Ultrasound-guided ilioinguinal/iliohypogastric block did not reduce emergence delirium after ambulatory pediatric inguinal hernia repair: a prospective randomized double-blind study.

PURPOSE: Emergence delirium (ED) is a common postoperative complication of ambulatory pediatric surgery done under general anesthesia with sevoflurane. However, perioperative analgesic techniques have been shown to reduce sevoflurane-induced ED. The primary objective of this investigation was to examine whether an ultrasound-guided ilioinguinal/iliohypogastric (II/IH) nerve block for ambulatory pediatric inguinal hernia repair could reduce the incidence of sevoflurane-induced ED. METHODS: The subjects of this prospective randomized double-blind study were 40 boys ranging in age from 1 to 6 years, who were scheduled to undergo ambulatory inguinal hernia repair. The patients were randomized to either receive or not to receive an ultrasound-guided II/IH nerve block (Group B and Group NB, respectively). General anesthesia was maintained with sevoflurane and nitrous oxide. The primary outcome assessed was ED, evaluated using the Pediatric Anesthesia Emergence Delirium (PAED) scale 30 min after emergence from general anesthesia. The secondary outcomes assessed were postoperative pain, evaluated using the Behavioral Observational Pain Scale (BOPS), and the amount of intra-operative sevoflurane given. RESULTS: The median PAED scale scores did not differ between Groups B and NB at 30 min (P = 0.41). BOPS scores also did not differ significantly between the groups, but the mean amount of intraoperative sevoflurane given was significantly lower in Group B than in Group NB (P < 0.01). CONCLUSIONS: Ultrasound-guided II/IH nerve block for ambulatory pediatric inguinal hernia repair did not reduce ED, but it did decrease the amount of intra-operative sevoflurane needed. CLINICAL TRIAL REGISTRATION: UMIN000008586.

Measurement of Hymenoptera venom specific IgE by the IMMULITE 3gAllergy in subjects with negative or positive results by ImmunoCAP.

BACKGROUND: Patients may receive negative results from a specific IgE (sIgE) test such as the ImmunoCAP (CAP) despite a documented history of systemic reaction to a Hymenoptera sting. Thus, further testing may be required using another serological method or venom skin prick tests to confirm allergy diagnosis and correct species. OBJECTIVE: To evaluate the sensitivity and the specificity of CAP and IMMULITE 3gAllergy (IMMULITE) for detecting sIgE to Paper wasp (WA) and Yellow Jacket (YJ) venoms using patient clinical history as the comparator. METHODS: Sera from 70 participants with a history of systemic reactions (SR) to WA and/or YJ stings were tested using CAP and IMMULITE. Fifty participants from this group had negative results on CAP. To assess specificity, sera from 71 participants who had never experienced either a WA or YJ sting were tested using CAP and IMMULITE. Fifty participants from this group tested positive using CAP. RESULTS: In participants with a history of systemic reaction to a Hymenoptera sting, yet who tested negative for WA and/or YJ sIgE according to CAP, the positivity rate according to IMMULITE was 20-42% using 0.10 IU(A)/mL as the limit of detection (LoD), per the manufacturer's specification. When the LoD for CAP (0.35 IU(A)/mL) was applied to the IMMULITE results, positivity according to IMMULITE was 14-26%. Overall, sensitivity, specificity, and agreement with SR were greater for IMMULITE than for CAP. For YJ: sensitivity (IMMULITE:CAP), 42.8%:28.5%; specificity, 53.5%:39.4%; agreement, 48.2%:34%. For WA, sensitivity (IMMULITE:CAP), 58.6%:28.5%; specificity, 49.3%:47.8%; agreement, 43.9%:38.3%. CONCLUSION: The IMMULITE performed well for detecting sIgE to Hymenoptera venom.

[Anesthetic management of a child with congenital myotonic dystrophy and perioperative hypoxia].

A 7-year-old boy with congenital myotonic dystrophy (MD) and developmental retardation underwent an emergency surgery for strangulation ileus. General anesthesia was maintained using sevoflurane and fentanyl. While intraoperative arterial blood pressure, pulse and rectal temperature remained stable, the arterial blood oxygenation gradually deteriorated during the procedure. We suspected the existence of atelectasis or some other obstructive lung lesion to be the underlying cause, and performed bronchoscopic examination which revealed a collapse of the left main bronchus. Therefore, postoperative mechanical ventilation was continued for several hours in the ICU. According to the postoperative computed tomography, the left main bronchus was sandwiched between the aortic arch and thoracic vertebra. It has been reported that MD patients have a risk of perioperative pulmonary complications, particularly in those who have severe muscular disability undergoing upper abdominal surgery. These risk factors combined with bronchial stenosis could have caused intraoperative hypoxia in our patient. We conclude that when a severe MD patient is scheduled for an upper abdominal surgery, mechanical ventilation should be considered until spontaneous recovery from muscle relaxants occurs. Also, since MD has been related to malignant hyperthermia, total intravenous anesthesia, possibly combined with regional blockade, is a preferable method of anesthesia for such patients.

[Massive hemorrhage during cesarean section for placenta accreta].

A 37-year-old multigravida presented at 37 weeks of gestation with low-lying placenta and highly suspected placenta accreta. The placenta adhered widely to the anterior wall of the uterus. Therefore, a longitudinal incision of the uterine corpus at the thinnest part of the placenta was made during surgery. Concurrent with the incision, rapid and massive hemorrhage occurred. After the delivery of the baby and confirmation of the placental adhesion, the hysterectomy was started promptly. The bladder adhered strongly to the uterus, and was injured during the dissection. The total volume of hemorrhage was estimated to be 24,480 ml (including amniotic fluid and urine). No arterial clamp for hemostasis was used during the procedure. The patient was discharged on the 12th postoperative day with no sequela. The pathological diagnosis was placenta percreta. Placenta accreta is a rare disease with a high mortality rate. The hemorrhage becomes difficult to control in case of injury of placenta accreta. The hysterectomy following cesarean section also becomes complicated. Bladder injury is one of the complications of the cesarean hysterectomy which makes the hemorrhage greader. In conclusion, when placenta accreta is suspected a strategy to minimize blood loss during surgery should be discussed by a multidisciplinary team.