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Chlorhexidine is a common cause of perioperative anaphylaxis, and global regulatory authorities have issued warnings about anaphylaxis due to chlorhexidine-containing central venous catheters (CVC) and its mucosal absorption. We present a case of life-threatening anaphylaxis after CVC insertion caused by chlorhexidine used for skin preparation. The onset of anaphylaxis was rapid and very severe, resulting in pulseless electrical activity. The patient was successfully resuscitated by emergency veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Our case suggests that even skin preparation before chlorhexidine-free CVC insertion can cause life-threatening anaphylaxis. We reviewed the literature on chlorhexidine anaphylaxis cases and categorized all potential routes of chlorhexidine exposure to assess the risk following skin preparation. Our results showed that skin preparation before CVC insertion was the third most common cause of chlorhexidine anaphylaxis after transurethral exposure and chlorhexidine-containing CVCs. However, skin preparation with chlorhexidine before CVC insertion was sometimes overlooked as a cause of chlorhexidine anaphylaxis, and its risk might be underestimated. Further, no previous reports have described life-threatening anaphylaxis solely due to chlorhexidine skin preparation before CVC insertion. CVC insertion might cause the chlorhexidine used for skin preparation to reach the vascular system and should be recognized as a potential cause of life-threatening chlorhexidine anaphylaxis., Author(s): Yasuhiro Amano [sup.1], Akari Matsuura [sup.1], Takahiro Tamura [sup.1], Yuki Kato [sup.1], Natsumi Kameyama [sup.2], Tomonori Takazawa [sup.3], Kimitoshi Nishiwaki [sup.1] Author Affiliations: (1) grid.437848.4, 0000 0004 0569 8970, [...]

Background: From the standpoint of infection prevention, anesthesiologists need to simultaneously use a surgical mask and an oxygen mask when administering oxygen to patients. However, there is a lack of scientific evidence to justify this method. We aimed to investigate a suitable method of oxygen administration when using a surgical mask in postoperative patients. Methods: This was a randomized, single-blind, cross-over study involving 42 patients admitted to the ICU. We compared three methods of oxygen administration: nasal cannula under the surgical mask, oxygen mask under the surgical mask, and oxygen mask above the surgical mask, using a cross-over design. The primary endpoint was partial pressure of arterial oxygen (PaO2). The secondary endpoint was partial pressure of arterial carbon dioxide (PaCO2). Results: PaO2 was higher when the oxygen mask was placed under the surgical mask (median values 197.7 mmHg), the nasal cannula was under the surgical mask (180.6 mmHg), and the oxygen mask was above the surgical mask (143.0 mmHg), in descending order, with significant differences between all groups (P < 0.001). PaCO2 did not differ between groups. Conclusions: The current standard method of administering oxygen to postoperative patients using an oxygen mask over a surgical mask results in poor oxygenation. Adopting the method of oxygen administration under the surgical mask via an oxygen mask or nasal cannula should be considered instead. [ABSTRACT FROM AUTHOR]

Purpose From the perspective of infection prevention during the Coronavirus disease 2019 (COVID-19) pandemic, a recommendation was made to use surgical masks after extubation in patients in the operating room. For compliance with this recommendation, anesthesiologists need to administer oxygen to the patient with an oxygen mask over the surgical mask. However, no studies have investigated whether this method allows good maintenance of oxygenation in patients. This study aimed to investigate which method of oxygen administration lends itself best to use with a surgical mask in terms of oxygenation. Method We administered oxygen to the study subjects using all the following three methods in random order: an oxygen mask over or under a surgical mask and a nasal cannula under the surgical mask. Oxygenation was assessed using the oxygen reserve index (ORi) and end-tidal oxygen concentration (EtO.sub.2). Result This study included 24 healthy volunteers. ORi values with administration of oxygen were higher in the order of a nasal cannula under the surgical mask, an oxygen mask under the surgical mask, and an oxygen mask over the surgical mask, with median values of 0.50, 0.48, and 0.43, respectively, and statistically significant differences between all groups (P < 0.001). EtO.sub.2 values were in the same order as ORi, with median values of 33.0%, 31.0%, and 25%, respectively, and statistically significant differences between all groups (P < 0.001). Conclusion Wearing a surgical mask over the nasal cannula during oxygen administration is beneficial for oxygenation and might help prevent aerosol dispersal., Author(s): Yusuke Matsui [sup.1], Tomonori Takazawa [sup.2], Akihito Takemae [sup.1], Yukie Murooka [sup.1], Masafumi Kanamoto [sup.2], Shigeru Saito [sup.1] Author Affiliations: (1) grid.256642.1, 0000 0000 9269 4097, Department of Anesthesiology, [...]

Perioperative anaphylaxis is a severe adverse event during anesthesia that requires prompt diagnosis and treatment by physicians, including anesthesiologists. Muscle relaxants and antibiotics are the most common drugs that cause perioperative anaphylaxis in Japan, as in many countries. In addition, sugammadex appears to be a primary causative agent. Obtaining previous anesthesia records is necessary in a patient with a history of allergic reactions during anesthesia, whenever possible, to avoid recurrence of anaphylaxis. Although medical staff are likely to notice abnormal vital signs because of complete monitoring during anesthesia, surgical drapes make it difficult to notice the appearance of skin symptoms. Even if there are no skin symptoms, anaphylaxis should be suspected, especially when hypotension resistant to inotropes and vasopressors persists. For improving the diagnostic accuracy of anaphylaxis, it is helpful to collect blood samples to measure histamine/tryptase concentrations immediately after the events and at baseline. The first-line treatment for anaphylaxis is adrenaline. In the perioperative setting, adrenaline should be administered through the intravenous route, which has a faster effect onset and is secured in most cases. Adrenaline can cause serious complications including severe arrhythmias if the appropriate dose is not selected according to the severity of symptoms. The anesthesiologist should identify the causative agent after adverse events. The gold standard for identifying the causative agent is the skin test, but in vitro tests including specific IgE antibody measurements and basophil activation tests are also beneficial. The Working Group of the Japanese Society of Anesthesiologists has developed this practical guide to help appropriate prevention, early diagnosis and treatment, and postoperative diagnosis of anaphylaxis during anesthesia. Grade of recommendations and levels of evidence Anaphylaxis is a relatively rare condition with few controlled trials, and thus a so-called evidence-based scrutiny is difficult. Therefore, rather than showing evidence levels and indicating the level of recommendation, this practical guideline only describes the results of research available to date. The JSA will continue to investigate anaphylaxis during anesthesia, and the results may lead to an amendment of this practical guideline., Author(s): Tomonori Takazawa [sup.1], Ken Yamaura [sup.2], Tetsuya Hara [sup.3], Tomoko Yorozu [sup.4], Hiromasa Mitsuhata [sup.5], Hiroshi Morimatsu [sup.6] Author Affiliations: (1) grid.411887.3, 0000 0004 0595 7039, Intensive Care Unit, [...]

Background: Patients with severe aortic valve stenosis (AS) are particularly prone to developing hypotension during general anesthesia induction, which increases postoperative morbidity and mortality. Although the preventive effect of a single vasopressor dose on anesthesia-induced hypotension has been reported, the effects of continuous vasopressor infusion are unknown. This study aimed to assess the effect of noradrenaline (NAd) infusion on hemodynamic stability during general anesthesia induction in severe AS patients undergoing transcatheter aortic valve replacement (TAVR). Methods: This single-center, retrospective study included severe AS patients who underwent elective TAVR. Patients in the NAd group received a continuous prophylactic NAd infusion of 0.1 μg/kg/min from the time of anesthesia induction. The control group received inotropes and vasopressors as indicated by the occurrence of hypotension. The primary outcome was the lowest mean blood pressure (MBP) before the start of surgery. Results: The study included 68 patients in the NAd group and 113 in the control group. The lowest MBP before the start of surgery was significantly higher in the NAd group than in the control group (63 ± 15 vs 47 ± 13 mmHg, P < 0.01). MBP immediately before intubation was also significantly higher in the NAd group (75 ± 17 vs 57 ± 16 mmHg, P < 0.01). Differences in postoperative complications between the groups were negligible. Conclusion: Continuous administration of NAd at 0.1 μg/kg/min in patients with severe AS might prevent hypotension during general anesthesia induction for TAVR. [ABSTRACT FROM AUTHOR]

This document is a reply to a comment made on an article about treatment-resistant hiccups during general anesthesia possibly caused by remimazolam. The authors of the original article disagree with the argument made in the comment that hiccups were induced because remimazolam is less effective in suppressing brainstem reflexes. They provide reasons and evidence to support their disagreement, including the fact that additional doses of remimazolam did not reduce or eliminate the hiccups and that the hiccups disappeared as the blood level of remimazolam decreased. The authors also mention other studies that suggest a higher incidence of hiccups with remimazolam compared to propofol and the potential of benzodiazepines, like remimazolam, to induce hiccups. They conclude by recommending the consideration of muscle relaxants or changing the anesthetic used when hiccups occur during general anesthesia with remimazolam. [Extracted from the article]

Diagnosis of perioperative anaphylaxis is difficult because of its non-specific and variable signs and symptoms. Therapeutic agents used to treat anaphylaxis and anaesthesiologist responses also vary depending on the case, which might affect outcomes; however, only a few studies have focused on these factors. This prospective study of perioperative anaphylaxis, a part of the Japanese Epidemiologic Study for Perioperative Anaphylaxis, investigated the clinical signs, its severity, therapeutic drugs, epinephrine administration, and anaesthesiologist responses in cases of perioperative anaphylaxis to assess trends and variability. Shock index was used to assess severity of cardiovascular collapse. In 43 patients analysed in this study, cardiovascular signs (88.4%) were the most frequent, followed by skin (81.4%) and respiratory signs (60.5%). The presence of signs increased during the clinical course. The median time from the first signs to diagnosis of anaphylaxis was 10 (5.0–17.8) min. The rates of epinephrine use were 30.2% (unused), 48.8% (i.v.), and 20.9% (i.m.). The median time from diagnosis of anaphylaxis to epinephrine administration was 7 (inter-quartile range: 1.5–8.0) min. Antihistamines and corticosteroids were each used in 69.8% of cases. The worst shock index was higher in patients who received i.v. epinephrine (2.77 [0.90] mean [standard deviation]) than in both no epinephrine use cases (1.35 [0.41]) and i.m. epinephrine cases (1.89 [0.77] (P <0.001]). The clinical signs and treatments of perioperative anaphylaxis are variable, and the choice regarding epinephrine administration is based on symptom severity. UMIN000035350. [ABSTRACT FROM AUTHOR]

Although surgery is a basic therapy for cancer, it causes inflammation and immunosuppression, often resulting in recurrence and metastasis. Previous studies have suggested that anesthetic management influences the prognosis of cancer surgery patients. Administration of local anesthetics, such as lidocaine, for pain control reportedly improves their clinical outcomes; however, the precise underlying mechanism has not been fully elucidated. The growth of human embryonic kidney (HEK) 293T and cervical cancer HeLa cells was inhibited by lidocaine treatment and these cell lines showed different sensitivities for lidocaine. Ki‐67 is a significant prognostic marker of cancer because it is expressed in the nucleus of actively proliferating cells. In lidocaine‐treated HeLa cells, Ki‐67 was detected not only in the nucleus but also in the cytoplasm. In addition, lidocaine‐induced cytoplasmic Ki‐67 partly colocalized with the increased ER chaperone, glucose‐regulated protein 78, which is crucial for protein folding and maintenance of cellular homeostasis. Furthermore, lidocaine decreased Ki‐67 levels and increased the population of HeLa cells in the G0/G1 phase. These results indicate that lidocaine plays a significant role in growth suppression by regulating the expression and distribution of Ki‐67. [ABSTRACT FROM AUTHOR]

We present a case report on anesthesia management for a 16-year-old male with Fontan circulation undergoing pacemaker implantation, necessitating one-lung ventilation. The patient had a complex congenital heart condition and had previously undergone multiple surgeries, including a Fontan procedure. Due to his unique cardiovascular anatomy, a left thoracotomy was chosen for pacemaker implantation, which required one-lung ventilation for surgical approach and visualization. This procedure can pose significant risks in patients with Fontan circulation due to potential intraoperative increases in pulmonary vascular resistance, which is notoriously difficult to manage in the acute setting. Preoperative assessments showed that the patient had good exercise tolerance, preserved biventricular contractility, and normal liver and kidney function. However, he had a slightly elevated central venous pressure. We employed a meticulous anesthetic plan to minimize the risks associated with one-lung ventilation. This included inserting pre-induction arterial and central venous catheters, using total intravenous anesthesia with propofol and remifentanil, and administering circulatory support agents, such as dobutamine and norepinephrine. Arterial blood and central venous pressure were closely monitored throughout the procedure. Further, cardiac activity was monitored using transesophageal echocardiography (TEE). The patient's hemodynamic stability was maintained intraoperatively, and the pacemaker lead was successfully implanted without significant complications. Postoperatively, we administered continuous intravenous fentanyl infusion and intercostal nerve blocks for pain control. He had an uneventful recovery and was discharged from the intensive care unit the day after surgery. This case contributes to the limited but growing body of literature on anesthesia management in patients with Fontan circulation, particularly related to the use of one-lung ventilation, and appropriate selection of anesthetic agents and circulatory support drugs. Further research is necessary to establish best practices and improve surgical outcomes in these patients., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Kawakami et al.)