A comparison of nasogastric tube insertion techniques without using other instruments in anesthetized and intubated patients.

BACKGROUND AND OBJECTIVES: Several techniques are available to facilitate nasogastric (NG) tube insertion with or without using other instruments to guide the NG tube to the stomach. This study aimed to determine the success rate and time required for inserting NG tube by 2 non-instrumental methods of NG tube insertion and compare the findings with the common method of NG tube insertion. DESIGN AND SETTINGS: A prospective randomized, controlled clinical trial carried out at Chang Gung Memorial Hospital in Taiwan. SUBJECTS AND METHODS: A total of 150 patients were randomized into 3 groups: control group, neck flexion with lateral pressure group, and lifting of the larynx group. The number of attempted insertions, success rate, duration of insertion, and various complications were recorded. RESULTS: Both neck flexion with lateral pressure and lifting of the thyroid cartilage techniques had high success rates; however, the time required to insert the NG tube was shortest in the thyroid cartilage lifting group. CONCLUSION: Neck flexion with lateral pressure and lifting of the thyroid cartilage are convenient and reliable techniques for NG tube insertion without using any other instruments. Lifting of the thyroid cartilage had the highest success rate and was less time consuming than the other NG tube insertion techniques. Familiarization with the procedure influenced the success rate and the time required for insertion.

Anesthetic management of a repeat cesarean section in a parturient with severe peripartum cardiomyopathy requiring ECMO in a previous pregnancy: a case report.

The number of pregnant women with cardiac disease is increasing with improvements in technology. In addition, more people are part of the national health insurance plan. However, there are few reports concerning the best method for anesthesia and mode of delivery in these high-risk patients. We report a 29-year-old woman scheduled for a planned caesarean section, who had a history of severe peripartum cardiomyopathy requiring extracorporeal membrane oxygenation in a previous pregnancy. The patient had regular prenatal care in our obstetric clinic. At 29 weeks' gestation, she developed severe dyspnea. A chest radiograph revealed bilateral pulmonary edema and 2-dimensional echocardiography showed a global hypokinesis and severe valve regurgitation with left ventricular ejection fraction of 41.2%. She had an emergency caesarean section and a cardiovascular surgeon was consulted to stand-by. Anesthesia was induced by ketamine 25 mg, midazolam 2.5 mg and rocuronium 50 mg for rapid intubation. The patient tolerated the procedure well and was extubated on postoperative day 1. She was discharged one week after surgery. Postoperatively, the patient was followed in the obstetric and cardiovascular surgery outpatient departments and at 5 months after surgery she was in good condition without any complaints.

Ultrasonic cardiac output monitor provides accurate measurement of cardiac output in recipients after liver transplantation.

BACKGROUND: The ultrasonic cardiac output monitor (USCOM; USCOM Pty. Ltd., Sydney, NSW, Australia) has been accepted as a noninvasive device for measuring cardiac function in various clinical conditions. The present study aimed at comparing the accuracy of this device with that of the thermodilution technique in recipients in the early postoperative period after liver transplantation. METHODS: Fifteen mechanically ventilated patients were studied on the first postoperative day after liver transplantation. We compared the left-sided and right-sided cardiac output (CO) determined by USCOM with that obtained from the thermodilution technique with a pulmonary artery catheter every 8 hours in the intensive care unit. Each patient received a total of four paired measurements. Bland-Altman analysis was used for bias and precision testing. The CO measured by USCOM and the thermodilution method were considered interchangeable if the limits of agreement lay within +/- 1 L per minute or 20% of the mean CO. RESULTS: Forty-eight paired left-sided CO measurements were obtained from 12 patients. Three patients were excluded due to unacceptable signals. Comparison of these two techniques revealed a bias of 0.13 L per minute and limits of agreement at -0.65 L and 0.92 L per minute. Fifty-six paired right-sided CO measurements were obtained from 14 patients with one patient excluded due to an unobtainable optimal signal. A bias of 0.11 L per minute with limits of agreement at -0.51 L and 0.72 L per minute were found for these two techniques. CONCLUSION: This is the first study to evaluate the accuracy of USCOM in the post-liver transplant setting. This device is accurate in measuring CO in liver transplant recipients postoperatively. Possible risks of arrhythmia, infection and pulmonary artery rupture can be avoided because of its noninvasive nature. USCOM should be considered as an alternative in hemodynamic monitoring after liver transplantation.

Prediction model for the return to work of workers with injuries in Hong Kong.

This study attempts to formulate a prediction model of return to work for a group of workers who have been suffering from chronic pain and physical injury while also being out of work in Hong Kong. The study used Case-based Reasoning (CBR) method, and compared the result with the statistical method of logistic regression model. The database of the algorithm of CBR was composed of 67 cases who were also used in the logistic regression model. The testing cases were 32 participants who had a similar background and characteristics to those in the database. The methods of setting constraints and Euclidean distance metric were used in CBR to search the closest cases to the trial case based on the matrix. The usefulness of the algorithm was tested on 32 new participants, and the accuracy of predicting return to work outcomes was 62.5%, which was no better than the 71.2% accuracy derived from the logistic regression model. The results of the study would enable us to have a better understanding of the CBR applied in the field of occupational rehabilitation by comparing with the conventional regression analysis. The findings would also shed light on the development of relevant interventions for the return-to-work process of these workers.

Myocardial infarction masked by high level spinal anesthesia in a patient undergoing herniorrhaphy.

Myocardial infarction (MI) is one of the leading causes of perioperative morbidity. Although evidence to prove significant reduction of perioperative MI with regional anesthesia is lacking, anesthesiologists still prefer this technique over general anesthesia for surgery involving the lower abdomen or lower extremities, especially in patients with cardiac risks. However, high level of sensory block during spinal anesthesia may obscure the referred pain from MI, which could contribute to the delay of diagnosis and treatment of an acute perioperative attack. We report a case of MI which occurred either intraoperatively or postoperatively, with symptoms that were masked by high level of sensory block to T4 by spinal anesthesia. This perioperative MI was only diagnosed when the patient recovered from anesthesia in the post-anesthesia care unit (PACU).

Efficacy of ultrasound-guided axillary brachial plexus block: a comparative study with nerve stimulator-guided method.

BACKGROUND: The aim of this study was to compare the efficacy of axillary brachial plexus block using an ultrasound-guided method with the nerve stimulator-guided method. We also compared the efficacy of ultrasound-guided single-injection with those of double-injection for the quality of the block. METHODS: Ninety patients scheduled for surgery of the forearm or hand were randomly allocated into three groups (n = 30 per group), i.e., nerve stimulator-guided and double-injection (ND) group, ultrasound-guided and double-injection (UD) group, and ultrasound-guided and single-injection (US) group. Each patient received 0.5 ml kg(-1) of 1.5% lidocaine with 5 mg kg(-1) epinephrine. Patients in the ND group received half the volume of lidocaine injected near the median and radial nerves after identification using a nerve stimulator. Patients in the UD group received half the volume of lidocaine injected around the lateral and medial aspects of the axillary artery, while those in the US group were given the entire volume near the lateral aspect of the axillary artery. The extent of the sensory blockade of the seven nerves and motor blockades of the four nerves were assessed 40 min after the performance of axillary brachial plexus block. RESULTS: Seventy percent of the patients in the ND and US groups as well as 73% of the patients in the UD group obtained satisfactory sensory and motor blockades. The success rate of performing the block was 90% in patients in the ND and UD groups and 70% in the US group. The incidence of adverse events was significantly higher in the ND group (20%) compared with that in the US group and the UD group (0%; p = 0.03). CONCLUSIONS: Ultrasound-guided axillary brachial plexus block, using either single- or double-injection technique, provided excellent sensory and motor blockades with fewer adverse events.

Paraplegia by acute cervical disc protrusion after lumbar spine surgery.

Non-traumatic paraplegia caused by herniation of the cervical intervertebral disc is an uncommon postoperative complication. A patient with claudication and radiculopathy was scheduled for lumbar laminectomy due to spinal stenosis. Postoperatively, numbness below T6 was found in his both legs of the patient. MRI showed a protruded intervertebral disc between C6 and C7. Despite urgent disectomy, the patient's lower extremities remained paralyzed without significant improvement for 3 months. Loss of muscle support during general anesthesia, excessive neck extension during endotracheal intubation and positioning, as well as bucking and agitation are believed as triggering factors for the protrusion of the cervical disc. We suggest that a complete history taking and physical examination be accomplished in patients scheduled for lumbar spine surgery in order to exclude coexisting cervical spine disorders. In addition, skillful endotracheal intubation and careful neck positioning are mandatory for patients receiving surgery in the prone position.

Ultrasound-guided axillary brachial plexus block in patients with chronic renal failure: report of sixteen cases.

In this report, 16 patients with end-stage renal disease undergoing forearm arteriovenous shunt surgery were subjected to an ultrasound-guided axillary approach for brachial plexus nerve block. Two doses of 15 ml lidocaine 1.5% were injected using a double-shot technique The spread of the solution within the plexus sheath could be visualized using a high-resolution 12-MHz imaging probe. Most patients (94%) experienced an excellent analgesia in the regions innervated by median, ulnar and radial nerves with a lower percentage of complete analgesia (63%) in the areas innervated by musculocutaneous nerve. Three patients, who complained of pain during the surgery required further supplements of narcotics. There were no complications such as, nerve injury, puncture of the axillary vessels or other systemic reactions. This technique provides adequate analgesia - without complications and without difficulty - for extremity surgery in patients with end-stage renal diseases.

Anesthetic management of Boerhaave's syndrome.

Boerhaave's syndrome or spontaneous esophageal perforation is a life threatening condition which demands early diagnosis and urgent management. Although very selective patients can be treated nonoperatively, in most patients, better overall results can only be attained with early aggressive surgery. Clinical data and accounts of anesthetic management of this condition scarely appear in medical literature. Managing these patients for surgery is among the most challenging tasks facing the anesthesiologist because they may develop septic syndrome with shock. A rapid-sequence induction is mandatory, and the procedures that may aggravate the injury to esophagus should be avoided. Inotropic support and close attention to fluid balance may be required during operation. Because Boerhaave's syndrome is rare, we report here two cases to illustrate possible anesthetic implications of this disease. Both patients underwent thoracotomy to relieve empyema of mediastinum under general anesthesia. The first patient recovered completely after operation due to early diagnosis and treatment, but the second patient developed multiple organ failure and died after operation due to delayed diagnosis of esophageal rupture and severe sepsis. Because survival is directly related to the time to diagnosis and treatment, all clinicians need to be aware of this lethal disease.

High frequency jet ventilation in exploration of tracheostomy--a case report.

Exploration of tracheostomy is not uncommon, however, in case a patient with a facial reconstruction flap, trouble may arise because of difficulty in intubation. We hereby report a patient who had a fresh facial reconstruction flap after radical resection of buccal carcinoma, sustained bleeding around the tracheostomy and was scheduled for exploration of tracheostomy. Fiberoptic oral intubation was failed because of profuse secretion and edematous oral mucosa; high frequency jet ventilation (HFJV) was thus applied and made possible with a suction catheter put through the tracheostomy tube. Exploration was performed following withdrawal of the tracheostomy tube. The tracheostomy tube was reinserted under the guidance of the in-place suction tube after uneventful exploration. The probable concomitant complications and contraindications of using HFJV are discussed here. With thorough preparation and careful monitoring, and under the supervision of experienced physicians, transtracheal HFJV can substitute fiberoptic intubation for ventilation in case of exploration of tracheostomy.

Chemical burn caused by povidone-iodine alcohol solution--a case report.

Burns associated with chemical disinfectants for skin preparation are rare. Skin irritation and maceration associated with pressure factors may contribute to its occurrence. We report a 24-year-old female with thyroid tumor who was admitted for subtotal thyroidectomy. After anesthetic induction, the patient was placed in the supine position with the trunk elevated to 20 degree. The skin over the anterior neck was sterilized with 10% Povidone-iodine (PI) alcohol solution. After a 3-hour surgery, the patient complained of burning pain over the back at the recovery room. Physical examination revealed a 9 x 11 cm area of skin lesion partially thickened amid on the middle of the back suggestive of chemical burn. After conservative treatment, she was discharged uneventfully 4 days later. Upon follow-up, the wound was seen to heal with minimal scarring within 3 weeks.

Vascular injury during a lumbar laminectomy.

A lumbar laminectomy is a common and routine operation. Damage to abdominal vascular structures during surgery is a relatively infrequent complication; however, when it does occur, it is sudden and life-threatening. We herein report on 2 cases of abdominal vascular injury which occurred during lumbar microdiscectomies. The first case was a 34-year-old man. A bloody surgical field was noted 45 min into the operation along with an increase in heart rate and a decrease in blood pressure. After fluid resuscitation and an ephedrine injection, his vital signs stabilized. The patient was then sent to the surgical intensive care unit for observation. An emergent abdominal computer tomography scan revealed right retroperitoneal hematoma, and an urgent exploratory laparotomy was performed to check for bleeding and to remove the hematoma. The second case was a 61-year-old woman with recurrent disc herniation. The operation was proceeding smoothly for 90 min, when a large amount of fresh blood suddenly gushed out. Her blood pressure immediately dropped to that of a state of shock. The patient was turned back to a supine position, and an emergent laparotomy was done to repair the injured vessels. Both patients had uneventful recoveries.

Red Man's syndrome following administration of vancomycin in a patient under spinal anesthesia--a case report.

Prophylactic antibiotics are frequently administered during anesthesia to reduce the incidence of infection. The most common organisms revealed in wound infections are staphylococci. Vancomycin is the antibiotic of choice for resistant staphylococcal infections and bacterial endocarditis in patient allergic to penicillin. We had a case of tibial osteomyelitis, while undergoing removal of implants under spinal anesthesia developed hypotensions, bradycardia, consciousness change and skin erythematous macular rash after 0.1% vancomycin slow infusion for 10 min. After appropriate management, the patient recovered well and was discharged on the following day. Our report is intended to alert our colleagues that vancomycin can cause hypotension secondary to histamine release, direct myocardial depression and direct peripheral vasodilation. Even cardiac arrest had been reported in the literatures.