Improvement of the understanding of blood donors with human T-cell leukaemia virus type 1 using a new information booklet.

BACKGROUND: Human T-cell leukaemia virus type 1 (HTLV-1) tests have been mandated in Japan since 1986, and notification of HTLV-1-seropositive donors started in 1999. However, donor knowledge and response to notification has not been assessed. STUDY DESIGN AND METHODS: A questionnaire survey was conducted among blood donors notified of HTLV-1 seropositivity regarding their knowledge of HTLV-1 and unmet information needs. To reduce anxiety among notified individuals and raise awareness of their infection status, we created a booklet containing information that would be useful for these individuals without causing unnecessary anxiety while also requesting that they refrain from donating blood in the future. RESULTS: A questionnaire survey conducted before the distribution of a new booklet revealed that 15.0% of respondents donated blood again despite receiving an HTLV-1-seropositive notification at the previous donation. While 62.2% of respondents reacted to the notification favourably, 40.2% expressed anxiety and 32.5% requested information on related diseases and medical institutions for consultation. In the secondary survey after distribution of the new booklet, 87.9% of respondents reported that the information was comprehensible, and an increase in consultations of medical institutions by notification recipients was observed. Furthermore, no re-visiting donors were observed among the HTLV-1-seropositive recipients who were notified using the new information booklet. CONCLUSION: The new information booklet provided enlightenment on HTLV-1 infection and facilitated the consultation of medical institutions by seropositive donors, leading to an improvement in the health-related quality of life of seropositive blood donors and the safety of blood products.

Estimation of the window period of human T-cell leukemia virus type 1 and 2 tests by a lookback study of seroconverters among Japanese voluntary blood donors.

BACKGROUND: Japan is endemic for human T-cell leukemia virus type 1 (HTLV-1), and the horizontal transmission of HTLV-1 is often reported. However, the window period (WP) for serologic or molecular screening is unclear. STUDY DESIGN AND METHODS: Results for anti-HTLV-1 screening and confirmatory tests obtained from 648 591 repeated blood donors in the Kyushu district, one of the most endemic areas of HTLV-1 in the world, were evaluated. A lookback study was conducted for seroconverters. RESULTS: During 2012 to 2019, 436 seroconverters (155 men, 281women) were identified with use of a screening chemiluminescence enzyme-immunoassay (CLEIA) and multiple confirmatory tests. Because the period between the latest seronegative donation and seroconversion was highly variable (2.1-276.7 months), 19 cases that seroconverted within 6 months were subjected to the analysis. The WP of the particle agglutination assay and CLEIA was estimated to be 2.2 ± 0.6 and 2.6 ± 1.7 months, respectively. The WP of the indirect immunofluorescence assay was 4.8 ± 6.5 months. Although the WP of western blotting was estimated to be 6.3 ± 8.7 months, four cases were still indeterminate through the study period. Chemiluminescence and line immunoassays, the current screening and confirmatory tests used in the Japanese blood program, showed the shortest WP of 2.2 ± 0.6 months. The WP of real-time polymerase chain reaction for HTLV-1 was estimated to be 4.1 ± 7.8 months. CONCLUSIONS: The WP in commercially available testing systems for HTLV-1/2 was determined for natural infection among repeated blood donors. Considering the HTLV-1 WP will help increase transfusion safety and facilitate the accurate diagnosis of HTLV-1 infection.

Fine-scale geographic clustering pattern of human T-cell leukemia virus type 1 infection among blood donors in Kyushu-Okinawa, Japan.

Human T-cell leukemia virus type I (HTLV-1) infection is endemic in Japan, particularly clustered in the southwestern district, Kyushu-Okinawa, which consists of eight prefectures that further consist of 274 municipalities. However, no information is available about the fine-scale distribution of HTLV-1 infection within Kyushu-Okinawa. To assess the municipal-level distribution of people with HTLV-1 infection in Kyushu-Okinawa, we performed a cross-sectional study using a fine-scale geographic information system map based on HTLV-1 screening test results from the Japanese Red Cross database from September 2012 to February 2014. Of the 881 871 (646 914 male, 234 957 female) screened blood donors, 981 were seropositive for HTLV-1 by confirmatory test. The seroprevalence was 0.11% (95% confidence interval [CI] 0.10%-0.12%) for all, 0.094% (95% CI, 0.09%-0.10%) for male, and 0.16% (95% CI, 0.14%-0.18%) for female individuals. The sex- and age-specific HTLV-1 seroprevalence varied significantly across municipalities; particularly, the seroprevalence among women aged 50 years was significantly higher than that of men in both the mainland of Kyushu-Okinawa and the satellite island, in all of which the seroprevalence of HTLV-1 was more than 1.2%. These results show that, even in the Kyushu-Okinawa district, there are endemic clusters of HTLV-1 in small areas. This suggests that public health education programs are needed to eliminate new HTLV-1 infection in these areas.

Changes in the incidence, case fatality rate, and characteristics of symptomatic perioperative pulmonary thromboembolism in Japan: Results of the 2002-2011 Japanese Society of Anesthesiologists Perioperative Pulmonary Thromboembolism (JSA-PTE) Study.

PURPOSE: This study aimed to examine the incidence, case fatality rate, and characteristics of perioperative symptomatic pulmonary thromboembolism (PS-PTE) throughout Japan. METHODS: From 2002 to 2011, confidential questionnaires were mailed annually to all Japanese Society of Anesthesiologists-certified training hospitals for data collection to determine the incidence and case fatality rate of PS-PTE patients. Data from 10,537 institutions in which a total of 11,786,489 surgeries had been performed were analyzed using the Mann-Whitney and Chi-square tests. RESULTS: In total, 3,667 PS-PTE cases were identified. The average incidence of PS-PTE was 3.1 (2.2-4.8) per 10,000 surgeries, and the average case fatality rate was 17.9% (12.9-28.8%). The incidence of PS-PTE began to significantly decrease in 2004 compared with that of 2002 (0.0036 vs. 0.0044%: p < 0.01). The case fatality rate temporarily increased toward 2005 (17.9 to 28.8%); however, it gradually decreased since 2008 (15.7%) and was the lowest (12.9%) in 2011. Regarding the trends in prophylaxis, the rate of mechanical prophylaxis increased significantly in 2003 compared with that of 2002 (59.5 vs. 35.0%: p < 0.01), and almost plateaued (73.1-83.1%) after 2004. Furthermore, the rate of pharmacological prophylaxis started increasing in 2008 (17.6%) and reached around 30% after 2009 (28.8-30.2%). CONCLUSIONS: The results of our 10-year survey study show that the incidence of PS-PTE decreased significantly since 2004, and the case fatality rate seemed to show a downward trend since 2008. Major changes in the distribution of prophylaxis in PS-PTE patients were observed.

[Present status of critical hemorrhage and its management in the operating room].

Hemorrhage is a major cause of cardiac arrest in the operating room. Many human factors, including surgical procedures, transfusion practices, blood supply, and anesthetic management, are involved in the process that leads to hemorrhage developing into a critical situation. It is desirable for hospital transfusion committees to prepare hospital-based regulations on 'actions to be taken to manage critical hemorrhage', and practice the implementation of these regulations with simulated drills. If intraoperative hemorrhage may become critical, a state of emergency should immediately be declared to the operating room staff, the blood transfusion service staff, and blood bank staff in order to organize a systematic approach to the ongoing problem and keep all responsible staff working outside the operating room informed of events developing in the room. To rapidly deal with critical hemorrhage, not only cooperation between anesthesiologists and surgeons but also linkage of operating rooms with blood transfusion services and a blood bank are important. When time is short, cross-matching tests are omitted, and ABO-identical red blood cells are used. When supplies of ABO-identical red blood cells are not available, ABO-compatible, non-identical red blood cells are used. Because a systematic, not individual, approach is required to prevent and manage critical hemorrhage, whether or not a hospital can establish a procedure to deal with it depends on the overall capability of critical and crisis management of the hospital. (Review).

[Incidence and characteristics of perioperative pulmonary thromboembolism in Japan from 2009 through 2011 -the results of perioperative pulmonary thromboembolism research by the Japanese society of anesthesiologists (JSA-PTE research) --].

BACKGROUND: This study was designed to investigate the annual incidence and characteristics of perioperative pulmonary thromboembolism (PTE) in Japan from 2009 through 2011, and to compare the current trend with that observed in our previous studies conducted since 2002. METHODS: In the 3-year study period, a questionnaire was annually mailed to all institutions certified as training hospitals for anesthesiologists by the Japanese Society of Anesthesiologists (JSA). The survey included the parameters of age, sex, type of surgery, and the risk factors in patients who were operated upon. RESULTS: The questionnaire was sent out to total of 3,556 institutions and obtained answers from 2,511 institutions (70.6%) in the 3-year study period. Total 4,432,538 surgeries were conducted and 1,300 cases (0.03%) of perioperative PTE were registered. The incidence of PTE in all the 3 years was significantly lower than that observed in 2002-2003 (P<0.01). In addition, the mortality in 2011 was also significantly lower than that in 2002-2003 (P<0.05). The incidence of PTE in females (0.04%) was twice of the incidence of males (0.02%). The types of surgery with higher incidence of perioperative PTE were "thoracotomy with laparotomy" (0.08%),"hip joint, limbs" (0.07%) and"craniotomy" (0.06%). Compared with the middle age group (19-65 year-old), the incidence of PTE was twice in the elderly's (66-85 year-old) and in the super-elderly (over 86 year-old) it was thrice. In this survey, most approved risk factors were obesity (44%), malignancy (35%) and long term bed-rest (26%), and the ratio of long term bed-rest was decreasing compared with 2008. In the PTE cases, the ratio of the patients who received anticoagulant drugs (29-30%) or IVC filters placement (4-5%) increased compared with the results of JSA-PTE research in 2008 (P<0.01). CONCLUSIONS: The incidence and mortality of perioperative PTE decreased;although the factor of decrease in an incidence was considered to be the result of preventive method, as in the decrease in the mortality, the survey should be continued.

Risk and crisis management in intraoperative hemorrhage: Human factors in hemorrhagic critical events.

Hemorrhage is the major cause of cardiac arrest developing in the operating room. Many human factors including surgical procedures, transfusion practices, blood supply, and anesthetic management are involved in the process that leads to hemorrhage developing into a critical situation. It is desirable for hospital transfusion committees to prepare hospital regulations on 'actions to be taken to manage critical hemorrhage', and practice the implementation of these regulations by simulated drills. If intraoperative hemorrhage seems to be critical, a state of emergency should immediately be declared to the operating room staff, the blood transfusion service staff, and blood bank staff in order to organize a systematic approach to the ongoing problem and keep all responsible staff working outside the operating room informed of events developing in the operating room. To rapidly deal with critical hemorrhage, not only cooperation between anesthesiologists and surgeons but also linkage of operating rooms with blood transfusion services and a blood bank are important. When time is short, cross-matching tests are omitted, and ABO-identical red blood cells are used. When supplies of ABO-identical red blood cells are not available, ABO-compatible, non-identical red blood cells are used. Because a systematic, not individual, approach is required to prevent and manage critical hemorrhage, whether a hospital can establish a procedure to deal with it or not depends on the overall capability of critical and crisis management of the hospital.

[Current status of the treatment strategy for life-threatening hemorrhage in hospitals accredited by the Japanese Society of Anesthesiologists (JSA), and practical use of "Guidelines for Action Against Intraoperative Critical Hemorrhage"].

The JSA and the Japanese Society of Blood Transfusion and Cell Therapy established "Guidelines for Action Against Intraoperative Critical Hemorrhage" in 2007. This guideline shows practical strategies for managing life-threatening hemorrhage. From 2007 to 2009, we conducted the annual survey with transfusion services of 384 hospitals accredited by the JSA. From the results of these surveys, we proposed some new strategies for managing life-threatening hemorrhage as follows: 1) It is necessary to establish a documentation of institutional procedures for urgent transfusion practices including an emergency code for blood requirement, according to "Guidelines for Action Against Intraoperative Critical Hemorrhage". 2) The simulation exercise according to the documentation of institutional emergency transfusion procedures should be held. 3) On the occurrence of a life-threatening hemorrhage, we should make an appropriate decision to use uncrossmatched ABO-matched blood components and/or ABO-mismatched compatible blood components, to save the patient's life. 4) Though it is well known that the post-transfusion graft versus host disease (PT-GVHD) has poor prognosis and irradiation of blood products is essential for avoiding the PT-GVHD, in some hospitals, non-irradiated blood components were used in situation of critical hemorrhage. We recommend that irradiated blood components should be used if possible in resuscitating a patient with critical hemorrhage.

[Guidelines for management of critical bleeding in obstetrics].

Hemorrhage is the leading cause of maternal death. Pregnant woman can tolerate a larger amount of blood loss than non-pregnant woman, but obstetric hemorrhage is characterized by a high incidence of coagulopathy. The Japanese Society of Anesthesiologists and four related academic societies published "Guidelines for management of critical bleeding in obstetrics" in April 2010. The following points are emphasized in these guidelines. Firstly, the trend of the shock index (heart rate/systolic blood pressure) is useful to evaluate the necessity for blood transfusion. Secondly, coagulopathy should be evaluated in a timely manner and treated promptly, when blood loss including amniotic fluid exceeds 2,000 ml. Thirdly, an urgency code for hemorrhage should be introduced to facilitate communication among the related personnel with communication between the delivery/operating room and blood transfusion service. According to a triage tag in disaster medicine, code I or code red is an extreme emergency: overt hemorrhagic shock or evident massive hemorrhage. If code I is declared by the designated commander, transfusion of uncross-matched ABO-identical as well as ABO-compatible, non-identical red blood cells should be considered, if time is short or ABO-identical red blood cells are unavailable. The commander is selected from senior physicians of the anesthesiology or the obstetric department, and is responsible for crisis management. The major problems in crisis management are hesitation to declare an emergency and failure of communication. Declaration of an emergency is also essential for calling supportive medical personnel. To deal rapidly with critical bleeding, hospital actions to be taken should be prepared, and simulation exercise should be performed to correct inappropriate actions prior to an actual crisis. A systematic, not individual, approach is required to save the life of a bleeding pregnant woman.

Accuracy of arterial pressure waveform analysis for cardiac output measurement in comparison with thermodilution methods in patients undergoing living donor liver transplantation.

PURPOSE: The aim of this study was to assess the accuracy of the first and third versions of arterial pressure waveform cardiac output (APCO(v.1.0) and APCO(v.3.0)) measurements in comparison with thermodilution methods in patients undergoing living donor liver transplantation. METHODS: Twenty patients were anesthetized and mechanically ventilated. A radial arterial line was connected to a dedicated transducer for the APCO evaluation (FloTrac™). A pulmonary artery catheter was placed and connected to a computer system (Vigilance™) to measure intermittent thermodilution cardiac output (CO(TD)) and continuous cardiac output (CCO). RESULTS: A total of 138 measurements were analyzed. Bland-Altman analysis showed that the mean biases for CO(TD)-APCO(v.3.0), CO(TD)-APCO(v.1.0), and CO(TD)-CCO were 0.89, 1.73, and -0.79 L/min, and the adjusted percentage errors were 37.5, 30.3, and 43%, respectively. While the variance for CO(TD)-APCO(v3.0) was greater, the accuracy (bias) improved by 0.8 L/min as compared with CO(TD)-APCO(v1.0). The difference CO(TD)-APCO(v.3.0) became apparent when systemic vascular resistance was lower than 1000 dyne × s/cm(5), especially below 700 dyne × s/cm(5). CONCLUSION: These data suggest that the accuracy of APCO(v.3.0) has improved compared to APCO(v.1.0) due to the updated algorithm, but additional improvements should be evaluated, especially in patients undergoing living donor liver transplantation with low systemic vascular resistance.

Relationship between regional cerebral blood flow and electrocorticographic activities under sevoflurane and isoflurane anesthesia.

The aims of this study are (1) to assess the effects of volatile anesthetics on regional cerebral blood flow (rCBF) and electrocorticography (ECoG), and (2) to investigate the relationship between rCBF and ECoG influenced by volatile anesthetics. The authors measured rCBF using laser Doppler flowmetry and ECoG simultaneously and continuously from the same cortex during craniotomy, using the specially arranged probe. Patients received intravenous anesthetics with nitrous oxide until craniotomy, and after opening of dura, volatile anesthetic, either isoflurane or sevoflurane, was started and was gradually increased for the measurement. Four of the nine cases (44.4%) of the sevoflurane group showed no change both in rCBF and ECoG. In three cases (33.3%), rCBF increased as the frequency of the paroxysmal activities increased. In two cases (22.2%), decreased rCBF was accompanied by slow waves. In 12 cases of the isoflurane group, no apparent rCBF and ECoG changes were seen, except a case with decreased rCBF and slow waves. This is the first report of simultaneous recordings of regional CBF and neuronal activity under general anesthesia. During sevoflurane and isoflurane anesthesia <2.5 minimum alveolar anesthetic concentration, rCBF is affected by ECoG activities rather than pharmacologic action of inhalational anesthetics.

[Emergency compatible, ABO-different blood group transfusion in the operating theater: a survey in regional Japanese Society of Anesthesiologists-certified training hospitals in 2006].

BACKGROUND: In Japan, emergency blood transfusion practices including ABO-compatible, different blood group transfusion and uncross-matched, ABO-identical blood group transfusion are very limited possibly due to adherence to identical blood transfusion as well as fear of hemolytic reactions due to anti-A, anti-B, anti-RhD and unexpected antibodies. Purpose of the study is to examine the incidence of hemolytic reactions due to compatible, ABO-different blood group transfusion. METHODS: We conducted a questionnaire survey regarding emergency compatible, different blood group transfusion in the operating theater in hospitals with more than 500 beds among those with an accredited Department of Anesthesiology regarded as regional hospitals. Of 384 institutions, 247 responded to the questionnaire. During the year 2006, compatible, ABO-different blood group transfusion was reported in 112 patients from 32 hospitals, among which 105 patients in 26 hospitals were available for further analysis. RESULTS: Compatible red cell concentrate (RCC), fresh frozen plasma (FFP), and platelet concentrate (PC) were transfused in 23, 10, and 83 patients, respectively. Total amount of compatible RCC, FFP, and PC were 232, 162, and 1,679 units, respectively. In patients who were transfused with compatible RCC, two patients had unexpected antibodies. Overall mortality rate within the 30th post-operative day was 23%. In 80 patients, in whom only PCs were used as compatible blood products, blood loss was 86 +/- 85 ml x kg(-1), 65% of patients underwent cardiovascular surgery, and mortality was 11%, implying that compatible PC was transfused mainly to avoid hemorrhagic diathesis in cardiovascular patients. In 64 patients with blood type of A, B, or AB, who underwent compatible PC transfusion, type O PC, incompatible blood products, were transfused in 9 patients. In 21 patients, in whom only RCCs were used as compatible blood products, blood loss was 206 +/- 224 ml x kg(-1), and mortality was 57%. Therefore, compatible RCCs were transfused mainly to avoid life-threatening events. Uncross-matched, ABO-identical RCC transfusion was performed only in 29% of patients among these 21 patients. Transfusion-related hemolytic reactions were not reported in all 104 patients available for this analysis. CONCLUSIONS: Although the patient number was small, the finding that there were no hemolytic reactions might promote emergency blood transfusion practices in Japan. High mortality rate and a low rate of uncross-matched, ABO-identical RCC transfusion in patients with compatible RCC transfusion suggest that promoting emergency blood transfusion practices might reduce mortality rate due to massive hemorrhage in the operating theater.

[Present status of preparatory measures for massive hemorrhage and emergency blood transfusion in regional hospitals with an accredited department of anesthesiology in 2006].

BACKGROUND: Annual surveys conducted by the Japanese Society of Anesthesiologists repeatedly show that hemorrhage is the leading cause of life-threatening events in the operating room. METHODS: We performed a questionnaire survey regarding the present status of critical hemorrhage/ blood transfusion occurring in the operating room on an institutional scale and individual blood transfusion management in cases of massive hemorrhage (> or = 5,000 ml) in hospitals with > or = 500 beds and those with an accredited Department of Anesthesiology regarded as regional hospitals. RESULTS: Of 384 institutions, 247 responded to the questionnaire (response rate: 64%), and 692,241 cases managed by anesthesiologists in 2006 were registered. There were 2,657 cases of massive hemorrhage above the circulating blood volume in the operating room, and 404 of them were critical. Thus, the number of cases of massive hemorrhage was 6.6 times that of cases of critical events due to hemorrhage. In the survey of individual cases of massive hemorrhage (> or = 5,000 ml), 1,257 cases were registered in 2006, of whom 196 cases (15.6%) died within 30 post-operative days and 160 cases (12.7%) had some sequelae. The amount of transfused red blood cell concentrate was 25.2 +/- 24.2 units. The amount of red blood cell concentrates stocked for emergency was 12.7 +/- 10.1 units for blood group A, 9.7 +/- 7.3 units for group B, 11.9 +/- 9.6 group AB, and 11.3 +/- 11.0 for group O. Therefore, for those other than group O cases, 21-46 units of red blood cell concentrates seemed to be available in the hospital. The survey of individual cases showed uncross-matched, same blood group transfusion and compatible, different blood group transfusion were performed in only 8.2% and 4.3%, respectively. The lowest hemoglobin concentration was below 5 g x dl(-1) in 16.7% of the cases, but uncross-matched, same blood group transfusion was performed only in 19.0% and compatible, different blood group red cell concentrate transfusion in 5.2%. Even in cases who required cardiac massage, uncross-matched, same blood group transfusion was performed only in 17.1% and compatible, different blood group red cell concentrate transfusion in 8.5%. Intraoperative blood salvage was performed in only 5.7% in cases who underwent non-cardiac surgery. The "Guidelines for the Management of Critical Hemorrhage" proposed in 2007 or the manuals for in-hospital emergency blood transfusion were insufficiently recognized, even by anesthesiologists, and rarely known by surgeons. There were no such manuals in more than 60% of the institutions. CONCLUSIONS: Undertransfusion may occur in 16.7-28.3% of cases of massive hemorrhage in the operating room, and the rate of emergency blood transfusion was much lower than this percentage. To avoid operation-associated deaths from hemorrhage, the improvement of hospital systems for emergency blood transfusion, including the active use of intraoperative blood salvage, should be promoted.

[Incidence and characteristics of perioperative pulmonary thromboembolism in Japan from 2005 through 2007--results of research by Japanese Society of Anesthesiologists, Committee on Patient Safety and Risk Management, Perioperative Pulmonary Thromboembolism Working Group].

BACKGROUND: This study aimed to investigate the annual incidence and characteristics of perioperative pulmonary thromboembolism (PTE) in Japan from 2005 through 2007, and to compare the current trend with that observed in our previous studies conducted since 2002. METHODS: In the 3-year study period, a questionnaire was annually mailed to every institution certified as a training hospital for anesthesiologists by the Japanese Society of Anesthesiologists (JSA). The survey included the parameters of age, sex, type of surgery, and the risk factors in patients who were operated upon. RESULTS: The average rate of effective responses was 55.1%, and a total of 825 cases of perioperative PTE were registered in the 3-year study period. The incidence of perioperative PTE was 2.79 per 10,000 cases in 2005, 2.25 per 10,000 cases in 2006, and 2.57 per 10,000 cases in 2007. The incidence of PTE in all the 3 years was significantly lower than that observed in 2002-03 (P < 0.01). In addition, the incidence of fetal PTE in 2006 and 2007 was also significantly lower than that in 2002-03. The incidence of PTE in older persons (66-85 years) was approximately twice (4.70 per 10,000 cases) and that in the oldest persons (> 86 years) was approximately thrice (6.28 per 10,000 cases) the incidence in middle-aged individuals (2.17 per 10,000 cases). PTE was found to be more frequent in females than in males (males, 1.89 per 10,000 cases; females, 3.75 per 10,000 cases). The types of surgery that most commonly resulted in perioperative PTE were limb and/or hip joint surgery (5.57 per 10,000 cases), thoracotomy with laparotomy (5.19 per 10,000 cases), and spinal surgery (4.49 per 10,000 cases). Perioperative PTE was fatal in 185 patients (22.4%), and the mortality rate of patients who had not received prophylaxis was significantly higher (37.8%) than that of patients who received anticoagulant drugs (20.8%). Guidelines for prevention of perioperative PTE were accepted by 58% of all training institutions. CONCLUSIONS: The incidence of perioperative PTE and fetal PTE has currently decreased; however, prophylaxis with anticoagulant drugs may have reduced the mortality in some cases.

[Risk and crisis management by anesthesiologists regarding 'Guidelines for Actions Against Intraoperative Critical Hemorrhage' published by the Japanese Society of Anesthesiologists and the Japan Society of Transfusion Medicine and Cell Therapy].

According to a survey of anesthesia-related critical incidents by the Japanese Society of Anesthesiologists, hemorrhage was the major cause of cardiac arrest developing in the operating room. To deal with critical hemorrhage swiftly, not only cooperation between anesthesiologists and surgeons but also the linkage of operating rooms with transfusion management divisions and the blood center is important. It is desirable for the hospital transfusion committee to prepare hospital regulations on 'actions to be taken to manage critical hemorrhage', and practice the implementation of these guidelines by simulated drills. When critical hemorrhage occurs, a person in charge is appointed, and an emergency is declared (call for manpower and notification of the emergency to the transfusion management divisions). A person in charge comprehensively assesses the hemostatic condition, hemodynamics, laboratory data, and blood product supply system, and consults the operator regarding the continuation of surgery or changing surgical procedures. When time is short, the cross-matching test is omitted, and the ABO-identical blood is used. When a supply of the identical ABO-type blood is not available, compatible blood type is used. The evolving concept of hemostatic resuscitation seems to be important to prevent coagulopathy, which easily develops during massive hemorrhage. Anesthesiologists should be aware of the risk of such an emergency transfusion and procedures to be taken to switch to transfusion of the ABO-identical blood. Establishment of a hospital emergency transfusion system depends on the overall capability of the critical and crisis management systems of the hospital.

Incidence of anesthesia-related medication errors over a 15-year period in a university hospital.

To clarify the incidence of anesthesia-related medication errors in Kyushu University Hospital, a retrospective analysis of anesthesia-related incidents from 1993 to 2007 was conducted based on the "Investigation of anesthesia-related medication incidents" by the Japanese Society of Anesthesiologists. Out of a total of 64,285 anesthesia cases, drug errors occurred in 50 cases (0.078%), but none of the incidents led to serious sequelae. Wrong medication was the most common type of drug error (48%), followed by overdose (38%), underdose (4%), omission (2%), and incorrect administration route (8%). The most commonly involved drugs were opioids, cardiac stimulants, and vasopressors. Syringe swap was the leading cause of wrong medication, accounting for 42%, drug ampoule swap occurred in 33%, and the wrong choice of drug was made in 17%. The first, second, and third most frequent causes of overdose involved a misunderstanding or preconception of the dose (53%), pump misuse (21%), and dilution error (5%). The error frequency did not decrease over the 15-year period. The responsible anesthesiologists were most likely to be doctors with a little experience. To reduce anesthesia-related medication errors, improvements of protocols for handling medication and instruction, and an improved education system for the anesthesia trainees are essential.

[Recent changes in the incidence of life-threatening events in the operating room: JSA surveys between 2001 and 2005].

BACKGROUND: In Japan, the number of medical staff charged with criminal liability has been increasing since 2000, and this medico-legal trend seems to be promoting topics of medical risk management in government, academic meetings and individual hospital. A survey conducted by the Japanese Society of Anesthesiologists (JSA) has been widely accepted among JSA-certified training hospitals, and its denominator has exceeded one million since 2001. The purpose of this investigation is to examine changes in the incidence of life-threatening events in the operating theater between 2001 and 2005 based on the data of the surveys. METHODS: JSA has conducted annual surveys of life-threatening and neurological events in the operating theater by sending and collecting confidential questionnaires to all JSA certified training hospitals. Cases of life-threatening events between 2001 and 2005 were analyzed. The recovery rates ranged from 76.2% (in 2005) to 91.6% (in 2002), and the annual patient numbers available for analysis ranged from 1,051,245 (in 2005) to 1,367,790 (in 2003) during the study period. The patients with ASA PS 1 or 2 were classified as having good physical status, and those with ASA PS 3 or 4 were classified as having poor physical status. Because mortalities (within 7 postoperative days) are more common in patients with poor physical status, in emergency patients, in neonate, in the elderly, and in patients undergoing cardiovascular surgery, the mortality rate in these patients were investigated. The recovery rate from cardiac arrest without any sequelae was also investigated. The causes of events were classified as follows: totally attributable to anesthetic management (AM), mainly to intraoperative pathological events (IP), to preoperative co-morbidity (PC), and to surgical management (SM). IP consists of pulmonary thromboembolism, acute coronary syndrome, anaphylaxis and so on. The incidence of cardiac arrest and mortality are indicated per 10,000 patients. Odds ratio and 95% confidential interval are shown in comparison with the incidence in 2001 to that in 2005. RESULTS: The incidences of cardiac arrest were 6.12 in 2001, 5.79 in 2002, 5.89 in 2003, 5.09 in 2004, and 4.24/10,000 patients in 2005, respectively (odds ratio 0.69; CI 0.62-0.78). The incidences of death within 7 postoperative days due to intraoperative life-threatening events were 6.41 in 2001, 6.31 in 2002, 6.61 in 2003, 5.88 in 2004, and 4.91/10,000 patients in 2005, respectively (OR 0.77; CI 0.69-0.85). The incidences of death in patients with poor physical status (from 35.48 to 26.87/10,000 patients; OR 0.76; CI 0.66-0.86), in emergency patients (from 37.25 to 30.55/10,000 patients; OR 0.82; CI 0.72-0.93), in neonates (from 70.09 to 31.70/10,000 patients; OR 0.45; CI 0.22-0.91) and in the elderly (from 11.03 to 8.75/10,000 patients; OR 0.79; CI 0.68 to 0.92) decreased. The incidence of death in patients undergoing cardiovascular surgery ranged between 61.22 and 76.88/10,000 patients, and has not shown any significant decline. The incidences of death due to IP (from 0.65 to 0.42/10,000 patients; OR 0.64; CI 0.44-0.92), PC (from 4.14 to 3.30/10,000 patients; OR 0.80; CI 0.70-0.91) and SM (from 1.49 to 1.02/10,000 patients; OR 0.68; CI 0.54-0.87) decreased. However, the incidence of death due to AM ranged between 0.07 and 0.11/10,000 patients, and has not shown any significant decline partly because of the small number of deaths from this cause. Although recent trends in life-threatening events seemed to be favorable, the recovery rate from cardiac arrest decreased from 40.3% in 2001 to 30.7% in 2005 (OR 0.66; CI 0.51-0.84). CONCLUSIONS: The incidence of life-threatening events in the operating room and mortality due to these events seemed to have decreased during the recent five years, probably because of progress in risk management in JSA-certified training hospitals. The decrease was obvious in the recent two years. However, the results should be interpreted cautiously, because the response rate to the questionnaire in 2005 was the lowest. To confirm this trend, we should perform a follow-up survey for 2006 and continue the survey. The reasons for the deterioration in the recovery rate from cardiac arrest should also be examined.

[Cerebrovascular accidents developing in the operating theater: a JSA survey for the year 2004].

BACKGROUND: The incidence of cerebrovascular accidents (CVA) developing in the operating theater has not been investigated on a large scale. In 2004, the Japanese Society of Anesthesiologists (JSA) started to survey neurological as well as life-threatening events in the operating theater. The incidence of CVA developing in the operating theater was examined using data obtained by the 2004 survey. METHODS: JSA has conducted annual surveys of life-threatening and neurological events in the operating theater by sending and collecting confidential questionnaires to all JSA certified training hospitals. The recovery rate was 91% (874/960 hospitals) in 2004. Seven hundred fourteen hospitals sent valid responses, and 1,218,371 anesthesias were registered. Among these cases, 123 patients were reported to have developed CVA in the operating theater. Incidences according to age class, ASA PS and surgical sites, causes, and their outcome were investigated. The patients with ASA PS 1 or 2 were classified as having good physical status, and those with ASA PS 3-5 were classified as having poor physical status. The causes of events were classified as follows: totally attributable to anesthetic management (AM), mainly to intraoperative pathological events (IP), to preoperative co-morbidity (PC), and to surgical management (SM). RESULTS: Overall incidence of CVA was 1.01/10,000 anesthesias. The incidence in patients aged 66 years or above was 2.00/10,000 anesthesias, which was 3.83-(95% confidential interval 2.57-5.71) fold higher than that in patients aged between 19 and 65 years. The incidences in elective and emergency patients with poor physical status were 3.27 and 7.91/10,000 anesthesias, respectively, which was 7.04- (4.56-10.87) and 17.06-(10.90-26.69) fold higher than that in elective patients with good physical status, respectively. The incidences in patients undergoing thoracotomy combined with laparotomy, craniotomy, or cardiovascular surgery were 2.76, 5.96 and 11.65/10,000 anesthesias, respectively, which were 7.22- (1.64-31.76), 15.59- (8.14-29.86), and 30.52- (16.80-55.44) fold higher than that in patients undergoing laparotomy alone. Among cardiovascular surgery, thoracic aortic surgery showed the highest number of incidents (57.98/10,000 anesthesias), followed by on-pump coronary artery bypass (11.07/10,000 anesthesias). Only one patient undergoing off-pump coronary artery bypass developed CVA, resulting in an 8.14- (1.00-66.18) fold lower incidence of CVA compared to that of on-pump coronary artery bypass. AM, IP, PC and SM were responsible for 4.1%, 24.4%, 27.6% and 35.0% of CVA. The incidence of CVA caused by AM or IP was calculated to be 0.29/ 10,000 anesthesias. If patients undergoing cardiovascular surgery or craniotomy were excluded, the incidence of CVA caused by AM or IP was calculated to be 0.13/ 10,000 anesthesias (15/ 1,134,398 anesthesias). The overall outcome of CVA was as follows: uneventful recovery 9.8%, death within 30 post-operative days 26.0%, vegetative state 6.5%, and sequelae involving deficits in the central nervous system 52.0%. The outcome of CVA caused by AM or IP was as follows: uneventful recovery 20.0%, death within 30 post-operative days 22.9%, vegetative state 8.6%, or sequelae involving deficits in central nervous system 45.7%. Twenty-seven point six percent of reported CVA were considered to have been preventable. CONCLUSIONS: The overall incidence of CVA developing in the operating theater in Japan was reported to be 123 among 1.2 million anesthesias. The incidence was high in elderly patients, in patients with poor physical status, and in patients undergoing cardiovascular surgery. Because the prognosis of CVA developing in the operating theater was poor, clinical strategies for prevention, early detection, prompt diagnosis, and appropriate treatment of CVA should be established.

Evaluation of finger and forehead pulse oximeters during mild hypothermic cardiopulmonary bypass.

OBJECTIVE: The purpose of this study was to examine and compare the four combination of pulse oximeters (POs) and monitoring sites, the Nihon Kohden BSS-9800 (N), the Masimo SET Radical (M), the Nellcor N550 D-25 (N-D) and the Nellcor N550 Max-Fast (N-MF) in patients with peripheral hypoperfusion. METHODS: About 20 adult patients undergoing cardiac surgery using mild hypothermic cardiopulmonary bypass (CPB) were studied prospectively. PO sensors were applied on fingers in N, M and N-D, while on the forehead in N-MF. RESULTS: PO failure was defined as failure to show no SpO2 value or incorrect SpO2 values. PO failure occurred in 12 patients with N, ten patients with M, four patients with N-D and ten patients with N-MF, respectively (p < 0.05 N-D vs. N, M, N-MF). The duration of PO failure was 19 +/- 30% of aortic cross-clamping with N, 29 +/- 33% with M, 10 +/- 26% with N-D and 43 +/- 57% with N-MF, respectively (p < 0.05 N-D vs. M and N-MF). CONCLUSIONS: The results suggested that N-D is most useful among four combinations of POs and monitoring sites tested in this study for monitoring SpO2 during hypoperfusion. The superiority of N-MF during hypoperfusion was not evident in the present study.