Showing papers in "Pediatric Anesthesia in 2015"

Development of a guideline for the management of the unanticipated difficult airway in pediatric practice

Abstract: • Pictorial guidelines for three scenarios—difficult mask ventilation, difficult intubation, and CICV—are provided, and the justification for the design of each is addressed. Implications for translation • These guidelines can be used in any clinical context, will have a use in training, and can have a role in anesthesia, emergency care, and ICU. • The pictorial guidelines were published on the APA and DAS websites in 2012.

Low incidence of pulmonary aspiration in children allowed intake of clear fluids until called to the operating suite

Abstract: BACKGROUND: International guidelines recommend 2 h of clear fluid fasting prior to general anesthesia. The pediatric anesthesia unit of Uppsala University Hospital has been implementing a more libe ...

Treating perioperative anxiety and pain in children: a tailored and innovative approach

Abstract: Millions of children undergo outpatient surgery in the United States each year; the overwhelming majority will experience significant perioperative anxiety and pain. Behavioral preparation programs focused on skills acquisition and modeling, considered essential for effective preparation, are no longer offered to most children and families in the outpatient surgery setting. Moreover, what little preparation does occur is typically generic in nature, rather than tailored to unique characteristics of the child and family. Untreated anxiety and pain have significant implications for children's short- and long-term recovery and future interactions in the medical environment. The rapid growth of the World Wide Web and increasing access to Internet by families across the country provide an opportunity to develop tailored, Web-based behavioral preparation programs that can be accessed repeatedly at times convenient to the child and family, that include coping skills training and modeling, and that can provide unique output based upon child and parent characteristics known to impact perioperative pain and anxiety. In this review article, we present a conceptual framework for a computer-based intervention that may transform the way we manage children and parents before and after surgery.

Anesthesia-related neurotoxicity and the developing animal brain is not a significant problem in children.

Abstract: A multitude of animal studies have shown that virtually all general anesthetics used in clinical practice possibly during a vulnerable period of brain development (i.e., brain growth spurt, peak of synaptogenesis) may lead to neurodegeneration (particularly apoptosis) and abnormal synaptic development with functional deficits in learning and behavior later in life. Initial studies were mainly performed in immature rodent pups, but more recent studies have included nonhumans primates (rhesus monkeys). Given the number of neonates, infants, and young children anesthetized annually worldwide, these findings could have significant public health implications. So far, relatively few human (cohort) studies focusing on this topic have been published with inconsistent results. While some studies have indicated an association between exposure to anesthesia and surgery, other studies have indicated no such association. Prospective studies are underway, but the result will not be available for several years. This paper reviews some of the preclinical background behind anesthesia-related neurotoxicity but focuses mainly on the human studies so far. It is concluded that although disturbing, the animal data lack verification in humans. Fortunately, the humans studies performed so far have been unable to confirm these animal data. A single brief anesthetic seems safe in infants. Multiple anesthetic and surgical exposures on the other hand are different. But there may be other reasons for this than merely the anesthetics. Currently, there is no need to change current anesthetic clinical practice or to postpone or cancel truly urgent surgeries in young children.

Perioperative care of infants with pyloric stenosis

Abstract: Pyloric stenosis (PS) is one of the most common surgical conditions affecting neonates and young infants. The definitive treatment for PS is surgical pyloromyotomy, either open or laparoscopic. However, surgical intervention should never be considered urgent or emergent. More importantly, emergent medical intervention may be required to correct intravascular volume depletion and electrolyte disturbances. Given advancements in surgical and perioperative care, morbidity and mortality from PS should be limited. However, either may occur related to poor preoperative resuscitation, anesthetic management difficulties, or postoperative complications. The following manuscript reviews the current evidence-based medicine regarding the perioperative care of infants with PS with focus on the preoperative assessment and correction of metabolic abnormalities, intraoperative care including airway management (particularly debate related to rapid sequence intubation), maintenance anesthetic techniques, and techniques for postoperative pain management. Additionally, reports of applications of regional anesthesia for either postoperative pain control or as an alternative to general anesthesia are discussed. Management recommendations are provided whenever possible.

Ultrasound assessment of gastric volume in the fasted pediatric patient undergoing upper gastrointestinal endoscopy: development of a predictive model using endoscopically suctioned volumes

Abstract: SummaryBackground Aspiration of gastric contents can be a serious anesthetic-related complication. Gastric antral sonography prior to anesthesia may have a role in identifying pediatric patients at risk of aspiration. We examined the relationship between sonographic antral area and endoscopically suctioned gastric volumes, and whether a 3-point qualitative grading system is applicable in pediatric patients. Methods Fasted patients presenting to a pediatric hospital for upper gastrointestinal endoscopy were included in the study. Sonographic measurement of the antral cross-sectional area (CSA) in supine (supine CSA) and right lateral decubitus (RLD CSA) position was completed, and the antrum was designated as empty or nonempty. Gastric contents were endoscopically suctioned and measured. Multiple regression analysis was used to fit a mathematical model to estimate gastric volume. Results One hundred patients (aged 11–216 months) were included. The gastric antrum was measured in 94% and 99% of patients in the supine and RLD positions, respectively. Gastric antral CSA correlated with total gastric volume in both supine (ρ = 0.63) and RLD (ρ = 0.67) positions. A mathematical model incorporating RLD CSA and age (R2 = 0.60) was determined as the best-fit model to predict gastric volumes. Increasing gastric antral grade (0–2) was associated with increasing gastric fluid volume. Conclusion The results suggest that sonographic assessment of the gastric antrum provides useful information regarding gastric content (empty versus nonempty) and volume (ml·kg−1) in pediatric patients. Results suggest that the three-point grading system may be a valuable tool to assess gastric ‘fullness’ based on a qualitative exam of the antrum.

Pediatric airway anatomy may not be what we thought: implications for clinical practice and the use of cuffed endotracheal tubes.

Abstract: One of the long held tenets of pediatric anesthesia has been the notion that the pediatric airway is conical shape with the narrowest area being the cricoid region. However, recent studies using radiologic imaging techniques (magnetic resonance imaging and computed tomography) or direct bronchoscopic observation have questioned this suggesting that the narrowest segment may be at or just below the glottic opening. More importantly, it has been clearly demonstrated that the airway is elliptical in shape rather than circular with the anterior-posterior dimension being greater than the transverse dimension. These findings coupled with the development of a new generation of cuffed endotracheal tubes (ETTs) with a thin, polyurethane cuff have caused a transition in the practice of pediatric anesthesiology with an increased use of cuffed ETTs, even in neonates and infants. The following article reviews the historical data leading to the assumption that the pediatric airway is conical as well as the more recent imaging and direct bronchoscopic observational studies which refute this tenet. The transition to the use of cuffed ETTs is discussed and potential advantages presented in both the operating room and the intensive care unit. Issues regarding the monitoring of intracuff pressure and techniques to limit potential morbidity related to a high intracuff pressure are outlined.

Anesthesia and the pediatric cardiac catheterization suite: a review

Abstract: Advances in technology over the last couple of decades have caused a shift in pediatric cardiac catheterization from a primary focus on diagnostics to innovative therapeutic interventions. These improvements allow patients a wider range of nonsurgical options for treatment of congenital heart disease. However, these therapeutic modalities can entail higher risk in an already complex patient population, compounded by the added challenges inherent to the environment of the cardiac catheterization suite. Anesthesiologists caring for children with congenital heart disease must understand not only the pathophysiology of the disease but also the effects the anesthetics and interventions have on the patient in order to provide a safe perioperative course. It is the aim of this article to review the latest catheterization modalities offered to patients with congenital heart disease, describe the unique challenges presented in the cardiac catheterization suite, list the most common complications encountered during catheterization and finally, to review the literature regarding different anesthetic drugs used in the catheterization lab.

Total intravenous anesthesia will supercede inhalational anesthesia in pediatric anesthetic practice

Abstract: Inhalational anesthesia has dominated the practice of pediatric anesthesia. However, as the introduction of agents such as propofol, short-acting opioids, midazolam, and dexmedetomidine a monumental change has occurred. With increasing use, the overwhelming advantages of total intravenous anesthesia (TIVA) have emerged and driven change in practice. These advantages, outlined in this review, will justify why TIVA will supercede inhalational anesthesia in future pediatric anesthetic practice.

Dexmedetomidine vs midazolam as preanesthetic medication in children: a meta-analysis of randomized controlled trials.

Abstract: SummaryIntroduction The preoperative period is a stressing occurrence for most people undergoing surgery, in particular children. Approximately 50–75% of children undergoing surgery develop anxiety which is associated with distress on emergence from anesthesia and with later postoperative behavioral problems. Premedication, commonly performed with benzodiazepines, reduces preoperative anxiety, facilitates separation from parents, and promotes acceptance of mask induction. Dexmedetomidine is a highly selective α2-agonist with sedative and analgesic properties. A meta-analysis of all randomized controlled trials (RCTs) on dexmedetomidine versus midazolam was performed to evaluate its efficacy in improving perioperative sedation and analgesia, and in reducing postoperative agitation when used as a preanesthetic medication in children. Methods Studies were independently searched in PubMed, BioMedCentral, Embase, and the Cochrane Central Register of clinical trials and updated on August 15th, 2014. Primary outcomes were represented by improved sedation at separation from parents, at induction of anesthesia, and reduction in postoperative agitation. Secondary outcomes were reduction in rescue analgesic drugs, and duration of surgery and anesthesia. Inclusion criteria were random allocation to treatment and comparison between dexmedetomidine and midazolam. Exclusion criteria were adult studies, duplicate publications, intravenous administration, and no data on main outcomes. Results Data from 1033 children in 13 randomized trials were analyzed. Overall, in the dexmedetomidine group there was a higher incidence of satisfactory sedation at separation from parents (314 of 424 [74%] in the dexmedetomidine group vs 196 of 391 [50%] in the midazolam group, RR = 1.30 [1.05–1.62], P = 0.02), a reduced incidence of postoperative agitation (14 of 140 [10%] vs 56 of 141 [40%], RR = 0.31 [0.13–0.73], P = 0.008), and a significant reduction in the rescue doses of analgesic drugs (49 of 241 [20%] vs 95 of 243 [39%], RR = 0.52 [0.39–0.70], P < 0.001). There was no evidence of a higher incidence of satisfactory sedation at anesthesia induction or any reduction of duration of surgery and anesthesia. Conclusions Dexmedetomidine is effective in decreasing anxiety upon separation from parents, decreasing postoperative agitation, and providing more effective postoperative analgesia when compared with midazolam.

Autism spectrum disorder (ASD) and its perioperative management

Abstract: Autism spectrum disorder (ASD) is now diagnosed in more than 1 in 100 children, so it is not surprising that anesthetists are increasingly providing care for children with this diagnosis. The diagnostic classification for ASD has recently changed and our understanding of the causes and management of ASD are also changing rapidly. This review provides a timely update to increase understanding and awareness of the problems that children with ASD experience, and to minimize perioperative problems. Current literature on premedication and the increasing use of alpha-2 agonists such as clonidine and dexmedetomidine as well as the use of old favorites midazolam and ketamine is reviewed. Some simple strategies that will improve care and decrease anxiety, like social stories, the use of tablet computers, other comfort items or games for distraction, and using favorite drinks to disguise the bitter taste of medications, are described. Remember, the parents are their child's expert and will know what agitates and settles them. Talking to them prior to the day of the procedure is ideal. The importance of staff training and having a clinical practice guideline available at every institution cannot be overstated.

Intraoperative changes in blood pressure associated with cerebral desaturation in infants.

Abstract: Summary Background Intraoperative hypotension has been linked to poor postoperative neurological outcomes. However, the definition of hypotension remains controversial in children. We sought to determine arterial blood pressure threshold values associated with cerebral desaturation in infants. Methods After ethics committee approval, infants younger than 3 months were included in this prospective observational study. Cerebral saturation was assessed using near-infrared spectroscopy. The primary goal of the study was to determine percentage reductions in intraoperative systolic blood pressure (SBP) and mean blood pressure (MBP) associated with decreases in cerebral blood oxygen saturation of >20%, when compared to baseline. Analyses were performed using a bootstrap receiving operator characteristic (ROC) curves with determination of the gray zone. Results Sixty patients were recruited and 960 measurement points were recorded. Fifty-nine data points (6.1%) recorded cerebral desaturation of >20% when compared to baseline. The areas under the ROC curves were 0.79 (0.74–0.84) and 0.67 (0.6–0.75) for percentage decreases in SBP and MBP, respectively. Gray zone values with false-positive and negative rates <10% were SBP decreases of 20.5% and 37.5%, respectively, and MBP decreases of 15.5% and 44.5%, respectively. Conclusion Our results indicate that falls in noninvasive systolic blood pressure of <20% from baseline are associated with a <10% chance of cerebral desaturation in neonates and infants <3 months of age undergoing noncardiac surgery. As such, maintaining systolic blood pressure above this threshold value appears a valid clinical target.

Intranasal dexmedetomidine for sedation in children undergoing transthoracic echocardiography study--a prospective observational study.

Abstract: Summary Background Intranasal dexmedetomidine has been used for sedation in children undergoing nonpainful procedures. Objective The aim of this study was to determine the success rate of intranasal dexmedetomidine sedation for children undergoing transthoracic echocardiography examination. Methods This was a prospective observational study of 115 children under the age of 3 years undergoing echocardiography examination under sedation with intranasal dexmedetomidine at 3 mcg·kg−1. Results Of the 115 children, 100 (87%) had satisfactory sedation with intranasal dexmedetomidine. The mean onset time was 16.7 ± 7 min (range 5–50 min). The mean wake up time was 44.3 ± 15.1 min (range 12–123 min). The wake up time was significantly correlated with duration of procedure with R = 0.540 (P < 0.001). Aside from one patient who required oxygen supplementation, all children in this investigation had an acceptable heart rate and blood pressure and required no medical intervention. Conclusion Sedation by intranasal dexmedetomidine at 3 mcg·kg−1 is associated with acceptable success rate in children undergoing echocardiography with no adverse events in this cohort.

Does a prophylactic dose of propofol reduce emergence agitation in children receiving anesthesia? A systematic review and meta-analysis.

Abstract: SummaryIntroduction Emergence agitation (EA) is common after sevoflurane anesthesia in children, and can lead to distressing inconsolability, agitation, crying, and injury. Use of a single dose of the short-acting sedative-hypnotic agent propofol at the end of a procedure has shown promise for preventing EA, but evidence evaluating the efficacy and safety of this approach has not been formally summarized. Objective The objective of this review was to assess the effects of a prophylactic dose of propofol vs placebo on the incidence and severity of EA in children age 0–13 years receiving general inhalational anesthesia. Search methods We searched PubMed (1946–2013) via Medline, CENTRAL (1898–2013), and Web of Science (1900–2013) without limits or language restrictions; we also searched ClinicalTrials.gov and reference lists. We reviewed abstracts from the 2012 and 2013 Society for Pediatric Anesthesia meetings and pediatric anesthesia-related abstracts from the 2012 and 2013 International Anesthesia Research Society meetings. Selection criteria We assessed randomized, double-blind trials evaluating the efficacy of a prophylactic dose of propofol (1 mg·kg−1) vs placebo given at the end of inhalational anesthesia to prevent EA in pediatric patients. Studies were required to follow patients through recovery and report at least one prespecified outcome. Data collection and analysis Two authors independently assessed trial quality and extracted data from included studies. We contacted study authors regarding any missing data. We used the random effects models to calculate pooled relative risks (RR) and weighted mean differences (WMD). We collected Pediatric Anesthesia Emergence Delirium (PAED) scale scores from included studies. PAED scale scores can range from 0 to 20. Main results Of 276 studies screened, nine trials involving 997 children met all inclusion criteria. All were considered low risk of bias. For one non-English trial, we obtained a full-text translation and for one non-English trial, we used the English-language abstract, tables, and figures. Based on available evidence, prophylactic propofol was associated with both decreased incidence of EA (29% vs 58%, RR 0.50, 95% confidence intervals [CI] 0.41, 0.61, I2 = 37%, seven studies), and reduced severity of EA as assessed by mean PAED scale score (WMD −2.08 points, 95% CI −3.20, −0.96, I2 = 0%, three studies), when compared to placebo. In addition, though prophylactic propofol did lengthen the time to awakening (WMD 4.07 min, 95% CI 2.22, 5.91, I2 = 82%, six studies), it did not increase recovery time (WMD 2.91 min, 95% CI −0.59, 6.41, I2 = 82%, six studies) when compared to placebo. No significant adverse events were reported in either arm. Conclusion Based on high quality evidence, prophylactic propofol appears to be effective for reducing the incidence and severity of EA in children emerging from general anesthesia.

Transition to propofol after sevoflurane anesthesia to prevent emergence agitation: a randomized controlled trial

Abstract: SummaryBackground Emergence agitation (EA) is a common behavioral disturbance after sevoflurane anesthesia in children. Propofol 1 mg·kg−1 bolus at the end of sevoflurane anesthesia has had mixed results in reducing the incidence of EA, whereas propofol infusion throughout anesthesia maintenance seems effective but is more complex to administer. If a simple, short transition to propofol anesthesia was found to be effective in reducing EA, this could enhance the recovery of children following sevoflurane anesthesia. We therefore aimed to determine whether transition to propofol over 3 min at the end of sevoflurane anesthesia reduces the incidence of EA in children. Methods In this prospective randomized controlled trial, 230 children aged 1–12 years, undergoing magnetic resonance imaging (MRI) scans under sevoflurane anesthesia were randomized to receive either propofol 3 mg·kg−1 over 3 min (propofol group), or no propofol (control group), at the end of sevoflurane anesthesia. EA was assessed by a blinded assessor using the Pediatric Emergence Anesthesia Delirium (PAED) scale and the Watcha scale until 30 min after emergence. EA on the PAED scale was defined as a PAED score >12. EA on the Watcha scale was defined as a score ≥3. Times to emergence, postanesthesia care unit (PACU) discharge, and discharge home were also recorded. Results Data were analyzed for 218 children. The incidence of EA was lower in the propofol group on both PAED (29% vs 7%; relative risk = 0.25; 95% confidence interval 0.12–0.52; P < 0.001) and Watcha (39% vs 15%; relative risk = 0.37; 95% confidence interval 0.22–0.62; P < 0.001) scales. Duration and severity of EA were also reduced in the propofol group. Preplanned subgroup analyses for midazolam premedication, preexisting cognitive or behavioral disturbance, and age group did not alter our findings. Emergence time and time in PACU were both increased by a mean of 8 min in the propofol group (P < 0.001) with no difference in time to discharge home. Conclusions Transition to propofol at the end of sevoflurane anesthesia reduces the incidence of EA and improves the quality of emergence. There is a small increase in recovery time, but no delay in discharge home.

Anesthesia‐related critical incidents in the perioperative period in children; a proposal for an anesthesia‐related reporting system for critical incidents in children

Abstract: Background The incidence, type and severity of anesthesia-related critical incidents during the perioperative phase has been investigated less in children than in adults. Aim The aim of the study was to identify and analyze anesthesia-related critical incidents in children to identify areas to improve current clinical practice, and to propose a specialized anesthesia-related critical incidence registration for children. Method All reported pediatric anesthesia-related critical incidents reported on a voluntary reporting based on a 20-item complication list of the Dutch Society of Anesthesiology between January 2007 and August 2013 were analyzed. An anesthesia-related critical incident was defined as 'any incident that affected, or could have affected, the safety of the patient while under the care of an anesthetist'. As the 20-item complications list was too crude for detailed analyses, all critical incidents were reclassified into the more detailed German classification lists with the adjustment of specific items for children (in total 10 categories with 101 different subcategories). Results During the 6-year period, a total of 1214 critical incidents were reported out of 35 190 anesthetics (cardiac and noncardiac anesthesia cases). The most frequently reported incidents (46.5%) were related to the respiratory system. Infants <1 year, children with ASA physical status III and IV, and emergency procedures had a higher rate of adverse incidents. Conclusion Respiratory events were the most reported commonly critical incidents in children. Both the Dutch and German existing lists of critical incident definitions appeared not to be sufficient for accurate classification in children. The present list can be used for a new registration system for critical incidents in pediatric anesthesia.

Nurse-driven pediatric analgesia and sedation protocol reduces withdrawal symptoms in critically ill medical pediatric patients.

Abstract: Background While several analgesia and sedation guidelines and protocols have been developed and implemented for adults, there is still little evidence of clinical use of analgesia and sedation protocols and the impact on withdrawal symptoms in critically ill children. Objective The aim of this study was to evaluate the effects of a nurse-driven goal-directed analgesia and sedation protocol for mechanically ventilated pediatric patients (pASP) on duration of mechanical ventilation, pediatric intensive care unit (PICU) length of stay, total doses of opioids and benzodiazepines, and occurrence of withdrawal symptoms. Patients and methods This is a before and after protocol implementation study in a 14-bed medical-surgical-cardiac pediatric intensive care unit at a university children's hospital. A total of 337 medical pediatric patients requiring mechanical ventilation with PICU length of stay for at least 24 h were included. Prior to implementation of the protocol, analgesia and sedation was managed by the attending physician's order. Afterwards, postimplementation, nurses managed analgesia and sedation following a pASP, including COMFORT 'behavioral' Scale, Nurse Interpretation Sedation Scale, and Sophia Observation Withdrawal Symptoms Scale. Results One hundred and sixty-five patients were included in the 15-month period before and 172 patients were included in the 15-month period after implementation of the pASP. Median duration of mechanical ventilation was 2.02 (0.96-25.0) days in the group preceding protocol implementation and 1.71 (0.96-66.0) days afterwards (P = 0.23). Median PICU length of stay was 5.8 (1-37.75) days in the preimplementation and 5.0 (1-120) days in the postimplementation group (P = 0.14). Total doses of opioids and benzodiazepines were 3.9 mg·kg(-1) ·day(-1) (0.1-70) vs 3.1 mg·kg(-1) ·day(-1) (0.05-56); P = 0.38 and 5.9 mg·kg(-1) ·day(-1) (0-82.0) vs 4.2 mg·kg(-1) ·day(-1) (0-66); P = 0.009 after implementation. Incidence of withdrawal was significantly lower over the postimplementation period (12.8% vs 23.6%; P = 0.005). Conclusion Implementation of a nurse-driven pASP reduced the total dose of benzodiazepines and the occurrence of withdrawal symptoms significantly.

An update on newer pediatric supraglottic airways with recommendations for clinical use

Abstract: Summary Supraglottic airways are an established part of routine and emergency pediatric airway management, including use in difficult airways and neonatal resuscitation. With the introduction of newer supraglottic airways in children, efficacy can only be determined by comparing these devices with those that are already well established (laryngeal mask airway Classic and laryngeal mask airway ProSeal). This narrative review aims to present the current literature on these newer supraglottic airways and give recommendations for their use in various clinical scenarios based on the existing evidence.

Cyanotic congenital heart disease (CCHD): focus on hypoxemia, secondary erythrocytosis, and coagulation alterations

Abstract: Children with cyanotic congenital heart disease (CCHD) have complex alterations in their whole blood composition and coagulation profile due to long-standing hypoxemia. Secondary erythrocytosis is an associated physiological response intended to increase circulating red blood cells and oxygen carrying capacity. However, this response is frequently offset by an increase in whole blood viscosity that paradoxically reduces blood flow and tissue perfusion. In addition, the accompanying reduction in plasma volume leads to significant deficiencies in multiple coagulation proteins including platelets, fibrinogen and other clotting factors. On the one hand, these patients may suffer from severe hyperviscosity and subclinical 'sludging' in the peripheral vasculature with an increased risk of thrombosis. On the other hand, they are at an increased risk for postoperative hemorrhage due to a complex derangement in their hemostatic profile. Anesthesiologists caring for children with CCHD and secondary erythrocytosis need to understand the pathophysiology of these alterations and be aware of available strategies that lessen the risk of bleeding and/or thrombosis. The aim of this review is to provide an updated analysis of the systemic effects of long-standing hypoxemia in children with primary congenital heart disease with a specific focus on secondary erythrocytosis and hemostasis.

Sevoflurane anesthesia and brain perfusion

Abstract: SummaryObjective/Aim To assess the impact of sevoflurane and anesthesia-induced hypotension on brain perfusion in children younger than 6 months. Background Safe lower limit of blood pressure during anesthesia in infant is unclear, and inadequate anesthesia can lead to hypotension, hypocapnia, and low cerebral perfusion. Insufficient cerebral perfusion in infant during anesthesia is an important factor of neurological morbidity. In two previous studies, we assessed the impact of sevoflurane anesthesia on cerebral blood flow (CBF) by transcranial Doppler (TCD) and on brain oxygenation by NIRS, in children ≤2 years. As knowledge about consequences of anesthesia-induced hypotension on cerebral perfusion in children ≤6 months is scarce, we conducted a retrospective analysis to compare the data of CBF and brain oxygenation, in this specific population. Methods We performed a retrospective analysis of data collected from our two previous studies. Baseline values of TCD or NIRS were recorded and then during sevoflurane anesthesia. From a database of 338 patients, we excluded all patients older than 6 months. Then, we compared physiological variables of TCD and NIRS population to ensure that the two groups were comparable. We compared rSO2c and TCD measurements variation according to MAP value during sevoflurane anesthesia, using anova and Student–Newman–Keuls for posthoc analysis. Results One hundred and eighty patients were included in the analysis. TCD and NIRS groups were comparable. CBF velocities (CBFV) or rSO2c reflects a good cerebral perfusion when MAP is above 45 mmHg. When MAP is between 35 and 45 mmHg, CBFV variation reflects a reduction of CBF, but rSO2c increase is the consequence of a still positive balance between CMRO2 and O2 supply. Below 35 mmHg of MAP during anesthesia, CBFV decrease and rSO2c variation from baseline is low. For each category of MAP and for the two groups, etCo2 and expired fraction of sevoflurane (FeSevo) were comparable (anova P > 0.05). Conclusion In a healthy infant without dehydration, with normal PaCO2 and hemoglobin value, scheduled for short procedures, MAP is a good proxy of cerebral perfusion as we found that CBF assessed by CBFV and rSO2c decreased proportionally with cerebral perfusion pressure. During 1 MAC sevoflurane anesthesia, maintaining MAP beyond 35 mmHg during anesthesia is probably safe and sufficient. But when MAP decreases below 35 mmHg, CBF decreases and rSO2c variation from baseline is low despite CMRO2 reduction. In this situation, cerebral metabolic reserve is low and further changes of systemic conditions may be poorly tolerated by the brain.

Monitoring depth of anesthesia: from consciousness to nociception. A window on subcortical brain activity.

Abstract: Anesthesia results from several inhibitor processes, which interact to lead to loss of consciousness, amnesia, immobility, and analgesia. The anesthetic agents act on the whole brain, the cortical and subcortical areas according to their receptor targets. The conscious processes are rather integrated at the level of the cortical neuronal network, while the nonconscious processes such as the nociception or implicit memory require subcortical processing. A reliable and meaningful monitoring of depth of anesthesia should provide assessment of these different processes. Besides the EEG monitoring which gives mainly information on cortical anesthetic effects, it would be relevant to have also a subcortical feedback allowing an assessment of nociception. Several devices have been proposed in this last decade, to give us an idea of the analgesia/nociception balance. Up to now, most of them are based on the assessment of the autonomic response to noxious stimulation. Among the emerging clinical devices, we can mention those which assess vascular sympathetic response (skin conductance), cardiac and vascular sympathetic response (surgical pleth index), parasympathetic cardiac response (analgesia nociception index), and finally the pupillometry which is based on the assessment of the pupillary reflex dilatation induced by nociceptive stimulations. Basically, the skin conductance might be the most adapted to assess the stress in the awake or sedated neonate, while the performances of this method appear disappointing under anesthesia. The surgical pleth index is still poorly investigated in children. The analgesia nociception index showed promising results in adults, which have to be confirmed, especially in children and in infants, and lastly pupillometry, which can be considered as reliable and reactive in children as in adults, but which is still sometimes complicated in its use.

Risk assessment and anesthetic management of patients with Williams syndrome: a comprehensive review.

Abstract: Since the first description in 1961, several case reports have documented an increased incidence of anesthesia-related cardiac arrest in patients with Williams-Beuren syndrome, commonly known as Williams syndrome (WS). Widespread arteriopathy secondary to an elastin gene defect results in various cardiac defects, including supravalvar aortic stenosis (SVAS) and coronary artery anomalies, which can increase the risk of myocardial ischemia. Even though patients with WS are known to have increased risk of adverse events during anesthesia and sedation, they often undergo several procedures that require anesthesia during their lifetimes, and cases of perianesthetic cardiac arrest continue to be reported. To date, no prospective studies have been reported that quantify anesthetic risk in individual patients with WS. In this article, we review the clinical manifestations of WS, propose a consensus, expert-informed method to estimate anesthetic risk based on the current literature, and provide recommendations for periprocedural management of this patient population.

The impact of obesity on pediatric procedural sedation-related outcomes: results from the Pediatric Sedation Research Consortium

Abstract: SummaryObjectives To evaluate the impact of obesity on adverse events and required interventions during pediatric procedural sedation. Methods The Pediatric Sedation Research Consortium database of prospectively collected procedural sedation encounters was queried to identify patients for whom body mass index (BMI) could be calculated. Obesity was defined as BMI ≥95th percentile for age and gender. Sedation-related outcomes, adverse events, and therapeutic interventions were compared between obese and nonobese patients. Results For analysis, 28 792 records were eligible. A total of 5 153 patients (17.9%) were obese; they were predominantly male and older and had a higher median American Society of Anesthesiologists Physical Status classification (P < 0.001). Total adverse events were more common in obese patients (odds ratio [OR] 1.49, 95% confidence interval [1.31, 1.70]). Respiratory events (airway obstruction OR 1.94 [1.54, 2.44], oxygen desaturation OR 1.99 [1.50, 2.63], secretions OR 1.48 [1.01, 2.15], laryngospasm OR 2.30 [1.30, 4.05]), inability to complete the associated procedure (OR 1.96 [1.16, 3.30]), and prolonged recovery (OR 2.66 [1.26, 5.59]) were increased in obese patients. Obese patients more frequently required airway intervention including repositioning, suctioning, jaw thrust, airway adjuncts, and bag-valve-mask ventilation. Multivariate regression analysis demonstrated obesity to be independently associated with minor and moderate but not major adverse events. Conclusions Obesity is an independent risk factor for adverse respiratory events during procedural sedation and is associated with an increased frequency of airway interventions, suggesting that additional vigilance and expertise are required when sedating these patients.

Perioperative respiratory complications following awake and deep extubation in children undergoing adenotonsillectomy.

Abstract: Summary Background: Perioperative respiratory complications after adenotonsillectomy (TA presence of Down syndrome, cranio-facial abnormality, or cerebral palsy; obstructive sleep apnea confirmed by polysomnography; diagnosis of obstructive sleep apnea by clinical history; presence of an upper respiratory tract infection (URI) within 2 weeks of presentation; history of reactive airway disease; status at extubation; endtidal sevoflurane and carbon dioxide concentrations at extubation; total intraoperative opioids administered in morphine equivalents (mgkg 1 ); administration of propofol at extubation; and intraoperative administration of an anticholinergic drug. Conclusions: There was no difference in the incidence of perioperative respiratory complications in children undergoing a T&A following an awake vs deep extubation. Only weight ≤14 kg was associated with increased perioperative respiratory complications.

Perioperative pulmonary aspiration is infrequent and low risk in pediatric anesthetic practice

Abstract: Recent studies have reported perioperative pulmonary aspiration in pediatric practice to be an uncommon problem associated with low morbidity and mortality. This paper examines the recent publications in both the adult and pediatric literature and looks at some of the potential risk factors involved, both patient and anesthetic, in the development of aspiration of gastric contents. We also look at the risk of severe morbidity following pulmonary aspiration and speculate on possible reasons behind the assertion that pulmonary aspiration in pediatric anesthetic practice is rare and a low-risk event.

Intranasal dexmedetomidine premedication reduces minimum alveolar concentration of sevoflurane for laryngeal mask airway insertion and emergence delirium in children: a prospective, randomized, double-blind, placebo-controlled trial

Abstract: Summary Background We conducted a prospective, randomized, double-blind, placebo-controlled study to verify the hypothesis that intranasal dexmedetomidine premedication can reduce the minimum alveolar concentration of sevoflurane for laryngeal mask airway insertion in children. Methods Ninety American Society of Anesthesiologists (ASA) physical status I subjects, aged 3–7 years, were randomized to three equal groups to receive saline (Group S), dexmedetomidine 1 μg·kg−1 (Group D1), or dexmedetomidine 2 μg·kg−1 (Group D2) approximately 45 min before anesthesia. The minimum alveolar concentration for laryngeal mask airway insertion of sevoflurane was determined according to the Dixon's up-and-down method. Emergence delirium was evaluated using the Pediatric Anesthesia Emergence Delirium (PAED) scale in the postanesthesia care unit (PACU). Results Dexmedetomidine premedication of 1 and 2 μg·kg−1 was associated with reduction in sevoflurane from 1.92% to 1.53% and 1.23%, corresponding to decrease of 20% and 36%, respectively. The peak PAED scores (median [IQR]) were 9 [8–11.5], 5 [3–5.3], and 3 [2–4] in Group S, Group D1, and Group D2, respectively. The incidence of emergence delirium (defined as peak PAED score ≥10) was significantly lower in Groups D1 and D2 than in Group S (P < 0.001). Simultaneously, the induction qualities and the parent's satisfaction scores were significantly higher in Groups D1 and D2 than in Group S (P < 0.001). Conclusion Intranasal dexmedetomidine premedication produces a dose-dependent decrease in the minimum alveolar concentration for laryngeal mask airway insertion of sevoflurane and emergence delirium in the PACU.

Rapid sequence induction has no use in pediatric anesthesia.

Abstract: (Classic) rapid sequence induction and intubation (RSII) has been considered fundamental to the provision of safe anesthesia. This technique consists of a combination of drugs and techniques and is intended to prevent pulmonary aspiration of gastric content with catastrophic outcomes to the patient. This review investigates aspects of this technique and highlights dangers and frauds if this technique is transferred directly into pediatric anesthesia practice. The author recommends a controlled anesthesia induction by trained pediatric anesthesiologist with suitable equipment for the children considered at risk of pulmonary aspiration. RSSI is a dangerous technique if adopted without modification into pediatric anesthesia and has in its 'classic' form no use.

Ultrasound‐guided supraclavicular cannulation of the right brachiocephalic vein in small infants: a consecutive, prospective case series

Abstract: Summary Background The supraclavicular ultrasound (US)-guided cannulation of the brachiocephalic vein (BCV) is one option of central venous line placement in infants. Aim The aim of this prospective study was to evaluate whether there was an association between the optimum ultrasonographic view as obtained of the entire longitudinal extension of the right BCV and the ease of supraclavicular cannulation when using a strict in-plane technique via a linear US probe in small infants. Methods The US probe was placed in the right supraclavicular region. If the optimum obtainable sonographic view presented the entire longitudinal extension of the right BCV demonstrating clearly its path caudally alongside the pleura, it was graded as I. If, however, only a circular view, i.e., the initial part of the right BCV was obtainable via US, it was graded as II. The right BCV was cannulated by advancing a 22-gauge i.v. cannula from lateral to medial strictly under the long axis of the US probe under direct US vision into the vein. Results Seventy-nine infants weighing between 0.8 and 4.5 kg (Median: 3.4 ± 0.09) were included. In 50 (63.3%) patients, the sonographic view was graded as I and in 29 (36.7%) as II. The proportion of patients successfully cannulated on the first attempt was significantly smaller in patients graded as II, i.e., circular, sonographic view of the right BCV than in patients graded as I, i.e., sonographic view of the entire longitudinal extension of the right BCV (41% vs 90%; chi-square analysis: P < 0.01). Conclusion The sonographic view obtainable of the entire longitudinal extension of the right BCV resulted in significantly fewer required cannulation attempts.

Emergence delirium, pain or both? a challenge for clinicians

Abstract: SummaryBackground Children commonly display early postoperative negative behavior (e-PONB) after general anesthesia, which includes emergence delirium (ED), discomfort, temperament, and pain. However, it is often difficult for the caregiver to discriminate between various aspects of e-PONB. Objective This prospective observational study evaluates the possibility to distinguish between ED and pain in young children using validated pediatric observational scales in the early postoperative phase. Methods Following institutional approval and written consent, children undergoing elective adenoidectomy and/or tonsillectomy were enrolled. Following standardized anesthesia, two trained observers simultaneously evaluated children's behavior with the Paediatric Anaesthesia Emergence Delirium Scale (PAED) and with the Face, Legs, Activity, Cry, Consolability scale (FLACC) at extubation, and at 5, 10, and 15 min. Results Of 150 children that completed the study, 32 (21%) had ED, 7 (5%) had pain, and 98 (65%) had simultaneously both ED and pain. The association of ‘No eye contact’, ‘No purposeful action’ and ‘No awareness of surroundings’ (ED1) had a sensitivity of 0.96 and a specificity of 0.80 (PPV 0.97, NPV 0.78) to identify ED. ‘Inconsolability’ and ‘Restlessness’ (ED2) had a sensitivity of 0.69 and a specificity of 0.88 (PPV 0.83 and NPV 0.78) to identify pain. Conclusion It is difficult to differentiate between ED and pain using FLACC and PAED scores. ‘No eye contact’, ‘No purposeful action’, and ‘No awareness of surroundings’ significantly correlated with ED. ‘Inconsolability’ and ‘Restlessness’ are not reliable enough to identify pain or ED in the first 15 min after awakening.

Sevoflurane exposure during the neonatal period induces long-term memory impairment but not autism-like behaviors.

Abstract: Summary Objective To examine whether neonatal exposure to sevoflurane induces autism-like behaviors in mice. Background There are continuing reports regarding the potential negative effects of anesthesia on the developing brain. Recently, several studies suggest that neurotoxicity caused by anesthesia may lead to neurodevelopmental impairments. However, unlike reports focusing on learning and memory, there are only a few animal studies focusing on neurodevelopmental disorders after general anesthesia. Therefore, we have focused on autism, a representative neurodevelopmental disorder. Methods Neonatal mice (P6–7) were exposed to a titrated dose of sevoflurane for 6 h. Apoptosis was evaluated by assessing the expression level of cleaved (activated) caspase-3. Autism-like behaviors, general activity, anxiety level, and long-term memory were evaluated with multiple behavioral assays. Results Western blotting confirmed that neonatal exposure to sevoflurane increased the expression level of activated caspase-3, indicative of apoptosis. Mice exposed to sevoflurane also showed impaired long-term memory in fear tests. However, sevoflurane-exposed mice did not exhibit autism-like features in all of the following assays: social interaction (three-chamber test, caged social interaction), social communication (ultrasonic vocalization test), or repetitive behavior (self-grooming test, digging). There were also no differences in general activity (open field test, home cage activity) and anxiety (open field test, light-dark box) after sevoflurane exposure. Conclusions Our results confirm previous studies that neonatal sevoflurane exposure causes neurodegeneration and long-term memory impairment in mice. However, sevoflurane did not induce autism-like features. Our study suggests that mice are more vulnerable to long-term memory deficits than autism-like behaviors after exposure to sevoflurane.