Successful Double-lumen Tube Intubation in the Lateral Position for a Patient with a Giant Superior Mediastinal Tumor.

OBJECTIVE: Anesthetic management of patients with giant mediastinal tumors is challenging from the perspective of both cardiovascular and respiratory management, and airway assessment is important for both concerns. We report the successful induction of general anesthesia and double-lumen tube intubation in the right lateral position for a patient with a giant mediastinal tumor with tracheal compression, using pre-operative chest radiograph imaging to minimize tracheal compression during induction. METHODS: A 41-year-old man required thoracoscopic giant superior mediastinal tumor resection. His trachea was compressed and displaced because of the tumor. Because preoperative chest radiography revealed that the tracheal diameter increased in the right lateral position, we chose this position for induction. RESULTS: Prompt and smooth intubation with a 35-Fr double-lumen tube (DLT) was achieved, and no adverse events associated with intubation were encountered. CONCLUSION: Safe and smooth induction with a DLT was performed owing to the perioperative chest radiograph imaging examination, which revealed the most advantageous position regarding minimal tracheal compression.

Usefulness of the Universal Adapter for Smartphones® in a Mannequin Study.

OBJECTIVE: Because of the shape of a double-lumen tube (DLT), it is more difficult to use for intubation than an ordinary endotracheal tube. We prospectively investigated the usefulness of the Airtraq DL® attached to the Universal Adapter for Smartphones® for DLT intubation. METHOD: At Tokai University Hachioji Hospital, anesthesiologists with ≥ 5 years' clinical experience intubated a tracheal intubation training mannequin with DLTs using the Airtraq DL® (Airtraq-alone phase) and the Airtraq DL® attached to the Universal Adapter for Smartphones® (adapter phase), and the time required was measured. RESULT: The mean time required for intubation was shorter in the adapter phase than in the Airtraq-alone phase for all anesthesiologists (adapter phase, 9.05±2.48 seconds; Airtraq-alone phase, 10.67±2.19 seconds). CONCLUSION: The use of Airtraq DL® a ttached to t he Universal Adapter for Smartphones® significantly reduced the time required for DLT intubation. Furthermore, the combination of these devices was found to be useful and safe for DLT intubation because they provide a significant amount of information on the area from the oral cavity to the opening of the trachea and have high educational value because their combined use allows several physicians to share imaging information.

Successful Intubation Using the Airtraq Double Lumen® with the Universal Adapter for Smartphones® in a Case of Intubation Difficulty.

OBJECTIVE: The Universal Adapter for Smartphones® c an record s till images and movies during intubation using the monitor display and recording functions of a smartphone. Here, we describe the successful use of the Airtraq Double Lumen® with the Universal Adapter for Smartphones® for airway management during anesthesia in a patient with intubation difficulty. METHODS: A 78-year-old man required thoracoscopic upper lobectomy for a pulmonary tumor. Preoperative examination revealed micrognathia, mouth opening equivalent to a three-finger width, Mallampati Class II, mentum-hyoid bone distance equal to a 2.5-finger width, hyoid bone-thyroid cartilage distance equal to a two-finger width, and Class I findings in the Upper Lip Bite Test. After inducing anesthesia and confirming the feasibility of mask ventilation, we administered 70 mg of rocuronium and inserted the Airtraq Double Lumen®. The Universal Adapter for Smartphones® connected to a 4-inch iPod Touch® was attached to its eye cup, through which the iPod Touch displayed images for easy visualization of the glottal area. RESULTS: Prompt and smooth intubation with a 35-Fr double-lumen tube (DLT) was achieved. There were no adverse events associated with intubation. CONCLUSION: Combination of the Universal Adapter for Smartphones® and the Airtraq Double Lumen® can facilitate smooth tracheal intubation with a DLT in cases of difficult intubation.

Airtraq DL and AWS-200 for Double-lumen Endotracheal Tube Intubation: A Prospective Randomized Clinical Trial.

OBJECTIVE: This prospective randomized study aimed to assess the usefulness of two videolaryngoscopes with a side channel, the Airtraq DLTM and the AWS-200TM, for intubation with a double-lumen tube (DLT). METHODS: In 60 patients with an American Society of Anesthesiologists physical status of 1-3 who were not expected to have difficult airway, the Airtraq DLTM and the AWS-200TM were randomly used for DLT intubation. The primary outcome was intubation time. The secondary outcomes included exposure time, the glottis view with the Macintosh and study videolaryngoscopes, the number of attempts before successful intubation, the intubation difficulty scale (IDS) score, and the subjectively rated ease of blade insertion and DLT advancement. RESULTS: No significant differences were observed in patient characteristics. In all patients, DLT intubation was successful at the first attempt. Intubation time was significantly shorter in the Airtraq DLTM group (17.2±0.9 seconds, range = 9.6-29.4 seconds) than in the AWS-200TM group (21.6±1.1 seconds, range = 13.1-33.9 seconds) (P = 0.005). No significant differences were observed in any other outcomes. CONCLUSION: In patients who were not expected to have difficult airway, DLT intubation with the Airtraq DLTM required significantly less time than with the AWS-200TM.

Pharmacotherapy for Neuropathic Pain in Japan.

Neuropathic pain (NeP) results from injury to, or disease of, the peripheral or central components of the neural systems involved in pain. In contrast to inflammatory pain, NeP can persist after healing from the initial injury has resolved. Antipyretic agents, such as non-steroidal anti-inflammatory drugs, steroids, and acetaminophen are ineffective, while specific agents such as gabapentinoids, antidepressants, antiepileptics, and opioids are effective in treating NeP. In this review, we address the definition of NeP, pharmacotherapy for NeP in Japan, pain classification, setting goals for successful NeP medication, and the Japanese algorithm for the pharmacotherapy of NeP with specific prescription guidance.

Effect of three peptidase inhibitors on antinociceptive potential and toxicity with intracerebroventricular administration of dynorphin A (1-17) or (1-13) in the rat.

PURPOSE: The N- and C-terminal regions of dynorphin (Dyn) A (1-17) activate opioid and N-methyl-D-aspartate receptors, respectively. Earlier studies demonstrated that Dyn-converting enzyme cleaved Dyn A (1-17) mainly at the Arg(6)-Arg(7) bond, resulting in the production of N- and C-terminal region peptide fragments, and that this enzyme was not inhibited by a mixture of the three peptidase inhibitors (PIs) amastatin (A), captopril (C), and phosphoramidon (P). The purpose of the present study was to evaluate antinociceptive potential and toxicity with intracerebroventricular administration of Dyn A (1-17) or (1-13) under pretreatment with a mixture of A, C, and P and/or Dyn-converting enzyme inhibitor (p-hydroxymercuribenzoate). METHODS: Peptide fragments from Dyn A (1-17) following incubation with membrane preparation under pretreatment with a mixture of the three PIs was identified by matrix-assisted laser desorption ionization time-of-flight mass spectrometer (MALDI-TOF-MS). Infusion of drugs and peptides into the third ventricle in rats was performed via indwelling cannulae. Induction of antinociception and toxicity by Dyn A (1-17), Dyn A (1-13), Dyn A (1-6), or Dyn A (7-17) were determined by the tail-flick test and induction of barrel rotation, respectively. The effects of the PIs on antinociception and toxicity were evaluated by a dose-response study and a comparison of differences among various combinations of Dyn A (1-17) or Dyn A (1-13) and the three PIs and p-hydroxymercuribenzoate. RESULTS: MALDI-TOF-MS analysis identified Dyn A (1-6) and Dyn A (1-10) fragments as products following incubation of Dyn A (1-17) with membrane preparation of rat midbrain under pretreatment with a mixture of the three PIs. Pretreatment with a mixture of the three PIs produced an approximately 30-fold augmentation in antinociception induced by low-dose intracerebroventricular administration of Dyn A (1-17) or (1-13) in a µ-, δ- and κ-opioid receptor antagonist-reversible manner, but without signs of toxicity such as barrel rotation in the rat. Dyn A (1-17)-induced antinociception and toxicity was greater than that of Dyn A (1-6), Dyn A (1-13), or Dyn A (7-17) at the same dose. Dyn A (1-17)-induced antinociception and toxicity under pretreatment with various combinations of the three PIs and p-hydroxymercuribenzoate was greater than that with a mixture of the three PIs alone. CONCLUSION: These findings suggest that administration of a mixture of the three PIs increases Dyn A (1-17)- or (1-13)-induced antinociception under physiological conditions without toxicity.

Increase in antinociceptive effect of [leu5]enkephalin after intrathecal administration of mixture of three peptidase inhibitors.

OBJECTIVE: Previous in vitro studies have shown that the degradation of [Leu5]enkephalin during incubation with cerebral membrane preparations is almost completely prevented by a mixture of three peptidase inhibitors such as amastatin, captopril, and phosphoramidon. The present in vivo study was performed to examine the antinociceptive effect of [Leu5]enkephalin administered intrathecally under pretreatment with these three peptidase inhibitors. METHODS: A tail-flick test was used to determine the nociceptive threshold after administration of [Leu5]enkephalin. The time-course profiles of the latency to flick the tail and the area under the time response curve were evaluated for the antinociceptive action of the drug. RESULTS: The antinociceptive effect of [Leu5]enkephalin administered intrathecally on the tail-flick test was increased more than 100-fold under i.t. pretreatment with three peptidase inhibitors. The antinociceptive effect produced by [Leu5]enkephalin in rats pretreated with any single peptidase inhibitor increased antinociception compared to that with saline. The antinociceptive potency of [Leu5]enkephalin under pretreatment with any combination of two peptidase inhibitors was smaller than that in rats pretreated with three peptidase inhibitors together. These results indicate that any residual single peptidase inactivates significant amounts of [Leu5]enkephalin. CONCLUSION: The present data, together with those of earlier studies, clearly demonstrate that amastatin-, captopril-, and phosphoramidon-sensitive enzymes play an important role in the inactivation of [Leu5]enkephalin administered intrathecally in rat.

[Case report: removing the press through package (PTP) containing a tablet from the subglottic region].

A 58-year-old female patient was prescribed different drugs in both tablet and powder form and inadvertently ingested the tablet along with its press through package (PTP), which thus became lodged in the subglottic region. An emergency operation was then performed to remove this foreign material, under neuroleptic anesthesia, and the foreign material was removed successfully. Furthermore, no abnormal findings, such as enlarged vocal cords, were noted. Vocal cord granuloma developed three months after the operation but it improved after conservative treatment.

A questionnaire survey on operability of syringe pumps for prefilled syringes.

Some types of syringe pumps currently available for use of prefilled syringes (PFS) require setting for syringe size which varies from manufacturer to manufacturer. We conducted a questionnaire survey for 10 nurses at the emergency critical care center of this hospital on the operating procedures of two different types of syringe pump (i.e., from turning on the power to PFS setting, PFS mounting, flow rate setting, and start of drug infusion), in terms of (1) manipulation time, (2) accuracy of task performance, and (3) operability. The syringe pumps used were: type A, TE-331S0N (Terumo Corporation), and type B, CSP-100S (Daiken Medical Co., Ltd.). The PFS product used was Inovan Injection 0.3% Syringe (dopamine hydrochloride injection; Kyowa Hakko Kirin Co., Ltd.). Type A required no mode setting for exclusive use of PFS, while mode setting for exclusive use of PFS is mandatory for type B. The task process from turning on the power to drug infusion start comprised 5 and 13 steps for type A and B, respectively. Manipulation time was significantly shorter with type A, compared to type B. As for accuracy of task performance, 90% of nurses performed manipulations accurately with type A; whereas with type B, 90% of nurses were close to failing or actually failed to follow the procedures appropriately, and only 10% followed accurately. Thus, type A proved superior in 4 of the 5 points of issue except "easy to set flow rate". In conclusion, the results indicate the importance of standardizing the syringe size and other specifications through the cooperation of pharmaceutical companies and medical device manufacturers to cope with the future spread of PFS.

Airway management during the laryngoscopic surgery for the benign laryngeal obstructive disease.

The airway management and anesthesia maintenance during the laryngoscopic surgery is essential for a safe operation. For the benign laryngeal obstructive disease such as a large mass or a foreign body of the upper airway, it is difficult to secure the airway. Sometimes they might be hazardous and potentially lethal. We present two cases of a large laryngeal polyp and a laryngeal foreign body of pressthrough-package (PTP). They were successfully operated on with laryngomicrosurgery under neuroleptanalgesia (NLA) without intubation. The choice of the operation and airway management were discussed.

Difficult placement of Univent tube blocker due to aberrant right subclavian artery aneurysm.

There have been few reports on aneurysms of the anomalous branch of the aortic arch. We present a rare case in which correct placement of the movable blocker of a Univent tube was difficult due to an aberrant right subclavian artery aneurysm. A 72-year-old man with a history of hypertension had manifested coughing and wheezing for four months prior to admission to our hospital. A chest computed tomogram revealed that his aortic arch had four branches and that the right subclavian artery did not originate from the first branch, but was the fourth branch. The angiogram disclosed that an aneurysm had developed in the anomalous artery close to the aorta, and behind the other three branches, trachea, and esophagus. The aneurysm not only had pushed the trachea out of place but was also pressing against it. After anesthetic induction, his trachea was intubated using an endotracheal tube with a movable blocker, the Univent tube, for single-lung ventilation. The blocker could not be advanced into the left main bronchus due to the tracheal deviation caused by the aneurysm. Several methods of blocker placement, including those recommended in the manual attached to the product, were attempted without success. Finally, the trachea was intubated again using a Univent tube with the blocker tip bent manually, which permitted entrance of the blocker into the bronchus. Blocker placement should be modified to suit patients with a problem in the trachea or bronchi.