Venoarterial extracorporeal membrane oxygenation for cardiopulmonary resuscitation: A retrospective study comparing the outcomes of fluoroscopy.

Background: Extracorporeal cardiopulmonary resuscitation (ECPR) using venoarterial extracorporeal membrane oxygenation is performed for out-of-hospital cardiac arrest; however, it is associated with a risk of several complications. Objective: To investigate whether the fluoroscopy equipment was removed from the emergency department (ED) and whether it would be beneficial to transport the patient to the fluoroscopy room to reduce vascular complications without affecting the induction time. Methods: This single-center, retrospective, before-and-after analysis was conducted at a tertiary emergency medical center and included 59 patients who underwent ECPR for out-of-hospital cardiac arrest between May 2017 and March 2022. The patients were divided into two groups: those who underwent cannulation in the ED without fluoroscopy (ED-ECPR group) and those who were transferred directly from the ED to the cardiac angiography room (ECPR call group). Results: The rate of vascular complications associated with ECPR was significantly lower in the ECPR group than in the ED-ECPR group (40.6 % [14/32] vs. 10 % [2/20], respectively; p = 0.014). The duration from ED arrival to venoarterial extracorporeal membrane oxygenation initiation was similar in the two groups (median: 23.0 min in the ED-ECPR group vs. 25.5 min in the ECPR call group, p = 0.71). Results adjusted for confounding factors showed that performing ECPR under fluoroscopy was a consistent and independent element of vascular complication rates (adjusted odds ratio: 9.92, 95 % confidence interval: 2.04 to 81.2, p = 0.011). Conclusions: Fluoroscopy-guided ECPR can significantly reduce the incidence of vascular complications even if the ED and fluoroscopy room are far apart. However, no significant difference was observed in the time required to establish ECPR in the cardiac catheterization laboratories.

Cricothyrotomy for an Unexpected Cannot Intubate, Cannot Ventilate Situation for a Patient with Chronic Graft-Versus-Host Disease After Induction of General Anesthesia: A Case Report.

BACKGROUND Chronic graft-versus-host disease (GVHD) is a major complication of hematopoietic stem cell transplantations. Due to fibrotic changes, patients with GVHD are at risk for difficult airway management. We encountered a case of chronic GVHD that went into a "cannot intubate, cannot ventilate" (CICV) condition after induction of general anesthesia and was managed using cricothyrotomy. CASE REPORT A 45-year-old man with uncontrolled chronic GVHD developed pneumothorax of the right lung. Thoracoscopic dissection of the adhesions, closure of the pneumostomy, and drainage under general anesthesia were planned. In the preoperative airway assessment, we concluded that using a video laryngoscope or endotracheal fiber would be sufficient to intubate the patient after sedation and that airway management after the loss of consciousness would not be difficult. Therefore, general anesthesia was induced by rapid induction; however, the patient developed difficult mask ventilation. Intubation was attempted via a video laryngoscope or bronchofiber but failed. Ventilating using a supraglottic instrument was difficult. The patient was evaluated to have a CICV condition. Thereafter, because of a rapid decrease in oxygen saturation (SpO2) and bradycardia, a cricothyrotomy was performed. Subsequently, ventilation became adequate, SpO2 increased immediately and drastically, and respiration and circulatory dynamics recovered. CONCLUSIONS We believe that anesthesiologists should practice, prepare, and simulate airway emergencies that can be experienced during surgery. In this case, we recognized that skin sclerosis in the neck and chest could lead to CICV. It may be suitable for airway management of scleroderma-like patients to select conscious intubation with a bronchoscope as a first choice.

A patient with myotonic dystrophy diagnosed after experiencing sudden respiratory failure: a case report.

BACKGROUND: Myotonic dystrophy is a disorder affecting multiple organs including skeletal muscles and causes respiratory failure. We describe a patient who developed respiratory failure, with delayed diagnosis of myotonic dystrophy type 1 as the cause. CASE PRESENTATION: A 62-year-old woman developed acute onset of dyspnea after showing hypertension and tachycardia and was transported to our hospital. On arrival at our institution, SpO2 was 80% with a non-rebreather mask. With a diagnosis of acute phase heart failure, she underwent tracheal intubation. However, weaning from the respirator was difficult in the intensive care unit (ICU). A detailed interview revealed that her brother was affected with myotonic dystrophy type 1. She was also diagnosed with myotonic dystrophy type 1 by a genetic test. CONCLUSIONS: Taking a careful past and family history and prompt genetic testing is required on suspicion of neuromuscular diseases in a patient with respiratory failure by an unknown cause.

The Impact of Air Transport for Acute Coronary Syndrome Patients.

OBJECTIVE: For patients with acute coronary syndrome (ACS), percutaneous coronary intervention (PCI) within 120 minutes from onset is recommended. A helicopter emergency medical service (HEMS) is useful for transporting ACS patients. The purposes of this study were to investigate whether patients with ACS in the eastern part of Hokkaido could be transported to a PCI hospital by HEMS and undergo PCI within 120 minutes and to clarify the factors most related to delayed access to PCI. METHODS: This was a retrospective cohort study that analyzed 513 patients diagnosed with ACS at our institution, an HEMS base/PCI hospital. We investigated transport modes for each patient and identified the processes by which access to PCI was delayed. RESULTS: HEMS reduced transport time compared with ground emergency medical services but did not contribute to access to PCI within 120 minutes. The most important factor was transport directly to a PCI hospital (P < .01). CONCLUSION: HEMS did not achieve a total transport time of patients to a PCI hospital within 120 minutes from onset. Transport using HEMS is insufficient to access early PCI; patient condition must also be considered to determine whether to go through a non-PCI hospital.

[McGRATH® MAC Is Useful to Learn Tracheal Intubation Using a Macintosh Laryngoscope].

BACKGROUND: Learning tracheal intubation using a Macintosh laryngoscope (McL) is important although video laryngoscope is becoming popular. The purpose of this study was to compare the usefulness as a training device for intubation technique using McL with three devices; McGRATH® MAC (MAC), Airwayscope® (AWS) and McL. METHODS: In this prospective study, 60 nurses not experienced in tracheal intubation were randomly assigned to MAC, AWS, and McL groups (each group: n=20), and 10 times of practice using each device were carried out. We compared the intubation time using McL and the nurse's anatomical understanding of the larynx before and after the practice. RESULTS: The intubation time before the practice was comparable among the three groups, but the time after the practice was significantly shorter in the McL and MAC groups compared to the AWS group (P=0.001). The practice significantly improved anatomical understanding of the larynx in all groups (P<0.05), and in particular it was improved in the MAC and AWS groups compared with the McL group (P<0.001). CONCLUSIONS: The McGRATH® MAC may possess advantages compared to Airwayscope® and Macintosh laryngoscope as a training device for learning intubation technique using Macintosh laryngoscope and understanding anatomy of the larynx.

Pulmonary embolism caused by a carbon dioxide blower during off-pump coronary artery bypass grafting.

We report a rare case of pulmonary embolism (PE) caused by a carbon dioxide (CO2) blower during off-pump coronary artery bypass grafting (OPCAB). When the anastomosis of the right internal thoracic artery to left anterior descending artery was performed, the operator tore the right ventricle outflow track (RVOT) that was adjacent to the left anterior descending artery. Immediately after the anastomosis and repair of the torn RVOT with CO2 blower, the systolic pulmonary artery pressure (PAP) increased from 28 to 64 mmHg, and end-tidal CO2 decreased from 32 to 12 mmHg. Because transesophageal echocardiograph (TEE) showed numerous gas bubbles in the main pulmonary artery, we diagnosed PE caused by invasion of CO2 gas bubbles via the torn RVOT. Although a CO2 blower is useful to enhance visualization of the anastomosis during OPCAB, it should not be used for the venous system because it may cause CO2 embolism.

[Anesthetic management of cesarean section in a patient with severe obesity].

A 35-year-old pregnant woman (weight, 129.5 kg; height, 156 cm; 37 weeks of pregnancy) with a body mass index of 53 was scheduled for a cesarean section. It was thought that epidural or spinal anesthesia might result in complications due to her severe obesity. It was therefore decided to use general anesthesia following awake intubation. Her baby was delivered, and her Apgar scores at 1 and 5 minutes after delivery were 8 and 9 points, respectively. During surgery, she developed hypoxia due to upper shift of the diaphragm. After surgery, she was extubated after improvement of her oxygenation under spontaneous breathing. This case demonstrates that difficulties may be encountered during anesthetic management of a severely obese patient undergoing cesarean section.

[Anesthetic management for a patient with Charcot-Marie-Tooth disease using propofol and nitrous oxide].

A 65-year-old woman who had been diagnosed as having Charcot-Marie-Tooth disease (CMTD) 8 years ago and was scheduled to undergo excision of a spinal tumor in the prone position. General anesthesia using propofol was selected as the anesthetic method in order to avoid possible occurrence of malignant hyperthermia due to inhalation anesthetics. The patient was given 80 mg of propofol for anesthetic induction, and then propofol was infused at a rate of 4-5 mg.kg-1.h-1 with intermittent administration of fentanyl (total dose of 0.25 mg) for anesthetic maintenance. Vecuronium 4 mg was injected for intratracheal intubation, and then vecuronium 1 mg was injected at 50 min intervals. The operation proceeded uneventfully. The necessary time for anesthesia was over 460 minutes. There was no delay in wakening, and the patient experienced no problems in the postoperative course. Intravenous anesthesia using propofol is thought to be a safe and effective method of anesthesia for patients with CMTD.

Respiratory and cardiovascular effects of fentanyl during propofol-induced sedation under spinal anesthesia.

PURPOSE: To determine whether fentanyl augments respiratory and cardiovascular problems during propofol-induced sedation, we investigated the effects of propofol and fentanyl on respiratory and hemodynamic profiles in 30 female patients under spinal anesthesia, administering oxygen via face mask. METHODS: After spinal anesthesia, 20 patients were sedated with propofol (0.5 mg·kg-1 bolus, 3 mg·kg-1·h-1), followed by administration of either 2 µg·kg-1 fentanyl in group PF or normal saline in group P, whereas another 10 patients (group F) received 2 µg·kg-1 fentanyl without propofol. We measured heart rate, mean arterial pressure, end-tidal carbon dioxide tension, and respiratory rate before and after treatment. We also evaluated apnea, arterial oxygen desaturation, and airway obstruction. RESULTS: Mean arterial pressure was significantly lower in group P and PF than in group F. However, there were comparable changes in heart rate in the three groups. The combination of fentanyl and propofol decreased respiratory rate and increased end-tidal carbon dioxide tension more than fentanyl or propofol alone. Although apnea occurred in groups F and PF, arterial oxygen desaturation did not occur in any of the groups. CONCLUSION: The combination of fentanyl and propofol augmented the risks of respiratory depression and apnea compared with the use of fentanyl or propofol alone.

Effects of reduction of carrier gas flow rate on sevoflurane and isoflurane consumption and costs.

PURPOSE: To evaluate whether sevoflurane and isoflurane consumption would be actually halved by halving the carrier gas flow rate, as predicted by a theoretical model, we measured the consumed volume of liquid sevoflurane and isoflurane and total costs of anesthetic gas at carrier gas flow rates of 3 and 61·min-1. METHODS: Eighty patients of ASA physical status I or II were randomly assigned to one of four groups: sevoflurane at 3 or 61·min-1 and isoflurane at 3 or 61·min-1. Anesthesia was induced with thiamylal and maintained with sevoflurane or isoflurane, as well as with nitrous oxide in oxygen. The consumption of sevoflurane and isoflurane was measured by weighing the bottle of liquid agent, which was greater in the groups receiving 61·min-1 gas than in those receiving 31·min-1. RESULTS: Halving the carrier gas flow rate reduced the consumption of sevoflurane by 41.8% and that of isoflurane by 52.6%. It also reduced the total cost by 44.3% for sevoflurane and 49.2% for isoflurane. CONCLUSION: Halving the carrier gas flow rates halved the consumption of isoflurane but not of sevoflurane, indicating that factors other than carrier gas flow rates are involved in determining consumption in the clinical setting.