Transversal Survey of Emergency Medicine Policy and Quality Metrics in Japan's Regional Health Care Plans.

Introduction: It is essential to establish appropriate medical quality metrics and make improvements to safely and efficiently deliver optimum emergency medical services. The Ministry of Health, Labor and Welfare (MHLW) recommends prefectures to establish numerical quality metrics in their regional healthcare plans (RHCP). The 7th RHCP was issued by the MHLW in 2017 along with a notice of planning in covering the six-year period from 2018 to 2023. In this descriptive study, the emergency medicine policies in the 7th RHCP of each prefecture were analyzed from a quality improvement perspective. Method: The authors examined the chapters on emergency medicine in the RHCPs of 47 prefectural governments for the overall structure, cost-benefits, and connection to community-based integrated care systems. The type and number of clinical measures listed as numerical metrics and their classification methods were emphasized. Result: Regarding the overall plan structure, 40 prefectural governments began their description with an analysis of current surroundings. In total, 24 prefectural governments mentioned community-based integrated care systems but none mentioned cost-benefit analysis. Altogether, only 43 of 47 prefectural governments (91%) indicated numerical metrics. The maximum number of numerical targets for quality measures by prefecture was 19, the minimum was 0, and the median was 4 (IQR: 3-6.5); there were 220 metrics in total, with 82 structural, 96 process, and 42 outcome measures. Additionally, 13 prefectures (28%) classified quality measures according to the MHLW's guidance, 6 (13%) used their own classification manner, while the others did not classify their measures. Conclusions: There were significant differences in emergency medicine policies and quality metrics among the prefectural governments. Further research is needed to develop and establish more comprehensive and appropriate metrics based on a common methodology to improve the quality of emergency medicine.

Impact of different medical direction policies on prehospital advanced airway management for out-of hospital cardiac arrest patients: A retrospective cohort study.

BACKGROUND: Although optimal prehospital airway management after out-of-hospital cardiac arrest (OHCA) remains undetermined, no studies have compared different advanced airway management (AAM) policies adopted by two hospitals in charge of online medical direction by emergency physicians. We examined the impact of two different AAM policies on OHCA patient survival. METHODS: This observational cohort study included adult OHCA patients treated in Okayama City from 2013 to 2016. Patients were divided into two groups: the O group - those treated on odd days when a hospital with a policy favoring laryngeal tube ventilation (LT) supervised, and the E group - those treated on even days when the other hospital with a policy favoring endotracheal intubation (ETI) supervised. Multiple logistic regression analysis was performed to assess airway device effects. The primary outcome measure was seven-day survival. RESULTS: Of 2,406 eligible patients, 50.1% were in the O group and 49.9% were in the E group. O group patients received less ETI (1.0% vs. 12.0%) and more LT (53.3% vs. 43.0%) compared with E group patients. In univariate analysis, no differences were observed in seven-day survival (9.4% vs 10.1%). Multiple regression analysis revealed neither LT nor ETI had a significant independent effect on seven-day survival, considering bag-valve mask ventilation as a reference (OR, 0.78; 95% CI, 0.54 to 1.13, OR, 0.79; 95% CI, 0.36 to 1.72, respectively). CONCLUSION: Despite different advanced airway medical direction policies in a single city, there were no substantial impact on outcomes for OHCA patients.

Arrhythmogenic Right Ventricular Cardiomyopathy Diagnosed during Hospitalization for Cardiac Arrest.

Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a genetically mediated cardiomyopathy charac-terized by progressive myocardial loss of the right ventricle and its replacement by fibrofatty tissue, causing dyskinesia, aneurysm, and/or arrhythmia. The prevalence of ARVC is estimated to be 1 in 2,000-5,000, with the condition accounting for up to 20% of sudden cardiac deaths in individuals < 35 years old. This report describes the case of 61-year-old Japanese who was diagnosed with ARVC after cardiac arrest (CA) and successful resusci-tation. After the sudden CA, the restoration of spontaneous circulation was achieved with appropriate resusci-tation, followed by the introduction of target temperature management in the intensive care unit. He was diag-nosed with ARVC based on angiography and histology results. An ICD (implantable cardioverter-defibrillator) was implanted, and he was discharged without neurological sequelae 1 month post-CA. ARVC is an important cause of sudden CA, and successfully resuscitated patients with right ventricular dilation should undergo testing to rule out ARVC.

State-of-the-art methods for the treatment of severe hemorrhagic trauma: selective aortic arch perfusion and emergency preservation and resuscitation-what is next?

Trauma is a primary cause of death globally, with non-compressible torso hemorrhage constituting an important part of "potentially survivable trauma death." Resuscitative endovascular balloon occlusion of the aorta has become a popular alternative to aortic cross-clamping under emergent thoracotomy for non-compressible torso hemorrhage in recent years, however, it alone does not improve the survival rate of patients with severe shock or traumatic cardiac arrest from non-compressible torso hemorrhage. Development of novel advanced maneuvers is essential to improve these patients' survival, and research on promising methods such as selective aortic arch perfusion and emergency preservation and resuscitation is ongoing. This review aimed to provide physicians in charge of severe trauma cases with a broad understanding of these novel therapeutic approaches to manage patients with severe hemorrhagic trauma, which may allow them to develop lifesaving strategies for exsanguinating trauma patients. Although there are still hurdles to overcome before their clinical application, promising research on these novel strategies is in progress, and ongoing development of synthetic red blood cells and techniques that reduce ischemia-reperfusion injury may further maximize their effects. Both continuous proof-of-concept studies and translational clinical evaluations are necessary to clinically apply these hemostasis approaches to trauma patients.

Cardiac arrest due to liquid nicotine intoxication: a case report.

BACKGROUND: With the introduction of electronic cigarettes, reports of nicotine intoxication due to ingestion of large amounts of liquid nicotine have increased. This report presents a rare case of cardiac arrest due to nicotine intoxication that was successfully treated with appropriate respiratory and circulatory support. CASE PRESENTATION: A 55-year-old man ingested 600 mg of liquid nicotine and developed sinus bradycardia followed by asystole. Appropriate and prompt resuscitation led to the return of spontaneous circulation. He was admitted to the intensive care unit and discharged 24 days later without any medical sequelae of nicotine intoxication. CONCLUSION: Ingestion of a large amount of liquid nicotine, as in this case, can result in lethal bradycardia followed by cardiac arrest. Prompt basic life support by paramedic produced good neurological outcomes. Emergency physicians should be aware of the symptoms and appropriate treatment of severe nicotine intoxication.

[Tooth Mobility Evaluation -A Comparison with Dental Assessment-].

BACKGROUND: Patients with mobile teeth are at an increased risk of tooth injury related to tracheal intu- bation. Although the presence/absence of mobile teeth is confirmed through interviews during preoperative visits, patients are frequently unaware of the presence of such teeth. In our facility, dental consultation is pro- vided for all patients undergoing thoracoscopically- assisted surgery as part of the management of oral hygiene. This study examined the presence/absence of mobile teeth reported by patients during preoperative visits and those identified on dental consultation, focus- ing on the inconsistency between them. METHODS: Patients who had undergone thoraco- scopically-assisted surgery in our facility between Janu- ary and October 2014 were retrospectively studied. Tooth mobility was evaluated using the Miller index. RESULTS: Among the 76 (46 males and 30 females) patients aged 36 to 88 (mean: 67.8), mobile teeth were identified on dental consultation in 13 and reported during preoperative visits by 8. CONCLUSIONS: Based on this findings, it may be nec- essary to pay sufficient attention when inserting tubes even when mobile teeth have not been reported by patients during preoperative visits.

[Anesthesia in a Patient with Giant Goiter in Whom Tracheotomy Was Performed with Standby of Percutaneous Cardiopulmonary Support].

In a 53-year-old female patient total thyroidectomy for a giant goiter under general anesthesia was scheduled. On talking, airway stenosis sounds were heard. Cervical to thoracic CT revealed left and right lobe tumors measuring 5.3 x 5.6 x 10.0 and 9.1 x 8.6 x 10.0 cm, respectively. The trachea showed stenosis at a site 3.8 to 6.5 cm below the glottis, and the narrowest lumen diameter was 3.1 mm. Due to marked tracheal stenosis, awake intubation was not selected. To maintain the airway, tracheotomy was performed under local anesthesia. Considering the risk of difficulty in ventilation during tracheostomy, 4 Fr catheter sheaths were inserted into the right femoral artery and vein for percutaneous cardiopulmonary support (PCPS). Subsequently, tracheotomy was conducted in an area peripheral to the site of stenosis. After tracheotomy, general anesthesia was started. During general anesthesia, there were no problems regarding ventilation. The tracheal cannula was removed 7 days after surgery, and the patient was discharged after 14 days. For general anesthesia in patients with giant goiter, it is important to select an airway management method in consideration of tumor-related compression of the trachea. Airway management by tracheotomy under local anesthesia with standby of PCPS may be a treatment option.

[General Anesthesia for the Thoracoscopic Lung Resection Surgery in 12 Very Elderly Patients above 85 Years of Age].

We investigated perioperative management and clinical outcome of 12 patients who were 85 years old or older and received video-assisted thoracic surgery under general anesthesia. Although all the patients had preoperative respiratory complications or cardiovascular complications, they were discharged without any additional respiratory assistance such as home oxygen therapy. Our observation suggests that it is important to evaluate the indication of anesthesia from their daily activities and pulmonary function test even if they are oldest-old. If the patient demonstrates good physical function, he or she should not be excluded from anesthesia.

[Two cases of general anesthesia after recovery from ARDS].

There are few reports on general anesthesia in survivors of ARDS. Patients after recovery from ARDS are at risk for compromised pulmonary function, neuromuscular weakness and cognitive dysfunction. We report 2 cases of general anesthesia in survivors of ARDS. In Case 1, a 64-year-old man who had recovered from ARDS associated with Legionella pneumonia underwent carotid endarterectomy. In Case 2, a 69-year-old man who had recovered from ARDS associated with pneumococcal pneumonia underwent hepatectomy. Concerning the preoperative assessments, the spirometry data were almost normal but Hugh-Jones classification scale was II in both cases. Diffusion disturbance might be the cause of discrepancies between good respiratory functions and limited daily activities. In both cases, anesthesia was given with propofol, fentanyl remifentanil and sevoflurane. Peak airway pressure was maintained below 15 cmH2O with pressure control ventilation. They were extubated at the end of surgery and there were no serious complications during the perioperative period.

Reliability of central venous pressure to assess left ventricular preload for fluid resuscitation in patients with septic shock.

BACKGROUND: Initial fluid resuscitation is an important hemodynamic therapy in patients with septic shock. The Surviving Sepsis Campaign Guidelines recommend fluid resuscitation with volume loading according to central venous pressure (CVP). However, patients with septic shock often develop a transient decrease in cardiac function; thus, it may be inappropriate to use CVP as a reliable marker for fluid management. METHODS: We evaluated 40 adult patients with septic shock secondary to intra-abdominal infection who received active treatment and were monitored using transthoracic echocardiography (TTE) and CVP for 2 days after admission to our intensive care unit (ICU). We measured left ventricular end-diastolic diameter (LVEDD), left atrial diameter (LAD), and the pressure gradient of tricuspid regurgitation (TR∆P). The shock status was treated with volume loading and inotrope/vasopressor administration according to the TTE findings. We assessed left ventricular fractional shortening (LVFS) as an index of left ventricular contractility and TR∆P as an index of right ventricular afterload and then examined the correlation between CVP and LVEDD/LAD/TR∆P. RESULTS: LVFS decreased to ≤30% in 42.5% and 27.5% of patients with septic shock, and severe left ventricular dysfunction with LVFS ≤20% developed in 12.5% and 15.0% of patients on the first and second ICU days, respectively, despite the use of inotropes/vasopressors. Mild pulmonary hypertension as indicated by TR∆P ≥30 mmHg was present in 27.5% and 30.0% of patients on their first and second ICU days, respectively. There was no significant correlation between CVP and LVEDD/LAD/TR∆P. The hospital mortality rate in this study was 10.0%, although the predicted mortality based on the Acute Physiology and Chronic Health Evaluation II score was 58.7%. CONCLUSIONS: Our results suggest that CVP is not a reliable marker of left ventricular preload for fluid management during the initial phase of septic shock. Assessment of left ventricular preload, right ventricular overload, and left ventricular contractility using TTE seems to be more informative than the measurement of CVP for fluid resuscitation since some patients developed left ventricular dysfunction and/or right ventricular overload.

[General anesthesia for lung resection in 7 patients with forced expiratory volume in 1 second of less than 1l].

Preoperative forced expiratory volume in 1 second less than 1 l is a risk factor for anesthesia. We report perioperative management and prognosis of 7 patients with restricted lung function who underwent lung resection under general anesthesia. We assessed the patients preoperatively from the point of view of heart-lung functions such as predicted postoperative forced expiratory volume in 1 second greater than 0.8 l, an ability of walking on the level for more than 5 minutes at his own speed without a rest, presence of hypercapnia, and degree of pulmonary hypertension. One patient was extubated on the first postoperative day because of an asthmatic attack, whereas the remaining 6 patients were extubated in the operating room. Although 1 patient developed postoperative complications of lung air leakage and pneumonia, he recovered with conservative therapy. All patients were discharged without any sequela. We were able to manage high-risk patients with limited lung functions successfully during the perioperative period without serious complications.

[A case of rocuronium-induced anaphylactic shock successfully treated with sugammadex].

We report a case of a 19-year-old male with rocuronium-induced anaphylactic shock. He was scheduled for endoscopic sinus surgery for chronic sinusitis under general anesthesia. Induction of anesthesia was done with fentanyl, propofol and sevoflurane. Just after administration of rocuronium, he developed tachycardia with extended exanthema on the face, anterior chest wall and abdomen. He was difficult to ventilate manually with mask and then intubated without difficulty. The carotid arterial pulse was not palpable and adrenaline was given intermittently to maintain blood pressure. Although the systolic blood pressure increased to 80 mmHg, hemodynamics was unstable with adrenaline. Sugammadex was then given and the blood pressure became stable without adrenaline. Exanthema also disappeared gradually. He was then transferred to ICU and extubated without any sequela. The plasma beta-tryptase increased to 46 microg x l(-1) during the shock state and returned to 14.1 microg x l(-1) 8 hrs after the event. The blood hemoglobin level also increased to 21.3 g x dl(-1) during the shock state and returned to 17.2 g x dl(-1) during the recovery phase. The laboratory data showed a marked increase in vascular permeability caused by rocuronium-induced anaphylactic shock.

[ A case of general anesthesia for the removal of extra-adrenal pheochromocytoma in a patient complicated with severe hypertrophic obstructive cardiomyopathy].

We report a case of general anesthesia for the removal of pheochromocytoma in a patient complicated with severe hypertrophic obstructive cardiomyopathy. A 65-year-old woman complained of fatigability with hypertension and diabetes mellitus. She was diagnosed as an extra-adrenal peri-aortic pheochromocytoma with severe hypertrophic obstructive cardiomyopathy. The left ventricular outflow gradient (LVOG) was 199 mmHg and the serum noradrenaline level was 13,567 pg x ml(-1) (100-450). As a preoperative management, atenolol, verapamil and disopyramide were given to decrease LVOG. Then doxazosin was given to control hypertension and to increase the circulating blood volume without deteriorating the outflow tract obstruction. LVOG decreased to 50 mmHg preoperatively. Anesthesia was given with propofol, fentanyl, remifentanil and isoflurane with a continuous infusion of diltiazem. The circulating blood volume was maintained with adequate volume loading assessed by the measurement of the left ventricular end-diastolic diameter and LVOG with transesophageal echocardiography. After the removal of the tumor, continuous infusion of noradrenaline was given to maintain the blood pressure. She was extubated in the ICU. LVOG decreased to 20 mmHg with stable hemodynamics on the second postoperative day. She was discharged from the ICU without any adverse cardiac events during the perioperative period.

A case of acquired hemophilia A with massive hemothorax.

Acquired hemophilia A (AHA) is an uncommon but potentially life-threatening hemorrhagic disorder caused by the development of an inhibitor against coagulation factor VIII (FVIII). AHA is very rare, affecting approximately 1 in 1 million individuals. However, the incidence may actually be higher, because diagnosis is difficult and the disease can be overlooked. We report a case of an 80-year-old man who presented with sudden onset of severe hemothorax. The patient was diagnosed with presumed AHA based on acute onset of bleeding symptoms and unexplained isolated prolonged activated partial thromboplastin time. Diagnosis was definitely established by demonstrating a decrease in FVIII activity, presence of FVIII inhibitor activity, and normal von Willebrand factor. The patient was successfully treated with recombinant activated coagulation factor VII and transcatheter artery embolization of the intercostal arteries.

Half-logistic time constant: a more reliable lusitropic index than monoexponential time constant regardless of temperature in canine left ventricle.

Temperature changes influence cardiac diastolic function. The monoexponential time constant (tauE), which is a conventional lusitropic index of the rate of left ventricular (LV) pressure fall, increases with cooling and decreases with warming. We have proposed that a half-logistic time constant (tauL) is a better lusitropic index than tauE at normothermia. In the present study, we investigated whether tauL can remain a superior measure as temperature varies. The isovolumic relaxation LV pressure curves from the minimum of the first time derivative of LV pressure (dP/dtmin) to the LV end-diastolic pressure were analyzed at 30, 33, 36, 38, and 40 degrees C in excised, cross-circulated canine hearts. tauL and tauE were evaluated by curve-fitting using the least squares method and applying the half-logistic equation, P(t) = PA/[1 + exp(t/tauL)] + PB, and the monoexponential equation, P(t) = P0exp(-t/tauE) + Pinfinity. Both tauL and tauE increased significantly with decreasing temperature and decreased with increasing temperature. The half-logistic correlation coefficient (r) values were significantly higher than the monoexponential r values at the 5 above-mentioned temperatures. This implies that the superiority of the goodness of the half-logistic fit is not temperature dependent. The half-logistic model characterizes the amplitude and time course of LV pressure fall more reliably than the monoexponential model. Hence, we concluded that tauL is a more useful lusitropic index regardless of temperature.

[Successful anesthetic management of a patient with thyroid storm using landiolol].

We report successful anesthetic management of a 38-year-old man with thyroid storm using an ultra-short acting beta blocker, landiolol. The patient was admitted to the hospital for severe abdominal pain. An emergency laparotomy was scheduled for perforated gastric ulcer under a condition of uncontrolled thyrotoxicosis. On arriving the operating room, he showed tachycardia of 140 beats x min(-1) and blood pressure of 140/75 mmHg and high fever of 39 degrees C with tremor, sweating and diarrhea. He was anesthetized with oxygen, nitrous oxide, sevoflurane and fentanyl. Heart rate was around 130 beats x min(-1), and the landiolol was given continuously at a rate of 0.02-0.04 microg x kg(-1) x min(-1). Heart rate was controlled bellow 120 beats x min(-1) without hypotension during anesthesia. Thiamazole and inorganic iodine were given through an enterostomy tube postoperatively, and heart rate decreased gradually. He was extubated on the third postoperative day without any sequelae.

[A case of general anesthesia combined with epidural anesthesia in a pregnant woman undergoing laparoscopic cholecystectomy].

We report a case of general anesthesia for laparoscopic cholecystectomy at 12 weeks of gestation. A 20-year-old woman weighing 123 kg was admitted with epigastralgia. She was diagnosed as pregnancy of 6 weeks of gestation and acute cholecystitis. Percutaneous trans-gallbladder drainage was performed to delay operation until 12 weeks of gestation. Laparoscopic cholecystectomy was performed uneventfully under general anesthesia combined with epidural anesthesia. There were no clinical signs of fetal distress during the perioperative period.

Starling-effect-independent lusitropism index in canine left ventricle: logistic time constant.

The logistic time constant (tau(L)) has been proposed as a better index of the rate of left ventricular (LV) relaxation or lusitropism than the conventional monoexponential time constant (tau(E)). However, whether and how the Frank-Starling effect influences tau(L) remains to be elucidated. We compared the effect of LV volume (LVV) loading on both logistic and monoexponential fittings. The isovolumic LV relaxation pressure curves from the maximum negative time derivative of pressure (-dP/dt(max)) were analyzed at 3 different end-points at 4 LVVs of 10, 12, 14, and 16 mL in 8 excised, cross-circulated canine hearts. We found that the logistic fitting was superior to the monoexponential fitting at all LVVs and end-points. LVV loading did not affect tau(L) but affected tau(E) slightly. Although the advancing end-point increased both tau(L) and tau(E), the increases were significantly smaller for tau(L) than for tau(E) at all LVVs. Moreover, the changes in both the amplitude constants and nonzero asymptotes with the advancing end-point were significantly smaller for the logistic fitting than for the monoexponential fitting. We conclude that tau(L) served as a more reliable index of lusitropism that is independent of the change in LVV loading or the Frank-Starling effect.

Temperature-dependent postextrasystolic potentiation and Ca(2+) recirculation fraction in canine hearts.

We have found that cardiac temperature proportionally changes O(2) cost of contractility, defined as O(2) consumption for myocardial total Ca(2+) handling normalized to contractility in terms of the end-systolic pressure-volume ratio (maximal elastance, E(max)), in the canine left ventricle (temperature sensitivity, Q(10) = 2). We have separately found that a decrease in the recirculation fraction (RF) of Ca(2+) within myocardial cells underlies an increased O(2) cost of E(max) in stunned hearts. We therefore hypothesized that a similar change in RF would underlie the Q(10) of O(2) cost of E(max). We tested this hypothesis by analyzing RF calculated from an exponential decay component of the transiently alternating postextrasystolic potentiation in the canine left ventricle. RF decreased from 0.7 to 0.5 as cardiac temperature increased from 33 to 38 degrees C with Q(10) of 0.5, reciprocal to that of O(2) cost of E(max). We conclude that Q(10) of ATP-consuming reactions involved in Ca(2+) handling and E(max) response to it could reasonably account for the reciprocal Q(10) of RF and O(2) cost of E(max).