Chao-Shun Tang

The effect of timing of dexamethasone administration on its efficacy as a prophylactic antiemetic for postoperative nausea and vomiting.

We evaluated the timing effect of a 10-mg IV administration of dexamethasone on its efficacy as a prophylactic antiemetic on postoperative nausea and vomiting (PONV). One hundred twenty women (n = 40 in each of three groups) undergoing abdominal total hysterectomy under general anesthesia were enrolled in this randomized, double-blinded, placebo-controlled study. Group 1 received dexamethasone before the induction of anesthesia, Group 2 received dexamethasone at the end of anesthesia, and Group 3 received placebo (saline). The incidence of PONV was evaluated. During the postoperative period of 0–2 h, patients in Group 1 reported a less frequent incidence of PONV (15%) than those in Groups 2 and 3 (45% and 53%, respectively). Patients in Group 1 also requested less rescue antiemetic (8%) than those in Groups 2 and 3 (30% and 35%, respectively). During the postoperative period of 2–24 h, patients in both Groups 1 and 2 reported less frequent incidences of PONV (25% and 28%) and requested fewer rescue antiemetics (13% and 15%) than those in Group 3 (55% and 38%, respectively). In conclusion, the prophylactic IV administration of dexamethasone immediately before the induction, rather than at the end of anesthesia, was more effective in preventing PONV. Implications We evaluated the effect of timing of dexamethasone administration on its efficacy as a prophylactic antiemetic on postoperative nausea and vomiting. We found that dexamethasone, when given immediately before the induction of anesthesia, was more effective than when given at the end of anesthesia.

Low-dose dexamethasone effectively prevents postoperative nausea and vomiting after ambulatory laparoscopic surgery.

Purpose“To evaluate the prophylactic effect of low-dose dexamethasone (5 mg) on postoperative nausea and vomiting (PONV) in women undergoing ambulatory laparoscopic surgery. Metoclopramide and saline served as controls.MethodsOne hundred twenty women (n=40 in each of the three groups) undergoing ambulatory laparoscopic tubal ligation under general anesthesia were enrolled in this randomized, double-blinded, placebo-controlled study. After tracheal intubation, group I receivediv dexamethasone 5 mg, whereas groups II and III receivediv metoclopramide 10 mg and saline, respectively.ResultsPatients in group I reported a lower incidence of PONV and requested less rescue antiemetics than those in group III during the first four postoperative hours (P < 0.0l). Patients in group I reported a lower incidence of PONV than those in groups II (P < 0.05) and III (P < 0.0l) during the 24-hr postoperative period. Groups II and III did not differ from each other in the incidence of PONV and the proportion of patients who requested rescue antiemetics.ConclusionProphylacticiv dexamethasone 5 mg significantly reduces the incidence of PONV in women undergoing ambulatory laparoscopic tubal ligation. At this dose, dexamethasone is more effective than metoclopramide 10 mg or placebo.RésuméObjectifÉvaluer l’effet prophylactique d’une faible dose de dexaméthasone (5 mg) sur les nausées et vomissements postopératoires (NVPO) chez des patientes de chirurgie laparoscopique ambulatoire. Le métoclopramide et une solution salée ont servi de témoins.MéthodeCent vingt femmes (n = 40 dans chacun des trois groupes formés de façon aléatoire), devant subir une ligature des trompes sous anesthésle générale en chirurgie laparoscopique ambulatoire, ont participé à l’étude randomisée, en double Insu et contrôlée contre placebo. Après l’intubation endotrachéale, les patientes du groupe I ont reçu 5 mg de dexaméthasone iv tandis que celles des groupes II et III ont reçu 10 mg de métoclopramide ou de solution salée iv, respectivement.RésultatsLes patientes du groupe I ont signalé une plus faible Incidence de NVPO et ont demandé moins d’antiémétiques de secours que les patientes du groupe III pendant les quatre premières heures postopératoires (P < 0,01). Les patients du groupe I ont eu moins de NVPO que celles des groupes II (P < 0,05) et III (P < 0,01) pendant une période de 24 h après l’intervention. Aucune différence intergroupe quant à l’incidence de NVPO et au nombre de patientes qui ont eu recours aux antiémétiques n’a été notée entre les patientes des groupes II et III.ConclusionL’administration iv de 5 mg de dexaméthasone réduit significativement l’incidence de NVPO chez des patientes qui subissent une ligature des trompes en chirurgie laparoscopique ambulatoire. Cést plus efficace que 10 mg de métoclopramide ou de placebo.

A Novel Approach of Intravenous Electrocardiograph Technique in Correct Position the Long-Term Central Venous Catheter

Intravenous electrocardiograph (IVECG) can correctly positioning the catheter tip by enlarging p wave as it is moved toward right atrium, and it is a safe, reliable and accurate technique. To evaluate the efficacy of wire-conducted IVECG signal and IVECG signal from the port with sodium bicarbonate (NaHCO3) flushed catheter and to compare those with conventional anatomy landmark method was the propose of this study. This prospective study was carried out in 216 patients who suffered from malignant diseases. The correct position of the catheter tip among these groups was confirmed as follows. In group 1 (n = 80), the anatomy landmark method and portable chest radiograph recognized the correct position. In group 2 (n = 72), IVECG signal was conducted from guide wire to identify the tip position. In group 3 (n = 64), IVECG signal was conducted from the port with NaHCO3 (0.8 mEq/mL) flushed catheter to ascertain the tip position. The patient characteristics did not differ significantly among the groups. The duration of operation was significantly (P < 0.001) longer in group 1 than in group 2 and group 3 (45.4 +/- 9.3 minutes vs 35.7 +/- 8.0 minutes and 35.2 +/- 9.7 minutes, respectively). Catheter tip placement times were shorter in group 2 and group 3 than in group 1 (5.3 +/- 2.9 minutes and 6.4 +/- 3.0 minutes vs 16.7 +/- 5.7 minutes, respectively); there was a statistically significant difference between the group 1 and group 2 and group 3 (p < 0.001). Nonetheless, the duration of operation and catheter tip placement time was similar in group 2 and group 3. Early and late complications within the subsequent 3 months showed no significant difference among groups. We concluded that IVECG signal conducted from guide wire obtained a similar efficiency to that signal from the port with NaHCO3 flushed catheter on positioning the catheter tip of the venous Port-A-Cath system. It is recommended to use these methods to facilitate implanting long-term central venous devices.

Total intravenous anesthesia using propofol and ketamine for ambulatory gynecologic laparoscopy.

Laparoscopy under total intravenous anesthesia (TIVA) with spontaneous respiration is a commonly encountered procedure in ambulatory gynecologic surgery. The purpose of this study was to evaluate the efficacy of TIVA using propofol and ketamine, compared with endotracheal inhalational general anesthesia (EIGA) for ambulatory gynecologic laparoscopy. Fifty-eight female patients, aged 17-48 years, were randomly allocated into two groups. Group 1 (TIVA) (n = 28) received propofol at the induction of anesthesia followed by propofol infusion for maintenance. Intravenous ketamine 0.5 mg/kg was administered before operation for anesthetic effect. Natural airway and spontaneous breathing were then maintained in patients. Group 2 (n = 30) received EIGA with isoflurane under controlled ventilation. We found that the two groups demonstrated similar trend characters of pH and PaCO2 during operation and in recovery room. The incidence of postoperative vomiting was higher in group 2 than in group 1 (30% vs. 7%; p < 0.05). The incidence of intraoperative arrhythmia was higher in group 2 than in group 1 (40% vs. 3%; p < 0.001). Furthermore, the incidence of sore throat was higher in group 2 than in group 1 (47% vs. 7%; p < 0.001). We conclude that TIVA with spontaneous respiration is suitable for ambulatory gynecologic laparoscopy.

Influences of Tramadol on Emergence Characteristics Form Sevoflurane Anesthesia in Pediatric Ambulatory Surgery

Sevoflurane is used for pediatric ambulatory surgery due to its low blood solubility, rapid emergence, non-pungency and low airway irritability. Nevertheless, its tendency to induce agitation during emergence may offset its benefits. The following study was designed to evaluate the effects of intravenous (i.v.) tramadol (1 mg/kg) on the emergence from sevoflurane anesthesia. Forty ASA I children, ranging from 1 to 8 years old, scheduled for inguinal surgery, were randomized into two groups (Group S--control group, Group ST--i.v. tramadol, 20 in each group). The patients were first premedicated with oral atropine (0.01 mg/kg), then anesthesia was induced with i.v. application of thiamylal (3-4 mg/kg) and maintained with mask anesthesia with sevoflurane. Topical infiltration with 2-3 ml of 1% lidocaine was applied over skin incision area. I.v. tramadol (1 mg/kg) was given before the end of operation in Group ST. The emergence agitation was recorded on a visual analog scale (VAS, 0-10) by a blinded anesthesiologist in the PACU (postoperative anesthesia care unit), as well as the length of other recovery stages and complications after anesthesia. The age, weight, gender, and duration of surgery and anesthesia were similar in the two groups. The emergence agitation score (6.3 +/- 3.5 vs. 3.2 +/- 2.8, P < 0.05), incidences of agitation (VAS > 5, 55% vs 20%, P < 0.05), and postoperative pain (65% vs 30%, P < 0.05) were higher for the control group. I.v. Tramadol (1 mg/kg) before the end of operation reduced postoperative pain and the incidence and degree of emergence agitation from sevoflurane anesthesia in pediatric ambulatory surgery.

Lightwand-assisted intubation of patients in the lateral decubitus position.

In some situations, patients need endotracheal intubation to maintain airway patency while they are constrained in the lateral position. In this study we compared lightwand-guided intubation of 120 randomly enrolled patients placed in the supine, right, or left lateral position. Group S patients were initially placed in the supine position, and subsequent to the artificial airway having been established they were turned to the lateral decubitus position. Group R patients were initially placed in a right decubitus position during induction and intubation. Group L patients were initially placed in a left decubitus position during induction and intubation. The duration of each intubation attempt, the total time to successful intubation, and the incidence of intubation-related intraoral injury, hemodynamic changes, and postoperative sore throat and hoarseness were recorded. Intubation took a similar length of time in the supine (14.5 ± 13.4 s), left lateral (13.3 ± 10.2 s), and right lateral positions (15.5 ± 13.0 s) and resulted in a similar trend in hemodynamic changes. Patients in the lateral and supine positions revealed a comparable incidence of successful first-attempt intubation, sore throat, hoarseness, oral mucosal injury, and dysrhythmia. Insignificantly more esophageal intubations were performed in the lateral position in the first attempt at intubation; however, all patients were correctly intubated shortly after reattempting intubation. We concluded that lightwand-assisted intubation is easily performed and a similar technique may be used whether the patient is in a lateral, recumbent, or a supine position. This alternative technique should be practiced and is recommended for patients who must remain in a lateral position during intubation and surgery.

Ropivacaine 0.1% with or without fentanyl for Epidural Postoperative Analgesia: A Randomized, Double-Blind Comparison

Epidural analgesia is often considered optimal postoperative analgesia for certain surgical procedures. Ropivacaine is a new local anesthetic that is less toxic than its homologue, bupivacaine. Epidural infusions usually comprise a local anesthetic, an opioid, or a combination of the two to improve analgesic efficacy and reduce unwanted side effects. All 210 patients undergoing lower abdominal or lower extremity surgery received epidural analgesia infusions at 7 mL/hour, 105 with 0.1% ropivacaine and 105 with 0.1% ropivacaine plus 1 μg/mL fentanyl. Pain score and side effects (hypotension, nausea, vomiting, pruritus, paresthesia, urinary retention and motor block) were measured at 0, 0.5, 1, 3, 6, 12, and 24 hours. There was no statistical difference in patient profile between the groups. Pain relief scores were similar in the two groups in the first hour after the drugs were given. However, pain relief was significantly better in the ropivacaine/fentanyl group after the first hour and this difference lasted for the remaining time. There was no significant difference in adverse events between the two groups during 24 hours of assessment. In conclusion, the quality of analgesia was significantly improved by the addition of fentanyl 1 μg/mL to ropivacaine.

The Train of Four Ratio Decreases to Zero in Anesthetized Children is the Guide to Achieve a Satisfactory Intubation Condition

The purpose of this study is to investigate the satisfactory (excellent or good) intubation conditions attained when the TOF ratio was zero in anesthetized children. Sixty children undergoing elective ophthalmic surgery were allocated randomly into three groups. Anesthesia was induced with thiopentone 4 mg/kg and halothane in combination with 66% N2O and O2 (2 L/min). Patients maintained spontaneous breathing with assisted ventilation to limit the values of end tidal CO2 within the range of 36-44 mmHg, maintained the stable end tidal expiratory 1 MAC halothane concentration for three minutes and followed by 0.1 mg/kg vecuronium in group 1, 0.6 mg/kg rocuronium in group 2, and 0.9 mg/kg rocuronium in group 3. Intubation was attempted as the TOF ratio decreased from 1.0 to 0. The intubation condition was scored by assessing the degree of jaw relaxation, vocal cord opening grades, and cough responses. The overall intubation conditions were graded as excellent, good, fair, and poor on the basis of the scores. Excellent or good intubation conditions were considered satisfactory. After neuromuscular blockade administration, TOF ratio required 160.5 +/- 28.9 seconds in group 1, 70.7 +/- 18.5 seconds in group 2, and 55.7 +/- 13.5 seconds in group 3 to decrease to zero. There is a significant difference between group 1 and group 2 and 3 (p < 0.001, group 1 vs group 2 and group 3). All children were intubated, during which procedures satisfactory intubation conditions were observed in all of the group 3 patients, in 17 of the 20 group 2, and in 16 of the 20 group 1 patients. We concluded that zero of TOF from monitoring the adductor pollicis muscle indicated the proper moment for intubation in anesthetized pediatric patients and it was a reliable guide in adequately anesthetized children to achieve satisfactory intubation conditions following 0.9 mg/kg rocuronium administration.

Epidural ropivacaine for postoperative analgesia in Taiwanese patients.

BACKGROUND Ropivacaine is the latest long-acting amide local anesthetic. As it is less cardiovasculotoxic and neurotoxic than bupivacaine it is an attractive anesthetic agent used in clinical anesthesia and postoperative analgesia. This study was undertaken to seek for a suitable dosage of ropivacaine in postoperative analgesia for Taiwanese patients whose average physicality is not entirely compatible with the pharmacopeially recommended dosage for western people. METHODS For assessment of epidural ropivacaine for postoperative analgesia 105 adult patients were enrolled and randomly allotted to three groups. Patients in Group A were given epidurally 0.15% ropivacaine, while those in Group B and Group C were given 0.125% and 0.10% ropivacaine respectively. Pain was evaluated with visual analogue scale (VAS) and modified Bromage scale, and adverse effects were recorded at the designated points of time during the postoperative 24-hour period. RESULTS The demographic profiles were comparable among three groups. In VAS score, Group A (3.20 +/- 0.47) and B (3.11 +/- 0.41) did not differ much, while Group C (3.97 +/- 0.71) the score was signally higher than Group A and Group B (P < 0.05). Adverse effects, such as paraesthesia, nausea and urinary retention were observed more in Group A. CONCLUSIONS From the results of this study, we are of the opinion that 0.125% ropivacaine could provide a postoperative analgesia in Taiwanese patients to their satisfaction with less adverse effects.

A Series of Stellate Ganglion Block for Ischemic Monomelic Neuropathy Chronic Ischemic Pain after Arteriovenous Shunt Surgery-A Case Report

We report a case of ischemic monomelic neuropathy (IMN) occurring in a 51 years old diabetic female patient with end-stage renal disease. She underwent arteriovenous (A-V) shunt creation but subsequent severe steal syndrome developed. Unfortunately, she complained moderate to severe left forearm pain and a cold hand after revision of A-V shunt for more than 6 months. Under the impression of ischemic neuropathy, she was prescribed with weak opioid, antiepileptics and mecobalamine. She was transferred to our pain clinic because of inadequate pain control. We arranged left side stellate ganglion block once per week for 2 months to improve upper arm circulation and relieve pain and buprenorphone also added for breakthrough pain. Outcome measurements for peripheral circulation and chronic pain were done by infrared thermography and numerical rating scale respectively. Gradually, her intractable pain was controlled with much satisfaction.