A comparison of parecoxib and thoracic epidural analgesia for postoperative analgesia following Nuss procedure.

BACKGROUND: The purpose of this study was to compare the results of thoracic epidural analgesia (TEA) and parecoxib in controlling postoperative pain after the Nuss procedure. METHODS: Between August 2005 and July 2014, 120 adolescents and adults underwent Nuss procedures and received either TEA or parecoxib for postoperative pain control. Demographic data, preoperative preparation times, visual analog scale (VAS) pain scores from postoperative day 1 to day 5, medical costs of pain control, days to Foley catheter removal, days to being able to sit up, days to being able to walk, days of hospital stay, nausea/vomiting scores, and complications related to pain control were compared. RESULTS: A total of 106 patients received TEA, and 14 received parecoxib. No between-group differences in demographics were observed. Patients in the parecoxib group had shorter preparation times (p<0.001), lower VAS pain scores from postoperative day 2 to day 5 (day 2, p=0.006; day 3, p=0.006; day 4, p<0.001; day 5, p<0.001), shorter hospital stays (p<0.001), lower pain control costs (p<0.001), and lower nausea/vomiting scores (p=0.046). CONCLUSIONS: For adolescents and adults undergoing the Nuss procedure, parecoxib affords better pain control efficacy, a shorter hospital stay, lower medical pain control costs, and fewer side effects compared with TEA.

Efficacy of intramuscular nalbuphine versus diphenhydramine for the prevention of epidural morphine-induced pruritus after cesarean delivery.

BACKGROUND: Pruritus is the most common side effect of epidural morphine analgesia. Diphenhydramine is a widely used agent for the treatment of urticarial pruritus. Nalbuphine is a mixed opioid agonist-antagonist and has been reported to be effective in treating opioid-induced pruritus. We compared the effectiveness of intramuscular diphenhydramine and nalbuphine for the prevention of epidural morphine-induced pruritus after cesarean section. METHODS: One hundred and fifty, American Society of Anesthesiologists physical status I or II, women undergoing cesarean section with epidural anesthesia were randomly assigned to three groups. Group S, group D, and group N received intramuscular normal saline (1 ml; n = 50), diphenhydramine (30 mg/1 ml; n = 50), and nalbuphine (10 mg/1 ml; n = 50), respectively, after delivery of the baby. The occurrence and the severity of pruritus were assessed at 1, 4, 12, and 24 hours after surgery. RESULTS: The overall incidence of pruritus during the 24 hr follow-up period was 72%, 68%, and 44% for group S, group D, and group N, respectively. Pruritus occurred less frequently in group N than group D (p = 0.027). At 4 and 12 hrs postoperatively, the pruritus severity was significantly different (p = 0.003 and p = 0.002) and was significantly less in group N than group D in the intergroup comparison (p = 0.013 and p = 0.012). CONCLUSION: Nalbuphine proved better than diphenhydramine for prevention of epidural morphine-induced pruritus in patients who underwent cesarean section. Prophylactic intramuscular nalbuphine (10 mg) is effective in decreasing the incidence and severity of pruritus and does not affect analgesia.

Effects of postoperative analgesia on postpartum urinary retention in women undergoing cesarean delivery.

AIM: Various analgesics and administration methods are used to provide women undergoing cesarean delivery pain relief after surgery. We compared three methods of postoperative analgesia regarding the incidence of postpartum urinary retention (PUR) in primiparous women undergoing elective cesarean delivery. METHODS: We estimated post-void residual bladder volume after the first postpartum micturition among 150 parturient women. Risk factors stratified for PUR defined by 150-mL post-void residual bladder volume were analyzed. Obstetric parameters and prevalence of lower urinary tract symptoms after surgery were compared among three groups of parturient women given different postoperative analgesia: epidural bolus morphine (EBM), patient-controlled epidural analgesia (PCEA) with ropivacaine-fentanyl, and intramuscular pethidine. RESULTS: The incidence of PUR was higher in the group given EBM (33.3%) than the groups receiving ropivacaine-fentanyl by PCEA (15%) or intramuscular pethidine (16.7%) (P = 0.038). Eighteen (12%) parturient women needed bladder catheterization to resolve their urinary retention at 1 day postpartum but all achieved spontaneous micturition prior to hospital discharge. The need for catheterization was also increased in the group with EBM (21.7%) in comparison with the other two groups (6.7% and 3.3%, respectively, P = 0.011). At the 3-month follow up, six women (4%) had obstructive voiding problems and seven women (4.7%) had irritating voiding problems. At the 1-year follow up, only one woman in the EBM group had incomplete emptying and another in the PCEA group had urinary incontinence. CONCLUSION: Epidural analgesia with morphine was significantly associated with post-cesarean urinary retention. Nonetheless, it was not detrimental to later urinary function.

Accuracy of a new body length-based formula for predicting tracheal tube size in Chinese children.

BACKGROUND: Variations in body weight and length (height) in children in the same age group have increased. Traditional age-based formulas often fail to predict the correct endotracheal tube (ETT) size. In our previous study, we devised a new length-based formula as follows: ETT internal diameter (ID) (mm) = 2 + (body length in cm/30). The current study was undertaken to assess the accuracy of this formula in Chinese children. METHODS: The ETT size was selected according to this length-based formula for 336 children who required tracheal intubation during general anesthesia. Incidences of tube change were recorded. Statistical analysis was performed using the chi-square test for differences in accuracy between age groups and body length groups. RESULTS: The length-based formula predicted a suitable ETT size in 277 (82.4%) of 336 subjects. There were 59 (17.6%) reintubations. Only 5 (1.49%) patients needed two tube changes when the correct ETT size was 1 mm larger or smaller than predicted. There were no statistically significant differences between age groups or length groups. CONCLUSIONS: The length-based formula ID (mm) = 2 + body length in cm/30 has high accuracy in predicting the appropriate ETT size in Chinese children.

Does intrapartum epidural analgesia affect nulliparous labor and postpartum urinary incontinence?

BACKGROUND: The effect of epidural analgesia on nulliparous labor and delivery remains controversial. In addition, pregnancy and delivery have long been considered risk factors in the genesis of stress urinary incontinence (SUI). We sought to determine the effect of epidural analgesia and timing of administration on labor course and postpartum SUI. METHODS: Five hundred and eighty three nulliparous women were admitted for vaginal delivery at > or = 36 gestational weeks. We compared various obstetric parameters and SUI, at puerperium and 3 months postpartum, among patients who had epidural and non-epidural analgesia, and among those who had early (cervical dilatation < 3 cm) and late (cervical dilatation > or = 3 cm) epidural analgesia. RESULTS: When compared with the non-epidural analgesia group (n = 319), the group that received epidural analgesia (n = 264) had significant prolongation of the first and second stages of labor, and higher likelihood for instrumental and cesarean delivery but similar incidence of severe vaginal laceration and postpartum SUI. Except for the first stage of labor, early administration of epidural analgesia did not result in a significant influence on obstetric parameters or an increased incidence of postpartum SUI. CONCLUSION: Our findings showed that epidural analgesia is associated with an increased risk of prolonged labor, and instrumental and cesarean delivery but is not related to increased postpartum SUI. Regarding the impact of the timing of epidural analgesia given in the labor course, the first stage of labor appeared to last longer when analgesia was administered early rather than late.

A randomized blinded study of the incidence of postoperative nausea and vomiting in women after major gynecologic laparoscopic surgery.

STUDY OBJECTIVE: To estimate the incidence of postoperative nausea and vomiting (PONV) in women undergoing major gynecologic laparoscopic surgery with an expected surgical duration exceeding 1 hour and anticipated overnight hospitalization. DESIGN: Randomized, double-blind, placebo-controlled study. SETTING: This study was set at a university hospital. PATIENTS: One hundred forty female patients with an American Society of Anesthesiology (ASA) physical status I or II and scheduled for gynecologic inpatient laparoscopic surgery. INTERVENTIONS: Patients were randomly assigned to receive 1 mg granisetron (Group A, n=70), or saline solution (Group B, n=70) intravenously after induction of general anesthesia. MEASUREMENTS AND MAIN RESULTS: The endpoints were evaluated by the following parameters: the incidence of PONV, episodes of nausea, retching, vomiting, rescue antiemetics, and complete response. Patients were closely observed for 24 hours after administration of the study drug. The two groups were generally well balanced in terms of demographic variables. The surgical period was longer in the granisetron group compared with the saline solution group. The total incidence of PONV was 41/70 (59%) in patients who underwent inpatient gynecologic laparoscopic surgery when no prophylactic antiemetic was given. Administration of granisetron decreased the incidence of PONV (29/70 [41%] vs 41/70 [59%], p<.05), the incidence of vomiting (18/70 [26%] vs 31/70 [44%], p<.05), and the proportions of patients requiring rescue antiemetics (14/70 [20%] vs 47/70 [67%], p<.01), but these results were not comparable to other studies. CONCLUSION: A long surgical period may have great impact on the PONV in women who undergo gynecologic laparoscopic surgery, which implies the need for skilled gynecologic laparoscopists.

Comparison of patient-controlled epidural analgesia and continuous epidural infusion for labor analgesia.

BACKGROUND: In recent years, patient-controlled epidural analgesia (PCEA) has been developed as an attractive alternative to continuous epidural infusion (CEI) for labor pain control. PCEA is still not popular for labor pain control in Taiwan and disparities may exist between different ethnic and cultural groups toward the attitude of labor pain control. The aim of this study was to investigate whether there were any differences between PCEA and CEI in the maintenance of epidural analgesia for Taiwanese parturients undergoing spontaneous delivery. METHODS: We collected data of 179 parturient requests for epidural labor analgesia. They were allocated into two groups with PCEA (n = 81) or CEI (n = 98) for maintenance with the same solution of 0.08% ropivacaine and 2 microg/mL fentanyl mixture. The demographic characteristics, epidural maintenance methods, dosage requirements, obstetrical outcomes, intervention of inadequate analgesia or side effects, and the quality of labor analgesia of parturient were also analyzed. RESULTS: There were no differences in demographic characteristics, duration of 1st and 2nd stages, delivery methods, fetal Apgar scores, local anesthetics usage, and analgesic qualities between the PCEA and CEI groups. There were also more requirements for intervention by the anesthesiologist due to inadequate analgesia in the CEI group. CONCLUSION: The results of this study provided further evidence that PCEA is a highly effective method of the control of labor pain, which was highly accepted by women in labor. In a busy obstetric unit, this could potentially improve parturient satisfaction and reduce the workloads of clinicians and nurses.

Extensive sensory block caused by accidental subdural catheterization during epidural labor analgesia.

A 32-year-old parturient requested epidural analgesia for labor. A lumbar epidural block was performed at the L1-2 interspace. Thirty minutes after the loading dose of the local anesthetic mixture, she suffered numbness in both arms and high sensory block up to the C6 dermatome without significant motor blockade. The retained epidural catheter was later confirmed radiologically to be in the subdural space. Accidental subdural catheterization is a rare complication of epidural block. Due to the smaller potential space, a subdural injection usually produces a high level block disproportional to the volume injected. Thus, patients receiving epidural block should be closely monitored following injection of local anesthetics regardless of the concentration or volume administered.

Profound hypoxemia during major abdominal surgery in a small infant with tetralogy of Fallot.

We report a protracted hypoxic event during Soave's endorectal pull-through for Hirschsprung's disease in a 2-month-old male infant with tetralogy of Fallot. After the bowel loops were delivered out of the abdominal cavity, profound hypoxemia occurred which persisted for about 120 min. The hypoxemia was completely resolved after the intestine was reduced back into the peritoneal cavity. The immediate cause was postulated to have been decreased systemic vascular resistance. Associated factors included hypothermia and acidosis leading to high pulmonary vascular resistance which further aggravated the right-to-left blood-shunting situation in this patient. Postoperative follow-up showed no neurological complications. Small infants with complex heart disease should be carefully evaluated before major abdominal surgery.

Postpartum unilateral Horner's syndrome following lumbar epidural anesthesia after a Cesarean delivery.

We report on a case demonstrating unilateral Horner's syndrome (HS) after lumbar epidural obstetric anesthesia. A healthy, 32-year-old woman with a breech presentation was scheduled for an elective Cesarean section. The patient had normal vital signs throughout the surgical procedure. The operation lasted for 50 min. In the recovery room, she complained of left nasal stuffiness, left cheek numbness, and heaviness in her left eye. Meanwhile, left nipple sensory loss was noted during baby suckling training. On physical examination, her left eyelid was droopy along with left-side ptosis and facial flushing. Reduced sensation over the left hemifacial region and upper arm was also noted, which resolved completely over the next 110 min. A diagnosis of unilateral HS was then made. Although typically a benign side effect which often spontaneously resolves, HS is likely to cause anxiety in both the patient and the doctor. Prompt recognition of this syndrome and determination of its cause from lumbar epidural anesthesia can prevent unnecessary and potentially dangerous diagnostic workup and can reassure both patients and clinicians. The patient was discharged from the hospital 5 days after onset with a good outcome.

Factors influencing time of intubation with a lightwand device in patients without known airway abnormality.

STUDY OBJECTIVE: To evaluate the correlation between accepted screening tests for difficult tracheal intubation and ease of intubation with a lightwand blind technique. DESIGN: Prospective study. SETTING: Anesthetic rooms of a university hospital. PATIENTS: 122 female, ASA physical status I, II, and III patients requiring tracheal intubation for elective surgery. INTERVENTIONS: After receiving a standardized anesthetic induction, patients first underwent direct laryngoscopy to determine Cormack laryngoscopy grade, then tracheal intubation was performed using a transillumination method. MEASUREMENTS AND MAIN RESULTS: Patient demographics, Mallampati class (MC), mouth opening (MO; cm), and thyromental distance (TMD; cm) were all measured and the values recorded. Body mass index (BMI; kg/m2) was calculated for each patient. Laryngoscopy grades obtained by laryngoscopy were also recorded. Times to intubation were measured by a chronometer and failures were recorded. Patients were then allocated to groups according to the measured parameters: BMI > or = 30 kg/m2, BMI < 30 kg/m2; TMD > or = 6 cm, TMD < 6 cm; MO > or = 3, MO < 3; MC I, MC II, MC III, MC IV, and Laryngoscopy Grade (LG) 1, LG 2, LG 3, LG 4. Intubation times at the first attempt were compared within the groups for each variable. The total results of 119 patients were studied; overall success was 99%, and mean time to intubation at the first attempt was 9.2 +/- 4.9 seconds. Although time to intubation was prolonged with increasing Mallampati and laryngoscopy scores, and in the TMD < 6 cm and BMI > or = 30 kg/m2 groups, only the MC III and BMI > or = 30 kg/m2 groups represented a statistically significant difference of prolongation. Mean time to intubation in the MC III and BMI > or = 30 kg/m2 groups were 13.2 +/- 5.4 (p = 0.011) and 14.8 +/- 1.7 (p < or = 0.001), respectively. CONCLUSION: Mallampati class III airway significantly increases time to intubation when the transillumination technique is used. BMI > or = 30 kg/m2 is another factor that interferes with the ease and success of intubation with this technique.

Caudal epidural block for minor gynecologic procedures in outpatient surgery.

BACKGROUND: Caudal epidural block (CEB) has become increasingly important for pediatric analgesia in recent years. However, data regarding CEB in adult ambulatory surgery are scarce. The aim of this study was to verify whether CEB could be applied as a simple, safe and economic method of anesthesia for adult patients undergoing minor gynecologic procedures (MGP). METHODS: One hundred and seventy-two female patients were enrolled in this study. Each patient received a 20-mL bolus of 1.5% lidocaine caudal epidural injection. The efficacy of CEB was evaluated. Types and duration of surgery, success rate, sensory level of analgesia, caudal epidural depth, complications and duration in the postanesthesia care unit (PACU) were also under investigation. RESULTS: No side effects occurred and only few hemodynamic changes were noted in the study. All patients experienced excellent surgical anesthesia except seven patients, who required rescue supplement opioids (4.1% of failure rate). The success rate of CEB was 95.9% (165/172). Duration of anesthesia and surgery were 46.66 +/- 11.76 min and 23.08 +/- 9.54 min, respectively. The highest sensory dermatome level reached below T10. The average epidural depth was 3.06 +/- 0.23 cm. No postoperative anti-emetic was given in the study. Only three patients required postoperative narcotics. Four patients had spontaneous voiding before discharge. The average PACU stay was 74.30 +/- 10.80 min. CONCLUSION: Single-dose CEB with 1.5% lidocaine 20-mL was an easy and simple technique. It provided satisfactory anesthesia for MGP and did not prolong patients' discharge time. CEB may be another choice of anesthetic technique in such cases of clinical practice.

Aspiration of a dislodged endotracheal tube: a rare cause of acute total airway obstruction.

We report an unusual cause of acute total airway obstruction after aspiration of a dislodged tube that was separated from its metallic connector. A 5-year-old boy had an emergence agitation and bucking to the endotracheal tube with a vigorous bite before extubation of the trachea. The whole uncuffed endotracheal tube was aspirated deep into the lower trachea causing laryngotracheal obstruction. The patient showed sudden oxygen desaturation and was then in an immediate life-threatening airway obstruction. We could not rescue oxygenation and were unable to establish a patent airway. Mask ventilation failed to relieve the progressive of hypoxemia. Immediate extraction of the tube using a pair of Magill's forceps before irreversible exacerbation was performed. We discuss our experience and the importance of prompt decision making and management for the extraction of the dislodged tube.

Anesthesia for pediatric patients with Prader-Willi syndrome: report of two cases.

Prader-Willi syndrome (PWS) is a sporadic disorder of chromosome abnormalities with an estimated prevalence of 1 in 15,000. It mainly affects the central nervous system, and often involves the hypothalamus. Both general and regional anesthesia for these patients is difficult mainly due to morbid obesity. Other common problems include hypotonia, disturbance in thermoregulation, arrhythmia, cor pulmonale, diabetes mellitus, behavior problems, and convulsions. We report on 2 pediatric patients with PWS receiving general anesthesia. The first patient experienced life-threatening episodes of severe hypoxemia in the postanesthesia care unit (PACU) as well as in the pediatric intensive care unit (PICU). Nasal continuous positive airway pressure (CPAP) was suggested by the pediatric pulmonary medicine specialist, and thereafter the patient's condition improved. The clinical course of the second patient was uneventful except for transient intermittent episodes of bronchospasms during emergence. In addition, we discuss differences between these 2 cases and our strategy for the prevention of perioperative complications for PWS patients in the future.

Epidural anesthesia does not increase the incidences of urinary retention and hesitancy in micturition after ambulatory hemorrhoidectomy.

BACKGROUND: This randomized, prospective study was designed to evaluate the role of various anesthesias in postoperative urinary retention and hesitancy in micturition in patients receiving hemorrhoidectomy on ambulatory basis. METHODS: In a randomized order, 128 ambulatory patients, ASA physical status I or II, were divided into two groups to receive hemorrhoidectomy under epidural or local anesthesia. In all patients, the intraoperative intravenous fluid given was limited to 200 ml +/- 2 ml/kg/h of Ringer's lactate solution. Patients were requested to void urine voluntarily before discharge. The incidences of postoperative urinary retention and hesitancy in micturition were evaluated by telephone interview 24 hours after surgery. RESULTS: Neither the incidence of urinary retention, nor the incidence of hesitancy in micturition was significantly different between the two groups. Patients with age over 50 had a significantly higher incidence of hesitancy in micturition than younger patients. The incidence of hesitancy in micturition seemed higher in male patients (31.3%) than that in females (15.6%), but the difference was not statistically different (P = 0.0585). CONCLUSIONS: With judicious intraoperative fluid restriction and voluntary voiding before discharge, epidural anesthesia does not increase the incidence of postoperative urinary retention or hesitancy in micturition following ambulatory hemorrhoidectomy.

Awake fiberoptic intubation for cesarean section in a parturient with odontoid fracture and atlantoaxial subluxation.

We report on the anesthetic experience of a 38-week pregnant patient in labor with an upper cervical spinal cord injury after an unusual trauma. She was transferred from a district hospital to our medical center with acute quadriplegia and sensory loss. Plain cervical spine x-ray and computed tomographic scan showed a C2 odontoid (dens of axis) process type II fracture and atlantoaxial (C1-C2) subluxation. Due to having regular uterine contractions and labor pain, she was scheduled for an urgent cesarean section. The instability of her cervical spine precluded the use of regional anesthesia; so awake nasal fiberoptic endotracheal intubation followed by general anesthesia was performed. The anesthetic course was uneventful, and the outcome of the parturient and newborn was good. We discuss our anesthetic considerations, intubation techniques and a review of the literature.

Airway management in a patient with a cleft palate after pharyngoplasty: a case report.

PURPOSE: To describe a practical method of aiding nasotracheal intubation in a cleft palate patient with previous pharyngoplasty using a suction catheter under tactile guidance. Problems of airway management in these patients are also discussed. CLINICAL FEATURES: A 26-yr-old woman presented for elective Le Fort maxillary osteotomy. She had a history of cleft lip and palate and subsequent palatoplasty and pharyngeal flap. She had no symptoms of upper airway obstruction or obstructive sleep apnea. Preoperative examination revealed a hypernasal voice and patent nasal passages. Anesthesia was induced and the patient paralyzed. An attempt to pass a 6.5-mm cuffed endotracheal tube through the right nostril met with resistance. A suction catheter was introduced into the nostril, while a finger was positioned over the flap and the velopharyngeal port, until its tip rested against the flap, the catheter coiled and a small loop could be palpated past the patent velopharyngeal port. The catheter was then hooked into the oropharynx. The endotracheal tube was "railroaded" over it and advanced into the glottis. There was minimal bleeding and no desaturation during the procedure. CONCLUSION: Preoperative determination of the type of pharyngoplasty is essential to understand the anatomy of the patent velopharyngeal port. A history of pharyngeal flap infection, hyponasal voice or upper airway obstruction suggests possible port stenosis. We describe a tactile guided technique that is useful and practical. Use of a flexible suction catheter of small external diameter minimizes the potential for trauma, bleeding and creation of false passages.

Use of intravenous anesthesia for tension-free vaginal tape therapy in elderly women with genuine stress incontinence.

OBJECTIVES: To study the efficacy of the tension-free vaginal tape (TVT) procedure for elderly patients. METHODS: Forty-five women, 65 years old or older (mean 69.1; range 65 to 85), were treated for genuine stress incontinence with the tension-free vaginal tape procedure under intravenous anesthesia with heavy sedation. Urodynamic studies and 1-hour pad test were performed before the procedure and at 1 year postoperatively. Vigorous manual pressure against the abdominal wall and ensuring no lifting of urethra by intraoperative introital ultrasonography were used to position and adjust the vaginal taping. RESULTS: Forty-one (91%) were cured, one improved, and three failed. No major surgical complications occurred. Two bladder perforations were noted. The pad test disclosed a reduction in urine leakage from a mean of 28.9 to 1.6 g/hr (P <0.001). The average blood loss was 72 mL (range 30 to 250), operating time was 21 minutes (range 18 to 35), and postoperative hospital stay was 24.2 hours (range 12 to 72). Spontaneous voiding with an adequate volume of postvoid residual urine was noted for all patients by the fourth day postoperatively. Urodynamic parameters related to the voiding dysfunction showed no significant difference before and after surgery. De novo detrusor instability was observed in 2 patients. CONCLUSIONS: With modifications of the technique and the aid of intraoperative ultrasonography, the TVT procedure can be performed under intravenous anesthesia with heavy sedation. The procedure is safe, effective, and minimally invasive for elderly patients. However, long-term follow-up is needed to determine whether this surgery achieves long-lasting results.