Simplified equation for determining proper depth of peripherally inserted central catheter in relation to anatomical landmarks.

BACKGROUND: The aim of this study was to develop a formula guiding the peripherally inserted central catheter (PICC) tip placement based on anatomical landmarks such as the upper arm, clavicle, and sternum as well as the patient's height, weight, and body mass index. METHODS: Fifty-five patients who were scheduled to have PICCs were included in the study. We measured four distances along the passage of the PICC, which were as follows; the tip of the third finger to the middle of the elbow crease (Distance A), the middle of the elbow crease to the acromion process (Distance B), the acromion process to the sternal head of the clavicle (Distance C), and the sternal head of the clavicle to the end of the xiphoid process (Distance D). The lengths from the elbow creases to their carina bifurcations as determined by fluoroscopy during PICC insertions were recorded and used as reference. RESULTS: The formula for determining PICC depth based on the four distances was determined by regression analysis. The optimal formula was determined to be 25.3 + 0.5 × (Distance C) + 0.6 × (Distance D) which yielded an R2 value of 0.3. CONCLUSIONS: The formula proposed for proper depth of the adult, 25.0 + 0.5 × (clavicle length) + 0.6 × (sternum length) for PICC insertion can be used to place the tip at the carina bifurcation level. The distance from elbow crease to catheter insertion point should be added to the length generated by this formula.

The efficacy of elastomeric patient-control module when connected to a balloon pump for postoperative epidural analgesia: A randomized, noninferiority trial.

When considering the principles of a pain control strategy by patients, reliable administration of additional bolus doses is important for providing the adequate analgesia and improving patient satisfaction. We compared the efficacy of elastomeric patient-control module (PCM) with conventional PCM providing epidural analgesia postoperatively.A noninferiority comparison was used. Eighty-six patients scheduled for open upper abdominal surgery were randomized to use either an elastomeric or conventional PCM connected to balloon pump. After successful epidural catheter insertion at T6-8 level, fentanyl (15-20 µg/kg) in 0.3% ropivacaine 100 mL was administered at basal rate 2 mL/h with bolus 2 mL and lock-out time 15 minutes. The primary outcome was the verbal numerical rating score for pain.The 95% confidence intervals for differences in pain scores during the first 48 hours postoperatively were <1, indicating noninferiority of the elastomeric PCM. The duration of pump reservoir exhaustion was shorter for the elastomeric PCM (mean [SD], 33 hours [8 hours] vs 40 hours [8 hours], P = 0.0003). There were no differences in the frequency of PCM use, additional analgesics, or adverse events between groups.The elastomeric PCM was as effective as conventional PCM with and exhibited a similar safety profile.

Erratum: Heart rate variability as a predictor of hypotension after spinal anesthesia in hypertensive patients.

[This corrects the article on p. 317 in vol. 65, PMID: 24228144.].

Bispectral index monitoring during anesthesiologist-directed propofol and remifentanil sedation for endoscopic submucosal dissection: a prospective randomized controlled trial.

PURPOSE: Endoscopic submucosal dissection (ESD) is a technically difficult and lengthy procedure requiring optimal depth of sedation. The bispectral index (BIS) monitor is a non-invasive tool that objectively evaluates the depth of sedation. The purpose of this prospective randomized controlled trial was to evaluate whether BIS guided sedation with propofol and remifentanil could reduce the number of patients requiring rescue propofol, and thus reduce the incidence of sedation- and/or procedure-related complications. MATERIALS AND METHODS: A total of 180 patients who underwent the ESD procedure for gastric adenoma or early gastric cancer were randomized to two groups. The control group (n=90) was monitored by the Modified Observer's Assessment of Alertness and Sedation scale and the BIS group (n=90) was monitored using BIS. The total doses of propofol and remifentanil, the need for rescue propofol, and the rates of complications were recorded. RESULTS: The number of patients who needed rescue propofol during the procedure was significantly higher in the control group than the BIS group (47.8% vs. 30.0%, p=0.014). There were no significant differences in the incidence of sedation- and/or procedure-related complications. CONCLUSION: BIS-guided propofol infusion combined with remifentanil reduced the number of patients requiring rescue propofol in ESD procedures. However, this finding did not lead to clinical benefits and thus BIS monitoring is of limited use during anesthesiologist-directed sedation.

Finding the 'ideal' regimen for fentanyl-based intravenous patient-controlled analgesia: how to give and what to mix?

PURPOSE: This analysis was done to investigate the optimal regimen for fentanyl-based intravenous patient-controlled analgesia (IV-PCA) by finding a safe and effective background infusion rate and assessing the effect of adding adjuvant drugs to the PCA regimen. MATERIALS AND METHODS: Background infusion rate of fentanyl, type of adjuvant analgesic and/or antiemetic that was added to the IV-PCA, and patients that required rescue analgesics and/or antiemetics were retrospectively reviewed in 1827 patients who underwent laparoscopic abdominal surgery at a single tertiary hospital. RESULTS: Upon multivariate analysis, lower background infusion rates, younger age, and IV-PCA without adjuvant analgesics were identified as independent risk factors of rescue analgesic administration. Higher background infusion rates, female gender, and IV-PCA without additional 5HT3 receptor blockers were identified as risk factors of rescue antiemetics administration. A background infusion rate of 0.38 µg/kg/hr [area under the curve (AUC) 0.638] or lower required rescue analgesics in general, whereas, addition of adjuvant analgesics decreased the rate to 0.37 µg/kg/hr (AUC 0.712) or lower. A background infusion rate of 0.36 µg/kg/hr (AUC 0.638) or higher was found to require rescue antiemetics in general, whereas, mixing antiemetics with IV-PCA increased the rate to 0.37 µg/kg/hr (AUC 0.651) or higher. CONCLUSION: Background infusion rates of fentanyl between 0.12 and 0.67 µg/kg/hr may safely be used without any serious side effects for IV-PCA. In order to approach the most reasonable background infusion rate for effective analgesia without increasing postoperative nausea and vomiting, adding an adjuvant analgesic and an antiemetic should always be considered.

Comparison of 2 cuff inflation methods of laryngeal mask airway Classic for safe use without cuff manometer in adults.

PURPOSE: This single-center, prospective, randomized, double-blind, 2-arm, parallel group comparison trial was performed to establish whether the adult-sized laryngeal mask airway (LMA) Classic (The Laryngeal Mask Company Ltd, Henley-on-Thames, UK) could be used safely without any consideration of cuff hyperinflation when a cuff of the LMA Classic was inflated using half the maximum inflation volume or the resting volume before insertion of device. BASIC PROCEDURES: Eighty patients aged 20 to 70 years scheduled for general anesthesia using the LMA Classic were included. Before insertion, the cuff was partially filled with half the maximum inflation volume in the half volume group or the resting volume created by opening the pilot balloon valve to equalize with atmospheric pressure in the resting volume group. Several parameters regarding insertion, intracuff pressure, airway leak pressure, and leakage volume/fraction were collected after LMA insertion. MAJOR FINDINGS: The LMA Classic with a partially inflated cuff was successfully inserted in all enrolled patients. Both groups had the same success rate of 95% at the first insertion attempt. The half volume group had a lower mean intracuff pressure compared with the resting volume group (54.5 ± 16.1 cm H2O vs 61.8 ± 16.1 cm H2O; P = .047). There was no difference in airway leak pressure or leakage volume/fraction between the 2 groups under mechanical ventilation. CONCLUSIONS: The partially inflated cuff method using half the maximum recommended inflation volume or the resting volume is feasible with the adult-sized LMA Classic, resulting in a high success rate of insertion and adequate range of intracuff pressures.

Heart rate variability as a predictor of hypotension after spinal anesthesia in hypertensive patients.

BACKGROUND: Hypotension is a common phenomenon after spinal anesthesia in hypertensive patients. We investigated whether heart rate variability could predict the occurrence of hypotension after spinal anesthesia in hypertensive patients. METHODS: Forty-one patients undergoing spinal anesthesia were included. Heart rate variability was measured at five different time points such as before fluid loading (baseline), after fluid loading as well as 5 min, 15 min and 30 min after spinal anesthesia. Fluid loading was performed using 5 ml/kg of a crystalloid solution. Baseline total power and low to high frequency ratio (LF/HF) in predicting hypotension after spinal anesthesia were analyzed by calculating the area under the receiver operating characteristic curves (AUC). RESULTS: Moderate hypotension, defined as a decrease of mean arterial pressure to below 20-30% of the baseline, occurred in 13 patients and severe hypotension, defined as a decrease of mean arterial pressure greater than 30% below the baseline, occurred in 7 patients. LF/HF ratiosand total powers did not significantly change after spinal anesthesia. AUCs of LF/HF ratio for predicting moderate hypotension was 0.685 (P = 0.074), severe hypotension was 0.579 (P = 0.560) and moderate or severe hypotension was 0.652 (P = 0.101), respectively. AUCs of total power for predicting moderate hypotension was 0.571 (P = 0.490), severe hypotension was 0.672 (P = 0.351) and moderate or severe hypotension was 0.509 (P = 0.924), respectively. CONCLUSIONS: Heart rate variability is not a reliable predictor of hypotension after spinal block in hypertensive patients whose sympathetic activity is already depressed.

Risk assessment of postoperative nausea and vomiting in the intravenous patient-controlled analgesia environment: predictive values of the Apfel's simplified risk score for identification of high-risk patients.

PURPOSE: Opioid-based intravenous patient-controlled analgesia (IV PCA) is popular method of postoperative pain control, but many patients suffer from IV PCA-related postoperative nausea and vomiting (PONV). In this retrospective observational study, we have determined independent predictors of IV PCA-related PONV and predictive values of the Apfel's simplified risk score in pursuance of identifying high-risk patients. MATERIALS AND METHODS: We analyzed 7000 patients who received IV PCA with background infusion after elective surgery. Patients who maintained IV PCA for a postoperative period of 48 hr (completion group, n=6128) were compared with those who have discontinued IV PCA within 48 hr of surgery due to intractable PONV (cessation group, n=872). Patients, anesthetics, and surgical factors known for predicting PONV were evaluated by logistic regression analysis to identify independent predictors of IV PCA related intractable PONV. RESULTS: In a stepwise multivariate analysis, weight, background infusion dose of fentanyl, addition of ketolorac to PCA, duration of anesthesia, general anesthesia, head and neck surgery, and Apfel's simplified risk score were revealed as independent risk factors for intractable PONV followed by the cessation of IV PCA. In addition, Apfel's simplified risk score, which demonstrated the highest odds ratio among the predictors, was strongly correlated with the cessation rate of IV PCA. CONCLUSION: Multimodal prophylactic antiemetic strategies and dose reduction of opioids may be considered as strategies for the prevention of PONV with the use of IV PCA, especially in patients with high Apfel's simplified risk scores.

Patient-controlled Epidural Analgesia with Ropivacaine and Fentanyl: Experience with 2,276 Surgical Patients.

BACKGROUND: Good postoperative pain control is an important part of adequate postoperative care. Patient-controlled epidural analgesia (PCEA) provided better postoperative analgesia compared to other conventional analgesic methods, but several risks have been observed as well. We therefore surveyed the efficacy and safety of PCEA in this retrospective observational study. METHODS: We analyzed collected data on 2,276 elective surgical patients who received PCEA with ropivacaine and fentanyl. Patients were assessed by a PCA service team in the post-anesthesia care unit (PACU), at 1-6 h, 6-24 h, and 24-48 h postoperatively for adequate pain control. The presence of PCEA-related adverse events was also assessed. RESULTS: Numerical pain score (median [interquartile range]) were 3 [1-4], 5 [4-7], 4 [3-5], and 3 [3-5] in the PACU, at 1-6 h, 6-24 h, and 24-48 h postoperatively. Median pain scores in patients underwent major abdominal or thoracic surgery were higher than other surgical procedure in the PACU, at 1-6 h after surgery. Nausea and vomiting (20%) and numbness and motor weakness (15%) were revealed as major PCEA-related adverse events during the postoperative 48 h period. There were 329 patients (14%) for whom PCEA was ceased within 48 h following surgery. CONCLUSIONS: Our data suggest that the use of PCEA provides proper analgesia in the postoperative 48 h period after a wide variety of surgical procedures and that is associated with few serious complications. However, more careful pain management and sustainable PCEA monitoring considering the type of surgical procedure undergone is needed in patients with PCEA.

Anesthetic experience of a patient with relapsing polychondritis -A case report-.

Relapsing polychondritis is a rare disease characterized by progressive inflammation and destruction of cartilaginous structures such as ears, nose, and tracheolaryngeal structures. As a result, tracheolaryngeal involvement makes anesthetic management a challenge. Anesthetic management of a patient with relapsing polychondritis may encounter airway problems caused by severe tracheal stenosis. We present the case of a 60-year-old woman with relapsing polychondritis who underwent wedge resection of the stomach under epidural analgesia. Thoracic epidural blockade of the T4-10 dermatome was achieved by epidural injection of 7 ml of 0.75% ropivacaine and 50 µg of fentanyl. The patient was tolerable during the operation. We suggest that epidural analgesia may be an alternative to general anesthesia for patients with relapsing polychondritis undergoing upper abdominal surgery.

Comparison of the trapezius squeezing test and jaw thrust as indicators for laryngeal mask airway insertion in adults.

BACKGROUND: The purpose of this study was to compare the effectiveness of the trapezius squeezing test with that of the jaw thrust maneuver as clinical indicators of adequate conditions for laryngeal mask airway (LMA) insertion in adults under sevoflurane anesthesia. METHODS: One hundred adult patients of ASA physical status 1 or 2 undergoing minor surgical procedures were randomly allocated to the T (trapezius squeezing, n = 50) group or the J (jaw thrust, n = 50) group. The LMA was inserted immediately after the loss of response to trapezius squeezing or jaw thrust. Successful and unsuccessful attempts were recorded. An unsuccessful attempt was defined as the occurrence of coughing, gagging, gross purposeful movements, breath-holding, laryngospasm, or an SpO(2) < 90% during LMA insertion. Insertion time, end-tidal sevoflurane concentration, mean arterial pressure, and heart rate were recorded. RESULTS: The incidence of successful attempts was significantly higher in the T than in the J group (48/50 vs. 36/50, respectively). CONCLUSIONS: The trapezius squeezing test is a superior indicator of an adequate condition for LMA insertion compared to the jaw thrust maneuver in adults under sevoflurane anesthesia.

The effect of postoperative pain on postoperative blood loss after sequential bilateral total knee arthroplasty.

BACKGROUND: Bilateral total knee arthroplasty is generally accompanied by a significant amount of blood loss. We investigated the relationship between the intensity of pain and the amount of blood loss in the early postoperative period after bilateral total knee arthroplasty. METHODS: A prospective study was conducted on 91 patients who underwent elective sequential bilateral total knee arthroplasty for osteoarthritis. All patients received combined spinal and epidural anesthesia. Patients were divided into three groups based on their scores on the verbal numerical rating scale (VNRS) for pain at 6 hours postoperatively. The VNRS was classified as follows; mild pain (n = 34, VNRS score 0-4), moderate pain (n = 24, VNRS score 5-6), and severe pain (n = 33, VNRS score 7-10). We compared the mean arterial pressures and the amount of blood loss during the first 24 postoperative hours in the three groups. Factors influencing postoperative blood loss were analyzed. RESULTS: Postoperative mean arterial pressures and blood loss were not different among the groups. Of the factors examined, the amount of postoperative blood loss was only dependent on the amount of intraoperative blood loss (P = 0.001). CONCLUSIONS: Early postoperative pain has no effect on postoperative blood pressure and the amount of blood loss after bilateral total knee arthroplasty. For postoperative blood loss, intraoperative blood loss is the main determinant.

Effect of caudal block on sevoflurane requirement for lower limb surgery in children with cerebral palsy.

BACKGROUND: Caudal block is a widely used technique for providing perioperative pain management in children. In this randomized double-blinded study, we evaluated the effects of preoperative caudal block on sevoflurane requirements in children with cerebral palsy (CP) undergoing lower limb surgery while bispectral index (BIS) values were maintained between 45 and 55. METHODS: 52 children undergoing Achilles-tendon lengthening were randomized to receive combined general-caudal anesthesia (caudal group, n = 27) or general anesthesia alone (control group, n = 25). Caudal block was performed with a single dose of 0.7 ml·kg(-1) of 1.0% lidocaine containing epinephrine at 5 µg·ml(-1). The control group received no preoperative caudal block. The endtidal sevoflurane concentrations (ET(sev)) were adjusted every minute to maintain the BIS values between 45 and 55. RESULTS: The ET(sev) required to maintain the BIS values were not significantly different between the control and caudal groups after induction of anesthesia [2.1 (0.2) vs 2.2 (0.4); P = 0.773]. However, significantly higher ET(sev) was observed in the control group before surgical incision [2.0 (0.2) vs 1.8 (0.3); P = 0.013] and during the first 20 min after surgical incision [2.2 (0.3) vs 1.4 (0.3); P < 0.001]. There was no significant difference in BIS values between the control and caudal groups throughout the study period (P > 0.05). In the caudal group, the caudal block was successful in 25 of 27 (92.6%) patients. CONCLUSIONS: Caudal block effectively reduced sevoflurane requirements by 36% compared to general anesthesia alone in children with CP undergoing lower limb surgery while BIS values were maintained between 45 and 55.

The effect of phenylephrine on the onset time of rocuronium.

BACKGROUND: Several studies have demonstrated that ephedrine shortens the onset time of muscle relaxants, and it does so probably by increasing the cardiac output. However, elevation of the systemic blood pressure through α adrenergic stimulation via ephedrine may affect the onset of muscle relaxants during the induction of anesthesia. We investigated the effect of phenylephrine, which is a selective α-1 agonist, on the onset time of rocuronium and the intubating conditions in adults after the administration of propofol. METHODS: Sixty-four patients were randomly assigned to two groups. Phenylephrine (0.9 µg/kg) (P group) or the same volume of saline (S group) was injected before rocuronium (0.6 mg/kg) administration. Anesthesia was induced with fentanyl 2 µg/kg and propofol 2 mg/kg. The onset time was defined as the time from the end of rocuronium injection to the time when a single twitch height gets to 0% or the minimum level. A well-trained anesthesiologist who was 'blinded' to the treatment groups evaluated the intubating conditions. The mean arterial pressure and heart rate were recorded before induction, before intubation, immediately after intubation and 1 minute and 2 minutes after intubation. RESULTS: The onset time was 84 ± 18 sec in the P-group and 72 ± 14 sec in the S-group. There was no difference of the intubating conditions, the mean arterial pressure and the heart rate between the two groups. CONCLUSIONS: A small dose of phenylephrine, which has a limited effect on blood pressure, delayed the onset time of rocuronium after the administration of propofol, and the vasoconstriction effect of phenylephrine may affect the prolongation of the rocuronium onset time at the induction of anesthesia with using propofol.

Subarachnoid and intraventricular hemorrhage due to ruptured aneurysm after combined spinal-epidural anesthesia.

A patient received combined spinal-epidural anesthesia for a scheduled total knee arthroplasty. After an injection of spinal anesthetic and ephedrine due to a decrease in blood pressure, the patient developed a severe headache. The patient did not respond to verbal command at the completion of the operation. A brain CT scan revealed massive subarachnoid and intraventricular hemorrhages, and a CT angiogram showed a ruptured aneurysm. Severe headaches should not be overlooked in an uncontrolled hypertensive patient during spinal anesthesia because it may imply an intracranial and intraventricular hemorrhage due to the rupture of a hidden aneurysm.

A randomized, clinical trial of frozen versus standard nasogastric tube placement.

BACKGROUND: Insertion of a nasogastric tube (NGT) in an anesthetized, paralyzed, and intubated patient is difficult, and many methods have been proposed to aid in the procedure. We present a simple insertion technique. METHODS: A silicone NGT was made rigid by filling it with distilled water and freezing it. Patients were randomized into either the control or the frozen group, and an NGT was inserted after intubation. RESULTS: A total of 100 patients (50 in each group) were included in this study. The success rate increased significantly by making the tube more rigid (control:frozen = 58%:88%; p = 0.001). There was no difference between groups in the incidence of nasal bleeding. CONCLUSIONS: A simple method of freezing an NGT with distilled water increased the success rate of insertion for intubated patients.

Spinal anesthesia with isobaric tetracaine in patients with previous lumbar spinal surgery.

PURPOSE: Previous lumbar spinal surgery (PLSS) is not currently considered as a contraindication for regional anesthesia. However, there are still problems that make spinal anesthesia more difficult with a possibility of worsening the patient's back pain. Spinal anesthesia using combined spinal-epidural anesthesia (CSEA) in elderly patients with or without PLSS was investigated and the anesthetic characteristics, success rates, and possible complications were evaluated. MATERIALS AND METHODS: Fifty patients without PLSS (Control group) and 45 patients with PLSS (PLSS group) who were scheduled for total knee arthroplasty were studied prospectively. A CSEA was performed with patients in the left lateral position, and 10 mg of 0.5% isobaric tetracaine was injected through a 27 G spinal needle. An epidural catheter was then inserted for patient controlled analgesia. Successful spinal anesthesia was defined as adequate sensory block level more than T12. The number of skin punctures and the onset time were recorded, and maximal sensory block level (MSBL), time to 2-segment regression, success rate and complications were observed. RESULTS: The success rate of CSEA in Control group and PLSS group was 98.0%, and 93.3%, respectively. The median MSBL in PLSS group was higher than Control group [T4 (T2-L1) vs. T6 (T3-T12)] (p < 0.001). There was a significant difference in the number of patients who required ephedrine for the treatment of hypotension in PLSS group (p = 0.028). CONCLUSION: The success rate of CSEA in patients with PLSS was 93.3%, and patients experienced no significant neurological complications. The MSBL can be higher in PLSS group than Control group.

Spinal anesthesia with 3.75 mg of 0.25% hyperbaric bupivacaine for diabetic foot surgery.

BACKGROUND: Spinal anesthesia in the sitting position with low-dose local anesthetics usually provides satisfactory anesthesia for diabetic foot surgery because most operations do not require tourniquet application. This study was designed to investigate the influence of different sitting periods after subarachnoid injection of low dose bupivacaine on the spread of analgesia. METHODS: In this randomized, controlled clinical trial, 60 patients undergoing diabetic foot surgery under spinal anesthesia without a tourniquet were randomized to three groups. Patients remained sitting for 2 (Group D2, n = 20), 5 (Group D5, n = 20), or 10 (Group D10, n = 20) min after the completion of subarachnoid administration of 3.75 mg of 0.25% hyperbaric bupivacaine solution. They were then placed in the supine position. Analgesia levels were assessed bilaterally using pinpricks. Blood pressure and heart rate were also recorded. RESULTS: The maximal sensory block level [median (range)] was higher in Group D2 [L3 (L2-L3)] compared with Group D10 [L4 (L3-L4)] (P = 0.002). The highest sensory block levels were T12, T11, and L2 in Group D2, 5 and 10, respectively. There were no hemodynamic differences among the three groups and none of the patients showed hemodynamic instability except for one patient in Group D10. CONCLUSIONS: Although spinal anesthesia using a minimal dose of 0.25% hyperbaric bupivacaine provides adequate anesthesia for diabetic foot surgery without profound hypotension, regardless of the time spent in the sitting position, maintaining the position for 10 min required to confine the sensory blockade on the lower level.

Anesthetic experience for orthopedic surgery on a patient with Glanzmann's thrombasthenia refractory to platelet transfusion: A case report.

Glanzmann's thrombasthenia is an autosomal recessive bleeding disorder caused by qualitative or quantitative abnormalities of the platelet glycoprotein IIb/IIIa (GP IIb/IIIa), which can lead to excessive bleeding. Glanzmann thrombasthenia is associated with clinical variability, with some patients only having minimal bruising and others having frequent, severe and potentially fatal hemorrhages. Platelet transfusions, which used to be the standard treatment, may lead to the development of antibodies to HLA and/or GPIIb/IIIa, thereby rendering future transfusions ineffective. Glanzmann's thrombasthenia can be a severe hemorrhagic disease; however, the prognosis is excellent with careful supportive care. In this case, administering allogenic plateletpheresis to patients with Glanzmann's thrombasthenia who were refractory to platelet transfusions was found to be successful during bone surgeries.