Epidural waveform analysis (with pressure transduction through the needle) provides a simple adjunct to LOR for thoracic epidural blocks. Although its use was devoid of complications, further confirmatory studies are required before its routine implementation in clinical practice.

Background The dead space washout and provision of some level of positive airway pressure by nasal high-flow (NHF) cannula could improve the efficiency of ventilation, oxygenation and maintenance of the upper airway in patients undergoing deep sedation. This study aimed to compare the incidences of events represented oxygenation and ventilation, i.e. desaturation and upper airway obstruction, and arterial blood gas (ABG) levels between using NHF cannula and conventional nasal cannula (NC2) during deep sedation of adult surgical patients. Methods In this prospective randomized single-blinded study, the patients who were 20–80 years old, ASA physical status of 1 to 3, scheduled for surgery under intravenous sedation (IVS) were included. The patients were randomly divided into two groups, i.e., NC2 or NHF groups. Propofol infusion was given to maintain deep sedation. The desaturation (SpO2 < 92%) and upper airway obstruction events (presence of snoring with paradoxical breathing) after application of NC2 or NHF were observed and collected. Other outcomes included interventions during IVS, such as jaw lifting or airway instrument insertion, mouth dryness, and post- ABG analyses were also collected and compared. Results Thirty-six patients undergoing endovascular surgery were randomized into NC2 or NHF groups (18 in each group). No patients dropped out of the study. There were no significant differences in age, sex, ASA physical status, pre-sedation and pre-application of NC2 and NHF ABG analyses (PaO2, SaO2, pH, PaCO2, and PaO2/FiO2). NHF group had significantly lower in the incidence of desaturation [5 (27.78%) vs 13 (72.22%), p = 0.008], upper airway obstruction [4 (22.22%) vs 13 (72.22%), p = 0.003], and airway maneuver [6 (33.33%) vs 13 (72.22%), p = 0.019] than NC2 group. There were no differences in the ABG analyses after oxygen supplementation and no significant differences in mouth dryness between groups. Conclusion The use of NHF cannula in patients undergoing endovascular surgery under deep sedation reduced desaturation events and required fewer airway interventions than NC2 with no difference in arterial blood gas analyses and mouth dryness.

Compared with its conventional counterpart, EWA-confirmed LOR results in a lower failure rate for thoracic epidural blocks (2% vs 24%) in our teaching centers. Confirmatory EWA provides significant benefits for inexperienced operators.

Background Video-assisted thoracoscopic surgery (VATS) is a minimally invasive procedure, but patients may still experience intense pain, especially during the early postoperative period. Intrathecal morphine (ITM) is an effective pain control method that involves a simple maneuver and has a low risk of complications. This study aimed to study the effectiveness of ITM for pain control in patients who undergo VATS. Materials and methods A randomized controlled study was conducted who were in ASA classes 1–3, aged over 18 years, and scheduled for elective VATS. Patients were randomized into two groups: the ITM group (n = 19) received a single shot of 0.2 mg ITM before general anesthesia; and the control group (n = 19) received general anesthesia only. For 48 hours after surgery, other than intravenous patient-controlled analgesia (IVPCA) morphine, patients received no sedatives or opioid medications except for 500 mg acetaminophen four times daily orally. Postoperative pain scores and IVPCA morphine used, side effects, sedation at specific time-points, i.e., 1, 6, 12, 24, and 48-hours and overall treatment satisfaction scores were assessed. Results Postoperative pain scores (median [IQR]) in ITM group were significantly lower than control group (repeated-measure ANOVA, p = 0.006) and differed at the first (7 [2, 7] vs 8 [6, 9], p = 0.007) and sixth hours (3 [2, 5] vs 5 [5, 7], p = 0.002). The cumulative dose of post-operative morphine (median [IQR]) in ITM group was also lower (6 [3, 20] vs 19 [14, 28], p = 0.006). The incidence of pruritus was significantly higher in ITM group (68.42% vs. 26.32%, p = 0.009). No significant differences in nausea and vomiting, sedation scores, and satisfaction scores were observed between the two groups. Conclusion ITM could reduce pain scores and opioid consumption after VATS compared to IVPCA-opioids. However, pain scores and opioid consumption still remained high. No difference in patient satisfaction was detected.

Purpose Thoracic paravertebral block (TPVB) is a recommended regional analgesia during video-assisted thoracoscopic surgery (VATS). However, single-injection TPVB does not last long enough to provide sufficient acute postoperative pain relief. Continuous TPVB through a catheter is technically challenging and often unreliable. Intravenous dexamethasone extends the analgesic duration with some peripheral nerve blocks. However, data on the effect of intravenous dexamethasone on pain relief with TPVB are limited. This study aimed to assess the analgesic efficacy of intravenous dexamethasone in patients who received TPVB for VATS. Patients and Methods In this multicenter prospective randomized controlled trial, we recruited patients aged between 18 and 80 years with the American Society of Anesthesiologists of physical status class 1–3 and underwent elective VATS. Patients under general anesthesia randomly received 8 mg of intravenous dexamethasone (group D) or normal saline (group C). Ultrasound-guided TPVB (USG-TPVB) was performed at the T4–T5 and T6-T7 spaces. Multimodal analgesia was achieved via paracetamol, tramadol and intravenous morphine for both study groups. The primary outcome was time for the first analgesic requirement. Postoperative pain in terms of numeric rating score (NRS), total morphine consumption and postoperative nausea and vomiting (PONV) were assessed. Results After excluding one patient, 59 patients were analyzed. There were no intergroup differences in baseline characteristics. The time to first analgesic requirement was longer in group D (305 [240, 510] minutes) than in group C (270 [180, 300] minutes) ( P value = 0.02). The NRS at rest and on movement was lower in group D than in group C at 12 hours but did not differ at other time points. Postoperative morphine consumption was significantly lower in group D than in group C at 6,12,24 and 48 hours. Incidences of PONV were comparable between the groups. Conclusion Intravenous dexamethasone, used as an adjunct to a single-injection USG-TPVB prolonged analgesic duration, had an opioid-sparing effect and provided better postoperative pain relief after VATS.

Background Insertion of a nasogastric tube in an anesthetized intubated patient may be difficult. A nasogastric tube is prone to coil and kink during insertion. We hypothesize that gastric biopsy forceps can be used as a flexible stylet-assisted nasogastric tube insertion. It can improve the first-attempt success rate over the conventional blind technique during nasogastric tube insertion in the anesthetized intubated patient. Methods Eighty adult patients who required intraoperative nasogastric tube insertions were randomized to the gastric biopsy forceps assisted technique (stylet group) or the conventional blind technique (control group) for insertion of a nasogastric tube. The success rates, the duration of insertion, the incidences of coiling and kinking of a nasogastric tube, and the occurrences of complications were recorded. Results The first-attempt success rate was 92.5% in the stylet group compared with 65% in the control group (P = 0.013). The overall success rate was higher in the stylet group (100% vs 85%; P = 0.026). The mean time required to insert the nasogastric tube was shorter in the stylet group (24.85 ± 9.62 vs 62.4 ± 59.38 seconds; P = 0.002). The incidences of coiling and kinking were lower in the stylet group (7.5% vs 32.5%; P = 0.005). The incidence of minor bleeding was lower in the stylet group, but not statistically significant (2.5% vs 17.5%; P = 0.057). No other complications were observed in either of the groups. Conclusion The gastric biopsy forceps-assisted nasogastric tube insertion resulted in a higher success rate, less time for insertion, and lower incidence of coiling and kinking of a nasogastric tube than the conventional blind technique in anesthetized intubated patients without serious complications. Trial registration: Thai Clinical Trials Registry (www.clinicaltrials.in.th), TCTR20141018001 (19/09/2014).