Chueng-He Lu

Effect on postoperative sore throat of spraying the endotracheal tube cuff with benzydamine hydrochloride, 10% lidocaine, and 2% lidocaine.

BACKGROUND:Postoperative sore throat (POST) is a common complication after endotracheal intubation. We compared the effectiveness on POST of spraying the endotracheal tube (ETT) cuff with benzydamine hydrochloride, 10% lidocaine, and 2% lidocaine. METHODS:Three hundred seventy-two patients were randomly allocated into 4 groups. The ETT cuffs in each group were sprayed with benzydamine hydrochloride, 10% lidocaine hydrochloride, 2% lidocaine hydrochloride, or normal saline before endotracheal intubation. After insertion, the cuffs were inflated to an airway leak pressure of 20 cm H2O. Anesthesia was maintained with propofol. The patients were examined for sore throat (none, mild, moderate, or severe) at 1, 6, 12, and 24 hours after extubation. RESULTS:The highest incidence of POST occurred at 6 hours after extubation in all groups. There was a significantly lower incidence of POST in the benzydamine group than 10% lidocaine, 2% lidocaine, and normal saline groups (P < 0.05) at each observation time point. At 6 hours after extubation, the incidence of POST was significantly lower in the benzydamine group (17.0%) compared with 10% lidocaine (53.7%), 2% lidocaine (37.0%), and normal saline (40.8%) groups (P < 0.05). The benzydamine group had significantly decreased severity of POST compared with the 10% lidocaine, 2% lidocaine, and normal saline groups (P < 0.05) at each observation time point. Compared with the 2% lidocaine and normal saline groups, the 10% lidocaine group had significantly increased severity of POST at 1, 6, and 12 hours after extubation. There were no significant differences among groups in local or systemic side effects. CONCLUSIONS:Spraying benzydamine hydrochloride on the ETT cuff is a simple and effective method to reduce the incidence and severity of POST.

Intracranial subdural hematoma after unintended durotomy during spine surgery.

PurposeTo report a case of intracranial subdural hematoma occurring after a spinal dural tear that was made unintentionally during the course of a posterior laminectomy and spinal fusion at the L5-S1 level. The possible physiopathological mechanisms are discussed.Clinical featuresOn the fourth postoperative day, a 59-yr-old woman displayed persistent headache following unintended durotomy during spine implant revision. Perioperative blood loss was 2840 mL and intravascular replacement was about 3000 mL. She was hydrated with iv fluids and treated with non-steroidal antiinflammatory drugs. The symptoms improved but persisted. With the aggravation of the headache complicated with unconsciousness and the appearance of focal neurological signs on the eighth day, a computed tomography was obtained and revealed a right subdural hematoma. Following surgical drainage, the patient made an uneventful recovery.ConclusionThis case reminds us that subdural hematoma formation can complicate durotomy during spine surgery. Neurological deterioration in the postoperative period should prompt clinicians to rule out the diagnosis and intervene rapidly as appropriate.RésuméObjectifRapporter un cas d’hématome sous-dural intracrânien survenu après une brèche involontaire de la dure-mère spinale au cours d’une laminectomie postérieure et d’une arthrodèse au niveau L5-S1. Les mécanismes physiopathologiques possibles sont discutés.Éléments cliniquesAu quatrième jour postopératoire, une femme de 59 ans présentait des céphalées persistantes après une durotomie involontaire survenue pendant la reprise d’un implant rachidien. La perte sanguine périopératoire a été de 2 840 mL et le remplissage vasculaire d’environ 3 000 mL. La patiente a été hydratée avec des liquides iv et traitée par des anti-inflammatoires non stéroïdiens. Ce qui a diminué les symptômes sans les éliminer. Étant donné l’aggravation des céphalées, compliquées d’inconscience, et de l’apparition de signes neurologiques le huitième jour, on a demandé un examen tomodensitométrique qui a révélé un hématome sous-dural droit. Après le drainage chirurgical, la patiente s’est bien rétablie.ConclusionCe cas rappelle que la formation d’un hématome sousdural peut compliquer la durotomie survenant pendant une opération à la colonne vertébrale. La détérioration neurologique postopératoire incite à poser rapidement le diagnostic et à intervenir en conséquence.

Preincisional intravenous pentoxifylline attenuating perioperative cytokine response, reducing morphine consumption, and improving recovery of bowel function in patients undergoing colorectal cancer surgery

Cytokine release during surgery can produce a long-lasting hyperalgesia. Thus, preoperatively-administered cytokine inhibitors might reduce the production of cytokines, decreasing central nervous system sensitization and improving the quality of postoperative pain relief. We investigated the hypothesis that preincisional IV pentoxifylline (PTX) treatment could attenuate the release of proinflammatory (tumor necrosis factor, interleukin (IL)-1&bgr;, IL-6, and IL-8) and antiinflammatory (IL-1 receptor antagonist) cytokines in patients who underwent elective colorectal cancer surgery. Forty patients were randomly assigned to 1 of 2 groups of 20 each: the PTX group received a PTX 5 mg/kg IV infusion before the induction of anesthesia, whereas the control group received an equal volume of normal saline. Venous blood samples were obtained at frequent intervals. After surgery, all patients received patient-controlled analgesia (PCA) morphine for postoperative pain relief. Patients in the PTX group exhibited longer PCA trigger times, less morphine consumption, and a faster return of bowel function compared with patients in the control group. Moreover, the plasma levels of IL-6, IL-8, and IL-1 receptor antagonist were less in the treatment group, and there was no significant difference in wound infections, tumor recurrence, or metastatic rates between groups during a 2-yr follow-up.

Neuroprotective effect of curcumin in an experimental rat model of subarachnoid hemorrhage.

BACKGROUND Subarachnoid hemorrhage (SAH) causes a high mortality rate and morbidity. It was suggested that oxidant stress plays an important role in neuronal injury after SAH. Therefore, we assessed the effect of curcumin on reducing cerebral vasospasm and neurologic injury in a SAH model in rat. METHODS A double-hemorrhage model was used to induce SAH in rats. Groups of animals were treated with intraperitoneal injection of 20 mg/kg curcumin (curcumin group, n = 24) or dimethyl sulfoxide (vehicle group, n = 33), normal saline (SAH group, n = 34) or normal saline (sham group, n = 22), 3 h after SAH induction and daily for 6 days. Glutamate was measured before SAH induction and once daily for 7 days. Glutamate transporter-1, wall thickness and the perimeter of the basilar artery, neurologic scores, neuronal degeneration, malondialdehyde, superoxide dismutase, and catalase activities were assessed. RESULTS Changes of glutamate levels were lower in the curcumin group versus the SAH and vehicle groups, especially on day 1 (56 folds attenuation vs. vehicle). Correspondingly, glutamate transporter-1 was preserved after SAH in curcumin-treated rats. In the hippocampus and the cortex, malondialdehyde was attenuated (30% and 50%, respectively). Superoxide dismutase (35% and 64%) and catalase (34% and 38%) activities were increased in the curcumin rats compared with the SAH rats. Mortality rate (relative risk: 0.59), wall thickness (30%) and perimeter (31%) of the basilar artery, neuron degeneration scores (39%), and neurologic scores (31%) were improved in curcumin-treated rats. CONCLUSIONS Curcumin in multiple doses is effective against glutamate neurotoxicity and oxidative stress and improves the mortality rate in rats with SAH.

Early use of small-dose vasopressin for unstable hemodynamics in an acute brain injury patient refractory to catecholamine treatment: a case report.

IMPLICATIONS Small-dose IV vasopressin infusion may be beneficial in acute brain injury patients with unstable hemodynamics who are refractory to fluid resuscitation and catecholamine vasopressors.

An analysis of anesthesia-controlled operating room time after propofol-based total intravenous anesthesia compared with desflurane anesthesia in ophthalmic surgery: a retrospective study.

BACKGROUND:Anesthetic techniques can contribute to reduction of anesthesia-controlled time to improve operating room (OR) efficiency. However, little is known about the difference in anesthesia-controlled time between propofol-based total IV anesthesia (TIVA) and desflurane anesthesia (DES) techniques for ophthalmic surgery under general anesthesia. METHODS:We performed a retrospective analysis using hospital databases to compare the anesthesia-controlled times of ophthalmic surgery patients receiving either TIVA via target-controlled infusion with propofol/fentanyl or desflurane/fentanyl-based anesthesia between January 2010 and December 2011. The various time intervals (surgical time, incision to surgical completion and application of dressings; anesthesia time, start of anesthesia to extubation; extubation time, surgery complete and dressings applied to extubation; time in OR, arrival in the OR to departure from the OR; postanesthetic care unit (PACU) stay time, arrival in the PACU to discharge from the PACU to the general ward; and total surgical suite time, arrival in the OR to discharge from the PACU to the general ward) that comprise a patient’s hospital stay and the incidence of postoperative nausea and vomiting were compared between the 2 anesthetic techniques. RESULTS:We included data from 1405 patients, with 595 patients receiving TIVA and 810 receiving DES. The extubation time was faster (TIVA-DES = −1.85 minutes, 99.2% confidence interval [CI], −2.47 to −1.23 minutes) and the PACU stay time was shorter (TIVA-DES = −3.62 minutes, 99.2% CI, −6.97 to −0.10 minutes) in the TIVA group than in the DES group. However, there was no significant difference in total surgical suite time between groups (TIVA-DES = −5.03 minutes, 99.2% CI, −11.75 to 1.69 minutes). We performed the random-effects analyses while stratifying for procedure and showed that the extubation time in the TIVA group was faster by 14% (99.2% CI, 9% to 19%, P < 0.0001) relative to the DES group, and the PACU stay time was faster by 5% (99.2% CI, 1% to 10%, P = 0.002). Significantly fewer patients suffered postoperative nausea and vomiting and required rescue therapy in the TIVA group than in the DES group (11.3% vs 32.2%, risk difference 21.0%, 95% CI, 16.9% to 25.1%, P < 0.001 and 23.9% vs 54.0%, risk difference 30.1%, 95% CI, 18.3% to 42.0%, P = 0.002, respectively). CONCLUSIONS:In our hospital, the use of TIVA reduced the mean time to extubation by at least 9% and PACU stay time by more than 1% when compared with the use of DES anesthesia for ophthalmic surgery.

Analgesic effects of preincisional administration of dextromethorphan and tenoxicam following laparoscopic cholecystectomy

Background:  Pre‐incisional treatment with either N‐methyl‐D‐aspartate (NMDA) receptor antagonists or non‐steroidal anti‐inflammatory drugs (NSAIDs) improves postoperative pain relief. This study examines the effect on postlaparoscopic cholecystectomy (LC) pain of a combination of dextromethorphan (DM), a NMDA‐receptor antagonist, and tenoxicam, a NSAID, given preoperatively.

Combined general-epidural anesthesia decreases the desflurane requirement for equivalent A-line ARX index in colorectal surgery

Background:  The present study used the A‐line ARX index, derived from auditory evoked potential measurements, to examine the effect of epidural lidocaine on the end‐tidal concentration of desflurane during general anesthesia.

Composite auditory evoked potential index versus bispectral index to estimate the level of sedation in paralyzed critically ill patients: a prospective observational study.

BACKGROUND: Electromyographic activity (EMG) has been reported to elevate the Bispectral Index (BIS) in patients not receiving neuromuscular blockade while under sedation in the intensive care unit (ICU). We investigated the change of the composite A-line autoregressive index (AAI) and BIS after administration of muscle relaxants in sedated surgical ICU patients. METHODS: We prospectively investigated 38 patients who required administration of a muscle relaxant while continuously sedated with midazolam hydrochloride and fentanyl citrate to achieve a Ramsay Sedation Scale value equal to 5. BIS, EMG activity of BIS (EMG-BIS), signal quality index of BIS, AAI, EMG activity of AAI (EMG-AAI), and acceleromyography at the adductor pollicis muscle were recorded simultaneously every 5 min for 30 min before and after neuromuscular blockade. Students t-test, the Wilcoxon′s signed ranks test, and the Spearman test were calculated using the standard statistics software SPSS 10.0 (SPSS Inc., Chicago, IL). RESULTS: After administration of a muscle relaxant, BIS (58.61 ± 7.45 vs 44.68 ± 6.65, P < 0.001), EMG-BIS (37.33 ± 7.15 vs 27.24 ± 1.51, P < 0.001), AAI (34.11 ± 10.96 vs 15.97 ± 6.69, P < 0.001), and EMG-AAI (59.58 ± 9.57 vs 1.00 ± 0.00, P < 0.001) decreased significantly. Significant correlations between BIS and EMG-BIS (rs = 0.75, P < 0.001) and AAI and EMG-AAI (rs = 0.87, P < 0.001) were also found during the baseline period. CONCLUSIONS: This study demonstrated that, in sedated ICU patients, BIS and AAI markedly decreased after administration of myorelaxant, and the decreased BIS and AAI values after neuromuscular blockade were correlated to those usually seen in the state of surgical anesthesia, respectively.

Preoperative cotreatment with dextromethorphan and ketorolac provides an enhancement of pain relief after laparoscopic-assisted vaginal hysterectomy.

ObjectivesBoth N-methyl-D-aspartate receptor antagonists and nonsteroidal anti-inflammatory drugs have been demonstrated to produce better postoperative pain relief. The concept of multimodal analgesia has also been used for clinical pain management. The aim of the present study was to examine the analgesic effect of preoperative cotreatment with dextromethorphan (DM) and ketorolac on postoperative pain management after laparoscopic-assisted vaginal hysterectomy (LAVH). MethodsEighty ASA physical status I or II patients scheduled for LAVH were included and randomly assigned to 1 of 4 groups. Patients received intramuscular (IM) chorpheniramine 20 mg+ intravenous (IV) 2 mL of normal saline, IM DM 40 mg+IV 2 mL of normal saline, IM chorpheniramine 20 mg+IV 60 mg (2 mL) of ketorolac, and IM DM 40 mg+IV ketorolac 60 mg as the groups C, DM, Keto, and DM+Keto, respectively. All patients were given a patient-controlled analgesia (PCA) with morphine for pain relief postoperatively. Analgesic effects were evaluated using Visual Analog Scale pain scores at rest and during coughing, time to first PCA request for pain relief, total morphine consumption, bed rest time, and the time to first passage of flatus for 48 hours after surgery. ResultsPatients in DM and Keto groups had significantly better pain relief than patients in group C. Patients in DM+Keto group exhibited the best postoperative pain relief among groups in the following several categories: time to first trigger of PCA, total morphine consumption, the worst Visual Analog Scale, bed rest time, and the time to first passage of flatus, demonstrating an enhanced effect between DM and ketorolac. Neither synergistic nor antagonistic interaction was observed between DM and ketorolac. DiscussionPreoperative treatment with both DM and ketorolac diminish postoperative pain. Our results suggest that the N-methyl-D-aspartate antagonist-DM and the nonsteroidal anti-inflammatory drugs-ketorolac cotreatment provide an enhancement of analgesia for postoperative pain management in patients after LAVH surgery.