Appearance of burning abdominal pain during cesarean section under spinal anesthesia in a patient with complex regional pain syndrome: a case report.

INTRODUCTION: The mechanism of complex regional pain syndrome (CRPS) was reported as being related to both the central and peripheral nervous systems. Recurrence of CRPS was, reportedly, induced by hand surgery in a patient with upper limb CRPS. However, there is no documentation of mechanical allodynia and burning abdominal pain induced by Cesarean section under spinal anesthesia in patients with upper limb CRPS. CASE: We report the case of a patient who suffered from burning abdominal pain during Cesarean section under spinal anesthesia 13 years after the occurrence of venipuncture-induced CRPS of the upper arm. The patient's pain characteristics were similar to the pain characteristics of her right arm during her previous CRPS episode 13 years earlier. In addition, mechanical allodynia around the incision area was confirmed after surgery. We provided ultrasound-guided rectus sheath block using 20 mL of 0.4% ropivacaine under ultrasound guidance twice, which resulted in the disappearance of the spontaneous pain and allodynia. DISCUSSION: The pain relief was probably related to blockade of the peripheral input by this block, which in turn would have improved her central sensitization. CONCLUSION: Our report shows that attention should be paid to the appearance of neuropathic pain of the abdomen during Cesarean section under spinal anesthesia in patients with a history of CRPS.

A prominent Eustachian valve dividing the right atrium imaged by three-dimensional transesophageal echocardiography.

A 63-year-old man underwent transesophageal echocardiography (TEE) to rule out left atrial thrombi prior to cardioversion. Initial two-dimensional TEE with color flow Doppler imaging was suggestive of an atrial septal defect. However, three-dimensional TEE imaging revealed that the unusually large elongated Eustachian valve extended toward the superior vena cava and mimicked the interatrial septum, while the true septum was located more posteriorly than the Eustachian valve. Three-dimensional TEE imaging was crucial to understanding the anatomical relationship between the Eustachian valve and the interatrial septum and hence proved helpful in characterizing this unusual anatomical variant.

Incidence and prognosis of persistent pain induced by venipuncture for blood sampling: an observational study over a 5-year period.

OBJECTIVE: The purpose of this study was to determine the incidence and prognosis of persistent and neuropathic pain induced by venipuncture for blood sampling in clinical practice. DESIGN & SETTING: We investigated the incidence of persistent and neuropathic pain after venipuncture for blood sampling and evaluated the prognosis of patients with neuropathic pain at Nihon University Itabashi Hospital, Japan, based on an observational study. SUBJECTS: Outpatients who required venipuncture for blood sampling at the laboratory room of Nihon University Itabashi Hospital between 2004 and 2008 were included as study subjects. RESULTS: In the present study, of the 587,551 venipunctures performed at our hospital between 2004 and 2008, the incidences of persistent and neuropathic pain after venipuncture were 1 in every 4,418 venipunctures (133/587,551) and 1 in every 30,923 venipunctures (19/587,551), respectively. All the 19 patients who were identified as having neuropathic pain recovered completely. CONCLUSIONS: We demonstrated that the incidence of persistent pain after venipuncture for blood sampling is low and that its prognosis is good.

[Comprehensive evaluation of the effect of triazolam on amnesia during the preoperative period].

BACKGROUND: Triazolam reportedly has greater amnesic potential than other benzodiazepines. The present study was designed to investigate whether this amnesic potential can be applied to surgical patients as premedication, thus relieving them from postoperatively remembering preoperative fears of anesthesia and surgery. METHODS: We prospectively evaluated the effect on amnesia of triazolam administered during the preoperative period in 80 patients between 20-64 years of age (mean, 43.1 +/- 14.3 years) who underwent surgeries for non-malignant diseases under general anesthesia maintained with sevoflurane and nitrous oxide in oxygen throughout the operation, or general anesthesia maintained with the same anesthetics combined with epidural or spinal anesthesia. Patients with diseases or factors influencing the effect of triazolam, such as a history of mental diseases, recent sedative or antihistamine usage, or current sleep disturbances, were excluded from this study. Triazolam was administered to the 80 patients orally at a dose of 0.375 mg 60 minutes prior to entering the operating room. During structured interviews on postoperative day 1, the patients were asked to state what they remembered of the preoperative period. Amnesia was classified based on the patients' last memory before the anesthetic induction as follows: loss of memory from immediately after taking triazolam, loss of memory at departure from the ward, loss of memory at the entrance to the operating room, loss of memory at the operating table and some recall of events at the operating table. RESULTS: Interviews revealed that 26.3% of the patients experienced loss of memory immediately after taking triazolam, this number increasing to 28.8% of the patients at departure from the ward, 35.0% at the entrance to the operating room and 67.5% on the operating table. The remaining patients (32.5%) had some memory of the operating room and table. Triazolam caused no respiratory depression at the operating table, although 2 of the patients experienced dizziness, 1 patient had nausea and 1 patient felt heavy-headed during the period between taking triazolam and the induction of anesthesia. Although 13 patients had delayed emergence from general anesthesia, these patients remaining anesthetized even 5 minutes after the concentration of sevoflurane in the expired gas decreased and remained below 0.1 percent, all these patients emerged immediately after intravenous administration of flumazenil. CONCLUSIONS: The use of triazolam as premedication produced a high incidence of amnesia for preoperative events without causing respiratory depression. Triazolam appears to be a useful premedicant for surgical patients who wish to have no memory at the operating room.

Anesthetic management for mastectomy and total hysterectomy in a 49-year-old woman with type 1 sialidosis: a case report.

BACKGROUND: Sialidosis is an autosomal recessive glycoprotein storage disorder, caused by neuraminidase deficiency which leads to abnormal intracellular accumulation and urinary excretion of sialylated oligosaccharides, resulting in various morphological and functional disorders. Only a few reports have described the anesthetic managements of patients with sialidosis. CASE PRESENTATION: A 49-year-old woman with type 1 sialidosis suffered from all limb contractures, an ocular cherry-red spot, and myoclonic seizures of the limbs. She had been cognitively normal. She was separately scheduled for mastectomy under total intravenous anesthesia and total hysterectomy under combined general and epidural anesthesia uneventfully. CONCLUSIONS: Our patient with type 1 sialidosis received both general and epidural anesthesia uneventfully. Anesthesiologists should carefully assess patients with sialidosis and give careful consideration to individually tailored anesthetic managements.

The Mechanism of Mitral Regurgitant Jets Identified by 3-Dimensional Transesophageal Echocardiography.

This study is a case report, which presents a case of severe mitral regurgitation in a 77-year-old man. Two-dimensional transesophageal echocardiography (TEE), regurgitant jets directed anteriorly in early systole and centrally to laterally in late systole were seen, while three-dimensional TEE showed a flail posterior middle scallop not only angulated centrally, but also laterally, which provided insight into the mechanism of mitral regurgitant jet direction. This case demonstrates the clinical usefulness of 3-dimensional TEE for identifying the mechanism of mitral regurgitant jets. The institution where the figures and the videos were recorded: Division of Cardiology, Mazankowski Alberta Heart Institute, University of Alberta Hospital, Edmonton, Alberta, Canada.

Reflex sympathetic activity after intravenous administration of midazolam in anesthetized cats.

BACKGROUND: Although intrathecal midazolam has been reported to produce antinociceptive effects mediated by gamma-aminobutyric acid type A-benzodiazepine receptor complexes in the spinal cord, the effects of systemic midazolam on nociception remain unclear. We performed this study to examine the effects of IV-administered midazolam on somatosympathetic Adelta and C reflex discharges in brain-intact cats and decerebrate cats (with transection at midbrain level). METHODS: Somatosympathetic Adelta and C reflexes were elicited in the inferior cardiac sympathetic nerve by electrical stimulation of myelinated (Adelta) and unmyelinated (C) afferent fibers of the superficial peroneal nerve in 28 mature cats. After control somatosympathetic reflex responses were obtained, midazolam was administered IV to four groups of randomly allocated cats as follows: brain-intact cats at a dose of 0.03 mg/kg, brain-intact cats at a dose of 0.1 mg/kg, brain-intact cats at a dose of 0.5 mg/kg, and decerebrate cats at a dose of 0.1 mg/kg. RESULTS: C reflex discharges were significantly augmented at the dose of 0.03 mg/kg and significantly depressed at the dose of 0.1 and 0.5 mg/kg in brain-intact cats. C reflex discharges were also significantly depressed at the dose of 0.1 mg/kg in decerebrate cats. CONCLUSIONS: We have demonstrated that IV midazolam produces dose-related effects on somatosympathetic reflex discharges. The clinical implication of these findings is that the effect of midazolam on nociception depends on its dosage. It also appears that the infra-midbrain region plays a major role in mediating the depressive effects of midazolam on somatosympathetic C reflex discharges.

Anesthesia for repair of ventricular septal rupture after acute myocardial infarction.

A surgical patient with ventricular septal rupture after acute myocardial infarction is presented. The primary concern of general anesthesia was in the maintenance of systemic arterial pressure and reduction of afterload. General anesthesia was induced with a combination of fentanyl, ketamine, and propofol, which successfully suppressed fluctuations of hemodynamic variables associated with induction of anesthesia and tracheal intubation. Intravenous milrinone was used for inotropic support and reduction of systemic vascular resistance. The ventricular septal rupture was successfully repaired.

[Pulmonary embolism induced by evacuator during transurethral resection of the prostate].

A 79-year-old man was scheduled to undergo transurethral resection of the hypertrophied prostate during general anesthesia. Anesthesia was maintained with sevoflurane 0.5-1.0% and nitrous oxide 50% in oxygen mixture. Immediately after using an evacuator to remove small resected pieces of the prostate, end-tidal carbon dioxide pressure (EtCO2) decreased suddenly from 31 mmHg to 18 mmHg. Concurrently, decreases in systolic blood pressure from 110 mmHg to 60 mmHg and oxygen saturation from 100% to 95%, and an increase in arterial-alveolar carbon dioxide tension difference (a-ADCO2) were observed. We initially suspected the onset of pulmonary thrombosis as the cause of these events, ventilated the patient's lungs with 100% oxygen and administered 5,000 units of heparine and vasopressors intravenously. However, transesophageal echocardiography done subsequently revealed the presence of strongly echogenic images compatible with the air in the left cardiac atrium and the contribution of the air to those events. The EtCO2, blood pressure, and oxygen saturation improved in about 20 minutes after the initial decrease of the EtCO2 had been detected. Thereafter, surgical procedure was done uneventfully. In routine anesthetic management of transurethral surgery, it should be considered that the sudden deterioration in vital signs may have been caused by evacuator used.

[Anesthesia for cesarean section in a patient with isolated unilateral absence of a pulmonary artery]. / Anestesia para cesariana em paciente com ausência unilateral isolada de artéria pulmonar.

BACKGROUND AND OBJECTIVES: Congenital unilateral absence of a pulmonary artery (UAPA) is a rare anomaly. Although there are several reports regarding pregnancy in patients with unilateral absence of a pulmonary artery, there are no case reports describing anesthesia for Cesarean section in a patient with unilateral absence of a pulmonary artery. CASE REPORT: We present a patient with unilateral absence of a pulmonary artery who underwent Cesarean sections twice at the ages of 24 and 26 years under spinal anesthesia for surgery and epidural analgesia for postoperative pain relief. Both times, spinal anesthesia and epidural analgesia enabled successful anesthesia management without the development of either pulmonary hypertension or right heart failure. CONCLUSION: Spinal anesthesia combined with epidural analgesia is a useful anesthetic method for a Cesarean section in patients with unilateral absence of a pulmonary artery.

Anesthesia for cesarean section in a patient with isolated unilateral absence of a pulmonary artery.

BACKGROUND AND OBJECTIVES: Congenital unilateral absence of a pulmonary artery (UAPA) is a rare anomaly. Although there are several reports regarding pregnancy in patients with unilateral absence of a pulmonary artery, there are no case reports describing anesthesia for Cesarean section in a patient with unilateral absence of a pulmonary artery. CASE REPORT: We present a patient with unilateral absence of a pulmonary artery who underwent Cesarean sections twice at the ages of 24 and 26 years under spinal anesthesia for surgery and epidural analgesia for postoperative pain relief. Both times, spinal anesthesia and epidural analgesia enabled successful anesthesia management without the development of either pulmonary hypertension or right heart failure. CONCLUSION: Spinal anesthesia combined with epidural analgesia is a useful anesthetic method for a Cesarean section in patients with unilateral absence of a pulmonary artery.

Recurrent ST-segment elevations in a patient without significant coronary disease.

We report a case of recurrent ST-segment elevations totaling 7 times over 3 hours during subtotal gastrectomy and the early postoperative period in a patient with no history of coronary artery disease. Possible contributing factors include cold stimulus, epidural anesthesia, and inadequate depth of anesthesia. The first episode almost resulted in cardiac arrest and was treated with intravenous epinephrine. The second episode was associated with ventricular fibrillation, which was treated with defibrillation and intravenous verapamil. The third to the seventh episodes were successfully treated with intravenous nitrate. The electrocardiographic changes and postoperative coronary angiography were consistent with a clinical diagnosis of coronary artery spasm. This case suggests that coronary artery spasm is capable of occurring repeatedly in a cyclic pattern during perioperative periods.

[The effects of intrathecally administered baclofen on somato-sympathetic reflex potentials].

We investigated the antinociceptive effect of intrathecally administered S(-)-baclofen and R (+)-baclofen in cats using somato-sympathetic reflex potentials derived from lumbar sympathetic ganglion by stimulation of the femoral nerve. S(-)-baclofen 10 mg maximally reduced both A reflex potential and C reflex potential to 65.3% and 83.7% of control values, respectively, 1 minute after the administration, but these changes were not significant. The inhibition of A reflex potential at this dosage was greater than that of blood pressure and heart rate induced by the same dosage of S(-)-baclofen. While, R(+)-baclofen 1 mg maximally inhibited A reflex potential to 48.6% of control value 20 minutes after the administration, and this change was significant (P < 0.05). The inhibition of A reflex potential was greater than that of blood pressure and heart rate induced by the same dosage of R(+)-baclofen. This dosage of baclofen reduced C reflex potential to 66.4% of control value 10 minutes after the administration. The degree of reduction of A and C reflex potentials induced by 1 mg of R(+)-baclofen was higher in comparison with that induced by 10 mg of S(-)-baclofen. These reduction of A and C reflex potentials were reversed by 1 to 1.5 mg of intrathecally administered saclofen. These results indicate that R(+)-baclofen has higher potency than S(-)-baclofen and suggest that S(-)-baclofen and R(+)-baclofen show antinociceptive effect by intrathecal administration. On the other hand, it is possible that these two drugs exert antinociceptive effect via A delta fiber.

Anesthesia for cesarean section in a patient with isolated unilateral absence of a pulmonary artery / Anestesia para cesariana em paciente com ausência unilateral isolada de artéria pulmonar

Abstract Background and objectives: Congenital unilateral absence of a pulmonary artery (UAPA) is a rare anomaly. Although there are several reports regarding pregnancy in patients with unilateral absence of a pulmonary artery, there are no case reports describing anesthesia for Cesarean section in a patient with unilateral absence of a pulmonary artery. Case report: We present a patient with unilateral absence of a pulmonary artery who underwent Cesarean sections twice at the ages of 24 and 26 years under spinal anesthesia for surgery and epidural analgesia for postoperative pain relief. Both times, spinal anesthesia and epidural analgesia enabled successful anesthesia management without the development of either pulmonary hypertension or right heart failure. Conclusion: Spinal anesthesia combined with epidural analgesia is a useful anesthetic method for a Cesarean section in patients with unilateral absence of a pulmonary artery.

Resumo Justificativa e objetivos: A ausência congênita unilateral de uma artéria pulmonar (ACAP) é uma anomalia rara. Embora existam vários relatos sobre pacientes grávidas com ACAP, não há relatos de casos que descrevam anestesia para cesariana em pacientes com ACAP. Relato de caso: Apresentamos uma paciente com ACAP que foi submetida a duas cesarianas, aos 24 e 26 anos, sob raquianestesia para a cirurgia e analgesia epidural para a dor no pós-operatório. Nas duas cesarianas, a raquianestesia e a analgesia epidural possibilitaram o manejo bem-sucedido da anestesia, sem a ocorrência de qualquer hipertensão pulmonar ou insuficiência cardíaca direita. Conclusão: Raquianestesia combinada com analgesia epidural é um método anestésico útil para cesarianas em pacientes com ACAP.

Severe back pain following epidural analgesia in patients with spinocerebellar ataxia: a report of two cases.

Two patients with spinocerebellar ataxia received epidural analgesia with no exacerbation of their symptoms. The patients developed transient, but extremely severe, low back pain as a result of the epidural analgesia.