THE JOURNAL OF JAPAN SOCIETY FOR CLINICAL ANESTHESIA
Online ISSN : 1349-9149
Print ISSN : 0285-4945
ISSN-L : 0285-4945
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Volume 36, Issue 1
Displaying 1-23 of 23 articles from this issue
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Case Reports
  • Recurarization Following Adequate Dose of Sugammadex Reversal in a Patient Monitored with Aceleromyography
    Shinji IGA, Kazuyoshi SHIMIZU, Kenji KAWADE, Tomoyuki KANAZAWA, Kyoko ...
    2016 Volume 36 Issue 1 Pages 1-6
    Published: January 15, 2016
    Released on J-STAGE: February 12, 2016
    DOIhttps://doi.org/10.2199/jjsca.36.1
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    There are a few reports regarding recurarization, which is mainly caused by insufficient dosage of sugammadex. However, there is no report of recurarization after adequate usage of sugammadex according to recommendation. We experienced a patient in whom recurarization occurred despite using sugammadex under proper monitoring with aceleromyography during the operation. A 78-year-old man with a slight renal impairment was scheduled for laparoscopic distal gastrectomy under general anesthesia with sevoflurane, fentanyl and remifentanil. Muscle relaxation was induced and maintained with rocuronium with continuous monitoring using TOF Watch SX®. At the end of the procedure, two twitches were visualized after supramaximal train-of-four stimulation at the adductor pollicis muscle. His tracheal tube was removed after administration of sugammadex 200 mg (3.6 mg/kg). Seventy minutes later, he complained of difficulty breathing and an immobilization of his limbs with desaturation. After the additional dose of sugammadex 200 mg (3.6 mg/kg), oxygenation and mobilization were dramatically improved. There is a risk of recurarization even when the recommended dose of sugammadex is administered, so it is necessary to observe a patient closely for a while even after extubation.
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  • A Case of Cardiac Tamponade during Thoracoscopic Surgery : Usefulness of Transesophageal Echocardiography
    Miyuki TAKAHASHI, Yasunori NIWA, Miho URAYAMA, Nobuhiro SHIMADA, Mamor ...
    2016 Volume 36 Issue 1 Pages 7-10
    Published: January 15, 2016
    Released on J-STAGE: February 12, 2016
    DOIhttps://doi.org/10.2199/jjsca.36.7
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    A 65-year-old man underwent video-assisted left upper segmentectomy for pulmonary metastasis in the right lateral position. Systolic pressure suddenly decreased to 50 mmHg immediately after the resection during surgery. Because bleeding from the chest wall was observed, volume expansion and administration of vasoactive drugs were started, but the patient remained hemodynamically unstable after hemostasis. Searching for a cause, we decided to use transesophageal echocardiography (TEE) and were able to make a diagnosis of cardiac tamponade. Subsequently, pericardiotomy rapidly stabilized circulatory dynamics. Intraoperative cardiac tamponade is a rare complication, but should be considered in differential diagnosis. TEE was useful in monitoring and diagnosis when cardiovascular failure rapidly appeared during surgery.
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  • Two Cases of Airway Obstruction after Radiation Therapies
    Yuki MATSUMOTO, Kazuyoshi HASHIMOTO, Ryu YOSHIDA, Yuzou SHIMAZU, Hisas ...
    2016 Volume 36 Issue 1 Pages 11-14
    Published: January 15, 2016
    Released on J-STAGE: February 12, 2016
    DOIhttps://doi.org/10.2199/jjsca.36.11
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    We report two cases of airway obstruction due to several radiotherapies. In the first case, although a “cannot ventilate, cannot intubate” (CVCI) situation arose, we performed cricothyrotomy, thus saving the patient. In the second case, we were able to perform bronchoscopy early to assess her laryngeal edema before nasal intubation and tracheotomy were performed. As a result, a potentially distressing situation for the patient was prevented. We must be careful of airway obstructions that can occur in patients after several radiotherapies.
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  • Combined Spinal-epidural Anesthesia for Cesarean Section in a Patient with Ventriculoperitoneal Shunt
    Takuya DOUSEI, Tomoko FUJII, Mikiko IGA, Arata YAMADA, Atsunori SAKAMO ...
    2016 Volume 36 Issue 1 Pages 15-19
    Published: January 15, 2016
    Released on J-STAGE: February 12, 2016
    DOIhttps://doi.org/10.2199/jjsca.36.15
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    A 36-year-old pregnant patient received a ventriculoperitoneal shunt operation for congenital hydrocephalus at 1 year and 27 years of age. The VP shunt functioned normally, and she did not have any intracranial hypertensive symptoms. Elective cesarean section was planned for the breech position of the baby. A review of the literature related to pregnant patients with VP shunt found that both regional and general anesthesia has been used. The choice of anesthesia should be based on neurological status and obstetric advice. The preoperative abdominal X-ray examination indicated that the VP shunt tube was located on the surface of the uterus. The delivery of the baby was expected to take time. We therefore chose CSEA instead of general anesthesia. Spinal anesthesia was performed at the L3/L4 space with a 25-gauge Quincke needle. The drug used was 7.5 mg of 0.5% hyperbaric bupivacaine. Sensory blockade reached the Th3 level within 10 minutes. The patient was hemodynamically stable during the anesthesia. The operating procedure was uneventful. The mother and child were discharged from the hospital on the 8th day after birth.
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Brief Reports
Other Reports
  • The Effectiveness of Intravenous Patient-controlled Analgesia with Fentanyl and Ketamine for the Management of Postoperative Pain after Orthopedic Surgery
    Mariko MUTO, Yoichi TANAKA
    2016 Volume 36 Issue 1 Pages 25-28
    Published: January 15, 2016
    Released on J-STAGE: February 12, 2016
    DOIhttps://doi.org/10.2199/jjsca.36.25
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    Severe postoperative pain is expected after orthopedic surgeries such as osteosynthesis of upper limb fractures, and it is sometimes difficult to treat with intravenous infusion of fentanyl only. We observed the quality of postoperative pain management using intravenous patient-controlled analgesia with a mixture of 1 mg fentanyl, 100 mg ketamine, 5 mg droperidol, 2 mL combined diphenhydramine and diprophylline preparation, and 16 mL normal saline solution at a basic rate of 0.6-1.4 mL/h in 35 adult patients who had undergone orthopedic surgery of distal radius fractures under general anesthesia. Additional analgesics including intravenous flurbiprofen axetil, tramadol, or dexamethasone were also administered. Neurological tests could even be performed just after surgery. Patients had a satisfactory analgesic effect. No severe adverse effects associated with analgesics ware observed. Among the 35 patients, 8.5% experienced nausea but did not vomit. We introduced this pain management method after upper limb orthopedic surgeries.
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Symposium (1)
  • [title in Japanese]
    Kazuya SOBUE, Masashi NAKAGAWA
    2016 Volume 36 Issue 1 Pages 29
    Published: January 15, 2016
    Released on J-STAGE: February 12, 2016
    DOIhttps://doi.org/10.2199/jjsca.36.29
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  • Rapid Response System Improves Postoperative Safety
    Yoshiki SENTO, Shigeki FUJITANI, Kazuaki ATAGI, Kazuya SOBUE
    2016 Volume 36 Issue 1 Pages 30-34
    Published: January 15, 2016
    Released on J-STAGE: February 12, 2016
    DOIhttps://doi.org/10.2199/jjsca.36.30
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    There is a need to promote the efficiency of perioperative management in Japan. Serious adverse events (SAEs) may increase when postoperative patients in general wards are not given sufficient and timely attention in adequate settings. Implementing the Rapid Response System (RRS), which aims to identify patients at an earlier stage of clinical deterioration to prevent SAEs such as cardiac arrest and unexpected death, could be one solution for improving safety management in the postoperative phase. RRS could be a safety net for postoperative SAEs. In Nagoya City University Hospital, RRS has been successfully implemented to improve the safety of postoperative patients. However, 69% of unplanned postoperative admissions to the ICU bypass RRS. The characteristics of postoperative patients managed by RRS were reviewed.
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  • Potentiality of PACU
    Reinii SAKAMOTO, Toshiyasu SUZUKI
    2016 Volume 36 Issue 1 Pages 35-42
    Published: January 15, 2016
    Released on J-STAGE: February 12, 2016
    DOIhttps://doi.org/10.2199/jjsca.36.35
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    With the increasing number of surgical patients due to the centralization of medical care in the acute phase, the postoperative management systems of general hospital wards may not be adequate to respond to such an increase. Our institution experienced one case where a patient developed respiratory arrest in our general ward after an operation. In response to this incident, our institution has established and is effectively utilizing a post-anesthesia care unit (PACU) within the operating room to manage postoperative patients for a certain critical period. In this paper, we discuss the history of PACUs, their usefulness, their current status in Japan, our institution’s approach to PACU management, and also address future challenges.
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  • Simulation Training Using Postoperative SAEs (Serious Adverse Events) Cases Is a Good Teaching Method for RRS (Rapid Response System)
    Masashi NAKAGAWA
    2016 Volume 36 Issue 1 Pages 43-49
    Published: January 15, 2016
    Released on J-STAGE: February 12, 2016
    DOIhttps://doi.org/10.2199/jjsca.36.43
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    The Rapid Response System (RRS) was developed as a new strategy to improve in-hospital patient safety. The system consists of 4 components as follows : 1) to detect a newly worsening patient and start this system : 2) to treat the patient by a well-trained medical team : 3) to summarize the patient’s clinical course and feed it back to on-site staff : and 4) to analyze the data and improve a hospital safety policy. Scenario-based simulation training using a high-fidelity human simulator was often employed for training component 1) and 2).
    Most hospitals have department-based wards, so patients in each ward have similar disease configurations. To enhance the realism of scenario-based simulation training, we used a case scenario based on events that occurred in each ward, especially postoperative serious adverse event (SAE) cases in surgery-related wards. Those who were trained using the SAE case scenario found the RRS more familiar than those trained using a general case scenario. Simulation training using postoperative SAE cases is a good teaching method for the RRS.
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Symposium (2)
  • [title in Japanese]
    Shunichi TAKAGI
    2016 Volume 36 Issue 1 Pages 50
    Published: January 15, 2016
    Released on J-STAGE: February 12, 2016
    DOIhttps://doi.org/10.2199/jjsca.36.50
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  • Acetylcholine Receptors at Neuromuscular Junctions
    Tomoki SASAKAWA, Hiroshi IWASAKI
    2016 Volume 36 Issue 1 Pages 51-56
    Published: January 15, 2016
    Released on J-STAGE: February 12, 2016
    DOIhttps://doi.org/10.2199/jjsca.36.51
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    Acetylcholine (ACh) released from nerve terminals binds with numerous nicotinic ACh receptors in neuromuscular junctions, causing depolarization and muscular contractions. When bound with ACh, these receptors dynamically regulate channel closing and opening by rotational movements. ACh receptors present on end plates are commonly called mature ACh receptors and have 5 subunits. Nerve-type ACh receptors composed of α3β2 are present before synapses and contribute to remobilization of synaptic vesicles via positive feedback. Immature ACh receptors composed of an α2βγδ subunit in which an ε subunit is replaced by a γ subunit are expressed on muscles in the fetal stage or denervated muscles. This often causes clinical problems due mainly to differences in responses to suxamethonium. In addition, studies conducted in recent years have suggested the presence of α7 ACh receptors composed only of the α7 subunit in muscles under specific conditions, raising interest in their physical roles, because these ACh receptors have been believed to be present only in central nerves.
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  • Methodological Review and Trends of Neuromuscular Function Monitor
    Yoshifumi KOTAKE, Daisuke TOYODA, Yuichi MAKI
    2016 Volume 36 Issue 1 Pages 57-62
    Published: January 15, 2016
    Released on J-STAGE: February 12, 2016
    DOIhttps://doi.org/10.2199/jjsca.36.57
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    Two distinct modalities of neuromuscular monitoring are available : qualitative (subjective) and quantitative (objective) monitoring. The difference between the two is the ability to display the train-of-four ratio (TOFR). Currently, the use of quantitative monitoring is strongly recommended since TOFR>90% is needed to prevent postoperative complications. Quantitative neuromuscular monitors include electromyogram, mechanomyogram, kinemyogram, acceleromyogram (AMG) and phonomyogram. Among them, AMG is regarded as the clinical standard in current anesthetic practice. However, anesthesiologists should be aware of several issues related to AMG such as staircase phenomenon and phenomenon that the response to fourth stimulus is significantly higher than the response to the first twitch. Providing universal availability of quantitative neuromuscular monitoring as well as continued education seems to be indispensable for wider application of neuromuscular monitoring and subsequent elimination of postoperative residual curarization.
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  • Neuromuscular Monitoring Equipment, Neuromuscular Monitoring Sites, Practical Neuromuscular Monitoring
    Osamu KITAJIMA
    2016 Volume 36 Issue 1 Pages 63-71
    Published: January 15, 2016
    Released on J-STAGE: February 12, 2016
    DOIhttps://doi.org/10.2199/jjsca.36.63
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    Neuromuscular blocking drugs act on the neuromuscular junction, but there is no way to directly measure their effects on the neuromuscular junction, so neuromuscular function is monitored by evaluating the muscular response to stimulation of a peripheral motor nerve. Neuromuscular monitoring equipment : Mostly TOF-Watch® is clinical used. Neuromuscular monitoring sites : The adductor pollicis muscle response to ulnar nerve stimulation is the most popular site. The other monitoring sites are facial nerve stimulation and observation of the corrugator supercilii muscle, flexor hallucis brevis muscle and posterior tibial nerve, and masseter muscle and masseteric nerve. Neuromuscular monitoring : The black electrode should be placed at the distal position, the white electrode at the proximal position, and the acceleration transducer attached so as to be perpendicular to the motion. Finally, calibration should be done.
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Lectures
  • An Update in Meta-Analysis : Multiple Treatment Comparison
    Toshiya SHIGA
    2016 Volume 36 Issue 1 Pages 72-78
    Published: January 15, 2016
    Released on J-STAGE: February 12, 2016
    DOIhttps://doi.org/10.2199/jjsca.36.72
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    Meta-analysis has been established as a powerful tool to answer research questions in clinical practice, but the conventional methods are limited to performing pairwise comparisons, most of which are ‘intervention group vs. placebo group.’ The Bayesian approach enables simultaneous comparison of the effect size among trials with more than two intervention arms (multiple comparisons or network meta-analysis), or ranking the best intervention (probability of ranking). This review’s aim was to refresh what we already know about meta-analysis using the Bayesian framework.
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[JSIVA] Other Reports
  • Education of Intravenous Anesthesia Based on Case Conferences
    Shoko FUJIOKA, Yoshihiro KIMURA, Shuya KIYAMA
    2016 Volume 36 Issue 1 Pages 79-82
    Published: January 15, 2016
    Released on J-STAGE: February 12, 2016
    DOIhttps://doi.org/10.2199/jjsca.36.79
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    Total intravenous anesthesia using propofol and remifentanil is a very versatile technique which can be applied to many types of surgical patients. On the other hand, standard doses of these agents may cause clinically significant hypotension and myocardial depression in patients with limited cardiovascular reserve. Ketamine is a unique intravenous anesthetic with sympathomimetic activity and analgesic effect. However, ketamine is not routinely used in daily practice and not all trainees would have an opportunity to use this drug during their residency. In our University Department of Anesthesia, we hold case conferences once a week and discuss perioperative management of patients who have developed significant problems during and/or after anesthesia. Even if the perioperative course was uneventful, presentation of clinical course will help distribute basic knowledge as well as practical tips on not so frequently used drugs such as ketamine. We propose that case conferences could be utilized as a valuable opportunity to learn practical anesthetic pharmacology.
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[JARMA] Special Lecture
  • What We Can Learn from Autopsy Imaging
    Seiji YAMAMOTO
    2016 Volume 36 Issue 1 Pages 84-91
    Published: January 15, 2016
    Released on J-STAGE: February 12, 2016
    DOIhttps://doi.org/10.2199/jjsca.36.84
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    Autopsy imaging (Ai) is an examination procedure to identify causes of death using CT scan or magnetic resonance imaging. Ai is performed to prevent missing of crime or in cases in who medical-related death is suspected. However, Ai system is going to be socially accepted and be more popular in the future. Because CT scan is already spread over the country in Japan, it is possible for anybody to have Ai in any place. There is no other method to identify causes of death to perform equally. Ai will play a more important role after the new system to investigate medical mishap has started.
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[JARMA] Educational Lecture
[JARMA] Other Reports
  • A Monitoring System for Medical Accidents Initiated Based on an Amendment of the Medical Service Law System, Overview, Comparison with Draft Outline, and Future Challenges
    Atsuko KIUCHI, Kazumasa EHARA, Miyuki YOKOTA, Naoki MIZUNUMA, Sadato G ...
    2016 Volume 36 Issue 1 Pages 106-116
    Published: January 15, 2016
    Released on J-STAGE: February 12, 2016
    DOIhttps://doi.org/10.2199/jjsca.36.106
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    A new monitoring system for medical accidents was established based on an amendment of the Medical Service Law in June 2014 and will come into effect starting in October 2015. The aim of the system is to prevent the recurrence of medical accidents to ensure safety in medical practice. Two systems are described in the draft guideline from the World Health Organization, 1) a “Reporting system for accountability” and 2) a “Reporting system for learning.” The new monitoring system was clearly indicated as corresponding to the latter by the Ministry of Health, Labor and Welfare in Japan. This paper describes the background of the development of the system, the content of the amended Medical Service Law and the flow of the system, controversial points in the Investigative Commission, differences from the draft outline, and challenges that remain to be solved.
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[JAMS] Seminar
  • [title in Japanese]
    Kazuaki ATAGI
    2016 Volume 36 Issue 1 Pages 118
    Published: January 15, 2016
    Released on J-STAGE: February 12, 2016
    DOIhttps://doi.org/10.2199/jjsca.36.118
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  • Risk Management System in the Operating Room : Fire Hazard Response
    Takamitsu KODAMA, Yoichi KASE, Masashi NAKAGAWA, Kazuaki ATAGI, Takash ...
    2016 Volume 36 Issue 1 Pages 119-126
    Published: January 15, 2016
    Released on J-STAGE: February 12, 2016
    DOIhttps://doi.org/10.2199/jjsca.36.119
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    Acute care during large-scale disasters has been enhanced and crisis management systems introduced in hospitals since the Great Hanshin earthquake. Disaster response in the operating room is still insufficient, although disaster key hospitals are required to have the ability to treat seriously ill patients. It is necessary to provide secure medical care in the operating room under any conditions, so it is essential for all healthcare providers involved with the operation to have a thorough knowledge of crisis management. Anesthesiologists have to correctly respond to any kinds of disaster and/or incident, especially operating room fires.
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  • Concept of the “Seven Operation Steps” and Its Electronic Management System
    Toshio KANAI
    2016 Volume 36 Issue 1 Pages 127-133
    Published: January 15, 2016
    Released on J-STAGE: February 12, 2016
    DOIhttps://doi.org/10.2199/jjsca.36.127
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    We have classified every surgical procedure into seven categories named the Seven Operation Steps (S.O.S.) composed of Step 1 Induction, Step 2 Incision, Step 3 Critical / Resection, Step 4 Lethal, Step 5 off Critical / Reconstruction, Step 6 Closing and Step 7 Recovery. We can define critical steps as Step 3 and Step 5, which mean to switch anesthesia off, clamp the organs, close the cavity or wound and transfer the patient when we are forced to terminate the surgery. We call this sequential multi-order as “CCT” (clamp, close & transfer). We can also define life-threatening step as Step 4, which indicates the need to continue the surgery to the next step no matter what happens. In addition, we have developed an electronic management system so that we can understand the “Step” in each surgery in a timely manner at a glance even out of the operating theater. The in-hospital disaster headquarters can make quick decisions based on S.O.S. information for surgery patients, who are extremely vulnerable in cases of tsunami disasters. The daily operation of “S.O.S.” is also useful for managing the operating room and surgical ward.
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