[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.

Postoperative Noninvasive Hemoglobin Monitoring Is Useful to Prevent Unnoticed Postoperative Anemia and Inappropriate Blood Transfusion in Patients Undergoing Total Hip or Knee Arthroplasty: A Randomized Controlled Trial.

INTRODUCTION: Postoperative nadir hemoglobin (Hb) is related to a longer length of stay for geriatric patients undergoing orthopedic surgery. We investigated whether postoperative pulse Hb (SpHb) measurement is useful for avoiding anemia and inappropriate blood transfusion after total hip arthroplasty and total knee arthroplasty. MATERIAL AND METHODS: This prospective randomized controlled study included 150 patients randomly assigned to receive blood transfusion, either guided by SpHb monitoring (SpHb group) or based on the surgeons' experience (control group). The target laboratory Hb value was set to >8 g/dL at postoperative day 1 (POD1). The primary endpoints were the product of total time and degree of SpHb <8 g/dL (area under SpHb 8 g/dL) during the period up to POD1 and the incidence of laboratory Hb <8 g/dL at POD1. The secondary endpoints were the amount of blood transfusion and inappropriate blood transfusion, which was defined as allogeneic blood transfusion unnecessary in a case of SpHb >12 g/dL or delayed transfusion in a case of SpHb <8 g/dL. RESULTS: The area under SpHb 8 g/dL was 37.6 ± 44.1 g/dL-min (5 patients) in the control group and none in the SpHb group (P = .0281). There was 1 patient with Hb <8 g/dL at POD1 in the control group. There was no difference in laboratory Hb levels and the amount of blood transfusion. Forty-one patients (19 in the control group and 22 in the SpHb group) received an allogeneic blood transfusion. Among these patients, 7 in the control group and none in the SpHb group received inappropriate blood transfusion (P = .0022). DISCUSSION: The SpHb monitoring could reduce unnoticed anemia, which may prevent complications and be useful in avoiding unnecessary and excessive blood transfusion. CONCLUSION: Postoperative SpHb monitoring decreased the incidence of transient, unnoticed anemia during the period up to POD1 and inappropriate blood transfusion.

Malposition of Peripherally Inserted Central Catheter Into the Right Inferior Thyroid Vein: A Case Report.

BACKGROUND A peripherally inserted central catheter (PICC) causes few serious complications but can be malpositioned. To avoid malpositioning, ultrasound guidance is widely used. Here, we report the case of a patient who received a PICC that was inserted under ultrasound guidance, but the catheter tip accidentally entered the right inferior thyroid vein. CASE REPORT A 58-year-old woman was scheduled for reconstructive mammoplasty. After general anesthesia, a PICC was inserted via the right basilic vein. The PICC was inserted under guidance using a portable ultrasound machine with a high-frequency linear transducer. The tip of the guide wire and catheter were confirmed by ultrasound to be in the right subclavian vein, not in the right internal jugular vein, during insertion. However, the chest X-ray performed after the PICC insertion showed that the catheter had moved into the right inferior thyroid vein. CONCLUSIONS Malpositioning of a PICC can occur into any small vein. Ultrasound should be used not only to avoid malpositioning into the IJV, but also to confirm the proper position of the catheter tip during PICC insertion.

Neurally Mediated Syncope During Cesarean Delivery: A Case Report.

A 28-year-old woman with preeclampsia at 32 weeks of gestation underwent a cesarean delivery under spinal anesthesia. Administration of nitroglycerin at 200 µg to relax uterine smooth muscles and the application of fundal pressure led to severe bradycardia and loss of consciousness, followed by cardiac arrest. Delivery was completed immediately and recovery was achieved 10 seconds later following cardiopulmonary resuscitation. Neurally mediated syncope was considered the cause of cardiac arrest. Anesthetists should be aware of the potential risk during cesarean delivery following the administration of nitroglycerin, fundal pressure, regional anesthesia, and hypovolemia because of preeclampsia.