The placement of an intravenous cannula is always necessary during general anesthesia in children: a pro-con debate. The case against

Ambulatory anesthetic care in children undergoing myringotomy and tube placement: current perspectives

PURPOSE

Myringotomy and tube placement is one of the most frequently performed ear, nose and throat (ENT) surgeries in the pediatric population. Effective anesthetic management is vital to ensuring successful ambulatory care and ensuring child and parental satisfaction.

RECENT FINDINGS

This review summarizes recently published studies about the long-term effects of general anesthesia in young children, novel approaches to preoperative fasting and simplified approaches to the assessment and management of emergence delirium (ED) and emergence agitation (EA). New developments in perioperative ambulatory care, including management of comorbidities and day care unit logistics, are discussed.

SUMMARY

Long-term follow-up of children exposed to general anesthesia before the age of 4 years has limited impact on academic achievement or cognitive performance and should not delay the treatment of common ENT pathology, which can impair speech and language development. A more liberal approach to fasting, employing a 6-4-0 regime allowing children fluids up until theater, may become an accepted practice in future. ED and EA should be discriminated from pain in recovery and, where the child is at risk of harm, should be treated promptly. Postoperative pain at home remains problematic in ambulatory surgery and better parental education is needed. Effective ambulatory care ultimately requires a well-coordinated team approach from effective preassessment to postoperative follow-up.

Anesthetic complications during general anesthesia without intravenous access in pediatric ophthalmologic clinic: assessment of 5216 cases

BACKGROUND

General anesthesia utilizing inhalational agents without intravenous (IV) access for minor procedures is controversial. Eliminating IV access increases efficiency and patient satisfaction; however, the ability to introduce rapid acting medications into the circulation during an unanticipated emergency becomes challenging. The objective of this study was to examine complication risk following pediatric ophthalmologic examinations under anesthesia (EUA) without IV placement.

METHODS

A retrospective review of consecutive pediatric patients who underwent EUA for retinoblastoma management was performed from 2004 to 2014. The total number of anesthetics and elective IV placement were identified. Patient characteristics, length of the procedure, laryngeal mask airway (LMA) placement, and complications were also recorded. A survey of specialized ophthalmology institutions was performed in order to ascertain the state of standard practices.

RESULTS

Over 10 years, 5216 anesthetics were identified. The mean age and weight of the patients were 2.7±2.0 years and 14.4±6.6 kg, respectively. In all, 298 elective IVs were placed (6%) and 4918 cases (94%) were performed without IV access. A total of 1687 (32%) anesthetics were administered with a laryngeal mask airway (LMA), of which 1389 (82%) did not have IV access. There were no deaths and no unplanned admissions. There were 8/5216 complications (0.153%) which all resolved safely.

CONCLUSIONS

The current study shows that it is safe to perform EUA and procedures for the diagnosis and treatment of retinoblastoma in pediatric patients without securing IV access. All emergency post-complication IV placements were successful and no long-term sequelae were seen.

Anesthetic management of common pediatric emergencies

PURPOSE OF REVIEW

To keep pediatric anesthesiologists up-to-date in their management of pediatric emergencies by identifying the key publications from 2012 that are relevant to the anesthetic management of common pediatric emergencies.

RECENT FINDINGS

Little has been published about specific pediatric emergencies. A large multi-institutional audit of tracheo-esophageal fistula demonstrated a wide range of anesthesia practice and a difficulty with ventilation on induction in 7% of cases. Large audits of bronchoscopy for foreign body have also demonstrated a variety of effective practices with a low complication rate. More generally, studies have increasingly demonstrated that postoperative pain may be substantial after many common procedures including some emergency surgery. The management of the full stomach remains controversial and the use of ultrasound to assess gastric volume is promising but unproven. Recent guidelines for resuscitation have been published. It is increasingly recognized that meticulous management of pediatric brain injury is vital, and although the evidence base is very weak, a more coherent anesthetic approach is emerging.

SUMMARY

Many areas of the management of pediatric emergencies remain controversial and based on little good evidence. In spite of this, the complication rate is low. Postoperative pain is an emerging problem while the optimal management of the full stomach is still unresolved.