Unexpected cholinergic crisis caused by distigmine bromide: A case report.

RATIONALE: Distigmine bromide is a cholinesterase (ChE) inhibitor used to treat dysuria due to a hypotonic bladder. We encountered a case of cholinergic crisis caused by distigmine bromide, which resulted in a rapid decrease in serum ChE levels, hypothermia, respiratory failure, and circulatory failure within a short period of time. PATIENT CONCERNS: A 51-year-old man was admitted to a psychiatric hospital to treat behavioral disorders due to irritability and violent behavior. The patient was referred to our hospital for septic shock secondary to urinary tract infection and respiratory failure. He had not defecated for 5 days before visiting our hospital. He had moderate intellectual disability. Immediately after admission, he developed hand tremors and drooling. The airway was obstructed by drooling due to vomiting of yellow clear gastric juice. DIAGNOSIS: The patient's high saliva volume, bradycardia, respiratory failure (54 breaths/min), constricted pupils (2.5/mm), poor oxygenation, and a history of oral medication were consistent with the diagnosis of cholinergic crisis due to distigmine bromide. INTERVENTIONS: On admission, the patient was immediately intubated. He was treated with noradrenaline (0.1 µg/kg/min) to increase his blood pressure. He was admitted to the intensive care unit (ICU). Since he had circulatory failure, vasopressin (approximately 1 U/h) was administered. Continuous intravenous atropine sulfate (0.6 mg/h) was also administered for high saliva volume. OUTCOMES: On the 8th ICU day, the patient's drooling and bradycardia improved. The patient was physically and mentally stable, and transferred to the referring hospital. LESSONS: ChE levels and symptoms before onset may not be useful for the early detection and prevention of adverse effects of cholinergic crisis caused by distigmine bromide. In addition to known risks such as renal impairment and older age, constipation should be recognized and communicated as a risk factor.

Effect of baricitinib in patients with coronavirus disease 2019 and respiratory failure: A propensity score-matched retrospective cohort study.

In this retrospective cohort study, we evaluated the efficacy of baricitinib in the treatment of coronavirus disease 2019 (COVID-19). Among 404 adult patients with COVID-19 who were admitted to our hospital between October 23, 2020, and July 31, 2021, 229 patients with respiratory failure were included. Among these, 41 patients in the baricitinib group and 41 patients in the control group were selected by propensity score matching to adjust for background factors. We compared the survival rates of the two groups at 30 and 60 days after admission. The 30-day survival rate was significantly higher in the baricitinib group than in the control group. However, there was no significant difference in 60-day survival in the two groups. Baricitinib may improve the early prognosis of patients with respiratory failure associated with COVID-19. However, efforts should be made to improve the long-term prognosis.

Comparison of video and conventional laryngoscopes for simulated difficult emergency tracheal intubations in the presence of liquids in the airway.

The presence of vomit, blood, or other foreign liquid materials in the upper airway is a major obstacle in difficult tracheal intubations (TIs) especially in prehospital care. However, the usefulness of video laryngoscopes (VLs) in these situations has not been investigated. The objective of this study was to compare the Airway Scope (AWS) and the Macintosh laryngoscope (ML) for their performance in TIs performed by emergency medical technicians (EMTs) using mannequin models with liquids in the airway. Rice gruel and mock blood were used to fill the upper airways of mannequins to create mock vomit and hematemesis models, respectively. TIs were performed by certified EMTs after visualizing the glottis using an AWS with an 18-Fr suction catheter and a ML with an 18-Fr suction catheter. TIs with AWS and ML were performed in random order in a comparative crossover trial. The TI success rate was evaluated based on the following: (a) the time taken from laryngoscope insertion into the oral cavity to glottis visualization, tracheal tube passage through the glottis, until the initiation of ventilation and (b) the subjective level of difficulty, which was assessed using a visual analog scale (VAS). TIs in vomiting and hematemesis scenarios were performed by 25 and 26 EMTs, respectively. The TI success rates for these scenarios were 100% with both AWS and ML. The median time required until successful ventilation was significantly shorter with AWS than with ML in both the vomiting (42 vs. 58 s) and hematemesis models (33 vs. 39 s), respectively. In the hematemesis scenarios, difficulty assessed using a VAS was lower with AWS than with ML (13 vs. 38 in median), respectively. Compared to the ML, the AWS was capable of faster and easier TIs, in a simulated model of liquid foreign material in the upper airway.

Comparison of three video laryngoscopes and direct laryngoscopy for emergency endotracheal intubation: a retrospective cohort study.

OBJECTIVE: Video laryngoscopes are used for managing difficult airways. This study compared three video laryngoscopes' (Pentax-Airway Scope [Pentax], King Vision[King] and McGrath MAC [McGrath]) performances with the Macintosh direct laryngoscope (Macintosh) as emergency tracheal intubations (TIs) reference. DESIGN: Retrospective cohort study. SETTING: The emergency department (ED) and the intensive care unit (ICU) of two Japanese tertiary-level hospitals. PARTICIPANTS: All consecutive video-recorded emergency TI cases in EDs and ICUs between December 2013 and June 2015. PRIMARY OUTCOME MEASURES: The primary study endpoint was first-pass intubation success. A subgroup analysis examined the first-pass intubation success of expert versus non-expert operators. A logistic regression analysis was performed to identify the predictors of first-pass intubation success. RESULTS: A total of 287 emergency TIs were included. The first-pass intubation success rates were 78%, 58%, 78% and 58% for the Pentax, King, McGrath and Macintosh instruments, respectively (p=0.004, Fisher's exact test). The non-expert operators' success rates were significantly higher (p=0.00004, Fisher's exact test) for the Pentax (87%) and McGrath (78%) instruments than that for the King (50%) and Macintosh (46%) instruments, unlike that of the experts (67%, 67%, 78% and 78% for Pentax, McGrath, King and Macintosh, respectively; p=0.556, Fisher's exact test). After TI indication, difficult airway characteristics, and expert versus non-expert operator parameters adjustments, the Pentax (OR=3.422, 95% CI 1.551 to 7.550; p=0.002) and McGrath (OR= 3.758, CI 1.640 to 8.612; p=0.002) instruments showed significantly higher first-pass intubation success odds when compared with the Macintosh laryngoscope (reference, OR=1). The King instrument, however, (OR=1.056; 95% CI 0.487 to 2.289, p=0.889) failed to show any significant superiority. CONCLUSION: The Pentax and McGrath laryngoscopes showed significantly higher emergency TI first-pass intubation success rates than the King laryngoscope when compared with the Macintosh laryngoscope, especially for non-expert operators. TRIAL REGISTRATION NUMBER: UMIN000027925; Results.

Influence of clinical experience of the Macintosh laryngoscope on performance with the Pentax-AWS Airway Scope(®), a rigid video-laryngoscope, by paramedics in Japan.

PURPOSE: We sought to establish the clinical utility of the Pentax-AWS Airway Scope(®) (AWS) when used by paramedics to intubate the trachea, and to evaluate whether their performance was influenced by previous clinical experience with the Macintosh laryngoscope (ML). METHODS: Twenty paramedics attempted tracheal intubation using the AWS in five patients each in the operating room. We recorded the success rate, the number of intubation attempts, and the time for intubation and adverse events, and compared these based on the paramedics' previous clinical experience with the ML. Ten paramedics had no prior clinical experience of the ML (group A) and 10 had used it on more than 30 occasions (group B). RESULTS: The intubation success rate was 99 % (99/100). Notably, 96 % (47/49) of intubations were achieved on the first attempt by the inexperienced paramedics in group A, compared with 64 % (32/50) by the experienced paramedics in group B (p = 0.0001). The time to intubation (mean ± SD) was significantly shorter in group A than in group B (37 ± 24 vs. 48 ± 21 s, p = 0.002). There were marked variations in the times taken to intubate, but no apparent improvement as the intubators gained experience between their first and fifth cases. No complications were encountered in either group. CONCLUSION: We found that paramedics could achieve a high tracheal intubation success rate using the AWS independent of previous airway management experience. Better intubation performance with the AWS was observed in paramedics without clinical experience with the ML.

Intermittent reinflation is safe to maintain oxygenation without alteration of extravascular lung water during one-lung ventilation.

STUDY OBJECTIVE: To investigate whether a maneuver for repeated cycles of collapse and reexpansion of the operative lung, termed "intermittent reinflation" (IR), to counter hypoxemia during one-lung ventilation (OLV), results in a time-dependent alteration of extravascular lung water. DESIGN: Prospective, randomized clinical study. SETTING: Operating room and postsurgical intensive care unit of a university hospital. PATIENTS: 36 ASA physical status 1 and 2 patients undergoing elective, video-assisted thoracic surgery for lung tumors. INTERVENTIONS: Patients were randomly assigned to two groups. Group C consisted of 18 patients whose nondependent lung was kept collapsed during OLV, while Group IR included 18 patients with IR that consisted of 4 separate, 10-second manual inflations and 5-second openings within one minute at intervals of 20 minutes during OLV. MEASUREMENTS: Perioperative parameters included transcutaneous oxygen saturation (SpO2), hemodynamic data, extravascular lung water index (EVLWI), pulmonary vascular permeability index (PVPI) as determined by the single-indicator transpulmonary thermodilution technique, and partial pressure of arterial oxygen/inspired oxygen fraction (PaO2/FIO2) ratio. MAIN RESULTS: Group IR had significantly higher SpO2 at 20 minutes after commencement of OLV (98.9% vs 96.3%, P = 0.029) and average SpO2 throughout OLV (98.7% vs 97.0%, P = 0.020). Hemodynamic data, EVLWI, PVPI, and PaO2/FIO2 ratio did not differ between the groups, and there were no differences between groups in postoperative morbidity or hospital stay. CONCLUSIONS: Intermittent reinflation had a beneficial effect on oxygenation during OLV, without any significant effects on EVLW or postoperative outcomes.

[Use of i-gel supraglottic airway for emergency airway management by novice personnel in comparison with laryngeal mask airway and tracheal intubation in manikin models].

BACKGROUND: Tracheal intubation (TI) is a difficult skill to acquire and its proficiency deteriorates over time if not regularly practiced. However, inexperienced personnel may be required to perform airway management in emergency situations. We compared a novel supraglottic device, i-gel, with laryngeal mask airway classic (cLMA) and TI devices in regard to total success count, time required for placement, and difficulties encountered by novice personnel using a manikin model. METHODS: Following a brief training, 24 residents were asked to insert each of i-gel, cLMA, and TI in a randomize fasion using a manikin. Success counts for placement and time required to chest rise were recorded. After completing the tests, the participants scored the difficulty of each device using a visual ana-log scale (0-100 mm, very easy to very difficult). RESULTS: The total success count with i-gel (46 times) was significantly higher than those of both cLMA (32 times) and TI (38 times), and the time to chest rise with i-gel (14 +/- 6 seconds) was significantly shorter than with cLMA (38 +/- 26 seconds). The difficulty score for i-gel (12 [0-51] mm) was significantly lower than those for both cLMA (51 [0-94] mm) and TI (25 [0-73] mm). CONCLUSIONS: An i-gel may be useful for emergency airway management by inexperienced personnel. Further studies in a clinical setting are necessary to confirm these findings.

Difficult anesthesia management in a case of living donor liver transplantation with hypertrophic obstructive cardiomyopathy.

Liver transplantation with hypertrophic obstructive cardiomyopathy is associated with acute hemodynamic changes, which can exacerbate left ventricular outflow tract obstruction during surgery. Therefore, selection of general anesthetic agents is important, as most can result in hemodynamic instability by reducing systemic vascular resistance and blood pressure. We report successful anesthetic management in a case of living donor liver transplantation with hypertrophic obstructive cardiomyopathy using ketamine, propofol, and fentanyl to avoid vasodilation by anesthetic agents. In addition, landiolol, phenylephrine, and low-dose dopamine were administered to prevent left ventricular outflow tract obstruction, and were found to be effective for improving acute hemodynamic changes during surgery. In the case of this patient, the combination of transesophageal echocardiography and a pulmonary artery catheter was beneficial for intraoperative hemodynamic monitoring.

[Out-of-hospital tracheal intubation practice by advanced level ambulance crews and reeducation program for skill retention: survey of emergency life saving technicians].

BACKGROUND: Five years have passed since out-of-hospital tracheal intubation training for advanced level ambulance crews (emergency life saving technicians: ELSTs) was started in Japan. Herein, we reviewed results of the initial training and reeducation program. METHODS: Using a questionnaire sent by post, we surveyed out-of-hospital tracheal intubations performed by 19 ELSTs trained at Hiroshima University Hospital. RESULTS AND CONCLUSIONS: Sixty-three tracheal intubations were attempted between 2004 and 2009, of which 56 (89%) were successful and 7 (11%) unsuccessful, with ventilation maintained using another means such as a laryngeal mask airway or bag-valve-mask in the latter cases. Esophageal intubation occurred in 6 cases, but were immediately recognized and dealt with appropriately. Only 1 failed intubation patient, in whom esophageal intubation was changed to bag-valve-mask ventilation, survived until discharge. The average number of yearly intubation attempts (1.2) was small, thus nearly all ELSTs replied that they desired a reeducation program to maintain their intubation skills. Furthermore, some expressed a preference to receive reeducation under conditions close to actual emergency settings. That latter finding reflects the difficulty of out-of-hospital tracheal intubation performed in adverse conditions, such as in inappropriate patient or rescuer positions, and secretion or bleeding in the oral cavity.

[Prospective study of respiratory complications during urological retroperitoneal laparoscopic surgery].

BACKGROUND: Retroperitoneal laparoscopic surgery has recently become a common procedure for urological fields. We investigated the incidence of respiratory complications and their background during retroperitoneal laparoscopic surgical procedures performed in the kidney position. METHODS: We prospectively enrolled 51 patients undergoing urological retroperitoneal laparoscopic surgery, and assessed perioperative respiratory complications using postoperative chest x-ray (CXR) and physical examinations. RESULTS: CXR revealed abnormalities in 32 patients (63%), including atelectasis in 22 (43%), pneumomediastinum in 8 (16%), and subcutaneous emphysema in 4 (8%). All of the atelectasis cases occurred in a middle or inferior robe, or a lingular segment of the lower lung in the lateral decubitus position. Furthermore, atelectasis occurred chiefly in older patients or in those who underwent right side surgical procedures, while pneumomediastinum was more common in left side procedures. One case was switched to an open laparotomy procedure because of possible pneumothorax; however, postoperative respiratory status was stable in all patients. CONCLUSIONS: Respiratory complications, such as atelectasis or pneumomediastinum, occurred in more than half of the patients after urological retroperitoneal laparoscopic surgical procedures in the kidney position. Careful perioperative management and postoperative CXR examinations are essential for early detection of such potentially life-threatening complications.

[Survey of skills needed to assist tracheal intubation: nurse assistants lack accurate knowledge of BURP and cricoid pressure maneuvers].

BACKGROUND: The backward, upward and rightward pressure (BURP) maneuver and cricoid pressure (CP) are easily confused because of their similarities. We surveyed nurses to determine their knowledge and skills regarding these maneuvers. METHODS: Forty nurses (OR, n=20; ER, n=20) answered questionnaires regarding BURP and CP, and were then asked to apply CP to a laryngopharynx model equipped with a digital scale to measure compression force. RESULTS: As for the BURP maneuver, 26 nurses (OR 20, ER 6) noted previous experience, while only 13 (OR 3, ER 10) and 1 (OR) nurses answered correctly regarding the compression point and correct direction, respectively. As for CP, 16 nurses (OR 14, ER 2) noted previous experience, but only 3 (all ER) answered correctly. Twenty-six nurses (OR 16, ER 10) incorrectly compressed the thyroid cartilage on the laryngopharynx model, and 24 (OR 18, ER 6) incorrectly applied backward and upward pressure, which was significantly frequent among the OR nurses. The measured forces of CP were 2.11 +/- 1.3 kg (mean +/- SD) and 2.5 +/- 2.1 kg for the OR and ER nurses, respectively, which were not significantly different. CONCLUSIONS: We found that the nurses are confused with the BURP and CP maneuvers. Unless applied correctly, these maneuvers may interfere with tracheal intubation. Constant education and training are essential for effective and safe implementation of these maneuvers.

[Total intravenous anesthesia for a patient with cardiac sarcoidosis associated with left ventricular dysfunction using remifentanil and propofol].

An 81-year-old man with cardiac sarcoidosis was scheduled for an open colectomy and partial resection of liver metastasis. He had undergone implantation of a permanent cardiac pacemaker for complete atrioventricular block 5 years before. Preoperative echocardiography revealed severely reduced left ventricular function, with an ejection fraction of 30%. General anesthesia was induced and maintained with remifentanil 0.2 microg x kg(-1) x min(-1), along with a target-controlled infusion of propofol combined with intermittent administrations of low-dose fentanyl. Perioperative hemodynamic monitoring with a pulmonary artery catheter and transesophageal echocardiography was useful for management of cardiac function and control of infusion volume. The surgery was conducted uneventfully and the patient entered the ICU without endotracheal intubation. Thereafter, the postoperative course was stable without major complications. Cardiac sarcoidosis is characterized by a high incidence of complete atrioventricular block, ventricular arrhythmia, and cardiac dysfunction. We consider that a combination of remifentanil and propofol is useful for careful anesthetic management of patients with cardiac sarcoidosis.

Tracheal intubation of a difficult airway using Airway Scope, Airtraq, and Macintosh laryngoscope: a comparative manikin study of inexperienced personnel.

BACKGROUND: The Airway Scope (AWS) (Pentax-AWS, Hoya Corp., Tokyo, Japan) and the Airtraq (ATQ) (Prodol, Vizcaya, Spain) have similarities in the novel structures of their blades. In this study, we evaluated the ease of use of the AWS and ATQ compared with the Macintosh laryngoscope (ML) by inexperienced personnel in a simulated manikin difficult airway. METHODS: Twenty-four fifth-year medical students with no previous experience in tracheal intubation participated in this study. We used an advanced patient simulator (SimMan(R), Laerdal Medical, Stavanger, Norway) to simulate difficult airway scenarios including cervical spine rigidity, limited mouth opening, and pharyngeal obstruction. The sequences in selecting devices and scenarios were randomized. Success rates for tracheal intubation, and the time required for visualization of the glottis, tracheal intubation, and inflation of the lungs, and the number of optimization maneuvers and dental click sounds were analyzed. The 3 different intubation devices were tested in 4 different scenarios by 24 students. RESULTS: Both the AWS and ATQ had very high success rates of tracheal intubation compared with the ML (AWS 100%*; ATQ 98%*; and ML 89%; *P < 0.05 AWS, ATQ versus ML). The time to intubation with the AWS was significantly shorter than with the ATQ and ML (AWS 11 +/- 6 seconds; ATQ 16 +/- 12 seconds; and ML 16 +/- 11 seconds; *P < 0.05 AWS versus ATQ, ML). The number of optimization maneuvers with the AWS was significantly lower than with the ATQ and ML. There were significantly more audible dental click sounds with the ML than with the AWS and ATQ. CONCLUSION: Both the AWS and ATQ may be suitable devices for difficult intubation by inexperienced personnel in this manikin simulated scenario. Further studies in a clinical setting are necessary to confirm these findings.

[Difficult tracheal intubation using airway scope in a pediatric patient with Hunter syndrome].

Hunter syndrome, manifested by mucopolysaccharidosis II (MPS II), is a hereditary disorder caused by accumulation of glycosaminoglycans. An important issue in regard to anesthesia in affected individuals is airway management, because of gargoylism. An 8-year-old boy with MPS II was scheduled for adenotonsillectomy. We performed slow induction with sevoflurane, then utilized an Airway Scope (AWS; HOYA Corporation Tokyo, Japan), which enables operators to observe tube passage through the vocal cords with an LCD monitor, for tracheal intubation, because intubation guided by a fiberoptic bronchoscopy (FOB) was considered to be risky for glottic damage. Attempted tracheal intubations with the AWS alone and in combination with an FOB inserted through the tracheal tube failed, even though a clear image of the glottis was obtained. Finally, we inserted a stylet into the tracheal tube attached to the blade of the AWS and successful tracheal intubation was accomplished. The operation was completed uneventfully and the patient entered the ICU with his trachea intubated, because of pharyngeal and laryngeal edema. Although useful for difficult airway management, tracheal intubation with the AWS may be difficult when used in patients with a narrow oral cavity or small tracheal tube.

Safety of the inter-nipple line hand position landmark for chest compression.

BACKGROUND: No previous study has investigated the safety of hand position during chest compression determined by the inter-nipple line, in which the heel of one hand is positioned on the centre of the chest between the nipples, from the standpoint of prevention of organ injury. METHODS: We measured the distance from the xiphisternal junction to the inter-nipple line (dN) in 1000 surgical patients and the heel length (H) of hands in 100 healthy volunteers, then used the formula H/2-dN to determine the amount of deviation when the heel of the rescuer's hand extended to the xiphoid process (D). Next, 100 surgical patients were randomly assigned to 18 anaesthesiologists, who placed the heels of their hands on the sternum for validation. RESULTS: The D value was positive in 551 patients, indicating that the heel may extend to the xiphoid process during chest compression in those individuals. Multivariate logistic-regression analyses showed that deviations beyond the xiphoid process to the epigastric region were more likely to occur in female (OR 3.52), elderly (OR 2.00), and short-statured (OR 2.09) patients, and with male rescuers (OR 2.81). During actual positioning, deviation occurred in 51 patients and extended to the epigastric region in 5 females. CONCLUSIONS: Simulation of hand position determined by the inter-nipple line resulted in placement of the rescuer's hands over the xiphoid process in nearly half of the patients. Hand deviation to the epigastric region may occur when the patient is a short-statured or elderly female, and when the rescuer is male.

[Case of transfusion-related acute lung injury associated with severe intraoperative hypoxemia].

A 39-year-old woman, undergoing debridement and flap reconstruction for a soft tissue infection in an upper limb, developed transfusion-related acute lung injury (TRALI) and hypoxemia after an intraoperative transfusion. Perioperatively, she received 8 units of packed red blood cells (RBCs) and 5 units of fresh frozen plasma. Shortly thereafter, hemoglobin oxygen saturation decreased from 100% to 94%, as measured with a pulse oximeter. Chest radiography showed diffuse bilateral pulmonary edema without heart enlargement and echocardiography revealed normal cardiac function. Based on the findings and clinical course, we diagnosed TRALI, started respiratory support with positive endexpiratory pressure ventilation, and administrated sivelestat and dopamine. Hemodynamics and pulmonary vascular permeability were assessed using transpulmonary thermodilution method (PiCCO, PULSION Medical Systems), which enabled determination of cardiac output and extravascular lung water index (EVLWI). EVLWI is useful for quantification of pulmonary edema, a beneficial indicator of cardiorespiratory management. Pulmonary edema improved and the trachea was extubated 34 hours after surgery. Antibodies against HLA were detected in the RBC donor serum sample, and a crossmatch test between the patient lymphocytes and donor serum was positive. We concluded that perioperative transfusion of blood components has a potential to provoke serious TRALI.

Airway Scope for emergency intubations: usefulness of a new video-laryngoscope.

The Airway Scope (AWS-S100, Pentax, Tokyo, Japan) is a new video-laryngoscope, which has a specially designed blade and a portable, battery-powered, 2.4-inch built-in liquid crystal device (LCD) full-color video screen at the top of the handle. In this study, we tested the usefulness of the AWS for tracheal intubation in acute, urgent situations. Patients admitted to the Advanced Emergency and Critical Care Center at Hiroshima University Hospital and who required orotracheal intubations were prospectively enrolled. Tracheal intubations were performed using the AWS by residents (the novice group) or staff physicians (the experienced group), who received a brief instruction in the AWS. We enrolled 38 patients (23 males, 15 females; age, 60 +/- 19 years). Intubations were attempted by 22 intubators (11 residents and 11 experienced personnel). The durations from inserting the blade via the oral cavity until observing the glottis (T1), inserting the tube into the trachea (T2), and confirming the chest rise (T3) were 22 +/- 15, 34 +/- 21 and 49 +/- 27 sec, respectively. When the results were classified into t experienced and novice groups, T1, T2 and T3 were 17 +/- 10 vs. 26 +/- 17, 32 +/- 23 vs. 36 +/- 20, and 45 +/- 25 vs. 53 +/- 27 sec, respectively (the experienced vs. the novice group, n.s.). These results suggested that the AWS may be a suitable device particularly for less experienced personnel, such as novice Advanced Life Support providers.