[Femoral and sciatic nerve blocks for open reduction and internal fixation of a femoral condylar fracture in a patient with post-polio syndrome].

The post polio symdrome (PPS) refers to the development of delayed neuromuscular symptoms among survivors, years after the initial presentation of acute poliomyelitis. The symptoms of PPS vary widely and include flaccid palsy, muscle weakness, scoliosis, osteoarthritis, gait disturbance, sleep apnea syndrome (SAS), dysphagia, chronic lung dysfunction, and others. We report the successful combination of peripheral nerve blocks, femoral and sciatic nerve blocks, for surgery on the lower extremity in a patient with PPS. A 51-year-old man with continuous positive airway pressure therapy for restrictive ventilatory impairment due to scoliosis and SAS as part of the PPS was scheduled for open reduction and internal fixation (OR-IF) for a right femoral condylar fracture. Respiratory function tests demonstrated a vital capacity (VC) 1.41l (41% predicted). Arterial blood gas analysis on room air was; pH 7.376, PaCO2 55.0 mmHg, and PaO2 77.9 mmHg. With the patient in the supine position, ultrasound-guided right femoral nerve block in the infra-inguinal region was performed using 1.5% mepivacaine 10 ml and 0.75% ropivacaine 5 ml, followed by sciatic nerve block in the popliteal fossa using 1.5% mepivacaine 8 ml and 0.75% ropivacaine 4 ml in the prone position. OR-IF of the fractured femoral condyle was then successfully performed with propofol under spontaneous ventilation. Postoperatively, there were no adverse events; respiratory function was adequate, and his pain was within manageable bounds. Femoral and sciatic nerve blocks are safe and effective anesthetic methods for lower extremity surgery in patients with restrictive ventilatory impairment and hypercapnia due to scoliosis and SAS as PPS.

[Tracheal intubation in patients with Williams syndrome].

Williams syndrome is caused by the deletion of genetic material from chromosome 7, including the elastin gene. Affected individuals frequently have connective tissue disorders and skeletal hypoplasia, resulting in micrognathia and mandibular retrusion. These conditions hinder adequate visualization of the larynx and render intubation difficult. We used different methods of tracheal intubation for two patients with Williams syndrome. The first case was a 35-year-old woman with micrognathia, mandibular retrusion, and a Mallampati class III airway, scheduled for mitral valve replacement. She had a three fingerbreadth oral aperture, 3.0 cm mandibulohyoid distance, and 30 degree neck flexion. Since she had previously been successfully intubated at age 18 for patch enlargement of the aorta and extended aortoplasty, we elected to use intravenous anesthetic agents for this intubation. After administration of diazepam and fentanyl, mask ventilation was difficult and the direct laryngoscopic view was Cormack grade IV. Fortunately, blind orotracheal intubation using a Mallinckrodt tracheal tube with direct laryngoscopy was accomplished on the first attempt. The second case was a 71-year-old woman with micrognathia, slight mandibular retrusion, macroglossia, and a Mallampati class IV airway, scheduled for sigmoidectomy and insertion of a ureteral stent. She had a 2.5 fingerbreadth oral aperture, 4.0 cm mandibulohyoid distance, and 30 degree neck flexion. From our experience with the first patient, we expected difficult ventilation and intubation. After 8% lidocaine spray to the larynx, and then 4% lidocaine spray to the vocal cords and trachea using a bronchoscope, we accomplished awake, fibreoptic-guided orotracheal intubation easily and quickly on the first attempt using a Parker Flex-Tip tube. Difficult tracheal intubation should be anticipated in Williams syndrome patients. Awake, fibreoptic-guided technique is easier and safer than direct laryngoscopy for intubating such patients.

[Intermittent bradycardia-dependent bundle branch block during sevoflurane and remifentanil anesthesia].

Cardiac arrhythmia and bradycardia occasionally occur from the effect of inhaled anesthetic agent and opioid on cardiac conduction. We experienced a case of intermittent bradycardia-dependent bundle branch block (IBDBBB) during sevoflurane and remifentanil anesthesia. A 17-year-old woman suffering from recurrent left ottitis media was scheduled for tympanoplasty under general anesthesia. Her preoperative electrocardiogram (ECG) revealed normal sinus rhythm at heart rate (HR) of 48 beats x min(-1). Her tracheal was intubated following anesthesia induction with propofol and vecuronium, and anesthesia was maintained using inhalation of 40% oxygen with air and 1.5-2.0% sevoflurane, and continuous venous infusion of remifentanil at a rate of 0.15 microg x kg(-1) min(-1). Two hours 20 minutes after starting operation, the P-P interval was constant but the waveforms of low and broad QRS complexes appeared intermittently on the ECG monitor. The blood pressure remained stable at 95/55 mmHg and the HR decreased to 46 beats x min(-1). The waveform of pulse oxymetric oxygen saturation (Spo2) did not change. We diagnosed the ECG pattern as IBDBBB. After intravenous injection of atropine 0.5 mg, the waveforms of QRS complexes recovered to normal sinus rhythm at HR 90 beats x min(-1). Sevoflurane and remifentanil in adolescence could induce ventricular conduction disturbance and result in IBDBBB. Atropine could be effective for IBDBBB induced by sevoflurane and remifentanil.