Chia-Chan Wu

Local infusion of bupivacaine combined with intravenous patient-controlled analgesia provides better pain relief than intravenous patient-controlled analgesia alone in patients undergoing minimally invasive cardiac surgery

OBJECTIVE This prospective randomized double-blind study examined the effect of local wound infusion of anesthetics on pain control in the thoracotomy wound of patients undergoing minimally invasive cardiac surgery. METHODS Patients who underwent coronary artery bypass grafting or cardiac valvular procedures via a minimally invasive thoracotomy were studied. Patients were enrolled and randomly allocated to two groups with different modalities of postoperative analgesia. The thoracotomy wound infusion group received 0.15% bupivacaine infused continuously at 2 mL/h through a catheter embedded in the wound, as well as intravenous patient-controlled analgesia. The control group had patient-controlled analgesia alone with a sham thoracotomy wound infusion of normal saline. Verbal analog pain scores (0-10 points) and recovery profiles were investigated. RESULTS There were 19 patients in each group for complete data analysis. On the first day after the operation, infusion of local anesthetics significantly reduced the verbal analog pain scores both at rest and during motion (thoracotomy wound infusion vs control). The improved pain relief with thoracotomy wound infusion persisted at day 3 and even at 3 months after the operation. No difference was noted about time to extubation, length of intensive care unit stay, or hospital stay. CONCLUSION In this controlled double-blind study, thoracotomy wound infusion and patient-controlled analgesia were superior to patient-controlled analgesia alone in reducing pain at 1, 3, and 90 days after minimally invasive cardiac surgery.

Tetrandrine ameliorated reperfusion injury of small bowel transplantation

PURPOSE In small bowel transplantation, the bowel graft is susceptible to reperfusion injury. This study investigated the effects of tetrandrine, a bisbenzylisoquinoline alkaloid, on the development of intestinal reperfusion injury in small bowel transplantation in pigs. MATERIALS AND METHODS Pigs underwent small bowel transplantation and were treated with tetrandrine or a vehicle. Blood and small bowel specimens were harvested at 1, 3, and 24 hours after reperfusion. Histopathologic analysis of the small bowel was assessed for tissue damage. Serum levels of tumor necrosis factor-alpha, interleukin-1beta (IL-1beta), and IL-6 were measured by enzyme-linked immunosorbent assay. Reverse-transcriptase polymerase chain reaction analysis was performed to analyze the expression of proinflammatory cytokines, and immunohistochemical analysis was used to study the expression of intercellular adhesion molecule-1 (ICAM-1) in the small bowel. Myeloperoxidase staining detected neutrophil infiltration in the small bowel and the number of myeloperoxidase positively stained cells was counted. RESULTS Pigs receiving small bowel transplantation had elevated serum proinflammatory cytokine levels. The transplanted small bowel showed mucosal damage, increased expression of proinflammatory cytokines and ICAM-1, and prominent neutrophil infiltration. Tetrandrine administration reduced mucosal damage, serum and tissue proinflammatory cytokine levels, ICAM-1 expression, and neutrophil accumulation in the transplanted small bowel. CONCLUSIONS Tetrandrine reduced the reperfusion injury in porcine intestinal transplantation during the first 24 hours after the procedure.

Does Different Time Interval Between Staggered Bilateral Total Knee Arthroplasty Affect Perioperative Outcome? A Retrospective Study

Staggered bilateral total knee arthroplasty (BTKA) performed 4 to 7 days apart has been shown to have fewer postoperative complications than sequential or staged BTKA. However, there has been no comparison of staggered BTKA with different intervals. A retrospective study involving 79 patients who underwent BTKA from 2002 to 2004 was performed to determine whether the interval between each TKA influenced the clinical outcome. Staggered operations performed 2 days (n = 46) or 7 days (n = 33) apart had similar incidence of major (acute myocardial infarction, pulmonary embolism, etc) and minor complications (transient hypotension or low Sp(o)(2)) throughout hospitalization. Perioperative complications in the first and second TKAs were similar when TKAs were performed with a 2- or a 7-day interval.

Palmitoylethanolamide Inhibits Glutamate Release in Rat Cerebrocortical Nerve Terminals

The effect of palmitoylethanolamide (PEA), an endogenous fatty acid amide displaying neuroprotective actions, on glutamate release from rat cerebrocortical nerve terminals (synaptosomes) was investigated. PEA inhibited the Ca2+-dependent release of glutamate, which was triggered by exposing synaptosomes to the potassium channel blocker 4-aminopyridine. This release inhibition was concentration dependent, associated with a reduction in cytosolic Ca2+ concentration, and not due to a change in synaptosomal membrane potential. The glutamate release-inhibiting effect of PEA was prevented by the Cav2.1 (P/Q-type) channel blocker ω-agatoxin IVA or the protein kinase A inhibitor H89, not affected by the intracellular Ca2+ release inhibitors dantrolene and CGP37157, and partially antagonized by the cannabinoid CB1 receptor antagonist AM281. Based on these results, we suggest that PEA exerts its presynaptic inhibition, likely through a reduction in the Ca2+ influx mediated by Cav2.1 (P/Q-type) channels, thereby inhibiting the release of glutamate from rat cortical nerve terminals. This release inhibition might be linked to the activation of presynaptic cannabinoid CB1 receptors and the suppression of the protein kinase A pathway.

Bullet embolisation from the right subclavian vein to the right ventricle: a case report

Bullet embolism to the heart is an unusual complication of penetrating gunshot injuries. A bullet may reach the heart by direct cardiac penetration or entry into the peripheral venous system with embolisation to the heart, which must be differentiated. This is a report of an unusual case of bullet embolism to the heart that was extracted by direct cardiotomy without cardiopulmonary bypass.

Antiemetic efficacy of metoclopramide and diphenhydramine added to patient-controlled morphine analgesia: a randomised controlled trial.

Background and objective The objective of this study was to assess whether antiemetic drugs metoclopramide and diphenhydramine, administered together as opposed to alone, can have better efficacy in preventing postoperative nausea and vomiting when added to patient-controlled morphine analgesia. Patients and methods During the period July 2007 to August 2008, 200 women scheduled for abdominal total hysterectomy were randomised to one of four postoperative, patient-controlled analgesia regimens: group 1, morphine 1 mg ml−1; group 2, morphine 1 mg ml−1 with metoclopramide 0.5 mg ml−1; group 3, morphine 1 mg ml−1 with diphenhydramine 0.6 mg ml−1; and group 4, morphine 1 mg ml−1 with metoclopramide 0.5 mg ml−1 and diphenhydramine 0.6 mg ml−1. Dexamethasone 4 mg was administered to all patients in all groups after anaesthesia induction as a prophylactic antiemetic medication, and prochlorperazine 5 mg was administered by intramuscular injection as necessary as a salvage/rescue therapy. Nausea, vomiting, pruritus, level of sedation, pain and morphine consumption were compared between the four groups. Results The incidence of nausea was significantly (P < 0.05) lower in group 4 compared to the other groups. In addition, there was a significant (P = 0.006) difference in the incidence of vomiting between groups 1 and 4. Repeated measurement analysis showed that numeric rating scale scores for group 4 were significantly (P < 0.001) lower than those for the other groups. Conclusion Results of this study showed that a combination of metoclopramide with diphenhydramine in patients treated with dexamethasone at anaesthesia induction decreased postoperative nausea and vomiting compared to metoclopramide or diphenhydramine in these patients, when added to patient-controlled anaesthesia with morphine.

Acute Myocarditis-related Complete Atrioventricular Block—An Accidental Finding in an Acute Appendicitis Patient

We report a 20-year-old male patient with preoperatively undiagnosed myocarditis, who received general anesthesia for laparoscopic appendectomy. Because of arrhythmia, a cardiologist was consulted postoperatively. The 12-lead electrocardiogram showed complete atrioventricular block and the echocardiogram showed global hypokinesia of the left ventricle with impaired contractility, a left ejection fraction of 37%, and a dilated right heart. Subsequently, a permanent pacemaker was implanted and the patient was discharged from hospital without any complications.

Spleen Rupture After Mitral Valve Replacement for Infective Endocarditis

We present a case of splenic rupture as the cause of a sudden drop in blood pressure soon after mitral valve surgery for infective endocarditis. This case suggests that, in addition to more common causes of unstable vital signs after valvular surgery, such as cardiac tamponade or bleeding at the operation site, splenic rupture, although rare, should be considered in the differential diagnosis. This is particularly important in the case of infective endocarditis.

A Simple Method for Dilatation of the Trachea Compressed by Large Bilateral Goiter

The anesthetic management of a 63-year-old woman with a large bilateral thyroid goiter causing tracheal deviation and compression was described. Thyroidectomy was planned for severe airway compromise. Extracorporeal membrane oxygenation (ECMO) was established before anesthesia induction. The trachea was intubated, beginning with a small cuffed endotracheal tube that was inflated and sequentially replaced with larger tubes until a 7-mm tube was placed to dilate the trachea successfully. ECMO was discontinued after the airway was established. There was minimal bleeding during thyroidectomy.

Limited Myocardial Protective Effect of Leukocyte-depleted Blood Cardioplegia in Mitral Valve Surgery

Objective: Leukocytes are the main effectors to cause reperfusion injury in patients undergoing heart surgery, which may result in myocardial damage and unfavorable outcome. The aim of this study was to investigate whether leukocyte depletion by commercially available leukocyte filter could decrease myocardial injury after mitral valve surgery. Methods: Forty patients proposed to have mitral valve surgery were enrolled in this study. They were randomly allocated to one of these two groups: group 1 had leukocyte filter and group 2 did not have leukocyte filter during the blood cardioplegia delivery. Blood samples were drawn from the arterial line before aortic clamping and 2, 6, 18, 30 hours after removal of the cross clamp for troponin-I level determination. The recovery profiles were also recorded. Results: The demographic data and crossclamp time were comparable in both groups. The leukocyte filter did not cause consistent changes in troponin-I level at every check point. The intubation time, intensive care unit stay and hospital stay were also similar. The patients with the leukocyte filter seemed to have less dopamine dose at ICU admission, but without statistical significance. Conclusion: Our data did not support the routine use of a commercially available leukocyte depleting filter for blood cardioplegia delivery in mitral valve surgery without low LVEF or prolonged cross-clamp time.