Assessing Continuous Epidural Infusion and Programmed Intermittent Epidural Bolus for Their Effectiveness in Providing Labor Analgesia: A Mono-Centric Retrospective Comparative Study.

Background and Objectives: Local anesthetics administered via epidural catheters have evolved from intermittent top-ups to simultaneous administration of continuous epidural infusion (CEI) and patient-controlled epidural analgesia (PCEA) using the same device. The latest programmed intermittent epidural bolus (PIEB) model is believed to create a wider and more even distribution of analgesia inside the epidural space. The switch from CEI + PCEA to PIEB + PCEA in our department began in 2018; however, we received conflicting feedback regarding workload from the quality assurance team. This study aimed to investigate the benefits and drawbacks of this conversion, including the differences in acute pain service (APS) staff workload, maternal satisfaction, side effects, and complications before and after the changeover. Materials and Methods: Items from the APS records included total delivery time, average local anesthetic dosage, and the formerly mentioned items. The incidence of side effects, the association between the duration of delivery and total dosage, and hourly medication usage in the time subgroups of the CEI and PIEB groups were compared. The staff workload incurred from rescue bolus injection, catheter adjustment, and dosage adjustment was also analyzed. Results: The final analysis included 214 and 272 cases of CEI + PCEA and PIEB + PCEA for labor analgesia, respectively. The total amount of medication and average hourly dosage were significantly lower in the PIEB + PCEA group. The incidences of dosage change, manual bolus, extra visits per patient, and lidocaine use for rescue bolus were greater in the PIEB + PCEA group, indicating an increased staff workload. However, the two groups did not differ in CS rates, labor time, maternal satisfaction, and side effects. Conclusions: This study revealed that while PIEB + PCEA maintained the advantage of decreasing total drug doses, it inadvertently increased the staff burden. Increased workload might be a consideration in clinical settings when choosing between different methods of PCEA.

Association of General Anesthesia and Neuraxial Anesthesia in Caesarean Section with Maternal Postpartum Depression: A Retrospective Nationwide Population-Based Cohort Study.

Although cesarean section (CS) has become a common method of child delivery in recent decades, the choice between general anesthesia (GA) and neuraxial anesthesia (NA) for CS must be carefully considered. Depending on the type of anesthesia used in CS, a major outcome observed is the occurrence of postpartum depression (PPD). This study investigated the association between PPD risk and the anesthesia method used in CS by using data from three linked nationwide databases in Taiwan, namely, the National Health Insurance Research Database, the National Birth Reporting Database, and the National Death Index Database. After propensity score matching by baseline depressive disorders, maternal demographics, status at delivery, infant's health, maternal diseases during pregnancy, and age of partner, we included women who had natural births (n = 15,706), cesarean sections with GA (n = 15,706), and cesarean sections with NA (n = 15,706). A conditional logistic regression was used to estimate the odds ratios and 95% confidence intervals (CIs) of PPDs, including depression, sleep disorder, and medication with hypnotics or antidepressants, under anesthesia during CS. The prevalence rates of combined PPDs were 26.66%, 43.87%, and 36.30% in natural births, CS with GA, and CS with NA, respectively. In particular, the proportions of postpartum use of hypnotic drugs or antidepressants were 21.70%, 39.77%, and 31.84%, which were significantly different. The aORs (95% CIs) were 2.15 (2.05-2.25) for the included depressive disorders, 1.10 (1.00-1.21) for depression, 1.03 (0.96-1.11) for sleep disorder, and 2.38 (2.27-2.50) for medication with hypnotics or antidepressants in CS with GA compared with natural births. Women who underwent CS with GA had a significantly higher risk of depressive disorders and a higher need for antidepressants for sleep problems than those who underwent CS with NA. The risks of PPD were significantly associated with the anesthesia method, especially GA. Our results can assist physicians in carefully considering the appropriate anesthesia method for CS delivery, particularly with regard to postpartum drug abuse and drug safety.

Association Between Aortic Aneurysm and Aortic Dissection With Fluoroquinolones Use in Patients With Urinary Tract Infections: A Population-Based Cohort Study.

Background Fluoroquinolones are first-line antibiotics recommended for the treatment of complicated urinary tract infections (UTIs), with frequent reports of adverse effects of aortic aneurysm (AA) and aortic dissection (AD). We examined whether fluoroquinolones can increase the risk of AA and AD in patients with UTIs in the Taiwanese population. Methods and Results We used the National Health Insurance Research Database to identify patients diagnosed with UTIs under single antibiotic treatment of fluoroquinolones and first-, second-, or third-generation cephalosporins. An AA and AD diagnosis within a year constituted the study event. Multivariable analysis with a multiple Cox regression model was applied for comparing the hazard risk of AA and AD between fluoroquinolones and first- or second-generation cephalosporins. Propensity score matching was performed to reduce the potential for bias caused by measured confounding variables. Among 1 249 944 selected patients with UTIs, 28 568 patients were assigned to each antibiotic group after propensity score matching. The incidence of AA and AD was not significantly different between the fluoroquinolones and first- or second-generation cephalosporins (adjusted HR [aHR], 0.86 [95% CI, 0.59-1.27]). However, the mortality increased in the fluoroquinolones group (aHR, 1.10 [95% CI, 1.04-1.16]). Conclusions Compared with first- or second-generation cephalosporins, fluoroquinolones were not associated with increased risk of AA and AD in patients with UTI. However, a significant risk of mortality was still found in patients treated with fluoroquinolones. The priority is to control infections with adequate antibiotics rather than exclude fluoroquinolones considering the risk of AA and AD for patients with UTI.

Impact of Computed Tomography Scans on the Risk of Thyroid Disease in Minor Head Injury Patients: A Population-Based Retrospective Cohort Study.

We investigated the association between head computed tomography (CT) scans and the risk of noncancer thyroid diseases in patients with minor head injury in a Taiwanese healthcare setting. For this retrospective population-based cohort study, the 2009-2013 Longitudinal Health Insurance Database was used to include patients with a minor head injury at admission or emergency visit between 2009 and 2013. Multivariate analysis with a multiple Cox regression model was applied to analyze the data. According to whether a CT scan was conducted within 14 days of admission, patients were divided into a CT scan group (n = 14,041) or a non-CT scan group (n = 34,684). No increased incidence of thyroid diseases was observed in the CT scan group regardless of the number of CT scans performed. The incidence rate ratio for one scan was 1.10 (95% confidence interval: 0.94-1.29) and for two or more scans was 1.09 (95% confidence interval: 0.93-1.28). In conclusion, this population-based cohort study showed that a head CT scan is not associated with increased risk of thyroid disease in patients with minor head injury. The short-term adverse effects on the thyroid could be mild when a regular CT scan is appropriately performed.

Pain management experience at a central Taiwan medical center.

Pain management is typically more developed in western countries compared to Asia. From the accreditation standard of the Joint Commission International (JCI), there is a broad scope for pain management. In 2008, our medical center established the pain management policy, and the goal is to be a pain-free medical facility. The Framework of Pain Management Policy including: 1. the rights of patients and family members 2. Employee education 3. Assessment of pain (screening, evaluating, monitoring) 4. Patient care of pain. After implementation of pain management program, the compliance of pain assessment, the analysis of pain score before and after pain management and the analysis of Pain Management Index (PMI), all showed improvement in pain management program. The consumption of opioids usage steadily increased from 2010 to 2014. The success of our pain management program implementation could be attributed to the clear pain management policy, the firm support of higher leadership, the cooperation of IT department, and the quality control.

A comparison of spinal and epidural anesthesia for cesarean section following epidural labor analgesia: A retrospective cohort study.

INTRODUCTION: This study aimed to investigate different types of regional anesthesia for cesarean section (CS) following epidural labor analgesia that could lead to various perioperative and postoperative outcomes. METHODS: We retrospectively included those parturients who received epidural labor analgesia but needed subsequent CS under regional anesthesia in our institution from January 2008 to June 2012. RESULTS: In all, 2341 of 6609 parturients underwent painless labor, and 334 of them converted to CS. Spinal anesthesia (SA) was used with 163 parturients, and epidural anesthesia (EA) with 96; the two groups were then compared. No high-level block or total SA was noted. The primary outcome revealed that the time from anesthesia to surgical incision and the total anesthesia time were shorter, hypotension episodes were more frequent, the rate of perioperative ephedrine administration was higher, and the rate of midazolam was lower in the SA group. With regard to secondary outcomes, the Apgar scores of the neonates recorded at 1 minute and 5 minutes and maternal satisfaction were similar. The neuraxial morphine dose was converted to parenteral morphine equivalent dose (MED), which revealed that the parturients in the spinal morphine group had lower dosages and visual analog scale (VAS) pain scores on postoperative Day 1. CONCLUSION: For parturients with labor epidural analgesia needing CS, the use of SA led to shorter anesthetic time and lower postoperative pain scores, with lower morphine doses compared with EA. However, the high failure rate with both neuraxial techniques needs to be addressed.

Use of a video fiberoptic bronchoscope to assist double-lumen endobronchial tube intubation in a patient with a difficult airway.

In clinical scenarios, the insertion of double-lumen endobronchial tubes (DLTs) is usually employed as a technique of separation of lungs for treatment purposes inclusive of one-lung ventilation for the ease of thoracic surgery. However, in patients with difficult airways, the DLT intubation can be challenging, even with the aid of a fiberoptic bronchoscope (FOB). Insertion of the FOB itself into the trachea may be relatively simple, but the advancement of the DLT with the FOB enclosed in the lumen may be hindered by the abnormal or diseased laryngeal aperture. Herein, we present an alternative approach by using a 5.5-mm video FOB to monitor the DLT rather than using it to act as an introducer to overcome the difficulties often met in DLT intubation in oral cancer patients.

Treating frozen shoulder with ultrasound-guided pulsed mode radiofrequency lesioning of the suprascapular nerve: two cases.

OBJECTIVE: Many approaches to treatment of frozen shoulder, or adhesive capsulitis, including use of steroid injections, provide only short-term relief. We present a method for pulsed mode radiofrequency (PRF) lesioning of the suprascapular nerve using ultrasound guidance in patients with severe pain from frozen shoulder. DESIGN: Patients with frozen shoulder were treated by using real-time, high-resolution ultrasound guidance to facilitate PRF lesioning of the suprascapular nerve. SETTING AND PATIENTS: Two patients with frozen shoulder of a tertiary hospital were reported. MEASURES: Pain intensity and shoulder movement before and after procedure were recorded. Results. In the two cases presented, both patients experienced pain relief and increased shoulder flexibility for 5-6 months. CONCLUSION: Ultrasound can not only quickly and effectively identify the suprascapular notch and nerve, but also helps the operator manipulate and advance the needle to a more precise position.

A modified technique for ultrasound-guided cannulation of radial and brachial arteries in patients with circulation collapse.

We present a modified method for arterial cannulation using ultrasound guidance in patients with collapsed circulation. The method makes use of ultrasonographic landmarks that enable cannulation of both the radial and brachial arteries, even when the pulse is extremely faint.

Penetrating injury of the palatoglossal arch associated with use of the GlideScope videolaryngoscope in a flame burn patient.

The GlideScope is used to facilitate exposure of the larynx in both routine and difficult airways. A 38-year-old woman with a flame burn (second/third-degree, 40% total body surface area) and inhalation injury accompanied by acute respiratory failure under mechanical ventilation support presented for wound debridement and split thickness skin grafting. After the surgery, the endotracheal tube was reinserted successfully with a GlideScope because we anticipated a problematic airway. However, direct laryngoscopy revealed the endotracheal tube had pierced through the right palatoglossal arch. Because the consulting otolaryngologist confirmed there was no active bleeding, it was decided that no further management was needed for the wound; the patient was re-intubated under direct laryngoscopy. Postoperatively, she was transferred to the intensive care unit of the burn center under mechanical ventilation. This is a report on a rare complication caused by tracheal intubation associated with the use of the GlideScope. We recommend manipulation of the GlideScope should be performed with care under vigilant surveillance to minimize injury to the oropharyngeal tissues when an endotracheal tube is advanced from the mouth to the pharynx. Potential complications should be always kept in mind when the GlideScope is used for intubation.

Double-lumen endobronchial tube intubation in patients with difficult airways using Trachlight and a modified technique.

We present a modified method for the insertion of double-lumen endobronchial tubes with Trachlight in patients with difficult airways. We also discuss whether our method is applicable to smaller double-lumen endobronchial tubes.

Methemoglobinemia induced by exposure to topical benzocaine for an awake nasal intubation--a case report.

Topical benzocaine and lidocaine are widely used in general anesthesia to minimize the stimulation by awake intubation and in very rare occasion they may induce methemoglobinemia. Although this complication is uncommon, it may be potentially lethal. Here we report a 29-year-old female who was scheduled to receive correction of malocclusion and developed acute methemoglobinemia soon after induction of general anesthesia. Three weeks ago, she had received open reduction for fracture of mandible with intermaxillary fixation under general anesthesia, for which awake fiberoptic intubation was smoothly performed after premedication with 2% topical lidocaine and intravenous fentanyl. This time, trachomucosal block with 4 mL of 4% topical lidocaine and spray of 20% topical benzocaine over the oral cavity and nostrils were carried out before intubation. Awake blind intubation was performed because she could not open her mouth for more than 1 cm. A 6.5 mm-sized nasal endotracheal tube was smoothly placed in first attempt. About 10 min later, an unexplained cyanosis occurred and SpO2 fell to about 70%. Based on a high oxygen tension by arterial blood gas analysis (PaO2) with a contradictory fall of oxygen saturation by pulse oximetry (SpO2), acute methemoglobinemia was highly suspected. The diagnosis was confirmed by multiple-wavelength CO-oximetry. The methemoglobinemia was resolved gradually after methylene blue was given. In conclusion, we must always take the possibility of methemoglobinemia into consideration for differential diagnosis in case of unexplained cyanosis, particularly when patients have prior exposure to methemoglobin-inducing agents.