Association between postinduction hypotension and postoperative mortality: a single-centre retrospective cohort study.

PURPOSE: We aimed to elucidate whether postinduction hypotension (PIH), defined as hypotension between anesthesia induction and skin incision, and intraoperative hypotension (IOH) are associated with postoperative mortality. METHODS: We conducted a retrospective cohort study of adult patients with an ASA Physical Status I-IV who underwent noncardiac and nonobstetric surgery under general anesthesia between 2015 and 2021 at Nagoya City University Hospital. The primary and secondary outcomes were 30-day and 90-day postoperative mortality, respectively. We calculated four hypotensive indices (with time proportion of the area under the threshold being the primary exposure variable) to evaluate the association between hypotension (defined as a mean blood pressure < 65 mm Hg) and mortality using multivariable logistic regression models. We used propensity score matching and RUSBoost (random under-sampling and boosting), a machine-learning model for imbalanced data, for sensitivity analyses. RESULTS: Postinduction hypotension and IOH were observed in 82% and 84% of patients, respectively. The 30-day and 90-day postoperative mortality rates were 0.4% (52/14,210) and 1.0% (138/13,334), respectively. Postinduction hypotension was not associated with 30-day mortality (adjusted odds ratio [aOR], 1.03; 95% confidence interval [CI], 0.93 to 1.13; P = 0.60) and 90-day mortality (aOR, 1.01; 95% CI, 0.94 to 1.07; P = 0.82). Conversely, IOH was associated with 30-day mortality (aOR, 1.19; 95% CI, 1.12 to 1.27; P < 0.001) and 90-day mortality (aOR, 1.12; 95% CI, 1.06 to 1.19; P < 0.001). Sensitivity analyses supported the association of IOH but not PIH with postoperative mortality. CONCLUSION: Despite limitations, including power and residual confounding, postoperative mortality was associated with IOH but not with PIH.

RéSUMé: OBJECTIF: Nous avons cherché à déterminer si l'hypotension post-induction (HPI), définie comme une hypotension entre l'induction de l'anesthésie et l'incision cutanée, et l'hypotension peropératoire (HPO) étaient associées à la mortalité postopératoire. MéTHODE: Nous avons mené une étude de cohorte rétrospective de patient·es adultes ayant un statut physique I-IV selon l'ASA et ayant bénéficié d'une chirurgie non cardiaque et non obstétricale sous anesthésie générale entre 2015 et 2021 à l'Hôpital universitaire de la ville de Nagoya. Les critères d'évaluation principal et secondaire étaient la mortalité postopératoire à 30 et 90 jours, respectivement. Nous avons calculé quatre indices d'hypotension (la proportion temporelle de la zone sous le seuil étant la principale variable d'exposition) pour évaluer l'association entre l'hypotension (définie comme une tension artérielle moyenne < 65 mm Hg) et la mortalité à l'aide de modèles de régression logistique multivariée. Nous avons utilisé l'appariement par score de propension et le RUSBoost (sous-échantillonnage et boosting aléatoire), un modèle d'apprentissage automatique pour les données déséquilibrées, pour les analyses de sensibilité. RéSULTATS: Une HPI et une HPO ont été observées chez 82 % et 84 % des patient·es, respectivement. Les taux de mortalité postopératoire à 30 et 90 jours étaient respectivement de 0,4 % (52/14 210) et de 1,0 % (138/13 334). L'hypotension post-induction n'était pas associée à la mortalité à 30 jours (rapport de cotes ajusté [RCa], 1,03; intervalle de confiance [IC] à 95 %, 0,93 à 1,13; P = 0,60) et à la mortalité à 90 jours (RCa, 1,01; IC 95 %, 0,94 à 1,07; P = 0,82). À l'inverse, l'HPO était associée à une mortalité à 30 jours (RCa, 1,19; IC 95 %, 1,12 à 1,27; P < 0,001) et à la mortalité à 90 jours (RCa, 1,12; IC 95 %, 1,06 à 1,19; P < 0,001). Les analyses de sensibilité ont confirmé l'association de l'HPO, mais pas de l'HPI, avec la mortalité postopératoire. CONCLUSION: Malgré les limitations, y compris la puissance et persistance de facteurs confondants, la mortalité postopératoire était associée à l'hypotension peropératoire mais pas à l'hypotension post-induction seule.

Intercristal line determined by palpation in parturients in the sitting and the lateral decubitus positions: a prospective observational study.

PURPOSE: We aimed to investigate intersected vertebral level changes in the palpated intercristal line (PI-line) when shifting from a sitting to a lateral decubitus position in parturients. METHODS: We consecutively enrolled parturients with a gestational age of ≥36 weeks. The attending anesthesiologists palpated the superior aspects of the posterior iliac crests bilaterally in a sitting position and then in a lateral decubitus position. The blinded investigators performed the ultrasound and recorded the intersected segment level of the PI-line. The distance between any two consecutive vertebral interspaces was divided into 3 segments, and comparisons were made with 15 segments of five vertebral interspaces above the sacrum. The primary outcome was the concordance rate of intersected segment level of the PI-line between the two positions. We also examined the intersected segment level of the PI-line of the two positions and the magnitude of these changes. RESULTS: Thirty-nine parturients were analyzed. The concordance rate of intersected segment levels of the PI-line between the two positions was 21% (8/39). In 56% (22/39) of the parturients, the intersected segment level of the PI-line in the sitting position was more cephalad and 23% (9/39) were more caudal. Fifteen percent (6/39) of parturients had three or more segment differences between the two positions. CONCLUSIONS: The intersected segment level of the PI-line, measured with trisected segments in each vertebral interspace, was different between the sitting and the lateral decubitus positions in approximately 80% of the parturients. Notably, 15% (6/39) of the parturients had at least one vertebral interspace deviation.

AutoFlow® versus volume-controlled ventilation for laparoscopic gynecological surgery using LMA® ProSeal™: a randomized controlled trial.

BACKGROUND: During laparoscopic gynecological surgery, increased peak airway pressure (PAWP) can cause airway leak upon ventilation with the LMA® ProSeal™. We hypothesized that compared with the use of volume-controlled ventilation (VCV), the use of the AutoFlow® mode would decrease PAWP and airway leak during laparoscopic gynecological surgery with LMA ProSeal. METHODS: This single-center, randomized, controlled trial allocated 80 adult women undergoing elective laparoscopic gynecological surgery to one of two groups, namely, the AutoFlow group or the VCV group. Ventilation settings for both groups were 8 ml/kg of tidal volume and 5 cmH2O of positive end-expiratory pressure, and respiratory rate was adjusted to maintain end-tidal carbon dioxide at 35-40 mmHg. Airway leak, PAWP, and other ventilatory parameters and vital signs were recorded at four timepoints (1, 1 min after insertion of the gastric tube; 2, 2 min after intravenous administration of rocuronium 0.6-0.8 mg/kg; 3, 1 min after initiation of pneumoperitoneum; and 4, 1 min after changing to the Trendelenburg position). The primary outcome was PAWP during pneumoperitoneum and in the Trendelenburg position, whereas the secondary outcomes included PAWP at other timepoints and airway leak development. We used the Mann-Whitney U test for PAWP and Fisher's exact test for comparing airway leak among the groups. RESULTS: Data from 40 patients in the AutoFlow group and 39 in the VCV group were used for analysis. PAWP at pneumoperitoneum pressure and in the Trendelenburg position was significantly lower in the AutoFlow group than in the VCV group [median (interquartile range), 16 (15-18) cmH2O vs. 18 (17-19) cmH2O; P < 0.001]. Similarly, patients in the AutoFlow group showed lower PAWP at the other three timepoints measured. Airway leak occurred in four patients in the AutoFlow group and in two patients in the VCV group; however, this incidence was not significantly different (P = 0.68). CONCLUSIONS: Even though AutoFlow ventilation decreased PAWP, it did not reduce the incidence of airway leak compared with VCV during laparoscopic gynecological surgery with the LMA ProSeal. TRIAL REGISTRATION: UMIN Clinical Trials Registry, identifier UMIN000023173 .

Remimazolam for induction of anesthesia in elderly patients with severe aortic stenosis: a prospective, observational pilot study.

BACKGROUND: Remimazolam, a novel benzodiazepine, has been reported to cause less hypotension than propofol during induction of anesthesia. Therefore, remimazolam might be a valuable option in elderly patients with severe aortic stenosis who are considered to be the most vulnerable to hemodynamic instability. We aimed to evaluate the feasibility and hemodynamic effects of remimazolam as an induction agent in elderly patients with severe aortic stenosis. METHODS: This prospective, open-label, single-arm, observational pilot study was conducted in a university hospital between November 2020 and April 2021. We included 20 patients aged 65 years or older scheduled for transcatheter or surgical aortic valve replacement for severe aortic stenosis under general anesthesia. Patients were administered intravenous remimazolam infusion at 6 mg/kg/h combined with 0.25 µg/kg/min of remifentanil infusion. The primary outcome was the vasopressor dosage between the induction of anesthesia and the completion of tracheal intubation. The secondary outcomes included hemodynamic changes, bispectral index changes, and the time from the start of remimazolam infusion to loss of consciousness. We also recorded awareness during anesthesia induction and serious adverse events related to death, life-threatening events, prolonged hospitalizations, and disability due to permanent damage. RESULTS: Twenty patients aged 84 [79-86] (median [interquartile range]) with American Society of Anesthesiologists physical status 4 were analyzed. Ephedrine 0 [0-4] mg and phenylephrine 0.1 [0-0.1] mg were administered to 14/20 patients (3 doses in 1 patient, 2 doses in 4 patients, and one dose in 9 patients). Loss of consciousness was achieved at 80 [69-86] s after the remimazolam infusion was started. The mean arterial pressure decreased gradually after loss of consciousness but recovered immediately after tracheal intubation. The bispectral index values gradually decreased and reached < 60 at 120 s after loss of consciousness. Neither awareness during induction of anesthesia nor serious adverse events, such as severe bradycardia (< 40 bpm), life-threatening arrhythmia, myocardial ischemia, or anaphylactic reactions were observed. CONCLUSIONS: Remimazolam could be used as an induction agent with timely bolus vasopressors in elderly patients with severe aortic stenosis. TRIAL REGISTRATION: UMIN Clinical Trials Registry, identifier UMIN000042318 .

Effects of the anesthesiologist's experience on postoperative hoarseness after double-lumen endotracheal tube intubation: a single-center propensity score-matched analysis.

BACKGROUND: Postoperative hoarseness after general anesthesia is associated with patient discomfort and dissatisfaction. A recent large retrospective study showed that single-lumen endotracheal tube intubation by a trainee did not alter the incidence of postoperative pharyngeal symptoms compared with intubation by a senior anesthesiologist. However, there is limited information about the relationship between the anesthesiologist's experience and hoarseness after double-lumen endotracheal tube intubation. We tested the hypothesis that double-lumen endotracheal tube intubation performed by a trainee increases the incidence of postoperative hoarseness compared to intubation by a senior anesthesiologist. METHODS: This retrospective observational study included patients who underwent lung resection between April 2015 and March 2018 at a university hospital. Double-lumen endotracheal tube intubation was carried out with a Macintosh laryngoscope. We divided the patients into 2 groups - one group comprised of patients who were intubated by a trainee anesthesiologist with < 2 years of experience, and the other group comprised of those who underwent intubation by a senior anesthesiologist with ≥2 years of experience. The primary outcome was the incidence of postoperative hoarseness 24 h after surgery and we collected data on postoperative hoarseness using a checklist of postanesthetic adverse events. One-to-one propensity score matching was conducted and P values < 0.05 were considered statistically significant. RESULTS: There was a total of 256 eligible patients, of which 153 underwent intubation by trainee anesthesiologists, and the remaining 103 patients were intubated by a senior anesthesiologist. The one-to-one propensity score matching resulted in 96 pairs of patients for the groups. The incidence of postoperative hoarseness 24 h after surgery was significantly higher in patients who were intubated by a trainee anesthesiologist than in patients who were intubated by a senior anesthesiologist (9.4% vs. 2.1%, respectively; P = 0.03). CONCLUSIONS: Double-lumen endotracheal tube intubation by trainee anesthesiologists with < 2 years of experience increased the incidence of postoperative hoarseness 24 h after surgery compared to intubation by senior anesthesiologists with ≥2 years of experience.

A learning curve of LMA® ProSeal™ insertion: a prospective analysis of cumulative sum method.

PURPOSE: LMA® ProSeal™ (pLMA) has been used as an alternative to tracheal tubes. It is unclear how many cases are required to achieve proficiency in performing pLMA insertion among novice residents. Therefore, we analyzed the learning curve of pLMA insertion using a cumulative sum (CUSUM) chart and assessed the effects of learning. METHODS: In this single-center, prospective, observational study, we included 15 novice residents. Staff anesthesiologists recorded success or failure; insertion time; and incidences of bleeding or reflex including cough, hiccups, and limb movement. A successful pLMA insertion was defined as effective ventilation within two attempts with an insertion time of ≤ 120 s. Regarding CUSUM, we set acceptable and unacceptable failure rates as 20% and 40%, respectively. Further, α and ß errors were designated as 0.1. We stratified the number of cases encountered by each resident into four groups of 10 cases each (1-10, 11-20, 21-30, and ≥ 31 cases) and evaluated the effects of learning. RESULTS: Each resident encountered 44 ± 5 (mean ± SD) cases of pLMA insertion, and 14/15 achieved proficiency in performing pLMA insertion after 20 ± 8 cases. Success rate (76%, 86%, 91%, and 93%; P < 0.001) and insertion time (45 s, 35 s, 31 s, and 26 s; P < 0.001) significantly improved with increased experience; however, incidences of bleeding (16%, 10%, 8%, and 10%; P = 0.124) and reflex (5%, 3%, 3%, and 3%; P = 0.54) remained unchanged. CONCLUSION: Experience with 20 ± 8 cases is needed to achieve proficiency in performing pLMA insertion for novice residents in a tertiary teaching hospital.

Age is a predictive factor in the femoral nerve positioning: an anatomical ultrasound study.

Precise identification of the femoral nerve (FN) is essential for an ultrasound-guided femoral nerve block. We hypothesized that the distance between the FN and the femoral artery (FA) is correlated with patient age. In this prospective observational study, we evaluated the FN-FA (from the lateral edge of the FA to the medial edge of the FN) distance [0.42 ± 0.42 (mean ± standard deviation) cm] in 102 patients using ultrasound. In addition, we calculated the cross-sectional area of the iliopsoas muscle using computed tomography or magnetic resonance imaging. Multiple regression analyses revealed that age was significantly and positively correlated with the FN-FA distance (R2 = 0.72, p < 0.001) and that this correlation was greater than that between height, weight, or gender and the FN-FA distance. Further, the cross-sectional area of the iliopsoas muscle per weight was significantly correlated with age (R2 = 0.54, p < 0.001) and the FN-FA distance (R2 = 0.50, p < 0.001). These findings may help refine the ultrasound techniques used for the femoral nerve block.

Unexpected Systolic Anterior Motion of the Mitral Valve Diagnosed by Transthoracic Echocardiography after the Induction of General Anesthesia.

We report an 87-year-old woman who presented with unexpected systolic anterior motion (SAM) of the mitral valve after the induction of general anesthesia. She was receiving medication for hypertension and cerebral infarction. There were no abnormal findings on her preoperative transthoracic echocardiography (TTE) examination. After the induction of general anesthesia, she presented with refractory hypotension. We performed TTE and diagnosed SAM of the mitral valve. Her hemodynamic state was improved by fluid infusion and administering intravenous phenylephrine. After the surgery, we performed a morphologic assessment of the patient's heart using TTE. We found a thick basal interventricular septum and a small distance from the mitral coaptation point. to the septum. This case shows that SAM of the mitral valve can occur in a patient without preoperative cardiac abnormalities. SAM of the mitral valve should be considered in the differential diagnosis of refractory hypotension, particularly in elderly patients. Perioperative TTE is a useful tool for the rapid diagnosis and treatment of hemodynamic instability.

In-Hospital Onset of Transient Myoclonic State in Older Adults: A Case Report.

Background: Transient myoclonic (TM) state in older adults is a neurological condition characterised by short-lived, repetitive myoclonus without consciousness disturbance. First reported in 1992, it predominantly affects older individuals with chronic diseases. Despite its clear symptomatology, TM often remains under-recognised, leading to potential misdiagnoses. Case description: We report a case of a 68-year-old woman with a history of chronic heart failure who developed TM during hospitalisation following medication adjustment for acute heart failure. The patient, who had no history of intracranial disease or epilepsy, experienced acute involuntary movements of the face and limbs three days after diuretic adjustment. She responded well to intravenous diazepam and oral clonazepam, with no recurrence of symptoms post-treatment. Discussion: TM presents with bilateral, irregular, and repetitive myoclonus, mostly affecting the head, neck and upper extremities. Diagnosis is clinical, based on symptomatology and normal laboratory results. This case underscores the importance of recognising TM in differential diagnosis, especially in older patients in the acute or recovery phase of infection, or with medication changes. The potential role of fluid volume changes in TM pathophysiology in patients with underlying conditions such as hypertension or chronic heart failure is also highlighted. This case emphasises the need for heightened awareness and knowledge of TM among healthcare professionals. Conclusions: TM, though rare, requires awareness among clinicians for accurate diagnosis and management. It is crucial to avoid misdiagnosis and unnecessary interventions, and to provide appropriate information during care transitions, particularly in older adults with chronic conditions. LEARNING POINTS: Transient myoclonic (TM) state is a rare neurological condition in older adults, characterised by brief and repetitive myoclonus, primarily affecting the head, neck and upper extremities.The distinctive clinical diagnostic feature is myoclonus occurring without disturbances in consciousness, without amnesia or paralysis, while retaining the ability to perform directed movements. This condition can manifest at rest, may worsen with posture or movement, and tends to improve during sleep.Management strategies include ensuring smooth care transitions, avoiding misdiagnosis and educating patients and families about the risk of recurrence.

Peritonsillar abscess associated with Helicobacter cinaedi bacteremia: A case report.

Helicobacter cinaedi, a gram-negative spiral bacterium, has historically been associated with infections primarily in immunocompromised patients. Recently, however, its potential to cause infections in immunocompetent individuals has been recognized. We report a unique case of a man in his 20 s who reported having sex with men. He presented with symptoms of fever and throat discomfort and was diagnosed with a peritonsillar abscess. While the rapid antigen test for Group A Streptococcus was positive and antibiotics were administered, a puncture fluid from the peritonsillar abscess taken the day after antibiotic treatment revealed the presence of Group C Streptococcus. By the fifth day, the blood culture taken on the first day detected a gram-negative spirochete, which was subsequently identified H. cinaedi. The patient had engaged in oral sex with his male partner, suggesting a potential transmission route. This is significant as H. cinaedi was initially identified from rectal cultures in men who have sex with men (MSM), raising the possibility of pharyngeal transmission through oral sex. In our patient, although H. cinaedi was not isolated from the aspirate of the peritonsillar abscess, its presence in the blood culture and lack of other potential sources of bacteremia make the abscess a likely primary site of infection. This case highlights the importance of considering H. cinaedi as a potential pathogen in immunocompetent patients, particularly in cases of MSM. The potential for H. cinaedi transmission through oral sex and its role in the development of peritonsillar abscesses, a previously unreported association, requires further investigation.

Chronic bromine intoxication complicated with Fanconi syndrome: A case report.

In this report, we describe a unique case of an 80-year-old woman who developed chronic bromine poisoning due to the prolonged ingestion of over-the-counter (OTC) medication containing bromovalerylurea (BVU), thus leading to the onset of drug-induced partial Fanconi syndrome and resultant osteomalacia. The patient's condition improved following the cessation of bromide intake. This case highlights the potential risks of chronic BVU exposure and the importance of caution regarding the use of OTC medications containing BVU.

Development and Validation of a Prediction Model for Acute Hypotensive Events in Intensive Care Unit Patients.

Background: Persistent hypotension in the intensive care unit (ICU) is associated with increased mortality. Predicting acute hypotensive events can lead to timely intervention. We aimed to develop a prediction model of acute hypotensive events in patients admitted to the ICU. Methods: We included adult patients admitted to the Nagoya City University (NCU) Hospital ICU between January 2018 and December 2021 for model training and internal validation. The MIMIC-III database was used for external validation. A hypotensive event was defined as a mean arterial pressure < 60 mmHg for at least 5 min in 10 min. The input features were age, sex, and time-series data for vital signs. We compared the area under the receiver-operating characteristic curve (AUROC) of three machine-learning algorithms: logistic regression, the light gradient boosting machine (LightGBM), and long short-term memory (LSTM). Results: Acute hypotensive events were found in 1325/1777 (74.6%) and 2691/5266 (51.1%) of admissions in the NCU and MIMIC-III cohorts, respectively. In the internal validation, the LightGBM model had the highest AUROC (0.835), followed by the LSTM (AUROC 0.834) and logistic regression (AUROC 0.821) models. Applying only blood pressure-related features, the LSTM model achieved the highest AUROC (0.843) and consistently showed similar results in external and internal validation. Conclusions: The LSTM model using only blood pressure-related features had the highest AUROC with comparable performance in external validation.

Writing Case Reports Can Improve Seven Components in Clinical Reasoning.

Case reports provide scientific knowledge and opportunities for new clinical research. However, it is estimated that less than 5% of cases presented by Japanese generalists at academic conferences are published due to various barriers such as the complex process of writing articles, conducting literature searches, the significant time required, the reluctance to write in English, and the challenge of selecting appropriate journals for publication. Therefore, the purpose of this opinion paper is to provide clinicians with practical tips for writing case reports that promote diagnostic excellence. In recent years, clinical practitioners have been striving for diagnostic excellence and optimal methods to accurately and comprehensively understand the patient's condition. To write a case report, it is essential to be mindful of the elements of diagnostic excellence and consider the quality of the diagnostic reasoning process. We (the authors) are seven academic generalists who are members of the Japanese Society of Hospital General Medicine (JSHGM) - Junior Doctors Association, with a median of 7 years after graduation and extensive experience publishing case reports in international peer-reviewed journals. We conducted a narrative review and discussed ways to write case reports to promote diagnostic excellence, leveraging our unique perspectives as academic generalists. Our review did not identify any reports addressing the critical points in writing case reports that embody diagnostic excellence. Therefore, this report proposes a methodology that describes the process involved in writing diagnostic excellence-promoting case reports and provides an overview of the lessons learned. Based on our review and discussion, we explain the essential points for promoting diagnostic excellence through case reports categorized into seven components of clinical reasoning. These strategies are useful in daily clinical practice and instrumental in promoting diagnostic excellence through case reports.

Concise synthesis of a probe molecule enabling analysis and imaging of vizantin.

Trehalose 6,6'-dicorynomycolate (TDCM) was first characterized in 1963 as a cell surface glycolipid of Corynebacterium spp. by Ioneda and co-workers. TDCM shows potent anti-tumor activity due to its immunoadjuvant properties. Furthermore, the toxicity of TDCM in mice is much weaker than the related trehalose diester of mycolic acid; trehalose 6,6'-dimycolate (TDM, formerly known as cord factor). We have investigated the chemical modification of this class of compound to generate novel agents that display increased immunoadjuvant activity with minimal associated toxicity. During the course of this work we recently developed 6,6'-bis-O-(3-nonyldodecanoyl)-α,α'-trehalose (designated as vizantin). Our results show that vizantin exhibited a potent prophylactic effect on experimental lung metastasis of B16-F0 melanoma cells without a loss of body weight and death in mice. Furthermore, vizantin effectively stimulated human macrophages in an in vitro model, making it a promising candidate for a safe adjuvant in clinical applications. In order to elucidate the pharmacokinetics of vizantin, a probe molecule with similar activity was developed on the basis of a structure-activity relationship (SAR) study with vizantin. The distribution of the probe molecule after intravenous administration into a mouse was assessed by macro confocal microscopy, where it was found to accumulate in the lungs and liver.

Prediction model of postoperative pain exacerbation using an intravenous patient-controlled analgesia device and a wearable electrocardiogram sensor.

There is a need to develop objective and real-time postoperative pain assessment methods in perioperative medicine. Few studies have evaluated the relationship between pain severity and temporal changes of physiological signals in actual postoperative patients. In this study, we developed a machine learning model which was trained from intravenous patient-controlled analgesia (IV-PCA) records and electrocardiogram (ECG) of postoperative patients to predict pain exacerbation. A self-attentive autoencoder (SA-AE) model achieved 54% of sensitivity and a 1.76 times/h of false positive rate.Clinical relevance- We proposed a novel method for evaluating postoperative pain in real time and demonstrated the possibility of predicting pain exacerbation. The proposed method would realize the automatic administration of analgesics and the optimization of opioid doses.

Anesthetic Management of Inguinal Hernia Surgery Using a Second-Generation Supraglottic Airway in a Patient With Trisomy 18: A Case Report.

Children with trisomy 18 have abnormal airway anatomy, making their airway management challenging. Only a few papers have comprehensively described and discussed the use of supraglottic airway devices in patients with trisomy 18. We present a case of a 20-month-old boy with trisomy 18 who was scheduled for open repair of the right inguinal hernia. He had micrognathia, a short neck, and an atrial septal defect but was in a clinically stable condition. A supraglottic airway device was inserted under general anesthesia. The patient's respiration was maintained by pressure support ventilation with spontaneous breathing. A right ilioinguinal-iliohypogastric nerve block was performed for perioperative analgesia. The surgery ended without complications. After removing the supraglottic airway device and ensuring proper respiratory parameters, the patient was transferred to the post-anesthesia care unit. In our case, supraglottic airway devices could be effectively used as a primary airway for inguinal hernia repair. The concomitant ilioinguinal-iliohypogastric nerve block was helpful for anesthetic management with spontaneous breathing maintained using pressure support ventilation. A supraglottic airway device may be a potential alternative as a primary airway for superficial surgery in pediatric patients with trisomy 18. For pediatric patients with difficult airways, a second-generation supraglottic airway device with the insertion of a gastric tube to prevent gastric insufflation combining pressure support ventilation and positive end-expiratory pressure may be a beneficial choice for the maintenance of spontaneous breathing.

Learning curve of i-gel insertion in novices using a cumulative sum analysis.

The i-gel, a popular second-generation supraglottic airway device, has been used in a variety of airway management situations, including as an alternative to tracheal intubation for general anesthesia, rescue in difficult airway settings, and out-of-hospital cardiac arrest resuscitation. We aimed to investigate the number of experiences needed to achieve a rapid, highly successful first attempt i-gel insertion in novices with a cumulative sum analysis. We also looked at how learning affected success rates, insertion time, and bleeding and reflex (limb movement, frowning face, or coughing) incidences. This prospective observational study included 15 novice residents from March 2017 to February 2018 in a tertiary teaching hospital. Finally, 13 residents with 35 [30-42] (median [interquartile range]) cases of i-gel insertion were analyzed. The cumulative sum analysis showed that 11 of 13 participants had an acceptable failure rate after 15 [8-20] cases. With increasing experience, success rate (P = 0.004), insertion time (P < 0.001), and incidence of bleeding (P = 0.006) all improved. However, the incidence of reflex did not change (P = 0.43). Based on our results, we suggest that 20 cases are preferable for novices to develop skills in using the i-gel in airway management.

Malposition of a pulmonary artery catheter in the left ventricle: a case report.

BACKGROUND: Placement of pulmonary artery catheters may be associated with a variety of complications. We present a case where a pulmonary artery catheter was accidentally advanced into the left ventricle by perforating the intraventricular septum. CASE PRESENTATION: A 73-year-old woman underwent mitral valve dysfunction. A pulmonary artery catheter could not pass the tricuspid valve under general anesthesia, which was manually advanced via the right ventricle during surgery. After valve replacement, systolic pulmonary artery pressure was higher than radial arterial blood pressure. Transesophageal echocardiography (TEE) revealed the tip of the catheter in the left ventricle. The catheter was withdrawn and then advanced to the pulmonary artery under monitoring of TEE. Transseptal shunt flow gradually decreased and finally disappeared. The surgery was completed without additional procedures. CONCLUSIONS: Although ventricular septal perforation is rare, it should be recognized as a potential complication of pulmonary artery catheter insertion.

Osmotic Demyelination Syndrome in a Patient with Diabetic Ketoacidosis Despite No Rapid Sodium Correction.

Osmotic demyelination syndrome (ODS) occurs in patients with diabetes and hyponatremia. We herein report a case of ODS with chorea detected on serial magnetic resonance imaging (MRI), despite no prompt hyponatremia correction. A 74-year-old man with cirrhosis and uncontrolled type 2 diabetes developed an altered mental status and chorea during treatment for diabetic ketoacidosis (DKA). Despite no rapid sodium correction and normal initial brain MRI findings, serial MRI revealed ODS-related abnormalities. Clinicians should consider ODS in patients with DKA and a hyperosmolar hyperglycemic state displaying unconsciousness and neurological manifestations, including chorea, even without substantial changes in serum sodium levels. An MRI re-examination can help capture missing ODS complications.