Prolonged neuromuscular blockade and insufficient reversal after sugammadex administration in cesarean section under general anesthesia: a case report.

BACKGROUND: We present a rare case of prolonged neuromuscular blockade and insufficient reversal after sugammadex administration in a pregnant patient being treated with magnesium sulfate and nifedipine undergoing cesarean section under general anesthesia. CASE PRESENTATION: A 37-year-old woman at 34 weeks gestation, weighing 42.5 kg, and receiving magnesium sulfate 94 mg/kg for preeclampsia and nifedipine 20 mg, underwent cesarean section under general anesthesia for abruptio placentae. Her trachea was intubated after administering rocuronium 0.94 mg/kg. Postoperatively, sugammadex 4.7 mg/kg was administered at post-tetanic count 2, 163 min after rocuronium administration. However, 9 min after sugammadex administration, the train-of-four ratio only reached 0.7. Fifteen min after sugammadex administration, extubation was successfully performed when the train-of-four ratio reached 0.9 after administration of atropine 0.5 mg and neostigmine 1.0 mg. CONCLUSIONS: Caution is required in pregnant women on high-dose magnesium sulfate with nifedipine, which may cause prolongation of neuromuscular blockade and insufficient reversal.

Selecting an Appropriate Cuffed Endotracheal Tube Using Ultrasound of the Cricoid in a Child with Down Syndrome.

A 7-year-old girl (height, 94 cm; weight, 15.1 kg) with Down syndrome was scheduled for right patellar dislocation repositioning. The ultrasonographically measured internal transverse width of the cricoid before intubation was 7.8 mm. Attempted insertion of a cuffed Mallinckrodt® endotracheal tube (ETT) (internal diameter, 5.0 mm; deflated cuff portion, 8.4 mm diameter) failed. In contrast, the insertion of a cuffed Microcuff® ETT (5.0 mm ID; deflated cuff portion, 7.3 mm diameter) was successful. Thicker folds in the deflated cuff of the Mallinckrodt ETT could have hindered passage through the vocal cord, including the cricoid region. It is becoming standard to use the ultrasonographically measured internal width of the cricoid when choosing cuffed paediatric ETTs, and this approach may be suitable for patients with Down syndrome as well. In these children, approximately 20% of uncuffed ETTs inserted were one or two sizes smaller in diameter than those predicted for the same age. We may choose the ETT size in reference to an ultrasonographically obtained internal transverse width of the cricoid, stated outer diameter (OD) by the producer, and the actual OD depending on the cuff bulk instead of a tube size calculation in patients with growth retardation.

Adjusting Pediatric Endotracheal Tube Depths Relative to the Cricoid by Using Longitudinal Ultrasound Images of the Saline-Inflated Cuff in the Trachea: Two Case Reports.

Cuff positions of endotracheal tubes should be confirmed to ensure safe anesthesia. However, determining the cuff positions relative to the cricoid by using chest radiography or fiberoptic bronchoscopy is difficult. We identified the cephalad edges of saline-inflated pediatric endotracheal tube cuffs relative to the cricoid on longitudinal ultrasound images over the larynx and trachea in 2 children. Thereafter, we adjusted the endotracheal tube depths and confirmed the cuff positions relative to the cricoid. Longitudinal ultrasound images over the larynx and trachea can help confirm the distance from the caudal edge of the cricoid to the saline-inflated cuff.

Difficulty in inserting left double-lumen endobronchial tubes at the cricoid level in small-statured women: A retrospective study.

BACKGROUND AND AIMS: Left double-lumen endobronchial tube (DLT) sizes are selected using tracheal diameters and left mainstem bronchial diameters (LMBDs) determined from chest radiographs or computed tomography (CT) scans. In Western women, 35-Fr or 37-Fr DLTs are often selected. However, difficulties can be encountered when inserting 32-Fr or 35-Fr DLTs in Japanese women. We investigated success rates for 32-Fr or 35-Fr DLT insertion in Japanese women and determined the causes of unsuccessful DLT insertion. METHODS: We searched anaesthesia records of Japanese women aged ≥20 years who underwent thoracic surgery with 32-Fr or 35-Fr DLTs between April 2010 and March 2015 in our hospital. In the successful group (SG), patients were intubated using the initially selected DLTs. By contrast, in the unsuccessful group (UG), the DLT size had to be changed. The Mann-Whitney U-test and Fisher's exact test were used to compare groups. RESULTS: The SG included 149 (96.1%) of 155 cases of 32-Fr DLT use and 119 (95.2%) of 125 cases of 35-Fr DLT use. Patient height was significantly lower in the UG than in the SG for the 35-Fr DLT (P = 0.0036). In seven of 12 UG patients (three for 32-Fr and four for 35-Fr), the transverse diameters of cricoid cartilages were smaller than the DLTs' tracheal diameters, thereby preventing passage through the cricoid cartilages. CONCLUSION: Along with LMBDs, transverse diameters of cricoid cartilages based on CT scans or ultrasonogram findings may help in selecting the appropriate left DLT size.

Difficulty Inserting Cuffed Endotracheal Tubes in a Child: A Case Report.

We experienced difficulty inserting cuffed inner diameter (ID) 4.5- and 5.0-mm endotracheal tubes (ETTs) in a 5-year-old boy. Postoperative ultrasound investigations showed that the internal transverse width of the cricoid cartilage was 8.0 mm. The maximum outer diameter (OD) of the deflated cuff portion of the cuffed ID 4.5- and 5.0-mm ETTs was 8.5 and 9.6 mm, respectively. The OD of an uncuffed ID 5.5-mm ETT was 7.6 mm; this tube passed the cricoid cartilage. Hence, the transverse width of the cricoid cartilage and ETT diameter including cuff folds should be considered when selecting cuffed ETTs.

[Hemodynamic Management of a Patient at Risk for Stroke Using Regional Cerebral Oxygen Saturation Monitoring and an Arterial Pressure-based Cardiac Output and Stroke Volume Measuring System].

An 88-year-old man, 155 cm in height and 45 kg in weight, was scheduled for total stomach extirpation. Partial cerebral infarction and cerebral arterial stenosis were diagnosed 20 days before the operation. The patient's mean arterial pressure was 80 mmHg. Regional brain 02 saturation (rSO2) obtained via non- invasive monitoring using the INVOS™ system was above 65% on both sides, and these were used as con- trol values before anesthesia induction. Anesthesia was induced with propofol 50 mg and rocuronium 40 mg intravenously after thoracic epidural catheter placement. Throughout the operation, mean blood pressure was over 70% of the control value. Stroke volume variation (SVV) was tracked during the operation by arterial pressure-based continuous cardiac output monitoring (FloTrac™); SVV values under 13 were maintained using vasopressors and fluid loading. The rS02 levels were consistently above control values on both sides. The operation was completed as a gas- tric-bypass surgery and the patient was discharged from the hospital without complications. Using the INVOS™ and FloTraTM systems to maintain mean pressure over 70% of the control value may have prevented a new cerebral ischemic event This potentially useful application of the INVOS™ and FloTrac™ systems should be validated in future stud- ies.

[Longitudinal Ultrasonography Detected a Guidewire Outside the Internal Jugular Vein Left during Adult Central Venous Catheter Placement].

A 58-year-old man (height, 160.5 cm; weight 46.7 kg) underwent partial esophagectomy under general anesthesia. A resident anesthesiologist punctured the right internal jugular vein (IJV) (20 mm wide, 4.7-7.6 mm long antero-posteriorly, and 7.6 mm deep) with a 22-gauge metal puncture needle under ultrasono- graphic guidance to secure a central venous catheter (CVC) after surgery under artificial respiration. After obtaining venous blood return without an ultrasono- graphic image of the needle tip inside the IJV, the anesthesiologist advanced a flexible straight-type guidewire into the IJV without resistance. Longitudinal ultrasonography of the guidewire outside the IJV indi- cated extravasation. After withdrawing the guidewire, the anesthesiologist re-punctured the IJV. After obtain- ing blood return with two-echo enhancement inside the IJV, indicating the needle tip, the anesthesiologist advanced the guidewire without resistance and ultra- sonographically confirmed the course of the guidewire inside the IJV along the posterior wall. CVC placement was confirmed via plain radiography of the chest Even a flexible guidewire can penetrate the IJV at posterior wall if a puncture needle tip is positioned near the pos- terior wall Longitudinal ultrasonographic imaging of guidewires can help physicians avoid misplacing dila- tors.

Difficult 32-Fr Double-Lumen Tube Intubation in a Small Japanese Woman With Narrow Transverse Width of the Cricoid Cartilage.

We encountered difficulty in inserting a 32-Fr left double-lumen tube (DLT) in a small 75-year-old Japanese woman (height, 144 cm). The 32-Fr DLT with 10.1 × 11.2-mm tracheal diameter could not pass through the cricoid cartilage with a 9.2-mm transverse inner width. The transverse inner width of the cricoid cartilage, in addition to the tracheal and bronchial diameter, can be measured using computed tomography or ultrasonography in small women. Thus, a 28-Fr DLT or single-lumen tube and a blocker can be selected instead of a 32-Fr DLT when the width of the cricoid cartilage is <10 mm.

[Sniffing Position and i-gel Rotation Approach for i-gel Insertion under General Anesthesia].

BACKGROUND: Insertion assistance techniques, such as the sniffing position (SP) and i-gel? rotation approach (RA), are recommended in the i-gel supraglottic airway device insertion manual. The usefulness of these techniques was evaluated, in this study, under general anesthesia. METHODS: In 50 adult patients, the i-gel was inserted with the patient in the mild-SP with 5 degrees head extention at first attempt. When resistance was encountered during insertion or airway patency was not obtained after insertion, the i-gel was re-inserted with the patient in the full-SP with maximum head extention during second attempt. When re-insertion failed, the i-gel was inserted with the patient in the full-SP and by using the i-gel RA during third attempt. RESULTS: Airway patency was established in the mild-SP in 36 of 50 patients, in the full-SP in 11 of the remaining 14, and in the full-SP with the i-gel RA in the remaining 3. The average insertion time was 24.0 s during the first attempt, 22.2 s during the second, and 18.2 s during the third. No major complications were observed. CONCLUSIONS: Both the full-SP and the i-gel RA can be used for i-gel insertion.

Failed Mask Ventilation due to Air Leakage around the Orbit in a Patient with a History of Radical Maxillofacial Surgery with Orbital Exenteration.

A 72-year-old male (height: 160 cm, weight: 53 kg) was scheduled to undergo left renal and male with ans uterine tract resection. The patient had previously undergone right radical maxillofacial surgery with orbital exenteration 14 years before the present operation to treat squamous cell carcinoma of the right maxillary sinus, with tumour invasion to the orbital floor. An anaesthesiologist encountered difficulty in performing mask ventilation during the induction of anaesthesia in the patient, despite a good mask fit on the face, because the adhesive tape around the orbit had moved. Urgent endotracheal intubation was successful without desaturation. A postoperative examination revealed that a communication between the nasal cavity and the orbit was visible on computed tomograms obtained nine years before the surgery. The patient felt the air leakage around the adhesive tape. The anaesthesiologist should have removed the adhesive tape to directly observe the lesion and should have realised that the communication might cause difficulty in mask ventilation. Careful examination of the airways using computed tomography and precise interviews may improve the understanding of patients' airways and may help avoid similar events.

[Blood Transfusion in a Patient with Severe Anemia and Immunoglobulin A Deficiency during an Emergency Total Hysterectomy on a Holiday].

A 45-year-old woman diagnosed with immunoglobu- lin A (IgA) deficiency during blood donation and undiagnosed with anti-IgA antibodies possession underwent emergency total abdominal hysterectomy due to bleeding from the uterus. The patient needed washed red blood cell (RBC) transfusion to avoid severe reaction to blood transfusion. However, Kitakyushu's Blood Center could not supply adequate RBCs immedi- ately because it was a holiday. The patient her rela- tives, and medical staff decided to use 4 units of trans- fused unwashed RBC to increase-her hemoglobin level from 5.4 to 6.5 g - d1- before anesthesia. We prepared an autologous blood collection device and started anes- thesia. Intraoperatively, 155 g bleeding was noted, and the patient was discharged uneventfully. Selective IgA deficiency is the most common primary hypogamma- globulinemia and is less frequent in the Japanese than in Caucasians. Up to 40% of patients with IgA defi- ciency had anti-IgA antibodies that can cause anaphy- lactic reactions to IgA in transfused blood. Blood cen- ters usually maintain a list of IgA-deficient blood donors to prepare compatible blood components. Wash- ing can remove>99% IgA in blood components that may prevent anaphylaxis. Blood transfusion in the present case might have generated anti-IgA antibodies. The patient would need washed RBCs in a subsequent operation.

Evaluating the detailed position of the subclavian artery to avoid inadvertent subclavian artery puncture during right internal jugular vein catheterization.

PURPOSE: Central venous catheter placement is useful but is associated with complications. Inadvertent subclavian artery (SCA) puncture is a rare complication associated with internal jugular vein (IJV) catheterization. We determined the position of the SCA by ultrasonography, and propose a needle-insertion position for avoiding inadvertent SCA puncture. METHODS: We positioned an ultrasound probe at an angle of 60° to the skin to mimic a puncture needle halfway between the clavicle and the angle of the mandible (center) and moved the probe parallel to the right IJV (RIJV) toward the clavicle until locating the SCA. We measured the distance from the clavicle to the probe 60 and from the probe to the SCA (P60-SCA) where the SCA was visible by ultrasonography. RESULTS: For 50 volunteers with a mean age of 27.3 years, the center position was, on average, 67 mm from the clavicle. The image of the SCA appeared within 65 mm of the clavicle. P60-SCA differed significantly between men and women (p = 0.0058). For 45 volunteers, P60-SCA was <25 mm with the probe 65 mm from the clavicle on the skin. RIJVP-SCA averaged 4.4 mm. Only P60-SCA correlated well with BMI for men (r = 0.732, p = 0.0068). CONCLUSION: Puncturing the RIJV away from the center should avoid SCA puncture; puncturing it while approaching the clavicle is more dangerous. The exact location of the SCA varies from person to person; thus, confirming SCA position by ultrasonography is recommended every time before puncturing.