Determining the Optimal Dosage of Dexmedetomidine for Smooth Emergence in Older Patients Undergoing Spinal Surgery: A Study of 44 Cases.

BACKGROUND Emergence agitation, or delirium, occurs during early recovery from general anesthesia and involves disorientation, excitation, and uncontrolled physical movements. Dexmedetomidine is an alpha agonist that has sedative, anxiolytic, analgesic, and sympatholytic activities and is used as a continuous infusion to prevent emergence agitation. This study aimed to evaluate patients aged 65 years and older undergoing general anesthesia to determine the 90% effective dose (ED90) of dexmedetomidine continuous intraoperative infusion to prevent emergence agitation. MATERIAL AND METHODS We enrolled 44 patients aged 65 years and older undergoing spinal surgery under general anesthesia. Dexmedetomidine administration commenced 30 minutes before surgery completion, with a predetermined infusion dose (µg/kg/h), without a loading dose. The initial dose was 0.2 µg/kg/h, and subsequent step size was ±0.05 µg/kg/h. We tried to find ED90 of dexmedetomidine using the biased-coin design. Vital signs, extubation quality scores, extubation-related complications, and postoperative outcomes were monitored. RESULTS Dexmedetomidine ED90 for smooth emergence in older patients was 0.34 µg/kg/h. Peri-extubation vital signs remained within 20% of baseline values, without requiring pharmacological intervention. No hypoxia, hypoventilation, or post-extubation agitation occurred. In the recovery room, 1 patient briefly exhibited excitement but quickly calmed. Nine patients initially unresponsive in the recovery room fully awoke and were promptly discharged. CONCLUSIONS For older patients who are vulnerable to adverse effects of anesthetics and opioids, dexmedetomidine enables gentle awakening without adverse vital sign changes, respiratory depression, excessive sedation, or emergence agitation (ED90=0.34 µg/kg/h). Further studies should involve a larger patient cohort, considering diverse medical conditions in older individuals.

Comparison of the effects of dexmedetomidine and propofol on the cardiovascular autonomic nervous system during spinal anesthesia: preliminary randomized controlled observational study.

Spinal anesthesia induces sympatholysis and is usually combined with dexmedetomidine or propofol which induce different hemodynamic changes. The purpose of this study was to compare the effect on autonomic nervous system between dexmedetomidine and propofol combined with spinal anesthesia. Patients aged 20-65 undergoing elective surgery under spinal anesthesia were randomly assigned to dexmedetomidine or propofol group. Heart rate variability (HRV) and hemodynamic variables were measured at four time points: T0, baseline; T1, 10 min after spinal anesthesia; T2, 10 min after sedative administration; and T3, 20 min after sedative administration. In 59 patients, dexmedetomidine and propofol groups had significantly different hemodynamic changes over time (time × group effect P < 0.001). The dexmedetomidine group had slower heart rate at T2 (P = 0.001) and higher blood pressures at T2 and T3 (P < 0.001) than the propofol group. Overall HRV dynamics showed a significant change over time from T0 to T3, but both groups exhibited similar trends. Compared to the baseline data within the group, the low frequency (LF) decreased in both groups but the decrease occurred at T2 in the propofol group and at T3 in the dexmedetomidine group. The high frequency (HF) increased at T2 and T3 only in the dexmedetomidine group. The LF/HF ratio decreased in the dexmedetomidine group at T3. Dexmedetomidine showed slower heart rate and higher blood pressure than propofol when combined with spinal anesthesia, however, dexmedetomidine and propofol exhibited similar trends in HRV dynamics. Compared with the baseline within each group, both agents decreased LF, but only dexmedetomidine increased HF and decreased in the LF/HF ratio significantly.

Pediatric Application of Cuffed Endotracheal Tube.

A young child's larynx was formerly believed to be narrowest at the cricoid level, circular in section, and funnel shaped. This supported the routine use of uncuffed endotracheal tubes (ETTs) in young children despite the benefits of cuffed ETTs, such as lower risk for air leakage and aspiration. In the late 1990s, evidence supporting the pediatric use of cuffed tubes emerged largely from anesthesiology studies, while some technical flaws of the tubes remained a concern. Since the 2000s, imaging-based studies have clarified laryngeal anatomy, revealing that it is narrowest at the glottis, elliptical in section, and cylindrical in shape. The update was contemporaneous with technical advances in the design, size, and material of cuffed tubes. The American Heart Association currently recommends the pediatric use of cuffed tubes. In this review, we present the rationale for using cuffed ETTs in young children based on our updated knowledge of pediatric anatomy and technical advances.

Comparison of silicone double-lumen tube and polyvinyl chloride single-lumen tube in fiberoptic tracheal intubation on a difficult airway model: a randomized controlled non-inferiority trial.

The management of patients with history or suspicion of difficult intubation can be challenging, especially in surgical procedures requiring one-lung ventilation. The ease of insertion of silicone double lumen tube (DLT) have previously been shown to be comparable to polyvinyl single lumen tube (SLT) in fiberoptic bronchoscope (FOB) tracheal intubation. Hence, in difficult airway situation, we hypothesized that the performance of insertion of silicone DLT would also be non-inferior to polyvinyl SLT in FOB intubation. We used a neck collar to mimic patients with difficult airway. 80 patients who required one-lung ventilation were enrolled in a prospective, randomized, non-inferiority trial. Patients were randomly allocated to the DLT or SLT groups (SLT with bronchial blocker). Neck collar was supplied to all patients before FOB intubation. The time of insertion for FOB, railroading, tracheal intubation, and total procedure were measured. The difficulty of railroading was evaluated in 4 grades. In the DLT group, the railroading was significantly shorter and easier comparing to the SLT group. The total procedure was also simpler and faster in the DLT group. While simulated difficult airways may not fully replicate actual difficult airways, we suggest that fiberoptic intubation with silicone DLT could be a feasible first-line option for patients with expected difficult airways requiring lung separation, unless the size of the DLT relative to the patient's airway is problematic.Trial registration: NCT03392766.

Comparison of fiberoptic bronchoscopic intubation using silicone and polyvinyl chloride double-lumen tubes.

BACKGROUND: Direct insertion of a double-lumen tube (DLT) using a flexible fiberoptic bronchoscope (FOB) is an option for DLT intubation. The difficult process of fiberoptic intubation is that the different properties of polyvinyl chloride and silicone DLTs may affect railroading differently. Therefore, we aimed to compare intubation using polyvinyl chloride and silicone DLTs over an FOB. METHODS: Patients aged 19-75 years who required one-lung ventilation under general anesthesia were enrolled in this study. After induction of anesthesia, the anesthesiologist intubated the DLT using FOB. The primary outcome was the difficulty of railroading over the flexible FOB scaled into five grades (I, II-1, II-2, III, and IV). Additionally, the intubation time and mucosal damage were recorded. RESULTS: A total of 46 patients participated in this study, 23 each in the silicone and polyvinyl groups. The difficulty of railroading over the FOB was significantly different between the two groups (P < 0.001). In the silicone group, the grades of difficulty in railroading were limited to I and II-1; 20 patients (87%) presented no difficulty in advancing the tube. In contrast, in the polyvinyl group, 13 patients (57%) had scores of II-2 and III. Both the intubation time and mucosal damage were significantly better in the silicone group than in the polyvinyl group. CONCLUSIONS: Intubation using a silicone DLT over an FOB was easier and faster than that with a polyvinyl chloride DLT with lesser trauma around the glottis.

Prevention of Bradycardia during Spinal Anesthesia under Dexmedetomidine Sedation in Older Adults.

Older adults exhibit reduced physiological responses to beta-adrenergic stimulation and parasympathetic inhibition. This study aimed to investigate the effect of reducing the incidence of bradycardia in the atropine and ephedrine pretreatment group compared to the control group in older adults who received spinal anesthesia with intravenous dexmedetomidine. Overall, 102 older adults aged over 65 years were randomly divided into three groups, and saline (control group), atropine at 0.5 mg (atropine group), and ephedrine at 8 mg (ephedrine group) were administered intravenously to each group as pretreatment. Immediately after spinal anesthesia, dexmedetomidine loading and study drug injections were commenced. The primary outcome was the incidence of bradycardia (<50 beats per min) within 60 min following dexmedetomidine loading. The incidence of bradycardia requiring atropine treatment was significantly higher in the control group than in the atropine and ephedrine groups (27.3% vs. 6.1% and 8.8%, respectively; p = 0.035), and no difference was noted between the atropine and ephedrine groups. Therefore, if ephedrine or atropine is selected and used according to the patient's condition and clinical situation, it may be helpful in preventing bradycardia during spinal anesthesia using dexmedetomidine in older patients.

Effects of ramosetron orally disintegrating tablets on the prophylaxis of post-discharge nausea and/or vomiting in female patients undergoing day surgery under general anesthesia: a randomized controlled trial.

BACKGROUND: This study was performed to evaluate the effectiveness of ramosetron orally disintegrating tablets (ODTs) in preventing post-discharge nausea and/or vomiting (PDNV) in female patients following outpatient surgery under general anesthesia. METHODS: This multicenter randomized study included three South Korean tertiary hospitals. Before surgery, 138 patients were randomly allocated into two groups. In the ramosetron group, ramosetron ODT 0.1 mg was administered after discharge in the morning of postoperative days 1 and 2. Metoclopramide 10 mg was administered as a rescue antiemetic (capped at 30 mg per day). In the control group, patients were administered only metoclopramide 10 mg when nausea and/or vomiting occurred. The primary outcome was the incidence of nausea during 24 h after discharge. RESULTS: We found significant differences in the incidence (13% vs. 33%, P = 0.008) and severity (P = 0.011) of nausea between the ramosetron and the control groups during 24 h after discharge. In addition, the rate of rescue antiemetic (metoclopramide) administration during 24 h after discharge was lower in the ramosetron group (6%) than in the control group (18%) (P = 0.033). Patient satisfaction score was higher in the ramosetron group than in the control group (P < 0.001). CONCLUSION: Ramosetron ODT reduces the incidence and severity of postoperative nausea after discharge during the first 24 h and may be a valuable option for the prevention of PDNV in female patients after day surgery under general anesthesia. TRIAL REGISTRATION: ClinicalTrials.gov, NCT04297293 . Registered on 05 March 2020.

Comparison of learning direct laryngoscopy using a McGrath videolaryngoscope as a direct versus indirect laryngoscope: a randomized controlled trial.

OBJECTIVE: Tracheal intubation using a direct laryngoscope is difficult to teach. The McGrath videolaryngoscope, a Macintosh-like device with a camera, can be used as a direct laryngoscope to educate novices under supervision using the screen. We compared the effect on Macintosh laryngoscopy skills following training with a McGrath videolaryngoscope as a direct versus indirect laryngoscope. METHODS: Thirty-seven participants were randomized into direct and indirect groups according to the training method using a McGrath videolaryngoscope. Participants attempted Macintosh direct laryngoscopy in normal and difficult airway scenarios. The primary endpoint was the intubation time, and the rate of successful intubation, dental trauma, and difficulty were secondary outcomes. RESULTS: The intubation time after education decreased significantly in both groups and was significantly shorter in the direct group than in the indirect group across time. The difficulty degree in the direct group was lower than that in the indirect group across time; however, the rate of dental trauma was not significantly different. CONCLUSION: Both direct and indirect laryngoscopy using a McGrath videolaryngoscope improved the performance of Macintosh direct laryngoscopy in novices, while direct laryngoscopy using a McGrath videolaryngoscope demonstrated better educational effects than indirect laryngoscopy.Registered at ClinicalTrials.gov (NCT03471975).

Late Mortality Prediction of Neutrophil-to-Lymphocyte and Platelet Ratio in Patients With Trauma Who Underwent Emergency Surgery: A Retrospective Study.

BACKGROUND: We aimed to evaluate the usefulness of neutrophil-to-lymphocyte (N/L) and neutrophil-to-lymphocyte platelet (N/LP) ratios in predicting late mortality of patients with trauma who underwent emergency surgery. MATERIALS AND METHODS: We retrospectively evaluated patients with trauma older than 19 y who underwent emergency surgery at our level I trauma center. Blood count-based ratios (N/L and N/LP at days 1, 3, and 7 of hospitalization) and trauma scores were analyzed. Statistical analysis was performed using univariable logistic regression and receiver operating curves. RESULTS: A total of 209 patients were evaluated. N/LP at day 7, N/L at day 7, Trauma Injury Severity Score, Revised Trauma Score, and Injury Severity Score were significantly associated with late mortality. Area under the receiver operating characteristic curves for predicting mortality was highest for N/LP at day 7 (0.867 [95% confidence interval 0.798-0.936], P < 0.001). The group with N/LP greater than the cutoff value (9.3, sensitivity 77.3%, specificity 83.1%) at day 7 showed higher mortality than the group with N/LP less than the cutoff value (35.4% versus 3.2%, P < 0.001, respectively) at day 7. CONCLUSIONS: N/LP at day 7 may be a superior predictor of late mortality compared with preexisting trauma scores in patients with major trauma undergoing emergency surgery, by better reflecting the systemic inflammation status.

Lightwand-Guided Insertion of Flexible Reinforced Laryngeal Mask Airway: Comparison with Standard Digital Manipulation Insertion.

BACKGROUND The flexibility of the long flexometallic tube makes insertion of the flexible reinforced laryngeal mask airway (f-LMA) difficult. We compared the usefulness of rigid lightwand-guided f-LMA insertion with standard digital manipulation. MATERIAL AND METHODS Fifty-four patients (aged 19-70 years) were randomly divided into a control group (digital manipulation technique) or the lightwand group (lightwand-guided insertion technique). The insertion profiles, oropharyngeal leak pressure (OLP), peak inspiratory pressure (PIP), expiratory tidal volume, and ventilatory score were measured in patients with neutral, extension, rotation, flexion, and re-neutral head-neck positions in turn. RESULTS The success rate and ease of insertion did not differ between groups, but the insertion time was longer in the lightwand group. The fiberoptic laryngeal view was significantly better in the lightwand group than in the control group. However, the OLP, PIP, expiratory tidal volume, and ventilatory scores were not significantly different between groups according to head-neck positions. The extension posture was associated with a significant negative effect on ventilation, but ventilation returned to initial levels with the other postures. CONCLUSIONS Lightwand-guided f-LMA insertion showed a better fiberoptic laryngeal view than standard digital manipulation, but no improvement in the ventilatory state was observed due to position. Therefore, lightwand-guided insertion could facilitate correct placement of the f-LMA, but it has limited clinical usefulness.

Conversion of I-gel to definitive airway in a cervical immobilized manikin: Aintree intubation catheter vs long endotracheal tube.

BACKGROUND: After prehospital insertion of i-gel, a popular supraglottic airway (SGA), fiberoptic-guided intubation through i-gel is often required to switch the i-gel to a definitive airway for anticipated difficult airway. The Aintree intubation catheter (AIC) was developed for this purpose yet it requires many procedural steps during which maintenance of adequate ventilation is difficult. We custom-made a long endotracheal tube (LET) which may facilitate this procedure and compared the efficacy of the AIC and LET in a cervical immobilized manikin. METHODS: In this 2 × 2 crossover manikin-based trial, 20 anaesthesiologists and residents performed both methods in random order. Total intubation time, fiberoptic time, and procedure time were recorded. The ease of insertion, procedure failure rate, difficulty score, and participants' preference were recorded. RESULTS: Total intubation time was significantly shorter for the LET than the AIC group (70.8 ± 16.4 s vs 94.0 ± 28.4 s, P = 0.001). The procedure time was significantly shorter in the LET group (51.9 ± 13.8 s vs 76.5 ± 25.4 s, P <  0.001). The ease of insertion score was lower, i.e., easier, in the AIC than the LET group (2.0 [1.0-2.75] vs 1.0 [1.0-1.0], P <  0.001). Fiberoptic time (19.0 ± 6.9 s vs 17.5 ± 12.3 s) and subjective difficulty (4.0 [3.0-6.0] vs 4.0 [3.0-5.75]) were similar between groups. Fourteen participants preferred the LET method (70%) due to its fewer procedural steps. CONCLUSIONS: LET resulted in a shorter intubation time than the AIC during fiberoptic-guided intubation through the i-gel, possibly due to the less procedural steps compared to AIC. TRIAL REGISTRATION: NCT03645174 (ClinicalTrials.gov, Aug 22, 2018).

Continuous Fentanyl Background Infusion Regimen Optimised by Patient-Controlled Analgesia for Acute Postoperative Pain Management: A Randomised Controlled Trial.

Owing to a lack of studies investigating the effect of adjustments in fentanyl background infusion (BI) with patient-controlled analgesia (PCA) on postoperative analgesia, we evaluated three BI regimens with fentanyl PCA for acute postoperative pain management. This randomised controlled trial enrolled 105 patients, who were assigned to three parallel groups: constant rate BI of 2 mL/h (CRBI group); time-scheduled decremental BI of 6, 2 and 1 mL/h (TDBI group); and BI rates optimised to the demand of PCA (POBI group). The incidence of insufficient analgesia, visual analogue scale (VAS) pain score and side effects were evaluated. The incidence of insufficient analgesia in the post-anaesthesia care unit was lower in the TDBI and POBI groups than the CRBI group. Incidence of insufficient analgesia in the ward was lower in the POBI group than the CRBI group. Postoperative VAS scores were significantly lower in the TDBI and POBI groups for up to 4 h and 24 h, respectively, compared with the CRBI group. Side effects and infused fentanyl dose were highest in the CRBI group. Adjusting BI rate based on time or patient demands could improve postoperative analgesia and reduce side effects. Compared to a constant BI rate, PCA-optimised BI achieved higher patient satisfaction.

A comparison of McGrath MAC, Pentax AWS, and Macintosh direct laryngoscopes for nasotracheal intubation: a randomized controlled trial.

PURPOSE: Videolaryngoscopy in nasotracheal intubation has been reported to be better than direct laryngoscopy. The most suitable type of videolaryngoscope remains unknown. This study aimed to compare two videolaryngoscopes (McGrath MAC and Pentax AWS) with a Macintosh laryngoscope during nasotracheal intubation. METHODS: Overall, 123 patients older than 18 with normal airways who needed nasotracheal intubation were randomly allocated into three groups: Macintosh (n=41), McGrath (n=41), and Pentax (n=41). Intubation time was the primary outcome and subdivided into three steps: nose to oropharynx, oropharynx to laryngeal inlet, and laryngeal inlet to trachea. Time required, ease of each step, glottic view grade, modified nasal intubation-difficulty score, and subjective difficulty were evaluated. RESULTS: Intubation time among the three groups was not significantly different (Macintosh 34.6±8.1 seconds, McGrath 35.2±7.9 seconds, Pentax 36.2±9.7 seconds; p=0.727). While the glottal view was better with videolaryngoscopes (I/IIa/IIb/III 36.6%/36.6%/19.5%/7.3% vs 82.9%/9.8%/7.3%/0%, vs 63.4%/29.3%/4.9%/2.4%, p=0.000), modified nasal intubation-difficulty score and subjective difficulty and ease of each step were not significantly different. However, the Pentax took longest for the second step (11.8±6.3 vs 10.3±3.5 vs 15.1±7.6 seconds, p=0.001) but was shortest for the third step (2.9±2.6 vs 4.4±5.6 vs 1.7±0.7 seconds, p=0.001). CONCLUSION: The McGrath MAC and Pentax AWS showed no benefits in intubation time or difficulty, despite better glottal views, compared to the Macintosh laryngoscope in nasotracheal intubation. Additionally, videolaryngoscopes had variable performance at different steps of nasotracheal intubation.

Time to tracheal intubation over a fibreoptic bronchoscope using a silicone left double-lumen endobronchial tube versus polyvinyl chloride single-lumen tube with bronchial blocker: a randomized controlled non-inferiority trial.

BACKGROUND: Direct insertion of a double-lumen endobronchial tube (DLT) over a fibreoptic bronchoscope (FOB) is considered more difficult and traumatic than that of a single-lumen tube (SLT). We hypothesized that time to intubation over an FOB using a silicone left DLT would be non-inferior to that using a polyvinyl chloride (PVC) SLT. METHODS: Eighty patients were enrolled in this open-label, randomized controlled, non-inferiority trial. Patients were randomly allocated to fibreoptic tracheal intubation with either a silicone DLT or PVC SLT (DLT and SLT groups, respectively). Time to tracheal intubation [time to insertion of FOB plus railroading (advancement over the FOB) time]; total time for correct tube and bronchial blocker positioning; difficulty of railroading; and the incidence of sore throat, swallowing difficulty, and hoarseness were compared between groups. RESULTS: The median time to intubation over the FOB was 20 s in the DLT group and 23 s in the SLT group. The upper limit of the confidence interval of this difference was below the non-inferiority margin of 10 s (median difference: -2 s; 95% confidence interval: -4 to 0 s). Railroading time was significantly shorter in the DLT group than in the SLT group (median time: 10 vs. 11 s; median difference: -1 s; 95% confidence interval: -3 to 0 s; P=0.03). Railroading over the FOB (rated on a four-point scale) was less difficult in the DLT group than in the SLT group (P<0.01). CONCLUSIONS: Tracheal intubation using an FOB can be achieved at least as fast using the silicone DLT as using the PVC SLT. The silicone DLT exhibited superior railroading performance to the PVC SLT.

Thirty-Day Postoperative Outcomes Following Sugammadex Use in Colorectal Surgery Patients; Retrospective Study.

PURPOSE: Sugammadex rapidly reverses muscle relaxation compared to acetylcholinesterase inhibitors. The long-term outcomes of sugammadex, however, are not well known. We compared 30-day postoperative outcomes following sugammadex and acetylcholinesterase inhibitor use in colorectal surgery patients. PATIENTS AND METHODS: Colorectal surgical patients older than 21 were included in this retrospective study, and were dichotomized according to use of reversal agents, sugammadex (group S), and acetylcholinesterase inhibitor (group A). We assessed 30-day postoperative outcomes, including total length of hospital stay, length of postoperative hospital stay, readmission rate, and delayed discharge rate. Additional parameters included postanesthetic care unit stay time, time to first successful oral intake, unforeseen intensive care unit (ICU) admission rate, postoperative pulmonary complications, and mortality. RESULTS: Among a total of 585 patients, 157 patients remained in each group after propensity score matching. Total length of hospital stay, length of postoperative hospital stay, and readmission rates did not differ between the two groups, while the incidence of delayed discharge was significantly lower in group S (23 (15%) vs. 40 (25%), p = 0.017). Other outcomes did not differ between the two groups. CONCLUSION: We found no difference in 30-day postoperative outcomes following sugammadex and acetylcholinesterase inhibitor use. The only difference between these treatments was the associated incidence of delayed discharge, which was lower in group S.

A comparison of the Macintosh laryngoscope, McGrath video laryngoscope, and Pentax Airway Scope in paediatric nasotracheal intubation.

We evaluated the performance of the McGrath video laryngoscope and Pentax Airway Scope in comparison with the Macintosh laryngoscope for nasotracheal intubation in paediatric patients. For this, 108 patients were enrolled in an open-label, randomized controlled trial. Patients were randomly allocated to one of three groups based on use of the Macintosh laryngoscope, McGrath video laryngoscope, or Pentax Airway Scope. Time to intubation, the intubation difficulty, and the quality of navigation were compared among groups. The median nasotracheal intubation time [interquartile range] in the Macintosh group (33.5 [28.3-39.8] s) was significantly shorter than those of the McGrath (39.0 [32.0-43.0] s) and Pentax groups (43.0 [35.0-52.0] s). The difficulty of nasotracheal intubation was similar among all groups. When navigating and aligning the tube from the oropharynx into the glottic inlet, the cuff inflation method was required in significantly fewer patients for the Macintosh group (11.1%) than for the McGrath (48.6%) and Pentax (51.4%) groups. Thus, compared to the McGrath video laryngoscope and Pentax Airway Scope, the Macintosh laryngoscope allowed shorter nasotracheal intubation times and better facilitated tracheal navigation, requiring less use of the cuff inflation method to navigate the tracheal tube into the glottic inlet.

Discrimination ability of the endotracheal tube location using real-time palpation during intubation using an endotracheal tube with a preloaded stylet.

PURPOSE: Palpation during intubation could be used as an ancillary method of providing real-time information of the endotracheal tube (ETT) placement before manual ventilation. This study aimed to evaluate the ability to discriminate the ETT location using a modified real-time palpation method with a preloaded stylet during intubation. PATIENTS AND METHODS: The examiner performing the real-time palpation method placed three fingers on the lateral sides of the trachea between the sternal notch and the thyroid cartilage to determine if endotracheal intubation was successful. Endotracheal intubation was confirmed by auscultation and quantitative carbon dioxide waveform using capnography. RESULTS: Eighty-eight patients were enrolled in this study. The discrimination accuracy of the real-time palpation method was 98.9% (95% CI: 93.8-99.8) for identifying the location of ETT between the trachea and esophagus. There was one false negative, reported as esophageal intubation rather than tracheal intubation. CONCLUSION: The real-time palpation method during intubation using an ETT with a preloaded stylet is an instantly applicable technique with good discrimination ability. The addition of real-time information through this palpation method to the conventional intubation process, especially in patients with poor vocal cord visualization, would be useful to facilitate the process of safe and careful endotracheal intubation.

Postoperative Analgesic Effect of Ultrasound-Guided Intermediate Cervical Plexus Block on Unipolar Sternocleidomastoid Release With Myectomy in Pediatric Patients With Congenital Muscular Torticollis: A Prospective, Randomized Controlled Trial.

BACKGROUND AND OBJECTIVES: Unipolar sternocleidomastoid release with myectomy (USRM) for correction of congenital muscular torticollis in pediatric patients produces moderate to severe postoperative pain. The objective of this trial was to examine the effect of ultrasound-guided intermediate cervical plexus block on postoperative pain after USRM. METHODS: Thirty-two patients (1-7 years old) were enrolled in this parallel-group, patient- and observer-blinded, randomized controlled trial. In the block group, 0.25% ropivacaine (0.2 mL/kg) was injected into the interfascial plane between the sternocleidomastoid muscle and the prevertebral fascia under ultrasound guidance at the fourth to fifth cervical vertebral level. The primary outcome measure was the face, legs, activity, cry, and consolability (FLACC) score at 5 minutes after entering the postanesthesia care unit (PACU), and secondary outcome measures were the FLACC score at discharge from the PACU and 3, 6, and 24 hours after operation and the use of rescue analgesic in the PACU and ward. RESULTS: The FLACC score at 5 minutes after admission to the PACU was significantly reduced (3 vs 8; median difference, 4; 95% confidence interval, 1-7; P = 0.044), and the fentanyl dose and the number of patients requiring rescue analgesics in the PACU were significantly lower (0.0 vs 0.5 µg/kg, P = 0.014; 5 [29.4%] vs 12 [75.0%], P = 0.032) in the block than in the control group. However, after discharge from PACU, there was no difference in FLACC scores and use of rescue analgesics between groups. CONCLUSIONS: Ultrasound-guided intermediate cervical plexus block decreased immediate postoperative pain and opioid requirements in the PACU in pediatric patients who underwent USRM. CLINICAL TRIAL REGISTRATION: This study was registered at ClinicalTrials.gov, identifier NCT02651311.

Prediction of emergence agitation using withdrawal reaction following rocuronium injection in preschool-aged patients undergoing inguinal herniorrhaphy: a preliminary exploratory observational trial.

PURPOSE: The development of emergence agitation (EA) is associated with several factors including age, preoperative anxiety, postoperative pain, anesthesia method, and surgery type. No studies have investigated whether the withdrawal reaction following rocuronium injection can predict the occurrence of EA. Therefore, we investigated this relationship in preschool-aged children undergoing inguinal herniorrhaphy, and which grade of withdrawal reaction is appropriate for identifying patients at risk of experiencing EA. METHODS: A total of 40 patients were enrolled in this study. During anesthesia induction, the withdrawal reaction after loss of consciousness following rocuronium injection was assessed using a 4-point scale. After surgery, EA was assessed using the Watcha scale. RESULTS: There was a correlation between withdrawal reaction and EA on admission to the postanesthesia care unit (PACU). Patients with a severe withdrawal reaction (grade 3) showed a significantly higher incidence of severe EA requiring medication on admission to the PACU. CONCLUSION: The findings of this preliminary exploratory observational study suggest that it is possible for withdrawal movement following rocuronium injection during anesthesia induction to reflect pain sensitivity of pediatric patients, which in turn may be useful in identifying those at risk of severe EA on admission to the PACU among preschool children undergoing inguinal herniorrhaphy. Further studies with a larger sample size are required to validate these findings. The exact correlation between pain reaction following rocuronium injection and postoperative pain or pain-related phenomenon should be elucidated.