Difficult airway management resources and capnography use in Japanese intensive care units: a nationwide cross-sectional study.

PURPOSE: The availability of difficult airway management (DAM) resources and the extent of capnometry use in Japanese intensive care units (ICUs) remained unclear. The purpose of this study was to clarify whether: (1) DAM resources were adequate, and (2) capnometry was routinely applied in Japanese ICUs. METHODS: This nationwide cross-sectional study was conducted from September 2015 to February 2016. All ICUs received a mailed questionnaire about their DAM resources and use of capnometry. Outcome measures were availability of: (1) 24-h in-house backup coverage; (2) a supraglottic airway device (SGA); (3) a dedicated DAM cart; and (4) surgical airway devices, and (5) routine use of capnometry to verify tube placement and for continuous monitoring of ventilator-dependent patients. The association between these outcomes and ICU type (academic, high-volume, closed, surgical) was also analyzed. RESULTS: Of the 289 ICUs, 196 (67.8 %) returned completed questionnaires. In-house backup coverage and surgical airway devices were highly available (89.3 and 95.9 %), but SGAs and dedicated DAM carts were not (60.2 and 60.7 %). The routine use of capnometry to confirm tube placement was reported by 55.6 % of the ICUs and was highest in closed ICUs (67.2 %, p = 0.03). The rate of continuous capnography monitoring was also 55.6 % and was highest in academic ICUs (64.5 %, p = 0.04). CONCLUSION: In Japanese ICUs, SGAs and dedicated DAM carts were less available, and capnometry was not universally applied either to confirm tube placement, or for continuous monitoring of ventilated patients. Our study revealed areas in need of improvement.

Are prehospital airway management resources compatible with difficult airway algorithms? A nationwide cross-sectional study of helicopter emergency medical services in Japan.

PURPOSE: Immediate access to the equipment required for difficult airway management (DAM) is vital. However, in Japan, data are scarce regarding the availability of DAM resources in prehospital settings. The purpose of this study was to determine whether Japanese helicopter emergency medical services (HEMS) are adequately equipped to comply with the DAM algorithms of Japanese and American professional anesthesiology societies. METHODS: This nationwide cross-sectional study was conducted in May 2015. Base hospitals of HEMS were mailed a questionnaire about their airway management equipment and back-up personnel. Outcome measures were (1) call for help, (2) supraglottic airway device (SGA) insertion, (3) verification of tube placement using capnometry, and (4) the establishment of surgical airways, all of which have been endorsed in various airway management guidelines. The criteria defining feasibility were the availability of (1) more than one physician, (2) SGA, (3) capnometry, and (4) a surgical airway device in the prehospital setting. RESULTS: Of the 45 HEMS base hospitals questioned, 42 (93.3 %) returned completed questionnaires. A surgical airway was practicable by all HEMS. However, in the prehospital setting, back-up assistance was available in 14.3 %, SGA in 16.7 %, and capnometry in 66.7 %. No HEMS was capable of all four steps. CONCLUSION: In Japan, compliance with standard airway management algorithms in prehospital settings remains difficult because of the limited availability of alternative ventilation equipment and back-up personnel. Prehospital health care providers need to consider the risks and benefits of performing endotracheal intubation in environments not conducive to the success of this procedure.

Massive subcutaneous emphysema, bilateral pneumothorax, pneumomediastinum, pneumoperitoneum, pneumoretroperitoneum, and pneumoscrotum after multiple direct laryngoscopies: an autopsy case report.

Multiple endotracheal intubation (ETI) attempts increase the risk of airway-related adverse events. However, little is known about autopsy findings after severe ETI-related complications. We present the detailed pathological findings in a patient with severe ETI-related complications. A 77-year-old obese male suffered cardiopulmonary arrest after choking at a rehabilitation facility. Spontaneous circulation returned after chest compressions and foreign-body removal. After multiple failed direct laryngoscopies, the patient was transferred to our hospital. He had massive subcutaneous emphysema, bilateral pneumothorax, pneumomediastinum, pneumoperitoneum, pneumoretroperitoneum, and pneumoscrotum on admission, and died from hypoxic brain injury 15 h later. Autopsy revealed severe oropharyngeal, laryngeal, and left lung lower lobe injury. The likely mechanisms of diffuse emphysema were (1) oropharyngeal injury associated with multiple ETI attempts and excessive ventilation pressures and (2) left lung lower lobe injury associated with chest compressions and other resuscitative procedures. Multiple laryngoscopies can cause severe upper-airway injury, worsen respiratory status, and make ETI more difficult-a vicious circle that can be prevented by limiting ETI attempts. This is particularly important in unfavorable environments, in which backup devices and personnel are not easily obtained. The pathological findings in our patient caution against repeated attempts at ETI during resuscitation.

Emergency endotracheal intubation-related adverse events in bronchial asthma exacerbation: can anesthesiologists attenuate the risk?

PURPOSE: Airway management in severe bronchial asthma exacerbation (BAE) carries very high risk and should be performed by experienced providers. However, no objective data are available on the association between the laryngoscopist's specialty and endotracheal intubation (ETI)-related adverse events in patients with severe bronchial asthma. In this paper, we compare emergency ETI-related adverse events in patients with severe BAE between anesthesiologists and other specialists. METHODS: This historical cohort study was conducted at a Japanese teaching hospital. We analyzed all BAE patients who underwent ETI in our emergency department from January 2002 to January 2014. Primary exposure was the specialty of the first laryngoscopist (anesthesiologist vs. other specialist). The primary outcome measure was the occurrence of an ETI-related adverse event, including severe bronchospasm after laryngoscopy, hypoxemia, regurgitation, unrecognized esophageal intubation, and ventricular tachycardia. RESULTS: Of 39 patients, 21 (53.8 %) were intubated by an anesthesiologist and 18 (46.2 %) by other specialists. Crude analysis revealed that ETI performed by an anesthesiologist was significantly associated with attenuated risk of ETI-related adverse events [odds ratio (OR) 0.090, 95 % confidence interval (CI) 0.020-0.41, p = 0.001]. The benefit of attenuated risk remained significant after adjusting for potential confounders, including Glasgow Coma Score, age, and use of a neuromuscular blocking agent (OR 0.058, 95 % CI 0.010-0.35, p = 0.0020). CONCLUSIONS: Anesthesiologist as first exposure was independently associated with attenuated risk of ETI-related adverse events in patients with severe BAE. The skill and knowledge of anesthesiologists should be applied to high-risk airway management whenever possible.

Is preoperative period associated with severity and unexpected death of injured patients needing emergency trauma surgery?

PURPOSE: Early operative control of hemorrhage is the key to saving the lives of severe trauma patients. We investigated whether emergency room (ER) stay time [time from the ER to the operating room (OR)] is associated with trauma severity and unexpected trauma death [Trauma and Injury Severity Score (TRISS) method-based probability of survival (Ps) ≥0.5 but died] of injured patients needing emergency trauma surgery. METHODS: We performed a retrospective review of all trauma patients requiring emergency surgery and all patients with pelvic fractures requiring transcatheter arterial embolization at our hospital from January 2002 to December 2012. We analyzed the relationships among injury severity on ER admission [Injury Severity Score (ISS); Revised Trauma Score (RTS); Ps; Shock Index (SI); American Society of Anesthesiologists Physical Status (ASA-PS)]; mortality rate; unexpected trauma death rate; and ER stay time. RESULTS: ER stay times were significantly shorter for patients with life-threatening conditions [RTS <6.0 (p < 0.01), Ps <0.5 (p < 0.001), SI ≥1.0 (p < 0.01), and ASA-PS ≥4E (p < 0.001)]. In particular, ER stay time was inversely related to injury severity up to 120 min. The risk of unexpected trauma death significantly increased as ER stay time increased over 90 min (p < 0.01). CONCLUSIONS: Our results suggest that all medical staff should work together effectively on high-risk patients in the ER, bringing them immediately to the OR according to their level of risk. If injured patients need emergency trauma surgery, ER stay times should be kept as short as possible to reduce unexpected trauma death.

Development of takotsubo cardiomyopathy with severe pulmonary edema before a cesarean section.

Takotsubo cardiomyopathy is an acute syndrome involving apical ballooning and consequent dysfunction of the left ventricle. Most cases of left ventricular dysfunction resolve within 1 month. We present the case of a 40-year-old woman who developed severe heart failure caused by takotsubo cardiomyopathy with severe left ventricular dysfunction during the perinatal period. Because of the presence of multiple myomas, she was scheduled to undergo a cesarean section under general anesthesia. However, after induction of general anesthesia, she had to be awakened because of the presence of a difficult airway. Because she exhibited insufficient oxygenation, she was transferred to the emergency center. Upon hospital admission, she expectorated large amounts of pink sputum, indicating severe pulmonary edema. Cesarean section was performed immediately. Echocardiography revealed severe left ventricular dysfunction. Full recovery of cardiac function required almost 1 month, after which she was discharged from the hospital without further complications. This is the first reported case of takotsubo cardiomyopathy induced by a failed intubation during a scheduled cesarean section. Takotsubo cardiomyopathy usually shows a good prognosis, but if this myopathy develops during the perinatal period, it can worsen because of excessive preload following the termination of fetoplacental circulation.

Emergency/disaster medical support in the restoration project for the Fukushima nuclear power plant accident.

The Fukushima Daiichi Nuclear Power Plant (1F) suffered a series of radiation accidents after the Great East Japan Earthquake on 11 March 2011. In a situation where halting or delaying restoration work was thought to translate directly into a very serious risk for the entire country, it was of the utmost importance to strengthen the emergency and disaster medical system in addition to radiation emergency medical care for staff at the frontlines working in an environment that posed a risk of radiation exposure and a large-scale secondary disaster. The Japanese Association for Acute Medicine (JAAM) launched the 'Emergency Task Force on the Fukushima Nuclear Power Plant Accident' and sent physicians to the local response headquarters. Thirty-four physicians were dispatched as disaster medical advisors, response guidelines in the event of multitudinous injury victims were created and revised and, along with execution of drills, coordination and advice was given on transport of patients. Forty-nine physicians acted as directing physicians, taking on the tasks of triage, initial treatment and decontamination. A total of 261 patients were attended to by the dispatched physicians. None of the eight patients with external contamination developed acute radiation syndrome. In an environment where the collaboration between organisations in the framework of a vertically bound government and multiple agencies and institutions was certainly not seamless, the participation of the JAAM as the medical academic organisation in the local system presented the opportunity to laterally integrate the physicians affiliated with the respective organisations from the perspective of specialisation.

Surgical airways for trauma patients in an emergency surgical setting: 11 years' experience at a teaching hospital in Japan.

PURPOSE: Airway management of trauma patients during emergency surgeries can be very difficult and presents a challenge for anesthesiologists. Difficult airways are associated with emergency surgical airways (ESA), but little is known about ESA in the operating room. We conducted this study to clarify the present use of ESA for trauma patients in emergency surgery settings. METHODS: We performed a retrospective review of all trauma patients requiring emergency surgery under general anesthesia at our hospital from January 2002 to December 2012, focusing on ESA. RESULTS: During the study period, 15,654 trauma patients were treated at our hospital, of whom 554 (3.5 %) required emergency surgery. Four of these patients (0.72 %) received ESA as definitive airway management. Two patients with severe facial injury and distorted upper airways and 1 patient with penetrating neck trauma received open standard tracheostomy (OST). These three patients received OST as the initial approach to intubation. A fourth OST was performed after several unsuccessful attempts at endotracheal intubation. No cases were classified as "cannot ventilate, cannot intubate" (CVCI), and there were no complications associated with ESA. All cases had good outcomes. Statistical analysis revealed that patients with severe facial trauma (Abbreviated Injury Scale ≥3) received ESA at a significantly higher rate than others (p = 0.015, odds ratio 14.1). CONCLUSION: One of the most important functions of anesthesiologists is risk management. We should recognize risks that can cause CVCI situations, and make proper clinical decisions, including providing ESA, to assure patient safety.

Activation intervals for a helicopter emergency medical service in Japan.

INTRODUCTION: Prehospital time is crucial for treating acute disease; therefore, it is important to activate helicopter emergency medical services (HEMS) promptly. We investigated the differences in the activation intervals (the time elapsed from receiving the emergency call to the time of HEMS request) under various conditions to evaluate the current status of HEMS-related prehospital triage in Japan. METHODS: We retrospectively investigated activation intervals under exogenous (trauma, n = 553; intoxication, n = 56; and burns, n = 32) and endogenous conditions (acute coronary syndrome [ACS], n = 47; and stroke, n = 173) between January 31, 2008, and January 31, 2012, by reviewing flight records. RESULTS: Activation intervals were trauma (14.3 ± 11.5 min), intoxication (10.3 ± 8.6 min), burns (15.0 ± 13.1 min), ACS (17.9 ± 14.6 min), and stroke (19.1 ± 13.1 min). One-way analysis of variance showed a significant difference between exogenous and endogenous groups (P < .001). Post-hoc analysis using Tukey's honestly significant difference test showed significant differences between ACS and intoxication (P < .05), stroke and intoxication (P < .001), and stroke and trauma (P < .001). CONCLUSIONS: Endogenous conditions had longer activation intervals, which may reflect a lack of mechanisms assessing their severity. We are considering developing new triage criteria for dispatchers.

[Case of iodism complicated with severe airway stenosis due to pharyngolaryngeal edema].

A 22-year-old man was admitted to our hospital with dilute iodine tincture poisoning. He had ingested 150 mL in a suicide attempt. On arrival, he was in need of urgent airway management as he was repeatedly vomiting. Although we had difficulty with endotracheal intubation because of remarkable pharyngolaryngeal mucosal edema induced by dilute iodine tincture, we managed to secure the airway. On the 2nd day, laryngoscope showed severe mucosal erosion from the upper to middle pharynx and epiglottis. On the 4th day, we performed a tracheoctomy in anticipation of prolonged airway management. On the 16th day, laryngoscopy showed improvement in each of the 2nd day findings. On the 30th day, the patient was transferred to a psychiatric hospital. Generally, iodine poisoning induces multiple organ disorders and there have been several reports describing iatrogenic iodine poisoning. However, cases of severe airway stenosis due to ingestion of iodine are very rare. Presently, members of the public can easily purchase dilute iodine tincture in Japan, therefore emergency medical personnel should be aware of iodine poisoning as a method of suicide attempt.

Investigation of final destination hospitals for patients in helicopter emergency medical services (doctor-helicopter) in Fukushima Prefecture.

PURPOSE: In using an emergency medical service helicopter with an emergency medicine doctor on board (doctor-helicopter), transporting all patients to the University Hospital (base hospital for the helicopter) could cause a chronic bed shortage at the University Hospital. It is also disadvantageous for patients from distant areas. We investigated whether appropriate hospital selections are being carried out in Fukushima Prefecture. METHODS: The subjects of the study were patients who were transported by doctor-helicopter since the services started. We investigated the medical conditions of patients at emergency scenes, whether they were transported to a hospital inside or outside the region, the means of transportation, and the final destination hospital. RESULTS: There were 450 flights, of which 295 were to emergency scenes, involving 307 patients. The majority were trauma patients (191 patients, 62.2%). The final destination hospital was the University Hospital for 104 patients (33.9%); 99 patients (30.3%) were transported to three emergency and critical care medical centers (ECCMCs) in other regions. Most patients were transported to appropriate hospitals in the respective regions. The means of transportation from the emergency scene was by doctor-helicopter in the largest number of cases (223 patients, 72.6%), and the final destination hospital was ECCMCs in 81.6% of cases. CONCLUSION: Patients from emergency scenes are transported by doctor-helicopter to appropriate hospitals in the region, and hospitals in each region are cooperating with the doctor-helicopter operations.

Helicopter emergency medical services (doctor-helicopter) in Fukushima Prefecture: present state and problems.

The purpose of this study is to identify the problems in operating an emergency medical service helicopter with an emergency medicine doctor on board (doctor-helicopter) in Fukushima Prefecture, Japan, which covers wide regions and many rural areas. The study looked at the numbers of flights and patients during the 523 days since the start of the doctor-helicopter service at the Fukushima Medical University Hospital. The items investigated were: number of flights, number of helicopter dispatches per month, number of patients, the hospitals where patients were taken to, the fire department dispatch centers that requested the doctor-helicopter, and the number of times each doctor flew on the helicopter. There were 450 flights. When the service was started, there were a few flights, but they gradually increased. The majority of the flights were to emergency scenes (295), while 75 flights were interfacility transports of critically ill patients, 79 flights were cancelled after take-off, and one flight was for a disaster relief operation. The nature of requests differed greatly depending on the fire department dispatch center requesting the service. The majority of patients were trauma patients (62.2%). Stroke (8.5%) and acute coronary syndrome (5.2%) patients requiring emergency treatment were fewer than anticipated. The final destination hospitals were appropriate hospitals in the region. Because the number of flight doctors is small, the burden on individual doctors is large. A system for early on-site diagnosis and helicopter request by emergency rescue team is required to maintain a high quality of emergency care.

IL-13 attenuates early local CXCL2-dependent neutrophil recruitment for Candida albicans clearance during a severe murine systemic infection.

To investigate the role of IL-13 during a severe systemic Candida albicans infection, BALB/c control and IL-13-/- mice were examined for colony forming units (CFU) in the kidneys and survival days after intravenous infection. Proinflammatory mediators and cell recruitment into the tissue were measured by quantitative real-time PCR, a multiple ELISA system, and morphological cell differentiation. The IL-13-/- group exhibited a lower CFU number in the kidneys at 4 days and survived longer than the control mice, which was accompanied by significantly higher expression of C-X-C motif ligand 2 (CXCL2), IFN-γ, and polymorphonuclear neutrophils (PMNs) in the infected kidneys. By contrast, the expression of transforming growth factor ß (TGF-ß) and IL-17 A on day 10 were significantly higher in the control mice than in the IL-13-/- group. When using an intratracheal infection model, the IL-13-/- group recruited a greater number of PMNs in 6 h, with rapidly increased CXCL2 in the alveolar space. In vitro testing with cultured bone-marrow-derived cells demonstrated rapid CXCL2 mRNA upregulation at 3 h after contact with C. albicans, which decreased with recombinant IL-13 pretreatment, whereas rIL-13 retained TGF-ß upregulation. In a murine model of Candida systemic infection, preexistent IL-13 limits both the rapid CXCL2 elevation and PMN aggregation in the target organ to suppress inflammatory mediators, which also attenuates local pathogen clearance within four days.

Anesthetic Management of a Patient With Antimuscle-Specific Kinase Antibody-Positive Myasthenia Gravis Undergoing an Open Cholecystectomy: A Case Report.

Myasthenia gravis (MG) is an autoimmune disease characterized by the production of antibodies against the acetylcholine receptor, muscle-specific kinase (MuSK), or other proteins at the neuromuscular junction. MG with antibodies against MuSK (MuSK-MG) has been described recently. Here, we report the first case of anesthetic management of a patient with MuSK-MG undergoing an open cholecystectomy. In our case, propofol and remifentanil-based anesthesia were used for successful management without using muscle relaxants. Patients with MuSK-MG have predominantly ocular, bulbar, and respiratory symptoms that may increase the risk of aspiration. Anesthesiologists need to pay attention to perioperative respiratory failure and respiratory crisis.

EARLY STAGE RESPONSES OF INTENSIVE CARE UNITS DURING MAJOR DISASTERS: FROM THE EXPERIENCES OF THE GREAT EAST JAPAN EARTHQUAKE.

The present study investigated the role of intensive care units (ICU) during disasters, including the responses of our ICU following the Great East Japan Earthquake on March 11, 2011. Our ICU comprises 8 beds for postoperative inpatients and those with rapidly deteriorating conditions; 20 beds in an emergency unit for critically ill patients; and 17 beds for neonates. It is important to secure empty beds when a major disaster occurs, as was the case after the Great Hanshin Earthquake, due to the resulting large numbers of trauma patients. Therefore, each ICU section cooperated to ensure sufficient space for admissions following the Great East Japan Earthquake. However, unlike the Great Hanshin Earthquake, securing beds was ultimately unnecessary due to the nature of the recent disaster, which also consisted of a subsequent tsunami and nuclear accident. Therefore, air quality monitoring was required on this occasion due to the risk of environmental radioactive pollution from the nuclear disaster causing problems with artificial respiration management involving atmospheric air. The variability in damage arising during different disasters thus requires a flexible response from ICUs that handle seriously ill patients.

Polytetrafluoroethylene fume-induced pulmonary edema: a case report and review of the literature.

INTRODUCTION: Polytetrafluoroethylene is ubiquitous in materials commonly used in cooking and industrial applications. Overheated polytetrafluoroethylene can generate toxic fumes, inducing acute pulmonary edema in some cases. However, neither the etiology nor the radiological features of this condition have been determined. For clarification, we report an illustrative case, together with the first comprehensive literature review. CASE PRESENTATION: A previously healthy 35-year-old Japanese man who developed severe dyspnea presented to our hospital. He had left a polytetrafluoroethylene-coated pan on a gas-burning stove for 10 hours while unconscious. Upon admission, he was in severe respiratory distress. A chest computed tomographic scan showed massive bilateral patchy consolidations with ground-glass opacities and peripheral area sparing. A diagnosis of polytetrafluoroethylene fume-induced pulmonary edema was made. He was treated with non-invasive positive pressure ventilation and a neutrophil elastase inhibitor, which dramatically alleviated his symptoms and improved his oxygenation. He was discharged without sequelae on hospital day 11. A literature review was performed to survey all reported cases of polytetrafluoroethylene fume-induced pulmonary edema. We searched the PubMed, Embase, Web of Science and OvidSP databases for reports posted between the inception of the databases and 30 September 2014, as well as several Japanese databases (Ichushi Web, J-STAGE, Medical Online, and CiNii). Two radiologists independently interpreted all chest computed tomographic images. Eighteen relevant cases (including the presently reported case) were found. Our search revealed that (1) systemic inflammatory response syndrome was frequently accompanied by pulmonary edema, and (2) common computed tomography findings were bilateral ground-glass opacities, patchy consolidation and peripheral area sparing. Pathophysiological and radiological features were consistent with the exudative phase of acute respiratory distress syndrome. However, the contrast between the lesion and the spared peripheral area was striking and was distinguishable from the common radiological features of acute respiratory distress syndrome. CONCLUSION: The essential etiology of polytetrafluoroethylene fume-induced pulmonary edema seems to be increased pulmonary vascular permeability caused by an inflammatory response to the toxic fumes. The radiological findings that distinguish polytetrafluoroethylene fume-induced pulmonary edema can be bilateral ground-glass opacity or a patchy consolidation with clear sparing of the peripheral area.

The off-hour effect on trauma patients requiring subspecialty intervention at a community hospital in Japan: a retrospective cohort study.

BACKGROUND: Because most community hospitals in Japan do not maintain 24-h availability of in-house anesthesiologists, surgeons, and interventional radiologists, staffing dramatically declines during off hours. It is unclear whether, in such under-resourced hospitals, trauma patients presenting during off hours and requiring subspecialty intervention have worse outcomes than those who present during business hours. METHODS: This was a retrospective cohort study at a community hospital in Japan. Participants were all injured patients requiring emergency trauma surgery or transarterial embolization who presented from January 2002 to December 2013. We investigated whether outcomes of these patients differed between business hours (8:01 AM to 6:00 PM weekdays) and off hours (6:01 PM to 8:00 AM weekdays plus all weekend hours). The primary outcome measure was mortality rate, and the secondary outcome measures were duration of emergency room (ER) stay; unexpected death (death/probability of survival > 0.5); and adverse events occurring in the ER. We adjusted for potential confounders of age, sex, Injury Severity Score (ISS), Revised Trauma Score, presentation phase (2002-2005, 2006-2009, and 2010-2013), Charlson Comorbidity Index, and injury type (blunt or penetrating) using logistic regression models. RESULTS: Of the 805 patients included, 379 (47.1%) presented during business hours and 426 (52.9%) during off hours. Off-hours presentation was associated with longer ER stays for patients with systolic blood pressure < 90 mmHg on admission (p = 0.021), ISS >15 (p = 0.047), and pelvic fracture requiring transarterial embolization (p < 0.001). Off-hours presentation was also associated with increased risk of adverse events in the ER (odds ratio [OR] 1.7, 95% confidence interval [CI] 1.1-2.7, p = 0.020). After adjustment for confounders, an increased risk of adverse events (OR 1.6, 95% CI 1.1-2.7, p = 0.049) persisted, but no differences were detected in mortality (p = 0.80) and unexpected death (p = 0.44) between off hours and business hours. CONCLUSIONS: At a community hospital in Japan, presentation during off hours was associated with a longer ER stay for severely injured patients and increased risk of adverse events in the ER. However, these disadvantages did not impact mortality or unexpected outcome.