Kazuo Higa

Retropharyngeal hematoma after stellate ganglion block: Analysis of 27 patients reported in the literature.

Background:Retropharyngeal hematoma (RPH) is rare; however, it causes airway obstruction and can be fatal. Stellate ganglion block (SGB) can cause RPH. The authors analyzed reports of patients with RPH after SGB to clarify the initial symptoms and signs, and the urgency of airway management. Methods:MEDLINE and Japana Centra Revuo Medicina were searched for reports of RPH after SGB using the following terms and key words: stellate ganglion block, complication, hematoma, and retropharyngeal hematoma. Results:The authors found 27 patients with RPH after SGB in the past 40 yr. The initial symptoms included neck pain (n = 10), dyspnea (n = 10), neck swelling (n = 8), and hoarseness (n = 5). The symptoms occurred 2 h or more after SGB in 14 patients (52%). Emergency airway management was needed in 21 patients (78%) because of airway obstruction. Among the 21 patients, orotracheal intubation was attempted first in 17 patients; however, it was unsuccessful in 5 patients who immediately needed emergency tracheostomy. Tracheal intubation was impossible by distortion of the anatomy of the markedly edematous pharyngolarynx. Failed airway management caused one death. There were no statistically significant predictors of the initial symptoms or signs for later emergency airway management. Conclusions:RPH after SGB necessitates emergency airway management. Because airway obstruction cannot be predicted by the initial symptoms or signs, emergency airway management tools should be at hand, and the patency of the airway should be continuously evaluated after onset of RPH after SGB.

Factors influencing the duration of treatment of acute herpetic pain with sympathetic nerve block: Importance of severity of herpes zoster assessed by the maximum antibody titers to varicella-zoster virus in otherwise healthy patients

&NA; Antibody responses to varicella‐zoster virus (VZV) were serially investigated by the complement‐fixation test in 72 Japanese of both sexes, suffering from herpes zoster (HZ), but otherwise healthy. Our objective was to elucidate whether there were mutual relationships among severities of skin lesion, maximum antibody titers to VZV, and duration of treatment for acute herpetic pain (AHP). Patients were divided into 3 groups: mild group (n = 26), moderate group (n = 26) and severe group (n = 20), according to the severity of the skin lesions. The 3 groups did not differ significantly with respect to age (P > 0.6). All patients were treated with regional sympathetic nerve blocks (SNBs) until pain relief was achieved. The durations of treatment for AHP became significantly longer as HZ increased in severity; the mean log10 durations of treatment (± S.E.) for the mild, moderate, and severe groups were 1.383 ± 0.037, 1.616 ± 0.055, and 1.888 ± 0.069 days, respectively (P < 0.01 for the mild group vs. the moderate group, and P < 0.001 for the moderate group vs. the severe group). Irrespective of age, the maximum antibody titers closely paralleled the severities of the skin lesion of HZ; the mean maximum log10 antibody titers (±S.E.) for the mild, moderate, and severe groups were 5.12 ± 0.24, 6.73 ± 0.20, and 8.00 ± 0.18, respectively (P < 0.001 for the mild group vs. the moderate group and for the moderate group vs. the severe group). There was a highly significant positive linear correlation between maximum antibody titers and duration of treatment for the entire group of patients (r = 0.56, P < 10−6). It is concluded that, irrespective of age, the severities of HZ in otherwise healthy patients can be defined objectively and quantitatively by the maximum antibody titers to VZV, and that the severity of HZ itself rather than age is of utmost importance in influencing the duration of treatment of AHP with intensive SNB. We propose that reports dealing with the treatment of AHP should include data on the severity of HZ and that the results be analyzed according to the severity of HZ itself, defined preferably by the maximum antibody titers to VZV, in otherwise healthy patients.

Severity of skin lesions of herpes zoster at the worst phase rather than age and involved region most influences the duration of acute herpetic pain

Abstract Duration of acute herpetic pain (AHP) in 1431 patients for whom treatment was begun within 14 days after the onset of herpes zoster (HZ) was analyzed with respect to age, involved region, and severity of skin lesions. All patients were treated with repeated sympathetic nerve blocks until their pain was almost nil. Severity of the skin lesions at the worst phase was defined as mild when they covered less than one‐quarter of the primary dermatome, as severe when they covered more than three‐quarters of the primary dermatome, and moderate if they were between mild and severe. Without taking into account the severity of skin lesions, the duration of AHP for those aged 60 years or over and for those with trigeminal involvement was significantly longer than for patients aged under 40 years (P<0.01 and P<0.001) and for patients with thoracic (P<0.001) and lumbosacral (P<0.01) involvement, respectively. However, duration of AHP was significantly longer with increase in the severity of skin lesions in all age groups (the mild group versus the moderate group, P<0.01 and P<0.001; the moderate group versus the severe group, P<0.01 and P<0.001). The mean duration of AHP for patients aged 60 years or over with mild skin lesions ranged from 17.4 to 22.9 days, while that for patients aged 30–59 years with severe skin lesions ranged from 37.2 to 50.1 days. In addition, duration of AHP was significantly longer with increase in the severity of skin lesions in all regions (the mild group versus the moderate group, P<0.01 and P<0.001; the moderate group versus the severe group, P<0.05 and P<0.001). The mean duration of AHP for those with trigeminal involvement with mild skin lesions was 19.5 days, while the range was from 51.3 to 55.0 days for patients with severe skin lesions involving regions other than the trigeminal area. The frequency of severe skin lesions was significantly higher (P<0.001) in patients aged 60 years or over and in those with trigeminal involvement. Multiple stepwise regression analysis revealed that the most important factors influencing the duration of AHP were the severity of skin lesions of HZ at the worst phase (r=0.412), age (r=0.277) and the involved region (r=‐0.101). Thus, AHP in the elderly and in cases of trigeminal involvement is longer because of higher frequencies of severe HZ in the elderly and in trigeminal involvement rather than ‘being aged’ and ‘trigeminal involvement’ itself. We propose that one needs to analyze the results of treatment of AHP with respect to the severity of skin lesions at the worst phase.

Continuous Epidural Infusion of Local Anesthetics and Shorter Duration of Acute Zoster-associated Pain

Objective:The purpose of this study was to investigate the effects of continuous epidural blockade on acute zoster-associated pain, compared with intermittent epidural blocks. Design:The design was a retrospective, nonrandomized study. Setting:The study was conducted at a university hospital in Japan from 1982 through 1992. Patients:A total of 178 otherwise healthy patients hospitalized with moderate or severe herpes zoster lesions. Interventions:Group A (n = 66) had intermittent epidural blocks using 1% mepivacaine, 4–6 ml, three to six times daily; group B (n = 43) were given intermittent epidural blocks and parenteral acyclovir (500 mg/day) or vidara- bine (600 mg/day) for 5 days; group C (n = 69) were administered a continuous epidural 0.5% bupivacaine infusion (0.3–1.0 ml/h) for ∼2 weeks and antiviral agents followed by intermittent blocks. Main Outcome Measures:The number of treatment days was used as the outcome measure. Results:The length of treatment was significantly shorter in group C than in groups A or B. For moderate lesions the means (days) were 36.2 [95% confidence interval (CI), 31.4–41.7), 45.6 (95% CI, 34.0–61.4), and 26.8 (95% CI, 22.3–32.3) for groups A, B, and C, respectively (p < 0.01). For severe lesions they were 73.3 (95% CI, 55.1–97.7), 81.7 (95% CI, 59.1–113.0), and 44.9 (95% CI, 35.2–57.3) for groups A, B, and C, respectively (p < 0.01). Conclusions:Continuous epidural blockade for patients with acute zoster can shorten the duration of treatment and may reduce the incidence of postherpetic neuralgia.

T-lymphocyte subsets in otherwise healthy patients with herpes zoster and relationships to the duration of acute herpetic pain.

&NA; T‐lymphocyte subsets (CD3, CD4, and CD8 lymphocytes) in peripheral blood, parameters of cell‐mediated immunity, were serially measured in 62 otherwise healthy Japanese patients with herpes zoster (HZ), and the findings were compared with those of 20 age‐matched healthy controls who had had varicella but not HZ. Our objective was to elucidate whether there were changes in cell‐mediated immunity, even in immunocompetent patients with HZ, and to investigate relationships between these variables and the duration of acute herpetic pain (AHP). All the patients underwent repeated sympathetic nerve blocks until pain was relieved. As compared with controls, there were slight increases in the percentages of CD4 lymphocytes (helper/inducer) and highly significant increases in the percentages of CD8 lymphocytes (suppressor/cytotoxic), resulting in marked decreases in CD4/CD8 ratios in the acute phase of HZ. The percentages of CD3 lymphocytes (pan‐T lymphocytes) did not differ significantly. The duration of AHP was analyzed in 49 patients in whom T‐lymphocyte subsets were measured more than twice. There was a weak but statistically significant positive linear correlation between age and the duration of AHP (r = 0.43, P < 0.01). There were statistically highly significant positive linear correlations between the number of days on which percentages of CD3 (r = 0.72, P < 10−8) and CD4 lymphocytes (r = 0.60, P < 10−5), and CD4/CD8 ratios (r = 0.62, P < 10−5) reached the maximum values after the onset of HZ and the duration of AHP. These correlation coefficients were higher than that between age and the duration of AHP. Thus, there are significant changes in peripheral blood T‐lymphocyte subsets after the onset of HZ even in otherwise healthy patients and cell‐mediated immunity plays an important role in the recovery from AHP.

Optimum pain relief with continuous epidural infusion of local anesthetics shortens the duration of zoster-associated pain.

Objective:To investigate effects of continuous epidural infusion (CEI) of 0.5% bupivacaine added to intermittent epidural boluses (IEB) on the duration of zoster-associated pain (ZAP), as compared with continuous infusion of normal saline placebo added to IEB. Design:A prospective, double-blind, randomized, placebo-controlled study. Setting:A university hospital and an affiliated clinic in Japan from 1996 through 1999. Patients:56 immunocompetent herpes zoster (HZ) patients, 50 years or older, within 10 days of rash onset and with severe pain and eruption. Interventions:Patients were hospitalized and randomly allocated into 2 groups. CEI group given CEI of 0.5% bupivacaine (0.5–1.0 mL/h) plus IEB of 0.5% bupivacaine 4 times daily (n = 29). IEB group given normal saline infusion plus IEB of 0.5% bupivacaine 4 times daily (n = 27). All patients received oral acyclovir 800 mg, 5 times daily, for 7 days. Outcome Measures:The number of days required for complete cessation of ZAP and the proportion of subjects with allodynia beyond 30 days. Results:The median time to cessation of ZAP was significantly shorter in the CEI group than in the IEB group (29 days vs. 40 days, P = 0.002). The number of patients whose allodynia persisted beyond 30 days of treatment was significantly lower in the CEI group than in the IEB group (10% vs. 37%, P = 0.027). Conclusions:CEI of 0.5% bupivacaine plus IEB was associated with a shorter duration of ZAP and fewer patients with allodynia beyond 30 days, compared with IEB plus normal saline infusion. Patients at high risk for developing postherpetic neuralgia (PHN) can be managed with intensive therapies at the early stage of disease, such as CEI, which maintains effective analgesia and may reduce the burden of PHN.

High thoracic epidural block relieves acute herpetic pain involving the trigeminal and cervical regions: comparison with effects of stellate ganglion block.

Background and Objectives. Stellate ganglion block can promptly relieve acute herpetic pain (AHP) involving the trigeminal and cervical regions. However, repeated blocks are needed to maintain pain relief in most patients with severe AHP. Because continuous epidural block is easily performed using an indwelling catheter, we compared the effect of high thoracic epidural block with that of stellate ganglion block to relieve moderate‐to‐severe AHP involving these regions. Methods. Six patients received stellate ganglion blocks and seven patients received high thoracic epidural blocks. Six milliliters 1% of mepivacaine was given to each patient. Acute herpetic pain was evaluated before and up to 60 minutes after the blocks, using a visual analog scale (VAS) of pain. Results. There was no significant difference in VAS pain scores before the blocks between the groups, but there were significant (P < .05) decreases in VAS pain scores for both groups between 10 and 60 minutes after the blocks. There were no significant differences in VAS pain scores between the groups after the blocks. Conclusions. High thoracic epidural block was as effective as stellate ganglion block in relieving moderate‐to‐severe AHP involving the trigeminal and cervical regions.

Optimal depth of insertion of left-sided double-lumen endobronchial tubes cannot be predicted from body height in below average-sized adult patients

Background and objective: The optimal depth of insertion of left‐sided double‐lumen endobronchial tubes is strongly correlated with body height in average‐sized adults. However, this relationship has not been studied in below average‐sized adult patients. We investigated whether or not there is a clinically useful relationship in below average‐sized adult patients. Methods: One hundred and ninety six consecutive adult patients undergoing thoracic surgery under one‐lung anaesthesia (body height ≤ 155 cm) were included in this study. Left‐sided double‐lumen tubes were inserted under the guidance of a fibre‐optic bronchoscope. Optimal depth was defined as the proximal surface of the bronchial cuff positioned just below the carina. Results: There was a statistically significant positive correlation between body height and the optimal depth of insertion (r = 0.61, P < 0.0001); however, the correlation coefficient was low. The actual optimal depth of insertion of one patient was even 4.5 cm shorter than that obtained from the equation. Conclusion: Although there was a statistically significant correlation between body height and the optimal depth of insertion of left sided double lumen tubes in adult patients of short stature (≤ 155 cm), clinical application of the equation is not warranted and these tubes should be inserted under direct vision with a fibre‐optic bronchoscope.

Mexiletine-induced severe skin eruption, fever, eosinophilia, atypical lymphocytosis, and liver dysfunction

A 64-year-old man developed a severe generalized pruritic morbilliform skin eruption, fever, eosinophilia, atypical lymphocytosis, and liver dysfunction 30 days after ingestion of mexiletine, a sodium channel blocker, prescribed to treat postherpetic neuralgia. Following intravenous dexamethasone, body temperature normalized the next day. However, the skin eruption did not disappear completely for 4 weeks. The patch test was positive for mexiletine. Clinical features and the result of patch test indicated that the patient developed hypersensitivity syndrome, a severe adverse cutaneous drug reaction, caused by mexiletine. We propose that mexiletine be added to the list of drugs that can cause severe adverse cutaneous drug reactions and that patients receiving mexiletine be warned to stop taking the drug immediately if a skin eruption occurs.

Anesthetic management of a patient with Bartter's syndrome

Bartters syndrome is a rare disorder characterized by normal or low arterial blood pressure (BP), despite marked elevation in plasma renin activity, angiotensin II (Ang-II), and aldosterone, along with hypokalemic metabolic alkalosis. Perioperative changes in the cardiovascular and renin-angiotensin-aldosterone (RAA) systems in Bartters syndrome patients are not well understood. We managed a 44-year-old Japanese man with rectal cancer and Bartters syndrome complicated by renal dysfunction. He underwent anterior resection of the rectum with general anesthesia (50% nitrous oxide-oxygen with 0.5% to 0.8% isoflurane, supplemented with intravenous midazolam and butorphanol). Epidural morphine was given postoperatively. Although BP tended to be lower (75/35 to 110/60 mmHg) during surgery, there were no profound perioperative hemodynamic derangements. Plasma renin activity. Ang-II, and aldosterone values were highest during surgery. These responses of the RAA system to anesthesia and surgery were the same as previously noted in otherwise healthy surgical patients.