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Background: Remimazolam is an ultrashort-acting benzodiazepine. Few studies have evaluated the effects of remimazolam-based total intravenous anesthesia (TIVA) on emergence agitation (EA). This study aimed to compare the incidence and severity of EA between TIVA using remimazolam and desflurane., Methods: This prospective randomized controlled study enrolled 76 patients who underwent nasal surgery under general anesthesia. Patients were randomized into two groups of 38 each: desflurane-nitrous oxide (N2O) (DN) and remimazolam-remifentanil (RR) groups. The same protocol was used for each group from induction to emergence, except for the use of different anesthetics during maintenance of anesthesia according to the assigned group: desflurane and nitrous oxide for the DN group and remimazolam and remifentanil for the RR group. The incidence of EA as the primary outcome was evaluated using three scales: Ricker Sedation-Agitation Scale, Richmond Agitation-Sedation Scale, and Aono's four-point agitation scale. Additionally, hemodynamic changes during emergence and postoperative sense of suffocation were compared., Results: The incidence of EA was significantly lower in the RR group than in the DN group in all three types of EA assessment scales (all P < 0.001). During emergence, the change in heart rate differed between the two groups (P = 0.002). The sense of suffocation was lower in the RR group than in the DN group (P = 0.027)., Conclusions: RR reduced the incidence and severity of EA in patients undergoing nasal surgery under general anesthesia. In addition, RR was favorable for managing hemodynamics and postoperative sense of suffocation.

Background: Although fiberoptic-guided endotracheal intubation using a supraglottic airway device (SAD) is a good alternative for the management of difficult airways, its learning curve for residents has not been evaluated in pediatric patients. We aimed to train residents using a pediatric manikin and obtain learning curves to evaluate the efficiency of the training., Methods: We conducted a single-armed prospective study with anesthesiology residents. Plain endotracheal tube (ETT) intubation guided by a fiberoptic bronchoscope through Ambu® AuraGainTM was demonstrated in a pediatric manikin to the participants before training. The procedure was divided into four steps: SAD insertion, vocal cord identification, carina identification, and ETT insertion into the trachea. The results and elapsed procedure times of each trial were recorded. The learning curves for the participants were constructed and analyzed using the cumulative sum method., Results: All the 30 participants acquired proficiency at the end of practice between eight and 25 trials. The overall success rate for the procedure was 92.8%, and above 80% for all participants. Mean ± standard deviation procedure time was 71.3 ± 50.7 s. The 4th step accounted for 86.2% and 48.0% of the total failures and procedure time, respectively. The procedure time rapidly decreased in the 2nd trial; a modest decline was observed thereafter., Conclusions: Trainees can obtain proficiency for fiberoptic-guided intubation through SAD within 25 times when using pediatric manikin. Effect of the training on performance in actual clinical situation should be studied.

Background: Catheter-related bladder discomfort (CRBD) is common in patients with a urinary catheter and is a risk factor for emergence agitation (EA). The mainstay of CRBD management is anticholinergics. Dexamethasone inhibits acetylcholine release. This study aimed to evaluate the effects of dexamethasone on postoperative CRBD and EA., Methods: In this prospective study, 90 patients undergoing urological surgery requiring urinary catheterization were allocated randomly to one of two groups (each n = 45). Before induction of anesthesia, the dexamethasone group received 10 mg (2 ml) of dexamethasone intravenously, while the control group received 2 ml of saline in the same manner. The incidence and severity of CRBD were assessed 0, 1, 2, and 6 h after the patient arrived in the post-anesthesia care unit (PACU) as the primary outcomes. The incidence and severity of EA were also compared during emergence and recovery from anesthesia as secondary outcomes., Results: The incidences of CRBD in the control group and dexamethasone group at 0, 1, 2, and 6 h postoperatively were 28.9% and 15.6%, 55.6% and 55.6%, 57.8% and 46.7%, and 53.3% and 51.1%, respectively. The incidence and severity of CRBD assessed at 0, 1, 2, and 6 h postoperatively did not show intergroup differences. The incidence and severity of EA in the operating room and PACU also showed no difference between the groups., Conclusions: Dexamethasone (10 mg) administered before induction of anesthesia did not further reduce the incidence or severity of CRBD or EA in patients undergoing urological surgery.

Background: Geriatric patients are susceptible to respiratory and hemodynamic adverse events during endotracheal intubation and extubation due to anatomic and physiological changes with aging. Supraglottic airway devices (SADs) provide reduced airway morbidity and increased hemodynamic stability in adults. However, studies that have compared the clinical performance of SADs in geriatric patients are limited. Therefore, we evaluated the clinical performance of airway management with i-gel® and laryngeal mask airway Supreme (LMA SupremeTM) in geriatric patients., Methods: The subjects were American Society of Anesthesiologists physical status classification I-III geriatric (65-85 years) patients who underwent elective surgery with general anesthesia and were randomly allocated into the i-gel® group and the LMA SupremeTM group. We compared the time for successful insertion on a first attempt as a primary outcome, and the secondary outcomes were success rate, ease of insertion, maneuver for successful ventilation, oropharyngeal leak pressure, gastric insufflation, fiberoptic view grades, ventilator problems, and adverse events., Results: Insertion time was significantly shorter for the i-gel® than the LMA SupremeTM (21.4 ± 6.8 vs. 29.3 ± 9.9 s; P = 0.011). The i-gel® was also easier to insert than the LMA SupremeTM (P = 0.014). Gastric insufflation was less frequent with the i-gel® than the LMA SupremeTM (0% vs. 31.3%; P = 0.013). Other measurements were comparable between groups., Conclusions: Both devices can be safely applied to geriatric patients with similar success rates and oropharyngeal leak pressures. However, inserting the i-gel® was faster and easier compared to the LMA SupremeTM in geriatric patients.

Background: Propofol is used for supraglottic airway device insertion, often with the i-gel. However, the propofol requirement for i-gel insertion has not been explored in paralyzed patients. This study was performed to explore hemodynamic changes and sedation level with different propofol doses in healthy paralyzed patients when the i-gel was inserted., Methods: A total of 141 patients undergoing a urologic operation were randomly allocated to three groups depending on the propofol dose (1.5, 2, and 2.5 mg/kg; Groups P1.5, P2, and P2.5, respectively). After patients had been administered each propofol dose and rocuronium, the i-gel was inserted and changes in hemodynamic parameters and bispectral index were evaluated., Results: Group P2 showed a lower incidence of complications (17%) such as hemodynamic instability and inadequate sedation than Group P1.5 (55.3%, P < 0.001) or Group P2.5 (40.4%, P = 0.012). The incidence and dose of additional propofol increased in Group P1.5 (51%, median [range]; 20 [0-50]) compared with those in the other groups (0%, 0 [0-0] in Group P2 and 8.5%, 0 [0-50] in Group P2.5, all P < 0.001), and the incidence and dose of additional ephedrine were significantly higher in Group P2.5 (31.9%; 0 [0-20]) than in Group P1.5 (10.6%, P = 0.012; 0 [0-5], P = 0.007, respectively)., Conclusions: For the stable maintenance of hemodynamic parameters and proper sedation level during i-gel insertion, 2 mg/kg propofol has an advantage over 1.5 mg/kg or 2.5 mg/kg propofol in healthy paralyzed patients.

Thrombus-in-transit appears to increase the risk of mortality compared to pulmonary embolism alone and can require alteration in therapeutic plan. We present the case of a biatrial thromboembolus caught in transit across a patent foramen ovale diagnosed by intraoperative transesophageal echocardiogram in a 69-year-old female with acute pulmonary embolism and subsequent acute cerebral infarction. We suggest that echocardiography should be performed in a patient with suspected pulmonary thromboembolism to evaluate right heart function and diagnose emboli in transit.

Background: Hypotension is a common phenomenon after spinal anesthesia in hypertensive patients. We investigated whether heart rate variability could predict the occurrence of hypotension after spinal anesthesia in hypertensive patients., Methods: Forty-one patients undergoing spinal anesthesia were included. Heart rate variability was measured at five different time points such as before fluid loading (baseline), after fluid loading as well as 5 min, 15 min and 30 min after spinal anesthesia. Fluid loading was performed using 5 ml/kg of a crystalloid solution. Baseline total power and low to high frequency ratio (LF/HF) in predicting hypotension after spinal anesthesia were analyzed by calculating the area under the receiver operating characteristic curves (AUC)., Results: Moderate hypotension, defined as a decrease of mean arterial pressure to below 20-30% of the baseline, occurred in 13 patients and severe hypotension, defined as a decrease of mean arterial pressure greater than 30% below the baseline, occurred in 7 patients. LF/HF ratiosand total powers did not significantly change after spinal anesthesia. AUCs of LF/HF ratio for predicting moderate hypotension was 0.685 (P = 0.074), severe hypotension was 0.579 (P = 0.560) and moderate or severe hypotension was 0.652 (P = 0.101), respectively. AUCs of total power for predicting moderate hypotension was 0.571 (P = 0.490), severe hypotension was 0.672 (P = 0.351) and moderate or severe hypotension was 0.509 (P = 0.924), respectively., Conclusions: Heart rate variability is not a reliable predictor of hypotension after spinal block in hypertensive patients whose sympathetic activity is already depressed.

Duchenne muscular dystrophy is a hereditary disorder characterized by progressive muscle weakness and contracture, and special care during anesthesia is needed in these patients. Because inhalational anesthetics and succinylcholine can cause fatal results, intravenous anesthetics are commonly used. However, monitorings for the pediatric population are not otherwise specified. We report our experience of a 6 year-old boy that underwent muscle biopsy suspicious of muscle dystrophy under general anesthesia. The patient received midazolam, fentanyl, propofol and a small dose of rocuronium. He was monitored with bispectral index (BIS), acceleromyography (TOF). At the end of surgery, recovery of TOF ratio to 90% was evaluated, followed by injection of pyridostigmine and glycopyrrolate. When reversal of neuromuscular block was confirmed quantitatively and clinically, the patient was extubated and he experienced no complication.