Pediatric Anesthesia最新文献

Background: Patients with hypoplastic left heart syndrome undergo the comprehensive stage 2 procedure as the second stage in the hybrid approach toward Fontan circulation. The complexity of comprehensive stage 2 procedure is considered a potential limitation, and limited information is available on its anesthetic management. This study aims to address this gap.

Methods: A single-center retrospective cohort study analyzed 148 HLHS patients who underwent comprehensive stage 2 procedure, divided into Group A (stable condition, n = 116) and Group B (requiring preoperative intravenous inotropic therapy, n = 32). Demographic data, intraoperative hemodynamics, anesthetic management, and postoperative outcomes were collected.

Results: Etomidate (40%) was the most common induction agent, followed by esketamine (24%), midazolam (16%), and propofol (13%). Inhaled induction was rarely necessary (2%), occurring only in Group A patients. No statistical differences were found between groups for induction drug choice. Post-cardiopulmonary bypass management included moderate hypoventilation, inhaled nitric oxide (100%), and hemodynamic support with milrinone (97%) and norepinephrine (77%). Group B patients more frequently required additional levosimendan (20%) and epinephrine (18%). Extracorporeal membrane oxygenation was necessary in 8 patients (5%) with no between-group differences. Switching from fentanyl to remifentanil reduced postoperative ventilation time overall. However, Group B experienced significantly longer ventilation (6.3 vs. 3.5 h) and ICU stay (22 vs. 14 days). In-hospital mortality was 5% overall (Group A: 4%, Group B: 9%). Long-term survival analysis revealed a significant advantage for Group A.

Conclusion: The use of short-acting opioids and adjusted ventilation modes enables optimal pulmonary blood flow and rapid transition to spontaneous breathing. Differentiated hemodynamic support with milrinone, norepinephrine, supplemented by levosimendan and epinephrine in high-risk patients, can mitigate the effects on the preoperatively volume-loaded right ventricle. However, differences in long-term survival probability were observed between groups.

Trial registration: Local ethics committee, Medical Faculty, Justus-Liebig-University-Giessen (Trial Code Number: 216/14).

Identifying and treating pediatric arrhythmias is essential for pediatric anesthesiologists. Pediatric patients can present with narrow or wide complex tachycardias, though the former is more common. Patients with inherited channelopathies or cardiomyopathies are at increased risk. Since most pediatric patients present for anesthesia without a baseline electrocardiogram, the first identification of an arrhythmia may occur under general anesthesia. Supraventricular tachycardia, the most common pediatric tachyarrhythmia, represents a broad category of predominately narrow complex tachycardias. Stimulating events including intubation, vascular guidewire manipulation, and surgical stimulation can trigger episodes. Valsalva maneuvers are unreliable as treatment, making adenosine or other intravenous antiarrhythmics the preferred acute therapy. Reentrant tachycardias are the most common supraventricular tachycardia in pediatric patients, including atrioventricular reciprocating tachycardia (due to a distinct accessory pathway) and atrioventricular nodal reentrant tachycardia (due to an accessory pathway within the atrioventricular node). Patients with ventricular preexcitation, often referred to as Wolff-Parkinson-White syndrome, have a wide QRS with short PR interval, indicating antegrade conduction through the accessory pathway. These patients are at risk for sudden death if atrial fibrillation degenerates into ventricular fibrillation over a high-risk accessory pathway. Automatic tachycardias, such as atrial tachycardia and junctional ectopic tachycardia, are causes of supraventricular tachycardia in pediatric patients, the latter most typically noted after cardiac surgery. Patients with inherited arrhythmia syndromes, such as congenital long QT syndrome, are at risk of developing ventricular arrhythmias such as polymorphic ventricular tachycardia (Torsades de Pointes) which can be exacerbated by QT prolonging medications. Patients with catecholaminergic polymorphic ventricular tachycardia are at particular risk for developing bidirectional ventricular tachycardia or ventricular fibrillation during exogenous or endogenous catecholamine surges. Non-selective beta blockers are first line for most forms of long QT syndrome as well as catecholaminergic polymorphic ventricular tachycardia. Anesthesiologists should review the impact of medications on the QT interval and transmural dispersion of repolarization, to limit increasing the risk of Torsades de Pointes in patients with long QT syndrome. This review explores the key anesthetic considerations for these arrhythmias.

Background: Peripherally measured oxygen saturation (SpO₂) may often differ from arterial oxygen saturation (SaO₂), measured by co-oximetry, especially within the lower range of oxygen saturations. This can potentially impact clinical decisions and therapy in children with congenital heart disease, as critical hypoxemia might remain unnoticed.

Aims: Our aim was to investigate the accuracy of two different pulse oximeters compared to SaO₂ in infants with congenital heart diseases.

Methods: Simultaneous recordings of SpO₂, measured by two different pulse oximeters (Philips IntelliVue X3 Monitor and Nellcor™ OxiMax™), were compared to SaO₂ obtained by arterial blood gas analysis.

Results: A total of 153 measurements were performed in 44 infants with arterial oxygen saturation between 70 and 100%. We divided the measurements into 3 subgroups: group 1-SaO₂ 70.0%-85.0%, group 2-SaO₂ 85.1%-94.0%, group 3-SaO₂ >94.1%. For Philipps, the median bias was 5.3 (IQR: 2.6-8.7) %, 2.3 (IQR: 0.9-6.0) % and 1.1 (IQR: -0.8-2.4) % in group 1, 2 and 3, respectively. For OxiMax™, the median bias was 2.7 (IQR: 0.5-5.1) %, 0.2 (IQR: -0.9-2.6) % and -0.5 (IQR: -1.3-0.6) % in group 1, 2 and 3, respectively. Regarding the accuracy of these oximeters, as evaluated with the Accuracy root mean squared index (Arms), it was 9.8 versus 4.5% in group 1, 4.5 versus 2.9% in group 2 and 2.4 versus 1.9% in group 3 for Philipps and OxiMax™, respectively.

Conclusions: In lower range saturations between 70% and 85% the accuracy of both pulse oximeters exceeded the threshold of ≤3% recommended by the Food and Drug Administration (FDA). Therefore, peripheral pulse oximetry within the lower range of oxygen saturations should be interpreted with caution in infants with congenital heart diseases, taking into consideration its limitations. Direct co-oximetry should be the preferred method to support clinical decisions in children with cyanotic congenital heart diseases.

Background: Dexmedetomidine, an α₂-adrenergic agonist, reduces propofol and remifentanil requirements when used as an adjunct to total intravenous anesthesia in adults, but studies in a pediatric population are sparse. This study investigates the magnitude of dose-sparing effects of a postinduction dexmedetomidine bolus on propofol and remifentanil requirements during pediatric surgery.

Methods: In this randomized, double-blind, controlled trial, children aged 2-10 years undergoing elective dental surgery were assigned to one of four groups: placebo, 0.25 mcg/kg dexmedetomidine, 0.5 mcg/kg dexmedetomidine, and 1 mcg/kg dexmedetomidine. Maintenance with fixed-ratio propofol and remifentanil total intravenous anesthesia followed a bispectral index (BIS)-guided algorithm designed to maintain a stable depth of anesthesia. The primary outcomes were time-averaged maintenance infusion rates of propofol and remifentanil. Secondary outcomes in the postanesthetic care unit included sedation scores, pain scores, and time to discharge.

Results: Data from 67 patients were available for analysis. The median [interquartile range] propofol infusion rate was lower in the 1 mcg/kg dexmedetomidine group (180 [164-185] mcg/kg/min) versus placebo (200 [178-220] mcg/kg/min): percent change -10.0%; 95% CI -2.4 to -19.8; p = 0.013. The remifentanil infusion rate was also lower in the 1 mcg/kg dexmedetomidine group (0.089 [0.080, 0.095] mcg/kg/min) versus placebo (0.103 [0.095, 0.106] mcg/kg/min): percent change, -13.7%; 95% CI -5.47 to -21.0; p = .022. However, neither propofol nor remifentanil infusion rates were significantly different in the 0.25 or 0.5 mcg/kg dexmedetomidine groups. In the postanesthesia care unit, there were no differences in pain or sedation scores, and time to discharge was not significantly prolonged in any dexmedetomidine group.

Conclusion: Dexmedetomidine 1 mcg/kg reduced the propofol and remifentanil requirements during maintenance of anesthesia in children when administered as a postinduction bolus.

Trials registration: ClinicalTrials.gov: NCT03422978, date of registration 2018-02-06.

Background: The Nociception Level Index has shown benefits in estimating the nociception/antinociception balance in adults, but there is limited evidence in the pediatric population. Evaluating the index performance in children might provide valuable insights to guide opioid administration.

Aims: To evaluate the Nociception Level Index ability to identify a standardized nociceptive stimulus and the analgesic effect of a fentanyl bolus. Additionally, to characterize the pharmacokinetic/pharmacodynamic relationship of fentanyl with the Nociception Level Index response during sevoflurane anesthesia.

Methods: Nineteen children, 5.3 (4.1-6.7) years, scheduled for lower abdominal or urological surgery, were studied. After sevoflurane anesthesia and caudal block, a tetanic stimulus (50 Hz, 60 mA, 5 s) was performed in the forearm. Following the administration of fentanyl 2 μg/kg intravenous bolus, three similar consecutive tetanic stimuli were performed at 5-, 15-, and 30-min post-fentanyl administration. Changes in the Nociception Level Index, heart rate, mean arterial pressure, and bispectral index were compared in response to the tetanic stimuli. Fentanyl plasma concentrations and the Nociception Level Index data were used to elaborate a pharmacokinetic/pharmacodynamic model using a sequential modeling approach in NONMEM®.

Results: After the first tetanic stimulus, both the Nociception Level Index and the heart rate increased compared to baseline (8 ± 7 vs. 19 ± 10; mean difference (CI95) -12(-18--6) and 100 ± 10 vs. 102 ± 10; -2(-4--0.1)) and decrease following fentanyl administration (19 ± 10 vs. 8 ± 8; 12 (5-18) and 102 ± 10 vs. 91 ± 11; 11 (7-16)). In subsequent tetanic stimuli, heart rate remained unchanged, while the Nociception Level Index progressively increased within 15 min to values similar to those before fentanyl. An allometric weight-scaled, 3-compartment model best characterized the pharmacokinetic profile of fentanyl. The pharmacokinetic/pharmacodynamic modeling analysis revealed hysteresis between fentanyl plasma concentrations and the Nociception Level Index response, characterized by plasma effect-site equilibration half-time of 1.69 (0.4-2.9) min. The estimated fentanyl C50 was 1.93 (0.73-4.2) ng/mL.

Conclusion: The Nociception Level Index showed superior capability compared to traditional hemodynamic variables in discriminating different nociception-antinociception levels during varying fentanyl concentrations in children under sevoflurane anesthesia.

Background: Although direct oral anticoagulants (DOACs) have been used in the adult population for over a decade, DOACs use has begun to rise in pediatric populations since FDA approval of rivaroxaban and dabigatran, DOACs offer several advantages for pediatric patients, to other anticoagulants, including a similar safety profile, minimal lab monitoring, and ease of administration. The rise in DOAC use has led to an increasing number of pediatric patients managed on DOACs presenting for elective and urgent procedures. Perioperative management of anticoagulation is often challenging for providers due to the lack of expert consensus guidelines and the difficulty in balancing a patient's thrombotic risk with bleeding risk for a given procedure.

Aims: Using the most up to date literature, we provide a focused review on the perioperative management of DOACs in pediatric patients.

Conclusions: This work presents a focused review for pediatric anesthesiologists on clinically available DOACs, perioperative monitoring and management of DOACs, as well as options and indications for reversal. While consensus expert practice guidelines are still needed, we hope this work will familiarize perioperative physicians with these agents, recommended uses, and potential perioperative management.

Background: Strabismus surgery, which is commonly performed in children, poses a high risk of postoperative vomiting. The current anesthesia guidelines for the prevention of postoperative vomiting in children are based on heterogeneous populations involving different types of surgery, and risk factors for postoperative vomiting in, specifically, the pediatric strabismus surgery population are unclear. Moreover, the effects of manipulating the deeply attached extraocular muscles and the oculocardiac reflex on this risk remain inconclusive.

Aim: To evaluate the associations among inferior oblique muscle manipulation, the oculocardiac reflex, and postoperative vomiting in children with retrospectively collected data.

Methods: The study had a multicenter retrospective cross-sectional design and was conducted at three institutions (two tertiary-care children's hospitals and one pediatric-adult mixed community hospital). It included children aged < 18 years and without major comorbidities undergoing strabismus surgery. The primary exposure was inferior oblique muscle manipulation during surgery. The outcome of interest was postoperative vomiting or antiemetic medication usage within 24 h postsurgery or by discharge.

Results: Among 3152 children postoperative vomiting occurred in 108/795 (13.6%) children with and 227/2357 (9.6%) without inferior oblique muscle manipulation (unadjusted odds ratio, 1.57; 95% confidence interval, 1.21-2.05; p = 0.001). Multilevel logistic regression analysis, adjusting for potential confounders and surgeon-related variance, revealed that inferior oblique muscle manipulation (adjusted odds ratio, 1.58; 95% confidence interval, 1.15-2.18; p = 0.005), but not the oculocardiac reflex (adjusted odds ratio, 1.06; 95% confidence interval, 0.76-1.48; p = 0.73), was associated with postoperative vomiting after adjusting for confounders.

Conclusions: Stronger preventive measures against postoperative vomiting are recommended in healthy children undergoing strabismus surgery with inferior oblique muscle manipulation. Additionally, inferior oblique muscle manipulation should be considered a potential confounder in future related studies. However, the oculocardiac reflex was not associated with postoperative vomiting in pediatric strabismus surgery.