[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.

[Anesthetic Management of a 105-year-old Man Undergoing Emergency Abdominal Surgery].

As Japan's population ages, the number of cases of emergency abdominal surgery at advanced ages is increasing. A 105-year-old man weighing 37 kg combined with aortic stenosis and regurgitation was scheduled for emergency surgery for incarcerated inguinofemoral hernia. General anesthesia was induced with short-acting analgesics and sedatives. The patient was extubated uneventfully in the operating room and discharged without any major complications. Anesthetic management of elderly patients requires appropriate preoperative evaluation of complicating diseases, degree of consciousness, and nutritional condition. For those aged 100 years and older in particular, their quality of life should be considered. Close and cooperative communication between surgeons and anesthesiologists are also an important aspect in treating these charged without any major complications.

[Nasal Endotracheal Intubation Using a Gum-elastic Bougie and the Nasopharyngeal Airway in a Patient under Cervical Stabilization].

Here we report a case of successful nasal endotra- cheal intubation using a gum-elastic bougie and the nasopharyngeal airway (NPA) in a patient under cervical stabilization. A 40-year-old woman was sched- uled to undergo spinal fusion surgery from the anterior approach for symptomatic cervical spondylotic myelop- athy under general anesthesia with nasal intubation. As she had paralysis and presented with numbness in her limbs, the airway was planned to be secured under cervical stabilization. After induction of anesthesia with propofol, fentanyl, and rocuronium, mask ventilation was achieved with the jaw-thrust maneuver. A gum- elastic bougie (GEB) was inserted into her nasal cavity and passed into the trachea under gentle laryngoscopy. We attempted insertion of the spiral tracheal tube (internal diameter, 7.0 mm) along the GEB, which was impossible. We then inserted NPA (internal diameter, 8.0 mm) via the GEB and dilated the cavity. After NPA removal, the spiral tube successfully progressed railing on the GEB. The operation was uneventful, and the patient was extubated in the operating room.

[Severe Hemostatic Dysfunction during Multiple Spinal Fusion Surgery in a Patient with Multiple Myeloma].

We report a patient with multiple myeloma who developed severe hemostatic dysfunction during spinal fusion surgery. A 74-year-old man presented with lower limb paralysis due to thoracic supine pathological fracture and was scheduled for spinal fusion surgery. He suffered from multiple myeloma for decades but did not present with any significant abnormalities in a preoperative blood exam. Prothrombin time international normalized ratio (PT-INR, 0.97) and activated partial thromboplastin time (APTT, 31 sec) were normal. Surgeons confronted hemostatic difficulty during surgery. At the point of 1,000 ml blood loss, PT-INR was 9.99, APTT was 300 sec, and platelet count was 116,000 x µl(-1). The patient was administered 1,400 ml of frozen plasma concentrate; PT-INR and APTT recovered to 1.04 and 39.6 sec, respectively. Hemostatic dysfunction in this patient may have resulted from an inherent coagulation deficiency associated with multiple myeloma.

[The Attitudes of Anesthesiologists toward Paramedic Tracheal Intubation Clinical Training].

BACKGROUND: We performed a questionnaire survey to investigate anesthesiologist attitudes toward para- medic tracheal intubation clinical training and related issues. METHODS: Twenty-four anesthesiologists (clinical expe- rience, 18.4?12.2 years) answered a questionnaire regarding their attitudes toward paramedic clinical training and complications encountered during training. Participants were also asked about the number of cases paramedics should be required to handle for tra- cheal intubation training. RESULTS: Over 75% and 80% of anesthesiologists responded that paramedics had difficulty performing mask ventilation and stomach expansion, respectively. Moreover, roughly 25% encountered tooth injury, and 75% lip injury. Over 90% agreed that simulation train- ing before clinical training is important. The respon- dents thought 37.5 ?25.0 cases should be required for Macintosh laryngoscope training, and 20.0?13.6 cases for videolaryngoscope training. CONCLUSIONS: Our results suggest the need for improvements in paramedic clinical training, including pre-training education about perioperative medicine and operating room rules.

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

We report the development of a multi-center/multispecialist obstetrics perioperative team training program. Participants were members of the team, including anesthesiologists, obstetricians, and operation nurses. A questionnaire survey was conducted prior to course participation 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 cesarean section, massive bleeding after vaginal delivery, and emergency cesarean section for premature placental abruption. After each course, participants discussed problems associated with obstetrics medical safety in the context of each theme. Simulation-based perioperative team training with anesthesiologists, obstetricians, and operation nurses may serve as a vehicle to promote perioperative obstetrics patient safety.

Muscle relaxant effects on insertion efficacy of the laryngeal mask ProSeal(®) in anesthetized patients: a prospective randomized controlled trial.

BACKGROUND: Anesthesiologists often encounter LMA-ProSeal(®) (ProSeal) insertion difficulty due to its large cuff size. We performed a randomized clinical trial to examine how insertion efficacy and sealing pressure of ProSeal are affected by muscle relaxant administration in anesthetized patients. METHODS: Our adult patients were either administered rocuronium (0.9 mg kg(-1)) as a muscle relaxant (R group; 40 patients) or not (C group; 40 patients). Anesthesia was induced with propofol and fentanyl. We compared the two groups with regard to the number of attempts required for successful insertion, sealing pressure, and subjective difficulty for insertion. RESULTS: Total insertion attempts required for successful ventilation in the two groups were one (R group, 38 patients; C group, 28 patients), two (R group, one patient; C group, seven patients), and three (R group, one patient; C group, five patients), revealing a significant difference between groups (p < 0.001). Sealing pressure was significantly higher in the R group than in the C group (R group, 27.4 ± 5.4 cmH2O; C group, 21.2 ± 5.2 cmH2O; p < 0.001). Leakage volume by mechanical ventilation was significantly smaller in the R group than in the C group (R group, 17.4 ± 29.1 ml; C group, 46.8 ± 45.5 ml; p < 0.001). Subjective difficulty of insertion was significantly lower in the R group than in the C group (R group, 12.3 ± 23.1 mm; C group, 39.4 ± 31.9 mm; p < 0.001). CONCLUSIONS: Muscle relaxation appears to facilitate ProSeal insertion efficacy by enabling higher successful insertion rates, higher sealing pressure, lower leakage volume, and lower subjective difficulty of insertion in anesthetized patients.

[Ossification of the Posterior Longitudinal Ligament Found in a Case of Sudden Head-tilt Difficulty following Induction of General Anesthesia].

We report a case of sudden head-tilt difficulty after induction of general anesthesia which was postoperatively diagnosed as ossification of the posterior longitudinal ligament. A 42-year-old man weighing 115 kg was scheduled for emergent laparoscopic appendectomy for acute appendicitis. Prior to induction of anesthesia, the patient could tilt his head, but was unable to do so afterwards. Following mask ventilation with jaw-thrust maneuver, we successfully performed tracheal intubation using the Pentax-AWS Airwayscope. After surgery, he was diagnosed with ossification of the posterior longitudinal ligament by an orthopedist.

[A Case of Neuroleptic Malignant Syndrome Associated with Undiagnosed Dementia with Lewy Bodies].

A 78-year-old woman was transferred to our hospital for clouded consciousness and a high fever. She had been diagnosed with Parkinsonian syndrome, which was controlled with amantadine. Hallucination appeared a week prior to the transfer and she was treated with haloperidol. Suspecting neuroleptic malignant syndrome, dantrolene sodium was administered along with symptomatic treatment with mechanical ventilation and cooling. Her symptoms were reversed and she was transferred to another hospital for neurological evaluation. Magnetic resonance imaging revealed dementia with Lewy bodies (DLB). The high drug sensitivity of DLB was considered the cause of neuroleptic malignant syndrome induced by haloperidol. DLB should be considered in neurological emergencies in patients with Parkinsonism.

[Lateral Approach Tracheal Intubation in a Semi-sitting Position Utilizing a Videolaryngoscope in a Patient with Respiratory Failure due to Septic Shock].

Here we report our success in performing lateral approach tracheal intubation in a patient with severe respiratory failure due to septic shock caused by shoulder joint abscess. A 71-year-old woman presented with severe respiratory difficulty due to sepsis from a shoulder joint abscess and was scheduled for emergent drainage and irrigation. She could not breathe sufficiently in the supine position and thus maintained a semi-sitting position. She was also unable to move from the ward bed to the operating table due to severe shoulder pain. We induced anesthesia in a semi-sitting position in the ward bed. Mask ventilation was performed using the two-hand technique from the lateral approach. Tracheal intubation was also performed with a left lateral approach utilizing the Pentax-AWS Airwayscope (AWS). Lateral approach for tracheal intubation utilizing AWS may be useful in patients who present with severe respiratory difficulty.

[Simulation-based Perioperative Team Training in the Operating Room].

Here, we report the development of a simulation-based perioperative training course. Participants were anesthesiologists and operating room nurses. Three different courses were held with different themes, such as airway management, circulation management and central venous management. The courses included a lecture and simulation training with scenario-based discussions or a simulator. At the end of each course, participants discussed problems associated with medical safety in the context of each theme. Participants commented not only on changes in their views regarding individual technical or non-technical improvements, but also on general medical safety in the operating room. Our findings suggest that simulation-based perioperative team training may serve as a vehicle to promote operating room safety.

[Usefulness of tranexamic acid in patients with severe head injury].

UNLABELLED: It is known that patients with severe head injury experience marked hypercoagulability and excessive hyperfibrinolysis due to the release of tissue factors from injured cerebral parenchyma. METHODS: We retrospectively evaluated the usefulness of tranexamic acid (TA) in patients with single, severe head trauma, who showed a Glasgow coma scale (GCS) 8 or D-dime > or = 20 microg ml-1. Twenty-five patients receiving TA [TA (+) ] were given the agent 2 g taking 30 minutes soon after their visit. Those not receiving TA [TA (--)] were 25 consecutive patients who met the criteria before the initiation of treatment with TA. RESULTS: The mortality rate was 4% in TA (+) and 24% in TA (-), significantly lower than in the former. The prognosis showed a tendency to improve in TA (+), but without significant differences between the groups. D-dimer was compared between the groups with a favorable prognosis in TA (+) and those in TA (-), its value was significantly higher in the former (60+/-56 microg ml-1) than the latter (28 +/- 27 microg ml-1) group. In addition, no thrombotic complications occurred in the former. CONCLUSIONS: Patients with severe head injury receiving TA showed a significantly better mortality rate without complications suggesting its usefulness.

Effects of stylet use during tracheal intubation on postoperative pharyngeal pain in anesthetized patients: A prospective randomized controlled trial.

STUDY OBJECTIVE: This study aimed to compare the impact of stylet application for tracheal intubation for postoperative pharyngeal pain or hoarseness in patients undergoing elective surgery. DESIGN: Randomized clinical trial. SETTING: Operating room. PATIENTS: Forty adult patients scheduled for elective surgery under tracheal intubation with an ASA physical status of 1-3. INTERVENTIONS: Tracheal intubation was performed by anesthesiologists with stylet group (Stylet group; 20 patients) or without stylet group (Control group; 20 patients). MEASUREMENTS: Incidence of postoperative pharyngeal pain or hoarseness was assessed. MAIN RESULTS: The incidence of postoperative pharyngeal pain was significantly higher in the Stylet group (10/20 patients) than in the Control group (2/20 patients) (P=0.013). The incidence of hoarseness did not significantly differ between the Stylet group (6/20 patients) and the Control group (3/20 patients) (P=0.45). CONCLUSIONS: Stylet use increases the incidence of postoperative pharyngeal pain.

[Evaluation of 38 cases of employing aortic occlusion balloon catheter].

BACKGROUND: Aortic occlusion balloon catheter (AOBC), which occludes the descending aorta without thoracotomy, is expected to prevent further blood loss and raise blood pressure (BP). We investigated the effects of AOBC retrospectively. METHOD: AOBC was used in 38 patients for perioperative management only if the BP responded insufficiently despite rapid resuscitation due to massive hemorrhage below the diaphragm. There were 33 trauma cases, and five cases of ruptured abdominal aortic aneurysm. We inserted AOBC via the femoral artery or left common carotid artery in the emergency room(ER) or in the operating room (OR). RESULTS: BP increased for 38.7 +/- 33.9 mmHg following AOBC, with a survival rate of 36%. CONCLUSIONS: In our experience, AOBC was effective for raising BP in patients in hemorrhagic shock.

Does prewarming the i-gel supraglottic airway device fit the larynx better compared to keeping it at room temperature for non-paralysed, sedated patients: a randomised controlled trial.

OBJECTIVE: This study aimed to test the hypothesis that the i-gel supraglottic airway device would fit the larynx and provide better sealing pressure if prewarmed to 42°C relative to the device kept at room temperature in non-paralysed, sedated patients. METHODS: A total of 74 adult patients were assigned to the warm (i-gel prewarmed to 42°C; W group; 37 patients) or the control (i-gel kept at room temperature; C group; 37 patients) groups. Anaesthesia was induced with propofol and fentanyl. The i-gel was prewarmed to 42°C for 30 min before insertion in the W group, but kept at room temperature (approximately 23°C) for the C group. The number of attempts made until successful insertion and sealing pressure were compared between the two groups. RESULTS: Insertion was successful with one attempt in 35 cases each for the W and C groups. Two attempts were needed in two cases for the W group and one case for the C group. There was one failed attempt in the C group, but none in the W group. None of the differences between the two groups were significant (p=0.51). Sealing pressure was slightly, but not significantly, higher in the W group than in the C group (W group 22.6±6.1 cm H2O; C group 20.7±6.1 cm H2O; p=0.15). CONCLUSIONS: Prewarming of the i-gel to 42°C did not increase the success rate of insertion, nor did it significantly increase sealing pressure in anaesthetised, non-paralysed patients. Our data suggest that we can keep the i-gel at room temperature for emergency airway management for non-paralysed, sedated patients. TRIAL REGISTRATION NUMBER: University Medical Information Network, Japan 000012287.

Nitric oxide mediates allodynia induced by intrathecal administration of prostaglandin E2 or prostaglandin F2 alpha in conscious mice.

We recently reported that intrathecal (i.t.) administration of prostaglandin (PG) E2 or PGF2 alpha in conscious mice induced allodynia through a pathway that includes the glutamate receptor system. Allodynia induced by PGE2 and PGF2 alpha was blocked by antagonists for NMDA and metabotropic glutamate receptor subtypes, respectively. In the present study, we examined the possibility for the involvement of nitric oxide (NO) in the PG-evoked allodynia. Allodynia was assessed once every 5 min by light stroking of the flank of mice with a paintbrush. Intrathecal administration of L-arginine, a substrate of nitric oxide synthase (NOS), in conscious mice resulted in allodynia. Dose dependency of L-arginine for allodynia showed a bell-shaped pattern (1-10 micrograms/mouse). The maximal allodynic effect was observed with 5.0 micrograms at 10-15 min after i.t. injection, similar in time course and magnitude to that induced by L-glutamate. L-Arginine-induced allodynia was dose-dependently reduced by the NOS inhibitor N omega-nitro-L-arginine methyl ester (L-NAME) and the soluble guanylate cyclase inhibitor methylene blue with IC50 values of 7.68 and 8.70 pg/mouse, respectively. PGE2-induced allodynia was also dose-dependently inhibited by L-NAME and methylene blue with IC50 values of 94.7 and 74.9 pg/mouse. PGF2 alpha-induced allodynia was inhibited by methylene blue with an IC50 value of 40.6 pg/mouse, but not by L-NAME at doses up to 1.0 ng.(ABSTRACT TRUNCATED AT 250 WORDS)

Involvement of glutamate receptors in allodynia induced by prostaglandins E2 and F2 alpha injected into conscious mice.

In order to investigate the involvement of glutamate receptor systems in allodynia induced by prostaglandin (PG) E2 or F2 alpha, we co-administered antagonists for N-methyl-D-aspartate (NMDA), non-NMDA, or metabotropic glutamate receptors intrathecally with PGE2 or PGF2 alpha and examined their effects on the allodynia evoked in conscious mice by non-noxious brushing of the flanks. MK-801, a non-competitive NMDA receptor channel blocker, and D-AP-5, a selective NMDA receptor antagonist, dose-dependently blocked PGE2-induced allodynia with an IC50 of 1.60 and 0.52 microgram/mouse, respectively. A glycine binding-site antagonist for the NMDA receptor, 7-Cl-KYNA, did not influence it. None of these NMDA receptor antagonists inhibited PGF2 alpha-evoked allodynia. Non-NMDA receptor antagonists GAMS and CNQX inhibited both PGE2- and PGF2 alpha-induced allodynia. On the other hand, L-AP-3 and L-AP-4, putative metabotropic glutamate receptor antagonists, dose-dependently antagonized the allodynia induced by PGF2 alpha with an IC50 of 0.92 and 3.26 ng/mouse, respectively, but not that induced by PGE2. Intrathecal administration of L-glutamate produced allodynia over a wide range of low doses from 0.1 pg to 0.1 microgram/mouse, and the maximal effect was observed at 1 ng. Similar to allodynia induced by prostaglandins, the response lasted over a 50-min experimental period. These results demonstrate that both PGE2- and PGF2 alpha-evoked allodynia are mediated through a pathway that includes the glutamate receptor system but that subtypes of glutamate receptors involved and sites of action in the spinal cord may be different between them.

Prewarming of the i-gel facilitates successful insertion and ventilation efficacy with muscle relaxation: a randomized study.

STUDY OBJECTIVE: To determine if prewarming of the i-gel (Intersurgical, Wokingham, United Kingdom) improves insertion and ventilation efficacy with muscle relaxation in patients undergoing elective surgery. DESIGN: Clinical randomized study. SETTING: Operating room. PATIENTS: Sixty-eight adult patients scheduled for elective surgery under general anesthesia with American Society of Anesthesiologists physical status 1-3. INTERVENTIONS: The i-gel was warmed to 42°C for 30 minutes before insertion (W group; 34 patients) or kept at room temperature (approximately 23°C) (C group; 34 patients). MEASUREMENTS: The number of attempts for a successful insertion and the sealing pressure and leak volume 30 seconds and 30 minutes after initiating mechanical ventilation. MAIN RESULTS: The total insertion attempts were 1 (W group, 31 cases; C group, 24 cases) and 2 (W group, 3 cases; C group, 10 cases), which was significant (P = .001). Sealing pressure was significantly higher in the W group than the C group (W group, 21.8 ± 3.7 cm H2O; C group, 18.5 ± 3.4 cm H2O; P = .001). Leak volume was significantly smaller after 30 seconds in the W group than the C group (P = .002), but not after 30 minutes (P = .69). CONCLUSIONS: Prewarming the i-gel to 42°C demonstrated a higher successful ventilation initiation.