Introduction of Otolaryngology Outpatient Examination Training Program for junior residents as part of rural regional medical support in Japan.

Background: Nagasaki Prefecture is located in the most western part of Japan, and there are a considerable number of clinics in its many remote islands and rural areas. Thus, the Regional Medical Support Center in Nagasaki Prefecture dispatches doctors to rural hospitals to provide medical support. We introduced an outpatient training program at these rural hospitals for all residents to improve their clinical training in the field of otorhinolaryngology, whereby one otolaryngologist trains one resident. Methods: This otolaryngology outpatient training program is randomly assigned, and conducted for 4-5 days a year, transported by a helicopter in Nagasaki Prefecture, which is a 30-minute one-way trip. We used a case checklist that included the 35 items that should be experienced and are defined as frequent by the Ministry of Health, Labor and Welfare. We also conducted a survey using an anonymous questionnaire. Results: The survey response rate was 100%. Comparing the experience rate of symptoms between the pre-introduction resident and the post-introduction resident who underwent the otolaryngology outpatient training program, the experience rates of common diseases, including vertigo and otolaryngologic symptoms such as nasal bleeding and hoarseness, significantly increased after the program was introduced (p ≤ .001). Notably, the experience rate of headache, cough/sputum, and vertigo was 100%. Conclusion: Our training program provides a suitable medical environment for the resident and secures a doctor who can provide secondary medical service support. Furthermore, the program will improve the level of primary care provided by the residents in remote island and rural area hospitals.

An adult case of laryngopharyngeal burn by drinking hot water.

Case: A 61-year-old man who was hospitalized with schizophrenia in a psychiatric hospital drank hot water estimated to be 90°C. Eight hours after injury, laryngopharynx edema gradually progressed, and his breathing deteriorated. Upon arrival at our emergency room, we secured his respiratory tract by nasal intubation under a bronchoscope. Outcome: The edema gradually improved after peaking at hospital day 2, and he was extubated on hospital day 18. There were no apparent respiratory or esophageal problems, and he was discharged back to the psychiatric hospital on day 28. Conclusion: These types of laryngopharynx burns caused by ingesting hot foods or drinks have been rarely reported for adults. In cases of adults, when the patient is in a special situation such as having a psychiatric disorder, it is necessary to assume that the laryngopharynx burns might be aggravated.

Portable system for monitoring of regional cerebral oxygen saturation during prehospital cardiopulmonary resuscitation: a pilot study.

Aim: We aimed to create a system for monitoring of regional cerebral oxygen saturation (rSO 2) in patients with prehospital cardiopulmonary arrest and clarify the changes in rSO 2 during cardiopulmonary resuscitation. Methods: We measured rSO 2 in cardiopulmonary arrest patients who were transferred by the emergency response vehicle of Nagasaki University Hospital. We developed a portable rSO 2 monitor (HAND ai TOS), which is small enough to carry during prehospital treatment. The sensor is attached to the forehead of the patient and monitors rSO 2 continuously during treatment and transfer. Results: No difficulties were experienced in monitoring rSO 2 during patient treatment and transfer. Median time (interquartile range) from the emergency medical service call to emergency response vehicle arrival was 15.0 min (11.0-19.5 min). Median rSO 2 on emergency response vehicle arrival at the scene was 46.3% (44.0-48.2%) (n = 9; median age, 74.0 years; four men, five women). Median rSO 2 showed significant increase within 5 min after return of spontaneous circulation (n = 6, 46.6% versus 58.7%, P < 0.05). There was no significant increase in rSO 2 during prehospital cardiopulmonary resuscitation until return of spontaneous circulation was established. Conclusions: We developed an rSO 2 monitoring system for use during prehospital cardiopulmonary resuscitation. The monitoring system showed a significant increase in rSO 2 after return of spontaneous circulation, whereas there was no significant increase in rSO 2 during cardiopulmonary resuscitation after intubation but before return of spontaneous circulation.

[Anesthetic management of a pregnant patient with congenitally corrected transposition of the great arteries for emergency cesarean delivery].

A 30-year-old woman at 35 weeks' gestation with congenitally corrected transposition of the great arteries (CCTGA), whose associated anomalies were VSD, ASD and pulmonary stenosis, underwent emergency cesarean delivery under general anesthesia. She had hypoxemia due to right-to-left shunt. We discussed with obstetricians and pediatric cardiologists about her at 25 weeks' gestation. Discussed points included: 1) delivery after 30 weeks' gestation, 2) her cardiac function and anomalies, 3) cesarean delivery under general anesthesia in case of emergency, 4) management of a sleeping baby after cesarean delivery by pediatricians. Cyanosis and heart failure were noted worsening during pregnancy. General anesthesia was induced by midazolam and fentanyl following cannulation of radial artery and right internal jugular vein for blood pressure and CVP monitoring. Anesthesia was maintained with sevoflurane and fentnyl. Dopamine and dobutamine were used to support blood pressure and cardiac function. After delivery, because of decreased CVP, lactated Ringer's solution was administrated. After operation, the patient was hemodynamically stable and trachea was extubated. Anesthetic management of the patient depends on the anatomical defects of CCTGA and associated conditions. Anesthesiologist should obtain information about a pregnant woman with CCTGA from cardiologists and obstetricians in early gestation to manage patient successfully.

[Anesthetic management of a neonate with laryngotracheoesophageal cleft and tracheoesophageal fistula].

Laryngotracheoesophageal cleft (LTEC) is an extremely rare congenital anomaly characterized by an absence of all or a part of the tracheoesophageal septum producing an abnormal communication between the trachea and esophagus, and is often difficult to be diagnosed. A 2-day-old male baby was tentatively diagnosed as tracheoesophageal fistula type Gross C, and underwent gastrostomy. The trachea was intubated before anesthetic induction. When a balloon of gastrostomy catheter was inflated, the lung could not be ventilated. After extubation of endotracheal tube and removal of gastrostomy catheter, the lung could be ventilated with mask. When endotracheal tube was intubated again, the lung could not be ventilated at all. Thus the surgery was performed under mask ventilation. Endoscopic examination performed 2 weeks later gave diagnosis of LTEC type 3. It is likely that the endotracheal tube might have been advanced into the end of the esophagus due to absence of the tracheoesophageal septum. In spite of a rare disease, LTEC should be considered as an extreme case of transesophageal fistula with a high risk of difficult airway.

High frequency jet ventilation is associated with increased levels of plasma alpha-atrial natriuretic peptide -- a preliminary study.

PURPOSE: To determine if high frequency jet ventilation (HFJV) influences the secretion of alpha-atrial natriuretic peptide (alpha- ANP). METHODS: Sixteen patients undergoing otolaryngeal surgery were studied. Nine patients were subjected to intermittent positive pressure ventilation (IPPV), and seven patients underwent HFJV. Blood samples were drawn for the measurement of plasma alpha-ANP levels and blood gases before anesthesia, and at 30-min after starting either type of ventilation. The study was started at 2:00 p.m., and was completed before surgery. The plasma concentration of alpha-ANP was assayed by radioimmunoassay. RESULTS: There were no significant differences in mean arterial pressure, heart rate, oxygenation index and PaCO(2) between the two groups. IPPV was not associated with any changes in plasma -ANP levels, whereas HFJV was associated with significantly increased plasma alpha-ANP levels (from 60.0 +/- 5.7 pg x mL(-1) before anesthesia to 112.0 +/- 11.6 pg x mL(-1) after ventilation, P < 0.01). The urine output of the HFJV patients was significantly greater than that of the IPPV patients (P < 0.05). CONCLUSION: These preliminary results suggest that HFJV is associated with a significant increase in plasma ANP and in urine output in anesthetized patients.