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.

Preventing pressure sores of the nasal ala after nasotracheal tube intubation: from animal model to clinical application.

PURPOSE: Nasal-ala pressure sores induced by nasotracheal intubation are common complications of oral and maxillofacial surgery, but are easily ignored. To determine whether such sores could be prevented, we studied the effects of a combination of cushioning material in an animal model, and then analyzed the efficacy of this combination clinically. MATERIALS AND METHODS: Four pigs received nasotracheal intubation. Each pig received intubation for 4, 8, 12, or 16 hours. Outcomes from pigs undergoing 500-gram-weight compression on each nostril were compared: one nostril received an application of cushioning materials, and the contralateral nostril did not. After the required study period, clinical assessment and further evaluation were performed by measuring pressure-sore dimensions and performing incisional biopsies. Clinical applications of this protective technique were then undertaken. Eight patients who underwent intubation without Soft Liner (GC Co, Tokyo, Japan) and DuoDERM CGF (ConvaTec, Inc, Princeton, NJ) protection, and 10 patients with Soft Liner and DuoDERM protection, were evaluated. RESULTS: The protective efficacy of the cushioning materials was significant in the animal model as well as in clinical practice. Pressure sores were avoided on the protected side, with severe tissue necrosis documented on the control side. CONCLUSION: We found that the combined use of Soft Liner and DuoDERM reduced the size and severity of nasal-ala pressure sores attributable to nasotracheal intubation during oral and maxillofacial surgery.

Video-assisted thoracoscopic neurectomy of intercostal nerves in a patient with intractable cancer pain.

Cancer-related pain is complicated and unbearable. Pain management techniques must be constantly modified and improved, with the goal of decreasing pain and enabling patients to withstand it. A 56-year-old man with colon cancer and multiple metastases was suffering from intense pain that was not relieved by extremely high doses of intravenous morphine. Temporary pain relief was achieved twice by blockade of the intercostal nerves with local anesthetics. Radiofrequency ablation was then performed under fluoroscopic monitoring; however, the procedure resulted in little pain relief. Finally, a neurectomy to cauterize the intercostal nerves was completed with video-assisted thoracoscopy under general anesthesia.

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.

Fiberoptic intubation with patients in sitting position.

Flexible fiberoptic endoscope is the most valuable tool for anesthesiologists to manage difficult airways. Correctly positioning of the patient during fiberoptic intubation aids the clinician to rapidly secure the airway, because it not only saves time, but also minimizes the risk of repeated attempts of intubation with possible serious consequences in the wake. In general, fiberoptic intubation is carried out with the patient in the supine position, but there are situations in which the intubation requires the subjects to be in the sitting position. The sitting position also changes the position of performing anesthesiologist relative to the patient, presenting an inverse view contrary to that of traditional laryngoscopy. We can often obtain a superior view from fiberoptic intubation. Fiberoptic intubation in the sitting position can be applied to all patients, as long as there is no contraindication of having a patient be sat.

Total airway occlusion in a parturient with a mediastinal mass after anesthetic induction--a case report.

A 26-year-old primigravida having suffered from dry cough, dyspnea and orthopnea for two months came to our hospital for a check up at 34 weeks gestation. Physical examination and ultrasonic study showed a lot of lymph nodes around her neck. After close coordination of opinion from responsible doctors, it was decided to deliver the baby first. After anesthetic induction, bronchoscopy revealed that the lower trachea was totally collapsed with obvious tracheobronchial mucosal swelling. A high inspiratory pressure was applied, and high-dose corticosteroid and bronchodilator were immediately given, but the airway resistance was still high and her SpO2 level was falling down. Fortunately, after we changed the patient's position from supine to semi-sitting, ease of ventilation was reestablished and SpO2 rose up from 40% to 100%. We then delivered a healthy baby, and malignant lymphoma was proven by biopsy of the cervical lymph nodes performed immediately after delivery. In this case, the change to semi-sitting position and relevant medication helped reestablish her ventilation and save her life. At the moment we write she is undergoing chemotherapy and does her follow-up at our hospital as advised.

Intraoperative pneumothorax during laparoscopic cholecystectomy.

Anesthesiologists currently view laparoscopic cholecystectomy resemblant to other laparoscopic procedures with respect to the necessity of inducing a pneumoperitoneum via abdominal insufflation of carbon dioxide (CO2). The present case report describes a healthy 63-year-old man who while undergoing elective laparoscopic cholecystectomy under general anesthesia, developed hypoxemia in the course in consequence of pneumothorax. This complication, although rare, can be catastrophic if prompt diagnosis and rapid intervention and management do not come in the nick of time.