Validation of Simple Methods to Select a Suitable Nostril for Nasotracheal Intubation

Background. Nasotracheal intubation is a blind procedure that may lead to complications; therefore, several tests were introduced to assess a suitable nostril for nasotracheal intubation. However, the value of simple tests in clinical practice was insufficient to evaluate. Method. A diagnostic prospective study was conducted in 42 patients, ASA classes I–III, undergoing surgery requiring nasotracheal intubation for general anesthesia. Two simple methods for assessing the patency of nostrils were investigated. Firstly, the occlusion test was evaluated by asking for the patient’s own assessment of nasal airflow during occlusion of each contralateral nostril while in a sitting posture. Secondly, patients breathed onto a spatula held 1 cm below the nostrils while in a sitting posture. All patients were assessed using these two simple tests. Nasal endoscopic examination of each patient was used as a gold standard. Results. The diagnostic value of the occlusion test (sensitivity of 91.7%, specificity of 61.1%, PPV of 75.9%, NPV of 84.6%, LR+ of 2.36, and LR− of 0.14) seemed better than that of the spatula test (sensitivity of 95.8%, specificity of 25.0%, PPV of 63.0%, NPV of 81.8%, LR+ of 1.28, and LR− of 0.17). When both tests were combined in series, the diagnostic value increased (sensitivity of 87.9%, specificity of 70.8%, PPV of 80.1%, NPV of 81.4%, LR+ of 3.01, and LR− of 0.17). Conclusion and Recommendations. The simple occlusion test is more useful than the spatula test. However, combining the results from both tests in series helped to improve the diagnostic value for selecting a suitable nostril for nasotracheal intubation

Comparison of dexmedetomidine and fentanyl to prevent haemodynamic response to skull pin application in neurosurgery: double blind randomized controlled trial

  BACKGROUND: Skull pin application during craniotomy is a highly noxious stimulus. Therefore, the attenuated effect between dexmedetomidine and fentanyl was investigated. METHOD: A randomized, double-blind controlled trial included sixty patients, randomly allocated into groups A and B. After patients entered the operative room, blood pressure and heart rate were measured (T1). At 5 minutes after propofol induction (T2), group A received dexmedetomidine 1 µg kg-1 whereas group B received normal saline. At 3 minutes before skull pin insertion (T3), group B received a single bolus of fentanyl 1 µg kg-1 whereas group A received normal saline. The hemodynamic responses were recorded at 1 minute before skull pin insertion (T4), during skull pin insertion (T5), then repeated every minute for 5 minutes (T6-T10). RESULTS: Controlling blood pressure in the dexmedetomidine group (Group A) was better than in the fentanyl group (Group B) at T4 and T10 (P < 0.05) and T5-T8 (P < 0.01) for systolic blood pressure whereas diastolic blood pressure was significantly different at T4 and T8 (P < 0.05) and T5-T7 (P < 0.01). Mean arterial pressure, also was better controlled in group A at T4 and T10 (P < 0.05) and T5-T8 (P < 0.01). The heart rate in group A was lower than group B at T9 (P < 0.05) and T3-T6 (P < 0.01). Regarding adverse events, 11 hypertensive and 2 hypotensive responses occurred in group B whereas group A just only had 7 incidences of hypotension. CONCLUSION: The attenuated effect of dexmedetomidine infusion is significantly greater than fentanyl infusion.    BACKGROUND: Skull pin application during craniotomy is a highly noxious stimulus. Therefore, the attenuated effect between dexmedetomidine and fentanyl was investigated. METHOD: A randomized, double-blind controlled trial included sixty patients, randomly allocated into groups A and B. After patients entered the operative room, blood pressure and heart rate were measured (T1). At 5 minutes after propofol induction (T2), group A received dexmedetomidine 1 µg kg-1 whereas group B received normal saline. At 3 minutes before skull pin insertion (T3), group B received a single bolus of fentanyl 1 µg kg-1 whereas group A received normal saline. The hemodynamic responses were recorded at 1 minute before skull pin insertion (T4), during skull pin insertion (T5), then repeated every minute for 5 minutes (T6-T10). RESULTS: Controlling blood pressure in the dexmedetomidine group (Group A) was better than in the fentanyl group (Group B) at T4 and T10 (P < 0.05) and T5-T8 (P < 0.01) for systolic blood pressure whereas diastolic blood pressure was significantly different at T4 and T8 (P < 0.05) and T5-T7 (P < 0.01). Mean arterial pressure, also was better controlled in group A at T4 and T10 (P < 0.05) and T5-T8 (P < 0.01). The heart rate in group A was lower than group B at T9 (P < 0.05) and T3-T6 (P < 0.01). Regarding adverse events, 11 hypertensive and 2 hypotensive responses occurred in group B whereas group A just only had 7 incidences of hypotension. CONCLUSION: The attenuated effect of dexmedetomidine infusion is significantly greater than fentanyl infusion.

Appropriate Blood Pressure in Cerebral Aneurysm Clipping for Prevention of Delayed Ischemic Neurologic Deficits

Background. Delayed ischemic neurologic deficit (DNID) is a problem after cerebral aneurysm clipping. Intraoperative hypotension seems to be indicated as a risk factor, but it remains a controversial issue with varying low-blood pressure levels accepted. Methods. A retrospective, hospital-based, case-control study was performed with patients who received general anesthesia for cerebral aneurysm clipping. 42 medical record charts were randomly selected and matched 1 : 2 (1 case with DNID : 2 controls without DNID) based on the type of general anesthetic techniques and severity of subarachnoid hemorrhage. The optimal cutoff points of hemodynamic response were calculated by the area under the curve. Results. Data suggested that the optimal cutoff points for lowest blood pressure for prevention of DNID should be systolic blood pressure (SBP) of 95 mmHg (sensitivity of 78.6%; specificity of 53.6%), diastolic blood pressure (DBP) of 50 mmHg (sensitivity of 71.4%; specificity of 67.9%), and mean arterial pressure (MAP) of 61.7 mmHg (sensitivity of 85.7%; specificity of 35.7%). Furthermore, the optimal cutoff point mean difference baseline blood pressure was recommended as Δ SBP of 36 mmHg (sensitivity of 85.7%; specificity of 60.7%), Δ DBP of 27 mmHg (sensitivity of 92.9%; specificity of 71.4%), and Δ MAP of 32 mmHg (sensitivity of 92.9%; specificity of 85.7%). No significant difference between DNID and non-DNID groups was found for end-tidal carbon dioxide (ETCO2) and has poor diagnostic value for predicting DNID. Conclusion. To prevent DNID, we recommend that optimal blood pressure should not be lower than 95 for SBP, 50 for DBP, and 61.7 mmHg for MAP. Additionally, we suggest that Δ SBP, Δ DBP, and Δ MAP should be less than 36, 27, and 32 mmHg, respectively

Appropriateness of Preoperative Screenings in Patients Undergoing Elective Gynecologic Surgery at Srinagarind Hospital, Khon Kaen University, Thailand: An observational study

Objectives: To evaluate the appropriateness of routine preoperative screening for patients who undergoing elective major gynecologic surgery at a tertiary care university hospital, Khon Kaen Province based on the hospital guideline.Materials and Methods: This retrospective descriptive study reviewed 808 medical records of gynecologic patients undergoing elective surgery in 2014.results: The mean age of the patients was 44.2 years. Approximately 36% of patients had associated co-morbidity. Almost 90% of the patients had inappropriate screening tests. Complete blood count and chest x-ray were the two most appropriate screening test. The most inappropriate tests were urinalysis and fasting blood sugar. Patients were classified into 4 groups: 1) patients < 45 years old with no underlying conditions; 2) patients < 45 years old with at least one underlying conditions; 3) patients ≥ 45 years old with no underlying conditions and 4) patients ≥ 45 years old with at least one underlying conditions. The first group had highest rate of performing inappropriate preoperative tests with blood urea nitrogen/creatinine as the most overuse test. The costs of inappropriateness preoperative tests were 39.8% of the total costs of preoperative assessment.Conclusion: Almost 90% of the patients had inappropriate screening tests which increased the cost by about 40%. Hospital administrators should find appropriate mechanisms to reinforce doctors to strict their requests for only tests that are necessary

Effects of Intraoperative Dexamethasone and Ondansetron on Postoperative Nausea and Vomiting in Microvascular Decompression Surgery: A Randomized Controlled Study

Background. Postoperative nausea and vomiting (PONV) is a common problem and may lead to catastrophic complications, especially in neurosurgical cases. The aim of this study was to evaluate the effects of dexamethasone and ondansetron for preventing PONV in patients who underwent microvascular decompression (MVD) surgery. Methods. A prospective, double-blinded, randomized control trial was conducted with 54 patients who underwent MVD. Patients were allocated into two groups. The study group (Gr. D) received intraoperative dexamethasone 4 mg iv and ondansetron 4 mg iv, whereas the control group (Gr. N) received placebo (0.9% normal saline 1 ml iv and 0.9% normal saline 2 ml iv). The incidence and severity of PONV were observed at 1, 2, 4, and 24 hr postsurgery. Results. At 1, 2, 4, and 24 hr postsurgery, Gr. D had a lower incidence (7.4%, 11.1%, 29.6%, and 66.7%) and lower severity of PONV than Gr. N (18.5%, 29.6%, 37.0%, and 81.5% at 1, 2, 4, and 24 hr; p>0.05). The requirement for antiemetic drugs was not significantly different between the groups (p>0.05). Conclusion. Administration of dexamethasone and ondansetron 4 mg seemed to decrease the incidence of PONV in the first 24 hours but not significantly. Therefore, further studies are to be carried out by escalating either dexamethasone dose or the dose of ondansetron or both

Subcutaneous calcification as a supportive radiologic finding for diagnosis of rhinofacial entomophthoromycosis

Rhinofacial entomophthoromycosis is an uncommon chronic fungal infection of the head and neck. The diagnosis is usually based on clinical manifestations; however, diagnosis of this infection based on early manifestations is difficult and occasionally rhinofacial entomophthoromycosis is mistaken for other diseases. Therefore, computed tomography is introduced to support the diagnosis. Radiologic findings were non-specific with swelling of the sinonasal mucosa and perinasal region. However, subcutaneous calcification, that was observed in all our cases, may be a supportive radiologic evidence for diagnosis. The diagnosis should be confirmed definitively using histopathology or fungal culture. Early diagnosis allows prompt and appropriate treatment that will achieve excellent outcomes

Survival Benefit of Intervention Treatment in Advanced Anaplastic Thyroid Cancer

Background. The management of anaplastic thyroid cancer (ATC) is controversial; thus, proper treatment and prognostic factors should be investigated. Objectives. To compare the survival outcomes of the intervention and palliative treatment in ATC patients. Methods. A hospital-based retrospective study was conducted at a single tertiary university hospital. The medical record charts were retrieved from November 20, 1987, to December 31, 2016. The final follow-up ended by December 31, 2017. The patients’ demographic data, laboratory data, clinical presentation, and treatment modality results were analyzed. Results. One hundred twenty-one records were analyzed with a one-year overall survival rate of 3.5% (median survival time: 77 days); however, 16 cases had insufficient data to classify staging and treatment modalities. Therefore, 105 ATC patients (37 with stage IVa, 39 with stage IVb, and 29 with stage IVc disease) were included with a one-year overall survival rate of 4.0% (median survival time of 82 days). Intervention treatment allowed longer median survival times (p<0.05) and a better survival rate (p<0.05). Among the interventional treatment groups, postoperative chemoradiation yielded the longest median survival time (187 days) and the highest survival rate (20%) (p<0.05). The intervention modality allowed a better median survival time at all stages, particularly in stage IVa (p<0.05). Unfavorable prognostic factors were adjusted for in a multiple Cox regression model showing that significant factors included age ≥65 years (hazard ratio HR: 2.57), palliative treatment (HR: 1.85), and leukocytosis ≥10,000 cells/mm3 (HR: 2.76). Conclusions. Intervention treatment provided a better survival outcome in all stages, particularly in stage IVa, with a significantly better median survival time. Among interventional treatments, postoperative chemoradiation led to the longest survival rate, suggesting that this treatment should be considered in ATC patients with resectable tumors and no poor prognostic factors, such as older age and leukocytosis