Toshiyuki Shigematsu

Nasal intubation with Bullard laryngoscope : a useful approach for difficult airways

Since the original technique using the Bullard laryngoscope requires considerable practice to be reliable, we have developed an easier method with a directional-tip endotracheal tube through the nostril. We first examined the feasibility of our method in patients with or without difficult airways. All 26 patients with difficult airways were successfully tracheally intubated with our method, and times for visualization and intubation were not different from those in 10 patients with normal airways. We further examined the direction of the tips of endotracheal tubes through the nostril in 128 patients with normal airways using four combinations of two kinds of both laryngoscopes (Bullard and Macintosh) and endotracheal tubes (directional-tip tube: EndotrolTM Mallinckrodt Laboratories, Athlone, Ireland; or straight distal-end tube: Blue LineTM, Portex Ltd., Hythe Kent, United Kingdom). We found that a combination of the Bullard laryngoscope and the EndotrolTM tube had a higher probability of accessing the center of the glottis than the others. In conclusion, nasal insertion of a directional-tip tube assisted by the Bullard laryngoscope is an assured and prompt procedure for intubating the tracheas of patients with difficult airways.

Trigeminal nerve palsy after lumbar epidural anesthesia.

Epidural anesthesia is a safe and useful method to control pain, but it is not completely free of complications. A patient was treated using this method and we experienced a rare complication, that, although already published in Japanese (Shigematsu S, Kobayashi M, Ochiai R, Nagano M. The Journal of Pain Clinic 1984;5(4):371-4), we feel deserves to be called to the attention of those who do not read Japanese. A patient with periarteritis nodosa and severe bilateral leg pain was referred to our pain clinic. Epidural block was performed through an indwelling catheter at the L3-4 level. Bupivacaine, 18 ml of 0.5% solution, was injected through this catheter, and analgesia to the T9 level was achieved successfully. When the second dose of the same agent was given the next day, analgesia was not achieved but a right sided Horner’s syndrome, paresthesia of the C4 and C5 dermatome area of the right arm, and evidence of trigeminal nerve palsy consisting of paresthesia of the right side of the face and dysarthria of the right side of the temper0 mandibular joint appeared. The area of the facial paresthesia was that innervated by the ophthalmic and maxillary branches of the trigeminal nerve, and dysarthria was due to the paralysis of the muscles of mastication that are innervated by the motor (mandibular) branch of the trigeminal nerve. There was no change in the level of conciousness or dyspnea and the symptoms subsided after 20 to 30 min. Bupivacaine, 10 ml of 0.5% solution, was subsequently injected through the same catheter on the same day, but none of these symptoms appeared. An x-ray study using a contrast dye showed that the dye spread around the L3-4 level in the epidural space and no abnormality was disclosed. A few cases of Horner’s syndrome, but no case of trigeminal nerve palsy after epidural block have been reported previously. On approaching the nucleus about 50% of the trigeminal nerve fibers divide into ascending and descending branches. The descending fibers form the spinal tract of the trigeminal nerve, which descends into the upper cervical part of the spinal cord. Also, the nucleus of the spinal tract of the trigeminal nerve is continuous below with the substantia gelatinosa. This may explain the trigeminal nerve palsy after epidural block that occurred in our patient.

Comparative effect of 6% hydroxyethyl starch (containing 1% dextrose) and lactated Ringer's solution for cesarean section under spinal anesthesia

AbstractPurpose. This study aimed to compare low-molecular weight hydroxyethyl starch containing 1% dextrose (HES) infusion and lactated Ringers solution (LR) in the prevention of hypotension associated with spinal anesthesia for cesarean section. Methods. Sixty-seven patients scheduled for cesarean section under spinal anesthesia were randomly allocated to receive either LR (n= 35) or HES (n= 32) infusion before cesarean delivery. Infusion of the fluid was started immediately after arrival at the operating room, through two fully open i.v. routes of 18 or 16 gauge. The two groups were compared in terms of the incidence of hypotension; ephedrine dose; cord and maternal blood gas, hemoglobin, and glucose; and Apgar scores. Results. Intravenous fluid volume until delivery in the LR group was significantly greater than that in the HES group (1298 ± 503 and 973 ± 339 ml, respectively) in spite of the similar periods of intravenous infusion (18.1 ± 3.9 and 18.2 ± 4.1 min). The incidence of hypotension, and the ephedrine dose, blood gas analyses, and Apgar scores were not significantly different between the groups. The ephedrine dose correlated with the anesthesia level by spinal anesthesia (P < 0.05). Conclusion. This study did not show an advantage of HES compared with LR in the prevention of hypotension or in the reduction of ephedrine dose during cesarean section under spinal anesthesia. The anesthesia level, rather than the choice of intravenous fluid solution, might be related to the ephedrine dose.

Epidural anesthesia during upper abdominal surgery provides better postoperative analgesia

Since repeated noxious stimuli may sensitize neuropathic pain receptors of the spinal cord, we tested the hypothesis that the appropriate blockade of surgical stimuli with epidural anesthesia during upper abdominal surgery would be beneficial for postoperative analgesia. Thirty-six adult patients undergoing either elective gastrectomy or open cholecystectomy were randomly allocated to receive either inhalational general anesthesia alone (group G) or epidural anesthesia along with light general anesthesia (group E) throughout the surgery. Postoperative pain management consisted of patient-controlled analgesia (PCA) with bupivacaine accompanied by the continuous infusion of buprenorphine. To assess postoperative pain, a visual analogue scale (VAS) was employed at 2, 24, and 48 h postoperatively. While there was no significant difference in the bupivacaine dose, more patients undergoing gastrectomy in group G required supplemental analgesics than those in group E, and the VAS scores in group E demonstrated significantly better postoperative analgesia compared to group G after both types of surgery. Thus, an appropriate epidural blockade during upper abdominal surgery likely provides better postoperative pain relief.

Epidural anesthesia during hysterectomy diminishes postoperative pain and urinary cortisol release

PurposeTo examine the hypothesis that epidural anesthesia throughout lower abdominal surgery would depress both postoperative pain and cortisol release.MethodsForty adult patients undergoing abdominal total hysterectomy were studied. The patients were randomly assigned to two groups. Group G received general anesthesia alone (sevoflurane 1.5%–2.5%); group E received a combination of epidural anesthesia (1.5% mepivacaine) with a light plane of general anesthesia (sevoflurane<0.5%). Postoperative analgesia was obtained epidurally by patient-controlled analgesia. Postoperative pain at rest and during movement was assessed by a visual analogue scale (VAS) at 2, 24, and 48 h following surgery. The plasma concentration and urinary excretion of cortisol were measured during the perioperative period.ResultsVAS values were lower in group E than in group G during movement at 24h (4.6±0.5vs 6.1±0.4 cm). Urinary cortisol excretion on the first postoperative day was less in group E than in group G (192±34vs 480±120μg).ConclusionsEpidural blockade prior to surgical stimuli and throughout lower abdominal surgery reduces the postoperative dynamic pain and stress response.

Effects of epidural buprenorphine on bowel movement following gynecological surgery

While epidural administration of opioids has been widely employed to relieve either acute or chronic pain [1], this method likely disturbs physiological bowel motility [2,3]. The question as to whether or not buprenorphine epidurally administered modifies the bowel movement after abdominal surgery has not yet been answered. We compared the effects of postoperative lumbar epidural infusion and intermittent intramuscular administration of buprenorphine, on bowel motility following gynecological surgery. After obtaining approval from the hospital ethics committee and informed consent from all participants, 30 adult patients (ASA grade 1 to 2) undergoing elective abdominal total hysterectomy under the diagnosis of myoma uteri were included in the study. None of the patients had a history of either abnormal bowel habits, taking any drugs known to influence gastrointestinal motility, or abdominal surgery. All patients were given ranitidine 150 mg orally at 9:00 p.m. on the day before surgery, and hydroxyzine 50 mg with atropine 0.5 mg, i.m. 60min before surgery. The patients were then randomly allocated to two groups according to the postoperative analgesic management: control group (n = 15) or epidural group (n = 15). In the latter group, an epidural catheter was inserted at the T12/L1 or L1/2 level prior to the induction of general anesthesia. The epidural space was identified by the loss-ofresistance method, followed by injection of 5 mL of 1% mepivacaine.

Laryngeal mask airway is useful for fiberoptic bronchoscopic evaluation of subglottic stenosis in children: a report of eleven cases

lines, with size No. 1 being used for children less than 6.5kg and size No. 2 for children weighing 6.5–20 kg. Endoexpiratory carbon dioxide concentration and blood oxygen saturation, by pulse oximetry, were monitored in all cases. Ventilation in patients without a tracheostomy was performed through the main entry of the Y-connector between the LMA and the anesthesia circuit, and through the tracheostomy in patients with a tracheostomy (Fig. 1b). Ventilation was usually spontaneous, but was supported by assisted ventilation when patients hypoventilated. Next, a fiberoptic bronchoscope (FOB) with a diameter of 3.5 mm (3C10, Olympus Optical, Tokyo, Japan) was inserted through the side entry of the Y-connector in patients without a tracheostomy, and directly through the LMA in patients with a tracheostomy, and was advanced into the subglottic space (Fig. 1c). If the FOB was too large to pass through the stenotic portion of the subglottic space, a smaller FOB, 1.8mm diameter (PF, Olympus Optical, Tokyo, Japan), was tried. Since the FOB does not have a movable tip, it was not possible to pass it through the slits of the LMA which was already in place, and the LMA had to be removed first. The LMA was then reinserted with the FOB through its slit. If this technique failed to allow the PF to be advanced into the subglottic space, we attempted to examine the subglottic area with the FOB positioned close the vocal cord. In patients with a tracheostomy, several other techniques were attempted after removal of the LMA, such as oral or nasal insertion of either size FOB, followed by an attempt to insert it through the vocal cords while holding it with Magill forceps. Ease of insertion of the LMA was subjectively assessed as “good” if it was possible to insert it with a clear view of the vocal cord on the first attempt, “acceptable” if the first attempt failed, but changing the depth or angle by bronchoscopy yielded a clear view of the vocal cord in the middle of the slits of the LMA, “unacceptable” if, after several trials, no view of the vocal cord

Does increasing end-tidal carbon dioxide during laparoscopic cholecystectomy matter?

To examine the adverse effects of peritoneal carbon dioxide (CO2) insufflation during laparoscopic cholecystectomy, both hemodynamic and respiratory alterations were continously monitored in 17 adult patients using noninvasive Doppler ultrasonography and a continuous spirometric monitoring device. During the surgery, which was performed under inhalational general anesthesia, intraabdominal pressure was maintained automatically at 10mmHg by a CO2 insufflator, and a constant minute ventilation, initially set to 30–33 mmHg of end-tidal CO2 (ETCO2), was maintained. Despite considerable depth of anesthesia, peritoneal CO2 insufflation induced a significant and immediate increase of mean blood pressure (+42%) and systemic vascular resistance (+62%), accompanied by a slight depression of cardiac index (−12%, nonsignificant), while the ETCO2 gradually increased and maximized around 30min following the initial CO2 insufflation. The stress of 10mmHg pneumoperitoneum was a major cause of hemodynamic changes during laparoscopic cholecystectomy. Some clinical strategies such as deliberate intraabdominal insufflation at the initial phase might be required to minimize these hemodynamic changes.