Severe neurologic manifestations in acute intermittent porphyria developed after spine surgery under general anesthesia: a case report.

Porphyrias are inherited metabolic disorders resulting from a specific enzyme defect in the heme biosynthetic pathway. Porphyrias are induced by various precipitants. Clinical features include abdominal pain, neurologic manifestations, autonomic neuropathy, and mental disturbance. Diagnosis may be delayed because of variable symptoms that mimic other diseases and because of the rarity of of porphyrias. Although most patients with known porphyria can complete anesthesia and surgery safely, undiagnosed porphyric patients are in danger of porphyric crisis due to inadvertent exposure to precipitating drugs and environment. We report a case of a patient who experienced delayed emergence with neurological disturbance after general anesthesia, ultimately diagnosed as acute intermittent porphyria.

Aspiration pneumonia caused by fentanyl-induced cough -a case report-.

Although fentanyl-induced cough is generally transient and benign, it can give rise to serious problems in patients to whom increasing intracranial, intraocular or intraabdominal pressures may create dangerous situations. This case demonstrates aspiration pneumonia as a complication, exhibiting severe cough induced by intravenous injection of fentanyl.

Comparison of ramosetron with combined ramosetron and midazolam for preventing postoperative nausea and vomiting in patients at high risk following laparoscopic gynaecological surgery.

OBJECTIVES: This randomized, double-blind study compared the antiemetic efficacy of ramosetron with that of ramosetron combined with midazolam, and investigated whether the timing of midazolam administration affected the incidence of postoperative nausea and vomiting (PONV). METHODS: Nonsmoking female patients undergoing laparoscopic gynaecological surgery were randomized to three groups: group R received intravenous (i.v.) normal saline at induction of anaesthesia and 30 min before the end of surgery; group RM1 received midazolam i.v. at induction of anaesthesia and normal saline i.v. 30 min before the end of surgery; group RM2 received normal saline i.v. at induction of anaesthesia and midazolam i.v. 30 min before the end of the surgery. All patients received 0.3 mg ramosetron i.v. at the end of surgery. Incidence of PONV and need for rescue antiemetics were assessed during the 48-h postoperative period. RESULTS: A total of 126 patients were included in the analyses. There was no significant difference in the incidence of severe nausea, emetic episodes or use of antiemetics among the three groups. The incidence of complete response (no PONV and no rescue antiemetics) was significantly higher in the RM1 (30/41; 73%) and RM2 (30/42; 71%) groups compared with group R (19/43; 44%). CONCLUSIONS: Midazolam given at induction of anaesthesia or at the end of the surgery, combined with ramosetron, was more effective than ramosetron alone in reducing the incidence of PONV.

Tapia's syndrome following cervical laminoplasty -A case report-.

Tapia's syndrome is the palsy of the 10th and 12th cranial nerves, resulting in ipsilateral paralysis of the vocal cord and tongue. It is a rare complication which is related to the anesthetic airway management and positioning of the patient's head during the surgery. We describe a patient with a postoperative unilateral Tapia's syndrome, after general anesthesia, with uncomplicated endotracheal intubation. The patient's symptoms improved gradually for three months.

The effects of single-dose intravenous dexmedetomidine on hyperbaric bupivacaine spinal anesthesia.

PURPOSE: Dexmedetomidine, a selective α2-adrenoceptor agonist, has analgesic and sedative effects. The purpose of this study was to investigate the effects of small, single-dose intravenous dexmedetomidine administration after hyperbaric bupivacaine spinal anesthesia. METHODS: Sixty adult patients classified as American Society of Anesthesiologists physical status 1 or 2 and scheduled for lower extremity surgery under spinal anesthesia were studied. Patients were randomly assigned to one of three groups and administered hyperbaric intrathecal bupivacaine 12 mg. 5 min after spinal anesthesia, patients in groups 1, 2, and 3 received normal saline 10 ml, dexmedetomidine 0.25 µg/kg, and dexmedetomidine 0.5 µg/kg, respectively, over 10-min intravenous administration. The onset time, maximum block level, two-dermatome sensory regression time, duration of motor and sensory anesthesia, and side effects were assessed. RESULTS: The two-dermatome sensory regression time was significantly increased in groups 2 and 3. The duration of motor and sensory anesthesia was significantly increased in group 3. Onset time, maximum block level, level of sedation, and incidence of hypotension and treatment-needed bradycardia were no different among the groups. CONCLUSION: Single-dose intravenous dexmedetomidine 0.25-0.5 µg/kg, administered 5 min after intrathecal injection of hyperbaric bupivacaine, improved the duration of spinal anesthesia without significant side effects. This method may be useful for increasing the duration of spinal anesthesia, even after intrathecal injection of local anesthetics.

The effect of full expiration on the position and size of the subclavian vein in spontaneously breathing adults.

BACKGROUND: If full expiration during subclavian venous cannulation increases the distance between the subclavian vein (SCV) and the pleura or increases the diameter of the vein, it might decrease the incidence of pneumothorax and/or increase the success rate of venous cannulation. In this study, we evaluated the effect of full expiration on the distance from the SCV to the pleura and on the crosssectional area (CSA) of the SCV in spontaneously breathing adults. METHODS: The distance from the inferior border of the right SCV and the pleura (SCVinf-Pleura distance), the distance from the center of the vein to the pleura (SCVcen-Pleura distance), and the CSA of the vein were measured using ultrasound at the end of inspiration and at the end of full expiration in 20 adults placed in the horizontal position. The subjects were then placed in 15° Trendelenburg tilt, and the distances and the CSA were measured again. RESULTS: The SCVcen-Pleura distances were changed minimally in the horizontal position (0.005 cm, 95% confidence interval [CI] -0.04 to 0.05) and in the Trendelenburg position (0.02 cm, 95% CI -0.005 to 0.05). The SCVinfPleura distances decreased at the end of full expiration in the horizontal position, but the change was only 0.07 cm (95% CI 0.03-0.11; P = 0.003). In the Trendelenburg position, those distances remained unchanged (0.02 cm, 95% CI -0.01 to 0.06). Compared with endinspiration, the SCV CSA after full expiration increased by at least 14% in both the horizontal position and the Trendelenburg position. CONCLUSIONS: The distance from the SCV to the pleura did not change after full expiration. However, this simple technique can still be considered during placement of subclavian catheters in spontaneously breathing patients, because it significantly enlarges the CSA of the SCV.

The effect of lung deflation on the position and size of the subclavian vein in mechanically ventilated infants and children.

BACKGROUND: If lung deflation increases the distance from the subclavian vein (SCV) to the pleura and the diameter of the vein, it might decrease the risk of pneumothorax and increase the success rate of subclavian venous cannulation. We evaluated the effect of lung deflation on the distance from the SCV to the pleura (SCV-pleura distance) and on the cross-sectional area (CSA) of the SCV in mechanically ventilated pediatric patients. METHODS: Fifty patients (25 infants younger than 1 year and 25 children aged 1 to 8 years) were placed supine over a shoulder roll, and their lungs were ventilated with a tidal volume of 6 to 7 mL/kg. Lung deflation was achieved by opening the endotracheal tube to the atmosphere. The SCV-pleura distances and the SCV CSAs were measured using ultrasound at the end of inflation and 0, 30, 60, 90, and 120 seconds after lung deflation. A P value <0.05 was considered statistically significant. Increases of 5% in the distance and 25% in the CSA were defined as clinically relevant. RESULTS: The available data from 43 patients, 22 infants and 21 children, were analyzed. No clinically relevant changes in the SCV-pleura distance or in the SCV CSA were induced by lung deflation. Neither the SCV-pleura distance nor the CSA showed any further increase with time. CONCLUSIONS: Lung deflation failed to increase the SCV-pleura distance and the CSA of the SCV. Its application is unlikely to be advantageous in avoiding pneumothorax or improving the success rate of subclavian venous cannulation.