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Papers by Hung-Wei Cheng

Clinical Value of Application of Cerebral Oximetry in Total Replacement of the Aortic Arch and Concomitant Vessels

Acta Anaesthesiologica Taiwanica, Dec 1, 2008

Cerebral ischemia or infarction caused by several equivocal mechanisms is a major complication af... more Cerebral ischemia or infarction caused by several equivocal mechanisms is a major complication after aortic arch replacement. Here, we report a 28-year-old male who underwent total replacement of the aortic arch and concomitant tributaries for hypoplasia of the transverse aortic arch and aortic branches. Continuous cerebral oxygen saturation (rSO2) monitoring was applied throughout the whole surgical course. According to the trend of rSO2, we could not only optimize the cerebral perfusion, but also confirm the patency of graft anastomosis. Therefore, monitoring rSO2 is very useful for determining cerebral perfusion during major surgery, especially in complicated repair of an aortic aneurysm, or replacement of the aortic arch and/or arch vessels.

How early warning with the Oxygen Reserve Index (ORi™) can improve the detection of desaturation during induction of general anesthesia?

Journal of Clinical Monitoring and Computing, 2021

The Oxygen Reserve Index (ORi™) is a dimensionless parameter with a value between 0 and 1. It is ... more The Oxygen Reserve Index (ORi™) is a dimensionless parameter with a value between 0 and 1. It is related to the real-time oxygenation status in the moderate hyperoxic range. The purpose of this study is to investigate the added warning time provided by different ORi alarm triggers and the continuous trends of ORi, SpO2, and PaO2. We enrolled 25 patients who were scheduled for elective surgery under general anesthesia with planned arterial catheterization before induction. The participants received standardized preoxygenation, induction, and intubation. The patients remained apneic and ventilation was resumed when the SpO2 fell below 90%. The ORi and SpO2 were recorded every ten seconds and arterial blood was sampled every minute, from preoxygenation to resumed ventilation. Alarm triggers set to the ORi peak and the ORi 0.55 values provided 300 and 145 s of significant added warning time compared to SpO2 (p < 0.0001). The coefficient of determination was 0.56 between the ORi and the PaO2 ≤ 240 mmHg and showed a positive correlation. The ORi enables the clinicians to monitor the patients’ oxygen status during induction of general anesthesia and can improve the detection of impending desaturation. However, further studies are needed to assess its clinical potential in the high hyperoxic range. The protocol was retrospectively registered at ClinicalTrials.gov on July 21, 2021 (NCT04976504).

Journal of the Chinese Medical Association, 2014

Background: Totally implantable access ports (TIAPs) are alternatives to central venous catheters... more Background: Totally implantable access ports (TIAPs) are alternatives to central venous catheters for patients requiring chemotherapy. Since January 2003, we have used a central approach two-point incision technique to insert TIAPs. Following advances in ultrasound technique and clinical experience for tunneled dialysis catheter placement, we modified the central approach to a low-approach technique. Methods: From January 2009 to June 2010, patients consulted for TIAP insertion in our department were enrolled in our study. Different brands and materials of central venous catheters of TIAPs were inserted by the low-approach two-point incision technique (Phase I) or the low-approach one-point incision technique (Phase II). The insertion time, failure rate, procedural and late complications, degree of satisfaction, and cosmetic scores were recorded. Results: Ninety-seven patients and 107 patients were implanted via the two-point and one-point low-approach techniques, respectively, with different kinds of TIAP. No matter which type of TIAP was used, the success rate in both phases was 100% without procedural complications using the low-approach technique. The average time for device insertion was 30 minutes for the two-point incision technique used during Phase I and 26e28 minutes for the one-point incision technique used during Phase II. Satisfaction and cosmetic scores were high. Conclusion: Our study highlights a revised technique for placement of TIAP systems of differing types of material or size. Not only was the curvature of the device catheter smooth, but patients were satisfied with the cosmetic appearance.

Journal of Clinical Anesthesia, 2012

Study Objective: To explore the influence of shoulder roll height on internal jugular vein (IJV) ... more Study Objective: To explore the influence of shoulder roll height on internal jugular vein (IJV) diameter and IJV/common carotid artery (CCA) overlap. Design: Cross-sectional study. Setting: University-affiliated hospital. Patients: 40 healthy participants. Measurements: Ultrasonography to measure the effects of using shoulder rolls ranging between 0 and 5 cm high on IJV diameter, CCA diameter, and percentage overlap of the CCA. Main Results: The percentage overlap of CCA decreased for both left (LIJV) and right IJV (RIJV) with the use of higher shoulder rolls. Greater values were seen in depth from skin surface to anterior wall of left IJV in almost all stages, with the exception of Stages 0 and 1 (P b 0.016); and the use of a 5 cm shoulder roll resulted in a significantly decreased anteroposterior (AP) diameter of both RIJVs and LIJVs (both P b 0.008). Conclusions: Shoulder rolls can reduce the overlap between the IJV and CCA, and may be useful in positioning patients for IJV puncture.

Innovation in sedation and analgesia training

Current Opinion in Anaesthesiology

PURPOSE OF REVIEW We reviewed evidence of recent innovations in sedation education and discuss ex... more PURPOSE OF REVIEW We reviewed evidence of recent innovations in sedation education and discuss experiences with sedation training in Taiwan. RECENT FINDINGS Current Status of Sedation Training: Didactic training and supervised clinical mentoring are common methods of sedation training. Although training course designed by professional societies to meet individual hospital credentialing requirements, the course content and training expectations vary and are likely inadequate to non-anesthesiologist sedation practitioners. Less Common Forms of Sedation Training: These include screen-based simulation, high-fidelity manikin-based simulation. Screen-based simulation sedation training is popular, convenient, and relatively inexpensive. Although there are numerous courses available, course content has not been standardized. High-fidelity simulation has been accepted to improve knowledge, self-confidence, awareness of emergency, crisis resource management, and teamwork, but it is costly, time intensive, and requires expertise in using simulation equipment. Although screen-based training is attractive and convenient, there is no evidence to suggest that it can replace high-fidelity simulation. Another recently developed education modality is virtual reality simulation. It has gained recent popularity as an immersive approach to medical training, but minimal content has been developed for sedation training. Beyond training, several other potential innovations may improve sedation effectiveness and patient safety. These include adherence to practice guidelines established by professional organizations, utilization of a pre-procedure sedation checklist, interpreting capnography, and implementation of real-time bedside drug displays that provide predictions of concentrations and their associated effects. SUMMARY Effective sedation education and training, especially for nonanesthesiologists, is essential to improve patient safety for procedural sedation. Several innovative approaches have been proposed and are relatively early in their development and implementation. Further studies designed to assess the impact of these new training modalities on patient safety and outcomes are warranted.

Journal of thoracic disease, 2017

There is no current consensus on which lumen an airway exchange catheter (AEC) should be passed t... more There is no current consensus on which lumen an airway exchange catheter (AEC) should be passed through in double-lumen endotracheal tube (DLT) to exchange for a single-lumen endotracheal tube (SLT) after thoracic surgery. We report an unusual case to provide possible solution on this issue. A 71-year-old man with lung adenocarcinoma had an event of a broken exchange catheter used during a DLT replacement with a SLT, after a video-assisted thoracic surgery. The exchange catheter was impinged at the distal tracheal lumen and snapped during manipulation. All three segments of the catheter were retrieved without further airway compromises. Placement of airway tube exchanger into the tracheal lumen of double-lumen tube is a potential contributing factor of the unusual complication. We suggest an exchange catheter be inserted into the bronchial lumen in optimal depth with the adjunct of video laryngoscope, as the safe method for double-lumen tube exchange.

Patient centered modeling of dynamic postoperative pain trajectories

Journal of the Chinese Medical Association

Validated Simulation: The Preliminary Experience of Anesthesiologist Board Examination in Taiwan

Studies in health technology and informatics, 2017

High fidelity simulation-based teaching has played an important role in medical education, especi... more High fidelity simulation-based teaching has played an important role in medical education, especially in anesthesiology and emergency. But there is not any currently validated scoring system or prediction model for high fidelity simulation. We will develop a validated prediction model to enhance the efficiency and validation of clinical training with high fidelity simulation.

Seminars in Dialysis, 2010

We evaluated two methods for preprocedure predicting the insertion depth of tunneled dialysis cat... more We evaluated two methods for preprocedure predicting the insertion depth of tunneled dialysis catheter (TDC) on chest radiograph (CXR). Patients undergoing TDC insertion via right internal jugular vein were enrolled. By Method 1, the insertion depth was calculated on preprocedure CXR as the distance from the anticipated venous tip (3.5 cm below the cavoatrial junction) to the prearranged skin puncture site (1.5 cm above the right clavicle). By Method 2, the insertion depth was derived by adding the length between the skin puncture site and the upper edge of the clavicle and the length of clavicle-to-tip. The TDC was placed at the estimated insertion depth. The distance of cavoatrial junction-to-arterial tip was then measured from postoperative supine CXR. One hundred and seventy and 121 TDCs were inserted by Method 1 and Method 2, respectively, while 127 and 92 preoperative supine CXR were used for preprocedure measurement. The mean distance of cavoatrial junction-to-arterial tip was 12.055 (8.5684) [mean (SD)], 11.27 (3.3261), 9.524 (5.1590), and 10.538 (2.6956) mm. Methods of determining the insertion depth by preprocedure measurement enable successful TDC tip placement. Method 2 and using preoperative supine CXR enabled more precise and flexible insertion.

Seminars in Dialysis, 2010

We evaluated two methods for preprocedure predicting the insertion depth of tunneled dialysis cat... more We evaluated two methods for preprocedure predicting the insertion depth of tunneled dialysis catheter (TDC) on chest radiograph (CXR). Patients undergoing TDC insertion via right internal jugular vein were enrolled. By Method 1, the insertion depth was calculated on preprocedure CXR as the distance from the anticipated venous tip (3.5 cm below the cavoatrial junction) to the prearranged skin puncture site (1.5 cm above the right clavicle). By Method 2, the insertion depth was derived by adding the length between the skin puncture site and the upper edge of the clavicle and the length of clavicle-to-tip. The TDC was placed at the estimated insertion depth. The distance of cavoatrial junction-to-arterial tip was then measured from postoperative supine CXR. One hundred and seventy and 121 TDCs were inserted by Method 1 and Method 2, respectively, while 127 and 92 preoperative supine CXR were used for preprocedure measurement. The mean distance of cavoatrial junction-to-arterial tip was 12.055 (8.5684) [mean (SD)], 11.27 (3.3261), 9.524 (5.1590), and 10.538 (2.6956) mm. Methods of determining the insertion depth by preprocedure measurement enable successful TDC tip placement. Method 2 and using preoperative supine CXR enabled more precise and flexible insertion.

Seminars in Dialysis, 2010

We evaluated two methods for preprocedure predicting the insertion depth of tunneled dialysis cat... more We evaluated two methods for preprocedure predicting the insertion depth of tunneled dialysis catheter (TDC) on chest radiograph (CXR). Patients undergoing TDC insertion via right internal jugular vein were enrolled. By Method 1, the insertion depth was calculated on preprocedure CXR as the distance from the anticipated venous tip (3.5 cm below the cavoatrial junction) to the prearranged skin puncture site (1.5 cm above the right clavicle). By Method 2, the insertion depth was derived by adding the length between the skin puncture site and the upper edge of the clavicle and the length of clavicle-to-tip. The TDC was placed at the estimated insertion depth. The distance of cavoatrial junction-to-arterial tip was then measured from postoperative supine CXR. One hundred and seventy and 121 TDCs were inserted by Method 1 and Method 2, respectively, while 127 and 92 preoperative supine CXR were used for preprocedure measurement. The mean distance of cavoatrial junction-to-arterial tip was 12.055 (8.5684) [mean (SD)], 11.27 (3.3261), 9.524 (5.1590), and 10.538 (2.6956) mm. Methods of determining the insertion depth by preprocedure measurement enable successful TDC tip placement. Method 2 and using preoperative supine CXR enabled more precise and flexible insertion.

Clinical Value of Application of Cerebral Oximetry in Total Replacement of the Aortic Arch and Concomitant Vessels

Acta Anaesthesiologica Taiwanica, 2008

Cerebral ischemia or infarction caused by several equivocal mechanisms is a major complication af... more Cerebral ischemia or infarction caused by several equivocal mechanisms is a major complication after aortic arch replacement. Here, we report a 28-year-old male who underwent total replacement of the aortic arch and concomitant tributaries for hypoplasia of the transverse aortic arch and aortic branches. Continuous cerebral oxygen saturation (rSO2) monitoring was applied throughout the whole surgical course. According to the trend of rSO2, we could not only optimize the cerebral perfusion, but also confirm the patency of graft anastomosis. Therefore, monitoring rSO2 is very useful for determining cerebral perfusion during major surgery, especially in complicated repair of an aortic aneurysm, or replacement of the aortic arch and/or arch vessels.

Seminars in dialysis

We evaluated two methods for preprocedure predicting the insertion depth of tunneled dialysis cat... more We evaluated two methods for preprocedure predicting the insertion depth of tunneled dialysis catheter (TDC) on chest radiograph (CXR). Patients undergoing TDC insertion via right internal jugular vein were enrolled. By Method 1, the insertion depth was calculated on preprocedure CXR as the distance from the anticipated venous tip (3.5 cm below the cavoatrial junction) to the prearranged skin puncture site (1.5 cm above the right clavicle). By Method 2, the insertion depth was derived by adding the length between the skin puncture site and the upper edge of the clavicle and the length of clavicle-to-tip. The TDC was placed at the estimated insertion depth. The distance of cavoatrial junction-to-arterial tip was then measured from postoperative supine CXR. One hundred and seventy and 121 TDCs were inserted by Method 1 and Method 2, respectively, while 127 and 92 preoperative supine CXR were used for preprocedure measurement. The mean distance of cavoatrial junction-to-arterial tip was 12.055 (8.5684) [mean (SD)], 11.27 (3.3261), 9.524 (5.1590), and 10.538 (2.6956) mm. Methods of determining the insertion depth by preprocedure measurement enable successful TDC tip placement. Method 2 and using preoperative supine CXR enabled more precise and flexible insertion.

New simulation-based airway management training program for junior physicians: Advanced Airway Life Support

Medical Teacher, 2009

All junior physicians in Taiwan were enrolled into a 3-month post-graduate year 1 (PGY1) course a... more All junior physicians in Taiwan were enrolled into a 3-month post-graduate year 1 (PGY1) course after Severe Acute Respiratory Syndrome (SARS) attack in 2003. To develop and evaluate a new airway management training protocol by using an integrated course of lectures, technical workshops and medical simulations. In each PGY1 course, the trainees participated in the Advanced Airway Life Support (AALS) program. After 2 h lecture, the trainees were divided into three groups for 4 h technical workshop, including 10 skill stations and medical simulation at the Clinical Skills Resources Center of the hospital at different times. Video-based debriefing and feedback were performed after each simulation. The same scenario was re-simulated after debriefing. Participants&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; performance was assessed by single global rating and a 5 key actions scoring. A total of 266 junior physicians have been trained with this AALS programs in 2 years. They learned the techniques of airway management, passed the performance checklist of technical workshop, and received higher scores during re-simulation regardless of scoring methods. The AALS training program can provide methodical and systematic training for junior residents to mature with specialized technical skills and higher-order cognitive skills, behaviors and leadership in airway management.

Journal of the Chinese Medical Association, 2008

Journal of the Chinese Medical Association, 2013

Background: The Trendelenburg position has been suggested for right internal jugular vein (RIJV) ... more Background: The Trendelenburg position has been suggested for right internal jugular vein (RIJV) catheterization. However, this position can sometimes be functionally intolerable for chronic kidney disease patients. We conducted an ultrasound study to further investigate the efficacy of the use of the Trendelenburg position during tunneled dialysis catheter insertion via the RIJV in chronic kidney disease patients. Methods: We recruited into our study patients without a history of prior tunneled dialysis catheter insertion or neck surgery. Those patients with stenosis or thrombus in the RIJV were excluded. Serial ultrasound images were acquired with patients in the supine position, with the head rotated 30 to the left: Stage 0, table flat; Stage T, Trendelenburg tilt. Then, measurements of patient RIJV transverse diameter, anteroposterior (AP) diameter, and cross-sectional area (CSA) were obtained. Results: Fifty dialysis patients and 40 healthy volunteers completed the study. There were no significant differences in the lateral diameter, AP diameter, or AP/lateral diameter ratio between the dialysis patients and healthy volunteers, whether in the supine or the Trendelenburg position. However, the CSA of the RIJV of the healthy volunteers in the Trendelenburg position was significantly larger than that in dialysis patients. The change in CSA from the supine to the Trendelenburg position was also significantly different between the two groups. Conclusion: In contrast to healthy volunteers, there was no enlargement of the RIJV when dialysis patients were in the Trendelenburg position. The reason for this phenomenon may be multifactorial, with diastolic dysfunction being the most likely cause, and further investigation is required to clarify the cause. Our investigation suggests that the supine position for central venous catheterization in dialysis patients is superior to the Trendelenburg position.

Journal of clinical anesthesia, 2012

Study Objective: To explore the influence of shoulder roll height on internal jugular vein (IJV) ... more Study Objective: To explore the influence of shoulder roll height on internal jugular vein (IJV) diameter and IJV/common carotid artery (CCA) overlap. Design: Cross-sectional study. Setting: University-affiliated hospital. Patients: 40 healthy participants. Measurements: Ultrasonography to measure the effects of using shoulder rolls ranging between 0 and 5 cm high on IJV diameter, CCA diameter, and percentage overlap of the CCA. Main Results: The percentage overlap of CCA decreased for both left (LIJV) and right IJV (RIJV) with the use of higher shoulder rolls. Greater values were seen in depth from skin surface to anterior wall of left IJV in almost all stages, with the exception of Stages 0 and 1 (P b 0.016); and the use of a 5 cm shoulder roll resulted in a significantly decreased anteroposterior (AP) diameter of both RIJVs and LIJVs (both P b 0.008). Conclusions: Shoulder rolls can reduce the overlap between the IJV and CCA, and may be useful in positioning patients for IJV puncture.

Background: Totally implantable access ports (TIAPs) are alternatives to central venous catheters... more Background: Totally implantable access ports (TIAPs) are alternatives to central venous catheters for patients requiring chemotherapy. Since
January 2003, we have used a central approach two-point incision technique to insert TIAPs. Following advances in ultrasound technique and
clinical experience for tunneled dialysis catheter placement, we modified the central approach to a low-approach technique.
Methods: From January 2009 to June 2010, patients consulted for TIAP insertion in our department were enrolled in our study. Different brands
and materials of central venous catheters of TIAPs were inserted by the low-approach two-point incision technique (Phase I) or the low-approach
one-point incision technique (Phase II). The insertion time, failure rate, procedural and late complications, degree of satisfaction, and cosmetic
scores were recorded.
Results: Ninety-seven patients and 107 patients were implanted via the two-point and one-point low-approach techniques, respectively, with
different kinds of TIAP. No matter which type of TIAP was used, the success rate in both phases was 100% without procedural complications
using the low-approach technique. The average time for device insertion was 30 minutes for the two-point incision technique used during Phase I
and 26e28 minutes for the one-point incision technique used during Phase II. Satisfaction and cosmetic scores were high.
Conclusion: Our study highlights a revised technique for placement of TIAP systems of differing types of material or size. Not only was the
curvature of the device catheter smooth, but patients were satisfied with the cosmetic appearance.

Clinical Value of Application of Cerebral Oximetry in Total Replacement of the Aortic Arch and Concomitant Vessels

Acta Anaesthesiologica Taiwanica, Dec 1, 2008

Cerebral ischemia or infarction caused by several equivocal mechanisms is a major complication af... more Cerebral ischemia or infarction caused by several equivocal mechanisms is a major complication after aortic arch replacement. Here, we report a 28-year-old male who underwent total replacement of the aortic arch and concomitant tributaries for hypoplasia of the transverse aortic arch and aortic branches. Continuous cerebral oxygen saturation (rSO2) monitoring was applied throughout the whole surgical course. According to the trend of rSO2, we could not only optimize the cerebral perfusion, but also confirm the patency of graft anastomosis. Therefore, monitoring rSO2 is very useful for determining cerebral perfusion during major surgery, especially in complicated repair of an aortic aneurysm, or replacement of the aortic arch and/or arch vessels.

How early warning with the Oxygen Reserve Index (ORi™) can improve the detection of desaturation during induction of general anesthesia?

Journal of Clinical Monitoring and Computing, 2021

The Oxygen Reserve Index (ORi™) is a dimensionless parameter with a value between 0 and 1. It is ... more The Oxygen Reserve Index (ORi™) is a dimensionless parameter with a value between 0 and 1. It is related to the real-time oxygenation status in the moderate hyperoxic range. The purpose of this study is to investigate the added warning time provided by different ORi alarm triggers and the continuous trends of ORi, SpO2, and PaO2. We enrolled 25 patients who were scheduled for elective surgery under general anesthesia with planned arterial catheterization before induction. The participants received standardized preoxygenation, induction, and intubation. The patients remained apneic and ventilation was resumed when the SpO2 fell below 90%. The ORi and SpO2 were recorded every ten seconds and arterial blood was sampled every minute, from preoxygenation to resumed ventilation. Alarm triggers set to the ORi peak and the ORi 0.55 values provided 300 and 145 s of significant added warning time compared to SpO2 (p < 0.0001). The coefficient of determination was 0.56 between the ORi and the PaO2 ≤ 240 mmHg and showed a positive correlation. The ORi enables the clinicians to monitor the patients’ oxygen status during induction of general anesthesia and can improve the detection of impending desaturation. However, further studies are needed to assess its clinical potential in the high hyperoxic range. The protocol was retrospectively registered at ClinicalTrials.gov on July 21, 2021 (NCT04976504).

Journal of the Chinese Medical Association, 2014

Background: Totally implantable access ports (TIAPs) are alternatives to central venous catheters... more Background: Totally implantable access ports (TIAPs) are alternatives to central venous catheters for patients requiring chemotherapy. Since January 2003, we have used a central approach two-point incision technique to insert TIAPs. Following advances in ultrasound technique and clinical experience for tunneled dialysis catheter placement, we modified the central approach to a low-approach technique. Methods: From January 2009 to June 2010, patients consulted for TIAP insertion in our department were enrolled in our study. Different brands and materials of central venous catheters of TIAPs were inserted by the low-approach two-point incision technique (Phase I) or the low-approach one-point incision technique (Phase II). The insertion time, failure rate, procedural and late complications, degree of satisfaction, and cosmetic scores were recorded. Results: Ninety-seven patients and 107 patients were implanted via the two-point and one-point low-approach techniques, respectively, with different kinds of TIAP. No matter which type of TIAP was used, the success rate in both phases was 100% without procedural complications using the low-approach technique. The average time for device insertion was 30 minutes for the two-point incision technique used during Phase I and 26e28 minutes for the one-point incision technique used during Phase II. Satisfaction and cosmetic scores were high. Conclusion: Our study highlights a revised technique for placement of TIAP systems of differing types of material or size. Not only was the curvature of the device catheter smooth, but patients were satisfied with the cosmetic appearance.

Journal of Clinical Anesthesia, 2012

Study Objective: To explore the influence of shoulder roll height on internal jugular vein (IJV) ... more Study Objective: To explore the influence of shoulder roll height on internal jugular vein (IJV) diameter and IJV/common carotid artery (CCA) overlap. Design: Cross-sectional study. Setting: University-affiliated hospital. Patients: 40 healthy participants. Measurements: Ultrasonography to measure the effects of using shoulder rolls ranging between 0 and 5 cm high on IJV diameter, CCA diameter, and percentage overlap of the CCA. Main Results: The percentage overlap of CCA decreased for both left (LIJV) and right IJV (RIJV) with the use of higher shoulder rolls. Greater values were seen in depth from skin surface to anterior wall of left IJV in almost all stages, with the exception of Stages 0 and 1 (P b 0.016); and the use of a 5 cm shoulder roll resulted in a significantly decreased anteroposterior (AP) diameter of both RIJVs and LIJVs (both P b 0.008). Conclusions: Shoulder rolls can reduce the overlap between the IJV and CCA, and may be useful in positioning patients for IJV puncture.

Innovation in sedation and analgesia training

Current Opinion in Anaesthesiology

PURPOSE OF REVIEW We reviewed evidence of recent innovations in sedation education and discuss ex... more PURPOSE OF REVIEW We reviewed evidence of recent innovations in sedation education and discuss experiences with sedation training in Taiwan. RECENT FINDINGS Current Status of Sedation Training: Didactic training and supervised clinical mentoring are common methods of sedation training. Although training course designed by professional societies to meet individual hospital credentialing requirements, the course content and training expectations vary and are likely inadequate to non-anesthesiologist sedation practitioners. Less Common Forms of Sedation Training: These include screen-based simulation, high-fidelity manikin-based simulation. Screen-based simulation sedation training is popular, convenient, and relatively inexpensive. Although there are numerous courses available, course content has not been standardized. High-fidelity simulation has been accepted to improve knowledge, self-confidence, awareness of emergency, crisis resource management, and teamwork, but it is costly, time intensive, and requires expertise in using simulation equipment. Although screen-based training is attractive and convenient, there is no evidence to suggest that it can replace high-fidelity simulation. Another recently developed education modality is virtual reality simulation. It has gained recent popularity as an immersive approach to medical training, but minimal content has been developed for sedation training. Beyond training, several other potential innovations may improve sedation effectiveness and patient safety. These include adherence to practice guidelines established by professional organizations, utilization of a pre-procedure sedation checklist, interpreting capnography, and implementation of real-time bedside drug displays that provide predictions of concentrations and their associated effects. SUMMARY Effective sedation education and training, especially for nonanesthesiologists, is essential to improve patient safety for procedural sedation. Several innovative approaches have been proposed and are relatively early in their development and implementation. Further studies designed to assess the impact of these new training modalities on patient safety and outcomes are warranted.

Journal of thoracic disease, 2017

There is no current consensus on which lumen an airway exchange catheter (AEC) should be passed t... more There is no current consensus on which lumen an airway exchange catheter (AEC) should be passed through in double-lumen endotracheal tube (DLT) to exchange for a single-lumen endotracheal tube (SLT) after thoracic surgery. We report an unusual case to provide possible solution on this issue. A 71-year-old man with lung adenocarcinoma had an event of a broken exchange catheter used during a DLT replacement with a SLT, after a video-assisted thoracic surgery. The exchange catheter was impinged at the distal tracheal lumen and snapped during manipulation. All three segments of the catheter were retrieved without further airway compromises. Placement of airway tube exchanger into the tracheal lumen of double-lumen tube is a potential contributing factor of the unusual complication. We suggest an exchange catheter be inserted into the bronchial lumen in optimal depth with the adjunct of video laryngoscope, as the safe method for double-lumen tube exchange.

Patient centered modeling of dynamic postoperative pain trajectories

Journal of the Chinese Medical Association

Validated Simulation: The Preliminary Experience of Anesthesiologist Board Examination in Taiwan

Studies in health technology and informatics, 2017

High fidelity simulation-based teaching has played an important role in medical education, especi... more High fidelity simulation-based teaching has played an important role in medical education, especially in anesthesiology and emergency. But there is not any currently validated scoring system or prediction model for high fidelity simulation. We will develop a validated prediction model to enhance the efficiency and validation of clinical training with high fidelity simulation.

Seminars in Dialysis, 2010

We evaluated two methods for preprocedure predicting the insertion depth of tunneled dialysis cat... more We evaluated two methods for preprocedure predicting the insertion depth of tunneled dialysis catheter (TDC) on chest radiograph (CXR). Patients undergoing TDC insertion via right internal jugular vein were enrolled. By Method 1, the insertion depth was calculated on preprocedure CXR as the distance from the anticipated venous tip (3.5 cm below the cavoatrial junction) to the prearranged skin puncture site (1.5 cm above the right clavicle). By Method 2, the insertion depth was derived by adding the length between the skin puncture site and the upper edge of the clavicle and the length of clavicle-to-tip. The TDC was placed at the estimated insertion depth. The distance of cavoatrial junction-to-arterial tip was then measured from postoperative supine CXR. One hundred and seventy and 121 TDCs were inserted by Method 1 and Method 2, respectively, while 127 and 92 preoperative supine CXR were used for preprocedure measurement. The mean distance of cavoatrial junction-to-arterial tip was 12.055 (8.5684) [mean (SD)], 11.27 (3.3261), 9.524 (5.1590), and 10.538 (2.6956) mm. Methods of determining the insertion depth by preprocedure measurement enable successful TDC tip placement. Method 2 and using preoperative supine CXR enabled more precise and flexible insertion.

Seminars in Dialysis, 2010

We evaluated two methods for preprocedure predicting the insertion depth of tunneled dialysis cat... more We evaluated two methods for preprocedure predicting the insertion depth of tunneled dialysis catheter (TDC) on chest radiograph (CXR). Patients undergoing TDC insertion via right internal jugular vein were enrolled. By Method 1, the insertion depth was calculated on preprocedure CXR as the distance from the anticipated venous tip (3.5 cm below the cavoatrial junction) to the prearranged skin puncture site (1.5 cm above the right clavicle). By Method 2, the insertion depth was derived by adding the length between the skin puncture site and the upper edge of the clavicle and the length of clavicle-to-tip. The TDC was placed at the estimated insertion depth. The distance of cavoatrial junction-to-arterial tip was then measured from postoperative supine CXR. One hundred and seventy and 121 TDCs were inserted by Method 1 and Method 2, respectively, while 127 and 92 preoperative supine CXR were used for preprocedure measurement. The mean distance of cavoatrial junction-to-arterial tip was 12.055 (8.5684) [mean (SD)], 11.27 (3.3261), 9.524 (5.1590), and 10.538 (2.6956) mm. Methods of determining the insertion depth by preprocedure measurement enable successful TDC tip placement. Method 2 and using preoperative supine CXR enabled more precise and flexible insertion.

Seminars in Dialysis, 2010

We evaluated two methods for preprocedure predicting the insertion depth of tunneled dialysis cat... more We evaluated two methods for preprocedure predicting the insertion depth of tunneled dialysis catheter (TDC) on chest radiograph (CXR). Patients undergoing TDC insertion via right internal jugular vein were enrolled. By Method 1, the insertion depth was calculated on preprocedure CXR as the distance from the anticipated venous tip (3.5 cm below the cavoatrial junction) to the prearranged skin puncture site (1.5 cm above the right clavicle). By Method 2, the insertion depth was derived by adding the length between the skin puncture site and the upper edge of the clavicle and the length of clavicle-to-tip. The TDC was placed at the estimated insertion depth. The distance of cavoatrial junction-to-arterial tip was then measured from postoperative supine CXR. One hundred and seventy and 121 TDCs were inserted by Method 1 and Method 2, respectively, while 127 and 92 preoperative supine CXR were used for preprocedure measurement. The mean distance of cavoatrial junction-to-arterial tip was 12.055 (8.5684) [mean (SD)], 11.27 (3.3261), 9.524 (5.1590), and 10.538 (2.6956) mm. Methods of determining the insertion depth by preprocedure measurement enable successful TDC tip placement. Method 2 and using preoperative supine CXR enabled more precise and flexible insertion.

Clinical Value of Application of Cerebral Oximetry in Total Replacement of the Aortic Arch and Concomitant Vessels

Acta Anaesthesiologica Taiwanica, 2008

Cerebral ischemia or infarction caused by several equivocal mechanisms is a major complication af... more Cerebral ischemia or infarction caused by several equivocal mechanisms is a major complication after aortic arch replacement. Here, we report a 28-year-old male who underwent total replacement of the aortic arch and concomitant tributaries for hypoplasia of the transverse aortic arch and aortic branches. Continuous cerebral oxygen saturation (rSO2) monitoring was applied throughout the whole surgical course. According to the trend of rSO2, we could not only optimize the cerebral perfusion, but also confirm the patency of graft anastomosis. Therefore, monitoring rSO2 is very useful for determining cerebral perfusion during major surgery, especially in complicated repair of an aortic aneurysm, or replacement of the aortic arch and/or arch vessels.

Seminars in dialysis

We evaluated two methods for preprocedure predicting the insertion depth of tunneled dialysis cat... more We evaluated two methods for preprocedure predicting the insertion depth of tunneled dialysis catheter (TDC) on chest radiograph (CXR). Patients undergoing TDC insertion via right internal jugular vein were enrolled. By Method 1, the insertion depth was calculated on preprocedure CXR as the distance from the anticipated venous tip (3.5 cm below the cavoatrial junction) to the prearranged skin puncture site (1.5 cm above the right clavicle). By Method 2, the insertion depth was derived by adding the length between the skin puncture site and the upper edge of the clavicle and the length of clavicle-to-tip. The TDC was placed at the estimated insertion depth. The distance of cavoatrial junction-to-arterial tip was then measured from postoperative supine CXR. One hundred and seventy and 121 TDCs were inserted by Method 1 and Method 2, respectively, while 127 and 92 preoperative supine CXR were used for preprocedure measurement. The mean distance of cavoatrial junction-to-arterial tip was 12.055 (8.5684) [mean (SD)], 11.27 (3.3261), 9.524 (5.1590), and 10.538 (2.6956) mm. Methods of determining the insertion depth by preprocedure measurement enable successful TDC tip placement. Method 2 and using preoperative supine CXR enabled more precise and flexible insertion.

New simulation-based airway management training program for junior physicians: Advanced Airway Life Support

Medical Teacher, 2009

All junior physicians in Taiwan were enrolled into a 3-month post-graduate year 1 (PGY1) course a... more All junior physicians in Taiwan were enrolled into a 3-month post-graduate year 1 (PGY1) course after Severe Acute Respiratory Syndrome (SARS) attack in 2003. To develop and evaluate a new airway management training protocol by using an integrated course of lectures, technical workshops and medical simulations. In each PGY1 course, the trainees participated in the Advanced Airway Life Support (AALS) program. After 2 h lecture, the trainees were divided into three groups for 4 h technical workshop, including 10 skill stations and medical simulation at the Clinical Skills Resources Center of the hospital at different times. Video-based debriefing and feedback were performed after each simulation. The same scenario was re-simulated after debriefing. Participants&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; performance was assessed by single global rating and a 5 key actions scoring. A total of 266 junior physicians have been trained with this AALS programs in 2 years. They learned the techniques of airway management, passed the performance checklist of technical workshop, and received higher scores during re-simulation regardless of scoring methods. The AALS training program can provide methodical and systematic training for junior residents to mature with specialized technical skills and higher-order cognitive skills, behaviors and leadership in airway management.

Journal of the Chinese Medical Association, 2008

Journal of the Chinese Medical Association, 2013

Background: The Trendelenburg position has been suggested for right internal jugular vein (RIJV) ... more Background: The Trendelenburg position has been suggested for right internal jugular vein (RIJV) catheterization. However, this position can sometimes be functionally intolerable for chronic kidney disease patients. We conducted an ultrasound study to further investigate the efficacy of the use of the Trendelenburg position during tunneled dialysis catheter insertion via the RIJV in chronic kidney disease patients. Methods: We recruited into our study patients without a history of prior tunneled dialysis catheter insertion or neck surgery. Those patients with stenosis or thrombus in the RIJV were excluded. Serial ultrasound images were acquired with patients in the supine position, with the head rotated 30 to the left: Stage 0, table flat; Stage T, Trendelenburg tilt. Then, measurements of patient RIJV transverse diameter, anteroposterior (AP) diameter, and cross-sectional area (CSA) were obtained. Results: Fifty dialysis patients and 40 healthy volunteers completed the study. There were no significant differences in the lateral diameter, AP diameter, or AP/lateral diameter ratio between the dialysis patients and healthy volunteers, whether in the supine or the Trendelenburg position. However, the CSA of the RIJV of the healthy volunteers in the Trendelenburg position was significantly larger than that in dialysis patients. The change in CSA from the supine to the Trendelenburg position was also significantly different between the two groups. Conclusion: In contrast to healthy volunteers, there was no enlargement of the RIJV when dialysis patients were in the Trendelenburg position. The reason for this phenomenon may be multifactorial, with diastolic dysfunction being the most likely cause, and further investigation is required to clarify the cause. Our investigation suggests that the supine position for central venous catheterization in dialysis patients is superior to the Trendelenburg position.

Journal of clinical anesthesia, 2012

Study Objective: To explore the influence of shoulder roll height on internal jugular vein (IJV) ... more Study Objective: To explore the influence of shoulder roll height on internal jugular vein (IJV) diameter and IJV/common carotid artery (CCA) overlap. Design: Cross-sectional study. Setting: University-affiliated hospital. Patients: 40 healthy participants. Measurements: Ultrasonography to measure the effects of using shoulder rolls ranging between 0 and 5 cm high on IJV diameter, CCA diameter, and percentage overlap of the CCA. Main Results: The percentage overlap of CCA decreased for both left (LIJV) and right IJV (RIJV) with the use of higher shoulder rolls. Greater values were seen in depth from skin surface to anterior wall of left IJV in almost all stages, with the exception of Stages 0 and 1 (P b 0.016); and the use of a 5 cm shoulder roll resulted in a significantly decreased anteroposterior (AP) diameter of both RIJVs and LIJVs (both P b 0.008). Conclusions: Shoulder rolls can reduce the overlap between the IJV and CCA, and may be useful in positioning patients for IJV puncture.

Background: Totally implantable access ports (TIAPs) are alternatives to central venous catheters... more Background: Totally implantable access ports (TIAPs) are alternatives to central venous catheters for patients requiring chemotherapy. Since
January 2003, we have used a central approach two-point incision technique to insert TIAPs. Following advances in ultrasound technique and
clinical experience for tunneled dialysis catheter placement, we modified the central approach to a low-approach technique.
Methods: From January 2009 to June 2010, patients consulted for TIAP insertion in our department were enrolled in our study. Different brands
and materials of central venous catheters of TIAPs were inserted by the low-approach two-point incision technique (Phase I) or the low-approach
one-point incision technique (Phase II). The insertion time, failure rate, procedural and late complications, degree of satisfaction, and cosmetic
scores were recorded.
Results: Ninety-seven patients and 107 patients were implanted via the two-point and one-point low-approach techniques, respectively, with
different kinds of TIAP. No matter which type of TIAP was used, the success rate in both phases was 100% without procedural complications
using the low-approach technique. The average time for device insertion was 30 minutes for the two-point incision technique used during Phase I
and 26e28 minutes for the one-point incision technique used during Phase II. Satisfaction and cosmetic scores were high.
Conclusion: Our study highlights a revised technique for placement of TIAP systems of differing types of material or size. Not only was the
curvature of the device catheter smooth, but patients were satisfied with the cosmetic appearance.