Acta Anaesthesiologica Taiwanica

Editorial Board

2009-12-01

Competition and Cooperation Between Nurse Anesthetists and Anesthesiologists: Win-win, Win-loss, or Loss-loss Game in Taiwan?

Wei-Zen Sun — 2009-12-01

Anesthesia Does Not Increase the Rate of Bowel Perforation During Colonoscopy: A Retrospective Study

2009-12-01

Objective: To compare the complication rates of bowel perforation during colonos-copy performed with or without anesthesia. Methods: We retrospectively analyzed 9501 case records of colonoscopy performed at the Chi Mei Medical Center between 2000 and 2004, and compared the rates of bowel perforation between patients receiving anesthesia during the procedure versus those that did not receive anesthesia. Poisson distribution was used for statistical analysis. Results: Only one case of perforation was found in the non-anesthetized group (n = 2460) compared with two cases in the anesthetized group (n = 7041). No statistical difference was found (p = 0.6173; risk ratio = 0.6988; 95% confidence interval by Byar's method = 0.063 – 7.705). Conclusion: During colonoscopy, anesthesia per se does not affect the rate of bowel perforation.

Optimizing Epidural Fentanyl Loading Dose for Early Labor Pain

2009-12-01

Objective: Sufficient sensory blockade between L1 and T10 is required to relieve visceral pain during early labor. We examined whether the addition of fentanyl to a loading dose of 0.0625% bupivacaine could provide dose-dependent analgesic effects on early-stage labor pain. Methods: Sixty parturients who requested epidural analgesia for labor pain were enrolled and randomly allocated to one of three groups. Group A (n = 20) received 10 mL of 0.0625% epidural bupivacaine as a loading dose alone. Group B (n = 20) received the same bupivacaine loading dose in combination with 2 mg/mL fentanyl. Group C (n = 20) received the same loading bupivacaine dose plus 4 mg/mL fentanyl. All patients received diluted bupivacaine plus 2 mg/mL fentanyl at a rate of 10 mL/hr as a maintenance dose. Fifteen minutes later, we recorded the highest cephalic and lowest caudal anesthetized dermatomes, side effects, and the number of patients who asked for supplemental analgesia. Results: The highest anesthetized cephalic dermatome was at the level of T12 (T9 – L1) in Group A, T9 (T8 – T12) in Group B and T7 (T5 – T9) in Group C (p < 0.05 among the three groups). Eleven patients (55%) requested supplemental bupivacaine for inadequate analgesia in Group A, six in Group B (30%), and none in Group C (0%). Pruritus was reported by seven (35%) patients in Group B and eight (40%) patients in Group C, but none in Group A. Conclusion: The addition of fentanyl to epidural bupivacaine dose-dependently increased the analgesic effect and higher loading doses of fentanyl increased the dermatomic coverage. We suggest that 0.0625% bupivacaine plus 4 mg/mL fentanyl is the ideal loading dose to provide the greatest segmental analgesia for early labor pain with minimal side effects.

Optimal Duration of Urinary Catheterization After Thoracotomy in Patients Under Postoperative Patient-controlled Epidural Analgesia

Yuan-Yi Chia, Ren-Jye Wei, Huang-Chou Chang, Kang Liu — 2009-12-01

Background: Epidural analgesia is widely used for efficient pain relief after major surgery. However, it may cause urinary retention, leading to delayed removal of bladder catheters with prolonged patient discomfort. Using a specific regimen in patient-controlled epidural analgesia (PCEA), we examined the optimal duration of urinary catheterization in patients undergoing major thoracic surgery. Methods: Seventy-eight patients scheduled for elective thoracotomy were prospectively randomized into two groups: Group 1, removal of the transurethral catheter on the first postoperative day (n = 38); Group 2, removal of the catheter after discontinuation of PCEA (n = 40). The PCEA regimen was a mixture containing low-dose morphine, bupivacaine and neostigmine and was given for 3 days after surgery in all subjects. Micturition problems, pain scores assessed by the visual analog scale (VAS), and side effects were evaluated during and after PCEA treatment. Results: The average duration of urinary drainage after surgery was 30.2 ± 5.1 hours and 78.5 ± 7.3 hours in Groups 1 and 2, respectively. After removal of the bladder catheter, no patient in either group required re-catheterization for urinary retention or encountered catheter-related infection. VAS scores were significantly lower in Group 1 at rest and at 24, 36 and 48 hours after cessation of PCEA. VAS scores were significantly higher in Group 2 patients, possibly due to catheter-induced pain related to prolonged catheterization. Conclusion: Routine continuous bladder catheterization may not necessarily be required after thoracotomy in patients with ongoing continuous thoracic epidural analgesia.

Patient Satisfaction With Anesthesia Care in Taiwan: Development and Validation of a Pilot Version of a Psychometric Questionnaire

2009-12-01

Background: To date, no pilot questionnaire of perioperative anesthetic care has been developed based on psychometric methodology in Taiwan. We describe the development and qualitative and quantitative validation of a pilot version of a psychometric questionnaire designed to measure patient satisfaction with perioperative anesthetic care in Taiwan. Methods: A rigorous protocol was followed and involved expert consultation, literature review, development of the interview guide, semi-structured in-depth interviews, pretest and application of Aiken's two quantitative methods to determine the content validity coefficient (V value) and homogeneity reliability coefficient (H value) of each item, and the questionnaire as a whole, to ensure the pilot questionnaire showed high-content validity and reliable homogeneity. Results: Our final pilot questionnaire contained six dimensions with 32 items; five of the domains were similar to those reported in the literature. One dimension entitled anesthesia-related sequelae was new. The V values for the 32 items ranged from 0.80 to 0.97 (p < 0.01) and the mean value (V —) of the questionnaire as a whole was 0.90 (p < 0.01). The H values ranged from 0.55 to 0.88 (p < 0.01) and the mean H value (H—) of the questionnaire as a whole was 0.71 (p < 0.01). Conclusion: We have developed a valid and reliable pilot questionnaire to measure patient satisfaction with perioperative anesthetic care in Taiwan. The final version of the pilot questionnaire is a 32-item instrument with six dimensions, one of which, anesthesia-related sequelae, is new.

Analysis of Manpower and Career Characteristics of Nurse Anesthetists in Taiwan: Results of a Cross-sectional Survey of 113 Institutes

Wen-Jan Dai, Yi-Fang Chao, Chien-Ju Kuo, Kuei-Min Liang, Ta-Liang Chen — 2009-12-01

Background: Manpower and the quality of nurse anesthetists (NA) have become critical concerns in Taiwan over the past few decades because of increasing clinical demand and the supervision of NAs by anesthesiologists. To understand manpower distribution, clinical load, job description and limitations, and job satisfaction of NAs, we conducted a cross-sectional survey in Taiwan in 2005. Methods: The structure of the questionnaire was initially developed by a drafting group that included members of the Taiwan Society of Anesthesiologists and the Taiwan Association of Nurse Anesthetists. The validity and reliability of the questionnaire was evaluated by specialists. The survey contained questions regarding the demographic characteristics of manpower (anesthesiologist/NA ratio), clinical work load, present job roles, professional expectations, job satisfaction, and reasons for career transfer. The questionnaires were mailed to the superintendents or matrons of NAs, and the administrators of anesthesiology departments across 228 institutions with different accreditation levels and 1953 NA staff between February 1 and December 31, 2005. Results: The validity and reliability of the questionnaire for the department chief and anesthesiology nursing staff was 0.8 and 0.7, respectively. Questionnaires were returned by 113 executives (39 anesthesiology department directors, 74 NA superintendents or matrons) with a response rate of 49.6%, and from 1452 NAs with a response rate of 74.3%. The average clinical load (2002 – 2004) for the anesthesiologists was 1500 – 1700 cases/year and 350 – 380 cases/year for the NAs. The manpower ratio of attending anesthesiologists to NAs was 1:4.3, while the medical centers held the highest ratio. The job stipulation for NAs in Taiwan was compatible with that in the United States and there was a high consistency of opinions between the directors and NA superintendents or matrons. The average rate of career transfer was relatively low (5.5%). From the executives' view, the concerns regarding management of NAs included limited staff capacity, recruiting difficulty, shortage of staff and undefined roles for NAs. On the other hand, NAs showed relatively high job satisfaction and work acceptance and a lower turnover rate in comparison with the general nursing staff. Conclusion: This study represents the first large-scale assessment of the distribution, clinical load, and job satisfaction for NAs in Taiwan. The roles of NAs, which include preoperative preliminary preparation and postoperative intensive care, need to be more well-defined. To improve the quality of NAs and anesthetic care in Taiwan, it is vital to establish an official accreditation system and formal education programs, to institute well-defined and standardized job descriptions, and to improve resource allocation for NAs.

Iatrogenic Left Internal Iliac Artery Perforation During Lumbar Discectomy

2009-12-01

Iatrogenic intra-abdominal vascular injury can result from lumbar discectomy via the posterior approach. Although it is well known and documented in the literature, few anesthesiologists have personal experience with this life-threatening incident. Here, we report a patient who sustained perforation of the left internal iliac artery at the L4-5 level during posterior lumbar discectomy. The patient experienced refractory hypotension with tachycardia at the end of surgery, even with prompt fluid resuscitation and medical treatment. Abdominal distension and tenderness of the left lower abdominal quadrant were also noted. Emergency laparotomy was performed by the consulting vascular surgeon and revealed perforation of the left internal iliac artery. The vascular injury was successfully repaired. It is important that, as anesthesiologists, we must be aware of this potentially fatal complication. Prompt diagnosis and immediate laparotomy to control hemorrhage can result in favorable outcomes.

Temporomandibular Joint Dislocation During Orotracheal Extubation

Li-Kai Wang, Ming-Chung Lin, Fuh-Cheng Yeh, Ying-Hui Chen — 2009-12-01

Temporomandibular joint (TMJ) dislocation can occur whenever the mouth is opened wide during upper airway manipulation, even without external force. In the perioperative period, the majority of TMJ dislocations occur during anesthetic induction. We report the occurrence and management of bilateral TMJ dislocation upon orotracheal extubation in a 35-year-old woman. At the end of an otherwise unremarkable uterine myomectomy under general anesthesia, with the patient having regained consciousness in the operating room, we asked the patient to open her mouth so we could extubate her. Immediately after orotracheal extubation, however, the patient was found to be unable to close her mouth. The diagnosis of bilateral TMJ dislocation was made. The bilateral TMJ dislocation was reduced with the traditional transoral approach under morphine analgesia/sedation. The dislocation possibly occurred in consequence of her compliance with our request to open her mouth excessively before she was fully awake. As TMJ dislocation is a possible complication of upper airway manipulation, anesthesiologists should be prepared for its occurrence and to manage it competently.

Eisenmenger's Syndrome in Pregnancy: Use of Proseal® Laryngeal Mask Airway (PLMA) and Epidural Analgesia for Elective Cesarean Section

2009-12-01

We describe the successful anesthetic management of cesarean section in a patient with Eisenmenger's syndrome secondary to an atrial septal defect. Although conception is discouraged in women with Eisenmenger's syndrome, in inevitable circumstances, careful and meticulous planning of anesthesia can help the parturient survive the ordeal of a cesarean section. The cardiac output must be maintained and systemic vascular resistance must not be allowed to fall. This should ensure that there is minimal change in the right to left shunt. In our patient, the scenario of Eisenmenger's syndrome was complicated by biventricular hypertrophy. We achieved the goals in our patient by using general anesthesia with the Prosea® laryngeal mask airway, a combination of ketamine and propofol, and epidural analgesia.

General Anesthesia in a Juvenile With Attention-deficit Hyperactivity Disorder Accompanied by Long-term Use of Methylphenidate (Concerta®)

2009-12-01

Methylphenidate, a central stimulant, is used in the treatment of individuals who have attention-deficit hyperactivity disorder (ADHD). ADHD is a notorious worldwide disorder with a prevalence rate of 8 – 12% in schoolchildren, which is characterized by hyperactivity, impulsivity, and inattention. Currently, there have been few reports in the anesthetic literature examining ADHD patients who have had long-term use of methylphenidate, especially the extended-release formulation. Here, we report a case of a 14-year-old boy with ADHD treated chronically with the long-acting form of methylphenidate (Concerta®), and who was scheduled to receive orthopedic surgery under general anesthesia. No significant problems or fluctuations in hemodynamics were encountered during anesthesia induction, maintenance, and emergence. The patient made an uncomplicated recovery and was discharged 3 days later without incident.

Recurrent Attacks of Post-intubation Right Upper Lobe Atelectasis

2009-12-01

A 22-year-old woman with no history of asthma developed an acute recurrent attack of severe bronchoconstriction and right upper lobe atelectasis immediately after laryngoscopy and endotracheal intubation. The first attack had taken place 2 months earlier under identical circumstances. Induction of anesthesia for tracheal intubation was achieved using propofol, fentanyl, and rocuronium. Bronchial obstruction and bronchial intubation were excluded by bronchoscopy. The atelectasis was quickly resolved with mechanical ventilation and spasmolytic treatment on both occasions. The surgical procedure could proceed soon after resolution of the atelectasis.

Critical Debate on Establishing a Scheme for Nurse Anesthetists in Japan

Yukihide Koyama, Takahisa Goto — 2009-12-01

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2009-12-01

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2009-12-01