Peripheral Nerve Blocks in the Preoperative Management of Hip Fractures: A Systematic Review and Network Meta-Analysis.

STUDY OBJECTIVE: We conducted a systematic review and network meta-analysis to evaluate the comparative efficacy of peripheral nerve block types for preoperative pain management of hip fractures. METHODS: We searched Cochrane, Central Register of Controlled Trials, MEDLINE, EMBASE, ICTRP, ClinicalTrials.gov, and Google Scholar for randomized clinical trials. We included participants aged more than 16 years with hip fractures who received peripheral nerve blocks or analgesics for preoperative pain management. The primary outcomes were defined as absolute pain score 2 hours after block placement, preoperative consumption of morphine equivalents, and length of hospital stay. We used a random-effects network meta-analysis conceptualized in the Bayesian framework. Confidence of evidence was assessed using Confidence in Network Meta-Analysis (CINeMA). RESULTS: We included 63 randomized controlled studies (4,778 participants), of which only a few had a low risk of bias. The femoral nerve block, 3-in-1 block, fascia iliaca compartment block, and pericapsular nerve group block yielded significantly lowered pain scores at 2 hours after block placement compared with those with no block (standardized mean differences [SMD]: -1.1; 95% credible interval [CrI]: -1.7 to -0.48, [confidence of evidence: low]; SMD: -1.8; 95% CrI: -3.0 to -0.55, [low]; SMD: -1.4; 95% CrI: -2.0 to -0.72, [low]; SMD: -2.3; 95% CrI: -3.2 to -1.4, [moderate], respectively). The pericapsular nerve group block, 3-in-1 block, fascia iliaca compartment block, and femoral nerve block resulted in lower pain scores than the no-block group. Additionally, the pericapsular nerve group block yielded a lower pain score than femoral nerve block or fascia iliaca compartment block (SMD: -1.21; 95% CrI: -2.18 to -0.23, [very low]: SMD: -0.92; 95% CrI: -1.70 to -0.16, [low]). However, both the fascia iliaca compartment block and femoral nerve block did not show a reduction in morphine consumption compared with no block. To our knowledge, no studies have compared the pericapsular nerve group block with other methods regarding morphine consumption. Furthermore, no significant difference was observed between peripheral nerve blocks and no block in terms of the length of hospital stay. CONCLUSIONS: Compared with no block, preoperative peripheral nerve blocks for hip fractures appear to reduce pain 2 hours after block placement. Comparing different blocks, pericapsular nerve group block might be superior to fascia iliaca compartment block and femoral nerve block for pain relief, though the confidence evidence was low in most comparisons because of the moderate to high risk of bias in many of the included studies and the high heterogeneity of treatment strategies across studies. Therefore, further high-quality research is needed.

Comparative efficacy of ultrasound guidance or conventional anatomical landmarks for neuraxial puncture in adult patients: a systematic review and network meta-analysis.

BACKGROUND: Preprocedural, real-time, and computer-aided three-dimensional ultrasound has been widely used for neuraxial puncture; however, the optimal guidance is unclear. We examined the comparative efficacy of three ultrasound guidance and anatomical landmarks for neuraxial puncture in adults. METHODS: We searched for randomised controlled studies comparing the efficacy of ultrasound guidance and anatomical landmarks for neuraxial puncture in adults using electronic databases and unpublished studies. The primary outcomes were first-pass success and patient satisfaction. A random-effects network meta-analysis (NMA) was used. RESULTS: We identified 74 eligible studies (7090 patients). Preprocedural ultrasound and real-time ultrasound-guided neuraxial puncture improved first-pass success compared with anatomical landmarks (risk ratio [RR] 1.6; 95% credible interval [CrI] 1.3-1.9; RR 1.9; 95% CrI 1.3-2.9, respectively, moderate confidence). Computer-aided ultrasound-guided neuraxial puncture also increased first-pass success (RR 1.8; 95% CrI 0.97-3.3, low confidence), although estimates were imprecise. However, real-time ultrasound-guided neuraxial puncture resulted in minimal difference in first-pass success compared with preprocedural ultrasound (RR 1.2; 95% CrI 0.8-1.8, moderate confidence). Preprocedural ultrasound improved patient satisfaction slightly compared with anatomical landmark use (standardised mean differences 0.28; 95% CrI 0.092-0.47, low confidence). CONCLUSIONS: This NMA provides evidence supporting ultrasound-guided neuraxial puncture compared with use of anatomical landmarks, including indirect comparisons. Among the three ultrasound guidance methods, preprocedural ultrasound appears to be a better adjunctive option.

Rapid Response System and Limitations of Medical Treatment Among Children With Clinical Deterioration in Japan: A Multicenter Retrospective Cohort Study.

Objective: We investigated the role of rapid response systems (RRSs) in limitations of medical treatment (LOMT) planning among children, their families, and health care providers. Methods: This multicenter retrospective cohort study examined children with clinical deterioration using the Japanese RRS registry between 2012 and 2021. Results: Children (n = 348) at 28 hospitals in Japan who required RRS calls were analyzed. Eleven (3%) of the 348 patients had LOMT before RRS calls and 11 (3%) had newly implemented LOMT after RRS calls. Patients with LOMT were significantly less likely to be admitted to an intensive care unit compared with those without (36% vs. 61%, p < 0.001) and were more likely to die within 30 days (45% vs. 11%, p < 0.001). Conclusions: LOMT issues existed in 6% of children who received RRS calls. RRS calls for clinically deteriorating children with LOMT were associated with less intensive care and higher mortality.

Combined use of the ProSeal laryngeal mask airway and a bronchial blocker vs. a double-lumen endobronchial tube in thoracoscopic surgery: A randomized controlled trial.

STUDY OBJECTIVE: The combined use of the ProSeal laryngeal mask airway and a bronchial blocker may reduce postoperative hoarseness and sore throat. We aimed to test the feasibility and efficacy of this combination technique in thoracoscopic surgery. DESIGN: A single-center, patient-assessor blinded, randomized controlled trial. SETTING: Nagoya City University Hospital (between November 2020 and April 2022). PATIENTS: A total of 100 adult patients undergoing lobectomy or segmentectomy by video- or robotic-assisted thoracoscopic surgery. INTERVENTIONS: Patients were randomly assigned to either group using a combination of the ProSeal laryngeal mask airway and a bronchial blocker (pLMA+BB group) or a double-lumen endobronchial tube (DLT group). MEASUREMENTS: The primary outcome was the hoarseness incidence on 1-3 postoperative days. Secondary outcomes included sore throat, intraoperative complications (hypoxemia, hypercapnia, surgical interruption, malposition of devices, unintended lung expansion, and ventilatory difficulty), lung collapse, device placement-related outcomes, and coughing during emergence. MAIN RESULTS: A total of 100 patients underwent randomization (51 to the pLMA+BB group and 49 to the DLT group). After drop outs, a total of 49 patients in each group were analyzed per-protocol. The incidences of hoarseness in the pLMA+BB and DLT groups were 42.9% and 53.1% (difference, -10.2%; 95% confidence interval, -30.1% to 10.3%; p = 0.419), 18.4% vs. 32.7%, and 20.4% vs. 24.5% on postoperative day 1, 2, and 3, respectively. The incidences of sore throat in the pLMA+BB and DLT groups were 16.3% vs. 34.7% (difference, -18.4%; 95% confidence interval, -35.9% to -0.9%; p = 0.063) on postoperative day 1. In the pLMA+BB group, more intraoperative complications and less coughing during emergence were observed compared to the DLT group. Lung collapse and placement-related outcomes were comparable between the groups. CONCLUSIONS: The combination of ProSeal laryngeal mask airway and bronchial blocker did not significantly reduce hoarseness compared to the double-lumen endobronchial tube.

Efficacy of intravenous dexamethasone on postoperative pain after caesarean delivery under spinal anaesthesia with an intrathecal long-acting opioid: a systematic review and meta-analysis.

PURPOSE: Intravenous dexamethasone is recommended in elective caesarean delivery to decrease postoperative pain. However, the efficacy of spinal anaesthesia with an intrathecal long-acting opioid such as morphine or diamorphine for caesarean delivery has not been systematically investigated. METHODS: We searched all randomized controlled trials (RCTs) of pregnant women undergoing caesarean delivery under spinal anaesthesia with an intrathecal morphine or diamorphine via MEDLINE, CENTRAL, EMBASE, ICTRP, and ClinicalTrials.gov on May 18, 2022. Primary outcomes were time to first rescue analgesia, consumption of oral morphine equivalents, and incidence of drug-related adverse reactions. We evaluated the risk of bias for each outcome using the Risk of Bias 2. We conducted a meta-analysis using a random effects model. We evaluated the certainty of evidence with the GRADE approach. RESULTS: Five RCTs (455 patients) were included. The results of intravenous dexamethasone were as follows: time to first rescue analgesia (mean difference [MD] 0.99 h, 95% confidence interval [CI] - 0.86 to 2.84; very low certainty) and consumption of oral morphine equivalents (MD - 6.55 mg, 95% CI - 17.13 to 4.02; moderate certainty). No incidence of drug-related adverse reactions was reported (very low certainty). CONCLUSION: The evidence was very uncertain about the efficacy of intravenous dexamethasone on time to first rescue analgesia and the incidence of drug-related adverse reactions. Intravenous dexamethasone probably reduces the consumption of oral morphine equivalents. Anaesthesiologists might want to consider intravenous dexamethasone for postoperative pain after caesarean delivery under spinal anaesthesia with an intrathecal long-acting opioid.

3M microfoam™ surgical tape prevents nasal pressure injury associated with nasotracheal intubation: A randomized double-blind trial.

BACKGROUND: 3M microfoam™ surgical tape (3ST: 3M Japan Limited) is used for pressure wound control of medical equipment. It is cushioned and can be fitted to any body part. Here we investigated whether 3ST prevents nasal pressure injury associated with nasotracheal intubation (NTI). METHODS: We conducted a prospective, randomized double-blind study, enrolling 63 patients aged 20 to 70 years, who underwent general anesthesia with NTI. They were divided into 2 groups; those treated with 3ST (group S; n = 31) and control (group C; n = 31). After NTI and before securing the nasotracheal tube, a 35 × 25 mm 3ST was used to protect the nasal wing in group S, and the nasotracheal tube was fixed in place after NTI without protection in group C. The primary outcome was the presence or absence of nasal pressure injury after extubation. The Chi-Square test was used to assess the association between the 2 categorical variables. RESULTS: Nasal pressure injury was observed in 7 and 19 patients from groups S and C, respectively, representing a significant difference between the 2 groups (24.1% vs 67.8%, P = .001). Remarkably, none of the patients developed ulcers. CONCLUSION: 3ST prevents nasal pressure injury associated with NTI.

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.

Trends and patterns in the practice of pediatric sedation for magnetic resonance imaging in Japan: A longitudinal descriptive study from 2012 to 2019.

BACKGROUND: Worldwide, pediatric sedation for magnetic resonance imaging is a standard practice; however, there are few studies on its trends and patterns. AIMS: This study aimed to investigate the trends and patterns of pediatric sedation for magnetic resonance imaging in Japan and determine the incidence of and risk factors for adverse events/interventions. METHODS: This longitudinal descriptive study assessed children (age < 15 years) who underwent sedation for magnetic resonance imaging between April 2012 and December 2019 in Japan using a nationwide claims database. We assessed the patients' demographic characteristics, time trends in sedatives, sedative patterns by age, and adverse events/interventions within two post-sedation days. Further, we used multivariable logistic regression models to explore factors related to the incidence of adverse events/interventions. RESULTS: We identified 29 187 cases (median age, 2.0 years; 55.2% males). The most common sedative was triclofos sodium (n = 18 812, 51.7%). There was an increasing trend in barbiturate use (17.0% [2012] to 25.0% [2019]) and decreasing trends in the use of triclofos sodium (56.4% [2012] to 47.7% [2019]) and chloral hydrate (15.6% [2012] to 10.8% [2019]). We identified 534 adverse events/interventions in 460 cases (1.5%). Multivariable logistic regression analyses revealed that the incidence of adverse events/interventions mainly increased with the number of sedatives (≥3; adjusted odds ratio, 5.10; 95% confidence interval, 3.67-7.10) and unscheduled setting (adjusted odds ratio, 6.28; 95% confidence interval, 4.85-8.61); further, it decreased with high hospital procedure volume (adjusted odds ratio, 0.62; 95% confidence interval, 0.49-0.78). CONCLUSIONS: Based on a Japanese real-world setting, there is an increasing trend in barbiturate use and decreasing trends in the use of triclofos sodium and chloral hydrate in pediatric sedation for magnetic resonance imaging. Low hospital procedure volumes were associated with an increased risk of adverse events/interventions.

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 .

Comparison of hemostatic effect and safety between epinephrine and tramazoline during nasotracheal intubation: a double-blind randomized trial.

BACKGROUND: Nasal bleeding is the most common complication during nasotracheal intubation (NTI). To reduce nasal bleeding, the nasal mucosa is treated with vasoconstrictors (epinephrine [E] or tramazoline [T]) prior to NTI. This study aimed to determine whether E or T is more effective and safe for reducing nasal bleeding during NTI. METHODS: This study was preregistered on UMIN-CTR after being approved by the IRB of the School of Dentistry at Aichi Gakuin University. Written consent was received from all the patients. Total 206 patients aged 20-70 years and classified as 1-2 on American Society of Anesthesiologists-physical status were scheduled to undergo general anesthesia with NTI. At last, 197 patients were randomly divided into two groups and treated with either E (n = 99; 3 patients were discontinued) or T (n = 98; 2 patient were discontinued). After induction of general anesthesia, each patient's nasal mucosa was treated using either E or T. The E used in this study was BOSMIN® SOLUTION 0.1% (Daiichi-Sankyo Co., Ltd., Tokyo), and the T used in this study was TRAMAZOLIN Nasal Solution 0.118% AFP, (Alfresa Pharma Corporation, Osaka). E was diluted five times according to the package insert (final concentration of E = 0.02%), and T was used in its original solution. After 2 min, NTI was performed via the right nostril. Primary outcome were the presence of nasal bleeding (if bleeding was recognized at the posterior pharyngeal wall via nasal cavity during intubation, it was defined as bleeding) and the degree of bleeding (classified as none, mild, moderate, or severe). Secondary outcomes were arrhythmia, and hemodynamic (mean atrial pressure and heart rate) changes associated with vasoconstrictors. RESULTS: The presence of bleeding was comparable in both groups (12.5%, E; 14.5%, T; P = 0.63). No significant difference between the groups regarding the degree of bleeding (P = 0.78) was observed, with most patients having no bleeding (n = 84, E; n = 82, T). No severe bleeding and no arrhythmias induced by vasoconstrictor were observed in the two groups. CONCLUSIONS: Nasal treatment with E or T shows no difference in nasal bleeding during NTI. Although no arrhythmia associated with E was observed in this study, it has been reported in literature. Therefore, as frequency and degree of nasal bleeding were comparable, nasal treatment with T could reduce the risk of NTI. TRIAL REGISTRATION: UMIN-CTR (Registration No. UMIN000037907 ). Registered (05/09/2019).

Macintosh laryngoscope and i-view™ and C-MAC® video laryngoscopes for tracheal intubation with an aerosol box: a randomized crossover manikin study.

BACKGROUND: We tested the hypothesis that the C-MAC® video laryngoscope (C-MAC) with an external display is more useful than the disposable i-view™ video laryngoscope (i-view) with an integrated display or a Macintosh direct laryngoscope (Macintosh) for tracheal intubation with an aerosol box. METHODS: In this randomized, crossover manikin study, we recruited 37 medical personnel with > 2 years of dedicated anesthesia experience from five hospitals. After the three successful intubations within 60 s using each laryngoscope without a box, the participants performed tracheal intubation thrice with each laryngoscope with at least 2-h intervals in a determined order. The primary outcome was the intubation time. The secondary outcomes were success rate, Cormack-Lehane grade, and subjective difficulty scale score. RESULTS: Thirty-seven personnel (11 women and 26 men) with 12 [5-19] (median [interquartile range]) years of anesthesia and intensive care experience were enrolled. There was no significant difference in the intubation time: 30 [26-32] s for Macintosh, 29 [26-32] s for i-view, and 29 [25-31] s for C-MAC (P = 0.247). The success rate was 95-100%, without a significant difference (P = 0.135). The i-view and C-MAC exhibited superior Cormack-Lehane grades and lower subjective difficulty scale scores than the Macintosh; however, there were no differences between the i-view and C-MAC. CONCLUSIONS: Rapid and highly successful tracheal intubation was possible with both Macintosh, i-view, and C-MAC on a normal airway manikin in an aerosol box. Improved Cormack-Lehane grade and the ease of performing the procedure may support the use of video laryngoscopes. TRIAL REGISTRATION: UMIN Clinical Trials Registry, UMIN000040269 . Registered 30 April 2020.

Anesthetic management of a patient with Freeman-Sheldon syndrome undergoing oral surgery: A case report.

In the anesthetic management in this case was how to manage the patient without causing respiratory depression and respiratory muscle fatigue.

Anesthetic considerations for cesarean delivery in a parturient with hereditary hemorrhagic telangiectasia: a case report.

BACKGROUND: Hereditary hemorrhagic telangiectasia (HHT), also known as Rendu-Osler-Weber syndrome, is a rare autosomal dominant disorder characterized by mucocutaneous telangiectasia and arteriovenous malformations (AVMs). There are some anesthetic considerations for cesarean delivery in a parturient with HHT. CASE PRESENTATION: A 27-year-old parturient with pulmonary hemorrhage was admitted to our tertiary perinatal center. She was first diagnosed with HHT and a cesarean delivery using spinal anesthesia at 37 weeks of gestation was initially planned. However, magnetic resonance imaging (MRI) at 32 weeks of gestation revealed spinal AVM ranging from the thoracic to the lumbar levels. Thus, elective cesarean delivery under general anesthesia was planned. The parturient had an uneventful perioperative course. CONCLUSIONS: HHT should be considered as a differential diagnosis when parturients develop pulmonary hemorrhage. In a cesarean delivery of parturients with HHT, spinal MRI during pregnancy can help in deciding the anesthetic procedure to be used.

Perioperative management of thyroglossal duct cystectomy in a pediatric patient: A case report.

Thyroglossal duct on the dorsum of the tongue in the pediatric patient can cause a difficult airway due to the large mass and risk of airway obstruction associated with a swollen tongue after surgery.

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.

Comparison of disinfection effect between benzalkonium chloride and povidone iodine in nasotracheal intubation: a randomized trial.

BACKGROUND: Nasotracheal intubation can potentially result in microbial contamination from the upper respiratory tract to the lower respiratory tracts. However, an ideal nasotracheal disinfection method is yet to be determined. Therefore, we compared the disinfection effects between benzalkonium chloride and povidone iodine in nasotracheal intubation. METHODS: Overall, this study enrolled 53 patients aged 20-70 years who were classified into classes 1 and 2 as per American Society of Anesthesiologists-physical status and were scheduled to undergo general anesthesia with NTI. Patients who did not give consent (n = 2) and who has an allergy for BZK or PVI were excluded from the study. The patients were randomly divided into two groups on the basis of the disinfection method: BZK (n = 26, one patient was discontinued intervention) and PVI (n = 25). 50 patients were assessed finally. The subjects' nasal cavities were swabbed both before (A) and after disinfection (B), and the internal surface of the endotracheal tube was swabbed after extubation (C). The swabs were cultured on Brain heart infusion agar and Mannitol salt agar. The number of bacteria per swab was determined and the rates of change in bacterial count (B/A, C/B) were calculated. The growth inhibitory activity of the disinfectants on Staphylococcus aureus were also investigated in vitro. RESULTS: Although the initial disinfection effects (B/A) were inferior for benzalkonium chloride compared with those for povidone iodine, the effects were sustained for benzalkonium chloride (C/B). In the in vitro growth inhibitory assay against S. aureus, benzalkonium chloride showed higher inhibitory activity than povidone iodine. CONCLUSION: Although both disinfectants were inactivated or diffused/diluted over time, benzalkonium chloride maintained the threshold concentration and displayed antimicrobial effects longer than povidone iodine; therefore, benzalkonium chloride appeared to show a better sustained effect. Benzalkonium chloride can be used for creating a hygienic nasotracheal intubation environment with sustained sterilizing effects. TRIAL REGISTRATION: UMIN-CTR (Registration No. UMIN000029645 ). Registered 21 Oct 2017.

General anesthetic management of a patient with multiple chemical sensitivity for oral surgery: a case report.

BACKGROUND: Multiple chemical sensitivity (MCS) was first described in 1987. It is said that MCS is caused by neurological and immunological mechanisms in addition to psychosomatic mechanisms. When performing general anesthesia in patients with MCS, careful perioperative management is necessary. CASE PRESENTATION: The patient was a 32-year-old man. Wisdom teeth extraction under general anesthesia was scheduled under the diagnosis of pericoronitis. In 2015, he was diagnosed with MCS. Since then, he experienced sweating and urticaria when exposed to artificial fragrances. We prepared the surgical surroundings by letting the patient touch every possible equipment. In selecting the anesthetic drugs, a completely intravenous route was selected because of the possibility that artificial fragrance of inhalation anesthesia could induce symptoms. There was no allergic reaction during the preoperative period. CONCLUSIONS: It is important to reduce psychological burden of patient and to eliminate all possible reactive substances to prevent symptom onset.

General Anesthetic Management of a Child With Horseshoe Lung and Left Lung Hypoplasia for Cheiloplasty: A Case Report.

Horseshoe lung is an extremely rare congenital malformation in which the right and left lungs are fused due to stenosis of the lung parenchyma. In anesthetic management, it is important to avoid hypoxemia and hypercapnia caused by a decline in lung capacity and functional residual capacity. A 3-year-old boy with horseshoe lung and left lung hypoplasia was scheduled to undergo cheiloplasty. Regarding respiratory management, to prevent hypoxemia and hypercapnia, we avoided intraoperative peripheral airway obstruction with positive end-expiratory pressure, set a long inspiratory phase time for sufficient alveolar expansion, and maintained sufficient gas exchange in lungs with low reserve capacity.

Characterization of antibiotic resistance and the emergence of AmpC-producing Salmonella Infantis from pigs.

During the period of 2007-2008, a total of 270 pig fecal samples were collected from a meat processing plant located in southern Japan and examined for Salmonella species. A total of 44 Salmonella isolates were recovered, and antimicrobial resistance was detected in serotypes Typhimurium (n=9), Infantis and Choleraesuis (n=2), and Derby, Miyazaki and Schwarzengrund (n=1). Multidrug resistance was seen in serotypes Typhimurium (n=8) and Infantis (n=2). The most commonly observed resistance phenotypes were against streptomycin, oxytetracycline and sulfamethoxazole (100%), ampicillin (90%), chloramphenicol (50%), cephalothin (30%) and cefoxitin, ceftazidime and kanamycin (each 20%). Extended-spectrum cephalosporin-resistant Salmonella Infantis isolates producing plasmid-mediated, bla(CMY-2) gene were detected. These AmpC-producing isolates showed resistance to ampicillin and cephems (cephalothin, cefoxitin and ceftazidime). Resistance transfer experiments showed that transconjugants and transformants coexpressed resistance phenotypes similar to the donor isolates. To the best of our knowledge, this is the first report worldwide describing serovar Infantis from pigs capable of producing AmpC ß-lactamase. Then, we detected the pentadrug-resistance phenotype in Salmonella Typhimurium isolates, which yielded class 1 integron amplicons of 1.0 and 1.2 kb. Genetic fingerprinting analysis by pulsed-field gel electrophoresis and an assay by polymerase chain reaction confirmed the isolates to be Salmonella Typhimurium DT104. In conclusion, the findings of this survey call for the systematic and comprehensive domestic and international surveillance programs to determine the true rates of occurrence of AmpC-producing Salmonella both in the livestock and public health sectors.