Pediatric Anesthesia最新文献

Background: Sevoflurane is preferred for induction of anesthesia in children because of its rapid wash-in and minimal airway reactivity.

Aims: The primary aim of this study was to compare the washin profiles of sevoflurane in children using the Dräger Apollo and Ohmeda Aisys workstations.

Methods: Twenty-four healthy children (12 per workstation) scheduled for elective surgery underwent inhalational inductions with 8% sevoflurane and 66% nitrous oxide in this prospective observational study. The inspired and end-tidal sevoflurane concentrations were recorded every 30 for the first 5 min and every minute thereafter until the airway was secured. Primary and secondary outcomes consisted of the derived wash-in metrics during the induction.

Results: The end-tidal to inspired ratios of sevoflurane were similar with both workstations. The mean (±SD) inspired sevoflurane concentrations with the Apollo were less than with the Aisys workstation (p < 0.013). The mean (±SD) inspired concentration at 1 min with the Apollo, 6.4% ± 0.4%, was 22% less than that with the Aisys, 7.8% ± 0.67% (mean difference 1.4, 95% CI 0.88 to 1.8, p < 0.0001). The mean (±SD) maximum inspired and expired sevoflurane concentrations during the induction period with the Apollo, 7.2% ± 0.3% and 6.8% ± 0.37%, were 18% and 15% less than those with the Aisys, 8.5% ± 0.4% and 7.8% ± 0.9%, (mean difference 1.3, 95% CI 0.99 to 1.6, p < 0.0001) and (mean difference 1.01, 95% CI 0.41 to 1.6, p < 0.002) respectively. The median (25-75th percentile) time to reach 90% of the maximum inspired concentration during the induction with the Apollo, 1.75 (1-2.4) min was 3.5-fold greater than that with the Aisys, 0.5, 0.5-0.5 min (median difference -1.25, 95% CI -1.5 to -0.5, p < 0.0019).

Conclusions: The washing of sevoflurane with the Dräger Apollo workstation is slower, and the maximum sevoflurane concentrations are less in children than with the Ohmeda Aisys workstation.

Background: Midazolam is commonly used and effective in reducing preoperative anxiety in children. Nonpharmacological interventions, such as video distraction, are also well established for alleviating preoperative anxiety in pediatric patients, particularly those treated in ambulatory settings.

Aims: To explore whether video distraction during anesthesia induction provides additional anxiety reduction in children premedicated with midazolam.

Methods: In this prospective randomized controlled trial, children aged 2-10 years scheduled for elective noncardiac surgery were premedicated with midazolam and randomly assigned to either a video group (n = 54) or a control group (n = 51). In the video group, videoclips were displayed as a distraction prior to anesthesia induction, while the control group received standard care. Anxiety was measured using the short form of the modified Yale Preoperative Anxiety Scale (mYPAS-SF). The primary endpoint was the change in mYPAS-SF scores between transfer to the operating theater and anesthesia induction (ΔmYPAS-SF). Secondary endpoints included emergence delirium, postoperative pain, and compliance during anesthesia induction. Character traits were assessed.

Results: There was no additional anxiety reduction in the video group compared to the control group. The change in mYPAS-SF scores (median [interquartile range]) was 4.2 (-2.1, 16.7) in the control group and 4.16 (-2.1, 7.0) in the video group (p = 0.246). Similarly, there were no significant differences between the groups regarding compliance during anesthesia induction, emergence delirium, or postoperative pain. Compliance during anesthesia induction, emergence delirium, and postoperative pain was similar between the groups. Additional anxiety reduction through video distraction was observed in children with pronounced anxiety traits, including "General Phobia," "Separation," "Panic," and the overall "Total Phobia" score.

Conclusion: In our study, video distraction did not result in additional anxiety reduction in children premedicated with midazolam prior to anesthesia induction in a hospital setting. Certain children with specific personality traits may still benefit from this intervention.

Trial registration: Registry: German Clinical Trial Register; Registration number: DRKS00025411; Principal investigator's name: Armin Sablewski; Date of registration: February 15, 2022; https://drks.de/search/en/trial/DRKS00025411.

Background: While enhanced recovery after surgery protocols have been successful in adults, their impact in pediatric surgery is less documented.

Smart aim: Reduce opioid use in morphine milligram equivalents by 25% over 32 months through an enhanced recovery after surgery protocol. This period included 5 months dedicated to testing and implementing the protocol, followed by 27 months of full implementation. Process measures ensured adherence, with 30-day readmission rates, pain scores, postoperative nausea and vomiting, pruritus, and hospital length of stay as balancing measures.

Methods: Inconsistent perioperative management led to variable opioid use in pediatric laparoscopic cholecystectomy patients at our hospital. A quality improvement project using the Model for Improvement was implemented at a 443-bed pediatric academic hospital. A multidisciplinary enhanced recovery after surgery team implemented perioperative standardizations supported by electronic medical record best practice advisories, monthly educational sessions, and stakeholder engagement.

Results: After full enhanced recovery after surgery protocol implementation, morphine milligram equivalents decreased by 27% over 32 months. Mean pain scores decreased from 4.69 (95% CI: 4.32-5.06) pre-enhanced recovery after surgery to 4.10 (95% CI: 3.84-4.36) post-enhanced recovery after surgery. Postoperative nausea and vomiting incidence decreased from 18% (95% CI: 11.7-26.7) to 15% (95% CI: 9.3-23.3), and pruritus incidence declined from 6% (95% CI: 2.8-12.5) to 5% (95% CI: 2.2-11.2). Mean hospital length of stay was 1.37 days (95% CI: 1.33-1.41) pre-enhanced recovery after surgery and 1.34 days (95% CI: 1.30-1.38) post-enhanced recovery after surgery. The 30-day readmission rate remained unchanged, with the sole readmission attributed to constipation.

Conclusion: Standardizing care through enhanced recovery after surgery protocols effectively reduces opioid use in pediatric laparoscopic cholecystectomy without increasing mean postoperative pain scores, postoperative nausea and vomiting, pruritus, or hospital length of stay.

Background: Metabolic alkalosis in pediatric patients following cardiac surgery warrants a comprehensive study. Newer methods of arterial blood gas (ABG) assessment can offer more insights into the mechanisms behind such derangement.

Objective(s): To study the incidence of metabolic alkalosis in postsurgical infants admitted to the pediatric cardiac intensive care unit and analyze factors associated with its development and its effect on prognosis.

Design: Prospective observational study.

Setting: Tertiary care teaching hospital in India during 2020-2021.

Patients: One hundred four infants < 1 year of age undergoing elective cardiac surgery and who required more than 6 h of postoperative mechanical ventilation were included. Infants on preoperative mechanical ventilation or with metabolic alkalosis were excluded.

Main outcome measures: Incidence of metabolic alkalosis and causative preoperative, intraoperative, and postoperative factors were studied along with their morbidity profile.

Results: Metabolic alkalosis was detected in 23 (22.1%) subjects. In group MA (who developed metabolic alkalosis), 73.9% of infants belonged to risk adjustment for congenital heart surgery-1 (RACHS-1) category 3 and above (p = 0.009). They also had longer cardiopulmonary bypass time (200.04 ± 83.35 min vs. 144.59 ± 64.77; 95% confidence interval of the difference in means [23, 87.9]), longer cross-clamp time (119.78 ± 63.12 min vs. 84.95 ± 48.8; 95% CI [10.4, 59.3]), greater application of modified ultrafiltration (MUF) (91.3% vs. 60.5%, p = 0.005), and larger volume of MUF removed (60 (44.4, 70) ml kg^-1 vs. 44.44 (32.9, 54.3), p = 0.003). Partitioning of base excess showed similar standard base excess due to free water (SBE_FW) (MA -0.18 ± 0.94 vs. No MA 0.25 ± 1.1; confidence interval of the difference in means [-0.95, 0.09]) and due to chloride (SBE_Cl) (MA -5.7 ± 4.8 vs. No MA -5.18 ± 5.05; 95% CI [-2.9, 1.8]) in both groups. A longer period of ventilation, intensive care unit stay, and hospital stay were found in group MA.

Conclusion: This prospective study on postcardiotomy infants revealed a much lower incidence of metabolic alkalosis than historical data. Physicochemical analysis of the blood samples for mechanisms underlying metabolic alkalosis found that its development is not entirely dependent on overt volume depletion or significant chloride loss. The administration of chloride-containing solutions appears to mitigate both the occurrence and severity of metabolic alkalosis.

Background: Surgical Patients in tertiary care centers can be healthy or extremely ill with comorbidities, and procedures vary from simple to difficult and complicated. High-acuity cases, or those involving anesthesia and procedural complexities, require specific anesthesia staff arrangements, specific nursing team assignments, and additional support staff. These cases are identified manually, and there is no ready-to-use scoring system to stratify high-acuity, complex pediatric surgical patients.

Aims: We aim to develop an electronic medical record-generated rule-based clinical coverage scoring system to identify high-acuity, complex cases and compare its accuracy with human performance.

Methods: In this quality improvement project, an automated scoring system using rule-based clinical criteria was designed and implemented in a quaternary children's hospital. These rules were based on patient characteristics, procedure and anesthetic complexity, and the patient's acute condition. The cases with clinical coverage scores higher than zero were compared to those manually identified as high-acuity, complex cases by the anesthesia clinical directors and operating room charge nurses. The accuracy was reported using sensitivity, specificity, PPV, NPV, accuracy, and F-1 scores.

Results: There were 10 761 pediatric surgical cases during the study period (April 7-September 8, 2023). 1450 (13.5%) cases were manually identified as high-acuity, complex cases, while the automated system identified 1906 (17.7%) cases. The accuracy of the automated scoring system improved over time. Eventually, it became better than manual identification with 95.86% (94.48%-97.24%) sensitivity, 99.84% (99.71%-99.98%) specificity, 99.35% (98.78%-99.92%) PPV, 98.97% (98.62%-99.32%) NPV, and 99.04% (98.62%-99.47%) accuracy by the end of the study period. The most impactful interventions were removing canceled cases and adding procedure codes to the rules for automated scores.

Conclusion: EHR-generated clinical coverage scores can reliably replace manual reviews of high-acuity, complex pediatric surgical patients. This tool can guide clinical decision-making in real time.

Background: Processed electroencephalogram (EEG) indices are widely used to monitor anesthetic depth. However, their reliability in children under 2 years of age remains questionable. During anesthesia maintenance in this age group, processed EEG indices frequently exhibit unexpectedly elevated values that exceed the intended target range.

Aim: This study aimed to identify EEG spectral parameters associated with false positive elevations in processed EEG indices and investigate their differences from true positive elevations during emergence.

Methods: This prospective observational study included 50 children aged 4-24 months undergoing general anesthesia. Bispectral index (BIS), patient state index (PSi), and raw EEG were continuously recorded throughout anesthesia. False positive was defined as elevated processed EEG indices when end-tidal sevoflurane concentration was maintained at 0.7-1.3 minimum alveolar concentration, with heart rate and mean blood pressure between 80% and 120% of baseline values. We analyzed EEG power spectra and band power values during periods of false positives and compared them with those of true positives during emergence. Bonferroni-corrected p < 0.05 was considered significant.

Results: False positives in processed EEG indices were observed in 35 (70%) of the children during anesthesia maintenance, occupying 28% of the maintenance phase. These false positives were associated with decreased power in delta (269-174 dB) and theta (115-97 dB) bands, but widespread increases in alpha and beta bands, resulting in elevated spectral edge frequency (19-22 Hz). Notably, EEG band power during false positives significantly differed from those observed during emergence (delta: 52 dB, theta: 38 dB) (all p < 0.001).

Conclusions: Processed EEG indices may exhibit unexpectedly elevated values during anesthesia maintenance in children under 2 years of age. Quantitative assessments derived from raw EEG data may improve the evaluation of anesthetic depth in this population.

Background: In children, monitoring depth of anesthesia is challenging because of the still developing brain. Electroencephalographic density spectral array monitoring provides age- and anesthetic drug-specific electroencephalographic patterns, making it suitable for use in children. Yet, not much is known about the benefits of using density spectral array on post-operative recovery in children.

Aim: In this randomized controlled trial, the primary aim was to investigate the influence of density spectral array monitoring during general anesthesia on the speed of recovery after surgery.

Methods: Children aged 6 months-12 years scheduled for elective surgery under general anesthesia supplemented with caudal analgesia had either sevoflurane anesthesia titrated to maintain a characteristic density spectral array pattern or based on a predefined end-tidal sevoflurane concentration of 2.3% (standard care group). The time interval between the discontinuation of sevoflurane and the moment when discharge criteria from the operating room were met (Steward score of 3 or more) was defined as the primary outcome parameter of this trial.

Results: Data from 96 children were analyzed. The time until discharge readiness from the operating room was shorter in group density spectral array (6 min. [13[4-16.8]]) than in group standard care (12 min. [18[6-24.3]]), with a difference between medians of 6 min (95% CI -7 to 0), p = 0.041. The mean end-tidal sevoflurane concentration during the surgical procedure was lower in group density spectral array, 1.8% (0.34) versus 2.3% (0.1) in group standard care (95% CI 0.4-0.7), p < 0.001.

Conclusion: This randomized controlled trial provides initial evidence of an added value of density spectral array monitoring in terms of the speed of recovery and allows sevoflurane to be dosed 22% lower during maintenance than with a more traditional approach using a minimal alveolar concentration of 0.9.

Trial registration: ClinicalTrials.gov identifier: NCT05525104.