The association between intraoperative anesthesia methods used during gastric cancer surgery and long-term mortality: A retrospective observational study using a Japanese claims database.

PURPOSE: Various basic and clinical studies have investigated the association between the types of anesthetic agents and prognosis. However, the results have varied among studies and remain controversial. In the present study, we aimed to investigate whether the risk of all-cause mortality differs between inhaled or intravenous anesthetics in patients with gastric cancer undergoing gastrectomy. METHODS: Using a Japanese nationwide insurance claims database, we analyzed patients who underwent gastrectomy under general anesthesia for gastric cancer between January 2005 and September 2019. Postoperative outcomes were compared between two groups: those who received inhaled anesthetics (Sevoflurane, Isoflurane, or Desflurane) and those who received intravenous anesthetics (propofol), using a multivariable Cox proportional hazards model. The primary outcome was overall survival. RESULTS: Among 2671 eligible patients, 2105 were in the inhaled anesthetic group, and 566 were in the intravenous anesthetic group. The median (interquartile range) age was 58 (51-63) years, and 1979 (74.1%) were men. The median follow-up period was 795 days. We identified 56 (2.7%) and 16 (2.8%) deaths during the follow-up period in the inhaled and intravenous anesthetic use groups, respectively. There was no difference in postoperative overall survival between the two groups (hazard ratio, 0.97; 95% confidence interval, 0.56-1.70; P = 0.93). CONCLUSIONS: We found no significant difference in the postoperative risks of overall survival between inhaled and intravenous anesthesia in patients with gastric cancer undergoing gastrectomy.

Update on the Features and Measurements of Experimental Acute Lung Injury in Animals: An Official American Thoracic Society Workshop Report.

Advancements in methods, technology, and our understanding of the pathobiology of lung injury have created the need to update the definition of experimental acute lung injury (ALI). We queried 50 participants with expertise in ALI and acute respiratory distress syndrome using a Delphi method composed of a series of electronic surveys and a virtual workshop. We propose that ALI presents as a "multidimensional entity" characterized by four "domains" that reflect the key pathophysiologic features and underlying biology of human acute respiratory distress syndrome. These domains are 1) histological evidence of tissue injury, 2) alteration of the alveolar-capillary barrier, 3) presence of an inflammatory response, and 4) physiologic dysfunction. For each domain, we present "relevant measurements," defined as those proposed by at least 30% of respondents. We propose that experimental ALI encompasses a continuum of models ranging from those focusing on gaining specific mechanistic insights to those primarily concerned with preclinical testing of novel therapeutics or interventions. We suggest that mechanistic studies may justifiably focus on a single domain of lung injury, but models must document alterations of at least three of the four domains to qualify as "experimental ALI." Finally, we propose that a time criterion defining "acute" in ALI remains relevant, but the actual time may vary based on the specific model and the aspect of injury being modeled. The continuum concept of ALI increases the flexibility and applicability of the definition to multiple models while increasing the likelihood of translating preclinical findings to critically ill patients.

Epidemiology and patterns of tracheostomy practice in patients with acute respiratory distress syndrome in ICUs across 50 countries.

BACKGROUND: To better understand the epidemiology and patterns of tracheostomy practice for patients with acute respiratory distress syndrome (ARDS), we investigated the current usage of tracheostomy in patients with ARDS recruited into the Large Observational Study to Understand the Global Impact of Severe Acute Respiratory Failure (LUNG-SAFE) study. METHODS: This is a secondary analysis of LUNG-SAFE, an international, multicenter, prospective cohort study of patients receiving invasive or noninvasive ventilation in 50 countries spanning 5 continents. The study was carried out over 4 weeks consecutively in the winter of 2014, and 459 ICUs participated. We evaluated the clinical characteristics, management and outcomes of patients that received tracheostomy, in the cohort of patients that developed ARDS on day 1-2 of acute hypoxemic respiratory failure, and in a subsequent propensity-matched cohort. RESULTS: Of the 2377 patients with ARDS that fulfilled the inclusion criteria, 309 (13.0%) underwent tracheostomy during their ICU stay. Patients from high-income European countries (n = 198/1263) more frequently underwent tracheostomy compared to patients from non-European high-income countries (n = 63/649) or patients from middle-income countries (n = 48/465). Only 86/309 (27.8%) underwent tracheostomy on or before day 7, while the median timing of tracheostomy was 14 (Q1-Q3, 7-21) days after onset of ARDS. In the subsample matched by propensity score, ICU and hospital stay were longer in patients with tracheostomy. While patients with tracheostomy had the highest survival probability, there was no difference in 60-day or 90-day mortality in either the patient subgroup that survived for at least 5 days in ICU, or in the propensity-matched subsample. CONCLUSIONS: Most patients that receive tracheostomy do so after the first week of critical illness. Tracheostomy may prolong patient survival but does not reduce 60-day or 90-day mortality. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02010073 . Registered on 12 December 2013.

Effect of pressure-controlled inverse ratio ventilation on dead space during robot-assisted laparoscopic radical prostatectomy: A randomised crossover study of three different ventilator modes.

BACKGROUND: Pressure-controlled inverse inspiratory to expiratory ratio ventilation (PC-IRV) is thought to be beneficial for reducing the dead space volume. OBJECTIVE: To investigate the effects of PC-IRV on the components of dead space during robot-assisted laparoscopic radical prostatectomy (RLRP). DESIGN: A randomised crossover study of three different ventilator modes. SETTING: A single university hospital from September 2014 to April 2015. PATIENTS: Twenty consecutive study participants undergoing RLRP. INTERVENTIONS: Patients were ventilated sequentially with three different modes in random order for 30 min: volume control ventilation (VCV; inspiratory to expiratory ratio 0.5), pressure control ventilation (PCV; inspiratory to expiratory ratio 0.5) and PC-IRV. Inverse inspiratory to expiratory ratio was adjusted individually by observing the expiratory flow-time wave to prevent the risk of dynamic pulmonary hyperinflation. MAIN OUTCOME MEASURES: The primary outcome included physiological dead space (VDphys), airway dead space (VDaw), alveolar dead space (VDalv) and shunt dead space (VDshunt). VDphys was calculated by Enghoff's method. We also analysed respiratory dead space (VDresp) and VDaw using a novel analytical method. Then, VDalv and VDshunt were calculated by VDalv = VDresp - VDaw and VDshunt = VDphys - VDresp, respectively. RESULTS: The VDphys/expired tidal volume (VTE) ratio in PC-IRV (29.2 ±â€Š4.7%) was significantly reduced compared with that in VCV (43 ±â€Š8.5%) and in PCV (35.9 ±â€Š3.9%). The VDshunt/VTE in PC-IRV was significantly smaller than that in VCV and PCV. VDaw/VTE in PC-IRV was also significantly smaller than that in VCV but not that in PCV. There was no significant change in VDalv/VTE. CONCLUSION: PC-IRV with the inspiratory to expiratory ratio individually adjusted by the expiratory flow-time wave decreased VDphys/VTE in patients undergoing RLRP. TRIAL REGISTRATION: University Hospital Medical Information Network in Japan 000014004.

Novel ultrasound-guided inter-semispinal plane block: a comparative pilot study in healthy volunteers.

We previously reported that a novel multifidus cervicis plane (MCP) block could anesthetize the dorsal rami of the cervical spinal nerves. While MCP sonoanatomy is easily detectable in most patients, it is sometimes difficult to recognize the MCP injection plane, especially in elderly patients. Thus, we proposed the inter-semispinal plane (ISP) block as an alternative for the MCP block. The aim of this study was to evaluate the utility of the ISP block by evaluating the area and duration of anesthesia, compared with that of the MCP block in eight healthy volunteers. Each participant underwent unilateral ultrasound-guided MCP block and ISP block. For each block, 20 ml of ropivacaine 0.2% was injected, and the area of anesthesia was determined using the pinprick test. The anesthetic area ranged from C4 to T2 (3/8; 37.5%), T3 (2/8; 25%), or T4 (3/8; 37.5%) in the MCP block, and from C4 to T1 (1/8; 12.5%), T2 (3/8; 37.5%), T3 (2/8; 25%), or T4 (1/8; 12.5%) in the ISP block. The mean (standard deviation) duration of sensory loss following MCP and ISP blocks was 329 (77) min and 349 (70) min, respectively. Thus, the ISP block may be a reliable alternative to the MCP block.

Adenovirus vector expressing keratinocyte growth factor using CAG promoter impairs pulmonary function of mice with elastase-induced emphysema.

Pulmonary emphysema impairs quality of life and increases mortality. It has previously been shown that administration of adenovirus vector expressing murine keratinocyte growth factor (KGF) before elastase instillation prevents pulmonary emphysema in mice. We therefore hypothesized that therapeutic administration of KGF would restore damage to lungs caused by elastase instillation and thus improve pulmonary function in an animal model. KGF expressing adenovirus vector, which prevented bleomycin-induced pulmonary fibrosis in a previous study, was constructed. Adenovirus vector (1.0 × 109 plaque-forming units) was administered intratracheally one week after administration of elastase into mouse lungs. One week after administration of KGF-vector, exercise tolerance testing and blood gas analysis were performed, after which the lungs were removed under deep anesthesia. KGF-positive pneumocytes were more numerous, surfactant protein secretion in the airspace greater and mean linear intercept of lungs shorter in animals that had received KGF than in control animals. Unexpectedly, however, arterial blood oxygenation was worse in the KGF group and maximum running speed, an indicator of exercise capacity, had not improved after KGF in mice with elastase-induced emphysema, indicating that KGF-expressing adenovirus vector impaired pulmonary function in these mice. Notably, vector lacking KGF-expression unit did not induce such impairment, implying that the KGF expression unit itself may cause the damage to alveolar cells. Possible involvement of the CAG promoter used for KGF expression in impairing pulmonary function is discussed.

Inhibition of Prolyl Hydroxylase Attenuates Fas Ligand-Induced Apoptosis and Lung Injury in Mice.

Alveolar epithelial injury and increased alveolar permeability are hallmarks of acute respiratory distress syndrome. Apoptosis of lung epithelial cells via the Fas/Fas ligand (FasL) pathway plays a critical role in alveolar epithelial injury. Activation of hypoxia-inducible factor (HIF)-1 by inhibition of prolyl hydroxylase domain proteins (PHDs) is a possible therapeutic approach to attenuate apoptosis and organ injury. Here, we investigated whether treatment with dimethyloxalylglycine (DMOG), an inhibitor of PHDs, could attenuate Fas/FasL-dependent apoptosis in lung epithelial cells and lung injury. DMOG increased HIF-1α protein expression in vitro in MLE-12 cells, a murine alveolar epithelial cell line. Treatment of MLE-12 cells with DMOG significantly suppressed cell surface expression of Fas and attenuated FasL-induced caspase-3 activation and apoptotic cell death. Inhibition of the HIF-1 pathway by echinomycin or small interfering RNA transfection abolished these antiapoptotic effects of DMOG. Moreover, intraperitoneal injection of DMOG in mice increased HIF-1α expression and decreased Fas expression in lung tissues. DMOG treatment significantly attenuated caspase-3 activation, apoptotic cell death in lung tissue, and the increase in alveolar permeability in mice instilled intratracheally with FasL. In addition, inflammatory responses and histopathological changes were also significantly attenuated by DMOG treatment. In conclusion, inhibition of PHDs protects lung epithelial cells from Fas/FasL-dependent apoptosis through HIF-1 activation and attenuates lung injury in mice.

Low tidal volume ventilation with low PEEP during surgery may induce lung inflammation.

BACKGROUND: Compared to conventional tidal volume ventilation, low tidal-volume ventilation reduces mortality in cased of acute respiratory distress syndrome. The aim of the present study is to determine whether low tidal-volume ventilation reduces the production of inflammatory mediators in the lungs and improves physiological status during hepatic surgery. METHODS: We randomly assigned patients undergoing hepatectomy into 2 groups: conventional tidal-volume vs. low tidal-volume (12 vs. 6 mL•kg(-1) ideal body weight) ventilation with a positive end-expiratory pressure of 3 cm H2O. Arterial blood and airway epithelial lining fluid were sampled immediately after intubation and every 3 h thereafter. RESULTS: Twenty-five patients were analyzed. No significant changes were found in hemodynamics or acid-base status during the study. Interleukin-8 was significantly elevated in epithelial lining fluid from the low tidal-volume group. Oxygenation evaluated immediately after admission to the post-surgical care unit was significantly worse in the low tidal-volume group. CONCLUSIONS: Low tidal-volume ventilation with low positive end-expiratory pressure may lead to pulmonary inflammation during major surgery such as hepatectomy. TRIAL REGISTRATION: The effect of ventilatory tidal volume on lung injury during hepatectomy that requires transient liver blood flow interruption. UMIN000021371 (03/07/2016); retrospectively registered.

Protective effects of continuous positive airway pressure on a nonventilated lung during one-lung ventilation: A prospective laboratory study in rats.

BACKGROUND: The use of one-lung ventilation (OLV) to facilitate intrathoracic surgery is a cause of lung injury. OBJECTIVE: We hypothesised that application of continuous positive airway pressure (CPAP) to a nonventilated lung during OLV would prevent alveolar hypoxia and blood flow shift from the nonventilated to the ventilated lung, thereby attenuating lung injury. DESIGN: Controlled animal study. SETTINGS: University laboratory. STUDY PARTICIPANTS: Adult male Sprague-Dawley rats (n = 4 to 8 per group, depending on experiments). INTERVENTIONS: Rats were alternately assigned to one of two ventilation protocol groups: control and CPAP groups. Rats received 240 min of OLV followed by 240 min of two-lung reventilation (re-TLV). The nonventilated lungs of rats in the control group were collapsed during OLV whereas rats in the CPAP group received CPAP (5 cmH2O with 100% oxygen) to the nonventilated lungs. MAIN OUTCOME MEASURES: Pulmonary blood flow during OLV was measured by quantification of lung radioactivity after intravenous infusion of indium-labelled macroaggregated albumin. Inflammatory cytokines in the lungs after 240 min of OLV, and after the subsequent 240 min of re-TLV were measured. Additionally, we measured lung wet-to-dry weight ratios after re-TLV. We also measured lung malondialdehyde levels after re-TLV as an indicator of reactive oxygen species produced by reoxygenation. RESULTS: Application of CPAP attenuated the pulmonary blood flow shift from the nonventilated to the ventilated lung. CPAP decreased the levels of IL-6, CXC chemokine ligand-1 and CC chemokine ligand-2 in both lungs after 240 min of OLV. CPAP also decreased CXC chemokine ligand-1 in the nonventilated lung and CC chemokine ligand-2 in both lungs after re-TLV. Moreover, wet-to-dry weight ratios of both lungs were decreased by application of CPAP. However, lung malondialdehyde concentrations were not affected by CPAP. CONCLUSIONS: CPAP applied to the nonventilated lung during OLV suppresses blood flow shift and decreases inflammatory cytokines and water content in both lungs. Application of CPAP may attenuate lung injury during and after OLV.

Edaravone prevents lung injury induced by hepatic ischemia-reperfusion.

BACKGROUND: Lung injury is a major clinical concern after hepatic ischemia-reperfusion (I/R), due to the production of reactive oxygen species in the reperfused liver. We investigated the efficacy of edaravone, a potent free-radical scavenger, for attenuating lung injury after hepatic I/R. MATERIALS AND METHODS: Adult male Sprague-Dawley rats were assigned to sham + normal saline (NS), I/R + NS, or I/R + edaravone group. Rats in the I/R groups were subjected to 90 min of partial hepatic I/R. Five minutes before reperfusion, 3 mg/kg edaravone was administered to the I/R + edaravone group. After 6 h of reperfusion, we evaluated lung histopathology and wet-to-dry ratio. We also measured malondialdehyde (MDA), an indicator of oxidative stress, in the liver and the lung, as well as cytokine messenger RNA expressions in the reperfused liver and plasma cytokine concentrations. RESULTS: Histopathology revealed lung damages after 6 h reperfusion of partial ischemic liver. Moreover, a significant increase in lung wet-to-dry ratio was observed. MDA concentration increased in the reperfused liver, but not in the lungs. Edaravone administration attenuated the lung injury and the increase of MDA in the reperfused liver. Edaravone also suppressed the reperfusion-induced increase of interleukin-6 messenger RNA expressions in the liver and plasma interleukin-6 concentrations. CONCLUSIONS: Edaravone administration before reperfusion of the ischemic liver attenuates oxidative stress in the reperfused liver and the subsequent lung injury. Edaravone may be beneficial for preventing lung injury induced by hepatic I/R.

Modified rapid shallow breathing index adjusted with anthropometric parameters increases predictive power for extubation failure compared with the unmodified index in postcardiac surgery patients.

OBJECTIVE: The aim of this study was to determine the best predictors of successful extubation after cardiac surgery, by modifying the rapid shallow breathing index (RSBI) based on patients' anthropometric parameters. DESIGN: Single-center prospective observational study. SETTING: Two general intensive care units at a single research institute. PARTICIPANTS: Patients who had undergone uncomplicated cardiac surgery. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The following parameters were investigated in conjunction with modification of the RSBI: Actual body weight (ABW), predicted body weight, ideal body weight, body mass index (BMI), and body surface area. Using the first set of patient data, RSBI threshold and modified RSBI for extubation failure were determined (threshold value; RSBI: 77 breaths/min (bpm)/L, RSBI adjusted with ABW: 5.0 bpm×kg/mL, RSBI adjusted with BMI: 2.0 bpm×BMI/mL). These threshold values for RSBI and RSBI adjusted with ABW or BMI were validated using the second set of patient data. Sensitivity values for RSBI, RSBI modified with ABW, and RSBI modified with BMI were 91%, 100%, and 100%, respectively. The corresponding specificity values were 89%, 92%, and 93%, and the corresponding receiver operator characteristic values were 0.951, 0.977, and 0.980, respectively. CONCLUSIONS: Modified RSBI adjusted based on ABW or BMI has greater predictive power than conventional RSBI.

[Boy with Coffin-Lowry syndrome associated with spinal cord injuries].

A 12-year-old male patient with Coffin-Lowry syndrome was scheduled for posterior cervical decompression and fusion for cervical spinal injuries. The patient had features of Coffin-Lowry syndrome including mental retardation, prominent forehead, a short nose with a wide tip, a wide mouth with full lips, short stature, microcephaly, and kyphoscoliosis. We anticipated major troubles related to anesthesia such as difficult ventilation and intubation, communication difficulty during induction and extubation, and difficulty in using a naso-pharyngeal airway. In addition, we had to stabilize neck alignments during intubation because cervical vertebrae were unstable and spinal cord has already been injured. Therefore, we scheduled slow induction with sevoflurane maintaining spontaneous respiration. As we found the full mouth opening of the patient after the induction, we inserted an intubating laryngeal mask, through which ventilation was successfully maintained. A tracheal tube was inserted through the intubating laryngeal mask. When the surgery was completed, we extubated using a tube introducer in the trachea. As we found that the patient's airway was open, we removed the introducer. In conclusion, with a thorough planning of the anesthetic management, we successfully managed anesthesia for cervical spinal surgery in a patient with Coffin-Lowry syndrome.

[Effect of concentration on counting numbers on pain induced by injection of propofol].

BACKGROUND: One of the concerns in the use of propofol is the pain on injection of the drug. Many attempts were made to prevent such pain, none of which has been reasonably successful. We hypothesized that the pain is attenuated when the patient is directed to concentrate on counting numbers while propofol is injected. METHODS: Ninety-one patients undergoing elective surgery under general anesthesia were enrolled. They were randomly assigned to counting or non-counting group. Patients in counting group were instructed to verbally count numbers backwards starting 100 when propofol was injected, while patients in non-counting group were injected propofol without any instructions. The size of the i.v. cannula, the temperature of the drug, and speed by which the drug was injected were controlled. No premedication was given. We interviewed the patients after the surgery and scored the pain on propofol injection, the pain on the placement of the iv cannula, and the anxiety level on entering the operating room. RESULTS: There was no significant difference in the incidence of pain on injection of propofol (34% and 33% in the counting and the non-counting group, respectively). A multiple logistic-regression analysis revealed that the significant factors to cause pain on the injection of propofol were age and the degree of pain on inserting intravenous line. CONCLUSIONS: Intensive counting did not reduce the incidence of pain on injection of propofol. Age and the degree of pain on inserting intravenous cannula can be a useful predictor for an intolerable pain on injection of propofol.

[A case of delayed arousal after anesthesia due to aberrant epidural catheter placement in a blood vessel].

A 71-year-old man underwent a total gastrectomy. An epidural catheter was inserted before the induction of general anesthesia. Blood was withdrawn from an epidural catheter inserted at T8-9 interspace with a median approach. The epidural catheter was then reinserted in T8-9 interspace with a paramedian approach and neither blood nor cerebrospinal fluid was withdrawn with careful aspiration. The catheter placement was confirmed with 1% lidocaine 3 ml. Anesthesia was induced with fentanyl, propofol, and rocuronium, and was maintained with sevoflurane, oxygen, air, fentanyl, and epidural analgesia. Total of 0.375% ropivacaine 15 ml was administered through the epidural catheter in about 1 hr. All anesthetics but continuous epidural analgesia with 0.2% ropivacaine at a speed of 4 ml x hr(-1) were terminated when the operation was completed; however, the patient was not arousable for 2 hours thereafter. When we carefully aspirated the epidural catheter, fresh blood was withdrawn from the catheter. We confirmed that the delayed arousal was due to the administration of ropivacaine into the blood by aberrant epidural catheter placement in a blood vessel. Unaccountable tachycardia and mild hypertension observed persistently during the operation would have been the warning to the toxicity of local anesthetics during general anesthesia.

[Continuous hemodiafiltration during graft repair for a ruptured thoracoabdominal aortic aneurysm was useful in a patient with chronic renal failure].

A 74-year-old man with ruptured thoracoabdominal aortic aneurysm was scheduled for open surgical repair under partial cardiopulmonary bypass. He had a history of diabetes mellitus and a concomitant renal dysfunction, requiring regular intermittent hemodialysis. To maintain electrolytes, acid base as well as water balance within adequate ranges, we planned to use continuous hemodiafiltration (CHDF) during the surgery because there was a high incidence of bolus transfusion to deal with massive bleeding in these surgeries. We increased fluid removal speed of ultrafiltration when blood components had to be infused rapidly. With these considerations, the patient did not develop fluid overload, hyperkalemia, or aggravation of acidosis. We did not administer anticoagulants into CHDF circuit because activated coagulation time was prolonged probably due to massive bleeding prior to the surgery. Heparin was administered just before the partial car diopulmonary bypass. There was no evidence for thromboembolic complications due to CHDF use. In conclusion, we successfully managed electrolytes as well as acid base balance, and hydration of a patient with chronic renal failure by using CHDF during open graft repair of ruptured thoracoabdominal aortic aneurysm.

[Mechanical ventilation during surgery -can we prevent postoperative lung injury?-].

We have patients who develop lung injury after surgery even they are without lung diseases preoperatively. What is the cause of this perioperative complication? Can we prevent postoperative lung injury by any measures during surgery? In the present paper, the etiology of acute respiratory distress syndrome (ARDS) is reviewed and possible methods to prevent ARDS is discussed. Inflammation occurs during surgery, the degree of which depends on multiple factors including surgical insults, the use of cardiopulmonary bypass (CPB), ischemia and reperfusion of any organ during surgery, transfusion, and organ damages. Preexisting conditions such as malignancy, sepsis; shock and lung diseases are other factors that may lead to lung injury. Mechanical ventilation does not initiate lung injury by itself; however, conventional mechanical ventilation (tidal volume of 10-12 ml x kg-1 ideal body weight) may induce ARDS if lungs are primed. Accordingly, lung protective strategies should be carried out if patients have such condition or does receive such surgery. The brief outline of the lung protective strategies is to reduce tidal volume, to apply open lung approach with positive end-expiratory pressure and lung recruitment maneuver, and to avoid any lung lesion causing hypoxia during CPB or one-lung ventilation.

[Acute myocardial infarction overlooked during preoperative evaluation: usefulness of measuring highly sensitive troponin I].

A 68-year-old man was admitted to our hospital with an open fracture. Physical examinations of the patient showed normal status, and laboratory examination and chest X-ray film showed no abnormal findings. Electrocardiogram revealed ST-segment elevations in V2 and V3, but diagnosed as an early repolarization by a cardiologist. We noticed when he entered the OR that highly sensitive troponin I (hsTnI) level was 0.303 ng ml-1 (cut off : 0.04ng ml-1). Since he had no symptoms suggesting acute coronary syndrome, we proceeded with the operation partly supported by the golden time for the operation. Except Spo2 92% on arrival at the OR, the anesthetic course was uneventful. Soon after extubation, Spo2 dropped below 90% and he was re-intubated. After a thorough evaluation, he was diagnosed with acute myocardial infarction (AMI) and underwent emergency percutaneous coronary intervention. In this case, hsTnI value was slightly elevated before the surgery. Since there is increasing evidence that hsTnI is a sensitive and specific marker for early diagnosis of AMI, we have to take the value into consideration.

[Safe induction of anesthesia in 3 patients with severe tracheal stenosis caused by thyroid cancer].

Anesthetic induction in a patient with a giant thyroid cancer is challenging for anesthetists. Tracheostomy under local anesthesia is usually impossible in these cases because the tumor mass occupies the anterior mediastinum and interferes with the approach to the trachea. The tumor may further cause tracheal stenosis and laryngeal malformation, leading to airway complications including difficult ventilation, difficult intubation, airway hemorrhage or swelling, and suffocation in the patient. Extracorporeal membrane oxygenation (ECMO) or high-frequency jet ventilation (HFJV) is reported to be a useful tool for safe induction in these patients; however, each of them alone would leave a possibility of inadequate oxygenation. We successfully managed anesthesia using both ECMO and HFJV in 3 patients with imminent danger of airway obstruction due to an extra-large thyroid cancer. A combination of ECMO and HFJV may be a useful tool for safe induction of anesthesia in patients with severe tracheal stenosis.

[Smoking cessation program run by anesthesiologists in a preoperative clinic].

BACKGROUND: Perioperative complications are prevalent among current smokers. Smoking cessation program is covered by national insurance for patients who meet certain criteria in Japan. We established a smoking cessation program in a preoperative clinic of our anesthesia department in July 2010. METHODS: We pick up patients who meet the following criteria; Brinkman index of over 200, tobacco dependence screener test of 5 or higher, and having a will to quit smoking, and encourage them to enroll in the program. The program consists of counseling, prescription of varenicline, and an examination of carbon monoxide fraction in exhaled breath. Patients who lose impulse to smoke and actually quit smoking when 12 weeks' program is completed are considered as successes. RESULTS: As of December 2012, 24 patients were enrolled in the program. Eighteen succeeded, 2 failed, and 4 discontinued the program. The discontinuers of the program were patients who had side effects (2) and patients who lost will to quit smoking (2). The success rate was 75%. DISCUSSION: Varenicline is one of the first-line medications for smoking cessation aid in the U.S.A. and is also approved in Japan. It is also well documented that counseling in addition to medication results in higher smoking abstinence rate than either counseling or medication alone. Anesthesiologists usually have better knowledge about perioperative complications related to smoking than physicians of other specialties. Therefore, there is an advantage in anesthesiologists being the counselor of the smoking cessation program. In addition, patients may be well motivated for quitting smoking right before receiving a surgery. CONCLUSIONS: Smoking cessation program is effective when offered to patients right before surgery. Preoperative anesthesia clinic may be one of the most suitable opportunities for the program.

Predictors of Catheter-Related Bladder Discomfort After Surgery: A Literature Review.

Background: Indwelling bladder catheters are routinely used in clinical practice. Patients may experience postoperative indwelling catheter-related bladder discomfort (CRBD). This study aimed to perform a literature review to identify predictors of postoperative CRBD. Methods: We searched PubMed for relevant articles published between 2000 and 2020 using the search items "CRBD", "catheter-related bladder discomfort", and "prediction". Additionally, we searched for articles that matched the research objectives from the references of the extracted articles. We included only prospective observational studies involving human participants and excluded interventional studies, observational studies that did not report sample sizes, or observational studies that did not research on predictors of CRBD. We narrowed our search to the keyword "prediction" and found five references. We selected five studies that met the objectives of the study as the target literature. Results: Using the keywords "CRBD" and "catheter-related bladder discomfort", we identified 69 published articles. The results were narrowed down by the keyword "prediction", and five studies that recruited 1,147 patients remained. The predictors of CRBD can be divided into four factors: 1) patient factors; 2) surgical factors; 3) anesthesia factors; and 4) device and insertion technique factors. Conclusion: Our study suggests that patients with predictors of CRBD should be closely monitored to reduce postoperative patient suffering, and their quality of life should be improved after anesthesia.