Takuro Sanuki

Significance of debriefing methods in simulation-based sedation training courses for medical safety improvement in Japan

Based on the American Society of Anesthesiologists’ Practice Guidelines for Sedation and Analgesia by Non-Anesthesiologists (ASA-SED), a sedation training course aimed at improving medical safety was developed by the Japanese Association for Medical Simulation in 2011. This study evaluated the effect of debriefing on participants’ perceptions of the essential points of the ASA-SED.A total of 38 novice doctors participated in the sedation training course during the research period. Of these doctors, 18 participated in the debriefing group, and 20 participated in non-debriefing group. Scoring of participants’ guideline perceptions was conducted using an evaluation sheet (nine items, 16 points) created based on the ASA-SED.The debriefing group showed a greater perception of the ASA-SED, as reflected in the significantly higher scores on the evaluation sheet (median, 16 points) than the control group (median, 13 points; p < 0.05). No significant differences were identified before or during sedation, but the difference after sedation was significant (p < 0.05).Debriefing after sedation training courses may contribute to better perception of the ASA-SED, and may lead to enhanced attitudes toward medical safety during sedation and analgesia.

Perioperative Management of Tooth Extractions for a Patient With Hereditary Angioedema

Hereditary angioedema (HAE) is a rare genetic disorder that causes a deficiency in or dysfunction of C1 esterase inhibitor (C1-INH) and is clinically characterized by sudden and recurrent attacks of angioedema. Although almost any part of the body can be affected, HAE is of greatest concern and can be life-threatening when the upper airway is involved, particularly the larynx (laryngeal attack). HAE attacks can be triggered by physical or psychological stress or can arise spontaneously without any apparent trigger. Dental treatments and routine oral surgical procedures, such as tooth extraction, abound with factors that can trigger an attack of HAE. Indeed, several cases of death resulting from HAE attacks have been reported after such procedures. Therefore, patients with HAE are of special concern in dentistry and require precautionary preparations before treatment. This report describes the successful management of tooth extractions in a patient with HAE who was at high risk of an HAE-induced laryngeal attack.

Effect of nasal high-flow oxygen therapy on the swallowing reflex: an in vivo volunteer study

ObjectiveThe advantages of nasal high-flow oxygen therapy (NHF) include not only allowing talking, but also eating and drinking, during the therapy. However, the effect of NHF on the swallowing reflex remains unclear. In the present study, we aimed to assess the effects of NHF on the swallowing reflex.MethodsNine healthy adult Japanese male volunteers with no history of dysphagia or diseases that may cause dysphagia, such as stroke or Parkinson’s disease, were evaluated. Participants received one of four levels of NHF intervention (0 (control), 15, 30 and 45xa0L/min of oxygen) with the NHF system through the nasal cannula. Swallowing was induced by the administration of a bolus injection of 5xa0mL of distilled water over 3xa0s through a polyethylene catheter at each level of oxygen flow. The primary end-point was the latency period of the swallowing reflex after bolus injection, which was defined as the time from the start of the bolus injection to the onset of the electromyogram (EMG) burst of the first swallow.ResultsMean latency times of the swallowing reflex with 15 (9.8xa0±xa02.9xa0s), 30 (9.0xa0±xa02.7xa0s) and 45 (8.5xa0±xa03.0xa0s)xa0L/min of NHF were significantly shorter than those under control conditions (11.9xa0±xa03.7xa0s; Pxa0<xa00.05).ConclusionsOur study demonstrates that NHF may enhance swallowing function with increasing levels of NHF by reducing the latency of the reflex.Clinical relevanceNHF may allow continuation of oral intake without aspiration during oxygen therapy.

Management of post-hyperventilation apnea during dental treatment under monitored anesthesia care with propofol

Although hyperventilation syndrome generally carries a good prognosis, it is associated with the risk of developing severe symptoms, such as post-hyperventilation apnea with hypoxemia and loss of consciousness. We experienced a patient who suffered from post-hyperventilation apnea. A 17-year-old female who suffered from hyperventilation syndrome for several years developed post-hyperventilation apnea after treatment using the paper bag rebreathing method and sedative administration during a dental procedure. We subsequently successfully provided her with monitored anesthesia care with propofol. Monitored anesthesia care with propofol may be effective for the general management of patients who have severe hyperventilation attacks and post-hyperventilation apnea. This case demonstrates that appropriate emergency treatment should be available for patients with hyperventilation attacks who are at risk of developing post-hyperventilation apnea associated with hypoxemia and loss of consciousness.

Comparison of insertion of the modified i-gel airway for oral surgery with the LMA Flexible: a manikin study.

We previously modified the i-gel airway to enable its use in the field of oral and maxillofacial surgery and reported its fabrication methods. In general, the standard i-gel airway is quick to insert and has a high success rate, but the modified i-gel airway has yet to be assessed for these attributes. We, therefore, set out to compare the ease of insertion of the modified i-gel airway with the LMA Flexible to investigate the usefulness of the modified i-gel airway. The study participants, who included 20 new interns with no experience using either the LMA Flexible or the modified i-gel airway, inserted each device 3 times into an intubation practice manikin. The variables measured in this study were insertion time and rate of successful insertions. Mean insertion time over 3 attempts was significantly shorter for the modified i-gel™ airway (18.9 ± 4.7 seconds) than the LMA Flexible (24.9 ± 5.1 seconds, P < .001). The rate of successful insertions as a total of all 3 attempts was significantly higher for the modified i-gel airway (56/60 times, 93.3%) than the LMA Flexible (45/60 times, 75%; P = .012). When used by an inexperienced operator, the modified i-gel™ airway is faster and has a higher success rate than the LMA Flexible, suggesting that it can be easily manipulated during insertion.

Nitrous Oxide Inhalation Sedation Through a Nasal High-Flow System: The Possibility of a New Technique in Dental Sedation

High-flow nasal cannula (HFNC) systems are increasingly used for patients with both acute and chronic respiratory failure because of the clinical effectiveness and patient comfort associated with their use. Recently, HFNC has been used not only as a respiratory support device, but also as a drug delivery system. HFNC is designed to administer heated and humidified inspiratory oxygen flows (100% relative humidity at 37°C). Therefore, HFNC can provide high flows (up to 60 L/min) without discomfort. Moreover, HFNC improves oxygenation by exerting physiologic effects such as (a) dead-space washout and (b) moderate positive airway pressure. These characteristics and physiologic effects of HFNC may permit administration of high-flow nitrous oxide sedation while ensuring patient comfort and adequate sedative effect.

A liquid crystal display monitor failure of a McGRATH video laryngoscope.

The McGRATH MAC (MAC; Aircraft Medical Ltd, Edinburgh, UK) is a rigid indirect video laryngoscope that we frequently use for tracheal intubation. It consists of a liquid crystal display monitor, high-resolution video camera, and an angulated single-use blade of adjustable length [1,2]. The power supply for this portable instrument is provided by a battery contained within the handle [1,2]. We have successfully used the MAC for tracheal intubations of both normal and difficult airways. Our high intubation success rates are likely due to its improved laryngeal views provided by its liquid crystal display monitor. Consequently, if the liquid crystal display monitor does not work properly, the improved efficiency of the MAC is lost. Our department purchased the MAC model 14 months ago, and it has been used for approximately 50 to 100 intubations. Recently, we planned to use the MAC for a patient with limited neck extension and mouth opening. Before the patient entered the operating room, the MAC was checked to assure that it was working properly. Prior to initiating the intubation, it was observed that objects displayed on the MAC monitor turned bright pink (Fig. 1). We ceased using the MAC for the intubation and successfully completed the intubation using a fiberoptic laryngoscope. A similar failure of the display monitor had been observed a week prior to our experience. However, after that initial failure, the MAC had continued to work normally. Although the reasons for the failure are still unclear, it is likely due to deterioration of the output characteristics of the battery within the handle of the MAC. Several studies have demonstrated that the MAC is a useful device for difficult intubation. However, we recommend that the normal operation must be checked before using MAC for a case. As far as we know, this is the first report of a display monitor failure with this useful instrument.

Transcutaneous vocal cord ultrasonography after oral and maxillofacial surgery requiring intermaxillary fixation: A technical report.

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Comparison of the hemodynamic effects of propofol and ketamine as anesthetic induction agents during high-dose remifentanil administration: a single-center retrospective comparative study

Background We hypothesized that ketamine, when administered as the anesthetic induction agent, may prevent cardiovascular depression during high-dose remifentanil administration, unlike propofol. To test our hypothesis, we retrospectively compared the hemodynamic effects of ketamine, during high-dose remifentanil administration, with those of propofol. Methods Thirty-eight patients who underwent oral surgery at the Nagasaki University Hospital between April 2014 and June 2015 were included in this study. Anesthesia was induced by the following procedure: First, high-dose remifentanil (0.3-0.5 µg/kg/min) was administered 2-3 min before anesthesia induction; next, the anesthetic induction agent, either propofol (Group P) or ketamine (Group K), was administered. Mean arterial pressure (MAP) and the heart rate were recorded by the automated anesthesia recording system at four time points: immediately before the administration of high-dose remifentanil (T1); immediately before the administration of propofol or ketamine (T2); 2.5 min (T3), and 5 min (T4) after the administration of the anesthetic induction agent. Results In Group P, the MAP at T3 (75.7 ± 15.5 mmHg, P = 0.0015) and T4 (68.3 ± 12.5 mmHg, P < 0.001) were significantly lower than those at T1 (94.0 ± 12.4 mmHg). However, the MAP values in the K group were very similar (P = 0.133) at all time points. The heart rates in both Groups P (P = 0.254) and K (P = 0.859) remained unchanged over time. Conclusions We showed that ketamine, when administered as the anesthetic induction agent during high-dose remifentanil administration, prevents cardiovascular depression.

Upside-Down Mask Ventilation Technique for a Patient With a Long and Narrow Mandible

Mask ventilation, along with tracheal intubation, is one of the most basic skills for managing an airway during anesthesia. Facial anomalies are a common cause of difficult mask ventilation, although numerous other factors have been reported. The long and narrow mandible is a commonly encountered mandibular anomaly. In patients with a long and narrow mandible, the gaps between the corners of the mouth and the lower corners of the mask are likely to prevent an adequate seal and a gas leak may occur. When we administer general anesthesia for these patients, we sometimes try to seal the airway using several sizes and shapes of commercially available face masks. We have found that the management of the airway for patients with certain facial anomalies may be accomplished by attaching a mask upside down.