We report a case of MECP2 (methyl-CpG-binding protein 2) duplication syndrome in a patient who underwent corpus callosotomy under general anesthesia. A 5-year-old boy with IUGR (intrauterine growth retardation) and microcephaly from fetal stage was diagnosed with MECP2 duplication syndrome. When he was 3 years old, myoclonic seizures appeared in his whole body and he received medical treatment with several anti-epileptic medications. However, it was difficult to control his epilepsy, and he was scheduled to undergo corpus callosotomy. After the surgery, sugammadex was administered at the point of TOFR (train-of-four ratio) 70%, and it took about 10 minutes until TOFR 100%. After tracheal extubation, laryngeal edema was suspected and hydrocortisone was administered. MECP2 duplication syndrome is a very rare disease, but it is necessary to pay attention to perioperative airway management and prolonged muscle relaxant.
A 38-year-old male patient with Hallermann-Streiff syndrome underwent general anesthesia for extraction of urachal remnant. Patients with this syndrome often present upper airway deformities which result in difficult tracheal intubation. Furthermore, this patient had undergone pexis for basilar invagination 19 years ago, and he could not flex his head backwards at all. We chose semi-awake intubation using Airway Scope®. Fortunately, it was easy to intubate by visual identification of the larynx and the glottis. We extubated without any problems after the patient was fully awake. No complications were observed during or after general anesthesia.
Among anesthetic procedures, paravertebral block combined with sedation (PVB + MAC) has attracted attention because of its marked usefulness in terms of quality and side effects in comparison with conventional procedures. Anesthesia was managed using PVB + MAC in 8 patients undergoing inguinal hernia repair. PVB at the level of T10 to L1 was performed in 4 places under sedation with propofol. When an increase in body motion or heart rate in association with an increase in nociceptive stimulation was noted during surgery, local infiltration anesthesia in the operative field or additional intravenous fentanyl was administered. All patients were able to perform bed transfer without assistance immediately after surgery, and only one of the 8 patients required an analgesic within 12 hours after surgery. No patients had complications related to the block.
Next-generation sequencing (NGS) technologies has been widely used in medical and life sciences. A major application of NGS is RNA-seq that sequences RNAs (or transcriptomes) expressed in cells. This technique can be used to elucidate the action mechanisms of anesthesia at the transcriptome expression level. This includes to identify genes or transcripts related to anesthetic complication, hypoxia, hypothermia, concentration, and so on. This article describes NGS technologies, applications for transcriptome analyses, useful websites especially for educations, and guidelines for statistical analyses.
Anesthesiology is a branch of medicine that focuses on pain relief during and after surgery, and is aimed at the patient’s safety and comfort. On the other hand, palliative medicine is an academic discipline about approaches that improve the quality of life of patients and their families facing problems associated with life-threatening illnesses. Anesthesia and palliative care have shared objectives such as analgesia, sedation and reduction of stress. Cancer patients have a significant symptom burden, most often involving pain, dyspnea, anxiety and depression. Although pain control is the major concern of cancer patients and their families, they are often dissatisfied with the quality of pain control. Anesthesiologists have detailed knowledge of drugs and methods for pain relief, and have specific skills in symptom management that may benefit the patient. For these reasons, anesthesiologists can play a key role in palliative care. To manage many palliative care problems and improve the quality of health care, it is necessary to cultivate not only palliative care specialists but also physicians with primary palliative care skills.
There are currently three international definitions for acute kidney injury (AKI) : Risk-Injury-Failure-Loss-Endstage renal disease, Acute Kidney Injury Network, and Kidney Disease : Improving Global Outcomes. Incidence of postoperative AKI is highest in patients undergoing transplantation followed by cardiac/aortic surgery, major abdominal surgery, and noncardiac minor surgery. A wide variety of risk factors for postoperative AKI are known including comorbidities (e.g., chronic renal disease, hypertension, peripheral vascular disease), pre- and intraoperative medications (e.g., contrast agents, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers), intraoperative interventions (e.g., cardiopulmonary bypass, transfusion), and intraoperative pathological conditions (e.g., massive hemorrhage, fluid overload). Anesthesiologists are expected to play an important role in preventing postoperative AKI from occurring by maintaining optimal intravascular volume status and optimal hemodynamic status, and by not administering drugs with possible nephrotoxicity. Oliguria is often encountered during anesthesia because of hemodynamic or hormonal effects of anesthesia drugs, surgical procedures, and positive pressure ventilation. In case of oliguria, risk evaluation based on characteristics of patients and surgical procedures is essential to decide how to cope with it.
Intraoperative glycemic control is definitely important, because perioperative hyperglycemia is considered to be an independent risk factor for morbidity and mortality associated with surgery. During anesthetic management, energy demand/supply balance should be appropriately maintained and possible adverse events exaggerated by hyperglycemia should be prevented. Several factors, such as surgical stress and anesthetics, significantly modify intraoperative glucose metabolism. Unfortunately, mechanisms underlying the modifying effects of these factors on intraoperative glucose metabolism have not been elucidated so a standard regimen for intraoperative glycemic management has not been established. Further investigations focusing on intraoperative glucose metabolism are definitely required in order to establish management guidelines which can contribute to improving surgical prognosis.
Prompt postanesthesia recovery is required for ambulatory anesthesia. Minimal perioperative adverse events, namely, safe and high quality care is essential. Patient and procedure selection suitable to the facility and staff is crucial. In addition, it is critical to prevent delayed discharge and unexpected admission due to untoward effects before discharge home, and to inhibit revisit and readmission after discharge due to unwanted reactions at home. Therefore, an integrated and standardized care system is required. The system should include refined organizational protocols such as preoperative assessment and preparation including patient and caregiver education, intra- and post-operative care, pre-discharge information, and post-discharge follow-up. The anesthesiologist is best suitable for the medical director who is in an organizing and managing function in ambulatory surgery facility.
At Tokai University hospital, anesthesiologists can go between the central operating room and anesthetic outpatient clinic using the one-footwear system, which makes it possible to execute more than one duty. We report on the current state of the anesthetic outpatient clinic, the frequency of preoperative examinations at the anesthetic outpatient clinic according to the day of the week, the time a medical examination takes, and the relationship between severity of illness and preoperative examination time and refer about the problem and the measure.
We describe management in the preoperative evaluation system at the Gifu University Hospital. To improve the efficiency and safety of anesthesia, we have to identify high-risk patients before their operations. However, it is difficult to efficiently quantify the risk of perioperative complications and obtain a relevant informed consent from the patient. We started a new preoperative evaluation system in 2012. Although this system has raised efficiency and the satisfaction of both of surgical patients and anesthesiologists, much time is required to carry out medication control and additional checking for precise preoperative evaluation when anesthesiologists first identify new medical problems. Information that may impact efficiency and safety in perioperative management should be gathered completely before admission. For proper risk assessment and optimization of medical condition in outpatients, we established a preoperative control center in 2015. We hope to improve patients’ prognoses by standardizing preoperative preparation.
Anesthesiologists need to perform effective preoperative examinations, since the main cause of untoward perioperative events is preoperative complications. However, this is very difficult due to the complex nature of current medical treatments. In our hospital, anesthesiologists, nurses, pharmacists, and physicians examine surgical patients. According to the accumulated information, anesthesiologists evaluate preoperative risk factors and plan the perioperative management of the patient. Although specialists currently evaluate the risk factors individually, in the future they will work as a perioperative management team.
The goal of education of junior residents during a course in anesthesia is acquisition of fundamental technical skills such as those associated with intubation. In view of safe practices during surgery/anesthesia, preanesthetic management is also very important, as patient condition is the chief factor affecting outcome. However, with increasing numbers of surgeries and shorter hospital stays, adequate preanesthetic management training of junior residents has become difficult. The relative importance of preanesthetic management work, which is thought to be as vital as intraoperative anesthetic care, is assessed by senior anesthesiologists at our institution using a questionnaire. Presentation of the case is considered to be most important aspect, followed in order by collection of patient data, the preanesthetic patient visit, determination of anesthetic procedures, providing the patient with information regarding anesthetic management, completion of a consent form, and consultation/negotiation with the operator/nurse associated with the case. Residents who are studying to become anesthesiologists are encouraged to take part in preanesthetic management training. Preanesthetic examination program should be designed to be attractive to junior residents to help them fully prepare for their future as anesthesiologists.
Although various simulation training courses exist, some are vague in their objectives and effects. Some courses place excessive focus on acquiring technical skills, and underestimate the importance of non-technical aspects. In order to maximize the effect of simulation training courses, simulation education should be tightly linked with clinical training. Here, we introduce 20 points of instruction based on the American Heart Association’s adult education principle, which can be applied to both simulation training and clinical education.