Detection of Subclinical Peripheral Artery Ischemia in Healthy Male Smokers by an Ankle-Brachial Index After Exercise: Sasayama Study.

We investigated the relationship between smoking and the risk of nonnormal (≤0.99) ankle-brachial index (ABI) at rest and after ankle plantar flexion exercise in healthy male community dwellers. A cross-sectional study was performed including 228 Japanese men aged 40 to 64 years without a history of cardiovascular diseases. Participants were classified as never, ex-, and current smokers. We estimated the multivariate-adjusted odds ratios (ORs) for nonnormal ABI of ex- and current smokers in relation to never smokers after adjusting for age and other confounding factors. At rest, the prevalence of nonnormal ABI was not significantly different by smoking status. After exercise, the prevalence of nonnormal ABI increased from 1.8% to 11.5% in ex-smokers and from 3.8% to 17.0% in current smokers, while the prevalence did not significantly change in never smokers. The multivariate-adjusted OR for nonnormal ABI after ankle plantar flexion exercise, in relation to never smokers, was 3.85 (95% confidence interval [CI]: 0.79-18.9) for ex-smokers and 6.97 (95% CI: 1.32-36.7) for current smokers. Our results suggest that ABI after ankle plantar flexion exercise is useful for early detection of subclinical peripheral artery ischemia in male smokers without typical symptoms.

Effect of decreased fetal perfusion on placental clearance of volatile anesthetics in a dual perfused human placental cotyledon model.

Placental transfer of volatile anesthetics is a critical issue in managing fetal distress during cesarean section under general anesthesia. Using dual perfused human placental cotyledons obtained from parturients undergoing elective cesarean section (n = 5), we investigated the effect of decreased fetal perfusion on placental clearance of sevoflurane and isoflurane. Keeping the maternal flow rate fixed, fetal flow rate was consecutively decreased from 3 ml/min (control perfusion) to 2 ml/min (intermediate perfusion) and to 1 ml/min (hypoperfusion). Placental transfer was assessed by the clearance of anesthetics by the placenta, defined by the ratio of anesthetic concentration in fetal vein and maternal artery, multiplied by fetal flow rate. Placental clearance was compared between different fetal perfusion states and anesthetics. Hypoperfusion resulted in a lower clearance of sevoflurane and isoflurane compared with control (P = 0.002, P < 0.001) and intermediate (P = 0.04, P = 0.018) perfusion. Clearances of sevoflurane and isoflurane were comparable during control perfusion (P = 0.93), intermediate perfusion (P = 1.00), and hypoperfusion (P = 0.88). Thus, maintenance of volatile anesthetics at a marginally low concentration may not be necessary when fetal distress is observed during emergency cesarean delivery because placental transfer of volatile anesthetics decreases with decreasing fetal perfusion.

[Application of air-Q laryngeal airway and gum elastic bougie in a case of anticipated difficult. Mask ventilation and tracheal intubation in a man with morbid obesity].

A 46-year-old man was diagnosed with descending colon cancer and was planned to undergo left hemicolectomy under general anesthesia. His body mass index was 42.6 and due to his small mouth and jaw, we anticipated difficult mask ventilation and tracheal intubation. To avoid 'can't ventilate, can't intubate', we first inserted a size 3.5 air-Q laryngeal airway under moderate sedation, maintaining spontaneous ventilation. After confirming sufficient assisted ventilation, we used a bronchofiberscope to visualize placement of a gum elastic bougie in the trachea via the air-Q. Then, we replaced the air-Q with an outside diameter 8.5 mm tracheal tube. This case was a successful use of the air-Q under moderate sedation for airway management in the setting of anticipated difficult mask ventilation and tracheal intubation.

Utility of the Pentax-AWS Airwayscope and Macintosh laryngoscope for airway management during chest compressions in 27° left-lateral tilt: a manikin simulation study of maternal cardiopulmonary resuscitation.

PURPOSE: American Heart Association (AHA) 2010 cardiopulmonary resuscitation guidelines recommend high-quality chest compressions (minimum interruption, a pace >100 compressions/min, and a depth more than 5 cm). They propose minor changes for pregnant women: manual left deviation of the uterus or a left-lateral incline of 27°-30° to alleviate pressure on the inferior vena cava. We examined the performance of the Pentax-AWS Airwayscope (AWS) and Macintosh laryngoscope (McL) for airway management during chest compressions on a 27° left-lateral tilt (27 LLT) operating table. METHODS: The study included 18 novice doctors in our anesthesia department. They performed tracheal intubation on a manikin positioned on a 27 LLT operating table using the AWS or McL with or without chest compressions. We measured the intubation time and success rate for tracheal intubation. RESULTS: Intubation success rate with the McL decreased with chest compressions compared to without chest compressions (12/18 vs. 18/18, P < 0.05). Intubation time with the McL was lengthened with chest compressions compared to without chest compressions (18.9 ± 4.0 s vs. 11.1 ± 1.0 s, P < 0.05). Intubation success rate was the same for the AWS with and without chest compressions (18/18 in both cases), and intubation time did not increase significantly without compressions compared to with compressions (11.6 ± 1.4 s vs. 12.6 ± 1.2 s, NS). CONCLUSIONS: The AWS is an effective tool for airway management during chest compressions in 27 LLT in a manikin, suggesting that the AWS may be a useful device for airway management during maternal resuscitation.

Comparison of Pentax-AWS Airwayscope, Airtraq and Miller laryngoscope for tracheal intubation by novice doctors during infant cardiopulmonary resuscitation simulation: a randomized crossover trial.

Recent guidelines for infant cardiopulmonary resuscitation emphasize that all rescuers should minimize interruption of chest compressions, even for endotracheal intubation. We compared the utility of the Pentax-AWS Airway Scope (AWS) with an infant-sized Intlock (AWS-I), Airtraq laryngoscope (ATQ) and Miller laryngoscope during chest compressions on an infant manikin. Twenty-three novice doctors performed tracheal intubation on an infant manikin using the AWS-I, ATQ and Miller laryngoscope, with or without chest compressions. In Miller laryngoscope trials, one participant failed to secure the airway without chest compressions, while nine failed with compressions (P < 0.05). In ATQ trials, none of the participants failed without compressions, while six failed with compressions (P < 0.05). In AWS-I trials, all participants succeeded regardless of chest compressions. Intubation time was significantly longer with chest compressions with the Miller laryngoscope and ATQ, but not with the AWS-I. The AWS-I is an effective device for endotracheal intubation during chest compressions in infant simulations managed by novice doctors.

[A case of awake intubation using the Pentax-AWS airwayscope in a patient with a difficult airway combined with severe hemorrhagic shock].

We report a case of awake intubation in a patient with a difficult airway combined with severe hemorrhagic shock using the Pentax-AWS Airwayscope (AWS). A 65-year-old man experienced severe hemorrhagic shock due to diaphragmatic hernia after extrapleural pneumonectomy and was scheduled for emergent exploratory thoracotomy under general anesthesia. Blood pressure was maintained with dopamine-noradrenaline support, and rapid transfusion. We anticipated difficult ventilation due to a swollen face and tongue. The patient underwent awake intubation with the AWS under dexmedetomidine sedation and lidocaine spray for laryngotracheal anesthesia. The patient did not buck during intubation and hemodynamic changes were minimal.

[Use of the air-Q intubating laryngeal airway for tracheal intubation in predicted difficult airway management in a pediatric patient].

The intubating laryngeal airway, air-Q ILA, was recently introduced in Japan. It has been used in adult patients for difficult airway management; however, there are few reports available on its use in pediatric patients. We report the use of the air-Q ILA in predicted difficult airway management in a 16-month-old patient with Apert syndrome characterized by acrocephalosyndactyly undergoing a syndactyly operation. It was somewhat difficult to keep his airway with a facemask, and an air-Q ILA was inserted. Following the ventilation via air-Q ILA, tracheal intubation guided by a tracheal fiberscope was attempted through the air-Q ILA. Five months after this operation, the patient again underwent the same operation. We managed his airway in the same way as previously, and the tracheal was intubated. This case shows that the air-Q ILA can be an alternative device in pediatric difficult airway management.

[Use of the air-Q laryngeal airway and tube exchanger in a case of difficult tracheal extubation after maxillectomy].

A 79-year-old man was diagnosed with maxillary cancer and underwent total maxillectomy under general anesthesia. The oropharyngeal airway was needed for efficient mask ventilation during anesthesia induction. The maxilla was totally resected and reconstructed with skin from a femoral flap. Tracheal extubation was considered to be difficult given that mask ventilation was contraindicated due to reconstruction of the maxilla. After inserting a tube exchanger (TE) into the trachea, the tracheal tube was exchanged with an air-Q laryngeal airway through the TE. After confirming effective ventilation with the air-Q mask, the patient was awakened from anesthesia. We confirmed sufficient spontaneous breathing and no active bleeding in the pharynx. After re-inserting the TE thorough air-Q, the air-Q was removed, followed by removal of the TE. These findings suggest that the air-Q and TE were effective in a case of difficult extubation after maxillectomy.

Comparison of air-Q(®) and Soft Seal(®) laryngeal mask for airway management by novice doctors during infant chest compression: a manikin study.

BACKGROUND: Recent resuscitation guidelines for infant cardiopulmonary resuscitation (CPR) emphasise that rescuers should minimise the interruption of chest compressions. To that end, supraglottic devices such as laryngeal mask airways (LMAs) are suggested as a backup for airway management during infant CPR. We therefore compared the utility of the air-Q(®) LMA (air-Q) with that of the Soft Seal(®) LMA (Soft Seal) for infant CPR in an infant manikin. METHODS: Twenty-four novice doctors in the anaesthesia department performed insertion and ventilation with air-Q and Soft Seal on an infant manikin with or without chest compression. RESULTS: Two doctors failed to insert the Soft Seal without chest compression, while nine failed during chest compression (P<0.05). However, only one doctor failed to insert the air-Q without chest compression, and two doctors failed during chest compression. Insertion time was not significantly increased with chest compression using either device. Insertion time during chest compression was significantly shorter for the air-Q than for the Soft Seal (P<0.05). The visual analogue scale (VAS) was used to evaluate difficulty of use (0mm (extremely easy) to 100mm (extremely difficult)). VAS scores did not change significantly by the addition of chest compression with either device; however, VAS scores during chest compression were significantly higher with Soft Seal than with the air-Q device. CONCLUSION: We conclude that novice doctors find the air-Q easier to use than Soft Seal for emergency airway management during chest compression in infants, in an infant manikin.

[Efficacy of cryoprecipitate transfusion for coagulopathy after cardiopulmonary bypass in thoracic aortic surgery].

BACKGROUND: Excessive bleeding after cardiopulmonary bypass remains a major complication for cardiac surgery. The principal causes of hemostatic bleeding are related to inadequate surgical hemostasis or diluted coagulopathy. We investigated the efficacy of cryoprecipitate (Cryo) transfusion in thoracic aortic surgery with cardiopulmonary bypass. METHODS: We divided 30 patients undergoing thoracic aortic surgery into two groups retrospectively. Fifteen patients transfused with cryoprecipitate and fresh frozen plasma (FFP) were defined as Group Cryo, and the other 15 patients transfused with FFP only were defined as Group FFP We compared the amount of blood products administered and the blood loss during the perioperative period between the two groups with P <0.05 to be significant. RESULTS: There were no significant differences in the clinical background between the two groups. There were significant differences in the volume of blood loss (Group Cryo 544 +/- 233 ml, Group FFP 888 +/- 339 ml), requirements of FFP (Group Cryo 0.6 +/- 1.7 unit, Group FFP 4.3 +/- 6.0 unit) in ICU. CONCLUSIONS: Cryoprecipitate transfusion is an effective treatment for coagulopathy caused by dilution of coagulation factors after cardiopulmonary bypass.

[Intubating laryngeal mask airway for fiberoptic bronchoscopy in a woman with right bronchial tumor].

A 37-year-old woman with bronchial tumor was scheduled for the removal of the mass with fiberoptic bronchoscope. Intubating laryngeal mask airway (ILMA) was used for fiberoptic surgery. Through a size 3 ILMA, a 5.9 mm outer diameter fiberoptic bronchoscope reached the trachea easily. The operation was successfully performed with assisted ventilation. Intraoperative laryngospasm was treated with intravenous suxamethonium. The ILMA allowed removal of the bronchial tumor with fiberoptic bronchoscope.

Hydration status after overnight fasting as measured by urine osmolality does not alter the magnitude of hypotension during general anesthesia in low risk patients.

BACKGROUND: The increased distribution of crystalloid solution into the interstitial space may decrease the effectiveness of intravascular volume loading in patients. We investigated whether preoperative hydration status after overnight fasting affects interstitial fluid redistribution and thus the magnitude of hypotension during general anesthesia. METHODS: Sixty ASA physical status I/II patients undergoing tympanoplasty fasted from midnight. Anesthesia was induced by fentanyl and propofol and maintained with sevoflurane and remifentanil. Coinciding with the induction of anesthesia, 15 mL/kg acetated Ringer solution was infused IV over 60 minutes followed by 1 mL/kg acetated Ringer solution over the next 30 minutes. Urine osmolalities after induction of anesthesia and during the study period (pre-U(osm), post-U(osm)) and percent decreases of whole-body bioelectrical resistance for extracellular fluid relative to baseline at the end of the study period (ΔR(e)) were measured. Patients with a pre-U(osm) < the 25th percentile or with a pre-U(osm) > the 75th percentile of pre-U(osm) were categorized in the hydrated or the dehydrated group, respectively. A range of variables, including mean arterial blood pressure during the 30- to 90-minute period relative to baseline, and ΔR(e), were compared between the groups. RESULTS: The dehydrated group (pre-U(osm) >759.5 mOsm/kg, n = 15) had a lower age (44 vs 52 years, P = 0.049) and had a higher post-U(osm) (181 vs 55 mOsm/kg, P = 0.001) compared with the hydrated group (pre-U(osm) <378.5 mOsm/kg, n = 15). Mean arterial blood pressure during the 30- to 90-minute period relative to baseline (0.67 vs 0.67, P = 0.85) with 95% confidence interval for the difference of means (-0.070 to 0.084) and ΔR(e) (5.6% vs 6.0%, P = 0.58) with 95% confidence interval for the difference of means (-1.85% to 1.06%) were similar for the hydrated and dehydrated groups. CONCLUSIONS: Preoperative dehydration after overnight fasting as measured by urine osmolality did not alter the magnitude of hypotension during general anesthesia. This finding suggests that intravascular volume loading with crystalloid solution to prevent hypotension during general anesthesia is an unfounded practice for low risk patients after overnight fasting.

Comparison of optic laryngoscope Airtraq(®) and Miller laryngoscope for tracheal intubation during infant cardiopulmonary resuscitation.

BACKGROUND: Recent resuscitation guidelines for infant cardiopulmonary resuscitation (CPR) emphasize that all rescuers should minimize interruption of chest compressions, even for endotracheal intubation. We compared the utility of the Miller laryngoscope (Mil) with Airtraq (ATQ) during chest compression in an infant manikin. METHODS: Twenty staff doctors in intensive care and emergency medicine performed tracheal intubation on an infant manikin with Mil and ATQ with or without chest compression. RESULTS: In Mil trials, no participants failed without chest compression, but 6 of them failed during chest compression (P < 0.05). In ATQ trials, all participants successfully secured the airway regardless of chest compression. Intubation time was significantly lengthened due to chest compression in Mil trials, but not in ATQ trials. The visual analog scale (VAS) for laryngoscope image did not significantly change due to chest compression for ATQ or Mil trials. In contrast, chest compression worsened VAS scores for tube passage through the glottis in Mil trials, but not in ATQ trials. CONCLUSION: We conclude that ATQ performed better than Mil for endotracheal intubation during chest compression in infant simulations managed by expert doctors.

[Case of awake intubation in semi-sitting position for a patient with myasthenia gravis combined with cervical disc hernia utilizing Pentax-AWS Airwayscope].

We report a case of awake intubation utilizing Pentax-AWS Airwayscope in semi-sitting position. A 74-year-old man with myasthenia gravis and cervical disc hernia was scheduled for distal gastrectomy under general anesthesia. He could not move his head due to severe cervical disc hernia and also could not sufficiently breathe due to the fatigue of respiratory muscles by myasthenia gravis in supine position. With fentanyl bolus administration and lidocaine spray for laryngotracheal anesthesia, we performed awake intubation in semi-sitting position with AWS from cranial side. The patient did not buck during intubation and no hemodynamic change was observed.

[Combined epidural-spinal anesthesia for radical hysterectomy in a patient complicated with bronchiectasis diagnosed on preoperative anesthetic consultation].

A radical hysterectomy was performed in a patient complicated with bronchiectasis, under combined spinal-epidural anesthesia. The patient was asymptomatic and preoperatively diagnosed with bronchiectasis on an anesthetic consultation with an anesthesiologist. An epidural catheter was inserted between T12 and L1, and spinal anesthesia was subsequently performed with 0.5% bupivacaine 2.8 ml and fentanyl 10 microg. It was necessary to administer a supplemental epidural dose of 0.375% ropivacaine fifty minutes after the start of the operation. Postoperative epidural analgesia was effective and no perioperative complications were observed.

[Case of tension pneumothorax associated with asthma attack during general anesthesia].

We report a case of tension pneumothorax associated with asthma attack during general anesthesia. An 86-year-old woman with dementia underwent cataract surgery under general anesthesia. At 70 min after the start of operation, airway pressure suddenly increased from 19 to 28 cm HO2O. In spite of bag ventilation with 100% oxygen, Sp(O2) decreased to 81%. Chest-Xp showed typical image of tension pneumothorax. Chest drainage was immediately performed, after which Pa(O2) recovered soon. She was extubated on postoperative day 1 without any neurological disorder. Hyperinflation of fragile alveoli by mechanical ventilation was likely a cause of tension pneumothorax.

[Spinal anesthesia for cesarean section--safe and effective anesthetic management].

Spinal anesthesia is a safe and effective anesthetic technique for cesarean section, considering its simplicity, rapidity, accompanied maternal awareness and distribution of anesthetic agents. The problems of spinal anesthesia, hypotension, postdural puncture headache, failed spinal anesthesia, and its duration, have been investigated. Intravenous fluid therapy may reduce the incidence and severity of the hypotension. Colloid administration is one of the interventions for prevention of hypotension. Low dose phenylephrine is effective without fetal acidosis in healthy mother. The fluid and vasoconstrictor therapies for hypotension induced by spinal anesthesia were briefly reviewed. Postdural puncture headache is one of the troublesome problems. Epidural blood patch is one of the definitive treatments; however further randomized trials are required. Spinal opioid has improved the quality of spinal anesthesia. The recommended dose of spinal opioid in the recent obstetric anesthesia textbooks has been reviewed. The recent issue about safety and effectiveness in obstetric anesthesia has been briefly discussed.

[Anesthetic management for pneumonectomy in a patient with cardiac amyloidosis].

Cardiac amyloidosis may cause restrictive cardiomyopathy associated with heart failure, conduction disorder and ischemic heart disease. Therefore, patients with amyloidosis require careful hemodynamic monitoring in perioperative period. A 63-year-old man with cardiac amyloidosis was scheduled for pneumonectomy. His transthoracic echocardiography assessment showed a hypertrophic interventricular septum and slight decreased ejection fraction of 55%, but left ventricular (LV) diastolic function was decreased. Pulse Doppler for mitral valve inflow showed that the early peak velocity/atrial peak velocity (E/A) ratio was 0.9, the deceleration time (DT) was 163 msec and the early diastolic mitral annular tissue velocity (E') was 4 cm x sec(-1). These data suggested a pseudonormalization state. We performed careful monitoring using arterial pressure-based cardiac output (APCO), central venous oxygen saturation (ScvO2) and transesophageal echocardiography. There were no severe complications such as circulatory collapse and arrhythmia in the perioperative period.

Comparison of placental transfer of local anesthetics in perfusates with different pH values in a human cotyledon model.

PURPOSE: We aimed to investigate the placental transfer of local anesthetics in perfusates with different pH values, using a dual-perfused human cotyledon model. METHODS: The dual-perfused human cotyledon model was prepared from placentas obtained following cesarean delivery (n = 5). Protein-free solution was perfused through both maternal and fetal arteries. Four amide-type local anesthetics (mepivacaine [Mep]; lidocaine [Lid]; bupivacaine [Bup]; and ropivacaine [Rop]) were added to the maternal perfusate at 1 microg ml(-1). Three conditions were tested (stage 1, maternal pH 7.4, fetal pH 7.4; stage 2, maternal pH 7.4, fetal pH 6.9; and stage 3, maternal pH 6.9, fetal pH 6.9). Venous blood samples were collected from the fetal circuit after stabilization. The fetal vein/maternal artery concentration ratio (F/M ratio) of the local anesthetics was used as an index of placental transfer. The concentration of human chorionic gonadotropin (hCG) in the maternal vein was measured at the end of each stage. RESULTS: The F/M ratios in all stages were in the order of: Mep > Lid > Bup [symbol: see text] Rop. The F/M ratios of Mep were significantly higher than those of the other local anesthetics in all stages. The F/M ratios of Lid were higher than those of Rop in stages 2 and 3. The F/M ratios of Lid and Rop were higher in stage 2 than in stage 3. However, the differences between the F/M ratios in the three stages were not as large as expected from the basic uncharged ([B]) condition and pH gap. The concentration of hCG showed a time-dependent decrease with increasing stage (stage 1, 81.0 +/- 58.9 mIU ml(-1); stage 2, 57.4 +/- 31.8 mIU ml(-1); stage 3, 32.1 +/- 19.7 mIU ml(-1)). CONCLUSION: Our data clearly show that it is the basic uncharged concentration that mainly determines the placental transfer of amide-type local anesthetics with protein-free perfusate. This finding suggests that Rop and Bup can be used more safely than Mep in terms of placental transfer.