Kazuhisa Shiroyama

myofascial Pain in Patients With Postthoracotomy Pain Syndrome

Objective: Postthoracotomy pain syndrome is generally considered to be neuropathic pain due to intercostal nerve injury. However, nonneuropathic pain can also occur following thoracic surgery. We present a series of cases with postthoracotomy pain syndrome in which myofascial pain was thought to be a causative component of postthoracotomy pain syndrome. Case Report: Twenty‐seven patients (17 men and 10 women) were treated with trigger point injections, intercostal nerve blocks, and/or epidural blocks. Clinical criteria were used to diagnose the myofascial pain. A visual analogue scale was used, and sensory disturbances were recorded before and after treatment. A trigger point in a taut muscular band within the scapular region, which we diagnosed as myofascial pain, was observed in 67% of the patients. The existence of this trigger point significantly increased the rate of success for the treatments. Conclusions: Postthoracotomy pain may result, at least in part, from a nonneuropathic origin (myofascial pain). It is recommended that each patient be examined in detail to determine whether there is a trigger point in a taut muscular band within the scapular region. If found, this point is suggested as a good area for anesthetic injection.

An advanced puncture technique decreases the incidence of coring during the use of 50-ml propofol vials

puncture at a 90° angle, (3) slow puncture, and (4) puncture at a thin site in the vial cap. The incidence of coring was then examined in a further 150 propofol vials in which the advanced puncture technique was used. The incidence of coring before the training in the advanced puncture technique was 8.7% (13 of 150 vials). The results of the examination of the nurses’ puncture technique before the training were as follows. (1) All 15 fifteen nurses punctured the rubber vial cap using a 21G or 22G injection needle as an air needle for taking air into the vial. Ten nurses punctured the rubber cap with an air needle to make it easier to insert the 18G injection needle for withdrawing propofol; that is, they punctured the same site on the vial cap twice. (2) Five nurses punctured the rubber cap aslant with the 18G injection needle with its bevel facing away from the surface of the rubber cap. (3) Seven nurses punctured the rubber cap rapidly. (4) One nurse punctured the rubber cap at a thick site rather than at a thin site. The incidence of coring after the training was 2.7% (4 of 150 vials), which was significantly lower than that found before training (P 0.021 by Fisher’s exact probability test). The incidence of coring potentially increases as the number of punctures in the rubber cap increases. This potential for coring is caused by the creation of channels at the same site during repeat puncturing of the rubber cap [4,5]. The high incidence of repeat puncturing at the same site among the nurses examined here before their training may have contributed to the high incidence of coring. In addition, one-third to one-half of the nurses punctured the rubber cap aslant or rapidly, which may also have contributed to the high incidence of coring. Coring will remain a hazard wherever vials are punctured more than once. It is important for medical and nursing staff to have sufficient knowledge of coring and an adequate puncture technique.

Rocuronium-sugammadex use for electroconvulsive therapy in a hemodialysis patient: a case report

BackgroundRecently, rocuronium with subsequent use of sugammadex was proposed for electroconvulsive therapy (ECT) as an alternative to succinylcholine. Because sugammadex is cleared via the kidney with no metabolism, it is unknown that rocuronium-sugammadex use is safe in hemodialysis patients who received ECT.Case presentationIn this case report, we used rocuronium with subsequent administration of sugammadex in a 69-year-old female, hemodialysis patient, scheduled for ten ECT sessions for severe major depression. In the initial eight sessions, we tested the feasibility of rocuronium-sugammadex use for ECT. During the series of four ECT sessions, we measured plasma concentrations for the sum of sugammadex and sugammadex-rocuronium complex and observed whether possible residual sugammadex affected muscle relaxation during subsequent sessions of ECT. The results showed the feasibility of rocuronium-sugammadex use as muscle relaxants for ECT in patients undergoing hemodialysis. However, an accumulation of sugammadex did occur even after two sessions of hemodialysis, and residual sugammadex decreased the effect of the rocuronium given in the subsequent ECT sessions. Rocuronium-sugammadex was successfully utilized as muscle relaxants for ECT in this patient.ConclusionsOur experience in this case may indicate that if succinylcholine is contraindicated, rocuronium-sugammadex can be an alternative method for muscle relaxation during ECT in patients undergoing hemodialysis. When this rocuronium-sugammadex procedure is used, the effect of residual sugammadex after hemodialysis on the subsequently administered rocuronium should be considered.