Caution:Patient-specific preoperative preparations combined with procedure-specific 5-aminolevulinic acid may lead to critical events.

5-Aminolevulinic acid (5-ALA) is orally administered 2-4 hours before surgery to identify tumor location. Hypotension is sometimes observed after 5-ALA administration. Case reoprtWe present a case of a patient with 5-ALA-induced hypotension that resulted in the development of cerebral infarction. An 83-year-old man with a bladder tumor was scheduled for photodynamic diagnosis-assisted transurethral resection of bladder tumor (PDD-TURBT) and right radical nephroureterectomy. 5-ALA was orally administered and his ordinary antihypertensive and antianginal agents were also administered an hour after 5-ALA administration. Following this, his blood pressure dropped, and he developed muscle weakness and paralysis in his left upper extremity. Magnetic resonance imaging showed evidence of cerebral infarction. ConclusionsWe cannot conclude definitively that our patient's cerebral infarction was solely caused by 5-ALA-induced hypotension because hypotension under these circumstances is not rare. We consider that additional factors, such as patient-specific doses of antihypertensive and antianginal agents may have played a role in the development of his cerebral infarction.

Critical aspiration pneumonia during induction of anesthesia in elective abdominal surgery: a case report.

BACKGROUND: We experienced the critical aspiration pneumonia during induction of anesthesia in elective abdominal surgery which standard fasting period was complied with. CASE PRESENTATION: A 64-year-old male was scheduled for gastrojejunostomy because of gastrointestinal obstruction. He fasted from the night before surgery. General anesthesia was induced, and cricoid pressure was applied during intubation. However, he vomited huge amount of gastric contents. The scheduled surgery was performed without surgical complications, and postoperatively respiratory management, including mechanical ventilation with prone positioning, was performed in high care unit. He was extubated on postoperative day 2. He was discharged from the hospital on POD 25. CONCLUSION: The standard fasting period can prevent aspiration pneumonia in most cases. However, even in elective cases without abdominal symptoms, we consider that massive-volume gastric residual contents, especially in susceptible cases. We suggest that point-of-care gastric ultrasonography be performed in suspicious cases before induction of anesthesia.

Establishment and implementation of an effective rule for the interpretation of computed tomography scans by emergency physicians in blunt trauma.

INTRODUCTION: Computed tomography (CT) can detect subtle organ injury and is applicable to many body regions. However, its interpretation requires significant skill. In our hospital, emergency physicians (EPs) must interpret emergency CT scans and formulate a plan for managing most trauma cases. CT misinterpretation should be avoided, but we were initially unable to completely accomplish this. In this study, we proposed and implemented a precautionary rule for our EPs to prevent misinterpretation of CT scans in blunt trauma cases. METHODS: WE ESTABLISHED A SIMPLE PRECAUTIONARY RULE, WHICH ADVISES EPS TO INTERPRET CT SCANS WITH PARTICULAR CARE WHEN A COMPLICATED INJURY IS SUSPECTED PER THE FOLLOWING CRITERIA: 1) unstable physiological condition; 2) suspicion of injuries in multiple regions of the body (e.g., brain injury plus abdominal injury); 3) high energy injury mechanism; and 4) requirement for rapid movement to other rooms for invasive treatment. If a patient meets at least one of these criteria, the EP should exercise the precautions laid out in our newly established rule when interpreting the CT scan. Additionally, our rule specifies that the EP should request real-time interpretation by a radiologist in difficult cases. We compared the accuracy of EPs' interpretations and resulting patient outcomes in blunt trauma cases before (January 2011, June 2012) and after (July 2012, January 2013) introduction of the rule to evaluate its efficacy. RESULTS: Before the rule's introduction, emergency CT was performed 1606 times for 365 patients. We identified 44 cases (2.7%) of minor misinterpretation and 40 (2.5%) of major misinterpretation. After introduction, CT was performed 820 times for 177 patients. We identified 10 cases (1.2%) of minor misinterpretation and two (0.2%) of major misinterpretation. Real-time support by a radiologist was requested 104 times (12.7% of all cases) and was effective in preventing misinterpretation in every case. Our rule decreased both minor and major misinterpretations in a statistically significant manner. In particular, it conspicuously decreased major misinterpretations. CONCLUSION: Our rule was easy to practice and effective in preventing EPs from missing major organ injuries. We would like to propose further large-scale multi-center trials to corroborate these results.

Repeated embolization of intercostal arteries after blunt chest injury.

To deal with an arterial bleeding from the chest wall after a blunt chest injury, embolization of the bleeding arteries can be a valuable therapeutic option, which is less invasive than a thoracotomy. However, its results are variable, being highly operator-dependent. In the present case, we performed successful emergency embolization of the 4th and 5th intercostal arteries for persistent hemorrhage following blunt trauma to the chest. Several days after the first embolization, secondary embolization was required for treating a pseudoaneurysm that was formed in the 5th intercostal artery. Although the mechanisms underlying pseudoaneurysm formation are not clearly understood, its rupture is potentially fatal. Therefore, it is essential to carefully follow-up patients who experience blunt chest injury to avoid this serious complication.

Development of takotsubo cardiomyopathy with severe pulmonary edema before a cesarean section.

Takotsubo cardiomyopathy is an acute syndrome involving apical ballooning and consequent dysfunction of the left ventricle. Most cases of left ventricular dysfunction resolve within 1 month. We present the case of a 40-year-old woman who developed severe heart failure caused by takotsubo cardiomyopathy with severe left ventricular dysfunction during the perinatal period. Because of the presence of multiple myomas, she was scheduled to undergo a cesarean section under general anesthesia. However, after induction of general anesthesia, she had to be awakened because of the presence of a difficult airway. Because she exhibited insufficient oxygenation, she was transferred to the emergency center. Upon hospital admission, she expectorated large amounts of pink sputum, indicating severe pulmonary edema. Cesarean section was performed immediately. Echocardiography revealed severe left ventricular dysfunction. Full recovery of cardiac function required almost 1 month, after which she was discharged from the hospital without further complications. This is the first reported case of takotsubo cardiomyopathy induced by a failed intubation during a scheduled cesarean section. Takotsubo cardiomyopathy usually shows a good prognosis, but if this myopathy develops during the perinatal period, it can worsen because of excessive preload following the termination of fetoplacental circulation.

Patient questionnaire following closure of tracheotomy fistula: percutaneous vs. surgical approaches.

BACKGROUND: Tracheotomy is an indispensable component in intensive care management. Doctors in charge of the intensive care unit (ICU) usually decide whether tracheotomy should be performed. However, long-term follow-up of a closed fistula by these doctors is rarely continued in most cases. Doctors in charge of the ICU should be interested in the long-term prognosis of tracheotomy. The purpose of this study was to evaluate whether different tracheotomy procedures affect the long-term outcome of a closed tracheal fistula. METHODS: We mailed questionnaires to patients undergoing tracheotomy in Fukushima Medical University Hospital between January 2008 and December 2010. Questions concerned problems related to perception, laryngeal function, and the appearance of a closed fistula. Patients were classified into percutaneous tracheotomy (PT) group and surgical tracheotomy (ST) group. We evaluated the statistical significance of differences in the frequency and degree of each problem between the two groups. A door-to-door objective evaluation using the original scoring system was then performed for patients who replied to the mailed questionnaire. We evaluated the percentage of patients with high scores as well as the mean scores for problems with function and appearance. RESULTS: We received completed questionnaires from 28/40 patients in the PT group and 35/55 patients in the ST group. There were no significant differences in age, mean hospital stay, or APACHE II score between the groups. Regarding problems with appearance, the outcomes of PT were significantly better than those of ST with respect to self-evaluation (p = 0.04) and the frequency (p = 0.03) and degree (p = 0.02) of scar unevenness according to door-to-door evaluation. However, there were no significant differences in the frequency or degree of self-evaluation in problems with perception and function between the two groups. There were no significant differences in the frequency or degree of door-to-door evaluation of problems with function. CONCLUSIONS: This study shows that PT might be superior to ST with respect to problems with long-term appearance. Continuous follow-up of closed tracheal fistulas can help assure that patients recovering from a critical condition experience a better return to their former lives. A systematic follow-up of post-critical-care patients is required.

Usefulness of initial diagnostic tests carried out in the emergency department for blunt trauma.

AIM: To evaluate the usefulness of the initial diagnostic tests carried out in blunt trauma patients in our emergency department. METHODS: Blunt trauma patients admitted between October 2009 and October 2011 were retrospectively reviewed. A scoring system was developed (0 to 28 points) to differentiate between potential major trauma patients and physiologically stable patients. Patients were classified into three groups: Group I (minor trauma), revised trauma score normal and our score 0-14; Group II (potential major trauma), revised trauma score normal and our score 15-28; Group III (major trauma), revised trauma score low. The proportions of patients with positive initial diagnostic test results (blood tests, X-rays, and computed tomography) were determined in each group. RESULTS: The study included 1,291 patients (Group I, 1,019; Group II, 85; Group III, 187). Blood tests and X-rays were carried out frequently in all groups, but positive results were infrequent in Group I. Comparisons using Pearson's χ2-test showed significant differences in the proportions of patients with positive blood test, X-ray, and computed tomography results among the three groups. The proportions of patients with positive blood test and chest X-ray results were significantly lower in Group II than in Group III, but there were no significant differences in the proportions of patients with other positive results between these two groups. CONCLUSIONS: In physiologically stable blunt trauma patients, diagnostic tests should be selected only after careful patient evaluation. To achieve this, standardized criteria for the identification of minor trauma patients should be established.

Activation intervals for a helicopter emergency medical service in Japan.

INTRODUCTION: Prehospital time is crucial for treating acute disease; therefore, it is important to activate helicopter emergency medical services (HEMS) promptly. We investigated the differences in the activation intervals (the time elapsed from receiving the emergency call to the time of HEMS request) under various conditions to evaluate the current status of HEMS-related prehospital triage in Japan. METHODS: We retrospectively investigated activation intervals under exogenous (trauma, n = 553; intoxication, n = 56; and burns, n = 32) and endogenous conditions (acute coronary syndrome [ACS], n = 47; and stroke, n = 173) between January 31, 2008, and January 31, 2012, by reviewing flight records. RESULTS: Activation intervals were trauma (14.3 ± 11.5 min), intoxication (10.3 ± 8.6 min), burns (15.0 ± 13.1 min), ACS (17.9 ± 14.6 min), and stroke (19.1 ± 13.1 min). One-way analysis of variance showed a significant difference between exogenous and endogenous groups (P < .001). Post-hoc analysis using Tukey's honestly significant difference test showed significant differences between ACS and intoxication (P < .05), stroke and intoxication (P < .001), and stroke and trauma (P < .001). CONCLUSIONS: Endogenous conditions had longer activation intervals, which may reflect a lack of mechanisms assessing their severity. We are considering developing new triage criteria for dispatchers.

[A case of respiratory distress due to massive pleural effusion after surgery for ovarian tumor].

A 59-year-old woman with ovarian tumor was scheduled for radical hysterectomy under general anesthesia. Preoperative examination showed massive ascites and slight pleural effusion. Since respiratory status had improved by oxgen therapy, she underwent a surgery as scheduled, although she complained of slight dyspnea and low Sp(O2). Induction of anesthesia was uneventful. However, oxygenation deteriorated and airway pressure increased after suction of ascites during the operation. We treated it with increased FI(O2). After surgery, we found bilateral massive pleural effusion on the chest X-ray and drained it. Oxygenation improved, and the endotracheal tube was removed. Patients with ovarian tumor with pleural effusion and ascites may have desaturation due to increased pleural effusion during the operation, or pleural effusion might increase preoperatively. Therefore, we need to be cautious about anesthetic management of them and examine chest X-ray and arterial blood gas frequently.

Effects of dexmedetomidine, midazolam, and propofol on acetylcholine release in the rat cerebral cortex in vivo.

Acetylcholine plays an important role as a neurotransmitter in the central nervous system with involvement in both sleep and arousal. Dexmedetomidine, midazolam, and propofol are widely used for sedation of patients in intensive care medicine. In this study, we have examined the effect of continuous administration of dexmedetomidine, midazolam, and propofol on acetylcholine release in the rat cerebral cortex, using an in vivo microdialysis technique. Following infusion of a control solution, male Wistar rats (n = 6/group) were administered dexmedetomidine at 0.3 µg/kg/min, midazolam at 20 mg/kg/h, or propofol at 50 mg/kg/h over a 2-h period. Using a brain microdialysis method, extracellular acetylcholine concentrations were measured up to 2 h after administration of each agent at 15-min intervals. In the midazolam group, acetylcholine levels were significantly reduced with midazolam infusion, remaining low even after the drug was stopped. In the propofol group, acetylcholine levels were significantly decreased during propofol infusion, but returned to control levels once the infusion was stopped. Dexmedetomidine administration decreased acetylcholine release, but this finding was not statistically significant. From this study, midazolam and propofol but not dexmedetomidine significantly suppressed acetylcholine release in the cerebral cortex at sedative doses. Even though the righting reflex recovered almost the same after the cessation of drug administration, midazolam suppressed acetylcholine release longer than propofol.