OBJECTIVE: To investigate the sensory block onset time, duration time, and side effects of adding dexmedetomidine to ropivacaine for cervical plexus block. METHODS: Forty American Society of Anesthesiologists (ASA) Class...OBJECTIVE: To investigate the sensory block onset time, duration time, and side effects of adding dexmedetomidine to ropivacaine for cervical plexus block. METHODS: Forty American Society of Anesthesiologists (ASA) Class I or II adult patients who were scheduled to undergo thyroid surgery were randomly allocated to the following groups to receive cervical plexus block: 30 mL of 0.375% ropivacaine combined with 1 μg kg(-1) of dexmedetomidine; 30 mL of 0.375% ropivacaine combined with saline (control). The sensory block onset time, duration of analgesia, mean arterial pressure (MAP), heart rate (HR), and the incidences of side effects, such as hypotension, bradycardia, and hypoxemia were recorded. RESULTS: The addition of dexmedetomidine to ropivacaine (Group D) shortened the sensory block onset time compared with the ropivacaine group (Group C) (95% confidence interval [CI] 4.18-5.26; p < 0.05). The duration of analgesia of cervical plexus block in Group D was significantly longer than that in Group C (95% CI 295.96-311.12; p < 0.05). The Ramsay sedation score at 5, 10, 20, 40, 60, 90, and 120 minutes after local anesthetic administration in Group D was significantly higher than that in Group C (p < 0.05). MAP level and HR level in Group D were significantly lower than that in Group C (p < 0.05). CONCLUSION: The addition of 1 μg kg(-1) dexmedetomidine to ropivacaine for cervical plexus block could shorten the sensory block onset time and extend the duration of analgesia, and increased the quality of analgesia, with the patients being sedated and arousable.
OBJECTIVE: Unanticipated difficult tracheal intubation is a significant source of morbidity and mortality in anesthetized patients. A number of modules have been developed to predict difficult airways, but they are often...OBJECTIVE: Unanticipated difficult tracheal intubation is a significant source of morbidity and mortality in anesthetized patients. A number of modules have been developed to predict difficult airways, but they are often complex in nature. We combined the modified Mallampati score (M), thyromental distance (T), anatomical abnormality (A), and cervical mobility (C) into a single scoring system with the acronym M-TAC, and evaluated it against Mallampati scoring. METHODS: We prospectively analyzed 500 adult patients of the American Society of Anesthesiologists (ASA) class I or II, scheduled for elective surgery under general anesthesia. Preoperative airway assessments using M-TAC were performed, all of which were given a score. Anesthesiologists, blinded to the pre-anesthetic airway assessment, performed laryngoscopy and graded the laryngoscopic view as per Cormack and Lehane's classification. For the study purpose, difficult laryngoscopy was defined as Cormack and Lehane Grade 3 or 4 of laryngoscopic view. RESULTS: An M-TAC score ≥ 4 had a significantly higher sensitivity (96% vs. 72%) and specificity (86% vs. 78%) with a high positive predictive value (44% vs. 28%) and a very low false negative value (2% vs. 15%) in comparison with Mallampati scoring (p < 0.05). Analysis of the receiver operating characteristic (ROC) curve for predicting difficult laryngoscopy revealed an area under the curve of 0.83 (95% CI = 0.78-0.88) for Mallampati scoring and 0.94 (95% CI = 0.92-0.96) for M-TAC scoring system. CONCLUSION: The M-TAC scoring system has provided a higher sensitivity and specificity in predicting difficult laryngoscopy in comparison with Mallampati classification.
OBJECTIVES: The aim of the study is to investigate the efficacy of different dosages of single bolus propofol administered on the basis of total body weight or corrected body weight for the intravenous induction of anest...OBJECTIVES: The aim of the study is to investigate the efficacy of different dosages of single bolus propofol administered on the basis of total body weight or corrected body weight for the intravenous induction of anesthesia in obese patients undergoing bariatric surgery. MATERIALS AND METHODS: Thirty-eight obese patients with a body mass index (BMI) of 30 kg/m(2) or greater were randomly divided into two groups. They received single-bolus propofol (2 mg/kg) for intravenous induction of anesthesia based on either total body weight (TBW; 20 patients) or corrected body weight 60% (CBW60; 18 patients). Patients' characteristics, biochemical data, monitored bispectral index (BIS) values, and hemodynamic parameters were compared between the two groups. RESULTS: The propofol dose was significantly lower in the CBW60 group than in the TBW group (189.5 ± 36.3 mg vs. 217.3 ± 39.1 mg, respectively; p = 0.03). The highest BIS value, representing potential awareness after intubation, was relatively higher in the CBW60 group, but this difference was not statistically significant (CBW60 group, 53.6 ± 11.1; TBW group, 48.6 ± 8.1; p = 0.22). Eighty-three percent of patients experienced hypotension during induction and at least 44% patients showed marked hypotension. There was no significant difference between the TBW and CBW60 groups in blood pressure after intubation. CONCLUSION: When using single bolus propofol, the CBW60 group showed similar BIS values and hemodynamic effects as the TBW group during the intravenous induction of general anesthesia for obese patients.
A vascular access with good function for drug delivery is the basis of chemotherapy. If there is any congenital or acquired vascular abnormality, procedurally related and late complications such as vessel rupture, malpos...A vascular access with good function for drug delivery is the basis of chemotherapy. If there is any congenital or acquired vascular abnormality, procedurally related and late complications such as vessel rupture, malposition, and dysfunction of the catheter with ensuing thrombosis may occur, especially when it is undiagnosed or ignored. We describe a case of implantable central venous catheter (CVC) malposition and subsequent insertion of a Hickman catheter for stem cell transplantation after the diagnosis of persistent left superior vena cava (PLSVC) by radiologic image studies. The case is about a 60-year-old male who suffered from mantle cell lymphoma. He complained of discomfort when chemotherapeutic drugs were delivered through an implanted subcutaneous port system. Malposition of the CVC with aberrant path venous catheter, which led to its migration to the right internal jugular vein (RIJV) was noted on the chest X-ray. In addition, results of ultrasound imaging revealed total occlusion of the RIJV, and a subsequent three-dimensional (3D) computed tomography (CT) reconstruction image revealed a PLSVC with an atretic right SVC. Ultrasound-guided venous puncture of the left internal jugular vein and intraoperative fluoroscopy for confirming the correct guide-wire path were used for successful insertion of Hickman catheter without any complication. When unexpected occurrence of migration or malposition of the long-term CVC is detected, early removal of the catheter is vital for preventing further complications. Proper and advanced image studies including ultrasound, contrast-enhanced venography, CT, and magnetic resonance imaging may be necessary for understanding the potential vascular abnormality and guiding the following treatment.
An 81-year-old male scheduled for debridement of a perianal abscess sustained acute upper airway obstruction with atelectasis of the left lower lobe during induction of anesthesia. Results of a fiberoptic bronchoscopy re...An 81-year-old male scheduled for debridement of a perianal abscess sustained acute upper airway obstruction with atelectasis of the left lower lobe during induction of anesthesia. Results of a fiberoptic bronchoscopy revealed dorsal bulging and obstruction of the left bronchus. Under the context of tortuous aorta and calcified left border of the heart silhouette, aortic aneurysm was suspected; the diagnosis was confirmed by a computed tomography scan. Aortic aneurysm without specific symptoms cannot be screened by a single preoperative chest X-ray. The anesthesiologist should promptly request further radiographic studies to rule out potential aortic pathology if in doubt.
A 63-year-old man developed acute transverse myelitis (ATM) with a rapid progression of sensory and motor deficits and autonomic dysfunction 2 days after chest surgery. Thoracic epidural anesthesia/analgesia (TEA) had be...A 63-year-old man developed acute transverse myelitis (ATM) with a rapid progression of sensory and motor deficits and autonomic dysfunction 2 days after chest surgery. Thoracic epidural anesthesia/analgesia (TEA) had been administered in this case. Since the temporal and spatial relationships between TEA and ATM are so close, one may easily mistake the TEA as the cause. Therefore, we discuss here the differential diagnoses for cord damage after TEA and the characteristics of ATM, and suggest that it is unlikely that TEA is the cause of ATM in this case.
Atrial fibrillation (AF) is not only the most common arrhythmia in the global population but also the most frequent one encountered in the operating room. For an anesthesiologist, it is crucial to have the ability to mai...Atrial fibrillation (AF) is not only the most common arrhythmia in the global population but also the most frequent one encountered in the operating room. For an anesthesiologist, it is crucial to have the ability to maintain hemodynamics and prevent complications of patients who present AF perioperatively. Here we provide a brief review in the novel concept of the classification, pathophysiology, and management of AF to provide a practical approach for physicians coming across this arrhythmia during the perioperative period.
HMGB1 is a chromosome-binding protein that also acts as a damage-associated molecular pattern molecule. It has potent proinflammatory effects and is one of key mediators of organ injury. Evidence from research has reveal...HMGB1 is a chromosome-binding protein that also acts as a damage-associated molecular pattern molecule. It has potent proinflammatory effects and is one of key mediators of organ injury. Evidence from research has revealed its involvement in the signaling mechanisms of Toll-like receptors and the receptor for advanced glycation end-products in organ injury. HMGB1-mediated organ injuries are acute damage including ischemic, mechanical, allograft rejection and toxicity, and chronic diseases of the heart, kidneys, lungs, and brain. Strategies against HMGB1 and its associated cellular signal pathways need to be developed and may have preventive and therapeutic potentials in organ injury.
OBJECTIVES: Medical institutions are eager to introduce new information technology to improve patient safety and clinical efficiency. However, the acceptance of new information technology by medical personnel plays a key...OBJECTIVES: Medical institutions are eager to introduce new information technology to improve patient safety and clinical efficiency. However, the acceptance of new information technology by medical personnel plays a key role in its adoption and application. This study aims to investigate whether perceived organizational learning capability (OLC) is associated with user acceptance of information technology among operating room nurse staff. MATERIALS AND METHODS: Nurse anesthetists and operating room nurses were recruited in this questionnaire survey. A pilot study was performed to ensure the reliability and validity of the translated questionnaire, which consisted of 14 items from the four dimensions of OLC, and 16 items from the four constructs of user acceptance of information technology, including performance expectancy, effort expectancy, social influence, and behavioral intention. Confirmatory factor analysis was applied in the main survey to evaluate the construct validity of the questionnaire. Structural equation modeling was used to test the hypothetical relationships between the four dimensions of user acceptance of information technology and the second-ordered OLC. Goodness of fit of the hypothetic model was also assessed. RESULTS: Performance expectancy, effort expectancy, and social influence positively influenced behavioral intention of users of the clinical information system (all p < 0.001) and accounted for 75% of its variation. The second-ordered OLC was positively associated with performance expectancy, effort expectancy, and social influence (all p < 0.001). However, the hypothetic relationship between perceived OLC and behavioral intention was not significant (p = 0.87). The fit statistical analysis indicated reasonable model fit to data (root mean square error of approximation = 0.07 and comparative fit index = 0.91). CONCLUSION: Perceived OLC indirectly affects user behavioral intention through the mediation of performance expectancy, effort expectancy, and social influence in the operating room setting.
BACKGROUND: Acute detoxification may lead to withdrawal syndrome. The syndrome is sufficiently aversive in those who are morphine-dependents and thus it hinders abstinence. The opioids are most often used clinically to l...BACKGROUND: Acute detoxification may lead to withdrawal syndrome. The syndrome is sufficiently aversive in those who are morphine-dependents and thus it hinders abstinence. The opioids are most often used clinically to lighten this syndrome. Here, we evaluated the effects of tricyclic antidepressants (TCAs) in treating physical dependence to opioids upon acute detoxification in mice. MATERIALS AND METHODS: Adult NRL mice were rendered physically dependent on morphine by increasing daily doses of subcutaneous morphine for 3 days and precipitated withdrawal jumping by subcutaneous naloxone on Day 4. The mice were then assigned to receive intramuscular saline or one of the five TCAs 1 hour prior to creating naloxone-precipitated withdrawal. The withdrawal jumping frequency in 30 minutes was counted after naloxone-precipitated withdrawal. RESULTS: Our results (the newest findings) based on the equimolar dose (30 μmol/kg), showed that the severity of physical dependence on morphine could be attenuated with less intramuscular TCAs [percent maximal possible effect (MPE) < 50). Amoxapine, protriptyline, amitriptyline, clomipramine, and trimipramine produced a mean percent MPE (43, 18, 37, 45, and 36, respectively); amoxapine, protriptyline, amitriptyline, and clomipramine, also produced a dose-related effect on attenuating the severity of morphine dependence, but not trimipramine. A higher dose had a stronger effect. CONCLUSION: Amoxapine, trimipramine, protriptyline, amitriptyline, and clomipramine could have a lightening effect on physical dependence on morphine.
OBJECTIVE: Because ketamine, clonidine, and morphine modulate nociceptive pain, coadministration of these drugs would augment the activity of postoperative analgesic drugs. The purpose of this study was to evaluate the e...OBJECTIVE: Because ketamine, clonidine, and morphine modulate nociceptive pain, coadministration of these drugs would augment the activity of postoperative analgesic drugs. The purpose of this study was to evaluate the effects of coadministration of ketamine and clonidine on postoperative morphine consumption in patients after spine surgery. METHODS: The patients undergoing spine surgery were allocated randomly to one of the four study groups, which are as follows: group M (n = 12), intravenously (IV) administered patient-controlled analgesia (PCA) morphine alone; group MK (n = 12), IV-PCA morphine plus intra- and postoperative ketamine; group MC (n = 13), IV-PCA morphine plus oral clonidine premedication; group MCK (n = 12), IV-PCA morphine plus intra- and postoperative ketamine and clonidine premedication. The patients in the MC and MCK groups received 4 μg/kg clonidine orally, whereas those in the MK and MCK groups received IV bolus of ketamine (10 mg) at a rate of 2 mg/kg/hour during anesthesia. Patients were arranged to use IV-PCA mode for administration of drugs, which was programmed to deliver a bolus dose of 2-mg morphine (groups M and MC), or boluses of 2-mg morphine and 2-mg ketamine (groups MK and MCK). Scores of visual analog scale (VAS) for pain, morphine requirement, vital signs, nausea, sedation, and other side effects were followed up to 60 hours after surgery. RESULTS: Although there were significant differences in VAS pain scores at rest 24-48 hours after the surgery, the VAS pain score at movement was similar among the groups. The number of PCA request and cumulative morphine requirement were significantly lower in the MCK group than in the M group. CONCLUSION: This study results show that the administration of perioperative low-dose ketamine combined with clonidine premedication could reduce the consumption of postoperative PCA morphine following spine surgery.
STUDY OBJECTIVE: Gabapentin is an inhibitory neurotransmitter of the central nervous system. This prospective randomized double-blind study was conducted to evaluate the effects of gabapentin on intraoperative propofol r...STUDY OBJECTIVE: Gabapentin is an inhibitory neurotransmitter of the central nervous system. This prospective randomized double-blind study was conducted to evaluate the effects of gabapentin on intraoperative propofol requirements, hemodynamic variables, and postoperative pain relief in breast cancer patients. MATERIALS AND METHODS: Forty adult females of the American Society of Anesthesiologists (ASA) Grade I-II physical status, undergoing total mastectomy for breast cancer were included. Patients were randomly allocated into two groups. Two hours prior to surgery the gabapentin group received gabapentin 600 mg and the control group received placebo. Anesthesia was induced with intravenous fentanyl, propofol, and vecuronium, and maintained with propofol infusion titrated according to the bispectral index. Postoperative analgesia was provided with intramuscular diclofenac sodium and intravenous morphine on demand. RESULTS: The intraoperative propofol consumption was significantly less in the gabapentin group as compared with the control group (p = 0.009), whereas there was no difference in fentanyl and vecuronium requirements. Patients in the gabapentin group had lower pain scores at 30 minutes, 1 hour, and 2 hours postoperatively (p < 0.001). The postoperative morphine consumption was also less in the gabapentin group compared with the control group (p = 0.006). No significant adverse effects were noticeable. CONCLUSION: Preoperative administration of gabapentin reduced intraoperative propofol requirements and postoperative analgesic consumption in breast cancer patients undergoing total mastectomy.
OBJECTIVES: Postoperative reintubation after planned extubation (RAP) following general anesthesia is a major anesthetic morbidity. A previous study on RAP identified the various risk factors for RAP, including chronic o...OBJECTIVES: Postoperative reintubation after planned extubation (RAP) following general anesthesia is a major anesthetic morbidity. A previous study on RAP identified the various risk factors for RAP, including chronic obstructive pulmonary disease (COPD), pneumonia, systemic inflammatory response syndrome (SIRS), and airway surgery. However, the prognosis and predictive risk index of RAP were not investigated. METHODS: Data on surgical patients who were reintubated after planned extubation at the end of surgery between January 1, 2005 and December 31, 2009 were retrospectively sorted out from the quality assurance database of the Department of Anesthesiology, Chang Gung Memorial Hospital. Risk factors and prognosis of RAP cases were compared with the control group (successful planned extubation) using descriptive statistics and logistic regression. The RAP predictive risk index was developed from multivariate logistic regression and the predictive accuracy was evaluated by goodness-of-fit test. RESULTS: Of the 227,876 patients who were subjected to endotracheal intubation for general anesthesia, 130 (0.06%) sustained postoperative RAP. The control group consisted of 390 patients who were randomly selected from those who underwent endotracheal intubation without RAP. A total of 30 variables, including demographic, operative, anesthetic data, and prognosis were analyzed. We found that significant risk factors for RAP included COPD (odds ratio: 4.30), pneumonia (odds ratio: 6.60), ascites (odds ratio: 4.86), SIRS (odds ratio: 7.52), hypothermia (body temperature <35°C; odds ratio: 2.45), rocuronium as muscle relaxant (odds ratio: 1.90), inexperienced anesthetic service (odds ratio: 3.44), and airway surgery (odds ratio: 4.34). An RAP predictive risk index was developed and the predictive accuracy was confirmed by goodness-of-fit test as excellent discrimination (c statistic: 0.873). RAP significantly increased postoperative stay in hospital (odds ratio: 2.46) and intensive care unit, as well as tracheostomy and mortality (odds ratio: 58.52). CONCLUSION: The RAP predictive risk index included higher American Society of Anesthesiologists classification, conscious disturbance, COPD, pneumonia, SIRS, room air SpO2 <95%, hypothermia, airway surgery, and head and neck surgeries. The RAP predictive risk index provides us an opportunity to take preventive measures including renewal of risk-reduction protocols for high-risk patients.
Enteral feeding is now standard and routine practice in intensive care. The use of a nasogastric tube for enteral feeding is generally considered to be safe, but tubes with small bores can sometimes lead to aspiration or...Enteral feeding is now standard and routine practice in intensive care. The use of a nasogastric tube for enteral feeding is generally considered to be safe, but tubes with small bores can sometimes lead to aspiration or passage clogging when malpositioned in sedated patients who are on long-term mechanical ventilation. Thus, accurate confirmation of correct placement is mandatory in such patients. This is not always the case, but this faulty practice can lead to serious complications in the absence of potential bezoar-forming medicines or gastrointestinal pathology. We present here one such interesting case of a patient who developed esophageal bezoar due to a malpositioned nasogastric tube for administering a casein-containing feed. In addition, we present a review of the literature.