Low effect-site concentration of propofol target-controlled infusion reduces the risk of hypotension during endoscopy in a Taiwanese population.

OBJECTIVE: Target-controlled infusion (TCI) of propofol is an effective way of delivering propofol during endoscopy. However, the ideal effect-site concentration (Ce) of propofol has not yet been defined in an Asian population. This study aimed to determine the ideal Ce of propofol in painless gastrointestinal endoscopy in a Taiwanese population. METHODS: A total of 121 consecutive patients undergoing diagnostic endoscopy were recruited for this study. The endoscopic procedure was carried out within 1 h. TCI of propofol was utilized during the procedure. All patients received the same regimen to induce conscious sedation, including a bolus of midazolam (0.04 mg/kg) and fentanyl (0.5 µg/kg). The Ce of propofol was calculated using the Schneider model. Patients were randomly assigned to either the low Ce group (1.5-2.5 µg/mL) or high Ce group (3.0-4.0 µg/mL). Their cardiovascular and respiratory events were monitored during the procedure and the patients' post-procedure satisfaction was evaluated. RESULTS: The mean requirement for propofol was 232.02 mg in the low Ce group and 329.56 mg in the high Ce group, respectively (P < 0.0001). No unexpected event was observed in either group. However, more episodes of hypotension were observed in the high Ce group (P = 0.026). The post-procedure satisfaction rate between the two groups was comparable. CONCLUSION: A low Ce of propofol TCI (1.5-2.5 µg/mL) achieved adequate anesthesia, reduced the risk of hypotension, and attained a high satisfaction rate in a Taiwanese population undergoing diagnostic painless endoscopy.

Betel-quid dependence and oral potentially malignant disorders in six Asian countries.

BACKGROUND: Despite gradual understanding of the multidimensional health consequences of betel-quid chewing, information on the effects of dependent use is scant. AIMS: To investigate the 12-month prevalence patterns of betel-quid dependence in six Asian populations and the impact of this dependence on oral potentially malignant disorders (OPMD). METHOD: A multistage random sample of 8922 participants was recruited from Taiwan, mainland China, Indonesia, Malaysia, Sri Lanka and Nepal. Participants were evaluated for betel-quid dependency using DSM-IV and ICD-10 criteria and assessed clinically for oral mucosal lesions. RESULTS: The 12-month prevalence of dependence was 2.8-39.2% across the six Asian samples, and 20.9-99.6% of those who chewed betel-quid were betel-quid dependent. Men dominated the prevalence among the east Asian samples and women dominated the prevalence in south-east Asian samples. 'Time spent chewing' and 'craving' were the central dependence domains endorsed by the Chinese and southern/south-east Asian samples respectively, whereas the Nepalese samples endorsed 'tolerance' and 'withdrawal'. Dependency was linked to age, gender, schooling years, drinking, smoking, tobacco-added betel-quid use and environmental accessibility of betel-quid. Compared with non-users, those with betel-quid dependency had higher pre-neoplastic risks (adjusted odds ratios 8.0-51.3) than people with non-dependent betel-quid use (adjusted odds ratio 4.5-5.9) in the six Asian populations. CONCLUSIONS: By elucidating differences in domain-level symptoms of betel-quid dependency and individual and environmental factors, this study draws attention to the population-level psychiatric problems of betel-quid chewing that undermine health consequences for OPMD in six Asian communities.

Anaphylaxis to benzalkonium chloride-coated central venous catheter.

Benzalkonium chloride (BAC) is commonly used as a bactericidal preservative and it may cause allergic reactions in some patients. An unusual case of anaphylactic shock in a 55-year-old woman following insertion of a central venous catheter (CVC) that was coated with BAC is presented. Assuming anaphylactic shock from the CVC, the catheter was removed immediately. Standard resuscitation was started with 100% oxygen, epinephrine, and saline infusion. The patient recovered without any sequelae. One month later, an intradermal skin test was positive for BAC.

KMUP-1 inhibits pulmonary artery proliferation by targeting serotonin receptors/transporter and NO synthase, inactivating RhoA and suppressing AKT/ERK phosphorylation.

KMUP-1 inhibits monocrotaline (MCT)-induced pulmonary artery (PA) proliferation by targeting serotonin (5-HT) receptors, inactivating RhoA and reducing phosphorylation of AKT/ERK. In MCT-treated rats, KMUP-1 f (5 mg/kg p.o.; 1mg/kg i.p.x 21 days) decreased proliferation (PCNA-positive) cells and 5-HTT-expression in lung and 5-HT levels in plasma. In isolated PA, KMUP-1 and simvastatin (0.1-100 µM) inhibited 5-HT (10 µM)-induced PA constriction. l-NAME-pretreatment reduced KMUP-1-induced relaxation. In pulmonary arterial smooth muscle cells (PASMCs), KMUP-1 (1-100 µM) and simvastatin (10 µM) inhibited 5-HT-induced cell migration and proliferation and KMUP-1 (1-100 µM) inhibited 5-HT-induced Ca²+ influx. Similar to Y27632, KMUP-1 (1-100 µM) inhibited 5-HT-induced RhoA/ROCK expression, while KMUP-1, Y27632 and simvastatin at 10 µM inhibited 5-HT-induced 5-HTT expression and KMUP-1 inhibited 5-HT-induced phosphorylation of AKT and ERK1/2 in PASMCs. In human pulmonary arterial endothelial cell (HPAEC), KMUP-1 (1-100 µM) increased the expression of eNOS and 5-HT(2B) and also at 10 µM augmented eNOS expression and production of nitric oxide (NO) in 5-HT-treated HPAEC. In radioligand binding, the IC50/K(i) values of KMUP-1 for 5-HT(2A), 5-HT(2B) and 5-HT(2C) receptors were 0.34/0.0971, 0.04/0.0254, and 0.408/0.214 µM respectively. In conclusion, KMUP-1 inhibits MCT-induced PA proliferation by binding to 5-HT(2A), 5-HT(2B) and 5-HT(2C) receptors, increasing endothelial eNOS/5-HT(2B) receptor expression and NO release and inhibiting 5-HTT/RhoA/ROCK expression and AKT/ERK phosphorylation. KMUP-1 is suggested to be useful in the treatment of 5-HT-induced pulmonary artery proliferation.

The xanthine derivative KMUP-1 inhibits models of pulmonary artery hypertension via increased NO and cGMP-dependent inhibition of RhoA/Rho kinase.

BACKGROUND AND PURPOSE: KMUP-1 is known to increase cGMP, enhance endothelial nitric oxide synthase (eNOS) and suppress Rho kinase (ROCK) expression in smooth muscle. Here, we investigated the mechanism of action of KMUP-1 on acute and chronic pulmonary artery hypertension (PAH) in rats. EXPERIMENTAL APPROACH: We measured pulmonary vascular contractility, wall thickening, eNOS immunostaining, expressions of ROCK II, RhoA activation, myosin phosphatase target subunit 1 (MYPT1) phosphorylation, eNOS, soluble guanylyl cyclase (sGC), protein kinase G (PKG) and phosphodiesterase 5A (PDE-5A), blood oxygenation and cGMP/cAMP, and right ventricular hypertrophy (RVH) in rats. KEY RESULTS: In rings of intact pulmonary artery (PA), KMUP-1 relaxed the vasoconstriction induced by phenylephrine (10 microM) or the thromboxane A(2)-mimetic U46619 (0.5 microM). In endothelium-denuded PA rings, this relaxation was reduced. In acute PAH induced by U46619 (2.5 microg x kg(-1) x min(-1), 30 min), KMUP-1 relaxed vasoconstriction by enhancing levels of eNOS, sGC and PKG, suppressing those of PDE-5A, RhoA/ROCK II activation and MYPT1 phosphorylation, and restoring oxygenation in blood and cGMP/cAMP in plasma. Incubating smooth muscle cells from PA (PASMCs) with KMUP-1 inhibited thapsigargin-induced Ca(2+) efflux and angiotensin II-induced Ca(2+) influx. In chronic PAH model induced by monocrotaline, KMUP-1 increased eNOS and reduced RhoA/ROCK II activation/expression, PA wall thickening, eNOS immunostaining and RVH. KMUP-1 and sildenafil did not inhibit monocrotaline-induced PDE-5A expression. CONCLUSION AND IMPLICATIONS: KMUP-1 decreased PAH by enhancing NO synthesis by eNOS, with consequent cGMP-dependent inhibition of RhoA/ROCK II and Ca(2+) desensitization in PASMCs. KMUP-1 has the potential to reduce vascular resistance, remodelling and RVH in PAH.

Influence of nondepolarizing muscle relaxants on intraoperative neuromonitoring during thyroid surgery.

OBJECTIVE: The objective of this study was to find a nondepolarizing muscle relaxant to replace succinylcholine during thyroid surgery with intraoperative neuromonitoring (IONM) because succinylcholine can cause severe adverse effects. DESIGN: Prospective study of 232 patients undergoing thyroidectomies. SETTING: A tertiary medical centre. METHODS: One hundred thirty-one patients received 0.5 mg/kg rocuronium (group R) and 101 patients received 0.5 mg/kg atracurium (group A) to facilitate electromyographic (EMG) endotracheal tube insertion. EMG signals were obtained from the vagus nerve before and after dissection of the recurrent laryngeal nerve and were defined as the V1 and the V2 signal, respectively. Accelerometry (twitch [% TW]) was used to monitor the quantitative degree of neuromuscular transmission at the adductor pollicis muscle. MAIN OUTCOME MEASURES: The amplitude (muV) of the V1 and V2 signals and the correlated degree of neuromuscular transmission (% TW). RESULTS: V1 and V2 signals were obtained from all patients successfully. The % TW at the V1 signal was significantly lower than that at the V2 signal in group R and group A. The mean recovery time from complete neuromuscular blockade to the initial twitch was 43.9 +/- 11 minutes. Only in the subgroup in which the correlated TW was 0% while eliciting the V1 signal were the amplitudes of the V1 signals significantly lower than those of the V2 signal in both groups. CONCLUSIONS: A single dose (0.5 mg/kg) of rocuronium and atracurium was feasible for IONM during thyroid surgery. This study showed that 44 minutes after administration of these two muscle relaxants is adequate for eliciting an EMG signal from the vagus nerve.

Phenothiazine-type antipsychotics elicit cutaneous analgesia in rats.

BACKGROUND: Local anesthetics exert their anesthetic and analgesic effects by blocking the sodium channels in the nervous system. Phenothiazine-type antipsychotics also block sodium channels, but the local anesthetic characteristics of these drugs have not been evaluated. The aim of this study was to evaluate the cutaneous analgesic effect of phenothiazine-type antipsychotics. METHODS: Using a subcutaneous injection model in rats, we tested the cutaneous analgesic effects of six phenothiazine-type antipsychotics (mesoridazine, promazine, chlorpromazine, fluphenazine, perphenazine and triflupromazine) at a dose of 0.6 mumol, and compared them with those of bupivacaine and lidocaine. A saline injection was used as the control. RESULTS: All six phenothiazine-type antipsychotics elicited cutaneous analgesia. At the dose of 0.6 mumol, the potencies of mesoridazine and promazine were similar to that of bupivacaine; the other four drugs were less potent (p<0.001 for each comparison). Mesoridazine had a longer duration of action than bupivacaine (p<0.001). In terms of ED(50) values, mesoridazine was more potent and longer-acting than bupivacaine and lidocaine (p<0.01 for each comparison). CONCLUSION: Of the antipsychotic drugs tested, mesoridazine is potentially the best candidate for development into a potent, long-acting local anesthetic. However, toxicity studies are needed before these agents can be used clinically as analgesics.

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.

Baicalin, a flavonoid from Scutellaria baicalensis Georgi, activates large-conductance Ca2+-activated K+ channels via cyclic nucleotide-dependent protein kinases in mesenteric artery.

Baicalin isolated from Scutellaria baicalensis is a traditional Chinese herbal medicine used for cardiovascular dysfunction. The ionic mechanism of the vasorelaxant effects of baicalin remains unclear. We investigated whether baicalin relaxes mesenteric arteries (MAs) via large-conductance Ca2+-activated K+ (BK(Ca)) channel activation and voltage-dependent Ca2+ channel (VDCC) inhibition. The contractility of MA was determined by dual wire myograph. BK(Ca) channels and VDCCs were measured using whole-cell recordings in single myocytes, enzymatically dispersed from rat MAs. Baicalin (10-100 microM) attenuated 80 mM KCl-contracted MA in a concentration-related manner. L-NAME (30 microM) and indomethacin (10 microM) little affected baicalin (100 microM)-induced vasorelaxations. Contractions induced by iberiotoxin (IbTX, 0.1 microM), Bay K8644 (0.1 microM) or PMA (10 microM) were abolished by baicalin 100 microM. In MA myocytes, baicalin (0.3-30 microM) enhanced BK(Ca) channel activity in a concentration-dependent manner. Increased BK(Ca) currents were abolished by IbTX (0.1 microM). Baicalin-mediated (30 microM) BK(Ca) current activation was significantly attenuated by an adenylate cyclase inhibitor (SQ 22536, 10 microM), a soluble guanylate cyclase inhibitor (ODQ, 10 microM), competitive antagonists of cAMP and cGMP (Rp-cAMP, 100 microM and Rp-cGMP, 100 microM), and cAMP- and cGMP-dependent protein kinase inhibitors (KT5720, 0.3 microM and KT5823, 0.3 microM). Perfusate with PMA (0.1 microM) abolished baicalin-enhanced BK(Ca) currents. Additionally, baicalin (0.3-30 microM) reduced the amplitude of VDCC currents in a concentration-dependent manner and abolished VDCC activator Bay K8644-enhanced (0.1 microM) currents. Baicalin produced MA relaxation by activating BK(Ca) and inhibiting VDCC channels by endothelium-independent mechanisms and by stimulating the cGMP/PKG and cAMP/PKA pathways.

The effectiveness of dexmedetomidine infusion for sedating oral cancer patients undergoing awake fibreoptic nasal intubation.

BACKGROUND AND OBJECTIVE: Dexmedetomidine is characterized with effects of sedation, analgesia, amnesia and lack of respiratory depression. Hence, it should be suitable for awake fibreoptic intubation (AFOI). METHODS: We enrolled 30 oral cancer patients with limited mouth openings who were undergoing AFOI for elective surgery. Patients were randomly allocated into two groups; the Dex group (n = 16) that received dexmedetomidine (1.0 microg kg(-1)) infusion and the Control group (n = 14) that received fentanyl (1.0 microg kg(-1)) infusion. Main outcomes were evaluated by grading scores presenting conditions for nasal intubation and postintubation. Other analysed parameters included airway obstruction, haemodynamic changes, consumption time for intubation, amnesia level and satisfaction. RESULTS: Intubation score (1-5) representing condition for nasal intubation was significantly better in the Dex group [2(1-3)] than in the Control group [3(2-5)] (P = 0.001). Postintubation score (1-3) representing tolerance to intubation also showed more favourable results in the Dex group [1(1-3)] than in the Control group [2(2-3)] (P = 0.002). The Dex group showed significantly reduced haemodynamic response to intubation than the Control group. Incidence requiring temporary haemodynamic support was higher in the Dex group but not of significance. Both levels of amnesia and satisfaction score were significant in the Dex group. Other analysed parameters such as consumption time for intubation, airway obstruction score and postoperative adverse events did not differ significantly. CONCLUSION: Combination of dexmedetomidine loading with topical anaesthesia provides significant benefit for AFOI in intubation condition, patient tolerance, haemodynamic response, amnesia and satisfaction. Dexmedetomidine is effective for AFOI in anticipated difficult airway with only minor and temporary haemodynamic adverse effects.

Predictive factors of early relapse in UICC stage I-III colorectal cancer patients after curative resection.

BACKGROUND AND OBJECTIVES: To predict the clinicopathologic factors for early relapse of UICC stage I-III colorectal cancer (CRC) patients undergoing curative resection and thus to identify a subgroup of patients who are at high risk for postoperative early relapse. METHODS: Between January 2001 and June 2007, a total of 778 UICC stage I-III CRC patients who underwent a radical resection and regular follow-up were retrospectively analyzed. Of these 778 CRC patients, 521 colon cancer and 257 rectal cancer cases were analyzed, respectively, to determine the predictors of early relapse postoperatively. These 778 patients were followed-up intensively, and their outcomes were investigated retrospectively. RESULTS: Out of 521 colon cancer patients, postoperative relapse after primary resection was found in 142 (27.3%) patients, and 77 (54.2%) of 142 recurrent colon cancer patients were classified as postoperative early relapse. Meanwhile, among 257 rectal cancer patients, postoperative relapse was found in 68 (26.5%) patients and 44 (64.7%) of 68 recurrent rectal cancer patients were identified as postoperative early relapse. Forty-nine (63.6%) of 77 early relapsed colon cancer patients were stage III, and likewise, 26 (59.1%) of 44 early relapsed rectal cancer patients were stage III. Univariately, postoperative early relapse of colon cancer patients was significantly correlated with the presence of vascular invasion (P < 0.001), perineural invasion (P < 0.001), high postoperative carcinoembryonic antigen (CEA) level (P = 0.001), and type of surgery (P = 0.016). Using a Cox proportional hazards analysis, the presence of vascular invasion (P = 0.033), perineural invasion (P = 0.005), and high postoperative CEA levels (P = 0.001) were demonstrated to be independent predictors of postoperative early relapse of colon cancer patients, while in rectal cancer patients, both vascular invasion (P = 0.039) and perineural invasion (P = 0.008) were statistically significant predictors of early relapse by univariate analysis. Using a Cox proportional hazards analysis, only perineural invasion (P = 0.043) was an independent factor. Early relapse cases had significant lower overall survival rates than non-early relapse cases either in colon cancer (P < 0.001) or in rectal cancer (P = 0.0091) patients. CONCLUSIONS: This study suggests that vascular invasion, perineural invasion, and postoperative CEA level may be significant factors for postoperative early relapse of colon cancer; while only perineural invasion is considered to be a significant predictor in rectal cancer patients. Identification of these high-risk UICC stage I-III CRC patients of early relapse is important, and thus could help to define patients with this tumor entity for an enhanced follow-up and therapeutic program.

Accuracy of the central landmark for catheterization of the right internal jugular vein after placement of the ProSeal laryngeal mask airway.

OBJECTIVE: Catheterization of the internal jugular vein (IJV) after placement of a laryngeal mask airway (LMA) has been reported to be difficult. The purpose of this study was to evaluate the accuracy of the central landmark for catheterization of the right IJV after placement of a ProSeal LMA. METHODS: We enrolled 80 patients (30 men and 50 women) who were scheduled to undergo surgery under general anesthesia conveyed by a size 3 ProSeal LMA. A needle pathway based on the central landmark for right IJV catheterization was simulated. Ultrasound images were obtained, which we contrasted with the simulated pathway to evaluate whether the landmark accuracy remained unchanged after placement of the ProSeal LMA. Both frequency of simulated right carotid artery (CA) puncture and overlap between the right IJV and right CA were also investigated. RESULTS: The simulated needle pathway ran along the course of the right IJV in 60% (48/80) of subjects, and transected the CA in 31.3% (25/80) of subjects. Both events together occurred in 20% (16/80) of subjects. The central landmark had a medial bias of 6.8 mm (95% confidence interval, 5.3-8.4). In 83.8% (67/80) of subjects, the center of the right IJV was lateral to the central landmark. The possibility of overlap of the right IJV and CA was high after ProSeal LMA placement. CONCLUSION: After placement of the ProSeal LMA, the central landmark could not offer a good success rate at the first puncture attempt. When using the central landmark to catheterize the IJV after a ProSeal LMA placement, medial deviation of the central landmark should be considered. Ultrasound guidance may be helpful in difficult cases.

Preoperative serum carcinoembryonic antigen, albumin and age are supplementary to UICC staging systems in predicting survival for colorectal cancer patients undergoing surgical treatment.

BACKGROUND: The aim of this study was to determine influence of prognostic factors in addition to UICC staging systems, on cancer-specific and overall survival rates for patients with colorectal cancer (CRC) undergoing surgical treatment. METHODS: Between January 1996 and December 2006, a total of 1367 CRC patients who underwent surgical treatment in Kaohsiung Medical University Hospital were analyzed. We retrospectively investigated clinicopathologic features of these patients. All patients were followed up intensively, and their outcomes were investigated completely. RESULTS: Of 1367 CRC patients, there were seven hundred and fifty-seven males (55.4%) and 610 (44.6%) females. The median follow-up period was 60 months (range, 3-132 months). A multivariate analysis identified that low serum albumin level (P = 0.011), advanced UICC stage (P < 0.001), and high carcinoembryonic antigen (CEA) level (P < 0.001) were independent prognostic factors of cancer-specific survival. Meanwhile, a multivariate analysis showed age over 65 years (P < 0.001), advanced UICC stage (P < 0.001), and high CEA level (P < 0.001) were independent prognostic factors of overall survival. Furthermore, combination of UICC stage, serum CEA and albumin levels as predictors of cancer-specific survival showed that the poorer the prognostic factors involved, the poorer the cancer-specific survival rate. Likewise, combination of UICC stage, age and serum CEA level as predictors of overall survival showed that the poorer the prognostic factors involved, the poorer the overall survival rate. Of these prognostic factors, preoperative serum CEA level was the only significant prognostic factor for patients with stage II and III CRCs in both cancer-specific and overall survival categories. CONCLUSION: Preoperative serum albumin level, CEA level and age could prominently affect postoperative outcome of CRC patients undergoing surgical treatment. In addition to conventional UICC staging system, it might be imperative to take these additional characteristics of factors into account in CRC patients prior to surgical treatment.

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.

Detection of KRAS oncogene in peripheral blood as a predictor of the response to cetuximab plus chemotherapy in patients with metastatic colorectal cancer.

PURPOSE: Previously we developed membrane-arrays as a promising tool to detect circulating tumor cells (CTC) with KRAS oncogene in patients with malignancies. This study was conducted to determinate the predictive values of CTCs with KARS mutation by membrane-arrays for metastatic colorectal cancer patients treated with cetuximab plus chemotherapy. EXPERIMENTAL DESIGN: Seventy-six metastatic colorectal cancer patients receiving cetuximab plus FOLFIRI or FOLFOX-4 chemotherapy were enrolled. KRAS mutation status in the peripheral blood of these patients was analyzed using membrane-arrays, and KRAS mutation status in tumors was analyzed by DNA sequencing. RESULTS: Among 76 metastatic colorectal cancer patients, KRAS mutations in tumors and in peripheral blood were identified in 33 (43.4%) and 30 (39.5%) patients, respectively. The detection sensitivity, specificity, and accuracy of membrane-arrays for CTCs with KRAS oncogene were 84.4%, 95.3%, and 90.8%, respectively, and indeed a highly significant correlation to KRAS mutations in tumors (P < 0.0001) was observed. Forty-five (59.2%) patients responded to cetuximab plus chemotherapy, and 41 and 40 were wild-type KRAS in tumors and peripheral blood, respectively (both P < 0.0001). Patients with tumors that harbor wild-type KRAS are more likely to have a better progression-free survival and overall survival when treated with cetuximab plus chemotherapy (P < 0.0001). Likewise, patients with CTCs of wild-type KRAS in peripheral blood express a better progression-free survival and overall survival when treated with cetuximab plus chemotherapy (P < 0.0001). CONCLUSIONS: These findings provide evidence that detection of KRAS mutational status in CTCs, by gene expression array, has potential for clinical application in selecting metastatic colorectal cancer patients most likely to benefit from cetuximab therapy.

A review of intraoperative airway management for midface facial bone fracture patients.

In craniofacial trauma patients, oral route endotracheal intubation may thwart the accuracy of dental occlusion and nasotracheal intubation carries the risk of intracranial invasion in skull base fracture cases. Between November 2005 and June 2006, patients receiving facial bone fracture operations at Kaohsiung Medical University Hospital were enrolled in this study. Intraoperatively, the endotracheal tube was pushed to either the retromolar space or the missing tooth space and secured by two 4.0 silk stitches. Then, surgeons could perform the usual procedure to explore the fracture sites, check the occlusion and correct the deviated nose without limitation. Also, for better understanding the time needed for various intubation techniques, a time-measuring study was performed. Ninety-one patients were treated by this method. Most of them were satisfied with the result of occlusion and nasal contour. Only 2 patients received second surgery to correct nasal deformity. One hundred seventeen anesthesia procedures were checked. In average, an experienced anesthesiologist could successfully intubate a patient in less than 105 seconds. The advantages and reported complications of different intubation methods were discussed. This retromolar position and tooth fixation technique allowed surgeons to correct the dental occlusion and nasal deformity simultaneously. It has served well for zygoma fracture, maxilla fracture, and Le Fort II fracture patients. It is worthy of consideration in management of middle face trauma patients involving occlusion change and nasal deviation.

Feasibility of intraoperative neuromonitoring during thyroid surgery after administration of nondepolarizing neuromuscular blocking agents.

BACKGROUND: A short-acting depolarizing neuromuscular blocking agent (NMBA), succinylcholine, has been utilized for thyroid operations with intraoperative neuromonitoring (IONM). Because of its potential to cause serious side effects, this prospective study tried to determine the feasibility of IONM after administration of a nondepolarizing NMBA during thyroid operations. METHODS: Complete IONM data for 179 patients who had normal cord mobility were investigated: 90 patients received an induction dose of rocuronium (group R) and 89 received atracurium (group A). Electromyography signals were obtained from the vagus nerve before and after resection of the thyroid lobe and were defined as V(1) and V(2) signals, respectively. Accelerometry (percent twitch) was used to monitor the quantitative degree of neuromuscular blockade. RESULTS: V(1) and V(2) signals were obtained successfully in all patients. The percent twitch at the V(1) signal was significantly lower than that at the V(2) signal in both groups (39% +/- 20% vs. 69% +/- 26% in group R; 35% +/- 28% vs. 56% +/- 35 % in group A; both p < 0.01). However, the magnitude of the V(1) and V(2) signals did not differ significantly in either in group (473.8 +/- 290.8 microV vs. 528 +/- 316.2 microV in group R; 584.8 +/- 394.3 microV vs. 637.8 +/- 458.2 microV in group A; both p > 0.05). CONCLUSIONS: A single dose of either rocuronium or atracurium was feasible for IONM during thyroid surgery and provided adequate muscle relaxation for tracheal intubation.

Haloperidol plus ondansetron prevents postoperative nausea and vomiting in patients undergoing laparoscopic cholecystectomy.

BACKGROUND: A combination of antiemetic drugs could be an effective method to prevent severe postoperative nausea and vomiting (PONV). Therefore, we examined the prophylactic effect of haloperidol plus ondansetron on PONV. METHODS: We enrolled 210 patients (n = 70 in each of 3 groups) undergoing elective laparoscopic cholecystectomy for this randomized double-blind study. Patients were randomized to intravenous saline 2 mL and intramuscular haloperidol 2 mg (Group H), intravenous ondansetron 4 mg and intramuscular saline 2 mL (Group O), or intravenous ondansetron 4 mg and intramuscular haloperidol 2 mg (Group H+O), administered after induction of general anesthesia and 30 minutes before the conclusion of surgery. We compared the complete response rates, incidence of PONV, nausea scores, the need for rescue medication, patient satisfaction scores, and adverse events during the 24-hour study. RESULTS: The H+O group had the highest complete response rate to treatment (79%) compared with group H (61%) and group O (62%) (p < 0.05 for both). Patient satisfaction scores were significantly higher in the H+O group (8.3 +/- 1.8) than in the H (7.0 +/- 2.4) and O (7.2 +/- 2.5) groups (p < 0.05 for both). In addition, nausea scores were significantly lower in the H+O group (1.2 +/- 2.6) than in the H (2.5 +/- 3.3) and O (2.2 +/- 3.1) groups (p < 0.05 for both). CONCLUSION: We conclude that the combination of prophylactic haloperidol (2 mg) plus ondansetron (4 mg) provides a higher complete response rate and greater patient satisfaction after laparoscopic cholecystectomy than either drug used alone.

Perioperative airway management in a child with Treacher Collins syndrome.

We report the perioperative airway management in a 12-year-old boy suffering from Treacher Collins syndrome (TCS) and severe mental retardation who was scheduled for elective dental treatment under general anesthesia. TSC is also known as mandibulofacial dysostosis or Franceschetti syndrome, usually with a potentially difficult airway presentation. It is a major challenge for the anesthesiologist to manage an uncooperative child with such a congenital airway anomaly. A difficult airway was encountered during induction of general anesthesia, and both oral intubation by direct laryngoscopy and classic laryngeal mask airway (LMA) insertion were unsuccessful. In an expedient critical trial, with the cooperation of two anesthesiologists, one performing nasal fiberoptic intubation and the other maintaining oral mask ventilation, a nasal endotracheal tube was successfully placed at the first attempt, although at the expense of prolonged respiratory depression in the patient. Therefore, fiberoptic nasal intubation simultaneously with mask ventilation for placement of the endotracheal tube is a practical substitute for a difficult airway usually managed by LMA with inadequate ventilation. After extubation, tracheostomy may be indicated if the TCS patient suffers from persistent difficult upper airway in consequence of a traumatic intubation.

Optimal depth of NIM EMG endotracheal tube for intraoperative neuromonitoring of the recurrent laryngeal nerve during thyroidectomy.

BACKGROUND: Malpositioning of the endotracheal surface electrodes can result in dysfunction of intraoperative neuromonitoring (IONM) and increase the risk of recurrent laryngeal nerve injury. The purpose of this study was to investigate the optimal depth of the nerve integrity monitor (NIM) EMG endotracheal tube. METHODS: We enrolled 105 adult patients undergoing elective thyroidectomy. Each Medtronic Xomed NIM EMG endotracheal tube was placed with the middle of the exposed electrodes well in contact with the true vocal cords under direct laryngoscopy. Function of IONM was documented and the insertion depth was measured and analyzed. RESULTS: Ninety-nine (94.3%) patients had successful IONM with the initial endotracheal tube position. Six (5.7%) patients needed further tube depth adjustment under fiberoptic bronchoscopy. All patients were finally had successful IONM. The optimal mean depth was 20.6 +/- 0.97 cm in men and 19.6 +/- 1.0 cm in women (p < 0.01). There was the trend that taller subjects had a deeper tube depth (p < 0.05). CONCLUSION: We concluded that the mean depth of the NIM EMG tube would be a useful reference value for detecting the malposition of electrodes and adjusting the depth of tube during the operation.