JA Clinical Reports最新文献

Background: Accidental intra-arterial administration of a medication can lead to serious iatrogenic harm. Most studies have discussed single cases of accidental intra-arterial administration of a medication, but only a few have described multiple cases occurring in a single, pediatric hospital setting.

Methods: The subjects were pediatric patients with an accidental intra-arterial administration of a medication. After obtaining approval from the institutional review board, the relevant cases were extracted from incident reports submitted to the patient safety office of the study center between November 2016 and April 2023.

Results: A review of 18,204 incident reports yielded 10 cases (patient age: 27 days to 13 years) of accidental intra-arterial administration of a medication. The most common site of the cannulation was the dorsum of the foot followed by the dorsum of the hand. The medications administered were narcotics, sedatives, muscle relaxants, antibiotics, and crystalloids. No serious adverse events occurred after injection. In some cases, the accidental arterial cannulation was not discovered immediately (53 min to 26 days). Seven patients had difficult intravenous access; in two of these, ultrasound-guided peripheral venous cannulation was used.

Conclusions: We experienced 10 cases of accidental intra-arterial administration of a medication. The dorsalis pedis artery and the radial artery around the anatomical tobacco socket were common sites of unintentional arterial cannulation. Difficult intravenous (IV) access may be associated with unintentional arterial cannulation. If IV access is difficult or the free IV drip is sluggish, strict vigilance and repeated confirmation are needed to prevent unintentional arterial cannulation.

Background: There is no consensus regarding the choice of anesthetic method for patients with pulmonary hypertension (PH). We report two cases in which neuraxial anesthesia was safely performed without general anesthesia during open abdominal surgery in patients with severe PH.

Case presentation: Case 1: A 59-year-old woman had an atrial septal defect and a huge abdominal tumor with a mean pulmonary arterial pressure (PAP) of 39 mmHg and pulmonary vascular resistance (PVR) of 3.5 Wood units. Case 2: A 23-year-old woman who had hereditary pulmonary artery hypertension (mean PAP, 65 mmHg; PVR, 16.45 Wood units). Both patients underwent open abdominal surgery under neuraxial anesthesia without circulatory collapse with intraoperative administration of vasoconstrictors.

Conclusion: Although anesthetic care must be personalized depending on the pathology and severity of PH, neuraxial anesthesia may be an option for patients with severe PH undergoing abdominal surgery.

Background: Dysfunction of ventriculoperitoneal (VP) shunts can lead to decreased levels of consciousness. We report a case of delayed emergence from anesthesia due to the malfunction of a VP shunt during neurosurgery in the prone position.

Case presentation: A 75-year-old male with a history of VP shunt for a fourth ventricle obstruction underwent cerebral vascular anastomosis in the prone position. His preoperative level of consciousness was clear. The surgery under general anesthesia was completed without any particular issues. After discontinuation of anesthesia, the patient did not awaken for over an hour. Postoperative CT revealed exacerbated hydrocephalus, likely from VP shunt occlusion. After pumping the reservoir of the VP shunt, the patient regained consciousness. He was extubated and discharged from ICU on the second postoperative day with no neurological issues.

Conclusion: For surgical patients with a VP shunt, anesthesia management must consider the risk of shunt malfunction due to patient positioning.

Background: An aorto-caval fistula is a rare but critical complication of abdominal aortic aneurysm (AAA) rupture, leading to high-output heart failure and increased venous pressure. The anesthetic management of such cases, particularly when complicated by an intraoperative right-to-left shunt, is seldom reported.

Case presentation: A 71-year-old man with a history of atrial fibrillation and catheter ablation presented with heart failure and abdominal pain, leading to cardiac arrest. Imaging revealed an AAA rupture into the inferior vena cava. During emergency surgery, severe venous bleeding was managed using intra-aortic balloon occlusion (IABO). Transesophageal echocardiography (TEE) identified a right-to-left shunt due to an iatrogenic atrial septal defect.

Conclusion: Early TEE recognition and timely IABO intervention were crucial in managing this complex case, underscoring the importance of these techniques in similar emergency scenarios.

Background: Mitochondrial cardiomyopathy occurs when impaired mitochondrial energy production leads to myocardial dysfunction. Anesthetic management in such cases is challenging due to risks of circulatory depression associated with anesthesia and mitochondrial dysfunction induced by anesthetics. Although there are reports of anesthetic management for patients with mitochondrial diseases, there are few reports specifically addressing cardiac anesthesia for patients with mitochondrial cardiomyopathy. We present a case where percutaneous mitral valve repair with MitraClip™ was successfully performed under remimazolam anesthesia in a patient with mitochondrial cardiomyopathy who developed functional mitral valve regurgitation due to low cardiac function and cardiomegaly.

Case presentation: A 57-year-old woman was diagnosed with chronic cardiac failure, with a 10-year history of dilated cardiomyopathy. She was diagnosed with mitochondrial cardiomyopathy 8 years ago. Over the past 2 years, her cardiac failure worsened, and mitral valve regurgitation gradually developed. Surgical intervention was considered but deemed too risky due to her low cardiac function, with an ejection fraction of 26%. Therefore, percutaneous MitraClip™ implantation was selected. After securing radial artery and central venous catheterization under sedation with dexmedetomidine, anesthesia was induced with a low dose of remimazolam 4 mg/kg/h. Anesthesia was maintained with remimazolam 0.35-1.0 mg/kg/h and remifentanil 0.1 μg/kg/min. Noradrenaline and dobutamine were administered intraoperatively, and the procedure was completed successfully without circulatory collapse. The patient recovered smoothly from anesthesia and experienced no complications. She was discharged on the eighth day after surgery.

Conclusion: Anesthesia management with remimazolam appears to be a safe and effective for MitraClip™ implantation in patients with mitochondrial cardiomyopathy.

Background: The skin-prick and intradermal tests are the main diagnostic methods used to identify the causative agent in patients with suspected perioperative anaphylaxis. Although the intradermal test is more sensitive than the skin-prick test, multiple intradermal injections can be painful for children. Here, we present the case of a child with autism and suspected perioperative anaphylaxis. The causative agent was successfully identified using the intradermal test under general anesthesia.

Case presentation: An 8-year-old boy with autism developed anaphylaxis during general anesthesia for the fourth cleft lip and palate surgery. An allergic workout was performed, but both the skin-prick and basophil activation tests for suspected causative agents yielded negative results. The patient was afraid of multiple injections, and an intradermal test was performed under general anesthesia by anesthesiologists and allergists. Piperacillin was confirmed as the causative agent, and subsequent surgery using the same anesthetic agents without piperacillin was uneventful.

Conclusions: Concerted efforts should be made to identify the causative agent for diagnosing perioperative anaphylaxis.

Background: Opioid-induced rigidity is typically observed during rapid administration of fentanyl. Herein, we present a case in which rigidity occurred after reversal of rocuronium during emergence from anesthesia.

Case presentation: A 73-year-old man underwent video-assisted partial lung resection. General anesthesia was induced with propofol, remimazolam, remifentanil, and rocuronium. Fentanyl was administered early during anesthesia. The surgery was completed without complications, and sugammadex sodium was administered for rocuronium reversal. The patient became agitated, but spontaneous breathing was maintained; therefore, the intratracheal tube was removed after the administration of flumazenil. The patient developed stiffness in the neck and jaw muscles along with remarkable skeletal muscle contractions. Dramatic improvement was observed immediately after administration of naloxone.

Conclusions: Even as the simulated effect site concentration of fentanyl decreases during anesthesia emergence, opioid-induced rigidity may still occur. Rapid reversal of remimazolam by flumazenil might have contributed to the rigidity in this case.

Background: In esophageal atresia type C, identifying the tracheoesophageal fistula (TEF) location is crucial for airway management. However, a thin bronchoscope may not always be available.

Case presentation: We report on a low-birth-weight neonate with esophageal atresia type C who required immediate gastrostomy after birth. With no suitable thin bronchoscope available, alternative methods were utilized to estimate the TEF location post-gastrostomy. Submerging the gastrostomy tube tip in water and applying positive pressure ventilation via a tracheal tube allowed for observation of air bubbles emerging from the gastrostomy tube. As the tracheal tube was advanced, the cessation of bubbles indicated that the TEF was sealed by the tracheal tube. The location of the tracheal tube tip, confirmed by chest radiographs, was consistent with the TEF location identified during corrective surgery for TEF.

Conclusions: This innovative technique facilitated successful estimation of the TEF location without bronchoscopy, demonstrating its efficacy in resource-limited settings.