Su-Man Lin

Clindamycin-induced Anaphylactic Shock During General Anesthesia

Clindamycin-related anaphylactic reaction is rarely reported. We report a male patient with buccal cancer who was undergoing radical neck dissection when life-threatening anaphylactic shock developed soon after intravenous infusion of clindamycin. Immediate cardiopulmonary resuscitation was performed, and the patient recovered uneventfully. Perioperative anaphylactic shock is a serious problem due to the difficulty of judgment and potentially disastrous outcome. Immediate diagnosis and halting of drug infusion should be the first actions taken.

Thoracic epidural anesthesia for a polymyositis patient undergoing awake mini-thoracotomy and unroofing of a huge pulmonary bulla.

General anesthesia with one-lung ventilation is a conventional anesthetic strategy for most chest surgery, including resection of pulmonary bullae. However, this anesthetic management may cause alveolar barotrauma, hemodynamic instability, pulmonary atelectasis and long-term ventilator dependency. Here, we report a 64-year-old female with polymyositis and bronchiolitis obliterans organizing pneumonia who was scheduled for surgical intervention for a huge pulmonary bulla over the right upper lung. Under thoracic epidural anesthesia, with the patient maintaining clear consciousness and spontaneous breathing, a mini-thoracotomy was accomplished to unroof and partially resect the bulla. There were no perioperative complications, and the patient was satisfied with the anesthetic care. Pulmonary function tests and daily physical performance also improved postoperatively.

Lateral medullary syndrome after prone position for general surgery.

IMPLICATIONS We describe postoperative lateral medullary syndrome with myoclonic spasm. Improper head rotation during positioning in the anesthetized patient might obstruct the flow of the vertebral artery at the neck and result in diminished perfusion of the associated regions in patients with a history of cervical spinal trauma.

Patient controlled epidural analgesia for bilateral versus unilateral total knee arthroplasty: A retrospective study of pain control

Background: Patient controlled epidural analgesia (PCEA) has been used commonly for postoperative pain management following total knee arthroplasty (TKA). The purpose of this study was to compare a single standardized PCEA protocol in patients who received unilateral TKA with patients who received simultaneous bilateral TKA. Methods: From October 2003 to October 2008, 912 patients were enrolled. Patient‐machine interaction data were retrieved from PCA machines and stratified into 12 hour intervals. The data were analyzed according to the side of surgery, gender and methods of anesthesia. Patient demographic data, pain scores and side effect scores were compared to evaluate clinical efficacy. Results: There was no significant difference between the unilateral and bilateral TKA groups for pain scores, severity of side effects, and total drug use. However, there was a paradoxical increase in demand, delivery, and demand/delivery ratio of analgesics for unilateral rather than bilateral TKA. This was only noted in the first 12 hours. Both genders demanded more bolus doses than set by the standard protocol. Women with unilateral TKA received more delivery doses. All of the patients who received general anesthesia had a higher demand/delivery ratio while spinal anesthesia patients had no significant ratio difference. Conclusion: PCEA provided equal analgesia for patients with unilateral or bilateral TKA. However, the paradoxical increase in demand suggested that psychological factors may play a role in pain perception. A comprehensive pain management program that addresses gender and anesthesia methods in the first 12 hours will improve clinical efficacy and patient satisfaction of PCEA.

Priming with Rocuronium to Accelerate the Onset Time of Cisatracurium During Intubation

Background: The priming technique, in which a small dose of nondepolarizing muscle relaxant is administered 3–6 minutes before giving the intubation dose, can speed up the onset of muscle relaxation in patients with paralysis during intubation. We investigated the priming technique and compared 2 different priming agents (rocuronium and cisatracurium) at a priming time of 3 minutes and its effect on decreasing the onset time of cisatracurium. Methods: A total of 60 patients with ASA physical status I–II scheduled for elective surgery were enrolled. After induction with propofol and fentanyl, the patients were randomized into 1 of 3 groups. Group 1 received rocuronium 0.06 mg/kg as a priming dose. Group 2 received cisatracurium 0.01 mg/kg as a priming dose. Group 3 received normal saline and constituted the control group. After a 3‐minute priming time, intubation doses of cisatracurium were given (Groups 1 and 2, 0.14 mg/kg; Group 3, 0.15 mg/kg). First twitch height percentage (T1/T0%; % of control) and train‐of‐four percentage (T4/T1%) were recorded every 10 seconds from baseline until T1/T0% reached 0. Results: Rocuronium (Group 1) and cisatracurium (Group 2) significantly accelerated the onset of cisatracurium (Group 1, 117.0 ± 29.0 seconds; Group 2, 151.0 ± 37.5 seconds; Group 3, 221.5 ± 36.6 seconds; all p < 0.001). Conclusion: Priming with rocuronium or cisatracurium for 3 minutes significantly accelerated the onset of cisatracurium. Priming with rocuronium for 3 minutes improved the onset time of cisatracurium even more than priming with cisatracurium itself.

Anesthetic management of comprehensive dental restoration in a child with glutaric aciduria type 1 using volatile sevoflurane.

Glutaric aciduria type 1 (GA1) is a rare, inherited mitochondrial disorder that results from deficiency of mitochondrial glutaryl-CoA dehydrogenase. Most patients develop neurological dysfunction early in life, which leads to severe disabilities. We present a 37-month-old girl with GA1 manifested as macrocephaly and hypotonia who received comprehensive dental restoration surgery under general anesthesia with sevoflurane. She was placed on specialized fluid management during a preoperative fasting period and anesthesia was administered without complications. All the physiological parameters, including glucose and lactate blood levels and arterial blood gas were carefully monitored and maintained within normal range perioperatively. Strategies for anesthetic management should include prevention of pulmonary aspiration, dehydration, hyperthermia and catabolic state, adequate analgesia to minimize surgical stress, and avoidance of prolonged neuromuscular blockade. We administered general anesthesia with sevoflurane uneventfully, which was well tolerated by our patient with GA1. Additionally, communication with a pediatric geneticist and surgeons should be undertaken to formulate a comprehensive anesthetic strategy in these patients.

Reversal of Mivacurium Chloride: Edrophonium of Spontaneous Recovery in Microscopic Laryngeal Surgery

BACKGROUND A double-blind, randomized study was designed to compare the recovery manner of mivacurium infusion with or without edrophonium reversal in microscopic laryngeal surgery. Neuromuscular blockade was quantified using the train-of-four stimuli to the ulnar nerve and quantification of the ratio of the fourth twitch to the first twitch. METHODS With the approval of the Human Studies Committee of the Taipei Veterans General Hospital and patient informed consent, 40 healthy (ASA I or II) patients with age from 24 to 54 years, undergoing microscopic laryngeal surgery were randomly selected for study. Mivacurium chloride 0.2 mg/kg was given intravenously, and then it was given in continuous infusion to maintain muscle relaxation at 90% twitch block during the procedure. At the end of operation, mivacurium infusion was terminated. In a double-blind manner, group I patients (n = 20) received intravenous edrophonium 1 mg/kg and atropine 0.01 mg/kg for reversal when T1 was at 10% recovery whereas patients in Group II (n = 20) received placebo in the same manner. Mean infusion rate, recovery index (RI50, time from T1 25% to T1 50%; RI75, time from T1 25% to T1 75%), extubation time, and discharge time between groups were compared. Nausea, vomiting, and dysrhythmias were also documented until the patient was discharged from hospital. RESULTS The demographic data between two groups were similar. The recovery index (RI75) for group I was shorter than that of placebo group (5.3 +/- 2.19 min vs. 7.3 +/- 0.9 min) and the difference was statistically significant (P = 0.017). There were no statistically significant differences in mean infusion rate, incidence of nausea and vomiting, and discharge time from the POR. The incidence of tachycardia or arrhythmia in group I was significantly greater than that in group placebo. CONCLUSIONS Mivacurium, a short-acting nondepolarizing agent, is a suitable muscle relaxant for patients receiving microscopic laryngeal surgery. Recovery time with the use of edrophonium as reversal agent was shorter than with placebo, but extubation and discharge time did not differ in two groups. The time which could be saved by the use of edrophonium for reversal of mivacurium to hasten the maximal recovery appears to be less than a few minutes. Therefore, clinically, the value of routine use of edrophonium to obtain a faster recovery does not outweigh its demerits of cost and risk and is not worthy of recommendation.

Comparison of balloon-expandable valves versus self-expandable valves in high-risk patients undergoing transcatheter aortic valve replacement for severe aortic stenosis.

Background Transcatheter aortic valve implantation (TAVI) has emerged as an alternative to surgical aortic valve replacement for patients with symptomatic severe aortic stenosis (AS) who have a high surgical risk. In Taiwan, this is the first study reporting TAVI outcomes at a single center offering two different transcatheter heart valve technologies via four types of approaches. Our aim was to compare 30‐day and 6‐month Valve Academic Research Consortium‐2 (VARC‐2) outcomes of the two valves. Methods We reported the procedural, 30‐day, and 6‐month VARC‐2 outcomes of high‐risk patients who were consecutively treated with the Medtronic CoreValve (MCV) or with the Edwards SAPIEN valve or SAPIEN XT valve (ESV; Edwards Lifesciences, Irvine, CA, USA) delivered via four types of approaches. Results From May 2010 to December 2013, 30 consecutive patients with severe AS underwent TAVI: 15 patients were treated with the MCV and 15 patients were treated with the ESV. The transfemoral approach was the most frequently used route (13 MCV and 6 ESV), followed by the transapical approach (9 ESV), trans‐subclavian approach (1 MCV), and direct aortic approach (1 MCV). There were no procedural deaths. “Device success” was achieved in 29 (96.7%) patients, and is defined as the absence of procedural mortality, correct positioning of one prosthetic heart valve into the proper anatomical location, and intended performance of the heart valve without moderate or severe regurgitation. The VARC‐2–defined combined safety endpoint at 30 days was comparable between patients treated with the ESV and the MCV (33.3% vs. 20%, respectively; group, p = 0.409). At the 6‐month follow up, the combined efficacy endpoint was not significantly different between the two groups (13.3% in the ESV group vs. 20% in the MCV group; p = 0.624). There was only one (3.3%) patient who required permanent pacemaker implantation. Conclusion For the first time in Taiwan, we have demonstrated that TAVI using either device is complementary and feasible for treating a wide range of patients by using a careful selection of approaches. Favorable overall procedural success rates and 30‐day and 6‐month outcomes were achieved with both devices.

Double trouble for transcatheter aortic valve implantation: a patient with no vascular access and high-risk features for bilateral coronary obstruction

A 69-year-old female with a history of hypertension and coronary artery disease presented with progressive exertional dyspnoea. Echocardiography revealed severe aortic stenosis with a mean aortic pressure gradient of 61 mmHg and an aortic valve area of 0.6 cm2. Surgical aortic valve replacement was aborted due to an unexpected porcelain aorta identified during exploratory pericardiotomy and transcatheter aortic valve replacement (TAVR) was considered. Extensive horseshoe calcifications and small diameters (from 4.2 to 5.6 mm) of the bilateral iliofemoral arteries and small left subclavian artery diameter (5.3 mm) precluded the transfemoral and trans-subclavian access. A direct aortic approach was prohibited due to the porcelain aorta. The right and left carotid arteries measured 6.6 and 6.8 mm, respectively, smaller than the 7.5 mm recommended for transcarotid access. Thus, …

Successful removal of a potentially lethal left atrial thrombus detected by transesophageal echocardiography following the removal of a left ventricular assist device inflow cannula

The left ventricular assist device (LVAD) is a battery-operated, mechanical pump-type device that helps in maintaining the pumping ability of a failing heart. Thromboembolism poses a significant risk during and after LVAD implantation. It occurs in up to 35% of patients with adverse sequelae. We present the case of a 75-year-old man who underwent coronary artery bypass graft surgery and LVAD implantation for acute myocardial ischemia and severe left ventricular dysfunction. However, subsequent transthoracic echocardiographic examination revealed an LVAD thrombus, and LVAD removal was suggested following the failure of thrombolytic therapy. After the LVAD cannula was removed, transesophageal echocardiography (TEE) revealed a residual thrombus in the left atrium. Thrombectomy was successfully performed by opening the left atrium with cardiopulmonary bypass. We believe that TEE monitoring aided the implantation and removal of the LVAD device. In this case, we found that TEE not only helped in monitoring the ventricular function but also in detecting other problems such as the residual thrombus. We strongly recommend TEE monitoring during the entire LVAD-removal procedure, particularly for patients who need to undergo LVAD removal because of thrombosis formation.