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.

Enhancement of immunity against VZV by giving live varicella vaccine to the elderly assessed by VZV skin test and IAHA, gpELISA antibody assay

The enhancement of immunity against varicella-zoster vaccine (VZV) by subcutaneous injection of a live varicella vaccine was assessed by the VZV skin test for cell-mediated immunity (CMI), and immunoadherence hemagglutination assay (IAHA) and gpELISA antibody assays in the elderly people of 50-79 years of age. A total of 127 subjects were examined: 79 aged 50-59, 25 aged 60-69, and 25 aged 70-79. All were seropositive by the gpELISA assay (one was seronegative in the IAHA antibody assay). In contrast, a notable decline was observed in the VZV skin test with increasing age. Negative reaction was observed in 16/79 (20.2%) of the subjects in their 50s, 12/25 (48.0%) in their 60s and 14/25 (56.0%) in the 70s. After the vaccination, the results of the VZV skin test changed from negative to positive in 15/16 (91.8%) of subjects in their 50s, 11/12 (91.7%) in their 60s and 12/14 (85.7%) in their 70s. The mean antibody titer in the IAHA and the gpELISA increased approximately two-fold after the vaccination in each group. Immunity to VZV in 35 elderly subjects who were vaccinated previously was followed up for 4 years. All were positive by the VZV skin test after the previous vaccination. After 4 years, 31 (88.6%) were positive by the skin test, 4 were negative and became positive after revaccination. Although this study was uncontrolled open study, the results suggest that administering live varicella vaccine to the elderly is effective for enhancing immunity, particularly CMI to VZV.

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.

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

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 greater than 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 less than 0.01 for the mild group vs. the moderate group, and P less than 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 log2 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 less than 0.001 for the mild group vs. the moderate group and for the moderate group vs. the severe group).(ABSTRACT TRUNCATED AT 250 WORDS)

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

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.

Holt-Oram syndrome

Holt-Oram syndrome (HOS) is a rare disorder characterized by congenital anomalies of the upper limbs and heart. Cardiac arrhythmias are common in patients with HOS. We successfully managed a 24-yr-old woman with HOS who underwent laparoscopic ovarian cystectomy. Potential problems in the anaesthetic management of patients with HOS are discussed.

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 time daily; group B (n = 43) were given intermittent epidural blocks and parenteral acyclovir (500 mg/day) or vidarabine (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 approximately 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.

Neuromuscular effects of sevoflurane in myasthenia gravis patients

BACKGROUND

Little information is available regarding the neuromuscular effects of sevoflurane in patients with myasthenia gravis (MG). We evaluated the neuromuscular effects of sevoflurane alone in patients with MG and in those with normal neuromuscular transmission.

METHODS

Sixteen patients with generalized type MG (MG group) and 12 otherwise healthy patients (control group) entered into this study. Anaesthesia was induced with propofol, fentanyl, and midazolam followed by nitrous oxide in oxygen. Neuromuscular monitoring was recorded from the adductor pollicis muscle using electromyography with train-of-four stimulation of the ulnar nerve. After a stabilization period, and before sevoflurane administration, baseline T4/T1 was obtained and MG patients were classified as non-fade MG group (baseline T4/T1 > or = 0.90) (n = 10) and fade MG group (baseline T4/T1 < 0.90) (n = 6). End-tidal sevoflurane concentration was kept constant at 1.7% for 30 min and doubled thereafter to 3.4% and maintained for a further 30 min.

RESULTS

Sevoflurane produced a concentration-dependent decrease in T1 and T4/T1 values. At 3.4% sevoflurane, T1 and T4/T1 decreased significantly from baseline values in all three groups. From baseline until the patient woke up from anaesthesia, the T4/T1 of the fade MG group was significantly lower than the other groups. At the end of anaesthesia, T4/T1 returned to values similar to the baseline in all three groups.

CONCLUSIONS

During sevoflurane anaesthesia, concentration-dependent inhibition of neuromuscular transmission was observed in MG and control patients. The inhibitory effects of sevoflurane were more prominent in MG patients with baseline T4/T1 <0.90.

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

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.(ABSTRACT TRUNCATED AT 250 WORDS)

Skin blood flow and plasma catecholamine concentrations during removal of a phaeochromocytoma in a child

A 9-yr-old boy with an adrenal phaeochromocytoma underwent removal of the tumour under general anaesthesia using sevoflurane and nitrous oxide combined with thoracic epidural anaesthesia. Skin blood flow in the first toe, as measured by laser Doppler flowmetry, markedly decreased during manipulation of the tumour and increased after removal of it. Skin blood flow correlated more significantly with plasma catecholamine concentrations than did mean arterial blood pressure. Skin blood flow may be used as a non-invasive measure of plasma catecholamine concentrations during removal of a phaeochromocytoma in paediatric patients.

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.

One-year follow-up of zoster-associated pain in 764 immunocompetent patients with acute herpes zoster treated with famciclovir (FAMILIAR study)

BACKGROUND

Herpes zoster (HZ), a reactivation of varicella zoster virus manifested by skin blisters and neuralgia, can lead to postherpetic neuralgia in 10-20% of affected subjects.

METHOD

In this study, a cohort of 764 patients with HZ was treated with 1500 mg/day of famciclovir for 7 days, and zoster-associated pain (ZAP) was monitored monthly thereafter for up to 12 months until pain resolution was achieved. Patients were questioned monthly by telephone, and pain was recorded using a numerical rating scale (NRS, 0-10).

KEY RESULTS

A total of 751 of 764 (98.3%) patients completed follow-up. The percentage of patients with ZAP was 12.4% at day 90, 7.1% at 6 months and 4.0% at 1 year. After the third month, the NRS were 3 or less in most of the remaining patients with ZAP. Stratified analysis revealed significant persistence of ZAP in patients aged ≥50 years and in those aged ≥65 years, and in patients with either moderate-to-severe skin symptoms or severe pain at the initial consultation.Stratified analyses unexpectedly showed patients who commenced famciclovir at 0-2 days after onset of the eruption had a higher prevalence of ZAP at day 90 than those treated at 3-5 days or ≥6 days after rash onset (P = 0.0164, log-rank test). On further analysis, a higher proportion of patients (45.4%) treated at 0-2 days had moderate to severe symptoms compared with those treated at 3-5 days (40.5%) or ≥6 days (37.0%) (P = 0.0987, Cochran-Armitage test). CONCLUSION & INFERENCE: This study, with an exceptionally high follow-up rate, revealed several new findings, including the influence of disease severity on the delay between the onset of symptoms and seeking medical attention. Six adverse drug reactions were reported in five of 721 patients in the safety analysis, including two severe cases of vomiting and convulsions.

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 < or = 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 (< or = 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.

Use of epidural anaesthesia for surgery in a patient with Kennedy's disease

Use of neuraxial block in a patient with motor neuron disease is controversial. We describe the anaesthetic management by epidural anaesthesia of a patient with Kennedy's disease, a rare lower motor neuron disease characterized by progressive weakness and wasting of limbs and bulbar muscles. The perioperative course was uneventful, and there was no exacerbation of neurologic signs or symptoms. We suggest that a patient with Kennedy's disease may be successfully managed by epidural anaesthesia for surgical internal urethrotomy.

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.

Risk Vessels of Retropharyngeal Hematoma During Stellate Ganglion Block

BACKGROUND AND OBJECTIVE

Bleeding into the retropharyngeal space is a potential complication in stellate ganglion block (SGB). Retropharyngeal hematoma formation is considered to be due to damage of small arteries in the region, although only scanty details of the region are available. The aim of this study was to map the risk blood vessels in the retropharyngeal space to avoid accidental damage during SGB.

METHODS

Contrast-enhanced 3-dimensional computed tomography images performed on 80 patients were reanalyzed retrospectively to construct detailed map of cervical blood vessels that are prone to damage and bleeding during SGB.

RESULTS

Of the 160 bilateral necks, 6 (3.8%) and 82 (51.3%) small arteries were identified in the medial portions of the ventral surface of the transverse processes of the sixth and seventh cervical vertebrae, respectively. In particular, 5 of the 6 small arteries detected in the medial portion of the ventral surface of the transverse process of the sixth cervical vertebra were the inferior thyroid artery (ITA). Of the 160 vertebral arteries, 2 arteries were missing, 4 (2.5%) entered the transverse foramen of the fifth cervical vertebra, whereas 1 artery (0.6%) entered the transverse foramen of the fourth cervical vertebra.

CONCLUSIONS

Three-dimensional computed tomography identified the ITA in the medial portion of the ventral surface of the transverse process of the sixth cervical vertebra. The risk vessels of retropharyngeal hematoma during SGB could include the ITA.

Depression of evoked electromyographic (EEMG) responses by propofol in a patient with human T-cell lymphotropic virus type I-associated myelopathy (HAM)

We report a patient with human T-cell lymphotropic virus type I-associated myelopathy. Although muscle strength in both of the upper extremities was normal in this patient, evoked electromyogram of the adductor pollicis was depressed by propofol at the induction of anesthesia.

Effect of bolus injection of 20 ml saline with arm elevation on the onset time of vecuronium administered via a peripheral vein: a randomised controlled trial

We investigated whether a bolus injection of 20 ml saline with arm elevation might shorten the onset time of vecuronium administered via a dorsal hand vein. Thirty patients were randomly allocated to the bolus saline group or control group. General anaesthesia was induced and maintained with remifentanil and propofol. Vecuronium 0.1 mg.kg(-1) was administered to all patients, followed in the treatment group by bolus injection of 20 ml saline and arm elevation. Response to train-of-four stimulation was measured by acceleromyography at the adductor pollicis muscle. The mean (SD) lag time was 47.2 (14.5) s in the bolus saline group and 67.9 (12.2) s in the control group (p = 0.0002). The time to 95% block of T1 was 104.6 (29.9) s in the bolus saline group and 128.3 (15.8) s in the control group (p = 0.011). Bolus saline injection results in shortened lag time and onset time of neuromuscular block with vecuronium.

Acceleromyography at the Flexor Hallucis Brevis Muscle Underestimates Residual Neuromuscular Blockade

Purpose:

Recovery of the train-of-four ratio (TOFR) to > 0.9 in the upper limb is commonly used to determine that neuromuscular function has returned to the preoperative level. It is not known whether recovery of neuromuscular function can be determined in the same way using lower limb acceleromyography. We compared measurements of recovery from neuromuscular blockade using upper limb electromyography and lower limb acceleromyography.

Methods:

Twenty-nine patients who were scheduled for elective surgery were enrolled in this study. Patients were excluded if they had neuromuscular disease or contraindications to neuromuscular blockade. General anesthesia was induced and maintained with propofol and fentanyl. Patients were monitored using electromyography at the first dorsal interosseous muscle of the upper limb and acceleromyography at the flexor hallucis brevis muscle of the lower limb. Vecuronium 0.1 mg/kg was administered for neuromuscular blockade, and the profile of the blockade was recorded, including onset time and recovery times to TOFR 0.7 and 0.9. Results were compared between the upper and lower limbs.

Results:

The first dorsal interosseous muscle of the upper limb was slower to recover to TOFR 0.7 and 0.9 than the flexor hallucis brevis muscle. When the TOFR at the flexor hallucis brevis muscle had recovered to 0.9, the TOFR at the first dorsal interosseous muscle was 0.44 ± 0.23.

Conclusion:

Monitoring the flexor hallucis brevis muscle using acceleromyography underestimates the residual neuromuscular blockade.

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 nerve-tibialis 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.

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.