Practical guide for safe sedation.

This practical guide has been developed to ensure safe and effective sedation performed in adult patients outside of the operating room, for instance in intensive care units and dental treatment rooms and in the field of palliative care. Sedation levels are classified based on level of consciousness, airway reflex, spontaneous ventilation, and cardiovascular function. Deep sedation induces loss of consciousness and protective reflexes, and can cause respiratory depression and pulmonary aspiration. Invasive medical procedures necessitating deep sedation include cardiac ablation, endoscopic submucosal dissection, and internal radiation therapy. Appropriate analgesia is necessary for procedures that require deep sedation. The sedationist should evaluate the risks of the planned procedure, explain the sedation process to the patient, and obtain the patient's informed consent. Major parameters to be evaluated preoperatively are the patient's airway and general condition. Equipment, instruments, and drugs necessary for emergency situations should be defined and routinely maintained. To prevent aspiration, patients scheduled for moderate or deep sedation should fast preoperatively. In both inpatients and outpatients, biological monitoring should be continued until the discharge criteria are met. Anesthesiologists should be involved in management systems that ensure safe and effective sedation even if they do not personally perform all sedation procedures.

Efficacy of cEEG and hepatic function to diagnose early acute encephalopathy.

BACKGROUND: Early treatment may improve the prognosis of acute encephalopathy (AE). However, methods for early diagnosis have not yet been established. In this paper, we examined methods for the early diagnosis of AE. METHODS: We extracted data on patients with febrile status epilepticus from the electronic medical records in our department between March 2016 and April 2021. Among these, 79 patients who underwent continuous electroencephalography (cEEG) were included in this study. Patients who exhibited psychomotor retardation or abnormal brain magnetic resonance imaging findings were assigned to Group E (n = 20), and the remaining patients were the control group (Group C, n = 59). The following tests were compared retrospectively between these two groups on admission: cEEG, serum hepatic function tests, and blood coagulation tests. RESULTS: The percentage of patients who exhibited high-amplitude slow waves or flat waves on cEEG at the time of admission was statistically significantly higher in Group E than in Group C (p < 0.01). Moreover, the percentage of patients whose high-amplitude slow waves or flat brain waves on admission disappeared within 6 h after an initial episode of convulsion was statistically significantly lower in Group E than in Group C (p < 0.01). Furthermore, all the items in the coagulation and the hepatic function tests were statistically significantly different in Group E from those in Group C (p < 0.05). CONCLUSION: These results showed that cEEG together with hepatic function and coagulation tests may be useful for the differential diagnosis of AE.

Foot pressure analysis of gait pattern in older Japanese females requiring different personal care support levels.

[Purpose] This study evaluated gait parameters and foot pressure in two regions of the feet among older females with different personal care support needs to analyze factors that contribute to higher support requirements. [Subjects and Methods] Thirty-two older females were divided into support-need and care-need level groups. Gait parameters (speed, cadence, step length, step width, gait angle, toe angle, double support phase, swing phase, and stance phase) and foot pressure during a 5-m walk were measured and analyzed in the two groups. [Results] The percentage of the double support phase on both feet and the right stance phase were significantly higher in the care-need level group, while that of the right swing phase was significantly lower than that of the support-need level group. Additionally, the phase showing peak pressure on the left rear foot was significantly delayed and the left forefoot pressure in the terminal stance was significantly lower in the care-need level group than in the support-need level group. [Conclusion] These findings show that the temporal duration parameters and foot pressure on a particular side were significantly different between the two groups and suggest that these differences were associated with a higher care level.

Effective Use of Computed Tomography for Detection of Press-Through-Package Sheet Ingestion in a Pediatric Patient.

Press-through-package sheet (PTPS) ingestion can cause perforation of gastrointestinal tract. Such incidents, which require immediate medical attention, are often observed in elderly people. In this report, we describe the case of a 12-year-old patient who ingested PTPS. The patient, who has attention-deficit/hyperactivity disorder, presented with abdominal pain at our hospital. While it was not revealed by a chest x-ray, computed tomography scan showed a PTPS lodged in his lower esophagus. The ingested PTPS was removed by endoscopy without complications. Press-through-package sheets ingestion can occur in pediatric patients, and computed tomography scan is useful in the diagnosis.

Pediatric resident perceptions of shift work in ward rotations.

Although the long working hours of physicians are considered to be a social issue, no effective policies such as duty hour regulations have so far been proposed in Japan. We implemented an overnight call shift (OCS) system for ward rotations to improve the working environment for residents in a pediatric residency program. We later conducted a cross-sectional questionnaire asking the residents to compare this system with the traditional overnight call system. Forty-one pediatric residents participated in this survey. The residents felt that the quality of patient care improved (80.4% agreed). Most felt that there was less emphasis on education (26.8%) and more emphasis on service (31.7%). Overall, the residents reported that the OCS was beneficial (90.2%). In conclusion, the pediatric residents considered the OCS system during ward rotations as beneficial. Alternative solutions are vital to balance improvements in resident work conditions with the requirement for a high quality of education.

Independent risk factors for recurrence of apparent life-threatening events in infants.

The risk factors for recurrent apparent life-threatening event (ALTE) are unclear although the risk of recurrent ALTE is an important consideration for the management of ALTE patients. This study aimed to identify the risk factors for recurrent ALTE. We conducted a secondary analysis of the data from a single center retrospective cohort study in Japan conducted from March 2002 to January 2012, which included children diagnosed with ALTE at a pediatric emergency department (ED) in Tokyo. Among 112 ALTE patients, 18 (16%) had recurrences and 94 (84%) did not. Symptoms of respiratory tract infection (RTI) were more frequent in the recurrent group than in the non-recurrent group (44 vs. 14% p = 0.0055), and the proportion of patients triaged as level 1 was larger in the recurrent group than in the non-recurrent group (31 vs. 7%, p = 0.0312). Pallor was observed more frequently in the recurrent group than in the non-recurrent group (100 vs. 76%, p = 0.0216). Multivariate analysis demonstrated that the independent risk factors of recurrent ALTE were respiratory tract infection symptoms (OR, 5.02; 95% CI, 1.48-16.98). CONCLUSION: ALTE patients who had RTI symptoms at the ED visit for first ALTE should be admitted for close observation of potential recurrences. What is Known: • Approximately 10% of ALTE patients experienced recurrence of ALTE episodes. • The risk of recurrent ALTE is one of the major consideration for the management of ALTE patients at the ED because these patients have higher rates of serious underlying diseases which require interventions. What is New: • Respiratory infection symptoms at ED presentation can be independent risk factors for recurrent ALTE.

Limitation of duty hour regulations for pediatric resident wellness: A mixed methods study in Japan.

Duty hour regulations have been placed in residency programs to address mental health concerns and to improve wellness. Here, we elucidate the prevalence of depressive symptoms after implementing an overnight call shift system and the factors associated with burnout or depression among residents.A sequential exploratory mixed methods study was conducted in a tertiary care pediatric and perinatal hospital in Tokyo, Japan. A total of 41 pediatric residents participated in the cross-sectional survey. We determined and compared the prevalence of depressive symptoms and the number of actual working hours before and after implementing the shift system. A follow-up focus-group interview with 4 residents was conducted to explore the factors that may trigger or prevent depression and burnout.Mean working hours significantly decreased from 75.2 hours to 64.9 hours per week. Prevalence of depressive symptoms remained similar before and after implementation of the shift system. Emotional exhaustion and depersonalization from the burnout scale were markedly associated with depression. High workload, stress intolerance, interpersonal difficulties, and generation gaps regarding work-life balance could cause burnout. Stress tolerance, workload monitoring and balancing, appropriate supervision, and peer support could prevent burnout.Although the overnight call shift system was effective in reducing working hours, its effectiveness in managing mental health issues among pediatric residents remains unclear. Resident wellness programs represent an additional strategy and they should be aimed at fostering peer support and improvement of resident-faculty interactions. Such an approach could be beneficial to the relationship between physicians of different generations with conflicting belief structures.

Efficacy of pediatric acute pancreatitis scores at a Japanese tertiary center.

BACKGROUND: Pediatric acute pancreatitis (AP) is a rare but important clinical entity associated with significant morbidity. Predicting the severity and outcome of AP in pediatric patients can be challenging because there are few validated severity scoring systems. Moreover, the etiology of pediatric AP in the Japanese population is different from that of Western populations. The performance of severity scores in pediatric AP with a high prevalence of severe cases is still unknown. The aim of this study was to assess the performance of existing severity scoring systems when used for Japanese children at a tertiary care center. METHODS: We reviewed the electronic medical records of all children (≤18 years) treated for AP at between 2002 and 2012 at National Center for Child Health and Development, Tokyo. The modified Glasgow acute pancreatitis severity score (modified Glasgow), Ranson criteria (Ranson), Balthazar computed tomography severity index (CTSI), and pediatric acute pancreatitis severity (PAPS) score were assessed for their ability to distinguish severe pancreatitis from the milder forms. RESULTS: Thirty-three Japanese children with AP were identified. Among them, 37 episodes were analyzed for the performance of the scoring systems and 33 for the etiology. The most common etiology of AP was structural abnormality (n = 8). Sensitivity for the modified Glasgow, Ranson, PAPS, and CTSI was 42.9%, 52.4%, 81.0%, and 50.0%, respectively, while specificity was 81.3%, 81.3%, 37.5%, and 76.9%, respectively. CONCLUSION: We found PAPS to be the most reliable when used for discriminating the severe form of AP from the milder forms at a Japanese tertiary pediatric care center.

[Development and effectiveness of a tailored education program for caregivers of asthmatic children].

BACKGROUND: We developed a tailored education program using a touch-screen computer for changing management behavior with asthmatic children and their caregivers. The purpose of this study was to examine the effect of the tailored education program. METHODS: Caregivers including children with asthma were recruited during visits to a national children's hospital and those whose month-long asthma condition on the JPAC (Japanese Pediatric Asthma Program) score was 14 and below were included. Caregivers were randomized to the tailored education (intervention group) or non-tailored education (control group). The intervention group underwent a patient education program using a touch-screen computer, and they received tailored messages generated by a computer program. A research nurse and clinical psychologist used a computer-based resource to tailor the education messages and provided counseling using motivational interviewing for the caregivers including children with asthma. The control group received only a booklet on asthma. RESULTS: Forty-seven subjects aged 1 to 6 years were enrolled. Forty-seven caregivers were randomized to the tailored education (n=22) or non-tailored education (n=25) group. The results of two-way ANOVA showed that interactions between groups were observed in the score of JPAC and asthma knowledge for preschool children whose asthma onset was within one year and a half. The main effects of time were observed in the total and subscale score of QOL (Quality of Life) and the total score of P-CASES (Parental Childhood Asthma's Self-efficacy Scale). CONCLUSION: These findings indicate the benefit of a tailored education program to control symptoms in such caregivers.

Factor-associated caregiver burden in medically complex patients with special health-care needs.

BACKGROUND: Many medically complex patients with special health-care needs (PSHCN) receive home-based medical support, placing a major burden on their caregivers. We characterized the caregiving factors involved in PSHCN and their relationship with caregiver burden. METHODS: The PSHCN and their families were recruited from children's hospitals and rehabilitation centers. A medical information handbook was distributed to the families on enrollment, followed by a self-report questionnaire 1 year later. Data on the type of caregiving involved, family circumstances, and caregiver burden were collected. The Zarit caregiver burden scale (ZS) was used to evaluate caregiver burden. Logistic regression (proportional odds model) was used to determine associations between each variable and caregiver burden in each of two PSHCN age groups: <15 years old (younger group) and ≥ 15 years (older group). RESULTS: Sixty-eight PSHCN and their families were included in the analysis. The mean age of the PSHCN was 15.4 ± 11.8 years. On multivariate analysis there was a significant positive correlation between ZS score and older siblings (odds ratio [OR], 3.65), but no significant correlation between caregiver burden and type of care involved in the younger group. In the older group, a positive correlation was observed between caregiver burden and home mechanical ventilation with tracheostomy (OR, 15.16), but a negative correlation with younger siblings (OR, 0.04). CONCLUSIONS: Family circumstances play a bigger role than type of care required in increasing caregiver burden in families of PSHCN aged less than 15 years.

Comparison of patients with Kawasaki disease with retropharyngeal edema and patients with retropharyngeal abscess.

UNLABELLED: Kawasaki disease with retropharyngeal edema (KD with RPE) is a rare complication, and it is diagnosed by neck CT. Most reported cases had a delayed diagnosis because those patients' conditions were misdiagnosed as retropharyngeal abscess (RPA). The purpose of this study was to differentiate KD with RPE from RPA. We performed a retrospective case-control study comparing children with KD with RPE to those with RPA hospitalized at the tertiary pediatric hospital in Tokyo between 2005 and 2011. The 39 patients revealing RPE on neck CT were divided into two groups: group A was classified as KD (n = 21) and group B was classified as non-KD (n = 18). Patients in group B were finally evaluated as having RPA clinically and were treated with antibiotic therapy. A significantly higher proportion of patients in group B complained of dysphagia (11 patients vs. 5 patients; p = 0.0170) and neck pain (17 patients vs. 12 patients; p = 0.0106). Neck CT revealed a ring enhancement (16 patients vs. no patients; p < 0.0001) and mass effect in a greater proportion of patients in group B (11 patients vs. 1 patient; p < 0.0003). CONCLUSION: Careful attention to manifestations and close analyses of CT imaging may allow clinicians to differentiate KD with RPE from RPA.

Late development of coronary artery abnormalities could be associated with persistence of non-fever symptoms in Kawasaki disease.

BACKGROUND: Persistent fever after intravenous immunoglobulin (IVIG) is considered to be a major criterion of IVIG resistance in Kawasaki disease (KD), and a risk factor for the development of coronary artery abnormalities (CAA). However, the importance of persistent non-fever symptoms after defervescence has not yet been investigated. We examined the relationship between persistent non-fever symptoms and CAA in KD. METHODS: We conducted a retrospective cohort study of patients hospitalized with KD at the National Center for Child Health and Development between 1 April 2008 and 31 March 2009. Patients were divided into two groups; group A included patients who still had non-fever symptoms one month after onset of the illness and group B included patients who did not have persistent non-fever symptoms. Demographic, clinical variables were compared between the groups. RESULTS: Seventy-seven KD patients treated with IVIG were retrospectively analyzed. Patients were divided into two groups; group A included 12 (15.6%) patients and group B 65 (84.4%) patients. Demographic data, baseline laboratory data, and fever duration did not differ between the groups. In group A patients the most common persistent non-fever symptoms were lip erythema (n = 6) and bulbar conjunctivitis (n = 8). One month after onset of the illness CAA developed in seven of 77 patients (9.1%), four (33%) in group A and three (4.6%) in group B (odds ratio 10.3; 95% CI 1.9-54.8). Three patients in group A and one patient in group B developed CAA after the resolution of fever. CONCLUSIONS: Persistence of non-fever symptoms after IVIG may suggest persistence of latent inflammation, which may increase the risk of CAA. Therefore, patients with persistent non-fever symptoms may be at risk of developing CAA, even after defervescence. A prospective trial of additional IVIG for such patients should be considered.

[Diagnostic value of brain biopsy in a pediatric multiple sclerosis mimicking brain stem glioma].

Diagnosis of multiple sclerosis (MS) is difficult when the lesion mimics glioma or cerebral enchephalitis. We report a case of pediatric MS initially suspected as brain stem glioma. An 11-year-old boy developed left foot joint pain followed by progressive symptoms such as left arm and leg weakness, dysarthria, paraplegia, and decreased level of consciousness. He subsequently developed respiratory distress requiring endotracheal intubation and mechanical ventilation. Magnetic resonance imaging showed a mass measuring 2 cm in the medulla oblongata. Although this mass was initially suspected as a glioma, the patient's acutely progressive disease course was not consistent with this diagnosis. Open biopsy revealed inflammation and demyelination, but no malignant cells were detected. He was treated with steroid pulse therapy, which showed dramatic effects. Nine months later, he developed another episode characterized by several neurological symptoms, and the diagnosis of MS was clinically confirmed. Open brain stem biopsy is technically demanding, but this case demonstrates that appropriate neurosurgical evaluation can play an important role in diagnosis by ruling out glioma and confirming MS.

[Successful management of neurosurgical procedures with continuous infusion of recombinant factor IX in a child with hemophilia B].

This report describes the successful management of neurosurgical procedures with continuous infusion of recombinant factor IX (rFIX). A 1-year-old boy with severe hemophilia B was administered prophylactic therapy with rFIX after intracranial bleeding. We found the enlargement of an arachnoid cyst in a follow-up CT scan. He underwent marsupialization of the cyst under the continuous infusion of rFIX. FIX levels were examined in our hospital and the rFIX infusion rate was adjusted in an attempt to keep FIX levels above 90% intraoperatively, and 70% until his 7th post-operative day. We studied the pharmacokinetic profile of rFIX and found a half-time of 25 hours and mean in vivo recovery of 0.69 IU/dl/IU/kg. Reconstituted rFIX also retained at least 95% activity after 72 hours at room temperature. This is the first report of the perioperative management of a child undergoing a neurosurgical procedure under the continuous infusion of rFIX in Japan. Further studies are required before the routine use of this product for continuous infusion.

[Anaphylaxis and biphasic reaction in a children hospital].

BACKGROUND AND AIMS: Anaphylaxis is an acute multi-systemic and potentially fatal reaction, resulting from the exposure to antigens. There are few detailed reports of children with anaphylaxis. We studied the actual condition of an anaphylaxis including biphasic reaction. METHODS: This is a retrospective case study of children presenting to the Emergency Department of the National Center for Child Health and Development with anaphylaxis between 2002 and 2010. Etiology, age, sex ratio, clinical features, and management were examined. RESULTS: The median age of the patients was 36 months. Boys were predominant (63%). Seven cases developed anaphylactic shock, but all survived. As causes of anaphylaxis, food was identified in 85% of the patients, including eggs, dairy products and nuts, and drugs were identified in 3% of the patients. Initial symptoms consisted of mucocutaneous lesions (90%) and respiratory symptoms (71%). Epinephrine was given in 75 patients (22%). The biphasic anaphylactic reaction was observed in 3 out of the 340 cases (0.9%). In age, sex, grade and symptoms, there was no significant difference between patients with biphasic anaphylactic reaction and monophasic reaction. CONCLUSION: We clarified that the incidence of biphasic anaphylactic reaction was 0.9% in pediatric patients for the first time in Japan.

Antibiotic administration can be an independent risk factor for therapeutic delay of pediatric acute appendicitis.

OBJECTIVES: Little is known about the relationship between prior treatment with antibiotics and delay of diagnosis and treatment in pediatric acute appendicitis (AA). We have defined a situation requiring more than 48 hours from the onset of symptoms to surgery in pediatric AA as "therapeutic delay." The aim of this study was to investigate the risk factors contributing to therapeutic delay in pediatric AA. METHODS: We conducted a retrospective chart review of AA children operated on between 2003 and 2008 at tertiary-care pediatric and perinatal hospitals. Univariate and multivariate logistic regressions were analyzed to determine independent risk factors of therapeutic delay in pediatric AA. RESULTS: The duration between the onset of symptoms and surgery was more than 48 hours (therapeutic delay) in 50 patients (25%, group A) and 48 hours or less in 151 patients (75%, group B). The patients in group A had a significantly higher frequency of diarrhea (48% vs 12%; P < 0.0001). The percentages of children who had previously received antibiotics were more frequent in group A (46% vs 8%; P < 0.0001). The median C-reactive protein levels (72 vs 7 mg/L; P < 0.0001) and frequency of perforation (60% vs 13%; P < 0.0001) were statistically significantly higher in group A. A multivariate analysis demonstrated that the independent risk factors of therapeutic delay were history of receiving antibiotics (odds ratio [OR], 5.8; 95% confidence interval [CI], 2.3-15.5), diarrhea (OR, 5.2; 95% CI, 2.1-13.1), and elevated C-reactive protein levels (OR, 4.5; 95% CI, 1.9-10.8). CONCLUSIONS: Prior treatment with antibiotics was an independent risk factor for therapeutic delay in pediatric AA.

Cerebral hypoperfusion during pediatric cardiac surgery detected by combined bispectral index monitoring and transcranial doppler ultrasonography.

Bispectral index monitoring (BIS) measures depth of anesthesia and sedation. The case of a neonatal patient who underwent surgical repair for a double aortic arch is presented. During surgery, BIS decreased to 0, and cerebral blood flow (CBF), as measured by transcranial doppler ultrasonography, could not be detected immediately after clamping of the arch. BIS returned to baseline, and CBF was detected only after the aortic arch was unclamped. The arch was then carefully reclamped during close BIS and CBF monitoring.

New method of chest compression for infants in a single rescuer situation: thumb-index finger technique.

We introduce a new method of external chest compression (ECC), an essential part of cardiopulmonary resuscitation, using a thumb and index finger method (TIFM) on infants, and compares, this with two standard methods of the two finger method (TFM) and the two-thumb encircling hands method (TTEM). Sixty trained PALS (Pediatric Advanced Life Support) providers were randomly assigned into three groups and provided one-rescuer ECC for a period of five continuous minutes. Results without coaching or feedback were recorded on a recording CPR simulator (Laerdal, Inc). ECC was performed according to the BLS recommendations of the International Liaison Committee on Resuscitation (ILCOR). The quality of ECC in the TFM group deviated considerably from guideline recommendations. The same parameters in the TTEM and new TIFM groups during this study were in accordance with the parameters recommended by the guidelines. Thus, our new TIFM technique of chest compression, in infants was shown to be better than the currently TFM, especially for achieving adequate compression depth and avoiding fatigue, and is equally as effective as the TTEM. We propose this new method (TIFM) should be considered as the method of choice in single rescuer situations.

[Evaluation of standard regimen of single shot spinal anesthesia for cesarean section in Japanese parturients].

BACKGROUND: Recently, single shot spinal anesthesia using local anesthetic and opiate has been thought to be an ideal anesthetic method for cesarean section. For single shot spinal anesthesia, it is important to administer appropriate dose of drugs. However, optimal regimen for cesarean section in Japanese parturients has not been well studied. METHODS: In the present study, the validity of standard regimen of single shot spinal anesthesia for cesarean section was evaluated retrospectively. In the reviewed five month period (from May 2007 to September 2007), there were 183 cases of cesarean section, and single shot spinal was adopted in 144 cases. RESULTS: All of them were treated by the standard regimen (hyperbalic 0.5% bupivacaine 10 mg, fentanyl 25 microg, and morphine hydrochloride 0.1 mg). Among 144 cases, 139 cases (96.6%) required no additional pain relief until the delivery, and no parturient experienced critical adverse effects such as total spinal anesthesia. CONCLUSIONS: It is suggested that the studied regimen was valid for most of Japanese parturients.

Anesthesia protocols for early vitrectomy in former preterm infants diagnosed with aggressive posterior retinopathy of prematurity.

Aggressive posterior retinopathy of prematurity (ROP) can, if left untreated, rapidly progress to total retinal detachment within 1-2 weeks. Early surgical intervention with vitrectomy has been attempted to treat and prevent further retinal detachment. We investigated the anesthetic management of 29 infants with aggressive posterior ROP undergoing early vitrectomy. Postmenstrual age at surgery ranged from 35 to 47 weeks (median 41). Weight ranged from 1408 to 3478 g (median 1875). All infants underwent general anesthesia with fentanyl and sevoflurane. Mean surgical and anesthetic times were 88.6 and 143.6 min, respectively. In two patients, vitrectomy was postponed for one week due to enteric perforation in one patient and meningitis in the other, because the anticipated perioperative risk was deemed high. There were no intraoperative complications, except in one patient who developed pulmonary edema following upper airway obstruction. All patients survived to be discharged from NICU or transferred to the referring hospital. In all cases, complete or partial retinal reattachment was successfully achieved. Early vitrectomy for aggressive posterior ROP may be effective despite associated perioperative risks. As this condition progresses rapidly, prompt preoperative organization, including anesthetic planning, is important and useful. Anesthesiologists can play an important role in the perioperative management of such high-risk infants.