Cost-Effectiveness of First-Line Atezolizumab versus Chemotherapy in Non-Small-Cell Lung Cancer Patients Ineligible for Platinum-Containing Regimens

Purpose

The IPSOS study provided evidence supporting the efficacy and tolerability of first-line atezolizumab compared to single-agent chemotherapy for non-small-cell lung cancer (NSCLC) patients ineligible for treatment with a platinum-containing regimen. This study aimed to assess the cost-effectiveness of atezolizumab specifically in this population, considering the perspective of the Chinese healthcare system.

Patients and Methods

In this analysis, a three-state Markov model was utilized. The survival data were derived from the IPSOS clinical trial. Direct medical costs and utility values were collected from national authoritative database and published literature. The primary outcomes were costs, quality-adjusted life-years (QALYs) and incremental cost-effectiveness ratio (ICER). To ensure the robustness of our model, both one-way and probabilistic sensitivity analyses were conducted.

Results

Atezolizumab monotherapy led to an increase in costs of $4139.23 compared to single-agent chemotherapy. Additionally, it resulted in a gain of 0.14 QALYs, leading to an ICER of $29,365.79 per QALY, which was below the willingness-to-pay threshold of $36,066 per QALY used in the model. One-way sensitivity analyses revealed cost of atezolizumab and utility of progressive disease (PD) as major influencing factors for ICER. Furthermore, probabilistic sensitivity analyses confirmed our base-case results.

Conclusion

From the perspective of the Chinese healthcare system, atezolizumab emerges as a cost-effective choice for the first-line treatment of NSCLC patients ineligible for platinum-based chemotherapy.

[Analysis of suspected occupational diseases cases and subsequent diagnosis follow-up investigation in Hubei Province from 2020 to 2021]

Objective: To understand the epidemiological characteristics of suspected occupational diseases cases, and to track the subsequent diagnosis of suspected cases in Hubei Province from 2020 to 2021, and to provide theoretical basis for the supervision of suspected occupational diseases. Methods: In April 2022, the data of suspected occupational diseases cases and occupational diseases in Hubei Province from 2020 to 2021 were collected by the Occupational Diseases and Health Risk Factors Information Surveillance System. The distribution and diagnosis of suspected occupational diseases cases were analyzed. We investigated undiagnosed suspected occupational diseases by telephone. Results: From 2020 to 2021, a total of 1872 cases of suspected occupational diseases in 6 categories and 18 species were reported in Hubei Province. The top three suspected occupational diseases were suspected occupational noise deafness (36.75%, 688/1872), suspected coal worker's pneumoconiosis (33.07%, 619/1872) and suspected silicosis (20.99%, 393/1872). The diagnosis rate of suspected occupational diseases was 33.60% (629/1872). The rate of confirmed diagnosis was 63.59% (400/629). The diagnosis rate (26.86%, 456/1698) and rate of confirmed diagnosis (55.48%, 253/456) of suspected occupational diseases detected by occupational health examination were the lowest. The diagnosis rate of suspected occupational diseases detected by comprehensive medical institutions and private medical institutions were lower than disease prevention and control institutions and occupational disease prevention center (P<0.05). The main reasons for not entering the diagnostic procedure included that workers were not informed that they were diagnosed as suspected occupational diseases (31.55%, 124/393), workers were unwilling to apply for occupational disease diagnosis (18.56%, 73/393), and some workers planned to apply for diagnosis but had not yet applied (10.69%, 42/393) . Conclusion: Occupational noise deafness, coal worker's pneumoconiosis and silicosis are the main diseases of suspected occupational diseases in Hubei Province. In order to increase the diagnosis rate and confirmed diagnosis rate of suspected occupational diseases, it is suggested to strengthen management and supervision from the aspects of case management, information warning and worker notification.

[Epidemiological characteristics and trend of new cases of occupational pneumoconiosis in Hubei Province from 2011 to 2020]

Objective: The epidemiological characteristics and trend of occupational pneumoconiosis in Hubei Province from 2011 to 2020 were analyzed to provide a theoretical basis for the development of prevention and control strategies for occupational pneumoconiosis. Methods: In March 2021, the data of newly occupational pneumoconiosis in Hubei Province from 2011 to 2020 were collected by the Occupational Diseases and Health Risk Factors Information Surveillance System. Descriptive statistics were adopted to analyze basic situation, region, industry, type of disease, year of diagnosis, age of onset and dust exposureduration of the cases. Results: From 2011 to 2020, a total of 7203 new cases of occupational pneumoconiosis were reported in Hubei Province, including 7125 (98.92%) men and 78 (1.08%) women. The average age of onset was (54.03±10.12) years old. The average duration of dust exposure was (13.80±9.56) years. The mainly types of pneumoconiosis were coal worker's pneumoconiosis (3593 cases, 49.88%) and silicosis (3301 cases, 45.83%). The cases included 4814 cases (66.83%) of stage Ⅰ pneumoconiosis, 1270 cases (17.63%) of stage Ⅱ and 1119 cases (15.54%) of stage Ⅲ. New cases mainly distributed in Yichang City (1586 cases, 22.02%), Shiyan City (1257 cases, 17.45%), Enshi Tujia and Miao Autonomous Prefecture (1050 cases, 14.58%) and Huangshi City (1009 cases, 14.01%), and occurred most frequently in coal mining and washing industry (3743 cases, 51.96%) and nonmetallic mining industry (582 cases, 8.08%). Pneumoconiosis patients of stage Ⅲ were mainly distributed in small enterprises (401 cases, 50.25%) and domestic enterprises (796 cases, 99.75%) . Conclusion: Coal worker's pneumoconiosis and silicosis accounted for the vast majority pneumoconiosis in Hubei Province. The new cases show obvious regions, industries and type of disease distribution. We should strengthen occupational health supervision in small and domestic enterprises.

[The application of Chinese version of anterior skull base questionnaire (ASBQ) in patients with anterior and middle skull base tumors]

Objective: To develop the Chinese version of anterior skull base questionnaire(ASBQ) and to verify its application in patients with anterior and middle skull base tumors. Methods: The following steps were finished including getting the permission from the author of the original English scale, translating and back-translating, tentative test, discussing the consequence and cultural debugging. From October 2016 to December 2018, 51 patients with skull base tumors from Xuanwu Hospital and China-Japan Friendship Hospital were enrolled as an experimental group, aged from 24 to 70 years old, with 19 males and 32 females, which included 27 patients with anterior skull base tumor and 24 patients with middle skull base tumor. From December 2016 to January 2018, 46 healthy volunteers were selected as a control group, aged from 18 to 36 years old, including 26 females and 20 males. The subjects in the test group and the control group were rigorously tested with official manuscripts and judged whether the manuscript was applicable. The SPSS 22.0 statistical software was used to analyze the data of the test group, the anterior skull base group, the middle skull base group and the control group to evaluate the performance of the scale. Results: Both the rate of the recovery and efficiency in experimental group, anterior skull base group and middle skull base group were 100%, with the average time of completion of (8.7±3.2), (11.2±4.0) and (7.3±2.1) min, respectively in each group. The r value of test-retest reliability was 0.96, 0.99 and 0.97 in experimental group, anterior skull base group and middle skull base group, with the split-half reliability coefficient of 0.91, 0.90 and 0.96, with the entire scale Cronbach's coefficient of 0.91, 0.95 and 0.93, respectively. The content validity and the construct validity of the scale were good enough, and the criteria validity was-0.483,-0.509 and -0.489 in experimental group, anterior skull base group and middle skull base group. The scale could well distinguish the difference of the quality of life between the preoperative and postoperative patients in experimental group and the middle skull base group. The difference of the quality of life in anterior skull base group was not found between preoperative and postoperative patients. Conclusion: The Chinese version of ASBQ has good reliability and validity, which is suitable for a wide range of Chinese patients with anterior and middle skull base tumors to assess their quality of life.

[An investigation of reproductive health in female workers engaged in administrative management]

Objective: To investigate the reproductive health status of female workers engaged in administrative management, and to provide a reference for protecting the reproductive health of female workers. Methods: From April to November, 2016, a cross-sectional survey was performed for 2717 female workers aged 18-60 years and engaged in administrative management from 13 cities and provinces in China, and a questionnaire was used to investigate their general information, occupational hazards in workplace, and reproductive health status, and the reproductive health status of female workers was analyzed. Results: Of all 2 717 female workers, 1 170 had gynecological diseases or symptoms, resulting in an incidence rate of 43.06%, and among these workers, 11.15% had abnormal menstruation, 34.64% had infertility, and 38.76% had a history of abortion. There were significant differences in the rates of abnormal results of gynecological examination, abnormal menstruation, abortion, and infertility between the female workers in different age groups (P<0.01) . Unhealthy living habits and major events were risk factors for gynecological diseases, abnormal menstruation, and abortion (P<0.05) ; bad working status was a risk factor for gynecological diseases and abortion (P<0.05) ; exposure to harmful factors was a risk factor for gynecological diseases and abnormal menstruation (P<0.05) . Conclusion: Living habits, major events, working status, and occupational harmful factors have certain influence on reproductive health of female workers engaged in administrative management. Occupational health protection should be strengthened, working patterns should be improved, self-protection awareness should be raised, and health protection should be enhanced for women of childbearing age to protect and promote the reproductive health of female workers.

[The impact of resection of skull base tumor via an endoscopic endonasal approach on the visual function of vision impaired patients and the analysis of factors affecting their visual recovery]

Objective: To evaluate the visual outcomes of patients with visual impairment after resecting skull base tumor via an endoscopic endonasal approach, and to analyze the factors affecting visual recovery. Methods: One hundred and fifty-three patients with skull base tumor who suffered from preoperative visual impairment from Skull Base Surgery Center of Xuanwu Hospital were operated through an endoscopic endonasal approach. Both preoperative and postoperative visual function outcomes as well as factors that might have affected their visual recovery were analyzed retrospectively by Chi square test and Logistic regression analysis. Results: Complete resection was achieved in 85.6% of the patients using this technique. The rate of postoperative visual recovery in the female group (86.1%) was higher than that in the male group (73.9%), the benign group (90.2%) higher than the malignant group (20.0%), the group without optic atrophy (97.1%) higher than the one with (51.2%), and the acute group (96.6%) higher than the chronic group (80.0%). Significant differences were found between the abovementioned groups (χ(2) value was 5.849, 87.860, 79.757, 4.745, respectively, all P<0.05). The degree of optic atrophy and the property of tumors were significantly associated with visual improvement after treatment (Wold χ(2) value was 18.597 and 35.623, all P<0.001). Conclusions: Our results indicate that endoscopic endonasal surgery shows its ability both to resect skull base tumors and to improve visual function in the majority of patients. The timing of treatment for patients suffered from preoperative visual impairment should be selected in early stage before optic atrophy occurs.

[Occupational health status of electronics manufacturing female employees in China]

Electronics industry is a typical labor-intensive industry in China. There are a lot of female workers and various occupational hazard factors in the workplace. This article reviewed the characteristics of employment of women in electronics industry, occupational hazards of exposure, protective measures, occupational disease situation, influence of reproductive health and mental health, and occupational health management. Electronics female emplyees have the priority in reproductive health and mental health. Besides, this group has poor protective measures, occupational health management and policy should be taken to enhance the level of women health in electronics industry.

Correlation of HLA-DP/DQ polymorphisms with transplant etiologies and prognosis in liver transplant recipients

Previous study has identified that the genetic variants in the human leukocyte antigen (HLA)-DP/DQ region were strongly associated with hepatitis B virus (HBV) infection. But their roles in liver function recovery after hepatic transplantation were still obscure. This study aimed to investigate whether HLA-DP/DQ polymorphisms were associated with post-transplant etiologies and prognosis in Chinese liver transplant recipients.A total of 144 liver transplant recipients were enrolled, which were divided into 2 groups according to the transplant etiology: HBV-related disease and non-HBV-related disease. HBV-related disease includes 3 subgroups: liver cirrhosis, hepatocellular carcinoma, and progressive HBV hepatitis. Three single-nucleotide polymorphisms HLA-DP (rs3077 and rs9277535) and HLA-DQ (rs7453920) were studied in all recipients by high-resolution melting curve analysis. Liver function indices (albumin, alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, gamma-glutamyltranspeptidase, direct bilirubin, total bilirubin) and coagulation indices (prothrombin time, platelet, international normalized ratio, fibrinogen) were routinely tested. After transplant, 10 recipients who were positive for HBsAg or with elevation in HBV virus load were regarded as HBV recurrence.No significant association of HLA-DP/DQ polymorphisms with HBV recurrence or transplant etiology was observed (P < .05). Recipients with HLA-DQ (rs7453920) AG and AA genotype had lower direct bilirubin levels than GG genotype individuals, especially on the 14th day after surgery (17.80 vs. 5.35, P  =  .038). Patients with A alleles displayed earlier liver function recovery than patients with G alleles (7 vs. 6 months). No significant correlation was shown in HLA-DP rs3077 and rs9277535 with HBV infection or liver function recovery (P < .05).Our study concluded that HLA-DP (rs3077 and rs9277535) and HLA-DQ (rs7453920) were not significantly associated with HBV recurrence or HBV susceptibility, but HLA-DQ rs7453920 was related to prognosis of liver transplant recipients. HLA-DQ rs7453920 A might be used as an indicator of earlier recovery and better prognosis after transplantation.

Association between the interleukin 4 gene -590C>T promoter polymorphism and asthma in Xinjiang Uighur children

We investigated the association between the interleukin 4 gene (IL-4) -590C>T polymorphism and forced expiratory volume in one second (FEV1) values, immunoglobulin E (IgE) levels, and susceptibility to asthma in Uighur children. IL-4 -590C>T frequencies were analyzed in 38 bronchial asthmatic patients and 35 non-asthmatic controls. Polymerase chain reaction and direct sequencing were applied to determine the residue at position -590 of IL-4. Total serum IgE levels were detected by enzyme-linked immunosorbent assay, while lung function was examined by professionals. There were significant differences in the distribution of IL-4 -590C>T genotypes and alleles between patient and control groups (genotypes: chi-square = 11.476, P < 0.05; alleles: chi-square = 14.572, P < 0.05). Frequencies of CC, CT, and TT genotypes were 21, 29, and 50% among patients, and 49, 37, and 14% among controls, respectively, indicating that the T allele was significantly more frequent in the asthma group than in the control group. Total serum IgE levels were significantly higher (P < 0.05) and FEV1 values were significantly lower (F = 13.294, P < 0.05) in patients than in control subjects of the same genotype. In conclusion, the IL-4 -590C>T polymorphism is related to bronchial asthma in Uighur children, and the T allele may constitute a susceptibility factor in this group. Furthermore, this genetic variant can result in raised IgE levels and decreased FEV1 values, suggesting that both factors are associated with bronchial asthma in Uighur children.

Comparison of inhalation induction with 2%, 4%, 6%, and 8% sevoflurane in nitrous oxide for pediatric patients

BACKGROUND

Sevoflurane is almost the idealest volatile anesthetic agent regarding inhalation induction of general anesthesia. Previous studies have established a role of sevoflurane in high concentration primed in the circuit for inhalation induction in pediatric patients. However, which concentration of sevoflurane is suitable has not yet been reported. This study was designed to compare the efficiency of different concentration of sevoflurane i.e. 2%, 4%, 6%, and 8% and with N2O in 50% oxygen for induction of anesthesia in pediatric patients and at the same time to evaluate the tolerance of patients.

METHODS

One hundred and twenty children who were 3 to 10 years old, of ASA class I, were randomly assigned to receive either 2%, 4%, 6%, and 8% sevoflurane and N2O in 50% O2 for induction of anesthesia. The time to loss of eyelash reflex, responses of airway reflex, involuntary movement, and hemodynamic responses were recorded.

RESULTS

Ninety-nine children completed the study. The times to loss of eyelash reflex with 2% in sequence to 8% sevoflurane were 114 +/- 21 s, 87 +/- 11 s, 75 +/- 6 s, and 48 +/- 8 s respectively. Incidence of airway reflex response including coughing, laryngospasm, and breath holding was the highest in the 8% group (P < 0.05). Inhalation induction with sevoflurane significantly decreased systolic as well as diastolic blood pressure compared with baseline blood pressure in all the four groups. The extent of decrease of blood pressure was within 20% range of baseline blood pressure in all groups. Significant increase of heart rate was only observed in the 4% and 6% groups.

CONCLUSIONS

Sevoflurane 6% for inhalation induction apparently caused low incidence of adverse effects and hastened induction. We suggest that 6% sevoflurene is a concentration more practical for inhalation induction in pediatric patients.

Epidural phenylephrine attenuates hypotension induced by alkalinized lidocaine epidural anesthesia

In this double-blinded, randomized study, we examined the hemodynamic effects of lumbar epidural injection of alkalinized lidocaine with phenylephrine in 81 patients undergoing inguinal herniorrhaphy. Patients assigned to four equal groups received 20 mL of alkalinized lidocaine (17 mL of 2% lidocaine + 3 mL of 7% sodium bicarbonate) with one of four doses of phenylephrine: 0 (Group 1), 50 (Group 2), 100 (Group 3), or 200 microg (Group 4) injected via a lumbar epidural catheter. Blood pressure, heart rate, and skin temperature on the foot were recorded every 5 min for 1 h after injection and were compared among groups. Hypotension was defined as mean arterial pressure < 80% of baseline. The incidence of hypotension was 45%, 55%, 35%, and 15% in Groups 1-4, respectively. Patients in Group 4 showed the smallest reduction in blood pressure compared with Groups 1 and 2 (one-sided Fisher's exact test, P < 0.05). We conclude that the 200-microg dose of epidural phenylephrine (1:100,000 concentration) reduced the incidence of hypotension after epidural anesthesia with alkalinized lidocaine.

IMPLICATIONS

Hypotension after epidural anesthesia is common in general clinical practice. Phenylephrine administered epidurally in combination with alkalinized lidocaine may reduce the incidence of hypotension.

In vitro diffusion of lidocaine across endotracheal tube cuffs

PURPOSE

Lidocaine diffuses across endotracheal tube cuffs, which may serve as a reservoir for local anesthetic to assist in the prevention of ETT-induced cough while emerging from general anesthesia. However, the rate of diffusion is slow. Two techniques, alkalization and warming, may increase the proportion of uncharged drug available for diffusion. The purpose of this study is to determine the effectiveness of warming alkalization or warming with alkalization on diffusion.

METHODS

Four preparations of lidocaine 4% were studied. Group (Gr) L-lidocaine (24 degrees C), Gr WL--warmed lidocaine (38 degrees C), Gr AL--alkalized lidocaine (24 degrees C), Gr WAL--warmed, alkalized lidocaine (38 degrees C). Twenty-four Mallinckrodt 8.0 ID (Mallinckrodt Critical Care Division of Mallinckrodt, Inc., Glens Falls, New York) endotracheal tube cuffs were filled with 6 ml of one of the four preparations. They were then placed in a 20 ml water bath at 38 degrees C and samples were drawn from the water bath at intervals for up to 360 min. The lidocaine concentration in each sample was determined by gas chromatography.

RESULTS

The highest lidocaine concentration was reached in Gr WAL (410.98 +/- 8.53 micrograms.ml-1) after 300 min and then decreased to 376.18 +/- 4.59 micrograms.ml-1 after 360 min. In Gr AL the highest concentration (235.05 +/- 2.99 micrograms.ml-1) was reached after 360 min. Lidocaine concentrations in Gr L and WL after 360 min were 3.19 +/- 1.16 micrograms.ml-1 and 4.32 +/- 2.02 micrograms.ml-1 respectively.

CONCLUSION

Alkalization with or without warming, but not warming alone, promotes lidocaine diffusion from endotracheal tube cuff.

Comparison of the cuffed oropharyngeal airway and laryngeal mask airway in spontaneous breathing anesthesia

BACKGROUND

The cuffed oropharyngeal airway (COPA) is a modified Guedel airway with a cuff at its distal end and a standard 15 mm connector at its proximal end. This study was performed to determine if the COPA would offer any advantage over the laryngeal mask airway (LMA).

METHODS

Eighty ASA class I to II adult patients scheduled for short elective procedures (less than 1 h) were randomly allocated into two groups. All patients were given atropine 0.01 mg/kg, fentanyl 2 micrograms/kg and propofol 2 mg/kg intravenously for induction of anesthesia. The COPA or LMA was inserted following the loss of eyelash reflex. If the jaw was not relaxed enough for insertion of a COPA or LMA, succinylcholine 1 mg/kg was given to facilitate the insertion. When correctly positioned, the cuff was immediately inflated with an appropriate volume. Gentle positive pressure ventilation was applied before spontaneous breathing resumed. Capnography was used to assess the patency of the airway. Anesthesia was maintained with isoflurane-N2O-O2 until the end of surgery. The success rate, vital signs, and adverse events were evaluated and compared.

RESULTS

The success rate in the LMA group (95%) was higher than the COPA group (85%). The increase in circulatory response after the LMA insertion was greater than that after the COPA insertion (P < 0.05). Nine patients (22.5%) in the LMA group needed succinylcholine to facilitate insertion compared with only two patients (5%) in the COPA group. Additional manipulation was frequently (57.5%) needed after inserting the COPA to maintain the patency of the airways, but none needed so in the LMA group. Two patients had laryngospasms upon removal of the LMA, but none had laryngospasm in the COPA group. The incidence of sore throat in the LMA group was higher than in the COPA group (18% vs. 10%).

CONCLUSIONS

We demonstrated that the COPA could be easily inserted without the need of muscle relaxants in most patients. But the COPA needed airway intervention to provide an effective airway in most patients. Compared with the LMA, the COPA caused less stimulation than the LMA.

Views of obstetric patients who refuse regional anesthesia in cesarean section

BACKGROUND

Regional anesthesia for cesarean section has gained widespread popularity. However, there are still a good few of obstetric patients who refuse it. This study was to investigate the reasons for refusing regional anesthesia in order to gain some insights into the attitudes and concerns of patients.

METHODS

Three hundred and twenty-four obstetric patients scheduled for Cesarean section were interviewed just before entering the operating room. They were asked to give one or two reasons for refusing regional anesthesia.

RESULTS

Two hundreds of them refused regional anesthesia. The most frequent reasons were apprehension of witnessing the operation (auditory or visional) (45.42%) and fear of backache following regional anesthesia (14.58%).

CONCLUSIONS

Anesthesiologists should be aware of patients' feeling or concern and could be capable and willing to discuss with them the relevant problems.

Prevention of coughing induced by endotracheal tube during emergence from general anesthesia--a comparison between three different regimens of lidocaine filled in the endotracheal tube cuff

BACKGROUND

"Deep" extubation, administration of intravenous (i.v.) narcotics, i.v. lidocaine and forestalling local spray of lidocaine have been used to help diminish coughing during emergence. However, the respective efficacy of these techniques has not been concluded. Sconzo et al. indicated that endotracheal tube (ETT) cuff might serve as a reservoir for local anesthetic. Alkalizing and warming are two techniques frequently used to increase in the proportion of uncharged drugs available. Matias indicated that alkalization could prompt a 63-fold increase of the rate of diffusion of lidocaine across the ETT cuff. Huang et al. also observed that alkalization together with warming could achieve a 118-fold increase further. However, the in vivo effects of ETT-cuff lidocaine have not been studied.

METHODS

Eighty patients of ASA Class I-II undergoing elective surgeries were included. They were randomly assigned into four groups. After tracheal intubation, the ETT cuff was filled with one of the following solutions: normal saline 6 ml (Group A), 4% lidocaine 6 ml at room temperature (Group B), 4% lidocaine 5 ml + 7% sodium bicarbonate 1 ml at room temperature (Group C), and 4% lidocaine 5 ml + 7% sodium bicarbonate 1 ml warmed to 38 degrees C (Group D). Changes of vital signs as well as the times of coughing in the course of extubation and post-extubation complications were recorded. One way ANOVA (SPSS for windows) was used for data analysis.

RESULTS

The respective number of coughing per patient in the experimental groups (Group B, C and D) was significantly less than the saline or control group (mean = 9.70, 9.15 and 3.95, respectively, p < 0.05). The incidence of sore throat in Group C and Group D was significantly less than the control group (35% and 25%, respectively, p < 0.05). Regarding the hemodynamic changes, systolic arterial pressure (SAP) and mean arterial pressure (MAP) were higher in Group B and C (p < 0.05) before extubation.

CONCLUSIONS

Alkalized and warmed lidocaine prestored in the endotracheal tube (ETT) cuff can greatly reduce ETT-induced coughing and thus promote a smoother emergence from general anesthesia with endotracheal intubation.

Comparison of local infiltration of tenoxicam and intravenous tenoxicam for postoperative analgesia in herniorrhaphy

BACKGROUND

The major complaint of herniorrhaphy is postoperative pain which occurs during the first 24 h after operation. Tenoxicam has a long half-life of 60-80 h. Local infiltration of the drug concentrates the pain control effects in the local area. The local infiltration dose can be smaller than the recommended systemic dose needfully to reach the target area to be effective. Therefore we studied the effect of preoperative local infiltration of tenoxicam on postoperative pain.

METHODS

Sixty patients, belonging to ASA classes I and II, undergoing unilateral herniorrhaphy, were randomly assigned to 4 groups. General anesthesia was induced with thiamylal 5 mg/kg, fentanyl 2 micrograms/kg, and atracurium 5 mg/kg. Group 1 (G1) patients were preoperatively injected with 10 mg of tenoxicam in 10 ml normal saline or distilled water, in the operative area. Group 2 (G2) and Group 3 (G3) patients were preoperatively given intravenous tenoxicam, 20 mg and 10 mg, respectively. Group 4 (G4) patients were not given preoperative local infiltration or intravenous tenoxicam to serve as control group. The pain score was assessed at 2 h, 9 h, 24 h postoperatively in all groups. We recorded the total amount of acetaminophen used and the form of administration of the analgesic drug. All patients received general anesthesia in uniform technique.

RESULTS

Pain score and amount of analgesic drug required in G1 (local infiltration group) patients were significantly decreased compared with the other groups. The postoperative pain score of Visual Analog Scale (VAS) and analgesic requirement in the four groups were ranked as follows: G1 < G2 < G3 < G4. No significant difference was observed between G2, G3 and G4. Only the pain score in G2 patients significantly decreased (p < 0.05) during the late postoperative period (24 h) when compared with G4 patients.

CONCLUSIONS

Preoperative local infiltration of tenoxicam can decrease postoperative pain score significantly during the most painful period (24 h) in herniorrhaphy.

Enhancement of analgesic effect of intrathecal neostigmine and clonidine on bupivacaine spinal anesthesia

BACKGROUND AND OBJECTIVES

Intrathecal administration of neostigmine has been shown to produce analgesia in both animals and humans. The concurrent administration of intrathecal neostigmine and clonidine has been reported to produce no neurotoxicity in sheep. The purpose of the present study was to evaluate the efficacy and safety of the combining intrathecal neostigmine and clonidine for the relief of pain in patients after cesarean delivery.

METHODS

After giving their consents, 80 parturients who were scheduled for cesarean delivery during spinal anesthesia were enrolled by a double-blind randomized design into four groups: bupivacaine group (n = 20) received intrathecal (i.t.) 10 mg bupivacaine; bupivacaine + neostigmine group (n = 19) received i.t. 10 mg bupivacaine + 50 microg neostigmine; bupivacaine + clonidine group (n = 20) received i.t. 10 mg bupivacaine + 150 microg clonidine; and bupivacaine + both (n = 21) received i.t. 10 mg bupivacaine + 50 microg neostigmine + 150 microg clonidine. The maximum spread of anesthesia, duration of analgesia and motor block, vital signs, and incidence of adverse effects were recorded for 14 hours postinjection. Fifty milligrams intramuscular meperidine was given as a rescue analgesic whenever patient's pain score was greater than 5/10 by the visual analog scale.

RESULTS

The demographic data were similar for all four groups. Bupivacaine + both group had a significantly higher maximum spread of anesthesia of 23.3 +/- 2.9 segments than bupivacaine group of 20.5 +/- 2.9 segment. Bupivacaine + both group showed a later onset of postsurgical pain of 6.5 +/- 1.5 hours as compared to bupivacaine group of 1.3 +/- 0.6 hours. The pain score in bupivacaine + both group was significantly lower than that of bupivacaine group during the first 10 hours. The 24-hour meperidine consumption also was lower in bupivacaine + both group than that of bupivacaine group. However, motor block was significantly prolonged from 3.5 +/- 1.1 hours in bupivacaine group to 7.1 +/- 1.6 hours in bupivacaine + both group. In addition, other side effects such as nausea and vomiting and dizziness were significantly increased in bupivacaine + both group.

CONCLUSION

Our study showed that the combination of 150 microg i.t. clonidine and 50 microg neostigmine provided longer postsurgical analgesia than with either drug used alone. However, this combination also produced significantly more adverse effects of prolonged motor block and nausea and vomiting. A further study combining the two study drugs but using a lower dose of i.t. neostigmine (e.g., 25 microg) is recommended.

Dyspnea resulting from phrenic nerve paralysis after interscalene brachial plexus block in an obese male--a case report

Phrenic nerve paralysis is a common complication in interscalene brachial plexus block. This complication is often ignored by most anesthesiologists because no clinical symptoms occur in patients who have no underlying lung disease. We present a case of an obese male suffering from dyspnea due to phrenic nerve block after interscalene brachial plexus block. The decreased respiratory reserve and direct compressing effect of the abdominal organs on the diaphragm in the supine position are thought to be the risk factors in this obese patient. Also discussed are the incidence, diagnostic methods, clinical presentation and treatments of phrenic nerve paralysis during interscalene brachial plexus block.

Effectiveness of a manually controlled infusion scheme of propofol and alfentanil mixture for endotracheal intubation in hypertensive patients: in comparison with thiamylal and nifedipine plus thiamylal

BACKGROUND

Bolus administration of propofol for induction causes hypotension, especially in elderly hypertensive patient. Carefully titrated infusion of propofol minimizes adverse effects, such as hypotension, and permits a rapid recovery of its central effects. The objective of this study was to investigate the effect of a manually controlled infusion scheme of propofol and alfentanil mixture on hemodynamic stability during induction and endotracheal intubation for hypertensive patient. At the same time, the effectiveness of this scheme was compared with two other induction regimens (thiamylal or nifedipine plus thiamylal).

METHODS

Sixty hypertensive patients undergoing orthopedic surgery were randomized into 3 groups (n = 20 per each group), None of the patients received premedication. Anesthesia was induced in group 1 (G1) with alfentanil 10 micrograms/kg. 30 s later, manual infusion of a mixture of propofol (10-12 mg/kg/h) and alfentanil (25 micrograms/kg/h) was performed for 2 min, followed by atracurium (5 mg) and propofol (1-1.5 mg/kg) as a bolus induction dose over 20 s, and then Suxamethonium (1.5 mg/kg) at 30-40 s later. Intubation was done while giving a continuous infusion of propofol and alfentanil. After intubation, the infusion rate was adjusted according to the blood pressure (BP) variation. Group 2 patients (G2) were induced with fentanyl (2 micrograms/kg), thiamylal (4-5 mg/kg), atracurium (5 mg) and succinylcholine (1.5 mg/kg). Induction of anesthesia in group 3 patients (G3) was the same as for G2, with additional sublingual nifedipine (1/2 capsule) 10 min prior to induction. Extra bolus dose of propofol (20 mg) or thiamylal (20 mg) was given at every 15 s if the systolic BP was still higher than 160 mmHg after induction by the above 3 regimens. The radial arterial pressure and electrocardiogram were continuously recorded for evaluation of hemodynamic changes.

RESULTS

Post-intubation peak mean arterial pressure (MAP) in G1 and G3 were below to awake baseline values, while MAP of G2 was significantly higher than over awake baseline level (p < 0.001). The lowest MAP of G3 at post-intubation period before surgical stimulation were significantly lower than those of G1 and G2 (p < 0.001). Peak tachycardiac response to intubation in G2 was significantly higher than G1 (p < 0.05). After intubation, the peak rate pressure product were significantly higher in G2 compared with that in G1 (p < 0.05) and G3 (p < 0.001).

CONCLUSIONS

The proposed manual infusion scheme of propofol and alfentanil mixture performed during induction and intubation attenuated the subsequent peak pressor response to incubation and reduced the hypotensive effect, in comparison to thiamylal or thiamylal plus nifedipine treatment, during post-intubation period. The same infusion scheme also attenuated the tachycardiac response to intubation.

The use of intranasal nitroglycerin to prevent pressor responses during intubation in general anesthesia--a comparison of various doses

BACKGROUND

Intranasal nitroglycerin (NTG) was first reported to successfully prevent an increase in arterial blood pressure following laryngoscopy and tracheal intubation by Hill et al. Various different effective dosages of NTG have been reported. Grover et al. indicated 0.75 mg of intranasal NTG to be the most suitable dose. However, no definite conclusion has yet been made. This study was designed to compare the efficacy of four different dosages of intranasal NTG (0.3, 0.5, 0.75, and 1.0 mg) in preventing pressor responses to laryngoscopy and tracheal intubation during the induction of general anesthesia.

METHODS

One hundred patients (ASA I or II) scheduled for elective surgery were included. These study subjects were divided into five groups and randomly assigned to four different dosages of intranasal NTG and a placebo. Each group consisted of 20 patients. The NTG solution was administered 1 min before the injection of thiopental. Systolic arterial pressure (SAP), diastolic arterial pressure (DAP), mean arterial pressure (MAP) and heart rate (HR) were recorded before the induction of anesthesia (T1), before laryngoscopy (T2), and at 0, 3, and 5 min after tracheal intubation (T3, T4, and T5 respectively).

RESULTS

In patients who received a placebo (control group), there were significant increases in SAP, MAP, HR and rate-pressure-product (RPP) associated with tracheal intubation. Tachycardia was noted in all experimental groups. The increases in MAP associated with tracheal intubation were significantly less in patients who received NTG of 0.5 mg or more but not 0.3 mg. Although 0.5 mg of NTG did attenuate the increases in SAP after tracheal intubation, the increases in SAP of the other three experimental groups were no less than that of the control group. Rate-pressure-product (RPP) values of the experimental groups were noted to be equal to or higher than those of the control group during the period of study. Contrary to the results of the study conducted by Grover et al., 0.75 mg of NTG did not attenuate the pressor responses.

CONCLUSIONS

Intranasal NTG does not attenuate the pressor responses to laryngoscopy and tracheal intubation.

[A proper size of endotracheal tube for infant and young child--a retrospective study in Mackay Memorial Hospital]

BACKGROUND

There are more than 2000 pediatric patients receiving surgery in Mackay Memorial Hospital each year. Most of these surgery were performed under general anesthesia with endotracheal tube; therefore choosing an appropriate size of endotracheal tube becomes an important issue in our daily practice.

METHODS

Our principle is to choose an uncuffed Mallinckrodt endotracheal tube with a proper internal diameter (ID), ranging from 2.5 mm to 6.5 mm, which could be suitably and gently inserted into the trachea under full muscle relaxation. The tube would then be immediately removed and replaced with a smaller one if facing obvious resistance during intubation. After intubation, a leak test was applied to ascertain that there was no excessive gas leakage. We reviewed all anesthetic records of elective pediatric surgery in the recent 6 years, and the patients whose age above 8.5 years old and body weight (Wt) above 30 kg were excluded from this study. Using age (6476 cases) and Wt (6406 cases) as our parameters, we analyzed these data according to the distribution of each size of uncuffed endotracheal tube (UCETT) in different age and Wt intervals and compared them with the recommended Western reports.

RESULTS

Our results revealed that (1) the UCETT size increases as age or Wt increases; (2) considerable spread of UCETT sizes for different age and Wt intervals and basically represent as normal distribution; (3) for the case of even age equal or above 2 years old (up to 8 years old), the ID of the most frequently used UCETT can be memorized as (18 + age in years) divided by 4 or the outer circumference (OC) of the Mallinckrodt UCETT (in French unit, Fr) = 19 + age in years; and (4) Wt as a parameter for tube size selection was as powerful as age (94.76% vs. 94.65%).

CONCLUSIONS

From our results, we concluded that "whatever method of predicting tube size is used, tracheal tubes 0.5 mm larger and smaller should be available at the time of intubation so that the proper size can be chosen when the glottis is visualized."

Pulmonary edema induced by upper airway obstruction--report of 3 cases

Pulmonary edema is a well-recognized complication of upper airway obstruction, and has been reported sporadically both in children and adults since 1977. Although the pathogenesis of pulmonary edema associated with upper airway obstruction is multifactorial, attention is primarily focused on excessive negative intrapleural and transpulmonary pressure produced by forceful inspiration against a closed glottis that results in transudation of fluid from the pulmonary capillary into the interstitial and alveolar spaces. We report 3 cases of pulmonary edema induced by upper airway obstruction after extubation following general anesthesia.

[4P- syndrome (Wolf-Hirschhorn syndrome) complicated with delay onset of malignant hyperthermia: a case report]

One 8-month-old female patient, weighted 5 kg, with congenital abnormality (4P- syndrome) underwent elective cheiloplasty for cleft lip and palate. Two hours later, with smooth anesthesia and operation, a life-threatening anesthetic complication of malignant hyperthermia occurred at pediatric intensive care unit. The immediate treatments were initially hyperventilating the patient with 100% O2 and cooling the patient with ice bags. Subsequently, intravenous dantrolene 2.5 mg/kg and symptomatic supportive care were administered successfully to treat the event. Upon reviewing the articles, we found that a congenital chromosome 4P deletion abnormality complicated with a delay onset of malignant hyperthermia has not been described previously.

Comparative analgesic enhancement of alfentanil, fentanyl, and sufentanil to spinal tetracaine anesthesia for cesarean delivery

Clinical investigations have shown that intrathecal local anesthetic combined with alfentanil, fentanyl, or sufentanil results in a synergetic interaction that improves perioperative analgesia. However, there are as yet few studies designed to compare equal potency dose of these three 4-anilinopiperidine analogues. This prospective study is an attempt to study the comparative analgesic properties of these three drugs. 156 parturients who had consented to spinal anesthesia for cesarean delivery, were anesthetized with 12 mg of tetracaine which was combined with various doses of these three opioids. The addition of these intrathecal opioids significantly improved analgesia. Intra-operatively, 26% of the control group had insufficient analgesia while all patients in the sufentanil or fentanyl groups had sufficient analgesia without needing any analgesic supplementation. Postoperatively 10 micrograms of sufentanil delayed the onset of any postoperative pain from 106 to 286 min. Side effects such as pruritus, respiratory depression, nausea, and vomiting were not different from those of the control group. This study indicates that 10ug sufentanil appears to be better than alfentanil or fentanyl in improving intra- and postoperative analgesia in parturient undergoing hyperbaric tetracaine spinal anesthesia for cesarean section.

[Anesthetic management of tetralogy of Fallot with absent pulmonary valve--a case report]

Tetralogy of Fallot is characterized by a VSD, overriding of the aorta, right ventricular hypertrophy, and pulmonary stenosis. Absence of the pulmonary valve occurs in 2.6-6% of patients with tetralogy of Fallot. Operative procedures to relieve respiratory symptoms have been described with an mortality of 35-100%. Respiratory compromise may be severe in these infants secondary to bronchial compression by the aneurysmally dilated pulmonary arteries and present a different hemodynamic profile than those with classic tetralogy of Fallot. An understanding of the anatomic and physiologic principles and their anesthetic implications will lead to improved management of these extremely ill infants. We reported the anesthetic considerations and management of a case of tetralogy of Fallot with absent pulmonary valve of an infant who experienced severe respiratory distress on the supine position.

[Intrathecal meperidine attenuates shivering induced by spinal anesthesia]

Shivering is a common and complex phenomenon that occurs in many patients during spinal anesthesia. Shivering can increase oxygen consumption up to 500 per cent which may be detrimental to patients with decreased myocardial reserve. The metabolic costs and cardiorespiratory consequences of shivering are important particularly for patients with anemia, coronary arterial disease, cardiopulmonary insufficient, debilitated status or are elderly. We studied whether intrathecal meperidine could prevent shivering after spinal anesthesia. 60 patients with ASA class I-II were divided into intrathecal meperidine group (Group I) (n = 30) and control group (Group II) (n = 30). Group I received spinal tetracaine 12-16 mg with meperidine 0.2 mg/kg and Group II received spinal tetracaine 12-16 mg without meperidine. During operation the highest level of spinal anesthesia, ambient and rectal temperatures, blood pressure (BP) and heart rate (HR), presence or absence of shivering, intensity of shivering in both groups were recorded. Close observation for side effects was given post-operatively. There was a significant reduction (p < .005) in incidence of shivering in group I patients (16.7%) when compared with group II (56.7%). There was no or less side effects observed with other neuraxial opioids except nausea. We concluded that intrathecal meperidine could suppress shivering induced by spinal anesthesia.

[Nifedipine in preeclampsia for cesarean section]

The patients with preeclampsia undergoing emergent cesarean section is always a challenge to an anesthesiologist, because severe hypertensive response after laryngoscopy and tracheal intubation may result in life-threatening complication such as cerebral hemorrhage. Most of these patients receive magnesium sulfate for the prevention of convulsion. An ideal anti-hypertensive drug for preeclampsia should be effective, limited fall in blood pressure, rapid onset, maintaining uteroplacental blood flow, and less maternal and fetal side effects. We studied the efficacy of 10 mg sublingual nifedipine in attenuating the pressor response to intubation. We were also concerned about whether this calcium antagonist may inhibit uterine contraction and increase intra and postpartum hemorrhage when it is used with magnesium sulfate and general anesthesia. There were thirty-three patients in our study (16 in nifedipine group and 17 in control group). This study revealed that nifedipine attenuate the hypertensive response effectively. Uterine contraction response to oxytocic drugs was quite well in both groups. There was no significant difference in blood loss between nifedipine and control group. And no severe maternal and fetal adverse effect.

[Intramuscular meperidine for the prevention of shivering in spinal anesthesia]

Intravenous meperidine 25mg has been employed effectively to treat shivering following regional anesthesia and general anesthesia. The study was designed to evaluate the effectiveness of intramuscular meperidine for the prevention of shivering in spinal anesthesia. The series consisted of 60 patients who were divided into 2 groups with 30 patients in each, undergoing lower abdominal or lower extremity surgery. All patients were given diazepam 0.1mg/kg i.v. for anxiolysis when they came to the operating room. In a double blind and randomized fashion, patients in the study (meperidine) group received meperidine 25mg IM (= 0.5ml). In the control group 0.9% N/S 0.5ml IM was given instead. All patients received spinal anesthesia 15 minutes later. Measurement of the levels of sensory loss to pinprick was made. The ambient temperature and the rectal temperature were continuously monitored to evaluate the effect of the change in body temperature on shivering during operation. The degree and the occurrence of shivering were carefully evaluated and recorded by a blind-trust observer. There was no significant difference in maximal analgesic level, ambient temperature and change of rectal temperature during operation between the groups. Shivering occurred in 17 patients (56.7%) in the saline group with an onset time of 7.9 +/- 2.5min following spinal anesthesia. In the meperidine group, shivering occurred only in 3 patients (10%) with an onset time of 54 +/- 29.5min after spinal anesthesia. There was a significantly lower incidence of shivering in the meperidine group than in the saline group (p < 0.005).(ABSTRACT TRUNCATED AT 250 WORDS)

Is routine preanesthetic hemoglobin test necessary in minor pediatric surgery?

The value of preanesthetic assessment of anemia and analysis of the hemoglobin level prior to a minor pediatric surgery has been recently questioned in some reports. This study was to retrospectively analyse 8859 pediatric patients who underwent minor surgery in the period from January 1987 to December 1990 in our hospital. They were all ASA class I-II in physical status with age ranging from one month to 19 years. Those patients with their hemoglobin values determined at other laboratories or hospitals in spite of our recognition and those suspected of having an immune or oncologic disease were excluded from this study. The mean hemoglobin value of the patients under study was 12.99 +/- 0.82 g/dl. 0.62% of the patients (55) were found to have hemoglobin values less than 10 g/dl which were similar to the results obtained by Wood et al (0.7%) in 1981 and Roy et al (0.5%) in 1990. Among the 55 anemic patients, 41 (74.5%) were at the age between 2 to 4 months (within the physiologic anemic period of infancy). Sampling of blood for routine preanesthetic hemoglobin determination which caused discomfort and pain was often rejected by pediatric patients and struggle for escape also upset the children very much. Based on the results from our analysis, we suggest that in healthy pediatric patient scheduled for minor surgery routine hemoglobin test could be excluded. Hemoglobin test is selectively performed in a patient is anemic or under suspicious circumstances. The value and shortcomings of selective hemoglobin test before surgery require further evaluation.

[Changes in arterial pressure and heart rate during laryngeal mask insertion in hypertensive patients: comparison with endotracheal intubation]

The pressor response associated with laryngoscopy and endotracheal intubation may be harmful to patients with ischemic heart disease, hypertension or cerebrovascular disease. The Brain laryngeal mask airway can be inserted blindly and avoid the need for laryngoscopy. Our preliminary study compared the pressor response of tracheal intubation (T group) with that of laryngeal mask insertion (L group) in 19 and 33 hypertensive patients respectively. We also divided the patients of L group into sub-groups I (n = 16) and II (n = 17). All patients in T group and sub-group I were induced with fentanyl, thiopentone and succinylcholine while in subgroup II patients were induced with the same dosage of thiopentone and succinylcholine without fentanyl. The changes of blood pressure and heart rate exhibited a similar but attenuated pattern of response with laryngeal mask insertion in comparison with tracheal intubation. We also found no significant difference in pressor response between sub-group I and sub-group II in L group. In sum, laryngeal mask insertion may therefore offer some advantages over tracheal intubation in the anesthetic management of hypertensive patients in whom less pressor response is of particular concern.

[Clinical assessment of laryngeal mask airway in general anesthesia with spontaneous breathing]

The laryngeal mask airway (LMA) is a new form of oropharyngeal airway that provides an alternative to endotracheal intubation and face mask anesthesia in certain cases. Once the patient is adequately anesthetised, it can be inserted blindly without recourse to laryngoscopy. The advantages over standard mask anesthesia are: better airway control, minimal leakage of anesthetic gases, and it frees the anesthetist's hands, as no mandibular support is needed. LMA does not guarantee against the risk of aspiration and it is not recommended for use in patients who may have risk of gastric regurgitation. Our preliminary study revealed that a clear and clinical satisfactory airway was obtained in 98.2% of patients. According to the intraoperative respiratory minute volume and arterial blood gases, the patency of the airway did not deteriorate during the course of the anesthesia. Blood pressure and heart rate were compared on induction in group I and II. Succinylcholine 1 mg/kg, thiopentone 4-6 mg/kg and fentanyl 2 micrograms/kg were used in group I while using the same dosage of succinylcholine and thiopentone without fentanyl for group II. We found no significant differences in vital signs between the two groups.

[Surgical and anesthetic mortality in Mackay Memorial Hospital 1988-1989]

The mortality associated with 52128 anesthetics administered over two years (1988-1989) at Mackay Memorial Hospital, Taipei, was reported. The frequency of death to which anesthesia contributed was 0.4/10000 (2 cases in 52128 anesthetics). The total mortality rate from surgery within one week was 0.2% (105 cases in 52128 anesthetics). Anesthetic deaths were responsible for 1.9% of the total mortality. There were 25 cases of cardiac arrest with 18 fatal cases (7 cases were recovered after cardiopulmonary resuscitation). The causes of cardiac arrest during anesthesia included anesthetic factors (24%), surgical factors (24%) and patients' pathological factors (52%).

[Does flumazenil antagonize the anesthetic effect of ketamine, etomidate or thiopental?]

The effect of flumazenil, a benzodiazepine antagonist, was assessed in a random, double-blind clinical study in which each of the four groups of surgical outpatients comprising 20 in each was given either ketamine 100 mg (K), etomidate 20 mg (E), thiopental 300 mg (T) or flunitrazepam 4 mg (F) for induction of anesthesia. On emergence, patients in each group were randomly given 2cc of either 2 coded solutions, one of which contained 0.2 mg flumazenil and the other of which was normal saline. Following injection of coded solution, all patients were assessed at 0, 5, 15, 30, 60 and 120 min for wakefulness. All 10 patients of group F who received flumazenil were alert and able to recall at 5 min, whereas in group T this was noted from 15 to 30 min. Patients of group E and K responded alike in a manner as of those who received normal saline placebo with onset of wakefulness at 30 and 60 min respectively. These results confirm that flumazenil antagonizes flunitrazepam (within 5 min) and also indicate that the antagonizing effect occurs 30 min following injection for thiopental, suggestive of some cross-reactivity between these two drugs.

[The effect of epidural anesthesia on tourniquet pain: a comparison of 2% lidocaine and 0.5% bupivacaine]

The incidence of tourniquet pain was evaluated in two groups of patients with 20 each undergoing orthopedic surgery of the lower extremities during epidural anesthesia using plain solution of either 2% lidocaine or 0.5% bupivacaine. The drugs were administered in a randomized fashion. Measurement of the levels of sensory loss to pinprick and incidence of tourniquet pain were made by blind-trust. The maximum analgesia level, time between 1st injection and onset of pain, time between tourniquet inflation and onset of pain were recorded similarly in both groups of patients. The incidence of tourniquet pain was significantly greater in patients given 2% lidocaine (40%) than in patients given 0.5% bupivacaine (10%). The incidence of pain was not related to the time of tourniquet inflation, because patients in the bupivacaine group had a significant longer duration of tourniquet inflation than did patients in the lidocaine group. The incidence of pain was also not related to tachyphylaxis, because 7 of 8 patients who complained tourniquet pain in lidocaine group received less than 3 injections for maintenance of analgesia when tourniquet pain started. In summary, it is apparent that tourniquet pain occurs less frequently when bupivacaine is employed for epidural anesthesia as compared to lidocaine.

[Anesthetic considerations in complete obstruction of major veins of upper trunk--report of two cases]

This article presents two cases about complete obstruction of major veins of upper trunk. One was a 45 year-old woman who suffered from complete obstruction of superior vena cava due to bronchogenic carcinoma. Venous bypass grafting from left innominate vein to right atrium was performed. The other was a 41 year-old man. Both of his right and left, internal and external jugular veins were completely obstructed after radical laryngectomy and radiotherapy due to hypopharyngeal carcinoma. Venous bypass grafting from cerebral transverse sinus to right atrium was performed. In both cases, general anesthesia with neurosurgical anesthetic concepts were performed with continuous blood pressure monitoring, CVP monitoring, pulse oximetry, end-tidal CO2 monitoring, blood gas analysis, urine output and EKG monitoring. The outcome was satisfactory in both cases.

[Comparative study of the antagonizing effect to flunitrazepam between Ro 15-1788 and physostigmine]

In a double blind, randomized, placebo-controlled study, thirty patients who had received flunitrazepam during operation were divided into three groups. At the end of surgery, one group was given a placebo, one group was given Ro 15-1788 (Benzodiazepine antagonist) and a third group was given physostigmine. Each group was assessed at the end of 5 minutes, 15 minutes, 30 minutes 60 minutes and 120 minutes for alertness/sedation, recall, recognition and motor coordination. At the end of 5 and 15 minutes, the patients who had received Ro 15-1788 showed a statistically significant difference in alertness/sedation from those in the other two groups (p less than 0.01). This group also showed a statistically significant difference in motor coordination at the end of 5 minutes (p less than 0.05). There was no significant difference in recognition or recall at anytime. Physostigmine showed no significant difference change from the control group at anytime in every aspect. In conclusion, Ro 15-1788 is an effective antagonist to the alertness/sedation of flunitrazepam, but physostigmine is not.

[Pulmonary lavage for alveolar proteinosis. A case report]

Pulmonary alveolar proteinosis is characterized by an amorphous lipoproteinaceous material filling the acini of the lung, resulting in hypoxemia. At present, the most effective treatment for alveolar proteinosis is lung lavage. Here, we report the first case in Taiwan treated with this method. A 38-year-old male with a 6-month history of cough and increasing breathlessness was transferred from another hospital. On admission, his arterial oxygen tension was 51 mmHg when breathing room air. Chest X-ray films showed diffuse infiltration of both lung fields. Transbronchoscopic lung biopsy was consistent with alveolar proteinosis, therefore the patient was submitted to pulmonary lavage. Under general anesthesia, the patient was intubated with a left-sided double lumen endotracheal tube, and lavage of the right lung was repeated with 0.9% saline until the washing became clear. At the end of the procedure, the patient was extubated after making strong respiratory efforts. Several days later, the left lung was lavaged using the same technique. The mechanical washing of amorphous material from alveoli by pulmonary lavage is of great benefit in relieving hypoxemia. Judicious use of lung lavage is effective and safe for patient with alveolar proteinosis.