The effect of endotracheal tubes versus laryngeal mask airways on perioperative respiratory adverse events in infants: a randomised controlled trial

Comparison of supraglottic airway device and endotracheal tube in former preterm infants receiving general anesthesia: a randomized controlled trial

To date, endotracheal tube (ETT) remains the mainstream for preterm infants receiving general anesthesia. We aim to compare the perioperative respiratory adverse events between using supraglottic airway device (SAD) and ETT in former preterm infants receiving general anesthesia. Former preterm infants below 52 weeks of postmenstrual age scheduled for herniorrhaphy were randomized to receive SAD or ETT for general anesthesia. Infants with severe congenital cardiopulmonary disease, prolonged oxygen or mechanical ventilation dependence, and recent respiratory tract infection were excluded. Muscle relaxant agents and opioids were avoided in this study. 40 infants were assigned into SAD or ETT groups. Infants in the SAD group had a much lower rate of intraoperative desaturation than those in the ETT group (21.1% vs. 73.7%, p = 0.003). Incidences of other intraoperative and postoperative 24-h respiratory adverse events were similar between groups, including laryngospasm/bronchospasm, cough and stridor during anesthesia, and postoperative apnea, bradycardia, and supplemental oxygen use. All participants were extubated successfully in the operation room. SAD is recommended in former preterm infants receiving general anesthesia for herniorrhaphy in their early infancy as it much decreases the incidence of intraoperative desaturation compared to ETT.

Impact of varied anesthesia maintenance strategies on postoperative respiratory complications in pediatric patients undergoing tonsillectomy and adenoidectomy (AmPRAEC study): study protocol for a multicenter randomized, double-blind clinical trial

BACKGROUND

Postoperative respiratory adverse events are the most common perioperative complications in pediatric anesthesia, particularly prevalent in children undergoing tonsillectomy and adenoidectomy, with an incidence rate as high as 50%. The choice of anesthetic induction regimen directly influences the incidence of respiratory adverse events during the induction period. However, this effect seems to have minimal impact on postoperative outcomes. The occurrence rate of postoperative respiratory adverse events is likely more closely associated with the anesthetic maintenance phase, yet this relationship remains uncertain at present.

METHODS

The objective of this study was to assess the impact of different anesthetic maintenance regimens on postoperative respiratory adverse events in pediatric patients undergoing tonsillectomy and adenoidectomy. The AmPRAEC study is a multicenter, randomized, double-blind controlled trial. A total of 717 pediatric patients were recruited from 12 medical centers and randomly assigned to three groups: group A (intravenous maintenance group, receiving propofol infusion); group B (intravenous-inhalational combination group, maintained with 1% sevoflurane combined with propofol); and group C (inhalational maintenance group, maintained with 2-3% sevoflurane inhalation). The primary outcome measure was the incidence rate of postoperative respiratory adverse events.

DISCUSSION

This clinical trial aims to elucidate the impact of various anesthetic maintenance regimens on postoperative respiratory adverse events in pediatric patients. The outcomes of this study are anticipated to facilitate anesthesiologists in devising more comprehensive perioperative management strategies, enhancing comfort, and improving the clinical outcomes for this patient population.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ( http://www.chictr.org.cn ) ChiCTR2300074803. Registered on August 16, 2023.

[Airway management in neonates and infants : Recommendations according to the ESAIC/BJA guidelines]

Securing an airway enables the oxygenation and ventilation of the lungs and is a potentially life-saving medical procedure. Adverse and critical events are common during airway management, particularly in neonates and infants. The multifactorial reasons for this include patient-dependent, user-dependent and also external factors. The recently published joint ESAIC/BJA international guidelines on airway management in neonates and infants are summarized with a focus on the clinical application. The original publication of the guidelines focussed on naming formal recommendations based on systematically documented evidence, whereas this summary focusses particularly on the practicability of their implementation.

Clinical evaluation of laryngeal mask airways in video-assisted thoracic surgery: a meta-analysis of randomized controlled trials

BACKGROUND

Endotracheal intubation is often associated with postoperative complications such as sore throat discomfort and hoarseness, reducing patient satisfaction and prolonging hospital stays. Laryngeal mask airway (LMA) plays a critical role in reducing airway complications related to endotracheal intubation. This meta-analysis was performed to determine the efficacy and safety of LMA in video-assisted thoracic surgery (VATS).

METHODS

The PubMed, Embase, Cochrane Library, Medline and Web of Science databases were searched for eligible studies from inception until October 5, 2023. Cochrane's tool (RoB 2) was used to evaluate the possibility biases of RCTs. We performed sensitivity analysis and subgroup analysis to assess the robustness of the results.

RESULTS

Seven articles were included in this meta-analysis. Compared with endotracheal intubation, there was no significant difference in the postoperative hospital stay (SMD = -0.47, 95% CI = -0.98-0.03, P = 0.06), intraoperative minimum SpO2 (SMD = 0.00, 95% CI = -0.49-0.49, P = 1.00), hypoxemia (RR = 1.00, 95% CI = 0.26-3.89, P = 1.00), intraoperative highest PetCO2 (SMD = 0.51, 95% CI = -0.12-1.15, P = 0.11), surgical field satisfaction (RR = 1.01, 95% CI = 0.98-1.03, P = 0.61), anesthesia time (SMD = -0.10, 95% CI = -0.30-0.10, P = 0.31), operation time (SMD = 0.06, 95% CI = -0.13-0.24, P = 0.55) and blood loss (SMD =- 0.13, 95% CI = -0.33-0.07, P = 0.21) in LMA group. However, LMA was associated with a lower incidence of throat discomfort (RR = 0.28, 95% CI = 0.17-0.48, P < 0.00001) and postoperative hoarseness (RR = 0.36, 95% CI = 0.16-0.81, P = 0.01), endotracheal intubation was found in connection with a longer postoperative awake time (SMD = -2.19, 95% CI = -3.49 - -0.89, P = 0.001).

CONCLUSION

Compared with endotracheal intubation, LMA can effectively reduce the incidence of throat discomfort and hoarseness post-VATS, and can accelerate the recovery from anesthesia. LMA appears to be an alternative to endotracheal intubation for some specific thoracic surgical procedures, and the efficacy and safety of LMA in VATS need to be further explored in the future.

Airway management may influence postoperative ventilation need in preterm infants after laser eye treatment

BACKGROUND

Retinopathy of prematurity is treated with laser photocoagulation under general anaesthesia with intubation using endotracheal tube (ETT), which carries a risk for postoperative mechanical ventilation (MV). Laryngeal mask airway (LMA) may provide a safe alternative. We assessed the need for postoperative MV in preterm infants who received LMA versus ETT.

METHODS

In this single-centre, retrospective cohort study, preterm infants who underwent laser photocoagulation between 2014-2021 were enroled. For airway management, patients received either LMA (n = 224) or ETT (n = 47). The outcome was the rate of postoperative MV.

RESULTS

Patients' age were 37 [35;39] weeks of postmenstrual age, median bodyweight of Group LMA was higher than Group ETT's (2110 [1800;2780] g versus 1350 [1230;1610] g, respectively, p < 0.0001). After laser photocoagulation, 8% of Group LMA and 74% of Group ETT left the operating theatre requiring MV. Multiple logistic regression revealed that the use of LMA and every 100 g increase in bodyweight significantly decreased the odds of mechanical ventilation (OR 0.21 [95% CI 0.07-0.60], and 0.73 [95% CI 0.63-0.84], respectively). Propensity score matching confirmed that LMA decreased the odds of postoperative MV (OR 0.30 [95% CI 0.11-0.70]).

CONCLUSION

The use of LMA is associated with a reduced need for postoperative MV.

IMPACT

Using laryngeal mask airway instead of endotracheal tube for airway management in preterm infants undergoing general anaesthesia for laser photocoagulation for treating retinopathy of prematurity could significantly decrease the postoperative need for mechanical ventilation. According to our current understanding, this has been the largest study investigating the effect of laryngeal mask airway during general anaesthesia in preterm infants. Our study suggests that the use of laryngeal mask airway is a viable alternative to intubation in the vulnerable population of preterm infants in need of laser treatment.

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.

A systematic review on safety and surgical and anesthetic risks of elective abdominal laparoscopic surgery in infants to guide laparoscopic ovarian tissue harvest for fertility preservation for infants facing gonadotoxic treatment

Background

Infertility is an important late effect of childhood cancer treatment. Ovarian tissue cryopreservation (OTC) is established as a safe procedure to preserve gonadal tissue in (pre)pubertal girls with cancer at high risk for infertility. However, it is unclear whether elective laparoscopic OTC can also be performed safely in infants <1 year with cancer. This systematic review aims to evaluate the reported risks in infants undergoing elective laparoscopy regarding mortality, and/or critical events (including resuscitation, circulatory, respiratory, neurotoxic, other) during and shortly after surgery.

Methods

This systematic review followed the Preferred reporting Items for Systematic Review and Meta-Analyses (PRISMA) reporting guideline. A systematic literature search in the databases Pubmed and EMbase was performed and updated on February 15th, 2023. Search terms included 'infants', 'intubation', 'laparoscopy', 'mortality', 'critical events', 'comorbidities' and their synonyms. Papers published in English since 2000 and describing at least 50 patients under the age of 1 year undergoing laparoscopic surgery were included. Articles were excluded when the majority of patients had congenital abnormalities. Quality of the studies was assessed using the QUIPS risk of bias tool.

Results

The Pubmed and Embase databases yielded a total of 12,401 unique articles, which after screening on title and abstract resulted in 471 articles to be selected for full text screening. Ten articles met the inclusion criteria for this systematic review, which included 1778 infants <1 years undergoing elective laparoscopic surgery. Mortality occurred once (death not surgery-related), resuscitation in none and critical events in 53/1778 of the procedures.

Conclusion

The results from this review illustrate that morbidity and mortality in infants without extensive comorbidities during and just after elective laparoscopic procedures seem limited, indicating that the advantages of performing elective laparoscopic OTC for infants with cancer at high risk of gonadal damage may outweigh the anesthetic and surgical risks of laparoscopic surgery in this age group.

Less invasive surfactant administration methods: Who, what and how

Surfactant administration via an endotracheal tube (ETT) has been the standard of care for infants with respiratory distress syndrome for decades. As non-invasive ventilation has become commonplace in the NICU, methods for administering surfactant without use of an ETT have been developed. These methods include thin catheter techniques (LISA, MIST), aerosolization/ nebulization, and surfactant administration through laryngeal (LMA) or supraglottic airways (SALSA). This review will describe these methods and discuss considerations and implementation into clinical practice.

The Incidence of Postoperative Complications Following Lumbar and Bone Marrow Punctures in Pediatric Anesthesia: Insights From APRICOT

OBJECTIVE

Bone marrow aspiration and lumbar puncture are procedures frequently performed in pediatric oncology. We aimed at assessing the incidence and risk factors of perioperative complications in children undergoing these procedures under sedation or general anesthesia.

METHODS

Based on the APRICOT study, we performed a secondary analysis, including 893 children undergoing bone marrow aspiration and lumbar puncture. The primary outcome was the incidence of perioperative complications. Secondary outcomes were their risk factors.

RESULTS

We analyzed data of 893 children who underwent 915 procedures. The incidence of severe adverse events was 1.7% and of respiratory complications was 1.1%. Prematurity (RR 4.976; 95% CI 1.097-22.568; P = 0.038), intubation (RR: 6.80, 95% CI 1.66-27.7; P =0.008), and emergency situations (RR 3.99; 95% CI 1.14-13.96; P = 0.030) increased the risk for respiratory complications. The incidence of cardiovascular instability was 0.4%, with premedication as risk factor (RR 6.678; 95% CI 1.325-33.644; P =0.021).

CONCLUSION

A low incidence of perioperative adverse events was observed in children undergoing bone marrow aspiration or lumbar puncture under sedation and/or general anesthesia, with respiratory complications being the most frequent. Careful preoperative assessment should be undertaken to identify risk factors associated with an increased risk, allowing for appropriate adjustment of anesthesia management.

General Anesthesia Exposure in Infancy and Childhood: A 10-year Bibliometric Analysis

PURPOSE

Heated discussions have divided health care providers and policymakers on the risks versus benefits of general anesthesia in pediatric populations. We conducted this study to provide a comprehensive bibliometric analysis of general anesthesia in this specific population over the past decade.

DESIGN

We summarized and quantitatively analyzed the studies related to general anesthesia in children and infants over the past decade.

METHODS

Using the Web of Science Core Collection as the data source, we analyzed the literature using CiteSpace software, focusing on authors, countries, institutions, keywords, and references to identify hotspots and predict research trends.

FINDINGS

A total of 2,364 publications on pediatric anesthesia were included in the analysis. The number of related publications and citations steadily increased from 2013 to 2022. The United States was the leading country in terms of output, and University of Toronto was the primary contributing institution. Co-citation analysis revealed that over the past decade research has mainly focused on the long-term adverse effects of general anesthesia on neurodevelopment and acute perioperative crisis events. Keyword analysis identified infant sedation and drug selection and compatibility as promising areas for development. In addition, improving the quality of perioperative anesthesia will be a major research focus in the future.

CONCLUSIONS

Recent research in pediatric anesthesia has focused on mitigating the adverse effects of general anesthesia in infants and young children and studying the pharmacological compatibility of anesthetics. Our study results would assist researchers and clinicians in understanding the current research status and optimizing clinical practice in this field.

Benefits of remimazolam as an anesthetic sedative for older patients: A review

Owing to the decreased levels of receptors in the peripheral and central nervous systems, the functions of various organ systems decline in older patients. When administering anesthesia to older patients, it is necessary to consider the effects of medication on the homeostatic balance. Remimazolam, a new benzodiazepine, was recently developed as an anesthetic drug that has shown promise in clinical anesthesia application owing to its molecular structure, targets, pharmacodynamics, and pharmacokinetic characteristics. Remimazolam exhibits a rapid onset and metabolism, with minor effects on liver and kidney functions. Moreover, the drug has a specific antagonist, flumazenil. It is safer to use in older patients than other anesthetic sedatives and has been widely used since its introduction. Comparisons of the pharmacokinetics, metabolic pathways, effects on target organs, and hemodynamics of different drugs with those of commonly used anesthetic sedative drugs are useful to inform clinical practice. This article elaborates on the benefits of remimazolam compared with those of other anesthetic sedatives for sedation in older patients to demonstrate how it offers a new option for anesthetics in older patients. In cases involving older patients with increased clinical complexities or very old patients requiring anesthesia, remimazolam can be selected as the preferred anesthetic sedative, as outlined in this review.

Airway management in neonates and infants: European Society of Anaesthesiology and Intensive Care and British Journal of Anaesthesia joint guidelines

Airway management is required during general anaesthesia and is essential for life-threatening conditions such as cardiopulmonary resuscitation. Evidence from recent trials indicates a high incidence of critical events during airway management, especially in neonates or infants. It is important to define the optimal techniques and strategies for airway management in these groups. In this joint European Society of Anaesthesiology and Intensive Care (ESAIC) and British Journal of Anaesthesia (BJA) guideline on airway management in neonates and infants, we present aggregated and evidence-based recommendations to assist clinicians in providing safe and effective medical care. We identified seven main areas of interest for airway management: i) preoperative assessment and preparation; ii) medications; iii) techniques and algorithms; iv) identification and treatment of difficult airways; v) confirmation of tracheal intubation; vi) tracheal extubation, and vii) human factors. Based on these areas, Population, Intervention, Comparison, Outcomes (PICO) questions were derived that guided a structured literature search. GRADE (Grading of Recommendations, Assessment, Development and Evaluation) methodology was used to formulate the recommendations based on those studies included with consideration of their methodological quality (strong '1' or weak '2' recommendation with high 'A', medium 'B' or low 'C' quality of evidence). In summary, we recommend: 1. Use medical history and physical examination to predict difficult airway management (1C). 2. Ensure adequate level of sedation or general anaesthesia during airway management (1B). 3. Administer neuromuscular blocker before tracheal intubation when spontaneous breathing is not necessary (1C). 4. Use a videolaryngoscope with an age-adapted standard blade as first choice for tracheal intubation (1B). 5. Apply apnoeic oxygenation during tracheal intubation in neonates (1B). 6. Consider a supraglottic airway for rescue oxygenation and ventilation when tracheal intubation fails (1B). 7. Limit the number of tracheal intubation attempts (1C). 8. Use a stylet to reinforce and preshape tracheal tubes when hyperangulated videolaryngoscope blades are used and when the larynx is anatomically anterior (1C). 9. Verify intubation is successful with clinical assessment and end-tidal CO2 waveform (1C). 10. Apply high-flow nasal oxygenation, continuous positive airway pressure or nasal intermittent positive pressure ventilation for postextubation respiratory support, when appropriate (1B).

Airway management in neonates and infants: European Society of Anaesthesiology and Intensive Care and British Journal of Anaesthesia joint guidelines

Airway management is required during general anaesthesia and is essential for life-threatening conditions such as cardiopulmonary resuscitation. Evidence from recent trials indicates a high incidence of critical events during airway management, especially in neonates or infants. It is important to define the optimal techniques and strategies for airway management in these groups. In this joint European Society of Anaesthesiology and Intensive Care (ESAIC) and British Journal of Anaesthesia (BJA) guideline on airway management in neonates and infants, we present aggregated and evidence-based recommendations to assist clinicians in providing safe and effective medical care. We identified seven main areas of interest for airway management: i) preoperative assessment and preparation; ii) medications; iii) techniques and algorithms; iv) identification and treatment of difficult airways; v) confirmation of tracheal intubation; vi) tracheal extubation, and vii) human factors. Based on these areas, Population, Intervention, Comparison, Outcomes (PICO) questions were derived that guided a structured literature search. GRADE (Grading of Recommendations, Assessment, Development and Evaluation) methodology was used to formulate the recommendations based on those studies included with consideration of their methodological quality (strong '1' or weak '2' recommendation with high 'A', medium 'B' or low 'C' quality of evidence). In summary, we recommend: 1. Use medical history and physical examination to predict difficult airway management (1С). 2. Ensure adequate level of sedation or general anaesthesia during airway management (1B). 3. Administer neuromuscular blocker before tracheal intubation when spontaneous breathing is not necessary (1С). 4. Use a videolaryngoscope with an age-adapted standard blade as first choice for tracheal intubation (1B). 5. Apply apnoeic oxygenation during tracheal intubation in neonates (1B). 6. Consider a supraglottic airway for rescue oxygenation and ventilation when tracheal intubation fails (1B). 7. Limit the number of tracheal intubation attempts (1C). 8. Use a stylet to reinforce and preshape tracheal tubes when hyperangulated videolaryngoscope blades are used and when the larynx is anatomically anterior (1C). 9. Verify intubation is successful with clinical assessment and end-tidal CO 2 waveform (1C). 10. Apply high-flow nasal oxygenation, continuous positive airway pressure or nasal intermittent positive pressure ventilation for postextubation respiratory support, when appropriate (1B).

Comparison of laryngeal mask airway and endotracheal tube in general anesthesia in children

At present, there is no relevant expert consensus indicating which ventilation device is more efficient for general anesthesia. The present literature review and meta-analysis compared the effects of the laryngeal mask airway and endotracheal intubation on airway complications during general anesthesia. The keywords 'laryngeal mask airway', 'endotracheal tube', 'tracheal tube', 'children', 'pediatric', 'anesthesia', 'randomized controlled trials' (RCTs) and 'randomized' were used to perform the literature search in PubMed. Quality assessment was performed by two reviewers according to domains defined by the Cochrane Collaboration tool. Data extraction, risk of bias assessment and quality of evidence assessment were performed with the Cochrane tool. A total of 16 RCTs were included. The results indicated that the effects of the laryngeal mask airway group on heart rate variability [mean difference=-13.76; 95% CI, -18.19-(-9.33); P<0.00001], the incidence of hypoxemia [odds ratio (OR)=0.52; 95% CI, 0.28-0.97; P=0.04] and the incidence of postoperative cough (OR=0.22; 95% CI, 0.12-0.40; P<0.0001) were significantly lower than those of the endotracheal intubation group. The success rate of one-time implantation in the laryngeal mask airway group was significantly higher than that noted in the endotracheal intubation group (OR=0.20; 95% CI, 0.07-0.59; P=0.003). However, no significant differences were noted between the two groups in bronchospasm, sore throat, mucosal injury, nausea and vomiting and reflux aspiration. In conclusion, the results indicated that laryngeal mask airway application can reduce complications during general anesthesia compared with endotracheal intubation.

Pre-operative gastric ultrasound in patients at risk of pulmonary aspiration: a prospective observational cohort study

Point-of-care gastric sonography offers an objective approach to assessing individual pulmonary aspiration risk before induction of general anaesthesia. We aimed to evaluate the potential impact of routine pre-operative gastric ultrasound on peri-operative management in a cohort of adult patients undergoing elective or emergency surgery at a single centre. According to pre-operative gastric ultrasound results, patients were classified as low risk (empty, gastric fluid volume ≤ 1.5 ml.kg-1 body weight) or high risk (solid, mixed or gastric fluid volume > 1.5 ml.kg-1 body weight) of aspiration. After sonography, examiners were asked to indicate changes in aspiration risk management (none; more conservative; more liberal) to their pre-defined anaesthetic plan and to adapt it if patient safety was at risk. We included 2003 patients, 1246 (62%) of which underwent elective and 757 (38%) emergency surgery. Among patients who underwent elective surgery, 1046/1246 (84%) had a low-risk and 178/1246 (14%) a high-risk stomach, with this being 587/757 (78%) vs. 158/757 (21%) among patients undergoing emergency surgery, respectively. Routine pre-operative gastric sonography enabled changes in anaesthetic management in 379/2003 (19%) of patients, with these being a more liberal approach in 303/2003 (15%). In patients undergoing elective surgery, pre-operative gastric sonography would have allowed a more liberal approach in 170/1246 (14%) and made a more conservative approach indicated in 52/1246 (4%), whereas in patients undergoing emergency surgery, 133/757 (18%) would have been managed more liberally and 24/757 (3%) more conservatively. We showed that pre-operative gastric ultrasound helps to identify high- and low-risk situations in patients at risk of aspiration and adds useful information to peri-operative management. Our data suggest that routine use of pre-operative gastric ultrasound may improve individualised care and potentially impact patient safety.

Perioperative management of infant inguinal hernia surgery; a review of the recent literature

Inguinal hernia surgery is one of the most common electively performed surgeries in infants. The common nature of inguinal hernia combined with the high-risk population involving a predominance of preterm infants makes this a particular area of interest for those concerned with their perioperative care. Despite a large volume of literature in the area of infant inguinal hernia surgery, there remains much debate amongst anesthetists, surgeons and neonatologists regarding the optimal perioperative management of these patients. The questions asked by clinicians include; when should the surgery occur, how should the surgery be performed (open or laparoscopic), how should the anesthesia be conducted, including regional versus general anesthesia and airway devices used, and what impact does anesthesia choice have on the developing brain? There is a paucity of evidence in the literature on the concerns, priorities or goals of the parents or caregivers but clearly their opinions do and should matter. In this article we review the current clinical surgical and anesthesia practice and evidence for infants undergoing inguinal hernia surgery to help clinicians answer these questions.

A Predictive Model of Major Postoperative Respiratory Adverse Events in Pediatric Patients Undergoing Rigid Bronchoscopy for Exploration and Foreign Body Removal

Background: No nomogram has been established to predict the incidence of major postoperative respiratory adverse events (mPRAEs) in children undergoing rigid bronchoscopy for airway foreign bodies (AFB) removal and exploration of the airway, though some studies have confirmed the risk factors. Methods: 1214 pediatric patients (≤3 years old) undergoing rigid bronchoscopy for AFB from June 2014 to December 2020 were enrolled in this study. The primary outcome was the occurrence of mPRAEs, including laryngospasm and bronchospasm. Following that, a nomogram prediction model for the mPRAEs was developed. Results: The incidence of mPRAEs was 84 (6.9%) among 1214 subjects. American Society of Anesthesiologists physical status (ASA-PS), intraoperative desaturation (SpO2 < 90%), procedural duration and ventilatory approach were all independent risk factors of mPRAEs. The area under the receiver operating characteristic curve (AUC) value of the nomogram for predicting mPRAEs was 0.815 (95% CI: 0.770-0.861), and the average AUC for ten-fold cross-validation was 0.799. These nomograms were well calibrated by Hosmer-Lemshow (p = 0.607). Decision curve analysis showed that the nomogram prediction model is effective in clinical settings. Conclusions: Combining ASA-PS, intraoperative desaturation, procedural duration, and ventilatory approach, the nomogram model is adequate for predicting the risk of developing mPRAEs, followed by rigid bronchoscopy for AFB removal and exploration.

Aerosol generation with the use of positive pressure ventilation via supraglottic airway devices: an observational study

The amount of aerosol generation associated with the use of positive pressure ventilation via a supraglottic airway device has not been quantified. We conducted a two-group, two-centre, prospective cohort study in which we recruited 21 low-risk adult patients scheduled for elective surgery under general anaesthesia with second-generation supraglottic airway devices. An optical particle sizer and an isokinetic sampling probe were used to record particle concentrations per second at different size distributions (0.3-10 μm) during use as well as baseline levels during two common activities (conversation and coughing). There was a median (IQR [range]) peak increase of 2.8 (1.5-4.5 [1-28.1]) and 4.1 (2.0-7.1 [1-18.2]) times background concentrations during SAD insertion and removal. Most of the particles generated during supraglottic airway insertion (85.0%) and removal (85.3%) were < 3 μm diameter. Median (IQR [range]) aerosol concentration generated by insertion (1.1 (0.6-5.1 [0.2-22.3]) particles.cm^-3 ) and removal (2.1 (0.5-3.0 [0.1-18.9]) particles.cm^-3 ) of SADs were significantly lower than those produced during continuous talking (44.5 (28.3-70.5 [2.0-134.5]) particles.cm^-3 ) and coughing (141.0 (98.3-202.8 [4.0-296.5]) particles.cm^-3 ) (p < 0.001). The aerosol levels produced were similar with the two devices. The proportion of easily inhaled and small particles (<1 μm) produced during insertion (57.5%) and removal (57.5%) was much lower than during talking (99.1%) and coughing (99.6%). These results suggest that the use of supraglottic airway devices in low-risk patients, even with positive pressure ventilation, generates fewer aerosols than speaking and coughing in awake patients.

Adjuvant Transthoracic Negative-Pressure Ventilation in Nonintubated Thoracoscopic Surgery

BACKGROUND

To minimize the risks of barotrauma during nonintubated thoracoscopic-surgery under spontaneous ventilation, we investigated an adjuvant transthoracic negative-pressure ventilation (NPV) method in patients operated on due to severe emphysema or interstitial lung disease.

METHODS

In this retrospective study, NPV was employed for temporary low oxygen saturation and to achieve end-operative lung re-expansion during nonintubated lung volume reduction surgery (LVRS) for severe emphysema (30 patients, LVRS group) and in the nonintubated wedge resection of undetermined interstitial lung disease (30 patients, wedge-group). The results were compared following 1:1 propensity score matching with equivalent control groups undergoing the same procedures under spontaneous ventilation, with adjuvant positive-pressure ventilation (PPV) performed on-demand through the laryngeal mask. The primary outcomes were changes (preoperative-postoperative value) in the arterial oxygen tension/fraction of the inspired oxygen ratio (ΔPO₂/FiO₂;) and ΔPaCO₂, and lung expansion completeness on a 24 h postoperative chest radiograph (CXR-score, 2: full or 1: incomplete).

RESULTS

Intergroup comparisons (NPV vs. PPV) showed no differences in demographic and pulmonary function. NPV could be accomplished in all instances with no conversion to general anesthesia with intubation. In the LVRS group, NPV improved ΔPO₂/FiO₂ (9.3 ± 16 vs. 25.3 ± 30.5, p = 0.027) and ΔPaCO₂ (-2.2 ± 3.15 mmHg vs. 0.03 ± 0.18 mmHg, p = 0.008) with no difference in the CXR score, whereas in the wedge group, both ΔPO₂/FiO₂ (3.1 ± 8.2 vs. 9.9 ± 13.8, p = 0.035) and the CXR score (1.9 ± 0.3 vs. 1.6 ± 0.5, p = 0.04) were better in the NPV subgroup. There was no mortality and no intergroup difference in morbidity.

CONCLUSIONS

In this retrospective study, NITS with adjuvant transthoracic NPV resulted in better 24 h oxygenation measures than PPV in both the LVRS and wedge groups, and in better lung expansion according to the CXR score in the wedge group.

Effect of dexmedetomidine on preventing perioperative respiratory adverse events in children: A systematic review and meta‑analysis of randomized controlled trials

The most common critical incidents in pediatric anesthesia are perioperative respiratory adverse events (PRAEs). The present meta-analysis aimed to assess the preventive effect of dexmedetomidine on PRAEs in children. Dexmedetomidine is a highly selective α₂-adrenoceptor agonist that provides sedation, anxiolysis and analgesic effects without causing respiratory depression. Dexmedetomidine can diminish airway and circulatory responses during extubation in children. Original randomized controlled trial data were analyzed to study the putative effect of dexmedetomidine on PRAEs. By searched the Cochrane Library, EMBASE and PubMed, a total of ten randomized controlled trials (1,056 patients) was identified. PRAEs included cough, breath holding, laryngospasm, bronchospasm, desaturation (percutaneous oxygen saturation <95%), body movement and pulmonary rales. Compared with placebo, dexmedetomidine resulted in a significant reduction of incidence of cough, breath holding, laryngospasm and emergence agitation. The incidence of PRAEs was significantly reduced in dexmedetomidine compared with active comparators group. Moreover, dexmedetomidine decreased heart rate and increased post-anesthesia care unit stay duration by 11.18 min. The present analysis suggested that dexmedetomidine improved the airway function and decreased risks associated with general anesthesia in children. The present data demonstrated that dexmedetomidine may be a good choice to prevent PRAEs in children.

Esketamine opioid-free intravenous anesthesia versus opioid intravenous anesthesia in spontaneous ventilation video-assisted thoracic surgery: a randomized controlled trial

Background

Opioid-free anesthesia (OFA) provides adequate analgesia and can reduce postoperative opioid consumption, but its efficacy in spontaneous ventilation video-assisted thoracic surgery (SV-VATS) has not been demonstrated. We aimed to investigate the hypothesis that OFA could provide the same perioperative pain control as opioid anesthesia (OA), maintain safe and stable respiration and hemodynamics during surgery, and improve postoperative recovery.

Methods

Sixty eligible patients (OFA group: n=30; OA group: n=30) treated between September 15, 2022, and December 15, 2022, at The First Hospital of Guangzhou Medical University were included. They were randomized to receive standard balanced OFA with esketamine or OA with remifentanil combined with sufentanil. The primary outcome was the pain numeric rating score (NRS) at postoperative 24 h, and the secondary outcomes were intraoperative respiratory and hemodynamic data, opioid consumption, vasoactive drug dosage, and recovery in the post-anesthesia care unit and ward.

Results

There was no significant difference in the postoperative pain scores and recovery quality between the two groups. The OFA group had a significantly lower dose of phenylephrine (P=0.001) and a lower incidence of hypotension (P=0.004) during surgery. The OFA group resumed spontaneous respiration faster (P<0.001) and had a higher quality of lung collapse (P=0.02). However, the total doses of propofol and dexmetomidine were higher (P=0.03 and P=0.02), and the time to consciousness was longer (P=0.039) in the OFA group.

Conclusions

OFA provides the same level of postoperative pain control as OA, but it is more advantageous in maintaining circulatory and respiratory stability and improving the quality of pulmonary collapse in SV-VATS.

Fatality in the perioperative period: A case report on refractory hypoxemia in an infant following open inguinal herniotomy

INTRODUCTION AND IMPORTANCE OF THE CASE

Post-operative adverse respiratory events are not uncommon among infants.

PRESENTATION OF CASE

A 2-month-old male infant with an acyanotic heart disease underwent an elective open inguinal herniotomy under general anaesthesia. The intraoperative period was uneventful. The infant developed intermittent respiratory apnea and low oxygen saturation, followed by bradycardia in the post-anaesthesia care unit. Despite continued resuscitative efforts, the baby succumbed. The autopsy did not reveal new pathology. A period of interrupted monitoring during the recovery was noted. This could have led to undetected apnoea following an obstructed airway and resultant prolonged hypoxemia, further complicated by underlying structural heart disease.

CLINICAL DISCUSSION

Hypoxemia in the postoperative period in infants could be multifactorial. Airway obstruction due to secretions, airway spasms, and apnoea are common causes.

CONCLUSION

Prolonged hypoxia among paediatric patients could rapidly progress to cardiovascular collapse, hypoxic brain injury, and even death. This warrants close monitoring and active management during impaired oxygenation and ventilation during perioperative LMA use.

Randomized Trial of Surfactant Therapy via Laryngeal Mask Airway Versus Brief Tracheal Intubation in Neonates Born Preterm

OBJECTIVE

To evaluate the possible noninferiority of surfactant administration via laryngeal mask airway (LMA) vs endotracheal tube (ETT) in avoiding the requirement for mechanical ventilation in preterm neonates with respiratory distress syndrome (RDS).

STUDY DESIGN

This was a randomized controlled trial including infants born at 27 to 36 weeks of gestation, >800 g, diagnosed with RDS and receiving fraction of inspired oxygen 0.30-0.60 via noninvasive respiratory support. Infants were randomized to surfactant via LMA (with atropine premedication) or ETT (InSuRE approach with atropine and remifentanil premedication). Primary outcome was failure of surfactant treatment to prevent the need for mechanical ventilation.

RESULTS

Patients were randomized, 51 to LMA and 42 to the ETT group. Both groups had similar baseline characteristics, with birth weights ranging from 810 to 3560 g. Failure rate was 29% in the ETT group and 20% in the LMA group (P = .311). This difference was due to early failures (within 1 hour), with 12.5% in the ETT group and 2% in the LMA group (P = .044). Surfactant therapy via LMA was non-inferior to administration via ETT; failure risk difference -9.0% (CI -∞ to 5.7%). Efficacy in decreasing fraction of inspired oxygen, number of surfactant doses administered, time to wean off all respiratory support, rates of adverse events, and outcomes including pneumothorax and BPD diagnosis did not differ between groups.

CONCLUSIONS

Surfactant therapy via LMA was noninferior to administration via ETT and it decreased early failures, possibly by avoiding adverse effects of premedication, laryngoscopy, and intubation. These characteristics make LMA a desirable conduit for surfactant administration.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02164734.

Effect of Tulobuterol Patch Versus Placebo on the Occurrence of Respiratory Adverse Events in Children Undergoing Tonsillectomies: A Randomized Controlled Trial

BACKGROUND

Perioperative respiratory adverse events are common in children. We aimed to evaluate the effect of the transdermal β-2 agonist, tulobuterol, compared with that of placebo on the incidence of perioperative respiratory adverse events in pediatric patients undergoing tonsillectomy.

METHODS

In this triple-blinded (patient, anesthesia provider, and outcome assessor) randomized controlled trial, 188 patients were randomly allocated to receive tulobuterol or a placebo. The tulobuterol groups received a tulobuterol patch (1 mg) masked with a bandage, whereas the placebo only received the bandage. The assigned bandage was applied to the patients 8 to 10 hours before the surgery. The primary outcome was the occurrence of any perioperative respiratory adverse events: oxygen desaturation <95%, airway obstruction, laryngospasm, bronchospasm, severe coughing, or stridor. The outcomes were evaluated using the average relative effect test, which estimates the effect of individual components of a composite outcome and then averages effects across components.

RESULTS

A total of 88 and 94 patients who received tulobuterol and placebo, respectively, were analyzed. The incidence of any perioperative respiratory adverse event was lower with tulobuterol (n = 13/88; 14.7%) than that with the placebo (n = 40/94; 42.5%), with an estimated average relative risk (95% confidence interval) across components of 0.35 (0.20-0.60; P < .001). The symptoms of airway obstruction were lower with tulobuterol (n = 8/88; 9.0%) than that with the placebo (n = 32/94; 34.0%), with relative risk (95% CI) of 0.31 (0.17-0.56; P < .001). The occurrence of severe coughing was lower with tulobuterol (n = 1/88; 1.1%) than that with the placebo (n = 8/94; 8.5%), with relative risk (95% CI) of 0.15 (0.03-0.68; P = .014).

CONCLUSIONS

In preschool children undergoing tonsillectomy, the preoperative application of a tulobuterol patch could decrease the occurrence of perioperative respiratory adverse events. Further studies are needed to elucidate the effect of the tulobuterol patch in a broad spectrum of pediatric anesthesia.

[Perioperative Complications in Pediatric Anesthesia]

Perioperative complications are more frequent in younger children, especially under the age of 3 years and in infants. The anatomy and physiology of children cause more respiratory adverse events compared to adult patients. Respiratory adverse events account for 60% of all anesthetic complications. Main risk factors for respiratory adverse events are upper respiratory tract infections. Keeping the airway management as noninvasive as possible helps prevent major complications.Perioperative hypotension can compromise cerebral oxygenation, especially when hypocapnia and anemia are present. Congenital heart disease leads to a higher cardiovascular adverse event rate and should be diagnosed preoperatively whenever possible.Venous and arterial cannulation is more challenging in children and complications are more frequent even for experienced practitioners. Ultrasound is an essential tool for peripheral venous access as well as for central venous catheterization.Medication errors are more common in pediatric than in adult patients. Charts and electronic calculation of dosing can increase safety of prescriptions. Standardized storage of medications at all workplaces, avoiding look-alike medications in the same compartment and storing high-risk medications separately help prevent substitution errors.Emergence delirium and postoperative nausea and vomiting (PONV) are the most frequent postoperative adverse events. For diagnosing emergence delirium, the PAED scale is a helpful tool. Prevention of emergence delirium by pharmacological and general measures plays a key role for patient outcome. Routine prophylaxis of PONV above the age of 3 years is recommended.Frequency and severity of perioperative adverse events in pediatric anesthesia can be reduced by using algorithms and defined processes to allow for structured actions. Efficient communication and organization are mainstays for utilizing all medical options to reduce the risk of complications.

Effect of Intranasal Dexmedetomidine or Midazolam for Premedication on the Occurrence of Respiratory Adverse Events in Children Undergoing Tonsillectomy and Adenoidectomy: A Randomized Clinical Trial

IMPORTANCE

Perioperative respiratory adverse events (PRAEs) are the most common complication during pediatric anesthesia, and they may be affected by the administration of preoperative sedatives.

OBJECTIVE

To investigate the effect of intranasal dexmedetomidine or midazolam used for premedication on the occurrence of PRAEs.

DESIGN, SETTING, AND PARTICIPANTS

This single-center, double-blind, randomized clinical trial was conducted among children aged 0 to 12 years undergoing elective tonsillectomy and adenoidectomy from October 2020 to June 2021 at Children's Hospital of Xuzhou Medical University, Xuzhou, China. Data analysis was performed from June to October 2021.

INTERVENTIONS

Children were randomly assigned to 3 groups: the midazolam group received intranasal midazolam (0.1 mg/kg), and the dexmedetomidine group received intranasal dexmedetomidine (2.0 μg/kg) for premedication. The normal saline group received intranasal 0.9% saline for control.

MAIN OUTCOMES AND MEASURES

The primary outcome was the difference in the incidence of PRAEs among the 3 groups. The secondary outcomes were the frequency of the individual PRAEs, including the incidence of such events during the induction and recovery periods, postoperative emergence delirium, postoperative pain score, sedation success rate, and heart rate values.

RESULTS

A total of 384 children (median [IQR] age, 7 [5-10] years; 227 boys [59.1%]) were enrolled and randomized; 373 data sets were available for intention-to-treat analysis (124 children in the midazolam group, 124 children in the dexmedetomidine group, and 125 children in the normal saline group). After the data were adjusted for age, sex, American Society of Anesthesiologists physical status, body mass index, obstructive sleep apnea, upper respiratory tract infection, and passive smoking, children in the midazolam group were more likely to experience PRAEs than those in the normal saline group (70 of 124 children [56.5%] vs 51 of 125 children [40.8%]; adjusted odds ratio [aOR], 1.99; 95% CI, 1.18-3.35), whereas the dexmedetomidine group had a significantly lower PRAEs incidence than the normal saline group (30 of 124 children [24.2%] vs 51 of 125 children [40.8%]; aOR, 0.45; 95% CI, 0.26-0.78). Compared with the dexmedetomidine group, the midazolam group had a higher risk of PRAEs (aOR, 4.44; 95% CI, 2.54-7.76), but no other serious clinical adverse events were observed.

CONCLUSIONS AND RELEVANCE

In this randomized clinical trial, intranasal midazolam used for premedication was associated with increased incidence of PRAEs, whereas premedication with intranasal dexmedetomidine was associated with reduced incidence of PRAEs. Where clinically appropriate, anesthesiologists should consider using intranasal dexmedetomidine for sedation in children undergoing tonsillectomy and adenoidectomy.

TRIAL REGISTRATION

Chinese Clinical Trial Register Identifier: ChiCTR2000038359.

Perioperative respiratory adverse events during ambulatory anesthesia in obese children

Obesity is one of the most common clinical conditions in the pediatric population with an increasing prevalence ranging from 20 to 30% worldwide. It is well known that during ambulatory anesthesia, obese children are more prone to develop perioperative respiratory adverse events (PRAEs) associated with obesity. To avoid or at least minimize these adverse effects, a thorough preoperative assessment should be undertaken as well as consideration of specific anesthetic approaches such as preoxygenation before induction of anesthesia and optimizing drug dosing. The use of short-acting opioid and nonopioid analgesics and the frequent implementation of regional anesthesia should also be included. Noninvasive airway management, protective mechanical ventilation, and complete reversion of neuromuscular blockade and awake extubation also proved to be beneficial in preventing PRAEs. During the postoperative period, continuous monitoring of oxygenation and ventilation is mandatory in obese children. In the current review, we sought to provide recommendations that might help to reduce the severity of perioperative respiratory adverse events in obese children, which could be of particular importance for reducing the rate of unplanned hospitalizations and ultimately improving the overall postoperative recovery.

Laryngeal Masks in Neonatal Resuscitation-A Narrative Review of Updates 2022

Positive pressure ventilation (PPV) is crucial to neonatal cardiopulmonary resuscitation because respiratory failure precedes cardiac failure in newborns affected by perinatal asphyxia. Prolonged ineffective PPV could lead to a need for advanced resuscitation such as intubation, chest compression, and epinephrine. Every 30 s delay in initiation of PPV increased the risk of death or morbidity by 16%. The most effective interface for providing PPV in the early phases of resuscitation is still unclear. Laryngeal masks (LMs) are supraglottic airway devices that provide less invasive and relatively stable airway access without the need for laryngoscopy which have been studied as an alternative to face masks and endotracheal tubes in the initial stages of neonatal resuscitation. A meta-analysis found that LM is a safe and more effective alternative to face mask ventilation in neonatal resuscitation. LM is recommended as an alternative secondary airway device for the resuscitation of infants > 34 weeks by the International Liaison Committee on Resuscitation. It is adopted by various national neonatal resuscitation guidelines across the globe. Recent good-quality randomized trials have enhanced our understanding of the utility of laryngeal masks in low-resource settings. Nevertheless, LM is underutilized due to its variable availability in delivery rooms, providers’ limited experience, insufficient training, preference for endotracheal tube, and lack of awareness.

Aerosolized drug delivery in awake and anesthetized children to treat bronchospasm

Bronchospasm is a common respiratory adverse event in pediatric anesthesia. First-line treatment commonly includes inhaled salbutamol. This review focuses on the current best practice to deliver aerosolized medications to awake as well as anesthetized pediatric patients and discusses the advantages and disadvantages of various administration techniques. Additionally, we detail the differences between various airway devices used in anesthesia. We highlight the unmet need for innovation of orally inhaled drug products to deliver aerosolized medications during pediatric respiratory critical events such as bronchospasm. It is therefore important that clinicians remain up to date with the best clinical practice for aerosolized drug delivery in order to prevent and efficiently treat pediatric patients experiencing life-threatening respiratory emergencies.

Risk assessment and optimization strategies to reduce perioperative respiratory adverse events in pediatric anesthesia-Part 1 patient and surgical factors

Pediatric surgery cases are increasing worldwide. Within pediatric anesthesia, perioperative respiratory adverse events are the most common precipitant leading to serious complications. They can have intraoperative impact on the surgical procedure itself, lead to premature case termination and in addition may have postoperative impact resulting in longer hospitalization stays and costs. Although most perioperative respiratory adverse events can be promptly detected and managed, and will not lead to any sequelae, the risk of life-threatening progression remains. The incidence of respiratory adverse events increases in children with comorbid respiratory and/or nonrespiratory illnesses. Optimized perioperative patient care, risk-stratified care level choice, and practitioners with appropriate training allow for risk mitigation. This review will discuss patient and surgical risk factors with a focus on common patient comorbid illnesses and review scoring systems to quantify risk.

Risk assessment and optimization strategies to reduce perioperative respiratory adverse events in Pediatric Anesthesia-Part 2: Anesthesia-related risk and treatment options

Perioperative respiratory adverse events are the most common cause of critical events in children undergoing anesthesia and surgery. While many risk factors remain unmodifiable, there are numerous anesthetic management decisions which can impact the incidence and impact of these events, especially in at-risk children. Ongoing research continues to improve our understanding of both the influence of risk factors and the effect of specific interventions. This review discusses anesthesia risk factors and outlines strategies to reduce the rate and impact of perioperative respiratory adverse events with a chronologic based inquiry into anesthetic management decisions through the perioperative period from premedication to postoperative disposition.

Perioperative Respiratory Adverse Events Among Pediatric Surgical Patients in University Hospitals in Northwest Ethiopia; A Prospective Observational Study

INTRODUCTION

Perioperative respiratory adverse events (PRAEs) are frequent among pediatrics surgical patients and are accountable for 3/4^th of perioperative critical incidents and 1/3^rd of cardiac arrests.

OBJECTIVE

Assess the prevalence and factors associated with PRAEs among pediatric surgical patients in University Hospitals in Northwest Ethiopia, 2020.

METHODOLOGY

After ethical approval obtained prospective observational study was conducted among 210 pediatric surgical patients. Perioperative respiratory adverse events were defined as the occurrence of any episode of single/combination of coughing, breath holding, hypoxemia, laryngospasm and bronchospasm. Bivariate and multivariate binary logistic regression analyses were performed and variables with p < 0.05 at 95% confidence interval were considered as statistically significant.

RESULTS

The prevalence of PRAEs was 26.2% (CI: 20.5-30.9%). A total of 129 episodes of PRAEs were occurred and of them, 89 (69.0%) were occurred in the postoperative period. Desaturation was the predominant adverse event which was observed 61 (47.3%) times. Age <1 year (AOR: 3.6, CI: 1.3-10.0), ASA ≥ 3 (AOR: 5.2, CI: 1.9-22.9), upper respiratory tract infections (URTIs) (AOR: 7.6, CI: 1.9-30.2), secretions in the upper airway (AOR: 4.8, CI: 1.4-15.9) and airway related surgery (AOR: 6.0, CI: 1.5-24.1) were significantly associated with PRAEs.

CONCLUSIONS

Prevalence of PRAEs was high among pediatric surgical patients; the postoperative period was the most critical time for the occurrence of PRAEs and desaturation was the commonest PRAE. Age <1 year, URTIs (recent or active), secretions in the upper airways, ASA ≥ 3 and airway related surgery were significantly associated with PRAEs. Clinicians should perform effective risk assessment, preoperative optimization and preparation for the management of PRAEs.

Perioperative and long-term outcomes of spontaneous ventilation video-assisted thoracoscopic surgery for non-small cell lung cancer

Background

Spontaneous ventilation video-assisted thoracoscopic surgery (SV-VATS) exhibits dual intraoperative and postoperative advantages for patients with non-small cell lung cancer (NSCLC). However, there is a lack of data regarding its long-term survival superiority over the double-lumen intubated mechanical ventilation video-assisted thoracoscopic surgery (MV-VATS) or thoracotomy.

Methods

A retrospective study was conducted from 2011 to 2018 in the First Affiliated Hospital of Guangzhou Medical University among patients with NSCLC who underwent the SV-VATS or the MV-VATS. Patients receiving the SV-VATS were the study group, and patients receiving the MV-VATS were the control group. Propensity score matching (PSM) was performed to establish 1:1 SV-VATS versus MV-VATS group matching to balance potential baseline confounding factors. Primary endpoints were overall survival (OS) and disease-free survival (DFS). Secondary endpoints were perioperative outcomes. The baseline information of these patients was recorded. The perioperative data and survival data were collected using a combination of electronic data record system and telephone interview. A 1:1:1 SPM was also used to compare the OS in the SV-VATS, the MV-VATS and thoracotomy group by using another database, including patients undergoing thoracotomy and the MV-VATS.

Results

For the two-group comparison, after 1:1 PSM, a matched cohort with 400 (200:200) patients was generated. The median follow-up time in this cohort was 4.78 years (IQR, 3.78–6.62 years). The OS (HR =0.567, 95% CI, 0.330 to 0.974, P=0.0498) and the DFS (HR =0.546, 95% CI, 0.346 to 0.863, P=0.013) of the SV-VATS group were significantly better than the MV-VATS group. There were no statistically differences between the SV-VATS and the MV-VATS group on the operative time (158.56±40.09 vs. 172.06±61.75, P=0.200) anesthesia time (247.4±62.49 vs. 256.7±58.52, P=0.528), and intraoperative bleeding volume (78.88±80.25 vs. 109.932±180.86, P=0.092). For the three-group comparison, after 1:1:1 PSM, 582 (194:194:194) patients were included for the comparison of SV-VATS, MV-VATS and thoracotomy. The OS of the SV-VATS group was significantly better than the thoracotomy group (HR =0.379, 95% CI, 0.233 to 0.617, P<0.001).

Conclusions

Invasive NSCLC patients undergoing SV-VATS lobectomy demonstrated better long-term outcomes compared with MV-VATS.

Comparison of laryngeal mask airway and endotracheal tube in preterm neonates receiving general anesthesia for inguinal hernia surgery: a retrospective study

Background

Preterm neonates are at higher risk of developing inguinal hernia, and have an increased risk of perioperative adverse events. Laryngeal mask airway (LMA) is claimed to be associated to decreasing perioperative respiratory complications compared to endotracheal tube (ETT) in infants under one year of age receiving minor surgery; thus, we conducted a retrospective survey in former preterm neonates below 5000 g to compare the respiratory complications between LMA and ETT in general anesthesia for inguinal hernia surgeries.

Methods

The inclusion criteria were: gestational age at birth under 37 weeks, body weight at surgery below 5000 g, and receiving scheduled inguinal hernia repair under general anesthesia with LMA or ETT. Infants who were dependent on mechanical ventilation preoperatively were excluded. The postoperative respiratory complications including delayed extubation, re-intubation, and apnea within postoperative 24 h were compared between groups.

Results

From July 2014 to December 2017, 72 neonates were enrolled into final analysis. There were 57 neonates managed with LMA, and only 15 neonates intubated with ETT during the study period. The gestational age at birth and post-menstrual age at surgery showed no significant difference between groups, although in the ETT group, the body weight at birth and at surgery were lower, and more infants had history of severe respiratory distress syndrome and had received oxygen therapy within two weeks prior to surgery. Surprisingly, none one of the infants developed delayed extubation, re-intubation, or postoperative apnea in the LMA group. In the ETT group, 40 percent of the neonates could not be successfully extubated in the operation theater.

Conclusion

In preterm neonates, even in those younger than 52 weeks post-menstrual age who undergoing inguinal hernia repair in their early infancy, LMA appears feasible and safe as the airway device during general anesthesia in specific patient group. However, anesthesiologist might prefer ETT rather than LMA in some complex situation. In neonates with lower body weight at birth and at surgery, and with a history of severe RDS and oxygen-dependence, further prospective study is required.

Non-intubated spontaneous ventilation in video-assisted thoracoscopic surgery: a meta-analysis

It remains unclear whether non-intubated video-assisted thoracoscopic surgery (VATS) is comparable or advantageous compared with conventional intubated VATS. Thus, we systematically assessed the feasibility and safety of non-intubated VATS compared with intubated VATS perioperatively for the treatment of different thoracic diseases. An extensive search of literature databases was conducted. Perioperative outcomes were compared between 2 types of operations. The time trend of the overall results was evaluated through a cumulative meta-analysis. Subgroup analyses of different thoracic diseases and study types were examined. Twenty-seven studies including 2537 patients were included in the analysis. A total of 1283 patients underwent non-intubated VATS; intubated VATS was performed on the other 1254 patients. Overall, the non-intubated VATS group had fewer postoperative overall complications [odds ratios (OR) 0.505; P < 0.001]; shorter postoperative fasting times [standardized mean difference (SMD) -2.653; P < 0.001]; shorter hospital stays (SMD -0.581; P < 0.001); shorter operative times (SMD -0.174; P = 0.041); shorter anaesthesia times (SMD -0.710; P < 0.001) and a lower mortality rate (OR 0.123; P = 0.020). Non-intubated VATS may be a safe and feasible alternative to intubated VATS and provide a more rapid postoperative rehabilitation time than conventional intubated VATS.

[Ventilation in Pediatric Anesthesia]

About nine percent of all anesthesia procedures per year are performed in children. The risk for complications in pediatric anesthesia is higher in comparison with adults. There are significant differences in anatomy, physiology and pharmacology between pediatric and adult patients. Respiratory complications and circulations dysregulation occur more often in children. The most important consideration in the safe practice of pediatric anesthesia is to ensure a patent airway. Appropriate intraoperative management of newborns and infants needs a senior anesthetist with good knowledge and clinical experience including the management of possible complications.

Intranasal dexmedetomidine premedication in children with recent upper respiratory tract infection undergoing interventional cardiac catheterisation: A randomised controlled trial

BACKGROUND

Recent upper respiratory tract infection (URI) is a risk factor for the occurrence of peri-operative respiratory adverse events (PRAE). This risk may be higher in children with congenital heart disease (CHD), particularly in those undergoing interventional cardiac catheterisation. It is therefore essential to adapt the anaesthetic strategy in these children to prevent from the occurrence of PRAE.

OBJECTIVE

To determine whether intranasal dexmedetomidine (DEX) premedication can reduce the incidence of PRAE in children with recent URI undergoing interventional cardiac catheterisation.

DESIGN

Randomised controlled trial.

SETTING

Single-centre study based at a tertiary care centre in Shanghai, China.

PATIENTS

A total of 134 children with CHD aged 0 to 16 years with recent URI undergoing interventional cardiac catheterisation.

INTERVENTIONS

Children were randomised to receive either intranasal DEX 1.5 μg kg (DEX group) or intranasal saline (Placebo group) 30 to 45 min before anaesthesia induction.

MAIN OUTCOME MEASURES

The incidence of PRAE.

RESULTS

Intranasal DEX significantly reduced the incidence of PRAE (P = 0.001), particularly oxygen desaturation (P = 0.012). Most PRAE were observed during the emergence phase. The incidence of PRAE was comparable among the three types of left-right shunt CHD children in both groups. In children aged less than 3 years, the incidence of PRAE was significantly lower in the DEX group (P = 0.003). In contrast, the incidence of PRAE was comparable between the two groups in children aged at least 3 years. No differences in the incidence of emergence agitation, fever and vomiting between the two groups were noted.

CONCLUSION

Administration of intranasal DEX 1.5 μg kg 30 to 45 min before induction led to a reduction in the incidence of PRAE in children aged less than 3 years with recent URI undergoing interventional cardiac catheterisation.

TRIAL REGISTRATION

chictr.org.cn identifier: ChiCTR-RRC-17012519.

Predicting Perioperative Respiratory Adverse Events in Children With Sleep-Disordered Breathing

BACKGROUND

No evidence currently exists to quantify the risk and incidence of perioperative respiratory adverse events (PRAEs) in children with sleep-disordered breathing (SDB) undergoing all procedures requiring general anesthesia. Our objective was to determine the incidence of PRAEs and the risk factors in children with polysomnography-confirmed SDB undergoing procedures requiring general anesthesia.

METHODS

Retrospective review of all patients with polysomnography-confirmed SDB undergoing general anesthesia from January 2009 to December 2013. Demographic and perioperative outcome variables were compared between children who experienced PRAEs and those who did not. Generalized estimating equations were used to build a predictive model of PRAEs.

RESULTS

In a cohort of 393 patients, 51 PRAEs occurred during 43 (5.6%) of 771 anesthesia encounters. Using generalized estimating equations, treatment with continuous positive airway pressure or bilevel positive airway pressure (odds ratio, 1.63; 95% confidence interval [CI], 1.05-2.54; P = .031), outpatient (odds ratio, 1.37; 95% CI, 1.03-1.91; P = .047), presence of severe obstructive sleep apnea (odds ratio, 1.63; 95% CI, 1.09-2.42; P = .016), use of preoperative oxygen (odds ratio 1.82; 95% CI, 1.11-2.97; P = .017), history of prematurity (odds ratio, 2.31; 95% CI, 1.33-4.01; P = .003), and intraoperative airway management with endotracheal intubation (odds ratio, 3.03; 95% CI, 1.79-5.14; P < .001) were associated with PRAEs.

CONCLUSIONS

We propose the risk factors identified within this cohort of SDB patients could be incorporated into a preoperative risk assessment tool that might better to identify the risk of PRAE during general anesthesia. Further investigation and validation of this model could contribute to improved preoperative risk stratification, decision-making (postoperative admission and level of monitoring), and health care resource allocation.

Spontaneous versus mechanical ventilation during video-assisted thoracoscopic surgery for spontaneous pneumothorax: A randomized trial

OBJECTIVE

Spontaneous ventilation video-assisted thoracic surgery (SV-VATS) is reported to have superior or equal efficacy on postoperative recovery to mechanical ventilation VATS (MV-VATS). However, perioperative safety of the SV-VATS blebectomy is not entirely demonstrated.

METHODS

We performed a noninferiority, randomized controlled trial (No. NCT03016858) for primary spontaneous pneumothorax patients aged 16 to 50 years undergoing a SV-VATS and the MV-VATS procedure. The trial was conducted at 10 centers in China from April 2017 to January 2019. The primary outcome was the comparison of intra- and postoperative complications between SV-VATS and MV-VATS procedures. Secondary outcomes included total analgesia dose, change of vital sign during surgery, procedural duration, recovery time, postoperative visual analog pain scores, and hospitalization length.

RESULTS

In this study, 335 patients were included. There was no significant difference between the SV-VATS group and the MV-VATS group in the intra- and postoperative complication rates (17.90% vs 22.09%; relative risk, 0.81; 95% confidence interval, 0.52-1.26; P = .346). The SV-VATS group was associated with significantly decreased total dose of intraoperative opioid agents; that is, sufentanil (11.37 μg vs 20.92 μg; P < .001) and remifentanil (269.78 μg vs 404.96 μg; P < .001). The SV-VATS procedure was also associated with shorter extubation time (12.28 minutes vs 17.30 minutes; P < .001), postanesthesia care unit recovery time (25.43 minutes vs 30.67 minutes; P = .02) and food intake time (346.07 minute vs 404.02 minutes; P = .002). Moreover, the SV-VATS procedure deceased the anesthesia cost compared with the MV-VATS ($297.81 vs $399.81; P < .001).

CONCLUSIONS

SV-VATS was shown to be noninferior to MV-VATS in term of complication rate and in selected patients undergoing blebectomy for primary spontaneous pneumothorax.

Supraglottic airway device versus tracheal intubation and the risk of emergent postoperative intubation after general anaesthesia in adults: a retrospective cohort study

BACKGROUND

We examined the association between emergent postoperative tracheal intubation and the use of supraglottic airway devices (SGAs) vs tracheal tubes.

METHODS

We included data from adult noncardiac surgical cases under general anaesthesia between 2008 and 2018. We only included cases (n=59 991) in which both airways were deemed to be feasible options. Multivariable logistic regression, instrumental variable analysis, propensity matching, and mediation analysis were used.

RESULTS

Use of a tracheal tube was associated with a higher risk of emergent postoperative intubation (adjusted absolute risk difference [ARD]=0.80%; 95% confidence interval (CI), 0.64-0.97; P<0.001), and a higher risk of post-extubation hypoxaemia (ARD=3.9%; 95% CI, 3.4-4.4; P<0.001). The effect was modified by the use of non-depolarising neuromuscular blocking agents (NMBAs); mediation analyses revealed that 28.9% (95% CI, 14.4-43.4%; P<0.001) of the main effect was attributable to NMBA. Airway management modified the association of NMBA and risk of emergent postoperative intubation (P_interaction=0.02). Patients managed with an SGA had higher odds of NMBA-associated reintubation compared to patients managed with a tracheal tube (adjusted odds ratio [aOR]=3.65, 95% CI, 1.99-6.67 vs aOR=1.68, 95% CI, 1.29-2.18 [P<0.001], respectively).

CONCLUSIONS

In patients undergoing procedures under general anaesthesia that could be managed with either SGA or tracheal tube, use of an SGA was associated with lower risk of emergent postoperative intubation. The effect can partly be explained by use of NMBAs. Use of NMBAs in patients with an SGA appears to increase the risk of emergent postoperative intubation.

A comparison of the breathing apparatus deadspace associated with a supraglottic airway and endotracheal tube using volumetric capnography in young children

Background

Supraglottic airway (SGA) devices including the air-Q^® are being used with increasing frequency for anesthesia in infants and younger pediatric patients. To date, there is minimal research documenting the potentially significant airway deadspace these devices may contribute to the ventilation circuit when compared to an endotracheal tube (ETT). The aim of this study was to evaluate the airway apparatus deadspace associated with an air-Q^® versus an ETT in young children.

Methods

In a prospective cohort study, 59 patients between 3 months and 6 years of age, weighing between 5 and 20 kg, scheduled for outpatient urologic or general surgery procedures were recruited. An air-Q^® or ETT was inserted at the discretion of the attending anesthesiologist, and tidal volume, positive end expiratory pressure, respiratory rate, and end-tidal CO₂ were controlled according to protocol. Airway deadspace was recorded using volumetric capnography every 2 min for 10 min.

Results

Groups were similar in demographics. There was a significant difference in weight-adjusted deadspace volume between the air-Q^® and ETT groups, 4.1 ± 0.8 ml/kg versus 3.0 ± 0.7 ml/kg, respectively (P < 0.001). Weight-adjusted deadspace volume (ml/kg) increased significantly with decreasing weight for both the air-Q^® and ETT groups.

Conclusions

In healthy children undergoing positive pressure ventilation for elective surgery, the air-Q^® SGA introduces significantly greater airway deadspace than an ETT. Additionally, airway deadspace, and minute ventilation required to maintain normocarbia, appear to increase with decreasing patient weight irrespective of whether a SGA or ETT is used.

Comparison of the Effect of Laryngeal Mask Airway Versus Endotracheal Tube on Airway Management in Pediatric Patients with Tonsillar Hypertrophy

PURPOSE

The laryngeal mask airway (LMA) has become an important choice in both routine and difficult airway management. We aimed to evaluate the safety and effectiveness of LMA use in pediatric patients with tonsillar hypertrophy.

DESIGN

This study was a randomized controlled trial.

METHODS

The study included 100 pediatric patients who had first or second degree tonsillar hypertrophy. Pediatric patients undergoing elective laparoscopic inguinal hernia repair were randomly divided into two groups (n = 50): LMA group and the endotracheal tube (ETT) group. The primary outcomes were ventilation leak volume, peak airway pressure, and partial pressure of end-tidal carbon dioxide (P_ETco₂). Data for primary outcomes were collected before and 5-, 15-, and 25-minute after opening pneumoperitoneum, and on closing the pneumoperitoneum. Complications such as laryngospasm, bronchospasm, desaturation, severe coughing, blood on the device after removal, and sore throat were recorded.

FINDINGS

A total of 100 pediatric patients were assessed and 97 eligible patients were randomly assigned to receive an LMA (n = 49) or an ETT (n = 48). There was no statistically significant difference in ventilation leak volume and P_ETco₂ between the LMA and ETT groups (P > .05). Compared with T_1-4, peak airway pressure was significantly lower in T₀ (LMA group 12.6 ± 0.9, 95% confidence interval 12.2 to 13.0; ETT group 12.8 ± 1.2, 95% confidence interval 12.2 to 13.3; P < .05). The incidences of laryngospasm 11 (22.9%), desaturation 18 (37.5%), and severe coughing 13 (27%) were higher in the ETT group (11 [22.9%] vs 3 [6.1%], 18 [37.5%] vs 6 [12.2%], 13 [27%] vs 3 [6.1%]; P < .05).

CONCLUSIONS

The application of LMA has a lower incidence of complications. LMA as an airway device is effective and perhaps superior in appropriate patients.

Spontaneous ventilation video-assisted thoracic surgery for mediastinal tumor resection in patients with pulmonary function deficiency

BACKGROUND

Whether non-intubated spontaneous ventilation video-assisted thoracoscopic surgery (SV-VATS) is a safe procedure remains controversial for mediastinal tumor patients with impaired lung function. Herein, we assessed feasibility of SV-VATS in lung function deficiency patients underwent mediastinal tumor resection.

METHODS

From December 2015 to February 2020, 32 mediastinal tumor patients with impaired lung function (preoperative forced expiratory volume in 1 second <70% of the predicted value) were retrospectively collected. Patients were divided into two groups: SV-VATS group and mechanical ventilation VATS (MV-VATS) group. Intraoperative and postoperative variables were compared between two cohorts.

RESULTS

Fifteen patients (46.88%) underwent SV-VATS and 17 patients (53.12%) were performed with MV-VATS. The most common causes of lung function deficiency were smoking (81.25%) and COPD (71.88%). Patients in the SV-VATS group had similar blood loss (20.63 vs. 18.76 mL, P=0.417) with MV-VATS group. The anesthesia time (217.51 vs. 197.76 min; P=0.343) and surgery time (141.23 vs. 132.36 min; P=0.209) were also similar between groups. Five people suffered postoperative complications in each group, in which 1 patient underwent MV-VATS was transferred to intensive care unit (ICU) because of prolonged extubation owing to hypoxia. There was no difference on chest tube removal time (2.6 vs. 2.3 days; P=0.172) or hospital duration (5.03 vs. 4.74 days; P=0.297) in patients underwent SV-VATS and MV-VATS.

CONCLUSIONS

SV-VATS is safe and provides similar short-term results to MV-VATS for mediastinal tumor resection in patients with limited pulmonary function.

Evaluation of Different Positive End-Expiratory Pressures Using Supreme™ Airway Laryngeal Mask during Minor Surgical Procedures in Children

Background and objectives: The laryngeal mask is the method of choice for airway management in children during minor surgical procedures. There is a paucity of data regarding optimal management of mechanical ventilation in these patients. The Supreme™ airway laryngeal mask offers the option to insert a gastric tube to empty the stomach contents of air and/or gastric juice. The aim of this investigation was to evaluate the impact of positive end-expiratory positive pressure (PEEP) levels on ventilation parameters and gastric air insufflation during general anesthesia in children using pressure-controlled ventilation with laryngeal mask. Materials and Methods: An observational trial was carried out in 67 children aged between 1 and 11 years. PEEP levels of 0, 3 and 5 mbar were tested for 5 min in each patient during surgery and compared with ventilation parameters (dynamic compliance (mL/cmH₂O), etCO₂ (mmHg), peak pressure (mbar), tidal volume (mL), respiratory rate (per minute), FiO₂ and gastric air (mL)) were measured at each PEEP. Air was aspirated from the stomach at the start of the sequence of measurements and at the end. Results: Significant differences were observed for the ventilation parameters: dynamic compliance (PEEP 5 vs. PEEP 3: p < 0.0001, PEEP 5 vs. PEEP 0: p < 0.0001, PEEP 3 vs. PEEP 0: p < 0.0001), peak pressure (PEEP 5 vs. PEEP 3: p < 0.0001, PEEP 5 vs. PEEP 0: p < 0.0001, PEEP 3 vs. PEEP 0: p < 0.0001) and tidal volume (PEEP 5 vs. PEEP 3: p = 0.0048, PEEP 5 vs. PEEP 0: p < 0.0001, PEEP 3 vs. PEEP 0: p < 0.0001). All parameters increased significantly with higher PEEP, with the exception of etCO₂ (significant decrease) and respiratory rate (no significant difference). We also showed different values for air quantity in the comparisons between the different PEEP levels (PEEP 5: 2.8 ± 3.9 mL, PEEP 3: 1.8 ± 3.0 mL; PEEP 0: 1.6 ± 2.3 mL) with significant differences between PEEP 5 and PEEP 3 (p = 0.0269) and PEEP 5 and PEEP 0 (p = 0.0209). Conclusions: Our data suggest that ventilation with a PEEP of 5 mbar might be more lung protective in children using the Supreme™ airway laryngeal mask, although gastric air insufflation increased with higher PEEP. We recommend the use of a laryngeal mask with the option of inserting a gastric tube to evacuate potential gastric air.

[Different anesthesia management in preterm infants undergoing surgeries for retinopathy of prematurity: A retrospective study]

OBJECTIVE

To evaluate the effect of different anesthesia management on clinical outcomes in former prematurely born infants undergoing surgeries for retinopathy of prematurity (ROP).

METHODS

In this retrospective study, electronic medical record database was searched for all former prematurely born infants (gestational age < 37 weeks and post conceptual age < 60 weeks) who received ROP surgery under inhalational general anesthesia between November 2016 and October 2018. The patients were divided into two groups based on anesthesia management: laryngeal mask airway (LMA) insertion without intravenous muscle relaxant injection and with pressure support ventilation (LMA group) or airway secured with endotracheal tube (ETT) with intravenous muscle relaxant injection and pressure controlled ventilation (ETT group). Primary outcomes included perioperative adverse events and complications. Extubation time and length of stay after surgery were also recorded.

RESULTS

Sixty eight preterm infants in the LMA group and 100 preterm infants in the ETT group were included. The incidence of adverse events during surgery (including airway management change and desaturation) was similar in LMA group and ETT group (4.4% vs. 1.0%, P =0.364). During the early recovery period after surgery, the incidence of difficult extubation (extubation time >30 min) was significantly lower in LMA group compared with ETT group (4.4% vs.15.0%, RR=0.262, 95%CI:0.073－0.942, P=0.029). The incidence of respiratory events was similar between the two groups (20.6% vs. 27.0%, P =0.342). However, the incidence of apnea was significantly lower in the LMA group than in the ETT group (5.9% vs.19.0%, RR=0.266, 95%CI: 0.086－0.822, P =0.015). No significant difference was observed between the LMA group and ETT group in incidences of cardiovascular events (0% vs. 1.0%, P =1.000) and unplanned admission to neonatal intensive care unit (5.9% vs. 7.0%, P=0.774). No airway spasm, re-intubation, aspiration or regurgitation was observed during early recovery. During late recovery after returning to ward, the incidence of adverse events was also similar between the two groups (0% vs. 2.0%, P =0.241). The median (IQR) extubation time was 6 (5, 10) min in LMA group and 10 (6, 19) min in ETT group (P < 0.001). The median length of stay after surgery was significantly shortened in LMA group compared with ETT group [20 (17, 22) hours vs. 22 (17, 68) hours, P =0.002].

CONCLUSION

Compared with endotracheal intubation with intravenous muscle relaxant injection, laryngeal mask airway insertion without muscle relaxant could achieve an early extubation, and reduce the incidence of apnea during early recovery period in former prematurely born infants undergoing ROP surgery.

Anaesthesia, pain and recovery profiles in children following dental extractions

The aim of this prospective cohort study was to describe the anaesthetic practices, rates of postoperative pain and the recovery trajectory of children having urgent dental extractions at our institution. Demographic, anaesthetic and surgical details of children undergoing dental extractions were obtained by case note review. Parent-proxy pain scores were collected via telephone on the day of surgery and on postoperative days, as well as details of analgesia given, behavioural disturbance, and nausea and vomiting. Follow-up was continued until each child no longer had pain. Datasets were analysed for 143 patients. Fasting times were prolonged, with 81 children (56.6%) fasted for over four hours from fluids. Moderate or severe pain was recorded in 14 children (9.8%) postoperatively on the day of surgery, with higher rates in children who had a greater number of teeth extracted. Low rates of moderate to severe pain were observed during follow-up, affecting six children (4.2%) on postoperative day 1 and three children (2.1%) on postoperative day 2 with primarily simple analgesia administered at home. Only eight children (5.6%) had nausea and/or vomiting on the day of surgery. Rates of reported behavioural disturbance at home were low, extending beyond the second postoperative day in only two children (1.4%), and only four children (2.8%) attended a dentist during the follow-up period. In conclusion, the low rates of pain and nausea and vomiting reported in the days following surgery for urgent dental procedures suggest that children can be cared for at home with simple analgesia.