Efficacy of an aid (gastric tube insertion guide) for oral insertion of a gastric tube: a randomized controlled trial.

PURPOSE: Insertion of a gastric tube orally may be more difficult than its insertion nasally, and thus, any aid to facilitate its insertion may be useful. Gastric tube insertion guide (Fuji Medical Corporation, Tokyo, Japan) has recently become commercially available. We felt that this device might be useful in facilitating oral insertion of a gastric tube, but there has been no formal study assessing its efficacy. The main aim of this study was to assess whether or not this "tube guide" would facilitate insertion of an orogastric tube. METHODS: As a randomized controlled clinical study, we planned to study 40 patients, to assess the hypothesis that the success rate of insertion of an orogastric tube would be higher with the use of the "tube guide" than without. Patients were recruited when they were 20 years old, or older, and allocated randomly to one of two groups (20 people each group). In one group, the conventional "blind" insertion method was used and in the other group the "tube guide" insertion method. RESULTS: The success rate was significantly higher for the "tube guide" method than the "blind" insertion method (P = 0.0012, 95% CI for difference: 23-67%). CONCLUSION: We have shown that the use of the gastric tube insertion guide® facilitates insertion of an orogastric tube.

Efficacy of a gastric tube insertion guide for insertion of a nasogastric tube: a prospective, randomized controlled clinical study.

PURPOSE: We studied whether a newly available gastric tube insertion guide (Fuji Medical, Tokyo, Japan) was effective in insertion of a nasogastric tube. METHODS: Sixty anesthetized patients were randomly allocated to three groups, and we attempted to insert a nasogastric tube with a blind technique (Group B), with the lateral neck pressure (Group L), or with the tube guide (Group G). If the insertion failed in Group B or L, its insertion was attempted with the tube guide. Primary outcome measure was the insertion success rate within 300 s. RESULTS: The success rate in Group G (19 of 20 patients) was significantly higher than Group L (13 of 20 patients) (P = 0.04; 95% confidence intervals for difference: 16-44%), and than Group B (11 of 19 patients) (P = 0.008; 23-50%). In the 15 patients of Groups B and L, in whom insertion had failed, insertion with the tube guide was successful in 14 patients. There was no significant difference in insertion time between the groups, but in patients in whom insertion was successful, it was significantly longer in Group G (median of 147 s) than in Group L (66 s) (P < 0.01) and Group B (46 s) (P < 0.01). Minor complications occurred in 2 patients in Group B, 1 in Group L, and 5 in Group G (P > 0.05). CONCLUSION: We conclude that the gastric tube insertion guide (Fuji Medical, Tokyo, Japan) may be useful when the conventional method of insertion has failed.

Margin of safety for needle puncture of a radial artery.

The radial artery is the preferred site for arterial cannulation because of consistent anatomic accessibility, ease of cannulation, and a low incidence of complications. One possible risk associated with cannulation is an injury to the superficial branch of the radial nerve. The radial nerve divides to the superficial branch and the deep branch at the top of the forearm, and the superficial branch lies behind the brachioradialis muscle close to the lateral side of the radial artery and terminates the lateral side of the radial artery about 7 cm proximal to the wrist. The segment where the superficial branch of the radial nerve runs side-by-side the radial artery ("run side-by-side segment) is an increased risk area of nerve injury. We studied 100 volunteers to measure a "safe" segment (the length between the styloid process and the distal edge of the "run side-by-side segment), using an ultrasonograph. The 95%reference interval (which indicates the central 95% of a reference population) of the "safe" segment was 6.8-11.6 cm [with the mean 9.4 (standard variation: 1.7)] in men, and 5.4-11.0 [8.2 (1.4)] cm in women. In conclusion, we have shown that the margin of safety for needle puncture of a radial artery is about 6.8 cm from the wrist for in men, and 5.4 cm from the wrist for in women.

[Utility of McGRATH MAC for a Patient with a Large Epiglottic Cyst].

A 76-year-old man with an epiglottic cyst was scheduled for transoral rigid endoscopic epiglottic cystectomy under general anesthesia. The epiglottic cyst was found accidentally when he had an operation of radical cystectomy 2 weeks before. When he had the radical cystectomy, the ventilation through a mask was easy. He had no subjective respiratory symptoms. We chose rapid induction with propofol, remifentanl, and rocuronium. When we inserted the McGRATH MAC laryngoscope, we could only see a big epiglottic cyst not vocal cord but the pressure on the neck enabled the laryngologist to see the vocal cord. We could identify the space through which we could insert tracheal tube without touching the cyst. After the operation, his trachea was extubed.

[The Use of a Tracheal Tube for Guiding Nasogastric Tube Insertion].

An obese patient was scheduled for shoulder joint surgery under general anesthesia. After induction of anesthesia and tracheal intubation, insertion of a gastric tube was difficult. A new tracheal tube was prepared, the connecter was removed, and the tube was cut longitudinally. The tube was inserted orally into the esophagus. A gastric tube was passed through the nose, and its tip was taken out of the mouth. The tip of the gastric tube was passed through the tracheal tube, and its correct position in the stomach was confirmed by auscultation of the epigastrium. The tracheal tube was carefully taken out from the esophagus leaving the gastric tube in the stomach. The cut tracheal tube was peeled off from the gastric tube. Correct positioning of the gastric tube was re-confirmed.

[Stroke Volume Variation (SVV) as an Indicator of Intraoperative Transfusion Management during Laparoscopic Colectomy.]

BACKGROUND: Intraoperative transfusion manage- ment is difficult during laparoscopic surgery, because peumoperitoneum affects hemodynamics. We studied whether stroke volume variation (SVV) is useful as an indicator of transfusion management Methods : We studied 44 patients undergoing lapa- roscopic colectomy. Patients were randomly allocated to two groups, and the volume of transfusion was decided with the SVV as an indicator in one group (SVV group, n=22) or with conventional indicators, such as blood pressure, heart rate, volume of urine in the other group (control group, n=22) Results : In the SVV group, total transfusion volume and total blood loss during operation were significantly decreased, and the length of hospital stay was signifi- cantly shorter, compared with the control group. CONCLUSIONS: We believe that the SVV is a useful indicator of intraoperative transfusi6h management during laparoscopic colectomy.

[Complication and Anesthetics-induced Toxicity of Stellate Ganglion Block].

Stellate ganglion block (SGB) is a commonly used safe procedure. In rare cases, it is associated with life- threatening complications [retropharyngeal hematomas (RPH), local anesthetics-induced toxicity, et al.). Man- agement and preventive measures of these complica- tions are described. RPH after SGB necessitates emer- gency airway management Intoxication is mainly the result of accidental intra- arterial injection and is difficult to treat but higher doses of intravenous lipid emulsions can improve the outcome.

[Emergency Tracheal Intubation Using Airwayscope in a Patient with Hematoma after Thyroidectomy].

We report a case of emergency awake intubation using Airwayscope (AWS) in a patient with difficulty of the ventilation combined with severe neck swelling due to hematoma after thyroidectomy. A 28-year-old woman with thyroid tumor received, general anesthesia induced, easily with facemask ventilation and tracheal intubation. Her trachea was extubated after she had become awake. Several minutes later, sudden swelling of the neck was observed, and she lost her consciousness. Despite attempts at facemask ventilation, hypoxia with bradycardia was observed. We judged that insertion of the supraglottic airway or the needle cannulation of the cricothyroid membrane would be difficult reducing the chance of re-intubation. While we asked surgeons to prepare for emergency surgical tracheotomy, we attempted to intubate the trachea using the AWS under sedation. Despite difficulty in opening the mouth and swelling of the tongue, we managed to intubate the trachea. We consider that knowledge of difficult airway management (DAM) is necessary, but we must be flexible to judge which method should be used in each patient In addition we conclude that the AWS is useful for awake intubation.

[Combined Use of a Videolaryngoscope and a Transilluminating Device for Intubation with Two Difficult Airways].

Videolaryngoscope is useful in patients with difficult airways, but it may not be in some patients. We report the use of a lighted stylet to facilitate tracheal intubation in 2 patients in whom laryngoscopy with a videolaryngoscope was difficult. Case 1: A 52-year-old female with loose teeth and lockjaw presented for a scoliosis surgery under general anesthesia. Laryngoscopy using a blade 3 of a Glide-Scope® (Laerdal Medical Corporation, New York, NY, USA) videolaryngoscope (GVL) showed a Cormack-Lehanne grade 3 view. Bag mask ventilation was easily achieved. By using the Trachilight™ (Saturn Biomedical System Burnaby, BC, Canada) with the GVL, we could intubate the trachea succesfully. Case 2: A 16-year-old male with a history of difficult tracheal intubation due to a limited cervical spine movement presented for an external fixation of a femur under general anesthesia. After induction of anaesthesia, bag mask ventilation was easily achieved but the GVL laryngoscopy did not provide a good view of the glottis (Cormack-Lehanne grade 3). Combined use of the Trachilight™ with the GVL, facilitated tracheal intubation. The Trachilight™ is a recognized aid to facilitate trachal intubation but the device is now commercially not available. Neverthless, we believe that a lighted stylet is potentially useful for tracheal intubation when the view of the glottis with a videolaryngoscopy is not ideal.

[Use of a new video-laryngoscope (McGRATH MAC) in patients with a difficult airway].

We describe the clinical use of a new video-laryngoscope (McGRATH MAC, McG) in patients with a difficult airway and morbid obesity. In a patient, case no. 2, with a difficult airway, showing a Cormack-Lehane grade III view with Macintosh direct laryngoscope, the glottis opening (Cormack-Lehane grade I) was visualized with McG. McG also provided a good view of glottis opening in a patient with morbid obesity. McG will have a profound impact on the management of the difficult airway.

[Effect of landiolol and combined use of landiolol and olprinone on hemodynamics in patients undergoing off-pump coronary artery bypass grafting].

BACKGROUND: Beta blockers are frequently used to reduce cardiac oxygen demand in off-pump coronary artery bypass grafting (OPCAB). However, significant bradycardia or negative inotropic effects are seen on occasion. We hypothesized that combined use of landiolol (L), an ultra short-acting beta blocker, and olprinone (O), a phosphodiesterase 3 inhibitor, is useful because it can increase cardiac index and prevent tachyarrhythmia even during dislocation of the heart in OPCAB. METHODS: Twenty-four patients were divided into two groups, L group and LO group randomly. Landiolol infusion was started at a rate of 3 microg x kg(-1) x min(-1) for patients in L group and LO group, and olprinone infusion was administered at a rate of 0.2 microg x kg(-1) x min(-1) for 90 minutes followed by 0.1 microg x kg(-1) x min(-1) for patients in LO group. Intra-aortic balloon pumping and atrial pacing were initiated for patients with expected unstable hemodynamics. RESULTS: Cardiac indices were greater in LO group and systemic vascular resistances were lower in LO group. However, total amount of noradrenaline used was greater in LO group. CONCLUSIONS: Combined use of landiolol and olprinone increases cardiac index and decreases systemic vascular resistance index during OPCAB.

[Anesthetic management for a patient with heparin-induced thrombocytopenia (HIT) undergoing off-pump coronary bypass surgery using argatroban, a direct thrombin inhibitor].

HIT type II is one of the severe complications of heparin therapy. The antibody for the heparin-PF 4 complex, which causes thrombocytopenia of less than 100 x 10(3) microl(-1), thrombosis and DIC-like symptoms, is produced. We managed the patient with HIT type II undergoing off-pump CABG. Anesthesia was induced and maintained with fentanyl, midazolam, vecuronium and sevoflurane. The operation was performed using argatroban, a direct thrombin inhibitor, as an anticoagulant. Intraoperative activated coagulation time (ACT) was maintained above 250 sec with 2.5-5.0 microg x kg(-1) x min(-1) of argatroban infusion without bolus injection and all the procedures were successful.