Ultrasound-guided central venous catheterization around the neck: Systematic review and network meta-analysis.

BACKGROUND: Ultrasound-guided central venous catheterization (CVC) has become the standard of care. However, providers use a variety of approaches, encompassing the internal jugular vein (IJV), supraclavicular subclavian vein (SupraSCV), infraclavicular subclavian vein (InfraSCV), proximal axillary vein (ProxiAV), distal axillary vein (DistalAV), and femoral vein. OBJECTIVE: This review aimed to compare the first-pass success rate and arterial puncture rate for different approaches to ultrasound-guided CVC above the diaphragm. METHODS: In May 2023, Embase, MEDLINE, CENTRAL, ClinicalTrials.gov, and World Health Organization International Clinical Trials Platform were searched for randomized controlled trials (RCTs) comparing the 5 CVC approaches. The Confidence in Network Meta-Analysis tool was used to assess confidence. Thirteen RCTs (4418 participants and 13 comparisons) were included in this review. RESULTS: The SupraSCV approach likely increased the proportion of first-attempt successes compared to the other 4 approaches. The SupraSCV first-attempt success demonstrated risk ratios (RRs) > 1.21 with a lower 95% confidence interval (CI) exceeding 1. Compared to the IJV, the SupraSCV approach likely increased the first-attempt success proportion (RR 1.22; 95% confidence interval [CI] 1.06-1.40, moderate confidence), whereas the DistalAV approach reduced it (RR 0.72; 95% CI 0.59-0.87, high confidence). Artery puncture had little to no difference across all approaches (low to high confidence). CONCLUSION: Considering first-attempt success and mechanical complications, the SupraSCV may emerge as the preferred approach, while DistalAV might be the least preferable approach. Nevertheless, head-to-head studies comparing the approaches with the greatest first attempt success should be undertaken.

Effect of Arginine Vasopressin on Intraoperative Hypotension Caused by Oral Administration of 5-Aminolevulinic Acid.

5-Aminolevulinic acid (5-ALA) is used for the photodynamic diagnosis of malignant tumors and has been effectively utilized to improve the complete resection rate and reduce the risk of tumor recurrence. However, intraoperative hypotension is a common adverse effect of oral 5-ALA, and it occasionally progresses to severe prolonged hypotension requiring high-dose catecholamine administration. We report a case of intraoperative hypotension due to oral 5-ALA in which arginine vasopressin (AVP) administration was effective for increasing the blood pressure. A 77-year-old man scheduled for a craniotomy for glioma was administered 5-ALA orally before surgery. After the induction of anesthesia, his blood pressure decreased substantially. Although we administered various vasopressor agents, hypotension was prolonged. However, after starting a continuous administration of AVP, the systolic blood pressure increased, and the hemodynamic parameters remained stable during the remainder of the operation. 5-ALA administration may lower blood pressure by inducing nitric oxide production, and AVP inhibits inducible nitric oxide synthase messenger RNA expression and interleukin-1ß-stimulated nitric oxide production. In light of these mechanisms, AVP may be a reasonable treatment agent for hypotension induced by 5-ALA.

An infantile traumatic brain injury with a bright tree appearance detected before the late seizure.

INDRODUCTION: Infantile traumatic brain injury (TBI) rarely follows a biphasic clinical course and exhibits a bright tree appearance (BTA) on magnetic resonance imaging (MRI). This is termed infantile traumatic brain injury with a biphasic clinical course and late reduced diffusion (TBIRD). TBIRD has clinical features similar to those of acute encephalopathy with biphasic seizures and late reduced diffusion (AESD). It remains to be clarified which patients with infantile TBI will develop TBIRD and the prevention and treatment of TBIRD. CASE AND REVIEW: We report a case of TBIRD that exhibited BTA 1 day before the late seizure and review 12 cases of TBIRD. All patients developed a subdural hematoma (SDH), were younger than 2 years, and presented with a biphasic phase within 3-6 days. The median interval between BTA and TBI was 5 days. Of the 5 cases examined with MRI before the biphasic phase, only our case was detected with BTA 4 days after TBI. CONCLUSION: Predicting the biphasic clinical course may be possible by examining MRI after TBI in patients under 2 years of age who develop SDH with unconsciousness, seizure, or hemiplegia, and these patients should be strictly followed up for 1 week.

A case of complete atrioventricular block in secondary hemophagocytic syndrome/hemophagocytic lymphohistiocytosis recovered by plasma exchange and cytokine absorbing therapy with AN69ST continuous hemodiafiltration.

We report a case of incipient systemic lupus erythematosus (SLE) that rapidly progressed to complete atrioventricular block (cAVB). A 20-year-old man was admitted with facial erythema, painless oral aphtha, polyarthritis, and myalgia of each extremity. On admission, he developed first-degree atrioventricular block, pericarditis, pleuritis, renal failure, hemophagocytic lymphohistiocytosis, neurophychiatric SLE (left cerebellar infarction), and Staphylococcus aureus bacteremia. He was subsequently diagnosed with SLE based on several positive findings on immunological tests (including positive for antinuclear antibody). Despite immediate glucocorticoid pulse therapy and plasma exchange (PE) along with antibiotic, he developed cAVB that required temporary pacing on day 2. Because it was thought that hypercytokinemia exacerbated pericarditis, which progressed to myocarditis and cAVB, we decided to PE and cytokine-adsorbing therapy with AN69ST-continuous hemodiafiltration (CHDF). Other than renal failure, his organ dysfunctions improved with the multidisciplinary therapy. CAVB improved and temporary pacing was no longer required on day 11. Even a first-degree atrioventricular block can rapidly progress to cAVB; therefore, strict attention to electrocardiogram is necessary in severe SLE cases. When presenting with organ dysfunctions caused by hypercytokinemia such as severe SLE cases or SLE with severe infection cases, use of the combination of PE and AN69ST-CHDF might be beneficial.

A comparison of the Airtraq®, McGrath®, and Macintosh laryngoscopes for difficult paediatric intubation: A manikin study.

BACKGROUND: The efficacy of devices for difficult intubation in paediatric patients, especially with a Cormack-Lehane grade 4 view, has yet to be established. We compared intubating parameters among three devices (the Airtraq®, McGrath®, and Macintosh laryngoscopes). METHODS: This study is a randomised cross-over trial. Participants were 20 anaesthetists. Each device was tested three times using a paediatric manikin with a Cormack-Lehane grade 4 view. The order to use each device was randomised by a computer-generated random sequence. The primary endpoint was the rate of successful intubation. Secondary endpoints included the time taken to intubate, percentage of glottic opening score, and severity of potential dental trauma. RESULTS: The successful intubation rates of the Airtraq®, McGrath®, and Macintosh laryngoscopes were 100%, 72%, and 45%, respectively. The risk ratio of the success rates of Airtraq® compared with McGrath® and Macintosh laryngoscopes were 1.40 (95% CI; 1.19-1.64, P < 0.001) and 2.22 (95% CI; 1.68-2.94, P < 0.001), respectively. The modified Cormack-Lehane grade and percentage of the glottic opening score were better for the Airtraq® than for the other devices. The dental trauma score was lower for the Airtraq® than for the other devices. There were no significant differences in the intubation time among the groups. CONCLUSIONS: The Airtraq® had higher success rate, had better visibility, and was associated with less dental trauma than the other devices in a difficult paediatric intubation model with a Cormack-Lehane grade 4 view.

[Usefulness of ultrasound pre-scanning for cricothyroid membrane puncture in a patient with rupture of a pseudoaneurysm].

A 63-year-old man with von Recklinghausen disease was transported to the emergency department for swelling and pain of his right neck. Chest X-ray and computed tomography scan showed displacement of the trachea to the left by a tumor mass. Urgent airway management was required and fiberoptic intubation in awake condition was planned. First we pre-scanned cricothyroid membrane by ultrasound in a case of emergency. Regardless of several trials, his trachea could not be secured by fiberscope because of narrow pharyngeal space. Suddenly, his consciousness level and Sp(O2) went down, therefore surgical airway was required. Due to pre-scanning, emergency cricothyroid membrane puncture could be performed immediately without any complications. We recommend ultrasound pre-scanning for cricothyroid membrane puncture in a patient with suspected tracheal displacement.