Setting a universal standard: Should we benchmark quality outcomes for pediatric anesthesia care?

Anesthesiology is a medical specialty well known for its work in patient safety, allowing the field to show a dramatic decrease in perioperative morbidity and mortality in both adults and children since the 1950s. Currently, anesthesia-related mortality is close to zero in healthy children, with deaths occurring primarily in children ASA physical status ≥4. Survival during anesthesia today represents the expectation and standard of care, rather than a marker of quality. Several programs and organizations have created measures to assess safety in pediatric anesthesia-yet none are universally accepted as safety metrics or bundled to evaluate specific aspects of care. In addition, collection of this nonstandardized data in individual centers requires a significant investment of resources and personnel limiting access to only large, "resource-rich" institutions. In this perspective paper, we provide an overview of the efforts made to enhance quality of care across medical specialties with a specific emphasis on pediatric anesthesiology. We discuss the need for standardization of metrics to establish targets and benchmarks for the delivery of high-quality care to children and adolescents mainly in North America. The time has come to move beyond mortality and establish universally accepted minimum outcome standards in pediatric anesthesia. We believe this will ultimately improve confidence in the quality of pediatric anesthesia care offered to children, no matter where they are receiving that care.

Ortner’s Syndrome in an Infant With Congenital Heart Disease

Cardio-vocal or Ortner’s syndrome is dysphonia or hoarseness resulting from left recurrent laryngeal nerve palsy caused by a mechanical effect on the nerve due to enlarged cardiovascular or mediastinal structures. It was first described in adults with left atrial enlargement due to mitral stenosis. To date, there are a paucity of reports regarding its occurrence in infants and children. We report hoarseness and left vocal cord paresis in an infant with a large left-to-right shunt associated with a patent ductus arteriosus. The history of Ortner’s syndrome is presented, its pathogenesis described, and previous reports of its occurrence in infants and children reviewed.

Intermittent Cerebrospinal Leak After Inadvertent Dural Puncture During Epidural Catheter Placement for Postoperative Analgesia

Regional anesthesia is being used more frequently in pediatric anesthesia practice, including the perioperative care of neonates and infants. Adverse effects may be encountered during epidural needle placement, with catheter advancement, or subsequently during infusion of local anesthetic agents. We present the rare occurrence of a persistent cerebrospinal fluid (CSF) leak following inadvertent dural puncture (wet tap) during attempted placement of an epidural catheter in a 6-year-old child. Potential adverse effects of epidural anesthesia in children are discussed, and options for treatment of a persistent CSF leak after inadvertent dural puncture are reviewed.

Ambulatory spinal anesthesia in infants ≤ six months of age: A retrospective review of outcomes and safety

PURPOSE

To review experience with outpatient spinal anesthesia (SA) from a single center in infants ≤6 months of age.

METHODS

Retrospective review of all SAs performed in the ambulatory setting in the outpatient surgery centers in infants ≤6 months of age from 2016 to 2020, focusing on success rate, adverse events, post-anesthesia care unit (PACU) times, and emergency department (ED) or urgent care (UC) returns within 7 days of the operation.

RESULTS

The study cohort included 175 SAs performed on 173 patients ≤6 months of age. One hundred and sixty-two patients (93%) were able to undergo their respective surgical procedures under SA without conversion to general anesthesia. One hundred and thirty-six patients (78%) did not require additional sedation or analgesic agents. The median time from entering the operating room until the start of surgical procedure was 17 min. One hundred and twenty-six patients (72%) were able to bypass Phase I of the PACU. One hundred and forty-seven patients (86%) were discharged in less than two hours postoperatively. Only one complication related to SA was noted. This was a patient who returned on postoperative day 2 with a possible CSF leak noted by ultrasound. After overnight hospital floor admission, he was discharged the next day after receiving intravenous fluids without further sequelae.

CONCLUSIONS

SA is a viable option for anesthetic care in infants ≤6 months of age presenting for outpatient surgery. Advantages included the ability to bypass PACU Phase I and facilitation of hospital discharge.

LEVEL OF EVIDENCE

IV. Retrospective cohort treatment study.

Racial disparities in postoperative morbidity and mortality among high-risk pediatric surgical patients

STUDY OBJECTIVE

With increasing improvement in perioperative care, post-surgical complication and mortality rates have continued to decline in the United States. Nonetheless, not all racial groups have benefitted equally from this transformative improvement in postoperative outcomes. We tested the hypothesis that among a cohort of "sick" (ASA physical status 4 or 5) Black and White children, there would be no systematic difference in the incidence of postoperative morbidity and mortality.

DESIGN

Retrospective cohort study.

SETTING

Institutions participating in the National Surgical Quality Improvement Program-Pediatric (2012-2019).

PATIENTS

Black and White children who underwent inpatient operations and were assigned ASA physical status 4 or 5.

MEASUREMENTS

risk adjusted odds ratios for 30-day postoperative mortality and complications using multivariable logistic regression models, controlling for various baseline covariates.

MAIN RESULTS

There were 16,097 children included in the analytic cohort (77.0% White and 23.0% Black). After adjusting for baseline covariates, Black children were estimated to be 20% more likely than their White counterparts to die within 30 days after surgery (9.3% vs. 7.2%, adjusted-OR: 1.20, 95% CI: 1.05-1.38, P = 0.007). Black children were also more likely to develop pulmonary complications compared to their White peers (52.1% vs. 44.6%, adjusted-OR: 1.13, 95%CI: 1.04, 1.23, P = 0.005). Being Black also conferred an estimated 28% relative greater odds of developing cardiovascular complications (4.6% vs. 3.3%, 95%CI: 1.06, 1.54, P = 0.010). Finally, being Black conferred an estimated 33% relative greater odds of requiring an extended LOS compared to Whites (50.7% vs. 38.7%, adjusted-OR: 1.33, 95% CI: 1.22-1.46, P < 0.001).

CONCLUSION

In this cohort of children with high ASA physical status, Black children compared to their White peers experienced significantly higher rates of 30-day postoperative morbidity and mortality. These findings suggest that racial differences in postoperative outcomes among the sickest pediatric surgical patients may not be entirely explained by preoperative health status.

Noninvasive Blood Pressure Measurement Using the NICCI Monitor in Adolescents During Intraoperative Anesthetic Care

Background

Methods

Results

Conclusions

Role of sugammadex in the treatment of anaphylaxis due to rocuronium in children: Extrapolation from adult and animal reports

Allergic reactions are generalized hypersensitivity processes triggered by different antigenic stimuli, resulting in the end effect of mast cell degranulation and adverse physiologic effects. During the perioperative period, the most commonly identified agents include antibiotics, neuromuscular blocking agents (rocuronium and succinylcholine), chlorhexidine, and iodinated dyes for radiologic imaging. Sugammadex is a novel agent for the reversal of neuromuscular blockade achieved with rocuronium or vecuronium. Its unique mechanism of action, whereby it encapsulates and forms a one-to-one complex with rocuronium, has led to its anecdotal use as an adjunct in the treatment of anaphylactic and anaphylactoid reactions following rocuronium. The current manuscript discusses the potential use of sugammadex in the treatment of allergic reactions following the administration of rocuronium, reviews previous anecdotal reports of its use in these scenarios, and provides recommendations for future care.

Association of Severe Obesity and Chronic Obstructive Pulmonary Disease With Pneumonia Following Non-Cardiac Surgery

Background

Pneumonia is the third most common surgical complication after urinary tract infection and wound infections. In addition to increased mortality, patients who develop postoperative pneumonia have a higher risk of prolonged hospital stay, intensive care unit (ICU) admissions, and higher healthcare costs. Obesity and chronic obstructive pulmonary disease (COPD) are both independent risk factors for the development and severity of postoperative pneumonia, although the combined effect of these comorbidities is unknown. Therefore, we evaluated whether the combination of severe obesity and COPD is associated with an increased risk of postoperative pneumonia.

Methods

We performed a multicenter retrospective cohort study of 365,273 patients aged 18 - 64 years who were either severely obese (body mass index (BMI) ≥ 40 kg/m²) or normal-weight (BMI between 18.6 and 24.9 kg/m²) and underwent general surgery, orthopedic surgery, neurosurgery, otolaryngology surgery, urology surgery, and vascular surgery in the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) participating hospitals from 2014 to 2018. We evaluated the combined effect of COPD and severe obesity on the risk for postoperative pneumonia, unplanned tracheal reintubation, and extended length of stay.

Results

The co-occurrence of severe obesity and COPD appeared to have a protective effect on the risk of postoperative pneumonia. In the presence of COPD, patients with severe obesity were 14% less likely to develop pneumonia compared to their normal-weight counterparts (2.9% vs. 4.4%; adjusted relative risk (RR): 0.76; 95% confidence interval (CI): 0.60, 0.95). In addition, in the presence of COPD, severe obesity conferred a lower risk for requiring an extended length of stay (37.6% vs. 47.9%; adjusted RR: 0.83; 95% CI: 0.78, 0.89).

Conclusions

Counterintuitively, the co-occurrence of severe obesity with COPD appeared to buffer the negative impact of COPD on postoperative pneumonia, unplanned tracheal reintubation, and prolonged hospital stay after noncardiac surgery. These findings are consistent with the obesity paradox and warrant further investigations.

Characterization of the Difficult Peripheral IV in the Perioperative Setting: A Prospective, Observational Study of Intravenous Access for Pediatric Patients Undergoing Anesthesia

Background

Various criteria exist for defining difficult intravenous access (DIVA) in infants and children. The current study evaluated the factors associated with DIVA in a prospective cohort of over 1000 infants and children presenting for anesthetic care.

Methods

This was a prospective, observational study of patients aged 0 to 18 years undergoing elective surgical or radiologic procedures under general anesthesia. Prior to the initial attempt at peripheral intravenous (PIV) cannulation, the anticipated difficulty of PIV catheter placement was determined by the provider using a visual analogue scale (VAS) from 1 to 10. The number of attempts was recorded as well as the time required to achieve PIV access. DIVA was defined as requiring three or more attempts. After successful cannulation, the actual difficulty of the PIV placement was assessed by the provider and recorded using the same VAS. Patient characteristics, including age, race, body mass index (BMI), American Society of Anesthesiologists (ASA) physical classification, and history of difficult PIV placement, were evaluated as covariates.

Results

In our cohort of 1002 pediatric patients, 78% of patients were successfully cannulated in a single attempt and 91% of patients were successfully cannulated in two or fewer attempts. Factors associated with requiring three or more PIV attempts included younger age (OR 8.73; 95% CI: 3.38, 22.6 for age <1 year and OR 4.93; 95% CI: 2.05, 11.8 for age 1-3 years), higher ASA physical classification (OR 1.95; 95% CI: 1.10, 3.46 for ASA II), and prior history of difficult PIV placement (OR 3.46; 95% CI: 1.70, 7.08). BMI, racial category or gender were not independent predictors of DIVA.

Conclusion

We found that approximately 9% of patients required three or more attempts at IV placement in the operating room. Patients that required multiple PIV attempts were more likely to be younger, have a higher ASA classification or a history of difficult PIV placement.

Morbidity and mortality following noncardiac surgical procedures among children with autosomal trisomy

BACKGROUND

Trisomy 13 (T13), trisomy 18 (T18), and trisomy 21 (T21) are the most common autosomal trisomies. One unifying feature of all trisomies is their association with major congenital malformations, which often require life-prolonging surgical procedures. Few studies, mostly among cardiac surgery patients, have examined the outcome of those who undergo surgical procedures. We examined the differences in postsurgical outcomes between the trisomy groups.

METHOD

Using the National Surgical Quality Improvement Program dataset, we identified children (<18 years of age) with T13, T18, or T21 who underwent noncardiac surgery (2012-2018). We estimated the incidence of mortality and indicator of resource utilization (unplanned reoperation, unplanned tracheal reintubation, and extended length of hospital stay).

RESULTS

Of the 349 158 inpatient surgical cases during the study period, we identified 4202 children with one of the autosomal trisomies of interest (T13: 152; T18: 335; and T21: 3715). The rates of postoperative mortality were substantially higher for T18 and T13 than T21 and nontrisomy children (T18 vs. T21: 11.1% vs. 1.6%, adjusted odds ratio: 5.01, 95%CI: 2.89,8.70, p < .01), (T13 vs. T21: 8.1% vs. 1.6%, adjusted odds ratio: 2.86, 95%CI: 1.25,6.54, p = .01). Children with T18 had the highest rates of extended length of stay (62.7%) and prolonged mechanical ventilation (32.5%). T18 and T13 neonates had the highest surgical mortality burden (T13: 26.5%, T18: 31.8%, and T21: 2.8%).

CONCLUSION

Approximately, one-third of T18 and T13 neonates, who had surgery, died, underscoring the lethality of these trisomies and the need for a comprehensive preoperative ethical discussion with families of these children.

Ultrasound assessment of the inferior vena cava in children: A comparison of sub-xiphoid and right lateral coronal views

OBJECTIVES

The inferior vena cava collapsibility index (IVCCI) has been used to assess the respiratory variation of the inferior vena cava (IVC) diameter and hence intravascular volume. The sub-xiphoid view (SXV) is the standard view to evaluate the IVC. The right lateral transabdominal view (RLV) has been shown in adults to be an alternative view to evaluate the IVC when the SXV is not feasible. The aim of the study was to compare IVC dimensions from these two views and thus determine whether the RLV view can be used instead of the SXV in pediatric patients.

METHODS

We conducted a single-center prospective observational crossover study. Study subjects were ASA physical status 1-2 children, 1-12 years of age scheduled for elective surgery under general anesthesia. Anesthesia was maintained by mask with spontaneous ventilation with end-tidal sevoflurane at 2%-5% after the induction of anesthesia. IVCCI was measured using M-mode in both the SXV and RLV.

RESULTS

The study cohort included 50 children with a mean age of 5.1 years. The median value for the IVCCI-sx was 0.45 (IQR: 0.28-0.70) while the IVCCI-rl was 0.30 (0.19-0.5). The mean difference between the two groups was 0.12 (95% CI: 0.177-0.066, p < .001, two-tailed paired t-test). Spearman's rank correlation coefficient was 0.66. The univariate linear regression model was IVCCIsx = 0.21 + 0.77 × IVCCIrl.

CONCLUSIONS

IVCCIrl was lower than IVCCIsx. IVCCI measured from the right lateral view tended to overestimate the patient's fluid-responsiveness and therefore these two values are not interchangeable.

An Evaluation of the NICCI Monitor in Providing Continuous, Noninvasive Blood Pressure Readings in Children During Intraoperative Anesthetic Care

Background

In specific clinical scenarios or with patient comorbid conditions, continuous blood pressure (BP) monitoring may be required as it can be expected to provide superior physiologic monitoring to intermittent techniques. However, continuous BP monitoring requires an arterial cannula (AC) placement, which may be time-consuming, technically challenging, or associated with adverse events. Various noninvasive BP devices have been developed which provide a continuous BP reading. The current study evaluates the accuracy of a novel continuous BP device, the NICCI monitor (NM), in pediatric patients weighing 10 - 40 kg.

Methods

The study cohort included pediatric patients weighing between 10 and 40 kg, scheduled for surgery for which placement of an AC was planned. Systolic (SBP), diastolic (DBP), and mean arterial (MAP) blood pressure readings were captured from the AC and the NM every second during anesthetic care.

Results

The study cohort included 24 pediatric patients undergoing major orthopedic, cardiac, and neurosurgical procedures. A total of 146,562 pairs of SBP, DBP, and MAP values from the AC and NC were analyzed. The absolute difference for the NM and the AC’s SBP, DBP, and MAP values were 11 ± 9, 10 ± 7, and 10 ± 7 mm Hg, respectively. The difference between the BP values from the NM and the AC was ≤ 10 mm Hg for 57% of the SBP readings, 60% of the DBP readings, and 56% of the MAP readings. The bias was 4, 4, and 6 mm Hg for the SBP, DBP, and MAP, respectively.

Conclusions

Although there were some technical limitations given patient size, potentially resulting in variation in accuracy, the NM provided a continuous noninvasive BP measurement within clinically useful limits during a significant portion of anesthetic care compared to values obtained from an AC. Ongoing modification of the technology to improve its application in pediatric patients will likely increase its accuracy.

Intraoperative Anaphylaxis Following Injection of a Bleomycin-Gelatin Solution for Sclerotherapy

During the perioperative period, the most commonly identified agents that are responsible for acute allergic reactions include antibiotics, neuromuscular blocking agents, opioids, chlorhexidine, and iodinated dyes for radiologic imaging. However, whenever an allergic reaction is suspected, all of the agents to which the patient has been exposed must be considered. Although bleomycin is utilized as the primary agent for sclerotherapy in the treatment of vascular malformations, other substances such as Surgiflo^® may be added to the bleomycin solution to increase its efficacy and promote thrombosis of the smaller vessels. These products are derived from animal collagen and contain gelatin which may lead to an allergic reaction. We present an 11-year-old girl undergoing sclerotherapy treatment of an extensive left lower extremity venous malformation who subsequently developed perioperative hemodynamic instability requiring intervention after receiving an injection of a bleomycin and Surgiflo^® solution. Further investigation identified gelatin in the Surgiflo^® as the causative agent of the allergic event. Previous reports of such reactions are reviewed and the perioperative care and treatment of patients who experience anaphylaxis is addressed.

Ultrasound-Guided Placement of a Hemodialysis Catheter into the Distal Femoral Vein in a Patient with Multiple Catheters: A Case Report

Cardiac surgery-associated acute kidney injury may require postoperative renal replacement therapy. Although the right internal jugular vein and femoral veins are generally the preferred insertion sites for the hemodialysis catheter for continuous renal replacement therapy, the presence of other indwelling catheters or prior thrombotic events from previous catheters may preclude use of these sites. We present a case in which the hemodialysis catheter was inserted into the distal femoral vein using point-of-care ultrasound in a patient with multiple catheter insertions after coronary artery bypass grafting. Although the tip of the dialysis catheter was more distal than the classic femoral approach, renal replacement therapy was performed without problems. Moreover, it was easier for the nurses to keep the insertion site clean and to change the patient’s position.

Association of Race and Family Socioeconomic Status With Pediatric Postoperative Mortality

IMPORTANCE

Racial disparities in postoperative outcomes have remained difficult to eliminate. It is commonly understood that socioeconomic status (SES) is an important factor associated with excess risk of postoperative morbidity and death. To date, comparable data exploring the association of family SES with pediatric postoperative mortality are unavailable, and it is unknown whether the advantage provided by higher income status is equitable across racial groups.

OBJECTIVE

To assess whether increasing family SES is associated with lower pediatric postoperative mortality and, if so, whether this association is equitable among Black and White children.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study used data from 51 freestanding pediatric tertiary care hospitals across the US that reported to the Children's Hospital Association Pediatric Health Information System. The study included 1 378 111 Black and White children younger than 18 years who underwent inpatient surgical procedures between January 1, 2004, and December 31, 2020.

EXPOSURES

The exposures of interest were race (Black and White) and parental income quartile (used as a proxy for SES and measured by median income quartile of the zip code of residence). Race was self-reported by parents or guardians at admission or assessed by the registration team consistent with each hospital's policy and state legislation.

MAIN OUTCOMES AND MEASURES

The primary outcome was risk-adjusted in-hospital mortality rates by race and parental income quartile controlled for baseline covariates. To evaluate whether belonging to the highest income quartile modified the association between race and postoperative mortality, multiplicative and additive interactions were examined.

RESULTS

Among 1 378 111 children (773 364 [56.1%] male; mean [SD] age, 7 [6] years) who received inpatient surgical procedures during the study period, 248 464 children (18.0%) were Black, and 1 129 647 children (82.0%) were White; 211 127 children (15.3%) were Hispanic, and 825 477 (59.9%) were non-Hispanic. Only 49 541 Black children (20.3%) belonged to the highest income quartile compared with 482 758 White children (43.0%). The overall mortality rate was 1.2%, and mortality rates decreased as income quartile increased (1.4% in quartile 1 [lowest income], 1.3% in quartile 2, 1.0% in quartile 3, and 0.9% in quartile 4 [highest income]; P < .001). Among those belonging to the 3 lowest income quartiles, Black children had 33% higher odds of postoperative death compared with White children (adjusted odds ratio, 1.33; 95% CI, 1.27-1.39; P < .001). This racial disparity gap persisted among children belonging to the highest income quartile (adjusted odds ratio, 1.39; 95% CI, 1.25-1.54; P < .001). Postoperative mortality rates among Black children in the highest income quartile (1.30%; 95% CI, 1.19%-1.42%) were comparable to those of White children in the lowest income quartile (1.20%; 95% CI, 1.16%-1.25%). The interaction between Black race and income was not statistically significant on either the multiplicative scale (β for interaction = 1.04; 95% CI, 0.93-1.17; P = .45) or the additive scale (relative excess risk due to interaction = 0.01; 95% CI, -0.11 to 0.11; P > .99), suggesting no reduction in the disparity gap across increasing income levels.

CONCLUSIONS AND RELEVANCE

In this cohort study, increasing SES was associated with lower pediatric postoperative mortality. However, postoperative mortality rates were significantly higher among Black children in the highest SES category compared with White children in the same category, and mortality rates among Black children in the highest SES category were comparable to those of White children in the lowest SES category. These findings suggest that increasing family SES did not provide equitable advantage to Black compared with White children, and interventions that target socioeconomic inequities alone may not fully address persistent racial disparities in pediatric postoperative mortality.

Prothrombin Complex Concentrates to Treat Coagulation Disturbances: An Overview With a Focus on Use in Infants and Children

Various factors may lead to coagulation disturbances following cardiopulmonary bypass and surgery for congenital heart disease. In addition to the risks associated with the administration of allogeneic blood products, persistent disturbances in coagulation function and ongoing bleeding may lead to prolonged surgical times, hemodynamic alterations, intracranial hemorrhage, and even mortality. In most clinical scenarios, coagulation disturbances are treated by targeted blood product therapy including fresh frozen plasma, platelet transfusions, or the administration of cryoprecipitate. When routine blood product therapy fails, coagulation adjuncts such as activated recombinant factor VII or prothrombin complex concentrates (PCCs) may be an option to rapidly replenish depleted coagulation factors and correct coagulation disturbances. The PCC formulations including three-factor PCC, four-factor PCC, and factor eight-inhibitor bypass activator (FEIBA) have been used mainly in the adult population with sporadic case series and anecdotal reports in the pediatric population. The following manuscript discusses the various PCC products available for clinical use, reviews previous reports of their use in infants and children with an emphasis on their role following surgery for congenital heart disease, and outlines their potential role in these clinical scenarios.

Craniotomy Complicated by Severe Metabolic Acidosis Requiring Massive Transfusion in an Infant on Ketogenic Diet Therapy for Intractable Epilepsy

The induction of a ketotic state through dietary manipulation, known as the ketogenic diet (KD), is an alternative or supplementary treatment to drug-resistant epilepsy. By sustaining a ketogenic state, the KD results in various biological adaptations which contribute to its success as an anti-seizure therapy. While the induction and maintenance of ketosis generally results in only a low-grade metabolic acidosis, various exogenous stresses such as surgery and anesthetic care may disrupt homeostasis resulting in exaggerated ketosis and severe metabolic acidosis. Metabolic acidosis may have significant effects on various physiologic functions including cardiovascular performance, coagulation function, and electrolyte balance. We present a 7-month-old patient receiving a KD who presented for craniotomy and resection of an epileptogenic focus. During intraoperative care, progressive acidosis and hyperchloremia were noted with ongoing tissue fragility and hyperemia, parenchymal friability, and coagulopathy. Though the acidosis was temporarily blunted by administration of sodium bicarbonate and a change to sodium acetate containing fluids, ultimately poor hemostasis resulted requiring significant blood product transfusion. The metabolic effects of the KD are reviewed with emphasis on acid-base disturbances and impact on coagulation function.

Anesthetic Care of a Child Harboring the KCNH2 Gene

Epilepsy is a heterogeneous group of disorders characterized by recurrent and generally unprovoked seizures. Genetic mutations may play an important role in the etiology of epilepsy. Over the past few years, genetic mutations in various genes have been identified in patients with epilepsy. One of the more common mutations responsible for seizures involves the KCNH2 gene. The KCNH2 gene encodes the Kv11.1 protein, which involves the pore-forming subunit of a rapidly activating-delayed rectifier potassium channel. This channel plays an essential role in phases 2 and 3 of the cardiac action potential involving cardiac repolarization as well as being expressed in various parts of the central nervous system where it regulates neuronal function. As such, patients presenting with this gene mutation may be at risk not only for seizures, but also abnormalities in cardiac repolarization leading to lethal arrhythmias. We present an 11-year-old girl who required general anesthesia for magnetic resonance imaging as part of her evaluation for non-convulsive status epilepticus. An epilepsy gene panel evaluated revealed a KCNH2 gene mutation. End-organ involvement of KCNH2 gene mutations is presented, previous reports of anesthetic care for these patients are reviewed, and options for anesthetic care are discussed.

Postoperative Apnea in a Neonate Following an Epidural Bolus Dose Through a High Thoracic Epidural Catheter

Regional anesthesia is being used more frequently in the practice of pediatric anesthesia including neonates and infants. While generally safe and effective, adverse effects may occur related to catheter placement or its subsequent use. We present the rare occurrence of high motor blockade with apnea following the administration of a bolus dose of the local anesthetic agent, 2-chloroprocaine, into the thoracic epidural catheter of a 4-week-old, 2.2-kg former premature neonate. The patient had an epidural catheter that had been threaded from the caudal space to the thoracic level to provide analgesia following an abdominal surgical procedure. Subsequent investigation with a standard chest radiograph revealed a higher than intended placement of the epidural catheter (T4 instead of T8-10) which resulted in a transient high motor blockade with apnea. The epidural infusion was discontinued and assisted ventilation was provided by bag-valve-mask ventilation. Immediately, the heart rate and oxygen saturation returned to baseline values, and within 5 min the patient became more active, spontaneous ventilation resumed, and a strong cry was noted. The epidural catheter was removed and the remainder of the postoperative course was unremarkable. Adverse effects of epidural anesthesia in neonates are discussed and options for identifying the correct placement of a thoracic epidural catheter are reviewed.

Hemodynamic and Respiratory Effects of Regadenoson During Radiologic Imaging in Infants and Children

Background

Myocardial perfusion imaging using radionuclides is a well-validated, noninvasive method to aid in the diagnosis of patients with suspected or known myocardial ischemia. To increase the sensitivity of the technique, pharmacologic agents which induce coronary vasodilatation are administered. Regadenoson is a novel selective A2A receptor agonist that has similar efficacy to adenosine for cardiac magnetic resonance imaging (MRI) with a more favorable adverse effect profile and is the most widely used pharmacologic stress agent. While widely used in adults, there is limited experience with it in pediatrics, particularly young children.

Methods

The current study retrospectively reviews our experience with stress cardiac MRI using regadenoson in children requiring general anesthesia. The study cohort included eight patients, all male, ranging in age from 2 to 6.2 years (mean age of 4.2 years) and in weight from 10 to 30.5 kg (mean weight of 18.5 kg). All patients received general anesthesia with endotracheal intubation and a volatile anesthetic agent.

Results

Heart rate 1 min prior to regadenoson was 99 ± 19.2 (mean ± standard deviation (SD)) beats per minute. Peak heart rate was achieved at an average of 4 min post regadenoson administration with a mean heart rate of 122 ± 15 beats per minute. The average of the mean arterial pressure 1 min prior to regadenoson was 53.4 ± 5.2 mm Hg. Mean arterial pressure nadir was noted at 6 min post regadenoson with a value of 44.1 ± 6.3 mm Hg. Blood pressure support with phenylephrine was required in four of the eight (50%) of patients. No adverse respiratory events were noted. Only one of the eight (13%) patients had a perfusion defect but had preserved ventricular function and recovered without incident.

Conclusions

Use of regadenoson in pediatric patients requiring general anesthesia is safe and feasible.

High-Dose Gabapentin and Amitriptyline in the Treatment of Refractory Chemotherapy-Induced Peripheral Neuropathy in a Toddler

Pharmacologic management of chemotherapy-induced peripheral neuropathy (CIPN) in pediatric patients remains a challenge. Without effective treatment to control pain from CIPN in children, reduction or discontinuation of life-saving chemotherapeutic medications may be required. Various combinations of medications are available, but none have been thoroughly evaluated for their effectiveness in managing CIPN in the pediatric population. We present the clinical management of severe CIPN in a 3-year-old child with pre-B acute lymphoblastic lymphoma that was refractory to a regiment that included high-dose gabapentin and opioids. Therapy was subsequently adjusted to include amitriptyline, eliminating the need for opioids with complete resolution of symptoms. The potential combination pharmacotherapies for pediatric CIPN are discussed and mechanisms accounting for inadequate response with monotherapy are presented.

Point-of-care ultrasound to confirm endotracheal tube cuff position in relationship to the cricoid in the pediatric population

BACKGROUND

Anatomically, the subglottic area and the cricoid ring are the narrowest portions of the larynx. To limit the potential for damage related to mucosal pressure injuries from the presence of an endotracheal tube, the cuff should be placed below the cricoid in children. Previously, no clinical or imaging method has been used in real time to determine the exact location of the endotracheal tube cuff after endotracheal intubation. Point-of-care ultrasound may provide an option as a safe and rapid means of visualizing the endotracheal tube cuff and its relationship to the cricoid ring thereby achieving ideal endotracheal tube cuff positioning-below the cricoid.

METHODS

In this prospective, nonrandomized trial, point-of-care ultrasound was used following endotracheal intubation in children to evaluate the position of the endotracheal tube cuff in relationship to the cricoid and tracheal rings. After anesthesia was induced and the trachea was intubated, the endotracheal tube cuff and its position in relation to the cricoid and tracheal rings were identified in the longitudinal plane using point-of-care ultrasound. With the patient's neck in a neutral position, the level of the proximal (cephalad) margin of the saline-filled cuff of the endotracheal tube was identified and recorded in relationship to the cricoid and tracheal rings. The ideal position is defined as the cephalad margin of the endotracheal tube cuff below the level of the cricoid.

RESULTS

The study cohort included 80 patients, ranging in age from 1 to 78 months. In all patients, the cuff of the ETT, cricoid, and tracheal rings were identified. The cephalad end of the endotracheal tube cuff was found at the level of the cricoid in 16.3% of patients, at the first tracheal ring in 27.5% of patients, at the second tracheal ring in 23.8% of patients, at the third tracheal ring in 17.5% of patients, and at below the fourth tracheal ring in 15% of patients. Initial endotracheal tube cuff position had no significant association with age, height, weight, endotracheal tube size, and endotracheal tube type.

CONCLUSION

Point-of-care ultrasound provides a rapid and effective means of identifying the position of the endotracheal tube cuff in relationship to the cricoid ring. The technique may have applications in the perioperative arena, emergency departments, and intensive care units.

Incidence and Causes of Adverse Events in Diagnostic Radiological Studies Requiring Anesthesia in the Wake-Up Safe Registry

OBJECTIVES

General anesthesia or sedation can facilitate the completion of diagnostic radiological studies in children. We evaluated the incidence, predictors, and causes of adverse events (AEs) when general anesthesia is provided for diagnostic radiological imaging.

METHODS

Deidentified data from 24 pediatric tertiary care hospitals participating in the Wake-Up Safe registry during 2010-2015 were obtained for analysis. Children 18 years or younger receiving general anesthesia for radiological procedures were identified using Current Procedural Terminology codes, and reported AEs were analyzed if they were associated with anesthetic care at magnetic resonance imaging or computed tomography locations. Logistic regression was used to determine predictors of AE occurrence in cases with complete covariate data.

RESULTS

We identified 175,486 anesthetics for diagnostic radiological exams, compared with 83 AEs in magnetic resonance imaging or computed tomography locations (AE incidence of 0.05%). In multivariable analysis, AEs were more likely among patients with American Society of Anesthesiologists physical status IV compared with American Society of Anesthesiologists physical status I patients (adjusted odds ratio, 8.9; 95% confidence interval, 2.8-28.0; P < 0.001). Twenty-three AEs resulted in harm to the patient, whereas 32 AEs required unplanned hospital or intensive care unit admission. Anesthetic complications or issues were the most common cause of AEs (n = 52).

CONCLUSIONS

Anesthesia provided for pediatric radiological studies is very safe and with an overall low AE incidence. The contribution of anesthetic complications to reported AEs suggests opportunities for further process improvement in this setting.

Anesthesia for thoracic surgery in infants and children

The management of infants and children presenting for thoracic surgery poses a variety of challenges for anesthesiologists. A thorough understanding of the implications of developmental changes in cardiopulmonary anatomy and physiology, associated comorbid conditions, and the proposed surgical intervention is essential in order to provide safe and effective clinical care. This narrative review discusses the perioperative anesthetic management of pediatric patients undergoing noncardiac thoracic surgery, beginning with the preoperative assessment. The considerations for the implementation and management of one-lung ventilation (OLV) will be reviewed, and as will the anesthetic implications of different surgical procedures including bronchoscopy, mediastinoscopy, thoracotomy, and thoracoscopy. We will also discuss pediatric-specific disease processes presenting in neonates, infants, and children, with an emphasis on those with unique impact on anesthetic management.

The Anesthesiologist's Perspective and Experience in Global Congenital Cardiac Surgery: Results of a Survey of the Congenital Cardiac Anesthesia Society Membership

Anesthesiologists are important components of volunteer teams which perform congenital cardiac surgery in low-resource settings throughout the world, but limited data exist to characterize the nature and breadth of their work. A survey of Congenital Cardiac Anesthesia Society (CCAS) members was conducted with the objective of understanding the type of voluntary care being provided, its geographic reach, the frequency of volunteer activities, and factors which may encourage or limit anesthesiologists' involvement in this work. The survey was completed by 108 participants. Respondents reported a total of 115 volunteer trips during the study period, including work in 41 countries on 5 continents. Frequent motivating factors to begin volunteering included invitations from charitable groups, encouragement from senior colleagues, and direct connections to individual locations. Discouraging factors included familial responsibilities, the need to use vacation time, and a lack of support from home institutions. The year 2020 saw a marked decrease in reported volunteer activity, and respondents reported multiple pandemic-related factors which might discourage future volunteer activities. The results of this study demonstrate the global reach of anesthesiologists in providing care for children having cardiac surgery. It also offers insights into the challenges faced by interested individuals, many of which are related to a lack of institutional support. These challenges have only mounted under the COVID-pandemic, leading to a dramatic downturn in volunteer activities. Finally, the survey reinforces the need for better coordination of volunteer activities to optimize clinical impact.

Topical Nasal Decongestant Oxymetazoline: Safety Considerations for Perioperative Pediatric Use

The over-the-counter nasal decongestant oxymetazoline (eg, Afrin) is used in the pediatric population for a variety of conditions in the operating room setting. Given its vasoconstrictive properties, it can have cardiovascular adverse effects when systemically absorbed. There have been several reports of cardiac and respiratory complications related to use of oxymetazoline in the pediatric population. Current US Food and Drug Administration approval for oxymetazoline is for patients ≥6 years of age, but medical professionals may elect to use it short-term and off label for younger children in particular clinical scenarios in which the potential benefit may outweigh risks (eg, active bleeding, acute respiratory distress from nasal obstruction, acute complicated sinusitis, improved surgical visualization, nasal decongestion for scope examination, other conditions, etc). To date, there have not been adequate pediatric pharmacokinetic studies of oxymetazoline, so caution should be exercised with both the quantity of dosing and the technique of administration. In the urgent care setting, emergency department, or inpatient setting, to avoid excessive administration of the medication, medical professionals should use the spray bottle in an upright position with the child upright. In addition, in the operating room setting, both monitoring the quantity used and effective communication between the surgeon and anesthesia team are important. Further studies are needed to understand the systemic absorption and effects in children in both nonsurgical and surgical nasal use of oxymetazoline.

Short Communication: Lumbar Plexus Block versus Suprainguinal Fascia Iliaca Block to Provide Analgesia Following Hip and Femur Surgery in Pediatric-Aged Patients - An Analysis of a Case Series

Introduction

For surgical procedures involving the hip and femur, various regional anesthetic techniques may be used to provide analgesia. Although there has been an increase in the use of lumbar plexus block (LPB), the technique may be time consuming and associated with complications. Suprainguinal fascia iliaca compartment block (FICB) is a potentially easier and safer alternative. The current study prospectively compares LPB with suprainguinal FICB.

Methods

This prospective, double-blinded, randomized, study included patients undergoing elective orthopedic procedures of the hip and/or femur. All study patients received general anesthesia with randomization to either an LPB or suprainguinal FICB using 0.5% ropivacaine with epinephrine and dexamethasone. Postoperative pain control was achieved with intravenous hydromorphone delivered by patient-controlled analgesia with scheduled acetaminophen and ketorolac. Outcome data included time to perform the block, perioperative opioid consumption, postoperative pain scores (VAS) and hospital length of stay.

Results

The study cohort included 15 patients between the ages of 7 and 16 years (LPB N = 7, FICB N = 8). The median block time was 6 minutes (IQR: 4.11) for the LPB group and 3 minutes (IQR: 3.6) for the FICB group (p = 0.107). Median postoperative pain scores were 4 (IQR: 0.6) for the LPB group and 2 (IQR: 0.5) for the FICB group (p = 0.032). There were no differences in the intraoperative or postoperative opioid and NSAID use between the two groups.

Discussion

The suprainguinal FICB provides analgesia that is at least as effective as a LPB following hip and femur surgery. Time to perform the block was shorter with the FICB due to the supine patient position and limited needle trajectory. Although we noted no adverse effects, the superficial needle trajectory of the FICB offers a less invasive approach and the potential for decreased risks of adverse effects.

Perioperative Care of a Patient With Waardenburg Syndrome

Waardenburg syndrome is a genetic disorder, resulting in defective control of the division and migration of neural crest cells including the melanocyte lineage during embryonic development. Primary involvement of melanocytes results in the characteristic phenotypic involvement including a white forelock, vitiligo, and heterochromia. Involvement of the organ of Corti leads to sensorineural hearing loss. Involvement of the craniofacial mesenchyme results in abnormal facial features, airway abnormality, and upper limb involvement malformations. Given the potential for end-organ involvement, surgical intervention may be required. Specific concerns during anesthetic care include the potential for difficulties with endotracheal intubation, tracheal involvement, impairment of communication related to deafness, and associated congenital heart disease.

Endotracheal tube cuff position in relation to the cricoid in children: A retrospective computed tomography-based analysis

Background:

The use of cuffed endotracheal tubes (ETT) has become the standard of care in pediatric practice. The rationale for the use of a cuffed ETT is to minimize pressure around the cricoid while providing an effective airway seal. However, safe care requires that the cuff lie distal to the cricoid ring following endotracheal intubation. The current study demonstrates the capability of computed tomography (CT) imaging in identifying the position of the cuff of the ETT in intubated patients.

Methods:

In this retrospective study, the ETT cuff position was examined on the sagittal plane images of neck and chest CT scans of 44 children. The position of the proximal and the distal aspect of the ETT cuff inside the trachea was recorded in relation to the vertebral levels. The vertebral levels were used to estimate the location of the cricoid ring and its relationship to the cuff.

Results:

The vertebrae were used as the primary landmarks to define the position of the cricoid and its relationship to the cuff of the ETT. Correlating vertebral levels with the cricoid for different age groups, the proximal (cephalad) edge of the ETT cuff was below the cricoid in 41 of 44 patients (93%). The ETT cuff was deep in 6 patients, below the 1^st thoracic vertebra, with 2 ETTs in the right mainstem bronchus.

Conclusion:

This is the first study demonstrating that the cuff of the ETT and its position in the trachea can be identified on CT imaging in children. The ETT cuff was below the level of the cricoid in the majority of patients irrespective of the patient's age as well as the size, make, and type of ETT.

Economic Trends of Racial Disparities in Pediatric Postappendectomy Complications

BACKGROUND

Despite unparalleled advances in perioperative medicine, surgical outcomes remain poor for racial minority patients relative to their white counterparts. Little is known about the excess costs to the health care system related to these disparities.

METHODS

We performed a retrospective analysis of data from the Nationwide Inpatient Sample between 2001 and 2018. We included children younger than 18 years admitted with appendicitis who underwent an appendectomy during their hospital stay. We examined the inflation-adjusted hospital costs attributable to the racial disparities in surgical complications and perforation status, focusing on differences between non-Hispanic white patients and non-Hispanic Black patients.

RESULTS

We included 100 639 children who underwent appendectomy, of whom 89.9% were non-Hispanic white and 10.1% were non-Hispanic Black. Irrespective of perforation status at presentation, surgical complications were consistently higher for Black compared with white children, with no evidence of narrowing of the racial disparity gap over time. Black children consistently incurred higher hospital costs (median difference: $629 [95% confidence interval: $500-$758; P < .01). The total inflation-adjusted hospital costs for Black children were $518 658 984, and $59 372 044 (11.41%) represented the excess because of the racial disparities in perforation rates.

CONCLUSIONS

Although all patients had a progressive decline in post appendectomy complications, Black children consistently had higher rates of complications and perforation, imposing a significant economic burden. We provide an empirical economic argument for sustained efforts to reduce racial disparities in pediatric surgical outcomes, notwithstanding that eliminating these disparities is simply the right thing to do.

Association of Race With Postoperative Mortality Following Major Abdominopelvic Trauma in Children

BACKGROUND

The leading cause of mortality among children is trauma. Race and ethnicity are critical determinants of pediatric postsurgical outcomes, with minority children generally experiencing higher rates of postoperative morbidity and mortality than White children. This pattern of poorer outcomes for racial and/or ethnic minority children has also been demonstrated in children with head and limb traumas. While injuries to the abdomen and pelvis are not as common, they can be life-threatening. Racial and/or ethnic differences in outcomes of pediatric abdominopelvic operative traumas have not been examined. Our objective was to determine whether disparities exist in postoperative mortality among children with major abdominopelvic trauma.

MATERIALS AND METHODS

We performed a retrospective analysis of the Healthcare Cost and Utilization Project Kids' Inpatient Database for 2003, 2006, 2009, and 2012. Patients were included if they were < 18 years, sustained a major abdominopelvic injury, and underwent subsequent surgical intervention. Our primary outcome was inpatient mortality, comparing children of different race and/or ethnicity.

RESULTS

We identified a weighted cohort of 13,955 children, of whom 6765 (48.5%) were White, 3614 (25.9%) Black, and 2647 (19.0%) Hispanic. After adjusting for covariates, Black children were 94% more likely to die than their White peers (3.3% versus 1.6%, adjusted-RR:1.94, 95%CI: 1.33-2.82, P = 0.001). Hispanic children (adjusted-RR:1.99, 95%CI: 1.36-2.91, P < 0.001) and those of other race and/or ethnicity (adjusted-RR: 2.02, 95%CI:1.20-3.40, P = 0.008) were also more likely to die compared to their White peers.

CONCLUSIONS

Black and Hispanic children who require operative intervention following major abdominopelvic trauma have a higher risk of postoperative mortality compared with White children.

The Role of a Handheld Ultrasound Device to Facilitate Remote Learning for a Point-of-Care Ultrasound Certificate Program

Point-of-care ultrasound is a growing field within anesthesiology as well as several other medical and surgical specialties. The recent development of handheld ultrasound devices has the potential to expand the use or this technology by decreasing the cost and increasing accessibility for the healthcare provider. These handheld devices may be used to assist with education, training, and even direct patient care. We outline our process for using a handheld ultrasound device, the Lumify, to assist in the completion of a point-of-care ultrasound certificate program offered by the American Society of Anesthesiologists. We outline the unique advantages of this device as it relates to cost, portability, and applicability of its web-based technology compared to a traditional standalone ultrasound machine for the completion of this course.

Risk Assessment for Postoperative Pneumonia in Children Living With Neurologic Impairments

BACKGROUND

Approximately one-third of all pediatric hospital charges are attributable to the care for children living with neurologic comorbidities. These children often require various surgical procedures and may have an elevated risk of lower respiratory infections because of poor neuromuscular coordination, poor cough, uncoordinated swallowing, and poor oral hygiene. Our objective was to evaluate the risk of pneumonia in children presenting with neurologic comorbidities.

METHODS

We performed a retrospective study of children (<18 years) who underwent inpatient surgery between 2012 and 2018 in hospitals participating in the National Surgical Quality Improvement Program. Our primary outcome was the time to incident pneumonia within the 30 days after surgery.

RESULTS

We identified 349 163 children, of whom 2191 developed pneumonia (30-day cumulative incidence: 0.6%). The presence of a preoperative neurologic comorbidity conferred approximately twofold higher risk of postoperative pneumonia (hazard ratio [HR]: 1.91, 95% confidence interval [CI]: 1.73-2.11). We explored the risk of pneumonia conferred by the components of neurologic comorbidity: cerebral palsy (HR: 3.92, 95% CI: 3.38-4.56), seizure disorder (HR: 2.93, 95% CI: 2.60-3.30), neuromuscular disorder (HR: 2.63, 95% CI: 2.32-2.99). The presence of a neurologic comorbidity was associated with a longer length of hospital stay (incidence rate ratio: 1.26, 95% CI: 1.25-1.28).

CONCLUSIONS

The risk of postoperative pneumonia was almost twofold higher in children with neurologic comorbidity. The magnitude of these associations underscores the need to identify areas of research and preventive strategies to reduce the excess risk of pneumonia in children with preoperative neurologic conditions.

Intraoperative Cardiac Arrest: Immediate Treatment and Diagnostic Evaluation

Although perioperative cardiac arrest during anesthetic care in infants and children is a rare event, its consequences can be devastating. Risk factors associated with perioperative cardiac arrest include cardiac surgery, younger age, presence of comorbid conditions and emergency surgery. Although medication-related etiologies formerly predominated, the elimination of halothane from anesthetic care has resulted in a shift in etiology to hemodynamic events related to blood loss or hyperkalemia associated with the rapid administration of blood products. Rarely, cardiac arrest can be sudden and unexpected without an obvious pre-existing etiology in an otherwise apparently healthy patient. We present a 16-month-old child who experienced a sudden cardiac arrest following anesthetic induction for a routine urologic procedure. The potential etiology of cardiac arrest during anesthesia is reviewed, keys to resuscitation discussed, and an outline for the investigative work-up presented.

Sulfamethoxazole-Trimethoprim and Hyperkalemia in an Infant

Hyperkalemia is a potentially life-threatening electrolyte abnormality in both children and adults. In the setting of elevated serum potassium concentrations, cardiac conduction disturbances and cardiac arrest may occur. In the pediatric intensive care unit (PICU) setting, the differential diagnosis of hyperkalemia may be extensive including increased potassium intake or administration, increased endogenous production, decreased renal excretion, and intracellular to extracellular shifts related to changes in acid-base status. We present a 4-month-old infant who developed hyperkalemia during the recovery phase of her PICU course for respiratory failure. A thorough investigation demonstrated that the hyperkalemia was most likely the result of the commonly used antibiotic, trimethoprim-sulfamethoxazole (Bactrim^®). Potential etiologies of hyperkalemia in the PICU patient are discussed and previous reports of hyperkalemia associated with trimethoprim-sulfamethoxazole presented.

Perioperative Care of a Child With Cri Du Chat Syndrome

Cri du chat syndrome (CdCS) is a chromosomal disorder resulting from a deletion in the short arm of chromosome 5. Anatomical abnormalities of the larynx result in a distinctive high-pitched, cat-like cry for which the disorder is named. Typical findings of the syndrome involve the upper airway, cardiovascular, and central nervous system (CNS). Of particular concern during anesthetic care is the potential for airway abnormalities leading to difficulties with endotracheal intubation as well as the presence of congenital heart disease (CHD). We present a 15-month-old child with CdCS who required anesthetic care during direct laryngoscopy and supraglottoplasty. The perioperative concerns of such patients are discussed, and previous reports of anesthetic care reviewed.

Combined Spinal-Epidural Anesthesia for Subtotal Colectomy in a Patient With Hamman Syndrome and Epidural Pneumatosis: A Case Report

It remains unclear how epidural pneumatosis affects the efficacy of neuraxial anesthesia. Spontaneous pneumomediastinum (Hamman syndrome) with epidural pneumatosis is rare. Regardless of its etiology, general anesthesia with positive pressure ventilation in patients with pneumomediastinum carries the risk of pneumothorax. We present a 19-year-old patient with Hamman syndrome and epidural pneumatosis who required emergency laparotomy. Effective analgesia was obtained using neuraxial anesthesia with a combined spinal-epidural anesthesia technique.

Sugammadex to Reverse Neuromuscular Blockade Prior to Withdrawal of Life Support

In certain end-of-life scenarios, pharmacologic reversal of neuromuscular blockade may be indicated. However, given the depth of blockade frequently necessitated in the ICU setting, rapid reversal of neuromuscular blockade is generally not feasible with conventional reversal agents such as neostigmine that inhibit acetylcholinesterase. Sugammadex is a novel pharmacologic agent for the reversal of neuromuscular blockade that acts by directly encapsulating steroidal neuromuscular blocking agents and providing effective 1:1 binding of rocuronium or vecuronium. This unique mechanism of action is rapid and allows for complete reversal and recovery of neuromuscular function. We report the use of sugammadex to reverse neuromuscular blockade prior to compassionate extubation in three pediatric patients. Its clinical use in children is reviewed, potential applications in the palliative care arena discussed, and dosing algorithms presented.

Update on Local Anesthetic Toxicity, Prevention and Treatment During Regional Anesthesia in Infants and Children

Local anesthetic agents play a key role in the treatment and prevention of pain in children. Although generally safe and effective, as with any pharmacologic agent, adverse effects may occur with the administration of these medications. Systemic absorption or inadvertent systemic injection during bolus dosing or continuous infusion can result in local anesthetic systemic toxicity with life-threatening neurological and cardiac complications. The following article reviews the pharmacology of local anesthetic agents, outlines previous reports of systemic toxicity during regional anesthesia, and discusses prevention and treatment algorithms.

Acute Hepatic Dysfunction Related to Chronic Acetaminophen Administration

Toxicity related to acetaminophen is most encountered with the acute ingestion of large doses. However, toxicity may also result from chronic ingestion, even when recommended doses are administered over a prolonged period of time. We present the case of a 20-month-old female toddler who received therapeutic recommended doses of acetaminophen (oral or intravenous) following multiple surgical interventions for treatment of a tracheo-esophageal fistula following ingestion of a button battery. The potential role of chronic acetaminophen administration in the etiology of hepatoxicity is discussed and prevention strategies are presented.

Successful management of an aorto-esophageal fistula following button battery ingestion: A case report and review of the literature

Foreign body ingestion is a common event among pediatric patients, especially in children less than 6 years of age. Although most cases are relatively benign, with the foreign body passing spontaneously or requiring a brief endoscopic procedure for removal, button battery ingestion is known to cause significant morbidity with the potential for mortality. Although aorto-esophageal fistula (AEF) is a rare complication following button battery ingestion, its clinical manifestations are significant and outcomes are poor. Early diagnosis and aggressive treatment are key in preventing fatal complications. We describe the successful management of an AEF which presented with hematemesis 8 days after removal of a button battery in a 17-month-old female. The literature regarding button battery ingestion and AEF is reviewed and treatment options including intraoperative anesthetic care discussed.

Perioperative Opioid Consumption is Not Reduced in Cyanotic Patients Presenting for the Fontan Procedure

Adequate pain control is a critical component of the perioperative approach to children undergoing repair of congenital heart disease (CHD). The impact of specific anatomic and physiologic disturbances on the management of analgesia has been largely unexplored at the present time. Studies in other pediatric populations have found an association between chronic hypoxemia and an increased sensitivity to the effects of opioid medications. The purpose of this retrospective study was to examine perioperative opioid administration and opioid-associated adverse effects in children undergoing surgical repair of CHD, with a comparison between patients with and without chronic preoperative cyanosis. Patients between the ages of 2 and 5 years whose tracheas were extubated in the operating room were included and were classified in the cyanotic group if they presented for the Fontan completion. The primary outcomes of interest were intraoperative and postoperative opioid administration. Secondary outcomes included pain scores and opioid-related side effects. The study cohort included 156 patients. Seventy-one underwent the Fontan procedure, twelve of which were fenestrated. Fontan patients received fewer opioids intraoperatively (11.33 µg/kg fentanyl equivalents versus 12.56 µg/kg, p = 0.03). However, there were no differences with regards to opioid consumption postoperatively and no correlation between preoperative oxygen saturation and total opioid administration. There were no differences between groups with regards to the respiratory rate nadir, postoperative pain scores, or the incidence of opioid-related side effects. In contrast to other populations with chronic hypoxemia exposure, children with cyanotic CHD did not appear to have increased sensitivity to the effects of opioid medications.

Prolonged Postoperative Mechanical Ventilation (PPMV) in children undergoing abdominal operations: An analysis of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database

BACKGROUND

Prolonged postoperative mechanical ventilation (PPMV) increases length of stay, hospitalization costs, and postoperative complications. Independent risk factors associated with PPMV are not well-known for children.

METHOD

We identified children (<18 years) in the ACS NSQIP-P database who underwent a general surgical abdominal operation. We excluded children with preoperative ventilator dependence and mortality within 48 h of surgery. PPMV was defined as cumulative postoperative mechanical ventilation exceeding 72 h. A multivariable logistic regression model identified independent predictors of PPMV.

RESULTS

We identified 108,392 children who underwent a general surgical abdominal operation in the ACS NSQIP-P database from 2012 to 2017. We randomly divided the population into a derivation cohort of 75,874(70%) and a validation cohort of 32,518(30%). In the derivation cohort, we identified PPMV in 1,643(2.2%). In the multivariable model, the strongest independent predictor of PPMV was neonatal age (OR:20.66; 95%CI:16.44-25.97). Other independent risk factors for PPMV were preoperative inotropic support (OR:10.56; 95%CI:7.56-14.77), an operative time longer than 150 min (OR:4.30; 95%CI:3.72-4.52), and an American Society of Anesthesiologists classification >3 (OR:12.16; 95%CI:10.75-13.75).

CONCLUSION

Independent preoperative risk factors for PPMV in children undergoing a general surgical operation were neonatal age, preoperative ionotropic support, duration of operation, and ASA classification >3.