Applicability of a compact PT-INR measuring device CoaguChek XS to perioperative management.

OBJECTIVE: In perioperative management, prothrombin time (PT) expressed as the international normalized ratio (INR) is an important preoperative test to assess bleeding risk. It is also used to assess the effect of discontinuing anticoagulant therapy, to determine whether to treat patients with vitamin K or fresh frozen plasma, and to decide whether a deep nerve block (e.g., epidural anesthesia) is needed. Compared with other devices used to measure prothrombin time, the CoaguChek XS is a smaller, lighter and more convenient-to-use PT-INR monitoring system that requires a smaller venous, skin puncture or arterial blood sample than other systems. In a surgical setting, it is often more convenient to collect arterial blood. However, the applicability of arterial blood PT-INR values has not been verified. METHODS: We evaluated the usefulness of the CoaguChek XS in anesthetic management by comparing PT-INR values for arterial blood with those of venous blood in 50 patients who were scheduled for elective surgery under general anesthesia. RESULTS: Arterial PT-INR values were well correlated with venous PT-INR values (r2 = 0.9239; regression line y = 0.9537x + 0.0505). CONCLUSION: These results indicate that the CoaguChek XS system can provide arterial PT-INR values and should be available in operating and emergency rooms.

[Case report: removing the press through package (PTP) containing a tablet from the subglottic region].

A 58-year-old female patient was prescribed different drugs in both tablet and powder form and inadvertently ingested the tablet along with its press through package (PTP), which thus became lodged in the subglottic region. An emergency operation was then performed to remove this foreign material, under neuroleptic anesthesia, and the foreign material was removed successfully. Furthermore, no abnormal findings, such as enlarged vocal cords, were noted. Vocal cord granuloma developed three months after the operation but it improved after conservative treatment.

[Obtaining informed consent in the training of endotracheal intubation by emergency medical technicians].

BACKGROUND: There are some problems in the training of endotracheal intubation enforced for the emergency medical technicians. It is important to obtain the informed consent from preoperative patients which is difficult, and time is spent. In addition, patients sometimes refuse in spite of full explanation about this training. METHODS: We examined the situation where we can obtain the informed consent and what were the reasons the patient refuse this training. RESULTS: The refusal rate was 22.5% and women of their 50's to 60's of ages tended to decline more. And there seemed to be difference in each department slightly. The reasons of the patients who refused the informed consent were an anxiety to the training of endotracheal intubation and unwilling to be sacrificed for that. These reasons comprised about 66%. CONCLUSIONS: We could not find the important point to obtain more informed consent. But it was thought that we should know these results to obtain consent more effectively from now.

A questionnaire survey on operability of syringe pumps for prefilled syringes.

Some types of syringe pumps currently available for use of prefilled syringes (PFS) require setting for syringe size which varies from manufacturer to manufacturer. We conducted a questionnaire survey for 10 nurses at the emergency critical care center of this hospital on the operating procedures of two different types of syringe pump (i.e., from turning on the power to PFS setting, PFS mounting, flow rate setting, and start of drug infusion), in terms of (1) manipulation time, (2) accuracy of task performance, and (3) operability. The syringe pumps used were: type A, TE-331S0N (Terumo Corporation), and type B, CSP-100S (Daiken Medical Co., Ltd.). The PFS product used was Inovan Injection 0.3% Syringe (dopamine hydrochloride injection; Kyowa Hakko Kirin Co., Ltd.). Type A required no mode setting for exclusive use of PFS, while mode setting for exclusive use of PFS is mandatory for type B. The task process from turning on the power to drug infusion start comprised 5 and 13 steps for type A and B, respectively. Manipulation time was significantly shorter with type A, compared to type B. As for accuracy of task performance, 90% of nurses performed manipulations accurately with type A; whereas with type B, 90% of nurses were close to failing or actually failed to follow the procedures appropriately, and only 10% followed accurately. Thus, type A proved superior in 4 of the 5 points of issue except "easy to set flow rate". In conclusion, the results indicate the importance of standardizing the syringe size and other specifications through the cooperation of pharmaceutical companies and medical device manufacturers to cope with the future spread of PFS.

Utilization of PCIA (patient-controlled intravenous analgesia) for postoperative analgesia of spine fusion.

We examined the effect of patient-controlled intravenous analgesia (PCIA) using metoclopramide hydrochloride and morphine hydrochloride in 30 patients (15 males, 15 females) who underwent spine fusion surgery under general anesthesia. The intravenous administration of 2 mg morphine hydrochloride was done prior to the completion of surgery. Subsequently, morphine hydrochloride was administed via venous injection at a dose of 1 ml/hr. Additionally, a 1 ml bolus dosage was administered at a 60-minute lockout interval employing a pump which contained 36 mg of morphine hydrochloride, 30 mg of metoclopramide hydrochloride in 62 ml of physiologic saline. At approximately 72 hours, we observed the resting VAS (visual analog scale) and the side effects of morphine hydrochloride and thereafter the button pressing frequency (1 button have 0.5 mg morphine hydrochloride) was investigated. The resting VAS was stable through 72 hours in 13 males and 15 females of the 30 cases exhibiting from 2 to 3. The frequency of button pressing was investigated regarding time and gender. One male and two female patients exhibited metastatic tumors of the spine but demonstrated no button manipulation. For the remaining 27 subjects the button pressing frequency increased in most instances furthermore, from 24-48 hours after surgery, the frequency for male patients clearly increased. From 48 hours after surgery, no gender differences were evident regarding the button frequency. However, differences were observed regarding the disease, gender and postoperative time course of analgesia. As a result, no alteration in the background dose appeared to provide the best result, as did a short duration lockout interval.

Difficult placement of Univent tube blocker due to aberrant right subclavian artery aneurysm.

There have been few reports on aneurysms of the anomalous branch of the aortic arch. We present a rare case in which correct placement of the movable blocker of a Univent tube was difficult due to an aberrant right subclavian artery aneurysm. A 72-year-old man with a history of hypertension had manifested coughing and wheezing for four months prior to admission to our hospital. A chest computed tomogram revealed that his aortic arch had four branches and that the right subclavian artery did not originate from the first branch, but was the fourth branch. The angiogram disclosed that an aneurysm had developed in the anomalous artery close to the aorta, and behind the other three branches, trachea, and esophagus. The aneurysm not only had pushed the trachea out of place but was also pressing against it. After anesthetic induction, his trachea was intubated using an endotracheal tube with a movable blocker, the Univent tube, for single-lung ventilation. The blocker could not be advanced into the left main bronchus due to the tracheal deviation caused by the aneurysm. Several methods of blocker placement, including those recommended in the manual attached to the product, were attempted without success. Finally, the trachea was intubated again using a Univent tube with the blocker tip bent manually, which permitted entrance of the blocker into the bronchus. Blocker placement should be modified to suit patients with a problem in the trachea or bronchi.