Cloacal exstrophy (CE) is a rare and complex congenital anomaly. Perioperative anesthetic management is challenging when CE is accompanied by extreme prematurity and extremely low birth weight (ELBW). A 670-g infant born at 25 weeks and 3 days of gestation underwent initial-stage surgery for CE on postnatal day 8. Opioid-based anesthesia with neuromuscular blockade was administered without hypnotic agents. A neonatal intensive care unit ventilator was transferred to the operating room to maintain ventilatory continuity. Invasive arterial pressure monitoring, active thermal control, and anticipation of circulatory compromise during abdominal wall closure were applied. Transient hypotension was treated with colloid administration, and the procedure was completed without major complications. No significant long-term complications occurred during the 4-year follow-up. Perioperative stability in an extremely high-risk neonate with CE and ELBW was achieved by applying basic anesthetic principles, including ventilatory continuity, vigilant hemodynamic monitoring, and active thermal control.
Ventricular tachycardia (VT) storm during emergence from anesthesia is rare. The significance of a persistent rhythm abnormality after treatment of profound intraoperative bradycardia is uncertain. A 60-year-old hemodialysis patient with prior inferior infarction and preserved ejection fraction underwent toe disarticulation. Near the end of surgery, the heart rate fell to about 25 beats/min, with 1:1 atrioventricular conduction. Atropine restored the rate, but not stable sinus rhythm. Five minutes into emergence, monomorphic VT storm began, with no preceding rise in heart rate, blood pressure, or bispectral index. VT persisted or recurred and required multiple shocks; angiography showed patent grafts. The patient survived neurologically intact. Heart rate increased after atropine and blood pressure remained stable, but an abnormal rhythm persisted before VT storm developed during emergence. A persistent unexplained rhythm abnormality after treatment of profound bradycardia may warrant rhythm reassessment before emergence.
Although cardiac asystole during balloon dilation to create a retroperitoneal working space has been reported in endoscopic extraperitoneal radicalprostatectomy, it is quite rare during retroperitoneal nephrectomy. We report such a case. An 84-year-old woman underwent retroperitoneal laparoscopic nephrectomy under general anesthesia. After positioning in the right flank position, hypotension with bradycardia occurred and was treated using ephedrine and phenylephrine. During balloon inflation to create the retroperitoneal working space, asystole occurred, which lasted for 14 s, followed by a single heartbeat and another 6.2 s of asystole, after which spontaneous circulation was restored. The surgery was completed uneventfully thereafter. Reduced venous return caused by the flank position and balloon compression, together with triggering of the vagal reflex by retroperitoneal distention, may contribute to development of asystole during retroperitoneal space creation. Persistent hypotension and bradycardia before balloon dilation may be important warning signs of impending cardiovascular collapse.
Peripheral nerve injury is a rare complication of central venous catheterization, and suspected injury to the great auricular nerve (GAN) after internal jugular vein (IJV) catheterization has not previously been reported. A 50-year-old woman with recurrent uterine sarcoma developed pain and numbness over the ear lobule, mastoid region, angle of the mandible, and lateral neck after ultrasound-guided right IJV catheterization, predominantly involving the GAN territory. The catheter had been inserted cranial and lateral to the standard landmark to avoid an overlapping carotid artery, toward the region of Erb’s point, where the GAN courses superficially over the sternocleidomastoid muscle. When vessel overlap necessitates a more cranial or lateral IJV puncture, the needle trajectory may approach the superficial course of the GAN. Clinicians should consider suspected GAN injury when a purely sensory deficit follows IJV catheterization in this distribution; in this patient, the disturbance showed near-complete recovery over approximately four months.
