Propofol alone versus propofol in combination with meperidine for sedation during colonoscopy.

BACKGROUND: Despite the increasing popularity of propofol for sedation in colonoscopy, the optimal regimen is still controversial. Both propofol alone and propofol in combination with meperidine are frequently used during colonoscopy, but the impact of adding meperidine has not been evaluated. This study aimed to investigate if adding meperidine to propofol offers any advantage in terms of patient tolerance, recovery time, and postcolonoscopy discomforts. METHOD: Consecutive patients admitted to the physical checkup department of our hospital were randomized to receive either meperidine plus propofol (combination group, n=100) or propofol alone (propofol group, n=100) for sedated colonoscopy. The patients' tolerance and postcolonoscopy discomforts (pain, bloating, dizziness, and nausea/vomiting) were assessed with a 0-10 visual analog scale. The recovery times were assessed with 5-minute and 10-minute Aldrete scores. RESULTS: The dose of propofol was less in the combination group than the propofol group (129.80+/-37.93 mg vs. 147.90+/-47.85, mean+/-SD, P=0.003). The endoscopists, anesthetists, and nurses all rated patients' tolerance in favor of the combination group than the propofol group (mean+/-SD, endoscopists, 9.17+/-1.23 vs. 8.49+/-1.60, P=0.001; anesthetists, 9.21+/-1.08 vs. 8.63+/-1.37, P=0.001; nurses, 9.18+/-1.34 vs. 8.71+/-1.47, P=0.019, respectively). Patients in the combination group recovered earlier than the placebo group (5-min Aldrete scores: 9.48+/-1.09 vs. 9.05+/-1.32, mean+/-SD, P=0.013; short intervals to speak: 4.29+/-4.05 min vs. 6.30+/-5.22 min, P=0.003; and departure: 18.62+/-5.28 min vs. 20.28+/-5.68 min, P=0.034). There was also less abdominal bloating in the combination group after colonoscopy (1.23+/-1.79 vs. 2.19+/-2.12, mean+/-SD, P=0.004). Incidences of hypoxemia, hypotension, and overall satisfaction scores were comparable between the 2 groups. CONCLUSIONS: For sedated colonoscopy, propofol in combination with meperidine is better than propofol alone in improving patients' tolerance and recovery.

Temporomandibular joint dislocation after laryngeal mask airway insertion.

Temporomandibular joint (TMJ) dislocation after general anesthesia is not rare. Most victims usually have a past history of TMJ dysfunction or subluxation. It is possible that incomplete TMJ integrity, inadequate articular eminence shape and anesthetic agents that precipitate masticatory muscle hypotonicity are the main factors leading to dislocation. However, some patients suffer from post-anesthesia TMJ dislocation with no connection to prior history. We propose here different mechanisms that may cause TMJ dislocation. TMJ dislocation has been reported after the placement of a laryngeal mask airway for general anesthesia. After reviewing two such cases between August 2004 and July 2007, we found that some iatrogenic factors might intensify the risk of TMJ dislocation. The clinical implications of these findings are discussed herein.

Unilateral fixed dilated pupil during plastic surgery--a case report.

A 34-year-old man was referred to our hospital for management of multiple trauma in consequence of a car accident. Initial examination showed mild intracranial hemorrhage proven by computed tomographic scan (CT) of the brain and multiple fractures of face and thigh. Surgical repair of the multiple fractures was undertaken with stable vital signs and neurological condition. Anesthesia was induced with fentanyl and thiamylal and rocuronium was used to facilitate oroendotracheal intubation. Sevoflurane in a mixture of oxygen and air and rocuronium were used for maintenance of anesthesia and surgical relaxation, respectively. The surgeon decided to perform fixation of facial bone first, so he infiltrated the nasal mucosa with epinephrine solution to minimize blood loss. After the operation was completed, the surgeon routinely checked both pupils and found that the left pupil was fully dilated without light reflex. In fear of exacerbation of the existing intracranial hemorrhage with progressive bleeding, the operation was hastily brought to an end. An urgent CT of the brain was immediately carried out but it revealed no obvious progression compared with the preoperative examination. The patient awaked in the postanesthesia care unit (PACU) uneventfully with the left pupil returning to normal condition.

Lateral rotation of the lower extremity increases the distance between the femoral nerve and femoral artery: an ultrasonographic study.

Femoral nerve block (FNB) is by far the most useful lower extremity regional anesthetic technique for the anesthesiologist, and high-resolution ultrasonography is a useful tool with which to guide the performance of FNB. However, the relationships between the femoral nerve and the femoral artery in different lower extremity positions have rarely been discussed. The purpose of this study was to evaluate the relative positions of the femoral nerve and artery at different lateral rotational angles of the lower extremities using ultrasonographic imaging. We enrolled 41 healthy volunteers in this study. Two-dimensional ultrasonographic images of the femoral nerve were obtained using an ultrasound unit, in the inguinal crease, for four positions of the bilateral lower extremities: 0 degrees , 15 degrees , 30 degrees and 45 degrees lateral rotation of each extremity. The following assessments were made in each position: minimal skin-to-nerve distance (SN) and deviation of nerve-to-landmark (femoral artery pulsation) horizontal distance (NF). A trend towards lateral rotation of both lower extremities was identified. The Pearson correlation values between rotational degree to SN and rotational degree to NF were -0.216 and 0.430, with p values of 0.001 and less than 0.001, respectively. Body mass index had a good correlation ( r = 0.76-0.78) with SN. The results of our ultrasound study revealed that the more lateral the rotation of both lower extremities, the closer the femoral nerve was to the skin and the farther away it was from the femoral artery. In order to increase the success rate and decrease the rate of complications, a suggested lateral 45 rotation of both lower extremities is strongly recommended when performing FNB using the peripheral nerve stimulator technique or the field block technique. In any situation, individual ultrasound guidance is recommended for FNB whenever possible.

Total intravenous anesthesia for repair of congenitral diaphragmatic hernia: a case report.

Congenital diaphragmatic hernia is a cardiopulmonary anomaly that causes severe respiratory disorder. Traditionally, inhalational anesthetics with mechanical hyperventilation, opioids, and muscle relaxants are used in anesthesia for repair surgery. In this case, we used total intravenous anesthesia combined with high-frequency oscillatory ventilation and inhaled nitric oxide for surgical repair of the diaphragm. After surgery, the patient recovered well and was discharged from hospital 1 month later.

Lightwand-assisted intubation of patients in the lateral decubitus position.

In some situations, patients need endotracheal intubation to maintain airway patency while they are constrained in the lateral position. In this study we compared lightwand-guided intubation of 120 randomly enrolled patients placed in the supine, right, or left lateral position. Group S patients were initially placed in the supine position, and subsequent to the artificial airway having been established they were turned to the lateral decubitus position. Group R patients were initially placed in a right decubitus position during induction and intubation. Group L patients were initially placed in a left decubitus position during induction and intubation. The duration of each intubation attempt, the total time to successful intubation, and the incidence of intubation-related intraoral injury, hemodynamic changes, and postoperative sore throat and hoarseness were recorded. Intubation took a similar length of time in the supine (14.5 +/- 13.4 s), left lateral (13.3 +/- 10.2 s), and right lateral positions (15.5 +/- 13.0 s) and resulted in a similar trend in hemodynamic changes. Patients in the lateral and supine positions revealed a comparable incidence of successful first-attempt intubation, sore throat, hoarseness, oral mucosal injury, and dysrhythmia. Insignificantly more esophageal intubations were performed in the lateral position in the first attempt at intubation; however, all patients were correctly intubated shortly after reattempting intubation. We concluded that lightwand-assisted intubation is easily performed and a similar technique may be used whether the patient is in a lateral, recumbent, or a supine position. This alternative technique should be practiced and is recommended for patients who must remain in a lateral position during intubation and surgery.