Enlarged Brachial Plexus Nerve Found During Ultrasound-Guided Peripheral Nerve Block Diagnosed as Charcot-Marie-Tooth Disease: A Case Report.

Ultrasound-guided peripheral nerve block (PNB) has become a popular anesthetic procedure. We report a case of an enlarged brachial plexus nerve noted on ultrasonographic images, as part of PNB, which was diagnosed postoperatively as Charcot-Marie-Tooth disease (CMTD), an inherited neurological disorder of the peripheral nerves. Although nerve enlargement is characteristic of demyelinating diseases such as CMTD, the use of ultrasonography in the diagnosis of neurological disorders is a developing area for neurologists and anesthesiologists can lack knowledge in this emerging field. Unusual nerve presentation on ultrasonographic images during PNB anesthetic procedures should be recognized as being indicative of underlying neurologic disorders. This case highlights that increased awareness of the diagnosis of underlying neurologic disorders by ultrasonography would assist the general practice of PNB in anesthetic medicine. This is especially important as underlying neurological conditions can have important consequences for patient-appropriate anesthesia and may inform best anesthetic practice. A new category, "neurological disorder on ultrasound image", should be introduced to PNB knowledge in anesthetic field.

Anaphylaxis caused by butylscopolamine bromide: a case report.

BACKGROUND: There have been only few reports on butylscopolamine-induced anaphylaxis despite its global usage as an anticholinergic agent for approximately 70 years. We present a case of anaphylaxis caused by butylscopolamine. CASE PRESENTATION: A 63-year-old woman underwent gastrointestinal endoscopic examination. She developed facial cyanosis and hypoxia after intravenous administration of butylscopolamine 10 mg, and her blood pressure was unmeasurable. Her hemodynamic condition recovered after a total of 0.6 mg adrenaline and bolus administration of 100 mg hydrocortisone. One hour after the onset of hypotension, both plasma histamine and serum tryptase were remarkably elevated to 271.7 nmol/L and 174 µg/L, respectively. Skin tests performed 47 days after anaphylaxis showed a positive result only for butylscopolamine among the exposed agents, which was confirmed by basophil activation tests using CD203c and CD63 as markers. CONCLUSION: Butylscopolamine has the potential to cause severe anaphylaxis; hence, identification of the causative agent is important to prevent recurrence of anaphylaxis.

Gastric Fluid Volume Change After Oral Rehydration Solution Intake in Morbidly Obese and Normal Controls: A Magnetic Resonance Imaging-Based Analysis.

BACKGROUND: Although preoperative fluid intake 2 hours before anesthesia is generally considered safe, there are concerns about delayed gastric emptying in obese subjects. In this study, the gastric fluid volume (GFV) change in morbidly obese subjects was investigated after ingesting an oral rehydration solution (ORS) and then compared with that in nonobese subjects. METHODS: GFV change over time after the ingestion of 500 mL of ORS containing 2.5% carbohydrate (OS-1) was measured in 10 morbidly obese subjects (body mass index [BMI], >35) scheduled for bariatric surgery and 10 nonobese (BMI, 19-24) using magnetic resonance imaging. After 9 hours of fasting, magnetic resonance imaging scans were performed at preingestion, 0 min (just after ingestion), and every 30 minutes up to 120 minutes. GFV values were compared between morbidly obese and control groups and also between preingestion and postingestion time points. RESULTS: The morbidly obese group had a significantly higher body weight and BMI than the control group (mean body weight and BMI in morbidly obese, 129.6 kg and 46.3 kg/m, respectively; control, 59.5 kg and 21.6 kg/m, respectively). GFV was significantly higher in the morbidly obese subjects compared with the control group at preingestion (73 ± 30.8 mL vs 31 ± 19.9 mL, P = .001) and at 0 minutes after ingestion (561 ± 30.8 mL vs 486 ± 42.8 mL; P < .001). GFV declined rapidly in both groups and reached fasting baseline levels by 120 minutes (morbidly obese, 50 ± 29.5 mL; control, 30 ± 11.6 mL). A significant correlation was observed between preingestion residual GFV and body weight (r = .66; P = .001). CONCLUSIONS: Morbidly obese subjects have a higher residual gastric volume after 9 hours of fasting compared with subjects with a normal BMI. However, no differences were observed in gastric emptying after ORS ingestion in the 2 populations, and GFVs reached baseline within 2 hours after ORS ingestion. Further studies are required to confirm whether the preoperative fasting and fluid management that are recommended for nonobese patients could also be applied to morbidly obese patients.

Transcutaneous near-infrared spectroscopy for monitoring spinal cord ischemia: an experimental study in swine.

We aimed to assess the ability of near-infrared spectroscopy (NIRS) to detect spinal cord ischemia, and to evaluate changes in regional oxygen saturation (rSO2) following recovery of spinal cord circulation and cerebrospinal fluid drainage. Four 12-month-old female swine weighing 28.7-29.5 kg were acquired for this study. NIRS probes were placed along the midline of the upper (T6/7) and lower (T9/T10) thoracic vertebrae. The thoracic aorta was clamped distal of the left subclavian artery to induce spinal ischemia. Aortic cross-clamping was maintained for 30 min. Fifteen minutes after aortic de-clamping, the cerebrospinal fluid drainage catheter was opened to air, and cerebrospinal fluid drainage was initiated. Following aortic clamping, rSO2 in both upper and lower regions of the spinal cord decreased by 15 % within 5 min and by 20 % within 10 min (relative change). After aortic de-clamping, rSO2 values in both regions returned to baseline within 5 min. No changes in rSO2 in either the upper or lower vertebrae were observed following initiation of cerebrospinal fluid drainage. Histological analysis revealed that ischemic changes had occurred in all spinal levels. NIRS may be used to detect decreases in and recovery of spinal cord circulation following aortic clamping and de-clamping, whereas it may not reflect minor changes in spinal cord circulation due to cerebrospinal fluid drainage. Further clinical studies are required to investigate the potential for NIRS as an index of spinal cord circulation.

Hypotension from spinal anesthesia in patients aged greater than 80 years is due to a decrease in systemic vascular resistance.

STUDY OBJECTIVES: To determine the exact mechanism underlying spinal anesthesia-induced hypotension in the elderly patient. DESIGN: Retrospective case-control study. SETTING: Operating room (OR) in a general hospital. MEASUREMENTS: Records from 60 consecutive patients over 80 years of age, who underwent hip fracture repair (intramedullary nail or compression hip screw) during spinal anesthesia were studied. After injection of isobaric 0.5% bupivacaine in the L(3)-L(4) intervertebral space in the lateral decubitus position, patients were turned supine. Acetate Ringer's solution (300 mL) was infused over 30 minutes after subarachnoid puncture. A decrease in systolic arterial pressure to less than 100 mmHg was treated with an intravenous injection of 5 mg ephedrine. The hypotension group (n=18) comprised patients who required ephedrine during the 30 minutes after the puncture, and the nonhypotension group (n=42) consisted of patients who maintained stable arterial pressure with crystalloid infusion only. MEASUREMENTS: Cardiac output (CO) and stroke volume variation (SVV) every 20 seconds using the Vigileo-FloTrac system continuously from arrival in the operating room (OR) to 30 minutes after the subarachnoid puncture were recorded. Serial changes in systemic vascular resistance (SVR), CO, and SVV from baseline after puncture were compared between the two groups. MAIN RESULTS: The decrease in SVR over 20 minutes after the puncture was significantly greater in the hypotension group than the nonhypotension group (P = 0.047). Cardiac output was stable in the two groups. Stroke volume variation in the first 10 minutes after the puncture increased to similar levels in the two groups, then decreased gradually to baseline. No significant differences were noted in circulatory parameters on arrival at the OR. CONCLUSIONS: A decrease in SVR, not CO, is the main mechanism of hypotension seen during spinal anesthesia in elderly patients.

An intraoperative small dose of ketamine prevents remifentanil-induced postanesthetic shivering.

Patients undergoing gynecological laparotomy were randomized to receive either 0.5 mg/kg ketamine at induction of anesthesia followed by an infusion of 0.3 mg/kg/h until the end of surgery (ketamine group, n = 32), or an equivalent volume of normal saline (control group, n = 32). Anesthesia was maintained with IV propofol, a fixed infusion rate of remifentanil (0.25 µg/kg/min), and epidural ropivacaine. Postanesthetic shivering (PAS) was evaluated for 30 minutes after emergence. Intraoperative temperatures were similar between the 2 groups. The incidence of PAS was less frequent in the ketamine group (n = 2, 6%) compared with the control group (n = 12, 38%, P = 0.005). We conclude that, during the early recovery phase, intraoperative ketamine reduces remifentanil-induced PAS.

[Ebstein's anomaly in an adult patient detected by sinus tachycardia by preoperative anesthetic interview].

A 54-year-old man, scheduled for a clavicle fracture repair, appeared asymptomatic with 120 beats x min(-1) tachycardia and ECG abnormalities in preoperative anesthetic interview. He was not suffering from pain derived from clavicle fracture despite tachycardia. He was consulted with a cardiac physician. Downward displacement of tricuspid valve was detected by echocardiography and he was diagnosed Ebstein's anomaly. Right-left shunt did not exist, tricuspid regurgitation was grade I, and LV function was within normal ranges. Hence our anesthetic goal was to avoid arrhythmia, anesthesia was induced and maintained with propofol and remifentanil, and arterial pressure-based cardiac output monitor (FloTrac, Edwards Lifesciences, Irvine, CA, USA) was applied to measure cardiac output. Consequently, heart rate was controlled adequately, and intraoperative anesthetic course was uneventful. The number of adult patients with congenital heart disease has increased because techniques of echocardiography and surgical procedure have been improved. Anesthesiologists should be more aware of congenital heart disease in adults.

[Pitfall in intraoperative electrolyte management for a patient with pseudohyperkalemia caused by thrombocytosis].

An 81-year-old woman was scheduled for gastrectomy due to advanced gastric cancer. Preoperative serum potassium concentration was 6.5 mEq x l(-1), and the operation was postponed. Renal function was normal and hematopathy was denied after bone marrow biopsy. But thrombocyte was 130.5 x 10(4) x mm(-3). Plasma potassium concentration was within normal ranges, and she was diagnosed as pseudohyperkalemia caused by thrombocytosis. Difference between serum and plasma potassium concentrations was more than 1 mEq x l(-1) throughout the surgery. We should take a blood plasma sample in patients with hyperkalemia combined with thrombosis, when renal function was within normal ranges and hemolysis was denied.

Bispectral index during epidural puncture predicts anterograde amnesia in patients given midazolam premedication.

PURPOSE: We hypothesized anterograde amnesia could be predicted by the bispectral index (BIS) during epidural puncture in patients premedicated with intramuscular midazolam. METHODS: We investigated 64 consecutive patients undergoing gynecological laparotomy under general anesthesia combined with epidural anesthesia. Midazolam (5 mg) was administered intramuscularly at 15 min before arrival at the operating room. The anesthesiologist informed the patient of the operating room number after evaluating her using the Observer's Assessment of Alertness and Sedation (OAA/S) scale. A BIS probe was then attached to the patient's forehead while she was in the lateral position for epidural puncture. Another anesthesiologist interviewed the patient on the day after surgery and asked her the operating room number and whether there was recall of pain. Group A comprised patients with no recall of the room number and no recall of pain during epidural puncture and group R comprised patients who remembered both the room number and the pain. Patients recalling only the room number or the pain were excluded. RESULTS: Forty patients were classified as group A and 20 as group R. Four patients remembered only the room number and they were excluded. There were significant differences in body weight, OAA/S scale on arrival at the operating room, and average BIS, and electromyogram (EMG) values during epidural puncture between the two groups. These four parameters were entered into a multiple logistic regression model for multivariate analysis. The analysis identified the BIS value as the only independent predictor of complete amnesia during epidural puncture. CONCLUSION: BIS assessment during epidural puncture is informative for the anesthesiologist to predict amnesia following midazolam premedication.

[Hypertension with tachycardia caused by propofol during induction of general anesthesia].

A 75-year-old man underwent elective posterior lumbar interbody fusion due to canal stenosis. Anesthesia was induced with fentanyl 100 microg, propofol 65 mg (0.95 mg x kg(-1)) and vecronium 7 mg. Bag and mask ventilation was easy and end-tidal sevoflurane reached 3% but arterial blood pressure (ABP) and heart rate (HR) increased to 180-200/90-110 mmHg and 90-110 beats x min(-1) respectively. Additional fentanyl 100 microg and propofol 70 mg were not effective. N2O was started and fentanyl 50 microg and landiolol 5 mg were administerd. Twenty-five minutes after initiation of anesthesia, ABP and HR decreased to 123/76 mmHg and 83 beats x min(-1), respectively. When right ureteral dilatation was undertaken due to obstruction on POD 7, thiamylal 300 mg for anesthetic induction did not increase ABP and HR. Hypertension with tachycardia during induction of general anesthesia can be usually caused by pain, hypoventilation, intracranial hemorrhage and myocardial ischemia etc but all of them were denied in this clinical course. Previous reports had shown that a small amount of propofol itself induced vasoconstriction and we concluded that a low dose of propofol to avoid hypotension during induction could cause hypertension with tachycardia.

[Efficacy and safety of AirWay Scope in using a bronchofiberscope in patients with difficult airway].

Case 1: A 41-year-old woman was scheduled for pinning of fractured finger and repair of a ligamentum. Preoperative problems did not exist except mandibular hypoplasia. General anesthesia was induced and Cormack classification was grade III in laryngeal view by laryngoscope and we tried a new videolaryngoscope PENTAX-AirWay Scope (AWS). We did not catch the epiglottis directly by Intlock and the target mark was not located at the middle of the vocal cord. Bronchofiberscope was guided to the vocal cord through a tracheal tube attached to AWS by another anesthesiologist and the patient was successfully intubated. Case 2: A 46-year-old man was scheduled for anterior screw-plate fixation due to C3/4 herniated disc. AWS using bronchofiberscope procedure was tried to keep the neutral position of the neck. The patient was successfully intubated. We did not view the bronchofiberscope and used it just as a flexible bougie. Case 3: A 56-year-old man was scheduled for free radial forearm flap reconstruction of a diabetic necrotic toe. Ten minutes were needed to finish intubation due to difficult airway (Cormack classification grade III) when free latissimus dorsi flap reconstruction was perfomed two month before. Hence, AWS using a bronchofiberscope procedure was tried first and 39 seconds were needed to intubate. We concluded that AWS using bronchofiberscope procedure was useful for patients with difficult airway, though two anesthesiologist, one keeping AWS and the other using a bronchofiberscope, were needed.