Oxygen reserve index (ORi™) contributes to prediction of hypoxemia and patient safety during tracheal stent insertion using rigid bronchoscopy: a case report.

The oxygen reserve index (ORi™) is a new noninvasive and continuous variable, which represents a moderate hyperoxygenation status, with a unitless scale between 0.00 and 1.00. When percutaneous oxygen saturation (SpO2) exceeds 100%, arterial blood oxygen partial pressure cannot be evaluated without performing arterial blood gas analysis. Because of significant air leakage during rigid bronchoscopy, it is difficult to monitor respiration using capnography, which does not measure end-tidal carbon dioxide (ETCO2) accurately. A 66-year-old man (175 cm, 76.8 kg) with a chief complaint of difficulty in breathing was diagnosed with a thyroid tumor. Computed tomography revealed tracheal stenosis due to direct invasion of the thyroid tumor; therefore, tracheal stenting was planned immediately. After supplying 6 L/min oxygen with a face mask and administering 180 mg of propofol intravenously, the supraglottic airway was intubated. General anesthesia (total intravenous anesthesia) through continuous administration of 6-10 mg/kg/h of propofol and intermittent administration of 50 µg of fentanyl (total 200 µg) preserved spontaneous breathing. During tracheal stent insertion, disconnection between the oxygen supply system and rigid bronchoscopy, and tracheal stent expansion, the ORi tended to decrease before SpO2 decreased. Thus, measuring ORi could prevent hypoxemia during tracheal stent insertion using rigid bronchoscopy.

Near-infrared spectroscopy might be a useful tool for predicting the risk of vascular complications after pediatric liver transplants: Two case reports.

In patients that have undergone liver transplants, a postoperative reduction in the blood flow of the liver graft represents a critical complication. We recently encountered an interesting phenomenon; that is, we found that the rSO2 level of the liver graft, as measured by NIRS, drops in patients that subsequently require an emergency liver biopsy. An 8-month-old female and an 8-month-old male underwent living donor liver transplants for biliary atresia. In both cases, a reduction in rSO2 was detected before an emergency liver biopsy was required. As a result of biopsy examinations, both patients were diagnosed with acute graft rejection. NIRS might be useful for graft management during the postoperative period in pediatric patients that undergo liver transplantation. After a liver transplant, a reduction in the rSO2 of the graft might be indicative of the onset of vascular complications.

[A Case of Living Donor Liver Transplantation Complicated by Thrombosis due to a Central Venous Catheter in the Right Internal Jugular Vein].

Central venous catheter-related infection and throm- bosis frequently occur, leading to serious complications in some cases. We encountered a case of thrombosis developing on the sixth day after surgery, in a patient with a PreSep Central Venous Oximetry Catheter™ placed in the internal jugular vein. A 53-year-old woman with a height of 160.8 cm and weight of 52.9 kg, showing normal coagulation test results, was scheduled for living donor liver transplantation under general anesthesia with sevoflurane/remifentanil. The durations of surgery and anesthesia were 6 hours and 56 minutes and 8 hours and 24 minutes, respectively. Although central venous catheter insertion and postop- erative management were appropriately performed, the patient reported chest pain and dyspnea just after the removal of the central venous catheter on the sixth day after surgery, and was diagnosed with thrombosis on CT. This case highlights the importance of selecting appropriate catheters considering perioperative risks and removing them in the early stages.

[Abdominal Oblique Muscle Hematoma after Ultrasound-guided Transverse Abdominis Plane Block].

A 41-year-old female patient with no remarkable medical history underwent a uterine myomectomy under general anesthesia. Ultrasound-guided lateral TAP block was performed using a 21-gauge blunt needle after surgery. Heparin calcium at 5,000 units was administered subcutaneously twice on postopera- tive day (POD)Y 1, and fondaparinux at 2.5 mg was administered subcutaneously once daily from POD 2 to POD 5. On POD 3, right-sided flank pain was noticed, which persisted until POD 7. Abdominal ultrasonogra- phy revealed an abdominal oblique muscle hematoma with a size of 43x19x31 mm. The patient had no anemia, and was discharged on POD 8. Right-sided flank pain disappeared, and the hematoma could not be identified by ultrasonography on POD 20.

[McGRATH MAC Videolaryngoscope: clinical assessment of its performance in 50 surgical patients].

BACKGROUND: The aim of this study was to evaluate the utility of McGRATH MAC Videolaryngoscope in tracheal intubation of surgical patients. METHODS: McGRATH MAC Videolaryngoscope was used for the tracheal intubation in 50 surgical patients undergoing general anesthesia. We compared the percentage of glottic opening score between McGRATH MAC Videolaryngoscope and Coopdech Videolaryngoscope Portable VLP-100 by anesthesia staffs and unexperienced anesthetic trainees. The number of intubation attempts and the time to complete intubation were also recorded. RESULTS: In 49 of 50 surgical patients including 18 patients with potential difficult airways, successful intubation was performed with McGRATH MAC. Not only anesthesia staffs but also unexperienced anesthetic trainees could obtain better view of the glottis with McGRATH compared with Coopdech Videolaryngoscope Portable VLP-100. CONCLUSIONS: McGRATH MAC Videolaryngoscope facilitates tracheal intubation in surgical patients.

[Comparative study of the KingVision videolaryngoscope and Airwayscope using manikins].

BACKGROUND: KingVision (KV) is a new videolaryngoscope. In this study, we compared the ease of use of the KV with the Airwayscope (AWS) by experienced personnel in a simulated manikin. METHODS: Twenty-eight anesthesiologists participated in this study. We used an advanced patient simulator (AIRSIM) to simulate normal manikin and difficult airway scenarios including cervical spine rigidity and limited mouth opening. We compared the time required for visualization of the glottis (Tv) and tracheal intubation (Ti), and analyzed the percentage of glottic opening (POGO) score and the success rates for tracheal intubation. RESULTS: In normal manikin, the Tv and Ti with the KV were significantly shorter than with the AWS (P < 0.05). The POGO score with the KV was higher than with the AWS (P < 0.05). In difficult airway scenarios including both cervical spine rigidity and limited mouth opening, the Tv and Ti with the KV were shorter than with only the AWS (P < 0.05). There is not much difference between KV and AWS regarding the POGO score in difficult airway. CONCLUSIONS: KV may be a suitable device for routine anesthesia care and difficult airway intubation. Further studies in a clinical setting are necessary to confirm these findings.

[The KINGVISION: clinical assessment of performance in 50 patients].

BACKGROUND: The aim of this study was to evaluate the suitability of the KINGVISION videolaryngoscope for tracheal intubation. METHODS: Endotracheal intubation was performed using the KINGVISION in 50 patients undergoing general anesthesia. We compared the percentage of glottic opening score between Coopdech Videolaryngoscope Portable VLP100 and the KINGVISION with staff anesthesiologist and novice personnel. The time to complete instrumentation and optimizing procedures were also recorded. RESULTS: The KINGVISION allowed visualization of the glottis and successful intubation in all patients, including 11 patients with difficult airway. There were no differences in the time to intubation between staff anesthesiologist and novice personnel. Furthermore, percentage of glottic opening score was higher with KINGVISION than with Coopdech Videolaryngoscope Portable VLP100 among staff anesthesiologist and novice personnel. CONCLUSIONS: The KINGVISION could be an effective aid to airway management in surgical patients.

[Use of RRa sensor in a pediatric patient with post-adenotonsillectomy].

Rad-87 and RRa are new acoustic monitoring devices which can monitor the respiratory rate. To our knowledge, no studies have reported the RRa sensor used in pediatric patients after surgery. We succeeded in measuring the respiratory rate with the RRa sensor in the Pediatric Intensive Care Unit(PICU). A 10-year-old boy, 14.5 kg in weight and 119.6 cm in height, with cerebral palsy, mental retardation, epilepsy, and obstructive sleep apnea due to adenoidal and tonsillar hypertrophy, was scheduled for adenotonsillectomy under general anesthesia. Anesthesia was maintained with oxygen, air, sevoflurane (1.5-2.0%), remifentanil (0.1 to 0.5 microg . kg-1. min-1), and fentanyl (4 microg . kg-1). The operating time was 55 minutes, and the duration of anesthesia was 133 minutes. After finishing the surgery, we attached the RRa sensor to his anterior neck and monitored his respiratory rate. Furthermore, RRa could count his respiratory rate, during transfer from the operating room to PICU. The patient was sedated with dexmedetomidine (0.28 microg . kg-1 . min-1) at PICU, and his respiratory rate was accurately measured with the RRa sensor. We hope that Rad-87 and RRa sensors will become useful for measuring the respiratory rate in pediatric patients in the future.

[Tracheal intubation using Airtraq optical laryngoscope in an adult patient with Goldenhar syndrome].

A 23-year-old woman with Goldenhar syndrome and conductive deafness was scheduled for tympanoplasty. Goldenhar syndrome is a developmental disorder characterized by ear malformation, mandibular hypoplasia, and vertebral anomalies. Furthermore, she had micrognathia, trismus, and mandibular hypoplasia. Awake taracheal intubation was attempted to prevent airway obstruction, because we had anticipated her difficult airway (micrognathia, trismus, and mandibular hypoplasia). The vocal cords were visualized with a Cormac and Lehane grade I, using the Airtraq optical laryngoscope Small (Size 2), under sedation. Then, an endotracheal tube was inserted after induction of general anesthesia. This is the first case report on the successful orotracheal intubation using Airtraq in an adult with Goldenhar syndrome.

[Anesthetic management of a morbidly obese patient in prone position for lumbar laminectomy].

A 22-year-old man weighing 188.7kg, 170cm tall (body mass index 65.2 kg x m(-2)) with bladder and rectal disturbances due to lumbar disc hernia (L4/5 and L5/S1) was scheduled for L4-5 laminectomy under general anesthesia. Awake fiberoptic intubation was attempted to prevent airway obstruction because we predicted difficult airway. During fiberoptic tracheal intubation, we easily succeeded in the insertion of the fiberscope itself into the trachea, and we succeeded in placing the reinforced tube into the trachea. Fentanyl and sugammadex were calculated with total body weight, but, remifentanil, propofol, and rocuronium were re-calculated with ideal body weight. They were given intravenously. Anesthesia was maintained with sevoflurane (1.5 to 2.0%), the fraction of inspiratory oxygen (about 0.6), remifentanil (0.1 to 0.4 microg x kg(-1) x min(-1)), and fentanyl (100 to 150 microg) as needed. After turning to prone position, severe physiological abnormal signs were not recognized. We concluded that awake fiberoptic intubation was useful and safe; moreover, anesthetic agents were administrated appropriately for morbid obesity.

[The C-MAC videolaryngoscope: its utility in tracheal intubation by novice personnel].

BACKGROUND: The aim of this study was to evaluate the suitability of the C-MAC videolaryngoscope for the tracheal intubation especially by novice personnel. METHODS: Endotracheal intubation was performed using the C-MAC videolaryngoscope in 40 patients undergoing general anesthesia. We compared the percentage of glottic opening score between Macintosh laryngoscope and the C-MAC videolaryngoscope by anesthesia staff and novice personnel. The time to complete instrumentation and optimizing procedures were also recorded. RESULTS: The C-MAC videolaryngoscope allowed visualization of the glottis and successful intubation in 39 patients. There was no difference in the time to intubation between anesthesia staff and novice personnel. Furthermore, there was significant difference in percentage of glottic opening score between Macintosh laryngoscope and the C-MAC videolaryngoscope in novice personnel, because of appropriate guidance by anesthesia staff. CONCLUSIONS: The C-MAC videolaryngoscope is a useful device in education of endotracheal intubation by novice personnel.

[Use of Parker Flex-Tip tracheal tube in a patient with Kniest dysplasia].

A 37-year-old man with Kniest dysplasia and thoracic myelopathy was scheduled for T3-12 laminectomy. Kniest dysplasia is a severe chondrodysplasia characterized by short trunk and limbs. Awake fiberoptic intubation was attempted to prevent airway obstruction because we had predicted his difficult airway. During fiberoptic tracheal intubation, we easily succeeded in the insertion of the fiberscope itself into the trachea, but were not able to insert the tip of a reinforced tube into the trachea, because the tip of the reinforced tube impinged on laryngeal structures. We succeeded in placing the Parker Flex-Tip tracheal tube into the trachea. We considered that the Parker Flex-Tip tube, having a tip that reduces the gap between the fiberscope and the inside of the tube, resulted in success of the passage of the tube into the trachea during fiberoptic intubation.

Successful Double-lumen Tube Intubation in the Lateral Position for a Patient with a Giant Superior Mediastinal Tumor.

OBJECTIVE: Anesthetic management of patients with giant mediastinal tumors is challenging from the perspective of both cardiovascular and respiratory management, and airway assessment is important for both concerns. We report the successful induction of general anesthesia and double-lumen tube intubation in the right lateral position for a patient with a giant mediastinal tumor with tracheal compression, using pre-operative chest radiograph imaging to minimize tracheal compression during induction. METHODS: A 41-year-old man required thoracoscopic giant superior mediastinal tumor resection. His trachea was compressed and displaced because of the tumor. Because preoperative chest radiography revealed that the tracheal diameter increased in the right lateral position, we chose this position for induction. RESULTS: Prompt and smooth intubation with a 35-Fr double-lumen tube (DLT) was achieved, and no adverse events associated with intubation were encountered. CONCLUSION: Safe and smooth induction with a DLT was performed owing to the perioperative chest radiograph imaging examination, which revealed the most advantageous position regarding minimal tracheal compression.

Association between stroke and metabolic syndrome in a Japanese population: Jichi Medical School (JMS) Cohort Study.

BACKGROUND: Metabolic syndrome increases the morbidity and mortality of cardiovascular diseases. However, few studies have examined the association between the incidence of stroke and metabolic syndrome, as defined by Japanese criteria. The aim of this study was to identify the association between stroke and metabolic syndrome, as defined by criteria used in Japan. METHODS: A total of 2205 subjects (920 men and 1285 women) were examined between 1992 and 1995 as part of the Jichi Medical School Cohort Study. Metabolic syndrome was defined using the Japanese criteria. Medical records, computed tomography, and magnetic resonance imaging were used to diagnose stroke. The Cox proportional-hazards model was used to analyze the association between metabolic syndrome and incident stroke. RESULTS: The prevalence of metabolic syndrome at baseline was 9.0% in men and 1.7% in women. There were 96 incident strokes during an 11.2-year follow-up period, 14 of which occurred in subjects with metabolic syndrome. Among subjects with metabolic syndrome, the age-adjusted hazard ratio (95% confidence interval) for stroke was 1.93 (0.94-3.96) in men and 6.85 (2.68-17.47) in women. After adjusting for age, smoking status, and alcohol drinking status, the hazard ratio was 1.89 (0.88-4.08) in men and 7.24 (2.82-18.58) in women. Age-adjusted hazard ratios associated with having 2 or more components of metabolic syndrome, with and without central obesity, were 2.93 (1.21-7.08) and 3.20 (1.23-8.31) in men and 1.75 (0.69-4.44) and 8.64 (2.82-28.03) in women, respectively. CONCLUSIONS: The presence of metabolic syndrome, as defined by Japanese criteria, increases the risk of stroke; this effect was highly significant among women.

Resolution of anti-neutrophil cytoplasmic antibody-associated vasculitis after resection of gastric cancer.

We report a case of anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis in a 62-year-old patient with gastric cancer. The myeloperoxidase-anti-neutrophil cytoplasmic antibody (MPO-ANCA) level was threefold above normal preoperatively. Vasculitis was seen on renal biopsy. Gastric resection revealed well-differentiated adenocarcinoma and vasculitis. The MPO-ANCA level returned to normal post-operatively. Although ANCA-associated vasculitis occasionally accompanies malignant tumors, this is the first documented case of concurrent gastric cancer-associated and ANCA-associated vasculitis, with post-operative resolution of the vasculitis.

[Inadvertent arterial misplacement of a large-caliber cannula during jugular vein catheterization].

We report a case of inadvertent arterial misplacement of a large-caliber cannula during jugular vein catheterization. A tip of a 9F cannula was inadvertently placed into the brachiocephalic trunk via the subclavian artery. The arterial trauma was managed by cannula removal and external compression without secondary traumas. Our case emphasizes that the excursion of the subclavian artery is associated with a significant risk of trauma on the subclavian artery during jugular vein catheterization.

Pregabalin for postherpetic itch: a case report.

BACKGROUND: Postherpetic itch has not commonly received attention as a complication of herpes zoster because pain predominates over itch in most patients with herpes zoster. Most cases of postherpetic itch are mild; however, cases of severe postherpetic itch reducing quality of life are rare. CASE PRESENTATION: A 52-year-old woman complained of severe itch in her left pinna and cheek 1 month after the first onset of herpes zoster at the same site. Owing to her scratching, she developed ulcers on her left pinna and cheek. Pregabalin was prescribed, and the itch subsided immediately, with the ulcers disappearing within 1 month. DISCUSSION: Severe itch was thought to be caused by neural injury from herpes zoster. Pregabalin may be a useful treatment option for neuropathic itch induced by herpes zoster.

[Nasal endotracheal intubation using GlideScope].

We describe the performance of GlideScope in 34 consecutive patients who required nasal endotracheal intubation for surgical convenience. In the 34 patients, nasal endotracheal intubation was achieved in 52 +/- 22 (mean +/- SD) sec by unexperienced clinicians, and in 50 +/- 17 sec by anesthetists in the department. Margill forceps were not needed for any patient during nasotracheal intubation. The improved coordination afforded by an image on a video monitor seen by both the assistant providing laryngeal manipulation and the anesthetist handling the laryngoscope resulted in a significant advantage over the conventional laryngoscope technique. GlideScope seems to be a novel useful device for nasal endotracheal intubation.