A shortage of anesthesiologists in Japan has become a serious problem in recent years. To counter this, perioperative team medical care has been promoted through measures including the introduction of training systems for nurse-specific procedures. In order to improve the quality of perioperative work, we conducted a questionnaire-based survey of the heads of anesthesiology at 20 hospitals in Kagoshima Prefecture, Japan on the current status of perioperative team medical care at their facilities and their future expectations regarding such work. The responses showed 47% parts of perioperative work was expected to be delegated to medical personnel other than anesthesiologists. Training and assigning perianesthesia nurses takes time, so perioperative task-shifting should be promoted for preoperative and postoperative management tasks that can be performed even by considered general nurses and medical clerks.
We encountered two patients undergoing emergency surgery, in whom red blood cell transfusion was delayed due to the presence of non-ABO antibodies. One patient underwent acute epidural hematoma evacuation and the other underwent omentoplasty for gastric perforation. Although they needed red blood cell transfusion, an anti-E antibody was detected, and E antigen-negative red blood cells were required in each patient. As a result, we spent more than two hours between applying for and securing blood for transfusion and we transfused E antigen-negative blood cells after surgery. Our present cases demonstrate that hospital staff including doctors and laboratory specialists should adequately share information in order to be able to promptly perform compatible blood transfusions in emergencies.
Objective：To describe two cases of postoperative septic shock after endoscopic combined intrarenal surgery（ECIRS）that were managed well by early recognition and early intervention by anesthesiologists. Case presentation：［Case 1］ECIRS was performed to treat a stone in the left kidney of a 56-year-old woman. She fell into a state of shock immediately after removal of her tracheal tube in the operating room. She was diagnosed with sepsis based on quick SOFA score and other findings and was treated in the intensive care unit for three days.［Case 2］ECIRS was performed to treat stones in the right kidney of a 39-year-old woman who suffered from recurrent urinary tract infections. After the procedure, her condition deteriorated during her stay in the postanesthesia care unit. She was treated in the intensive care unit for three days for septic shock. Conclusion：Although its incidence is rare, septic shock is one of the most important complications associated with patients who have undergone ECIRS.
The i-NTER LENSTM and ENDO SCOPETM devices（Micronet Inc.）enable a smartphone to be used as a bronchoscope monitor. These devices allow for clear pictures to be taken and for easy manipulation of the bronchoscope. Little preparation is required to use the i-NTER LENSTM, which allows us to make diagnose laryngeal edema in the emergency room. The i-NTER LENSTM simplifies observation of the vocal cords during operations, which enables immediate detection of laryngospasm. The i-NTER LENSTM is a revolutionary device which makes it easy to share the bronchoscope monitor.
A 69-year-old male with a history of upper lobectomy of the right lung and bronchopleural fistula was scheduled for hybrid video-assisted thoracoscopic surgery for partial resection of the left upper lobe. His trachea was deformed and his residual right lung was damaged. We assumed that differential lung ventilation with a double-lumen tube or bronchial blocker would be difficult, so we decided to use peripheral veno-arterial extracorporeal membrane oxygenation（ECMO）for respiratory support. This was cannulated in the femoral artery with an arterial cannula. Because we were concerned about differential hypoxia, which occurs when poorly oxygenated blood is delivered to the myocardium and the brain, we connected a closed-loop soft reservoir bag to the ECMO circuit and reduced cardiac output by draining. The oxygenated blood was delivered retrogradely. We monitored right peripheral capillary oxygen saturation and right regional cerebral oxygenation and checked for optimal oxygenation to the upper part of the body and brain. We completed the surgical procedures, and the postoperative course was uneventful.
A 67-year-old male patient underwent off-pump coronary artery bypass（OPCAB）surgery under general anesthesia. The surgery was uneventful until the bilateral internal thoracic arteries were dissected free from the chest wall. When a wound retractor was applied to median sternotomy incision, invasive blood pressure（IBP）of the left radial artery（RA）decreased. Intravenous administration of vasopressors failed to increase IBP of the left RA. Non-IBP（NIBP）of the right upper arm was higher than IBP of the left RA. There were no remarkable changes in cardiac function evaluated by transesophageal echocardiography and pulmonary artery catheter. We inserted a catheter into the left femoral artery for IBP monitoring and continued surgical procedures. When the wound retractor was removed, the discrepancy between IBP of the left RA and NIBP of the right upper arm disappeared. At the time of tracheal extubation in the operation room, remarkable muscle weakness of the left upper limb was found. In addition, the patient complained of pain on the left upper limb and paresthesia on the ulnar side of forearm on the first post-operative day. Neurological examinations revealed ulnar nerve palsy. We concluded that thoracic outlet syndrome was caused by the wound retractor during OPCAB surgery.
Osteogenesis imperfecta（OI）is a congenital disease characterized by bone fragility. Care must be taken to avoid additional bone fractures because of perioperative excitement in pediatric patients with OI undergoing surgery. We performed entropion surgery under general anesthesia in a 7-year-old girl with OI who had previously experienced multiple fractures. She received a bromazepam suppository（3 mg）before entering the operating room to prevent excitement during induction of anesthesia. Induction was successful with sevoflurane and oxygen. After tracheal intubation, we changed sevoflurane to continuous administration of propofol. Dexmedetomidine（0.4 µg/kg/h）was started to prevent emergence agitation（EA）. Propofol was stopped after surgery and dexmedetomidine was continued after extubation. The patient did not show EA on awakening and was extubated safely. Dexmedetomidine has recently been reported to be effective for preventing EA in pediatric patients, and was effective in our case with OI as well.
［Introduction］We report a case of subglottic stenosis as a cause of respiratory distress in a patient with end-stage idiopathic dilated cardiomyopathy.
［Case presentation］A 41-year-old man was diagnosed with severe tracheal stenosis on imaging examination for heart failure and underwent tracheectomy of the stenosis. Before inducing anesthesia, a veno-arterial extracorporeal membrane oxygenator（VA-ECMO）and intra-aortic balloon pump（IABP）were attached, and the airway was secured with a supraglottic device（SGA）. After the resection at the distal site of tracheal stenosis, operative field intubation was performed. After excision of the stricture, tracheal anastomosis was performed, and oral intubation was switched to complete as planned. Intraoperative SGA controlled breathing had become impossible, but hypoxia and hypercapnia did not occur. The patient’s symptoms improved postoperatively.
［Conclusion］We performed anesthesia for tracheectomy in a patient with hypocardiac function in which respiratory distress was caused by subglottic tracheal stenosis. Using SGA, VA-ECMO and IABP, the operation could be completed while maintaining stable respiration and circulation.
Hemolytic uremic syndromes associated with a Shiga toxin-producing enterohemorrhagic E.coli infection（ST-HUS）can be diagnosed by identifying the pathogenic Shiga toxin-producing enterohemorrhagic E.coli（STEC）or Shiga-toxin in patient stool samples. However, these syndromes are particularly difficult to diagnose due to the number of false-negative outcomes. Here, we report a case of ST-HUS with an O-157 infection that was diagnosed via a serum anti-lipopolysaccharide（LPS）antibody and could not be otherwise diagnosed by stool culture. Serum anti-LPS antibody examinations may be essential in clinically suspected STEC infections.
With the rapidly increasing elderly population in Japan, the number of high-risk patients requiring surgery is increasing as well. Since 2010, the clinical engineers at our hospital have been working with anesthesiologists to maintain intraoperative quality.
They work as assistants to anesthesiologists and support them during surgery（e.g., preparation for anesthesia, entry of anesthesia records, and support for the central venous catheter insertion）. This report discusses the anesthesia assistant system provided by our clinical engineers.
Most patients undergoing surgery receive intravenous fluids to maintain circulating blood volume and electrolyte balance. Insufficient fluid administration may cause damage to major organs because of low tissue perfusion, while excess fluid administration may cause tissue edema and may delay the recovery of gastrointestinal function. Therefore, administration of an optimal amount of intravenous fluid is necessary to prevent perioperative complications and promote patient recovery. Recently, the concept of goal-directed fluid therapy, which utilizes feedback from intraoperative clinical indicators to determine the optimal amount of fluid administration for an individual patient, has become widely accepted. While dynamic variables are frequently used to predict fluid responsiveness and guide fluid therapy, fluid responsiveness alone cannot confirm adequate tissue perfusion, which is the ultimate goal of fluid therapy. Hemodynamic management based on indicators of tissue perfusion along with the dynamic variables is desirable, particularly for patients who are at high risk of perioperative complications.
In the postoperative period, early rehabilitation is necessary to prevent complications, maintain muscle strength（upper and lower limbs, trunk muscle strength）, and enhance exercise endurance. Patients with stable general condition should get out of bed as soon as possible. Patients with mechanical ventilation also need early mobilization to prevent physical impairment due to immobilization.
Preoperative evaluation of physical function and living conditions is important to predict postoperative activity of daily living. If patient has some impairment before surgery, rehabilitation should begin preoperatively to prevent delayed mobilization. Multi-professional collaboration can promote multidisciplinary team medical care, early mobilization, and early discharge from hospital. In addition, each profession has to unify and clarify the goals and policies of treatment. The goal of postoperative rehabilitation is not only early mobilization after surgery but also return to preoperative life after discharge.
Two major points for successful early post-operative rehabilitation are early patient exposure to its necessity and sufficient post-operative pain control. At Chiba University Hospital, a perioperative outpatient center has been established to give patients the opportunity to realize the need for pre- and early rehabilitation after surgery. A certain training menu is provided during the waiting period. Rehabilitation staff again meet patients the day before surgery and recommence training the day after the surgery. Post-operative pain control is the key to early rehabilitation. Regular check-ups and feedback have been performed in several surgery groups at our hospital. Sufficient pain control with no nausea and vomiting is our ideal goal.
When considering circulatory management in perioperative patients, the first thing to do is provide adequate analgesia, as pain stimulation alters hemodynamics dramatically. If hemodynamics would be unstable and hypotensive even after controlling pain and optimizing blood circulation volume, the use of catecholamine for perioperative patients needs to be considered. Noradrenaline has some advantages compared to dopamine, and has therefore been recommended as a first choice vasopressor. Since cardiac dysfunction may occur in perioperative patients, transthoracic echocardiography should be used to confirm cardiac function in patients with unstable hemodynamics, especially those with poor fluid response. The use of dobutamine or PDE III inhibitors should be considered in patients with impaired cardiac function and poor response to noradrenaline and fluids.
Circulatory management of patients with pulmonary hypertension undergoing surgery is discussed in this paper. There are no vasodilators that specifically affect pulmonary circulation. Concomitant administration of vasoconstrictors is common. Effects of anesthetics on pulmonary circulation varies. Propofol and volatile anesthetics markedly depress right heart contractility. Nitrous oxide, thiopental and ketamine depress right heart contractility. Nitrous oxide markedly increases pulmonary vascular resistance（PVR）. Isoflurane and desflurane increase PVR. Sevoflurane and thiopental have no effect on PVR. Propofol decreases PVR. Ketamine increases PVR in adults, but it has no effect on PVR in children. Opioids have no effect on right heart contractility or PVR. Potential drug interactions between anesthetics and vasodilators should be considered. To prevent right heart failure, optimal preload and sustained sinus rhythm are important. Monitoring according to surgical risk is necessary. Dobutamine and phosphodiesterase 3 inhibitors are commonly used. Dopamine, noradrenaline and vasopressin may be used in patients with hypotension. Inhaled nitric oxide therapy is indicated restrictively in persistent pulmonary hypertension of the newborn and patients with PH after cardiac surgery in Japan. In high risk patients, a pulmonary hypertension referral center and team approach play important roles.
The intra-aortic balloon pump（IABP）is a simple device to support hemodynamics of patients with cardiac instability or cardiac shock caused by heart conditions such as acute coronary syndrome. The aims of IABP are to maintain cardiac function of patients and to assist further therapies. The balloon, inserted into the aorta, is repeatedly inflated and deflated in synchronization with the cardiac cycle. Adjustment of the synchronizing is important to properly assist hemodynamics of patients, so anesthesiologists should know cardiac physiology and the mechanism of IABP to obtain satisfactory outcomes with this device. The effects of IABP are called diastolic augmentation and systolic unloading, which augment diastolic perfusion and increasing diastolic blood pressure respectively. As a result, increase of myocardial perfusion and decrease of myocardial demand are achieved. Although it has potential serious complications, such as limb ischemia, vascular laceration necessitating surgical repair, and major hemorrhage, these seldom occur.
This article provides basic information on IABP such as its mechanism, indications, and complications, adding some aspects to the lecture presented at the 39th annual meeting of the Japan Society for Clinical Anesthesia.
Percutaneous cardiopulmonary support（PCPS）, usually femoral vein to femoral artery cannulation with an extracorporeal membrane oxygenator and retrograde femoral artery bypass, retrieves de-oxygenated blood from the venous system and reinfuses the oxygenated blood into the arterial system. The common indications for administrating PCPS are acute refractory cardiogenic shock and cardiac arrest. According to the Extracorporeal Life Support Organization registry, > 15,000 adult patients have been supported with PCPS with an almost 40% survival rate to hospital discharge. PCPS provides greater hemodynamic support with high cardiac flow（3-7 L/min）. While PCPS can unload the central veins, right atrium, and right ventricle, it does not intrinsically unload the left ventricle, particularly when contractile function is severely compromised. There are several absolute contraindications, such as irrecoverable condition（neurologic injury, irreversible organ dysfunction）, unwitnessed asystole, and goals of care not in keeping with temporary mechanical support. Major complications following the use of PCPS are bleeding, thrombosis, and limb ischemia. Guidelines recommend that decisions regarding PCPS candidacy and subsequent management be made via a multi-disciplinary, team-based approach. We need to have a better understanding of PCPS systems and proper patient selection when we use this device.
Education & Training Package of Advanced Perioperative Nurse Practices includes eight practices of the training system of advanced nurse practices, certified by the Japanese Ministry of Health, Labour and Welfare. Trainees of this package, performed by the Japanese Society of Anesthesiologists（JSA）, are able to take all lectures, exercises, practical training, and Objective Structured Clinical Examination（OSCE）at their hospital. All nurses completing this package can receive brush-up programs of the JSA every 5 years.
In response to demographic changes in Japan stemming from the declining birthrate and aging population, the Ministry of Health, Labour and Welfare has introduced changes in the work doctors are required to perform in order to reform the medical care supply system. It has also developed a system to train nurses to perform specific actions. In addition, it has specified the categorization of perioperative management by area and the “packaging” of the training system. In the field of anesthesiology, training has been introduced for specific actions to be taken during anesthesia management.
Introducing intraoperative anesthesia management by specific nurses, we discuss the current issues of perioperative medical treatment from the perspective of hospital managers and nursing managers. Among other issues, the following points need to be specified：（1）the purposes and benefits of introducing specific nurses, （2）the patient safety management system, （3）the location of nurses, and（4）the qualifications of specific nurses and recommendation criteria for trainees.
When a specific nurse undertakes a task shift in intraoperative anesthesia management that should be performed by an anesthesiologist, a system is required that allows the perioperative management team to perform its original role safely and with confidence. I would like to consider how to make that more effective with the cooperation of specific nurses.