JA Clinical Reports最新文献

Background: Plasma exchange (PE) removes high-molecular-weight substances and is sometimes used for antineutrophil cytoplasmic antibody-associated vasculitis (AAV) with alveolar hemorrhage. Hypotension during PE is rare, except in allergic cases. We report a case of shock likely caused by increased pulmonary vascular resistance (PVR) during PE.

Case presentation: A 66-year-old man with pulmonary hypertension (PH) and glomerulonephritis was admitted with dyspnea. He had discontinued sildenafil prior to admission. Alveolar hemorrhage associated with AAV was suspected, and PE was performed. Soon after, he developed circulatory failure and hyperlactatemia. Echocardiography revealed right ventricular dilation, suggesting increased PVR. Inhaled nitric oxide (iNO) was administered, rapidly improving hyperlactatemia and oxygenation. The shock observed during PE was attributed to multiple factors, including the potential removal of sildenafil, which may have led to an increase in PVR.

Conclusions: The shock was attributable to acute right heart failure caused by an exacerbation of PH, possibly due to sildenafil removal via PE, although other contributing factors could not be excluded.

Background: Simultaneous cardiac and non-cardiac surgeries can be beneficial for patients, but there are still few reports on this approach.

Case presentation: A 90-year-old woman was diagnosed with a femoral trochanteric fracture and severe aortic stenosis. A heart team conference decided to perform transcatheter aortic valve implantation (TAVI) and femoral osteosynthesis under general anesthesia on the same day. A preoperative simulation was conducted to review the surgical procedure and confirm the arrangement of the operating table and instruments. Preoperative management was carried out with attention to the risk of myocardial ischemia caused by bleeding or pain from the fracture. Transfemoral TAVI was completed without trouble, and after the patient was moved to the traction table, osteosynthesis was started. Back-up pacing with a temporary pacemaker was activated for atrioventricular block and bradycardia. After completing the surgery, the patient recovered from anesthesia, and extubation was performed after confirming the absence of paralysis. The patient had no noticeable postoperative complications and successfully underwent rehabilitation.

Conclusions: Through meticulous preparation and perioperative management, we were able to perform TAVI and femoral osteosynthesis simultaneously, achieving a favorable outcome.

Background: Cold agglutinin disease (CAD) is an autoimmune hemolytic anemia that induces blood coagulation and hemolysis upon exposure to cold temperatures. Strict temperature control is essential to mitigate these effects, especially during surgical procedures where hypothermia is possible.

Case presentation: A 57-year-old male, 165 cm and 72 kg, diagnosed with CAD, underwent cerebral vascular anastomosis. Intraoperatively, mean arterial pressure was maintained at or above 65 mmHg with phenylephrine administration, while body temperature was rigorously controlled between 36.5 °C and 37.5 °C using forced-air warming blankets and heated intravenous infusions. Despite these measures, thrombotic occlusion occurred, necessitating surgical thrombus removal, intravenous heparin administration, and irrigation of the surgical field with warmed saline followed by re-anastomosis. The anastomosis remained patent without recurrence of thrombus formation thereafter.

Conclusion: Preventing hypothermia is extremely important in the anesthesia management of CAD patients. However, careful attention must also be paid to temperature regulation in the surgical field.

Background: Bilateral trigeminal neuralgia secondary to multiple sclerosis is an extremely rare condition. When Gasserian ganglion block is performed, it is necessary to achieve reliable long-term analgesic effects while avoiding treatment-related complications.

Case presentation: A 49-year-old male with multiple sclerosis exhibited persistent dull pain and paroxysmal electric shock-like pain in his bilateral maxillary molars and mandible. He was diagnosed with trigeminal neuralgia due to multiple sclerosis. Due to severe side effects, it was difficult to achieve adequate pain control with medication alone. By performing low-temperature radiofrequency thermocoagulation and pulsed radiofrequency of the Gasserian ganglion while monitoring masseter muscle contraction, a satisfactory and rapid analgesic effect was obtained without masticatory atonia.

Conclusions: To the best of our knowledge, this is the first case of bilateral trigeminal neuralgia due to multiple sclerosis in which low-temperature radiofrequency thermocoagulation combined with pulsed radiofrequency was successfully performed for pain relief without masticatory atonia.

Background: Local anesthetic systemic toxicity (LAST) is a rare but potentially life-threatening complication. Under general anesthesia, neurological signs are often masked, delaying diagnosis and increasing the risk of sudden cardiovascular collapse. Therefore, early detection methods are critically needed.

Case presentation: A 48-year-old male patient (height: 182 cm, weight: 98 kg) underwent resection of a mediastinal goiter. He received 10 mL of 4% lidocaine for topical airway anesthesia and 20 mL of 1% lidocaine with 1:100,000 epinephrine for chest wall anesthesia. Thirty minutes after airway anesthesia, continuous theta waves appeared on the frontal electroencephalogram (EEG), which were enhanced following chest wall anesthesia. These waves transitioned into a repeating pattern and evolved into sharp periodic discharges. After administering 150 mL of 20% lipid emulsion, the EEG normalized.

Conclusions: This case highlights that EEG monitoring during general anesthesia may facilitate the early detection of LAST and provide real-time feedback on treatment efficacy.

Background: Non-ketotic hyperglycinemia (NKH) is a rare autosomal recessive disorder caused by defects in the glycine cleavage system, leading to elevated glycine levels in the central nervous system. NKH manifests in various forms, with the neonatal type being the most severe and often associated with high mortality and significant neurological impairment. This case report highlights the successful uses of desflurane and nitrous oxide for anesthetic management in a patient with NKH.

Case presentation: A 6-year-old girl with severe NKH, who had a history of delayed emergence from sevoflurane anesthesia, underwent tracheostomy for recurrent upper airway obstruction and severe obstructive sleep apnea. To address the previous issues with sevoflurane, general anesthesia was induced with propofol and fentanyl and maintained with 4% desflurane and 60% nitrous oxide. The electroencephalogram (EEG) showed near-complete suppression upon induction, which gradually resolved. Following cessation of desflurane and nitrous oxide, the patient exhibited early recovery, with eyes opening 3 min later and spontaneous breathing restored 19 min later. The patient experienced no postoperative complications and was discharged on the 14th postoperative day.

Conclusion: This case suggests that desflurane, with its favorable pharmacological profile, may offer a superior alternative to sevoflurane for anesthetic management in NKH patients, particularly those with a history of delayed emergence. The observed EEG suppression may indicate heightened sensitivity to anesthetics in NKH, highlighting the need for tailored anesthetic strategies in this population.

Background: The standard of care for placement of a central venous catheter (CVC) includes a real-time ultrasound (US)-guided technique. We describe a rare case in which the guidewire penetrated the posterior wall of the vessel, forming a knot, which precluded simple removal. This occurred despite the procedure being performed under real-time US guidance. The guidewire was eventually removed under fluoroscopic guidance in a hybrid operation room.

Case presentation: An 89-year-old male underwent the placement of a CVC in the left internal jugular vein. During the US-guided procedure, the guidewire penetrated the posterior wall of the vessel and formed a knot, which impeded simple removal. This was confirmed by radiologic imaging. Using a short sheath and a push-pull technique, the radiologist was able to untangle the knot to allow for catheter removal. The guidewire was safely removed without vascular injury.

Conclusions: A very rare complication of guidewire knotting was observed despite the use of US-guidance during needle and wire placement. The use of US, computed tomography, and fluoroscopy were beneficial for diagnosis, while the hybrid operating room provided the optimal environment for the removal procedure.

Background: Hypermagnesemia is a rare complication, leading to fatal cardiovascular and respiratory conditions. We present severe hypermagnesemia developed in a patient with a rectal stenosis after pretreatment with oral magnesium citrate for rectosigmoid surgery.

Case presentation: A 78-year-old woman demonstrated consciousness disturbance, muscle weakness, and respiratory depression requiring tracheal intubation after preparation with oral magnesium for rectosigmoid surgery. Endoscopic examination showed a rectal obstruction due to fecal impaction. General condition improved after emergency Hartmann's surgery. Blood test revealed a remarkable increase of serum magnesium level to 17.5 mg/dL when the general condition deteriorated, which would have been responsible for her symptoms. She was discharged from the ICU after extubation on the third postoperative day with a normal magnesium level.

Conclusions: Pretreatment with large doses of oral magnesium-containing bowel cleanser may cause severe hypermagnesemia in patients with colorectal stenosis.