Shunsuke Takaki

Perioperative considerations in adult mitochondrial disease: A case series and a review of 111 cases.

Mitochondrial disease has been uncommon conditions, still results in death during childhood in many cases. The ideal anesthetic pharmacological management strategy for adult patients with mitochondrial disease is currently unclear. In this study, we presented features of the anesthesia methods employed and the perioperative complications of patients in our institution and in previously published case reports. We report the use of general anesthesia 7 times in 6 adult patients with mitochondrial disease during 2004-2014. All cases were performed with maintained intravenous anesthesia. One case was reintubated on the day after surgery, but the cause of death was not directly related to anesthesia. One hundred and eleven general anesthesia cases in 97 adult patients with mitochondrial disease were described in 83 the literature. Although several severe perioperative complications and deaths have been reported, malignant hyperthermia had not been reported in adult cases, and metabolic disorder called propofol infusion syndrome had also not been reported in adult patients undergone total intravenous anesthesia. Perioperative complications of lactic acidosis were reported more in inhalation anesthesia than intravenous anesthesia. Therefore we recommended intravenous anesthesia rather than inhalation anesthesia for adult mitochondrial disease.

Blood pH is a Useful Indicator for Initiation of Therapeutic Hypothermia in the Early Phase of Resuscitation after Comatose Cardiac Arrest: A Retrospective Study

BACKGROUND Therapeutic hypothermia (TH) is one of the key treatments after cardiac arrest (CA). Selection of post-CA patients for TH remains problematic, as there are no clinically validated tools to determine who might benefit from the therapy. OBJECTIVE The aim of this study was to investigate retrospectively whether laboratory findings or other patient data obtained during the early phase of hospital admission could be correlated with neurological outcome after TH in comatose survivors of CA. METHODS Medical charts of witnessed CA patients admitted between June 2003 and July 2009 who were treated with TH were reviewed retrospectively. The subjects were grouped based on their cerebral performance category (CPC) 6 months after CA, as either good recovery (GR) for CPC 1-2 or non-good recovery (non-GR) for CPC 3-5. The following well-known determinants of outcome obtained during the early phase of hospital admission were evaluated: age, gender, body mass index, cardiac origin, presence of ventricular fibrillation (VF), time from collapse to cardiopulmonary resuscitation, time from collapse to return of spontaneous circulation, body temperature, arterial blood gases, and blood test results. RESULTS We analyzed a total of 50 (25 GR and 25 non-GR) patients. Multivariate logistic analysis showed that initial heart rhythm and pH levels were significantly higher in the GR group than in the non-GR group (ventricular tachycardia/VF rate: p = 0.055, 95% confidence interval [CI] 0.768-84.272, odds ratio [OR] 8.047; pH: 7.155 ± 0.139 vs. 6.895 ± 0.100, respectively, p < 0.001, 95% CI 1.838-25.827; OR 6.89). CONCLUSION These results imply that in addition to initial heart rhythm, pH level may be a good candidate for neurological outcome predictor even though previous research has found no correlation between initial pH value and neurological outcome.

Evaluation of an Oxygen Mask-Based Capnometry Device in Subjects Extubated After Abdominal Surgery

BACKGROUND: For early detection of respiratory and hemodynamic changes during anesthesia, continuous end-tidal carbon dioxide concentration (PETCO2) is monitored by capnometry. However, the accuracy of CO2 monitoring during spontaneous breathing in extubated patients remains undetermined. Therefore, we aimed to compare PETCO2 measured by capnometry using an oxygen mask with a carbon dioxide sampling port (capnometry-type oxygen mask) and PCO2 in extubated subjects who had undergone abdominal surgery. Furthermore, we investigated whether spontaneous deep breathing affected dissociation between PaCO2 and PETCO2. METHODS: Adult post-abdominal surgery subjects admitted to the ICU were enrolled in this study. After extubation, oxygen was supplied at 6 L/min using the capnometry-type oxygen mask. After 30 min of oxygen supply, PaCO2 blood gas analysis was performed, and PETCO2 was measured under resting and deep-breathing conditions. For both resting and deep-breathing conditions, the correlation between PaCO2 and PETCO2 was analyzed. Furthermore, bias, precision, and limits of agreement were calculated using the Bland-Altman method. RESULTS: Twenty-five subjects (15 men, 10 women) with a mean age of 62 y (interquartile range of 57–76 y) and body mass index of 20–24 kg/m2 were studied. The correlation (r) between PaCO2 and PETCO2 under resting and deep-breathing conditions was 0.50 and 0.56, respectively. Compared with PaCO2, the bias and limits of agreement were −12.6 (−20.6 to −4.6) for resting PETCO2 and −9.1 (−16.0 to −2.1) for deep-breathing PETCO2. The association between PaCO2 and deep-breathing PETCO2 was significantly smaller compared with resting PETCO2 (P = .002). CONCLUSIONS: It is possible to measure the PETCO2 under varying breathing conditions with the capnometry-type oxygen mask in subjects receiving oxygen supplementation after extubation following upper abdominal surgery to determine whether they are properly ventilating. (ClinicalTrials.gov registration UMIN000011925.)

Percutaneous Transtracheal Jet Ventilation with Various Upper Airway Obstruction

A “cannot-ventilate, cannot-intubate” situation is critical. In difficult airway management, transtracheal jet ventilation (TTJV) has been recommended as an invasive procedure, but specialized equipment is required. However, the influence of upper airway resistance (UAR) during TTJV has not been clarified. The aim of this study was to compare TTJV using a manual jet ventilator (MJV) and the oxygen flush device of the anesthetic machine (AM). We made a model lung offering variable UAR by adjustment of tracheal tube size that can ventilate through a 14-G cannula. We measured side flow due to the Venturi effect during TTJV, inspired tidal volume (TVi), and expiratory time under various inspiratory times. No Venturi effect was detected during TTJV with either device. With the MJV, TVi tended to increase in proportion to UAR. With AM, significant variations in TVi was not detected with changes in any UAR. In conclusion, UAR influenced forward flow of TTJV in the model lung. The influence of choked flow from the Venturi effect was minimal under all UAR settings with the MJV, but the AM could not deliver sufficient flow.

Influence of Mental Workload on the Performance of Anesthesiologists during Induction of General Anesthesia: A Patient Simulator Study

The aim of this study was to reveal the effect of anesthesiologists mental workload during induction of general anesthesia. Twenty-two participants were categorized into anesthesiology residents (RA group, n = 13) and board certified anesthesiologists (CA group, n = 9). Subjects participated in three simulated scenarios (scenario A: baseline, scenario B: simple addition tasks, and scenario C: combination of simple addition tasks and treatment of unexpected arrhythmia). We used simple two-digit integer additions every 5 seconds as a secondary task. Four kinds of key actions were also evaluated in each scenario. In scenario C, the correct answer rate was significantly higher in the CA versus the RA group (RA: 0.370 ± 0.050 versus CA: 0.736 ± 0.051, p < 0.01, 95% CI −0.518 to −0.215) as was the score of key actions (RA: 2.7 ± 1.3 versus CA: 4.0 ± 0.00, p = 0.005). In a serious clinical situation, anesthesiologists might not be able to adequately perform both the primary and secondary tasks. This tendency is more apparent in young anesthesiologists.

Effects of Breathing Pattern on Oxygen Delivery Via a Nasal or Pharyngeal Cannula

BACKGROUND: During sedation for upper gastrointestinal endoscopy, oxygen delivery via a nasal cannula is often necessary. However, the influences of the oxygen delivery route and breathing pattern on the FIO2 have not been thoroughly investigated. The aim of this simulation study was to investigate the difference in the FIO2 with a pharyngeal cannula versus nasal cannula during high- or low-tidal volume (VT) ventilation and open- or closed-mouth breathing. METHODS: Six healthy volunteers were asked to breathe using 2 patterns of ventilation (high or low VT) via a sealed face mask connected to an endotracheal tube that was retrogradely inserted into the trachea of a mannequin. The mannequin also had a pharyngeal or nasal cannula inserted into the pharynx or attached to the nose, through which oxygen (2 or 5 L/min) was delivered. The mouth of the mannequin was kept open or closed by packing. We measured the FIO2 of every breath for 1 min at each setting. RESULTS: During low- and high-VT ventilation, the FIO2 was highest at a flow of 5 L/min with a pharyngeal cannula. Oxygen delivery was higher with the pharyngeal cannula compared with the nasal cannula at all settings. Differences in flow did not result in significant differences in the FIO2 with high- and low-VT ventilation. At a flow of 5 L/min via a pharyngeal cannula, open-mouth breathing resulted in a significantly higher FIO2 compared with closed-mouth breathing. Conclusions: A pharyngeal cannula provided a higher FIO2 compared with a nasal cannula at the same oxygen flow. Open-mouth breathing resulted in a higher FIO2 compared with closed-mouth breathing when 5 L/min oxygen was delivered via a pharyngeal cannula. The breathing pattern did not affect the FIO2 in this study.

Self-inflicted oral penetration injury: An intravenous drip pole advanced from the mouth to the retroperitoneum

Highlights • Oral penetration injury has risk of airway occlusion due to bleeding and edema.• Prophylactic establishment of airway should be prepared.• Emergency physician should coordinate with multidisciplinary team.• Exploratory operation in case of hemodynamic and respiratory deterioration.

Perioperative change in creatinine following cardiac surgery with cardiopulmonary bypass is useful in predicting acute kidney injury: a single-centre retrospective cohort study

OBJECTIVES Acute kidney injury is common following cardiac surgery. Experimental models of acute kidney injury suggest that successful therapy should be implemented within 24-48 h of renal injury. However, it is difficult to detect acute kidney injury shortly after cardiac surgery, because creatinine concentration is diluted by cardiopulmonary bypass. We hypothesized that, following cardiopulmonary bypass, creatinine reduction ratios would correlate with haematocrit reduction ratios and would be associated with the incidence of acute kidney injury. METHODS We collected demographic and blood test data from consecutive patients (n = 1137) who had undergone cardiac surgery with cardiopulmonary bypass. The creatinine reduction ratio was calculated as follows: (preoperative creatinine-postoperative creatinine)/preoperative creatinine. Patients were assigned to either of two groups. The first group (Group 1) was used to determine the threshold for acute kidney injury, and the second group (Group 2) was used to assess diagnostic performance. Acute kidney injury was defined as an increase in serum creatinine level >0.3 mg/dl or >150% from baseline. RESULTS The incidence of acute kidney injury was 14.5% (79/545) in Group 1 and 15.5% (92/592) in Group 2. Postoperatively, creatinine concentration correlated strongly with haematocrit concentration (Pearsons r(2): 0.91). In Group 1, the area under the receiver operating characteristic curve, sensitivity and specificity were 0.71, 64.1 and 66.4%, respectively, for creatinine reduction ratios of <20%. In Group 2, the odds ratio, positive predictive value, negative predictive value and relative risk for creatinine reduction ratio performance were 4.3 (95% confidence interval 2.6-7.0), 0.27 (0.21-0.32), 0.92 (0.89-0.95) and 3.42 (2.22-5.27), respectively. CONCLUSIONS The creatinine reduction ratio may be associated with perioperative renal injury. Therefore, it is a good diagnostic indicator with high performance, and may be useful in detecting acute kidney injury at an earlier stage relative to conventional means. In addition, using creatinine reduction ratios in this manner is financially feasible.

Comparison between High- and Low-Cost Transmission of Tele-Anesthesia in Japan

Background We previously reported a tele-anesthesia system that connected Sado General Hospital (SGH) to Yokohama City University Hospital (YCUH) using a dedicated virtual private network (VPN) that guaranteed the quality of service. The study indicated certain unresolved problems, such as the high cost of constantly using a dedicated VPN for tele-anesthesia. In this study, we assessed whether use of a best-effort system affects the safety and cost of tele-anesthesia in a clinical setting. Methods One hundred patients were enrolled in this study. We provided tele-anesthesia for 65 patients using a guaranteed transmission system (20 Mbit/s; guaranteed, 372,000 JPY per month: 1 JPY = US

Relationship between fresh frozen plasma to packed red blood cell transfusion ratio and mortality in cardiovascular surgery

0.01) and for 35 patients using a best-effort system (100 Mbit/s; not guaranteed, 25,000 JPY per month). We measured transmission speed and number of commands completed from YCUH to SGH during tele-anesthesia with both transmission systems. Results In the guaranteed system, anesthesia duration was 5780 min (88.9 min/case) and surgical duration was 3513 min (54.0 min/case). In the best-effort system, anesthesia duration was 3725 min (106.4 min/case) and surgical duration was 2105 min (60.1 min/case). The average transmission speed in the best-effort system was 17.3 ± 3.8 Mbit/s. The system provided an acceptable delay time and frame rate in clinical use. All commands were completed, and no adverse events occurred with both systems. Discussion In the field of tele-anesthesia, using a best-effort internet VPN system provided equivalent safety and efficacy at a better price as compared to using a guaranteed internet VPN system.