[Background] Laparoscopic surgery, which aims to minimize surgical invasiveness, achieves satisfactory therapeutic results. Surgical and anesthesiological methods have been improved, but many laparoscopic surgeries have been associated with cardiorespiratory complications. [Objective] We hypothesized that severe bradycardia during surgery is caused by increased baroreflex sensitivity (BRS) when the pneumoperitoneum is created. We conducted BRS analysis and heart rate variability (HRV) analyses in order to concurrently assess arterial baroreceptor sensitivity and autonomic nerve balance. [Methods] Twenty-three ASA 1-2 patients undergoing laparoscopic gynecological surgeries were enrolled in the study. After anesthesia was induced with propofol, remifentanyl, sevoflurane, and rocuronium, tracheal intubation was performed. The depth of hypnosis was monitored with a bispectral index sensor. Spectral analysis of HRV that was conducted with a logistic regression analysis resulted in a characteristic power spectrum with two main regions : high frequency (HF) and low frequency (LF). BRS-up and -down sensitivities were obtained in linear regression if three-beat intervals occurred with successive increases or decreases in blood pressure and in the RR interval. Mean blood pressure (MBP), heart rate (HR), LF region, HF region, LF/HF, and BRS were recorded at 1 min at each time point (baseline, equilibration period, pneumoperitoneum period, and head-down tilting period). [Result] LF/HF was 1.1, 0.5, 1.2, and 0.6 at each respective time interval. LF/HF significantly increased after the pneumoperitoneum. The BRS-up value was 12.2, 8.2, 9.0, and 34.7 ms/mmHg, respectively. [Consideration and conclusion] During the head-down tilting period, the combined effects of anesthesia, the pneumoperitoneum, and posture resulted in a significant increase in BRS with an LF/HF decrease. Contrary to expectations, the effect of the pneumoperitoneum on BRS was restrictive. This study demonstrated that the effect of pneumoperitoneum, anesthesia and head-down posture in cardiac autonomic function should seriously be taken into account, and strict BRS monitoring should be done in all patients, especially in those with cardiac risk.
A 52-year-old obese man was scheduled to undergo laparoscopic rectectomy. The operation was performed in the lithotomy position with the Trendelenburg position under general and epidural anesthesia for 6.5 hours, and was completed uneventfully. In the ICU, the patient complained of worsening pain in his left posterior calf and was diagnosed with acute compartment syndrome by high intra-compartmental pressure, 43 mmHg. The orthopedic consultants treated the patient with conservative therapy using analgesia and repeated assessment based on adequate perfusion pressure. The patient was discharged to the ward the next day. Rehabilitation was initiated from postoperative day 10 and led to temporal pain and paresthesia but was continued under careful repeated assessment. On postoperative day 49, the patient was discharged without complications. In acute compartment syndrome, early fasciotomy is important to avoid critical complications. However, the threshold for fasciotomy differs among surgeons. If conservative management is selected, the patient should be constantly assessed to reduce the chance of missing compartment syndrome.
We experienced anesthetic management during pancreatectomy in a pediatric patient with congenital hyperinsulinemia. The patient was 6 months of age, measured 65.2 cm in length (-1.2SD), and weighed 10.6 kg (+3.2SD). His blood sugar was 24 mg/dL at birth, so he received an insulin secretion suppressant and dextrose. However, blood sugar management was difficult and hypoglycemia occurred. During pancreatectomy, anesthesia was maintained with oxygen, air, sevoflurane, fentanyl, and remifentanil. Dextrose administration was regulated and ranged from 7 mg/kg/min to 1 mg/kg/min based on blood sugar measurement. The patient’s blood sugar rose to a maximum of 300 mg/dL but gradually decreased with insulin administration, stabilizing at 150 mg/dL. Hypoglycemia did not occur intraoperatively. We were able to achieve blood sugar stability with appropriate dextrose administration. Because blood insulin concentration changes dramatically during pancreatectomy for congenital hyperinsulinemia, frequent blood sugar measurement and dextrose infusion adjustment are required during anesthesia.
A 76-year-old man was scheduled to undergo superficial temporal artery to middle cerebral artery bypass. A thoracic aortic aneurysm was detected during preoperative examination. Because exacerbation of his cerebral infarction was expected if thoracic surgery was performed first, we performed head surgery first. Scalp blocks were performed to suppress blood pressure fluctuations. Before induction of general anesthesia, a left greater occipital nerve block, left lesser occipital nerve block, and left greater auricular nerve block were performed under ultrasound guidance. General anesthesia was induced and a bilateral supraorbital nerve and supratrochlear nerve block, left zygomaticotemporal nerve block, and left auriculotemporal nerve block were performed according to the landmark method. The scalp block combined with general anesthesia during craniotomy had two effects : it inhibited hypertension due to surgical stress and avoided hypotension due to a high volume of anesthetic.
Administration of a large amount of fresh frozen plasma (FFP) is commonly required during massive bleeding because of the low concentration of fibrinogen in FFP. Transfusing high volumes of FFP involves a high risk of transfusion-associated circulatory overload (TACO). Here we report a case of acute lung injury associated with massive transfusion during cardiac surgery with cardiopulmonary bypass (CPB). A 78-year-old woman (height 146 cm, weight 45.3 kg) who had distal arch aortic aneurysm, aortic regurgitation, and angina pectoris underwent replacement of the aortic arch and aortic valve as well as coronary artery bypass graft surgery. After weaning off CPB, we administered 46 units of red blood cell concentrate, 40 units of FFP, and 60 units of platelet concentrate to stop uncontrolled bleeding. Although the patient was extubated on postoperative day 1, she presented with dyspnea and hypoxemia requiring the use of non-invasive positive pressure ventilation and high-flow nasal oxygen. A chest X-ray demonstrating pulmonary edema with bilateral effusions raised the suspicion of TACO. The use of cryoprecipitate and/or concentrated fibrinogen formulation is a potential option to prevent postoperative TACO and achieve rapid hemostasis.
Dentures were found in the airway following a sore throat complaint by an extubated 58-year-old patient. The object was successfully removed under local anesthesia by a McGRATH MAC video laryngoscope and SUZY forceps, which were designed to match the curved blade. McGRATH MAC is a relatively new device for tracheal intubation which has been shown, to provide a better view with less invasiveness. We propose that the application of McGRATH MAC combined with SUZY forceps to remove airway foreign objects, is easy and reliable practice.
The Japan Association for Clinical Ethics (JACE) organized a working group on DNAR order to discuss the ethics of the decision making process and issued a Japanese version of POLST (DNAR) in March, 2015. Until recently, consensus regarding DNAR was lacking, with different interpretations among different individual physicians. As a result, various life-sustaining medical treatments other than CPR were withdrawn or withheld. The Japanese version of POLST (DNAR) has 3 parts : 1. Basal Concept, 2. Guidance (with check sheets), and 3. Form. Regarding ‘guidance’, the following six reference points are considered relevant : Chap.1. Communication with patient, family members and medical staffs ; Chap.2. Autonomy : respect for patient’s wishes and values ; Chap.3. Substituted judgment : respect for family member’s opinions and ethically adequate process of proxy consent ; Chap.4. Medical matters in consideration of POLST (DNAR) ; Chap.5. Procedual justice of decision making on POLST (DNAR) ; Chap.6. Consideration for the patient and family members after POLST (DNAR) is made. To reduce and resolve ethical dilemmas relating to end-of-life care, Advance Care Planning is proposed as being of paramount importance. To this end, we advocate the implementation of ethically appropriate POLST (DNAR).
Anesthesiologists are able to perform and maintain numerous skills necessary for critical care based on daily anesthesia practice. The Japanese Society of Anesthesiologists encourages us to explore abroad field of anesthesia-related practices such as emergency medicine, intensive care, pain management and palliative care. Although recent hospital management based on the DPC system forces us to provide OR anesthesia as a first priority, the author suggests that young physicians should be given the opportunity to experience out-of-OR fields to develop generalist expertise in the whole of critical care.
The 1st practice seminar on DAM was held in 2004. The Study Group for DAM was founded to organize the seminar in the same year. In April 2005, the study group was reorganized as the Japanese Association for Medical Simulation (JAMS) and became one of the subcommittees of JAMS. Seventy DAM practice seminars have been held so far. Correspondence with the airway management guideline of the Japanese Society of Anesthesiologists will be a matter of great urgency for us.
Patient safety during central venous catheterization is an important issue. Ultrasound-guided technique is safer than anatomic landmark technique for central venous catheterization. The central venous catheterization committee of the Japanese Association for Medical Simulation (JAMS) established an education program for ultrasound-guided central venous catheterization. The purpose of the education course is to produce instructors in ultrasound-guided central venous catheterization. The training course covers theory, pitfalls, and hands-on training for the ultrasound-guided technique and teaching skills for simulation education. Instructors who finished the training can return to their hospitals and conduct hands-on seminars by themselves. Holding a course in ultrasound-guided central venous catheterization requires a great deal of effort and money. The central venous catheterization committee of JAMS should continue to work hard to promote patient safety.
Around 1990, malpractice caused by anesthesia occurred frequently and became a public issue. The high performance patient simulator (HPS) was introduced as a systematic way of preventing these incidents. In training using HPS, understanding of human errors, latent error factors, trigger events for activating these latent error factors, and defense mechanisms to prevent their activation hide in the event background at first, and handling of these events is based on human behavior analysis (dynamic decision making model). Many HPS symposiums and workshops were held at anesthesiology-related scientific meetings in Japan, and the recognition of HPS as a social infrastructure for medical safety spread gradually. With the establishment of the Japanese Association for Medical Simulation in 2005, a place for further educational activities was born. In this paper, we discuss the progress that has been made and argue for a future plan.
We developed a sedation training course (SEDTC) based on ‘Practice Guidelines for Sedation and Analgesia by Non-Anesthesiologists’ to improve safety in sedation. The SEDTC was developed by applying several education methods from various simulation-based training courses. To this end, we surveyed complications that novice doctors encounter and established learning goals. We then conducted a survey regarding how the SEDTC affected attitudes toward sedation. Pre- and post-surveys were conducted to evaluate the extent to which participants understood the course content and the effects of debriefing on learning efficacy, and satisfaction with the SEDTC was also validated. The SEDTC has been continuously improved upon and used to educate medical staff. Anesthesiologists are expected to play a crucial role in these courses and safety improvement.
Ten years have passed since JAMS was founded. JAMS has contributed to patient safety and medical specialist education by developing and popularizing various simulation seminars among other things. Each committees has developed different seminars and put improvements into practice. To improve the seminars further, improvements from the perspective of andragogy are needed. In this report, I discuss the refinement of the seminar from the viewpoint of andragogy and instructional design.