Pediatric Anesthesia最新文献

Background: Caudal epidural block is commonly used in pediatric surgeries but may fail due to anatomical variations or operator experience. Early recognition of block effectiveness is useful for timely pain management, improving outcomes and analgesic strategies.

Aims: This study aimed to assess the ability of infrared thermography to determine caudal block success in children.

Methods: In this prospective observational study, children (2-12 years) undergoing infra-umbilical surgery received a caudal block after the induction of general anesthesia. FLIR C2 thermal camera was used to assess skin temperature at the dorsum of the foot, little toe, and suprapubic area at the baseline and 2, 5, 10, and 15 min after the block. Temperature change (Δ) was calculated as the difference from baseline. The primary outcome was the ability of Δ temperature at 10 min to detect a successful block, assessed via the area under the receiver operating characteristics curve (AUC).

Results: Data from 143 patients were analyzed; 29/143 (20%) patients had failed block. In the successful block group, the temperature increased over time and was significantly higher than that of the failed block group at 10 and 15 min. At 10 min, the AUC (95% confidence interval) for detecting successful block was higher at the dorsum of the foot (0.92 [0.86-0.96]) and little toe (0.87 [0.81-0.92]) compared to the suprapubic area (0.74 [0.66-0.81]). The positive predictive value for Δ temperature at the dorsum of the foot and little toe for detecting successful block was 95%-96% with cut-offs of 1.2°C and 1.4°C, respectively.

Conclusion: In anesthetized children undergoing infra-umbilical surgeries, infrared thermography can accurately confirm successful caudal block. Ten minutes after the block, an increase in the skin temperature by 1.2°C-1.4°C at the dorsum of the foot and little toe can confirm block success with 95%-96% accuracy.

Background: Pulmonary hydatid disease (PH) remains a significant health challenge in children from endemic regions. The anesthetic and surgical management of PH is complex, particularly in the presence of ruptured cysts, which pose risks such as airway obstruction and anaphylaxis.

Methods: A 10-year retrospective cohort study was conducted on children ≤ 18 years undergoing surgery for PH at our tertiary care center between January 2012 and December 2022. Data were collected from medical records, operative notes, and imaging reports.

Results: There were 37 cases with diagnosis of pulmonary hydatid disease in last decade, we have included 28 children with complete records. Three had bilateral disease, totaling 31 procedures. Ruptured cysts were noted in 12 cases. Common symptoms included cough, fever, and hemoptysis. One lung ventilation (OLV) was achieved in 96% of cases with DLT (45%), Arndt blocker (33%) and Fogarty blocker (13%) commonly used. Complications included desaturation (75%), transient bradycardia (29%), and three major perioperative events, all in children with ruptured cysts. The mean OLV duration was longer in complicated cases (3.42 vs. 2.3 h, p = 0.019). Postoperative air leaks occurred in 10 children, with three requiring re-surgery. All patients were extubated on-table, with mean length of stay of 7 days and no long-term morbidity or mortality.

Conclusion: OLV is critical in minimizing spillage and facilitating surgical management in pediatric PH. The incidence of intraoperative complications was higher in those with bilateral Pulmonary hydatid disease. The duration of One Lung Ventilation (OLV) and hospital stay was prolonged in those with complicated pulmonary hydatid cyst.

Background: Integrating evidence-based findings into perioperative medicine is key to allowing improvements in care. The perioperative environment involves multiple stakeholders and processes that require coordination to deliver high-quality care. Various barriers can challenge the implementation of changes in this setting, but key facilitators may enable them. This research explored barriers and facilitators to implementing new practices and innovations in the pediatric perioperative ecosystem, as experienced by pediatric anesthetists returning to work in a sub-Saharan African country.

Methods: This was a mixed methods study following an explanatory sequential design. A survey was sent to 28 fellowship-trained pediatric anesthetists identified through fellowship leads of established programs, who had returned to work in sub-Saharan Africa post-fellowship. Respondents were invited to participate in interviews. Reflexive thematic analysis was used to represent the experiences described by the participants, and to categorize barriers and facilitators.

Results: Seventeen anesthetists from 10 countries responded to the survey (response rate 17/28, 61%). All respondents indicated that they had encountered barriers to change implementation (17/17, 100%), and 12/15 (80%) indicated that facilitators that enabled change existed. Resource constraints were the main barrier, followed by resistant behaviors by individuals and at the organizational level. Ten anesthetists were subsequently interviewed. Respondents attempted to bring about change in a variety of areas, including operational logistics, patient safety, clinical practice, and organizational culture. Key barriers were encountered at individual, environmental and organizational levels. Key enablers included personal traits such as persistence and adaptability, ongoing mentorship, supportive leadership, and the strategic contextualization of skills.

Conclusion: Fellows experience significant challenges when attempting to implement changes based on the knowledge and skills acquired during advanced training. Facilitators enabling successful change implementation exist. Including training in leadership and change management in fellowship programs may better prepare those from sub-Saharan Africa to introduce their envisioned improvements to the perioperative environment upon their return.

Background: Dexmedetomidine is an a₂-adrenoreceptor agonist with sedative, analgesic, and anxiolytic properties. It has gained remarkable attention in the adult and pediatric population predominantly because of its minimal respiratory depression. However, in the pediatric population, very limited information is available regarding the action of intravenous dexmedetomidine on neuromuscular blockade and on anesthesia induction. The aim of this study was to investigate the impact of dexmedetomidine on rocuronium-induced neuromuscular blockade and on anesthesia induction with propofol in children.

Material and method: A total of 60 children undergoing elective surgery, ages 4-12 years, were enrolled in the study. Before the induction of anesthesia with propofol, 30 children received dexmedetomidine 0.5 μg/kg given over 10 min (group D). Another group of 30 children received the same volume of N/S 0.9% over 10 min as well (group P). We recorded time to achieve TOF = 0 from the end of rocuronium infusion, time for BIS < 60 from the end of propofol infusion, intubation conditions, haemodynamic changes, intubation attempts, and adverse effects.

Results: The onset time of rocuronium was significantly lower in group D compared to group P (177.8 s, 95% CI 161.1-194.0 s vs 205 s, 95% CI 188.0-222.0 s; p = 0.021). Time for BIS to reach a value < 60 (34.3 s, 95% CI 29.1-39.6 s for group D vs 33.2 s, 95% CI 27.2-39.2 s for group P, p = 0.772) was unaffected by dexmedetomidine infusion. Intubation conditions showed a more stable haemodynamic response in group D (systolic, diastolic, mean arterial pressure, and heart rate were significantly lower in group D at intubation). No difference was found regarding intubation attempts and adverse effects.

Conclusion: Our results showed that dexmedetomidine infusion before induction of anesthesia with propofol reduced the onset time of rocuronium and provided a better hemodynamic profile during endotracheal intubation in children.

Trial registration: The study protocol was registered in ClinicalTrials.gov (NCT03923075).

Background: Both intraoperative hypotension (IOH) and vasopressor administration are independently associated with postoperative acute kidney injury (AKI) in adults undergoing major noncardiac surgery. Whether these associations extend to children undergoing major noncardiac surgery, such as liver transplantation, remains unknown.

Aims: This study aimed to evaluate whether IOH, defined as time spent with a mean arterial pressure (MAP) less than one standard deviation (SD) below age- and sex-adjusted normal, and vasopressor administration in children are associated with postoperative AKI in liver transplantation (LT). We hypothesized that both IOH and vasopressor use would be independent predictors of postoperative AKI after pediatric LT.

Methods: This single-center retrospective cohort study analyzed all patients < 18 years undergoing LT, excluding those with preoperative end-stage renal disease. The primary outcome was AKI, within 7 postoperative days defined according to KDIGO criteria. Multivariable logistic regression models were performed to determine whether IOH and vasopressor use, specifically maximum intraoperative epinephrine infusion, were independently associated with AKI. Exploratory K-means clustering was applied to IOH and vasopressor exposure to identify hemodynamic phenotypes, which were evaluated for associations with AKI and other outcomes.

Results: Of 144 pediatric LT cases, 22 were excluded for preexisting renal failure, leaving 122 for analyses. Postoperative AKI occurred in 39%. The mean cumulative duration MAP was < 1 standard deviation of age- and sex-adjusted mean was 26.6 versus 26.1 min, respectively, among patients who developed AKI versus those who did not (mean difference 0.52 min: 95% CI -15.03, 16.07, p = 0.948). In the multivariate analysis neither hypotension (by the same definition) nor maximum epinephrine appeared to be associated with AKI: adjusted odds ratio 1.003 (95% CI: 0.992-1.014) and 1.003 (95% CI: 0.994-1.012). Exploratory cluster analysis revealed distinct intraoperative hemodynamic phenotypes based on IOH and vasopressor use, which were significantly associated with some perioperative outcomes, highlighting the need for larger studies with more robust control of patient factors.

Conclusions: IOH and vasopressor exposure were not independently associated with AKI in children undergoing LT.

Background: Preoperative Anxiety in Young Children Is Common and Can Lead to Adverse Outcomes. In Clinical Routine, Anesthesiologists Must Often Predict Anxiety Based on Limited Interaction.

Aims: This study aimed to evaluate the accuracy of early anxiety predictions and to identify early predictors of heightened anxiety at anesthesia induction.

Methods: In this prospective observational study, anesthesiologists and parents of children aged 2-6 years undergoing elective procedures were asked during the preoperative consultation to predict the child's anxiety at anesthesia induction using the visual analog scale (VAS). These predictions were compared to observed anxiety during induction, measured with the Modified Yale Preoperative Anxiety Scale-Short Form (mYPAS-SF). Prediction accuracy was assessed using Spearman's correlation (r_s) and receiver operating characteristics (ROC) analysis. Potential predictors of significant anxiety defined as a mYPAS-SF > 30 were analyzed.

Results: A total of 92 prediction sets were analyzed. Correlation between predicted and observed anxiety was weak for parents (r_s = 0.220, 95% CI 0.01-0.41) and very weak for anesthesiologists (r_s = 0.106, 95% CI -0.11-0.31). Predictive performance was limited for parents (AUC = 0.643) and negligible for anesthesiologists (AUC = 0.517). Children who responded positively to a greeting ('high-five') during consultation showed significantly lower anxiety during anesthesia induction (median mYPAS-SF score 34.4 [22.9-65.1] vs. 75.0 [45.8-90.6], p < 0.001). Significant anxiety was also associated with younger age of both children and parents, migration background, and inhalational induction.

Conclusions: Anxiety at induction remains difficult to predict during preoperative consultation. While parents performed slightly better than anesthesiologists, both lack sufficient precision. Simple behavioral cues, such as a response to a greeting, may help identify at-risk children early. Future strategies should involve children and parents in individualized anxiety management.

Trial registration: German Clinical Trials Registry, registration number: DRKS00035033.

Background: Infants with gastroschisis represent a high-risk surgical population, particularly in low- and middle-income countries (LMICs) where perioperative resources are constrained. While survival in high-income settings exceeds 90%, reported mortality in Sub-Saharan Africa ranges from 58.1% to 100%. Anesthesia-related adverse events (ARAEs) may contribute to poor perioperative risk, yet data on their incidence and associated factors in this population are limited.

Aims: To describe the incidence and nature of ARAEs in infants with gastroschisis and identify associated risk factors. A secondary aim was to assess the frequency and safety of general anesthesia administered solely for central venous catheter (CVC) procedures.

Methods: A retrospective cohort study of all infants with gastroschisis admitted to Red Cross War Memorial Children's Hospital between 2012 and 2021. ARAEs were defined using criteria from APRICOT and NECTARINE studies. Generalized estimating equations (GEE) were used to account for repeated anesthetic exposures per patient.

Results: Sixty-five infants underwent 196 general anesthetics (median 2 [IQR 1-4] per patient). Sixteen infants underwent 4 or more GAEs for CVC procedures alone. ARAEs occurred in 79 procedures (40.3%), affecting 51 patients (78.5%). Cardiovascular instability was most common, followed by respiratory complications. ARAEs were significantly more frequent during pathology-related surgery than during CVC procedures (45.7% vs. 12.5%; adjusted OR 0.17, 95% CI 0.08 to 0.35, p < 0.001).

Conclusions: ARAEs are common in infants with gastroschisis, particularly during pathology-related procedures. Potential lessons include careful fluid management, anticipatory extubation planning, and reducing repeated anesthetic exposure. Strengthening perioperative data systems in LMICs and conducting prospective studies are needed to identify modifiable risks and develop safe, context-specific care pathways to improve outcomes for infants with gastroschisis in resource-limited settings.

Background: Binaural beats, which induce brainwave entrainment, have reduced anxiety and sedative use. This study evaluated the effect of binaural beats on emergence delirium (ED) in children undergoing strabismus surgery under general anesthesia.

Methods: This randomized controlled trial included 73 pediatric patients aged 2-7 years receiving binaural beats (n = 36) or noise-canceled silence (n = 37) during general anesthesia. ED was defined as a Pediatric Anesthesia Emergence Delirium (PAED) score > 12 or Watcha score > 2. Primary outcome was the incidence of ED. Secondary outcomes included PAED, Watcha, and Faces Legs Activity Cry Consolability (FLACC) scores in the postanesthesia care unit (PACU), intraoperative electroencephalogram band power differences, and PACU stay duration.

Results: The incidence of ED did not significantly differ between groups (38.89% vs. 54.05%; relative risk 1.39 [95% confidence interval (CI), 0.84-2.31]; p = 0.287). However, PAED scores at PACU arrival, at 20 min, and the highest score during PACU stay were significantly lower in the binaural group (median difference -1 [95% CI, -3 to 0]; p = 0.026 at arrival; -4 [95% CI, -4 to 0]; p = 0.035 at 20 min; -1 [95% CI, -3 to 0]; p = 0.048 for the highest score). Watcha and FLACC scores, band powers, and PACU stay duration did not differ significantly between groups.

Conclusions: Binaural beat application during general anesthesia did not significantly reduce the incidence of ED. Exploratory analyses suggested a reduction in maximum PAED score, but this requires further study.

Trial registration: NCT05883280 (registered at http://clinicaltrials.gov (registration number, principal investigator: Jeong-Hwa Seo, registration date: May 22, 2023)).