THE JOURNAL OF JAPAN SOCIETY FOR CLINICAL ANESTHESIA

Review Articles

Consciousness and Memory Function during Anesthesia

Shuji DOHI

2015 Volume 35 Issue 1 Pages 001-014
Published: 2015
Released on J-STAGE: February 17, 2015

DOIhttps://doi.org/10.2199/jjsca.35.001

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Nearly 170 years have passed since William Morton successfully demonstrated the use of inhaled ether for surgical anesthesia in 1846. During the last 40 years, the development of new anesthetics and safe general anesthesia techniques have contributed greatly to the advancement of surgery and other invasive procedures. Although the general anesthetic state comprises multiple components (amnesia, unconsciousness, analgesia, and immobility), each of which is mediated by effects on different neurotransmitter receptors and neuronal pathways, it is not clear as yet whether a patient is having memories during anesthesia and is able to recall them after anesthesia. In several of my own patients, I could not understand what happened in the anesthetized brain, especially in inferring same gaps between amnesia and unconsciousness. The neural mechanisms by which the state of general anesthesia is achieved are only just beginning to be understood. In this brief review, I report five anesthetic cases and focus on the mechanisms of anesthetic action with respect to unconsciousness and memory consolidation involved in mediating the clinically relevant events such as awareness during anesthesia.

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Original Articles

Can Intubation Guide Mark Provide Adequate Information for Tube Positioning?

Hiroshi ARAKI, Kenji NISHIOKA, Hiroko ARAKI, Sungsam CHO, Tetsuya HARA ...

2015 Volume 35 Issue 1 Pages 015-020
Published: 2015
Released on J-STAGE: February 17, 2015

DOIhttps://doi.org/10.2199/jjsca.35.015

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We retrospectively investigated the incidence of endobronchial intubation when the intubation guide mark was positioned at the level of the vocal cords. The chest radiographies of 283 patients who underwent general anesthesia were reviewed, and the distance between the endotracheal tube (ETT) tip and the carina (TT-C) was measured. The incidence of endobronchial intubation and the high risk (TT-C < 2.5 cm) subjects was 1.4% and 18.4% of all, respectively. Females had significantly higher risk of endobronchial intubation. The distance between the intubation guide mark and the tube tip (DM) of the ETT is not consistent among manufacturers. These findings suggest that when DM is considered in choosing the tube size, the intubation guide mark would be useful in deciding adequate ETT positioning.

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Case Reports

A Case of Cardiac Arrest Due to Coronary Spasm during Mediastinal Tumor Resection

Atsuko TAKAMATSU, Itsuko SHIBATA, Osamu YOSHITOMI, Takuji MAEKAWA, Sun ...

2015 Volume 35 Issue 1 Pages 021-026
Published: 2015
Released on J-STAGE: February 17, 2015

DOIhttps://doi.org/10.2199/jjsca.35.021

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A 63-year-old man without history of ischemic heart disease was scheduled for mediastinal tumor resection. His blood pressure markedly decreased when surgeons separated the tumor from pulmonary veins. Following ST-segment elevation, ventricular fibrillation and ventricular tachycardia developed. The operation was completed and the patient awoke without neurological deficits. Coronary artery spasm was suspected from intraoperative electrocardiographic change and postoperative echographic examination of the cause of cardiac arrest. Hypotension due to the surgical procedure was suspected as the cause of the coronary spasm. In non-cardiac surgery, coronary spasm has been observed more commonly in patients without history of ischemic heart disease, the stress of the operation or anesthesia being responsible for coronary spasm. Smoking is considered to be a crucial risk factor for coronary spasm. In this case, intraoperative hypotension due to the surgical procedure, the clinical characteristics, and vascular endothelial dysfunction by smoking may have caused coronary artery spasm.

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Respiratory Disorder after Posterior Cervical Laminoplasty and Spine Fusion Surgery : A Case Report

Tadanori YAMADA, Yoshiko KASUYA

2015 Volume 35 Issue 1 Pages 027-031
Published: 2015
Released on J-STAGE: February 17, 2015

DOIhttps://doi.org/10.2199/jjsca.35.027

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A 41-year-old man with ossification of the posterior longitudinal ligament of the cervical spine underwent posterior cervical laminoplasty and spine fusion surgery. Although the operation, which was performed under general anesthesia, was uneventful and successful, severe dyspnea occurred 2 hours after extubation. We therefore re-intubated the patient for ventilator management. The dyspnea was caused by diaphragmatic nerve paralysis with C5 palsy, which was a complication of the operation. C5 palsy is an important and risky complication of cervical decompression surgery, which occurs some hours or days after surgery. Some reports suggest that a respiratory disorder due to C5 palsy after cervical surgery, as seen in the present case, is rare. It is therefore critical to ascertain the cause of a respiratory disorder, as it is difficult to anticipate the same before awareness from general anesthesia.

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A Case of Arytenoid Cartilage Dislocation Diagnosed Five Days after Anesthesia for Distal Gastrectomy

Takehito SATO, Sigenori YOKOYAMA, Kousei OTAKA

2015 Volume 35 Issue 1 Pages 032-035
Published: 2015
Released on J-STAGE: February 17, 2015

DOIhttps://doi.org/10.2199/jjsca.35.032

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A 77-year-old female with stomach cancer was scheduled for surgery. Distal gastrectomy was performed under general and epidural anesthesia. Intraoperative and postextubation periods were unremarkable. No complaints of obvious hoarseness or throat soreness were made by the patient during postoperative rounds by the anesthesiologist and nurse the next day, but the patient complained of hoarseness on postoperative day 5. Laryngoscopy revealed that the right arytenoid cartilage had been dislocated to the level of the anterior vocal folds. As a result of conservative treatment by the otolaryngologist, the arytenoid cartilage was repositioned by postoperative day 41. Although arytenoid cartilage dislocation is a rare postoperative complication, it should be kept in mind by anesthesiologists.

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A Very Elderly Case of Idiopathic Superior Lumbar Hernia Showing Atypical Symptoms

Satoshi YAMAGUCHI, Giichiro OHNO

2015 Volume 35 Issue 1 Pages 036-040
Published: 2015
Released on J-STAGE: February 17, 2015

DOIhttps://doi.org/10.2199/jjsca.35.036

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We report a very elderly case of an idiopathic superior lumbar hernia requiring emergency surgery because of delayed diagnosis owing to atypical symptoms. The patient was a 101-year-old woman who was hospitalized owing to right lumbago, which was estimated to be caused by complicated osteoporosis. On the 3rd day after admission, her lumbago suddenly worsened and was associated with nausea and the urge to vomit, and a soft bulge appeared in her right lower back area. Computed tomography revealed a prolapse of the intestinal tract through the posterolateral abdominal wall. Diagnosis of a lumbar hernia was established, and the patient underwent emergency abdominal repair surgery. General anesthesia was performed, and her hemodynamic state was stable during surgery despite her very advanced age. Although intestinal necrosis and peritonitis were suspected, they were not diagnosed. The operative view was a superior lumbar hernia, and incarceration was repaired without any complication. There have been no signs of recurrence. Lumbar hernia is a very rare disease with atypical symptoms such as lumbago and lumbar bulge. The diagnosis therefore tends to be delayed, and emergency surgery is frequently required for incarceration of the intestinal tract. We suggest that anesthesiologists should keep this disease in mind during daily clinical consultations.

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Invited Lecture

Intraoperative Fluid Management in High-risk Surgical Patients

Yoshifumi KOTAKE, Shigeo SHINODA, Yuichi MAKI, Daisuke TOYODA

2015 Volume 35 Issue 1 Pages 041-047
Published: 2015
Released on J-STAGE: February 17, 2015

DOIhttps://doi.org/10.2199/jjsca.35.041

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Liberal fluid strategy mostly using crystalloid solution to achieve adequate blood pressure and urine output has been widely used in intraoperative fluid management. However, recent increases in high-risk surgical patients and trends toward early recovery after surgery require more advanced strategies of fluid management. In high-risk surgical patients, the advantages of fluid optimization using less-invasive hemodynamic monitor and synthetic colloid administration, have been reported. For patients in early recovery after surgery, a restrictive fluid strategy has successfully reduced gastrointestinal complications and contributed to achieving the goal of early recovery. For these reasons, goal-directed fluid management, which includes both fluid optimization and fluid restriction, is a logical choice as a future trend in intraoperative fluid management.

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Symposium (1)

[title in Japanese]

Kazuya SOBUE, Munetaka HIROSE

2015 Volume 35 Issue 1 Pages 048
Published: 2015
Released on J-STAGE: February 17, 2015

DOIhttps://doi.org/10.2199/jjsca.35.048

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Surgical Site Infection and Antimicrobial Prophylaxis

Takehiro WAKASUGI, Takaki YOSHIKAWA, Haruhiko CHO, Hiroyuki ITOH, Atsu ...

2015 Volume 35 Issue 1 Pages 049-055
Published: 2015
Released on J-STAGE: February 17, 2015

DOIhttps://doi.org/10.2199/jjsca.35.049

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Preventing the development of surgical site infections is important. There are numerous management factors involved in preventing surgical site infections over the perioperative period. The appropriate use of antimicrobial prophylaxis is an effective measure to prevent surgical site infections. Inappropriate use of antimicrobial prophylaxis does not prevent surgical site infections and, can lead to drug-resistant organisms. It is important to formulate antimicrobial prophylaxis manuals that specify the dose, the timing of administration, the timing of re-dosing, and the duration of administration, considering each hospital's circumstances.

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Improved Anesthetic Management Can Reduce Perioperative Infection

Soshi IWASAKI

2015 Volume 35 Issue 1 Pages 056-060
Published: 2015
Released on J-STAGE: February 17, 2015

DOIhttps://doi.org/10.2199/jjsca.35.056

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This article shows that anesthesiologists would reduce surgical-site infections (SSI) by enforcing perioperative non-smoking and body temperature management. Hypothermia during surgery may also increase SSI rates. Furthermore, SSI may occur due to differences in methods of anesthesia or anesthetic drugs. We also describe the relationship between perioperative infection and the ERAS protocol.

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Perioperative Infection and Maintenance of the Operating Room Environment

Motoi ITANI, Sachiko IWAYAMA, Emi SHIGETA, Yasuko IKEDA

2015 Volume 35 Issue 1 Pages 061-066
Published: 2015
Released on J-STAGE: February 17, 2015

DOIhttps://doi.org/10.2199/jjsca.35.061

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  The air conditioning in an operating room is strictly controlled because of established evidence that maintaining cleanliness in an operating room reduces perioperative infections.
  Doctors working in an operating room wear masks and caps in order to prevent infections due to droplets or skin coming into contact with the surgical field. Furthermore, it is necessary to 1) provide ventilation through high-performance filters, 2) maintain a vertical laminar flow, 3) minimize the number of times doors are opened, and 4) decrease the number of people in the room to reduce dust coming into the room. All of these measures are part of maintaining a clean environment in an operating room.
  However, despite having advanced equipment, this system breaks down easily if even one person behaves inappropriately in the room. Therefore, everyone in the operating room, including anesthesiologists, surgeons, and nurses, should cooperate to maintain the environmental cleanliness of an operating room.

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Surgical Site Infection Prevention : The Role of the Infection Control Nurse

Noriko SHINKAI, Takahiro SHIMOZONO

2015 Volume 35 Issue 1 Pages 067-072
Published: 2015
Released on J-STAGE: February 17, 2015

DOIhttps://doi.org/10.2199/jjsca.35.067

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Surgical site infections (SSI) accounts for 20% of all health care-associated infections and are a serious post-operative complication, so preventing them is important. The surgical staff plays a critical role to this end, as bacterial contamination during surgery could lead to SSI. Pre-operative and post-operative care are also needed to reduce the risks of SSI. This requires a multi-disciplinary approach in which physicians, nurses, medical technicians, laboratory technologists, and pharmacists work collectively for the prevention, early detection, and treatment of SSI.
An infection control nurse (ICN) coordinates the cross-departmental efforts by implementing the PDCA cycle to identify problems with surveillance, enlist various health care professionals to execute preventive strategies throughout the perioperative processes, evaluate their effectiveness, and introduce new interventions.

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Symposium (2)

[title in Japanese]

Yoshiro SAKAGUCHI, Shoichi UEZONO

2015 Volume 35 Issue 1 Pages 073
Published: 2015
Released on J-STAGE: February 17, 2015

DOIhttps://doi.org/10.2199/jjsca.35.073

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Intraoperative Use of Dexmedetomidine in Pediatric Patients : Advantages and Disadvantages

Yukako ABUKAWA, Koichi HIROKI, Makoto OZAKI

2015 Volume 35 Issue 1 Pages 074-077
Published: 2015
Released on J-STAGE: February 17, 2015

DOIhttps://doi.org/10.2199/jjsca.35.074

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  In pediatric anesthesia, dexmedetomidine (DEX) is used off-label all over the world. I herein describe the present conditions, and the advantages of using DEX based on the current literature.
  DEX is associated with several advantages, including the fact that it induces minimal respiratory depression, and it has a pain-killing effect in addition to an antianxiety effect. The disadvantages of DEX are that it must be used off-label and can lead to changes in blood pressure and heart rate depending on the dose administered.
  In our institution, DEX is used for children aged five to seven years old who are undergoing a pectus excavatum operation and being treated using patient-controlled epidural or intravenous analgesia. We do not use a loading dose because it can lead to changes in blood pressure and heart rate. We start to inject a concentration of 0.4 μg/kg/hr DEX intravenously when the wound is sutured. We can reduce the risk of respiratory failure, allow for smooth extubation, and make the stay in the ICU more comfortable using DEX.
  I believe that the drug will likely be adopted in the future, and it appears to be an especially useful drug in the field of pediatric anesthesia.

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Potential of Dexmedetomidine as an Intraoperative Sedative

Ami SUGAWARA, Takayuki KUNISAWA

2015 Volume 35 Issue 1 Pages 078-081
Published: 2015
Released on J-STAGE: February 17, 2015

DOIhttps://doi.org/10.2199/jjsca.35.078

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Dexmedetomidine (DEX) is now available for sedation during surgery under local anesthesia in non-intubated patients. The sedative effect of DEX is characterized by the fact that patients wake up immediately following verbal instructions, but remain asleep if there is no stimulation. Additionally, DEX has analgesic effects and causes less respiratory depression than other sedatives. DEX has many attractive properties that are grouped into the following three categories : (1)Anesthetic-sparing action : It is well known that combining DEX with other agents decreases anesthetic requirements. We reported that advancing the start time of DEX administration caused hemodynamic stability at the time of anesthesia induction ; (2)Use as a single anesthetic : DEX has analgesic effects ; therefore, it is thought that high-dose DEX may cause a state of unconsciousness like general anesthesia despite the maintenance of spontaneous respiration ; (3)Application to awake surgery : Patients administered DEX wake up immediately in response to verbal instructions.
This off-label use of DEX was approved and monitored by the Research Ethics Committee of Asahikawa Medical University, and informed consent was obtained from the patients' parents. We introduce our cases and discuss how DEX should be used in anesthesia practice.

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Intraoperative Dexmedetomidine Usage for Difficult Airway Cases

Mitsuko MIYAUCHI, Takehiko ADACHI

2015 Volume 35 Issue 1 Pages 082-087
Published: 2015
Released on J-STAGE: February 17, 2015

DOIhttps://doi.org/10.2199/jjsca.35.082

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Dexmedetomidine is widely used in ICUs. In June 2013, dexmedetomidine was approved in Japan for unintubated patients undergoing operations with local anesthesia. This decision will facilitate the usage of dexmedetomidine during surgery. We anesthesiologists should have more detailed knowledge of dexmedetomidine to provide safer, high-quality sedation. We have some experience with intraoperative dexmedetomidine use, especially in patients who have trouble with their airway. Here, we report the advantages and pitfalls of intraoperative dexmedetomidine usage.

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Symposium (3)

[title in Japanese]

Yoshihito UJIKE

2015 Volume 35 Issue 1 Pages 088
Published: 2015
Released on J-STAGE: February 17, 2015

DOIhttps://doi.org/10.2199/jjsca.35.088

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The Selection and Settings of Mechanical Ventilation Mode in Patients with Acute Respiratory Failure

Akinori UCHIYAMA

2015 Volume 35 Issue 1 Pages 089-097
Published: 2015
Released on J-STAGE: February 17, 2015

DOIhttps://doi.org/10.2199/jjsca.35.089

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One of the historically significant improvements in mechanical ventilation in critically ill patients was the improvement of synchrony between the ventilator and spontaneous breathing effort. Development of the superior ventilator mode has improved the comfort of patients and reduced the incidence of pulmonary complications due to dyssynchrony. Reduction of the amount of sedatives during mechanical ventilation has led to improved prognosis of critically ill patients. When the physician selects the ventilation mode and determines ventilatory settings in patients with acute respiratory failure, major concerns are the preservation of spontaneous breathing efforts and synchrony between the ventilator and spontaneous breathing effort. Recently, however, it was reported that 48 hours of muscle relaxation improved the prognosis in early phase of severe ARDS. The use of muscle relaxants in patients with acute respiratory failure has been reexamined. Our study also showed that spontaneous breathing effort itself might enhance the development of lung injury in animal trials. In this review, I introduce how to think about spontaneous breathing effort in selecting ventilation modes and determining mechanical ventilation settings.

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Management of Pain, Agitation, and Delirium in Mechanically Ventilated Patients

Shin NUNOMIYA

2015 Volume 35 Issue 1 Pages 098-105
Published: 2015
Released on J-STAGE: February 17, 2015

DOIhttps://doi.org/10.2199/jjsca.35.098

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Current concepts in the management of pain, agitation, and delirium in adult, mechanically ventilated patients are described here. The key element of the concepts are summarized as ‘ABCDE bundles’, and all medical personnel involved in the management of mechanically ventilated adults are now required to keep these concepts in mind.

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Weaning from Mechanical Ventilation

Masahide OTSUKA

2015 Volume 35 Issue 1 Pages 106-111
Published: 2015
Released on J-STAGE: February 17, 2015

DOIhttps://doi.org/10.2199/jjsca.35.106

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Patients who require mechanical ventilation have respiratory center failure, inadequate ventilatory mechanics, oxygenation failure, or failure of upper airway patency. Patients with respiratory center failure must be ventilated using controlled mechanical ventilation mode. In contrast, patients with inadequate ventilatory mechanics may be ventilated with partial ventilatory support (i.e. pressure support ventilation). Ventilatory support must be set to a minimum level so that the ventilatory muscles will not be fatigued, and there is no need to decrease the support level slowly, or to decrease the support under the requirement level to train the ventilatory muscles. There is usually a tendency to decrease the support level slowly. Therefore, a spontaneous breathing trial, which is a challenge involving removal of the ventilator and making the patient breathe spontaneously, can shorten the period of mechanical ventilation after recovery from ventilatory failure.

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Lectures

Prevention of Preventable Death

Tomoko YOROZU

2015 Volume 35 Issue 1 Pages 112-117
Published: 2015
Released on J-STAGE: February 17, 2015

DOIhttps://doi.org/10.2199/jjsca.35.112

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Central venous catheter related blood stream infection (CRBSI) is preventable, so deaths due to it are also preventable. Pronovost reported a remarkable reduction in CRBSI after strictly implementing five key preventive steps by using a checklist in intensive care units. This required a change in the work culture prevalent among the staff in the unit, which meant a change in the staff's attitude toward improving safety measures to ensure a high compliance in following simple procedures proven to prevent CRBSI. Adding to Pronovost's recommendations, we introduced additional measures such as recommending 1% chlorhexidine (CHG) alcohol solution as a skin disinfectant and using CHG-impregnated dressings. However, introducing some of these new measures into practice (translating research into practice) was difficult in our hospital due to differences in customs or culture of working units. In order to implement the new measures, a comprehensive unit-based safety program is necessory to change work culture. All staff members in a working unit need to work together. Once the safety program is established in the unit, measuring performance is important to obtain feedback regarding the program. Strict surveillance of CRBSI, especially in intensive care units, is therefore vital.

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[JARMA] Case Reports

Investigation of a Medical Case Leading to Criminal Proceedings on Grounds of Guidelines

Atsuko KIUCHI, Kazumasa YASUMOTO, Takahisa GOTO, Shuichi NOSAKA, Yoshi ...

2015 Volume 35 Issue 1 Pages 120-127
Published: 2015
Released on J-STAGE: February 17, 2015

DOIhttps://doi.org/10.2199/jjsca.35.120

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We reviewed and report a case of criminal medical malpractice from 2008. A corrugated tube was accidentally disconnected from a patient and adverse events occurred while the anesthesiologist in charge was called away from the operating room to aid another physician. The in-hospital investigative commission concluded that the reason the tube was disconnected could not be determined, and that the surgeons in the operating room did not hear the alarm sound. The anesthesiologist was prosecuted based on the guideline “an anesthesiologist should stay beside the patient and consistently monitor him/her.” The judge, however, acquitted the anesthesiologist based on the following grounds: (1) there was no description of predictability in the indictment document; (2) the corrugated tube may have become disconnected due to the actions of other medical personnel in the operating room; (3) it is not reasonable that medical personnel in the operating room would not have heard the alarm sound; and (4) the guideline is only a recommendation of an academic society. Clinical practice guidelines had previously been assumed to be a criterion on which to determine medical standards, based on sentences handed down in preceding civil medical cases.

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[JACM] Educational Lecture

Clinical Interpretation of CO₂ Monitor

Yoshiro SAKAGUCHI

2015 Volume 35 Issue 1 Pages 130-137
Published: 2015
Released on J-STAGE: February 17, 2015

DOIhttps://doi.org/10.2199/jjsca.35.130

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Capnography is useful as a real time ventilatory monitor. By analyzing capnograms and the partial pressure gradient of carbon dioxide between arterial blood and end-tidal gas, we can evaluate the appropriateness of ventilation, the ventilation perfusion ratio mismatch, and the alveolar dead space. Volume capnograms indicate the measurement of anatomical and alveolar dead space. In non-intubated patients, it is essential to recognize the capnogram pattern caused by hypoventilation.

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The Basic Interpretation of Surface Electrocardiography (2) : The Theory of Generation in T Waves

Yoshifumi TANAKA

2015 Volume 35 Issue 1 Pages 138-145
Published: 2015
Released on J-STAGE: February 17, 2015

DOIhttps://doi.org/10.2199/jjsca.35.138

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The author has found that the right hand electrode detects extracellular potential in endocardium and the left foot electrode detects the extracellular potential of epicardium, and if the epicardial potential subtracted from the endocardial potential, the results will be set to surface electrocardiogram. In a normal electrocardiogram, the resting potential of endocardium and epicardium are the same voltage and depolarizing potential are also the same. Hence there is no difference between base line and ST segment. However there are four combinations in abnormal situations, namely higher or lower voltage of epicardium in resting state or in depolarizing state. This article is written about the four corresponding diseases : angina pectoris, myocardial infarction, Brugada syndrome, and early repolarization syndrome.

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Knowledge of Statistics and Study Design Required in Clinical Research

Hiroto NARIMATSU

2015 Volume 35 Issue 1 Pages 146-151
Published: 2015
Released on J-STAGE: February 17, 2015

DOIhttps://doi.org/10.2199/jjsca.35.146

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One of the major aims of clinical research is to develop practical applications of basic medical research. Stagnation in clinical research in Japan would cause serious disadvantages to the Japanese people. Clinical research is therefore required from both the scientific and social points of view. Physicians can play an important role in clinical research, but opportunities for education and training clinical research is limited in Japan. In this paper, we review essential elements of clinical research including study design, study ethics, and the biological statistics used in clinical research. Physicians with knowledge of these can be leaders in promoting clinical research.

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