Combination of high-flow nasal oxygen and ketamine/dexmedetomidine sedation for diagnostic catheterization in a child with pulmonary arterial hypertension: a case report.

Pulmonary hypertension is associated with significant risk of perioperative life-threatening events. We present a case of a 12-year-old child with severe pulmonary arterial hypertension who successfully underwent diagnostic cardiac catheterization under ketamine and dexmedetomidine sedation with the support of high-flow nasal oxygen. Ketamine and dexmedetomidine are reported to have minimal effect on pulmonary vasculature in children with pulmonary hypertension and can be safely used in this population along with its lack of respiratory depression. Positive pressure generated by high-flow nasal oxygen improves upper airway patency, prevents micro-atelectasis, and is shown to improve the effectiveness of ventilation and oxygenation in patients under sedation breathing spontaneously. The presented strategy may contribute to enhancing the safety and effectiveness of procedural sedation for children with life-threatening pulmonary hypertension.

Criteria for immediate extubation after pediatric liver transplantation in a single pediatric liver transplant center in Japan.

Immediate extubation (IE) following liver transplantation (LT) has become the standard practice, even for pediatric patients. However, no preoperative or postoperative case selection protocols for IE are currently available. We have developed selection criteria for IE following pediatric LT. The aim of this study is to assess the safety and effectiveness of these selection criteria and anesthetic management protocol implemented in our hospital for IE after pediatric LT. METHOD: This was a retrospective study. The records of all cases undergoing LT in our center from January 2016 to December 2020 were collected. We excluded cases > 18 years old at the time of LT. Enrolled cases were divided into two groups: cases with immediate extubation (IE) or without immediate extubation (NIE). We compared preoperative conditions, intraoperative management, and postoperative courses. Finally, we classified NIE group patients into cases extubated at postoperative day 1 (early; E-NIE) and others (delayed; D-NIE) and compared their underlying diseases and postoperative courses. RESULTS: In the IE group, there were 81 cases, while the NIE group consisted of 185 cases. All patients in the IE group were successfully extubated without any instances of re-intubation due to respiratory failure. Within the E-NIE group, comprising 130 cases, all patients were ultimately extubated without the need for tracheostomy. However, in the D-NIE group, which encompassed 53 cases, seven patients required tracheostomy. CONCLUSION: In our center, the implementation of our anesthesia management protocol and the use of pre/postoperative case selection criteria have allowed for the safe practice of IE following pediatric LT. However, it should be noted that patients who cannot be extubated by Postoperative Day 1 (POD1) may be at an increased risk of requiring a tracheostomy. When contemplating IE, it is crucial to take into account the disease-specific physiological aspects and surgical site situations.

Impact of preoperative bloodstream infection on outcomes of pediatric liver transplant recipients treated for acute liver failure.

BACKGROUND: Acute liver failure (ALF) is a component of multisystem organ failure that causes severe liver dysfunction in patients without underlying chronic liver disease. The patients with ALF are prone to have infections, including bacteremia. However, studies of the infectious impact for post liver transplantation (LT) in pediatric ALF are limited. We aimed to evaluate our current practice for pediatric LT cases of ALF with preoperative bacteremia. METHODS: The records of all patients under 18 years old undergoing LT for ALF in our center from November 2005 to December 2021 were collected. They were divided into two groups: those with a preoperative bloodstream infection (BSI) and those without (NBSI). We compared the preoperative status and also reviewed the details of the BSI group. Intraoperative course and postoperative outcomes were also compared. RESULTS: There were 19 BSI patients and 66 NBSI patients. One BSI case was detected on the day of LT. This patient had no changes in vital signs and general condition. After evaluation and therapeutic intervention by pediatric infectious disease specialists, LT was performed on the same day. Five cases developed septic shock at the time of detection of BSI. All BSI patients were in stable condition on the operation day with proper interventions. There were no significant differences in mortality and hospital stay between both groups. CONCLUSIONS: LT might be able to be performed for pediatric ALF even with positive blood cultures. In addition, appropriate therapeutic intervention by specialists and patient's stable condition before LT are essential.

Anesthesia management protocol for liver transplantation as treatment for ornithine transcarbamylase deficiency.

BACKGROUND: Ornithine transcarbamylase deficiency is an X-linked genetic disorder that induces accumulation of ammonia in the liver and is the most common urea cycle disorder. The clinical manifestation of ornithine transcarbamylase deficiency is hyperammonemia that causes irreversible neurological damage. Liver transplantation is a curative therapy for ornithine transcarbamylase deficiency. The aim of this study is to suggest, from our previous experience, an anesthesia management protocol of liver transplantation for ornithine transcarbamylase deficiency, particularly focused on liver transplantation for cases with uncontrolled hyperammonemia. METHOD: We retrospectively reviewed our anesthesia-related experience in all cases of liver transplantation for ornithine transcarbamylase deficiency in our center. RESULTS: Twenty-nine liver transplantation cases for ornithine transcarbamylase deficiency were found between November 2005 and March 2021 in our center. Of these, 25 cases were stable through the perioperative period. However, 2 cases with carrier donor graft had hyperammonemia after liver transplantation. Another two cases had uncontrolled hyperammonemia before liver transplantation, even with continuous hemodialysis. They underwent life-saving liver transplantation. Their metabolic status stabilized after the anhepatic phase. CONCLUSION: Liver transplantation for cases with uncontrolled hyperammonemia can be performed with proper management. Second, liver transplantation with carrier donors should be avoided because of the risk of postoperative recurrence.

Epidemiology of adverse events attributed to airway management in paediatric anaesthesia: protocol for the prospective, multicentre, registry-based, cross-sectional Japan Pediatric Difficult Airway in Anesthesia study (J-PEDIA).

INTRODUCTION: Failure to secure an airway during general anaesthesia is a major cause of adverse events (AEs) in children. The safety of paediatric anaesthesia may be improved by identifying the incidence of AEs and their attributed risk factors. The aim of the current study is to obtain real-world data on the incidence of adverse peri-intubation events and assess their association with patient characteristics (including the prevalence of difficult airway features) and choice of anaesthesia management. These data can be used to develop a targeted education programme for anaesthesia providers towards quality improvement activities. METHODS AND ANALYSIS: This prospective, multicentre, registry-based, cross-sectional study will be conducted in four tertiary care hospitals in Japan from June 2022 to May 2025. Children <18 years of age undergoing surgical and/or diagnostic test procedures under general anaesthesia or sedation by anaesthesiologists will be enrolled in this study. Data on patient characteristics, discipline of anaesthesia providers and methodology of airway management will be collected through a standardised verification system. The exposure of interest is the presence of difficult airway features defined based on the craniofacial appearance. The primary and secondary endpoints are all AEs associated with airway management and reduced peripheral capillary oxygen saturation values. Potential confounders are related to the failure to secure the airway and variations in the anaesthesia providers' levels, adjusted using hierarchical multivariable regression models with mixed effects. The sample size was calculated to be approximately 16 000 assuming a 99% probability of obtaining a 95% Wilson CI with±0.3% of the half-width for the 2.0% of the incidence of critical AEs. ETHICS AND DISSEMINATION: The study protocol was approved by the Institutional Review Board at Aichi Children's Health and Medical Center (2021051). The results will be reported in a peer-reviewed journal and a relevant academic conference. TRIAL REGISTRATION NUMBER: UMIN000047351.

Risk prediction models for emergence delirium in paediatric general anaesthesia: a systematic review.

OBJECTIVES: Emergence delirium (ED) occurs in approximately 25% of paediatric general anaesthetics and has significant adverse effects. The goal of the current systematic review was to identify the existing literature investigating performance of predictive models for the development of paediatric ED following general anaesthesia and to determine their usability. DESIGN: Systematic review using the Prediction model study Risk Of Bias Assessment Tool (PROBAST) framework. DATA SOURCES: Medline (Ovid), PubMed, Embase (Ovid), Cochrane Database of Systematic Reviews (Ovid), Cochrane CENTRAL (Ovid), PsycINFO (Ovid), Scopus (Elsevier) and Web of Science (Clarivate Analytics), ClinicalTrials.gov, International Clinical Trials Registry Platform and ProQuest Digital Dissertations and Theses International through 17 November 2020. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: All randomised controlled trials and cohort studies investigating predictive models for the development of ED in children undergoing general anaesthesia. DATA EXTRACTION AND SYNTHESIS: Following title, abstract and full-text screening by two reviewers, data were extracted from all eligible studies, including demographic parameters, details of anaesthetics and performance characteristics of the predictive scores for ED. Evidence quality and predictive score usability were assessed according to the PROBAST framework. RESULTS: The current systematic review yielded 9242 abstracts, of which only one study detailing the development and validation of the Emergence Agitation Risk Scale (EARS) met the inclusion criteria. EARS had good discrimination with c-index of 0.81 (95% CI 0.72 to 0.89). Calibration showed a non-significant Homer-Lemeshow goodness-of-fit test (p=0.97). Although the EARS demonstrated low concern of applicability, the high risk of bias compromised the overall usability of this model. CONCLUSIONS: The current systematic review concluded that EARS has good discrimination performance but low usability to predict ED in a paediatric population. Further research is warranted to develop novel models for the prediction of ED in paediatric anaesthesia. PROSPERO REGISTRATION NUMBER: CRD42019141950.

Perioperative management of living-donor liver transplantation for methylmalonic acidemia.

Methymalonic acidemia (MMA) is a hereditary metabolic disorder characterized by a defect of the methylmalonyl-CoA mutase that breaks down propionate. The efficacy of liver transplantation for MMA was recently reported. However, the anesthetic management of liver transplant for MMA is not clear. The aim of this article is to describe an anesthetic management algorithm of liver transplant for MMA by reviewing our cases of liver transplant for MMA. Fourteen patients received a liver transplant; three cases showed metabolic decompensation during the transplant and two of the patients died. In the two patients who expired, propofol was used for maintenance anesthesia and preoperative continuous hemodiafiltration was used to reduce plasma methylmalonic acid level in one case, and to control severe metabolic decompensation before transplant for the other case. Their renal function was also worse than others and they were already experiencing metabolic decompensation before induction of anesthesia. Based on our experience of these 14 cases, we have established an anesthetic algorithm for patients with MMA undergoing liver transplant or other procedures. There are three important points in our experience: propofol should be avoided, dextrose infusion therapy should be continued to prevent metabolic decompensation, and liver transplant or other procedures should be avoided during metabolic decompensation.

[Anesthetic management for children undergoing magnetic resonance imaging (MRI) at Department of Anesthesia and ICU, National Center for Child Health and Development (NCCHD)].

We present here anesthetic management for children undergoing MRI at the Department of Anesthesia in NCCHD. Remaining motionless in the scanner of MRI is extremely important for data integrity because motion will blur the image. In patients who cannot remain still and in small children, general anesthesia or sedation is required for MRI. The MRI room is different from the conventional operating room as follows; the MRI machine emits the large sound continuously: the MRI room is the powerful magnetic field and the generation of radio frequency emissions necessitate the use of special equipment to provide continuous patient monitoring: the temperature in the MRI room is kept at 23 degrees to maintain the MRI machine: the patients positioned at the restricted area during the MRI scanning are hard to be accessed. We describe two cases of anesthetic management for children undergoing MRI by using propofol and in these cases we found that it should be better to follow the conventional setting for general anesthesia including monitoring system. Some hospitals encountered with serious complications such as cardiac arrest during MRI scanning under general anesthesia/sedation. MRI scanning under general anesthesia/sedation has a high risk due to the environment, indicating that we should be careful about the safety of the patients.

The effect of ligation on the load deflection characteristics of nickel titanium orthodontic wire.

This study examined the effect of ligation on the load-deflection characteristics of nickel-titanium (NiTi) orthodontic wire. A modified three-point bending system was used for bending the NiTi round wire, which was inserted and ligated in the slots of three brackets, one of which was bonded to each of the three bender rods. Three different ligation methods, stainless steel ligature (SSL), slot lid (SL), and elastomeric ligature (EL), were employed, as well as a control with neither bracket nor ligation (NBL). The tests were repeated five times under each condition. Comparisons were made of load-deflection curve, load at maximum deflection of 2,000 microm, and load at a deflection of 1,500 microm during unloading. Analysis of Variance (ANOVA) and Dunnett's test were conducted to determine method difference (alpha = 0.05). The interaction between deflection and ligation was tested, using repeated-measures ANOVA (alpha = 0.05). The load values of the ligation groups were two to three times greater than the NBL group at a deflection of 1,500 microm during unloading: 4.37 N for EL, 3.90 N for SSL, 3.02 N for SL, and 1.49 N for NBL (P < 0.01). For the EL, a plateau region disappeared in the unloading curve. SL showed the smallest load. The ligation of the bracket wire may make NiTi wire exhibit a significantly heavier load than that traditionally expected. NiTi wire exhibited the majority of its true superelasticity with SL, whereas EL may act as a restraint on its superelasticity.

Oral high-dose midazolam premedication for infants and children undergoing cardiovascular surgery.

BACKGROUND: The purpose of this study was to determine whether oral midazolam 1.5 mg x kg(-1) is a safe and effective alternative to standard-dose midazolam (0.5-1.0 mg x kg(-1)) premedication for infants and children with congenital heart disease. METHODS: A total of 193 infants and children (4 months to 2 years) undergoing cardiovascular surgery were studied. Each patient received 0.5, 1.0, or 1.5 mg x kg(-1) of oral midazolam. The level of sedation was assessed with a 5-point scale and vital signs were measured including blood pressure (BP), heart rate (HR) and oxyhaemoglobin saturation (SpO2) before and after the medication. RESULTS: Infants and children premedicated with oral midazolam 1.5 mg x kg(-1) were better sedated than those with standard-dose midazolam: 4% of infants and children given 1.5 mg x kg(-1) of midazolam became agitated compared with 14% given 1.0 mg x kg(-1) and 26% in those given 0.5 mg x kg(-1). Ninety percentage of infants and children given 1.5 mg x kg(-1) of midazolam achieved satisfactory sedation (calm, drowsy, or asleep) in 30 min, whereas 68% in those given 1.0 mg x kg(-1) and 35% in those given 0.5 mg x kg(-1). Midazolam 1.5 mg x kg(-1) did not cause any statistically significant decrease in BP, HR, or SpO2, although eight infants and children showed > or =20% drop in systolic BP and six infants and children showed >5% drop in SpO2. No 'spelling attacks', seizure-like activity, apnoea, nor laryngospasm were observed in any infants and children during and after the medication. CONCLUSIONS: Oral midazolam 1.5 mg x kg(-1) is excellent for preanaesthetic medication for infants and children undergoing cardiovascular surgery.