Phrenic Nerve Block at the Azygos Vein Level Versus Sham Block for Ipsilateral Shoulder Pain After Video-Assisted Thoracoscopic Surgery: A Randomized Controlled Trial.

BACKGROUND: Ipsilateral shoulder pain (ISP) is a common problem after pulmonary surgery. We hypothesized that phrenic nerve block (PNB) at the azygos vein level, near the location of the surgical operation, would be effective for reducing ISP. Our primary aim was to assess the effect of PNB on postoperative ISP, following video-assisted thoracic surgery (VATS). METHODS: This prospective, randomized, patient-blinded, single-institution trial was registered at the University Hospital Medical Information Network (UMIN000030464). Enrolled patients had been scheduled for VATS under general anesthesia with epidural analgesia. Patients were randomly allocated to receive infiltration of the ipsilateral phrenic nerve at the azygos vein level with either 10 mL of 0.375% ropivacaine (PNB group) or 0.9% saline (control group) before chest closure. Postoperative ISP was assessed using a numerical rating scale (NRS, 0-10) at rest at 2, 4, 8, 16, and 24 hours. The incidence of ISP was defined as the proportion of patients who reported an NRS score of ≥1 at least once within 24 hours after surgery. In the primary analysis, the proportion of patients with ISP was compared between PNB and control groups using the χ2 test. NRS values of ISP and postoperative incision pain within 24 hours were investigated, as was the frequency of postoperative analgesic use. Incision pain was assessed using an NRS at the time of ISP assessment. Finally, the incidence of postoperative nausea and vomiting and shoulder movement disorders were also evaluated. RESULTS: Eighty-five patients were included, and their data were analyzed. These patients were randomly assigned to either PNB group (n = 42) or control group (n = 43). There were no clinically relevant differences in demographic and surgical profiles between the groups. There was no significant difference in the incidence of ISP (the control group 20/43 [46.5%] versus the PNB group 14/42 [33.3%]; P = .215). The severity of ISP was lower in the PNB group than in the control group (linear mixed-effects model, the main effect of treatment [groups]: P < .001). There were no significant differences between groups in terms of postoperative incision pain. The frequency of postoperative analgesic use was significantly higher in the control group (Wilcoxon rank sum test, P < .001). Postoperative nausea and vomiting did not significantly differ between the 2 groups. There were no changes in the range of shoulder joint movement. CONCLUSIONS: Azygos vein level PNB did not significantly affect the incidence of ISP after VATS.

Remifentanil for sedation and analgesia during awake division of tongue flap in children: a report of two cases.

BACKGROUND: The tongue flap is an accepted treatment method for cleft palate repair. Orotracheal or nasotracheal intubation using a fiberoptic scope is preferred for the division of the tongue flap. We report two cases of tongue flap division in which the patients received adequate sedation and analgesia without tracheal intubation. CASE PRESENTATION: Twelve- and 13-year-old male patients were treated at our hospital for tongue flap division, performed as part of a cleft palate repair. We planned to divide the tongue flap under sedation with remifentanil (1 µg/kg/min continuous infusion) and local anesthesia, followed by induction of general anesthesia, and orotracheal intubation after the tongue flap was divided. During the procedure, patients were breathing spontaneously and were cooperative. Patients were able to follow the surgeons' verbal cues to thrust out the tongue during the procedure, so that the surgeons could easily insert the sutures. CONCLUSIONS: During the division of the tongue flap in two children, excellent sedative and analgesic effects were achieved using continuous remifentanil infusion.

[Postoperative numerical rating scale in patients undergoing gynecological laparotomy under general anesthesia combined with either single epidural injection or transverses abdominis plane block].

BACKGROUND: After the operation, early postoperative ambulation has been recommended for thromboprophylaxis. As more anticoagulant drugs have become available, hemorrhagic complication of epidural anesthesia is the focus of attention. Recently, the spread of ultrasound-guided nerve block has improved the efficacy of the transversus abdominis plane block Therefore, we compared transversus abdominis plane block with epidural anesthesia regarding postoperative numerical scale in patients undergoing gynecological surgery. METHODS: Doses of administrated narcotics during anesthesia, frequencies of administration of analgesics and vomiting up to 24 hours postoperatively, and numerical rating scale (NRS) at the first and 18th postoperative hours were retrospectively surveyed in patients undergoing gynecological laparotomy. Anesthesia was maintained with sevoflurane combined with either single epidural injection of 6-12 ml of 0.375- 0.75% lopivacaine with 2-4 mg of morphine in 16 patients (Epi group) or ultrasound-guided transverses bilateral abdominis plane block (TAPB) using 20 ml of 0.375% lopivacaine, respectively, in 16 patients (TAP group). RESULTS: No significant differences were found in age, height, weight, ASA-physical status, volume of intraoperative blood loss and surgical time. Both the total administrated doses of remifentanil and fentanyl during anesthesia in TAP group were significantly larger than those in Epi group. Number of postoperative vomiting was larger in Epi group. However, NRS at the postoperative first and 18th hours showed no significant differences between the two groups. The technique of ultrasound-guided TAPB is relatively easy compared with that of epidural injection and TAPB has an advantage in availability in patients receiving anticoagulant therapy. CONCLUSIONS: No significant difference in postoperative NRS between two groups in this survey suggests that TAPB in combination with appropriate postoperative pain service is useful in patients contraindicated to epidural puncture.

[Anesthesia for a hemodialysis patient with HIT undergoing CABG using argatroban].

Anesthetic Management of CABG in a Hemodialysis patient complicated by heparin-induced thrombocytopenia (HIT) type II is one of the different procedures in hemodialysis patients using heparin. An 81-year-old man receiving hemodialysis complicated by HIT type II was scheduled for coronary artery bypass grafting (CABG). Anesthesia was induced and maintained with propofol, remifentanil and rocuronium. During artificial cardiopulmonary bypass, activated clotting time (ACT) was maintained above 300 sec by in initial 0.1 mg x kg(-1) and subsequent 2.0-7.0 microg x kg(-1) x min(-1) doses of argatroban; a direct thrombin inhibitor. Immediately after the completion of the external cardiopulmonary circulation, continuous infusion of argatroban was discontinued. Seven hours later ACT was restored to the preoperative level. Both intra and postoperative courses were uneventful.

[Anesthetic management of patients with neuronal ceroid lipofusucinosis].

Neuronal ceroid lipofuscinoses (NCL) are in a group of autosomal recessive inherited neurodegenerative diseases characterized by the accumulation of autofluorescent storage material in many cell types. Clinical manifestations of NCL are progressive mental and motor deterioration, seizures, and visual loss. We report anesthetic management for two siblings with NCL. Placement of percutaneous endoscopic gastrostomy tubes were scheduled for both 31-year-old woman and her 29-year-old sister with NCL. Although they were treated with several anticonvulsants, the grand mal and myoclonic seizures persisted. Anesthesia was maintained with propofol, nondepolarizing muscle relaxant, and narcotics. They showed no complications except for mild hypothermia during anesthesia. However, BIS index fluctuated widely during anesthesia in both cases. Their postoperative course was uneventful.

[Differential lung ventilation using laryngeal mask airway and a bronchial blocker tube for a patient with unanticipated difficult intubation].

We experienced differential lung ventilation using laryngeal mask airway (LMA) and a bronchial blocker tube for a patient with unanticipated difficult intubation. A 27-year-old man was diagnosed as the left spontaneous pneumothorax and scheduled for bulla excision with video-assisted thoracic surgery. Because of failure in tracheal intubation of the usual double lumen tube, we inserted LMAProseal #4 and accomplished differential lung ventilation using a bronchial blocker tube through LMA. This method will be effective in differential lung ventilation of the patient with difficult airway.

[Effects of landiolol hydrochloride on cardiohemodynamics in patients who underwent coronary artery bypass grafting].

BACKGROUND: It is important to control heart rate for coronary artery bypass grafting. The purpose of this study was to evaluate the effects of landiolol hydrochloride, ultra-short-acting beta-blocker, on cardiohemodynamics in 10 patients who underwent coronary artery bypass grafting. METHODS: Anesthesia was induced and maintained with midazolam and fentanyl. After stabilization of anesthesia, landiolol hydrochloride was administered at a rate of 0.04 mg x kg(-1) x min(-1) for 30 min after 0.125 mg x kg(-1) x min(-1). Hemodynamic measurements were made before and every 5 min after administration of landiolol hydrochloride. RESULTS: Heart rate decreased significantly although arterial pressure was unchanged. There were no changes in cardiac index, left ventricular stroke volume index, systemic vascular resistances and pulmonary vascular resistance after landiolol hydrochloride administration. CONCLUSIONS: These results suggest that landiolol hydrochloride possesses less negative inotropic action than negative chronotropic action. Landiolol hydrochloride did not affect both systemic and pulmonary vascular resistances because of high cardioselectivity.