Yusuke Kusaka

Comparison of McGRATH MAC and Macintosh laryngoscopes for double-lumen endotracheal tube intubation by anesthesia residents: a prospective randomized clinical trial.

STUDY OBJECTIVE This study aimed to compare the utility of McGRATH MAC (McG) and Macintosh (McL) laryngoscopes for double-lumen endotracheal tube intubation in patients undergoing elective surgery. DESIGN Randomized clinical trial. SETTING Operating room. PATIENTS Fifty adult patients scheduled for elective surgery under 1-lung ventilation with American Society of Anesthesiologists physical status 1 to 3. INTERVENTIONS Double-lumen endotracheal tube intubation was performed with the McG (McG group; 25 patients) or conventional McL (McL group; 25 patients) laryngoscope by anesthesia residents. MEASUREMENTS The number of attempts to successful intubation, intubation time, percentage of glottis opening score, and subjective difficulty of laryngoscopy and tube passage through the glottis were assessed. MAIN RESULTS The total numbers of intubation attempts were 1 (McG group, 24 patients; McL group, 16 patients), 2 (McG group, 1 patient; McL group, 8 patients), and 3 (McG group, 0 patient; McL group, 1 patient), with significant differences between the two groups (P = .018). Intubation time was significantly shorter in the McG group compared with the McL group (McG: 17.1 ± 4.6 seconds vs McL: 20.8 ± 5.9 seconds, P = .026). The percentage of glottis opening score was significantly higher in the McG group compared with the McL group (McG: 88.4% ± 13.7% vs McL: 71.4% ± 20.4%, P = .004). CONCLUSIONS The McG demonstrated a better intubation profile compared with the McL, possibly due to its ease of use for double-lumen endotracheal tube intubation. Clinical Trial registry number: UMIN000014636.

Clinical comparison of an echocardiograph-derived versus pulse counter-derived cardiac output measurement in abdominal aortic aneurysm surgery.

OBJECTIVE To compare cardiac output (CO) measurements acquired using the Flotrac/Vigileo system (Edwards Lifesciences, Irvine, CA) and CO measured by transesophageal echocardiography using the product of the aortic valve area, the time integral of flow at the same site, and the heart rate during abdominal aortic aneurysm (AAA) surgery. DESIGN A prospective clinical study. SETTING Cardiac surgery operating room of 1 heart center hospital. PARTICIPANTS Twenty patients undergoing elective AAA surgery. INTERVENTIONS CO was determined simultaneously using the Flotrac/Vigileo system (CO(AP)) and transesophageal echocardiography (CO(TEE)) as the reference method at 8 time points during AAA surgery. MEASUREMENTS AND MAIN RESULTS One hundred sixty simultaneous datasets were obtained. The authors observed a significant correlation between CO(AP) and CO(TEE) values (R = 0.56, p < 0.001). Bland-Altman analysis of CO(AP) and CO(TEE) showed a bias of 0.12 L/min and limits of agreement from -1.66 to 1.90 L/min, with a percentage error of 41%. Just after aortic clamping, CO(AP) significantly increased, but CO(TEE) decreased in comparison with previous measurements. There was a significant association among changes in CO(AP) and pulse pressure, heart rate, and central venous pressure (CVP). However, changes in CO(TEE) were only associated with variations in heart rate. CONCLUSIONS CO(AP) values were not clinically acceptable for use in AAA surgery because of wide variations during aortic clamping and declamping. Changes in pulse pressure, heart rate, and CVP were associated with significant changes in CO(AP), whereas only changes in heart rate showed associated changes in CO(TEE).

Visceral Pericardial Lipoma Involving the Great Cardiac Vein with Large Pericardial Effusion

• Volume 115 • Number 6 www.anesthesia-analgesia.org 1279 A 77-year old woman was hospitalized for evaluation of a large pericardial effusion of unknown etiology detected on transthoracic echocardiography without clinical evidence of heart failure. Computed tomography (CT) revealed a 20-mm × 20-mm, solid mass on the posterolateral wall of the heart with no evidence of cardiac compression (Fig. 1). No evidence of coronary artery disease or abnormal myocardial function was noted on coronary angiography and left ventriculography. Based on imaging, drainage of the pericardial effusion and biopsy of the mass were planned. After induction of general anesthesia, pressures obtained by pulmonary artery catheter were normal except for a slightly increased central venous pressure (13 mm Hg). Transesophegeal echocardiography (TEE)

Evaluation of the Fourth-Generation FloTrac/Vigileo System in Comparison With the Intermittent Bolus Thermodilution Method in Patients Undergoing Cardiac Surgery

OBJECTIVES The aim of this study was to evaluate the accuracy, precision, and trending ability of the fourth-generation FloTrac/Vigileo system (version 4.00; Edwards Lifesciences, Irvine, CA) by comparing cardiac output derived from FloTrac/Vigileo system (COAP) with that measured by a pulmonary artery catheter (COTD), and to determine the effects of hemodynamic variables on the bias between COTD and COAP. DESIGN A prospective study. SETTING University hospital. PARTICIPANTS Thirty patients undergoing elective cardiac surgery using cardiopulmonary bypass. INTERVENTIONS Including hemodynamic variables, COTD and COAP were measured simultaneously at the following 10 time points: after the induction of anesthesia, at the start of operation, after sternotomy, before and after the administration of heparin, before and after the administration of protamine, at the start of sternal closure, at the end of operation, and on arrival to intensive care unit. MEASUREMENTS AND MAIN RESULTS In total, 280 pairs of datasets were obtained. Bland-Altman analysis showed a bias of -0.41 L/min, a precision of 0.72 L/min, and limits of agreement of -1.85 and 1.03 L/min, with a percentage error of 37.1%. The concordance rate determined by 4-quadrant plot analysis and the polar concordance rate were 76% and 79%, respectively. The linear mixed-effect model revealed that the bias was influenced strongly by the difference in pulse pressure between the radial and femoral artery (p < 0.001), and the systemic vascular resistance index (p < 0.001). CONCLUSION The fourth-generation FloTrac/Vigileo system still lacks accuracy and trending ability in cardiac surgery, and the discrepancy in cardiac output measurement depends on the peripheral vascular tone. Further improvement of this system is needed.

The Influence of Human Soluble Recombinant Thrombomodulin on In-Hospital Mortality in Patients with Acute Respiratory Distress Syndrome and Disseminated Intravascular Coagulation: A Retrospective Multicenter Study

Background: Patients with acute respiratory distress syndrome (ARDS) often develop disseminated intravascular coagulation (DIC), which can worsen clinical outcomes. Anticoagulant therapy such as human soluble recombinant thrombomodulin (rTM) treatment may help to resolve DIC and improve prognoses. This study analyzes the influence of rTM treatment on in-hospital mortality in patients with both ARDS and DIC. Methods: In a retrospective cohort study, we examined 75 patients with ARDS and DIC who had been admitted to the intensive care units of 3 university hospitals between March 1, 2008 and February 29, 2016. Data were extracted from clinical records. Subjects were divided into a control group comprising 38 patients who were not administered rTM and an rTM group comprising 37 patients who were administered rTM. Kaplan-Meier survival analysis was performed to produce survival curves and the log-rank test was used to compare survival between the 2 groups. We conducted a Cox proportional hazards regression analysis where the dependent variable was in-hospital mortality and the main independent variable of interest was the use of rTM; the hazard ratio of rTM use was calculated. Results: The variables of with P values below 0.2 were age (P=0.15), source of sepsis (P=0.17), rTM use (P=0.02) and AT concentrate use (P=0.17) between the survivors and non-survivors. There was no significant difference in the ARDS severity levels between the rTM group and the control group (P=0.71). In-hospital mortality was significantly lower (P=0.02) in the rTM group (37.8%) than in the control group (65.8%). The hazard ratio of rTM use for mortality was 0.49 (95% confidence interval: 0.26-0.95; P=0.03). In addition, the log-rank test showed that the rTM group had significantly better survival than the control group (P=0.04). Conclusion: Our study indicates that rTM treatment significantly improved prognoses in patients with both ARDS and DIC.

Persistent left superior vena cava with absent right superior vena cava detected during emergent coronary artery bypass grafting surgery

Although persistent left superior vena cava (PLSVC) itself is a common venous anomaly in congenital heart disease, PLSVC with absent right superior vena cava (RSVC) is a rare venous congenital malformation. Due to the lack of symptoms, this malformation is often detected fortuitously when patients undergo central venous catheter placement, pacemaker implantation, or open cardiac surgery. This particular venous malformation is rare, but clinicians in many fields should be well aware of its variations and management techniques to avoid complications. Anesthesiologists should know that patients with PLSVC rarely have absent RSVC. TEE was helpful in the diagnosis of PLSVC with absent RSVC during emergent surgery.

Rapid-Sequence Intubation in the Left-Lateral Tilt Position in a Pregnant Woman with Premature Placental Abruption Utilizing a Videolaryngoscope

Case A 24-year-old pregnant woman was admitted to our hospital with decreased fetal heart rate. Obstetric examination revealed premature placental abruption; emergent caesarean section was planned under general anesthesia. On entering the operating room, the patient showed severe vital sign deterioration (blood pressure, 75/45 mm Hg; heart rate, 142 beats per minute). As left uterine displacement may worsen the premature placental abruption, the patient was placed in the left-lateral tilt position by rotating the operating table to release compression on the inferior vena cava by theuterus. To avoid circulatory collapse, rapid-sequence intubation was performed in this position. Tracheal intubation was performed with the Pentax-AWS Airwayscope (AWS videolaryngoscope, AWS; HOYA, Japan) to obtain a good laryngeal view and minimize stress from laryngoscopy. After sufficient oxygenation, 120 mg of thiopental was administered. A second anesthesiologist performed cricoid pressure and 50 mg of rocuronium was administered after confirming loss of consciousness. This was followed by insertion of the AWS with a thin intlock into the mouth. Tracheal intubation was performed uneventfully. Discussion Rapid-sequence intubation in the left-lateral tilted position with the AWS videolaryngoscope may be beneficial for pregnant women with vital sign deterioration.