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Kim EH, Park JB, Kang P, Ji SH, Jang YE, Lee JH, Kim JT, Kim HS. Effect of positive end expiratory pressure on non-hypoxic apnea time and atelectasis during induction of anesthesia in infant: A randomized controlled trial. Paediatr Anaesth 2024. [PMID: 38980197 DOI: 10.1111/pan.14965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Revised: 06/25/2024] [Accepted: 06/30/2024] [Indexed: 07/10/2024]
Abstract
INTRODUCTION This study aimed to assess the impact of positive-end-expiratory pressure (PEEP) on the non-hypoxic apnea time in infants during anesthesia induction with an inspired oxygen fraction of 0.8. METHODS This age stratified randomized controlled trial included patients under 1 year of age. Preoxygenation was performed using an inspired oxygen fraction of 0.8 for 2 min. Inspired oxygen fraction of 0.8 was administered via a face mask with volume-controlled ventilation at a tidal volume of 6 mL.kg-1, with or without 7 cmH2O of PEEP. Tracheal intubation was performed after 3 min of ventilation; however, it was disconnected from the breathing circuit. Ventilation was resumed once the pulse oximetry readings reached 95%. The primary outcome was the non-hypoxic apnea time, defined as the time from the cessation of ventilation to achieving a pulse oximeter reading of 95%. The secondary outcome measures included the degree of atelectasis assessed by ultrasonography and the presence of gastric air insufflation. RESULTS Eighty-four patients were included in the final analysis. In the positive end-expiratory pressure group, the atelectasis score decreased (17.0 vs. 31.5, p < .001; mean difference and 95% CI of 11.6, 7.5-15.6), while the non-hypoxic apnea time increased (80.1 s vs. 70.6 s, p = .005; mean difference and 95% CI of -9.4, -16.0 to -2.9), compared to the zero end-expiratory pressure group, among infants who are 6 months old or younger, not in those aged older than 6 months. DISCUSSION The application of positive end-expiratory pressure reduced the incidence of atelectasis and extended the non-hypoxic apnea time in infants who are 6 months old or younger. However, it did not affect the incidence of atelectasis nor the non-hypoxic apnea time in patients aged older than 6 months.
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Affiliation(s)
- Eun-Hee Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jung-Bin Park
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Pyoyoon Kang
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Sang-Hwan Ji
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Young-Eun Jang
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Ji-Hyun Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jin-Tae Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Hee-Soo Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
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Zannin E, Nguyen J, Vigevani S, Hauser N, Sommerfield D, Dellacà R, Khan RN, Sommerfield A, von Ungern-Sternberg BS. Effect of different lung recruitment strategies and airway device on oscillatory mechanics in children under general anaesthesia. Eur J Anaesthesiol 2024; 41:513-521. [PMID: 38769936 DOI: 10.1097/eja.0000000000001999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
BACKGROUND Atelectasis has been reported in 68 to 100% of children undergoing general anaesthesia, a phenomenon that persists into the recovery period. Children receiving recruitment manoeuvres have less atelectasis and fewer episodes of oxygen desaturation during emergence. The optimal type of recruitment manoeuvre is unclear and may be influenced by the airway device chosen. OBJECTIVE We aimed to investigate the different effects on lung mechanics as assessed by the forced oscillation technique (FOT) utilising different recruitment strategies: repeated inflations vs. one sustained inflation and different airway devices, a supraglottic airway device vs. a cuffed tracheal tube. DESIGN Pragmatic enrolment with randomisation to the recruitment strategy. SETTING We conducted this single-centre trial between February 2020 and March 2022. PARTICIPANTS Seventy healthy patients (53 boys) aged between 2 and 16 years undergoing general anaesthesia were included. INTERVENTIONS Forced oscillations (5 Hz) were superimposed on the ventilator waveform using a customised system connected to the anaesthesia machine. Pressure and flow were measured at the inlet of the airway device and used to compute respiratory system resistance and reactance. Measurements were taken before and after recruitment, and again at the end of surgery. MAIN OUTCOME MEASURES The primary endpoint measured is the change in respiratory reactance. RESULTS Statistical analysis (linear model with recruitment strategy and airway device as factors) did not show any significant difference in resistance and reactance between before and after recruitment. Baseline reactance was the strongest predictor for a change in reactance after recruitment: prerecruitment Xrs decreased by mean (standard error) of 0.25 (0.068) cmH 2 O s l -1 per 1 cmH 2 O -1 s l -1 increase in baseline Xrs ( P < 0.001). After correcting for baseline reactance, the change in reactance after recruitment was significantly lower for sustained inflation compared with repeated inflation by mean (standard error) 0.25 (0.101) cmH 2 O ( P = 0.0166). CONCLUSION Although there was no significant difference between airway devices, this study demonstrated more effective recruitment via repeated inflations than sustained inflation in anaesthetised children. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry: ACTRN12619001434189.
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Affiliation(s)
- Emanuela Zannin
- From the Technologies for Respiration Laboratory, Electronics, Information and Bioengineering Department (DEIB), Politecnico di Milano, Milan (EZ, SV, RD), Neonatal Intensive Care Unit, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy (EZ), Department of Anaesthesia and Pain Medicine, Perth Children's Hospital (JN, NH, DS, AS, BSvU-S), Perioperative Team, Perioperative Care Program, Telethon Kids Institute (JN, NH, DS, RNK, AS, BSvU-S), Institute for Paediatric Perioperative Excellence (NH, DS, RNK, AS, BSvU-S), Division of Emergency Medicine, Anaesthesia and Pain Medicine, Medical School (NH, DS, AS, BSvU-S) and Department of Mathematics and Statistics, The University of Western Australia, Perth, Western Australia, Australia (RNK)
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Jain A, Bhardwaj N, Yaddanapudi S, Sen IM, Mathew P. Comparison of the effect of two recruitment manoeuvres to conventional ventilation on lung atelectasis in paediatric laparoscopic surgery- a prospective randomised controlled trial. BMC Anesthesiol 2024; 24:211. [PMID: 38909220 PMCID: PMC11193267 DOI: 10.1186/s12871-024-02596-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 06/12/2024] [Indexed: 06/24/2024] Open
Abstract
BACKGROUND There is a high incidence of pulmonary atelectasis during paediatric laparoscopic surgeries. The authors hypothesised that utilising a recruitment manoeuvre or using continuous positive airway pressure may prevent atelectasis compared to conventional ventilation. OBJECTIVE The primary objective was to compare the degree of lung atelectasis diagnosed by lung ultrasound (LUS) using three different ventilation techniques in children undergoing laparoscopic surgeries. DESIGN Randomised, prospective three-arm trial. SETTING Single institute, tertiary care, teaching hospital. PATIENTS Children of ASA PS 1 and 2 up to the age of 10 years undergoing laparoscopic surgery with pneumoperitoneum lasting for more than 30 min. INTERVENTION Random allocation to one of the three study groups: CG group: Inspiratory pressure adjusted to achieve a TV of 5-8 ml/kg, PEEP of 5 cm H2O, respiratory rate adjusted to maintain end-tidal carbon dioxide (ETCO2) between 30-40 mm Hg with manual ventilation and no PEEP at induction. RM group: A recruitment manoeuvre of providing a constant pressure of 30 cm H2O for ten seconds following intubation was applied. A PEEP of 10 cm H2O was maintained intraoperatively. CPAP group: Intraoperative maintenance with PEEP 10 cm H2O with CPAP of 10 cm H2O at induction using mechanical ventilation was done. OUTCOME MEASURES Lung atelectasis score at closure assessed by LUS. RESULTS Post induction, LUS was comparable in all three groups. At the time of closure, the LUS for the RM group (8.6 ± 4.9) and the CPAP group (8.8 ± 6.8) were significantly lower (p < 0.05) than the CG group (13.3 ± 3.8). In CG and CPAP groups, the score at closure was significantly higher than post-induction. The PaO2/FiO2 ratio was significantly higher (p < 0.05) for the RM group (437.1 ± 44.9) and CPAP group (421.6 ± 57.5) than the CG group (361.3 ± 59.4) at the time of pneumoperitoneum. CONCLUSION Application of a recruitment manoeuvre post-intubation or CPAP during induction and maintenance with a high PEEP leads to less atelectasis than conventional ventilation during laparoscopic surgery in paediatric patients. TRIAL REGISTRY CTRI/2019/08/02058.
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Affiliation(s)
- Aditi Jain
- Department of Anesthesia and Intensive Care, Government Medical College and Hospital, Chandigarh, India.
| | - Neerja Bhardwaj
- Department of Anesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sandhya Yaddanapudi
- Department of Anesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Indu Mohini Sen
- Department of Anesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Preethy Mathew
- Department of Anesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Patterson H, Eady J, Sommerfield A, Sommerfield D, Hauser N, von Ungern-Sternberg BS. Patient positioning and its impact on perioperative outcomes in children: A narrative review. Paediatr Anaesth 2024; 34:507-518. [PMID: 38546348 DOI: 10.1111/pan.14883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 03/12/2024] [Accepted: 03/13/2024] [Indexed: 05/12/2024]
Abstract
Patient positioning interacts with a number of body systems and can impact clinically important perioperative outcomes. In this educational review, we present the available evidence on the impact that patient positioning can have in the pediatric perioperative setting. A literature search was conducted using search terms that focused on pediatric perioperative outcomes prioritized by contemporary research in this area. Several key themes were identified: the effects of positioning on respiratory outcomes, cardiovascular outcomes, enteral function, patient and carer-centered outcomes, and soft issue injuries. We encountered considerable heterogeneity in research in this area. There may be a role for lateral positioning to reduce respiratory adverse outcomes, head elevation for intubation and improved oxygenation, and upright positioning to reduce peri-procedural anxiety.
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Affiliation(s)
- Heather Patterson
- Department of Anaesthesia and Pain Medicine, Perth Children's Hospital, Perth, Western Australia, Australia
| | - Jonathan Eady
- Department of Anaesthesia and Pain Medicine, Perth Children's Hospital, Perth, Western Australia, Australia
- Department of Anaesthesia, Antrim Area Hospital, Northern Health and Social Care Trust, Antrim, UK
| | - Aine Sommerfield
- Department of Anaesthesia and Pain Medicine, Perth Children's Hospital, Perth, Western Australia, Australia
- Institute for Paediatric Perioperative Excellence, The University of Western Australia, Perth, Westren Australia, Australia
- Perioperative Care Program, Perioperative Medicine Team, Telethon Kids Institute, Perth, Western Australia, Australia
- Division of Emergency Medicine, Anaesthesia and Pain Medicine, The University of Western Australia, Perth, Western Australia, Australia
| | - David Sommerfield
- Department of Anaesthesia and Pain Medicine, Perth Children's Hospital, Perth, Western Australia, Australia
- Institute for Paediatric Perioperative Excellence, The University of Western Australia, Perth, Westren Australia, Australia
- Perioperative Care Program, Perioperative Medicine Team, Telethon Kids Institute, Perth, Western Australia, Australia
- Division of Emergency Medicine, Anaesthesia and Pain Medicine, The University of Western Australia, Perth, Western Australia, Australia
| | - Neil Hauser
- Department of Anaesthesia and Pain Medicine, Perth Children's Hospital, Perth, Western Australia, Australia
- Institute for Paediatric Perioperative Excellence, The University of Western Australia, Perth, Westren Australia, Australia
- Perioperative Care Program, Perioperative Medicine Team, Telethon Kids Institute, Perth, Western Australia, Australia
- Division of Emergency Medicine, Anaesthesia and Pain Medicine, The University of Western Australia, Perth, Western Australia, Australia
| | - Britta S von Ungern-Sternberg
- Department of Anaesthesia and Pain Medicine, Perth Children's Hospital, Perth, Western Australia, Australia
- Institute for Paediatric Perioperative Excellence, The University of Western Australia, Perth, Westren Australia, Australia
- Perioperative Care Program, Perioperative Medicine Team, Telethon Kids Institute, Perth, Western Australia, Australia
- Division of Emergency Medicine, Anaesthesia and Pain Medicine, The University of Western Australia, Perth, Western Australia, Australia
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Shen C, Shi Y. The Prevalence of Difficult Airway and Associated Risk Factors in Pediatric Patients: A Cross-sessional Observational Study. J Craniofac Surg 2024; 35:1192-1196. [PMID: 38578083 DOI: 10.1097/scs.0000000000010114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 01/28/2024] [Indexed: 04/06/2024] Open
Abstract
BACKGROUND Difficult airway remains a great challenge in pediatric anesthesia practice. Previously published data show the prevalence of difficult airways in pediatric population varies in a wide range. However, there is a lack of studies in the Asian region. METHODS This cross-sectional single-center study was conducted in a tertiary pediatric hospital in China from October 2022 to October 2023. The patients who underwent elective surgery under general anesthesia with tracheal intubation were recruited consecutively. Data on patient characteristics, airway assessment, and airway management information were collected. Multivariable logistic regression analysis was performed to detect the independent variables of difficult airway in pediatric patients. RESULTS A total of 18,491 pediatric patients were included in this study. The overall incidence of difficult airways was 0.22%, 39% of whom were unanticipated. Very few previous airway management information was available in the patients presented with a known difficult airway. Patients with younger age, higher American Society of Anesthesiologists (ASA) physical status classification grade, and presented for craniofacial and thoracic surgery were associated with higher incidence of difficult airway. Further multivariable logistic regression analysis revealed that age ≤28 days (OR=50.48), age between 28days and 1 year (OR=6.053), craniofacial surgery (OR=1.81), and thoracic surgery (OR=0.2465) were independent risk factors of increased incidence of difficult airway. CONCLUSIONS Our study showed the prevalence of difficult airways in pediatric surgical patients. Patient characteristics, age, and type of surgery were identified as the independent factors associated with increased occurrence of difficult airways. Unanticipated difficult airway was not unusual in our study population, even for the patients with previous surgical history.
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Affiliation(s)
- Chen Shen
- Department of Anesthesiology, Children's Hospital of Fudan University, Minhang District, Shanghai, China
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Díaz F, Cruces P. Airway Management of Critically Ill Pediatric Patients with Suspected or Proven Coronavirus Disease 2019 Infection: An Intensivist Point of View. J Pediatr Intensive Care 2024; 13:1-6. [PMID: 38571985 PMCID: PMC10987222 DOI: 10.1055/s-0041-1732345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Accepted: 06/27/2021] [Indexed: 10/20/2022] Open
Abstract
Advanced airway management of critically ill children is crucial for novel coronavirus disease 2019 (COVID-19) management in the pediatric intensive care unit, whether due to shock and hemodynamic collapse or acute respiratory failure. In this article, intubation is challenging due to the particularities of children's physiology and the underlying disease's pathophysiology, especially when an airborne pathogen, like COVID-19, is present. Unfortunately, published recommendations and guidelines for COVID-19 in pediatrics do not address in-depth endotracheal intubation in acutely ill children. We discussed the caveats and pitfalls of intubation in critically ill children.
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Affiliation(s)
- Franco Díaz
- Unidad de Paciente Crítico Pediátrico, Hospital el Carmen de Maipú, Santiago, Chile
- Escuela de Medicina, Universidad Finis Terrae, Santiago, Chile
- Red Colaborativa Pediátrica de Latinoamérica (LARed Network), Santiago, Chile
| | - Pablo Cruces
- Unidad de Paciente Crítico Pediátrico, Hospital el Carmen de Maipú, Santiago, Chile
- Red Colaborativa Pediátrica de Latinoamérica (LARed Network), Santiago, Chile
- Centro de Investigación de Medicina Veterinaria, Escuela de Medicina Veterinaria, Facultad de Ciencias de la Vida, Universidad Andres Bello, Santiago, Chile
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Lundquist J, Shams N, Wallin M, Hallbäck M, Lönnqvist PA, Karlsson J. Capnodynamic end-expiratory lung volume assessment in anesthetized healthy children. Paediatr Anaesth 2024; 34:251-258. [PMID: 38055609 DOI: 10.1111/pan.14804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 10/18/2023] [Accepted: 11/21/2023] [Indexed: 12/08/2023]
Abstract
BACKGROUND Capnodynamic lung function monitoring generates variables that may be useful for pediatric perioperative ventilation. AIMS Establish normal values for end-expiratory lung volume CO2 in healthy children undergoing anesthesia and to compare these values to previously published values obtained with alternative end-expiratory lung volume methods. The secondary aim was to investigate the ability of end-expiratory lung volume CO2 to react to positive end-expiratory pressure-induced changes in end-expiratory lung volume. In addition, normal values for associated volumetric capnography lung function variables were examined. METHODS Fifteen pediatric patients with healthy lungs (median age 8 months, range 1-36 months) undergoing general anesthesia were examined before start of surgery. Tested variables were recorded at baseline positive end-expiratory pressure 3 cmH2 O, 1 and 3 min after positive end-expiratory pressure 10 cmH2 O and 3 min after returning to baseline positive end-expiratory pressure 3 cmH2 O. RESULTS Baseline end-expiratory lung volume CO2 was 32 mL kg-1 (95% CI 29-34 mL kg-1 ) which increased to 39 mL kg-1 (95% CI 35-43 mL kg-1 , p < .0001) and 37 mL kg-1 (95% CI 34-41 mL kg-1 , p = .0003) 1 and 3 min after positive end-expiratory pressure 10 cmH2 O, respectively. End-expiratory lung volume CO2 returned to baseline, 33 mL kg-1 (95% CI 29-37 mL kg-1 , p = .72) 3 min after re-establishing positive end-expiratory pressure 3 cmH2 O. Airway dead space increased from 1.1 mL kg-1 (95% CI 0.9-1.4 mL kg-1 ) to 1.4 (95% CI 1.1-1.8 mL kg-1 , p = .003) and 1.5 (95% CI 1.1-1.8 mL kg-1 , p < .0001) 1 and 3 min after positive end-expiratory pressure 10 cmH2 O, respectively, and 1.2 mL kg-1 (95% CI 0.9-1.4 mL kg-1 , p = .08) after 3 min of positive end-expiratory pressure 3 cmH2 O. Additional volumetric capnography and lung function variables showed no major changes in response to positive end-expiratory pressure variations. CONCLUSIONS Capnodynamic noninvasive and continuous end-expiratory lung volume CO2 values assessed during anesthesia in children were in close agreement with previously reported end-expiratory lung volume values generated by alternative methods. Furthermore, positive end-expiratory pressure changes resulted in physiologically expected end-expiratory lung volume CO2 responses in a timely manner, suggesting that it can be used to trend end-expiratory lung volume changes during anesthesia.
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Affiliation(s)
- Johanna Lundquist
- Pediatric perioperative medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Niki Shams
- Pediatric perioperative medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Mats Wallin
- Department of Physiology and Pharmacology (FYFA), C3, Eriksson I Lars, PA Lönnqvist group, Section of Anesthesiology and Intensive Care, Anestesi- och Intensivvårdsavdelningen, Karolinska Institute, Stockholm, Sweden
| | | | - Per-Arne Lönnqvist
- Pediatric perioperative medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
- Department of Physiology and Pharmacology (FYFA), C3, Eriksson I Lars, PA Lönnqvist group, Section of Anesthesiology and Intensive Care, Anestesi- och Intensivvårdsavdelningen, Karolinska Institute, Stockholm, Sweden
| | - Jacob Karlsson
- Pediatric perioperative medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
- Department of Physiology and Pharmacology (FYFA), C3, Eriksson I Lars, PA Lönnqvist group, Section of Anesthesiology and Intensive Care, Anestesi- och Intensivvårdsavdelningen, Karolinska Institute, Stockholm, Sweden
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Stepanovic B, Sommerfield A, Sommerfield D, von Ungern-Sternberg B. The influence of the COVID pandemic on the management of URTI in children. BJA Educ 2023; 23:473-479. [PMID: 38009138 PMCID: PMC10667611 DOI: 10.1016/j.bjae.2023.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2023] [Indexed: 11/28/2023] Open
Affiliation(s)
| | - A. Sommerfield
- Perth Children's Hospital, Perth, Australia
- Telethon Kids Institute, Perth, Australia
| | - D. Sommerfield
- Perth Children's Hospital, Perth, Australia
- Telethon Kids Institute, Perth, Australia
- University of Western Australia, Perth, Australia
| | - B.S. von Ungern-Sternberg
- Perth Children's Hospital, Perth, Australia
- Telethon Kids Institute, Perth, Australia
- University of Western Australia, Perth, Australia
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Lei G, Wu L, Xi C, Xiao Y, Wang G. Transnasal Humidified Rapid Insufflation Ventilatory Exchange Augments Oxygenation in Children With Juvenile Onset Recurrent Respiratory Papillomatosis During Surgery: A Prospective Randomized Crossover Controlled Trial. Anesth Analg 2023; 137:578-586. [PMID: 37590935 DOI: 10.1213/ane.0000000000006521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
BACKGROUND Evidence is lacking regarding the efficacy of transnasal humidified rapid insufflation ventilatory exchange (THRIVE) in tubeless anesthesia, especially in pediatric patients. This study aimed to evaluate the use of THRIVE for juvenile onset recurrent respiratory papillomatosis (JORRP) patients. METHODS Twenty-eight children aged 2 to 12 years with JORRP, abnormal airways, and ASA physical status II-III that presented for surgical treatment under general anesthesia were included in this study. Each patient received 2 interventions in random order, with a 5-minute washout period between treatments: apnea without oxygen supplementation and apnea with THRIVE intervention. The primary outcome apnea time was defined as the duration from withdrawal of intubation to reintubation and resumption of controlled ventilation. The secondary outcomes were the mean transcutaneous carbon dioxide (tc co2 ) increase rate, the minimum pulse oxygen saturation (Sp o2 ) during apnea, and the occurrence of unexpected adverse effects. RESULTS The median apnea time in the THRIVE period was significantly longer than that in the control period (8.9 [8.6-9.4] vs 3.8 [3.4-4.3] minutes; mean difference [95% confidence interval (CI)], 5.0 [4.4-5.6]; P < .001) for all patients. The rate of CO 2 change in the control period was higher than that in the THRIVE period both for patients aged 2 to 5 years old (6.29 [5.19-7.4] vs 3.22 [2.92-3.76] mm Hg min -1 ; mean difference [95% CI], 3.09 [2.27-3.67]; P < .001) and for patients aged 6 to 12 years old (4.76 [3.7-6.2] vs 3.38 [2.64-4.0] mm Hg min -1 ; mean difference [95% CI], 1.63 [0.75-2.56]; P < .001). The minimum Sp o2 was significantly higher in the THRIVE period than in the control period (mean difference [95% CI], 19.7 [14.8-22.6]; P < .001). CONCLUSIONS Our findings demonstrate that THRIVE safely increased the apnea time among children with JORRP undergoing surgery and decreased the rate of carbon dioxide increase. THRIVE is clinically recommended as an airway management technique for tubeless anesthesia in apneic children.
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Affiliation(s)
- Guiyu Lei
- From the Department of Anesthesiology, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Lili Wu
- From the Department of Anesthesiology, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Chunhua Xi
- From the Department of Anesthesiology, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Yang Xiao
- Department of Otolaryngology Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Key Laboratory of Otolaryngology, Head and Neck Surgery (Ministry of Education of China), Beijing, China
| | - Guyan Wang
- From the Department of Anesthesiology, Beijing Tongren Hospital, Capital Medical University, Beijing, China
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Holden KI, Martino AM, Guner YS, Harting MT. Extracorporeal life support in congenital diaphragmatic hernia. Semin Pediatr Surg 2023; 32:151328. [PMID: 37939639 DOI: 10.1016/j.sempedsurg.2023.151328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2023]
Abstract
Congenital diaphragmatic hernia (CDH) is the most common indication for ECLS in neonatal respiratory failure. The ultimate purpose of ECLS is to grant cardiopulmonary support, allowing time for operative intervention and optimization of cardiopulmonary function as the pathophysiologic processes of pulmonary hypertension, pulmonary hypoplasia, and ventricular dysfunction either improve or resolve. In CDH, ECLS plays a crucial role in the management of the most challenging patients, facilitating postnatal stabilization, allowing a ventilation strategy which minimizes barotrauma and volutrauma, and permitting treatment of and recovery from pulmonary hypertension and/or cardiac dysfunction. Understanding the nuances of CDH patients, which differ from other forms of neonatal respiratory failure, and the benefits of ECLS for these infants, is crucial for effective management. CDH patients present distinct challenges. Every aspect of ECLS, from mode of support and anticoagulation medication to pump selection, ventilation strategy, pulmonary hypertension management, and the weaning process, requires meticulous consideration. ECLS for CDH serves as a bridge to making informed decisions, granting clinicians stability and time to manage / recover from specific pathophysiologic consequences, and it offers the potential for survival among even the most challenging and complex patients. As overall care and management for infants with CDH receiving ECLS continue to improve, the focus has shifted toward managing survivor morbidity. Given the multisystem nature of the disease, this requires significant experience, expertise, and multidisciplinary teamwork to optimize long-term outcomes for these patients.
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Affiliation(s)
- Kylie I Holden
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center and Children's Memorial Hermann Hospital, Houston, TX, United States; Center for Surgical Trials and Evidence-Based Practice (CSTEP), University of Texas McGovern Medical School, Houston, TX, United States
| | - Alice M Martino
- Department of Surgery, University of California Irvine, and Division of Pediatric Surgery Children's Hospital of Orange County, United States
| | - Yigit S Guner
- Department of Surgery, University of California Irvine, and Division of Pediatric Surgery Children's Hospital of Orange County, United States
| | - Matthew T Harting
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center and Children's Memorial Hermann Hospital, Houston, TX, United States; Center for Surgical Trials and Evidence-Based Practice (CSTEP), University of Texas McGovern Medical School, Houston, TX, United States.
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Jayaram K, Gurajala I, Kumar A, Durga P, Tejasri K. Effect of etomidate and propofol on airway mechanics during induction - A prospective randomized trial. J Anaesthesiol Clin Pharmacol 2023; 39:482-487. [PMID: 38025560 PMCID: PMC10661644 DOI: 10.4103/joacp.joacp_534_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Revised: 07/03/2022] [Accepted: 08/14/2022] [Indexed: 12/01/2023] Open
Abstract
Background and Aims Intravenous induction agents like propofol and etomidate change the airway mechanics and thus influence mask ventilation. These changes have an impact on the administration of muscle relaxant in a difficult mask ventilation scenario. The difference in dynamics of airway after administration of two different intravenous agents has been assessed in this study. Material and Methods After formal registry in clinical trials, patients undergoing general anesthesia were recruited and randomized into group P and E. Patients were induced with either of the intravenous agents, and mask ventilation was performed with a ventilator. After 60 s, rocuronium was administered and ventilation continued. Measurements of tidal volume, peak airway pressure, and compliance were taken from the anesthesia ventilator at different time points - induction, relaxant, and intubation. Results There was no statistically significant difference between the two groups with respect to demographics, airway parameters, and airway mechanics, as measured by tidal volume, peak airway pressure, and lung compliance. There was an improvement in the tidal volume and compliance following induction with propofol, with a P value of 0.007 and 0.032, respectively, obtained in within-group comparison. Conclusion Propofol and etomidate were comparable in airway mechanics, but compliance and tidal volumes improved with propofol, which facilitated face mask ventilation.
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Affiliation(s)
- Kavitha Jayaram
- Department of Anesthesiology and Critical Care, Nizam’s Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Indira Gurajala
- Department of Anesthesiology and Critical Care, Nizam’s Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Annekiran Kumar
- Department of Anesthesiology and Critical Care, Nizam’s Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Padmaja Durga
- Department of Anesthesiology and Critical Care, Nizam’s Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Ketireddy Tejasri
- Department of Anesthesiology and Critical Care, Nizam’s Institute of Medical Sciences, Hyderabad, Telangana, India
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12
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Weems MF, Grover TR, Seabrook R, DiGeronimo R, Gien J, Keene S, Rintoul N, Daniel JM, Johnson Y, Guner Y, Zaniletti I, Murthy K. Analgesia, Sedation, and Neuromuscular Blockade in Infants with Congenital Diaphragmatic Hernia. Am J Perinatol 2023; 40:415-423. [PMID: 34044457 DOI: 10.1055/s-0041-1729877] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE The aim of this study was to describe the use, duration, and intercenter variation of analgesia and sedation in infants with congenital diaphragmatic hernia (CDH). STUDY DESIGN This is a retrospective analysis of analgesia, sedation, and neuromuscular blockade use in neonates with CDH. Patient data from 2010 to 2016 were abstracted from the Children's Hospitals Neonatal Database and linked to the Pediatric Health Information System. Patients were excluded if they also had non-CDH conditions likely to affect the use of the study medications. RESULTS A total of 1,063 patients were identified, 81% survived, and 30% were treated with extracorporeal membrane oxygenation (ECMO). Opioid (99.8%), sedative (93.4%), and neuromuscular blockade (87.9%) use was common. Frequency of use was higher and duration was longer among CDH patients treated with ECMO. Unadjusted duration of use varied 5.6-fold for benzodiazepines (median: 14 days) and 7.4-fold for opioids (median: 16 days). Risk-adjusted duration of use varied among centers, and prolonged use of both opioids and benzodiazepines ≥5 days was associated with increased mortality (p < 0.001) and longer length of stay (p < 0.001). Use of sedation or neuromuscular blockade prior to or after surgery was each associated with increased mortality (p ≤ 0.01). CONCLUSION Opioids, sedatives, and neuromuscular blockade were used commonly in infants with CDH with variable duration across centers. Prolonged combined use ≥5 days is associated with mortality. KEY POINTS · Use of analgesia and sedation varies across children's hospital NICUs.. · Prolonged opioid and benzodiazepine use is associated with increased mortality.. · Postsurgery sedation and neuromuscular blockade are associated with mortality..
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Affiliation(s)
- Mark F Weems
- Division of Neonatology, Department of Pediatrics, Le Bonheur Children's Hospital and the University of Tennessee Health Science Center, Memphis, Tennessee
| | - Theresa R Grover
- Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, Colorado
| | | | - Robert DiGeronimo
- Seattle Children's Hospital and University of Washington, Seattle, Washington
| | - Jason Gien
- Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, Colorado
| | - Sarah Keene
- Department of Pediatrics, Children's Healthcare of Atlanta at Egleston, Emory University School of Medicine, Atlanta, Georgia
| | - Natalie Rintoul
- Children's Hospital of Philadelphia and University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - John M Daniel
- Department of Pediatrics, Children's Mercy Hospitals & Clinics, University of Missouri Kansas, Kansas City, Missouri
| | - Yvette Johnson
- Department of Neonatology, Cook Children's Hospital, Fort Worth, Texas
| | - Yigit Guner
- Children's Hospital of Orange County and University of California Irvine, Orange, California
| | | | - Karna Murthy
- Department of Pediatrics, Ann & Robert H Lurie Children's Hospital of Chicago, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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13
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Papastefanou A, Rioja E. Severe Hypercapnia during Anaesthesia under Mechanical Ventilation in Two Paediatric Patients. Animals (Basel) 2023; 13:ani13040663. [PMID: 36830450 PMCID: PMC9951664 DOI: 10.3390/ani13040663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 02/07/2023] [Accepted: 02/11/2023] [Indexed: 02/17/2023] Open
Abstract
A 2-month-old male 1.56 kg Yorkshire terrier (Case No. 1) and a 3-month-old male 2.3 kg Jack Russell Terrier (Case No. 2) were scheduled for ophthalmological surgery under general anaesthesia and neuromuscular blockade. For both patients, volume-controlled ventilation (VCV) was used with set tidal volumes (VT) of 13 mL/kg and 20 mL/kg for cases No. 1 and 2, respectively. The type of ventilator used did not take into account the intrinsic compliance of the breathing system; therefore, a significant part of the delivered VT was wasted in the expansion of the breathing system, and did not reach the patients, causing alveolar hypoventilation. Both cases developed low dynamic compliance (CD), and after a recruitment manoeuvre, EtCO2 of up to 116 mmHg and 197 mmHg were revealed for cases No. 1 and 2, respectively. The two cases had to be ventilated manually, using positive inspiratory pressures (PIP) of 20-25 mmHg, in order to improve alveolar ventilation and reduce the EtCO2, as adjustments to the VCV were ineffective. Both patients maintained an oxygen haemoglobin saturation between 94% and 100% throughout the procedure and they recovered well. Using a higher VT from the beginning, to compensate for the compliance of the breathing system, or the use of pressure-controlled ventilation (PCV), could have potentially helped to avoid these two incidences of severe hypercapnia.
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14
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Cha YM, Faulk DJ. Management of Neuromuscular Block in Pediatric Patients — Safety Implications. CURRENT ANESTHESIOLOGY REPORTS 2022. [DOI: 10.1007/s40140-022-00537-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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15
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Trittmann JK, Almazroue H, Nelin LD, Shaffer TA, Celestine CR, Green HW, Malbrue RA. PATET ratio by Doppler echocardiography: noninvasive detection of pediatric pulmonary arterial hypertension. Pediatr Res 2022; 92:631-636. [PMID: 34795389 PMCID: PMC9114166 DOI: 10.1038/s41390-021-01840-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 10/09/2021] [Accepted: 10/28/2021] [Indexed: 11/12/2022]
Abstract
Pulmonary artery acceleration time (PAT) and PAT: ejection time (PATET) ratio are echocardiographic measurements of pulmonary arterial hypertension (PAH). These noninvasive quantitative measurements are ideal to follow longitudinally through the clinical course of PAH, especially as it relates to the need for and/or response to treatment. This review article focuses on the current literature of PATET measurement for infants and children as it relates to the shortening of the PATET ratio in PAH. At the same time, further development of PATET as an outcome measure for PAH in preclinical models, particularly mice, such that the field can move forward to human clinical studies that are both safe and effective. Here, we present what is known about PATET in infants and children and discuss what is known in preclinical models with particular emphasis on neonatal mouse models. In both animal models and human disease, PATET allows for longitudinal measurements in the same individual, leading to more precise determinations of disease/model progression and/or response to therapy. IMPACT: PATET ratio is a quantitative measurement by a noninvasive technique, Doppler echocardiography, providing clinicians a more precise/accurate, safe, and longitudinal assessment of pediatric PAH. We present a brief history/state of the art of PATET ratio to predict PAH in adults, children, infants, and fetuses, as well as in small animal models of PAH. In a preliminary study, PATET shortened by 18% during acute hypoxic exposure compared to pre-hypoxia. Studies are needed to establish PATET, especially in mouse models of disease, such as bronchopulmonary, as a routine measure of PAH.
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Affiliation(s)
- Jennifer K. Trittmann
- Center for Perinatal Research, Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus, OH,Department of Pediatrics, The Ohio State University, College of Medicine, Columbus, OH,Jennifer K. Trittmann, MD, MPH, Center for Perinatal Research, Abigail Wexner Research Institute at, Nationwide Children’s Hospital and, The Ohio State University, College of Medicine, Columbus, OH, USA,
| | - Hanadi Almazroue
- Center for Perinatal Research, Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus, OH
| | - Leif D. Nelin
- Center for Perinatal Research, Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus, OH,Department of Pediatrics, The Ohio State University, College of Medicine, Columbus, OH
| | - Terri A. Shaffer
- Animal Resources Core, Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus, OH
| | - Charanda R. Celestine
- Louisiana State University, School of Veterinary Medicine, Department of Veterinary Clinical Sciences, Baton Rouge, LA, USA
| | - Henry W. Green
- Louisiana State University, School of Veterinary Medicine, Department of Veterinary Clinical Sciences, Baton Rouge, LA, USA
| | - Raphael A. Malbrue
- Animal Resources Core, Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus, OH,The Ohio State University, College of Veterinary Medicine, Columbus, OH
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16
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Wildfire Smoke Exposure is Associated with Adverse Respiratory Events Under General Anesthesia in At-Risk Pediatric Patients. Anesthesiology 2022; 137:543-554. [PMID: 35950818 DOI: 10.1097/aln.0000000000004344] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Increasing wildfire activity worldwide has led to exposure to poor air quality and numerous detrimental health impacts. This study hypothesized an association between exposure to poor air quality from wildfire smoke and adverse respiratory events under general anesthesia in pediatric patients. METHODS This was a single-center retrospective double-cohort study examining two significant wildfire events in Northern California. Pediatric patients presenting for elective surgery during periods of unhealthy air quality were compared to those during periods of healthy air quality. The primary exposure, unhealthy air, was determined using local air quality sensors. The primary outcome was the occurrence of an adverse respiratory event under anesthesia. Secondary analysis included association with other known risk factors for adverse respiratory events. RESULTS 625 patients were included in the analysis. The overall risk of a respiratory complication was 42.4% (265/625). In children without history of reactive airway disease, the risk of adverse respiratory events did not change during unhealthy air periods (102/253, 40.3%) as compared with healthy air periods (95/226, 42.0%) (relative risk 0.96 (0.77 to 1.19), p = 0.703). In children with history of reactive airway disease, the risk of adverse respiratory events increased from 36.8% (25/68) during healthy air periods to 55.1% (43/78) during periods with unhealthy air (1.50 (1.04 to 2.17), p = 0.032). The effect of air quality on adverse respiratory events was significantly modified by reactive airways disease status (1.56 (1.02 to 2.40), p = 0.041). CONCLUSIONS Pediatric patients with underlying risk factors for respiratory complications under general anesthesia had a greater incidence of adverse respiratory events during periods of unhealthy air quality caused by wildfire smoke. In this vulnerable patient population, postponing elective anesthetics should be considered when air quality is poor.
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17
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Bruins S, Sommerfield D, Powers N, von Ungern-Sternberg BS. Atelectasis and lung recruitment in pediatric anesthesia: An educational review. Paediatr Anaesth 2022; 32:321-329. [PMID: 34797011 DOI: 10.1111/pan.14335] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 11/11/2021] [Accepted: 11/15/2021] [Indexed: 12/24/2022]
Abstract
General anesthesia is associated with development of pulmonary atelectasis. Children are more vulnerable to the development and adverse effects of atelectasis. We review the physiology and risk factors for the development of atelectasis in pediatric patients under general anesthesia. We discuss the clinical significance of atelectasis, the use and value of recruitment maneuvers, and other techniques available to minimize lung collapse. This review demonstrates the value of a recruitment maneuver, maintaining positive end-expiratory pressure (PEEP) until extubation and lowering FiO2 where possible in the daily practice of the pediatric anesthetist.
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Affiliation(s)
- Suze Bruins
- Department of Anaesthesia and Pain Management, Perth Children's Hospital, Nedlands, WA, Australia
| | - David Sommerfield
- Department of Anaesthesia and Pain Management, Perth Children's Hospital, Nedlands, WA, Australia.,Division of Emergency Medicine, Anaesthesia and Pain Medicine, The University of Western Australia, Crawley, WA, Australia.,Perioperative Medicine Team, Telethon Kids Institute, Nedlands, WA, Australia
| | - Neil Powers
- Department of Medical Imaging, Perth Children's Hospital, Nedlands, WA, Australia
| | - Britta S von Ungern-Sternberg
- Department of Anaesthesia and Pain Management, Perth Children's Hospital, Nedlands, WA, Australia.,Division of Emergency Medicine, Anaesthesia and Pain Medicine, The University of Western Australia, Crawley, WA, Australia.,Perioperative Medicine Team, Telethon Kids Institute, Nedlands, WA, Australia
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18
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Shi YC, Hiscock H, Oakley E, Freed G, O'Loughlin R. Nonindicated Brain Computed Tomography Scans for Children: Adaptation of an American Measurement Tool and Contrast of Current Practice in an Australian Hospital. Pediatr Emerg Care 2022; 38:e550-e555. [PMID: 34393214 DOI: 10.1097/pec.0000000000002515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Clinical guidelines state brain computed tomography (CT) for atraumatic headache or first generalized afebrile, atraumatic seizure as nonindicated in neurologically normal children. We aimed to adapt 2 rigorously validated United States-based measures that examine overuse of CT in children with these conditions, and to determine whether these measures can be used in an Australian setting to determine rates of CT scanning in current practice. METHODS Within an Australian tertiary pediatric hospital, we successfully adapted the measures from the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) coding system of the United States measures to the International Classification of Diseases, Tenth Revision, Australian Modification (ICD-10-AM) coding system used in Australia. We conducted a retrospective audit of electronic medical record data from April 1, 2017, to March 31, 2018. Eligible patients were children aged 4 to 17 years who attended one of the hospital outpatient clinics and/or emergency department and/or were admitted to an inpatient ward. The conditions of interest were (1) atraumatic headache and (2) first generalized afebrile, atraumatic seizure. RESULTS The measure for afebrile seizure was found to have low accuracy and low feasibility in this setting and was not tested further. The adapted measure for atraumatic headache was highly accurate in determining the encounters of interest; however, manual chart review was required to identify nonindicated brain CTs. Using this measure, 601 encounters for atraumatic headache were identified, of which 98 (16.3%) received at least 1 brain CT. We found that 14.1% of these scans were nonindicated, meaning 2% all atraumatic headache encounters received a nonindicated scan; lower than rates reported in international literature. CONCLUSIONS Using the tool developed in this study, rigorous measurement of the overuse of CT scans in other settings may determine the reasons for the lower rates observed in this study; inform future interventions to minimize overuse; and provide safer, higher quality care to children.
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Affiliation(s)
| | | | - Ed Oakley
- Critical Care, The Royal Children's Hospital, Parkville, VIC, Australia
| | - Gary Freed
- Department of Pediatrics, University of Michigan, Ann Arbor, MI
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19
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Spaeth J, Schumann S, Humphreys S. Understanding pediatric ventilation in the operative setting. Part I: Physical principles of monitoring in the modern anesthesia workstation. Paediatr Anaesth 2022; 32:237-246. [PMID: 34902201 DOI: 10.1111/pan.14378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 12/01/2021] [Accepted: 12/02/2021] [Indexed: 11/27/2022]
Abstract
The modern anesthesia workstation provides a wealth of information some of which is of particular interest when it comes to optimizing ventilation settings. This knowledge gains even more importance in the therapy of pediatric patients. In the absence of evidence-based recommendations on optimal ventilation settings in pediatric patients, the evaluation of individual factors becomes crucial and challenging at the same time. Even when equipped with the latest sensor technology, the user will always have to be in charge of interpreting the provided monitoring variables. The purpose of this review is to outline the clinical impact, technological background, and reliability of the most relevant information measured and calculated by a modern anesthesia workstation. It aims at translating the technical knowledge into a more competent and vigilant application in the clinical setting.
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Affiliation(s)
- Johannes Spaeth
- Department of Anesthesiology and Critical Care, Medical Center - University of Freiburg, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Stefan Schumann
- Department of Anesthesiology and Critical Care, Medical Center - University of Freiburg, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Susan Humphreys
- Paediatric Critical Care Research Group, Child Health Research Centre, The University of Queensland, Brisbane, Queensland, Australia.,Department of Anaesthesia, Queensland Children's Hospital, South Brisbane, Queensland, Australia
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20
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Garland A, Hopton P. Airway closure in anaesthesia and intensive care. BJA Educ 2022; 22:126-130. [PMID: 35531076 PMCID: PMC9073299 DOI: 10.1016/j.bjae.2021.12.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/16/2021] [Indexed: 11/15/2022] Open
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21
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Dost B, Kömürcü Ö, Bilgin S, Dökmeci H, Terzi Ö, Barış S. Investigating the Effects of Protective Face Masks on the Respiratory Parameters of Children in the Postanesthesia Care Unit During the COVID-19 Pandemic. J Perianesth Nurs 2022; 37:94-99. [PMID: 34824000 PMCID: PMC7877201 DOI: 10.1016/j.jopan.2021.02.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 02/03/2021] [Accepted: 02/07/2021] [Indexed: 12/15/2022]
Abstract
PURPOSE The purpose of this study was to investigate the effect of protective face mask usage during the postoperative period on carbon dioxide retention in children during the COVID-19 pandemic. DESIGN This study was designed as a prospective, randomized trial including 40 ASA I-II patients aged 3 to 10 years who were scheduled for elective surgery. METHODS Patients were randomly allocated to two groups. The first group (group 1) received O2 treatment over the protective face mask. In the second group (group 2), the protective face mask was worn over the O2 delivery system. Heart rate, oxygen saturation (SPO2) level, end-tidal carbon dioxide (EtCO2) level, and respiratory rate were measured using a patient monitor at 0, 5, 10, 15, 30, and 45 minutes and recorded. The primary outcome of the study was the determination of the EtCO2 levels, which were used to assess the safety of the mask in terms of potential carbon dioxide retention. FINDINGS None of the participants' SPO2 levels fell below 92% while wearing masks. There was no statistically significant difference between the groups in terms of EtCO2, heart rate, SPO2, and respiratory rate (P > .05). CONCLUSIONS During the COVID-19 pandemic, protective surgical face masks can be used safely in the postoperative period for pediatric patients aged 3 to 10 years.
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Affiliation(s)
- Burhan Dost
- Department of Anesthesiology and Reanimation, Faculty of Medicine, OndokuzMayis University, Samsun, Turkey.
| | - Özgür Kömürcü
- Division of Intensive Care, Department of Anesthesiology and Reanimation, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - Sezgin Bilgin
- Department of Anesthesiology and Reanimation, Faculty of Medicine, OndokuzMayis University, Samsun, Turkey
| | - Hilal Dökmeci
- Department of Anesthesiology and Reanimation, Faculty of Medicine, OndokuzMayis University, Samsun, Turkey
| | - Özlem Terzi
- Department of Public Health, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - Sibel Barış
- Department of Anesthesiology and Reanimation, Faculty of Medicine, OndokuzMayis University, Samsun, Turkey
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22
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Heath C, Hauser N. Is there a role for lung-protective ventilation in healthy children? Paediatr Anaesth 2022; 32:278-285. [PMID: 34839569 DOI: 10.1111/pan.14345] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 11/24/2021] [Accepted: 11/25/2021] [Indexed: 12/27/2022]
Abstract
Lung-protective ventilation (LPV) has been adopted in the theater environment as a strategy to reduce pulmonary complications under anesthesia. Postoperative pulmonary complications are not infrequent and may have significant implications on the postoperative length of stay as well as the morbidity and mortality of pediatric patients. There is evidence in the adult literature to suggest that intraoperative LPV strategies may reduce the risk of such complications. The utility of LPV strategies in healthy children is not well researched, and the data from critical care studies appear to be conflicting. To ascertain the value of intraoperative LPV in pediatric patients, it is important to understand the pathophysiology of pediatric ventilator-induced lung injury and the basis of LPV strategies. The current evidence in adult and pediatric populations, including pediatric intensive care, is reviewed to gain insight into the role and value of intraoperative LPV for pediatric patients.
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Affiliation(s)
- Chloe Heath
- Department of Anaesthesia and Pain Management, Perth Children's Hospital, Perth, WA, Australia
| | - Neil Hauser
- Department of Anaesthesia and Pain Management, Perth Children's Hospital, Perth, WA, Australia.,Perioperative Medicine Team, Telethon Kids Institute, Nedlands, WA, Australia.,Division of Emergency Medicine, Anaesthesia and Pain Medicine, Medical School, the University of Western Australia, Perth, WA, Australia
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23
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Ndikontar Kwinji R, Evans F, Gray RM. Challenges with pediatric anesthesia and intraoperative ventilation of the child in the resource-constrained setting. Paediatr Anaesth 2022; 32:372-379. [PMID: 34861089 DOI: 10.1111/pan.14353] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 11/29/2021] [Accepted: 12/01/2021] [Indexed: 01/31/2023]
Abstract
The systemic challenges in providing safe anesthesia, including safe ventilation, to children in resource-constrained settings are many. For anesthesia providers caring for children, the lack of appropriate equipment, inadequate anesthesia workforce and deficiencies in postoperative care are especially difficult. The clinical decisions made by anesthesia providers around when and how to ventilate a child for surgery are influenced by all of these factors and can result in patient management which may vary significantly from that in a high-resource setting. This educational review considers the intraoperative ventilation of a small child in a resource-constrained setting and discusses specific challenges and context-sensitive solutions.
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Affiliation(s)
- Raymond Ndikontar Kwinji
- Department of Surgery and Specialties, Faculty of Medicine and Biomedical Sciences, University of Yaounde 1, Yaounde, Cameroon.,Department of Anesthesia and Intensive Care, Yaounde Gyneco Obstetric and Pediatric Hospital, Yaounde, Cameroon
| | - Faye Evans
- The Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Rebecca M Gray
- Division of Paediatric Anaesthesia, Department of Anaesthesia and Perioperative Medicine, Red Cross War Memorial Children's Hospital, University of Cape Town, Rondebosch, South Africa.,Division of Global Surgery, Department of Surgery, University of Cape Town, Rondebosch, South Africa
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24
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Trachsel D, Erb TO, Hammer J, von Ungern‐Sternberg BS. Developmental respiratory physiology. Paediatr Anaesth 2022; 32:108-117. [PMID: 34877744 PMCID: PMC9135024 DOI: 10.1111/pan.14362] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 12/02/2021] [Accepted: 12/05/2021] [Indexed: 12/25/2022]
Abstract
Various developmental aspects of respiratory physiology put infants and young children at an increased risk of respiratory failure, which is associated with a higher rate of critical incidents during anesthesia. The immaturity of control of breathing in infants is reflected by prolonged central apneas and periodic breathing, and an increased risk of apneas after anesthesia. The physiology of the pediatric upper and lower airways is characterized by a higher flow resistance and airway collapsibility. The increased chest wall compliance and reduced gas exchange surface of the lungs reduce the pulmonary oxygen reserve vis-à-vis a higher metabolic oxygen demand, which causes more rapid oxygen desaturation when ventilation is compromised. This review describes the various developmental aspects of respiratory physiology and summarizes anesthetic implications.
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Affiliation(s)
- Daniel Trachsel
- Pediatric Intensive Care and PulmonologyUniversity Children’s Hospital of Basel UKBBBaselSwitzerland
| | - Thomas O. Erb
- Department AnesthesiologyUniversity Children’s Hospital of Basel UKBBBaselSwitzerland
| | - Jürg Hammer
- Pediatric Intensive Care and PulmonologyUniversity Children’s Hospital of Basel UKBBBaselSwitzerland
| | - Britta S. von Ungern‐Sternberg
- Department of Anaesthesia and Pain ManagementPerth Children’s HospitalPerthWAAustralia,Division of Emergency Medicine, Anaesthesia and Pain MedicineMedical SchoolThe University of Western AustraliaPerthWAAustralia,Perioperative Medicine TeamTelethon Kids InstitutePerthWAAustralia
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25
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Hii J, Templeton TW, Sommerfield D, Sommerfield A, Matava CT, von Ungern-Sternberg BS. Risk assessment and optimization strategies to reduce perioperative respiratory adverse events in pediatric anesthesia-Part 1 patient and surgical factors. Paediatr Anaesth 2022; 32:209-216. [PMID: 34897906 DOI: 10.1111/pan.14377] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 12/08/2021] [Accepted: 12/09/2021] [Indexed: 01/22/2023]
Abstract
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.
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Affiliation(s)
- Justin Hii
- Perioperative Medicine Team, Telethon Kids Institute, Nedlands, Western Australia, Australia.,Department of Anaesthesia, Joondalup Health Campus, Joondalup, Western Australia, Australia
| | - T Wesley Templeton
- Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - David Sommerfield
- Perioperative Medicine Team, Telethon Kids Institute, Nedlands, Western Australia, Australia.,Division of Emergency Medicine, Anaesthesia and Pain Medicine, Medical School, University of Western Australia, Crawley, Western Australia, Australia.,Department of Anaesthesia and Pain Management, Perth Children's Hospital, Nedlands, Western Australia, Australia
| | - Aine Sommerfield
- Perioperative Medicine Team, Telethon Kids Institute, Nedlands, Western Australia, Australia.,Department of Anaesthesia and Pain Management, Perth Children's Hospital, Nedlands, Western Australia, Australia
| | - Clyde T Matava
- Department of Anesthesia and Pain Medicine, Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Anesthesiology and Pain Medicine, Termerty Faculty of Medicine, University of Toronto, Ontario, Canada
| | - Britta S von Ungern-Sternberg
- Perioperative Medicine Team, Telethon Kids Institute, Nedlands, Western Australia, Australia.,Division of Emergency Medicine, Anaesthesia and Pain Medicine, Medical School, University of Western Australia, Crawley, Western Australia, Australia.,Department of Anaesthesia and Pain Management, Perth Children's Hospital, Nedlands, Western Australia, Australia
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Evaluation of atelectasis using electrical impedance tomography during procedural deep sedation for MRI in small children: A prospective observational trial. J Clin Anesth 2021; 77:110626. [PMID: 34902800 DOI: 10.1016/j.jclinane.2021.110626] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 11/29/2021] [Accepted: 12/02/2021] [Indexed: 12/14/2022]
Abstract
STUDY OBJECTIVE To investigate the variation of poorly ventilated lung units (i.e., silent spaces) in children undergoing procedural sedation in a day-hospital setting, until discharge home from the Post-Anesthesia Care Unit (PACU). DESIGN Prospective, single-center, observational cohort trial. SETTING This study was conducted at the radiology department and in PACU at Bern University Hospital (Switzerland), a tertiary care hospital. PATIENTS We included 25 children (1-6 years, ASA I-III) scheduled for cerebral magnetic resonance imaging scan, spontaneously breathing under deep sedation. Children planned for tracheal intubation, supraglottic airway insertion, or with contraindication for propofol were excluded. INTERVENTION After intravenous or inhaled induction, deep sedation was performed with 10 mg/kg/h Propofol. All children received nasal oxygen 0.3 ml/kg/min. MEASUREMENTS The proportion of silent spaces and the global inhomogeneity index were determined at each of five procedural points, using electrical impedance tomography: before induction (T1); before (T2) and after (T3) magnetic resonance imaging; at the end of sedation before transport to the PACU (T4); and before hospital discharge (T5). MAIN RESULTS The median [interquartile range (IQR)] proportion of silent spaces at the five analysis points were: T1, 5% [2%-14%]; T2, 10% [7%-14%]; T3, 12% [5%-23%]; T4, 12% [7%-24%]; and T5, 3% [2%-11%]. These defined significant changes in silent spaces over the course of sedation (p = 0.009), but no differences in silent spaces from before induction to before discharge from the PACU (T1 vs. T5; p = 0.29). Median [IQR] global inhomogeneity indices were 0.57 [0.55-0.58], 0.56 [0.53-0.59], 0.56 [0.54-0.59], 0.57 [0.54-0.60] and 0.56 [0.54-0.57], respectively (p = 0.93). None of the children reported anesthesia-related complications. CONCLUSION Deep sedation results in significantly increased poorly ventilated lung units during sedation. However, this does not significantly affect ventilation homogeneity, which was fully resolved at discharge from the PACU. TRIAL REGISTRATION clinicaltrials.gov, identifier NCT04507581.
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Lee JH, Kang P, Song IS, Ji SH, Lee HC, Jang YE, Kim EH, Kim HS, Kim JT. Determining optimal positive end-expiratory pressure and tidal volume in children by intratidal compliance: a prospective observational study. Br J Anaesth 2021; 128:214-221. [PMID: 34686309 DOI: 10.1016/j.bja.2021.09.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 08/30/2021] [Accepted: 09/10/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Limited data exist regarding optimal intraoperative ventilation strategies for the paediatric population. This study aimed to determine the optimal combination of PEEP and tidal volume (VT) based on intratidal compliance profiles in healthy young children undergoing general anaesthesia. METHODS During anaesthesia, infants (1 month-1 yr), toddlers (1-3 yr), and children (3-6 yr) were assigned serially to four ventilator settings: PEEP 8 cm H2O/VT 8 ml kg-1 (PEEP8/VT8), PEEP 10 cm H2O/VT 5 ml kg-1 (PEEP10/VT5), PEEP 10 cm H2O/VT 8 ml kg-1 (PEEP10/VT8), and PEEP 12 cm H2O/VT 5 ml kg-1 (PEEP12/VT5). The primary outcome was intratidal compliance profile, classified at each ventilator setting as horizontal (indicative of optimal alveolar ventilatory conditions), increasing, decreasing, or combinations of increasing/decreasing/horizontal compliance. Secondary outcomes were peak inspiratory, plateau, and driving pressures. RESULTS Intratidal compliance was measured in 15 infants, 13 toddlers, and 15 children (15/43 [35%] females). A horizontal compliance profile was most frequently observed with PEEP10/VT5 (60.5%), compared with PEEP10/VT8, PEEP8/VT8, and PEEP12/VT5 (23.3-34.9%; P<0.001). Decreasing compliance profiles were most frequent when VT increased to 8 ml kg-1, PEEP increased to 12 cm H2O, or both. Plateau airway pressures were lower at PEEP8/VT8 (16.9 cm H2O [2.2]) and PEEP10/VT5 (16.7 cm H2O [1.7]), compared with PEEP10/VT8 (19.5 cm H2O [2.1]) and PEEP12/VT5 (19.0 cm H2O [2.0]; P<0.001). Driving pressure was lowest with PEEP10/VT5 (4.6 cm H2O), compared with other combinations (7.0 cm H2O [2.0]-9.5 cm H2O [2.1]; P<0.001). CONCLUSIONS VT 5 ml kg-1 combined with 10 cm H2O PEEP may reduce atelectasis and overdistension, and minimise driving pressure in the majority of mechanically ventilated children <6 yr. The effect of these PEEP and VT settings on postoperative pulmonary complications in children undergoing surgery requires further study. CLINICAL TRIAL REGISTRATION NCT04633720.
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Affiliation(s)
- Ji-Hyun Lee
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Pyoyoon Kang
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - In Sun Song
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Sang-Hwan Ji
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Hyung-Chul Lee
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea; Department of Anaesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Young-Eun Jang
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Eun-Hee Kim
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Hee-Soo Kim
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea; Department of Anaesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jin-Tae Kim
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea; Department of Anaesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea.
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Effect of positive end-expiratory pressure during anaesthesia induction on non-hypoxic apnoea time in infants: A randomised controlled trial. Eur J Anaesthesiol 2021; 38:1012-1018. [PMID: 33259454 DOI: 10.1097/eja.0000000000001400] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Hypoxaemia occurs frequently in infants during anaesthetic induction. OBJECTIVE We evaluated the effect of positive end-expiratory pressure during anaesthesia induction on nonhypoxic apnoea time in infants. DESIGN Randomised controlled trial. SETTING Tertiary care children's hospital, single centre, from November 2018 to October 2019. PATIENTS We included patients under 1 year of age receiving general anaesthesia. INTERVENTION We assigned infants to a 7 cmH2O or 0 cmH2O positive end-expiratory pressure group. Anaesthesia was induced with 0.02 mg kg-1 atropine, 5 mg kg-1 thiopental sodium and 3 to 5% sevoflurane, and neuromuscular blockade with 0.6 mg kg-1 rocuronium. Thereafter, 100% oxygen was provided via face mask with volume-controlled ventilation of 6 ml kg-1 tidal volume, and either 7 cmH2O or no positive end-expiratory pressure. After 3 min of ventilation, the infants' trachea was intubated but disconnected from the breathing circuit, and ventilation resumed when pulse oximetry reached 95%. MAIN OUTCOME MEASURE The primary outcome was nonhypoxic apnoea time defined as the time from cessation of ventilation to a pulse oximeter reading of 95%, whereas the secondary outcome was the incidence of significant atelectasis (consolidation score ≥2) assessed by lung ultrasound. RESULTS Sixty patients were included in the final analysis. Apnoea time in the 7 cmH2O positive end-expiratory pressure group (105.2 s) increased compared with that in the control group (92.1 s) (P = 0.011, mean difference 13.0 s, 95% CI, 3.1 to 22.9 s). Significant atelectasis was observed in all patients without positive end-expiratory pressure and 66.7% of those with 7 cmH2O positive end-expiratory pressure (P = 0.019, 95% CI, 1.7 to 563.1, odds ratio 31.2). CONCLUSION Positive end-expiratory pressure during anaesthesia induction with face mask ventilation increased nonhypoxic apnoea time in infants. CLINICAL TRIAL REGISTRATION www.clinicaltrials.gov, NCT03540940.
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Kim PH, Park YS, Yoon HM, Jung AY, Joo EY, Choi IC, Song MH. Factors Associated with Occurrence of Atelectasis during Sedation for Imaging in Pediatric Patients: A Retrospective Single Center Cohort Study. J Clin Med 2021; 10:jcm10163598. [PMID: 34441894 PMCID: PMC8397091 DOI: 10.3390/jcm10163598] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 08/10/2021] [Accepted: 08/12/2021] [Indexed: 12/29/2022] Open
Abstract
Sedation can induce atelectasis which may cause suboptimal image quality. This study aimed to identify factors associated with the occurrence of atelectasis during sedation for imaging in pediatric patients. Patients < 18 years who had undergone whole-body magnetic resonance imaging (MRI) under sedation with propofol or dexmedetomidine were included in this study. The development of atelectasis was visually and quantitatively assessed by coronal short tau inversion recovery images of the thoracic level. Multivariable logistic regression was performed to identify the independent factors associated with the development of atelectasis. Ninety-one patients were included in the analysis. In the multivariable analysis, administration of supplemental oxygen was the only factor significantly associated with the occurrence of atelectasis (adjusted odds ratio, 4.84; 95% confidence interval, 1.48-15.83; p = 0.009). Univariable analysis showed that the use of dexmedetomidine was associated with a lower incidence of atelectasis; however, this could not be verified in the multivariable analysis. Among the pediatric patients who had undergone imaging under sedation, additional oxygen supplementation was the only independent factor associated with atelectasis occurrence. A prospective clinical trial is required to identify the cause-effect relationship between oxygen administration and occurrence of atelectasis during sedation.
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Affiliation(s)
- Pyeong Hwa Kim
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea; (P.H.K.); (H.-M.Y.); (A.Y.J.)
| | - Yong-Seok Park
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea; (Y.-S.P.); (E.-Y.J.); (I.-C.C.)
| | - Hee-Mang Yoon
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea; (P.H.K.); (H.-M.Y.); (A.Y.J.)
| | - Ah Young Jung
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea; (P.H.K.); (H.-M.Y.); (A.Y.J.)
| | - Eun-Young Joo
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea; (Y.-S.P.); (E.-Y.J.); (I.-C.C.)
| | - In-Cheol Choi
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea; (Y.-S.P.); (E.-Y.J.); (I.-C.C.)
| | - Myung-Hee Song
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea; (Y.-S.P.); (E.-Y.J.); (I.-C.C.)
- Correspondence: ; Tel.: +82-2-3010-3992; Fax: +82-2-3010-6790
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Zanza C, Longhitano Y, Leo M, Romenskaya T, Franceschi F, Piccioni A, Pabon IM, Santarelli MT, Racca F. Practical Review of Mechanical Ventilation in Adults and Children in The Operating Room and Emergency Department. Rev Recent Clin Trials 2021; 17:20-33. [PMID: 34387167 DOI: 10.2174/1574887116666210812165615] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 03/03/2021] [Accepted: 05/24/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND During general anesthesia, mechanical ventilation can cause pulmonary damage through mechanism of ventilator-induced lung injury which is a major cause of postoperative pulmonary complications, which varies between 5 and 33% and increases significantly the 30-day mortality of the surgical patient. OBJECTIVE The aim of this review is to analyze different variables which played key role in safe application of mechanical ventilation in the operating room and emergency setting. METHOD Also, we wanted to analyze different types of population that underwent intraoperative mechanical ventilation like obese patients, pediatric and adult population and different strategies such as one lung ventilation and ventilation in trendelemburg position. The peer-reviewed articles analyzed were selected according to PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) from Pubmed/Medline, Ovid/Wiley and Cochrane Library, combining key terms such as: "pulmonary post-operative complications", "protective ventilation", "alveolar recruitment maneuvers", "respiratory compliance", "intraoperative paediatric ventilation", "best peep", "types of ventilation". Among the 230 papers identified, 150 articles were selected, after title - abstract examination and removing the duplicates, resulting in 94 articles related to mechanical ventilation in operating room and emergency setting that were analyzed. RESULTS Careful preoperative patient's evaluation and protective ventilation (i.e. use of low tidal volumes, adequate PEEP and alveolar recruitment maneuvers) has been shown to be effective not only in limiting alveolar de-recruitment, alveolar overdistension and lung damage, but also in reducing the onset of pulmonary post-operative complications (PPCs). CONCLUSION Mechanical ventilation is like "Janus Bi-front" because it is essential for surgical procedures, for the care of critical care patients and in life-threatening conditions but it can be harmful to the patient if continued for a long time and where an excessive dose of oxygen is administered into the lungs. Low tidal volume is associated with minor rate of PPCs and other complications and every complication can increase length of Stay, adding cost to NHS between 1580 € and 1650 € per day in Europe and currently the prevention of PPCS is only weapon that we possess.
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Affiliation(s)
| | | | - Mirco Leo
- Department of Anesthesiology and Critical Care Medicine - AON SS Antonio e Biagio e Cesare Arrigo -Alessandria. Italy
| | - Tatsiana Romenskaya
- Department of Anesthesiology and Critical Care Medicine - AON SS Antonio e Biagio e Cesare Arrigo -Alessandria. Italy
| | - Francesco Franceschi
- Department of Emergency Medicine - Fondazione Policlinico A.Gemelli/Catholic University of Sacred Heart-Rome. Italy
| | - Andrea Piccioni
- Department of Emergency Medicine - Fondazione Policlinico A.Gemelli/Catholic University of Sacred Heart-Rome. Italy
| | - Ingrid Marcela Pabon
- Department of Emergency Medicine, Anesthesia and Critical Care Medicine- Michele and Pietro Ferrero Hospital- Verduno. Italy
| | | | - Fabrizio Racca
- Department of Anesthesiology and Critical Care Medicine - AON SS Antonio e Biagio e Cesare Arrigo -Alessandria. Italy
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Papoff P, Rosini T, Oliva S, Luciani S, Midulla F, Montecchia F. Nasopharyngeal tubes in pediatric anesthesia: Is the flow-dependent pressure drop across the tube suitable for calculating oropharyngeal pressure? Paediatr Anaesth 2021; 31:809-819. [PMID: 33853203 PMCID: PMC8252547 DOI: 10.1111/pan.14194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 04/06/2021] [Accepted: 04/07/2021] [Indexed: 11/02/2022]
Abstract
BACKGROUND Nasopharyngeal tubes are useful in pediatric anesthesia for insufflating oxygen and anesthetics. During nasopharyngeal tube-anesthesia, gas insufflation provides some positive oropharyngeal pressure that differs from the proximal airway pressure owing to the flow-dependent pressure drop across the nasopharyngeal tube (ΔPNPT ). AIMS This study aimed to investigate whether ΔPNPT could be used for calculating oropharyngeal pressure during nasopharyngeal tube-assisted anesthesia. METHODS In a physical model of nasopharyngeal tube-anesthesia, using Rohrer's equation, we calculated ΔPNPT for three nasopharyngeal tubes (3.5, 4.0, and 5.0 mm inner diameter) under oxygen and several sevoflurane in oxygen combinations in two ventilatory scenarios (continuous positive airway pressure and intermittent positive pressure ventilation). We then calculated oropharyngeal pressure as proximal airway pressure minus ΔPNPT . Calculated and measured oropharyngeal pressure couples of values were compared with the root mean square deviation to assess accuracy. We also investigated whether oropharyngeal pressure accuracy depends on the nasopharyngeal tube diameter, flow rate, gas composition, and leak size. Using ΔPNPT charts, we tested whether ΔPNPT calculation was feasible in clinical practice. RESULTS When we tested small-diameter nasopharyngeal tubes at high-flow or high-peak inspiratory pressure, proximal airway pressure measurements markedly overestimated oropharyngeal pressure. Comparing measured and calculated maximum and minimum oropharyngeal pressure couples yielded root mean square deviations less than 0.5 cmH2 O regardless of ventilatory modality, nasopharyngeal tube diameter, flow rate, gas composition, and leak size. CONCLUSION During nasopharyngeal tube-assisted anesthesia, proximal airway pressure readings on the anesthetic monitoring machine overestimate oropharyngeal pressure especially for smaller-diameter nasopharyngeal tubes and higher flow, and to a lesser extent for large leaks. Given the importance of calculating oropharyngeal pressure in guiding nasopharyngeal tube ventilation in clinical practice, we propose an accurate calculation using Rohrer's equation method, or approximating oropharyngeal pressure from flow and pressure readings on the anesthetic machine using the ΔPNPT charts.
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Affiliation(s)
- Paola Papoff
- Paediatric Intensive Care UnitDepartment of PaediatricsSapienza University of RomeRomeItaly
| | - Talitha Rosini
- Medical Engineering LaboratoryDepartment of Civil Engineering and Computer Science EngineeringUniversity of Rome “Tor Vergata”RomeItaly
| | - Salvatore Oliva
- Paediatric Gastroenterology and Liver UnitDepartment of PaediatricsSapienza University of RomeRomeItaly
| | - Stefano Luciani
- Paediatric Intensive Care UnitDepartment of PaediatricsSapienza University of RomeRomeItaly
| | - Fabio Midulla
- Paediatric Emergency CareDepartment of PaediatricsSapienza University of RomeRomeItaly
| | - Francesco Montecchia
- Medical Engineering LaboratoryDepartment of Civil Engineering and Computer Science EngineeringUniversity of Rome “Tor Vergata”RomeItaly
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Effects of different anesthetic methods on immune function and oxidative stress in patients undergoing laparoscopic herniorrhaphy. Wideochir Inne Tech Maloinwazyjne 2021; 16:329-335. [PMID: 34136028 PMCID: PMC8193758 DOI: 10.5114/wiitm.2021.105528] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 03/23/2021] [Indexed: 11/17/2022] Open
Abstract
Introduction The influence of anesthetic method on the immune function and oxidative stress in patients receiving laparoscopic herniorrhaphy remains largely unknown. Aim To assess the effects of different anesthetic methods on the immune function and oxidative stress in patients undergoing laparoscopic herniorrhaphy. Material and methods A total of 280 eligible patients were randomly divided into two groups to receive total intravenous anesthesia (TIVA group) and inhalation anesthesia (IA group). T lymphocyte subsets, oxidative stress response indices and inflammatory factor levels were measured before anesthesia, at the end of the operation, and 1 and 3 days after the operation. The incidence rates of adverse reactions were compared. Results At the end of and 1 day after the operation, CD3+ and CD4+ T cells and CD4+/CD8+ decreased in both groups compared with those before anesthesia (p < 0.05). Three days after the operation, CD3+ and CD4+ T cells decreased in both groups compared with those before anesthesia, which were higher in the TIVA group (p < 0.05). Interleukin-6 and C-reactive protein levels were significantly lower in the TIVA group (p < 0.05). At the end of and 1 and 3 days after the operation, oxidative stress response indices superoxide dismutase, catalase and glutathione peroxidase declined in both groups compared with those before anesthesia, which were higher in the IA group (p < 0.05). The incidence rate of adverse reactions was significantly higher in the IA group (p = 0.002). Conclusions Compared with IA, TIVA has less effect on the immune function and oxidative stress of patients undergoing laparoscopic herniorrhaphy, and controls the inflammatory response more effectively, accompanied by a lower incidence rate of adverse reactions.
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Karlsson J, Fodor GH, dos Santos Rocha A, Lin N, Habre W, Wallin M, Hallbäck M, Peták F, Lönnqvist P. Determination of adequate positive end-expiratory pressure level required for carbon dioxide homeostasis in an animal model of infant laparoscopy. Acta Anaesthesiol Scand 2020; 64:1114-1119. [PMID: 32386340 DOI: 10.1111/aas.13617] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Revised: 04/22/2020] [Accepted: 04/22/2020] [Indexed: 01/02/2023]
Abstract
BACKGROUND Capnoperitoneum provides a ventilatory challenge due to reduction in end-expiratory lung volume and peritoneal carbon dioxide absorption in both children and adults. The primary aim of this controlled interventional trial was to determine the positive end-expiratory pressure (PEEP) level needed to ensure for adequate carbon dioxide clearance and preservation of carbon dioxide homeostasis in an experimental model of infant laparoscopy. The secondary aim was to evaluate potential effects on cardiac output of PEEP and abdominal pressure level variations in the same setting. METHODS Eight chinchilla bastard rabbits were anesthetized and mechanically ventilated. Intra-abdominal pressures were randomly set to 0, 6, and 12 mm Hg by carbon dioxide insufflation. Carbon dioxide clearance using volumetric capnography, arterial blood gas data, and cardiac output was recorded, while PEEP 3, 6, and 9 cmH2 O were applied in a random order. RESULTS A PEEP of 9 cmH2 O showed restoration of carbon dioxide clearance without causing changes in arterial partial pressure of carbon dioxide and bicarbonate and with no associated deterioration in cardiac output. CONCLUSION The results promote a PEEP level of 9 cmH2 O in this model of infant capnoperitoneum to allow for adequate carbon dioxide removal with subsequent preservation of carbon dioxide homeostasis. The use of high PEEP was not associated with any decrease in cardiac output.
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Affiliation(s)
- Jacob Karlsson
- Anestesi‐ochIntensivvårdsavdelningen Department of Physiology and Pharmacology (FYFA) C3, Eiksson I Lars Group – Section of Anesthesiology and Intensive Care Karolinska Institute Stockholm Sweden
- Pediatric Perioperative Medicine and Intensive Care Karolinska University Hospital Eugenivägen 23 Stockholm Sweden
| | - Gergely H. Fodor
- Unit for Anaesthesiological Investigations Department of Anesthesiology Pharmacology Intensive Care and Emergency Medicine University of Geneva Geneva Switzerland
| | - Andre dos Santos Rocha
- Unit for Anaesthesiological Investigations Department of Anesthesiology Pharmacology Intensive Care and Emergency Medicine University of Geneva Geneva Switzerland
| | - Na Lin
- Unit for Anaesthesiological Investigations Department of Anesthesiology Pharmacology Intensive Care and Emergency Medicine University of Geneva Geneva Switzerland
| | - Walid Habre
- Unit for Anaesthesiological Investigations Department of Anesthesiology Pharmacology Intensive Care and Emergency Medicine University of Geneva Geneva Switzerland
- Pediatric Anesthesia Unit Geneva Children’s Hospital Geneva Switzerland
| | - Mats Wallin
- Anestesi‐ochIntensivvårdsavdelningen Department of Physiology and Pharmacology (FYFA) C3, Eiksson I Lars Group – Section of Anesthesiology and Intensive Care Karolinska Institute Stockholm Sweden
- Maquet Critical Care AB Solna Sweden
| | | | - Ferenc Peták
- Departmenet of Medical Physics and Informatics University of Szeged Szeged Hungary
| | - Per‐Arne Lönnqvist
- Anestesi‐ochIntensivvårdsavdelningen Department of Physiology and Pharmacology (FYFA) C3, Eiksson I Lars Group – Section of Anesthesiology and Intensive Care Karolinska Institute Stockholm Sweden
- Pediatric Perioperative Medicine and Intensive Care Karolinska University Hospital Eugenivägen 23 Stockholm Sweden
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Lyons C, Callaghan M. Apnoeic oxygenation in paediatric anaesthesia: a narrative review. Anaesthesia 2020; 76:118-127. [PMID: 32592510 DOI: 10.1111/anae.15107] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/25/2020] [Indexed: 12/19/2022]
Abstract
Apnoeic oxygenation refers to oxygenation in the absence of any patient or ventilator effort to move the lungs. This phenomenon was first described in humans in the mid-20th century but has seen renewed interest in the last decade following the demonstration of apnoeic oxygenation with low-flow, and subsequently high-flow, nasal oxygen. This narrative review summarises our understanding of apnoeic oxygenation in the paediatric population. We examine the evidence supporting oxygenation via tracheal tube, modified laryngoscopes and nasal cannulae. The evidence for prolongation of safe apnoea time at induction of anaesthesia is also appraised. We explore the capacity for carbon dioxide clearance, flow rate selection with high-flow nasal oxygen and complications associated with the technique. It remains uncertain whether apnoeic oxygenation in paediatric patients results in a meaningful clinical benefit compared with standard care for outcomes such as the number of tracheal intubation attempts or the incidence of hypoxaemia. In particular, the role of apnoeic oxygenation in paediatric difficult airway management is unclear as this has not been the targeted focus of any published research to date.
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Affiliation(s)
- C Lyons
- Department of Anaesthesia, Children's Health Ireland at Crumlin, Dublin, Ireland
| | - M Callaghan
- Department of Anaesthesia, Galway University Hospitals, Galway, Ireland
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Effect of regular alveolar recruitment on intraoperative atelectasis in paediatric patients ventilated in the prone position: a randomised controlled trial. Br J Anaesth 2020; 124:648-655. [DOI: 10.1016/j.bja.2020.01.022] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Revised: 01/26/2020] [Accepted: 01/27/2020] [Indexed: 02/07/2023] Open
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Cruces P, González-Dambrauskas S, Cristiani F, Martínez J, Henderson R, Erranz B, Díaz F. Positive end-expiratory pressure improves elastic working pressure in anesthetized children. BMC Anesthesiol 2018; 18:151. [PMID: 30355345 PMCID: PMC6201576 DOI: 10.1186/s12871-018-0611-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 10/09/2018] [Indexed: 12/15/2022] Open
Abstract
Background Positive end-expiratory pressure (PEEP) has been demonstrated to decrease ventilator-induced lung injury in patients under mechanical ventilation (MV) for acute respiratory failure. Recently, some studies have proposed some beneficial effects of PEEP in ventilated patients without lung injury. The influence of PEEP on respiratory mechanics in children is not well known. Our aim was to determine the effects on respiratory mechanics of setting PEEP at 5 cmH2O in anesthetized healthy children. Methods Patients younger than 15 years old without history of lung injury scheduled for elective surgery gave informed consent and were enrolled in the study. After usual care for general anesthesia, patients were placed on volume controlled MV. Two sets of respiratory mechanics studies were performed using inspiratory and expiratory breath hold, with PEEP 0 and 5 cmH2O. The maximum inspiratory and expiratory flow (QI and QE) as well as peak inspiratory pressure (PIP), plateau pressure (PPL) and total PEEP (tPEEP) were measured. Respiratory system compliance (CRS), inspiratory and expiratory resistances (RawI and RawE) and time constants (KTI and KTE) were calculated. Data were expressed as median and interquartile range (IQR). Wilcoxon sign test and Spearman’s analysis were used. Significance was set at P < 0.05. Results We included 30 patients, median age 39 (15–61.3) months old, 60% male. When PEEP increased, PIP increased from 12 (11,14) to 15.5 (14,18), and CRS increased from 0.9 (0.9,1.2) to 1.2 (0.9,1.4) mL·kg− 1·cmH2O− 1; additionally, when PEEP increased, driving pressure decreased from 6.8 (5.9,8.1) to 5.8 (4.7,7.1) cmH2O, and QE decreased from 13.8 (11.8,18.7) to 11.7 (9.1,13.5) L·min− 1 (all P < 0.01). There were no significant changes in resistance and QI. Conclusions Analysis of respiratory mechanics in anesthetized healthy children shows that PEEP at 5 cmH2O places the respiratory system in a better position in the P/V curve. A better understanding of lung mechanics may lead to changes in the traditional ventilatory approach, limiting injury associated with MV. Electronic supplementary material The online version of this article (10.1186/s12871-018-0611-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Pablo Cruces
- Pediatric Intensive Care Unit, Hospital El Carmen de Maipú, Santiago, Chile.,Centro de Investigación de Medicina Veterinaria, Escuela de Medicina Veterinaria, Facultad de Ecología y Recursos Naturales, Universidad Andres Bello, Santiago, Chile
| | | | - Federico Cristiani
- Department of Anesthesiology, Centro Hospitalario Pereira Rossell, Montevideo, Uruguay
| | - Javier Martínez
- Pediatric Intensive Care Unit, Centro Hospitalario Pereira Rossell, Montevideo, Uruguay
| | - Ronnie Henderson
- Department of Anesthesiology, Centro Hospitalario Pereira Rossell, Montevideo, Uruguay
| | - Benjamin Erranz
- Unidad de Cuidados Intensivos Pediátricos, Clínica Alemana de Santiago, Avda. Vitacura, 5951, Santiago, Chile
| | - Franco Díaz
- Unidad de Cuidados Intensivos Pediátricos, Clínica Alemana de Santiago, Avda. Vitacura, 5951, Santiago, Chile. .,Facultad de Medicina Clínica Alemana Universidad del Desarrollo, Santiago, Chile. .,Area de Cuidados Críticos, Hospital Padre Hurtado, Santiago, Chile.
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