Efficacy of bilateral thoracoscopic sympathectomy in a patient with catecholaminergic polymorphic ventricular tachycardia.

A 27-year-old woman with frequent implantable cardioverter defibrillator (ICD) shocks related to catecholaminergic polymorphic ventricular tachycardia (VT) experienced aborted sudden death due to incessant polymorphic VT despite the administration of beta-blockers, verapamil, and flecainide. Catheter ablation failed to suppress the polymorphic VT. Based on the temporary efficacy of the local anesthetic administered at the left and right cervical sympathetic nerves to suppress VT under an isoproterenol infusion, stepwise, bilateral thoracoscopic sympathectomy was performed. Postoperatively, no further VT or syncopal episodes were documented under ICD telemetry. Bilateral thoracoscopic sympathectomy may be an alternative for patients with drug-refractory catecholaminergic polymorphic VT.

Ultrasound-guided continuous thoracic paravertebral block provides comparable analgesia and fewer episodes of hypotension than continuous epidural block after lung surgery.

PURPOSE: Both paravertebral block (PVB) and thoracic epidural block (TEB) are recommended for postoperative pain relief after lung surgery. The addition of fentanyl to the anesthetic solution became popular for TEB because of the stronger effects; however, there have been few comparable trials about the addition of fentanyl to PVB. The purpose of this study was thus to compare postoperative analgesia, side effects, and complications between ultrasound-guided PVB (USG-PVB) and TEB with the addition of fentanyl to ropivacaine after lung surgery. METHODS: We examined 90 consecutive patients (age 18-75 years) scheduled for video-assisted thoracic surgery (VATS). In both groups, all blocks (four blocks in USG-PVB and one block in TEB) and one catheter insertion were performed preoperatively. Continuous postoperative infusion (0.1% ropivacaine plus fentanyl at 0.4 mg/day) was undertaken for 36 h in both groups. The recorded data included the verbal rating scale (VRS) for pain, blood pressure, side effects, complications for 2 days, and overall satisfaction score. RESULTS: There was no difference in the frequency of taking supplemental analgesics (twice or more frequently), or in VRS. Hypotension occurred significantly more frequently in TEB (n = 7/33) than in PVB (n = 1/36) (P = 0.02); on the other hand, the incidences of PONV and pruritus, as well as overall satisfaction score, were similar. There were no complications in both groups; however, the catheters migrated intrathoracically in four patients in PVB. CONCLUSION: USG-PVB achieved similar pain relief and lowered the incidence of hypotension compared with TEB. We conclude that both blocks with the same concentration of ropivacaine and fentanyl can provide adequate postoperative analgesia for VATS.

[Anesthetic management of a patient with deep brain stimulators].

A 68-year man with severe Parkinson's disease who had been implanted with deep brain stimulators into both sides, received an emergency surgery uneventfully under general anesthesia with standard monitoring. During the operation, the surgeon turned off the impulse generators and used bipolar diathermy. Postoperatively, he had transient episodes of severe Parkinson symptoms, which were controled by levodopa drugs.

[Prolonged paralysis after long-term administration of vecuronium in the intensive care unit].

A 51-year-old woman with renal failure requring hemodialysis received a total of 446 mg of vecuronium over a period of 4 days to help mechanical ventilation and developed generalized muscle weakness after its discontinuation. It took 2 wks to wean her from mechanical ventilation and 3 wks for her to be able to walk. She did not receive drugs which might alter neuromuscular transmission such as corticosteroid and aminoglycoside antibiotics. Electromyogram and nerve conduction studies were normal. We believe that the cause is the accumulation of vecuronium and active metabolites due to renal failure. The case suggests that we should minimize the duration of neuromuscular block in patients with renal failure by aggressive use of sedatives and analgesics and the optimization of ventilator settings.

[Successful resuscitation of intractable hyperkalemic cardiac arrest].

We report on a 42-year-old oliguric uremic man on regular hemodialysis who developed sudden cardiac arrest, secondary to severe hyperkalemia, with a plasma potassium concentration of 9.7 mEq x l(-1). The cardiac arrest persisted after the initiation of cardiopulmonary resuscitation and intensive treatment for marked hyperkalemia for an hour and 55 minutes. Therefore a portable percutaneous cardiopulmonary support (PCPS) system had to be instituted while the patient had very prolonged refractory ventricular fibrillation. His cardiac rhythm was restored immediately after application of PCPS and he recovered without neurological sequelae. We therefore suggest that PCPS should be considered as a therapeutic option during cardiopulmonary resuscitation for life-threatening cardiac arrest secondary to severe hyperkalemia.