Respiratory Adverse Events Research Articles

Desensitization and remission after peanut sublingual immunotherapy in 1- to 4-year-old peanut-allergic children: A randomized, placebo-controlled trial

Prior studies of peanut sublingual immunotherapy (SLIT) have suggested a potential advantage with younger age at treatment initiation. We studied the safety and efficacy of SLIT for peanut allergy in 1- to 4-year-old children. Peanut-allergic 1- to 4-year-old children were randomized to receive 4 mg peanut SLIT versus placebo. Desensitization was assessed by double-blind, placebo-controlled food challenge (DBPCFC) after 36monthsoftreatment. Participants desensitized to at least443mg peanut protein discontinued therapy for 3 months and then underwent DBPCFC to assess for remission. Biomarkers were measured at baseline and longitudinally during treatment. Fifty participants (25 peanut SLIT, 25 placebo) with a median age of 2.4 years were enrolled across 2 sites. The primary end point of desensitization was met with actively treated versus placebo participants having a significantly greater median cumulative tolerated dose (4443 mg vs 143 mg), higher likelihood of passing the month 36 DBPCFC (60% vs 0), and higher likelihood of demonstrating remission (48% vs 0). The highest rate of desensitization and remission was seen in1- to 2-year-olds, followed by 2- to 3-year-olds and 3- to 4-year-olds. Longitudinal changes in peanut skin prick testing, peanut-specific IgG4, and peanut-specific IgG4/IgE ratio were seen in peanut SLIT but not placebo participants. Oropharyngeal itching was more commonly reported by peanut SLIT than placebo participants. Skin, gastrointestinal, upper respiratory, lower respiratory, and multisystem adverse events were similar between treatment groups. Peanut SLIT safely induces desensitization and remission in 1- to 4-year-old children, with improved outcomes seen with younger age at initiation.

Comparison of ciprofol–alfentanil and propofol–alfentanil sedation during bidirectional endoscopy: A prospective, double-blind, randomised, controlled trial

BackgroundAlthough propofol is widely used for gastrointestinal endoscopic sedation, cardiopulmonary adverse events remain common. Ciprofol is a new intravenous anaesthetic agent demonstrating respiratory and hemodynamic stability. AimsThis study aimed to clarify the benefits of ciprofol combined with alfentanil in bidirectional endoscopy (esophagogastroduodenoscopy followed by colonoscopy) to reduce adverse events and improve post-endoscopic recovery. MethodsA total of 185 patients scheduled to undergo bidirectional endoscopy were randomly divided into two groups: ciprofol combined with alfentanil or propofol combined with alfentanil. All patients received 7 µg/kg alfentanil intravenously before the study drugs were administered. The propofol group received a bolus of 1.2 mg/kg (0.12 ml/kg) propofol intravenously, whereas the ciprofol group received a bolus of 0.3 mg/kg (0.12 ml/kg) ciprofol intravenously. The primary outcome was the proportion of patients with cardiopulmonary adverse events (i.e., any one of the airway obstruction, apnoea, hypotension, hypertension, bradycardia, tachycardia or arrhythmias). ResultsCompared with propofol, ciprofol reduced cardiopulmonary adverse events by 43.51 % (34.4% vs. 60.9 %, P <0.001), mitigated respiratory adverse events by 54.74 % (17.2% vs. 38.0 %, P = 0.002) overall and by 59.05 % (12.9% vs. 31.5 %, P = 0.002) during the induction period. ConclusionsCiprofol can significantly decrease respiratory depression events and provides a better sedative efficacy than propofol with higher recovery quality and satisfaction.

Comparative study of the clinical performance of two supraglottic airway devices, Laryngeal Mask Airway Supreme and BASKA Balum Mask in adult patients for general anaesthesia

BackgroundThe oropharyngeal leak pressure (OLP) of supraglottic airway devices (SGADs) is an important determinant of their efficacy to provide positive pressure ventilation, whereas the provision to prevent aspiration determines its safety. This study aims to compare the clinical performance of Laryngeal Mask Airway (LMA) Supreme versus BASKA Balum Mask. MethodsSeventy adult patients (18–65 years) posted for elective surgeries general anaesthesia were prospectively randomised into group B (BASKA Mask) and Group S (LMA Supreme). The primary outcome was to measure the OLP at 5 and 30 min after device insertion and secondarily, to compare the ease and time of insertion, number of attempts, leak fraction, anatomical position of the devices, and adverse respiratory event if any. ResultsThe OLP of BASKA Mask was significantly higher than LMA Supreme (31.37 ± 1.73 cmH2O versus 23.6 ± 1.73 cmH2O at 5 min and 35.94 ± 3.84 cmH2O versus 23.71 ± 1.69 cmH2O at 30 min). The time taken to insert BASKA Mask was also less (11.49 ± 2.38 s) than LMA Supreme (14.66 ± 2.79 s). Peak airway pressures were also notably less in group B than group S at both 5 and 30 min after device placement (13.43 ± 1.44 vs 18.66 ± 1.43 cmH2O and 14.91 ± 1.46 vs 21.37 ± 1.88 cmH2O). The leak fraction ranged between 1.5 and 4.3% in both groups. All other parameters studied were also comparable. ConclusionsBASKA Mask had a higher OLP, lower peak pressure, shorter time to insertion than LMA Supreme. The leak fraction, ease of insertion, number of attempts, and anatomical position of the devices were comparable in both groups.

Estimation of historical daily airborne pollen concentrations across Switzerland using a spatio temporal random forest model

High concentrations of airborne pollen trigger seasonal allergies and possibly more severe adverse respiratory and cardiovascular health events. Predicting pollen concentration accurately is valuable for epidemiological studies, in order to study the effects of pollen exposure. We aimed to develop a spatiotemporal machine learning model predicting daily pollen concentrations at a spatial resolution of 1 × 1 km across Switzerland between 2000 and 2019. Daily pollen concentrations for five common, highly allergenic pollen types (hazel, alder, birch ash, and grasses) were available from fourteen measurement sites across Switzerland. We considered several predictors such as elevation, species distribution, wind speed, wind direction, temperature, precipitation, relative humidity, satellite-observed Normalized Difference Vegetation Index, and land-use (CORINE, Landsat satellite) to explain variation in pollen concentration. We employed feature engineering techniques to encode categorical variables and fill in missing values. We applied a random forest machine learning model with 5-fold cross-validation. The 5th–99th percentiles for concentrations of hazel, alder, birch, ash, and grass pollen at the pollen monitoring stations were 0–298, 0–306, 0–1153, 0–800, and 0–290 pollen grains/m3, respectively. The results of a predictive model for these concentrations yielded overall R2 values of 0.87, 0.84, 0.89, 0.88, and 0.91, and temporal root mean squared errors (RMSEs) of 16.07, 16.72, 69.04, 41.50, and 22.45 pollen grains/m3. An analysis of predictor variable importance indicates that the average national daily pollen concentration is the most important predictor of pollen concentrations for all pollen types. Furthermore, meteorological variables including temperature, total precipitation, humidity, boundary layer height, wind speed, and wind direction, as well as date and satellite features, are important factors in pollen concentration prediction. These spatiotemporal pollen models will serve to estimate individual residential pollen exposure for epidemiological studies. Resulting estimates will enable us to study respiratory and cardiovascular mortality and hospital admissions in Switzerland.

The Role of Prognostic Factors in Peri¬operative Adverse Events and Complications in Children with Cleft Palate Re¬pair.

Aim: Cleft lip and palate (CLP) deformity is the most common type of craniofacial malformation and is usually corrected surgically in infancy. Anesthetic management of children undergoing CLP repair has many challenges. In this study, it was aimed to evaluate the effect of prognostic factors on perioperative complications in children with cleft palate (CP) repair.&#x0D; Methods: In this study, pediatric cases who underwent cleft palate surgery in a tertiary care hospital between 2015 and 2020 were analyzed retrospectively. The primary outcome measure was perioperative adverse outcomes rate.&#x0D; Results: The incidence of all perioperative adverse events including airway, and respiratory complications, ICU admission, blood transfusion and re-operation requirement was determined as 40.7% (n=88) and the incidence of respiratory adverse events was found as 28.7% (n=62). Moreover, low body weight (OR 0.69, 95% CI 1.18-1.78, p

Association between preoperative respiratory symptoms and perioperative respiratory adverse events in pediatric patients with positive viral testing

Study objectiveTo determine the association between the presence of upper respiratory tract viral infection symptoms and occurrence of perioperative respiratory adverse events (PRAE) in children with positive viral screening, and to analyze the risk of PRAE in children with SARS-CoV-2 compared to non-SARS-CoV-2 infection. DesignA prospective cohort study. SettingA tertiary, freestanding pediatric hospital in Dallas, Texas. PatientsChildren <18 years of age with positive respiratory viral testing who underwent general anesthesia. InterventionMeasurement of incidence of PRAE and severe adverse events during the first 7 postoperative days. MeasurementsThe primary outcome was a composite of PRAE: oxygen saturation < 90% for >5 min, supplemental oxygen for >2 h after anesthesia, laryngospasm, and bronchospasm. The secondary outcome was severe adverse events: high flow nasal cannula >6 l of oxygen per minute, admission to the ICU for escalation of respiratory support post-anesthetic, acute respiratory distress syndrome, postoperative pneumonia, cardiovascular arrest, extracorporeal life support, and death. Main resultsIn this convenience sample of 196 children, 83 were symptomatic and 113 were asymptomatic. The risk of PRAE was similar in children with active viral symptoms and asymptomatic children (risk difference: −1.9%; 95% CI: −10.9, 7.9%), but higher among children with documented fever within 48 h of the anesthetic (risk difference: 20.8%; 95% CI: 5.3, 39.7%). The multivariable adjusted odds ratio of PRAE was 0.68 (95% CI: 0.25, 1.85) for symptomatic compared to asymptomatic patients, and 0.46 (95% CI: 0.14, 1.44) for patients with SARS-CoV-2 compared to non-SARS-CoV-2 infection. ConclusionsThere was no significant difference in the incidence of PRAE between symptomatic and asymptomatic children with laboratory confirmed viral respiratory infection, and between children with the Omicron variant of SARS-CoV-2 compared to non-SARS-CoV-2 respiratory viruses. However, the risk was increased in children with recent fever.

A Predictive Model of Major Postoperative Respiratory Adverse Events in Pediatric Patients Undergoing Rigid Bronchoscopy for Exploration and Foreign Body Removal.

Background: No nomogram has been established to predict the incidence of major postoperative respiratory adverse events (mPRAEs) in children undergoing rigid bronchoscopy for airway foreign bodies (AFB) removal and exploration of the airway, though some studies have confirmed the risk factors. Methods: 1214 pediatric patients (≤3 years old) undergoing rigid bronchoscopy for AFB from June 2014 to December 2020 were enrolled in this study. The primary outcome was the occurrence of mPRAEs, including laryngospasm and bronchospasm. Following that, a nomogram prediction model for the mPRAEs was developed. Results: The incidence of mPRAEs was 84 (6.9%) among 1214 subjects. American Society of Anesthesiologists physical status (ASA-PS), intraoperative desaturation (SpO2 < 90%), procedural duration and ventilatory approach were all independent risk factors of mPRAEs. The area under the receiver operating characteristic curve (AUC) value of the nomogram for predicting mPRAEs was 0.815 (95% CI: 0.770-0.861), and the average AUC for ten-fold cross-validation was 0.799. These nomograms were well calibrated by Hosmer-Lemshow (p = 0.607). Decision curve analysis showed that the nomogram prediction model is effective in clinical settings. Conclusions: Combining ASA-PS, intraoperative desaturation, procedural duration, and ventilatory approach, the nomogram model is adequate for predicting the risk of developing mPRAEs, followed by rigid bronchoscopy for AFB removal and exploration.

Comparison of propofol-esketamine versus propofol for anesthesia in gastroscopy: a double-blind, randomized controlled clinical trial.

To compare the effects of propofol-esketamine and propofol in gastroscopy in adults. This randomized controlled clinical trial was performed from January 2021 to March 2021. Eighty patients were enrolled and allocated into normal saline group (group N) and esketamine group (group E). The primary outcome was total amount of propofol. Secondary outcomes included incidences of injection pain, involuntary movement, hemodynamic and respiratory adverse events during examination, total examination time, recovery time and postoperative adverse effects. Total amount of propofol was significantly smaller in group E (101.64 ± 32.64 mg) than in group N (129.55 ± 36.34 mg, p = 0.001). Incidences of injection pain, involuntary movement and hypotension was significantly lower in group E than in group N. Incidences of hypertension and tachycardia was higher in group E than in group N. There was no significant difference in incidences of laryngospasm or hypoxemia, total examination time, recovery time, incidences of postoperative adverse effects between two groups. Combination of propofol with 0.2 mg/kg esketamine reduced total amount of propofol, provided a more stable hemodynamic status and did not affect recovery time in gastroscopy. http://www.chictr.org, identifier ChiCTR2100042406.

The safety and efficacy of remimazolam tosylate combined with propofol in upper gastrointestinal endoscopy: A multicenter, randomized clinical trial.

Hypotension is the most common adverse event under propofol-mediated sedation and is possible to cause varying degrees of damage to patients. Whereas remimazolam has a poorer sedative effect than propofol. The aim of this study was to explore the advantages of the combination of remimazolam tosylate and propofol. 304 patients were divided into the remimazolam tosylate group (RT group), the propofol group (P group), and the remimazolam tosylate plus propofol group(R+T group). The primary outcome was the incidence of hypotension. Secondary outcomes included the results of sedation and recovery. The safety results mainly include the incidence of Hypotension, adverse respiratory events, postoperative nausea and vomiting, hiccup, cough, body movement and bradycardia. The incidence of hypotension was 56.7% in the P group, 12.6% in the RT group, and 31.3% in the R+P group, three groups of pairwise comparisons showed statistical differences, with P< 0.001. The incidence of body movement was significantly higher in the RT group (26.1%) than in the P group (10.3%) and the R+P group (12.5%), P = 0.004. The endoscopist satisfaction was higher in the P (3.87±0.44) and R+P (3.95±0.22)groups than in the RT(3.53±0.84) group. The incidence of adverse events, in descending order, was P group, RT group, and R+P group (93.8%vs.61.3%vs.42.7%). Co-administration had fewer adverse events than propofol monotherapy, also had a better sedative effect and higher endoscopist satisfaction than remimazolam monotherapy. Clinical trial registration number: NCT05429086.

The Impact of Left Ventricular Diastolic Dysfunction on Respiratory Adverse Events in Cardiac Surgery Patients-An Observational Prospective Single-Center Study.

Left ventricular diastolic dysfunction (LV DD) is the most dominant cause of heart failure with preserved ejection fraction (HFpEF) worldwide. This pathological condition may contribute to postcapillary pulmonary hypertension (pcPH) development. Hypoxemia, often observed in pcPH, may significantly negatively impact the course of hospitalization in patients after cardiac surgery. The aim of our study was to investigate the impact of LV DD on the frequency of postoperative respiratory adverse events (RAE) in patients undergoing Coronary Artery Bypass Grafting (CABG). The left ventricular (LV) diastolic function was assessed in 56 consecutive patients admitted for CABG. We investigated the relationship between LV DD and postoperative respiratory adverse events (RAE) in groups with normal LV diastolic function and LV DD stage I, II, and III. Left ventricular diastolic dysfunction stage I was observed in 11 patients (19.6%) and LV DD stage II or III in 19 patients (33.9%). Arterial blood partial pressure of oxygen (PaO2) to the fraction of inspired oxygen (FiO2) index during postoperative mechanical ventilation was significantly lower in LV DD stage II or III than in the group with normal LV diastolic function. Patients with DD stage II or III had a higher occurrence of postoperative pneumonia than the group with normal LV diastolic function. Left ventricular diastolic dysfunction is widespread in cardiac surgery patients and is an independent risk factor for lower minimal PaO2/FiO2 index during mechanical ventilation and higher occurrence of pneumonia.

Utilization of deep neuromuscular blockade combined with reduced abdominal pressure in laparoscopic radical gastrectomy for gastric cancer: An academic perspective.

Few studies have examined the specific efficacy of deep neuromuscular blockade (NMB) combined with pneumoperitoneal pressure reduction in laparoscopic radical gastrectomy (LRG) in the elderly. To investigate the application effect of deep neuromuscular blockade (NMB) combined with reduced pneumoperitoneum pressure in LRG for gastric cancer (GC) in elderly patients and its influence on inflammation. Totally 103 elderly patients with GC treated in our hospital between January 2020 and January 2022 were retrospectively analyzed. Among them, 45 patients treated with surgery based on deep NMB and conventional pneumoperitoneum pressure were assigned to the control group, while the rest of the 58 patients who underwent surgery based on deep NMB and reduced pneumoperitoneum pressure were assigned to the observation group. The two groups were compared in the changes of the Leiden-surgical rating scale score, serum tumor necrosis fact-α (TNF-α) and interleukin 6 (IL-6) before and after therapy. The visual analogue scale (VAS) was adopted for evaluating the shoulder pain of patients at 8 h, 24 h and 48 h after the operation. The driving pressure of the two groups at different time points was also compared. Additionally, the operation time, pneumoperitoneum time, infusion volume, blood loss, extubation time after surgery, residence time in the resuscitation room, TOF% = 90% time and post-anesthetic recovery room (PACU) stay time were all recorded, and adverse PACU-associated respiratory events were also recorded. The postoperative hospitalization time and postoperative expenses of the two groups were counted and compared. No significant difference was found between the two groups at the time of skin incision, 60 minutes since the operation and abdominal closure after surgery (P > 0.05). The observation group exhibited significantly lower VAS scores than the control group at 24 and 48h after surgery (P < 0.05). Additionally, the observation group had significantly lower driving pressure than the control group at 5 min and 60 min after the establishment of pneumoperitoneum (P < 0.05). Additionally, the two groups were similar in terms of the operation time, pneumoperitoneum time, infusion volume, blood loss, extubation time after surgery, residence time in the resuscitation room and TOF% = 90% time (P > 0.05), and the observation group showed significantly lower TNF-α and IL-6 Levels than the control group at 24 h after therapy (P < 0.05). Moreover, the incidence of adverse events was not significantly different between the two groups (P > 0.05), and the observation group experienced significantly less hospitalization time and postoperative expenses than the control group (P < 0.05). Deep NMB combined with reduced pneumoperitoneum pressure can decrease the VAS score of shoulder pain and inflammatory reaction, without hindering the surgical vision and increasing adverse PACU-associated respiratory events, and can thus shorten the hospitalization time and treatment cost for patient.

Ultrasound-Guided Peripheral Nerve Blocks for Shoulder Dislocation in the Emergency Department: A Systemic Review

BackgroundShoulder dislocations are among the most common orthopedic emergencies encountered in the emergency department (ED). Ultrasound-guided peripheral nerve blocks (USG-PNBs) are increasingly being used for acute pain management in the ED, but clinical evidence supporting their utility for shoulder dislocation is limited and often conflicting. ObjectiveThe aim of this review was to summarize and evaluate the utility of USG-PNB for analgesia during closed reduction of dislocated shoulders in the ED. MethodsAdhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a systematic literature search of the PubMed, Scopus, and Cochrane databases was performed from database inception to September 2022. We included clinical studies examining USG-PNB for pain management of dislocated shoulders in the ED. Information collected from eligible studies included patient demographic characteristics, USG-PNB approach, alternate analgesia techniques, anesthetic regimens, clinical outcomes, and adverse events. ResultsFive studies met inclusion criteria, all of which were randomized controlled trials comparing USG-PNB with procedural sedation and analgesia. Pooled patient satisfaction scores were similar for both analgesia methods (3.5 ± 0.6 vs. 3.9 ± 0.6 out of 5; p = 0.76). Patients managed with procedural sedation and analgesia achieved higher rates of overall shoulder reduction (100% vs. 67%; p < 0.001) and successful reduction on the first attempt (86% vs. 48%; p < 0.001). The USG-PNB groups in all but one study had shorter lengths of ED stay. Overall, USG-PNB was associated with a lower risk of adverse events and complications (3.9% vs. 24.9%; p < 0.001), especially adverse respiratory events (0% vs. 14.7%; p < 0.001). ConclusionsUSG-PNBs performed by adequately trained emergency physicians should be considered a safe and effective alternative for analgesia during closed reduction of dislocated shoulders in the ED, particularly in patients with cardiorespiratory comorbidities.

CDK4/6 inhibitors and cardiovascular toxicity: Real-world evidence.

e15074 Background: Cyclin-dependent kinases 4/6 inhibitors (CDK4/6i) have fundamentally transformed the therapeutic landscape of hormone receptor-positive and human epidermal growth factor receptor 2 (HER2) negative breast cancer, either as monotherapy (abemaciclib) or combined with classic endocrine therapy (ribociclib, abemaciclib, and palbociclib). However, evidence regarding treatment-related cardiovascular complications, beyond the context of clinical trials, remains scarce. Methods: We retrospectively explored the FDA Adverse Events Reporting System (FAERS) to gain insight into both frequency and spectrum of cardiovascular toxicities of these novel targeted agents in real-world setting. Results: For the period January 2018 - September 2022, a total of 90,999 adverse events (AEs) in patients under CDK4/6i have been reported, with 2,739 (3.01%) and 5,176 (5.69%) records being submitted as cardiac and vascular events, respectively. The incidence of these AEs was higher in the case of ribociclib, with arrhythmia representing the main cardiac complication (512 cases), followed by palpitations (120 cases), and acute coronary syndrome (115 cases). Interestingly, there was only one report of QT prolongation; of note, ribociclib has labeling guidance for QTc assessment. Hypertension/hypertensive crisis (302 cases), flushing (251 cases), and thrombotic events (226 cases) -with the exception of pulmonary embolism which was categorized as respiratory AE- comprised the foremost vascular toxicities associated with ribociclib. Conclusions: FAERS displays a public, post-market safety evaluation database with reports from healthcare professionals as well as consumers, yet it may include duplicates, inaccurate information, and fails to confirm causal relationship between the AEs and the medicinal product. In the light of CDK4/6i long-term usage, pharmacovigilance studies are warranted to elucidate their potential cardiovascular hazard. [Table: see text]

Evaluation of risk prediction model for perioperative respiratory adverse events in pediatric anesthesia

Background: Perioperative respiratory adverse events are among the most common critical incidents in pediatric anesthesia. Three risk prediction models have been developed to predict occurrence of such adverse events in children. However, these tools were only internally validated, limiting generalization. The Perioperative Respiratory Adverse Events in Pediatric Ambulatory Anesthesia risk prediction tool developed by Subramanyam et al. consists of five predictors: age ≤ 3 years, ASA physical status II and III, morbid obesity, preexisting pulmonary disorder, and surgery. Aims and Methods: We aimed to evaluate the suitability of Subramanyam’s model in predicting the occurrence of perioperative respiratory adverse events in a more general tertiary care pediatric population, including anesthesia for both outpatient and inpatient procedures. Therefore we validated this scoring system in a tertiary care cohort of 204 children included in the APRICOT study at our hospital through retrospective analysis of this data. Secondarily, we aimed to study the incidence of perioperative respiratory adverse events in our hospital. Results: Overall incidence of perioperative respiratory adverse events in our sample was 19,6%. Applying Subramanyam’s prediction model to our cohort, we found no patients categorized as low risk, 76 patients as intermediate risk and 128 patients as high risk. Discriminatory ability of the risk scoring system was modest, with AUC of the simplified model 0,65 (95% CI 0,57-0,74) and AUC of the original logistic regression model 0,66 (95% CI 0,57-0,75). Calibration of the simplified model was rather poor, with Brier score 0,49. The original logistic regression model calibrated better, with Brier score 0,18. A subgroup analysis considering solely ambulant patients in Ghent-APRICOT yielded comparable results. Conclusions: We conclude that the overall performance of Subramanyam’s risk prediction tool in our cohort was moderate. Modest discrimination and calibration suggest that the risk score may not reliably predict perioperative respiratory adverse events in individual patients in our tertiary care pediatric population. Therefore the clinical relevance of the implementation of this scoring system in our tertiary hospital would be negligible, which leaves us with the lack of good scoring systems to predict perioperative respiratory adverse events in our population. In addition, we found the incidence of these adverse events in our hospital to be markedly higher as compared to the sample of Subramanyam.

Outcomes and predictors of delayed endoscopic biliary drainage for severe acute cholangitis due to choledocholithiasis in an intensive care unit.

Acute cholangitis (AC) is an infection of the biliary tract secondary to biliary obstruction requiring biliary drainage through endoscopic retrograde cholangiopancreatography. This study aims to compare the outcome between the early and delayed ERCP in patients with severe AC. Patient with severe AC due to choledocholithiasis admitted to intensive care unit were included. Early ERCP was defined was as ERCP performed within 24h following hospital admission. Propensity-score matching was used to reduce the imbalance between groups. The primary outcome was 30-day mortality. Secondary outcomes included length of hospital and ICU stay, onset or persistent organ failure. The delayed ERCP group had a higher mortality rate at 30 days (45,5 versus 13%, <0.001) and at 1 year (59,7% versus 15,6%, p <0.001). Delayed ERCP had also a higher rate of respiratory adverse events (54,5 versus 27,8%, p=0,002), longer ICU (7.41 versus 4.61, p=0,004) and hospital (11,88 versus 9,22, p=0,042) length of stay. Predictors of delayed ERCP were cardiac arrythmias, liver disease, creatinine value and white blood cell count at baseline. Delays in ERCP for patients with severe AC appear to be associated with higher mortality rate and prolonged ICU and hospital stays.

Effect of Tulobuterol Patch Versus Placebo on the Occurrence of Respiratory Adverse Events in Children Undergoing Tonsillectomies: A Randomized Controlled Trial.

Perioperative respiratory adverse events are common in children. We aimed to evaluate the effect of the transdermal β-2 agonist, tulobuterol, compared with that of placebo on the incidence of perioperative respiratory adverse events in pediatric patients undergoing tonsillectomy. In this triple-blinded (patient, anesthesia provider, and outcome assessor) randomized controlled trial, 188 patients were randomly allocated to receive tulobuterol or a placebo. The tulobuterol groups received a tulobuterol patch (1 mg) masked with a bandage, whereas the placebo only received the bandage. The assigned bandage was applied to the patients 8 to 10 hours before the surgery. The primary outcome was the occurrence of any perioperative respiratory adverse events: oxygen desaturation <95%, airway obstruction, laryngospasm, bronchospasm, severe coughing, or stridor. The outcomes were evaluated using the average relative effect test, which estimates the effect of individual components of a composite outcome and then averages effects across components. A total of 88 and 94 patients who received tulobuterol and placebo, respectively, were analyzed. The incidence of any perioperative respiratory adverse event was lower with tulobuterol (n = 13/88; 14.7%) than that with the placebo (n = 40/94; 42.5%), with an estimated average relative risk (95% confidence interval) across components of 0.35 (0.20-0.60; P < .001). The symptoms of airway obstruction were lower with tulobuterol (n = 8/88; 9.0%) than that with the placebo (n = 32/94; 34.0%), with relative risk (95% CI) of 0.31 (0.17-0.56; P < .001). The occurrence of severe coughing was lower with tulobuterol (n = 1/88; 1.1%) than that with the placebo (n = 8/94; 8.5%), with relative risk (95% CI) of 0.15 (0.03-0.68; P = .014). In preschool children undergoing tonsillectomy, the preoperative application of a tulobuterol patch could decrease the occurrence of perioperative respiratory adverse events. Further studies are needed to elucidate the effect of the tulobuterol patch in a broad spectrum of pediatric anesthesia.

Beta Agonists for Prevention of Respiratory Adverse Events in Children Undergoing Adenotonsillectomy: Long-Acting, Short Acting, or Not Acting.

Adler, Adam C. MS, MD, FAAP, FASE*,†; von Ungern-Sternberg, Britta S. MD, PhD, DEAA, FANZCA‡,§,‖ Author Information

Application of Bispectral Index System (BIS) Monitor to Ambulatory Pediatric Dental Patients under Intravenous Deep Sedation.

Purpose Intravenous sedation has been well accepted to allow dental restoration in uncooperative children while avoiding aspiration and laryngospasm; however, intravenous anesthetics such as propofol may lead to undesired effects such as respiratory depression and delayed recovery. The use of the bispectral index system (BIS), a monitoring system reflective of the hypnotic state, is con-troversial in the reduction in the risk of respiratory adverse events (RAEs), recovery time, the in-travenous drug dosage, and post-procedural events. The aim of the study is to evaluate whether BIS is advantageous in pediatric dental procedures. Methods A total of 206 cases, aged 2-8 years, receiving dental procedures under deep sedation with propofol using target-controlled infusion (TCI) technique were enrolled in the study. BIS level was not monitored in 93 children whereas it was for 113 children, among which BIS values were maintained between 50-65. Physiological variables and adverse events were recorded. Statistical analysis was conducted using Chi-square, Mann Whitney U, Independent Samples t and Wilcoxon signed tests, with a p value of <0.05 considered to be statistically significant. Results Although no statistical significance in the post-discharge events and total amount of propofol used was observed, a clear significance was identified in periprocedural adverse events (hypoxia, apnea, and recurrent cough, all p value < 0.05) and discharge time (63.4 ± 23.2 vs. 74.5 ± 24.0 min, p value < 0.001) between these two groups. Conclusions The application of BIS in combination with TCI may be beneficial for young children undergoing deep sedation for dental procedures.

Effect of Nebulized Salbutamol Premedication on Perioperative Respiratory Adverse Events in Children with Recent Respiratory Tract Infections

BACKGROUND&#x0D; A recent upper respiratory tract infection is linked to the development of peri-operative respiratory complications. In this study we wanted to evaluate the effect of salbutamol premedication on the incidence of peri-operative respiratory adverse events in children with a recent upper respiratory tract infection (PRAE).&#x0D; METHODS&#x0D; A randomized clinical trial study that was conducted at the Children Welfare Teaching Hospital for a period of six months. It included 90 children aged ≤ 16 years who underwent a surgical operation under general anesthesia with a laryngeal mask airway or a tracheal tube and were divided into three groups; (had a recent URTI and received preoperative salbutamol, those who had a recent URTI and didn’t receive preoperative salbutamol, and those with no URTI group). The preferred outcome was the difference in the rate of occurrence of PRAE between children who had received salbutamol and those who hadn’t.&#x0D; RESULTS&#x0D; Four children with no URTI (13.3%) developed peri-operative respiratory adverse events. The incidence of bronchospasm and severe cough was significantly higher in patients with URTI and who didn’t receive preoperative salbutamol than in those with URTI who received preoperative salbutamol.&#x0D; CONCLUSIONS&#x0D; Preoperative salbutamol doses 10 – 30 minutes before surgery have been demonstrated to reduce and treat peri-operative respiratory adverse events.

Effect of dexmedetomidine on preventing perioperative respiratory adverse events in children: A systematic review and meta‑analysis of randomized controlled trials.

The most common critical incidents in pediatric anesthesia are perioperative respiratory adverse events (PRAEs). The present meta-analysis aimed to assess the preventive effect of dexmedetomidine on PRAEs in children. Dexmedetomidine is a highly selective α2-adrenoceptor agonist that provides sedation, anxiolysis and analgesic effects without causing respiratory depression. Dexmedetomidine can diminish airway and circulatory responses during extubation in children. Original randomized controlled trial data were analyzed to study the putative effect of dexmedetomidine on PRAEs. By searched the Cochrane Library, EMBASE and PubMed, a total of ten randomized controlled trials (1,056 patients) was identified. PRAEs included cough, breath holding, laryngospasm, bronchospasm, desaturation (percutaneous oxygen saturation <95%), body movement and pulmonary rales. Compared with placebo, dexmedetomidine resulted in a significant reduction of incidence of cough, breath holding, laryngospasm and emergence agitation. The incidence of PRAEs was significantly reduced in dexmedetomidine compared with active comparators group. Moreover, dexmedetomidine decreased heart rate and increased post-anesthesia care unit stay duration by 11.18 min. The present analysis suggested that dexmedetomidine improved the airway function and decreased risks associated with general anesthesia in children. The present data demonstrated that dexmedetomidine may be a good choice to prevent PRAEs in children.