Effect of Tracheal Intubation Mode on Cuff Pressure During Retractor Splay and Dysphonia Recovery After Anterior Cervical Spine Surgery: A Randomized Clinical Trial.

MINI: This randomized clinical trial showed different intubation mode in anesthesia did not affect the increase of endotracheal cuff pressure caused by the retractor splay in anterior cervical spine surgery. However, nasotracheal intubation improved postoperative dysphonia recovery after anterior cervical spine surgery. STUDY DESIGN: Prospective, randomized, double-blinded trial. OBJECTIVE: The aim of this study was to investigate whether the mode of tracheal intubation affects intraoperative endotracheal tube cuff pressure on retractor splay and post-anterior cervical spine surgery (ACSS) voice outcome. SUMMARY OF BACKGROUND DATA: The combination of endotracheal tube (ETT) and cervical retractors has been implicated in recurrent laryngeal nerve compression and neuropraxia after ACSS. The asymmetric position of the oroETT within the larynx, as being fixed distally by the cuff and proximally by taping on one side of the mouth, may contribute to unilateral vocal palsy. METHODS: Adult patients undergoing ACSS were randomized to receive either nasotracheal or orotracheal intubation under anesthesia. The primary endpoint was the maximal endotracheal tube cuff pressure (ETCP) when the retractors were set up. After the maximal ETCPs were recorded, then ETCPs were controlled to less than 25 mmHg. Secondary endpoints were self-assessed hoarseness, pitch, and loudness of voice on postoperative days (PODs) 1, 2, 7, and 30. RESULTS: We equally allocated 110 patients to nasotracheal and orotracheal intubation. The maximal ETCP during retractor splay did not differ for both the means and distributions of pressure range. After the surgery, more patients in the nasotracheal intubation group reported none or mild change of voice than did the orotracheal intubation group on PODs 1 and 2, in terms of hoarseness, pitch, and loudness (P = 0.001, 0.001, and 0.005, respectively, on POD 1; P = 0.002, 0.003, and 0.011, respectively, on POD 2). Mixed model analysis demonstrated that patients with nasotracheal intubation had significantly lower dysphonia scores after surgery (estimate treatment effect: -1.62, P < 0.0001). Statistics was adjusted to exclude interaction with ETT sizes. CONCLUSION: The tracheal intubation modes did not affect ETCP during retractor splay. However, nasotracheal intubation had a beneficial effect on dysphonia recovery after ACSS. LEVEL OF EVIDENCE: 2.

Prospective, randomized, double-blinded trial. The aim of this study was to investigate whether the mode of tracheal intubation affects intraoperative endotracheal tube cuff pressure on retractor splay and post-anterior cervical spine surgery (ACSS) voice outcome. The combination of endotracheal tube (ETT) and cervical retractors has been implicated in recurrent laryngeal nerve compression and neuropraxia after ACSS. The asymmetric position of the oroETT within the larynx, as being fixed distally by the cuff and proximally by taping on one side of the mouth, may contribute to unilateral vocal palsy. Adult patients undergoing ACSS were randomized to receive either nasotracheal or orotracheal intubation under anesthesia. The primary endpoint was the maximal endotracheal tube cuff pressure (ETCP) when the retractors were set up. After the maximal ETCPs were recorded, then ETCPs were controlled to less than 25 mmHg. Secondary endpoints were self-assessed hoarseness, pitch, and loudness of voice on postoperative days (PODs) 1, 2, 7, and 30. We equally allocated 110 patients to nasotracheal and orotracheal intubation. The maximal ETCP during retractor splay did not differ for both the means and distributions of pressure range. After the surgery, more patients in the nasotracheal intubation group reported none or mild change of voice than did the orotracheal intubation group on PODs 1 and 2, in terms of hoarseness, pitch, and loudness (P = 0.001, 0.001, and 0.005, respectively, on POD 1; P = 0.002, 0.003, and 0.011, respectively, on POD 2). Mixed model analysis demonstrated that patients with nasotracheal intubation had significantly lower dysphonia scores after surgery (estimate treatment effect: −1.62, P < 0.0001). Statistics was adjusted to exclude interaction with ETT sizes. The tracheal intubation modes did not affect ETCP during retractor splay. However, nasotracheal intubation had a beneficial effect on dysphonia recovery after ACSS. Level of Evidence: 2.

An interprofessional training program for intrahospital transport of critically ill patients: model build-up and assessment.

Intrahospital transport of critically ill patients for diagnostic or therapeutic procedures can be compromised by patient instability, equipment problems or inexperienced teamworking. This quasi-experimental study aimed to assess the effectiveness of an in-situ interprofessional simulation-based training (IIST) model for junior member transport teams. Newly registered postgraduate physicians, nurses and respiratory therapists underwent the IIST. The technical skills (TS) of each participant and non-technical skills (NTS) of each interprofessional team were assessed using well-validated checklists. Thirty-six participants enrolled and were randomly assigned to six experimental and six control teams. Most participants achieved a significantly higher level of both TS and NTS. Both the control and experimental teams overvalued their NTS in the pretest, while the posttest self-assessment scores among the experimental groups more closely matched the expert assessments. Despite challenges in scheduling and the setting, the IIST was successfully conducted in a crowded hospital, which enabled trainees to optimize their learning in a real-life environment. In conclusion, the IIST model can facilitate the development of both TS and NTS for transport team members. Transport teams made up of newly registered staff from different disciplines may lack insight into their NTS in critical patient transfer management, but simulation training may cause improvements.

A desflurane and fentanyl dosing regimen for wake-up testing during scoliosis surgery: Implications for the time-course of emergence from anesthesia.

BACKGROUND/PURPOSE: The Stagnara wake-up test assesses neurological deficits during scoliosis surgery, and response surface interaction models for opioids and inhaled agents predicts anesthetic drug effects. We hypothesized that there is an optimal desflurane-fentanyl dosing regimen that can provide a faster and more predictable wake-up time, while also ensuring adequate analgesia during wake-up testing. METHODS: Twenty-three American Society of Anesthesiologists Class I-II scoliosis patients who received desflurane-fentanyl anesthetic regimens were enrolled in this posthoc study, and their intraoperative drug administration data were collected retrospectively. Desflurane and fentanyl effect site concentrations were calculated using pharmacokinetic models, and converted to equivalent remifentanil-sevoflurane concentrations. RESULTS: Results were fitted into Greco models for predicting the probability of an Observers Assessment of Alertness/Sedation score of <2. At time of wake-up, the models correctly predicted the probability that patients would respond to voice prompts and prodding was approximately 50%. The probability of pain intensity was distributed between 50% and 95%, indicating a low degree of pain at emergence. When comparing subgroups defined by calculated effect-site fentanyl concentrations, the wake-up time in the intermediate concentration group was significantly shorter than that in the high concentration group (p = 0.024). CONCLUSION: This study provides evidence that desflurane-fentanyl-based anesthesia is conducive to rapid emergence followed by an immediate neurological evaluation. Intermediate fentanyl effect-site concentrations (1-2 ng/mL) at time of wake-up were associated with good balance between rapid emergence and adequate analgesia. Furthermore, we believe that generalizing response surface models to a variety of inhalation agent-opioid combinations using simple relative potency relationships is possible and practical.

Validated Simulation: The Preliminary Experience of Anesthesiologist Board Examination in Taiwan.

High fidelity simulation-based teaching has played an important role in medical education, especially in anesthesiology and emergency. But there is not any currently validated scoring system or prediction model for high fidelity simulation. We will develop a validated prediction model to enhance the efficiency and validation of clinical training with high fidelity simulation.

Successful percutaneous tracheostomy via puncture through the thyroid isthmus.

Tracheostomy is one of the most frequently performed procedures in intensive care units. Bedside percutaneous tracheostomy has become an increasingly popular option to standard open tracheostomy. Several contraindications for percutaneous tracheostomy, including an enlarged thyroid isthmus, have been described. However, as experience with this technique has increased, most of the described contraindications appear to be relative rather than absolute, provided the procedure is performed by an experienced practitioner. Herein we present a case of an unavoidable direct puncture of the thyroid isthmus during a percutaneous tracheostomy. The procedure was performed smoothly, and no complications occurred.

Application of an ultrasound-guided low-approach insertion technique in three types of totally implantable access port.

BACKGROUND: Totally implantable access ports (TIAPs) are alternatives to central venous catheters for patients requiring chemotherapy. Since January 2003, we have used a central approach two-point incision technique to insert TIAPs. Following advances in ultrasound technique and clinical experience for tunneled dialysis catheter placement, we modified the central approach to a low-approach technique. METHODS: From January 2009 to June 2010, patients consulted for TIAP insertion in our department were enrolled in our study. Different brands and materials of central venous catheters of TIAPs were inserted by the low-approach two-point incision technique (Phase I) or the low-approach one-point incision technique (Phase II). The insertion time, failure rate, procedural and late complications, degree of satisfaction, and cosmetic scores were recorded. RESULTS: Ninety-seven patients and 107 patients were implanted via the two-point and one-point low-approach techniques, respectively, with different kinds of TIAP. No matter which type of TIAP was used, the success rate in both phases was 100% without procedural complications using the low-approach technique. The average time for device insertion was 30 minutes for the two-point incision technique used during Phase I and 26-28 minutes for the one-point incision technique used during Phase II. Satisfaction and cosmetic scores were high. CONCLUSION: Our study highlights a revised technique for placement of TIAP systems of differing types of material or size. Not only was the curvature of the device catheter smooth, but patients were satisfied with the cosmetic appearance.

Relative contraindications for percutaneous tracheostomy: from the surgeons' perspective.

PURPOSE: Percutaneous tracheostomy (PT) has gained worldwide acceptance as a bedside procedure by intensivists, but its popularity has declined based on reports of some relative contraindications. The aim of this study was to ascertain the perioperative comorbidities of PT when it is performed by surgeons with experience performing standard tracheostomy. METHODS: Prospective data were collected and analyzed for consecutive PTs performed in intensive care units. RESULTS: No procedure-related mortality occurred in the present study. No significant differences in perioperative comorbidities, such as transient hemodynamic instability and postoperative wound infection, were noted between the relative contraindication (RC) and normal condition (NC) groups. Otherwise, instrument failure (5 cases, p = 0.052) and procedure failure (2 cases, p = 0.222) occurred in the RC group, but not in the NC group. Two patients in the NC group and one patient in the RC group needed to undergo a reoperation to check for bleeding. In a subgroup analysis, more bleeding events were noted for the patients with coagulopathy (p = 0.057), and premature extubation of the endotracheal tube/instrument failure (p = 0.073) was more common in the patients with neck anatomical difficulty in the RC group. CONCLUSIONS: For patients with relative contraindications, the potential of using PT should be determined on an individual basis. Special attention should be paid to the possibility of instrument failure and bleeding events for the patients with relative contraindications for PT.

No enlargement of the right internal jugular vein of the dialysis patients in the Trendelenburg position.

BACKGROUND: The Trendelenburg position has been suggested for right internal jugular vein (RIJV) catheterization. However, this position can sometimes be functionally intolerable for chronic kidney disease patients. We conducted an ultrasound study to further investigate the efficacy of the use of the Trendelenburg position during tunneled dialysis catheter insertion via the RIJV in chronic kidney disease patients. METHODS: We recruited into our study patients without a history of prior tunneled dialysis catheter insertion or neck surgery. Those patients with stenosis or thrombus in the RIJV were excluded. Serial ultrasound images were acquired with patients in the supine position, with the head rotated 30° to the left: Stage 0, table flat; Stage T, Trendelenburg tilt. Then, measurements of patient RIJV transverse diameter, anteroposterior (AP) diameter, and cross-sectional area (CSA) were obtained. RESULTS: Fifty dialysis patients and 40 healthy volunteers completed the study. There were no significant differences in the lateral diameter, AP diameter, or AP/lateral diameter ratio between the dialysis patients and healthy volunteers, whether in the supine or the Trendelenburg position. However, the CSA of the RIJV of the healthy volunteers in the Trendelenburg position was significantly larger than that in dialysis patients. The change in CSA from the supine to the Trendelenburg position was also significantly different between the two groups. CONCLUSION: In contrast to healthy volunteers, there was no enlargement of the RIJV when dialysis patients were in the Trendelenburg position. The reason for this phenomenon may be multifactorial, with diastolic dysfunction being the most likely cause, and further investigation is required to clarify the cause. Our investigation suggests that the supine position for central venous catheterization in dialysis patients is superior to the Trendelenburg position.

Diagnosis and insertion of Hickman catheter for a patient with persistent left superior vena cava.

A vascular access with good function for drug delivery is the basis of chemotherapy. If there is any congenital or acquired vascular abnormality, procedurally related and late complications such as vessel rupture, malposition, and dysfunction of the catheter with ensuing thrombosis may occur, especially when it is undiagnosed or ignored. We describe a case of implantable central venous catheter (CVC) malposition and subsequent insertion of a Hickman catheter for stem cell transplantation after the diagnosis of persistent left superior vena cava (PLSVC) by radiologic image studies. The case is about a 60-year-old male who suffered from mantle cell lymphoma. He complained of discomfort when chemotherapeutic drugs were delivered through an implanted subcutaneous port system. Malposition of the CVC with aberrant path venous catheter, which led to its migration to the right internal jugular vein (RIJV) was noted on the chest X-ray. In addition, results of ultrasound imaging revealed total occlusion of the RIJV, and a subsequent three-dimensional (3D) computed tomography (CT) reconstruction image revealed a PLSVC with an atretic right SVC. Ultrasound-guided venous puncture of the left internal jugular vein and intraoperative fluoroscopy for confirming the correct guide-wire path were used for successful insertion of Hickman catheter without any complication. When unexpected occurrence of migration or malposition of the long-term CVC is detected, early removal of the catheter is vital for preventing further complications. Proper and advanced image studies including ultrasound, contrast-enhanced venography, CT, and magnetic resonance imaging may be necessary for understanding the potential vascular abnormality and guiding the following treatment.

Neonatal nociception elevated baseline blood pressure and attenuated cardiovascular responsiveness to noxious stress in adult rats.

Neonatal nociception has significant long-term effects on sensory perception in adult animals. Although neonatal adverse experience affect future responsiveness to stressors is documented, little is known about the involvement of early nociceptive experiences in the susceptibility to subsequent nociceptive stress exposure during adulthood. The aim of this study is to explore the developmental change in cardiovascular regulating activity in adult rats that had been subjected to neonatal nociceptive insults. To address this question, we treated neonatal rats with an intraplantar injection of saline (control) or carrageenan at postnatal day 1. The carrageenan-treated rats exhibited generalized hypoalgesia at basal state, and localized hyperalgesia after re-nociceptive challenge induced by intraplantar injections of complete Freund's adjuvant (CFA) as adults. Then we recorded baseline cardiovascular variables and 24-h responsiveness to an injection of CFA in the free-moving adult rats with telemetric technique. The carrageenan-treated rats showed significantly higher basal blood pressures (110.3±3.16 vs. control 97.0±4.28 mmHg). In control animals, baroreceptor reflex sensitivity (BRS) decreased, sympathetic vasomotor activity increased, and parasympathetic activity was inhibited after CFA injection. Blood pressure elevation was evident (107.0±2.75 vs. pre-injection 97.0±4.28 mmHg). Comparatively, the carrageenan-treated rats showed a higher BRS (BrrLF 1.03±0.09 vs. control 0.70±0.06 ms/mmHg) and higher parasympathetic activity [0.93±0.17 vs. control 0.32±0.02 ln(ms²)] after CFA injection. The change in blood pressure is negligible (111.9±4.05 vs. pre-injection 110.3±3.16 mmHg). Our research has shown that neonatal nociception alters future pain sensation, raises basal blood pressure level, and attenuates cardiovascular responsiveness to nociceptive stress in adult rats.

Optimal shoulder roll height for internal jugular venous cannulation: a study of awake adult volunteers.

STUDY OBJECTIVE: To explore the influence of shoulder roll height on internal jugular vein (IJV) diameter and IJV/common carotid artery (CCA) overlap. DESIGN: Cross-sectional study. SETTING: University-affiliated hospital. PATIENTS: 40 healthy participants. MEASUREMENTS: Ultrasonography to measure the effects of using shoulder rolls ranging between 0 and 5 cm high on IJV diameter, CCA diameter, and percentage overlap of the CCA. MAIN RESULTS: The percentage overlap of CCA decreased for both left (LIJV) and right IJV (RIJV) with the use of higher shoulder rolls. Greater values were seen in depth from skin surface to anterior wall of left IJV in almost all stages, with the exception of Stages 0 and 1 (P < 0.016); and the use of a 5 cm shoulder roll resulted in a significantly decreased anteroposterior (AP) diameter of both RIJVs and LIJVs (both P < 0.008). CONCLUSIONS: Shoulder rolls can reduce the overlap between the IJV and CCA, and may be useful in positioning patients for IJV puncture.

Innominate artery dissection with presentation of sudden right frontal desaturation detected by cerebral oximetry in complicated thoracic aortic aneurysm repair surgery: a case report.

Cerebral oximetry is a noninvasive bedside monitor for cerebral oxygen saturation (rSO(2)). A patient with a thoracic aneurysm underwent combined surgical and endovascular repair. A sudden decrease in right rSO(2) led to the finding of acute innominate artery dissection. Immediate repair was instituted. Sudden asymmetry of rSO(2) may be a warning sign of underlying pathology.

Lack of beneficial effect for preemptive analgesia in postoperative pain control: verifying the efficacy of preemptive analgesia with N-methyl-D-aspartate receptor antagonists in a modified animal model of postoperative pain.

BACKGROUND: In previous animal studies, preemptive treatments with N-methyl-d-aspartate (NMDA) antagonists were ineffective at preventing incision-induced allodynia. It is very likely that the model was not clinically relevant for testing treatment effects on postoperative pain. The beneficial effects of preemptive treatment can be verified only by treatments with a pharmacologically proven effect in a specific pain type or animal model. We previously showed that NMDA receptor antagonists effectively alleviate enhanced mechanical hyperalgesia after plantar incision in adult rats that had been given an intraplantar injection of carrageenan as neonates. Here, using this modified model, we tested the efficacy of preemptive treatment with the NMDA antagonist MK-801. METHODS: We injected rat pups subcutaneously with 0.25% carrageenan or saline in the plantar surface of one hindpaw on postnatal day 1. On postnatal day 50, rats were killed and the ipsilateral side of the lumbar spinal cords were harvested for biochemical analysis of the expression of NR2A and NR2B at baseline, 2 hours, 4 hours, 8 hours, and 24 hours after plantar incision (n = 5 per group for each time point). For pharmacological study, rats were allocated into one of the following groups: 1 intrathecal injection of 40 nmol MK-801 15 minutes before plantar incision, 1 intrathecal injection 30 minutes after plantar incision, or 2 injections of 20 nmol or 40 nmol given at 15 minutes and 60 minutes after plantar incision (n = 10 per group for neonatally saline-treated and 12 for carrageenan-treated rats). Paw withdrawal thresholds were measured with von Frey filaments, and weight-bearing percentages were measured hourly after plantar incision. RESULTS: Expressions of NMDA receptor subunits NR2A and NR2B were increased maximally 4 hours postoperatively and were significantly greater in carrageenan-treated rats than in saline-treated rats. Tests of pain sensitivity showed that MK-801 significantly alleviated the incision-induced mechanical hyperalgesia and increased weight-bearing percentage on the injured paw in carrageenan-treated rats. However, preincisional treatment was not superior to postincisional treatment as assessed during the 6-hour postoperative observation period. Groups with 2 successive postoperative injections exhibited prolonged analgesic effects. Only the group that received 2 postoperative injections and increased total dosage had improved analgesic indices. CONCLUSIONS: Under conditions of proven analgesic action of an NMDA antagonist, we demonstrated that preincisional treatment is not more beneficial than postincisional treatment for postoperative pain relief in the modified animal model. Increasing the duration of administration and/or total dosage had an incremental analgesic effect in comparison with a single injection.

Prevention of dental damage and improvement of difficult intubation using a paraglossal technique with a straight Miller blade.

Patients with diseased teeth, or those who are difficult to intubate, have a higher risk of dental injury during laryngoscopy. We report 3 cases of smooth endotracheal intubation using a paraglossal technique with a straight Miller blade in patients with poor dentition. Three patients with poor dentition were scheduled to undergo surgery under general anesthesia. All patients presented with extremely loose upper central incisors and had lost the other right upper teeth, while micrognathia and prominent, loose upper incisors were noted in 1 case. We elected to use a straight Miller blade using a paraglossal approach. A nasopharyngeal airway was inserted after induction of general anesthesia to facilitate mask ventilation and prevent air leakage from the mask. The Miller blade was then inserted from the right corner of the mouth, avoiding contact with the vulnerable incisors, and advanced along the groove between the tongue and tonsil. The endotracheal tube was subsequently smoothly inserted after obtaining a grade 1 Cormack and Lehane view without dental trauma in all 3 cases. Direct laryngoscopy using the paraglossal straight blade technique avoids dental damage in patients with mobile upper incisors and no right maxillary molars. It is a practical alternative method that differs from the traditional Macintosh laryngoscope in patients with a high risk of dental injury during the procedure. This technique, which provides an improved view of the larynx, might also be helpful with patients in whom intubation is difficult.

A new technique to assist epidural needle placement: fiberoptic-guided insertion using two wavelengths.

BACKGROUND: Up to 10% of epidurals fail due to incorrect catheter placement. We describe a novel optical method to assist epidural catheter insertion in a porcine model. METHODS: Optical emissions were tested on ex vivo tissues from porcine paravertebral tissues to identify optical reflective spectra. The wavelengths of 650 and 532 nm differentiated epidural space from the ligamentum flavum. We then used a hollow stylet that contained optical fibers to place epidural needles in anesthetized pigs. Real-time data were displayed on an oscilloscope and stored for analysis. A total of 50 punctures were done in four laboratory pigs. Data were expressed as mean +/- SD. RESULTS: Paired t test shows significant optical differences between the epidural space and the ligamentum flavum at both 650 nm (P < 0.001) and 532 nm (P = 0.014). Mean magnitudes for 650 nm, 532 nm, and their ratio were 3.565 +/- 0.194, 2.542 +/- 0.145, and 0.958 +/- 0.172 at epidural space and 3.842 +/- 0.191, 2.563 +/- 0.131, and 1.228 +/- 0.244 at ligamentum flavum, respectively. There were no differences in the optical characteristics of the ligamentum flavum and epidural space at different levels in the lumbar and thoracic region (two-way ANOVA P > 0.05). CONCLUSIONS: This is the first study to introduce a new optical method to localize epidural space in a porcine model. Epidural space could be identified by the changes in the reflective pattern of light emitted at 650 nm, which were specific for the ligamentum flavum and dural tissue. Real-time optical information successfully guided a modified Tuohy needle into the epidural space.

Practical preprocedure measurement to estimate the required insertion depth and select the optimal size of tunneled dialysis catheter in uremic patients.

We evaluated two methods for preprocedure predicting the insertion depth of tunneled dialysis catheter (TDC) on chest radiograph (CXR). Patients undergoing TDC insertion via right internal jugular vein were enrolled. By Method 1, the insertion depth was calculated on preprocedure CXR as the distance from the anticipated venous tip (3.5 cm below the cavoatrial junction) to the prearranged skin puncture site (1.5 cm above the right clavicle). By Method 2, the insertion depth was derived by adding the length between the skin puncture site and the upper edge of the clavicle and the length of clavicle-to-tip. The TDC was placed at the estimated insertion depth. The distance of cavoatrial junction-to-arterial tip was then measured from postoperative supine CXR. One hundred and seventy and 121 TDCs were inserted by Method 1 and Method 2, respectively, while 127 and 92 preoperative supine CXR were used for preprocedure measurement. The mean distance of cavoatrial junction-to-arterial tip was 12.055 (8.5684) [mean (SD)], 11.27 (3.3261), 9.524 (5.1590), and 10.538 (2.6956) mm. Methods of determining the insertion depth by preprocedure measurement enable successful TDC tip placement. Method 2 and using preoperative supine CXR enabled more precise and flexible insertion.

Prophylactic antibiotic administration induced bronchospasm as increased airway pressure during general anesthesia.

BACKGROUND: Anaphylactic reaction induced bronchospasm as wheezing and severe elevation of airway pressure was observed in a succession of patients during general anesthesia at our institute in November 2007. The aim of this survey was to investigate the suspected causes and risk factors of these anaphylactic reactions and the degree of correlation. METHODS: All patients who received general anesthesia between November 1 and November 10, 2007 were enrolled. Underlying diseases, substances including intravenous and inhalational anesthetics, antibiotics, and the degree of increase in airway pressure were recorded. Enrolled patients were divided into a significant-airway-pressure-elevation group (Group P) and a no-airway-pressure-elevation group (Group N). RESULTS: A new brand of cephalexin (Roles) used as a prophylactic antibiotic was identified as the most likely causative substance of this succession of suspected anaphylactic reactions (28 in 185 patients, 15.14%), and rapid administration was a contributor to these anaphylactic reactions. CONCLUSION: In this study, we found that rapid administration of Roles was the main cause of suspected anaphylactic reaction presenting as bronchospasm with severe elevated airway pressure. Using Roles as the prophylactic antibiotic is not recommended in patients receiving general anesthesia.

New simulation-based airway management training program for junior physicians: Advanced Airway Life Support.

BACKGROUND: All junior physicians in Taiwan were enrolled into a 3-month post-graduate year 1 (PGY1) course after Severe Acute Respiratory Syndrome (SARS) attack in 2003. AIMS: To develop and evaluate a new airway management training protocol by using an integrated course of lectures, technical workshops and medical simulations. METHODS: In each PGY1 course, the trainees participated in the Advanced Airway Life Support (AALS) program. After 2 h lecture, the trainees were divided into three groups for 4 h technical workshop, including 10 skill stations and medical simulation at the Clinical Skills Resources Center of the hospital at different times. Video-based debriefing and feedback were performed after each simulation. The same scenario was re-simulated after debriefing. Participants' performance was assessed by single global rating and a 5 key actions scoring. RESULTS: A total of 266 junior physicians have been trained with this AALS programs in 2 years. They learned the techniques of airway management, passed the performance checklist of technical workshop, and received higher scores during re-simulation regardless of scoring methods. CONCLUSIONS: The AALS training program can provide methodical and systematic training for junior residents to mature with specialized technical skills and higher-order cognitive skills, behaviors and leadership in airway management.

Clinical value of application of cerebral oximetry in total replacement of the aortic arch and concomitant vessels.

Cerebral ischemia or infarction caused by several equivocal mechanisms is a major complication after aortic arch replacement. Here, we report a 28-year-old male who underwent total replacement of the aortic arch and concomitant tributaries for hypoplasia of the transverse aortic arch and aortic branches. Continuous cerebral oxygen saturation (rSO2) monitoring was applied throughout the whole surgical course. According to the trend of rSO2, we could not only optimize the cerebral perfusion, but also confirm the patency of graft anastomosis. Therefore, monitoring rSO2 is very useful for determining cerebral perfusion during major surgery, especially in complicated repair of an aortic aneurysm, or replacement of the aortic arch and/or arch vessels.