Airway management in children with COVID-19

The novel coronavirus disease (COVID-19) may result in acute respiratory distress syndrome and respiratory failure, necessitating mechanical respiratory support. Healthcare professionals are exposed to a particularly high risk of contracting the virus while providing resuscitation and respiratory support, which may in turn result in grave consequences and even death. Although COVID-19 has been shown to cause milder disease in children, paediatricians and intensivists who provide care for children must be prepared to provide optimal respiratory support without putting themselves or other medical, nursing, and paramedical staff at undue risk. We propose an airway management approach that is especially relevant in the current COVID-19 pandemic and provides instructions for: (1) Elective intubation for respiratory failure; and (2) Emergency intubation during cardiopulmonary resuscitation. To minimise risk, intubation methods must be kept as straightforward as possible and should include the provision of appropriate personal protection and equipment to healthcare workers. We identify two key considerations: that bag-mask ventilation should be avoided if possible and that bacterial and viral filters should be placed in the respiratory circuit. Our novel approach provides a framework for airway management that could benefit paediatric critical care practitioners who provide care for any children with a novel viral illness, with a focus on infection prevention during high-risk airway management procedures.

Cardiovascular collapse due to right heart failure following ethanol sclerotherapy: a case report

Ethanol sclerotherapy for the treatment of low-flow vascular malformations can cause catastrophic cardiopulmonary complications, including pulmonary embolism and pulmonary hypertension, that can result in right heart failure and fatal arrhythmias, leading to death. We here report a case of abrupt cardiovascular collapse that developed immediately following ethanol sclerotherapy in 31-year-old female patient who had a large arteriovenous malformation in her leg. Anesthesiologists should be aware of the fatal cardiopulmonary complications that are associated with ethanol sclerotherapy and consider the use of invasive hemodynamic monitoring, such as pulmonary artery pressure monitoring, when large doses of ethanol are required.

The effects of sevoflurane with propofol and remifentanil on tracheal intubation conditions without neuromuscular blocking agents

Background

Propofol and remifentanil are used for tracheal intubation in the absence of neuromuscular blocking agents. We hypothesized that the addition of sevoflurane to propofol and remifentanil would improve intubation conditions and provide hemodynamic stability.

Methods

Seventy-six patients scheduled for elective surgery were randomly allocated to be ventilated with either 4% (group I) or 7% sevoflurane (group II) after propofol injection (2 mg/kg). All patients received remifentanil (1 µg/kg) 30 seconds after administration of propofol. Ninety seconds after remifentanil was given, laryngoscopy and tracheal intubation were performed. Intubation conditions and hemodynamic changes were evaluated.

Results

The overall incidence of clinically acceptable intubation conditions was significantly higher in group II (92%) than group I (58%) (P = 0.001). Scores for vocal cord position, coughing, and limb movement were significantly better in group II (P < 0.05). Mean blood pressure remained significantly lower than the pre-induction level throughout the investigation in both groups (P < 0.001), but there was no incidence of bradycardia or hypotension requiring treatment.

Conclusions

Tracheal intubation without neuromuscular blocking agents can be achieved safely and reliably by adding 7% sevoflurane to propofol (2 mg/kg) and remifentanil (1 µg/kg).

Comparison of the effects of propofol and pentobarbital on hydrogen peroxide-stimulated hepatic SNU761 cells

BACKGROUND

Propofol and barbiturates are both known to protect cells of several organs against ischemia/reperfusion injury, but there are few reports on any possible protective effects on human hepatocytes. We investigated the activities of both agents on human hepatic SNU761 cells under hydrogen peroxide (H(2)O(2))-induced oxidative stress.

METHODS

To determine whether propofol and pentobarbital protect hepatocytes from H(2)O(2)-induced toxicity, we used SNU761 cells, a human hepatocellular carcinoma (HCC) cell line. Cells were pretreated with different dosages (1, 10, 50 microM) of propofol or pentobarbital (1, 10, 50, 100, 400 microM) 30 min before H(2)O(2) application. Lactate dehydrogenase (LDH) was measured to assess and quantify cell death. To determine the nature of cell death, treated hepatocytes were doubly stained with fluorescein isothiocyanate (FITC)-labeled Annexin V and propidium iodide (PI), and analyzed by flow cytometry.

RESULTS

Pretreatment with propofol, but not pentobarbital, suppressed H(2)O(2)-induced LDH release. In Annexin V-FITC/PI binding analysis, propofol decreased the number of necrotic and late apoptotic cells, but no significant decreases in such cell numbers were seen when pentobarbital was used.

CONCLUSIONS

Unlike pentobarbital, propofol, at clinical concentrations, protected SNU-761 HCC cells against oxidative stress.

Effects of propofol and etomidate on hydrogen peroxide-induced oxidative damage in hepatocyte

BACKGROUND

The present investigation was undertaken to evaluate the protective effect of propofol and etomidate against hydrogen peroxide (H2O2) induced oxidative damage in human hepatic SNU761 cells by measuring lactate dehydrogenase (LDH).

METHODS

The cell line of human hepatocellular carcinoma was grown for 24 hours in dissociated cell culture. They were divided into eight groups: negative control (NC) group with no drug administration, positive control (PC) group with H2O2 250 micrometer and other groups pretreated with propofol (P; 1, 10, 50 micrometer) or etomidate (ET; 1, 10, 50 micrometer) followed H2O2 administration. After 7 hours, cell death was assessed by morphology under the light microscope and quantified by measuring the LDH in the culture media.

RESULTS

In the light microscopic findings, the intact cells were increased in all three propofol groups compared to group PC. H2O2-induced LDH production was also significantly suppressed in all three propofol groups compared to group PC (P < 0.001). There were no significant differences in the microscopic findings and LDH production between the etomidate groups and group PC.

CONCLUSIONS

These results suggest that the propofol has protective effect on the hepatocyte against H2O2-induced oxidative stress.

Protective Effect of Isoflurane Anesthesia on Noise-Induced Hearing Loss in Mice

HYPOTHESIS/OBJECTIVES

To examine the protective effect of general anesthesia with isoflurane against noise-induced hearing loss in mice.

STUDY DESIGN

Animal study using noise stimulation and measurement of hearing in BALB/c mice.

METHODS

Mice were exposed to 122 dB peak equivalent sound pressure level click noise for 3 hours per day for 3 consecutive days with or without anesthesia using isoflurane. Hearing levels were measured and hair cell survival ratio was observed.

RESULTS

In mice without anesthesia, hearing threshold increased after noise stimulation (73.7 dB hearing level [HL]) and persisted for at least 1 month. However, in mice exposed to noise under anesthesia, hearing loss was less severe (44.1 dB HL) and had recovered more (26.5 dB HL) by one month. Histological examination showed hair cell survival was higher in anesthetized compared to non-anesthetized mice.

CONCLUSION

These data indicate isoflurane general anesthesia protects against noise-induced hearing loss and tissue damage in mice.

Subacute hepatic failure after the perinatal period with haemochromatotic siderosis at the age of 11 months: an unusual perspective on neonatal haemochromatosis

Neonatal haemochromatosis is a rare disease characterized by the early onset of liver failure, a rapidly deteriorating clinical course and high mortality. An unusual case is presented of subacute hepatic failure in which autopsy findings at the age of 11 mo showed a haemochromatotic pattern of siderosis. Despite the similarity in the pattern of iron distribution to neonatal haemochromatosis, the clinical course was highly atypical in that the infant had later and milder presentation at 1 mo of age and slow progression into liver failure. This case illustrates the heterogeneous nature of the haemochromatotic phenotype in newborns and infants.

CONCLUSION

The entity "neonatal haemochromatosis" may reflect a spectrum of diseases with diverse aetiologies. Fulminant liver disease in the newborn period can also result in similar pattern of iron distribution.