BACKGROUND: Postdural puncture headache (PDPH) is one of the common complications of spinal anesthesia; it is observed in 1-40% of cases involving spinal anesthesia. It can cause considerable morbidity and 40% of cases m...BACKGROUND: Postdural puncture headache (PDPH) is one of the common complications of spinal anesthesia; it is observed in 1-40% of cases involving spinal anesthesia. It can cause considerable morbidity and 40% of cases may require invasive treatments such as epidural blood patch. With the exception of invasive treatments such as an epidural blood patch, current standard treatment modalities have not proved efficacious. There had been some research done that indicated successful prophylaxis and/or treatment of PDPH by administration of intravenous steroids. Based on those findings, we hypothesize that a direct injection of corticosteroids to the anesthesia puncture site could increase the amount of corticosteroid that accumulates in the puncture site, and will be more effective in decreasing dural inflammation and incidence of PDPH than that of parenteral steroids. We formulated our study to evaluate the effect of dexamethasone directly injected into spinal anesthesia puncture sites. METHODS: A total of 268 patients undergoing spinal anesthesia were randomly allocated into two groups; one group received a prophylactic epidural injection of dexamethasone (2 mL, 8 mg) and the other group received 2 mL of normal saline. The incidence and intensity of PDPH and puncture site backache were each measured at 24 hours, 72 hours, and 7 days after spinal anesthesia. The intensity of the headache was graded according to the meningeal headache index. RESULTS: The overall incidence of headache during the 7-day period was 5 patients (3.7%) in the control group and 11 patients (8.2%) in the study group, which is not statistically significant (X(2) = 2.393 and p = 0.122. The severity of headache also shows no statistical significance (2.2% in cases versus 6% in controls; z = 1.53, p = 0.126). The intensity of headache reported at the 24 hours (z = 0.698; p = 0.485), 72 hours (z = 0.849; p = 0.396), and 7 days (z = 0.008; p = 0.994) was not different. There also was no difference in the incidence of backache in the two groups. CONCLUSION: In contrast to other studies that showed the efficacy of intravenous dexamethasone in the prevention and treatment of PDPH, our study did not show any significant effect of prophylactic epidural injection of dexamethasone in prevention of PDPH. However regarding the low number of PDPH in routine cases, evaluation of this intervention in groups with a high incidence of PDPH by using of particulate steroids is recommended to confirm these preliminary findings.
A 54-year-old patient with Becker muscular dystrophy and dilated cardiomyopathy underwent laparoscopic cholecystectomy under total intravenous anesthesia. Muscle relaxation was induced by rocuronium (0.4 mg/kg body weigh...A 54-year-old patient with Becker muscular dystrophy and dilated cardiomyopathy underwent laparoscopic cholecystectomy under total intravenous anesthesia. Muscle relaxation was induced by rocuronium (0.4 mg/kg body weight) under train-of-four (TOF) ratio monitoring. The TOF ratio was 0 at intubation, and 0.2 at the end of surgery. Residual muscle relaxant activity was successfully reversed by sugammadex (2 mg/kg body weight) without any hemodynamic adverse effects (TOF ratio 1.0 at extubation). The clinical and hemodynamic findings suggest that sugammadex can be safely used in patients with Becker muscular dystrophy and dilated cardiomyopathy.
OBJECTIVE: The aim of this study was to assess the right placement of the double lumen endotracheal tube with fluoroscopic guidance, which is used in first intention prior to the fiberscope in our institution. METHODS: T...OBJECTIVE: The aim of this study was to assess the right placement of the double lumen endotracheal tube with fluoroscopic guidance, which is used in first intention prior to the fiberscope in our institution. METHODS: This was a prospective observational study. The study was conducted in vascular and thoracic operating rooms. We enrolled 205 patients scheduled for thoracic surgery, with ASA physical statuses of I (n = 37), II (n = 84), III (n = 80), and IV (n = 4). Thoracic procedures were biopsy (n = 20), wedge (n = 34), culminectomy (n = 6), lobectomy (n = 82), pneumonectomy (n = 4), sympathectomy (n = 9), symphysis (n = 47), and thymectomy (n = 3). The intubation with a double lumen tube was performed with the help of a laryngoscope. Tracheal and bronchial balloons were inflated and auscultation was performed after right and left exclusions. One shot was performed to locate the position of the bronchial tube and the hook. Fluoroscopic guidance was used to relocate the tube in case of a wrong position. When the fluoroscopic guidance failed to position the tube, a fiberscope was used. Perioperative collapse of the lung was assessed by the surgeon during the surgery. RESULTS: Correct fluoroscopic image was obtained after the first attempt in 58.5% of patients therefore a misplaced position was encountered in 41.5%. The fluoroscopic guidance allowed an exact repositioning in 99.5% of cases, and the mean duration of the procedure was 8 minutes. A fiberscope was required to move the hook for one patient. We did not notice a moving of the double lumen endotracheal tube during the surgery. The surgeon satisfaction was 100%. CONCLUSION: The fluoroscopy evidenced the right position of the double lumen tube and allowed a right repositioning in 99.5% of patients with a very simple implementation.
Deep neck infection with airway obstruction may complicate endotracheal intubation with limited neck motion, pharyngeal swelling, and prominent secretion. Unrecognized esophageal intubation (EI) may unduly overinflate th...Deep neck infection with airway obstruction may complicate endotracheal intubation with limited neck motion, pharyngeal swelling, and prominent secretion. Unrecognized esophageal intubation (EI) may unduly overinflate the stomach to inhibit effective ventilation, increase the incidence of hypoxia, and produce a ruptured visceral organ. We report an 81-year-old female patient with deep neck infection and impending respiratory failure who suffered gastric perforation after accidental EI in the intensive care unit. After failed attempts of intubation, EI was recognized rapidly as the culprit, although roughly audible bilateral breathing sounds were present but not gastric bubble sounds. A catastrophic complication of gastric rupture occurred due to ambu-bagging and mechanical ventilation. Surgical intervention was performed immediately. Possible mechanisms are discussed.
OBJECTIVE: Amino acid administration helps to prevent intraoperative hypothermia but may enhance thermogenesis when combined with glucose infusion. The aim of this study was to examine the effect of intraoperative amino...OBJECTIVE: Amino acid administration helps to prevent intraoperative hypothermia but may enhance thermogenesis when combined with glucose infusion. The aim of this study was to examine the effect of intraoperative amino acid administration, with or without glucose infusion, on temperature regulation during laparoscopic colectomy. METHODS: Twenty-one patients whose physical status was classified I or II by the American Society of Anesthesiologists, and who were undergoing elective laparoscopic colectomy were enrolled. The exclusion criteria were a history of diabetes and/or obesity, preoperative high levels of C-reactive protein, high blood glucose and/or body temperature after anesthesia induction, and surgical time >500 minutes. Each patient received an acetate ringer solution and was randomly assigned to one of three groups. Group A patients were given only amino acids. Group AG patients were given amino acids and glucose. Group C patients were given neither amino acids nor glucose. Tympanic membrane temperatures and blood glucose and insulin levels were measured intraoperatively. RESULTS: Intraoperative amino acid infusion significantly increased body temperature during surgery as compared with either Group AG or C. The blood glucose levels in Group AG were significantly higher than those in Groups A and C. However, there were no significant differences between Groups A and C. Two hours after anesthesia induction, serum insulin levels in Groups A and AG significantly increased compared with Group C. No significant differences in the postoperative complications or patient hospitalization lengths were detected between the groups. CONCLUSION: Intraoperative amino acid infusion without glucose administration maintains body temperature more effectively than combined amino acid and glucose infusion in patients undergoing laparoscopic colectomy, despite unaltered intraoperative insulin levels.
Difficult tracheal extubation is a rare but potentially dangerous problem that can be life threatening especially when it is unexpected and there is a lack of preparation. Most of these cases are associated with orofacia...Difficult tracheal extubation is a rare but potentially dangerous problem that can be life threatening especially when it is unexpected and there is a lack of preparation. Most of these cases are associated with orofacial surgery. We herein present two patients with oral cavity cancer who experienced unexpected postoperative difficult nasotracheal extubation by a Kirschner pin penetrating the endotracheal tube and fixing the tube at the maxillary bone following tumor resection. The pins were found by fiberoptic bronchoscopy. Both patients were returned to the operating theater immediately for removal of the penetrating pins as well as the endotracheal tubes. The common causes of difficult tracheal extubation and strategies of managing these situations are discussed in the article.
BACKGROUND: Combined introducer tool and stylet technique of ProSeal laryngeal mask airway (PLMA) insertion was compared with the conventional digital manipulation and introducer tool technique in children with a rigid n...BACKGROUND: Combined introducer tool and stylet technique of ProSeal laryngeal mask airway (PLMA) insertion was compared with the conventional digital manipulation and introducer tool technique in children with a rigid neck collar. METHODS: This was a randomized, single blinded, prospective study. Ninety ASA Grade I-II children weighing 10-20 kg were randomly allocated for PLMA insertion using the digital, introducer tool (IT) or combined IT and stylet techniques. Each group contained 30 patients. Difficult laryngoscopy was simulated using a rigid neck collar. The laryngoscopic view was graded prior to PLMA insertion. The digital and IT techniques were performed according to the manufacturer's instructions. The combined technique involved attaching the IT to the PLMA and inserting a flexible stylet through the drain tube. RESULTS: The median Cormack and Lehane grade was 2 in all three groups. Insertion was more frequently successful with the combined technique at the first attempt (combined 100%, digital 65.38%, IT 66.67%; p < 0.05), but success after three attempts was similar (combined 100%, digital 86.67%, IT 90%; p > 0.05). The time taken for successful placement was similar among groups at the first attempt, but was shorter for the combined technique for overall attempts (combined 18.33 ± 1.27 seconds, digital 27.85 ± 9.05 seconds, IT 26.89 ± 7.17 seconds; p < 0.05). There was no difference in postoperative airway morbidity. CONCLUSION: PLMA insertion with combined IT and stylet technique was more frequently successful than the digital or IT technique in pediatric patients without cervical spine motion.
Difficult airway is always of special concern to anesthesiologists, but in a trauma setting where having a secured airway is most important, the incidence of difficult airway increases manifold. We report a "cannot venti...Difficult airway is always of special concern to anesthesiologists, but in a trauma setting where having a secured airway is most important, the incidence of difficult airway increases manifold. We report a "cannot ventilate cannot intubate" situation in a trauma patient who was later diagnosed to have arthrogryposis multiplex congenita, a syndrome known to affect the airway, and in whom all measures of securing a nonsurgical airway failed.
Here, we report that, under the assistance of both the GlideScope and a fiberoptic bronchoscope, tracheal intubation was accomplished successfully in a 50-year-old woman with severe rheumatoid arthritis who underwent ton...Here, we report that, under the assistance of both the GlideScope and a fiberoptic bronchoscope, tracheal intubation was accomplished successfully in a 50-year-old woman with severe rheumatoid arthritis who underwent tongue lump resection under general anesthesia. Either the GlideScope or the fiberoptic bronchoscope alone failed to secure the airway; the use of both in combination facilitated airway intubation. This case report indicate that, even with careful preoperative assessment, patients who suffer from rheumatoid arthritis may have severe airway difficulty with intubation, and the combined use of the GlideScope and a fiberoptic bronchoscope can be a novel alternative for tracheal intubation in patients with severe airway difficulty.
Aneurysmal subarachnoid hemorrhage (aSAH) is a serious and debilitating condition that leads to the development of many complications, which are followed by mortality and morbidity. As anesthesiologists, we may require t...Aneurysmal subarachnoid hemorrhage (aSAH) is a serious and debilitating condition that leads to the development of many complications, which are followed by mortality and morbidity. As anesthesiologists, we may require to manage aSAH at various settings such as in the perioperative period or in a nonoperative setting such as the neuroradiology suite for diagnostic and therapeutic interventions. Therefore, it is important to understand the pathophysiology of aSAH and anesthetic management for operations and interventions. For decades, early brain injury and cerebral vasospasm have played major roles in the outcome following aSAH. The purpose of this article is to review recent advances and future perspectives in the treatment of aSAH, early brain injury, and cerebral vasospasm.
Cancer remains one of the major causes of death worldwide, and the global burden of the disease is rising continuously. Clinical retrospective data suggested that inhalational anesthetics might affect the prognosis of ca...Cancer remains one of the major causes of death worldwide, and the global burden of the disease is rising continuously. Clinical retrospective data suggested that inhalational anesthetics might affect the prognosis of cancer patients, but the underlying molecular mechanism remained unknown. Hypoxia-inducible factor-1 (HIF-1) is a dimeric transcription factor and mediates various cellular responses to hypoxia, including metabolism, cell death and survival, angiogenesis, oxygen delivery, immune evasion, and genomic adaptation. HIF-1 system has been shown to be the driving force of solid tumor progression and substantially contributes to the malignancy of cancer. Inhalational anesthetics such as isoflurane have been demonstrated to confer cytoprotection in a HIF-1-dependent manner in various vital organs. In addition, a recent study has demonstrated the pivotal involvement of HIF-1 in the impact of inhalational anesthetics on cancer cells. This review provides critical insights into the new understanding of cancer sensing of inhalational anesthetics and examines the recent understanding of the underlying molecular mechanisms. However, this area of research is just beginning and warrants further studies preclinically and clinically prior to making any conclusions that inhalational anesthetics may affect cancer outcomes. In addition, it is important to note that there is not enough evidence to support any change in the current clinical practice.
BACKGROUND AND OBJECTIVES: Craniosynostosis surgery is considered a very painful procedure due to extended scalp and periosteal detachment, and is associated with prolonged postoperative consumption of opioids and their...BACKGROUND AND OBJECTIVES: Craniosynostosis surgery is considered a very painful procedure due to extended scalp and periosteal detachment, and is associated with prolonged postoperative consumption of opioids and their side effects. In this observational descriptive case series study, we investigated perioperative opioid consumption in children undergoing craniosynostosis repair under general anesthesia when scalp nerve block with levobupivacaine was involved. METHODS: After standard anesthesia induction, scalp nerve block with levobupivacaine 2 mg/kg plus epinephrine 1:800,000 was performed. Hemodynamic parameters and opioid consumption were noted. Patients were monitored in the recovery room. Requirements of additional analgesia, indicated by the Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) pain score of >9, and incidence of side effects (sedation, nausea, and vomiting) were recorded during the first 24 hours. RESULTS: A total of 32 patients were recruited in this study; 88% of them needed morphine rescue in the recovery room because they had high CHEOPS scores. Trigonocephaly was the most frequent type of craniosynostosis (37.5%), requiring 50% more opioids in the postoperative period than other forms of craniosynostosis. CONCLUSION: Scalp nerve block can be proposed as a complement to the routine craniosynostosis anesthetic protocol, because it is easy to perform, seems to reduce the need for supplementary opioids during the perioperative period, and can reduce the risk of developing acute opioid tolerance and chronic pain. In the event of trigonocephaly or craniofacial reconstruction, a complementary infraorbital nerve block can be added.
AIM: Articaine and bupivacaine are both amide-type local anesthetic (LA) agents, of almost equal potency. However, lidocaine is considered the gold standard and is the most widely used anesthetic agent because of its pot...AIM: Articaine and bupivacaine are both amide-type local anesthetic (LA) agents, of almost equal potency. However, lidocaine is considered the gold standard and is the most widely used anesthetic agent because of its potency, safety, and efficiency. Articaine is fast acting and bupivacaine is a long-lasting LA. The aim of this randomized controlled crossover clinical study was to evaluate and compare the clinical anesthetic efficacy of 4% articaine and 0.5% bupivacaine in orthodontic extractions models. METHODS: Forty systemically healthy patients (age range: 10-18 years), requiring premolar extraction for orthodontic reasons (all 4 premolars) were included. Patients were categorized into two groups (4% articaine and 0.5% bupivacaine) in a crossover manner (160 premolars). Parameters recorded included: time of anesthetic onset, duration of postoperative analgesia, time to first rescue analgesic medication, and visual analog scale (VAS). At the first appointment, both upper and lower premolars were extracted on one side of the jaws (right or left). A fixed volume of 1.4 mL of 4% articaine or 0.5% bupivacaine (based on a computer-generated list) was infiltrated in the buccal vestibule (local infiltration) for extraction. At the second appointment, after a washout period of 15 days, the anesthetic agent that was not administered at the first appointment was administered in a crossover manner. Each patient was evaluated using a 100-mm VAS during and after extraction. RESULTS: The results showed that 4% articaine had significantly faster onset of action and lower VAS scores when compared with bupivacaine. However, the duration of analgesia and time to first rescue analgesic medication was longer in the bupivacaine group. CONCLUSION: Articaine seemed to have better potency and efficacy in terms of onset of action and lower pain scores compared to the bupivacaine group. Further studies are required to confirm these results.
OBJECTIVE: Sugammadex rapidly reverses neuromuscular blockade (NMB) induced by rocuronium. NMB induced by rocuronium is prolonged in patients with liver dysfunction, because the drug is mainly excreted into the bile. How...OBJECTIVE: Sugammadex rapidly reverses neuromuscular blockade (NMB) induced by rocuronium. NMB induced by rocuronium is prolonged in patients with liver dysfunction, because the drug is mainly excreted into the bile. However, the efficacy and safety of sugammadex in terms of reversing rocuronium-induced NMB in patients with liver dysfunction undergoing hepatic surgery have not been evaluated. This observational study investigated the efficacy and safety of sugammadex after continuous infusion of rocuronium in patients with liver dysfunction undergoing hepatic surgery. METHODS: Remifentanil/propofol anesthesia was administered to 31 patients: 15 patients in the control group, and 16 patients from a group with liver dysfunction. Rocuronium (0.6 mg/kg) was administered, followed by continuous infusion. The enrolled patients were then subdivided into two groups according to the dose of sugammadex. In the first group a single dose of sugammadex (2.0 mg/kg) was given at the reappearance of the second twitch (T2). In the second group a single dose of sugammadex (4.0 mg/kg) was given at the first twitch response if T2 did not reappear in 15 minutes after stopping rocuronium. The primary outcome was time from administration of sugammadex to recovery of a train-of-four ratio to 0.9. RESULTS: The dose of rocuronium required in the liver dysfunction group was lower than that in the control group (6.2 vs. 8.2 μg/kg/min, p = 0.002). The mean time from the administration of sugammadex to recovery of the train-of-four ratio to 0.9 was not significantly different between the liver dysfunction group and the control group (2.2 minutes vs. 2.0 minutes in the 2 mg/kg administration group, p = 0.44 and 1.9 minutes vs. 1.7 minutes in the 4 mg/kg administration group, p = 0.70, respectively). No evidence of recurarization was observed in any of the patients. Most of the adverse events were found to be mild and such events were not related to the use of sugammadex. None of the patients was eliminated from the study because of an adverse event. One patient died due to cholestatic liver cirrhosis because of repeated hepatic surgery. CONCLUSION: Sugammadex can rapidly reverse NMB after continuous infusion of rocuronium in patients with liver dysfunction undergoing hepatic surgery. Sugammadex was found to be safe and well tolerated. However, further studies of sugammadex under similar conditions should be conducted involving a large number of patients with liver dysfunction undergoing hepatic surgery.
OBJECTIVE: The basis for the transversus abdominis plane (TAP) block involves infiltration of a local anesthetic into the neurofascial plane between the internal oblique and the transversus abdominis muscles, causing a r...OBJECTIVE: The basis for the transversus abdominis plane (TAP) block involves infiltration of a local anesthetic into the neurofascial plane between the internal oblique and the transversus abdominis muscles, causing a regional block that spreads between the L1 and T10 dermatomes. Thus, the TAP block is said to be suitable for lower abdominal surgery. This study was designed to compare the analgesic efficacy of two different concentrations of ropivacaine for TAP block in patients undergoing appendectomy. METHODS: Fifty-six patients with American Society of Anesthesiologists physical status I or II, aged 18 years and above, undergoing appendectomy were recruited in this prospective, randomized, double-blind study. They were divided into two groups: Group A patients who received 0.5 mL/kg of ropivacaine 0.5% and Group B patients who received 0.5 mL/kg of ropivacaine 0.2% via TAP block under ultrasound guidance. Postoperative pain was assessed using the visual analog scale upon arrival at the recovery room in the operating theatre, just prior to being discharged to the ward, and at 6 hours, 12 hours, 18 hours, and 24 hours postoperatively to compare the effectiveness of analgesia. RESULTS: Intraoperatively, patients in Group B required a significantly greater amount of additional intravenous fentanyl than those in Group A. There were no significant statistical differences in pain scores at rest and on movement at all assessment times as well as in the dose of 24-hour intravenous morphine consumption given via patient-controlled analgesia postoperatively between the two groups. CONCLUSION: The effectiveness of two different concentrations of ropivacaine (0.5% versus 0.2%) given via TAP block was comparable in providing postoperative analgesia for patients undergoing appendectomy.