INJEX50 could improve the success rate of local anesthesia for arterial cannulation in the pediatric intensive care unit: A randomized, double-blind, single-center study.

BACKGROUND: Quick arterial cannulation is required in pediatric emergency situation, which require effective local anesthesia to avoid withdrawal movement. However, pediatric local anesthesia could be difficult because of withdrawal movement. Jet injectors, which are needleless and provide local anesthesia quickly, could be helpful for pediatric local anesthesia during arterial cannulation. AIMS: This study aimed to examine whether new jet injector "INJEX50" could improve the success rate of local anesthesia for arterial cannulation in pediatric intensive care unit compared with the current standard of care, infiltration using a 26-gauge needle. METHODS: This study was a randomized, double-blind, single-center study. Participants were infants and young children in the pediatric intensive care unit, who required an arterial line. Local anesthesia was performed with either a 26-gauge needle (group C) or INJEX50 (group I) before arterial cannulation. The primary outcome (success of local anesthesia) was the presence of withdrawal movement at the time of skin puncture for arterial cannulation. The secondary outcomes included rescue sedation during arterial cannulation. Data were analyzed using Fisher's exact test and the Mann-Whitney U-test, with values of p < .05 considered statistically significant. RESULTS: Seventy patients were randomly assigned to groups C and I. The local anesthesia success rate in group I (30/35 [86%]) was significantly higher than that in group C (15/35 [43%], odds ratio, 8.00; 95% confidence interval, 2.51-25.5; p = .0005). In conclusion, INJEX50 could improve success rate of local anesthesia for arterial cannulation in pediatric intensive care unit compared with 26-gauge needle.

Venoarterial extracorporeal membrane oxygenation for cardiopulmonary resuscitation: A retrospective study comparing the outcomes of fluoroscopy.

Background: Extracorporeal cardiopulmonary resuscitation (ECPR) using venoarterial extracorporeal membrane oxygenation is performed for out-of-hospital cardiac arrest; however, it is associated with a risk of several complications. Objective: To investigate whether the fluoroscopy equipment was removed from the emergency department (ED) and whether it would be beneficial to transport the patient to the fluoroscopy room to reduce vascular complications without affecting the induction time. Methods: This single-center, retrospective, before-and-after analysis was conducted at a tertiary emergency medical center and included 59 patients who underwent ECPR for out-of-hospital cardiac arrest between May 2017 and March 2022. The patients were divided into two groups: those who underwent cannulation in the ED without fluoroscopy (ED-ECPR group) and those who were transferred directly from the ED to the cardiac angiography room (ECPR call group). Results: The rate of vascular complications associated with ECPR was significantly lower in the ECPR group than in the ED-ECPR group (40.6 % [14/32] vs. 10 % [2/20], respectively; p = 0.014). The duration from ED arrival to venoarterial extracorporeal membrane oxygenation initiation was similar in the two groups (median: 23.0 min in the ED-ECPR group vs. 25.5 min in the ECPR call group, p = 0.71). Results adjusted for confounding factors showed that performing ECPR under fluoroscopy was a consistent and independent element of vascular complication rates (adjusted odds ratio: 9.92, 95 % confidence interval: 2.04 to 81.2, p = 0.011). Conclusions: Fluoroscopy-guided ECPR can significantly reduce the incidence of vascular complications even if the ED and fluoroscopy room are far apart. However, no significant difference was observed in the time required to establish ECPR in the cardiac catheterization laboratories.

Comparing leak pressure of LMA® ProSeal™ versus i-gel® at head rotation: a randomized controlled trial.

PURPOSE: The effect of head rotation on supraglottic airway (SGA) oropharyngeal leak pressure (OPLP) has not been well elucidated. The aim of this study was to help clarify which SGA device provides higher OPLP at head-rotated position. METHODS: Patients who underwent elective surgery under general anesthesia were enrolled and randomly divided into laryngeal mask airway (LMA®) ProSeal™ and i-gel® groups. The allocated SGA device was inserted under anesthesia. The primary outcome was OPLP, and secondary outcomes were ventilation score, expiratory tidal volume, and maximum pressure under volume-controlled ventilation (VCV) with an inspiratory tidal volume of 10 mL·kg-1 ideal body weight and fibreoptic view of the vocal cords at 0°, 30°, and 60° head rotation. RESULTS: Data from 78 and 76 patients were analyzed in the LMA ProSeal and i-gel groups, respectively. The mean (standard deviation) OPLP of the LMA ProSeal was significantly higher than that of the i-gel at the 60° head-rotated position (LMA ProSeal, 20.4 [6.5] vs i-gel, 16.9 [7.8] cm H2O; difference in means, 3.6; adjusted 95% confidence interval, 0.5 to 6.6; adjusted P = 0.02, adjusted for six comparisons). The maximum pressure under VCV at 60° head rotation was significantly higher in the LMA ProSeal group than in the i-gel group. The expiratory tidal volume of the LMA ProSeal did not significantly change with head rotation and was significantly higher than that of the i-gel at 60° head rotation. Ventilation score, fibreoptic view of the vocal cords, and complications were not significantly different between the ProSeal and i-gel groups. CONCLUSIONS: The LMA ProSeal provides higher OPLP than the i-gel at a 60° head-rotated position under general anesthesia. TRIAL REGISTRATION: Japan Registry of Clinical Trials (https://jrct.niph.go.jp) (JRCT1012210043); registered 18 October 2021.

RéSUMé: OBJECTIF: L'effet de la rotation de la tête sur la pression de fuite oropharyngée (OPLP en anglais) des dispositifs supraglottiques (DSG) n'est pas encore bien élucidé. L'objectif de cette étude était d'aider à déterminer quel DSG procurait une pression de fuite oropharyngée plus élevée lorsque la tête est en rotation. MéTHODE: Les patient·es qui ont bénéficié d'une intervention chirurgicale non urgente sous anesthésie générale ont été recruté·es et aléatoirement réparti·es en deux groupes, soit masque laryngé (LMA®) ProSeal™ ou i-gel®. Le DSG alloué a été inséré sous anesthésie. Le critère d'évaluation principal était la pression de fuite oropharyngée, et les critères d'évaluation secondaires étaient le score de ventilation, le volume courant expiratoire et la pression maximale sous ventilation à volume contrôlé (VVC) avec un volume courant inspiratoire de 10 mL·kg−1 du poids corporel idéal et une visualisation fibroscopique des cordes vocales à une rotation de la tête de 0°, 30° et 60°. RéSULTATS: Les données de 78 et 76 patient·es ont été analysées dans les groupes LMA ProSeal et i-gel, respectivement. La pression de fuite oropharyngée moyenne (écart type) du LMA ProSeal était significativement plus élevée que celle de l'i-gel en position de rotation de la tête à 60° (LMA ProSeal, 20,4 [6,5] vs i-gel, 16,9 [7,8] cm H2O; différence de moyennes, 3,6; intervalle de confiance ajusté à 95 %, de 0,5 à 6,6; P = 0,02 ajusté, ajusté pour six comparaisons). La pression maximale sous VVC à une rotation de la tête de 60° était significativement plus élevée dans le groupe LMA ProSeal que dans le groupe i-gel. Le volume courant expiratoire du LMA ProSeal n'a pas changé de manière significative avec la rotation de la tête et était significativement plus élevé que celui de l'i-gel à une rotation de la tête de 60°. Le score de ventilation, la visualisation fibroscopique des cordes vocales et les complications n'étaient pas significativement différents entre les groupes ProSeal et i-gel. CONCLUSION: Le LMA ProSeal procure une pression de fuite oropharyngée plus élevée que l'i-gel dans une position de rotation de la tête à 60° sous anesthésie générale. ENREGISTREMENT DE L'éTUDE: Registre japonais des essais cliniques (https://jrct.niph.go.jp) (JRCT1012210043); enregistré le 18 octobre 2021.

I-gel Plus acts as a superior conduit for fiberoptic intubation than standard i-gel.

The supraglottic airway (SGA) is widely used. I-gel Plus is a next-generation i-gel with some improvements, including facilitation of fiberoptic tracheal intubation (FOI). To compare the performance of i-gel Plus and standard i-gel as conduits for FOI, a Thiel-embalmed cadaveric study was conducted. Twenty-two anesthesiologists were enrolled as operators in Experiment 1. The i-gel Plus and standard i-gel were inserted into one cadaver, and the FOI was performed through each SGA. The primary outcome was time required for FOI. The secondary outcomes were the number of attempts and visual analog scale (VAS) score for difficulty in FOI. Moreover, fiberoptic views of the vocal cords in each SGA were assessed by an attending anesthesiologist using nine cadavers in Experiment 2. The percentage of glottic opening (POGO) score without fiberscope tip upward flexion and upward angle of the fiberscope tip to obtain a 100% POGO score were evaluated as secondary outcomes. The time for FOI through i-gel Plus was significantly shorter than that through standard i-gel (median (IQR), i-gel Plus: 30.3 (25.4-39.0) s, vs standard i-gel: 54.7 (29.6-135.0) s; median of differences, 24.4 s; adjusted 95% confidence interval, 3.0-105.7; adjusted P = 0.040). Although the number of attempts for successful FOI was not significantly different, the VAS score for difficulty in the i-gel Plus group was significantly lower (easier) than that in the standard i-gel group. Moreover, i-gel Plus required a significantly smaller upward angle of the fiberscope tip to obtain a 100% POGO score. FOI can be performed more easily using i-gel Plus than using standard i-gel because of the improved fiberoptic visibility of vocal cords.

Cricothyrotomy for an Unexpected Cannot Intubate, Cannot Ventilate Situation for a Patient with Chronic Graft-Versus-Host Disease After Induction of General Anesthesia: A Case Report.

BACKGROUND Chronic graft-versus-host disease (GVHD) is a major complication of hematopoietic stem cell transplantations. Due to fibrotic changes, patients with GVHD are at risk for difficult airway management. We encountered a case of chronic GVHD that went into a "cannot intubate, cannot ventilate" (CICV) condition after induction of general anesthesia and was managed using cricothyrotomy. CASE REPORT A 45-year-old man with uncontrolled chronic GVHD developed pneumothorax of the right lung. Thoracoscopic dissection of the adhesions, closure of the pneumostomy, and drainage under general anesthesia were planned. In the preoperative airway assessment, we concluded that using a video laryngoscope or endotracheal fiber would be sufficient to intubate the patient after sedation and that airway management after the loss of consciousness would not be difficult. Therefore, general anesthesia was induced by rapid induction; however, the patient developed difficult mask ventilation. Intubation was attempted via a video laryngoscope or bronchofiber but failed. Ventilating using a supraglottic instrument was difficult. The patient was evaluated to have a CICV condition. Thereafter, because of a rapid decrease in oxygen saturation (SpO2) and bradycardia, a cricothyrotomy was performed. Subsequently, ventilation became adequate, SpO2 increased immediately and drastically, and respiration and circulatory dynamics recovered. CONCLUSIONS We believe that anesthesiologists should practice, prepare, and simulate airway emergencies that can be experienced during surgery. In this case, we recognized that skin sclerosis in the neck and chest could lead to CICV. It may be suitable for airway management of scleroderma-like patients to select conscious intubation with a bronchoscope as a first choice.

The intraoperative motor-evoked potential when propofol was changed to remimazolam during general anesthesia: a case series.

Remimazolam is a short-acting benzodiazepine that was approved for clinical use in 2020. We report three patients who underwent surgery for cerebral and spinal cord tumors, in whom transcranial electrical stimulation-motor-evoked potential (TES-MEP) was successfully monitored under general anesthesia with remimazolam. During total intravenous anesthesia with propofol at a target concentration of 2.7 - 3.5 µg/mL and 0.1 - 0.35 µg/kg/min of remifentanil, delayed awakening, bradycardia, and hypotension during propofol anesthesia were expected in all three cases. With patient safety as the top priority, we considered changing the anesthetic agent. Propofol was replaced with remimazolam at a loading dose of 12 mg/kg/h for a few seconds (case 3), followed by 1 mg/kg/h for maintenance (cases 1-3). TES-MEP was recorded during propofol and remimazolam administration in all three patients. Amplitudes of TES-MEP during anesthesia with propofol and remimazolam were 461.5 ± 150 µV and 590.5 ± 100.9 µV, 1542 ± 127 µV and 1698 ± 211 µV, and 581.5 ± 91.3 µV and 634 ± 82.7 µV sequentially from Case 1. Our findings suggest that intraoperative TES-MEP could be measured when anesthesia was managed with remimazolam at 1 mg/kg/h.

Remimazolam enabled safe anesthetic management during tracheostomy in a patient with amyotrophic lateral sclerosis: a case report.

BACKGROUND: Amyotrophic lateral sclerosis (ALS) is known to cause generalized muscle atrophy and respiratory complications. Anesthetic agents and methods for patients with ALS are extremely important because they critically influence postoperative outcomes. In this clinical case, we mainly used remimazolam for safe anesthesia management. CASE PRESENTATION: A 66-year-old man had a gradual onset of numbness and weakness in his extremities over 2 years. He was diagnosed with ALS after the appearance of dysarthria and restrictive ventilation disorder. Due to the rapid progression of respiratory dysfunction, the patient was placed on artificial respiration, and a tracheostomy was planned. General anesthesia was induced with remimazolam (6 mg/kg/h) and remifentanil (0.5 µg/kg/min). Tracheal intubation was performed without muscle relaxants, followed by total intravenous anesthesia (TIVA) with continuous administration of remimazolam 0.8-1.2 mg/kg/h and remifentanil 0.3-0.5 µg/kg/min. At the end of the surgery, the anesthetic effect of remimazolam was reversed with 0.4 mg of flumazenil. The patient was discharged from the operating room with stable breathing, and changes to preoperative ventilator settings were not necessary. CONCLUSIONS: We safely performed tracheostomy for a patient with ALS using remimazolam during general anesthesia.

Investigations into the efficacy of a novel extubation-aerosol shield: a cough model study.

BACKGROUND: Physicians have had to perform numerous extubation procedures during the prolonged coronavirus disease 2019 (COVID 19) pandemic. Future pandemics caused by unknown pathogen may also present a risk of exposure to infectious droplets and aerosols. AIM: This study evaluated the ability of a newly developed aerosol barrier, "Extubation-Aerosol (EA)-Shield" to provide maximum protection from aerosol exposure during extubation via an aerosolised particle count and high-quality visualisation assessments. METHODS: We employed a cough model having parameters similar to humans and used micron oil aerosol as well as titanium dioxide as aerosol tracers. Aerosol barrier techniques employing a face mask (group M) and EA-Shield (group H) were compared. FINDINGS: The primary outcome was the difference in the number of particles contacting the physician's face before and after extubation. The maximum distances of aerosol dispersal after extubation were measured as the secondary outcomes. All aerosolised particles of the two tracers were significantly smaller in group H than in group M (p < 0.05). In addition, the sagittal and axial maximum distances and sagittal areas of aerosol dispersal for 3, 5, and 10 s after extubation were significantly smaller in group H than in group M (p < 0.05). CONCLUSION: This model indicates that EA-Shield could be highly effective in reducing aerosol exposure during extubation. Therefore, we recommend using it as an aerosol barrier when an infectious aerosol risk is suspected.

Aerosol boxes decrease aerosol exposure only in depressurized rooms during aerosol-generating procedures in a simulation study.

PURPOSE: The aim of this study was to compare aerosol exposure with or without an aerosol box in a pressurized/depressurized room during aerosol-generating procedures using an experimental model. METHODS: Cake flour (aerosol model) was expelled from an advanced life support training mannequin. The primary outcome measure was the number of 0.3-10 µm-sized particles at three locations corresponding to the physician, medical staff, and environmental aerosol exposure levels. The aerosol dispersion was visualized using a high-resolution video. The number of expelled particles was measured after artificial coughing during simulated tracheal intubation and extubation in four situations, with or without an aerosol box in a pressurized or depressurized room (≤ 2.5 Pa). RESULTS: The particles arising from tracheal intubation at the three positions in the four groups differed significantly in size (p < 0.05). The sizes of particles arising from extubation at the physicians' and medical staff's faces in the four groups differed significantly in size (p < 0.05). Post hoc analysis showed that the counts of all particles at the three positions were significantly lower in the depressurized room with an aerosol box than in the pressurized room without an aerosol box during tracheal intubation (p < 0.05 at three positions) and extubation (p < 0.05) at the physician's and medical staff's positions). Visual assessments supported these results. CONCLUSION: The aerosol box decreased the exposure of the aerosol to the physician, medical staff, and environment during aerosol-generating procedures in the depressurized room only.

Dexmedetomidine Ameliorates Perioperative Neurocognitive Disorders by Suppressing Monocyte-Derived Macrophages in Mice With Preexisting Traumatic Brain Injury.

BACKGROUND: Traumatic brain injury (TBI) initiates immune responses involving infiltration of monocyte-derived macrophages (MDMs) in the injured brain tissue. These MDMs play a key role in perioperative neurocognitive disorders (PNDs). We tested the hypothesis that preanesthetic treatment with dexmedetomidine (DEX) could suppress infiltration of MDMs into the hippocampus of TBI model mice, ameliorating PND. METHODS: We first performed bone marrow transplantation from green fluorescent protein-transgenic mice to C57BL/6 mice to identify MDMs. We used only male mice for homogeneity. Four weeks after transplantation, a controlled cortical impact model of TBI was created using recipient mice. Four weeks after TBI, mice received pretreatment with DEX before general anesthesia (GA). Mice performed the Barnes maze test (8-12 mice/group) 2 weeks after GA and were euthanized for immunohistochemistry (4-5 mice/group) or immunoblotting (7 mice/group) 4 weeks after GA. RESULTS: In Barnes maze tests, TBI model mice showed longer primary latency (mean difference, 76.5 [95% confidence interval, 41.4-111.6], P < .0001 versus Naïve), primary path length (431.2 [98.5-763.9], P = .001 versus Naïve), and more primary errors (5.7 [0.62-10.7], P = .017 versus Naïve) than Naïve mice on experimental day 3. Expression of MDMs in the hippocampus was significantly increased in TBI mice compared to Naïve mice (2.1 [0.6-3.7], P = .003 versus Naïve). Expression of monocyte chemotactic protein-1 (MCP1)-positive areas in the hippocampus was significantly increased in TBI mice compared to Naïve mice (0.38 [0.09-0.68], P = .007 versus Naïve). Immunoblotting indicated significantly increased expression of interleukin-1ß in the hippocampus in TBI mice compared to Naïve mice (1.59 [0.08-3.1], P = .035 versus Naïve). In contrast, TBI mice pretreated with DEX were rescued from these changes and showed no significant difference from Naïve mice. Yohimbine, an α2 receptor antagonist, mitigated the effects of DEX (primary latency: 68.3 [36.5-100.1], P < .0001 versus TBI-DEX; primary path length: 414.9 [120.0-709.9], P = .0002 versus DEX; primary errors: 6.6 [2.1-11.2], P = .0005 versus TBI-DEX; expression of MDMs: 2.9 [1.4-4.4], P = .0001 versus TBI-DEX; expression of MCP1: 0.4 [0.05-0.67], P = .017 versus TBI-DEX; expression of interleukin-1ß: 1.8 [0.34-3.35], P = .01 versus TBI-DEX). CONCLUSIONS: Preanesthetic treatment with DEX suppressed infiltration of MDMs in the hippocampus and ameliorated PND in TBI model mice. Preanesthetic treatment with DEX appears to suppress infiltration of MDMs in the hippocampus and may lead to new treatments for PND in patients with a history of TBI.

Effect of remimazolam on intraoperative neuromonitoring during thyroid surgery: a case series.

Intraoperative neuromonitoring is widely used to prevent accidental injury during thyroid surgery. Anesthesia should be performed without muscle relaxant or agents with high muscle-relaxant potency. Remimazolam, a novel intravenous anesthetic, became available for clinical use in 2020. Remimazolam is an ultra-short-acting benzodiazepine with a very high clearance rate. However, there are very few data regarding its effect on currently used intraoperative neurological monitoring. Five patients underwent thyroid surgery using intraoperative recurrent laryngeal neuromonitoring. In all cases, intubation was performed after the administration of rocuronium. Anesthesia was maintained by continuous administration of remimazolam at the recommended dose and remifentanil, and no additional rocuronium or sugammadex was administered. Recurrent laryngeal nerve activity could be detected at the first stimulus after surgery was started, and monitoring continued thereafter. Intraoperative monitoring was performed without problems and all surgeries were completed without any complications. Anesthesia with remimazolam at the normal dose did not prolong the time to first positive electromyogram in patients undergoing thyroid surgery, and enables intraoperative recurrent laryngeal nerve monitoring to be performed without any serious perioperative adverse events. Remimazolam may provide a comparable quality of anesthesia to that of existing drugs for neuromonitoring during thyroid surgery.

Safety of an improved pediatric epidural tunneling technique for catheter shear.

BACKGROUND: Epidural tunneling could help with prolonged catheterization and be effective in preventing infection and dislodgement. However, epidural tunneling techniques carry a risk of catheter shear or needlestick injuries. AIMS: This study aimed to examine the safety of our epidural tunneling technique in terms of catheter shear. METHODS: This study was designed as a double-blinded, single-crossover, in vitro study. Each of the operators performed two techniques to create a subcutaneous tunnel. We compared outcomes between the control tunneling technique (group C) and our improved technique (group I). Microscopic findings of catheter shear were assessed as the primary outcome. Secondary outcomes included the tension and displacement required to break the epidural catheter and the frequency of catheter breakage due to catheter shear. Data were analyzed using the Fisher's exact test and Mann-Whitney U test. A p-value of <.05 was considered statistically significant. RESULTS: Ten catheters were assessed in each group. The frequency of catheter shear was 10% in group I and 90% in group C (odds ratio, 0.019; 95% confidence interval [CI], 0.01-0.31; p < .001). The frequency of catheter breakage due to catheter shear was significantly lower in group I (0%) than in group C (80%; p < .001). The mean tension and displacement required to break the catheter were significantly higher in group I than in group C (4.13 ± 0.37 N vs. 3.14 ± 1.00 N; mean difference, 0.99 N; 95% CI, 0.25-1.73 N; p = .013 and 222 ± 59.9 mm vs. 122 ± 77.7 mm; mean difference, 100 mm; 95% CI, 34.1-165 mm; p = .005). CONCLUSIONS: Our improved epidural tunneling technique, which was designed for pediatric cases, could reduce the risk of catheter shear.

Remimazolam for a patient with myotonic dystrophy type 1 who underwent endoscopic retrograde cholangiopancreatography under general anesthesia: a case report.

BACKGROUND: Remimazolam is a benzodiazepine receptor agonist with an ultra-short-acting anesthetic effect. We used remimazolam for anesthesia in a patient with myotonic dystrophy type 1 who underwent endoscopic retrograde cholangiopancreatography (ERCP). CASE PRESENTATION: A 58-year-old woman received ERCP under general anesthesia. She had impaired respiratory function due to myotonic dystrophy type I and was at a risk of respiratory complications after anesthesia. General anesthesia was induced with remimazolam 12 mg/kg/h, remifentanil 0.1 µg/kg/min and rocuronium 15 mg, followed by tracheal intubation and maintained with remimazolam 0.8-1.0 mg/kg/h. At the end of anesthesia, we injected sugammadex 150 mg and flumazenil 0.2 mg, allowing smooth and clear emergence from anesthesia. She was discharged from the hospital without any respiratory problems on postoperative day 5. CONCLUSIONS: Remimazolam was safe to use for general anesthesia in a patient with myotonic dystrophy type 1 undergoing ERCP.

Careful medical interview and ultrasonography enabled detection of acute kidney injury and hematoma after lumbar trigger point injection-a case report.

BACKGROUND: Trigger point blocks are now widely practiced, especially in pain treatment. Among the complications of lumbar trigger point injection, reports of medically induced kidney injury are very rare, and diagnosis during emergency treatment is rare. CASE PRESENTATION: A 78-year-old woman on antiplatelet medication following a stroke was diagnosed with treatable type A aortic dissection at another hospital after undergoing lumbar trigger point injection. On arrival at our hospital, there were no signs of hemodynamic deterioration. Additional careful medical re-interview and ultrasonography by anesthesiologists enabled a definitive diagnosis of acute kidney damage and hematoma caused by lumbar trigger point injection, and aortic dissection surgery was abandoned. CONCLUSION: This clinical case demonstrates the importance of awareness of potential kidney injury and hematoma during lumbar trigger point injection.

Head Rotation Reduces Oropharyngeal Leak Pressure of the i-gel and LMA® Supreme™ in Paralyzed, Anesthetized Patients: A Randomized Trial.

BACKGROUND: Second-generation supraglottic airway (SGA) devices are useful for airway management during positive pressure ventilation in general anesthesia and emergency medicine. In some clinical settings, such as the anesthetic management of awake craniotomy, SGAs are used in the head-rotated position, which is required for exposure of the surgical field, although this position sometimes worsens the efficiency of mechanical ventilation with SGAs. In this study, we investigated and compared the influence of head rotation on oropharyngeal leak pressures (OPLP) of the i-gel and LMA® Supreme™, which are second-generation SGA devices. METHODS: Patients who underwent elective surgery under general anesthesia were enrolled in this study and randomly divided into i-gel or LMA Supreme groups. After induction of anesthesia with muscle relaxation, the i-gel or LMA Supreme was inserted according to computerized randomization. The primary outcome was the OPLP at 0°, 30°, and 60° head rotation. The secondary outcomes were the maximum airway pressure and expiratory tidal volume when patients were mechanically ventilated using a volume-controlled ventilation mode with a tidal volume of 10 mL/kg (ideal body weight), ventilation score, and fiber-optic views of vocal cords. RESULTS: Thirty-four and 36 participants were included in the i-gel and LMA Supreme groups, respectively. The OPLPs of the i-gel and LMA Supreme significantly decreased as the head rotation angle increased (mean difference [95% confidence interval], P value: i-gel; 0° vs 30°: 3.5 [2.2-4.8], P < .001; 30° vs 60°: 2.0 [0.6-3.5], P = .002; 0° vs 60°: 5.5 [3.3-7.8], P < .001, LMA Supreme; 0° vs 30°: 4.1 [2.6-5.5], P < .001; 30° vs 60°: 2.4 [1.1-3.7], P < .001; 0° vs 60°: 6.5 [5.1-8.0], P < .001). There were statistically significant differences in expiratory tidal volume and ventilation score between 0° and 60° in the i-gel group and in ventilation score between 30° and 60° in the LMA Supreme group. There was no statistically significant difference between the 2 devices in all outcome measures. The incidences of adverse events, such as hoarseness or sore throat, were not significantly different between i-gel and LMA Supreme. CONCLUSIONS: Head rotation to 30° and 60° reduces OPLP with both i-gel and LMA Supreme. There is no difference in OPLP between i-gel and LMA Supreme in the 3 head rotation positions.

A patient with myotonic dystrophy diagnosed after experiencing sudden respiratory failure: a case report.

BACKGROUND: Myotonic dystrophy is a disorder affecting multiple organs including skeletal muscles and causes respiratory failure. We describe a patient who developed respiratory failure, with delayed diagnosis of myotonic dystrophy type 1 as the cause. CASE PRESENTATION: A 62-year-old woman developed acute onset of dyspnea after showing hypertension and tachycardia and was transported to our hospital. On arrival at our institution, SpO2 was 80% with a non-rebreather mask. With a diagnosis of acute phase heart failure, she underwent tracheal intubation. However, weaning from the respirator was difficult in the intensive care unit (ICU). A detailed interview revealed that her brother was affected with myotonic dystrophy type 1. She was also diagnosed with myotonic dystrophy type 1 by a genetic test. CONCLUSIONS: Taking a careful past and family history and prompt genetic testing is required on suspicion of neuromuscular diseases in a patient with respiratory failure by an unknown cause.