Asian journal of anesthesiology最新文献

Introduction: Deep neuromuscular blockade (d-NMB) is an essential requirement for carboperitoneum during laparoscopy surgery. However, sustaining d-NMB till the completion of surgery delays the reversal of the residual block. Therefore, there is a merit in exploring the effect of synergistic vecuronium-atracurium combination on the duration-of-action of d-NMB during "laparoscopic" surgery when we compare intubating bolus non-depolarizers (atracurium, vecuronium) administered alone. This study aims to evaluate whether the synergistic effect atracurium-vecuronium combination increases duration-of-action of d-NMB "laparoscopic" surgery settings.

Methods: Forty-eight patients (18-60 years, American Society of Anesthesiologists physical status- II/III, either sex) undergoing laparoscopic cholecystectomy were randomly allocated to receive vecuronium (vecuronium group, n = 16) or atracurium (atracurium group, n = 16) or vecuroniumatr-acurium combination (vecuronium-atracurium combination group, n = 16) and analyzed for the effects on the duration-of-action (primary objective); onset-of-action, reversibility, and quality of intubating conditions (secondary objectives) profile of neuromuscular blockade in patients undergoing laparoscopic cholecystectomy.

Results: Duration-of-action of neuromuscular blockade was significantly longer in patients who received atracurium-vecuronium combination (53.9 ± 9.7 minutes) versus atracurium-alone (41.1 ± 3.8 minutes) or vecuronium-alone (43.5 ± 9.2 minutes) (P = 0.000). No difference was found for the time to onset-of-action (vecuronium [198.1 ± 34.9 seconds], atracurium [188.5 ± 50.6 seconds], or atracurium-vecuronium combination [196.3 ± 46.3 seconds] [P = 0.829]); time for the reversal of muscle relaxation effect (vecuronium [559.9 ± 216.2 seconds], atracurium [584.7 ± 258.3 seconds], and atracurium-vecuronium combination [555.0 ± 205.4 seconds] [P = 0.925]); and quality-of-intubating conditions (vecuronium group [9.6 ± 1.3]; atracurium group [10.0 ± 0.0]; atracurium-vecuronium group [10.0 ± 0.0] [P = 0.182]).

Conclusion: The synergistic effect of the atracurium-vecuronium combination leads to an increased duration-of-action of d-NMB during laparoscopic cholecystectomy without impacting onset-of-action, quality of intubating conditions, and reversal of muscle relaxant effect.

Background: Advancing a tracheal tube over a tracheal tube exchanger into the trachea frequently causes difficulties because of the tube impingement on laryngeal structures. In the present study, we measured the resistance of tube advancement both objectively and subjectively with a variety of combinations of tube exchanger sizes and tracheal tubes using a manikin simulator.

Methods: Lubricated 7.5 mm ID standard and Parker Flex-Tip (PFT) tracheal tubes were railroaded over the tube exchangers (OD 1-6 mm) into the trachea through the oral route in a manikin. Consequently, 12 combinations of tracheal tube-exchanger tube assemblies were evaluated. Tube advancing resistance at the laryngeal inlet was subjectively evaluated. The objective tube advancing resistance (force) at the laryngeal inlet was evaluated using a digital force gauge. The execution of each tracheal tube-exchanger trial was conducted 10 times.

Results: With a 1-mm tube exchanger, all intubation attempts with both standard and PFT tubes failed. Esophageal intubation or severe impingement at the right arytenoid accompanied with a bent tracheal tube was observed. With a 2-mm tube exchanger, during intubation with a standard tracheal tube, rotation of the tube was sometimes required; however, all other intubations were done without problems. When PFT tubes were used, all intubation attempts were performed without problems. The rest of the trials were successfully performed regardless of the combinations of tube exchangers and tracheal tubes; however, one attempt of intubation with a combination of a 5 mm tube exchanger and a standard tracheal tube required withdrawal and rotation of the tube because of impingement at the epiglottis. In cases where there was no gap resistance, which means tube advancing resistance generated by a gap between an introducer and a tracheal tube, the pressing force was approximately less than 10 N. However, in the cases requiring some interventions to overcome the gap, the pressing force reached around 15 N. When intubation failed, for example when the tube bent, or esophageal intubation, the pressing force reached around 30 N.

Conclusions: Impingement due to the gap between the tube exchanger and the tracheal tube is thought to occur in the PFT tube less frequently. Once an impingement occurs, we can feel approximately twice the amount of resistance as usual, which may be a chance to consider taking some interventions. When the impingement is not released, regardless of interventions, excessive force may result in esophageal intubation or tracheal injury.

Background: Programmed intermittent bolus (PIB) is a novel method of intermittent drug delivery commonly employed in labor epidural analgesia. This study aimed to evaluate the potential benefits of PIB over continuous infusion (CI) for postoperative analgesia following upper limb surgeries distal to the mid-humerus level using ultrasound-guided infraclavicular brachial plexus block (USG-IBPB).

Methods: The USG-IBPB was performed on a total of 30 patients scheduled for upper limb surgery distal to the mid-humerus level. The patient-controlled regional analgesia pump delivered a combination of 6 mL of 0.2% ropivacaine and 2 μg/mL fentanyl via a perineural catheter as PIB in group I and as a CI in group II. The primary outcome measure was overall drug consumption, and secondary outcomes included pain scores, patient satisfaction, sensory and motor blockade, and adverse effects.

Results: The PIB group exhibited significantly lower overall drug consumption (306.20 ± 13.07 mL vs. 323.73 ± 11.79 mL; P = 0.001), a reduced need for patient-controlled analgesia boluses (3.87 ± 2.67 vs. 7.13 ± 2.36; P = 0.001), and higher patient satisfaction (91.93 ± 10.09 vs. 78.67 ± 17.57; P = 0.017) compared to the CI group. Pain scores at rest were significantly lower at the 24-hour mark (P = 0.007), and on movement, lower scores were observed after 1, 24, and 36 hours (P = 0.031, P = 0.031, and P = 0.011, respectively). Sensory block, motor block, and adverse effects were similar between the two groups.

Conclusion: PIB demonstrated superior efficacy in postoperative analgesia compared to the CI technique for upper limb surgeries distal to the mid-humerus level. Therefore, PIB may be considered an effective alternative to CI for optimal postoperative pain management.

Background: Preoperative fasting is a common practice to decrease perioperative aspiration risk. The American Society of Anesthesiologists (ASA) recommends preoperative fasting of 8 hours after a full meal. ASA preoperative fasting recommendation is based on the Western diet. A typical Western diet has a higher fat content than Asian standard solid meals. This study aimed to analyze intragastric volume with ultrasound after 6-hour and 8-hour fasting after an Asian traditional solid meal.

Methods: This cohort study recruited 37 subjects from January to February 2019. Subjects were patients scheduled for elective non-digestive surgery and planned for preoperative fasting of 8 hours. Before preoperative fasting, all subjects consumed standard Asian meals. We performed an ultrasound of the gastric antrum during the relaxation phase after two contractions. After a good image was acquired, the cross-sectional area and gastric volume (GV) were calculated. GV was grouped based on a border value of 1.5 mL/kg.

Results: GV 6 hours after solid intake was 30.93 (1.60-205.25) mL, and GV 8 hours after solid intake was 16.34 (0.73-62.49) mL (P = 0.002). After 6 hours, 5.4% of the subjects had a GV above 1.5 mL/ kg, while after fasting for 8 hours, the GV of all subjects was below 1.5 mL/kg. Age was correlated moderately and negatively with the GV of 6 hours and 8 hours fasting (P < 0.001, correlation coefficient = -0.610, and P < 0.001, correlation coefficient = -0.580).

Conclusion: Intragastric volume 8 hours after a standard Asian meal intake was lower than 6 hours after a traditional Asian meal.

Background: In pediatric patients due to shorter trachea suboptimal positioning of endotracheal tube (ETT) is seen in 20%-50% of patients triggering grave complications. We compared standard auscultation and ultrasound-guided lung sliding to confirm the position of ETT in children.

Methods: Seventy-five pediatric patients between 2-8 years of age, American Society of Anesthesiologists physical status classification I and II scheduled for surgery under general anesthesia with endotracheal intubation were studied. The position of ETT was confirmed by chest auscultation for the breath sounds bilaterally and by ultrasound on the same sites for lung-sliding signs. The data obtained were compared to findings on waveform capnography. Study outcomes included position of the ETT; tracheal or esophageal, accuracy of diagnosis and time taken till confirming the diagnosis.

Results: Compared to waveform capnography findings, an ultrasound revealed a sensitivity of 94.31%, a specificity of 72.33%, and an accuracy of 90.7% while that for standard auscultation were 82.8%, 47.28%, and 74.67%, respectively. The mean time taken for confirmation of ETT position was significantly shorter with waveform capnography (10.29 ± 2.25 s) compared to auscultation (12.96 ± 2.23 s) and ultrasonography (USG) (14.28 ± 3.77 s).

Conclusion: Confirmation of ETT position using USG or waveform capnography is essential because of high false results using standard auscultation alone. Ultrasound-guided lung sliding method is a simple, fast, and a reliable method used for detecting tube malposition.

Backgrounds: The duration and potency of the subarachnoid block (SAB) can be enhanced by incorporating spinal additives into local anesthetics. In this study, the effectiveness of intrathecal fentanyl and magnesium sulphate as adjuvant anesthetics to 0.5% hyperbaric bupivacaine is compared in regard to the onset and duration of sensory and motor block, along with circulatory variables.

Methods: After authorization of ethical committee , 100 patients belonging to American Society of Anesthesiologists grades I and II, were chosen and split into two groups with 50 patients each. A SAB was administered; Group 1 was given 2.5 mL of 0.5% hyperbaric bupivacaine + 0.5 mL of fentanyl (25 μg), and Group 2 received 2.5 mL of 0.5% hyperbaric bupivacaine + 0.2 mL of magnesium sulphate (100 mg). 0.3 mL of distilled water was added to both groups making an intrathecal drug volume of 3.0 mL. Perioperative circulatory parameters and sensory and motor block features are noted and compared. Version 21.0 of Statistical Package for the Social for Windows was used for all statistical calculations.

Results: Group 1 had a faster onset of sensory and motor block in comparison to Group 2. However, both groups were statistically similar with regard to the duration of sensory and motor blockade, visual analog scale scores, intra and postoperative hemodynamic parameters.

Conclusion: 0.5 mL fentanyl functions as a better spinal adjuvant to 0.5% hyperbaric bupivacaine compared to magnesium sulphate, block but both the agents had similar duration of block, postoperative analgesia and hemodynamic parameters.

Background: The insufficient treatment of postoperative pain is considered a major barrier to enhanced patient recovery following surgery. Opioids remain the standard therapy for postoperative pain; however, the epidemic crisis of opioid abuse in the US has resulted in opioid-sparing multimodal analgesia (MMA) strategies in anesthesia practice. Complete perioperative pain management, particularly after discharge, may be undermined, resulting in chronic postsurgical pain. Thus, anesthesiologists and pain physicians should provide comprehensive MMA guidance for perioperative pain management.

Methods: The Taiwan Pain Society organized a working group, which included experts in the field of anesthesia, pain, and surgery. This group performed an extensive literature search, quality review, and drafted a consensus, which was discussed by experts and edited for feedback. Recommendations covered consent instruction, treatment interventions, intramuscular injection techniques, and prophylaxis for postoperative adverse events.

Results: This consensus included (1) a comparison of the pharmacology and pharmacokinetics between nalbuphine and dinalbuphine sebacate, (2) recommendations to help clinicians establish MMA with extended-release dinalbuphine sebacate injection, and (3) management of common adverse events during the perioperative pain period.

Conclusion: Extended-release dinalbuphine sebacate combined with the MMA strategy can reduce the medical burden and improve the quality of recovery following surgery.