Cholinergic Crisis with Normal Serum Cholinesterase Levels due to Excessive Galantamine Ingestion: A Case Report.

Galantamine is a cholinesterase inhibitor employed in Alzheimer's disease management. Cholinesterase inhibitors are associated with potential cholinergic side effects that, when severe, can result in cholinergic crises. Although crises induced by other cholinesterase inhibitors, such as distigmine and rivastigmine, have been reported, cases of galantamine-induced cholinergic crises remain undocumented. This study presents a case of cholinergic crisis triggered by galantamine overdose in an 89-year-old woman weighing 37 kg with Alzheimer's disease history, even though her serum cholinesterase levels were normal. The patient overdosed on 264 mg of galantamine, leading to rapid deterioration, marked by restlessness, tremors, sweating, diarrhea, pharyngeal gurgling, and severe hypoxia. Upon arrival at the emergency department, the patient exhibited pinpoint pupils, compromised airway, and low oxygen saturation, necessitating immediate intubation and transfer to the intensive care unit. After 72 h, the patient successfully recovered and was weaned off mechanical ventilation, maintaining normal serum cholinesterase levels. Animal studies suggest a lethal galantamine threshold of 3 to 6 mg/kg in humans. Unlike other cholinesterase inhibitors that typically reduce serum cholinesterase levels during cholinergic crises, galantamine appears to selectively inhibit acetylcholinesterase, possibly sparing butyrylcholinesterase. This selectivity may explain the normal serum cholinesterase levels.

Position-Dependent Symptoms of Pneumothorax During Mechanical Ventilation: A Case Report.

A 54-year-old male with severe hypoxia was transferred to our hospital after choking on a mochi. Chest computed tomography revealed negative pressure pulmonary edema without pneumothorax. Endotracheal intubation was performed, and pressure-controlled ventilation was initiated. Following admission to the intensive care unit, his respiratory condition was stable in both the supine and left decubitus positions. However, every time he was placed in the right decubitus position, the tidal volume decreased by half, and SpO2 dropped rapidly to 80%, which recovered soon after returning to the supine position. Chest radiography was performed the following day, revealing grade II right pneumothorax, and a chest tube placement stabilized his respiratory status in the right decubitus position. Air leakage ceased within a few hours. Extubation was successful on the fifth hospital day, and the chest tube was removed on the eighth hospital day. To our knowledge, there are no previous reports on position-dependent symptoms of pneumothorax during mechanical ventilation. Clinicians should consider the possibility of pneumothorax on that same side when respiratory deterioration is observed only in one lateral decubitus position during mechanical ventilation.

Spontaneous hyperinflation of a giant bulla of the non-ventilated lung during laparoscopic cholecystectomy under one-lung ventilation: a case report.

BACKGROUND: Anesthetic management of non-thoracic surgery in patients with giant bullae is challenging. We present a case of laparoscopic cholecystectomy in a patient with a giant bulla managed with one-lung ventilation (OLV). CASE PRESENTATION: A 75-year-old man with a giant bulla occupying the lower half of the right hemithorax underwent laparoscopic cholecystectomy. We managed anesthesia with OLV to avoid positive pressure ventilation of the giant bulla. Surgery was completed uneventfully; however, postoperative chest radiography indicated a large lucency occupying the entire right hemithorax. Although we suspected a pneumothorax due to a ruptured bulla, chest computed tomography (CT) led to a diagnosis of giant bulla hyperinflation. The giant bulla deflated gradually to its preoperative size within three postoperative days. CONCLUSIONS: Managing laparoscopic cholecystectomy in a patient with a giant bulla with OLV resulted in spontaneous hyperinflation of the giant bulla. Chest CT ruled out a pneumothorax.

The role of CRF1 receptors for sympathetic nervous response to laparotomy in anesthetized rats.

Corticotropin-releasing factor (CRF) is released in response to various types of stressors and mediates endocrine, autonomic, immune, and behavioral responses to stress through interaction with CRF1 and CRF2 receptors. To investigate the role of CRF1 receptors in physiological responses to surgical stress, we analyzed the effects of two different non-peptide selective CRF1 receptor antagonists (JTC-017 and CP-154,526) and a peptide non-selective CRF receptor antagonist (astressin) on laparotomy-induced sympathetic nervous responses in isoflurane-anesthetized rats. JTC-017, CP-154,526, and astressin similarly suppressed plasma ACTH elevation induced by laparotomy. JTC-017 and CP-154,526 significantly augmented plasma noradrenaline and adrenaline responses to laparotomy, while astressin showed no effect on these responses. Laparotomy-induced maximum increases in mean blood pressure and heart rate were augmented by JTC-017, but were not affected by astressin. The results suggested for the first time that there was a pathway to attenuate sympathetic nervous response to surgical stress through CRF1 receptors in the central nervous system.

Conversion of atrial fibrillation to sinus rhythm during landiolol infusion.

A 71-year-old woman with a history of persistent atrial fibrillation underwent clipping of a ruptured cerebral artery aneurysm. During the surgery her cardiac rhythm was atrial fibrillation and the ventricular rate increased to 130 beats.min(-1). Administration of landiolol was started with 1-min loading infusion at 0.125 mg.kg(-1).min(-1) and continuous infusion at 0.04 mg.kg(-1).min(-1), which was effective in controlling the ventricular rate without causing hypotension. Approximately 120 min after the landiolol infusion was started, the atrial fibrillation was converted to sinus rhythm. Her sinus rhythm was maintained until she left the operating room, even after discontinuation of landiolol.

[Epidural anesthesia for ileocecectomy in a patient with severe aortic stenosis].

Severe aortic stenosis is a significant risk factor for perioperative cardiac morbidity and mortality in patients undergoing noncardiac surgery. We experienced a case of a 74-year-old female with symptomatic aortic stenosis who underwent ileocecectomy for ileocecum cancer. She frequently complained of chest pain and fell into syncope when she walked a short distance. Preoperative catheter study revealed severe aortic stenosis in which valve area was 0.5 cm2 and pressure gradient between the left ventricle and the aorta was 101 mmHg. To avoid abrupt hemodynamic change that would accompany induction of and emergence from general anesthesia, we chose epidural anesthesia. Though hypotension was expected following epidural anesthesia, adequate fluid loading and intermittent phenylephrine administration was effective for maintaining hemodynamic stability throughout the operation. Perioperative course was uneventful with no cardiac complication.