[A Case of Postoperative Paraplegia Caused by Idiopathic Spinal Cord Infarction following Hepatectomy under Both General and Epidural Anesthesia].

A 73-year-old woman (height : 155 cm, weight : 55 kg) was scheduled to undergo a laparotomic hepatectomy and radiofrequency ablation for hepatocellular carcinoma. Her medical history did not include any relevant conditions such as cardiovascular or neurological disorders. A thoracic epidural catheter was introduced at T8-9 before the induction of anesthesia with intravenous propofol. General anesthesia was maintained with the inhalation of oxygen, air, and desflurane, and the continuous infusion of remifentanil. Several intraoperative episodes of mild hypotension occurred, each of which was successfully treated with intravenous ephedrine, but otherwise her anesthetic course was uneventful, and she recovered from the anesthesia smoothly. Her postoperative pain was well controlled with continuous epidural infusion of levobupivacaine and fentanyl, and she could walk by herself on postoperative day (POD) 1. However, she suffered weakness in her lower extremities on POD2 and subsequently fell into complete paraplegia with sensory loss below the T4 level on POD3. A magnetic resonance imaging scan taken on POD4 showed an idiopathic spinal cord infarction (SCI) involving levels T1 through T4, although no epidural abnormalities, e.g., hematomas, were detected. Immediate treatment with methylprednisolone, ozagrel, and edaravone failed to resolve her symptoms. We suggest that it is of great importance to consider SCI as a differential diagnosis as soon as possible in cases of unanticipated postoperative paraplegia.

The use of amplitude-integrated electroencephalography combined with continuous conventional electroencephalography during therapeutic hypothermia for an infant with postnatal cardiac arrest.

INTRODUCTION: Amplitude-integrated electroencephalography (aEEG) has been employed in therapeutic hypothermia (TH) trials of neonates after perinatal hypoxic-ischemic encephalopathy (HIE). We present a case report involving the use of aEEG during TH with continuous conventional electroencephalography (cEEG) for an infant who experienced postnatal intraoperative cardiac arrest. CASE DESCRIPTION: A five-month-old infant developed cardiac arrest during operation. Return of spontaneous circulation was achieved after one hour of cardiopulmonary resuscitation. Therapeutic hypothermia was applied with neuromuscular blockades. During the TH, the brain function and seizures were monitored with aEEG, which can also display continuous cEEG. Intermittent and discrete seizures were detected on aEEG and confirmed with raw cEEG during the TH and rewarming periods. Several kinds of antiepileptic drugs (AEDs) were administered to manage seizures according to the findings of aEEG with cEEG. Seizures were controlled by the treatments, and she showed no clinical seizures after TH and AED discontinuation. DISCUSSION AND EVALUATION CONCLUSIONS: This case indicated the possibility that the use of aEEG with continuous cEEG for a postnatal infant after cardiac arrest was feasible to detect and assess seizures and the effects of antiepileptic therapy while undergoing TH.

[A case of ventricular tachycardia that was probably caused by coronary artery spasm induced by pericardial manipulation].

We present a case of ventricular tachycardia (VT) that was probably caused by coronary artery spasm. A 74-year-old man was scheduled to undergo right lower lobectomy for lung cancer. Although he had never suffered from any episodes of ischemic heart disease, he had several risk factors for coronary artery disease (CAD); i. e., a history of smoking, a low high-density lipoprotein cholesterol level, and diabetes mellitus type 2. Anesthesia for one-lung ventilation was maintained by inhalation of sevoflurane (1-1.5%), the continuous intravenous infusion of remifentanil (0.1-0.15 µg x kg(-1) x min(-1)), and the intermittent administration of epidural (T4-5) 2% mepivacaine (4 ml) and 0.75% ropivacaine (5 ml). During manipulation of the pericardium, the patient's systolic blood pressure suddenly increased to 200 mmHg, followed by an ST elevation on his electrocardiogram. Despite the immediate infusion of nitroglycerin (1 mg), he developed non-sustained VT, lasting for about 30 seconds. Then, diltiazem (0.5 µg x kg(-1) x min(-1)) was continuously administered, and the infusion rate of remifentanil was increased to 0.3 µg x kg(-1) x min(-1). The patient recovered smoothly from anesthesia and his postoperative course was uneventful. Anesthesiologists should be aware of the possibility of coronary artery spasms induced by sudden modulation of the autonomic nervous system, particularly in patients who are at high risk of CAD.

A case of delayed emergence from anesthesia caused by postoperative brain edema associated with unexpected cerebral venous sinus thrombosis.

Cerebral venous sinus thrombosis (CVST) is rare but displays various and often dramatic clinical symptoms. Few cases of CVST have been reported in the field of anesthesiology. We encountered an unexpected case of CVST that presented with delayed emergence from anesthesia after resection of a brain tumor. A 55-year-old man was scheduled for resection of an oligoastrocytoma in his right frontal lobe. After smooth induction of general anesthesia, anesthesia was maintained uneventfully for about 7 h with target-controlled infusion (TCI) of propofol and remifentanil, except for a seizure generated when the right anterior central gyrus was stimulated to allow motor evoked potential monitoring. Immediately after the cessation of TCI, spontaneous respiration was restored. However, the patient was unexpectedly comatose, and no response to painful stimuli or coughing during tracheal suctioning was observed. A computed tomogram taken 2 h after surgery showed diffuse brain edema, even though the neurosurgeons did not notice any cerebral swelling during closing of the dura mater. A magnetic resonance venogram revealed thromboses in the superior sagittal and straight sinuses. On the 9th postoperative day, the patient died without recovering consciousness or his brainstem reflexes. Anesthesiologists should be aware of CVST as a cause of delayed emergence from anesthesia after craniotomy.

Crystallization and preliminary X-ray analysis of human MTH1 with a homogeneous N-terminus.

Human MTH1 (hMTH1) is an enzyme that hydrolyses several oxidized purine nucleoside triphosphates to their corresponding nucleoside monophosphates. Crystallographic studies have shown that the accurate mode of interaction between 8-oxoguanine and hMTH1 cannot be understood without determining the positions of the H atoms, as can be observed in neutron and/or ultrahigh-resolution X-ray diffraction studies. The hMTH1 protein prepared in the original expression system from Escherichia coli did not appear to be suitable for obtaining high-quality crystals because the hMTH1 protein had heterogeneous N-termini of Met1 and Gly2 that resulted from N-terminal Met excision by methionine aminopeptidase from the E. coli host. To obtain homogeneous hMTH1, the Gly at the second position was replaced by Lys. As a result, mutant hMTH1 protein [hMTH1(G2K)] with a homogeneous N-terminus could be prepared and high-quality crystals which diffracted to near 1.1 Šresolution using synchrotron radiation were produced. The new crystals belonged to space group P2(1)2(1)2(1), with unit-cell parameters a = 46.36, b = 47.58, c = 123.89 Å.

[Case of possible transfusion-related acute lung injury during thoracic endovascular aortic repair].

Transfusion-related acute lung injury (TRALI) is a serious complication of blood transfusion, which is characterized by the acute onset of non-cardiogenic pulmonary edema and hypoxemia following the administration of blood products. We report a case of possible TRALI during thoracic endovascular aortic repair (TEVAR). The patient was a 61-year-old man (161 cm in height, 61 kg in weight) who underwent TEVAR for the traumatic injury at the isthmus of aorta. He had a light preexisting lung injury. About 1 hour following the blood transfusion (red cell concentrates, fresh-frozen plasma, and platelet concentrates), he suddenly fell into severe hypoxemia (PaO2 52 mmHg in FI(O2) of 1.0). The radiographic examination showed pulmonary edema, i. e., bilateral infiltrates and pleural effusion. No evidence of circulatory overload was observed. Anti-human leukocyte antigen antibodies in his serum and anti-granulocyte antibodies in the donor blood were detected. In spite of intensive care including artificial ventilation with positive end-expiratory pressure and the administration of methylprednisolone and a granulocyte elastase inhibitor, he died of exacerbated hypoxemia and hypotension 4 hours after the onset of acute lung injury. Of great importance is being aware of an unexpected occurrence of TRALI during and soon after blood transfusion.

Prognostic factors associated with mortality in patients undergoing emergency surgery for abdominal aortic aneurysms.

PURPOSE: Surgical mortality rates following emergency surgery for ruptured abdominal aortic aneurysms (AAAs) remain high. This study investigated the mortality rate and identified prognostic factors affecting mortality in patients undergoing emergency repair of AAAs in our hospital. METHODS: Between January 2005 and June 2010, a total of 42 patients underwent emergency surgery for AAAs and were included in this retrospective study. The following variables concerning each patient were collected by chart review and compared between survivors and nonsurvivors: age; gender; preoperative levels of hemoglobin (Hb), hematocrit (Ht), platelets (Plts), base excess (BE), and serum glucose and lactate; presence of preoperative shock defined as hypotension (systolic blood pressure of less than 80 mmHg); incidence of blood transfusion, whether AAA was ruptured or impending; interval from admission to the hospital or arrival in the operating room until aortic cross-clamping; surgical duration; and volume of intraoperative blood loss and transfusion, total fluid infusion, and urine output. RESULTS: Nine patients died within 30 days postoperatively, a 30-day mortality rate of 21.4%. Among these nine nonsurvivors, eight had shown persistent preoperative shock (P = 0.0004 vs. survivors). Compared with the survivors, nonsurvivors were significantly older (P = 0.0052) and had lower preoperative levels of Hb/Ht (P < 0.0001), Plts (P = 0.0003), and BE (P < 0.0001), an elevated lactate level (P = 0.0048), shorter interval from admission (P = 0.0459) or arrival in the operating room (P = 0.0288) until aortic clamping, and intraoperatively more hemorrhage (P = 0.0038) associated with larger amounts of blood transfusion (P = 0.0083) and less urine output (P = 0.0004). CONCLUSIONS: The authors clarified that certain features such as age, persistent preoperative shock, and greater amounts of transfusion associated with greater blood loss and anemia were factors affecting the mortality in patients undergoing emergency surgery for AAAs. It might be of great importance to correct preoperative shock and anemia caused by massive bleeding before the onset of hemodynamic deterioration.

A case of nonsustained ventricular tachycardia immediately following modified electroconvulsive therapy in a depressive patient.

Modified electroconvulsive therapy (mECT) with the use of hypnotics and muscle relaxants is an optional and prevailing treatment for depression in patients who have failed on antidepressant regimens. We describe a patient who developed ventricular tachycardia (VT) immediately after mECT. A 64-year-old man with no remarkable past history underwent a course of mECT for drug-resistant depression. Anesthesia was induced with intravenous thiopental (150 mg) followed by rocuronium (50 mg). Three minutes after the administration of rocuronium, the brain was electrically stimulated using a pulse wave. The first mECT session was performed uneventfully. However, the second session 2 days later elicited acute hypertension (182/134 mmHg) and tachycardia (130 bpm), resulting in the appearance of single and couplets of premature ventricular contractions on the electrocardiogram followed by VT lasting about 10 s. The chest was immediately compressed several times, then normal sinus rhythm was spontaneously restored without administering antiarrhythmic agents. The patient recovered from anesthesia without complications. Postoperatively, close examination was unable to definitively determine the cause of VT, resulting in the cancellation of subsequent mECT sessions. It is important to bear in mind that mECT can induce life-threatening arrhythmias such as VT.

A case of serious laryngeal edema unpredictably detected during laryngoscopy for orotracheal intubation following induction of anesthesia.

We report a case of unpredictable and serious laryngeal edema probably caused by preoperative esophagogastroduodenoscopy (EGD). A 54-year-old man with type 2 diabetes mellitus was scheduled to undergo coronary artery bypass grafting (CABG). Two days before surgery, EGD was performed to explore the cause of occult bleeding, resulting in a slightly sore throat and an increased white blood cell count (18,300/µl). Without premedication, general anesthesia was uneventfully induced with intravenous midazolam (10 mg) and fentanyl (50 µg), followed by inhalation of sevoflurane (3%) and intravenous rocuronium (50 mg). Thereafter, manual ventilation was easily performed with a bag and mask. However, on laryngoscopy for orotracheal intubation, serious swelling with rubor and light pus in the epiglottis extending to the arytenoid cartilage was detected, leading to the cancellation of surgery. Immediately following intravenous drip of hydrocortisone (300 mg) and bolus of sugammadex (200 mg), the patient recovered smoothly from anesthesia without complications such as dyspnea, but his sore throat persisted. He was diagnosed with acute epiglottitis. Treatment consisted of intravenous cefazolin (2 g/day) and hydrocortisone (300 mg/day tapered to 100 mg/day) for 9 consecutive days. Consequently, the patient recovered gradually from the inflammation and underwent CABG as scheduled 28 days later. Anesthesiologists should be aware that EGD performed just before anesthesia could unpredictably cause acute epiglottitis, especially in immunocompromised patients, such as those with diabetes.

[Factors that affect the mortality in patients receiving emergency surgery for ruptured abdominal aortic aneurysms].

This retrospective study was performed to identify the perioperative factors affecting the mortality rate in 28 patients, who had received emergency surgery for ruptured abdominal aortic aneurysms from January, 2005 to June, 2008. Five (17.9%) of these 28 patients died of massive bleeding, sepsis, or multiple organ failure during or within 11 days after surgery. Various factors which might influence the outcomes were compared between the survivors and non-survivors. Preoperative hypotension defined as a systolic blood pressure < or = 80 mmHg associated with hemorrhagic shock was the only significant factor affecting the mortality. There were no significant differences in age, gender, the time from the admittance to the hospital to aortic cross clamping, duration of surgery, and the amount of blood products transfused and intraoperative blood loss, between the two groups. Of great importance is that preoperative hypotension should be corrected before the onset of hemodynamic deterioration.