Impact of intervention time on hospital survival in patients requiring emergent airway management: a preliminary study.

BACKGROUND: The time in the day of intervention for physiological deterioration reportedly impacts patient outcomes. This study aimed at determining the impact of the time of ETI on hospital survival in critically ill patients. METHODS: Between January 2014 and December 2016, 151 patients who underwent emergency tracheal intubation (ETI) by the airway response team (ART) in the general wards of a tertiary referral center were retrospectively reviewed. Patients were divided into two groups based on the time of ETI (daytime group, 8:00 a.m.-4:00 p.m., n = 57, mean age 63.5 ± 14.1 years; nighttime group, 4:00 p.m.-8:00 a.m., n = 94, mean age 60.4 ± 14.9 years). Data regarding demographic information, comorbidities, trigger events for intubation, survival-to-discharge rates, acute physiology and chronic health evaluation II (APACHE II), ventilator-free days, and airway techniques were collected. RESULTS: There was no significant difference in sex, age, body mass index, APACHE II, or comorbidities between the two groups, except that a higher proportion of patients presented with arrhythmias (21.1 vs. 8.5%, p = 0.028) and received fiberoptic intubation (24.6 vs. 11.7%, p = 0.039) in the daytime group than in the nighttime group. The time of the ART arrival after call was also shorter in daytime than that in nighttime (6.1 ± 1.4 vs. 10.5 ± 3.2 min, respectively, p < 0.001). There were no differences in the survival-to-discharge rate (45.6 vs. 43.6%, p = 0.811), ventilator-free days, or trigger events between the two groups. CONCLUSIONS: Emergent tracheal intubation in the nighttime may not have negative impact on the survival-to-discharge rate compared with that performed in the daytime.

To characterize the incidence of airway misplacement of nasogastric tubes in anesthetized intubated patients by using a manometer technique.

This study characterized the incidence of airway misplacement of nasogastric (NG) tubes in surgical patients, and the benefit of using a manometer to discriminate gastric placement from airway placement of NG tubes. Subjects included adult patients scheduled for abdominal surgery. After tracheal intubation, a 16 Fr. NG tube was inserted blindly through the nostril, and its position was assessed using the auscultation (10-ml air insufflation) or manometer (attached to NG tubes) techniques. Briefly, a biphasic pressure change synchronous with airway pressure during mechanical ventilation indicated airway misplacement. The presence of a notable pressure change while compressing the epigastric area indicated a gastric placement. A surgeon made the final confirmation of NG tube placement within the stomach using manual palpation of the tube immediately after laparotomy. The first-attempt success rate was 82.7 % in 104 patients. There were 29 misplacements of 130 attempted insertions (oral cavity, n = 23; trachea, n = 3; distal esophagus, n = 3). The incidence of airway misplacement was 2.9 % (3 of 104 cases). For confirmation of gastric placement, the auscultation technique had a sensitivity of 100.0 % and a specificity of 79.3 %. In contrast, the manometer technique had a sensitivity of 100.0 % and a specificity of 100.0 % in the discrimination of gastric placement from airway placement of NG tubes. Airway misplacement of NG tubes is not uncommon in surgical patients, and the manometer technique may be a reliable and safe method to discriminate gastric placement from airway placement of NG tubes.

Topical lidocaine improves conditions for laryngeal mask airway insertion.

PURPOSE: We hypothesized that optimal laryngeal mask airway (LMA) insertion conditions might be achieved with topical lidocaine and a smaller dose of propofol. In this study, insertion conditions after topical lidocaine 40 mg followed by propofol 2 mg.kg(-1) were compared with propofol 2 mg.kg(-1) or propofol 3 mg.kg(-1) alone. METHODS: Ninety patients were recruited for this randomized prospective double-blind study. One group received four sprays of topical lidocaine (40 mg) over the posterior pharyngeal wall followed by propofol 2 mg.kg(-1) (Group 2PL; n = 30). The other two groups received four sprays of 0.9% normal saline followed by propofol 2 mg.kg(-1) (Group 2P; n = 30) or by propofol 3 mg.kg(-1) (Group 3P; n = 30). The frequency of optimal insertion conditions (successful insertion at the first attempt without adverse responses) and side effects were recorded. RESULTS: The frequency of optimal insertion conditions was greater in Group 2PL (20/30, 67%) and Group 3P (22/30, 73%) than in Group 2P (11/20, 37%) (P = 0.009). In Group 3P, the mean blood pressure was lower than in the other groups prior to LMA-Classic insertion (P = 0.003) but was similar after insertion. The incidence of apnea was greater in Group 3P patients (17/30, 57%) than in Group 2P (2/30, 7%) or Group 2PL patients (1/30, 3%) (P < 0.001). CONCLUSION: Topical lidocaine 40 mg followed by propofol 2 mg.kg(-1) can provide optimal insertion conditions of the LMA-Classic comparable to those of propofol 3 mg.kg(-1), with fewer hemodynamic changes and a lower incidence of apnea.

Pharmacoepidemiology of chronic noncancer pain patients requiring chronic opioid therapy: A nationwide population-based study.

OBJECTIVE: This study was aimed to explore the pharmacoepidemiology of chronic noncancer pain (CNCP) patients who required chronic opioid therapy (COT) in the Taiwanese population. METHODS: Using the Taiwan National Health Insurance Research Database during 2008-2009, COT-requiring CNCP patients were identified by the inclusion criteria of both chronic analgesic requirement for >3 months per year and long-term use of controlled opioids for >28 therapeutic days during any 3-month period in ambulatory visits with malignancy-related pain excluded. Their demographic data and pharmacoepidemiological characteristics of opioid consumption and opioid prescriptions issued in ambulatory visits were analyzed. RESULTS: In total, 159 patients were enrolled as COT-requiring CNCP patients, and the prevalence was calculated at 0.016% in a 2-year period. Females were outnumbered by males (45.3% vs. 54.7%). Almost 60% of them were of working age and 93.7% belonged to low-income households, as in the health insurance claims, probably implying socioeconomic disadvantages associated with CNCP. The leading three diagnoses were unspecified myalgia and myositis, lumbago, and abdominal pain of unspecified site. The most common department from where these 159 CNCP patients obtained their opioid prescriptions was the emergency department (27.6%), ensued by a pain clinic (25.3%), but they could acquire only a few opioid therapeutic days through emergency department visits. Moreover, pain clinic satisfied the majority of opioid therapeutic days. Among all opioids, morphine was the most frequently prescribed in opioid-obtaining ambulatory visits, accounting for most of the opioid therapeutic days as well as opioid consumption. CONCLUSION: COT-requiring CNCP patients were easily associated with adverse socioeconomic liabilities and often visited emergency department as well as pain clinics. Morphine was the main opioid used for their chronic pain. Transfer of COT-requiring CNCP patients to appropriate departments is strongly recommended for efficient long-term pharmacotherapy for their chronic pain.

Does postoperative pain induce emesis?

OBJECTIVE: The aim of this prospective, controlled study was to evaluate the risk factors for postoperative emesis in patients undergoing gynecologic surgery and receiving patient-controlled analgesia for three days. METHODS: Six hundred twenty-five gynecologic patients with an American Society of Anesthesiologists physical status of I to III undergoing lower-abdominal surgeries were enrolled. A standard, general anesthetic technique was used. Postoperative pain was treated by a patient-controlled analgesia device with bolus intravenous doses of 1 mg morphine. For 3 days after surgery patients were assessed for occurrence of emesis, sedation, and pain intensity when at rest and during movement. RESULTS: The incidence of emesis was 26% on postoperative day 1, 13% on day 2, and 4% on day 3. On all 3 days, patients' pain scores when at rest and when coughing were higher for those with emesis than for those without. During the first 2 postoperative days the patients with and those without emesis consumed similar amounts of morphine daily, but on the third day the patients with emesis consumed significantly more morphine than did those without emesis ( <0.05). Further logistic regression analysis showed that incident pain was the main risk factor for postoperative emesis on all 3 days. CONCLUSIONS: The results suggested that postoperative pain was an associative risk factor to increase the incidence of emesis in these female patients.

Massive pulmonary embolism presented as sudden cardiac arrest in the immediate postoperative period after laparoscopic hysterectomy.

A rare case of postoperative cardiac arrest in an otherwise healthy, 49-year-old female patient who had a laparoscopic hysterectomy, is presented. The cause of cardiac arrest was due to massive pulmonary embolism, which was detected by transesophageal echocardiography. Laparoscopic surgery is regarded as a less invasive procedure and provides a lower risk for postoperative complications. However, our is a case reminer that pneumoperitoneum may interfere with venous flow of lower extremities and predispose one to deep vein thrombosis or pulmonary embolism.

Difficult fiber-optic intubation in a patient with giant neck masses: The role of McCoy laryngoscope in elevating compressed laryngeal aperture.

Airway management in patients with giant neck masses is usually a challenge to anesthesiologists. A giant neck mass could compress the airway and thus impede endotracheal intubation. We encountered a situation where the giant neck masses of a patient pushed the epiglottis posteriorly toward the posterior pharyngeal wall and compressed the laryngeal aperture narrowing after anesthetic induction, causing direct laryngoscopic intubation and sequential fiber-optic intubation failed. The neck masses twisted the aryepiglottic fold tortuously and clogged the laryngeal aperture tightly, making a flexible fiber-optic bronchoscope unable to pass through the laryngeal aperture. Later, we utilized a McCoy laryngoscope alternately to lift the compressed larynx up and away from the posterior pharyngeal wall, creating a passage and completing endotracheal intubation successfully with the aid of a gum elastic bougie. Our case suggested that the tilting tip blade of the McCoy laryngoscope could lever the tongue base up against the tumor mass compression to improve laryngeal views and facilitate endotracheal intubation when a difficult fiber-optic intubation was encountered on a compressed laryngeal aperture.

Pulmonary alveolar proteinosis undergoing whole lung lavage in south Taiwan--a case report.

Pulmonary alveolar proteinosis (PAP) is rarely seen in Taiwan. According to the literature the incidence is one in two million with a male to female ratio of 3 to 1. The pathohistology of PAP is associated with the filling of the alveoli by a proteinaceous material. PAP can be divided into primary and secondary forms. PAP was once diagnosed by open lung biopsy, but since the introduction of bronchoalveolar lavage, open lung biopsy is less common now for the diagnosis of PAP. The most definite and effective therapy for PAP is whole lung lavage (WLL). Therapeutic WLL is performed under one-lung general anesthesia with a double lumen tube (DLT). This procedure is associated with three problems: 1. hypoxia. 2. circulatory disturbance. 3. difficulty in positioning the DLT. We present a case undergoing WLL in our hospital who had contracted pulmonary TB was diagnosed as a case of PAP by open lung biopsy. She was convinced to receive WLL because of intolerance of daily activity. The result of the left lung lavage was excellent, but the attempt on the other lung at a later time was cancelled because of difficulty in positioning the DLT due to tracheal stenosis. Here we would like to give an account of our management and discuss about PAP and WLL after literature review.