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Izzi A, Marchello V, Manuali A, Cassano L, Di Francesco A, Mastromatteo A, Recchia A, Tonti MP, D’Onofrio G, Del Gaudio A. Perioperative Management of a Pediatric Patient with Beckwith-Wiedemann Syndrome Undergoing a Partial Glossectomy According to Egyedi/Obwegeser. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1467. [PMID: 37761428 PMCID: PMC10529883 DOI: 10.3390/children10091467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 08/22/2023] [Accepted: 08/25/2023] [Indexed: 09/29/2023]
Abstract
Here, we report the perioperative management of a clinical case of a 6 year, 5 month old girl suffering from Beckwith-Wiedemann syndrome undergoing a partial glossectomy procedure in a patient with surgical indication for obstructive sleep apnea syndrome (OSAS), difficulty swallowing, feeding, and speech. On surgery day, Clonidine (4 µg/kg) was administered. Following this, a general anesthesia induction was performed by administering Sevoflurane, Fentanyl, continuous intravenous Remifentanil, and lidocaine to the vocal cords, and a rhinotracheal intubation with a size 4.5 tube was carried out. Before starting the procedure, a block of the Lingual Nerve was performed with Levobupivacaine. Analgosedation was maintained with 3% Sevoflurane in air and oxygen (FiO2 of 40%) and Remifentanil in continuous intravenous infusion at a rate of 0.08-0.15 µg/kg/min. The surgical procedure lasted 2 h and 32 min. At the end of the surgery, the patient was under close observation during the first 72 h. In the pediatric patient with Beckwith-Wiedemann syndrome submitted to major maxillofacial surgery, the difficulty in managing the airways in the preoperative phase during intubation and in the post-operative phase during extubation should be considered.
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Affiliation(s)
- Antonio Izzi
- UOC of Anesthesia and Resuscitation II, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, 71013 Foggia, Italy; (A.I.); (V.M.); (A.M.); (A.R.); (M.P.T.); (A.D.G.)
| | - Vincenzo Marchello
- UOC of Anesthesia and Resuscitation II, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, 71013 Foggia, Italy; (A.I.); (V.M.); (A.M.); (A.R.); (M.P.T.); (A.D.G.)
| | - Aldo Manuali
- UOC of Anesthesia and Resuscitation II, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, 71013 Foggia, Italy; (A.I.); (V.M.); (A.M.); (A.R.); (M.P.T.); (A.D.G.)
| | - Lazzaro Cassano
- UOC of Maxillofacial Surgery and Otolaryngology, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, 71013 Foggia, Italy; (L.C.); (A.M.)
| | - Andrea Di Francesco
- UOS of Pediatric Maxillofacial Surgery, ASST Lariana, San Fermo della Battaglia, 22020 Como, Italy;
| | - Annalisa Mastromatteo
- UOC of Maxillofacial Surgery and Otolaryngology, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, 71013 Foggia, Italy; (L.C.); (A.M.)
| | - Andreaserena Recchia
- UOC of Anesthesia and Resuscitation II, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, 71013 Foggia, Italy; (A.I.); (V.M.); (A.M.); (A.R.); (M.P.T.); (A.D.G.)
| | - Maria Pia Tonti
- UOC of Anesthesia and Resuscitation II, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, 71013 Foggia, Italy; (A.I.); (V.M.); (A.M.); (A.R.); (M.P.T.); (A.D.G.)
| | - Grazia D’Onofrio
- Health Department, Clinical Psychology Service, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, 71013 Foggia, Italy
| | - Alfredo Del Gaudio
- UOC of Anesthesia and Resuscitation II, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, 71013 Foggia, Italy; (A.I.); (V.M.); (A.M.); (A.R.); (M.P.T.); (A.D.G.)
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A comparative evaluation of intranasal α2-adrenoceptor agonists and intranasal midazolam as premedication in pediatric sedation: A meta-analysis of randomized controlled trials. PLoS One 2023; 18:e0281751. [PMID: 36787332 PMCID: PMC9928077 DOI: 10.1371/journal.pone.0281751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 01/31/2023] [Indexed: 02/15/2023] Open
Abstract
BACKGROUND Midazolam and α2-adrenoceptor agonists have been widely used off-label as intranasal sedatives for children. The present meta-analysis aimed to evaluate the effects of two interventions in pediatric sedation. METHODS PubMed, Embase, and Cochrane Library were searched from inception to April 2022. All randomized controlled trials used intranasal α2-adrenoceptor agonists and midazolam as sedatives in children were enrolled. Parental separation, anesthesia induction or facemask acceptance, sedation level, different hemodynamic parameters and adverse events were considered as outcomes. RESULTS Totally 21 studies with 1,495 patients were included. Only one study reported comparison between midazolam and clonidine met the inclusion criteria, and patients in clonidine group had significantly better mask acceptance compared to midazolam group. Compared with midazolam, using of dexmedetomidine was associated with higher rate of satisfactory parental separation (52.88% vs 75.18%, RR = 0.70, with 95%CI [0.55, 0.90]), anesthesia induction or facemask acceptance (60.92% vs 81.47%, RR = 0.76, 95% CI [0.68, 0.84]) and less incidence of postoperative pain and nasal irritation. CONCLUSION Compared with midazolam, dexmedetomidine should be considered as the preferred intranasal sedative option for pediatric patients, since it provides more satisfactory sedative level with less incidence of several side effects. But insufficient evidences about effects of intranasal clonidine and overall low and moderate quality evidences evaluated by GRADE system indicate that superiority of intranasal α2-adrenoceptor agonists in pediatric sedation needs to be validated by more studies with high quality and large sample size in future.
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Garioud ALDB, Nielsen BN, Falcon L, Mondrup F, Afshari A. Clonidine for preventing emergence agitation in infants (PREVENT AGITATION II): Protocol and statistical analysis plan. Acta Anaesthesiol Scand 2023; 67:663-669. [PMID: 36762465 DOI: 10.1111/aas.14212] [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: 01/13/2023] [Accepted: 01/20/2023] [Indexed: 02/11/2023]
Abstract
BACKGROUND Emergence agitation is a common clinical condition in children. Symptoms pertaining to the spectrum of early postoperative negative behavior typically occur upon emergence from anesthesia. Clonidine is an effective adjunctive agent for the prevention of emergence agitation in children, but evidence in the smallest age groups is sparse We aim to investigate the efficacy and safety of an intraoperative bolus of intravenous clonidine for preventing emergence agitation in children 3-12 months of age. METHODS This is a randomized, placebo-controlled, double-blind trial. We will enroll 320 patients aged 3-12 months who have been scheduled for general anesthesia maintained with sevoflurane and opioid. The randomization is parallel and stratified by age group, sex, and site. The investigational medicinal product will be administered intravenously ~20 min before the anticipated end of the surgical procedure. The intervention is clonidine 3 μg/kg and placebo is isotonic saline in a corresponding volume. RESULTS The primary outcome is the incidence of emergence agitation as assessed on the Watcha scale, that is, any Watcha score >2 during participants' stay in the postanesthetic care unit. Secondary outcomes are the proportion of participants with postoperative pain, with postoperative nausea and vomiting, and a composite safety outcome. Statistical analysis will be conducted according to the Statistical Analysis Plan with the intention-to-treat population for our primary analyses. CONCLUSION The PREVENT AGITATION II trial will contribute valuable knowledge on efficacy for the prevention of emergence agitation and safety in infants.
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Affiliation(s)
- Anne Louise de Barros Garioud
- Department of Anesthesiology, Juliane Marie Center, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Bettina Nygaard Nielsen
- Department of Anesthesiology, Juliane Marie Center, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Lars Falcon
- Department of Anesthesiology, Juliane Marie Center, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Frederik Mondrup
- Department of Anesthesiology, Juliane Marie Center, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Arash Afshari
- Department of Anesthesiology, Juliane Marie Center, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Templeton TW, Sommerfield D, Hii J, Sommerfield A, Matava CT, von Ungern-Sternberg BS. Risk assessment and optimization strategies to reduce perioperative respiratory adverse events in Pediatric Anesthesia-Part 2: Anesthesia-related risk and treatment options. Paediatr Anaesth 2022; 32:217-227. [PMID: 34897894 DOI: 10.1111/pan.14376] [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: 12/03/2021] [Revised: 12/08/2021] [Accepted: 12/09/2021] [Indexed: 12/17/2022]
Abstract
Perioperative respiratory adverse events are the most common cause of critical events in children undergoing anesthesia and surgery. While many risk factors remain unmodifiable, there are numerous anesthetic management decisions which can impact the incidence and impact of these events, especially in at-risk children. Ongoing research continues to improve our understanding of both the influence of risk factors and the effect of specific interventions. This review discusses anesthesia risk factors and outlines strategies to reduce the rate and impact of perioperative respiratory adverse events with a chronologic based inquiry into anesthetic management decisions through the perioperative period from premedication to postoperative disposition.
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Affiliation(s)
- Thomas 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, School of Medicine, University of Western Australia, Crawley, Western Australia, Australia.,Department of Anaesthesia and Pain Management, Perth Children's Hospital, Nedlands, Western Australia, Australia
| | - Justin Hii
- Perioperative Medicine Team, Telethon Kids Institute, Nedlands, Western Australia, Australia.,Department of Anaesthesia, Joondalup Health Campus, Joondalup, 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, School of Medicine, 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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Nielsen BN, Anderson BJ, Falcon L, Henneberg SW, Lauritsen T, Lomstein E, Ydemann M, Afshari A. Pharmacokinetics of an intravenous bolus dose of clonidine in children undergoing surgery. Paediatr Anaesth 2020; 30:607-613. [PMID: 32166831 DOI: 10.1111/pan.13856] [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: 12/03/2019] [Revised: 02/17/2020] [Accepted: 03/10/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Clonidine is used off-label in children but only limited pediatric pharmacokinetic data are available for intravenously administered clonidine. OBJECTIVES To determine pharmacokinetic parameter estimates of clonidine in healthy children undergoing surgery and to investigate age-related differences. Furthermore, to investigate possible pharmacokinetic differences of clonidine between this group of children and a cohort with cardiac diseases. METHODS In a randomized placebo-controlled trial (The PREVENT AGITATION trial), blood samples for clonidine pharmacokinetic analysis were collected in a proportion of the enrolled patients. Healthy children with ASA score 1-2 in the age-groups 1 to <2 years and 2-5 years were randomized for blood sampling. Clonidine was administered as a single intravenous bolus of 3 µg/kg intraoperatively. Blood samples were drawn at baseline, 5, 10, 15, 30, 60 minutes after dosing and additionally every hour until discharge from the PACU. Clonidine analysis was performed on liquid chromatography-mass spectrometry. RESULTS Data form eighteen children were available for pharmacokinetic analysis (ASA I; male/female: 17/1; age: 1-5 years; weight 8.7-24 kg). Population parameter estimates for the 2-compartment model were similar to previous published data for children who underwent cardiac surgery. A pooled analysis including data from 59 children indicated clearance of 14.4 L h-1 70 kg-1 and volume of distribution of 192.6 L 70 kg-1 . No age-related pharmacokinetic differences and no difference in time from administration of study medication to awakening were found. Children 1 to <2 years had a shorter PACU stay than children 2-5 years (mean difference 17% 95% CI:3%-34%, P = .02). CONCLUSION Pharmacokinetic parameter estimates were similar for children undergoing general surgery and cardiac surgery given a single dose of intravenous clonidine. These results indicated that no dose reduction is needed in children aged 1 to <2 years compared with those 2-5 years, which was supported by pharmacodynamic observations.
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Affiliation(s)
- Bettina N Nielsen
- Department of Anaesthesia, The Juliane Marie Centre, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Brian J Anderson
- Department of Anaesthesiology, University of Auckland, Auckland, New Zealand
| | - Lars Falcon
- Department of Anaesthesia, The Juliane Marie Centre, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Steen W Henneberg
- Department of Anaesthesia, The Juliane Marie Centre, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Torsten Lauritsen
- Department of Anaesthesia, The Juliane Marie Centre, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Erik Lomstein
- Center for Laboratory, Food and Environmental Technology, The Business Academy Aarhus, Aarhus, Denmark
| | - Mogens Ydemann
- Department of Neuroanaethestesiology, Copenhagen University Hospital, Copenhagen, Denmark
| | - Arash Afshari
- Department of Anaesthesia, The Juliane Marie Centre, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
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Becker JE, Smith JR, Hazen EP. Pediatric Consultation-Liaison Psychiatry: An Update and Review. PSYCHOSOMATICS 2020; 61:467-480. [PMID: 32482345 PMCID: PMC7194908 DOI: 10.1016/j.psym.2020.04.015] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 04/18/2020] [Accepted: 04/20/2020] [Indexed: 12/11/2022]
Abstract
Background In recent years, there has been an increasing burden of child and adolescent mental illness recognized in the United States, and the need for pediatric mental health care is growing. Pediatric consultation-liaison (C-L) psychiatrists are increasingly playing a role in the management of medical and psychiatric disease for pediatric patients. The field is a fast-moving one, with understanding of new neuropsychiatric disease entities; reformulation of prior disease entities; and new interdisciplinary treatments and models of care. Methods In this study, we aim to review recent advances in the field of pediatric C-L psychiatry, including new diagnostic entities, updated management of frequently encountered clinical presentations, and developments in systems of care. Conclusion The advances in pediatric C-L psychiatry are broad and serve to promote more streamlined, evidence-based care for the vulnerable population of psychiatrically ill pediatric medical patients. More work remains to determine the most effective interventions for the wide array of presentations seen by pediatric C-L psychiatrists.
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Affiliation(s)
- Jessica E Becker
- Division of Child and Adolescent Psychiatry, Department of Psychiatry, Massachusetts General Hospital, Boston, MA.
| | - Joshua R Smith
- Division of Child and Adolescent Psychiatry, Department of Psychiatry, Massachusetts General Hospital, Boston, MA
| | - Eric P Hazen
- Division of Child and Adolescent Psychiatry, Department of Psychiatry, Massachusetts General Hospital, Boston, MA
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