Effect of Back-Cut Point Needle Bevel Angle on Deterioration After Multiple Punctures in Central Vein Simulation.

Background: Multiple needle punctures during central venous line insertion can lead to serious complications. Needle deterioration owing to repeated punctures may be a major cause. We hypothesized that there is an optimal bevel angle for a back-cut point needle that is resistant to deterioration. In this study, we examined the effect of bevel angle differences in a back-cut point needle on needle tip deterioration caused by multiple punctures. Methods: The resin target was punctured perpendicularly using back-cut point needles with three bevel angles (15°, 17°, and 19°; n=8 for each angle) at a speed of 200 mm/min. The same needle was used for ten consecutive punctures at different locations on the target. The force applied to the needle was recorded as puncture force. The puncture force waveform is bimodal. The second peak values, which formed the maximum values of puncture force, were the focus of the main analysis. We considered a 5% elevation from the first to the 10th puncture force as needle deterioration, and the average slope value of the regression line between the puncture number and puncture force was used. When the upper limit of the 95% confidence interval (CI) of the slope value was less than 0.008889, the needle was considered to be resistant to deterioration. Results: The slopes of the second peak values during 10 consecutive punctures for each bevel angle (15°, 17°, 19°) were 0.003011 ± 0.01085 [-0.006056, 0.012077], 0.006116±0.007431 [-0.000096, 0.012328], and 0.001515 ± 0.005783 [-0.003320, 0.006349], respectively (mean ± standard deviation [95% CI]). Only the 19° angle needle had a smaller upper limit of the 95% CI for a slope value of 0.008889. Conclusion: The 19° bevel angle back-cut point needle was more resistant to deterioration than the 15° and 17° angle needles were.

Feasibility and Outcome of Transjugular Intracardiac Echocardiography-Guided Transcatheter Aortic Valve Replacement.

Background: There are limited data on the impact of intracardiac echocardiography (ICE)-guided transcatheter aortic valve replacement (TAVR) on the new permanent pacemaker implantation (PPMI) rate. Objectives: This study investigated the feasibility and outcome of transjugular ICE (TJ-ICE) -guided TAVR, by visualizing the relationship between the membranous septum (MS) and the transcatheter aortic valve (TAV). Methods: Among patients with severe aortic stenosis who underwent TAVR between February 2017 and June 2020, this study enrolled a total of 163 patients with TJ-ICE-guided TAVR. MS length was measured by ICE. The primary endpoint of this study was the incidence of new PPMI at 30 days. Results: The mean age of the patients in this study was 84.9 ± 4.6 years, and 71.2% of the patients were female. Device success was 96.3% with TJ-ICE guidance. A TJ-ICE-related complication occurred in 1 case (0.6%). The median length of the MS was 5.8 mm (IQR: 5.0-6.9 mm). Excellent intraobserver (intraclass correlation coefficient [ICC]: 0.94; 95% CI:0.79-0.98; P < 0.001) and interobserver (ICC: 0.93; 95% CI: -0.05 to 0.98; P < 0.001) agreements were shown. The new PPMI rate was 6.7% at 30 days without a significant difference between balloon-expandable valves and self-expandable valves (3.4% vs 8.7%; P = 0.226). Patients with a TAV implantation depth less than MS length had a significantly lower incidence of new PPMI compared with patients with a TAV implantation depth greater than MS length (2.1% vs 13.4%; P = 0.005), regardless of baseline right bundle branch block presence (6.7% vs 66.7%; P = 0.004) or absence (1.2% vs 8.2%; P = 0.041). Conclusions: TJ-ICE-guided TAVR demonstrated remarkable feasibility and safety. The TJ-ICE-guided final TAV position had a significant impact on the new PPMI rate. (Tokai Valve Registry; UMIN000036671).

[Two cases of parturients with intracranical hemorrhage accompanied by seizure].

Intracranial hemorrhage during pregnancy is a rare complication, and it results in a high perinatal mortality rate. We recently encountered 2 cases of intracranial hemorrhage during pregnancy. They underwent cesarean section under general anesthesia. Anesthetic management is difficult because we must avoid hemodynamic change and increasing intracranial pressure, and we have difficult airway management. It is also very difficult to prepare for the prevention before the onset because it develops suddenly, and quick action is important. We must prepare tools of airway management and assemble people. In addition, it is important to use the hypotensive drugs which do not affect placental blood-flow to keep systolic blood pressure around 120-140 if it is necessary to suppress the rise of the blood pressure.

Applicability of a compact PT-INR measuring device CoaguChek XS to perioperative management.

OBJECTIVE: In perioperative management, prothrombin time (PT) expressed as the international normalized ratio (INR) is an important preoperative test to assess bleeding risk. It is also used to assess the effect of discontinuing anticoagulant therapy, to determine whether to treat patients with vitamin K or fresh frozen plasma, and to decide whether a deep nerve block (e.g., epidural anesthesia) is needed. Compared with other devices used to measure prothrombin time, the CoaguChek XS is a smaller, lighter and more convenient-to-use PT-INR monitoring system that requires a smaller venous, skin puncture or arterial blood sample than other systems. In a surgical setting, it is often more convenient to collect arterial blood. However, the applicability of arterial blood PT-INR values has not been verified. METHODS: We evaluated the usefulness of the CoaguChek XS in anesthetic management by comparing PT-INR values for arterial blood with those of venous blood in 50 patients who were scheduled for elective surgery under general anesthesia. RESULTS: Arterial PT-INR values were well correlated with venous PT-INR values (r2 = 0.9239; regression line y = 0.9537x + 0.0505). CONCLUSION: These results indicate that the CoaguChek XS system can provide arterial PT-INR values and should be available in operating and emergency rooms.

Spinal epidural hematoma following epidural catheter removal during antiplatelet therapy with cilostazol.

A 90-year-old man underwent emergency thrombectomy for acute occlusion of the right femoral and popliteal arteries. After an epidural catheter (used for intraoperative/postoperative management) was removed, a spinal epidural hematoma involving the Th12 to L3 areas developed. Emergency removal of the hematoma and decompression of the spinal cord were performed. Possibly, the hematoma had developed due to therapy with an antiplatelet agent, cilostazol, which had been started on the first postoperative day, and due to the removal of the catheter, on the third postoperative day, in addition to the patient's advanced age. This case may be the first report of spinal epidural hematoma associated with both cilostazol and epidural anesthesia. From the time course in this patient, important knowledge of drug actions and follow-up may be gained for determining the timing of catheter removal in a patient receiving antiplatelet therapy with cilostazol.