Lumbosacral and thoracolumbosacral cerebrospinal fluid volume changes in neonates, infants, children, and adolescents: A retrospective magnetic resonance imaging study

BACKGROUND

The volume of cerebrospinal fluid can affect the pharmacokinetics and pharmacodynamics of local anesthetics for spinal anesthesia and other intrathecal medications.

AIMS

The objective of this study was to estimate the lumbosacral cerebrospinal fluid volume and thoracolumbosacral cerebrospinal fluid volume using magnetic resonance images in pediatric patients from neonates and infants to adolescents.

METHODS

Spinal magnetic resonance images of 500 pediatric patients (age <18 years) were reviewed. The lumbosacral cerebrospinal fluid volumes of 418 patients and thoracolumbosacral cerebrospinal fluid volumes of 248 patients were measured. The relationship between cerebrospinal fluid volumes and age, height, and weight were evaluated. The lumbosacral and thoracolumbosacral cerebrospinal fluid volumes per weight were calculated to elucidate developmental changes.

RESULTS

The lumbosacral and thoracolumbosacral cerebrospinal fluid volumes showed linear correlations with height (r²  = 0.730 and r²  = 0.661, respectively), whereas they showed curvilinear correlations with age (r²  = 0.752 and r²  = 0.717, respectively) and weight (r²  = 0.734 and r²  = 0.734, respectively). The mean lumbosacral cerebrospinal fluid volume per weight (mL/kg) was 0.85 (standard deviation [SD]: 0.19, 95% confidence interval [CI]: 0.81-0.90) in neonates and infants, 0.86 (SD: 0.22, 95% CI: 0.83-0.89) in toddlers and preschoolers, 0.71 (SD: 0.26, 95% CI: 0.66-0.76) in schoolers, and 0.54 (SD: 0.20, 95% CI: 0.49-0.60) in adolescents. The mean thoracolumbosacral cerebrospinal fluid volume per weight (mL/kg) was 1.95 (SD: 0.37, 95% CI: 1.86-2.04) in neonates and infants, 1.82 (SD: 0.41, 95% CI: 1.75-1.88) in toddlers and preschoolers, 1.38 (SD: 0.40, 95% CI: 1.23-1.52) in schoolers, and 0.99 (SD: 0.34, 95% CI: 0.45-1.53) in adolescents.

CONCLUSION

The lumbosacral and thoracolumbosacral cerebrospinal fluid volumes in pediatric patients were much smaller than previously presented values, showing linear correlations with height, and demonstrate curvilinear correlations with age and weight.

Safety margin for needle placement during lumbar plexus block: An anatomical study using magnetic resonance imaging

PURPOSE

We aimed to provide anatomic characteristics of the lumbar plexus and a safety margin for needle placement during lumbar plexus block in adults.

METHODS

Lumbar spine magnetic resonance images from 377 adults were reviewed. We determined the depth of the lumbar plexus from the needle insertion point for the modified traditional and Capdevila's approaches at the L4 and L5 levels. The relationship of age, height, and body weight with lumbar plexus depth, and the presence of the kidney on the transverse plane at the L4 level were assessed.

RESULTS

The lumbar plexus was deeper at the L5 level than at the L4 level for both approaches (mean difference 3.2 mm [95% confidence interval (CI), 2.4 to 4.0] for the modified traditional approach; mean difference 4.4 mm [95% CI, 3.7 to 5.2] for Capdevila's approach). Eighty-six (22.8%) patients had an L4 transverse process shorter than 40 mm, which implies that the needle may not contact the L4 transverse process with the modified traditional approach. The mean (standard deviation) of safety margins for needle insertion, defined as the distance from the posterior aspect of the L4 transverse process to the anterior margin of the psoas muscle, were 45 (8) and 44 (6) mm, respectively for the modified traditional and Capdevila's approach (mean difference, 0.5 mm; 95% CI, -0.1 to 1.1]). The lumbar plexus depth for each approach at the L4 level was predicted using the following equations: Depth (mm) = 87.24 - 0.36 × height (cm) + 0.69 × weight (kg) for the modified traditional approach (r² = 0.37) and Depth (mm) = 86.51 - 0.35 × height (cm) + 0.61 × weight (kg) for Capdevila's approach (r² = 0.33). The kidney was observed at the L4 level in 60 (15.9%) patients, with higher incidence in patients over 70 yr and those shorter than 150 cm.

CONCLUSION

The surface anatomic relations of the lumbar plexus found in this study may be useful for performing successful and safe lumbar plexus block.

Predicting the Depth of the Lumbar Plexus in Pediatric Patients: A Retrospective Magnetic Resonance Imaging Study

BACKGROUND

The lumbar plexus (LP) block is commonly used for analgesia for lower extremities. If the depth of the LP (LPD) can be predicted, the performance time and procedure-related complications could be reduced.

METHODS

Three hundred sixty-one magnetic resonance images of pediatric patients (<18 years of age) were analyzed. Simple linear regression and multiple linear regression analyses were performed to predict the LPD using patient age, weight, height, and the distance between the midline and posterior superior iliac spine (midline-PSIS). The ratio of the distance between the midline and the most lateral aspect of the LP (midline-LP) to midline-PSIS (midline-LP/midline-PSIS ratio) was calculated to suggest a needle insertion point at the L4/L5 intervertebral level. The presence of the kidney at the L4 level and the L4/L5 intervertebral level was determined.

RESULTS

The LPD at the L4/L5 intervertebral levels was predicted using the equation LPD = 0.844 × weight (kg) + 25.8 (mm) in pediatric patients <18 years of age (r = 0.791; 95% confidence interval [CI] of r, 0.753-0.829). The overall midline-LP/midline-PSIS ratio was 0.87 (95% CI, 0.86-0.89), and the ratio was higher in neonates and infants (0.98 [95% CI, 0.95-1.02]) than in the other age groups. The presence of the lower kidney pole at the L4 level was common in pediatric patients (43.7% of neonates and infants and 13.7% of toddlers and preschool-aged children). The lower kidney pole was observed at the L4/L5 level in 6 patients (1.7%).

CONCLUSIONS

When LP block is performed in pediatric patients, the LPD and risk of renal injury should be considered for successful and safe analgesic block.

Comparative effectiveness of pharmacologic interventions to prevent shivering after surgery: a network meta-analysis

INTRODUCTION

Although many drugs have been studied to prevent postoperative shivering, their comparative effectiveness is unknown. We attempted to assess the comparative effectiveness of the pharmacologic strategies to prevent shivering after surgery including intravenous (IV) and intrathecal (IT) meperidine, IV and IT dexmedetomidine, IV and IT clonidine, nefopam, tramadol, ketamine, and serotonin receptor antagonists.

EVIDENCE ACQUISITION

We implemented a frequentist network meta-analysis of randomized trials. Random effect model was selected according to deviance information criteria. The incidence of moderate or severe shivering and the overall incidence of postoperative shivering were compared in all patients and subgroups of general and spinal anesthesia.

EVIDENCE SYNTHESIS

Seventy trials with 6062 participants were included. All interventions except clonidine IT and dexmedetomidine IT significantly decreased the incidence of moderate or severe shivering. All interventions except clonidine IT significantly decreased the overall incidence of shivering. Nefopam IV was ranked best regarding both the incidence of moderate or severe shivering (odds ratio [OR] 0.04, 95% confidence interval [CI] 0.04-0.25, SUCRA 86.2, moderate quality-evidence), and the overall incidence of shivering (OR 0.07, 95% CI 0.03 to 0.15, SUCRA 85.7, moderate quality-evidence), which was consistent in the subgroups of anesthesia.

CONCLUSIONS

Nefopam was ranked best regarding both severity and incidence of postoperative shivering. In addition to nefopam, tramadol, meperidine IV and IT, and dexmedetomidine IV were ranked high. However, there was significant heterogeneity regarding the individual drug regimen and surgery type, precluding firm conclusion. Further randomized trials are required to compare the efficacy of the drugs with high rank.

Safety and efficacy of propofol anesthesia for pediatric target-controlled infusion in children below 3 years of age: a retrospective observational study

BACKGROUND

Although the requirement of propofol in children is increasing, propofol for induction and maintenance of anesthesia below 3 years old has not been approved in Korea. This study can provide a clinical evidence to increase the range of approval.

RESEARCH DESIGN AND METHODS

We reviewed the medical records of patients below 3 years of age who underwent surgery between September 2013 and December 2016. Safety was evaluated on the basis of vital signs, and laboratory findings and efficacy were evaluated on the basis of the bispectral index (BIS). Adverse events were examined.

RESULTS

A total of 109 patients anesthetized with propofol (propofol group) were compared with 109 patients with volatile anesthetics (volatile group) after propensity score matching. There was a difference in the proportion of patients showing decreased systolic pressure (P < 0.001) and heart rate (P = 0.03), but there was no difference in diastolic pressure (P = 0.238), mean arterial pressure (P = 0.175) during surgery. After surgery, there was no difference in all vital signs and the proportion patients who experienced adverse events of two groups.

CONCLUSIONS

Propofol anesthesia by target-controlled infusion was effective and didn't show serious propofol-related perioperative adverse events.

Safety and Efficacy of Off-label and Unlicensed Medicines in Children

BACKGROUND

The aim of this study was to explore the use of off-label/unlicensed drugs to confirm the safety and efficacy of their prescription in children in Korea.

METHODS

In this retrospective study, we analyzed data of patients who received any of the 32 drugs between January-December 2014 in tertiary hospitals in Korea, including demographics, diagnoses, reasons for the medication, administration route, and details of adverse drug reactions. Additionally, the mortality in the cohort was assessed. The primary outcomes were efficacy and safety, including mortality, of these drugs in pediatric patients. The secondary outcomes were the current statuses of the use of off-label/unlicensed drugs in two centers.

RESULTS

Totally, 5,130 prescriptions were found in 2,779 patients. Age (73.5%) and indication (11.7%) were the most frequent reasons for prescriptions being off-labeled/unlicensed. Approximately 88% of the prescriptions were effective, and 19% of the patients developed adverse drug reactions. The number of prescriptions was significantly higher in children with adverse drug reactions than it was in those without (2.8 vs. 1.5; P < 0.001). The number of prescribed off-label/unlicensed medicines and age at prescription were independently associated with adverse drug events (odds ratio, 1.55 and 1.1; P < 0.001 and 0.034, respectively).

CONCLUSION

Children are still prescribed medicines that are not authorized in terms of age, weight, indications, or routes of administration. Therefore, many old products require re-assessment of authorization. More prospective clinical studies should be performed to confirm the efficacy and safety of drugs in the pediatric population.

The effect of remote ischemic preconditioning on serum creatinine in patients undergoing partial nephrectomy: a study protocol for a randomized controlled trial

Background

Acute kidney injury (AKI) may develop during partial nephrectomy due to ischemic reperfusion injury induced by renal artery clamping or surgical insult. The effect of remote ischemic preconditioning (RIPC) on reducing the renal injury after partial nephrectomy has not been evaluated in terms of urinary biomarkers.

Methods/design

We will conduct a randomized controlled trial enrolling the patients who will undergo partial nephrectomy. In the study group, RIPC which consisted of four 5-min cycles of limb ischemia and reperfusion will be conducted after induction of anesthesia. Postoperative serum creatinine values, the incidence of AKI, and urinary biomarkers, including urinary creatinine, microalbumin, β-2 microglobulin, and N-acetyl-beta-D-glucosaminidase, will be compared between groups during the postoperative 2 weeks. Regional oxygen saturation on the skin of the contralateral kidney will be measured to evaluate the association between intraoperative regional oxygen saturation values and renal injury of the operating side.

Discussion

We expect that our trial may demonstrate the effect of RIPC on mitigating the immediate postoperative renal injury and improving patient outcomes after partial nephrectomy. Moreover, our patients will undergo ^99mTc-DTPA radionuclide scintigraphy to calculate glomerular filtration rate 6 and 12 months after surgery. This data should show the long-term effect of RIPC.

Trial registration

ClinicalTrials.gov, ID: NCT03273751. Registered on 6 September 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2820-3) contains supplementary material, which is available to authorized users.

Time to consider the contact force during photoplethysmography measurement during pediatric anesthesia: A prospective, nonrandomized interventional study

BACKGROUND

Respiratory variations in photoplethysmography amplitude enable volume status assessment. However, the contact force between the measurement site and sensor can affect photoplethysmography waveforms. We aimed to evaluate contact force effects on respiratory variations in photoplethysmography waveforms in children under general anesthesia.

METHODS

Children aged 3-5 years were enrolled. After anesthetic induction, mechanical ventilation commenced at a tidal volume of 10 mL/kg. Photoplethysmographic signals were obtained in the supine position from the index finger using a force sensor-integrated clip-type photoplethysmography sensor that increased the contact force from 0-1.4 N for 20 respiratory cycles at each force. The AC amplitude (pulsatile component), DC amplitude (nonpulsatile component), AC/DC ratio, and respiratory variations in photoplethysmography amplitude were calculated.

RESULTS

Data from 34 children were analyzed. Seven contact forces at 0.2-N increments were evaluated for each patient. The normalized AC amplitude increased maximally at a contact force of 0.4-0.6 N and decreased with increasing contact force. However, the normalized DC amplitude increased with a contact force exceeding 0.4 N. ΔPOP decreased slightly and increased from the point when the AC amplitude started to decrease as contact force increased. In a 0.2-1.2 N contact force range, significant changes in the normalized AC amplitude, normalized DC amplitude, AC/DC ratio, and respiratory variations in photoplethysmography amplitude were observed.

CONCLUSION

Respiratory variations in photoplethysmography amplitude changed according to variable contact forces; therefore, these measurements may not reflect respiration-induced stroke volume variations. Clinicians should consider contact force bias when interpreting morphological data from photoplethysmography signals.

Association of nefopam use with postoperative nausea and vomiting in gynecological patients receiving prophylactic ramosetron: A retrospective study

Background

Postoperative nausea and vomiting (PONV) is a common adverse effect of opioid-based intravenous patient-controlled analgesia (IV PCA). Nefopam has been considered as a good candidate for inclusion in multimodal analgesia because of its opioid sparing effect, but it can be emetic. This study aims to examine whether the use of nefopam combined with fentanyl in IV PCA was associated with the higher incidence of PONV in patients receiving prophylactic ramosetron after gynecological surgery.

Methods

Data from 296 patients who underwent gynecological surgery were retrospectively reviewed. The patients received IV PCA containing either fentanyl 1500 μg and ketorolac 90 mg (Group K) or fentanyl 1500 μg and nefopam 80 mg (Group N). All patients in both groups received 0.3 mg of ramosetron at the end of surgery. The primary outcome measure was the incidence of PONV during the 3-day postoperative period.

Results

No difference was observed in the incidence of PONV during the 3-day postoperative period between the two groups. However, the incidence of nausea on postoperative day 2 was significantly higher in Group N (10.3%) than in Group K (2.8%) (P = 0.016). Multivariable logistic regression analysis showed that the use of nefopam was not associated with a higher incidence of PONV (adjusted odds ratio, 1.616; 95% confidence interval, 0.952–2.743, P = 0.076). There were no differences in postoperative pain scores between the two groups.

Conclusion

The combined use of nefopam with fentanyl in IV PCA was not associated with the higher incidence of PONV compared with the use of ketorolac and fentanyl combination in patients who received ramosetron as PONV prophylactic agent. However, prospective trials are required for a confirmative conclusion.

Utility of Perioperative Lung Ultrasound in Pediatric Cardiac Surgery

Background

Pediatric cardiac patients are at risk for perioperative respiratory insufficiency. The objective of this study was to assess the utility of perioperative lung ultrasound examination in pediatric cardiac surgery.

Methods

In this randomized, controlled trial, children (5 yr old or younger) undergoing cardiac surgery were allocated into a control (n = 61) or intervention (n = 61) group. The control group received only lung ultrasound examinations at the end of surgery and 6 to 12 h after surgery. The intervention group received lung ultrasound examinations and an ultrasound-guided recruitment maneuver depending on ultrasound findings after inducing anesthesia, at the end of surgery, and 6 to 12 h after surgery. Primary outcomes were incidences of intra- and postoperative desaturation, and postoperative pulmonary complications. Multiple comparisons were corrected (P ≤ 0.017) in the primary outcome analysis.

Results

Of the 120 children included in the analysis, postoperative desaturation (64% vs. 27%; P &lt; 0.001; odds ratio [OR], 0.210; 95% CI, 0.097 to 0.456) occurred more in the control group. The incidences of intraoperative desaturation (36% vs. 19%; P = 0.033; OR, 0.406; 95% CI, 0.176 to 0.939) and postoperative pulmonary complications (12% vs. 3%; P = 0.093; OR, 0.271; 95% CI, 0.054 to 1.361) were similar between the groups. Lung ultrasound scores were better in the intervention group than in the control group. Duration of mechanical ventilation was longer in the control group than in the intervention group (38 ± 43 vs. 26 ± 25 h; 95% CI of mean difference, 0 to 25; P = 0.048).

Conclusions

Perioperative lung ultrasound examination followed by ultrasound-guided recruitment maneuver helped decrease postoperative desaturation events and shorten the duration of mechanical ventilation in pediatric cardiac patients.

The Efficacy of Intraoperative EEG to Predict the Occurrence of Emergence Agitation in the Postanesthetic Room After Sevoflurane Anesthesia in Children

PURPOSE

Emergence agitation (EA) is common after sevoflurane anesthesia, but there are no definite predictors. This study investigated whether intraoperative electroencephalography (EEG) can indicate the occurrence of EA in children.

DESIGN

A prospective predictive study design was used.

METHODS

EEG-derived parameters (spectral edge frequency 95, beta, alpha, theta, and delta power) were measured at 1.0 minimum alveolar concentration (MAC) and 0.3 MAC of end-tidal sevoflurane (EtSEVO) in 29 patients. EA was evaluated using an EA score (EAS) in the postanesthetic care unit on arrival (EAS 0) and at 15 and 30 minutes after arrival (EAS 15 and EAS 30). The correlation between EEG-derived parameters and EAS was analyzed using Spearman correlation, and receiver-operating characteristic curve analysis was used to measure the predictability.

FINDINGS

EA occurred in 11 patients. The alpha power at 1.0 MAC of EtSEVO was correlated with EAS 15 and EAS 30. The theta/alpha ratio at 0.3 MAC of EtSEVO was correlated with EAS 30. The area under the receiver-operating characteristic curve of percentage of alpha bands at 0.3 MAC of EtSEVO and the occurrence of EA was 0.672.

CONCLUSIONS

Children showing high-alpha powers and low theta powers (= low theta/alpha ratio) during emergence from sevoflurane anesthesia are at high risk of EA in the postanesthetic care unit.

Risk Factors for Intraoperative Hypocapnia in Pediatric Neurosurgical Patients: A Retrospective Cohort Study

BACKGROUND

Hypocapnia has been associated with an increased risk and adverse outcomes in the injured brain. This study aimed to identify risk factors of intraoperative hypocapnia in pediatric neurosurgical patients when tidal volumes and respiratory rates were determined based on their weight and age, respectively.

METHODS

Electronic medical records of pediatric patients (≤18 years) who underwent neurosurgery from December 2014 to January 2016 were retrospectively reviewed. Minute ventilation was fixed according to each patient's weight and age. Hypocapnia was defined as arterial partial pressure of carbon dioxide <35 mm Hg from intraoperative arterial blood gas analysis. Patients were divided into hypocapnia and nonhypocapnia groups. Risk factors for intraoperative hypocapnia were found using univariable and multivariable logistic regression analyses.

RESULTS

Of the 333 pediatric patients analyzed, 101 (30%) and 232 (70%) were included in the hypocapnia and nonhypocapnia groups, respectively. There was no difference in the minute ventilation between the two groups. The hypocapnia group had more patients taking valproate (8.9 vs. 2.2%; p = 0.008; OR, 4.441; 95% CI, 1.449-13.61) and carbonic anhydrase inhibitors (7.9 vs. 2.2%; p = 0.018; OR, 3.905; 95% CI, 1.245-12.25). An operation for hydrocephalus was more commonly performed in the hypocapnia group (26.7 vs. 15.9%; p = 0.017; OR, 1.923; 95% CI, 1.094-3.379). In the multivariable regression analysis, valproate (OR, 3.939; 95% CI, 1.250-12.41; p = 0.019), carbonic anhydrase inhibitor (OR, 3.345; 95% CI, 1.029-10.88; p = 0.045), and operation for hydrocephalus (OR, 1.838; 95% CI, 1.032-3.272; p = 0.039) were independent risk factors for intraoperative hypocapnia.

CONCLUSIONS

Pediatric patients taking valproate and carbonic anhydrase inhibitors and who were scheduled for surgery of hydrocephalus were at risk of developing intraoperative hypocapnia during neurosurgery, a finding warning the surgeon that a conventional ventilatory strategy would endanger these patients.

Comparison of the effect of different infusion rates of sufentanil on surgical stress index during cranial pinning in children under general anaesthesia: a randomized controlled study

Background

Surgical stress index (SSI) is an established indicator for intraoperative nociception. Opioids are used to block stimulus of cranial pinning in neurosurgery. We investigated the effect of different infusion rates of sufentanil on SSI during cranial pinning in children under general anaesthesia.

Methods

Forty-nine children (2–12 years of age) underwent neurosurgery with pinning. The children were randomized into three groups based on the rate of sufentanil infusion: 0.2, 0.5, and 0.8 μg·kg⁻¹·hr.⁻¹. Continuous sufentanil infusion began following neuromuscular blockade administration, at a rate determined by each patient’s assigned treatment group. Following preparation for surgery, cranial pinning was performed. Systolic, diastolic, and mean blood pressures, along with heart rate and photoplethysmographic data, were continuously recorded from 1 min prior to cranial pinning through 5 min after cranial pinning, in 1-min intervals. SSI was calculated following the completion of surgery. Differences in measured outcomes over time among the three groups were evaluated using a generalized estimation equation. Differences in pinning outcomes in the same group were evaluated with Freidman test.

Results

We found no statistical differences in long-term SSI that were associated with different infusion rates of sufentanil during cranial pinning. Blood pressures in all groups increased for 2 min after cranial pinning, and then decreased; we found no statistical difference in long-term blood pressure values among the groups. Heart rate increased after pinning in the group that received a low-dose infusion of sufentanil.

Conclusions

Since SSI was intended to measure the blunting effects of sufentanil towards the noxious stimulus of cranial pinning, our results suggest that SSI might not be sufficiently sensitive to monitor the nociceptive response in children.

Trial registration

(KCT0000978, Jan-07, 2014).

Determination of the optimal depth of a left internal jugular venous catheter in infants: A prospective observational study

BACKGROUND

Few reports exist regarding the optimal depth of a left-sided central venous catheter in pediatric patients. We aimed to provide a guideline for the optimal depth of central venous catheters at the left internal jugular vein in infants, using anatomical landmarks, age, height, and weight.

METHODS

A two-stage study was conducted. In the first observational study, infants aged ≤1 year and scheduled for elective surgery requiring a central venous catheter were enrolled. The tip of the central venous catheter was confirmed using transthoracic echocardiography. Linear regression modeling was performed to determine the association between the insertion depth of the central venous catheter and the I-A-B distance (I, the insertion point; A, the sternal head of the left clavicle; B, the midpoint of the perpendicular line drawn between the sternal head of the right clavicle and an imaginary line between the nipples), based on age, height, and weight. In the second study, the results of the first study were validated in another group of consecutive infants.

RESULTS

In the first study, the data of 67 patients were analyzed. The infant's height and I-A-B distance were highly correlated with the level of the central venous catheter tip (R² =0.763 and 0.772, respectively; all P < .01), using the regression equations 0.11 ×  height (cm) + 0.19 and 1.02 ×  I-A-B (cm) + 1.55, respectively. In the second study, height was also highly correlated with the insertion depth of the central venous catheter in another 42 infants (r = .938, P = <.001). In a Bland-Altman's analysis, the mean bias and precision of the actual insertion depth and predicted depth using height were 0.09 and 0.15 cm, respectively. The limits of agreement were -0.19 and 0.38 cm, respectively.

CONCLUSION

In infants, the optimal depth of a central venous catheter at the left internal jugular vein can be determined with a simple formula using height.

Pediatric Clinical Trials Conducted in South Korea from 2006 to 2015: An Analysis of the South Korean Clinical Research Information Service, US ClinicalTrials.gov and European Clinical Trials Registries

BACKGROUND

The status of pediatric clinical trials performed in South Korea in the last decade, including clinical trials of drugs with unapproved indications for children, has not been previously examined.

OBJECTIVE

The aim was to provide information regarding the current state of pediatric clinical trials and create a basis for future trials performed in South Korea by reviewing three databases of clinical trials registrations.

METHODS

We searched for pediatric clinical studies (participants <18 years old) conducted in South Korea between 2006 and 2015 registered on the Clinical Research Information Service (CRIS), ClinicalTrials.gov, and the European Clinical Trials Registry (EuCTR). Additionally, we reviewed whether unapproved indications were involved in each trial by comparing the trials with a list of authorized trials provided by the Ministry of Food and Drug Safety (MFDS). The primary and secondary outcomes were to determine the change in number of pediatric clinical trials with unapproved indications over time and to assess the status of unauthorized pediatric clinical trials from the MFDS and the publication of articles after these clinical trials, respectively.

RESULTS

We identified 342 clinical studies registered in the CRIS (n = 81), ClinicalTrials.gov (n = 225), and EuCTR (n = 36), of which 306 were reviewed after excluding duplicate registrations. Among them, 181 studies were interventional trials dealing with drugs and biological agents, of which 129 (71.3%) involved unapproved drugs. Of these 129 trials, 107 (82.9%) were authorized by the MFDS.

CONCLUSIONS

Pediatric clinical trials in South Korea aiming to establish the safety and efficacy of drugs in children are increasing; however, non-MFDS-authorized studies remain an issue.

Comparative efficacy and safety of anticoagulants for prevention of venous thromboembolism after hip and knee arthroplasty

Background and purpose - New oral anticoagulants have been developed to prevent venous thromboembolism (VTE) after knee or hip arthroplasty. Although there have been several network meta-analyses (NMA) to compare different regimens, an NMA including 2 different enoxaparin doses and edoxaban has not been performed. Methods - Standard NMA for fondaparinux, dabigatran, rivaroxaban, apixaban, edoxaban, and enoxaparin was performed. Outcome variables included a composite of total VTE and major/clinically relevant bleeding. The rank probabilities of each treatment outcome were summarized by the surface under the cumulative ranking curve. Results - Fondaparinux, rivaroxaban, and apixaban were associated with a reduced risk of VTE compared with enoxaparin, while dabigatran was not. None of these 3 drugs increased bleeding compared with enoxaparin 30 mg twice daily. However, fondaparinux and rivaroxaban increased bleeding compared with enoxaparin 40 mg once daily, while apixaban did not. Apixaban was even associated with decreased major/clinically relevant bleeding compared with enoxaparin 30 mg twice daily or 40 mg once daily. When edoxaban was included in the NMA, edoxaban decreased VTE and did not increase bleeding compared with enoxaparin. Interpretation - A higher efficacy of fondaparinux and rivaroxaban compared with enoxaparin was associated with increased bleeding tendency, while apixaban was superior to enoxaparin regarding both efficacy and safety. A clustered ranking plot showed that apixaban might be the most preferred regarding efficacy and safety. However, our results were driven by indirect statistical inference and were limited by the heterogeneity of the bleeding outcome definitions, drug initiation and continuation, and different surgery types.

Position and relative size of the vertebral artery according to age: Implications for internal jugular vein access

AIM

The purpose of this retrospective observational study was to investigate the anatomical characteristics of the vertebral artery in pediatric patients using computed tomography images.

METHODS

We evaluated anatomical characteristics of the right and left vertebral artery at the cricoid level and at a lower level, which was mid-level between the cricoid cartilage and the origin of vertebral artery from the subclavian artery. At each level, the cross-sectional areas of the vertebral artery and internal jugular vein, the relative size of vertebral artery to internal jugular vein, the minimum distance between them, and the extent of overlap between them were investigated.

RESULTS

According to the chest computed tomography images of 344 patients, the sizes of internal jugular vein and vertebral artery were found to increase with age. On the other hand, the relative size of the vertebral artery to internal jugular vein was found to increase conversely with decreasing age. The distance between the vertebral artery and internal jugular vein increased with age at both sides and levels. The vertebral artery was mostly located at the medial side of the internal jugular vein, and overlapped with the internal jugular vein in at least 54% of the patients at the cricoid level and in 74% at the lower level.

CONCLUSION

The theoretical risk of vertebral artery puncture is higher in younger children during internal jugular vein catheterization.

Desflurane versus sevoflurane in pediatric anesthesia with a laryngeal mask airway: A randomized controlled trial

BACKGROUND

Desflurane with a laryngeal mask airway may have advantages during ambulatory anesthesia. However, desflurane-induced airway irritability makes the use of desflurane challenging, especially in children. This study compared desflurane with sevoflurane maintenance anesthesia in terms of respiratory events and the emergence characteristics in children with a laryngeal mask airway.

METHODS

This randomized controlled trial evaluated 200 children undergoing strabismus surgery allocated to desflurane or sevoflurane groups. After inducing anesthesia with sevoflurane and thiopental sodium 5 mg kg, the anesthetic agent was changed to desflurane in the desflurane group, whereas sevoflurane was continued in the sevoflurane group. Respiratory events, emergence time, recovery time, and emergence agitation were compared between the groups.

RESULTS

The overall respiratory events did not differ between the groups. However, the incidence of mild desaturation (90% ≤ SpO2 < 97%) was significantly higher in the desflurane group (7%) than in the sevoflurane group (0%) (P = .007). Emergence was significantly faster in the desflurane group (6.6 ± 3.9 vs 8.0 ± 2.2 min, P = .003). The recovery time and emergence agitation in the postanesthesia care unit were comparable between groups. Laryngospasm developed in 5 children (1 in the sevoflurane group and 4 in the desflurane group, P = .365); of these, 4 patients were younger than 3 years.

CONCLUSION

Desflurane maintenance anesthesia in children with a laryngeal mask airway shows a similar rate of overall respiratory events compared with sevoflurane anesthesia. However, anesthesiologists should be cautious of using desflurane in younger children concerning desaturation events during emergence.