THE JOURNAL OF JAPAN SOCIETY FOR CLINICAL ANESTHESIA Vol. 37(2017) No. 4

Postoperative nausea and vomiting（PONV）, the most frequent complication after surgery, may evoke severe morbidities such as postoperative bleeding, aspiration and others. This complication, possibly caused by patient-related, surgical and anesthesia-related aspects, occurs through at least over 5 different neural pathways. Unlike other countries, the indication of effective anti-emetics to prevent or to treat PONV is quite limited in Japan due to little regard to the risk of this significant complication and its high cost. In this article, we reviewed the cause of PONV, known predictors, and promising new predictors. In our country, a more accurate scoring system or high-sensitive and specific biomarkers would be very helpful in preventing PONV by allowing the effective use of prophylactic antiemetic drugs.

We used an Airway Scope^®（AWS）to intubate a 79-year-old man with a back injury. The patient could not be placed in the supine position because a knife was stuck in his back approximately 20 cm toward the midline in the cranial direction. He was in hemorrhagic shock and was carried to the operating room with fluid resuscitation. Because of concern about the potential development of pneumothorax and cardiac tamponade, we administered low-dose fentanyl and ketamine and intubated the patient with the AWS while maintaining spontaneous breathing in the right lateral position. Upon completion of successful intubation, we started positive-pressure manually assisted ventilation and confirmed that his vital signs had not worsened. We then administered the anesthetics and started mechanical ventilation.

The patient left the hospital on foot on the 26th postoperative day. Intubation with the AWS in the lateral position was useful in this case of dorsal thoracic trauma.

A 70-year-old man was scheduled for laparoscopic left hepatic lobe expansion resection. Intraoperatively, his systolic blood pressure temporarily dropped to 60 mmHg because the hepatic vein was damaged and compressed to stop bleeding, but following blood vessel repair, the patient was hemodynamically stable. Before the completion of surgery, a gauze count revealed a mismatch, and chest radiography showed a linear shadow indicative of gauze near the left pulmonary hilar area. Although there were no symptoms suggestive of pulmonary embolism, we considered the risk for severe pulmonary embolism as substantial, and endovascular retrieval followed by endovascular treatment and inguinal surgical small incision resulted in the successful retrieval of the gauze. Anticoagulant therapy was undertaken for a month postoperatively and his clinical course was without complications including pulmonary embolism.

Postoperative drug-induced liver injury is a rare but serious perioperative complication, but identification of the responsible agent among numerous drugs is usually difficult. Here we describe a case of possible ropivacaine-induced liver injury. A 45-year-old woman with severe dysmenorrhea underwent total hysterectomy under general anesthesia with transversus abdominis plane block using ropivacaine. Her past history and laboratory data were unremarkable with the exception that she was receiving prednisolone for Behçet’s disease. Surgery was completed uneventfully with no remarkable hemodynamic changes. A notable increase of serum AST/ALT as well as prolongation of prothrombin time was detected on the day of surgery, with no abnormal findings in the liver examined by ultrasonography or laboratory data indicating virus infection. All medications except fentanyl were discontinued based on a diagnosis of drug-induced liver injury. Laboratory data recovered to the normal ranges within three weeks after surgery. Ropivacaine had a positive response in a drug-induced lymphocyte stimulation test and would have been responsible for the liver injury.

We report a case of spontaneous urinary bladder rupture with hyperkalemia, metabolic acidosis and pseudo renal failure whose clinical course was excellent with prompt diagnosis and perioperative management.

A 66-year-old man was admitted to our hospital for acute alcohol intoxication and gross hematuria. CT scan showed urinary ascites and urinary bladder perforation was suspected, so emergency surgery was scheduled.

Preoperatively, metabolic acidosis and hyperkalemia was corrected by sodium bicarbonate and glucose-insulin therapy. The level of potassium, acidemia and renal function was remarkably improved on the next day after serous fluid drainage and bladder repair.

The peritoneal-self-dialysis seemed to be a pathogenesis on this clinical course. We should bear in mind the risk of life-threatening cardiac arrhythmia caused by hyperkalemia in patients with spontaneous urinary bladder rupture.

There have been few reports regarding Transversus Abdominis Plane block（TAPB）in liver transplant recipients during perioperative periods. We performed an uncomplicated TAPB after living-donor liver transplantation（LDLT）. The patient was a 16 year-old female（BMI：24）with liver cirrhosis（MELD score：10）who previously underwent Kasai’s operation for congenital biliary atresia. LDLT from her mother was successfully conducted and her graft function had also kept good condition. TAPB was performed by ultrasound-guided subcostal approach after surgery in the operating room. The total volume of local anesthetic was 30 mL of 0.2% ropivacaine（15 mLs on each side）. Numerous Rating Scale was maintained at 3/10 less until 12 hours postoperatively. There were no evidence of local anesthetic toxicity or complication related to TAPB.

Among the physiological changes seen in pregnant women starting from the third trimester through to postpartum, circulating plasma levels during late pregnancy are increased by 40-50％ from pre-pregnancy levels. When the strain from the sympathetic system is aggravated by the stimulus of labor pain, sudden changes in circulation can occur which sometimes lead to circulatory failure, complicating the condition of the heart. I was able to manage the delivery of a multipara woman, that was complicated with severe mitral insufficiency and pulmonary hypertension without heart failure, and perform a painless delivery using epidural anesthesia. It is believed that pregnant women with heart conditions can increase their chances of a successful delivery with improvements in convalescence management. I believe that patients with heart conditions can become pregnant and deliver safely if attention is paid to fluid management during pregnancy and the appropriate painkilling assistance is provided during labor.

We investigated the usefulness and safety of Airway Scope（hereafter AWS；MIC Medical Co., Tokyo）for insertion of a TEE probe.

Methods：

The subjects were 38 adult patients who underwent cardiovascular surgery in our hospital from August 2012 to August 2013. We used AWS for insertion of the TEE probe in those patients. AWS is one type of video laryngoscope used in tracheal intubation. Images of the hypopharynx can be obtained by inserting the Intlock into the oral cavity. We measured success rate, procedure time, and the incidence of complications including sore throat, dental injury, and upper gastrointestinal hemorrhage.

Results：

The success rate of TEE probe insertion using AWS was 97.4％（37/38 cases）. The mean （median） period needed for insertion with AWS was 16.3 seconds（13.5 seconds）. There were no complications except one sore throat.

Conclusions：

The use of AWS enabled smooth placement of the TEE probe without severe complications. The results also suggest that AWS might be useful when blind TEE probe insertion is difficult.

While outcomes of cardiovascular surgery have improved tremendously in recent years, an increasing number of aged and/or frail patients have become candidates for surgery, which makes surgery more complicated and necessitates more individualized, tailor-made treatments to maximize certainty and safety of treatments rather than refinement through large volume experiences. To achieve constant success, more sophisticated “strategy” in addition to “tactics（surgical skill）” are essential. As radar is commonly utilized to compensate a limited visual flying in the aviation industry, limited visual inspection by surgeons should also be reinforced by adequate information provided by transesophageal echocardiography. For this purpose, anesthesiologists need to thoroughly master it, while surgeons should support to it. Genuine “team medicine” is not just a group effort but should be a collaborative effort with synergistic effects based on a mindset of mutual nurture and support between anesthesiologists and surgeons.

The main purpose of cerebral protection is to protect brain function during operation.

In our daily clinical work, we always should pay attention to management of patients who are scheduled for cardiopulmonary bypass operation, carotid endoarterectomy（CEA）, clipping for cerebral aneurysm with subarachnoid hemorrhage, stroke, traumatic brain injury, postcardiac arrest syndrome（PCAS）after cardiopulmonary resuscitation, and so on. If our management is not appropriate, sometimes it induces adverse effects in patients such as ischemic brain damage.

Also, the purpose of the neurointensive care is to prevent the progress of brain damage due to primary ischemic insult that we mentioned above. To perform acute cerebral protection is 1）to recover cerebral blood flow quickly and 2）to prevent the progress of brain damage due to primary ischemic insult. The main goal for patients who are resuscitated from cardiac arrest is to prevent the Post Cardiac Arrest Syndrome（PCAS）. At present, evidence to improve a neurologic prognosis for out of the hospital cardiac arrest patients and perinatal cerebral ischaemia by hypothermia therapy are being obtained.

In this review, we would like to focus on cerebral protection in neuroanesthesia and neurointensive care and discuss the mechanisms of neuroprotective and neurotoxic effects of anesthetic agents.

Supraglottic airway device（SGD）is reported as the most popular device for emergent airway management in airway management guidelines such as the DAS guideline, DAM guideline and JSA airway management guideline. However, we rarely use the SGD when we perform emergent airway management.

The reason is that the SGD has limitations and problems. The limitations are that it is difficult to ventilate after an insertion of the SGD in patients who are male, aged 45 or older, have short thyromental distance, or limited neck movement. The problems are that we are worried about whether the SGD is a more effective ventilation than the endotracheal tube.

We do not know anything about the SGD.

In a “cannot intubate, cannot ventilate” scenario, guidelines on airway management unanimously recommend inserting a supraglottic airway, and if that fails, invasive access to the infraglottic airway（such as cricothyrotomy or tracheostomy）as the last resort. Nevertheless, recent studies have shown that the success rate of this last resort may be low. Therefore, it is necessary to find out which method is most effective. There is growing evidence that percutaneous cricothyrotomy using a narrow-bore cannula（with jet ventilation）may frequently be ineffective. Studies using cadavers and animal models have shown that, compared with percutaneous cricothyrotomy, surgical cricothyrotomy is associated with a higher success rate and a lower incidence of complications. For these reasons, surgical cricothyrotomy should be regarded as the most reliable method, and should be learned and regularly rehearsed by all anesthesiologists.

The Japanese Society of Anesthesiologists airway management algorithm（JSA-AMA）recommends that the emergency surgical airways through the cricothyroid membrane（CTM）should be established as soon as possible when ventilation status is moved to the Red zone. There are few situations where surgical cricothyroidotomy is needed. There seem to be few anesthesiologists who have performed surgical cricothyroidotomy. Appropriate skills need to be acquired through simulation training in order to perform the right procedure when necessary. It is more important to draw up an anesthesia strategy that does not reach Red zone.

Total anomalous pulmonary venous connection（TAPVC）and transposition of the great arteries（TGA）are congenital heart diseases for which radical surgery can be performed during the neonatal period. Cardiac surgery during the neonatal period is considered high-risk because of the immaturity of cardiac function. In addition, there is a risk of left heart failure and pulmonary hypertension in patients with TAPVC and TGA. It is important to optimize cardiac condition by controlling preload, afterload, contractility, and heart rate during the perioperative period.

Esophageal atresia is a congenital anomaly which requires surgical treatment in the early neonatal period. Ventilation difficulties of the lung and insufflation of the stomach due to tracheoesophageal fistula（TEF）are the most important anesthetic problems in type-C esophageal atresia, which accounts for 85％ of cases. In addition, low birth weight and comorbidities of the patient should be taken into consideration. It is necessary to confirm the location and size of TEF as well as the relationship between tracheal tube tip and TEF using fiberoptic bronchoscope because the dislocation of the tracheal tube tip may cause ventilation insufficiency and hypoxia. Techniques such as ventilation with low airway pressure, adjustments of tracheal tube tip and insertion of Fogarty catheter into the TEF are used to maintain adequate ventilation and to avoid gastric insufflation until TEF ligation.