Recovery of train-of-four ratio to 0.70 and 0.90 is delayed in type 2 diabetes with vecuronium-induced neuromuscular block.

CONTEXT: The recovery profile of train-of-four ratio to more than 0.70 in patients with diabetes mellitus has not been well investigated. OBJECTIVE: Our primary objective was to evaluate the spontaneous recovery profile of neuromuscular block by vecuronium until train-of-four ratio more than 0.90 in patients with type 2 diabetes mellitus compared with controls, using first dorsal interosseous electromyography. DESIGN: Single-centre prospective case-control study. SETTING: The operating theatres of Fukuoka University Hospital. PATIENTS: Fourteen adults with type 2 diabetes mellitus (diabetes mellitus group) and 14 control patients (control group) were included in this study. INTERVENTION: Evoked responses to train-of-four stimuli were measured by electromyography at the first dorsal interosseous muscle. General anaesthesia was induced with propofol, fentanyl and remifentanil. Vecuronium (0.1  mg kg) was administered to all patients. Anaesthesia was maintained with propofol, fentanyl and remifentanil. The neuromuscular block was assessed until spontaneous recovery to train-of-four ratio more than 0.90. MAIN OUTCOME MEASURES: Recovery times to train-of-four ratio 0.70 and 0.90. RESULTS: Recovery times to train-of-four ratio 0.70 and 0.90 were significantly longer in the diabetes mellitus group than the control group (P = 0.041 and P = 0.027, respectively). The time from train-of-four ratio 0.25 to 0.90 was also significantly longer in the diabetes mellitus group than the control group (P = 0.029). In five of 14 patients in the diabetes mellitus group, the time from train-of-four ratio 0.25 to 0.90 was longer than 60  min, which is longer than the duration of action of neostigmine. The time from train-of-four ratio 0.25 to 0.90 was longer than 60  min in only one of 14 in the control group. CONCLUSION: Recovery times to train-of-four ratio 0.70 and 0.90 were delayed in patients with type 2 diabetes mellitus. Neuromuscular block by vecuronium should be carefully monitored in patients with type 2 diabetes mellitus until recovery of train-of-four ratio to a safe level is confirmed.

[Anesthetic management of a patient with diaphragmatic relaxation and megacolon].

We managed an 87-year-old man with diaphragmatic relaxation under general anesthesia. He had dyspnea and severe constipation. The chest X-ray revealed that two thirds of the left chest cavity were compressed by the megacolon gas. The Spo2 before the operation was 93%. The colon gas was deflated before and after the induction of anesthesia. There was no significant improvement in the tidal volume and the arterial oxygen tension. The postoperative chest X-ray showed that the shift of the left diaphragm was improved. He was able to walk 100 meters and the severe constipation disappeared after the operation.

[Reversal of rocuronium induced neuromuscular block with sugammadex in a patient with myasthenia gravis].

We report a patient with myasthenia gravis whose rocuronium induced neuromuscular block was reversed with sugammadex. A 26-year-old man, 175 cm and 76 kg, with myasthenia gravis, was scheduled for extended thymectomy under general anesthesia. An epidural catheter was inserted at the T5-6 interspace before induction of general anesthesia. Anesthesia was induced with propofol and remifentanil. Rocuronium was given in divided doses to obtain > 95% neuromuscular block to intubate the trachea. The ED50 and ED95 of rocuronium for this patient were 0.18 mg x kg(-1) and 0.39 mg x kg(-1), respectively. The values were similar to the ED50 and ED95 of rocuronium for normal patients. General anesthesia was maintained with propofol and remifentanil. Additional doses of rocuronium were given intermittently. Sugammadex, 2 mg x kg(-1), was given at the end of the surgery. The train-of-four ratio reached 93% 105 sec later. His postoperative course was uneventful.

[Anesthetic management of total hysterectomy in a patient with pulmonary thromboembolism].

We report anesthetic management of a 38-year-old woman with pulmonary thromboembolism for total hysterectomy. She had been taking oral contraceptives for adenomyosis of the uterus. She had thrombi in the arteries from pulmonary trunk to bilateral main pulmonary arteries. Thrombolytic and anticoagulant therapies did not decrease the thrombi. Removal of the swollen uterus suspected to be the origin of the thrombi, rather than thromboembolectomy, was scheduled. Cannulation for percutaneous cardiopulmonary support was set up just in case of hemodynamic derangement, before the surgery. Cardiac contraction was evaluated with transesophageal echocardiography during the surgery. There was no untoward perioperative event. Pulmonary thromboembolectomy was not done because the postoperative CT revealed shrinkage of the pulmonary thrombi after anticoagulation treatment.

[Cardiac asystole in the postanesthetic care unit: a case report].

We report a patient without apparent heart disease who developed asystole postoperatively. A 24-year-old woman was scheduled for acetabulectomy under lumbar epidural anesthesia with intravenous propofol infusion. There was no profound hypotension or arrhythmia during anesthesia and surgery. She complained of nausea 50 minutes after the operation. The ECG showed an abrupt decrease in the heart rate followed by cardiac asystole 30 seconds after the onset of nausea. Prompt cardiac massage resumed the heart beats in eight seconds. There was no neurological deficit.

[Hypoxia after cesarean section in a patient with myotonic dystrophy].

A 28-year-old woman, 35 week-pregnant, underwent emergency cesarean section. Although she had no apparent symptoms before the operation, myotonic dystrophy was suspected from physical examination and laboratory data. The anesthesiologist in charge recognized only high creatine kinase. Combined spinal-epidural anesthesia was performed. During the operation and on the 1st postoperative day, Spo2 remained 99% with 3 l x min(-1) oxygen administration. However, on the 2nd postoperative day Spo2 decreased. The low Spo2 persisted for 4 days. Hypoventilation and difficulty in expectoration as a result of respiratory muscle weakness might have been the cause of the prolonged hypoxemia.

[Unilateral temporary meralgia paresthetica after caesarean section: report of a case].

We report a patient who developed unilateral temporary meralgia paresthetica after caesarean section. A 28-year-old morbidly obese woman underwent caesarean section under combined spinal and epidural anesthesia. Intraoperative position was 5-degree head down lithotomy position. She noted pain and hypesthesia along the anterolateral aspect of the right thigh on the second postoperative day, when postoperative continuous epidural analgesia was stopped. The pain and sensory impairment resolved 8 days after surgery without medications.

[Hypoxemia caused by retention of irrigation fluid to detect leaks from the lungs during subtotal esophagectomy].

We report a patient who developed hypoxemia caused by retention of irrigation fluid used to detect leaks from the lungs during subtotal esophagectomy. A 58-year-old man developed a sudden onset of hypoxemia with a decrease in tidal volume during subtotal esophagectomy. Chest X-ray revealed a homogeneous opacity of the left lung field, suggesting the presence of fluid in the pleural cavity on the left. The tidal volume and SpO2 increased after drainage of the fluid from the left pleural cavity. The postoperative course was uneventful and the patient was discharged on the 16th postoperative day.

[Surgical treatment of acute cholecystitis].

Fundamental treatment for acute cholecystitis is cholecystectomy. However, the adoption of a treatment is dependend on degree of a severity of acute cholecystitis in each patient because its degree is influenced by factors such as duration from the onset of symptoms to medical examination. Early laparoscopic cholecystectomy is the preferred procedure for mild acute cholecystitis. Early cholecystectomy is also performed for moderately acute cholecystitis. However, if patients have severe local inflammation (gangrenous and purulent cholecystitis) early gallbladder drainage or open cholecystectomy is indicated. Emergency operation under adequate medical treatment is indicated for a patient with severe local inflammation of the gallbladder, torsion of the gallbladder, emphysematous cholecystitis, gangrenous cholecystitis, and purulent cholecystitis. Pericholecystic abscess, necrosis of the gallbladder wall, and perforation of the gallbladder can be diagnosed accurately by use of imaging diagnosis. The optimal surgical treatment for acute cholecystitis according to grade of severity should be performed referring to imaging findings.

Leg Muscle Strength Correlates with Gait Performance in Advanced Parkinson Disease.

Objective Leg muscle strength (LMS) is decreased in early-stage Parkinson disease (PD) patients and is associated with slower walking and falls. However, LMS in advanced PD has not been well investigated. The purpose of this study was to evaluate LMS in advanced PD patients and its effects on gait performance, activities of daily living, and the cognitive function. Methods The medical records of 132 patients with idiopathic advanced PD [Hoehn and Yahr (H&Y) stages 3 and 4] with a mean disease duration of 9.6 years were retrospectively reviewed. Leg extensor muscle strength of the patients was measured using a Strength Ergo 240. The associations between the LMS and gait performance, Barthel index, H&Y stage, and Mini-Mental State Examination (MMSE) score were analyzed. Results A Spearman's correlation analysis showed that LMS was correlated with the sex, age, age of disease onset, H&Y stage, Barthel index, MMSE score, and gait parameters. A multivariable linear regression analysis for identifying predictors of LMS showed that the gait velocity (ß=0.377), Barthel index (ß=0.281), sex (ß=-0.187), and disease duration (ß=-0.155) were significant. A receiver operating characteristic curve analysis for discriminating between H&Y stage 3 and 4 was performed for LMS; the area under the curve was 0.774 (95% confidence interval=0.696-0.851). Conclusions LMS was strongly associated with multiple domains of clinical characteristics, especially gait velocity and the Barthel index. Our study also suggested that LMS can be a predictor of PD progression.

[Rhabdomyolysis after prolonged surgery in lateral decubitus position].

We report an obese patient who developed rhabdomyolysis after prolonged surgery in lateral decubitus position. A 55-year-old woman, with a body mass index of 29.3 kg x m(-2), underwent removal of an acoustic neurinoma in lateral decubitus position which lasted 20 hours. There was no intraoperative muscle rigidity, redness of the urine or rapid elevation of PET(CO2) and body temperature. The patient developed skin ulcer in the left flank after the surgery. There were elevated levels of serum creatinine phosphokinase, AST, ALT, and myoglobin in the urine. CT of the abdomen taken two days after the surgery suggested the presence of rhabdomyolysis of the transverse abdominal muscles.

[Atelectasis after induction of general anesthesia in an infant with cleft palate].

We report an infant with cleft palate who developed atelectasis as a result of aspiration of food residue after induction of general anesthesia. A 12-month-old girl with cleft palate was scheduled for palatoplasty. The trachea was intubated after 6.5-hour fasting. Breath sounds were not audible on the left. Chest X-ray demonstrated complete atelectasis of the left lung. Bronchoscopy revealed that the left primary bronchus was blocked by a white stick. Pathological examination showed that the white stick consisted of milk residue with abundant candida species. It was speculated that the milk residue accumulated in the cleft palate had been aspirated during induction of general anesthesia.

[Skin lesions on the back along the epidural Catheter].

We report a patient with anemia and hypoalbuminemia who developed decubitus ulcer along the epidural catheter. A 35-year-old woman underwent cesarean section under combined spinal-epidural anesthesia. Erosive and erythematous skin lesions along the epidural catheter were noted 48 hours after insertion of the epidural catheter. The skin lesions were thought to be decubitus ulcer along the epidural catheter due to mechanical pressure caused by fixation of the catheter with an adhesive tape after prolonged supine position.

[Management of drugs used by anesthesiologists in the operating room].

We report the results of reviews by pharmacists of clerical errors in drugs used in the operating room by anesthesiologists from August 2005 to March 2007 at Fukuoka University Hospital. During the period, 9907 surgical patients were managed by anesthesiologists. There were 4868 clerical errors by anesthesiologists. Failed description of used drugs was the most frequent error (n=3,777). One medication error was detected by the review. The review of used drugs in the operating room by pharmacists can prevent financial loss and improve patients' safety.

[Herpes zoster and its prevention].

The mean herpes zoster incidence in Japan was 4.15/1,000 person-years and was 5.23-7.84/1,000 person-years among those 50 years old and older. One in three persons experiences herpes zoster before age 80, indicating how common it is. The Oka varicella vaccine was developed to prevent varicella in healthy and immunocompromized children and is now used to prevent varicella in 20 million people worldwide. Contact with varicella patients and Oka varicella vaccine are reported to augment varicella-zoster virus immunity in adults and the elderly. Oxman et al. have shown that Oka varicella vaccine prevents herpes zoster and postherpetic neuralgia (PHN) in the elderly. Oka varicella vaccine is approved to prevent herpes zoster and PHN in the elderly in USA and Europe. We review the relationship between varicella/Oka varicella vaccine and herpes zoster, the study by Oxman et al., and the need to introduce this new application of Oka varicella vaccine in Japan.

[Postherpetic neuralgia].

Varicella-zoster virus (VZV) causes two clinically distinct diseases: varicella and herpes zoster. Herpes zoster, recurrent infection of VZV occurs when the cell-mediated immunity to VZV declines. Since the cell-medicated immunity to VZV declines with aging, herpes zoster occurs more frequently in the elderly. Most frequent and dreaded complication of herpes zoster is postherpetic neuralgia (PHN). The first line of treatment of PHN is medication with tricyclic antidipressants and anticonvulsants. Double-blind studies showed that effective tricyclic antidepressants for the treatment of PHN are amitriptyline and nortriptyline, and effective anticonvulsants gabapentin and pregabalin. When tricyclic antidepressant and/or anticonvulsant cannot relieve PHN, opioids should be considered in some selected patients. Although neuroablative procedures have been performed for the treatment of PHN, their effectiveness was not confirmed by double-blind studies. They rather aggravate PHN with time. Recent research with a live attenuated varicella vaccine to prevent herpes zoster indicated that the vaccine decreased the occurrence of herpes zoster and postherpetic neuralgia by almost half as compared with placebo. Vaccination of high risk subjects with the varicella vaccine seems to be the most effective measure for the prevention of postherpetic neuralgia.

[History and current issues of anesthesia in Korea].

We report the history and current issues of anesthesia in Korea. Korean medical doctors have to take 1-year internship and 4-year residency to be qualified to take the national examination for a board-certified anesthesiologist. The national examination began in 1963, and there were 3,050 board-certified anesthesiologists as of 2006. The calculated patients who were managed by a board-certified anesthesiologist were 5.8 patients a day. The Korean government adopted nurse-anesthetists in 1973 because of shortage of board-certified anesthesiologists. The Korean Society of Anesthesiologists is now demanding its amendment.

[Subdural block which appeared 21 days after beginning continuous epidural block].

An epidural catheter was inserted at the T10-11 interspace for the treatment of acute herpetic pain in a 68-year-old woman. Loss of resistance method with saline was used for identifying the epidural space. After negative aspiration test for cerebrospinal fluid and blood, continuous epidural infusion of 0.2% ropivacaine 2 ml x hr(-1) with intermittent injections of 1% mepivacaine 3 ml was performed for 20 days without side effects. However, on the 21st day, Horner's syndrome and weakness of the left arm and leg appeared 10 minutes after injection of 1% mepivacaine 3 ml. The symptoms and signs suggested subdural block. Migration of the epidural catheter into the subdural space may have occurred. Subdural block may occur even if the catheter is initially properly placed in the epidural space.

[Aseptic precautions in epidural catheterization for surgery].

We describe aseptic precautions in epidural catheterization for surgery. Every patient has to be checked for immunodeficiency, atopic dermatitis, preoperative use of antibiotics, and local infection of the epidural puncture site. Physicians who perform epidural catheterization should wear a mask and a cap and take off a wrist watch and rings on the fingers before an epidural kit is opened. Fingers and hands should be disinfected before wearing surgical gloves. The skin for epidural puncture site should be disinfected with 0.5% chlorhexidine in 80% ethanol. A micropore filter should be used when epidural catheterization is expected to remain over 24 hours.

[Propofol-induced generalized tonic-clonic seizure: a case report].

A 23-year-old man with no history of convulsion underwent removal of the nails in his upper arm. He received propofol infusion after axillary brachial plexus block. Ten minutes after propofol infusion (15 minutes after axillary block), generalized tonic-clonic seizure occurred. The rate of propofol infusion was increased, and midazolam was given intravenously ; however, the seizure continued. Propofol infusion was withheld, and anesthesia was maintained with sevoflurane. The seizure gradually decreased in 15 minutes after termination of propofol infusion, and it finally stopped 30 minutes after termination of propofol infusion.