Acta Anaesthesiologica Taiwanica

Discogenic low back pain – is there an ideal treatment strategy?

Yu-Chuan Tsai — 2012-04-05

Back pain is not only a common health problem but is also a significant social economic issue. The prevalence rate ranges from 12% to 35% in a number of studies. Back pain is strongly associated with the degeneration of the intervertebral disc. As estimated, 45% of chronic lumbosacral spinal pain is attributed to be discogenic in origin. With increasing age or abnormal mechanical loads, degeneration of disc occurs, following loss of hydration of the nucleus pulposus, leading to the tears within the annulus fibrosus. During these processes, nociceptive nuclear material leaks through the outer rim of anuulus. Nerve and blood vessels are increasingly found with degenerative discs. Outer annular rupture may facilitate the “leakage” of inflammatory mediators to the adjacent structures. The ingrowth of nociceptors into the deeper layers of the disc may introduce pain reaction to normal mechanical loads. A fracture in the vertebral endplate also can result in the appearance of inflammatory cytokines in the nucleus pulposus. All these mechanisms may cause chronic discogenic pain.

Preoperative anxiety in surgical patients - experience of a single unit

Anne Thushara Matthias, Dharmanbandhu Nandadeva Samarasekera — 2012-04-05

Abstract: Objectives: Preoperative anxiety has a significant effect on the outcome of anesthesia and surgery. At present, there is no published data on the preoperative anxiety levels in Sri Lankan patients. In the West, several validated questionnaires such as The Amsterdam Preoperative Anxiety and Information Scale (APAIS) and State Trait Anxiety Inventory (STAI) are used. To measure the preoperative anxiety levels in patients using APAIS and to analyze the factors affecting anxiety and the role played by the anesthetist in allaying anxiety.Methods: One hundred patients scheduled for elective surgery were prospectively studied using the APAIS. The internal consistency was checked using Cronbach's alpha.Results: The ages varied 25 to 72 years (mean=48.7 years, SD=13.6). Reliability of the APAIS was high; Cronbach's alpha=0.864 in the overall component and 0.84, 0.73 and 0.97 in the anxiety related to surgery, anesthesia and in the information desire components, respectively.Females were more anxious than males (p=0.02) and those who had never sustained surgery were more anxious than those who previously had surgery (p=0.05).An anesthetist's visit and premedication reduced total anxiety scores (Z=−3.07, p=0.002) and anesthesia related anxiety scores (Z=−3.45, p=0.001).Conclusions: The prevalence of anxiety is high among Sri Lankan patients. Females are more anxious than males and those who have never had surgery are more anxious than those who have had surgery. The anesthetist's visit could reduce anxiety. Sinhala version of the APAIS is highly reliable in assessing the preoperative anxiety levels.

Direct endotracheal intubation using a novel detachable optic probe (Sunscope) by emergency medical technicians with various training backgrounds

2012-04-06

Abstract: Objective: Effective airway management requires both proper technique and the appropriate devices. With the widespread implementation of advanced life-support techniques in emergency medical services (EMS), orotracheal intubation is now performed not only by professional practitioners but, in many occasions, nonprofessionals. With extensively diversified skill equipped, we tested whether the Sunscope, a patented tracheal intubation device with a digital display, is able to facilitate tracheal intubation by naïve EMS personnel with various training backgrounds.Methods: We conducted a study to determine rate of success and time required to insert an orotracheal tube into a mannequin using Sunscope. The participants were placed into the professional group (i.e., anesthesiologists and emergency medical paramedics; EMT-P) or the nonprofessional group (i.e., emergency medical technicians; EMT). Intubation required three steps: equipment preparation, vocal cord exposure, and tube insertion. The time required for each step was recorded by a senior staff member, and the data were analyzed by nonparametric statistics.Results: Each consecutive step in the operating procedure was significantly shorter for the professional group in comparison with the nonprofessional group during the first trial: equipment preparation, 10.5 ± 2.1 vs. 11.9 ± 4.1 seconds; vocal cord exposure, 7.4 ± 7.7 vs. 12.2 ± 7.7 seconds; tube insertion, 8.8 ± 4.8 vs. 17.6 ± 9.4 seconds; and total time required for intubation, 26.7 ± 8.8 vs. 35.8 ± 19.6 seconds. The professional practitioners showed no significant improvement, in terms of time reduction, on the following three trials. On the other hand, the nonprofessional practitioners showed no significant differences, in terms of time required to expose the vocal cords and total operation time, following the third trial in comparison with the professional practitioners.Conclusion: Our research demonstrates that professional practitioners are able to use the Sunscope on their first attempt. Despite a lack of training in conventional endotracheal intubation, emergency medical technicians (EMT-I and -II) were able to complete intubation on their first attempt; a significant reduction in the time required to intubate was noted after repeated practice. All levels of naïve EMTs were able to readily visualize the vocal cords through Sunscope and, thereby, reliably insert the endotracheal tube in less than 1 minute, regardless of their skills before testing.

Poincaré plot indexes of heart rate variability detect dynamic autonomic modulation during general anesthesia induction

2012-04-04

Abstract: Purpose: Beat-to-beat heart rate variability (HRV) is caused by the fluctuating balance of sympathetic and parasympathetic tone. The Poincaré plot has been used to evaluate HRV. In this study, we validate that this new method may qualitatively and quantitatively assess the sympathovagal fluctuation in patients during induction of anesthesia with sevoflurane.Methods: Twenty-eight young patients were allocated for the study. The patients received a tilt test and on the next day they sustained anesthesia induced with inhaled anesthetics. Electrocardiography signals from the patients were relayed to an analogue-digital converter. The Poincaré plot is quantified by measuring SD1, SD2, and SD1/SD2. Power spectral analyses were performed and LF, HF and HF/LF were calculated.Results: The LF power and the SD2 of the Poincaré plot increased while subjects were tilt-up from the supine position. Additionally, a significant correlation were found between LF and SD2, HF and SD1 (p < 0.05), and LF/HF and SD2/SD1 (p < 0.01). Sevoflurane inhalation for 10 minutes had no effect on heart rate, but diminished LF, total power and SD1, SD2 of the Poincaré plot respectively. However, the LF, SD2 and LF/HF increased; the HF, SD1 and SD1/SD2 ratio decreased after intubation stimulation.Conclusion: Poincaré plot and power spectral analysis of HRV during tilt test and sevoflurane induction significantly correlate. Poincaré plot analysis is easier and more sensitive at evaluating the sympathovagal balance and observing the beat-to-beat HRV.

Comparison of postoperative analgesic effect of intrathecal magnesium and fentanyl added to bupivacaine in patients undergoing lower limb orthopedic surgery

Marzieh-Beigom Khezri, Siamak Yaghobi, Mahsa Hajikhani, Saeid Asefzadeh — 2012-04-05

Abstract: Objective: To compare the analgesic efficacy and side effects of magnesium and fentanyl as an additive to intrathecal bupivacaine.Methods: Ninety adult patients scheduled for femur surgery under spinal anesthesia were randomly allocated to one of the following three groups to receive intrathecally: bupivacaine 15 mg combined with 0.5 mL magnesium 10%; bupivacaine 15 mg combined with 0.5 mL fentanyl; or bupivacaine 15 mg combined with 0.5 mL distilled water (control). The time to first analgesic request, sensory and motor blockade onset time, duration of sensory and motor blockade, analgesic requirement in the first 12 hours after surgery, and the incidences of hypotension, bradycardia, hypoxemia and ephedrine were recorded.Results: Magnesium caused a significant delay in the onset of both sensory and motor blockade compared with the fentanyl (95% CI 3 to 4; p < 0.001) and control (95% CI 3.5–5; p < 0.001) groups. The duration of spinal analgesia in group F (fentanyl) was significantly greater than in group C (control) (95% CI 365–513; p < 0.001) and group M (magnesium) (95% CI 385–523; p < 0.001). The total amount of methadone consumption over 12 hours was significantly lower in the magnesium and fentanyl groups than in the control group (5 mg vs. 5.666 ± 1.728 mg; p = 0.04).Conclusion: Addition of intrathecal magnesium sulfate to spinal anesthesia induced by bupivacaine significantly prolonged the onset of both sensory and motor blockade compared with fentanyl. Although magnesium failed to prolong the time to first analgesic requirement as seen with fentanyl, it reduced the total consumption of opioids in the first 12 hours postoperatively compared with the control group.

Percutaneous intradiscal treatments for discogenic pain

Sang Chul Lee — 2012-04-05

Abstract: Severe discogenic pain including axial or radicular pain is not easy to treat properly. Although mechanical correction was made possible to some extent, the high incidence of failed back surgery syndrome frustrates both patients and physicians. For discogenic pain, like other disorders, pain management is the discipline of intervention, principally with the application of certain techniques, such as intradiscal electrothermal therapy, nucleoplasty, Dekompressor and targeted disc decompression (TDD). These techniques are simple to use, have low complication rates and seem to be effective. The goals of interventional pain management include decrease the frequency and intensity of the pain, increase daily activities, quality of life, enhancement of coping skills and lowering narcotic use and/or other pain medications.

Review of interscalene block for postoperative analgesia after shoulder surgery in obese patients

Bassam Al-Nasser — 2012-03-27

Abstract: In recent years, the prevalence of obesity has significantly increased in developed countries, a trend that has been just as apparent in France as elsewhere. Obesity may predispose to osteoarthritis, which may subject a high percentage of patients to shoulder surgery. Interscalene block remains one of the most efficient technique for postoperative analgesia after shoulder surgery. However, there are no specific guidelines or discussions in the literature about the use and management of interscalene block for obese patients. No study has yet specifically assessed obesity relative to interscalene block. Regional anesthesia offers certain advantages in obese patients: minimal airway intervention, improved postoperative analgesia, and decreased opioid consumption. In obese patients undergoing shoulder surgery, the goal of postoperative pain management is to provide comfort, early mobilization, and improved respiratory function without the worry of inadequate sedation and respiratory compromise. The ongoing debate on the relevance of obesity, for example in terms of obstructive sleep apnea syndrome, obesity hypoventilation syndrome, and other related respiratory disturbances, in relation to the choice of analgesic techniques, especially interscalene block, patient-controlled intravenous analgesia and patient monitoring, demands large-scale, well-designed studies to resolve it. Nevertheless, obesity per se should not dissuade patients from undergoing shoulder surgery under interscalene block.

Anesthetic breathing circuit obstruction mimicking severe bronchospasm: An unusual manufacturing defect

Chien-Hui Yang, Kuan-Hung Chen, Ying-En Lee, Chung-Ren Lin — 2012-03-29

Abstract: We report an unexpected ventilation difficulty with an anesthetic breathing circuit in a pediatric patient receiving left herniorrhaphy. A manufacturing defect in a limb of the anesthetic breathing circuit caused this problem. This defect induced a high-pitched, wheezing-like sound, which was difficult to differentiate from a hyper-reactive airway, commonly seen in pediatric patients with recent upper respiratory tract infection. We recommend that the patency of the anesthetic breathing circuit should routinely be examined before connecting it to the anesthesia machine.

Early recognition of an entrapped pulmonary artery catheter by blood leaking into the syringe and thermistor connector during cardiac surgery

2012-04-09

Abstract: An 84-year-old male was scheduled for coronary artery bypass graft surgery under general anesthesia. During cardiopulmonary bypass, the leakage of blood into the syringe being used for balloon inflation and the thermistor connector of the pulmonary artery catheter (PAC) was detected. Resistance was encountered when trying to withdraw the PAC. A surgical suture of the right atrium cannulation was stitched to PAC and was immediately released. Early detection of surgical damage to PAC and recognition of the entrapped PAC by gently withdrawing it avoided possible life-threatening complications, including pulmonary air embolism, and the inevitable of resternotomy. Transesophageal echocardiography, chest radiography, and fluoroscopy can help confirm any postoperative surgical damage following closure of the sternum or while in the intensive care unit.

Development of acute ischemic stroke in a patient with acute respiratory distress syndrome (ARDS) resulting from H1N1 pneumonia

Jyoti Burad, Pradipta Bhakta, Jojy George, Sinna Kiruchennan — 2012-03-29

Abstract: Pneumonia due to H1N1 infection is now very common. We report a case of ischemic stroke which arose subsequently to H1N1 influenza. The patient was a female who developed acute respiratory distress syndrome (ARDS) after H1N1 influenza, was ventilated as per standard protocol and started treatment with oseltamivir. When sedation was stopped during weaning from the ventilator, she was found to have left hemiparesis resulting from multiple infarctions in the brain. Contrary to thrombocytosis usually seen in acute influenza, the platelet counts in our patient actually dropped. We suspected that increased interleukin release or stickiness of the platelets might have caused this ischemic stroke. In the course of time, she had acceptable neurological recovery following treatment with aspirin and neuro-rehabilitation. This case report provides evidence that a rare, debilitating complication like stroke can occur in H1N1 infection. A high index of suspicion of the probability of a cerebrovascular event should be borne in mind and regular neurological assessment should be done in such cases.