Clinical significance of assessing cerebral blood volume by time-domain near-infrared spectroscopy in children with congenital heart disease.

BACKGROUND: Despite providing cerebral tissue oxygen saturation (StO2 ), the lack of quantitative information for continuous wave near-infrared spectroscopy (CW-NIRS) is an obstacle in evaluating cerebral hemodynamic conditions. Time-domain NIRS (TD-NIRS) provides both StO2 and cerebral blood volume and has recently become clinically available. AIM: To investigate if the additional monitoring of cerebral blood volume by TD-NIRS facilitates the understanding of cerebral hemodynamic conditions in patients with congenital heart disease. METHODS: Preoperative TD-NIRS values were retrospectively reviewed in patients who underwent a cardiac surgery or catheter examination. We compared the values between patients with single and two ventricles. Moreover, we investigated the association of these values with the demographic and clinical variables. RESULTS: There was no significant difference in StO2 between single ventricle and two ventricles groups (median: 59.9 vs. 54.4, median difference [95% CI]: -4.06 [-9.90 to 2.90], p = .37). However, cerebral blood volume was significantly higher in the single ventricle group (median: 4.68 vs. 2.84, median difference [95% CI]: -2.01 [-2.88 to -1.06], p < .001). Spearman's rank correlation analysis demonstrated an association between StO2 and postmenstrual age (r = 0.35, p = .03). In contrast, cerebral blood volume was correlated with single ventricle physiology (r = 0.62, p < .001), postmenstrual age (r = 0.74, p < .001), central venous pressure (r = 0.38, p = .02), and SaO2 (r = -0.38, p = .02). The multivariable regression analysis identified the postmenstrual age, single ventricle physiology, and SaO2 as independent factors associated with cerebral blood volume. In the logistic analysis, cerebral blood volume was identified as a significant predictor of unfavorable conditions. CONCLUSION: Cerebral blood volume monitoring detected differences in cerebral hemodynamic conditions, related to the age and the type of ventricle physiologies. However, the differences were not apparent in StO2 . The additional monitoring of cerebral blood volume by TD-NIRS would facilitate a better understanding of cerebral hemodynamic conditions in patients with congenital heart disease.

Age-Specific Dose Regimens of Dexmedetomidine for Pediatric Patients in Intensive Care Following Elective Surgery: A Phase 3, Multicenter, Open-Label Clinical Trial in Japan.

OBJECTIVES: To demonstrate the efficacy, safety, and pharmacokinetics of dexmedetomidine as a potential sedative for pediatric surgery patients in the ICU. DESIGN: Phase 3, multicenter, open-label study. SETTING: This study included 61 patients at 13 tertiary hospitals in Japan. PATIENTS: Pediatric patients (≥ 45 wk corrected gestational age to < 17 yr) undergoing intensive care treatment with mechanical ventilation requiring greater than 6 hours estimated duration of sedation following elective cardiac surgery. INTERVENTIONS: Dexmedetomidine was IV administered without a loading dose at age-specific dose regimens 0.2-1.4 (< 6 yr) and 0.2-1.0 µg/kg/hr (≥ 6 yr). The primary endpoint was the percentage of patients who did not require a rescue sedative (midazolam) infusion during mechanical ventilation or for the first 24 hours of a greater than 24 hours ventilation following the commencement of dexmedetomidine administration. MEASUREMENTS AND MAIN RESULTS: Overall, 47 of the 61 patients (77.0%) did not require rescue midazolam. Adverse events were reported in 53 patients (86.9%). Frequently observed adverse events were hypotension (47.5%), bradycardia (31.1%), and respiratory depression (26.2%). Most of these adverse events were mild, a few moderate, and none severe. Although serious adverse events occurred in four patients, including one cardiac tamponade resulting in the withdrawal of dexmedetomidine, none of the adverse events resulted in mortality or were directly related to dexmedetomidine. The plasma dexmedetomidine concentration generally reached the target concentration of 0.3-1.25 ng/mL at 1-2 hours prior to completion of administration or immediately prior to the commencement of tapering. CONCLUSIONS: The age-specific dose regimens of dexmedetomidine without an initial loading dose achieved an adequate sedation level during mechanical ventilation and caused no clinically significant adverse events in the intensive care pediatric patients. These effects were achieved within the therapeutic range of dexmedetomidine plasma concentration and were accompanied by minimal effects on hemodynamics and respiration.

Perioperative management of Fontan operation for the child with panhypopituitarism: a case report.

With the surgical improvement of congenital heart disease, Fontan operation has been applied to many complicated patients in recent years. This is the first report of a child with panhypopituitarism who underwent Fontan operation. A 5-year-old boy was scheduled for Fontan operation. He previously underwent Blalock-Taussig shunt and bidirectional Glenn operations for univentricular heart with double-outlet right ventricle and pulmonary atresia. He was receiving hydrocortisone and 1-desamino-8-D-arginine vasopressin (DDAVP) for panhypopituitarism secondary to removal of craniopharyngioma performed at the age of three years. Although urine output and serum sodium concentration were adequately controlled by adjustment of vasopressin infusion rate during surgery, massive pleural effusions and ascites developed postoperatively, which required several days for control by adjusting the dose of oral DDAVP and normalize the serum sodium level. Intraoperative management of Fontan operation for a patient with panhypopituitarism was controllable by appropriate hormone replacement. However, postoperative fluid management was complicated by the clinical features of panhypopituitarism and Fontan physiology.

M1 macrophage infiltration exacerbate muscle/bone atrophy after peripheral nerve injury.

BACKGROUND: Peripheral nerve injury causes limb muscle/bone atrophy, leading to chronic pain. However, the mechanisms underlying muscle/bone atrophy after peripheral nerve injury remain unknown. It was recently reported that M1 macrophages are the main factors responsible for neurogenic inflammation after peripheral nerve injury. We hypothesized that M1 macrophages are important in muscle/bone atrophy after nerve injury. Therefore, we investigated the influence of M1 macrophages on muscle/bone atrophy after nerve injury in mice to prevent muscle/bone atrophy by suppressing M1 macrophages. METHODS: Hindlimb muscle weight and total bone density were measured in a chronic constriction injury (CCI) mouse model. Immunohistochemical analysis and intravital microscopy were performed to visualize hindlimb muscles/bones, and cells were quantified using flow cytometry. We compared M1 macrophage infiltration into muscles/bones and muscle/bone atrophy between macrophage depletion and untreated groups. We also investigated muscle/bone atrophy using administration models for anti-inflammatory and neuropathic pain drugs. RESULTS: Peripheral nerve injury caused significant reduction in muscle weight and total bone density at 1 and 3 weeks after CCI, respectively, compared with that in controls. Osteoclast numbers were significantly higher at 1 week after CCI in the CCI group than in the control group. M1 macrophage infiltration into muscles was observed from 2 h after CCI via intravital microscopy and 1 week after CCI, and it was significantly higher 1 week after CCI than in the control group. In the macrophage depletion group, dexamethasone, pregabalin, and loxoprofen groups, M1 macrophage infiltration into muscles/bones was significantly lower and muscle weight and total bone density were significantly higher than in the untreated group. CONCLUSIONS: M1 macrophage infiltration exacerbates muscle/bone atrophy after peripheral nerve injury. By suppressing M1 macrophages at the neural injury local site, muscle/bone atrophy could be avoided.

Influence of the aldehyde dehydrogenase 2 polymorphism on the vasodilatory effect of nitroglycerin in infants with congenital heart disease and pulmonary arterial hypertension.

PURPOSE: The influence of the aldehyde dehydrogenase 2 (ALDH2) gene polymorphism on the pharmacokinetics and haemodynamics of nitroglycerin (GTN) was determined in human subjects. METHODS: Eighteen infants (nine each with and without ALDH2 gene polymorphism) with congenital heart disease and pulmonary arterial hypertension participated in this study. GTN treatment started at a dose of 2 µg/kg/min, and the dose was escalated by 1-2 µg/kg/min until pulmonary vascular resistance (PVR) was reduced by more than 30%. The plasma GTN concentration and PVR were measured at the end of each infusion period. RESULTS: Plasma GTN concentrations were significantly higher in patients with the ALDH2 gene polymorphism than in those without the polymorphism. Conversely, the reduction in PVR was smaller in patients with the ALDH2 gene polymorphism than in those without. CONCLUSIONS: These data suggest that the ALDH2 gene polymorphism influences the pharmacokinetics and haemodynamics of GTN in human subjects.

Oxygen reserve index (ORi™) contributes to prediction of hypoxemia and patient safety during tracheal stent insertion using rigid bronchoscopy: a case report.

The oxygen reserve index (ORi™) is a new noninvasive and continuous variable, which represents a moderate hyperoxygenation status, with a unitless scale between 0.00 and 1.00. When percutaneous oxygen saturation (SpO2) exceeds 100%, arterial blood oxygen partial pressure cannot be evaluated without performing arterial blood gas analysis. Because of significant air leakage during rigid bronchoscopy, it is difficult to monitor respiration using capnography, which does not measure end-tidal carbon dioxide (ETCO2) accurately. A 66-year-old man (175 cm, 76.8 kg) with a chief complaint of difficulty in breathing was diagnosed with a thyroid tumor. Computed tomography revealed tracheal stenosis due to direct invasion of the thyroid tumor; therefore, tracheal stenting was planned immediately. After supplying 6 L/min oxygen with a face mask and administering 180 mg of propofol intravenously, the supraglottic airway was intubated. General anesthesia (total intravenous anesthesia) through continuous administration of 6-10 mg/kg/h of propofol and intermittent administration of 50 µg of fentanyl (total 200 µg) preserved spontaneous breathing. During tracheal stent insertion, disconnection between the oxygen supply system and rigid bronchoscopy, and tracheal stent expansion, the ORi tended to decrease before SpO2 decreased. Thus, measuring ORi could prevent hypoxemia during tracheal stent insertion using rigid bronchoscopy.

Current Ventilator and Oxygen Management during General Anesthesia: A Multicenter, Cross-sectional Observational Study.

BACKGROUND: Intraoperative oxygen management is poorly understood. It was hypothesized that potentially preventable hyperoxemia and substantial oxygen exposure would be common during general anesthesia. METHODS: A multicenter, cross-sectional study was conducted to describe current ventilator management, particularly oxygen management, during general anesthesia in Japan. All adult patients (16 yr old or older) who received general anesthesia over 5 consecutive days in 2015 at 43 participating hospitals were identified. Ventilator settings and vital signs were collected 1 h after the induction of general anesthesia. We determined the prevalence of potentially preventable hyperoxemia (oxygen saturation measured by pulse oximetry of more than 98%, despite fractional inspired oxygen tension of more than 0.21) and the risk factors for potentially substantial oxygen exposure (fractional inspired oxygen tension of more than 0.5, despite oxygen saturation measured by pulse oximetry of more than 92%). RESULTS: A total of 1,786 patients were found eligible, and 1,498 completed the study. Fractional inspired oxygen tension was between 0.31 and 0.6 in 1,385 patients (92%), whereas it was less than or equal to 0.3 in very few patients (1%). Most patients (83%) were exposed to potentially preventable hyperoxemia, and 32% had potentially substantial oxygen exposure. In multivariable analysis, old age, emergency surgery, and one-lung ventilation were independently associated with increased potentially substantial oxygen exposure, whereas use of volume control ventilation and high positive end-expiratory pressure levels were associated with decreased potentially substantial oxygen exposure. One-lung ventilation was particularly a strong risk factor for potentially substantial oxygen exposure (adjusted odds ratio, 13.35; 95% CI, 7.24 to 24.60). CONCLUSIONS: Potentially preventable hyperoxemia and substantial oxygen exposure are common during general anesthesia, especially during one-lung ventilation. Future research should explore the safety and feasibility of a more conservative approach for intraoperative oxygen therapy.

Near-infrared spectroscopy might be a useful tool for predicting the risk of vascular complications after pediatric liver transplants: Two case reports.

In patients that have undergone liver transplants, a postoperative reduction in the blood flow of the liver graft represents a critical complication. We recently encountered an interesting phenomenon; that is, we found that the rSO2 level of the liver graft, as measured by NIRS, drops in patients that subsequently require an emergency liver biopsy. An 8-month-old female and an 8-month-old male underwent living donor liver transplants for biliary atresia. In both cases, a reduction in rSO2 was detected before an emergency liver biopsy was required. As a result of biopsy examinations, both patients were diagnosed with acute graft rejection. NIRS might be useful for graft management during the postoperative period in pediatric patients that undergo liver transplantation. After a liver transplant, a reduction in the rSO2 of the graft might be indicative of the onset of vascular complications.

[Present and Future of the Peripheral Nerve Block for Upper Extremities].

Ultrasound guidance has become the standard tech- nique for brachial plexus block. Evidence has been accumulating that the ultrasound-guided brachial plex- us block can provide various advantages such as shorter block performance time, fewer needle passes, reduced incidence of vascular puncture, increased suc- cess rate, and rapid sensory block onset when compared with the conventional nerve localization tech- niques. Real-time ultrasound visualization during the procedure can reduce the amount of local anesthetics and the incidence of complications. Brachial plexus block has a strong analgesic effect with minimal effect on the cardiorespiratory and gastrointestinal systems. Therefore, ultrasound-guided brachial plexus block is a valuable regional anesthetic technique for upper ex- tremity surgery.

Comparison of the analgesic effect between continuous wound infiltration and single-injection transversus abdominis plane block after gynecologic laparotomy.

PURPOSE: Both single-injection transversus abdominis plane (TAP) block and continuous wound infiltration (CWI) provide postoperative analgesia, but no study has compared the two regional techniques. We tested the hypothesis that CWI is more effective for controlling postoperative pain compared with single-injection TAP block after laparotomy. METHODS: We conducted a prospective randomized study of patients undergoing gynecologic laparotomy with midline incision through the umbilicus under general anesthesia. The patients were allocated to receive either single-injection TAP block (TAP group) or CWI (CWI group) for postoperative analgesia. All patients received intravenous patient-controlled analgesia with morphine and intravenous flurbiprofen twice daily after surgery. Postoperative pain at rest and on coughing, postoperative morphine consumption, incidence of postoperative nausea and vomiting (PONV), pruritus and urinary retention, ambulation, and satisfaction score were recorded. Patients were assessed at 3 h after surgery and twice daily on postoperative days (POD) 1 and 2. RESULTS: Data of 54 patients were analyzed. Compared to the TAP group (n = 27), pain score on coughing was significantly lower in the CWI group (n = 27) on POD1 and POD2 (P < 0.05). Pain score on coughing at 3 h after surgery, pain score at rest at all assessed time points, morphine consumption, incidence of PONV, pruritus and urinary retention, ambulation, and satisfaction score were not different between the two groups. CONCLUSION: CWI reduced pain on coughing after the day of surgery compared with single-injection TAP block when performed as part of multimodal analgesia in patients undergoing gynecologic laparotomy.

[A Case of Living Donor Liver Transplantation Complicated by Thrombosis due to a Central Venous Catheter in the Right Internal Jugular Vein].

Central venous catheter-related infection and throm- bosis frequently occur, leading to serious complications in some cases. We encountered a case of thrombosis developing on the sixth day after surgery, in a patient with a PreSep Central Venous Oximetry Catheter™ placed in the internal jugular vein. A 53-year-old woman with a height of 160.8 cm and weight of 52.9 kg, showing normal coagulation test results, was scheduled for living donor liver transplantation under general anesthesia with sevoflurane/remifentanil. The durations of surgery and anesthesia were 6 hours and 56 minutes and 8 hours and 24 minutes, respectively. Although central venous catheter insertion and postop- erative management were appropriately performed, the patient reported chest pain and dyspnea just after the removal of the central venous catheter on the sixth day after surgery, and was diagnosed with thrombosis on CT. This case highlights the importance of selecting appropriate catheters considering perioperative risks and removing them in the early stages.

[Abdominal Oblique Muscle Hematoma after Ultrasound-guided Transverse Abdominis Plane Block].

A 41-year-old female patient with no remarkable medical history underwent a uterine myomectomy under general anesthesia. Ultrasound-guided lateral TAP block was performed using a 21-gauge blunt needle after surgery. Heparin calcium at 5,000 units was administered subcutaneously twice on postopera- tive day (POD)Y 1, and fondaparinux at 2.5 mg was administered subcutaneously once daily from POD 2 to POD 5. On POD 3, right-sided flank pain was noticed, which persisted until POD 7. Abdominal ultrasonogra- phy revealed an abdominal oblique muscle hematoma with a size of 43x19x31 mm. The patient had no anemia, and was discharged on POD 8. Right-sided flank pain disappeared, and the hematoma could not be identified by ultrasonography on POD 20.

Correlation of ischemia-modified albumin with SOFA and APACHE II scores in preoperative patients with colorectal cancer.

PURPOSE: Critical illnesses are assessed according to the sequential organ failure assessment (SOFA) and acute physiology and chronic health evaluation (APACHE) II. Circulating ischemia-modified albumin (IMA) is a biomarker generated under ischemic and oxidative conditions and may reflect disease severity in preoperative patients. This study investigated the correlations of IMA with SOFA and APACHE II scores in inpatients admitted for colorectal surgery. METHODS: We examined 27 patients with advanced colorectal cancers (mean age 69 years, men/women=15/12). Correlations between SOFA and APACHE II scores in addition to preoperative serum IMA and C-reactive protein (CRP) levels were analyzed. RESULTS: The mean IMA level was 0.5 AU, and the median CRP level was 0.6 mg/dL. Median scores for SOFA and APACHE II were 2 and 12 points, respectively. Significant positive correlations between IMA and SOFA (r=0.45, P<0.05) and IMA and APACHE II (r=0.45, P<0.05) were identified which remained significant in confounder-adjusted analyses. In contrast, weak correlations were observed between CRP and the SOFA and APACHE II scores. CONCLUSIONS: The positive correlations between IMA and both SOFA and APACHE II scores suggest that serum IMA measurements reflect the severity of systemic failure in patients admitted for colorectal surgery in the preoperative phase.

[Successful tracheal intubation using the GlideScope AVL in a pediatric patient with Pierre Robin syndrome].

We report a successful use of GlideScope AVL in a pediatric patient with Pierre Robin syndrome. A 36-day-old boy weighing 2.8 kg with Pierre Robin syndrome presented for tracheostomy after several weeks of trial airway management in prone position, who had failed to relieve his obstructive apnea. The Pentax-AWS videolaryngoscope equipped with the neonate Introck could not visualize his glottic opening. The GlideScope AVL single-use video laryngoscope equipping the #1 stat captured the view of the vocal cords. A tracheal tube (2.5 mm ID) with 90 degrees angled stylet, however, did not advance into the glottic opening, colliding with the anterior wall of the larynx and/or the laryngeal ventricle. Bending the tip of the stylet in a direction opposite to the inherent memory of the tube facilitated the placement of the tube into the trachea

[McGRATH MAC Videolaryngoscope: clinical assessment of its performance in 50 surgical patients].

BACKGROUND: The aim of this study was to evaluate the utility of McGRATH MAC Videolaryngoscope in tracheal intubation of surgical patients. METHODS: McGRATH MAC Videolaryngoscope was used for the tracheal intubation in 50 surgical patients undergoing general anesthesia. We compared the percentage of glottic opening score between McGRATH MAC Videolaryngoscope and Coopdech Videolaryngoscope Portable VLP-100 by anesthesia staffs and unexperienced anesthetic trainees. The number of intubation attempts and the time to complete intubation were also recorded. RESULTS: In 49 of 50 surgical patients including 18 patients with potential difficult airways, successful intubation was performed with McGRATH MAC. Not only anesthesia staffs but also unexperienced anesthetic trainees could obtain better view of the glottis with McGRATH compared with Coopdech Videolaryngoscope Portable VLP-100. CONCLUSIONS: McGRATH MAC Videolaryngoscope facilitates tracheal intubation in surgical patients.

[Comparative study of the KingVision videolaryngoscope and Airwayscope using manikins].

BACKGROUND: KingVision (KV) is a new videolaryngoscope. In this study, we compared the ease of use of the KV with the Airwayscope (AWS) by experienced personnel in a simulated manikin. METHODS: Twenty-eight anesthesiologists participated in this study. We used an advanced patient simulator (AIRSIM) to simulate normal manikin and difficult airway scenarios including cervical spine rigidity and limited mouth opening. We compared the time required for visualization of the glottis (Tv) and tracheal intubation (Ti), and analyzed the percentage of glottic opening (POGO) score and the success rates for tracheal intubation. RESULTS: In normal manikin, the Tv and Ti with the KV were significantly shorter than with the AWS (P < 0.05). The POGO score with the KV was higher than with the AWS (P < 0.05). In difficult airway scenarios including both cervical spine rigidity and limited mouth opening, the Tv and Ti with the KV were shorter than with only the AWS (P < 0.05). There is not much difference between KV and AWS regarding the POGO score in difficult airway. CONCLUSIONS: KV may be a suitable device for routine anesthesia care and difficult airway intubation. Further studies in a clinical setting are necessary to confirm these findings.

[GlideScope Cobalt: assessment of performance in 50 children].

BACKGROUND: GlideScope Cobalt video laryngoscope is a new type of GlideScope series. A reusable camera baton is inserted into a disposable plastic curved blade. The blade has 5 choices of size and can be used from infants to adults. The aim of the current study was to evaluate the efficacy of GlideScope Cobalt in children. METHODS: Endotracheal intubation was performed in 50 surgical children undergoing general anesthesia. The length of time in intubation, percentage of glottic opening (POGO) score and optimizing procedures were recorded. RESULTS: 100% POGO score was obtained in 42 cases. Successful endotracheal intubation was performed in 47 cases and 37 patients were intubated within 1 minute. It took over 1 minute to intubate in 13 cases, because of the difficulty of tracheal tube maneuver. Particular children, mostly aged 6-8, had difficulty in matching the size of the blade because of the large difference between the sizes of blade 2 and that of blade 3. CONCLUSIONS: GlideScope Cobalt is a useful tool in chidlren's airway management but it necessitates getting used to the tracheal tube maneuver and lacks the suitable blade size for 6-8 years old children.

[The KINGVISION: clinical assessment of performance in 50 patients].

BACKGROUND: The aim of this study was to evaluate the suitability of the KINGVISION videolaryngoscope for tracheal intubation. METHODS: Endotracheal intubation was performed using the KINGVISION in 50 patients undergoing general anesthesia. We compared the percentage of glottic opening score between Coopdech Videolaryngoscope Portable VLP100 and the KINGVISION with staff anesthesiologist and novice personnel. The time to complete instrumentation and optimizing procedures were also recorded. RESULTS: The KINGVISION allowed visualization of the glottis and successful intubation in all patients, including 11 patients with difficult airway. There were no differences in the time to intubation between staff anesthesiologist and novice personnel. Furthermore, percentage of glottic opening score was higher with KINGVISION than with Coopdech Videolaryngoscope Portable VLP100 among staff anesthesiologist and novice personnel. CONCLUSIONS: The KINGVISION could be an effective aid to airway management in surgical patients.

[Use of RRa sensor in a pediatric patient with post-adenotonsillectomy].

Rad-87 and RRa are new acoustic monitoring devices which can monitor the respiratory rate. To our knowledge, no studies have reported the RRa sensor used in pediatric patients after surgery. We succeeded in measuring the respiratory rate with the RRa sensor in the Pediatric Intensive Care Unit(PICU). A 10-year-old boy, 14.5 kg in weight and 119.6 cm in height, with cerebral palsy, mental retardation, epilepsy, and obstructive sleep apnea due to adenoidal and tonsillar hypertrophy, was scheduled for adenotonsillectomy under general anesthesia. Anesthesia was maintained with oxygen, air, sevoflurane (1.5-2.0%), remifentanil (0.1 to 0.5 microg . kg-1. min-1), and fentanyl (4 microg . kg-1). The operating time was 55 minutes, and the duration of anesthesia was 133 minutes. After finishing the surgery, we attached the RRa sensor to his anterior neck and monitored his respiratory rate. Furthermore, RRa could count his respiratory rate, during transfer from the operating room to PICU. The patient was sedated with dexmedetomidine (0.28 microg . kg-1 . min-1) at PICU, and his respiratory rate was accurately measured with the RRa sensor. We hope that Rad-87 and RRa sensors will become useful for measuring the respiratory rate in pediatric patients in the future.

[A case of extensive pulmonary atelectasis after intubation in a patient undergoing elective tympanoplasty].

A 33-year-old male, without significant medical history, underwent elective tympanoplasty. It was difficult to manage his airway because of overbites, small jaw, and short neck. After intubation, his left chest revealed obvious abnormality in sound and movement, and showed free air in the mediastinum on X ray. CT revealed extensive atelectasis. Although he is a current smoker, the length of preoperative smoking cessation necessary to decrease postoperative pulmonary complications is not clear. This case demonstrates the importance of preoperative preparation including education in smoking damage.