Multimodal Analgesia with Local Wound Infiltration and Intravenous Parecoxib for Thyroidectomy.

Background and objective: Adequate postoperative pain control is an important component to enhance recovery. Multimodal analgesia with various pain control techniques has been widely used to alleviate postoperative pain. The use of either wound infiltration or a superficial cervical plexus block has been reported to be effective for pain management after thyroid surgery. The present study evaluated the effect of multimodal analgesia using lidocaine wound infiltration combined with intravenous parecoxib for patients monitored after thyroidectomy. Materials and Methods: A total of 101 patients with a multimodal analgesia protocol being monitored after thyroidectomy were enrolled. After the induction of anesthesia, multimodal analgesia was performed through wound infiltration of 1% lidocaine and epinephrine at a ratio of 1:200,000 (5 µg/mL) combined 40 mg intravenous parecoxib before skin excision. Patients were divided into two groups for this retrospective analysis based on the injection dose of lidocaine they received. Patients in Group I (the control, n = 52) received a 5 mL injection solution, while those in Group II (the study, n = 49) received a 10 mL dosage in a time-sequential manner, in accordance with a previous clinical trial. The primary outcome was measuring postoperative pain intensity at rest, as well as during motion and coughing, which was measured at the postoperative anesthetic care unit (PACU) and on the first day after the operation (POD 1) in the ward. Pain intensity was assessed using a numerical rating scale (NRS). The secondary outcomes were postoperative adverse events including anesthetic-related side effects, as well as airway and pulmonary complications. Results: Most of the patients reported no pain or mild pain during the observation period. The patients in Group II had a lower pain intensity during motion than Group I (NRS 1.47 ± 0.89 vs. 1.85 ± 0.96, p = 0.043) when measured at the postoperative anesthetic care unit. Pain intensity during coughing was also significantly lower in the study group than in the control group (NRS 1.61 ± 0.95 vs. 1.96 ± 0.79, p = 0.049) when measured at the postoperative anesthetic care unit. There were no severe adverse events in either of the groups. Only one patient (1.9%) in Group I experienced temporary vocal palsy. Conclusions: The use of lidocaine with an equal volume of intravenous parecoxib provided comparable analgesia with minimal adverse events when monitoring thyroidectomy.

Optimization of electromyographic endotracheal tube electrode position by UEScope for monitored thyroidectomy.

OBJECTIVE: Proper position of an electromyographic (EMG) endotracheal tube within the larynx plays a key role in functional electrophysiologic intraoperative neural monitoring (IONM) in thyroid surgery. The purpose of this study was to determine the feasibility of a portable video-assisted intubation device (UEScope) to verify the optimal placement of an EMG tube. METHODS: A retrospective study enrolled 40 consecutive patients who underwent monitored thyroidectomies. After positioning the patient for surgery, an anesthesiologist performed tracheal intubation with UEScope and checked the position of the tube at the proper depth without rotation to the vocal cords. The main outcome measured was the proper EMG tube position, free from further adjustment. The secondary outcomes assessed were the percentage of available initial vagal stimulation (V1) signals. RESULTS: All tracheal intubations were successful at first attempt. Proper EMG tube placement without position adjustment was found in 97.5% of the patients. Tube withdrawal was required in a male patient. All patients obtained detectable V1 signals; the lowest and median V1 amplitude was 485 and 767 µV as a reference value, respectively. CONCLUSION: The UEScope is a valuable and reliable tool for placing an EMG tube and confirming its position during monitored thyroidectomy. In addition, further tube adjustment might be waived in most cases when the anesthesiologist placed the EMG tube after patient positioning for surgery. Routine use of video-assisted intubation devices is highly recommended. LEVEL OF EVIDENCE: 4.

Propofol target-controlled infusion for sedated gastrointestinal endoscopy: A comparison of propofol alone versus propofol-fentanyl-midazolam.

Gastrointestinal (GI) endoscopy is the major technique for diagnosis of GI disease and treatment. Various sedation and analgesia regimens such as midazolam, fentanyl, and propofol can be used during GI endoscopy. The purpose of the study was to compare propofol alone and propofol combination with midazolam and fentanyl in moderate sedation for GI endoscopy. One hundred patients undergoing GI endoscopy were enrolled in this study. All patients received a propofol target-controlled infusion (TCI) to maintain sedation during the procedure. Patients were randomly allocated into either Group P (propofol TCI alone) or Group C (combination of propofol TCI plus midazolam and fentanyl). Dermographic data, anesthetic parameters (sedation regimen, blood pressure, heart rate, and oxygen saturation), procedure parameters (procedure time, colonoscopy, or panendoscopy), propofol consumption, and adverse events (hypoxia, hypotension, and bradycardia) were all recorded. Postprocedural records included recovery time, postoperative adverse events (nausea, vomiting, dizziness, recall, and pain) and satisfaction. The average propofol consumption was 251 ± 83 mg in Group P and 159 ± 73 mg in Group C (p < 0.001). The incidence of transient hypotension was higher in Group P (p = 0.009). The recovery time and discharge time were both shorter in Group C (p < 0.001 and p = 0.006 respectively). Overall, postprocedural adverse events were similar in both groups. The postanesthetic satisfaction was comparable in both groups. TCI of propofol combined with midazolam and fentanyl achieved sedation with fewer hypotension episodes and shorter recovery and discharge time than propofol TCI alone in patients undergoing GI endoscopy.

Soft catheters reduce the risk of intravascular cannulation during epidural block--a retrospective analysis of 1,117 cases in a medical center.

A wet or bloody tap is an inevitable complication while performing epidural block. The influence of different catheters on the incidence of intravascular cannulation during epidural catheterization has not been reported. We observed an initial, relatively different incidence of intravascular cannulation during the placement of different sorts of epidural catheter; hence, a retrospective review was conducted to explore the possible association. We reviewed 1-year interval anesthetic records of 1117 patients who had undergone epidural anesthesia or received patient-controlled epidural analgesia. Epidural catheter placement was performed by a loss of resistance technique with an 18-G Tuohy needle in lateral position. Patients were divided into two groups according to the different types of epidural catheters used (Perifix One, n=590; Perifix Standard, n=527). Primary outcome measurement was the incidence of intravascular injection. Other analyzed outcomes included dura puncture, failure rate, and low back pain. The incidence of epiduralintravascular cannulation was significantly lower using the Perifix One catheter (1.5%; 9/590) than using the Perifix Standard (4.6%; 24/527), p=0.003. The dura puncture rate did not differ significantly between the Perifix One (1.9%; 11/590) and the Perifix Standard (2.5%; 13/527), p=0.49. Failure rates and low back pain incidence were also comparable between the two groups. Application of the soft epidural catheter (Perifix One) may reduce the incidence of epidural intravascular cannulation. We suggest the use of Perifix One catheter instead of Perifix Standard catheter in daily practice.

[The collaborative nursing care plan: integration of the clinical pathway with the traditional nursing care plan].

The nursing care plan is a commonly used teaching tool in nursing education. By developing individualized nursing care plans for specific clients, students practice use of nursing process and making clinical judgments and decisions. However, the system of managed care has impacted current clinical practice, and many health care agencies have shifted their emphasis from requiring the traditional columnar nursing care plans to use of clinical pathways and standards of care. As result of this trend, nursing educators are faced with the problem of preparing students to cope with today's reality in clinical practice. In response to this problem, this article reexamines the practical utility of the traditional nursing care plan in nursing education. The article also introduces a collaborative nursing care plan, the integration of the clinical pathway with the traditional nursing care plan, and its application in teaching.

Effects of a continuing education program on nurses' practices of cancer pain assessment and their acceptance of patients' pain reports.

A hospital-based quasi-experimental (pretest and post-test) study was conducted in Kaohsiung Veteran General Hospital, Taiwan. This study was to evaluate a continuing education program (CEP) on nurses' practices of cancer pain assessment and their acceptance of patients' pain reports with respect to four types of misconceptions. A questionnaire was sent to on-duty nurses or head nurses with patient care responsibilities before the implementation of CEP (n=645) and six months after the program (n=630). The response rates were 92.6% and 91.3% for pretest and post-test surveys, respectively. The CEP was implemented in 8 weeks with four-repeated sessions of 4-hour lectures. A one-day workshop focused on cancer pain assessment and treatment was held 3 months after the four-repeated sessions. Several educational strategies and teaching materials were used in the CEP. The results showed that CEP made statistically significant yet moderate improvement in nurses' practices of pain assessment using pain rating scales (pretest 3.29+/-0.76 vs. post-test 3.48+/-0.75, P<0.001) and acceptance of patient's pain reports without misconceptions on addiction (3.12+/-0.80 vs. 3.39+/-0.90, P<0.001), phantom pain (3.91+/-0.96 vs. 4.07+/-0.92, P=0.005), and placebo testing (3.63+/-0.72 vs. 3.81+/-0.73, P<0.001), except on patient gender-age-related doubts (3.60+/-0.72 vs. 3.67+/-0.77, P=0.109). In order to achieve further improvement, additional follow-up CEP combined with a hospital-wide institutionalization of pain assessment should be promoted and implemented in the future.