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ABSTRACT: OBJECTIVES: We hypothesize that the laryngeal mask airway (LMA) is a safe technique for airway management in pediatric adenotonsillectomy (T&A). METHODS: After institutional review board (I.R.B.) approval, we conducted a retrospective review of 1199 medical records of children who underwent T&A from 2002 to 2006 at Doernbecher Children's Hospital, a teaching institution in Portland, OR. There were no significant demographic differences between the LMA (n=451), endotracheal tube (ETT) (n=715), and failed LMA groups (n=33). Outcome variables were LMA failure (LMA replaced with endotracheal tube), and any complication. We collected demographic and medical data to determine the incidence and predictors of LMA failure, and to characterize the failed LMA group. RESULTS: The incidence of LMA failure was 6.8%. Patients who underwent adenoidectomy had significantly lower odds of LMA failure compared to patients who had a tonsillectomy or adenotonsillectomy (OR 0.28, 95% CI 0.15-0.52, P<0.0001). One of the surgeons (OR 0.46, 95% CI 0.45-0.48, P<0.0001) was also associated with decreased odds of LMA failure. Controlled ventilation (OR 7.17, 95% CI 4.99-10.32, P<0.0001), and younger patients (OR 1.05 for each year decrease in age, 95% CI 1.03-1.07, P≤0.0001) were associated with increased odds of LMA failure. The complication rate was 14.2% in the LMA group and 7.7% in the ETT group. Increased odds of developing any complication were seen in male patients (OR 1.4, 95% CI 1.01-1.7, P=0.04), and in patients with co-morbidities other than obstructive sleep apnea syndrome or upper respiratory tract infection (OR 4.2, 95% CI 1.03-17.2, P=0.04). The odds of developing a complication were lower in the ETT group compared to the LMA group (0.63, 0.46, 0.8, P=0.005). CONCLUSIONS: LMA use for pediatric T&A is associated with a higher incidence of complications, mainly as a result of airway obstruction following insertion of the LMA or McIvor gag placement. Complications were more likely if tonsillectomy was performed when compared to adenoidectomy alone. Appropriate patient selection, careful insertion, and avoidance of controlled ventilation may decrease the incidence of LMA failure, especially if tonsillectomy is performed. The ability of surgeons to work around the LMA can modify the failure rate significantly.
International journal of pediatric otorhinolaryngology 10/2012; · 0.85 Impact Factor
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ABSTRACT: Analyze pediatric ERG data for adverse events, interventions, and outcomes of propofol sedations performed in near-complete darkness.
To demonstrate that deep sedation with propofol for ERG can be performed efficiently and safely in children in near-total darkness.
Full-field electroretinography (ERG) is a valuable tool for the diagnosis of vision loss in children. The ERG measures the electrical activity of the retina. In children, ERG quality significantly improves with deep sedation by allowing easier eye electrode placement and decreasing motion artifacts. As this procedure must be performed in darkness, administering sedation imposes unique challenges.
ERGs are performed outside of the operating room in our hospital's electrophysiology suite. IVs are placed, and patients are allowed to adapt to complete darkness. An anesthesiologist then administers propofol sedation in the dark with the aid of a red-filter light source and monitor light shields. Data were collected on 379 patients (411 ERGs) performed from 1996 to 2008. These records were reviewed and analyzed for demographic, medical, and anesthetic data.
Propofol sedation resulted in an ERG completion rate of 99.5%. During sedation, 8.5% (35) of patients experienced minor respiratory complications such as airway obstruction that resulted in an oxygen saturation <90%. A total of 9.7% (40) of patients required minor airway interventions such as a chin lift.
We demonstrated that pediatric sedation is a safe, efficient, and a cost-effective method for measuring ERGs in a challenging environment. The incidence of minor complications is low and appears similar to other studies of propofol sedation.
Pediatric Anesthesia 01/2011; 21(1):65-71. · 2.10 Impact Factor
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ABSTRACT: To investigate factors affecting parental satisfaction with a pediatric sedation service in a university hospital setting.
Prospective, observational study with interviews using a survey instrument.
Academic university hospital.
Parents (or legal guardians; hereafter "parents") of 220 children scheduled for sedation with the hospital's pediatric sedation service.
Caregivers of children scheduled for sedation were interviewed using a validated survey instrument. The instrument was designed to investigate the quality of communication, environment, care provided, and the overall experience. We followed patients by telephone the day after discharge. Chi-square or linear-by-linear association tests were used to evaluate associations between satisfaction scores and demographic variables; the Mann-Whitney test was used for mean levels of satisfaction in anxious versus non-anxious children.
Of 222 parents approached, 220 agreed to participate (response rate = 99.1%). Significant associations between each area of satisfaction and parents' overall satisfaction existed (P < 0.001). Previous sedations, types of sedation, age of child, or any individual provider were not significantly associated with overall satisfaction. Caregivers of anxious children reported less satisfaction than caregivers of non-anxious children. Parents of children who underwent magnetic resonance imaging reported the lowest mean satisfaction scores.
Overall satisfaction was high, and care provided by anesthesiologists was significantly associated with overall satisfaction. A site in our institution was associated with significantly lower satisfaction as a result of inadequate space and privacy.
Journal of clinical anesthesia 02/2010; 22(1):29-34. · 1.32 Impact Factor
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ABSTRACT: In this study, the authors evaluated the efficacy and safety of modified orbitozygomatic craniotomy for resection of craniopharyngioma in children.
A prospective, institutional review board-approved database was retrospectively reviewed for pediatric patients undergoing craniopharyngioma resection performed by a single surgeon.
Ten patients underwent craniopharyngioma resection surgery between July 2000 and January 2006 (4 girls and 6 boys, ages 1.5-17 years). Nine patients presented to the authors' institution, and 1 patient was referred after surgery and radiation therapy were administered elsewhere. Nine patients presented with visual field deficits (2 with unilateral or bilateral light perception only) and 5 with endocrine dysfunction. Eight patients had large tumors that significantly displaced the optic chiasm and hypothalamus. All patients underwent a modified frontotemporal orbitozygomatic osteotomy in a single piece. The lamina terminalis was opened in 4 patients with third ventricular extension. One patient required a staged transsphenoidal operation to remove residual tumor in the sella turcica, and 1 patient underwent a contralateral subtemporal approach to resect a daughter lesion in the prepontine cistern. Complete radiographic resection was achieved in all patients. Follow-up averaged 55 months (range 12-95 months). Vision was improved in 8 patients and remained stable in 2. All patients had postoperative endocrine dysfunction. One patient experienced transient cranial nerve IV palsy and 1 suffered a small caudate stroke 5 months after surgery without sequelae. Two patients experienced polyphagia and weight gain without other symptoms of hypothalamic dysfunction. There were no other new neurological deficits.
Modified orbitozygomatic craniotomy provides excellent exposure of the suprasellar region with minimal brain retraction, allowing complete resection of craniopharyngiomas with good visual and neurological results.
Journal of Neurosurgery Pediatrics 10/2009; 4(4):345-52. · 1.53 Impact Factor
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ABSTRACT: We describe a case of intraoperative neonatal cardiac arrest during attempted laparoscopic surgery. Circulatory collapse occurred before peritoneal insufflation, initially obscuring the diagnosis. Emergent transthoracic echocardiography during resuscitation demonstrated intracardiac gas bubbles consistent with venous gas embolism. The site of entrainment was probably a bleeding umbilical vein transected by the umbilical trocar. Greater awareness of this complication in neonates will facilitate early diagnosis and encourage preventive measures, such as the avoidance of umbilical vessels, use of an open instead of closed access technique, and ligation of bleeding vessels after peritoneal access.
Anesthesia and analgesia 10/2009; 109(3):760-2. · 3.08 Impact Factor
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ABSTRACT: 1) To review our experience with office-based sedation/anesthesia for children with special healthcare needs who underwent dental rehabilitation at our institution. 2) To compare the cost to comparable patients who underwent similar procedures in the operating room.
Retrospective review of patients' medical records and the sedation service database. Group CL: 114 patients who underwent office-based dental rehabilitation (135 procedures). Group OR: 23 patients who underwent dental rehabilitation under general anesthesia in the operating room for cost comparison. Outcomes: 1) Efficacy (procedure completion rate and unplanned admissions); 2) Safety (complications and interventions); 3) Comparison of mean hospital charges billed between groups.
Demographics were similar in both groups. The most common specific underlying diagnoses were autism (38%), cerebral palsy/developmental delay (18%) and ADHD (4%) in both groups. Efficacy: procedure completion rate was 98.5% (2 aborted). There was 1 (0.7%) unplanned postanesthetic care unit admission due to an adverse drug event. Safety: 2 (1.5%) patients required invasive airway control. Eighteen (13.3%) patients developed transient hypoxemia. Twenty-three (17%) patients had airway obstruction needing simple intervention, and 1 (0.7%) patient had hypotension. There were no serious complications. Cost: mean total hospital charges were considerably higher in group OR ($6,126), versus group CL ($1,277), even after adjustment for inflation and length of procedure (P<.0001).
Office-based dental rehabilitation using a pediatric sedation service model in children with special needs is efficient, and can achieve average savings of $4,849 in hospital charges per patient.
Journal of Oral and Maxillofacial Surgery 03/2007; 65(3):427-33. · 1.64 Impact Factor
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Kirk Lalwani
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ABSTRACT: Nonoperating-room anesthesia includes sedation or anesthesia for radiological imaging, cardiac catheterization, office-based surgery, and pediatric procedures or investigations, all of which have seen explosive growth over the last decade. This review discusses the factors that are driving this growth and the challenges we face as a profession to accommodate new practice paradigms.
Many departments have difficulty providing services for nonoperating-room anesthesia. A shortage of providers, insufficient reimbursement, and lack of institutional support have been identified as barriers limiting delivery of pediatric nonoperating-room sedation services. Practitioners from other specialties appear increasingly eager to provide sedation at an institutional level. The use of propofol by nonanesthesiologists is widespread, and the issue of provider credentialing has yet to be fully resolved. The shift to nonoperating-room locations will continue, driven by cost savings and convenience for patients and providers.
Nonoperating-room anesthesia will play a central role in anesthesia practice in the future. Provision of these services requires planning, personnel, and institutional resources. This should be a high priority for anesthesiology departments to ensure delivery of the highest quality of patient care in a cost-effective and organized manner.
Current Opinion in Anaesthesiology 09/2006; 19(4):430-5. · 2.21 Impact Factor
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Kirk Lalwani
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ABSTRACT: We describe a healthy neonate with abdominal distention, inadequate ventilation, and delayed extubation during anesthesia for minor surgery. Following rectal decompression and successful extubation, extreme abdominal distention recurred postoperatively after ingestion of clear fluids. We elicited a history of frequent and excessive flatus from the parents, and abdominal radiography revealed distended loops of small bowel with small lung volumes suggestive of aerophagia. The differential diagnosis of aerophagia is reviewed, the anesthetic implications discussed, and relevant literature pertaining to this condition summarized.
Pediatric Anesthesia 11/2005; 15(10):897-9. · 2.10 Impact Factor
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ABSTRACT: We describe a 12-year-old patient with severe, protracted complex regional pain syndrome type I. His pain did not respond to gabapentin, amitriptyline, physical therapy, opioids, or nonsteroidal drugs. Sympathetic or regional block was not attempted because of persistent bacteremia and severe local sepsis. His pain responded dramatically to the addition of oxcarbazepine, with rapid improvement in his symptoms and functional status. We suggest that oxcarbazepine might be a useful adjunct in the treatment of gabapentin-resistant complex regional pain syndrome type I in children and should be considered. PERSPECTIVE: Oxcarbazepine's antinociceptive effect is mediated via sodium channel inhibition in neuropathic models and by inhibition of substance P and prostaglandins in anti-inflammatory models. The efficacy of oxcarbazepine in this patient might be attributable to these mechanisms or possibly to synergism with either gabapentin or the anti-inflammatory effects produced by amitriptyline.
Journal of Pain 11/2005; 6(10):704-6. · 4.93 Impact Factor
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ABSTRACT: Information about the existence and organization of pediatric sedation services in North America is not available. We conducted a survey to collect this information from anesthesiologists at pediatric institutions and to identify factors perceived as limiting the development of sedation services.
We electronically mailed a confidential survey about pediatric sedation practice to an attending anesthesiologist involved in pediatric sedation at 116 children's hospitals in the United States and Canada. We identified the institutions using Internet resources. Electronic mailing addresses were obtained from departmental websites, society membership directories and departmental administrators. Our follow-up for nonresponders was by a second e-mail and a telephone call.
A total of 54 completed questionnaires were received, a response rate of 47%. Forty-nine (91%) were received from US hospitals, and the remainder from Canadian. Fifty percent of hospitals had a formal pediatric sedation service. Fifty-four percent utilized a 'mobile' provider model. Hospital credentialing for nonanesthesiologist providers varied between 66 and 76% for 'deep' and 'conscious' sedation, respectively. A nurse-physician provider combination was the most common, utilized in 59% of hospitals. Anesthesiologists were the sole sedation providers in 26% of institutions. Propofol was used regularly by nonanesthesiologists for sedation of nonintubated (42%) and intubated (63%) patients. Eighty-seven percent of institutions reported barriers to development of pediatric sedation services. The most common barrier was a shortage of providers, particularly anesthesiologists.
Propofol use by nonanesthesiologists is common. Addressing the shortage of providers, and allocating resources for credentialing providers will encourage further development of pediatric sedation practice.
Pediatric Anesthesia 04/2005; 15(3):209-13. · 2.10 Impact Factor
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ABSTRACT: To compare efficacy, safety, and hospital charges for common pediatric otolaryngology procedures with the use of intravenous sedation (IVS) vs general anesthesia (GA).
Retrospective chart study.
Hospital-based pediatric otolaryngology practice.
Patients younger than 18 years who underwent tympanostomy tube removal and/or patch myringoplasty with absorbable gelatin sponge, nasal ciliary biopsy, fine-needle aspiration, or other minor procedures between September 1, 1998, and August 31, 2001.
Procedures performed in 2 settings: outpatient clinic with IVS or operating room with GA.
Procedure completion rate, tympanic membrane perforation rate after ear procedures, complications, and hospital charges.
Of 103 procedures, 54 were performed with IVS and 49 with GA. Within the GA group, 32 of 49 patients had additional operations performed and were excluded from analysis of safety and hospital charges. Procedure completion rate was 100% in both groups. The most common procedure was tympanostomy tube removal with patch myringoplasty (IVS, 52 ears; GA, 42 ears). The rate of persistent tympanic membrane perforation was similar between these groups (IVS, 7 [16%] of 45 ears; GA, 5 [15%] of 33; P =.96). All complications were minor and occurred at similar rates (IVS, 10 [19%] of 54 ears; GA, 3 [18%] of 17; P =.94). These events included hypoxia, airway obstruction, and bradycardia, all of which resolved spontaneously or responded to noninvasive interventions such as oxygen or repositioning. Average hospital charges were significantly higher for the GA group (IVS, $356.22; GA, $1516.55; P<.001).
Various procedures can be performed safely, effectively, and with decreased hospital charges with the use of IVS administered by a pediatric sedation service.
Archives of Otolaryngology - Head and Neck Surgery 06/2003; 129(6):637-41. · 1.63 Impact Factor
