Endotracheal intubation by inexperienced trainees using the Clarus Video System: learning curve and orodental trauma perspectives

BACKGROUND: The ideal alternative airway device should be intuitive to use, yielding proficiency after only a few trials. The Clarus Video System (CVS) is a novel optical stylet with a semi-rigid tip; however, the learning curve and associated orodental trauma are poorly understood. METHODS: Two novice practitioners with no CVS experience performed 30 intubations each. Each trial was divided into learning (first 10 intubations) and standard phases (remaining 20 intubations). Total time to achieve successful intubation, number of intubation attempts, ease of use, and orodental trauma were recorded. RESULTS: Intubation was successful in all patients. In 51 patients (85%), intubation was accomplished in the first attempt. Nine patients required two or three intubation attempts; six were with the first 10 patients. Learning and standard phases differed significantly in terms of success at first attempt, number of attempts, and intubation time (70% vs. 93%, 1.4 ± 0.7 vs. 1.1 ± 0.3, and 71.4 ± 92.3 s vs. 24.6 ± 21.9 s, respectively). The first five patients required longer intubation times than the subsequent five patients (106.8 ± 120.3 s vs. 36.0 ± 26.8 s); however, the number of attempts was similar. Sequential subgroups of five patients in the standard phase did not differ in the number of attempts or intubation time. Dental trauma, lip laceration, or mucosal bleeding were absent. CONCLUSIONS: Ten intubations are sufficient to learn CVS utilization properly without causing any orodental trauma. A relatively small number of experiences are required in the learning curve compared with other devices.

Dynamic optic nerve sheath diameter responses to short-term hyperventilation measured with sonography in patients under general anesthesia / 대한마취과학회지

BACKGROUND: Rapid evaluation and management of intracranial pressure (ICP) can help to early detection of increased ICP and improve postoperative outcomes in neurocritically-ill patients. Sonographic measurement of optic nerve sheath diameter (ONSD) is a non-invasive method of evaluating increased intracranial pressure at the bedside. In the present study, we hypothesized that sonographic ONSD, as a surrogate of ICP change, can be dynamically changed in response to carbon dioxide change using short-term hyperventilation. METHODS: Fourteen patients were enrolled. During general anesthesia, end-tidal carbon dioxide concentration (ETCO2) was decreased from 40 mmHg to 30 mmHg within 10 minutes. ONSD, which was monitored continuously in the single sonographic plane, was repeatedly measured at 1 and 5 minutes with ETCO2 40 mmHg (time-point 1 and 2) and measured again at 1 and 5 minutes with ETCO2 30 mmHg (time-point 3 and 4). RESULTS: The mean +/- standard deviation of ONSD sequentially measured at four time-points were 5.0 +/- 0.5, 5.0 +/- 0.4, 3.8 +/- 0.6, and 4.0 +/- 0.4 mm, respectively. ONSD was significantly decreased at time-point 3 and 4, compared with 1 and 2 (P < 0.001). CONCLUSIONS: The ONSD was rapidly changed in response to ETCO2. This finding may support that ONSD may be beneficial to close ICP monitoring in response to CO2 change.

Dynamic optic nerve sheath diameter responses to short-term hyperventilation measured with sonography in patients under general anesthesia / 대한마취과학회지

BACKGROUND: Rapid evaluation and management of intracranial pressure (ICP) can help to early detection of increased ICP and improve postoperative outcomes in neurocritically-ill patients. Sonographic measurement of optic nerve sheath diameter (ONSD) is a non-invasive method of evaluating increased intracranial pressure at the bedside. In the present study, we hypothesized that sonographic ONSD, as a surrogate of ICP change, can be dynamically changed in response to carbon dioxide change using short-term hyperventilation. METHODS: Fourteen patients were enrolled. During general anesthesia, end-tidal carbon dioxide concentration (ETCO2) was decreased from 40 mmHg to 30 mmHg within 10 minutes. ONSD, which was monitored continuously in the single sonographic plane, was repeatedly measured at 1 and 5 minutes with ETCO2 40 mmHg (time-point 1 and 2) and measured again at 1 and 5 minutes with ETCO2 30 mmHg (time-point 3 and 4). RESULTS: The mean +/- standard deviation of ONSD sequentially measured at four time-points were 5.0 +/- 0.5, 5.0 +/- 0.4, 3.8 +/- 0.6, and 4.0 +/- 0.4 mm, respectively. ONSD was significantly decreased at time-point 3 and 4, compared with 1 and 2 (P < 0.001). CONCLUSIONS: The ONSD was rapidly changed in response to ETCO2. This finding may support that ONSD may be beneficial to close ICP monitoring in response to CO2 change.

An awake double lumen endotracheal tube intubation using the Clarus Video System in a patient with an epiglottic cyst: a case report / 대한마취과학회지

A 54-year-old male patient was scheduled for an elective pylorus-preserving pancreaticoduodenectomy combined with video-assisted thoracic surgery at our hospital. This patient had a history of intubation failure in other institutions due to an epiglottic cyst. An airway assessment of the patient was normal. A preoperative laryngoscopy revealed a bulging epiglottic mass covering most of the epiglottis and occupying most of the pharyngeal space. The patient was administered intravenous midazolam 1 mg, fentanyl 50 microg, and glycopyrrolate 0.2 mg. A bilateral superior laryngeal nerve block was then performed with 2% lidocaine 2 ml on each side. A 10% lidocaine spray was applied on to the oropharynx. After preoxygenation with 100% oxygen over 10 minutes, a rigid fiberscope with an optical stylet loaded with a 37 Fr double lumen endotracheal tube was inserted orally and passed into the glottic aperture. The patient was fully awakened after surgical procedure and was transferred to the recovery room after extubation.

Anaphylactic reactions after cisatracurium administration in two patients: a report of two cases / 대한마취과학회지

Cisatracurium was initially characterized to have no evident histamine-releasing potential with excellent cardiovascular stability. However, severe anaphylactic reactions to cisatracurium that resulted in bronchospasms and cardiovascular collapse have been reported worldwide. Two cases of severe anaphylactic reactions after the administration of cisatracurium are presented. The anesthetics used in both cases were lidocaine, midazolam, propofol (microemulsion propofol in the second case), remifentanil and cisatracurium. After the administration of these drugs, bronchospasm and hypotension manifested, leading to the diagnosis of anaphylaxis and appropriate treatment. Skin intradermal testing confirmed that both cases were due to immune-mediated anaphylaxis to cisatracurium, despite the fact that neither of the patients had been exposed to the allergen previously. The anaphylaxis may be due to cross-reactivity between neuromuscular blocking agents and substances with quaternary ammonium ions. Anesthesiologists should be aware that cisatracurium has the potential to trigger severe anaphylactic reactions via an immune-mediated mechanism.

The effect of positive-end expiratory pressure on oxygenation during high frequency jet ventilation and conventional mechanical ventilation in the rabbit model of acute lung injury / 대한마취과학회지

BACKGROUND: The use of positive end expiratory pressure (PEEP) in patients with acute lung injury (ALI) improves arterial oxygenation by alleviating pulmonary shunting, helping the respiratory muscles to decrease the work of breathing, decreasing the rate of infiltrated and atelectatic tissues, and increasing functional residual capacity. In a rabbit model of saline lavage-induced ALI, we examined the effects of PEEP on gas exchange, hemodynamics, and oxygenation during high frequency jet ventilation (HFJV), and then compared these parameters with those during conventional mechanical ventilation (CMV). METHODS: Twelve rabbits underwent repeated saline lavage to create ALI. The animals were divided in 2 groups: 1) Group CMV (n = 6), and 2) Group HFJV (n = 6). In both groups, we applied 2 levels of PEEP (5 cmH2O and 10 cmH2O) and then measured the arterial blood gas, mixed venous blood gas, and hemodynamic parameters. RESULTS: With administration of PEEP of either 5 cmH2O or 10 cmH2O, the arterial oxygen content of both groups was increased, although without statistically significant differences between groups. On the contrary, the arterial carbon dioxide content was significantly decreased in the HFJV group, as compared with the CMV group, during the entire experiment. Furthermore, there was significant decreases in mean arterial pressures in both groups with a PEEP of 10 cmH2O. CONCLUSIONS: The application of PEEP in rabbits with ALI effectively improves oxygenation in either HFJV or CMV.

Anaesthetic experience in a patient with severe thoracolumbar kyphosis: A case report

Kyphosis is a deformity characterized by anterior flexion of the vertebral column. When severe, kyphosis may decrease lung volume and compliance, leading to increased work of breathing and deterioration of pulmonary function. Moreover, postoperative respiratory failure is a common problem for patients with severe spinal deformities. We describe the successful case of general anaesthesia in a 71-year-old male patient with severe thoracolumbar kyphosis undergoing open surgery converted from robotic surgery.

Amplatzer septal occluder found in the thoracic descending aorta by transesophageal echocardiography: A case report / 대한마취과학회지

Percutaneous device closure of atrial septal defect (ASD) has proven to be safe and effective, and become a widely accepted option to the surgical repair. However, the embolization of Amplatzer septal occluder (ASO) occurs in about 0.55% to 3.5% of cases, regardless of ASD size, device size, or the physician's expertise. We report a case of embolization of an ASO into the thoracic descending aorta, successfully removed through a surgical approach.

Correction of Hump-nose Depending on Size of Hump

Nose is the most three dimensional structure located on the central portion of the face. Therefore, the nasal shape is one of the most important factors on deciding upon one's impression. Hump-nose is characterized by nasal hump, acute tip angle, drooping or/and under-projection of tip, and broad nasal dorsum. Because of these characteristics, recently more patients with hump-nose are inclined to correct their problematic nose. The purpose of this study was to classify hump-nose according to hump size and provide proper operating methods in each group. From August 2003 to August 2005, in 46 cases, we classified the hump nose into three groups, small(group A; n=30), medium(group B; n=6), and large(group C; n=10) in accordance with size and location of hump and in each group we effectively corrected the hump with our proper operating methods. In the large group, one case of tension nose temporarily appeared but soon improved and we obtained satisfactory results in the other cases.

Comparison between Regional Cerebral Oxygen Saturation and Jugular Bulb Venous Oxygen Saturation in Patients Undergoing OPCAB Surgery / 대한마취과학회지

BACKGROUND: Hypoperfusion during manipulation of the heart in off-pump coronary artery bypass (OPCAB) surgery may lead to postoperative neurological complications. Therefore, it will be necessary to monitor cerebral function during OPCAB surgery. In this study, we compared regional cerebral oxygenation (rSO2) by near-infrared spectroscopy (NIRS) with jugular bulb venous oxygen saturation (SjvO2) and assessed whether rSO2 measured by NIRS could be an alternative method of SjvO2 during OPCAB surgery. METHODS: A total of 20 patients who underwent OPCAB surgery were studied. A fiberoptic catheter was placed in the right jugular bulb to measure SjvO2 while a cerebral oximeter based on NIRS, INVOS 5100B was used to monitor rSO2. Radial arterial and jugular bulb blood samples were drawn simultaneously from baseline every hour during operation. The values of rSO2 were compared with SjvO2 values. RESULTS: For all data points (n = 78) for all patients combined, rSO2 values were significantly correlated with SjvO2 values (r = 0.513, P < 0.0001). There were significant correlations between arterial carbon dioxide and values of SjvO2 (r = 0.393, P = 0.0002) and rSO2 (r = 0.432, P < 0.0001). CONCLUSIONS: We concluded that NIRS correlates with SjvO2 in this patient population. These findings suggest that near-infrared spectroscopy may be useful in assessing cerebral oxygenation during OPCAB surgery.

The Relationship between the Variable Measurements of Nose and the Amount of Harvested Septal Cartilage

The nose is the most 3-dimensional structure located on the central area of the face. Rhinoplasty using autogenous tissues and alloplastic materials has been performed for augmentation of nasal tip and dorsum in Asia. For batten graft, spreader graft, columellar strut and/or tip plasty, autogenous tissue especially nasal septal cartilage is very useful. Sometimes surgeon is faced to the situation when usable septal cartilage is too small so other tissues or materials are needed during the operation. The purpose of this study is that we should predict the amount of obtainable septal cartilage by variant measurements of the nose and investigated relationship each other. From December 2002 to February 2004, on the 31 cases that operated rhinoplasty using septal cartilage, we took variable measurements such as nasal length, tip width, nasal basal width, nasal height, columellar width and length of nostril long axis preoperatively. Then we investigated the relationship with amount of actual harvested septal cartilage. As a result, the nasal length was the most correlated with cartilage amount statistically and tip and base width were correlated as well. In this study we concluded that nasal length was the most indicating parameter to predict amount of septal cartilage.

Central Anticholinergic Syndrome Confirmed with Physostigmine after Open Heart Surgery / 대한마취과학회지

Central anticholinergic syndrome (CAS) can be caused by many anesthetic drugs. Early diagnosis and treatment are very important because untreated CAS may result in a life-threatening condition. Physostigmine, though not available in Korea, is the only drug which can confirm and treat CAS. A forty five year old patient underwent open heart surgery due to patent foramen ovale. Anesthetic agents which were used for anesthetic induction and maintenance were midazolam, fentanyl and isoflurane. Following anesthesia, he showed irritated and excited behavior and delayed recovery from anesthesia more than 3 h after operation in the ICU, even though flumazenil and naloxone were given to rule out the residual anesthetic effect. After physostigmine 4 mg was administered intravenously, he calmed down and became more coherent. There was no evidence of neurologic deficit in the following brain MRI and neurologic examination. We report the first case of CAS confirmed with physostigmine in Korea.

A long term follow up of reduced isolated zygomatic arch fracture by Gillies' approach

Many methods have been developed for the reduction of the isolated zygomatic arch fracture. Even though the reduction of isolated zygomatic arch fracture can be made well according to the various methods, the Gillies' method has been selected as the 1st choice. But long term follow-up study of this method was not reported. So long term follow up of zygomatic arch fracture was performed in 35 patients who were treated by Gillies' method. Authors divided isolated zygomatic arch fractures into three classes (Type A : a simple fracture with one fracture line and one greenstick fracture, TyPe B : medially depressed fracture with three fracture lines, Type C : a medially depressed fracture segment with two fracture lines) and followed up the reduced isolated zygomatic arch fracture cases using Gillies' method by radiographes and interview. The depression of lesion site was estimated by comparing with tracing the zygomatic arch shadow of normal side. The results were as follows: 1. The mean follow up time was 33.4 month. 2. The isolated zygomatic fractures were classified by three group. A: a simple fracture (16 cases) B: the central fracture point was a medially depressed fracture (14 cases) C: fracture with a medially depressed segment (5 cases) 3. The mean depression of lesion site was 2.3 mm. (Type A: 2.0 mm, Type B: 3.2 mm, Type C: 2.4 mm and difference between A and B was significant statistically (p < 0.037)). 4. The mean depression of zygomatic arch fracture was 2.1 mm in excellent group, 2.4 mm in good group and 5.2 mm in poor group and difference between excellent and poor, and between good and poor group were statistically significant (p < 0.0001). 5. On result of subjective satisfaction, number of excellent case was 17(48.6%), it of good case was 15(42.9%) and it of poor case was 3(8.6%) (Type A: 9, 7, 0, Type B: 5, 7, 2 and Type C: 3, 1, 1 excellent, good and poor in sequence). 6. The mean depression of overcorrection group(17, 8, 1 excellent good and poor in sequence) and nonovercorrection group(2, 5 and 2 in excellent, good and poor in sequence) was 2.26 and 3.6 mm in each other(p < 0.004). After reviewing all of results, it is concluded that Gillies' method is acceptable as the 1st choice for the reduction method of an isolated zygomatic arch.

A long term follow up of reduced isolated zygomatic arch fracture by Gillies' approach

Many methods have been developed for the reduction of the isolated zygomatic arch fracture. Even though the reduction of isolated zygomatic arch fracture can be made well according to the various methods, the Gillies' method has been selected as the 1st choice. But long term follow-up study of this method was not reported. So long term follow up of zygomatic arch fracture was performed in 35 patients who were treated by Gillies' method. Authors divided isolated zygomatic arch fractures into three classes (Type A : a simple fracture with one fracture line and one greenstick fracture, TyPe B : medially depressed fracture with three fracture lines, Type C : a medially depressed fracture segment with two fracture lines) and followed up the reduced isolated zygomatic arch fracture cases using Gillies' method by radiographes and interview. The depression of lesion site was estimated by comparing with tracing the zygomatic arch shadow of normal side. The results were as follows: 1. The mean follow up time was 33.4 month. 2. The isolated zygomatic fractures were classified by three group. A: a simple fracture (16 cases) B: the central fracture point was a medially depressed fracture (14 cases) C: fracture with a medially depressed segment (5 cases) 3. The mean depression of lesion site was 2.3 mm. (Type A: 2.0 mm, Type B: 3.2 mm, Type C: 2.4 mm and difference between A and B was significant statistically (p < 0.037)). 4. The mean depression of zygomatic arch fracture was 2.1 mm in excellent group, 2.4 mm in good group and 5.2 mm in poor group and difference between excellent and poor, and between good and poor group were statistically significant (p < 0.0001). 5. On result of subjective satisfaction, number of excellent case was 17(48.6%), it of good case was 15(42.9%) and it of poor case was 3(8.6%) (Type A: 9, 7, 0, Type B: 5, 7, 2 and Type C: 3, 1, 1 excellent, good and poor in sequence). 6. The mean depression of overcorrection group(17, 8, 1 excellent good and poor in sequence) and nonovercorrection group(2, 5 and 2 in excellent, good and poor in sequence) was 2.26 and 3.6 mm in each other(p < 0.004). After reviewing all of results, it is concluded that Gillies' method is acceptable as the 1st choice for the reduction method of an isolated zygomatic arch.