Face-to-face intubation using a lightwand in a patient with severe thoracolumbar kyphosis: a case report.

BACKGROUND: Severe deformity of the thoracolumbar spine may cause difficulty in airway management during induction of anesthesia. Therefore, special attention must be devoted to patient safety. CASE PRESENTATION: A 65-year-old male with severe thoracolumbar kyphosis was scheduled to undergo posterior spinal fusion under general anesthesia. Due to his inability to lie supine, conventional tracheal intubation under direct laryngoscopy was difficult. Alternatively, face-to-face tracheal intubation using a lightwand in the semi-recumbent position was performed. Intubation was successful on the first attempt without any complications. CONCLUSIONS: The face-to-face intubation technique using a lightwand is one of several alternative techniques for tracheal intubation in patients who cannot lie supine.

Age and gender are important considerations in choosing the sniffing position for laryngoscopic view.

AIMS: The sniffing position is considered to be the standard position for direct laryngoscopic viewing. This crossover study evaluated age and gender as variables in comparing the benefits of the sniffing position over simple head extension for laryngeal view during direct laryngoscopy. METHODS: Laryngoscopy with a curved blade was performed on 200 anesthetized adults (100 males, 100 females) presenting for routine elective surgery. Glottic visualization was assessed by using the percentage of glottic opening (POGO) score in both simple extension and sniffing positions without the aid of the assistant or external laryngeal manipulation. Each gender group was divided into a younger group (< 50 years) and an older group (≥ 50 years). POGO scores were compared between both positions within each group. RESULTS: Mean (SD) POGO scores increased significantly only in younger male patients from 43% (39%) in the head extension position to 76% (30%) in the sniffing position. CONCLUSION: The sniffing position seems to be advantageous for getting a better laryngeal view during laryngoscopy for tracheal intubation in adult male patients less than 50 years old.

Remifentanil prevents tourniquet-induced arterial pressure increase in elderly orthopedic patients under sevoflurane/N2O general anesthesia.

AIMS: Prolonged tourniquet inflation produces a hyperdynamic cardiovascular response. We investigated the effect of continuous remifentanil infusion on systemic arterial pressure, heart rate, and cardiac output changes during prolonged tourniquet use in elderly patients under sevoflurane/N(2)O general anesthesia. METHODS: Thirty female patients scheduled for knee replacement arthroplasty were infused with either remifentanil at a target organ concentration of 2.0 ng/mL (remifentanil group, n = 15) or saline (control group, n = 15) after induction of anesthesia. Anesthesia was maintained with sevoflurane and N(2)O. Heart rate (HR), systolic arterial pressure (SAP), diastolic arterial pressure (DAP), cardiac index (CI), total systemic vascular resistance index (TSVRI), BIS, end-tidal sevoflurane concentration (EtSEVO), and end-tidal carbon dioxide concentration (EtCO(2)) were measured during the study period. RESULTS: There were significant differences in mean HR, SAP, DAP, and EtSEVO over time between the groups (P = 0.047, P < 0.001, P = 0.017, and P < 0.001, respectively). There was a statistically significant time trend effect (P < 0.001) in HR, SAP, DAP, and CI between the groups, with a statistically significant time-group interaction between the two groups (P = 0.02, 0.007, 0.001, 0.01, respectively). CONCLUSION: The present study demonstrated that infusion with remifentanil prevented an increase in hemodynamic pressure during tourniquet inflation in elderly patients under sevoflurane/N(2)O general anesthesia.

An estimation of right- and left-sided central venous catheter insertion depth using measurement of surface landmarks along the course of central veins.

BACKGROUND: In this study we sought to determine whether the topographical measurement along the course of the central veins can estimate the approximate insertion depths of central venous catheters (CVC). METHODS: Two hundred central venous catheterizations were performed via the right and left internal jugular vein (IJV) or subclavian vein (SCV). The anterior approach, using the sternocleidomastoid muscle as a landmark, was used for IJV catheterization and the infraclavicular approach for SCV. Topographical measurement was performed by placing the catheter with its own curvature over the draped skin starting from the insertion point of the needle through the ipsilateral clavicular notch, and to the insertion point of the second right costal cartilage to the manubriosternal joint. The CVC was inserted and secured to a depth determined topographically. The distance between the CVC tip and the carina and the angle of the left-sided CVC tip to the vertical were measured on the postoperative chest radiograph. RESULTS: The mean (SD) tip position of 50 CVCs placed via the right IJV was 0.1 (1.1) cm above the carina; right SCV, 0.0 (0.9) cm; left IJV, 0.3 (1.0) cm above the carina, and left SCV, 0.2 (0.9) cm below the carina. CVC locations could be predicted with a margin of error between 2.2 cm below the carina and 2.3 cm above the carina in 95% of patients. There were steeper (≥ 40°) angles to the vertical in the left-sided CVCs whose tips were above the carina (17 out of 54) than below the carina (2 out of 46). CONCLUSIONS: The approximate insertion depth of a CVC can be estimated using measurement of surface landmarks along the pathway of central veins.

Psychometric characteristics of the Korean version of the Roland-Morris Disability Questionnaire.

The aims of this study were; 1) to develop the final version of the Korean Roland-Morris Disability Questionnaire (RDQ), and 2) to compare the responsiveness between the RDQ and the Oswestry Disability Index (ODI) scores in patients having low back pain. The psychometric properties of the final Korean RDQ were evaluated in 221 patients. Among them, 30 patients were reliability tested. Validity was evaluated using an 11-point numerical rating scale (NRS) and the Korean ODI. The receiver operating characteristic (ROC) curve analysis of the RDQ and the ODI was compared in 54 patients with lumbar zygapophyseal (facet) joint pain. There was a moderate relationship between the RDQ and NRS (r = 0.59, P < 0.01) and a strongly positive correlation between the RDQ and the ODI (r = 0.76, P < 0.001). The Korean RDQ with the higher area under the ROC curve showed a better overall responsive performance than did the ODI in patients with lumbar facet joint pain after medial branch radiofrequency neurotomy (P < 0.01). The results of the study present the final version of the Korean RDQ is valid for assessing functional status in a Korean population with chronic low back pain.

Membranous obstructive Candida tracheitis as a complication of endotracheal intubation and tracheostomy.

This report describes a rare case of acute life-threatening stridor that was due to membranous obstructive Candida tracheitis, and this condition occurred after long-term endotracheal intubation and tracheostomy. An obstructive membrane was found 2 cm above the carina by bronchofiberscopy. The removal of the membrane resulted in the complete relief of the airway obstruction.

Bedside prediction of airway length in adults and children.

BACKGROUND: Malpositioning of the endotracheal tube within the airway leads to serious complications such as endobronchial intubation. Prediction of the correct depth of an endotracheal tube is important and should be individualized. The manubriosternal joint (MSJ) is on the same horizontal plane with the tracheal carina. We compared the straight length from the upper incisor to the MSJ in the fully extended position (incisor-MSJ extension length) with the length from the upper incisor to the carina after intubation with a flexible fiberoptic bronchoscope through the endotracheal tube in the neutral position (incisor-carina neutral length). METHODS: One hundred adults and 50 children were studied. Induction of anesthesia was achieved with 1.5 mg/kg propofol and 0.6 mg/kg rocuronium IV. The incisor-MSJ extension length was measured after adequate mask ventilation. After intubation, the endotracheal tube was positioned properly at the upper incisor teeth, and the incisor-carina neutral length was measured with the fiberoptic bronchoscope at the carina. RESULTS: The correlation between the incisor-MSJ extension length and the incisor-carina neutral length is significant (P < 0.001) in both adults and children. A formula for the regression line in adults (children) can be obtained as the incisor-carina neutral length (cm) = 0.868 (1.009) x the incisor-MSJ extension length (cm) + 4.260 (0.468) with a high coefficient of determination; r(2) = 0.88 (0.98). CONCLUSIONS: The airway length from the upper incisor to the carina in the neutral position can be predicted by the straight length from the upper incisor to the MSJ in the fully extended position.

No supplemental muscle relaxants are required during propofol and remifentanil total intravenous anesthesia for laparoscopic pelvic surgery.

BACKGROUND: No administration of supplemental muscle relaxants may be beneficial to the recovery of the ambulatory laparoscopic surgery. For this study, we compared the cardiorespiratory factors during propofol and remifentanil anesthesia for laparoscopic pelvic surgery (LPS) with or without supplemental muscle relaxants. MATERIALS AND METHODS: In total, 56 healthy female patients scheduled to undergo laparoscopic pelvic surgeries were randomly assigned to two groups (A and B). Anesthesia was induced with lidocaine 30 mg, propofol target organ concentration 5.0 microg/mL, remifentanil 3.0 ng/mL, and rocuronium 0.6 mg/kg intravenously (i.v.). After tracheal intubation, anesthesia was maintained with 2.0-5.0 microg/mL of propofol and 1-4 ng/mL of remifentanil i.v. All the patients' lungs were mechanically ventilated in both groups and intermittent bolus doses of rocuronium (0.15 mg/kg i.v.) were administered in group A-however, not in group B. Heart rate (HR) and systolic arterial pressure (SAP), diastolic arterial pressure (DAP), end-tidal carbon-dioxide concentration (EtCO(2)), peak inspiratory pressure (PIP), expired minute ventilation (MV), intra-abdominal pressure (IAP), and temperature were measured during the pneumoperitoneum. RESULTS: There were no group differences in HR, SAP, DAP, EtCO(2), PIP, IAP, MV, PaO(2), PaCO(2), and temperature between groups A and B. CONCLUSIONS: No supplemental muscle relaxants are required during propofol and remifentanil total i.v. anesthesia for LPS.

Delayed preconditioning effect of isoflurane on spinal cord ischemia in rats.

Paraplegia is one of the most common complications following aortic aneurysmal surgery. This study was designed to determine if isoflurane-induced delayed preconditioning is mediated by nuclear factor kappaB (NF-kappaB) in the rat spinal cord. The animals were divided into four groups: the control group, the pyrrolidinedithio carbamate (PDTC, an NF-kappaB inhibitor)-treated group, the isoflurane-treated group, and the PDTC/isoflurane-treated group. In the PDTC-treated groups, 2% 100mg/kg PDTC was administered intraperitoneally at 1h before operation and at 24h and 48 h after reperfusion. The rats in the isoflurane-treated groups received 30 min inhalation of 2.8% isoflurane at 24h before spinal cord ischemia. Pretreatment with NF-kappaB inhibitor significantly reduced NF-kappaB expression and the number of intact motor neurons when compared to the control group. Preconditioning with isoflurane increased the number of normal motor neurons, whereas pretreatment with both PDTC and isoflurane significantly decreased them, compared to the isoflurane-treated group. Isoflurane-induced delayed preconditioning on spinal cord ischemia improved histopathological outcomes. This neuroprotective effect of isoflurane preconditioning on spinal cord ischemia is associated with NF-kappaB expression.

The comparison of insertion depth for orotracheal intubation between standard polyvinyl chloride tracheal tubes and straight reinforced tracheal tubes.

STUDY OBJECTIVE: To investigate whether these properties of reinforced tubes cause difference in insertion depth compared to standard polyvinyl chloride tracheal tubes. DESIGN: A randomized controlled trial. SETTING: Operation room. MATERIALS: Standard polyvinyl chloride tracheal tubes, reinforced tubes. INTERVENTIONS: Seventy-six adult patients undergoing surgery under general anesthesia were randomly allocated with standard tube (n=38) or reinforced tube (n=38) intubation. The endotracheal tube was fixed at the right canine with a predetermined insertion depth using the formula: endotracheal tube insertion length (cm)=0.1977 × [body height (cm)] - 12.7423. MEASUREMENTS: The distances between the tracheal tube tip and the carina using fiberoptic bronchoscope. MAIN RESULTS: The mean tip-to-carina distance of reinforced tube was about 1.2cm longer than that of standard tube (P<.001). CONCLUSIONS: The insertion depth of straight reinforced tracheal tubes can be shorter than that of standard polyvinyl chloride tracheal tubes due to different tube pathways in the upper airway.

Myoclonus-like involuntary movements following cesarean delivery epidural anesthesia.

Spinal myoclonus following neuraxial anesthesia is rare. This report describes a case of myoclonus-like involuntary movement that occurred during the recovery from epidural anesthesia for a cesarean delivery. The patient's symptom improved with the administration of benzodiazepine, and the patient recovered with no neurological sequelae. In conclusion, epidural anesthesia can cause spinal myoclonus, which can be treated with a benzodiazepine.

Time course of end-tidal desflurane concentration during delivery and elimination according to the type and location of filters in a semi-closed circuit system.

BACKGROUND: The aim of this study was to determine whether the end-tidal concentration of desflurane would be affected by a breathing circuit system filter attached at two different positions in anesthetic breathing circuit systems. METHODS: An artificial lung was ventilated under five different conditions. The first group was without any filter or desflurane (n = 5, sham), the second was with desflurane but without any filter (n = 10, control), the third group had a bacterial filter on the expiratory limb (n = 10), and the fourth and fifth groups had a viral/bacterial filter added on the expiratory limb (n = 10) or at the Y-piece of the breathing circuit (n = 10), respectively. In all groups except the sham, administration of 10% desflurane was performed for 5 minutes and then stopped for 5 minutes. RESULTS: The mean (SD) end-tidal concentration of desflurane for the groups described above peaked at 0 (0), 9.8 (0.1), 9.8 (0.1), 8.5 (0.1), and 6.7% (0.1) (P < 0.001), respectively. There was no difference in the desflurane concentrations and the expired tidal volume over time between the control and bacterial group, but there was a significant difference between the control and the fourth and fifth groups (P < 0.001). CONCLUSIONS: Filters can affect the expiratory desflurane concentration during anesthesia.

Alternative technique for changing from nasal to oral endotracheal tube for orthognathic and nasal surgery by using an airway exchange catheter: a case report.

A 28-year-old male patient with right maxillar, zygomatic arch, orbital wall, and nasal bone fractures had an orthognathic and nasal surgery. Naso-endotracheal intubation is the first choice during surgical correction of dentofacial deformities in an orthognathic surgery; however, its presence can interfere with concomitant surgical procedures on the nose. Traditionally, the naso-endotracheal tube will be removed and replaced with an oro-endotracheal tube. We changed the endotracheal tube from nasal to oral by using an airway exchange catheter.

Endotracheal tube intubation with the aid of a laryngeal mask airway, a fiberoptic bronchoscope, and a tube exchanger in a difficult airway patient: a case report.

A 28-year-old male patient with occipito-atlanto-axial instability underwent a cervical fusion with posterior technique. Post-operatively, the endotracheal tube (ETT) was removed, and the patient was transferred to the intensive care unit. After transfer, an upper airway obstruction developed and reintubations with a laryngoscope were attempted but failed. We inserted a #4 proseal laryngeal mask airway (LMA) and passed a 5.0 mm ETT through the LMA with the aid of a fiberoptic bronchoscope. We passed a tube exchanger through the 5.0 mm ETT and exchanged it with a 7.5 mm ETT. This method may be a useful alternative for difficult tracheal intubations.

The comparison of monitored anesthesia care with dexmedetomidine and spinal anesthesia during varicose vein surgery.

PURPOSE: The purpose of this study was to investigate the effectiveness and safety of monitored anesthesia care (MAC) using dexmedetomidine for its sedative and analgesic effect during varicose vein surgery. METHODS: Forty-two patients, who underwent varicose vein surgery, were divided into the MAC group (n = 20) or the spinal anesthesia group (n = 22) for randomized clinical trial. In the MAC group, dexmedetomidine was administered by a loading dose of 1 µg/kg for 10 minutes, followed by a maintenance infusion of 0.2-1.0 µg/kg/hr. Ketamine was used for intermittent injection. In the spinal anesthesia group, midazolam was used for sedation. Intraoperative vital signs, the number of adverse events, and the satisfaction of patients and surgeons concerning the anesthetic condition were compared between the two groups. RESULTS: Systolic blood pressure was intraoperatively significantly different over time between the two groups. The groups had statistical differences in the change in heart rate with regard to time. In the postanesthetic care unit, patients and surgeons in the MAC group had a lower satisfaction score, compared to patients and surgeons in the spinal anesthesia group. However, in the recovery period, patients had a positive perception concerning MAC anesthesia. In addition, without significant adverse events, the MAC group had a shorter time to possible ambulation, which indicated an early recovery. CONCLUSION: We believe that MAC using dexmedetomidine in combination with ketamine may be an alternative anesthetic technique for varicose vein surgery with regard to a patient's preference and medical condition.

Anesthetic management of a patient with Huntington's chorea -A case report-.

Huntington's chorea is a rare hereditary disorder of the nervous system. It is inherited as an autosomal dominant disorder and is characterized by progressive chorea, dementia and psychiatric disturbances. The best anesthetic technique is yet to be established for these patients with increased risk of aspiration due to involvement of pharyngeal muscles and an exaggerated response to sodium thiopental and succinylcholine. The primary goal in general anesthesia for these patients is to provide airway protection and a rapid and safe recovery. We report the anesthetic management of a 51-year-old patient with Huntington's chorea admitted for an emergency operation.

Isoflurane Induces Transient Anterograde Amnesia through Suppression of Brain-Derived Neurotrophic Factor in Hippocampus.

OBJECTIVE: Transient anterograde amnesia is occasionally observed in a number of conditions, including migraine, focal ischemia, venous flow abnormalities, and after general anesthesia. The inhalation anesthetic, isoflurane, is known to induce transient anterograde amnesia. We examined the involvement of brain-derived neurotrophic factor (BDNF) and its receptor tyrosine kinase B (TrkB) in the underlying mechanisms of the isoflurane-induced transient anterograde amnesia. METHODS: Adult male Sprague-Dawley rats were divided into three groups : the control group, the 10 minutes after recovery from isoflurane anesthesia group, and the 2 hours after recovery from isoflurane anesthesia group (n=8 in each group). The rats in the isoflurane-exposed groups were anesthetized with 1.2% isoflurane in 75% nitrous oxide and 25% oxygen for 2 hours in a Plexiglas anesthetizing chamber. Short-term memory was determined using the step-down avoidance task. BDNF and TrkB expressions in the hippocampus were evaluated by immunofluorescence staining and western blot analysis. RESULTS: Latency in the step-down avoidance task was decreased 10 minutes after recovery from isoflurane anesthesia, whereas it recovered to the control level 2 hours after isoflurane anesthesia. The expressions of BDNF and TrkB in the hippocampus were decreased immediately after isoflurane anesthesia but were increased 2 hours after isoflurane anesthesia. CONCLUSION: In this study, isoflurane anesthesia induced transient anterograde amnesia, and the expressions of BDNF and TrkB in the hippocampus might be involved in the underlying mechanisms of this transient anterograde amnesia.

Comparison of two topographical airway length measurements in adults.

BACKGROUND: A correct estimate of the tracheal tube insertion depth can prevent complications, including endobronchial intubation and vocal cord trauma. We evaluated a new topographical method for endotracheal tube positioning relative to the carina, using a well-known prior topographical method for comparison. METHODS: One hundred adult (male 50, female 50) patients were studied. The comparison topographic length (in cm) was measured by adding the distance between the right mouth corner and the right mandibular angle to the distance between the right mandibular angle and the center of the sternal manubrium. The new endotracheal tube insertion depth (in cm) was determined by adding the distance between the right mouth corner and the vocal cords, measured with the endotracheal tube itself, to the distance between the thyroid prominence and the manubriosternal joint, and then subtracting 4 cm. After intubation, the endotracheal tube was positioned properly at the right mouth corner and the endotracheal tube tip was evaluated using a fiberoptic bronchoscope at the carina. RESULTS: The distances from the tip of the endotracheal tube to the carina were not significantly different between the methods in the same gender. However, our method allowed endotracheal tube tip placement between 3 cm and 5 cm, above the carina more frequently than the prior method in males. CONCLUSIONS: The new topographical method can be used as a guide to positioning the endotracheal tubes.