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Yuan I, Bong CL, Chao JY. Intraoperative pediatric electroencephalography monitoring: an updated review. Korean J Anesthesiol 2024; 77:289-305. [PMID: 38228393 PMCID: PMC11150110 DOI: 10.4097/kja.23843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 12/05/2023] [Accepted: 01/16/2024] [Indexed: 01/18/2024] Open
Abstract
Intraoperative electroencephalography (EEG) monitoring under pediatric anesthesia has begun to attract increasing interest, driven by the availability of pediatric-specific EEG monitors and the realization that traditional dosing methods based on patient movement or changes in hemodynamic response often lead to imprecise dosing, especially in younger infants who may experience adverse events (e.g., hypotension) due to excess anesthesia. EEG directly measures the effects of anesthetics on the brain, which is the target end-organ responsible for inducing loss of consciousness. Over the past ten years, research on anesthesia and computational neuroscience has improved our understanding of intraoperative pediatric EEG monitoring and expanded the utility of EEG in clinical practice. We now have better insights into neurodevelopmental changes in the developing pediatric brain, functional connectivity, the use of non-proprietary EEG parameters to guide anesthetic dosing, epileptiform EEG changes during induction, EEG changes from spinal/regional anesthesia, EEG discontinuity, and the use of EEG to improve clinical outcomes. This review article summarizes the recent literature on EEG monitoring in perioperative pediatric anesthesia, highlighting several of the topics mentioned above.
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Affiliation(s)
- Ian Yuan
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Choon L. Bong
- Department of Pediatric Anesthesia, KK Women’s and Children’s Hospital, Duke-NUS Medical School, Singapore
| | - Jerry Y. Chao
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
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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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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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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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Wingert TEA, Hekmat D, Ayad I. Regional Anesthesia for Neonates. Neoreviews 2023; 24:e626-e641. [PMID: 37777613 DOI: 10.1542/neo.24-10-e626] [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: 10/02/2023]
Abstract
Pain management in neonates and infants has many unique and important facets, particularly in former preterm infants. Untreated pain and surgical stress in neonates are associated with myriad negative sequelae, including deleterious inflammatory, autonomic, hormonal, metabolic, and neurologic effects. Meanwhile, opioid side effects are also very impactful and affect multiple systems and pathways, particularly in the neonatal and infant population. Regional anesthesia presents a unique opportunity to provide highly effective analgesia; prevent deleterious signaling cascade pathways within the endocrine, immune, and nervous systems from occurring; and create conditions to facilitate reduced reliance on opioids and other analgesics. In some cases, clinicians can completely avoid general anesthesia and systemic anesthetics. This review will discuss some of the unique aspects of pain management in neonates and infants and provide an overview of the different regional anesthetic options available, namely, spinal anesthesia, epidural anesthesia, and peripheral nerve blocks.
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Affiliation(s)
- Theodora E A Wingert
- Department of Anesthesiology and Perioperative Medicine, University of California at Los Angeles, Los Angeles, CA
| | - Diana Hekmat
- Department of Anesthesiology and Perioperative Medicine, University of California at Los Angeles, Los Angeles, CA
| | - Ihab Ayad
- Department of Anesthesiology and Perioperative Medicine, University of California at Los Angeles, Los Angeles, CA
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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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Kabbani OM, Alhabdan KA, Almahbub AY, Kabbani NM, Ardah HI, Mahmoud AHM. Comparison of Postoperative Outcome in Children Undergoing Inguinal Hernia Repair Using Regional With General Versus General Anesthesia Alone: A Single Center Study. Cureus 2023; 15:e37382. [PMID: 37182070 PMCID: PMC10171397 DOI: 10.7759/cureus.37382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/09/2023] [Indexed: 05/16/2023] Open
Abstract
BACKGROUND Inguinal hernia repair is one of the most common general surgical procedures. It has been performed under local, regional, or general anesthesia. We hypothesized that using regional plus general anesthesia rather than general anesthesia alone would improve outcomes in neonates and pediatric patients undergoing hernia repair. METHODS This is a retrospective cohort study, including all pediatric patients who underwent inguinal hernia repair from 2015-2021. We divided patients into two groups. The first group was labeled "general anesthesia" (GA), while the second group was labeled "combined general and regional anesthesia" (GA+RA). We compared both groups in terms of demographic data, intraoperative outcome variables, and postoperative outcome variables. RESULTS 212 children fulfilled the study criteria, with 57 in the GA group and 155 in the GA+RA group. Demographic and preoperative data were comparable between both groups except for age, which was 60.3±49.4 months in the GA group versus 26.7±33.13 months in the GA+RA group (p<.0001). Outcome variables demonstrated statistically significant improvement in postoperative pain occurrence, length of hospital stay, incidence of bradycardia, and need for mechanical ventilation in the GA+RA group in comparison to the GA group with P values of 0.031, 0.02, 0.005, and 0.02, respectively. CONCLUSION Using regional and general anesthesia techniques rather than general anesthesia alone is associated with a decrease in postoperative pain, length of hospital stay, incidence of bradycardia, and need for mechanical ventilation. Further studies are still warranted to validate our conclusions.
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Affiliation(s)
- Omar M Kabbani
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, SAU
| | - Khaled A Alhabdan
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, SAU
| | - Abdulaziz Y Almahbub
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, SAU
| | - Nasib M Kabbani
- Department of Anesthesia, King Abdulaziz Medical City, Ministry of the National Guard Health Affairs, Riyadh, SAU
| | - Husam I Ardah
- Biostatistics and Epidemiology, King Abdullah International Medical Research Center, Riyadh, SAU
| | - Ahmed Haroun M Mahmoud
- Medical Education, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, SAU
- Research and Development, King Abdullah International Medical Research Center, Riyadh, SAU
- Pediatric Anesthesiology, King Abdullah Specialised Children Hospital, Riyadh, SAU
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de Graaff JC, Frykholm P. Ephedrine to treat intraoperative hypotension in infants: what is the target? Br J Anaesth 2023; 130:510-515. [PMID: 36906461 DOI: 10.1016/j.bja.2023.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Revised: 02/07/2023] [Accepted: 02/09/2023] [Indexed: 03/11/2023] Open
Abstract
Off-label use of medications in paediatric anaesthesia is common practice, owing to the relative paucity of evidence-based dosing regimens in children. Well-performed dose-finding studies, especially in infants, are rare and urgently needed. Unanticipated effects can result when paediatric dosing is based on adult parameters or local traditions. A recent dose-finding study on ephedrine highlights the uniqueness of paediatric dosing in comparison with adult dosing. We discuss the problems of off-label medication use and the lack of evidence for various definitions of hypotension and associated treatment strategies in paediatric anaesthesia. What is the aim of treating hypotension associated with anaesthesia induction: restoring the MAP to awake baseline values or elevating it above a provisional hypotension threshold?
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Affiliation(s)
| | - Peter Frykholm
- Department of Surgical Sciences, Section of Anaesthesiology and Intensive Care Medicine, Uppsala University, Uppsala, Sweden
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Kiblawi R, Beck C, Keil O, Schukfeh N, Hofmann AD, Ure BM, Kuebler JF. Laparoscopic versus Open Inguinal Hernia Repair Is Feasible in Infants with Caudal Anesthesia and Spontaneous Respiration. Eur J Pediatr Surg 2023; 33:26-34. [PMID: 36220133 DOI: 10.1055/a-1958-7989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
INTRODUCTION Minimally invasive surgery (i.e., laparoscopy) and minimally invasive anesthesia (i.e., caudal anesthesia with spontaneous respiration) have separately shown benefits for inguinal hernia repair in infants, yet to what degree these techniques can be combined remains unknown. This study investigated whether laparoscopy impacts the feasibility of performing caudal anesthesia with spontaneous respiration in infants. METHODS Prospectively collected data of all infants less than 12 months old and over 3 kg weight who underwent laparoscopic indirect hernia repair (LAP) at our department from 2019 to 2021 were compared with a historical control-matched group of infants who underwent open repair (OPEN) from 2017 to 2021. We assessed the patients' characteristics, anesthesia, and surgical data as well as intra- and postoperative complications. RESULTS A total of 87 infants were included (LAP n = 29, OPEN n = 58). Caudal anesthesia with spontaneous respiration was feasible in 62.1% of cases (LAP n = 55.2%, OPEN n = 65.5%; nonsignificant). Neither group registered anesthetic intra- or postoperative complications. Sedatives were utilized in 97% of LAP patients versus 56.9% of OPEN patients (p < 0.00001). The airway was secured with a laryngeal mask in 89.7% of patients during LAP versus 41.4% during OPEN (p < 0.00001). No significant differences were found regarding the use frequency of opioids (48.3% LAP vs. 34.5% OPEN; nonsignificant) or neuromuscular blockers (6.9% LAP vs. 5.2% OPEN; nonsignificant). CONCLUSION This is the first comparative study on caudal anesthesia and spontaneous respiration in infants undergoing laparoscopic versus open inguinal hernia surgery. Laparoscopy increased the need for ventilatory support and sedatives but did not significantly impair the feasibility of caudal anesthesia and spontaneous respiration.
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Affiliation(s)
- Rim Kiblawi
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Niedersachsen, Germany
| | - Christiane Beck
- Anaesthesiology and Intensive Care Medicine, Hannover Medical School, Hannover, Niedersachsen, Germany
| | - Oliver Keil
- Clinic for Anesthesiology and Intensive Care Medicine, Hannover Medical School, Hannover, Niedersachsen, Germany
| | - Nagoud Schukfeh
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Niedersachsen, Germany
| | | | - Benno Manfred Ure
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Niedersachsen, Germany
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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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Andropoulos DB, Dunbar BS. Neuroprotective Strategies in Anesthesia-Induced Neurotoxicity. Best Pract Res Clin Anaesthesiol 2022. [DOI: 10.1016/j.bpa.2022.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
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Shbeer A. Regional Anesthesia (2012-2021): A Comprehensive Examination Based on Bibliometric Analyses of Hotpots, Knowledge Structure and Intellectual Dynamics. J Pain Res 2022; 15:2337-2350. [PMID: 35996451 PMCID: PMC9391991 DOI: 10.2147/jpr.s372303] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 07/31/2022] [Indexed: 11/23/2022] Open
Abstract
In the last decade, there has been a significant advancement in the area of regional anesthesia (RA). Continuous evaluation of research in any developing field using modern technologies and available software is critical to identify future trends, hot spots, and intellectual dynamics. The current study was designed to bibliometrically evaluate the global research in RA using VOSviewer, MS Excel, and CVS-Scopus bibliographic data (2012–2021). Knowledge structure and intellectual dynamics were analyzed using clustering of keyword co-occurrence. Literature screening in the last decade found 6092 original articles (96.1%) and conference papers (3.9%). The top four countries producing articles were the United States (n = 30.57%), India (7.51), the United Kingdom (7.22%), and Canada (6.06%). A significant positive correlation was found in global publication productivity (R2 = 0.9161). The most productive organizations were Harvard University, the University of Toronto, and the Hospital for Special Surgery – New York. A tremendous collaboration was spotted nationally and internationally, especially in pediatric RA. This comprehensive study, which summarizes and evaluates 6902 original research materials on regional anesthesia, may serve as a resource for anesthesiologists, physicians, researchers, and students.
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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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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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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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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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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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Continuous epidural chloroprocaine after abdominal surgery is associated with lower postoperative opioid exposure in NICU infants. J Pediatr Surg 2022; 57:683-689. [PMID: 34154813 DOI: 10.1016/j.jpedsurg.2021.05.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 04/27/2021] [Accepted: 05/17/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Epidural anesthesia in infants undergoing open abdominal surgery has the potential to reduce opioid consumption, lower pain scores, and expedite tracheal extubation. We evaluated associations between use of continuous epidural chloroprocaine and improved intra- and post-operative outcomes. METHODS This matched retrospective cohort study first identified 24 patients who between April 2018 through December 2019 were treated with a caudal catheter and epidural chloroprocaine infusion for a laparotomy at postnatal age of 6 months or less. A matched comparator group of 24 patients was derived based on age and type of surgery. Exclusion criteria were the presence of a preoperative opioid infusion, comorbidities that would preclude appropriate pain assessment, or a recent surgical procedure. Primary outcomes included opioid consumption and pain scores; we secondarily analyzed intraoperative anesthetic requirements, other systemic analgesic use, vital signs, tracheal extubation time, and procedural times. RESULTS Treatment with epidural anesthesia was associated with lower 5-day total postoperative opioid consumption (3.2 mg/kg vs. 19.7 mg/kg in the respective epidural vs. systemic groups, p = 0.001) and time to tracheal extubation (1.3 days vs. 3.2 days, p = 0.005). Any statistically significant differences in pain scores were not clinically meaningful. There were no differences in mean arterial pressure or intraoperative inhaled anesthetic doses. CONCLUSION Continuous infusion of epidural chloroprocaine in infants following open abdominal surgery may limit exposure to systemic opioid medications while providing adequate postoperative analgesia and shortening time to tracheal extubation.
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20
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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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Walker SM, Malkmus S, Eddinger K, Steinauer J, Roberts AJ, Shubayev VI, Grafe MR, Powell SB, Yaksh TL. Evaluation of neurotoxicity and long-term function and behavior following intrathecal 1 % 2-chloroprocaine in juvenile rats. Neurotoxicology 2021; 88:155-167. [PMID: 34801587 DOI: 10.1016/j.neuro.2021.11.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 11/08/2021] [Accepted: 11/16/2021] [Indexed: 01/20/2023]
Abstract
Spinally-administered local anesthetics provide effective perioperative anesthesia and/or analgesia for children of all ages. New preparations and drugs require preclinical safety testing in developmental models. We evaluated age-dependent efficacy and safety following 1 % preservative-free 2-chloroprocaine (2-CP) in juvenile Sprague-Dawley rats. Percutaneous lumbar intrathecal 2-CP was administered at postnatal day (P)7, 14 or 21. Mechanical withdrawal threshold pre- and post-injection evaluated the degree and duration of sensory block, compared to intrathecal saline and naive controls. Tissue analyses one- or seven-days following injection included histopathology of spinal cord, cauda equina and brain sections, and quantification of neuronal apoptosis and glial reactivity in lumbar spinal cord. Following intrathecal 2-CP or saline at P7, outcomes assessed between P30 and P72 included: spinal reflex sensitivity (hindlimb thermal latency, mechanical threshold); social approach (novel rat versus object); locomotor activity and anxiety (open field with brightly-lit center); exploratory behavior (rearings, holepoking); sensorimotor gating (acoustic startle, prepulse inhibition); and learning (Morris Water Maze). Maximum tolerated doses of intrathecal 2-CP varied with age (1.0 μL/g at P7, 0.75 μL/g at P14, 0.5 μL/g at P21) and produced motor and sensory block for 10-15 min. Tissue analyses found no significant differences across intrathecal 2-CP, saline or naïve groups. Adult behavioral measures showed expected sex-dependent differences, that did not differ between 2-CP and saline groups. Single maximum tolerated in vivo doses of intrathecal 2-CP produced reversible spinal anesthesia in juvenile rodents without detectable evidence of developmental neurotoxicity. Current results cannot be extrapolated to repeated dosing or prolonged infusion.
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Affiliation(s)
- Suellen M Walker
- Department of Anesthesiology, University of California San Diego, CA, USA; Developmental Neurosciences Department, UCL Great Ormond Street Institute of Child Health and Department of Anaesthesia and Pain Medicine, Great Ormond St Hospital Foundation Trust, London, United Kingdom.
| | - Shelle Malkmus
- Department of Anesthesiology, University of California San Diego, CA, USA
| | - Kelly Eddinger
- Department of Anesthesiology, University of California San Diego, CA, USA
| | - Joanne Steinauer
- Department of Anesthesiology, University of California San Diego, CA, USA
| | - Amanda J Roberts
- Animal Models Core, Scripps Research Institute, La Jolla, CA, USA
| | - Veronica I Shubayev
- Department of Anesthesiology, University of California San Diego, CA, USA; Veterans Affairs San Diego Healthcare System, La Jolla, CA, USA
| | - Marjorie R Grafe
- Department of Pathology, Oregon Health & Science University, Portland, OR, USA
| | - Susan B Powell
- Veterans Affairs San Diego Healthcare System, La Jolla, CA, USA; Department of Psychiatry, University of California San Diego, La Jolla, CA, USA
| | - Tony L Yaksh
- Department of Anesthesiology, University of California San Diego, CA, 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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A decade later, there are still major issues to be addressed in paediatric anaesthesia. Curr Opin Anaesthesiol 2021; 34:271-275. [PMID: 33935174 DOI: 10.1097/aco.0000000000000990] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
PURPOSE OF REVIEW Despite real advances in paediatric anaesthesia management, such as a growing awareness of the relevance of anaesthesia conduct as well as of the lack of evidence for neurotoxicity of anaesthetic agents, it must be said that there are still important questions in our specialty that remain unanswered. Standardization and harmonization of airway management, analgesia techniques and outcome measures are the important issues we are facing at the beginning of this decade. RECENT FINDINGS Major improvements in airway management of neonates and infants resulted from the introduction of videolaryngoscopes and the systematic use of nasal oxygenation during endotracheal intubation. Similarly, the increasing popularity of dexmedetomidine has led to the generalization of its use, which, considering that it may produce undesirable effects, poses a challenge for the future. Moreover, recent systematic reviews have confirmed a lack of evidence for the efficacy of many techniques used in clinical practice. SUMMARY The shift in research from the neurotoxicity of anaesthetic agents to factors related to anaesthetic conduct are discussed. Examples for an improvement in anaesthesia management are highlighted with advocacy for including these evidence-based findings in routine clinical practice. Finally, the impact of using clinically relevant age-related and patient-centred perioperative outcomes is essential for comparing and/or interpreting the safety and efficacy of anaesthesia and analgesia management in children.
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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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Systemic and regional cerebral perfusion in small infants undergoing minor lower abdominal surgery under awake caudal anaesthesia: An observational study. Eur J Anaesthesiol 2021; 37:696-700. [PMID: 31972600 DOI: 10.1097/eja.0000000000001150] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Infants undergoing general anaesthesia have an increased risk of severe respiratory and cardiovascular critical events. Awake caudal anaesthesia is an alternative for small infants undergoing minor lower abdominal surgery. While clinical experience has shown stable intra-operative haemodynamic conditions, there are no studies evaluating systemic and regional cerebral perfusion during such a procedure. OBJECTIVES The purpose of this study was to evaluate the effects of awake caudal anaesthesia on systemic and regional cerebral perfusion in small infants. DESIGN A prospective observational cohort study. SETTING Clinic of Anaesthesiology, University Children's Hospital, between November 2017 and June 2018. PATIENTS Twenty small infants (postmenstrual age 36 to 54 weeks, weight 1800 to 5700 g) scheduled for lower abdominal surgery under awake caudal anaesthesia were enrolled in this study. INTERVENTION Standard monitoring was expanded to include cardiac index using electrical velocimetry and regional cerebral oxygen saturation using near infrared spectroscopy. The caudal block was performed with 0.3% ropivacaine 1 ml kg Hypotension was defined as mean arterial blood pressure (BP) less than 35 mmHg and regional cerebral desaturation as regional cerebral oxygen saturation less than 80% of baseline. MAIN OUTCOMES Mean arterial BP, cardiac index and regional cerebral oxygen saturation parameters under awake caudal anaesthesia. RESULTS Mean arterial BP, cardiac index and regional cerebral oxygen saturation remained above the predefined lower limits. No episodes of hypotension or regional cerebral desaturation were observed. Operation time was 35 ± 13 (range 20 to 71) min. The infants were discharged to the neonatal ward after the end of surgery, and milk was fed 22 ± 15 (range 6 to 55) min thereafter. Five preterm infants experienced self-limiting episodes of apnoea intra-operatively. CONCLUSION The current study shows that awake caudal anaesthesia does not impair systemic and regional cerebral perfusion in small infants. TRIAL REGISTRATION German registry of clinical studies (DRKS-ID: 800015742).
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Gleich SJ, Shi Y, Flick R, Zaccariello MJ, Schroeder DR, Hanson AC, Warner DO. Hypotension and adverse neurodevelopmental outcomes among children with multiple exposures to general anesthesia: Subanalysis of the Mayo Anesthesia Safety in Kids (MASK) Study. Paediatr Anaesth 2021; 31:282-289. [PMID: 33320392 PMCID: PMC8237208 DOI: 10.1111/pan.14106] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 11/16/2020] [Accepted: 12/08/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND The potential adverse effects of exposures to general anesthesia on the developing human brain remain controversial. It has been hypothesized that hypotension accompanying anesthesia could be contributory. We hypothesized that among children exposed to multiple anesthetics prior to age 3, children developing adverse neurodevelopmental outcomes would be more likely to have intraoperative hypotension. METHODS Two previously published study cohorts were utilized for analysis: the retrospective and prospective Mayo Anesthesia Safety in Kids cohorts. The two lowest consecutive systolic blood pressure measurements were abstracted and standardized by calculating a z-score for noninvasive blood pressure reference ranges for children. The lowest systolic blood pressure z-score (continuous variable) and intraoperative hypotension (lowest systolic blood pressure z-score <-1.0) were used to assess the association of intraoperative hypotension with the incidence of learning disabilities or attention-deficit/hyperactivity disorder(retrospective cohort) and factor scores/cluster membership (prospective cohort). RESULTS One hunderd and sixteen and 206 children with multiple exposures to general anesthesia were analyzed in the retrospective and prospective cohorts with mean lowest systolic blood pressure z-scores -0.26 (SD 1.02) and -0.62 (SD 1.10), respectively. There was no overall association of the lowest z-score or hypotension with learning disabilities or attention-deficit/hyperactivity disorder in the retrospective cohort. In the prospective cohort, there was no overall association of the lowest systolic blood pressure or hypotension with factor scores or cluster membership. CONCLUSIONS We did not find evidence to support the hypothesis that, among children exposed to multiple anesthetics prior to age 3, children developing adverse neurodevelopmental outcomes would be more likely to have intraoperative hypotension compared with those who did not.
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Affiliation(s)
- Stephen J. Gleich
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Yu Shi
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Randall Flick
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - Darrell R. Schroeder
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Andrew C. Hanson
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - David O. Warner
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
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Heydinger G, Tobias J, Veneziano G. Fundamentals and innovations in regional anaesthesia for infants and children. Anaesthesia 2021; 76 Suppl 1:74-88. [PMID: 33426659 DOI: 10.1111/anae.15283] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/07/2020] [Indexed: 12/18/2022]
Abstract
Regional anaesthesia in children has evolved rapidly in the last decade. Although it previously consisted of primarily neuraxial techniques, the practice now incorporates advanced peripheral nerve blocks, which were only recently described in adults. These novel blocks provide new avenues for providing opioid-sparing analgesia while minimising invasiveness, and perhaps risk, associated with older techniques. At the same time, established methods, such as infant spinal anaesthesia, under-utilised in the last 20 years, are experiencing a revival. The impetus has been the concern regarding the potential long-term neurocognitive effects of general anaesthesia in the young child. These techniques have expanded from single shot spinal anaesthesia to combined spinal/epidural techniques, which can now effectively provide surgical anaesthesia for procedures below the umbilicus for a prolonged period of time, thereby avoiding the need for general anaesthesia. Continuous 2-chloroprocaine infusions, previously only described for intra-operative regional anaesthesia, have gained popularity as a means of providing prolonged postoperative analgesia in epidural and continuous nerve block techniques. The rapid, liver-independent metabolism of 2-chloroprocaine makes it ideal for prolonged local anaesthetic infusions in neonates and small infants, obviating the increased risk of local anaesthetic systemic toxicity that occurs with amide local anaesthetics. Debate continues over certain practices in paediatric regional anaesthesia. While the rarity of complications makes comparative analyses difficult, data from large prospective registries indicate that providing regional anaesthesia to children while under general anaesthesia appears to be at least as safe as in the sedated or awake patient. In addition, the estimated frequency of serious adverse events demonstrates that regional blocks in children under general anaesthesia are no less safe than in awake adults. In infants, the techniques of direct thoracic epidural placement or caudal placement with cephalad threading each have distinct advantages and disadvantages. As the data cannot support the safety of one technique over the other, the site of epidural insertion remains largely a matter of anaesthetist discretion.
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Affiliation(s)
- G Heydinger
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - J Tobias
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - G Veneziano
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
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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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Chen FK, Li LT, Kelleher CM, Liu CA. Infant spinal anesthesia reduces postoperative pain scores and pain medication consumption in infants undergoing inguinal herniorrhaphy. J Pediatr Surg 2020; 55:2840-2843. [PMID: 32972743 DOI: 10.1016/j.jpedsurg.2020.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 08/12/2020] [Accepted: 08/14/2020] [Indexed: 11/17/2022]
Affiliation(s)
- Frances K Chen
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, USA
| | - Lucy T Li
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, USA
| | - Cassandra M Kelleher
- Department of Surgery, MassGeneral Hospital for Children, Massachusetts General Hospital, Boston, USA
| | - Chang A Liu
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, USA.
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Clausen NG, Filipovic M, Pater GH, Zickerman C, Ydemann M. Blood pressure in Danish children during general anaesthesia: Hypotension in a paediatric population observational (HIPPO) study. Acta Anaesthesiol Scand 2020; 64:1453-1459. [PMID: 32589795 DOI: 10.1111/aas.13662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 06/05/2020] [Accepted: 06/11/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND In Denmark, thousands of infants and children require general anaesthesia annually. Hypotension during general anaesthesia might reduce cerebral blood flow and oxygen delivery to the brain. Safe lower limits of blood pressure are ill defined. The Hypotension in Paediatric Populations Observational study objective was to assess blood pressure in Danish children during general anaesthesia. METHODS This study is a prospective observational multicentre study. Primary outcomes were mean arterial blood pressures in children aged 0-12 years. Lowest mean arterial blood pressure, intervention thresholds to increase blood pressure and type of intervention were secondary outcomes. Premature infants and children scheduled for cardio-thoracic surgery were excluded. Blood pressures were measured by oscillometry or invasively. RESULTS In total, 726 patients were included. In children < 1 year, median arterial pressure was 51 mm Hg, (interquartile range; 43-58) and increased to 58 mm Hg (interquartile range; 52-65) for 12-year-old children. In 32 patients, 49 actions were taken to modulate blood pressure. Pre-induction blood pressures were recorded for 29%. CONCLUSION This study presents pragmatic, multicentre, prospectively collected observations of blood pressure in children undergoing general anaesthesia in usual practice. In the youngest infants, variability in blood pressure appears to be large. Measurement of blood pressure is recommended during every general anaesthesia and in children of all ages. Safe ranges of blood pressure remain to be defined.
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Affiliation(s)
- Nicola G. Clausen
- Anaesthesiology and Intensive Care Section Paediatric Anaesthesia Odense University Hospital Odense Denmark
| | - Maja Filipovic
- Department of Neuroanesthesiology and intensive careRigshospitalet Copenhagen Denmark
| | - Gerrit H. Pater
- Department of Anesthesiology and Intensive Care Haukeland University Hospital Bergen Norway
| | - Caroline Zickerman
- Department of Surgical and Perioperative Sciences Anesthesiology and Intensive Care MedicineUmeå University Umeå Sweden
| | - Mogens Ydemann
- Department of Neuroanesthesiology and intensive careRigshospitalet Copenhagen Denmark
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Abstract
Blood pressure (BP) is routinely measured in newborn infants. Published BP nomograms demonstrate a rise in BP following delivery in healthy infants at all gestational ages (GA) and evidence that BP values are higher with increasing birth weight and GA. However, the complex physiology that occurs in newborn infants and range of BP values observed at all GA make it difficult to identify "normal" BP for a specific infant at a specific time under specific conditions. As such, complete hemodynamic assessment should include the physical examination, perinatal history, other vital signs, and laboratory values in addition to BP values.
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Affiliation(s)
- Beau Batton
- Department of Pediatrics, Southern Illinois University School of Medicine, PO Box 19676, Springfield, IL 62794, USA.
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Soriano SG, McCann ME. Is Anesthesia Bad for the Brain? Current Knowledge on the Impact of Anesthetics on the Developing Brain. Anesthesiol Clin 2020; 38:477-492. [PMID: 32792178 DOI: 10.1016/j.anclin.2020.05.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
There are compelling preclinical data that common general anesthetics cause increased neuroapoptosis in juvenile animals. Retrospective studies demonstrate that young children exposed to anesthesia have school difficulties, which could be caused by anesthetic neurotoxicity, perioperative hemodynamic and homeostatic instability, underlying morbidity, or the neuroinflammatory effects of surgical trauma. Unnecessary procedures should be avoided. Baseline measures of blood pressure are important in determining perioperative blood pressure goals. Inadvertent hypocapnia or moderate hypercapnia and hyperoxia or hypoxia should be avoided. Pediatric patients should be maintained in a normothermic, euglycemic state with neutral positioning. Improving outcomes of infants and children requires the collaboration of anesthesiologists, surgeons, pediatricians and neonatologists.
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Affiliation(s)
- Sulpicio G Soriano
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Mary Ellen McCann
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA.
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Many BT, Rizeq YK, Vacek J, Cheon EC, Johnson E, Hu YY, Raval MV, Abdullah F, Goldstein SD. A contemporary snapshot of circumcision in US children's hospitals. J Pediatr Surg 2020; 55:1134-1138. [PMID: 32199703 DOI: 10.1016/j.jpedsurg.2020.02.031] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 02/20/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND In 2012, the American Academy of Pediatrics (AAP) concluded the health benefits of circumcision during the neonatal period outweigh the risks. This study describes recent trends in male circumcision in freestanding children's hospitals in the United States. METHODS Using the Pediatric Health Information System (PHIS), male patients <18 years of age who were circumcised without any additional procedures between the years 2010 and 2017 were identified. Data included age at procedure (neonate: 0-30 days, infant: 31-365 days, early childhood: ≥1 to <5 years, and older child: ≥5 to<18 years), cost, and specialty performing the circumcision. RESULTS Of the 171,680 circumcisions performed, 85,270 (50%) were during neonatal period, 29,060 (17%) during infancy, 30,276 (18%) early childhood, and 26,355 (16%) thereafter. Circumcision in neonates increased from 39% to 58% (p < 0.001), and the proportion performed during infancy decreased over time. System level cost for ambulatory circumcision averaged $32 million USD annually, and median cost per ambulatory circumcision was $2892 USD. Obstetricians and Pediatricians are performing proportionally more circumcisions. CONCLUSION Since 2012, proportionally more neonates are undergoing circumcision in US children's hospitals. Perinatal specialties are performing an increasing proportion of circumcisions. Circumcision during the birth hospitalization in the neonatal period is more resource-effective than postponing until later in infancy. TYPE OF STUDY Retrospective, cross-sectional analysis. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Benjamin T Many
- Division of Pediatric Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago; Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine
| | - Yazan K Rizeq
- Division of Pediatric Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago
| | - Jonathan Vacek
- Division of Pediatric Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago; Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine
| | - Eric C Cheon
- Division of Pediatric Anesthesia, Ann and Robert H. Lurie Children's Hospital of Chicago
| | - Emilie Johnson
- Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine; Division of Pediatric Urology, Ann and Robert H. Lurie Children's Hospital of Chicago
| | - Yue-Yung Hu
- Division of Pediatric Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago; Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine
| | - Mehul V Raval
- Division of Pediatric Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago; Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine
| | - Fizan Abdullah
- Division of Pediatric Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago; Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine
| | - Seth D Goldstein
- Division of Pediatric Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago.
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Somaini M, Ingelmo P. Anesthesia and analgesia in preterm infants is still something in between art and science. Minerva Anestesiol 2020; 86:699-700. [PMID: 32449340 DOI: 10.23736/s0375-9393.20.14463-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- Marta Somaini
- Department of Anesthesia, Niguarda Ca'Granda Hospital, Milan, Italy -
| | - Pablo Ingelmo
- Department of Anesthesia, Montreal Children's Hospital, McGill University, Montreal, QC, Canada
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Role of TFA-1 adhesive forehead sensors in predicting fluid responsiveness in anaesthetised children: A prospective cohort study. Eur J Anaesthesiol 2020; 37:713-718. [PMID: 32412989 DOI: 10.1097/eja.0000000000001235] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND The TFA-1 adhesive forehead sensor is a newly developed pulse oximeter for the measurement of the plethysmographic variability index (PVI) at the forehead, and for the rapid detection of changes in oxygen saturation during low perfusion. OBJECTIVES We evaluated the ability of the TFA-1 sensor to predict fluid responsiveness in children under general anaesthesia. DESIGN Prospective cohort study. SETTING Single tertiary care children's hospital. PATIENTS Thirty-seven children aged 1 to 5 years under general anaesthesia and requiring invasive arterial pressure monitoring. MAIN OUTCOME MEASURES The baseline PVI of TFA-1 and finger sensors, respiratory variation of aorta blood flow peak velocity (ΔVpeak) and stroke volume index (SVI) obtained using transthoracic echocardiography were assessed. After fluid loading of 10 ml kg crystalloids over 10 min, SVI was reassessed. Responders were defined as those with an increase in SVI greater than 15% from the baseline. Receiver operating characteristic (ROC) curve analysis was performed to evaluate the predictive ability of the PVI of TFA-1 and finger sensors and ΔVpeak for fluid responsiveness. RESULTS Seventeen (56.6%) patients responded to volume expansion. Before fluid loading, the PVI of TFA-1 and finger sensors and ΔVpeak (mean ± SD) of the responders were 11.2 ± 4.4, 11.4 ± 5.1 and 14.8 ± 3.9%, respectively, and those of the nonresponders were 7.4 ± 3.9, 8.1 ± 3.6 and 11.0 ± 3.3%, respectively. ROC curve analysis indicated that the PVI of TFA-1 and finger sensors and ΔVpeak could predict fluid responsiveness. The areas under the curve were 0.8 [P = 0.00; 95% confidence interval (CI) 0.60 to 0.91], 0.7 (P = 0.02; 95% CI 0.53 to 0.87) and 0.8 (P = 0.00; 95% CI 0.59 to 0.91), respectively. The cut-off values for the PVI of TFA-1 and finger sensors and ΔVpeak were 6.0, 9.0 and 10.6%, respectively. CONCLUSION The PVI of TFA-1 forehead sensor is a good alternative, but is not superior to the finger sensor and ΔVpeak in evaluating fluid responsiveness in mechanically ventilated children under general anaesthesia. CLINICAL TRIAL REGISTRATION www.clinicaltrials.gov, NCT03132480.
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Abstract
Background
Children are required to fast before elective general anesthesia. This study hypothesized that prolonged fasting causes volume depletion that manifests as low blood pressure. This study aimed to assess the association between fluid fasting duration and postinduction low blood pressure.
Methods
A retrospective cohort study was performed of 15,543 anesthetized children without preinduction venous access who underwent elective surgery from 2016 to 2017 at Children’s Hospital of Philadelphia. Low blood pressure was defined as systolic blood pressure lower than 2 standard deviations below the mean (approximately the 2.5th percentile) for sex- and age-specific reference values. Two epochs were assessed: epoch 1 was from induction to completion of anesthesia preparation, and epoch 2 was during surgical preparation.
Results
In epoch 1, the incidence of low systolic blood pressure was 5.2% (697 of 13,497), and no association was observed with the fluid fasting time groups: less than 4 h (4.6%, 141 of 3,081), 4 to 8 h (6.0%, 219 of 3,652), 8 to 12 h (4.9%, 124 of 2,526), and more than 12 h (5.0%, 213 of 4,238). In epoch 2, the incidence of low systolic blood pressure was 6.9% (889 of 12,917) and varied across the fasting groups: less than 4 h (5.6%, 162 of 2,918), 4 to 8 h (8.1%, 285 of 3,531), 8 to 12 h (5.9%, 143 of 2,423), and more than 12 h (7.4%, 299 of 4,045); after adjusting for confounders, fasting 4 to 8 h (adjusted odds ratio, 1.33; 95% CI, 1.07 to 1.64; P = 0.009) and greater than 12 h (adjusted odds ratio, 1.28; 95% CI, 1.04 to 1.57; P = 0.018) were associated with significantly higher odds of low systolic blood pressure compared with the group who fasted less than 4 h, whereas the increased odds of low systolic blood pressure associated with fasting 8 to 12 h (adjusted odds ratio, 1.11; 95% CI, 0.87 to 1.42; P = 0.391) was nonsignificant.
Conclusions
Longer durations of clear fluid fasting in anesthetized children were associated with increased risk of postinduction low blood pressure during surgical preparation, although this association appeared nonlinear.
Editor’s Perspective
What We Already Know about This Topic
What This Article Tells Us That Is New
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Walkden GJ, Pickering AE, Gill H. Assessing Long-term Neurodevelopmental Outcome Following General Anesthesia in Early Childhood: Challenges and Opportunities. Anesth Analg 2019; 128:681-694. [PMID: 30883414 PMCID: PMC6436726 DOI: 10.1213/ane.0000000000004052] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Neurodegeneration has been reported in young animals after exposure to all commonly used general anesthetic agents. The brain may be particularly vulnerable to anesthetic toxicity during peak synaptogenesis (in gestation and infancy). Human studies of long-term neurodevelopmental outcome following general anesthesia in early childhood report contradictory findings. This review assesses the strengths and deficiencies in human research methodologies to inform future studies. We identified 76 studies, published between 1990 and 2017, of long-term neurodevelopmental outcome following early childhood or in utero general anesthesia exposure: 49 retrospective, 9 ambidirectional, 17 prospective cohort studies, and 1 randomized controlled trial. Forty-nine studies were explicitly concerned with anesthetic-induced neurotoxicity. Full texts were appraised for methodological challenges and possible solutions. Major challenges identified included delineating effects of anesthesia from surgery, defining the timing and duration of exposure, selection of a surgical cohort and intervention, addressing multiple confounding life course factors, detecting modest neurotoxic effects with small sample sizes (median, 131 children; interquartile range, 50–372), selection of sensitive neurodevelopmental outcomes at appropriate ages for different developmental domains, insufficient length of follow-up (median age, 6 years; interquartile range, 2–12 years), and sample attrition. We discuss potential solutions to these challenges. Further adequately powered, multicenter, prospective randomized controlled trials of anesthetic-induced neurotoxicity in children are required. However, we believe that the inherent methodological challenges of studying anesthetic-induced neurotoxicity necessitate the parallel use of well-designed observational cohort studies.
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Affiliation(s)
- Graham J Walkden
- From the School of Physiology, Pharmacology and Neuroscience, University of Bristol, Bristol, United Kingdom.,Bristol Anaesthesia, Pain and Critical Care Sciences, Translational Health Sciences, Bristol Medical School, Bristol Royal Infirmary, Bristol, United Kingdom
| | - Anthony E Pickering
- From the School of Physiology, Pharmacology and Neuroscience, University of Bristol, Bristol, United Kingdom.,Bristol Anaesthesia, Pain and Critical Care Sciences, Translational Health Sciences, Bristol Medical School, Bristol Royal Infirmary, Bristol, United Kingdom
| | - Hannah Gill
- From the School of Physiology, Pharmacology and Neuroscience, University of Bristol, Bristol, United Kingdom.,Bristol Anaesthesia, Pain and Critical Care Sciences, Translational Health Sciences, Bristol Medical School, Bristol Royal Infirmary, Bristol, United Kingdom.,Department of Paediatric Anaesthesia, Bristol Royal Hospital for Children, Bristol, United Kingdom
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Abstract
Regional anesthesia provides effective anesthesia and pain relief in infants with age-specific data attesting to safety and efficacy. Regional anesthesia decreases exposure to opioids and general anesthetic agents and associated adverse drug effects, suppresses the stress response, and provides better hemodynamic stability compared to general anesthesia. Regional anesthesia can prevent long-term behavioral responses to pain. As a result, the overall number and variety of nerve blocks being used in infants is increasing. While neuraxial blocks are the most common blocks performed in infants, the introduction of ultrasound imaging and a better safety profile has advanced the use of peripheral nerve blocks. Infant-specific pharmacokinetic and pharmacodynamic data of local anesthetic medications are reviewed including risk factors for the accumulation of high serum levels of unbound, pharmacologically active drug. Bupivacaine accumulates with continuous infusion and 2-chloroprocaine can be used as an alternative. Local anesthetic systemic toxicity has the highest incidence in infants less than 6 months of age and is associated with bolus dosing and penile nerve blocks. Local anesthetic toxicity is treated by securing the airway, suppression of seizure activity and implementation of cardiopulmonary resuscitation. Administration of intralipid (intravenous lipid emulsion) is initiated at the first sign of toxicity. A high level of expertise in regional anesthesia is needed when treating infants due to their unique development.
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Abstract
Neuraxial (spinal and epidural) anesthesia has become commonplace in the care of neonates undergoing surgical procedures. These techniques afford many benefits, and, when properly performed, are extremely safe. This article reviews the benefits, risks, and applications of neuraxial anesthesia in neonates.
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Dohms K, Hein M, Rossaint R, Coburn M, Stoppe C, Ehret CB, Berger T, Schälte G. Inguinal hernia repair in preterm neonates: is there evidence that spinal or general anaesthesia is the better option regarding intraoperative and postoperative complications? A systematic review and meta-analysis. BMJ Open 2019; 9:e028728. [PMID: 31597647 PMCID: PMC6797401 DOI: 10.1136/bmjopen-2018-028728] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES Whether spinal anaesthesia (SA) reduces intraoperative and postoperative complications compared with general anaesthesia (GA) was investigated. DESIGN The meta-analysis was structured based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. Databases (PubMed, MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials and Web of Science) were searched, and four randomised controlled trials (RCTs) and two retrospective cohort studies were included. A random-effects model with pooled risk ratios and mean differences with 95% CIs were used. Statistical heterogeneity was evaluated using the I2 statistic. Quality assessment of the studies was performed by assessing the risk of bias according to the Cochrane and GRADE methodology. SETTING Publications from January 1990 to November 2018 were included. PARTICIPANTS AND INTERVENTIONS Our study selection captured information from studies focusing on neonates born before the 37th gestational week who were scheduled for an inguinal hernia repair operation under either SA or GA. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcome measures were apnoea, postoperative ventilation and method failure rates according to predefined eligibility criteria. The duration of surgery, desaturation events <80%, hospital stay duration and postoperative bradycardia were secondary outcomes. RESULTS We found significantly fewer events for the outcomes 'any episode of apnoea' and 'mechanical ventilation postoperatively' in the SA group. Bradycardias were significantly less common in the SA group. In total, 7.5% of the SA group were converted to GA. The duration of surgery was significantly shorter in the SA group. No significant differences were found in the outcome measures 'postoperative oxygen supplementation', 'prolonged apnoea', 'postoperative oxygen desaturation <80%' and 'hospital stay'. CONCLUSIONS We consider SA a convenient alternative for hernia repair in preterm infants, providing more safety regarding postoperative apnoea. To the best of our knowledge, this is the first meta-analysis to include studies exclusively comparing SA versus GA. More high-quality RCTs are needed. TRIAL REGISTRATION NUMBER CRD42016048683.
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Affiliation(s)
- Katharina Dohms
- Department of Anesthesiology, University Hospital RWTH Aachen, Medical Faculty, Aachen, Germany
| | - Marc Hein
- Department of Anesthesiology, University Hospital RWTH Aachen, Medical Faculty, Aachen, Germany
| | - Rolf Rossaint
- Department of Anesthesiology, University Hospital RWTH Aachen, Medical Faculty, Aachen, Germany
| | - Mark Coburn
- Department of Anesthesiology, University Hospital RWTH Aachen, Medical Faculty, Aachen, Germany
| | - Christian Stoppe
- Department of Intensive Care Medicine, University Hospital RWTH Aachen, Medical Faculty, Aachen, Germany
| | - Constanze Barbara Ehret
- Department of Anesthesiology, University Hospital RWTH Aachen, Medical Faculty, Aachen, Germany
| | - Tanja Berger
- Department of Medical Statistics, Univeristy Hospital RWTH Aachen, Medical Faculty, Aachen, Germany
| | - Gereon Schälte
- Department of Anesthesiology, University Hospital RWTH Aachen, Medical Faculty, Aachen, Germany
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Holman A, Haydar B, Kraft K, Park J. Infant spinal anesthesia: a safe, efficient, and worthwhile collaboration. J Pediatr Urol 2019; 15:583-584. [PMID: 31401223 DOI: 10.1016/j.jpurol.2019.07.008] [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] [Received: 06/25/2019] [Accepted: 07/01/2019] [Indexed: 11/20/2022]
Affiliation(s)
- A Holman
- Department of Anesthesiology, Division of Pediatric Anesthesiology, University of Michigan, C. S. Mott Children's Hospital, 1540 E. Hospital Drive, Ann Arbor, MI, 48109, USA.
| | - B Haydar
- Department of Anesthesiology, Division of Pediatric Anesthesiology, University of Michigan, C. S. Mott Children's Hospital, 1540 E. Hospital Drive, Ann Arbor, MI, 48109, USA
| | - K Kraft
- Department of Urology, Division of Pediatric Urology, University of Michigan, C. S. Mott Children's Hospital, 1540 E. Hospital Drive, Ann Arbor, MI, 48109, USA
| | - J Park
- Department of Urology, Division of Pediatric Urology, University of Michigan, C. S. Mott Children's Hospital, 1540 E. Hospital Drive, Ann Arbor, MI, 48109, USA
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Holman AE, Puglia MP. Loss of Corneal Reflex in Children Undergoing Spinal Anesthesia: A Case Series. A A Pract 2019; 14:9-11. [DOI: 10.1213/xaa.0000000000001127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Abstract
Anaesthesia for neonates is a composite of good knowledge of neonatal and transitional physiology combined with skill in airway maintenance and vascular access. When the newborn is a preterm, the complexities of management increase due to the small size and accompanying issues such as bronchopulmonary dysplasia and apnoea. World over, the number of survivors of preterm birth is on the increase. We searched Pubmed for "Anesthesia, apnea, neonatal, neonates, physiology, preterm, spinal anesthesia", as well as cross references from review articles. These babies have a high incidence of conditions warranting surgery (e.g., tracheoesophaeal fistula, congenital diaphragmatic hernia, anorectal malformations, incarcerated hernia, necrotising enterocolitis). The possibility of neurodevelopmental harm by anaesthetics is currently the topic of active research. In parallel, advances in paediatric anaesthesia equipment, use of regional and neuraxial anaesthesia and availability of monitoring have steadily increased the safety of anaesthesia in these tiny patients.
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Affiliation(s)
- Rajeshwari Subramaniam
- Department of Anesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
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Haydar B, Gray H, Holman A. Avoiding General Anesthesia in Treating Port-Wine Stains in Infants to Avoid Neurotoxic Events. JAMA Dermatol 2019; 155:983-984. [DOI: 10.1001/jamadermatol.2019.1780] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Bishr Haydar
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor
| | - Holly Gray
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor
| | - Ashlee Holman
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor
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Goel P, Jain S, Bajpai M, Khanna P, Jain V, Yadav DK. Does caudal analgesia increase the rates of urethrocutaneous fistula formation after hypospadias repair? Systematic review and meta-analysis. Indian J Urol 2019; 35:222-229. [PMID: 31367075 PMCID: PMC6639986 DOI: 10.4103/iju.iju_252_18] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Accepted: 06/21/2016] [Indexed: 01/07/2023] Open
Abstract
INTRODUCTION Caudal block analgesia is administered to lower the requirements of systemic and inhaled anesthetic drugs during hypospadias surgery. However, recent reports, all clustered in a short time-span have generated controversial and mutually opposing results while evaluating caudal block as an independent risk factor for urethroplasty-related complications after hypospadias repair. There is no consensus statement on the role of caudal block analgesia in formation of urethrocutaneous fistula (UCF) after hypospadias surgery. We performed a systematic review and meta-analysis of the studies evaluating the relative rates of UCF formation after hypospadias surgery in patients who were administered caudal block analgesia versus in those who were not. METHODS Electronic searches were performed using PubMed, PubMed Central, Google Scholar, Ovid, and the Cochrane library. Statistical analysis was performed using a fixed-effect model, odds ratios, risk ratios (RR), and heterogeneity (I2) were calculated. Funnel plot was used to assess for publication bias. RESULTS Seven studies with 1706 patients were included. Caudal block analgesia is associated with a significantly higher risk of UCF formation (RR: 1.81; 95% confidence interval [CI]: 1.30-2.53), (P = 0.0004) and other urethroplasty-related complications (RR 2.01; 95% CI: 1.48-2.74), (P < 0.00001) after hypospadias surgery. Funnel plots indicate some publication bias. CONCLUSIONS In patients undergoing hypospadias repair, administration of caudal analgesia is associated with a higher risk of UCF formation and other urethroplasty-related complications.
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Affiliation(s)
- Prabudh Goel
- Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Shikha Jain
- Department of Anesthesiology, All India Institute of Medical Sciences, New Delhi, India
| | - Minu Bajpai
- Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Puneet Khanna
- Department of Anesthesiology, All India Institute of Medical Sciences, New Delhi, India
| | - Vishesh Jain
- Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Devendra Kumar Yadav
- Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India
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Eizaga Rebollar R, García Palacios MV, Morales Guerrero J, Torres Morera LM. Spinal Anesthesia for Pediatric Laparoscopic Hernia Repair: A Case Report. A A Pract 2019; 11:293-295. [PMID: 29851688 DOI: 10.1213/xaa.0000000000000810] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Spinal anesthesia is practical and safe in infants and toddlers and prevents perioperative complications including cardiorespiratory instability and apnea. Other perioperative advantages include reduced time from surgery completion to operating room exit and first feed. This article presents the case of an ex-premature infant who underwent laparoscopic inguinal hernia repair under spinal anesthesia. The infant remained calm and stable throughout the uneventful procedure and postoperative period. Spinal anesthesia may be feasible for laparoscopic herniotomy when pneumoperitoneum pressure and operative time are restricted to 8 mm Hg and 60 minutes, respectively, with sensory level at T10 or higher.
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Affiliation(s)
- Ramón Eizaga Rebollar
- From the Department of Anesthesiology and Reanimation, Puerta de Mar University Hospital, Cádiz, Spain
| | | | - Javier Morales Guerrero
- From the Department of Anesthesiology and Reanimation, Puerta de Mar University Hospital, Cádiz, Spain
| | - Luis Miguel Torres Morera
- From the Department of Anesthesiology and Reanimation, Puerta de Mar University Hospital, Cádiz, Spain
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Dahmani S, Laudenbach V. Neurotoxicity of anaesthetics on developing brain: a relevant question or just a "bias"? Anaesth Crit Care Pain Med 2019; 38:329-330. [PMID: 31018161 DOI: 10.1016/j.accpm.2019.04.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Souhayl Dahmani
- Department of anaesthesia and intensive care, Robert-Debré University Hospital, assistance publique des Hôpitaux de Paris, 48, boulevard Serurier, 75019 Paris, France; Paris Diderot University (Paris VII). PRES Paris Sorbonne Cité, DHU PROTECT. Inserm U1141, Robert-Debré University Hospital, 75019 Paris, France.
| | - Vincent Laudenbach
- Department of neonatology and paediatric intensive care, Charles-Nicolle University Hospital, 1, rue de Germont, 76031 Rouen cedex, France
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Bong CL, Tan J, Lim S, Low Y, Sim SW, Rajadurai VS, Khoo PC, Allen J, Meaney M, Koh WP. Randomised controlled trial of dexmedetomidine sedation vs general anaesthesia for inguinal hernia surgery on perioperative outcomes in infants. Br J Anaesth 2019; 122:662-670. [PMID: 30916007 DOI: 10.1016/j.bja.2018.12.027] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 12/27/2018] [Accepted: 12/28/2018] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Neonates and infants undergoing general anaesthesia for hernia surgery are at risk of perioperative cardiorespiratory adverse events. The use of regional anaesthesia with dexmedetomidine preserves airway tone and may potentially avoid these complications. This study compares the perioperative conditions and adverse events between dexmedetomidine sedation with caudal block and general anaesthesia with caudal block for inguinal hernia surgery in infants. METHODS A randomised controlled trial was conducted in a tertiary hospital in Singapore involving 104 infants younger than 3 months, who were randomised to receive either dexmedetomidine sedation (DEX) with caudal block or general sevoflurane anaesthesia with tracheal intubation and caudal block (GA) for inguinal hernia surgery. Perioperative conditions, haemodynamics and adverse events were compared between groups. RESULTS Fifty-one infants received DEX and 48 infants received GA. In the DEX group, 46 infants (90.2%) had their operations completed solely under this technique, two (3.9%) were converted to general anaesthesia with intubation, and three (5.9%) required brief administration of nitrous oxide or low-dose sevoflurane. Overall, 96.1% of infants in the DEX group did not require intubation. Perioperative conditions were similar in both groups. The DEX group had significantly lower heart rates and higher mean arterial pressures intraoperatively. Two infants in the DEX group (3.9%) required postoperative intensive care admission compared with six infants (12.5%) in the GA group. CONCLUSIONS Dexmedetomidine sedation with caudal block provides a feasible alternative to general anaesthesia in infants undergoing hernia surgery. This technique avoids the need for tracheal intubation, which may be beneficial in neonates. CLINICAL TRIAL REGISTRATION NCT02559102.
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Affiliation(s)
- Choon L Bong
- Department of Paediatric Anaesthesia, KK Women's and Children's Hospital, Singapore.
| | - Josephine Tan
- Department of Paediatric Anaesthesia, KK Women's and Children's Hospital, Singapore
| | - Serene Lim
- Department of Paediatric Anaesthesia, KK Women's and Children's Hospital, Singapore
| | - Yee Low
- Department of Paediatric Surgery, KK Women's and Children's Hospital, Singapore
| | - Siam-Wee Sim
- Department of Paediatric Surgery, KK Women's and Children's Hospital, Singapore
| | - Victor S Rajadurai
- Department of Neonatology, KK Women's and Children's Hospital, Singapore
| | - Poh-Choo Khoo
- Department of Neonatology, KK Women's and Children's Hospital, Singapore
| | - John Allen
- Centre for Quantitative Medicine, Office of Clinical Sciences, Duke-NUS Medical School, Singapore
| | - Michael Meaney
- Singapore Institute for Clinical Sciences, Agency for Science, Technology and Research, Singapore; Department of Psychiatry and Neurology and Neurosurgery, McGill University, Montreal, QC, Canada
| | - Woon-Puay Koh
- Health Services and Systems Research, Duke-NUS Medical School, Singapore; Saw Swee Hock School of Public Health, National University of Singapore, Singapore
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Abstract
The article reviews frequently encountered preoperative concerns with a goal of minimizing complications during administration of pediatric anesthesia. It is written with general anesthesiologists in mind and provides a helpful overview of concerns for pediatric patient preparation for routine and nonemergent procedures or interventions. It covers unique topics for the pediatric population, including gestational age, respiratory and cardiovascular concerns, fasting guidelines, and management of preoperative anxiety, as well as the current hot topic of the potential neurotoxic effects of anesthetics on the developing brain.
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Affiliation(s)
- Allison Basel
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215, USA; Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Dusica Bajic
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA; Department of Anaesthesia, Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA.
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