Jan-Uwe Schreiber

Airway injuries after one-lung ventilation: A comparison between double-lumen tube and endobronchial blocker : A randomized, prospective, controlled trial

Background:Vocal cord injuries, postoperative hoarseness, and sore throat are common complications after general anesthesia. One-lung ventilation can be achieved via two techniques: double-lumen endotracheal tube or endobronchial blocker such as the Arndt blocker. The current study was designed to assess the impact of these techniques for one-lung ventilation on the incidence and severity of postoperative hoarseness, vocal cord lesions, and sore throat. Methods:In this prospective trial, 60 patients were randomly assigned to two groups. One-lung ventilation was achieved with either an endobronchial blocker (blocker group) or a double-lumen-tube (double-lumen group). Postoperative hoarseness and sore throat were assessed at 24, 48, and 72 h after surgery. Bronchial injuries and vocal cord lesions were examined by bronchoscopy immediately after surgery. Results:In 56 included patients, postoperative hoarseness occurred significantly more frequently in the double-lumen group compared with the blocker group: 44% versus 17%, respectively (P = 0.046). Similar findings were observed for vocal cord lesions: 44% versus 17%, respectively (P = 0.046). The incidence of bronchial injuries was comparable between groups (P = 0.540). Cumulative number of days with hoarseness and sore throat were significantly increased in the double-lumen group compared with the blocker group (P < 0.01). No major complications such as bronchial ruptures were observed. Conclusions:Clinicians should be aware of an increased incidence of minor airway injuries that may impair patient satisfaction when using a double-lumen tube instead of an endobronchial blocker for one-lung ventilation.

Prevention of Succinylcholine-induced Fasciculation and Myalgia A Meta-analysis of Randomized Trials

Fifty-two randomized trials (5,318 patients) were included in this meta-analysis. In controls, the incidence of fasciculation was 95%, and the incidence of myalgia at 24 h was 50%. Nondepolarizing muscle relaxants, lidocaine, or magnesium prevented fasciculation (number needed to treat, 1.2–2.5). Best prevention of myalgia was with nonsteroidal antiinflammatory drugs (number needed to treat, 2.5) and with rocuronium or lidocaine (number needed to treat, 3). There was a dose-dependent risk of blurred vision, diplopia, voice disorders, and difficulty in breathing and swallowing (number needed to harm, < 3.5) with muscle relaxants. There was evidence of less myalgia with 1.5 mg/kg succinylcholine (compared with 1 mg/kg). Opioids had no impact. Succinylcholine-induced fasciculation may best be prevented with muscle relaxants, lidocaine, or magnesium. Myalgia may best be prevented with muscle relaxants, lidocaine, or nonsteroidal antiinflammatory drugs. The risk of potentially serious adverse events with muscle relaxants is not negligible. Data that allow for a risk–benefit assessment are lacking for other drugs.

Rocuronium is not associated with more vocal cord injuries than succinylcholine after rapid-sequence induction: a randomized, prospective, controlled trial.

Postoperative hoarseness (PH), sore throat (ST), and vocal cord injuries (VCI) are common complications after general anesthesia. Excellent endotracheal intubating conditions are associated with less laryngeal morbidity than good or poor intubating conditions. Thus, we tested the hypothesis that a rapid-sequence induction (RSI) with succinylcholine would lead to less PH and VCI than with rocuronium. In this prospective trial, 160 patients were randomized in 2 groups to receive thiopental 5.0 mg/kg, fentanyl 3.0 &mgr;g/kg, succinylcholine 1.0 mg/kg, or rocuronium 0.6 mg/kg during RSI. PH and ST were assessed at 24, 48, and 72 h after surgery, VCI were examined by stroboscopy in those patients who had PH >3 days. Excellent and clinically acceptable intubating conditions were significantly increased in the succinylcholine group compared with the rocuronium group: 57% versus 21% and 89% versus 59%, respectively (P < 0.001). The incidence and severity of PH, and VCI between the succinylcholine and the rocuronium groups did not differ significantly: PH: 50% versus 51% (P = 0.99) and VCI: 3% versus 1% (P = 0.98), respectively. Similar findings were found for ST, 39% versus 28% (P = 0.22), and postoperative myalgia, 39% versus 29% (P = 0.25), respectively. Intubating conditions were significantly better in the succinylcholine group compared with the rocuronium group. The incidence and severity of ST and myalgia were not increased in the patients receiving succinylcholine. However, the rate of PH and VCI was similar to the rocuronium group.

The Effect of Different Lung-Protective Strategies in Patients During Cardiopulmonary Bypass: A Meta-Analysis and Semiquantitative Review of Randomized Trials

OBJECTIVES A variety of lung-protective techniques, including continuous positive airway pressure and vital capacity maneuvers, have been suggested as beneficial when applied during cardiopulmonary bypass (CPB). To better define the efficacy of these techniques, a systematic review of different ventilation strategies during and after CPB was performed. DESIGN A systematic review and meta-analysis according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses recommendations. SETTING Hospitals. PARTICIPANTS Eight hundred fourteen participants of 16 randomized controlled trials. INTERVENTIONS Continuous positive airway pressure (CPAP), low-volume ventilation, or vital capacity maneuvers (VCMs) during CPB. MEASUREMENTS AND MAIN RESULTS The methodologic validity of the included trials was scored according to the Oxford scale. Included trials had to report on at least 1 of the following parameters: oxygenation, oxygenation index, alveolar-arterial oxygen difference, or shunt fraction. The average quality of the included trials was as low as 2 on a scale from 1 to 5. The use of CPAP or VCM during CPB led to a significant increase in oxygenation parameters immediately after weaning from CPB, but this effect was not sustainable and did not improve patient outcome. CONCLUSIONS This meta-analysis showed that the positive effects of the designated techniques are probably short-lived with a questionable impact on the long-term clinical outcome of the treated patients. Based on the available data, it might be impossible to advise an optimal or best-evidence strategy of lung preservation during CPB.

Women report more pain on injection of a precurarization dose of rocuronium: A randomized, prospective, placebo‐controlled trial

Background:  The purpose of this study was to investigate whether gender influences the perception of pain on injection of rocuronium.

Pretreatment Before Succinylcholine for Outpatient Anesthesia

IMPLICATIONS This study demonstrated that pretreatment of succinylcholine with rocuronium failed to decrease the incidence or the severity of postoperative myalgia. However, in most patients, pretreatment was associated with muscle weakness before loss of consciousness. Thus, there is no convincing evidence supporting routine pretreatment with succinylcholine.

Acceleromyography to assess neuromuscular recovery: is calibration before measurement mandatory?

Background: Acceleromyography has been shown to be an appropriate method in the detection of residual paralysis. However, the clinical importance of an individual calibration of the device in the single patient to improve reliability in detecting residual paralysis remains unclear.

Postoperative Myalgia After Succinylcholine: No Evidence for an Inflammatory Origin

A common side effect associated with succinylcholine is postoperative myalgia. The pathogenesis of this myalgia is still unclear; inflammation has been suggested but without convincing evidence. We designed the present study to investigate whether an inflammatory reaction contributes to this myalgia. The incidence and severity of succinylcholine-associated myalgia was determined in 64 patients pretreated with saline or dexamethasone before succinylcholine (n = 32 for each). Incidence and severity of myalgia did not differ significantly between the two groups: 15 patients in the dexamethasone group complained of myalgia compared with 18 patients in the saline group, and severe myalgia was reported by five patients and three patients, respectively (not significant). At 48 h after surgery, 12 patients in both groups still suffered from myalgia (not significant). In addition, interleukin-6 (IL-6) as an early marker of inflammation was assessed in a subgroup of 10 patients pretreated with saline. We found an increase of IL-6 for only three patients, but only one patient reported myalgia; no relationship between myalgia and the increase of IL-6 was found. In conclusion, there is no evidence for an inflammatory origin of succinylcholine-associated myalgia. IMPLICATIONS: Administration of dexamethasone before succinylcholine was not effective in decreasing the incidence or the severity of succinylcholine-induced postoperative myalgia. Furthermore, there was no significant relationship between postoperative myalgia and time course of interleukin-6 concentrations, a marker of inflammation. Pretreatment with dexamethasone is not justified to prevent postoperative myalgia after succinylcholine.

Con: succinylcholine should not be replaced by rocuronium for rapid sequence induction.

‘So long, succinylcholine!’ concluded Lee and Katz in a review article in 2009 after discussing why this agent should be sent out to retirement 60 years after its clinical introduction. During this time, clinical appraisal has changed from ‘close to ideal’ into ‘pharmacologically dirty and dangerous’. Probably unlike any other drug in clinical anaesthesia, succinylcholine has been subject to controversies due to its number of side effects. Lifethreatening complications such as malignant hyperthermia or cardiac arrests are associated with this drug as well as minor problems such as postoperative myalgia. Undoubtedly, succinylcholine has taught anaesthesiologists and pharmacologists a lot about neuromuscular pharmacology, and probably, millions of patients have benefited from treatment with this agent. Now, more than 60 years after the introduction of ‘SUX’ into clinical practice, the anaesthesiologist’s portfolio contains a variety of neuromuscular blocking agents and it seems that there are suitable alternatives for all clinical situations. However, several surveys have shown that the majority of anaesthesiologists still trust this old drug and that, even now, none of the newer agents can force succinylcholine out of the management of one of the most

Laryngeal morbidity after single lung ventilation: a comparison of two different techniques: A-1015

Clinic of Anaesthesiology and Intensive Care Medicine, Saint Anna’s University Hospital, Brno, Czech Republic Background and Goal of Study: Airway protective reflex activation is less frequent with a flexible laryngeal mask airway (FLMA) than with a tracheal tube (TT). (1,2). We decided to switch from the usual practice of tracheal intubation to the use of an FLMA. Materials and Methods: We studied 41 (23 F, 18 M) children with cleft palate undergoing primary cleft palate suture. Ages ranged from 8–12 months and weights from 6580–9990 g, average 8323 g. After induction of anesthesia with sevorane, a size 2 FLMA was inserted with midline approach. A Dingmann mouth gag was then inserted by the surgeon. Maintenance anesthesia: minimal flow anaesthesia, sufentanil, PCV, PEEP, no muscle relaxants. Results and Discussions: The FLMA was successfully used in 38 out of 41 children (92.7% success rate). Two operations (4.9%) were cancelled because of bronchospasm in the placement phase. In one case (2.4%), that of a very small child, tracheal intubation was needed because of interference from the FLMA tube within the field of operation. No major complications occurred during the operations. Removal of the FLMA took place when the patient awoke in PACU – in 15 cases removed by the anesthesiologist, in 23 cases by a trained PACU nurse. In all cases the interior side of the FLMA was clean. Conclusion(s): This method is simple and safer than TT for patients with coexisting upper airway disease. Use of the FLMA increases operation theatre case turnover and enables smooth postoperative recovery. References: 1 Williams PJ, Bailey PM. Br J Anaesth 1993; 70:30–33. 2 Habre W, Sims C, Johnson C. Anesthesiology 1999; 91:A 1262.