The sniffing position facilitated easier light wand guided endotracheal intubation compared with the neutral position with chin-lift.

BACKGROUND: Traditionally, the patient's head is placed in a neutral position with a chin-lift to facilitate light wand guided endotracheal intubation. However, our study found that the sniffing position was more effective. In this study, we aimed to compare the two positions of light wand guided endotracheal intubation. METHODS: Sixty adult patients were included in the study, after obtaining informed consent, and were randomly assigned to one of two groups: a control group in a neutral position with a chin-lift (group C, n = 30) and a sniffing position group (group S, n = 30). In group C, the anesthesiologist inserted a light wand after lifting the patient's mandible using the thumb of their non-dominant hand inside the patient's mouth. In group S, a light wand was inserted after the patient's head was flexed with the neck extended. We assessed variables such as light-search time, number of intubation attempts, time to achieve intubation, and side effects including blood tinge on the endotracheal tube, hoarseness, sore throat, and anesthesiologist satisfaction. RESULTS: The light-search and intubation times were shorter in group S than in group C. The incidence of blood tinge on the endotracheal tube was higher in group C than in group S. Anesthesiologist satisfaction was higher in group S than in group C. CONCLUSIONS: The sniffing position was more effective in facilitating light wand guided endotracheal intubation than the neutral position with a chin-lift.

Comparison of two-lung and one-lung ventilation in bilateral video-assisted thoracoscopic extended thymectomy in myasthenia gravis: a retrospective study.

BACKGROUND: Myasthenia gravis (MG) is an autoimmune disease, and early thymectomy is recommended. Since the introduction of video-assisted thoracoscopic surgery, the safety and effectiveness of carbon dioxide insufflation in the thoracic cavity (capnothorax) has been controversial. This study aimed to compare the safety and effectiveness of ventilation methods in bilateral video-assisted thoracoscopic extended thymectomy (BVET) with capnothorax. METHODS: We retrospectively investigated the medical records of patients with MG who underwent BVET between August 2016 and January 2018. Patients were divided into two groups: group D (n = 26) for one-lung ventilation and group S (n = 28) for two-lung ventilation. We set nine anesthesia time points (T0-T8) and collected respiratory and hemodynamic variables, including arterial O2 index (PaO2/FiO2). RESULTS: SpO2 at T1-T3 and T8 was significantly lower in group D than in group S. The FiO2 in group S was lower than that in group D at all time points. The number of PaO2/FiO2 ≤ 300 and PaO2/FiO2 ≤ 200 events was significantly higher in group D than in group S. Hemodynamic variables were not significantly different between the two groups at any time point. The duration of surgery and anesthesia was shorter in group S than in group D. CONCLUSIONS: This retrospective study suggests that anesthesia using two-lung ventilation during BVET with capnothorax is a safe and effective method to improve lung oxygenation and reduce anesthesia time.

Safety Monitoring after the BNT162b2 COVID-19 Vaccine among Adults Aged 75 Years or Older.

BACKGROUND: Older adults are given high priority for coronavirus disease 2019 (COVID-19) vaccination; however, little is known about the safety of vaccines. This study was conducted to examine the safety of the COVID-19 vaccine for people who were ≥ 75 years of age, specifically those who first took two doses of the vaccine at the COVID-19 central vaccination center in South Korea. METHODS: Safety monitoring after the BNT162b2 vaccine was conducted in three ways for older adults who received the first dose of the vaccine at our center between April 5 and April 23, 2021. For immediate adverse reactions, every person who was vaccinated was observed for 15-30 minutes after injection at the center. For active surveillance, a telephone interview was conducted for stratified randomly sampled people after 7 days of each vaccination to enquire regarding types of adverse reactions they experienced, and its severity and duration. For passive surveillance, reported adverse event data were collected from the COVID-19 vaccine adverse event following immunization (AEFI) surveillance system-run by the Korea Disease Control and Prevention Agency (KDCA). The data were then reviewed. RESULTS: In total, 2,123 older adults received at least one vaccine dose during the study period. The frequency of acute adverse reactions that developed during the observed 15-30 minutes after injection was 8.5 cases per 1,000 doses. None of the reactions was assessed as acute allergic reactions to the vaccine and no cases required special treatment or drug administration. Overall, 638 people were followed up at least once by telephone interview 7 days post vaccination. The overall response rate was 82.3%. The rates of local reactions were 50.3% after the first dose and 45.2% after the second dose, and the rates of systemic reactions were 15.2% and 26.0%, respectively. During the study period, 23 medically attended adverse events (5.4 cases per 1,000 administered doses) were reported to the KDCA AEFI surveillance system. The most common symptoms of medically attended cases were nonspecific general weakness (26%) and dizziness (26%), followed by muscle pain (22%), headache (13%), fever (13%), and skin rash or urticaria (13%). Among them, there were five serious adverse events reported, which required hospitalization, including one death. However, most of them were not related to the vaccines. CONCLUSION: BNT162b2 vaccination was tolerable among adults who were ≥ 75 years of age.

Analgesic effect of ropivacaine with fentanyl in comparison with ropivacaine alone for continuous femoral nerve block after knee replacement arthroplasty: a prospective, randomized, double-blinded study.

BACKGROUND: The analgesic effect of perineural opioid in clinical practice are still controversial. This randomized controlled trial compared analgesic effect of ropivacaine with fentanyl or ropivacaine alone for continuous femoral nerve block following unilateral total knee arthroplasty. METHODS: Fourty patients of ASA PS Ⅰ or Ⅱ receiving total knee arthroplasty with spinal anesthesia were enlisted and randomly allocated into two groups. Group R; bolus injection of 0.375% ropivacaine, 30 ml and an infusion of 0.2% ropivacaine at 8 ml/h (n = 20). Group RF; 0.375% ropivacaine, 29 ml added with 50 µg of fentanyl as a bolus and an infusion of 0.2% ropivacaine mixed with 1 µg/ml of fentanyl at 8 ml/h (n = 20). Local anesthetic infusion via a femoral nerve catheter was started at the end of operation and continued for 48 h. Intravenous patient-controlled analgesia with hydromorphone (0.15 mg/ml, 0-1-10) were used for adjuvant analgesics. Position of catheter tip and contrast distribution, visual analogue scale of pain, hydromorphone consumption, side effects were recorded for 48 h after operation. Patient satisfaction for the pain control received were noted. RESULTS: The pain visual analogue scale, incidences of side effects and satisfaction were not different between the two groups (P > 0.05), but the hydromorphone usage at 48 h after operation were lower in the Group RF than in the Group R (P = 0.047). CONCLUSIONS: The analgesic effect of ropivacaine with fentanyl for continuous femoral nerve block after knee replacement arthroplasty was not superior to that of the ropivacaine alone.

Emergency exploratory laparotomy in a COVID-19 patient - A case report.

BACKGROUND: Surgeries in patients with coronavirus disease 2019 (COVID-19) put medical staff at a high risk of infection. We report the anesthetic management and infection control of a mechanically ventilated COVID-19 patient who underwent exploratory laparotomy for suspected duodenal ulcer perforation. CASE: A 73-year-old man, mechanically ventilated for confirmed COVID-19, showed clinical and radiographic signs of a perforated duodenal ulcer, and he was transferred under sedation and intubation to a negative-pressure operating room. The operating and assistant staff wore personal protective equipment. High-efficiency particulate absorbing filters were inserted into the expiratory circuits of the anesthesia machine and portable ventilator. No participating staff contracted COVID-19, although the patient later died due to pneumonia. CONCLUSIONS: This report can contribute to establishing clinical guidelines for the surgical management and operation room setting of COVID-19 patients.

Role of reactive oxygen species at reperfusion stage in isoflurane preconditioning-induced neuroprotection.

In this in vivo and in vitro study, we aimed to investigate whether isoflurane preconditioning-induced neuronal protection is mediated by reactive oxygen species (ROS) signaling at the reperfusion stage. In the in vivo study, Sprague-Dawley rats were subjected to middle cerebral artery occlusion (MCAO) and in the in vitro study, rat pheochromocytoma (PC12) cells were subjected to oxygen glucose deprivation (OGD). Isoflurane preconditioning was carried out prior to MCAO or OGD and the ROS scavenger, N-2-mercaptopropiopylglycine (2-MPG), was administered at the start of reperfusion. Infarct volume, neurological severity score, and TUNEL staining were analyzed in the in vivo study and cell viability, Bcl-2/Bax ratio, cleaved caspase 3/caspase 3 ratio, and ROS fluorescence intensity were measured in the in vitro study. In the in vivo study, infarct volume, neurological severity score, and TUNEL-positive cell count were significantly decreased with preconditioning but were abrogated by administration of 2-MPG. In the in vitro study, cell viability and Bcl-2/Bax ratio were significantly increased with preconditioning, and cleaved caspase-3/caspase-3 ratio and ROS fluorescence intensity were significantly decreased. Administration of 2-MPG for 10 min abrogated this preconditioning effect, but it did not abolish the protection when administered for 60 min of reperfusion. Isoflurane preconditioning-induced protection was abolished by ROS scavengers at the start of reperfusion, indicating that ROS signaling can mediate the isoflurane preconditioning effect, which suggests that the time window can be important.

Anaphylactic shock after sugammadex administration, induced by formation of a sugammadex-rocuronium complex -a case report.

BACKGROUND: Sugammadex is a reversal agent for non-depolarizing neuromuscular blockers and widely used worldwide on account of its rapid and effective reversal from neuromuscular blockade, despite its advantages, multiple cases of sugammadex-induced anaphylactic shock have been reported. CASE: A 42-year-old man developed anaphylactic shock in the postanesthesia care unit. Initially, sugammadex was suspected as the causative agent, but an intradermal skin test revealed negative results. A further skin test was performed with sugammadex-rocuronium complex that yielded positive results. CONCLUSIONS: Anesthesiologists and healthcare providers should be aware of the possibility of anaphylaxis from the sugammadex-rocuronium complex, as well as from sugammadex or rocuronium alone.

Exposure of isoflurane-treated cells to hyperoxia decreases cell viability and activates the mitochondrial apoptotic pathway.

Isoflurane has either neuroprotective or neurotoxic effects. High-dose oxygen is frequently used throughout the perioperative period. We hypothesized that hyperoxia will affect cell viability of rat pheochromocytoma (PC12) cells that were exposed to isoflurane and reactive oxygen species (ROS) may be involved. PC12 cells were exposed to 1.2% or 2.4% isoflurane for 6 or 24h respectively, and cell viability was evaluated. To investigate the effects of hyperoxia, PC12 cells were treated with 21%, 50%, or 95% oxygen and 2.4% isoflurane for 6h, and cell viability, TUNEL staining, ROS production, and expression of B-cell lymphoma 2 (BCL-2), BCL2-associated X protein (BAX), caspase-3 and beta-site APP cleaving enzyme (BACE) were measured. ROS involvement was evaluated using the ROS scavenger 2-mercaptopropiopylglycine (MPG). The viability of cells exposed to 2.4% isoflurane was lower than that of cells exposed to 1.2% isoflurane. Prolonged exposure (6h vs. 24h) to 2.4% isoflurane resulted in a profound reduction in cell viability. Treatment with 95% (but not 50%) oxygen enhanced the decrease in cell viability induced by 2.4% isoflurane alone. Levels of ROS, Bax, caspase-3 and BACE were increased, whereas expression of Bcl-2 was decreased, in cells treated with 95% oxygen plus 2.4% isoflurane compared with the control and 2.4% isoflurane plus air groups. MPG attenuated the effects of oxygen and isoflurane. In conclusion, isoflurane affects cell viability in a dose- and time-dependent manner. This effect is augmented by hyperoxia and may involve ROS, the mitochondrial apoptotic signaling pathway, and ß-amyloid protein.

Postoperative nausea and vomiting after endoscopic thyroidectomy: total intravenous vs. balanced anesthesia.

BACKGROUND: Endoscopic thyroidectomy was recently introduced and has been rapidly accepted by surgeons and patients. The present study was conducted to estimate and compare the incidences of postoperative nausea and vomiting (PONV) after endoscopic thyroidectomy using two different anesthetic methods: sevoflurane based balanced anesthesia; total intravenous anesthesia (TIVA). METHODS: Ninety nine female patients that were scheduled to undergo elective endoscopic thyroidectomy under general anesthesia were enrolled. These patients were randomly allocated to receive sevoflurane based balanced anesthesia (BA group) or propofol-remifentanil anesthesia (TIVA group). PONV was evaluated using a 4-point Likert scale, and pain using a visual analogue scale (VAS; range 0 to 100) for 0-2, 2-6, and 6-24 hours postoperatively. At 24 hours postoperatively, overall patient satisfaction regarding PONV and pain were recorded. RESULTS: The incidence of PONV was 14.6% in the TIVA group and 51.3% in the BA group. The incidence of nausea at 0-2 and 2-6 hours postoperatively was lower in the TIVA group than in the BA group (4.2% vs. 35.9%, 6.3% vs. 23.1%, respectively), but no between-group difference was observed at 6-24 hours postoperatively (8.3% vs. 5.1%). Antiemetic usage at 0-2 and 2-6 hours was lower in the TIVA than the BA group (4.2% vs. 38.5%, 6.3% vs. 23.1%), but no between-group difference was observed for 6-24 hours (6.3% vs. 7.7%). There were no differences in pain or in patient satisfaction. CONCLUSIONS: After endoscopic thyroidectomy, total intravenous anesthesia with propofol-remifentanil is associated with less PONV during the early postoperative period (0-6 hours) than sevoflurane based balanced anesthesia.

A comparison of the effects of preanesthetic administration of crystalloid versus colloid on intrathecal spread of isobaric spinal anesthetics and cerebrospinal fluid movement.

BACKGROUND: Movement of the cerebrospinal fluid (CSF) is one of the most important factors in determining the intrathecal spread of isobaric spinal anesthetics. Preanesthetic administration of either crystalloid or colloid immediately before spinal anesthesia (preload) may result in different CSF pulsatile movement because of their different physical properties. We examined whether preload of crystalloid versus colloid may have different effects on the intrathecal spread of isobaric spinal anesthetics as a result of their different CSF dynamics regarding its pulsatile movement. METHODS: In a clinical study of isobaric spinal anesthesia, patients were allocated into 1 of 2 groups according to preload with either crystalloid (n = 30) or colloid (n = 30) before spinal anesthesia with 0.5 isobaric tetracaine. The pulsatile movements of CSF at the L2-3 intervertebral space and midportion of the aqueduct of Sylvius were also examined by magnetic resonance images in healthy volunteers (n = 23) at 0, 30, and 60 minutes after administering either crystalloid or colloid. RESULTS: In the clinical study, the time to reach the peak sensory block level was delayed significantly in the crystalloid preload group (27.2 ± 17.8 minutes; P < 0.01) compared with the colloid preload group (13.9 ± 7.0 minutes). The median sensory block levels of the crystalloid preload group at 15 minutes (T10, P < 0.05) and 20 minutes (T9.5, P < 0.05) were significantly lower than those (T8, T7, respectively) of the colloid preload group. In the magnetic resonance imaging study, cranially directed CSF pulsatile movement decreased significantly at the L2-3 intervertebral intrathecal space at 30 minutes after crystalloid administration, but not after colloid administration. The CSF production rate significantly increased at 30 minutes (637 µL/min, P < 0.05) after crystalloid preload compared with the baseline measurement (448 µL/min), and then slightly decreased (609 µL/min) at 60 minutes. In the colloid preload group, the CSF production rate was not statistically significant compared with the baseline measurement (464, 512, and 542 µL/min at baseline, 30, and 60 minutes, respectively). CONCLUSIONS: Compared with a colloid preload, which may be comparable to the no-preload condition, crystalloid preload prolonged the time to reach the peak sensory block level in isobaric spinal anesthesia, which might have been caused by a significant decrease in CSF pulsatile movement. This attenuated CSF pulsatile movement in the crystalloid preload group might have resulted from significant increases of CSF production.

Improvement of sleep-related breathing disorder in patients with end-stage renal disease after kidney transplantation.

Sleep-related breathing disorder (SRBD) is a common symptom of end-stage renal disease (ESRD). The aim of this study was to determine whether kidney transplantation improves SRBD. Twenty-four patients with ESRD, who were admitted for kidney transplantation, underwent a sleep study using a portable ventilation effort recorder on the night before transplantation. Of these patients, 20 could repeat the overnight monitoring two wk after the transplantation. The median apnea-hypopnea index (AHI) of the 20 patients was 13.5 (range, 2-40), and significantly reduced to 4.5 (range, 0-20) after transplantation (p = 0.003). This reduction was most prominent in 12 patients with SRBD, for whom the median AHI fell from 22 (range, 10-40) to 6.5 (range, 1-20; p = 0.010). SRBD improvement, defined as an AHI equal to or >50% and/or reduced to <10/h, was observed in eight of the 12 apneic patients. These results suggest that kidney transplantation may immediately improve SRBD in patients with ESRD. However, conclusions from this study should be taken with caution because of the limitations of our method, specifically the use of a portable recorder and a small number of patients.

Comparison of the effectiveness of lidocaine and salbutamol on coughing provoked by intravenous remifentanil during anesthesia induction.

BACKGROUND: Coughing is a side effect of opioids that is rarely studied. Here, we evaluated the incidence of remifentanil induced coughing during anesthesia induction in an attempt to identify its risk factors and to examine the preventive effects of lidocaine and salbutamol. METHODS: A total of 237 patients scheduled to undergo general anesthesia were allocated randomly into three groups. Group C received no medication, while Group L received 2% lidocaine at 0.5 mg/kg intravenously 1 minute prior to remifentanil infusion and Group S inhaled one metered aerosol puff of salbutamol 15 minutes prior to entering the operating room. Remifentanil was infused at 5 ng/ml by target controlled infusion and coughing was measured for five minutes and graded as none, mild, moderate, or severe based on the number of coughs. RESULTS: The incidences of coughing were 30.4%, 25.3%, and 35.4% in Groups C, L, and S, respectively. The incidences, onset times, and severity of coughing did not differ significantly among groups. In addition, multivariate analysis showed that non-smoking and a lower body weight were risk factors of remifentanil-induced coughing (odds ratio, 8.13; P = 0.024, 1.11, and 0.004, respectively). CONCLUSIONS: The incidence of remifentanil-induced coughing was 30%. A total of 0.5 mg/kg lidocaine and 1 metered aerosol puff of salbutamol did not prevent coughing. Non-smoking and low body weight were found to be risk factors of remifentanil-induced coughing.

Transient bilateral vocal cord paralysis after endotracheal intubation with double-lumen tube -A case report-.

Vocal cord paralysis is one of the most serious anesthetic complications related to endotracheal intubation. The practitioner should take extreme care, as bilateral vocal cord paralysis can obstruct the airway and lead to disastrous respiratory problems. There have been many papers on bilateral vocal cord paralysis after neck surgery, but reports on such a condition after lung surgery are very rare. We report a case of bilateral vocal cord paralysis detected after removal of a double-lumen endotracheal tube in a 67-year-old patient who underwent wedge resection by video-assisted thoracoscopic surgery. We also note that he recovered spontaneously without complications within a day.

The comparison of complications on the endovascular and surgical treatment in elderly cerebral aneurysm patients.

BACKGROUND: The aim of this study was to compare intraoperative and postoperative complications and clinical outcome of endovascular coiling (EVT) with neurosurgical clipping (NST) under general anesthesia in the cerebral aneurysm patients older than 60 years. METHODS: We retrospectively reviewed the charts, operative reports of patients who underwent EVT or NST at our hospital between January 2006 and August 2008. A total of 181 patients (EVT = 78, NST = 103) were included in this study. RESULTS: The rate of intraoperative event was higher in EVT than in NST but postoperative complication and Glasgow outcome scale (GOS) at 6 months did not show statically significance in both groups. Preoperative aneurysm rupture, age and the World Federation of Neurological Surgeons grade (WFNS) were the influencing factors for outcome in both groups. Anesthetic agents, body temperature and vasoactive drugs were significantly different between the two groups but the effects of these on the outcome of patients were insignificant. CONCLUSIONS: In EVT and NST, the variables related to the postoperative complications were preoperative aneurysm rupture, age and WFNS. When the elderly patients get these procedures, more close care should be considered postoperatively.