Predictive value of SUVmax from initial 18F-FDG PET/CT scans for treatment outcomes in endometrial cancer patients undergoing fertility sparing management.

OBJECTIVE: To evaluate whether the maximum standardized uptake value (SUVmax) from initial 18F-FDG PET/CT (fluorine-18 fluorodeoxyglucose positron emission tomography/computed tomography) scans could be a predictor of complete response and recurrence in patients with endometrial cancer who are undergoing fertility sparing management. METHODS: We conducted a retrospective review of patients who were diagnosed with endometrial cancer through biopsy and chose to undergo fertility sparing management using progestin at the Asan Medical Center, from January 2011 to December 2020. Of these, 113 patients who had an 18-FDG-PET/CT scan before starting treatment were included in our study. We measured SUVmax and examined its correlation with complete response and time to progression after achieving complete response to progestin therapy. RESULTS: Of 113 patients, 73 (64.6%) achieved a complete response through fertility sparing management. The receiver operating characteristic curve analysis revealed that the optimal cut-off value of SUVmax for predicting complete response was 6.2 (sensitivity 79.5%, specificity 57.5%, p=0.006). After analyzing recurrence in the 73 patients who achieved complete response, we found that patients with an SUVmax value >6.2 had a significantly shorter time to progression compared with those with a value <6.2. (p=0.04). CONCLUSIONS: SUVmax values of PET-CT, along with other clinicopathological parameters, could be used to predict treatment response and recurrence risk in patients with stage I endometrial cancer undergoing fertility sparing management.

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 ß-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.

How Does the Addition of Dexamethasone to a Brachial Plexus Block Change Pain Patterns After Surgery for Distal Radius Fractures? A Randomized, Double-blind Study.

BACKGROUND: Although brachial plexus block in volar plating surgery for distal radius fractures is reportedly associated with lower postoperative pain scores, rebound pain has been reported to occur after the initial block wears off. Dexamethasone can be used in multimodal strategies for antiemesis and to control pain postoperatively. Although prior studies have suggested that anesthesia can be prolonged by adding dexamethasone to regional blocks, no randomized trials we are aware of have ascertained whether doing so will make a clinically important difference in pain after surgery for distal radius fractures. QUESTIONS/PURPOSES: Do patients who receive supplemental dexamethasone in a brachial plexus block for volar plating of unstable distal radius fractures have (1) better pain scores at 4, 8, 24, and 48 hours postoperatively than patients who have not received dexamethasone, and (2) lower fentanyl consumption and administration of antiemetic drugs without change in serum blood glucose, as well as a longer analgesic duration from the block after surgery than patients who have not received dexamethasone? METHODS: This randomized, double-blind trial included 69 patients undergoing surgery for distal radius fractures under ultrasound-guided supraclavicular brachial plexus blocks who were randomly allocated into two groups: a nondexamethasone group receiving a brachial plexus block with 0.5% ropivacaine and a dexamethasone group receiving 0.5% ropivacaine and 5 mg of dexamethasone. Thirty-four patients were allocated to the dexamethasone group and 35 were allocated to the nondexamethasone group. Nine patients (four in the dexamethasone group and five in the nondexamethasone group) were excluded after randomization because local anesthetics were used during their surgical procedures owing to an incomplete block or they requested patient-controlled analgesia after surgery. The treatment groups did not differ in any important ways, including age, gender, BMI, hand dominance, and AO/Orthopaedic Trauma Association classification. All patients received the same surgical procedure and perioperative care protocol, except for the injected agents during their brachial plexus block. The primary outcome was postoperative pain, evaluated using a 10-mm VAS at 4, 8, 12, 24, and 48 hours after surgery. The minimum clinically important difference for the VAS score was 2 of 10 points. Secondary outcome variables included fentanyl administration as a rescue analgesic, the number of patients receiving antiemetic medications because of fentanyl administration, and the duration of brachial plexus block. Serum blood glucose was measured 1 day before, immediately after, and 24 hours after surgery. Patients, surgeons, and outcome assessors were blinded to treatment allocation. RESULTS: The only clinically important between-group difference in VAS pain scores was at 8 hours, favoring the group that received dexamethasone over the group that did not (1.9 ± 1.6 versus 4.7 ± 2.7; mean difference -2.8 [95% CI -3.9 to -1.6]; p < 0.001). After brachial plexus block, the most severe pain score in both groups was reported at 12 hours postoperatively and gradually diminished over time. There was no between-group difference in fentanyl use between those who received dexamethasone and those who did not (21 ± 38 mcg versus 31 ± 29 mcg; mean difference -10 [95% CI -27.4 to 7.4]; p = 0.26). Furthermore, the use of antiemetics did not differ between the groups (27% [eight of 30] versus 37% [11 of 30]; odds ratio 1.6 [95% CI 0.5 to 4.8]; p = 0.41). Baseline and 24-hour postoperative serum blood glucose level did not differ between the groups. However, the immediately postoperative serum blood glucose level was higher in the dexamethasone group than in the nondexamethasone group (121 ± 29 versus 104 ± 20; mean difference 16 [95% CI 3.3 to 28.8]; p = 0.02). The brachial plexus block duration was 3 hours longer (95% CI 0.8 to 5.2 hours) in the dexamethasone group than that in the nondexamethasone group (11 ± 5 hours versus 8 ± 3 hours; p = 0.01). CONCLUSION: The postoperative pain level in patients who received supplemental dexamethasone in a regional block was not clinically different from that of patients who received conventional brachial plexus block anesthesia when undergoing volar plating for distal radius fractures. However, patients who received a brachial plexus block with dexamethasone experienced slight prolongation of their block and decrease in pain 8 hours after surgery. LEVEL OF EVIDENCE: Level I, therapeutic study.

Comparison of the accuracy of noninvasive hemoglobin monitoring for preoperative evaluation between adult and pediatric patients: a retrospective study.

We measured noninvasive hemoglobin (SpHb) levels during the pre-anesthesia visit in patients planning elective surgery. Differences between SpHb and laboratory-measured hemoglobin (Hblab) were compared between adult and pediatric patients. In the pre-anesthesia visiting office, we routinely monitor noninvasive Hb levels with oxygen saturation and heart rate using Masimo Radical-7® Pulse CO-Oximetry (Masimo Corp., Irvine, CA, USA). We attached the R1 20 (body weight, 10-50 kg) or R1 25 (body weight > 30 kg) probe on the index finger. After signal stabilization, SpHb and perfusion index (PI) were recorded. We retrospectively reviewed the recorded data and included patients who visited the anesthesiologist within 24 h after venous sampling. Bias was calculated by subtracting Hblab from SpHb. We compared the biases of adult and pediatric patients (< 18 years) and evaluated correlation coefficients between the bias and Hblab. Records of 105 patients were reviewed and 100 data points of 50 patients in each group were analyzed. The median ± interquartile range bias was - 2.6 ± 2.2 and - 1.2 ± 1.5 g/dL in adult and pediatric patients, respectively (P < 0.001); the corresponding mean ± standard deviation PIs were 4.4 ± 3.1 and 5.9 ± 2.7, respectively (P = 0.19). Bias was inversely proportional to Hblab irrespective of age. The correlation coefficient between the bias and Hblab was - 0.81 in adults and - 0.54 in pediatric patients (P < 0.001). SpHb and Hblab measured during pre-anesthesia visits showed a smaller difference in pediatric than in adult patients. Lower Hblab corresponded to higher accuracy.

Effect of ultrasound-guided phrenic nerve block on shoulder pain after laparoscopic cholecystectomy-a prospective, randomized controlled trial.

BACKGROUND: Post-laparoscopic shoulder pain (PLSP) frequently follows a laparoscopic cholecystectomy. A proposed mechanism for PLSP is the irritation or injury of the phrenic nerve by the CO2 pneumoperitoneum during laparoscopic surgery. Here, we investigated whether a phrenic nerve block (PNB), performed under ultrasound guidance, could reduce the incidence and severity of PLSP after laparoscopic cholecystectomy. METHOD: Sixty patients were randomized into two groups, with one group receiving PNB with 4 ml (30 mg) of 0.75% ropivacaine (group P, n = 28) and a control group (group C, n = 32). The existence and severity of PLSP were assessed for 2 days postoperatively. A pulmonary function test (PFT) and diaphragmatic excursion test were performed pre- and postoperatively. RESULTS: With ultrasound guidance, all PNBs were performed successfully in group P. In group P, the overall incidence and severity of PLSP decreased significantly. There were no significant differences in incisional pain, visceral pain, and analgesic requirements between the groups. Right-side diaphragmatic excursion decreased significantly in group P at 1 h postoperatively. The PFT results and respiratory discomfort assessed by a modified Borg's scale were not different significantly between the groups. CONCLUSION: Based on these findings, ultrasound-guided PNB can prevent or reduce the PLSP without clinically significant respiratory discomfort.

Optimal Transducer Level for Atrial and Pulmonary Arterial Pressure Measurement in Patients with Functional Single Ventricle.

This study aimed to investigate the optimal transducer level for accurate measurement of atrial and pulmonary arterial pressures in the supine position for patients with functional single ventricle. Contrast-enhanced chest computed tomographic images of 108 patients who underwent either the bidirectional cavopulmonary shunt (BCPS) placement or the Fontan procedure were reviewed. Vertical distances from the skin of the back to the uppermost levels of fluid in the single atrium or the pulmonary artery confluence and their ratios to the greatest anteroposterior (AP) diameter of the thoracic cage were determined. In patients who underwent BCPS, the ratios of the uppermost levels of blood in the atrium and pulmonary artery confluence to the greatest AP diameter of the thorax were 76.0 ± 8.1 and 56.3 ± 5.5 %, respectively. The distance (mm) between these two levels was calculated as 24.2 + 0.31 × age (years) (r 2 = 0.08, P < 0.03). In patients who underwent the Fontan procedure, the ratios were 79.3 ± 10.0 and 58.3 ± 5.8 %, respectively. The distance (mm) between these two levels was calculated as 31.1 + 0.44 × age (years) (r 2 = 0.05, P < 0.11). The optimal transducer levels for measuring atrial and pulmonary arterial pressures in the supine position are 75-80 and 55-60 % of the AP diameter of the thorax, respectively, in patients with functional single ventricle. We should consider the difference of the pressure when atrial and pulmonary arterial pressures were measured with the same level of transducers.

Intraoperative trans-fontanellar cerebral ultrasonography in infants during cardiac surgery under cardiopulmonary bypass: an observational study.

This study was performed to evaluate the feasibility of intraoperative point-of-care trans-fontanellar cerebral ultrasonography (TFCU) to obtain blood flow velocity (BFV) reference values at the internal carotid arteries (ICAs) and peri-callosal part of the anterior cerebral artery (pACA) during pediatric cardiac surgery under cardiopulmonary bypass (CPB). TFCU was performed at three time points (after induction of anesthesia, during CPB, after CPB) in 35 infants. BFV was measured at both ICAs and pACA through the anterior fontanelle with an ultrasound sector probe. We divided patients into Group S (<5 kg, n = 16) and Group L (≥5 kg, n = 19) for comparisons according to weight. We also analyzed BFV in low cerebral regional oxygen saturation (rSO2) data. All measurements of the BFV at both the ICAs and the pACA were possible. BFVs at the ICAs were lower in Group S than in Group L at all three time points. BFVs at the pACA were similar in both groups except higher value in Group L after CPB. When the rSO2 was <50, most BFVs (14 of 15 measurements) were lower than the median BFV value during CPB. However, a low rSO2 did not always reflect low BFV before and after CPB. Point-of-care TFCU can determine BFV at the ICAs and pACA during pediatric cardiac surgery. BFV differs according to the patient's size and CPB application. TFCU can be a practical cerebral blood flow monitoring method when rSO2 changes without any specific reason in infants.ClinicalTrials.gov NCT01996020.

Comparison of hemodynamic response to tracheal intubation and postoperative pain in patients undergoing closed reduction of nasal bone fracture under general anesthesia: a randomized controlled trial comparing fentanyl and oxycodone.

BACKGROUND: The present study aimed to compare the intravenous bolus effect of oxycodone and fentanyl on hemodynamic response after endotracheal intubation and postoperative pain in patients undergoing closed reduction of nasal bone fracture. METHODS: In this prospective randomized double-blinded study, 64 patients undergoing closed reduction of nasal bone fracture were randomized into one of two groups: the fentanyl group (Group F) or the oxycodone group (Group O). Each drug (fentanyl 2 mcg/kg in Group F and oxycodone 0.2 mg/kg in Group O) was administered prior to the induction of general anesthesia. Hemodynamic changes after endotracheal intubation and postoperative pain were then measured in both groups. RESULTS: There was no significant difference in the change in mean arterial pressure and heart rate between pre-induction and post-intubation in both Groups F and O (P > 0.05). Postoperative pain in Group O was milder than that in Group F (P < 0.001); however, time to awakening from the end of operation was shorter in Group F (P = 0.012). CONCLUSION: In patients undergoing closed reduction of nasal bone fracture, oxycodone attenuates hemodynamic response to endotracheal intubation similar to fentanyl. However, oxycodone is more effective than fentanyl in improving postoperative pain. TRIAL REGISTRATION: Clinical Research Information Service (Trial registry number: KCT0001153 ) on 3 July, 2014.

Randomized controlled trial on preemptive analgesia for acute postoperative pain management in children.

BACKGROUND: Preemptive analgesia is an anti-nociceptive treatment that starts before surgery and prevents the establishment of central sensitization. Whether preemptive analgesia is more effective than conventional regimens for managing postoperative pain remains controversial. This study evaluated the efficacy of intravenous preemptive analgesia for acute postoperative pain control in pediatric patients. METHODS: In this prospective randomized controlled trial, 51 children aged 3-7 years, scheduled for corrective osteotomy were randomized into control (group C) or preemptive (group P) group. Both groups received standardized general anesthesia, including intravenous patient-controlled analgesia (IV-PCA) with fentanyl, which was started before skin incision in group P or 5 min thereafter in group C. IV-PCA data, pain scores using verbal rating scale (VRS) and Wong-Baker FACES(®) pain rating scale (WBFS), emergence agitation score (EAS) using the Pediatric Anesthesia Emergence Delirium (PAED) scale, analgesic requirements, and complications were recorded. RESULTS: The primary outcome, pain score at postoperative 1 h, showed no difference between the groups. Both groups did not demonstrate emergence agitation (PAED cutoff value ≥ 12), although the EAS at admission to the postanesthetic care unit (PACU) was lower in group P than in group C (P = 0.002; mean difference 4.85, 95% CI 1.97-7.73). There were no differences in the delivered volume of IV-PCA, frequency of pushing the IV-PCA button, effective push attempts, VRS, WBFS, EAS at discharge from the PACU, additional analgesic requirements, and complications. CONCLUSION: Preemptive analgesia using IV-PCA with fentanyl showed no significant advantages for postoperative analgesia after corrective osteotomy in pediatric patients.

Analgesic efficacy of two interscalene blocks and one cervical epidural block in arthroscopic rotator cuff repair.

PURPOSE: Despite its effectiveness in other surgeries, studies on continuous epidural block in upper-extremity surgery are rare because of technical difficulties and potential complications. This study compared postoperative analgesic efficacy and safety of ultrasound-guided continuous interscalene brachial plexus block (UCISB) and fluoroscopy-guided targeted continuous cervical epidural block (FCCEB) in arthroscopic rotator cuff repair (ARCR). METHODS: Seventy-five patients were randomly and equally assigned to groups FCCEB (0.2%), UCISB75 (0.75%), and UCISB20 (0.2%) according to the initial ropivacaine dose (8 ml). The background infusion (0.2% ropivacaine at 5 ml/h), bolus (3 ml of 0.2% ropivacaine), and lockout time (20 min) were consistent. Respiratory effects [respiratory discomfort (modified Borg scale), ventilatory function, and hemidiaphragmatic excursion (ultrasound)], analgesic quality [pain severity at rest and motion attempt (VAS-R and -M), number of boluses, analgesic supplements, and sleep disturbance], neurologic effects, procedural discomfort, satisfaction, and adverse effects were evaluated preprocedurally and up to 72 h postoperatively. RESULTS: FCCEB caused less respiratory depression and sensorimotor block, but had less analgesic efficacy than UCISBs (P < 0.05). FCCEB caused nausea, vomiting, and dizziness more frequently (P < 0.05) and had lower patient satisfaction than UCISBs (P < 0.05). UCISB75 can cause severe respiratory distress in patients with lung disorders. Other variables were not significantly different between the groups. CONCLUSIONS: UCISB20 may provide superior postoperative analgesia and is the most recommendable postoperative analgesic method in ARCR. LEVEL OF EVIDENCE: Randomized controlled trials, Therapeutic study, Level I.

Appropriate dose of dexmedetomidine for the prevention of emergence agitation after desflurane anesthesia for tonsillectomy or adenoidectomy in children: up and down sequential allocation.

BACKGROUND: Dexmedetomidine can be used for the prevention of emergence agitation (EA) in children. However, an inadequate dose of dexmedetomidine can induce prolonged sedation and cardiovascular complications. The aim of this study was to evaluate the effective dose of dexmedetomidine for the prevention of EA after desflurane anesthesia for patients undergoing a tonsillectomy or adenoidectomy. METHODS: We enrolled 21 unpremedicated children, between 2 and 12 years, undergoing either a tonsillectomy or an adenoidectomy. General anesthesia was induced using sevoflurane and oxygen, and dexmedetomidine was administered before surgery. Anesthesia was maintained using desflurane resulting in a BIS range of 40-60. In the postanesthetic care unit (PACU), EA (agitation measured at level 4 or more at least once) was assessed on arrival in the PACU,15 min later, and 30 min later. The dose of dexmedetomidine for consecutive patients was determined by the response of the previous patient, using an increment or decrement of 0.1 µg/kg. RESULTS: The 50% effective dose of dexmedetomidine for prevention of EA was 0.25 µg/kg (95% confidence limits, 0.17-0.33 µg/kg), and the 95% effective dose was 0.38 µg/kg (95% confidence limits, 0.29-0.39 µg/kg). CONCLUSIONS: For prevention of EA after desflurane anesthesia for 50% and 95% of children undergoing tonsillectomies or adenoidectomies, 0.25 µg/kg or 0.38 µg/kg of dexmedetomidine is suggested. Further study is needed to validate the suggested dose of dexmedetomidine to prevent the EA that was identified in the present study. TRIAL REGISTRATION: Clinical Research Information Service KCT0000126 .

Determination of the 95% effective dose of remifentanil for the prevention of coughing during extubation in children undergoing tonsillectomy (with or without adenoidectomy).

BACKGROUND: Limited data are available regarding the 95% effective dose (ED95 ) of remifentanil to prevent the cough response during emergence from general anesthesia in children. METHODS: This study included 40 patients aged 3-12 years who underwent elective tonsillectomy with or without adenoidectomy. A predetermined remifentanil dose was infused continuously with desflurane during surgery and was continued until extubation. In the emergence period, the cough response during awake extubation was assessed to determine the remifentanil dose for the next patient. The first patient received remifentanil at the rate of 0.01 µg·kg(-1) ·min(-1) , and subsequent patients received a 0.01 µg·kg(-1) ·min(-1) higher dose than the previous patient if there was more than moderate coughing detected, and the patient after those with less than mild coughing received either the same dose (95% probability) or a 0.01 µg·kg(-1) ·min(-1) lower dose (5% probability) using the biased coin design. Times to extubation and adverse events were recorded. The ED95 was calculated using the maximum-likelihood estimation. RESULTS: The ED95 of remifentanil for preventing coughing during extubation was 0.060 µg·kg(-1) ·min(-1) (95% confidence interval, 0.037-0.068). There was moderate coughing in all groups receiving 0.01-0.06 µg·kg(-1) ·min(-1) of remifentanil, but no cough response occurred in the group receiving remifentanil 0.07 µg·kg(-1) ·min(-1) . Time to extubation was weakly correlated with remifentanil infusion rate (r = 0.331). One patient who received remifentanil 0.07 µg·kg(-1) ·min(-1) showed desaturation over 5 s immediately after extubation, but recovered after receiving 100% oxygen. CONCLUSION: The ED95 of the continuous remifentanil infusion rate was 0.060 µg·kg(-1) ·min(-1) to prevent the cough response during extubation in children after tonsillectomy.

Comparison of two devices using near-infrared spectroscopy for the measurement of tissue oxygenation during a vascular occlusion test in healthy volunteers (INVOS® vs. InSpectra™).

The aim of this study was to compare tissue oxygen saturation as measured by INVOS® and InSpectra™ during a vascular occlusion test (VOT) in the same subject. Twenty healthy adults were investigated. The INVOS® and InSpectra™ probes were placed randomly on the right and left thenar eminence in the same participant and monitoring of tissue oxygen saturation (SrO2 from INVOS® and StO2 from InSpectra™) were begun. Pneumatic cuffs placed around each upper arm were inflated simultaneously to 30 mmHg above the initial systolic blood pressure and maintained until the tissue oxygen saturation had decreased to 40% or below. The cuff pressure was then released rapidly. The time to achieve initial stability, the baseline value, the time from the baseline value to 40%, the rate of deoxygenation, the rate of reoxygenation, and the hyperemic area under the curve were calculated from SrO2 and StO2. The baseline value by INVOS® was lower than that by InSpectra™ (75.6±8.2 vs. 81.8±3.4%, p<0.01). The time to reach stable baseline value was significantly longer for SrO2 than for StO2 (249±86 and 54±40 s respectively; p<0.01). SrO2 declined to 40% more rapidly than did the StO2 (147±38 vs. 199±41 s, p<0.01). The deoxygenation and reoxygenation rates were higher (p<0.01) and the reactive hyperemic area was more extensive for INVOS® than for InSpectra™ (p=0.015). In conclusion, the VOT on the thenar muscle using INVOS® was as clinically applicable as InSpectra™, but baseline values and dynamic changes of INVOS® differed from those of InSpectra™.

Transthoracic echocardiographic guidance for obtaining an optimal insertion length of internal jugular venous catheters in infants.

BACKGROUND: There are multiple methods of determining the optimal position of central venous catheter (CVC) tips. The purpose of this study was to assess the feasibility of transthoracic echocardiography (TTE), and compare TTE and height-based method for correct positioning of CVCs in infants undergoing cardiac surgery. METHODS: Ultrasonography-guided central venous catheterization was performed via the right internal jugular vein. Longitudinal images of the right atrium and superior vena cava were obtained using TTE. The catheter tip was located 10 mm above the crista terminalis. If the catheter tip was not clearly visualized, the probe was rotated to obtain transverse images and the CVC tip was positioned at the level of the pulmonary artery bifurcation. The mean distance from the catheter tip to the level of the carina was compared with that calculated using a height-based formula. RESULTS: Among 106 cases, positioning of the CVC tip under TTE guidance failed in four patients; thus, the success rate was 96.2%. The mean distance from the CVC tip to the level of the carina was different for positioning using the TTE method (-3.8 ± 8.2 mm; 95% confidence interval, -5.5 to -2.2 mm) and that using the height-based formula (6.1 ± 9.6 mm; 95% CI, 4.2 to 8.0 mm; P = 0.001). The distance was consistent regardless of the height when the insertion length was determined using TTE (r = -0.048, P > 0.05). CONCLUSIONS: Transthoracic echocardiography is a practical method for the correct placement of the CVC tip with less variability compared to the height-based method.

The effect of sevoflurane and ondansetron on QT interval and transmural dispersion of repolarization in children.

BACKGROUND: This study evaluated the prolongation of QT interval by the combination of sevoflurane and ondansetron in pediatric patients. Additionally, transmural dispersion of repolarization as interval between the peak and end of the T wave (Tp-e) and Tp-e/QT ratio was also measured to assess the risk of ventricular arrhythmia. METHODS: The 3-lead electrocardiography (ECG) in lead II was sampled at three stages: at preinduction, just before (Sevo alone) and finally, after administration of ondansetron (Sevo+Ondansetron) in 41 children aged from 3 to 12 years. The QT interval was corrected for heart rate using Bazett's formula. And, Tp-e interval was obtained, and Tp-e/QT ratio was calculated. For analysis of the changes of parameters, a repeated-measures analysis of variance was used to identify significant differences in QTc, Tp-e interval and Tp-e/QT ratio at the three epochs. RESULTS: The mean QTc at preinduction period was 413.8 (20.8) ms. The mean Sevo alone and Sevo+Ondansetron QTcs were 432.5 (28.1) and 439.2 (27.6) ms, and the differences in QTc prolongation between stages were all significant (P < 0.01). Ondansetron increased Tp-e interval significantly; however, Tp-e/QT ratio was not different among three stages. There were no ECG abnormalities such as atrial or ventricular arrhythmia and T-wave abnormality in any patient. CONCLUSIONS: Sevoflurane prolongs the QTc interval and its combination with ondansetron further increased this effect in children. However, the dispersion of ventricular repolarization was not significantly affected, and there were no adverse events such as ventricular arrhythmia in this study. The combination of sevoflurane and ondansetron may be clinically safe, but careful ECG monitoring is still advisable.

Ultrasound-guided Prolotherapy with Polydeoxyribonucleotide Sodium in Ischiofemoral Impingement Syndrome.

Ischiofemoral impingement syndrome is an uncommon disorder defined by hip pain caused by the narrowing of the space between the ischial tuberosity and lesser trochanter with associated entrapment of the quadratus femoris muscle. We effectively treated two male patients using ultrasound-guided prolotherapy with polydeoxyribonucleotide sodium mixed with local anesthetics. A 24-year-old male patient with no history of trauma or surgery complained of bilateral hip and groin pain; magnetic resonance imaging demonstrated slight narrowing of the bilateral ischiofemoral spaces with mild enhancement of the left quadratus femoris muscle. A 23-year-old male patient with a history of iliotibial band release and iliopsoas tendon release complained of left hip and groin pain; magnetic resonance imaging revealed swelling of the left quadratus femoris muscle. After the fifth treatment session of prolotherapy, the pain severity score using the visual analog scale was found to be minimal (0-1/10), and follow-up magnetic resonance imaging revealed a slightly decreased enhancement of the quadratus femoris muscle compared with that on previous images. Prolotherapy with polydeoxyribonucleotide sodium was an efficacious treatment for two patients with ischiofemoral impingement syndrome who were not candidates for surgery.

Application of the Bair Hugger™ core body temperature at wrist region with upper body warming blanket: a prospective observational study.

BACKGROUND: Body temperature monitoring is essential during the perioperative period. However, core body temperature measurement requires invasive device that may cause complications. This study aimed to evaluate the accuracy of non-invasive Bair Hugger™ core body temperature monitoring system (BHTMS) at the wrist compared with esophageal temperature under general anesthesia. METHODS: Twenty adult patients of the American Society of Anesthesiologists physical status I or II were enrolled. BHTMS sensor was applied at wrist region. After tracheal intubation, an esophageal probe was inserted. Bair Hugger™ upper body warming blankets were used. Esophageal temperature (Teso) and BHTMS at wrist (Twrist) were recorded every 10 min. RESULTS: Total of 257 pairs of data sets were analyzed: Teso and Twrist had no statistically significant difference (P = 0.103). Median of Teso and Twrist were 36.5°C and 36.4°C. Bland-Altman analysis showed Teso - Twrist of 0.14°C ± 1.44. Subsequently, 99 pairs of 0-40 min data set were analyzed and showed significant difference at 0 and 10 min (P < 0.001) but no significant difference at 20, 30 and 40 min. Bland- Altman plot by times showed difference (Teso - Twrist) of 1.49°C ± 2.00, 0.82°C ± 1.30, 0.29°C ± 1.32, -0.03°C ± 0.84, and -0.12°C ± 0.82 at 0, 10, 20, 30 and 40 min respectively. CONCLUSIONS: BHTMS at wrist area under the upper body warming blanket is a potential alternative other than esophageal temperature for monitoring body temperature after 30 min of anesthesia induction.

Feasibility of automated measurement of fetal right ventricular modified myocardial performance index with development of reference values and clinical application.

To establish normal reference ranges for fetal right ventricular modified myocardial performance index (RV Mod-MPI) using automatic synchronization of the RV inflow and outflow images (MPI+TM). Additionally, we aimed to clinically apply RV Mod-MPI to investigate its changes in fetal right congenital diaphragmatic hernia (CDH) compared to normal fetuses. This prospective study included uncomplicated singleton pregnancies between 16 and 38 weeks of gestational age. Cases with any maternal or fetal complications that developed during the enrollment period were excluded. Two experienced operators measured the RV Mod-MPI using the automated and manual methods. The intraclass correlation coefficients (ICC) were calculated for intra- and inter-operator reproducibility. The mean differences between the manual and automated measurements were also compared. The RV Mod-MPI was then compared between the right CDH fetuses and normal fetuses. Seventy normal fetuses were analyzed for the feasibility of an automated system, and 364 examinations from 272 fetuses were analyzed for developing the normal references. The automated system showed significantly higher intra- and inter-operator reproducibility of Mod-MPI than those of manual measurements (ICC = 0.962 vs. 0.913 and 0.961 vs. 0.889, respectively). The mean difference in Mod-MPI between the manual and automated method was 0.0002 ± 0.0586 with a 95% confidence interval of -0.0095-0.0099. The Mod-MPI and isovolumetric relaxation time increased throughout the gestational weeks. The isovolumetric contraction time increased until 24 weeks of gestation and then slightly decreased afterwards, and the ejection time also increased until 31 weeks of gestation and then decreased. There was no significant difference in the Mod-MPI between right CDH and normal fetuses. The automated system showed high inter- and intra-operator reproducibility. Furthermore, the normal reference values of Mod-MPI for each gestational age were established. Our results suggest that the automated system might be clinically feasible for evaluating fetal cardiac function.

A comparative trial of the GlideScope(R) video laryngoscope to direct laryngoscope in children with difficult direct laryngoscopy and an evaluation of the effect of blade size.

BACKGROUND: GlideScope® video laryngoscope (GVL) has been proposed to be useful for airway management, but its efficacy for difficult airways has not been confirmed in pediatric patients. In this study, we evaluated the usefulness of the GVL for improving the laryngoscopic view in patients whose Cormack and Lehane grade (C&L grade) was ≥3 under direct laryngoscopy. We also assessed the effect of GVL blade size on the laryngoscopic view. METHODS: This randomized open trial was conducted in a tertiary pediatric center. Patients whose previous C&L grade was ≥3, or who were anticipated to have a difficult airway, were enrolled. The initial modified C&L grade was scored using a direct laryngoscope (DL). If the patient's C&L grade was ≥3, the laryngoscopic view was scored again using GVLw (selected based on weight) and GVLs (1 size smaller than GVLw) in random order by a single experienced anesthesiologist. All laryngoscopic views were graded both with and without the backward, upward, and right lateral displacement of the thyroid cartilage (BURP) maneuver. The primary outcome was the difference in the C&L grade between DL and GVLw, and the secondary outcome was that between GVLw and GVLs. For statistical analysis, the modified C&L grade was converted to an ordinal scale. RESULTS: Data from 23 pediatric patients were analyzed. When compared with DL, improvement of laryngoscopic view with the GVLw wa not obvious (98.3% confidence interval [CI] for differences of ordinal scale, 0-1 without BURP, P = 0.15 and 0-1 with BURP, P = 0.11). However, GVLs improved the laryngoscopic view in comparison with both DL (98.3% CI for differences, 3.5-5.0 without BURP, P = 0.00007 and 3.5-4.5 with BURP, P = 0.0001) and GVLw (98.3% CI for differences, 3.0-4.5 without BURP, P = 0.00007 and 2.5-4.0 with BURP, P = 0.0001). There was no adverse outcome during this study. CONCLUSIONS: In patients with C&L grade ≥3 under direct laryngoscopy, GVLs significantly improved the laryngoscopic view when compared with DL or GVLw. The GVLs is recommended for improving the laryngoscopic view in patients with a difficult airway.

Comparison of the efficacy of ramosetron and ondansetron in the prophylaxis of postoperative vomiting in children receiving fentanyl by patient-controlled analgesia after orthopedic surgery: a randomized controlled trial.

BACKGROUND: This study was designed to compare the efficacy of prophylactic ramosetron and ondansetron in preventing postoperative vomiting in children who received fentanyl by patient-controlled analgesia after orthopedic surgery. METHODS: Two hundred and eighteen children, 2-15 years old, ASA physical status 1 or 2, scheduled for elective orthopedic surgeries, were randomly divided into the ramosetron group (n = 109) or ondansetron group (n = 109). Patients in ondansetron group received ondansetron 100 µg·kg(-1) and patients in ramosetron group received ramosetron 6 µg·kg(-1) after surgery. Intravenous patient-controlled analgesia with fentanyl was used in both groups. The incidence of postoperative vomiting and side effects were assessed during the 48 h after surgery. RESULTS: There was significantly less vomiting during the first 24-h and 6-24-h period after surgery in ramosetron group than in ondansetron group (P < 0.01). There were no significant differences in side effect of 5-HT(3) antagonist between the two groups. CONCLUSION: Ramosetron was more effective during the first 24-h period after surgery than ondansetron in children using fentanyl patient-controlled analgesia after general anesthesia.