The effect of fentanyl coadministration on sneezing during nasal local anesthetic injection for plastic surgery under propofol-based intravenous sedation: A retrospective case-controlled study.

BACKGROUND: Injection of local anesthetic for surgical procedures on the skin of the nose under intravenous sedation can provoke sneezing, which can be hazardous to the patient, surgeon, and other staff. Yet, there is little information on factors that influence sneezing under these circumstances. The aim of our study was to investigate the influence of adding fentanyl to propofol-based sedation on the incidence of sneezing during local anesthetic injection on the nose for plastic surgery. METHODS: A retrospective chart review was conducted on 32 patients who had undergone plastic surgery procedures on the nose under local anesthetic with intravenous sedation. RESULTS: Twenty-two patients received fentanyl in addition to propofol. Of these, only two patients sneezed (9.1 percent). In contrast, nine out of the 10 patients who did not receive fentanyl sneezed (90 percent). This included two patients who had received midazolam and propofol. CONCLUSIONS: These findings indicate that there was a high rate of sneezing during nasal local anesthetic injections performed under propofol-based intravenous sedation, unless the sedation was supplemented with fentanyl. We now recommend the coadministration of fentanyl during nasal local anesthetic injections under propofol-based sedation. Further studies are required to determine whether this observation is related to the depth of sedation alone, or whether the reduction in sneezing is related to the coadministration of an opioid. Further studies should also investigate potential side effects of coadministration of fentanyl or other opioids.

Acute Airway Obstruction from Megaoesophagus Secondary to Achalasia Evaluated with Flexible Bronchoscope.

A 94-year-old female presented to the emergency department with acute expiratory stridor. In the absence of an otorhinolaryngologist, an urgent laryngoscopy was performed using a flexible bronchoscope by an anaesthesiologist in the emergency department leading to a change in management. Subsequent radiographs confirmed severe tracheal compression from megaoesophagus secondary to achalasia as the cause of acute airway obstruction. Use of flexible bronchoscope as a diagnostic tool by an anaesthesiologist to evaluate a patient presenting with signs of acute airway obstruction may lead to a safer and more careful airway management planning. Suggestions are also made regarding establishment of emergency surgical airways when conventional approaches fail.

Pulmonary aspiration during procedural sedation for colonoscopy resulting from positional change managed without oral endotracheal intubation.

BACKGROUND: Pulmonary aspiration under anaesthesia is a feared complication. It is likely that the incidence of aspiration occurring during procedural sedation is underreported; although rare, fatalities do occur. The supine position increases the risk of pulmonary aspiration in gastrointestinal endoscopy during procedural sedation. Immediate oral endotracheal intubation has traditionally been the cornerstone of management for aspiration during anaesthesia; however, this may not be always beneficial when aspiration occurs during procedural sedation. To my knowledge, this is the first case report of aspiration pneumonitis resulting from surgical repositioning during colonoscopy under procedural sedation. CASE PRESENTATION: A 72-year-old female underwent elective outpatient diagnostic colonoscopy. Intravenous propofol infusion was commenced for the procedural sedation. A large amount of non-particulate vomitus was expelled from the oropharynx as the patient was repositioned from the left lateral to supine position. Oxygen saturation on pulse oximetry immediately dropped to below 90% during the event. The patient was managed successfully without oral endotracheal intubation. CONCLUSIONS: Anaesthesiologists need to be mindful of factors that raise the risk of aspiration during procedural sedation. Gastrointestinal endoscopy poses a higher risk of aspiration than other procedures, and positional change may be a precipitant. Aspiration that occurs during procedural sedation may be more safely managed by avoiding immediate oral endotracheal intubation.

Stigma and perception of psychological distress and depression in Australian-trained medical students: results from an inter-state medical school survey.

Stigmatisation towards depression has previously been reported amongst medical students from a variety of backgrounds. This study explored personal and perceived stigmas associated with depression, and their relationship with demographics, knowledge of depression, levels of personal stress and history of medical illness amongst Australian-trained medical students. A cross-sectional survey was undertaken amongst students enroled June-to-August 2009 across four Australian medical schools. In total, 1010 students completed the survey, a response rate of 29.6%. Approximately 25% of students reported a past history of depression. Higher stress (K-10 scores) was reported by females and those with a past history of depression. On a scale of 0-to-5, the mean (±S.D.) personal and perceived stigma depression scores were 1.83±1.49 and 4.05±1.42 respectively. In multivariate analysis, higher perceived stigma and K-10 scores, a past history of anxiety and Year 3 of medical school indicated higher personal stigma scores. Perceived stigma was positively associated with K-10 scores, personal stigma scores, and a Caucasian background. Our findings suggest a high level of personal and particularly perceived stigma associated with depression amongst medical students, especially those displaying higher levels of stress. Adequate support and screening for psychological stress may de-stigmatise depression and improve mental health amongst future Australian doctors.

Outcome of endovascular treatment of acute type B aortic dissection.

Complicated type B aortic dissection is a life-threatening condition. For the last decade, endovascular stent-graft placement has been increasingly used to treat this condition. We undertook a summary analysis of published studies reporting the outcome of stent-grafts to treat complicated type B dissection. Studies were identified from a literature search using the MEDLINE database, and included studies when 10 or more patients were reported and at least in-hospital mortality was presented. A total of 942 patients were included from 29 studies. All patients were reported to have complications requiring intervention (hypotension in 17%). In-hospital mortality was 9% and other major complications (ie, stroke, paraplegia, conversion to type A dissection, bowel infarction, major amputation) occurred in 8.1%. Long-term follow-up was limited to a mean of 20 months. During this time, reintervention was required in 10.4% and aortic rupture was reported in 0.8%. Endovascular treatment of complicated acute type B aortic dissection seems to provide favorable initial outcomes and would seem to be a great addition to the treatment options for this condition. Further study of long-term outcomes is required.