Multisystem inflammatory syndrome in children: an Umbrella review.

We conducted an Umbrella review of eligible studies to evaluate what patient features have been investigated in the multisystem inflammatory syndrome in children (MIS-C) population, in order to guide future investigations. We comprehensively searched MEDLINE, EMBASE, and Cochrane Database of Systematic Reviews from December 1, 2019 to the May 6, 2022. The time period was limited to cover the coronavirus disease-2019 (COVID-19) pandemic period. The protocol was registered in the PROSPERO registry (CRD42022340228). Eligible studies included (1) a study population of pediatric patients ≤21 years of age diagnosed with MIS-C; (2) an original Systematic review or Mata-analysis; (3) published 2020 afterward; and (4) was published in English. A total of 41 studies met inclusion criteria and underwent qualitative analysis. 28 studies reported outcome data of MIS-C. 22 studies selected clinical features of MIS-C, and 6 studies chose demographic data as a main topic. The mortality rate for children with MIS-C was 1.9% (interquartile range (IQR) 0.48), the ICU admission rate was 72.6% (IQR 8.3), and the extracorporeal membrane oxygenation rate was 4.7% (IQR 2.0). A meta-analysis of eligible studies found that cerebral natriuretic peptide in children with MIS-C was higher than that in children with COVID-19, and that the use of intravenous immunoglobulin (IVIG) in combination with glucocorticoids to treat MIS-C compared to IVIG alone was associated with lower treatment failure. In the future, for patients with MIS-C, studies focused on safety of surgery requiring general anesthesia, risk factors, treatment, and long-term outcomes are warranted.

Anesthetic management of pheochromocytoma and paraganglioma for patients with Fontan circulation: a case series.

BACKGROUND: Anesthetic management of pheochromocytoma and paraganglioma with Fontan circulation is challenging for physicians, with attention to cardiovascular physiology. CASE PRESENTATION: We performed anesthetic management for pheochromocytoma and paraganglioma in three patients with Fontan circulation. We maintained intraoperative central venous pressure at preoperative level under fluid infusion and administrating nitric oxide to decrease pulmonary arterial resistance. We administered noradrenaline or vasopressin if low blood pressure was present despite adequate central venous pressure. Although noradrenaline is prevalent for the case of noradrenaline-secreting tumor especially after resection, we could maintain blood pressure to administrate vasopressin without increasing central venous pressure. Retroperitoneal laparoscopic approach which could avoid intra-abdominal adhesions might be selectable as case 3. CONCLUSIONS: Sophisticated management is required for pheochromocytoma and paraganglioma with Fontan circulation.

Anesthetic management of hepatectomy for the patient with Fontan circulation: a case series.

BACKGROUND: Hepatectomy for patients with Fontan circulation consists of high central venous pressure and low pulmonary vascular resistance, and is challenging for physicians. CASE PRESENTATION: We performed anesthetic management for hepatectomy in three patients with Fontan circulation. Massive bleeding and transfusion as well as careful management were needed. Open abdominal surgery had to be conducted instead of laparoscopic surgery for controlling bleeding in one case. We successfully performed general anesthesia using nitric oxide and inotropes while monitoring arterial pressure and central venous pressure in all the cases. CONCLUSIONS: To maintain Fontan circulation during hepatectomy, it is important to manage central venous pressure and ensure appropriate circulatory volume.

A pressure-resistant peripherally inserted central catheter is as useful as a central venous catheter for rapid fluid infusion: an in vitro study.

BACKGROUND: Although peripherally inserted central catheters (PICCs) have been widely used, they have not been frequently used in anesthesia practice. The central venous pressure measured via PICCs are reportedly as accurate as that measured via central venous catheters (CVCs), but the findings concerning rapid infusion are unclear. This study examined whether or not pressure-resistant PICCs could be used for rapid fluid infusion.  METHODS: The in-line pressure was measured in similar-sized double-lumen catheters-4-Fr PICC (55, 45 and 35 cm) and 17-G CVC (20 and 13 cm)-at flow rates of saline decided using a roller pump system. We also examined the flow rate at an in-line pressure of 300 mmHg, which is the critical pressure at which hemolysis is considered to occur during blood transfusion. RESULTS: The pressure-resistant PICCs obtained a high flow rate similar to that of CVCs, but the in-line pressures increased in proportion to the flow rate and catheter length. Flow rates at an intra-circuit pressure of 300 mmHg were not significantly different between the 45-cm PICC and 20-cm CVC. CONCLUSION: Pressure-resistant PICCs can be used for rapid fluid infusion.

Anesthetic management of cesarean section in a patient with Takayasu's arteritis: a case report.

BACKGROUND: Takayasu's arteritis (TA) is a chronic, progressive, inflammatory arteritis. We presented the case of cesarean section in a patient with TA. CASE PRESENTATION: A 31-year-old pregnant woman with TA underwent a planned cesarean section at 34 weeks of pregnancy. She had stenosis of the cerebral and coronary arteries and heart failure due to aortic regurgitation. Spinal anesthesia was performed. In addition to standard monitoring, arterial blood pressure in the dorsalis pedis artery and regional cerebral tissue oxygen saturation were monitored. Intraoperative arterial blood pressure was maintained using continuous infusion of noradrenaline with a careful intermittent bolus infusion of phenylephrine. All the procedures were successfully performed without significant complications. CONCLUSIONS: In a pregnant woman with TA, severe stenosis of the cerebral and coronary arteries, and heart failure due to valvular heart disease, careful anesthetic management by selecting catecholamines and assessing the perfusion pressure for critical organs is important.

Predictors of failure of intersegmental line creation using bronchoscopic jet ventilation for thoracoscopic pulmonary segmentectomy.

BACKGROUND: During pulmonary segmentectomy, identification of the target segment is essential. We used bronchoscopic jet ventilation (BJV) to delineate the intersegmental plane by selectively sending air into the target segment. The purpose of this study was to investigate the factors associated with BJV failure. METHODS: Data were retrospectively collected from 48 patients who underwent pulmonary segmentectomy with BJV between March 2014 and May 2019 at a single center. Data were compared between BJV succeeded cases and failed cases. RESULTS: In 13 cases (27%), BJV were unsuccessful. The Brinkman index was significantly higher in failed cases (962 ± 965 failed vs. 395 ± 415 successful, P = 0.0067). The success rate was significantly lower when BJV was applied to the posterior basal segmental bronchus (B10) (B10: 1/5 (20%) vs others: 34/43 (79%), P = 0.015). CONCLUSION: Long-term smoking and the bronchus corresponding to the posterior basal segment might make successful performance of BJV difficult.

Association between ionized magnesium and postoperative shivering.

PURPOSE: Ionized magnesium (iMg) is considered to be the biologically active fraction of circulating total serum Mg (tMg). However, only the relationship between tMg and postoperative shivering has been studied. To our knowledge, hitherto no clinical studies have investigated the association between serum ionized magnesium concentration ([iMg]) and postoperative shivering. Therefore, we aimed to retrospectively examine this association, focusing on hypomagnesemia and depletion of [iMg]. METHODS: This retrospective study involved 421 patients who underwent pancreaticoduodenectomy under general anesthesia at our center from December 2012 to September 2019. Logistic regression analysis was performed to estimate the odds ratio (OR) for the incidence of postoperative shivering. RESULTS: Postoperative shivering developed in 111 out of 421 patients. The post-surgical concentration of [iMg] was significantly associated with postoperative shivering in the non-adjusted model, but not in the multivariable-adjusted model. In multivariable-adjusted analysis, progressive decrease of [iMg] by 0.1 mmol/L significantly increased the risk of postoperative shivering (OR: 1.64, 95% CI 1.02-2.64, p = 0.04). The multivariable-adjusted OR for postoperative shivering was 3.65 (95% CI 1.25-13.55, p = 0.02) in subjects with post-surgical [iMg] less than 0.6 mmol/L and decrease in [iMg] during surgery compared with those with post-surgical [iMg] more than 0.6 mmol/L and constant or increased of [iMg] during surgery. CONCLUSION: A decrease in the [iMg] during surgery was significantly associated with postoperative shivering. Subjects who had an [iMg] lower than 0.6 mmol/L post-surgery and decreased [iMg] during surgery had a significantly higher risk of postoperative shivering. Intraoperative depletion of [iMg] was significantly associated with shivering.

The effect of remimazolam on postoperative memory retention and delayed regeneration in breast surgery patients: Rationale and design of an exploratory, randomized, open, propofol-controlled, single-center clinical trial: A study protocol.

BACKGROUND: Remimazolam, a benzodiazepine ultra-short-acting sedative, has been used in general anesthesia since August 2020. It is used in awake surgeries that require awakening the patient in the middle of the surgery because of its rapid awakening effect as well as antagonistic interactions. If remimazolam has associated anterograde amnesia similar to benzodiazepines, it will have a positive effect on preventing psychological trauma. However, to our knowledge, the effect of remimazolam on anterograde amnesia has not been previously examined. METHODS/DESIGN: The aim of this exploratory, open, propofol-controlled, single-center, randomized clinical trial is to examine the effect of remimazolam on postoperative memory retention and delayed regeneration. Seventy patients undergoing breast surgery will be included in the study. The patients will be randomly assigned to receive propofol or remimazolam as sedatives during surgery. The primary endpoint is the number of posters patients remember 24 hours after surgery (among 4 posters shown after awakening from anesthesia) as an assessment of anterograde amnesia. Secondary endpoints are retrograde amnesia, dose of analgesic given from the time the patient returns to the ward until 24 hours after surgery, immediate postoperative pain numerical rating scale scores, and pain numerical rating scale scores 24 hours after leaving the operating room. Recruitment will take place between October 2021 and March 2022 to achieve the target sample size. DISCUSSION: To our knowledge, this is the first trial designed to examine the effects of remimazolam on postoperative memory retention and delayed regeneration in patients undergoing breast surgery. TRIAL REGISTRATION: This clinical trial was registered at the University Hospital Medical Information Network (UMIN) Center on September 28, 2021 (UMIN-CTR: UMIN000045593).

Antinociceptive effect of selective G protein-gated inwardly rectifying K+ channel agonist ML297 in the rat spinal cord.

The G protein-gated inwardly rectifying K+ (GIRK) channels play important signaling roles in the central and peripheral nervous systems. However, the role of GIRK channel activation in pain signaling remains unknown mainly due to the lack of potent and selective GIRK channel activators until recently. The present study was designed to determine the effects and mechanisms of ML297, a selective GIRK1/2 activator, on nociception in the spinal cord by using behavioral studies and whole-cell patch-clamp recordings from substantia gelatinosa (SG) neurons. Rats were prepared for chronic lumber catheterization and intrathecal administration of ML297. The nociceptive flexion reflex was tested using an analgesy-meter, and the influence on motor performance was assessed using an accelerating rotarod. We also investigated pre- and post-synaptic actions of ML297 in spinal cord preparations by whole-cell patch-clamp recordings. Intrathecal administration of ML297 increased the mechanical nociceptive threshold without impairing motor function. In voltage-clamp mode of patch-clamp recordings, bath application of ML297 induced outward currents in a dose-dependent manner. The ML297-induced currents demonstrated specific equilibrium potential like other families of potassium channels. At high concentration, ML297 depressed miniature excitatory postsynaptic currents (mEPSCs) but not their amplitude. The ML297-induced outward currents and suppression of mEPSCs were not inhibited by naloxone, a µ-opioid receptor antagonist. These results demonstrated that intrathecal ML297 showed the antinociceptive effect, which was mediated through direct activation of pre- and post-synaptic GIRK channels. Selective GIRK channel activation is a promising strategy for the development of new agents against chronic pain and opioid tolerance.

Resting pupil size is a predictor of hypotension after induction of general anesthesia.

PURPOSE: Arterial hypotension is a major adverse effect of general anesthesia. Patients with pre-existing autonomic dysfunction are at greater risk of hypotension. This study was performed to examine whether objective measurement of the pupillary light reflex is predictive of intraoperative hypotension. METHODS: We studied 79 patients who underwent scheduled surgery under general anesthesia. Patients with severe cardiovascular disease or receiving antihypertensive agents were excluded. The light reflex was measured preoperatively using a portable infrared pupillometer, and the hemodynamic parameters were obtained from the anesthesia records. The patients were divided into two groups according to the development of hypotension: the hypotension and normotension groups. Multivariate logistic regression analysis was performed to determine the pupil parameters predictive of hypotension. RESULTS: Patients in the hypotension group were older and had a greater pupil size or constriction velocity than those in the normotension group. Logistic regression analysis showed that post-induction hypotension was significantly associated with maximum pupil size or constriction velocity after adjustment for age and other clinical variables. Latency of the light reflex and the percent reduction of pupil size were not associated with hypotension. Age was a relatively strong predictor of hypotension; other confounding factors were not associated with hypotension. CONCLUSION: Measurement of maximum pupil size is useful to identify patients at risk for intraoperative hypotension. The influence of age must be considered during measurement of the pupil response. CLINICAL TRIAL NUMBER: UMIN000023729 REGISTRY URL: https://www.umin.ac.jp.

Perioperative anesthetic management of intestinal pseudo-obstruction as a complication of pheochromocytoma.

BACKGROUND: Intestinal pseudo-obstruction, which is a rare complication of pheochromocytoma, can be caused by hypersecreted catecholamines. CASE PRESENTATION: A 45-year-old woman was admitted for local recurrence of pheochromocytoma complicated by intestinal pseudo-obstruction. The intestinal pseudo-obstruction showed poor response to α-adrenergic receptor blocker and she was scheduled for surgical resection of pheochromocytoma. The surgery was uneventfully accomplished with general anesthesia combined with epidural anesthesia. The latter was performed with the aim of not only perioperative pain management but also of promoting intestinal peristalsis. The anticipated effect for intestinal peristalsis was not apparent in the early postoperative phase. The abdominal symptoms were gradually relieved over the course of about 1 month. CONCLUSIONS: For intestinal pseudo-obstruction induced by pheochromocytoma, although inhibition of the sympathetic system by epidural infusion of local anesthetics may be promising, short-term usage of epidural local anesthetics infusion did not provide a quick recovery after pheochromocytoma removal surgery.

Direct Effect of Remifentanil and Glycine Contained in Ultiva® on Nociceptive Transmission in the Spinal Cord: In Vivo and Slice Patch Clamp Analyses.

BACKGROUND: Ultiva® is commonly administered intravenously for analgesia during general anaesthesia and its main constituent remifentanil is an ultra-short-acting µ-opioid receptor agonist. Ultiva® is not approved for epidural or intrathecal use in clinical practice. Previous studies have reported that Ultiva® provokes opioid-induced hyperalgesia by interacting with spinal dorsal horn neurons. Ultiva® contains glycine, an inhibitory neurotransmitter but also an N-methyl-D-aspartate receptor co-activator. The presence of glycine in the formulation of Ultiva® potentially complicates its effects. We examined how Ultiva® directly affects nociceptive transmission in the spinal cord. METHODS: We made patch-clamp recordings from substantia gelatinosa (SG) neurons in the adult rat spinal dorsal horn in vivo and in spinal cord slices. We perfused Ultiva® onto the SG neurons and analysed its effects on the membrane potentials and synaptic responses activated by noxious mechanical stimuli. RESULTS: Bath application of Ultiva® hyperpolarized membrane potentials under current-clamp conditions and produced an outward current under voltage-clamp conditions. A barrage of excitatory postsynaptic currents (EPSCs) evoked by the stimuli was suppressed by Ultiva®. Miniature EPSCs (mEPSCs) were depressed in frequency but not amplitude. Ultiva®-induced outward currents and suppression of mEPSCs were not inhibited by the µ-opioid receptor antagonist naloxone, but were inhibited by the glycine receptor antagonist strychnine. The Ultiva®-induced currents demonstrated a specific equilibrium potential similar to glycine. CONCLUSIONS: We found that intrathecal administration of Ultiva® to SG neurons hyperpolarized membrane potentials and depressed presynaptic glutamate release predominantly through the activation of glycine receptors. No Ultiva®-induced excitatory effects were observed in SG neurons. Our results suggest different analgesic mechanisms of Ultiva® between intrathecal and intravenous administrations.

[Acute upper airway obstruction after extubation due to excessive anteflexion of the neck with occipitocervical fusion].

A patient developed upper airway obstruction immediately after tracheal extubation due to excessive anteflexion of the neck with occipitocervical fusion. A 59-year-old woman who had undergone mastectomy 17 years previously was scheduled for occipitocervical fusion for C2 vertebral metastasis. Retroflexion of her neck was restricted. Nasal intubation under sedation was performed using bronchial fiberscopy under fentanyl and propofol anesthesia. Emergence from anesthesia was smooth, and extubation was performed. Immediately after extubation, the patient could not breathe, and manual mask ventilation was impossible. Re-intubation was performed 30 minutes after the extubation. Oral fiberscopy revealed pharyngeal obstruction, and laryngeal edema was not observed. Fixation of her neck in excessive anteflexion was suspected to have caused her dyspnea. Therefore, re-operation was performed, and she was transferred to the intensive care unit under anesthesia. One day postoperatively, extubation was performed successfully with no dyspnea. Fixation of the neck in excessive anteflexion is one of the causes of upper airway obstruction after occipitocervical fusion. We must carefully observe cervical X-ray films to locate the upper airway obstruction, and careful extubation using a tube exchanger is strongly recommended in this operation.

[Anesthetic management of a cervicoisthmic pregnancy patient undergoing cesarean section].

Cervicoisthmic pregnancy is a rare obstetric condition that is potentially dangerous for the pregnant woman due to a high risk of abortion or preterm delivery. We here present a 29-year-old woman with cervicoisthmic pregnancy undergoing cesarean section at full-term. Under combined epidural and spinal anesthesia, an infant was delivered alive, and the placenta was preserved without any forces to detach from the uterus. The surgery was completed without massive bleeding. The retained placenta was treated with methotrexate infusion into the uterus from the 6th day as well as uterine artery embolization at the 51th day postpartum. She subsequently required manual removal of the retained placenta under combined epidural and spinal anesthesia with only small bleeding. She was discharged from our hospital uneventfully. Meticulous preparation for massive bleeding and long-term treatment of the retained placenta are important in the perioperative management for cesarean section of a full-term patient with cervicoisthmic pregnancy.