Suspected migration of cervical epidural catheter into the brainstem after a difficult catheter insertion.

We report a case of diplopia during continuous epidural injection presumably caused by catheter migration. A 61-year-old woman underwent shoulder surgery under general anesthesia with cervical epidural anesthesia. The epidural catheter was placed in the C6-C7 epidural space with some difficulty before general anesthesia. The depth of the catheter placed under the skin was 10 cm. On POD 2, the patient noticed diplopia and developed dysarthria despite of good pain control so far. She complained of sudden headache after the rate of continuous epidural infusion was increased to relieve postoperative pain. Computed tomography and T2-weighted cerebral magnetic resonance imaging revealed an air image and surrounding edema in the pons. Diplopia and dysarthria disappeared after ceasing continuous epidural injection. A 15-cm-long mark under the skin and leak of colorless clear fluid from the puncture site were noted at removal of the catheter. On POD 13, diplopia recurred, which improved gradually. On the 9-month radiologic follow-up, we considered that the symptoms on POD 2 were caused by migration of the epidural catheter into the pons and that her later diplopia was induced by intracranial hypotension syndrome. One should be aware that such an unexpected migration of the catheter can occur following a difficult insertion.

[A case of fulminant myocarditis successfully treated by percutaneous cardiopulmonary support after 50 minuite-cardiopulmonary resuscitation].

We report a case of an 8-year-old girl with fulminant myocarditis successfully treated with percutaneous cardiopulmonary support (PCPS). She was first taken to our hospital for treatment of suspected infective enterocolitis since her main symptoms were fever, vomiting and diarrhea. On day 2 after admission, her ECG showed wide QRS and echocardiography demonstrated severe hypokinesis. She was transferred to the ICU with suspected acute myocarditis. On admission to the ICU, circulatory collapse was not detected. ECG showed severe bradycardia and ventricular fibrillation after intubation. Cardiopulmonary resuscitation was performed immediately for 50 minutes prior to initiation of PCPS. She was treated intensively with catecholamines, plasma exchange, continuous hemodiafiltration, high-dose gamma-globulin, and high dose methylprednisolone. Hypothermia therapy was also performed. She was weaned from PCPS on day 6 after initiation of PCPS. The patient was finally discharged from the hospital without any neurological complications on day 68 after weaning from PCPS. The proportion of patients in whom cardiopulmonary resuscitation was performed or having ventricular tachycardia or fibrillation were higher in non-survivors than in survivors.

[Changes in palmar skin blood flow, perfusion index and temperature during endoscopic thoracic sympathectomy].

BACKGROUND: In endoscopic thoracic sympathectomy (ETS), it is required to perform accurate cautery of the sympathetic trunk. Monitoring of palmar skin blood flow and temperature has been used to assess the efficacy of ETS. This study investigated whether Perfusion Index (PI) is useful in assessing palmar skin blood flow and temperature in ETS. METHODS: We studied 5 patients (1 man, 4 women) with palmar hyperhidrosis who had undergone a total of 10 ETS procedures. We measured skin blood flow, temperature and PI during ETS and evaluated the results. RESULTS: Significant correlations were found between increases in skin blood flow and PI after ETS in cases with the palmar skin temperature just before ETS of below 35 degrees C. CONCLUSIONS: In these cases, we can substitute increases in PI with increases in skin blood flow during ETS.

[Effects of bicarbonated Ringer's solution for infants and children undergoing open-heart surgery].

BACKGROUND: There is no study on the use of bicarbonated Ringer's solution (BR) for pediatric patients. We evaluated the effect of BR on infants and children undergoing open-heart surgery, compared with acetated Ringer's solution (AR). METHODS: The records of 18 pediatric patients with congenital heart disease who had undergone elective open-heart surgeries with cardiopulmonary bypass (CPB) were reviewed retrospectively. Eight patients received AR as infusion and CPB priming solution, and ten patients received BR. The pH, HCO3-, base excess and lactate were measured at seven points ; (1) after anesthesia induction, (2) CPB-start, (3) before CPB withdrawal or 60-minute after CPB, (4) after CPB withdrawal, (5) end of operation, (6) 6-hour after operation, and (7) 24-hour after operation, and administered volume of sodium bicarbonate during surgery and 24-hour after surgery were evaluated. Data were compared between two groups. RESULTS: There were no significant differences in values of pH, HCO3-, base excess and lactate between the two groups at any measurement point. The administered volume of sodium bicarbonate during the procedure in BR was significantly smaller than that in AR. CONCLUSIONS: BR was useful as infusion fluid and CPB priming solution for infants and children who underwent open-heart surgeries, and reduced the administration of sodium bicarbonate during surgery.