Absence of Adverse Neurological Outcomes in a Non-Neurologically Injured Polytrauma Patient Despite Extreme and Prolonged Treatment-Resistant Hypotension: A Case Report.

Temporary hypotension after severe trauma might help achieve hemostasis and increase the chances of survival. However, excessive hypotension can lead to adverse neurological sequelae or be fatal. The relationship between the degree of hypotension and neurological prognosis after trauma is not fully understood. Our report describes a patient with severe trauma who survived with a favorable neurological outcome despite extreme and prolonged treatment-resistant hypotension.

Ultrasound-guided para-umbilical block: a pediatric case.

BACKGROUND: Rectus sheath block is a common peripheral nerve block for patients undergoing umbilical hernia repair surgery. However, rectus sheath block alone can affect only anterior branches of intercostal nerves and, therefore, is incomplete for postoperative analgesia for the anterior abdomen, which is innervated by both anterior and lateral branches. We describe a successful perioperative analgesia with ultrasound-guided para-umbilical block after pediatric umbilical hernia surgery. CASE PRESENTATION: A 4-year-old child underwent hernia repair surgery. Following induction of general anesthesia, the anatomy of the umbilical region was observed under ultrasound with a 5-10-MHz linear probe. An ultrasound-guided injection between the rectus abdominis muscle and the posterior lobe of the rectus sheath and an injection into the subcutaneous space around the umbilicus were performed. The peripheral nerve block was effective during surgery, and the patient required no additional rescue analgesia during the perioperative period. There were no complications. CONCLUSION: We performed ultrasound-guided para-umbilical block with four injections. This peripheral nerve block could be an efficient technique for complete perioperative analgesia.

Learning curve for paramedic endotracheal intubation and complications.

BACKGROUND: Pre-hospital laryngoscopic endotracheal intubation (ETI) is potentially a life-saving procedure but is a technique difficult to acquire. This study aimed to obtain a recommendation for the number of times ETI should be practiced by constructing the learning curve for endotracheal intubation by paramedics, as well as to report the change in the frequency of complications possibly associated with intubation over the training period. METHODS: Under training conditions, 32 paramedics performed a total of 1,045 ETIs in an operating room. Trainees performed ETIs until they succeeded in 30 cases. For each patient, the number of laryngoscopic maneuvers and any complications potentially associated with ETI were recorded. We built a generalized logistic model to construct the learning curve for ETI and the frequency of complications. RESULTS: During the training on the first 30 patients the rate of ETI success at the first attempt improved from 71% to 87%, but there was little improvement during the first 13 cases. The frequency of complications decreased from 53% to 31%. More laryngoscopic maneuvers and longer operation time increased complications. CONCLUSIONS: It seems that 30 live experiences of performing an ETI is sufficient for obtaining a 90% ETI success rate, but there seems to be little benefit with fewer than 13 experiences. The frequency of complications remained at a high level even after the training. It is desirable to conduct a more detailed and rigorous evaluation of the benefit of pre-hospital ETI by controlling for the skill level of paramedics.

[Intraoperative cardiac arrest due to coronary vasospasm after tourniquet release--a case report].

A 55-year-old man with no past history of ischemic heart disease underwent open reduction and internal fixation of the right arm because of an open fracture. Under general anesthesia with brachial plexus block, the operation was started after the upper arm had been pressurized at 280 mmHg by tourniquet. The patient had cardiac arrest 15 min after the tourniquet release, and was resuscitated by CPR. Postoperative intracoronary infusion of acetylcholine revealed that the coronary artery is sensitive to the agent, indicating that the intraoperative cardiac arrest might have been due to coronary vasospasm. Although the similar case is rare, attention should be taken during the anesthetic management with the use of tourniquet.

[A case of Guillain-Barré Syndrome complicated with Fat Embolism syndrome].

A 22-year-old man was admitted to our ICU for treatment of fat embolism syndrome complicated with multiple bone fractures. Acute respiratory distress syndrome developed, and the patient received steroid therapy. During the steroid therapy, symmetrical proximal muscle weakness of all four limbs without sensory abnormalities and autonomic nervous system dysfunction developed. Cerebrospinal fluid showed albuminocytologic dissociation. Blood examination showed herpes simplex virus and cytomegalovirus infection. The patient was diagnosed as having Guillain-Barré syndrome, but he recovered completely one month after admission. It is thought that the prolonged steroid therapy for acute respiratory distress syndrome in this case induced viral infection that might have caused Guillain-Barré syndrome.