Postgraduate Developments Among Perianesthesia-Trained Nursing Graduates in Japan: A Cross-Sectional Survey.

PURPOSE: To elucidate the postgraduation situation of those who have completed a perianesthesia nurse (PAN) educational course offered in master's degree programs in Japan. DESIGN: This cross-sectional study used an anonymous self-administered questionnaire. METHODS: Of the 42 individuals who completed a PAN educational course offered in master's degree programs in Japan by March 2021, 41 were targeted, excluding the author of this study. The questionnaire was distributed by mail between November 20, 2021, and January 14, 2022, and the participants were asked to return the completed questionnaire by mail. Those working as PANs were asked about their work content, work satisfaction, and thoughts on their prospects in the perianesthesia nursing field. Those not working as a PAN were asked about their future intentions to do so. FINDINGS: The response rate was 95.1% (39/41). PANs are involved in various perianesthesia tasks, and there were no respondents who answered "No" to the question of whether they were glad to have become a PAN. However, of those working as PANs, only 16 (53.3%) indicated that they would like to continue working in that role. Few respondents (n = 3; 10.0%) considered future PAN prospects to be "good," while eight (26.7%) respondents answered "poor," and many (n = 19; 63.3%) stated "neither." CONCLUSIONS: Under the current situation, PANs in Japan do not necessarily have a positive outlook for the future, the causes for which must be analyzed to make the necessary improvements.

Incidence of perioperative hypotension in patients undergoing transurethral resection of bladder tumor after oral 5-aminolevulinic acid administration: a retrospective multicenter cohort study.

PURPOSE: Tumors can be visualized using 5-Aminolevulinic acid hydrochloride (5-ALA) during transurethral resection of bladder tumors (TURBT). Hypotension is an adverse effect of 5-ALA; however, its incidence and morbidity rates are unknown. This study aimed to describe the incidence of perioperative hypotension and identify risk factors for hypotension among patients after 5-ALA administration in TURBT. METHODS: This retrospective multicenter cohort study was conducted at three general hospitals in Japan. Adult patients who underwent elective TURBT after 5-ALA administration between April 2018 and August 2020 were included. The primary outcome was the incidence of perioperative hypotension (mean blood pressure < 65 mmHg). The secondary outcomes were the use of vasoactive agents and adverse events, including urgent intensive care unit (ICU) admission. Multivariate logistic regression analysis was performed to investigate risk factors of the incidence of intraoperative hypotension. RESULTS: The median age of 261 patients was 73 years. General anesthesia was induced in 252 patients. The intraoperative hypotension was observed in 246 (94.3%) patients. Three patients (1.1%) were urgently admitted to the ICU for continued vasoactive agent use after surgery. All three patients had renal dysfunction. Multivariate logistic regression analysis revealed that general anesthesia was significantly associated with intraoperative hypotension (adjusted odds ratio, 17.94; 95% confidence interval, 3.21-100.81). CONCLUSION: The incidence of hypotension in patients undergoing TURBT after 5-ALA administration was 94.3%. The incidence of urgent ICU admission with prolonged hypotension was 1.1% in all patients with renal dysfunction. General anesthesia was significantly associated with intraoperative hypotension.

Ultrasound-Guided Placement of a Hemodialysis Catheter into the Distal Femoral Vein in a Patient with Multiple Catheters: A Case Report.

Cardiac surgery-associated acute kidney injury may require postoperative renal replacement therapy. Although the right internal jugular vein and femoral veins are generally the preferred insertion sites for the hemodialysis catheter for continuous renal replacement therapy, the presence of other indwelling catheters or prior thrombotic events from previous catheters may preclude use of these sites. We present a case in which the hemodialysis catheter was inserted into the distal femoral vein using point-of-care ultrasound in a patient with multiple catheter insertions after coronary artery bypass grafting. Although the tip of the dialysis catheter was more distal than the classic femoral approach, renal replacement therapy was performed without problems. Moreover, it was easier for the nurses to keep the insertion site clean and to change the patient's position.

Predictive factors of postoperative fentanyl consumption in patients with inflammatory bowel disease: a retrospective cohort study.

BACKGROUND: Patients with inflammatory bowel disease (IBD), including Crohn's disease and ulcerative colitis, might present difficulties in achieving postoperative analgesia. Prior studies have suggested that patients with IBD undergoing major abdominal surgery require higher doses of perioperative opioids than do patients without IBD. Considering patients with IBD potentially require high-dose opioids, identifying those requiring higher opioid doses will allow clinicians to optimize the perioperative opioid dose and avoid insufficient pain management or complications of opioid overdose. Therefore, we conducted this study to identify predictive factors that might influence postoperative opioid consumption in patients with IBD. METHODS: This single-center, historical cohort study reviewed the medical records of all patients admitted to the IBD center of our institution for surgery and who used intravenous fentanyl patient-controlled analgesia (PCA) after open abdominal surgery between June 2013 and April 2017. Ultimately, 179 patients were enrolled in the analysis. Variables expected to influence and/or represent pain, analgesia, inflammation, disease condition, and extent of surgery were selected as potential explanatory variables for predicting postoperative opioid consumption. Multivariable linear regression analysis was used to examine the effect of independent variables on postoperative fentanyl consumption. RESULTS: Of the nine predictive variables selected using the stepwise-selection method, eight were significant. Intraoperative fentanyl consumption, current smoking, ulcerative colitis, administration of biologics during the month before surgery, and the use of supplementary analgesics had a significant increasing effect on postoperative fentanyl consumption, whereas droperidol concentration in the PCA solution, age, and diabetes mellitus had a significant decreasing effect. Preoperative use of opioids was a non-significant variable. The adjusted coefficient of determination was 0.302. CONCLUSIONS: Intraoperative fentanyl consumption, current smoking, ulcerative colitis, administration of biologics during the month before surgery, and the use of supplementary analgesics had a significant increasing effect, whereas droperidol concentration in the PCA solution, age, and diabetes mellitus had a significant decreasing effect on postoperative fentanyl consumption. These factors should be considered when adopting postoperative intravenous fentanyl PCA administration for patients with IBD. TRIAL REGISTRATION: Registry: UMIN Clinical Trials Registry. CLINICAL TRIAL NUMBER: UMIN000031198 . Date of registration: February 8, 2018.

Anesthetic Care During Tracheostomy in a Patient with Generalized Tetanus: A Case Report.

Tetanus is a potentially fatal infectious disease caused by the toxins produced by the anaerobic bacterium, Clostridium tetani. Of major concern during the perioperative care of these patients is control of muscle spasms, skeletal rigidity, and autonomic dysfunction. Several of the modern sedative and opioid agents including remifentanil have not been fully evaluated in managing tetanus. We present the intraoperative use of remifentanil in a 75-year-old woman with generalized tetanus who required anesthetic care during placement of a tracheostomy. The end-organ involvement of tetanus is presented, previous reports of anesthetic care reviewed, and the potential utility of remifentanil explored.

Combined Spinal-Epidural Anesthesia for Subtotal Colectomy in a Patient With Hamman Syndrome and Epidural Pneumatosis: A Case Report.

It remains unclear how epidural pneumatosis affects the efficacy of neuraxial anesthesia. Spontaneous pneumomediastinum (Hamman syndrome) with epidural pneumatosis is rare. Regardless of its etiology, general anesthesia with positive pressure ventilation in patients with pneumomediastinum carries the risk of pneumothorax. We present a 19-year-old patient with Hamman syndrome and epidural pneumatosis who required emergency laparotomy. Effective analgesia was obtained using neuraxial anesthesia with a combined spinal-epidural anesthesia technique.

Desflurane impairs hippocampal learning on day 1 of exposure: a prospective laboratory study in rats.

BACKGROUND: Quick and complete recovery of cognitive function after general anesthesia is desirable, particularly for working-age patients. Desflurane is less likely to have long-term effects than older-generation inhalational anesthetics, however, its short-term effects have not been fully investigated. Our objective was to elucidate the short-term effects of desflurane exposure on learning and memory in young adult rats. METHODS: Seven-week old male Sprague-Dawley rats were exposed to air (control), or desflurane at 0.7 or 1.2 minimum alveolar concentration (MAC) for 2 h (day 0). The inhibitory avoidance (IA) test was performed on day 1 to delineate the effects on contextual learning. Separate groups of control and 1.2 MAC desflurane animals underwent the IA test on days 3 and 7 to examine the time-dependent changes. Because the IA test is known to be dependent on the long-term potentiation (LTP) of the hippocampus and the trafficking of the GluR1 subunit of the α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor into the synapses, the effects of 1.2 MAC desflurane on these phenomena were evaluated on day 1. RESULTS: Desflurane at 1.2 MAC, but not 0.7 MAC, significantly decreased the IA latencies on day 1 compared with the control (one-way ANOVA, F [2,48] = 5.974, P = 0.005, post hoc Tukey's, mean difference [95% confidence interval], control vs. 1.2 MAC, 168 [49.9 to 287], P = 0.004; control vs. 0.7 MAC, 67.5 [- 51.2 to 186], P = 0.362). The latencies were not affected on days 3 and 7 (day 3, control vs. desflurane, P = 0.861; day 7, control vs. desflurane, P > 0.999). Consistently, hippocampal LTP on day 1 was significantly suppressed in the desflurane group compared with the control group (P = 0.006). Moreover, immunoblotting analysis of synaptic GluR1 expression revealed that desflurane exposure significantly suppressed GluR1 delivery to the synapses after IA training. CONCLUSION: Exposure to a relatively high concentration of desflurane caused reversible learning and memory impairment in young adult rats associated with suppression of GluR1 delivery to the synapses in the hippocampus.

K-Y™ jelly inhibits increase in endotracheal tube cuff pressure during nitrous oxide exposure in vitro.

BACKGROUND: The increase in endotracheal tube cuff pressure due to nitrous oxide diffusion is a well-known risk during general anesthesia using nitrous oxide. We hypothesized that lubricating endotracheal tube cuffs with K-Y™ Jelly might inhibit the increase in cuff pressure that occurs during exposure to nitrous oxide. METHODS: We used two types of endotracheal tube cuffs: one made from ultrathin polyurethane (PU) and another made from conventional polyvinyl chloride (PVC). Using a pediatric trachea model, which consisted of an acrylic cylinder with an internal diameter of 12 mm, we measured changes in the cuff pressure during nitrous oxide exposure in size 5.0-mm internal diameter endotracheal tubes with each type of cuff, with and without lubrication with K-Y™ Jelly. RESULTS: During nitrous oxide exposure, the increase in cuff pressure was significantly lower in the lubricated cuffs than in the non-lubricated cuffs in both types of cuffs (PVC, P < 0.0001; PU, P < 0.0001). However, the cuff compliance in the trachea model was unaffected by lubrication in both types of cuffs. CONCLUSIONS: Lubrication of endotracheal tube cuffs with K-Y™ Jelly may effectively delay the increase in cuff pressure that occurs during general anesthesia using nitrous oxide.

A comparison of the Airtraq®, McGrath®, and Macintosh laryngoscopes for difficult paediatric intubation: A manikin study.

BACKGROUND: The efficacy of devices for difficult intubation in paediatric patients, especially with a Cormack-Lehane grade 4 view, has yet to be established. We compared intubating parameters among three devices (the Airtraq®, McGrath®, and Macintosh laryngoscopes). METHODS: This study is a randomised cross-over trial. Participants were 20 anaesthetists. Each device was tested three times using a paediatric manikin with a Cormack-Lehane grade 4 view. The order to use each device was randomised by a computer-generated random sequence. The primary endpoint was the rate of successful intubation. Secondary endpoints included the time taken to intubate, percentage of glottic opening score, and severity of potential dental trauma. RESULTS: The successful intubation rates of the Airtraq®, McGrath®, and Macintosh laryngoscopes were 100%, 72%, and 45%, respectively. The risk ratio of the success rates of Airtraq® compared with McGrath® and Macintosh laryngoscopes were 1.40 (95% CI; 1.19-1.64, P < 0.001) and 2.22 (95% CI; 1.68-2.94, P < 0.001), respectively. The modified Cormack-Lehane grade and percentage of the glottic opening score were better for the Airtraq® than for the other devices. The dental trauma score was lower for the Airtraq® than for the other devices. There were no significant differences in the intubation time among the groups. CONCLUSIONS: The Airtraq® had higher success rate, had better visibility, and was associated with less dental trauma than the other devices in a difficult paediatric intubation model with a Cormack-Lehane grade 4 view.

[Anesthetic Management under Spinal Anesthesia in a Patient with Erythropoietic Protoporphyria].

Erythropoietic protoporphyria (EPP) is a hereditary disease resulting from a deficiency in ferrochelatase required for haem synthesis system. We describe the anesthetic management of a 51-year-old man with EPP undergoing open reduction and internal fixation of patella fracture. Spinal anesthesia was induced with bupivacaine. The surgery was performed without any complications. No skin symptom was observed periop- eratively. Spinal anesthesia with bupivacaine can be safe for an EPP patient.

[A Case of Esophageal Polyp Regurgitated into the Pharynx at the Induction of General Anesthesia].

We report the case of a mass in the pharynx found at the induction of general anesthesia that vanished postoperatively. A 46-year-old man underwent abdominal surgery. After the induction of general anesthesia, there was a mass occupying his pharynx and we could see neither the vocal cords nor the epiglottis using a Macintosh laryngoscope. Airwayscope (AWS) enabled us to successfully intubate the trachea. On postoperative examination, there was no mass on his pharynx. Imaging studies of the esophagus revealed a polyp suspected as being a fibrovascular polyp (FVP) arising from the upper esophagus. Three months later, excision of the polyp was planned. Awake intubation with AWS was planned so that if the polyp was regurgitated, he could swallow it Intubation was uneventful without regurgitation of the polyp. At the beginning of surgery, the polyp was not found in the pharynx, but was easily regurgitated by air supplied by the endoscope. FVPs are rare benign esophageal tumors and most originate from the cervical esophagus. If a polyp is regurgitated, obstruction of the airway may occur, and asphyxiation and sudden death have been reported. The fatal complication of airway obstruction requires anesthesiologists to be aware of FVP.

[Anesthetic Management of a Patient for Total Gastrectomy after Coronary Artery Bypass Grafting Using the Right Gastroepiploic Artery].

We report anesthetic management of total gastrectomy for gastric cancer under general anesthesia supplemented with a transversus abdominis plane (TAP) block. The patient was a 78-year-old man who had received coronary artery bypass grafting (CABG) with the right gastroepiploic artery (RGEA) 12 years before. Preoperative coronary angiography (CAG) showed that RCA was obstructed completely and RGEA was patent and the surgeons carried out gastrectomy with the utmost attention not to injure the RGEA. There were no signs of myocardial ischemia under monitoring by transesophageal echocardiography (TEE). The ultrasound-guided TAP block was effective. This case demonstrates that the ultrasound-guided TAP block is an alternative approach for providing analgesia and intraoperative TEE monitoring is useful in a patient with gastrectomy after CABG using the RGEA with coagulation abnormality.

Isoflurane impairs learning and hippocampal long-term potentiation via the saturation of synaptic plasticity.

BACKGROUND: General anesthesia induces long-lasting cognitive and learning deficits. However, the underlying mechanism remains unknown. The GluA1 subunit of AMPAR is a key molecule for learning and synaptic plasticity, which requires trafficking of GluA1-containing AMPARs into the synapse. METHODS: Adult male rats were exposed to 1.8% isoflurane for 2 h and subjected to an inhibitory avoidance task, which is a hippocampus-dependent contextual fear learning paradigm (n = 16 to 39). The in vitro extracellular field potential of hippocampal synapses between the Schaffer collateral and the CA1 was evaluated using a multielectrode recorder (n = 6 per group). GluA1 expression in the synaptoneurosome was assessed using Western blotting (n = 5 to 8). The ubiquitination level of GluA1 was evaluated using immunoprecipitation and Western blotting (n = 7 per group). RESULTS: Seven days after exposure to 1.8% isoflurane for 2 h (Iso1.8), the inhibitory avoidance learning (control vs. Iso1.8; 294 ± 34 vs. 138 ± 28, the mean ± SEM [%]; P = 0.002) and long-term potentiation (125.7 ± 6.1 vs. 105.7 ± 3.3; P < 0.001) were impaired. Iso1.8 also temporarily increased GluA1 in the synaptoneurosomes (100 ± 9.7 vs. 138.9 ± 8.9; P = 0.012) and reduced the GluA1 ubiquitination, a main degradation pathway of GluA1 (100 ± 8.7 vs. 71.1 ± 6.1; P = 0.014). CONCLUSIONS: Isoflurane impairs hippocampal learning and modulates synaptic plasticity in the postanesthetic period. Increased GluA1 may reduce synaptic capacity for additional GluA1-containing AMPARs trafficking.

[Usefulness of ultrasound pre-scanning for cricothyroid membrane puncture in a patient with rupture of a pseudoaneurysm].

A 63-year-old man with von Recklinghausen disease was transported to the emergency department for swelling and pain of his right neck. Chest X-ray and computed tomography scan showed displacement of the trachea to the left by a tumor mass. Urgent airway management was required and fiberoptic intubation in awake condition was planned. First we pre-scanned cricothyroid membrane by ultrasound in a case of emergency. Regardless of several trials, his trachea could not be secured by fiberscope because of narrow pharyngeal space. Suddenly, his consciousness level and Sp(O2) went down, therefore surgical airway was required. Due to pre-scanning, emergency cricothyroid membrane puncture could be performed immediately without any complications. We recommend ultrasound pre-scanning for cricothyroid membrane puncture in a patient with suspected tracheal displacement.

[Anesthetic management in a patient with trifunctional protein deficiency].

A 4-year-old girl with trifunctional protein deficiency was scheduled for gastrostomy. She had recurrent episodes of rhabdomyolysis triggered by fasting, infection, stress and uncertain causes. In the management of anesthesia, we avoided both propofol and inhalational anesthetics and anesthetized her with benzodiazepine and opioid combined with regional anesthesia to minimize the stress response. Her metabolism was kept stable throughout the intraoperative period. However, on the second postoperative day, she developed rhabdomyolysis and was treated with glucose containing infusion. This case provides instructive information that strict management is needed for patients with trifunctional protein deficiency in the perioperative period.

Airway scope laryngoscopy under manual inline stabilization and cervical collar immobilization: a crossover in vivo cinefluoroscopic study.

BACKGROUND: Direct laryngoscopy along with manual inline stabilization (MIS) is currently the standard care for patients with suspected neck injuries. However, cervical collar immobilization is more commonly performed in the prehospital environment, and its early removal is necessary before intubation. We hypothesized that if usability of Airway Scope (AWS) in a difficult airway could also bring merits to intubation under cervical collar immobilization, unnecessary risk caused by the removal of a neck collar may be prevented. METHODS: In this crossover study, 30 consenting patients presenting for surgery were assigned to undergo intubation using AWS. Neck was stabilized manually and by a neck collar in a random order before laryngoscopy was performed by the same anesthesiologist. Measurements include interincisor distance (IID), success rate, intubation time, and fluoroscopic examination of the upper and middle cervical spine. RESULTS: IID was notably narrower after application of a neck collar (mean ± SE: MIS, 19 mm ± 1 mm; collar, 10 mm ± 1 mm; p < 0.01). One and 9 failures were encountered in MIS and collar groups, respectively (p = 0.012). Intubation time proved no statistical significance. Extension of craniocervical junction was observed in both groups, but occipitoatlantal joint was significantly more extended in collar group (median [range]: AWS, 10-degree angle [-1 to 20-degree angle]; collar, 14-degree angle [5 to 26-degree angle]; p < 0.01). DISCUSSION: AWS laryngoscopy under cervical collar immobilization fails to meet our expectation. Intubation failed in 30% of the cases in collar group whereas only 3.3% of the cases in MIS group. Significant difference of mouth opening limitation is probably the major reason, as 7 of 9 failed cases in collar group had IID <10 mm. This was insufficient to insert the 18-mm blade of AWS. In addition, occipitoatlantal joint suffered a greater extension when wearing a neck collar. Differences in the method to stabilize the neck may be the reason. CONCLUSION: When compared with cervical collar immobilization, AWS laryngoscopy along with MIS seems to be a safer and more definite method to secure airway of neck-injured trauma patients because it limits less mouth opening and upper cervical spine movement.

Airway scope versus macintosh laryngoscope in patients with simulated limitation of neck movements.

BACKGROUND: Tracheal intubation in patients with suspected neck injuries should achieve two contradicting goals-sufficient laryngeal exposure and the least cervical spine movement. Because the former involves displacements of the cervical vertebrae, intubation under immobilization is widely performed today to prevent exacerbation of spinal code injuries. The unique curving blade of the Airway Scope (AWS) is designed to fit the oropharyngeal anatomy. A camera at the tip of the blade displays the view of the larynx, but unlike the direct laryngoscope, it needs no line-of-sight of the oral, pharyngeal, and tracheal axis. Our purpose is to determine whether AWS could be a suitable airway device for the intubation of patients with potential neck injury. METHODS: Thirty-six patients scheduled for surgery were randomly assigned to undergo intubation using either AWS or Macintosh laryngoscope (MLS). After general anesthetic induction, the patient's head was set in a neutral position, and an appropriately sized semi-rigid neck collar was placed. Measurements include intubation time, number of attempts, success rate, Cormack-Lehane classification, airway optimization maneuver, Intubation Difficulty Scale scores, and complications. RESULTS: Intubation time proved no statistical significance (mean ± SD, AWS, 62.9 seconds ± 26.0 seconds, MLS, 55.6 seconds ± 26.0 seconds; p = 0.42). AWS scored less in Cormack-Lehane classification (median [range], AWS I [I-I], MLS IIIa [I-IIIb]; p < 0.0001), required fewer additional airway optimization maneuvers (p = 0.0003), and scored less in Intubation Difficulty Scale scores (AWS 0 [0-1], MLS 2 [0-5]; p < 0.0001). CONCLUSIONS: In neck-immobilized patients using semi-rigid cervical collars, AWS improves laryngeal exposure and facilitates tracheal intubation. AWS may be a suitable intubation device for trauma patients.

Successful intubation using a simple fiberoptic assisted laryngoscope for Treacher Collins syndrome.

A fiberoptic-assisted laryngoscope (FLS) (Acoma Medical Industry Co. Ltd., Tokyo, Japan) is a modified Macintosh laryngoscope with a tubular holder into which a fiberoptic bronchoscope can be inserted. We present three cases of Treacher Collins syndrome whose tracheas were successfully intubated with the aid of the FLS. These cases suggest that the FLS may be a useful alternative in the case of difficult pediatric intubation.