Anesthetic management of comprehensive dental restoration in a child with glutaric aciduria type 1 using volatile sevoflurane.

Glutaric aciduria type 1 (GA1) is a rare, inherited mitochondrial disorder that results from deficiency of mitochondrial glutaryl-CoA dehydrogenase. Most patients develop neurological dysfunction early in life, which leads to severe disabilities. We present a 37-month-old girl with GA1 manifested as macrocephaly and hypotonia who received comprehensive dental restoration surgery under general anesthesia with sevoflurane. She was placed on specialized fluid management during a preoperative fasting period and anesthesia was administered without complications. All the physiological parameters, including glucose and lactate blood levels and arterial blood gas were carefully monitored and maintained within normal range perioperatively. Strategies for anesthetic management should include prevention of pulmonary aspiration, dehydration, hyperthermia and catabolic state, adequate analgesia to minimize surgical stress, and avoidance of prolonged neuromuscular blockade. We administered general anesthesia with sevoflurane uneventfully, which was well tolerated by our patient with GA1. Additionally, communication with a pediatric geneticist and surgeons should be undertaken to formulate a comprehensive anesthetic strategy in these patients.

Successful anesthetic management of a patient with thyroid carcinoma invading the trachea with tracheal obstruction, scheduled for total thyroidectomy.

We report a case of large thyroid carcinoma with tracheal and esophageal invasion who presented with preoperative stridor scheduled for total thyroidectomy and segmental tracheal resection. Careful and comprehensive preoperative anesthetic planning was done. Extracorporeal circulation membrane oxygenation (ECMO) was set up and running prior to induction under local anesthesia, due to an increased international normalized ratio (INR) and fear of bleeding in the airway. Fiberoptic bronchoscopy (FOB) is the first choice in many circumstances of difficult airway. However, we twice failed to intubate under FOB guidance. Successful intubation was done with traditional laryngoscopy and a Glidescope. The operative course was smooth. The oral endotracheal tube (ETT) was changed to a nasal ETT after surgery with the Glidescope. FOB-assisted intubation carries a chance of failure, and in critical patients, the presence of other intubating modalities such as video-assisted or fiberoptic-assisted technology or safety measures, including ECMO, will greatly increase the safety of anesthesia and surgery.

Increased requirement for minute ventilation and negative arterial to end-tidal carbon dioxide gradient may indicate malignant hyperthermia.

Characteristic signs of malignant hyperthermia (MH) include unexplained tachycardia, increased end-tidal carbon dioxide (Etco2) concentration, metabolic and respiratory acidosis, and an increase in body temperature above 38.8°C. We present the case of a patient with highly probable MH. In addition to sinus tachycardia and metabolic and respiratory acidosis, this patient also had a negative arterial to Etco2 gradient and an increased requirement for minute ventilation to maintain a normal Etco2 concentration, with signs of increased CO2 production. Despite these signs of MH, the patient's rectal temperature monitoring equipment did not show an increase in temperature, although the temperature measured in the mouth was increased. This case illustrates the unreliability of measuring rectal temperature as a means of reflecting body temperature during MH and the usefulness of increased CO2 production signs in helping to diagnose MH.

An investigation on influential factors of patient-controlled epidural analgesic requirement over time for upper abdominal surgeries.

BACKGROUND: Patient-controlled epidural analgesia (PCEA) is commonly used to relieve postoperative pain for upper abdominal surgeries. However, there is still a lack of studies exploring factors associated with PCEA consumption over time after upper abdominal surgery; our study intended to provide further elucidation about this issue. METHODS: This study retrospectively evaluated postoperative PCEA consumption over time after upper abdominal surgery. Cumulative PCEA consumption in the first four 12-hour intervals was directly retrieved from the data recorded by infusion pumps. Potentially influential factors of PCEA requirements, including demographic variables and infusion pump settings, were also collected. A linear mixed model was applied to investigate the relationships between these factors and PCEA consumption over time. A backward elimination strategy was used to select independent factors significantly associated with PCEA consumption. RESULTS: A total of 1001 patients were included in the analysis. On average, PCEA consumption after upper abdominal surgery peaked during the 2(nd) 12-hour interval and then decreased gradually over time. After the model selection processes were completed, four independent factors were identified to have significant effects on PCEA consumption. Surgery for malignant disease and background infusion rate were positively associated with PCEA consumption and did not interact with time. Additionally, female patients tended to consume less and less PCEA over time relative to males. Age had a negative effect on PCEA consumption, which peaked during the 2(nd) 12-hour interval and then decreased gradually over time. The final selected model exhibited acceptable predictive power relative to the observed data. CONCLUSION: Our analyses provided valuable information about the factors associated with PCEA consumption over time after upper abdominal surgery. However, the mechanism of how these factors interact over the course of time awaits further investigation.

No enlargement of the right internal jugular vein of the dialysis patients in the Trendelenburg position.

BACKGROUND: The Trendelenburg position has been suggested for right internal jugular vein (RIJV) catheterization. However, this position can sometimes be functionally intolerable for chronic kidney disease patients. We conducted an ultrasound study to further investigate the efficacy of the use of the Trendelenburg position during tunneled dialysis catheter insertion via the RIJV in chronic kidney disease patients. METHODS: We recruited into our study patients without a history of prior tunneled dialysis catheter insertion or neck surgery. Those patients with stenosis or thrombus in the RIJV were excluded. Serial ultrasound images were acquired with patients in the supine position, with the head rotated 30° to the left: Stage 0, table flat; Stage T, Trendelenburg tilt. Then, measurements of patient RIJV transverse diameter, anteroposterior (AP) diameter, and cross-sectional area (CSA) were obtained. RESULTS: Fifty dialysis patients and 40 healthy volunteers completed the study. There were no significant differences in the lateral diameter, AP diameter, or AP/lateral diameter ratio between the dialysis patients and healthy volunteers, whether in the supine or the Trendelenburg position. However, the CSA of the RIJV of the healthy volunteers in the Trendelenburg position was significantly larger than that in dialysis patients. The change in CSA from the supine to the Trendelenburg position was also significantly different between the two groups. CONCLUSION: In contrast to healthy volunteers, there was no enlargement of the RIJV when dialysis patients were in the Trendelenburg position. The reason for this phenomenon may be multifactorial, with diastolic dysfunction being the most likely cause, and further investigation is required to clarify the cause. Our investigation suggests that the supine position for central venous catheterization in dialysis patients is superior to the Trendelenburg position.

Diagnosis and insertion of Hickman catheter for a patient with persistent left superior vena cava.

A vascular access with good function for drug delivery is the basis of chemotherapy. If there is any congenital or acquired vascular abnormality, procedurally related and late complications such as vessel rupture, malposition, and dysfunction of the catheter with ensuing thrombosis may occur, especially when it is undiagnosed or ignored. We describe a case of implantable central venous catheter (CVC) malposition and subsequent insertion of a Hickman catheter for stem cell transplantation after the diagnosis of persistent left superior vena cava (PLSVC) by radiologic image studies. The case is about a 60-year-old male who suffered from mantle cell lymphoma. He complained of discomfort when chemotherapeutic drugs were delivered through an implanted subcutaneous port system. Malposition of the CVC with aberrant path venous catheter, which led to its migration to the right internal jugular vein (RIJV) was noted on the chest X-ray. In addition, results of ultrasound imaging revealed total occlusion of the RIJV, and a subsequent three-dimensional (3D) computed tomography (CT) reconstruction image revealed a PLSVC with an atretic right SVC. Ultrasound-guided venous puncture of the left internal jugular vein and intraoperative fluoroscopy for confirming the correct guide-wire path were used for successful insertion of Hickman catheter without any complication. When unexpected occurrence of migration or malposition of the long-term CVC is detected, early removal of the catheter is vital for preventing further complications. Proper and advanced image studies including ultrasound, contrast-enhanced venography, CT, and magnetic resonance imaging may be necessary for understanding the potential vascular abnormality and guiding the following treatment.

Patient-machine interactions of intravenous patient-controlled analgesia in bilateral versus unilateral total knee arthroplasty: a retrospective study.

BACKGROUND: Continuous passive motion after a major knee surgery optimizes functional prognosis, but causes severe pain. In this study, we assessed the effect of intravenous patient-controlled analgesia (IVPCA) on postoperative pain management in unilateral and bilateral total knee arthroplasty (TKA). METHODS: Data were collected retrospectively from a single medical center from March 2003 to October 2007. All patients who had undergone TKA were given general anesthesia, and the type of surgery that each patient received was planned according to individual needs. A total of 223 patients qualified for this study, with 174 patients in the unilateral TKA group. Data on patient demography, pain scores, and side effect scores were collected. Total dose consumption, demand, delivery doses, demand-to-delivery ratio, and infusion rate were collected from PCA machines and analyzed. RESULTS: The patient pain score and patient satisfaction showed no significant difference between the unilateral and bilateral TKA groups. The incidence of sedation (p < 0.001), nausea (p = 0.013), and vomiting (p = 0.044) during the postoperative 24-48-hour period was higher in the bilateral TKA group. Compared with the patients in the unilateral group, those in the bilateral group showed significantly greater dose consumption during the postoperative 6-12-, 12-18-, and 18-24-hour periods. They also showed more demand for medication during the postoperative 12-18- and 18-24-hour periods and received more bolus doses during the postoperative 12-18-, 18-24-, and 30-36-hour periods. In addition, there was also a significantly higher demand-to-delivery ratio for patients in the bilateral group during the postoperative 6-12-, 12-18-hour periods. CONCLUSION: In this study, we successfully demonstrated that our IVPCA protocol can provide adequate analgesia for patients after both bilateral and unilateral TKA. However, sedation, nausea, and vomiting occurred more frequently during the postoperative 24-48-hour period in patients who underwent bilateral than unilateral TKA. This may due of the increased number of bolus doses administered to the patients in the bilateral TKA group during the postoperative 12-18, 18-24, and 30-36-hour periods. Therefore, the initial infusion rates for patients undergoing bilateral TKA could be set at a lower threshold in order to reduce the incidence of these side effects.

Effect on pain relief and inflammatory response following addition of tenoxicam to intravenous patient-controlled morphine analgesia: a double-blind, randomized, controlled study in patients undergoing spine fusion surgery.

OBJECTIVE: This study tested the hypothesis that adding tenoxicam (T) to intravenous patient-controlled analgesia (IV-PCA) with morphine (M) would improve postoperative pain relief and wound inflammatory responses compared with M alone after spine surgery. DESIGN: Randomized, prospective, double-blind, controlled study. SUBJECTS: Ninety-four patients eligible for elective spine surgery. SETTING: Teaching hospital. METHODS: Patients were randomized to one of three groups: the M group (PCA regimen with M), the TM group (PCA regimen with T and M), or the T+TM group (20 mg T administered 30 minutes before wound closure in addition to the TM regimen). The primary end point was the numeric rating scale score for pain intensity, and secondary end points pertaining to postoperative pain management included M consumption, PCA demand/delivery, use of rescue analgesics, adverse events, and levels of inflammatory mediators in wound drainages. RESULTS: PCA demand was reduced in both the TM and T+TM groups compared with the M group (both P ≤ 0.001). The incidence of skin itching was significantly reduced in the T+TM group compared with the other groups (both P ≤ 0.05). PGE2 and interleukin-6 levels in wound drainages were reduced in the TM and T+TM groups compared with the M group (both P ≤ 0.001). CONCLUSIONS: The combination of T and M for IV-PCA was not more efficacious than IV-PCA with M alone in reducing postoperative pain after spine surgery but reduced PCA demand and suppressed local inflammation at the surgical site. Administration of T before wound closure may ameliorate IV-PCA M-induced skin itching.

Successful removal of a potentially lethal left atrial thrombus detected by transesophageal echocardiography following the removal of a left ventricular assist device inflow cannula.

The left ventricular assist device (LVAD) is a battery-operated, mechanical pump-type device that helps in maintaining the pumping ability of a failing heart. Thromboembolism poses a significant risk during and after LVAD implantation. It occurs in up to 35% of patients with adverse sequelae. We present the case of a 75-year-old man who underwent coronary artery bypass graft surgery and LVAD implantation for acute myocardial ischemia and severe left ventricular dysfunction. However, subsequent transthoracic echocardiographic examination revealed an LVAD thrombus, and LVAD removal was suggested following the failure of thrombolytic therapy. After the LVAD cannula was removed, transesophageal echocardiography (TEE) revealed a residual thrombus in the left atrium. Thrombectomy was successfully performed by opening the left atrium with cardiopulmonary bypass. We believe that TEE monitoring aided the implantation and removal of the LVAD device. In this case, we found that TEE not only helped in monitoring the ventricular function but also in detecting other problems such as the residual thrombus. We strongly recommend TEE monitoring during the entire LVAD-removal procedure, particularly for patients who need to undergo LVAD removal because of thrombosis formation.

Difficult weaning from mechanical ventilator in a patient with corticosteroid insufficiency after low anterior resection of sigmoid colon.

A 75-year-old man underwent low anterior resection for sigmoid colon cancer under general anesthesia. Comprehensive preoperative surveys showed normal cardiopulmonary functions. In spite of adequate fluid administration, persistent intraoperative hypotension required vasopressors to maintain an acceptable blood pressure. Although the patient was fully awakened from anesthesia with adequate oxygenation, repeated attempts to wean him from the ventilator failed in the postanesthesia intensive care unit, despite recovery from the effect of muscle relaxant. Low plasma cortisol level was found in a series of laboratory analyses. After supplementation with corticosteroid, the patient was successfully weaned from the mechanical ventilator without any sequelae.

Use of higher thromboelastogram transfusion values is not associated with greater blood loss in liver transplant surgery.

Plasma-containing products are given during the pre-anhepatic stage of liver transplant surgery to correct abnormal thromboelastogram (TEG) values and prevent blood loss due to coagulation defects. However, evidence suggests that abnormal TEG results do not always predict bleeding. We questioned what effect using higher TEG values to initiate treatment would have on blood loss. A single transfusion protocol was used for all patients who underwent liver transplantation between 2007 and 2010. Thirty-eight patients received coagulation products when standard TEG cutoff values were exceeded, whereas another 39 patients received coagulation products when the TEG values were 35% greater than normal. The results of postoperative coagulation tests for total blood loss and the use of blood products were compared for the 2 groups. When the critical TEG values for transfusion were higher, significantly fewer units of fresh frozen plasma (5.58 ± 6.49 versus 11.53 ± 6.66 U) and pheresis platelets (1.84 ± 1.33 versus 3.55 ± 1.43 U) were used. There were no differences in blood loss or postoperative blood product use. In conclusion, the use of higher critical TEG values to initiate the transfusion of plasma-containing products is not associated with increased blood loss. Further testing is necessary to identify what TEG value predicts bleeding due to a deficit in coagulation factors.

Acute life-threatening arrhythmias caused by severe hyperkalemia after induction of anesthesia in an infant with methylmalonic acidemia.

Methylmalonic acidemia (MMA) is a very rare genetic disease of metabolism that progressively leads to neurological and renal sequelae. This report describes an unusual case of a patient with MMA who developed severe hyperkalemia and severe dysrhythmia during anesthesia. A 13-month-old male infant with MMA underwent urgent insertion of a port-a-cath under general anesthesia. A life-threatening arrhythmia suddenly occurred, with severe hyperkalemia (up to 7.4 mmol/L), immediately following induction of anesthesia. Emergent resuscitation was successfully carried out, with a complete neurological recovery after 7 days after surgery. Although MMA is a rare complication, the possibility of severe hyperkalemia should be considered in the differential diagnosis of patients with MMA presenting with wide QRS complex tachycardia. The management and intraoperative complications of this disorder are reported here, and the available literature is reviewed.

Innominate artery dissection with presentation of sudden right frontal desaturation detected by cerebral oximetry in complicated thoracic aortic aneurysm repair surgery: a case report.

Cerebral oximetry is a noninvasive bedside monitor for cerebral oxygen saturation (rSO(2)). A patient with a thoracic aneurysm underwent combined surgical and endovascular repair. A sudden decrease in right rSO(2) led to the finding of acute innominate artery dissection. Immediate repair was instituted. Sudden asymmetry of rSO(2) may be a warning sign of underlying pathology.

Prevention of dental damage and improvement of difficult intubation using a paraglossal technique with a straight Miller blade.

Patients with diseased teeth, or those who are difficult to intubate, have a higher risk of dental injury during laryngoscopy. We report 3 cases of smooth endotracheal intubation using a paraglossal technique with a straight Miller blade in patients with poor dentition. Three patients with poor dentition were scheduled to undergo surgery under general anesthesia. All patients presented with extremely loose upper central incisors and had lost the other right upper teeth, while micrognathia and prominent, loose upper incisors were noted in 1 case. We elected to use a straight Miller blade using a paraglossal approach. A nasopharyngeal airway was inserted after induction of general anesthesia to facilitate mask ventilation and prevent air leakage from the mask. The Miller blade was then inserted from the right corner of the mouth, avoiding contact with the vulnerable incisors, and advanced along the groove between the tongue and tonsil. The endotracheal tube was subsequently smoothly inserted after obtaining a grade 1 Cormack and Lehane view without dental trauma in all 3 cases. Direct laryngoscopy using the paraglossal straight blade technique avoids dental damage in patients with mobile upper incisors and no right maxillary molars. It is a practical alternative method that differs from the traditional Macintosh laryngoscope in patients with a high risk of dental injury during the procedure. This technique, which provides an improved view of the larynx, might also be helpful with patients in whom intubation is difficult.

Evaluation of the relationships between intravenous patient-controlled analgesia settings and morphine requirements among patients after lumbar spine surgery.

BACKGROUND: To evaluate the association between daily morphine requirement and the intravenous patient-controlled analgesia (IVPCA) setting in patients undergoing spinal surgery. METHODS: We conducted a retrospective analysis of 179 patients of American Society of Anesthesiologists physical status class I-III who underwent elective posterior lumbar spinal surgery and consented to IVPCA for postoperative pain control. The regi-mental solution contained morphine 1 mg/mL. The IVPCA program was set to deliver a priming dose of 1.5-4 mL, a basal infusion rate of 0-1.2 mL/hr, and a 0.5-1.5 mL bolus on demand with a 5-minute lockout interval. Demographic data, surgical procedures, analgesia program setting variables, 4-hour cumulative morphine dose and 11-point numeric rating scale for pain on postoperative days 1 and 2 were collected for comparison. RESULTS: The IVPCA requirement decreased gradually over time (p < 0.001). The number of vertebrae involved significantly influenced the daily morphine requirements (p = 0.01). None of the IVPCA settings, including continuous infusion, affected daily morphine requirements. On average, the analgesic requirement on postoperative day 2 was 18% less than that on postoperative day 1. CONCLUSION: The number of vertebrae involved was significantly associated with the daily IVPCA requirement. The IVPCA settings, including priming dose, basal infusion rate and bolus dose, did not affect the daily morphine requirements.

Butterfly-like knotting of a lumbar epidural catheter.

We report a female patient with osteoarthritis of both knees, who was scheduled for bilateral total knee arthroplasty under spinal and lumbar (L) epidural anesthesia. An epidural catheter was inserted at the L3-L4 intervertebral space and threaded 9 cm cephalad beyond the tip of the Tuohy needle. Attempts to remove the catheter met with resistance. Because changing the patient's position failed to relieve the resistance, we suspected that the epidural catheter had kinked. After explaining to the patient and her family the need for surgical removal of the catheter and its associated risks, the catheter was successfully removed by an orthopedist by laminectomy. A butterfly-like knot was found about 5 cm away from the tip of the epidural catheter. She experienced no complications during surgery and no neurological sequelae were observed during her stay in hospital.

An analysis of patient variables that influence intravenous patient-controlled analgesic use of morphine with quantile regression.

BACKGROUND: Previous studies using linear regression analysis have shown that age, weight, gender, and the site of operation affect intravenous patient-controlled analgesia (IVPCA) narcotic use. However, there are inconsistent observations in the literature. The authors postulate that patient variables could have different effects at various doses of narcotics. To test this hypothesis, the authors analyzed the effect of patient variables on increasing doses of IVPCA narcotic with quantile regression. METHODS: The authors collected retrospective data from 1,782 patients who received IVPCA for a minimum of 3 days after surgery. The authors used stepwise linear regression model to identify variables that significantly affected the total IVPCA requirements. Quantile regression model was further applied to assess the effects of selected variables on the ascending percentile of IVPCA narcotic use. RESULTS: Gender, age, body weight, cancer, and surgical site were identified as significant predictors for IVPCA demand. Body weight had the most and cancer had the least significant effects on total IVPCA demands. The results of quantile regression model revealed that the determinants under consideration varied with different percentiles of IVPCA demand. The patient variables correlated with IVPCA narcotic use differently when the dose exceeded the seventieth to eightieth percentiles compared with other percentiles of narcotic use. CONCLUSIONS: The authors' findings highlight the heterogeneous postoperative pain requirements among patients and the consequent complex process of efficiently managing postoperative pain.

Intraoperative wake-up test in a deaf-mute adolescent undergoing scoliosis surgery.

We present our experience in intraoperative wake-up test in a deaf-mute feminine teenager who underwent spine surgery for correction of lordoscoliosis. Inadequate comprehension of the preoperative instructions, together with higher threshold of arousal in deaf-mutism may possibly contribute to lingering of the test. The report implicated direct, painful stimulation of the tested limbs, rather than indirect cues, such as flap on the dorsum of hands would be required for performance of wake-up test in the deaf-mute patients.

Risk factors of vomiting among females on patient-controlled epidural analgesia.

BACKGROUND: Postoperative pain and postoperative vomiting (POV) are both sources of distress in the postoperative period. Patient-controlled epidural analgesia (PCEA) is used in patients undergoing lower extremity surgery to improve postoperative quality but is accompanied by a certain incidence of vomiting. We wanted to determine the risk factors of POV in patients using PCEA with the aim of improving the quality of the postoperative period. METHODS: We conducted a retrospective study to analyze the risk factors among patients using PCEA after lower-limb surgery under regional anesthesia. A total of 195 patients (91 males, 104 females) were enrolled. They were categorized into 2 groups: vomiting and non-vomiting. We found that female gender predominated in the vomiting group. Hence, we analyzed the female subgroup in order to find the risk factors of vomiting in the female PCEA population. RESULTS: Female gender was the most significant factor related to vomiting (crude OR, 11.55; 95% CI, 4.88-27.33). From analysis of the female subgroup, puncture site (OR, 4.07; 95% CI, 1.41-11.79), catheter length in the epidural space (OR, 0.28; 95% CI, 0.16-0.50) and patient's height (OR, 1.07; 95% CI, 1.00-1.14) were also factors for vomiting, i.e. higher epidural catheter puncture site, shorter length in the epidural space, and greater height caused a higher incidence of POV. CONCLUSION: The most important risk factor for POV in patients using PCEA was female gender. Among the female subgroup, the risk factors for POV included higher epidural catheter puncture site, shorter length in the epidural space and greater body height.

Priming with rocuronium to accelerate the onset time of cisatracurium during intubation.

BACKGROUND: The priming technique, in which a small dose of nondepolarizing muscle relaxant is administered 3-6 minutes before giving the intubation dose, can speed up the onset of muscle relaxation in patients with paralysis during intubation. We investigated the priming technique and compared 2 different priming agents (rocuronium and cisatracurium) at a priming time of 3 minutes and its effect on decreasing the onset time of cisatracurium. METHODS: A total of 60 patients with ASA physical status I-II scheduled for elective surgery were enrolled. After induction with propofol and fentanyl, the patients were randomized into 1 of 3 groups. Group 1 received rocuronium 0.06 mg/kg as a priming dose. Group 2 received cisatracurium 0.01 mg/kg as a priming dose. Group 3 received normal saline and constituted the control group. After a 3-minute priming time, intubation doses of cisatracurium were given (Groups 1 and 2, 0.14 mg/kg; Group 3, 0.15 mg/kg). First twitch height percentage (T1/T0%; % of control) and train-of-four percentage (T4/T1%) were recorded every 10 seconds from baseline until T1/T0% reached 0. RESULTS: Rocuronium (Group 1) and cisatracurium (Group 2) significantly accelerated the onset of cisatracurium (Group 1, 117.0 +/- 29.0 seconds; Group 2, 151.0 +/- 37.5 seconds; Group 3, 221.5 +/- 36.6 seconds; all p < 0.001). CONCLUSION: Priming with rocuronium or cisatracurium for 3 minutes significantly accelerated the onset of cisatracurium. Priming with rocuronium for 3 minutes improved the onset time of cisatracurium even more than priming with cisatracurium itself.