Helmut Galligioni

The effects of acupuncture after thyroid surgery: A randomized, controlled trial.

BACKGROUND Acupuncture is a safe and well-tolerated treatment for pain relief. Previous studies supported the effectiveness of several acupuncture techniques for postoperative pain. The aim of this randomized, controlled trial was to evaluate the efficacy of acupuncture in reducing pain after thyroid surgery. METHODS We randomized 121 patients to a control group (undergoing only standard postoperative analgesic treatment with acetaminophen) and an acupuncture group, undergoing also either electroacupuncture (EA) or traditional acupuncture (TA). Pain was measured according to intraoperative remifentanil use, acetaminophen daily intake, Numeric Rating Scale (NRS), and McGill Pain Questionnaire on postoperative days (POD) 1-3. RESULTS Acupuncture group required less acetaminophen than controls at POD 2 (P = .01) and 3 (P = .016). EA patients required less remifentanil (P = .032) and acetaminophen than controls at POD 2 (P = .004) and 3 (P = .008). EA patients showed a trend toward better NRS and McGill scores from POD 1 to 3 compared with controls. EA patients had a lower remifentanil requirement and better NRS and McGill scores than TA patients. No differences occurred between TA patients and controls. CONCLUSION Acupuncture may be effective in reducing pain after thyroid surgery. EA is more useful; TA achieves no significant effects.

Unusual Displacement of a Mobilised Dental Bridge during Orotracheal Intubation

Dental trauma during tracheal intubation mostly happens in case of poor dentition, restricted mouth opening, and/or difficult laryngoscopy. 57-year-old man undergoing laparoscopic radiofrequency ablation of unresectable hepatocellular carcinoma had his dental work detached at induction of anesthesia. Oropharyngeal direct view, manual inspection, fibreoptic nosendoscopy, tracheobronchoscopy, and fiberoptic inspection of the esophagus and stomach were unsuccessful in locating the dislodged bridge. While other possible exams were considered, such as lateral and AP x-ray of head and neck, further meticulous manual “sweepings” of the mouth were performed, and by moving the first and second fingers below the soft palate deep towards the posterolateral wall of the pharynx, feeling consistent with a dental prosthesis was detected in the right pharyngeal recess. Only after pulling the palatopharyngeal arch upward was it possible to grasp it and extract it out with the aid of a Magill Catheter Forceps. Even though the preexisting root and bridge deficits were well reported by the consultant dentist, the patient was fully reimbursed. The lack of appropriate documentation of the advanced periodontal disease in the anesthesia records, no mention of potential risks on anesthesia consent, and insufficient protective measures during airway instrumentation reinforced the reimbursement claim.

The perils of dental vacation: possible anaesthetic and medicolegal consequences

Introduction The aim of this paper is to emphasize anaesthesiologists’ difficulty in detecting poor dentition in cases of poorly applied prostheses and/or advanced periodontal disease, and to establish whether it is possible, and in which conditions, to calculate compensation in cases of dental damage postlaryngoscopy and/or intubation. The main complex problem here lies in trying to reconstruct exactly what the dental situation was before the teeth were damaged. For this reason the important preoperative factors (dental prostheses, crown fractures, parodontal disease, etc.) must be clearly shown before surgery on a dental chart. Clinical cases Two cases of interest, both to anaesthesiologists practising intubation and medicolegal physicians who have to deal with potential claims, are briefly reported. The first patient was a 55-year-old diabetic patient, who underwent emergency surgery for acute abdominal pathology. He had gone outside Italy for dental treatment three years previously and now presented with very poor pre-existing dentition, carefully noted on an anaesthetic chart. He now demanded compensation for dental damage due to intubation in Italy; the resulting dental treatment was very expensive because substantial remedial work was required. The second patient had received treatment outside Italy, work which involved cosmetic coating of the teeth. After surgery in Italy, she demanded compensation because one tooth, which had been coated and appeared to be healthy, was broken after emergency intubation. In both cases, the patients demanded very high compensation. Comment Dental tourism alone accounts for more than 250,000 patients each year who combine a holiday with dental treatment in Eastern Europe. However, if prosthetic devices or conservative treatments are not applied correctly, it should be noted that durability may be poorer than expected, but iatrogenic damage may also be caused.

Subclavian oblique-axis catheterization technique

We read with interest the work by Saugel et al. [1] about ultrasound-guided central venous catheter placement. In their work the authors accurately describe “in-plane” and “out of plane” techniques for central venous catheter access. However, they describe only briefly the oblique-axis technique and for this approach only articles about internal venous jugular catheterization are cited [2, 3] and nothing in the literature about the oblique axis for subclavian access could be found. In our experience we make regular use of the obliqueaxis technique for placing subclavian catheters with a high success rate and a low rate of complications. An important aspect for a successful procedure is patient positioning; in fact, the best visualization of the subclavian vein and artery is, in our experience, possible with a 90° abduction of the arm. After aseptic preparation the ultrasound probe is covered with a protective plastic sheath. Ultrasound inspection is started laterally near the axilla to identify the axillary vein and artery in a classic “out of plane” view, after which the vessels are followed until the joint point of the axillary vein with the cephalic vein (Fig. 1): this is the anatomic subclavian starting point. After a 45° rotation of the probe an oblique view is then possible (Fig. 2). It is an easy method with great advantages in comparison with “in-plane” and “out of plane” views because it permits both visualization of the tip of the needle and important anatomical structures such as the artery or vein (both with an oval shape due to projection) and, moreover, sliding of the lung.