The goal of emergency cesarean sections is to deliver the newborn expeditiously while ensuring maternal safety. We devised a shared interdisciplinary protocol for emergency cesarean sections in our hospital with well-delineated directives for shortening the decision-to-delivery interval （DDI）. We investigated the value of the creation and implementation of the protocol by focusing on the DDI and its constituent elements before and after the protocol’s introduction. We found that the overall DDI and the time from entry to the operating theater to tracheal intubation were both significantly reduced after the protocol was instituted. Practicing of a protocol for emergency cesarean sections is useful for curtailing the DDI, and anesthesiologists can play a crucial role in this reduction.
We report the case of a female infant with congenital tracheal stenosis complicated by total anomalous pulmonary venous return who needed anesthetic management. To avoid simultaneous tracheal and cardiac surgery in the neonatal period due to its high surgical invasiveness, ligation of the patent ductus arteriosus for increased pulmonary blood flow was first performed at 9 days old. Repair for total anomalous pulmonary venous return was performed at 71 days of age because of worsening cardiac insufficiency, and it was decided to perform tracheoplasty at the same time for safe long-term ventilatory management. After repair of TAPVR under cardiopulmonary bypass, the infant was placed on extracorporeal membrane oxygenation support, and tracheoplasty was performed to minimize invasion and bleeding. We successfully accomplished anesthetic management for both tracheal and cardiac surgery in a child weighing less than 3 kg, but a further accumulation of cases will be needed to establish the optimal timing for these surgeries.
There are various factors in the decrease of FIO2 during general anesthesia management, and fresh gas leak is one of these factors. The patient was 78-year-old man with no specific medical history. He was scheduled for laparoscopic hepatectomy. Before the operation, no gas leakage was observed in the start-up inspection of anesthesia machine. About 3 hours after the start of the operation, FIO2 and SpO2 decreased （FIO2：0.35→0.23 SpO2：100％→96％）. There was no change in gas supply pressure, oxygen flow rate, or tidal volume. Increasing oxygen flow improved FIO2. After that, an improper installation of the anesthesia machine and vaporizer was detected, and after re-attachment the decrease in FIO2 was no longer observed. During the operation, a leak occurred between the vaporizer and the anesthesia machine for some reason, and the discovery and response were thought to be delayed due to the small amount of the leak.
A 77-year-old man with severe chronic obstructive pulmonary disease（mainly secondary to a 59-year history of smoking）was diagnosed with left hilar carcinoma extending into the left upper bronchus. He underwent laparoscopic ileocecal resection under general anesthesia combined with epidural anesthesia. Patency of the left upper lobar bronchus was confirmed intraoperatively by auscultation and bronchoscopy. The ventilator settings were adjusted based on a graphical record of the flow- and pressure-time curves. The positive end-expiratory pressure（PEEP）was set to 5-12 cmH2O to maintain high static lung compliance. The highest intraoperative driving pressure（plateau pressure-PEEP）was 12 cmH2O even with the maximal airway pressure at 28 cmH2O. Noninvasive positive pressure ventilation was introduced immediately postoperatively. High-flow nasal oxygen therapy was also useful for postoperative respiratory support, and this treatment was safe and effective without any postoperative pulmonary complications.
We experienced a case of Tracheobronchopathia Osteochondroplastica（TO）discovered by difficult tracheal intubation during general anesthesia. A 66 year-old woman was diagnosed with acute appendicitis, and underwent emergency surgery under general anesthesia. Mask ventilation was easily performed after induction of anesthesia. Despite Cormack-Lehane grade I with direct laryngoscopy, the end-tracheal tube with an internal diameter（ID）of 7.0 mm could not pass through the glottis because of friction beneath the glottis. After confirming mask ventilation, we re-assessed the airway with computed tomography images. Several protrusions from the anterior part of the tracheal wall seemed to disrupt tracheal intubation. Finally, the trachea was successfully intubated with the thinner tube（ID 6.0 mm）, rotating the bevel toward the posterior wall of the trachea after passing the glottis.
Because TO often progresses asymptomatically, patients with TO may undergo general anesthesia without a diagnosis. Although TO is one cause of difficult intubation, patients can be managed safely.
Recently, there has been a shortage of anesthesiologists in Japan. However, it is difficult to evaluate this objectively as there are no definitive means of quantifying their staffing at hospitals. Our hospital is forced to limit days off for full-time anesthesiologists to ensure the functioning of the operating room. To counter this problem, we tried to quantify and evaluate staffing by focusing on full-time anesthesiologists. Their average number, calculated from current weekday full-time anesthesiologists only and assuming that days off could be secured, would be 2.31 people/day, which is insufficient to run the operating room. However, by hiring one part-time senior anesthesiologist for the weekends and holidays, the average would increase to 2.81 people/day, allowing a little leeway to run the operating room during the weekday without limiting days off. These quantified results indicate the possibility of improving the working conditions of full-time anesthesiologists, by efficiently allocating part-time anesthesiologists.
There are few reports concerning the educational effects of mentor systems as they relate to junior residents. In debriefing conferences introduced as educational opportunities for junior residents, participants presented cases they wanted to review, with several senior physicians serving in a facilitator role. The contents were categorized into problems associated with anesthetic management and skills necessary for improving clinical proficiency. We compared changes to the contents of the debriefing conferences before and after the introduction of the mentor system. The core problems for the pre-introduction group consisted of circulation(n=11), airways(n=4), safety(n=2), incidental symptoms(n=2), metabolism(n=4), and pain(n=4). Core skills for the pre-introduction group consisted of anesthesia planning(n=14), emergency response(n=9), and communication(n=4). Core problems for the post-introduction group consisted of circulation(n=17), airways(n=7), incidental symptoms(n=1), metabolism(n=7), systemic assessment(n=1), and central nervous functions(n=3). Core skills for the post-introduction group consisted of anesthesia planning(n=24)and emergency response(n=12). A comparison between the pre- and post-introduction groups found inter-group differences for the core problem of pain(p=0.017)and the core skill of communication(p=0.017). The introduction of the mentor system resulted in changes in pain management and issues with communication.
Intraoperative accidental extubation of the endotracheal tube during surgery, especially in the prone position, is one of the most critical perioperative complications. In this report, we introduce the “ear-hooking method” of the endotracheal tube to avoid accidental extubation during surgery. We have used this method for more than 10 years in approximately 200 patients with multiple injuries who required posterior cervical supine surgery. For the ear-hooking method, two crafted elastic adhesive tapes fix the intubation tube to the head；one to the upper jaw and the other to the lower jaw. By correctly performing this tube-fixation method, we reduced the risk of fatal intraoperative accidental extubation.
The introduction of the small bore connectors for neuraxial applications（ISO 80369-6）makes it impossible to connect infusion line to the needle for nerve block. We always used the micro drip infusion method to detect the epidural space instead of the loss of resistance method in pediatric patients. It contributed to the safety of pediatric epidural anesthesia including for infants, and we succeeded using that method uneventful in thousands of the cases.
The production of the infusion line connecting the intravenous and neuraxial applications is far from the concept of the standardization of the neuraxial anesthesia connector. When we were close to giving up on the micro drip infusion method, Nipro Corporation fortunately decided to produce a specialized infusion line. We would like to express our utmost gratitude for all the parties concerned with the production of this line. It’s not too much to say this device will protect both this valuable medical procedure and the smiles of postoperative pediatric patients.
Sugammadex was introduced into clinical anesthesia in Japan in 2010, ahead of its introduction in other countries. At that time, it was great pleasure to inform the world of its real effects, feeling in use, and side effects based on our experience in Japan. However, 36 cases of recurarization even after the use of sugammadex had been reported as of January 2018. It is well known that the adequate dose of sugammadex depends on the depth of neuromuscular block evaluated by neuromuscular monitoring and cannot be correctly judged by re-appearance of spontaneous respiration and patient’s movement. To help ensure postoperative patient safety and good work by anesthesiologists, I would like to see the further popularization of neuromuscular monitoring in clinical anesthesia and the extirpation of residual neuromuscular block and recurarization.
Sugammadex restores neuromuscular contraction by encapsulating rocuronium molecules inside its structure within the plasma, decreasing plasma rocuronium concentrations, and then decreasing rocuronium concentrations at the neuromuscular junction. The JSA airway guideline recommends administering 16 mg/kg sugammadex in cannot intubate/cannot ventilate situations during anesthesia induction with rocuronium. However, many case reports suggest the usefulness of much smaller doses of sugammadex for managing difficult airway situations. I discuss the advantages of using muscle relaxant during anesthesia induction and potential mechanisms for the usefulness of sugammadex for avoiding disaster in “cannot intubate/cannot ventilate” situations.
Sugammadex is an antagonist of aminosteroid muscle relaxants. In Japan, the usage of sugammadex has expanded since its release in 2010 due to its reliable antagonistic action. However, there have been several reports of anaphylaxis caused by sugammadex. Our recent study found the incidence of anaphylaxis due to sugammadex to be approximately 1 in 5,000 cases. Although clinical symptoms associated with sugammadex-induced anaphylaxis do not differ from those caused by other drugs, anesthesiologists should always be aware that critical symptoms such as severe bronchospasm may be observed even after extubation. Since the mechanisms of anaphylaxis due to sugammadex remains unclear, future research is needed.
In order to advance work style reform for doctors, it is necessary to transfer work previously performed by doctors to other occupations（task shifting）. For anesthesiologists, it is possible to shift tasks to nurses, clinical engineers, and pharmacists, and many tasks can be considered before, during, and after surgery. Currently, specific procedures have been defined and training has begun to advance the task shift to nurses. In order to train more nurses, the training as a group of procedure will begin. The Japanese Society of Anesthesiologists will promote the training as a group procedure during surgery, and now is preparing a system for this training.
The “work-style reform bill” has been passed into law and for physicians will take effect in 2024. We examined the current work conditions of surgeons at a core local hospital and evaluated possible strategies to promote work-style reform. At our hospital, the average overtime per surgeon was 650 hours a year.
However, younger rotating physicians sent from universities worked 1,220 hours of overtime, about 2.6 times more than senior full-time surgeons. We must consider the field of specialty and age to evaluate the working hours of physicians. “Work-style reform” often places emphasis on shortening and limiting work hours, but for a “true reform” it is important to analyze factors in each work environment and to develop a strategy to reduce work load.
Multidisciplinary work sharing and task shifting are thought to be effective.
Anesthesiologists are facing manpower shortages across Japan, and the Tohoku region is considered the most advanced area worldwide for a super-aging society. Thus, we are training a new type of anesthesiologists, who can share a multi-disciplinary framework, create practical requirements, and accomplish them with a highly social impact. To cooperate with other medical staff or districts, we qualify them to perform medical-engineering collaboration, while integrating arts and sciences, diversity, and entrepreneurship. Based on these abilities, anesthesiologists should provide practical and sustainable results. We also strive to overcome our society of manpower shortage, decreasing birth rate and aging population.