Kumi Moriyama

Intrathecal Administration of Morphine Decreases Persistent Pain after Cesarean Section: A Prospective Observational Study

Purpose Chronic pain after cesarean section (CS) is a serious concern, as it can result in functional disability. We evaluated the prevalence of chronic pain after CS prospectively at a single institution in Japan. We also analyzed perioperative risk factors associated with chronic pain using logistic regression analyses with a backward-stepwise procedure. Materials and Methods Patients who underwent elective or emergency CS between May 2012 and May 2014 were recruited. Maternal demographics as well as details of surgery and anesthesia were recorded. An anesthesiologist visited the patients on postoperative day (POD) 1 and 2, and assessed their pain with the Prince Henry Pain Scale. To evaluate the prevalence of chronic pain, we contacted patients by sending a questionnaire 3 months post-CS. Results Among 225 patients who questionnaires, 69 (30.7%) of patients complained of persistent pain, although no patient required pain medication. Multivariate analyses identified lighter weight (p = 0.011) and non-intrathecal administration of morphine (p = 0.023) as determinant factors associated with persistent pain at 3 months. The adjusted odds ratio of intrathecal administration of morphine to reduce persistent pain was 0.424, suggesting that intrathecal administration of morphine could decrease chronic pain by 50%. In addition, 51.6% of patients had abnormal wound sensation, suggesting the development of neuropathic pain. Also, 6% of patients with abnormal wound sensation required medication, yet no patients with persistent pain required medication. Conclusion Although no effect on acute pain was observed, intrathecal administration of morphine significantly decreased chronic pain after CS.

Quadratus lumborum block for femoral-femoral bypass graft placement: A case report.

Introduction:Atherosclerosis has a complex etiology that leads to arterial obstruction and often results in inadequate perfusion of the distal limbs. Patients with atherosclerosis can have severe complications of this condition, with widespread systemic manifestations, and the operations undertaken are often challenging for anesthesiologists. Case report:A 79-year-old woman with chronic heart failure and respiratory dysfunction presented with bilateral gangrene of the distal lower extremities with obstruction of the left common iliac artery due to atherosclerosis. Femoral–femoral bypass graft and bilateral foot amputations were planned. Spinal anesthesia failed due to severe scoliosis and deformed vertebrae. General anesthesia was induced after performing multiple nerve blocks including quadratus lumborum, sciatic nerve, femoral nerve, lateral femoral cutaneous nerve, and obturator nerve blocks. However, general anesthesia was abandoned because of deterioration in systemic perfusion. The surgery was completed; the patient remained comfortable and awake without the need for further analgesics. Conclusion:Quadratus lumborum block may be a useful anesthetic technique to perform femoral–femoral bypass.

Oxygen at a high flow rate (35 L·min -1) via face mask for preoxygenation.

To the Editor, Administration of 100% oxygen before induction of anesthesia (preoxygenation) is a widely accepted method to maximize oxygen stores. One conventional method for preoxygenation is ‘‘tidal breathing for three minutes’’ by connecting the patient to an anesthesia machine via a closefitting face mask to avoid leaks in the circuit. In the clinical setting, however, this conventional method may fail to produce maximum oxygen stores because some patients do not tolerate a close-fitting face mask. Delivery of oxygen at a high flow rate ([ 30 L min) enables patients to build up oxygen stores in the lungs without using a close-fitting face mask. The HighFO Nebulizer (Koike Medical, Tokyo, Japan) can supply 100% oxygen at 35 L min via a non-rebreathing face mask. We hypothesized that this could be a valid method of preoxygenation without the need for a close-fitting facemask. To test this hypothesis, we used a high-fidelity human patient simulator (HPS; CAE Healthcare, Sarasota, FL, USA) to compare preoxygenation using tidal volume breathing for three minutes via the conventional method vs using high-flow 100% oxygen via face mask. We used a standard model simulator computerized to simulate the physiology of a 33-yr-old male with a weight of 70 kg and height of 182 cm. Bellows generate negative pressure in the model lung of the simulator to mimic spontaneous breathing. We drew out the gases inside the model lung every five seconds at rate of 3 L min and measured the partial pressure of oxygen (PAO2) and carbon dioxide (PACO2). We extracted a volume of oxygen equivalent to the O2 consumption and added a volume of CO2 equivalent to the CO2 consumption. These mixed gases were returned into the model lung as exhalation gases. The initial settings of the component of returned gases were: PAO2, 110 mmHg; PACO2, 40 mmHg, and vapour pressure 0 mmHg as during inspiration of room air. The initial settings of the respiratory variables of this model were: tidal volume, 700 mL and respiratory rate, 14 breaths min. These values were adjusted to maintain PACO2 at 40 mmHg. After breathing room air spontaneously for ten minutes, the patient simulator received oxygen either by the conventional method or by the HighFO Nebulizer. A generic three-gas anesthesia machine (MERA MD303; Senko medical instrument manufacturing company Ltd, Hongo, Tokyo, Japan) was used for the conventional method. Before preoxygenation, the reservoir bag was fully inflated with 100% oxygen using the oxygen flush while occluding the mask. The reservoir bag was emptied three times to expel the air and replace it with 100% oxygen. The anesthesia machine supplied 100% oxygen at a flow rate of 10 L min via a close-fitting face mask applied tightly to the face of the HPS. Alternatively, the HighFO Nebulizer supplied 100% oxygen at 35 L min via a nonrebreathing plastic face mask. The measurements of PAO2 in simulated alveoli were recorded every five seconds for five minutes. As shown in the Figure, higher PAO2 values were achieved at each time point with the HighFO Nebulizer compared with the anesthesia machine (P \ 0.001 by oneway analysis of variance repeated measures; n = 3 in both groups). Although the maximum (SD) PAO2 value did not differ significantly [646 (8) mmHg with the HighFO Nebulizer vs 655 (14) mmHg with the anesthesia A. Motoyasu, MD K. Moriyama, MD (&) S. Mitsuda, MD K. Moriyama, MD T. Yorozu, MD, PhD Department of Anesthesiology, Kyorin University School of Medicine, Mitaka, Tokyo, Japan e-mail: mokiyo@ks.kyorin-u.ac.jp

Scheduled perioperative switch from oral sildenafil to intravenous epoprostenol in a patient with Eisenmenger syndrome undergoing a sigmoidectomy

The perioperative management of pulmonary hypertension in a patient with Eisenmenger syndrome, the most advanced form of associated pulmonary artery hypertension (PAH), who required a sigmoidectomy is presented. The treatment for pulmonary hypertension was switched from oral sildenafil to intravenous epoprostenol to avoid the unexpected discontinuation of vasodilation during the perioperative period. The scheduled perioperative conversion should be considered for patients with severe PAH undergoing major abdominal surgery to ensure the stabilization of pulmonary and systemic hemodynamics.

A Shallow Angle Short-Axis Out-of-Plane Approach Reduces the Rate of Posterior Wall Injuries in Central Venous Catheterization: A Simulation Study

The short-axis out-of-plane approach (SAX-OOP) is commonly used in ultrasound-guided internal jugular vein catheterization. However, this approach has a risk of posterior vein wall injuries. The authors hypothesized that a shallow angle of approach may reduce the rate of posterior wall injuries compared with the conventional steep angle approach. The present study aimed to evaluate whether a difference in the angle of approach of the needle affects the rate of posterior wall injuries. The present study was a randomized crossover-controlled trial involving 40 medical residents, conducted in the clinical training center at a hospital with a residency program. The primary outcome measure was the rate of posterior vessel wall injuries. Subjects received a didactic lecture during which the instructors taught three SAX-OOP techniques including the conventional free-hand method (procedure C), a needle navigation system (procedure N), and a shallow puncture angle using a guidance system (procedure S). Participants were trained in these approaches under supervision and each technique tested in a simulation environment. Thirty-four of 40 residents had no previous experience with central venous catheterization and were included in the final analysis. The rate of posterior vessel wall injuries in procedure S (9%) was significantly lower than using the other approaches (procedure C, 53%; procedure N, 41%). In conclusion, a shallow angle of approach using the SAX-OOP technique resulted in significantly fewer posterior vein wall injuries in central venous catheterization compared with steep angle techniques.

Postoperative analgesia comparing levobupivacaine and ropivacaine for brachial plexus block: A randomized prospective trial

Background: On a pharmacologic basis, levobupivacaine is expected to last longer than ropivacaine. However, most reports of these anesthetics for brachial plexus block do not suggest a difference in analgesic effect. The aim of this study is to compare the postoperative analgesic effects of levobupivacaine and ropivacaine when used for treating ultrasound-guided brachial plexus block. Methods: A total of 62 patients undergoing orthopedic surgery procedures were prospectively enrolled and randomized to receive levobupivacaine (group L, N = 31) or ropivacaine (group R, N = 31). The duration of analgesia, offset time of motor block, need for rescue analgesics, and sleep disturbance on the night of surgery were recorded. Pain score was recorded on the day of surgery, and on postoperative days 1 and 2. Results: There was no difference in the time interval until the first request for pain medication comparing the two groups (group L: 15.6 [11.4, 16.8] hours; group R: 12.5 [9.4, 16.0] hours, P = 0.32). There was no difference in the duration of motor block (group L: 12.2 [7.6, 14.4] hours; group R: 9.4 [7.9, 13.2] hours, P = 0.44), pain score (P = 0.92), need for rescue analgesics (group L: 55%; group R: 65%, P = 0.6), or rate of sleep disturbance (group L: 61%, group R: 58%, P = 1.0) on comparing the two groups. Conclusions: There was no difference in postoperative analgesia comparing levobupivacaine and ropivacaine when used for brachial plexus block.

Iatrogenic carpal tunnel syndrome induced by wrist extension for placement of an indwelling radial artery catheter: a case report

A 38-year-old man with pancreatic cancer was scheduled to undergo pancreaticoduodenectomy. He had an unremarkable past medical history. After inducing general anesthesia, a left radial arterial catheter was successfully placed at first attempt. A wrist splint was used to obtain good arterial pulse waveforms.After the operation, he was transferred to the intensive care unit. The radial artery catheter was removed on the fourth postoperative day. He experienced numbness and a tingling sensation in the left thumb, the second and third fingers, and the lateral half of the fourth finger. He was diagnosed with carpal tunnel syndrome. Diagnostic imaging revealed a swollen median nerve, but no hematoma or injury.Some studies have suggested that excessive extension of the wrist may cause neuropathy. We recommend that patients’ wrists not be over-extended, even if good arterial waveforms cannot be obtained.

Postoperative Pulmonary Thromboembolism and Compliance of Venous Thromboembolism Prevention Guidelines at a University Hospital

肺血栓塞栓症(pulmonary embolism:PE)は,周 術期に発症する代表的な致死的合併症であり,その 発症を予防することは病院全体の取り組みとして重 要である.杏林大学医学部付属病院では 2004年に 静脈血栓塞栓症ワーキンググループが発足し,『静 脈血栓塞栓症ガイドライン ダイジェスト版』(肺塞 栓症研究会)や,全国各大学および海外のガイド ラインを参考にして 9月にガイドラインを策定し た.2005年に改訂し,手術症例の静脈血栓塞栓症 (venous thromboembolism:VTE)リスクファクタ ー A群に気腹手術を追加,B群の開頭腫瘍摘出術 を開頭術に改めた.2009年には低分子ヘパリンと Xa阻害薬が保険適応となったことを受けて改訂し, ヘパリンとワルファリンに加えて使用可能とした. また,手術症例のVTEリスクレベルの決定法にお いて,A群のリスクファクターの合計が3点以上の 場合はリスクレベルを1ランク上げるという方法か ら,A群の合計が3点以上の場合にはDダイマーを 測定し,高値であれば臨床所見を確認し,深部静脈 血栓症(deep venous thrombosis:DVT)が疑われ る場合にはリスクC群とする方法に変更した。そし て,VTEリスク別対処法においては,高リスクと 最高リスクの対処法に抗凝固療法を追加した.2010 年には院内でワルファリンの休薬期間が3~4日か ら4日に統一されたことを受けて改訂され(図1, 図2),現在に至っている. 本研究では,当院独自で作成した「静脈血栓塞栓 症予防ガイドライン」の効果を検証するため,術後 患者を対象に,過去3年間のPE発症例について後 ろ向きに調査した. 日臨麻会誌 Vol.34 No.4, 485 〜 490, 2014