The effect of combining prewarming with intraoperative phenylephrine infusion on the prevention of hypothermia in patients undergoing urological surgery: a prospective, randomized, and controlled trial.

Background: Hypothermia is common in patients undergoing urological surgery; however, no single preventative modality is completely effective. This study evaluated the effects of combining prewarming with intraoperative phenylephrine infusion for the prevention of hypothermia in patients undergoing urological surgery. Methods: This prospective study enrolled 58 patients scheduled for urological surgery under general anesthesia. The patients were randomized into two groups (n = 29). Patients in the experimental (prewarming and phenylephrine infusion) group (PP group) received prewarming for 20 min and intraoperative phenylephrine infusion, whereas those in the control group (C group) received no active prewarming with only intermittent administration of vasoactive agents. The patient's sublingual temperatures before and after anesthesia and nasopharyngeal temperature during anesthesia were recorded as core temperatures. Results: The incidence of intraoperative hypothermia was higher in the C group than in the PP group (57.7% [15/26] vs. 23.1% [6/26], P = 0.01). The severity of intraoperative hypothermia was higher in the C group than in the PP group (P = 0.004). The nasopharyngeal temperature at the end of surgery was lower in the C group than in the PP group (35.8 ± 0.6°C vs. 36.3 ± 0.4°C, P = 0.002). The trend of core temperature decline during the first hour after anesthesia induction differed between the two groups (P = 0.003; its decline was more gradual in the PP group). Conclusions: The combination of prewarming for 20 min and intraoperative phenylephrine infusion reduced the incidence and severity of intraoperative hypothermia and modified the trend of decreasing core temperatures in patients undergoing urological surgery.

Cor triatriatum sinister diagnosed in a patient with postoperative cerebral infarction after beach chair position: A case report.

Cor triatriatum sinister is a rare congenital heart disease in which the left atrium is divided into two compartments by a fibromuscular membrane. In most cases, its symptoms appear in childhood, and it is rarely diagnosed in adulthood. Patients with cor triatriatum sinister are more prone to neurological diseases, such as cerebral infarction. Herein, we report the case of a patient whose cor triatriatum sinister went undiagnosed in the preoperative evaluation, but was diagnosed whilst investigating a cerebral infarction that occurred following a surgery in the beach chair position. It highlights the potential complications in otherwise healthy asymptomatic patients undergoing surgery in the beach chair position. Additionally, in high-risk patients, the provision of clear communication, in advance, regarding potential complications and their management, may reduce the patient's morbidity.

Evaluation of Portal, Splenic, and Hepatic Vein Flows in Children Undergoing Congenital Heart Surgery.

OBJECTIVE: Little is known about changes in portal, splenic, and hepatic vein flow patterns in children undergoing congenital heart surgery. This study aimed to determine the characteristics of portal, splenic, and hepatic vein flow patterns using ultrasonography in children undergoing cardiac surgery. DESIGN: Single-center, prospective observational study. SETTING: Tertiary children's hospital, operating room. PARTICIPANTS: Children undergoing cardiac surgery. MEASUREMENT AND MAIN RESULTS: The authors obtained ultrasound data from the heart, inferior vena cava, portal, splenic, and hepatic veins before and after surgeries. In the biventricular group, which included children with atrial and ventricular septal defects and pulmonary stenosis (n = 246), the portal pulsatility index decreased from 38.7% to 25.6% (p < 0.001) after surgery. The preoperative portal pulsatility index was significantly higher in patients with pulmonary hypertension (43.3% v 27.4%; p < 0.001). In the single-ventricle group (n = 77), maximum portal vein flow velocities of Fontan patients were significantly lower (13.5 cm/s) compared with that of patients with modified Blalock-Taussig shunt (19.7 cm/s; p = 0.035) or bidirectional cavopulmonary shunt (23.1 cm/s; p < 0.001). The cardiac index was inversely correlated with the portal pulsatility index in the bidirectional cavopulmonary shunt and Fontan circulation. (ß = -5.693, r2 = 0.473; p = 0.001) The portal pulsatility index was correlated with splenic venous pulsatility and hepatic venous atrial reverse flow velocity in biventricular and single-ventricle groups. CONCLUSIONS: The characteristics of venous Doppler patterns in the portal, splenic, and hepatic veins differed according to congenital heart disease. Further studies are required to determine the association between splanchnic venous Doppler findings and clinical outcomes in this population.

Effect of tidal volume change on pressure-based prediction of fluid responsiveness in children.

INTRODUCTION: It is known that pulse pressure variation and systolic pressure variation cannot predict fluid responsiveness in children. In adults, the ability of these dynamic parameters to predict fluid responsiveness is improved by increasing tidal volume. We planned to investigate whether pulse pressure variation or systolic pressure variation can predict fluid responsiveness in children when augmented by increasing tidal volume by conducting a prospective study. METHODS: We enrolled children younger than 7 years who underwent cardiac surgery for atrial septal defect or ventricular septal defect. After sternum closure, pulse pressure variation and systolic pressure variation were continuously recorded while changing the tidal volume to 6, 10, and 14 mL/kg. Fluid loading was done with 10 mL/kg of crystalloids for 10 min, and stroke volume index was measured via transesophageal echocardiography. Children whose stroke volume index increased by more than 15% after the fluid loading were defined as responders to fluid therapy. We set primary outcome as the predictability of pulse pressure variation and systolic pressure variation for fluid responsiveness and measured the area under the curve of receiver operating characteristics curve. RESULTS: Twenty-six children were included, of which 15 were responders. At the tidal volume of 14 mL/kg, the area under the curves of receiver operating characteristics curves of pulse pressure variation and systolic pressure variation were 0.576 (p = .517) and 0.548 (p = .678), respectively. The differences in dynamic parameters between responders and nonresponders were not significant. DISCUSSION: Failure of pulse pressure variation or systolic pressure variation at augmented tidal volume in children may be due to difference in their arterial compliance from those of adults. Large compliance of thoracic wall may be another reason. CONCLUSIONS: Augmented pulse pressure variation or systolic pressure variation due to increased tidal volume cannot predict fluid responsiveness in children after simple cardiac surgery.

Risk Factors for Postoperative Hypothermia in Patients Undergoing Robot-Assisted Gynecological Surgery: A Retrospective Cohort Study.

Since postoperative hypothermia increases the morbidity and mortality rates of surgery, identifying its risk factors is an important part of perioperative management. Considering the increasing demand for robot-assisted surgery and other characteristics of conventional laparoscopic surgery, identifying the risk factors for hypothermia in robot-assisted surgery is necessary. However, this has not yet been clearly established. This study aimed to identify the risk factors and incidence rate of postoperative hypothermia in patients undergoing robot-assisted gynecological surgery. In total, 516 patients aged ≥ 19 years undergoing robot-assisted gynecological surgery at a single university hospital between January 2018 and November 2020 were retrospectively analyzed. Postoperative hypothermia was defined as 36.0°C or lower body temperature at the end of the surgery, and multivariate logistic regression analysis was performed to identify the risk factors for postoperative hypothermia. Among the 516 patients, the incidence rate of postoperative hypothermia was 28.1% in 145 patients. The independent risk factors for postoperative hypothermia included body mass index ≤ 22.9 kg/m2, baseline heart rate ≤ 73 rate/min, baseline body temperature ≤ 36.8°C, use of intraoperative nicardipine, and amount of administered intravenous fluid larger than 800 mL. Therefore, to prevent hypothermia in patients undergoing robot-assisted gynecological surgery, these risk factors must be considered.

Comparison of the effects of dexmedetomidine and propofol on hypothermia in patients under spinal anesthesia: a prospective, randomized, and controlled trial.

Background: Redistribution hypothermia caused by vasodilation during anesthesia is the primary cause of perioperative hypothermia. Propofol exerts a dose-dependent vasodilatory effect, whereas dexmedetomidine induces peripheral vasoconstriction at high plasma concentrations. This study compared the effects of dexmedetomidine and propofol on core temperature in patients undergoing surgery under spinal anesthesia. Methods: This prospective study included 40 patients (aged 19-70 years) with American Society of Anesthesiologists Physical Status class I-III who underwent elective orthopedic lower-limb surgery under spinal anesthesia. Patients were randomly allocated to a dexmedetomidine or propofol group (n = 20 per group). After induction of spinal anesthesia, patients received dexmedetomidine (loading dose: 1 µg/kg over 10 min; maintenance dose: 0.2-0.7 µg/kg/h) or propofol (loading dose: 75 µg/kg over 10 min; maintenance dose: 12.5-75 µg/kg/min). The doses of sedatives were titrated to maintain moderate sedation. During the perioperative period, tympanic temperatures, thermal comfort score, and shivering grade were recorded. Results: Core temperature at the end of surgery did not differ significantly between the groups (36.4 ± 0.4 and 36.1 ± 0.7°C in the dexmedetomidine and propofol groups, respectively; P = 0.118). The lowest perioperative temperature, incidence and severity of perioperative hypothermia, thermal comfort score, and shivering grade did not differ significantly between the groups (all P > 0.05). Conclusions: In patients undergoing spinal anesthesia with moderate sedation, the effect of dexmedetomidine on patients' core temperature was similar to that of propofol.

Clinical efficacy of short-term prewarming in elderly and adult patients: A prospective observational study.

Background: Short-term prewarming effectively reduces intraoperative hypothermia in adult patients. However, few data exist regarding its efficacy in elderly patients. Elderly people have a reduced ability to regulate their body temperature, which affects the efficacy of prewarming. This study aimed to compare the clinical efficacy of short-term pre-warming in elderly patients with that in adult patients. Methods: We enrolled 25 adult (20-50 years) and 25 elderly (> 65 years) patients scheduled for ureteroscopic stone surgery under general anaesthesia. All patients received preanaesthetic forced-air warming for 20 min. The core temperature was measured using an infrared tympanic thermometer during awakening and nasopharyngeal thermistors during anaesthesia. Incidence and severity of intraoperative hypothermia (< 36°C) was compared. Postoperative shivering and number of patients requiring active warming in the post-anaesthesia care unit were also assessed. Results: Intraoperative hypothermia was more frequent in elderly than in adult patients (58.3% vs. 12.0%; relative risk 2.6; 95% confidence interval 1.5 to 4.6; effect size h = 1.010; p = 0.001). The severity of intraoperative hypothermia showed a significant intergroup difference (p = 0.002). Postoperative shivering was more frequent in elderly than in adult patients (33.3% vs. 8.0%, p = 0.037). A greater number of elderly patients in the post-anaesthesia care unit required active warming (33.3% vs. 8.0%, p = 0.037). Conclusions: The effects of short-term prewarming on the prevention of hypothermia and maintenance of perioperative normothermia are not the same in the elderly and adult patients.

Pupil response to painful stimuli during inhalation anaesthesia without opioids in children.

BACKGROUND: Pupil dilation reflex measured by a pupillometer is known to be a useful parameter for assessing the response to perioperative noxious stimuli. In children, pupillometer can reflect changes after painful stimuli during anaesthesia or guide anaesthesia to reduce opioid consumption. However, to date, there are no data regarding pupil response during inhalation anaesthesia with analgesia by intravenous acetaminophen in children. METHODS: We planned a prospective, single-armed study of children aged between 3 and 12 years who underwent surgery under general anaesthesia. Anaesthesia was maintained by 1 minimum alveolar concentration (MAC) of sevoflurane, and 15 mg/kg of acetaminophen was administered. Patients' left eye was examined using a pupillometer after induction, before and after skin incision and train-of-four stimulus. Pupil diameter and other pupillometric parameters were recorded. Increase in heart rate by 15% was regarded as insufficient analgesia to skin incision and indicative powers of pupillometric parameters for insufficient analgesia were examined by receiver-operating characteristics. RESULTS: A total of 33 patients were included. Enlarged pupil, large increase in pupil diameter and low neurological pupil index (NPi) after skin incision were good indicators of insufficient analgesia for skin incision. Children with insufficient analgesia showed abnormal NPi value. However, increase in pupil diameter and decrease in NPi were observed even in patients without increase in the heart rate after the skin incision. CONCLUSIONS: We suggest dilation of the pupil and decrease in NPi can indicate response to noxious stimuli in children. Regardless of sufficiency of analgesia, pupil dilation and decrease in NPi were observed after skin incision in children under general anaesthesia with 1 MAC of sevoflurane and intravenous acetaminophen.

Ultrasound-guided esophageal compression during mask ventilation in small children: a prospective observational study.

BACKGROUND: The use of cricoid compression to prevent insufflation remains controversial, and its use in children is limited. This study aimed to examine the effect of real-time ultrasound-guided esophageal compression on the prevention of gastric insufflation. METHOD: This prospective observational study was conducted with fifty children aged < 2 years undergoing general anesthesia. Patients were excluded if they were at an increased risk for gastric regurgitation or pulmonary aspiration. Following anesthetic induction under spontaneous breathing, ultrasound-guided esophageal compression was performed during pressure-controlled face-mask ventilation using a gradual increase in peak inspiratory pressure from 10 to 24 cm H2O to determine the pressure at which gastric insufflation occurred. The primary outcome was the incidence of gastric insufflation during anesthetic induction with variable peak inspiratory pressure after real-time ultrasound-guided esophageal compression was applied. RESULTS: Data from a total of 42 patients were analyzed. Gastric insufflation was observed in 2 (4.7%) patients. All patients except one had their esophagus on the left side of the trachea. Applying ultrasound-guided esophageal compression did not affect the percentage of glottic opening scores (P = 0.220). CONCLUSIONS: The use of real-time ultrasound-guided esophageal compression pressure can aid preventing gastric insufflation during face-mask ventilation in children less than 2 years old. TRIAL REGISTRATION: Clinicaltrials.gov identifier: NCT04645043.

Performance time of anesthesiology trainees for cricothyroid membrane identification and characteristics of cricothyroid membrane in pediatric patients using ultrasonography.

BACKGROUND: Identifying the cricothyroid membrane is an essential technical skill for front-of-neck access procedures. AIMS: This study evaluated the usefulness of cricothyroid membrane identification in pediatric patients using ultrasonography by anesthesiology trainees without experience in airway ultrasound and collected anatomical data on the cricothyroid membrane and its surrounding airway structures in children. METHODS: This prospective observational study included children aged <18 years scheduled to undergo general anesthesia and anesthesiology trainees who identified the cricothyroid membrane in five sequential anesthetized patients using ultrasonography. A pediatric anesthesiologist confirmed the accuracy of the identified cricothyroid membrane and recorded the performance time. The primary aims were the cricothyroid membrane identification success rate and performance time. The secondary aims were the characterization of the cricothyroid membrane and its surrounding structures. RESULTS: Overall, 150 pediatric patients and 30 anesthesiology trainees were analyzed. The cricothyroid membrane identification success rate using ultrasonography was 100% in all the attempts using a transverse approach. The mean (standard deviation) performance time was 27.2 (18.6) s and 31.0 (23.8) s using the transverse and longitudinal approaches, respectively. The performance time decreased by 3.1 (p = .003, 95% confidence interval [CI] = -5.1--1.0) and 5.2 (p = .007, 95% CI = -8.9--1.4) seconds per increase in number of attempts with the transverse and longitudinal approaches, respectively. The cricothyroid membrane length was mostly correlated with the patients' height (r = .75, p < .001), and the blood vessels surrounding the cricothyroid membrane were observed in 95.9% of the patients. CONCLUSIONS: Anesthesiology trainees without experience in airway ultrasound successfully identified the cricothyroid membrane in pediatric patients using ultrasonography after a brief training period. Further research is required as the identification of a structure does not predict the success of the actual procedure, particularly if done in an emergency situation.

Smart Glasses for Radial Arterial Catheterization in Pediatric Patients: A Randomized Clinical Trial.

BACKGROUND: Hand-eye coordination and ergonomics are important for the success of delicate ultrasound-guided medical procedures. These can be improved using smart glasses (head-mounted display) by decreasing the head movement on the ultrasound screen. The hypothesis was that the smart glasses could improve the success rate of ultrasound-guided pediatric radial arterial catheterization. METHODS: This prospective, single-blinded, randomized controlled, single-center study enrolled pediatric patients (n = 116, age less than 2 yr) requiring radial artery cannulation during general anesthesia. The participants were randomized into the ultrasound screen group (control) or the smart glasses group. After inducing general anesthesia, ultrasound-guided radial artery catheterization was performed. The primary outcome was the first-attempt success rate. The secondary outcomes included the first-attempt procedure time, the overall complication rate, and operators' ergonomic satisfaction (5-point scale). RESULTS: In total, 116 children were included in the analysis. The smart glasses group had a higher first-attempt success rate than the control group (87.9% [51/58] vs. 72.4% [42/58]; P = 0.036; odds ratio, 2.78; 95% CI, 1.04 to 7.4; absolute risk reduction, -15.5%; 95% CI, -29.8 to -12.8%). The smart glasses group had a shorter first-attempt procedure time (median, 33 s; interquartile range, 23 to 47 s; range, 10 to 141 s) than the control group (median, 43 s; interquartile range, 31 to 67 s; range, 17 to 248 s; P = 0.007). The overall complication rate was lower in the smart glasses group than in the control group (5.2% [3/58] vs. 29.3% [17/58]; P = 0.001; odds ratio, 0.132; 95% CI, 0.036 to 0.48; absolute risk reduction, 24.1%; 95% CI, 11.1 to 37.2%). The proportion of positive ergonomic satisfaction (4 = good or 5 = best) was higher in the smart glasses group than in the control group (65.5% [38/58] vs. 20.7% [12/58]; P <0.001; odds ratio, 7.3; 95% CI, 3.16 to 16.8; absolute risk reduction, -44.8%; 95% CI, -60.9% to -28.8%). CONCLUSIONS: Smart glasses-assisted ultrasound-guided radial artery catheterization improved the first-attempt success rate and ergonomic satisfaction while reducing the first-attempt procedure time and overall complication rates in small pediatric patients.

Prediction of gastric fluid volume by ultrasonography in infants undergoing general anaesthesia.

BACKGROUND: Point-of-care ultrasonography can estimate gastric contents and volume to assess the risk of pulmonary aspiration; however, its use in infants has not been well validated. We aimed to develop a predictive model for estimating gastric fluid volume using ultrasonography in infants. METHODS: This prospective observational study enrolled 200 infants (≤12 months) undergoing general anaesthesia. After anaesthetic induction, while preserving spontaneous respiration, we measured gastric antral cross-sectional area using ultrasonography in both the supine and right lateral decubitus positions. We then suctioned the gastric content and measured its volume. The primary outcome was development of a gastric fluid volume prediction model with multiple regression analysis. Agreement between the predicted volume and the suctioned volume was evaluated using a Bland-Altman plot. RESULTS: Overall, 192 infants were included in the final analysis. Pearson correlation analysis showed that the gastric antral cross-sectional area in the supine (P<0.001; correlation coefficient: 0.667) and right lateral decubitus (P<0.001; correlation coefficient: 0.845) positions and qualitative antral grade (P<0.001; correlation coefficient: 0.581) correlated with suctioned volume. We developed a predictive model: predicted volume (ml)=-3.7+6.5 × (right lateral decubitus cross-sectional area [cm2])-3.9 (supine cross-sectional area [cm2])+1.7 × grade (P<0.01). When comparing the predicted volume and suctioned volume, the mean bias was 0.01 ml kg-1 and the limit of agreement was -0.58 to 0.62 ml kg-1. CONCLUSIONS: Gastric fluid volume can be estimated using a predictive model based on ultrasonography data in infants. CLINICAL TRIAL REGISTRATION: NCT03155776.

Effects of tip-manipulated stylet angle on intubation using the GlideScope® videolaryngoscope in children: A prospective randomized controlled trial.

BACKGROUND: An optimal endotracheal tube curve can be a key factor in successful intubation using the GlideScope videolaryngoscope. AIMS: This study aimed to evaluate the effects of tube tip-modified stylet curve on the intubation time in children. METHODS: Children aged 1-5 years were randomly assigned to either the standard curve (group S, n = 60) or tip-modified curve (group T, n = 60) groups. In group S, the endotracheal tube curve was similar to that in the GlideScope. In group T, a point approximately 1.5 cm from the tube tip was additionally angled to the left by 15°-20°. The primary outcome was the total intubation time, and the secondary outcomes were incidence of successful intubation in the first attempt, number of additional manipulations of the stylet curve, and visual analog scale (VAS) score for the easiness of intubation. RESULTS: The mean total intubation time was significantly longer in group S than that in group T (13.9 [10.8] vs. 9.0 [3.4] sec, mean difference, 4.9 s; 95% confidence interval [CI], 2.0-7.8; p = .001). All patients in group T were successfully intubated in the first attempt, whereas those in group S were not (100% vs. 93.3%, relative risk [RR], 0.11; 95% CI, 0.01-2.02; p = .1376). Three patients in group S could be intubated after modifying the ETT curve similar to that in group T. Operators reported that tracheal intubation was easier in group T than in group S (median [interquartile range] for VAS; 1 [1-2] vs. 2 [1-3]; p < .001). CONCLUSIONS: Having additional angle of the endotracheal tube tip to the left could be a useful technique to facilitate directing and advancing endotracheal tube into the vocal cords.

Effect of positive end-expiratory pressure during anaesthesia induction on non-hypoxic apnoea time in infants: A randomised controlled trial.

BACKGROUND: Hypoxaemia occurs frequently in infants during anaesthetic induction. OBJECTIVE: We evaluated the effect of positive end-expiratory pressure during anaesthesia induction on nonhypoxic apnoea time in infants. DESIGN: Randomised controlled trial. SETTING: Tertiary care children's hospital, single centre, from November 2018 to October 2019. PATIENTS: We included patients under 1 year of age receiving general anaesthesia. INTERVENTION: We assigned infants to a 7 cmH2O or 0 cmH2O positive end-expiratory pressure group. Anaesthesia was induced with 0.02 mg kg-1 atropine, 5 mg kg-1 thiopental sodium and 3 to 5% sevoflurane, and neuromuscular blockade with 0.6 mg kg-1 rocuronium. Thereafter, 100% oxygen was provided via face mask with volume-controlled ventilation of 6 ml kg-1 tidal volume, and either 7 cmH2O or no positive end-expiratory pressure. After 3 min of ventilation, the infants' trachea was intubated but disconnected from the breathing circuit, and ventilation resumed when pulse oximetry reached 95%. MAIN OUTCOME MEASURE: The primary outcome was nonhypoxic apnoea time defined as the time from cessation of ventilation to a pulse oximeter reading of 95%, whereas the secondary outcome was the incidence of significant atelectasis (consolidation score ≥2) assessed by lung ultrasound. RESULTS: Sixty patients were included in the final analysis. Apnoea time in the 7 cmH2O positive end-expiratory pressure group (105.2 s) increased compared with that in the control group (92.1 s) (P = 0.011, mean difference 13.0 s, 95% CI, 3.1 to 22.9 s). Significant atelectasis was observed in all patients without positive end-expiratory pressure and 66.7% of those with 7 cmH2O positive end-expiratory pressure (P = 0.019, 95% CI, 1.7 to 563.1, odds ratio 31.2). CONCLUSION: Positive end-expiratory pressure during anaesthesia induction with face mask ventilation increased nonhypoxic apnoea time in infants. CLINICAL TRIAL REGISTRATION: www.clinicaltrials.gov, NCT03540940.

Prediction of fluid responsiveness using lung recruitment manoeuvre in paediatric patients receiving lung-protective ventilation: A prospective observational study.

BACKGROUND: Pressure-based dynamic variables are poor predictors of fluid responsiveness in children, and their predictability is expected to reduce further during lung-protective ventilation with a low tidal volume. OBJECTIVE: We hypothesised that lung recruitment manoeuvre (LRM)-induced changes in dynamic variables improve their ability to predict fluid responsiveness in children. DESIGN: Prospective observational study. SETTING: Tertiary care children's hospital, single-centre study performed from June 2017 to May 2019. PATIENTS: We included patients less than 7 years of age undergoing cardiac surgery. Neonates and patients with pulmonary hypertension, significant dysrhythmia, ventricular ejection fraction of less than 30% or pulmonary disease were excluded. INTERVENTION: All patients were provided with lung-protective volume-controlled ventilation (tidal volume 6 ml kg-1, positive end-expiratory pressure 6 cmH2O). A LRM was applied with a continuous inspiratory pressure of 25 cmH2O for 20 s. MAIN OUTCOME MEASURE: The ability of dynamic variables to predict fluid responsiveness was evaluated by the area under the receiver operating characteristic curve [area under the curve (AUC)]. Fluid responsiveness was defined as an increase in the cardiac index by more than 15% with crystalloid administration (10 ml kg-1). RESULTS: Thirty patients were included in the final analysis, of whom 19 were responders. The baseline pleth variability index (PVI) (AUC 0.794, 95% confidence interval 0.608 to 0.919, P < 0.001) and LRM-induced PVI (AUC 0.711, 95% confidence interval 0.517 to 0.861, P = 0.026) could predict fluid responsiveness. The respiratory variation of pulse oximetry photoplethysmographic waveform and pulse pressure variation did not predict fluid responsiveness regardless of the LRM. CONCLUSION: The PVI is effective in predicting fluid responsiveness in paediatric patients with lung-protective ventilation regardless of a LRM. However, the LRM did not improve the ability of the other dynamic variables to predict fluid responsiveness in these patients. CLINICAL TRIAL REGISTRATION: www.clinicaltrials.gov identifier: NCT03184961.

Comparison of remimazolam and desflurane in emergence agitation after general anesthesia for nasal surgery: a prospective randomized controlled study.

BACKGROUND: Remimazolam is an ultrashort-acting benzodiazepine. Few studies have evaluated the effects of remimazolam-based total intravenous anesthesia (TIVA) on emergence agitation (EA). This study aimed to compare the incidence and severity of EA between TIVA using remimazolam and desflurane. METHODS: This prospective randomized controlled study enrolled 76 patients who underwent nasal surgery under general anesthesia. Patients were randomized into two groups of 38 each: desflurane-nitrous oxide (N2O) (DN) and remimazolam-remifentanil (RR) groups. The same protocol was used for each group from induction to emergence, except for the use of different anesthetics during maintenance of anesthesia according to the assigned group: desflurane and nitrous oxide for the DN group and remimazolam and remifentanil for the RR group. The incidence of EA as the primary outcome was evaluated using three scales: Ricker Sedation-Agitation Scale, Richmond Agitation-Sedation Scale, and Aono's four-point agitation scale. Additionally, hemodynamic changes during emergence and postoperative sense of suffocation were compared. RESULTS: The incidence of EA was significantly lower in the RR group than in the DN group in all three types of EA assessment scales (all P < 0.001). During emergence, the change in heart rate differed between the two groups (P = 0.002). The sense of suffocation was lower in the RR group than in the DN group (P = 0.027). CONCLUSIONS: RR reduced the incidence and severity of EA in patients undergoing nasal surgery under general anesthesia. In addition, RR was favorable for managing hemodynamics and postoperative sense of suffocation.

What is your optimal target of oxygen during general anesthesia in pediatric patients?

The optimal oxygen target during general anesthesia remains difficult to define in pediatric and adult patients. Although access to pediatric patients has become difficult owing to a decrease in birth rate, pediatric anesthesia remains an important part of anesthesiology, and oxygenation related to general anesthesia is an essential part of any anesthesiologist. The use of oxygen has increased survival rates in adults and children; however, the side effects related to oxygen use have also increased. This review addresses the considerations of oxygenation in pediatric patients undergoing general anesthesia.

The Effect of Neuromuscular Blockade Reversal Agents on Postoperative Pulmonary Complications in Patients undergoing Femur Fracture Repair Surgery: A Retrospective Observational Study.

BACKGROUND: Femoral fracture repair surgery under general anesthesia is associated with postoperative pulmonary complications (PPCs). However, information on PPCs caused by residual neuromuscular blockade following perioperative use of neuromuscular blockers is limited. This study aimed to identify the differences in the incidence of PPCs according to the type of neuromuscular blockade reversal agent used in femoral fracture repair surgery, as well as the risk factors for PPCs. METHODS: We retrospectively analyzed the electronic medical records of 604 patients aged >18 years who underwent general anesthesia for femoral fracture repair surgery at a single university hospital between March 2017 and March 2022. Patients in whom sugammadex or anticholinesterase was used to reverse the neuromuscular block were subjected to propensity score matching. Multivariate logistic regression analysis was performed to identify risk factors for PPCs. RESULTS: Among the 604 patients, 108 were matched in each group. The incidence rates of PPCs overall and in the anticholinesterase and sugammadex groups were 7.0%, 8.3%, and 5.6%, respectively, with no significant differences between the groups. Older age, higher ASA (American Society of Anesthesiologists) physical status, and lower preoperative oxygen saturation were risk factors, whereas emergency surgery was a preventive factor. CONCLUSIONS: Our results demonstrated that the incidence of PPC did not differ significantly between sugammadex and anticholinesterase in patients undergoing femur fracture repair under general anesthesia. Identifying the risk factors and confirming complete recovery from neuromuscular blockade might be more important.