Anesthetic induction and endotracheal intubation in the sitting position due to the fixed forearm caught by a meat grinder.

A male patient was scheduled for urgent amputation of his right forearm. His right forearm was stuck inside the insertion slot of a meat grinder, resulting in severe pain to his injured arm. His upper body could not move to sit in a semi-upright position. An endotracheal tube was successfully placed after rapid sequence intubation using a video laryngoscope from behind the patient on the first attempt. This case report is the first documentation of successful anesthetic induction with subsequent endotracheal intubation using a video laryngoscope from behind an injured patient whose upper body was upright with limited positioning.

[A case where the tracheotomy tube was burned during Nd-YAG laser cautery treatment for tracheal neoplasm].

For the treatment of the residual tumor above the incision site, laser cautery was scheduled. Artificial ventilation was carried out using a tracheotomy tube, and a laser fiber was inserted orally for tumor ablation. During the procedure, white smoke appeared in the oral cavity. Considering the damage to the tube, laser use was discontinued and the tube was replaced with a new one. The removed tube had burn marks, but penetration of the tube wall was not observed. Neither respiratory tract burn was found. Prior consultation with technicians regarding the use and settings of the laser appatrates is required.

Anesthetic induction and endotracheal intubation in the sitting position due to the fixed forearm caught by a meat grinder

Abstract A male patient was scheduled for urgent amputation of his right forearm. His right forearm was stuck inside the insertion slot of a meat grinder, resulting in severe pain to his injured arm. His upper body could not move to sit in a semi-upright position. An endotracheal tube was successfully placed after rapid sequence intubation using a video laryngoscope from behind the patient on the first attempt. This case report is the first documentation of successful anesthetic induction with subsequent endotracheal intubation using a video laryngoscope from behind an injured patient whose upper body was upright with limited positioning.

[Palliative care in Seirei Mikatahara General Hospital Department of Palliative and Supportive Care, Seirei Mikatahara General Hospital].

This paper illustrates a brief review of the development process of the palliative care team at the Seirei Mikatahara General Hospital. Palliative care team has been first instituted in 2002, and currently providing general support for cancer patients receiving chemotherapy not only for terminally ill patients. In future, we would start a regional palliative care program, including community palliative care team, to provide appropriate palliative care for all cancer population.

[Severe orthostatic headache: a retrospective study on clinical presentation, radiological characteristics, and outcome in 12 patients].

To determine clinical characteristics and therapeutic outcome of severe orthostatic headache, we retrospectively studied 12 consecutive patients with severe orthostatic headache and unremarkable medical history. Headache is defined as severe when it interferes with patient's daily activities. Baseline characteristics of our patients are essentially similar to those reported in other published series of spontaneous intracranial hypotension: female preponderance; mean age of approximately 40 years; frequently associated nausea, hearing disturbances, or vertigo. Diffuse pachymeningeal gadolinium enhancement was demonstrated on MRI in 64% of the patients. Low CSF pressure was present in 78%. Of 8 patients underwent radionuclide cisternography, CSF leak site was identified in 4 patients. Severe orthostatic headache resolved in 13.6 days in 5 patients who received supportive measures only. Conservative treatment was ineffective in 7 patients. Of 6 patients treated with epidural blood patch (EBP), 5 patients (83%) responded well to the first EBP. Patients with severe orthostatic headache which persisted 2 weeks and longer in spite of conservative measures are candidate for EBP. Our study and a literature review suggest that at least 2 EBPs should be performed for each leak site. Studies with more patients are needed for establishing a better treatment protocol for this syndrome.

Preexisting morbidity as an independent risk factor for perioperative acute thromboembolism syndrome.

HYPOTHESIS: Preexisting morbidities are risk factors for perioperative arterial or venous thromboembolic events and subsequent death within 30 postoperative days. DESIGN: Prospective cohort study. SETTING: University-affiliated general hospital. PATIENTS: A total of 21,903 surgery patients treated from January 1, 1991, through December 31, 2002. MAIN OUTCOME MEASURES: Independent risk factors for perioperative arterial or venous thromboembolic events. RESULTS: History of atrial fibrillation and coronary artery disease increased the risk of myocardial infarction (odds ratio [95% confidence interval], 4.3 [2.8-6.7]). History of stroke increased the risk of stroke (2.4 [1.4-4.1]) and death (4.7 [1.3-17.3]). Diabetes mellitus increased the risk of myocardial infarction (2.1 [1.3-3.2]), and hyperuricemia increased the risk of stroke (3.5 [1.2-9.8]), and both increased the risk of death (4.3 [1.3-14.1] and 11.8 [2.2-63.5], respectively). History of myocardial infarction increased the risk of deep vein thrombosis (7.7 [1.7-34.7]). Cancer increased the risk of all thromboembolism (2.4 [1.9-3.2]). Trend analysis showed that preexisting morbidities will increase 1.5-fold and thromboembolic events will increase 3-fold during the next decade. CONCLUSION: Cardiac and cerebrovascular diseases, metabolic diseases, and cancer are becoming increasingly high-risk comorbidities for perioperative acute thromboembolism syndrome.

[A case of spontaneous intracranial hypotension with multiple CSF leaks in the thoracic region].

A case of spontaneous intracranial hypotension (SIH) with multiple cerebrospinal fluid (CSF) leaks is reported. A 54-year-old man experienced a severe generalized headache associated with nausea and decreased hearing. The headache appeared when he was sitting or standing but was completely relieved by lying down. Cranial MRI with gadolinium infusion showed diffuse pachymeningeal enhancement. Spinal MRI demonstrated small amount of epidural fluid collection in the upper thoracic region. Radionuclide cisternography demonstrated CSF leaks at the Th2 and Th7 levels on the left side and at the Th3 through Th5 levels on the right side. Since bed-rest and intravenous transfusion for 10 days showed no beneficial effects, epidural blood patch (EBP) at the Th6/7 interspace was performed. After receiving EBP four times repeatedly, his symptoms entirely disappeared. SIH patients with multiple CSF leaks are rare in the literature. Although no consensus exists on the treatment strategy for such cases, our case suggests that at least 2 EBPs should be performed for each leak site before considering surgical treatment.

Age- and sex-specific incidence, risk, and latency period of a perioperative acute thromboembolism syndrome (PATS).

We investigated age- and sex-specific incidence, risk factors, and latency period of a perioperative acute thromboembolism syndrome (PATS) in a large cohort study. We prospectively analyzed data on 21903 consecutive surgery patients to determine the incidence of myocardial infarction, pulmonary embolism, deep venous thrombosis, stroke, and cardiovascular death within 30 postoperative days. Among 255 (1.2 percent) patients with thromboembolism, 105 (0.48 percent) suffered myocardial infarction (mean latency: 5 days), 30 (0.14 percent) suffered pulmonary embolism (6 days), 23 (0.11 percent) suffered deep venous thrombosis (10 days), 97 (0.44 percent) suffered stroke (11 days), and 13 (0.06 percent) died (12 days). The critical period was postoperative week 1 for myocardial infarction and pulmonary embolism, and postoperative week 1 and 2 for deep venous thrombosis, stroke, and death. Risk of all events increased with age (P<0.0001), particularly for over 70 years (odds ratio: 12.5; 95 percent confidence interval, 7.8 to 19.9). Males had an increased risk (P<0.0001) of myocardial infarction (odds ratio; 1.5; 95 percent confidence interval, 1.0 to 2.3). Females had an increased risk (P<0.0001) of pulmonary embolism (odds ratio: 2.7; 95 percent confidence interval, 1.3 to 5.9) and deep venous thrombosis (odds ratio: 9.8; 95 percent confidence interval, 3.3 to 29.3). Risk of thromboembolic event was higher (P<0.0001) in patients with a history of arterial thrombotic events or cancer. Trend analysis indicates that thromboembolic events will increase 3-fold over the next decade. Our findings enable identification of higher risk patients for prophylactic anti-thromboembolic treatment and awareness of the critical postoperative period.

Orthostatic tinnitus: an otological presentation of spontaneous intracranial hypotension.

Spontaneous intracranial hypotension (SIH) is a syndrome characterized by orthostatic headache, low cerebrospinal fluid (CSF) pressure without apparent causes for CSF loss, and diffuse pachymeningeal gadolinium enhancement on cranial MRI. Hearing is affected in some patients with SIH. A case of SIH with orthostatic tinnitus is reported. A 51-year-old woman developed a severe headache that was almost completely relieved on recumbency. Cranial MRI with gadolinium infusion showed diffuse enhancement of the dura mater. Radionuclide cisternography demonstrated CSF leaks at the upper and lower thoracic levels. Epidural blood patches at these leak sites alleviated the orthostatic headache, however, orthostatic tinnitus and muffled hearing persisted. Initial audiometry was unremarkable; repeat audiometry performed 6 weeks later demonstrated low-frequency hearing loss in the right ear. Continuous epidural saline infusion for 3 consecutive days was performed; auditory symptoms disappeared 4 weeks thereafter. This case illustrates that orthostatic tinnitus represent intracranial hypotension even in the absence of orthostatic headache. MRI with gadolinium infusion should be carried out in the evaluation of patients with orthostatic tinnitus.

A noninvasive partial carbon dioxide rebreathing technique for measurement of pulmonary capillary blood flow is also a useful oxygenation monitor during one-lung ventilation.

STUDY OBJECTIVES: To test the hypothesis that effective pulmonary capillary blood flow can be a useful indicator for estimating appropriate oxygenation and ventilation during one-lung ventilation in lung surgery. DESIGN: Prospective data analysis. SETTING: A 770-bed general teaching hospital. PATIENTS: 15 ASA physical status II and III patients undergoing elective lung surgery. INTERVENTIONS: Patients received general and thoracic epidural anesthesia and underwent lung operation with one-lung ventilation. MEASUREMENTS: We measured effective pulmonary capillary blood flow by a partial CO2 rebreathing method and oxygenation parameters during two-lung ventilation before surgery, during one-lung ventilation, and during two-lung ventilation after lung surgery. MAIN RESULTS: The effective pulmonary capillary blood flow index significantly decreased by 31.6%, which was associated with a significant decrease in arterial oxygen tension (PaO2). The pulmonary shunt fraction increased to 46.3% during one-lung ventilation. During two-lung ventilation, after chest closure, effective pulmonary capillary blood flow index divided by heart rate (i.e., effective pulmonary blood stroke flow index) was still significantly lower than that seen during two-lung ventilation before thoracotomy. There were significant correlations between effective pulmonary capillary blood flow, pulmonary blood stroke flow index, and PaO2. CONCLUSIONS: Effective pulmonary capillary blood flow index and effective pulmonary blood stroke flow index are useful indicators for determining appropriate oxygenation therapy during one-lung ventilation.