Perioperative Management During the COVID-19 Pandemic: Strategies at Three General Hospitals in Japan and a Narrative Review.

Coronavirus disease 2019 (COVID-19) has rapidly spread globally ever since the virus was first identified in December 2019 in Wuhan, China. Despite efforts to accelerate the supply of COVID-19 vaccines worldwide, the global pandemic has continued. Polymerase chain reaction (PCR) test is currently considered the gold standard for the diagnosis of COVID-19. However, the rate of false-negative PCR for COVID-19 has been reported to be over 10%. Furthermore, an asymptomatic period can last up to 14 days following the infection. Under these circumstances, standard anesthetic practice, surgery scheduling, and approaches to appropriate management of the operating room to protect both patients and medical personnel against COVID-19 transmission need to be reviewed and appropriately modified. In this review, based on our institutional experiences along with the guidelines reported elsewhere, we propose safer and more effective perioperative management amidst the COVID-19 pandemic.

A Missing Tooth Found in the Nasal Cavity After an Attempt at Insertion of a Nasogastric Tube: A Case Report.

Dental injury is one of the most common complications of tracheal intubation. Although teeth dislodged during tracheal intubation are usually found in the oral cavity, we encountered a case of a missing tooth found in the nasal cavity in an intubated patient. A 62-year-old man with 4 loose teeth in the upper jaw was scheduled for laparoscopic hernia repair. After our second attempt at insertion of a nasogastric tube via the left naris, we discovered that a tooth had been dislodged. A lateral-view radiograph revealed the dislodged tooth in the nasal cavity. The ectopic tooth was removed by an otorhinolaryngologist.

Difficult Removal of a Nasogastric Tube Because of Knot Formation Around a Nasotracheal Tube: A Case Report.

Knotting of a nasogastric (NG) tube around a left nasotracheal tube occurred in the pharynx during its blind insertion via the right nares. Unusual resistance was encountered during its advancement and attempted withdrawal. The nasotracheal tube moved in tandem with the NG tube. The NG tube was cut and the lower portion removed via the mouth and the upper portion removed via the right nares.

[Postoperative takotsubo cardiomyopathy caused by an ectopic paraganglinoma after gastric submucosal tumor resection].

We encountered an 80-year-old woman with an ectopic paraganglioma of the bladder who developed takotsubo cardiomyopathy after gastric submucosal resection performed for an unrelated tumor. Preoperative blood pressure control was not necessary despite the presence of the noradrenaline-producing paraganglioma However, the patient developed severe intraoperative hypotension, and thereafter manifested takotsubo cardiomyopathy after the operation. Perioperative stress and catecholamine production by the bladder paraganglioma were considered to have induced the takotsubo cardiomyopathy. In retrospect, considering the influence of potential catecholamine release from the paraganglioma, we should probably have scheduled preferential treatment of the bladder paraganglioma and strictly monitored the perioperative hemodynamics.

[Combined subarachnoidal block and continuous femoral nerve block for two patients undergoing bilateral simultaneous total knee arthroplasty].

We administered combined spinal anesthesia plus bilateral femoral nerve block in two cases undergoing bilateral simultaneous total knee arthroplasty. Although epidural catheters must be removed before anticoagulant treatment can be performed after surgery, femoral nerve block, poses minimal hindrance to anticoagulant therapy. Because femoral nerve block alone cannot provide sufficient postoperative pain relief after total knee arthroplasty, additional sciatic nerve block, spinal anesthesia, opioid administration, or some other means of analgesia is necessary. A combined femoral nerve block plus sciatic nerve block is useful. A large quantity of local anesthetic is required for this purpose, and its application is difficult in bilateral simultaneous surgery. Spinal anesthesia can be used to reduce the quantity of the local anesthetic, and intrathecal morphine can be used to prolong the pain relief. However, intrathecal morphine can cause itching and late respiratory depression. Respiratory depression did not occur in either of the present patients, although case 2 experienced some itching. In conclusion, combined bilateral femoral nerve block with spinal anesthesia poses minimal hindrance to postoperative anticoagulation therapy and enables control of postoperative pain in patients undergoing bilateral simultaneous total knee arthroplasty.

[Ultrasound-guided rectus sheath blockade is a safe and accurate method for emergency ileostomy for patients with coagulopathy].

Obstructive ileus is a life-threatening gastrointestinal condition that requires emergency operation. Patients with obstructive ileus sometimes develop coagulopathy. In such cases, central neuraxial blockade should be avoided. Rectus sheath blockade (RSB) is one of the popular methods for abdominal wall surgery. Ultrasound imaging of the rectus sheath may facilitate successful RSB by indicating the presence and location of rectus abdominis. Two patients presented with ileus secondary to rectal or sigmoid cancer and underwent emergency ileostomy. The patients had mild coagulopathy [platelet count, 77,000 microl(-1) in case 1, and platelet count, 98,000 microl(-1) in case 2]. Each patient underwent general anesthesia using propofol and remifentanil. They were given 0.5% ropivacaine 20ml for RSB under ultrasound-guidance. Their hemodynamics was stable and they did not need another muscle relaxant during operation, except succinylcholine during induction. RSB is useful for abdominal operations. In addition, ultrasonogrhaphy facilitates the prediction of depth of the posterior rectus sheath and improves the accuracy of local anesthetic placement. We conclude that RSB is effective for improving postoperative pain and intraoperative muscle relaxation of the abdominal wall. Ultrasound-guided RSB is an alternative method to central neuraxial blockade.

Ultrasound-guided medial mid-thigh approach to sciatic nerve block with a patient in a supine position.

We report the use of a 'medial mid-thigh approach (medial approach),' a new approach for performing ultrasound-guided sciatic nerve blockade (SNB) with patients in a supine position. Fifty-four patients undergoing knee surgery under general anesthesia and a combined femoral nerve block (FNB) and SNB were included in the study. After FNB, an ultrasound-guided medial approach was used to perform the SNB. The patient was placed in a supine position, and the hip and knee joints were flexed with the leg rotating externally. A linear ultrasound transducer was positioned perpendicular to the skin at the level of the upper mid-thigh. The sciatic nerve was identified in all patients using ultrasound imaging, and the distance to the nerve was 3.0-5.5 cm. A combined ultrasound- and nerve stimulator-guided SNB was then performed, and 0.375% ropivacaine was administered. The block was successful in all patients, and the mean duration of the sensory and motor blockade was 11.9 and 8.2 h, respectively. In this study, the medial approach was highly successful and easy to perform. As performing a simultaneous FNB and SNB with patients in a supine position has several potential advantages, future studies should compare this approach with other more proximal approaches for performing SNB.

[Peripheral nerve blocks for a patient with spondylolysis undergoing anterior cruciate ligament reconstruction].

A 24-year-old man, 178 cm tall and weighting 82 kg, underwent anterior cruciate ligament reconstruction. We gave general anesthesia and ultrasound-guided combined femoral and sciatic nerve block. Neuraxial blocks increase the risk of neuropathy in the patient with spondylolysis compared with peripheral nerve blocks. In this report, we describe the successful postoperative pain control with peripheral nerve blocks to a patient with spondylolysis.

[Ultrasound-guided rectus sheath block for upper abdominal surgery].

Upper abdominal surgery leads to severe postoperative pain. Insufficient postoperative analgesia accompanies a high incidence of complications. Therefore, postoperative analgesia is very important. The epidural analgesia has many advantages. However it has a high risk of epidural hematoma in anticoagulated patients. Rectus sheath block provided safer and more reliable analgesia in recent years, by the development of ultrasound tools. We experienced two cases of the rectus sheath block in upper abdominal surgery under ultrasound guidance. Ultrasound guided rectus sheath block can reduce the risk of peritoneal puncture, bleeding, and other complications. Rectus sheath block is very effective to reduce postoperative pain in upper abdominal surgery as an alternative method to epidural anesthesia in anticoagulated patients.

[Ultrasound-guided combined femoral-obturator nerve block for the knee arthroscopic surgery of meniscal lesions: case report].

We report successful management of anesthesia in two cases of knee arthroscopic surgery of meniscal lesions using ultrasound-guided combined femoral-obturator nerve block with inhalation anesthesia. The blocks were performed with 30 ml of 0.5% ropivacaine under ultrasonographic visualization. The perioperative courses were uneventful and there was no complaint about postoperative pain. Unlike spinal or epidural anesthesia, combined femoral-obturator nerve block has advantages of no muscle weakness in healthy lower limbs, no urinary retention, and no post dural puncture headache. Our technique relieved postoperative pain effectively because knee joint is innervated by the femoral and obturator nerves in great measure. Ultrasound-guided femoral and obturator nerve block is easier and more successful than sciatic nerve block. General anesthesia with combined femoral-obturator nerve block could be a useful technique with less complication for knee arthroscopic surgery.

[The relationship between the respiratory parameters under spontaneous breathing and effect site propofol concentrations].

BACKGROUND: The prediction of the hypnotic states is useful to maintain the adequate anesthesia. During propofol anesthesia, the respiratory depression has been documented in a dose-dependent manner. Therefore, we investigated whether the respiratory depression under the spontaneous breathing reflected the estimated effect site propofol concentrations (Cp) in a dose-dependent fashion. METHODS: We enrolled 12 patients for elective lower limb surgery under combined subarachnoid anesthesia and propofol sedation. The respiratory parameters and BIS were measured at the Cp of 5 microg x ml(-1) followed by the 0.5 microg x ml(-1) decrements until the patients' movement. Effective indices to predict patients' movement were determined by receiver-operator characteristics. RESULTS: The significant correlations within a particular patient between the respiratory parameters and Cp were observed, although those were not between the patients. An EtCO2 of 53 mmHg or greater represents a clinically determinant condition for non-movement of the patients. CONCLUSIONS: We concluded that the respiratory parameters during spontaneous breathing were useful indices to predict the changes in the effect site propofol concentrations and to maintain the adequate anesthetic levels.