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Background@#Optimizing endotracheal tube (ETT) shape is important for successful videolaryngoscope-aided intubation. This prospective randomized controlled study aimed to compare the tube-handling time between a C-curved and hockey stick-shaped stylet in infants and neonates using the C-MAC® videolaryngoscope Miller blade. @*Methods@#A total of 110 infants (age < 1 year) were randomly assigned to either the hockey stick-curved stylet group (group H, n = 53) or the C-curved stylet group (group C, n = 57). The primary outcome was tube handling time after glottis visualization and the secondary outcomes were the total intubation time, incidence of successful intubation, initial tube tip location at the laryngeal inlet, and numerical rating scale for ease of intubation. @*Results@#Tube insertion time and total intubation duration (both in seconds) were significantly shorter in group C than in group H (13.3 ± 8.9 vs. 25.1 ± 27.0, P = 0.002; 19.9 ± 9.4 vs. 32.8 ± 27.1, P = 0.001, respectively). Group C displayed a higher rate of intubation success within 30 s than group H (87.7% vs. 69.8%, P = 0.029). The initial tube tip was located at the center in 34 children in group C (59.6%) and 12 children in group H (26.1%, P < 0.001). Laryngoscope operators rated intubation as easier when provided with a C-curved stylet. @*Conclusions@#In neonates and infants, modification of the ETT shape into a C-curve may reduce tube handling time compared to the conventional hockey stick-shaped tube during intubation using a C-MAC® video laryngoscope Miller blade.
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Background@#Although fiberoptic-guided endotracheal intubation using a supraglottic airway device (SAD) is a good alternative for the management of difficult airways, its learning curve for residents has not been evaluated in pediatric patients. We aimed to train residents using a pediatric manikin and obtain learning curves to evaluate the efficiency of the training. @*Methods@#We conducted a single-armed prospective study with anesthesiology residents. Plain endotracheal tube (ETT) intubation guided by a fiberoptic bronchoscope through Ambu® AuraGainTM was demonstrated in a pediatric manikin to the participants before training. The procedure was divided into four steps: SAD insertion, vocal cord identification, carina identification, and ETT insertion into the trachea. The results and elapsed procedure times of each trial were recorded. The learning curves for the participants were constructed and analyzed using the cumulative sum method. @*Results@#All the 30 participants acquired proficiency at the end of practice between eight and 25 trials. The overall success rate for the procedure was 92.8%, and above 80% for all participants. Mean ± standard deviation procedure time was 71.3 ± 50.7 s. The 4th step accounted for 86.2% and 48.0% of the total failures and procedure time, respectively. The procedure time rapidly decreased in the 2nd trial; a modest decline was observed thereafter. @*Conclusions@#Trainees can obtain proficiency for fiberoptic-guided intubation through SAD within 25 times when using pediatric manikin. Effect of the training on performance in actual clinical situation should be studied.
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Background@#Many studies have examined the risk factors for postoperative acute kidney injury (AKI), but few have focused on intraoperative peripheral perfusion index (PPI) that has recently been shown to be associated with postoperative morbidity and mortality. Therefore, this study aimed to evaluate the relationship between intraoperative PPI and postoperative AKI under the hypothesis that lower intraoperative PPI is associated with AKI occurrence. @*Methods@#We retrospectively searched electronic medical records to identify patients who underwent surgery at the general surgery department from May 2021 to November 2021. Patient baseline characteristics, pre- and post-operative laboratory test results, comorbidities, intraoperative vital signs, and discharge profiles were obtained from the Institutional Clinical Data Warehouse and VitalDB. Intraoperative PPI was the primary exposure variable, and the primary outcome was postoperative AKI. @*Results@#Overall, 2,554 patients were identified and 1,586 patients were included in our analysis. According to Kidney Disease Improving Global Outcomes (KDIGO) criteria, postoperative AKI occurred in 123 (7.8%) patients. We found that risks of postoperative AKI increased (odds ratio: 2.00, 95% CI [1.16, 3.44], P = 0.012) when PPI was less than 0.5 for more than 10% of surgery time. Other risk factors for AKI occurrence were male sex, older age, higher American Society of Anesthesiologists physical status, obesity, underlying renal disease, prolonged operation time, transfusion, and emergent operation. @*Conclusions@#Low intraoperative PPI was independently associated with postoperative AKI.
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Objectives@#. In this study, we review our institutional experience with pediatric laryngomalacia (LM) and report our experiences of patients undergoing supraglottoplasty using the spontaneous respiration using intravenous anesthesia and high-flow nasal oxygen (STRIVE Hi) technique. @*Methods@#. The medical records of 29 children with LM who visited Seoul National University Hospital between January 2017 and March 2019 were retrospectively reviewed. Surgical management was performed using the STRIVE Hi technique. Intraoperative findings and postoperative surgical outcomes, including complications and changes in symptoms and weight, were analyzed. @*Results@#. Of the total study population of 29 subjects, 20 (68.9%) were female. The patients were divided according to the Onley classification as follows: type I (n=13, 44.8%), II (n=10, 34.5%), and III (n=6, 20.7%). Twenty-five patients (86.2%) had comorbidities. Seventeen patients (58.6%) underwent microlaryngobronchoscopy under STRIVE Hi anesthesia. Four patients with several desaturation events required rescue oxygenation by intermittent intubation and mask bagging during the STRIVE Hi technique. However, the procedure was completed in all patients without any severe adverse effects. Overall, 15 children (51.7%) underwent supraglottoplasty, of whom 14 (93.3%) showed symptom improvement, and their postoperative weight percentile significantly increased (P=0.026). One patient required tracheostomy immediately after supraglottoplasty due to associated neurological disease. @*Conclusion@#. The STRIVE Hi technique is feasible for supraglottoplasty in LM patients, while type III LM patients with micrognathia or glossoptosis may have a higher risk of requiring rescue oxygenation during the STRIVE Hi technique.
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Background@#Pediatric patients with moyamoya disease are vulnerable to ischemic attacks following physical or emotional stress, such as those experienced during blood sampling. A central venous catheter might be beneficial for blood sampling, and a peripherally inserted central catheter (PICC) is a considerable option for central venous access. However, PICC insertion during anesthetic management is relatively rare.Case: Thirty cases of ultrasound-guided PICC insertion were performed in children undergoing surgery for moyamoya disease after anesthetic induction. Positioning was successful in 22 cases, and 5 were malpositioned. In three cases, the peripheral insertion failed. Adjustment of the insertion depth was performed in nine cases. No complications related to catheterization were observed during the procedure or the catheter indwelling period. @*Conclusions@#We report the successful use of PICC in children undergoing surgery for moyamoya disease with a considerable success rate and low incidence of malpositioning or complications.
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Ultrasonography facilitates arterial catheterization compared to traditional palpation techniques, especially in small arteries. For successful catheterization without complications, practitioners should be familiar with the anatomic characteristics of the artery and ultrasound-guided techniques. There are two approaches for ultrasound-guided arterial catheterization: the short-axis view out-of-plane approach and the long-axis view in-plane approach. There are several modified techniques and tips to facilitate ultrasound-guided arterial catheterization. This review deals with the anatomy relevant to arterial catheterization, several methods to improve success rates, and decrease complications associated with arterial catheterization.
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Ultrasonography facilitates arterial catheterization compared to traditional palpation techniques, especially in small arteries. For successful catheterization without complications, practitioners should be familiar with the anatomic characteristics of the artery and ultrasound-guided techniques. There are two approaches for ultrasound-guided arterial catheterization: the short-axis view out-of-plane approach and the long-axis view in-plane approach. There are several modified techniques and tips to facilitate ultrasound-guided arterial catheterization. This review deals with the anatomy relevant to arterial catheterization, several methods to improve success rates, and decrease complications associated with arterial catheterization.
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Background@#Ambu AuraGain and i-gel have different characteristics in design each other. However, few reports evaluate which device has more benefits for ventilation in children undergoing paralyzed general anesthesia. This prospective, randomized controlled trial compared the clinical performance AuraGain and i-gel in anesthetized children. @*Methods@#Children aged between 1 month and 7 years undergoing elective surgery were randomly assigned to the AuraGain and i-gel groups. The primary outcome was initial oropharyngeal leak pressure (OLP). Secondary outcomes were OLP at 10 min post-insertion, first-attempt and total insertion success rates, number of attempts and ease of gastric suction catheter placement, peak inspiratory pressure, fiberoptic bronchoscopic view score, ventilation quality, requirement of additional manipulation post-insertion, and complications. @*Results@#Data of 93 patients were analyzed. The initial OLPs of the AuraGain and i-gel were 27.5 ± 7.7 and 25.0 ± 8.0 cmH2O, respectively (P = 0.13). The OLP was significantly increased 10 min post-insertion in both groups. The initial success rates of the AuraGain and i-gel insertion were comparable. Suction catheter placement via the gastric port was easier (P = 0.02) and fiberoptic bronchoscopic view was better with the AuraGain (P < 0.001). The i-gel required additional manipulations post-insertion (P = 0.04). The incidence of complications during the emergence period was 2.2% for the i-gel and 10.8% for the AuraGain (P = 0.1) @*Conclusions@#OLP is comparable between AuraGain and i-gel. The AuraGain would be more favorable than the i-gel for use in pediatric patients under general anesthesia considering other outcomes.
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BACKGROUND@#Previously, a linked pharmacokinetic-pharmacodynamic model (the Kim model) of propofol with concurrent infusion of remifentanil was developed for children aged 2–12 years. There are few options for pharmacokinetic-pharmacodynamic model of propofol for children under two years old. We performed an external validation of the Kim model for children under two years old to evaluate whether the model is applicable to this age group.@*METHODS@#Twenty-four children were enrolled. After routine anesthetic induction, a continuous infusion of 2% propofol and remifentanil was commenced using the Kim model. The target effect-site concentration of propofol was set as 2, 3, 4, and 5 μg/mL, followed by arterial blood sampling after 10 min of each equilibrium. Population estimates of four parameters—pooled bias, inaccuracy, divergence, and wobble—were used to evaluate the performance of the Kim model.@*RESULTS@#A total of 95 plasma concentrations were used for evaluation of the Kim model. The population estimate (95% confidence interval) of bias was −0.96% (−8.45%, 6.54%) and that of inaccuracy was 21.0% (15.0%–27.0%) for the plasma concentration of propofol.@*CONCLUSION@#The pooled bias and inaccuracy of the pharmacokinetic predictions are clinically acceptable. Therefore, our external validation of the Kim model indicated that the model can be applicable to target-controlled infusion of propofol in children younger than 2 years, with the recommended use of actual bispectral index monitoring in clinical settings that remifentanil is present.Trial RegistrationClinical Research Information Service Identifier:TRIAL REGISTRATION: Clinical Research Information Service Identifier: KCT0001752
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BACKGROUND: Previously, a linked pharmacokinetic-pharmacodynamic model (the Kim model) of propofol with concurrent infusion of remifentanil was developed for children aged 2–12 years. There are few options for pharmacokinetic-pharmacodynamic model of propofol for children under two years old. We performed an external validation of the Kim model for children under two years old to evaluate whether the model is applicable to this age group.METHODS: Twenty-four children were enrolled. After routine anesthetic induction, a continuous infusion of 2% propofol and remifentanil was commenced using the Kim model. The target effect-site concentration of propofol was set as 2, 3, 4, and 5 μg/mL, followed by arterial blood sampling after 10 min of each equilibrium. Population estimates of four parameters—pooled bias, inaccuracy, divergence, and wobble—were used to evaluate the performance of the Kim model.RESULTS: A total of 95 plasma concentrations were used for evaluation of the Kim model. The population estimate (95% confidence interval) of bias was −0.96% (−8.45%, 6.54%) and that of inaccuracy was 21.0% (15.0%–27.0%) for the plasma concentration of propofol.CONCLUSION: The pooled bias and inaccuracy of the pharmacokinetic predictions are clinically acceptable. Therefore, our external validation of the Kim model indicated that the model can be applicable to target-controlled infusion of propofol in children younger than 2 years, with the recommended use of actual bispectral index monitoring in clinical settings that remifentanil is present. Trial Registration Clinical Research Information Service Identifier:TRIAL REGISTRATION: Clinical Research Information Service Identifier: KCT0001752
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BACKGROUND@#Previously, a linked pharmacokinetic-pharmacodynamic model (the Kim model) of propofol with concurrent infusion of remifentanil was developed for children aged 2–12 years. There are few options for pharmacokinetic-pharmacodynamic model of propofol for children under two years old. We performed an external validation of the Kim model for children under two years old to evaluate whether the model is applicable to this age group.@*METHODS@#Twenty-four children were enrolled. After routine anesthetic induction, a continuous infusion of 2% propofol and remifentanil was commenced using the Kim model. The target effect-site concentration of propofol was set as 2, 3, 4, and 5 μg/mL, followed by arterial blood sampling after 10 min of each equilibrium. Population estimates of four parameters—pooled bias, inaccuracy, divergence, and wobble—were used to evaluate the performance of the Kim model.@*RESULTS@#A total of 95 plasma concentrations were used for evaluation of the Kim model. The population estimate (95% confidence interval) of bias was −0.96% (−8.45%, 6.54%) and that of inaccuracy was 21.0% (15.0%–27.0%) for the plasma concentration of propofol.@*CONCLUSION@#The pooled bias and inaccuracy of the pharmacokinetic predictions are clinically acceptable. Therefore, our external validation of the Kim model indicated that the model can be applicable to target-controlled infusion of propofol in children younger than 2 years, with the recommended use of actual bispectral index monitoring in clinical settings that remifentanil is present.Trial RegistrationClinical Research Information Service Identifier:TRIAL REGISTRATION: Clinical Research Information Service Identifier: KCT0001752
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Ceramide metabolism is known to be an essential etiology for various diseases, such as atopic dermatitis and Gaucher disease. Glucosylceramide synthase (GCS) is a key enzyme for the synthesis of glucosylceramide (GlcCer), which is a main ceramide metabolism pathway in mammalian cells. In this article, we developed a liquid chromatography-tandem mass spectrometry (LC-MS/MS) method to determine GCS activity using synthetic non-natural sphingolipid C8-ceramide as a substrate. The reaction products, C8-GlcCer for GCS, could be separated on a C18 column by reverse-phase high-performance liquid chromatography (HPLC). Quantification was conducted using the multiple reaction monitoring (MRM) mode to monitor the precursor-to-product ion transitions of m/z 588.6 → 264.4 for C8-GlcCer at positive ionization mode. The calibration curve was established over the range of 0.625–160 ng/mL, and the correlation coefficient was larger than 0.999. This method was successfully applied to detect GCS in the human hepatocellular carcinoma cell line (HepG2 cells) and mouse peripheral blood mononuclear cells. We also evaluated the inhibition degree of a known GCS inhibitor 1-phenyl-2-decanoylamino-3-morpholino-1-propanol (PDMP) on GCS enzymatic activity and proved that this method could be successfully applied to GCS inhibitor screening of preventive and therapeutic drugs for ceramide metabolism diseases, such as atopic dermatitis and Gaucher disease.
Subject(s)
Animals , Humans , Mice , Calibration , Carcinoma, Hepatocellular , Cell Line , Chromatography, Liquid , Dermatitis, Atopic , Gaucher Disease , Mass Screening , Mass Spectrometry , Metabolism , MethodsABSTRACT
It is challenging to predict fluid responsiveness, that is, whether the cardiac index or stroke volume index would be increased by fluid administration, in the pediatric population. Previous studies on fluid responsiveness have assessed several variables derived from pressure wave measurements, plethysmography (pulse oximeter plethysmograph amplitude variation), ultrasonography, bioreactance data, and various combined methods. However, only the respiratory variation of aortic blood flow peak velocity has consistently shown a predictive ability in pediatric patients. For the prediction of fluid responsiveness in children, flow- or volume-dependent, noninvasive variables are more promising than pressure-dependent, invasive variables. This article reviews various potential variables for the prediction of fluid responsiveness in the pediatric population. Differences in anatomic and physiologic characteristics between the pediatric and adult populations are covered. In addition, some important considerations are discussed for future studies on fluid responsiveness in the pediatric population.
Subject(s)
Adult , Child , Humans , Blood Pressure , Cardiac Output , Fluid Therapy , Oximetry , Plethysmography , Pulse Wave Analysis , Stroke Volume , Ultrasonography , Ultrasonography, DopplerABSTRACT
BACKGROUND: The assessment of intravascular volume status is very important especially in children during anesthesia. Pulse pressure variation (PPV) and pleth variability index (PVI) are well known parameters for assessing intravascular volume status and fluid responsiveness. We compared PPV and PVI for children aged less than two years who underwent surgery in the prone position. METHODS: A total of 27 children were enrolled. We measured PPV and PVI at the same limb during surgery before and after changing the patients’ position from supine to prone. We then compared PPV and PVI at each period using Bland-Altman plot for bias between the two parameters and for any correlation. We also examined the difference between before and after the position change for each parameter, along with peak inspiratory pressure, heart rate and mean blood pressure. RESULTS: The bias between PPV and PVI was −2.2% with a 95% limits of agreement of −18.8% to 14.5%, not showing significant correlation at any period. Both PPV and PVI showed no significant difference before and after the position change. CONCLUSIONS: No significant correlation between PVI and PPV was observed in children undergoing surgery in the prone position. Further studies relating PVI, PPV, and fluid responsiveness via adequate cardiac output estimation in children aged less than 2 years are required.
Subject(s)
Child , Humans , Anesthesia , Arterial Pressure , Bias , Blood Pressure , Cardiac Output , Extremities , Fluid Therapy , Heart Rate , Plethysmography , Prone PositionABSTRACT
The article by Lee et al. entitled, “Fluid responsiveness in the pediatric population” (Korean J Anesthesiol 2019 Oct; 72(5): 429-440) contained an error in Fig. 2.
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It is challenging to predict fluid responsiveness, that is, whether the cardiac index or stroke volume index would be increased by fluid administration, in the pediatric population. Previous studies on fluid responsiveness have assessed several variables derived from pressure wave measurements, plethysmography (pulse oximeter plethysmograph amplitude variation), ultrasonography, bioreactance data, and various combined methods. However, only the respiratory variation of aortic blood flow peak velocity has consistently shown a predictive ability in pediatric patients. For the prediction of fluid responsiveness in children, flow- or volume-dependent, noninvasive variables are more promising than pressure-dependent, invasive variables. This article reviews various potential variables for the prediction of fluid responsiveness in the pediatric population. Differences in anatomic and physiologic characteristics between the pediatric and adult populations are covered. In addition, some important considerations are discussed for future studies on fluid responsiveness in the pediatric population.
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BACKGROUND@#The assessment of intravascular volume status is very important especially in children during anesthesia. Pulse pressure variation (PPV) and pleth variability index (PVI) are well known parameters for assessing intravascular volume status and fluid responsiveness. We compared PPV and PVI for children aged less than two years who underwent surgery in the prone position.@*METHODS@#A total of 27 children were enrolled. We measured PPV and PVI at the same limb during surgery before and after changing the patients’ position from supine to prone. We then compared PPV and PVI at each period using Bland-Altman plot for bias between the two parameters and for any correlation. We also examined the difference between before and after the position change for each parameter, along with peak inspiratory pressure, heart rate and mean blood pressure.@*RESULTS@#The bias between PPV and PVI was −2.2% with a 95% limits of agreement of −18.8% to 14.5%, not showing significant correlation at any period. Both PPV and PVI showed no significant difference before and after the position change.@*CONCLUSIONS@#No significant correlation between PVI and PPV was observed in children undergoing surgery in the prone position. Further studies relating PVI, PPV, and fluid responsiveness via adequate cardiac output estimation in children aged less than 2 years are required.
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The article by Lee et al. entitled, “Fluid responsiveness in the pediatric population†(Korean J Anesthesiol 2019 Oct; 72(5): 429-440) contained an error in Fig. 2.
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BACKGROUND: Despite well-known advantages, propofol remains off-label in many countries for general anesthesia in children under 3 years of age due to insufficient evidence regarding its use in this population. This study aimed to evaluate the efficacy and safety of propofol compared with other general anesthetics in children under 3 years of age undergoing surgery through a systematic review and meta-analysis of existing randomized clinical trials. METHODS: A comprehensive literature search was conducted of MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials to find all randomized clinical trials comparing propofol with another general anesthetic that included children under 3 years of age. The relative risk or arcsine-transformed risk difference for dichotomous outcomes and the weighted or standardized mean difference for continuous outcomes were estimated using a random-effects model. RESULTS: A total of 249 young children from 6 publications were included. The children who received propofol had statistically significantly lower systolic and diastolic blood pressures, but hypotension was not observed in the propofol groups. The heart rate, stroke volume index, and cardiac index were not significantly different between the propofol and control groups. The propofol groups showed slightly shorter recovery times and a lower incidence of emergence agitation than the control groups, while no difference was observed for the incidence of hypotension, desaturation, and apnea. CONCLUSION: This systematic review and meta-analysis indicates that propofol use for general anesthesia in young healthy children undergoing surgery does not increase complications and that propofol could be at least comparable to other anesthetic agents.