A 74-year-old female with diabetes mellitus type II and Alzheimer's disease, taking donepezil for 4 months was operated for right modified radical mastectomy under general anesthesia. During the procedure a higher dose of non-depolarizing muscle relaxant was required than those recommended for her age yet the muscle relaxation was inadequate intra-operatively. Residual neuromuscular blockade persisted postoperatively, due to the cumulative effect of large doses of non-depolarizing muscle relaxant, needing post-operative ventilatory assistance. After ruling out other causes of resistance to non-depolarizing muscle relaxants, we concluded that acetylcholinesterase inhibitor donepezil was primarily responsible for inadequate muscle relaxation and delayed post-operative neuromuscular recovery.
Foreign body aspiration into the airway is common in the pediatric age group and its anesthetic management is a challenge. Iatrogenic tracheo-bronchial injury further worsens the situation. Flexible pediatric fiberscope is the gold standard for securing the airway in cases of airway injury. We present a case of a 7-year-old girl who presented to the hospital with signs and symptoms of foreign body aspiration and suspected tracheo-bronchial tree injury. The impacted foreign body was removed by rigid bronchoscopy and the presence of a tracheo-bronchial tear was confirmed. To repair the airway tear, thoracotomy was planned necessitating one lung ventilation. A pediatric flexible fiberscope was not available, so left endobronchial intubation for one lung ventilation was done with the help of an airway exchange catheter using a rigid bronchoscope as a conduit. Subsequent intra-operative and post-operative period were uneventful.
Objective: To evaluate the feasibility of sensory mapping of lumbar facet joint pain in patients scheduled to undergo radiofrequency (RF) denervation. Design: Prospective cohort study. Setting: University teaching hospital. Subjects: A total of 15 participants listed for RF denervation of lumbar facet joint. Method: After written informed consent, participants were recruited to the study. Participants completed a pain diagram prior to their procedure. After successful image-guided placement of RF cannulas, the sensory detection threshold using 50 Hz stimulation was obtained, followed by application of suprathreshold stimulation. Participants mapped their stimulated area in comparison to their pre-procedure pain diagram. Results: All 15 participants had previously undergone diagnostic blocks. All participants were able to report either pain or paraesthesia during suprathreshold stimulation. In total, 14 out of 15 participants reported complete coverage of their usual painful area with suprathreshold stimulation of nerves scheduled for RF denervation. In one of the participants, an area of upper lumbar pain was not covered during suprathreshold stimulation. Nearly two-thirds of the participants (n = 9), reported either pain or paraesthesia, outside their normal painful area during suprathreshold stimulation. A total of 71 nerves were scheduled for RF denervation. Sensory electrical stimulation was successfully achieved in 68 out of 71 nerves (96%). The average sensory detection threshold was found to be 0.3 V while the suprathreshold stimulation was 0.6 V. Conclusion: Lumbar facet joint pain can be mapped using suprathreshold sensory stimulation, which has the potential to introduce objectivity during RF denervation.
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