Hereditary Neuropathy with Liability to Pressure Palsy and Vocal Cord Paralysis After Pulmonary Lobectomy: A Case Report.

Hereditary neuropathy with liability to pressure palsy (HNPP) is a rare peripheral neurological disorder that manifests with increased sensitivity to pressure. In people with this disorder, the peripheral nerves are unusually sensitive to pressure. Minor trauma or compression causing paralysis in the extremities is a hallmark of this disorder. Ensuring there is no pressure on the extremities is recommended as a preventive measure. We describe for the first time, postoperative vocal cord paralysis in a patient with HNPP due to left recurrent laryngeal nerve palsy. Anesthesiologists and surgeons should be aware of this possible complication in patients with HNPP.

General anesthesia for cesarean section in a pregnant woman with systemic vascular malformation: a case report.

BACKGROUND: Vascular malformations are composed of morphologically abnormal vascular tissue, and when located in the head and neck region, they can make it difficult to secure the airway during general anesthesia. CASE PRESENTATION: A 28-year-old pregnant woman with vascular malformations in the pharynx was scheduled to undergo a cesarean section, for which spinal anesthesia was initially chosen. However, after magnetic resonance imaging results revealed the presence of multiple vascular malformations in the lumbar multifidus muscles, spinal anesthesia was considered to be of high risk. Thus, the patient was subjected to general anesthesia tracheal intubation under sedation, and the course of the surgery was without complications. CONCLUSIONS: Because the pathophysiology and clinical sequelae of vascular malformations may be involved in complications, thorough presurgical evaluation of the patient's physical condition and careful anesthesia planning should be done.

Inadvertent catheter misplacement into the subclavian artery during ultrasound-guided internal jugular venous catheterization: a case report.

BACKGROUND: Ultrasound-guided central venous catheterization has become a standard procedure. However, mechanical complications are still reported. CASE PRESENTATION: An 85-year-old woman presented with coagulopathic bladder tamponade. Ultrasound-guided right internal jugular venous catheterization was planned because of difficult peripheral venous access. A guidewire was advanced through a needle inserted at the midpoint of the right carotid triangle. The guidewire was identified in the short axis, but not in the long-axis ultrasound view, leading to inadvertent insertion of the catheter into the right subclavian artery through the internal jugular vein. Stent graft insertion was performed for perforation closure. The patient exhibited no symptoms of cerebral ischemia following stent graft insertion. DISCUSSION: This case demonstrated that the needle-sticking site should not be placed close to the clavicle for ultrasound-guided internal jugular venous catheterization, as it may not confirm the position of guidewire in the long-axis ultrasound view.

Ultrasound-Guided Glossopharyngeal Nerve Block for an Awake Intubation in a Patient Predicted to Have a Difficult Airway: A Case Report.

A peripheral nerve block may be used to improve patient tolerance of awake intubation. During an awake intubation, the glossopharyngeal, superior laryngeal, and recurrent laryngeal nerves can mediate discomfort, pain, cough, glottic closure, and gag reflexes. We describe the use of ultrasound-guided superior laryngeal, recurrent laryngeal, and glossopharyngeal nerve blocks to facilitate awake intubation in a patient predicted to have a difficult airway. The glossopharyngeal nerve block was performed via the parapharyngeal space approach targeting the distal glossopharyngeal nerve. This procedure resulted in an uneventful awake intubation.

Airway ultrasound for patients anticipated to have a difficult airway: Perspective for personalized medicine.

Airway ultrasound allows for precise airway evaluation, particularly for assessing the difficult airway and the potential for front of neck access. Many studies have shown that identification of the cricothyroid membrane by airway ultrasound is more accurate than digital palpation. However, no reports to date have provided clinical evidence that ultrasound identification of the cricothyroid membrane increases the success rate of cricothyroidotomy. This is a narrative review which describes patients with difficult airways for whom airway ultrasound may have been useful for clinical decision making. The role of airway ultrasound for the evaluation of difficult airways is summarized and an approach to the use of ultrasound for airway management is proposed. The goal of this review is to present practical applications of airway ultrasound for patients predicted to have a difficult airway and who undergo cricothyroidotomy.

Near-infrared venous imaging may be more useful than ultrasound guidance for novices to obtain difficult peripheral venous access: A crossover simulation study.

BACKGROUND: Difficult peripheral venous access, especially in obese people, is challenging for novices. We conducted a randomized cross-over study to examine whether near-infrared venous imaging or ultrasound guidance is more useful for novice operators to obtain difficult peripheral venous access. METHODS: Medical students were recruited as participants. After receiving basic training using commercial simulators, participants were randomly assigned to obtain simulated venous access using a difficult venous access simulator with near-infrared venous imaging or ultrasound guidance in a randomized cross-over design. A difficult venous access simulator was newly developed with deep and narrow vessels to simulate an obese patient. The primary outcome measure of the study was the first-time success rate (%), and the secondary outcome measures included procedure time (seconds) and the number of 3 consecutive successful attempts, to represent proficiency with the procedure. Pearson chi-square test, the Wilcoxon signed-rank test, and generalized estimating equations were used for statistical analysis. RESULTS: Forty-one medical students with no experience performing peripheral venous access were enrolled in this study. The rate of successful first attempts did not differ between the 2 groups (70% for near-infrared; 65% for ultrasound guidance; P = .64). The duration of the procedure for the first attempt was significantly shorter using near-infrared imaging (median: 14; interquartile range: 12-19) compared to ultrasound guidance (median 46; interquartile range: 26-52; P = .007). The number of attempts until 3 consecutive successes was not significantly different comparing the 2 approaches (near-infrared: 3 (3, 7.25), ultrasound guidance: 3 (3, 6.25), P = .63). CONCLUSION: There was no difference in success rate of first-time attempts or acquiring proficiency for the 2 methods. However, duration of the first attempt was significantly shorter with near-infrared imaging than with ultrasound guidance. Near-infrared imaging may require less training than ultrasound guidance. Near-infrared venous imaging may be useful for novices to obtain difficult peripheral venous access in obese patients.

Use of a photoacoustic needle improves needle tip recognition in a video recording of simulated ultrasound-guided vascular access: A pilot study.

BACKGROUND: We developed a novel photoacoustic needle, which emits ultrasound produced by the photoacoustic effect. This study focused on the most common "pitfall" associated with placement during ultrasound-guided vascular access, which is misidentification of the needle tip. METHODS: The study was conducted as a prospective cohort study using a questionnaire. The authors intentionally created two successful and one failed ultrasound-guided central venous catheterization videos using the photoacoustic needle on a simulator. Each of these three videos was then split into two movies for viewing, one with standard ultrasound images only and the second including the images from the photoacoustic needle, for a total of six movies. RESULTS: Participants who were 18 anesthesiologists, 12 residents, and 10 medical students, watched each of the six movies and completed a survey whether the puncture was successful or not. In the results, there was a significant difference in the percentage of correct answers whether the movie depicted successful or failed puncture with and without the photoacoustic ultrasound (p = 0.0001). CONCLUSION: The novel photoacoustic needle improved the ability to identify the needle tip on recorded videos. It may have efficacy to prevent serious mechanical complication during the ultrasound-guided vascular access in clinical practice.

A web-based self-learning system for ultrasound-guided vascular access.

Ultrasound-guided vascular access is practiced widely. Optimal educational methods have not yet been established. We hypothesized that a step-by-step web-based learning system is effective for self-learning. In this study, we examined the potential of this system as a self-learning tool. This was an observational study at a single institution. Participants included residents, who were self-educated through the web-based system. Skill proficiency was measured after self-learning. The primary outcome was the extent to which self-learning enabled residents to acquire proficiency in the basic skills of ultrasound-guided vascular access: needle visualization, hand-eye coordination, and avoiding posterior wall penetration. A secondary outcome was the time required to achieve proficiency. Thirty-nine residents were enrolled in this study. Eleven residents (28%) passed the first skill assessment test. There was no significant difference in the number of days that the web-based system was accessed, the total number of screen views, or the total learning time between participants who passed and those who failed the first test. Skill assessment scores between those who passed and those who failed the first test were different, especially the score for hand-eye coordination, and the number of posterior wall penetrations. Self-learning with a web-based system enabled 28% of residents to pass the first skill assessment test. The remaining 72% failed the first skill assessment test but continued to learn using the web-based system and eventually passed the test. Hence, the web-based system needed formative testing to function as a self-learning system. Simulation education for vascular access is expected to increase in educational content and methods. Self-learning through a web-based learning system is a leading candidate for this growth.

Risk factors associated with increased incidences of catheter-related bloodstream infection.

We have implemented several preventive measures to reduce central line-associated bloodstream infection (CLABSI) in the general intensive care unit (ICU) of a university hospital in Japan. Here, we analyzed the factors associated with CLABSI in patients with central venous catheter (CVC) insertions and evaluated the effects of our implemented preventive measures. From July 2013 to June 2018, data was collected from the medical records of 1472 patients with 1635 CVC insertions, including age, sex, Acute Physiology and Chronic Health Evaluation II (APACHE II) score, duration of ICU stay, duration of catheter insertion, insertion site, and mechanical ventilation status. During weekly conferences, a surveillance team comprising intensive care and infection control doctors and nurses determined the patients' CLABSI status. The analyzed factors were compared between CLABSI and central line patients without bloodstream infection. Multivariate analysis revealed three factors associated with CLABSI. Adjusted odds ratios with 95% confidence intervals were as follows: duration of ICU stay, 1.032 (1.019-1.044); duration of catheter insertion, 1.041 (1.015-1.066); and APACHE II score, 1.051 (1.000-1.105). The prominent risk factors were associated with the severity of the initial condition and exacerbation of the clinical condition of the patients during their stays in the ICU. Further strategies to reduce CLABSI must be developed.

Bleeding After Central Venous Catheter Placement in a Patient With Undiagnosed Acquired Hemophilia A: A Case Report.

Acquired hemophilia A is a rare condition caused by autoantibodies against endogenous coagulation factor VIII, which results in spontaneous bleeding. Workup of a patient with difficult hemostasis after removing and placing a central venous catheter led to the diagnosis of acquired hemophilia A. A 64-year-old man was transferred with an intramuscular right thigh mass. Initial biopsy at an outside facility showed degenerated muscle and coagula and he was transferred for incisional biopsy and definitive treatment. The patient had difficult venous access, and a right internal jugular venous catheter was placed. The catheter insertion site showed slow continuous bleeding. Achieving adequate hemostasis after removing the catheter was difficult, and a hematoma formed after the placement of an infraclavicular axillary venous catheter under ultrasound guidance. Coagulation studies revealed a prolonged activated partial thromboplastin time at 96 seconds. The patient was then diagnosed with acquired hemophilia A by enzyme-linked immunosorbent assay using anti-factor VIII antibodies. Even if ultrasound-guided central venous catheterization is performed carefully, bleeding may occur in some patients, suggesting the possibility of coagulopathy. Decision-making for performing central venous catheterization requires extensive knowledge of coagulopathies to understand the causes of bleeding complications.

Formalin-free soft embalming of human cadavers using N-vinyl-2-pyrrolidone: perspectives for cadaver surgical training and medical device development.

The traditional apprenticeship approach to surgical skill education for young surgeons has drastically changed to more systematic surgical training using cadavers. Cadavers fixed with formalin are not suitable for surgical training because of their associated health hazards and overhardening. Recently, we established a formalin-free soft preservation method for human cadavers using N-vinyl-2-pyrrolidone. Since 2012, 61 cadavers have been embalmed with pyrrolidone in our institution. Tissues of pyrrolidone-embalmed cadavers are soft and pliable, and their bodies can be preserved for as long as 37 months without any signs of corruption. In this review, we introduce our recent attempts to apply pyrrolidone-embalmed cadavers in surgical and medical procedure training, including endotracheal intubation, motion physiology of the vocal folds, laparoscopic surgery, endoscopic skull base surgery, and development of novel medical devices. Future research perspectives on pyrrolidone embalming are discussed.

Ultrasound-guided rectus sheath block for anterior cutaneous nerve entrapment syndrome after laparoscopic surgery: A case report.

BACKGROUND: Anterior cutaneous nerve entrapment syndrome is defined as abdominal pain due to entrapped intercostal nerves. This is the first report of a patient successfully treated for anterior cutaneous nerve entrapment syndrome after laparoscopic surgery with an ultrasound-guided rectus sheath block. The rectus sheath block physically lysed adhesions and relieved pain from anterior cutaneous nerve entrapment syndrome. CASE SUMMARY: The patient is a 44-year-old man who presented with severe left upper abdominal pain at an operative scar one month after laparoscopic ulcer repair. Diagnosis and treatment were performed using an ultrasound-guided rectus sheath block with 0.1% lidocaine 20 mL. The pain was relieved after the block. The diagnosis was anterior cutaneous nerve entrapment syndrome. Rectus sheath block may be effective for patients with anterior cutaneous nerve entrapment syndrome. CONCLUSION: Ultrasound-guided rectus sheath block is a promising treatment modality for patients with postoperative anterior cutaneous nerve entrapment syndrome due to adhesions.

A novel system for teaching the in-plane vascular access technique: A simulation study.

ABSTRACT: The long-axis in-plane approach is amenable to ultrasound-guided central venous catheterization. However, the long-axis in-plane approach is considered difficult to learn because the needle should remain visible in the ultrasound beam during the procedure. We developed a novel competency-based modular system to acquire the skills for the long-axis in-plane approach. The purpose of this study is to evaluate the efficacy of this system.The study was approved by the local ethics committee. Participants performed ultrasound guided venous catheterization (pre-test), attended a 2-hour hands-on session with the teaching system and were then evaluated again (posttest). The teaching system is a simulator device consisting of an ultrasound probe, a simulated vessel, a needle, and an endoscope connected to a computer to visualize the image inside the simulated vessel. The success rate, visualization of the needle tip, and puncture accuracy were measured before and after training. The puncture accuracy was determined by evaluating the distance of the needle tip and needle shaft from the center of a simulated vessel. Primary outcomes were the success rate and the puncture accuracy. The secondary outcome was needle tip visualization. McNemar test was used to analyze success rate and needle tip visualization. Tukey test was used to analyze puncture accuracy. A P value <.05 was considered statistically significant.Forty-seven participants were enrolled in this study. The success rate was significantly increased (pre-test 79%, posttest 94%, P = .04). Ultrasound images from 42 participants were analyzed for puncture accuracy. Puncture accuracy significantly increased for needle tip distance (P = .03), but not shaft distance (P = .1). The needle tip visualization was significantly improved (P = .02).A novel competency-based teaching system was constructed in a step-by-step manner, which improved needle tip visualization and puncture accuracy, with a higher success rate.

Outcomes of Simulation-Based Education for Vascular Access: A Systematic Review and Meta-Analysis.

Simulation training is key to developing skills for vascular access. However, the efficacy of simulation-based education remains unclear. We conducted a well-designed and updated systematic review to investigate the efficacy of these programs. Randomized controlled trials (RCTs) were researched using the following databases from inception until July 26, 2020: MEDLINE, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), Education Resources Information Center (ERIC), Cumulative Index to Nursing and Allied Health Literature (CINAHL), ClinicalTrials.gov, and International Clinical Trials Registry Platform (ICTRP). RCTs included patients undergoing insertion of central venous catheters (CVCs), peripherally inserted central catheters (PICCs), and radial arterial catheters. We compared the group that received simulation training with the group that received traditional training. We also assessed the success rate, adverse events, and first-attempt success using a random-effects meta-analysis. The protocol was registered at Protocols.io (dx.doi.org/10.17504/protocols.io.biu6keze). Seven RCTs (n=866) were evaluated. The meta-analysis showed that simulation-based education increased the overall success rate compared with traditional education (risk ratio: 1.08, 95% CI: 1.03 to 1.13; six RCTs; 840 participants; I2=0%; moderate certainty of evidence). However, it was unclear whether or not simulation-based education had an effect on reducing adverse events when compared with traditional education (risk ratio: 1.00, 95% CI: 0.63 to 1.58; five studies; 750 participants; I2=37%; very low certainty of evidence) or on raising first-attempt success rates (risk ratio: 1.34, 95% CI: 0.93 to 1.94; three studies; 244 participants; I2=59%; very low certainty of evidence). Simulation-based education may help develop skills for successful vascular access. However, it is unclear whether simulation-based education actually reduces the incidence of adverse events. Fine control of the needle tip is probably necessary to prevent adverse events. Simulation-based education might be required in the future for outcome-based task training.

Photoacoustic needle improves needle tip visibility during deep peripheral nerve block.

We developed a novel technology using the photoacoustic effect that improve needle tip visibility. We evaluated whether this technology improves needle tip visibility when performing a deep peripheral nerve block in a cadaver model. A photoacoustic needle was developed using a conventional echogenic needle with an intraluminal optical fiber. A pulsed laser sends light from a source through the fiber, which is converted to ultrasound at the needle tip using the photoacoustic effect. A nerve block expert performed deep nerve blocks using the photoacoustic needle and the ultrasound views recorded, with or without photoacoustic ultrasound at the needle tip. Needle tip visibility was evaluated by questionnaire (Likert scale 1: very poor, 5: very good) completed by anesthesiologists evaluating recorded images. The score was presented as median [first quartile, third quartile]. Statistical analysis was performed using the Wilcoxon matched-pairs signed rank test. The scores of needle tip visibility with photoacoustic ultrasound from the needle tip (4.3 [4.0, 4.5]) was significantly higher than that without photoacoustic ultrasound (3.5 [3.2, 3.8]) (p < 0.01). Ultrasound emitted at the needle tip using the photoacoustic effect improves needle tip visibility during deep peripheral nerve blocks.Clinical trial number University Hospital Medical Information Network Center Clinical Trials Registration System (UMIN000036974).

Massive Leak in CO2 Absorber of Perseus A500 Did Not Inhibit Mechanical Ventilation but Manual Bag Ventilation: A Case Report With Experimental Reproduction.

Massive leaks in the anesthesia circuit may cause intraoperative hypoventilation and awareness; we experienced this with a disposable CO2 absorber in Perseus A500, which uses turbine ventilation to create positive-pressure ventilation. Consequently, manual ventilation was rendered impossible. During prolonged surgeries, CO2 absorbers may be replaced by a new one. In our case, the replacement had an occult leak. Absorbers should be checked before the exchange, and the econometer or reservoir bag's filling state should be monitored. Anesthesia providers should know an anesthesia machine's dynamics and breathing system to provide appropriate management of such a leak.

Shallow-angle needle guide for ultrasound-guided internal jugular venous catheterization: A randomized controlled crossover simulation study (CONSORT).

BACKGROUND: Needle guides for ultrasound-guided internal jugular venous catheterization facilitate successful cannulation. The ability of a needle guide to prevent a posterior vein wall injury which may secondarily induce lethal complications, is unknown. Previous studies showed that a shallow angle of approach may reduce the incidence of posterior wall injuries. We developed a novel needle guide with a shallow angle of approach for ultrasound-guided venous catheterization and examined whether this needle guide reduces the incidence of posterior wall injuries compared to a conventional needle guide and free-hand placement in a simulated vein. METHODS: This study was a randomized crossover-controlled trial. The primary outcome was the rate of posterior vein wall injuries. Participants had a didactic lecture about three ultrasound-guided techniques using the short-axis out-of-plane approach, including free-hand (P-free), a commercial needle guide (P-com), and a novel needle guide (P-sha). The view inside a simulated vein was recorded during venipuncture. RESULTS: Thirty-five residents participated in this study. Posterior vein wall injuries occurred in 66% using P-free, 60% using P-com, and 0% using P-sha (p< 0.01). There was no significant difference in the incidence of posterior vein wall injuries between P-free and P-com. CONCLUSIONS: Use of a shallow angle of approach needle guide resulted in a lower rate of posterior vein injuries during venipuncture of a simulated vein compared with other techniques using a steeper angle techniques.