We analyzed the serious accidents reported by an anesthesia practice between 2012 and 2014 using the original SHELL model. The model classifies accidents based on a human（liveware）, environmental, hardware and software. A total of 53 incidents and accidents reported from 2012 to 2014 were drug administration in nine cases, epidural technique in nine cases, anesthesia procedure in eight cases, blood transfusion in five cases, circulatory failure in four cases, complications related to endotracheal intubation in four cases, patient position during surgery in three cases, sterile technique in one case, and non-specific causes in 10 cases. Based on the SHELL model, the serious accidents derived from human factors which include misunderstandings, a lack of clarified instructions, communication failures, as well as insufficient knowledge, skills, and/or experience. Some of the serious accidents were associated with protocol（software）, equipment（hardware）, and environmental factors.
Postoperative delirium has increased with the aging of the population. Postoperative delirium affects prognosis and is associated with the occurrence of complications and post-operative cognitive dysfunction. We developed a program to prevent postoperative delirium with the aim of early ambulation using a team approach. The program provides a summary of points to alleviate perioperative stress and facilitate rapid recovery after surgery. We explained the objectives of the program to attending physicians, ward staff, patients, and their families in order to gain their understanding and cooperation. While targeting orthopedic surgical patients aged 70 and older, we evaluated the severity of delirium on a 4-point scale from 0 to 3 and compared preoperative to postoperative changes in delirium scores before and after the introduction of the program. Cases that reached score 3（severe）decreased significantly after introducing the program, suggesting its usefulness.
Ultrasound-guided peripheral nerve block is regarded as safer than general, spinal or epidural anesthesia, since it does not block sympathetic nerves and depress respiratory function and hemodynamic stability. We successfully managed anesthesia using ultrasound-guided femoral, lateral-femoral cutaneous and sciatic nerve blocks, in combination with infiltration anesthesia and fentanyl injection in two elderly patients with femoral neck fracture who had respiratory and cardiac disorders.
An 83-year-old man developed syncope after sustaining a bone fracture. The results of tests were normal and joint surgery was performed under general anesthesia without complications. Plate removal surgery was planned under local anesthesia eight months later. During the procedure, syncope occurred followed by asystole（10 secs on ECG）. Because the findings of tests after syncope were normal, we believe that vagal reflex was the most probable cause. The patient also had an enlarged small intestine and abdominal wall hernia associated with previous abdominal surgeries, which might have had an important effect on the vagal reflex.
We experienced a case of severe bradycardia while inserting a nasogastric tube during general anesthesia. An 83-year-old man was diagnosed with an appendiceal tumor and underwent laparoscope-assisted colectomy. He had bilateral glaucoma and blindness on the right side. For general anesthesia, we used fentanyl 200 μg, propofol 50 mg, and rocuronium 40 mg and performed tracheal intubation. The patient suddenly developed severe bradycardia（heart rate：15 beats/min）during insertion of the nasogastric tube. We suspect that the trigemino-cardiac reflex caused bradycardia and recommend that clinicians be aware of this during anesthesia.
A tracheobronchial stent insertion was scheduled under general anesthesia in a 67-year-old man with a gastric tube-bronchial fistula after esophagectomy for cancer. Because the duration of apnea was expected to be long, we decided to use percutaneous cardiopulmonary support（PCPS）for gas exchange. The catheter insertion for PCPS was done under spinal anesthesia to eliminate pain during the procedure. Total intravenous anesthesia was performed after PCPS started, and the patient was intubated orally. When the Y-stent was inserted through a rigid bronchoscope, the patient had to be extubated. After extubation, oxygen saturation in his right hand dropped temporarily, whereas that in his left hand remained at 100%. This discrepancy occurred because arterial blood that was not fully oxygenated circulated in his right limb due to cardiac output rather than PCPS. We could minimize this desaturation in the right limb by ventilating the right lung through intubation into the right main trachea. We were able to manage this patient without critical accidents through detailed planning and special attention under PCPS.
It is well known that effectiveness of analgesics is strongly affected by placebo and nocebo effects. In particular, patient’s expectation and anxiety regarding analgesics when they are first recommended by a physician is thought to be important for the expression of these two phenomenons. In this pilot study, we conducted a questionnaire survey to access the correlation between expectation and anxiety for a representative weak opioid anesthetic, tramadol. One hundred eight medical students were recruited for this survey. In order to simulate a clinical situation, the treatment explanation for tramadol was given to the subjects by a pain physician as usual for patients with chronic pain. After that, expectation and anxiety was evaluated using an 11-grade numerical scale. The results showed a positive correlation between the rating of subject’s expectation and anxiety（Spearman’s rank correlation：0.392）, indicating that both can progress together. Our findings suggest that it is difficult not only to increase expectance but also to decrease anxiety for newly presented analgesics stimulaneouly. Although it may be the ultimate achievement for the medical staffs to increase placebo effect and minimize nocebo effect in clinical settings, further study will be needed to assess this issue.
A 31-year-old woman underwent Cesarean section for a low-lying placenta under combined spinal and epidural anesthesia. Despite uneventful spinal anesthesia and epidural catheter insertion, she developed intense occipital headache which worsened with adoption of upright posture on the day after surgery, and a diagnosis of postdural puncture headache was made. Bed rest, non-steroidal anti-inflammatory drugs, intravenous infusion of solutions and continuous epidural infusion of normal saline were ineffective. On postoperative day seven, intravenous caffeine 200 mg, three times a day, was started, which effectively alleviated her headache and enabled her to walk. No symptoms of caffeine intoxication were detected in the newborn fed with breast milk. Administration of caffeine was continued until postoperative day 12 and it was replaced by oral loxoprofen. She was discharged from the hospital on postoperative day 13. Caffeine is safe and effective for treating postdural puncture headache accompanied with spinal/epidural anesthesia for Cesarean section.
Early enteral feeding can be administered using a post-pyloric tube, and it is considered a reliable alternative for providing adequate nutrition. Various methods have been reported for the insertion of enteral tubes, and the procedure is not easy to perform. We created a protocol for inserting a feeding tube at bedside and investigated its usefulness by using a digital radiographic imaging device. This procedure combines the findings of auscultation and radiographic imaging in order to verify the tube position in the stomach. In 35 of 39 cases, post-pyloric placement of the enteral tube was achieved in less than 15 minutes, without complications. This procedure is convenient and minimally invasive. For these reasons, it is considered a practical method for critically ill patients.
Advances in pediatric cardiology and surgery have resulted in a remarkable increase in the prevalence of adult congenital heart disease（ACHD）. Accordingly, non-pediatric cardiac anesthesiologists are more frequently required to manage ACHD patients undergoing non-cardiac surgeries such as orthopedic and general surgery, and also provide anesthesia for adult patients undergoing transcatheter closure of an atrial septal defect（ASD）.
To provide anesthesia for ACHD patients undergoing non-cardiac surgeries, anesthesiologists should have a thorough understanding of ACHD-specific complications, including heart failure, dysrhythmias, pulmonary hypertension, and also of the extracardiac complications of long-term cyanosis. It is also important to assess the influence of adult comorbidities like hypertension, diabetes and atherosclerosis on the pathophysiology of congenital heart disease.
Left ventricular diastolic dysfunction, which is often associated with right heart volume overload, left heart volume underload, and age-related left heart stiffness, may exist, especially in older patients with ASD. Therefore, the risk of development of left heart failure should also be borne in mind following transcatheter closure of ASDs.
With the increasing popularity of perioperative anticoagulation therapy in recent years, epidural analgesia has become difficult in some situations. On the other hand, use of systemic administration of opioids with patient-controlled analgesia（PCA）is increasing as an alternative to epidural analgesia, though the possibility of side effects must be considered. As a result, cases of peripheral nerve block have rapidly increased. In addition, multimodal analgesia, which combines different analgesics with various action mechanisms including non-opioid and adjustment analgesics, has attracted increasing interest. Unfortunately, with increased numbers of surgical procedures, many facilities do not have adequate time or personnel to maintain postoperative pain management. For safe postoperative pain management in this era of manpower shortages, our facility has instituted a team-based postoperative pain management strategy. This article describes recent trends of postoperative pain management, and introduces our pain management system utilizing a medical team approach, which we have found to be safe and efficient.
Owing to recent advancements in surgical techniques and developments in perioperative patient care, greater numbers of surgeries are being performed worldwide. In order to reduce surgery-related deaths and complications, the World Health Organization（WHO）published the WHO Guidelines for Safe Surgery 2009. This article outlines global trends in patient safety in the perioperative period；summarized the WHO guidelines；describes Japanese efforts to follow the guidelines；and discusses the Helsinki Declaration on Patient Safety in Anesthesiology, which aims to ensure patient safety, especially in the field of anesthesiology by focusing on the WHO Guidelines for Safe Surgery 2009 and other protocols. The Helsinki Declaration was firstly ratified by the European Society of Anesthesiology, and then by many other bodies all over the world including the Japanese Society of Anesthesiologists.
A modified version of the WHO surgical safety checklist（CL）was implemented in April 2012 at our hospital. We investigated yearly changes before and after the CL’s implementation in the sum of incident reports submitted with operations, comprehensively evaluated the CL through a questionnaire survey of health care providers, and investigated problems and their countermeasures in the practical use of the CL.
Over the 5 year study period, claims of harmful injury to patients diminished after implementing the CL, especially during the first 3 years after implementation, when we had no “never events” such as patient misconception, wrong surgical site, errors in operation methods and so on. In the comprehensive evaluation of the CL by health care providers（medical doctors and nurses）, positive evaluations of the CL ranged from 87% to 100%.
Problems in the practical use of the CL such as becoming a mere name at time-out, the necessity of complete enforcement of 3 phases（sign-in, time-out, sign-out）, and whether or not we ought to implement CL in emergency situations were identified through the questionnaire.
The WHO’s CL is essential to ensure patient safety and is expected to be a tool which nurtures a safety culture in the field of operative medicine.
The WHO’s Surgical Safety Checklist was introduced in 2009, and around 60％ of hospitals in Japan have adopted the original or modified CHECKLISTS. The CHECKLIST can help identify most of problems that are often missed by surgical teams, clarify the process of complex procedures, and/or enhance overall performance by improving teamwork in the operating theater. No doubt the CHECKLIST can be meaningless if ignored by the operating room staff. While we cannot totally eliminate incidents happening during anesthesia and surgery even when using the CHECKLISTS, we should make efforts to implement and promote Safety Culture.
Anesthesiologists should protect patients from danger during a disaster（e.g., fire and earthquake）in the operating room, as well as ensure their own safety. In addition, anesthesiologists must cope with delicate situations in the operating room during a disaster. We need to remain in charge of the operating room as well as all operating rooms. We should understand the structure of the hospital, layout of operating rooms and proper safety measures in response to a disasters, including fires, earthquakes, power failures, and suspension of water supplies. Surgeons and anesthesiologist must decide whether or not to continue surgery after sufficient information on various conditions under the control of the director of the hospital. We require training in disaster countermeasures using manuals including action cards to avoid confusion during a real disaster.
TeamSTEPPS training has been conducted since July 2010 to promote interprofessional team healthcare, which has led to increased understanding of the tools and strategies of TeamSTEPPS. However, many staff members still resist change. How each staff member is involved in this work thus needs to be reviewed.
Teaming, as proposed by Amy C. Edmondson, calls for learning partly through interaction and cooperation among staff members at work in an environment where members can discuss issues and ask questions easily. The first step is for leaders to create an environment where team members can freely express their opinions and ask questions in the presence of interpersonal risk of not speaking in front of others. Voices and attitudes of team members to inspire and activate the team are also important. Teaming will hopefully promote the progress of TeamSTEPPS and thereby prevent stagnation.
The Japanese Society of Anesthesiologists is being asked what roles certified nurses should play on “perioperative management teams” that are currently under discussion. Here, the author considers the work of certified nurses. When we cooperate with certified medical staff, major part of anesthesiologists can accept the following issues：to improve the safety of the patients, to reduce the labor burden of us and not to decrease the medical revenue. The author discusses the work of certified nurses in cooperation with anesthesiologists in mainly preoperative examinations for anesthesia.
In 2014, “Certified Nurse for Perioperative Management” was launched by the Japanese Society of Anesthesiologists and related professional societies. This is designed to reduce the burden of anesthesiologists who work to guarantee the safety and quality of perioperative medicine in a team of nurses, pharmacists and other co-medicals. Demand for general anesthesia keeps increasing as the proportion of elderly patients grows. It is therefore very important to leverage these human resources to provide safer and higher-quality perioperative medicine.
The transfer of patient information between departments（surgical ward, operating room, intensive care unit）is crucial in safe perioperative care. Certified Nurses for Perioperative Care（Perioperative Nurse）can play a significant role in this setting. They have broad knowledge of pathophysiology/pharmacology in the perioperative period, particularly in patients with unstable cardiorespiratory function, as well as knowledge of various surgical procedures. They should also have good non-technical skills such as situational awareness and communication. Certified Nurses can join an Acute Pain Service team and manage postoperative pain, nausea and vomiting. The Post Anesthesia Care Unit（PACU）is a suitable place where the knowledge and clinical skills of Perioperative Nurses are greatly appreciated.
The purpose of presentations is to provide more information within a limited time. To achieve this purpose, narrow the topic and decreasing the number of words is essential. One method is to use short words rather than sentences. The information should be expressed by figures in the methods and discussion sections. Fine adjustments including adjustment of the type and size of fonts is also essential for graphs and tables. The final finishing process is the most important key to a good presentation.
In the symposium “Polish the power of presentation”, I explained how to improve your presentations. The most important element of a presentation is time management. Do not exceed the presentation time allowed. To do this, be sure to prepare slides you can easily follow. Then you can explain them easily, which allows audience to understand them easily as well.
Every presentation has a purpose. For the presenter to achieve that purpose, it is necessary to attract the audience to the story being told and keep them interested from beginning to end.
The presentation is not complete when the slides have been made. In fact, the attitude and behavior of the presenter when telling the story of their results are crucial. Furthermore, depending on the reaction of the audience, it is important to adjust the tone and narrative while the presentation is being given.
In order to explain something clearly, it is always necessary to have a purpose, just as in daily conversation. Unlike a conversation, however, a presentation must be given to the audience with a specific purpose in mind and within a limited period of time.
A good presentation may be equivalent to good communication. Communication consists of verbal, written, and heard communication. The best presentators can handle all of these effectively. Therefore, we need to acquire knowledge of communication in order to draw attention to something and to communicate easily to make a good presentation.