A comparison of hemodynamic changes after endotracheal intubation by the Optiscope™ and the conventional laryngoscope.

BACKGROUND: Optiscope™ is a newly developed video stylet device. This study evaluated and compared the hemodynamic changes observed after endotracheal intubation with video stylet and after conventional laryngoscopic endotracheal intubation. METHODS: Fifty-eight adult patients with American Society of Anesthesiologists (ASA) physical status class 1 or 2, undergoing general anesthesia, were randomized into two groups: one group of patients were intubated using video stylet (n = 29) and the other group were intubated using direct laryngoscope (n = 29). Systolic blood pressure (SBP), mean arterial pressure (MAP), diastolic blood pressure (DBP), heart rate (HR), POGO (percentage of glottic opening) score, time for intubation and degree of sore throat were recorded. RESULTS: There were no significant differences in the SBP, MAP, DBP, HR, and the sore throat incidence between the two groups. Optiscope™ produced better POGO scores, but time for intubation was longer than with conventional laryngoscope. CONCLUSIONS: Optiscope™, when compared with conventional laryngoscope for intubation, does not modify the hemodynamic response, but it provides a better view of the vocal cords.

Fascia iliaca compartment block reduces emergence agitation by providing effective analgesic properties in children.

STUDY OBJECTIVE: To determine whether fascia iliaca compartment block (FICB) reduces emergence agitation. DESIGN: Prospective, randomized, blinded clinical trial. SETTING: Operating room and Postanesthesia Care Unit (PACU) of a university hospital. PATIENTS: 64 ASA physical status 1 and 2 pediatric patients aged three to 7 years, scheduled for orthopedic surgery involving the anterior or lateral thigh. INTERVENTIONS: Patients enrolled in the FICB group received FICB immediately after the operation, while control group patients received intravenous (IV) patient/parent-controlled analgesia (PCA) with fentanyl. MEASUREMENTS: Severity of agitation and pain were evaluated using the Pediatric Agitation and Emergence Delirium (PAED) scale and the Children's Hospital of Eastern Ontario Pain Scale (CHEOPS). Data were collected at 10-minute intervals in the PACU. The results were analyzed using the t-test. MAIN RESULTS: PAED scores in the FICB group were significantly lower than those of the control group on arrival at the PACU (7.3 ± 2.9 vs 10.4 ± 3.2, P < 0.001). The FICB group also had significantly lower CHEOPS pain scores than the control group, both on arrival at the PACU and 10 minutes after arrival (6.4 ± 1.5 vs 10.4 ± 1.8, P < 0.001 and 6.7 ± 1.6 vs 8.0 ± 1.4, P = 0.009, respectively). CONCLUSION: In children having surgery on the thigh, FICB effectively reduced the severity of emergence agitation and postoperative pain during the immediate postoperative period.

A comparison of GlideScope(®) videolaryngoscopy and direct laryngoscopy for nasotracheal intubation in children.

BACKGROUND: The relative effectiveness of GlideScope(®) videolaryngoscopy (GV) for nasotracheal intubation in pediatric patients is unclear. The purpose of this study is to evaluate the usefulness of GV for nasotracheal intubation compared with direct laryngoscopy (DL) in pediatric patients. METHODS: Our patient cohort consisted of 80 children <10 years of age who required nasotracheal intubation for elective dental or facial surgery. The patients were randomly allocated to GV (n = 40) or DL (n = 40) group. The time to intubation (TTI), glottic view grade, frequency of Magill forceps use, and degree of difficulty in intubation were evaluated. RESULTS: The median TTI was similar between the groups. The TTI of the former 20 patients was faster in the DL group (53.3 s, interquartile range: 42.0-64.3) than GV group (65.9 s, interquartile range: 56.0-93.9) (P = 0.007), whereas the TTI of the latter 20 patients was comparable between the groups. There were no significant differences in glottic view grade, frequency of Magill forceps use, and degree of difficulty in intubation between the two groups. CONCLUSIONS: GV can provide similar intubation performance characteristics compared with DL when used for nasotracheal intubation in pediatric patients. However, experience is needed to be skillful in the GV to acquire comparable TTI with DL.

Less perilaryngeal gas leakage with SLIPA™ than with LMA-ProSeal™ in paralyzed patients.

PURPOSE: The aim of this study was to compare the Streamlined Liner of the Pharynx Airway (SLIPA™) with the ProSeal Laryngeal Mask Airway (LMA-ProSeal™) in mechanically ventilated paralyzed patients undergoing laparoscopic gynecologic surgery. METHODS: One hundred and one patients were allocated randomly to SLIPA (n = 50) or to LMA-ProSeal (n = 51) treatment groups. After induction of general anesthesia and insertion of the assigned supralaryngeal airway (SLA) device, we made note of the occurrence of any gastric insufflation and perilaryngeal leakage. We then evaluated the anatomical fit of the SLA device using a fibreoptic bronchoscope, and we assessed the airway sealing pressure and respiratory mechanics with change in head position and during peritoneal insufflation. After surgery, we evaluated the severity of postoperative sore throat and the presence of blood or regurgitated fluid on the SLA device. RESULTS: The insertion success rate, gastric insufflation, perilaryngeal leakage, anatomical fit, airway sealing pressure, respiratory mechanics, severity of sore throat, and incidence of blood and regurgitated fluid on the device were similar between the two groups. The incidence of perilaryngeal leakage with changes in the patient's head position was lower with the SLIPA group than with the LMA-ProSeal group (3/50 vs 11/51, respectively; P = 0.026). During peritoneal insufflation, perilaryngeal leakage did not occur with the SLIPA but occurred in four cases with the LMA-ProSeal (P = 0.045). CONCLUSION: Both the SLIPA and the LMA-ProSeal can be used effectively and without severe complications in paralyzed patients undergoing laparoscopic gynecological surgery. However, the SLIPA offers the advantage of less perilaryngeal gas leakage than the LMA-ProSeal with change in head position and during insufflation of the peritoneal cavity. This trial is registered with ANZCTR (ACTRN12609000914268).

The effect of intraperitoneal ropivacaine on pain after laparoscopic colectomy: a prospective randomized controlled trial.

BACKGROUND: Although laparoscopic procedures are becoming more common, postoperative pain remains a major factor causing delayed patient recovery. There have been several trials to reduce pain by instilling local anesthetics into the peritoneal cavity, but there has been no study on prolonged (∼300 min) or intensive surgery. We investigated the analgesic effect of intraperitoneal ropivacaine instillation after laparoscopic colectomy. MATERIALS AND METHODS: Sixty patients were randomized to three groups. Twenty patients in each group received 50 mL of appropriate solutions after the formation of a pneumoperitoneum. The solution was normal saline (control) in group C and 1 mg/kg of ropivacaine in each of groups I and D. In group D, ropivacaine was sprayed again before the elimination of the pneumoperitoneum. Patients reported their postoperative pain using a subjective visual analogue scale. Fentanyl use for pain relief and frequency of pushing a button (FPB) for a bolus of patient controlled analgesia were evaluated, and scales of recovery rates were obtained. RESULTS: The immediate postoperative pain score was lower in groups I and D than in group C. In groups I and D, FPB measures and fentanyl use were both less than in group C. The time taken to resume a regular diet was shorter in group D than in group C. CONCLUSIONS: The intraperitoneal instillation of ropivacaine was effective in reducing postoperative pain and in shortening the recovery course after laparoscopic colectomy. The additional instillation of ropivacaine at the end of the surgery proved even more effective.

A comprehensive model of factors affecting adoption of clinical practice guidelines in Korea.

This study aims to investigate the factors related to the adoption of clinical practice guidelines in clinical settings in Korea; it also aims to determine how these factors differ depending on the specific situation of health care system and professional climate. The research sample comprised physicians who are board members of academic societies with experiences in development of clinical practice guidelines using a convenient sampling. We analyzed 324 physicians with pooling two-year sample of 2007 and 2008. From all the respondents, 48.8% stated that they followed Clinical Practice Guidelines, and 93.4% agreed with the content in the Clinical Practice Guidelines. With regard to the item on the self-efficacy of practicing guidelines, 90.3% of the respondents selected 'low level'. In the regression analysis, the factors associated with implementation were level of recognition, agreement and self-efficacy and positive attitude towards practice guidelines. Although the health care system in Korea differs from those in Western countries, our results revealed that the factors related to the adoption of practice guidelines were similar to the research results of Western countries. These results suggest that professionals' attitudes towards clinical practice guidelines are universal, and implementation strategies should be developed globally.

The effects of changing from isoflurane to desflurane on the recovery profile during the latter part of anesthesia.

It is not known whether changing from isoflurane to desflurane during the latter part of anesthesia shows early emergence and recovery in long surgery. We therefore evaluated the effects of changing isoflurane to desflurane on emergence and recovery. Eighty-two patients were randomly assigned to receive isoflurane (Group I) or desflurane (Group D) or to change from isoflurane to desflurane anesthesia (Group X). At the point when there was an hour until the operation would end, isoflurane was replaced with 1 MAC of desflurane in Group X, and isoflurane and desflurane were maintained at 1 MAC in Groups I and D. When the operation ended, we compared the emergence and recovery characteristics among the 3 groups. Compared with Group I, Group X showed faster emergence and recovery. Group X and Group D showed similar emergence and recovery. In conclusion, changing isoflurane to desflurane during the latter part of anesthesia improves emergence and recovery.

Cardiac arrest induced by tension pneumothorax during ventilating bronchoscopy -A case report-.

Tension pneumothorax during ventilating bronchoscopy for foreign body removal is a rare but life-threatening complication. The authors present a case of cardiac arrest caused by tension pneumothorax in a 9-month-old girl who underwent ventilating bronchoscopy for foreign body (peanut) removal. Tension pneumothorax was due to tracheobronchial lacerations caused by a bronchoscope. The patient was successfully resuscitated by cardiopulmonary resuscitation and chest tube insertion. The airway injury was effectively repaired by thoracotomy under extracorporeal membrane oxygenation.

Prolonged paradoxical air embolism during intraoperative intestinal endoscopy confirmed by transesophageal echocardiography -A case report-.

Venous air embolism (VAE) during intestinal endoscopy is a rare complication. We report a case of cardiovascular collapse due to VAE confirmed by transesophageal echocardiography (TEE) during intraoperative intestinal endoscopy. TEE detected air bubbles in the left ventricle up to 1 hour after the event. When a patient deteriorates during endoscopic procedures, VAE and possible paradoxical air embolism (PAE) should be suspected. This case demonstrates that TEE can play an important role in diagnosing and managing an air embolism in anesthetized patients. In addition, this case demonstrates that PAEs may occur longer than expected after recovery from VAE-induced cardiovascular collapse.

Head rotation, flexion, and extension alter endotracheal tube position in adults and children.

PURPOSE: The purpose of this study was to evaluate the effect of head rotation in adults and children on endotracheal tube (ETT) position and to confirm previous results regarding the influence of head flexion and extension on ETT position. METHODS: After inducing anesthesia in 24 young adults and 22 children (aged 1-9 yr), ETTs were secured on the right corner of each of their mouths. Using a fiberoptic bronchoscope, the distance from the carina to the tip of the ETT was measured with each patient's head and neck placed in a neutral position, flexed, extended, rotated to the right, and rotated to the left. RESULTS: In all patients, flexing the head resulted in the ETT moving towards the carina, and extension resulted in the tube being displaced in the opposite direction. In adults, head rotation to the right resulted in withdrawal of the ETT in all but one patient; displacement was 0.8 +/- 0.5 cm (mean +/- SD) (P < 0.001). Head rotation to the left resulted in the endotracheal tube being displaced in an unpredictable direction by 0.1 +/- 0.6 cm. In children, head rotation to the right resulted in withdrawal of the ETT in all patients; displacement was 1.1 +/- 0.6 cm (P < 0.001). Head rotation to the left also resulted in partial withdrawal in all patients; displacement measured 0.6 +/- 0.4 cm (P < 0.001). CONCLUSIONS: In adult patients under general anesthesia, head rotation towards the side of ETT fixation resulted in partial withdrawal of the tube tip away from the carina, whereas head rotation to the opposite side displaced the tube in an unpredictable manner. In children, head rotation to either side resulted in withdrawal of the ETT away from the carina.

The effect of inguinal compression, Valsalva maneuver, and reverse Trendelenburg position on the cross-sectional area of the femoral vein in children.

BACKGROUND: For facilitation of femoral venous cannulation, the larger cross-sectional area (CSA) of the vein is helpful and can be achieved by inguinal compression, Valsalva maneuver, or the reverse Trendelenburg position. In this study, we evaluated these methods using ultrasonography in children. METHODS: Ultrasound was used to measure the CSA of the common femoral vein of 50 anesthetized pediatric patients (Group L: 25 patients more than 2 yr, Group S: 25 patients younger than 2 yr). The following six measurements of the CSA of the femoral vein were made: 1) in the supine position (control), 2) with digital compression above the inguinal ligament, 3) in the Trendelenburg position 15 degrees , 4) in the Trendelenburg position 15 degrees plus inguinal compression, 5) with Valsalva maneuver, and 6) in the reverse Trendelenburg position 15 degrees . We defined 20% change of the CSA as clinically significant. RESULTS: Inguinal compression increased the CSA of the femoral vein by 40% in Group L and by 57% in Group S (each P < 0.001). Inguinal compression during the Trendelenburg position also increased the CSA by 43% in Group L and by 73% in Group S (each P < 0.001). Valsalva maneuver for increasing the CSA of the femoral vein was more effective in Group S (increased by 35%) than in Group L (by 19%). The changes in the CSA were not clinically significant during the Trendelenburg position or the reverse Trendelenburg position. CONCLUSIONS: Inguinal compression effectively increases the CSA of the femoral vein and its effect is also prominent in the Trendelenburg position. Valsalva maneuver is more effective in small children. Gravitational position changes have little effect on the size of the femoral vein in children.

Flexion compromises ventilation with the laryngeal tube suction II in children.

BACKGROUND: There are insufficient data as to the influence of the head and neck flexion, extension, and rotation on the ventilation with laryngeal tube suction II (LTS II). The purpose of this study was to investigate the influence of the head and neck position on oropharyngeal sealing pressure (primary outcome) and ventilation score (secondary outcome) during ventilation with the LTS II in children. METHODS: We studied 33 children scheduled for elective surgery. Oropharyngeal sealing pressure and ventilation score were measured with the head and neck in a neutral position, flexed, extended and rotated to the right. The ventilation score was scored from 0 to 3 based on three items (no leakage with an airway pressure of 15 cmH2O, bilateral chest excursion, and a square wave capnogram; each item scored 0 or 1 point). Peak inspiratory pressure (PIP) at a tidal volume of 10 ml x kg(-1) and fiberoptic laryngeal views were also assessed in each position. RESULTS: Although the sealing pressure was lower in the extended position [22 (8) cmH2O] than that in the neutral position [25 (7) cmH2O], there was no significant leakage during ventilation with a tidal volume of 10 ml x kg(-1). In the neutral, extended and rotated positions, the median ventilation scores were better (3 point respectively) than that with the head and neck flexed (1 point). PIP was decreased with the head and neck extended or rotated but was significantly increased in flexion position. During fibreoptic examination, the vocal cords were more easily seen in extension and right rotation, compared with the neutral position and flexion. CONCLUSIONS: Although oropharyngeal sealing pressure is decreased with the head and neck extended, effective ventilation with LTS II can be performed like in the neutral position or the rotated position. While the sealing pressure is maintained with the head and neck flexed, flexion compromises the ventilation with LTS II in children.

Anesthetic management of children with Beckwith-Wiedemann syndrome : Two cases report.

Beckwith-Wiedemann syndrome consists of various abnormalities, including macroglossia, visceromegaly, omphalocele, and neonatal hypoglycemia. These abnormalities frequently require operative correction and careful anesthetic management. Principal problems associated with anesthetic management in this syndrome are congenital heart disease, hypoglycemia, and difficult airway combined with macroglossia. We report two cases of general anesthetic management in children with Beckwith-Wiedemann syndrome.

Hemothorax due to injuries of subclavian artery and first intercostal artery after subclavian venous catheterization in a pediatric patient : A case report.

Central venous catheterization is useful to evaluate intravascular volume status, while it has a chance of severe complications such as tension pneumothorax, cardiac tamponade, and so on. Now, we report a case of hemothorax after trying subclavian venous catheterization over again in a 2-year-old patient undergoing encephalo-duro-arterio-synangiosis, that required surgical intervention at the end. Though arterial puncture and massive hemothorax is a possible complication of subclavian venous catheterization, the injury of first intercostal artery might be due to inappropriate introducer needle accidentally. In conclusion, both routine chest image confirmation and close observation of expert might be important to prevent iatrogenic complication by anesthetic maneuvers.

Measuring depth of anesthesia with EEG and ECG in children.

BACKGROUND: Heart rate is tightly controlled by brain. If activity of brain and electroencephalograph (EEG) are changed by anesthetics, electrocardiograph (ECG) might be changed. We investigated whether there is a correlation between EEG and ECG, ECG could replace EEG as a monitor for depth of anesthesia. METHODS: We recruited 50 patients, aged 2-8 years. Inspired and expired end-tidal sevoflurane concentrations were held constant at 1.0 or 2.5 vol%, after which ECG and EEG were obtained for 15 minutes. Total power (TP), low-frequency power (LFP), high-frequency power (HFP), approximate entropy (ApEn), and Hurst exponent (H) were calculated from the ECG. The relationship between EEG and ECG indices at the two sevoflurane concentrations was measured by Pearson's correlation coefficient. RESULTS: As anesthesia deepened, ApEn, H of ECG and beta wave decreased and those of delta and theta increased in 4 channels. In FP2, changes of beta and theta wave were negatively correlated with ApEn and H of ECG (P < 0.05), and changes of delta wave was positively correlated with ApEn (P < 0.05) and H (P < 0.01). In F8, changes of beta and theta wave were negatively correlated with ApEn (P < 0.05) and only theta wave was negatively correlated with H (P < 0.05). In C4, change of delta wave was positively correlated with ApEn (P < 0.001) and H (P < 0.05). CONCLUSIONS: EEG and ECG indices are correlated during sevoflurane anesthesia in children, and ECG-derived indices could possibly be used to monitor depth of anesthesia.

Effect of active warming on shivering during spinal anesthesia.

BACKGROUND: Hypothermia is considered one of the reasons for intraoperative shivering. The purpose of this study is to assess whether active warming can prevent hypothermia and shivering in young adults under spinal anesthesia. METHODS: Fifty male patients scheduled for an elective operation on lower extremity under spinal anesthesia were randomly assigned into the warming group (n = 25) and the control group (n = 25). The active warming was performed using a forced air-warming device, a warmed blanket and warmed fluid. Axillary and tympanic temperatures, shivering degree, thermal discomfort, and anesthetic level were checked every 10 minutes after intrathecal injection of local anesthetics. RESULTS: Patients' characteristics and anesthetic levels were comparable between the groups. Axillary and tympanic temperatures were maintained higher in the warming group than the control group 10 minutes and 20 minutes after intrathecal injection respectively. The lowest temperature in operating room was higher in the warming group (36.3 +/- 0.5degrees C) compared with the control group (35.7 +/- 0.5degrees C) (P < 0.05). Incidences of intraoperative shivering and thermal discomfort were lower in the warming group. CONCLUSIONS: We conclude that intraoperative active warming can prevent hypothermia and shivering during spinal anesthesia.

Effects of ATP and LTC4 on hypoxic pulmonary vasoconstriction in isolated rat lungs.

BACKGROUND: Hypoxic pulmonary vasoconstriction (HPV) is unique to pulmonary circulation but the mechanism remains elusive. Red blood cells (RBCs) are known to augment HPV and to release more ATP as oxygen content falls. Leukotrienes constrict smooth muscle and could be important for the regulation of the pulmonary circulation. Hence we hypothesized that ATP and leukotrienes are mediators of HPV produced during acute alveolar hypoxia. METHODS: In forty Sprague-Dawley rats, lungs were isolated and perfused. We administered ATP (10 micrometer) to the ATP group (n = 8), the ATP antagonist, suramin (100 micrometer) to the suramin group (n = 8), leukotriene C4 (LTC4, 5 microgram) to the LTC4 group (n = 8), the LTC4 antagonist, LY171883 (20 micrometer) to the LY171883 group (n = 8), and LTC4 (5 microgram) + ATP (10 micrometer) to the LTC4 + ATP group (n = 8) during normoxic ventilation. HPV responses were induced by three hypoxic challenges for 5 minutes separated by 5 minutes of ventilation with a normoxic gas mixture. Baseline pulmonary artery pressure change after exposure to each drug and hypoxic pressor response between a period 21% normoxic gas ventilation and that of 3% hypoxic gas ventilation were measured. RESULTS: ATP and LTC4 + ATP increased baseline pulmonary artery pressures but LTC4 did not alter it. ATP did not affect hypoxic pressor response. Suramin, LY171883 and LTC4 + ATP inhibited the pressor response to hypoxia. LTC4 increased hypoxic pressor response. CONCLUSIONS: In isolated rat lungs, HPV may be mediated by ATP and LTC4 appears more likely to be a modulator than a mediator of HPV.

Luminal ATP-induced contraction of rabbit pulmonary arteries and role of purinoceptors in the regulation of pulmonary arterial pressure.

The effects of luminal ATP between rabbit pulmonary (PAs) and coronary arteries (CAs) were compared to understand the role of purinoceptors in the regulation of pulmonary arterial pressure (PAP) under hypoxia. Diameters of vessels were video analyzed under luminal perfusion. ATP-induced membrane currents and intracellular Ca(2+) signals ([Ca(2+)](i)) were compared in pulmonary (PASMCs) and coronary myocytes (CASMCs) using patch clamp and spectrofluorimetry. PAP was measured in perfused lungs under ventilation. Luminal ATP induced constriction of rabbit PAs in the presence of endothelium. In contrast, CAs showed dilating responses to luminal ATP even in the absence of endothelium. In PASMCs, both P2X-mediated inward current and P2Y-mediated store Ca(2+) release were consistently observed. In contrast, CASMCs showed neither P2X nor P2Y responses. In the perfused lungs, hypoxia-induced PAP increase was decreased by suramin, a purinergic antagonist. A luminal application of alpha,beta-meATP largely increased PAP, whereas UTP decreased PAP. The combined application of P2X- and P2Y-selective agonists (alpha,beta-meATP and UTP) increased PAP. However, the perfusion of ATP alone decreased PAP, and the ATP-induced PAP decrease was affected neither by adenosine receptor antagonist nor by nitric oxide synthase inhibitor. In summary, although the luminal ATP constricts isolated PAs and suramin attenuated the HPV of perfused lungs, the bimodal responses of PAP to purinergic agonists indicate that the luminal ATP regulates pulmonary circulation via complex signaling interactions in situ.

A comparison of the end-tidal sevoflurane concentration for removal of the laryngeal mask airway and laryngeal tube in anesthetized children.

BACKGROUND: In this study we quantified and compared the optimal sevoflurane concentration required to prevent coughing or moving during or after removal of the laryngeal mask airway (LMA) and the laryngeal tube (LT) in anesthetized children. METHODS: Forty unpremedicated children, aged 8 mo to 12 yr, were randomly allocated to receive the LMA or LT. General anesthesia was induced via mask with sevoflurane and the LMA or LT was inserted. Anesthesia was maintained with sevoflurane and oxygen. At the end of surgery, a predetermined end-tidal sevoflurane concentration was maintained for at least 10 min and the LMA or LT was removed. Using Dixon's up-down method, the concentration for LMA and LT removal was determined by adjusting the dose by a 0.2% increment. Success was defined by the absence of coughing, teeth clenching, gross purposeful movement, breath holding, laryngospasm, and desaturation. RESULTS: The end-tidal concentration of sevoflurane to achieve successful LMA removal in 50% of children was 1.90%, in 95% of children was 2.15%. For the LT, the concentrations were 1.83% and 2.00%. The 50% effective dose values did not differ significantly between groups. CONCLUSIONS: LMA and LT removal in 95% of anesthetized children (aged 8 mo to 12 yr) can be safely accomplished without coughing, moving, or any other airway complications at 0.86 and 0.80 minimum alveolar anesthetic concentration, respectively, and a similar concentration should be used for removal of the LT or LMA in children.