Real-time two-dimensional ultrasound guidance for central venous cannulation: a meta-analysis.

BACKGROUND: Use of ultrasound-guided techniques to facilitate central venous cannulation (CVC) may reduce the risk of misplacement and complications. A meta-analysis was conducted to compare real-time two-dimensional ultrasound (RTUS) guidance technique with anatomical landmark technique for CVC to determine whether RTUS has any advantages. METHODS: Randomized studies comparing outcomes in patients undergoing CVC with either RTUS or landmark technique were retrieved from PubMed, ISI Web of Knowledge, EMBASE, and OVID EBM Reviews from their inception to March 2012. RESULTS: Twenty-six studies involving 4,185 CVC procedures met the inclusion criteria. Compared with landmark technique, patients with RTUS had a pooled relative risk (RR) of 0.18 (95% CI: 0.10-0.32) for cannulation failure, 0.25 (95% CI: 0.15-0.42) for arterial puncture, 0.30 (95% CI: 0.19-0.46) for hematoma, 0.21 (95% CI: 0.06-0.73) for pneumothorax, and 0.10 (95% CI: 0.02-0.54) for hemothorax from random-effects models. However, RTUS did not show a reduction in the risk of cannulation failure (RR = 0.26, 95% CI: 0.03-2.55), arterial puncture (RR = 0.34, 95% CI: 0.05-2.60), hematoma (RR = 0.13, 95% CI: 0.01-2.42), pneumothorax (RR = 0.40, 95% CI: 0.02-9.61), and hemothorax (RR = 0.40, 95% CI: 0.02-9.61) in children or infants when the limited data were analyzed. CONCLUSIONS: Among adults receiving CVC, RTUS was associated with decreased risks of cannulation failure, arterial puncture, hematoma, and hemothorax. Additional data of randomized studies are necessary to evaluate these outcomes in pediatric patients.

[Application of a narcotrend-assisted anesthesia in-depth monitor in the microwave coagulation for liver cancer during total intravenous anesthesia with propofol and fentanyl].

BACKGROUND AND OBJECTIVE: CT-guided microwave coagulation is a minimally invasive surgery for patients with liver cancer. Total intravenous anesthesia with propofol and fentanyl is commonly used. The depth of anesthesia during microwave coagulation for liver cancer is still monitored by clinical signs. There are few subjective and effective indicators. This study explored the application of Narcotrend-assisted "depth of anesthesia" monitoring on microwave coagulation for patients with liver cancer during total intravenous anesthesia with propofol and fentanyl. METHODS: Forty liver cancer patients underwent CT-guided microwave coagulation were randomly assigned to receive Narcotrend index monitoring or standard clinical monitoring for depth of anesthesia with 20 patients in each group. All patients received total intravenous anesthesia with propofol and fentanyl. The depth of anesthesia for patients in the Narcotrend group was measured according to a Narcotrend index, which was maintained between D2 and E0. The depth of anesthesia for those in the standard clinical practice group was measured according to heart rate, mean arterial pressure, and patient movement. Changes of hemodynamics, the duration of the emergence from anesthesia, and the recovery of orientation were recorded. The doses of propofol and fentanyl, postoperative visual analogue scores (VAS), and the incidence of postoperative nausea and vomiting were also recorded. RESULTS: There was no significant alteration in heart rate or mean arterial pressure between the two groups. Compared with other anesthetic stages, both heart rate and mean arterial pressure decreased during the induction of the anesthesia in the two groups(P<0.05). The doses of propofol were higher in the standard clinical practice group than in the Narcotrend group [(460+/-30) mg vs. (380+/-35) mg, P<0.01]. The duration of emergence and orientation were longer in the standard clinical practice group than in the Narcotrend group [(9.5+/-2.9) min vs. (4.9+/-2.2) min, P<0.01; (12.2+/-3.5) min vs. (6.6+/-3.2) min, P<0.01, respectively]. There was no difference in the dosage of fentanyl, VAS, or the incidence of postoperative nausea or vomiting between the two groups (P>0.05). CONCLUSION: For patients with liver cancer, monitoring the depth of anesthesia with Narcotrend on microwave coagulation can contribute to lower dosage of propofol and shorten duration of recovery during total intravenous anesthesia with propofol and fentanyl.

[Tracheal stent implantation for the treatment of tumor-induced acute airway stenosis].

BACKGROUND & OBJECTIVE: Tumor-induced acute airway stenosis is a medical emergency. Metal airway stent implantation can relieve dyspnea of patients suffering from this symptom and provide time for their further treatment. This study was to investigate the clinical application, efficacy, and complication management of tracheal stent implantation for the treatment of tumor-induced acute airway stenosis. METHODS: Nickel-titanium (Ni-Ti) alloy stent implantation was performed under the guidance of fiber-optic bronchoscopy in 52 patients with tumor-induced acute airway stenosis. RESULTS: Stent implantation was successful in all 52 patients. Dyspnea in all patients was significantly relieved. Values of arterial partial pressure of oxygen (PaO2), arterial partial pressure of carbon dioxide (PaCO2), and Karnofsky performance status (KPS) changed from (7.74+/-0.99) kPa, (5.37+/-0.39) kPa, and (68.85+/-8.08) preoperatively to (11.12+/-0.61) kPa, (4.58+/-0.30) kPa, and (84.62+/-5.03) postoperatively (P<0.01). The three-year survival rate was higher in lymphoma group than in lung cancer or esophageal cancer group. Postoperative complications were properly managed in all cases after symptomatic treatments. CONCLUSIONS: Tracheal stent implantation is an effective palliative treatment for acute dyspnea caused by local tumor compression or tumor invasion of large airways. It can rescue patients at risk for airway obstruction, improve the quality of life in terminal cancer patients, and provide further treatment opportunities for them.

[Application of total intravenous anesthesia with remifentanyl and propofol to radiofrequency ablation].

BACKGROUND & OBJECTIVE: Percutaneous radiofrequency ablation (PRFA) is a new and effective microinvasive operation for small hepatocellular carcinoma, but the effect of local anesthesia or single analgesic injection as regular anesthesia is unsatisfied. This study was to evaluate the efficacy and safety of continuous intravenous infusion of remifentanyl combined with propofol as total intravenous anesthesia during PRFA. METHODS: Sixty patients scheduled for PRFA were randomized into remifentanyl group (R) and fentanyl group (F). Each group contained 30 patients. Group R received remifentanyl infusion at the dose of 0.1 microg x kg(-1) x min(-1) by micro pump; group F received bolus intravenous injection of fentanyl at 1.5 microg x kg(-1) before operation. Anesthesia was maintained with propofol. The mean arterial pressure (MAP), heart rate (HR), pulse oxygen saturation (SPO2), respiration rate (RR), partial pressure of carbon dioxide in artery (PaCO2) and recovery time were measured and recorded by monitor. The limb movement, apnea, body movements, and chest wall rigidity were recorded during operation. RESULTS: The recovery time of group R was significantly shorter than that of group F [(5.0+/-1.8) min vs. (10.7+/-3.0) min, P<0.001]; the total consumption of propofol was less in group R than in group F [(172.0+/-37.3) mg vs. (330.3+/-61.2) mg, P<0.001]. Group R had less cases with limb movement (5 cases vs. 12 cases) but more cases with apnea (12 cases vs. 6 patients) as compared with group F. CONCLUSIONS: Total intravenous anesthesia with remifentanyl and propofol for PRFA is safe and reliable. Respiratory depression should be monitored instantly and strictly.

[Beneficial effects of metoprolol on perioperative cardiac function of elderly esophageal cancer patients].

BACKGROUND & OBJECTIVE: The elderly esophageal cancer patients undergoing esophagectomy are increasing now. How to protect their cardiac functions and reduce perioperative mortality and morbidity of cardiac events is an urgent problem to be solved. Prophylactic beta-blockers have been recently applied during surgery. This study was to evaluate the beneficial effects of metoprolol on perioperative cardiac function of elderly esophageal cancer patients. METHODS: The esophageal cancer patients, no less than 65 years old, scheduled for elective esophagectomy were enrolled, and randomized into metoprolol group and control group. The patients of metoprolol group received metoprolol to control heart rate from anesthesia induction to 72 h after operation. Perioperative hemodynamic data were recorded at time points of baseline, drug administration, 2 min after induction, intubation, 4 min after intubation, incision, thoracic exposure, 60 min after incision, 10 min before the completion of operation, the completion of operation, extubation, and 15 min after extubation. The serum level of cardiac troponin T (cTnT), the occurrence of perioperative cardiac events and postoperative sinus tachycardia were also recorded. RESULTS: Compared with preoperative values, systolic arterial pressure was significantly higher at intubation (P<0.05), heart rate was significantly faster at intubation and extubation (P<0.05) in control group; while the hemodynamic data had no obvious changes in metoprolol group (P>0.05). The serum level of cTnT was elevated in 3 patients of control group within 3 days after operation, and remained normal in all patients of metoprolol group (P=0.237); cardiac events occurred in 6 patients of control group (including 2 cases of myocardial ischemia and 4 cases of atrial fibrillation), but didn't occur in metoprolol group (P=0.024). No myocardial infarction and death occurred in the 2 groups during operation. The occurrence rate of tachycardia was significantly higher in control group than in metoprolol group (15 cases vs. 6 cases, P<0.05). CONCLUSION: Metoprolol can reduce the occurrence of perioperative cardiac events and postoperative tachycardia in the elderly esophageal cancer patients undergoing esophagectomy, and restrain the effects of tracheal intubation or extubation on heart rate and blood pressure.

[Effects of ulinastatin on interleukin-8 during one-lung ventilation in surgery].

BACKGROUND & OBJECTIVE: Ulinastatin is a kind of broad- spectrum hydrolase inhibitors purified from urine of healthy males.There was no data showing whether ulinastatin could affect alveolar inflammatory reactions.This study was designed to investigate the changes of pulmonary alveolar interleukin-8 during one lung ventilation (OLV) in surgery and the effects of ulinastatin on alveolar IL-8. METHODS: Sixty patients,ASA II- III,who underwent lobectomy, were randomly divided into two groups [30 patients in each group,surgery group(II) and control group (I)].Patients in surgery group were treated with ulinastatin 5,000 u/kg preoperatively. Alveolar IL-8 was harvested by bronchoalveolar lavage at 0, 1, and 2 hours after one lung ventilation and at the end of surgery. The changes of concentration of IL-8 in bronchoalveolar lavage fluid were analyzed statistically. RESULTS: (1)Alveolar interleukin 8 was significantly higher at 2 hours after OLV [(160.85+/-46.58)ng/L] than before OLV [(128.26+/-35.35)ng/L] in control group. The results indicated that OLV and/or the stimulation of surgery could induce the pulmonary inflammatory reaction. (2)The concentrations of alveolar IL-8 at 2 hours [(140.32+/-41.25)ng/L] after OLV and at the end of surgery [ (156.74+/-43.58) ng/L] were significantly lower in surgery group than those in control group [(160.85+/-46.58)ng/L and (172.41+/-52.60)ng/L] respectively(P< 0.05). CONCLUSION: Ulinastatin could alleviate the pulmonary alveolar inflammatory reactions in OLV.

[Influence of different doses of fentanyl on T-lymphocyte subpopulations and natural killer cells of patients with esophageal tumor during preoperation and postoperation].

BACKGROUND & OBJECTIVE: Morphine has been proved to inhibit human immune system, and large dose of fentanyl also decrease the activation of natural killer cells. This study was designed to investigate the effects of different doses of fentanyl on T-lymphocyte subpopulations and natural killer cells during esophageal cancer surgery under general anesthesia. METHODS: Forty-five patients with esophageal cancer were randomly divided into 3 groups (I, II,III) with 15 cases in each group respectively. The doses of fentanyl in three groups were 5, 10, and 20 microg/kg, respectively. Central venous blood samples (6 ml) were collected before anesthesia, 24 hours and 48 hours after the operation, respectively. Monoclonal antibodies assay was used to identify T cells and NK cells. RESULTS: The counts of CD3(+) (T%) (Group I 50.30+/-8.42, Group II 48.53+/-9.62, GroupIII 46.58+/-8.56), CD4(+) (T%) (Group I 30.04+/-7.24, Group II 28.67+/-7.52, Group III 26.65+/-6.55),and NK cells (Group I 3.26+/-1.62, Group II 3.01+1.56, GroupIII 3.01+/-1.54) in three groups decreased significantly at 24 hours after surgery (P< 0.01). The decrease at 48 hours after surgery were more significant in groupIII (CD3(+) 48.89+/-9.82, CD4(+) 22.64+/-6.02, NK Cells 3.41+/-1.88) than in group I(CD3(+) 57.32+/-9.13, CD4(+) 35.62+/-5.98, NK cells 5.96+/-1.08) and group II(CD3(+) 55.62+/-10.21, CD4(+) 34.24+/-6.85, NK cells 6.04+/-1.09) (P< 0.05). There was no statistical significance in the counts of CD3(+), CD4(+), and NK cells between the time of 48 hours after the operation and preoperation in group I and group II. CONCLUSION: Fentanyl, as a kind of opiate drug, could contribute to the immunosuppression, and large-dose fentanyl administration would be more effective in suppression of immunity function than small dose fentanyl.

[Comparison of postoperative analgesia with tramadol, morphine versus their combination in patients undergoing abdominal cancer surgery].

BACKGROUND & OBJECTIVE: Morphine is a widely used analgesic in management of postoperative pain with well documented analgesic properties and side effects. Tramadol, a new synthetic mu-opioid receptor agonist, little is known about its efficacy and side effects when administered in epidural for pain relief. The aim of this study is to compare the efficacy and side effects of tramadol, morphine versus their combination for postoperative analgesia. METHODS: One hundred and twenty patients undergoing abdominal cancer surgery were assigned to one of three groups randomly, tramadol group (Group T, n = 40), morphine group(Group M, n = 40) and combination of tramadol and morphine group(group T + M, n = 40), for postoperative analgesia. In group T, 12 mg/kg tramadol and 0.125% bupivacaine 100 ml were used for 48 h postoperative analgesia. In group M, 0.12 mg/kg morphine and 0.125% bupivacaine 100 ml; and in group T + M, 6 mg/kg tramadol, 0.12 mg/kg morphine and 0.125%. Bupivacaine 100 ml were used for postoperative analgesia. Efficacy was assessed by comparing visual analogue scale(VAS), Bruggman comfort score (BCS), global satisfaction score (GSS) at several time points over 48 hours. Possile adverse events were recorded. RESULTS: There is no significant difference among three groups in VAS, but in group T, there are more patients whose VAS > 5 score than those in group M and group T + M. BCS; GSS in group T + M are lower than that in group T and group M. The occurrence rate of nausea and vomiting in group T + M are lower than that in group M. CONCLUSIONS: The efficacy of tramadol in epidural postoperative analgesia is similar to that of morphine, but varied from patient to patient, so the dose of tramadol should be individualized. Combination of tramadol and morphine can provide effective analgesia for postoperative pain and cause little adverse effect, especially reduce the occurrence rate of nausea and vomiting.

[Effects of midazolam premedication on induction doses of propofol and hemodynamic changes during tumor patient induction].

BACKGROUND AND OBJECTIVE: Midazolam is a useful drug used preoperatively because it can produce anxiolysis and sedation. This study compared the propofol requirements and haemodynamic effects during anaesthetic induction using propofol with premedication of midazolam or luminal. METHODS: Thirty patients (aged 20-65, ASA I-II) undergoing tumor surgery were randomly assigned into 2 groups (group M and group L): group M, receiving 0.5 mg atropine and 0.05 mg/kg midazolam; group L, receiving atropine and 2 mg/kg phenobarbital sodium 30 min before induction as premedication. Anesthesia was induced with propofol at the rate of 30 mg.kg-1.h-1 to achieve enough depth of anesthesia to intubate. Induction time, total propofol dosage, blood pressure, heart rate were recorded before and after induction, and after intubation. Awaken time was also recorded. RESULTS: The time of induction and the propofol dosage in group M (2.8 +/- 0.37 min and 79.9 +/- 15.3 mg) were significantly (P < 0.05) less than that in group L (3.3 +/- 0.54 min and 98.9 +/- 17.4 mg). Blood pressure was unchanged in M group after propofol induction and after the intubation. Heart rate change was much less in group M (P < 0.05). CONCLUSIONS: The results indicate that midazolam compered to phenobarbital sodium as premedication could reduce the usage of propofol, and also provide stable cardiovascular state during propofol induction.