Allergic Reactions to Sugammadex: A Case Series and Review of the Literature.

Sugammadex is a novel agent for the reversal of neuromuscular blockade; it acts by encapsulating -rocuronium or vecuronium, eliminating the active compound from the circulation, thereby providing rapid and complete recovery even with profound or complete neuromuscular blockade. Clinical advantages, including reduced incidence of residual blockade, decreased nausea and vomiting, decreased dry mouth, less change in heart rate, and reduced pulmonary complications, have been demonstrated when comparing sugammadex to conventional agents, such as neostigmine, that inhibit acetylcholinesterase. Although generally safe and effective, anaphylactoid and allergic reactions have been reported with sugammadex. The potential for hypersensitivity reactions with sugammadex and previous reports from the literature, as well as diagnostic and treatment strategies, are presented in 3 pediatric cases.

Oropharyngeal and Tongue Pulse Oximetry in 2 Critically Ill Pediatric Patients: A Case Report.

Pulse oximetry has become a standard of care to monitor oxygenation. Absent or inaccurate readings can occur with varied patient states. We present preliminary experience with a modification of a standard pulse oximetry using readily available equipment (oral airway and a tongue blade) to allow for continuous pulse oximetry from the oral cavity and tongue in 2 critically ill pediatric patients when standard application of pulse oximetry was not feasible or nonfunctional. These modifications can assist in the care of critically ill patients, allowing for adaptability in monitoring techniques when other options are unavailable.

Effect of Intrapapillary Local Anesthetic on Postoperative Pain Following Dental Treatment Under General Anesthesia in Pediatric Patients.

OBJECTIVE: This randomized, prospective, blinded study compared pain in children following dental treatment under general anesthesia (GA) using 1 of 2 established analgesia methods. METHODS: Patients age 4 to 7 years were randomly assigned to a control group (intravenous [IV] analgesics) or experimental group (IV analgesics and intrapapillary local anesthetic infiltrations) between July 2017 and February 2018. During recovery from surgery, Faces, Legs, Activity, Cry, and Consolability (FLACC) scores were recorded upon regaining consciousness and reassessed every 15 minutes until discharge. Overall pain occurrence (FLACC ≥1) and moderate/severe pain occurrence (FLACC ≥4) were analyzed using mixed effects logistic regression (N = 88). RESULTS: The experimental group had a 17% lower overall pain occurrence than the control group (16 vs 33%; p = .02). Moderate/severe pain occurrence between the groups was not significant (9 vs 22%; p = .23). The dental treatment subjects received (number of completed stainless steel crowns, extractions, and/or pulpotomies) did not significantly affect pain occurrence. CONCLUSION: Local anesthesia intrapapillary infiltrations around stainless steel crowns decrease overall pain occurrence but not moderate/severe pain occurrence following dental treatment under GA in pediatric patients.

Clinical Outcomes of a Modified Laryngeal Mask Airway (LMA® Gastro™ Airway) During Esophagogastroduodenoscopy in Children and Adolescents: A Randomized Study.

INTRODUCTION: During esophagogastroduodenoscopy (EGD), general anesthesia (GA) may be provided using a laryngeal mask airway (LMA) with the endoscope inserted behind the cuff of the LMA into the esophagus. Passage of the endoscope may increase the intracuff of the LMA. We evaluated a newly designed LMA (LMA® Gastro™ Airway) which has an internal channel exiting from its distal end to facilitate EGD. The current study compared the change of LMA cuff pressure between this new LMA and a standard clinical LMA (Ambu® AuraOnce™) during EGD. METHODS: Patients less than 21 years of age and weighing more than 30 kg were randomized to receive airway management with one of the two LMAs during EGD. After anesthetic induction and successful LMA placement, the intracuff pressure of the LMAs was continuously monitored during the procedure. The primary outcome was the change of intracuff pressure of the LMAs. RESULTS: The study cohort included 200 patients (mean age 13.6 years and weight 56.6 kg) who were randomized to the LMA® Gastro™ Airway (n=100) or the Ambu® AuraOnce™ LMA (n=100). Average intracuff pressures during the study period (before and after endoscope insertion) were not different between the two LMAs. Ease of the procedure was slightly improved with the LMA® Gastro™ Airway (p<0.001). DISCUSSION: The LMA® Gastro™ Airway blunted, but did not prevent an increase in intracuff pressure during EGD when compared to the Ambu® AuraOnce™ LMA. Throat soreness was generally low, and complications were infrequent in both groups. The ease of the procedure was slightly improved with the LMA® Gastro™ Airway compared to the Ambu® AuraOnce™ LMA.

Enclosure with augmented airflow to decrease risk of exposure to aerosolized pathogens including coronavirus during endotracheal intubation. Can the reduction in aerosolized particles be quantified?

INTRODUCTION: As the pandemic of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2 or COVID-19) has impacted hospital routines in recent weeks, recommendations to reduce healthcare worker infections are being developed. METHODS: We report preliminary experience with the efficacy of an enclosure with augmented airflow to decrease the risk of exposure to aerosolized pathogens during airway management including endotracheal intubation. A particle generator was used to test the efficacy of the reduction of aerosolized particles by measuring their concentration within the enclosure and in the environment. RESULTS: No reduction in the concentration of aerosolized particles was noted with the enclosure flap open, whether the interior suction was on or off. However, with the enclosure closed and no augmented airflow (suction off), the particle concentration decreased to 1.2% of baseline. The concentration decreased even further, to 0.8% of baseline with the enclosure closed with augmented airflow (suction on). DISCUSSION: Aerosolized particulate contamination in the operating room can be decreased using a clear plastic enclosure with minimal openings and augmented airflow. This may serve to decrease the exposure of healthcare providers to aerosolized pathogens.

Management of the Difficult Airway in the Pediatric Patient.

Loss of airway control in children, if not resolved quickly, will lead to devastating consequences. Successful management of the pediatric difficult airway, both anticipated and unanticipated, is facilitated by preprocedure assessment and preparation. Accessibility of and continued hands-on training with modern airway instruments, familiarization with difficult airway guidelines, and collaboration with multidisciplinary airway teams can aid in the management of the difficult pediatric airway. This review outlines the importance of airway assessment and advanced airway equipment for children. It also discusses difficult airway management techniques and algorithms for the management and rescue of the pediatric difficult airway.

Spinal anesthesia after intraoperative cardiac arrest during general anesthesia in an infant.

Although generally safe and effective, severe perioperative complications, including cardiac arrest, may occur during general anesthesia in infants. With the emergence of evidence that specific anesthetic agents may affect future neurocognitive outcomes, there has been an increased focus on alternatives to general anesthesia, including spinal anesthesia. We present a case of cardiac arrest during general anesthesia in an infant who required urologic surgery. During the subsequent anesthetic care, spinal anesthesia was offered as an alternative to general anesthesia. The risks of severe perioperative complications during general anesthesia are reviewed, etiologic factors for such events are presented, and the use of spinal anesthesia as an alternative to general anesthesia is discussed.

Establishing a community pharmacy residency at an independent pharmacy: Time allocation and valuation.

PURPOSE: The value of a first-year community pharmacy residency program (CPRP) at an independent pharmacy was estimated based on time allocation for resident responsibilities. METHODS: Predefined time allocation categories for the pharmacy resident were used to consistently classify and document time completing residency activities. Benefit-to-cost ratio was determined by tabulating total costs and total benefits of the residency program. A retrospective-prospective comparison of overall change in revenue, operating expense, and prescription volume was performed between the preresident time period (July 2012 to June 2013) and the postresident time period (July 2013 to June 2014). This comparison accounted for resident activities that did not directly generate revenue. RESULTS: Time allocations for the resident out of 2,221 total hours logged were dispensing (40%), clinical setup (16%), research (8%), professional meetings (7%), clinical activities (5%), resident education (5%), site precepting (4%), residency meetings (4%), didactic teaching (3%), miscellaneous (3%), marketing (2%), training (2%), and public health promotion (1%). Total costs were $77,422, and total benefits were $118,410. The benefit-to-cost ratio was 1.53. The postresident time interval had $172,451 more revenue and $6,622 more in operating expenses than the preresident time interval, and prescription volume decreased by 2,000 prescriptions compared to the previous year. CONCLUSION: The benefit-to-cost analysis indicated a $1.53 return for every $1.00 invested into a CPRP. An increase in revenue and operating expenses for the pharmacy was observed after implementation of the CPRP compared to the previous year.

Effect of cuffed and uncuffed endotracheal tubes on the oropharyngeal oxygen and volatile anesthetic agent concentration in children.

BACKGROUND: Over the past 5 years, there has been a change in the clinical practice of pediatric anesthesiology with a transition to the use of cuffed instead of uncuffed endotracheal tubes (ETTs) in infants and children. As the trachea is sealed, one advantage is to eliminate the contamination of the oropharynx with oxygen which should be advantageous during adenotonsillectomy where there is a risk of airway fire. The current study prospectively assesses the oropharyngeal oxygen and volatile anesthetic agent concentration during adenotonsillectomy in infants and children. METHODS: Following the induction of general anesthesia in patients scheduled for adenoidectomy, tonsillectomy or adenotonsillectomy, the trachea was intubated. The use of a cuffed or uncuffed ETT and the use of spontaneous (SV) or positive pressure ventilation (PPV) were at the discretion of the anesthesia team. The oxygen concentration was kept at 100% oxygen until the study was completed. Following placement of the mouth gag, the otolaryngolist placed into the oropharynx a small bore catheter, which was attached to a standard anesthesia gas monitoring device which sampled the gas at 150mL/min. The concentration of the oxygen and the concentration of the anesthetic agent in the oropharynx were measured for 5 breaths. RESULTS: The cohort for the study included 200 patients ranging in age from 1 to 18 years. With the use of a cuffed ETT and either SV or PPV, the oxygen concentration in the oropharynx was 20-21% and the volatile agent concentration was 0% in all 118 patients. With the use of an uncuffed ETT and the administration of 100% oxygen, there was significant contamination of the oropharynx noted during both PPV and SV. The mean oxygen concentration was 71% during PPV with an uncuffed ETT and 65% during SV with an uncuffed ETT. In these patients, the oropharyngeal oxygenation concentration exceeded 30% in 73 of the 82 patients (89%). The oropharyngeal oxygen and agent concentration was greater when the leak around the uncuffed ETT was ≥10cmH(2)O versus less than 10cmH(2)O and when the leak around the uncuffed ETT was ≥15cmH(2)O versus less than 15cmH(2)O. CONCLUSIONS: With the use of an uncuffed ETT and the administration of 100% oxygen, there was significant contamination of the oropharynx noted during both PPV and SV. The oropharyngeal concentration of oxygen is high enough to support combustion in the majority of patients. The use of a cuffed ETT eliminates oropharyngeal contamination with oxygen during the administration of anesthesia and may be useful in limiting the incidence of an airway fire.

Accurate whole human genome sequencing using reversible terminator chemistry.

DNA sequence information underpins genetic research, enabling discoveries of important biological or medical benefit. Sequencing projects have traditionally used long (400-800 base pair) reads, but the existence of reference sequences for the human and many other genomes makes it possible to develop new, fast approaches to re-sequencing, whereby shorter reads are compared to a reference to identify intraspecies genetic variation. Here we report an approach that generates several billion bases of accurate nucleotide sequence per experiment at low cost. Single molecules of DNA are attached to a flat surface, amplified in situ and used as templates for synthetic sequencing with fluorescent reversible terminator deoxyribonucleotides. Images of the surface are analysed to generate high-quality sequence. We demonstrate application of this approach to human genome sequencing on flow-sorted X chromosomes and then scale the approach to determine the genome sequence of a male Yoruba from Ibadan, Nigeria. We build an accurate consensus sequence from >30x average depth of paired 35-base reads. We characterize four million single-nucleotide polymorphisms and four hundred thousand structural variants, many of which were previously unknown. Our approach is effective for accurate, rapid and economical whole-genome re-sequencing and many other biomedical applications.

When is red urine not hematuria?: A case report.

The definition of gross hematuria is "the presence of blood in the urine in sufficient quantity to be visible to the naked eye." Certainly red urine, especially after trauma, immediately sparks the concern for genitourinary trauma. However, we report the unique case of a 19-year-old male who presented with "gross hematuria" after a motorcycle accident that turned out not to be hematuria but rather urine discoloration caused by the liberal use of a topical sulfa ointment containing an azo dye obtained in Mexico. We discuss the differential diagnosis of pigmenturia due to drugs or food ingestion, which is sparsely reported in the literature, as well as the frequency of alternative treatments used by patients presenting to the Emergency Department and the impact that can have on their evaluation.