Postoperative pulmonary complications in older patients undergoing elective surgery with a supraglottic airway device or tracheal intubation

The two most commonly used airway management techniques during general anaesthesia are supraglottic airway devices and tracheal tubes. In older patients undergoing elective non-cardiothoracic surgery under general anaesthesia with positive pressure ventilation, we hypothesised that a composite measure of in-hospital postoperative pulmonary complications would be less frequent when a supraglottic airway device was used compared with a tracheal tube. We studied patients aged ≥ 70 years in 17 clinical centres. Patients were allocated randomly to airway management with a supraglottic airway device or a tracheal tube. Between August 2016 and April 2020, 2900 patients were studied, of whom 2751 were included in the primary analysis (1387 with supraglottic airway device and 1364 with a tracheal tube). Pre-operatively, 2431 (88.4%) patients were estimated to have a postoperative pulmonary complication risk index of 1-2. Postoperative pulmonary complications, mostly coughing, occurred in 270 of 1387 patients (19.5%) allocated to a supraglottic airway device and 342 of 1364 patients (25.1%) assigned to a tracheal tube (absolute difference -5.6% (95%CI -8.7 to -2.5), risk ratio 0.78 (95%CI 0.67-0.89); p < 0.001). Among otherwise healthy older patients undergoing elective surgery under general anaesthesia with intra-operative positive pressure ventilation of their lungs, there were fewer postoperative pulmonary complications when the airway was managed with a supraglottic airway device compared with a tracheal tube.

[Value of hypoxic burden in evaluating the impairments of organ systems in obstructive sleep apnea]

Obstructive sleep apnea (OSA) is a common sleep-disordered-breathing with decreased or even suspended ventilation due to upper airway obstruction, which is characterized by intermittent hypoxia and sleep fragmentation. OSA can damage a variety of organ systems, especially the cardiovascular system, seriously affecting the quality of life of patients. Therefore, more attention is paid to the precise assessment of the impairments of the organ systems caused by OSA and the evaluation of indicators, in order to carry out preventive measures as soon as possible. However, due to the limitations of traditional indicators such as apnea-hypopnea index (AHI) in assessing the severity of disease, it is necessary to explore other alternative indicators to obtain multi-dimensional characteristics of OSA. A promising parameter, hypoxic burden (HB) can better quantify the severity of OSA and capture the disease load of OSA. This review mainly focused on the basic concept, main features, calculating method of HB and its clinical significance in predicting the adverse consequences of OSA, aiming at a better management of patients with OSA.

[Spatial-temporal analysis on the human immunodeficiency virus/acquired immunodeficiency syndrome among permanent residence and migrants in Shanghai, 2005-2015]

Objective: To describe the spatial and temporal characteristics of human immunodeficiency virus/acquired immunodeficiency syndrome(HIV/AIDS) in permanent residents and migrants in Shanghai during 2005 to 2015 and provide suggestions for the HIV/AIDS prevention. Methods: The data of HIV/AIDS was collected from the National HIV/AIDS Comprehensive Information Management System based on report date. The population data was collected from the statistical yearbook of Shanghai. Spatial analysis was conducted using the hotspots model in ArcGIS. SaTScan software was employed to determine the distribution of HIV clusters in space, time or both. Results: During 2005 to 2015, a total of 13 498 cases of HIV/AIDS were reported in Shanghai. The prevalence of HIV increased from 0.025/10(5) (450 cases) to 0.093/10(5) (2 236 cases). The prevalence of AIDS increased from 0.002/10(5) (32 cases) to 0.028/10(5) (683 cases). Hotspot analysis showed that the hot spot of incidence of migrants had moved from Hongkou (2005) (Z=2.96, P=0.003) to Changning (2006-2015) (all Z>1.96, P<0.05); whereas the hot spot of incidence of permanent residents had moving from Jinshan (2005-2007) (all Z>2.58, P<0.01) to downtown area (2006-2015) (all Z>1.96, P<0.05). The spatial high clusters of HIV and AIDS were same, including Huangpu, Xuhui, Changning, Jingan, Putuo, Hongkou and Yangpu; The temporal high clusters of HIV cases among permanent residents were 2011 to 2015, and the spatial clusters were Huangpu, Xuhui, Changning, Jingan. The temporal high clusters of HIV cases among migrants were 2014 to 2015, and the spatial clusters was Xuhui, Changning, Jingan. Conclusion: The total HIV/AIDS incidence in Shanghai was clustered in downtown area. The cluster of the incidence of the permanent residents had moving towards that of migrants, indicating the cluster area deserves a close surveillance.

Growth responses of broiler chickens to different periods of artificial light

This study aimed to establish response curves between broiler chicken growth parameters and artificial light periods, as opposed to optimizing a lighting regimen for broiler production. Medium-growing broiler chickens were illuminated for periods of 12, 14, 16, 18, 20, 22, or 24 h each day. The BW of the broilers were significantly influenced by light periods ( < 0.05). Moreover, BW responded to light periods in a linear fashion, suggesting that long light periods result in greater BW. In addition, a linear relationship was found between feed intake and light periods. However, the relationship between shank length and light period was quadratic. When the light period was too short (12 h) or too long (24 h), the light stimulus did not enhance shank growth in the broiler chickens ( < 0.05). In addition, a quadratic relationship between the quantity of abdominal adipose tissue and light period suggested that the quantity of abdominal adipose decreases when the period of the light stimulus was too short or too long ( < 0.05). Moreover, a broken-stick analysis suggested that the triiodothyronine (T3) concentration in the blood was minimally affected beyond 18 h ( = 0.267), although a quadratic relationship was found between the period (from 18 to 24 h) and T3 concentrations in the blood. The response curves established in the present study will be valuable for designing future lighting regimes for medium-growing broiler strains.

A paraspinal abscess following spinal anaesthesia for caesarean section and patient-controlled epidural analgesia for postoperative pain

We present a rare case in which a healthy parturient developed a paraspinal abscess after spinal anaesthesia for caesarean section and epidural analgesia for postoperative pain management. The catheter was in situ for 58 h. Backache was the initial and major symptom. A concealed course with no neurological deficit resulted in a delayed diagnosis and treatment in this case. The infection was not diagnosed until 20 days after the removal of the epidural catheter when there was a purulent discharge from the epidural puncture site. Surgical drainage was required. Anaesthesiologists should be aware that serious epidural analgesia-related infections can happen in extra spinal-epidural spaces. Vigilance for these infections, especially in postpartum patients with backache, is needed.

Postoperative right atrial and pulmonary embolism after prolonged spinal surgery

Perioperative pulmonary thromboembolism can proceed rapidly with grave prognosis, in which immediate or accurate diagnosis and management is not easy. According to the literatures, patients receiving spinal surgery are at relatively lower risk of developing thromboembolism. We would like to present a case of postoperative pulmonary thromboembolism which developed after a prolonged lumbar spinal surgery. Tachycardia and unstable hemodynamics were noted postoperatively. Pulmonary and right atrial thrombi were disclosed by transesophageal echocardiography. Although cardiotomy and thrombectomy were immediately performed, the patient finally died 3 days after the operation. The pathogenesis of venous thromboembolism (VTE) in the surgical patients, the risk factors which predispose a patient to VTE, diagnosis, and treatment as well as the prophylactic measures of VTE are herein reviewed and discussed.

Postoperative pulmonary edema after cervical spine surgery--a case report

Injury of the cervical spine may cause serious complications and neurological sequelae. Recently, a patient with C1-2 spinal cord compression developed pulmonary edema postoperatively associated with unstable hemodynamics, which might result from overzealous fluid administration in order to correct neurogenic shock during anesthesia. Therefore, early recognition and timely use of vasoconstrictors, together with judicious fluid replacement are important in the anesthetic management of patients with cervical spine injury undergoing surgery. In addition, the placement of pulmonary artery catheter is crucial for assessing the cardiac function and fluid status.

Normative data of quantitative thermal and vibratory thresholds in normal subjects in Taiwan: gender and age effect

BACKGROUND

Quantitative sensory testing has gained popularity as a tool in the diagnosis of peripheral neuropathies. This study aims to establish normative data of quantitative thermal and vibratory thresholds in normal subjects in Taiwan. In addition, we also examined the effect of age and gender differences on these thresholds.

METHODS

The study included 100 healthy subjects (50 males and 50 females) who were admitted for regular physical examination. The quantitative testing of thermal, cold and vibratory sensations were performed having recourse to a Thermotest instrument applied on the right hand and foot of these subjects. Measurements included perception thresholds of warm (WT), cold (CT), heat pain, cold pain and vibration as well as a visual analog pain scale.

RESULTS

Age was comparable between the sexes, but the male subjects were taller than the female subjects. A higher WT and CT in the hand, but not in the foot, were found in the male subjects in comparison with the female subjects. Heat pain threshold and cold pain threshold of both sites did not significantly differ between genders. Moreover, the groups did not differ in vibration threshold and visual analog pain scale. Young subjects (age < 30 years) showed a higher CT in the foot than the older subjects (age > 50 years). None of the above parameters were different between these two age groups. Overall, the age or height bore no significant relation to the difference between WT and CT (DDWT-CT).

CONCLUSIONS

The female subjects were found to be more sensitive to warm and cold stimulation in the hand than their counterparts. These results have provided valuable normative data on sensory perceptive thresholds in Taiwanese, which are useful as a tool in the diagnosis of peripheral neuropathy.

Unexpected transurethral resection of prostate syndrome complicated with acute myocardial infarction during transurethral incision procedure--a case report

Transurethral incision (TUI) is a simple and safe procedure. We, herein, present a case undergoing transurethral incision procedure during which he developed transurethral resection of prostate syndrome (TURP syndrome) and hypothermia precipitating an acute perioperative myocardial infarction attack. The potential risk of development of TURP syndrome in settings other than TURP surgery as well as its prevention are reviewed and discussed.

Effects of high thoracic epidural anaesthesia on the peripheral airway reactivity in dogs

BACKGROUND

It has been speculated that epidural anaesthesia may induce bronchoconstriction via the mechanism of a sympathetic blockade. However, this hypothesis has not been confirmed by any experimental evidence. Therefore, we investigated the effects of high thoracic epidural anaesthesia with neural sympathetic blockade on basal airway resistance and airway reactivity in response to bronchoconstrictive stimuli in a canine periphery lung model.

METHODS

Acetylcholine (Ach, 8 microg kg[-1] i.v.) or histamine (His, 3 microg kg[-1] i.v.) was administered to 7 anaesthetized mongrel dogs before and after thoracic epidural anaesthesia. Successful neuronal sympathectomy was confirmed by nitroglycerin test. The changes of peripheral airway resistance (Rp), haemodynamics, cardiac output (CO), and the recovery time for Rp from peak returning to baseline in each challenge were studied.

RESULTS

Thoracic epidural anaesthesia altered neither the baseline Rp nor the peak Rp evoked by Ach or His. However, the recovery time of the Rp was prolonged significantly after epidural anaesthesia (P<0.01) and correlated inversely with the CO in response to Ach or His challenge (Ach, r=0.542; His, r=0.651).

CONCLUSIONS

Our results suggest that epidural anaesthesia with neural sympathetic blockade has no influence on the basal peripheral airway resistance; however, it prolongs the airway reactivity to Ach or His challenge, probably by the mechanism of reducing CO.

The interaction of diazepam with vecuronium: a clinical study

BACKGROUND

Diazepam, known to possess myorelaxation property, has been widely used clinically to control muscular rigidity and spasticity. The interactions of diazepam with neuromuscular blocking agents have been extensively studied, yet the results reported are somewhat controversial and inconclusive.

METHODS

The interaction of diazepam with one of the neuromuscular blocking agents, vecuronium, was studied in 20 ASA I-II patients undergoing elective surgery. They were randomly assigned to two groups with ten in each group. Anesthesia was induced with fentanyl, thiopental and vecuronium and maintained with 1% halothane and 70% N2O in O2. The experimental group received diazepam (0.2 mg/kg) 3 minutes prior to vecuronium (0.1 mg/kg) during induction while the control group received vecuronium (0.1 mg/kg) straight without diazepam. Control records of the integrated electromyography showed the response to train-of-four supramaximal stimulation by a Datex Relaxograph during induction. In no time when the first twitch (T1) recovered to 25% of the control, it was topped up again with another intraoperative dose of vecuronium (0.025 mg/kg). From the derived data, the following parameters were calculated and analysed: (1) onset time T10 (the time from the end of injection of vecuronium during induction to depression of T1 to 10% of control twitch height); (2) duration time T25 (the time from administering vecuronium during induction to the time when T1 recovered to 25% of the original twitch height); (3) topup time T25-25 (the time from administering the top dose of vecuronium to the time when T1 returned to 25% of control twitch height again) and (4) recovery time T25-50 (the time of recovery of T1 from 25% to 50% of the control twitch height at the end of the operation).

RESULTS

Significant differences between both groups were found in T10 (221.8 +/- 62.2 vs 135.4 +/- 23.3 sec, p < 0.01) and T25 (41.9 +/- 10.2 vs 50.6 +/- 9.4 min, p < 0.05). The results of T25-25 and T25-50 did not differ much (26.6 +/- 6.9 vs 29.3 +/- 4.4 min, p > 0.05 and 15.0 +/- 8.9 vs 16.9 +/- 8.7 min, p > 0.05 respectively).

CONCLUSIONS

The administration of diazepam (0.2 mg/kg) three minutes prior to vecuronium (0.1 mg/kg) during induction may hasten the onset of vecuronium and prolong its duration of action.

Fatal gas embolism as a complication of Nd-YAG laser surgery during treatment of bilateral choanal stenosis

A 40-day-old infant boy underwent Nd-YAG laser surgery because of congenital bilateral choanal stenosis. Cyanosis and cardiovascular collapse occurred during the operation. Resuscitation was initiated, but in vain; the patient died. The evolution of clinical events was consistent with a diagnosis of gas embolism. In the investigation of causes, the use of a sapphire tip with the Nd-YAG laser and the cooling of the tip with N2 gas were thought to have contributed to the fatal outcome. The authors warn of the potential risk of gas embolism with the Nd-YAG laser and a coaxial gas cooling system, and they emphasize the importance of monitoring for gas embolism in high-risk patients.