Anaphylaxis in the operating room treated with an anaphylaxis response kit: A case report.

Anaphylaxis is a rapidly fatal complication of anesthesia, and it needs to be appropriately diagnosed and treated by anesthesiologists. A 37-year-old man underwent surgery for pneumothorax under general anesthesia. Postoperatively, the train-of four count was four, and sugammadex was administered. Soon after, the patient's oxygen saturation and blood pressure decreased, and skin flushing was noted. We suspected anaphylaxis and administered adrenaline. Once the blood pressure normalized, we administered hydrocortisone, famotidine, and d-chlorpheniramine maleate. Thereafter, his condition stabilized, he recovered well, and he was discharged. Blood samples obtained after the onset of the episode indicated anaphylaxis, and a prick test performed 10 weeks postoperatively confirmed sugammadex as the causative agent. We report a case of sugammadex-induced anaphylaxis, which we could properly diagnose and treat because an anaphylaxis kit was available in our department.

Dyspnea after discharge from hospital due to pulmonary vein thrombosis after video-assisted left upper lobectomy: a case report.

BACKGROUND: Thrombus formation at the pulmonary vein transection site is more common in left upper lobectomy than other lobectomies. We report a case of dyspnea and contrast-enhanced computed tomography (CT) findings of pulmonary vein thrombosis after left upper lobectomy. CASE PRESENTATION: A 68-year-old man with left lung cancer underwent video-assisted thoracoscopic left upper lobectomy under general anesthesia with thoracic epidural analgesia. He had no postoperative complications and was discharged home on the 5th day postoperatively. He visited the outpatient clinic at 8 days after surgery because of dyspnea and underwent contrast-enhanced CT, which revealed a thrombus at the resected edge of the left upper pulmonary vein. Anticoagulation therapy was started. Thereafter, the thrombus shrank, and the patient's dyspnea improved. CONCLUSIONS: Left upper lobe resection is particularly associated with pulmonary venous thrombosis, and dyspnea due to pulmonary venous thrombus may develop late after surgery. Postoperative management methods such as anticoagulation and postoperative pain management should be reexamined.

Extremely low bispectral index value during robotic-assisted laparoscopic prostatectomy: A case report.

The steep Trendelenburg position and pneumoperitoneum during surgery may affect intracranial pressure and cerebral oxygenation, which in turn may affect the values of the bispectral index (BIS). Prolonged maintenance of the Trendelenburg position and pneumoperitoneum may impair cerebrovascular autoregulation. We present a case of a patient with an extremely low BIS value during robotic-assisted laparoscopic prostatectomy (RALP). We managed the patient under general anesthesia and he showed a prominent decrease in BIS values 6 h after the start of surgery. Suppression ratio (SR) of electroencephalography (EEG) is also decreased, suggesting that the brain activity decreased. The BIS value increased quickly after the Trendelenburg position was released and the anesthesia was terminated. The patient recovered without any neurological deficits and was discharged. Steep Trendelenburg position and pneumoperitoneum can cause EEG abnormalities.

Respiratory distress associated with acute hydrothorax during transurethral electrocoagulation: a case report.

BACKGROUND: In patients undergoing abdominal radiotherapy or transurethral surgery, bladder perforations are a possible complication. Likewise, pleural effusions due to a pleuroperitoneal leak caused by either a congenital or acquired diaphragmatic defect can also occur. We report a case in which a saline solution, which migrated into the abdominal cavity from a bladder perforation during transurethral electrocoagulation, further formed bilateral pleural effusions and caused rapid ventilation failure. CASE PRESENTATION: A patient undergoing radiation therapy and hormone therapy for prostate cancer underwent emergency surgery for electrocoagulation due to hematuria and a rapid drop in hemoglobin. The surgery began under general anesthesia, and we first noticed an increase in airway pressure and a decrease in dynamic lung compliance, followed by abdominal distension. Based on readouts from the respiratory mechanics monitor, we suspected lung abnormalities and performed a pulmonary ultrasound, leading to a diagnosis of bilateral pleural effusions, which we then drained. CONCLUSIONS: Respiratory mechanics monitoring is simple and can be performed at all times during anesthesia, and when combined with pulmonary ultrasound, diagnoses can be made quickly and prevent deaths.

Migration of fractured guidewire and its retrieval by endovascular snare catheter: A case report.

Central venous catheterization is commonly used in patients undergoing cardiovascular surgery and it is a relatively safe procedure. A 62-year-old woman who underwent emergency mitral valve replacement for infective endocarditis received a central venous catheter after induction of anesthesia. Postoperative chest radiography revealed a wire-like foreign body near the puncture site of the internal jugular vein, which was later retrieved successfully using a snare catheter under fluoroscopy. This report highlights the importance of careful observation of the withdrawn guidewire and dilator and the role of perivascular ultrasound in all cases requiring this procedure.

Platypnea-orthodeoxia syndrome associated with COVID-19 pneumonia: a case report.

BACKGROUND: Platypnea-orthodeoxia syndrome (POS) is a rare clinical condition characterized by respiratory distress and/or hypoxia developing in the sitting/upright position, which is relieved in the recumbent position. This syndrome is known to have an intracardiac shunt as its primary etiology. Here, we report the case of a patient who was found to have POS without an intracardiac shunt while recovering from coronavirus disease (COVID-19) pneumonia. CASE PRESENTATION: A 73-year-old woman was diagnosed with severe COVID-19 pneumonia and was managed according to our institutional protocol. Although her oxygenation improved at rest, oxygen saturation dropped to lower than 80% when she was in the sitting position. She had no patent foramen ovale or other intracardiac shunts. She showed gradual improvement and was discharged under home oxygen therapy 28 days after admission. CONCLUSIONS: This report highlights the importance of continuous bedside monitoring of pulse oximetry during positional changes, even if it is stable at rest, in patients with moderate to severe COVID-19.

Preferred display size and visual distance for ultrasound-guided radial artery cannulation / Tamaño preferido de la imagen en pantalla y distancia visual para la canalización de la arteria radial guiada por ecografía

Abstract Introduction: In-line positioning of an ultrasound image provides higher success rates and less time to completion for radial arterial cannulation. But preferable size and distance of ultrasound display has not been previously discussed. Objective: To assess the ideal visual distance and display size when using a smart phone or tablet as the ultrasound image display. Methods: Four smart phones or tablets were used as ultrasound displays in six different configurations in a simulated radial artery puncture. In a questionnaire, 116 anaesthesiologists working in Ibaraki Prefecture, Japan, were asked which of the six configurations was preferable for radial artery cannulation. Results: Sixty anaesthesiologists answered the questionnaire. About half (53%) preferred the smaller display (4- or 5.5-inch) fixed at a distance of 30 to 40 cm, and most of the rest (44%) preferred the larger display (7.9- or 9.7-inch) placed posterior to the probe with a visual distance of 45 to 60 cm. Conclusions: Among the anaesthesiologists, the preferable size and visual distance for ultrasound-guided radial artery cannulation varied using a smart phone or tablet for in-line display.

Resumen Introducción: El posicionamiento en línea con una imagen ecográfica permite mayores tasas de éxito y reduce el tiempo para realizar la canalización de la arteria radial. Sin embargo, no se ha hablado sobre cuál es el tamaño y la distancia preferibles para la imagen en pantalla. Objetivo: Evaluar la distancia visual y el tamaño de la imagen en pantalla cuando se utiliza un teléfono inteligente o una tableta para visualizar la imagen ecográfica. Métodos: Se utilizaron cuatro teléfonos inteligentes o tabletas como pantalla para visualizar las imágenes ecográficas en seis configuraciones distintas, en una simulación de la canalización de la arteria radial. Mediante un cuestionario se preguntó a 116 anestesiólogos que trabajan para la Prefectura de Ibaraki, Japón, cuál de las seis configuraciones era preferible para la canalización de la arteria radial. Resultados: Sesenta anestesiólogos respondieron el cuestionario. Aproximadamente la mitad (53%) prefirieron la imagen más pequeña (4 o 5,5 pulgadas), fija a una distancia de 30 a 40 cm, y la mayoría de los otros (44%) prefirieron la imagen más grande (7,9- o 9,7 pulgadas), colocada en la parte posterior al transductor, con una distancia visual de 45 a 60 cm. Conclusiones: Entre los anestesiólogos, el tamaño preferido y la distancia visual para la canalización de la arteria radial guiada por ecografía, varió utilizando un teléfono inteligente o una tableta para su visualización en línea.

Occlusion of multi-holed catheters used in continuous wound infusion in open gynecologic surgery: A pathological study.

BACKGROUND: Continuous wound infusion (CWI) with local anesthetics is useful as a method of pain management after abdominal surgery. However, there have been no studies regarding the obstruction of multi-holed catheters in this application. METHODS: We conducted from July to November 2015. In the first portion of the study, we obtained 34 catheters used postoperatively with open gynecologic surgery, and evaluated the status of each hole in vitro. Each catheter had eight holes, and we investigated the number of open holes after the removal of the catheter. In the second portion of the study, we reviewed pathological specimens from four occluded catheters. Statistical analysis was performed using the statistical software MedCalc™ (MedCalc, Ostend, Belgium), and intergroup comparisons were made with independent sample t-test. Data are expressed by mean and standard deviation. RESULTS: In each catheter, the number of remaining open holes was 0-7, and there were no catheters with all eight holes still open. Although the occlusion may be occurred after the end of infusion, 38.2% (n = 12) did not have any open holes remaining in our investigation. The composition of the emboli in the catheters was clotted blood and plasma, with a mass of fibrin and possibly some inflammation around the embolus. CONCLUSIONS: Occlusion of these catheters occurs at a very high rate, and the catheter embolus might be composed of clotted blood, plasma, and/or fibrin.

Acute arterial occlusion due to left ventricular thrombus of Takotsubo cardiomyopathy in a young adult: a case report.

BACKGROUND: Thromboembolism is a rare complication of Takotsubo cardiomyopathy. Importantly, an acute arterial occlusion needs rapid diagnosis and urgent treatment to help save the patient's life. Here, we report a case of arterial occlusion due to ventricular thrombus of Takotsubo cardiomyopathy. CASE PRESENTATION: A woman in her 30s, without previous medical history, felt sudden strong pain on her right leg and was diagnosed with right femoral arterial occlusion. An emergency operation was subsequently performed to take out thrombus. The patient's oxygenation deteriorated to 93% of hemoglobin saturation just after extubation and exacerbated in the intensive care unit. Transthoracic echocardiography revealed Takotsubo cardiomyopathy-like left ventricular wall motion abnormalities and left ventricular thrombus. Heparin treatment was immediately started. After 10 days, the thrombus disappeared and the left ventricular wall motion improved and she was discharged from the hospital. CONCLUSIONS: The patient's acute arterial occlusion in this case report was mainly caused by thrombus of cardiac origin. We suggest to routinely check echocardiography reports before surgery and perform anesthetic management carefully to better control the patient's blood pressure and heart rhythm.

Functional residual capacity increase during laparoscopic surgery with abdominal wall lift / Aumento da capacidade residual funcional durante cirurgia laparoscópica com elevação da parede abdominal

Abstract Background and objectives: The number of laparoscopic surgeries performed is increasing every year and in most cases the pneumoperitoneum method is used. One alternative is the abdominal wall lifting method and this study was undertaken to evaluate changes of functional residual capacity during the abdominal wall lift procedure. Methods: From January to April 2013, 20 patients underwent laparoscopic cholecystectomy at a single institution. All patients were anesthetized using propofol, remifentanil and rocuronium. FRC was measured automatically by Engstrom Carestation before the abdominal wall lift and again 15 minutes after the start of the procedure. Results: After abdominal wall lift, there was a significant increase in functional residual capacity values (before abdominal wall lift 1.48 × 103 mL, after abdominal wall lift 1.64 × 103 mL) (p < 0.0001). No complications such as desaturation were observed in any patient during this study. Conclusions: Laparoscopic surgery with abdominal wall lift may be appropriate for patients who have risk factors such as obesity and respiratory disease.

Resumo Justificativa e objetivos: O número de cirurgias laparoscópicas feitas tem aumentado a cada ano e, na maioria dos casos, o método com pneumoperitônio é o escolhido. Uma opção é o método de elevação da parede abdominal. Este estudo foi feito para avaliar as alterações da capacidade residual funcional durante o procedimento de elevação da parede abdominal. Métodos: De janeiro a abril de 2013, 20 pacientes foram submetidos à colecistectomia laparoscópica em uma única instituição. Todos foram anestesiados com propofol, remifentanil e rocurônio. A CRF foi medida automaticamente com o Engström Carestation antes da elevação da parede abdominal e, novamente, 15 minutos após o início do procedimento. Resultados: Após elevar a parede abdominal, um aumento significativo foi observado nos valores da capacidade residual funcional (antes da elevação da parede abdominal: 1,48 × 103 mL: após a elevação da parede abdominal: 1,64 × 103 mL) (p <0,0001). Não houve complicações, como dessaturação, em nenhum paciente durante este estudo. Conclusões: A cirurgia laparoscópica com elevador da parede abdominal pode ser apropriada para pacientes com fatores de risco como obesidade e doenças respiratórias.

[Functional residual capacity increase during laparoscopic surgery with abdominal wall lift]. / Aumento da capacidade residual funcional durante cirurgia laparoscópica com elevação da parede abdominal.

BACKGROUND AND OBJECTIVES: The number of laparoscopic surgeries performed is increasing every year and in most cases the pneumoperitoneum method is used. One alternative is the abdominal wall lifting method and this study was undertaken to evaluate changes of functional residual capacity during the abdominal wall lift procedure. METHODS: From January to April 2013, 20 patients underwent laparoscopic cholecystectomy at a single institution. All patients were anesthetized using propofol, remifentanil and rocuronium. FRC was measured automatically by Engstrom Carestation before the abdominal wall lift and again 15minutes after the start of the procedure. RESULTS: After abdominal wall lift, there was a significant increase in functional residual capacity values (before abdominal wall lift 1.48×103mL, after abdominal wall lift 1.64×103mL) (p<0.0001). No complications such as desaturation were observed in any patient during this study. CONCLUSIONS: Laparoscopic surgery with abdominal wall lift may be appropriate for patients who have risk factors such as obesity and respiratory disease.

[Influence of Propofol and Remifentanil on Pupillary Light Reflex Assessed by a Hand-held Point-and-shoot Pupillometer].

BACKGROUND: Anisocoria and abnormality of pupil- lary light reflex may indicate sight-threatening or life- threatening neurological injury. Many perioperative patients are given opioids for analgesia, and opioids produce miosis and make it hard to assess anisocoria or pupillary light reflex. This study was designed to determine the influence of induction of anesthesia on pupillary light reflex assessed by a hand-held point- and-shoot pupillometer. METHODS: Eighteen patients receiving general anes- thesia were enrolled. Anesthesia was inducted by remifentanil, propofol and rocuronium after' pre-oxy- genation and tracheal intubation or insertion of supra- glottic airway device. The pupillary measurement data before induction and after intubation or insertion of supraglottic airway device were taken from records. RESULTS: With eighteen patients, thirty six eye data were compared. After intravenous injection of propofol and remifentanil infusion, pupils were constricted from 4.0±1.1 mm to 1.8±0.4 mm, and average constriction velocity (CV), neurological pupil index (NPI) measured automatically from light reflex decreased for 2.5±0.9 mm, sec⁻¹ to 0.3±0.2 mm · sec⁻¹, 4.4±0.4 to 3.9±0.4, respectively (P<0.0001). CONCLUSIONS: Propofol and remifentanil infusion in- fluence pupillary light reflex and decreases values of NPI and CV. When using these drugs, it is necessary to perform neurologic evaluation using NPI and CV.

[Experience of mismatched blood transfusion for an rh negative patient and reconsideration of emergency blood transfusion manual in the hospital].

We report a B Rh negative patient undergoing total pelvic exenteration, who received both ABO and Rh incompatible packed red blood cells in an emergency situation. After this experience, we revised the manual of emergency blood transfusion. We defined level of severity to share information with surgeon, nurses, anesthesiologists and the member of the blood center. We changed anesthesia information management system for showing blood type including Duffy blood group system and checking out whether we can transfuse Rh positive blood to Rh negative patient in an emergency situation at the timeout of surgery.

[Fixation of the epidural catheter using Tegaderm].

BACKGROUND: Effect of epidural anesthesia is affected by catheter tip position. Migration of an epidural catheter is known and several methods were reported to secure fixation of the catheter, but there were no gold standard method to fix it. METHODS: We compared six different methods to fix the epidural catheter with Tegaderm transparent film dressing. Three groups employed forming circular loop at the skin exit site and other three groups employed directing straight up to the right shoulder. Each group was divided into three subgroups by position and use of record label of Tegaderm transparent film dressing. Epidural catheter migration was recorded for two postoperative days. We compared the magnitude of catheter movement in two days and changes in length of catheter insertion in two days for each group. RESULTS: The magnitude of catheter movement is smaller in the group without circular loop formed at skin exit but all these three subgroups showed significant outward migration in two days. CONCLUSIONS: We conclude that fixation of epidural catheter by only Tegaderm can not be a gold standard even if circular loop and record label are used.

[Case of median nerve paralysis after hepatic segmentectomy].

We report a case of a median nerve palsy. Hepatic segmentectomy and lymphnode dissection were performed in a 21-year-old man for multiple liver and retroperitoneal lymph nodes metastasis of seminoma. After surgery, patient complained of motor paralysis and hypesthesia of the left palm side of the thumb, first finger and radial half of the middle finger. He was diagnosed as having median nerve palsy. Motor paralysis and hypesthesia gradually disappeared over the two weeks after surgery. We should pay attention to appropriate positioning of the arm during surgery, and preoperative use of paclitaxel needs to be considered as etiology for perioperative peripheral nerve palsy.

[Case of bilateral obturator neuropathy after caesarean section].

We describe a case of bilateral obturator neuropathy after caesarean section. A 33-year-old woman expecting her first baby had rotational acetabular osteotomy 8 and 9 years ago. After the surgery, she complained of weakness in the lower limbs and diagnosed as bilateral obturator neuropathy by orthopedist. Rotational acetabular osteotomy is known as one of the causes of narrow mid-pelvis diameter and it raises probability of caesarean section. Contracted pelvis may cause obturator neuropathy after delivery and we need to exclude complications by epidural blockade.

[Patient with posterior reversible encephalopathy syndrome with prolonged disturbance of consciousness and convulsion after cerebral aneurysm surgery].

A 73-year-old patient developed convulsion and prolonged disturbance of consciousness after clipping surgery for unruptured cerebral aneurysm. The patient's consciousness improved four days after surgery, and radiological findings suggested posterior reversible encephalopathy syndrome (PRES). The cause of PRES is thought to be dysfunction of blood brain barrier by a sudden increase in blood pressure. In case of unexplained convulsion and decreased level of consciousness, PRES should be considered with radiographic examinations including CT and MRI.

[Coronary artery spasm during one-lung ventilation].

We experienced a case of coronary artery spasm during one-lung ventilation. A 66-year-old man was scheduled for right upper lobectomy for lung cancer. He had a history of hypertension and cerebral infarction, but without any history or evidence of ischemic heart disease. After induction of general anesthesia, a left-sided double lumen tube was inserted. The patient was placed in the left lateral position, and one lung ventilation was started. Before skin incision, we noticed marked ST elevation on the ECG monitor, after which continuous infusion of nitroglycerin and two lung ventilation were initiated. In several minutes, ST elevation subsided completely. We cancelled the surgery and performed the coronary angiography, which demonstrated normal coronary arteries. A diagnosis of coronary artery spasm was made. Possible triggering factors for coronary artery spasm in this case were considered to be an increase in right ventricular pressure due to one-lung ventilation, and vagal stimulation associated with remifentanil use. The importance of evaluation of preoperative risk factors, avoidance of triggering factors and perioperative treatments are emphasized to prevent the coronary artery spasm.