Jee-Eun Chang

Effect of prophylactic benzydamine hydrochloride on postoperative sore throat and hoarseness after tracheal intubation using a double-lumen endobronchial tube: a randomized controlled trial

PurposeWe evaluated the prophylactic effect of benzydamine hydrochloride (BH) spray on postoperative sore throat and hoarseness secondary to intubation with a double-lumen endobronchial tube (DLT).MethodsNinety-two adult patients undergoing thoracic surgery using DLT intubation were studied. The DLT cuff and oropharyngeal cavity were sprayed with normal saline (Group S; n = 46) or BH (Group BH; n = 46) prior to intubation. Postoperative sore throat and hoarseness were evaluated at one, six, and 24 hr after surgery. Sore throat was evaluated using a 0-100 mm visual analogue scale (VAS). Hoarseness was defined as a change in voice quality.ResultsCompared with Group S, postoperative sore throat occurred less frequently in Group BH at one hour (mean difference, 28.3%; 95% confidence interval [CI], 8.7 to 45.1; P = 0.01), at six hours (mean difference, 32.6%; 95% CI, 12.6 to 49.2; P < 0.01), and at 24 hr (mean difference, 28.3%; 95% CI, 9.3 to 44.7; P = 0.01) after surgery. Group BH had lower VAS scores for postoperative sore throat at one hour (mean difference, 12.8; 95% CI, 4.9 to 20.7), at six hours (mean difference, 11.9; 95% CI, 4.8 to 19.1; P < 0.01), and at 24 hr (mean difference, 5.3; 95% CI, 0.9 to 9.7; P = 0.01) after surgery. Hoarseness also occurred less frequently in Group BH at one hour (mean difference, 23.9%; 95% CI, 6.8 to 39.6; P = 0.01), at six hours (mean difference, 23.9%; 95% CI, 7.4 to 39.3; P = 0.01), and at 24 hr (mean difference, 21.7%; 95% CI, 5.5 to 37.0; P = 0.02) after surgery (P < 0.01).ConclusionsProphylactic application of BH to the DLT cuff and oropharyngeal cavity reduces the incidence and severity of postoperative sore throat and the incidence of hoarseness associated with DLT intubation. The trial was registered at the Clinical Research Information Service (KCT0001068).RésuméObjectifNous avons évalué l’effet prophylactique d’un vaporisateur de chlorhydrate de benzydamine (CB) sur les maux de gorge et l’enrouement postopératoires découlant d’une intubation réalisée avec une sonde endobronchique à double lumière (SDL).MéthodeQuatre-vingt-douze patients adultes subissant une chirurgie thoracique et intubés avec une SDL ont pris part à l’étude. Le ballonnet de la SDL et la cavité oropharyngée ont été vaporisés avec du sérum physiologique (groupe S; n = 46) ou du CB (groupe CB; n = 46) avant l’intubation. Les maux de gorge et l’enrouement postopératoires ont été évalués à une, six et 24 heures après la chirurgie. Les maux de gorge ont été évalués à l’aide d’une échelle visuelle analogique (EVA) de 0-100 mm. L’enrouement a été défini comme un changement de la qualité vocale.RésultatsPar rapport au groupe S, les maux de gorge postopératoires étaient moins fréquents dans le groupe CB une heure (différence moyenne, 28,3 %; intervalle de confiance [IC] 95 %, 8,7 à 45,1; P = 0,01), six heures (différence moyenne, 32,6 %; IC 95 %, 12,6 à 49,2; P < 0,01) et 24 heures (différence moyenne, 28,3 %; IC 95 %, 9,3 à 44,7; P = 0,01) après la chirurgie. Les scores du groupe CB sur l’EVA étaient plus bas en matière de maux de gorge postopératoires une heure (différence moyenne, 12,8; IC 95 %, 4,9 à 20,7), six heures (différence moyenne, 11,9; IC 95 %, 4,8 à 19,1; P < 0,01) et 24 heures (différence moyenne, 5,3; IC 95 %, 0,9 à 9,7; P = 0,01) après la chirurgie. L’enrouement était également moins fréquent dans le groupe CB une heure (différence moyenne, 23,9 %; IC 95 %, 6,8 à 39,6; P = 0,01), six heures (différence moyenne, 23,9 %; IC 95 %, 7,4 à 39,3; P < 0,01) et 24 heures (différence moyenne, 21,7 %; IC 95 %, 5,5 à 37,0; P = 0,02) après la chirurgie (P < 0,01).ConclusionL’application prophylactique de CB au ballonnet de la SDL et à la cavité oropharyngée réduit l’incidence et la gravité des maux de gorge postopératoires et l’incidence d’enrouement associées à l’intubation via SDL. Cette étude a été enregistrée au Clinical Research Information Service (KCT0001068).

Successful weaning from mechanical ventilation in the quadriplegia patient with C2 spinal cord injury undergoing C2-4 spine laminoplasty -A case report-.

In patients with cervical spine injuries, respiratory function requires careful attention. Voluntary respiratory control is usually possible with lesions below C4 level although paralysis of the abdominal musculature results in a decreased ability to cough and to clear secretions, which may later lead to respiratory insufficiency. Therefore, injuries above C5 usually necessitate long term mechanical ventilation. Even though weaning criteria are not definitive for the quadriplegic patient, M-mode ultrasonography of the diaphragm may be useful in identifying patients at high risk of difficulty weaning. Diaphragmatic dysfunction (vertical excursion < 10 mm or paradoxical movements) results in frequent early and delayed weaning failures. We present our clinical experience with successful weaning by using M-mode ultrasonography and a cough-assist device for secretion clearance after extubation in a quadriplegic patient undergoing C2-4 spine laminoplasty.

A comparison of direct laryngoscopic views in different head and neck positions in edentulous patients

OBJECTIVE Proper head and neck positioning is an important factor for successful direct laryngoscopy, and the optimum position in edentulous patients is unclear. We compared direct laryngoscopic views in simple head extension, sniffing, and elevated sniffing positions in edentulous patients. METHODS Eighteen adult edentulous patients scheduled for elective surgery were included in the study. After induction of anesthesia, the laryngeal view was assessed under direct laryngoscopy using the percentage of glottic opening (POGO) score in 3 different head and neck positions in a randomized order: simple head extension without a pillow, sniffing position with a pillow of 7 cm, and elevated sniffing position with a pillow of 10 cm. After assessment of the laryngeal views, tracheal intubation was performed. RESULTS A significant difference was observed in the laryngeal views assessed at the 3 head positions (P= .001). The POGO scores (mean [SD]) in the sniffing position (78.9% [19.7%]) and elevated sniffing position (72.6% [20.8%]) were significantly improved compared to that with simple head extension (53.8% [25.9%]) (P= .001, respectively). The sniffing position provided the best laryngeal view. The mean POGO scores were higher in the sniffing position than the elevated sniffing position, but no significant difference was observed between these 2 positions (P= .268). CONCLUSIONS The sniffing and elevated sniffing positions provide better laryngeal views during direct laryngoscopy compared to simple head extension in edentulous patients.

Perioperative complications following preoperative cessation of antithrombotic agents for total knee arthroplasty: A retrospective study.

AbstractThe number of elderly patients undergoing total knee arthroplasty (TKA) has steadily increased. Elderly patients undergoing TKA usually have underlying diseases, and some of them take antithrombotic agents for the prevention or treatment of these co-morbidities, including cardiovascular, cerebrovascular, or thromboembolic diseases. When these patients are scheduled to undergo TKA, preoperative cessation of antithrombotic agents is considered on the basis of its risks and benefits. This study was aimed to evaluate the impact of discontinuing antithrombotic agents for primary total knee arthroplasty (TKA) on perioperative complications.Patients who underwent primary TKA between 2008 and 2012 were identified, and classified into two groups: group A, in whom antithrombotic agents were ceased preoperatively, and group B, in which patients did not receive antithrombotic therapy. Patient characteristics, history of antithrombotic therapy, intraoperative blood loss, perioperative blood transfusion, postoperative 30-day complications, and postoperative hospital stay were recorded.Of 885 patients undergoing primary TKA, 218 (24.6%) patients were included in group A, and 667 (75.4%) in group B. Group A received transfusion more frequently than group B (P < 0.001). However, there was no difference between the two groups in terms of intraoperative blood loss, postoperative 30-day complications, and postoperative hospital stay.Patients who discontinued antithrombotic drugs before primary TKA do not have a higher incidence of postoperative 30-day complications, including cardiovascular, cerebrovascular, or thromboembolic events. Moreover, the estimated intraoperative blood loss was not different compared with patients not receiving antithrombotic agents preoperatively. Larger prospective studies of this issue are required.

Effect of Jaw Thrust on Transesophageal Echocardiography Probe Insertion and Concomitant Oropharyngeal Injury.

OBJECTIVE The aim of this study was to evaluate the effect of jaw thrust on transesophageal echocardiography probe insertion and concomitant oropharyngeal injury. DESIGN A prospective, randomized study SETTING Medical center governed by a university hospital PARTICIPANTS Forty-two adult patients undergoing cardiovascular surgery were included. INTERVENTIONS After the induction of anesthesia, a transesophageal echocardiography probe was inserted using an anterior jaw lift technique (conventional group, n = 21) or a jaw thrust-assisted technique (jaw thrust group, n = 21). MEASUREMENTS AND MAIN RESULTS The incidence of oropharyngeal injury, number of insertion attempts, blood on the probe tip, and presence of persistent oropharyngeal bleeding were evaluated. In the conventional group, oropharyngeal injury occurred more frequently than in the jaw-thrust group (52.4% v 9.5%, respectively; p = 0.006). Regarding transesophageal echocardiography probe insertion, the conventional group required more attempts than the jaw-thrust group (p = 0.043). The incidence of blood on the probe tip was higher in the conventional group than in the jaw-thrust group (p = 0.020), but the presence of persistent oropharyngeal bleeding was similar between the 2 groups. CONCLUSIONS The jaw-thrust maneuver facilitated the insertion of the transesophageal echocardiography probe and reduced concomitant oropharyngeal injury.

Effect of the Macintosh curved blade size on direct laryngoscopic view in edentulous patients

Objective: In the present study, we compared the laryngoscopic view depending on the size of the Macintosh curved blade in edentulous patients. Methods: Thirty‐five edentulous adult patients scheduled for elective surgery were included in the study. After induction of anesthesia, two direct laryngoscopies were performed alternately using a standard‐sized Macintosh curved blade (No. 4 for men and No. 3 for women) and smaller‐sized Macintosh curved blade (No. 3 for men and No. 2 for women). During direct laryngoscopy with each blade, two digital photographs of the lateral view were taken when the blade tip was placed in the valleculae; the laryngoscope was lifted to achieve the best laryngeal view. Then, the best laryngeal views were assessed using the percentage of glottic opening (POGO) score. On the photographs of the lateral view of direct laryngoscopy, the angles between the line extending along the laryngoscopic handle and the horizontal line were measured. Results: The POGO score was improved with the smaller‐sized blade compared with the standard‐sized blade (87.3% [11.8%] vs. 71.3% [20.0%], P < 0.001, respectively). The angles between the laryngoscopic handle and the horizontal line were greater with the smaller‐sized blade compared to the standard‐sized blade when the blade tip was placed on the valleculae and when the laryngoscope was lifted to achieve the best laryngeal view (both P < 0.001). Conclusions: Compared to a standard‐sized Macintosh blade, a smaller‐sized Macintosh curved blade improved the laryngeal exposure in edentulous patients.

A Randomized Controlled Trial Comparing the Utility of Lighted Stylet and GlideScope for Double-Lumen Endobronchial Intubation

OBJECTIVE To compare GlideScope and lighted stylet for double-lumen endobronchial tube (DLT) intubation in terms of intubation time, success rate of first attempt at intubation, difficulty in DLT advancement toward the glottis, and postoperative sore throat and hoarseness. DESIGN A prospective, randomized study. SETTING Medical center governed by a university hostpial. PARTICIPANTS Sixty-two adult patients undergoing thoracic surgery using DLT intubation. INTERVENTION After the induction of anesthesia, DLT intubation was performed using GlideScope (n = 32) or lighted stylet (n = 32). MEASUREMENTS AND MAIN RESULTS Number of intubation attempts, difficulty of DLT advancement toward the glottis, time taken for DLT intubation, and the incidence and severity of postoperative sore throat and hoarseness at 1 and 24 hours after surgery were evaluated. Time taken for DLT intubation was shorter in the lighted stylet group compared with the GlideScope group (30 [28-32] s v 45 [38-53] s, median [interquartile range], respectively; p < 0.001). DLT advancement toward the glottis was easier in the lighted stylet group than in the GlideScope group (p = 0.016). The success rate of DLT intubation in the first attempt (96.9% v 90.6% for lighted stylet and GlideScope, respectively), and the incidence and severity of postoperative sore throat and hoarseness were not different between the two groups. CONCLUSIONS The use of lighted stylet allowed easier advancement of the DLT toward the glottis in the oropharyngeal space and reduced time for achieving DLT intubation compared with GlideScope.

Bilateral vocal cord paralysis following coronary artery bypass surgery

We report a case of bilateral vocal cord paralysis (VCP) that occurred after coronary artery bypass surgery and we review the mechanisms of VCP and the preventable factors. We emphasize to consider VCP if respiratory insufficiency occurs following extubation in cardiac surgery, and an early diagnosis is sure to prevent life-threatening problems such as airway compromise and aspiration pneumonia. A 66-year-old female patient (153.4 cm, 46.8 kg) was scheduled for a coronary artery bypass surgery. She had a medical history of hypertension, coronary artery disease, and diabetes mellitus. Recent coronary angiography showed progressed lesions at the left anterior descending and left circumflex arteries. After the patient was transferred to the operating room and an arterial cannulation was done, anesthesia was induced. Tracheal intubation was performed with a 7.0 mm-internal diameter endotracheal tube (SoftVent® Pro, HVLP-Cuff, Murphy, Unomedical, Malaysia) using a direct curved laryngoscope. The balloon was inflated until the cuff pressure was measured as 25 cmH2O by a handheld aneroid manometer (VBM, Germany). The cuff was palpated at the suprasternal notch and the endotracheal tube was fixed at 20 cm from the incisors. An ultrasound guided insertion of a central venous cannula was performed in the right internal jugular vein and a transesophageal echocardiographic (TEE) probe (diameter: 10.5 mm, width of tip: 14.5 mm; TEV5Ms, Siemens Medical Solutions, Mountain View, USA) was inserted without difficulty. After median sternotomy, the left internal mammary artery was harvested and off-pump coronary artery bypass surgery was performed. The cuff pressure of the endotracheal tube was intermittently measured maintaining the intracuff pressure at 25 cmH2O during the operation and the post operation period, and the fraction of inspired oxygen was maintained below 0.5 using medical air and oxygen. A planned extubation was performed after ventilator care for 2 days. Immediately after extubation, the patient complained of respiratory difficulties and an inspiratory stridor was detected. Dexamethasone 5 mg was given and respiration was assisted with a bag-valve-mask for several minutes. The respiratory difficulties were relieved and the stridor disappeared. Chest X-ray findings and arterial blood gas analysis were within normal range. Methylprednisolone 25 mg/day was administered due to the suspicion of laryngeal edema and spontaneous breathing was maintained without events under oxygen 10 L/min via a facial mask. One day after extubation the patient complained of hoarseness. The otorhinolaryngeal department was consulted for a vocal cord examination and a gap was shown between the vocal cords and both vocal folds were shown to be immobile. Feeding through a nasogastric tube was started and the patient was kept under close observation. The patient had no respiratory difficulties even though a minimal stridor was detected intermittently. On the 18th post-operative day, the videofluoroscopic swallowing study showed an aspiration at the pharyngeal stage and the patient was put on rehabilitation for dysphagia. On the 20th post-operative day, the fiberoptic endoscopic evaluation of swallowing (FESS) showed improved movement of both vocal cords and no aspiration signs. The patient was discharged one week later and after three months, her voice was normalized and the FESS showed no abnormal findings. VCP results from a direct vocal cord injury or a recurrent laryngeal nerve (RLN) paralysis following cardiac surgery. Direct manipulation and retraction of the heart, median sternotomy, as well as an excessive sternal traction for harvesting of the internal mammary artery may be a cause of RLN paralysis related to the anatomy of RLN [1]. The right RLN crosses the subclavian artery, winds the artery backward, and ascends in the tracheoesophageal groove. The left RLN crosses the aortic arch and reaches the tracheoesophageal groove [1]. Hypothermic injury with ice/slush collecting in the pleural cavity in close proximity to the left RLN has been also reported to contribute to RLN paralysis [2]. The repeated and unsuccessful attempts of inserting TEE probe can compress the nerve at its entry into the larynx, resulting in RLN paralysis [3]. During central venous catheterization, direct RLN injury is possible because the catheterized vessels are close to the RLN. In addition, traumatic endotracheal intubation can cause a direct mechanical injury such as a cricoarytenoid dislocation, and an excessively inflated endotracheal tube cuff can compress the RLN or its anterior branch at the tracheoesophageal groove [4]. In this case, the chest x-ray and manometer findings checked during the intubation period show that endotracheal tube location and cuff pressure were within a normal range. The central line, TEE, and the endotracheal tube also were all inserted without any difficulty and events. Therefore, controllable or intubation related factors can be excluded. We suppose that the causes of VCP in this case were the factors associated with the heart operation such as excessive sternal traction and direct manipulation of the heart. The clinical manifestations of a bilateral VCP are respiratory insufficiency, stridor, and hoarseness. In this case, the patient had respiratory difficulties and stridor immediately after extubation and the symptoms subsided after steroid injection. The day after extubation, the patient complained of hoarseness and was diagnosed with bilateral VCP. This shows that laryngeal spasm or edema that causes respiratory difficulties and stridor immediately after extubation [5] could be accompanied by bilateral VCP in this case. Generally, bilateral VCP is clinically fatal and prompt management such as re-intubation and mechanical ventilation can be required because the vocal cords can be immobile while being closed. In our case, a gap existed between the vocal folds. Therefore adequate ventilation and oxygenation was possible via the gap. However, re-intubation and mechanical ventilation under the suspicion of bilateral VCP should have taken place if the stridor or respiratory symptoms had still existed after the use of steroid or the assistance of ventilation. It is not easy to prevent a VCP in cardiac surgery, because there are several contributing factors for the occurrence. We should take effort to avoid any controllable risk factors, including abnormal tube size and location, high intra-cuff pressure, and traumatic insertion of TEE probe or central venous catheter. Also, a VCP must be suspected if patients have hoarseness, stridor, and respiratory difficulties after extubation.

Postoperative pulmonary edema in a patient with POEMS syndrome

POEMS syndrome is a rare multisystemic disorder. It is characterized by polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, and skin changes [1]. Because it is also associated with pulmonary dysfunction, a patient with POEMS syndrome may have postoperative respiratory difficulty. In this report, we describe a patient with this syndrome who underwent surgery under general anesthesia and failed ventilator weaning due to pulmonary edema. A 58-year-old male (height 163 cm; weight 48.5 kg) with POEMS syndrome was diagnosed with rectal cancer and planned to undergo low anterior resection. He displayed weakness and paresthesia of the right arm and both legs, skin lesions such as hypertrichosis, scleroderma, and thickened extremities, and orthopnea, which had developed 2 weeks previously. Chest radiography showed bilateral mild pleural effusion. A pulmonary function test (PFT) revealed a mild restrictive pattern. Arterial blood gas analysis (ABGA) in room air was pH 7.398, partial carbon dioxide pressure (PaCO2) was 27.8 mmHg, partial oxygen pressure (PaO2) was 91.4 mmHg, and bicarbonate (HCO3-) concentration was 16.8 mEq/L. On echocardiogram, the estimated pulmonary artery systolic pressure (PASP) was 40 mmHg, and the other values were normal. Other laboratory data and vital signs were within normal limits. Anesthesia was induced with propofol 120 mg, fentanyl 100 µg, and rocuronium 50 mg. A size 7.5, cuffed tube was used for intubation. A radial arterial line and a central venous catheter were placed in the right internal jugular vein. Anesthesia was maintained with sevoflurane in air/O2. Thirty minutes into the surgery, systolic blood pressure (BP) decreased to 70-80 mmHg. Continuous infusion of dopamine and norepinephrine was initiated. An additional 5 mg of rocuronium were injected four times. The last ABGA intraoperatively was pH 7.263, PaCO2 40.3 mmHg, PaO2 96.0 mmHg, HCO3- 17.8 mEq/L under FiO2 0.5. The surgery duration was 190 min and the anesthesia time was 270 min. The total amount of administered fluid was 1500 ml of crystalloid and 300 ml of colloid solution. One and a half units of packed RBCs were transfused. Estimated blood loss was 400 ml, and urine output was 150 ml. Postoperatively, the patient was transferred to the intensive care unit (ICU). On arrival at the ICU, his vital signs were BP, 132/58 mmHg; heart rate, 70 beats/min; and oxygen saturation, 100%. Continuous infusion of dopamine 5 µg/kg/min and norepinephrine 0.01 µg/kg/min was maintained. No additional neuromuscular blocking agents were injected. On the second postoperative day (POD), desaturation was not detected after self-respiration with O2 6 L for 3 h, and the patient was extubated. Six hours after extubation, oxygen saturation decreased and the dyspnea appeared. The patient was reintubated and mechanical ventilation was initiated. Thoracic radiography revealed diffuse haziness and parahilar consolidation in both lung fields (Fig. 1). On the seventh POD, the patient was extubated again but was reintubated due to desaturation and dyspnea. On the 10th POD, the haziness and consolidation on simple X-ray decreased, but the third extubation attempt on the 19th POD also failed. Finally on the 27th POD, he was weaned from the ventilator successfully. Four days after extubation, he was transferred to the ward. Fig. 1 Chest radiography on the second postoperative day. Various respiratory manifestations are seen in patients with POEMS syndrome. Relatively common manifestations are pleural effusion, pulmonary hypertension, restrictive lung disease, and a reduced diffusion capacity of carbon dioxide. Pulmonary tumors and phrenic neuropathy are less common [2,3]. Weakness of respiratory muscles also contributes to the pulmonary symptoms. The patient in this report had several pulmonary manifestations-muscle weakness, pleural effusion, marginally high PASP, and restrictive pattern on PFT. Hence, in case he required postoperative respiratory support, we prepared the ICU before starting the surgery. Ifuku et al. [4] reported that POEMS syndrome patients had a higher sensitivity to vecuronium and that the effects of vecuronium persisted longer. Therefore, during the anesthesia of POEMS syndrome patients, neuromuscular blocking agents should be carefully used with neuromuscular monitoring, or should be avoided when possible. In this case, we used rocuronium, 50 mg during induction and four doses of 5 mg each during surgery. We attempted to use the lowest possible dose of muscle relaxants, but because self-respiration was detected and the surgeon reported abdominal muscle tension, we used a small amount of additional rocuronium. During induction of anesthesia, we checked the train of four (TOF) using nerve stimulators (Ministim® MS-IV, Life-Tech, Williston, Vermont, USA and E-NMT-OO, GE Healthcare Finland Oy, Helsinki, Finland) but the twitching was not detected. It is thought that severe subcutaneous edema and skin thickening blocked transmission of electric stimulation, which prevented observation of proper muscle contraction. Tschida et al. [5] reported that in patients with edematous and dry skin, TOF responses were inappropriate and did not correlate with the clinical assessment. There were no significant findings on preoperative cardiac evaluations. However, after the surgery began, persistent hypotension was observed and inotropics were infused continuously. We infused 1500 ml of crystalloid and 300 ml of colloid to maintain blood pressure, and large amounts of fluid and blood were infused in the ICU. Such fluid infusion could aggravate pulmonary edema. After the second failed attempt at extubation, pulmonology and neurology specialists were contacted to determine the cause of failure. Nerve conduction studies and an electromyogram could not be performed due to severe pitting edema, but the neurologist suggested that the dyspnea was not due to a neurological problem since no focal neurologic deficits were observed. In addition, the 6 kg weight gain after ICU admission, severe pitting edema, and chest radiography suggested that pleural effusion and pulmonary edema were the main causes of the failure. In the ICU, diuretics were used to manage the pulmonary edema, but it was difficult to balance input and output because the blood pressure dropped easily with a small volume deficit. Ventilator weaning was finally accomplished on the 27th POD. In summary, because the POEMS syndrome may be accompanied by pulmonary dysfunction leading to postoperative respiratory distress, fluids should be managed judiciously and neuromuscular blocking agents should be used cautiously in anesthetic management.