The surgical Apgar score is useful for predicting postoperative morbidity and mortality. However, its applicability in frail patients with minimal hemodynamic variation remains unknown. This study aimed to investigate the association between frailty and surgical Apgar score. This secondary analysis included 210 patients ≥ 65 years of age undergoing elective major abdominal surgery for cancer. Frailty was assessed using the Fried Frailty Phenotype Questionnaire and defined as a total score of ≥ 3. The surgical Apgar score (range, 0−10; including mean blood pressure, heart rate, and blood loss volume) was compared between patients with or without frailty using the Mann–Whitney U test. Postoperative severe complications and length of postoperative stay were compared between patients with surgical Apgar scores ≤ 7 and > 7. Among the included patients, 45 were classified as frail. The median [1st quartile, 3rd quartile] surgical Apgar scores in patients with and without frailty were 7.0 [7.0, 8.0] and 8.0 [7.0, 8.0], respectively (P = 0.03). Patients with surgical Apgar score ≤7 had a higher incidence of serious postoperative complications (P = 0.03) and longer hospital stays (P < 0.001) compared with patients with surgical Apgar score >7. Frail patients have lower SAS, and patients with lower SAS have higher postoperative complication rates and longer hospital stays in patients who underwent cancer surgery.
{"title":"Association between preoperative frailty and surgical Apgar score in abdominal cancer surgery: a secondary analysis of a prospective observational study","authors":"Sayaka Hirai, Mitsuru Ida, Yuki Kinugasa, Masahiko Kawaguchi","doi":"10.1186/s40981-024-00687-3","DOIUrl":"https://doi.org/10.1186/s40981-024-00687-3","url":null,"abstract":"The surgical Apgar score is useful for predicting postoperative morbidity and mortality. However, its applicability in frail patients with minimal hemodynamic variation remains unknown. This study aimed to investigate the association between frailty and surgical Apgar score. This secondary analysis included 210 patients ≥ 65 years of age undergoing elective major abdominal surgery for cancer. Frailty was assessed using the Fried Frailty Phenotype Questionnaire and defined as a total score of ≥ 3. The surgical Apgar score (range, 0−10; including mean blood pressure, heart rate, and blood loss volume) was compared between patients with or without frailty using the Mann–Whitney U test. Postoperative severe complications and length of postoperative stay were compared between patients with surgical Apgar scores ≤ 7 and > 7. Among the included patients, 45 were classified as frail. The median [1st quartile, 3rd quartile] surgical Apgar scores in patients with and without frailty were 7.0 [7.0, 8.0] and 8.0 [7.0, 8.0], respectively (P = 0.03). Patients with surgical Apgar score ≤7 had a higher incidence of serious postoperative complications (P = 0.03) and longer hospital stays (P < 0.001) compared with patients with surgical Apgar score >7. Frail patients have lower SAS, and patients with lower SAS have higher postoperative complication rates and longer hospital stays in patients who underwent cancer surgery.","PeriodicalId":14635,"journal":{"name":"JA Clinical Reports","volume":"2 1","pages":""},"PeriodicalIF":0.9,"publicationDate":"2024-01-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139465235","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Fragile lip in a patient with macroglossia due to hemodialysis-associated amyloidosis.","authors":"Tohru Shiratori, Masahiro Nishimura, Yusuke Horitani","doi":"10.1186/s40981-024-00686-4","DOIUrl":"10.1186/s40981-024-00686-4","url":null,"abstract":"","PeriodicalId":14635,"journal":{"name":"JA Clinical Reports","volume":"10 1","pages":"1"},"PeriodicalIF":0.9,"publicationDate":"2024-01-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10781912/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139402881","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-12-20DOI: 10.1186/s40981-023-00683-z
Tamayo Takahashi, Kana Oue, Eiji Imado, Mitsuru Doi, Yoshitaka Shimizu, Mitsuhiro Yoshida
Background: Glycogen storage disease (GSD) is a group of rare inherited metabolic disorders caused by enzyme deficiencies in glycogen catabolism. GSD type Ia is a congenital deficiency of the enzyme responsible for the final step in glucose production by glycolysis, resulting in impaired carbohydrate metabolism.
Case presentation: A 14-year-old boy with GSD type Ia was scheduled for a maxillary cystectomy under general anesthesia. He was taking oral sugars such as uncooked cornstarch regularly to prevent hypoglycemia. Perioperatively, glucose was administered via the peripheral vein for fasting; however, severe lactic acidosis occurred. He also developed hypercapnia because of intraoperative poor ventilation caused by hepatomegaly.
Conclusions: We experienced a child with GSD type Ia who developed severe lactic acidosis despite continuous glucose infusion. Further studies are required to determine appropriate perioperative management for patients with GSD, including fasting glucose administration.
背景：糖原贮积病（GSD）是一组罕见的遗传性代谢性疾病，由糖原分解酶缺乏引起。GSD Ia 型是一种先天性酶缺乏症，这种酶负责糖酵解产生葡萄糖的最后一步，从而导致碳水化合物代谢障碍：一名患有 GSD Ia 型的 14 岁男孩计划在全身麻醉下进行上颌膀胱切除术。他定期口服糖类，如未煮熟的玉米淀粉，以预防低血糖症。围手术期，他通过外周静脉注射葡萄糖以禁食，但发生了严重的乳酸酸中毒。由于肝脏肿大导致术中通气不良，他还出现了高碳酸血症：结论：我们遇到过一名 GSD Ia 型患儿，尽管持续输注葡萄糖，但还是出现了严重的乳酸酸中毒。需要进一步研究来确定 GSD 患者围手术期的适当管理，包括空腹葡萄糖管理。
{"title":"Severe perioperative lactic acidosis in a pediatric patient with glycogen storage disease type Ia: a case report.","authors":"Tamayo Takahashi, Kana Oue, Eiji Imado, Mitsuru Doi, Yoshitaka Shimizu, Mitsuhiro Yoshida","doi":"10.1186/s40981-023-00683-z","DOIUrl":"10.1186/s40981-023-00683-z","url":null,"abstract":"<p><strong>Background: </strong>Glycogen storage disease (GSD) is a group of rare inherited metabolic disorders caused by enzyme deficiencies in glycogen catabolism. GSD type Ia is a congenital deficiency of the enzyme responsible for the final step in glucose production by glycolysis, resulting in impaired carbohydrate metabolism.</p><p><strong>Case presentation: </strong>A 14-year-old boy with GSD type Ia was scheduled for a maxillary cystectomy under general anesthesia. He was taking oral sugars such as uncooked cornstarch regularly to prevent hypoglycemia. Perioperatively, glucose was administered via the peripheral vein for fasting; however, severe lactic acidosis occurred. He also developed hypercapnia because of intraoperative poor ventilation caused by hepatomegaly.</p><p><strong>Conclusions: </strong>We experienced a child with GSD type Ia who developed severe lactic acidosis despite continuous glucose infusion. Further studies are required to determine appropriate perioperative management for patients with GSD, including fasting glucose administration.</p>","PeriodicalId":14635,"journal":{"name":"JA Clinical Reports","volume":"9 1","pages":"91"},"PeriodicalIF":0.9,"publicationDate":"2023-12-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10730783/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"138800033","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-12-18DOI: 10.1186/s40981-023-00684-y
Sayaka Hirai, Mitsuru Ida, Ai Arima, Masahiko Kawaguchi
<p>To the Editor,</p><p>The Japanese Society of Anesthesiologists offers practical guidelines for dealing with perioperative anaphylaxis, emphasizing the importance of anesthesiologists’ involvement in identifying the causative agent to prevent recurrence [1]. However, identifying the causative agents is not always feasible. Herein, we report, with written informed consent, a case where anaphylaxis was suspected during anesthesia induction, yet no allergens were identified.</p><p>A 59-year-old man, 165.5 cm in height and weighing 65.1 kg, presented with congestive heart failure, chronic kidney disease, diabetes, hypertension, and hyperlipidemia, requiring coronary artery bypass grafting for triple-vessel coronary artery disease. The patient had not undergone any surgery previously and had not taken any angiotensin receptor blockers and angiotensin-converting enzyme inhibitors. In the operating room, standard vital signs were closely monitored, and non-invasive blood pressure (NIBP) was recorded at 160/120 mmHg. Anesthesia was induced using remifentanil (rate, 20 mL/h) and remimazolam (12 mg/kg/h). Upon confirming the loss of consciousness, the dosages of remifentanil and remimazolam were reduced to 5 mL/h and 1.0 mg/kg/h, respectively, four minutes after administering rocuronium (60 mg). This was followed by tracheal intubation and arterial catheter insertion. His blood pressure (BP) was 89/67 mm Hg (NIBP) and 47/25 mm Hg (arterial line) immediately before and after tracheal intubation, respectively. Despite fluid resuscitation of 500 mL and multiple boluses of ephedrine (16 mg), phenylephrine (0.3 mg), and norepinephrine (10 µg), he experienced cardiac arrest. During chest compressions, an intravenous bolus of epinephrine (0.1 mg) was administered, resulting in cardiopulmonary resuscitation with an arterial BP of 46/29 mmHg. However, due to persistent severe hypotension, continuous infusions of norepinephrine at 0.1 mcg/kg/min and dobutamine at 5 mcg/kg/min were initiated following additional boluses of epinephrine (0.3 mg). Figure 1 displays the patient’s vital signs during anesthesia. Edema with erythema of the extremities and trunk was observed throughout this sequence, and transesophageal echocardiography revealed no evidence of cardiogenic shock. Consequently, anaphylaxis was suspected, and the patient was transferred to the intensive care unit without proceeding with surgery. Blood samples taken before he left the operating room indicated an elevated serum tryptase level of 17.1 μg/L, exceeding the normal range of 1.2–5.7 μg/L. More than seven weeks after the onset, both basophil activation and skin prick tests using remimazolam and rocuronium yielded negative results. The patient declined surgery and was subsequently followed-up after percutaneous coronary intervention at coronary segments 6, 7, 11, and 14.</p><figure><figcaption><b data-test="figure-caption-text">Fig. 1</b></figcaption><picture><img alt="figure 1" aria-describedby="Fig1"
{"title":"Suspected anaphylaxis during anesthesia induction without identified allergens: a case report","authors":"Sayaka Hirai, Mitsuru Ida, Ai Arima, Masahiko Kawaguchi","doi":"10.1186/s40981-023-00684-y","DOIUrl":"https://doi.org/10.1186/s40981-023-00684-y","url":null,"abstract":"<p>To the Editor,</p><p>The Japanese Society of Anesthesiologists offers practical guidelines for dealing with perioperative anaphylaxis, emphasizing the importance of anesthesiologists’ involvement in identifying the causative agent to prevent recurrence [1]. However, identifying the causative agents is not always feasible. Herein, we report, with written informed consent, a case where anaphylaxis was suspected during anesthesia induction, yet no allergens were identified.</p><p>A 59-year-old man, 165.5 cm in height and weighing 65.1 kg, presented with congestive heart failure, chronic kidney disease, diabetes, hypertension, and hyperlipidemia, requiring coronary artery bypass grafting for triple-vessel coronary artery disease. The patient had not undergone any surgery previously and had not taken any angiotensin receptor blockers and angiotensin-converting enzyme inhibitors. In the operating room, standard vital signs were closely monitored, and non-invasive blood pressure (NIBP) was recorded at 160/120 mmHg. Anesthesia was induced using remifentanil (rate, 20 mL/h) and remimazolam (12 mg/kg/h). Upon confirming the loss of consciousness, the dosages of remifentanil and remimazolam were reduced to 5 mL/h and 1.0 mg/kg/h, respectively, four minutes after administering rocuronium (60 mg). This was followed by tracheal intubation and arterial catheter insertion. His blood pressure (BP) was 89/67 mm Hg (NIBP) and 47/25 mm Hg (arterial line) immediately before and after tracheal intubation, respectively. Despite fluid resuscitation of 500 mL and multiple boluses of ephedrine (16 mg), phenylephrine (0.3 mg), and norepinephrine (10 µg), he experienced cardiac arrest. During chest compressions, an intravenous bolus of epinephrine (0.1 mg) was administered, resulting in cardiopulmonary resuscitation with an arterial BP of 46/29 mmHg. However, due to persistent severe hypotension, continuous infusions of norepinephrine at 0.1 mcg/kg/min and dobutamine at 5 mcg/kg/min were initiated following additional boluses of epinephrine (0.3 mg). Figure 1 displays the patient’s vital signs during anesthesia. Edema with erythema of the extremities and trunk was observed throughout this sequence, and transesophageal echocardiography revealed no evidence of cardiogenic shock. Consequently, anaphylaxis was suspected, and the patient was transferred to the intensive care unit without proceeding with surgery. Blood samples taken before he left the operating room indicated an elevated serum tryptase level of 17.1 μg/L, exceeding the normal range of 1.2–5.7 μg/L. More than seven weeks after the onset, both basophil activation and skin prick tests using remimazolam and rocuronium yielded negative results. The patient declined surgery and was subsequently followed-up after percutaneous coronary intervention at coronary segments 6, 7, 11, and 14.</p><figure><figcaption><b data-test=\"figure-caption-text\">Fig. 1</b></figcaption><picture><img alt=\"figure 1\" aria-describedby=\"Fig1\"","PeriodicalId":14635,"journal":{"name":"JA Clinical Reports","volume":"28 1","pages":""},"PeriodicalIF":0.9,"publicationDate":"2023-12-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"138714628","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Vascular malformations are composed of morphologically abnormal vascular tissue, and when located in the head and neck region, they can make it difficult to secure the airway during general anesthesia. A 28-year-old pregnant woman with vascular malformations in the pharynx was scheduled to undergo a cesarean section, for which spinal anesthesia was initially chosen. However, after magnetic resonance imaging results revealed the presence of multiple vascular malformations in the lumbar multifidus muscles, spinal anesthesia was considered to be of high risk. Thus, the patient was subjected to general anesthesia tracheal intubation under sedation, and the course of the surgery was without complications. Because the pathophysiology and clinical sequelae of vascular malformations may be involved in complications, thorough presurgical evaluation of the patient’s physical condition and careful anesthesia planning should be done.
{"title":"General anesthesia for cesarean section in a pregnant woman with systemic vascular malformation: a case report","authors":"Noriko Takeuchi, Misa Koshihara, Akira Motoyasu, Joho Tokumine, Harumasa Nakazawa, Mine Ozaki, Tomoko Yorozu","doi":"10.1186/s40981-023-00682-0","DOIUrl":"https://doi.org/10.1186/s40981-023-00682-0","url":null,"abstract":"Vascular malformations are composed of morphologically abnormal vascular tissue, and when located in the head and neck region, they can make it difficult to secure the airway during general anesthesia. A 28-year-old pregnant woman with vascular malformations in the pharynx was scheduled to undergo a cesarean section, for which spinal anesthesia was initially chosen. However, after magnetic resonance imaging results revealed the presence of multiple vascular malformations in the lumbar multifidus muscles, spinal anesthesia was considered to be of high risk. Thus, the patient was subjected to general anesthesia tracheal intubation under sedation, and the course of the surgery was without complications. Because the pathophysiology and clinical sequelae of vascular malformations may be involved in complications, thorough presurgical evaluation of the patient’s physical condition and careful anesthesia planning should be done.","PeriodicalId":14635,"journal":{"name":"JA Clinical Reports","volume":"91 1","pages":""},"PeriodicalIF":0.9,"publicationDate":"2023-12-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"138631378","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-12-07DOI: 10.1186/s40981-023-00680-2
Satoki Inoue
{"title":"Family reunion activity may be used as an alternative item for sexual activity in the Duke Activity Status Index.","authors":"Satoki Inoue","doi":"10.1186/s40981-023-00680-2","DOIUrl":"10.1186/s40981-023-00680-2","url":null,"abstract":"","PeriodicalId":14635,"journal":{"name":"JA Clinical Reports","volume":"9 1","pages":"87"},"PeriodicalIF":0.9,"publicationDate":"2023-12-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10700227/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"138498403","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Background: Tetralogy of Fallot (TOF) is a complex cyanotic congenital heart disease. As most patients with TOF undergo palliative or radical surgical repair during childhood, cardiac surgery under cardiopulmonary bypass (CPB) for adult survivors with unrepaired TOF is exceedingly rare.
Case presentation: A 41-year-old woman with unrepaired TOF, pulmonary atresia (PA), and major aortopulmonary collateral arteries (MAPCAs) developed acute infectious endocarditis (IE). As vegetation gradually increased despite intravenous antibiotic administration, she was scheduled for urgent aortic valve replacement under CPB. Pulmonary blood flow was primarily provided by the MAPCAs originating from the descending aorta. Intra-aortic balloon occlusion for MAPCAs was performed to ensure a bloodless surgical field. Aortic valve replacement was successful.
Conclusion: An adult with uncorrected TOF developed acute IE and subsequently had successful cardiac surgery under CPB. Understanding TOF physiology with PA and MAPCAs, particularly pulmonary blood flow through MAPCAs, is crucial.
{"title":"Aortic valve replacement in a 41-year-old woman with uncorrected tetralogy of Fallot, pulmonary atresia, and major aortopulmonary collateral arteries: a case report.","authors":"Kazutomo Saito, Yudai Iwasaki, Takahiro Tasaki, Hidehisa Saito, Hiroaki Toyama, Yutaka Ejima, Masanori Yamauchi","doi":"10.1186/s40981-023-00674-0","DOIUrl":"10.1186/s40981-023-00674-0","url":null,"abstract":"<p><strong>Background: </strong>Tetralogy of Fallot (TOF) is a complex cyanotic congenital heart disease. As most patients with TOF undergo palliative or radical surgical repair during childhood, cardiac surgery under cardiopulmonary bypass (CPB) for adult survivors with unrepaired TOF is exceedingly rare.</p><p><strong>Case presentation: </strong>A 41-year-old woman with unrepaired TOF, pulmonary atresia (PA), and major aortopulmonary collateral arteries (MAPCAs) developed acute infectious endocarditis (IE). As vegetation gradually increased despite intravenous antibiotic administration, she was scheduled for urgent aortic valve replacement under CPB. Pulmonary blood flow was primarily provided by the MAPCAs originating from the descending aorta. Intra-aortic balloon occlusion for MAPCAs was performed to ensure a bloodless surgical field. Aortic valve replacement was successful.</p><p><strong>Conclusion: </strong>An adult with uncorrected TOF developed acute IE and subsequently had successful cardiac surgery under CPB. Understanding TOF physiology with PA and MAPCAs, particularly pulmonary blood flow through MAPCAs, is crucial.</p>","PeriodicalId":14635,"journal":{"name":"JA Clinical Reports","volume":"9 1","pages":"86"},"PeriodicalIF":0.9,"publicationDate":"2023-12-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10700252/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"138487494","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Background: The upper cervical spine is a major focus of damage by rheumatoid arthritis (RA). Specific screening for mobility of the upper cervical spine, which is essential for direct laryngoscopy, is lacking. Herein, we present a case of RA with Cormack-Lehane grade IV, which was not predicted by preoperative examination.
Case presentation: A 66-year-old woman with RA was scheduled for a right total knee arthroplasty and right elbow synovectomy. She had a long history of RA without symptoms related to the cervical spine or spinal cord. Although physical examination suggested moderate risk of difficult intubation with preserved cervical retroflexion, her Cormack-Lehane classification was grade IV under muscle relaxation. Bony integration of the occiput to axis was considered to be the main cause of difficult direct laryngoscopy, and restricted neck rotation was found postoperatively.
Conclusions: RA patients may have limited upper cervical spine motion despite normal cervical retroflexion.
背景：上颈椎是类风湿性关节炎（RA）的主要损害部位。上颈椎的活动度对直接喉镜检查至关重要，但目前还缺乏对上颈椎活动度的专门筛查。在此，我们介绍了一例 Cormack-Lehane 分级 IV 的 RA 病例，术前检查并未预测到这一情况：一名 66 岁的女性 RA 患者计划接受右全膝关节置换术和右肘滑膜切除术。她有长期的 RA 病史，但没有与颈椎或脊髓相关的症状。虽然体格检查提示她在保留颈椎后屈的情况下有中度插管困难的风险，但她的Cormack-Lehane分级在肌肉松弛状态下为IV级。枕骨与轴的骨性结合被认为是直接喉镜检查困难的主要原因，术后发现颈部旋转受限：结论：尽管颈椎后屈正常，但RA患者的上颈椎活动可能受限。
{"title":"Predictive underestimation of difficult direct laryngoscopy in a patient with rheumatoid arthritis-associated immobilized craniocervical junction.","authors":"Hirotaka Matsuyama, Masato Hara, Atsushi Seto, Teruyuki Hiraki","doi":"10.1186/s40981-023-00679-9","DOIUrl":"10.1186/s40981-023-00679-9","url":null,"abstract":"<p><strong>Background: </strong>The upper cervical spine is a major focus of damage by rheumatoid arthritis (RA). Specific screening for mobility of the upper cervical spine, which is essential for direct laryngoscopy, is lacking. Herein, we present a case of RA with Cormack-Lehane grade IV, which was not predicted by preoperative examination.</p><p><strong>Case presentation: </strong>A 66-year-old woman with RA was scheduled for a right total knee arthroplasty and right elbow synovectomy. She had a long history of RA without symptoms related to the cervical spine or spinal cord. Although physical examination suggested moderate risk of difficult intubation with preserved cervical retroflexion, her Cormack-Lehane classification was grade IV under muscle relaxation. Bony integration of the occiput to axis was considered to be the main cause of difficult direct laryngoscopy, and restricted neck rotation was found postoperatively.</p><p><strong>Conclusions: </strong>RA patients may have limited upper cervical spine motion despite normal cervical retroflexion.</p>","PeriodicalId":14635,"journal":{"name":"JA Clinical Reports","volume":"9 1","pages":"85"},"PeriodicalIF":0.9,"publicationDate":"2023-12-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10697918/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"138487495","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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