Differences in prevalence of self-reported oral hypofunction between older adult patients with rheumatoid arthritis and the general older population: A cross-sectional study using propensity score matching.

OBJECTIVE: To examine the association between rheumatoid arthritis (RA) and oral hypofunction (OHF) using propensity score matching (PSM) to adjust for differences between older adults with RA and the general older adult population. METHODS: We conducted a cross-sectional survey among 189 older adults with RA in 2019 (mean age, 71.9 ± 3.6) and 47 178 independent older adult residents in 2016 (mean age, 71.6 ± 4.0), respectively. The questionnaire covered information on socio-demographic characteristics and OHF for both groups. Age, sex, educational level and smoking history were used to determine PSM. Prevalence ratios (PRs) and 95% confidence intervals (CIs) of self-reported OHF (fewer remaining teeth, decreased masticatory function, deterioration of swallowing function and oral dryness) were estimated using Poisson regressions. RESULT: OHF was observed in 44.4% of patients with RA and 27.5% of residents. Before PSM, the prevalence of OHF among patients with RA was higher than that of residents (PR, 1.75; 95% CI, 1.50-2.05). After PSM, there were 189 patients with RA and residents, and the prevalence of OHF among patients with RA was still higher (PR, 1.61; 95% CI, 1.22-2.13). Poisson regression showed that the prevalence of 19 or fewer teeth (PR, 1.06; 95% CI, 0.82-1.36), difficulties eating tough foods (PR, 1.18; 95% CI, 0.90-1.55), difficulties swallowing tea or soup (PR, 1.77; 95% CI, 1.19-2.63), and dry mouth (PR, 2.79; 95% CI, 1.90-4.07) was higher among patients with RA than residents. CONCLUSION: Compared with the general older adult population, patients with RA have a higher prevalence of self-reported OHF.

Indirect laryngoscopy is more effective than direct laryngoscopy when tracheal intubation is performed by novice operators: a systematic review, meta-analysis, and trial sequential analysis.

PURPOSE: We sought to perform a systematic review and meta-analysis to determine whether indirect laryngoscopy has an advantage over direct laryngoscopy in terms of the tracheal intubation rate, glottic visualization, and intubation time when used by novice operators. METHODS: We extracted adult prospective randomized trials comparing tracheal intubation with indirect vs direct laryngoscopy in novice operators from electronic databases. We extracted the following data from the identified studies: success rate, glottic visualization, and intubation time. Data from each trial were combined via a random-effects model to calculate the pooled relative risk (RR) or weighted mean difference (WMD) with a 95% confidence interval (CI). We also performed a trial sequential analysis. RESULTS: We included 15 articles (17 trials) comprising 2,290 patients in the systematic review. Compared with the direct laryngoscopy, indirect laryngoscopy improved success rate (RR, 1.15; 95% CI, 1.07 to 1.24; P = 0.0002; I2 = 88%), glottic visualization (RR, 1.76; 95% CI, 1.36 to 2.28; P < 0.001; I2 = 85%), and intubation time (WMD, -9.06 sec; 95% CI, -16.4 to -1.76; P = 0.01; I2 = 98%) in tracheal intubation. Trial sequential analysis showed that the total sample size was sufficient to analyze the success rate and intubation time. CONCLUSION: In this systematic review, we found that the tracheal intubation success rate, glottic visualization, and intubation time were improved when novice operators used indirect laryngoscopy rather than direct laryngoscopy. Trial sequential analysis results indicated that the sample size was sufficient for examining the success rate and intubation time. STUDY REGISTRATION: PROSPERO (CRD42022309045); first registered 4 September 2022.

RéSUMé: OBJECTIF: Nous avons cherché à réaliser une revue systématique et une méta-analyse pour déterminer si la laryngoscopie indirecte présente un avantage par rapport à la laryngoscopie directe en termes de taux de succès d'intubation trachéale, de visualisation glottique et de temps d'intubation lorsqu'elle est utilisée par des opératrices et opérateurs novices. MéTHODE: Nous avons extrait des études randomisées prospectives chez l'adulte comparant l'intubation trachéale avec une laryngoscopie indirecte vs directe réalisée par des opérateurs et opératrices novices à partir de bases de données électroniques. Nous avons extrait les données suivantes des études identifiées : taux de succès, visualisation glottique et temps d'intubation. Les données de chaque étude ont été combinées au moyen d'un modèle à effets aléatoires pour le calcul du risque relatif (RR) groupé ou de la différence moyenne pondérée (DMP) avec un intervalle de confiance (IC) de 95 %. Nous avons également réalisé une analyse séquentielle des études. RéSULTATS: Nous avons inclus 15 articles (17 études) portant sur 2290 patient·es dans notre revue systématique. Par rapport à la laryngoscopie directe, la laryngoscopie indirecte a amélioré le taux de succès (RR, 1,15; IC 95 %, 1,07 à 1,24; P = 0,0002; I2 = 88 %), la visualisation glottique (RR, 1,76; IC 95 %, 1,36 à 2,28; P < 0,001; I2 = 85 %), et le temps d'intubation (DMP, −9,06 s; IC 95 %, −16,4 à −1,76; P = 0,01; I2 = 98 %) pour l'intubation trachéale. L'analyse séquentielle des études a montré que la taille totale de l'échantillon était suffisante pour analyser le taux de succès et le temps d'intubation. CONCLUSION: Dans cette revue systématique, nous avons constaté que le taux de succès de l'intubation trachéale, la visualisation glottique et le temps d'intubation étaient améliorés lorsque les opératrices et opérateurs novices utilisaient la laryngoscopie indirecte plutôt que la laryngoscopie directe. L'analyse séquentielle des études a montré que la taille totale de l'échantillon était suffisante pour analyser le taux de succès et le temps d'intubation. ENREGISTREMENT DE L'éTUDE: PROSPERO (CRD42022309045); première inscription le 4 septembre 2022.

Lipopolysaccharide Priming Exacerbates Anaphylatoxin C5a-Induced Anaphylaxis in Mice.

Anaphylaxis is a serious allergic or hypersensitivity reaction with a sudden onset that can be life-threatening or fatal. Previous studies have highlighted two pathways of anaphylaxis in mice. One is the classical immunoglobulin E (IgE)-mediated pathway that involves mast cells and histamine. The other is an alternative IgG-mediated pathway that involves basophils, monocytes/macrophages, neutrophils, and the platelet-activating factor (PAF). However, little is known about the mechanism by which complement anaphylatoxins contribute to the induction of anaphylaxis. Infection is a cofactor that potentially amplifies the risk of anaphylaxis. Here, we showed that priming with a lipopolysaccharide (LPS), which mimics bacterial infection, exacerbates anaphylatoxin C5a-induced anaphylaxis in mice. LPS plus C5a-induced anaphylaxis was mediated by histamine and lipid mediators, especially PAF. Cell depletion experiments demonstrated that LPS plus C5a-induced anaphylaxis depended on monocytes/macrophages, basophils, and neutrophils. These results suggest that C5a is a potent inducer of anaphylaxis in bacterial infections. Remarkably, the molecular and cellular mediators of LPS plus C5a-induced anaphylaxis are mostly shared with IgE- and IgG-mediated anaphylaxis. Therefore, combined inhibition of histamine and PAF may be beneficial as a second-line treatment for severe anaphylaxis.

Successful Tracheal Intubation With Airway Scope After Failure With McGrath.

The use of video laryngoscopy is growing in patients with anatomical factors suggestive of a difficult airway. This case report describes the successful tracheal intubation of a 54-year-old female patient with limited mouth opening scheduled for third molar extraction under general anesthesia. The Airway scope (AWS) along with a gum-elastic bougie was used to secure the airway after failed direct laryngoscopy and video laryngoscopy using the McGrath MAC with an X-blade. The AWS has a J-shaped structure in which the blade approximates the curvature of the pharynx and larynx. This blade shape makes it easy to match the laryngeal axis with the visual field direction, enabling successful tracheal intubation even for patients with limited mouth opening. A major key to successful video laryngoscopy is to select a video laryngoscope based on the anatomical characteristics of patients with a difficult airway.

Comparison of Indirect and Direct Laryngoscopes in Pediatric Patients with a Difficult Airway: A Systematic Review and Meta-Analysis.

This meta-analysis was performed to determine whether an indirect laryngoscope is more advantageous than a direct laryngoscope for tracheal intubation in the setting of a difficult pediatric airway. Data on the intubation failure and intubation time during tracheal intubation were extracted from prospective and retrospective studies identified through a comprehensive literature search. Data from 10 individual articles (11 trials) were combined, and a DerSimonian and Laird random-effects model was used to calculate either the pooled relative risk (RR) or the weighted mean difference (WMD) and the corresponding 95% confidence interval (CI). Meta-analysis of the 10 articles indicated that the intubation failure of tracheal intubation with an indirect laryngoscope was not significantly different from that of a direct laryngoscope in patients with a difficult airway (RR 0.86, 95% CI 0.51-1.46; p = 0.59; Cochrane's Q = 50.5; I2 = 82%). Intubation time with an indirect laryngoscope was also similar to that with a direct laryngoscope (WMD 4.06 s; 95% CI -1.18-9.30; p = 0.13; Cochrane's Q 39.8; I2 = 85%). In conclusion, indirect laryngoscopes had the same intubation failure and intubation time as direct laryngoscopes in pediatric patients with a difficult airway. Currently, the benefits of indirect laryngoscopes have not been observed in the setting of a difficult pediatric airway.

Anesthetic Management of a Patient With Spinocerebellar Ataxia Type 1.

Spinocerebellar ataxia type 1 (SCA1) is one of the autosomal dominant spinocerebellar degeneration (SCD) diseases characterized by progressive cerebellar ataxia, muscle atrophy, and peripheral neuropathy. We report the management of a 43-year-old man with SCA1 who underwent general anesthesia for open reduction and internal fixation of a mandibular fracture. Although anesthesia-induced vocal cord paralysis has been reported in patients with SCD, nasotracheal intubation was performed uneventfully with video laryngoscope. After taking into consideration the increased risk of postoperative respiratory depression in patients with SCD, rocuronium dosing was titrated carefully, and fentanyl was not used during surgery. Preparation for an anticipated difficult airway and avoiding significant respiratory depression are crucial when providing general anesthesia for patients with SCA1.

Severe Bleeding During Orthognathic Surgery for a Noonan Syndrome Patient.

Noonan syndrome (NS) is a genetic disorder characterized by craniofacial dysmorphism, chest deformities, congenital heart defects, and bleeding disorders. Although patients with NS have a high prevalence of orofacial deformity, few reports are available on their anesthetic management during orthognathic surgery. This case report describes a 31-year-old female with NS, anemia, hypertrophic cardiomyopathy, and mild mitral valve regurgitation who experienced severe bleeding during orthognathic surgery. After treating her anemia with oral iron therapy and subcutaneous epoetin ß, 4 units of autologous blood was deposited prior to surgery. General anesthesia was induced with remifentanil and propofol and maintained with sevoflurane, remifentanil, and fentanyl. Despite mild hypotensive anesthesia (targeted mean arterial pressure of 65 mm Hg) with nitroglycerine and intravenous tranexamic acid for bleeding, adequate hemostasis was difficult to achieve and led to severe blood loss (1442 mL). Therefore, the 4 units of autologous blood and 2 units of packed red blood cells were transfused. Her postoperative course proceeded uneventfully without abnormal postoperative bleeding. Because patients with NS can have difficulty with hemostasis, vascular malformations, and fragile blood vessels, extensive hematologic evaluation and thorough preparation for unexpected bleeding are crucial to accomplish orthognathic surgery.

Nasal protection strategy reduces the incidence of nasal pressure injuries during nasotracheal intubation: Meta-analysis with trial sequential analysis.

BACKGROUND: Nasal pressure injury is a serious problem during nasotracheal intubation. We performed this systematic review and meta-analysis to determine whether use of a nasal protection strategy (a protective dressing or a modified fixation method for the tracheal tube) reduces the incidence of nasal pressure injury during nasotracheal intubation. METHODS: Literature searches were performed using three electronic databases. Data from each of the eligible trials were combined, and calculations were made using DerSimonian and Laird random effects models. The pooled effect estimates for nasal pressure injury were evaluated using the relative risk and 95% confidence interval, the Cochrane Q statistic, and the I2 statistic. We also performed trial sequential analysis (TSA) to assess sensitivity to prevent type I error. We separated patients into subgroups to analyze the incidence of nasal pressure injury according to whether a protective dressing or a modified fixation method for the tracheal tube was used. RESULTS: The literature search yielded five eligible trials. Meta-analysis of these trials showed that a nasal protection strategy significantly reduced the incidence of nasal pressure injury during nasotracheal intubation (relative risk (RR) 0.34; 95% confidence interval (CI) 0.21-0.56; P < .0001; Cochrane's Q = 5.86, I2 = 32%). The TSA boundary for futility could not be calculated because of an insufficient sample size. In subgroup analysis, both methods significantly reduced the incidence of nasal pressure injury during nasotracheal intubation. CONCLUSIONS: The findings of this meta-analysis suggest that a nasal protection strategy significantly reduces the incidence of nasal pressure injury during nasotracheal intubation. During nasotracheal intubation, the use of a protective dressing or modified fixation method for the tracheal tube can prevent to the incidence of nasal pressure injuries. However, the number of samples in our meta-analysis was too small for TSA and further studies are required. TRIALS REGISTRATION: PROSPERO (International Prospective Register of Systematic Reviews; registration number 252091).

Effectiveness of Indirect and Direct Laryngoscopes in Pediatric Patients: A Systematic Review and Network Meta-Analysis.

This research aimed to produce a coherent ranking of the effectiveness of intubation devices in pediatric patients using network meta-analysis (NMA). We searched the electric databases for prospective randomized studies that compared different tracheal intubation devices in pediatric patients. The primary outcome was intubation failure at the first attempt. Secondary outcomes were glottic visualization and intubation time. The statistical analysis performed used DerSimonian and Laird random-effects models. Frequentist network meta-analysis was conducted, and network plots and network league tables were produced. Subgroup analysis was performed after excluding rigid-fiberscope-type indirect laryngoscopes. Thirty-four trials comparing 13 devices were included. Most laryngoscopes had the same intubation failure rate as the Macintosh reference device. Only the Truview PCD™ had a significantly higher intubation failure rate than the Macintosh (odds ratio 4.78, 95% confidence interval 1.11-20.6) The highest-ranking laryngoscope was the Airtaq™ (P score, 0.90), and the AirwayScope™, McGrath™, and Truview EVO2™ ranked higher than the Macintosh. The Bullard™ had the lowest ranking (P score, 0.08). All laryngoscopes had the same level of glottic visualization as the Macintosh and only the C-MAC™ had a significantly shorter intubation time. Intubation time was significantly longer when using the GlideScope™, Storz DCI™, Truview PCD™, or Bullard™ compared with the Macintosh. P score and ranking of devices in the subgroup analyses were similar to those in the main analysis. We applied NMA to create a consistent ranking of the effectiveness of intubation devices in pediatric patients. The findings of NMA suggest that there is presently no laryngoscope superior to the Macintosh laryngoscope in terms of tracheal intubation failure rate and glottic visualization in pediatric patients.

General Anesthetic Management of a Patient With Kleine-Levin Syndrome.

Kleine-Levin syndrome (KLS) is a rare sleep disorder characterized by periodic hypersomnia and behavioral or cognitive disturbances. Although prolonged emergence from general anesthesia and postoperative hypersomnia may occur in a patient with KLS, there is little information about the safe anesthetic management of these patients. We describe the case of a 22-year-old female previously diagnosed with KLS who was scheduled to have her third molars extracted under general anesthesia. Because the patient had symptoms of periodic hypersomnia and hyperphagia, the surgery was scheduled during a KLS crisis interval. General anesthesia was induced with propofol, remifentanil, and rocuronium, and maintained with desflurane and remifentanil. To prevent overuse of anesthetic agents, an electroencephalogram (EEG)-based depth of anesthesia monitor (SedLine; Masimo Corporation) was used intraoperatively. A neuromuscular monitor was also used to carefully titrate use of a neuromuscular blocking agent. After surgery, sugammadex was administered, and the patient quickly emerged within 10 minutes, as also confirmed by the EEG monitor. She had no KLS recurrence postoperatively. When anesthetizing patients with KLS, an EEG-based depth of anesthesia monitor and neuromuscular monitor may be warranted to ensure complete emergence from general anesthesia. In addition, elective surgery should be planned during crises intervals.

Airtraq® versus GlideScope® for tracheal intubation in adults: a systematic review and meta-analysis with trial sequential analysis.

PURPOSE: In recent years, various types of indirect laryngoscopes have been developed. Nevertheless, no conclusions have been drawn about which type of indirect laryngoscope is most effective for tracheal intubation. We performed a systematic review and meta-analysis to determine whether the Airtraq® or the GlideScope® is more effective for tracheal intubation. METHODS: We extracted studies of adult prospective randomized trials comparing tracheal intubation between the Airtraq and GlideScope. An electronic database was used to extract the studies included in our meta-analysis. We extracted the following data from the identified studies: success rate, glottic visualization, and intubation time. Data from each trial were combined via a random-effects model for calculation of pooled relative risk (RR) or weighted mean difference (WMD) with a 95% confidence interval (CI). We also performed trial sequential analysis. RESULTS: We included eight trials comprising 571 patients for review. Compared with the GlideScope, Airtraq did not improve success rate, glottic visualization, or intubation time in tracheal intubation (success rate: RR, 0.98; 95% CI, 0.91 to 1.05; P = 0.58; I2 = 65%; glottic visualization: RR, 1.07; 95% CI, 0.88 to 1.29; P = 0.69; I2 = 64%; and intubation time: WMD, 1.4 seconds ; 95% CI, -6.2 to 9.1; P = 0.72; I2 = 96%). The quality of evidence was graded as "very low." Trial sequential analysis showed that total sample size did not reach the required information size for all parameters. CONCLUSION: In this meta-analysis, use of the Airtraq indirect laryngoscope did not result in improved success rate, glottic visualization, or intubation time in tracheal intubation compared with the GlideScope. Trial sequential analysis suggests that further studies are necessary to confirm these findings.

RéSUMé: OBJECTIF: Ces dernières années, différents types de laryngoscopes indirects ont été mis au point. Néanmoins, aucune conclusion n'a été tirée sur le type de laryngoscope indirect le plus efficace pour l'intubation trachéale. Nous avons réalisé une revue systématique et une méta-analyse pour déterminer quel dispositif était le plus efficace pour l'intubation trachéale, soit l'Airtraq® ou le GlideScope®. MéTHODE: Nous avons extrait les études portant sur les essais randomisés prospectifs chez l'adulte comparant l'intubation trachéale avec l'Airtraq ou le GlideScope. Une base de données électronique a été utilisée pour extraire les études incluses dans notre méta-analyse. Nous avons extrait les données suivantes des études identifiées : taux de réussite, visualisation glottique et temps d'intubation. Les données de chaque étude ont été combinées au moyen d'un modèle à effets aléatoires pour le calcul du risque relatif (RR) groupé ou de la différence moyenne pondérée (DMP) avec un intervalle de confiance (IC) de 95 %. Nous avons également réalisé une analyse séquentielle des études. RéSULTATS: Nous avons inclus huit études portant sur 571 patients pour notre revue. Par rapport au GlideScope, l'Airtraq n'a pas amélioré le taux de réussite, la visualisation glottique ou le temps d'intubation pour l'intubation trachéale (taux de réussite : RR, 0,98; IC 95 %, 0,91 à 1,05; P = 0,58; I2 = 65 %; visualisation glottique : RR, 1.07; IC 95 %, 0,88 à 1,29; P = 0,69; I2 = 64 %; et temps d'intubation : DMP, 1,4 seconde; IC 95 %, -6,2 à 9,1; P = 0,72; I2 = 96 %). La qualité des données probantes a été classée comme « très faible ¼. L'analyse séquentielle des études a montré que la taille totale de l'échantillon n'atteignait pas la taille d'information requise pour tous les paramètres. CONCLUSION: Selon cette méta-analyse, l'utilisation du laryngoscope indirect Airtraq® n'entraîne pas d'amélioration du taux de réussite, de la visualisation glottique ou du temps d'intubation pour une intubation trachéale par rapport au GlideScope®. L'analyse séquentielle des études suggère que d'autres études sont nécessaires pour confirmer ces résultats.

Melatonin MT2 receptor is expressed and potentiates contraction in human airway smooth muscle.

Nocturnal asthma is characterized by heightened bronchial reactivity at night, and plasma melatonin concentrations are higher in patients with nocturnal asthma symptoms. Numerous physiological effects of melatonin are mediated via its specific G protein-coupled receptors (GPCRs) named the MT1 receptor, which couples to both Gq and Gi proteins, and the MT2 receptor, which couples to Gi. We investigated whether melatonin receptors are expressed on airway smooth muscle; whether they regulate intracellular cyclic AMP (cAMP) and calcium concentrations ([Ca2+]i), which modulate airway smooth muscle tone; and whether they promote airway smooth muscle cell proliferation. We detected the mRNA and protein expression of the melatonin MT2 but not the MT1 receptor in native human and guinea pig airway smooth muscle and cultured human airway smooth muscle (HASM) cells by RT-PCR, immunoblotting, and immunohistochemistry. Activation of melatonin MT2 receptors with either pharmacological concentrations of melatonin (10-100 µM) or the nonselective MT1/MT2 agonist ramelteon (10 µM) significantly inhibited forskolin-stimulated cAMP accumulation in HASM cells, which was reversed by the Gαi protein inhibitor pertussis toxin or knockdown of the MT2 receptor by its specific siRNA. Although melatonin by itself did not induce an initial [Ca2+]i increase and airway contraction, melatonin significantly potentiated acetylcholine-stimulated [Ca2+]i increases, stress fiber formation through the MT2 receptor in HASM cells, and attenuated the relaxant effect of isoproterenol in guinea pig trachea. These findings suggest that the melatonin MT2 receptor is expressed in ASM, and modulates airway smooth muscle tone via reduced cAMP production and increased [Ca2+]i.

Anesthetic Management of a Patient With Ring 18 Syndrome.

Ring 18 syndrome or ring chromosome 18 is an extremely rare genetic disorder involving the fusion of the 18th chromosomal ends to form a ring, often with genetic material loss of varying degrees. Although clinical presentation can be extremely variable, characteristic features usually include craniofacial malformations, delayed development, hypotonia, and other skeletal and congenital heart defects. We report the management of a 20-year-old male with ring chromosome 18 who underwent general anesthesia for dental treatment. Clinical manifestations for this patient included intellectual disability, short stature, hypertelorism, flat nasal bridge, micrognathia, a "carp-shaped" mouth, and aortic and pulmonary valve regurgitation. Although mask ventilation and oral intubation were easily performed, nasal intubation was difficult because of rhinostenosis. When providing general anesthesia for a patient with ring chromosome 18, anesthesiologists should evaluate the patient preoperatively for congenital heart defects and prepare for a potential difficult airway.

Patient satisfaction with deep versus light/moderate sedation for non-surgical procedures: A systematic review and meta-analysis.

BACKGROUND: Deep sedation relieves a patient's anxiety and stress during the procedure by inducing patient unconsciousness. However, it remains unclear whether deep sedation actually improves patient satisfaction with the procedure. Therefore, we performed a systematic review and meta-analysis to compare the satisfaction of patients undergoing deep sedation with that of those undergoing light/moderate sedation during non-surgical procedures. METHODS: A comprehensive literature search was performed using electronic databases (search until September 2020). The primary outcome was whether patient satisfaction was higher after deep sedation or light/moderate sedation. The secondary outcome was the relative safety of deep sedation compared with light/moderate sedation in terms of oxygen saturation, systolic blood pressure, and heart rate. The tertiary outcomes were the relative procedure and recovery times for deep versus light/moderate sedation.Data from each of the trials were combined, and calculations were made using DerSimonian and Laird random effects models. The pooled effect estimates for patient satisfaction were evaluated using relative risk (RR) with the 95% confidence interval (CI). The pooled effect estimates for continuous data are expressed as weighted mean difference with the 95% CI. We assessed heterogeneity with the Cochrane Q statistic and the I2 statistic. The risk of bias assessment and Grading of Recommendations Assessment, Development and Evaluation approach were used as the quality assessment method. RESULTS: After removing unrelated studies and applying the exclusion criterion, 5 articles satisfied the inclusion criteria. Patient satisfaction was significantly higher in those who received deep sedation compared with light/moderate sedation (relative risk = 1.12; 95% CI, 1.04-1.20; P = .003; Cochrane Q = 25.0; I2 = 76%).There was no significant difference in oxygen saturation, systolic blood pressure, heart rate, and procedure times according to whether the procedures were performed under deep or light/moderate sedation. However, the recovery time was significantly prolonged in patients under deep sedation. CONCLUSIONS: Our meta-analysis suggests that deep sedation resulted in improved patient satisfaction compared with light/moderate sedation. Deep sedation is recommended for patients undergoing procedures because it improves patient satisfaction. However, respiration and circulation should be carefully monitored both intra-operatively and postoperatively.

Asystole Triggered by the Mouth Opening With a Dental Mouth Gag Under General Anesthesia During Pediatric Oral Surgery: Report of a Rare Case.

The trigeminovagal reflex manifests as a sudden onset of bradycardia, hypotension, and cardiac arrest in response to the stimulation of the trigeminal nerve. The incidence of trigeminovagal reflex in maxillofacial surgical procedures is approximately 1.6%. We report a case of asystole in a pediatric patient in whom a dental mouth gag triggered the trigeminovagal reflex during oral surgery. The patient was a 5-year-old boy who was scheduled to undergo extraction of maxillary supernumerary teeth. After tracheal intubation, anesthesia was maintained with sevoflurane and remifentanil. At the beginning of the surgery, his mouth was opened with a dental mouth gag, and electrocardigram showed asystole for 20 seconds. Thereafter, his heart rate spontaneously returned to basal value within 60 seconds. Since sufficient mouth opening was required to conduct the surgery, his mouth was opened again with the gag. When the interincisal distance exceeded about 40 mm, his heart rate suddenly decreased, but spontaneously returned to baseline within 60 second. The subsequent anesthetic course was uneventful.

Comparison of Hemodynamic Responses to Administration of Vasopressin and Norepinephrine Under General Anesthesia: A Systematic Review and Meta-analysis of Randomized Controlled Trials with Trial Sequential Analysis.

OBJECTIVE: The authors performed a meta-analysis to determine if vasopressin improves hypotension more than norepinephrine under general anesthesia. DESIGN: Meta-analysis. SETTING: Operating room. PATIENTS: Patients who underwent surgery, with general anesthesia. INTERVENTIONS: Administration of vasopressin or norepinephrine in order to increase blood pressure. MEASUREMENTS AND MAIN RESULTS: The primary outcome of this study was to determine if vasopressin increased mean blood pressure more effectively compared with norepinephrine for patients under general anesthesia. The secondary outcome was to see if vasopressin increased heart rate (HR), central venous pressure (CVP), cardiac output (CO), and cardiac index (CI) more significantly compared with norepinephrine under general anesthesia. The authors calculated the weighted mean difference, with 95% confidence interval (CI) using the random-effects model, and calculated the required information size (RIS) by performing trial sequential analysis (TSA). The authors selected 6 studies for analysis. Vasopressin did not improve hypotension compared with norepinephrine under general anesthesia. (weighted mean difference = -0.84 mmHg, 95% CI: -5.90 to 4.23, p = 0.75, Cochran Q = 24.6, I2 = 84%) In TSA, only 35.5% of RIS was achieved. Similarly, vasopressin and norepinephrine were not significantly different in terms of HR, CVP, CO, and CI. In TSA, only 23.7% of the RIS was reached for HR but RIS was almost achieved for CVP and CO. CONCLUSIONS: Vasopressin did not improve hypotension compared with norepinephrine under general anesthesia. The RIS was not reached in TSA, and Grading of Recommendations Assessment, Development and Evaluation is very low. Therefore, further research is needed to reach more robust conclusions.

Anesthetic management in MAO-A and MAO-B deficiency: a case report.

Monoamine oxidase (MAO) deficiency is an X-linked hereditary disease characterized by spontaneous deletion of MAO-A and/or MAO-B on the X chromosome. Here, we describe the first reported case of a patient with MAO-A and MAO-B deficiency managed under general anesthesia in dental treatment. The patient was aged 11 years old when he was scheduled for dental treatment. He was diagnosed with MAO-A and MAO-B deficiency on genetic testing at 2 years of age. He was not given premedication, and standard monitoring with noninvasive blood pressure monitoring, pulse oximetry, and ECG was instituted. We also preemptively prepared a cardioverter-defibrillator. General anesthesia was induced with propofol 46 mg (2 mg/kg), then rocuronium 10 mg (0.4 mg/kg) and remifentanil 0.30 µg/kg/min were administered via separate infusion pumps. Orotracheal intubation was performed without complications. Anesthesia was maintained uneventfully with a continuous infusion of remifentanil 0.15-0.2 µg/kg/min and propofol 5.0-7.0 mg/kg. Fresh gas flow included oxygen and air. End-tidal CO2 concentration was maintained at around 35 mmHg throughout the procedure. We administered sugammadex 92 mg (4 mg/kg) for reversal of neuromuscular blockade and the patient was extubated. We achieved successful anesthetic management without any appreciable clinical signs of fatal arrhythmias in this patient with MAO-A and MAO-B deficiency.

The short-chain free fatty acid receptor FFAR3 is expressed and potentiates contraction in human airway smooth muscle.

Emerging evidence suggests that gut microbiota-derived short-chain fatty acids (SCFAs; acetate, propionate, and butyrate) are important modulators of the inflammatory state in diseases such as asthma. However, the functional expression of the Gi protein-coupled free fatty acid receptors (FFAR2/GPR43 and FFAR3/GPR41) has not been identified on airway smooth muscle (ASM). Classically, acute activation of Gi-coupled receptors inhibits cyclic AMP (cAMP) synthesis, which impairs ASM relaxation and can also induce crosstalk between Gi- and Gq-signaling pathways, potentiating increases in intracellular Ca2+ concentration ([Ca2+]i), favoring ASM contraction. In contrast, chronic activation of Gi-coupled receptors can sensitize adenylyl cyclase resulting in increased cAMP synthesis favoring relaxation. We questioned whether the Gi-coupled FFAR2 or FFAR3 is expressed in human ASM, whether they modulate cAMP and [Ca2+]i, and whether SCFAs modulate human ASM tone. We detected the protein expression of FFAR3 but not FFAR2 in native human ASM and primary cultured human airway smooth muscle (HASM) cells. In HASM cells, acute activation of FFAR3 with SCFAs inhibited forskolin-stimulated cAMP accumulation, but chronic activation did not sensitize cAMP synthesis. SCFAs induced [Ca2+]i increases that were attenuated by pertussis toxin, gallein, U73122, or xestospongin C. Acute treatment with SCFAs potentiated acetylcholine-stimulated [Ca2+]i increases and stress fiber formation in cells and contraction of ex vivo human airway tissues. In contrast, chronic pretreatment of human ASM with propionate did not potentiate airway relaxation. Together, these findings demonstrate that FFAR3 is expressed in human ASM and contributes to ASM contraction via reduced cAMP and increased [Ca2+]i.

Obesity-induced asthma: Role of free fatty acid receptors.

Obesity is a major risk factor for the development of asthma, and worsens the key features of asthma including airway hyperresponsiveness, inflammation, and airway remodeling. Although pro- and anti-inflammatory adipocytokines may contribute to the pathogenesis of asthma in obesity, the mechanistic basis for the relationship between asthma and obesity remains unclear. In obese individuals, the increased amount of adipose tissue results in the release of more long-chain free fatty acids as compared to lean individuals, causing an elevation in plasma long-chain free fatty acid concentrations. Recent findings suggest that the free fatty acid receptor 1 (FFAR1), which is a sensor of medium- and long-chain free fatty acids, is expressed on airway smooth muscle and plays a pivotal role in airway contraction and airway smooth muscle cell proliferation. In contrast, FFAR4, which is a sensor for long-chain n-3 polyunsaturated fatty acids and also expressed on airway smooth muscle, does not contribute to airway contraction and airway smooth muscle cell proliferation. Functional roles for short-chain fatty acid receptors FFAR2 and FFAR3 in the pathogenesis of asthma is still under debate. Taken together, adipose-derived long-chain free fatty acids may contribute to the pathogenesis of asthma in obesity through FFAR1.