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Montalva L, Clariot S, Bonnard A. Early vs Late Inguinal Hernia Repair in Preterm Infants. JAMA 2024; 332:254-255. [PMID: 38884959 DOI: 10.1001/jama.2024.10099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/18/2024]
Affiliation(s)
- Louise Montalva
- Department of General Pediatric Surgery and Urology, Robert-Debré Children's University Hospital, Paris, France
| | - Simon Clariot
- Department of Anesthesia, Adolphe de Rothschild Foundation, Paris, France
| | - Arnaud Bonnard
- Department of General Pediatric Surgery and Urology, Robert-Debré Children's University Hospital, Paris, France
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Krzyzaniak A, Dassinger M, Blakely ML. Early vs Late Inguinal Hernia Repair in Preterm Infants-Reply. JAMA 2024; 332:255-256. [PMID: 38884950 DOI: 10.1001/jama.2024.10102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/18/2024]
Affiliation(s)
| | - Melvin Dassinger
- Division of Pediatric Surgery, University of Arkansas for Medical Sciences, Little Rock
| | - Martin L Blakely
- Department of Pediatric Surgery, University of Texas Health Science Center, Houston
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Heydinger G, Roth C, Kidwell R, Tobias JD, Veneziano G, Jayanthi VR, Whitaker EE, Thung AK. A Single Center's Experience With Spinal Anesthesia for Pediatric Patients Undergoing Surgical Procedures. J Pediatr Surg 2024; 59:1148-1153. [PMID: 38418274 DOI: 10.1016/j.jpedsurg.2024.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 01/28/2024] [Accepted: 02/02/2024] [Indexed: 03/01/2024]
Abstract
PURPOSE To perform a single institution review of spinal instead of general anesthesia for pediatric patients undergoing surgical procedures. Spinal success rate, intraoperative complications, and postoperative outcomes including unplanned hospital admission and emergency department visits within seven days are reported. METHODS Retrospective chart review of pediatric patients who underwent spinal anesthesia for surgical procedures from 2016 until 2022. Data collected included patient demographics, procedure and anesthetic characteristics, intraoperative complications, unplanned admissions, and emergency department returns. RESULTS The study cohort included 1221 patients. Ninety-two percent of the patients tolerated their surgical procedure without requiring conversion to general anesthesia, and 78% of patients that had spinals placed successfully did not receive any sedation following lumbar puncture. The most common intraoperative event was systolic blood pressure below 60 mm Hg (14%), but no cases required administration of vasoactive agents, and no serious intraoperative adverse events were observed. Post-Anesthesia Care Unit Phase I was bypassed in 72% of cases with a median postoperative length of stay of 84 min. Forty-six patients returned to the emergency department following hospital discharge, but no returns were due to anesthetic concerns. CONCLUSIONS Spinal anesthesia is a viable and versatile option for a diversity of pediatric surgical procedures. We noted a low incidence of intraoperative and postoperative complications. There remain numerous potential advantages of spinal anesthesia over general anesthesia in young pediatric patients particularly in the ambulatory setting. LEVEL OF EVIDENCE IV. TYPE OF STUDY Retrospective cohort treatment study.
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Affiliation(s)
- Grant Heydinger
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA; Department of Anesthesiology, The Ohio State University College of Medicine, Columbus, OH, USA.
| | - Catherine Roth
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Rachel Kidwell
- Heritage College of Osteopathic Medicine, Dublin Campus (Dublin) and Ohio University, Athens, OH, USA
| | - Joseph D Tobias
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA; Department of Anesthesiology, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Giorgio Veneziano
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA; Department of Anesthesiology, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Venkata R Jayanthi
- Division of Pediatric Urology, Nationwide Children's Hospital and the Department of Urology, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Emmett E Whitaker
- Department of Anesthesiology, University of Vermont Larner College of Medicine, University of Vermont Medical Center, Burlington, VT, USA
| | - Arlyne K Thung
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA; Department of Anesthesiology, The Ohio State University College of Medicine, Columbus, OH, USA
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Ey Batlle A, Jordan I, Miguez Gonzalez P, Vinyals Rodriguez M. Comparative Study of Acute Stress in Infants Undergoing Percutaneous Achilles Tenotomy for Clubfoot vs. Peripheral Line Placement. CHILDREN (BASEL, SWITZERLAND) 2024; 11:633. [PMID: 38929212 PMCID: PMC11201921 DOI: 10.3390/children11060633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Revised: 05/08/2024] [Accepted: 05/22/2024] [Indexed: 06/28/2024]
Abstract
INTRODUCTION Percutaneous tenotomy of the Achilles tendon is a procedure that is part of the Ponseti method for clubfoot correction. The need to apply general anesthesia or sedation for this procedure is controversial. The objective of this study is to compare the acute stress generated in infants by percutaneous Achilles tenotomy under local anesthesia vs. peripheral line placement. MATERIAL AND METHODS This cross-sectional study compares the discomfort experienced by 85 infants undergoing percutaneous Achilles tenotomy with local anesthesia with that experienced by 39 infants undergoing peripheral line placement. The following parameters were determined: the duration of the procedure, crying time, average crying intensity, and maximum crying intensity. Other data recorded included the infant's age and complications arising during the procedure. RESULTS The mean ages of these patients were 1.95 and 2.18 months, respectively. The following data were obtained: the mean duration of the procedure for Group A was 8.13 s and for Group B it was 127.43 s; the mean duration of crying for Group A was 84.24 s and for Group B it was 195.82 s; the mean intensity of crying for Group A was 88.99 dB and for Group B it was 100.98 dB; and the maximum crying intensity for Group A was 96.56 dB and for Group B it was 107.76 dB. CONCLUSIONS Percutaneous Achilles tenotomy can be safely performed as an outpatient procedure, under local anesthesia. This method generates less discomfort than peripheral line placement.
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Affiliation(s)
- Anna Ey Batlle
- Equipo Ponseti Dra. Anna Ey, Clínica Diagonal, 08950 Barcelona, Spain
- Hospital Sant Joan de Déu, 08950 Barcelona, Spain
| | - Iolanda Jordan
- Hospital Sant Joan de Déu, 08950 Barcelona, Spain
- Faculty of Medicine and Health Sciences, University of Barcelona, 08907 Barcelona, Spain
| | | | - Marta Vinyals Rodriguez
- Equipo Ponseti Dra. Anna Ey, Clínica Diagonal, 08950 Barcelona, Spain
- Faculty of Medicine and Health Sciences, University of Barcelona, 08907 Barcelona, Spain
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Zhang Q, Xu J, Huang Q, Gong T, Li J, Cui Y. Risk factors for delayed extubation after pediatric perineal anaplasty in patients less than 1 year of age: a retrospective study. BMC Pediatr 2024; 24:307. [PMID: 38711038 DOI: 10.1186/s12887-024-04781-4] [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: 10/18/2023] [Accepted: 04/22/2024] [Indexed: 05/08/2024] Open
Abstract
BACKGROUND Anorectal malformation is a common congenital problem occurring in 1 in 5,000 births and has a spectrum of anatomical presentations, requiring individualized surgical treatments for normal growth. Delayed extubation or reintubation may result in a longer intensive care unit (ICU) stay and hospital stay, increased mortality, prolonged duration of mechanical ventilation, increased tracheostomy rate, and higher hospital costs. Extensive studies have focused on the role of risk factors in early extubation during major infant surgery such as Cardiac surgery, neurosurgery, and liver surgery. However, no study has mentioned the influencing factors of delayed extubation in neonates and infants undergoing angioplasty surgery. MATERIALS AND METHODS We performed a retrospective study of neonates and infants who underwent anorectal malformation surgery between June 2018 and June 2022. The principal goal of this study was to observe the incidence of delayed extubation in pediatric anorectal malformation surgery. The secondary goals were to identify the factors associated with delayed extubation in these infants. RESULTS We collected data describing 123 patients who had anorectal malformations from 2019 to 2022. It shows that 74(60.2%) in the normal intubation group and 49(39.8%) in the longer extubation. In the final model, anesthesia methods were independently associated with delayed extubation (P < 0.05). CONCLUSION We found that the anesthesia method was independently associated with early extubation in neonates and infants who accepted pediatric anorectal malformation surgery.
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Affiliation(s)
- Qianqian Zhang
- Department of Anesthesiology, The Affiliated Hospital, School of Medicine, UESTC Chengdu Women's & Children's Central Hospital, Chengdu, 610091, China
| | - Jing Xu
- Department of Anesthesiology, The Affiliated Hospital, School of Medicine, UESTC Chengdu Women's & Children's Central Hospital, Chengdu, 610091, China
| | - Qinghua Huang
- Department of Anesthesiology, The Affiliated Hospital, School of Medicine, UESTC Chengdu Women's & Children's Central Hospital, Chengdu, 610091, China
| | - Tianqing Gong
- Department of Anesthesiology, The Affiliated Hospital, School of Medicine, UESTC Chengdu Women's & Children's Central Hospital, Chengdu, 610091, China
| | - Jia Li
- Department of Anesthesiology, The Affiliated Hospital, School of Medicine, UESTC Chengdu Women's & Children's Central Hospital, Chengdu, 610091, China
| | - Yu Cui
- Department of Anesthesiology, The Affiliated Hospital, School of Medicine, UESTC Chengdu Women's & Children's Central Hospital, Chengdu, 610091, China.
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Frawley G. Second infant spinal anesthetic: Incidence, dose modification, and adverse events after initial failure. Paediatr Anaesth 2024; 34:324-331. [PMID: 38146636 DOI: 10.1111/pan.14831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Revised: 12/15/2023] [Accepted: 12/18/2023] [Indexed: 12/27/2023]
Abstract
INTRODUCTION Infant spinal anesthesia is an important technique in premature and ex-premature infants undergoing lower abdominal surgery. Previous studies of infant spinal anesthesia report high failure rates, but fail to adequately identify contributing factors. The aim of this study is to retrospectively review spinal anesthetics from a quaternary anesthetic centre to determine overall spinal failure rate, incidence of second spinal attempts and adverse events associated with a second spinal anesthetic. METHODS A retrospective review of infant spinal anesthetics performed between May 2016 and June 2023. RESULTS Five hundred and fifty-one infants (mean postmenstrual age 42.9 weeks and weight 3873 g) were included. The overall success rate on first attempt was 86.5% with a further 5.1% requiring a successful second spinal anesthetic after initial failure. Spinal anesthetic failure requiring conversion to general anesthesia occurred in 9.4% of cases The causes of failed spinal anesthetic were inability to access the subdural space (dry tap 4.2%), inadequate motor blockade (2.9%), and repeated bloody taps (2.2%). Spinal anesthetic failure was significantly increased in cases where the anesthetist was routinely performing less than 5 spinal anesthetics per year [OR 2.21 (95% CI 1.28, 3.83, p = .004)] but only weakly associated with years of pediatric anesthetic experience. Failure rates were 21.4% with styletted spinal needles and 9.2% for non styletted [OR 2.68 (95% CI 1.23-5.86, p = .012)]. The incidence of perioperative apnoea was 6.7% with the highest rate in infants in which failed spinal anesthesia required conversion to general anesthesia (25%). There were 28 cases where initial spinal anesthetic failed to produce adequate anesthesia and a repeat spinal anesthetic was performed. Repeat spinal anesthesia was successful in 92.8% of cases with awake caudal anesthesia successful in 7.2% of cases. In three cases high spinal blockade occurred, one after a single spinal and two after a repeat spinal. Both repeat spinal high block cases required intubation and brief resuscitation. CONCLUSION Infant spinal anesthesia is associated with high success rates if experienced anesthetists are present or performing the block. Repeat spinal anesthesia may be associated with an increased incidence of high spinal block. Greater awareness of the slow onset of high block should promote techniques aimed at minimizing cephalad spread of local anesthetic including slight head up positioning during surgery.
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Affiliation(s)
- Geoff Frawley
- Department of Paediatric Anaesthesia and Pain Management, Royal Children's Hospital, Melbourne, Victoria, Australia
- Murdoch Childrens Research Institute, Critical Care and Neurosciences Theme, Melbourne, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
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Frawley GP, McCann AJ. Awake caudal anesthesia in ex-premature infants undergoing lower abdominal surgery: A narrative review. Paediatr Anaesth 2024; 34:293-303. [PMID: 38146668 DOI: 10.1111/pan.14830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 12/11/2023] [Accepted: 12/12/2023] [Indexed: 12/27/2023]
Abstract
BACKGROUND AND OBJECTIVES The aim of this narrative review is to evaluate the literature describing the use of caudal anesthetic-based techniques in premature and ex-premature infants undergoing lower abdominal surgery. METHODS All available literature from inception to August 2023 was retrieved according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines from Medline, PubMed, Embase, and the Cochrane Library. Two authors reviewed all references for eligibility, abstracted data, and appraised quality. RESULTS Of the 211 articles identified, 45 met our inclusion criteria yielding 1548 cases with awake caudal anesthesia. The review included 558 (36.0%) cases of awake caudal anesthesia, 837 cases (54.1%) of "awake" caudal anesthesia with sedation, and 153 cases (9.9%) of combined spinal caudal epidural anesthesia without sedation. The overall anesthetic failure rate was 7.2% (71.9:1000 caudals). Failure rates were highest for CSEA (13.7%, 7.7-18.4), intermediate for awake caudal (6.6%, 5.26-9.51), and lowest for sedated caudal anesthesia (5.85%, 4.48-7.82). The incidence (range) of perioperative apnea was highest for sedated caudal anesthesia (8.16, 0%-24%), intermediate for awake caudal (7.62%, 0%-60%), and lowest for CSEA (5.53%, 0%-14.3%). High spinal anesthesia occurred in 0.84%, or 8.35:1000 caudals overall. The incidence was highest in awake caudal anesthesia cases (1.97% or 19.7:1000 caudals), intermediate with caudal with sedation (1.07% or 10.7:1000 caudals), and lowest in CSEA (0.7% or 6.6:1000 caudals). Our review was confounded by incomplete data reporting and small sample sizes as most were case reports. There were no high-quality randomized controlled trials, and the eight single-center retrospective data reviews lacked sufficient data to perform meta-analysis. CONCLUSIONS There is insufficient evidence to validate or refute the benefits of the use of "awake" caudal anesthesia in premature and ex-premature infants. The high doses of local anesthetics used, the high failure rate, and the increased incidence of high spinal anesthesia would suggest that the techniques offer no real advantages over awake spinal anesthesia or general anesthesia with a regional block.
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Affiliation(s)
- Geoff P Frawley
- Department of Paediatric Anaesthesia and Pain Management, The Royal Children's Hospital, Parkville, Melbourne, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Parkville, Melbourne, Victoria, Australia
- Murdoch Children's Research Institute, Parkville, Melbourne, Victoria, Australia
| | - Alexander John McCann
- Department of Paediatric Anaesthesia and Pain Management, The Royal Children's Hospital, Parkville, Melbourne, Victoria, Australia
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Handlogten K. Pediatric regional anesthesiology: a narrative review and update on outcome-based advances. Int Anesthesiol Clin 2024; 62:69-78. [PMID: 38063039 DOI: 10.1097/aia.0000000000000421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Affiliation(s)
- Kathryn Handlogten
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
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Baskin P, Berde C, Saravanan A, Alrayashi W. Ultrasound-guided spinal anesthesia in infants: a narrative review. Reg Anesth Pain Med 2023; 48:608-614. [PMID: 36517202 DOI: 10.1136/rapm-2022-104025] [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: 08/28/2022] [Accepted: 12/01/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND/IMPORTANCE Infant spinal anesthesia has many potential benefits. However, the delivery of infant spinal anesthesia is technically challenging. The landmark-based technique has not changed for over a century. Advancements in ultrasound technology may provide an opportunity to improve infant spinal procedures. OBJECTIVE Our primary objective is to conduct a comprehensive review of the current literature on ultrasonography for spinal anesthesia in infants. Given the narrow scope of this topic, our secondary objective is to review the current literature on ultrasonography for lumbar puncture in infants. EVIDENCE REVIEW We reviewed all papers related to the use of ultrasound for infant spinal anesthesia. Two large databases were searched with key terms. Eligibility criteria were full-text articles in English. For our secondary objective, we searched one large database for key terms relating to ultrasonography and infant lumbar puncture. Eligibility criteria were the same. FINDINGS Our primary search retrieved six articles. These consisted of four review articles, one case report, and one retrospective observational study. Our secondary search retrieved fourteen articles. These consisted of five randomized control trials, four prospective studies, three retrospective studies, and two review papers. CONCLUSIONS Ultrasound yields high-quality images of the infant spine. Most literature regarding ultrasound for infant spinal procedures arises from emergency medicine or interventional radiology specialties. The literature on ultrasound for infant spinal anesthesia is extremely limited, but shows promise. Future studies are needed in order to determine whether ultrasound can improve the success rate for delivery of infant spinal anesthesia.
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Affiliation(s)
- Paola Baskin
- Department of Anesthesiology Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Charles Berde
- Department of Anesthesiology Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Arjun Saravanan
- Department of Anesthesiology Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Walid Alrayashi
- Department of Anesthesiology Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts, USA
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Santa Cruz Mercado LA, Lee JM, Liu R, Deng H, Johnson JJ, Chen AL, He M, Chung ER, Bharadwaj KM, Houle TT, Purdon PL, Liu CA. Age-Dependent Electroencephalogram Features in Infants Under Spinal Anesthesia Appear to Mirror Physiologic Sleep in the Developing Brain: A Prospective Observational Study. Anesth Analg 2023; 137:1241-1249. [PMID: 36881544 DOI: 10.1213/ane.0000000000006410] [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: 03/08/2023]
Abstract
BACKGROUND Infants under spinal anesthesia appear to be sedated despite the absence of systemic sedative medications. In this prospective observational study, we investigated the electroencephalogram (EEG) of infants under spinal anesthesia and hypothesized that we would observe EEG features similar to those seen during sleep. METHODS We computed the EEG power spectra and spectrograms of 34 infants undergoing infraumbilical surgeries under spinal anesthesia (median age 11.5 weeks postmenstrual age, range 38-65 weeks postmenstrual age). Spectrograms were visually scored for episodes of EEG discontinuity or spindle activity. We characterized the relationship between EEG discontinuity or spindles and gestational age, postmenstrual age, or chronological age using logistic regression analyses. RESULTS The predominant EEG patterns observed in infants under spinal anesthesia were slow oscillations, spindles, and EEG discontinuities. The presence of spindles, observed starting at about 49 weeks postmenstrual age, was best described by postmenstrual age ( P =.002) and was more likely with increasing postmenstrual age. The presence of EEG discontinuities, best described by gestational age ( P = .015), was more likely with decreasing gestational age. These age-related changes in the presence of spindles and EEG discontinuities in infants under spinal anesthesia generally corresponded to developmental changes in the sleep EEG. CONCLUSIONS This work illustrates 2 separate key age-dependent transitions in EEG dynamics during infant spinal anesthesia that may reflect the maturation of underlying brain circuits: (1) diminishing discontinuities with increasing gestational age and (2) the appearance of spindles with increasing postmenstrual age. The similarity of these age-dependent transitions under spinal anesthesia with transitions in the developing brain during physiological sleep supports a sleep-related mechanism for the apparent sedation observed during infant spinal anesthesia.
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Affiliation(s)
- Laura A Santa Cruz Mercado
- From the Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Johanna M Lee
- From the Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Ran Liu
- From the Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Hao Deng
- From the Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Jasmine J Johnson
- From the Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Andrew L Chen
- From the Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Mingjian He
- From the Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Harvard-MIT Health Sciences and Technology, Massachusetts Institute of Technology, Cambridge, Massachusetts
| | - Evan R Chung
- From the Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Kishore M Bharadwaj
- From the Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Timothy T Houle
- From the Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Patrick L Purdon
- From the Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Chang A Liu
- From the Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
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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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Veyckemans F, Sola C, de Graaff JC, Becke-Jakob K, Zielinska M, Hansen TG, Walker SM, Disma N, Habre W. Epidemiology and outcomes of inguinal surgery with or without regional anaesthesia in neonates and small infants: A subanalysis of the NECTARINE database. Eur J Anaesthesiol 2023; 40:956-959. [PMID: 37357905 DOI: 10.1097/eja.0000000000001870] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/27/2023]
Affiliation(s)
- Francis Veyckemans
- From the UCLouvain, Brussels, Belgium (FV), Department of Anaesthesia and Critical Care Medicine, Paediatric Anaesthesia Unit, Montpellier University Hospital, Institute of Functional Genomics (IGF), University of Montpellier, CNRS, INSERM, Montpellier, France (CS), Department of Anesthesia, Adrz-Erasmus MC, Goes, The Netherlands (JCdG), Department of Anaesthesia and Intensive Care, Cnopf Children's Hospital - Hospital Hallerwiese, Nürnberg, Germany (KB), Department of Paediaric Anaesthesiology and Intensive Care, Wroclaw Medical University, Wroclaw, Poland (MZ), Department of Anaesthesia & Intensive Care, Akershus University Hospital and Olso University, Oslo, Norway (TGH), Department of Anaesthesia and Pain Management, Great Ormond Street Hospital NHS Foundation Trust, London, UK (SMW), Unit for Research in Anaesthesia, IRCCS, Istituto G Gaslini, Genova, Italy (ND), and Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, University Hospitals of Geneva, Geneva, Switzerland (WH)
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Taverner F, Krishnan P, Baird R, von Ungern‐Sternberg BS. Perioperative management of infant inguinal hernia surgery; a review of the recent literature. Paediatr Anaesth 2023; 33:793-799. [PMID: 37449338 PMCID: PMC10947457 DOI: 10.1111/pan.14726] [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: 04/24/2023] [Revised: 06/19/2023] [Accepted: 06/27/2023] [Indexed: 07/18/2023]
Abstract
Inguinal hernia surgery is one of the most common electively performed surgeries in infants. The common nature of inguinal hernia combined with the high-risk population involving a predominance of preterm infants makes this a particular area of interest for those concerned with their perioperative care. Despite a large volume of literature in the area of infant inguinal hernia surgery, there remains much debate amongst anesthetists, surgeons and neonatologists regarding the optimal perioperative management of these patients. The questions asked by clinicians include; when should the surgery occur, how should the surgery be performed (open or laparoscopic), how should the anesthesia be conducted, including regional versus general anesthesia and airway devices used, and what impact does anesthesia choice have on the developing brain? There is a paucity of evidence in the literature on the concerns, priorities or goals of the parents or caregivers but clearly their opinions do and should matter. In this article we review the current clinical surgical and anesthesia practice and evidence for infants undergoing inguinal hernia surgery to help clinicians answer these questions.
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Affiliation(s)
- Fiona Taverner
- College of Medicine and Public HealthFlinders UniversityAdelaideSouth AustraliaAustralia
- Department of Anaesthesia and Pain ManagementFlinders Medical CentreAdelaideSouth AustraliaAustralia
| | - Prakash Krishnan
- Department of AnesthesiaBC Children's HospitalVancouverBritish ColumbiaCanada
- Department of Anesthesiology, Pharmacology and Therapeutics UBCVancouverBritish ColumbiaCanada
| | - Robert Baird
- Division of Pediatric SurgeryBC Children's HospitalVancouverBritish ColumbiaCanada
| | - Britta S. von Ungern‐Sternberg
- Department of Anaesthesia and Pain MedicinePerth Children's HospitalNedlandsWestern AustraliaAustralia
- Division of Emergency Medicine, Anaesthesia and Pain MedicineThe University of Western AustraliaPerthWestern AustraliaAustralia
- Perioperative Medicine Team, Perioperative Care ProgramTelethon Kids InstituteNedlandsWestern AustraliaAustralia
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Treutlein C, Zeilinger MG, Dittrich S, Roth JP, Wetzl M, Heiss R, Wuest W, May MS, Uder M, Rompel O. Free-Breathing and Single-Breath Hold Compressed Sensing Real-Time MRI of Right Ventricular Function in Children with Congenital Heart Disease. Diagnostics (Basel) 2023; 13:2403. [PMID: 37510147 PMCID: PMC10377861 DOI: 10.3390/diagnostics13142403] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 06/26/2023] [Accepted: 07/14/2023] [Indexed: 07/30/2023] Open
Abstract
(1) Purpose: to compare right ventricular (RV) functional parameters in children with surgically repaired congenital heart disease (CHD) using single/double breath hold (BH) and free-breathing (FB) real-time compressed sensing (CS) cine cardiac magnetic resonance (cMRI) with standard retrospective segmented multi breath hold (RMB) cine cMRI. (2) Methods: Twenty patients with CHD underwent BH and FB, as well as RMB cine cMRI, at 3T to obtain a stack of continuous axial images of the RV. Two radiologists independently performed qualitative analysis of the image quality (rated on a 5-point scale; 1 = non-diagnostic to 5 = excellent) and quantitative analysis of the RV volume measurements. (3) Results: The best image quality was provided by RMB (4.5; range 2-5) compared to BH (3.9; range 3-5; p = 0.04) and FB (3.6; range 3-5; p < 0.01). The RV functional parameters were comparable among BH, FB, and RMB with a difference of less than 5%. The scan times for BH (44 ± 38 s, p < 0.01) and FB (24 ± 7 s, p < 0.01) were significantly reduced compared to for RMB (261 ± 68 s). (4) Conclusions: CS-FB and CS-BH real-time cine cMRI in children with CHD provides diagnostic image quality with excellent accuracy for measuring RV function with a significantly reduced scan time compared to RMB.
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Affiliation(s)
- Christoph Treutlein
- Institute of Radiology, University Hospital of Erlangen, Friedrich Alexander University Erlangen-Nürnberg, 91054 Erlangen, Germany
| | - Martin Georg Zeilinger
- Institute of Radiology, University Hospital of Erlangen, Friedrich Alexander University Erlangen-Nürnberg, 91054 Erlangen, Germany
| | - Sven Dittrich
- Department of Pediatric Cardiology, University Hospital of Erlangen, Friedrich Alexander University Erlangen-Nürnberg, 91054 Erlangen, Germany
| | - Jan-Peter Roth
- Institute of Radiology, University Hospital of Erlangen, Friedrich Alexander University Erlangen-Nürnberg, 91054 Erlangen, Germany
| | - Matthias Wetzl
- Institute of Radiology, University Hospital of Erlangen, Friedrich Alexander University Erlangen-Nürnberg, 91054 Erlangen, Germany
| | - Rafael Heiss
- Institute of Radiology, University Hospital of Erlangen, Friedrich Alexander University Erlangen-Nürnberg, 91054 Erlangen, Germany
| | | | - Matthias Stefan May
- Institute of Radiology, University Hospital of Erlangen, Friedrich Alexander University Erlangen-Nürnberg, 91054 Erlangen, Germany
| | - Michael Uder
- Institute of Radiology, University Hospital of Erlangen, Friedrich Alexander University Erlangen-Nürnberg, 91054 Erlangen, Germany
| | - Oliver Rompel
- Institute of Radiology, University Hospital of Erlangen, Friedrich Alexander University Erlangen-Nürnberg, 91054 Erlangen, Germany
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15
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Cronin JA, Satterthwaite B, Robalino G, Casella D, Hsieh M, Sohel Rana M, Fink A, Pestieau S. Improving Outcomes through Implementation of an Infant Spinal Anesthesia Program for Urologic Surgery Patients. Pediatr Qual Saf 2023; 8:e615. [PMID: 38571740 PMCID: PMC10990379 DOI: 10.1097/pq9.0000000000000615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 09/26/2022] [Indexed: 04/05/2024] Open
Abstract
Introduction Spinal anesthesia has a long history as an effective and safe technique to avoid general anesthesia in infants undergoing surgery. However, spinal anesthesia was rarely used as the primary anesthetic in this population at our institution. This healthcare improvement initiative aimed to increase the percentage of successful spinal placements as the primary anesthetic in infants undergoing circumcision, open orchidopexy, or hernia repair from 11% to 50% by December 31, 2019, and sustain that rate for 6 months. Methods An interdisciplinary team created a key driver diagram and implemented the following interventions: education of nurses, surgeons, and patient families; focused anesthesiologist training on the infant spinal procedure; premedication; availability of supplies; and surgical schedule optimization. The team collected data retrospectively by reviewing electronic medical records (Cerner, North Kansas City, Mo.). The primary outcome was the percentage of infants undergoing circumcision, open orchidopexy, or hernia repair who received a successful spinal as the primary anesthetic. The team tracked this measure and evaluated using a statistical process control chart. Results Between August 1, 2018, and February 29, 2020, researchers identified 470 infants (235 preintervention and 235 postintervention) who underwent circumcision, open orchidopexy, or inguinal hernia repair. Following the interventions in this project, there was a statistically significant increase in successful spinal placement from 11% to 45% (P < 0.0001). Conclusion This quality improvement project successfully increased the percentage of patients receiving spinal anesthesia for specific surgical procedures by increasing the number of patients who underwent successful spinal anesthesia placement.
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Affiliation(s)
- Jessica A. Cronin
- From the Division of Anesthesiology, Pain and Perioperative Medicine, Children’s National Hospital, Washington, D.C
| | - Brenda Satterthwaite
- From the Division of Anesthesiology, Pain and Perioperative Medicine, Children’s National Hospital, Washington, D.C
| | - Giannina Robalino
- From the Division of Anesthesiology, Pain and Perioperative Medicine, Children’s National Hospital, Washington, D.C
| | - Daniel Casella
- Division of Urology, Children’s National Hospital, Washington, D.C
| | - Michael Hsieh
- Division of Urology, Children’s National Hospital, Washington, D.C
| | - Md Sohel Rana
- The Joseph E. Robert Jr., Center for Surgical Care, Children’s National Hospital, Washington, D.C
| | - Alia Fink
- Performance Improvement Department, Children’s National Hospital, Washington, D.C
| | - Sophie Pestieau
- From the Division of Anesthesiology, Pain and Perioperative Medicine, Children’s National Hospital, Washington, D.C
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16
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Lönnqvist PA. Spinal anesthesia in children: a narrative review. Best Pract Res Clin Anaesthesiol 2023. [DOI: 10.1016/j.bpa.2023.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
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17
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Du J, Roth C, Dontukurthy S, Tobias JD, Veneziano G. Manual Palpation versus Ultrasound to Identify the Intervertebral Space for Spinal Anesthesia in Infants. J Pain Res 2023; 16:93-99. [PMID: 36647435 PMCID: PMC9840403 DOI: 10.2147/jpr.s392438] [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: 10/06/2022] [Accepted: 01/04/2023] [Indexed: 01/11/2023] Open
Abstract
Purpose Awake spinal anesthesia continues as an alternative to general anesthesia for infants. Standard clinical practice includes the manual palpation of surface landmarks to identify the desired intervertebral space for lumbar puncture (LP). The current study investigates the accuracy of manual palpation for identifying the intended intervertebral site for LP, using ultrasonography for confirmation and to determine the interspace where the conus medullaris ends. Patients and Methods After informed parental consent, patients less than one year of age undergoing spinal anesthesia for lower abdominal, urologic, or lower extremity surgical procedures were included. Patients were held in the seated position and an attending pediatric anesthesiologist or pediatric anesthesiology fellow declared the vertebral interspace intended for needle insertion, palpated surface landmarks, and placed a mark at the site. A research anesthesiologist then determined the actual vertebral interspace of the marked site and the location of the conus medullaris using ultrasonography. The time to complete both techniques (manual palpation and ultrasonography) was recorded. Results The study cohort included 50 infants (median age of 7 months). Sixteen vertebral interspaces (32%) were inaccurately marked. One was marked two spaces higher than intended, ten were marked one space higher than intended, and five were marked one space lower than intended. In one patient, the intended vertebral interspace for the lumbar puncture overlaid the conus medullaris. The median time required was 25 seconds (IQR 14.3, 32) for palpation and 39 seconds (IQR 29, 63.8) for ultrasonography. Conclusion Manual palpation of surface landmarks to determine the correct interspace for LP for spinal anesthesia in infants is inaccurate. The time required to perform spinal ultrasonography in infants for determination of the optimal site for LP is brief and may be useful in ensuring accurate identification of the correct interspace and the location of the conus medullaris.
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Affiliation(s)
- Joanne Du
- The Ohio State University College of Medicine, Columbus, OH, USA
| | - Catherine Roth
- Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital, Columbus, OH, USA
| | - Sujana Dontukurthy
- Department of Anesthesiology, Valley Children’s Hospital, Madera, CA, USA
| | - Joseph D Tobias
- Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital, Columbus, OH, USA,Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Giorgio Veneziano
- Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital, Columbus, OH, USA,Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA,Correspondence: Giorgio Veneziano, Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital, 700 Children’s Dr, Columbus, OH, 43205, USA, Tel + 1 614-722-4200, Email
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18
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Siegler BH, Dudek M, Müller T, Kessler M, Günther P, Hochreiter M, Weigand MA. Impact of supplemental anesthesia in preterm infants undergoing inguinal hernia repair under spinal anesthesia : A retrospective analysis. DIE ANAESTHESIOLOGIE 2023; 72:175-182. [PMID: 36121460 PMCID: PMC9974706 DOI: 10.1007/s00101-022-01199-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 08/26/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND In preterm infants, spinal anesthesia (SpA) is recognized as an alternative to general anesthesia for inguinal hernia repair (IHR); however, some patients require supplemental anesthesia during surgery. The purpose of this study was to investigate the frequency and impact of supplemental anesthesia on perioperative care and adverse respiratory and hemodynamic events. METHODS A retrospective study of preterm infants undergoing IHR at Heidelberg University Hospital within the first year of life between 2009 and 2018 was carried out. RESULTS In total, 230 patients (255 surgeries) were investigated. Among 189 procedures completed using SpA 24 patients received supplemental anesthesia. Reasons for supplemental anesthesia included loss of anesthetic effect, returning motor response, and respiratory complications. Compared to SpA alone, no differences were found concerning hemodynamic parameters; however, patients requiring supplemental anesthesia displayed higher rates of postoperative oxygen supplementation and unexpected admission to the intensive care unit. The rate of perioperative apnea was 2.7%. Apneic events exclusively occurred after supplemental anesthesia. Bilateral IHR and duration of surgery were associated with the need for supplemental anesthesia. CONCLUSION Whereas SpA might be favorable when compared to general anesthesia for IHR, the data indicate that particular caution is required in patients receiving supplemental anesthesia due to the possible risk for adverse respiratory events.
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Affiliation(s)
- Benedikt Hermann Siegler
- Department of Anesthesiology, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany.
| | - Martha Dudek
- Department of Anesthesiology, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany
| | - Thomas Müller
- Department of Anesthesiology, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany
| | - Markus Kessler
- Division of Pediatric Surgery, Department of Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Patrick Günther
- Division of Pediatric Surgery, Department of Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Marcel Hochreiter
- Department of Anesthesiology, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany ,Clinic for Anesthesiology and Intensive Care, Essen University Hospital, Hufelandstraße 55, 45147 Essen, Germany
| | - Markus Alexander Weigand
- Department of Anesthesiology, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany
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19
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Knottenbelt G. Anaesthesia for surgery in infancy. ANAESTHESIA & INTENSIVE CARE MEDICINE 2022. [DOI: 10.1016/j.mpaic.2022.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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20
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Vinyals Rodriguez M, Ey Batlle A, Jordan I, Míguez González P. Quantification of Procedure Time and Infant Distress Produced (as Crying) When Percutaneous Achilles Tenotomy Is Performed under Topical Local Anaesthesia: A Preliminary Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:13842. [PMID: 36360726 PMCID: PMC9656725 DOI: 10.3390/ijerph192113842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 07/29/2022] [Accepted: 10/08/2022] [Indexed: 06/16/2023]
Abstract
INTRODUCTION Percutaneous tenotomy of the Achilles tendon is part of the clubfoot management procedure known as the Ponseti method and is necessary for most infants requiring this treatment. However, the need to apply general anaesthesia or sedation during this procedure remains controversial. To our knowledge, no previous studies have been conducted to quantify infant distress, expressed as crying, when tenotomy is performed under local anaesthesia. MATERIAL AND METHODS This clinical, prospective, cross-sectional, and observational study was composed of infants subjected to percutaneous Achilles tenotomy with local anaesthesia at an outpatient clinic. The degree of distress was measured using two smartphone apps (voice recorder and timer) in two iPhones, with each apparatus placed one meter from the baby. The following parameters were determined: procedure duration, crying duration, average crying intensity and maximum crying intensity. In addition, the following data were obtained: age, complications (if any) and the caregiver's satisfaction with the process. RESULTS Among the 85 infants submitted to percutaneous tenotomy, the mean age was 1.95 (+/-1.632) months (ranging from 0 to 7 months), the mean duration of the procedure was 8.134 (+/-5.97) seconds, (range 2.1 to 33.5 s), the infants' mean crying intensity was 88.99 dB and the maximum crying intensity was 96.56 dB. No vascular or anaesthetic-related complications were recorded. 96% of the caregivers were absolutely satisfied with the process. CONCLUSIONS Percutaneous Achilles tenotomy performed under local anaesthesia can safely be performed at the outpatient clinic. The procedure is fast and the crying time and intensity (mean values: 84 s and 89 dB, respectively) are minimal and tolerable. Knowledge of these parameters provides more accurate knowledge about the procedure. The caregivers consulted were absolutely satisfied with the tenotomy performed under local anaesthesia. In future studies, these parameters can be used for comparison with related surgical approaches.
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Affiliation(s)
| | - Anna Ey Batlle
- Equipo Ponseti Dra. Anna Ey, Clínica Diagonal, 08950 Barcelona, Spain
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21
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Couser DF, Veneziano GC, Nafiu OO, Tobias JD, Beltran RJ. Use of a Spinal-Caudal Epidural Technique for Abdominal Surgery in a Newborn With Noonan Syndrome and Severe Hypertrophic Cardiomyopathy. A A Pract 2022; 16:e01611. [DOI: 10.1213/xaa.0000000000001611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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22
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Adverse Events in Infants Less Than 6 Months of Age After Ambulatory Surgery and Diagnostic Imaging Requiring Anesthesia. Pediatr Qual Saf 2022; 7:e574. [PMID: 35795591 PMCID: PMC9249270 DOI: 10.1097/pq9.0000000000000574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 05/27/2022] [Indexed: 11/27/2022] Open
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23
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Heydinger G, Kim SS, Beltran RJ, Veneziano G, Smith A, Tobias JD, Uffman JC. Ambulatory spinal anesthesia in infants ≤ six months of age: A retrospective review of outcomes and safety. J Clin Anesth 2022; 81:110920. [PMID: 35785653 DOI: 10.1016/j.jclinane.2022.110920] [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: 02/22/2022] [Revised: 05/19/2022] [Accepted: 06/26/2022] [Indexed: 10/17/2022]
Abstract
PURPOSE To review experience with outpatient spinal anesthesia (SA) from a single center in infants ≤6 months of age. METHODS Retrospective review of all SAs performed in the ambulatory setting in the outpatient surgery centers in infants ≤6 months of age from 2016 to 2020, focusing on success rate, adverse events, post-anesthesia care unit (PACU) times, and emergency department (ED) or urgent care (UC) returns within 7 days of the operation. RESULTS The study cohort included 175 SAs performed on 173 patients ≤6 months of age. One hundred and sixty-two patients (93%) were able to undergo their respective surgical procedures under SA without conversion to general anesthesia. One hundred and thirty-six patients (78%) did not require additional sedation or analgesic agents. The median time from entering the operating room until the start of surgical procedure was 17 min. One hundred and twenty-six patients (72%) were able to bypass Phase I of the PACU. One hundred and forty-seven patients (86%) were discharged in less than two hours postoperatively. Only one complication related to SA was noted. This was a patient who returned on postoperative day 2 with a possible CSF leak noted by ultrasound. After overnight hospital floor admission, he was discharged the next day after receiving intravenous fluids without further sequelae. CONCLUSIONS SA is a viable option for anesthetic care in infants ≤6 months of age presenting for outpatient surgery. Advantages included the ability to bypass PACU Phase I and facilitation of hospital discharge. LEVEL OF EVIDENCE IV. Retrospective cohort treatment study.
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Affiliation(s)
- Grant Heydinger
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, United States of America; Department of Anesthesiology, The Ohio State University College of Medicine, Columbus, OH, United States of America.
| | - Stephani S Kim
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, United States of America
| | - Ralph J Beltran
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, United States of America; Department of Anesthesiology, The Ohio State University College of Medicine, Columbus, OH, United States of America
| | - Giorgio Veneziano
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, United States of America; Department of Anesthesiology, The Ohio State University College of Medicine, Columbus, OH, United States of America
| | - Ashley Smith
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, United States of America; Department of Anesthesiology, The Ohio State University College of Medicine, Columbus, OH, United States of America
| | - Joseph D Tobias
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, United States of America; Department of Anesthesiology, The Ohio State University College of Medicine, Columbus, OH, United States of America
| | - Joshua C Uffman
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, United States of America; Department of Anesthesiology, The Ohio State University College of Medicine, Columbus, OH, United States of America
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24
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Abstract
PURPOSE OF REVIEW Neonates have a high risk of perioperative morbidity and mortality. The NEonate and Children audiT of Anaesthesia pRactice IN Europe (NECTARINE) investigated the anesthesia practice, complications and perioperative morbidity and mortality in neonates and infants <60 weeks post menstrual age requiring anesthesia across 165 European hospitals. The goal of this review is to highlight recent publications in the context of the NECTARINE findings and subsequent changes in clinical practice. RECENT FINDINGS A perioperative triad of hypoxia, anemia, and hypotension is associated with an increased overall mortality at 30 days. Hypoxia is frequent at induction and during maintenance of anesthesia and is commonly addressed once oxygen saturation fall below 85%.Blood transfusion practices vary widely variable among anesthesiologists and blood pressure is only a poor surrogate of tissue perfusion. Newer technologies, whereas acknowledging important limitations, may represent the currently best tools available to monitor tissue perfusion. Harmonization of pediatric anesthesia education and training, development of evidence-based practice guidelines, and provision of centralized care appear to be paramount as well as pediatric center referrals and international data collection networks. SUMMARY The NECTARINE provided new insights into European neonatal anesthesia practice and subsequent morbidity and mortality.Maintenance of physiological homeostasis, optimization of oxygen delivery by avoiding the triad of hypotension, hypoxia, and anemia are the main factors to reduce morbidity and mortality. Underlying and preexisting conditions such as prematurity, congenital abnormalities carry high risk of morbidity and mortality and require specialist care in pediatric referral centers.
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25
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Morini F, Dreuning KMA, Janssen Lok MJH, Wester T, Derikx JPM, Friedmacher F, Miyake H, Zhu H, Pio L, Lacher M, Sgró S, Zani A, Eaton S, van Heurn LWE, Pierro A. Surgical Management of Pediatric Inguinal Hernia: A Systematic Review and Guideline from the European Pediatric Surgeons' Association Evidence and Guideline Committee. Eur J Pediatr Surg 2022; 32:219-232. [PMID: 33567466 DOI: 10.1055/s-0040-1721420] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
INTRODUCTION Inguinal hernia repair represents the most common operation in childhood; however, consensus about the optimal management is lacking. Hence, recommendations for clinical practice are needed. This study assesses the available evidence and compiles recommendations on pediatric inguinal hernia. MATERIALS AND METHODS The European Pediatric Surgeons' Association Evidence and Guideline Committee addressed six questions on pediatric inguinal hernia repair with the following topics: (1) open versus laparoscopic repair, (2) extraperitoneal versus transperitoneal repair, (3) contralateral exploration, (4) surgical timing, (5) anesthesia technique in preterm infants, and (6) operation urgency in girls with irreducible ovarian hernia. Systematic literature searches were performed using PubMed, MEDLINE, Embase (Ovid), and The Cochrane Library. Reviews and meta-analyses were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) statement. RESULTS Seventy-two out of 5,173 articles were included, 27 in the meta-analyses. Laparoscopic repair shortens bilateral operation time compared with open repair. In preterm infants, hernia repair after neonatal intensive care unit (NICU)/hospital discharge is associated with less respiratory difficulties and recurrences, regional anesthesia is associated with a decrease of postoperative apnea and pain. The review regarding operation urgency for irreducible ovarian hernia gained insufficient evidence of low quality. CONCLUSION Laparoscopic repair may be beneficial for children with bilateral hernia and preterm infants may benefit using regional anesthesia and postponing surgery. However, no definite superiority was found and available evidence was of moderate-to-low quality. Evidence for other topics was less conclusive. For the optimal management of inguinal hernia repair, a tailored approach is recommended taking into account the local facilities, resources, and expertise of the medical team involved.
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Affiliation(s)
- Francesco Morini
- Department of Medical and Surgical Neonatology, Ospedale Pediatrico Bambino Gesù, Instituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Kelly M A Dreuning
- Department of Pediatric Surgery, Emma Children's Hospital, Amsterdam University Medical Centers, University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands
| | - Maarten J H Janssen Lok
- Division of General and Thoracic Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Tomas Wester
- Department of Pediatric Surgery, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Joep P M Derikx
- Department of Pediatric Surgery, Emma Children's Hospital, Amsterdam University Medical Centers, University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands
| | - Florian Friedmacher
- Department of Pediatric Surgery, The Royal London Hospital, London, United Kingdom.,Department of Pediatric Surgery, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt/Main, Germany
| | - Hiromu Miyake
- Department of Pediatric Surgery, Shizuoka Children's Hospital, Shizuoka, Japan
| | - Haitao Zhu
- Division of General and Thoracic Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.,Department of Pediatric Surgery, Children's Hospital of Fudan University, Shanghai, China
| | - Luca Pio
- Department of Pediatric Surgery and Urology, Hôpital Universitaire Robert-Debré, University of Paris, Paris, France
| | - Martin Lacher
- Department of Pediatric Surgery, University of Leipzig, Leipzig, Germany
| | - Stefania Sgró
- Department of Anesthesiology, Ospedale Pediatrico Bambino Gesù, IRCCS, Rome, Italy
| | - Augusto Zani
- Division of General and Thoracic Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.,Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Simon Eaton
- Developmental Biology and Cancer Programme, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - L W Ernest van Heurn
- Department of Pediatric Surgery, Emma Children's Hospital, Amsterdam University Medical Centers, University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands
| | - Agostino Pierro
- Division of General and Thoracic Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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26
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Camporesi A, Diotto V, Zoia E, Rotta S, Tarantino F, Eccher LMG, Calcaterra V, Pelizzo G, Gemma M. Postoperative apnea after pyloromyotomy for infantile hypertrophic pyloric stenosis. WORLD JOURNAL OF PEDIATRIC SURGERY 2022; 5:e000391. [DOI: 10.1136/wjps-2021-000391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 04/20/2022] [Indexed: 11/04/2022] Open
Abstract
ObjectiveInfantile hypertrophic pyloric stenosis (IHPS), which causes gastric outlet obstruction and hypochloremic hypokalemic metabolic alkalosis, could pose a risk of postoperative apnea in patients. The aim of this study is to evaluate the incidence of postoperative apnea in babies admitted to a tertiary-level pediatric surgical center in Milano, Italy with diagnosis of IHPS in 2010–2019. The secondary objective is to evaluate the risk factors for postoperative apnea.MethodsThis is a single-center, retrospective, observational cohort study. All patients admitted to our institution with diagnosis of IHPS during the study period were enrolled. Demographic and surgical variables, along with blood gas parameters, were obtained from the population. Postoperative apnea was defined as a respiratory pause longer than 15 s or a respiratory pause lasting less than 15 s, but associated with either bradycardia (heart rate <120 per minute), desaturation (SatO2 <90%), cyanosis, or hypotonia. Occurrence was obtained from nursing charts and was recorded as a no/yes dichotomous variable.ResultsOf 122 patients, 12 (9.84%) experienced apnea and 110 (90.16%) did not. Using univariate analysis, we found that only postoperative hemoglobin was significantly different between the groups (p=0.03). No significant multivariable model was better than this univariate model for prediction of apnea.ConclusionsPostoperative anemia, possibly due to hemodilution, increased the risk of postoperative apnea. It could be hypothesized that anemia can be added as another apnea-contributing factor in a population at risk due to metabolic changes.
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27
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Eizaga Rebollar R, García Palacios MV, Morales Guerrero J, Torres Morera LM. Pediatric spinal anesthesia at a tertiary care hospital: Eleven years after. Paediatr Anaesth 2022; 32:617-624. [PMID: 35156263 DOI: 10.1111/pan.14414] [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: 11/03/2021] [Revised: 02/01/2022] [Accepted: 02/04/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Pediatric spinal anesthesia is an old technique whose use is not widespread, in spite of reducing the risk of cardiorespiratory events (hypoxemia, bradycardia, and hypotension) associated with general anesthesia, especially in neonates and infants. This retrospective cohort study aimed to assess the safety and effectiveness of the pediatric spinal anesthesia program at our tertiary care hospital over 11 years. METHODS Two hundred children, between 8 days and 13 years of age, who underwent lower body surgery under spinal anesthesia from May 2010 to July 2021 were included. Demographic and procedural data were collected, and success, failure, and complication rates calculated. RESULTS The success rate was 97.5% (n = 195). The incidence of complications was 2% (n = 4). They were 2 cases of intraoperative hypoxemia and 2 cases of postoperative postdural puncture headache , and they quickly resolved with no sequelae. CONCLUSION Pediatric spinal anesthesia is a safe and effective technique with good acceptance among anesthesiologists. Thus, the implementation of a pediatric spinal anesthesia program at a tertiary care hospital is feasible and affordable.
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Affiliation(s)
- Ramón Eizaga Rebollar
- Department of Anesthesiology and Reanimation, Puerta de Mar University Hospital, Cádiz, Spain
| | | | - Javier Morales Guerrero
- Department of Anesthesiology and Reanimation, Puerta de Mar University Hospital, Cádiz, Spain
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Opfermann P, Kraft F, Obradovic M, Zadrazil M, Schmid W, Marhofer P. Ultrasound-guided caudal blockade and sedation for paediatric surgery: a retrospective cohort study. Anaesthesia 2022; 77:785-794. [PMID: 35460068 PMCID: PMC9322320 DOI: 10.1111/anae.15738] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 03/24/2022] [Accepted: 03/25/2022] [Indexed: 11/27/2022]
Abstract
Data on safety and success rates of ultrasound‐guided caudal blockade, performed on sedated children with an uninstrumented airway, are scarce. We performed a retrospective observational study of validated data from April 2014 to December 2020 in a paediatric cohort where the initial plan for anaesthetic management was sedation and caudal epidural without general anaesthesia or airway instrumentation. We examined success rates of this approach and rates of block failure and block‐related complications. In total, 2547 patients ≤ 15 years of chronological age met inclusion criteria. Among the 2547 cases, including 453 (17.8%) former preterm patients, caudal‐plus‐sedation success rate was 95.1%. The primary anaesthesia plan was abandoned for general anaesthesia in 124 cases. Pain‐related block failure in 83 (3.2%) was the most common cause for conversion. Complications included 39 respiratory events and 9 accidental spinal anaesthetics. Higher odds of pain‐related block failure were associated with higher body weight (adjusted OR 1.063, 95%CI 1.035–1.092, p < 0.001) as well as with mid‐abdominal surgery (e.g. umbilical hernia repair) (adjusted OR 15.11, 95%CI 7.69–29.7, p < 0.001), whereas extreme (< 28 weeks) former prematurity, regardless of chronological age, was associated with higher odds (adjusted OR 3.62, 95%CI 1.38–9.5, p = 0.009) for respiratory problems. Ultrasound‐guided caudal epidural, performed under sedation with an uninstrumented airway, is an effective technique in the daily clinical routine. Higher body weight and mid‐abdominal surgical procedures are risk factors for pain‐related block failure. Patients who, regardless of chronological age, had been born as extreme preterm babies are at the highest risk for respiratory events.
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Affiliation(s)
- P Opfermann
- Department of Anaesthesia, General Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - F Kraft
- Department of Anaesthesia, General Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - M Obradovic
- Department of Anaesthesia, General Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - M Zadrazil
- Department of Anaesthesia, General Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - W Schmid
- Department of Anaesthesia, General Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - P Marhofer
- Department of Anaesthesia, General Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria.,Department of Anaesthesia and Intensive Care Medicine, Orthopaedic Hospital Speising, Vienna, Austria
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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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30
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Schroepf S, Mayle PM, Kurz M, Wermelt JZ, Hubertus J. Prematurity is a critical risk factor for respiratory failure after early inguinal hernia repair under general anesthesia. Front Pediatr 2022; 10:843900. [PMID: 35958181 PMCID: PMC9357901 DOI: 10.3389/fped.2022.843900] [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: 12/27/2021] [Accepted: 06/27/2022] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION The purpose of this study was to determine the earliest timing of inguinal hernia repair under general anesthesia with minimized risk for respiratory complications during postoperative course. METHODS We performed a monocentric analysis of patient records of premature and full-term infants undergoing inguinal hernia repair between 2009 and 2016. In addition to demographic and medical parameters, preexisting conditions and the perioperative course were recorded. RESULTS The study included 499 infants (preterm n = 285; full term n = 214). The number of subsequently ventilated patients was particularly high among preterm infants with bronchopulmonary dysplasia, up to 45.3% (p < 0.001). Less than 10% of subsequent ventilation occurred in preterm infants after 45 weeks of postmenstrual age at the time of surgery or in patients with a body weight of more than 4,100 g. Preterm infants with a bronchopulmonary dysplasia had an increased risk of apneas (p < 0.05). Only 10% of the preterm babies with postoperative apneas weighed more than 3,600 g at the time of surgery or were older than 44 weeks of postmenstrual age. CONCLUSION Our data indicate that after the 45th week of postmenstrual age and a weight above 4,100 g, the risk for respiratory failure after general anesthesia seems to be significantly decreased in preterm infants.
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Affiliation(s)
- Sebastian Schroepf
- Department of Pediatrics and Neonatology, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Paulina M Mayle
- Department of Pediatrics and Neonatology, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University Munich, Munich, Germany.,Department of Internal Medicine, University Hospital Augsburg, Augsburg, Germany
| | - Matthias Kurz
- Department of Anesthesiology, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Julius Z Wermelt
- Department of Anesthesiology and Pediatric Anesthesiology, Bürgerhospital Frankfurt am Main, Frankfurt am Main, Germany
| | - Jochen Hubertus
- Department of Pediatric Surgery, Ruhr-University Bochum, Bochum, Germany
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31
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Karlsson J, Lönnqvist PA. Blood pressure and flow in pediatric anesthesia: An educational review. Paediatr Anaesth 2022; 32:10-16. [PMID: 34741785 DOI: 10.1111/pan.14328] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 10/31/2021] [Accepted: 11/02/2021] [Indexed: 01/01/2023]
Abstract
During recent years, a lot of interest has been focused on blood pressure in the context of pediatric anesthesia, trying to define what is normal in relation to age and what numeric values that should be regarded as hypotension, needing active intervention. However, blood pressure is mainly measured as a proxy for flow, that is, cardiac output. Thus, just focusing on specific blood pressure numbers may not necessarily be very useful or appropriate. The aim of this educational review is to put the issue of intraoperative blood pressure in the context of pediatric anesthesia in further perspective.
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Affiliation(s)
- Jacob Karlsson
- Karolinska Institute Department of Physiology and Pharmacology (FYFA), C3, Per-Arne Lönnqvist Group - Section of Anesthesiology and Intensive Care, Anestesi- och Intensivvårdsavdelningen, Stockholm, Sweden.,Pediatric perioperative medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Per-Arne Lönnqvist
- Karolinska Institute Department of Physiology and Pharmacology (FYFA), C3, Per-Arne Lönnqvist Group - Section of Anesthesiology and Intensive Care, Anestesi- och Intensivvårdsavdelningen, Stockholm, Sweden.,Pediatric perioperative medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
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32
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Opfermann P, Marhofer P, Springer A, Metzelder M, Zadrazil M, Schmid W. A prospective observational study on the feasibility of subumbilical laparoscopic procedures under epidural anesthesia in sedated spontaneously breathing infants with a natural airway. Paediatr Anaesth 2022; 32:49-55. [PMID: 34582607 PMCID: PMC9292952 DOI: 10.1111/pan.14302] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 09/20/2021] [Accepted: 09/26/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Laparoscopic procedures are usually performed under general anesthesia with a secured airway including endotracheal intubation or supraglottic airways. AIMS This is a prospective study of the feasibility of subumbilical laparoscopic procedures under epidural anesthesia in sedated, spontaneous breathing infants with a natural airway. METHODS We consecutively enrolled 20 children <3 years old with nonpalpable testes scheduled for diagnostic laparoscopy with or without an ensuing orchidopexy, inguinal revision, or Fowler-Stephens maneuver. Inhalational induction for venous access was followed by sedation with propofol and ultrasound-guided single-shot epidural anesthesia via the caudal or thoracolumbar approach using 1.0 or 0.5 ml kg-1 ropivacaine 0.38%, respectively. The primary outcome measure was block success, defined as no increase in heart rate by >15% or other indicators of pain upon skin incision. RESULTS Of the 20 children (median age: 10 months; IQR: 8.3-12), 17 (85%) were anesthetized through a caudal and 3 (15%) through a direct thoracolumbar epidural, 18 (90%) underwent a surgical procedure and 2 (10%) diagnostic laparoscopy only. Five patients (25%) received block augmentation using an intravenous bolus of fentanyl (median dose: 0.9 µg kg-1 ; IQR: 0.8-0.95) after the initial prick test and before skin incision. There was no additional need for systemic pain therapy in the operating theater or recovery room. No events of respiratory failure or aspiration were observed. CONCLUSIONS In experienced hands, given our success rate of 100%, epidural anesthesia performed in sedated spontaneously breathing infants with a natural airway can be an alternative strategy for subumbilical laparoscopic procedures.
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Affiliation(s)
- Philipp Opfermann
- Department of Anesthesia, General Intensive Care Medicine and Pain TherapyMedical University of ViennaViennaAustria
| | - Peter Marhofer
- Department of Anesthesia, General Intensive Care Medicine and Pain TherapyMedical University of ViennaViennaAustria,Department of Anesthesia and Intensive Care MedicineOrthopaedic Hospital SpeisingViennaAustria
| | - Alexander Springer
- Department of SurgeryDivision of Pediatric SurgeryMedical University of ViennaViennaAustria
| | - Martin Metzelder
- Department of SurgeryDivision of Pediatric SurgeryMedical University of ViennaViennaAustria
| | - Markus Zadrazil
- Department of Anesthesia, General Intensive Care Medicine and Pain TherapyMedical University of ViennaViennaAustria
| | - Werner Schmid
- Department of Anesthesia, General Intensive Care Medicine and Pain TherapyMedical University of ViennaViennaAustria
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Dreuning KMA, van Tulder MW, Been JV, Rovers MM, de Graaff JC, Stevens MF, Anema JR, Twisk JWR, van Heurn LWE, Derikx JPM. Contralateral surgical exploration during inguinal hernia repair in infants (HERNIIA trial): study protocol for a multi-centre, randomised controlled trial. Trials 2021; 22:670. [PMID: 34593022 PMCID: PMC8481323 DOI: 10.1186/s13063-021-05606-w] [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: 04/09/2021] [Accepted: 09/05/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The incidence of metachronous contralateral inguinal hernia (MCIH) is high in infants with an inguinal hernia (5-30%), with the highest risk in infants aged 6 months or younger. MCIH is associated with the risk of incarceration and necessitates a second operation. This might be avoided by contralateral exploration during primary surgery. However, contralateral exploration may be unnecessary, leads to additional operating time and costs and may result in additional complications of surgery and anaesthesia. Thus, there is no consensus whether contralateral exploration should be performed routinely. METHODS The Hernia-Exploration-oR-Not-In-Infants-Analysis (HERNIIA) study is a multicentre randomised controlled trial with an economic evaluation alongside to study the (cost-)effectiveness of contralateral exploration during unilateral hernia repair. Infants aged 6 months or younger who need to undergo primary unilateral hernia repair will be randomised to contralateral exploration or no contralateral exploration (n = 378 patients). Primary endpoint is the proportion of infants that need to undergo a second operation related to inguinal hernia within 1 year after primary repair. Secondary endpoints include (a) total duration of operation(s) (including anaesthesia time) and hospital admission(s); (b) complications of anaesthesia and surgery; and (c) participants' health-related quality of life and distress and anxiety of their families, all assessed within 1 year after primary hernia repair. Statistical testing will be performed two-sided with α = .05 and according to the intention-to-treat principle. Logistic regression analysis will be performed adjusted for centre and possible confounders. The economic evaluation will be performed from a societal perspective and all relevant costs will be measured, valued and analysed. DISCUSSION This study evaluates the effectiveness and cost-effectiveness of contralateral surgical exploration during unilateral inguinal hernia repair in children younger than 6 months with a unilateral inguinal hernia. TRIAL REGISTRATION ClinicalTrials.gov NCT03623893 . Registered on August 9, 2018 Netherlands Trial Register NL7194. Registered on July 24, 2018 Central Committee on Research Involving Human Subjects (CCMO) NL59817.029.18. Registered on July 3, 2018.
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Affiliation(s)
- Kelly M A Dreuning
- Department of Paediatric Surgery, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam & Vrije Universiteit Amsterdam, Amsterdam Reproduction and Development Research Institute and the Amsterdam Public Health Research Institute, P.O. Box 22660, 1100 DD, Amsterdam, The Netherlands.
| | - Maurits W van Tulder
- Department of Health Sciences and Amsterdam Movement Science research institute, Faculty of Sciences, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.,Department of Physiotherapy & Occupational Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - Jasper V Been
- Division of Neonatology, Department of Paediatrics, Sophia Children's Hospital, Erasmus University Medical Centre, Rotterdam, The Netherlands.,Department of Public Health, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands.,Department of Obstetrics and Gynaecology, Sophia Children's Hospital, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Maroeska M Rovers
- Radboud Institute for Health Sciences, Department of Health Evidence, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Jurgen C de Graaff
- Department of Anaesthesiology, Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Markus F Stevens
- Department of Anaesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Johannes R Anema
- Department of Public and Occupational Health, and the Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Jos W R Twisk
- Department of Methodology and Applied Biostatistics, and the Amsterdam Public Health research institute, Vrije Universiteit, Amsterdam, The Netherlands
| | - L W Ernest van Heurn
- Department of Paediatric Surgery, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam & Vrije Universiteit Amsterdam, Amsterdam Reproduction and Development Research Institute and the Amsterdam Public Health Research Institute, P.O. Box 22660, 1100 DD, Amsterdam, The Netherlands
| | - Joep P M Derikx
- Department of Paediatric Surgery, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam & Vrije Universiteit Amsterdam, Amsterdam Reproduction and Development Research Institute and the Amsterdam Public Health Research Institute, P.O. Box 22660, 1100 DD, Amsterdam, The Netherlands
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Su MP, Hu PY, Lin JY, Yang ST, Cheng KI, Lin CH. Comparison of laryngeal mask airway and endotracheal tube in preterm neonates receiving general anesthesia for inguinal hernia surgery: a retrospective study. BMC Anesthesiol 2021; 21:195. [PMID: 34289809 PMCID: PMC8293587 DOI: 10.1186/s12871-021-01418-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 07/05/2021] [Indexed: 11/18/2022] Open
Abstract
Background Preterm neonates are at higher risk of developing inguinal hernia, and have an increased risk of perioperative adverse events. Laryngeal mask airway (LMA) is claimed to be associated to decreasing perioperative respiratory complications compared to endotracheal tube (ETT) in infants under one year of age receiving minor surgery; thus, we conducted a retrospective survey in former preterm neonates below 5000 g to compare the respiratory complications between LMA and ETT in general anesthesia for inguinal hernia surgeries. Methods The inclusion criteria were: gestational age at birth under 37 weeks, body weight at surgery below 5000 g, and receiving scheduled inguinal hernia repair under general anesthesia with LMA or ETT. Infants who were dependent on mechanical ventilation preoperatively were excluded. The postoperative respiratory complications including delayed extubation, re-intubation, and apnea within postoperative 24 h were compared between groups. Results From July 2014 to December 2017, 72 neonates were enrolled into final analysis. There were 57 neonates managed with LMA, and only 15 neonates intubated with ETT during the study period. The gestational age at birth and post-menstrual age at surgery showed no significant difference between groups, although in the ETT group, the body weight at birth and at surgery were lower, and more infants had history of severe respiratory distress syndrome and had received oxygen therapy within two weeks prior to surgery. Surprisingly, none one of the infants developed delayed extubation, re-intubation, or postoperative apnea in the LMA group. In the ETT group, 40 percent of the neonates could not be successfully extubated in the operation theater. Conclusion In preterm neonates, even in those younger than 52 weeks post-menstrual age who undergoing inguinal hernia repair in their early infancy, LMA appears feasible and safe as the airway device during general anesthesia in specific patient group. However, anesthesiologist might prefer ETT rather than LMA in some complex situation. In neonates with lower body weight at birth and at surgery, and with a history of severe RDS and oxygen-dependence, further prospective study is required.
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Affiliation(s)
- Miao-Pei Su
- Department of Anesthesiology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, No.100, Tzyou 1st Rd, Kaohsiung, Taiwan
| | - Ping-Yang Hu
- Department of Anesthesiology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, No.100, Tzyou 1st Rd, Kaohsiung, Taiwan
| | - Jao-Yu Lin
- Division of Pediatric Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Shu-Ting Yang
- Division of Neonatology, Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Kuang-I Cheng
- Department of Anesthesiology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, No.100, Tzyou 1st Rd, Kaohsiung, Taiwan.,School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chia-Heng Lin
- Department of Anesthesiology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, No.100, Tzyou 1st Rd, Kaohsiung, Taiwan.
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Fanelli D, Kim D, King TS, Weller GE, Dalal PG. Recovery Characteristics in Neonates Following General Anesthesia: A Retrospective Chart Review. Cureus 2021; 13:e16126. [PMID: 34367758 PMCID: PMC8330508 DOI: 10.7759/cureus.16126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/02/2021] [Indexed: 11/22/2022] Open
Abstract
Introduction Preterm babies increasingly survive the neonatal period as a result of advanced care practices. Accordingly, anesthesiologists are likely to encounter these patients with greater frequency. Ex-premature infants and term neonates are known to have an increased risk of post-operative apneas following surgery and anaesthesia. Methods Following approval from the Institutional Review Board, we performed a retrospective chart review of neonates 0-28 days of age who underwent general anaesthesia procedures over two years. Data collected included age days, sex, weight, gestational age, American Society of Anaesthesiologists (ASA) physical status, type of anaesthetic (general/regional/spinal), airway management, surgical procedure, intraoperative adverse events, duration of anaesthesia, medications administered, post-operative recovery location, the occurrence of apneic events, medical co-morbidities, duration of post anaesthesia care unit (PACU) admission, a requirement for neonatal intensive care unit (NICU) admission, and duration of hospital admission. Results A total of 239 charts were reviewed from January 1, 2015, to December 31, 2016. Ninety-five cases were excluded for required postoperative mechanical ventilation. For the remaining 144 cases, the mean age was 12.8 days, 65% male, 35% female, mean gestational age 38.6 weeks, mean post-menstrual age 40.5 weeks, mean ASA status 3.5, and mean weight 3.46 kg. Post-operative apnea was observed in two neonates (1.4%). Risk factors for postoperative apnea included lower gestational age at birth (median 37.5 vs. 39.1 weeks, p=0.26), lower post-menstrual age (median 38.5 vs. 41.0 weeks, p=0.18), and lower weight (median 2.8 vs. 3.5kg, p=0.27), respectively. ASA classification, preoperative anaemia, and known pathology were all significant risk factors for apnea (p<0.05). Significant factors from the bivariate analysis were preoperative anaemia, known pathology, age, duration of anaesthesia, weight, intraoperative fentanyl, and amount of neuromuscular blocker. Age and preoperative anaemia were significant predictors for recovery location. The odds of going to PACU vs NICU/PICU for post-operative recovery were 7.4 times greater for every two weeks greater age (95% CI=(2.80-19.31), p<0.001). Conclusion This study corroborates previous findings of predictive risk factors for post-anaesthesia apnea in preterm and term neonates. Previously reported risk factors, including low gestational/post-menstrual age, lower weight, and intraoperative narcotic use, were likely contributors to one of the apneic events in our study. A larger sample size is warranted to confirm a valid predictive model. Standardized universal guidelines would be useful in eliminating local variation in PACU monitoring and discharge criteria in this vulnerable age group.
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Affiliation(s)
- David Fanelli
- Anesthesiology and Perioperative Medicine, Penn State Health Milton S. Hershey Medical Center, Hershey, USA
| | - Daniel Kim
- Anesthesiology and Perioperative Medicine, Penn State Health Milton S. Hershey Medical Center, Hershey, USA
| | - Tonya S King
- Epidemiology and Public Health, Penn State College of Medicine, Hershey, USA
| | - Gregory E Weller
- Anesthesiology and Perioperative Medicine, Penn State Health Milton S. Hershey Medical Center, Hershey, USA
| | - Priti G Dalal
- Anesthesiology and Perioperative Medicine, Penn State Health Milton S. Hershey Medical Center, Hershey, USA
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Acquaviva MA, Caltoum CB, Bielski RJ, Loder RT, Boyer TJ, Cossu AE, Castelluccio PF. Spinal Anesthesia is Superior to General Anesthesia for Percutaneous Achilles Tenotomy in Infants. J Pediatr Orthop 2021; 41:352-355. [PMID: 33843786 DOI: 10.1097/bpo.0000000000001826] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Concern about the effects of inhaled, halogenated anesthetics on neurodevelopment of infants has renewed interest in regional anesthesia as an alternative to general anesthesia (GA). Infants undergoing percutaneous Achilles tenotomy (PAT) are well suited for spinal anesthesia (SP). METHODS Thirty infants (mean age: 2.3 mo) undergoing PAT with SP were compared with 15 infants (mean age: 2.0 mo) undergoing PAT with GA. Data collected included perioperative times, heart rate and blood pressure, and the administration of opioids. RESULTS Ten of 15 GA (67%) patients received perioperative opioids as opposed to 1 of 30 SP patients (3.3%) (P<0.0001). The time from the start of anesthesia to the start of surgery was shorter in the SP group (8.5 vs. 14 min, P<0.0009). The time from the start of anesthesia to first oral intake was shorter in the SP group (12 vs. 31 min, P<0.0033). The time of first phase recovery (phase 1 post anesthesia care unit) was shorter in the SP group (15.5 vs. 34 min, P<0.0026). Surgery time was not significantly different between the groups (SP: 15.5 min, GA: 15 min, P=0.81). CONCLUSION Infants undergoing PAT with SP received less opioid, did not require an airway device, did not receive potent inhaled, halogenated hydrocarbon anesthetics, and exhibited faster and qualitatively better postoperative recovery. LEVEL OF EVIDENCE Level III-case control study.
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Ceccanti S, Cervellone A, Pesce MV, Cozzi DA. Feasibility, safety and outcome of inguinal hernia repair under spinal versus general anesthesia in preterm and term infants. J Pediatr Surg 2021; 56:1057-1061. [PMID: 33143880 DOI: 10.1016/j.jpedsurg.2020.09.064] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 09/22/2020] [Accepted: 09/24/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND Inguinal hernia repair (IHR) is a common operation in preterm and term infants. Recently, spinal anesthesia (SA) has been proposed as an alternative to avoid exposure to general anesthesia (GA) during early life. The aim of this study was to compare surgical outcomes of open IHR performed under SA versus GA in neonates and infants, and to detect criteria to predict the success or failure of SA. MATERIALS AND METHODS This is a 6-year, single center, nonrandomized interventional study (2013-2019). SA was performed with 0.5% bupivacaine. GA was given using propofol, fentanyl, sevoflurane, and laryngeal mask. Patient demographics, operative time, intraoperative events related to surgery or anesthesia, and complications were analyzed at short and long-term follow-up. RESULTS 68 infants (78 IHR) and 37 infants (44 IHR) received SA and GA at the discretion of the anesthesiologist, respectively. SA failure rate was 9%, and positively correlated with weight at surgery (p = 0.001; rp = 0.38). Conversion from SA to GA occurred in 4 (6%) patients owing to prolonged operative time (43.75 ± 4.8 vs 23.02 ± 11.3 min; p = 0.0006). There were no differences regarding operative time and intra- and postoperative complications among the two groups at mean follow-up of 18.53 ± 21.9 months. CONCLUSIONS This pilot study confirms that SA is safe, effective and not detrimental to surgical outcome of neonates and infants undergoing IHR. Additionally, it may help further define what patients may have a successful SA. Our experience suggests that SA is especially suitable in infants weighing <4000 g, and conversion to GA correlates with prolonged operative time. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Silvia Ceccanti
- Pediatric Surgery Unit, Sapienza University of Rome, Azienda Policlinico Umberto I, Rome, RM 00161, Italy
| | - Alice Cervellone
- Pediatric Surgery Unit, Sapienza University of Rome, Azienda Policlinico Umberto I, Rome, RM 00161, Italy
| | - Maria Vittoria Pesce
- Department of Anesthesia and Critical Care Medicine, Sapienza University of Rome, Azienda Policlinico Umberto I, Rome, RM 00161, Italy
| | - Denis A Cozzi
- Pediatric Surgery Unit, Sapienza University of Rome, Azienda Policlinico Umberto I, Rome, RM 00161, Italy.
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Safety challenges related to the use of sedation and general anesthesia in pediatric patients undergoing magnetic resonance imaging examinations. Pediatr Radiol 2021; 51:724-735. [PMID: 33860861 PMCID: PMC8049862 DOI: 10.1007/s00247-021-05044-5] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 01/17/2021] [Accepted: 03/01/2021] [Indexed: 12/17/2022]
Abstract
The use of sedation and general anesthesia has facilitated the significant growth of MRI use among children over the last years. While sedation and general anesthesia are considered to be relatively safe, their use poses potential risks in the short term and in the long term. This manuscript reviews the reasons why MRI examinations require sedation and general anesthesia more commonly in the pediatric population, summarizes the safety profile of sedation and general anesthesia, and discusses an amalgam of strategies that can be implemented and can ultimately lead to the optimization of sedation and general anesthesia care within pediatric radiology departments.
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Poirier C, Alencar Cavalcante Nascimento Lima L, Ingelmo P. It is time to prove that regional anesthesia can be a game changer in the recovery after surgery in children. Minerva Anestesiol 2020; 87:634-636. [PMID: 33331754 DOI: 10.23736/s0375-9393.20.15270-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
| | | | - Pablo Ingelmo
- Department of Anesthesiology, Montreal Children's Hospital, McGill University, Montreal, QC, Canada -
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Fernandez N, Santander J, Ceballos C. Regional Anesthesia. An Alternative to General Anesthesia in the Management of Neonatal Testicular Torsion. Urology 2020; 146:219-221. [DOI: 10.1016/j.urology.2020.06.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 06/15/2020] [Accepted: 06/22/2020] [Indexed: 10/23/2022]
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Handlogten K, Warner L, Granberg C, Gargollo P, Thalji L, Haile D. Implementation of a spinal anesthesia and sedation protocol that reliably prolongs infant spinal anesthesia: Case series of 102 infants who received spinal anesthesia for urologic surgery. Paediatr Anaesth 2020; 30:1355-1362. [PMID: 32966667 DOI: 10.1111/pan.14024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 08/18/2020] [Accepted: 09/06/2020] [Indexed: 01/01/2023]
Abstract
BACKGROUND The use of spinal anesthesia in infants is seeing resurgence as an alternative to general anesthesia. AIMS Our primary aims are to describe our institution's experience introducing a spinal anesthesia and sedation protocol for infants undergoing urologic surgery, to describe methods of improving prolonged anesthesia, and to describe the failure rate of spinal anesthesia in these patients. Sedation was provided for some infants with intranasal dexmedetomidine ± fentanyl. METHODS This is a retrospective case series examining infants aged 1-<14 months who received spinal anesthesia for circumcision, orchiopexy, orchiectomy, hypospadias repair, or epispadias repair. The electronic medical record was reviewed and compared with unmatched historical controls who received general anesthesia. RESULTS A total of 230 patients underwent a urologic procedure; 102 patients received spinal anesthesia and 128 received general anesthesia. Length of surgical time with spinal anesthesia ranged from 4 to 189 minutes. The hospital length of stay was shorter in the spinal anesthesia group (median [IQR] of 5.3 hours [4.3, 7.2]) compared to the general anesthesia group (17.1 hours [15.6, 17.5]).The median bupivacaine dose was 0.75 mg/kg [0.67, 0.85]. There was one case in which cerebral spinal fluid was unable to be obtained, and one case that required conversion to general anesthesia after surgery had started. There were no cases of apnea, bleeding, infection, or neurologic compromise. CONCLUSIONS We describe the successful implementation of an infant spinal anesthesia and sedation protocol and a technique that uniquely provides prolonged surgical anesthesia with a low failure rate. We also report shorter anesthesia time, surgical time, and recovery room length of stay in patients who received spinal anesthesia compared to general anesthesia.
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Affiliation(s)
- Kathryn Handlogten
- Department of Perioperative Medicine and Anesthesia, Mayo Clinic, Rochester, MN, USA
| | - Lindsay Warner
- Department of Perioperative Medicine and Anesthesia, Mayo Clinic, Rochester, MN, USA
| | - Candace Granberg
- Department of Pediatric Urology, Mayo Clinic, Rochester, MN, USA
| | | | - Leanne Thalji
- Department of Perioperative Medicine and Anesthesia, Mayo Clinic, Rochester, MN, USA
| | - Dawit Haile
- Department of Perioperative Medicine and Anesthesia, Mayo Clinic, Rochester, MN, USA
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Firth PG, Mai CL. The evolution of pediatric sedation and anesthesia patient safety: An interview with Dr Charles J. "Charlie" Coté. Paediatr Anaesth 2020; 30:1183-1190. [PMID: 33569801 DOI: 10.1111/pan.13999] [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: 07/18/2020] [Revised: 08/05/2020] [Accepted: 08/11/2020] [Indexed: 11/30/2022]
Abstract
The career of Dr Charles J. Coté covered a period of major advances in pediatric anesthesia patient safety. Dr Coté (1946 --), Professor Emeritus in Anaesthesia at Harvard Medical School, helped develop pediatric sedation guidelines, conducted influential clinical research, edited a major textbook, and promoted pediatric anesthesia training fellowships in low- and middle-income countries. Based on a series of interviews with Dr Coté, this article reviews the career of this Robert M. Smith Award winner through the lens of improvements in pediatric sedation and anesthesia patient safety.
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Affiliation(s)
- Paul G Firth
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Christine L Mai
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
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Zhang QF, Zhao H, Feng Y. [Different anesthesia management in preterm infants undergoing surgeries for retinopathy of prematurity: A retrospective study]. BEIJING DA XUE XUE BAO. YI XUE BAN = JOURNAL OF PEKING UNIVERSITY. HEALTH SCIENCES 2020; 53:195-199. [PMID: 33550356 PMCID: PMC7867972 DOI: 10.19723/j.issn.1671-167x.2021.01.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
OBJECTIVE To evaluate the effect of different anesthesia management on clinical outcomes in former prematurely born infants undergoing surgeries for retinopathy of prematurity (ROP). METHODS In this retrospective study, electronic medical record database was searched for all former prematurely born infants (gestational age < 37 weeks and post conceptual age < 60 weeks) who received ROP surgery under inhalational general anesthesia between November 2016 and October 2018. The patients were divided into two groups based on anesthesia management: laryngeal mask airway (LMA) insertion without intravenous muscle relaxant injection and with pressure support ventilation (LMA group) or airway secured with endotracheal tube (ETT) with intravenous muscle relaxant injection and pressure controlled ventilation (ETT group). Primary outcomes included perioperative adverse events and complications. Extubation time and length of stay after surgery were also recorded. RESULTS Sixty eight preterm infants in the LMA group and 100 preterm infants in the ETT group were included. The incidence of adverse events during surgery (including airway management change and desaturation) was similar in LMA group and ETT group (4.4% vs. 1.0%, P =0.364). During the early recovery period after surgery, the incidence of difficult extubation (extubation time >30 min) was significantly lower in LMA group compared with ETT group (4.4% vs.15.0%, RR=0.262, 95%CI:0.073-0.942, P=0.029). The incidence of respiratory events was similar between the two groups (20.6% vs. 27.0%, P =0.342). However, the incidence of apnea was significantly lower in the LMA group than in the ETT group (5.9% vs.19.0%, RR=0.266, 95%CI: 0.086-0.822, P =0.015). No significant difference was observed between the LMA group and ETT group in incidences of cardiovascular events (0% vs. 1.0%, P =1.000) and unplanned admission to neonatal intensive care unit (5.9% vs. 7.0%, P=0.774). No airway spasm, re-intubation, aspiration or regurgitation was observed during early recovery. During late recovery after returning to ward, the incidence of adverse events was also similar between the two groups (0% vs. 2.0%, P =0.241). The median (IQR) extubation time was 6 (5, 10) min in LMA group and 10 (6, 19) min in ETT group (P < 0.001). The median length of stay after surgery was significantly shortened in LMA group compared with ETT group [20 (17, 22) hours vs. 22 (17, 68) hours, P =0.002]. CONCLUSION Compared with endotracheal intubation with intravenous muscle relaxant injection, laryngeal mask airway insertion without muscle relaxant could achieve an early extubation, and reduce the incidence of apnea during early recovery period in former prematurely born infants undergoing ROP surgery.
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Affiliation(s)
- Q F Zhang
- Department of Anesthesiology, Peking University People's Hospital, Beijing, China, 100044, China
| | - H Zhao
- Department of Anesthesiology, Peking University People's Hospital, Beijing, China, 100044, China
| | - Y Feng
- Department of Anesthesiology, Peking University People's Hospital, Beijing, China, 100044, China
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Robles-Rubio CA, Kearney RE, Bertolizio G, Brown KA. Automatic unsupervised respiratory analysis of infant respiratory inductance plethysmography signals. PLoS One 2020; 15:e0238402. [PMID: 32915810 PMCID: PMC7485851 DOI: 10.1371/journal.pone.0238402] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 08/15/2020] [Indexed: 11/19/2022] Open
Abstract
Infants are at risk for potentially life-threatening postoperative apnea (POA). We developed an Automated Unsupervised Respiratory Event Analysis (AUREA) to classify breathing patterns obtained with dual belt respiratory inductance plethysmography and a reference using Expectation Maximization (EM). This work describes AUREA and evaluates its performance. AUREA computes six metrics and inputs them into a series of four binary k-means classifiers. Breathing patterns were characterized by normalized variance, nonperiodic power, instantaneous frequency and phase. Signals were classified sample by sample into one of 5 patterns: pause (PAU), movement (MVT), synchronous (SYB) and asynchronous (ASB) breathing, and unknown (UNK). MVT and UNK were combined as UNKNOWN. Twenty-one preprocessed records obtained from infants at risk for POA were analyzed. Performance was evaluated with a confusion matrix, overall accuracy, and pattern specific precision, recall, and F-score. Segments of identical patterns were evaluated for fragmentation and pattern matching with the EM reference. PAU exhibited very low normalized variance. MVT had high normalized nonperiodic power and low frequency. SYB and ASB had a median frequency of respectively, 0.76Hz and 0.71Hz, and a mode for phase of 4o and 100o. Overall accuracy was 0.80. AUREA confused patterns most often with UNKNOWN (25.5%). The pattern specific F-score was highest for SYB (0.88) and lowest for PAU (0.60). PAU had high precision (0.78) and low recall (0.49). Fragmentation was evident in pattern events <2s. In 75% of the EM pattern events >2s, 50% of the samples classified by AUREA had identical patterns. Frequency and phase for SYB and ASB were consistent with published values for synchronous and asynchronous breathing in infants. The low normalized variance in PAU, was consistent with published scoring rules for pediatric apnea. These findings support the use of AUREA to classify breathing patterns and warrant a future evaluation of clinically relevant respiratory events.
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Affiliation(s)
| | - Robert E. Kearney
- Department of Biomedical Engineering, McGill University, Montreal, Quebec, Canada
| | - Gianluca Bertolizio
- Department of Anesthesia, Division of Pediatric Anesthesia, McGill University Health Centre, Montreal, Quebec, Canada
| | - Karen A. Brown
- Department of Anesthesia, Division of Pediatric Anesthesia, McGill University Health Centre, Montreal, Quebec, Canada
- * E-mail:
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Salaün JP, de Queiroz M, Orliaguet G. Development: Epidemiology and management of postoperative apnoea in premature and term newborns. Anaesth Crit Care Pain Med 2020; 39:871-875. [PMID: 32791157 DOI: 10.1016/j.accpm.2020.07.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 07/17/2020] [Accepted: 07/17/2020] [Indexed: 11/27/2022]
Abstract
Postoperative apnoea (PA) is defined as a respiratory pause of more than 15seconds or as a respiratory pause associated with bradycardia < 120/min, desaturation (Sat02<90%), cyanosis or hypotonia. This is a relatively frequent phenomenon that affects 10% of infants under 60 weeks of post-conceptual age, born prematurely or not, and occurs during the first 12-48h postoperatively. The population exposed to PA is heterogeneous and it is necessary to standardise the management both during the intra- and postoperative period, and to adapt this management according to the risk factors for PA and the status as prematurely born infants or not, based on recent data from the literature.
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Affiliation(s)
- Jean-Philippe Salaün
- CHU Caen, Department of Anaesthesiology and Critical Care Medicine, Caen University Hospital, Avenue de la Côte de Nacre, 14033 Caen, France.
| | - Mathilde de Queiroz
- Department of Paediatric Anaesthesia and Intensive Care, Femme Mère Enfant Hospital, 69677 Bron, France
| | - Gilles Orliaguet
- Department of Paediatric Anaesthesia and Intensive Care, Necker-Enfants Malades University Hospital, AP-HP, Centre - Université de Paris, France; EA 7323 Université de Paris "Pharmacologie et évaluation des thérapeutiques chez l'enfant et la femme enceinte", Paris, France
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Caudal and Intravenous Anesthesia Without Airway Instrumentation for Laparoscopic Inguinal Hernia Repair in Infants: A Case Series. A A Pract 2020; 14:e01251. [PMID: 32633923 DOI: 10.1213/xaa.0000000000001251] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
We report a series of 20 neonates and infants (18 born preterm) who underwent laparoscopic inguinal hernia repair with caudal anesthesia, oxygen via nasal cannula, and intravenous anesthesia. Surgery was successful in all cases without airway instrumentation or intraoperative complications. Sedation was provided with dexmedetomidine, propofol, and remifentanil. Two patients had apnea in the following 24 hours. There were no unplanned intensive care admissions. Laparoscopy allowed unplanned bilateral repair in 2 cases. Caudal with intravenous anesthesia without airway instrumentation is a viable technique for laparoscopic inguinal hernia repair. Avoiding general endotracheal anesthesia may reduce perioperative complications and influence postoperative disposition.
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Liu X, Ji J, Zhao GQ. General anesthesia affecting on developing brain: evidence from animal to clinical research. J Anesth 2020; 34:765-772. [PMID: 32601887 PMCID: PMC7511469 DOI: 10.1007/s00540-020-02812-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Accepted: 06/06/2020] [Indexed: 11/29/2022]
Abstract
As the recent update of General anaesthesia compared to spinal anaesthesia (GAS) studies has been published in 2019, together with other clinical evidence, the human studies provided an overwhelming mixed evidence of an association between anaesthesia exposure in early childhood and later neurodevelopment changes in children. Pre-clinical studies in animals provided strong evidence on how anaesthetic and sedative agents (ASAs) causing neurotoxicity in developing brain and deficits in long-term cognitive functions. However pre-clinical results cannot translate to clinical practice directly. Three well designed large population-based human studies strongly indicated that a single brief exposure to general anesthesia (GAs) is not associated with any long-term neurodevelopment deficits in children's brain. Multiple exposure might cause decrease in processing speed and motor skills of children. However, the association between GAs and neurodevelopment in children is still inconclusive. More clinical studies with larger scale observations, randomized trials with longer duration exposure of GAs and follow-ups, more sensitive outcome measurements, and strict confounder controls are needed in the future to provide more conclusive and informative data. New research area has been developed to contribute in finding solutions for clinical practice as attenuating the neurotoxic effect of ASAs. Xenon and Dexmedetomidine are already used in clinical setting as neuroprotection and anaesthetic sparing-effect, but more research is still needed.
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Affiliation(s)
- Xinyue Liu
- Department of Anesthesiology, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Jing Ji
- Department of Anesthesiology, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Guo-Qing Zhao
- Department of Anesthesiology, China-Japan Union Hospital of Jilin University, Changchun, China.
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Wu G, Xu X, Fu G, Zhang P. General Anesthesia Maintained with Sevoflurane versus Propofol in Pediatric Surgery Shorter Than 1 Hour: A Randomized Single-Blind Study. Med Sci Monit 2020; 26:e923681. [PMID: 32572017 PMCID: PMC7333513 DOI: 10.12659/msm.923681] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background Sevoflurane was compared with propofol for general anesthesia maintenance in pediatric operations lasting less than 1 hour in terms of anesthetic effect and postoperative recovery. Material/Methods Children scheduled for inguinal hernia repair or hydrocele testis repair were randomly assigned to receive general anesthesia maintained with either sevoflurane (n=43) or propofol (n=43). The ilioinguinal nerve was blocked with 1% lidocaine (7 mg/kg) after intravenous administration of ketamine (2 mg/kg). At the end of the surgery in patients receiving sevoflurane, sevoflurane was stopped and a bolus of propofol of 1 mg/kg was administered. Results Sevoflurane was associated with significantly less use of ketamine (35.1±10.6 mg) than was propofol (59.0±28.0 mg; P<0.001). In addition, sevoflurane was associated with a significantly shorter time in the post-anesthesia care unit (52.1±9.0 min) than was propofol (68.8±15.3 min; P<0.001). Propofol was associated with a significantly higher incidence of intraoperative body movement (33.3%) than was sevoflurane (13.5%; P=0.045). However, the 2 groups showed no important differences in other adverse events such as hypoxia, emergence agitation, and additional use of propofol. Conclusions In pediatric surgery lasting less than 1 hour, anesthesia maintained with sevoflurane was associated with significantly less use of ketamine, shorter postoperative recovery time, and less intraoperative body movement than was propofol.
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Affiliation(s)
- Guisheng Wu
- Department of Anesthesiology, Liaocheng People's Hospital, Liaocheng, Shandong, China (mainland)
| | - Xia Xu
- Department of Anesthesiology, Liaocheng People's Hospital, Liaocheng, Shandong, China (mainland)
| | - Guanghua Fu
- Department of Anesthesiology, Liaocheng People's Hospital, Liaocheng, Shandong, China (mainland)
| | - Ping Zhang
- Department of Anesthesiology, Liaocheng People's Hospital, Liaocheng, Shandong, China (mainland)
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Abstract
Inguinal hernia is a common problem affecting infants in the NICU. As a group, preterm infants have the highest incidence of inguinal hernia and this risk increases as gestational age decreases. The etiopathologic factors leading to the development of an inguinal hernia are not clear and interventions to alter these factors have not been thoroughly investigated. Diagnosis of an inguinal hernia is often straightforward, but occasionally it may be difficult to determine if the hernia is strangulated or simply obstructed. Rarely, investigative modalities, such as ultrasonography, may be needed to rule out other potential causes. The ideal timing of surgical repair in this population is unknown and complicated by comorbid conditions and limited randomized controlled trials. During surgery, the choice of regional versus general anesthesia requires a team-based approach and studies have found that greater clinical experience is associated with lower morbidity. The techniques of hernia surgery range from open to laparoscopic repair and have been investigated in small prospective studies, while larger databases have been used to analyze outcomes retrospectively.
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