Shoichi Uezono

Anesthetic management of noncardiac surgery for patients with single ventricle physiology

Patients with congenital heart diseases are a growing population, and noncardiac surgeries will become an important health care issue. Patients with single ventricle physiology are a particularly challenging population who will undergo staged, palliative repair toward a final step of Fontan circulation. Although Fontan surgery creates a serial circulation in which the ventricle pumps blood to the systemic circuit, pulmonary blood flow occurs without a dedicated ventricle. Despite progress in outcomes, this abnormal circulation remains associated with various co-morbidities such as ventricular dysfunction, arrhythmias, protein losing enteropathy, and plastic bronchitis. Health care professionals must prepare for these patients to present to noncardiac surgery at any stage of intervention, possibly with complications. Given that staged, palliative repair has undergone multiple modifications, patients who present for surgery can vary in types and timing of the repair. Anesthesiologists who care for them must be familiar with perioperative issues to optimize outcomes, especially because congenital heart disease is a risk factor for increased mortality for noncardiac surgery.

Radiation exposure to anaesthetists during endovascular procedures

Medical radiation exposure increases the likelihood of cataract formation. A personal dosimeter was attached to the left temple of 77 anaesthetists during 45 endovascular aortic aneurysm repairs and 32 interventional neuroradiology procedures. Compared with interventional neuroradiology, the median (IQR [range]) total radiation dose emitted by fluoroscopic equipment was significantly lower during endovascular aortic aneurysm repair (4175 (3127–5091 [644–9761]) mGy than interventional neuroradiology (1420 (613–2424 [165–10 840]) mGy, p < 0.001). However, radiation exposure to the anaesthetists temple was significantly greater during endovascular aortic aneurysm repair (15 (6–41 [1–109]) μSv) than interventional neuroradiology (4 (2–8 [0–67]) μSv, p < 0.001). These data suggest that anaesthetists at our institution would have to deliver anaesthesia for ~1300 endovascular aortic aneurysm repairs and ~5000 interventional neuroradiology cases annually to exceed the general occupational limits, and ~10 000 endovascular aortic aneurysm repairs and ~37 500 interventional neuroradiology cases to exceed the ocular exposure limits recommended by the International Commission on Radiological Protection. Nevertheless, anaesthetists should be aware of the risk of ocular radiation exposure, and reduce this by limiting the time of exposure, increasing the distance from the source of radiation, and shielding.

The Impact of Ventilator-Associated Events in Critically Ill Subjects With Prolonged Mechanical Ventilation

BACKGROUND: The Centers for Disease Control and Prevention recently released a surveillance definition for respiratory complications in ventilated patients, ventilator-associated events (VAEs), to replace ventilator-associated pneumonia (VAP). VAEs consist of ventilator-associated conditions (VAC), infection-related ventilator-associated complications (IVAC), and possible VAP. A duration of mechanical ventilation of at least 4 d is required to diagnose VAE. However, the observed duration of mechanical ventilation was < 4 d in many previous studies. We evaluated the impact of VAEs on clinical outcomes in critically ill subjects who required mechanical ventilation for ≥ 4 d. METHODS: This single-center retrospective cohort study was conducted in the general ICU of an academic hospital. We included 407 adult subjects who were admitted to the ICU and required mechanical ventilation for at least 4 d. VAC and IVAC were identified from the electronic medical records. VAP was defined according to the Centers for Disease Control and Prevention 2008 criteria and was identified from the surveillance data of the infection control team of our hospital. Clinical outcomes were studied in the VAC, IVAC, and VAP groups. Possible VAP was not investigated. RESULTS: Higher mortality was seen in VAC and IVAC subjects, but not in VAP subjects, compared with those without VAEs and VAP. By multivariable hazard analysis for hospital mortality, IVAC was independently associated with hospital mortality (hazard ratio 2.42, 95% CI 1.39–4.20, P = .002). VAC also tended to show a similar association with hospital mortality (hazard ratio 1.45, 95% CI 0.97–2.18, P = .07). On the other hand, VAP did not increase a hazard of hospital death (hazard ratio 1.08, 95% CI 0.44–2.66, P = .87). CONCLUSIONS: We found that a VAE was related to hospital mortality in critically ill subjects with prolonged mechanical ventilation, and that VAP was not.

The impact of sustained new-onset atrial fibrillation on mortality and stroke incidence in critically ill patients: A retrospective cohort study

Purpose: The purpose of the study is to evaluate the impact of sustained new‐onset AF on mortality and the incidence of stroke in critically ill non‐cardiac surgery patients. Material and methods: This was a retrospective cohort study of non‐cardiac surgery patients with new‐onset AF conducted in a general intensive care unit. We compared patients remaining in AF with those restored to sinus rhythm (SR) at 6 h after the onset of AF and conducted multivariable logistic regression analysis for in‐hospital mortality. We also examined the impact of the cumulative time of AF duration in the first 48 h on hospital outcomes. Results: New‐onset AF occurred in 151 of 1718 patients (9%). Patients with sustained AF after 6 h (34% of 151 patients included) experienced greater in‐hospital mortality than patients with SR at 6 h (37% vs. 20%, p = 0.033). Multivariable logistic regression analysis confirmed the association between AF at 6 h and in‐hospital mortality (adjusted odds ratio, 3.14; 95% confidence intervals, 1.28–7.69; p = 0.012). Patients with longer AF duration had greater in‐hospital mortality (p = 0.043) and in‐hospital ischemic stroke incidence (p = 0.041). Conclusion: Sustained new‐onset AF is associated with poor outcomes. HighlightsNew‐onset AF occurred in 151 of 1718 patients (9%).52 patients (34%) remained in AF at 6 h after the onset of AF.AF at 6 h had greater in‐hospital mortality than SR at 6 h.Longer AF had greater in‐hospital mortality and ischemic stroke incidence.

Effect of availability of video laryngoscopy on the use of fiberoptic intubation in school‐aged children with microtia

With the increasing popularity of video laryngoscopy during intubation of pediatric patients with normal or difficult airways, fiberoptic‐assisted tracheal intubation, traditionally considered the gold standard for difficult intubation, may become underused.

Implications for Pediatric Anesthesia

Preclinical studies have shown that volatile and intravenous anesthetics increase neuroapoptosis in neonatal rodents and monkeys. These results raise concerns regarding the use of anesthetics in young children. Retrospective reports suggest an association between multiple surgeries under anesthesia at infancy and subsequent learning disabilities. Anesthesia is a requisite component of surgeries and procedures, and as anesthesia providers, it is important that we understand what is known about the risks of anesthesia in the developing brain. The aim of this chapter is to review the literature with respect to anesthesia-related neurotoxicity in neonatal animals and young children.

Use of Supraglottic Airway Devices in the Prone Position

Supraglottic airway devices (SADs) have revolutionized airway management. These advanced devices incorporate specific features to protect against gastric regurgitation and aspiration and also create a high oropharyngeal seal pressure. These developments have broadened indications for SADs, and some anesthetists use SADs with the patient in the prone position. SADs are also used as rescue device in instances of unintentional tracheal extubation. In addition, there is the elective use of SADs in the prone position. However, the use of SADs in the prone position remains controversial. This review aims to examine the published evidence regarding the use of SADs in patients undergoing surgery in the prone position.