A practical guide for perioperative smoking cessation.

The perioperative management of patients who are smokers presents anesthesiologists with various challenges related to respiratory, circulatory, and other clinical problems. Regarding 30-day postoperative outcomes, smokers have higher risks of mortality and complications than non-smokers, including death, pneumonia, unplanned tracheal intubation, mechanical ventilation, cardiac arrest, myocardial infarction, and stroke. Given the benefits of smoking cessation and the adverse effects of smoking on perioperative patient management, patients should quit smoking long before surgery. However, anesthesiologists cannot address these issues alone. The Japanese Society of Anesthesiologists established guidelines in 2015 (published in a medical journal in 2017) to enlighten surgical staff members and patients regarding perioperative tobacco cessation. The primary objective of perioperative smoking cessation is to reduce the risks of adverse cardiovascular and respiratory events, wound infection, and other perioperative complications. Perioperative preparations constitute a powerful teachable moment, a "golden opportunity" for smoking cessation to achieve improved primary disease outcomes and prevent the occurrence of tobacco-related conditions. This review updates the aforementioned guidelines as a practical guide to cover the nuts and bolts of perioperative smoking cessation. Its goal is to assist surgeons, anesthesiologists, and other medical professionals and to increase patients' awareness of smoking risks before elective surgery.

Neutron Bragg-edge transmission imaging for microstructure and residual strain in induction hardened gears.

A time-of-flight Bragg-edge neutron transmission imaging was used to investigate the microstructure and strain distributions in a gear hardened by a newly developed two-step induction-heating method: precursor (Sample 1) and final product (Sample 2). The edge-position and edge-broadening were determined and mapped with high spatial resolution, which enabled us to confirm the two-dimensional distributions of the microstructure and residual strain. A deep hardened layer was made for Sample 1 in which martensite was formed on the entire teeth and the outer peripheral portion of the gear body. Sample 2 was subjected to double induction-hardening, where a tempered martensite was formed as the thermal refined microstructure between a fine-grained martensite at the tooth surface and a ferrite-pearlite microstructure at the core. The relationship between edge-broadening and the Vickers hardness described by a linear equation was employed to derive the elastic residual strain. The residual strain map for Sample 2 revealed that a steep compressive strain was introduced into the fine-grained martensite at the tooth surface by the super rapid induction-heating and quenching process. The reversal of tension was speculated to occur below 2 mm from the tooth tip, and the strain was almost zero in the core region.

The energy-resolved neutron imaging system, RADEN.

The energy-resolved neutron imaging system, RADEN, has been installed at the pulsed neutron source in the Materials and Life Science Experimental Facility of the Japan Proton Accelerator Research Complex. In addition to conventional neutron radiography and tomography, RADEN, the world's first imaging beam-line at a pulsed neutron source, provides three main options for new, quantitative neutron imaging techniques: Bragg-edge imaging to visualize the spatial distribution of crystallographic information, resonance absorption imaging for elemental composition and temperature information, and polarized neutron imaging for magnetic field information. This paper describes the results of characterization studies of the neutronic performance and installed devices at RADEN and shows the results of several demonstration studies for pulsed neutron imaging.

Influence of the Arrangement of Surgical Light Axes on the Air Environment in Operating Rooms.

Purpose: Surgical lights in the operating rooms are typically installed in a single axis in the center of the room or in two axes on both sides of the operating table. In the single-axis installation, the air-conditioning outlet cannot be placed in the center of the ceiling, which may affect the air current. Therefore, we measured the air current and cleanliness in two equivalent operating rooms using a vertical laminar airflow system equipped with either single-axis or double-axis surgical lights. Methods: Air current was measured using a three-dimensional ultrasonic anemometer. Cleanliness was evaluated by measuring the amount of dust before and after air-conditioner activation. To visualize the air current, smoke was illuminated on a sheet of laser light while the air-conditioning was stopped, and changes after air-conditioning activation were observed. Results: In the single-axis room, an oblique fast air current flowing from the surrounding air outlet toward the center was observed, and the flow velocity fluctuated greatly. In the double-axis room, uniform downward laminar airflow was observed. The amount of dust at the center decreased significantly faster in the double-axis room; thus, the cleanliness at the center was higher in the double-axis room. Persistent stagnation of smoke was observed below the single-axis lighting, whereas smoke below the double-axis lighting was immediately dispersed and the air cleared even when surgical lights were in the position for surgery. Conclusion: Uniform vertical laminar airflow was formed and high cleanliness was achieved in the center of the room when the surgical lights were arranged in two axes.

Effects of Forced Air Warming on Airflow around the Operating Table.

BACKGROUND: Forced air warming systems are used to maintain body temperature during surgery. Benefits of forced air warming have been established, but the possibility that it may disturb the operating room environment and contribute to surgical site contamination is debated. The direction and speed of forced air warming airflow and the influence of laminar airflow in the operating room have not been reported. METHODS: In one institutional operating room, we examined changes in airflow speed and direction from a lower-body forced air warming device with sterile drapes mimicking abdominal surgery or total knee arthroplasty, and effects of laminar airflow, using a three-dimensional ultrasonic anemometer. Airflow from forced air warming and effects of laminar airflow were visualized using special smoke and laser light. RESULTS: Forced air warming caused upward airflow (39 cm/s) in the patient head area and a unidirectional convection flow (9 to 14 cm/s) along the ceiling from head to foot. No convection flows were observed around the sides of the operating table. Downward laminar airflow of approximately 40 cm/s counteracted the upward airflow caused by forced air warming and formed downward airflow at 36 to 45 cm/s. Downward airflows (34 to 56 cm/s) flowing diagonally away from the operating table were detected at operating table height in both sides. CONCLUSIONS: Airflow caused by forced air warming is well counteracted by downward laminar airflow from the ceiling. Thus it would be less likely to cause surgical field contamination in the presence of sufficient laminar airflow.

[Two Cases of Fetuses with Difficult Airway that Survived by the EXIT (Ex Utero Intrapartum Treatment) Procedure].

We successfully managed two fetuses complicated with suspected airway obstruction after birth by the EXIT (ex utero intrapartum treatment) procedure, whose placental circulation was maintained till their airway was secured during the cesarean section. The first fetus was suspected to have airway obstruction due to a large neck mass. At 36 weeks of gestation, the EXIT procedure was undertaken performing the tracheal intubation successfully by laryngoscope. The second fetus with micrognathia was expected to have airway obstruction after birth. The EXIT procedure was undertaken at 35 weeks of gestation. The tracheal intubation by laryngoscope or by stylet scope was impossible, and the airway was secured by tracheostomy. The direct roles of anesthesiologists in the EXIT procedure are to let the uterus relax enough, deal with bleeding, and manage the fetal airway. The EXIT procedure is a specialized operation in which various specialists are involved, and a variety of judgments are necessary within a short time. Therefore, all concerned personnel should discuss previously to make a concensus on the processes during the procedure. The organization may be also an important role of the anesthesiologists in the EXIT procedure.

[A case of persistent left superior vena cava with absent right superior vena cava found on the insertion of central venous catheter].

A 77-year-old man was scheduled to undergo the resection of hepatoma. After the induction of general anesthesia, a central venous (CV) catheter was inserted from the right internal jugular vein under the echographic observation. Then, we noticed that the size of the vein was smaller than usual, which caused a little difficulty in the insertion. The post-insertion chest X-ray showed unusual placement of the catheter's tip toward the left side of the trachea. Re-evaluation of preoperative CT revealed the persistent left superior vena cava (PLSVC) with absent right superior vena cava. Post-operative examination with echography of the neck showed that the left internal jugular vein was much greater than the right. When noticing a small right internal jugular vein in pre-procedure echography, existence of PLSVC should be considered, and meticulous CV catheterization is necessary for safety.

[Fiberoptic intubation using two tracheal tubes for a child with Goldenhar syndrome].

Goldenhar syndrome is associated with difficult airway due to the characteristic craniofacial anomalies such as hypoplasia of the mandible and molar bones. We present our method of fiberoptic intubation using two tracheal tubes for a girl with Goldenhar syndrome undergoing cochlear implant surgery. She had received general anesthesia for dental treatment one year before, but the treatment had been cancelled because of the failure of tracheal intubation. We induced anesthesia for her with inhalation of sevoflurane and nitrous oxide. After obtaining a stable anesthetic level, we inserted two tracheal tubes from the right and left nostrils, one for a tracheal tube and the other for a nasopharyngeal airway. During the procedure, the fiberscope was advanced through the tracheal tube with a slit connector, and her ventilation was assisted through the nasopharyngeal airway with her mouth closed by a tape to avoid a leak of ventilating gas. Using this two-tube method, we successfully intubated the trachea of a patient Goldenhar syndrome.

Obesity as a risk factor for unanticipated admissions after ambulatory surgery.

OBJECTIVE: To test the hypothesis that obesity is an independent risk factor for unplanned hospital admission or readmission among patients scheduled for ambulatory surgery in a tertiary medical center. PATIENTS AND METHODS: Existing databases were used to identify 235 obese patients (body mass index [BMI] >40) scheduled for ambulatory surgery from January 2, 2002, through December 31, 2003, at Mayo Clinic's site in Rochester, MN. Each patient was matched to a normal-weight control (BMI <25) by age, sex, surgical procedure, type of anesthesia, and date of surgery, and the medical records of all patients were reviewed. Conditional logistic regression analysis was performed to assess whether obesity is an independent risk factor for unplanned postoperative hospital admission. In all cases, 2-sided tests were performed. P<.05 was considered statistically significant. RESULTS: Obese patients (mean +/- SD BMI, 44+/-4) were matched with control patients (mean +/- SD BMI, 23+/-2). Comorbidity was more frequent in the obese cohort. The frequency of unplanned hospital admission did not differ between groups: 61 obese patients (26.0%) and 52 control patients (22.1%) were admitted (odds ratio, 1.3; 95% confidence interval, 0.8-2.0; P=.30). CONCLUSION: Obesity is not a significant independent risk factor for unplanned admission after ambulatory surgery, suggesting that obesity per se should not prevent ambulatory surgery from being scheduled.

[An investigation on the profits from surgery and anaesthesia in Kyushu University Hospital].

We calculated and analyzed the profits from surgery and anaesthesia for a period of one month of September 2006 in Kyushu University Hospital. It was confirmed that 27% of surgery-related profits were earned by anaesthesia. We were also able to confirm that the profits vary significantly depending on the material cost and the length of stay in the operating rooms. We believe that all the surgical workers must realize such fact and each of them is responsible to carry out the operations quickly and efficiently.

[Anesthesia for a patient with xeroderma pigmentosum].

A 23-year-old man with xeroderma pigmentosum underwent laparoscopic cholecystectomy. He experienced transient worsening of the neurological symptom after anesthesia with volatile agents in the previous surgery. Because volatile anesthetics potentially cause genotoxic effects in patients with xeroderma pigmentosum, this time we chose total ir.travenous anesthesia (TIVA). The intraoperative management and the post-operative course were uneventful this time. From these two anesthesia experiences in one patient, we suggest that TIVA is more appropriate than anesthesia with volatile agents as a method for general anesthesia for xeroderma pigmentosum patients. Minimum usage of muscle relaxants under the monitoring of neuromuscular blockade is also recommended, since xeroderma pigmentosum patients are sensitive to muscle relaxants due to the neuronal dysfunction and muscle