JA Clinical Reports最新文献

Background: Although newly developed electromyographic devices have been introduced in anesthetic practice, reports on their use in patients with myasthenia gravis (MG) are lacking. We describe electromyographic monitoring combined with acceleromyography in a myasthenic patient.

Case presentation: A 55-year-old female underwent robot-assisted thoracoscopic thymothymectomy due to MG associated with thymoma. At general anesthesia induction, 0.13 mg/kg of rocuronium completely suppressed the acceleromyographic train-of-four (TOF) response, enabling tracheal intubation. However, the electromyographic TOF count remained at 4. Intraoperatively, rocuronium was administered whenever the acceleromyographic TOF count reached 1, which was consistently delayed compared to the electromyographic TOF count of 1. After surgery, sugammadex 2 mg/kg was administered following confirmation of a TOF count of 2 on both monitors, which enabled successful extubation in the operating room.

Conclusions: This case suggests that combining electromyography with acceleromyography might be more beneficial than electromyography or acceleromyography alone in myasthenic patients, until further evidence is available.

Background: Acute type-A aortic dissection is a life-threatening condition requiring urgent intervention. Among its complications, coronary malperfusion is particularly fatal. Although rare, coronary artery stenosis after surgical repair is critical yet underrecognized.

Case presentation: A 77-year-old man underwent emergency aortic arch replacement for acute type-A aortic dissection. Intraoperative transesophageal echocardiography (TEE) initially showed no coronary involvement. However, ST-segment elevation and new hypokinesia appeared post-repair. TEE identified progressive left main coronary artery stenosis. Coronary angiography confirmed severe stenosis, leading to urgent coronary artery bypass grafting. The patient recovered well and was discharged on postoperative day 33.

Conclusions: This case highlights the importance of intraoperative TEE for early detection of coronary complications following acute type-A aortic dissection repair. Dissection can progress even after aortic replacement surgery and requires vigilance. Careful monitoring and prompt intervention are crucial to optimize the outcome of these rare but life-threatening events.

Background: Anaphylaxis is an immediate allergic reaction. However, in some cases, there is a delay between the administration of the causative agent and the onset of anaphylaxis.

Case presentation: A 41-year-old woman was scheduled for laparoscopic myomectomy under general anesthesia combined with epidural anesthesia. Midazolam was administered, and an epidural catheter was inserted. Seven minutes after the induction of general anesthesia (17 min after midazolam administration), the patient developed tachycardia, hypotension, and redness of the face and trunk. Her hemodynamic status improved after administration of phenylephrine and elevation of both legs, and the surgery was completed. Increased blood histamine and tryptase levels were observed 30 min after the onset of hemodynamic signs. Based on the above, anaphylaxis was diagnosed. Skin tests later showed that midazolam was the causative agent.

Conclusions: A case of perioperative anaphylaxis caused by midazolam, which was used before the induction of general anesthesia, was described.

Background: Sagittal split ramus osteotomy is often associated with significant postoperative pain. Intraoral inferior alveolar nerve blocks have variable success rates and higher risks of vascular complications, while ultrasound-guided approaches to the pterygomandibular space require precise needle placement in a narrow anatomical space. We present a novel perioperative application of ultrasound-guided lateral pterygoid muscle injection for regional anesthesia.

Case presentations: Three female patients underwent bilateral sagittal split ramus osteotomy under general anesthesia. After anesthesia induction, ultrasound-guided lateral pterygoid muscle injections were performed using 10 mL of 0.25% levobupivacaine. All patients demonstrated excellent postoperative pain control (numerical rating scale score ≤ 2) with minimal analgesic requirements and no complications.

Conclusion: This novel lateral pterygoid muscle injection technique for perioperative analgesia demonstrates promising clinical efficacy through a simplified ultrasound-guided approach, providing effective opioid-free postoperative pain management for sagittal split ramus osteotomy.

Introduction: The oxygen reserve index (ORi™), a non-invasive variable that continuously reflects oxygenation, was first reported in 2016. With the 2018 update of ORi, the scaling between 0.00 and 1.00 was modified. This article provides a follow-up report on the relationship between the updated ORi and arterial partial pressure of oxygen (PaO₂), based on our previous study using the original version of ORi.

Methods: The updated ORi version analyzed in the present study used a Revision M sensor. Twenty adult patients who were scheduled for surgery under general anesthesia with arterial catheterization were enrolled. After induction of general anesthesia, arterial blood gas analysis was performed with the fraction of inspiratory oxygen (FiO₂) set at 0.33. The PaO₂ and ORi at the time of blood collection were recorded. After that, FiO₂ was changed to achieve an ORi of around 0.5, 0.2, or 0, followed by arterial blood gas analysis. The relationship between ORi and PaO₂ was then investigated using the data obtained.

Results: Seventy-six datasets from the 20 patients were analyzed. When PaO₂ was < 240 mmHg (n = 73), linear regression analysis showed a relatively positive correlation (r² = 0.4683). The cut-off ORi value obtained from the receiver operating characteristic curve to detect PaO₂ ≥ 150 mmHg was 0.45 (sensitivity 0.833, specificity 0.810). Four-quadrant plot analysis demonstrated that ORi has good trending ability with respect to PaO₂ (concordance rate was 100.0%).

Conclusion: Although the original and updated versions of ORi demonstrate similar properties regarding their ability to track PaO₂ changes, the updated version has a wider absolute value range. Therefore, caution is warranted when interpreting ORi values, as absolute values may vary significantly between versions, even at the same PaO₂ level.

Background: Systemic capillary leak syndrome (SCLS) is a rare disorder characterized by hypotension, hypoalbuminemia, and hemoconcentration, typically caused by increased vascular permeability due to endothelial dysfunction. We report a case of SCLS complicated by bilateral lower extremity compartment syndrome.

Case presentation: A 29-year-old man developed fever, cough, and rhinorrhea. He was restless, hypotensive, and had generalized edema with tense extremities. Laboratory findings included a hemoglobin level of 24.9 g/dL, hematocrit of 69.3%, albumin of 1.8 g/dL, and creatinine of 3.27 mg/dL. SCLS-induced shock was diagnosed with detection of monoclonal gammopathy of the IgG-λ type. Treatment consisted of fluid resuscitation, vasopressors, high-dose corticosteroids, and intravenous immunoglobulin. Although hemodynamic status improved, he developed bilateral lower-limb compartment syndrome, necessitating fasciotomy. Although the patient exhibited sensory deficits and impaired dorsiflexion and plantarflexion in both ankles, he was able to ambulate with a cane and was discharged on hospital day 50.

Conclusion: This case highlights the risk of serious complications such as compartment syndrome in patients with SCLS.

Non-convulsive status epilepticus (NCSE) is an electrical discharge which occurs without prominent motor symptoms. NCSE is one of the causes of delayed emergence from anesthesia; however, as far as we know, previous reports of postoperative NCSE were related to patients after neurological surgery. Herein, we report a case of an elderly male who developed initial NCSE after thoracic surgery. The patient remained unresponsive and developed hemiplegia after lung resection, and then the symptoms fluctuated between better and worse. Metabolic disorders and stroke were ruled out, and NCSE was diagnosed by magnetic resonance imaging (MRI) and electroencephalography (EEG). NCSE occurred in a patient who had no predisposing factors or underwent non-neurological surgery. When anesthesiologists encounter delayed emergence, NCSE should be listed as a differential diagnosis and examined by MRI and EEG.