Journal of Clinical Anesthesia

Editorial Board

2010-02-01

Dexmedetomidine is an excellent agent for sedation status-post lung transplant

Rolf Alexander Schlichter — 2010-02-01

Zhang and colleagues describe, in this issue of Journal of Clinical Anesthesia , a 10-second episode of asystole in an adolescent with cystic fibrosis (CF) following double-lung transplant, whose lungs were being mechanically ventilated while receiving a dexmedetomidine infusion for sedation. Dexmedetomidine is a novel alpha-2A adenergic receptor agonist used as a sedative in the intensive care unit and the operating room. It has sedative, analgesic, and sympatholytic properties associated with minimal respiratory depression. Dexmedetomidine is FDA-approved at a dose of one mcg/kg administered over ten plus minutes followed by an infusion of 0.2-0.7 mcg/kg/hr for sedation of mechanically ventilated patients. Because it is sedating without either amnestic or respiratory depressive effects, it is ideal for weaning patients with pulmonary disease and/or patients requiring serial neurological examination.

The frequency of fentanyl-induced cough in children and its effects on tracheal intubation

Jong In Han, Heeseung Lee, Chi Hyo Kim, Guie Yong Lee — 2010-02-01

Abstract: Study Objective: To determine if fentanyl-induced cough was dose-dependent in children and whether it could affect tracheal intubation.Design: Prospective, randomized, double-blinded study.Setting: Operating room of a university-affiliated hospital.Patients: 160 ASA physical status I pediatric patients, aged two to 14 years, scheduled for elective surgery during general anesthesia and requiring orotracheal intubation.Interventions: Patients were divided into two groups. Group 1 patients were given fentanyl at a dosage of one μg/kg; Group 2 patients received two μg/kg of fentanyl. Induction of anesthesia was conducted immediately following cough cessation or one minute after the end of injection with propofol 2.5 mg/kg. At loss of eyelash reflex, rocuronium 0.6 mg/kg was given intravenously (IV). Two minutes later, tracheal intubation was started.Measurements: Onset and degree of cough and intubating conditions were observed and recorded.Main Results: No statistically significant differences in frequency of coughing or in intubating conditions between the two groups were noted. Cough severity in Group 1 was statistically lower than that of Group 2 (P < 0.05). Onset of cough in Group 2 (12.2 ± 3.4 sec) was statistically shorter than in Group 1 (16.9 ± 7.6 sec, P < 0.05).Conclusion: Fentanyl at doses of one and two μg/kg may induce coughing in pediatric patients.

Comfort and satisfaction during axillary brachial plexus block in trauma patients: comparison of techniques

2010-02-01

Abstract: Study Objective: To investigate the comfort and satisfaction of patients with trauma of the upper limb during two different techniques of axillary brachial plexus block, electrical nerve stimulation and fascial pop.Design: Randomized-prospective, observational study.Setting: University surgical center.Patients: 100 ASA physical status I and II patients undergoing surgery for trauma of the hand and forearm.Interventions: Patients received axillary brachial plexus block with a mixture of 0.5% bupivacaine and 2% lidocaine. They were then allocated to one of two groups to receive either electrical nerve stimulation (Group 1, n = 50), or fascial pop technique (Group 2, n = 50) for nerve location.Measurements: Data were collected on patient demographics, surgery, frequency of complications, and sedation required during the block. Discomfort during the block and surgical comfort were quantified by visual analog scale (0-10). Satisfaction was determined by the following scale: very satisfied, satisfied, dissatisfied, and very dissatisfied. Patients also indicated if in the future they would like to receive the same method of anesthesia.Main Results: No differences in demographic or surgical data were found. No serious complications were observed. Eighteen Group 1 patients (36%) and none in Group 2 needed sedation during the blocks. Discomfort during the procedures was greater in Group 1 than Group 2 (4.5 ± 1.2 vs 1.5 ± 1, P < 0.05), while patients reported good surgical comfort with both techniques (2.4 ± 2.9 vs 2.2 ± 2.1, NS). Eighteen patients in Group 1 and 48 patients in Group 2 would accept the same block for future surgery.Conclusions: In trauma patients, the fascial pop technique is effective, reduces sedation during axillary brachial plexus block, and has a higher patient acceptance rate than the electrical nerve stimulation technique.

Postoperative patient complaints: a prospective interview study of 12,276 patients

Michael Lehmann, Kai Monte, Paul Barach, Christoph H. Kindler — 2010-02-01

Abstract: Study Objective: To evaluate the incidence of perioperative minor adverse events and to analyze patient satisfaction based on potential explanatory variables.Design: Structured, face-to-face interview of 25% of all patients undergoing surgery during the period from January 2003 through June 2006.Setting: Academic university medical center.Patients: 12,276 patients (5,793 men and 6,483 women) from all surgical disciplines: 7,440 patients had general anesthesia, 4,236 patients had regional anesthesia, and 600 patients had a combined general-regional anesthetic technique.Measurements: Occurrence of perioperative minor adverse events was assessed during the interview. Patient satisfaction was measured with a 4-point Likert scale.Main Results: 3,652 (30%) patients reported at least one perioperative complaint and 737 (6%) patients reported multiple minor adverse events. Overall, a total of 4,475 minor adverse events were reported. Leading adverse events included postoperative nausea and vomiting (1,705 complaints), sore throat (1,228 complaints), and hoarseness (802 complaints). Patient satisfaction with anesthetic care was generally high (97% satisfied or highly satisfied). Patients were significantly more satisfied following regional than general anesthesia (P < 0.001). Patient dissatisfaction was also associated with the occurrence of at least one minor adverse event (P < 0.001) or with increasing ASA physical status (P < 0.001).Conclusion: Minor events occur with a surprisingly high incidence and are significantly associated with patient dissatisfaction. Regional anesthesia is associated with fewer patient complaints and significantly higher postoperative patient satisfaction.

Nitric oxide index is not a predictor of cognitive dysfunction following laparotomy

2010-02-01

Abstract: Study Objective: To determine the associations between postoperative cognitive dysfunction (POCD) and plasma concentrations of stable nitric oxide products [nitric oxide index (NOi)].Design: Prospective study.Setting: Academic hospital.Patients: 28 ASA physical status I, II, and III physical status patients undergoing major non-cardiac surgery.Interventions: Cognitive assessment was performed preoperatively and postoperatively at 4 days (early) and 6 weeks (late).Measurements: Serial measurements of plasma NOi were recorded.Main Results: Early POCD with a deficit in one cognitive domain was present in 18 patients (64%), and in 8 patients (28%) with deficits in two or more cognitive domains. Late POCD was evident in three patients (20%) who had a deficit in one domain. Eight patients were lost to late follow-up. There was no difference in baseline or subsequent serum concentrations of NOi between those who showed early and late POCD and those who showed no POCD.Conclusion: Factors other than nitric oxide-mediated injury is responsible for POCD following major non-cardiac surgery.

Factors affecting parental satisfaction following pediatric procedural sedation

Vincent K. Lew, Kirk Lalwani, Tonya M. Palermo — 2010-02-01

Abstract: Study Objective: To investigate factors affecting parental satisfaction with a pediatric sedation service in a university hospital setting.Design: Prospective, observational study with interviews using a survey instrument.Setting: Academic university hospital.Subjects: Parents (or legal guardians; hereafter “parents") of 220 children scheduled for sedation with the hospital's pediatric sedation service.Interventions and Measurements: Caregivers of children scheduled for sedation were interviewed using a validated survey instrument. The instrument was designed to investigate the quality of communication, environment, care provided, and the overall experience. We followed patients by telephone the day after discharge. Chi-square or linear-by-linear association tests were used to evaluate associations between satisfaction scores and demographic variables; the Mann-Whitney test was used for mean levels of satisfaction in anxious versus non-anxious children.Main Results: Of 222 parents approached, 220 agreed to participate (response rate = 99.1%). Significant associations between each area of satisfaction and parents' overall satisfaction existed (P < 0.001). Previous sedations, types of sedation, age of child, or any individual provider were not significantly associated with overall satisfaction. Caregivers of anxious children reported less satisfaction than caregivers of non-anxious children. Parents of children who underwent magnetic resonance imaging reported the lowest mean satisfaction scores.Conclusions: Overall satisfaction was high, and care provided by anesthesiologists was significantly associated with overall satisfaction. A site in our institution was associated with significantly lower satisfaction as a result of inadequate space and privacy.

A comparative study of dexmedetomidine with midazolam and midazolam alone for sedation during elective awake fiberoptic intubation

2010-02-01

Abstract: Study Objective: To evaluate the efficacy of dexmedetomidine with midazolam (DEX-MDZ) versus midazolam only (MDZ) for sedation during awake fiberoptic intubation (AFOI).Design: Randomized, double-blinded study.Setting: Academic medical center.Subjects: 55 ASA physical status I, II, III, and IV patients, aged 18-85 years, scheduled for non-emergency surgery with AFOI.Interventions: All patients received intravenous (IV) glycopyrrolate 0.2 mg premedication, oxygen by nasal cannula, and topical local anesthetics to the airway. MDZ subjects received IV midazolam 0.05 mg/kg with additional doses to achieve a Ramsay Sedation Scale (RSS) score of ≥ 2. DEX-MDZ patients received midazolam 0.02 mg/kg followed by dexmedetomidine one μg/kg, then an infusion of dexmedetomidine 0.1 μg/kg/hr and titrated to 0.7 μg/kg/hr to achieve RSS≥2.Measurements: Observers' Assessment of Alertness/Sedation (OAA/S) and RSS were evaluated. The anesthesiologist rated AFOI ease of placement. Two observers rated patients' comfort and reaction to placement at three time points: preoxygenation, at introduction of the fiberoptic laryngoscope, and at introduction of the endotracheal tube (ET) before surgery. Following surgery, patients were asked if they recalled the AFOI and also to rate their satisfaction with the intubation.Results: DEX-MDZ patients were significantly calmer and more cooperative during AFOI and had fewer adverse reactions to AFOI than did the MDZ patients. They also were more satisfied with the AFOI (P < 0.001) than were the midazolam-only patients. There were no significant hemodynamic differences between the two subject groups.Conclusions: Dexmedetomidine in combination with low doses of midazolam is more effective than midazolam alone for sedation in AFOI.

Anesthetic considerations in 65 patients undergoing unilateral pneumonectomy: problems related to fluid therapy and hemodynamic control

Koichi Suehiro, Ryu Okutani, Satoru Ogawa — 2010-02-01

Abstract: Study Objective: To examine perioperative management and complications in patients undergoing pneumonectomy.Design: Observational cohort study.Setting: University-affiliated city hospital.Measurements: 65 patients who underwent unilateral pneumonectomy for resection of lung cancer between March 1997 and October 2007 were included in this study. Patients who underwent pneumonectomy were then classified into two groups: Group C patients had signs of postoperative acute right heart failure, and Group N patients had no signs of postoperative acute right heart failure.Main Results: In the pneumonectomy patients, extubation did not occur in 8 patients (12%) and postoperative death occurred in 4 patients (6%), compared with no such occurrences among patients who underwent lobectomy. Perioperative respiratory function was significantly lower in Group C (P < 0.05) than Group N. Fluid infusion volume, fluid balance volume, intraoperative total fluid balance, urine output volume, blood loss volume, blood transfusion volume, times of administration of vasopressors intraoperatively, and number of patients requiring intraoperative administration of catecholamines were significantly greater in Group C (P < 0.05) than Group N.Conclusions: Fluid infusion volume, fluid balance volume, intraoperative total balance, blood loss volume, and blood transfusion volume were important intraoperative risk factors in the development of postoperative right-sided heart failure.

Bradycardia leading to asystole during dexmedetomidine infusion in an 18 year-old double-lung transplant recipient

Xiaopeng Zhang, Ulrich Schmidt, John C. Wain, Luca Bigatello — 2010-02-01

Abstract: The case of an 18 year-old double-lung transplant recipient recovering from acute respiratory distress syndrome who developed repeated episodes of bradycardia and asystole (maximum duration: 10 sec) during dexmedetomidine administration is presented. Increased baseline vagal tone, paroxysmal coughing spells, and opioid administration were likely contributors to the episodes. Discontinuation of the drug restored regular sinus rhythm. Double-lung transplant recipients may be at especially increased risk for this phenomenon as a result of changes in the autonomic innervation of the heart.

Clinical course of pain in a patient with neuropathic pain induced by ligation of an intercostal nerve

Jitsu Kato, Dai Gokan, Noriya Hirose, Miyako Baba, Toru Ehara, Setsuro Ogawa — 2009-10-26

Abstract: A patient with severe right chest pain and mechanical allodynia induced by an intercostal drainage tube to his chest is presented. It was not relieved by treatment with diclofenac sodium and was worsened by movement and touch to the right chest wall. Mechanical allodynia was also present. The patient's wrenching pain disappeared immediately after stitch removal, but the dull pain and mechanical allodynia persisted, gradually decreasing to zero in 7 days.

Unusual presentation of perioperative ischemic optic neuropathy following major spine surgery

2010-02-01

Abstract: Perioperative visual loss following spinal surgery has become of increasing concern among anesthesiologists, surgeons, and patients alike. Perioperative ischemic optic neuropathy often occurs in patients greater than 50 years of age, in association with a number of presumed risk factors, including diabetes, hypertension, small cup-to-disc ratio, preoperative anemia, intraoperative hypotension, prolonged operative time in the prone position, and significant blood loss during surgery. The visual loss is notably devastating, and generally leads to permanent disability. A 44-year-old man whose central visual acuity was completely preserved is presented.

Trigeminal nerve and facial nerve palsy after combined spinal-epidural anesthesia for cesarean section

Jie-Yu Fang, Jian-Wen Lin, Qiang Li, Nan Jiang, Yu Gao — 2010-02-01

Abstract: A case of emergency cesarean section due to a prolonged second stage of labor in a 29 year-old woman is presented. She had trigeminal nerve and facial nerve palsy after combined spinal-epidural anesthesia for cesarean section.

Early misconceptions about nitrous oxide, an “invigorating” asphyxiant

Theodore A. Alston — 2009-10-23

Abstract: Well into the twentieth century, nitrous oxide was often suspected to support life in the manner of oxygen. Authorities contributing to that life-threatening misimpression include Humphry Davy, Gardner Q. Colton, and George W. Crile. Concomitantly, deprivation of oxygen was long touted as a requisite for nitrous oxide anesthesia.

Perioperative transient left ventricular apical ballooning syndrome: Takotsubo cardiomyopathy: a review

Suyan Liu, Mohammed Saeed Dhamee — 2010-02-01

Abstract: Transient left ventricular apical ballooning syndrome (TLVAB), also known as Takotsubo cardiomyopathy, is a cardiac syndrome characterized by transient left ventricular dysfunction in the absence of obstructive atherosclerotic coronary artery disease. An episode of emotional and/or physiologic stress frequently precedes presentation of this syndrome. TLVAB may initially present as an acute coronary syndrome characterized by chest pain, pulmonary edema, electrocardiographic changes, elevated cardiac enzymes, and cardiogenic shock. This syndrome is still underestimated today and the potential appearance of TLVAB during the perioperative period can be a great challenge. Adequate β-blockade is the mainstay in the treatment of patients with TLVAB during the acute phase and also for long-term management.

Complications associated with 2-octyl cyanoacrylate (Dermabond™): considerations for the anesthesiologist

Narasimhan Jagannathan, Matthew Hallman — 2010-02-01

Cyanoacrylate is the active ingredient in many adhesives, including Super Glue® (Super Glue Corp., Rancho Cucamonga, CA, USA). 2-Octyl cyanoacrylate, or Dermabond™ (Ethicon, West Somerville, NJ, USA) is a new adhesive intended for topical application to hold closed easily approximated skin edges of wounds from surgical incisions .

Atracurium-like decomposition of remifentanil

Theodore A. Alston — 2010-02-01

It is not widely appreciated that the enzyme-independent decomposition of atracurium and cisatracurium is shared by another drug in anesthesia. Remifentanil undergoes an analogous reaction.

Nasotracheal intubation using the Airway Scope with the gum elastic bougie and modified guideless blade

Tsuyoshi Tagawa, Masahiro Okuda, Shigeki Sakuraba — 2010-02-01

Nasotracheal intubation is often required for dental and oral surgery. In conventional nasal intubation, direct laryngoscopy using the Macintosh laryngoscope and Magill forceps or the fiberoptic bronchoscope is applied. However, both of these methods are somewhat difficult to master by personnel who do not often perform nasotracheal intubation.

Patient safety in regional anesthesia: preventing wrong-site peripheral nerve block

Tanya O'Neill, Patrick Cherreau, Herve Bouaziz — 2010-02-01

“I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone….” Extract from the Hippocratic Oath, translated from the Greek,

Ouch! My hand burns

Aaron M. Joffe, Richard Galgon, Elaine C. Liew — 2010-02-01

We read with interest the report of Austin and Parke , regarding the comparative effects of admixtures of propofol 1% with either ephedrine hydrochloride (HCL) or lidocaine HCl on infusion pain and hemodynamic tolerance to anesthesia induction. Based on the theory that a reduction in pH of the propofol emulsion results in more unionized, lipid-phase drug and less free, aqueous phase drug to bind to vascular receptors (which causes injection pain), the authors hypothesized that an admixture of propofol 1% and ephedrine HCl 3% (either one mg or 1.5 mg ephedrine per mL of propofol) would be as effective as adding lidocaine HCl (one mg lidocaine per mL of propofol) in reducing injection pain. Indeed, their hypothesis appears correct, as the occurrence of infusion pain was similar among three groups of patients who received propofol 1% admixed with either lidocaine HCl (one mg/mL) or ephedrine HCl (one mg/mL and 1.5 mg/mL). An additional reported benefit of the propofol/ephedrine admixtures was that no patient required rescue medication for hypotension following induction of anesthesia. Thus, they concluded that adding ephedrine to propofol is as effective in reducing injection pain as adding lidocaine to propofol, with the added benefit of improved hemodynamic tolerance to induction of anesthesia, but they cautioned not to generalize their findings to brand formulations other than those used in this study.

Journal of Clinical Anesthesia

Editorial Board

Contents

Dexmedetomidine is an excellent agent for sedation status-post lung transplant

The frequency of fentanyl-induced cough in children and its effects on tracheal intubation

Comfort and satisfaction during axillary brachial plexus block in trauma patients: comparison of techniques

Postoperative patient complaints: a prospective interview study of 12,276 patients

Nitric oxide index is not a predictor of cognitive dysfunction following laparotomy

Factors affecting parental satisfaction following pediatric procedural sedation

A comparative study of dexmedetomidine with midazolam and midazolam alone for sedation during elective awake fiberoptic intubation

Anesthetic considerations in 65 patients undergoing unilateral pneumonectomy: problems related to fluid therapy and hemodynamic control

Bradycardia leading to asystole during dexmedetomidine infusion in an 18 year-old double-lung transplant recipient

Clinical course of pain in a patient with neuropathic pain induced by ligation of an intercostal nerve

Unusual presentation of perioperative ischemic optic neuropathy following major spine surgery

Trigeminal nerve and facial nerve palsy after combined spinal-epidural anesthesia for cesarean section

Early misconceptions about nitrous oxide, an “invigorating” asphyxiant

Perioperative transient left ventricular apical ballooning syndrome: Takotsubo cardiomyopathy: a review

Complications associated with 2-octyl cyanoacrylate (Dermabond™): considerations for the anesthesiologist

Atracurium-like decomposition of remifentanil

Nasotracheal intubation using the Airway Scope with the gum elastic bougie and modified guideless blade

Patient safety in regional anesthesia: preventing wrong-site peripheral nerve block

Ouch! My hand burns