Ju-Hao Lee

Electro-acupuncture and postoperative emesis

One hundred unpremedicated female patients of ASA grade 1 or 2 who underwent laparoscopy as outpatients were allocated randomly to one of four groups. All patients received general anaesthesia withfentanyl, thiopentone, halothane, nitrous oxide and oxygen; suxamethonium was given to facilitate tracheal intubation. In the recovery room, group I (control) received no treatment; group 2 received electro‐acupuncture at the P6 point (Neiguan) on the right side for 15 minutes, group 3 received transcutaneous electrical nerve stimulation at the P6 point on the right side for 15 minutes and group 4 received prochlorperazine 5 mg intravenously. Any act of vomiting, including dry retching, during the first 3 postoperative hours was regarded as postoperative emesis. The incidence of postoperative emesis was 11/25 (44%) in group 1, 3/25 (12%, p > 0.05) in group 2, 9/25 (36%) in group 3, and 3/25 (12%, p < 0.05) in group 4. Our results suggest that electro‐acupuncture is as effective as prochlorperazine, and may be better than transcutaneous electrical nerve stimulation, in reducing postoperative emesis.

Comparison of P6 acupoint injection with 50% glucose in water and intravenous droperidol for prevention of vomiting after gynecological laparoscopy

Postoperative vomiting causes patients distress and delays discharge after outpatient surgery. Although P6 electroacupuncture is recognized as having an antiemetic effect, its inconvenient instrumentation may limit its clinical applicability. The purpose of this study was to explore a simple and effective alternative method for control of postoperative vomiting in outpatient surgery. We prospectively compared the effect of P6 acupoint injection with 0.2 ml 50% glucose in water (G/W) and intravenous injection of 20 μg/kg droperidol for prevention of vomiting in 120 consecutive outpatients undergoing gynecological laparoscopy with general anesthesia. Patients were randomly allocated to receive P6 acupoint injection, i.v. droperidol, or nothing as control group. Both P6 acupoint injection and i.v. droperidol 20 μg/kg were found to have a significant antiemetic effect when compared with the control group. We conclude that P6 acupoint injection with 50% G/W is a simple and effective method for reducing the incidence of postoperative emesis in outpatient surgery.

Stress response to hepatectomy in patients with a healthy or a diseased liver.

Partial hepatectomy is a major upper abdominal operation associated with certain stress to the patient. Successful adaptation to such stress is a prerequisite for survival. Donor hepatectomy with maximal safety is a principal concern during living donor liver transplantation. The purpose of the study was to compare the stress response by assessing cytokines and the acute-phase response induced by hepatectomy in patients with a healthy liver and those with a diseased liver. Fourteen patients undergoing partial right hepatectomy were enrolled in this study. Seven of them were donors for living related liver transplantation (group I, or GI); the other seven were patients with hepatocellular carcinoma due to chronic hepatitis B (Child’s class A) (GII). Blood samples for interleukin-6 (IL-6), tumor necrosis factor-α (TNFα), and C-reactive protein (CRP) assays were collected before the operation, at the beginning and end of the operation, and 24 and 48 hours after the operation. The data were analyzed and compared in the same group using the Friedman test and between groups using the Mann-Whitney U-test. A value of p < 0.05 was regarded as significant. Results showed that resection of the liver in patients with both healthy and disease livers leads to significant increases in IL-6 and CPR but not TNFα. Significantly lower levels of IL-6 before and after operation in GI patients compared to those in GII patients suggests that GI patients adapted to surgical stress more easily than did the GII patients.

Aspiration in transtracheal jet ventilation.

Background: Transtracheal jet ventilation (TJV) has been used successfully for managing difficult airways. However, there are some controversies regarding pulmonary aspiration. It has been shown that TJV caused no aspiration as long as the frequency of ventilation was kept higher than 60/ min. On the other hand, it has been demonstrated that manual translaryngeal jet ventilation at 20 breaths per minute also provided good protection from aspiration even with 30‐degree head‐up position. The purpose of this study was to reevaluate this controversy with observation of the trachea and the lungs together during TJV.

Repeated hypotensive episodes due to hepatic outflow obstruction during liver transplantation in adult patients

We report two cases of unusual repeated hypotension, decreased cardiac output, decreased mixed venous oxygen saturation, decreased central venous pressure, pulmonary artery pressure, and pulmonary wedge pressure after the completion of all vascular anastamoses of liver transplantation. These unstable hemodynamics appear to reflect a clinically relevant picture of hypovolemia. However, the real cause was partial hepatic outflow obstruction. The obstruction was suspected because hypotension was alleviated by elevating the full-sized liver graft ventrally and to the left. Doppler ultrasound examination confirmed that the flow velocity of the hepatic vein outflow was insufficient when the liver fell to its resting position in the right hepatic fossa. An additional side-to-side cavo-caval anastomosis resolved the problem in one patient, whereas the other required not only the additional anastomosis, but also application of a tissue expander filled with 770 mL normal saline beneath the liver to eliminate the obstruction. We emphasize that obstruction of the hepatic outflow causes only temporal hypovolemia because of a decrease of venous return and that treatment of this complication should be surgical intervention to relieve the obstruction. Blind resuscitation with fluids will not solve the problem and, in fact, may result in fluid overload with subsequent complications.

Bullous eruptions caused by extravasation of mannitol--a case report.

Extravasation is one of the common complications seen with intravenous infusion. We bring forward a case of subcutaneous mannitol extravasation, which caused swelling and multiple cutaneous bullous eruptions in the hand and forearm during craniotomy. Treatment consisting of elevation of the affected extremity and application of silver sulfadiazine ointment twice daily to the injured area was successful. The possible mechanisms relevant to extravasation and its tissue damage are reviewed and discussed. Selecting proper intravenous infusion site, using pliable catheters and frequent inspection are important steps for prevention of extravasation.

Removal of an Aspirated Prosthetic Tooth by Tracheal Backflow Air

A 65-yr-old male (50 kg) patient with suspected small cell carcinoma of the lung was referred to our hospital. Chest radiograph and computerized tomogram revealed multiple small nodules over both lungs and left pleural effusion. Sputum cultures and aspiration cytology for tuberculosis were negative. Because the clinical course and laboratory data did not confirm either malignancy or tuberculosis, a thoracoscopic biopsy under anesthesia was planned. Preoperative laboratory data were within normal range. Moderate restrictive ventilatory impairment was found in a pulmonary function test. A double-lumen endotracheal tube was easily inserted after induction with fentanyl 200 mg, thiopental 250 mg, and vecuronium 10 mg. Anesthesia was maintained with 1%–1.5% isoflurane in 50% oxygen-air mixture. The operation became a minithoracotomy but was performed uneventfully in 4 h. The double-lumen endotracheal tube was replaced postoperatively by a 7.5 singlelumen tube without difficulty. The patient was sent to the cardiovascular surgery intensive care unit with ventilatory support On the second postoperative day, a routine chest radiograph was taken. Surprisingly, a FB was found in front of the endotracheal tube inside the trachea (Figure 1). A chest specialist was consulted, but bronchoscopic removal of the FB with the endotracheal tube in place was difficult, because there was insufficient space to manipulate the slippery tooth. After a half hour, the specialist gave up and asked if we could remove the endotracheal tube so that he could have a bigger space to work with. However, we did not agree, because we feared that the tooth might descend further down the airway and become lodged in the opening of the main bronchus. Because a different position of the tooth was found in a repeat chest radiograph, we thought that it might be floating above the cuff of the endotracheal tube. We therefore tried to deflate the cuff and, at the same time, compressed the breathing bag forcefully hoping that a strong airflow would push the tooth back up into the mouth. We succeeded and removed the tooth (Figure 2) from the mouth with Magill forceps. The patient was tracheally extubated later. The lung biopsy confirmed the diagnosis of pulmonary tuberculosis.

Endorphin and cortisol responses to surgical stress in newborns and infants

The beta-endorphin (BE) response to surgical stress in newborns and infants and its relation to pituitary-adrenal dynamics during stress is still unknown. Nine newborns 5 h to 5 days of age, and 5 infants 5 to 10 months old undergoing surgery were studied. All patients were anesthetized with N2O–O2 and halothane. Blood samples for BE and cortisol determinations were taken preoperatively and 30 min, 12 h, and 24 h after operation for radioimmunoassay. Both BE and cortisol levels in newborns were not significantly different from those in infants preoperatively (196±85.2 pg/ml vs. 138±47.8 pg/ml for BE and 23.7±17.5 μg/dl vs. 10.1±5.6 μg/dl for cortisol, P >0.05). At 30 min after operation, no significant increase in BE (220±106 pg/ml) and cortisol (36.1±21.2 μg/dl) was found in newborns, while significant increases (BE 493±281 pg/ml, cortisol 43.9±24.2 μg/dl) were found in infants compared to preoperative levels (both P <0.05). A significant difference between groups was seen in BE but not cortisol levels 30 min after operation. Both BE and cortisol declined to preoperative values within 24 h after surgery. Our study showed significant BE and cortisol responses to surgical stress in infants, but not in newborns. Factors such as age-related differential responses to the same anesthetic technique, duration of operation, and developmental differences in stress response are considered responsible for the differences.

Aspiration in transtracheal oxygen insufflation with different insufflation flow rates during cardiopulmonary resuscitation in dogs.

We investigated whether transtracheal insufflation of oxygen with different insufflation flow rates protects against aspiration of gastric contents during cardiopulmonary resuscitation (CPR). Its ventilation and oxygenation effects were also evaluated. Cardiac arrest was induced in anesthetized and paralyzed 18 mongrel dogs. Chest compression using an automatic thumper was performed while the dogs randomly received no mechanical ventilation (Group I, n = 6) or were transtracheally insufflated with 4 L/min oxygen (Group II, n = 6) or 10 L/min oxygen (Group III, n = 6). Blood samples were drawn every 5 min for 20 min for blood gas analysis. the mouths of the dogs were then filled with 70 mL mixed barium, and 10 min after chest compression, chest radiographs were taken to evaluate the incidence of pulmonary aspiration. Results showed that pulmonary aspiration occurred in all dogs of Group I and three of the six dogs in Group II, whereas dogs in Group III were free from pulmonary aspiration. Both transtracheal oxygen insufflation groups maintained oxygen saturation significantly better than Group I, but mild hypercapnia was observed in all groups after 20 min of CPR. We conclude that transtracheal oxygen insufflation, but not chest compression alone, was able to maintain oxygenation for 20 min during CPR in dogs with cardiac arrest. Mild hypercapnia was noted in all groups. Chest compression alone caused pulmonary aspiration, whereas insufflation of 10 L O2/min provided better protection against pulmonary aspiration than that of 4 L O2/min. Implications In case of difficult airway during cardiopulmonary resuscitation, insertion of an IV catheter through the trachea is easy, and insufflation of 10 L/min of oxygen through the needle can not only maintain the oxygenation but also prevent aspiration.

Effects of temperature on somatosensory evoked potentials during open heart surgery

Somatosensory evoked potentials (SEPs) have been found to be useful for early detection of brain ischemia during hypothermic cardiopulmonary bypass in cardiac surgery. However, the relationship between temperature and latency period remains unclear. We prospectively analyzed SEPs obtained during hypothermic cardiopulmonary bypass in 20 patients who had valvular replacement.