Use of Anesthetic Agents in Neonates and Young Children

Long-term outcomes of early exposure to repeated general anaesthesia in children with cystic fibrosis (CF-GAIN): a multicentre, open-label, randomised controlled phase 4 trial

BACKGROUND

Long-term effects of early, recurrent human exposure to general anaesthesia remain unknown. The Australasian Cystic Fibrosis Bronchoalveolar Lavage (ACFBAL) trial provided an opportunity to examine this issue in children randomly assigned in infancy to either repeated bronchoalveolar-lavage (BAL)-directed therapy with general anaesthesia or standard care with no planned lavages up to 5 years of age when all children received BAL-directed therapy under general anaesthesia.

METHODS

This multicentre, randomised, open-label phase 4 trial (CF-GAIN) used the original ACFBAL trial randomisation at 3·6 months (SD 1·6) to BAL-directed therapy or standard-care groups to assess the impact of general anaesthesia exposures over early childhood. Children who completed the ACFBAL trial, with a mean age of 5·1 (SD 0·18) years, received standardised neurobehavioural and health-related-quality-of-life assessment and brain MRI scans between Oct 8, 2013, and June 30, 2017, at a mean age of 12·8 (SD 1·7) years at three hospitals in Australia and one hospital in New Zealand. The primary outcome was a composite score of performance on a standardised, computer-based assessment of child attention, processing speed, and response inhibition skills (Conners Continuous Performance test, second edition). Secondary outcomes included intellectual function, other neurobehavioural measures, and brain imaging as an exploratory outcome. The trial was registered with the Australian New Zealand Clinical Trials Registry (ACTRN 12613000057785) and is completed.

FINDINGS

At 2 years, the BAL-directed therapy group (n=52) and standard-care group (n=45) had a median of 2·0 (IQR 1·0-3·0) and 0·0 (0·0-0·0) exposures, respectively. At completion of the ACFBAL trial, the BAL-directed therapy group had a median of 6·0 (4·0-9·5) exposures and the standard-care group 2·0 (1·0-4·0) exposures. At CF-GAIN completion, the BAL-directed therapy group had a median of 10·0 (IQR 6·5-14·5) exposures and the standard-care group 4·0 (3·0-7·0) exposures. Cumulative general anaesthesia exposure time was not prospectively collected but, for those with complete cumulative exposure time data to the end of the ACFBAL trial, the median cumulative exposure time for the BAL-directed therapy group (n=29) was 180 (IQR 140-285) min and for the standard-care group (n=32) was 48 (30-122) min. The mean Conners Continuous Performance test, second edition composite score was 51 (SD 8·1) in BAL-directed therapy group and 53 (8·8) in the standard-care group; difference -1·7 (95% CI -5·2 to 1·7; p=0·32) with similar performance on other neurobehavioural measures, including measures of executive function, intellectual quotient scores, and brain imaging.

INTERPRETATION

Our findings suggest that repeated general anaesthesia exposure in young children with cystic fibrosis is not related to functional impairment in attention, intellectual quotient, executive function, or brain structure compared with a group with fewer and shorter cumulative anaesthesia durations.

FUNDING

National Health and Medical Research Council Australia, Queensland Government Health Service and Clinical Innovation Fellowship, and the Children's Hospital Foundation Queensland.

Does anesthesia duration or number of cases per patient predict safety events?

BACKGROUND

The need for dental rehabilitation under general anesthesia is increasing, with varying needs between patients. Mortality has been found to be a rare event in these patients; however other perioperative events can and do occur. Previous studies have established increased incidence of perioperative events with younger, sicker children, and longer anesthetics, however, no studies to date have evaluated if the incidence of perioperative events is more closely associated with one long anesthetic or multiple anesthetics per patient.

AIMS

To evaluate the association of perioperative events related to single anesthetic duration or number of anesthetics per patient for dental rehabilitation.

METHODS

After Children's Wisconsin Human Research Protection Program determined this quality activity did not meet the definition of human subjects research, we performed an epidemiologic observational evaluation by extracting all dental related cases (dental alone or with oral surgeon vs. dental with other specialties) with an associated general anesthesia encounter from Children's Wisconsin electronic data warehouse from June 1, 2015 to December 31, 2021. These cases occurred at a free-standing children's hospital or associated pediatric-only ambulatory surgery center. The risk of perioperative safety events was analyzed for previously identified risk groups such as American Society of Anesthesiologists Physical Status (ASA-PS), patient age, anesthesia case time with the addition of number of dental cases per patient.

RESULTS

In this study, 8468 procedures were performed on 8082 patients. Of this cohort, 7765 patients underwent one procedure for dental care while 317 patients underwent a total of 703 dental-related procedures, ranging from two to five procedures per patient. Multivariable logistic regression identified increased risk of perioperative events in patients with ASA-PS 3 (n = 1459, rate 1.78%, p value .001, OR 5.7, CI 2.1-15.5) and ASA-PS 4 (n = 86, rate 5.8%, p < .001, OR 17.2, CI 4.4-67.3), anesthesia duration (p < .001, OR 1.46, CI 1.21-1.76), but no increased risk with number of anesthetics per patient (p value .54, OR 0.81, CI 0.4-1.61).

CONCLUSIONS

Limiting dental care under general anesthesia to multiple short cases may decrease the risk of perioperative events when compared to completing all treatment in one long operative session.

Differential Susceptibility to Propofol and Ketamine in Primary Cultures of Young and Senesced Astrocytes

The adverse effects of general anesthesia on the long-term cognition of young children and senior adults have become of concern in recent years. Previously, mechanistic and pathogenic investigations focused on neurons, and little is known about the effect of commonly used intravenous anesthetics such as propofol and ketamine on astrocytes. Recently, astrocyte dysfunction has been implicated in a wide range of age-related brain diseases. In this study, we examined the survival and viability of both young and senescent astrocytes in culture after adding propofol and ketamine to the media at varying strengths. Oxidative stimulus was applied to commercially available fetal cell lines of human astrocytes in vitro to induce morphological changes in cellular senescence. Our results indicate that propofol reduces the survival of young astrocytes as compared to controls, as well as to ketamine. These effects were seen in comparisons of total cell count and at both high and low dose concentrations. High doses of propofol also significantly reduced cell viability compared to those exposed to baseline controls and ketamine. Senescent astrocytes, on the other hand, demonstrated cell count reductions as compared to baseline controls and ketamine when exposed to either DMSO or propofol. The data show differential susceptibility of young astrocytes to propofol than to ketamine. The observed cell count reduction may be related to the adverse effects of propofol on mitochondrial function and free radical production, as described in previous studies. We speculate that ketamine may have a more favorable safety profile in infants and young children.

Comparison of the effects of ring block and dorsal penile nerve block on parental satisfaction for circumcision operation in children: randomized controlled trial

PURPOSE

In children, circumcision is a procedure associated with perioperative pain and parental satisfaction is an important parameter in the evaluation of anesthesia procedures. Inadequate dorsal penile nerve block (DPNB) for the ventral shaft of the penis might impact parental satisfaction negatively. To evaluate this hypothesis, we compared the effects of penile ring block (RB) and dorsal penile nerve block (DPNB) on parental satisfaction. Postoperative pain, need for additional analgesia, intraoperative hemodynamic data, recovery status, side effects, and postoperative complications were evaluated as secondary outcomes between the blocks.

METHODS

Parental satisfaction and anesthetic effectiveness of RB and DPNB for circumcision in children were compared. 86 patients were randomized 1:1 to Group RB and Group DPNB, which were administered the same dose of anesthesia. Parental satisfaction was evaluated with the Pediatric Anesthesia Parental Satisfaction Questionnaire (PAPS). Postoperative pain evaluations were made with the Face, Legs, Activity, Crying, Consolability Pain Scale (FLACC).

RESULTS

In terms of parent satisfaction, no differences were detected between the groups in the pre-anesthesia, pre-anesthesia and post-anesthesia, post-anesthesia, hospital team, and anesthesia team parameters (p > 0.05). The scores of Group DPNB patients were higher only in the "Q11" subparameter in the "anesthesia team" parameter, and this difference was significant (0.024).

CONCLUSION

RB and DPNB were compared in circumcision, which is the most common surgical procedure for children. Parental satisfaction, anesthesia, and analgesic effects of both blocks were found to be similar.

CLINICAL TRIALS

ACTRN12622001211752.

Risk of attention deficit hyperactivity disorder diagnosis following multiple exposures to general anesthesia in the paediatric population: A systematic review and meta-analysis

Objectives

The risk of attention deficit hyperactivity disorder (ADHD) following multiple exposures to anesthesia has been debated. Our objective was to systematically review the literature to examine the association between multiple exposures to general anesthesia before age 5 and subsequent diagnosis of ADHD.

Methods

A systematic search of EMBASE, PubMed, and SCOPUS was performed using key search terms in February 2022. We included studies that: were published after 1980, included only otherwise healthy children who experienced two or more exposures to general anesthetic before age 5, diagnosed ADHD by a medical professional before age 19 years after exposure to general anesthetic, were cross-sectional, case-control, or cohort study, and were published in English. The results (expressed as hazard ratios [HR] and associated 95% confidence intervals [CI]) were pooled using meta-analytic techniques. Studies which did not present their results as HR and 95% CI were analyzed separately. GRADE was used to determine the certainty of the findings. PRISMA guidelines were followed at each stage of the review.

Results

Eight studies (196,749 children) were included. Five reported HR and 95% CI and were subsequently pooled for meta-analysis. Multiple exposures to anesthesia were associated with diagnosis of ADHD before the 19th year of life (HR: 1.71; 95% CI: 1.59, 1.84). Two of the three studies not used in the meta-analysis also found an increased risk of ADHD diagnosis following multiple anesthetic exposures.

Conclusions

There was an association between multiple early exposures to general anesthesia and later diagnosis of ADHD.

The diversity of hypospadias management in North America: a survey of pediatric urologists

PURPOSE

To determine trends in hypospadias management, including surgical techniques and perioperative care, by pediatric urologists in North America.

METHODS

An anonymous online survey was devised to assess approaches to hypospadias repair and management, including anesthetic considerations, catheter placement, choice of dressing, and postoperative antibiotic treatment. The survey was sent to all practicing members of the Societies for Pediatric Urology.

RESULTS

The survey was completed by 133 (34.5%) respondents. Hypospadias repair was overwhelmingly recommended between ages 6-12 months (89.5%). A local or regional anesthetic block (caudal, penile, pudendal, spinal) is performed nearly universally (96.2%). The majority of surgeons perform distal repairs outpatient (70.7%), while fewer perform outpatient staged repairs (47.4%) or redo surgery (33.8%). Nearly all respondents preferred either VicrylTM/DexonTM (50.4%) or MaxonTM/PDSTM (48.1%) for urethroplasty. All but one respondent leaves a stent for midshaft to proximal repairs whereas stenting for glanular repairs was split with 53.4% leaving a stent. Most surgeons (60.9-70.9%) prescribe postoperative antibiotics regardless of severity and the majority (72.9%) prescribe narcotics for analgesia.

CONCLUSIONS

Approaches to hypospadias repair are extremely varied such that there is a lack of consensus among pediatric urologists regarding most aspects of hypospadias management. Investigations comparing hypospadias practice patterns are necessary to develop a standard of care for this complex pediatric urologic entity.

Functional measures on PEDI are associated with BSID-3 scales at 2 years, following neonatal surgery

BACKGROUND

Neonates requiring early surgical intervention for major non-cardiac congenital anomalies are at high risk of adverse neurodevelopmental outcomes. Early recognition of potential neuro-developmental delay is critical to facilitate access to early childhood intervention services and therefore maximise the functional capabilities of these children.

AIMS

This study aims to compare Bayley's Scales of Infant and Toddler Development (BSID-3) and the Paediatric Evaluation of Disability Inventory (PEDI) as early screening tools in predicting neuro-developmental disability across multiple domains. In addition, it looks at determining which pre, peri and post-operative risk factors lend themselves to more adverse outcomes.

STUDY DESIGN

Retrospective cohort study.

SUBJECTS

Neonates requiring surgical intervention at the Royal Children's Hospital from 2012 to 2018 who subsequently underwent neurodevelopmental assessment at 2 years of age.

OUTCOME MEASURES

The main outcome was the relationship between performance on the PEDI compared with the BSID-3, in 2-year-olds following neonatal surgery.

RESULTS

Parent -reported functional measures across all domains on PEDI strongly related to the more formal measures of cognition, language, and motor development assessed on BSID-3 (p < 0.05).

CONCLUSIONS

The questionnaire-based PEDI tool could be considered a reliable replacement to the formal Bayley (BSID-3) scale in low-risk infants and provide a more accessible means of assessment where there are deficiencies in availability of suitably trained clinicians or limited resource centres.

Pre-Test Manipulation by Intraperitoneal Saline Injection with or without Isoflurane Pre-Treatment Does Not Influence the Outcome of Social Test in Male Mice

Preclinical studies on rodents should follow the 3R principle minimising the suffering of the animals. To do so, some researchers use inhalation anaesthetic induction even before intraperitoneal injection. However, several studies suggested that both interventions might influence the behaviour of the animals. We aimed to test whether intraperitoneal injection alone or in combination with isoflurane anaesthesia is a preferable treatment method 30 min before a social test. Male C57BL/6 mice were studied using a behavioural test battery comparing three groups (one control group and intraperitoneal saline-treated groups with or without short isoflurane inhalation). Our results confirmed that both interventions had no profound influence on the conventionally measured parameters of social tests (interest in sociability, social discrimination memory, social interaction as well as resident–intruder test) and were not acutely stressful (measured by similar ACTH levels between the groups) not even after repeated administration (similar body weight gain during the one-week observation period). Taking into consideration the possible long-term harmful effect of isoflurane inhalation, we recommend using intraperitoneal injection without it as saline injection did not violate the 3R principle inducing only mild stress.

Suberoylanilide hydroxamic acid (SAHA) attenuates memory impairment in the offspring of rats exposed to sevoflurane anesthesia

BACKGROUND

SAHA was reported to enhance the expression of miR-129-5p, which was predicted to bind to 3' UTR of CASP-6, a gene playing crucial roles in the pathogenesis of memory impairment. Whether SAHA/miR-129-5p/CASP-6 is involved in the pathogenesis of prenatal exposure to sevoflurane remains to be explored.

METHODS

Morris water maze test was performed to evaluate the functional parameters of learning and memory. Quantitative real-time qPCR was carried out to analyze the expression of miRNAs and CASP-6 mRNA under different conditions.

RESULTS

Sevoflurane exposure of pregnant rats and SAHA treatment of the offspring had no effect on the blood gases, litter size, survival rate and weight. SAHA administration remarkably reversed the learning and memory impairment in prenatal rats caused by sevoflurane exposure. Mechanistically, the abnormal expression of miR-129-5p and CASP-6 in the offspring of pregnant rats exposed to sevoflurane was effectively restored by SAHA treatment. The luciferase activity of CASP-6 vector was effectively inhibited by miR-129-5p in primary neuron cells of rats. Moreover, the expression of CASP-6 mRNA and protein was significantly suppressed by miR-129-5p and SAHA treatment in a dose-dependent manner.

CONCLUSION

Our work demonstrated that the administration of SAHA suppressed the expression of CASP-6 via modulating the expression of miR-129-5p, and SAHA may rescue the apoptosis of neurons caused by exposure to sevoflurane. The underlying mechanism might be the ability of SAHA to relieve learning and memory impairment in the offspring of the pregnant rats exposed to sevoflurane.

Impact of a Faster Computed Tomography Scanner on Sedation for Pediatric Head Computed Tomography Scans in 2 Large Emergency Departments-A Retrospective Study

OBJECTIVES

Children in the emergency department (ED) often require sedation for head computed tomography (CT) to ensure adequate image quality. Image acquisition time for a head CT using a conventional single-source CT scanner is approximately 12 seconds; however, after installation in November 2017 of 2 new dual-source dual-energy CT scanners, that time decreased to 1 to 3 seconds. We hypothesized that fewer patients would require sedation using the faster CT scanners.

METHODS

We conducted a retrospective chart review of patients aged 0 to 18 years undergoing head CT at 2 pediatric EDs within 1 hospital system, 2 years before and 2 years after installation of the faster CT scanner. Patients undergoing multiple CTs or other procedures were excluded. Demographic information, diagnosis, disposition, sedatives (chloral hydrate, dexmedetomidine, etomidate, fentanyl, ketamine, midazolam, methohexital, pentobarbital, and propofol) administered before imaging, and ED length of stay were analyzed.

RESULTS

A total of 15,175 patient encounters met inclusion criteria, 7412 before and 7763 after installation of the new CT. The median age was 7 years and 44% were female. Before the new CT scanner was installed 8% required sedation, compared with 7% after (effect size, 0.0341). Midazolam was the most commonly administered sedative. Fewer patients required deep sedation using the faster CT scanner.

CONCLUSIONS

After installation of a dual-source dual-energy CT scanner, fewer patients required sedation to complete head CT in the pediatric ED. Faster image acquisition time decreased the need for deep sedation.

Effects of multiple exposures to general anesthesia on the sleep quality of children after plastic surgery in Beijing, China: a cohort study

To assess the effects of the number and duration of general anesthesia exposure on the sleep quality of 6-15-year-old school children who underwent plastic surgery. The study was conducted on 688 children who underwent plastic surgery between the ages of 6 and 15 years using the Sleep Disorder Scale for Children (SDSC). The children were divided into two groups according to their exposure to general anesthesia: No General Anesthesia (NGA) and General Anesthesia (GA) groups. The GA group was further divided into three subgroups according to the number of exposures: Single-exposure, Double-exposure, and Multiple-exposure groups. The GA group was also subdivided into two groups according to the cumulative total time of anesthesia exposure: < 3 h and ≥ 3 h groups. Multivariate logistic regression analysis was used to confirm the potential factors that affect children with sleep disturbance (SDSC scores > 39) after general anesthesia exposure. Linear regression was used to analyze the correlation of the factors with the SDSC scores. The SDSC scores were higher in the GA group [35.4 ± 4.3 vs. 34.0 ± 3.6, P < 0.0001] as compared to the NGA group. The number of children with SDSC scores > 39 was also higher in the GA group [80 (17.5%) vs. 17 (7.4%), P < 0.0001]. More anesthesia exposure was correlated with higher total SDSC scores [34.5 ± 4.3 for single exposure vs 35.1 ± 3.9 for double exposure vs 37.5 ± 4.5 for multiple exposures, P < 0.0001] and a higher proportion of SDSC scores > 39 [24 (12.0%) for single exposure vs 24 (15.5%) for double exposure vs 32 (31.1%) for multiple exposures, P < 0.0001]. Longer anesthesia exposure was also correlated with higher total SDSC scores [34.4 ± 4.5 for < 3 h vs. 35.8 ± 4.2 for ≥ 3 h, P = 0.002]. The number of exposures to general anesthesia was a potential factor in sleep disturbance among children, determined based on logistic regression. Children who underwent plastic surgery between the ages of 6 and 15 years with general anesthesia exposure might have worse sleep quality and a higher incidence of sleep disorders. More frequent anesthesia exposure leads to worsened sleep quality and a higher incidence of sleep disorders. This study also confirmed that a longer duration of cumulative anesthesia exposure also leads to worse sleep quality.

Advantages of ketamine in pediatric anesthesia

Although ketamine is primarily used for induction and maintenance of general anesthesia, it also presents sedative, amnestic, anesthetics, analgesic, antihyperalgesia, neuroprotective, anti-inflammatory, immunomodulant, and antidepressant effects. Its unique pharmacodynamics and pharmacokinetic properties allow the use of ketamine in various clinical settings including sedation, ambulatory anesthesia, and intensive care practices. It has also adopted to manage acute and chronic pain management. Clinically, ketamine produces dissociative sedation, analgesia, and amnesia while maintaining laryngeal reflexes, with respiratory and cardiovascular stability. Notably, it does not cause respiratory depression, maintaining both the hypercapnic reflex and the residual functional capacity with a moderate bronchodilation effect. In the pediatric population, ketamine can be administered through practically all routes, making it an advantageous drug for the sedation required setting such as placement of difficult vascular access and in uncooperative and oppositional children. Consequently, ketamine is indicated in prehospital induction of anesthesia, induction of anesthesia in potentially hemodynamic unstable patients, and in patients at risk of bronchospasm. Even more, ketamine does not increase intracranial pressure, and it can be safely used also in patients with traumatic brain injuries. This article is aimed to provide a brief and practical summary of the role of ketamine in the pediatric field.

Specific Impacts of Ketamine on Bladder Dysfunction and Associated Histological Alterations in Rats-A Time Course Validation through Transmission Electron Microscopy

This study explored the specific effects of ketamine on bladder function followed by a sequence of histological changes in a rat bladder at fixed time course intervals. The rats were grouped into normal control and experimental animals, and ketamine (100 mg/kg/day) was administrated to the experimental animals for 2, 4, and 8 weeks, respectively; similarly, the control animals received saline. All animals were evaluated for bladder function and histological responses to the treatment. Ultrastructural changes were observed by transmission electron microscopy (TEM). The results showed progressive bladder dysfunctions with hyperactive bladder conditions according to the time course and frequency of exposure to ketamine. Significantly, decreased inter contraction intervals, residual urine volume, peak micturition pressure, and increased micturition frequency were observed. Bladder histology results revealed substantial inflammation and comprehensive submucosa edema in week 2 and 4 rats along with fibrosis and significant bladder detrusor hypertrophy in week 8 rats. TEM analysis revealed bladder wall thickening, deformed blood vessels, detrusor hypertrophy, wobbled gap junction, and barrier dysfunction at different time course levels in experimental animals. These results provided a profound knowledge about the prognosis and step-by-step pathophysiology of the disease, which might help in developing new therapeutic interventions.

Quantitative renal magnetic resonance imaging: magnetic resonance urography

The goal of functional renal imaging is to identify and quantitate irreversible renal damage and nephron loss, as well as potentially reversible hemodynamic changes. MR urography has evolved into a comprehensive evaluation of the urinary tract that combines anatomical imaging with functional evaluation in a single test without ionizing radiation. Quantitative functional MR imaging is based on dynamic contrast-enhanced MR acquisitions that provide progressive, visible enhancement of the renal parenchyma and urinary tract. The signal changes related to perfusion, concentration and excretion of the contrast agent can be evaluated using both quantitative and qualitative measures. Functional evaluation with MR has continued to improve as a result of significant technical advances allowing for faster image acquisition as well as the development of new tracer kinetic models of renal function. The most common indications for MR urography in children are the evaluation of congenital anomalies of the kidney and urinary tract including hydronephrosis and renal malformations, and the identification of ectopic ureters in children with incontinence. In this paper, we review the underlying acquisition schemes and techniques used to generate quantitative functional parameters including the differential renal function (DRF), asymmetry index, mean transit time (MTT), signal intensity versus time curves as well as the calculation of individual kidney glomerular filtration rate (GFR). Visual inspection and semi-quantitative assessment using the renal transit time (RTT) and calyceal transit times (CTT) are fundamental to accurate diagnosis and are used as a basis for the interpretation of the quantitative data. The importance of visual assessment of the images cannot be overstated when analyzing the quantitative measures of renal function.

Optimization of pediatric FDG-PET/CT examinations based on physical indicators using the SiPM-PET/CT system

OBJECTIVE

This study aimed to investigate the appropriate Silicon photomultiplier -PET/CT acquisition and image reconstruction conditions for each age group.

METHODS

The original phantom was developed to reflect the thickness and width of the torso in each age group (neonates, 1-year-olds, 5-year-olds, 10-year-olds, 15-year-olds, and adults). The ratio of hot spheres to background radioactivity was 4:1, and the radioactivity concentration was adjusted according to the Japanese consensus guidelines for appropriate implementation of pediatric nuclear medicine examinations. We evaluated the root mean square error (RMSE) as an assessment/function of the standardized uptake value of each hot sphere, the background variability (N10 mm), the % contrast of the hot sphere (QH, 10 mm/N10 mm), and the noise equivalent counts to determine the optimal reconstruction parameters and the appropriate acquisition time.

RESULTS

The minimum RMSE was obtained by setting the half-width of the Gaussian filter to 0-2 mm for iteration 1 or 2 and to 2-4 mm for iteration 3 or more. The acquisition times that satisfied the image quality equivalent to 120 s acquisitions in the adult phantoms were 30 s in the neonatal and 1-year-old phantoms, 60 s in the 5- and 10-year-old phantoms, and 75 s in the 15-year-old phantoms.

CONCLUSION

This study demonstrated that good PET images could be obtained with short acquisition times when the examination is performed under appropriate reconstruction conditions.

Pediatric Urachal Anomalies: Monocentric Experience and Mini-Review of Literature

Background: Surgery is the current mainstay for the treatment of urachal anomalies (UA). Recent literature data support the theory of a spontaneous resolution within the first year of life. The aim of this study, comprising solely surgically treated children, was to identify age specific patterns regarding symptoms and outcomes that may support the non-surgical treatment of UA. Methods: Retrospective review on the clinico-laboratory characteristics of 52 children aged < 17 years undergoing resection of symptomatic UA at our pediatric surgical unit during 2006–2017. Data was dichotomized into age > 1 (n = 17) versus < 1 year (n = 35), and complicated (pre-/post-surgical abscess formation or peritonitis, n = 10) versus non-complicated course (n = 42). Results: Children aged < 1 year comprised majority (67%) of cohort and had lower complication rates (p = 0.062). Complicated course at surgery exclusively occurred in patients aged > 1 year (p = 0.003). Additionally, complicated group was older (p = 0.018), displayed leukocytosis (p < 0.001) and higher frequencies regarding presence of abdominal pain (p = 0.008) and abdominal mass (p = 0.034) on admission. Regression analysis identified present abdominal pain (OR (95% CI), 11.121 (1.152–107.337); p = 0.037) and leukocytosis (1.435 (1.070–1.925); p = 0.016) being associated with complicated course. Conclusions: This study provides evidence that symptomatic disease course follows an age-dependent complication pattern with lower complication rates at age < 1 year. Larger, studies have to clarify, if waiting for spontaneous urachal obliteration during the first year of life comprises a reasonable alternative to surgery.

Childhood Educational Outcomes of Children Born with Gastroschisis

OBJECTIVE

To compare third grade literacy and mathematics test proficiency among children born with gastroschisis vs unaffected controls and identify predictors of academic proficiency among these children.

STUDY DESIGN

Infants born with gastroschisis (2000-2005) were identified from the Arkansas Reproductive Health Monitoring System. For each case, 2 controls were selected at random from birth certificates and matched for hospital and month of birth, sex, and race/ethnicity. Data on rehospitalization within the first 6 years and payer data were abstracted from the Arkansas Hospital Inpatient Discharge database. Surviving cases and controls were linked to the Arkansas Department of Education database containing achievement test scores. The primary outcome was proficiency, defined as performance at or above grade level, on third grade achievement tests. Cases and controls who did not attend public schools could not be linked to education records. Multivariable logistic regression models evaluated the association between study characteristics and academic proficiency.

RESULTS

The final study cohort included 47 cases and 63 controls. There was no statistically significant difference in the rate of literacy (68% vs 81%; P = .65) or mathematics proficiency (89% vs 87%; P = .15) between cases and controls. On multivariable analysis, a complex gastroschisis (defined as atresia, volvulus, necrosis, or perforation of the bowel) was associated with lower proficiency in literacy (aOR, 0.1; 95% CI, 0.02-0.58; P = .01). No neonatal or maternal characteristics predictive of lower proficiency in mathematics were identified.

CONCLUSIONS

Among children born with gastroschisis, the presence of a complex gastroschisis was associated with lower proficiency on third grade literacy achievement tests.

Pediatric Congenital Lung Malformations: Imaging Guidelines and Recommendations

Congenital lung malformations are a spectrum of developmental anomalies comprised of malformations of the lung parenchyma, airways, and vasculature. Imaging assessment plays a pivotal role in the initial diagnosis, management, and follow-up evaluation of congenital lung malformations in the pediatric population. However, there is currently a lack of practical imaging guidelines and recommendations for the diagnostic imaging assessment of congenital lung malformations in infants and children. This article reviews the current evidence regarding the imaging evaluation of congenital lung malformations and provides up-to-date imaging recommendations for pediatric congenital lung malformations.

Neonatal Curettage of Large to Giant Congenital Melanocytic Nevi Under Local Anesthetic: A Case Series With Long-Term Follow Up

Background

Neonatal curettage of large to giant congenital melanocytic nevi (L-GCMN) is a simple, minimally invasive procedure typically performed within the first 2 weeks of life.

Objectives

To retrospectively review our experience with serial curettage of L-GCMN in the neonatal period performed under local anesthesia and their long-term outcomes.

Methods

Curettage was performed by a single pediatric dermatologist on nine neonates with L-GCMN under local anesthetic and with oral analgesia between 2002 and 2016 in Red Deer, Alberta, Canada. Patient charts were reviewed retrospectively to assess patient and procedure characteristics, tolerability, safety, cosmetic and functional outcomes, and malignant transformation.

Results

Patients were treated with an average of 6 curettage sessions (range 3 to 15) to remove the majority or entirety of the nevus. All patients tolerated local anesthesia well. The most common adverse event of the procedure was transient neutropenia. Two patients developed positive bacterial cultures without clinical signs of infection, treated with antibiotics. All curetted specimens demonstrated benign pathology. Patients were followed annually thereafter, for an average of 6 years. Eight patients with L-GCMN of the trunk had minimal to partial repigmentation with good cosmetic outcome. One patient had recurrence of a facial nevus. None of the patients developed cutaneous malignant melanoma.

Conclusions

Curettage appears to be a safe and effective treatment option for select cases of L-GCMNs of the trunk. We do not recommend the procedure for face or scalp CMN. This procedure can be performed under local anesthesia with serial curettage to avoid potential risks of general anesthesia.

Neonatal circumcision availability in the United States: a physician survey

BACKGROUND

A significant proportion of boys present to surgical specialists later in infancy/early childhood for elective operative circumcision despite the higher procedural risks. This study aims to assess physician perspectives on access to neonatal circumcision across the United States and identify potential reasons contributing to disparities in access.

METHODS

A cross-sectional survey was electronically distributed to physician members of the Societies for Pediatric Urology and the American Academy of Pediatrics Section on Hospital Medicine. Hospital characteristics and circumcision practices were assessed. Associations between NC availability and institutional characteristics were evaluated using chi-squared testing and multivariable logistic regression. Qualitative analyses of free-text comments were performed.

RESULTS

A total of 367 physicians responded (129 urologists [41%], 188 pediatric hospitalists [59%]). Neonatal circumcision was available at 86% of hospitals represented. On univariate and multivariate analysis, the 50 hospitals that did not offer neonatal circumcision were more likely to be located in the Western region (odds ratio [OR] = 8.33; 95% confidence interval [CI] 3.1-25 vs. Midwest) and in an urban area (OR = 4.2; 95% CI 1.6-10 vs. suburban/rural) compared with hospitals that offered neonatal circumcision. Most common reasons for lack of availability included not a birth hospital (N = 22, 47%), lack of insurance coverage (N = 8, 17%), and low insurance reimbursement (N = 7, 15%). Institutional, regional, or provider availability (68%), insurance/payment (12.4%), and ethics (12.4%) were common themes in the qualitative comments.

CONCLUSIONS

Overall availability of neonatal circumcision varied based on hospital characteristics, including geography. Information from this survey will inform development of interventions designed to offer neonatal circumcision equitably and comprehensively.

Neuropathology Evaluation in Juvenile Toxicity Studies in Rodents: Comparison of Developmental Neurotoxicity Studies for Chemicals With Juvenile Animal Studies for Pediatric Pharmaceuticals

The developmental neuropathology examination in juvenile toxicity studies depends on the nature of the product candidate, its intended use, and the exposure scenario (eg, dose, duration, and route). Expectations for sampling, processing, and evaluating neural tissues differ for developmental neurotoxicity studies (DNTS) for chemicals and juvenile animal studies (JAS) for pediatric pharmaceuticals. Juvenile toxicity studies typically include macroscopic observations, brain weights, and light microscopic evaluation of routine hematoxylin and eosin (H&E)-stained sections from major neural tissues (brain, spinal cord, and sciatic nerve) as neuropathology endpoints. The DNTS is a focused evaluation of the nervous system, so the study design incorporates perfusion fixation, plastic embedding of at least one nerve, quantitative analysis of selected brain regions, and sometimes special neurohistological stains. In contrast, the JAS examines multiple systems, so neural tissues undergo conventional tissue processing (eg, immersion fixation, paraffin embedding, H&E staining only). An "expanded neurohistopathology" (or "expanded neuropathology") approach may be performed for JAS if warranted, typically by light microscopic evaluation of more neural tissues (usually additional sections of brain, ganglia, and/or more nerves) or/and special neurohistological stains, to investigate specific questions (eg, a more detailed exploration of a potential neuroactive effect) or to fulfill regulatory requests.

The importance of non-coding RNAs in environmental stress-related developmental brain disorders: A systematic review of evidence associated with exposure to alcohol, anesthetic drugs, nicotine, and viral infections

Brain development is a dynamic and lengthy process that includes cell proliferation, migration, neurogenesis, gliogenesis, synaptogenesis, and pruning. Disruption of any of these developmental events can result in long-term outcomes ranging from brain structural changes, to cognitive and behavioral abnormality, with the mechanisms largely unknown. Emerging evidence suggests non-coding RNAs (ncRNAs) as pivotal molecules that participate in normal brain development and neurodevelopmental disorders. NcRNAs such as long non-coding RNAs (lncRNAs) and microRNAs (miRNAs) are transcribed from the genome but not translated into proteins. Many ncRNAs have been implicated as tuners of cell fate. In this review, we started with an introduction of the current knowledge of lncRNAs and miRNAs, and their potential roles in brain development in health and disorders. We then reviewed and discussed the evidence of ncRNA involvement in abnormal brain development resulted from alcohol, anesthetic drugs, nicotine, and viral infections. The complex connections among these ncRNAs were also discussed, along with potential overlapping ncRNA mechanisms, possible pharmacological targets for therapeutic/neuroprotective interventions, and potential biomarkers for brain developmental disorders.

Propofol detection for monitoring of intravenous anaesthesia: a review

This paper presents a review of established and emerging methods for detecting and quantifying the intravenous anaesthetic propofol in solution. There is growing evidence of numerous advantages of total intravenous anaesthesia using propofol compared to conventional volatile-based anaesthesia, both in terms of patient outcomes and environmental impact. However, volatile-based anaesthesia still accounts for the vast majority of administered general anaesthetics, largely due to a lack of techniques for real-time monitoring of patient blood propofol concentration. Herein, propofol detection techniques that have been developed to date are reviewed alongside a discussion of remaining challenges.

Anesthetic Exposure in Staged Versus Single-Stage Cleft Lip and Palate Repair: Can We Reduce Risk of Anesthesia-Induced Developmental Neurotoxicity?

ABSTRACT

Cleft lip and palate (CLP) repair is typically performed in a staged fashion, which requires multiple instances of anesthetic exposure during a critical period of infant neurodevelopment. One solution to this concern includes the implementation of a single-stage CLP repair performed between 6 and 12 months of age. This study aimed to compare total anesthetic exposure between single-stage and staged CLP repairs. A retrospective review of unilateral CLP repairs between 2013 and 2018 conducted at a single institution was performed. Patients underwent either traditional, staged lip and palate repair, or single-stage complete cleft repair, where palate, lip, alveolus, and nasal repair was performed simultaneously. Primary endpoints included: total surgical time and total anesthetic exposure. Secondary endpoints included: excess anesthesia time, recovery room time, length of stay, and type of anesthetic administered. Two hundred twenty-five (n = 225) unilateral CLP repairs were conducted at the Loma Linda University. Detailed anesthetic data for eighty-six (n = 86) single-stage and twenty-eight (n = 28) staged operations were available. There was a statistically significant decrease in anesthetic exposure in single-stage versus staged repairs (316 minutes versus 345 minutes, P = 0.017), despite similar procedure times (260 minutes versus 246 minutes, P = 0.224). This resulted in near double excess anesthetic exposure time in the staged group (98 minutes versus 56 minutes, P < 0.001), primarily occurring during induction. This analysis suggests that single-stage CLP repair can reduce wasted time under general anesthesia and potentially reduce harmful neuronal toxicity in the developmental period in this at-risk population.

Integrating neuroimaging biomarkers into the multicentre, high-dose erythropoietin for asphyxia and encephalopathy (HEAL) trial: rationale, protocol and harmonisation

INTRODUCTION

MRI and MR spectroscopy (MRS) provide early biomarkers of brain injury and treatment response in neonates with hypoxic-ischaemic encephalopathy). Still, there are challenges to incorporating neuroimaging biomarkers into multisite randomised controlled trials. In this paper, we provide the rationale for incorporating MRI and MRS biomarkers into the multisite, phase III high-dose erythropoietin for asphyxia and encephalopathy (HEAL) Trial, the MRI/S protocol and describe the strategies used for harmonisation across multiple MRI platforms.

METHODS AND ANALYSIS

Neonates with moderate or severe encephalopathy enrolled in the multisite HEAL trial undergo MRI and MRS between 96 and 144 hours of age using standardised neuroimaging protocols. MRI and MRS data are processed centrally and used to determine a brain injury score and quantitative measures of lactate and n-acetylaspartate. Harmonisation is achieved through standardisation-thereby reducing intrasite and intersite variance, real-time quality assurance monitoring and phantom scans.

ETHICS AND DISSEMINATION

IRB approval was obtained at each participating site and written consent obtained from parents prior to participation in HEAL. Additional oversight is provided by an National Institutes of Health-appointed data safety monitoring board and medical monitor.

TRIAL REGISTRATION NUMBER

NCT02811263; Pre-result.

Histopathological study on neuroapoptotic alterations induced by etomidate in rat hippocampus

In human, there is substantial neurogenesis in the hippocampus that is implicated in memory formation and learning. These new-born neurons can be affected by neuropathological conditions. Anesthesia and surgical procedures are associated with postoperative cognitive changes particularly, impaired memory and learning. Therefore, the aim of this study was to evaluate the possible neurodegenerative effects of etomidate in rat hippocampus. Thirty male Wistar rats weighing 250 ± 30 g were randomly divided into 3 groups: 1) Etomidate group; four times 20 mg intraperitoneal injection with 1-h intervals, 2) Control group; the equal volume of normal saline, and 3) Normal group; without any intervention. 6 h after the last injection, the brains were removed and processed according to routine histological methods. TUNEL assay and toluidine blue staining were performed to evaluate neuro-histopathological changes in different regions of hippocampus. Our results showed that the number of TUNEL positive cells and dark neurons (DNs) in etomidate group were significantly higher in the CA1, CA2, CA3, and dentate gyrus (DG) of hippocampus compared with the control and normal groups (p < 0.05). While, there was no significant difference between the various regions of hippocampus in control and normal groups. Our findings showed that etomidate can increase apoptotic cells and dark neurons induction in different regions of hippocampus mainly in DG.

Expression Signature of lncRNAs and mRNAs in Sevoflurane-Induced Mouse Brain Injury: Implication of Involvement of Wide Molecular Networks and Pathways

Sevoflurane, one of the most commonly used pediatric anesthetics, was found to cause developmental neurotoxicity. To understand specific risk groups and develop countermeasures, a better understanding of its mechanisms is needed. We hypothesize that, as in many other brain degeneration pathways, long non-coding RNAs (lncRNAs) are involved in the sevoflurane-induced neurotoxicity. Postnatal day 7 (PD7) mice were exposed to 3% sevoflurane for 6 h. To quantify neurotoxicity in these mice, we (1) detected neural apoptosis through analysis of caspase 3 expression level and activity and (2) assessed long-term learning ability via the Morris water maze at PD60. To elucidate specific mechanisms, profiles of 27,427 lncRNAs and 18,855 messenger RNAs (mRNAs) in mouse hippocampi were analyzed using microarray assays. Sevoflurane-induced abnormal lncRNA and mRNA expression-associated function pathways were predicted by bioinformatic analysis. We found that sevoflurane induced significant neurotoxicity, causing acute neuroapoptosis and abnormal expression of 148 mRNAs and 301 lncRNAs on PD7 in mouse hippocampus. Additionally, exposed mice exhibited impaired memory on PD60. Bioinformatic analysis predicted that the dysregulated mRNAs, which are highly correlated with their co-expressed dysregulated lncRNAs, might be involved in 34 neurodegenerative signaling pathways (e.g., brain cell apoptosis and intellectual developmental disorder). Our study reveals for the first time that neonatal exposure to 3% sevoflurane induces abnormal lncRNA and mRNA expression profiles. These dysregulated lncRNAs/mRNAs form wide molecular networks that might contribute to various functional neurological disease pathways in the hippocampus, resulting in the observed acute apoptosis and impaired long-term memory.

Auditory brainstem response testing using intranasal dexmedetomidine sedation in children: a pilot study

OBJECTIVE

Auditory brainstem response (ABR) is used to determine hearing thresholds in children who cannot undergo behavioural testing. Children must remain still during testing, with general anaesthesia (GA) in theatre required for those who cannot. We developed a protocol whereby an ABR was undertaken in a ward environment using only intranasal dexmedetomidine for sedation.

DESIGN

Prospective data were collected including the time of sedation onset, ABR duration and arrival to discharge time was recorded and feedback was requested using a questionnaire.

STUDY SAMPLE

Twenty-nine consecutive patients routinely undergoing an ABR.

RESULTS

From this pilot study, we demonstrated that intranasal dexmedetomidine could be used successfully to administer safe sedation to all twenty-nine children undergoing an ABR in a ward environment as opposed to theatre.

CONCLUSIONS

This allowed for faster time to discharge compared to GA, produced what was felt to be a better quality ABR trace, better utilization of a theatre slot, negated the need for GA in a child and created a less stressful experience for both parent and child according to information from feedback questionnaires.

One additional shot of brachial plexus block equates to less postoperative pain for younger children with elbow surgeries

Background

Postoperative pain in children has always been inadequately evaluated. This study aims to evaluate the postoperative pain response using an additional dose of brachial plexus block (BPB) for younger children receiving elbow surgeries under general anesthesia (GA).

Methods

This retrospective case-control study included pediatric patients (3–10 years) who underwent surgeries for elbow injuries between January 2015 and January 2019. Patients with previous history of surgeries around the elbow, neurological impairment of injured limb, polytrauma, undergoing pain management for different causes, and open or old fractures were excluded. Patients were dichotomized into the GA group and the GA + BPB group as per the presence or absence of BPB.

Results

In all, 150 patients (102/48, male/female) in the GA and 150 patients (104/46, male/female) in the GA + BPB group were included. There existed no significant differences between the two groups in age, sex, fracture side, and types of elbow procedures. As for the pain response after lateral condyle fracture of the humerus (LCFH), the FLACC pain scale was significantly higher for those in the GA group (6.2 ± 0.8) when compared to the GA + BPB group (1.6 ± 0.5) (P < 0.001). As for the pain response after medial epicondyle fracture of the humerus (MCFH), the FLACC pain scale was significantly higher for those in the GA group (6.0 ± 0.8) when compared to the GA + BPB group (1.5 ± 0.5) (P < 0.001). As for the pain response after supracondylar fracture of the humerus (SCFH), the FLACC pain scale was significantly higher for those in the GA group (6.0 ± 0.8) when compared to the GA + BPB group (1.6 ± 0.5) (P < 0.001). As for the pain response after cubitus varus correction, the FLACC pain scale was significantly higher for those in the GA group (6.7 ± 0.7) when compared to the GA + BPB group (2.1 ± 0.7) (P < 0.001).

Conclusion

An additional shot of BPB for patients undergoing surgeries for elbow surgeries resulted in better postoperative pain response in younger children without significant BPB-related complications.

The impact of introducing nurse-led analgesia and sedation guidelines in ventilated infants following cardiac surgery

INTRODUCTION

Enhanced clinical outcomes in the Paediatric Intensive Care Unit following standardisation of analgesia and sedation practice are reported. Little is known about the impact of standardisation of analgesia and sedation practice including incorporation of a validated distress assessment instrument on infants post cardiac surgery, a subset of whom have Trisomy 21. This study investigated whether the parallel introduction of nurse-led analgesia and sedation guidelines including regular distress assessment would impact on morphine administered to infants post cardiac surgery, and whether any differences observed would be amplified within the Trisomy 21 population.

METHODOLOGY

A retrospective single centre before/after study design was used. Patients aged between 44 weeks postconceptual age and one year old who had open cardiothoracic surgery were included.

RESULTS

61 patients before and 64 patients after the intervention were included. After the intervention, a reduction in the amount of morphine administered was not evident, while greater use of adjuvant sedatives and analgesics was observed. Patients with Trisomy 21 had a shorter duration of mechanical ventilation after the change in practice.

CONCLUSION

The findings from this study affirm the importance of the nurses' role in managing prescribed analgesia and sedation supported by best available evidence. A continued education and awareness focus on analgesia and sedation management in the pursuit of best patient care is imperative.

Metformin Inhibits Propofol-Induced Apoptosis of Mouse Hippocampal Neurons HT-22 Through Downregulating Cav-1

Objective

To elucidate the neuroprotective function of metformin in suppressing propofol-induced apoptosis of HT-22 cells.

Methods

HT-22 cells were treated with 0, 10 or 100 μmol/L propofol, followed by determination of their proliferative ability. Subsequently, changes in proliferation and apoptosis of propofol-treated HT-22 cells induced with metformin were assessed. Apoptosis-associated genes in HT-22 cells were detected by Western blot. At last, regulatory effects of Cav-1 on propofol and metformin-treated HT-22 cells were examined.

Results

Propofol treatment dose-dependently decreased proliferative ability and increased apoptosis ability in HT-22 cells, which were partially blocked by metformin administration. Upregulated Bcl-2 and downregulated Bax were observed in propofol-treated HT-22 cells following metformin administration. In addition, Cav-1 level in HT-22 cells was regulated by metformin treatment. Notably, metformin reversed propofol-induced apoptosis stimulation and proliferation decline in HT-22 cells via downregulating Cav-1.

Conclusion

In our study, we found that propofol could induce apoptosis of HT-22 cells and metformin could rescue the apoptosis effect regulated by propofol. Then, we found that metformin protects propofol-induced neuronal apoptosis via downregulating Cav-1.

Surgical treatment of children and youth with congenital melanocytic nevi: self- and proxy-reported opinions

PURPOSE

The role of surgery in the management of congenital melanocytic nevi (CMN) is controversial. Data on surgical outcomes and predictors of satisfaction remain scarce.

METHODS

An online survey was employed following worldwide recruitment of youth aged 14-25 years (n = 44) and parents of children ≤ 18 years (n = 249) with CMN to query patterns of treatment and satisfaction with and opinions about the benefits of surgery.

RESULTS

In proxy-reports, 121 of 249 (49%) and in self-reports 30 of 44 (75%) participants underwent CMN excision. The most common reasons for surgery were psychosocial determinants, aesthetic improvement, and melanoma risk reduction. The overall satisfaction with surgical management was good, although no predictors for satisfaction could be identified. Higher current age of the child was found to predict decision regret in proxy-reports. Most participants indicated that having a scar is more socially acceptable than a CMN. Opinions differed on whether surgery should be deferred until the child is old enough to be involved in the decision-making process.

CONCLUSIONS

Whether and when to perform surgery in children with CMN is a multifaceted question. Awareness of common concerns as well as risks and benefits of surgery are essential to ensure critical reflection and balanced decision-making.

Use of a magnetic double J stent in pediatric patients: A case-control study at two Canadian pediatric centers

BACKGROUND

Ureteral stents with magnetic tips (Blackstar©) were recently approved for use in Canada. To our knowledge this is the first published evidence of their use in pediatric patients. Traditionally, pediatric stent insertion and removal are performed under general anesthetic. Magnetic stents have three main benefits in pediatric patients; cost savings, decreased OR time and reduced general anesthetic exposure.

METHODS

This study was a proof of concept pilot, ran from May 2017-May 2018 to demonstrate the safety and efficacy of magnetic stents in pediatric patients. Patients undergoing ureteroscopy, ureteric re-implantation, and pyeloplasty with simultaneous magnetic stent insertion. Forty (40) patients had regular double J stents removed under anesthesia and served as control cases, and 40 patients had a magnetic double J at initial surgery at two different sites, CHU de Quebec and Alberta Children's Hospital.

RESULTS

Overall, 39 magnetic stents were successfully retrieved without general anesthetic, representing a retrieval failure rate of only 2.5%.

CONCLUSION

As demonstrated in our research, magnetic stents represent a safe and equally effective alternative to traditional stents, especially in a pediatric patient. This is because, at worst, if retrieval of the magnetic stent fails, traditional cystoscopic removal can be performed, so nothing is lost.

STUDY TYPE

Case-control study.

LEVEL OF EVIDENCE

Level III.

An evolving anesthetic protocol fosters fast tracking in pediatric cardiac surgery: A comparison of two anesthetic techniques

Background:

The past two decades have seen rapid development of new surgical techniques for repair as well as palliation of complex congenital heart diseases. For a better patient outcome, minimal postoperative ventilation remains one of the most important endpoints of an effectual perioperative management.

Aims and Objectives:

The aim of this randomized open-label trial was to compare postoperative extubation time and intensive care unit (ICU) stay when two different anesthetic regimens, comprising of induction with ketamine and low-dose fentanyl versus high-dose fentanyl, are used, in pediatric patients undergoing corrective/palliative surgery.

Materials and Methods:

Patients with congenital cardiac defects, under 14 years of age undergoing cardiac surgery under cardiopulmonary bypass (CPB) and epidural analgesia, were enrolled into two groups – Group K (ketamine with low-dose fentanyl) and Group F (high-dose fentanyl) – over a period of 10 months, starting from January 2018. The effect of both these drugs on postoperative extubation time and ICU stay was compared using Mann–Whitney U-test.

Results:

A total of 70 patients were assessed with equal distribution in both the groups. In Group K, 32 of 35 patients were extubated in the operation room, whereas extubation time in Group F was18.1 ± 11 h. Total ICU stay in Group K and Group F was 45.2 ± 30.1 and 60.1 ± 24.5 h, respectively (P = 0.02). Systolic blood pressure was significantly higher in Group K.

Conclusion:

Ketamine along with low-dose fentanyl, when used for anesthetic induction, in comparison to high-dose fentanyl, reduces postoperative extubation time and ICU stay, in pediatric patients undergoing corrective/palliative surgery under CPB and epidural analgesia for congenital cardiac defects.

Reaching Parents Through an Online Community

Scientific studies in animal models have demonstrated the neurotoxic effects of anesthetic and sedative drugs on the developing brain. Human studies, however, have been limited and less conclusive. The implications for clinical care remain unclear, and there is a critical need for further research on anesthetic toxicity to ensure safe anesthesia practices for infants and children. The sixth PANDA Symposium organized a session on "Engaging Stakeholders to Support Research" to facilitate dialog around improving communication and collaboration among stakeholders and to promote coordinated research efforts. Key stakeholders include patients, families, clinicians, researchers, community organizations, and federal agencies. This article provides an overview of an online platform called the Family Talkboard, a novel method which is destined to enhance patient outreach, engagement, and quality improvement, as well as outcomes research.

Ultrasound Elastography as a Non-Invasive Method to Monitor Liver Disease in Children with Short Bowel Syndrome: Updated Results

PURPOSE

The purpose of the study was to determine the accuracy of acoustic radiation force impulse (ARFI) ultrasound elastography in assessing the degree of liver disease in children with short bowel syndrome (SBS).

METHODS

A prospective observational cohort study of patients with SBS who underwent a liver biopsy and ARFI elastography was performed. Mean shear wave speed (SWS) and stage of fibrosis was evaluated using t-tests. Receiver operating characteristic curves (ROC) were generated and the area under the curves (AUC) estimated in order to assess the accuracy of SWS measurements to discriminate between stages of fibrosis.

RESULTS

Thirty-seven paired elastography and biopsy samples from 31 patients were included. The median age was 0.6 years, and 61% were male. There was a significant positive correlation between stage of fibrosis and mean SWS (β=0.16 m/s increase per stage, p=<0.001). ROC analysis revealed that mean SWS had good accuracy for discriminating between mild liver fibrosis (F0-F1) and moderate to severe fibrosis (F2-F4) (AUC=0.80, 95% CI 0.65-0.95). In addition, ROC analysis demonstrated that mean SWS can also accurately discriminate between mild to moderate fibrosis (F0-F2) and more severe fibrosis (F3-F4) (AUC=0.84, 95% CI 0.71-0.96).

CONCLUSION

ARFI elastography is an accurate, non-invasive method to monitor liver disease in children with SBS.

TYPE OF STUDY

Retrospective Cohort Study LEVEL OF EVIDENCE: II.

Embracing change: the era for pediatric ERAS is here

The concept of Enhanced Recovery After Surgery (ERAS) has increasingly been embraced by our adult surgical colleagues, but has been slow to crossover to pediatric surgical subspecialties. ERAS^® improves outcomes through multiple, incremental steps that act synergistically throughout the entire surgical journey. In practice, ERAS^® is a strategy of perioperative management that is defined by strong implementation and ongoing adherence to a patient-focused, multidisciplinary, and multimodal approach. There are increasing numbers of surgical teams exploring ERAS^® in children and there is mounting evidence that this approach may improve surgical care for children across the globe. The first World Congress in Pediatric ERAS^® in 2018 has set the stage for a new era in pediatric surgical safety.

Spinal anesthesia in children: most pediatric urologists are not on board

OBJECTIVE

In 2016, the Food and Drug Administration issued a warning on general anesthetic medications used for lengthy procedures (>3 h) in children younger than 3 years. Spinal anesthesia can be a safe alternative to general anesthesia for many pediatric urology procedures. It can shorten total operating room (OR) time, provide excellent pain control, and allow parents to reunite with their child immediately after surgery. However, use of spinal anesthesia can also directly affect the operating surgeon (awake patient, time constraints of spinal, and prolonged preoperative time). Members of the Societies for Pediatric Urology (SPU) and European Society of Pediatric Urology (ESPU) were surveyed to get their opinions on the use of spinal anesthesia for routine pediatric urology procedures. It was hypothesized that half of pediatric urologists would favor spinal anesthesia and that SPU members would be more likely to favor spinal anesthesia than their European colleagues.

MATERIALS AND METHODS

A short survey with five clinical scenarios was created. Scenarios assessed physicians' recommendations regarding timing and the type of anesthesia (general or spinal) for common pediatric urology procedures: undescended testicle, inguinal hernia, hypospadias, phimosis, and phimosis with penoscrotal webbing. Surveys were emailed to members of the SPU and ESPU. Responses and demographic information were collected and analyzed.

RESULTS

The survey was completed by 113 SPU members (46% response rate for members who opened the invitation) and 109 ESPU members. For all clinical scenarios, < 20% of pediatric urologists from the SPU and <25% from the ESPU favor doing any procedure with spinal anesthesia. The majority of respondents practice in children's hospitals with pediatric anesthesiologists, but roughly half of the responders (54% SPU and 43% ESPU) do not think their anesthesia colleagues would be comfortable performing spinal anesthesia. Furthermore, only 51% of SPU and 36% of ESPU members discuss the possible neurodevelopmental side-effects of anesthesia with parents; similarly, less than half of all respondents think their anesthesia colleagues address these potential side-effects when obtaining consent. The only significant difference between SPU and ESPU responses was that ESPU members tended to delay penile surgery more than SPU respondents.

CONCLUSION

Whether general anesthesia has any effect on the developing brain of children undergoing routine pediatric urology procedures is unclear. Yet, few pediatric urologists, independent of their region of practice, prefer spinal to general anesthesia. Collaboration in the OR is the key to success, and it is important that pediatric urologists and pediatric anesthesiologists work together to balance the benefits and risks of general and spinal anesthesia.

Practical considerations for establishing and maintaining a magnetic resonance imaging safety program in a pediatric practice

Magnetic resonance imaging is a multipurpose imaging modality that is largely safe, given the lack of ionizing radiation. However there are electromagnetic and biological effects on human tissue when exposed to magnetic environments, and hence there is a risk of adverse events occurring with these exams. It is imperative to understand these risks and develop methods to minimize them and prevent consequent adverse events. Implementing these safety practices in pediatric MR imaging has been somewhat limited because of gaps in information and knowledge among the personnel who are closely involved in the MR environment. The American College of Radiology has provided guidelines on MR safety practices that are helpful in minimizing such adverse events. This article provides an overview of the issues related to MR safety and practical ways to implement them across different health care facilities.

Long noncoding RNA SNHG16 reduced ketamine-induced neurotoxicity in human embryonic stem cell-derived neurons

BACKGROUND

Clinical evidence demonstrates that prolonged exposure to ketamine may cause irreversible injury to immature human brains. In this study, we utilized an in vitro model to examine the function of long noncoding RNA (lncRNA) SNHG16 in ketamine-induced neurotoxicity in human embryonic stem cell (hESC)-derived neurons.

METHODS

HESCs were induced toward neuronsin vitro, and treated with ketamine, at various concentrations, for 48 h. Viability, apoptosis, caspase-3 activity and ROS activity were then examined among hESC-derived neurons. Ketamine-induced gene expression change of SNHG16 was assessed by qRT-PCR. SNHG16 was overexpressed in hESC-derived neurons, which were then treated with ketamine, followed by biochemical assays to assess the effects of SNHG16 upregulation on ketamine-induced neurotoxicity. Correlation between SNHG16 and NeuroD1 gene was assess by qRT-PCR. In SNHG16-upregulated hESC-derived neurons, they were double transfected with siRNA to knock down NeuroD1. The functions of NeuroD1 inhibition on SNHG16-associated neural protection on ketamine-induced neurotoxicity were further assessed.

RESULTS

48-h in vitro treatment of ketamine induced significant neurotoxicity, and downregulated SNHG16 among hESC-derived neurons. Conversely, SNHG16 upregulation reduced ketamine-induced neurotoxicity. NeuroD1 expression was downregulated by ketamine in hESC-derived neurons, and concomitantly upregulated by SNHG16 overexpression. SiRNA-mediated NeuroD1 inhibition reversed the protection of SNHG16 upregulation on ketamine-induced neurotoxicity.

CONCLUSIONS

SNHG16 is an important epigenetic factor which may functionally modulate ketamine-induced neurotoxicity through NeuroD1.

General Anesthesia With Dexmedetomidine and Remifentanil in a Neonate During Oracotomy and Resection of a Congenital Cystic Adenomatoid Malformation

Based on animal data, concern has been expressed regarding the potential deleterious neurocognitive effects of general anesthesia during infancy and early life. Although there are no definitive data to prove this effect, the neonatal period has been suggested to be the most vulnerable period. While various inhaled and intravenous anesthetic agents have been implicated, dexmedetomidine and the opioids may be devoid of such effects. However, there are limited data regarding the combination of these agents during neonatal surgery and anesthesia. We present the use of these agents in combination with epidural anesthesia for postoperative analgesia in a 1-day-old neonate during thoracotomy and excision of a congental cystic adenomatoid malformation. Previous reports of the use of this unique combination of agents are reviewed and their role in this scenario discussed.

The idle central venous catheter in the NICU: When should it be removed?

PURPOSE

There is debate regarding the optimal timing of central line removal in the neonatal intensive care unit (NICU). The purpose was to evaluate outcomes of idle peripherally inserted central catheters (PICCs) and tunneled central venous catheters (TCVCs) and determine the incidence of line-related infections and replacements.

METHODS

Patients in the NICU with T-CVCs placed between 11/2008 and 8/2015 (n=134) or PICCs placed between 7/2013 and 10/2015 (n=467) were included. Demographics and outcomes were compared.

RESULTS

The most common indications for line placement were parenteral nutrition for PICCs (74%) and lack of access for T-CVCs (53%). T-CVCs had a greater proportion of idle days (T-CVC- 25.2% vs PICC- 5.1%, p<0.001) and removal within 24h of discharge (T-CVC-53% vs PICC-5.8%, p<0.001). Conversely, 81% of PICCs were removed within 24h of nonuse. Line replacement after removal for nonuse was required in 6% of PICCs and zero T-CVCs. In both groups, the central line-associated bloodstream infection (CLABSI) rate was lower in idle lines compared to ones in use.

CONCLUSION

Patients treated with PICCs and T-CVCs are different populations and should have different guidelines for removal. In neonates with difficult access, the low risk of CLABSIs in idle surgically placed catheters may justify maintaining access until discharge.

TYPE OF STUDY

Treatment study.

LEVEL OF EVIDENCE

III.

An Exploratory Study of Sevoflurane as an Alternative for Difficult Sedation in Critically Ill Children

OBJECTIVES

To analyze the effectiveness of inhaled sevoflurane in critically ill children with challenging sedation.

DESIGN

Prospective case series.

SETTING

Two PICUs of university hospitals in Spain.

INTERVENTIONS

Prospective observational study and exploratory investigation conducted in two PICUs in Madrid, Spain, over a 6-year period. Children treated with inhaled sevoflurane due to difficult sedation were included. Sevoflurane was administered via the anesthetic conserving device (AnaConDa) connected to a Servo-I ventilator (Maquet, Solna, Sweden). A morphine infusion was added to sevoflurane for analgesia. Demographic and clinical data, oral and IV sedatives, Sedation and Analgesic Clinical scores, and Bispectral Index Score monitoring were registered.

MEASUREMENTS AND MAIN RESULTS

Twenty-three patients with a median age of 6 months old were included. Fifty percentage of the patients had critical heart diseases. Sedative and analgesic drugs used before starting sevoflurane were mainly midazolam (63%) and fentanyl (53%). Six patients (32%) also received muscle relaxants. Sevoflurane was administered for a median of 5 days (interquartile range, 5.5-8.5 d). Median end-tidal sevoflurane concentration was 0.8% (interquartile range, 0.7-0.85%), achieved with an infusion rate of 7.5 mL/hr (5.7-8.6 mL/hr). After 48 hours of treatment, some sedative drugs could be removed in 18 patients (78%). Median Bispectral Index Score value prior to sevoflurane administration was 61 (interquartile range, 49-62), falling to 42 (interquartile range, 41-47; p < 0.05) after 6 hours of treatment. Six patients (26%) presented withdrawal syndrome after sevoflurane suspension, and all of them had received sevoflurane at least for 6 days. The main side effect was moderate hypotension in seven patients (30%).

CONCLUSIONS

Inhaled sevoflurane appeared to be an effective sedative agent in critically ill children and can be useful in those patients on mechanical ventilation difficult to sedate with conventional drugs. It can be administered easily in the PICU with conventional ventilators using the AnaConDa system. Withdrawal syndrome may occur with prolonged treatment.

The effect of regional anaesthesia versus general anaesthesia on behavioural functions in children

PURPOSE

The primary objective was to assess the effect of general anaesthesia versus regional anaesthesia in a single exposure before the age of 2 years on the development of long-term behavioural changes in children.

METHODS

The study was conducted between January 2014 and March 2015. Medical records of eligible children were reviewed. Then, parents of children who were included in the study were contacted and asked to visit the Outpatient Department to fill the Eyberg Child Behaviour Inventory questionnaire to measure behavioural changes in children. Children who were exposed to regional or general anaesthesia for surgery between January 2002 and December 2006 were included. Data collected were age and weight at the time of the first anaesthesia exposure and surgery duration. Chi-square test, t-test and multivariate analysis were used.

RESULTS

In total, 394 children were exposed to anaesthesia before the age of 2 years. Among the 168 patients who were exposed to general anaesthesia, 44 children (26.2%) developed behavioural abnormalities compared to 12 out of 226 patients (5.3%) who were exposed to regional anaesthesia (P-value<0.0001). Exposure to anaesthesia before age of 2 years increases the risk of developing behavioural disorder when surgery is accompanied by general anaesthesia, younger age at time of exposure, and longer surgery duration (P-value<0.0001, 0.001, 0.038 respectively).

CONCLUSION

Regional anaesthesia showed much lesser effect on children's behaviour compared to general anaesthesia. The incidence of behavioural disorder is increased with the use of general anaesthesia, younger age of the patient at time of exposure, and longer surgery duration.