Pediatric Anesthesia最新文献

Background: There remains a critical shortage of pediatric organ donors and there is a gap in understanding of optimal perioperative management to optimize donor organ outcomes for this valuable resource.

Aims: To survey practice patterns for intraoperative management of pediatric (age < 18 years) brain-dead donors during organ recovery procedures.

Methods: This retrospective observational study included organ recovery cases from 24 centers included in the Multicenter Perioperative Outcomes Group (MPOG) cohort in the United States from 2014 to 2020. Practice variation was evaluated using descriptive statistics, Fleiss' kappa, and logistic regression for between-group comparisons for volume-based analysis (case volume < 10 or ≥ 10) without adjustment for multiple comparisons.

Results: A total of 231 cases were included in this analysis. The median case volume for the Higher-Volume (≥ 10 cases) group was 25 [IQR 17, 46] cases and 7 [IQR 3, 8] cases for the Lower-Volume (< 10 cases) group. Descriptive analyses identified differences in case volume, race, and administration of steroids and vasoactives (bolus and infusion). The Fleiss' kappa scores were negative across all medications administered, suggesting a lack of within-group agreement. The odds ratio for steroid administration in the Lower-Volume group was 0.319 (95% CI: 0.116-0.745, p = 0.014).

Conclusions: This study found substantial practice variation across MPOG centers grouped based on case volume frequency for organ recovery procedures in pediatric donation after brain death. A major limitation of this study is the inability to correlate perioperative management with organ recipient outcomes. The main takeaway is an opportunity to improve consistency in perioperative management for brain-death donors from case classification to medication administration that reflects an understanding of brain death physiology.

Background: The infrequent occurrence of resuscitating critically ill pediatric patients poses educational challenges for pediatric anesthesiology residents developing competence. Traditional medical simulations, despite their utility, incur significant costs due to the need for monitors, mannequins, and personnel. Augmented reality (AR) medical simulation shows promise as an alternative clinical teaching tool. The Technology Acceptance Model (TAM) assesses usefulness, ease of use, and attitudes toward new technologies, offering insights into their adoption. Following successful application with other healthcare innovations, the TAM can also assess innovations in pediatric anesthesiology resident education, including AR medical simulation.

Aims: The primary aim identified factors that influenced acceptance of AR for medical simulation in pediatric anesthesiology using a TAM. The secondary aims assessed the model's reliability, usability, and ergonomics.

Methods: This prospective, multi-site study was carried out across nine academic children's hospitals around the United States and Hong Kong. We recruited anesthesiology residents with a minimum of two weeks of pediatric anesthesia experience, excluding those with severe motion sickness, seizures, or who wore corrective glasses. Using Magic Leap 1 headsets, participants underwent a simulated AR pediatric resuscitation scenario. Data were collected via electronic surveys, evaluating TAM factors, usability (System Usability Scale), and ergonomics (ISO 9241-400 standard).

Results: A total of 101 participants completed the study. The AR TAM model indicated that perceived ease of use and computer self-efficacy predicted perceived usefulness. Behavioral intention to use the AR system was influenced by perceived usefulness and perceived ease of use. System usability scores showed 83% agreement on ease of use. Ergonomic assessments indicated minimal physical discomfort.

Conclusion: AR simulations are highly acceptable and usable for pediatric resuscitation training, with perceived ease of use and computer self-efficacy influencing AR adoption. These findings align with previous TAM studies, supporting AR's potential to supplement traditional simulations and enhance accessibility.

Background: Intraoperative hemodynamic management goals in pediatric patients vary significantly with age. Physiologic variability and the absence of a widely accepted definition of intraoperative hypotension contribute to inconsistent treatment thresholds and practice variation.

Aims: The primary aim was to observe which blood pressure thresholds in various age groups led to clinical intervention in noncardiac surgery. The secondary aim was to determine the most commonly employed treatment interventions.

Methods: A single-center, retrospective, observational cohort study analyzed anesthesia records for 37 958 pediatric patients aged < 18 years of age who underwent noncardiac surgery and general anesthesia at our institution from January 1, 2015, through December 31, 2023. Age groups included: infants (0-12 months), preschool (1-6 years), children (7-12 years), and teenagers (13-17 years). The primary outcome was the adjusted rate of intervention, defined as any bolus of ephedrine, phenylephrine, epinephrine, norepinephrine, vasopressin, or 5% albumin. An algorithmic approach was used to examine the time epoch both before (6 min) and after (3 min) any study-defined interventions to identify the lowest mean arterial pressure that was associated with an intervention.

Results: Following exclusions, 37 958 anesthetic records were analyzed in this cohort. The median arterial pressure value and interquartile range associated with an intervention were: 36 mmHg [29, 43] in infants, 44 mmHg [38.5, 52] in preschool, 51 mmHg [44, 58] in children, and 57 mmHg [51, 63] in teenagers. The most common intervention was 5% albumin, followed by phenylephrine.

Conclusion: Intervention rates in pediatric patients were lower than those reported in adults, with intervention thresholds decreasing with younger age. Use of intravascular volume expansion appears to be more commonly used to treat hypotension in infants compared to older children. These findings highlight the need for multicenter studies to establish standardized intervention thresholds and assess their impact on clinical outcomes.

Background and objectives: Children with oropharyngeal cleft deformity (OPCD) undergoing reconstructive surgery are at greater risk for perioperative respiratory adverse events (PRAEs). Predictors for PRAE specific to this population have not been investigated, despite it being the most common congenital malformation seen worldwide.

Materials and methods: This single-center, prospective, observational study recruited 270 children under 2 years of age, undergoing elective cleft surgery from May 1, 2023, to June 30, 2024. The primary aim was to identify predictors of pre-determined PRAE (laryngospasm, bronchospasm, stridor, airway obstruction and desaturation). We also aimed to identify the more common PRAE in this patient population.

Results: Of the 345 children who underwent cleft correction surgery, 270 were included in the study. There was a statistically increased incidence of PRAE in children with a positive history of upper airway obstruction and a history of feeding disorder in early infancy, Cormack Lehane (CL) grade ≥ 3, and COLDS score ≥ 15. A significant association was found between the COLDS score (odds ratio [OR]: 0.005, 95% confidence interval [CI]: 0.001-0.049), CL grade ≥ 3 (OR: 0.008, 95% CI: 0.001-0.078) and PRAE.COLDS score ≥ 15 (p = 0.046; adjusted OR [AOR]: 18.07, 95% CI: 1.06-308.45) and CL grade ≥ 3 (p = 0.007; AOR: 41.79, 95% CI: 2.74-636.40) were associated with PRAEs in the multivariate regression. The overall incidence of PRAE was 1.85%, laryngospasm being the most common.

Conclusion: Children with OPCD with higher COLDS scores and/or those with a CL grade view ≥ 3 are more likely to develop PRAE following corrective surgery. The limited data indicate the increased possibility of PRAE in children with a positive history of airway obstruction and/or feeding disorder in early infancy. The relatively low incidence of PRAE restricts the generalizability.

Background: Propofol is a commonly used intravenous sedative and general anesthetic, with rapid onset and short duration of action. It has a narrow therapeutic index and significant interindividual variability in dosing requirements, which may elevate risks of its use, particularly in children.

Aims: We aimed to quantify the doses required to induce loss of consciousness and apnea in children by age and sex to contribute to tailored propofol dosing recommendations for improved safety and efficacy in pediatric anesthesia.

Methods: In this stratified- and purposive-sampling study, we enrolled children in six groups based on sex and age (3- to 5-year-olds, 6- to 10-year-olds, 11- to 18-year-olds), targeting 60 participants per group. For induction of anesthesia, we administered propofol at a constant rate until apnea was reached (absence of end-tidal CO₂ for 20 s) up to a maximum dose of 10 mg/kg. We measured the propofol dose required to reach pharmacodynamic endpoints, including loss of eyelash reflex (LOER) and apnea, and estimated the effect of sex and age on these doses.

Results: Data were available for 318 participants, with 162 females and a median (interquartile range) age of 8.1 (5.3-12.9) years. The mean (SD) propofol dose to LOER was 2.65 (0.69) mg/kg with no effect of sex (-0.10 mg/kg for male, 95% confidence interval (CI) -0.26 to 0.05, p = 0.183) or age (0.0 mg/kg per year, 95% CI -0.02 to 0.02, p = 0.876). The mean (SD) propofol dose to apnea was 6.82 (1.64) mg/kg, with significant effects of both sex (+0.67 mg/kg for male, 95% CI 0.30 to 1.03, p < 0.001) and age (-0.14 mg/kg per year, 95% CI -0.19 to -0.1, p < 0.001). Apnea was not reached in 62 participants.

Conclusions: Older and female children exhibited narrower therapeutic indices for the margin between LOER and apnea. This requires heightened vigilance, especially when maintaining spontaneous respiration. A planned genome-wide association study may identify pharmacogenetic-pharmacodynamic relationships and correlations with genetic ancestry.

Trial registration: The trial was registered on clinicaltrials.gov before enrolment (NCT04164264; date of registration 2019-11-15).