International multicentre review of perioperative management and outcome for catecholamine-producing tumours.

BACKGROUND: Surgery for catecholamine-producing tumours can be complicated by intraoperative and postoperative haemodynamic instability. Several perioperative management strategies have emerged but none has been evaluated in randomized trials. To assess this issue, contemporary perioperative management and outcome data from 21 centres were collected. METHODS: Twenty-one centres contributed outcome data from patients who had surgery for phaeochromocytoma and paraganglioma between 2000 and 2017. The data included the number of patients with and without α-receptor blockade, surgical and anaesthetic techniques, complications and perioperative mortality. RESULTS: Across all centres, data were reported on 1860 patients with phaeochromocytoma or paraganglioma, of whom 343 underwent surgery without α-receptor blockade. The majority of operations (78·9 per cent) were performed using minimally invasive techniques, including 16·1 per cent adrenal cortex-sparing procedures. The cardiovascular complication rate was 5·0 per cent overall: 5·9 per cent (90 of 1517) in patients with preoperative α-receptor blockade and 0·9 per cent (3 of 343) among patients without α-receptor blockade. The mortality rate was 0·5 per cent overall (9 of 1860): 0·5 per cent (8 of 517) in pretreated and 0·3 per cent (1 of 343) in non-pretreated patients. CONCLUSION: There is substantial variability in the perioperative management of catecholamine-producing tumours, yet the overall complication rate is low. Further studies are needed to better define the optimal management approach, and reappraisal of international perioperative guidelines appears desirable.

ANTECEDENTES: La cirugía de los tumores productores de catecolaminas puede complicarse por la inestabilidad hemodinámica intraoperatoria y postoperatoria. Se han propuesto distintas estrategias de manejo perioperatorio, pero ninguna ha sido evaluada en ensayos aleatorizados. Para evaluar este tema, se han recogido los datos de los resultados y del manejo perioperatorio contemporáneo de 21 centros. MÉTODOS: Veintiún centros aportaron datos de los resultados de los pacientes operados por feocromocitoma y paraganglioma entre 2000-2017. Los datos incluyeron el número de pacientes con y sin bloqueo del receptor α, las técnicas quirúrgicas y anestésicas, las complicaciones y la mortalidad perioperatoria. RESULTADOS: Los centros en su conjunto aportaron datos de 1.860 pacientes con feocromocitoma y paraganglioma, de los cuales 343 pacientes fueron intervenidos sin bloqueo del receptor α. La gran mayoría (79%) de las cirugías se realizaron utilizando técnicas mínimamente invasivas, incluido un 17% de procedimientos con preservación de la corteza suprarrenal. La tasa de complicaciones cardiovasculares fue de 5,0% en total; 5,9% (90/1517) en pacientes con bloqueo preoperatorio de los receptores α y 0,9% (3/343) en pacientes no pretratados. La mortalidad global fue del 0,5% (9/1860); 0,5% (8/1517) en pacientes pretratados y 0,3% (1/343) en pacientes no tratados previamente. CONCLUSIÓN: Existe una variabilidad sustancial en el manejo perioperatorio de los tumores productores de catecolaminas, aunque la tasa global de complicaciones es baja. Este estudio brinda la oportunidad para efectuar comparaciones sistemáticas entre estrategias de prácticas terapéuticas variables. Se necesitan más estudios para definir mejor el enfoque de manejo óptimo y parece conveniente volver a evaluar las guías internacionales perioperatorias.

Perioperative respiratory complications: current evidence and strategy discussed in 2017 JA symposium.

Respiratory management during general anesthesia aims to safely secure the airway and maintain adequate ventilation to deliver oxygen to the vital organs, maintaining homeostasis even during surgery. Despite its clinical importance, anesthesiologists often encounter difficulties in properly managing respiration during the perioperative period, leading to severe respiratory complications. In this year's JA symposium, 5 editorial board members of Journal of Anesthesia (JA) who are experts in the field of respiratory management in anesthesia discussed the following topics: quitting smoking before surgery: exposure to passive smoke is damaging to children, ventilator-associated pneumonia, high inspiratory oxygen concentration and lung injury, aspiration pneumonia, and postoperative respiratory management strategy in patients with obstructive sleep apnea. We hope that this special article regarding this year's JA symposium may be useful for JA readers to manage clinical anesthesia on a daily basis.

TACR1 gene polymorphism and sex differences in postoperative nausea and vomiting.

We hypothesised that the genetic effect of single nucleotide polymorphisms in the TACR1 gene, which encodes NK1 receptors, could influence the sex difference in postoperative nausea and vomiting. Thirty-two selected single nucleotide polymorphisms were genotyped by the Sanger sequencing method in 200 patients who underwent lower abdominal surgery. The incidence and severity of postoperative nausea and vomiting were evaluated after surgery. The rs3755468-SNP showed significant association with the incidence and severity of postoperative nausea and vomiting (p = 0.016). The TT haplotype defined by two single nucleotide polymorphisms, including the rs3755468-SNP, was associated with reduced incidence and severity of postoperative nausea and vomiting in female patients (p = 0.03). The rs3755468-SNP is located within the predicted oestrogen response element and a DNase I hypersensitive site. The single nucleotide polymorphisms in the TACR1 gene are associated with sex differences in postoperative nausea and vomiting and may help to elucidate the mechanisms underlying these differences.

Improved non-invasive total haemoglobin measurements after in-vivo adjustment.

We hypothesised that an in-vivo adjustment method and/or a newer sensor would increase the accuracy of non-invasive and continuous haemoglobin monitoring (SpHb) measurements. Two sensors, the R1-25 and R2-25a (the newer version), were used with laboratory total haemoglobin concentration (tHb) values simultaneously recorded. In-vivo adjusted SpHb (AdHb) was calculated by a simple formula: AdHb = SpHb - (1(st) SpHb - 1(st) tHb). The correlation coefficients between SpHb (or AdHb) and tHb were compared: SpHb in both sensors correlated strongly with tHb (p < 0.0001). In-vivo adjustment improved the correlation coefficient between SpHb and tHb from 0.86 to 0.95 for the R1-25 and from 0.83 to 0.93 for the R2-25a. There was no difference between the R1-25 and R2-25a sensors. The in vivo adjustment method improved the accuracy of SpHb measurements in both sensors.

Desflurane but not sevoflurane can increase lung resistance via tachykinin pathways.

BACKGROUND: Although there is evidence that the volatile anaesthetic desflurane directly relaxes preconstricted airway smooth muscle in vitro, the anaesthetic increases the lung resistance in vivo. The constrictive mechanisms of desflurane are, however, still unknown. This study was conducted to clarify the increasing mechanisms of desflurane on lung resistance by examining the vagal nerve reflexes in guinea pigs. METHODS: The effects of desflurane and sevoflurane on total lung resistance (R(L)) and dynamic lung compliance (C(Dyn)) were investigated in animals that were either untreated, pretreated with atropine or vagotomy, pretreated with the tachykinin receptor antagonists sendide or MEN-10376, or given chronic pretreatment with capsaicin. RESULTS: Desflurane biphasically and dose-dependently increased R(L) (by 180% and 230% at the first and second peaks, respectively, at 2 minimum alveolar concentration) concomitant with a decrease in C(Dyn). However, sevoflurane had little effect on either R(L) or C(Dyn). Although vagotomy partially inhibited the first peak of R(L) by 30%, neither atropine nor vagotomy had any effect on the other respiratory responses to desflurane. Antagonization of tachykinin receptors of airway smooth muscles completely diminished the increase in R(L) induced by desflurane. Desflurane also had little effect on respiratory parameters after the capsaicin pretreatment, in which tachykinin containing afferent C-fibres was desensitized. CONCLUSIONS: Desflurane but not sevoflurane increased R(L) concomitant with a decrease in C(Dyn) in guinea pigs. The increase in lung resistance by desflurane might be due to antidromic tachykinin release from afferent C-fibres but not acetylcholine release from parasympathetic efferent nerves.

Performance of four carbon dioxide absorbents in experimental and clinical settings.

To evaluate the performance of four kinds of carbon dioxide (CO(2)) absorbents (Medisorb GE Healthcare, Amsorb Plus Armstrong Medical, YabashiLime Yabashi Industries, and Sodasorb LF Grace Performance Chemicals), we measured their dust production, acceptability of colour indicator, and CO(2) absorption capacity in in vitro experimental settings and the concentration of compound A in an inspired anaesthetic circuit during in vivo clinical practice. In vitro, the order of the dust amount was Sodasorb LF > Medisorb > Amsorb Plus = YabashiLime both before and after shaking. The order of the color acceptability was similar: Sodasorb LF > Amsorb Plus = Medisorb > YabashiLime both initially and 16 h after CO(2) exhaustion. During exposure to 200 ml.min(-1) CO(2) in vitro, the period until 1 kg of fresh soda lime allowed inspired CO(2) to increase to 0.7 kPa (as a mark of utilisation of the absorbent) was longer with Medisorb (1978 min) than with the other absorbents (1270-1375 min). In vivo, compound A (1.0% inspired sevoflurane) was detected only when using Medisorb. While Medisorb has the best ability to absorb CO(2), it alone produces compound A.

Inhibitory effects of the alpha-2 adrenergic agonists clonidine and dexmedetomidine on enhanced airway tone in ovalbumin-sensitized guinea pigs.

BACKGROUND AND OBJECTIVE: The alpha-2 adrenergic agonists clonidine and dexmedetomidine are used as an antihypertensive and a sedative, respectively. The aim of this study was to determine the effects of these agonists on ovalbumin-sensitized airway tone in guinea pigs. METHODS: The animals were divided into two groups: control and sensitized. The sensitized group received ovalbumin intraperitoneally and was boosted by exposure to aerosolized ovalbumin. The effects of the alpha-2 agonists were investigated by measuring (1) total lung resistance and (2) smooth muscle tension using a tracheal ring preparation. RESULTS: In the control group, acetylcholine significantly increased total lung resistance in a dose-dependent manner. In the sensitized animals, total lung resistance was significantly higher (by 95%) at 6 mug kg-1 acetylcholine than that in the control group. Both clonidine and dexmedetomidine had a slight but significant inhibitory effect on the response curve of lung resistance at higher concentrations of carbachol, a potent muscarinic receptor agonist. Similar to the data obtained in the control group, both clonidine and dexmedetomidine significantly decreased total lung resistance and the inhibitory effects of these alpha-2 agonists on lung resistance were significantly distinguishable. Similar direct inhibitory effects of the alpha-2 agonists on carbachol-induced muscle contraction were observed in both the control and sensitized groups, the inhibitory effects in the sensitized group being significantly greater. CONCLUSION: Both clonidine and dexmedetomidine can relax the airway even in the hyper-reactive state.

Isovolaemic haemodilution decreases the shivering threshold in rabbits.

BACKGROUND AND OBJECTIVE: The inhibition of thermoregulatory control by anaesthesia is manifested by reduced vasoconstriction and shivering thresholds. As intraoperative bleeding can result in haemodynamic changes, including vasoconstriction, we investigated the effect of experimental bleeding on the shivering threshold in rabbits. METHODS: Twenty-four rabbits were randomly assigned to one of three treatment strategies: (1) no blood removal (control), (2) 5 mL kg(-1) isovolaemic blood removal and (3) 10 mL kg(-1) isovolaemic blood removal. After tracheal intubation under isoflurane anaesthesia, anaesthesia was maintained with 50% nitrous oxide in oxygen. The removed blood volume was replaced with the same volume of warm hydroxyethyl starch colloid solution. Oesophageal temperature was measured as a core temperature at 1-min intervals. After blood removal, the animal's body was cooled at a rate of 2-3 degrees C h(-1) by perfusing water at 10 degrees C through a U-shaped thermode positioned in the colon. Hypothermic shivering was evaluated by visual inspection, and the core temperature at which shivering was triggered was identified as the thermoregulatory threshold for this response. RESULTS: Just before the cooling, the body temperature of the animals was around 38.6 degrees C in all of the three groups. The shivering threshold in the control group was 37.2 +/- 0.2 degrees C (mean +/- SD). The shivering thresholds in the 5 mL kg(-1) (36.9 degrees +/- 0.3 degrees C) and 10 mL kg(-1) (36.5 degrees +/- 0.5 degrees C) blood removal groups were significantly lower and in proportion with the volume of blood removed than that in the control group. CONCLUSION: Isovolaemic haemodilution decreased the shivering threshold in rabbits in proportion with the volume of blood removed.

Urinary bladder and oesophageal temperatures correlate better in patients with high rather than low urinary flow rates during non-cardiac surgery.

BACKGROUND AND OBJECTIVE: To investigate the effect of urinary flow rate on the urinary bladder temperature, we compared the accuracy and precision of urinary bladder temperature with oesophageal temperature at both high and low urine flow rates. METHODS: Twenty-four patients ASA physical status I or II who were undergoing tympanoplasty were randomly assigned to two groups with different intravenous fluid volumes: high (10 mL kg(-1) h(-1), n = 12) and low (3 mL kg(-1) h(-1), n = 12). General anaesthesia was induced with propofol and maintained with sevoflurane (1.5-2.5%) in nitrous oxide and oxygen. Urinary bladder temperature was measured using a Foley urinary catheter; distal oesophageal temperature was measured using a stethoscope thermocouple. These temperatures were measured every 5 min during surgery and the accuracy and precision of urinary bladder temperature with oesophageal temperature were determined using regression and Bland and Altman analyses. RESULTS: The correlation coefficient for oesophageal and urinary bladder temperature was 0.90 in the high urinary volume group and 0.75 in the low urinary volume group. The offset (oesophageal-urinary bladder) was -0.13 +/- 0.32 degrees C and -0.46 +/- 0.45 degrees C, respectively. CONCLUSION: Urinary bladder temperature appears to be more accurate at high urinary flow rates than at low urinary flow rates for clinical use.

Analysis of the composition of 'original' and generic sevoflurane in routine use.

BACKGROUND: Original sevoflurane (Sevofrane) contains a small amount of water, which can inhibit the production of hydrofluoric acid. Hydrofluoric acid is highly pungent, and sevoflurane that contains a high concentration of hydrofluoric acid is not suitable for volatile induction of anaesthesia. Recently, generic sevoflurane (Sevoness) has become available in some countries. The generic product is produced by a different method and kept in a different kind of bottle. We questioned whether the original and generic sevoflurane differed in their composition and thus might differ in their resistance to degradation. METHODS: Sevoflurane from groups of three bottles of Sevofrane and three bottles of Sevoness was kept in the bottle at 24-37 degrees C for 2 weeks or in two kinds of vaporizer for 3 days, and the resulting contents measured by gas chromatography. RESULTS: Both products contained sevoflurane concentrations exceeding 99.998%. Fluoride ion concentration did not differ between the products (0.043 ppm). The original sevoflurane contained more (0.07% w/v) water than the generic anaesthetic (0.003% w/v). Original sevoflurane contained 5 ppm compound A, 10 ppm sevomethylether, and 5 ppm of unknown materials. Generic sevoflurane contained 32 ppm hexafluoroisopropanol and 12 ppm of unknown materials. While stored in a vaporizer for 3 days, the water content in the original sevoflurane decreased by two-thirds but the water in the generic sevoflurane increased by a factor of three-fold. CONCLUSIONS: Generic sevoflurane contains high-quality sevoflurane and only a small amount of fluoride ions, making it comparable with the original sevoflurane product.

Changes in work of breathing during continuous positive airway pressure with increased airway resistance.

STUDY OBJECTIVES: To describe the importance of measuring work of breathing (WOB) in patients with high airway resistance (Raw) during continuous positive airway pressure (CPAP) support. DESIGN: Fundamental study using an advanced model lung and a pulmonary function monitor. SETTING: A research laboratory at the ICU of a university hospital. INTERVENTIONS: Spontaneous breathing (tidal volume x respiratory rate: 400 ml x 15 min-1) was simulated with a time-cycled jet-flow generator. The CPAP and Raw were adjusted to 0, 5, and 10 cm H2O and to 5, 10, and 20 cm H2O.L-1.s-1, respectively. MEASUREMENTS AND RESULTS: Using four advanced demand-flow system type ventilators (Evita, 7200a, Servo 900C, and Servo 300), a two-bellows-in-a-box type model lung, and a pulmonary function monitor with an esophageal catheter (CP-100), we measured WOB during CPAP with increased Raw. The WOB of the model lung increased significantly with increase in CPAP. The WOB of the model lung also increased significantly with increase in Raw for all ventilators tested in this study; some values showed over 1 J.L-1. The WOB under the Servo 300 exhibited the lowest values in all situations of all the ventilators tested in this study. CONCLUSIONS: Patients with high Raw may suffer excessive WOB even during CPAP with advanced demand-flow system type ventilators. It is vital to monitor WOB continuously using an adequate pulmonary function monitor such as that used in this study.

Effects of adrenergic stimulus on the activities of Ca2+ and K+ channels of dorsal root ganglion neurons in a neuropathic pain model.

We hypothesized that abnormal activity and adrenergic sensitivity in injured dorsal root ganglion (DRG) neurons are due to an intrinsic alteration of the cell body membrane. We investigated the effects of adrenergic stimulus on the activities of Ca2+ and K+ channels of DRG neurons in a rat chronic constriction injury (CCI) model. At first, we demonstrated thermal hyperalgesia and sprouting sympathetic nerve fibers in the ipsilateral L4-L5 DRGs. Using whole-cell patch clamp techniques, we found that alpha2-adrenergic stimulus by 10 microM norepinephrine (NE) inhibited inward currents (IBa, Ba2+ as a charge carrier) through voltage-dependent Ca2+ channels (VDCCs) of DRGs in the CCI model by 42%, whereas it enhanced the IBa by 18% in control animals. The inhibitory effect of NE disappeared by pretreatment with the N-type VDCC antagonist omega-conotoxin GVIA (1 microM). NE shifted the inactivation curve to a more negative potential, showing that it has inhibitory effects on IBa both in activated and in inactivated states. alpha2-Adrenergic stimulus also inhibited outward K+ currents by 24% in the CCI model, while it had no effect on the currents in control animals. The inhibitory effect of NE was blocked by pretreatment with the Ca2+-activated K+ (KCa) channel antagonist charybdotoxin (40 nM). The NE-induced inhibitory effects both on N-type VDCC and on KCa channels in injured DRG neurons of the CCI model could lead to cell membrane depolarization, resulting in a spontaneous discharge of action potential and an increase in sensitivity to adrenergic stimulus.

The effects of extracellular pH on intracellular pH, Ca2+ and tension of canine tracheal smooth muscle strips.

The effects of changes in extracellular pH (pHo) on intracellular Ca2+ concentration ([Ca2+]i) or intracellular pH (pHi) were measured simultaneously with muscle tension in canine tracheal smooth muscle strips. [Ca2+]i and pHi were measured using the fluorescent dyes fura-2 and BCECF, respectively. During high K(+)-induced contractions (24.2, 36.4 or 72.7 mM) at pH 7.4, pHo was changed to 7.8 or 7.0 with NaOH or HCl, respectively. Induced changes in pHi were equal to approximately 50% of the changes in pHo. Alkalinization significantly increased [Ca2+]i and enhanced muscle contraction at all concentrations of K+ but did not alter the relationship between muscle tension and [Ca2+]i. Acidification significantly decreased [Ca2+]i without changing muscle tone; hence, the muscle tension-[Ca2+]i relationship was shifted to the left. These results suggest that changes in pHo can alter airway smooth muscle tone by changing [Ca2+]i and pHi.

Changes in respiratory pattern and arterial blood gases during sedation with propofol or midazolam in spinal anesthesia.

STUDY OBJECTIVE: To investigate changes in respiratory pattern and arterial blood gases during sedation with propofol or midazolam in spinal anesthesia. DESIGN: Randomized, placebo-controlled study. SETTING: Operating room of a university-affiliated hospital. PATIENTS: 40 ASA physical status I and II patients who required spinal anesthesia. INTERVENTIONS: Spinal anesthesia with tetracaine and subsequent sedation with propofol (n = 15), midazolam (n = 15), or placebo (n = 10) was performed. MEASUREMENTS: Respiratory pattern [rib cage contribution to the tidal volume (%RC) and phase shift between rib cage and abdominal movements (PSrc-ab)] with a respiratory inductive plethysmograph (Respigraph) and arterial blood gas analysis (pH, pO2, and pCO2) were recorded. MAIN RESULTS: Spinal anesthesia per se increased %RC by 35% without changing PSrc-ab values (1.00). Sedation with propofol and midazolam decreased %RC by 60% and by 40%, respectively. PSrc-ab increased in both groups following sedation, and the increase in this parameter was higher in the propofol group (1.12) than in the midazolam group (1.04). In the placebo group, %RC decreased by 20% without any change in PSrc-ab. The decrease in pO2 was more significant in the propofol group (65.1 mmHg) than in the midazolam (74.2 mmHg) and placebo (83.1 mmHg) groups. CONCLUSION: Significant decreases in %RC and pO2 during propofol sedation seem to depend on paradoxical respiration due, in part, to upper airway obstruction; therefore, attention should be directed to the respiratory pattern during sedation, especially with propofol.

[Mechanisms of action of volatile anesthetics on smooth muscle].

The development of intracellular Ca2+ fluorescent indicators and specific enzymatic substances as well as the application of the patch-clamp method have made it possible to clarify the mechanisms of action of volatile anesthetics inhibit smooth muscle contraction in part by decreasing intracellular Ca2+ concentration ([Ca2+]i); this effect is mediated by blocking calcium channels, especially the L-type voltage-operated channel, and by raising the intracellular cyclic AMP and cyclic GMP levels. Volatile anesthetic-induced suppression of smooth muscle contraction is also attributable to mechanisms independent of [Ca2+]i, which involve the depression of Ca2+ sensitization mediated by C kinase.

[Utility of Bullard intubating laryngoscope with a special stylet in two cases of difficult tracheal intubation].

The Bullard intubating laryngoscope is useful for cases of difficult tracheal intubation, but a skilled hand is needed to manipulate it. In two cases of difficult tracheal intubation, we used a recently improved Bullard intubating laryngoscope to which a special stylet is attached to introduce an endotracheal tube easily into the larynx. The difficulties of tracheal intubation were caused by micrognathia and trismus in one case and by restriction of neck movement and trismus due to ankylosing spondylitis in the other case. Using the Bullard intubating laryngoscope with the special stylet, intubation was done smoothly in both cases. This improved Bullard intubating laryngoscope is recommended for cases of difficult tracheal intubation.

[Complications of pediatric spinal anesthesia].

We evaluated retrospectively the complications of pediatric spinal anesthesia in our center based on the histories of 50 spinal anesthesia cases (5-15 years of age, 0.56%) over the last 15 years. Five cases (10%) showed transient hypotension. In the prospective study of those under 5 years of age (35 children), there were no hypotensive cases, and the only critical complication was high spinal anesthesia; this case was complicated by giant hepatoblastoma. There was no obvious neurological damage in any of the patients who underwent spinal anesthesia. Because of low incidence of complications, pediatric spinal anesthesia is a useful method especially for patients with respiratory insufficiency. It is advisable to watch carefully for changes in blood pressure in senior infants, and to avoid spinal anesthesia in patients with giant abdominal tumors.

[The evaluation of tracheal temperature to monitor core temperature in various operations].

Tracheal temperature was evaluated to monitor core temperature during cardiac, upper abdominal and lower abdominal operations. The tracheal temperature was measured by a thermistor attached to the intra-cuff of the tracheal tube. In cardiac surgery, there was a good correlation between tracheal temperature and forehead deep temperature (r = 0.93) before and after cardiopulmonary bypass, and also between tracheal temperature and the temperature of blood from the cardiopulmonary bypass (r = 1.00) during cardiopulmonary bypass. These results indicate that tracheal temperature accurately reflects carotid artery temperature. In upper abdominal operations, the tracheal temperature showed good correlations with forehead core, esophageal, bladder and rectal temperatures (r = 0.81-0.90). On the other hand, bladder and rectal temperatures were different from forehead deep (r = 0.43, 0.55) and tracheal temperatures in lower abdominal operations. These results suggest that the tracheal temperature is valuable to monitor core temperature.

[Changes in 3 different kinds of body temperature during CPR for DOA patients].

We monitored 3 different kinds of temperature (the tracheal, forehead deep and rectal) during CPR for 8 DOA patients. The forehead deep temperature rose slowly from room temperature, and gradually reached the tracheal temperature. The rectal temperature, except for 2 cases, almost immediately exhibited a temperature close to the tracheal temperature. In 2 exceptions, the rectal temperature exhibited a much lower value than the other temperature monitors. On the other hand, the tracheal temperature seemed to represent the core temperature in all cases during CPR. In conclusion, the tracheal temperature is useful for the monitoring of the patient's temperature during CPR because it represents the core temperature and endotracheal intubation is essential for CPR.

[A case report of monitoring neuromuscular blockade during anesthesia in a patient with facioscapulohumeral muscle dystrophy].

Facioscapulohumeral muscle dystrophy (FSHMD) is characterized by slowly progressive wasting of facial, pectoral and shoulder-girdle muscles that begins in adolescence. A 31 year-old man with FSHMD had dystrophic changes in the deltoid, anterior serratus and pectoralis major muscles but not in the distal muscle of his arms and legs. He underwent an operation for thoraco-scapula fixation under enflurane-nitrous oxide anesthesia with vecuronium 6 mg. At the end of the surgical procedure, the train-of-four (TOF) responses of a thumb and a toe, as measured by using an acceleration transducer, were recorded simultaneously. TOF stimulation in an arm demonstrated an apparent fade phenomenon (TOF; 0.54), while a TOF test in the leg showed complete recovery of the TOF ratio (TOF; 1.0). The patient revealed no clinical signs of residual neuromuscular blockade. It was clear that there was a difference in the degree of neuromuscular block between the arm and the leg in a FSHMD patient. Use of the peripheral nerve stimulator only in the arm may be an unreliable guide to assess neuromuscular block in FSHMD patients. Therefore, two sites should be chosen for monitoring neuromuscular blockade in a FSHMD patient.