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Fulltext Guidelines for the use and interpretation of assays for monitoring autophagy (3rd edition)

Klionsky DJ, Abdelmohsen K, Abe A, Abedin MJ, Abeliovich H, Acevedo Arozena A, et al.

Autophagy, 2016;12(1):1-222.
PMID: 26799652 DOI: 10.1080/15548627.2015.1100356
MortalitY in caRdIAc surgery (MYRIAD): A randomizeD controlled trial of volatile anesthetics. Rationale and design

Landoni G, Lomivorotov V, Pisano A, Nigro Neto C, Benedetto U, Biondi Zoccai G, et al.

Contemp Clin Trials, 2017 08;59:38-43.
PMID: 28533194 DOI: 10.1016/j.cct.2017.05.011

OBJECTIVE: There is initial evidence that the use of volatile anesthetics can reduce the postoperative release of cardiac troponin I, the need for inotropic support, and the number of patients requiring prolonged hospitalization following coronary artery bypass graft (CABG) surgery. Nevertheless, small randomized controlled trials have failed to demonstrate a survival advantage. Thus, whether volatile anesthetics improve the postoperative outcome of cardiac surgical patients remains uncertain. An adequately powered randomized controlled trial appears desirable.
DESIGN: Single blinded, international, multicenter randomized controlled trial with 1:1 allocation ratio.
SETTING: Tertiary and University hospitals.
INTERVENTIONS: Patients (n=10,600) undergoing coronary artery bypass graft will be randomized to receive either volatile anesthetic as part of the anesthetic plan, or total intravenous anesthesia.
MEASUREMENTS AND MAIN RESULTS: The primary end point of the study will be one-year mortality (any cause). Secondary endpoints will be 30-day mortality; 30-day death or non-fatal myocardial infarction (composite endpoint); cardiac mortality at 30day and at one year; incidence of hospital re-admission during the one year follow-up period and duration of intensive care unit, and hospital stay. The sample size is based on the hypothesis that volatile anesthetics will reduce 1-year unadjusted mortality from 3% to 2%, using a two-sided alpha error of 0.05, and a power of 0.9.
CONCLUSIONS: The trial will determine whether the simple intervention of adding a volatile anesthetic, an intervention that can be implemented by all anesthesiologists, can improve one-year survival in patients undergoing coronary artery bypass graft surgery.
Hypoxia during upper gastrointestinal endoscopy with and without sedation and the effect of pre-oxygenation on oxygen saturation

Wang CY, Ling LC, Cardosa MS, Wong AK, Wong NW

Anaesthesia, 2000 Jul;55(7):654-8.
PMID: 10919420

In Study A, the incidence of arterial oxygen desaturation was studied using pulse oximetry (SaO2) in 100 sedated and 100 nonsedated patients breathing room air who underwent diagnostic upper gastrointestinal endoscopy. Hypoxia (SaO2 92% or less of at least 15 s duration) occurred in 17% and 6% of sedated patients and nonsedated patients, respectively (p < 0.03). Mild desaturation (SaO2 94% or less and less than 15 s duration) occurred in 47% of sedated patients compared with 12% of nonsedated patients (p < 0.001). In Study B, the effects of supplementary oxygen therapy and the effects of different pre-oxygenation times on arterial oxygen saturation (SaO2) in sedated patients were studied using pulse oximetry. One hundred and twenty patients who underwent diagnostic upper gastrointestinal endoscopy with intravenous sedation were studied. Patients were randomly allocated to one of four groups: Group A (n = 30) received no supplementary oxygen while Groups B-D received supplementary oxygen at 4 1 x min(-1) via nasal cannulae. The pre-oxygenation time in Group B (n = 30) was zero minutes, Group C (n = 30) was 2 min and Group D (n = 30) was 5 min before sedation and introduction of the endoscope. Hypoxia occurred in seven of the 30 patients in Group A and none in groups B, C and D (p < 0.001). We conclude that desaturation and hypoxia is common in patients undergoing upper gastrointestinal endoscopy with and without sedation. Sedation significantly increases the incidence of desaturation and hypoxia. Supplementary nasal oxygen at 4 1 x min(-1) in sedated patients abolishes desaturation and hypoxia. Pre-oxygenation confers no additional benefit.
Fulltext Optimal size AMBU® laryngeal mask airway among Asian adult population

Tang MY, Tang IP, Wang CY

Med J Malaysia, 2014 Aug;69(4):151-5.
PMID: 25500841 MyJurnal

AIM: This was a randomized single blinded study to determine optimal size for Ambu®LMA (ALMA) among Malaysian adult population.

METHODS: One hundred and twenty six non-paralyzed anaesthetized adult patients were block randomized into size 3, 4 and 5 Ambu®LMA. Optimal size is defined primarily by oropharyngeal pressure (OLP). Pharyngeal injury and ease of insertion are also taken into consideration.

RESULTS: Mean OLP was significantly higher for Size 4 and 5 compared to size 3 (p<0.001) but similar between size 4 and 5. Number of insertion attempts and insertion time were similar between sizes. Size 5 required more manipulations during insertion (p<0.005) and had higher pharyngeal injury (p=0.001) compared to size 3 and 4.

DISCUSSION: We recommend size 4 ALMA as the optimal size for Malaysian adults in view of the higher OLP compared to size 3, yet less pharyngeal injury than size 5 in spontaneously breathing patients.
Fulltext The 50% and 95% effective doses of desflurane for removal of the classic laryngeal mask airway in spontaneously breathing anaesthetised adults

Hui MT, Subash S, Wang CY

Anaesthesia, 2011 Apr;66(4):274-7.
PMID: 21401540 DOI: 10.1111/j.1365-2044.2011.06620.x

The 50% and 95% effective doses of desflurane for removal of the classic laryngeal mask airway after suction of the upper airway, in anaesthetised spontaneously breathing adult patients, are not known. To determine these, we studied 38 healthy patients, aged between 18 and 44 years. The target desflurane concentration in each individual patient was determined by the Dixon up-and-down method. When the predetermined target end-tidal desflurane concentration reached steady state, we kept a constant end-expiratory partial pressure between the alveolus and the brain for 10 min before attempting to remove the classic laryngeal mask airway after suctioning the upper airway. The initial desflurane target concentration was set at 6% and up-down desflurane increments were 0.1%. This continued until there were at least six crossover pairs. From the probit analysis, the 50% effective dose of desflurane was 5.29% (95% CI 5.132-5.379%) and the 95% effective dose was 5.55% (95% CI 5.429-6.394%).
Randomised comparison of the LMA Supreme with the I-Gel in spontaneously breathing anaesthetised adult patients

Chew EE, Hashim NH, Wang CY

Anaesth Intensive Care, 2010 Nov;38(6):1018-22.
PMID: 21226431

We compared the performance of the LMA Supreme (SLMA) with the I-Gel during anaesthesia in spontaneously breathing adult patients. Ninety patients with American Society of Anesthesiologists physical status I or II were studied in a prospective randomised controlled study. Our primary outcome measure was oropharyngeal leak pressure. We also compared the overall insertion success rate, ease of insertion, adequacy of ventilation and incidence of complications. The mean (SD), oropharyngeal leak pressure for the SLMA was 25.6 (5.1) cmH2O, which was greater than for the I-Gel 20.7 (5.9) cmH2O (P = 0.0001). The first attempt and overall insertion success rates were similar between the two groups (SLMA 97.8 and 97.8%; I-Gel 93.3 and 100%, P = 0.132). The SLMA was rated easier to insert than the I-Gel (P = 0.011), but the time taken for insertion (P = 0.433) was similar. The incidence of complications was low in both groups. The grade of fibreoptic view was better with the I-Gel than the SLMA (P = 0.001). We conclude that in adults with normal airways, the SLMA is easier to insert and provides a higher oropharyngeal leak pressure, but fibreoptic views are better with the i-gel.
Fentanyl dose for the insertion of Classic Laryngeal Mask Airways in non-paralysed patients induced with propofol 2.5 mg/kg

Tan AS, Wang CY

Anaesth Intensive Care, 2010 Jan;38(1):65-9.
PMID: 20191779

The aim of this randomised, controlled trial was to determine the optimum dose of fentanyl in combination with propofol 2.5 mg x kg(-1) when inserting the Classic Laryngeal Mask Airway. Seventy-five ASA I or II patients were randomly assigned to five groups of fentanyl dosage: 0 microg x kg(-1) (placebo), 0.5 microg x kg(-1), 1.0 microg x kg(-1), 1.5 microg x kg(-1) and 2.0 microg x kg(-1). Anaesthesia was induced by first injecting the study drug over 10 seconds. Three minutes after the study drug was injected, propofol (2.5 mg x kg(-1)) was injected over 10 seconds. The Classic Laryngeal Mask Airway was inserted four minutes and 30 seconds after injection of the study drug. Insertion conditions were evaluated using a four-category score. Thirty-nine males and 36 females aged 19 to 59 years were studied. The incidence of prolonged apnoea increased as fentanyl dose increased. We found that there was a high rate of successful first attempt at insertion with 1 microg x kg(-1) and 1.5 microg x kg(-1), 93% and 87% respectively, compared to 87% in the 2.0 microg x kg(-1) group. The 1.0 microg x kg(-1) group also achieved an 80% optimal insertion conditions score of 4, compared to 73% in the 1.5 microg x kg(-1) group and 80% in the 2 microg x kg(-1) group. Therefore we recommend 1.0 microg x kg(-1) as the optimal dose of fentanyl when used in addition to propofol 2.5 mg/kg for the insertion of the Classic Laryngeal Mask Airway.
Superficial cervical plexus block combined with auriculotemporal nerve block for drainage of dental abscess in adults with difficult airways

Ling KU, Hasan MS, Ha KO, Wang CY

Anaesth Intensive Care, 2009 Jan;37(1):124-6.
PMID: 19157359

We report our use of a superficial cervical plexus block to manage three adults who presented for drainage of dental abscesses. All patients had difficult airways related to severe trismus (preoperative inter-incisor distance < or = 1.5 cm). The first two patients, whose abcesses involved both the submandibular and submasseteric spaces, were managed with combined superficial cervical plexus and auriculotemporal nerve block. In a third patient, a superficial cervical plexus block alone was sufficient because the abscess was confined to the submandibular region. The blocks were successful in all three cases with minimal requirement for supplemental analgesia. We recommend the consideration of superficial cervical plexus block, and if necessary an auriculotemporal nerve block, for the management of selected patients with difficult airways who present for drainage of dental abcesses.
Randomised crossover comparison of the Ambu AuraOnce Laryngeal Mask with the LMA Classic laryngeal mask airway in paralysed anaesthetised patients

Shariffuddin II, Wang CY

Anaesthesia, 2008 Jan;63(1):82-5.
PMID: 18086075

We compared the performance of the Ambu AuraOnce Laryngeal Mask with that of the LMA Classic laryngeal mask airway during controlled anaesthesia. Forty patients requiring intermittent positive pressure ventilation were studied using a randomised crossover design. The mean (SD) oropharyngeal leak pressure for the Ambu device (19 (7.5) cmH2O) was significantly greater than for the LMA Classic (15 (5.2) cmH2O; p = 0.004), and the number of attempts for successful insertions was significantly less (39 (50%) vs 45 (56%), respectively; p = 0.02). There was one failure to obtain a patent airway with the Ambu Laryngeal Mask and none with the LMA Classic. Insertion of the Ambu Laryngeal Mask required more manipulations to achieve a patent airway than did the LMA Classic (6 (15%) vs 1 (2.5%), respectively; p = 0.045), but the time taken for insertion was similar between the two groups. The incidence of trauma, grade of fibreoptic view, peak airway pressure and quality of ventilation during maintenance of anaesthesia were similar in both groups.
The effect of a forced-air warming blanket on patients' end-tidal and transcutaneous carbon dioxide partial pressures during eye surgery under local anaesthesia: a single-blind, randomised controlled trial

Sukcharanjit S, Tan AS, Loo AV, Chan XL, Wang CY

Anaesthesia, 2015 Dec;70(12):1390-4.
PMID: 26348782 DOI: 10.1111/anae.13212

Surgical drapes used during eye surgery are impermeable to air and hence risk trapping air underneath them. We investigated the effect of a forced-air warming blanket on carbon dioxide accumulation under the drapes in patients undergoing eye surgery under local anaesthesia without sedation. Forty patients of ASA physical status 1 and 2 were randomly assigned to either the forced-air warmer (n = 20) or a control heated overblanket (n = 20). All patients were given 1 l.min(-1) oxygen. We measured transcutaneous and end-tidal carbon dioxide partial pressures, heart rate, arterial pressure, respiratory rate, temperature and oxygen saturation before and after draping, then every 5 min thereafter for 30 min. The mean (SD) transcutaneous carbon dioxide partial pressure in the forced-air warming group stayed constant after draping at 5.7 (0.2) kPa but rose to a maximum of 6.4 (0.4) kPa in the heated overblanket group (p = 0.0001 for the difference at time points 15 min and later). We conclude that forced-air warming reduces carbon dioxide accumulation under the drapes in patients undergoing eye surgery under local anaesthesia.
Effect of rocuronium compared with succinylcholine on intraocular pressure during rapid sequence induction of anaesthesia

Chiu CL, Jaais F, Wang CY

Br J Anaesth, 1999 May;82(5):757-60.
PMID: 10536557

We have compared the effect of rocuronium and succinylcholine on intraocular pressure (IOP) during rapid sequence induction of anaesthesia using propofol and fentanyl, in a randomized double-blind study. We studied 30 adult patients, allocated to one of two groups. Anaesthesia was induced with fentanyl 2 micrograms kg-1 and propofol until loss of verbal response. This was followed by succinylcholine 1.5 mg kg-1 (group S; n = 15) or rocuronium 0.9 mg kg-1 (group R; n = 15). Laryngoscopy was performed 60 s later. IOP, mean arterial pressure (MAP) and heart rate (HR) were measured before induction, immediately before intubation and every minute after intubation for 5 min. A Keeler Pulsair air impulse tonometer was used to measure IOP and the mean of two readings obtained in the right eye at each measurement time was recorded. Intubating conditions were evaluated according to a simple scoring system. IOP in the succinylcholine group was significantly greater than that in the rocuronium group (mean 21.6 (SEM 1.4) mm Hg vs 13.3 (1.4) mm Hg; P < 0.001). Intubating conditions were equally good in both groups. We conclude that with rapid sequence induction of anaesthesia using propofol and fentanyl, rocuronium did not cause as great an increase in IOP as succinylcholine and may be an alternative in open eye injury cases.
Sevoflurane for dental extraction in children with Tetralogy of Fallot

Chiu CL, Wang CY

Paediatr Anaesth, 1999;9(3):268-70.
PMID: 10320610

Two children with Tetralogy of Fallot presented for dental extraction. Anaesthesia was induced rapidly and smoothly by inhalation of sevoflurane. We discussed the advantages of sevoflurane as an induction agent as compared to halothane in these children.
The effect of prophylactic metaraminol on systemic hypotension caused by induction of anaesthesia with propofol in patients over 55 years old

Chiu CL, Tew GP, Wang CY

Anaesthesia, 2001 Sep;56(9):893-7.
PMID: 11531679

We conducted a double-blind, randomised, placebo-controlled study evaluating the efficacy of prophylactic metaraminol for preventing propofol-induced hypotension. Thirty patients aged 55-75 years undergoing general anaesthesia were randomly allocated to receive either metaraminol 0.5 mg or saline before administration of fentanyl 1 microg.kg(-1) and propofol 2 mg.kg(-1). Induction of anaesthesia was associated with a decrease in mean and systolic arterial pressure in both groups (p = 0.0001). However, there was no significant difference between the two groups. These results show that prophylactic use of metaraminol 0.5 mg does not prevent the decrease in blood pressure following fentanyl and propofol induction in older patients.
Alfentanil for intubation under halothane anaesthesia in children

NG KP, Wang CY

Paediatr Anaesth, 1999;9(6):491-4.
PMID: 10597551

Intubating conditions under halothane anaesthesia aided with alfentanil 20 micrograms.kg-1 were compared with suxamethonium 2 mg.kg-1 in 40 children presenting for day dental procedures. The condition of vocal cords, jaw relaxation and presence of movement and coughing were scored to give the overall intubating conditions. Successful intubation was achieved in 100% of the suxamethonium group and 94.7% of the alfentanil group. The cardiovascular response to intubation was attenuated in the alfentanil group. Some 43.7% of those receiving suxamethonium developed myalgia the day after surgery compared with 0% in the alfentanil group (P < 0.01).
The effect of mivacurium pretreatment on intra-ocular pressure changes induced by suxamethonium

Chiu CL, Lang CC, Wong PK, Delilkan AE, Wang CY

Anaesthesia, 1998 May;53(5):501-5.
PMID: 9659028

Forty patients without eye disease, undergoing elective nonophthalmic surgery, were studied in a double-blind, randomised, placebo-controlled study evaluating the efficacy of mivacurium pretreatment in attenuating the rise in intra-ocular pressure in response to suxamethonium administration, laryngoscopy and intubation. The patients were randomly allocated to receive either mivacurium 0.02 mg.kg-1 or normal saline as pretreatment 3 min before a rapid sequence induction technique using alfentanil, propofol and suxamethonium. Suxamethonium induced a significant increase in intra-ocular pressure in the control group but not in the mivacurium pretreatment group (mean (SEM) increase = 3.5 (1.2) mmHg vs. 0.4 (0.8) mmHg, p < 0.05). There was a decrease in intra-ocular pressure in both groups after laryngoscopy and intubation with no significant difference between the two groups. These results show that mivacurium pretreatment is effective in preventing the increase in intra-ocular pressure after suxamethonium administration.
Fulltext Fibreoptic intubation--a case series and brief review

Tan I, Wang CY

Med J Malaysia, 1993 Jun;48(2):200-6.
PMID: 8350796

Fibreoptic intubation has been established as a major advance in the management of difficult or failed intubation in the awake patient. If necessary, it may be performed under general anaesthesia with either spontaneous or controlled ventilation. This should be considered early in the management of failed intubation, before multiple attempts with other techniques lead to haemorrhage and oedema in the airway. We describe here selected case reports to illustrate this in 8 different situations. This is followed by a brief review of the technique and indications of fibreoptic intubation.
The use of bispectral index during a cardiopulmonary arrest: a potential predictor of cerebral perfusion

Azim N, Wang CY

Anaesthesia, 2004 Jun;59(6):610-2.
PMID: 15144304

A 62-year-old male underwent off-pump coronary artery grafting surgery while cerebral function was monitored with bispectral index (BIS). The BIS monitoring was continued into the immediate postoperative period, during which time the patient experienced a cardiopulmonary arrest. The changes in the BIS values helped the resuscitating team in assessing the cerebral response to the cardiopulmonary resuscitation.
An evaluation of the modified Airway Management Device

Chiu CL, Wang CY

Anaesth Intensive Care, 2004 Feb;32(1):77-80.
PMID: 15058125

This is a preliminary report on the use of the modified Airway Management Device in 50 spontaneously breathing patients undergoing elective day care surgery. We were successful in establishing a clear airway in all 50 patients, 46 of these patients had a patient airway on the first attempt. All patients were successfully managed with the Airway Management Device throughout the surgery. Partial airway obstruction during maintenance of anaesthesia occurred in three cases requiring only minor manipulations. Our result showed that the Airway Management Device may be used as an alternative airway management in anaesthesia.
Temporary cardiopulmonary bypass and isolated lung ventilation for tracheal stenosis and reconstruction

Chiu CL, Teh BT, Wang CY

Br J Anaesth, 2003 Nov;91(5):742-4.
PMID: 14570801

A 27-yr-old lady with a past history of prolonged ventilation presented with worsening respiratory distress caused by tracheal stenosis. She required urgent tracheal resection and reconstruction. Because of the risk of an acute respiratory obstruction, spinal anaesthesia was used to establish cardiopulmonary bypass by cannulating the femoral artery and femoral vein. Adequate gas exchange was possible with full flow rate. Thoracotomy was then carried out to mobilize the left main bronchus. After successfully securing an airway by intubation of the left main bronchus, cardiopulmonary bypass was discontinued and tracheal resection and anastomosis was done under conventional one lung anaesthesia.
Fulltext Unilateral hypoglossal nerve palsy after the use of laryngeal mask airway (LMA) Protector

Tham LY, Beh ZY, Shariffuddin II, Wang CY

Korean J Anesthesiol, 2019 12;72(6):606-609.
PMID: 31304693 DOI: 10.4097/kja.d.18.00354

BACKGROUND: The laryngeal mask airway (LMAⓇ) ProtectorTM (Teleflex Medical Co., Ireland) is the latest innovation in the second generation of LMA devices. One distinguishing feature of this device is its integrated, color-coded cuff pressure indicator (Cuff PilotTM technology) which enables continuous cuff pressure monitoring and allows adjustments when necessary; this ensures patient safety due to better monitoring.
CASE: We report a case of postoperative unilateral hypoglossal nerve palsy after uncomplicated use of the LMA Protector. To the best of our knowledge, this could be the second reported case.
CONCLUSIONS: This case demonstrates that anesthetists need to routinely measure cuff pressure and that the Cuff PilotTM technology is not a panacea for potential cranial nerve injury after airway manipulation.

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