Measurement of S1 foramen depth for ultrasound-guided S1 transforaminal epidural injection.

Background: Ultrasound-guided first sacral transforaminal epidural steroid injection (S1 TFESI) is a useful and easily applicable alternative to fluoroscopy or computed tomography (CT) in lumbosacral radiculopathy. When a needle approach is used, poor visualization of the needle tip reduces the accuracy of the procedure, increasing its difficulty. This study aimed to improve ultrasound-guided S1 TFESI by evaluating radiological S1 posterior foramen data obtained using three-dimensional CT (3D-CT). Methods: Axial 3D-CT images of the pelvis were retrospectively analyzed. The radiological measurements obtained from the images included 1st posterior sacral foramen depth (S1D, mm), 1st posterior sacral foramen width (S1W, mm), the angle of the 1st posterior sacral foramen (S1A, °), and 1st posterior sacral foramen distance (S1ds, mm). The relationship between the demographic factors and measured values were then analyzed. Results: A total of 632 patients (287 male and 345 female) were examined. The mean S1D values for males and females were 11.9 ± 1.9 mm and 10.6 ± 1.8 mm, respectively (P < 0.001); the mean S1A 28.2 ± 4.8° and 30.1 ± 4.9°, respectively (P < 0.001); and the mean S1ds, 24.1 ± 2.9 mm and 22.9 ± 2.6 mm, respectively (P < 0.001); however, the mean S1W values were not significantly different. Height was the only significant predictor of S1D (ß = 0.318, P = 0.004). Conclusions: Ultrasound-guided S1 TFESI performance and safety may be improved with adjustment of needle insertion depth congruent with the patient's height.

Harmful gases including carcinogens produced during transurethral resection of the prostate and vaporization.

OBJECTIVE: To determine the chemical composition of surgical smoke produced during transurethral resection of the prostate (TURP) and vaporization. METHODS: A total of 12 smoke samples were collected from a continuous irrigation suction drainage system to a Tenax absorber at a 0.05L/min flow rate during TURP and vaporization. The gases were quantitatively and qualitatively analyzed by gas chromatography-mass spectrometry (GC-MS) equipped with a purge and trap sample injector. RESULTS: The main chemical constituents of surgical smoke produced during TURP and vaporization include propylene, allene, isobutylene, 1,3-butadiene, vinyl acetylene, mecaptomethane, ethyl acetylene, diacetylene, 1-pentene, EtOH, piperylene, propenylacetylene, 1,4-pentadiene, cyclopentadiene, acrylnitrile and butyrolactone. Three of the constituents are very toxic and carcinogenic (1,3-butadiene, vinyl acetylene and acrylonitrile). The amount (mean±standard deviation) of chemical components in the 45L of gas and room air mixture produced during TURP and vaporization were as follows: propylene, 0.80±0.52mg; isobutylene, 212.85±75.65mg; 1,3-butadiene, 0.93±0.34mg; ethyl acetylene, 0.09±0.05mg; 1-pentene, 6.75±1.62mg; 1,4-pentadiene, 0.06±0.02mg; and acrylonitrile, 1.62±1.19mg. CONCLUSIONS: Three of the toxic gases generated during TURP and vaporization are carcinogens (1,3-butadiene, vinyl acetylene and acrylonitrile). Therefore, higher quality filter masks, smoke evacuation devices and/or smoke filters should be developed for the safety of the operating room personnel and patients during TURP and vaporization.

A comparison of the temperature difference according to the placement of a nasopharyngeal temperature probe.

BACKGROUND: The purpose of this study was to compare temperatures measured at three different sites where a nasopharyngeal temperature probe is commonly placed. METHODS: Eighty elective abdominal surgical patients were enrolled. After anesthesia induction, four temperature probes were placed at the nasal cavity, upper portion of the nasopharynx, oropharynx, and the esophagus. The placement of the nasopharyngeal temperature probes was evaluated using a flexible nasendoscope, and the depth from the nares was measured. The four temperatures were simultaneously recorded at 10-minute intervals for 60 minutes. RESULTS: The average depths of the probes that were placed in the nasal cavity, upper nasopharynx, and the oropharynx were respectively 5.7 ± 0.9 cm, 9.9 ± 0.7 cm, and 13.6 ± 1.7 cm from the nares. In the baseline temperatures, the temperature differences were significantly greater in the nasal cavity 0.32 (95% CI; 0.27-0.37)℃ than in the nasopharynx 0.02 (0.01-0.04)℃, and oropharynx 0.02 (-0.01 to 0.05)℃ compared with the esophagus (P < 0.001). These differences were maintained for 60 minutes. Twenty patients showed a 0.5℃ or greater temperature difference between the nasal cavity and the esophagus, but no patient showed such a difference at the nasopharynx and oropharynx. CONCLUSIONS: During general anesthesia, the temperatures measured at the upper nasopharynx and the oropharynx, but not the nasal cavity, reflected the core temperature. Therefore, the authors recommend that a probe should be placed at the nasopharynx (≈ 10 cm) or oropharynx (≈ 14 cm) with mucosal attachment for accurate core temperature measurement.

The effect of acupuncture on postoperative nausea and vomiting after pediatric tonsillectomy: A meta-analysis and systematic review.

OBJECTIVES/HYPOTHESIS: Tonsillectomy is one of the most frequently performed pediatric surgical procedures worldwide. The complications of this procedure include postoperative nausea and vomiting (PONV) and pain; therefore, both the treatment and prevention of PONV are important. Classical antiemetics include drug therapies such as ondansetron, which are undesirable because they often carry a high cost and several side effects. Therefore, in this study we aimed to evaluate the antiemetic effect of acupuncture after pediatric tonsillectomy. METHODS: We searched for eligible articles that reported on the antiemetic effects of acupuncture after tonsillectomy using the three databases, MEDLINE, Embase, and Cochrane, through July 2015. We included full-length original articles with adequate data for evaluating the antiemetic effects on pediatric tonsillectomy in the form of a relative ratio. The Newcastle-Ottawa scale was used to assess the quality of case control and cohort studies, and the Cochrane risk of bias tool was employed for randomized controlled trials (RCTs). RESULTS: The search identified 415 publications. After screening, we selected eight articles for review (4 RCTs, 3 prospective cohorts, and 1 pilot study). A meta-analysis of acupuncture in pediatric tonsillectomy revealed that the number of patients with PONV was significantly reduced with acupuncture compared to the control group, with a risk ratio of 0.77 (95% confidence interval: 0.63-0.94, P < 0.05). CONCLUSION: When acupuncture at PC6 (neiguan) was used to prevent PONV after pediatric tonsillectomy, the risk ratio was significantly lower compared to that of conventional drug therapy. Although further randomized controlled trials are needed, acupuncture at PC6 is considered an economic and effective treatment for emesis after pediatric tonsillectomy. Laryngoscope, 126:1761-1767, 2016.

Pulmonary edema following phenylephrine intranasal spray administration during the induction of general anesthesia in a child.

Topical phenylephrine, an agent used to facilitate nasotracheal intubation and prevent nasal mucosal bleeding, can cause severe hypertension in some patients, secondary to its stimulation of alpha-adrenergic receptors. Moreover, a high incidence of pulmonary edema is found in patients whose phenylephrine administration is followed by treatment with beta-blocking agents. We report a case of acute pulmonary edema in a pediatric patient who developed severe hypertension after the inadvertent administration of a large dose of topical nasal phenylephrine, followed by beta-adrenergic antagonists (esmolol).

Comparative safety analysis of surgical smoke from transurethral resection of the bladder tumors and transurethral resection of the prostate.

OBJECTIVE: To analyze the gas generated from the transurethral resection of the prostate (TURP) and transurethral resection of bladder (TURB) tumor. METHODS: Thirty-six smoke samples were collected from a continuous irrigation suction system during the TURP and the TURB. Then, they were subdivided into 2 groups: the group I (n = 18; gases generated from the TURP) and the group II (n = 18; gases generated from the TURB). We performed qualitative and quantitative analysis of the samples on gas chromatography/mass spectrometry. RESULTS: A more diverse type of gas was generated from the TURB as compared with the TURP. A further quantitative analysis was performed for 7 of 16 gases and 13 of 39 gases in the group I and group II, respectively. This showed that there was no significant difference in the concentration of propylene (propylene: 148.36 ± 207.72 ug/g vs 96.956 ± 135.138 ug/g) and 1-pentene (5137.08 ± 2935.48 ug/g vs 4478.259 ± 5787.351 ug/g) between the TURP and the TURB (P >.05). CONCLUSION: Our results showed that 39 and 16 types of gases were generated from the TURB and the TURP, respectively. There were differences in the types of gases between benign hypertrophic prostate and malignant bladder tumor tissues. This indicates that electrosurgery of malignant tissue is possibly more hazardous to those who are involved in the surgical operation.

Lymphangiomyomatosis discovered by massive hemoptysis during general anesthesia -A case report-.

Lymphangiomyomatosis (LAM) is a rare lung disease that is characterized by the progressive proliferation of atypical smooth muscle-like cells, which leads to severe respiratory impairment and death. Dyspnea, cough, recurrent pneumothorax, and hemoptysis are the most common clinical symptoms of LAM. We report a 29-year-old female patient with massive hemoptysis during laparoscopic gynecologic surgery under general anesthesia, who was diagnosed with pulmonary LAM.

The preanesthetic interview by anesthesiology residents: analysis of time and content.

BACKGROUND: A preanesthetic visit can increase a patient's satisfaction. However, it is uncertain whether a preanesthetic visit by an anesthesiology resident can achieve the goal. We studied the time distribution for content of preanesthetic interviews (PI) and evaluated the patient's satisfaction with the PI. METHODS: We recorded the PI duration of 200 patients by a voice recorder. The degrees of patient satisfaction with the PI and the changes of anxiety level after the PI were quantified by a questionnaire. We analyzed the time distribution for content of the PI and the correlation between patient characteristics and PI duration or a patient's satisfaction. RESULTS: The total PI duration was 184 (134-286) sec (median, 25-75%), and the time distributions for content of the PI were 8 (5-10) of greeting, 45 (23-70) of history taking, 15 (10-20) of physical examination, 50 (25-98) for obtainingan informed consent, 20 (10-30) of explanation for anesthetic planning, 15 (5-28) for explanation of patient controlled analgesia, and 10 (0-4) sec for questions and answers. Age, ASA physical status, and educational level were correlated with PI duration (P < 0.001). The patient's level of satisfaction was "very satisfied" in 39%, "satisfied" in 50%, and "moderate" in 11% of interviews. The anxiety level was "decreased" in 50%, "increased" in 8%, and "not changed" in 42% of patients. CONCLUSIONS: Although the duration of a PI given by residents was a relatively short, 89% of patients of were satisfied with the interview. The PI took a longer time to complete in patients of older age, higher ASA physical status, or lower educational levels.

Comparison of harmful gases produced during GreenLight High-Performance System laser prostatectomy and transurethral resection of the prostate.

OBJECTIVE: To compare the gases generated from GreenLight High-Performance System (HPS) laser prostatectomy with Urosol or normal saline solution and transurethral resection and vaporization of the prostate (TURVP) with Urosol. METHODS: A total of 36 smoke samples were collected from a continuous irrigation suction system attached to a Tenax absorber during transurethral surgery of the prostate. The gases were qualitatively and quantitatively analyzed by gas chromatography-mass spectrometry equipped with a purge and trap sample injector. RESULTS: The gas produced during TURVP contained propylene, allene, isobutylene, 1,3-butadiene, vinyl acetylene, mercaptomethane, ethyl acetylene, diacetylene, 1-pentene, ethanol, piperylene, propenylacetylene, 1,4-pentadiene, cyclopentadiene, acrylnitrile, and butyrolacton. The types and amount of gas produced during HPS laser prostatectomy were fewer and smaller than during TURVP. However, 1,3-butadiene, a well-known human carcinogen, was also generated by HPS laser prostatectomy. HPS laser prostatectomy with saline produced a greater amount and number of gases than HPS laser prostatectomy with Urosol. CONCLUSION: The surgical smoke produced from TURVP and HPS laser prostatectomy contains potentially harmful chemical compounds, although HPS laser prostatectomy produced less surgical smoke than TURVP. Urosol produced fewer types and a smaller amount of gas than normal saline during HPS laser prostatectomy.

Isoflurane cracks the polycarbonate connector of extra-corporeal circuit -A case report-.

Cardiopulmonary bypass (CPB) is widely used for cardiac surgery by virtue of its proven safety over the course of its use during the past half century. Even though perfusion is safer, incidents still occur. During the repair of a ventricular-septal defect in an 11-month-old infant, we experienced a critical incident related to the potential hazardous effect of volatile anesthetics on the polycarbonate connector of extra-corporeal circuit. The damage to the polycarbonate connector had occurred after spillage of isoflurane during the filling of the vaporizer, causing it to crack and leak. The incident was managed by replacement of the cracked connector during a temporary circulatory arrest. The patient was hypothermic and the time off bypass was less than 1.5 min. There were no neurologic sequelae, the patient made an uneventful recovery. In conclusion, the spillage of volatile anesthetics can cause cracks in the polycarbonate connector of the extra-corporeal circuit, leading to potentially interruption of CPB.

Comparison between the index finger insertion and catheter-guided insertion techniques for airway placement of a ProSeal(TM) laryngeal mask by inexperienced personnel.

BACKGROUND: Insertion of a ProSeal(TM) laryngeal mask airway (PLMA(TM)) by experienced users was more successful with using a catheter-guided (CG) technique than a digital technique. The purpose of this study is to assess the efficacy of the CG insertion technique for a PLMA(TM) by inexperienced personnel. METHODS: Forty patients aged 18-65 yr and who were undergoing general anesthesia were randomly allocated to the index finger (IF) or CG insertion techniques for PLMA(TM) insertion. The IF technique was performed with the routine insertion technique. The CG technique was performed using a catheter inserted PLMA(TM), which was primed into the drain tube of the PLMA(TM) with using a soft flexible catheter. Successful insertion was primarily judged by the clinical function of the airway. The number of insertion attempts and the insertion time were recorded. Postoperative airway morbidity (sore throat, dysphonia, dysphagia) was assessed at 24 hr postoperatively. RESULTS: The success rate was similar between the groups (IF, 18/20; CG, 15/20). The successful insertion time (the time to provide an effective airway) was similar between the groups but the insertion time at the first attempt was shorter for the IF technique (IF, 21.6 +/- 5.3 s; CG, 27.4 +/- 10.3 s). There were no differences between the groups for the postoperative airway morbidity. CONCLUSIONS: This study suggests that the CG insertion technique is not a useful alternative technique for inexperienced personnel.

A comparison of the consumption of inhaled anesthetics according to fresh gas flow and anesthetic circuits.

BACKGROUND: In the Korean National Health Insurance Corporation (KNHIC), payment for inhaled anesthetics are made according to the simulated dose and not the consumed dose. We compare the consumption of inhaled anesthetics according to fresh gas flow (FGF) and anesthetic circuits to compare the consumption of anesthetics and the guidelines for KNHIC payments. METHODS: 161 patients were randomized into six groups who received isoflurane using a closed circuit (group I-C), a semi-closed circuit with FGF 3 L/min (group I-3), or 4 L/min (group I-4), as for the sevoflurane group (group S-C, S-3, and S-4). Mean arterial pressure (MAP) and heart rate (HR) were maintained within +/- 20% of baseline. Minimum alveolar concentration (MAC) and consumption of inhaled anesthetics were recorded by a new anesthetic machine. RESULTS: There were no significant differences among the groups for MAP, HR, and MAC. During anesthesia maintenance, the mean consumption per 15 minutes of inhaled anesthetics was significantly lower in group I-C (1.0 +/- 0.3 ml) than in group I-3 (3.5 +/- 0.7 ml) and than group I-4 (4.9 +/- 0.9 ml) and similar to the sevoflurane groups (group S-C [1.3 +/- 0.4 ml] vs group S-3 [5.3 +/- 1.0 ml] vs group S-4 [6.9 +/- 1.3 ml], respectively; P < 0.05). CONCLUSIONS: In sevoflurane groups, inhaled anesthetics were consumed more than in isoflurane groups. The KNHIC payment guidelines were close to the actual consumption of inhaled anesthetics under using a semi-closed circuit with FGF 3 L/min in sevoflurane and FGF 4 L/min in isoflurane.

Desflurane-induced hemodynamic changes in patients with diabetic cardiovascular autonomic neuropathy.

BACKGROUND: Diabetic cardiovascular autonomic neuropathy (CAN) causes perioperative cardiovascular instability. A rapid increase in the desflurane concentration induces tachycardia and hypertension (HTN). This study examined the effects of the cardiovascular response to desflurane on patients with diabetic CAN. METHODS: Forty diabetes mellitus (DM) patients with CAN were divided two groups: one with HTN (DM+HTN group, n = 17) and one without HTN (DM group, n = 23). The control group (n = 20) was composed of healthy patients without DM or HTN. In each group, the concentration of desflurane inspired was increased abruptly to 12.0 vol% 2 minutes after a thiopental injection. The target was to produce an end-tidal concentration of desflurane of 10.0 vol%, which was maintained until the end of the study by adjusting the vaporizer dial setting. The heart rate (HR), mean arterial pressure (MAP), and cardiac index (CI) were measured. RESULTS: The HR, MAP and CI increased significantly in all three groups when compared with the baseline (P<0.05). Additionally, the HR and MAP showed did not differ among the three groups at any of sampling times. However, the CI of the DM group and the DM+HTN group differed when compared with the control group at 90 and 120 seconds after intubation (P<0.05). CONCLUSIONS: In diabetic patients with CAN, the hemodynamic responses to a rapid increase in desflurane concentration are similar to those in non-diabetic patients before endotracheal intubation. However, after endotracheal intubation, increments in CI are blunted in diabetic patients with CAN.

Is warm temperature necessary to prevent urethral stricture in combined transurethral resection and vaporization of prostate?

OBJECTIVES: To compare the effect of warm and room temperature irrigation solution on the incidence of urethral stricture during combined transurethral resection and vaporization of the prostate (CTURVP). Urethral stricture after transurethral surgery of the prostate is a bothersome complication. Warm irrigation improves the blood flow and might decrease the incidence of urethral stricture compared with the use of room temperature irrigation, which decreases the blood flow in the urethral mucosa, resulting in ischemic injury. METHODS: The patients who underwent CTURVP were divided into those receiving only room temperature irrigation solution (group 1, 75 patients) or warm irrigation solution with a system maintaining the temperature of the ventral penile skin at about 36 degrees C continuously (group 2, 78 patients). At follow-up, 1, 3, and 6 months later, the International Prostate Symptom Score and peak urine flow rate were evaluated. RESULTS: The temperature of the ventral penile skin was 20 degrees C and 36 degrees C in groups 1 and 2, respectively. The rate of urethral stricture was 21.3% in group 1 and 6.3% in group 2 at the end of 6 months of follow-up (P = .002). CONCLUSIONS: The results of our study have shown that maintaining the temperature of the urethra with warm irrigation solution during CTURVP probably decreases the incidence of urethral stricture. The temperature in the urethra could be another important factor in stricture formation after CTURVP.