Pediatric Anesthesia最新文献

Introduction: Proton beam therapy (PBT) is becoming the radiotherapeutic modality of choice for children with curable cancer. A significant proportion require anesthetic care to facilitate precise positioning and immobility, and such patients undergo repetitive episodes of general anesthesia, 5 days a week for up to 8 weeks. Patients with central nervous tumors and those undergoing concurrent chemotherapy form a large proportion of referrals. Although X-ray therapy and PBT demonstrate similarities, factors including younger patient age, longer session length and a need for rigid immobilization, means that providing anesthetic care for PBT is more complex as compared to X-ray therapy. We present a case series of three patients who failed to complete PBT due to problems relating to anaesthesia. Our objective is to highlight specific PBT-related challenges in the pediatric population, because although serious complications are uncommon, there can still be significant risk.

Methods: We retrospectively reviewed the patient records of the three pediatric cases that failed to complete PBT at our outpatient regional center between January 2020 and December 2022.

Results: Two cases failed to complete PBT due to respiratory adverse events, including one that required admission to intensive care. Both of these cases had central nervous tumours. The third case developed neutropenic typhlitis relating to concurrent chemotherapy making the patient unfit for ongoing anesthesia.

Discussion: All three cases demonstrate that the risk of adverse events cannot be reliably predicted in this patient group. Detailed assessment must be performed prior to proceeding with anesthesia including regular review of blood tests, observations, and examining patients for any signs and symptoms of subclinical infection. The decision to proceed with anesthesia on a daily basis will require an anesthetic team that is highly skilled and familiar with their environment.

Conclusion: Anesthetic care for PBT is more complex as compared to X-ray therapy. A small group of children, particularly those with central nervous system tumors or altered respiratory control, may be at increased and sometimes unpredictable risk. Safe and sustainable care for PBT is possible with careful history taking, planning, and identification of patients at a higher risk of adverse events.

Background: Sickle cell disease (SCD) is an inherited hemoglobinopathy affecting approximately 100 000 Americans, disproportionately affecting Black individuals. Sickling of hemoglobin S red blood cells due to conditions in the perioperative period including hypoxemia, hypothermia, surgical stress, and pain can reduce organ perfusion and lead to adverse outcomes including pain crisis, acute chest syndrome, and stroke.

Aims: This study evaluates perioperative outcomes and risk factors for sickle cell crisis in children with SCD undergoing common inpatient surgical procedures.

Methods: A retrospective cohort was created using the Healthcare Cost and Utilization Project (HCUP) Kids' Inpatient Database (KID) 2003-2019. Hospital admissions for children < 18 years of age undergoing a selected group of surgical procedures (cholecystectomy, appendectomy, congenital cardiac surgery, and posterior spinal fusions) commonly requiring inpatient stay were included. Diagnoses and procedures were identified using ICD-9/ICD-10 codes. Perioperative outcomes included post-operative length of stay (LOS), blood transfusions, hematologic, and infectious complications. Children with SCD were compared to those without SCD using multivariable Poisson regression to adjust for surgical procedure and sociodemographic, clinical, and hospital characteristics.

Results: Of 5 75 005 children studied, 2357 (0.4%) had SCD. Relative to children without SCD, those with SCD had a longer post-operative LOS (adjusted incidence rate ratio [aIRR]: 1.29; 95% CI [1.26-1.32], p < 0.001). Children with SCD hospitalized for a surgical procedure were also more likely to receive a blood transfusion (adjusted risk ratio [aRR]: 13.1; 95% CI [12.1-14.2], p < 0.001). Significantly increased associated risks of hematologic and infectious complications, however, were not observed. Of children with SCD, 17.5% experienced a sickle cell crisis during hospitalization. The odds of sickle cell crisis in non-elective admissions were more than three times as high as in elective admissions (aOR 3.36; 95% CI [2.46-4.60], p < 0.001). Children with sickle cell crisis had a longer post-operative hospital stay (aIRR: 1.58; 95% CI [1.49-1.67]) than those without a crisis.

Conclusions: The perioperative course in children with SCD was associated with longer postoperative length of stay and higher blood transfusion rates relative to those without SCD undergoing similar surgical procedures. Perioperative sickle cell crisis was present in more than one out of six admissions, more common in non-elective admissions, and is associated with excess length of stay.

Background: Respiratory arrest during cardiopulmonary bypass (CPB) in pediatric cardiac surgery risks lung dysfunction including derecruitment, atelectasis, and inflammation. Continuous positive airway pressure (CPAP) and lung-protective ventilation (LPV) during aortic cross-clamping show inconsistent results in mitigating these risks.

Aims: To investigate whether LPV during aortic cross-clamping under CPB affects postoperative respiratory mechanics and ventilation inhomogeneity compared to apnea or CPAP.

Methods: This prospective, randomized pilot study compared three ventilation strategies during aortic cross-clamping under CPB: apnea, CPAP (5 mbar), and LPV. LPV was standardized using pressure-controlled ventilation at a positive end-expiratory pressure of 5 mbar, individualized driving pressure (20% of the pre-cross clamp inspiratory pressure), and age-adjusted respiratory rate. Recruitment maneuvers were applied at the end of CPB. Respiratory mechanics were assessed. Ventilation distribution was measured preoperatively and postoperatively under spontaneous breathing and mechanical ventilation using Electrical Impedance Tomography. Blood was analyzed pre- and postoperatively for pulmonary and systemic inflammatory markers. Feasibility of LPV was assessed. Statistical analysis used linear mixed-effects models.

Results: Driving pressure increased (11.8 (2.6) to 12.9 (2.6) mbar) and dynamic compliance decreased (9.9 (7.3) to 8.5 (7.4) Pa L^-1) statistically significantly preoperatively to postoperatively. The number of ventilated pixels increased statistically significantly from spontaneous breathing (408.2 (77.2)) to mechanical ventilation (495.1 (44.9)) and returned toward baseline postoperatively (433.9 (72.6)). The Center of Ventilation shifted statistically significantly ventrally during mechanical ventilation (0.491 (0.039) to 0.442 (0.027)) and normalized afterward (0.485 (0.037)). These changes were unaffected by the ventilation strategy. Biomarker analysis showed no statistically significant changes between groups. LPV during aortic cross-clamping was feasible.

Conclusion: In this pilot study, ventilation strategies did not differ in their effect on ventilation distribution, respiratory mechanics, or inflammatory markers when recruitment maneuvers were uniformly applied after CPB. LPV was feasible.

Trial registration: German Clinical Trials Register: DRKS00030219; https://drks.de/search/de/trial/DRKS00030219.