Jaegyok Song

Inspection of the nasopharynx prior to fiberoptic-guided nasotracheal intubation reduces the risk epistaxis☆☆☆★★★☆☆☆

BACKGROUND Various complications may occur during nasotracheal intubation. This may include epistaxis and damage to the nasopharyngeal airway. We tested the hypothesis that the use of fiberoptic bronchoscopy (FOB)-guided intubation is superior to endotracheal tube (ETT) obturated with an inflated esophageal stethoscope. METHODS Patients were randomly assigned to 1 of 2 groups (n=22 each): either an FOB-guided intubation group or ETT obturated with an inflated esophageal stethoscope group. After the induction of general anesthesia, patients in the FOB group received an FOB inspection through the nostril without advancement of ETT. Then, after confirming the placement of the bronchoscope tip in the trachea, the lubricated ETT was advanced via the nostril to the trachea along the bronchoscope. In the obturated ETT insertion group, the proximal opening of the ETT was blunted with an inflated esophageal stethoscope. The ETT was inserted into the selected nostril and advanced blindly into the posterior oropharynx. Then, the esophageal stethoscope was removed and tracheal intubation was performed with the bronchoscope. The number of attempts for successful tracheal intubation, the degree of difficulty during insertion, and bleeding during bronchoscopy were recorded. Another anesthesiologist, blinded to the intubation method, estimated the severity of epistaxis 5minutes after the intubation and postoperative complications. RESULTS The FOB group had significantly less epistaxis during bronchoscopy, better navigability, and fewer intubation attempts and redirections. CONCLUSION Fiberoptic-guided nasotracheal intubation was associated with less epistaxis. It also showed better navigability and less redirection rate. Therefore, FOB as an intubation guide is superior to ETT with an inflated esophageal stethoscope when intubating a patient via the nasotracheal route.

Severe brachial plexus injury after retropubic radical prostatectomy -A case report-

A 69-year-old man with prostate cancer underwent surgery for 16 h. Approximately 6 h after surgery, the patient developed severe pain and motor weakness in his right arm. After neurologic examinations that included a nerve conduction study and electromyography, the patient was diagnosed with a brachial plexus injury. The causes of the brachial plexus injury were thought to be abduction of both arms, direct compression of the shoulder brace, and prolonged surgery. Most of the postoperative peripheral nerve injuries due to patient position are preventable, and anesthetists and surgeons should be very careful in positioning the patient accurately.

Myoclonus of ipsilateral upper extremity after ultrasound-guided supraclavicular brachial plexus block with mepivacaine

and analgesic procedures. Myoclonus after regional anesthesia has rarely been reported, but there have been a few reports of myoclonus after a peripheral nerve block. We report a very rare case of myoclonus after a supraclavicular brachial plexus block in a healthy patient with a brief review of literature. A 22-year-old woman (height: 160 cm, body weight: 46 kg, American Society of Anesthesiologists physical status I) was scheduled for a capsular release operation. There was nothing specific in her past medical history. She had previously undergone an uncomplicated left hand procedure under general anesthesia with no anesthesia-related adverse events. Preoperative evaluations were also normal. A supraclavicular brachial plexus block was planned for the anesthesia. Electrocardiography, noninvasive blood pressure, and pulse oximetry were monitored. Before induction of anesthesia, midazolam 2 mg and fentanyl 50 μg were intravenously injected for sedation and pain relief. At the beginning of nerve block, her blood pressure and heart rate were 120/75 mmHg and 65 beats/min. A supraclavicular brachial plexus block was performed under ultrasonographic guidance with a 5 cm standard bevel needle (Profi needle, Shinchang medical Co., Seoul, Korea). We injected 1.5% mepivacaine 40 ml after confirming no aspiration of blood. She did not complain of any severe paresthesia or injection pain during the procedure. Fifteen minutes after procedure, we confirmed successful sensory and motor block of brachial plexus and 5 L/min of oxygen was supplied via facial mask during the operation. An additional 1 mg of midazolam was given intravenously for sedation. The patient was stable during the surgery and the duration of surgical procedure was about 40 minutes. After the surgical procedure, the patient was transferred to a recovery room. One hour after the injection of the local anesthetic, she showed a shivering motion without any chilling sensation. The body temperature was 36.7°C. Meperidine 25 mg was intravenously injected to relieve shivering and 5 L/min of oxygen was supplied via facial mask. However, her shivering continued for about 15 minutes and the patient began to show mild agitation. Thirty minutes after meperidine injection, she showed involuntary movement of left arm, while the other body parts were under control (Video 1). The patient was unable to suppress the movement intentionally but remained conscious and communicated appropriately. She did not complain of pain or any other discomfort and there were no other neurologic symptoms. The driving force for the abnormal movement was from the surrounding muscles of the shoulder with some contribution from the muscles of the elbow joint. We consulted to neurology and the patient was treated with an intravenous injection of midazolam 5 mg but it was not effective. The movement continued while patient was sedated with midazolam. The neurologist examined the patient and about 20 minutes after midazolam injection, lorazepam 4 mg was administered intravenously but it was also not effective. The abnormal movement did Letter to the Editor

Fiberoptic bronchoscope and C-MAC video laryngoscope assisted nasal-oral tube exchange: two case reports

In cases of multiple facial trauma and other specific cases, the anesthesiologist may be asked to convert an oral endotracheal tube to a nasal endotracheal tube or vice versa. Conventionally, the patient is simply extubated and the endotracheal tube is re-inserted along either the oral or nasal route. However, the task of airway management can become difficult due to surgical trauma or worsening of the airway condition. Fiberoptic bronchoscopy was considered a novel method of airway conversion but this method is not useful when there are secretions and bleeding in the airway, or if the anesthesiologist is inexperienced in using this device. We report a successful airway conversion under the aid of both, a fiberoptic bronchoscope and a C-MAC video laryngoscope.

A comparison of the effects of epinephrine and xylometazoline in decreasing nasal bleeding during nasotracheal intubation

Background Various techniques have been introduced to decrease complications during nasotracheal intubation. A common practice is to use nasal packing with a cotton stick and 0.01% epinephrine jelly. However, this procedure can be painful to patients and can damage the nasal mucosa. Xylometazoline spray can induce effective vasoconstriction of the nasal mucosa without direct nasal trauma. In this study, we aimed to compare the efficacy of these two methods. Methods Patients were randomly allocated into two groups (n = 40 each): xylometazoline spray group or epinephrine packing group. After the induction of general anesthesia, patients allocated to the xylometazoline spray group were treated with xylometazoline spray to induce nasal cavity mucosa vasoconstriction, and the epinephrine packing group was treated with nasal packing with two cotton sticks and 0.01% epinephrine jelly. The number of attempts to insert the endotracheal tube into the nasopharynx, the degree of difficulty during insertion, and bleeding during bronchoscopy were recorded. An anesthesiologist, blinded to the intubation method, estimated the severity of epistaxis 5 min after intubation and postoperative complications. Results No significant intergroup difference was observed in navigability (P = 0.465). The xylometazoline spray group showed significantly less epistaxis during intubation (P = 0.02). However, no differences were observed in epistaxis 5 min after intubation or postoperative epistaxis (P = 0.201). No inter-group differences were observed in complications related to nasal intubation and nasal pain. Conclusion Xylometazoline spray is a good alternative to nasal packing for nasal preparation before nasotracheal intubation.

Effectiveness of milrinone for cardiogenic shock due to massive pulmonary aspiration -a case report-

Pulmonary aspiration of gastric contents is one of the most frightening complications during anesthesia. Although pulmonary aspiration of gastric contents in general surgical patients is not common and resulting long-term morbidity and mortality are rare, severe hypoxemia and other sequelae of pulmonary aspiration continue to be reported. We report a case of massive aspiration of gastric contents during induction of general anesthesia, resulting in cardiac arrest due to severe pulmonary hypertension and myocardial infarction. Sustained cardiac arrest and shock that did not respond the conventional resuscitation was successfully treated using milrinone. The patient was discharged without complications in 20 days.