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.

[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.

[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.

[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.

[Landmark method and ultrasound-guided method of internal jugular vein puncture: comparison of residents with staffs].

BACKGROUND: We compared landmark with ultrasound-guided methods of internal jugular vein puncture in residents and staffs. METHODS: Seven residents and five staffs practiced internal jugular vein puncture with landmark and ultrasound-guided methods on a manikin for internal jugular vein cannulation. Thereafter, they performed internal jugular vein cannulation on 42 patients. RESULTS: Number of attempts of internal jugular vein cannulation by the residents was significantly lower with ultrasound-guided method than with landmark method. Three internal jugular veins could not be cannulated by residents with landmark method. The common carotid artery was punctured in one case with either method by residents. CONCLUSIONS: Residents need more practice of internal jugular vein puncture on a manikin before clinical practice.

[Spontaneous spinal subdural and epidural haematoma in a pregnant patient].

We report a pregnant woman who developed non-traumatic spinal subdural and epidural hematoma. A 31-year-old woman at 28 weeks of gestation developed progressive ascending paralysis. MRI suggested the presence of spinal subdural hematoma at T4-6 and spinal epidural hematoma at T4-9. An emergency cesarean section followed by spinal decompression was performed 60 hours after the onset. The patient's neulogical function recovered completely after the surgey.

[Postoperative contralateral brachial plexus palsy after prolonged operation in lateral decubitus position].

We report a patient who developed postoperative contralateral brachial plexus palsy after prolonged surgery in lateral decubitus position. A 58-year-old man underwent hepatectomy because of metastatic liver tumor in left decubitus position. The surgical table was rotated anteriorly at 15 degrees. The surgery lasted for 7 hours and 50 minutes. After the surgery, he complained of limited arm elevation, hypesthesia of the arm, impaired flexion and extension of the elbow, on the right. These sensory and motor impairements resolved after rehabilitation for 7 days.

[Intraoperative ventricular or supraventricular tachycardia? A case report].

A 68-year-old man with a history of paroxysmal supraventricular tachycardia developed wide QRS complex tachycardia one minute after induction of general anesthesia. As the wide QRS complex tachycardia appeared to be ventricular and pulsation of the radial artery could not be felt, intravenous antiarrhythmic drugs were given. Surgery was postponed. Postoperative electrophysiological study revealed ectopic atrial tachycardia. Catheter abration was performed. Regular P waves were noticed by precise review of the intraoperative electrocardiogram. The intraoperative tachycardia was thought to be supraventricular in origin.

[Neuromuscular monitoring].

In patients receiving a neuromuscular blocking agent, quantitative monitoring of neuromuscular function is essential. For this purpose, neuromuscular monitoring devices which provide train-of-four ratio values are necessary In the absence of a quantitative monitoring device, neuromuscular function may be evaluated with the use of a nerve stimulator. Muscle responses can be monitored either using the mechanomyography, electromyography, acceleromyography, or phonomyography. Although, mechanomyography is still considred the gold standard for assessing the neuromuscular function, mechanomyography is not easy to set up and use in a routine clinical setting. At present we have only two commercially available devices which are easy to set up and useful in daily clinical practice. One is M-NMT monitor which comes with Datex AS/3 or S/5 monitor. The other is TOF-Watch acceleromyographic monitor. In clinical anesthesia, sites of monitoring can be any superficially located peripheral nerves and innervated muscles. Since different muscle groups have different sensitivity to neuromuscular blocking agents, results obtained for one muscle cannot be extrapolated to other muscles. Also, results from one monitoring method cannot be extrapolated to other methods. Anesthesiologists should be aware of these differences. In this article, the basics of neuromuscular monitoring are summarized.

[Anesthetic management of a patient with spinal muscular atrophy type III].

We report a 38-year-old man with Kugelberg-Welander disease who underwent triple arthrodesis for talipes equinovarus under combined spinal-epidural anesthesia supplemented with continuous intravenous infusion of propofol. There was no ventilatory disturbance, muscle weakness, or neurologic untoward event during perioperative period.

[Monitoring of muscle relaxation at the corrugator supercilli muscle in a patient with atrophied upper limbs].

We report a patient whose muscle relaxation was monitored at the corrugator supercilli muscle. In a 51-year-old woman with markedly atrophied upper limbs, anesthesia was induced with propofol and fentanyl. Muscle relaxation was monitored at the adductor pollicis and corrugator supercilli muscles with accelomyography. Train-of-four ratio (TOFR) could be evaluated at the corrugator supercilli muscle; however, it could not be evaluated at the adductor pollicis muscle. The trachea was intubated when the TOFR was 0.09 at the corrugator supercilli muscle after intravenous vecuronium. As the TOFR was 1.44 when the surgery completed, the trachea was extubated without giving neostigmine to antagonize the effect of vecuronium. There was no recurarization after extubation. We conclude that evaluation of TOFR at the corrugator supercilli muscle is useful in some patients who have atrophied adductor pollicis muscle.

[Training of internal jugular vein cannulation: comparison of landmark method with ultrasound-guided method].

We compared training of internal jugular vein cannulation with ultrasound-guided method and that with landmark method in a group of 10 residents and that of 10 staffs. Cannulation was increasingly successful with both methods as the training proceeded, and with increasingly less time and fewer number of punctures. There was no statistically significant difference in time or in number of punctures with ultrasound-guided method between the groups. Ultrasound-guided method needed fewer number of punctures than those with landmark method in both groups.

[Postoperative profound hypoglycemia after resection of adrenaline-predominant pheochromocytoma].

A 54-year-old woman was scheduled for resection of pheochromocytoma. Anesthesia was maintained with general anesthesia combined with thoracic epidural anesthesia. The blood glucose decreased to 30 mg x dl(-1) about four hours after the tumor resection, despite intravenous administration of glucose at a rate of 15 g x hr(-1) with intermittent boluses of 5 g of glucose. The blood glucose levels increased over 100 mg x dl(-1) with intravenous administration of 15 g x hr(-1) glucose, 6 hours after tumor resection.

Immediate effect of subliminal priming with positive reward stimuli on standing balance in healthy individuals: A randomized controlled trial.

BACKGROUND: Information received subconsciously can influence exercise performance; however, it remains unclear whether subliminal or supraliminal reward is more effective in improving standing balance ability when priming stimuli are subconsciously delivered. The present study aimed to compare the effects of subliminal priming-plus-subliminal reward stimuli (experimental) with subliminal priming-plus-supraliminal reward stimuli (control) on standing balance ability. METHODS: This was a single-blind (outcome assessor), parallel-group, randomized controlled trial involving healthy young adults recruited from a university in Japan. Assessments were conducted at baseline and immediately after intervention. The primary outcome was the functional reach test (FRT) measurement. The secondary outcome was one-leg standing time (OLST) with eyes closed. Of the 52 participants screened, 25 were randomly assigned to experimental and control groups each. RESULTS: Both interventions were effective for improving the FRT between the baseline and intervention; however, smaller improvements were observed in the experimental group. We found a large between-groups effect size immediately after the intervention for the FRT (d = -0.92). In contrast, there were no differences in improvements in OLST between the 2 groups (d = -0.06); furthermore, neither intervention was found to be effective for this parameter. CONCLUSION: We concluded that subliminal priming with conscious reward stimuli results in improvements in immediate-term forward reach ability, which is superior to that achieved by subliminal priming with subconscious reward stimuli.

[Transfusion-related acute lung injury: a case report].

We report a patient who was suspected of transfusion-related acute lung injury. A 60-year-old man underwent emergency thoracotomy and hemostasis after pneumonectomy. The SpO2, decreased abruptly to 66% 90 minutes after transfusion of packed red blood cells and fresh frozen plasma. He was ventilated with 100% oxygen. The SPO2 returned to 100% in 3 minutes. Postoperative chest radiography showed diffuse pulmonary infiltrates. The pulmonary edema improved in 12 hours with mechanical ventilation.

Restoration of Train-of-Four Ratio with Neostigmine After Insufficient Recovery with Sugammadex in a Patient with Myasthenia Gravis.

We present a patient with myasthenia gravis in whom sugammadex failed to restore the train-of-four ratio (TOFR) sufficiently. When the patient's TOFR count had recovered to 2, we administered 2 mg/kg of sugammadex. However, the TOFR did not recover to the preoperative value. An additional 2 mg/kg of sugammadex also had no effect. We then administered 30 µg/kg of neostigmine which restored the TOFR to more than the preoperative value. We speculate that exacerbation of myasthenia symptoms during surgery interfered with recovery of TOFR after sugammadex administration.