David Vi Lu

Soft catheters reduce the risk of intravascular cannulation during epidural block—A retrospective analysis of 1117 cases in a medical center

A wet or bloody tap is an inevitable complication while performing epidural block. The influence of different catheters on the incidence of intravascular cannulation during epidural catheterization has not been reported. We observed an initial, relatively different incidence of intravascular cannulation during the placement of different sorts of epidural catheter; hence, a retrospective review was conducted to explore the possible association. We reviewed 1‐year interval anesthetic records of 1117 patients who had undergone epidural anesthesia or received patient‐controlled epidural analgesia. Epidural catheter placement was performed by a loss of resistance technique with an 18‐G Tuohy needle in lateral position. Patients were divided into two groups according to the different types of epidural catheters used (Perifix One, n = 590; Perifix Standard, n = 527). Primary outcome measurement was the incidence of intravascular injection. Other analyzed outcomes included dura puncture, failure rate, and low back pain. The incidence of epiduralintravascular cannulation was significantly lower using the Perifix One catheter (1.5%; 9/590) than using the Perifix Standard (4.6%; 24/527), p = 0.003. The dura puncture rate did not differ significantly between the Perifix One (1.9%; 11/590) and the Perifix Standard (2.5%; 13/527), p = 0.49. Failure rates and low back pain incidence were also comparable between the two groups. Application of the soft epidural catheter (Perifix One) may reduce the incidence of epidural intravascular cannulation. We suggest the use of Perifix One catheter instead of Perifix Standard catheter in daily practice.

Seizure after local anesthesia for nasopharyngeal angiofibroma.

We report a young male patient who experienced seizure after local injection of 3 mL 2% lidocaine with epinephrine 1:200,000 around a recurrent nasal angiofibroma. After receiving 100% oxygen via mask and thiamylal sodium, the patient had no residual neurologic sequelae. Seizure immediately following the injection of local anesthetics in the nasal cavity is probably due to injection into venous or arterial circulation with retrograde flow to the brain circulation. Further imaging study or angiography should be done before head and neck surgeries, especially in such highly vascular neoplasm.

Propofol target-controlled infusion for sedated gastrointestinal endoscopy: A comparison of propofol alone versus propofol–fentanyl–midazolam

Gastrointestinal (GI) endoscopy is the major technique for diagnosis of GI disease and treatment. Various sedation and analgesia regimens such as midazolam, fentanyl, and propofol can be used during GI endoscopy. The purpose of the study was to compare propofol alone and propofol combination with midazolam and fentanyl in moderate sedation for GI endoscopy. One hundred patients undergoing GI endoscopy were enrolled in this study. All patients received a propofol target‐controlled infusion (TCI) to maintain sedation during the procedure. Patients were randomly allocated into either Group P (propofol TCI alone) or Group C (combination of propofol TCI plus midazolam and fentanyl). Dermographic data, anesthetic parameters (sedation regimen, blood pressure, heart rate, and oxygen saturation), procedure parameters (procedure time, colonoscopy, or panendoscopy), propofol consumption, and adverse events (hypoxia, hypotension, and bradycardia) were all recorded. Postprocedural records included recovery time, postoperative adverse events (nausea, vomiting, dizziness, recall, and pain) and satisfaction. The average propofol consumption was 251 ± 83 mg in Group P and 159 ± 73 mg in Group C (p < 0.001). The incidence of transient hypotension was higher in Group P (p = 0.009). The recovery time and discharge time were both shorter in Group C (p < 0.001 and p = 0.006 respectively). Overall, postprocedural adverse events were similar in both groups. The postanesthetic satisfaction was comparable in both groups. TCI of propofol combined with midazolam and fentanyl achieved sedation with fewer hypotension episodes and shorter recovery and discharge time than propofol TCI alone in patients undergoing GI endoscopy.

Accuracy of the Central Landmark for Catheterization of the Right Internal Jugular Vein After Placement of the ProSeal™ Laryngeal Mask Airway

OBJECTIVE Catheterization of the internal jugular vein (IJV) after placement of a laryngeal mask airway (LMA) has been reported to be difficult. The purpose of this study was to evaluate the accuracy of the central landmark for catheterization of the right IJV after placement of a ProSeal LMA. METHODS We enrolled 80 patients (30 men and 50 women) who were scheduled to undergo surgery under general anesthesia conveyed by a size 3 ProSeal LMA. A needle pathway based on the central landmark for right IJV catheterization was simulated. Ultrasound images were obtained, which we contrasted with the simulated pathway to evaluate whether the landmark accuracy remained unchanged after placement of the ProSeal LMA. Both frequency of simulated right carotid artery (CA) puncture and overlap between the right IJV and right CA were also investigated. RESULTS The simulated needle pathway ran along the course of the right IJV in 60% (48/80) of subjects, and transected the CA in 31.3% (25/80) of subjects. Both events together occurred in 20% (16/80) of subjects. The central landmark had a medial bias of 6.8 mm (95% confidence interval, 5.3-8.4). In 83.8% (67/80) of subjects, the center of the right IJV was lateral to the central landmark. The possibility of overlap of the right IJV and CA was high after ProSeal LMA placement. CONCLUSION After placement of the ProSeal LMA, the central landmark could not offer a good success rate at the first puncture attempt. When using the central landmark to catheterize the IJV after a ProSeal LMA placement, medial deviation of the central landmark should be considered. Ultrasound guidance may be helpful in difficult cases.

Successful difficult airway management for a rare case of iatrogenic tracheal foreign body

To the Editor: Use of the Aintree Intubation Catheter (AIC; Cook Medical, Bloomington, IN, USA) as an airway exchange catheter to facilitate intubation through the Laryngeal Mask Airway has been reported [1,2]. A case of an iatrogenic tracheal foreign body resulting from a broken AIC during tracheal intubation via a classical Laryngeal Mask Airway (cLMA) is presented. A 57-year-old man who had received cervical spine (C3-C4) surgery 4 months previously was scheduled for elective hemithyroidectomy. Upper airway examination showed severe limitation of cervical spine motion, a Mallampati airway score of 3, and limited mouth opening. We planned to achieve tracheal intubation with a lightwand as there was no difficulty in ventilation. For induction of anesthesia, the patient received fentanyl 100 μg, thiamylal 250 mg, and rocuronium 30 mg. We failed with the lightwand on the first attempt, and a cLMA was inserted smoothly and immediately to provide adequate ventilation. The AIC was loaded over the fiberoptic bronchoscope and then passed through the cLMA into the trachea. After confirmation of tracheal placement with the fiberscope, the fiberscope and LMA were removed, leaving the AIC at the 34 cm mark at the mouth angle. A 7.5-mm Parker endotracheal tube (ETT; Parker Medical, Highlands Ranch, CO, USA) was then introduced over the AIC. Unfortunately, the AIC broke at the level of mouth angle and was left in the trachea (Fig. 1). The patient regained spontaneous breathing at this time and 3.0 L/min of oxygen was administered by nasal cannula. We tried to extract the AIC by endoscope, but we failed due to the slippery surface of the sheared AIC. Ventilation was maintained again by cLMA. A surgical airway (tracheostomy) was established to remove the AIC. Following removal, retrograde insertion of a 16-French nasogastric tube was performed through the orifice of the tracheostomy to the oral cavity. The nasogastric tube served as an introducer and guided the ETT into the trachea. The operation progressed smoothly and the patient was discharged uneventfully. The cLMA is one of the airway devices to use in cannotintubate situations, according to the ASA [3], and there are many methods to intubate a trachea with an ETT through a LMA; using an AIC is one of them. In our case, the fixed cervical spine may have contributed to the breakage of the AIC, with poor alignment of the pharyngeal axis, with the laryngeal axis leading to kinking and entrapment, hence, inducing excessive twisting force [4]. To reduce kinking, external laryngeal manipulation is suggested with concomitant use of a direct or indirect laryngoscope [5]. Application of AIC in tracheal intubation via cLMA is feasible but we should be cautious about the fragility of the materials. Breakage of a reusable bougie has been reported [6], and our AIC had been used once before.

Nalbuphine in Low Dose for the Prevention of Surgical Pain in Pediatric Population

The purpose was to determine whether nalbuphine in low dose intravenous injection discontinued before the end of surgery provided well pain control and low complication rate in children undergoing minor surgery. Method: We conducted a retrospective patient chart review between January 2006 and June 2006. Eighty ASA class I-IT patients, aged from 2-10 yr were included. Anesthetic records and charts were reviewed to assess differences in 2 groups of patients: those who received preventive low dose of nalbuphine (0.1mg/kg) and those who did not till awake or OPS＞5. We assessed emergence time, highest pain score and complications. Main Results: Seventy-eight children completed the smdy. Two patients were excluded. The highest pain score was statistically significantly different between the two group, 1.50±2.26 in group N Vs 6.13±2.48 in group S (P＜0.05). Postoperative adverse effects such as delay discharge from PACU or postoperative nausea and vomiting were no significant difference. Conclusion: Our results show that in children undergoing elective minor surgery, the concurrent use of nalbuphine (0.1mg/kg) significantly reduces the pain scores without prolonging the time to discharge in this retrospective review.