I-Chen Lu

Haloperidol Plus Ondansetron Prevents Postoperative Nausea and Vomiting in Patients Undergoing Laparoscopic Cholecystectomy

BACKGROUND A combination of antiemetic drugs could be an effective method to prevent severe postoperative nausea and vomiting (PONV). Therefore, we examined the prophylactic effect of haloperidol plus ondansetron on PONV. METHODS We enrolled 210 patients (n = 70 in each of 3 groups) undergoing elective laparoscopic cholecystectomy for this randomized double-blind study. Patients were randomized to intravenous saline 2 mL and intramuscular haloperidol 2 mg (Group H), intravenous ondansetron 4 mg and intramuscular saline 2 mL (Group O), or intravenous ondansetron 4 mg and intramuscular haloperidol 2 mg (Group H+O), administered after induction of general anesthesia and 30 minutes before the conclusion of surgery. We compared the complete response rates, incidence of PONV, nausea scores, the need for rescue medication, patient satisfaction scores, and adverse events during the 24-hour study. RESULTS The H+O group had the highest complete response rate to treatment (79%) compared with group H (61%) and group O (62%) (p < 0.05 for both). Patient satisfaction scores were significantly higher in the H+O group (8.3 +/- 1.8) than in the H (7.0 +/- 2.4) and O (7.2 +/- 2.5) groups (p < 0.05 for both). In addition, nausea scores were significantly lower in the H+O group (1.2 +/- 2.6) than in the H (2.5 +/- 3.3) and O (2.2 +/- 3.1) groups (p < 0.05 for both). CONCLUSION We conclude that the combination of prophylactic haloperidol (2 mg) plus ondansetron (4 mg) provides a higher complete response rate and greater patient satisfaction after laparoscopic cholecystectomy than either drug used alone.

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.

Perioperative Airway Management in a Child with Treacher Collins Syndrome

We report the perioperative airway management in a 12-year-old boy suffering from Treacher Collins syndrome (TCS) and severe mental retardation who was scheduled for elective dental treatment under general anesthesia. TSC is also known as mandibulofacial dysostosis or Franceschetti syndrome, usually with a potentially difficult airway presentation. It is a major challenge for the anesthesiologist to manage an uncooperative child with such a congenital airway anomaly. A difficult airway was encountered during induction of general anesthesia, and both oral intubation by direct laryngoscopy and classic laryngeal mask airway (LMA) insertion were unsuccessful. In an expedient critical trial, with the cooperation of two anesthesiologists, one performing nasal fiberoptic intubation and the other maintaining oral mask ventilation, a nasal endotracheal tube was successfully placed at the first attempt, although at the expense of prolonged respiratory depression in the patient. Therefore, fiberoptic nasal intubation simultaneously with mask ventilation for placement of the endotracheal tube is a practical substitute for a difficult airway usually managed by LMA with inadequate ventilation. After extubation, tracheostomy may be indicated if the TCS patient suffers from persistent difficult upper airway in consequence of a traumatic intubation.

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.

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.

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.

Cook ® Airway Exchange Catheter Used During Microlaryngeal Surgery

Abstract Anesthesia during laryngeal surgery presents the anesthesiologist with a number of potential challenges. It requires cooperation between the surgeon and anesthesiologist in order to maximize exposure for the surgeon and allow for adequate ventilation of the patient. Many anesthetic techniques have been used such as jet ventilation (subglottic or supraglottic) and endotracheal intubation (intermittently or continuously), with a variety of tubes. We present our experience of successful airway management with the assistance of the Cook® airway exchange catheter during microlaryngeal surgery. [ Tzu Chi Med J 2008;20(1):73–75]

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.

The Safe Depth of Coracoid Infraclavicular Brachial Plexus Block in Taiwan

Pneumothorax is a major complication caused by too deep puncture while performing infraclavicular block. The coracoid block provides a safer and easer approach than classic infraclavicular block. Our purpose was to design a prospective study in volunteers to evaluate the safe depth of the coracoid block by ultrasound guidance. Ultrasound examinations were performed in 41 volunteers in bilateral infraclavicular regions. The center of ultrasound probe was placed at the landmark puncture point 2 cm below and 2 cm medial to coracoid process. After identifying the neurovascular bundle, we try to identify pleura. Measured distances including skin to upper periphery of brachial plexus and skin to pleura were recorded. Safe depth was defined as vertical distance from skin to pleura. Demographic data was applied to correlate with the safety depth. Our results revealed that the mean depth from skin to plexus was 1.88±0.51cm. Pleura were identified in 84% ultrasound examinations. The mean safe depth was 3.49±0.63cm and positively correlated to both body weight and body mass index(both p＜0.001). In conclusion, safe depth of coracoid block was 3.49 cm within our demographic range and too deep puncture may result in pneumothorax. Ultrasound guidance is suggested whenever performing coracoid infraclavicular block