Cardiac arrest due to a sharp increase in serum potassium one minute after reperfusion in liver transplantation (LT) is fatal. We sought to compare prophylactic nebulized salbutamol versus glucose-insulin for decreasing potassium during reperfusion and to guide the selection of potassium reduction strategies in LT. We conducted a randomized, double-blind trial, enrolled patients undergoing LT with preoperative baseline serum potassium levels ≥ 4mmol/L. Patients were randomized into two groups to receive either glucose-insulin (Group A) or nebulized salbutamol (Group B) as preventive potassium reduction regimens. The primary outcome was the incidence of hyperkalemia (defined as serum potassium > 5.5mmol/L) 30s after reperfusion (Rep1). One hundred participants were included in the analysis. The incidence of hyperkalemia at Rep1 was significantly lower in Group B than in Group A (36% vs. 56%, P = 0.045). Following administration and prior to reperfusion, the lowest potassium levels were achieved at 30min in Group A and 45min in Group B, respectively. The maximum decrease in the serum potassium level was significantly greater in Group B (P < 0.001). No significant differences in the incidence of postreperfusion syndrome were observed between the groups. Surprisingly, Group B had milder blood glucose fluctuations, higher heart rate and mean arterial pressure, lower driving pressure, and lower incidence of postoperative atelectasis. Nebulized salbutamol is superior to glucose-insulin for preventing acute hyperkalemia during the reperfusion period and may benefit patients undergoing LT. Trial registration no. NCT05589441 ClinicalTrials.gov.

Congenital heart disease (CHD) affects 9.3 per 1000 live births in Asia, with 25% being cyanotic. Advanced imaging such as CT angiography is essential, but requires effective sedation in this high-risk group. While parental presence is known to reduce anxiety during mask induction in operating rooms, its effect on intravenous sedation in non-operating room anesthesia (NORA) settings, particularly for diagnostic imaging, has not been studied. This trial evaluates the effect of parental presence during intravenous procedural sedation on ketamine requirements for children with cyanotic CHD undergoing CT angiography in a NORA environment. This prospective, randomized trial included 60 children aged 6 months to 3 years with cyanotic CHD. Participants were randomized to receive sedation either on their mother's lap (n = 30) or on the CT table (n = 30). The primary outcome was ketamine dose required for a pediatric sedation state scale of 2. Secondary outcomes included preoperative anxiety scores, episodes of oxygen desaturation, time to achieve sedation, and recovery time. Children sedated on their mother's lap required significantly lower ketamine doses compared to those on the CT table (-0.15 mg/kg, 95% CI -0.29 to -0.01; p = 0.03). The mother's lap group also had lower preoperative anxiety scores and shorter recovery times (-3 min, 95% CI -4.08 to -1.92), with no increase in adverse events. This is the first randomized trial to demonstrate that parental presence during intravenous procedural sedation in a NORA setting reduces sedative requirements, anxiety, and recovery times in high-risk children undergoing CT angiography. Clinical trial registration: CTRI/2023/11/059539, https://www.ctri.nic.in/.

Acute kidney injury (AKI) is a significant postoperative complication associated with poor long-term outcomes. Dexmedetomidine, a selective α₂-adrenergic agonist with anti-inflammatory properties, may protect the kidney during non-cardiac surgery. This study examined whether intraoperative dexmedetomidine reduces AKI in both high-risk and low-risk patients. This was a secondary analysis of a randomized double-blind placebo-controlled trial. Patients aged ≥ 60years scheduled for elective non-cardiac surgery expected to last ≥ 2h under general anesthesia were enrolled and classified as low-risk or high-risk using the General Surgery Acute Kidney Injury Risk Index. Participants were randomly allocated to receive intraoperative dexmedetomidine (loading dose 0.6μg/kg over 10min before induction, followed by 0.5μg/kg/h until 1h before surgery end) or normal saline. The primary endpoint was AKI incidence within 7 postoperative days. Among high-risk patients, AKI occurred in 12.6% (13/103) of the dexmedetomidine group versus 23.4% (25/107) of controls (RR 0.54, 95% CI 0.29 to 1.00, P = 0.043); after multivariable adjustment, dexmedetomidine remained independently associated with lower AKI risk (OR 0.44, 95% CI 0.20 to 0.98, P = 0.045). In contrast, low-risk patients showed no significant difference with or without dexmedetomidine (7.9% vs 9.6%; RR 0.82, 95% CI 0.44 to 1.55, P = 0.543; adjusted OR 0.65, 95% CI 0.30 to 1.38, P = 0.260). Urological surgery was an independent predictor of AKI across the entire cohort. Intraoperative dexmedetomidine was associated with lower risk of AKI in high-risk but not in low-risk patients undergoing non-cardiac surgery.

We report a rare fatal hyperthermic crisis likely precipitated by drug-induced fever in a muscular, obese patient with chronic high-level spinal cord injury (SCI). Shortly after antibiotic therapy was changed to meropenem, the patient developed severe agitation and hyperthermia exceeding 41°C, accompanied by autonomic instability. Despite intensive management, including active cooling, intravenous fluids, and vasoactive support, the core temperature remained above 41°C. Computed tomography revealed a low-density brainstem lesion consistent with infarction. The patient experienced respiratory arrest and died 4 h after admission to the ICU. This case underscores the complex interplay between drug-induced fever, impaired thermoregulation due to SCI, and heat-retentive body composition. This case highlights the risk of rapid and disproportionate temperature elevation in patients with high-level SCI, even in response to relatively minor fever-provoking stimuli, due to impaired thermoregulation. Early recognition and prompt intervention are crucial to prevent fatal hyperthermic crises in this vulnerable population.

The administration of intrathecal morphine frequently induces pruritus as an adverse reaction. Xiaofeng Granules (XF) is a compound preparation improved from the ancient formula "Xiaofeng Powder". It has been proven to relieve skin itching caused by various reasons in clinical practice. The aim of the study was to evaluate the effect of XF on pruritus caused by intrathecal morphine and possible mechanism. Male C57BL/6 mice were intrathecally injected with morphine to induce scratching behavior. The effects of XF on intrathecal morphine-induced pruritus and analgesia were evaluated. The number of scratching response was counted within 30min after morphine injection. The warm-water tail immersion test was conducted to measure the tail flick latency (TFL) within 120min after morphine injection. The maximum possible effect percentage (%MPE) and area under the curve (AUC) were calculated based on TFL to evaluate the analgesic effect. Western blot was performed to evaluate the phosphorylation levels of NR2B, PKC and CAMK II in the dorsal horn of the lumbar spinal cord of mice. Compared with control treatment, intrathecal morphine elicited obvious scratching response when providing analgesic effect in a dose dependent manner. Gavage administration of XF can significantly reduce intrathecal morphine-induced scratching behavior without affecting its analgesic efficiency; besides, XF can inhibit the phosphorylation of NR2B, PKC, and CAMK II induced by intrathecal morphine, which can be reversed by intrathecal injection of NMDA. XF can relieve intrathecal morphine-induced pruritus and may be related to the inhibition of the NR2B/PKC/CAMKII signaling pathway.

Tissue factor pathway inhibitor (TFPI) is an intrinsic anticoagulant factor, and its plasma concentration is elevated by heparin administration. Because several hours are required to return to normal range after heparin reversal, we investigated the role of TFPI in the inhibition of thrombin generation (TG) in patients undergoing cardiac surgery. Blood samples were collected from adult patients undergoing cardiac surgery with cardiopulmonary bypass (CPB) before, at the end of, and 1day after surgery. Plasma concentration of TFPI, peak height of the TG assay (peak TG), and whole blood coagulation time by dielectric blood coagulometry using a Russell's viper venom cartridge system were evaluated. Nonparametric correlation was evaluated using Spearman's method, and time-dependent change was analyzed using repeated measures analysis of variance. The plasma concentration of TFPI was higher (54 [47-60] ng/mL vs. 18 [13-27] ng/mL; P < 0.001) and the peak TG value was lower (98.1 [48.9-148] nM vs. 268 [244-309]; P < 0.001) at the end of surgery than before surgery. Plasma TFPI concentration showed a positive correlation with whole blood coagulation time as measured by dielectric blood coagulometry (Rs = 0.643) and anegative correlation with peak TG (Rs = - 0.624). Anti-TFPI antibody neutralized reduction in peak TG. In patients undergoing cardiac surgery using CPB, the increase in plasma TFPI concentration at the end of surgery causes a reduction in TG and impairment of whole blood coagulation via a mechanism that includes inhibition of factor Xa activity.