Second-degree atrioventricular block induced by electrical stimulation of transcranial motor-evoked potential: a case report.

BACKGROUND: Although several complications of transcranial motor-evoked potentials (Tc-MEPs) have been reported, reports of arrhythmias during Tc-MEP are very rare. CASE PRESENTATION: A 71-year-old woman underwent transforaminal lumbar interbody fusion under general anesthesia, with intraoperative Tc-MEP monitoring. Preoperative electrocardiography showed an incomplete right bundle branch block but no cardiovascular events in her life. After induction of anesthesia, Tc-MEP was recorded prior to the surgery. During the Tc-MEP monitoring, electrocardiography and arterial blood pressure showed a second-degree atrioventricular block, but it improved rapidly at the end of the stimulation, and the patient was hemodynamically stable. Tc-MEP was recorded seven times during surgery; the incidence of P waves without QRS complexes was significantly higher than before stimulation. The surgery was uneventful, and she was discharged eight days postoperatively without complications. CONCLUSIONS: Our case suggests that electrical stimulation for Tc-MEP can cause arrhythmia. Electrocardiography and blood pressure must be closely monitored during Tc-MEP monitoring.

Ninety-day mortality of extremely elderly patients undergoing hip fracture surgery and its association with preoperative cardiac function: a single-center retrospective study.

PURPOSE: We investigated the 90-day mortality rate in elderly patients who underwent hip fracture surgery and the association of preoperative cardiac function with mortality. METHODS: We retrospectively enrolled 133 consecutive patients aged 80 years or older who underwent hip fracture surgery. We obtained information for patient sex, age, comorbidities, medications, anesthesia method, left ventricular systolic and diastolic functions assessed by echocardiography, and preoperative brain natriuretic peptide (BNP) levels. Multivariate logistic regression analysis was performed. RESULTS: The 90-day mortality rate in patients with a mean age of 88.9 years was 7.5% (10/133). More than half of the patients had diastolic dysfunction of the left ventricle. There were no significant differences in preoperative cardiac systolic and diastolic functions between the mortality group and non-mortality group. The preoperative BNP level in the mortality group was significantly higher than that in the non-mortality group (p = 0.038). Preoperative BNP level was not an independent risk factor for 90-day mortality (p = 0.081) in the primary multivariate logistic regression analysis but was an independent risk factor (p = 0.039) with an odds ratio of 1.004 (95% CI 1.000-1.008) in the sensitivity analysis with different explanatory variables. CONCLUSION: The 90-day mortality rate in patients over 80 years old after hip fracture surgery was 7.5%. There were no significant differences in preoperative cardiac function assessed by echocardiography between the mortality and non-mortality groups. Our results suggest that there is no association or only a weak association of high BNP level with 90-day mortality in this age population.

Hairy Cell Leukemia-Japanese Variant: Report of a Patient and Literature Review.

Hairy cell leukemia-Japanese variant (HCL-jv) shares some features with, but differs in other features from, HCL variant. Recently, it has been pointed out that HCL-jv and splenic diffuse red pulp small B-cell lymphoma (SDRPL) possibly constitute the same disease. We report a patient with HCL-jv, in which the neoplastic cells in the resected spleen were positive for CD11c, CD103, tartrate-resistant acid phosphatase (by immunohistochemistry), and weakly positive for cyclin D3. They were negative for CD25, CD123, annexin A1, and BRAF V600E-derived protein. Meta-analysis of HCL-jv cases in the literature showed considerable variation in the expression of HCL-related molecules. Although the clinical features and pattern of splenic involvement of HCL-jv are similar to those of SDRPL, some cytomorphological and phenotypical differences can be pointed out. To confirm whether the weak expression of cyclin D3 in our case suggests a spectrum from HCL-jv to SDRPL or one of the characteristics of HCL-jv, further studies on a large number of cases are necessary.

Successful Management of a Patient with Intraoperative Bleeding of More than 80,000 mL and Usefulness of QTc Monitoring for Calcium Correction.

Intraoperative massive bleeding is associated with high rates of mortality and anesthetic management of massive bleeding is challenging because it is necessary to achieve volume resuscitation and electrolyte correction simultaneously during massive transfusion. We report a case of life-threatening bleeding of more than 80,000 mL during liver transplantation in which real-time QTc monitoring was useful for an extremely large amount of calcium administration for treatment of hypocalcemia. A 47-year-old female with a giant liver due to polycystic liver disease was scheduled to undergo liver transplantation. During surgery, life-threatening massive bleeding occurred. The maximum rate of blood loss was approximately 15,000 mL/hr and the total amount of estimated blood loss was 81,600 mL. It was extremely difficult to maintain blood pressure and a risk of cardiac arrest continued due to hypotension. In addition, even though administration of insulin and calcium was performed, electrolyte disturbances of hyperkalemia and hypocalcemia with prolongation of QTc interval occurred. At that time, we visually noticed that the QT interval was shortened in response to bolus calcium administration, and we used the change of real-time QTc interval as a supportive indicator for calcium correction. This monitoring allowed for us to administer calcium at an unusually high rate, by which progression of hypocalcemia was prevented. Levels of hemoglobin and coagulation factors were preserved both by restriction of crystalloid infusion and by a massive transfusion protocol. The patient was extubated without pulmonary edema or cardiac overload and was finally discharged without any sequelae. Intensive and cooperative management for massive transfusion and electrolyte correction using QTc monitoring was considered to be a key for successful management.

[Sequential development of mantle cell lymphoma following chronic lymphocytic leukemia].

Richter syndrome (RS) is the development of an aggressive lymphoma in patients with chronic lymphocytic leukemia (CLL). Most cases of diffuse large B-cell lymphoma variant of RS are clonally related to the original CLL. Here, we present a case of mantle cell lymphoma (MCL) that developed sequentially during the clinical course of CLL. A 72-year-old man had been diagnosed with CLL 16 years ago and was followed-up without treatment. He developed autoimmune hemolytic anemia 2 years ago, which resolved with rituximab and prednisolone treatment. Subsequently, he presented with fever, abdominal bloating, and fatigue. Progressive lymphocytosis and splenomegaly with elevated lactic dehydrogenase levels were suggestive of RS. Bone marrow examination revealed a small- to medium-sized lymphoid infiltrate, which was positive for CD5, CD20, CCND1, and SOX-11 and negative for CD23 and LEF1 on immunostaining. Fluorescence in situ hybridization analysis was positive for IgH/CCND1, which indicated MCL. Southern blot analysis showed that both the MCL and the previous CLL expressed different IgH gene rearrangement bands. At the time of relapse or progression of CLL, sequential development of MCL should be considered.