Acta Anaesthesiologica Taiwanica - Articles in Press

One step toward the development of preoperative risk index for postoperative reintubation after planned extubation in the operation room - Corrected Proof

Ping-Wing Lui — 2011-03-23

To determine tracheal extubation during the emergence of anesthesia, anesthesia providers routinely assess the patient based on the balance between the residual effects of anesthetics inclusive of neuromuscular blocking agents and recovery of airway reflexes. Many studies have reported a significant number of complications such as hypoventilation, pulmonary aspiration, laryngospasm and bronchospasm at the time of extubation. In normal patients such as those of ASA status class 1, successful tracheal extubation can be easily accomplished at the end of surgery. In critical patients such as of ASA status class 4, ventilator support after surgery can be prearranged and carried out in the ICU on a planned strategy. In patients whose physical statuses are in between ASA class 2 and 3, delayed extubation should be considered at the end of surgery. However, few studies are available regarding the criteria or guidelines for delayed extubation beyond the operation room. Anesthesiologists usually extubate patients at the end of surgery if they have demonstrated return of adequate muscle power and airway reflex with clear conscious level and normal vital signs. However, failure of tracheal extubation at the end of surgery is still encountered in some patients. In Taiwan, the only one indicator to reflect the outcome of patient safety in anesthesia is the rate of reintubation in postanesthesia care unit (IPU017) stated in Taiwan Healthcare Indicator Series (THIS). Therefore, to minimize the risk of reintubation in PACU is an imperative issue for anesthesia providers.

Significant hypercapnia either in co2-insufflated or air-insufflated colonoscopy under deep sedation - Corrected Proof

2011-03-23

Abstract: Background: Previous reports showed that CO2-insufflated colonoscopy is safe and less discomfortable. However, hypercapnia remains a vital concernment if deep sedation is necessary for difficult colonoscopy with prolonged CO2 insufflation. This observational study is to measure bodily CO2 subjected to colonoscopy facilitated by CO2- and air- or air-insufflation in conscious-sedation, deep-sedation and awake patients.Objective: To investigate if CO2-insufflated colonoscopy could increase the risk of hypercapnia in awake, conscious-sedation and deep-sedation patients.Methods: 104 patients in our health center undergoing sequential esophagogastroscopy and colonoscopy screening were included. At patients’ request, incremental intravenous sedatives were given in order that the air-insufflated esophagogastroscopy could be carried out without the molestation of gag and cough reflexes. The sedation levels were re-evaluated before proceeding colonoscopy and the patients were divided into conscious-sedation (respond purposefully to verbal commands) and deep-sedation groups and randomly allocated for air or CO2 insufflation. Transcutaneous capnography (TcCO2) was recorded every minute throughout the colonoscopy procedure.Results: The baseline TcCO2 in the air- (50.9 ± 5.7 mmHg) and CO2-insufflated (53.1 ± 6.5 mmHg) groups under deep sedation was significantly higher than the groups under conscious-sedation and the awake groups (p < 0.01). In both air- and CO2-insufflation groups there were also a statistically significant (p < 0.01) correlation in TcCO2 between the start, the peak and the end of colonoscopy. TcCO2 did not significantly change throughout the colonoscopy in awake and conscious-sedation groups, either with air or CO2 insufflation. With deep sedation, TcCO2 significantly increased and peaked around the time when the scope touching the cecum, and then returned to original state with suction and withdrawl of the colonoscope without significant interaction of CO2 insufflation and deep sedation.Conclusion: The TcCO2 during colonoscopy was correlated to the data before inserting colonoscope but significantly different within awake, conscious-sedation and deep-sedation groups. TcCO2 did not change significantly either with CO2 insufflation or air insufflations in awake and conscious-sedation groups. However, in deep-sedation groups with significantly higher baseline TcCO2, further increase of TcCO2 were significant without interaction with CO2 insufflation. We concluded that when patients need deep sedation for colonoscopic procedures facilitated by gas insufflation, hypercapnia is still considerably present, not only with CO2 insufflation but also with air insufflation colonoscopy.

Postoperative reintubation after planned extubation: A review of 137,866 general anesthetics from 2005 to 2007 in a Medical Center of Taiwan - Corrected Proof

2011-03-23

Abstract: Background: Regarding general anesthesia, postoperative reintubation after planned extubation (RAP) is needed when circumstances compel us to do so, irrespective of prolongation of hospital stay and increase of medical expenditure. We describe here our implementation of a case-controlled model to identify the risk factors of RAP.Methods: Patients who saw RAP in the space from January 1, 2005 to December 31, 2007 were retrospectively sorted out from the Quality Assurance (QA) database of the Department of Anesthesiology. We compared RAP cases with the control group and analyzed the factors using descriptive statistics and logistic regression. Reintubation was defined as intubation after the extubation for the initial endotracheal intubation, for general anesthesia, at the time period before departure from the post-anesthesia care unit.Results: Of the 137,866 patients who underwent endotracheal intubation for general anesthesia, 83 (0.06%) sustained RAP. The control group included 249 patients randomly selected for endotracheal intubation without RAP. Twenty-two variables, including demographic, operative and anesthetic data, were analyzed. We found that patients with preoperative COPD (odds ratio: 7.17, 95% CI: 1.98–26.00), pneumonia (odds ratio: 7.94, 95% CI: 1.93–32.78), ascites (odds ratio: 13.76, 95% CI: 1.08–174.74) and systemic inflammatory response syndrome (SIRS) (odds ratio: 11.90, 95% CI: 2.63–53.86) were more likely to be subjected to RAP. Airway surgery and head–neck surgery also predisposed patients to reintubation. However, administration of both an extra dose of opioid and neuromuscular blocker at the end of surgery proved irrelevant to RAP.Conclusions: Risk factors for RAP are clear and unambiguous. This study will prompt further studies on preventative measures or evaluation of how to improve outcome.

The relationship between night time snoring and Cormack and Lehane grading - Corrected Proof

Ali Dabbagh, Mahmoud Puyani Rad, Abbas Daneshmand — 2011-03-23

Abstract: Introduction: Airway management is one of the greatest concerns of anesthesiologists and difficult intubation, well known as the anesthesiologist’s nightmare, is an event not easy to predict before induction of anesthesia. The aim of this study was to assess the relationship between history of snoring and the Cormack and Lehane grading score.Materials and methods: In a descriptive-analytical study, 120 candidates for elective surgery were selected and allocated in the two groups (snoring and snoring free groups, respectively). The history of night time snoring was taken from the patient’s wife/husband. After induction of anesthesia, each patient was assessed regarding the Cormack and Lehane grading under direct laryngoscopy.Results: The difference between the two groups regarding Cormack and Lehane grading system was statistically significant.Conclusion: The findings of this study demonstrated a relationship between the presence of snoring and increased number of Cormack & Lehane grading score.

Comparison of the efficacy of parecoxib vs ketorolac combined with morphine on patient-controlled analgesia for post-cesarean delivery pain management - Corrected Proof

2011-03-23

Abstracts: Background: We compared the clinical efficacy and safety between a new injectable cyclooxygenase-2 selective inhibitor, parecoxib, and an old nonselective, ketorolac combined with morphine in patient-controlled analgesia (PCA) for management of post-cesarean delivery pain.Methods: In this randomized, open-label study, 66 parturients undergoing cesarean section were divided into two groups: In Group P the patients received an initial intravenous bolus of 40mg parecoxib as a loading dose post-operatively and then two bolus doses of 20mg parecoxib were subsequently given at intervals of 24h. Morphine was basically used in PCA manner during the 3-day study course; and in Group K patients received an intravenous loading bolus of 30mg ketorolac post-operatively and then 90mg ketorolac combined with morphine in PCA fashion throughout the study course. Efficacy was evaluated by Verbal ranking scale (0–10) for pain intensity, Ramsay sedation score (1–6), profile of mood state (0–3) and quality of sleep (0–3), and patient satisfaction (0–4) with the analgesia. Efficacy evaluations and adverse effects were recorded every 24h and at 72h after initial loading boluses. The duration of hospital stay and total dose of morphine used throughout the study were also recorded.Results: There were no significant differences of sedation scale, mood state, quality of sleep and satisfaction between two groups, except patients of Group P had a lower pain scores than those of the Group K at 24h (3.1, range 0–5 vs. 4.3, range 0–8, p = 0.005) and 72h (1.1, range 0–3 vs. 1.9, range 0–4, p = 0.005). Moreover, there were also no significant differences in the duration of hospital stay, but there was a lower total morphine requirement (22% reduction) in Group P in comparison with Group K (43.5 ± 19.2 vs. 55.5 ± 21.5, p = 0.02). Regarding adverse effects, there were no statistical differences between two groups.Conclusions: We noted that parecoxib with PCA morphine can be used for post-cesarean delivery analgesia with the same efficacy as ketorolac for an opioid-sparing effect.

New device for Pentax-AirWayscope in pediatric intubation - Corrected Proof

Cheesang Ho — 2011-03-23

Abstract: The PBLADE® which is a component used with Pentax-AWS® (AWS) has only one size that is essentially for use in adults. It cannot be used in children and neonates. We have made a new device to fit the Pentax-AWS for use in children and neonates. This new device will provide a good indirect visualization for intubation in pediatric patients.

Pentax-AWS Airway Scope® for tracheal intubation breaks through the limitation of neck motion in an ankylosing spondylitis patient wearing halo vest – A case report - Corrected Proof

2011-03-23

Abstract: The Airway Scope® (AWS) provides better glottic view than the conventional direct laryngoscopy in tracheal intubation. With it, the endotracheal tube can be more easily inserted into the tracheal lumen easily. We hereby presented a 24-year-old ankylosing spondylitis (AS) patient wearing a halo vest who was successfully intubated for undergoing cervical spine surgery involving C1 and C2 under general anesthesia. Pre-operative airway assessment revealed that he was a case of difficult intubation. An AWS was used for oral tracheal intubation which was achieved smoothly in the first attempt. AWS can be an alternative device for airway management in a patient wearing halo vest.

Sudden transient paraplegia shortly after preoperative thoracic epidural catheterization – A case report - Corrected Proof

Cheng-Chun Liao, King-Chuen Wu, Yu-Cheng Liu, Rick S.C. Wu, Kar-Lok Wong — 2011-03-23

Abstract: We report a case of sudden onset of paraplegia shortly after thoracic epidural catheterization for postoperative analgesia and discuss the possible causes of this event. A 38-year-old woman was scheduled to receive right lobectomy of liver because of hepatocellular carcinoma. Thoracic epidural catheterization for postoperative analgesia was performed before the induction of anesthesia. After skin disinfection and local anesthetic skin infiltration with lidocaine, epidural catheterization through T10–11 interspace was performed. Dural puncture without any neurological symptoms was noticed in the attempt and the epidural space was successfully identified through T9–10 interspace in the second attempt. However, acute motor weakness and sensory impairment were met as the epidural catheter was being threaded into the epidural space. Magnetic resonance imaging (MRI) revealed no abnormal findings and the neurological deficits resolved spontaneously within 2h without any sequela. Finally, it was supposed that the transient neurological deficits were resultant from accidental subarachnoid injection of the local anesthetics used for skin infiltration. Preoperative image studies of the spine revealed a relatively short skin-to-dura distance either from median or paramedian approach, which might be the cause of the inadvertent intrathecal injection of local anesthetic during skin infiltration.

Intraoperative wake-up test in a deaf-mute adolescent undergoing scoliosis surgery - Corrected Proof

Yi-Chun Chen, Chien-Kun Ting, Mei-Yung Tsou, Kwok-Hon Chan, Ya-Chun Chu — 2011-03-23

Abstract: We present our experience in intraoperative wake-up test in a deaf-mute feminine teenager who underwent spine surgery for correction of lordoscoliosis. Inadequate comprehension of the preoperative instructions, together with higher threshold of arousal in deaf-mutism may possibly contribute to lingering of the test. The report implicated direct, painful stimulation of the tested limbs, rather than indirect cues, such as flap on the dorsum of hands would be required for performance of wake-up test in the deaf-mute patients.

Perioperative transient ischemic attack caused by the cessation of warfarin - Corrected Proof

Sing-Ong Lee, Min-Jia Li, Hsin-Ming Ho, Chih-Cheng Chien, Shu-Lin Guo — 2011-03-23

Abstract: This paper describes the circumstances of a patient who had been receiving long-term warfarin treatment, but ceased it prior to surgical operation, sustained a transient ischemic heart attack post-operatively, which eventuated in delayed extubation and locked-in syndrome. For patients at low risk of perioperative bleeding, anticoagulation with oral vitamin K antagonist can probably be able to maintain the therapeutic range (INR ≤ 2.0) extreme. For patients with a high risk of bleeding, the international normalized ratio (INR) should be kept ≤1.5. Within this range, patients at low risk of thrombosis can discontinue warfarin treatment for 2–5 days pre-operatively; patients at high risk for thrombosis can stop warfarin but should probably be treated with intravenous or subcutaneous heparin when the INR is subtherapeutic.

Coronary artery dissection in a patient with traumatic femoral shaft fracture - Corrected Proof

2011-03-23

Abstract: We report a 24-year-old man who developed postoperative pulmonary edema and desaturation, after open reduction with internal fixation for left femoral shaft fracture sustained in a motorcycle accident. Cardiac catheterization revealed a left anterior descending coronary artery dissection. Review of his present history, showed that he neither had chest discomfort nor suffered from hemodynamic decompensation preoperatively. Only the abnormal 12-lead ECG with moderate tachycardia was suggestive of myocardial ischemia. Coronary artery dissection, although uncommon, is a disastrous complication following blunt chest trauma, and needs thorough preoperative evaluation to exclude its occurrence.

Local anesthetic infiltration to the trachea facilitates spontaneous ventilation in a patient with giant lung bullae undergoing an emergent non-pulmonary surgery - Corrected Proof

Chia-Wen Chen, King-Chuen Wu, Yu-Cheng Kuo, Yi-Ying Chiang, Rick Sai-Chuen Wu — 2011-03-23

Bullous lung disease is an uncommon cause of respiratory distress. However, patients with giant lung bullae are sometimes scheduled for non-thoracic surgery. Specific problems associated with anesthesia in patients with bullae, such as acute enlargement or rupture of the bullae perioperatively, are challenging to the anesthesiologists. The anesthetic technique that most authors recommend is avoiding positive pressure ventilation and keeping spontaneous ventilation throughout the entire procedure. However, upon emergency from anesthesia, tracheal stimulation by the endotracheal tube (ETT) may sometimes evoke coughing or bucking reflex, the outgrowth of which may subsequently produce high intrathoracic pressure and even creation of barotraumas. Hereby we share our experience in maintaining spontaneous ventilation and using a modified technique for infiltrating local anesthetics (LA) around the ETT in a patient with multiple pulmonary giant bullae scheduled for emergent laparotomy.