Acute onset Lance-Adams syndrome following brief exposure to severe hypoxia without cardiac arrest -a case report-
A 48-year-old man underwent right partial glossectomy with neck dissection for tongue cancer under general anesthesia. Past medical history showed that he had been diagnosed with diabetes mellitus (DM) for five years and that he is a 30 pack-year smoker. During the five hours of operation, his vital signs were kept stable and blood sugar levels were well controlled between 82-84 mg/dl. Pulse oxygen saturation (SpO2), pulse rate, and non-invasive blood pressure (NIBP) were stable during immediate postoperative period in the recovery room.\nHe began complaining of troubled breathing and showed agitation 30 minutes after arrival in the recovery room. We informed his otolaryngologist of the situation and relieved the dressing bandage around his neck. As his oxygen saturation gradually decreased to 0%, we started bag-mask ventilation. NIBP was checked, 149/92 mmHg. SpO2 was immediately recovered to 96%. Although severe hypoxemia occurred, it did not lead to cardiac arrest, which was known from palpable pulse of radial artery throughout the course. His heart rate remained above 40 beats/min. At the same time, his otolaryngologist arrived and immediately opened the incision site for decompression. At once, he was able to breathe and his saturation was maintained 100%.\nHe was transported to the operating room to remove the hematoma of his neck. Intubation was performed without difficulty and mechanical ventilation was applied with FiO2 50%. All vital signs were unremarkable (SpO2 98-99%, heart rate 80-120 beats/min, and temperature 36.0-36.2℃), except blood pressure. It was checked below 90/60 mmHg twice during the 2 hours of operation, and ephedrine 10 mg was injected. On average, the mean arterial pressure was kept between 60-80 mmHg. At the end of the operation, his condition was stable and appropriate for extubation. Bispectral index (BIS) was increased to 90 and his eyes were opened spontaneously; he was extubated. However, soon after extubation, he showed generalized tonic-clonic seizure and it was only discontinued by inhalation of sevoflurane and administration of thiopental. He was reintubated and phenytoin, lorazepam, and midazolam were administered to control the seizures. He was admitted to the intensive care unit (ICU) in a sedated state. Light reflexes were normal. Blood glucose level was 200 mg/dl.\nSix hours later, when a tactile stimulus was applied, he developed widespread myoclonic seizures on all four limbs, even under infusion of large dose of anticonvulsants. Two days later, he was still deeply sedated to control myoclonic seizures, but the frequency and duration of seizures were only mildly reduced. His brain computed tomogram (CT) showed no remarkable evidence of hypoxic brain damage and his electroencephalogram (EEG) study showed normal findings. On day 10 of hospitalization, his sedatives were completely withdrawn and he became alert with a frowned face and myoclonus affecting both knees and ankles. The treatment with sodium valproate and levetiracetam were continued for recovery. Three weeks later, magnetic resonance (MR) brain imaging did not show any abnormalities (). Two months after surgery, he showed ataxic movement and gait disturbance. His myoclonic action has been well controlled by medications. He has been on intensive rehab for his recovery.