JA Clinical Reports最新文献

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.

Background: Anal and perineum pain caused by malignant tumor invasion is often difficult to control with opioids. Continuous sacral epidural ethanol injection therapy is less likely to cause bladder and rectal disturbances, making it a suitable treatment option for patients with preserved voiding function.

Case presentation: A 45-year-old woman with multiple metastases of malignant pheochromocytoma suffered severe anal pain that worsened, especially when sitting, and was unresponsive to opioid rescue therapy. With her NRS score of 9, a sacral epidural catheter was placed, and a continuous infusion of 2% lidocaine was administered overnight. This is followed by a 1.5mL bolus of ethanol and continuous ethanol administration at 2 mL/h. After administration, her anal pain decreased to approximately NRS 0-1, and she was subsequently discharged.

Conclusion: We report successful pain control using continuous sacral epidural ethanol injection therapy in a patient with anal pain due to malignant pheochromocytoma metastasis.

Background: The effects of factors related to anesthetic management, including anesthesia methods and infusion volume, on acute kidney injury (AKI) after esophagectomy have not been thoroughly investigated.

Methods: A historical cohort study of patients who underwent esophagectomy between January 2008 and December 2022 was conducted. AKI was defined according to the Kidney Disease Improving Global Outcomes creatinine criteria within 72 h after esophagectomy. Logistic regression was used to model the association between perioperative factors, including factors related to anesthetic management, and postoperative AKI.

Results: Of 1005 patients, 48 patients (4.8%) had AKI (40 stage 1 and 8 stage 2). AKI patients were older (67.8 vs. 65.0 years, P = 0.046) and more likely to have hypertension (72.9 vs. 37.9%, P < 0.001), chronic kidney disease (39.6 vs. 14.3%, P < 0.0001), red blood cell (RBC) transfusions (12.5 vs. 3.4%, P = 0.0085), and longer duration of anesthesia (518 vs. 490 min, P = 0.0058) than non-AKI patients. AKI patients were less likely to have epidural anesthesia (72.9 vs. 91.5%, P < 0.001). The distribution of inhaled anesthetics chosen was not significantly different between AKI and non-AKI patients. On multivariable logistic regression analysis, AKI was associated with the Brinkman index (per 100 units, odds ratio (OR) = 1.06), hypertension (OR = 3.39), chronic kidney disease (OR = 2.58), duration of anesthesia (per 10 min, OR = 1.03), epidural anesthesia (OR = 0.35) and RBC transfusion (OR = 3.27).

Conclusions: Except for epidural anesthesia, no significant association was found between AKI and factors related to anesthetic management. Epidural anesthesia may protect against early postoperative AKI in patients undergoing esophagectomy.

Background: Anesthetic management of a patient with multiple giant bullae is generally difficult due to an increased risk of respiratory complications, and there is no consensus regarding safe extubation methods. We report a case of an effective use of a supraglottic airway (i-gel™) during emergence from anesthesia in a patient with multiple giant bullae, in whom a double-lumen bronchial tube was being used during anesthesia.

Case presentation: A 52-year-old man with multiple giant bullae underwent video-assisted pulmonary resections, while the ventilation was controlled via a double-lumen bronchial tube. After successful thoracoscopic surgery, an i-gel™ was inserted while the double-lumen tube was still in place, and the double-lumen tube was subsequently removed under deep anesthesia. The i-gel™ was removed without complications after the patient had become able to respond to verbal command.

Conclusion: We believe that this method would minimize the risk of trauma to the respiratory system during emergence from anesthesia in patients with multiple giant bullae.

Background: Common causes of air leakage around an endotracheal tube include insufficient endotracheal tube cuff inflation and damage to the cuff, while damage to the pilot balloon or pilot balloon tubing is relatively rare.

Case presentation: A 74-year-old female with vertebral osteomyelitis was scheduled for an extreme lateral interbody fusion followed posterior fixation. A fiber-optic light was utilized as part of the surgical illuminator. A sudden decrease in tidal volume and airway pressure was noted intraoperatively. We suspected leakage around the endotracheal tube cuff; however, no decrease in cuff pressure was detected. Despite the normal cuff pressure, we decided to inject a small amount of air which led to a significant increase in the cuff pressure. Upon careful inspection of the endotracheal tube, we discovered that the pilot balloon tubing was damaged as a result of thermal energy emitted by the fiber-optic light, which had ignited the surgical drape. The pilot balloon tubing was partially severed in which the section proximal to the endotracheal tube cuff was burned and punctured, causing the cuff leak. Meanwhile, the section proximal to the pilot balloon had melted and occluded the lumen, resulting in a falsely normal cuff pressure reading followed by an elevated cuff pressure when a small amount of air was injected into the pilot balloon during troubleshooting. Appropriate ventilation was resumed after extubation and re-intubation with a new endotracheal tube.

Conclusions: We experienced an endotracheal tube cuff leakage caused by a damaged pilot balloon tubing due to thermal energy of the fiber-optic light. Our case report emphasizes the importance of suspecting damage to the endotracheal tube cuff and inflation system despite a normal cuff pressure reading, given that the measurement may be falsely elevated depending on the specific location of the damage. In addition, all operating personnel should be familiarized with safety warnings and cautions related to handling.

Background: Postoperative shivering is mainly associated with low body temperature. However, postoperative shivering can develop even at normal or high core temperatures. This study aimed to investigate the factors associated with postoperative shivering in patients with maintained core temperature after surgery.

Methods: This retrospective study involved 537 patients who had undergone radical surgery for pancreatic cancer under general anesthesia from January 2013 to December 2023. The final analysis included 441 patients whose core temperatures after surgery were ≥ 36.5℃. Logistic regression analysis was performed to estimate the odds ratio (OR) of the incidence of postoperative shivering.

Results: Postoperative shivering occurred in 119 patients. After multivariable-adjusted logistic regression, postoperative shivering was significantly associated with patient age (per 1 year increase; OR = 0.98; 95% confidence interval [CI]: 0.96-0.996; p = 0.02), operation time (per 30 min increase; OR = 1.10; 95% CI: 1.01-1.19; p = 0.03), postoperative core temperature (restricted cubic spline, p = 0.001), postoperative peripheral temperature (restricted cubic spline, p = 0.001), effect site fentanyl concentration at extubation (OR = 0.66; 95% CI: 0.24-0.99; p = 0.049), and acetaminophen use (OR = 0.32; 95% CI: 0.18-0.58; p < 0.001).

Conclusions: Low peripheral temperature was a risk factor for the occurrence of shivering, even if the core temperature was maintained postoperatively. Peripheral temperature monitoring could be utilized to prevent postoperative shivering. In addition, fentanyl and acetaminophen reduced the occurrence of shivering in patients with maintained core temperature after surgery.