Massive hemothorax following internal jugular vein catheterization under ultrasound guidance: A case report.

BACKGROUND: Hemothorax is a rare but life-threatening complication of central venous catheterization. Recent reports suggest that ultrasound guidance may reduce complications however, it does not guarantee safety. CASE SUMMARY: A 75-year-old male patient was admitted for laparoscopic radical nephrectomy. Under ultrasound guidance, right internal jugular vein catheterization was successfully achieved after failure to aspirate blood from the catheter in the first attempt. Sudden hypotension developed after surgical positioning and persisted until the end of the operation, lasting for about 4 h. In the recovery room, a massive hemothorax was identified on chest radiography and computed tomography. The patient recovered following chest tube drainage of 1.6 L blood. CONCLUSION: Hemothorax must be suspected when unexplained hemodynamic instability develops after central venous catheterization despite ultrasound guidance. So the proper use of ultrasound is important.

Fatal rhabdomyolysis and disseminated intravascular coagulation after total knee arthroplasty under spinal anesthesia: A case report.

BACKGROUND: Rhabdomyolysis develops as a result of skeletal muscle cell collapse from leakage of the intracellular contents into circulation. In severe cases, it can be associated with acute kidney injury and disseminated intravascular coagulation, leading to life threatening outcomes. Rhabdomyolysis can occur in the perioperative period from various etiologies but is rarely induced by tourniquet use during orthopedic surgery. CASE SUMMARY: A 77-year-old male underwent right total knee arthroplasty using a tourniquet under spinal anesthesia. About 24 h after surgery, he was found in a drowsy mental state and manifested features of severe rhabdomyolysis, including fever, hypotension, oliguria, high creatine kinase, myoglobinuria, and disseminated intravascular coagulation. Despite supportive care, cardiac arrest developed abruptly, and the patient was not able to be resuscitated. CONCLUSION: Severe rhabdomyolysis and disseminated intravascular coagulation can develop from surgical tourniquet, requiring prompt, aggressive treatments to save the patient.

Endotracheal intubation by inexperienced trainees using the Clarus Video System: learning curve and orodental trauma perspectives.

BACKGROUND: The ideal alternative airway device should be intuitive to use, yielding proficiency after only a few trials. The Clarus Video System (CVS) is a novel optical stylet with a semi-rigid tip; however, the learning curve and associated orodental trauma are poorly understood. METHODS: Two novice practitioners with no CVS experience performed 30 intubations each. Each trial was divided into learning (first 10 intubations) and standard phases (remaining 20 intubations). Total time to achieve successful intubation, number of intubation attempts, ease of use, and orodental trauma were recorded. RESULTS: Intubation was successful in all patients. In 51 patients (85%), intubation was accomplished in the first attempt. Nine patients required two or three intubation attempts; six were with the first 10 patients. Learning and standard phases differed significantly in terms of success at first attempt, number of attempts, and intubation time (70% vs. 93%, 1.4 ± 0.7 vs. 1.1 ± 0.3, and 71.4 ± 92.3 s vs. 24.6 ± 21.9 s, respectively). The first five patients required longer intubation times than the subsequent five patients (106.8 ± 120.3 s vs. 36.0 ± 26.8 s); however, the number of attempts was similar. Sequential subgroups of five patients in the standard phase did not differ in the number of attempts or intubation time. Dental trauma, lip laceration, or mucosal bleeding were absent. CONCLUSIONS: Ten intubations are sufficient to learn CVS utilization properly without causing any orodental trauma. A relatively small number of experiences are required in the learning curve compared with other devices.

Hypotension in patients administered indigo carmine containing impurities -A case report-.

Indigo carmine has been used for eight decades with few adverse effects. Several of our patients, however, experienced severe hypotensive episodes after indigo carmine administration within a period of one month. Analysis of the raw materials used to formulate the preparation of indigo carmine we used showed that they contained impurities. Following recall of these impure materials, none of our patients experienced further hypotensive episodes.

Evaluating a thrombosed azygous vein aneurysm combined with pulmonary arterial thromboembolism by ECG-gated multidetector CT: a case report.

Azygous vein aneurysm is a rare congenital lesion that needs to be differentiated from mediastinal mass lesions. Although almost of these anomalies are asymptomatic lesions, we experienced an interesting case in which a thrombus within an azygous vein aneurysm in a 75-year-old woman caused pulmonary thromboembolism. The patient was managed by medical treatment for one month and then the thrombus within both the azygous vein aneurysm and the pulmonary arteries completely resolved.

Multiple coronary aneurysms, ectasia, and myocardial infarction evaluated by multidetector row CT in a young adult.

Although coronary aneurysms and ectasia are well-recognized, they are uncommon sequelae and may evolve into myocardial infarction. When such a case is suspected, conventional coronary angiography and echocardiography are the most commonly used imaging modalities. Here we report a case of non-specific vasculitis in a 31-year-old woman presenting with multiple coronary aneurysms, ectasia, and myocardial infarction identified by multidetector row computed tomography.

The effects of sevoflurane with propofol and remifentanil on tracheal intubation conditions without neuromuscular blocking agents.

BACKGROUND: Propofol and remifentanil are used for tracheal intubation in the absence of neuromuscular blocking agents. We hypothesized that the addition of sevoflurane to propofol and remifentanil would improve intubation conditions and provide hemodynamic stability. METHODS: Seventy-six patients scheduled for elective surgery were randomly allocated to be ventilated with either 4% (group I) or 7% sevoflurane (group II) after propofol injection (2 mg/kg). All patients received remifentanil (1 microg/kg) 30 seconds after administration of propofol. Ninety seconds after remifentanil was given, laryngoscopy and tracheal intubation were performed. Intubation conditions and hemodynamic changes were evaluated. RESULTS: The overall incidence of clinically acceptable intubation conditions was significantly higher in group II (92%) than group I (58%) (P = 0.001). Scores for vocal cord position, coughing, and limb movement were significantly better in group II (P < 0.05). Mean blood pressure remained significantly lower than the pre-induction level throughout the investigation in both groups (P < 0.001), but there was no incidence of bradycardia or hypotension requiring treatment. CONCLUSIONS: Tracheal intubation without neuromuscular blocking agents can be achieved safely and reliably by adding 7% sevoflurane to propofol (2 mg/kg) and remifentanil (1 microg/kg).

Lymphangiomatosis involving the inferior vena cava, heart, pulmonary artery and pelvic cavity.

A 38-year-old woman who had undergone pelvic lymphangioma resection two months previously presented with cough and dyspnea. Transthoracic echocardiography and CT demonstrated the presence of a mixed cystic/solid component tumor involving the inferior vena cava, heart and pulmonary artery. Complete resection of the cardiac tumor was performed and lymphangioma was confirmed based on histopathologic examination. To the best of our knowledge, this is the first report of lymphangiomatosis with cardiac and pelvic involvement in the published clinical literature.

Stress-induced cardiomyopathy following cephalosporin-induced anaphylactic shock during general anesthesia.

PURPOSE: Anaphylaxis may be caused by various agents during general anesthesia. Sympathetic discharge may occur during anaphylaxis, which can trigger transient cardiomyopathy. We describe a case of stress-induced cardiomyopathy that occurred in association with an anaphylactic reaction during general anesthesia. CLINICAL FEATURES: A 32-year-old female undergoing laparoscopic enucleation of an ovarian cyst developed a severe anaphylactic reaction after cephalosporin infusion during general anesthesia. Her vital signs responded favourably to immediate resuscitative maneuvers, but cardiovascular collapse reappeared with transient ventricular tachycardia shortly after her transfer to the intensive care unit. ST-segment elevation appeared in electrocardiographic leads V(2)-V(6) and echocardiography showed diffuse regional wall motion abnormalities in the midventricular level. Increased MB fractions of creatine kinase and troponin T levels indicated myocardial necrosis, but cardiac catheterization demonstrated normal coronary arteries. Management was supportive and she was discharged 2 days after the onset of anaphylactic symptoms, without sequelae. A diagnosis of stress-induced cardiomyopathy of a midventricular type following anaphylaxis was made on the basis of the clinical features and the findings of cardiac evaluations. CONCLUSIONS: Transient, reversible left-ventricular dysfunction is a recently recognized phenomenon that may occur in the setting of anaphylactic reactions during the perioperative period.

Comparison of two approaches to internal jugular vein cannulation in young children: ultrasonographic evaluation.

BACKGROUND: Percutaneous cannulation of internal jugular vein is difficult in pediatric patients because of its small size and anatomic variation. The aim of this study is to investigate cross-sectional area and relative anatomy of right internal jugular vein with respect to the carotid artery in two approaches and thereby to find ideal cannulation site in young children. METHODS: The cross-sectional area of right internal jugular vein and the degree of the carotid artery overlap was evaluated in 47 children using ultrasound at two levels; 1) at the cricoid cartilage (high approach) and 2) at the junction of the two heads of the sternocleidomastoid muscle (low approach). RESULTS: The cross-sectional area was significantly larger by about 28.8% in the low approach than that of the high approach (P < 0.01). The internal jugular vein was partially overlapping the carotid artery in 48.9% and completely overlapping in 42.6% in the low approach and in 44.7% and 34.0% in the high approach respectively. The carotid artery overlap was significantly higher in the low approach when compared with the high approach (P < 0.02). CONCLUSIONS: In terms of cross-sectional area, the low approach with larger size is optimal for internal jugular vein cannulation. Although the degree of the carotid artery overlap was higher at the low approach, the internal jugular vein was partially or completely covering the carotid artery in most patients in both approaches. When attempting to cannulate the internal jugular vein, clinicians should be aware of the large anatomic variations.