MinHye So

Transient and reversible parkinsonism after acute organophosphate poisoning

Parkinsonism is a rare complication in patients with organophosphate poisoning. To date there have been two cases of transient parkinsonism after acute and severe cholinergic crisis, both of which were successfully treated using amantadine, an anti-parkinsonism drug. We report on an 81-year-old woman who was admitted for the treatment of acute severe organophosphate poisoning. Although acute cholinergic crisis was treated successfully with large doses of atropine and 2-pyridine aldoxime methiodide (PAM), extrapyramidal manifestations were noticed on hospital day 6. The neurological symptoms worsened, and the diagnosis of parkinsonism was made by a neurologist on hospital day 9. Immediately, biperiden (5 mg), an anti-parkinsonism drug, was administered intravenously, and her symptoms markedly improved. From the following day, biperiden (5 mg/day) was given intramuscularly for eight days. Subsequently, neurological symptoms did not relapse, and no drugs were required. Our patient is the third case of parkinsonism developing after an acute severe cholinergic crisis and the first case successfully treated with biperiden. Patients should be carefully observed for the presence of neurological signs in this kind of poisoning. If present, an anti-parkinsonism drug should be considered.

Anesthetic management of a patient with mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke-like episodes (MELAS) during laparotomy

A 53-year-old man with mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke-like episodes (MELAS) underwent a gastrectomy. We administered bicarbonated Ringers solution, which has a physiological concentration of bicarbonate. The level of serum lactate did not increase significantly, and metabolic acidosis did not occur throughout surgery or for 3 h after surgery. Aggressive warming was needed to maintain normothermia, presumably because the mitochondrial respiratory chain, which is responsible for thermogenesis, is impaired in MELAS patients. It is important to maintain normothermia in MELAS patients in order to avoid further mitochondrial metabolic depression.

Profound pain due to propofol injection triggered myocardial ischemia in a patient with a suspected pheochromocytoma.

References 1. Campos JH, Massa FC. Is there a better right-sided tube for one-lung ventilation? A comparison of the right-sided double-lumen tube with the single-lumen tube with the right-sided enclosed bronchial blocker. Anesth Analg 1998;86:696–700. 2. Arai T, Hatano Y. Yet another reason to use a fiberoptic bronchoscope to properly site a double-lumen tube. Anesthesiology 1987;66:581–2. 3. Doi Y, Uda R, Akatsuka M, et al. Damaged Univent® tubes. Anesth Analg 1998;87: 732–3. 4. Harioka T, Hosoi S, Nomura K. Foreign body in the trachea originated from the inner wall of the Univent® tube [letter]. Anesthesiology 1998;89:1596.

Circulatory collapse caused by unnoticed hypermagnesemia in a hospitalized patient

We report a case of hypermagnesemia in a hospitalized patient after prolonged laxative use; due to preexisting impaired consciousness and digestive problems, the hypermagnesemia was difficult to detect until it almost became fatal. A 64-year-old man who was a patient at another hospital for treatment of head injury and gastric ulcer had developed circulatory collapse and was transferred to our hospital. Hypermagnesemia (serum magnesium concentration 11.0 mg·dl−1) was thought to be the cause of the circulatory collapse and treatments were successful. A magnesium laxative had been administered for more than a month at the previous hospital, but the patients serum magnesium level was never measured. Care should be taken when a magnesium laxative is administered to patients who already have impaired consciousness and digestive problems that are early symptoms of hypermagnesemia.

Flexible, tapered-tip tube facilitates conventional orotracheal intubation by novice intubators

Orotracheal intubation is the standard technique for airway management, but several untoward airway complications are possible with this method. To avoid airway trauma caused by the tube tip during intubation, the Parker Flex-Tip tube (PFT), which has a flexible, tapered tip, was developed. It has been reported that the PFT facilitates fiberoptic orotracheal intubation and introducer-guided tracheal intubation. In this study, we compared the PFT to a standard endotracheal tube (SET), regarding the time of intubation during conventional orotracheal intubation and the incidence of postoperative sore throat and hoarseness. One hundred and thirty-four patients scheduled for elective anesthesia using orotracheal intubation were randomized to either the PFT or SET and 132 completed the study. The intubators were classified into three groups: staff anesthesiologists, inexperienced anesthesiologists, and anesthesia trainees. The tube was selected by another anesthesiologist and the time required for intubation was measured. PFT did not shorten the time required for intubation and did not reduce the incidence of sore throat and hoarseness. However, a detailed analysis revealed that the PFT decreased the time required for intubation in the anesthesia trainee group. The PFT may help novice intubators to conduct a smooth intubation.

Postextubation airway management with nasal continuous positive airway pressure in a child with Down syndrome

We describe our experience with use of variable-flow nasal continuous positive airway pressure (NCPAP) to manage postextubation stridor in a 31-month-old child with Down syndrome (DS). Although it has been recognized that children with DS tend to develop obstruction of the upper airway postoperatively, little is known concerning appropriate management of this situation. Although there are surprisingly few reports of use of variable-flow NCPAP for children older than preterm infants, we successfully treated postextubation ventilatory complications by providing variable-flow NCPAP without complications such as pneumothorax.

Orotracheal intubation with an AirWay Scope in a patient with Treacher Collins syndrome

Treacher Collins syndrome (TCS) is a congenital malformation of craniofacial development; in these patients conventional direct laryngoscopy is very difficult and often unsuccessful because of the upper airway malformation. A 20-year-old man with TCS was scheduled for elective tympanoplasty. The patient showed the characteristic facial appearance of TCS, and a difficult airway was anticipated. After careful anesthesia induction, direct laryngoscopy with Macintosh blade no. 4 of a direct laryngoscope failed to visualize the epiglottis, even with cricoid pressure, resulting in a grade 4 Cormack and Lehane view. Next, the AirWay Scope was easily inserted, and his glottic opening was clearly visualized. An 8.0-mm-internal-diameter tracheal tube was then advanced into the trachea without any difficulty. The AirWay Scope is a very useful airway device for orotracheal intubation; it provides an excellent view of the glottis without requiring alignment of the oral, pharyngeal, and laryngeal axes, and appears to be promising for use in patients with a difficult airway.

Use of landiolol in the perioperative management of supraventricular tachycardia

was stable. Her blood pressure then dropped, although the IABP worked well. The vasoconstrictive effect of dopamine appeared to be required for maintaining a stable hemodynamic status. Landiolol was discontinued 10 h after her admission to the intensive care unit. The SVT recurred immediately, resulting in failure of IABP synchronization. Landiolol infusion was recommenced. As a result, her HR decreased to 90– 100 bpm and her hemodynamic status improved again. The landiolol infusion was continued for another 50 h, at the same rate. She remained stable and was discharged from the intensive care unit on the tenth postoperative day. We believe that landiolol is useful for the HR control of perioperative SVT in patients undergoing cardiac surgery and that the resultant slow cardiac rhythm aids the synchronization of IABP with the patient’s heartbeat. In this patient, landiolol was safely administered not only intraoperatively but also postoperatively for as long as 3 days. Landiolol is considered to be effective in treating perioperative SVT because of its similarity to esmolol, another cardioselective and ultra-shortacting β-blocker, which, it is claimed, is safe and efficacious [4,5]. Further, landiolol has been shown to have a less depressive effect on the cardiovascular system than esmolol in animals [6,7]. In humans, it appears that the blood pressure does not significantly decrease at the optimal dose of landiolol required for HR control [8]. This characteristic would be advantageous for administration to a patient with hypotension.

Intra-operative monitoring of vagal nerve activity with wire electrodes.

A monitoring system for tracking the electromyogram (EMG) of the vocal cords with wire electrodes embedded in an endotracheal tube was designed to identify the recurrent laryngeal nerve during thyroidectomy. Our recent experience in two cases suggests that vagal nerve activity can be correctly detected by recording of the EMG of the vocal cords using a special endotracheal tube embedded with wire electrodes.

Aspiration pneumonia associated with a giant epiglottic cyst after cardiac surgery

To the Editor: Epiglottic cysts are found incidentally during induction of general anesthesia and can hamper tracheal intubation.1 Several methods have been reported to overcome these situations, however, to our knowledge, there has been no report of postoperative respiratory complications in patients with epiglottic cysts. We describe a patient with a giant asymptomatic epiglottic cyst who developed aspiration pneumonia after cardiac surgery. A 71-yr-old man (height 154 cm, weight 42 kg) was scheduled to undergo coronary artery bypass grafting. During induction of general anesthesia, a giant epiglottic cyst was found (Figure). Though manual ventilation was easy, the cyst had almost obstructed the larynx and tracheal intubation was difficult. The surgery was carried out uneventfully and he was admitted to the intensive care unit for postoperative management. On postoperative day one (POD1), he was extubated and his respiratory state was stable. On POD2, he was able to drink water and the cough reflex was present. Immediately following the reintroduction of solid food, he developed aspiration pneumonia of the right lower lobe. Mechanical ventilation and administration of antibiotics proved effective and the cyst was removed surgically on POD5 under general anesthesia. The postoperative course after cystectomy was uneventful and oral intake was normal. There are several factors that increase the risk for aspiration pneumonia after surgery; namely, loss of protective airway reflexes, vomiting, pregnancy, obesity, diminished level of consciousness, anatomic distortion of the airway and a history of cerebrovascular disease.2,3 Especially after cardiac surgery, age and duration of intubation are independent predictors of swallowing dysfunction.4 In our patient, age, the residual effects of anesthetics, the use of transesophageal echocardiography, duration of intubation and anatomic distortion due to the giant epiglottic cyst are all possible factors explaining aspiration. We cannot tell which factor was predominant. However, the presence of this large epiglottic cyst may have resulted in postoperative epiglottic dysfunction and aspiration of solid food.