and the endotracheal tube was inserted smoothly after the administration of 10 mg of rocuronium with which the muscle twitches disappeared in train-of-four monitoring. At the end of the surgery, 15 mg of flurbiprofen was administered intravenously. After surgery, we injected 40 mg of sugammadex to confirm a train-of-four count of 100%. OUTCOMES: Although the dose of remimazolam was reduced to 5 mg/h 30 minutes before the end of the surgery, it took 20 minutes after the discontinuation of remimazolam for the patient to open his eyes upon verbal command. On postoperative Day 2, he was discharged from the hospital without any complications. LESSONS: Remimazolam was shown to be safe to use for general anesthesia in a pediatric patient with DMD.

Diagnosis and management of temporomandibular joint dysfunction before surgery: a case report.

We present a case of colorectal cancer with temporomandibular joint dysfunction and discuss the management of the case. Type IIIb temporomandibular disorder involves anterior dislocation of the articular disk, trismus and difficult intubation. A 68-year-old woman was scheduled for colectomy. The day before surgery, the patient had temporomandibular pain. On examination, the mouth opening was 13 mm. We diagnosed type IIIb temporomandibular disorder. A simple splint was fabricated with gauze and she bit it. The mouth opening was 55 mm on the day of surgery. The pain disappeared, and intubation was uneventful. Temporomandibular disorders are generally treated by dentists. It is beneficial for general hospitals without a dentistry department to employ a dental anaesthesiologist to assist in potentially difficult intubations in patients with temporomandibular disorders.

Prophylactic Pentazocine Reduces the Incidence of Pruritus After Cesarean Delivery Under Spinal Anesthesia With Opioids: A Prospective Randomized Clinical Trial.

BACKGROUND: The incidence of pruritus after cesarean delivery under spinal anesthesia with opioids is high, ranging from 50% to 100%. Pruritus is difficult to prevent; however, pentazocine has been shown to be an effective treatment. Despite this, the prophylactic effect of pentazocine on pruritus has not been defined. This randomized double-blind trial aimed to evaluate the effect of intraoperative IV pentazocine on the incidence of opioid-induced pruritus within the first 24 hours after administration of neuraxial opioids. METHODS: We obtained institutional review board approval and written informed consent from the 122 patients (American Society of Anesthesiologists [ASA] physical status II; aged 20-40 years) scheduled for elective cesarean delivery who were included in this study. Spinal anesthesia was performed with 10 mg of 0.5% hyperbaric bupivacaine, 10 µg of fentanyl, and 100 µg of morphine. After delivery of the baby and placenta, the parturient women were randomized to intravenously receive 15 mg (1 mL) of pentazocine or 1 mL of saline. All women received postoperative analgesia with the epidural infusion of 0.15% levobupivacaine. The presence of pruritus within the first 24 hours after intrathecal administration of opioids was recorded, and severity of itch, numerical rating scale (NRS) for pain, and adverse effects were also recorded at the time of the arrival on the ward, as well as 3, 6, 12, and 24 hours after the intrathecal administration of opioids. RESULTS: A total of 119 women completed the study. IV pentazocine reduced the overall incidence of pruritus within the first 24 hours compared to IV saline, with an estimated relative risk of 69% (95% confidence interval [CI], 52%, 90%; P = .007). IV pentazocine also reduced the severity of pruritus. The incidence of nausea and vomiting was not significantly different. There were no significant differences in postoperative NRS scores. CONCLUSIONS: A single 15-mg dose of IV pentazocine after delivery can reduce both the incidence and severity of pruritus in women who have received subarachnoid opioids during cesarean delivery.

The use of sugammadex in a patient with Kennedy's disease under general anesthesia.

Kennedy's disease (KD), also known as spinal and bulbar muscular atrophy, is a rare, X-linked recessive, neurodegenerative disorder of the lower motor neurons characterized by progressive bulbar and appendicle muscular atrophy. Here we report a case of a 62-year-old male patient with KD, weighing 70 kg and 173 cm tall, was scheduled for frontal sinusectomy due to sinusitis. General anesthesia was induced through propofol 80 mg, remifentanil 0.25 µg/kg/min and 40 mg rocuronium. We were successfully able to use a sugammadex on a patient suffering from KD in order to reverse rocuronium-induced neuromuscular blockade.

[Case report of paradoxical arousal-like EEG changes during pediatric laparotomy].

An 8-year-old boy with Chiari malformation and myelomeningocele received total cystectomy and ileal neobladder surgery under general anesthesia with sevoflurane, nitrous oxide, and intravenous fentanyl. Bispectral index (BIS) suddenly decreased from 50 to 7 with large slow delta waves during ileal anastomosis, although there was no change regarding blood pressure and heart rate. This EEG change was considered first as 'paradoxical arousal', of which mechanism is commonly due to the unexpected noxious stimulation. In spite of additional intravenous fentanyl, this EEG pattern did not change at all, but disappeared spontaneously. This episode repeated two times under the similar condition during surgery. The patient recovered from anesthesia without any neurological complications. The effect-site fentanyl concentration simulated later was supposed to suppress the noxious stimulation adequately during this procedure. Although we can not elucidate the mechanism of paradoxical arousal-like EEG change, our case report suggests that paradoxical arousal may occur by factors other than inadequate anesthesia.

Preoperative epidural fentanyl reduces postoperative pain after upper abdominal surgery.

Forty patients, American Society of Anesthesiology (ASA) physical status 1-2, undergoing subtotal gastrectomy were enrolled in this study. The patients were allocated to two groups with or (group P) and without (group C) preoperative epidural fentanyl 100 microg. Postoperatively, all patients received continuous infusion of the study solution, containing fentanyl 30 microg x ml(-1) and 2 mg/ml bupivacaine, at a rate of 0.7 ml x h(-1) for 72 h. The scores on the Prince Henry Hospital self-assessed pain scale (PHPS) were recorded at 0, 4, 12, 24, 48, and 72 h after the surgery. We compared the total rescue doses of analgesics during each period of 24 h until 72 h postoperatively. Although the total rescue doses of analgesics were not different between the groups, the median PHPS score was lower in group P than in group C, except at 0 h after the surgery. Preoperative epidural fentanyl 100 microg may increase the analgesic potency of postoperative epidural low-dose infusion of bupivacaine with fentanyl.

Breath-holding spells in somatoform disorder.

Breath-holding spells (BHS) are commonly seen in childhood. However, there are no case reports of BHS occurring in adolescents or young adults. We report two young adult cases and discuss the pathogensis, both physically and psychologically. BHS occurred for 1-2 minutes after hyperventilation accompanied by cyanosis in both cases. Oxygen saturation was markedly decreased. Each patient had shown distress and a regressed state psychologically. These cyanotic BHS occurred after hyperventilation, and we considered that a complex interplay of hyperventilation followed by expiratory apnea increased intrathoracic pressure and respiratory spasm. Breath-holding spells can occur beyond childhood.

Sevoflurane requirements to suppress responses to transcutaneous electrical stimulation during epidural anesthesia with 0.5% and 1% lidocaine.

UNLABELLED: We sought to determine general anesthetic requirements to suppress skin vasomotor reflex (SVmR) and pupillary dilation (PD) in response to transcutaneous electrical stimulation (TES) during combined epidural-general anesthesia. Thirty-five patients undergoing lower abdominal surgery were randomly divided into 2 groups to epidurally receive 0.5% (Group 1) or 1% lidocaine (Group 2) with sevoflurane anesthesia. A bolus injection of either lidocaine was followed by the infusion of the same solution, and the central dermatomal level of loss of cold sensation (C) was determined. After the induction of general anesthesia with 5% sevoflurane and 67% nitrous oxide, nitrous oxide was discontinued, and sevoflurane concentration was decreased. TES was given at both site C and site three dermatomal segments (U) cephalad to C to determine the end-tidal sevoflurane concentration required to suppress SVmR and PD. End-tidal sevoflurane concentration that suppressed both responses was larger in Group 1 than in Group 2 at both sites and was larger at site U than at site C in both groups. We conclude that sevoflurane requirements to suppress SVmR and PD in response to TES during combined epidural-general anesthesia are different depending on the concentration of lidocaine and the site where surgical stimulation is applied. IMPLICATIONS: We evaluated sevoflurane requirements to suppress skin vasomotor reflex and pupillary dilation in response to a transcutaneous electrical stimulation at the surgical site during combined epidural-general anesthesia. Our results indicate that when epidural anesthesia is combined, general anesthetic requirements decrease depending on the lidocaine concentration for epidural anesthesia and the site where surgical stimulation is applied.

Intercostal nerve block with 5% tetracaine for chronic pain syndromes.

Treating chronic pain syndromes is always challenging. We describe an effective use of an intercostal nerve block using 5% tetracaine in three patients with postherpetic intercostal neuralgia or postoperative intercostal neuralgia.

Anesthetic management for a patient with Jansky-Bielschowsky disease.

PURPOSE: To describe the anesthetic management of a patient with Jansky-Bielschowsky disease (JBD), the late infantile form of neuronal ceroid lipofuscinosis, characterized by dementia, severe and drug resistant grand mal, myoclonic seizures, and blindness. CLINICAL FEATURES: A 14-yr-old girl with JBD was scheduled for resection of a gingival tumour and an infected sinus in the sacral area. Her preanesthetic examination revealed extreme muscle atrophy and dementia. Grand mal, myoclonic seizures, and upper airway obstruction were frequent. Following iv induction with thiamylal, anesthesia was maintained with sevoflurane, N(2)O and O(2). Her trachea was intubated without using muscle relaxants. Muscle relaxants were not used during the operation. Apart from an intractable hypothermia, the intraoperative course was uneventful. The emergence of anesthesia was smooth, except for persisting seizures. CONCLUSION: General anesthesia using thiamylal and sevoflurane provided satisfactory conditions during operation in a patient with JBD. Intraoperative hypothermia required particular attention.