Presepsin and prognostic nutritional index are predictors of septic acute kidney injury, renal replacement therapy initiation in sepsis patients, and prognosis in septic acute kidney injury patients: a pilot study.

BACKGROUND: Sepsis is the most common cause of acute kidney injury (AKI) among critically ill patients. This study aimed to determine whether presepsin is a predictor of septic acute kidney injury, renal replacement therapy initiation (RRTi) in sepsis patients, and prognosis in septic AKI patients. METHODS: Presepsin values were measured immediately after ICU admission (baseline) and on Days 2, 3, and 5 after ICU admission. Glasgow Prognostic Score (GPS), neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio, Prognostic Index, and Prognostic Nutritional Index (PNI) were measured at baseline, and total scores ("inflammation-presepsin scores [iPS]") were calculated for category classification. Presepsin values, inflammation-based prognostic scores, and iPS were compared between patients with and without septic AKI or RRTi and between survivors and non-survivors. RESULTS: Receiver operating characteristic curve analyses identified the following variables as predictors of septic AKI and RRTi in sepsis patients: presepsin on Day 1 (AUC: 0.73) and Day 2 (AUC: 0.71) for septic AKI, and presepsin on Day 1 (AUC: 0.71), Day 2 (AUC: 0.9), and Day 5 (AUC: 0.96), Δpresepsin (Day 2 - Day 1) (AUC: 0.84), Δpresepsin (Day 5 - Day 1) (AUC: 0.93), and PNI (AUC: 0.72) for RRTi. Multivariate logistic regression analyses identified presepsin on Day 2 as a predictor of prognosis in septic AKI patients. CONCLUSIONS: Presepsin and PNI were found to be predictors of septic AKI, RRTi in sepsis patients, and prognosis in septic AKI patients.

Evaluation of alveolar recruitment maneuver on respiratory resistance during general anesthesia: a prospective observational study.

BACKGROUND: Alveolar recruitment maneuvers enable easily reopening nonaerated lung regions via a transient elevation in transpulmonary pressure. To evaluate the effect of these maneuvers on respiratory resistance, we used an oscillatory technique during mechanical ventilation. This study was conducted to assess the effect of the alveolar recruitment maneuvers on respiratory resistance under routine anesthesia. We hypothesized that respiratory resistance at 5 Hz (R5) after the maneuver would be decreased after the lung aeration. METHODS: After receiving the ethics committee's approval, we enrolled 33 patients who were classified with an American Society of Anesthesiologists physical status of 1, 2 or 3 and were undergoing general anesthesia for transurethral resection of a bladder tumor within a 12-month period from 2017 to 2018. The recruitment maneuver was performed 30 min after endotracheal intubation. The maneuver consisted of sustained manual inflation of the anesthesia reservoir bag to a peak inspiratory pressure of 40 cmH2O for 15 s, including 5 s of gradually increasing the peak inspiratory pressure. Respiratory resistance was measured using the forced oscillation technique before and after the maneuver, and the mean R5 was calculated during the expiratory phase. The respiratory resistance and ventilator parameter results were analyzed using paired Student's t-tests, and p < 0.05 was considered statistically significant. RESULTS: We analyzed 31 patients (25 men and 6 women). R5 was 7.3 ± 1.6 cmH2O/L/sec before the recruitment maneuver during mechanical ventilation and was significantly decreased to 6.4 ± 1.7 cmH2O/L/sec after the maneuver. Peak inspiratory pressure and plateau pressure were significantly decreased, and pulmonary compliance was increased, although the values were not clinically relevant. CONCLUSION: The recruitment maneuver decreased respiratory resistance and increased lung compliance during mechanical ventilation. TRIAL REGISTRATION: Name of registry: Japan Medical Association Center for Clinical Trials. TRIAL REGISTRATION NUMBER: reference JMA-IIA00136. Date of registration: 2 September 2013. URL of trial registry record: https://dbcentre3.jmacct.med.or.jp/JMACTR/App/JMACTRE02_04/JMACTRE02_04.aspx?kbn=3&seqno=3582.

Correction to: Stiripentol alleviates neuropathic pain in L5 spinal nerve-transected mice.

In the original publication of the article, the value "40-µm thickness" was incorrect in the legend of Figure 4. The correct value is 10-µm thickness.

Stiripentol alleviates neuropathic pain in L5 spinal nerve-transected mice.

PURPOSE: Antiepileptic drugs are used not only for the treatment of epilepsy but also for that of neuropathic pain. However, their action mechanisms have not always been well explained. Stiripentol, an effective antiepileptic drug indicated as a therapeutic for Dravet syndrome, was recently shown to act as an inhibitor of lactate dehydrogenase in astrocytes. In this present study, we examined the effect of stiripentol on neuropathic pain in L5 spinal nerve-transected mice. METHODS: We carried out behavioral tests using calibrated von Frey filaments and the immunohistochemistry of glial fibrillary acidic protein, an astrocyte marker, in L5 spinal nerve-transected mice after intrathecal administration of drugs. RESULTS: Like other anticonvulsants such as gabapentin and carbamazepine, stiripentol alleviated mechanical hyperalgesia induced by L5 spinal nerve transection in a dose-dependent manner, when intrathecally administered to mice 7, 14, and 28 days after L5 spinal nerve transection. Likewise, α-cyano-4-hydroxycinnamic acid, a broad inhibitor of monocarboxylate transporters, diminished mechanical hyperalgesia induced by L5 spinal nerve transection. Simultaneous administration of L-lactate negated the analgesic effect elicited by stiripentol, carbamazepine or α-cyano-4-hydroxycinnamic acid, but not that by gabapentin. None of the anticonvulsants affected the immunoreactivity of glial fibrillary acidic protein. CONCLUSIONS: This present study demonstrated that stiripentol was effective against neuropathic pain and suggested that the astrocyte-neuron lactate shuttle was involved in such pain.

Evaluation of the Fourth-Generation FloTrac/Vigileo System in Comparison With the Intermittent Bolus Thermodilution Method in Patients Undergoing Cardiac Surgery.

OBJECTIVES: The aim of this study was to evaluate the accuracy, precision, and trending ability of the fourth-generation FloTrac/Vigileo system (version 4.00; Edwards Lifesciences, Irvine, CA) by comparing cardiac output derived from FloTrac/Vigileo system (COAP) with that measured by a pulmonary artery catheter (COTD), and to determine the effects of hemodynamic variables on the bias between COTD and COAP. DESIGN: A prospective study. SETTING: University hospital. PARTICIPANTS: Thirty patients undergoing elective cardiac surgery using cardiopulmonary bypass. INTERVENTIONS: Including hemodynamic variables, COTD and COAP were measured simultaneously at the following 10 time points: after the induction of anesthesia, at the start of operation, after sternotomy, before and after the administration of heparin, before and after the administration of protamine, at the start of sternal closure, at the end of operation, and on arrival to intensive care unit. MEASUREMENTS AND MAIN RESULTS: In total, 280 pairs of datasets were obtained. Bland-Altman analysis showed a bias of -0.41 L/min, a precision of 0.72 L/min, and limits of agreement of -1.85 and 1.03 L/min, with a percentage error of 37.1%. The concordance rate determined by 4-quadrant plot analysis and the polar concordance rate were 76% and 79%, respectively. The linear mixed-effect model revealed that the bias was influenced strongly by the difference in pulse pressure between the radial and femoral artery (p < 0.001), and the systemic vascular resistance index (p < 0.001). CONCLUSION: The fourth-generation FloTrac/Vigileo system still lacks accuracy and trending ability in cardiac surgery, and the discrepancy in cardiac output measurement depends on the peripheral vascular tone. Further improvement of this system is needed.

Sudden, Sharp Turn in an AIDS Patient's Course Following the Onset of Fulminant Type 1 Diabetes.

A previously healthy 40-year-old Japanese male was urgently admitted with a 2-month history of dysphagia, 30-kg weight loss, and fever. Human immunodeficiency virus (HIV) antibodies and cytomegalovirus antigenemia were positive. Pneumocystis pneumonia and cytomegalovirus pneumonia were suspected. The patient was diagnosed with acquired immune deficiency syndrome (AIDS). Cytomegalovirus antigenemia became negative 20 days after the positive result. On hospital day 41, he experienced cardiopulmonary arrest. The clinical diagnosis was fulminant type 1 diabetes mellitus. He later developed hypoglycemia and was diagnosed with adrenal insufficiency accompanied by septic shock. He died of multiple organ failure 29 h post-admission to our ICU.

Development of a novel photoaffinity probe for labeling nocistatin receptor.

Nocistatin (NST) is a neuropeptide produced from the same precursor protein of opioid peptide nociceptin/orphanin FQ, and it is involved in a broad range of central functions including pain transmission in the nervous system. However, the composition and structure of the receptor(s) for NST remain unclear. Here, we developed NST photoaffinity probe to identify NST receptor. The NST photoaffinity probe contains an azide moiety for the tagging of the binding protein as well as biotin for protein detection. Intrathecal administration of a NST photoaffinity probe, biotin-(AC5)2-[Y6,azF14]bNST, inhibited the nociceptin/orphanin FQ-evoked tactile pain allodynia in a manner similar to that of NST. The biotin-(AC5)2-[Y6,azF14]bNST-binding proteins were primarily localized in the gray matter of the spinal cord. After photo-crosslinking of the protein complex with biotin-(AC5)2-[Y6,azF14]bNST, two dominant binding protein bands were observed at 58 and 64 kDa. Thus, biotin-(AC5)2-[Y6,azF14]bNST has pharmacological activity and is useful for characterizing the NST receptor.

RNA editing enzyme ADAR2 is a mediator of neuropathic pain after peripheral nerve injury.

Transcriptional and post-translational regulations are important in peripheral nerve injury-induced neuropathic pain, but little is known about the role of post-transcriptional modification. Our objective was to determine the possible effect of adenosine deaminase acting on RNA (ADAR) enzymes, which catalyze post-transcriptional RNA editing, in tactile allodynia, a hallmark of neuropathic pain. Seven days after L5 spinal nerve transection (SNT) in adult mice, we found an increase in ADAR2 expression and a decrease in ADAR3 expression in the injured, but not in the uninjured, dorsal root ganglions (DRGs). These changes were accompanied by elevated levels of editing at the D site of the serotonin (5-hydroxytryptamine) 2C receptor (5-HT2CR), at the I/V site of coatomer protein complex subunit α (COPA), and at the R/G site of AMPA receptor subunit GluA2 in the injured DRG. Compared to Adar2+/+/Gria2R/R littermate controls, Adar2-/-/Gria2R/R mice completely lacked the increased editing of 5-HT2CR, COPA, and GluA2 transcripts in the injured DRG and showed attenuated tactile allodynia after SNT. Furthermore, the antidepressant fluoxetine inhibited neuropathic allodynia after injury and reduced the COPA I/V site editing in the injured DRG. These findings suggest that ADAR2 is a mediator of injury-induced tactile allodynia and thus a potential therapeutic target for the treatment of neuropathic pain.-Uchida, H., Matsumura, S., Okada, S., Suzuki, T., Minami, T., Ito, S. RNA editing enzyme ADAR2 is a mediator of neuropathic pain after peripheral nerve injury.

The Neutrophil to Lymphocyte Ratio Is Superior to Other Inflammation-Based Prognostic Scores in Predicting the Mortality of Patients with Pneumonia.

A neutrophil-to-lymphocyte ratio (NLR) > 7 is reportedly an independent marker of mortality in patients with bacteremia. However, no studies have shown an association between inflammation-based prognostic scores (including the Glasgow Prognostic Score, the NLR, the platelet-to-lymphocyte ratio, the Prognostic Nutritional Index, and the Prognostic Index) and mortality in patients with pneumonia. We retrospectively examined the cases of 33 patients diagnosed with pneumonia who were treated in the ICU of Osaka Medical College Hospital between January 2014 and June 2016. A multivariate analysis revealed that the NLR was a significant predictor of mortality in these pneumonia patients.

Head elevation and lateral head rotation effect on facemask ventilation efficiency: Randomized crossover trials.

PURPOSE: We performed two prospective randomized crossover trials to evaluate the effect of head elevation or lateral head rotation to facemask ventilation volume. METHODS: In the first trial, facemask ventilation was performed with a 12-cm high pillow (HP) and 4-cm low pillow (LP) in 20 female patients who were scheduled to undergo general anesthesia. In the second trial, facemask ventilation was performed with and without lateral head rotation in another 20 female patients. Ventilation volume was measured in a pressure-controlled ventilation (PCV) manner at 10, 15, and 20 cmH2O inspiratory pressures. RESULTS: In the first trial evaluating head elevation effect, facemask ventilation volume was significantly higher with a HP than with a LP at 15 and 20 cmH2O inspiratory pressure (15 cmH2O: HP median540 [IQR480-605] mL, LP 460 [400-520] mL, P=0.006, 20 cmH2O: HP 705 [650-800] mL, LP 560 [520-677] mL, P<0.001). In the second trial, lateral head rotation did not significantly increase facemask ventilation volume at all inspiratory pressure. CONCLUSION: Head elevation increased facemask ventilation volume in normal airway patients, while lateral head rotation did not.

Evaluation of gum-elastic bougie combined with direct and indirect laryngoscopes in vomitus setting: A randomized simulation trial.

PURPOSE: Videolaryngoscopes may not be useful in the presence of vomitus due to blurred images on the monitor. The objective of our study is to compare the utility of gum-elastic bougie (GEB) application for tracheal intubation with the Macintosh laryngoscope (McL), which is a direct laryngoscope, with that of the Pentax-AWS Airwayscope® (AWS) and McGRATH® MAC (McGRATH) in simulated vomitus settings. METHODS: Sixteen novice doctors performed tracheal intubation on an adult manikin using McL, AWS, and McGRATH with or without GEB under normal and vomitus simulations. RESULTS: In the normal setting the tracheal intubation was successful with the three laryngoscopes regardless of GEB application. In the vomitus setting, the intubation success rate did not significantly improve using McL, while it did using McGRATH or AWS. In the normal settings, GEB application significantly lengthened the intubation time in all three laryngoscopes. By contrast, in the vomitus settings, GEB application significantly shortened the intubation time in all three laryngoscopes. For the comparison of three laryngoscopes, the intubation time did not differ significantly in normal setting, while it was significantly longer in McG and AWS trials than McL trial. CONCLUSION: The GEB application facilitates the tracheal intubation in the vomitus setting using McGRATH and AWS in adult simulation.

Manual laryngeal fixation facilitates tracheal intubation during chest compression: A randomized crossover manikin study.

PURPOSE: We compared the effectiveness of external manual laryngeal fixation (MLF) for tracheal intubation during chest compression using three laryngoscopes, the Macintosh laryngoscope (McL), McGRATH® MAC (McGRGTH), and Pentax-AWS Airwayscope® (AWS) on an adult manikin. METHODS: Sixteen novice doctors and 15 experienced anesthesiologists performed tracheal intubation during chest compression on an adult manikin using the McL, McGRATH, and AWS with or without MLF. Tracheal intubation time and intubation success rate were measured. RESULTS: In the AWS trial, all novice and experienced doctors successfully secured the airway with or without MLF during chest compression. In McL and McGRATH trials, MLF significantly improved the rate of successful intubation during chest compression compared to without MLF for novice doctors. While intubation time did not significantly differ with or without MLF in the AWS trial, MLF significantly shortened intubation time in McL and McGRATH trials for both novice and experienced doctors. CONCLUSION: These findings suggest that MLF facilitates tracheal intubation with the McL and McGRATH during chest compression.

Contribution of the nasal passage to face mask ventilation: a prospective blinded randomized crossover trial.

BACKGROUND: Previous studies have shown that the nasal passage plays an important role in manual face mask ventilation, but this has yet to be quantitatively assessed. We conducted a prospective randomized crossover clinical trial to compare the change in pressure-controlled face mask tidal volume with and without nasal airway occlusion. METHOD: Female patients undergoing elective surgery under general anesthesia served as study subjects. Patients were randomly assigned to face mask ventilation beginning either with or without nasal passage occlusion (achieved with a swimmer's nose clip), followed by removal or application of the nose clip, respectively. After standardized induction of general anesthesia and muscle paralysis, a tight-fitting face mask was applied to each patient, and tidal volume was measured by the anesthesia machine during pressure-controlled ventilation (10, 15, 20 cm H2O; 8 breaths·min-1; inspiratory:expiratory ratio 1:2). RESULTS: The median [interquartile range] tidal volume was lower with vs without nasal passage occlusion at 10 cm H2O inspiratory pressure (100 [55-134] mL vs 300 [230-328] mL, respectively; median difference (MD), 200 mL; 95% confidence interval (CI), 157 to 229; P < 0.001), 15 cm H2O inspiratory pressure (190 [120-230] mL vs 520 [420-593] mL, respectively; MD, 340 mL; 95% CI, 257 to 395; P < 0.001), and 20 cm H2O inspiratory pressure (270 [215-390] mL vs 790 [713-823] mL, respectively; MD, 520 mL; 95% CI, 390 to 582; P < 0.001). CONCLUSION: Nasal passage obstruction considerably reduces tidal volume achieved during face mask ventilation. In some patients, it may be advantageous to relieve nasal airway obstruction for effective face mask ventilation. TRIAL REGISTRATION: UMIN Clinical Trials Registry, number UMIN000022184. Registered 2 May 2016.

Effect of Cricoid Pressure on the Insertion Efficacy of Six Supraglottic Devices: A Crossover Randomized Simulation Trial.

BACKGROUND: No study has ever compared the efficacy of various types of supraglottic devices (SGDs) for securing the airway under cricoid pressure. OBJECTIVE: This study aimed to evaluate the efficacy of six SGDs, LMA-ProSeal (ProSeal), LMA-Classic (Classic), Laryngeal Tube (LT), LMA-Supreme (Supreme), air-Q (air-Q), and i-gel (i-gel), in airway management under cricoid pressure using a manikin. METHODS: Fifteen novice doctors and 16 experienced doctors used the six SGDs under cricoid or sham pressure on an adult manikin. Insertion time, successful ventilation rate, and subjective insertion difficulty on a visual analogue scale (VAS) were measured. RESULTS: Both novice and experienced doctors had a significantly lower ventilation success rate under cricoid pressure than under sham pressure when using the ProSeal, Classic, and LT, but not when using the other three SGDs. Novice doctors required a significantly longer insertion time under cricoid pressure than under sham pressure with all SGDs. Experienced doctors required a significantly longer insertion time under cricoid pressure than with sham pressure when using the ProSeal, Classic, and LT, but not when using the other three SGDs. Subjective insertion difficulty on VAS was significantly higher under cricoid pressure than under sham pressure with all six SGDs. CONCLUSION: Ventilation success rate under cricoid pressure was significantly lower than under sham pressure when using the ProSeal, Classic, and LT, but not when using the other three SGDs in both novice and experienced doctors.

[A Difficult Airway after Anesthetic Induction in a Patient with Masticatory Muscle Tendon-Aponeurosis Hyperplasia].

We present a case of masticatory muscle tendon- aponeurosis hyperplasia in a patient who underwent general anesthesia for gynecologic surgery. The patient's square-shaped mandible was noticed during preoperative assessment by an anesthesiologist. Further investigation revealed masticatory muscle tendon- aponeurosis hyperplasia. Anesthetic induction agents were administered, and facemask ventilation was initi- ated easily. As the anesthesiologist had predicted, the patient's mouth opening was reduced after administration of muscle relaxants, and keeping her mouth open was more difficult than when she was conscious. Nasotracheal intubation was performed successfully using a bronchoscope. Patients with muscle tendon- aponeurosis hyperplasia do not generally have associated pain, and do not know that they have a limited mouth opening. They are therefore sometimes unaware that they have the condition. Anesthesiologists need to predict that airway intubation will be difficult when the patient has a limited mouth opening associated with a square-shaped mandible.

[Anesthetic Management of Emergency Thrombectomy for a Patient with Undiagnosed Polycythemia Vera].

Here we report successful anesthetic management of emergency thrombectomy for a patient with undiag- nosed polycythemia vera. A 67-year-old man com- plained of numbness of the right lower limb and was diagnosed with acute artery obstruction. Emergency thrombectomy was scheduled. Preoperative blood exam revealed hemoglobin 21.0 g · dl⁻¹ (hematocrit, 63.4%). During central venous catheter placement, we con- firmed high backflow blood viscosity; blood was diluted with plasma substitute. Hemoglobin was main- tained at 14-15 g · dl⁻¹ with continuous administration of plasma substitute. On re-perfusion of the right lower limb, potassium increased to 7.6 mEq · ml⁻¹, which responded to calcium carbonate, GI therapy, and furo- semide. Surgery was uneventful and the patient was diagnosed with polycythemia vera postoperatively. As perioperative management of polycythemia vera is challenging, particularly in undiagnosed and untreated cases, efforts should be made to avoid further throm- bosis and cardiac events.

[Efficacy of Go-rei-san for Pain Management in Four Patients with Intractable Trigeminal Neuralgia].

Go-rei-san is a Japanese traditional medicine that is used to treat motion sickness, nausea, and vomiting. We report here four patients for whom Go-rei-san was effective in treating pain associated with intractable trigeminal neuralgia. Three patients could not continue carbamazepine due to drug-induced rash, liver damage, and gastrointestinal injury, and suffered from pain. One patient experienced severe dizziness upon combination treatment with pregabalin and carbamazepine. All patients exhibited symptoms of water poisoning on their tongues. All patients experienced significant pain relief without major complications after daily adminis- tration of 7.5 g Go-rei-san. Our findings suggest that Go-rei-san can effectively alleviate pain associated with intractable trigeminal neuralgia without major compli- cations.

[Efficacy of Transversus Abdominis and Rectus Sheath Blocks in Combination with Continuous Intravenous Fentanyl for Postoperative Analgesia of Laparoscopic Colectomy: A Retrospective Study].

BACKGROUND: Ultrasound-guided transversus ab- dominis plane (TAP) and rectus sheath (RS) blocks are peripheral nerve blocks that diminish somatic pain of the abdominal wall and are useful for postoperative analgesia. Here, we retrospectively compared the effi- cacy of ultrasound-guided TAP and RS blocks in com- bination with continuous intravenous fentanyl for postoperative analgesia of laparoscopic colectomy. METHODS: The ethics committee of our institute ap- proved the study. In our hospital, postoperative analge- sia is performed with continuous intravenous fentanyl administration at three concentrations : 12.5, 18.75, and 31.25 µg · hr⁻¹. TAP and RS blocks were applied using 30-40 ml of 0.19-0.25% ropivacaine. We selected 43 patients who underwent laparoscopic colectomy from May to October 2015. We compared the fentanyl only group (F group, n=26) and block combination group (F+B group, n=17). Statistical analysis was performed with the Mann-Whitney U test P<0.05 was considered significant Results : Patient characteristics including age, height, body weight, duration of anesthesia, and surgery did not significantly differ between the two groups. The concentration of intravenous fentanyl was significantly lower in the F+B group than in the F group (F group : 19.5±8.4µg · hr⁻¹, F+B group : 14.7?4.9 µg · hr⁻¹, P=0.02). In the present study, TAP and RS blocks significantly reduced the dose of administered fentanyl. - Conclusions : Our findings suggest that a combina- tion of TAP and RS blocks lower the dose of continu- ous intravenous fentanyl needed, and may provide better postoperative analgesia after laparoscopic colec- tomy.

[Cesarean Section under General Anesthesia in a Pregnant Woman with Fibromyalgia].

We report a case of a 34-year-old pregnant woman with fibromyalgia (FM) who underwent cesarean sec- tion under general anesthesia. The patient was taking duloxetine and pregabalin for FM, as well as several anti-depressants due to severe depression. To avoid the exacerbation of FM by spinal anesthesia, we decided to perform cesarean section under general anesthesia. After a crash induction with propofol and rocuronium, tracheal intubation was performed using the Pentax- AWS Airwayscopeo. The procedure was completed uneventfully. Postoperatively, the patient received an ultrasound-guided transverse abdominal plane block and a continuous intravenous fentanyl infusion to relieve pain. No FM exacerbation was noted.

[Significance of Multi-center Respiratory Surgery Perioperative Team Training Including Various Medical Staffs].

We report the development of a multi-center/multi- specialist perioperative team development training program about respiratory surgery. Participants were members of the team, including anesthesiologists, respiratory surgeons, and operation nurses. A ques- tionnaire survey was conducted prior to course partici- pation to clarify any questions team members had. The courses included a lecture and simulation training with scenario-based discussions or the use of a simulator. Scenarios included massive bleeding during pulmonary artery damage, intractable hypoxia during one lung ventilation, and severe hypotension accompanied with hypoxia after tracheal extubation. We also discussed the best method for preoperative smoking cessation for better surgery outcome. After each course, participants discussed problems associated with perioperative medi- cal safety of respiratory surgery in the context of each theme. Simulation-based perioperative team training with anesthesiologists, respiratory surgeons, and opera- tion nurses may serve as a vehicle to promote periop- erative obstetrics safety.