Prolonged muscle weakness following emergency tonsillectomy in a patient with familial periodic paralysis and infectious mononucleosis

A thirteen-year-old girl with normokalaemic familial periodic paralysis (FPP) suffered life threatening upper airway obstruction secondary to tonsillopharyngitis resulting from infectious mononucleosis (IM). Emergency tonsillectomy was performed, but her postoperative course was complicated by persistent muscle weakness requiring a very prolonged period of artificial ventilation.     

残余肌松与麻醉后呼吸功能不全

手术麻醉后呼吸事件的发生与手术病人的安全密切相关,而残余肌松作用是引起麻醉后呼吸功能损害的高危因素之一。1残余肌松的评价及标准1.1神经刺激器以4个成串刺激(TOF)模式刺激尺神经,用加速度仪或肌电图记录拇内收肌的TOFR(T4/T1)是现在应用较广泛的客观定量监测方法。近20年     

Respiratory paralysis to improve oxygenation and mortality in large newborn infants with respiratory distress

The nonsynchronous respiratory efforts of neonates with surgically correctable disorders may inhibit effective mechanical ventilation. The records of 25 infants treated with metocurine for muscular paralysis to improve mechanical ventilation were reviewed. All patients were greater than 35 (37.6 +/- 2.1) weeks gestation and 2.27 (2.98 +/- .47) kg. All required ventilatory support with an FiO2 of 100%. The mortality rate of this group of infants was 20% as compared with 73% (p < .001) in a similar group of 26 infants managed without paralysis. In 10 of the 25 infants treated with metocurine, pre- and 1 hr postparalysis paO2 values were available. The mean paO2 prior to paralysis was 62 (45--111) mm Hg and the mean post-paralysis paO2 was 144 (75--227) mm Hg, representing at 132% increase in paO2 (p < .001). The mean dosage for metocurine was 3.5 (1.45--6.79) mg/kg/day; however, those requiring paralysis for greater than 7 days showed a dramatically increasing requirement. These preliminary data suggest that respiratory paralysis reduces right-to-left shunting, improves paO2 and decreases mortality in large infants with severe respiratory distress requiring ventilatory support.     

Cylcosporinepancuronium interaction in a patient with a renal allograft

A case is described of a 54-year-old 55 kg patient who presented for clipping of a middle cerebral aneurysm two years after a successful renal allograft. Immunosuppression was maintained with azathioprine 100 mg daily, cyclosporin 300 mg daily and prednisone 10 mg daily. The patient had chronic hypertension controlled with nifedipine 40 mg daily and furosemide 20 mg daily. The cyclosporine level taken on the morning of surgery was 166 ?,g·L^-1. Induction of anaesthesia consisted of fentanyl 350 ?g, thiopentone 125 mg and pancuronium 5.5 mg. Anaesthesia was maintained with nitrous oxide 70 per cent in oxygen and isoflurane 0.5-1 .5 per cent. No additional doses of pancuronium were given during the four hour surgical procedure. At the end of surgery, four twitches were present with train-of-four stimulation, but evidence of residual muscle paralysis was present. Residual neuromuscular blockade was reversed with atropine 1.2 mg and neostigmine2.5 mg. Residual paralysis was present in the Recovery Room and edrophonium 10 mg was given prior to extubation. Clinical testing demonstrated adequate reversal of neuromuscular blockade. Twenty minutes following extubation, increasing respiratory distress was noted. There was clinical evidence of muscle paralysis. The patient was re-intubated. It is proposed that cyclosporine potentiated the pancuronium blockade producing prolonged neuromuscular relaxation resulting in residual paralysis following surgery. The potential interactions of cyclosporine and muscle relaxants deserve further study.     

Lung metastasis from parathyroid carcinoma causing recurrent renal hyperparathyroidism in a hemodialysis patient: Report of a case

We report herein the case of a 46-year-old woman on hemodialysis (HD) who developed recurrent renal hyperparathyroidism induced by lung metastasis from parathyroid carcinoma. The patient had been commenced on HD for chronic renal failure about 20 years earlier and had undergone a parathyroidectomy for advanced renal hyperparathyroidism 8 years later. After the initial operation, further explorations of the neck were performed due to recurrence, despite which the hyperparathyroidism persisted and she was finally referred to our department. The appearance of multiple coinlike lesions ona chest X-ray and computed tomography led to the diagnosis of recurrent hyperparathyroidism induced by lung metastasis from parathyroid carcinoma. A pulmonary wedge resection was performed and the metastatic parathyroid nodules were removed. Of the several hypotheses about the etiology of parathyroid carcinoma in HD patients, it is most likely that the parathyroid hyperplasia induced by chronic renal failure develops into carcinoma. Even in renal hyperparathyroidism, we should bear in mind the possibility that metastatic parathyroid carcinoma is a possible source of excess parathyroid hormone secretion at recurrence.     

Long-term follow-up of renal transplantation in children: A 20-year experience at one kidney center in Japan

Background

We reviewed the results of renal transplantation in children who has received transplants between October 1973 and January 1984 at our center.

Methods

Twenty-six children, 4 to 15 years of age, underwent renal transplantation from livingrelated donors and were treated using conventional immunosuppressive drugs.

Results

Patient survival rates were 96% at 5 years and 88% at 10 years. Graft survival rates were 69% at 5 years and 45% at 10 years. Four patients died. The main cause of graft loss was chronic rejection. One patient lost the graft due to recurrence of the original disease. Henoch-Schönlein purpura nephritis. The graft was functioning at the end of follow-up in 7 patients, and their serum creatinine levels were all below 1.6 mg/dL at the last follow-up. Noncompliance with medication was confirmed in 4 patients. There was no uncontrollable hypertension observed in any case. Children younger than 5 years showed catch-up growth, but overal growth in these children with renal transplants without growth hormone therapy was not good.

Conclusion

The long-term prognosis of children who underwent living-related renal transplantation using conventional immunosuppressive drugs was favorable, compared to that of adults.     

Tubular aggregate myopathy presenting with acute type II respiratory failure and severe orthopnoea

Acute hypercapnic respiratory failure (AHRF) is a common reason for hospital admission. Most patients have an underlying chronic lung disease such as chronic obstructive pulmonary disease. We report the case of a man who presented with AHRF secondary to tubular aggregate myopathy.     

Hypokalaemia and paralysis in the Thai population.

BACKGROUND: Hypokalaemia with paralysis is a syndrome common in Thailand. This syndrome may result from hypokalaemic periodic paralysis (HypoPP), thyrotoxic periodic paralysis (TPP) or distal renal tubular acidosis (dRTA). We prospectively investigated the nature of this syndrome in afflicted Thai patients. METHODS: Blood and urine samples were collected from 47 patients during attacks for multiple biochemical and thyroid function tests. A long acid loading test was performed in all euthyroid patients. Mutation analyses were done in all HypoPP and TPP patients. RESULTS: Of the subjects, 34 completed the study. Of those, 11 (32%), eight (24%) and 15 (44%) had TPP, dRTA and HypoPP, respectively. Patients with dRTA and TPP were older than those with HypoPP. Males were more prevalent than females in HypoPP and TPP; the reverse was true for dRTA. Two-thirds of the HypoPP cases were sporadic. The majority of the HypoPP and dRTA patients resided in northeastern Thailand. Of the 11 TPP patients, nine (82%) had no previous thyroid disease. Moreover, four out of 11 patients (36%) had subtle clinical signs of hyperthyroidism; three of eight dRTA patients had renal stones, nephrocalcinosis or both. Only two patients had metabolic acidosis at the time of presentation. No common mutations were found in the HypoPP and TPP patients. CONCLUSIONS: In most of our patients, HypoPP is sporadic and not associated with the common mutations reported previously. Clinical clues that can assist in differentiating between the causes of hypokalaemia and paralysis are age at onset, gender and geographic region residence of the patients. However, the absence of previous histories of thyroid disease or overt thyrotoxicosis, and of stone disease/nephrocalcinosis or metabolic acidosis does not exclude the diagnosis of TPP or dRTA.     

Anesthetic management in a child with Arnold-Chiari malformation and bilateral vocal cord paralysis

We report a case of a child who was scheduled for an emergency ventriculoperitoneal shunt procedure. The patient had a type II Arnold-Chiari malformation (ACM) and associated hydrocephalus and presented with near complete respiratory obstruction from bilateral abductor vocal cord palsy. Early diagnosis and management of airway abnormalities associated with ACM may be lifesaving. Chiari malformations and anesthesia management are discussed.     

Acute barium nitrate intoxication treated by hemodialysis

A 22-year-old male was admitted to hospital with diarrhea and vomiting, cardiac arrhythmias, severe hypokalemia and gradual onset of muscular weakness. A potassium infusion was started, but for several hours serum potassium remained low. Evidence of toxic ingestion was initially lacking. When it became clear -- after a considerable delay -- that the patient had ingested barium nitrate, hemodialysis was started. This resulted in rapid clinical improvement with correction of hypokalemia and restored muscular function. Intoxication with barium causes hypokalemia, arrhythmias, muscular weakness and paralysis, often requiring respiratory support. This patient presented with symptoms typical of severe barium intoxication, non-responsive to potassium supplementation. There are few published reports on the use of hemodialysis in barium poisoning. This case confirms the possible benefit of hemodialysis in severe cases, where potassium supplementation alone is insufficient.     

Delayed awakening following inadvertent high-dose remifentanil infusion in a 13 year old patient

We report the case of a 13 year old patient who received 3.0 mg of remifentanil during a 50-minute surgical procedure as a result of a dosage miscalculation. The patient failed to awaken at the conclusion of the procedure and showed signs of opioid overdose. She recovered spontaneously two hours later.     

Anaesthetic management of labour and caesarean delivery of a patient with hyperkalaemic periodic paralysis

We describe a parturient with hyperkalaemic periodic paralysis who presented for induction of labour and subsequently, caesarean section. Epidural analgesia and anaesthesia were used successfully in a multidisciplinary plan aimed at avoiding a peripartum attack and providing safe delivery. Management of this rare condition is discussed along with a review of the available literature.     

残余肌松与全麻术后呼吸功能不全关系的临床研究

目的 了解全麻手术后在麻醉恢复室(postanesthesia care unit,PACU)内呼吸功能不全的发生率,并评估其与残余肌松的关系.方法 择期全麻手术成年患者623例,术后PACU内用4个成串刺激(TOF)监测肌松,按临床指征拔管,根据拔管后即刻测量TOF值将患者分成3组,TOF＞0.9为A组；TOF 0.7～0.9为B组；TOF＜0.7为C组,记录每组出现呼吸功能不全的例数.结果 全麻手术后在PACU内呼吸功能不全的发生率为4.5％,A组患者472例,其中有7例(1.5％)出现呼吸功能不全,B组患者112例,9例(8.0％)出现,C组患者39例,有12例(30.8％)出现,最常见的是低氧血症和上呼吸道梗阻.C组与A组和B组比较及B组与A组比较,出现呼吸功能不全比例明显增高(P＜0.01).结论 存在残余肌松(TOF＜0.9)的患者更易出现术后呼吸功能不全,应加强围手术期肌松监测,掌握恰当的拔管时机.     

Hamstring transfer for quadriceps paralysis in post polio residual paralysis

Context:

Paralysis of quadriceps muscle leads to severe disability as the knee is unstable and cannot be fully extended and locked in extension, which results in giving way of the knee joint. Because of this, the patient tries to get stability of the knee by various means like hand to knee gait, extreme internal or external rotation of the affected limb to stabilize knee by support of medial or lateral collateral ligament, respectively, or by tilting pelvis. When there is concomitant weakness of gluteus maximus quadriceps and hamstrings (MRC muscle power less than grade III), patient may develop compensatory hyperlordosis of spine. Hamstring (H) transfer is a well-accepted procedure for patients with quadriceps (Q) weakness. For hamstring transfer, we have used a modified technique of anchoring of biceps femoris and semitendinosus tendon to patella. Instead of cutting the periosteum over the patella in an I-shaped manner, an osteoperisoteal flap was raised after two parallel incisions over the patella and both tendons were sutured under the flap with each other. We conducted a retrospective evaluation of the results of modified hamstring transfer in 267 patients of post polio residual paralysis with residual quadriceps paralysis.

Materials and Methods:

Two hundred and fifty young patients (100 male and 150 female patients) who had quadriceps paralysis due to polio were managed by hamstring transfer at a single center between 1984 and 1996 and were followed for a mean of 5 years (range 4–12 years). Age of patients ranged from 7 to 18 years in 238 patients and 12 patients were above the age of 18 years. All cases were followed periodically, and assessment of knee extension, extension lag, knee flexion, elimination of calliper, and avoidance of hand to knee gait was done.

Results:

One hundred and sixty two patients (65%) showed excellent results, 38 patients (15%) had good results, and 50 patients (20%) showed poor results. Ninety three patients had major complications like genu recurvatum, restricted knee flexion, and extension lag. Ten patients had minor complications like superficial infection and epidermal edge necrosis.

Conclusions:

H to Q transfer in the presence of quadriceps paralysis with good power in hamstring is a better alternative than supracondylar osteotomy because it is a dynamic correction and it produces some degree of recurvatum with increasing stability of knee in extension while walking. While inserting hamstring over patella the periosteum is not cut in an I-shaped fashion to create a flap which gives additional strength to new insertion and also patella act as a fulcrum during the extension of knee by producing the bowstring effect.     

Acute respiratory failure after deep cervical plexus block for carotid endarterectomy as a result of bilateral recurrent laryngeal nerve paralysis

We report about a case of acute respiratory distress (73-year-old female), which occurred minutes after a deep cervical plexus block (40 ml ropivacaine 0.5%) for carotid endarterectomy (CEA) and required immediate endotracheal intubation of the patient's trachea and consecutive mechanical ventilation. Subsequently, CEA was performed under general anaesthesia (TIVA) with continuous monitoring by somatosensory-evoked potentials. After a period of 14 hours, the endotracheal tube could be removed, the patient being in fair respiratory, cardiocirculatory and neurological conditions. Retrospectively, acute respiratory distress was caused by a combination of ipsilateral plexus blockade-induced and pre-existing asymptomatic contralateral recurrent laryngeal nerve (RLN) paralysis confirmed by a postoperative ENT-check and related to previous thyroid surgery more than 50 years ago. RLN paralysis, often being asymptomatic, represents a typical complication of thyroid and other neck surgery with reported incidences of 0.5-3%. Therefore, a thorough preoperative airway check is advisable in all patients scheduled for a cervical plexus block. Particularly in cases with a history of respiratory disorders or previous neck surgery a vocal cord examination is recommended, and the use of a superficial cervical plexus block may lower the risk of respiratory complications. This may prevent a possibly life-threatening coincidence of ipsilateral plexus blockade-induced and pre-existing asymptomatic contralateral RLN paralysis.