Challenges in removing an aged spinal cord stimulator: A case study of complete fracture in a 9-year-old S-series paddle lead.

INTRODUCTION: This case report presents an instance of an S-Series™ slim paddle lead fracturing during extraction, highlighting potential risks associated with the removal of this lead. CASE REPORT: A 47-year-old male with complex regional pain syndrome type 2, unresponsive to pharmacotherapy, had undergone the implantation of two spinal cord stimulator (SCS) leads, an Octrode™ cylindrical and an S-series™ slim paddle, using the Epiducer™ system (St Jude Medical) 9 years earlier, with a subsequent intrathecal baclofen pump installed 1 year after SCS. Initially, these interventions stabilized the patient's pain symptoms. However, the diminishing effectiveness of SCS, coupled with a decrease in battery life and increased opioid consumption, necessitated recent surgical procedures. These included the removal and replacement of the implantable pulse generator (IPG) and leads to improve pain management and ensure MRI compatibility. During the removal of the S-series™ slim paddle type lead, complications arose, leading to the retention of an electrode fragment, which necessitated abandoning the replacement of both the IPG and lead. Post-surgical assessments revealed no new neurological impairments, and imaging studies confirmed the stable position of the retained fragment. The patient was discharged with a continued comprehensive pain management plan. CONCLUSION: This case highlights the challenges and risks of percutaneous removal of slim paddle type leads, emphasizing the need for careful procedural planning and consideration of surgical options to avoid complications. Further research is needed to evaluate the long-term durability and removal risks of various SCS lead types.

Transurethral resection of the prostate syndrome with severe lactic acidosis due to the use of sorbitol-mannitol irrigating fluid: A case report.

We report a case of transurethral resection of the prostate (TURP) syndrome with mild hyponatremia, severe lactic acidosis, and hypotension. A 73-year-old man with benign prostatic hyperplasia underwent monopolar TURP. Two episodes of hypotension occurred during the operation. These were corrected after injection of a bolus of ephedrine. After the operation, the hypotension persisted and lactic acidosis worsened. Abdominal distension was evident postoperatively. Abdominal ultrasound and computerized tomography revealed a large amount of fluid in the abdominal cavity. We suspected the leakage of sorbitol-containing irrigating fluid. After percutaneous drainage, the lactic acidosis resolved and hypotension stabilized.

Effect of Remifentanil on Postoperative Vomiting After Strabismus Surgery in Preschool Children: A Prospective Randomized Controlled Trial.

Background: Strabismus surgery and the use of opioid are risk factors of postoperative vomiting. We evaluated whether there is a dose-dependent effect of remifentanil on the incidence of postoperative vomiting. Methods: Sixty pediatric patients who were scheduled for strabismus surgery were enrolled. Patients were randomly divided into three groups; Group H (high-dose remifentanil group), Group L (low-dose remifentanil group), and Group C (control group). After endotracheal intubation, patients in the Group H and L received an intravenous bolus dose of remifentanil of 1.0 µg/kg and 0.5 µg/kg over 2 min, respectively. Group H and L patients received a continuous infusion of remifentanil (0.1 µg/kg/min) during the surgery. The patients in Group C did not have any dose of remifentanil. Intravenous fentanyl (1 µg/kg) was administered to the patients for postoperative pain control. Results: The primary outcome was a difference of the incidence of postoperative vomiting within 24 hours after surgery. There was no significant difference in incidence of postoperative vomiting between three groups. The degree of emergence agitation and postoperative pain did not show any significant difference between three groups. Conclusions: The intraoperative administration of remifentanil did not show dose-dependent effect on postoperative vomiting in pediatric strabismus surgery.

Effect of performing preoperative echocardiography in patients with cardiovascular risk on intraoperative anesthetic management and postoperative outcomes: A retrospective study.

Although echocardiography is widely used for preoperative cardiac risk evaluation, few studies have analyzed the effect of performing preoperative echocardiography on intraoperative anesthetic management and postoperative outcomes. We investigated the effect of performing echocardiography on intraoperative anesthetic management and postoperative outcomes in patients with cardiovascular risk. We retrospectively evaluated patients who had undergone major abdominal surgery and satisfied 2 or more of the following criteria: hypertension, diabetes mellitus, age ≥70 years, and previous cardiac disease. Patients were categorized into a group in which preoperative echocardiography was performed (echo) and a group in which it was not (non-echo). The primary outcomes were postoperative 30-day mortality and incidence of cardiovascular complications. Secondary outcomes were length of hospital stay, intraoperative incidence of hypotension, use of vasopressors, and findings on intraoperative invasive hemodynamic monitoring. There were no differences in 30-day mortality, incidence of postoperative cardiovascular complications, length of hospital stay, and intraoperative events between the groups. Only the incidence of cardiac output monitoring was lower in the echo group than in the non-echo group (59.6% vs 73.9%). Preoperative echocardiography does not affect postoperative outcomes, but it has the potential to affect intraoperative anesthetic management such as invasive hemodynamic monitoring during surgery.

Comment to: The utility of ultrasound examination in cubital tunnel syndrome caused by heterotopic ossification.

Ultrasound (US) could visualize the pathological anatomy of HO and the enlargement site and compression location of the nerve in the cubital tunnel [1]. We read with great interest the article of Jacisko et al[2]. In addition, we report rare US images of HO in direct contact with the swollen ulnar nerve in the cubital tunnel that was not detected by plain radiography. A 60-year-old female presented with a six-month history of elbow pain. Her pain was located at the medial side of the right elbow joint and accompanied by numbness of the fifth finger. She had a history of excessive manual labor due to her occupation as a gardener over the past few decades. The numbness began with the fifth finger initially and gradually extended toward the medial side of the elbow joint. US images showed hyperechoic masses causing acoustic shadowing, in direct contact with the ulnar nerve in the cubital tunnel. The HO seems to be related to compression of the ulnar nerve. The ulnar nerve was swollen (Figure 1-a, b). The maximal cross-sectional-area was 0.10 cm2. Plain elbow radiographs demonstrated osteophyte formation in the coronoid process of the ulna, the coronoid fossa of the humerus, and in the radial head (Figure 1-c). Radiographic imaging showed no heterotopic bone formation in the soft tissues surrounding the medial side of the right elbow. We performed US-guided perineural injection with a mixture of 1 cc of 10 mg triamcinolone and 3 cc of 0.2 % ropivacaine. Her pain and numbness gradually diminished with no adverse effects. Her pain reduced by 70% after two weeks, with pain improvement sustained for 6 months after the injection. Jacisko et al[2]have presented some diagnostic US imaging on neuropathy caused by HO located close to the ulnar nerve in the cubital tunnel. Especially, this case showed definite heterotopic bone formation in the soft tissue surrounding the medial side of the elbow on plain radiography. The classic sonographic patterns of HO were defined by the presence of central hypoechoic area surrounded by foci of calcification [3, 4]. The distortion of normal soft tissue and the formation of hypoechoic areas, with or without foci of calcification can also be shown as early signs[3, 4]. The use of US for HO is highly sensitive and provides an earlier diagnosis compared with other radiologic modalities [3-5]. It can be an effective treatment strategy and may improve the prognosis of neuropathy. We highlight that US evaluation can provide early diagnostic information about ulnar nerve morphology and various HO formations even if plane radiographs did not show heterotopic bone formation in the soft tissues surrounding the medial side of the elbow.

Correlation Between Anthropometric Measurements and Sensory Block Level of Spinal Anesthesia for Cesarean Section.

BACKGROUND: When performing spinal anesthesia for cesarean section, it is important to determine the appropriate anesthetic dose as well as to predict the level of spinal anesthesia. In this study, it was hypothesized that some anthropometric measurements may be related to maximum sensory block and hemodynamic changes. OBJECTIVES: The aim of this study are to find maternal anthropometric values that are correlate with the level of spinal anesthesia. METHODS: Maternal anthropometric measurements, including height, weight, supine and standing abdominal circumference (AC), and hip circumference, were recorded before spinal anesthesia for cesarean section. Spinal anesthesia was induced by administering 8 mg of 0.5% hyperbaric bupivacaine and 20 µg of fentanyl at the L3-L4 interspace. The level of sensory block was determined using pin-prick at 1, 5, 10, and 15 minutes after spinal anesthesia. The sensory block level and hemodynamic adverse events were analyzed in relationship to anthropometric measurements. RESULTS: The supine AC/height ratios significantly correlate with the maximal sensory block level at 5, 10, and 15 minutes after the injection of spinal anesthetic (P = 0.001, P < 0.001 and P < 0.001, respectively). Further, there were significant correlations between body mass index (BMI) and sensory block level at every assessment (P = 0.041, P = 0.002, P = 0.001 and P < 0.001, respectively). When comparing the groups with and without hypotension, BMI, weight, and supine AC/height ratio were found to be significantly higher in the group with hypotension (P = 0.002, P = 0.004 and P = 0.006, respectively). CONCLUSIONS: We conclude that BMI and AC/height ratio correlate with the sensory block level of spinal anesthesia for cesarean section.

Effect of phenylephrine infusion on hypotension induced by the beach chair position: A prospective randomized trial.

BACKGROUND: The beach chair position (BCP), used during shoulder surgery, is associated with hypotension, bradycardia, and risk of cerebral hypoperfusion. Phenylephrine is commonly used as a first treatment of choice of intraoperative hypotension during surgery. We evaluated the hemodynamic effects of 2 doses of intravenous phenylephrine infusion administered before being placed in BCP for arthroscopic shoulder surgery. The primary endpoint was the incidence of hypotension after positional change. METHODS: Sixty-six patients were randomized to receive either intravenous normal saline (group NS) or intravenous phenylephrine infusion (0.5 µg/kg/min, group LP or 1.0 µg/kg/min, group HP) for 5 minutes before being placed in the BCP. Mean arterial pressure(MAP), heart rate, stroke volume variation, and cardiac index were measured before and after positional change. RESULTS: The total incidence of hypotension after the BCP was 93.65%, but was not significantly different among the 3 groups. However, there was a significant difference in trends between the groups for MAP for 5 minutes after BCP (P = .028). Comparison of changes in MAP at 1 minute compared to post-induction MAP was significantly different between group HP and group NS (P = .014). CONCLUSION: Infusion of 0.5 and 1.0 µg/kg/min of phenylephrine for 5 minutes before the BCP has no preventive effect for incidence of hypotension. However, this study showed that 1.0 µg/kg/min of phenylephrine infusion for 5 minutes can attenuate the severity of hypotension.

Effect of depth of anesthesia on the phase lag entropy in patients undergoing general anesthesia by propofol: A STROBE-compliant study.

The PLEM100 (Inbody Co., Ltd., Seoul, Korea) is a device for measuring phase lag entropy (PLE), a recently developed index for the quantification of consciousness during sedation and general anesthesia. In the present study, we assessed changes in PLE along with the level of consciousness during the induction of general anesthesia using propofol. PLE was compared with the bispectral index (BIS), which is currently the most commonly used index of consciousness.After obtaining Institutional Review Board approval and written informed consent, we enrolled 15 patients (8 men, 7 women; mean age: 37 ±â€Š9 years; mean height: 168 ±â€Š8 cm; mean weight; 68 ±â€Š11 kg) undergoing nasal bone reduction. PLE and BIS sensors were attached simultaneously, and general anesthesia was induced via target-controlled infusion (TCI) of propofol. PLE and BIS scores were recorded when the calculated effect site concentration shown on the TCI pump was equal to the target concentrations of 1.5, 2.0, 2.5, 2.8, 3.0, 3.2, 3.4, and 3.5 µg/mL (and at each 0.1 µg/mL increase, thereafter). Observer's Assessment of Alertness/Sedation (OAA/S) scores were also recorded until unconsciousness was achieved. Throughout the anesthesia period, all pairs of PLE and BIS data were collected using data acquisition software.The partial correlation coefficients between OAA/S scores and PLE, and between OAA/S scores and BIS were 0.778 (P < .001) and 0.846 (P < .001), respectively. Throughout the period of anesthesia, PLE and BIS exhibited a significant positive correlation. The partial correlation coefficient prior to the loss of consciousness was 0.838 (P < .001), and 0.669 (P < .001) following the loss of consciousness. Intra-class correlation between the 2 indices was 0.889 (P < .001) and 0.791 (P < .001) prior and following the loss of consciousness, respectively.PLE exhibited a strong and predictable correlation with both BIS and OAA/S scores. These results suggest that PLE is reliable for assessing the level of consciousness during sedation and general anesthesia.

Analgesia for spinal anesthesia positioning in elderly patients with proximal femoral fractures: Dexmedetomidine-ketamine versus dexmedetomidine-fentanyl.

Elderly patients with femoral fractures are anticipated to endure the most pain caused by positional changes required for spinal anesthesia. To improve pain relief, we compared the analgesic effects of intravenous dexmedetomidine-ketamine and dexmedetomidine-fentanyl combinations to facilitate patient positioning for spinal anesthesia in elderly patients with proximal femoral fractures. Forty-six patients were randomly assigned to two groups and received either 1 mg/kg of intravenous ketamine (group K) or 1 µg/kg of intravenous fentanyl (group F) concomitant with a loading dose of dexmedetomidine 1 µg/kg over 10 minutes, then dexmedetomidine infusion only was continued at 0.6 µg/kg/h for following 20 minutes, and titrated at a rate of 0.2 to 0.6 µg/kg/h until the end of surgery. After completion of the infusion of either ketamine or fentanyl, the patients were placed in the lateral position with the fracture site up. The pain score (0 = calm, 1 = facial grimacing, 2 = moaning, 3 = screaming, and 4 = unable to proceed because of restlessness or agitation) was used to describe the pain intensity in each step during the procedure (lateral positioning, hip flexion, and lumbar puncture), and quality score (0 = poor hip flexion, 1 = satisfactory hip flexion, 2 = good hip flexion, and 3 = optimal hip flexion) was used to describe the quality of posture. Group K showed a median pain score of 0 (0-1), 0 (0-0) and 0 (0-0) in lateral positioning, hip flexion and lumbar puncture, respectively, while group F showed a score of 3 (2.75-3), 3 (2-3) and 0 (0-1), respectively. The pain score in lateral positioning (P < .0001) and hip flexion (P < .0001) was significantly lower in group K than group F. Group K showed the significantly higher quality scores of spinal anesthesia positioning (P = .0044) than group F. Hemodynamic adverse effects, such as bradycardia, hypotension, and desaturation, were not significantly different between the groups. The administration of dexmedetomidine-ketamine showed a greater advantage in reducing pain intensity and increasing the quality with patient positioning during spinal anesthesia in elderly patients with proximal femoral fractures, without any serious adverse effects.

Extremely Low Frequency Electromagnetic Field from Convective Air Warming System on Temperature Selection and Distance.

BACKGROUND: Hypothermia generates potentially severe complications in operating or recovery room. Forced air warmer is effective to maintain body temperature. Extremely low frequency electromagnetic field (ELF-EMF) is harmful to human body and mainly produced by electronic equipment including convective air warming system. We investigated ELF-EMF from convective air warming device on various temperature selection and distance for guideline to protect medical personnel and patients. METHODS: The intensity of ELF-EMF was measured as two-second interval for five minutes on various distance (0.1, 0.2, 0.3, 0.5 and 1meter) and temperature selection (high, medium, low and ambient). All of electrical devices were off including lamp, computer and air conditioner. Groups were compared using one-way ANOVA. P<0.05 was considered significant. RESULTS: Mean values of ELF-EMF on the distance of 30 cm were 18.63, 18.44, 18.23 and 17.92 milligauss (mG) respectively (high, medium, low and ambient temperature set). ELF-EMF of high temperature set was higher than data of medium, low and ambient set in all the distances. CONCLUSION: ELF-EMF from convective air warming system is higher in condition of more close location and higher temperature. ELF-EMF within thirty centimeters exceeds 2mG recommended by Swedish TCO guideline.