Bromisoval-induced bromism with status epilepticus mimicking Wernicke's encephalopathy: report of two cases.

BACKGROUND: Bromine compounds are used in several drugs, including over-the-counter drugs. They sometimes cause intoxication known as bromism. Although the acute neurological symptoms and sequelae of bromism vary, few reports have mentioned acute encephalopathy. CASE PRESENTATION: We report two cases of bromisoval-induced bromism with status epilepticus. Presence of pseudohyperchloremia and history of over-the-counter medication use guided the diagnosis. In the acute phase, our patients showed bilateral medial thalamic lesions on magnetic resonance imaging. The imaging findings were similar to those of Wernicke's encephalopathy. Although these findings improved in the chronic phase, neuropsychiatric sequelae, such as confabulation and amnesia, occurred. CONCLUSION: Bromism can cause acute encephalopathy, and it is important to differentiate it from Wernicke-Korsakoff syndrome.

[Delayed emergence from general anesthesia in a dementia patient with Lewy bodies].

A 73-year-old man (164cm height 51 kg body weight) with a history of Parkinson's disease and dementia was scheduled for a cervical lymph node biopsy under general anesthesia. We induced anesthesia with thiamylal and fentanyl, and maintained with sevoflurane and remifentanil without any incident. The patient did not emerge from anesthesia after the surgery. He developed coma and did not respond to painful stimuli. However, his breathing was spontaneous with stable hemodynamics. Although naloxone was given, he was still comatose. His clinical neurological findings showed no organic abnormalities. Forty minutes after the surgery, he suddenly woke up and followed instructions. We learned that previously he had been diagnosed with dementia with Lewy bodies.

[Three cases of perioperative anaphylaxis identified by using skin-prick tests].

We encountered three cases of perioperative anaphylaxis identified by using skin-prick tests. [Case 1] A 43-year-old woman was scheduled to undergo elective laparoscopic subtotal gastrectomy under general anesthesia for gastric tumor. However, the procedure was cancelled because of anaphylaxis that was noted at the beginning of the surgery. We performed a skin-prick test and observed a positive reaction with ro- curonium. [Case 2] A 79-year-old man underwent laparoscopic colon resection under general anesthesia for colon cancer. Anaphylaxis was noted at the end of surgery. We performed a skin-prick test and observed a positive reaction with sugammadex. [Case 3] A 44-year-old woman underwent myomectomy under general anesthesia for a uterine fibroid. Anaphylaxis was noted approximately 10 minutes after the beginning of surgery. We performed a skin-prick test and noted a positive reaction with latex. It is difficult to identify the reason for anaphylaxis during surgery under general anesthesia because various agents may be responsible for the anaphylactic reaction. Anaphylaxis during surgery is a rare but life-threatening event and it is important to identify the causative agent for anaphylaxis.

[General anesthesia with propofol for a pediatric patient on a ketogenic diet].

There are several specific considerations regarding seizure control during the perioperative period in patients who are on a ketogenic diet (KD). A KD is high in fat and low in protein and carbohydrates and has a long history of use for treatment of intractable seizures in children. Maintaining therapeutic ketosis and modifying the acid-base balance are particularly important for preventing seizures in patients on a KD. We report a case in which a 3-year-old boy with seizure was on a KD and scheduled for the treatment of left undescended testis under propofol anesthesia and acetate Ringer administration. Induction and maintaining of anesthesia using propofol was safe and reasonable for a patient on a KD.

A new method to estimate regional pulmonary blood flow using transesophageal echocardiography.

BACKGROUND: We report a novel method to estimate regional blood flow in the atelectatic lung using transesophageal echocardiography in an experimental dog model. To verify the efficacy of the method, we investigated the ability of this experimental model to detect changes in regional pulmonary blood flow. METHODS: Fourteen anesthetized and ventilated mongrel dogs were randomized into an isoproterenol group (n = 7) or a dopamine group (n = 7). To produce an atelectatic lesion, 60 mL/kg of saline was infused into the left pleural space. The velocity time integral (VTI) derived from pulse Doppler was evaluated as an index of blood flow in the atelectatic lesion. To investigate the response of the method to changes in blood flow, the VTI and the shunt fraction (Qs/Qt) were measured during systemic administration of isoproterenol 0.05 microg x kg(-1) x min(-1) (as a pulmonary vasodilator) and dopamine 10 microg x kg(-1) x min(-1) (as a pulmonary vasoconstrictor). RESULTS: Both VTI and Qs/Qt were increased significantly by isoproterenol administration. There was a significant correlation between the percentage changes of VTI and Qs/Qt with isoproterenol administration (r2 = 0.50, P < 0.001). Both VTI and Qs/Qt were unchanged during administration of dopamine. CONCLUSIONS: Transesophageal echocardiography may be useful in detecting changes in regional pulmonary blood flow in an atelectatic lesion.

Comparison of initial distribution volume of glucose and intrathoracic blood volume during hemodynamically unstable States early after esophagectomy.

STUDY OBJECTIVE: We have reported that initial distribution volume of glucose (IDVG) measures the central extracellular fluid volume in the presence of fluid gain or loss without apparent modification of glucose metabolism. We hypothesized that IDVG has a close relationship with intrathoracic blood volume (ITBV). We examined whether IDVG can correlate with ITBV during hemodynamically unstable states early after esophagectomy. DESIGN: Prospective clinical study. SETTING: General ICU. PATIENTS OR PARTICIPANTS: Twelve consecutive hypotensive patients who required volume loading during the first 10 postoperative hours after admission to the ICU. INTERVENTIONS: Indexed ITBV (ITBVI) and cardiac index (CI) were measured by single transpulmonary thermodilution technique using 10 mL of cold saline solution. Indexed IDVG (IDVGI) was then determined by the administration of 5 g of glucose and calculated by applying a one-compartment model. Three sets of measurements were performed: immediately after admission to the ICU, during hypotension, and after subsequent volume loading. MEASUREMENTS AND RESULTS: When hypotension developed, stroke volume index (SVI), central venous pressure, and ITBVI were decreased but IDVGI and CI were not. All these variables were increased after volume loading. IDVGI was correlated only slightly with either ITBVI (r2 = 0.23) or SVI (r2 = 0.38) but moderately with CI (r2 = 0.61). CONCLUSIONS: Results does not support that IDVGI can be equivalently used as an alternative measure of ITBVI or SVI, but IDVG may be clinically relevant as a measure of the fluid volume affecting CI even during hemodynamically unstable states after esophagectomy.

Evaluation of density area in dorsal lung region during prone position using transesophageal echocardiography.

OBJECTIVE: To evaluate the changes of density area in the dorsal lung regions of acute respiratory distress syndrome patients during prone position using transesophageal echocardiography. DESIGN: Retrospective clinical study. SETTING: General intensive care unit in a university hospital. PATIENTS: Ten patients with acute respiratory distress syndrome who underwent prone position therapy. INTERVENTIONS: Density areas in the left dorsal lung region were observed using transesophageal echocardiography before and after patients were in the prone position for 2 hrs. In five patients, a pediatric transesophageal echocardiography probe was left in the esophagus and used for observation during the prone procedure. MEASUREMENTS AND MAIN RESULTS: Changes of density area and PaO2/FiO2 were observed. The density areas decreased after prone position compared with those of preprone position (preprone 11.4 +/- 5.1 cm2, after prone 5.6 +/- 3.5 cm2, mean +/- sd, p <.01, respectively). There was also a significant correlation between the percentage change of density area and PaO2/FiO2 (r =.47, p <.05) after prone position. During prone position, the density area decreased; however, there was no correlation between the percent changes of density area and PaO2/FiO2. CONCLUSION: It was possible to observe the change in density area during prone position using transesophageal echocardiography. The change of density area estimated with transesophageal echocardiography during prone position was useful to estimate the effectiveness of the procedure.