Nasotracheal intubation in patients with limited mouth opening: a comparison between fibreoptic intubation and the Trachway®.

In patients with limited mouth opening, traditional laryngoscopy and videolaryngoscopes are not useful when performing nasotracheal intubation. Eighty patients with limited mouth opening who required nasotracheal intubation were randomly assigned to either fibreoptic intubation (n = 40) or the Trachway(®) (n = 40). Using the modified nasal intubation difficulty scale, 22 (55%) patients who received fibreoptic intubation were categorised as no difficulty compared with 40 (100%) patients in the Trachway group (p < 0.001). Mean (SD) total intubation time was 71.8 (23.3) s in patients who received fibreoptic intubation compared with 35.4 (9.8) s in the Trachway group (p < 0.001). We conclude that the Trachway technique for nasotracheal intubation is quicker and easier compared with fibreoptic intubation in patients with limited mouth opening.

Left endobronchial intubation with a double-lumen tube using direct laryngoscopy or the Trachway® video stylet.

We compared direct laryngoscopy with a Macintosh blade vs indirect bronchoscopy with a Trachway® stylet, for endobronchial intubation with a left-sided double-lumen tube. We allocated participants scheduled for thoracic surgery and who had normal predicted laryngoscopy, 30 to each group. The mean (SD) intubation times with laryngoscope and Trachway were 48 (11) s vs 28 (4) s, respectively, p < 0.001. The rates of hoarseness on the first postoperative day, categorised as none/mild/moderate/severe, were 10/12/7/1 and 22/6/2/0, respectively, p = 0.008, without differences on subsequent days. Left endobronchial intubation with a double-lumen tube is slower using direct laryngoscopy and causes more hoarseness than indirect bronchoscopy with a Trachway stylet.

Neuroprotective and anti-inflammatory activities of atorvastatin in a rat chronic constriction injury model.

Atorvastatin is an HMG-CoA reductase inhibitor used to treat hypercholesterolemic conditions associated with hypertension. This study aims to investigate the anti-inflammatory and neuroprotective effects of atorvastatin on peripheral neuropathic pain. Peripheral neuropathic pain was induced by chronic constriction injury (CCI) in Sprague-Dawley rats. Rats were divided into 3 groups including sham-operated, CCI, and atorvastatin-treated. Atorvastatin (10 mg/kg) or phosphate-buffered saline was orally administered for 2 weeks. All animals were assessed by neurobehavioral tests before surgery and at days 3, 7, 14 after surgery. Inflammatory and neuroprotective factors were evaluated by Western blot analysis. eNOS, COX2 and iNOS in the sciatic nerve were also studied using immunohistochemistry. Atorvastatin attenuated CCI-induced nociceptive sensitization and thermal hyperalgesia in a time-dependent manner. Atorvastatin improved CCI-induced neurobehavioral/inflammatory activity by inhibition of TGF-beta, pIkB/IkB, NFkB, COX2, iNOS, EP1 and EP4 in the sciatic nerve. Atorvastatin was also found to increase neuroprotection factors pAkt/Akt, eNOS and VEGF. Taken together, these data indicate that atorvastatin could protect the sciatic nerve against CCI-induced neuroinflammation and nociception.

Comparison of the GlideScope® videolaryngoscope and the Macintosh laryngoscope for double-lumen tube intubation.

Intubation with a double-lumen tube is important for achieving one-lung ventilation and facilitating thoracic surgery. The GlideScope(®) videolaryngoscope (Verathon Inc., Bothell, WA, USA) is designed to assist tracheal intubation for patients with a difficult airway. We wished to compare the GlideScope and direct laryngoscopy for double-lumen tube intubation. Sixty adult patients requiring a double-lumen tube for thoracic surgery and predicted uncomplicated laryngoscopy were randomly assigned to a direct Macintosh laryngoscopy group (n = 30) or a GlideScope group (n = 30). The mean (SD) duration of intubation was longer in the Macintosh group (62.5 (29.7) s) than in the GlideScope group (45.6 (10.7) s; p = 0.007). There was no difference in the success of the first attempt at intubation (26/30 (87%) and 30/30 (100%) for Macintosh and GlideScope groups, respectively; p = 0.112). The incidence of sore throat and hoarseness was higher in the Macintosh group (18 (60%) and 14 (47%), respectively) than in the GlideScope group (6 (20%) and 4 (13%), respectively; p = 0.003 and 0.004). We conclude that double-lumen tube intubation in patients with predicted normal laryngoscopy is easier using the GlideScope videolaryngoscope than the Macintosh laryngoscope.

Malignant mixed müllerian tumor of primary mesenteric origin associated with a synchronous ovarian cancer: case report and literature review.

Malignant mixed müllerian tumor (MMMT) is a rare tumor in females and extragenital MMMT is even more so. We report a patient with MMMT primarily in the mesentery with synchronous ovarian cancer. In the English literature, 42 cases of extragenital MMMT have been reported other than the presented case, and this is only the second MMMT arising from the mesentery. Furthermore, among the cases reviewed, MMMTs tend to be associated with synchronous or metachronous colonic cancer or gynecologic tumors originating from the müllerian duct, including ovarian tumors, fallopian tube cancer, endometrial cancer, cervical cancer, and serous carcinoma of the peritoneum (14 out of 43 patients; 32.6%). The risk factors for MMMT include obesity, nulliparity, exogenous estrogen, and long-term tamoxifen use. The prognosis of MMMT is catastrophic and the treatment is based on the experience of those of uterine sarcomas, which is composed of operation, radiotherapy and chemotherapy.

Thermal pain tolerance and pain rating in normal subjects: Gender and age effects.

BACKGROUND: Thermal detection thresholds and thermal pain thresholds are important in quantitative sensory testing. Although they have been well studied for assessing somatosensory function, the investigation of thermal pain tolerance has been insufficient. The aim of this study was to explore the characteristics of thermal pain tolerance and pain ratings in healthy subjects. METHODS: Cold pain tolerance (CPTol) and heat pain tolerance (HPTol) were tested in 213 healthy adults aged 18-81 years recruited from the local community. The thermal detection and thermal pain thresholds were also tested to investigate the association with pain tolerance. The visual analogue scale (VAS) was used for assessing pain severity immediately after the thermal pain and tolerance tests. RESULTS: The normality of the CPTol and HPTol was acceptable. Most participants rated the pain induced by the CPTol and HPTol testing as moderate. HPTol was lower in women than in men (p = 0.001), but CPTol did not differ between sexes. The pain ratings of CPTol and HPTol did not differ between sexes, but significant age effects were observed. The association of the tolerance temperature with pain ratings was weak, while those of pain ratings for CPTol and HPTol were strong (r = 0.87). CONCLUSIONS: Women were more sensitive to tolerance heat pain stimuli. Younger participants reported more pain for thermal pain and tolerance tests. SIGNIFICANCE: Thermal pain tolerance and pain rating for the thermal pain tolerance temperature depend on gender and age. Women are more sensitive to heat temperatures, young people rate more pain, and the pain ratings of heat and cold are strongly correlated.

Correlation of arterial and end-tidal carbon dioxide in spontaneously breathing patients during ambulatory gynecologic laparoscopy.

Laparoscopy can be performed while patients are under total intravenous anesthesia (TIVA), or sedated and breathing spontaneously through the normal airway. Respiratory monitoring is difficult when patients are sedated or anesthetized, however. The purposes of this study were to evaluate the reliability of end-tidal carbon dioxide (ETCO2) measurement for monitoring arterial carbon dioxide pressure (PaCO2), and to assess the PaCO2/ETCO2 gradient among patients receiving TIVA while breathing spontaneously through the normal airway. Sixty patients were divided into two groups: group 1 patients (n = 30) received general anesthesia with controlled ventilation, while group 2 patients (n = 30) received TIVA with spontaneous breathing through the normal airway; ETCO2 was sampled through a 10-French suction catheter inserted into the nasopharynx via the nasal airway. Arterial blood gas and ETCO2 were recorded at the time of preinduction, induction, CO2 insufflation, and change to Trendelenburg tilt position (20 degrees-30 degrees), and at 10-minute intervals thereafter. The results showed that ETCO2 was highly correlated with PaCO2 in group 1 (correlation coefficient r = 0.85), but not in group 2 (r = 0.55). In group 2, the PaCO2/ETCO2 gradient increased as time elapsed, with significant differences (p < 0.05) between the values at induction and those at 30 minutes after the change to the Trendelenburg position and thereafter. These results indicate that the ETCO2 and PaCO2 values correlate well during the first 20 minutes after the change to the Trendelenburg position in laparoscopy patients receiving TIVA with spontaneous breathing, but that PaCO2 monitoring is still necessary.

Anesthesia for pediatric herniorrhaphy or hydrocelectomy: comparison of propofol/ketamine and thiopentone/halothane.

Total intravenous anesthesia has recently become available for ambulatory surgery. It has the advantages of decreased air contamination from volatile anesthetics and decreased exposure of operating room personnel to volatile anesthetics. The purpose of this study was to compare the anesthetic properties of propofol/ketamine (total intravenous) anesthesia and thiopentone/halothane (intravenous and gaseous) anesthesia for herniorrhaphy or hydrocelectomy in children. Sixty children aged 2 to 7 years scheduled for herniorrhaphy or hydrocelectomy were allocated to two groups. The propofol/ketamine group (group 1) received a loading dose of intravenous propofol 3 mg/kg followed by propofol infusion 200 micrograms/kg/minute; additional bolus doses of propofol 1 mg/kg were given as needed or the infusion dose was increased or decreased by 33 micrograms/kg/minute as needed. Ketamine 1 mg/kg was administered intravenously 2 to 3 minutes before herniorrhaphy or hydrocelectomy to reinforce the analgesic and anesthetic effects of propofol. The thiopentone/halothane group (group 2) received intravenous thiopentone 6 mg/kg followed by halothane with 40% oxygen using a mask. Group 2 patients maintained spontaneous breathing with intermittent assistance and group 1 patients maintained spontaneous natural airway breathing during anesthesia. The scores on the postoperative assessment scale were higher in group 2 patients, indicating poorer anesthesia recovery characteristics, but the differences were not significant. Pain on injection was more frequent in group 1 (12/32) than in group 2 (2/28). The incidence of vomiting in group 2 (6/28) was significantly higher than in group 1 (0/32). We conclude that propofol/ketamine allows patients to maintain spontaneous natural airway breathing during anesthesia, and its analgesic and anesthetic effects are comparable to those of thiopentone/halothane. Propofol/ketamine is appropriate for pediatric herniorrhaphy and hydrocelectomy. It can be recommended for pediatric ambulatory surgery.

Intraoperative stroke under epidural anesthesia for bipolar hemiarthroplasty in a patient with multiple myeloma: a case report.

A 56-yr-old, 58-kg woman with right femoral neck fracture underwent right bipolar hemiarthroplasty. Her medical problems included diabetes mellitus and multiple myeloma. Epidural anesthesia was performed uneventfully. No other drug except for local anesthetic (2% lidocaine) was administered during the procedure. Unfortunately, we "witnessed" the dramatically hemodynamic change of an intraoperative stroke, which was preceded by a hypotensive episode and followed by sustained hypertension. The stroke was presented with decreased level of consciousness initially and confirmed by the brain CT, which revealed acute infarction at the right middle cerebral artery territory, four days after the procedure. Multiple mechanisms such as intraoperative hypotensive episode and vascular atherosclerotic change due to poor controlled diabetes mellitus might be involved in the event. In the meanwhile, hyperviscosity (3.7 centipoise units of the patient v.s. 1.4-1.8 centipoise units of normal range) caused by multiple myeloma might also have contributed to the intraoperative stroke. Clinical presentation of this case will be discussed.

Transcriptional mRNA of bone morphogenetic proteins 2, 3, 4, and 5 in trigeminal nerve, benign and malignant peripheral nerve sheath tumors.

Bone morphogenetic proteins (BMPs) have been shown to play an important role in cell growth and differentiation. BMPs, a rapidly expanding family closely related to transforming growth factor-beta (TGF-beta) superfamily, have been proven recently to possess a regulatory role and neurotrophic capacity in neurogenesis. The aim of the present study is to reveal the relationship among BMPs, peripheral nerve and neoplastic lesions of nerve sheath tumors. The mRNA transcriptions of BMP 2, 3, 4 and 5 in 12 cases of schwannoma, four cases of malignant schwannoma and three cases of trigeminal neuralgia were detected using an in situ hybridization technique. Our results demonstrated that the myelin sheaths of schwann cell from the peripheral neuroectomy of trigeminal neuralgia were positively expressing mRNA of BMP-2, 3, 4 and 5. However, the nerve fibers of trigeminal nerve showed only BMP-2 positive staining. All of the neoplastic lesions of nerve sheath showed a consistent but variant expression of BMP-2, 3, 4, and 5. Except for the BMP-4 mRNA, the expression signals of BMP-2, 3 and 5 mRNA in malignant schwannoma were relatively lower than in benign lesions. On the basis of the findings, we concluded that selected members of BMPs existed in the peripheral nerves and might contribute to the health maintenance, proliferation, regeneration and neoplastic transformation of the peripheral nerve system. Moreover, the effects of BMP-2, 3, 4 and 5 on peripheral nerve system and its neoplastic transformation might be widespread, diverse and antagonistic.

Total intravenous anesthesia using propofol and ketamine for ambulatory gynecologic laparoscopy.

Laparoscopy under total intravenous anesthesia (TIVA) with spontaneous respiration is a commonly encountered procedure in ambulatory gynecologic surgery. The purpose of this study was to evaluate the efficacy of TIVA using propofol and ketamine, compared with endotracheal inhalational general anesthesia (EIGA) for ambulatory gynecologic laparoscopy. Fifty-eight female patients, aged 17-48 years, were randomly allocated into two groups. Group 1 (TIVA) (n = 28) received propofol at the induction of anesthesia followed by propofol infusion for maintenance. Intravenous ketamine 0.5 mg/kg was administered before operation for anesthetic effect. Natural airway and spontaneous breathing were then maintained in patients. Group 2 (n = 30) received EIGA with isoflurane under controlled ventilation. We found that the two groups demonstrated similar trend characters of pH and PaCO2 during operation and in recovery room. The incidence of postoperative vomiting was higher in group 2 than in group 1 (30% vs. 7%; p < 0.05). The incidence of intraoperative arrhythmia was higher in group 2 than in group 1 (40% vs. 3%; p < 0.001). Furthermore, the incidence of sore throat was higher in group 2 than in group 1 (47% vs. 7%; p < 0.001). We conclude that TIVA with spontaneous respiration is suitable for ambulatory gynecologic laparoscopy.

Injection pain with propofol: the effectiveness of thiopentone on induction.

One hundred and twenty-seven children aged 3-6 years were allocated to four groups. All of them received venous cannulation on the dorsum of the hand. On induction, the group L1, L2 and L3 patients received propofol 3 mg/kg mixed with lignocaine 0.15 mg/kg, 0.3 mg/kg, 0.6 mg/kg, respectively. The group T patients received thiopentone 3 mg/kg, then propofol 1.5 mg/kg mixed with lignocaine 0.075 mg/kg. Pain on injection was categorized into two-assessment items (facial expression and limbs withdrawal). The facial expression category were subdivided into none, mild (knit of brows), moderate (grimace), and severe (crying). The withdrawal of limbs was categorized into none, mild (withdrawal of hand), moderate (withdrawal of fore-arm and arm), severe (withdrawal of arm and twisting of body). Patients were monitored using an electrocardiogram, pulse oximeter, autonomic noninvasive blood pressure measuring device and capnography. The patient characteristics did not differ significantly among the four groups. Pain on injection was significantly more frequent in the group L1 patients (81%) compared with the group T (27%) patients. Increasing lignocaine dose reduced the incidence of pain graded as "moderate" or "severe" though there was no significant difference. The incidences of excitatory effect on propofol injection were reduced with increasing lignocaine dose and prior administration of thiopentone but there were no obviously differences among groups. We concluded that thiopentone reduced injection pain on propofol and should be recommended.

A novel approach of intravenous electrocardiograph technique in correct position the long-term central venous catheter.

Intravenous electrocardiograph (IVECG) can correctly positioning the catheter tip by enlarging p wave as it is moved toward right atrium, and it is a safe, reliable and accurate technique. To evaluate the efficacy of wire-conducted IVECG signal and IVECG signal from the port with sodium bicarbonate (NaHCO3) flushed catheter and to compare those with conventional anatomy landmark method was the propose of this study. This prospective study was carried out in 216 patients who suffered from malignant diseases. The correct position of the catheter tip among these groups was confirmed as follows. In group 1 (n = 80), the anatomy landmark method and portable chest radiograph recognized the correct position. In group 2 (n = 72), IVECG signal was conducted from guide wire to identify the tip position. In group 3 (n = 64), IVECG signal was conducted from the port with NaHCO3 (0.8 mEq/mL) flushed catheter to ascertain the tip position. The patient characteristics did not differ significantly among the groups. The duration of operation was significantly (P < 0.001) longer in group 1 than in group 2 and group 3 (45.4 +/- 9.3 minutes vs 35.7 +/- 8.0 minutes and 35.2 +/- 9.7 minutes, respectively). Catheter tip placement times were shorter in group 2 and group 3 than in group 1 (5.3 +/- 2.9 minutes and 6.4 +/- 3.0 minutes vs 16.7 +/- 5.7 minutes, respectively); there was a statistically significant difference between the group 1 and group 2 and group 3 (p < 0.001). Nonetheless, the duration of operation and catheter tip placement time was similar in group 2 and group 3. Early and late complications within the subsequent 3 months showed no significant difference among groups. We concluded that IVECG signal conducted from guide wire obtained a similar efficiency to that signal from the port with NaHCO3 flushed catheter on positioning the catheter tip of the venous Port-A-Cath system. It is recommended to use these methods to facilitate implanting long-term central venous devices.

Persistent mechanical allodynia positively correlates with an increase in activated microglia and increased P-p38 mitogen-activated protein kinase activation in streptozotocin-induced diabetic rats.

BACKGROUND: In experimental early painful diabetic neuropathy, persistent hyperglycaemia induces dys-regulated sodium channel (Navs) expression in the dorsal root ganglion (DRG) and activates microglia in the spinal dorsal horn (SDH). However, information on diabetes-induced chronic neuropathic pain is limited. Therefore, we investigated abnormal Navs in the DRG and activated glial cells in the SDH of diabetic rats with chronic neuropathic pain. METHODS: Sixty-six rats were divided into diabetic and control groups: control rats (n = 18; 1 mL of normal saline via the right femoral vein) and diabetic rats [n = 48; 60 mg/kg streptozotocin (STZ) via the right femoral vein]. Hindpaw behavioural tests, Navs expression in the DRG, activation of glial cells in the SDH and the number of neurons in the SDH were measured at 1 and 2 weeks, and 1, 2, 3 and 6 months following saline and STZ administration. RESULTS: All diabetic rats exhibited hyperglycaemia from day 7 to 6 months. The diabetic rats decreased withdrawal threshold to mechanical stimuli but had blunted responses to thermal stimuli. Consistent up-regulation of Nav1.3 and down-regulation of Nav1.8 was observed. Microglial cells were activated early in the SDH and lasted for 6 months. A positive correlation between mechanical allodynia, Nav1.3 and microglial activation was observed. In addition, microglia activation in the SDH of STZ-induced diabetes was mediated, in part, by phosphorylation of p-38 mitogen-activated protein kinase. CONCLUSIONS: Diabetic rats showed hindpaw mechanical allodynia for 6 months. Persistent mechanical allodynia was positively associated with sustained increased activation of Nav1.3 and increased p38 phosphorylation in activated microglia.