THE JOURNAL OF JAPAN SOCIETY FOR CLINICAL ANESTHESIA

Invited Lecture

Anaphylaxis during General Anesthesia

Hiromasa MITSUHATA

2012 Volume 32 Issue 4 Pages 479-487
Published: 2012
Released on J-STAGE: October 11, 2012

DOIhttps://doi.org/10.2199/jjsca.32.479

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Anaphylaxis occurring during anesthesia is one of the most severe adverse reactions. Anaphylaxis is a clinical syndrome that affects multiple organ systems. The clinical manifestations of anaphylaxis are derived from the acute release of mediators from mast cells and basophils. Effective anticipation, prevention, and treatment of these reactions is largely based on the knowledge and vigilance of the attending clinicians. In clinical medicine, prompt recognition with appropriate and aggressive therapy can help to avoid a disastrous outcome. Muscle relaxants are the agents most commonly responsible for intraoperative anaphylaxis. Other agents that are responsible include latex, hyponotics, antibiotics, plasma substitutes, and opioids. The initial steps in the management of anaphylaxis are the same as for all life-threatening events that control airway, breathing and circulation. Also, it should be stressed that increased vascular permeability, vasodilatation and decreased vascular resistance may lead to the need for large volumes of fluid replacement. Epinephrine, oxygen, and fluids are accepted first line treatments. A careful medical history that focuses on previous adverse reactions is most important. Previous anesthetic-associated reactions should be evaluated thoroughly, with specific testing if indicated. Beta-tryptase should be measured for assessment of the pathophysiology of the adverse reaction.

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Guidelines for Treatment : Japan Society of Pain Clinicians

Yasuhisa OKUDA

2012 Volume 32 Issue 4 Pages 488-493
Published: 2012
Released on J-STAGE: October 11, 2012

DOIhttps://doi.org/10.2199/jjsca.32.488

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Guidelines may assist physicians and patients in decisions about effective and safe care. In 2003, 2006 and 2010, Japan Society of Pain Clinicians produced and published guidelines in order to improve the management of pain. We aimed to formulate guidelines for managing pain based on systematic review of the literature and a robust consensus process.
Throughout several discussions, we merged opinions from the subcommittee members and proposed a consensus on the major roles, recommended levels, clinically efficacy, adverse events and cautions of clinical practice regarding the management of pain. Japan Society of Pain Clinicians are well aware of the available evidence-based guidelines, and many use these to support their clinical practice. This document describes the process and the major issues discussed during the development of the guidelines.

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Panel Discussion

[title in Japanese]

Yoh HORIMOTO

2012 Volume 32 Issue 4 Pages 494
Published: 2012
Released on J-STAGE: October 11, 2012

DOIhttps://doi.org/10.2199/jjsca.32.494

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Peripheral Nerve Block with Ultrasound Guidance in Children

Yukio NAGATSUKA

2012 Volume 32 Issue 4 Pages 495-500
Published: 2012
Released on J-STAGE: October 11, 2012

DOIhttps://doi.org/10.2199/jjsca.32.495

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Pediatric peripheral nerve block is a well-established anesthetic approach. Recently however, ultrasound for peripheral nerve block has experienced immense growth as a result of the developments in ultrasound technology. Available evidence in children demonstrates that ultrasound-guided peripheral nerve blocks improve the quality, onset, duration, and success rate of nerve blocks while helping to lower the local anesthetic volume needed to perform such blocks. On the other hand, ultrasonographic identification of peripheral nerves requires knowledge of ultrasonography and anatomy. In addition, experience is required to fix the probe of the ultrasonic machine and insert the needle carefully. Therefore, this review aims to promote ultrasound-guided peripheral nerve blocks to not only pediatric anesthesiologists, but also general anesthesiologists on the basis of understanding both its advantages and complications.

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Pediatric Epidural Anesthesia

Yoshiko OSAKA

2012 Volume 32 Issue 4 Pages 501-506
Published: 2012
Released on J-STAGE: October 11, 2012

DOIhttps://doi.org/10.2199/jjsca.32.501

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  With the recent trend in clinical practice of transitioning from central to peripheral blocks, the incidence of epidural anesthesia has decreased.
  Epidural anesthesia is an efficient method of providing post-operative pain relief for patients undergoing surgery, such as the Nuss procedure.
  For the safe practice of pediatric epidural anesthesia, knowledge of the anatomical characteristics of pediatric patients and use of suitable equipment is indispensable. We use the drip and tube method to identify the epidural space in pediatric patients. With this technique, the anesthetist can advance the Tuohy needle with both hands, thus making the grip more stable. Using body weight to estimate the distance from the skin to the epidural space is very useful for performing epidural puncture safely. Ultrasound imaging may also permit more accurate prediction of the depth of the epidural space. Although caudal block via the sacral hiatus is a common regional technique in children, it is sometimes difficult to identify the sacral hiatus. Alternative methods, such as the sacral intervertebral approach, may be useful in pediatric patients.

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Special Lecture

Introduction of Postoperative Cases in Which Diagnosis and Treatment were Difficult in ICU

Motoshi KAINUMA, Takashi ICHIKAWA, Byeoknyeon KIM, Kimitoshi NISHIWAKI

2012 Volume 32 Issue 4 Pages 507-512
Published: 2012
Released on J-STAGE: October 11, 2012

DOIhttps://doi.org/10.2199/jjsca.32.507

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We introduces two postoperative cases in which the diagnosis and treatment were difficult in the ICU. Case 1 is a case who had frequent bleeding in thoracic cavity after lung surgery, and was diagnosed as having acquired hemophilia. PT was normal and APTT was prolonged preoperatively. Recombinant activated factor VII, activated prothrombin concentrates and steroid were administered. The inhibitor disappeared and the patient was discharged. Case 2 is a postoperative case of the LVOT stricture release and AVR. The patient had pulmonary hypertension and acute renal failure. PCPS and CHDF were performed. Sildenafil, bosentan and NO were administered, We performed APRV as respiratory management. The patient died of bowel ischemia. The anesthesiologist can influence the patient's outcome by taking part in the diagnosis and treatment in the ICU after the surgery.

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A Case of Retropharyngeal Hematoma after Stellate Ganglion Block (SGB) Which was Accompanied by a Recurrent Hemorrhage

Keiko MAMIYA, Motoi TERAO, Hanako OKADA, Yasuyuki AKAMA, Mitsuaki MATO ...

2012 Volume 32 Issue 4 Pages 513-518
Published: 2012
Released on J-STAGE: October 11, 2012

DOIhttps://doi.org/10.2199/jjsca.32.513

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  We experienced a case of retropharyngeal hematoma after SGB which was accompanied by a recurrent hemorrhage.
  The patient was transported to the emergency department and received hematoma exclusion operation after 7 days of SGB.
  It seems that this case was extremely rare and had an educational aspect for inexperienced young doctors. We reported this case with discussion from the literature.

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Lectures

New Protocol for IV-PCA with Newly- released Disposable Pump

MinHye SO, Kazuya SOBUE

2012 Volume 32 Issue 4 Pages 519-527
Published: 2012
Released on J-STAGE: October 11, 2012

DOIhttps://doi.org/10.2199/jjsca.32.519

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IV-PCA (intravenous-patient controlled analgesia) is a useful means of postoperative analgesia, if used appropriately. As a device for IV-PCA, electric pumps and disposable pumps are available now ; consequently, it makes the IV-PCA system confusing when adopted. We made new protocol for IV-PCA with the newly-released disposable pump and comparatively studied factors such as visual analogue scale, the incidence of postoperative nausea and vomiting between a new protocol group and a conventional protocol group. Quality of analgesia and side effects with the new protocol were equal to that with a conventional protocol when using an electric pump.

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Efficacy of a New Device : Changeable Continuous Flow Disposable PCA (Patient-Controlled Analgesia) Pump Using Intravenous PCA with Fentanyl for Postoperative Laparoscopic Colectomy

Yukitoshi NIIYAMA

2012 Volume 32 Issue 4 Pages 528-535
Published: 2012
Released on J-STAGE: October 11, 2012

DOIhttps://doi.org/10.2199/jjsca.32.528

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Intravenous patient-controlled analgesia (IV-PCA) is a widely used and effective analgesic method. Although a disposable PCA device is commonly used for postoperative pain analgesia, not being able to change the infusion setup is a disadvantage in Japan. Therefore, in this study, we investigated the efficacy of IV-PCA with fentanyl using the prototype of a changeable continuous flow disposable PCA device for laparoscopic colectomy in comparison with the fixed continuous flow type. The changeable type did not cause recovery of bowel function, but patients' reported higher satisfaction compared with the fixed type. The results imply that the changeable continuous flow disposable PCA device can play an important role in postoperative analgesia using IV-PCA with fentanyl.

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Original Articles

Incidence of Intraoperative Atelectasis Following Laparoscopic Surgery Performed in Lateral Position

Kiyoshi MORIYAMA, Yuka AZUMA, Akira MOTOYASU, Harumasa NAKAZAWA, Kumi ...

2012 Volume 32 Issue 4 Pages 536-540
Published: 2012
Released on J-STAGE: October 11, 2012

DOIhttps://doi.org/10.2199/jjsca.32.536

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Patients undergoing laparoscopic surgery in the lateral position have increased risk of developing gravity-dependent atelectasis. To assess the incidence of intraoperative atelectasis and postoperative hypoxia, we retrospectively compared the chest x-ray taken immediately after laparoscopic radical prostatectomy (the supine group) and laparoscopic radical nephrectomy/adrenalectomy (the lateral group), and the chest x-ray taken on postoperative day 1. The lateral group had significantly increased incidence of intraoperative atelectasis compared with the supine group (14/21 versus 1/25, p<0.0001). Fifty percent of intraoperative atelectasis remained unchanged on post-operative day 1. No pre-existing risk factor other than lateral position was evidently associated with the occurrence of intra-operative atelectasis. These results suggested that intraoperative atelectasis could lead to postoperative atelectasis.

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Postoperative Analgesia and Recovery with IV-PCA Morphine and Diclofenac Suppository after Spinal Surgery

Tsuyoshi SATSUMAE, Makoto TANAKA

2012 Volume 32 Issue 4 Pages 541-547
Published: 2012
Released on J-STAGE: October 11, 2012

DOIhttps://doi.org/10.2199/jjsca.32.541

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This study was designed to examine the efficacy of combination therapy with intravenous morphine and diclofenac suppository after spinal surgeries. Following informed consent, 32 patients undergoing elective spinal surgeries were studied. They were randomly assigned, according to the postoperative analgesic regimen, to either the morphine (M) group (n=16), who received IV-PCA morphine alone, or the morphine+diclofenac (M+D) group (n=16), who received, in addition to morphine PCA, diclofenac suppositories 50 mg every 6 h starting immediately before surgical incision for 48 h. Postoperative analgesic profiles, extent of side effects, and other complications were assessed using unpaired t-test, chi-squared test and Mann-Whitney U-test, with P < 0.05 being significant. Median pain score was lower in the M+D group. Postoperative morphine consumption and the extent of side effects (nausea/vomiting and sedation) were less in the M+D group. Time to first oral intake and bowel movement was shorter in the M+D group. Our data justify the combination therapy using IV-PCA morphine and diclofenac suppository for post-spinal surgery analgesia and recovery.

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Case Reports

Anesthetic Management of Total Arch Replacement in a Patient with Acute Aortic Dissection and Hemophilia A

Satsuki HAMADA, Asako ISHIKAWA, Yoshinori TANIGAWA, Kazukuni ARAKI, Yo ...

2012 Volume 32 Issue 4 Pages 548-554
Published: 2012
Released on J-STAGE: October 11, 2012

DOIhttps://doi.org/10.2199/jjsca.32.548

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A 61-year-old man with hemophilia A was diagnosed as having acute aortic dissection. After preoperative administration of 3,000 units of coagulation factor VIII (FVIII), coagulation laboratory data normalized (PT 86.3%, APTT 103%, FVIII 98.6%). FVIII (3.9 units/kg/hr) was continuously administered during surgery. Due to the heparin administered for cardiopulmonary bypass, PT, APTT, and FVIII values decreased to 57.9%, 10%, and 17.3%, respectively. After heparin reversal with protamine, however, hemostasis was difficult to achieve, and the PT and APTT values remained low. Hemostasis was eventually established, most likely due to the additional administration of FVIII (infusion rate up to 5 units/kg/hr and intermittent boluses of 500 to 1,500 units). FVIII was administered continuously until the 9th postoperative day (POD), and the FVIII level remained >100% after POD 2. The postoperative course was uneventful.

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A Case of Severe Tracheobronchial Compression and Superior Vena Cava Syndrome by Huge Anterior Mediastinal Tumor

Takako SASAI, Kyoichiro MAESHIMA, Satoshi SUZUKI, Tetsuya DANURA, Keij ...

2012 Volume 32 Issue 4 Pages 555-559
Published: 2012
Released on J-STAGE: October 11, 2012

DOIhttps://doi.org/10.2199/jjsca.32.555

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A 35-year-old man with a huge anterior mediastinal tumor, having tracheal compression, right primary bronchial stenosis, right pulmonary arterial occlusion and superior vena cava syndrome, was scheduled for tumor resection. Prior to general anesthesia, arterial and venous catheters were inserted in the left femoral vessels, and the right femoral vessels were exposed for extracorporeal membrane oxygenation in case of an emergency. Awake fiberoptic tracheal intubation was performed using a long thin tube through the tracheal stenotic portion. General anesthesia was induced after assuring controlled ventilation. Although facial edema, a sign of brain congestion, was observed during surgery, his conditions improved after bypass grafting from the innominate vein to the right atrium. Fatal ventilatory insufficiency or circulatory collapse was avoided through a careful preoperative evaluation.

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Three Cases of Upper Airway Obstruction after Posterior Cervical Spinal Fusion Surgery

Kumiko KITSUNEZUKA, Yuko URATSUJI, Yasuhiro KONO, Tomomi SUEHARA, Yayo ...

2012 Volume 32 Issue 4 Pages 560-563
Published: 2012
Released on J-STAGE: October 11, 2012

DOIhttps://doi.org/10.2199/jjsca.32.560

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We report three cases of upper airway obstruction after extended-duration posterior cervical spinal fusion surgery. Two cases showed dyspnea and reduction in arterial oxygen saturation immediately or within a few hours after operation, requiring tracheal intubation. The other case, however, could not be extubated because the patient showed severe anterior neck edema.
The risk factors of upper airway obstruction after posterior cervical spinal fusion surgery are as follows: extended-duration operation, multi-level spinal fusion, and rheumatic disease. In such cases, we should prepare to possibly re-intubate due to post-operative airway obstruction.

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A Case of Protracted Anaphylaxis Caused by TachoComb Application

Hirotsugu MIYOSHI, Ryuji NAKAMURA, Masakazu YASUJI, Ryuichi NAKANUNO, ...

2012 Volume 32 Issue 4 Pages 564-568
Published: 2012
Released on J-STAGE: October 11, 2012

DOIhttps://doi.org/10.2199/jjsca.32.564

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TachoComb is a ready-to-use collagen fleece-coated fibrinogen, thrombin, and aprotinin that is generally applied to an oozing site during surgical procedures. We treated a case of anaphylaxis caused by TachoComb application in a patient surgically treated for extrahepatic bile duct cancer. We were unaware that TachoComb was an allergen in our patient, until positive findings were obtained in a drug lymphocyte stimulation test performed 60 days after the operation. During surgery, the abdominal cavity was closed with the TachoComb remaining in the intraperitoneal cavity. Following the onset of anaphylactic reaction, continuous administration of adrenaline was necessary for about 20 hours. Interestingly, the serum concentrations of histamine and tryptase remained within normal ranges. We concluded that the anaphylactic reaction observed in this patient was caused by a mechanism unrelated to either histamine or tryptase.

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Brief Reports

Total Intravenous Anesthesia in Combination with Epidural Anesthesia for a Patient with Pseudocholinesterase Deficiency：A Case Report

Tatsunori WATANABE, Miho IKOMA, Chieko SHIBUE, Hiroshi BABA

2012 Volume 32 Issue 4 Pages 569-572
Published: 2012
Released on J-STAGE: October 11, 2012

DOIhttps://doi.org/10.2199/jjsca.32.569

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Anesthetic management of patients deficient in pseudocholinesterase can be problematic because of possible adverse reactions of suxamethonium and ester local anesthetics resulting in prolongation of neuromuscular blockade and local anesthetic intoxication, respectively. We report a case of a 70-year-old woman diagnosed with pseudocholinesterase deficiency who underwent open cholecystectomy under total intravenous anesthesia (TIVA) in combination with thoracic epidural anesthesia. Although the following agents were used for anesthesia management (propofol, remifentanil, fentanyl, rocronium, sugamadex, mepivacaine and ropivacaine), the patient was able to obey commands and was rapidly and safety extubated in a routine fashion after termination of TIVA at the end of surgery. In our case, propofol-remifentanil TIVA with amide local anesthetic epidural anesthesia could be safely performed in a patient with pseudocholinesterase deficiency.

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Other Reports

Keizo UENAKA : The Main Researcher in Adrenaline Purification

Shigeru SAITO

2012 Volume 32 Issue 4 Pages 573-581
Published: 2012
Released on J-STAGE: October 11, 2012

DOIhttps://doi.org/10.2199/jjsca.32.573

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  Ephedrine and adrenaline are key drugs that are indispensable for acute phase patient management. In the history of medicine and pharmaceuticals, Nagayoshi Nagai and Jokichi Takamine are commonly credited as having developed these drugs. However, Keizo Uenaka was the key scientist who worked on ephedrine and played a direct role in the purification and crystallization of adrenaline. After repeating his experiment from 111 years ago, I realized first-hand that Uenaka's technique was highly sophisticated, as he took special care to prevent the oxidization of adrenaline throughout the purification process.
  Although Uenaka was the main scientist and technician in adrenaline purification, his name is almost never referred to in scientific meetings nor documented explicitly in publications. This might be explained by the fact that Takamine was more focused on industrial applications than pure science.
  Only recently has Uenaka's contribution been brought to light. Historical research by Aiko Yamashita and Sosogu Nakayama uncovered Uenaka's handwritten memorandum, “On adrenalin, Memorandum, July to December, 1900”. This historically important evidence of adrenaline purification by Uenaka and Takamine, has been registered as Japanese cultural heritage by The Chemical Society of Japan and The National Museum of Nature and Science of Japan.

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[JAMS] Other Reports

Survey of Junior Resident Attitudes on Safe Sedation and Analgesia

Nobuyasu KOMASAWA, Masashi NAKAGAWA, Kazuaki ATAGI, Ryusuke UEKI, Nori ...

2012 Volume 32 Issue 4 Pages 582-587
Published: 2012
Released on J-STAGE: October 11, 2012

DOIhttps://doi.org/10.2199/jjsca.32.582

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The purpose of this study was to conduct a survey of junior resident attitudes after attending a sedation training course hosted by the Japanese Association of Medical Simulation. Survey contents included emergencies during sedation, monitoring and airway management devices and techniques, and impressions of the Sedation and Analgesia guidelines for non-anesthesia doctors developed by the American Society of Anesthesiologists. About 90% of trainee doctors had experience with respiratory suppression, 60% with circulation depression, and about 60% with manual airway support. Junior residents largely accepted the guidelines. Sedation training courses for junior residents are essential from the perspective of medical safety.

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Special feature article - Part2 -

Common Arrhythmia during Perioperative Periods, Diagnosis and Management : Narrow QRS Tachycardia

Shinji TAKAHASHI

2012 Volume 32 Issue 4 Pages 590-596
Published: 2012
Released on J-STAGE: October 11, 2012

DOIhttps://doi.org/10.2199/jjsca.32.590

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Tachycardia often develops into tachyarrhythmia in perioperative periods. It is important to maintain adequate anesthetic depth, analgesia, and fluid balance. If fatal tachyarrhythmia occurs, immediate electrical cardioversion is indicated. If the patient is hemodynamically stable, we should evaluate the ECG, then determine whether the narrow QRS tachycardia is regular or irregular. Regular tachycardia is usually paroxysmal supraventricular tachycardia (PSVT), which should be treated with vagal maneuver, ATP, or both. If the ATP fails to convert PSVT, it is reasonable to use beta-blocker or calcium channel blocker. Irregular tachycardia is most likely atrial fibrillation (AF). The management of AF should focus on rate control (beta-blocker or calcium channel blocker) or rhythm control (electrical cardioversion, amiodarone, procainamide). If the new-onset AF does not convert to sinus rhythm within 48 hours, anticoagulation therapy is recommended.

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Wide QRS Tachycardia

Toshiaki MOCHIZUKI

2012 Volume 32 Issue 4 Pages 597-600
Published: 2012
Released on J-STAGE: October 11, 2012

DOIhttps://doi.org/10.2199/jjsca.32.597

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The term “wide QRS” is defined as a QRS interval ≥ 120 ms on ECG (electrocardiogram). It is often difficult to differentiate whether the arrhythmia causing sustained (sustained time ≥ 30 sec) wide QRS tachycardia is ventricular tachycardia, paroxysmal supraventricular tachycardia with aberrant conduction, atrial flutter with aberrant conduction, or WPW (Wolff-Parkinson-White) syndrome. A patient should be considered “unstable” when a symptom and/or a sign such as loss of consciousness including syncope, ischemic chest pain, dyspnea, hypotension, or findings of shock are observed. These patients should receive immediate synchronized DC cardioversion. Patient diagnosed as “stable” wide QRS tachycardia should be immediately referred to a cardiologist and may be considered for drug therapy. A 12-lead ECG for further diagnosis is highly recommended in as many situations as possible.

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Brugada Syndrome and QT Prolongation Syndrome

Yoshihiko ONISHI

2012 Volume 32 Issue 4 Pages 601-605
Published: 2012
Released on J-STAGE: October 11, 2012

DOIhttps://doi.org/10.2199/jjsca.32.601

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  Brugada syndrome is defined as electrocardiographic (ECG) changes consisting of ST elevation in V1-V3 lead and is induced by ventricular fibrillation. This hereditary syndrome is often the cause of death in younger adult men, predominantly. Implantation of ICD is a definite therapy to prevent sudden death.
  QT prolongation syndrome (LQTS) is defined as prolonged QT interval (QTc > 440msec) and causes malignant ventricular arrhythmias to the development of torsade de pointes. This syndrome is heredity or induced by several drugs. The first therapy for LQTS is intravenous adopted be-ta blockers, mexiletine and verapamil. However, patients who have had mortal arrhythmias, including VF, are indicated for ICD implantation.
  Anesthetic consideration of the patients with implanted ICD is to arrest the ICD function and attach the DC pads on the thorax during the operation.

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Refractory Arrhythmia in Cardiac Surgery

Takeshi IRITAKENISHI

2012 Volume 32 Issue 4 Pages 606-610
Published: 2012
Released on J-STAGE: October 11, 2012

DOIhttps://doi.org/10.2199/jjsca.32.606

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Arrhythmias during cardiac surgery are common. The anesthesiologist is often confronted in situations where the method and need for treatment depend on the context of the operation. If refractory arrhythmias should occur before cardiopulmonary bypass (CPB), initiation of CPB should be chosen rather than pharmacological approach or electrical defibrillation, while if refractory arrhythmias should occur at weaning of CPB, combinations of multiple approaches including pacing therapy, antiarrhythmic drugs, defibrillation and induction of percutaneous cardiopulmonary support, should be considered in order to stabilize hemodynamics.

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Transplanted Heart and Arrhythmia

Takeshi IRITAKENISHI

2012 Volume 32 Issue 4 Pages 611-614
Published: 2012
Released on J-STAGE: October 11, 2012

DOIhttps://doi.org/10.2199/jjsca.32.611

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Recipients undergoing heart transplantation are deprived of autonomic reactions from the allograft heart. Due to this ‘denervation’ the cardiac output of the allograft highly depends on the preload of the ventricles, thus hypovolemia must be avoided. Pacing therapy and administration of isoproterenol may be necessary to maintain optimal heart rate and cardiac output upon weaning from cardiopulmonary bypass (CPB). Prevalence of arrhythmias after heart transplantation has been reported to be between 23 and 79%. Atrial arrhythmias are the most common. Incidence of cardiac sudden death (SD) varies 0.5-35%, with ventricular fibrillation (Vf) or asystole being reported to be the most common cause. Cardiac SD occurring within a year of the surgery is most often related to acute rejection. Cardiac allograft vasculopathy, the chronic rejection of the allograft, is the most common cause of cardiac SD occurring more than a year after heart transplantation.

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Treatment of the Lethal Arrhythmia Based on an AHA Guideline 2010

Choichiro TASE

2012 Volume 32 Issue 4 Pages 615-619
Published: 2012
Released on J-STAGE: October 11, 2012

DOIhttps://doi.org/10.2199/jjsca.32.615

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The lethal arrhythmia includes ventricular fibrillation (VF)/pulseless ventricular tachycardia (VT), “unstable tachycardia” and “unstable bradycardia” based on a 2010 AHA guideline. Generally, “Unstable” refers to a condition in which vital organ function is acutely impaired or cardiac arrest is ongoing or imminent. When an arrhythmia causes a patient to be unstable, immediate intervention is indicated. Survival from VF/pulseless VT rhythms requires both basic life support (BLS) and advanced cardiovascular life support (ACLS) with integrated post-cardiac arrest care. In particular, early CPR and rapid defibrillation are essential. On the other hand, it is reasonable for us to initiate transcutaneous pacing (TCP) in unstable bradycardic patients who do not respond to atropine. Also, unstable tachycardia needs immediate synchronized cardioversion.

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The Practical Indication of Defibrillation and Cardioversion for Critical Tachyarrhythmias during Perioperative Periods

Satoki INOUE

2012 Volume 32 Issue 4 Pages 620-623
Published: 2012
Released on J-STAGE: October 11, 2012

DOIhttps://doi.org/10.2199/jjsca.32.620

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Lifethreatening tachyarrhythmias are ventricular fibrillation (VF) and pulseless ventricular tachycardia (pulseless VT), which require immediate cardiopulmonary resuscitation and defibrillation. Other critical tacharrythmias may require synchronized cardioversion. High-energy unsynchronized shocks (defibrillation doses) are necessary for both VF and pulseless VT. Don't hesitate to apply electrodes on alternative pad positions. Self-adhesive defibrillation electrodes may be preferred for the purpose of safety. Synchronized cardioversion at 100J can be applied for regular VT. Relatively high-energy synchronized cardioversion may be applied for atrial fibrillation (Af), which appears to result in successful defibrillation. Paroxysmal supraventricular tachycardia (PSVT) and atrial flutter (AF) are respond well to relatively low-energy synchronized cardioversion (50-100J).

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The Perioperative Indication of Temporary Cardiac Pacing and Practical Considerations for Anesthetic Management

Satoki INOUE

2012 Volume 32 Issue 4 Pages 624-627
Published: 2012
Released on J-STAGE: October 11, 2012

DOIhttps://doi.org/10.2199/jjsca.32.624

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The indications for temporary pacing can be considered to fall into two broad categories: emergency or elective. Any patient with acute haemodynamic compromise caused by bradycardia or ventricular tachyarrhythmias in response to bradycardia should be considered for temporary cardiac pacing. Transcutaneous cardiac pacing is effective for emergency cases during anesthesia because this approach can be achieved rapidly without complicated procedures. It has been considered that prophylactic temporary cardiac pacing be established to cover general anesthesia in the presence of bifascicular block or second degree heart block, although there is little evidence to support this consideration, especially in the case of bifascicular block. However, intensive monitoring during the perioperative period and rapid preparation for emergency pacing can be required.

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Perioperative Management of Patients with a Permanent Pacemaker

Takahiro SUGIURA, Yosuke MORI

2012 Volume 32 Issue 4 Pages 628-631
Published: 2012
Released on J-STAGE: October 11, 2012

DOIhttps://doi.org/10.2199/jjsca.32.628

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With population aging and the new indications for implanting cardiac devices, which has led to an increase in the number of implantations, surgical procedures are increasingly performed on patients with an implanted pacemaker (PM). Preoperative management of patients with a PM includes evaluation and optimization of the coexisting disease. Important aspects of preanesthesia evaluation include defining the type of PM, evaluating PM-dependence, and assessing PM-function. Preoperative preparation includes determining whether electromagnetic interference (EMI) is likely to occur during the planned procedure, evaluating the need for reprogramming the pacemaker to asynchronous pacing, and ensuring the availability of temporary pacing and defibrillation equipment. Electrocardiogram and peripheral pulse monitoring are important components of the perioperative management of patients with a PM that help in detecting whether a PM or cardiac dysfunction has occurred. Procedures using electrocautery interfere with PM function, and this interference could result in severe adverse outcomes. Therefore, preparation of the patient is necessary before emergency defibrillation is performed or heart rate support is provided.
Postoperative care should include interrogating the PM and reprogramming it to the original settings if preoperative programming was performed.

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Anesthesia Management in Patients Undergoing Implantable Cardioverter-Defibrillator Implantation

Takahiro SUGIURA, Yosuke MORI

2012 Volume 32 Issue 4 Pages 632-635
Published: 2012
Released on J-STAGE: October 11, 2012

DOIhttps://doi.org/10.2199/jjsca.32.632

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  The implantable cardioverter-defibrillator (ICD) is highly effective in the primary and secondary prevention of life-threatening ventricular arrhythmias.
  With a decrease in the size of the ICD, administration of general anesthesia is not always required for implantation and testing. Rather, local anesthesia and sedation are extensively administered instead.
  In either situation, the important steps for anesthesia management during ICD implantation are as follows : 1) evaluating the patient's condition, including parameters such as cardiac function, 2) understanding the disease diagnostics, 3) appropriate sedation and airway management for conducting the test, and 4) performing emergency defibrillation, performing cardioversion, or providing heart rate support to identify potential precipitating causes and triggers.

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