Bromisoval-induced bromism with status epilepticus mimicking Wernicke's encephalopathy: report of two cases.

BACKGROUND: Bromine compounds are used in several drugs, including over-the-counter drugs. They sometimes cause intoxication known as bromism. Although the acute neurological symptoms and sequelae of bromism vary, few reports have mentioned acute encephalopathy. CASE PRESENTATION: We report two cases of bromisoval-induced bromism with status epilepticus. Presence of pseudohyperchloremia and history of over-the-counter medication use guided the diagnosis. In the acute phase, our patients showed bilateral medial thalamic lesions on magnetic resonance imaging. The imaging findings were similar to those of Wernicke's encephalopathy. Although these findings improved in the chronic phase, neuropsychiatric sequelae, such as confabulation and amnesia, occurred. CONCLUSION: Bromism can cause acute encephalopathy, and it is important to differentiate it from Wernicke-Korsakoff syndrome.

Anion gap-opening metabolic acidosis and urinary findings in the early diagnosis of ethylene glycol poisoning: A case report.

Causative agent identification is important in the treatment of poisoning. We report the case of a patient who presented with an altered level of consciousness after drinking a fluorescent pink liquid. Upon measuring the anion gap and urinary calcium oxalate level, the patient was diagnosed with early ethylene glycol poisoning.

Current Ventilator and Oxygen Management during General Anesthesia: A Multicenter, Cross-sectional Observational Study.

BACKGROUND: Intraoperative oxygen management is poorly understood. It was hypothesized that potentially preventable hyperoxemia and substantial oxygen exposure would be common during general anesthesia. METHODS: A multicenter, cross-sectional study was conducted to describe current ventilator management, particularly oxygen management, during general anesthesia in Japan. All adult patients (16 yr old or older) who received general anesthesia over 5 consecutive days in 2015 at 43 participating hospitals were identified. Ventilator settings and vital signs were collected 1 h after the induction of general anesthesia. We determined the prevalence of potentially preventable hyperoxemia (oxygen saturation measured by pulse oximetry of more than 98%, despite fractional inspired oxygen tension of more than 0.21) and the risk factors for potentially substantial oxygen exposure (fractional inspired oxygen tension of more than 0.5, despite oxygen saturation measured by pulse oximetry of more than 92%). RESULTS: A total of 1,786 patients were found eligible, and 1,498 completed the study. Fractional inspired oxygen tension was between 0.31 and 0.6 in 1,385 patients (92%), whereas it was less than or equal to 0.3 in very few patients (1%). Most patients (83%) were exposed to potentially preventable hyperoxemia, and 32% had potentially substantial oxygen exposure. In multivariable analysis, old age, emergency surgery, and one-lung ventilation were independently associated with increased potentially substantial oxygen exposure, whereas use of volume control ventilation and high positive end-expiratory pressure levels were associated with decreased potentially substantial oxygen exposure. One-lung ventilation was particularly a strong risk factor for potentially substantial oxygen exposure (adjusted odds ratio, 13.35; 95% CI, 7.24 to 24.60). CONCLUSIONS: Potentially preventable hyperoxemia and substantial oxygen exposure are common during general anesthesia, especially during one-lung ventilation. Future research should explore the safety and feasibility of a more conservative approach for intraoperative oxygen therapy.

[A Case of Well Leg Compartment Syndrome after Robot-assisted Laparoscopic Prostatectomy].

We report a case of well leg compartment syndrome (WLCS) in both legs after robot-assisted laparoscopic prostatectomy (RALP). A 65-year-old man underwent surgery for prostate cancer. He was placed in the lithotomy position and both his legs were protected with elastic stockings and intermittent pneumatic com- pression to prevent deep vein thrombosis during sur- gery. After surgery, he complained of pain in both calves. Movement and sensory disorder along with swelling were found in both legs. Computed tomogra- phy of the legs showed damage to the soleus and gas- trocnemius muscles of both legs. The creatinine phos- phokinase level had increased to 10,560 IU · l⁻¹. The patient was diagnosed with WLCS in both legs and underwent conservative treatment. Symptoms in both legs started to improve from the next day. The right leg swelling receded within 10 days, while the left leg swelling receded 67 days after surgery. WLCS in the legs after RALP is a rare but severe complication requiring early diagnosis and intervention. To prevent WLCS, it is important that we recognize this disease as a potential complication after RALP.

[Delayed emergence from general anesthesia in a dementia patient with Lewy bodies].

A 73-year-old man (164cm height 51 kg body weight) with a history of Parkinson's disease and dementia was scheduled for a cervical lymph node biopsy under general anesthesia. We induced anesthesia with thiamylal and fentanyl, and maintained with sevoflurane and remifentanil without any incident. The patient did not emerge from anesthesia after the surgery. He developed coma and did not respond to painful stimuli. However, his breathing was spontaneous with stable hemodynamics. Although naloxone was given, he was still comatose. His clinical neurological findings showed no organic abnormalities. Forty minutes after the surgery, he suddenly woke up and followed instructions. We learned that previously he had been diagnosed with dementia with Lewy bodies.

[Three cases of perioperative anaphylaxis identified by using skin-prick tests].

We encountered three cases of perioperative anaphylaxis identified by using skin-prick tests. [Case 1] A 43-year-old woman was scheduled to undergo elective laparoscopic subtotal gastrectomy under general anesthesia for gastric tumor. However, the procedure was cancelled because of anaphylaxis that was noted at the beginning of the surgery. We performed a skin-prick test and observed a positive reaction with ro- curonium. [Case 2] A 79-year-old man underwent laparoscopic colon resection under general anesthesia for colon cancer. Anaphylaxis was noted at the end of surgery. We performed a skin-prick test and observed a positive reaction with sugammadex. [Case 3] A 44-year-old woman underwent myomectomy under general anesthesia for a uterine fibroid. Anaphylaxis was noted approximately 10 minutes after the beginning of surgery. We performed a skin-prick test and noted a positive reaction with latex. It is difficult to identify the reason for anaphylaxis during surgery under general anesthesia because various agents may be responsible for the anaphylactic reaction. Anaphylaxis during surgery is a rare but life-threatening event and it is important to identify the causative agent for anaphylaxis.

Clinical benefits of methylprednisolone in off-pump coronary artery bypass surgery.

BACKGROUND: It has not been established whether off-pump coronary artery bypass grafting (OPCABG) is less invasive than conventional CABG. In our experience, OPCABG has several advantages such as shorter operative duration, decreased requirement of blood transfusion and myocardial protection compared with conventional CABG. However, frequency of postoperative paroxysmal atrial fibrillation (PAF) is similar between these techniques and early postoperative C-reactive protein (CRP) levels have been shown to be significantly higher in OPCABG. We hypothesized that preoperative steroid administration, routinely used only in conventional CABG, may alleviate high postoperative PAF and CRP levels. Therefore, a prospective, double-blind, clinical trial was conducted in OPCABG patients to investigate the clinical effects of preoperative steroid administration. METHODS: Thirty OPCABG patients were randomly divided into 2 groups: control (Group C: n = 15) and methylprednisolone (Group M: n = 15) groups. Group M patients were intravenously administered 1000 mg methylprednisolone during anesthesia induction. RESULTS: Hospital death and infectious complication such as mediastinitis were not observed in either group. Postoperative PAF occurred in 47 % (7/15) of patients in group C but in only 1 patient in group M (7 %, P = 0.013). Early postoperative CRP levels were significantly lower in group M than in group C (peak values on postoperative day 2: group M 15 ± 6 mg/dL vs. group C 23 ± 4 mg/dL; P = 0.0002). CONCLUSIONS: Preoperative steroid administration in OPCABG patients significantly suppresses CRP elevation and prevents postoperative PAF without increasing in-hospital mortality or infectious complications.

[Case of circulatory depression in an obese patient in prone position during general anesthesia].

A 25-year-old man [120 kg, 180 cm (body mass index=37 kg x m(-2)] underwent laminectomy and discectomy under general anesthesia in the prone position. Hall frame was used for supporting his body. In spite of a small amount of bleeding, the patient showed metabolic acidosis and hypotension with limb cyanosis one hour after changing position. Ephedrine hydrochloride was effective for the treatment of his hypotension. However, limb cyanosis continued until turning him to the supine position. Anuria continued during prone position. We consider that Hall frame allows patient's abdomen to hang freely, but compresses the body more strongly than expected, especially with heavy patients. It is possible for morbidly obese patients to develop seriously inhibited circulation due to Hall frame. Prone position with careful selection of support system may prevent these complications.