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Yuanming Pan,1 Chaoqin Chen,1 Lingya Yu,2 Shengmei Zhu,1 Yueying Zheng1 1Department of Anesthesiology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, People’s Republic of China; 2Department of Radiology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, People’s Republic of ChinaCorrespondence: Shengmei Zhu; Yueying ZhengDepartment of Anesthesiology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 31003, People’s Republic of ChinaTel +86-13777408863Email 1507128@zju.edu.cnBackground: The present study aimed to investigate the incidence and extent of difficult airway management in patients with massive retrosternal goiter.Design: An 8-year retrospective analysis was performed to identify patients who underwent massive retrosternal thyroidectomy. A total of 22 cases were identified as giant retrosternal goiter, followed by a review of each patient’s preoperative computerized tomography imaging.Interventions: There were no cases of failed intubation. Twenty patients underwent uneventful tracheal intubation using direct laryngoscopy or Glidescope. Thirteen patients received a muscle relaxant intravenously, and two patients were induced with sevoflurane. Five patients underwent awake tracheal intubation, including awake fiberoptic intubation in three patients. Before entering the operating theatre, the remaining two patients underwent oral tracheal intubation with Glidescope in the emergency department.Results: Two patients had tracheal intubation before they entered the operating theatre. Once entering vocal cords, tracheal intubation can pass beyond the site of the tracheal obstruction without difficulty. One patient died because of serious perioperative bleeding owing to the adhesion between the retrosternal goiter and large vessel within the thoracic cavity. One patient experienced dyspnea after extubation and was intubated again.Conclusion: Intravenous induction of muscle relaxant using laryngoscopy or Glidescope is feasible in patients with massive benign retrosternal goiter. The incidence of difficult intubation and postoperative tracheomalacia is likely too rare. Furthermore, perioperative bleeding and postoperative airway complication seem frequent.Keywords: airway management, anesthesia, retrosternal goiter, postoperative tracheomalacia

Accumulating evidence suggests a potential role of transient receptor potential vanilloid 1 (TRPV1) channels in inflammatory and cancer-related pain. However, the role of TRPV1 in the maintenance of neuropathic pain remains elusive. The current study investigated the effects of transient Trpv1 gene silencing using a small interference RNA (siRNA) on neuropathic pain induced by chronic constriction injury (CCI) of the sciatic nerve in rats. Seven days after CCI, the TRPV1 siRNA was intrathecally administered (5 µg/15 µl, once daily for 2 days). TRPV1 and Ca2+/calmodulin-dependent protein kinase II (CAMKII) expression and extracellular signal-regulated kinase (ERK) phosphorylation in the spinal cord were detected using western blotting. The thresholds to mechanical and thermal stimuli were determined before and after intrathecal TRPV1 siRNA administration. TRPV1 and CAMKII expression and ERK2 phosphorylation in the spinal cord were upregulated after CCI. Intrathecal administration of the TRPV1 siRNA not only attenuated behavioural hyperalgesia but also reduced the expression of TRPV1 and CAMKII, as well as ERK2 phosphorylation. Based on these results, silencing of the TRPV1 gene in the spinal cord attenuates the maintenance of neuropathic pain by inhibiting CAMKII/ERK2 activation and suggests that TRPV1 represents a potential target in pain therapy.

α2-Adrenoceptor agonists attenuate hypersensitivity under neuropathic conditions. However, the mechanisms underlying this attenuation remain largely unknown. In the present study, we explored the potential roles of purinergic receptor 7 (P2X7R)/extracellular signal-regulated kinase (ERK) signaling in the anti-nociceptive effect of dexmedetomidine in a rat model of neuropathic pain induced by chronic constriction injury (CCI) of the sciatic nerve. An animal model of CCI was adopted to mimic the clinical neuropathic pain state. Behavioral hypersensitivity to mechanical and thermal stimuli was determined by von Frey filament and Hargreaves' tests, and the spinal P2X7R expression level and ERK phosphorylation were analyzed using western blot analysis and immunohistochemistry. In parallel with the development of mechanical and thermal hyperalgesia, a significant increase in P2X7R expression was noted in the ipsilateral spinal cord on day 7 after CCI. Intrathecal administration of dexmedetomidine (2.5 µg) for 3 days not only attenuated neuropathic pain but also inhibited the CCI-induced P2X7R upregulation and ERK phosphorylation. Intrathecal dexmedetomidine administration did not produce obvious effects on locomotor function. The present study demonstrated that dexmedetomidine attenuates the neuropathic pain induced by CCI of the sciatic nerve in rats by inhibiting spinal P2X7R expression and ERK phosphorylation, indicating the potential therapeutic implications of dexmedetomidine administration for the treatment of neuropathic pain., Graphical Abstract

OBJECTIVES: This pilot study was designed to utilize stroke volume variation and cardiac index to ensure fluid optimization during one-lung ventilation in patients undergoing thoracoscopic lobectomies. METHODS: Eighty patients undergoing thoracoscopic lobectomy were randomized into either a goal-directed therapy group or a control group. In the goal-directed therapy group, the stroke volume variation was controlled at 10%±1%, and the cardiac index was controlled at a minimum of 2.5 L.min-1.m-2. In the control group, the MAP was maintained at between 65 mm Hg and 90 mm Hg, heart rate was maintained at between 60 BPM and 100 BPM, and urinary output was greater than 0.5 mL/kg-1/h-1. The hemodynamic variables, arterial blood gas analyses, total administered fluid volume and side effects were recorded. RESULTS: The PaO2/FiO2-ratio before the end of one-lung ventilation in the goal-directed therapy group was significantly higher than that of the control group, but there were no differences between the goal-directed therapy group and the control group for the PaO2/FiO2-ratio or other arterial blood gas analysis indices prior to anesthesia. The extubation time was significantly earlier in the goal-directed therapy group, but there was no difference in the length of hospital stay. Patients in the control group had greater urine volumes, and they were given greater colloid and overall fluid volumes. Nausea and vomiting were significantly reduced in the goal-directed therapy group. CONCLUSION: The results of this study demonstrated that an optimization protocol, based on stroke volume variation and cardiac index obtained with a FloTrac/Vigileo device, increased the PaO2/FiO2-ratio and reduced the overall fluid volume, intubation time and postoperative complications (nausea and vomiting) in thoracic surgery patients requiring one-lung ventilation.

Epidural lidocaine can be used when regional anesthesia needs to be established quickly, but the effect of co-administering epidural fentanyl on the minimum local analgesic concentration (MLAC) of lidocaine is not known. We compared the MLAC of epidural lidocaine in combination with different doses of fentanyl for epidural anesthesia in adults.One hundred and twenty patients requiring epidural analgesia were randomly allocated to receive 20 ml of one of four solutions: lidocaine, or lidocaine plus fentanyl 1 µg/ml, 2 µg/ml, or 3 µg/ml. The first patient in each group was administered 1% lidocaine weight by volume; subsequent patients received a concentration determined by the response of the previous patient to a higher or lower concentration according to up and down sequential allocation in 0.1% increments. Efficacy was assessed using a visual analog pain scale, and accepted if this was = 10 mm on a 100 mm scale within 30 minutes. The extent of motor block and of nausea and vomiting were recorded at 30 minutes after administration of the epidural solution and two hours after surgery, respectively.The MLAC of lidocaine in those receiving lidocaine alone was 0.785% (95%CI 0.738 - 0.864). A significant dose-dependent reduction was observed with the addition of fentanyl: the MLAC of lidocaine with fentanyl at 2 µg/ml was 0.596% (95%CI 0.537 - 0.660) and 0.387% with fentanyl at 3 µg/ml (95%CI 0.329 - 0.446, P0.001).Epidural fentanyl significantly reduces the dose of lidocaine required for effective epidural analgesia in adults without causing adverse side effects.

Study Objective To examine the influence of epidural and intravenous (IV) lidocaine, and height of the epidural sensory block, on the dose of propofol required for induction of general anesthesia. Design Randomized controlled study. Setting University hospital. Patients 66 adult, ASA physical status 1 and 2 patients, aged 25 to 65 years, undergoing elective abdominal surgery. Interventions Patients were randomized to 4 groups: the epidural saline control group (Group C; L 2 -L 3 puncture, epidural and IV saline), the IV lidocaine group (Group IV; L 2 -L 3 puncture, saline epidural, IV lidocaine 1 mg/kg), the lumbar epidural lidocaine group (Group EL; L 2 -L 3 puncture, 1.5% lidocaine epidural, IV saline), and the thoracic epidural lidocaine group (Group ET; T 9 -T 10 puncture, 1.5%lidocaine epidural, IV saline). Two minutes after the beginning of the infusion of IV lidocaine or saline, propofol anesthesia was initiated. Measurements Mean arterial blood pressure (MAP), heart rate (HR), and sensory block height were monitored. The induction dose of propofol, its estimated effect-site concentration (Ce), and plasma concentration were measured at various time points. Finally, we recorded the time taken for the bispectral index (BIS) to decrease to 60, the plasma concentration of lidocaine at induction, and the occurrence of adverse events. The induction time (when BIS reached 60) also was recorded. Main Results The induction propofol dose, Ce, and plasma concentration of propofol when BIS equaled 60 were significantly lower in Group IV, Group EL, and Group ET than Group C. The above parameters in Group ET (T 9 - T 10 puncture) were significantly less than in Group EL (L 2 - L 3 puncture). The induction doses of propofol and plasma concentration of propofol and lidocaine were significantly higher in Group IV than in Groups EL or ET. Conclusions Epidural and IV lidocaine reduce the dose of propofol required to induce general anesthesia. Administration of lidocaine via the epidural route reduces anesthetic requirements more so than the IV route. Propofol requirements were further reduced in patients with higher sensory epidural block.