Thoracic epidural anesthesia and blood glucose levels in diabetic patients undergoing cardiopulmonary bypass under insulin infusion according to the Portland protocol.

BACKGROUND: We investigated the effect of thoracic epidural anesthesia on perioperative blood glucose levels in diabetic patients undergoing cardiopulmonary bypass by continuous insulin infusion according to the Portland Protocol. MATERIAL AND METHODS: Diabetic patients undergoing surgery with cardiopulmonary bypass were assigned to receive either general anesthesia alone (n=40) or general anesthesia with thoracic epidural anesthesia (n=18). Patient data were retrospectively reviewed from prospective chart records used in our anesthesia clinic. In all study patients, insulin infusion with the Portland Protocol was used to maintain stable blood glucose levels. We evaluated blood glucose levels in both groups at 6 time points including before surgery, before cardiopulmonary bypass, during cardiopulmonary bypass, immediately following cardiopulmonary bypass, and on the first and second postoperative days. The amounts of insulin required at the intraoperative period and during two postoperative days were compared between two groups. RESULTS: Groups were similar with respect to the duration of cardiopulmonary bypass, aortic cross-clamping, surgery, and blood glucose levels at any of the 6 time points, mean insulin requirements during intraoperative period and mean insulin requirements and blood glucose levels during the first 2 postoperative days (General anesthesia alone, 189+/-29 mg/dl vs. General anesthesia with thoracic epidural anesthesia, 191+/-19 mg/dl; p=0.782). CONCLUSIONS: In diabetic patients undergoing cardiopulmonary bypass receiving insulin infusion by the Portland Protocol for glycemic control, thoracic epidural anesthesia provides no additional benefit for maintaining blood glucose levels during surgery.

Retropharyngeal submucosal dissection due to nasotracheal intubation.

PROBLEM: Nasal intubation is used often by anaesthetists because it offers many advantages; however, rare complications do arise. A 67-year-old man was admitted to our otorhinolaryngology clinic for uvulopalatopharyngoplasty. Nasotracheal intubation was performed without difficulty. At the beginning of surgery, the surgeon noticed that the nasotracheal tube had penetrated the oropharyngeal mucosa through a channel in the retropharyngeal space. METHODOLOGY: The tube was left in place during surgery to prevent bleeding. After surgery, a vertical incision was made through the mucosa surrounding the tube from the inferior pouch up to the nasopharynx to prevent hematoma. RESULT: The patient was extubated without complication and discharged on the second day postoperative. The oropharyngeal mucosa was healed by the 15th day postoperative. CONCLUSION: Nasal intubation tubes should be lubricated and inserted without force; the oropharynx should be examined carefully after intubation to rule out complications.

Does left molar approach to laryngoscopy make difficult intubation easier than the conventional midline approach?

BACKGROUND AND OBJECTIVE: It has been reported that the left molar approach of laryngoscopy can make difficult intubation easier. The aim of this study was to investigate whether left molar approach to laryngoscopy provided a better laryngeal view in cases of unexpected difficult intubation. METHODS: Following the approval of local Ethics Committee and written informed consent from the patients, out of 1386 patients who underwent general anaesthesia for surgery, 20 patients who could be ventilated by face mask but could not be intubated with conventional midline approach on the first attempt were included in the study. Those 20 patients, who had Grade III-IV laryngeal views on laryngoscopy by conventional midline approach, were subjected to left molar laryngoscopy, and their laryngeal views were evaluated. The external laryngeal compression was routinely used to improve the laryngeal view. When endotracheal intubation failed by left molar laryngoscopy, we performed the conventional midline approach again. All data were recorded. RESULTS: Of the 20 patients studied, 18 had a Grade III laryngeal view and two had a Grade IV laryngeal view. Eighteen of them had a better laryngeal view with left molar laryngoscopy. Eleven of the 20 patients underwent successful intubation with the left molar laryngoscopy, which provided a significantly better laryngeal view and success rate of tracheal intubation than did the conventional midline approach (P < 0.01 and P < 0.01, respectively). CONCLUSIONS: Left molar laryngoscopy can make unexpected difficult intubation easier and should be attempted in cases of difficult intubation.

A comparison of pre-emptive analgesic efficacy of diflunisal and lornoxicam for postoperative pain management: a prospective, randomized, single-blind, crossover study.

Diflunisal and lornoxicam are currently available non-steroidal anti-inflammatory drugs (NSAIDs) that have been shown to be effective to various degrees in pain relief when administered either pre-emptively or postoperatively. The pre-emptive analgesic efficacy of diflunisal 1000 mg was compared with that of lornoxicam 16 mg in 40 ASA I patients undergoing surgical removal of bilateral impacted third molars. The impacted third molar teeth on one side were removed at the first surgical appointment using one of the two drug regimens being assessed and the teeth on the contralateral side were removed at a second appointment using the alternate drug regimen; all operations were performed by the same surgeon. Acetaminophen up to 2000 mg daily was provided as rescue medication. The postoperative rescue analgesic consumption was recorded and pain scores were evaluated with a visual analogue scale at 2, 4, 6, 12 and 24h postoperatively. No statistically significant differences were found between groups with respect to rescue analgesic consumption and postoperative pain scores. Pre-emptive administration of both NSAIDs proved to be effective in the management of pain following the surgical removal of impacted third molar teeth.

One-stage repair of blepharophimosis: a new method.

Blepharophimosis is a congenital malformation involving the orbital region. It is associated with ptosis of the upper eyelids, epicanthal folds, telecanthus, and flattened and widened nasal bridge. We have surgically treated five cases of blepharophimosis by a procedure in which nasal bone graft, medial canthoplasty, and fascial suspension are performed in one stage. There is not any kind of operation for repair of the flattened and widened bridge of the nose in the literature. We have treated this anomaly using bone grafts. The follow-up period was 1 to 2 years, and good results have been obtained. A flattened and widened nasal bridge should be repaired by using bone grafts in addition to medial canthoplasty and fascial suspension in blepharophimosis.

Reverse W-M plasty in the repair of congenital syndactyly: a new method.

A W-M plasty is described as a means of establishing an interdigital web in the repair of congenital syndactyly. 25 cases of congenital syndactyly were operated using this method. The web created did not advance distally, nor cause a transverse scar-band.