Pediatric Anesthesia (Paediatr Anaesth)

Publications in this journal

• Article: Forced-air warming in infants and children.

  Daniel I Sessler
  Pediatric Anesthesia 06/2013; 23(6):467-8.
• Article: Hypospadias surgery and locoregional anesthesia.

  Pankaj Kundra, Kotteeswaran Yuvaraj
  Pediatric Anesthesia 06/2013; 23(6):567-8.
• Article: Wither codeine?

  Michael R Tremlett
  Pediatric Anesthesia 05/2013;
• Article: Postoperative pain, nausea and vomiting following adeno-tonsillectomy - a long-term follow-up.

  Dana Stanko, Ric Bergesio, Kylie Davies, Mary Hegarty, Britta S von Ungern-Sternberg
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  ABSTRACT: BACKGROUND: Adenotonsillectomy is a common pediatric surgical procedure. Our knowledge of the recovery profile, parental understanding, and expectations is limited. We aimed to assess the incidence of pain, nausea, and vomiting in children undergoing adenotonsillectomy on postoperative day 3 and 7. We also wished to evaluate parental understanding regarding discharge instructions as well as parental expectations and experience of their child's recovery. METHODS: We enrolled 100 children (0-16 years) undergoing elective adenotonsillectomy. On day 3 and 7, parents were questioned about their child's level of pain, nausea/vomiting and their understanding regarding postoperative instructions. RESULTS: Hundred children (median, 6.68 years) were recruited. 52% of parents rated their child's pain as VAS ≥ 5 on day 3, dropping to 30% by day 7. Almost 33% of patients experienced nausea on day 3, dropping to 11.6% by day 7. A similar trend was observed for postoperative vomiting. Most parents, 89%, agreed that postoperative instructions were clear. However, knowledge regarding when to seek emergency medical advice was found to be lacking. On day 7, only 44% of parents reported that their child's recovery met their expectations. CONCLUSION: Adenotonsillectomy is associated with significant pain and PONV, persisting into the seventh postoperative day. Parental education and information seems inadequate and needs to be improved.
  Pediatric Anesthesia 05/2013;
• Article: Cardioprotective effect of remote ischemic postconditioning on children undergoing cardiac surgery: a randomized controlled trial.

  Haixing Zhong, Zijun Gao, Min Chen, Jing Zhao, Feng Wang, Liya Li, Hailong Dong, Lixin Liu, Qiang Wang, Lize Xiong
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  ABSTRACT: BACKGROUND: Remote ischemic postconditioning (RPostC) is a noninvasive intervention that has demonstrated cardioprotection and neuroprotection in animal studies. OBJECTIVE: Our goal was to investigate the cardio-cerebral protective effects of RPostC on children undergoing open-heart surgery for repair of congenital heart defects (CHD). METHODS: Children undergoing open-heart repair of CHD were randomly assigned to a RPostC or control group. RPostC was induced by three 5-min cycles of lower limb ischemia and reperfusion using a blood pressure cuff (200 mmHg) at the onset of aortic unclamping. Serum cardiac troponin I (cTnI), creatine kinase-MB (CK-MB), neuron-specific enolase (NSE), S100β, cytokines, and clinical outcomes were assessed. RESULTS: There were 35 children in the control group and 34 in the RPostC group. The mean age (3.64 ± 1.95 years vs. 3.45 ± 3.02 years, P = 0.80), weight (15.11 ± 6.91 kg vs. 13.40 ± 6.33 kg, P = 0.37), surgical time (144.82 ± 38.51 min vs. 129.92 ± 30.76 min, P = 0.15), and bypass time (78.01 ± 27.22 min vs. 72.52 ± 26.05 min, P = 0.49) were not different. Compared with the control group, the postoperative levels of cTnI (P = 0.037) and CK-MB (P = 0.046) were significantly reduced in the RPostC group. Furthermore, the MAP was higher (P = 0.008), and ICU stay (36.87 ± 3.30 h vs. 60.57 ± 7.35 h, P = 0.006) and postoperative hospital stay (8.56 ± 1.50 days vs. 10.06 ± 2.41 days, P = 0.048) were shorter in the RPostC group than in the control group. However, the postoperative CVP and the concentrations of NSE, S100β, CRP, TNF-α, IL-1β, IL-6, and IL-10 were not significantly different. CONCLUSION: RPostC significantly alleviates cardiac injury in children undergoing open-heart repair of CHD and may also reduce cerebral injury.
  Pediatric Anesthesia 05/2013;
• Article: Robust closed-loop control of induction and maintenance of propofol anesthesia in children.

  Nicholas West, Guy A Dumont, Klaske van Heusden, Christian L Petersen, Sara Khosravi, Kristian Soltesz, Aryannah Umedaly, Eleanor Reimer, J Mark Ansermino
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  ABSTRACT: BACKGROUND: During closed-loop control, a drug infusion is continually adjusted according to a measure of clinical effect (e.g., an electroencephalographic depth of hypnosis (DoH) index). Inconsistency in population-derived pediatric pharmacokinetic/pharmacodynamic models and the large interpatient variability observed in children suggest a role for closed-loop control in optimizing the administration of intravenous anesthesia. OBJECTIVE: To clinically evaluate a robustly tuned system for closed-loop control of the induction and maintenance of propofol anesthesia in children undergoing gastrointestinal endoscopy. METHODS: One hundred and eight children, aged 6-17, ASA I-II, were enrolled. Prior to induction of anesthesia, NeuroSENSE™ sensors were applied to obtain the WAVCNS DoH index. An intravenous cannula was inserted and lidocaine (0.5 mg·kg(-1) ) administered. Remifentanil was administered as a bolus (0.5 μg·kg(-1) ), followed by continuous infusion (0.03 μg·kg(-1) ·min(-1) ). The propofol infusion was closed-loop controlled throughout induction and maintenance of anesthesia, using WAVCNS as feedback. RESULTS: Anesthesia was closed-loop controlled in 102 cases. The system achieved and maintained an adequate DoH without manual adjustment in 87/102 (85%) cases. Induction of anesthesia (to WAVCNS ≤ 60) was completed in median 3.8 min (interquartile range (IQR) 3.1-5.0), culminating in a propofol effect-site concentration (Ce ) of median 3.5 μg·ml(-1) (IQR 2.7-4.5). During maintenance of anesthesia, WAVCNS was measured within 10 units of the target for median 89% (IQR 79-96) of the time. Spontaneous breathing required no manual intervention in 91/102 (89%) cases. CONCLUSIONS: A robust closed-loop system can provide effective propofol administration during induction and maintenance of anesthesia in children. Wide variation in the calculated Ce highlights the limitation of open-loop regimes based on pharmacokinetic/pharmacodynamic models.
  Pediatric Anesthesia 05/2013;
• Article: The perioperative course of factor XIII and associated chest tube drainage in newborn and infants undergoing cardiac surgery.

  Ralph Gertler, Klaus Martin, Alexander Hapfelmeier, Peter Tassani-Prell, Siegmund Braun, Gunther Wiesner
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  ABSTRACT: BACKGROUND: Perioperative acquired factor XIII deficiency has been looked upon as a potential cause of postoperative bleeding in adult cardiac surgery. METHODS: Forty-four infants were prospectively studied for the time course of factor XIII in plasma and the effect on chest tube drainage (CTD) and transfusion requirements in the first 24 h after surgery. A reconstituted blood prime (RBP) with fresh-frozen plasma (FFP) and packed red blood cells (PRBC) was used. Samples were taken at baseline, after cardiopulmonary bypass and upon arrival in the ICU. Differences in blood loss and transfusion requirements based on a cutoff value of 70% factor XIII activity at the time of ICU admission were also calculated. RESULTS: Baseline factor XIII activity was 79%, decreased to 71% after CPB (P = 0.102) and increased back up to 77% at ICU arrival (P = 0.708). There was no significant correlation between factor XIII, CTD, age, cyanosis, platelet count, and transfusion requirements at any time point. Only preoperative fibrinogen levels correlated significantly with factor XIII activity. Perioperative blood transfusions (PRBC P = 0.712, FFP P = 0.909, platelets P = 0.807) and chest tube losses (P = 0.424 at 6 h and P = 0.215 at 24 h) were not significantly different above or below a 70% factor XIII activity at ICU arrival. CONCLUSION: Factor XIII activity in infants with congenital heart defects is within the lower range of normal adults, independent of patient's age and the presence of cyanosis. Reconstituted blood prime maintains factor XIII activity at sufficient levels during pediatric cardiac surgery. We could not detect a correlation between FXIII and CTD.
  Pediatric Anesthesia 05/2013;
• Article: Autonomic cardio-respiratory reflex reactions and superselective ophthalmic arterial chemotherapy for retinoblastoma.

  Trudie J Phillips, Simon P McGuirk, Hardeep K Chahal, Judith Kingston, Fergus Robertson, Stefan Brew, Derek Roebuck, John L Hungerford, Jane Herod
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  ABSTRACT: OBJECTIVE: To describe our experience with superselective ophthalmic artery chemotherapy (SOAC) in retinoblastoma and to report the serious adverse cardio-respiratory reactions we have observed. METHODS: SOAC was performed using a standardized protocol for general anesthesia, ophthalmic artery catheterization, and pulsed infusion of melphalan. Adverse reactions were defined as those in which the patient required active treatment to maintain cardio-respiratory stability. RESULTS: Between December 2008 and May 2012, 54 eyes in 52 patients were treated. 143 catheterization procedures were performed, with a technical success rate of 93% (n = 133). There were no deaths or major complications. Adverse cardio-respiratory reactions developed during 35 procedures (24%; 95% CI, 18-32%). All reactions occurred during second or subsequent catheterization procedures (39%; 95% CI, .29-49%) and were characterized by hypoxia, reduced lung compliance, systemic hypotension and bradycardia. Adverse events were successfully treated in all patients. One procedure was abandoned due to prolonged hemodynamic instability. CONCLUSION: Adverse cardio-respiratory reactions are commonly observed in SOAC for retinoblastoma. We believe that the adverse clinical signs represent an autonomic reflex response, akin to the trigemino-cardiac or oculo-respiratory reflexes, and all patients should be considered at-risk. Reactions occur only during second or subsequent procedures and can be life-threatening. The routine use of intravenous atropine does not seem to have altered the incidence or severity of these reactions. Anesthetists and interventional neuroradiologists involved in SOAC must be vigilant to ensure adverse reactions, when they develop, are treated quickly and effectively.
  Pediatric Anesthesia 05/2013;
• Article: Use of the Bonfils intubating fibrescope in a baby with a severely compromised airway.

  Priya L Krishnan, Bernd H Thiessen
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  ABSTRACT: We report the successful use of a 2-mm rigid Bonfils intubation endoscope as a rescue device in a 5-week-old baby presenting with an unstable airway due to massive macroglossia and multiple hemorrhagic lymphangiomata compressing the airway and resulting in a Cormack and Lehane grade 4 view. The limited intraoral space rendered it impossible to visualize the laryngeal inlet or insert a laryngeal mask, Glidescope or Airtraq blade into the patient's mouth. A 2-mm Bonfils fibrescope passed easily into the patient's mouth and facilitated a grade 1 view of the laryngeal inlet with subsequent successful intubation at first attempt with a 3.5-mm uncuffed endotracheal tube. There are very few alternatives to rescue such an airway in this age group with this type of pathology and surgical intervention would have been difficult due to the vascular nature of the lesion. Bonfils intubation endoscopes (Karl Storz Endoscopy, Tuttlingen, Germany) are a series of reusable devices consisting of a rigid metal tube with a fixed 40° anterior tip curvature containing a fibreoptic bundle. They are available in three sizes with outside diameters of 2, 3.5, or 5 mm. The advantage of the pediatric 2-mm Bonfils fibrescope is that it allows intubation with a 2.5-mm endotracheal tube. There is a paucity of the literature pertaining to the use of the Bonfils endoscope as a rescue device for intubation of small infants and neonates. In our case, the infant's airway was compromised as a result of a receding mandible, large protruding tongue, glottic distortion, and limited intraoral space. This prevented the use of bulkier rescue airway devices with the potential for traumatic manipulation, which could have lead to rapid deterioration of an already unstable airway. We feel that many clinicians are unaware of the benefits of the Bonfils fibrescope and suggest further studies to increase its use in elective and emergency situations.
  Pediatric Anesthesia 05/2013;
• Article: A review of 5434 percutaneous pediatric central venous catheters inserted by anesthesiologists.

  Serge Malbezin, Tobias Gauss, Ian Smith, Beatrice Bruneau, Nyamjargal Mangalsuren, Thierno Diallo, Alia Skhiri, Yves Nivoche, Souhayl Dahmani, Christopher Brasher
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  ABSTRACT: OBJECTIVE: To review the results of an anesthesiologist led pediatric percutaneous central venous access service. METHODS: Prospective data on percutaneous pediatric central venous catheter (CVC) insertions were collected over 22 years. Data included age, gender, weight, previous central CVCs, venous thromboses, investigations for great vein patency, type of CVC, external diameter, previous CVC insertions, intended use, operator identity, and the vein into which the CVC was inserted. The default technique was internal jugular vein cannulation using landmark technique (LT). Complication was defined as the following: failure to cannulate any vein, hemothorax, pneumothorax, right atrial perforation, extravenous wire positioning or CVC position and whether the patient was taken back to theater for CVC repositioning. RESULTS: Five thousand four hundred and thirty-four percutaneous CVC insertion procedures were performed on 3954 patients. One-third involved children <1 year of age (n = 1823: 34%). Five thousand one hundred and twenty-five CVCs (95.3%) were inserted into internal jugular veins. The majority were tunneled CVCs (n = 5190: 96.2%). The perioperative complication rate was 1.3%. Successful cannulation occurred in 99.5% of patients. Failure was more likely in children <3 kg, during large bore hemodialysis CVC insertions and during the first 4 years of the service - the latter suggesting a learning curve. Ninety-nine percent of CVCs were inserted using LTs. CONCLUSION: This study demonstrates a high success rate and low complication rate during pediatric percutaneous internal jugular vein CVC insertions by trained anesthesiologists using LTs. Smaller children, hemodialysis CVCs, and the team's learning curve were identified as risk factors for insertion failure.
  Pediatric Anesthesia 05/2013;
• Article: Is ramosetron superior to ondansetron?

  Takahiro Mihara, Takahisa Goto
  Pediatric Anesthesia 05/2013; 23(5):464.
• Article: Managing persisting pain in children with medical illnesses: another frontier unexplored.

  Ross Drake, Brian J Anderson, John N van den Anker, Boris Zernikow
  Pediatric Anesthesia 05/2013; 23(5):381-4.
• Article: Anesthesia for a child with Camurati-Engelmann disease.

  Maurizio Passariello, Nicole Almenrader
  Pediatric Anesthesia 05/2013; 23(5):464-6.
• Article: Evaluation of distal radial artery cross-sectional internal diameter in pediatric patients using ultrasound.

  Eliane Q S Varga, Keith A Candiotti, Bruce Saltzman, Steven Gayer, Jadelis Giquel, Catalina Castillo-Pedraza, Grace Sanchez, Norman Halliday
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  ABSTRACT: In this study, we measure the radial artery internal diameter (RAID) in children up to 4 years of age before and after the induction of anesthesia. A B-mode portable color Doppler ultrasound was used to measure the RAID. Three sets of measurements were taken for each child before and after the induction of anesthesia and with the wrist in the neutral and dorsiflexed positions. The reliability of the mean value of the RAID in the three sets in 24 patients was established. There were discrepancies between the RAID and the proposed catheter size in some individuals, which may not only render placement difficult but also have potential for arterial injury. There are good reasons to measure the RAID in small children prior to insertion of an intra-arterial catheter.
  Pediatric Anesthesia 05/2013; 23(5):460-2.
• Article: Pneumoperitoneum for neonatal laparoscopy: how safe is it?

  Melanie Olsen, Nicole Avery, Sanjeev Khurana, Rob Laing
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  ABSTRACT: We present the case of a 3 day old term neonate who experienced a cardiopulmonary arrest during creation of pneumoperitoneum for laparoscopic repair of duodenal atresia. The arrest was thought likely to have occurred as a result of a gas embolism. We discuss the features of the neonatal circulation which may predispose neonates to embolic phenomena during laparoscopic procedures, and the potential benefit of priming the insufflation apparatus with carbon dioxide. The possibility of gas embolism should be considered when contemplating laparoscopic surgery in this patient group.
  Pediatric Anesthesia 05/2013; 23(5):457-9.
• Article: Neuropathic pain in sickle cell disease triggered by Pain-Ease™.

  Sachin Rastogi, Lorraine Bird, Cengiz Karsli
  Pediatric Anesthesia 05/2013; 23(5):463.
• Article: The use of nitrous oxide as an adjuvant for inhalation inductions with sevoflurane: a pro-con debate.

  Richard Banchs, Jerrold Lerman, Samuel H Wald
  Pediatric Anesthesia 04/2013;
• Article: Neonatal clinical pharmacology.

  Karel Allegaert, Marc van de Velde, John van den Anker
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  ABSTRACT: Effective and safe drug administration in neonates should be based on integrated knowledge on the evolving physiological characteristics of the infant who will receive the drug and the pharmacokinetics (PK) and pharmacodynamics (PD) of a given drug. Consequently, clinical pharmacology in neonates is as dynamic and diverse as the neonates we admit to our units while covariates explaining the variability are at least as relevant as median estimates. The unique setting of neonatal clinical pharmacology will be highlighted based on the hazards of simple extrapolation of maturational drug clearance when only based on 'adult' metabolism (propofol, paracetamol). Second, maturational trends are not at the same pace for all maturational processes. This will be illustrated based on the differences between hepatic and renal maturation (tramadol, morphine, midazolam). Finally, pharmacogenetics should be tailored to neonates, not just mirror adult concepts. Because of this diversity, clinical research in the field of neonatal clinical pharmacology is urgently needed and facilitated through PK/PD modeling. In addition, irrespective of already available data to guide pharmacotherapy, pharmacovigilance is needed to recognize specific side effects. Consequently, pediatric anesthesiologists should consider to contribute to improved pharmacotherapy through clinical trial design and collaboration, as well as reporting on adverse effects of specific drugs.
  Pediatric Anesthesia 04/2013;
• Article: Core myopathies and malignant hyperthermia susceptibility: a review.

  Robert P Brislin, Mary C Theroux
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  ABSTRACT: The core myopathies are a subset of myopathies that present in infancy with hypotonia and muscle weakness. They were formerly considered a rare type of congenital myopathy but are now recognized as being more prevalent. Due to their genetic linkage to mutations in the ryanodine receptor gene (RYR1), core myopathies (in particular, central core disease) carry a high risk of malignant hyperthermia susceptibility. In this review article, we describe the phenotypical, genetic, and histopathological characteristics of core myopathies and further describe the currently understood nature of their risk of malignant hyperthermia. We also review the level of suspicion a clinician should exhibit with a child who has a possible core myopathy or other congenital myopathy presenting for an anesthetic prior to a definitive genetic analysis. For this review article, we performed literature searches using the key words anesthesiology, core myopathies, pediatric neurology, malignant hyperthermia, genetics, ryanodine receptor, and molecular biology. We also relied on literature accumulated by the two authors, who served as hotline consultants for the Malignant Hyperthermia Hotline of the Malignant Hyperthermia Association of the United States (MHAUS) for the past 12 years.
  Pediatric Anesthesia 04/2013;