Evaluation of ultrasound-guided posterior quadratus lumborum block for postoperative analgesia after laparoscopic gynecologic surgery.

STUDY OBJECTIVE: This study aimed to determine the efficacy of ultrasound-guided posterior quadratus lumborum block (QLB) in treating postoperative pain following laparoscopic gynecologic surgery. DESIGN: Prospective randomized controlled study. PATIENTS: Seventy adult patients scheduled for elective laparoscopic gynaecological surgery under general anesthesia. INTERVENTION: This randomized controlled study involved two groups of adult females who were scheduled to undergo laparoscopic gynecologic surgery under general anesthesia. Patients were randomly assigned to either the QLB group or Control group. In the QLB group, patients underwent posterior QLB with 20mL of 0.375% ropivacaine on each side. Patients were blinded to treatment. MEASUREMENTS: At 0, 1, 3, and 24 hours after anesthesia recovery, evaluator recorded the severity of postoperative pain in movement and at rest using a Numeric Rating Scale (NRS). We also evaluated the severity of nausea using NRS and number of additional analgesics. MAIN RESULTS: Immediately after recovery from anesthesia, the NRS score for pain in movement did not differ significantly between groups. NRS scores for pain both in movement and at rest were significantly higher in the Control group than in the QLB group at 1, 3, and 24h after recovery from anesthesia. CONCLUSION: Our results suggest that posterior QLB significantly reduces postoperative pain in movement and at rest following laparoscopic gynecologic surgery.

Contribution of the nasal passage to face mask ventilation: a prospective blinded randomized crossover trial.

BACKGROUND: Previous studies have shown that the nasal passage plays an important role in manual face mask ventilation, but this has yet to be quantitatively assessed. We conducted a prospective randomized crossover clinical trial to compare the change in pressure-controlled face mask tidal volume with and without nasal airway occlusion. METHOD: Female patients undergoing elective surgery under general anesthesia served as study subjects. Patients were randomly assigned to face mask ventilation beginning either with or without nasal passage occlusion (achieved with a swimmer's nose clip), followed by removal or application of the nose clip, respectively. After standardized induction of general anesthesia and muscle paralysis, a tight-fitting face mask was applied to each patient, and tidal volume was measured by the anesthesia machine during pressure-controlled ventilation (10, 15, 20 cm H2O; 8 breaths·min-1; inspiratory:expiratory ratio 1:2). RESULTS: The median [interquartile range] tidal volume was lower with vs without nasal passage occlusion at 10 cm H2O inspiratory pressure (100 [55-134] mL vs 300 [230-328] mL, respectively; median difference (MD), 200 mL; 95% confidence interval (CI), 157 to 229; P < 0.001), 15 cm H2O inspiratory pressure (190 [120-230] mL vs 520 [420-593] mL, respectively; MD, 340 mL; 95% CI, 257 to 395; P < 0.001), and 20 cm H2O inspiratory pressure (270 [215-390] mL vs 790 [713-823] mL, respectively; MD, 520 mL; 95% CI, 390 to 582; P < 0.001). CONCLUSION: Nasal passage obstruction considerably reduces tidal volume achieved during face mask ventilation. In some patients, it may be advantageous to relieve nasal airway obstruction for effective face mask ventilation. TRIAL REGISTRATION: UMIN Clinical Trials Registry, number UMIN000022184. Registered 2 May 2016.

[Efficacy of Transversus Abdominis and Rectus Sheath Blocks in Combination with Continuous Intravenous Fentanyl for Postoperative Analgesia of Laparoscopic Colectomy: A Retrospective Study].

BACKGROUND: Ultrasound-guided transversus ab- dominis plane (TAP) and rectus sheath (RS) blocks are peripheral nerve blocks that diminish somatic pain of the abdominal wall and are useful for postoperative analgesia. Here, we retrospectively compared the effi- cacy of ultrasound-guided TAP and RS blocks in com- bination with continuous intravenous fentanyl for postoperative analgesia of laparoscopic colectomy. METHODS: The ethics committee of our institute ap- proved the study. In our hospital, postoperative analge- sia is performed with continuous intravenous fentanyl administration at three concentrations : 12.5, 18.75, and 31.25 µg · hr⁻¹. TAP and RS blocks were applied using 30-40 ml of 0.19-0.25% ropivacaine. We selected 43 patients who underwent laparoscopic colectomy from May to October 2015. We compared the fentanyl only group (F group, n=26) and block combination group (F+B group, n=17). Statistical analysis was performed with the Mann-Whitney U test P<0.05 was considered significant Results : Patient characteristics including age, height, body weight, duration of anesthesia, and surgery did not significantly differ between the two groups. The concentration of intravenous fentanyl was significantly lower in the F+B group than in the F group (F group : 19.5±8.4µg · hr⁻¹, F+B group : 14.7?4.9 µg · hr⁻¹, P=0.02). In the present study, TAP and RS blocks significantly reduced the dose of administered fentanyl. - Conclusions : Our findings suggest that a combina- tion of TAP and RS blocks lower the dose of continu- ous intravenous fentanyl needed, and may provide better postoperative analgesia after laparoscopic colec- tomy.

[Efficacy of Go-rei-san for Pain Management in Four Patients with Intractable Trigeminal Neuralgia].

Go-rei-san is a Japanese traditional medicine that is used to treat motion sickness, nausea, and vomiting. We report here four patients for whom Go-rei-san was effective in treating pain associated with intractable trigeminal neuralgia. Three patients could not continue carbamazepine due to drug-induced rash, liver damage, and gastrointestinal injury, and suffered from pain. One patient experienced severe dizziness upon combination treatment with pregabalin and carbamazepine. All patients exhibited symptoms of water poisoning on their tongues. All patients experienced significant pain relief without major complications after daily adminis- tration of 7.5 g Go-rei-san. Our findings suggest that Go-rei-san can effectively alleviate pain associated with intractable trigeminal neuralgia without major compli- cations.

LMA-ProSeal insertion by novice doctors as affected by a 90° bend created by an intubating stylet: a randomized clinical trial.

STUDY OBJECTIVE: This study aimed to test the hypothesis that insertion of the supraglottic device LMA-ProSeal (ProSeal) by novice doctors in anesthetized patients can be improved by using an intubating stylet to create a 90° bend and that better sealing pressure is achieved. DESIGN: Randomized clinical trial. SETTING: Operating room. PATIENTS: Seventy adult patients scheduled for elective surgery under general anesthesia using ProSeal with American Society of Anesthesiologists physical status 1 to 3. INTERVENTIONS: ProSeal were inserted with the 90° bend created by the intubating stylet (90D group, 35 patients) or not (ie, conventional insertion; C group, 35 patients). MEASUREMENTS: The number of attempts to successful insertion, sealing pressure, subjective difficulty of insertion by novice doctors, and postoperative pharyngeal pain or hoarseness were compared between groups. MAIN RESULTS: The total number of insertion attempts for the 90D and control groups were 1 (24 and 8, respectively), 2 (8 and 13), 3 (3 and 9), and failure (0 and 5), respectively, showing significant differences between groups (P<.001). Sealing pressure was significantly higher in the 90D group than in the C group (90D group, 23.3±3.7cm H2O; C group, 19.5±2.6cm H2O; P<.001), and the subjective difficulty of insertion was significantly lower in the 90D group (90D group, 27.3±17.6mm; C group, 55.4±22.8mm; P<.001). The incidence of postoperative pharyngeal pain and hoarseness did not differ significantly between groups. CONCLUSIONS: Our results suggest that creating a 90° bend using an intubating stylet facilitates ProSeal insertion by novice doctors, as reflected by higher successful insertion rates, higher sealing pressure, and lower subjective difficulty of insertion in anesthetized patients.

Impact of pillow height on double-lumen endotracheal tube intubation with McGRATH MAC: a prospective randomized clinical trial.

STUDY OBJECTIVE: This study aimed to compare the impact of pillow height on double-lumen tracheal tube (DLT) intubation with McGRATH MAC (McG) in patients undergoing elective surgery. DESIGN: Randomized clinical trial. SETTING: Operating room. PATIENTS: Fifty adult patients scheduled for elective surgery under 1-lung ventilation with an American Society of Anesthesiologists physical status of 1 to 3. INTERVENTIONS: DLT intubation with McG was performed with a high pillow (HP group; 25 patients) or low pillow (LP group; 25 patients) by anesthesiologists. MEASUREMENTS: Intubation time, number of laryngoscopy, number of tracheal intubation attempts to successful intubation, percentage of glottic opening score, and subjective difficulty of laryngoscopy and tube passage through the glottis were assessed. MAIN RESULTS: Intubation time was significantly shorter in the HP group compared with the LP group (HP: 32.1±14.9seconds vs LP: 49.4±11.2seconds, P<.001). The number of laryngoscopy were 1 (HP group, 22 patients; LP group, 17 patients), 2 (HP group, 3 patient; LP group, 7 patients), and 3 (HP group, 0 patient; LP group, 1 patient), with no significant difference between the 2 groups (P=.197). Although the percentage of glottic opening score did not significantly differ between HP and LP groups (HP: 95.6%±6.7% vs LP: 96.0%±12.3%, P=.08), the number of tracheal intubation attempts was significantly lower in the HP group compared with the LP group (P=.009). The visual analog scale score for laryngoscopy did not significantly differ between the 2 groups (P=.54). However, the visual analog scale for tube passage through the glottis was significantly higher in the LP group than in the HP group (P<.001). CONCLUSIONS: Intubation with an HP was associated with a better DLT intubation profile than with an LP with McG, possibly due to smoother tracheal tube progression through the glottis.

Comparison of polyvinyl chloride and elastic stannum stylet extraction forces with various lubricants: a simulation study.

BACKGROUND: Stylets are the most frequently used devices for tracheal intubation, but can be a source of postoperative pharyngeal pain or hoarseness. In this study, we evaluated extraction forces between polyvinyl chloride (PVC) and stannum (Sn) stylets with various lubricants. FINDINGS: Using a manikin, we compared extraction forces between PVC and Sn stylets under four different conditions: without lubricant, 3 ml of water (water), three sprays of 8 % lidocaine (lidocaine), and olive oil. A force measuring device was used to accurately measure the extraction force for stylet removal. The extraction force was significantly smaller with the Sn stylet compared to the PVC stylet, regardless of the lubricant used for all three tracheal tubes with different diameters tested (P < 0.05). In comparisons by lubricant, lidocaine and olive oil resulted in significantly lower extraction forces than with no lubricant or water with the PVC stylet for all tracheal tubes tested. In contrast, there were no significant differences in extraction force by lubricant for the Sn stylet across all tracheal tubes tested. CONCLUSIONS: The Sn stylet required less extraction force compared to the PVC stylet, regardless of the lubricant used.

[Anesthetic Management of Peritonectomy and Extended Operation for Peritoneal Pseudomyxoma Combined with Massive Ascites].

We report successful anesthetic management of extended operation for peritoneal pseudomyxoma combined with massive ascites (16.5 l). A 66-year-old man (weight 76 kg) who could not keep a supine position due to massive ascites associated with peritoneal pseudomyxoma was scheduled for elective peritonectomy and extended surgery. With the patient in the semisitting position, we administered 3% sevoflurane to induce loss of consciousness while preserving spontaneous ventilation. We then performed crush induction with propofol and rocuronium after topical anesthesia to the tongue base. Tracheal intubation with the Macintosh laryngoscope was successful. During the operation, we aspirated about 16.5 l of ascites over 20 l normal saline irrigation. To maintain the body temperature, we performed both active and passive extracorporeal warming. The operation included not only total peritonectomy but also distal gastrectomy, right colon resection, splenectomy, and cholecystectomy. To perform effective postoperative analgesia, we placed two epidural catheters from the upper and lower thoracic epidural spaces. The patient was extubated 3 days after operation, and discharged uneventfully on the 18th postoperative day.

Muscle relaxant facilitates i-gel insertion by novice doctors: A prospective randomized controlled trial.

STUDY OBJECTIVE: This study aimed to determine whether muscle relaxants facilitates insertion efficacy of the i-gel supraglottic device (i-gel) by novice doctors in anesthetized patients. DESIGN: Randomized clinical trial. SETTING: Operating room. PATIENTS: Seventy adult patients scheduled for elective surgery under general anesthesia. INTERVENTIONS: Seventy adult patients were assigned to the rocuronium (MR group; 35 patients) or control group (C group; 35 patients). Anesthesia was induced with propofol and remifentanil, and 0.9mgkg(-1) rocuronium was administered in the MR group. MEASUREMENTS: The number of attempts to successful insertion, sealing pressure, and subjective difficulty of insertion were compared between the groups. MAIN RESULTS: The total number of insertion attempts were as follows: one (MR group, 17 cases; C group, 4 cases), two (MR group, 13 cases; C group, 14 cases), three (MR group, 4 cases; C group, 14 cases), and failure (MR group, 1 case; C group, 3 cases), which was significantly different (P<.001). Sealing pressure was significantly higher in the MR group than in the C group (MR group, 22.1±5.4 cmH2O; C group, 18.7±3.2 cmH2O, P<.001). Subjective difficulty of insertion was significantly lower in the MR group than in the C group (C group, 72.4±19.0mm; MR group, 29.4±18.3mm; P<.001). CONCLUSIONS: Our randomized clinical trial suggests that muscle relaxation facilitates i-gel insertion efficacy in anesthetized patients, as assessed by successful insertion rate, sealing pressure, and subjective difficulty of insertion.

[Anesthetic Management of Video-assisted Left Upper Lobectomy in a Patient with Ischemic Heart Disease Using an Intraaortic Balloon Pump].

We report the successful anesthetic management of video-assisted left upper lobectomy in a patient with ischemic heart disease using an intra-aortic balloon pump (IABP). An 81-year-old man with severe ischemic heart disease was scheduled for partial lobectomy for suspected lung cancer under general anesthesia. Although he had severe ischemic heart disease, coronary intervention such as percutaneous cardiac intervention or coronary artery bypass grafting was impossible due to severe coronary stenosis. IABP was instituted through the femoral artery before inducing anesthesia. Tracheal intubation was performed with the McGRATH MAC videolaryngoscope to minimize stress. Surgery was performed uneventfully and the patient was transferred to the intensive care unit under sedation. IABP was removed three hours postoperatively. After confirming no ischemic or vital sign changes, he was extubated the next day. No complications resulting from the IABP were observed.

[Effective Dexmedetomidine Administration for the Prevention of Emergence Agitation and Postoperative Delirium in Patients with a History of Postoperative Delirium].

We successfully performed intraoperative dexmedetomidine (DEX) administration for the prevention of emergence agitation or postoperative delirium after lung resection in four patients (71.3 ± 5.7 year old, 3 males and 1 female) with a past history of postoperative delirium. DEX was started at 0.35-0.45 µg x kg(-1) x hr(-1) continuously without loading. The average time from DEX initiation to extubation was 141.3 ± 94.4 minutes. No patient had emergence agitation, and DEX administration was continued until the following morning with monitoring in all patients without any symptoms of delirium. Intraoperative DEX administration may be beneficial for the prevention of emergence agitation or postoperative delirium in patients with a past history of postoperative delirium.

[Anesthetic Management for Lobectomy in a Patient with Pulmonary Arterial Hypertension].

Pulmonary arterial hypertension (PAH) is a known risk factor of perioperative complications, but the risks for non-cardiac operations have not yet been examined sufficiently. We report a case of a right lower lobectomy in a patient with PAH. A 73-year-old woman with Sjögren's syndrome was scheduled for right lowr lobectomy for primary lung cancer under general anesthesia. She was diagnosed with symptomatic PAH (estimated mean pulmonary arterial pressure, 40 mmHg) and medicated with ambrisentan. After induction of general anesthesia with propofol and fentanyl, a pulmonary artery catheter was placed to measure pulmonary artery pressure. The Pp/Ps was roughly 0.4 and the pulmonary artery clamp elevated it to 0.5. Milrinone administration gradually improved the Pp/Ps to 0.3. To avoid pulmonary artery pressure elevation during emergence of anesthesia, continuous dexmedetomidine was administered. The double-lumen tracheal tube was extubated uneventfully with minimal elevation in pulmonary arterial pressure.