Sevoflurane and desflurane anesthesia were associated with similar incidences of ED in children undergoing sub-umbilical surgery and receiving effective regional anesthesia. High scores on the first three items of the PAED scale were highly correlated with ED. The items restlessness and inconsolability had lower sensitivity for the diagnosis of ED.
In vertebrates, TFEB (transcription factor EB) and MITF (microphthalmia-associated transcription factor) family of basic Helix-Loop-Helix (bHLH) transcription factors regulates both lysosomal function and organ development. However, it is not clear whether these 2 processes are interconnected. Here, we show that Mitf, the single TFEB and MITF ortholog in Drosophila, controls expression of vacuolar-type H+-ATPase pump (V-ATPase) subunits. Remarkably, we also find that expression of Vha16-1 and Vha13, encoding 2 key components of V-ATPase, is patterned in the wing imaginal disc. In particular, Vha16-1 expression follows differentiation of proneural regions of the disc. These regions, which will form sensory organs in the adult, appear to possess a distinctive endolysosomal compartment and Notch (N) localization. Modulation of Mitf activity in the disc in vivo alters endolysosomal function and disrupts proneural patterning. Similar to our findings in Drosophila, in human breast epithelial cells we observe that impairment of the Vha16-1 human ortholog ATP6V0C changes the size and function of the endolysosomal compartment and that depletion of TFEB reduces ligand-independent N signaling activity. Our data suggest that lysosomal-associated functions regulated by the TFEB-V-ATPase axis might play a conserved role in shaping cell fate.
Myasthenia gravis (MG) is an autoimmune disease marked by weakness of voluntary musculature. Medical and surgical therapy of adult myasthenia is well documented. There is little pediatric surgical evidence, only a few case reports being available. The aim of this paper is to verify whether the surgical and anesthesiological techniques can warrant an early and safe discharge from the operating room. The secondary aim is to assess the presence of perioperative indicators that can eventually be used as predictors of postoperative care. During the years 2006–2009, 10 pediatric patients were treated according to a surgical approach based on video assisted thoracoscopic extended thymectomy (VATET). Standard preoperative evaluation is integrated with functional respiratory tests. Anesthetic induction was made with propofol and fentanyl/remifentanyl and maintenance was obtained with sevoflurane/desflurane/propofol ± remifentanyl. A muscle relaxant was used in only one patient. Right or left double-lumen bronchial tube (Rüsch Bronchopart® Carlens) placement was performed. Six patients were transferred directly to the surgical ward while 4 were discharged to the intensive care unit (ICU); ICU stay was no longer than 24 h. Length of hospital stay was 4.4±0.51 days. No patient was readmitted to the hospital and no surgical complications were reported. Volatile and intravenous anesthetics do not affect ventilator weaning, extubation or the postoperative course. Paralyzing agents are not totally contraindicated, especially if short-lasting agents are used with neuromuscular monitoring devices and new reversal drugs. Perioperative evaluation of the myasthenic patient is mandatory to assess the need for postoperative respiratory support and also predict timely extubation with early transfer to the surgical department. Availability of new drugs and of reversal drugs, the current practice of mini-invasive surgical techniques, and the availability of post anesthesia care units are the keys to the safety and successful prognosis of patients affected by MG who undergo thymectomy.
ondansetron group (n = 109). Patients in the latter group received ondansetron 100 μg/kg intravenously after surgery, and patients in the ramosetron group received 6 μg/mg intravenously after surgery. Intravenous PCA with fentanyl was used in both groups. The incidence of postoperative vomiting and other adverse effects was assessed during the first 48 hours after surgery. There was markedly less vomiting during the first 24-hour and 6-to 24-hour periods after surgery in the ramosetron group compared with the ondansetron group. No differences existed in the adverse effect between the 2 groups. Ramosetron was more effective than ondansetron during the first 24-hour period after surgery in children using fentanyl PCA. COMMENTAntiemetic prophylaxis with ondansetron, often in conjunction with dexamethasone, remains standard therapy in both adults and children despite studies suggesting that the efficacy of ondansetron may be less than previously thought. Ramosetron, a longer-acting 5-HT 3 receptor antagonist with greater receptor specificity, has shown promising results in populations at high risk of postoperative nausea and vomiting (PONV). 1 Here, Park et al present the first randomized study of ondansetron versus ramosetron in children at high risk for PONV undergoing extensive orthopedic reconstructive surgery. After randomization and study drug assignment, both groups received postoperative analgesia with a fentanyl PCA loading dose of 0.5 μg/kg, infusion of 2 μg/kg per hour, and a demand bolus of 0.5 μg/kg (15-minute lockout). Compared with ondansetron, patients receiving ramosetron had notably less PONV at both 0 to 24 hours and 6 to 24 hours (9% vs 23% in the first 24 hours).These results show that ramosetron provides better prophylaxis for fentanyl PCA-induced postoperative vomiting than ondansetron. Although ramosetron's longer half-life may explain these results, the study design may have magnified the differences between ondansetron and ramosetron. First, based on a 44% incidence of postoperative vomiting in similar orthopedic procedures, the study was powered to detect a reduction in emesis rate from 44% to 27%. In this investigation, the vomiting rate in the ondansetron group was 50% less than anticipated, suggesting that the study may be inadequately powered to show a difference between these groups. Next, study drug administration at the termination of anesthesia makes it difficult to distinguish whether these drugs prevented fentanyl PCA-induced vomiting or simply provided treatment during the emergence phase from general anesthesia. Ondansetron works poorly as an antiemetic, and as such, this investigation may be confirming that other drugs are superior to ondansetron as rescue antiemetics. Future investigations should examine whether ramosetron is superior to ondansetron as a rescue antiemetic. Comment by Christopher Stemland, MD Disclosure: The author declares no conflict of interest.REFERENCE 1. Choi YS, Shim JK, Yoon do H, et al. Effect of ramosetron on patient-controlled analgesia-related nause...
PURPOSE: The assessment of total body fluid volume, intracellular volume and extracellular volume before and after anesthesia may be useful to define a better intraoperative fluid administration. METHODS: A bioimpedance spectroscopy device (BCM) was used to measure total body fluid volume, extracellular volume, intracellular volume. BCM-measurements were performed before and after general anesthesia in unselected healthy children and adolescents visiting the Pediatric Institute of Southern Switzerland for low-risk surgical procedures. RESULTS: In 100 children and adolescents aged 7.0 [4.8 – 11] years (median and interquartile range), the average total body water (TBW) increased perioperatively with a delta value of 182 [0 – 383] mL/m2 from pre- to postoperatively, as well as the extracellular water content (ECW), which had an equivalent increase with a delta value of 169 [19 – 307] mL/m2. The changes in TBW and ECW significantly correlated with the amount of fluids administered. CONCLUSIONS: This preliminary report shows that intraoperative fluid administration results in a significant fluid accumulation in low-risk schoolchildren during general anesthesia. Children without major health problems undergoing short procedures, do not need any perioperative intravenous fluid therapy, because they are allowed to take clear fluids up to 1 hour prior anesthesia. BCM-measurements could become useful for guiding intraoperative fluid therapy in future studies.
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