Yi-Wei Kuo

Comparison of the GlideScope® videolaryngoscope and the Macintosh laryngoscope for double‐lumen tube intubation

Intubation with a double‐lumen tube is important for achieving one‐lung ventilation and facilitating thoracic surgery. The GlideScope® videolaryngoscope (Verathon Inc., Bothell, WA, USA) is designed to assist tracheal intubation for patients with a difficult airway. We wished to compare the GlideScope and direct laryngoscopy for double‐lumen tube intubation. Sixty adult patients requiring a double‐lumen tube for thoracic surgery and predicted uncomplicated laryngoscopy were randomly assigned to a direct Macintosh laryngoscopy group (n = 30) or a GlideScope group (n = 30). The mean (SD) duration of intubation was longer in the Macintosh group (62.5 (29.7) s) than in the GlideScope group (45.6 (10.7) s; p = 0.007). There was no difference in the success of the first attempt at intubation (26/30 (87%) and 30/30 (100%) for Macintosh and GlideScope groups, respectively; p = 0.112). The incidence of sore throat and hoarseness was higher in the Macintosh group (18 (60%) and 14 (47%), respectively) than in the GlideScope group (6 (20%) and 4 (13%), respectively; p = 0.003 and 0.004). We conclude that double‐lumen tube intubation in patients with predicted normal laryngoscopy is easier using the GlideScope videolaryngoscope than the Macintosh laryngoscope.

Lateral Rotation of the Lower Extremity Increases the Distance Between the Femoral Nerve and Femoral Artery: An Ultrasonographic Study

Femoral nerve block (FNB) is by far the most useful lower extremity regional anesthetic technique for the anesthesiologist, and high‐resolution ulrrasonography is a useful tool with which to guide the performance of FNB. However, the relationships between the femoral nerve and the femoral artery in different lower extremity positions have rarely been discussed. The purpose of this study was to evaluate the relative positions of the femoral nerve and artery at different lateral rotational angles of the lower extremities using ultrasonographic imaging. We enrolled 41 healthy volunteers in this study Two‐dimensional ultrasonographic images of the femoral nerve were obtained using an ultrasound unit, in the inguinal crease, for four positions of the bilateral lower extremities: 0°, 15°, 30° and 45° lateral rotation of each extremity. The following assessments were made in each position: minimal skin‐to‐nerve distance (SN) and deviation of nerve‐to‐landmark (femoral artery pulsation) horizontal distance (NF). A trend towards lateral rotation of both lower extremities was identified. The Pearson correlation values between rotational degree to SN and rotational degree to NF were −0.216 and 0.430, with p values of 0.001 and less than 0.001, respectively. Body mass index had a good correlation (r=0.76‐0.78) with SN. The results of our ultrasound study revealed that the more lateral the rotation of both lower extremities, the closer the femoral nerve was to the skin and the farther away it was from the femoral artery. In order to increase the success rate and decrease the rate of complications, a suggested lateral 45° rotation of both lower extremities is strongly recommended when performing FNB using the peripheral nerve stimulator technique or the field block technique. In any situation, individual ultrasound guidance is recommended for FNB whenever possible.

Left endobronchial intubation with a double‐lumen tube using direct laryngoscopy or the Trachway® video stylet

We compared direct laryngoscopy with a Macintosh blade vs indirect bronchoscopy with a Trachway® stylet, for endobronchial intubation with a left‐sided double‐lumen tube. We allocated participants scheduled for thoracic surgery and who had normal predicted laryngoscopy, 30 to each group. The mean (SD) intubation times with laryngoscope and Trachway were 48 (11) s vs 28 (4) s, respectively, p < 0.001. The rates of hoarseness on the first postoperative day, categorised as none/mild/moderate/severe, were 10/12/7/1 and 22/6/2/0, respectively, p = 0.008, without differences on subsequent days. Left endobronchial intubation with a double‐lumen tube is slower using direct laryngoscopy and causes more hoarseness than indirect bronchoscopy with a Trachway stylet.

Electromyographic study of differential sensitivity to succinylcholine of the diaphragm, laryngeal and somatic muscles: a swine model.

Neuromuscular blocking agents (NMBAs) might diminish the electromyography signal of the vocalis muscles during intraoperative neuromonitoring of the recurrent laryngeal nerve. The aim of this study was to compare differential sensitivity of different muscles to succinylcholine in a swine model, and to realize the influence of NMBAs on neuromonitoring. Six male Duroc‐Landrace piglets were anesthetized with thiamylal and underwent tracheal intubation without the use of an NMBA. The left recurrent laryngeal nerve, the spinal accessory nerve, the right phrenic nerve and the brachial plexus were stimulated. Evoked potentials (electromyography signal) of four muscle groups were elicited from needle electrodes before and after intravenous succinylcholine bolus (1.0 mg/kg). Recorded muscles included the vocalis muscles, trapezius muscle, diaphragm and triceps brachii muscles. The onset time and 80% recovery of control response were recorded and analyzed. The testing was repeated after 30 minutes. The onset time of neuromuscular blocking for the vocalis muscles, trapezius muscle, diaphragm and triceps brachii muscle was 36.3 ± 6.3 seconds, 38.8 ± 14.9 seconds, 52.5 ± 9.7 seconds and 45.0 ± 8.2 seconds during the first test; and 49.3 ± 10.8 seconds, 40.0 ± 12.2 seconds, 47.5 ± 11.9 seconds and 41.3 ± 10.1 seconds during the second test. The 80% recovery of the control response for each muscle was 18.3 ± 2.7 minutes, 16.5±6.9 minutes, 8.1±2.5 minutes and 14.8±2.9 minutes during the first test; and 21.5±3.8 minutes, 12.5 ± 4.3 minutes, 10.5 ± 3.1 minutes and 16.4 ± 4.2 minutes during the second test. The sensitivity of the muscles to succinylcholine, ranked in order, was: the vocalis muscles, the triceps brachii muscle, the trapezius muscle and the diaphragm. We demonstrated a useful and reliable animal model to investigate the effects of NMBAs on intraoperative neuromonitoring. Extrapolation of these data to humans should be done with caution.

Application of a Double-lumen Tube for One-lung Ventilation in Patients With Anticipated Difficult Airway

One-lung ventilation (OLV) is essential in some surgical situations. The use of double- lumen tubes (DLTs) can achieve OLV more quickly and more easily than bronchial blockers. The management of a difficult airway is a challenge for anesthesiologists when, at the same time, OLV is needed for a surgical procedure. This report describes the successful application of DLTs in two patients with difficult airways, and who were scheduled for pulmonary decortication. Case 1 already had a permanent tracheostomy, while Case 2 had oral cancer with an extremely limited mouth opening and needed elective tracheostomy for anesthesia. Nasal intubation of Case 2 was done with fiberoptic-guided intubation with the patient awake. OLV was achieved uneventfully after inserting the DLT directly through the tracheostomy in both cases. We also describe the appropriate use of airway devices for OLV, focusing on patients with an anticipated difficult airway.

Quality improvement program reduces perioperative dental injuries – A review of 64,718 anesthetic patients

Background Perioperative dental injury (PDI) is a common adverse event associated with anesthesia that can easily lead to medicolegal litigation. A quality improvement program was conducted with the electronic, standardized dental chart to document dentition before anesthesia and dentist consultation when necessary. This study aimed to reduce PDIs through execution of a quality improvement program. Methods We reviewed the 42‐month interval anesthetic records of 64,718 patients who underwent anesthesia. A standardized electronic dental chart was designed to identify any dental prosthetics, fixed and removable dentures, and degree of loose teeth. The incidence of dental injuries associated with anesthesia was separated into three time periods: baseline, initiative (Phase I), and execution (Phase II). Primary outcome measurement was the incidence of PDIs related to anesthesia. Results The overall incidence of dental injury related to anesthesia was 0.059% (38/64,718 patients). During the baseline period, the dental injury rate was 0.108% (26/24,137 patients), and it decreased from 0.051% in the initiative period (10/19,711 patients) to 0.009% in the execution period (2/20,870 patients) during implementation of the quality improvement program. Most dental injuries were associated with laryngeal mask airway (42.1%) and laryngoscopy (28.9%). The most commonly involved teeth were the upper incisors. Conclusion Dental injury incidence was significantly reduced and remained at low levels after implementation of the quality improvement program. We suggest the implementation of a standardized dental examination into the preoperative evaluation system adding pathologic teeth fixed or protected devices to minimize dental injury associated with anesthesia.

Continuous Infraclavicular Block for Forearm Amputation after Being Bitten by a Saltwater Crocodile (Crocodylus Porosus): A Case Report

Two important issues after a complete right forearm amputation are replantation and ongoing pain management. There are no reports of successful forearm replantation as a consequence of a crocodile bite. Here, we discuss our pain management in a case of complete forearm amputation after a bite from a saltwater crocodile (Crocodylus porosus), which necessitated six further operations to achieve successful replantation. Continuous infraclavicular brachial plexus block was effective for acute pain control in this case. We strongly recommend performing the block with an indwelling catheter under ultrasound guidance for higher accuracy and safety.

A Live Animal Model for Learning ultrasound-guided Spinal Anesthesia

Background: Ultrasound guidance has gained more popularity in both peripheral nerve and neuraxial block. A feasible live animal model for neuraxial block using ultrasound guidance has not been reported. The purpose of this study was to establish a feasible live swine model for learning ultrasound-guided spinal anesthesia. Materials and methods: Six Duroc-Landrace piglets were anesthetized and intubated. A Micromax ultrasound system with a low frequency curved array transducer was employed to obtain the spinal sonoanatomy in lumbar region. Spinal anesthesia was performed with a 22-guage spinal needle with in plane technique. Anesthetic records included pop sign of dural puncture, ultrasound image and finally cerebrospinal fluid flow. Results: Typical spinal sonoanatomy was obtained via paramedian sagittal oblique scan, The success of spinal anesthesia can be confirmed by pop sign of dural puncture, ultrasound image and/or finally cerebrospinal fluid flow, Conclusion: This report demonstrates a reliable and practical animal model for learning ultrasound-guided spinal anesthesia.

Impending Diabetic Ketoacidosis after Epidural Steroid and Local Anesthetics Administration for Herpes Zoster with Deafferentation Pain of a Diabetic Patient-A Case Report

Postherpetic neuralgia (PHN) is the most complication of Herpes zoster (HZ) and one of the most intractable neuropathic pains. The use of corticosteroids with or without other concomitant therapy for HZ and PHN is not guaranteed. Previous studies showed that epidural injection of steroids and local anesthetics or/and antiviral therapy in acute phase of herpes zoster is a promising therapy for reductions in the use of analgesics, the time to uninterrupted sleep, the time to resumption of usual activities ,and prevention of PHN. However, Corticosteroid therapy is seldom used in patients at risk for corticosteroid-induced toxicity (e.g., patients with diabetes mellitus or gastritis) and makes a restriction for these patients. We present a case of 67-year-old female patient with the history of diabetes mellitus who presented with impending diabetic ketoacidosis (DKA) 8 days after receiving 40 mg triamcinolone into the epidural space for prevention of PHN and relief of HZ with deafferentation pain. Further investigations of metabolic and endocrine sequelae of epidural corticosteroid, association between diabetic patient and the use of epidural steroid and the strategies of treatment and prevention of postherpetic neuralgia will be beneficial for clinicians in helping this kind of patients who suffered from this problem.

Acupuncture Injections Have Early Effect in Controlling Postoperative Nausea and Vomiting of Patients Receiving Pneumoperitoneal Laparoscopic Surgery

Acupuncture is generally accepted that there is clear evidence that acupuncture can be effective for nausea and vomiting associated with pregnancy, chemotherapy, and the postoperative period. Postoperative Nausea and Vomiting (PONV) is one of the dominant postoperative problems of pneumonperitoneal laparoscopic surgery which incidence was reported as high as 45%. Postoperative nausea and vomiting (PONV) is an important cause of delayed discharge from the recovery room and decreased patient satisfaction. Our study is designed to investigate whether P6 acupoint injections is effective as a preventive treatment for postoperative nausea and vomiting of adults receiving laparoscopic pneumonperitoneal surgery. We also examine the response between different sorts of injection agents. We collected 150 patients was randomly divided into 5 groups: (1) Control N group (Cn), bilateral P6 sham point injections with normal saline 1ml; (2) Control L group (Cl), bilateral P6 sham point injections with 1% lidocaine 1ml; (3) Experiment N group (En), bilateral P6 acupoint injection with normal saline 1ml; (4) Experiment L group(El), bilateral P6 acupoint injection with 1% lidocaine 1ml. (5) Reference (Rf), no acupoint injection used. We applied double-blinded method to follow up the events of postoperative nausea and vomiting which were recorded by another observer unknown about 5 groups for 24 hours. Incidence of PONV among Rf, Cn, Cl, En, El were 41%(12/30), 36%(11/30), 43%(13/30), 27%(8/30) and 33%(10/30). En group was found with significant difference in decreased incidence of PONV compared with other groups. But, no significant difference between El group and other three groups (Rf, Cn and Cl). In conclusion: P6 acupoint injections with normal saline may be an alternative, economic method to prevent early postoperative nausea and vomiting. 1%Lidocaine can block early antiernetic effect of P6 acupoint.