Intubation difficulty scale contributors and time delay in clinical practice.

ABSTRACT: The intubation difficulty scale (IDS) includes 7 contributors that provide a comprehensive assessment of difficult intubation. However, the effect of each contributor is unclear, and the scale has not been revalidated recently and has not been validated in orient. This study determined the duration of successful intubation (DSI) for each of these 7 contributors.The patients were intubated by attending anesthesiologists. The duration and other data were recorded by 2 research assistants. Anaesthesiologists reported the IDS and their perceptions. A linear mixed-effects model with a DSI was constructed using IDS factors.In total, 1095 patients were enrolled. The average DSI was 23.9 ±â€Š21.8 seconds (37.1% IDS = 0). All 7 factors were independently associated with duration, with the exception of vocal cord adduction. The best model was as follows: DSI (in seconds) = 15.2 + 31.1 (number of additional attempts) + 26.2 (number of additional operators) + 11.4 (number of alternative techniques) + 7.9 (increased lift force) + 4.9 (external laryngeal pressure) + 3.5 (Cormack grade 1). The mixed models were similar except for the regression coefficient for the number of alternative techniques that decreased from 11.4 to 6.9 seconds.We confirmed that each IDS contributor affects the DSI and validated a prediction model with 6 IDS contributors. This prediction model may facilitate the development of strategic plans for critical airway management. Furthermore, it could improve simulations and monitor learning progress and help provide valuable feedback.

An initial learning experience of tracheal intubation with video laryngoscope: Experiences from a novice PGY.

ABSTRACT: Tracheal intubation is an essential technique for many healthcare professionals and one of the mega code simulations in advanced cardiac life support. In recent years, video laryngoscopy (VL) has provided a rescue for difficult airways during intubation and has proven to have higher success rates. Moreover, VL facilitates a more rapid learning curve for inexperienced doctors.In this article, we report 16 cases intubated with VL by a novice doctor of postgraduate year 1, who shared the learning experience and the difficulties encountered in this case series. We also conducted a statistical analysis to evaluate the learning outcomes of the trainee after 1 month.Our results showed that the overall first-shot success rate was 81.3% for the 16 objectives. Over time, improvements in intubation performance measures, including shortened duration and lower Intubation Difficulty Scale score, have been observed. In this learning project, we found that limitation of mouth opening (<2.5 fingers wide) is an important risk factor for predicting the initial difficulty of tracheal intubation on the novice trainee.For inexperienced doctors, VL produces high first-shot success rates for tracheal intubation and may be useful for training their performance in a short period of time. In addition, mouth opening <3 fingers wide may result in difficult intubation by novice doctors.

High-frequency spinal cord stimulation treatment attenuates the increase in spinal glutamate release and spinal miniature excitatory postsynaptic currents in rats with spared nerve injury-induced neuropathic pain.

High-frequency spinal cord stimulation (HFSCS) at 10 kHz provides paresthesia-free treatment for chronic pain. However, the underlying mechanisms of its action have not been fully elucidated. The aim of the present study was to investigate the effect of HFSCS treatment on spinal glutamate release and uptake in spared nerve injury (SNI) rats. HFSCS was applied to the T10/T11 spinal cord 3 days after SNI. The concentration of spinal glutamate, glutamate transporter activity and miniature excitatory postsynaptic currents (mEPSCs) from neurons in lamina II were evaluated. HFSCS treatment alleviated SNI pain induced by mechanical and cold allodynia. HFSCS treatment also partially restored altered spinal glutamate uptake activity, the levels of spinal glutamate, and the frequency of mEPSCs following SNI. In conclusion, HFSCS treatment attenuated SNI-induced neuropathic pain and partially restored the altered glutamate uptake after SNI.

Early high-frequency spinal cord stimulation treatment inhibited the activation of spinal mitogen-activated protein kinases and ameliorated spared nerve injury-induced neuropathic pain in rats.

BACKGROUND: Neuromodulation therapies offer a treatment option that has minimal side effects and is relatively safe and potentially reversible. Spinal cord stimulation (SCS) has been used to treat various pain conditions for many decades. High-frequency SCS (HFSCS) involves the application of a single waveform at 10,000 Hz at a subthreshold level, therefore providing pain relief without any paresthesia. METHODS: We tested whether early HFSCS treatment attenuated spared nerve injury (SNI)-induced neuropathic pain. The phosphorylation profile of mitogen-activated protein kinases (MAPKs), i.e., extracellular signal-regulated kinases (ERKs), c-Jun N-terminal kinases (JNKs), and p38, was evaluated to elucidate the potential underlying mechanism. RESULTS: SNI of rat unilateral sciatic nerves induced mechanical hyperalgesia in the ipsilateral hind paws. Rats were assigned to SCS sessions with HFSCS (frequency 10 kHz; pulse width 30 µs; pulse shape of charge-balanced, current controlled; delivered continuously for 72 h), or sham stimulation immediately after SNI. Tissue samples were examined at 1, 3, 7, and 14 days after SNI. Behavioral studies showed that HFSCS applied to the T10/T11 spinal cord significantly attenuated SNI-induced mechanical hyperalgesia compared with the sham stimulation group. Moreover, western blotting revealed a significant attenuation of the activation of ERK1, ERK2, JNK1, and p38 in the dorsal root ganglia and the spinal dorsal horn. CONCLUSION: Application of HFSCS provides an effective treatment for SNI-induced persistent mechanical hyperalgesia by attenuating ERK, JNK, and p38 activation in the dorsal root ganglia and the spinal dorsal horn.

Betel-Nut Chewing Increases Difficulty in Tracheal Intubation.

BACKGROUND: Betel-nut chewing (BC) causes oral submucous fibrosis (OSF), and this leads to difficult tracheal intubation (DI). Unanticipated DI was reported in chewers with apparently normal preoperative airway evaluations (PAEs). This analysis aims to investigate whether BC is an independent risk on DI besides the common DI risk prediction factors. METHODS: After the approval of Institutional Review Board and the written informed consent were obtained, 2,682 patients were enrolled in a cohort. PAEs, intubation difficulty scale (IDS), intubation time, and perceived DI were recorded prospectively. All 805 male patients received classical intubation, 307 with BC and 498 without BC were analyzed. Data were analyzed by Student's t-test and chi-square test. Stepwise logistic regression was performed to identify BC effects on IDS adjusting for related factors with WEKA (Waikato Environment for Knowledge Analysis; Machine Learning Group at the University of Waikato, Hamilton, New Zealand). RESULTS: Fewer BC patients were Cormack-Lehane (CL) grade I (38.9% vs. 47.6%) or IDS degree 〞Easy〞 (24.8% vs. 33.5%). Compared with IDS degree 〞Easy〞, patients in the BC group had a significantly higher odds ratio (OR) for 〞Slight + Moderate-Major〞 degree than in the non-BC group (adjusted OR, 1.75; 95% CI, 1.15-2.68). Compared with CL grade I, patients with BC was an independent risk for II (adjusted OR, 1.53; 95% CI, 1.02-2.32) and IV (adjusted OR, 3.25; 95% CI 1.01-10.49). Otherwise, patient's age ≥ 46 and the presence of teeth were also significant risk factors for IDS degree 〞Slight + Moderate-Major〞. CONCLUSION: BC increased not only the tracheal intubation difficulty in patients with apparent OSF but also in patients with PAEs. BC is an independent risk factor besides the commonly used DI prediction factors. We suggest physicians operating on BC patients to be better prepared for DI.

Validation of simplified postoperative nausea and vomiting intensity scale in Taiwan.

This study determined whether the Simplified Postoperative Nausea and Vomiting Impact Scale (SPONVIS), could be used to predict clinically important PONV in Taiwanese. In this prospective, observational study, SPONVIS, simplified Apfel PONV Risk Scores, post-operative anti-emetic drug use, total PONV score, and 3-month recall score for PONV were recorded from Taiwanese patients who had undergone general anesthesia and surgery. With antiemetic use and 3-month recall score as validations of clinical significance, we determined whether the elements and cut-off points used in the original SPONVIS study could be used in Taiwanese patients. A total of 378 patients were included in the analysis. One hundred forty (37.1%) patients had PONV. Forty-eight patients (12.7%) had clinically important PONV (SPONVIS score ≥ 5). The odds ratios were 14.26 (CI 6.91-29.43; P < 0.001) and 4.95 (CI 2.42 to 10.11; P < 0.001), respectively, for prediction of anti-emetic drug use and 3-month recall. The SPONVIS and its construct elements were significantly related to anti-emetic drug use, 3-month recall score for PONV, total PONV score, and Apfel risk score (all P ≤ 0.005), results similar to those reported in the original Australian PONV impact score study. The SPONVIS cut-off points 3 and 5 were statistically significant predictors of anti-emetic drug use. However, a cut-off point of 3 had a higher OR (24.08) than a cut-off of 5 (14.26) for prediction of anti-emetic drug use. SPONVIS and both construct elements (the nausea and vomiting impact scores) are useful predictors of clinically important PONV in Taiwanese.

The Antinociceptive Effect of Light-Emitting Diode Irradiation on Incised Wounds Is Correlated with Changes in Cyclooxygenase 2 Activity, Prostaglandin E2, and Proinflammatory Cytokines.

Background. Light-emitting diode (LED) phototherapy has been reported to relieve pain and enhance tissue repair through several mechanisms. However, the analgesic effect of LED on incised wounds has never been examined. Objectives. We examined the analgesic effect of LED therapy on incision pain and the changes in cyclooxygenase 2 (COX-2), prostaglandin E2 (PGE2), and the proinflammatory cytokines interleukin 6 (IL-6), IL-1ß, and tumor necrosis factor α (TNF-α). Methods. Rats received LED therapy on incised skin 6 days before incision (L-I group) or 6 days after incision (I-L group) or from 3 days before incision to 3 days after incision (L-I-L group). Behavioral tests and analysis of skin tissue were performed after LED therapy. Results. LED therapy attenuated the decrease in thermal withdrawal latency in all the irradiated groups and the decrease in the mechanical withdrawal threshold in the L-I group only. The expression levels of COX-2, PGE2, and IL-6 were significantly decreased in the three LED-treated groups, whereas IL-1ß and TNF-α were significantly decreased only in the L-I group compared with their levels in the I groups (p < 0.05). Conclusions. LED therapy provides an analgesic effect and modifies the expression of COX-2, PGE2, and proinflammatory cytokines in incised skin.

Sequence variants of the HTR3A gene contribute to the genetic prediction of postoperative nausea in Taiwan.

Postoperative nausea (PON) is a common complication, and therefore, it is important to identify the associated genetic factors and the candidate predictive markers. Current clinical and basic research suggests that the 5-hydroxytryptamine type 3A receptor (HTR3A) may be important in the occurrence of PON. The association between three single nucleotide polymorphisms (SNPs) of the HTR3A gene and PON was examined to determine whether this can be used to predict the incidence of PON in a unique Taiwanese population without any reported postoperative nausea and vomiting (PONV) risk factors associated with PON occurrence. One thousand adult surgical patients who received general anesthesia were included in this analysis. A total of 369 patients were finally selected for a two-stage association study. Significant single-locus associations for all three HTR3A SNPs and PON were identified in both stages. In addition, two of the most common haplotypes, CTT and TAG, showed both a significant risk for and a protective effect against PON, respectively. Our findings support the notion that different haplotypes of HTR3A have reciprocal effects in the etiology of PON. Therefore specific haplotypes of HTR3A may be useful as predictors of PON for 24 h immediately after surgery in our population.

A survey of how patient-perceived empathy affects the relationship between health literacy and the understanding of information by orthopedic patients?

BACKGROUND: There is a lack of research examining patient-perceived empathy and its effect on low-literacy patients' understanding of health information. This study investigated the moderating effect of patient-perceived empathy on the relationship between health literacy and understanding of preoperative information. METHODS: During a 2-month period, a total of 144 patients took a survey that included the Chinese-edition Rapid Estimate of Adult Literacy in Medicine, the Barrett-Lennard Relationship Inventory and the Preoperative Information Understanding Scale. Hierarchical multiple regression analysis provided a test of moderator effects. RESULTS: All Cronbach's alphas exceeded 0.6, with REALM at 0.91, BLRI at 0.67, and PIUS at 0.77.The finding that the interaction term was significant suggests perceived empathy is a relevant factor when considering the relationship between health literacy and the understanding of information by patients. The relationship between the health literacy and understanding of information was stronger and positive among patients who perceived greater empathy from their physicians. CONCLUSION: Our study demonstrates that a focus on improving physician-patient empathy skills could be beneficial in helping to overcome the negative consequences associated with limited health-literacy capabilities. Healthcare providers who wish to improve the understanding of information by low health-literacy patients should first identify components of their empathic communication mechanisms, and then try to refine these skills to better serve their patients.

Acute coronary syndrome in cisatracurium-induced anaphylactic shock: Kounis syndrome.

In this case report, we describe a 70-year-old male patient who sustained Kounis syndrome induced by cisatracurium administration immediately following induction of general anesthesia. Acute coronary syndrome combined with anaphylactic shock, termed Kounis syndrome, should be investigated in percutaneous coronary intervention to solve this complex and life-threatening condition. A team effort by cardiologist and anesthesiologist is essential for successful resuscitation. In general, the incidence of an anaphylactic reaction to cisatracurium is low, but a high serum IgE level in combination with a positive skin prick test in our patient was strongly suggestive of cisatracurium-induced Kounis syndrome. In addition, a cross-reaction between cisatracurium and rocuronium is reported.

Intrathecal coelectrotransfer of a tetracycline-inducible, three-plasmid-based system to achieve tightly regulated antinociceptive gene therapy for mononeuropathic rats.

For optimal use of antinociceptive gene therapy, it may be important to have extrinsic control of the expression of the transfected gene. To achieve this goal, we used a tetracycline-inducible system (Tet-On) composed of three plasmids coding for beta-endorphin, the tetracycline transcriptional activator rtTA, and the silencer tTS. The regulation of beta-endorphin expression was first assessed in cultures of dorsal root ganglion neurons. The three plasmids were then electrotransfected into the spinal cord of mononeuropathic rats and the analgesic potential of this therapy in vivo was evaluated by thermal-withdrawal latency and the mechanical-withdrawal threshold. Intraperitoneal injections of doxycycline were made to evaluate the possibility of exogenous upregulation of transfected beta-endorphin gene expression in vivo. The levels of beta-endorphin were analyzed by intrathecal microdialysis and radioimmunoassay. We found that, after doxycycline administration, the expression of beta-endorphin was rapid, stable, and tightly regulated (low background and high induction level) both in vitro and in vivo. The beta-endorphin protein was secreted into cerebrospinal fluid at a peak level of 53 pmol/L in dialysate, which was sufficient to inhibit neuropathic pain. In conclusion, tightly controlled expression of beta-endorphin can be obtained following intrathecal electrotransfer of a tetracycline-inducible, three-plasmid-based system, and doxycycline-dependent beta-endorphin protein expression in this system alleviates sciatic nerve constriction-induced limb pain.

Use of a topical anesthetic cream (EMLA) to reduce pain after hemorrhoidectomy.

BACKGROUND AND OBJECTIVES: Hemorrhoidectomy usually leads to severe postoperative pain that often causes urinary retention. Topical EMLA cream (lidocaine 2.5% and prilocaine 2.5%) has been used extensively in the clinical setting. This prospective study tested the effectiveness of EMLA cream for postoperative pain control after hemorrhoidectomy. METHODS: Thirty patients admitted for hemorrhoidectomy were enrolled and randomly assigned into either a control group (n = 15) or EMLA group (n = 15). Postoperatively, the control group received approximately 5 g of neomycin ointment, and the EMLA group received approximately 5 g of EMLA. A visual analog scale (VAS) score was recorded on arrival in the postanesthesia recovery unit (PAR), after 2 hours in the PAR, on the first postoperative evening, and on the first postoperative morning. The requested frequency and dosage of meperidine, the first spontaneous voiding time, the frequency of single urinary catheterization, and a patient satisfaction score were also obtained. RESULTS: The VAS score and frequency and dosage of meperidine injections were significantly lower in the EMLA group than in the control group (P < .01). The voiding time was significantly later in the control group (P = .04). The frequency of single catheterization was significantly lower in the EMLA group than in the control group (P = .03). Patient satisfaction with postoperative pain control was significantly higher in the EMLA group than in the control group (P < .01). No systemic complications were observed. CONCLUSIONS: Topical EMLA cream decreased pain intensity and meperidine requests, reduced the frequency of single catheterizations, and improved patient satisfaction with postoperative pain management after hemorrhoidectomy in adults.

Improved satisfaction of preoperative patients after group video-teaching during interview at preanesthetic evaluation clinic: the experience of a medical center in Taiwan.

BACKGROUND: Anesthesiologist-directed anesthetic preoperative evaluation clinic (APEC) is used to prepare patients to receive anesthesia for surgery. Studies have shown that APEC can reduce preoperative tests, consultations, surgery delays and cancellations. APEC with video-teaching has been purposed as a medium to provide comprehensive information about the process of anesthesia but it has not been practiced in small groups of patients. It is rational to assume that video-teaching in a small group patients can provide better information to patients to understand the process of anesthesia and in turn improve their satisfaction in anesthesia practice. This study was designed to evaluate the difference of satisfaction between patients who joined in small group video-teaching at APEC and patients who paid a traditional preoperative visit in the waiting area, using questionnaire for evaluation. METHODS: Totally, 237 eligible patients were included in the study in a space of two months. Patients were divided in two groups; 145 patients joined the small group video-teaching designated as study group and 92 patients who were paid traditional preoperative visit at the waiting area served as control. All patients were requested to fill a special questionnaire after postoperative visit entrusted to two non-medical persons. RESULTS: There were significantly higher scores of satisfaction in anesthesia inclusive of waiting time for surgery in the operation room, attitude towards anesthetic staffs during postoperative visit and management of complications in patients who were offered small group video-teaching in comparison with patients of traditional preoperative visit. CONCLUSIONS: The results indicated that APEC with group video-teaching could not only make patients more satisfied with process of anesthesia in elective surgery but also reduce the expenditure of hospitalization and anesthetic manpower.

Combination of topical EMLA with local injection of lidocaine: superior pain relief after Ferguson hemorrhoidectomy.

OBJECTIVE: To determine whether a combination of topical anesthetic (EMLA) and local injection with lidocaine is better than lidocaine alone for pain relief after Ferguson hemorrhoidectomy. METHODS: Sixty patients scheduled for hemorrhoidectomy were randomized into 2 groups: (1) control group (CG, n=30) received neomycin ointment (5 g), and (2) EMLA group (EG, n=30) received EMLA (5 g), both agents applied topically after surgery. Before the surgical incision was made, lidocaine (10 mL of a 1% solution) was locally injected into all 60 patients. After surgery, analgesics were provided when necessary. The visual analog scale score was recorded at 4 time points: (1) upon arrival in the postanesthesia room, (2) 2 hours after arriving in the postanesthesia room, (3) between 9 and 10 PM on the first postoperative evening, and (4) on the first postoperative morning. The frequency of meperidine requests, 1-time catheterizations for urinary retention, and patient satisfaction with postoperative pain management, were also recorded. RESULTS: The median visual analog scale scores and cumulative dosages of meperidine were significantly lower in the EG than the CG (P<0.05). Patient satisfaction with postoperative pain control was also significantly higher in the EG than the CG (P<0.01). No systemic complications occurred. DISCUSSION: EMLA is considered a breakthrough in cutaneous analgesia, capable of reducing pain in many cutaneous procedures. Because Ferguson hemorrhoidectomy has been performed for years with ongoing concerns over postoperative pain, we felt that using EMLA could lower postoperative pain intensity and the number of requests for additional medication.

Earlier cessation of desflurane supply in closed-circuit anesthesia reduces emergence time in patients undergoing breast surgery.

BACKGROUND: Minimizing the time of anesthesia emergence can facilitate faster patient turnover in the operating rooms of a busy surgery center. According to Lin's new concept of inhalation uptake, after turning off the vaporizer under close-circuit anesthesia (CCA) with a very low fresh gas flow rate, the concentration of desflurane decreases at a slow rate. The aim of this study was to determine if earlier cessation of desflurane supply would shorten the emergence time and at the same time register the changes of desflurane concentration in the circuit after turning off the vaporizer. METHODS: 30 patients were randomly assigned to two groups, i.e., the control group and the study group. In the control group, the desflurane supply was continued up till the end of the operation, while in the study group the desflurane supply was cut off prior to the suturing the skin. In the study group, data regarding the hemodynamic changes, time from turning off desflurane with high flow washout to wakefulness, and the inspired as well as the expired desflurane concentrations at the low-flow anesthetic phase were collected. The time required from high flow washout to emergence was recorded in all patients. Inter-group and intra-group data were analyzed with nonparametric 2-independent-samples Mann-Whitney test and 2 related-samples Wilcoxon signed ranks test, respectively. RESULTS: Under CCA with similar surgical duration, the patients in the study group emerged from anesthesia significantly faster than those in the control group (5.6 +/- 1.9 min versus 8.8 +/- 2.3 min; P < 0.05), without molestation of stable hemodynamic signs. At the low-flow wash-in stage, the inspired desflurane concentrations were significantly higher than the expired ones from 0 to 2nd min; no significant difference was noted from the 3rd to 6th min, but after which the expired concentrations were significantly higher. Desflurane concentrations decreased most noticeably during the first 5 min (0.35 +/- 0.14%), and then the decrease was moderating from 6th to 10th min (0.21 +/- 0.58%) and staggered from 11th to 15th (0.14 +/- 0.06%). The mean duration of low flow wash was 25.6 +/- 11.6 min. No patient reported awareness during surgery. CONCLUSIONS: Ceasing desflurane supply earlier in CCA (250 mL/min) significantly shortens emergence time without significant hemodynamic changes.

Nitric oxide scavenger carboxy-PTIO reduces infarct volume following permanent focal ischemia.

BACKGROUND: Nitric oxide (NO) has been shown to play a dual role as a neuroprotectant and a neurotoxin in cerebral ischemia. Free radical scavengers protect brain tissue from ischemic injury. Consequently, we examined the neuroprotective action of NO scavenger, 2-(4-carboxyphenyl)-4,4,5,5-tetramethylimidazoline-1-oxyl-3-oxide (carboxy-PTIO), in cerebral ischemia induced by permanent middle cerebral artery occlusion (MCAO) in rats and mice. METHODS: All experiments were performed in a randomized fashion. In the first series of experiments, adult Sprague-Dawley rats (n = 31) subjected to permanent MCAO were treated with carboxy-PTIO (0.3, 0.6 mg/kg) or vehicle (normal saline) injected intraperitoneally (IP) 1 hr before permanent MCAO. In the second series of experiments, adult C57BL/6NCrj mice (n = 49) were treated with carboxy-PTIO (0.6, 1.2 mg/kg) or vehicle saline 30 min following MCAO. Neurobehavioral scores were determined 22-24 hr following permanent MCAO and infarct volumes determined by quantitative image analysis of 2, 3, 5-triphenyltetrazolium (TTC)-stained brain sections. RESULTS: Pre-treatment with carboxy-PTIO at 0.6 mg/kg IP in rats significantly attenuated infarct volume (19.9 +/- 2.9%; n = 10) as compared with vehicle-treated controls (29.2 +/- 2.7%; n = 16), but not at 0.3 mg/kg (28.3 +/- 8.4%; n = 5). Post-MCAO treatment in mice with 0.6 mg/kg carboxy-PTIO (30.3 +/- 3.9%; n = 16) significantly attenuated infarct volume as compared with vehicle-treated controls (46.1 +/- 2.8%; n = 18). CONCLUSIONS: These data demonstrate that NO scavenger, carboxy-PTIO, provides significant ischemic neuroprotection when given as a pre-treatment as well as after the onset of permanent focal ischemia in two animal species.

Human opioid receptor A118G polymorphism affects intravenous patient-controlled analgesia morphine consumption after total abdominal hysterectomy.

BACKGROUND: Animal and human studies indicate that genetics may contribute to the variability of morphine efficacy. A recent report suggested that cancer patients homozygous for the 118G allele caused by the single nucleotide polymorphism at nucleotide position 118 in the mu-opioid receptor gene require higher doses of morphine to relieve pain. The purpose of the current study was to investigate whether this polymorphism contributes to the variability of morphine efficacy in women who undergo abdominal total hysterectomy. METHODS: After informed consent was obtained, 80 female patients (American Society of Anesthesiologist physical status I or II) scheduled to undergo elective total hysterectomy surgery were enrolled in this study. All patients received general anesthesia and were screened for A118G polymorphism by blood sample. Intravenous morphine patient-controlled analgesia was provided postoperatively for satisfactory analgesia. The authors recorded the morphine consumption doses and demand times. Pain at rest and side effects were measured with rating scales. RESULTS: Forty-three women were A118 homozygous, 19 were heterozygous, and 18 were G118 homozygous. Patients homozygous for G118 required more morphine doses (33 +/- 10 mg) to achieve adequate pain relief compared with patients homozygous for A118 (27 +/- 10 mg) in the first 24 h (P = 0.02). However, there was no statistically significant difference for morphine consumption at 48 h. CONCLUSION: Genetic variation of the mu-opioid receptor may contribute to interindividual differences in postoperative morphine consumption. In the future, identifying single nucleotide polymorphisms of patients may provide information to modulate the analgesic dosage of opioid for better pain control.

Paravertebral transcutaneous electrical nerve stimulation reduces movement during general anesthesia with isoflurane.

We evaluated paravertebral transcutaneous electrical nerve stimulation (TENS) as a means of enhancing anesthesia during hysterectomy. Patients were randomly assigned to experimental (n = 21) and control (n = 20) groups. Anesthesia with isoflurane was performed uniformly for all patients. Paravertebral (T6 and T7) TENS (50 mA, 15 Hz, continuously) was applied in the experimental group. After 15 min of isoflurane, a lower abdominal, skin-to-adipose-tissue incision was made. Seventeen of 21 patients in the experimental group showed no arm or leg movements during the incision, compared to 8 with 20 patients in the control group (P = 0.007). TENS deserves further exploration as an adjunct technique for general anesthesia.