Sumio Amagasa

Absence of efficacy of ultrasonic two-way Doppler flow detector in routine percutaneous arterial cannulation

mark a point distal and a point proximal to the above marking along the course of the artery. The puncture site was disinfected with alcohol. Puncture was performed relying on the markings, without palpating the artery. Logistic regression analysis was used for statistical analysis. The dependent variables were “success” and “failure.” The independent variables were using or not using the ultrasonic two-way flow detector, sex, age, body mass index (BMI), systolic blood pressure (SBP), and hemoglobin (Hb). The significance level was 5%. The mean age of the patients was 62.2 11.8 (SD) years in group D and 64.1 11.9 years in group C. The male-to-female ratio was 43 :29 in group D and 59 :35 in group C. The BMI was 22.7 3.6 in group D and 23.0 3.6 in group C. The SBP was 104 14mmHg in group D and 105 18mmHg in group C. The Hb level was 12.4 1.6 g·dl 1 in group D and 12.6 1.8g·dl 1 in group C. In one patient each in groups C and D, the radial artery could not be accessed, even after multiple punctures (classified as “discontinued” in Table 1, but included as “failure” for statistical analysis). Irrespective of whether or not the flow detector was used, the first puncture was successful in over 80% of the patients. Access to the artery was obtained by two or more punctures in approximately 98% of the patients (Table 1). Sex was the only factor significantly influencing “success” (Table 2). We used logistic regression analysis, a multivariate analysis, in the present study because we had great doubts about the conclusion reached from simple regression analysis of only two groups “using” or “not

Usefulness of ultrasonic two-way Doppler flow detector in percutaneous arterial puncture in patients with hemorrhagic shock

1. As with conventional arterial puncture, place a pillow under the dorsum of the hand and extend the wrist. 2. Identify the arterial pulse using the probe tip. 3. Use an office clip to mark the position of the strongest pulse sound. 4. Mark a point distal and a point proximal along the course of the artery. 5. Disinfect the puncture site with alcohol. 6. Relying on the markings, perform the puncture without palpating the artery. Usefulness of ultrasonic two-way Doppler flow detector in percutaneous arterial puncture in patients with hemorrhagic shock

Influence of Carbon Dioxide on Respiratory Function during Posterior Retroperitoneoscopic Adrenalectomy in Prone Position

Objective: To evaluate the influences of CO₂ insufflation on changes in blood gas analysis and end tidal CO₂ tension (PetCO₂) during posterior retroperitoneoscopic adrenalectomy in the prone position. Methods: Arterial blood gas analysis and measurements of PetCO₂ were carried out during CO₂ insufflation in 16 patients who underwent posterior retroperitoneoscopic adrenalectomy in the prone position (PRA group). The results were compared to 10 patients who underwent open posterior adrenalectomy (OPA group). Ventilation was artificially controlled during the study period in all cases. Results: Arterial pH, PaCO₂, PetCO₂ and PaO₂ were not significantly different between the PRA and OPA groups. However, the PaCO₂–PetCO₂ gradient in the PRA group was significantly higher than that in the OPA group (p < 0.01). Conclusion: Transperitoneal absorption of CO₂ occurs in patients undergoing retroperitoneoscopy in the prone position. The alveolo-arterial CO₂ gradient may be the only parameter which indicates the absorption of CO₂ during PRA.

Pulmonary atelectasis manifested after induction of anesthesia: a contribution of sinobronchial syndrome?

A 31-year-old man underwent general anesthesia for sinus surgery. Anesthesia was induced with midazolam and butorphanol, and an endotracheal tube was orally placed with a bronchoscope, due to difficulty with temporomandibular joint opening. Ventilation difficulty and increased peak inspiratory pressure were noticed shortly after tracheal intubation, and bronchoscopy was performed for diagnosis. The bronchi were filled with a clear mucous secretion. Removal of the secretion improved respiration and decreased the peak inspiratory pressure. A chest roentgenogram taken prior to extubation showed right upper lobe atelectasis. A diagnosis of sinobronchial syndrome was made postoperatively. The etiology of the acutely developed atelectasis was unclear. However, the latent syndrome may have induced excessive airway secretion with stimuli such as endotracheal intubation.

Perioperative management of lobectomy in a patient with hypertrophic obstructive cardiomyopathy treated with dual-chamber pacing

previously. A routine chest roentgenogram taken during an annual check-up showed a suspicious shadow. The patient was referred to another hospital for a complete medical evaluation. Left lung cancer was diagnosed. His electrocardiogram (ECG) showed a negative T wave in leads V5 and V6, indicating a pattern of old septal and inferior myocardial infarction with mild left ventricular (LV) hypertrophy. Furthermore, epicardial echocardiography (EE) revealed interventricular septal hypertrophy (ISH) and LV outflow hypertrophy, without deterioration of LV wall motion but with mild mitral regurgitation (MR). His cardiac index (CI), ejection fraction (EF), and EE-derived LV-Ao PG were 3.85 l·min 1·m 2, 86%, and 72 mmHg, respectively. Finally, HOCM accompanied with MR were diagnosed. The patient was scheduled for right upper lobectomy in the same hospital without any specific medical treatment for HOCM prior to surgery. The patient was premedicated with intramuscular atropine (0.5 mg) and hydroxyzine (50mg) prior to the induction of anesthesia. On arrival at the operating theater, his heart rate was 78 beats·min 1, and his systolic and diastolic blood pressure showed 132/86mmHg. After the placement of an epidural catheter via the thoracic segment T8/9, anesthesia was induced with bolus intravenous (iv) fentanyl (0.8μg·kg 1) and propofol (1mg·kg 1), as well as with continuous infusion of propofol (10mg·kg 1·h 1), followed by vecuronium (0.03 mg·kg 1). Hypotension (60 mmHg) and profound bradycardia (35 beats·min 1) were observed after anesthesia was induced. Hypotension was controlled rapidly both by volume replacement and intermittent administration of bolus iv methoxamine (1mg), whereas bradycardia persisted at less than 40 beats·min 1. The anesthetists discontinued the induction of anesthesia and cancelled the operation. Ten minutes later, the heart rate of the patient gradually recovered to a level of 50 beats·min 1. Oral atenolol (50mg·day 1) and disopyramide (300 mg·day 1) were started immediately

A bullard laryngoscope holder for bedside use

Use of the Bullard laryngoscope (BL; Circon Corporation, Stanford, CT, USA) is a trustworthy countermeasure when endotracheal intubation is expected or found to be difficult [1]. Ease of handling is important for the effective employment of the BL. However, the BL itself is rather hard to handle due to its peculiar anatomical shape. A temporary holding aid is required to facilitate the bedside use of the BL. We specifically designed a helpful holder, named the Bullard mate, to put beside the BL temporarily before and after endotracheal intubation. It is made of stainless steel and is composed of a basal seat and a vertical pole (Fig. 1). The two portions of the BL body lean against the two hooks connected to the vertical pole. The root of the ocular arm is fixed firmly, and in contrast, the laryngeal blade is held lightly. It is designed neither for attaching the BL in the middle of intubation nor for storing the BL on the shelf. It keeps the styletted tube clean and safe before intubation and also holds the BL smeared with a patient’s saliva after the intubation has been completed. The Bullard mate can be sterilized readily in its normal configuration and is easily transportable to a bedside setting, which enhances its convenience during use in daily clinical anesthesia. We have used the Bullard mate easily and safely in endotracheal intubation by means of the BL in more than 860 adult patients. We believe that it is a valuable aid for anesthetists during the bedside use of the BL.

Cardiac arrest following induction of anesthesia in a patient with acute massive pulmonary thromboembolism

Patients with massive pulmonary thromboembolism (PE) occasionally develop acute right ventricular dysfunction followed by circulatory collapse or sudden death. Early diagnosis and aggressive treatment of this condition are therefore essential [1]. The present report is a case of cardiac arrest following induction of anesthesia for pulmonary thrombectomy in a patient with acute massive PE after lobectomy.

A comparison of sympathetic adrenal nerve responses to intravenous high-dose morphine and fentanyl administration in rats.

We compared the effects of intravenous morphine (5 mg·kg−1) and fentanyl, (50μg·kg−1) on systolic blood pressure (SBP), heart rate (HR), and efferent sympathetic adrenal nerve action potentials (SANA) in rats. We also determined the extent of the reflex responses of these parameters of 9% carbon dioxide (CO2) challenge during the above narcotic anesthesia. In the morphine group, SBP was elevated and the elevated levels were maintained, while changes in SBP in the fentanyl group were not significant. In the morphine group, SANA showed initial stimulation and subsequent depression, while in the fentanyl group, SANA showed sustained depression. CO2 challenge induced only very small changes in SBP and HR, suggesting that during high-dose narcotic anesthesia the hypercapnic stimulus may not be reflected in circulatory parameters. In both groups, hypercapnia increased SANA to 30% of the baseline values from the pre-challenge level. However, these values were only 91% and 56% of the baseline value in the morphine and the fentanyl, groups, respectively.

Effects of halothane and isoflurane anesthesia on sympathetic adrenal nerve responses to carbon dioxide challenge in rats.

We studied the influence of two volatile anesthetics, halothane and isoflurane, on the circulatory and sympathetic nerve responses to carbon dioxide (9% CO2) in rats.Systolic blood pressure was depressed throughout the CO2 challenge and after an initial reduction, a gradual increase was observed in heart rate. Sympathetic adrenal nerve action potentials (SANA) significantly increased in contrast to negative responses in the circulatory functions. SANA responses against time were trapezoid in shape. There were no significant differences in SANA responses between 1%(1 MAC) and 1.5%(1.5 MAC) halothane groups, nor between 1.4%(1 MAC) and 2%(1.5 MAC) isoflurane groups. Halothane and isoflurane, therefore, did not produce dose-dependent effects on sympathetic response to hypercapnia within these concentrations. The maximum changes in SANA from the baseline values were 110% and 40% for the halothane and isoflurane groups, respectively.The sympathetic reflex response to hyperacapnia was retained at 1.5 MAC for both anesthetics, though isoflurane depressed these responses more markedly than halothane.Our results suggest that halothane is a more preferable anesthetic than isoflurane when viewed from the standpoint of preservation of sympathetic nerve response in such undesirable situations as severe hypercapnia occurring during anesthesia.

Backup failure of an adjuvant battery in an Evita 4 ventilator.

To the Editor:—Electrical power failure in the hospital presents a severe challenge to intensive care unit patients. We recently experienced electrical backup failure in an Evita 4 ventilator (Dräger Medizintechnik, Lübeck, Germany), which was caused by the internal erosion of a connecting cable of an adjunct battery Dryfit A512 (Sonnenschein, Budingen, Germany) to the ventilator. Because of renovation of the power supply system in our hospital, the temporary interruption of electrical supply in the intensive care unit was scheduled. According to an advance notice from the hospital management division, the electrical supply would be stopped for only several minutes before the emergency electrical generator would start up to supply electricity. At the time of power interruption, three patients were ventilator dependent. The ventilators used in our intensive care unit are checked annually, and adjunct batteries are replaced by engineers from the manufacturers. At the time of power stoppage, two ventilators continued to function, but an Evita 4 ventilator shut down instantly without any alarm. An attending nurse noticed the incident and ventilated the patient manually using a resuscitation bag. Electricity was reestablished quickly, and the ventilator restarted immediately. The patient had no identifiable injury as a result of the shutdown. The AC and DC power modules of the ventilator were 8 yr old. The ventilator functioned steadily with an external power supply. Because the Evita 4 is normally configured to function for 10 min with backup from a fully charged battery in case of a power cut, the battery assembly was suspected to be responsible for the problem. The ventilator was sent to the manufacturers for close inspection to identify the source of the power backup failure. Dräger Germany found that the cable connector to an adjunct battery was eroded by leaked battery solution. Inside the moist electronic unit, the minor erosion had degraded the connecting cable over time and increased the electrical resistance, leading to the malconduction to the ventilator system and power failure even though the adjunct battery was properly charged (figs. 1–3). Close examination of the manufacturer’s database for batteries of approximately 10,000 serial numbers showed that the erosion occurred rarely. The current case was formally registered in the manufacturer’s incident list. The manufacturer replaced the emergency power unit of the ventilator with a Panasonic lead–acid battery (Mastushita Battery Industrial, Osaka, Japan). Dräger Japan explained that all Evita 4 ventilators used in Japan would be inspected eventually, and batteries would be replaced, because there was a risk of leakage with the current battery unit. The internal component of life-supporting devices including ventilators is a “black box” to medical users. We have no precise information about battery life. Depending on the rate of deterioration over time, the life of a battery is usually within 3–5 yr. Regular checkup and periodical replace-