Arytenoid cartilage dislocation is a rare complication of tracheal intubation. Although video laryngoscopy is widely used, single-device case series of this complication are scarce. Among 21,250 tracheal intubations using the McGRATH MAC video laryngoscope at a single center, six patients developed arytenoid dislocation (incidence 0.03
In ultrasound-guided needle insertion, continuous needle visualization is crucial for accurate needle placement, particularly for beginners. Novice operators may have difficulty maintaining the spatial relationship between the needle trajectory and the ultrasound imaging plane during freehand needle insertion. To address this educational challenge, we developed a detachable flat plate that can be attached to the needle shaft as a visual and tactile reference to assist alignment with the ultrasound imaging plane. The present study aimed to evaluate this plate's potential utility as an educational aid for novices performing both in-plane and out-of-plane techniques. This simulation-based randomized exploratory study included 32 practitioners who had no prior experience performing ultrasound-guided puncture. The participants were assigned to either the intervention group or the control group. In the intervention group, a custom-made flat plate was attached to the needle to assist alignment with the ultrasound imaging plane. After watching a brief video explaining how to do the procedure, the participants performed puncture tasks on a gelatin phantom at three probe positions—at the apex and at locations 45° to either side of the apex—using both in-plane and out-of-plane techniques. The primary endpoint was needle visualization during in-plane puncture at the right 45° position, assessed on a 5-point scale by a blinded evaluator. In addition, participants rated the ease of needle visualization using a 100-mm visual analogue scale. Of the 39 individuals assessed for eligibility, 32 were included in the analysis (16 in the control group and 16 in the intervention group). All participants were right-handed except for one left-handed individual in the control group. The distributions of sex and participant background (medical students or nurses) were comparable between the two groups. No significant difference in objective needle-visualization scores was observed between the intervention and control groups (p = 0.0516), whereas self-assessed ease of needle visualization was significantly higher in the intervention group (p = 0.0157). In subgroup analysis within the intervention group, angled in-plane puncture showed a tendency toward higher objective and subjective scores, with no such tendency observed for the out-of-plane technique. Our needle-mounted guide improved subjective assessments of needle visualization and showed potential benefits during angled in-plane puncture. These findings suggest that the guide may help novice practitioners maintain alignment between the needle and the ultrasound imaging plane. Further evaluation in more homogeneous and standardized novice populations is required to assess the educational value and potential clinical applications of the device.
Sever’s disease is a common cause of pediatric heel pain and usually improves with conservative treatment. However, persistent pain with allodynia and difficulty in heel contact may indicate a neuropathic mechanism. A 9-year-old boy developed persistent right heel pain after treatment for a suspected left calcaneal avulsion fracture. Despite a diagnosis of Sever’s disease and conservative therapy, pain, allodynia, and difficulty in heel contact persisted. The pain was localized to the medial and plantar heel, with a Tinel-like sign along the presumed course of the medial calcaneal nerve. Topical lidocaine–prilocaine cream and ultrasound-guided perineural injection of a local anesthetic temporarily relieved the allodynia and enabled heel contact. Ultimately, the symptoms resolved with multimodal treatment. Medial calcaneal neuropathic pain should be considered in children with persistent heel pain accompanied by sensory abnormalities, localized pain consistent with nerve distribution, and a Tinel-like sign.
The basophil activation test (BAT) is an adjunct in identifying causative agents of anaphylaxis. However, its limited sensitivity and methodological variability may lead to inaccurate allergen identification. A 74-year-old woman developed anaphylaxis during anesthetic induction. BAT performed 1 week after the anaphylaxis was negative at 1-hour incubation, whereas 24-hour incubation showed slight increase in basophil activation rates with propofol (7.9
Unintentional intrathecal catheter placement is a recognized complication of labor neuraxial analgesia. Although continuous spinal analgesia (CSA) may be used as a management option, prompt recognition, careful catheter management, and close monitoring are required to prevent complications such as severe spinal anesthesia. A 31-year-old primigravida underwent combined spinal-epidural analgesia for labor pain. Intrathecal catheter placement was diagnosed after a test dose was administered based on hypotension, motor weakness, sensory block, and glucose-positive aspirated fluid. The catheter was managed as CSA with fentanyl-based analgesia under strict monitoring. Although frequent breakthrough pain required rescue boluses, the vaginal delivery was achieved uneventfully. The patient developed a post-dural puncture headache that resolved after an epidural blood patch. This case illustrates the importance of early recognition of inadvertent intrathecal catheter placement and demonstrates that safe labor analgesia can be achieved through conversion to CSA with careful catheter management and close monitoring.
Transfusion-related acute lung injury (TRALI) and anaphylactic shock are rare but life-threatening transfusion-related complications. Differentiating between these conditions during general anesthesia is difficult because subjective symptoms cannot be assessed and intraoperative diagnostic evaluation is limited. A 40-year-old woman undergoing surgery for ovarian cancer under general anesthesia developed acute hypoxemia during transfusion. After completion of the transfusion, she developed sudden hypotension, tachycardia, and generalized erythema, which responded promptly to adrenaline administration. Respiratory failure persisted, and frothy sputum appeared in the endotracheal tube. Postoperative chest radiography showed bilateral pulmonary infiltrates, while echocardiography revealed preserved cardiac function. Anti-human leukocyte antigen (HLA) class I and II antibodies were detected in the transfused fresh frozen plasma, and serum tryptase levels were elevated postoperatively. This case demonstrated overlapping clinical features of TRALI and anaphylactic shock during general anesthesia. Although donor anti-HLA antibodies supported the possibility of TRALI, severe anaphylaxis alone could not be completely excluded as an explanation for the pulmonary edema.
Delayed emergence from general anesthesia has multiple etiologies; in rare cases, it may unmask an unrecognized neurodegenerative disorder. A 64-year-old man underwent laparoscopic cholecystectomy under general anesthesia. No neurological abnormalities were identified preoperatively. After surgery, response to verbal stimuli was inadequate; however, other extubation criteria were met and he was extubated. Approximately 45 min later, rapid nystagmus-like eye movements consistent with opsoclonus developed, initially oscillating horizontally and then vertically, and persisted for about six minutes. A similar episode recurred 125 min after extubation. Head computed tomography showed no acute lesions but revealed marked cerebellar and brainstem atrophy. Subsequent neurological evaluation, including magnetic resonance imaging demonstrating the “hot cross bun” sign, fulfilled the Movement Disorder Society diagnostic criteria for clinically established multiple system atrophy with predominant parkinsonism. In unexplained delayed emergence from general anesthesia, opsoclonus should prompt evaluation for an underlying neurodegenerative disorder.
BACKGROUND:Distinguishing cerebrospinal fluid (CSF) from epidural fluid is important when the origin of aspirated fluid is uncertain during neuraxial procedures. We evaluated the discriminative ability of β-trace protein (BTP). METHODS:Epidural samples were obtained via epidural catheters after local anesthetic administration, and CSF samples during spinal anesthesia. Glucose, total protein, and BTP were measured, and receiver operating characteristic (ROC) analyses were performed. RESULTS:BTP levels were markedly higher in CSF than in epidural samples, with no overlap. Glucose overlapped between groups, whereas total protein showed limited differences. ROC analysis demonstrated excellent discrimination for BTP (AUC = 1.000) under the present study conditions, outperforming glucose (AUC = 0.904) and total protein (AUC = 0.633). For glucose, the optimal cutoff was 56.5 mg/dL (sensitivity 83.3%, specificity 90.0%). For BTP, any cutoff between 0.42-4.03 mg/L achieved 100% sensitivity and specificity within this dataset. CONCLUSIONS:BTP shows strong discrimination between CSF and epidural fluid.
Abstract Background Distinguishing cerebrospinal fluid (CSF) from epidural fluid is important when the origin of aspirated fluid is uncertain during neuraxial procedures. We evaluated the discriminative ability of β-trace protein (BTP). Methods Epidural samples were obtained via epidural catheters after local anesthetic administration, and CSF samples during spinal anesthesia. Glucose, total protein, and BTP were measured, and receiver operating characteristic (ROC) analyses were performed. Results BTP levels were markedly higher in CSF than in epidural samples, with no overlap. Glucose overlapped between groups, whereas total protein showed limited differences. ROC analysis demonstrated excellent discrimination for BTP (AUC = 1.000) under the present study conditions, outperforming glucose (AUC = 0.904) and total protein (AUC = 0.633). For glucose, the optimal cutoff was 56.5 mg/dL (sensitivity 83.3%, specificity 90.0%). For BTP, any cutoff between 0.42–4.03 mg/L achieved 100% sensitivity and specificity within this dataset. Conclusions BTP shows strong discrimination between CSF and epidural fluid.
Abstract Background Kounis syndrome (KS) is an allergic acute coronary syndrome that may precipitate severe perioperative cardiovascular collapse. This study reports a case of remimazolam-induced refractory anaphylaxis complicated by KS and successfully treated with early extracorporeal cardiopulmonary resuscitation (ECPR). Case presentation A 69-year-old male with atrial fibrillation was scheduled for lung resection. After induction of anesthesia with remimazolam, he developed abrupt tachycardia, coughing, and circulatory collapse with ST-segment elevation. Despite repeated adrenaline doses, he progressed to cardiac arrest. Venoarterial extracorporeal membrane oxygenation was initiated during cardiopulmonary resuscitation. Return of spontaneous circulation occurred 15 min after the cardiac arrest. The patient recovered without neurological sequelae. Elevated serum tryptase levels (49.5 µg/L; 24-h postonset: 4.5 µg/L) and positive intradermal testing suggested remimazolam-induced anaphylaxis. Coronary computed tomography revealed no stenosis, compatible with suspected type 1 KS. Conclusions Remimazolam-induced anaphylaxis may be complicated by suspected KS. In refractory anaphylaxis complicated by cardiac arrest, early ECPR may be critical to survival.
Abstract Background Anaphylaxis in patients with a left ventricular assist device (LVAD) may critically reduce LVAD flow, particularly when the right ventricular function is impaired. Case presentation A 51-year-old man with a HeartMate III LVAD developed bronchospasm, profound hypotension, and decreased LVAD flow during anesthetic induction for endoscopic sinus surgery. The shock remained refractory despite epinephrine boluses and continuous infusions of epinephrine, norepinephrine, and vasopressin. Transesophageal echocardiography revealed severe right ventricular dilatation, leftward septal shift, and reduced left ventricular size, findings consistent with acute right heart failure (RHF). Treatment was escalated to include dobutamine, olprinone, and inhaled nitric oxide, achieving recovery of blood pressure and LVAD flow. Elevated serum tryptase supported the diagnosis of anaphylaxis, and a positive intradermal test identified remimazolam as the cause. Conclusions Successful anaphylaxis management in LVAD recipients may require rapid recognition and treatment of acute RHF in addition to standard treatment including epinephrine.
Abstract Background Previous abdominal wall repair may alter the rectus abdominis muscle structure and render rectus sheath block (RSB) infeasible in pediatric cardiac surgery. Case Presentation A 5-year-old boy with a history of siloplasty and omphalocele repair underwent right ventricle-to-pulmonary artery conduit replacement. Deep parasternal intercostal plane block and RSB had been planned. However, ultrasound pre-scanning failed to identify the rectus abdominis muscle in the upper abdomen, and the liver was visualized immediately beneath the abdominal wall. Preoperative computed tomography confirmed absence of the rectus abdominis muscle, rendering RSB anatomically infeasible. An alternative upper abdominal wall block was performed. The patient was extubated 2 h after admission to the intensive care unit and had no apparent discomfort from the chest and mediastinal drains. Conclusions Preprocedural ultrasound assessment can identify altered rectus abdominis muscle structure and help anesthesiologists select a safer and potentially effective alternative analgesic strategy when RSB is not feasible.
Abstract Background Large language models (LLMs) have shown promising performance for ASA Physical Status (ASA-PS) classification, but prior work suggests reduced agreement in high-risk patients. We evaluated LLM reliability for ASA-PS classification in cardiovascular surgery. Results Thirty-two anonymized cases were rated by two residents, two board-certified cardiovascular anesthesiologists, and four LLM modes (ChatGPT: GPT-5.2 Instant and GPT-5.2 Thinking; Gemini: Gemini 3 Fast and Gemini 3 High Thinking); all LLM assessments were zero-shot. Overall agreement across evaluators was moderate (intraclass correlation coefficient [ICC] 0.49–0.52); agreement between each LLM and specialists was good (ICC 0.61–0.65). Exact-match to a five-specialist consensus was 42.2% for residents versus 59.4–75.0% for LLMs; classifications outside the range of ratings assigned by individual specialists were rare (0–3.1%). Conclusions In cardiovascular surgery, contemporary LLMs showed good concordance with cardiovascular anesthesiologists and exceeded resident agreement with expert consensus, supporting prospective multicenter validation as adjuncts for ASA-PS assessment and training.
BACKGROUND: Inhaled nitric oxide is a selective pulmonary vasodilator commonly used to treat pulmonary hypertension and right ventricular failure. However, its effectiveness in treating right ventricular failure secondary to hypercapnia caused by abdominal compartment syndrome has not been well described. CASE PRESENTATION: This case describes a patient who developed severe hypercapnia and acute right ventricular failure due to abdominal compartment syndrome following massive intraoperative hemorrhage. Elevated intra-abdominal pressure impaired the respiratory mechanics, resulting in alveolar hypoventilation, hypercapnia, and acute pulmonary hypertension. Respiratory and circulatory failures progressively worsened. Administration of inhaled nitric oxide was associated with a rapid improvement in right ventricular afterload surrogates, leading to improved right ventricular output and enhanced carbon dioxide elimination, with concomitant improvement in systemic hemodynamics. DISCUSSION: Inhaled nitric oxide may serve as an effective rescue therapy for hypercapnia-induced pulmonary hypertension and acute right ventricular failure associated with abdominal compartment syndrome.
BACKGROUND: The use of transesophageal echocardiography (TEE) after esophagectomy remains controversial. Herein, we describe a case in which TEE use was safe and effective during cardiac surgery after esophagectomy with retrosternal gastric tube reconstruction. CASE PRESENTATION: A 71-year-old man, who had undergone esophagectomy with retrosternal gastric tube reconstruction, was scheduled for removal of a left atrial myxoma via right anterior thoracotomy under cardiopulmonary bypass. A multiplane TEE probe was smoothly inserted into the gastric tube, providing echocardiographic images similar to those acquired by transthoracic echocardiography via the parasternal and subcostal windows. TEE monitoring helped confirm the positions of the devices placed in the great vessels, tumor location, absence of residual air or leakage, and normal heart function. No complications related to the TEE were observed. CONCLUSIONS: Intraoperative TEE monitoring is a feasible option even in patients who have undergone esophagectomy with retrosternal gastric tube reconstruction.
BACKGROUND: Cardiac herniation is a rare but potentially fatal complication that may occur after surgery involving pericardial incision or resection. Most cases develop intraoperatively or in the early postoperative period, and delayed-onset cases after minimally invasive thoracic surgery have not been reported. CASE PRESENTATION: A 48-year-old woman developed left shoulder pain and nausea six years after thoracoscopic thymectomy for myasthenia gravis. Electrocardiography indicated ST-segment elevation myocardial infarction. Computed tomography of the chest showed cardiac herniation into the left thoracic cavity and coronary angiography revealed stenosis corresponding to the hernial defect. The patient was diagnosed with coronary artery compression due to cardiac herniation and underwent hernia reduction and coronary artery bypass grafting. The postoperative course was uneventful. CONCLUSIONS: Cardiac herniation may occur even long after minimally invasive thoracic surgery and should be considered in patients presenting with chest symptoms or hemodynamic instability.
Background We present a case of scoliosis surgery performed under general anesthesia with remimazolam in a 16-year-old patient with Leigh syndrome (LS), a subtype of mitochondrial encephalomyopathy. Anesthetic management in such patients is challenging because of the risks of malignant hyperthermia with inhalational agents and propofol infusion syndrome, and because many of these patients present with impaired consciousness and respiratory compromise, anesthetic management becomes extremely difficult. To date, very few reports have described remimazolam use in LS, and none have described cases requiring intraoperative motor-evoked potential (MEP) monitoring. Case presentation A patient diagnosed with LS at 7 months of age underwent corrective scoliosis surgery. Anesthesia was induced and maintained using remimazolam supplemented with opioids and muscle relaxants. Some intraoperative MEP signals were attenuated but remained monitorable. The patient was extubated with flumazenil and admitted to the intensive care unit, where a transient decrease in oxygenation was observed. However, the patient recovered without any complications and was discharged uneventfully. Conclusion Remimazolam may be a feasible anesthetic option for patients with LS undergoing surgery requiring MEP monitoring. However, its use should be carefully determined based on factors such as the patient's age, level of consciousness, respiratory function, and history of epilepsy.
Cerebral malperfusion during acute aortic dissection (AAD) surgery is a life-threatening event requiring prompt detection and intervention. We report a case of intraoperative extension of dissection into the brachiocephalic artery (BCA) detected by regional cerebral oxygen saturation (rSO₂) monitoring before cardiopulmonary bypass. A 78-year-old man undergoing emergency total aortic arch replacement showed a sudden bilateral rSO₂ decline after anesthesia induction, corresponding to BCA extension on transesophageal echocardiography. rSO₂ recovered during selective cerebral perfusion but fell again during CPB weaning. Carotid duplex ultrasonography revealed collapse of the right common carotid artery due to false lumen expansion compressing the true lumen. Reanastomosis of the BCA restored cerebral oxygenation. This case highlights the utility of multimodal monitoring—rSO₂ trends, transesophageal echocardiography, and carotid duplex ultrasonography—for detecting and managing cerebral malperfusion during AAD surgery. Early identification allows timely surgical revision and may improve neurological outcomes.
Background Unexpected difficult airway management, although rare, may occur after induction of anesthesia. In such cases, appropriate airway management is required to prevent life-threatening hypoxia. Case presentation In a 44-year-old woman without predicted difficult airway, after induction of general anesthesia, repeated attempts at tracheal intubation using videolaryngoscopes had failed, and ventilation using both a facemask and a supraglottic airway became difficult; the patient was awakened and the surgery cancelled. One week later, awake nasotracheal intubation using a flexible bronchoscope was attempted under high-flow nasal oxygenation. A clear view of the glottis was obtained by bronchoscopy and the trachea was intubated successfully without hypoxia. Conclusions In patients with unexpected difficult airway management, appropriate airway management (including awakening the patient) is required to prevent life-threatening hypoxia. High-flow nasal oxygenation would be useful for awake fiberoptic intubation, by providing a clear view of the glottis and by preventing hypoxia.
