Hirokazu Sakai

LINGUAL CYST IN INFANCY : IMPORTANCE OF PALPATION FOR DIAGNOSIS

Two infants, 5 and 12 weeks of age, with lingual cysts were presented. Histological findings were compatible with a salivary retention cyst in one and a thyroglossal duct cyst in the other. Both infants were admitted to our hospital because of severe stridor that had developed from one to two weeks of age. Their lingual cysts were easily recognizable by simple palpation and were confirmed by non‐invasive imaging techniques, such as ultrasound sonography, computed tomography and magnetic resonance imaging. Lingual cyst in infancy may be large enough to cause stridor and dyspnea, and occasionally result in sudden infant death, although once diagnosis is made a radical operation can be easily performed. Therefore, it is important that palpation in the oral cavity should be performed with all infants with persistent stridor as a part of a physical examination.

Factor‐associated caregiver burden in medically complex patients with special health‐care needs

Many medically complex patients with special health‐care needs (PSHCN) receive home‐based medical support, placing a major burden on their caregivers. We characterized the caregiving factors involved in PSHCN and their relationship with caregiver burden.

Toward better home respiratory monitoring: A comparison of impedance and inductance pneumography

Various respiratory monitoring methods have been used as a part of home respiratory care, but none has been accepted as a universal method. Impedance pneumography is the most popular method at present and is used in the form of cardiorespiratory monitoring, but it has limitations for diagnosing obstructive airway problems and a high incidence of false alarms.

Alternative treatment may lower the need for use of extracorporeal membrane oxygenation

Access to artificial surfactant and high frequency oscillatory ventilation (HFO) in Japan seems to affect the actual indications for extracorporeal membrane oxygenation (ECMO).

Limitation of duty hour regulations for pediatric resident wellness: A mixed methods study in Japan.

Abstract Duty hour regulations have been placed in residency programs to address mental health concerns and to improve wellness. Here, we elucidate the prevalence of depressive symptoms after implementing an overnight call shift system and the factors associated with burnout or depression among residents. A sequential exploratory mixed methods study was conducted in a tertiary care pediatric and perinatal hospital in Tokyo, Japan. A total of 41 pediatric residents participated in the cross-sectional survey. We determined and compared the prevalence of depressive symptoms and the number of actual working hours before and after implementing the shift system. A follow-up focus-group interview with 4 residents was conducted to explore the factors that may trigger or prevent depression and burnout. Mean working hours significantly decreased from 75.2 hours to 64.9 hours per week. Prevalence of depressive symptoms remained similar before and after implementation of the shift system. Emotional exhaustion and depersonalization from the burnout scale were markedly associated with depression. High workload, stress intolerance, interpersonal difficulties, and generation gaps regarding work–life balance could cause burnout. Stress tolerance, workload monitoring and balancing, appropriate supervision, and peer support could prevent burnout. Although the overnight call shift system was effective in reducing working hours, its effectiveness in managing mental health issues among pediatric residents remains unclear. Resident wellness programs represent an additional strategy and they should be aimed at fostering peer support and improvement of resident–faculty interactions. Such an approach could be beneficial to the relationship between physicians of different generations with conflicting belief structures.

Cerebral hypoperfusion during pediatric cardiac surgery detected by combined bispectral index monitoring and transcranial doppler ultrasonography.

Bispectral index monitoring (BIS) measures depth of anesthesia and sedation. The case of a neonatal patient who underwent surgical repair for a double aortic arch is presented. During surgery, BIS decreased to 0, and cerebral blood flow (CBF), as measured by transcranial doppler ultrasonography, could not be detected immediately after clamping of the arch. BIS returned to baseline, and CBF was detected only after the aortic arch was unclamped. The arch was then carefully reclamped during close BIS and CBF monitoring.

Anesthesia-compatible Magnetic Resonance Imaging

To the Editor:—We read with interest the correspondence by Zimmer et al. Although we agree with their conclusion that human error related to magnetic resonance imaging (MRI) use can only be minimized by adequate training, we believe lessening the risks of MRI technology itself is of equal importance. We feel it is time to stress the importance of “anesthesia-compatible” MRI, rather than putting all the emphasis on anesthesiologists adapting to the needs of the MRI machine. Anesthesiologists and patients are now forced into working under conditions that are far less than optimal in MRI suites that are cold and dark, have noisy equipment and facilities, and are often located far away from the main operating area. There are three aspects of MRI that are important to the anesthesiologist: 1) avoidance of materials and equipment that will be attracted to the MRI machine, 2) avoidance of anesthetic devices that interfere with the function of the MRI machine, and 3) avoidance of MRI interference with the patient and the functioning of materials and devices used for anesthesia. This third aspect is often neglected: most MRI machines are not “anesthesia compatible.” The first point is obvious, well known, and scary but can be handled with a little experience. It is, however, extremely important for everyone to realize that complete elimination of the use of ferromagnetic materials in devices used in MRI suites is not feasible and is sometimes impossible, as was made clear in the letter by Zimmer et al., among others. We have successfully dealt with this problem by anchoring all devices that have ferrous materials in them to a movable ceiling pendant system with a predetermined limited range of movement. Installation of metal detectors (similar to those used in airports) at the entrance to MRI suites can help to some degree. The second point involves the use of equipment such as ventilators and infusion pumps for treatment and various patient monitors, personal computer-related devices, and local area network connections for medical information. MRI technology now frequently forces the anesthesiologist to discontinue the use of these devices during MRI activity despite their importance for patient safety. Alternative “MRIcompatible” devices are not always available, functional, or suited for critically ill patients, causing anesthesiologists to make an uncomfortable choice between the continuity of safety of treatment and MRI diagnosis. The third aspect is the most difficult to resolve. We think more attention should be focused on alleviating this problem although some MRI properties, such as magnetic attraction, electric shock, or heating as a result of radiofrequency pulsing, seem to be inevitable. Anesthesiologists have been forced to adapt to MRI technology, raising a never-ending list of incompatibility issues. While working to build a new MRI suite, we realized that although there were few technical difficulties to overcome, lack of awareness of the issues involved with traditional MRI was playing a key role in holding back the development of more patient-friendly MRI technology. Companies we attempted to work with that already make both MRI and anesthesia-related equipment did not seem to find safety for patients under anesthesia during MRI a compelling enough reason to consider revising their MRI devices. It would be much more cost effective and safe to improve MRI machines and their installation, including the architectural design of MRI suites, than it would be to carry out patchwork renovation of numerous patient care devices. The demand for anesthesia care in MRI suites continues to increase as interventional procedures using MRI continue to increase in frequency. Time spent in MRI suites will only become longer. Anesthesiologists, as advocates for patients, should actively voice their concern to improve MRI technology not only in terms of radiologic diagnostic function but also in terms of working environment, duration of examination, and, most importantly, patient safety. We must seek solutions for safer anesthesia delivery. We should stop being cursed by the need for “MRI-compatibility” and start actively implementing an “anesthesia-compatible” MRI environment. To achieve this goal, anesthesiologists should be involved from the beginning of the conceptual design of MRI suites.

The use of the laryngeal mask airway in pediatric anesthesia.

Laryngeal mask airway (LMA) insertion was tried in 120 pediatric cases, from 2 months to 12 years of age. Initial indications for LMA were the same as for a face mask, except for two additional conditions; anticipation of difficulty with intubation and difficulty in management by a face mask. Size 2 LMA was used in the vast majority of cases. The insertion was successful on the first trial in 108 cases. More than one trial was necessary in 9 cases but only 3 cases required more than 3 trials. Insertion could not be completed in 3 cases. The relationship between the depth of LMA at the front teeth and age could be roughly described by “depth=10 cm+0.3×Age”.LMA was found to provide a better and more secure airway than the face mask without direct tracheal intervention. Heart rate did not increase with LMA insertion. It is easy to use and can be used in place of the face mask, but complications such as stomach air inflation due to too vigorous manual ventilation, slight pharyngeal injury, and airway obstruction due to kinking of LMA can occur. These complications can be avoided and must be kept in mind during it’s use.LMA itself can be used to obtain a patent airway where an endotracheal airway is difficult to obtain. LMA-aided tracheal intubation can be extremely useful in obtaining endotracheal airways. Non-blind techniques can be used with LMA to increase safety. LMA is a very useful addition to pediatric anesthesia practice.

Pediatric resident perceptions of shift work in ward rotations

Although the long working hours of physicians are considered to be a social issue, no effective policies such as duty hour regulations have so far been proposed in Japan. We implemented an overnight call shift (OCS) system for ward rotations to improve the working environment for residents in a pediatric residency program. We later conducted a cross‐sectional questionnaire asking the residents to compare this system with the traditional overnight call system. Forty‐one pediatric residents participated in this survey. The residents felt that the quality of patient care improved (80.4% agreed). Most felt that there was less emphasis on education (26.8%) and more emphasis on service (31.7%). Overall, the residents reported that the OCS was beneficial (90.2%). In conclusion, the pediatric residents considered the OCS system during ward rotations as beneficial. Alternative solutions are vital to balance improvements in resident work conditions with the requirement for a high quality of education.

Efficacy of pediatric acute pancreatitis scores at a Japanese tertiary center

Pediatric acute pancreatitis (AP) is a rare but important clinical entity associated with significant morbidity. Predicting the severity and outcome of AP in pediatric patients can be challenging because there are few validated severity scoring systems. Moreover, the etiology of pediatric AP in the Japanese population is different from that of Western populations. The performance of severity scores in pediatric AP with a high prevalence of severe cases is still unknown. The aim of this study was to assess the performance of existing severity scoring systems when used for Japanese children at a tertiary care center.