Hung-Te Hsu

Comparison of the GlideScope® videolaryngoscope and the Macintosh laryngoscope for double‐lumen tube intubation

Intubation with a double‐lumen tube is important for achieving one‐lung ventilation and facilitating thoracic surgery. The GlideScope® videolaryngoscope (Verathon Inc., Bothell, WA, USA) is designed to assist tracheal intubation for patients with a difficult airway. We wished to compare the GlideScope and direct laryngoscopy for double‐lumen tube intubation. Sixty adult patients requiring a double‐lumen tube for thoracic surgery and predicted uncomplicated laryngoscopy were randomly assigned to a direct Macintosh laryngoscopy group (n = 30) or a GlideScope group (n = 30). The mean (SD) duration of intubation was longer in the Macintosh group (62.5 (29.7) s) than in the GlideScope group (45.6 (10.7) s; p = 0.007). There was no difference in the success of the first attempt at intubation (26/30 (87%) and 30/30 (100%) for Macintosh and GlideScope groups, respectively; p = 0.112). The incidence of sore throat and hoarseness was higher in the Macintosh group (18 (60%) and 14 (47%), respectively) than in the GlideScope group (6 (20%) and 4 (13%), respectively; p = 0.003 and 0.004). We conclude that double‐lumen tube intubation in patients with predicted normal laryngoscopy is easier using the GlideScope videolaryngoscope than the Macintosh laryngoscope.

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.

Neuroprotective Effects of San-Huang-Xie-Xin-Tang in the MPP(+)/MPTP Models of Parkinson's Disease In Vitro and In Vivo.

San-Huang-Xie-Xin-Tang (SHXT), composed of Coptidis rhizoma, Scutellariae radix, and Rhei rhizoma, is a traditional Chinese medicine used for complementary and alternative therapy of cardiovascular and neurodegenerative diseases via its anti-inflammatory and antioxidative effects. The aim of this study is to investigate the protective effects of SHXT in the 1–methyl–4–phenylpyridinium (MPP+)/1–methyl–4–phenyl–1,2,3,6–tetrahydropyridine (MPTP) models of Parkinsons disease. Rat primary mesencephalic neurons and mouse Parkinson disease model were used in this study. Oxidative stress was induced by MPP+ in vitro and MPTP in vivo. In MPP+-treated mesencephalic neuron cultures, SHXT significantly increased the numbers of TH-positive neurons. SHXT reduced apoptotic signals (cytochrome and caspase) and apoptotic death. MPP+-induced gp91phox activation and ROS production were attenuated by SHXT. In addition, SHXT increased the levels of GSH and SOD in MPP+-treated neurons. In MPTP animal model, SHXT markedly increased TH-positive neurons in the substantia nigra pars compacta (SNpc) and improved motor activity of mice. In conclusion, the present results reveal the evidence that SHXT possesses beneficial protection against MPTP-induced neurotoxicity in this model of Parkinsons disease via its antioxidative and antiapoptotic effects. SHXT might be a potentially alternative and complementary medicine for neuroprotection.

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.

Propofol Attenuates Lipopolysaccharide-Induced Reactive Oxygen Species Production Through Activation of Nrf2/GSH and Suppression of NADPH Oxidase in Human Alveolar Epithelial Cells

Propofol is a widely used intravenous anesthetic. The aim of this study was to investigate the roles of nuclear factor erythroid-2-related factor 2 (Nrf2) and NADPH oxidase (NOX) in propofol protection in inflammatory conditions induced by lipopolysaccharide (LPS). Human alveolar epithelial cells (A549 cell line) were incubated with propofol (10, 25, and 50 μmol/L) for 1 h and then treated with LPS (100 ng/mL) for 24 h. Results indicated that propofol not only attenuated LPS-induced expression of iNOS, NOX, and COX2, but decreased the production of ROS, NO, and PGE2 as well. Propofol also increased the GSH levels and the mRNA and protein levels of Nrf2. Notably, Nrf2 siRNA and the inhibitors of COX-2 and NOX attenuated the inhibition of propofol on ROS production. In conclusion, propofol reduced LPS-induced ROS production via inhibition of inflammatory factors and enhancement of Nrf2-related antioxidant defense, providing its cytoprotective evidence under inflammatory conditions.

Left endobronchial intubation with a double‐lumen tube using direct laryngoscopy or the Trachway® video stylet

We compared direct laryngoscopy with a Macintosh blade vs indirect bronchoscopy with a Trachway® stylet, for endobronchial intubation with a left‐sided double‐lumen tube. We allocated participants scheduled for thoracic surgery and who had normal predicted laryngoscopy, 30 to each group. The mean (SD) intubation times with laryngoscope and Trachway were 48 (11) s vs 28 (4) s, respectively, p < 0.001. The rates of hoarseness on the first postoperative day, categorised as none/mild/moderate/severe, were 10/12/7/1 and 22/6/2/0, respectively, p = 0.008, without differences on subsequent days. Left endobronchial intubation with a double‐lumen tube is slower using direct laryngoscopy and causes more hoarseness than indirect bronchoscopy with a Trachway stylet.

A comparison between succinylcholine and rocuronium on the recovery profile of the laryngeal muscles during intraoperative neuromonitoring of the recurrent laryngeal nerve: a prospective porcine model.

The use of succinylcholine and rocuronium are reportedly feasible during intraoperative neuromonitoring (IONM) of the recurrent laryngeal nerve (RLN) in thyroid surgery. This study aimed to investigate and compare the recovery profiles of succinylcholine and rocuronium on the laryngeal muscle during IONM of the RLN in a porcine model. Nine male Duroc‐Landrace piglets were anesthetized with thiamylal and underwent tracheal intubation without neuromuscular blocking agents (NMBAs). Needle electrodes were inserted into the vocalis muscles through the cricothyroid ligament. The RLN was exposed and stimulated. Electromyographic (EMG) signals were obtained before and after the intravenous administration of a NMBA. The EMG amplitudes were measured before and after (at 1‐minute intervals) the administration of the study drug until complete recovery. The study NMBA regimen included succinylcholine (1 mg/kg), low‐dose rocuronium (0.3 mg/kg), and standard dose rocuronium (0.6 mg/kg). The maximal neuromuscular blockade and 80% recovery (i.e., duration) of the control responses were recorded and analyzed. The 80% recovery of the control response for succinylcholine (1 mg/kg) was 19.7 ± 1.5 minutes; low‐dose rocuronium (0.3 mg/kg), 16.3 ± 2.5 minutes; and standard dose rocuronium (0.6 mg/kg), 29.3 ± 5.7 minutes. Succinylcholine (1 mg/kg) and low‐dose rocuronium (0.3 mg/kg) had significantly shorter durations than standard dose rocuronium (0.6 mg/kg). The EMG signal recovery returned to baseline within 30 minutes in the succinylcholine and low‐dose rocuronium groups, but it did not return to baseline until 1 hour after surgery in the rocuronium (0.6 mg/kg) group. In this study, succinylcholine (1 mg/kg) and low‐dose rocuronium (0.3 mg/kg) had favorable recovery profiles on the laryngeal muscle. It is recommended that low‐dose rocuronium may replace succinylcholine for the induction of general anesthesia during IONM of the RLN in thyroid surgery.

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.

Techniques for the insertion of the proseal laryngeal mask airway: comparison of the foley airway stylet tool with the introducer tool in a prospective, randomized study

BackgroundMany tools have been developed to facilitate the insertion of the ProSeal laryngeal mask airway (LMA) insertion, which can be impeded by folding of its soft cuff. The aim of this study was to compare the efficiency of ProSeal LMA insertion guided by a soft, direct optical Foley Airway Stylet Tool (FAST) with the standard introducer tool (IT).MethodsOne hundred sixty patients undergoing general anesthesia using the ProSeal LMA as an airway management device were randomly allocated to either FAST-guided or IT-assisted groups. Following ProSeal LMA insertion, the glottic and esophageal openings were identified using a fiberoptic bronchoscope introduced through the airway and the drain tube. The primary outcomes were time taken to insert the ProSeal LMA and the success rate at the first attempt. Secondary end points included ease of insertion, hemodynamic response to insertion, and postoperative adverse events recorded in the recovery room and on the first postoperative morning.ResultsOne hundred forty patients were included in the final analysis: 66 in the FAST-guided group and 74 in the IT-assisted group. The success rate of FAST device-guided ProSeal LMA insertion (95.7%) was broadly comparable with IT-assisted insertion (98.7%). However, the time taken to insert the ProSeal LMA was significantly longer when the FAST technique was used (p <0.001). The incidence of correct alignment of the airway tube and the drain tube did not differ significantly between the groups. There were no significant differences in ease of insertion or hemodynamic responses to insertion, except that the incidence of postoperative sore throat was significantly higher in the FAST group on the first postoperative day (22.2% compared with 6.8% in the IT group; p =0.035).ConclusionBoth FAST-guided and IT-assisted techniques achieved correct ProSeal LMA positioning, but the IT technique was significantly quicker and less likely to cause a sore throat.Trial registrationClinicalTrials.gov Identifier: NCT02048657

Quality improvement program reduces perioperative dental injuries – A review of 64,718 anesthetic patients

Background Perioperative dental injury (PDI) is a common adverse event associated with anesthesia that can easily lead to medicolegal litigation. A quality improvement program was conducted with the electronic, standardized dental chart to document dentition before anesthesia and dentist consultation when necessary. This study aimed to reduce PDIs through execution of a quality improvement program. Methods We reviewed the 42‐month interval anesthetic records of 64,718 patients who underwent anesthesia. A standardized electronic dental chart was designed to identify any dental prosthetics, fixed and removable dentures, and degree of loose teeth. The incidence of dental injuries associated with anesthesia was separated into three time periods: baseline, initiative (Phase I), and execution (Phase II). Primary outcome measurement was the incidence of PDIs related to anesthesia. Results The overall incidence of dental injury related to anesthesia was 0.059% (38/64,718 patients). During the baseline period, the dental injury rate was 0.108% (26/24,137 patients), and it decreased from 0.051% in the initiative period (10/19,711 patients) to 0.009% in the execution period (2/20,870 patients) during implementation of the quality improvement program. Most dental injuries were associated with laryngeal mask airway (42.1%) and laryngoscopy (28.9%). The most commonly involved teeth were the upper incisors. Conclusion Dental injury incidence was significantly reduced and remained at low levels after implementation of the quality improvement program. We suggest the implementation of a standardized dental examination into the preoperative evaluation system adding pathologic teeth fixed or protected devices to minimize dental injury associated with anesthesia.