A fragmented segment of a central venous catheter caused delayed ventricular fibrillation: a case report.

BACKGROUND: Central venous port systems may be safely used for chemotherapy of patients with cancer, but several complications may occur associated with their use. CASE PRESENTATION: An 83-year-old man with heat stroke was transferred to our emergency department, where he was treated and became able to eat on the same day. He had been fit and healthy, except for colorectomy and chemotherapy using a central venous access port placed in the right upper jugular vein 8 years ago. The next day, he suddenly had ventricular fibrillation. Cardiopulmonary resuscitation was successful. Emergency coronary angiography showed a catheter-like foreign body in the coronary sinus. Physicians failed to remove the foreign body using catheter therapy, and ventricular fibrillation occurred repeatedly. After induction of general anesthesia, the fractured catheter was removed surgically. Postoperative course was uneventful. CONCLUSIONS: A fragmented segment of a catheter may suddenly cause ventricular fibrillation years later.

Standard of anesthesia care: possible dissociation from recommendations made by clinical practice guidelines.

A medical malpractice lawsuit may be brought against health care providers, if there was a possibility of a negligence, or failure to meet the standard of care. Recently, clinical practice guidelines have increasingly been used as evidence of the standard of care. Nevertheless, it is not clear whether these guidelines can be used as evidence of the standard of care. We carried out a snapshot study to know whether or not there were dissociations between the current standard of anesthesia care and recommendations made by clinical practice guidelines. We asked all the 80 heads of Anesthesiology departments of Japanese public and private Universities, to answer questions related to difficult airway management after induction of anesthesia, postoperative monitoring of breathing, and of the presence or the absence of neuropathy of the lower legs after regional anesthesia. The response rate was 71% (57/80). The majority of anesthesiologists had little experience with front-of-neck access in patient, and responders might frequently make repeated attempts at tracheal intubation. Postoperative monitoring was frequently not routinely performed. In conclusion, this study has shown that there may be various degrees of dissociations between the current standard of anesthesia care and the recommendations made by clinical practice guidelines that had been used as evidence of the standard of care in medical malpractice lawsuit cases in Japan.

[Utility of McGRATH MAC for a Patient with a Large Epiglottic Cyst].

A 76-year-old man with an epiglottic cyst was scheduled for transoral rigid endoscopic epiglottic cystectomy under general anesthesia. The epiglottic cyst was found accidentally when he had an operation of radical cystectomy 2 weeks before. When he had the radical cystectomy, the ventilation through a mask was easy. He had no subjective respiratory symptoms. We chose rapid induction with propofol, remifentanl, and rocuronium. When we inserted the McGRATH MAC laryngoscope, we could only see a big epiglottic cyst not vocal cord but the pressure on the neck enabled the laryngologist to see the vocal cord. We could identify the space through which we could insert tracheal tube without touching the cyst. After the operation, his trachea was extubed.

[Anesthetic Management of an Infant who Underwent Awake-intubation for Her Pharyngeal Injury Caused by a Toothbrush].

A 2-year-and-4-month-old female infant, 12 kg in weight and 90 cm in height fell off from a table, which was about 1 m height with a toothbrush in her mouth without her parents noticing. Urgent CT scan showed that it penetrated the left side of her oropharyngeal wall to the bifurcation of her right carotid artery. According to the initial assessment, carotid artery seemed intact and there seemed to be no sign of CNS involvement. She underwent general anesthesia for further investigation and operation. We could detect vocal code with ease by inserting Glidescope between her tongue and the toothbrush. After the intubation, we administered fentanyl 25 µg rocuronium 15 mg and sevoflulane 3-5% to her, and then she underwent arteriography. The neurosurgeon found no sign of major arterial injury nor traumatic aneurysm nor CNS involvement. She went to the ICU intubated after the removal of the toothbrush. She was extubated 5 days after operation. One of the benefits of the Glidescope is that we can share the visual image, and we chose it this time. When we expect a difficult airway during management for oropharyngeal trauma, we have to consider the way to manage the airway.

[Morphine-induced Anaphylaxis before Induction of Anesthesia].

We describe a case of anaphylaxia that occurred in a 67-year-old man. He was planned to have an operation on mitral valve prolapse (MVP) for mitral regurgitation (MR). Morphine 5 mg was injected intramusculaly 45 min before operation. Since then, he felt itchy sensation around his inguinal region. After he came to the operating room, he felt itchy sensation all over the body. Initially, his vatal signs were stable. We started to give extracellular fluid including ulinastatin 300,000 U, methylprednisolone 2 g, and ranitidine 50 mg. A few minutes later, he had nettle rash all over the body and his blood pressure decreased to 40/20 mmHg, and the heart rate increased to 120 beats x min(-1). Soon after, he had pulseless electric activity (PEA). We started chest compression and tracheal intubation. We injected adrenaline 1 mg. After doing the continuous chest compression for 2 min, he revived. He had continuous medications including dopamine 5 µg x kg(-1) x min(-1), dobutamine 5 µg x kg(-1) x min(-1), noradrenaline 0.05 µg x kg(-1) x min(-1). We cancelled the operation, and he was transfered to the high care unit (HCU), where his blood pressure was 120/65 mmHg, and heart rate 120 beats x min(-1). After 24 hours, we extubated his trachea. In this case, morphine was considered to be the most likely cause for anaphylaxis.

[Anesthetic Management of a Pregnant Woman Undergoing Cesarean Section and Intestinal Tract Perforation Restoration].

We describe anesthetic management of a pregnant woman (weight 42 kg, height 147 cm) with ileus, requiring emergency cesarean section and ileus operation. Cesarean section was performed under spinal anesthesia and epidural anesthesia, and ileus operation was performed under total intravenous general anesthesia. During ileus operation, the blood pressure decreased to 60/30 mmHg and the heart rate increased to 140 beats x min, indicating the intestinal traction syndrome. Repeated injections of phenylephrine 0.1 mg and albumin preparation 5% 1,500 ml were required to restore blood pressure. After the operation, the patient's trachea was extubated. The last level of the spinal anesthesia was T6.

[Anesthetic Management of an Adrenoleukodystrophy Patient for Intrathecal Baclofen Therapy].

A 34-year-old man with adrenoleukodystrophy (ALD) was scheduled for pump system insertion of intrathecal baclofen therapy under general anesthesia. ALD, a rare genetic disorder, is associated with a total body increase in long chain fatty acids caused by defective degradation, and includes various nervous system abnormalities, muscular weakness, in addition to adrenal insufficiency. He had contracture of the both legs, and muscular weakness of the left hand, and Mallampati class III, but no respiratory disability. In the operating room, we administered hydrocortisone 100 mg for steroid coverage, and low-dose midazolam, and fentanyl. As spontaneous breathing remained, we could easily see epiglottis and arytenoid cartilage by McGRATH. Therefore we selected rapid-induction of anesthesia with thiamylal, and rocuronium 40 mg, under cricoid pressure. We avoided propofol. Anesthsia was maintained with sevoflurane and remifentanil, monitoring BIS and train of four. No more rocuronium was administered, and anesthesia was uneventful. Intrathecal baclofen therapy is given to patients who have severe contracture. When we selected general anesthesia, we should be aware of the possibility of muscular weakness, and cannot intubate cannot ventilate scenario.

[Pentax AWS-s200: Its Advantages and Possible Problems].

The Pentax AWS-s200 (Hoya, Japan : s-200) is a new videolaryngoscope. Its weight is 190 g, and it is lighter than the original AWS (AWS-s100L: s-100). It has a USB port, and its screen is wider and clearer than the s-100. The INTROCK for the s-100 is all usable with the s-200. The target mark is positioned at the center of the screen in the s-200. We used the s-200 in 20 patients, and could see a full view of the glottis, and tracheal intubation was successful in all patients. But tracheal intubation was not smooth in 10 of 20 patients, mainly because the tube impacted the right arytenoid. We felt the target mark of the s-200 may be incorrectly positioned.

[Stroke Volume Variation (SVV) as an Indicator of Intraoperative Transfusion Management during Laparoscopic Colectomy.]

BACKGROUND: Intraoperative transfusion manage- ment is difficult during laparoscopic surgery, because peumoperitoneum affects hemodynamics. We studied whether stroke volume variation (SVV) is useful as an indicator of transfusion management Methods : We studied 44 patients undergoing lapa- roscopic colectomy. Patients were randomly allocated to two groups, and the volume of transfusion was decided with the SVV as an indicator in one group (SVV group, n=22) or with conventional indicators, such as blood pressure, heart rate, volume of urine in the other group (control group, n=22) Results : In the SVV group, total transfusion volume and total blood loss during operation were significantly decreased, and the length of hospital stay was signifi- cantly shorter, compared with the control group. CONCLUSIONS: We believe that the SVV is a useful indicator of intraoperative transfusi6h management during laparoscopic colectomy.

[Laryngeal Mask Airway for Ventilation during Fiberoptic Bronchoscopy in a Child with Bilateral Vocal Cord Palsy following Coin Lithium Battery Ingestion].

We report anesthetic management for fiberoptic laryngoscopy in a 10-month-old boy with stridor, due possibly to bilateral vocal cord palsy after coin lithium battery ingestion. After pre-oxygenation of the child, anesthesia was induced with propofol 16 mg (2 mg · kg(-1)) and rocuronium 8 mg (1 mg · kg(-1)). After assist mask ventilation with sevoflurane 5-6%, we inserted a laryngeal mask. The fiberoptic laryngoscopy was smoothly performed by passing a fiberscope through the laryngeal mask. At the end of the procedure, the patient was sent back to the ward.

[Anesthetic Management of Laparoscopic Lower Gastrointestinal Tract Surgery].

This article reviews anesthetic management of lapa- roscopic lower gastrointestinal tract surgery. The recommended anesthetic method is general anesthesia, and tracheal intubation is an appropriate airway control method. It is important to understand hemodynamics and respiratory changes with pneumoperitoneum and Trendelenburg position during operation, especially in a patient with compromised cardiopulmonary functions. It is necessary to consider postoperative analge- sic method. An'enhanced recovery after surgery program may be useful to laparoscopic lower gastrointestinal tract surgery.

[Intubation Using a Double-lumen Tube with a Combination of Fiberoptic Bronchoscope and the Glidescope in a Patient with Difficult Airway].

A 54-year-old man with lung cancer was scheduled for thoracoscopic upper lobe resection under general anesthesia. About half a year previously, he had undergone surgery for oropharyngeal cancer and tongue cancer. As a result of the surgery, elasticity of the neck skin bending of the neck were restricted (Mallampati classification IV). A narrow-bored tracheostomy tube (speech cannula) was inserted. In the operating room, the tip of a 5.0 mm ID standard tube was inserted from the tracheostomy tube, and connected to a breathing circuit. Anesthesia was induced with inhalation of sevoflurane, followed by intravenous propofol, fentanyl, and rocuronium. Four anesthesiologists were required to intubate the trachea. One person held the tracheal tube placed in the tracheotomy tube. The second person performed jaw thrusting. The third person inserted the Glidescope to shift the transplanted tongue to the side. It was then possible for the forth anesthesiologist to manage to see the glottis using a fiberoptic bronchoscope, and a double-lumen tube (DLT) could be inserted to the trachea orally. Inserting a DLT over the fiberoptic bronchoscope is a blind method, but we felt that combined with a variety of tools such as video laryngoscope, the success rate in intubation will increase.

[Usefulness of ACUSON Freestyle (Siemens), Wireless Ultrasound System].

The ACUSON Freestyle, the world's first wireless ultrasound system, was released in April 2014. We assessed its usefulness, using it for central venous cannulation, spinal anesthesia, brachial plexus or obturator nerve block, and for the surgery of metastatic liver cancer as well as the spine. Generally, we could use it smoothly in all situations. Comparing with the conventional ultrasound system, the machine is big, heavy, with many buttons to operate. The main problem with the conventional ultrasound system is the wire connecting probe and the main system, which can interfere with procedures. With ACUSON Freestyle, we could perform the nerve block and the central venous cannulation more easily with little concern about contamination.

[Comparison of Seven Intubation Devices in Difficult Airway Model].

BACKGROUND: The efficacy in tracheal intubation may differ between different video-optical devices, in particular in patients with difficult airways. The purpose of this study was to evaluate the efficacy of video-laryngoscopes and fiberoptic bronchoscope (FOB) in tracheal intubation on a mannequin with several difficult airways, including limited mouth opening, cervical spine rigidity and tongue edema. METHODS: Residents performed tracheal intubation on a mannequin using Macintosh laryngoscope (Mac), rigid indirect-optical intubation devices and FOB. The laryngeal view, the success rate of tracheal intubation, and the time to intubate trachea were recorded. RESULTS: With limited mouth opening and cervical spine rigidity, video-optical intubation devices showed a significantly higher success rate of tracheal intubation than the Mac or FOB. In contrast, with tongue edema, the success rate of tracheal intubation was lower when Mac-type videolaryngoscopes were used. CONCLUSIONS: Videolaryngoscopes can generally be useful in patients with all difficult airways, but may be difficult in some circumstances (such as tongue edema). The FOB provided good laryngeal view in all cases, but the success rate of tracheal intubation was low and the time to intubate trachea was long.

[Tracheal Intubation via the i-gel and the Aintree Intubation Catheter in a Patient with Unexpected Difficult Intubation].

A 64-year-old man was scheduled for radical sinus operation. Preoperatively, we did not expect difficult airway. We induced general anesthesia, and ventilation via facemask was adequate, but tracheal intubation using a Macintosh laryngoscope was difficult (Cormack-Lehane classification III). We inserted the i-gel, and a fiberoptic bronchoscope covered with the Aintree Intubation Catheter (AIC), was passed through the i-gel to the trachea. We removed i-gel and fiberscope, leaving the AIC in place, and could easily advance a reinforced tube over the AIC into the trachea. Fiberoptic tracheal intubation via the i-gel and AIC is useful in a patient with difficult intubation.

[Anesthetic Management of a Patient with Corrected Transposition of Great Arteries for Cesarean Section].

A 30-year-old woman with corrected transposition of great arteries (c-TGA) was scheduled for elective cesarean section at 37 weeks of gestation. At previous cesarean section, she received general anesthesia for dyspnea and lower cardiac function by severe mitral regurgitation, with a pulmonary catheter inserted. In the current pregnancy, she had tricuspid regurgitation, but she had no signs of heart failure. Cardiac index (CI) and stroke volume variation (SVV) were monitored by the FloTrack, before induction of anesthesia. Because the CI was 3.6 l x min(-1) x m(-2), and the SVV was 18%, we decided to perform combined spinal epidural anesthesia. Epidural anesthesia was performed at L1-2, and spinal anesthesia was performed at L3-4. Hyperbaric 0.5% bupivacaine 2.0 ml with fentanyl 10 µg was given to the subarachnoid space. The total dose of phenylephrine administered was 150 µg, and the CI as well as the SVV were stable during surgery. Her postpartum couse was uneventful. Anesthetic management of c-TGA is discussed, and we should select anesthetic method carefully.

A mathematical model to predict protein wash out kinetics during whole-lung lavage in autoimmune pulmonary alveolar proteinosis.

Whole-lung lavage (WLL) remains the standard therapy for pulmonary alveolar proteinosis (PAP), a process in which accumulated surfactants are washed out of the lung with 0.5-2.0 l of saline aliquots for 10-30 wash cycles. The method has been established empirically. In contrast, the kinetics of protein transfer into the lavage fluid has not been fully evaluated either theoretically or practically. Seventeen lungs from patients with autoimmune PAP underwent WLL. We made accurate timetables for each stage of WLL, namely, instilling, retaining, draining, and preparing. Subsequently, we measured the volumes of both instilled saline and drained lavage fluid, as well as the concentrations of proteins in the drained lavage fluid. We also proposed a mathematical model of protein transfer into the lavage fluid in which time is a single variable as the protein moves in response to the simple diffusion. The measured concentrations of IgG, transferrin, albumin, and ß2-microglobulin closely matched the corresponding theoretical values calculated through differential equations. Coefficients for transfer of ß2-microglobulin from the blood to the lavage fluid were two orders of magnitude higher than those of IgG, transferrin, and albumin. Simulations using the mathematical model showed that the cumulative amount of eliminated protein was not affected by the duration of each cycle but dependent mostly on the total time of lavage and partially on the volume instilled. Although physicians have paid little attention to the transfer of substances from the lung to lavage fluid, WLL seems to be a procedure that follows a diffusion-based mathematical model.

[Use of a New Video-laryngoscope (McGRATH® X-blade™) in Patients with Difficult Airways].

We describe the use of a new video-laryngoscope (McGRATH® X-blade™, X-blade) in patients with difficult airways. We report four cases of difficult and failed tracheal intubation using a conventional Machintosh laryngoscope and McGRATH® MAC in which tracheal intubation was accomplished swiftly and easily using a newly designed videolaryngoscope, the X-blade. The whole glottis was easily visible (Cormack-Lehane grade 1) with the X-blade. X-blade also provided a good view of glottic opening in a patient with obesity. We believe that X-blade is useful in patients with difficult airways.

[Usefulness of the McGRATH® Videolaryngoscope in 100 Children].

BACKGROUND: The McGRATH® MAC videolaryngoscope (McG) is a new device for tracheal intubation. Its utility has been reported in both tracheal intubation in children and difficult tracheal intubation for adults. Initially, the blade introduced was for adult use only, but the one for children was also in the market. We examined the usefulness of the McG for tracheal intubation in 100 children. METHODS: Tracheal intubation with the McG (blade # 2) was performed in 100 children who required tracheal intubation. The view of glottic opening was evaluated according to Cormack-Lehane classification. The time required for intubation was recorded. RESULTS: It was possible to perform tracheal intubation in all 100 cases including 10 children with predicted difficult intubation. There was no specific complication. The view of the glottis was good in all cases. Tracheal intubation was easily performed in 91 cases, and relatively easy in 9 cases. CONCLUSIONS: McG is useful in both routine and difficult airway management for children.