Suspected Accidental Infiltration of Rocuronium During General Anesthesia Induction: A Case Report.

There are few reports on rocuronium infiltration under general anesthesia. We report a case of suspected accidental rocuronium infiltration during anesthesia induction. A 25-year-old woman with autism spectrum disorder, intellectual disability, and epilepsy was scheduled for the extraction of 4 impacted third molars under general anesthesia. After induction with sevoflurane, an intravenous (IV) line was established in the left cephalic vein. Rocuronium was administered; however, subcutaneous swelling at the IV site was observed immediately. Spontaneous ventilations were maintained until additional rocuronium was administered via a new IV line. After heat pack application, the swelling disappeared 60 minutes after infiltration, and no tissue damage was observed. A strategy was developed to continue neuromuscular monitoring until recovery occurred. Acceleromyography was used, and the train-of-4 ratios at 99, 130, and 140 minutes after infiltration were 0.79, 0.91, and 1.0, respectively. Sugammadex was administered to prevent neuromuscular blockade recurrence. The patient was extubated once adequate return of muscle function and consciousness were observed. No neuromuscular block prolongation or recurrence were observed postoperatively. When rocuronium infiltration is suspected, it is important to eliminate swelling at the infiltration site and determine a management strategy based on neuromuscular monitoring.

Anesthetic management of a pediatric patient with Dravet syndrome: A case report.

INTRODUCTION: Dravet syndrome (DS) is a rare and severe myoclonic epilepsy, with onset commonly occurring in infancy. Seizures are triggered by various causes, including fever, bathing, and light stimulus. DS is refractory to drug treatment. Moreover, status epilepticus (SE) can cause serious encephalopathy and epilepsy-related deaths. There are very few reports of general anesthesia in DS patients. Herein, we report our experience with the anesthetic management of a pediatric patient with DS. PATIENT CONCERNS AND DIAGNOSES: A 5-year-old boy (height, 112 cm; weight, 19 kg) was diagnosed with DS through SCN1A genetic testing, which revealed a de novo novel missense mutation. His medical history included drug-resistant epilepsy, developmental delay, and hypotonia. His seizures tended to be triggered daily by a rise in body temperature (BT), bathing, and light stimulus. He could not receive adequate dental treatment due to DS, although he had previously undergone dental treatment under restraint at the pediatric dentistry department of our hospital. INTERVENTIONS AND OUTCOMES: The patient was scheduled for intensive dental treatment under general anesthesia due to noncooperation, and DS-related limitations. By considering the risk posed by elevated BT, seizure-inducing drugs were avoided, and general anesthesia was completed as planned, uneventfully. Although fluctuation of BT occurred during the procedure, it was finally controlled at the end of anesthesia at about the same level as at anesthesia induction. However, small seizures and a single generalized convulsion were observed accompanied by fever on postoperative day 1. The patient was discharged from the hospital without major problems on postoperative day 3, because of detailed planning and close preoperative cooperation with the attending pediatrician. CONCLUSION: It is essential to pay attention to managing BT and to avoid drugs that induce seizures during anesthesia for patients with DS. Cautious preoperative planning for anesthesia based on evaluation of the patient and rapid postoperative response in collaboration with the attending pediatrician is necessary in case an epileptic seizure occurs.

Effectiveness of intravenous sedation for oral surgery in a patient with multiple sclerosis and a past history of posterior reversible encephalopathy syndrome: A case report.

INTRODUCTION: Posterior reversible encephalopathy syndrome (PRES) is a relatively new syndrome comprising headache, altered mentation, and seizures, associated with neuroimaging findings characteristic of subcortical edema in the posterior regions. As previous studies have reported perioperative development and recurrence of PRES, a cautious anesthetic management of the syndrome is required. CASE REPORT: We describe the anesthetic management for oral surgery in a patient with multiple sclerosis and a history of PRES, both of which are risk factors of recurrent PRES. Although we faced a dilemma regarding the management method of anesthesia, we finally performed intravenous sedation for the surgery without any complications. CONCLUSION: Appropriate preoperative evaluation and anesthetic management are important to maintain hemodynamics and avoid recurrence of PRES.

Anesthetic Management of a Rett Syndrome Patient at High Risk for Respiratory Complications.

Rett syndrome (RTT) is a rare genetic disorder that can present challenges in airway management during general anesthesia. This is a case report involving a 23-year-old woman with RTT who received an intubated general anesthetic 3 times for dental treatment. The patient also had severe scoliosis, was bedridden, and had dysphagia. These contributing factors likely led to the development of postoperative respiratory complications including pneumonia after the first case. As a result, several changes were incorporated into the 2 subsequent anesthetic plans in efforts to reduce the risk of such complications. Despite these measures, the patient was suspected of having bronchitis postoperatively after the second anesthetic, although the third occurred uneventfully. Anesthetic management alterations included use of desflurane for anesthetic maintenance and postoperatively delaying oral intake and instituting active postural changes.

Methemoglobinemia caused by a low dose of prilocaine during general anesthesia.

Methemoglobinemia is a blood disorder in which an abnormal amount of methemoglobin is produced, and prilocaine is one of the drugs that can cause this disorder. The maximum recommended dose of prilocaine is 8 mg/kg. We report a case of methemoglobinemia caused by the administration of 4.2 mg/kg of prilocaine without other methemoglobinemia-inducing drugs during general anesthesia. A 17-year-old girl with hyperthyroidism and anemia was scheduled to undergo maxillary sinus floor elevation and tooth extraction. The patient's peripheral oxygen saturation (SpO2) decreased from 100% at arrival to 95% after receiving prilocaine with felypressin following induction of general anesthesia. However, the fraction of inspired oxygen was 0.6. Blood gas analysis showed that the methemoglobin level was 3.8% (normal level, 1%-2%), fractional oxygen saturation was 93.9%, partial pressure of oxygen was 327 mmHg, and arterial oxygen saturation was 97.6%. After administration of 1 mg/kg of methylene blue, her SpO2 improved gradually to 99%, and the methemoglobin value decreased to 1.2%. When using prilocaine as a local anesthetic, it is important to be aware that methemoglobinemia may occur even at doses much lower than the maximum recommended dose.

Anesthetic management of a patient with 15q tetrasomy for dental treatment / Manejo anestésico de paciente com tetrassomia 15q para tratamento odontológico

Abstract Background and objectives 15q tetrasomy is a chromosomal abnormality that is a part of the heterogeneous group of extra structurally abnormal chromosomes. This syndrome is characterized by epilepsy, central hypotonia, developmental delay and intellectual disability, and autistic behavior. This is the first report of the anesthetic management of a patient with this syndrome. Case report We administered general anesthesia for dental treatment in a patient with 15q tetrasomy. Conclusions Appropriate planning for the prevention of complications such as seizures and hypotonia, and for delayed emergence from anesthesia, is required. Specifically, choosing short-acting drugs that do not induce seizures, together with suitable monitoring, resulted in successful anesthetic management of the patient with 15q tetrasomy.

Resumo Justificativa e objetivos Tetrassomia 15q é uma anomalia cromossômica que faz parte do grupo heterogêneo de cromossomos extras, estruturalmente anormais. Essa síndrome é caracterizada por epilepsia, hipotonia central, atraso no desenvolvimento e deficiência intelectual e comportamento autista. Este é o primeiro relato do manejo anestésico de um paciente com essa síndrome. Relato de caso Administramos anestesia geral para tratamento odontológico em um paciente com tetrassomia 15q. Conclusões Um planejamento adequado para prevenir complicações como convulsões e hipotonia e para emergência tardia da anestesia é necessário. O manejo anestésico bem-sucedido do paciente com tetrassomia 15q foi o resultado específico da escolha de fármacos de curta duração que não induzem convulsões e monitoração adequada.

Quantitation of sevoflurane in whole blood and aqueous solutions by volatile organic compound sensing.

INTRODUCTION: It is difficult to quantify poorly soluble volatile anesthetics in aqueous solutions; this necessitates the development of alternative prompt methods to analyze the in vivo blood concentrations of anesthetics for the clinical assessment of anesthesia depth. In this study, we demonstrated that the difficulties can be overcome by using volatile organic compound (VOC) sensors, which allow the levels of vaporized VOCs to be quantified in several seconds and obviate the need for conventional techniques such as gas chromatography or nuclear magnetic resonance (NMR). METHODS: The concentrations of a volatile general anesthetic (sevoflurane) in aqueous solutions containing human blood components and rabbit blood were measured using a VOC sensor and those in distilled water and phosphatidylcholine suspension were compared to those determined by NMR. RESULTS: For all aqueous solutions with concentrations of up to 5 mM, the relationship between the VOC content and sevoflurane concentration was represented by a straight line passing through the origin. The concentration of sevoflurane determined by VOC sensing was well correlated with the values obtained by NMR at <1 mM, which is within the clinically relevant concentration levels. DISCUSSION: Considering the results from this study, we can conclude that VOC sensing may be useful for measuring intraoperative blood anesthetic concentrations.

[Anesthetic management of a patient with 15q tetrasomy for dental treatment]. / Manejo anestésico de paciente com tetrassomia 15q para tratamento odontológico.

BACKGROUND AND OBJECTIVES: 15q tetrasomy is a chromosomal abnormality that is a part of the heterogeneous group of extra structurally abnormal chromosomes. This syndrome is characterized by epilepsy, central hypotonia, developmental delay and intellectual disability, and autistic behavior. This is the first report of the anesthetic management of a patient with this syndrome. CASE REPORT: We administered general anesthesia for dental treatment in a patient with 15q tetrasomy. CONCLUSIONS: Appropriate planning for the prevention of complications such as seizures and hypotonia, and for delayed emergence from anesthesia, is required. Specifically, choosing short-acting drugs that do not induce seizures, together with suitable monitoring, resulted in successful anesthetic management of the patient with 15q tetrasomy.

Repeated anesthetic management for a patient with Klippel-Feil syndrome.

Klippel-Feil syndrome (KFS) is a rare disease characterized by a classic triad comprising a short neck, a low posterior hairline, and restricted motion of the neck due to fused cervical vertebrae. We report repeated anesthetic management for orthognathic surgeries for a KFS patient with micrognathia. Because KFS can be associated with a number of other anomalies, we therefore performed a careful preoperative evaluation to exclude them. The patient had an extremely small mandible, significant retrognathia, and severe limitation of cervical mobility due to cervical vertebral fusion. As difficult intubation was predicted, awake nasal endotracheal intubation with a fiberoptic bronchoscope was our first choice for gaining control of the patient's airway. Moreover, the possibility of respiratory distress due to postoperative laryngeal edema was considered because of the surgeries on the mandible. In the operating room, tracheotomy equipment was always kept ready if a perioperative surgical airway control was required. Three orthognathic surgeries and their associated anesthetics were completed without a fatal outcome, although once the patient was transferred to the intensive care unit for precautionary postoperative airway management and observation. Careful preoperative examination and preparation for difficult airway management are important for KFS patients with micrognathia.