High-flow nasal cannula vs standard respiratory care in pediatric procedural sedation: A randomized controlled pilot trial

Procedural sedation and analgesia in pediatric diagnostic and interventional radiology: An expert DELPHI consensus document developed by the ITALIAN scientific society of anesthesia, analgesia, resuscitation and intensive care (SIAARTI)

BACKGROUND

Children undergoing diagnostic and interventional radiology procedures often require sedation to achieve immobility and analgesia if the procedure is painful. In the past decades, leading scientific organizations have developed evidence-based guidelines for procedural sedation and analgesia in children outside of the operating room. Their recommendations are being applied to procedural sedation in radiology. However, some questions remain open regarding specific aspects contextualized to the radiology setting, such as elective prone sedation, the urgency of the procedure, when venous access or airway protection is required, and others.

AIMS

To address the unresolved issues of procedural sedation and analgesia in pediatric diagnostic and interventional radiology.

METHODS

An expert panel of pediatricians, pediatric anesthesiologists, intensivists, and neuroradiologists selected topics representative of current controversies and formulated research questions. Statements were developed by reviewing the literature for new evidence, comparing expertise and experience, and expressing opinions. Panelists' agreement with the statements was collected anonymously using the DELPHI method.

RESULTS

Twelve evidence-based or expert opinion incorporate are presented, considering risks, benefits, and applicability.

CONCLUSIONS

This consensus document, developed by a multidisciplinary panel of experts involved in the field, provides statements to improve the quality of decision-making practice in procedural sedation and analgesia in pediatric radiology.

High-flow nasal cannula use in pediatric patients for other indications than acute bronchiolitis-a scoping review of randomized controlled trials

The objective of the study is to summarize current literature on high-flow nasal cannula (HFNC) use for different indications in pediatric patient excluding acute bronchiolitis and neonatal care. The study design is a systematic scoping review. Pubmed, Scopus, and Web of Science databases were searched in February, 2023. All abstracts and full texts were screened by two independent reviewers. Randomized controlled trials focusing on HFNC use in pediatric patients (age < 18 years) were included. Studies focusing on acute bronchiolitis and neonatal respiratory conditions were excluded. Study quality was assessed by Cochrane risk of bias 2.0 tool. The main outcomes are patient groups and indications, key outcomes, and risk of bias. After screening 1276 abstracts, we included 22 full reports. Risk of bias was low in 11 and high in 5 studies. We identified three patient groups where HFNC has been studied: first, children requiring primary respiratory support for acute respiratory failure; second, perioperative use for either intraprocedural oxygenation or postoperative respiratory support; and third, post-extubation care in pediatric intensive care for other than postoperative patients. Clinical and laboratory parameters were assessed as key outcomes. None of the studies analyzed cost-effectiveness.Conclusion: This systematic scoping review provides an overview of current evidence for HFNC use in pediatric patients. Future studies should aim for better quality and include economic evaluation with cost-effectiveness analysis.Protocol registration: Protocol has been published https://osf.io/a3y46/ .

Recommendations from the Brazilian Society of Anesthesiology (SBA) for difficult airway management in pediatric care

Difficult airway management in pediatrics during anesthesia represents a major challenge, requiring a careful approach, advanced technical expertise, and accurate protocols. The task force of the Brazilian Society of Anesthesiology (SBA) presents a report containing updated recommendations for the management of difficult airways in children and neonates. These recommendations have been developed based on the consensus of a panel of experts, with the objective of offering strategies to overcome challenges during airway management in pediatric patients. Grounded in evidence published in international guidelines and expert opinions, the report highlights crucial steps for the appropriate management of difficult airways in pediatrics, encompassing assessment, preparation, positioning, pre-oxygenation, minimizing trauma, and, paramountly, the maintenance of arterial oxygenation. The report also delves into additional strategies involving the use of advanced tools, such as video laryngoscopy, flexible intubating bronchoscopy, and supraglottic devices. Emphasis is placed on the simplicity of implementing the outlined recommendations, with a focus on the significance of continuous education, training through realistic simulations, and familiarity with the latest available technologies. These practices are deemed essential to ensure procedural safety and contribute to the enhancement of anesthesia outcomes in pediatrics.

Efficacy and safety comparison of esketamine-propofol with nalbuphine-propofol for upper gastrointestinal endoscopy in children: a multi-center randomized controlled trial

Background and Aims

Anesthetics such as propofol, esketamine and nalbuphine are used during the upper gastrointestinal endoscopy to achieve and maintain the desired sedation level. The aim of the study was to evaluate the effectiveness and safety of propofol-nalbuphine and propofol-esketamine in children.

Methods

A multi-centered study was performed at three tertiary class-A hospitals. Children between 3 and 12 years old undergoing diagnostic painless upper gastrointestinal endoscopy were included and randomly divided into esketamine or nalbuphine group to estimate the primary outcome of successful endoscope insertion. The patients were given esketamine 0.5 mg/kg and propofol 2 mg/kg intravenously in esketamine group, with nalbuphine 0.2 mg/kg and propofol 2 mg/kg in the nalbuphine group. The primary outcome was success rate for the first attempt of endoscope insertion in each group. Secondary outcomes included the safety of both anesthesia regimens and gastroenterologist's satisfaction. We used the Face, Leg, Activity, Cry and Consolability (FLACC) scale to evaluate the level of pain before and during the procedure and the Pediatric Anesthesia Emergence Delirium (PAED) scale to assess the level of agitation and delirium after awakening from anesthesia.

Results

Among 246 patients, 200 were randomly included in the final intention-to-treat analysis, with 100 patients in each group. The success rate for the first attempt of endoscope insertion in the esketamine group was higher than the nalbuphine group (97% vs. 66%; P < 0.01). The heart rate and mean arterial pressure after intraoperative administration in the esketamine group were higher than those in the nalbuphine group, while the delirium incidence during awakening was higher in esketamine group (all P < 0.05).

Conclusion

The success rate for the first attempt of endoscope insertion of children undergoing upper gastrointestinal endoscopy in the esketamine group was higher than the nalbuphine group, propofol-related hemodynamic changes were reduced accordingly, while the incidence of esketamine-related adverse effects could be high.

Clinical Trial Registration

Chinese Clinical Trial Registry: ChiCTR2000040500.

High-flow Nasal Cannula versus Conventional Ventilation in Laryngeal Surgery: A Systematic Review and Meta-analysis

High-flow nasal cannula (HFNC) is an emerging option for maintaining oxygenation in patients undergoing laryngeal surgery, as an alternative to traditional tracheal ventilation and jet ventilation (JV). However, the data on its safety and efficacy is sparse. This study aims to aggregate the current data and compares the use of HFNC with tracheal intubation and jet ventilation in adult patients undergoing laryngeal surgery. We searched PubMed, MEDLINE (Medical Literature Analysis and Retrieval System Online, or MEDLARS Online), Embase (Excerpta Medica Database), Google Scholar, Cochrane Library, and Web of Science. Both observational studies and prospective comparative studies were included. Risk of bias was appraised with the Cochrane Collaboration Risk of Bias in Non-Randomized Studies - of Interventions (ROBINS-I) or RoB2 tools and the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for case series. Data were extracted and tabulated as a systematic review. Summary statistics were performed. Meta-analyses and trial sequential analyses of the comparative studies were performed. Forty-three studies (14 HFNC, 22 JV, and seven comparative studies) with 8064 patients were included. In the meta-analysis of comparative studies, the duration of surgery was significantly reduced in the THRIVE (Transnasal Humidified Rapid-Insufflation Ventilatory Exchange) group, but the number of desaturations, need for rescue intervention, and peak end-tidal CO₂ were significantly increased compared to the conventional ventilation group. The evidence was of moderate certainty and there was no evidence of publication bias. In conclusion, HFNC may be as effective as tracheal intubation in oxygenation during laryngeal surgery in selected adult patients and reduces the duration of surgery but conventional ventilation with tracheal intubation may be safer. The safety of JV was comparable to HFNC.

Utility of high-flow nasal oxygen in comparison to conventional oxygen therapy during upper gastrointestinal endoscopic procedures under sedation: A systematic review and meta-analyses

BACKGROUND

Sedation and analgesia are the integral components of modern-day upper gastrointestinal (GI) endoscopic procedures. Irrespective of the sedative agent, hypoxia is the most commonly encountered unwarranted event with sedation. The current study intends to scrutinize whether high-flow nasal oxygen (HFNO) is advantageous for providing respiratory support during upper GI endoscopic procedures over other conventional low-flow oxygen delivery modalities, e.g. nasal cannula, facemask, etc. METHODS: An extensive screening of electronic databases was done till July 31, 2022, after enlisting in International prospective register of systematic reviews (PROSPERO) (CRD42021245409). Randomized controlled trials (RCT), comparative cohort studies, case series, cross-sectional studies and case-control studies evaluating the utility of HFNO during upper GI endoscopy under sedation were included in this meta-analysis.

RESULTS

We retrieved eight randomized control studies and one longitudinal study with 3294 patients. The application of HFNO during endoscopy led to lesser incidence of desaturation spells (odds ratio [OR] = 0.23; 95% CI 0.11-0.48; I² = 71%), reduced procedural interruption (OR = 0.11; 95% CI 0.02-0.60; I² = 88%), better nadir SpO² level during procedure (mean difference [MD] = 3.16; 95% CI 0.54-5.78; I² = 73%), overall lesser incidence of sedation-related adverse events (OR = 0.63; 95% CI 0.42-0.93; I² = 25%), with no significant impact on the duration of endoscopy (MD = 0.15; 95% CI - 0.02 to 0.31, I² = 0%).

CONCLUSION

HFNO is a novel option for upper GI endoscopy under sedation.

CLINICAL TRIAL NUMBER AND REGISTRY URL

CRD42021245409 ( https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021245409 ).

Efficacy of high-flow nasal oxygenation compared with laryngeal mask airway in children undergoing ambulatory oral surgery under deep sedation: A randomized controlled non-inferiority trial

BACKGROUND

High-flow nasal oxygenation (HFNO) has been suggested as an alternative oxygenation method during procedural sedation. This randomized, non-inferiority trial evaluated the safety and efficacy of HFNO compared with laryngeal mask airway (LMA) in pediatric ambulatory oral surgery under deep sedation.

METHODS

In total, 120 children aged 2-7 years (weight: 10-30 kg) were equally assigned into two groups, namely, HFNO with propofol total intravenous anesthesia infusion (HFNO-IV) or LMA with propofol total intravenous anesthesia infusion (LMA-IV). The primary objective was to monitor carbon dioxide (CO2) accumulation during perioperative surgery. Secondary objectives included monitoring transcutaneous oxygen saturation, grade exposure to the surgical field, perioperative adverse events, or other events. The predefined non-inferiority margin was 7 mmHg. During the COVID-19 pandemic, a novel WeChat applet was implemented to gather follow-up data after discharge.

RESULTS

Non-inferiority could be declared for HFNO relative to LMA (mean difference in transcutaneous CO2 (TcCO2) = -1.4 mmHg, 95% CI: -2.9, 0.1 mmHg; P > 0.05). The pre-surgical TcCO2 of the HFNO-IV group (45.4 ± 4.5 mmHg) was similar to that of the LMA-IV group (44.0 ± 3.5 mmHg), within the clinically acceptable normal range. All the children maintained SpO2 levels of >97%. The surgical field exposure score of the HFNO group was significantly better than that of the LMA group. There was no significant difference between the two groups regarding risk or adverse events.

CONCLUSION

HFNO was not inferior to LMA for maintaining oxygenation and ventilation in patients undergoing pediatric ambulatory oral surgery under deep sedation under strict isolation from the oral cavity to the upper airway.

Apneic oxygenation in pediatric anesthesia

PURPOSE OF REVIEW

Apneic oxygenation is increasingly used in pediatric anesthesia. Its benefit for specific applications depends on the effect of apneic oxygenation on safe apnea time and carbon dioxide (CO2) elimination, on differences between low and high flow oxygen delivery, and on possible adverse effects. The present review summarizes current evidence on these pathophysiological aspects of apneic oxygenation as well as its applications in pediatric anesthesia.

RECENT FINDINGS

Apneic oxygenation with both low flow and high flow nasal oxygen increases the safe apnea time, but does not lead to increased CO2 elimination. Airway pressures and adverse effects like atelectasis formation, oxidative stress and aerosol generation under apneic oxygenation are not well studied in pediatric anesthesia. Data from adults suggest no important effect on airway pressures when the mouth is open, and no significant formation of atelectasis, oxidative stress or aerosol generation with high flow nasal oxygen.

SUMMARY

Apneic oxygenation in pediatric anesthesia is mainly used during standard and difficult airway management. It is sometimes used for airway interventions, but CO2 accumulation remains a major limiting factor in this setting. Reports highlight the use of high flow nasal oxygen in spontaneously breathing rather than in apneic children for airway interventions.

High-flow versus conventional nasal cannula oxygen supplementation therapy and risk of hypoxia in gastrointestinal endoscopies: Α systematic review and meta-analysis

BACKGROUND AND AIMS

Gastrointestinal endoscopy (GIE) represents a mainstay diagnostic and therapeutic procedure in modern clinical practice. Hypoxemia and respiratory failure during endoscopy constitute major complications and concerns for endoscopists. Emerging evidence supports the utilization of high-flow nasal cannula (HFNC) over conventional nasal cannula (CNC) for oxygen supplementation and avoidance of hypoxemia. Aim of our study was to compare the risk of hypoxemia in patients undergoing GIE with HFNC versus CNC oxygen supplementation recruited by randomized controlled trials (RCTs).

METHODS

We conducted an electronic literature search in established medical databases i.e. PubMed, EMBASE and Cochrane to identify RCTs investigating the abovementioned association. The enrolled studies were evaluated for risk of bias and inserted into a random effects model for meta-analysis; sub-group analyses and publication bias were also assessed.

RESULTS

Out of 271 initially retrieved articles, five RCTs were eligible for meta-analysis with totally 2656 recruited patients (1299 HFNC and 1357 CNC). A statistically significant reduced relative risk (RR) of hypoxemia among HFNC patients was revealed (RR=0.18, CI95%: 0.05-0.61), whilst with high heterogeneity (I²:79.94%, p<0.01). Patients undergoing upper GIE with HFNC displayed a significantly lower risk of hypoxemia (96%, p<0.001, I²:15.59%), even after exclusion of endoscopic retrograde cholangiopancreatography (ERCP) cases (RR:0.03, CI95%: 0.01-0.21), albeit with higher heterogeneity (I²:41.82%). Contrariwise, colonoscopy with HFNC did not yield a statistically significant RR reduction (p=0.14).

CONCLUSION

Patients undergoing upper GIE with HFNC oxygen experience significantly less hypoxemia burden than CNC counterparts. Further research is warranted to establish this emerging association to target optimal safety during endoscopy.

High flow nasal cannula versus standard low flow nasal oxygen during flexible bronchoscopy in children: A randomized controlled trial

BACKGROUND

Hypoxemia is the most frequent complication of fiberoptic bronchoscopy (FB) in children. Guidelines recommend oxygen supplementation and conventional nasal prongs (NC) are used for this purpose. The aim of this study was to evaluate if the use of high-flow nasal cannula therapy (HFNC) in children undergoing FB result in a lower incidence of hypoxemia than standard oxygen administration.

METHODS

Patients aged 1 month-16 years undergoing elective FB were included in a prospective randomized controlled, nonblinded, single-center clinical trial and randomly assigned to receive oxygen via NC or HFNC. Patients' baseline characteristics were recorded pre-bronchoscopy. The primary outcome was oxygen desaturation during the procedure defined as saturation less than 94%.

RESULTS

An intention to treat analysis for 53 patients receiving NC and 51 receiving HFNC, showed HFNC patients were less likely to have hypoxemia than were NC patients (p = .011), with an absolute risk reduction of 0.27 (95% confidence interval [CI]: 0.08-0.45) and a number needed to treat of 3.75 (95% CI: 2.22-12.04). Moderate hypoxemia (SpO₂  ≥ 90% and <94%, and <60 s) was observed significantly less often with HFNC than with NC (p = .012). Severe hypoxemia (SpO₂  < 90% and >30 s) was not different between groups. Patients undergoing bronchoalveolar lavage (BAL) presented fewer desaturations with HFNC (p = .0003).

CONCLUSIONS

HFNC offers optimized oxygenation during elective FB with a significant reduction in desaturations and can be considered for oxygen administration, especially when BAL is performed.

An update on pediatric sedation techniques in nonoperating room locations

PURPOSE OF REVIEW

To review advancements in care for pediatric patients in nonoperating room settings.

RECENT FINDINGS

Advances in patient monitoring technology, utilization of Child Life specialists, and alternative staffing models are helping anesthesia providers meet the rising demand for coverage of pediatric nonoperating room anesthesia (NORA) cases. The Wake Up Safe and Pediatric Sedation Research Consortium registries are exploring outcome measures regarding the safety of pediatric anesthesia in off-site locations and have reported an increased risk for severe respiratory and cardiac adverse events when compared to OR anesthesia sites. Additionally, malpractice claims for NORA have a higher proportion of claims for death than claims in operating rooms.

SUMMARY

Pediatric NORA requires thorough preparation, flexibility, and vigilance to provide safe anesthesia care to children in remote locations. Emerging techniques to reduce anesthetic exposure, improve monitoring, and alternative staffing models are expanding the boundaries of pediatric NORA to provide a safer, more satisfying experience for diagnostic and interventional procedures.

Procedural Sedation for Pediatric Upper Gastrointestinal Endoscopy in Korea

BACKGROUND

Sedative upper endoscopy is similar in pediatrics and adults, but it is characteristically more likely to lead to respiratory failure. Although recommended guidelines for pediatric procedural sedation are available within South Korea and internationally, Korean pediatric endoscopists use different drugs, either alone or in combination, in practice. Efforts are being made to minimize the risk of sedation while avoiding procedural challenges. The purpose of this study was to collect and analyze data on the sedation methods used by Korean pediatric endoscopists to help physicians perform pediatric sedative upper endoscopy (PSUE).

METHODS

The PSUE procedures performed in 15 Korean pediatric gastrointestinal endoscopic units within a year were analyzed. Drugs used for sedation were grouped according to the method of use, and the depth of sedation was evaluated based on the Ramsay scores. The procedures and their complications were also assessed.

RESULTS

In total, 734 patients who underwent PSUE were included. Sedation and monitoring were performed by an anesthesiologist at one of the institutions. The sedative procedures were performed by a pediatric endoscopist at the other 14 institutions. Regarding the number of assistants present during the procedures, 36.6% of procedures had one assistant, 38.8% had 2 assistants, and 24.5% had 3 assistants. The average age of the patients was 11.6 years old. Of the patients, 19.8% had underlying diseases, 10.0% were taking medications such as epilepsy drugs, and 1.0% had snoring or sleep apnea history. The average duration of the procedures was 5.2 minutes. The subjects were divided into 5 groups as follows: 1) midazolam + propofol + ketamine (M + P + K): n = 18, average dose of 0.03 + 2.4 + 0.5 mg/kg; 2) M + P: n = 206, average dose of 0.06 + 2.1 mg/kg; 3) M + K: n = 267, average dose of 0.09 + 0.69 mg/kg; 4) continuous P infusion for 20 minutes: n = 15, average dose of 6.6 mg/kg; 5) M: n = 228, average dose of 0.11 mg/kg. The average Ramsay score for the five groups was 3.7, with significant differences between the groups (P < 0.001). Regarding the adverse effects, desaturation and increased oxygen supply were most prevalent in the M + K group. Decreases and increases in blood pressure were most prevalent in the M + P + K group, and bag-mask ventilation was most used in the M + K group. There were no reported incidents of intubation or cardiopulmonary resuscitation. A decrease in oxygen saturation was observed in 37 of 734 patients, and it significantly increased in young patients (P = 0.001) and when ketamine was used (P = 0.014). Oxygen saturation was also correlated with dosage (P = 0.037). The use of ketamine (P < 0.001) and propofol (P < 0.001) were identified as factors affecting the Ramsay score in the logistic regression analysis.

CONCLUSION

Although the drug use by Korean pediatric endoscopists followed the recommended guidelines to an extent, it was apparent that they combined the drugs or reduced the doses depending on the patient characteristics to reduce the likelihood of respiratory failure. Inducing deep sedation facilitates comfort during the procedure, but it also leads to a higher risk of complications.