Determination of optimal positive end-expiratory pressure using electrical impedance tomography in infants under general anesthesia: Comparison between supine and prone positions

AIMS

This study determined the optimal positive end-expiratory pressure levels in infants in supine and prone positions under general anesthesia using electrical impedance tomography (EIT).

METHODS

This prospective observational single-centre study included infants scheduled for surgery in the prone position. An electrical impedance tomography sensor was applied after inducing general anesthesia. The optimal positive end-expiratory pressure in the supine position was determined in a decremental trial based on EIT and compliance. Subsequently, the patient's position was changed to prone. Electrical impedance tomography parameters, including global inhomogeneity index, regional ventilation delay, opening pressure, the centre of ventilation, and pendelluft volume, were continuously obtained up to 1 h after prone positioning. The optimal positive end-expiratory pressure in the prone position was similarly determined.

RESULTS

Data from 30 infants were analyzed. The mean value of electrical impedance tomography-based optimal positive end-expiratory pressure in the prone position was significantly higher than that in the supine position [10.9 (1.6) cmH2O and 6.1 (0.9) cmH2O, respectively (p < .001)]. Significant differences were observed between electrical impedance tomography- and compliance-based optimal positive end-expiratory pressure. Peak and mean airway, plateau, and driving pressures increased 1 h after prone positioning compared with those in the supine position. In addition, the centre of ventilation for balance in ventilation between the ventral and dorsal regions improved.

CONCLUSION

The prone position required higher positive end-expiratory pressure than the supine position in mechanically ventilated infants under general anesthesia. EIT is a promising tool to find the optimal positive end-expiratory pressure, which needs to be individualized.

[Correlation between insulin resistance and coronary collateral circulation in patients with chronic total coronary occlusion]

OBJECTIVE

To explore the impact of diabetes on collateral circulation (CC) development in patients with chronic total coronary occlusion (CTO) and the underlying regulatory mechanism.

METHODS

This study was conducted among 87 patients with coronary heart disease (CHD), who had CTO in at least one vessel as confirmed by coronary angiography. Among them 42 patients were found to have a low CC level (Cohen-Rentrop grades 0-1) and 45 had a high CC level (grades 2-3). In the 39 patients with comorbid diabetes mellitus and 48 non-diabetic patients, insulin resistance (IR) levels were compared between the subgroups with different CC levels. The steady-state mode evaluation method was employed for calculating the homeostatic model assessment for insulin resistance index (HOMA-IR) using a mathematical model. During the interventional procedures, collateral and peripheral blood samples were collected from 22 patients for comparison of the metabolites using non-targeted metabolomics analysis.

RESULTS

NT-proBNP levels and LVEF differed significantly between the patients with different CC levels (P<0.05). In non-diabetic patients, HOMA-IR was higher in low CC level group than in high CC level groups. Compared with the non-diabetic patients, the diabetic patients showed 63 upregulated and 48 downregulated metabolites in the collateral blood and 23 upregulated and 14 downregulated metabolites in the peripheral blood. The differential metabolites in the collateral blood were involved in aromatic compound degradation, fatty acid biosynthesis, and steroid degradation pathways; those in the peripheral blood were related with pentose phosphate metabolism, bacterial chemotaxis, hexanoyl-CoA degradation, glycerophospholipid metabolism, and lysine degradation pathways.

CONCLUSION

The non-diabetic patients with a low level of CC had significant insulin resistance. The degradation pathways of aromatic compounds, fatty acid biosynthesis, and steroid degradation are closely correlated with the development of CC.

Effectiveness of head-mounted ultrasound display for radial arterial catheterisation in paediatric patients by anaesthesiology trainees: A randomised clinical trial

BACKGROUND

The effectiveness of head mounted real-time ultrasound displays (hereafter referred to as 'smart glasses') in improving hand-eye coordination in less experienced individuals, such as trainees in anaesthesia, is unclear.

OBJECTIVES

To compare the first-attempt success rate of smart glasses-assisted ultrasound-guided paediatric radial artery catheterisation with conventional ultrasound guided catheterisation performed by anaesthesiology trainees.

DESIGN

Prospective randomised controlled trial.

SETTINGS

Tertiary university hospital from September 2021 to February 2023.

PATIENTS

One hundred and twenty-two paediatric patients (age <7 years, weight ≥3 kg) who required radial artery cannulation during general anaesthesia.

INTERVENTIONS

The participants were randomly assigned to either the ultrasound screen group (control) or the smart glasses group prior to radial artery catheterisation.

MAIN OUTCOME MEASURES

The primary outcome was the first attempt success rate. Secondary outcomes included the number of attempts, use of transfixion technique, overall complication rate, and clinical anaesthesiology (CA) year of the operators.

RESULTS

A total of 119 paediatric patients were included in the analysis. The smart glasses group exhibited higher first-attempt success rate than did the control group (89.8% [53/59] vs. 71.7% [43/60]; P = 0.023; odds ratio (OR) 3.49; (95% confidence interval (CI) 1.27-9.6). The overall number of attempts [median, 1; interquartile range (IQR), 1-1; range, 1-3 vs. median, 1; IQR, 1-2; range, 1-4; P  = 0.006], use of transfixion technique (12/59 [20.3%] vs. 28/60 [46.7%]; P = 0.002), and overall complication rate (6.8% [4/59] vs. 30.0% [18/60]; P = 0.002) were lower in the smart glasses group than in the control group. However, among paediatric anaesthesiology fellows (CA 5 years), the first- (89.3% [25/28] vs. 80.8% [21/26]; P = 0.619) and second-attempt success rates (96.4% [27/28] vs. 80.8% [21/26]; P = 0.163) did not differ between the two groups.

CONCLUSIONS

Smart glasses-assisted ultrasound guided radial artery catheterisation improved the first attempt success rate among anaesthesiology trainees, reducing the number of attempts and overall complication rates in small paediatric patients. Smart glasses were more effective for anaesthesia residents (CA 2-4 years) but were not effective for paediatric anaesthesiology fellows (CA 5 years).

TRIAL REGISTRATION

ClinicalTrials.gov (NCT05030649; registered 1 September 2021; principal investigator, Prof. Jin-Tae Kim) (https://classic.clinicaltrials.gov/ct2/show/NCT05030649).

Perioperative Respiratory-Adverse Events Following General Anesthesia Among Pediatric Patients After COVID-19

BACKGROUND

The perianesthetic morbidity, mortality risk and anesthesia-associated risk after preoperative coronavirus disease 2019 (COVID-19) omicron variant in pediatric patients have not been fully demonstrated. We examined the association between preoperative COVID-19 omicron diagnosis and the incidence of overall perioperative adverse events in pediatric patients who received general anesthesia.

METHODS

This retrospective study included patients aged < 18 years who received general anesthesia between February 1 and June 10, 2022, in a single tertiary pediatric hospital. They were divided into two groups; patients in a COVID-19 group were matched to patients in a non-COVID-19 group during the omicron-predominant period in Korea. Data on patient characteristics, anesthesia records, post-anesthesia records, COVID-19-related history, symptoms, and mortality were collected. The primary outcomes were the overall perioperative adverse events, including perioperative respiratory adverse events (PRAEs), escalation of care, and mortality.

RESULTS

In total, 992 patients were included in the data analysis (n = 496, COVID-19; n = 496, non-COVID-19) after matching. The overall incidence of perioperative adverse events was significantly higher in the COVID-19 group than in the non-COVID-19 group (odds ratio [OR], 1.92; 95% confidence interval [CI], 1.89-1.94). The difference was significant for PRAEs (OR, 2.00; 95% CI, 1.96-2.02) but not in escalation of care or mortality. The most pronounced difference between the two groups was observed in instances of high peak inspiratory pressure ≥ 25 cmH2O during the intraoperative period (OR, 11.0; 95% CI, 10.5-11.4). Compared with the non-COVID-19 group, the risk of overall perioperative adverse events was higher in the COVID-19 group diagnosed 0-2 weeks before anesthesia (OR, 6.5; 95% CI, 2.1-20.4) or symptomatic on the anesthesia day (OR, 6.4; 95% CI, 3.30-12.4).

CONCLUSION

Pediatric patients with the preoperative COVID-19 omicron variant had increased risk of PRAEs. Patients within 2 weeks after COVID-19 or those with symptoms had a higher risk of PRAEs.

Changes in diaphragmatic ultrasonography findings and their association with postoperative complications in children undergoing pulmonary resection: A single-centre, prospective, observational study

BACKGROUND

Few studies have investigated the changes in diaphragmatic function and their association with postoperative pulmonary complications (PPCs) in paediatric patients after lung resection.

OBJECTIVE

This study aimed to evaluate diaphragmatic function using ultrasound after lung resection and its influence on PCCs in children.

DESIGN

Prospective observational study.

SETTING

A tertiary children's hospital.

PATIENTS

Children aged 6 years or less who were scheduled for video-assisted thoracoscopic lung resection.

INTERVENTION

Ultrasonographic measurements of diaphragmatic excursion (DE) and thickening fraction (TF) were performed for three epochs: before anaesthesia induction (T0), 1 h postoperatively (T1) and 24 h postoperatively (T2). The thickening fraction is calculated from the thickness of the diaphragm at end expiration and end inspiration at each time point. DE T1 /DE T0 , DE T2 /DE T0 , TF T1 /TF T0 and TF T2 /TF T0 (%) were calculated. The incidence of PCCs was also determined.

MAIN OUTCOME MEASURES

The primary outcomes were changes in diaphragmatic excursion and thickening fraction over time, from T0 to T2. The secondary outcomes were the association between ultrasound parameters of diaphragm function and the occurrence of early PPCs within 3 days.

RESULTS

Data from 74 children were analysed. On the operated side, both diaphragmatic excursion and thickening fraction decreased at T1 and recovered slightly at T2, and were significantly lower than the T0 values. Children with PPCs had significantly lower DE T2 /DE T0 and TF T2 /TF T0 scores on the operated side than those without PPCs. According to the receiver operating characteristic analysis, the DE T2 /DE T0 (< 61.1%) on the operated side was associated with PPCs with an area under the curve of 0.764.

CONCLUSIONS

Peri-operative diaphragmatic function assessed by ultrasonography changed after lung resection in children. The diaphragmatic excursion and thickening fraction decreased postoperatively, and a prolonged decrease in diaphragmatic excursion was associated with pulmonary complications after lung surgery in children.

CLINICAL TRIAL REGISTRY

ClinicalTrials.gov, NCT04400370.

Higher portal venous pulsatility is associated with worse clinical outcomes following congenital heart surgery: a single-centre prospective cohort study

PURPOSE

Increased portal venous flow pulsatility is associated with major complications after adult cardiac surgery. Nevertheless, no data are available for pediatric patients with congenital heart disease. We hypothesized that Doppler parameters including portal flow pulsatility could be associated with postoperative outcomes in children undergoing various cardiac surgeries.

METHODS

We conducted a prospective observational cohort study in children undergoing congenital cardiac surgery. We obtained postoperative portal, splenic, and hepatic venous Doppler data and perioperative clinical data including major postoperative complications. Portal and splenic venous flow pulsatility were calculated. We evaluated the association between venous Doppler parameters and adverse outcomes. The primary objective was to determine whether postoperative portal flow pulsatility could indicate major complications following congenital heart surgery.

RESULTS

In this study, we enrolled 389 children, 74 of whom experienced major postoperative complications. The mean (standard deviation) portal pulsatility (44 [30]% vs 25 [14]%; 95% confidence interval [CI] for mean difference, 12 to 26; P < 0.001] and splenic pulsatility indices (41 [30]% vs 26 [16]%; 95% CI, 7 to 23; P < 0.001) were significantly higher in children with postoperative complications than in those without complications. The portal pulsatility index was able to help identify postoperative complications in biventricular patients and univentricular patients receiving bidirectional cavopulmonary shunt whereas it did not in other univentricular patients. An increased postoperative portal pulsatility index was significantly associated with major complications after pediatric cardiac surgery (odds ratio, 1.40; 95% CI, 1.29 to 1.91; P < 0.001).

CONCLUSIONS

Higher portal venous pulsatility is associated with major postoperative complications in children undergoing cardiac surgery. Nevertheless, more data are needed to conclude the efficacy of portal venous pulsatility in patients with univentricular physiology.

STUDY REGISTRATION

ClinicalTrials.gov (NCT03990779); registered 19 June 2019.

Effect of tidal volume change on pressure-based prediction of fluid responsiveness in children

INTRODUCTION

It is known that pulse pressure variation and systolic pressure variation cannot predict fluid responsiveness in children. In adults, the ability of these dynamic parameters to predict fluid responsiveness is improved by increasing tidal volume. We planned to investigate whether pulse pressure variation or systolic pressure variation can predict fluid responsiveness in children when augmented by increasing tidal volume by conducting a prospective study.

METHODS

We enrolled children younger than 7 years who underwent cardiac surgery for atrial septal defect or ventricular septal defect. After sternum closure, pulse pressure variation and systolic pressure variation were continuously recorded while changing the tidal volume to 6, 10, and 14 mL/kg. Fluid loading was done with 10 mL/kg of crystalloids for 10 min, and stroke volume index was measured via transesophageal echocardiography. Children whose stroke volume index increased by more than 15% after the fluid loading were defined as responders to fluid therapy. We set primary outcome as the predictability of pulse pressure variation and systolic pressure variation for fluid responsiveness and measured the area under the curve of receiver operating characteristics curve.

RESULTS

Twenty-six children were included, of which 15 were responders. At the tidal volume of 14 mL/kg, the area under the curves of receiver operating characteristics curves of pulse pressure variation and systolic pressure variation were 0.576 (p = .517) and 0.548 (p = .678), respectively. The differences in dynamic parameters between responders and nonresponders were not significant.

DISCUSSION

Failure of pulse pressure variation or systolic pressure variation at augmented tidal volume in children may be due to difference in their arterial compliance from those of adults. Large compliance of thoracic wall may be another reason.

CONCLUSIONS

Augmented pulse pressure variation or systolic pressure variation due to increased tidal volume cannot predict fluid responsiveness in children after simple cardiac surgery.

Association of the perfusion index with postoperative acute kidney injury: a retrospective study

BACKGROUND

Many studies have examined the risk factors for postoperative acute kidney injury (AKI), but few have focused on intraoperative peripheral perfusion index (PPI) that has recently been shown to be associated with postoperative morbidity and mortality. Therefore, this study aimed to evaluate the relationship between intraoperative PPI and postoperative AKI under the hypothesis that lower intraoperative PPI is associated with AKI occurrence.

METHODS

We retrospectively searched electronic medical records to identify patients who underwent surgery at the general surgery department from May 2021 to November 2021. Patient baseline characteristics, pre- and post-operative laboratory test results, comorbidities, intraoperative vital signs, and discharge profiles were obtained from the Institutional Clinical Data Warehouse and VitalDB. Intraoperative PPI was the primary exposure variable, and the primary outcome was postoperative AKI.

RESULTS

Overall, 2,554 patients were identified and 1,586 patients were included in our analysis. According to Kidney Disease Improving Global Outcomes (KDIGO) criteria, postoperative AKI occurred in 123 (7.8%) patients. We found that risks of postoperative AKI increased (odds ratio: 2.00, 95% CI [1.16, 3.44], P = 0.012) when PPI was less than 0.5 for more than 10% of surgery time. Other risk factors for AKI occurrence were male sex, older age, higher American Society of Anesthesiologists physical status, obesity, underlying renal disease, prolonged operation time, transfusion, and emergent operation.

CONCLUSIONS

Low intraoperative PPI was independently associated with postoperative AKI.

Comparison of effects of volatile and intravenous anesthetics on pupillary function during general anesthesia in children: A prospective observational study

BACKGROUND

The light reflex, which reflects central nervous system dysfunction, can also be affected by anesthetic agents.

AIMS

We evaluated whether these effects differed according to the anesthetic agent in pediatric patients.

METHODS

Twenty children aged 3-12 years who were scheduled to undergo elective surgery under general anesthesia were randomly allocated to propofol and sevoflurane groups and underwent pupillometric assessments at five points during anesthesia: T1, after confirming loss of consciousness; T2, after endotracheal intubation; T3, at the time of skin incision; T4, 1 h after skin incision; and T5, before endotracheal extubation. The primary outcome was the Neurological Pupil index at T4, and the secondary outcomes were other pupillometric parameters, including pupil diameter, percentage of change in pupil diameter, dilation velocity, and constriction velocity.

RESULTS

At T4, the Neurological Pupil index was significantly lower in the sevoflurane group (median difference, 0.30; 95% CI, 0.00 to 0.70; p = .036). Furthermore, the Neurological Pupil index at all time points was lower in the sevoflurane group. The time-and-group interaction effects on constriction velocity and dilation velocity were significantly different [F(1, 4) = 16.68, p = .002; F(1, 4) = 14.78, p = .008, respectively] but were not different on the Neurological Pupil index, pupil diameter, and percentage of change in pupil diameter. No intergroup differences were observed in the baseline characteristics, the flow rate of remifentanil at each time point, and total infused remifentanil.

CONCLUSION

The Neurological Pupil index value in pediatric patients under general anesthesia is affected by the anesthetic agent used; this factor requires consideration in evaluations of the Neurological Pupil index during general anesthesia.

Pharmacokinetics of dexmedetomidine in pediatric patients undergoing cardiac surgery with cardiopulmonary bypass

BACKGROUND

Cardiopulmonary bypass can affect the pharmacokinetics of anesthetic agents.

AIMS

We aimed to evaluate the pharmacokinetics of dexmedetomidine for infants and small children undergoing cardiac surgery with cardiopulmonary bypass based on population pharmacokinetics.

METHODS

We enrolled 30 pediatric cardiac surgical patients in this study. After anesthetic induction with atropine (0.02 mg/kg), thiopental sodium (5 mg/kg), and fentanyl (2-3 μg/kg), we administered 1 μg/kg of dexmedetomidine for 10 min, followed by administration of 0.5 μg/kg of dexmedetomidine per hour during surgery. At the initiation of cardiopulmonary bypass, 1 μg/kg of dexmedetomidine was infused over 5 min. Arterial blood was obtained at predefined time points. A pharmacokinetic model was developed using NONMEM. Theory-based allometric scaling with fixed exponents was applied. Weight, age, post-menstrual age, fat-free mass, whether to implement cardiopulmonary bypass and temperature were explored as covariates.

RESULTS

A total of 376 blood samples were obtained from 29 children (age: 20.3 ± 19.3 months, weight: 9.7 ± 4.1 kg). A two-compartment mammillary model with third compartment associated cardiopulmonary bypass procedure best explained the pharmacokinetics of dexmedetomidine. The pharmacokinetic parameter estimates (95% CI) standardized to a 70-kg person were as follows: V₁ (L) = 31.6 (17.9-39.5), V₂ (L) = 90.1 (44.0-330), Cl (L/min) = 1.08 (0.70-1.25), Q (L/min) = 2.0 (1.05-3.46). Volume for third compartment associated cardiopulmonary bypass procedure (L) = 39.4 (19.3-50.9). Clearance was not influenced by the presence of cardiopulmonary bypass in this model.

CONCLUSION

When cardiopulmonary bypass is applied, the plasma concentration of dexmedetomidine decreases due to an increase in the volume of distribution, so a loading dose is required to maintain the previous concentration.

Effect of Tulobuterol Patch Versus Placebo on the Occurrence of Respiratory Adverse Events in Children Undergoing Tonsillectomies: A Randomized Controlled Trial

BACKGROUND

Perioperative respiratory adverse events are common in children. We aimed to evaluate the effect of the transdermal β-2 agonist, tulobuterol, compared with that of placebo on the incidence of perioperative respiratory adverse events in pediatric patients undergoing tonsillectomy.

METHODS

In this triple-blinded (patient, anesthesia provider, and outcome assessor) randomized controlled trial, 188 patients were randomly allocated to receive tulobuterol or a placebo. The tulobuterol groups received a tulobuterol patch (1 mg) masked with a bandage, whereas the placebo only received the bandage. The assigned bandage was applied to the patients 8 to 10 hours before the surgery. The primary outcome was the occurrence of any perioperative respiratory adverse events: oxygen desaturation <95%, airway obstruction, laryngospasm, bronchospasm, severe coughing, or stridor. The outcomes were evaluated using the average relative effect test, which estimates the effect of individual components of a composite outcome and then averages effects across components.

RESULTS

A total of 88 and 94 patients who received tulobuterol and placebo, respectively, were analyzed. The incidence of any perioperative respiratory adverse event was lower with tulobuterol (n = 13/88; 14.7%) than that with the placebo (n = 40/94; 42.5%), with an estimated average relative risk (95% confidence interval) across components of 0.35 (0.20-0.60; P < .001). The symptoms of airway obstruction were lower with tulobuterol (n = 8/88; 9.0%) than that with the placebo (n = 32/94; 34.0%), with relative risk (95% CI) of 0.31 (0.17-0.56; P < .001). The occurrence of severe coughing was lower with tulobuterol (n = 1/88; 1.1%) than that with the placebo (n = 8/94; 8.5%), with relative risk (95% CI) of 0.15 (0.03-0.68; P = .014).

CONCLUSIONS

In preschool children undergoing tonsillectomy, the preoperative application of a tulobuterol patch could decrease the occurrence of perioperative respiratory adverse events. Further studies are needed to elucidate the effect of the tulobuterol patch in a broad spectrum of pediatric anesthesia.

Two-center randomized controlled trial comparing oral chloral hydrate and intranasal combination of dexmedetomidine and ketamine for procedural sedation in children: study protocol

BACKGROUND

Oral chloral hydrate is widely used in pediatric sedation. Intranasal dexmedetomidine has been increasingly used for pediatric sedation; however, its improvement is warranted. The combination of dexmedetomidine with ketamine can improve onset and hemodynamic stability while maintaining sedative efficacy. This study aims to determine the efficacy and safety of intranasal combination of dexmedetomidine and ketamine compared to oral chloral hydrate.

METHODS

This is a prospective, parallel-arm, single-blinded, two-center, superiority randomized controlled trial with 1:1 allocation, designed to compare the effects of intranasal combination of dexmedetomidine and ketamine with those of oral chloral hydrate. We shall enroll 136 patients aged < 7 years old in this study. Prior to the procedure, we shall randomize each patient into the control group (oral chloral hydrate 50 mg/kg) or study group (intranasal dexmedetomidine 2 μg/kg and ketamine 3 mg/kg). The primary outcome will be the rate of achieving an adequate sedation level (6-point Pediatric Sedation State Scale 1, 2, or 3) within 15 min. In addition, we shall measure the sedation time, sedation failure rate, completion of procedure, adverse events, patient acceptance, and physician satisfaction.

DISCUSSION

This study will provide evidence of the efficacy and safety of the intranasal combination of dexmedetomidine and ketamine in comparison with oral chloral hydrate.

TRIAL REGISTRATION

ClinicalTrials.gov , NCT04820205. Registered on 19th March 2021.

Response of internal carotid artery blood flow velocity to fluid challenge under general anesthesia in pediatric patients with moyamoya disease: A prospective observational study

BACKGROUND

Maintaining cerebral blood flow is important in intraoperative management of moyamoya disease patients.

AIMS

To access changes in the carotid artery blood flow velocity in response to fluid challenge, blood pressure, and cardiac output under general anesthesia in pediatric patients with moyamoya disease.

METHODS

This observational study included pediatric patients with moyamoya disease undergoing general anesthesia for encephaloduroarteriosynangiosis. Each patient underwent an ultrasound assessment thrice as follows: after anesthetic induction (T1), after fluid challenge (10 ml/kg, T2), and at the end of surgery (T3). The primary outcome was the change in the internal carotid artery blood flow velocity after fluid challenge and was assessed using a paired t-test. The secondary outcomes comprised changes in the internal, external, and common carotid artery blood flow peak velocities after fluid challenge and the factors influencing these changes.

RESULTS

We enrolled and analyzed 30 patients with a mean age of 7.2 years. After fluid challenge, the systolic (p = .003) and mean blood pressure (p = .017), stroke volume index (p = .008), and cardiac index (p = .140) were higher than those at T1. However, both internal carotid artery blood flow velocities did not change after fluid challenge (p = .798, mean difference and 95% confidence interval [CI], -1.1 and -10.3 to 8.0 for right, p = .164, mean difference and 95% CI, -5.2 and -12.7 to 2.2 for left). The internal carotid artery blood flow velocity was correlated with the cardiac index, stroke volume index, and mean and diastolic blood pressure, with low significance.

CONCLUSIONS

The internal carotid artery blood flow velocity did not increase in pediatric patients with moyamoya disease under general anesthesia, despite fluid challenge and corresponding changes in the blood pressure and cardiac output. Intraoperative hemodynamic management to improve the cerebral blood flow in these patients requires further investigation.

Validation of the Masimo O3™ regional oximetry device in pediatric patients undergoing cardiac surgery

We assessed the accuracy of Masimo O3™ regional cerebral oxygen saturation (rSO₂) readings by comparing them with reference values and evaluated the relationship between rSO₂ and somatic tissue oxygen saturation (StO₂) in children undergoing cardiac surgery. After anesthesia induction, pediatric sensors were applied to the forehead and foot sole, and rSO₂ and StO₂ values were monitored continuously. Before cardiopulmonary bypass (CPB), F_IO₂ was set to 0.2, 0.5, and 0.8 serially every 15 min. After CPB, F_IO₂ was reversed. The reference values (SavO₂) were calculated by combining arterial (SaO₂) and central venous oxygen saturation (SvO₂) readings from the arterial and central lines, respectively (0.7 [Formula: see text] SvO₂ + 0.3 [Formula: see text] SaO₂). In total, 265 pairs of rSO₂/StO₂ and SavO₂ from 49 patients were analyzed. The bias, standard deviation (SD), standard error (SE), and root mean squared error (RMSE) of rSO₂ were 2.6%, 4.5%, 0.3%, and 4.3%, respectively. The limits of agreement ranged from -6.3% to 11.6%. Trend accuracy analysis yielded a relative mean error of -1.4%, with an SD of 4.3%, SE of 0.2%, and RMSE of 3.9%. According to multiple linear regression analysis, the application of CPB, F_IO₂, Hb level, and tip location of the central venous catheter influenced the bias (all P < 0.05). Furthermore, the correlation between rSO₂ and StO₂ was weak (r = 0.254). rSO₂ readings by the Masimo O3™ device and pediatric sensor had good absolute and trending accuracies with respect to the calculated reference values in children undergoing cardiac surgery. rSO₂ and StO₂ cannot be used interchangeably.Clinical trial registration http://clinicaltrials.gov (number: NCT04208906).

Ultrasound-guided esophageal compression during mask ventilation in small children: a prospective observational study

Background

The use of cricoid compression to prevent insufflation remains controversial, and its use in children is limited. This study aimed to examine the effect of real-time ultrasound-guided esophageal compression on the prevention of gastric insufflation.

Method

This prospective observational study was conducted with fifty children aged < 2 years undergoing general anesthesia. Patients were excluded if they were at an increased risk for gastric regurgitation or pulmonary aspiration. Following anesthetic induction under spontaneous breathing, ultrasound-guided esophageal compression was performed during pressure-controlled face-mask ventilation using a gradual increase in peak inspiratory pressure from 10 to 24 cm H₂O to determine the pressure at which gastric insufflation occurred. The primary outcome was the incidence of gastric insufflation during anesthetic induction with variable peak inspiratory pressure after real-time ultrasound-guided esophageal compression was applied.

Results

Data from a total of 42 patients were analyzed. Gastric insufflation was observed in 2 (4.7%) patients. All patients except one had their esophagus on the left side of the trachea. Applying ultrasound-guided esophageal compression did not affect the percentage of glottic opening scores (P = 0.220).

Conclusions

The use of real-time ultrasound-guided esophageal compression pressure can aid preventing gastric insufflation during face-mask ventilation in children less than 2 years old.

Trial registration

Clinicaltrials.gov identifier: NCT04645043.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12871-022-01803-5.

Performance time of anesthesiology trainees for cricothyroid membrane identification and characteristics of cricothyroid membrane in pediatric patients using ultrasonography

BACKGROUND

Identifying the cricothyroid membrane is an essential technical skill for front-of-neck access procedures.

AIMS

This study evaluated the usefulness of cricothyroid membrane identification in pediatric patients using ultrasonography by anesthesiology trainees without experience in airway ultrasound and collected anatomical data on the cricothyroid membrane and its surrounding airway structures in children.

METHODS

This prospective observational study included children aged <18 years scheduled to undergo general anesthesia and anesthesiology trainees who identified the cricothyroid membrane in five sequential anesthetized patients using ultrasonography. A pediatric anesthesiologist confirmed the accuracy of the identified cricothyroid membrane and recorded the performance time. The primary aims were the cricothyroid membrane identification success rate and performance time. The secondary aims were the characterization of the cricothyroid membrane and its surrounding structures.

RESULTS

Overall, 150 pediatric patients and 30 anesthesiology trainees were analyzed. The cricothyroid membrane identification success rate using ultrasonography was 100% in all the attempts using a transverse approach. The mean (standard deviation) performance time was 27.2 (18.6) s and 31.0 (23.8) s using the transverse and longitudinal approaches, respectively. The performance time decreased by 3.1 (p = .003, 95% confidence interval [CI] = -5.1--1.0) and 5.2 (p = .007, 95% CI = -8.9--1.4) seconds per increase in number of attempts with the transverse and longitudinal approaches, respectively. The cricothyroid membrane length was mostly correlated with the patients' height (r = .75, p < .001), and the blood vessels surrounding the cricothyroid membrane were observed in 95.9% of the patients.

CONCLUSIONS

Anesthesiology trainees without experience in airway ultrasound successfully identified the cricothyroid membrane in pediatric patients using ultrasonography after a brief training period. Further research is required as the identification of a structure does not predict the success of the actual procedure, particularly if done in an emergency situation.

Prediction of fluid responsiveness following liver compression in pediatric patients with single ventricle physiology

INTRODUCTION

The role of liver compression in predicting fluid responsiveness in children with a single ventricle has never been evaluated. The purpose of this study was to assess whether blood pressure changes during liver compression predict fluid responsiveness in children with single ventricle physiology.

METHODS

This prospective, interventional study included children aged 3 months to 5 years who underwent surgery for bidirectional cavopulmonary shunt or extracardiac Fontan operation. Before fluid loading, the right upper abdomen was compressed at 30 mmHg for 10 s, and changes in the blood pressure waves were recorded before administering 10 ml kg^-1 of crystalloid solution. Systolic arterial pressure, diastolic arterial pressure, central venous pressure, pleth variability index, respiratory variation in aortic blood flow peak velocity, and stroke volume were measured before and after fluid loading. A volume responder was defined as a patient with >15% increase in stroke volume index.

RESULTS

Thirty patients underwent bidirectional cavopulmonary shunt (15 responders and 15 non-responders), and 32 underwent Fontan surgery (17 responders and 15 non-responders). In children with bidirectional cavopulmonary shunt, Δsystolic arterial pressure > 8 mmHg (sensitivity 76.9% and specificity 93.3%), Δdiastolic arterial pressure > 7 mmHg (sensitivity 69.2% and specificity 93.3%), and Δmean arterial pressure > 7 mmHg (sensitivity 69.2% and specificity 100%) during liver compression predicted fluid responsiveness. The areas under the receiver operating characteristic curves of Δsystolic arterial pressure, Δdiastolic arterial pressure, and Δmean arterial pressure were 0.928, 0.859, and 0.874 (all p < .001). In children who underwent Fontan surgery, only Δsystolic arterial pressure > 16 mmHg was predictive of fluid responsiveness (sensitivity of 41.2% and specificity of 100%), with the areas under the receiver operating characteristic curves curve of 0.786 (p < .001). Pleth variability index and respiratory variation in aortic blood flow peak velocity had no predictive value for fluid responsiveness after both types of surgeries.

DISCUSSION

In BCPS patients, liver compression increases the inferior vena cava flow which directly leads to an increase in preload. On the other hand, blood flow from the liver drains directly into the pulmonary arteries in Fontan circulation. Because of this characteristics for preload determination, the clinical application of liver compression to monitor hemodynamic changes might be more useful in patients with bidirectional cavopulmonary shunt than those with Fontan circulation.

CONCLUSION

Increase in blood pressure induced by liver compression is predictive of fluid responsiveness in children with single ventricle physiology.

The effect of dexmedetomidine on neuroprotection in pediatric cardiac surgery patients: study protocol for a prospective randomized controlled trial

Background

Infants undergoing cardiac surgery under cardiopulmonary bypass are vulnerable to postoperative neurodevelopmental delays. Dexmedetomidine has been shown to have protective effects on the heart, kidneys, and brain in animals and adults undergoing cardiac surgery with cardiopulmonary bypass. We hypothesized that dexmedetomidine would have a neuroprotective effect on infants undergoing cardiopulmonary bypass and planned a prospective randomized controlled trial with postoperative neurodevelopment measurements.

Methods

This is a single-center, prospective, double-blinded, randomized controlled trial with 1:1 allocation. A cohort of 160 infants undergoing cardiac surgery with cardiopulmonary bypass will be enrolled. After induction, dexmedetomidine will be infused with a loading dose of 1 μg/kg and a maintenance dose of 0.5 μg/kg/h or the same amount of normal saline will be administered. Upon initiation of cardiopulmonary bypass, an additional dose of dexmedetomidine (0.01 μg/cardiopulmonary priming volume) will be mixed with the cardiopulmonary bypass circuit. The primary outcome will be the proportion of infants who score lower than 85 in any of the cognitive, language, or motor Bayley scales of infant development-III tests 1 year after the surgery. Other feasible outcome measures will include differences in plasma glial fibrillary acidic protein, troponin I, interleukin-6, urinary neutrophil gelatinase-associated lipocalin, and perioperative major adverse events. The results of the Bayley scales of infant development-III test from the study group and the control group will be compared using a chi-squared test under intention-to-treat analysis. A generalized estimating equation will be used to analyze repeated measurements over time.

Discussion

This study will enable us to assess whether the use of dexmedetomidine can alter the early neurodevelopmental outcome in infants undergoing cardiac surgery with cardiopulmonary bypass and also estimate effects of dexmedetomidine on other organs.

Trial registration

ClinicalTrials.gov NCT04484922. Registered on 24 July 2020

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06217-9.

[RIP1/RIP3-MLKL signaling pathway correlates with occurrence, progression and prognosis of chronic heart failure]

OBJECTIVE

To detect plasma levels of receptor-interacting protein kinase 1 (RIP1), RIP3 and mixed lineage kinase domain-like protein (MLKL) in patients with chronic heart failure and explore the expression pattern of programmed necrosis signaling pathway RIP1/RIP3-MLKL in the progression of heart failure.

METHODS

The patients with chronic heart failure (NYHA class Ⅱ-Ⅳ) admitted in our hospital between February, 2020 and March, 2021 were prospectively enrolled in this study, with 21 healthy volunteers as the control group. The enrolled patients included 20 with grade Ⅱ, 33 with grade Ⅲ, and 43 with grade Ⅳ cardiac function. Fasting venous blood was collected from all the participants for detecting plasma levels of RIP1, RIP3, and MLKL and protein expressions of RIP1/RIP3-MLKL pathway using enzyme-linked immunosorbent assay (ELISA) and Western blotting. The patients with grade Ⅳ cardiac function were followed up for 5 months to evaluate the clinical prognostic indicators.

RESULTS

Compared with the healthy volunteers, the patients with grade Ⅱ, Ⅲ and Ⅳ cardiac function had significantly increased plasma levels of RIP1, RIP3, and MLKL (P < 0.01), and their levels were significantly higher in grade Ⅲ/Ⅳ patients than in those with grade Ⅱ cardiac function (P < 0.01); the plasma levels of RIP1 and MLKL were significantly higher in grade Ⅳ patients than in grade Ⅲ patients (P < 0.05). The results of Western blotting also showed increased expressions of the proteins in the RIP1/RIP3-MLKL pathway in patients with heart failure. Pearson correlation analysis suggested that in patients with heart failure, the expression levels of RIP1, RIP3, and MLKL were positively correlated with SCR, AST, LVEDD and NT-proBNP (P < 0.05). Follow-up study of the patients with grade Ⅳ cardiac function showed that higher expression levels of RIP1/RIP3-MLKL were associated with a poorer prognosis of the patients.

CONCLUSION

The expressions of RIP1, RIP3 and MLKL are significantly upregulated in patients with heart failure in positive correlation with the severity of the disease condition, and the activation of the RIP1/RIP3-MLKL signaling pathway may contribute to the occurrence, development and prognosis of chronic heart failure.

Determining optimal positive end-expiratory pressure and tidal volume in children by intratidal compliance: a prospective observational study

BACKGROUND

Limited data exist regarding optimal intraoperative ventilation strategies for the paediatric population. This study aimed to determine the optimal combination of PEEP and tidal volume (V_T) based on intratidal compliance profiles in healthy young children undergoing general anaesthesia.

METHODS

During anaesthesia, infants (1 month-1 yr), toddlers (1-3 yr), and children (3-6 yr) were assigned serially to four ventilator settings: PEEP 8 cm H₂O/V_T 8 ml kg^-1 (PEEP8/V_T8), PEEP 10 cm H₂O/V_T 5 ml kg^-1 (PEEP10/V_T5), PEEP 10 cm H₂O/V_T 8 ml kg^-1 (PEEP10/V_T8), and PEEP 12 cm H₂O/V_T 5 ml kg^-1 (PEEP12/V_T5). The primary outcome was intratidal compliance profile, classified at each ventilator setting as horizontal (indicative of optimal alveolar ventilatory conditions), increasing, decreasing, or combinations of increasing/decreasing/horizontal compliance. Secondary outcomes were peak inspiratory, plateau, and driving pressures.

RESULTS

Intratidal compliance was measured in 15 infants, 13 toddlers, and 15 children (15/43 [35%] females). A horizontal compliance profile was most frequently observed with PEEP10/V_T5 (60.5%), compared with PEEP10/V_T8, PEEP8/V_T8, and PEEP12/V_T5 (23.3-34.9%; P<0.001). Decreasing compliance profiles were most frequent when V_T increased to 8 ml kg^-1, PEEP increased to 12 cm H₂O, or both. Plateau airway pressures were lower at PEEP8/V_T8 (16.9 cm H₂O [2.2]) and PEEP10/V_T5 (16.7 cm H₂O [1.7]), compared with PEEP10/V_T8 (19.5 cm H₂O [2.1]) and PEEP12/V_T5 (19.0 cm H₂O [2.0]; P<0.001). Driving pressure was lowest with PEEP10/V_T5 (4.6 cm H₂O), compared with other combinations (7.0 cm H₂O [2.0]-9.5 cm H₂O [2.1]; P<0.001).

CONCLUSIONS

V_T 5 ml kg^-1 combined with 10 cm H₂O PEEP may reduce atelectasis and overdistension, and minimise driving pressure in the majority of mechanically ventilated children <6 yr. The effect of these PEEP and V_T settings on postoperative pulmonary complications in children undergoing surgery requires further study.

CLINICAL TRIAL REGISTRATION

NCT04633720.

[Exploring the therapeutic mechanism of quercetin for heart failure based on network pharmacology and molecular docking]

OBJECTIVE

To investigate the molecular mechanism of quercetin in the treatment of heart failure (HF) based on network pharmacology and molecular docking.

METHODS

Quercetin and HF-related targets were obtained using TCMSP, PharmMapper, CTD and GeneCards databases, and quercetin-HF intersection targets were obtained through the online website Venn; the protein interaction network was constructed and imported into Cytoscape 3.7.2 to identify the core targets of quercetin in the treatment of HF.GO and KEGG pathway enrichment analyses were performed using R package, and molecular docking was performed using Auto Dock Vina.The protein levels of AKT1, phospho-AKT(Ser473), eNOS, MMP9, and caspase-3 in quercetin-treated HF cell models were detected using protein immunoblotting.

RESULTS

We identified 80 quercetin-HF intersectional targets (AKT1, CASP3, MAPK1, MMP9, and MAPK8) and 5 core targets of quercetin for treatment of HF.GO analysis suggested that the therapeutic effect of quercetin for HF was mediated mainly by such biological processes as responses to peptide hormones, phosphatidylinositol-mediated signalling, responses to lipopolysaccharides, responses to molecules of bacterial origin and regulation of inflammatory responses.KEGG pathway enrichment analysis identified lipid and atherosclerosis pathway, proteoglycans in cancer, PI3K-AKT signaling pathway, diabetic cardiomyopathy and MAPK signaling pathway as the most significantly enriched signaling pathways.Molecular docking showed a good binding activity of quercetin to the 5 core targets.The results of protein immunoblotting showed that 100 μmol/L quercetin significantly reduced AKT1, phospho-AKT (Ser473), eNOS, MMP9 and caspase-3 levels in the cell models of HF (P < 0.01).

CONCLUSION

Quercetin improves the pathological changes in HF possibly by regulating the AKT1-eNOS-MMP9 pathway to inhibit cell apoptosis.

Use of nimotuzumab combined with cisplatin in treatment of nasopharyngeal carcinoma and its effect on expressions of VEGF and MMP-2

PURPOSE

This paper aims to observe the expressions of VEGF and MMP-2 in patients with nasopharyngeal carcinoma treated by nimotuzumab combined with cisplatin.

METHODS

Altogether, 104 patients with nasopharyngeal carcinoma treated in our hospital from April 2014 to August 2016 were selected as research subjects. Among them, 50 patients treated with cisplatin were divided into a control group and 54 patients treated with nimotuzumab combined with cisplatin were divided into an observation group. The two groups of patients were compared in terms of efficacy after treatment and incidence of adverse reactions. Changes of serum VEGF and MMP-2 concentrations before and after treatment were detected using enzyme-linked immunosorbent assay (ELISA), and the 3-year overall survival (OS) of patients was observed.

RESULTS

Compared with the control group, patients in the observation group had significantly higher total remission rate (RR) (P < 0.05) and significantly lower incidence of adverse reactions (P < 0.05). Before treatment, there was no significant difference between the observation and control groups in the concentrations of VEGF and MMP-2 (P > 0.05). After treatment, the concentrations in the two groups were significantly lower than those before treatment (P < 0.05), and the concentrations in the observation group were significantly lower than those in the control group (P < 0.05). There was no significant difference in the 3-year OS between the observation and control groups (P > 0.05).

CONCLUSIONS

Nimotuzumab combined with cisplatin could improve the conditions of patients with nasopharyngeal carcinoma. After treatment, the expression of VEGF and MMP-2 decreased significantly. We speculated that it improves the survival rate of patients by reducing the expression of VEGF and MMP-2.

A pharmacodynamic model of tidal volume and inspiratory sevoflurane concentration in children during spontaneous breathing

PURPOSE

High concentrations of sevoflurane causes respiratory depression, mainly due to the decrease in tidal volume (TV) during spontaneous ventilation. The purpose of this study was to identify clinical variables that affect the relationship between TV and sevoflurane concentration, and to establish a population pharmacodynamic modelling approach to TV and sevoflurane concentration in children. A prospective observational study involving 48 patients (≤ 6 years of age) scheduled to undergo general anesthesia using laryngeal mask airway was performed. When the inspiratory sevoflurane concentration reached 2 vol%, the vaporizer was increased to 4 vol% for 5 min, then sevoflurane was decreased to 2 vol% for 5 min. During the study period, TV, end-tidal carbon dioxide, and sevoflurane concentration were recorded every 30 s. Pharmacodynamic analysis using a sigmoid E_max model was performed to assess the TV-sevoflurane concentration relationship. To collapse hysteresis of the pharmacokinetic and pharmacodynamic relationship, the semicompartmental model was applied which does not require a structural model for equilibration delay causing the hysteresis. TV decreased with increasing inspiratory sevoflurane concentrations. Hysteresis between the TV and sevoflurane concentration was observed and was accounted for when the model was developed. Initial TV and maximal reduction in TV were related to body weight. The γ (a steepness of the concentration-response relation curve) was 8.78 and the k_eo, (a first-order rate constant determining the equilibrium between the end-tidal sevoflurane concentration and effect site sevoflurane concentration) was 2.27 min^-1. Changes in TV were correlated with sevoflurane concentration with spontaneous breathing during sevoflurane anesthesia. The initial and maximal TV were related to body weight, in a pediatric population.

Effects of ipsilateral tilt position on the cross-sectional area of the subclavian vein and the clinical performance of subclavian vein catheterization: a prospective randomized trial

BACKGROUND

The cross-sectional area of the subclavian vein (csSCV) is a crucial factor in the successful catheterization of the subclavian vein. This randomized controlled study investigated the effects of the csSCV on landmark-based subclavian vein catheterization.

METHODS

This study was performed using a two-stage protocol. During stage I, the csSCV was measured in 17 patients placed in the supine, 20° ipsilateral tilt, and 20° contralateral tilt positions in a random order. During stage II, landmark-based subclavian vein catheterization was randomly performed in patients placed in either the supine (group S, n = 107) or the ipsilateral tilt (group I, n = 109) position. The primary outcome measure was the csSCV in stage I and the primary venipuncture success rate in stage II. Secondary outcome measures were the time to successful venipuncture, the total catheterization time, the first-pass success rate, and the incidence of mechanical complications during catheterization.

RESULTS

The csSCV was significantly larger in the ipsilateral tilt than in either the supine or contralateral tilt position (1.01 ± 0.35 vs. 0.84 ± 0.32 and 0.51 ± 0.26 cm², P = .006 and < .001, respectively). The primary venipuncture success rate did not differ significantly between the group S and I (57.0 vs. 64.2%, P = .344). There were also no significant differences in the secondary outcome measures of the two groups.

CONCLUSIONS

The csSCV was significantly larger in patients placed in the ipsilateral tilt than in the supine position, but the difference did not result in better clinical performance of landmark-based subclavian vein catheterization.

TRIAL REGISTRATION

NCT03296735 for stage I ( ClinicalTrials.gov , September 28, 2017) and NCT03303274 for stage II ( ClinicalTrials.gov , October 6, 2017).

Elevated long non-coding RNA LINC00958 was associated with metastasis and unfavorable prognosis in gastric cancer

OBJECTIVE

To investigate the clinicopathological significance of long non-coding LINC00958 and its expression in gastric cancer (GC).

PATIENTS AND METHODS

A total of 200 patients with GC whose sample tissues were enrolled. Total RNA was isolated using the TRIzol method followed by quantitative Real Time-Polymerase Chain Reaction (qRT-PCR) detection of LINC00958 on mRNA level. The correlation was analyzed using Chi-square test, between the LINC00958 expression versus clinicopathological variables, including age, gender, clinical stage, tumor size, TNM classification and overall prognosis. The Kaplan-Meier survival curve was used to assess the prognostic value of LINC00958 expression, after which univariate and multivariate analysis was carried out with the COX proportional hazard analysis.

RESULTS

LINC00958 was shown to be dramatically elevated in GC relative to normal controls. Elevated LINC00958 significantly correlated with lymph nodes metastases, distance metastasis, peritoneal dissemination, and peritumoral tissues infiltration (p<0.05). The Kaplan-Meier survival analysis showed that up-regulated LINC00958 was markedly associated with inferior overall survival (p<0.001). In addition, multivariate analysis highlighted that LINC00958 expression was an independent prognostic factor in GC.

CONCLUSIONS

Our observation revealed that elevated LINC00958 was significantly associated with metastasis and was an independent prognostic factor in GC, indicating that LINC00958 can serve as a novel prognostic predictor in GC.

Effects of nalmefene hydrochloride on TLR4 signaling pathway in rats with lung ischemia-reperfusion injury

OBJECTIVE

To investigate the effect of nalmefene hydrochloride on TLR4 signaling pathway in rats with lung ischemia-reperfusion injury.

MATERIALS AND METHODS

Altogether 64 pure inbred male SD rats were divided into groups A, B, C, and D according to the principle of body weight similarity, with 24 rats in each group. Four groups of rats were respectively twisted on the left testis to establish unilateral testicular torsion rats. Group A was the control group, treated with normal saline, group B was the nalmefene hydrochloride high-dose group, treated with 20 μg/kg of nalmefene hydrochloride, group C was the nalmefene hydrochloride low-dose group, treated with 10 μg/kg of nalmefene hydrochloride, and group D was the sham operation group. Lung tissue was collected 60 h later. Western blotting was used to detect the expression levels of HMGB1, TLR4, CD14, and NF-κB protein, qPCR was used to detect the mRNA expression level, and enzyme-linked immunosorbent assay (ELISA) was used to detect the expression levels of inflammatory factors IL-17, IL-6, and ICAM-1.

RESULTS

The expression levels of HMGB1, TLR4, CD14, NF-κB protein, mRNA, IL-17, IL-6, and ICAM-1 in group A were significantly higher than those in groups B, C, and D (p<0.05), while were significantly lower in group D than in groups B and C (p<0.05), and were significantly lower in group B than in group C (p<0.05).

CONCLUSIONS

Nalmefene hydrochloride can effectively inhibit the signal pathway of TLR4, and can effectively reduce the injury caused by lung ischemia-reperfusion. The large dose is closely related to the good effect, which is worthy of promotion.

Airway management of a patient incidentally diagnosed with Mounier-Kuhn syndrome during general anesthesia

Mounier-Kuhn syndrome (MKS) is a disease characterized by dilation of the trachea and mainstem bronchi. Due to the risk of airway leakage, pulmonary aspiration, and tracheal damage, MKS can be fatal in patients undergoing tracheal intubation. Moreover, MKS may not be diagnosed preoperatively due to its rarity. In this case, a patient undergoing neurosurgery was incidentally diagnosed with MKS during general anesthesia. During anesthesia induction, difficulties in airway management led the anesthesiologist to suspect MKS. Airway leakage was resolved in this case using oropharyngeal gauze packing. Anesthesiologists should be aware of the possibility of MKS and appropriate management of the airways.

Association Between Postoperative Body Temperature and All-Cause Mortality After Off-Pump Coronary Artery Bypass Graft Surgery: A Retrospective Observational Study

BACKGROUND

Inadvertent perioperative hypothermia is common in patients undergoing off-pump coronary artery bypass grafting (OPCAB). We investigated the association between early postoperative body temperature and all-cause mortality in patients undergoing OPCAB.

METHODS

We reviewed the electronic medical records of 1714 patients who underwent OPCAB (median duration of follow-up, 47 months). Patients were divided into 4 groups based on body temperature at the time of intensive care unit admission after surgery (moderate-to-severe hypothermia, <35.5°C; mild hypothermia, 35.5°C-36.5°C; normothermia, 36.5°C-37.5°C; and hyperthermia, ≥37.5°C). Cox proportional hazards models were used to assess the association between body temperature and all-cause mortality. The association between early postoperative changes in body temperature and all-cause mortality was also assessed by dividing the patients into 4 categories according to the body temperature measured at postoperative intensive care unit admission and the average body temperature during the first 3 postoperative days.

RESULTS

Compared to the normothermia group, the adjusted hazard ratios of all-cause mortality were 2.030 (95% confidence interval, 1.407-2.930) in the moderate-to-severe hypothermia group and 1.445 (95% confidence interval, 1.113-1.874) in the mild hypothermia group. Patients who were hypothermic at postoperative intensive care unit admission but attained normothermia thereafter were at a lower risk of all-cause mortality compared to patients who did not regain normothermia (adjusted hazard ratio, 0.631; 95% confidence interval, 0.453-0.878), while they were still at a higher risk of all-cause mortality than those who were consistently normothermic (adjusted hazard ratio, 1.435; 95% confidence interval, 1.090-1.890).

CONCLUSIONS

Even mild early postoperative hypothermia was associated with all-cause mortality after OPCAB. Patients who regained normothermia postoperatively were at lower risk of all-cause mortality compared to those who did not.

Comparative effectiveness of pharmacologic interventions to prevent shivering after surgery: a network meta-analysis

INTRODUCTION

Although many drugs have been studied to prevent postoperative shivering, their comparative effectiveness is unknown. We attempted to assess the comparative effectiveness of the pharmacologic strategies to prevent shivering after surgery including intravenous (IV) and intrathecal (IT) meperidine, IV and IT dexmedetomidine, IV and IT clonidine, nefopam, tramadol, ketamine, and serotonin receptor antagonists.

EVIDENCE ACQUISITION

We implemented a frequentist network meta-analysis of randomized trials. Random effect model was selected according to deviance information criteria. The incidence of moderate or severe shivering and the overall incidence of postoperative shivering were compared in all patients and subgroups of general and spinal anesthesia.

EVIDENCE SYNTHESIS

Seventy trials with 6062 participants were included. All interventions except clonidine IT and dexmedetomidine IT significantly decreased the incidence of moderate or severe shivering. All interventions except clonidine IT significantly decreased the overall incidence of shivering. Nefopam IV was ranked best regarding both the incidence of moderate or severe shivering (odds ratio [OR] 0.04, 95% confidence interval [CI] 0.04-0.25, SUCRA 86.2, moderate quality-evidence), and the overall incidence of shivering (OR 0.07, 95% CI 0.03 to 0.15, SUCRA 85.7, moderate quality-evidence), which was consistent in the subgroups of anesthesia.

CONCLUSIONS

Nefopam was ranked best regarding both severity and incidence of postoperative shivering. In addition to nefopam, tramadol, meperidine IV and IT, and dexmedetomidine IV were ranked high. However, there was significant heterogeneity regarding the individual drug regimen and surgery type, precluding firm conclusion. Further randomized trials are required to compare the efficacy of the drugs with high rank.

Safety and efficacy of propofol anesthesia for pediatric target-controlled infusion in children below 3 years of age: a retrospective observational study

BACKGROUND

Although the requirement of propofol in children is increasing, propofol for induction and maintenance of anesthesia below 3 years old has not been approved in Korea. This study can provide a clinical evidence to increase the range of approval.

RESEARCH DESIGN AND METHODS

We reviewed the medical records of patients below 3 years of age who underwent surgery between September 2013 and December 2016. Safety was evaluated on the basis of vital signs, and laboratory findings and efficacy were evaluated on the basis of the bispectral index (BIS). Adverse events were examined.

RESULTS

A total of 109 patients anesthetized with propofol (propofol group) were compared with 109 patients with volatile anesthetics (volatile group) after propensity score matching. There was a difference in the proportion of patients showing decreased systolic pressure (P < 0.001) and heart rate (P = 0.03), but there was no difference in diastolic pressure (P = 0.238), mean arterial pressure (P = 0.175) during surgery. After surgery, there was no difference in all vital signs and the proportion patients who experienced adverse events of two groups.

CONCLUSIONS

Propofol anesthesia by target-controlled infusion was effective and didn't show serious propofol-related perioperative adverse events.

[Clinical analysis of 314 children with maxillofacial fracture]

A total of three hundred and fourteen patients with maxillofacial fracture under 14 years old were treated at Department of Oral and Maxillofacial Surgery, The First Affiliated Hospital of Zhengzhou University from October 2010 to October 2017 were collected and retrospective analysis was conducted. Age, gender, injury factors, type of fracture, associated injuries and treatment has been analysed. There were 196 male and 118 female. The most common injury factor was fall (148 cases), accounting for 47.1% of all patients. The most common fracture type was mandible fracture (221 cases). Children are not very cooperative with clinical examination, which often leading to misdiagnosis. Age, gender, fracture injury factors, comorbidity and treatment were analyzed to provide the reference for the prevention, diagnosis and treatment.

Utility of Perioperative Lung Ultrasound in Pediatric Cardiac Surgery

Background

Pediatric cardiac patients are at risk for perioperative respiratory insufficiency. The objective of this study was to assess the utility of perioperative lung ultrasound examination in pediatric cardiac surgery.

Methods

In this randomized, controlled trial, children (5 yr old or younger) undergoing cardiac surgery were allocated into a control (n = 61) or intervention (n = 61) group. The control group received only lung ultrasound examinations at the end of surgery and 6 to 12 h after surgery. The intervention group received lung ultrasound examinations and an ultrasound-guided recruitment maneuver depending on ultrasound findings after inducing anesthesia, at the end of surgery, and 6 to 12 h after surgery. Primary outcomes were incidences of intra- and postoperative desaturation, and postoperative pulmonary complications. Multiple comparisons were corrected (P ≤ 0.017) in the primary outcome analysis.

Results

Of the 120 children included in the analysis, postoperative desaturation (64% vs. 27%; P &lt; 0.001; odds ratio [OR], 0.210; 95% CI, 0.097 to 0.456) occurred more in the control group. The incidences of intraoperative desaturation (36% vs. 19%; P = 0.033; OR, 0.406; 95% CI, 0.176 to 0.939) and postoperative pulmonary complications (12% vs. 3%; P = 0.093; OR, 0.271; 95% CI, 0.054 to 1.361) were similar between the groups. Lung ultrasound scores were better in the intervention group than in the control group. Duration of mechanical ventilation was longer in the control group than in the intervention group (38 ± 43 vs. 26 ± 25 h; 95% CI of mean difference, 0 to 25; P = 0.048).

Conclusions

Perioperative lung ultrasound examination followed by ultrasound-guided recruitment maneuver helped decrease postoperative desaturation events and shorten the duration of mechanical ventilation in pediatric cardiac patients.

Comparative efficacy and safety of anticoagulants for prevention of venous thromboembolism after hip and knee arthroplasty

Background and purpose - New oral anticoagulants have been developed to prevent venous thromboembolism (VTE) after knee or hip arthroplasty. Although there have been several network meta-analyses (NMA) to compare different regimens, an NMA including 2 different enoxaparin doses and edoxaban has not been performed. Methods - Standard NMA for fondaparinux, dabigatran, rivaroxaban, apixaban, edoxaban, and enoxaparin was performed. Outcome variables included a composite of total VTE and major/clinically relevant bleeding. The rank probabilities of each treatment outcome were summarized by the surface under the cumulative ranking curve. Results - Fondaparinux, rivaroxaban, and apixaban were associated with a reduced risk of VTE compared with enoxaparin, while dabigatran was not. None of these 3 drugs increased bleeding compared with enoxaparin 30 mg twice daily. However, fondaparinux and rivaroxaban increased bleeding compared with enoxaparin 40 mg once daily, while apixaban did not. Apixaban was even associated with decreased major/clinically relevant bleeding compared with enoxaparin 30 mg twice daily or 40 mg once daily. When edoxaban was included in the NMA, edoxaban decreased VTE and did not increase bleeding compared with enoxaparin. Interpretation - A higher efficacy of fondaparinux and rivaroxaban compared with enoxaparin was associated with increased bleeding tendency, while apixaban was superior to enoxaparin regarding both efficacy and safety. A clustered ranking plot showed that apixaban might be the most preferred regarding efficacy and safety. However, our results were driven by indirect statistical inference and were limited by the heterogeneity of the bleeding outcome definitions, drug initiation and continuation, and different surgery types.