Fu-Yuan Wang

The effectiveness of dexmedetomidine infusion for sedating oral cancer patients undergoing awake fibreoptic nasal intubation.

Background and objective Dexmedetomidine is characterized with effects of sedation, analgesia, amnesia and lack of respiratory depression. Hence, it should be suitable for awake fibreoptic intubation (AFOI). Methods We enrolled 30 oral cancer patients with limited mouth openings who were undergoing AFOI for elective surgery. Patients were randomly allocated into two groups; the Dex group (n = 16) that received dexmedetomidine (1.0 μg kg−1) infusion and the Control group (n = 14) that received fentanyl (1.0 μg kg−1) infusion. Main outcomes were evaluated by grading scores presenting conditions for nasal intubation and postintubation. Other analysed parameters included airway obstruction, haemodynamic changes, consumption time for intubation, amnesia level and satisfaction. Results Intubation score (1–5) representing condition for nasal intubation was significantly better in the Dex group [2(1–3)] than in the Control group [3(2–5)] (P = 0.001). Postintubation score (1–3) representing tolerance to intubation also showed more favourable results in the Dex group [1(1–3)] than in the Control group [2(2–3)] (P = 0.002). The Dex group showed significantly reduced haemodynamic response to intubation than the Control group. Incidence requiring temporary haemodynamic support was higher in the Dex group but not of significance. Both levels of amnesia and satisfaction score were significant in the Dex group. Other analysed parameters such as consumption time for intubation, airway obstruction score and postoperative adverse events did not differ significantly. Conclusion Combination of dexmedetomidine loading with topical anaesthesia provides significant benefit for AFOI in intubation condition, patient tolerance, haemodynamic response, amnesia and satisfaction. Dexmedetomidine is effective for AFOI in anticipated difficult airway with only minor and temporary haemodynamic adverse effects.

Electromyographic endotracheal tube placement during thyroid surgery in neuromonitoring of recurrent laryngeal nerve

Intraoperative neuromonitoring (IONM) is widely used in thyroid surgery. This study aimed to investigate the influence of neck extension on electromyographic (EMG) endotracheal tube displacement and to determine the necessity of routinely checking the final electrode position after the patient had been fully positioned. A consecutive 220 patients undergoing thyroidectomy were enrolled. All patients were intubated with the EMG endotracheal tube under direct laryngoscopy. The electrode position and tube displacement were routinely checked and measured by laryngofiberoscopy before and after patient positioning. The patients were divided into two groups. In Group I (n = 110), the EMG tube was taped and fixed to the right mouth angle before full neck extension. In Group II (n = 110), the EMG tube was disconnected from the circuit tube and was not taped until full neck extension. In all patients, we ensured that the final electrode position was the optimal position with laryngofiberoscopic examination. The tube displacement after neck extension ranged from 16 mm upward to 4 mm downward in Group I and from 12 mm upward to 5 mm downward in Group II. The rate of tube displacement greater than 10 mm was 12.7% in Group I and 3.6% in Group II. Successful monitoring was achieved in all patients after the final optimal position of electrodes was ensured routinely. The electrode position can be severely displaced after the patient has been fully positioned. Verification of ideal position of electrodes before the beginning of the operation is a necessary step to guarantee functional intraoperative neuromonitoring.

Lateral Rotation of the Lower Extremity Increases the Distance Between the Femoral Nerve and Femoral Artery: An Ultrasonographic Study

Femoral nerve block (FNB) is by far the most useful lower extremity regional anesthetic technique for the anesthesiologist, and high‐resolution ulrrasonography is a useful tool with which to guide the performance of FNB. However, the relationships between the femoral nerve and the femoral artery in different lower extremity positions have rarely been discussed. The purpose of this study was to evaluate the relative positions of the femoral nerve and artery at different lateral rotational angles of the lower extremities using ultrasonographic imaging. We enrolled 41 healthy volunteers in this study Two‐dimensional ultrasonographic images of the femoral nerve were obtained using an ultrasound unit, in the inguinal crease, for four positions of the bilateral lower extremities: 0°, 15°, 30° and 45° lateral rotation of each extremity. The following assessments were made in each position: minimal skin‐to‐nerve distance (SN) and deviation of nerve‐to‐landmark (femoral artery pulsation) horizontal distance (NF). A trend towards lateral rotation of both lower extremities was identified. The Pearson correlation values between rotational degree to SN and rotational degree to NF were −0.216 and 0.430, with p values of 0.001 and less than 0.001, respectively. Body mass index had a good correlation (r=0.76‐0.78) with SN. The results of our ultrasound study revealed that the more lateral the rotation of both lower extremities, the closer the femoral nerve was to the skin and the farther away it was from the femoral artery. In order to increase the success rate and decrease the rate of complications, a suggested lateral 45° rotation of both lower extremities is strongly recommended when performing FNB using the peripheral nerve stimulator technique or the field block technique. In any situation, individual ultrasound guidance is recommended for FNB whenever possible.

Spinal Process Landmark as a Predicting Factor for Difficult Epidural Block: A Prospective Study in Taiwanese Patients

Although epidural anesthesia is a common practice in neuraxial blockade, difficult access to the epidural space is a frequent problem in operating theaters. We designed this study of epidural blocks to determine if the spinal landmark grading system is valuable in predicting a difficult epidural block. Before the epidural block, we collected the following data: demographics, body habitus (normal, thin, obese, pregnant), spinal anatomy (normal, deformed), spinal level (lumbar, thoracic), and spinal landmark grade (grade 1: spinous processes visible; grade 2: spinous processes not seen but easily palpated; grade 3: spinous processes not seen and not palpated but the interval between them is palpated as a low landmark under the thumb; grade 4: other). We performed all 848 epidural blocks initially using a midline approach and an 18‐gauge Touhy needle. We evaluated the technical difficulty of the epidural block using three methods: whether the epidural block was accomplished at the spinal level (first‐level success); the total number of attempts at skin puncture (attempts‐S); and total number of attempts to change ligament puncture direction (attempts‐L) required to complete the epidural block. Of all examined factors, spinal landmark grade correlated best with technical difficulty as measured by all three methods. Deformed spinal anatomy and body habitus both correlated with difficulty, merely from the total numbers of attempts (attempts‐S and attempts‐L). Thoracic epidurals were more difficult than lumbar epidurals by all three measures of difficulty. We concluded that this spinal landmark grading system is valuable in predicting a difficult epidural block and advocate its use as a predictor by anesthesiologists.

Premolar loss following insertion of a Classic Laryngeal Mask Airway in a patient in the prone position

increase the risk of bleeding complications if they are added to antiplatelet medication. Moreover, multiple antiplatelet medications are a risk for bleeding complication, as was noted in the case report of hematoma formation in a patient receiving three antiplatelet drugs [4]. On the other hand, the fact is that there are differences in the effects on platelet function according to type of antiplatelet medication given. For example, cyclooxygenase-2 inhibitors have minimal effect on platelet function. Our second patient received antiplatelet therapy using aspirin and cilostazol, which is a phosphodiesterase inhibitor (PDEI). Unfortunately, the effect of PDEI combined with a cyclooxygenase inhibitor, or even the effect of PDEI alone on the risk of bleeding, is not stated in the guidelines. Therefore, we precluded neuraxial blockage for anesthetic management. Details regarding risk for bleeding complications and indications in patients receiving deep plexus/peripheral techniques were not provided in the old guidelines [2]. We considered these techniques as one of the choices for anesthetic management but we decided not to use them. Deep plexus/peripheral techniques should be managed in similar fashion to neuraxial techniques, according to the new guidelines [3]. If the new guidelines had been published before our second case, one of our unresolved questions would have been answered.

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.

Equal volumes of undiluted nalbuphine and lidocaine and normal diluted saline prevents nalbuphine-induced injection pain

OBJECTIVES To determine if the intravenous co-administration of equal volumes of lidocaine and nalbuphine, with undiluted normal saline, prevents injection pain caused by nalbuphine. METHODS Eighty adult patients who were scheduled for minor surgeries under general anesthesia delivered via a laryngeal mask airway (LMA) were enrolled in this prospective, randomized, single-blind clinical trial. In the saline group (control) (n = 40), 1 mL (10 mg) nalbuphine was diluted with 9 mL normal saline. In the lidocaine group (experimental) (n = 40), 1 mL (10 mg) nalbuphine was diluted with 1 mL lidocaine (20 mg). The two respective nalbuphine solutions were injected into the cephalic vein at a rate of 20 mL/minute (0.33 mL/second). Pain scores were categorized into five grades. Pain responses upon intravenous injection of nalbuphine, site of cannulation, size of the catheter, and hemodynamic responses to nalbuphine were also recorded. RESULTS Overall, the median pain score of patients in the lidocaine group was lower than that of the saline group (p < 0.001). In addition, the incidence of injection pain was lower in the lidocaine group than the saline group (2.5% vs. 30%, p = 0.001). CONCLUSION A solution of equal volumes of lidocaine and nalbuphine can decrease intravenous nalbuphine-induced injection pain.

Application of a Double-lumen Tube for One-lung Ventilation in Patients With Anticipated Difficult Airway

One-lung ventilation (OLV) is essential in some surgical situations. The use of double- lumen tubes (DLTs) can achieve OLV more quickly and more easily than bronchial blockers. The management of a difficult airway is a challenge for anesthesiologists when, at the same time, OLV is needed for a surgical procedure. This report describes the successful application of DLTs in two patients with difficult airways, and who were scheduled for pulmonary decortication. Case 1 already had a permanent tracheostomy, while Case 2 had oral cancer with an extremely limited mouth opening and needed elective tracheostomy for anesthesia. Nasal intubation of Case 2 was done with fiberoptic-guided intubation with the patient awake. OLV was achieved uneventfully after inserting the DLT directly through the tracheostomy in both cases. We also describe the appropriate use of airway devices for OLV, focusing on patients with an anticipated difficult airway.

INTRAVENOUS THIAMYLAL AND LOCAL ANESTHETIC INFILTRATION FOR PEDIATRIC FACIAL REPAIR PROCEDURES PERFORMED IN EMERGENCY DEPARTMENTS

Thiamylal is widely used for procedural sedation in emergency departments (ED); however, there are limited safety data for doses of thiamylal > 5 mg/kg in children. We investigated whether intravenous thiamylal in combination with local anesthetics is safe and effective for pediatric procedural sedation in the ED and to identify the association between increasing doses thiamylal and adverse events. Between July 2004 and June 2008, 227 children who underwent procedural sedation met the inclusion criteria, including 105 males (46.3%) and 122 females (53.7%). Facial laceration was the most common indication for procedural sedation. All children received an intravenous injection of thiamylal, with a loading dose of 5 mg/kg. Eighty‐one children (35.7%) received a supplemental dose of 2.5 mg/kg thiamylal because of inadequate sedation. Of these, 27 (11.9%) received a second supplemental dose of 2.5 mg/kg because of inadequate sedation. Sixty‐six patients (29.1%) experienced 75 mild and self‐resolving adverse events, and most of which (15/75; 20%) were drowsiness. Four (1.8%) patients experienced oxygen saturation below 96%, which was related to the supplemental dose of thiamylal (p = 0.002). No children suffered from any lasting or potentially serious complications. Our results indicate that intravenous thiamylal in combination with local anesthetic infiltration is a well tolerated for therapeutic procedures in the ED. Thiamylal offers rapid onset of sedation without compromising the patients cardiorespiratory function during pediatric procedural sedation.

A pitfall of traumatic injury from a motorcycle crash: a case report.

Wearing a crash helmet when riding a motorcycle is strongly suggested and regulated to prevent casualties in traffic accidents. This article reports the case of a 22-year-old male patient sent to the emergency department by ambulance because of a motorcycle crash. The case presents an exceptional situation of airway compression and dysphonia caused by the strap of a crash helmet. This case is different from those seen in whiplash trauma, where laryngeal ruptures are often caused by vertical traction on the larynx and rupture of thyroid cartilage, which results in hemorrhage and causes death by suffocation. The authors emphasize that public education on wearing a helmet correctly is important to prevent neck injuries. The strap of a helmet should be fixed firmly at the chin instead of around the neck, to prevent neck injuries. Physicians in the emergency department should be alerted to the possibilities of suffocation from injuries of the thyroid cartilage in trauma patients with general and otolaryngological findings. Early detection, conservative therapy, and close monitoring of the patients are crucial to prevent fatal complications.