The mask or the needle? Which induction should we go for?

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

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

Intravenous cannula placement in children for induction of general anesthesia: Prospective audit and identification of success factors

BACKGROUND

Approaches to pediatric induction of anesthesia vary widely. While oral sedative premedication and inhalational induction are common, total intravenous anesthesia is becoming increasingly popular. Total intravenous anesthesia without anxiolytic premedication, which is the most commonly used technique in our hospital, requires intravenous (IV) cannula placement in an awake child.

AIMS

To quantify the success rate of IV cannula placement in 1 or 2 attempts and to identify success factors and barriers.

METHODS

With ethical approval and written informed consent from participating anesthesiologists, a prospective audit of IV cannulation was undertaken over a 1-month period. The attending anesthesiologist captured basic demographics, IV insertion characteristics, setting, distraction techniques, the behavior of the child, number of attempts, and success/failure. A logistic regression model for successful IV cannulation was created. Anesthesiologists and procedural suite nurses participated in semi-structured interviews to identify success factors, barriers, and teaching approaches.

RESULTS

Data from 984 cases were analyzed. IV induction was planned in 562 cases, and IV cannulation was successful in 90% of these patients. Anxiolytic premedication was given in 6% of cases. Observations indicated that 64% of children were pain- and reaction-free, and 90% experienced minimal or no reaction. Predictors for success included older child's age and child behavior at first encounter. Qualitative interview data from 13 participants suggested success factors included effective distraction, preparing the family for IV induction, parental presence, support of the operating room team, effective use of local analgesic cream, adapting the approach to the individual child, and the anesthesiologist's efficiency. Barriers included needle phobia, uncooperative child, anxious parents, ineffective use of analgesic cream, and unfavorable anatomy. Distraction techniques varied by age and developmental stage of the child.

CONCLUSIONS

Cannulation for planned IV induction is feasible for most children, enabling increased use of total intravenous anesthesia as an institutional anesthetic strategy.

Effects of intravenous and mask induction on post-operative emergence delirium in pediatric patients undergoing tonsillectomy with or without adenoidectomy

BACKGROUND

Emergence delirium occurs in children during recovery from general anesthesia. The aim of the study was to examine the effects of mask and intravenous sevoflurane anesthesia induction on emergence delirium in children undergoing tonsillectomy with or without adenoidectomy.

METHODS

This single-blinded, prospective, randomized clinical trial was conducted in the operating room and the post-operative recovery area at a university hospital. Sixty-seven children (aged 3-12 years) were randomly assigned to receive either mask induction (group M) or intravenous induction (group IV). Vascular access was provided in group M after 8% sevoflurane and 60% nitrous oxide in oxygen were given through a mask. In the IV cohort, an intravenous cannula was inserted prior to induction. The incidence of emergence delirium was assessed using the Pediatric Anesthesia Emergence Delirium (PAED) scale after arrival in the post-anesthesia care unit. Post-operative pain was assessed using the Face, Legs, Activity, Cry, and Consolability (FLACC) scale.

RESULTS

PAED scores were significantly higher in group M at 5 min (group M = 12.2 ± 4.215, group IV = 9.1 ± 4.0; mean difference = 3.094, 95% CI [1.108; 5.081]; P = 0.003), at 15 min (group M = 8.0 ± 2.6, group IV = 5.1 ± 2.3; mean difference = 2.942, 95% CI [1.586-4.301]; P < 0.001), and at 30 min (group M = 5.1 ± 2.8, group IV = 2.5 ± 1.8; mean difference = 2.620, 95% CI [1.457; 3.783]; P < 0.001) than in group IV. The FLACC scale scores were similar between the two groups.

CONCLUSION

Mask induction for pediatric patients undergoing tonsillectomy with or without adenoidectomy increased Pediatric Anesthesia Emergence Delirium scores more than intravenous induction.

TRIAL REGISTRATION

NCT03252405.

Reducing preoperative anxiety with Child Life preparation prior to intravenous induction of anesthesia: A randomized controlled trial

BACKGROUND

Induction of anesthesia can be stressful: Up to 60% of children suffer significant anxiety immediately before surgery. Anxiety is associated with higher postoperative analgesia requirements, higher incidence of emergence delirium, and detrimental effects on sleep and behavior. Child Life preparation includes role-play, expectation-setting, and teaching coping strategies. AIM : The aim of this trial was to determine whether preoperative Child Life preparation reduces anxiety prior to intravenous induction of anesthesia.

METHODS

Children aged 3-10 years, with no known preexisting anxiety and no preoperative anxiolytics, undergoing elective day surgery lasting ≤ 2 hours, were enrolled in a randomized controlled trial. Each child's baseline anxiety was assessed in the anesthetic care unit, using the modified Yale Preoperative Anxiety Scale-Short Form (mYPAS-SF, observational scores from 22.9, minimal anxiety, to 100, maximal anxiety) as the primary outcome. The child was randomly assigned to intervention (minimum 15 minutes Child Life preparation) or control (standard practice without Child Life preparation). Participants entered the operating room with one parent. A researcher (blinded to group allocation) scored the child's operating room anxiety using mYPAS-SF, up to the first attempt at intravenous cannulation.

RESULTS

Fifty-nine children completed the study, aged median [interquartile range] 5 [3-7] years. Baseline mYPAS-SF anxiety was 29.2 [22.9-37.5] for all children, and operating room anxiety was 29.2 [22.9-49.0]. Operating room anxiety was higher than baseline in 16/31 (52%) children in the control group and 6/28 (21%) in the Child Life preparation group. ANCOVA revealed a significant effect of baseline mYPAS-SF anxiety and group on operating room anxiety (F = 10.31, P < .001, adjusted R²  = .24); individual parameter estimates indicated that Child Life preparation reduced operating room anxiety by 13.8 (95% CI 4.4-23.1) points compared to control, P = .005.

CONCLUSION

A brief, targeted Child Life preparation session had a statistically significant effect on reducing preoperative anxiety prior to intravenous induction of anesthesia in young children, with no known preexisting anxiety. This effect may be clinically important and suggests that Child Life can be a valuable component of pediatric surgical care. Further research is required in specific populations.