We present a 36-year-old female patient who underwent transradial cerebrovascular angiography because of acute putaminal hemorrhage. Catheter entrapment occurred with severe pain in the right upper arm proximal to the elbow. A subclavian artery angiogram by way of a transfemoral crossover catheter revealed severe vasospasm in the axillary artery distal to the branch point between it and the posterior brachial circumflex artery. Diazepam 5 mg intravenously (IV) through a peripheral catheter, lidocaine 0.5% 5 mL injected subcutaneously, and lidocaine 2% 4 mL IV isosorbide dinitrate 2 mg IV through the angiographic crossover catheter failed to relieve the pain and catheter entrapment. An ultrasound-guided supraclavicular brachial plexus block relieved both within 3 minutes. In the past, general anesthesia would have been administered.
A 72-year-old man (166 cm, 80 kg, BMI 29 kg/m 2 ) underwent removal of a left acoustic neurinoma in park-bench position. He was under a treatment for diabetes and hyperlipidemia. Four hours after taking the position, tea-colored urine appeared. His vital signs were stable without high fever, muscle rigidity, or electrolyte abnormalities, so surgery was continued. Redness in the skin of the lateral chest was noted after surgery. Rhabdomyolysis was diagnosed by the elevation of creatine phosphokinase (7,563 IU/L) , myoglobinuria (87 ng/mL) , and diffuse swelling of the right transverse abdominal and lumbar muscles on the day after surgery. Kidney dysfunction was not observed during the perioperative period. In this case, the main cause of rhabdomyolysis is long-term surgery in park-bench position. However, there are several other risks involved such as dehydration by fluid restriction and mannitol use and obesity. Attention should be paid to hypotension, dehydration, and electrolyte imbalances in addition to the particular position. Early detection and management of rhabdomyolysis is crucial.
The purpose of this study was to determine hormonal levels in compensated liver cirrhotic patients under general anesthesia before and after liver surgery. We measured plasma norepinephrine, epinephrine, arginine vasopressin, and aldosterone levels and renin activity in non-cirrhotic and compensated cirrhotic patients undergoing liver resection after induction of anesthesia but before skin incision and after the end of operation but before discontinuation of nitrous oxide. We simultaneously measured hemodynamic variables. Plasma levels of norepinephrine (P < 0.001), epinephrine (P < 0.001), arginine vasopressin (P < 0.05), renin (P < 0.05) and aldosterone (P < 0.001) significantly increased after completion of surgery compared with those before incision in both groups. There was a significant positive correlation between plasma renin and aldosterone (r = 0.56, P < 0.01) levels in non-cirrhotics, but no correlation was observed in cirrhotics; and there was a significant positive correlation between plasma norepinephrine and arginine vasopressin (r = 0.45, P < 0.05) levels in non-cirrhotics, but no correlation in cirrhotics. Cardiac index and arterial pressure increased after the end of operation (P < 0.05). This increase after the operation was the same between cirrhotic and non-cirrhotic groups. There were no changes in heart rate, mean pulmonary arterial pressure, and pulmonary capillary wedge pressure after the end of operation. We conclude that hemodynamic and endocrinological changes were similar between compensated cirrhotic patients and non-cirrhotic patients during liver surgery. Endocrine changes might partly explain the hemodynamic changes during surgery.
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