Higher operating tables provide better laryngeal views for tracheal intubation.

BACKGROUND: The present study was conducted to investigate the influence of different operating table heights on the quality of laryngeal view and the discomfort of the anaesthetist during enodotracheal intubation. METHODS: Eight anaesthetists participated, to each of whom 20 patients were allocated. Before induction of anaesthesia, the height of the operating table was adjusted to place the patient's forehead at one of four landmarks on the anaesthetist's body (the order being determined by block randomization with eight blocks): umbilicus (Group U), lowest rib margin (Group R), xiphoid process (Group X), and nipple (Group N). Next, the anaesthetist began the laryngoscopy and evaluated the grade of laryngeal view. For this 'initial posture', the anaesthetist was not allowed to adjust his or her posture (flexion or extension of the neck, lower back, knee, and ankle). This laryngeal view was then re-graded after these constraints were relaxed. At each posture, the anaesthetist's joint movements and discomfort during mask ventilation or intubation were evaluated. RESULTS: The laryngeal view before postural changes was better in Group N than in Group U (P=0.003). The objective and subjective measurements of neck or lower back flexion during intubation were higher in Group U than in Groups X and N (P<0.01 for each). The improvement of laryngeal view resulting from postural changes correlated with the anaesthetist's discomfort score before the postural change (P<0.01). CONCLUSIONS: Higher operating tables (at the xiphoid process and nipple level of the anaesthetist) can provide better laryngeal views with less discomfort during tracheal intubation. TRIAL REGISTRY NUMBER: NCT01649973 (clinicaltrials.gov).

Midazolam dose for loss of response to verbal stimulation during the unilateral or bilateral spinal anesthesia.

BACKGROUND: We have conducted this study to investigate whether unilateral or bilateral spinal anesthesia with bupivacaine induces different sensitivity to intravenous (i.v.) midazolam for sedation. METHODS: Forty-two patients undergoing various elective unilateral lower extremity surgeries were allocated into two groups: (1) unilateral spinal anesthesia group (Group US, n=21; heavy bupivacaine 5 mg/ml, 9 mg) and (2) bilateral spinal anesthesia group (Group BS, n=21; heavy bupivacaine 5 mg/ml, 9 mg). One milligram of midazolam was injected i.v. at 30-s intervals until the patients did not respond to the hand grasp test beginning 15 min after spinal anesthesia. The concentration of plasma bupivacaine was evaluated every 15 min for the first 75 min after the start of the spinal anesthesia, and the bispectral index was monitored continuously. RESULTS: The mean venous plasma concentration of bupivacaine was not significantly different between Group US and BS. The dose of midazolam required to abolish responses to verbal commands was significantly lower in Group BS (mean 5.9+/-1.2 mg) vs. Group US (mean 9.0+/-1.4 mg). CONCLUSIONS: A higher dosage of midazolam is required for loss of response to verbal stimulation during unilateral spinal anesthesia than during bilateral spinal anesthesia.

Analgesia before a spinal block for femoral neck fracture: fascia iliaca compartment block.

BACKGROUND: In this prospective randomized study, the authors compared the analgesic effect of a fascia iliaca compartment (FIC) block with that of intravenous (i.v.) alfentanil when administered to facilitate positioning for spinal anaesthesia in elderly patients undergoing surgery for a femoral neck fracture. METHODS: The 40 patients were randomly assigned to one of two groups, namely, the FIC group (fascia iliaca compartment block, n=20) and the IVA group (intravenous analgesia with alfentanil, n=20). Group IVA patients received a bolus dose of i.v. alfentanil 10 microg/kg, followed by a continuous infusion of alfentanil 0.25 microg/kg/min starting 2 min before the spinal block, and group FIC patients received a FIC block with 30 ml of ropivacaine 3.75 mg/ml (112.5 mg) 20 min before the spinal block. Visual analogue pain scale (VAS) scores, time to achieve spinal anaesthesia, quality of patient positioning, and patient acceptance were compared. RESULTS: VAS scores during positioning (mean and range) were lower in the FIC group than in the IVA group [2.0 (1-4) vs. 3.5 (2-6), P=0.001], and the mean (+/- SD) time to achieve spinal anaesthesia was shorter in the FIC group (6.9 +/- 2.7 min vs. 10.8 +/- 5.6 min; P=0.009). Patient acceptance (yes/no) was also better in the FIC group (19/1) than in the IVA group (12/8)(P=0.008). CONCLUSIONS: An FIC block is more efficacious than i.v. alfentanil in terms of facilitating the lateral position for spinal anaesthesia in elderly patients undergoing surgery for femoral neck fractures.

Patient-controlled sedation vs. anaesthetic nurse-controlled sedation for cataract surgery in elderly patients.

BACKGROUND: Patient-controlled sedation (PCS) with propofol has been used successfully in various conditions, but controversies exist about its use in sedation of elderly patients for cataract surgery. This study evaluates the efficacy of anaesthetic nurse-controlled sedation (ACS) compared with PCS using the same device and the drug. METHODS: All of the 153 elderly patients (aged 51-88 years) undergoing cataract surgery with a sub-Tenon's infiltration were assigned to receive ACS (n = 51) or PCS (n = 51) with propofol or no intra-operative sedation (control, n = 51). Propofol was administered with a bolus dose of 10 mg and a lockout interval of 1 min. Cognitive function, sedation, pain, anxiety, side effects and satisfaction of patients were evaluated. RESULTS: The mean +/- SD doses of propofol administered were 34.9 +/- 8.8 mg and 30.1 +/- 30.4 mg in the groups ACS and PCS, respectively. The anxiety score was lower in both ACS and PCS groups compared with control group but was not different between the two groups. Patient's satisfaction was highest in PCS group, ACS group was the next, compared with non-sedated group. Other parameters were not different among the three groups. CONCLUSIONS: Both ACS and PCS using propofol provided reduced anxiety compared with control, but patient's satisfaction was higher in the PCS group compared with ACS group.

Comparative study of fluorodeoxyglucose positron emission tomography and magnetic resonance imaging for the detection of spinal bone marrow infiltration in untreated patients with multiple myeloma.

BACKGROUND: The presence and extent of osteolytic bone lesions in untreated patients with multiple myeloma are important factors in the staging of the disease, and the extent of bone lesions in multiple myeloma cases significantly influences decisions regarding therapy. Recently, fluorodeoxyglucose positron emission tomography (FDG-PET) and magnetic resonance imaging (MRI) have been used to detect bone marrow involvement in patients with multiple myeloma. PURPOSE: To compare the efficacy of FDG-PET and MRI for the detection of bone marrow infiltration into the spine in untreated patients with multiple myeloma. MATERIAL AND METHODS: Twenty-two patients with multiple myeloma underwent both FDG-PET and spine MRI. The examined spinal regions by MRI included 21 thoracic and lumbar spines, one lumbar spine, and 12 cervical spines. The following imaging sequences were performed: T1-weighted spin-echo MRI with and without fat suppression, and T2-weighted spin-echo MRI in the sagittal plane. In the patients with bone marrow abnormalities, an additional contrast-enhanced T1-weighted spin-echo MR image and a fat-suppressed T1-weighted spin-echo MR image were obtained. Patients were divided into three groups on the basis of the criteria defined by Durie and Salmon: stage I (n=9), stage II (n=3), and stage III (n=10). The number and location of lesions detected in both FGD-PET and MRI were recorded, and the lesions were compared using the McNemar test. Bone marrow biopsy results, the patient's clinical examinations, and other imaging findings (MRI, FDG-PET, etc.) were used as references. RESULTS: In stages I and II (37 lesions in 12 patients), FDG-PET and MRI detected lesions in 78% (29 of 37 lesions) and 86% (32 of 37 lesions), respectively. However, the difference between the abilities of FDG-PET and MRI to detect lesions was not statistically significant (P=0.317). In stage III (101 lesions in 10 patients), FDG-PET and MRI detected lesions in 80% (81 of 101 lesions) and 92% (93 of 101 lesions), respectively. The difference between the abilities of FDG-PET and MRI to detect lesions was statistically significant (P=0.038). CONCLUSION: MRI is superior to FDG-PET in detecting bone marrow involvement in the spine of patients with advanced multiple myeloma.

Effect of pre-emptive alveolar recruitment strategy before pneumoperitoneum on arterial oxygenation during laparoscopic hysterectomy.

In a randomised, controlled, single-blind trial, we examined the effect of a pre-emptive alveolar recruitment strategy on arterial oxygenation during subsequent pneumoperitoneum. After intubation, 50 patients were randomly allocated to receive either tidal volume 10 ml/kg with no positive end-expiratory pressure (group C) or alveolar recruitment strategy of 10 manual breaths with peak inspiratory pressure of 40 cmH2O plus positive end-expiratory pressure of 15 cmH2O before gas insufflation (group P). During pneumoperitoneum, group P was ventilated with the same setting as group C (FiO2,= 0.35, tidal volume 10 ml/kg). PaO2, measured during peumoperitoneum was higher in group P than in group C (166 +/- 32 mmHg vs 145 +/- 34 mmHg at 15 minutes, P = 0.028, 155 +/- 30 mmHg vs 136 +/- 32 mmHg at 30 minutes, P = 0.035). Alveolar-arterial oxygen gradient in group P increased less after gas insufflation (13 +/- 9 to 60 +/- 34 mmHg vs 10 +/- 9 to 37 +/- 31 mmHg, P = 0.013). We conclude that the alveolar recruitment strategy we applied before insufflation of the peritoneal cavity may improve oxygenation during laparoscopic hysterectomy

Comparison of desflurane with sevoflurane for the incidence of oculocardiac reflex in children undergoing strabismus surgery.

BACKGROUND: The oculocardiac reflex (OCR) is frequently observed during strabismus surgery. This study was designed to evaluate and compare the effect of sevoflurane and desflurane on the incidence of OCR. METHODS: After obtaining Institutional Review Board approval and informed consent from parents, we enrolled 237 paediatric patients, aged 2-10 yr, undergoing strabismus surgery. No premedication was given. Anaesthesia was induced with thiopental and rocuronium. Patients were randomly allocated to one of the two anaesthetic regimens. Group S (n = 123) received sevoflurane and Group D (n = 114) received desflurane, both with 60% N2O/O2 for maintenance of anaesthesia. The OCR was defined as a > or = 20% decrease in heart rate (HR) from baseline values obtained immediately before muscle manipulation. If the HR did not increase after release of muscle tension, atropine 0.01 mg kg(-1) was administered. RESULTS: There were no significant differences between the two groups in age, sex, body weight, and the number of muscles operated upon. The mean values of baseline HR were 123 (16) min(-1) in Group S and 121 (18) in Group D (NS). The minimum HR was 106 (22) min(-1) in Group S and 103 (21) in Group D (NS). There was no difference in the incidence of OCR between sevoflurane (26.0%) and desflurane (28.0%) anaesthesia. CONCLUSIONS: Both agents can be used safely during strabismus surgery in paediatric patients.

Hemodynamic changes in limb shaking TIA associated with anterior cerebral artery stenosis.

Limb shaking TIA is a rare but well-known feature of severe carotid artery stenosis. The authors report a patient who developed recurrent shaking movements of a leg. An angiogram showed the focal stenosis of the anterior cerebral artery. Ictal and postacetazolamide SPECT scans suggested a local hyperfunction of cortical neurons and an impaired hemodynamic reserve in the vicinity of the ischemic area.

Thyrotoxic autoimmune encephalopathy: a repeat positron emission tomography study.

Thyroid related autoantibodies have been related to the development of encephalopathy, known as Hashimoto's encephalopathy. However, their relation with the encephalopathy occurring in patients with Graves' disease has not been well established. The case is reported of a 51 year old woman presenting with subacute progressive dementia with evidence of hyperthyroidism. She had Graves' disease associated with high titres of thyroid related autoantibodies. Her encephalopathy was not improved by antithyroid drugs, but promptly responded to corticosteroid treatment, and stabilised with a gradual reduction of thyroid related autoantibody titres. Brain positron emission tomography initially showed a diffuse and multifocal cerebral hypometabolism with subsequent normalisation on her clinical recovery, which was consistent with the acute and reversible cerebral inflammation probably mediated by autoimmune mechanisms.

The differential flow of epidural local anaesthetic via needle or catheter: a prospective randomized double-blind study.

The extent of epidural anaesthesia and pattern of spread of contrast medium, using different injection techniques, has not been well documented. Therefore, in this prospective, randomized double-blind study, the extent of anaesthesia and pattern of spread of contrast medium following an epidural bolus injection, via either a Tuohy needle or an epidural catheter, were compared. The study had two parts. In the first, 59 of 79 patients scheduled for a lower extremity operation under epidural anaesthesia were randomly allocated to one of the two groups. Anaesthesia was achieved with an epidural injection of 10 to 15 ml (including a 3 ml test dose) of 0.75% ropivacaine and fentanyl 25 microg via either a Tuohy needle (Group N, n=31) or a catheter (Group C, n=28). The level of sensory anaesthesia was recorded. In the second part, the remaining 20 patients were randomized to initially receive 5 ml of contrast medium via either a Tuohy needle (Group NE, n= 10) or a catheter (Group CE, n = 10). The extent of spread was recorded radiologically. Unilateral or missed blocks and additional dose requirement were absent in Groups N and C. No differences were found in the extent of sensory anaesthesia or the spread of contrast medium. Twenty per cent of catheter tips lay outside the lateral margins of the vertebral bodies. We found that an epidural bolus injection, via either a Tuohy needle or a catheter, made no difference in regard to spread of local anaesthetic or contrast medium in the epidural space.