Shinjiro Shono

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.

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.

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.

Risk factors for nausea and vomiting following vitrectomy in adults.

Background and objective: Postoperative nausea and vomiting (PONV) after ophthalmic surgery under general anaesthesia remains a complex and perturbing complication associated with several factors. Little information is available regarding the risk factors for nausea and vomiting after vitrectomy in adults. In this study, we evaluated the potential risk factors for PONV after vitrectomy in adult patients. Methods: Univariate and multivariate analyses of clinical factors associated with PONV were undertaken in a retrospective case–control series of 247 adult patients undergoing vitrectomy under general anaesthesia. We examined PONV for the first 48 h. Factors examined were age, body mass index (BMI), smoking status, H2‐blocker as premedication, type of general anaesthesia (sevoflurane and fentanyl or total intravenous (i.v.) anaesthesia with propofol and fentanyl), duration of surgery, and intraoperative fentanyl dose. Results: Fifty‐nine patients (24%) reported one or more episodes of PONV during the study period. Female gender (P < 0.01), lower BMI (P < 0.01) and general anaesthesia with inhalational anaesthetics (P < 0.01) were significantly related to nausea during the first 2 h postoperatively. Female gender (P < 0.01) was significantly related to nausea and vomiting throughout the study period. Other factors, including smoking status, did not alter the risk for nausea and/or vomiting. Conclusions: We conclude that female gender, lower BMI and inhalation anaesthesia are the main risk factors for PONV after vitrectomy in adults. Smoking status did not reduce the incidence of PONV in our patients.

Subglottic Jet Ventilation for Pediatric Microlaryngosurgery: A Case Report

A 6-year-old girl with laryngeal papillomatosis underwent ablation of the tumors with Nd-YAG laser under microlaryngosurgery. During the surgery, she was managed with subglottic high-frequency jet ventilation using a stainless steel cannula made from a nerve block needle. It was passed through the light channel of the suspension laryngoscope and firmly affixed to it. There was no hypoxia or barotrauma to the lungs during the surgery. The postoperative course was uneventful.

Disappearance of wheezing during epidural lidocaine anesthesia in a patient with bronchial asthma.

BACKGROUND AND OBJECTIVES Local anesthetics in blood absorbed from the epidural space attenuate bronchial hyperreactivity to chemical stimuli. However, it is not documented whether local anesthetics at clinically relevant concentrations improve active wheezing in patients with bronchial asthma. CASE REPORT We managed a 60-year-old man with bronchial asthma and active wheezing under continuous epidural anesthesia using plain lidocaine. The wheezing gradually diminished 20 minutes after the epidural injection of 13 mL 2% lidocaine and completely disappeared over 155 minutes during continuous epidural injection of 2% lidocaine (6 mL/h). The plasma concentrations of lidocaine in arterial blood during the epidural anesthesia ranged from 2.5 to 3.9 microg/mL. Wheezing reappeared 55 minutes after termination of the continuous epidural injection of lidocaine. The plasma concentration of lidocaine at this time was 1.9 microg/mL. CONCLUSIONS At clinically relevant concentrations, lidocaine in the blood absorbed from the epidural space may improve bronchospasm in patients with bronchial asthma.

Neuromuscular Blockade by Vecuronium during Induction with 5% Sevoflurane or Propofol

This randomized trial investigated whether 5% sevoflurane potentiated neuromuscular blockade by vecuronium. General anaesthesia was induced with 5% sevoflurane in oxygen in 16 patients or with propofol in 16 patients. After loss of consciousness, vecuronium was administered to all participants at randomly assigned doses of 25, 30, 35 or 40 μg/kg. Neuromuscular blockade was assessed by use of acceleromyography to measure responses to train-of-four stimuli in the adductor pollicis and corrugator supercilii muscles. Maximum blockade was significantly more intense in the adductor pollicis among patients in the sevoflurane group than in the propofol group, whereas there was no significant between-group difference at the corrugator supercilii muscles. In both groups, maximum blockade at the corrugator supercilii was significantly less intense than that achieved at the adductor pollicis. In the dose–response analysis, the 50% and 95% effective doses were lower for sevoflurane than for propofol in both muscles, although this did not reach statistical significance. It is concluded that induction of general anaesthesia with sevoflurane might provide improved conditions for intubation and reduce airway problems.

Anesthetic management of a child with chromosome 22q11 deletion syndrome

Chromosome 22q11 deletion syndrome (22q11DS) is a congenital anomaly characterized by cardiovascular, oropharyngeal, immunologic, endocrine, and neurodevelopmental abnormalities. We successfully managed a 6‐year‐old girl with 22q11DS with general anesthesia. Potential problems in anesthetic management of patients with 22q11DS are reviewed.

Reversal of neuromuscular effects of adenosine by specific adenosine A1-receptor antagonist in live rats.

Intravenous adenosine in-vivo was shown to potentiate the effects of non-depolarizing neuromuscular blocking agents. This study aimed to determine whether adenosine A1-receptors mediated this potentiation. The authors investigated the effects of intravenous adenosine, N6-cyclopentyladenosine, specific A1-receptor agonist, and 8-cyclopentyl-1,3-dipropylxanthine, specific A1-receptor antagonist, on neuromuscular block by vecuronium, in in-vivo rat sciatic nervetibialis anterior preparations. In the presence of 50% steady state block by vecuronium, adenosine, and N6-cyclopentyladenosine caused similar degree of depressions of twitch tension. Twitch tension returned to its pre-injection value more rapidly when 8-cyclopentyl-1,3-dipropylxanthine was given at the maximal block than when it was allowed to recover spontaneously. It was concluded that in in-vivo adenosine potentiated the neuromuscular effects of vecuronium through adenosine A1-receptors in rats.

Splanchnic neurolysis using carbon dioxide as the contrast agent.

Background and Objective Iodinated contrast agents are usually used to verify correct spread of injectate during splanchnic neurolysis. We performed a splanchnic neurolysis by using carbon dioxide as the contrast agent in a patient who was allergic to iodinated contrast agents. Case Report A 49-year-old man had severe upper abdominal and back pain due to chronic pancreatitis. Because slow-release morphine 360 mg a day and epidural fentanyl 500 μg a day did not relieve the pain, a splanchnic neurolysis was performed by the posterior approach. The needle tip was placed into the retrocrural space under fluoroscopic guidance. Fifteen milliliters of carbon dioxide was injected as the contrast agent. It gave a less clear image than that obtained by iodinated contrast agents; however, the correct spread of the gas was easily visible under continuous fluoroscopy. Six percent aqueous phenol 8 mL was injected after confirming relief of the pain with a local anesthetic. The dose of slow-release morphine was gradually decreased after the procedure. His abdominal and back pain was controlled with slow-release morphine 120 mg a day. Conclusion Carbon dioxide was useful as the contrast agent to perform splanchnic neurolysis. Reg Anesth Pain Med 2003;28:68-69.