JA Clinical Reports

Congenital myasthenia syndrome is a heterogeneous disease with impaired neuromuscular transmission. This report describes a 13-year-old child with congenital myasthenia syndrome who underwent surgery for scoliosis under general anesthesia. We used a small dose of rocuronium, neuromuscular transmission monitoring, and non-invasive positive pressure ventilation for postoperative respiratory management. There were no respiratory complications during the perioperative period. As there are only a few reports on the anesthetic management of patients with congenital myasthenia syndrome, we applied the principles of managing autoimmune myasthenia gravis. The postoperative management described herein can prevent respiratory complications in patients with congenital myasthenia syndrome.

Mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes (MELAS) is a mitochondrial disease. We report here the safe use of remimazolam in a pediatric MELAS patient. A 10-year-old girl (118 cm, 16 kg) was scheduled for an open gastrostomy to improve nutrition and epileptic seizure control. We induced and maintained general anesthesia with remimazolam, remifentanil, fentanyl, and rocuronium. We also performed a bilateral subcostal transversus abdominis plane block before the surgery. The surgery finished uneventfully. After we discontinued remimazolam administration, the patient woke up immediately but calmly without flumazenil. Epileptic seizures did not occur during intra- and early post-operative periods. Remimazolam enabled us to provide a pediatric MELAS patient with general anesthesia without causing delayed emergence or epileptic seizures.

Blind epidural catheter placement can lead to inadvertent misplacement. We present a case of intercostal misplacement of a thoracic epidural catheter. A 67-year-old male underwent left lung cancer surgery via thoracotomy with epidural analgesia via the Th 5–6 intervertebral space, although with some difficulty. We detected dermatomal cold sensory loss around Th five min after initial administration of local anesthetics through the catheter before general anesthesia induction. However, the epidural catheter was intraoperatively found below the fifth rib, running along the course of the intercostal nerve. The catheter was successfully withdrawn via his back, and we postoperatively performed paravertebral block under ultrasound guidance. He did not complain of complications at discharge. Detailed bilateral assessment of sensory loss after initial local anesthetic administration might have facilitated preoperative detection of the misplacement. In cases requiring multiple catheter insertion attempts, switching to another analgesic method should be considered.

Remimazolam is an ultra-short-acting benzodiazepine anesthetic that is antagonized by flumazenil, and it is typically expected to be applied in anesthesia with the purpose of ensuring early postoperative recovery. We report a case of long-term delayed emergence with re-sedation even after three times of flumazenil administration. A 71-year-old man was scheduled for a robotic-assisted laparoscopic radical prostatectomy for prostate cancer. We used remimazolam for anesthetic induction and maintenance. The intraoperative bispectral index (BIS) was 30–50. Flumazenil was administered as patient emergence was delayed after surgery; however, re-sedation was observed. This finding persisted till 12 h after surgery, and the patient awakened on postoperative day 2. Remimazolam is a short-acting anesthetic, but long-term delayed emergence with re-sedation may occur even after flumazenil administration. Anesthesia using remimazolam requires anesthesia management that takes into account the individual differences in sensitivity and metabolism, with BIS as the indicator.

A 64-year-old female patient with spinocerebellar ataxia type 6 was referred to our department for pancreatic cancer and anesthetized with volatile anesthesia combined with epidural anesthesia for pancreaticoduodenectomy. No complications arose during surgery. On postoperative day 4, a head tremor was noticed at the time of mobilization. The tremor was a postural and “no-no” tremor rather than an intention or resting tremor. The head tremor caused difficulty in eating and in other activities of daily living. No abnormal results were obtained by magnetic resonance imaging of the brain. The tremor was resistant to drugs, including anti-Parkinson drugs and benzodiazepines, and was therefore difficult to treat.

Anesthetic management of coronary artery bypass grafting surgery (CABG) in a dextrocardia patient with situs inversus totalis is rarely encountered and seldom reported in the literature. A 76-year-old Japanese female patient had been diagnosed with situs inversus totalis and coronary artery disease of 3 vessels, and she subsequently underwent elective CABG. A preoperative examination showed almost normal results. ECG showed right deviation with the normal lead position. In the operating room, ECG leads were applied in reverse. Pulmonary artery catheterization was performed via the left internal jugular vein. A transesophageal echocardiography (TEE) probe was introduced without difficulty. A different angle was needed to acquire the desired views because of her atypical anatomy. Careful perioperative evaluation, intraoperative management, and inspection of multiplane angle and probe adjustments in TEE are needed for anatomically abnormal patients.

The intercostobrachial nerve blockade is required, in addition to brachial plexus block, to anesthetize the entire upper arm. No studies have described the use of erector spinae plane (ESP) block for an intercostobrachial nerve block. A 72-year-old man was scheduled to undergo left brachial vein transposition-arteriovenous fistula creation for hemodialysis access. An ultrasound-guided infraclavicular brachial plexus block was performed using a mixture of 0.5% levobupivacaine (12.5 ml) and 2% lidocaine (12.5 ml). An ESP block was implemented using 10 ml of the same local anesthetic at the T2 level. A pinprick test showed that the entire upper arm and lateral aspect of the left upper chest wall were anesthetized 20 min after the blocks. Surgery was successfully performed without the need for general anesthesia. In the present case, an ESP block performed at the T2 level provided sensory loss of the area innervated by the intercostobrachial nerve.

Although most epidural catheter knot formation has been reported in lumbar epidural catheter placement, knot formation in a thoracic epidural catheter has been experienced. A 72-year-old woman was scheduled for laparoscopic cholecystectomy under general anesthesia combined with epidural anesthesia. The epidural catheter was inserted through the Th10–Th11 intervertebral space and was placed 7 cm into the epidural space. Two days after the surgery, the anesthesiologist was called because of difficulty in removing the epidural catheter. The catheter was eventually removed when the anesthesiologist carefully pulled it while strongly bending the patient’s body to the right, although resistance was still noted. The removed catheter was observed to have a hard single knot formed at about 3 mm from the tip. A knot formation of an epidural catheter placed at the thoracic level was experienced. Limiting the length of catheter placement may prevent knot formation.