THE JOURNAL OF JAPAN SOCIETY FOR CLINICAL ANESTHESIA

Original Articles

A Retrospective Comparison of Anesthetic Management in Robot-assisted Laparoscopic Surgery versus Conventional Laparoscopic Surgery in Pediatric Urology

Tatsuya TSUJI, Mitsunori MIYAZU, Kazuya SOBUE

2015 Volume 35 Issue 3 Pages 295-300
Published: May 15, 2015
Released on J-STAGE: August 19, 2015

DOIhttps://doi.org/10.2199/jjsca.35.295

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In this study, we compared anesthetic management in robot-assisted laparoscopic surgery (da Vinci surgery : hereinafter, dV surgery) with conventional laparoscopic surgery in pediatric urology. We retrospectively examined the medical records of pediatric patients who received dV surgery (dV group : 15 cases) and those of a group of age-and surgical style-matched patients in whom conventional laparoscopy was performed (L group : 15 cases). The only significant intergroup difference was the time for anesthesia induction (60.3 ± 9.9 min in the dV group versus 42.6 ± 6.3 min in the L group). We believe that this may be attributed to the time required for patient positioning. Anesthetic management for dV surgery was performed safely, and no significant intergroup differences were observed. However, precautions should be taken regarding patient positioning as these problems are not encountered in adult cases.

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Appropriate Head Position for Tracheal Intubation Using Airway Scope^®

Naomi ONO, Mayumi SHIOMI, Eiji TSUJII, Soongji CHO

2015 Volume 35 Issue 3 Pages 301-304
Published: May 15, 2015
Released on J-STAGE: August 19, 2015

DOIhttps://doi.org/10.2199/jjsca.35.301

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We examined the appropriate head position for tracheal intubation using Airway Scope (AWS, HOYA made, Tokyo), a video type laryngoscope. Thirty nurses who have never used AWS conducted a tracheal intubation using the AWS with a mannequin. We set the head of the mannequin to a horizontal position that was substantially horizontal or to an elevated position, that was set about 5 cm higher than horizontal. We compared the time required for intubation (intubation time) in both head positions. Intubation time with the horizontal position was shorter than with the elevated position, suggesting that intubation using AWS is easier when the head position is nearly horizontal.

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Case Reports

Considerations Regarding Anesthetic Management of Scoliosis Surgery in Patients with Total Cavopulmonary Connection (TCPC)

Yurika ENDO, Takuji HOSOI, Takashi KOMATSUZAKI, Nobuyuki KATORI, Hiros ...

2015 Volume 35 Issue 3 Pages 305-310
Published: May 15, 2015
Released on J-STAGE: August 19, 2015

DOIhttps://doi.org/10.2199/jjsca.35.305

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Advances in the surgical and medical management of children with congenital heart disease have reduced mortality in these patients. As a result, more patients are undergoing non-cardiac surgery.
We anesthetized three patients for idiopathic scoliosis surgery who underwent Fontan procedures. We consulted with orthopedists before the operations to reduce operative time and avoid a drastic correction of the spine. We attempted to minimize pulmonary vascular resistance and to extubate as soon as possible. We used FloTrac^TM and PreSep oximetry catheter^TM to monitor blood pressure, cardiac index, central venous pressure, and central venous oxygen saturation. To maintain good hemodynamic states, adequate single ventricle preload and appropriate administration of fluid and blood are needed.
In anesthetic management of patients with the Fontan circulation for scoliosis surgery, it is important to understand the pathophysiology of the Fontan circulation and perioperative care.

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Effect of Rocuronium and Sugammadex in a Morbidly Obese Pregnant Patient with Spinal Muscular Atrophy Type Ⅲ

Satomi YAMAMOTO, Yusuke YAMAMOTO, Yuko KONDO, Noriya HIROSE, Osamu KIT ...

2015 Volume 35 Issue 3 Pages 311-314
Published: May 15, 2015
Released on J-STAGE: August 19, 2015

DOIhttps://doi.org/10.2199/jjsca.35.311

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We evaluated rocuronium-induced neuromuscular block and sugammadex-facilitated recovery from neuromuscular block in a pregnant patient with spinal muscular atrophy type Ⅲ scheduled to undergo a cesarean section under general anesthesia.
About 90 minutes after a bolus intubating dose of rocuronium 1 mg/kg, the first post-tetanic count finally reappeared at the adductor pollicis muscle.
A markedly longer duration of action of rocuronium was observed, but, the time for recovery to baseline train-of-four ratio was 75 s after an injection of sugammadex 4 mg/kg.
Even in a pregnant patient with spinal muscular atrophy, sugammadex was effective for rapid reversal from rocuronium-induced neuromuscular block.

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Symposium (1)

[title in Japanese]

Masayuki MIYABE, Shin KAWANA

2015 Volume 35 Issue 3 Pages 315
Published: May 15, 2015
Released on J-STAGE: August 19, 2015

DOIhttps://doi.org/10.2199/jjsca.35.315

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Pediatric Epidural Analgesia

Aki UEMURA

2015 Volume 35 Issue 3 Pages 316-324
Published: May 15, 2015
Released on J-STAGE: August 19, 2015

DOIhttps://doi.org/10.2199/jjsca.35.316

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Postoperative epidural analgesia is well established in adults. Pediatric epidural blockade also provides high quality analgesia. When we perform pediatric epidural analgesia, patients, parents, pediatric surgeons, and pediatric nurses are satisfied with the quality of postoperative analgesia. We do not need opioids for postoperative analgesia, and patients recover earlier and discharge earlier. This reduces medical expenses significantly as well. However, most anesthesiologists hesitate to choose pediatric epidural analgesia as postoperative pain relief. Pediatric epidural analgesia is not so complicated because of their anatomical structure. There are several points to keep in mind in order to perform pediatric epidural analgesia safely, precisely, and routinely. First is to use tools (needle, catheter and introducer) appropriate for pediatric patients. Second is to use a method such as the drip infusion method. Third is predicting the distance from the skin to the epidural space from body weight. This is most important. And we have to always think about the balance of risk and benefit before performing pediatric epidural analgesia for each patient. If there is more risk than benefit, we have to choose another postoperative analgesia.

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Perioperative Analgesia Using Ultrasound-Guided Peripheral Trunk Blocks in Children

Akemi SHIDO

2015 Volume 35 Issue 3 Pages 325-335
Published: May 15, 2015
Released on J-STAGE: August 19, 2015

DOIhttps://doi.org/10.2199/jjsca.35.325

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The basic idea of perioperative pain management in patients of all ages is to minimize opioid consumption using regional analgesia whenever possible. Epidural analgesia, a typical form of regional analgesia, is frequently used for perioperative abdominal analgesia in adults, but is used less frequently in pediatric patients because it requires more experience than adult epidural analgesia. However, ultrasound-guided peripheral nerve blocks have increased in popularity in both adults and children. Trunk blocks using ultrasound are becoming more frequent for perioperative abdominal wall analgesia, although the methodology has not yet been fully established even in adults. There are three important points in the use of peripheral nerve blocks for perioperative abdominal analgesia in children. The first point is to choose a block that covers the abdominal wound as completely as possible. The second is to assess and treat visceral pain, since it cannot be removed by peripheral trunk blocks. And the last is to consider the pharmacokinetic properties specific to children.Ultrasound-guided peripheral trunk blocks can contribute to pediatric perioperative multimodal abdominal analgesia. However, a number of subjects must be investigated to establish its methodology.

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Symposium (2)

[title in Japanese]

Kazumasa YASUMOTO, Koshi MAKITA

2015 Volume 35 Issue 3 Pages 336
Published: May 15, 2015
Released on J-STAGE: August 19, 2015

DOIhttps://doi.org/10.2199/jjsca.35.336

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Anesthesia Management during Surgery : A Lung Protective Ventilation Strategy

Kiyoyasu KURAHASHI

2015 Volume 35 Issue 3 Pages 337-343
Published: May 15, 2015
Released on J-STAGE: August 19, 2015

DOIhttps://doi.org/10.2199/jjsca.35.337

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Mechanical ventilation is mandatory for patients with severe hypoxemia. Lung-protective ventilation is originally referred to reduced tidal volume ventilation for patients with acute respiratory distress syndrome to prevent further lung injury. Open lung approach, permissive hypercapnia, and aiming to limit plateau pressure are other concepts included in lung-protective ventilation strategy. There is increasing evidence that demonstrates the benefit of lung-protective ventilation during surgery in some patients and surgical cohorts. In the present paper, the mechanism by which lung injury occurs during surgery, details about lung-protective ventilation, and patient cohorts that benefit from the lung-protective ventilation strategy will be discussed.

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Reconsideration of Respiratory Care during Pediatric Anesthesia

Kazuya TACHIBANA, Muneyuki TAKEUCHI

2015 Volume 35 Issue 3 Pages 344-350
Published: May 15, 2015
Released on J-STAGE: August 19, 2015

DOIhttps://doi.org/10.2199/jjsca.35.344

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The key points that pediatric anesthesiologists should consider while providing respiratory care during anesthesia may differ from those that apply to pediatric intensive care unit (PICU). We therefore reconsidered respiratory care during anesthesia from the point of view of PICU respiratory care. Airway management is the most important factor throughout an operation because the pediatric airway is very unstable and pediatric endotracheal tube can easily dislocate, so pediatric anesthesiologists must be able to respond quickly to sudden ventilatory insufficiency. For this reason, a simpler and lighter anesthetic respiratory circuit is desirable for pediatric anesthesia. Because of the simplicity of the anesthesia procedure, insufficient humidification, low positive end-expiratory pressure and inaccurate tidal volume measurement are often unavoidable, but we have to keep in mind that lung-protective ventilation is necessary to prevent ventilator-induced lung injury. The respiratory care adopted in PICU may be not practical for short-duration anesthesia, but lung-protective ventilation that includes sufficient humidification may affect the outcome in long-duration anesthesia and in children with pulmonary complications.

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Alternative Ventilation Strategy to One-lung Ventilation for Thoracic Surgery

Seiji ISHIKAWA

2015 Volume 35 Issue 3 Pages 351-356
Published: May 15, 2015
Released on J-STAGE: August 19, 2015

DOIhttps://doi.org/10.2199/jjsca.35.351

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One-lung ventilation is a standard ventilation strategy for thoracic surgery. However, it requires special equipment such as a double-lumen endobronchial tube and a bronchoscope, takes longer for intubation and confirmation of correct tube placement, and is associated with risks related to malposition of the tubes or blockers, as well as hypoxemia. Furthermore, the incidence and severity of hoarseness and throat pain as postoperative complications may be higher with a double-lumen tube than with a single-lumen tube. Taking these issues into consideration, researchers have been looking for alternative ventilation strategies to one-lung ventilation for thoracic surgery to establish a less invasive ventilation strategy or overcome difficult cases. In this review article, indications, tips, pitfalls, and contraindications for ventilation options other than one-lung ventilation, such as two-lung ventilation, high-frequency jet ventilation, and spontaneous respiration, are described. For example, two-lung ventilation with a single-lumen tube may be performed in patients with pneumothorax during bullectomy under video-assisted thoracoscopy. However, in such cases, tidal volume should be kept low, and ventilation may sometimes need to be paused in order to avoid complicating the surgical field.

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Symposium (3)

[title in Japanese]

Isao TSUNEYOSHI, Yuji KADOI

2015 Volume 35 Issue 3 Pages 357
Published: May 15, 2015
Released on J-STAGE: August 19, 2015

DOIhttps://doi.org/10.2199/jjsca.35.357

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Perioperative Circulatory Management in Septic Patients

Noboru HATAKEYAMA

2015 Volume 35 Issue 3 Pages 358-362
Published: May 15, 2015
Released on J-STAGE: August 19, 2015

DOIhttps://doi.org/10.2199/jjsca.35.358

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Perioperative circulatory management in septic patients should be started as early as possible after the recognition of sepsis. Compliance with surviving sepsis campaign guideline (SSCG) bundle is recommended as initial therapy. Crystalloid fluid infusion is encouraged while hematoxy ethyl starch (HES) infusion is avoided. Norepinephrine is recommended as initial choice of catecholamine. Treatment with phospho-di-esterase III inhibitors and/or calcium sensitizer in combination with beta blockers will be the future target of treatment for septic patients, and great attention should be paid to maintenance of urine output.

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Mechanical Ventilation in Septic Patients

Yasuhiro MORIMOTO

2015 Volume 35 Issue 3 Pages 363-367
Published: May 15, 2015
Released on J-STAGE: August 19, 2015

DOIhttps://doi.org/10.2199/jjsca.35.363

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The strategy of mechanical ventilation in septic patients during and after surgery is important to avoid pulmonary complications. Recently, protective mechanical ventilation including lower tidal volumes with appropriate PEEP has been shown to reduce mortality. This strategy is described in “The Japanese guidelines for the management of sepsis” and “Surviving sepsis campaign”. More protective mechanical ventilation including airway pressure release ventilation (APRV) and high frequency oscillatory ventilation (HFOV) have been tried in septic patients. However, the advantage of APRV and HFOV over lower tidal volume ventilation has not been shown in clinical trials. Therefore, the routine use of this new ventilation mode is not recommended for septic patients.

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Symposium (4)

[title in Japanese]

Ryoichi OCHIAI, Tomoko YOROZU

2015 Volume 35 Issue 3 Pages 368
Published: May 15, 2015
Released on J-STAGE: August 19, 2015

DOIhttps://doi.org/10.2199/jjsca.35.368

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First Four Years of a Postoperative Pain Management Team

Ichiro KONDO

2015 Volume 35 Issue 3 Pages 369-373
Published: May 15, 2015
Released on J-STAGE: August 19, 2015

DOIhttps://doi.org/10.2199/jjsca.35.369

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Postoperative pain management has been the subject of much attention and has been actively carried out abroad for more than 20 years. Management of postoperative pain relieves suffering and leads to earlier mobilization, shortened hospital stays, reduced hospital costs, and increased patient satisfaction.
Forming an APS (Acute Pain Service) team is essential to carrying out postoperative pain management that improves the quality of care and facilitates the management of patients with postoperative pain. However, a variety of difficulties need to be overcome to these teams to work well at large hospitals.
4 years have passed since an APS team was formed in the Jikei Medical University Hospital. I will introduce the course of the last four years in our APS team and its future direction.

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Postoperative Pain Management from the Viewpoint of Surgeons and Floor Nurses in the Surgery Ward : A Questionnaire Survey Study

Ken ETO, Katsuhiko YANAGA, Nobuo OMURA, Toshiaki MORIKAWA, Takao OHKI

2015 Volume 35 Issue 3 Pages 374-381
Published: May 15, 2015
Released on J-STAGE: August 19, 2015

DOIhttps://doi.org/10.2199/jjsca.35.374

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Due to the significance of pain management in postoperative care, Jikei Post-Operative Pain Service (JPOPS) was initiated by the Department of Anesthesiology of Jikei University Hospital, and the JPOPS team commenced full operations in April 2013. However, differences in pain management with conventional methods provided only by surgeons began to arise. Although the analgesic component of postoperative care is important, the environment and opinions of surgeons who are in charge of patients and of floor nurses who actually take direct care of patients on a daily basis are also important. Involvement of members of the Department of Anesthesiology who are familiar with analgesic methods is crucial in the management of postoperative pain, but it is also necessary to build a constructive framework in which cooperation between all care providers involved in postoperative patient care operates smoothly. Such a framework can be established only when sufficient communication between anesthesiologists, surgeons and floor nurses is well developed.

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Lectures

Introduction of the Updated ASA Practice Guidelines for Management of the Difficult Airway

Akihiro SUZUKI

2015 Volume 35 Issue 3 Pages 382-386
Published: May 15, 2015
Released on J-STAGE: August 19, 2015

DOIhttps://doi.org/10.2199/jjsca.35.382

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At the 33rd annual meeting of the Japan Society for Clinical Anesthesia, the author introduced the updated practice guidelines for management of the difficult airway issued by the American Society of Anesthesiologists in a difficult airway symposium. This manuscript summarizes the information presented and additional opinions discussed at the meeting.

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Are Current Guidelines about Difficult Airway Management Truly Useful? : What Factors Should Be Included to New Guidelines

Takashi ASAI

2015 Volume 35 Issue 3 Pages 387-392
Published: May 15, 2015
Released on J-STAGE: August 19, 2015

DOIhttps://doi.org/10.2199/jjsca.35.387

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The currently available guidelines about difficult airway management are not ideal. New guidelines are needed, but some practical difficulties remain for the following reasons : the cause of difficult intubation or difficult ventilation are numerous ; difficult mask ventilation occurs without apparent reason ; difficult airway management in itself may produce airway obstruction ; and difficult airways are associated with another two major life-threatening complications (pulmonary aspiration and unnoticed esophageal intubation). Nevertheless, new guidelines could be made more useful by incorporating the following factors : structured methods to plan airway management in patients with predicted difficult airways ; types and doses of analgesics and sedatives for “awake intubation” ; a clearer indication of when a supraglottic airway should not be used as a rescue ; and what the next plan should be when percutaneous cricothyroidotomy fails.

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Efficacy of Desflurane for Early Recovery and Early Detection of Neurological Abnormality in Spinal Surgery

Naoyuki HIRATA

2015 Volume 35 Issue 3 Pages 393-398
Published: May 15, 2015
Released on J-STAGE: August 19, 2015

DOIhttps://doi.org/10.2199/jjsca.35.393

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Spinal surgery may result in spinal cord injury. Therefore, early recovery from anesthesia including early recovery of cognitive function is preferable for detecting a neurological deficit immediately after spinal surgery. Our previous study and other studies have demonstrated that the use of desflurane enabled faster and better recovery from anesthesia than did other volatile anesthetics. Those results suggest that the use of desflurane is appropriate and effective in spinal surgery. To confirm the efficacy of desflurane in spinal surgery, a retrospective comparative study was conducted in 140 patients who underwent spinal surgery under general anesthesia. We investigated the differential effects of desflurane (n＝67) and sevoflurane (n＝73) on time to extubation and recovery after anesthesia. Our study showed that time to extubation and recovery in patients administered desflurane was significantly shorter than in patients administered sevoflurane. The use of desflurane is the best way to evaluate results of neurological tests during and immediately after spinal surgery.

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Pursuing Contemporary Cardiac Anesthesia

Hiroyuki IKEZAKI, Masayuki KIMOTO, Ken TAKEMORI

2015 Volume 35 Issue 3 Pages 399-405
Published: May 15, 2015
Released on J-STAGE: August 19, 2015

DOIhttps://doi.org/10.2199/jjsca.35.399

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Over the past two decades, cardiac surgery has greatly advanced and cardiac anesthesiology has fully adapted to this progress, which has brought us the contemporary practice of cardiac anesthesia. Improved techniques in anesthesia, surgical methods and cardiopulmonary bypass management have made it possible to free surgical patients from perioperative major complications. Utilizing pulmonary artery catheter and transesophageal echocardiography contributed to our decision making in cardiac anesthesia, but, we need to know about their indications, limitations, and complications when using these devices. The best practical method for anesthesia of the cardiac surgical patient has not yet been well established. The practice of cardiac anesthesia is strongly connected to cardiology, anesthesiology and intensive care, and continues to be very challenging. Thus, further investigations and daily practices for seeking the best standards for cardiac anesthesia are warranted.

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[JACM] Other Reports

Factors Affecting Arterial Blood Pressure Monitoring

Shigeki FUJIWARA, Keiichi TACHIHARA, Yoshifumi KAWAKUBO, Satoshi MORI, ...

2015 Volume 35 Issue 3 Pages 406-413
Published: May 15, 2015
Released on J-STAGE: August 19, 2015

DOIhttps://doi.org/10.2199/jjsca.35.406

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Pressure transducer monitoring kits have their own frequency characteristics (natural frequency, damping coefficient). These frequency characteristics are influenced by many factors. A Planecta^TM (JMS, Hiroshima, Japan) for blood sampling is one factor that has a remarkable influence on the natural frequency in the pressure transducer monitoring kits. Resonance Over-Shoot Eliminator (ROSE^TM) has been released by Argon Medical Devices (TX, USA). This device increases damping coefficient by suppressing resonance phenomenon in the pressure transducer monitoring kit. We describe the influence of the insertion of one or two Planectas^TM and insertion of the ROSE^TM on frequency characteristics.

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