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O'Reilly-Shah VN, Van Cleve W, Walters A, Hunyady AI, Morgan PG, Li L, Polaner DM. Hyperammonemia is associated with reduced objective anesthetic requirements in children: A retrospective case-control study. Paediatr Anaesth 2024; 34:374-376. [PMID: 38226795 DOI: 10.1111/pan.14839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 12/28/2023] [Accepted: 01/02/2024] [Indexed: 01/17/2024]
Affiliation(s)
- Vikas N O'Reilly-Shah
- Department of Anesthesiology & Pain Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - Wil Van Cleve
- Department of Anesthesiology & Pain Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - Andrew Walters
- Department of Anesthesiology & Pain Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - Agnes I Hunyady
- Department of Anesthesiology & Pain Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - Philip G Morgan
- Department of Anesthesiology & Pain Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - Li Li
- Department of Anesthesiology & Pain Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - David M Polaner
- Department of Anesthesiology & Pain Medicine, University of Washington School of Medicine, Seattle, Washington, USA
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Mandler TN, Gagliardi AG, Parikh HB, Austin TM, Yaster M, Polaner DM. Sterile techniques during regional anesthesia placement among pediatric anesthesiologists. Paediatr Anaesth 2023; 33:326-327. [PMID: 36441008 DOI: 10.1111/pan.14611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 10/26/2022] [Accepted: 11/17/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Tessa N Mandler
- Department of Pediatric Anesthesia, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Alexia G Gagliardi
- Department of Pediatric Anesthesia, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Harin B Parikh
- Department of Pediatric Anesthesia, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Thomas M Austin
- Department of Anesthesia, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Myron Yaster
- Departments of Anesthesiology, Critical Care Medicine and Pediatrics, The Johns Hopkins University, Baltimore, Maryland, USA
| | - David M Polaner
- University of Washington School of Medicine, Seattle, Washington, USA.,Seattle Children's Hospital, Seattle, Washington, USA
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Moguilevitch M, Polaner DM, Mann G, Mauner A, Beagley B, Hendrickse A, Stoll WD, DeMarchi L, Damian D, Sridhar S, Costandi A, Tran L, Jorge LM, Mandell MS. A comparison of pediatric liver transplant anesthesia practices with new organ procurement and transplant network pediatric policy requirements: A report from the society for the advancement of transplant anesthesia and the society for pediatric anesthesia. Clin Transplant 2022; 36:e14672. [PMID: 35443083 DOI: 10.1111/ctr.14672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 03/17/2022] [Accepted: 04/09/2022] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Organ Procurement and Transplant Network (OPTN) pediatric policies on knowledge and skill requirements for key personnel failed to address the Director of Anesthesia for Pediatric Liver Transplantation. A Joint Committee representing the Society for the Advancement of Transplant Anesthesia and Society for Pediatric Anesthesia (SPA) surveyed all pediatric anesthesia liver transplant practices to determine if practices were aligned with policies and what changes would be needed for compliance. METHODS A survey of the Director or equivalent at each program collected data about specialized knowledge and skill sets. Questions focused on (1) skill and knowledge of the Director and team, (2) requirements for appointment, (3) experience in pediatrics, and (4) characteristics of the program including the availability of pediatric resources. RESULTS Response rate was 73% (n = 63). Most responding programs had a Director (67%) with certification, selection committee, and continuing education credits outlined in existing policies. Team members met similar requirements. Alternate pathways for acquiring knowledge and skill sets were identified between programs. CONCLUSIONS Pediatric liver transplant anesthesiologists use knowledge and skill pathways that align with the new pediatric policies. We suggest that collaborative work with oversight agencies is needed to resolve high case volume requirements originally designed for adult programs. SUMMARY Most pediatric liver transplant anesthesiologists in the US have specialized knowledge and skills for expert care consistent with current oversight policies. Differences in pathways to acquire knowledge and skill sets were still aligned with the new policies for pediatric transplant surgeons and bylaws for the Director of Transplant Anesthesia. We conclude that minimal changes in case volume requirements to the existing Pediatric Transplant Anesthesiology Directorship criteria that authenticates the pediatric anesthesia Director's position would improve the safety of care without limiting access to transplantation.
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Affiliation(s)
- Marina Moguilevitch
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - David M Polaner
- Department of Anesthesiology and Pain Medicine, University of Washington and Seattle Children's Hospital, Seattle, Washington, USA
| | - Glenn Mann
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Aaron Mauner
- Department of Anesthesiology, University of Colorado, Aurora, Colorado, USA
| | - Britni Beagley
- Department of Anesthesiology, University of Colorado, Aurora, Colorado, USA
| | - Adrian Hendrickse
- Department of Anesthesiology, University of Colorado, Aurora, Colorado, USA
| | - William D Stoll
- Department of Anesthesiology, Medical University of South Carolina, Charlottesville, South Carolina, USA
| | - Lorenzo DeMarchi
- Department of Anesthesiology, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Daniela Damian
- Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Srikanth Sridhar
- Department of Anesthesiology, McGovern Medical School, University of Texas, Houston, Texas, USA
| | - Andrew Costandi
- Department of Anesthesiology Critical Care Medicine, Children's hospital Los Angeles, Keck School of Medicine, Los Angeles, California, USA
| | - Lieu Tran
- Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Lydia M Jorge
- Department of Anesthesiology, Jackson Health System, University of Miami, Miami, Florida, USA
| | - M Susan Mandell
- Department of Anesthesiology, University of Colorado, Aurora, Colorado, USA
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Polaner DM, Gregory G. Respiration-how did we get here? Paediatr Anaesth 2022; 32:97-98. [PMID: 35045217 DOI: 10.1111/pan.14363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 12/05/2021] [Indexed: 11/29/2022]
Affiliation(s)
- David M Polaner
- University of Washington School of Medicine, Seattle, Washington, USA.,Seattle Children's Hospital, Seattle, Washington, USA
| | - George Gregory
- School of Medicine, University of California, San Francisco, California, USA
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Bebic Z, Brooks Peterson M, Polaner DM. Respiratory physiology at high altitude and considerations for pediatric patients. Paediatr Anaesth 2022; 32:118-125. [PMID: 34919777 DOI: 10.1111/pan.14380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 12/03/2021] [Accepted: 12/06/2021] [Indexed: 11/29/2022]
Abstract
Over 150 million people, including many children, live at high altitude (>2500 m) with the majority residing in Asia and South America. With increases in elevation, the partial pressure of oxygen (pO2) is reduced, resulting in a hypobaric hypoxic environment. Fortunately, humans have evolved adaptive processes which serve to acclimate the body to such conditions. These mechanisms, occurring along a specific time course, result in tachypnea, tachycardia, diuresis, and hematopoiesis, and a shift in the oxygen dissociation curve favoring an increased affinity for oxygen. These, along with other physiological effects, including increased pulmonary vascular resistance, alterations in cerebral blood flow, and changes in sensitivity to opioids, must be considered when administering anesthesia at high altitudes. Susceptible individuals or those who ascend too quickly may outpace the body's ability to acclimate resulting in one or more forms of high-altitude sickness ranging from the milder acute mountain sickness to the more serious conditions of high-altitude pulmonary edema and cerebral edema, either of which can be life-threatening if not promptly recognized and treated. Since the adaptive mechanisms for acclimatization greatly affect the cardiopulmonary systems, patients with underlying health issues such as sleep apnea, congenital heart disease, and asthma may have susceptibilities and warrant special consideration. Clinicians should have an understanding of the physiologic adaptations, anesthetic considerations, and special concerns in these populations in order to offer the best care possible.
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Affiliation(s)
- Zvonimir Bebic
- Department of Anesthesiology, University of Colorado/Children's Hospital Colorado, Aurora, Colorado, USA
| | - Melissa Brooks Peterson
- Department of Anesthesiology, University of Colorado/Children's Hospital Colorado, Aurora, Colorado, USA
| | - David M Polaner
- Children's Hospital, University of Washington School of Medicine, Seattle, Washington, USA
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Masaracchia MM, Sunder RA, Polaner DM. Error traps in pediatric regional anesthesia. Paediatr Anaesth 2021; 31:1161-1169. [PMID: 34396637 DOI: 10.1111/pan.14275] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 08/06/2021] [Accepted: 08/10/2021] [Indexed: 11/30/2022]
Abstract
Ultrasound-guided nerve blocks have revolutionized the way we provide regional anesthesia. By providing effective perioperative pain control, regional anesthesia reduces opioid consumption, decreases length of stay, and increases patient/parental satisfaction. However, error traps (circumstances that lead to erroneous actions) can defeat its inherent benefits and may result in adverse outcomes. This article focuses on promoting a culture of safety by highlighting five common avoidable error traps encountered while providing regional anesthesia for pediatric patients. They include failure to confirm intended block site, failure to optimize ultrasound images and identify artifacts, failure to recognize when regional anesthesia is an acceptable option, failure to implement alternative imaging techniques when anatomy is challenging, and failure to recognize disease states with abnormal anatomy that may require alternative blocks. These issues are easily addressed if the pediatric regionalist is cognizant of the appropriate ways to mitigate them, and, as such, we review strategies to avoid them.
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Affiliation(s)
- Melissa M Masaracchia
- Department of Anesthesiology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, USA
| | - Rani A Sunder
- Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA, USA
| | - David M Polaner
- Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA, USA
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Taenzer AH, Herrick M, Hoyt M, Ramamurthi RJ, Walker B, Flack SH, Bosenberg A, Franklin A, Polaner DM. Variation in pediatric local anesthetic dosing for peripheral nerve blocks: an analysis from the Pediatric Regional Anesthesia Network (PRAN). Reg Anesth Pain Med 2020; 45:964-969. [DOI: 10.1136/rapm-2020-101720] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 07/23/2020] [Accepted: 07/29/2020] [Indexed: 11/04/2022]
Abstract
BackgroundVariation of local anesthetic dosing has been reported for adult peripheral nerve blocks (PNBs) and infant caudal blocks. As higher doses of local anesthetics (LA) are potentially associated with increased risk of complications (eg, local anesthetic systemic toxicity), it is important to understand the source of LA dose variation. Using the Pediatric Regional Anesthesia Network (PRAN) database, we aimed to determine if variation in dosing exists in pediatric single-injection PNBs, and what factors influence that variation.The primary aim of this study was to determine the factors associated with dosing for the 10 most commonly performed PNBs, with the secondary aim of exploring possible factors for variation such as number of blocks performed versus geographic location.MethodsThe PRAN database was used to determine the 10 most common pediatric PNBs, excluding neuraxial regional anesthetics. The 10 most common pediatric PNBs in the PRAN database were analyzed for variation of LA dose and causes for variation.ResultsIn a cohort of 34 514 children receiving PNBs, the mean age was 10.38 (+/-5.23) years, average weight was 44.88 (+/-26.66) kg and 61.8% were men. The mean bupivacaine equivalent (BE) dose was 0.86 (+/-0.5) mg kg−1 and ropivacaine was used in 65.4% of blocks. Dose decreases with age (estimate −0.016 (−0.017, –0.015; p<0.001)). In all blocks for all age groups, the range of doses that make up the central 80% of all doses exceeds the mean BE dose for the block. Variation is not related to the number blocks performed at an institution (p=0.33 (CI −0.42 to 0.15)). The dose administered for a PNB is driven in order of impact by the institution where the block was performed (Cohen’s ƒ=0.45), then by weight (0.31), type of block (0.27), LA used (0.15) and age (0.03).ConclusionsConsiderable variation in dosing exists in all age groups and in all block types. The most impactful driver of local anesthetic dose is the institution where the block was performed, indicating the dosing of a potentially lethal drug is more based on local culture than on evidence.
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Taenzer AH, Hoyt M, Krane EJ, Walker BJ, Flack S, Bosenberg A, Sethna NF, Franklin AD, Polaner DM. Variation Between and Within Hospitals in Single Injection Caudal Local Anesthetic Dose. Anesth Analg 2020; 130:1693-1701. [DOI: 10.1213/ane.0000000000004447] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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McCann ME, de Graaff JC, Dorris L, Disma N, Withington D, Bell G, Grobler A, Stargatt R, Hunt RW, Sheppard SJ, Marmor J, Giribaldi G, Bellinger DC, Hartmann PL, Hardy P, Frawley G, Izzo F, von Ungern Sternberg BS, Lynn A, Wilton N, Mueller M, Polaner DM, Absalom AR, Szmuk P, Morton N, Berde C, Soriano S, Davidson AJ. Neurodevelopmental outcome at 5 years of age after general anaesthesia or awake-regional anaesthesia in infancy (GAS): an international, multicentre, randomised, controlled equivalence trial. Lancet 2019; 393:664-677. [PMID: 30782342 PMCID: PMC6500739 DOI: 10.1016/s0140-6736(18)32485-1] [Citation(s) in RCA: 370] [Impact Index Per Article: 74.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Revised: 09/27/2018] [Accepted: 10/03/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND In laboratory animals, exposure to most general anaesthetics leads to neurotoxicity manifested by neuronal cell death and abnormal behaviour and cognition. Some large human cohort studies have shown an association between general anaesthesia at a young age and subsequent neurodevelopmental deficits, but these studies are prone to bias. Others have found no evidence for an association. We aimed to establish whether general anaesthesia in early infancy affects neurodevelopmental outcomes. METHODS In this international, assessor-masked, equivalence, randomised, controlled trial conducted at 28 hospitals in Australia, Italy, the USA, the UK, Canada, the Netherlands, and New Zealand, we recruited infants of less than 60 weeks' postmenstrual age who were born at more than 26 weeks' gestation and were undergoing inguinal herniorrhaphy, without previous exposure to general anaesthesia or risk factors for neurological injury. Patients were randomly assigned (1:1) by use of a web-based randomisation service to receive either awake-regional anaesthetic or sevoflurane-based general anaesthetic. Anaesthetists were aware of group allocation, but individuals administering the neurodevelopmental assessments were not. Parents were informed of their infants group allocation upon request, but were told to mask this information from assessors. The primary outcome measure was full-scale intelligence quotient (FSIQ) on the Wechsler Preschool and Primary Scale of Intelligence, third edition (WPPSI-III), at 5 years of age. The primary analysis was done on a per-protocol basis, adjusted for gestational age at birth and country, with multiple imputation used to account for missing data. An intention-to-treat analysis was also done. A difference in means of 5 points was predefined as the clinical equivalence margin. This completed trial is registered with ANZCTR, number ACTRN12606000441516, and ClinicalTrials.gov, number NCT00756600. FINDINGS Between Feb 9, 2007, and Jan 31, 2013, 4023 infants were screened and 722 were randomly allocated: 363 (50%) to the awake-regional anaesthesia group and 359 (50%) to the general anaesthesia group. There were 74 protocol violations in the awake-regional anaesthesia group and two in the general anaesthesia group. Primary outcome data for the per-protocol analysis were obtained from 205 children in the awake-regional anaesthesia group and 242 in the general anaesthesia group. The median duration of general anaesthesia was 54 min (IQR 41-70). The mean FSIQ score was 99·08 (SD 18·35) in the awake-regional anaesthesia group and 98·97 (19·66) in the general anaesthesia group, with a difference in means (awake-regional anaesthesia minus general anaesthesia) of 0·23 (95% CI -2·59 to 3·06), providing strong evidence of equivalence. The results of the intention-to-treat analysis were similar to those of the per-protocol analysis. INTERPRETATION Slightly less than 1 h of general anaesthesia in early infancy does not alter neurodevelopmental outcome at age 5 years compared with awake-regional anaesthesia in a predominantly male study population. FUNDING US National Institutes of Health, US Food and Drug Administration, Thrasher Research Fund, Australian National Health and Medical Research Council, Health Technologies Assessment-National Institute for Health Research (UK), Australian and New Zealand College of Anaesthetists, Murdoch Children's Research Institute, Canadian Institutes of Health Research, Canadian Anesthesiologists Society, Pfizer Canada, Italian Ministry of Health, Fonds NutsOhra, UK Clinical Research Network, Perth Children's Hospital Foundation, the Stan Perron Charitable Trust, and the Callahan Estate.
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Affiliation(s)
- Mary Ellen McCann
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Jurgen C de Graaff
- Department of Anaesthesiology, Erasmus Medical Centre, Rotterdam, Netherlands; Department of Anaesthesiology, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Liam Dorris
- Paediatric Neurosciences, Royal Hospital for Children, Glasgow, Scotland, UK; Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Nicola Disma
- Department of Anaesthesia, Istituto Giannina Gaslini, Genoa, Italy
| | - Davinia Withington
- Department of Anaesthesia, Montreal Children's Hospital, Montreal, QC, Canada; Department of Anaesthesia, McGill University, Montreal, QC, Canada
| | - Graham Bell
- Department of Anaesthesia, Royal Hospital for Children, Glasgow, Scotland, UK
| | - Anneke Grobler
- Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Parkville, VIC, Australia; Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia
| | - Robyn Stargatt
- Child Neuropsychology, Murdoch Children's Research Institute, Parkville, VIC, Australia; School of Psychological Science, La Trobe University, Melbourne, Victoria, Australia
| | - Rodney W Hunt
- Neonatal Research Group, Murdoch Children's Research Institute, Parkville, VIC, Australia; Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia; Department of Neonatal Medicine, The Royal Children's Hospital, Melbourne, VIC, Australia
| | - Suzette J Sheppard
- Anaesthesia and Pain Management Research Group, Murdoch Children's Research Institute, Parkville, VIC, Australia
| | - Jacki Marmor
- Department of Neurology, Boston Children's Hospital, Boston, MA, USA
| | - Gaia Giribaldi
- Department of Anaesthesia, Istituto Giannina Gaslini, Genoa, Italy
| | - David C Bellinger
- Department of Neurology, Boston Children's Hospital, Boston, MA, USA
| | - Penelope L Hartmann
- Anaesthesia and Pain Management Research Group, Murdoch Children's Research Institute, Parkville, VIC, Australia; School of Behavioural and Health Sciences, Australian Catholic University, Melbourne, VIC, Australia
| | - Pollyanna Hardy
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Geoff Frawley
- Anaesthesia and Pain Management Research Group, Murdoch Children's Research Institute, Parkville, VIC, Australia; Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia; Department of Anaesthesia and Pain Management, The Royal Children's Hospital, Melbourne, VIC, Australia
| | - Francesca Izzo
- Department of Anaesthesiology and Paediatric Intensive Care, Ospedale Pediatrico Vittore Buzzi, Milan, Italy
| | - Britta S von Ungern Sternberg
- Medical School, The University of Western Australia, Perth, WA, Australia; Department of Anaesthesia and Pain Management, Perth Children's Hospital, Perth, WA, Australia; Telethon Kid's Institute, Perth, WA, Australia
| | - Anne Lynn
- Department of Anesthesiology and Pain Medicine, and Pediatrics University of Washington, Seattle, WA, USA; Department of Anaesthesia and Pain Medicine, Seattle Children's Hospital, Seattle, WA, USA
| | - Niall Wilton
- Department of Paediatric Anaesthesia and Operating Rooms, Starship Children's Hospital, Auckland District Health Board, Auckland, New Zealand
| | - Martin Mueller
- Department of Anaesthesia, The University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - David M Polaner
- Department of Anaesthesiology, Children's Hospital Colorado, Denver, CO, USA; Department of Anaesthesiology, University of Colorado, Denver, CO, USA
| | - Anthony R Absalom
- Department of Anaesthesiology, University Medical Centre Groningen, Groningen University, Groningen, Netherlands
| | - Peter Szmuk
- Department of Anesthesiology and Pain Management, University of Texas Southwestern and Children's Medical Centre Dallas, Dallas, TX, USA; Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
| | - Neil Morton
- Department of Anaesthesia, Royal Hospital for Children, Glasgow, Scotland, UK; Academic Unit of Anaesthesia, Pain and Critical Care, University of Glasgow, Glasgow, UK
| | - Charles Berde
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Sulpicio Soriano
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Andrew J Davidson
- Anaesthesia and Pain Management Research Group, Murdoch Children's Research Institute, Parkville, VIC, Australia; Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia; Department of Anaesthesia and Pain Management, The Royal Children's Hospital, Melbourne, VIC, Australia.
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Szolnoki J, Polaner DM, Eckle T. Diurnal variations in recovery times after general anaesthesia in children. Br J Anaesth 2018; 121:776-786. [PMID: 30236240 PMCID: PMC6617965 DOI: 10.1016/j.bja.2018.06.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 06/14/2018] [Accepted: 06/14/2018] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Circadian rhythms coordinate almost all physiological functions and are implicated in major disease development. Even though circadian rhythms have a major impact on human health, little is known about how they affect general anaesthesia. The purpose of this study was to understand if the time of day affects the length of time a child needs to achieve readiness for discharge after general anaesthesia for brain MRI. METHODS A retrospective analysis over a 3 yr period (2013-5) on the length of stay in the postanaesthesia care unit (PACU) before discharge was performed for children (age <18 yr) undergoing brain magnetic resonance imaging as outpatients. PACU duration was correlated to either morning vs afternoon or to time clusters for discharge times (<9 AM, >9 AM <12 PM, >12 PM <3 PM, >3 PM <6 PM, >6 PM). RESULTS Data from 2340 procedures in children, with median age [inter-quartile range (range)] of 4.7 [2.3-7.25 (0.5-17.8)] yr were available for analysis. The length of stay in the PACU significantly increased over the course of the day with an observed maximum increase of 18 or 19 min (<9 AM vs >6 PM) in children older than 3 or 5 yr, respectively. Subgroup analysis suggested time of day dependent PACU time increase was independent of sex, co-medications, or obstructive sleep apnoea. CONCLUSION The time of day significantly affects PACU recovery times in children of both genders having brain imaging under general anaesthesia. Children younger than 3 yr might not be affected. Further validation of these findings may guide future strategies to reduce discharge times.
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Affiliation(s)
- J Szolnoki
- Department of Anaesthesiology, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA; Department of Anaesthesiology, Children's Hospital Colorado, Aurora, CO, USA
| | - D M Polaner
- Department of Anaesthesiology, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA; Department of Anaesthesiology, Children's Hospital Colorado, Aurora, CO, USA
| | - T Eckle
- Department of Anaesthesiology, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA.
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Scholes MA, Jensen EL, Polaner DM, Gao D. Multiple surgeries in pediatric otolaryngology patients and associated anesthesia risks. Int J Pediatr Otorhinolaryngol 2018; 113:115-118. [PMID: 30173968 DOI: 10.1016/j.ijporl.2018.07.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 06/01/2018] [Accepted: 07/09/2018] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To determine the risk of healthy children undergoing tympanostomy tubes of an additional surgery prior to age three and associated risk factors. METHODS A retrospective chart review of pediatric patients at a tertiary metropolitan children's hospital who underwent tympanostomy tube insertion procedure before age of three from January 2010 through March 2015. We determined patient demographics, indication for tympanostomy tube insertion, as well as information about additional procedures requiring general anesthesia before the age of three years. A prospective telephone interview was also performed on a portion of the study population to assess if there were additional surgeries before the age of three that did not occur at our institution. RESULTS In our institution there was a 13% risk of getting an additional surgery after tympanostomy tubes in children who are otherwise healthy. The most common second procedure was an otolaryngologic procedure in 77.8% of the cases. Children with a diagnosis of recurrent acute otitis media had a threefold greater chance of getting an additional surgery than those with a diagnosis of chronic otitis media with effusion. Patients that identified as Black or African American were 3.2 times more likely to have additional surgery. With every year increase at age of surgery, the odds of an additional surgery decreased by 77%. CONCLUSIONS In healthy children undergoing tympanostomy tube insertion at our institution, the incidence of additional procedures under general anesthesia (GA) is low at 13%. Although there is evidence of possible deleterious effects of anesthesia on the developing brain, it is generally accepted that one short (≤1 h) anesthetic exposure under the age of three has not been associated with adverse neurodevelopmental outcomes. As a specialty that regularly performs procedures on young children, we need to be aware of the possible effects of anesthetic agents on our patients. However, this study shows that the exposure risk is low and should help reassure patient's families.
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Affiliation(s)
- Melissa A Scholes
- Department of Otolaryngology, University of Colorado School of Medicine, Aurora, CO, USA; Department of Pediatric Otolaryngology, Children's Hospital Colorado, Aurora, CO, USA.
| | - Emily L Jensen
- Department of Otolaryngology, University of Colorado School of Medicine, Aurora, CO, USA; Department of Pediatric Otolaryngology, Children's Hospital Colorado, Aurora, CO, USA
| | - David M Polaner
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA; Department of Anesthesiology, Children's Hospital Colorado, Aurora, CO, USA
| | - Dexiang Gao
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
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Abstract
Improvements in anesthetic drugs and monitoring techniques over the past several decades have significantly reduced the anesthetic risks for pediatric patients. Neonates and infants are at increased risk for cardiovascular and pulmonary complications, and recent reports have led to concern that these young patients may be at risk for long-term detrimental neurodevelopmental effects as well. Although studies are currently under way to answer the question of anesthetic neurotoxicity in children, surgeons and anesthesiologists must work with parents to determine the best course of action for these vulnerable patients.
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Affiliation(s)
- Megan A Brockel
- Department of Anesthesiology, University of Colorado, Children's Hospital Colorado, Anschutz Medical Campus, 13123 East 16th Avenue, Aurora, CO 80045, USA.
| | - David M Polaner
- Department of Anesthesiology, University of Colorado, Children's Hospital Colorado, Anschutz Medical Campus, 13123 East 16th Avenue, Aurora, CO 80045, USA
| | - Vijaya M Vemulakonda
- Department of Urology, University of Colorado, Children's Hospital Colorado, Anschutz Medical Campus, 13123 East 16th Avenue, Aurora, CO 80045, USA
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Masaracchia MM, Polaner DM, Prager JD, DeBoer EM, Dewberry LC, Somme S, Wine T, Janosy NR. Pediatric tracheomalacia and the perioperative anesthetic management of thoracoscopic posterior tracheopexy. Paediatr Anaesth 2018; 28:768-773. [PMID: 29962064 DOI: 10.1111/pan.13420] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/19/2018] [Indexed: 12/25/2022]
Abstract
Tracheomalacia is a broad term used to describe an abnormally compliant trachea that can lead to exaggerated collapse and obstruction with expiration. We describe the perioperative management of a complex pediatric patient undergoing a posterior tracheopexy which is a relatively new surgical treatment, with a novel surgical approach-thoracoscopy. This procedure has competing surgical and anesthetic needs and presents unique challenges to the physicians involved in caring for these patients. We also review the current literature on pediatric tracheomalacia and examine the newest treatment options to highlight the potential anesthetic challenges and pitfalls associated with management.
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Affiliation(s)
- Melissa M Masaracchia
- Department of Anesthesiology, Section of Pediatric Anesthesiology, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
| | - David M Polaner
- Department of Anesthesiology, Section of Pediatric Anesthesiology, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
| | - Jeremy D Prager
- Department of Otolaryngology, Pediatric Otolaryngology, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
| | - Emily M DeBoer
- Department of Pediatrics, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
| | - Lindel C Dewberry
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Stig Somme
- Department of Surgery, Division of Pediatric Surgery, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
| | - Todd Wine
- Department of Otolaryngology, Pediatric Otolaryngology, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
| | - Norah R Janosy
- Department of Anesthesiology, Section of Pediatric Anesthesiology, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
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Bartels DD, McCann ME, Davidson AJ, Polaner DM, Whitlock EL, Bateman BT. Estimating pediatric general anesthesia exposure: Quantifying duration and risk. Paediatr Anaesth 2018; 28:520-527. [PMID: 29722100 PMCID: PMC6291204 DOI: 10.1111/pan.13391] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/28/2018] [Indexed: 01/14/2023]
Abstract
INTRODUCTION Understanding the duration of pediatric general anesthesia exposure in contemporary practice is important for identifying groups at risk for long general anesthesia exposures and designing trials examining associations between general anesthesia exposure and neurodevelopmental outcomes. METHODS We performed a retrospective cohort analysis to estimate pediatric general anesthesia exposure duration during 2010-2015 using the National Anesthesia Clinical Outcomes Registry. RESULTS A total of 1 548 021 pediatric general anesthetics were included. Median general anesthesia duration was 57 minutes (IQR: 28-86) with 90th percentile 145 minutes. Children aged <1 year had the longest median exposure duration (79 minutes, IQR: 39-119) with 90th percentile 210 minutes, and 13.7% of this very young cohort was exposed for >3 hours. High ASA physical status and care at a university hospital were associated with longer exposure times. CONCLUSION While the vast majority (94%) of children undergoing general anesthesia are exposed for <3 hours, certain groups may be at increased risk for longer exposures. These findings may help guide the design of future trials aimed at understanding neurodevelopmental impact of prolonged exposure in these high-risk groups.
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Affiliation(s)
- Devan Darby Bartels
- Massachusetts General Hospital, Department of Anesthesia, Critical Care, and Pain Medicine, Boston, United States
| | - Mary Ellen McCann
- Boston Children’s Hospital, Department of Anesthesia, Boston, United States
| | - Andrew J. Davidson
- Royal Children’s Hospital, Department of Anaesthesia and Pain Management, Melbourne, Australia
| | - David M. Polaner
- University of Colorado School of Medicine and Children’s Hospital Colorado, Departments of Anesthesia and Pediatrics, Aurora, United States
| | - Elizabeth L. Whitlock
- University of California, San Francisco, Department of Anesthesia and Perioperative Care, San Francisco, United States
| | - Brian T. Bateman
- The Department of Anesthesiology, Perioperative and Pain Medicine; Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine; Brigham and Women’s Hospital and Harvard Medical School, United States
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16
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McCann ME, Withington DE, Arnup SJ, Davidson AJ, Disma N, Frawley G, Morton NS, Bell G, Hunt RW, Bellinger DC, Polaner DM, Leo A, Absalom AR, von Ungern-Sternberg BS, Izzo F, Szmuk P, Young V, Soriano SG, de Graaff JC. Differences in Blood Pressure in Infants After General Anesthesia Compared to Awake Regional Anesthesia (GAS Study-A Prospective Randomized Trial). Anesth Analg 2017; 125:837-845. [PMID: 28489641 DOI: 10.1213/ane.0000000000001870] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The General Anesthesia compared to Spinal anesthesia (GAS) study is a prospective randomized, controlled, multisite, trial designed to assess the influence of general anesthesia (GA) on neurodevelopment at 5 years of age. A secondary aim obtained from the blood pressure data of the GAS trial is to compare rates of intraoperative hypotension after anesthesia and to identify risk factors for intraoperative hypotension. METHODS A total of 722 infants ≤60 weeks postmenstrual age undergoing inguinal herniorrhaphy were randomized to either bupivacaine regional anesthesia (RA) or sevoflurane GA. Exclusion criteria included risk factors for adverse neurodevelopmental outcome and infants born at <26 weeks of gestation. Moderate hypotension was defined as mean arterial pressure measurement of <35 mm Hg. Any hypotension was defined as mean arterial pressure of <45 mm Hg. Epochs were defined as 5-minute measurement periods. The primary outcome was any measured hypotension <35 mm Hg from start of anesthesia to leaving the operating room. This analysis is reported primarily as intention to treat (ITT) and secondarily as per protocol. RESULTS The relative risk of GA compared with RA predicting any measured hypotension of <35 mm Hg from the start of anesthesia to leaving the operating room was 2.8 (confidence interval [CI], 2.0-4.1; P < .001) by ITT analysis and 4.5 (CI, 2.7-7.4, P < .001) as per protocol analysis. In the GA group, 87% and 49%, and in the RA group, 41% and 16%, exhibited any or moderate hypotension by ITT, respectively. In multivariable modeling, group assignment (GA versus RA), weight at the time of surgery, and minimal intraoperative temperature were risk factors for hypotension. Interventions for hypotension occurred more commonly in the GA group compared with the RA group (relative risk, 2.8, 95% CI, 1.7-4.4 by ITT). CONCLUSIONS RA reduces the incidence of hypotension and the chance of intervention to treat it compared with sevoflurane anesthesia in young infants undergoing inguinal hernia repair.
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Affiliation(s)
- M E McCann
- From the *Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts; †Department of Anesthesia, Montreal Children's Hospital, Montreal, Canada; ‡Department of Anesthesia, McGill University, Montreal, Canada; §Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Melbourne, Victoria, Australia; ‖Anaesthesia and Pain Management Research Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia; ¶Department of Anaesthesia and Pain Management, the Royal Children's Hospital, Melbourne, Victoria, Australia; #Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia; **Department of Anaesthesia, Istituto Giannina Gaslini, Genoa, Italy; ††Academic Unit of Anaesthesia, Pain and Critical Care, University of Glasgow, Glasgow, United Kingdom; ‡‡Department of Anaesthesia, Royal Hospital for Sick Children, Glasgow, United Kingdom; §§Department of Neonatal Medicine, The Royal Children's Hospital, Melbourne, Victoria, Australia; ‖‖Neonatal Research Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia; ¶¶Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts; ##Department of Psychiatry, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts; ***Department of Environmental Health, Harvard T. H. Chan School of Public Health, Boston, Massachusetts; †††Departments of Anesthesiology and Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado; ‡‡‡Department of Anaesthesia, Royal Children's Hospital, Melbourne, Australia; §§§University Medical Center Groningen, Groningen University, the Netherlands; ‖‖‖Pharmacology, Pharmacy, Anaesthesiology Unit, School of Medicine and Pharmacology, the University of Western Australia, Perth, Western Australia, Australia; ¶¶¶Department of Anaesthesia and Pain Management, Princess Margaret Hospital for Children, Perth, Western Australia, Australia; ###Department of Anaesthesiology and Intensive Care, Paediatric Intensive Care Unit Children Hospital 'Vittore Buzzi', Milano, Italy; ****Department of Anesthesiology and Pain Management, University of Texas Southwestern and Children's Health Medical Center, Dallas, Texas; ††††Outcome Research Consortium, Cleveland, Ohio; ‡‡‡‡Department of Anaesthesiology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, the Netherlands; §§§§Brain Center Rudolph Magnus, University Medical Centre Utrecht, the Netherlands; and ‖‖‖‖Department of Anesthesia, Sophia Children's Hospital, Erasmus Medical Center Rotterdam, the Netherlands
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Affiliation(s)
- David M Polaner
- Departments of Anesthesiology and Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | | | - Vijaya Vemulakonda
- Department of Urology, Division of Pediatric Urology, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
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Affiliation(s)
- David M Polaner
- Departments of Anesthesiology and Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO 80045, USA.
| | - Jeannie Zuk
- Departments of Surgery and Anesthesiology, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO 80045, USA
| | - Mary Ellen McCann
- Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Andrew Davidson
- Anaesthesia and Pain Management Research Group, Murdoch Children's Research Institute, Department of Anaesthesia and Pain Management and Department of Paediatrics, The Royal Children's Hospital and University of Melbourne, Melbourne, VIC, Australia
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Lawley JS, Levine BD, Williams MA, Malm J, Eklund A, Polaner DM, Subudhi AW, Hackett PH, Roach RC. Cerebral spinal fluid dynamics: effect of hypoxia and implications for high-altitude illness. J Appl Physiol (1985) 2016; 120:251-62. [DOI: 10.1152/japplphysiol.00370.2015] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Accepted: 08/17/2015] [Indexed: 12/24/2022] Open
Abstract
The pathophysiology of acute mountain sickness and high-altitude cerebral edema, the cerebral forms of high-altitude illness, remain uncertain and controversial. Persistently elevated or pathological fluctuations in intracranial pressure are thought to cause symptoms similar to those reported by individuals suffering cerebral forms of high-altitude illness. This review first focuses on the basic physiology of the craniospinal system, including a detailed discussion of the long-term and dynamic regulation of intracranial pressure. Thereafter, we critically examine the available literature, based primarily on invasive pressure monitoring, that suggests intracranial pressure is acutely elevated at altitude due to brain swelling and/or elevated sagittal sinus pressure, but normalizes over time. We hypothesize that fluctuations in intracranial pressure occur around a slightly elevated or normal mean intracranial pressure, in conjunction with oscillations in arterial Po2 and arterial blood pressure. Then these modest fluctuations in intracranial pressure, in concert with direct vascular stretch due to dilatation and/or increased blood pressure transmission, activate the trigeminal vascular system and cause symptoms of acute mountain sickness. Elevated brain water (vasogenic edema) may be due to breakdown of the blood-brain barrier. However, new information suggests cerebral spinal fluid flux into the brain may be an important factor. Regardless of the source (or mechanisms responsible) for the excess brain water, brain swelling occurs, and a “tight fit” brain would be a major risk factor to produce symptoms; activities that produce large changes in brain volume and cause fluctuations in blood pressure are likely contributing factors.
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Affiliation(s)
- Justin S. Lawley
- Institute for Exercise and Environmental Medicine, Presbyterian Hospital of Dallas, Dallas, Texas
- UT Southwestern Medical Center, Dallas, Texas
| | - Benjamin D. Levine
- Institute for Exercise and Environmental Medicine, Presbyterian Hospital of Dallas, Dallas, Texas
- UT Southwestern Medical Center, Dallas, Texas
| | - Michael A. Williams
- Sandra and Malcolm Berman Brain & Spine Institute, Dept. of Neurology, Sinai Hospital, Baltimore, Maryland
| | - Jon Malm
- Department of Clinical Neuroscience, Umeå University, Umeå, Sweden
| | - Anders Eklund
- Department of Radiation Sciences, Umeå University, Umeå, Sweden
| | - David M. Polaner
- Departments of Anesthesiology and Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, Colorado
| | - Andrew W. Subudhi
- Department of Biology, University of Colorado, Colorado Springs, Colorado
- Altitude Research Center, Department of Emergency Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado; and
| | | | - Robert C. Roach
- Altitude Research Center, Department of Emergency Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado; and
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Fiadjoe JE, Nishisaki A, Jagannathan N, Hunyady AI, Greenberg RS, Reynolds PI, Matuszczak ME, Rehman MA, Polaner DM, Szmuk P, Nadkarni VM, McGowan FX, Litman RS, Kovatsis PG. Airway management complications in children with difficult tracheal intubation from the Pediatric Difficult Intubation (PeDI) registry: a prospective cohort analysis. The Lancet Respiratory Medicine 2016; 4:37-48. [DOI: 10.1016/s2213-2600(15)00508-1] [Citation(s) in RCA: 234] [Impact Index Per Article: 29.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Revised: 11/25/2015] [Accepted: 11/26/2015] [Indexed: 12/17/2022]
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Abstract
The American Academy of Pediatrics proposes guidance for the pediatric perioperative anesthesia environment. Essential components are identified to optimize the perioperative environment for the anesthetic care of infants and children. Such an environment promotes the safety and well-being of infants and children by reducing the risk of adverse events.
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22
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Subudhi AW, Bourdillon N, Bucher J, Davis C, Elliott JE, Eutermoster M, Evero O, Fan JL, Houten SJV, Julian CG, Kark J, Kark S, Kayser B, Kern JP, Kim SE, Lathan C, Laurie SS, Lovering AT, Paterson R, Polaner DM, Ryan BJ, Spira JL, Tsao JW, Wachsmuth NB, Roach RC. AltitudeOmics: the integrative physiology of human acclimatization to hypobaric hypoxia and its retention upon reascent. PLoS One 2014; 9:e92191. [PMID: 24658407 PMCID: PMC3962396 DOI: 10.1371/journal.pone.0092191] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2013] [Accepted: 02/19/2014] [Indexed: 11/19/2022] Open
Abstract
An understanding of human responses to hypoxia is important for the health of millions of people worldwide who visit, live, or work in the hypoxic environment encountered at high altitudes. In spite of dozens of studies over the last 100 years, the basic mechanisms controlling acclimatization to hypoxia remain largely unknown. The AltitudeOmics project aimed to bridge this gap. Our goals were 1) to describe a phenotype for successful acclimatization and assess its retention and 2) use these findings as a foundation for companion mechanistic studies. Our approach was to characterize acclimatization by measuring changes in arterial oxygenation and hemoglobin concentration [Hb], acute mountain sickness (AMS), cognitive function, and exercise performance in 21 subjects as they acclimatized to 5260 m over 16 days. We then focused on the retention of acclimatization by having subjects reascend to 5260 m after either 7 (n = 14) or 21 (n = 7) days at 1525 m. At 16 days at 5260 m we observed: 1) increases in arterial oxygenation and [Hb] (compared to acute hypoxia: PaO2 rose 9±4 mmHg to 45±4 while PaCO2 dropped a further 6±3 mmHg to 21±3, and [Hb] rose 1.8±0.7 g/dL to 16±2 g/dL; 2) no AMS; 3) improved cognitive function; and 4) improved exercise performance by 8±8% (all changes p<0.01). Upon reascent, we observed retention of arterial oxygenation but not [Hb], protection from AMS, retention of exercise performance, less retention of cognitive function; and noted that some of these effects lasted for 21 days. Taken together, these findings reveal new information about retention of acclimatization, and can be used as a physiological foundation to explore the molecular mechanisms of acclimatization and its retention.
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Affiliation(s)
- Andrew W. Subudhi
- Altitude Research Center, Department of Emergency Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States of America
- Department of Biology, University of Colorado Colorado Springs, Colorado Springs, Colorado, United States of America
| | - Nicolas Bourdillon
- Institute of Sports Sciences and Department of Physiology, Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Jenna Bucher
- Department of Human Physiology, University of Oregon, Eugene, Oregon, United States of America
| | - Christopher Davis
- Altitude Research Center, Department of Emergency Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States of America
| | - Jonathan E. Elliott
- Department of Human Physiology, University of Oregon, Eugene, Oregon, United States of America
| | - Morgan Eutermoster
- Altitude Research Center, Department of Emergency Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States of America
| | - Oghenero Evero
- Altitude Research Center, Department of Emergency Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States of America
| | - Jui-Lin Fan
- Institute of Sports Sciences and Department of Physiology, Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
- Lemanic Doctoral School of Neuroscience, University of Lausanne, Lausanne, Switzerland
| | - Sonja Jameson-Van Houten
- Altitude Research Center, Department of Emergency Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States of America
| | - Colleen G. Julian
- Altitude Research Center, Department of Emergency Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States of America
| | - Jonathan Kark
- Altitude Research Center, Department of Emergency Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States of America
| | - Sherri Kark
- Altitude Research Center, Department of Emergency Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States of America
| | - Bengt Kayser
- Institute of Sports Sciences and Department of Physiology, Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Julia P. Kern
- Department of Human Physiology, University of Oregon, Eugene, Oregon, United States of America
| | - See Eun Kim
- Department of Human Physiology, University of Oregon, Eugene, Oregon, United States of America
| | - Corinna Lathan
- AnthroTronix, Inc., Silver Spring, Maryland, United States of America
| | - Steven S. Laurie
- Department of Human Physiology, University of Oregon, Eugene, Oregon, United States of America
| | - Andrew T. Lovering
- Department of Human Physiology, University of Oregon, Eugene, Oregon, United States of America
| | - Ryan Paterson
- Altitude Research Center, Department of Emergency Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States of America
| | - David M. Polaner
- Departments of Anesthesiology and Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, Colorado, United States of America
| | - Benjamin J. Ryan
- Department of Integrative Physiology, University of Colorado Boulder, Boulder, Colorado, United States of America
| | - James L. Spira
- United States Department of Veterans Affairs, National Center for PTSD, Pacific Islands Health Care System, and Department of Psychiatry, University of Hawaii John A. Burns School of Medicine, Honolulu, Hawaii, United States of America
| | - Jack W. Tsao
- Wounded, Ill & Injured Directorate (M9), United States Navy Bureau of Medicine and Surgery, Falls Church, Virginia, United States of America
| | - Nadine B. Wachsmuth
- Department of Sports Medicine/Sports Physiology, University of Bayreuth, Bayreuth, Germany
| | - Robert C. Roach
- Altitude Research Center, Department of Emergency Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States of America
- * E-mail:
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Tan GM, Galinkin JL, Pan Z, Polaner DM. Laryngeal view and temperature measurements while using the perilaryngeal airway (Cobra-PLUS™) in children. Paediatr Anaesth 2013; 23:1180-6. [PMID: 24383601 DOI: 10.1111/pan.12266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/18/2013] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The Cobra-PLUS™ perilaryngeal airway (CP) is a modification of the Cobra perilaryngeal airway. It has a distal curve for easier placement and a thermistor on the pharyngeal cuff. We assessed the orientation of the larynx to the CP and compared temperatures measured using CP to temporal arterial (TA) and infrared tympanic (T) thermometers. METHODOLOGY American Society of Anesthesiologists (ASA) physical status 1 and 2 children 0-18 years old undergoing general anesthesia using CP were grouped into different weight cohorts. A fiberoptic scope was inserted through the CP, and laryngeal views were recorded and graded off line. Temperatures were measured from the CP, TA, and T at 15-min intervals for four readings or until the end of surgery. The CP was removed, while the patient was deeply anesthetized. RESULTS Eighty subjects were analyzed. 87.5% (cohort range 75-95%) had an unobstructed view of the larynx. No serious adverse effects noted. Three hundred and sixteen temperature data points were recorded for each measured site. CP temperatures were consistently lower than TA and T with a bias of 0.9 and 0.6°C, respectively. Using temperatures measured at time 0 and 15 min, CP was associated with a larger intraclass correlation coefficient and smaller repeatability coefficient when compared to TA or T (ICC 0.65, 0.46. 0.44 and RC 0.78, 1, 1.36, respectively), indicating it had a better measure and remeasure reliability. CONCLUSION The CP has a better orientation to the larynx compared with its previous version. It may be used to reliably trend intraoperative temperatures.
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Affiliation(s)
- Gee Mei Tan
- Department of Anesthesiology, Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, CO, USA
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Polaner DM, Taenzer AH, Walker BJ, Bosenberg A, Krane EJ, Suresh S, Wolf C, Martin LD. Pediatric Regional Anesthesia Network (PRAN). Anesth Analg 2012; 115:1353-64. [DOI: 10.1213/ane.0b013e31825d9f4b] [Citation(s) in RCA: 355] [Impact Index Per Article: 29.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Abstract
Quality assurance and improvement (QA/QI) is a critical activity in medicine. The use of large-scale collaborative databases is increasingly essential to obtain enough reports with which to establish standards of practice and define the incidence of complications and risk/benefit ratios for rare events. Such projects can enhance local QA/QI endeavors by enabling institutions to obtain benchmark data against which to compare their performance and can be used for prospective analyses of inter-institutional differences to determine 'best practice'. The pediatric regional anesthesia network (PRAN) is such a project. The first data cohort is currently being analyzed and offers insight into how such data can be used to detect trends in adverse events and improve care.
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Affiliation(s)
- David M Polaner
- Department of Anesthesiology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO 80045, USA.
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Subudhi AW, Olin JT, Dimmen AC, Polaner DM, Kayser B, Roach RC. Does cerebral oxygen delivery limit incremental exercise performance? J Appl Physiol (1985) 2011; 111:1727-34. [PMID: 21921244 DOI: 10.1152/japplphysiol.00569.2011] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Previous studies have suggested that a reduction in cerebral oxygen delivery may limit motor drive, particularly in hypoxic conditions, where oxygen transport is impaired. We hypothesized that raising end-tidal Pco(2) (Pet(CO(2))) during incremental exercise would increase cerebral blood flow (CBF) and oxygen delivery, thereby improving peak power output (W(peak)). Amateur cyclists performed two ramped exercise tests (25 W/min) in a counterbalanced order to compare the normal, poikilocapnic response against a clamped condition, in which Pet(CO(2)) was held at 50 Torr throughout exercise. Tests were performed in normoxia (barometric pressure = 630 mmHg, 1,650 m) and hypoxia (barometric pressure = 425 mmHg, 4,875 m) in a hypobaric chamber. An additional trial in hypoxia investigated effects of clamping at a lower Pet(CO(2)) (40 Torr) from ∼75 to 100% W(peak) to reduce potential influences of respiratory acidosis and muscle fatigue imposed by clamping Pet(CO(2)) at 50 Torr. Metabolic gases, ventilation, middle cerebral artery CBF velocity (transcranial Doppler), forehead pulse oximetry, and cerebral (prefrontal) and muscle (vastus lateralis) hemoglobin oxygenation (near infrared spectroscopy) were monitored across trials. Clamping Pet(CO(2)) at 50 Torr in both normoxia (n = 9) and hypoxia (n = 11) elevated CBF velocity (∼40%) and improved cerebral hemoglobin oxygenation (∼15%), but decreased W(peak) (6%) and peak oxygen consumption (11%). Clamping at 40 Torr near maximal effort in hypoxia (n = 6) also improved cerebral oxygenation (∼15%), but again limited W(peak) (5%). These findings demonstrate that increasing mass cerebral oxygen delivery via CO(2)-mediated vasodilation does not improve incremental exercise performance, at least when accompanied by respiratory acidosis.
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Affiliation(s)
- Andrew W Subudhi
- Altitude Research Center, Department of Emergency Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
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Abstract
The use of regional anesthetics, whether as adjuncts, primary anesthetics or postoperative analgesia, is increasingly common in pediatric practice. Data on safety remain limited because of the paucity of very large-scale prospective studies that are necessary to detect low incidence events, although several studies either have been published or have reported preliminary results. This paper will review the data on complications and risk in pediatric regional anesthesia. Information currently available suggests that regional blockade, when performed properly, carries a very low risk of morbidity and mortality in appropriately selected infants and children.
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Affiliation(s)
- David M Polaner
- Department of Pediatric Anesthesiology, The Children's Hospital Denver, University of Colorado School of Medicine, Aurora, CO 80045, USA.
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Malviya S, Gooden CK, Polaner DM, Ross AK. Review of the 23rd annual meeting of the Society for Pediatric Anesthesia: practice improvement. Anesth Analg 2010; 110:1250-1. [PMID: 20357172 DOI: 10.1213/ane.0b013e3181d2a523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Polaner DM, Zuk J, Luong K, Pan Z. Positive Intravascular Test Dose Criteria in Children During Total Intravenous Anesthesia with Propofol and Remifentanil Are Different than During Inhaled Anesthesia. Anesth Analg 2010; 110:41-5. [DOI: 10.1213/ane.0b013e3181c5f2dc] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Abstract
The COBRA perilaryngeal airway (PLA) is a new supraglottic airway device available for use in children. We studied the orientation of the larynx as viewed through the PLA using video obtained with a fiberoptic bronchoscope in 45 infants and children. Laryngeal view was scored, and position of the grill bars of the PLA and the epiglottis was assessed. An acceptable airway was obtained in all subjects, but the laryngeal view was nearly or completely obstructed in 76.9% of the patients 10 kg and less, with the epiglottis folded over the glottic opening. This was uncommon in larger children. The grill bars of the PLA were closely opposed to the epiglottis and supraglottic structures in nearly all subjects. We conclude that 1) the PLA provides an acceptable airway in infants and children, but infolding of the epiglottis with obstruction of the view of the glottic opening is common in infants, 2) extra vigilance for airway obstruction in this age group is necessary, and 3) the PLA's close opposition to the supraglottic structures suggests that removal in a deeper plane of anesthesia might minimize laryngeal stimulation.
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Affiliation(s)
- David M Polaner
- The Children's Hospital and University of Colorado School of Medicine, Department of Anesthesia, Denver, Colorado 80218, USA.
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Abstract
We report the use of clonidine in an infant as an adjunct to sedation and analgesia for 4.5 months in the critical care setting. Advantages, potential side effects, and dosing for multiple modes of delivery are discussed.
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Affiliation(s)
- Rebecca Lowery
- Department of Anesthesiology, The Children's Hospital, Denver, CO 80218, USA.
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Polaner DM, Krupp J. The 8th joint conference on pediatric anesthesiology of the Society of Pediatric Anesthesia and the American Academy of pediatrics section on anesthesiology and pain management, Miami Beach, Florida, March 7, 2002. Anesth Analg 2002; 95:1115-8. [PMID: 12351307 DOI: 10.1097/00000539-200210000-00062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- David M Polaner
- The Children's Hospital, University of Colorado School of Medicine, Denver 80218, USA
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Polaner DM, Krupp J. The 8th Joint Conference on Pediatric Anesthesiology of the Society of Pediatric Anesthesia and the American Academy of Pediatrics Section on Anesthesiology and Pain Management, Miami Beach, Florida, March 7, 2002. Anesth Analg 2002. [DOI: 10.1213/00000539-200210000-00062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Polaner DM, Houck CS, Rockoff MA, Mancuso TJ, Finley GA, Maxwell LG, Cravero J, Kain ZN, Bell C, Bosenberg A, Zwass M, Valley R, Agarwal R, Savarese A, Rice LJ, Coté CJ, Davidson PJ, Ferrari LR, Davis PJ. Sedation, risk, and safety: do we really have data at last? Pediatrics 2001; 108:1006-8. [PMID: 11581458 DOI: 10.1542/peds.108.4.1006] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Abstract
The provision of sedation and analgesia is an integral aspect of the care of PICU patients. A careful systems approach to the provision of sedation and analgesia can minimize complications and maximize benefit to patients. Vigilance in monitoring and adherence to published guidelines are important for safety. Physicians must define the goals in clearly devising a plan and tailor the prescription to those goals rather than use a regimented protocol for all patients.
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Affiliation(s)
- D M Polaner
- Department of Anesthesia, University of Colorado School of Medicine, Children's Hospital, Denver, Colorado, USA.
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Affiliation(s)
- R Schumann
- Department of Anesthesia, New England Medical Center and Tufts University School of Medicine, Boston, Massachusetts 02111, USA.
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Hackel A, Badgwell JM, Binding RR, Dahm LS, Dunbar BS, Fischer CG, Geiduschek JM, Gunter JB, Gutierrez-Mazzora JF, Kain Z, Liu L, Means L, Myer P, Morray JP, Polaner DM, Striker TW. Guidelines for the pediatric perioperative anesthesia environment. American Academy of Pediatrics. Section on Anesthesiology. Pediatrics 1999; 103:512-5. [PMID: 9925855 DOI: 10.1542/peds.103.2.512] [Citation(s) in RCA: 81] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
The American Academy of Pediatrics proposes the following guidelines for the pediatric perioperative anesthesia environment. Essential components are identified that make the perioperative environment satisfactory for the anesthesia care of infants and children. Such an environment promotes the safety and wellbeing of infants and children by reducing the risk for adverse events.
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Polaner DM. Airway Management in Pediatric Anesthesia. Vol. 35, No. 3 of International Anesthesiology Clinics. Anesth Analg 1998. [DOI: 10.1213/00000539-199804000-00062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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41
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Polaner DM. The Use of Heliox and the Laryngeal Mask Airway in a Child with an Anterior Mediastinal Mass. Anesth Analg 1996. [DOI: 10.1213/00000539-199601000-00037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Affiliation(s)
- D M Polaner
- Anesthesia Service, Madigan Army Medical Center, Tacoma, Washington, USA
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Polaner DM, Kimball WR, Fratacci MD, Wain JC, Zapol WM. Thoracic epidural anesthesia increases diaphragmatic shortening after thoracotomy in the awake lamb. Anesthesiology 1993; 79:808-16. [PMID: 8214761 DOI: 10.1097/00000542-199310000-00024] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND Prolonged inhibition of diaphragmatic function occurs after thoracic and upper abdominal surgery. It was hypothesized that thoracic epidural anesthesia on the day after a thoracotomy could block inhibitory neural pathways and increase the shortening of costal and crural diaphragmatic segments. METHODS Pairs of sonomicrometer crystals were implanted into the costal and crural regions of the diaphragm through a right lateral thoracotomy in 14 30-kg, 4-5-month-old lambs. One day after surgery, a thoracic epidural catheter was placed at the T8-T9 level. Regional diaphragmatic shortening normalized to end-expiratory length (%LFRC), was measured by sonomicrometry in these awake lambs. Changes in gastric (delta Pgas), esophageal (delta Pes), and transdiaphragmatic (delta Pdi) pressures were measured with transnasal balloon catheters. End-tidal carbon dioxide (FETCO2), costal and crural electromyogram (Edi), and tidal volume (VT) were measured. Inductance plethysmography was used in four lambs to assess relative contributions of the rib cage and abdomen to VT. Control values were obtained during quiet breathing and while rebreathing at up to 10% FETCO2. To block thoracic dermatomes, 1% or 2% lidocaine was injected through the epidural catheter. Measurements were repeated after each lidocaine injection. RESULTS There was no change of resting length with 1% lidocaine; costal resting length increased by 22% with 2% lidocaine. After 2% lidocaine, costal %LFRC increased from control both during quiet breathing (8.7 +/- 0.7 to 18.1 +/- 1, mean +/- SEM%) and at FETCO2 10% (22.1 +/- 2 to 33.7 +/- 3%). VT during quiet breathing was unchanged after 1% lidocaine but increased from 235 +/- 16 to 283 +/- 28 ml after 2% lidocaine. At 10% FETCO2, delta Pdi was unchanged after 1% lidocaine and decreased from 36.5 +/- 4.3 to 26.3 +/- 4.9 cmH2O after 2% lidocaine. Regional delta Edi was unchanged with both 1% and 2% lidocaine at rest and during carbon dioxide rebreathing. Plethysmography in three lambs showed a reduction in rib cage contribution to tidal volume with 2% lidocaine during quiet breathing. CONCLUSIONS Improved postoperative tidal volume and diaphragmatic shortening after thoracic epidural blockade may be due to changes of chest wall conformation and resting length and a shift of the workload of breathing from the rib cage to the diaphragm caused by intercostal muscle paralysis.
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Affiliation(s)
- D M Polaner
- Harvard Medical School, Massachusetts General Hospital, Boston
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Fratacci MD, Kimball WR, Wain JC, Kacmarek RM, Polaner DM, Zapol WM. Diaphragmatic shortening after thoracic surgery in humans. Effects of mechanical ventilation and thoracic epidural anesthesia. Anesthesiology 1993; 79:654-65. [PMID: 8214744 DOI: 10.1097/00000542-199310000-00005] [Citation(s) in RCA: 69] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND Diaphragmatic function is believed to be inhibited after thoracic surgery and may be improved by thoracic epidural anesthesia. METHODS Diaphragmatic function after a thoracotomy was monitored by implanting one pair of sonomicrometry crystals and two electromyogram (EMG) electrodes on the costal diaphragm of six patients undergoing an elective pulmonary resection. Crystals and EMG electrodes remained in place for 12-24 h. RESULTS During mechanical ventilation, costal diaphragmatic length (as a percent of rest length; %LFRC) decreased passively as tidal volume (VT) increased (%LFRC = 2.81 + 1.12 x 10(-2) VT (ml), r = 0.99). During spontaneous ventilation, the costal shortening (2.1 +/- 2.3 %LFRC) was less than during mechanical ventilation (7.9 +/- 3.0 %LFRC, P < 0.05) at the same VT. Comparing spontaneous ventilation before and 30 min after thoracic epidural anesthesia, there were increases of VT (390 +/- 78 to 555 +/- 75 ml), vital capacity (1.37 +/- 0.16 to 1.68 +/- 0.21 l), and esophageal (-8.5 +/- 1.5 to -10.6 +/- 1.7 cmH2O), gastric (-0.7 +/- 0.8 to +0.8 +/- 0.8 cmH2O), and transdiaphragmatic (7.7 +/- 1.5 to 11.5 +/- 1.9 cmH2O) pressures, but diaphragmatic EMG and shortening fraction remained constant. In three of six patients, epidural anesthesia produced paradoxical segment lengthening upon inspiration. CONCLUSIONS Thoracotomy and pulmonary resection produce a marked reduction of active diaphragmatic shortening, which is not reversed by thoracic epidural anesthesia despite improvement of other indices of respiratory function.
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Affiliation(s)
- M D Fratacci
- Department of Anesthesia, Harvard Medical School, Massachusetts General Hospital, Boston 02114
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Abstract
Nitric oxide (NO) has vasodilatory effects on the pulmonary vasculature in adults and animals. We examined the effects on systemic oxygenation and blood pressure of inhaling up to 80 parts per million by volume of NO at FiO2 0.9 for up to 30 minutes by 6 infants with persistent pulmonary hypertension of the newborn (PPHN). In all infants this treatment rapidly and significantly increased preductal oxygen saturation (SpO2); in 5 infants postductal SpO2 and oxygen tensions also increased. Inhalation of NO did not cause systemic hypotension or raise methaemoglobin. These data suggest that low levels of inhaled NO have an important role in the reversal of hypoxaemia due to PPHN.
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Affiliation(s)
- J D Roberts
- Department of Anesthesia, Massachusetts General Hospital, Boston 02114
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Polaner DM, Kimball WR, Fratacci MD, Wain JC, Torres A, Kacmarek RM, Zapol WM. Effects of aminophylline on regional diaphragmatic shortening after thoracotomy in the awake lamb. Anesthesiology 1992; 77:93-100. [PMID: 1610014 DOI: 10.1097/00000542-199207000-00014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Aminophylline has been reported to augment diaphragmatic contraction, although this remains a controversial finding. We studied the effect of aminophylline on regional diaphragmatic shortening, changes in transdiaphragmatic pressure (delta Pdi), and integrated regional electromyographic (EMG) activity of the diaphragm (Edi) after a right thoracotomy in nine lambs using sonomicrometry, esophageal and gastric balloons, and EMG. Sonomicrometer crystals and EMG leads were implanted into the costal and crural regions of the diaphragm through a right thoracotomy, and a tracheostomy was performed. The animals were studied while awake within 4 days after surgery. Fractional costal and crural diaphragmatic shortening was measured using the sonomicrometer; delta Pdi was calculated from esophageal and gastric pressures. Respiratory variables were measured through the tracheostomy. Data were collected during quiet breathing and during CO2 rebreathing. After control measurements, aminophylline (10 mg/kg) was administered intravenously, producing a serum concentration of 17.7 +/- 1.5 micrograms/ml. Aminophylline did not augment shortening, increase delta Pdi, or overcome postoperative diaphragmatic inhibition acutely in the awake sheep after a right lateral thoracotomy. A small decrease of end-tidal CO2, from 5.2% to 4.9%, was measured at rest during aminophylline infusion, but Edi was unchanged. Although during CO2 rebreathing diaphragmatic shortening increased, the addition of aminophylline did not further augment shortening. Our data in awake lambs suggest that aminophylline does not improve diaphragmatic contraction in the acute postoperative period.
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Affiliation(s)
- D M Polaner
- Department of Anesthesia, Harvard Medical School, Massachusetts General Hospital, Boston 02114
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Daniels AL, Coté CJ, Polaner DM. Continuous oxygen saturation monitoring following rectal methohexitone induction in paediatric patients. Can J Anaesth 1992; 39:27-30. [PMID: 1733529 DOI: 10.1007/bf03008668] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Rectal methohexitone has been used to induce anaesthesia in paediatric patients for a number of years. This study was conducted in order to confirm the safety of this method of induction for uncomplicated routine paediatric patients. Children between the ages of six months and six years were considered candidates for induction with methohexitone (10%, 25-30 mg.kg-1). Patients were monitored with a continuous oxygen saturation recording. Forty-nine patients participated in this study and anaesthesia was induced successfully in 44. The mean age of the patients was 2.7 +/- 1.6 yr. The mean weight was 13.8 +/- 4.3 kg and the mean dose of methohexitone for successful induction was 27.0 +/- 3.0 mg.kg-1. Continuous oximeter recordings were available in 31 of the 42 patients who allowed oximeter placement prior to administration of methohexitone. No major desaturation events were noted in any patient. Two brief episodes of desaturation occurred. One with a nadir of 90% which lasted for 45 sec and another with a nadir of 86% which lasted for 26 sec. Both children had their heads flexed over their parents' shoulders at the time of the event resulting in partial airway obstruction. Both of these episodes were the result of upper airway obstruction which was clinically diagnosed by the anesthetist and readily corrected by repositioning the head. This study confirms the efficacy and safety of rectal methohexitone for induction of general anaesthesia in children. Mechanical obstruction of the airway following induction seems to be the most likely cause for oxygen desaturation. Monitoring of pulse oximetry does not appear necessary provided the child is carefully observed for adequacy of air exchange.
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Affiliation(s)
- A L Daniels
- Department of Anaesthesia, Harvard Medical School, Massachusetts General Hospital, Boston 02114
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Polaner DM, Billet AL, Richardson MA. Cardiovocal syndrome. Pediatrics 1986; 78:380. [PMID: 2942836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
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