Effects of Simulation Study of High Neuraxial Block During Epidural Analgesia for Labor Pain on Pre/Posttest Evaluation in Junior Clinical Trainees.

BACKGROUND: Since a high neuraxial block is one of the serious complications in obstetric anesthesia, simulation training is required for the education of rapid diagnosis and treatment of this complication. OBJECTIVES: This study aimed to evaluate the effects of a simulation study of the high neuraxial block during epidural analgesia for labor pain on pre- and post-simulation tests in junior clinical trainees, who had graduated a medical school within one or two years and being under a two-month program for anesthesia during the Japanese Postgraduate Medical Education. METHODS: Twenty-two junior clinical trainees participated in this study from September 2016 to May 2017. Before the simulation training, the participants answered a pretest, providing written responses on "how to approach and treat the rapid spread of anesthesia (high neuraxial block) in painless epidural delivery" in a bullet-point form. The number of correct answers to 12 items was counted for each participant. These items were as follows: mask ventilation, preparation for tracheal intubation, oxygenation, supraglottic airway placement, checking the breathing, checking oxygen saturation using pulse oximetry, checking blood pressure, ephedrine injection, checking epidural tube, assessing the level of sensory block, assessing the level of consciousness, and left uterine displacement. After performing our original training, all participants were debriefed and written responses were obtained to a posttest containing the same content as the pretest. RESULTS: The percentage of correct answers significantly increased from 8.3 to 16.7% (P = 0.041) after training. The response rates for "mask ventilation" and "check epidural tube" significantly increased from 13.6 to 54.5% (P = 0.004) and from 4.5 to 27.3% (P = 0.039), respectively, after training. CONCLUSIONS: Simulation training is likely an effective method for junior clinical trainees on studying diagnosis and treatment of high neuraxial block during epidural analgesia in parturient patients.

Effects of anaesthesia-induced hypotension and phenylephrine on plasma volume expansion by hydroxyethyl starch: A randomised controlled study.

BACKGROUND: Changes in blood haemoglobin concentration indicate plasma volume expansion following hydroxyethyl starch (HES) infusion, but may be affected by vascular tone and HES-induced shedding of the endothelial surface layer (ESL). We hypothesised that anaesthesia-induced hypotension enhances changes in plasma volume as assessed by blood haemoglobin concentration (ΔPVHb , %) following HES infusion. METHODS: Fifty-two patients undergoing abdominal surgery were randomised to receive a continuous infusion of saline (S group) or phenylephrine to restore vascular tone (P group) (n = 26 each). Both groups received an infusion of 8 mL/kg 6% HES solution after induction of general anaesthesia. We compared ΔPVHb at the end of fluid infusion (15 minutes) and 15 minutes later (30 minutes) between the two groups. We assessed changes in ESL structure by measuring plasma concentrations of hyaluronate and syndecan-1. P < .05 was considered statistically significant. RESULTS: Mean arterial blood pressure was lower in the S group approximately by 30-40% compared to the P group (P < .001). ΔPVHb was larger in the S group compared to the P group at 15 minutes (24.9 [5.2] % vs 19.0 [5.2] %; P < .001) and 30 minutes (26.5 [5.9] % vs 16.9 [6.6] %; P < .001). There were no clinically significant differences in plasma concentrations of hyaluronate and syndecan-1 with time and between the groups. CONCLUSIONS: Increased volume expansion of circulating plasma following HES infusion in anaesthesia-induced hypotension compared to when blood pressure is restored by phenylephrine may result from an attenuation of transcapillary fluid filtration, rather than ESL shedding. UMIN Clinical Trial Registration Number: UMIN000017394 (http://www.umin.ac.jp/ctr/index.htm).

Effects of Thoracic Paravertebral Block on Nociceptive Levels After Skin Incision During Video-Assisted Thoracoscopic Surgery.

BACKGROUND Regional anesthesia provides excellent analgesic effects after surgery. However, the effects of regional anesthesia on nociceptive levels during surgery under general anesthesia have not been quantitatively evaluated. To reveal the effects of thoracic paravertebral block (PVB) on nociceptive levels after skin incision during general anesthesia, we performed a retrospective cohort study in patients without serious preoperative conditions or comorbidities undergoing elective video-assisted thoracoscopic surgery (VATS). Nociceptive levels during general anesthesia were calculated using our previously determined Nociceptive Response (NR) equation, which utilizes common hemodynamic parameters. MATERIAL AND METHODS Data on 77 adult patients who underwent VATS from May 2018 to August 2018 were retrospectively obtained from our institutional database. We then performed propensity score matching between patients who received thoracic PVB (PVB group: n=29) and those who did not (Control group: n=48). The averaged values of systolic blood pressure (SBP), heart rate (HR), perfusion index (PI), bispectral index (BIS), and NR from 10 to 5 minutes before skin incision (T0), 5 to 10 minutes (T1), 10 to 15 minutes (T2), 15 to 20 minutes (T3), and 20 to 25 minutes after skin incision (T4), were calculated. RESULTS Twenty-four propensity score-matched patients in each group were analyzed. Mean NR values at T1 and T2 in the PVB group were significantly lower than those in the Control group. SBP, HR, PI, and BIS, however, showed no significant differences between the 2 groups, except for SBP at T2. CONCLUSIONS Thoracic PVB prevented an increase in NR values, which quantitatively represent nociceptive levels under general anesthesia, in patients undergoing VATS.

Association between intraoperative phenylephrine administration and umbilical artery pH in women with hypertensive disorders of pregnancy: a retrospective cohort study.

PURPOSE: In healthy pregnant women undergoing Cesarean section, treatment of post-spinal hypotension (PSH) with phenylephrine is reportedly more efficacious than ephedrine in preventing a decline in umbilical artery pH (UApH), which is an indicator of fetal acidosis. However, phenylephrine has the potential to reduce placental blood flow and consequently decrease UApH in women who develop hypertensive disorders of pregnancy (HDP), due to decreased cardiac function and placental vascular abnormalities. We aimed to verify the association between decreased UApH and phenylephrine administered before delivery to treat PSH in women with HDP. METHODS: This single-center retrospective cohort study was conducted between April 2008 and October 2016 by assessing the records of pregnant women with confirmed or suspected HDP who underwent Cesarean section under spinal anesthesia. The association between phenylephrine and the primary endpoint of decreased UApH was investigated using logistic regression analysis and propensity score matching. RESULTS: In the original cohort of 107 pregnant women with HDP, neither univariate nor multivariate analysis indicated a significant association between phenylephrine treatment and decreased UApH [crude odds ratio (OR) = 2.26; 95% confidence interval (CI) 0.75-6.77; P = 0.14], (adjusted OR = 1.80; 95% CI 0.55-5.93; P = 0.33). Thirty patients each who were not treated with phenylephrine (control group) and were treated with phenylephrine (phenylephrine group) were matched by propensity score analysis. UApH [median (interquartile range)] was not significantly different between control and phenylephrine groups [7.30 (7.25-7.35) vs. 7.27 (7.25-7.30); P = 0.14]. CONCLUSION: Intraoperative phenylephrine administration to treat PSH in women with HDP was not associated with decreased UApH.

[Anesthesia for tracheal metal stent management utilizing venovenous extracorporeal life support].

We report a successful case of metal stent replacement utilizing venovenous extracorporeal life support (VV-ECLS). A 71-year-old woman, who had previously undergone tracheal metal stent placement, encountered dyspnea associated with inversion of the stent. Metal stent replacement was planned under general anesthesia. After securing the VV-ECLS in the right and left femoral vein, anesthesia was induced with propofol and remifentanil. Metal stent replacement was conducted under rigid and flexible bronchoscope through the tracheal tube. Oxygenation and carbon dioxide excretion were achieved uneventfully. VV-ECLS was considered useful for the management of subglottic difficult airway such as complex tracheal stenosis.

[Complementary use of central venous oxygen saturation for fluid management in abdominal surgery patients with severely compromised cardiac function: a report of two cases].

Perioperative fluid management for cases with severely compromised cardiac function undergoing major non-cardiac surgery remains a challenge. Dynamic parameters such as stroke volume variation (SVV) and cardiac index obtained by arterial pulse contour analysis may not be sufficient for fluid optimization because individualized optimal parameter values are difficult to determine in cardiac patients. We report two cases of abdominal surgery with severe pre-existing impairment of cardiac function (ejection fraction < 30%) complicated by severe pulmonary and renal dysfunction. In Case 1, because of unreliably high SVV values due to a sudden onset of cardiac arrhythmia, we performed colloid bolus infusion targeting central venous oxygen saturation (ScvO2) above 80%. In Case 2, cardiac index and stroke volume index remained unchanged despite the decrease of SVV after colloid bolus infusion. Infusion of dobutamine was useful for maintaining the ScvO2 above 75% in a rather hypovolemic state (SVV of 10-15%). Our cases suggest that the use of central venous oxygen saturation together with arterial pulse contour analysis may aid decision-making for individualized fluid optimization and use of inotropics in severely compromised cardiac patients undergoing major abdominal surgery.