Paradoxical vocal fold motion masquerading as post-anesthetic respiratory distress: A case report.

BACKGROUND: Functional vocal cord disorders can be a differential diagnosis for postoperative upper airway obstruction requiring urgent intervention. However, this may be unfamiliar to anesthesiologists who would favor inappropriate airway intervention and increased morbidity. CASE SUMMARY: A 61-year-old woman underwent cervical laminectomy, followed by laparoscopic cholecystectomy 10 mo later. Despite adequate reversal of neuromuscular blockade, the patient experienced repetitive respiratory difficulty with inspiratory stridor after extubation. After the second operation, the patient was diagnosed with paradoxical vocal fold motion (PVFM) by an otolaryngologist based on the clinical features and fiberoptic bronchoscopy results, and the patient was successfully treated. CONCLUSION: PVFM should be considered a differential diagnosis if a patient presents with stridor after general anesthesia.

Prophylactic antibiotics induce early postcraniotomy seizures in neurosurgery patients: A case series.

RATIONALE: Antibiotics can cause central nervous system disturbances, manifesting as dizziness, confusion, headache, and seizures. Seizures due to antibiotic administration are related to increased excitatory neurotransmission because antibiotics act as competitive antagonists of the γ-aminobutyric acid type A receptor. PATIENT CONCERNS AND CLINICAL FINDINGS: All 5 patients, comprising 4 females and one male and aged 45 to 72 years, underwent open craniotomy with additional surgical maneuvers according to their specific disease. All patients presented American Society of Anesthesiologists Physical Status grades 1 to 2. There were no specific underlying diseases, except hepatitis C and hypertension. However, seizures developed sequentially in the 5 patients after neurosurgery. DIAGNOSES, INTERVENTIONS, AND OUTCOMES: Early postcraniotomy seizures (PCS) developed in the patients after neurosurgery. Prophylactic antibiotics were administered in all cases to prevent infection due to open craniotomy. This included the administration of 10 g and 2 g of an antibiotic (cefotiam HCL; Jetiam Intravenous Injection 1g®) an hour before the surgery in the ward and half an hour before the surgery in the operating room, respectively. After surgery, cefotiam HCL 2 g was administered in all patients on the day of surgery. Five patients had myoclonic seizure or generalized tonic-clonic seizure several times at emergence or in the intensive care unit. LESSONS: Early PCS occurred in every patient when an overdose of the prophylactic antibiotic was administered. This report showed that the preoperative prophylactic antibiotic cefotiam administered in double doses evoked early PCS within a few hours of drug administration. Furthermore, such experiences caution that preoperative intravenous cephalosporins, including cefotiam, should be administered carefully in open craniotomy.

General anesthesia for patient with Fahr's syndrome: A case report.

RATIONALE: Fahr's syndrome (FS) is a rare neurological and psychiatric disorder characterized by bilateral brain calcifications when a secondary cause of the calcification is found. PATIENT CONCERNS: A 53-year-old female patient diagnosed with FS for laminectomy because of ossification of posterior longitudinal ligament. She had a history of generalized tonic-clonic (GTC) seizure and medication with anticonvulsant drugs. She had gait disturbance, spasticity, bradykinesia, and diffuse calcifications in the basal ganglia, thalamus, cerebellum, and cerebral hemispheres on the brain computed tomography. On the preoperative examination, the serum and ionized calcium (Ca) were decreased to 3.7 and 2.22 mg/dL. Hypomagnesemia is combined with hypocalcemia. Furthermore, the level of parathyroid hormone was decreased to 2.18 pg/mL. DIAGNOSES: Due to the radiologic findings and laboratory test results, she was diagnosed with FS with primary hypoparathyroidism. INTERVENTIONS: The Ca and magnesium (Mg) had been corrected before surgery but the electrolytes revealed low level at the intraoperative period. The 300 mg of calcium chloride was administered at 2 times and 1200 mg of it were infused for 1 hour during intraoperative periods. In addition, total 4 g of Mg sulfate intravenously administered. We used rocuronium as a neuromuscular block and checked neuromuscular function by train-of-four monitoring. OUTCOMES: Residual neuromuscular blockade was reversed with pyridostigmine and her muscle power completely recovered. The patient was extubated successfully and no unpredictable events occurred. On the day following transfer, serum electrolytes remained low, and although Ca was continuously supplied, serum Ca did not recover to a normal level. The patient was medicated with anticonvulsant drugs but experienced GTC seizure 2 weeks after surgery. LESSONS: We presume that the pathophysiology of FS was related to primary hypoparathyroidism and hypomagnesemia. FS raises concerns associated with neuromuscular problems, spasticity, and seizure, and concerns of hypotension, heart failure, cardiac arrhythmia, and cerebrovascular attack during perioperative periods, among anesthesiologists because of hypocalcemia and vessel calcification. During the perioperative period, Ca levels should be closely monitored, and titrated Ca replacement therapy is recommended. The simultaneous correction of hypomagnesemia is of considerable importance when correcting hypocalcemia.

Inhibition of Oxidative Stress in Renal Ischemia-Reperfusion Injury.

BACKGROUND: Superoxide, nitric oxide (NO), and peroxynitrite are important mediators in the pathogenesis of ischemia-reperfusion (I/R) injury. We tested the renoprotective effects of allopurinol (ALP), a xanthine oxidase inhibitor, N-nitro-L-arginine methyl ester (L-NAME), and 5,10,15,20-tetrakis (N-methyl-4-pyridyl) porphyrinato iron (III) (FeTMPyP) by selective inhibition of superoxide, NO, and peroxynitrite, respectively. METHODS: Male Sprague-Dawley rats were randomly assigned to 5 groups (n = 6 per group). Group 1 was a sham-operated group. Group 2 was the renal I/R group (30-minute ischemia followed by 24-hour reperfusion). Rats in groups 3, 4, and 5 received ALP, L-NAME, or FeTMPyP, respectively, at 5 minutes before the reperfusion. Serum creatinine (Cr), blood urea nitrogen (BUN), renal tissue malondialdehyde, superoxide dismutase, histological changes, apoptosis, and monocyte infiltration were evaluated. In addition, the combined treatment with ALP and L-NAME was compared with FeTMPyP in a second independent experiment. RESULTS: The administration of ALP, L-NAME, and FeTMPyP diminished the increase in Cr (P = .0066 for all) and BUN (P = .0066 for ALP; and P = .013 for L-NAME) induced by I/R injury and decreased the histological damage (P = .0066 for all). In addition, ALP, L-NAME, and FeTMPyP attenuated the oxidative stress response as determined by a decrease in malondialdehyde level (P = .0066 for all), apoptotic renal tubular cells (P = .0066 for all), and monocyte infiltration (P = .0066 for all). The combined treatment of ALP and L-NAME decreased Cr and BUN levels to a greater degree than FeTMPyP (P = .016 for Cr; P = .0079 for BUN). CONCLUSIONS: Superoxide, NO, and peroxynitrite are involved in renal I/R injury. The reduction of peroxynitrite formation, via inhibition of superoxide or NO, or the induction of peroxynitrite decomposition may be beneficial in renal I/R injury.

Optimal effect-site concentration of remifentanil for inhibiting response to laryngeal mask airway removal during emergence.

PURPOSE: This randomized, controlled, double-blind study was designed to determine the optimal dose of remifentanil for preventing complications associated with the removal of a laryngeal mask airway (LMA) without delaying emergence. MATERIALS AND METHODS: This study randomly assigned 128 patients to remifentanil effect-site concentrations (Ce) of 0 ng/mL (group R0), 0.5 ng/mL (group R0.5), 1.0 ng/mL (group R1.0), and 1.5 ng/mL (group R1.5) during emergence. The emergence and recovery profiles were recorded. Adverse events such as coughing, airway obstruction, breath-holding, agitation, desaturation, nausea, and vomiting were also evaluated. RESULTS: The number of patients with respiratory complications such as coughing and breath-holding was significantly lower in the R1.0 and R1.5 groups than in the R0 group (p<0.05). Emergence agitation also decreased in the R1.0 and R1.5 groups (p<0.0083). The time to LMA removal was significantly longer in the R1.5 group than in the other groups (p<0.05). CONCLUSION: Maintaining a remifentanil Ce of 1.0 ng/mL during emergence may suppress adverse events such as coughing, breath-holding, and agitation following the removal of LMA without delayed awakening.

Conversion of supraventricular arrhythmia to normal rhythm by propofol and remifentanil: three cases report.

We experienced conversion of supraventricular arrhythmia to normal sinus rhythm in three patients during general anesthesia using propofol and remifentanil. This may be related to direct inhibition of the cardiac conduction system or activation of the parasympathetic system. The literature review suggests that propofol and remifentanil have antiarrhythmic potential, reverting supraventricular arrhythmia during anesthesia.

The comparison of feasibility and safety on fiberoptic guided intubation under conscious sedation with remifentanil and propofol.

BACKGROUND: Oropharyngeal manipulation is problematic when patients have a gag reflex. Sedation can suppress gag reflex, but can cause serious airway problems. We compared remifentanil (Group R) and propofol (Group P) in terms of cooperation and loss of gag reflex, while drugs were administered incrementally using target controlled infusion (TCI). METHODS: Fifty seven patients who required awake fiberoptic intubation were randomized to Group R or Group P. After measurement of baseline gag trigger point index (GTPI), TCI was set to effect-site concentration (Ce) of 1 ng/ml (Group R) or 1 µg/ml (Group P), then titrated by 0.5 increment until GTPI score reached 0. The incidence of drop-out and decreased cooperation, Ramsay sedation scale (RSS) and Ce at loss of GR, and complications were assessed. RESULTS: Seven patients were dropped out in Group P due to deep sedation and disobedient behavior, but none in Group R (P = 0.015). Gag reflex suppressed as RSS increased in both groups (P < 0.001), however, the incidence of elimination of gag reflex clustered at RSS 2 in Group R (P < 0.001), whereas it was evenly distributed in Group P (P = 0.20). The incidence of patients who were spontaneously roused (gag reflex elimination at RSS 1 and 2) were higher in Group R than in Group P (P = 0.002). CONCLUSIONS: Deep sedation and impaired cooperation were observed only in Group P and spontaneously roused patients were higher in Group R, suggesting that remifentanil is more suitable for cooperative elimination of GR.

Jaw-thrust induces sympathetic responses during induction of general anesthesia.

BACKGROUND: Jaw-thrust is a noxious stimulus that might induce sympathetic responses. The purpose of this study, was to evaluate the effects of jaw-thrust on sympathetic responses. METHODS: We investigated seventy three patients. Patients who received general anesthesia were randomly divided into a control group (maintenance of combined airway maneuver with head tilt, open mouth by mouthpiece, and chin-lift, n = 30) and jaw-thrust group (maintenance of head tilt, open mouth and jaw-thrust, n = 30). In the jaw-thrust group, four minutes of endoscopy-guided force to the mandible to get the best laryngeal view were applied. For the control group, the combined airway maneuver was maintained during the same period. Arterial blood pressure (AP) and heart rate (HR) were recorded at predetermined time points (1 min before anesthesia induction, 2 min after fiberoptic bronchoscopy placement, and thereafter 1 min-interval during each airway maneuver) during jaw-thrust and chin-lift maneuver. The force amplitude applied for best laryngeal view during jaw-thrust was also measured. RESULTS: Peak systolic and diastolic AP increased 39.0 ± 17.6 and 39.9 ± 22.8 mmHg from the baseline (P < 0.001) in the jaw-thrust group. HR was also 32.5 ± 19.4 beats/min from the baseline (P < 0.001) in the jaw-thrust group. These remained high at all time points, compared with the control group (P < 0.01). The force magnitude applied for jaw-thrust was not correlated to the AP and HR changes (P > 0.05). CONCLUSIONS: Performing the jaw-thrust maneuver induces significant sympathetic responses, irrespective of the force magnitude.

Risk factors of morbidity and mortality following hip fracture surgery.

BACKGROUND: The preoperative coexisting chronic systemic illness, delay in surgery, gender, and age were considered as risk factors for the complications after hip fracture surgery. The wider range of surgical delay and immobility-related pulmonary morbidity may affect postoperative complications and mortality. This study examined the risk factors for morbidity and mortality following the hip fracture surgery. METHODS: The patient data was collected retrospectively. The consecutive 506 patients with hip fracture surgery, aged 60 years or older, were included. The patients' age, gender, preexisting diseases, American Society of Anesthesiologists (ASA) classification, delay in surgical repair, duration of surgical procedure, and methods of anesthesia were noted. The thirty-day postoperative complications were reviewed, and cardiac complications, pulmonary complications, delirium, and death were recorded. The data was analyzed for postoperative complications and risk factors. RESULTS: Atelectasis was associated with postoperative pulmonary complications. Male gender and age ≥ 80 years were associated with an increased incidence of postoperative delirium. ASA classification 3 was associated with death. A delay in surgery was not associated with any complications. Preexisting diseases and methods of anesthesia did not affect mortality and postoperative complications. CONCLUSIONS: The results suggest that a delay in surgery did not affect the postoperative complications and morbidity.

An acute postoperative intractable hyperventilation after an endoscopic third ventriculostomy.

This report describes a rare case of postoperative hyperventilation attack after an endoscopic third ventriculostomy in a 46-year-old woman. About 60 min after the termination of the operation, an intractable hyperventilation started with respiratory rate of 65 breaths/min and EtCO(2), 16.3 mm Hg. Sedation with benzodiazepine, thiopental sodium, fentanyl, and propofol/remifentanil infusion was tried under a rebreathing mask at a 4 L/min of oxygen. With aggressive sedative challenges, ventilation pattern was gradually returned to normal during the 22 hrs of time after the surgery. A central neurogenic hyperventilation was suspected due to the stimulating central respiratory center by cold acidic irrigation solution during the neuroendoscopic procedure.

Extensive demyelinating change in cerebrum after a total knee replacement -A case report-.

Demyelination is characterized by the loss of myelin with the preservation of axons. Demyelinating diseases can be classified into several categories: demyelination due to inflammation, viral infection, osmotic derangements and hypoxic ischemia. In particular, osmotic myelinolysis is representative, and is associated with hyperosmolality, hypokalemia or rapid correction of hyponatremia. Osmotic myelinolysis was reported to be associated with underlying conditions, such as alcoholism, diuretics and malnutrition. A 67-year-old woman with hypertension was scheduled to undergo both total knee replacements (TKR). She was observed to be lethargic with dysphagia and quadriplegia after the second TKR. She had been taking diuretics for a long time, and did not have an adequate amount of food intake due to patient controlled analgesia and a gastric ulcer after the first TKR. A laboratory examination revealed hypokalemia but normonatremia. T2 weighted-MRI revealed abnormal high signal intensity in the basal ganglia and periventricular area. This case was diagnosed with osmotic myelinolysis associated with hypokalemia without an apparent sodium imbalance.

Comparison of the incidences and risk factors for pulmonary complications after primary and revision total hip arthroplasty.

BACKGROUND: Risk factors for postoperative pulmonary complication (PPC) after total hip arthroplasty (THA) are poorly studied. In addition, the risk factors associated with revision THA may differ from those associated with primary THA. The purpose of this study was to compare the incidences of PPC after revision THA with those observed after primary THA, and to evaluate the risk factors. METHODS: We reviewed data describing patients who underwent primary (n = 410) and revision THA (n = 90) during a 10 year study period. The data included age, gender, body mass index, concurrent cardiopulmonary comorbidity, anesthetic techniques, operative time, the number of perioperative transfusions, the amount of fluid replaced, and the American Society of Anesthesiologists physical status. PPCs were grouped together as a single outcome and the incidence and the risk factors for PPC were analyzed. RESULTS: The incidence of PPC after revision THA was significantly higher than after primary THA (23.3% vs. 11.5%, P = 0.004). The significant risk factors in revision THA were the amount of fluid replaced > or = 3,000 ml (P = 0.014) and operative time > or = 180 min (P < 0.001), while there were no risk factors identified by primary THA during univariate analysis. Furthermore, the only significant risk factor identified by multiple logistic regression analysis was operative time (odds ratio = 8.2, P < 0.05). CONCLUSIONS: Patients undergoing revision THA are at higher risk of PPC than primary THA. The operative time is an important factor in the occurrence of PPC after revision THA.

The effect of pudendal block on voiding after hemorrhoidectomy.

PURPOSE: Urinary retention in common benign anal surgery is a burden to ambulatory surgery. A pudendal nerve block was used in hemorrhoid surgery to reduce voiding complications. METHODS: The effects of a pudendal nerve block in anal surgery were compared with those of spinal anesthesia. In this prospective study, 163 consecutive patients who underwent elective hemorrhoids surgery by a single surgeon were randomized to receive pudendal nerve block (pudendal group) with 0.5 percent bupivacaine (n = 81) with 1:20,000 epinephrine or spinal anesthesia (spinal group) with 0.5 percentbupivacaine (n = 82). RESULTS: There were no statistically significant differences in the patient demographics, total amount of fluid administered, time to the onset of anesthesia, or intraoperative pain. All patients had a successful block during surgery. However, puborectalis muscle relaxation was not complete in the pudendal group. The time from the injection of the anesthetics to the first sensation of pain was longer in the pudendal group (9.1 vs. 3.1 hours; P < 0.001). Urinary catheterization was required in only 6 patients in the pudendal group compared with 57 patients in the spinal group (P < 0.001). The degree of pain was significantly lower in the pudendal group (2.7 vs. 5.2, Visual Analog Scale; P < 0.001). The amount of analgesics injected was significantly lower in the pudendal group (16/81 vs. 45/82; P < 0.001). CONCLUSIONS: A pudendal nerve block with bupivacaine results in fewer postoperative voiding complications and less pain compared with the traditional spinal anesthesia in a hemorrhoidectomy.