Nasotracheal intubation in pediatrics: a narrative review.

Nasotracheal intubation (NTI) plays an important role in pediatric airway management, offering advantages in specific situations, such as oral and maxillofacial surgery and situations requiring stable tube positioning. However, compared to adults, NTI in children presents unique challenges owing to anatomical differences and limited space. This limited space, in combination with a large tongue and short mandible, along with large tonsils and adenoids, can complicate intubation. Owing to the short tracheal length in pediatric patients, it is crucial to place the tube at the correct depth to prevent it from being displaced due to neck movements, and causing injury to the glottis. The equipment used for NTI includes different tube types, direct laryngoscopy vs. video laryngoscopy, and fiberoptic bronchoscopy. Considering pediatric anatomy, the advantages of video laryngoscopy have been questioned. Studies comparing different techniques have provided insights into their efficacy. Determining the appropriate size and depth of nasotracheal tubes for pediatric patients remains a challenge. Various formulas based on age, weight, and height have been explored, including the recommendation of depth-mark-based NTI. This review provides a comprehensive overview of NTI in pediatric patients, including the relevant anatomy, equipment, clinical judgment, and possible complications.

Effect of converting from propofol to remimazolam with flumazenil reversal on recovery from anesthesia in outpatients with mental disabilities: a randomized controlled trial.

BACKGROUND: General anesthesia is often necessary for dental treatment of outpatients with mental disabilities. Rapid recovery and effective management of postoperative nausea and vomiting (PONV) are critical for outpatients. This study aimed to investigate the effect of transitioning from propofol to remimazolam with flumazenil reversal administered toward the end of surgery during propofol-based total intravenous anesthesia (TIVA) on recovery. METHODS: Adults with mental disabilities scheduled to undergo dental treatment were randomly assigned to receive either propofol-based TIVA (Group P) or propofol-remimazolam-based TIVA with flumazenil reversal (Group PR). Propofol was replaced with remimazolam 1 h before the end of surgery in Group PR; moreover, 0.5 mg of flumazenil was administered after the neuromuscular blockade reversal agent. The primary outcome was the duration of stay in the post-anesthesia care unit (PACU). The secondary outcomes included time to eye-opening, time to extubation, occurrence of PONV, and quality of recovery. RESULTS: Fifty-four patients were included in this study. The duration of stay in the PACU in Group PR was significantly shorter than that in Group P (mean difference, 8.7 min; confidence interval [95% CI], 3.3-14.2; P = 0.002). Group PR exhibited a shorter time to eye opening (mean difference, 5.4 min; 95% CI, 3.3-8.1; P < 0.001) and time to extubation (mean difference, 5.5 min; 95% CI, 3.6-7.9; P < 0.001) than Group P. Neither group required the administration of rescue analgesics, and the incidence of PONV was not reported. CONCLUSIONS: Transitioning from propofol to remimazolam 1 h before the end of surgery followed by flumazenil reversal reduced the duration of stay in the PACU and the time to eye opening and extubation without affecting the incidence of PONV and quality of recovery. TRIAL REGISTRATION NUMBER: Clinical Research Information Service (KCT0007794), Clinical trial first registration date: 12/10/2022.

Neuroprotective effect of erythropoietin on anesthesia-induced neurotoxicity through the modulation of autophagy in Caenorhabditis elegans.

BACKGROUND: The anti-oxidative, anti-inflammatory, and anti-apoptotic effects of erythropoietin may provide neuroprotective effects. Erythropoietin also modulates autophagy signaling that may play a role in anesthesia-induced neurotoxicity (AIN). Herein, we investigated whether AIN can be attenuated by the neuroprotective effect of erythropoietin in the Caenorhabditis elegans (C. elegans). METHODS: Synchronized worms were divided into the control, Iso, EPO, and EPO-Iso groups. The chemotaxis index (CI) was evaluated when they reached the young adult stage. The lgg-1::GFP-positive puncta per seam cell were used to determine the autophagic events. The erythropoietin-mediated pathway of autophagy was determined by measuring the genetic expression level of let-363, bec-1, atg-7, atg-5, and lgg-3. RESULTS: Increased lgg-1::GFP puncta were observed in the Iso, EPO, and EPO-Iso groups. In the Iso group, only the let-363 level decreased significantly as compared to that in the control group (P = 0.009). bec-1 (P < 0.001), atg-5 (P = 0.012), and lgg-3 (P < 0.001) were expressed significantly more in the EPO-Iso group than in the Iso groups. Repeated isoflurane exposure during development decreased the CI. Erythropoietin could restore the decreased CI by isoflurane significantly in the EPO-Iso group. CONCLUSIONS: Erythropoietin showed neuroprotective effects against AIN and modulated the autophagic pathway in C. elegans. This experimental evidence of erythropoietin-related neuroprotection against AIN may be correlated with the induced autophagic degradation process that was sufficient for handling enhanced autophagy induction in erythropoietin-treated worms.

The effects of intravenous dexmedetomidine on hemodynamic response in patients undergoing skull-pin head-holder application during neurosurgery - A meta-analysis of randomized controlled trials.

OBJECTIVES: Skull-pin head-holder application during neurosurgery is a highly noxious stimulus that may lead to abrupt hemodynamic change, which is an unfavorable response to maintain hemodynamics stability. The aim of this meta-analysis was to evaluate the effects of intravenous dexmedetomidine on hemodynamic response (blood pressure and heart rate) resulting from the application of skull-pin head-holder in neurosurgery. PATIENTS AND METHODS: A systematic review and meta-analysis was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement guidelines. The protocol was registered with the International Prospective Register of Systematic Reviews (CRD 420119127876). Electronic databases were searched, without discrimination of publication year, language, and region, to identify all randomized controlled trials investigating the effects of dexmedetomidine on hemodynamic response resulting from skull-pin head-holder application during general anesthesia for neurosurgery. The mean arterial pressure and heart rate were analyzed using random-effect model, and the mean difference (MD) was calculated. RESULTS: Seventeen trials were identified; a total of 878 patients were enrolled. The analysis indicated that dexmedetomidine infusion reduced the mean arterial pressure (MD -11.70, 95% confidence interval [CI] -16.33 to -7.07, p < 0.00001) and heart rate (MD -14.48, 95% CI -23.10 to -5.86, p = 0.001) during skull-pin head-holder application. Subgroup analysis showed that dexmedetomidine was superior to fentanyl for the attenuation of hemodynamic response. Dexmedetomidine infusion also reduced the incidence of hypertension, tachycardia and brain relaxation score. CONCLUSION: The result of this analysis indicates that intraoperative dexmedetomidine administration could decrease the hemodynamic response and provide hemodynamic stability during skull-pin head-holder application in neurosurgery.

Expression of antimicrobial peptides such as LL-37 and hBD-2 in nonlesional skin of atopic individuals.

Recurrent skin infection is one of the major complications of atopic dermatitis and can be partly explained by decreased expression of antimicrobial peptides such as human beta-defensin-2 and cathelicidin (LL-37). In the human epidermis, human beta-defensin-2 is packed in the lamellar body and LL-37 is co-localized with intercellular lipid lamellae of the stratum corneum; together, these antimicrobial peptides constitute the primary defense system. IL-1alpha, a potent inducer of LL-37 and human beta-defensin-2, is also secreted from the disrupted epidermis for barrier homeostasis. In this study, we investigated whether expression of human beta-defensin-2 and LL-37 is constitutively decreased in the skin of atopic individuals. Nonlesional foreskins from atopic (n=7) and nonatopic (n=7) individuals were analyzed. The expression of LL-37, human beta-defensin-2 and IL-1alpha was analyzed using immunohistochemical staining, Western blot, and real-time polymerase chain reaction. Lamellar body density and secretion were evaluated by electron microscope. Quantitative analysis showed that the expression of each parameter was not significantly different between groups. Thus, basal expression of LL-37 and human beta-defensin-2 was not changed in atopic individuals. These results indicate that the expression of antimicrobial peptides at baseline was not different between nonlesional skin of atopic individuals and normal skin of nonatopic individuals.

Development of a classification system for extrinsic hair damage: standard grading of electron microscopic findings of damaged hairs.

Human hairs experience damage and restoration processes consistently because of various external and internal factors. To analyze degrees of hair damage, morphological studies based on electron microscopy (EM), and biochemical studies based on protein and lipid analysis have been proposed and are widely used. Among them, morphological analysis through EM is a fundamental method in understanding the degree of damage and restoration. EM has been very useful in assessing extrinsic and intrinsic damage of hair and various pathological alopecias and also in estimating the efficacy of various kinds of products related to hair care. However, morphological studies have some limitations because they have been described using varying terms and subjective descriptions by different researchers. To establish an objective classification of damaged hair using uniform terms and standardizations. We analyzed over 2000 scanning electron microscopic and transmission electron microscopic findings of normal and of various kinds of damaged hairs to develop a standard grading system for the damaged hairs. After reviewing the results of the electron microscopic pictures, we proposed a standard grading system based on scanning electron microscope and transmission electron microscope. We developed and proposed an easy, objective, and useful standard grading system of damaged hairs.

A new method for investigation of the hair shaft: hard X-ray microscopy with a 90-nm spatial resolution.

Various methods have been used to investigate the hair shaft. In the ultrastructural hair field, scanning and transmission electron microscopies are widely used investigative methods, but they have some technical limitations. Recently, X-ray microscopes with sub-micron spatial resolution have emerged as useful instruments because they offer a unique opportunity to observe the interior of an undamaged sample in greater detail. In this report, we examined damaged hair shaft tips using hard X-ray microscopy with a 90 nm spatial resolution. The results of this study suggest that hard X-ray microscopy is an alternative investigative method for hair morphology studies.

Comparison of hair shaft damage after UVA and UVB irradiation.

Sunlight, especially ultraviolet (UV) light-induced hair damage is difficult to avoid during daily life. Concerns about the effects of ultraviolet light on hair are emerging recently. These photochemical changes mainly come from damage to hair proteins and melanins. In this study, we performed experiments to find the patterns of morphological and biochemical changes in UV-light-induced damage to hair by scanning and transmission electron microscopy and hair protein analysis. In our results, morphological damage is significant in UVB-irradiated hairs, while biochemical changes are greater in UVA-irradiated hairs.