The usefulness of a nasopharyngeal multiplex polymerase chain reaction system to screen pediatric patients with preoperative fever.

BACKGROUND: When children have a preoperative fever, anesthesiologists must help determine whether to postpone or proceed with surgery, as fever may be a sign of upper respiratory tract infection (URTI). Such infections are a known risk factor for perioperative respiratory adverse events (PRAEs), which are still one of the prime causes of anesthetic mortality and morbidity in pediatric patients. Since the COVID-19 pandemic, preoperative assessments have become drastically more complex as hospitals strive to balance practicality and safety. In our facility, if pediatric patients presented with preoperative fever, we used the FilmArray® Respiratory Panel 2.1 to determine whether to postpone or proceed with surgery. METHODS: This is a single-center retrospective observational study evaluating the efficacy of the FilmArray® Respiratory Panel 2.1 as a preoperative screening test. This study included pediatric patients scheduled for elective surgeries between March 2021 and February 2022. FilmArray was used if a patient had a preoperative fever (determined by axillary temperature, ≥38°C for <1-year-old, ≥37.5°C for ≥1-year-old) between hospital admission and before surgery. We excluded patients if they had apparent symptoms of URTI. RESULTS: In the FilmArray positive group, 11 of 25 (44%) cases developed subsequent symptoms after surgery was canceled. No patients in the negative group developed symptoms. The proportion of the development of subsequent symptoms between the FilmArray positive and negative groups was statistically significant (p < .001, odds ratio: 29.6, 95% confidence interval: [3.80-1356.01]). CONCLUSIONS: Our retrospective observational study revealed that 44% of the FilmArray positive group subsequently developed symptoms, and no PRAEs were observed in the FilmArray negative group. We suggest that FilmArray could be useful as a screening test for pediatric patients with preoperative fever.

[A Case of Aglossia for which the Airway Could Not be Managed with a Laryngoscope].

We encountered a case of congenital aglossia accom- panied by upper airway obstruction and faucal con- striction, for which mask ventilation was straightfor- ward and nasal intubation under bronchofiberscopic guidance was effective. The faucal constriction was easily alleviated under anesthesia, facilitating the pas- sage of a laryngoscope blade. The absence of the tongue base, a target site for laryngoscope manipulation, prevented visualization of the glottis. Airway Scope® AWS-SIOOL (Nihon Kohden Corporation, Tokyo) equipped with PBLADE® (ITL-NL-NEO- NATE) for newborns facilitated detection of the glottis, suggesting its usefulness as an intubator.

[A Case of EXIT (Ex-utero Intrapartum Treatment) in a Fetus with Prenatal Diagnosis of a Giant Cervical Tumor: Successful Airway Management but without Indication of Treatment for a Tumor].

The ex-utero intrapartum treatment (EXIT) is a rare procedure, and often comes as an emergency surgery. A careful preparation is crucial and a multidisciplinary team discussion during the prenatal period is necessary because it may be practically and ethically difficult to plan a surgical treatment for a fetus for EXIT. An elective caesarean section and EXIT for a fetus with a giant cervical tumor, which may cause airway obstruction and difficult intubation, were scheduled. The anesthesiologist tried oral intubation by direct laryngoscope; however, neither blade nor rigid bronchoscope insertion was impossible as a firm mass protruded in oral cavity from the left side. Tracheotomy was successfully performed and the airway was secured. As for maternal anesthesia, adequate uterine relaxation was obtained by inhalational agents and nitroglycerine. After ligation of the umbilical cord, anesthesia was maintained with propofol and fentanyl, and good uterine contraction was provided by infusion of oxytocin. The duration of EXIT was 44 minutes. The fetal tumor, containing both solid and cystic components, was 14 centimeters in diameter, and infiltrated into intracranial space. There was no indication of resection nor chemotherapy for the tumor. Palliative care was selected, and the neonate died forty days after birth.

[Side Effects of Continuous Fentanyl Infusion for Postoperative Pain Relief in Children].

BACKGROUND: There have been many reports on the use of morphine for postoperative pain relief in children, but the use of fentanyl for this purpose has not frequently been described. We clarified the details of side effects exhibited in children who had received continuous fentanyl infusion for postoperative pain relief METHODS: The subjects are 1,166 children aged between 0 and 14 years who underwent continuous fentanyl infusion for postoperative pain relief within the previous 4 years. Fentanyl was administered at a dose of 0.5 or 1.0 µg x kg(-1) x hr(-1), and with continuous use of pulse oximeter, the pulse rate, SpO2, respiratory rate, BP, sedation score, and presence/absence of nausea/vomiting were recorded every 2 hours. The frequencies of side effects were retrospectively examined. RESULTS: Severe side effects, including respiratory depression, for which mask ventilation or tracheal intubation was required were observed in 0.77% of cases. No subjects died or developed permanent sequelae. Nausea/vomiting occurred in 25.4% of cases. CONCLUSIONS: Using monitoring systems that facilitate the early detection of and intervention in respiratory depression, we can safely administer continuous fentanyl infusion for postoperative pain relief in children. It is necessary to adopt countermeasures against nausea/vomiting.

[Examination of the criteria for selecting the size of a cuffed tracheal tube in children].

BACKGROUND: This paper examined the criteria for selecting Mallinckrodt Hi-Contour pediatric cuffed tracheal tubes. METHODS: Different age groups are generally treated with tubes of the following internal diameters (mm): 0 to 8 months: 3.0; 8 to 18 months: 3.5; 18 to 36 months: 4.0; and 3 to 5 years: 4.5. When it was difficult to intubate, or there was no leak at an airway pressure of 25 cm H2O, the tube size was regarded as excessively large, and the size was reduced. In contrast, when there was a massive air leak, interfering with ventilation, the tube size was increased. RESULTS: Replacement was not necessary in 94% of those treated with a 3.0-mm tube, 89% of those treated with a 3.5-mm tube, 94% of those treated with a 4.0-mm tube, or 97% of those treated with a 4.5-mm tube. The overall incidence of complications was 4%. CONCLUSIONS: Based on these criteria, tube replacement was not necessary in 93% of pediatric patients.

Cardiac arrest after thoracic paravertebral block with ropivacaine in a 6-year-old child.

We encountered cardiac arrest induced by 0.375 % ropivacaine 7 ml administered via a catheter for continuous thoracic paravertebral block (TPVB) in a 6-year-old female who underwent pacemaker implantation for sick sinus syndrome (SSS). She was successfully resuscitated with adrenaline and lipid emulsion. Plasma concentration of ropivacaine was 5.2 µg/ml, suggesting intravascular administration of ropivacaine. Inadvertent intravascular administration is a crucial complication of TPVB.

[Anesthetic management of a patient with hemophilia B during scoliosis surgery].

Posterior spinal fusion for scoliosis was planned in a 14-year-old male patient with hemophilia B. Preoperative examination showed factor IX activity of 8.4% with no inhibitor development. A perioperative dosage schedule was prepared after examining the pharmacokinetics of recombinant coagulation factor IX in order to maintain levels of perioperative factor IX activity at < or = 80% for the first 6 days (days 0-6), and > or = 40% for days 7-14 postoperatively. The dose of recombinant coagulation factor IX was adjusted to maintain factor IX activity above 80%, while measuring coagulation activity every hour during the surgery. The patient showed a favorable course without hemorrhagic tendency. We could safely manage anesthesia without requiring allogeneic blood transfusion.

[Update on the practical use of new anesthetic agents].

Most drugs used in practical pediatric anesthesia are off-label. Pediatric anesthesiologists and non-pediatric anesthesiologists who rarely encounter pediatric patients need to be aware of the clinical usage of these drugs based on pediatric pharmacokinetics and pharmacodynamics to ensure that children are not exposed to unnecessary risks. Clinical guidelines on anesthetic drugs have been made available on the Japanese Society of Anesthesiologists website, and anesthesiologists are encouraged to access this site at least once. Propofol is commonly used in pediatric anesthesia and sedation in several situations. However, we should always consider the possibility of propofol infusion syndrome in the case of long-term administration. Rocuronium is widely used for general anesthesia in elective surgeries, examinations, and minor procedures in pediatric patients. Rocuronium can be used for rapid sequence induction, taking into consideration the dose and duration of action. Sugammadex has recently been introduced for practice in Japan. Rocuronium and sugammadex have been used safely in pediatric patients so far, and may change the induction methods used in difficult airway patients and the management of airway emergencies. Desflurane is novel in Japan and has not been commonly used in pediatric anesthesia. Desflurane may cause very high irritability in the airway and may be used for the maintenance of anesthesia in limited situations.

Successful one-lung ventilation in a patient with the Fontan circulation undergoing thoracotomy: a case report.

The incidence of noncardiac surgery in patients with the Fontan circulation has increased over the years due to the elongated life expectancy of these patients. In patients with the Fontan circulation, pulmonary blood flow is passive, so it is important to keep pulmonary vascular resistance low. One-lung ventilation (OLV) can have adverse effects on the Fontan circulation due to hypoxia, hypoxic pulmonary vasoconstriction, hypercarbia, and increased airway pressure. We present a case of successful OLV in a patient with the Fontan circulation and describe our perioperative management.

[General anesthesia for pediatric cardiac magnetic resonance imaging].

The performance of MRI in children under 5 or 6 years of age usually requires sedation. Cardiac MRI takes even longer time to perform than regular MRI and such patients have cardiac diseases. It is therefore desirable for anesthesiologists to secure the airway and pay close attention to patients'vital signs. We perform general anesthesia for cardiac MRI using non-MRI-compatible monitors and anesthesia machines at our institution, and we therefore use appropriate devices to perform MRI safely. For that purpose, we either obtain peripheral intravenous access or perform tracheal intubation outside the MRI scan room and use extension cables for monitoring the patient.

[Efficacy and complications of fentanyl intravenous infusions in postoperative pediatric patients].

BACKGROUND: The aim of the study was to evaluate the efficacy and the incidence of complication in pediatric patients for laparotomy receiving continuous fentanyl infusion for postoperative pain. METHODS: We treated 21 children, including 9 male and 12 female, aged 1-4 years old with the median age 2.0 +/- 1.0 years. They received postoperative intravenous fentanyl infusion 1 microg +/- kg(-1) x hr(-1) for about 50 hrs. We assessed the level of pain by Children's Hospital of Eastern Ontario pain scale (CHEOPS), and evaluated the additional medication of analgetics and the adverse events such as vomiting, the decrease of respiratory rate or Sp(O2) depression defined as the need for supplemental oxygen to maintain Sp(O2) > 95% and sedation by visiting the patients twice par day. RESULTS: Adequate analgesia occurred in over 90% of patients with the average CHEOPS score of 6.4 +/- 0.2 points. The incidences of vomiting and deep sedation were 14.3% and 19.0%, respectively, but there was no incidence of desaturations and decrease of respiratory rate, and we have no need to ensure emergency airway patency. CONCLUSIONS: Intravenous fentanyl infusion for postoperative pain in pediatric patients after laparotomy is an effective and safe procedure with a few complications.

[Anesthetic management of a pediatric patient with Beckwith-Wiedemann syndrome accompanied by macroglossia].

We report the anesthetic management of an infant with Beckwith-Wiedemann syndrome having massive macroglossia and umbilical hernia. Umbilical hernia repair and tongue reductions were performed under general anesthesia. Although a difficult airway was anticipated, we did not have difficulty in her airway management, even with tracheal intubation. After the operation, mechanical ventilation was required for three days because of airway obstruction by secretions in the mouth and her edematous tongue. She had no complications and the postoperative course was uneventful.

[Case report of anesthetic management for an infant with tricho-hepato-entric syndrome].

Tricho-hepato-entric syndrome is a rare congenital disorder characterized by hair anomalies, neonatal hemochromatosis and intractable diarrhea. A three-year-old girl with this syndrome received general anesthesia for inguinal hernia repair. Anesthesia was induced with nitrous oxide and sevoflurane, and maintained with sevoflurane and fentanyl without muscle relaxant. Rectal acetaminophen was administered and ilioinguinal block was performed for postoperative analgesia. The anesthetic course was uneventful.

[Pediatric airway management : cuffed endotracheal tube and other devices for tracheal intubation].

Uncuffed endotracheal tubes have been commonly used in pediatric patients, but cuffed pediatric endotracheal tubes are recently introduced and stirred up a controversy. Uncuffed tubes may require multiple laryngoscopies, pollute the environment, and cause pulmonary aspiration as well as unstable ventilation. A recent study revealed that the contours of the airway and the tracheal tube are different, so that the pressure exerted on some parts of the cricoid mucosa may not be appropriate. Cuffed endotracheal tubes overcome these shortcomings if anesthesiologists pay close attention to the insertion length of the tube and cuff pressure. Laryngeal mask airway has worked well, with few complications, as a ventilatory device in pediatric patients whose tracheas cannot be intubated and/or whose lungs cannot be ventilated with conventional techniques. It is also used for a conduit for fiberoptic intubation and emergent airway with patients in the prone position. The lightwand (Trachlight) is another device for pediatric intubation and is recommended as the first-line option in patients who can be ventilated but in whom laryngoscopic intubation has failed. AirWayScope (Pentax-AWS) is a novel intubation device which combines an airway, camera and monitor It can be an epoch-making intubation device for infants and children if a smaller size is available in the future.

[Pain control by caudal epidural infusion in a pregnant woman with hemorrhoids carrying triplets].

A 30-year-old woman in her 25th week of gestation with triplets complained of severe pain due to a hemorrhoid. The patient felt it was difficult to continue childbearing. First we performed caudal epidural block with 0.25% bupivacaine 20 ml and morphine hydrochloride 2 mg once a day, for 12 days without inserting a catheter because there were signs of infection. After the signs of infection had disappeared, we inserted a caudal epidural catheter and administered 0.125% bupivacaine 1-2 ml x hr(-1) for 6 days, up to the day of cesarean section. Liver function and blood bupivacaine levels of the mother were acceptable in the perioperative periods. The babies' Apgar scores and neurologic findings of the babies were normal. Blood bupivacaine levels of the babies were below the limit of measurement.

[Anesthetic management of a patient with xeroderma pigmentosum].

Xeroderma pigmentosum (XP) is a rare autosomal recessive disease, which is characterized by hypersensitivity of the skin to ultraviolet (UV)-radiation and progressive neurological complications. Patients with XP show a failure to properly repair UV-induced DNA lesions by the nucleotide excision repair (NER) mechanism. This results predominantly in a high frequency of UV-induced skin tumors at an early age. Therefore, patients with XP must avoid exposure to UV-radiation by use of protective clothing, sunscreen and UV-blocking film. We report a 15-year-old girl, who underwent surgical treatment twice for clubfoot under general anesthesia using propofol and fentanyl. We protected her skin from light with UV blocking film in the operating room. Both surgical procedures were performed uneventfully except for delayed awakening. A number of precautions must be taken in the perioperative management of XP patients, which include proper shielding from damaging light, avoidance of all drugs that harm DNA such as halothane and careful evaluation of neurological abnormalities. There is a possibility of difficult endotracheal intubation or prolonged effect of muscle relaxation due to skin atrophy and joint contracture.

Inhaled nitric oxide therapy after Fontan-type operations.

PURPOSE: Inhaled nitric oxide (NO) therapy is a newly developed strategy designed to reduce pulmonary vascular resistance after the Fontan-type operation. We reviewed our experience to evaluate its efficacy and true indications. METHODS: We retrospectively examined 47 children who received inhaled NO therapy after the Fontan-type operation between August 1996 and December 2002. The maximal dose of NO ranged from 5 to 30 ppm (median 10 ppm), and the duration of inhaled NO therapy ranged from 5 h to 52 days (median 2 days). RESULTS: Inhaled NO significantly decreased the central venous pressure (CVP), from 16.2 +/- 2.2 to 14.6 +/- 2.2 mmHg (P < 0.0001), and the transpulmonary pressure gradient between the CVP and left atrial pressure, from 9.9 +/- 2.9 to 8.4 +/- 2.7 mmHg (P < 0.0001). It also increased the systolic systemic arterial pressure from 71.9 +/- 15.2 to 76.8 +/- 14.5 mmHg (P < 0.05). In 26 patients with additional fenestration, inhaled NO led to a significant improvement in SaO(2) from 90.1% +/- 9.6% to 93.3% +/- 7.9% (P < 0.01). However, patients with a CVP <15 mmHg or a transpulmonary pressure gradient <8 mmHg, or both, after the Fontan-type operation, showed no significant changes in hemodynamics during inhaled NO therapy. CONCLUSIONS: We propose that a CVP >/=15 mmHg or a transpulmonary pressure gradient >/=8 mmHg, or both, after Fontan-type operations are appropriate indications for inhaled NO therapy.

The effects of enflurane, isoflurane, and intravenous anesthetics on rat diaphragmatic function and fatigability.

UNLABELLED: We examined the effect of isoflurane, enflurane, midazolam, ketamine, propofol, and thiopental on diaphragmatic functions under unfatigued and fatigued conditions in 228 rat isolated muscle strips. Diaphragmatic twitch characteristics and tetanic contractions were measured before and after muscle fatigue, which was induced by repetitive tetanic contraction with or without exposure to one of the anesthetics at clinically relevant plasma concentrations, and at 10 and 100 times this concentration, or at 1, 2, and 3 minimum alveolar anesthetic concentration (MAC). Isoflurane, midazolam, ketamine, propofol, and thiopental did not induce a direct inotropic or lusitropic effect under unfatigued and fatigued conditions. Enflurane did not change contraction or relaxation in fresh isolated diaphragm, but enflurane at 2-3 MAC enhanced diaphragmatic fatigability itself and fatigue-induced impairment of twitch characteristics and tetanic tensions. These effects were greater at 3 MAC than at 2 MAC. Our findings suggest that the reduction of diaphragm function previously reported in in vivo experiments using propofol, midazolam, and isoflurane is not related to a direct effect on intrinsic diaphragmatic contractility. Our results also indicate that large concentrations of enflurane may impair the diaphragmatic function at sites other than excitation-contraction coupling. IMPLICATIONS: Enflurane did not change contraction or relaxation in fresh isolated rat diaphragm, but enhanced diaphragmatic fatigability itself and fatigue-induced impairment of twitch characteristics and tetanic tensions. Isoflurane, midazolam, ketamine, propofol, and thiopental had no direct effects on diaphragmatic functions under unfatigued and fatigued conditions. Isoflurane and these i.v. anesthetics may be advantageous over enflurane to anesthetize and/or sedate patients who are predisposed to diaphragmatic fatigue.