BACKGROUND: The selection of anesthetic agents is important in mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke-like episodes (MELAS) syndrome patient because serious and unexpected complications can occur after anesthetic exposure.CASE: A 30-year-old man with MELAS syndrome and sepsis underwent colectomy. Propofol was administered by step-wise until target effect-site concentration (Ce) 1.0 µg/ml and stopped for the loss of consciousness and to avoid hemodynamic instability. After the loss of consciousness, total intravenous anesthesia (TIVA) using dexmedetomidine (1.0 µg/ml/h) and remifentanil (1–4 ng/ml of Ce) was performed for the maintenance of anesthesia to avoid malignant hyperthermia and mitochondrial dysfunction. During the surgery, the bispectral index score stayed between 26 and 44, and increased to 97 after the end of anesthesia.CONCLUSIONS: TIVA with dexmedetomidine and remifentanil as non-triggering anesthetic agents in patients with MELAS syndrome and systemic sepsis may have advantages to decrease damages associated with mitochondrial stress and metabolic burden.
Adult ; Anesthesia ; Anesthesia, Intravenous ; Anesthetics ; Colectomy ; Dexmedetomidine ; Hemodynamics ; Humans ; Malignant Hyperthermia ; MELAS Syndrome ; Propofol ; Sepsis ; Unconsciousness

BACKGROUND: In the construction industry, maintaining health and safety of workers often challenging. Among the workers at construction sites, painters are at particular risk of respiratory diseases and neurotoxicity. However, in Korea there is weak enforcement of workers' health and safety practices in the construction industry in Korea. Poisonings frequently occur at (semi)closed construction sites. In this study, we report a case of acute organic solvent poisoning during construction site painting. CASE PRESENTATION: A 71-year-old man was found unconscious at a construction site and immediately transferred to the emergency room. The consciousness level was 'stupor state' and the body temperature was hypothermic, at 32 degrees (Celsius). There were no acute brain or cardiac lesions that would have accounted for the faintness. In addition, blood and urine tests did not indicate a cause of loss of consciousness. He had been painting epoxy to waterproof the basement floor before fainting. According to exposure simulation, the patient was overexposed to various organic solvents, such as approximately 316–624 ppm toluene during the work before fainting. Considering the ventilation status of the workplace and the status of no protection, it is considered that exposure through the respiratory tract was considerable. CONCLUSIONS: The patient in this case lost consciousness during the epoxy coating in a semi-enclosed space. It can be judged as a result of acute poisoning caused by organic solvent exposure and considered to be highly related to work environment.
Aged ; Body Temperature ; Brain ; Consciousness ; Construction Industry ; Emergency Service, Hospital ; Humans ; Korea ; Occupational Diseases ; Paint ; Paintings ; Poisoning ; Respiratory System ; Solvents ; Syncope ; Toluene ; Unconsciousness ; Ventilation

Absence seizures (AS) are generalized non-convulsive seizures characterized by a brief loss of consciousness and spike-and-wave discharges (SWD) in an electroencephalogram (EEG). A number of animal models have been developed to explain the mechanisms of AS, and thalamo-cortical networks are considered to be involved. However, the cortical foci have not been well described in mouse models of AS. This study aims to use a high density EEG in pathophysiologically different AS models to compare the spatiotemporal patterns of SWDs. We used two AS models: a pharmacologically induced model (gamma-hydroxybutyric acid, GHB model) and a transgenic model (phospholipase beta4 knock-out, PLCβ4 model). The occurrences of SWDs were confirmed by thalamic recordings. The topographical analysis of SWDs showed that the onset and propagation patterns were markedly distinguishable between the two models. In the PLCβ4 model, the foci were located within the somatosensory cortex followed by propagation to the frontal cortex, whereas in the GHB model, a majority of SWDs was initiated in the prefrontal cortex followed by propagation to the posterior cortex. In addition, in the GHB model, foci were also observed in other cortical areas. This observation indicates that different cortical networks are involved in the generation of SWDs across the two models.
Animals ; Electroencephalography ; Epilepsy, Absence ; Frontal Lobe ; Mice ; Models, Animal ; Prefrontal Cortex ; Seizures ; Somatosensory Cortex ; Unconsciousness

Local anesthetic systemic toxicity (LAST) refers to the complication affecting the central nervous system (CNS) and cardiovascular system (CVS) due to the overdose of local anesthesia. Its reported prevalence is 0.27/1000, and the representative symptoms range from dizziness to unconsciousness in the CNS and from arrhythmias to cardiac arrest in the CVS. Predisposing factors of LAST include extremes of age, pregnancy, renal disease, cardiac disease, hepatic dysfunction, and drug-associated factors. To prevent the LAST, it is necessary to recognize the risk factors for each patient, choose a safe drug and dose of local anesthesia, use vasoconstrictor , confirm aspiration and use incremental injection techniques. According to the treatment guidelines for LAST, immediate application of lipid emulsion plays an important role. Although lipid emulsion is commonly used for parenteral nutrition, it has recently been widely used as a non-specific antidote for various types of drug toxicity, such as LAST treatment. According to the recently published guidelines, 20% lipid emulsion is to be intravenously injected at 1.5 mL/kg. After bolus injection, 15 mL/kg/h of lipid emulsion is to be continuously injected for LAST. However, caution must be observed for >1000 mL of injection, which is the maximum dose. We reviewed the incidence, mechanism, prevention, and treatment guidelines, and a serious complication of LAST occurring due to dental anesthesia. Furthermore, we introduced lipid emulsion that has recently been in the spotlight as the therapeutic strategy for LAST.
Anesthesia, Dental ; Anesthesia, Local ; Arrhythmias, Cardiac ; Cardiovascular System ; Causality ; Central Nervous System ; Dizziness ; Drug-Related Side Effects and Adverse Reactions ; Heart Arrest ; Heart Diseases ; Humans ; Incidence ; Parenteral Nutrition ; Pregnancy ; Prevalence ; Risk Factors ; Unconsciousness

OBJECTIVE: Previous studies of cognitive decline in patients with neurocognitive disorder due to traumatic brain injury (NCD-TBI) have often failed to control for baseline factors such as premorbid intelligence. The purpose of the current study was to estimate and compare cognitive function among three groups (controls, complicated mild/moderate TBI, and severe TBI) after controlling for premorbid intelligence.METHODS: Severity of TBI was classified as complicated mild/moderate or severe based on duration of loss of consciousness and brain neuroimaging results. Premorbid intelligence quotients (IQs) were estimated with the Oklahoma Premorbid Intelligence Estimate. There were no differences in premorbid intelligence between the groups, which were also matched for age and education. Current cognitive function was evaluated with the Wechsler Adult Intelligence Scale-Fourth Edition.RESULTS: Comparison of current cognitive function among the three groups indicated significant group differences for all indexes and subtest scores. Processing speed showed the highest effect size. However, only working memory differed significantly between the two NCD-TBI groups.CONCLUSION: The present findings suggest that mental memory manipulation processes seem to be more sensitive to TBI severity than are perceptual-motor processes. Specifically, both auditory rehearsal/discrimination and mental alertness/manipulation will be most strongly influenced by TBI severity.
Adult ; Brain ; Brain Injuries ; Cognition ; Education ; Humans ; Intelligence ; Memory ; Memory, Short-Term ; Neurocognitive Disorders ; Neuroimaging ; Oklahoma ; Unconsciousness

Despite the low incidence, seizures induced by repetitive transcranial magnetic stimulation (rTMS) have been studied as they may cause neurological and functional regression. Seizures may predict poor outcomes in stroke patients, with no reports of improved neurological status after seizures. This is the first Korean report of a seizure induced by rTMS, and the first report in the literature of prompt motor recovery following a seizure induced by high-frequency rTMS of the primary motor cortex in a stroke patient. A 43-year-old man with left hemiplegia due to infarction in the right basal ganglia was enrolled 10 sessions of rTMS (each session consisted of 15 trains, with each train consisting of 5 seconds of stimulation at 20 Hz and 90% of resting motor threshold for each session followed by 55 seconds of rest). The self-limited seizure occurred within 5 seconds after the 10th session. It lasted for 60 seconds, with generalized tonic features in all four extremities and the trunk and loss of consciousness followed by prompt improvement in left hand muscle strength and coordination. Though the seizure is known to usually cause neurologic regression, this case showed neurologic improvement after rTMS even after the rTMS-induced seizure.
Adult ; Basal Ganglia ; Extremities ; Hand ; Hemiplegia ; Humans ; Incidence ; Infarction ; Motor Cortex ; Muscle Strength ; Seizures ; Stroke ; Transcranial Magnetic Stimulation ; Unconsciousness

PURPOSE: This study was conducted to investigate relationship between delirium, risk factors on delirium, and patient prognosis based on Donabedian's structure-process-outcome model.METHODS: This study utilized a path analysis design. We extracted data from the electronic medical records containing delirium screening data. Each five hundred data in a delirium and a non-delirium group were randomly selected from electronic medical records of medical and surgical intensive care patients. Data were analyzed using SPSS 20 and AMOS 24.RESULTS: In the final model, admission via emergency department (B=.06, p=.019), age over 65 years (B=.11, p=.001), unconsciousness (B=.18, p=.001), dependent activities (B=.12, p=.001), abnormal vital signs (B=.12, p=.001), pressure ulcer risk (B=.12, p=.001), enteral nutrition (B=.12, p=.001), and use of restraint (B=.30, p=.001) directly affecting delirium accounted for 56.0% of delirium cases. Delirium had a direct effect on hospital mortality (B=.06, p=.038), hospital length of stay (B=5.06, p=.010), and discharge to another facility (not home) (B=.12, p=.001), also risk factors on delirium indirectly affected patient prognosis through delirium.CONCLUSION: The use of interventions to reduce delirium may improve patient prognosis. To improve the dependency activities and risk of pressure ulcers that directly affect delirium, early ambulation is encouraged, and treatment and nursing interventions to remove the ventilator and drainage tube quickly must be provided to minimize the application of restraint. Further, delirium can be prevented and patient prognosis improved through continuous intervention to stimulate cognitive awareness and monitoring of the onset of delirium. This study also discussed the effects of delirium intervention on the prognosis of patients with delirium and future research in this area.
Critical Care ; Delirium ; Drainage ; Early Ambulation ; Electronic Health Records ; Emergency Service, Hospital ; Enteral Nutrition ; Hospital Mortality ; Humans ; Intensive Care Units ; Length of Stay ; Mass Screening ; Nursing ; Pressure Ulcer ; Prognosis ; Risk Factors ; Unconsciousness ; Ventilators, Mechanical ; Vital Signs

A 74-year-old man presented with positional vertigo and prandial dizziness and syncope. He had experienced episodes of frequent dizziness and loss of consciousness for several months. He underwent total gastrectomy with esophagojejunostomy and brown anastomosis 30 years ago. Thirteen years ago, subtotal colectomy with ileo-descending colostomy was done due to colon cancer. And he also had mitral valve replacement and maze operation due to severe mitral valve stenosis and atrial fibrillation. After cardiac operation, he has suffered from sudden dizziness with diaphoresis and chalky face, which usually occurs especially within 30 minutes from the onset of eating. Sometimes, this event was followed by several seconds of loss of consciousness, which caused recurrent events of falling. Neurological examination showed positional nystagmus compatible with benign paroxysmal positional vertigo arising from posterior semicircular canal of the right ear. The positional vertigo disappeared immediately after canalith repositioning maneuver. We tried to monitor vital signs and serum level of glucose during eating. Hyperglycemia (range, 210–466 mg/dL) was noted during eating, which was accompanied by postprandial and prandial hypotension, up to 60/40 mmHg. The patient was prescribed 100 mg of the alfa-glucosidase, acarbose to be taken half an hour before each meal. Eventually, the treatment with acarbose ameliorated the prandial dizziness and hypotension associated with hyperglycemia. Our patient suggests the acarbose could prevent postprandial dizziness and hypotension.
Acarbose ; Accidental Falls ; Aged ; Atrial Fibrillation ; Benign Paroxysmal Positional Vertigo ; Colectomy ; Colonic Neoplasms ; Colostomy ; Dizziness ; Ear ; Eating ; Gastrectomy ; Glucose ; Humans ; Hyperglycemia ; Hypotension ; Meals ; Mitral Valve ; Mitral Valve Stenosis ; Neurologic Examination ; Nystagmus, Physiologic ; Semicircular Canals ; Syncope ; Unconsciousness ; Vertigo ; Vital Signs

Syncope is defined as a transient loss of consciousness and postural tone, characterized by rapid onset, short duration, and spontaneous recovery. Stellate ganglion block (SGB) is a nerve block method that is used for treatment of neuropathic pain in the head, neck and upper extremities, especially trigeminal neuralgia, postherpetic neuralgia and complex regional pain syndrome. SGB can modulate and stabilize the sympathetic nervous system, which prevents it from overexcitation and improves symptoms of syncope. The authors report a patient who was treated for pain and edema of both upper extremities with SGB, then showed improvement in recurrent syncope followed by chest pain and overall quality of life.
Chest Pain ; Edema ; Head ; Humans ; Methods ; Neck ; Nerve Block ; Neuralgia ; Neuralgia, Postherpetic ; Quality of Life ; Stellate Ganglion ; Sympathetic Nervous System ; Syncope ; Thorax ; Trigeminal Neuralgia ; Unconsciousness ; Upper Extremity

Tidal volume by sevoflurane in small amounts is stable due to the increase in the breathing rate. But alveolus ventilation decreases due to sevoflurane as the degree of sedation increases; this ultimately causes PaCO2 to rise. The occurrence of suppression of breath increases the risk of severe hypoxia and hypercapnia in deeply sedated patients with disabilities. Sevoflurane inhalation anesthesia has a number of risks and may have unexpected problems with hemodynamic changes depending on the underlying state of the body. This study was conducted to examine the stability of internal acid-base system caused by respiratory depression occurring when patients with disabilities are induced by sevoflurane.Anesthetic induction was carried out by placing a mask on top of the patient's face and through voluntary breathing with 4 vol% of sevoflurane, 4 L/min of nitrous oxide, and 4 L/min of oxygen. After the patient's loss of consciousness and muscle relaxation, IV line was inserted by an expert and intravenous blood gas was analyzed by extracting blood from vein.In a deeply sedated state, the average amount of pH of the entire patients was measured as 7.36 ± 0.06. The average amount of PvCO₂ of the entire patients was measured as 48.8 ± 8.50 mmHg. The average amount of HCO₃₋ of the entire patients was measured as 27.2 ± 3.0 mmol/L.In conclusion, in dental treatment of patients with disabilities, the internal acid base response to inhalation sedation using sevoflurane is relatively stable.
Anesthesia, General ; Anesthesia, Inhalation ; Anoxia ; Blood Gas Analysis ; Hemodynamics ; Humans ; Hydrogen-Ion Concentration ; Hypercapnia ; Inhalation ; Masks ; Muscle Relaxation ; Nitrous Oxide ; Oxygen ; Respiration ; Respiratory Insufficiency ; Tidal Volume ; Unconsciousness ; Veins ; Ventilation