[Palliative care in an acute care setting at Kumamoto Regional Medical Center].

BACKGROUND: The Japanese government promotes allowing patients in palliative care to choose where they wish to end their lives. Emergency hospital admissions are inevitable for those cared at home. There are not enough cancer centers in Japan with palliative care facilities and hospices to admit these patients without prior consultation. METHODS: We examined outcomes and characteristics of patients receiving palliative care who were transported by ambulance to our hospital. RESULTS: From April 2007 to March 2010, 58 patients under palliative care came to our emergency department by ambulance. Eight of the 58 (14%) were admitted between midnight and 8 am and 21 (36%) on Saturdays or Sundays. We were consulted for 19 patients (32%) within one week and saw 14 of these on the day they were admitted. Chief complaints were disturbed consciousness (31%), dyspnea (28%), pain (14%) and general fatigue (7%). Fifty patients (86%) came directly from their homes and the others from another hospital. Thirteen patients (22%) died within 48 hours, and 8 (14%) were discharged after their symptoms were treated. Thirty-three (57%) patients died and 4 (7%) were discharged within ten days. CONCLUSIONS: We admitted patients under palliative care into the acute care setting to Kumamoto Regional Medical Center any time.

[A Kumamoto model of clinical training in tracheal intubation for paramedics].

BACKGROUND: Since July 2004, the Japanese Ministry of Health, Labor and Welfare approved certified paramedics to perform emergency prehospital tracheal intubation. A specialized training system in tracheal intubation has been established in Kumamoto Prefecture. METHODS: The Kumamoto Prefectural Medical Control Organization, a tracheal intubation task force was established: consisting of the departments of Anesthesiology at Kumamoto University and 11 other major hospitals, along with Kumamoto Prefecture and the 14 prefectural fire-departments. This group published the Kumamoto training guidelines and a training system for paramedics. RESULTS: Kumamoto Prefecture appealed for support of paramedic activity on television and in newspapers as public education. The prefectural governor officially asked hospitals to train paramedics. Because 9 of the 14 fire-departments had no regional teaching hospital, trainees were matched with other hospitals by the task force. The task force published a pamphlet to inform surgical patients about tracheal intubation training and to recruit patients as practice volunteers. Anesthesiologists undertook significant roles in making arrangements to facilitate the project at their hospitals, in addition to teaching paramedics prior to surgical procedures. CONCLUSIONS: The Medical Control Organization, Kumamoto Prefecture, anesthesiologists and emergency response personnel worked together successfully to promote the training program for clinical tracheal intubation by paramedics.

[Incidence of inappropriate cases for training of emergency medical technicians in endotracheal intubation].

BACKGROUND: Before emergency medical technicians are licensed to perform prehospital endotracheal intubation, they must undergo training in the operating room setting. We investigated the incidence of cases of difficult intubation classified as Cormack & Lehane grade III or IV, because such cases are considered inappropriate for training emergency medical technicians. METHODS: We examined anesthesia records between March 2002 and April 2003, retrospectively. The survey included 585 adult surgical patients with ASA physical status I or II requiring general endotracheal anesthesia. RESULTS: Five anesthesiologists and three doctors from the surgical department performed laryngoscopy during this period. In initial laryngoscopy with a Macintosh blade, the view of larynx was grade I in 436, grade II in 98, grade III in 27 and grade IV in 24 patients. In 68 patients, application of cricoid pressure led to improvement of laryngoscopy grade. The use of McCoy blade was necessary for intubation in 16 patients. Out of 51 patients classified as difficult intubation grade III or IV, 35 were originally not expected to be difficult cases. CONCLUSIONS: Patients with grade I or II view of larynx with a Macintosh blade was only 91%. In order to prepare for unexpected case of difficult intubation, it is necessary to take various measures such as having instructors perform laryngoscopy.

[Anesthetic managements of a patient with congenital myotonia (Becker type)].

A 55-year-old woman with congenital myotonia (Becker type), diagnosed by muscle biopsy and gene examination, underwent a right lower lobectomy assisted with thoracoscopy for lung cancer. After epidural tube replacement at T 9-10, general anesthesia was introduced with propofol 2.5 mg x kg(-1) and fentanyl 2.5 mcg x kg(-1). Vecuronium was administered prudently for muscle relaxation assessed with T 1 response (%) and train-of-four (TOF) ratio (%). T 1 response decreased to 50% 3 min and disappeared 4 min after vecuronium administration. Then she was intubated with a double lumen endobronchial tube. T 1 increased 25% within 27 min and 75% in 40 min. Surgery was uneventful and completed in 180 min. At the end of the operation, there was neither fading of twitch responses nor tetanic responses, and TOF ratio returned to 100%. An acetylcholinesterase inhibitor was not given. She was extubated when normal spontaneous breathing, clear consciousness and adequate pharyngeal reflex were present 25 min after discontinuing propofol. There were no perioperative adverse events including hyperthermia and myoglobinuria related to malignant hyperthermia. In conclusion, we managed the anesthesia for a patient with congenital myotonia (Becker type) with thoracic epidural anesthesia and total intravenous anesthesia. Non-depolarizing muscle relaxant could be used safely at the same dose as that used in non-myotonic patients, and did not cause malignant hyperthermia.

[Tuberculosis detected after emergency cesarean section].

A 29-year-old woman at 37 weeks of gestation was brought to our hospital as an emergency patient complaining of severe cough, hemoptysis and dyspnea. On arrival, we suspected that she was suffering from bronchial asthma or pulmonary embolism, but were unable to improve her respiratory condition. The decision was made to terminate gestation immediately and an emergency cesarean section was performed under spinal anesthesia. Postoperatively diagnosis of tuberculosis was made. Fortunately, there was no intramural tuberculous infection. She was a nurse. Nurses are twice as likely as the general public to contract tuberculosis. Medical workers must keep in mind that they may be infected with tuberculosis and they could also become the source of infection of tuberculosis. It is important to rule out tuberculosis when a patient, particularly a medical worker, complains of severe cough, hemoptysis and dyspnea.

[A case of airway obstruction after posterior occipito-cervical fusion].

A 62-year-old female with rheumatoid arthritis underwent posterior occipito-cervical fusion. Although the operation was successfully performed, airway obstruction developed immediately after the extubation. We succeed in fiberoptic intubation. We consider that airway obstruction was caused by the preexisting reduction of the pharyngeal space and the occipito-cervical fusion malalignment. On the extubation after occipito-cervical fusion, we should always consider the possibility of re-intubation and its difficulty.