Pediatric Anesthesia最新文献

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.

Context: On-table extubation after pediatric cardiac surgery has been increasingly considered a safe and effective strategy to reduce postoperative ventilation time. However, concerns regarding reintubation risk, patient selection, and variability in outcomes remain.

Objective: To systematically review the available literature on the effectiveness and safety of on-table extubation compared to off-table extubation in pediatric cardiac surgery. Primary outcomes were reintubation rate, mortality, intensive care unit (ICU) and hospital length of stay (LOS). Secondary outcomes were arterial pH, lactate, and PaCO₂ after surgery.

Data sources: MEDLINE, Cochrane Library, Web of Science, and Embase were searched from inception to January 8th, 2025, without language or date restrictions. Additional studies were identified through the backward snowballing technique.

Study selection: We included randomized controlled trials (RCTs) and observational studies comparing on-table and off-table extubation in pediatric patients (< 18 years) undergoing cardiovascular surgery. Studies with overlapping populations or conference abstracts were excluded.

Data extraction: Two independent reviewers screened studies completed a quality assessment, and extracted data.

Results: Twenty-nine studies (2 RCTs, 27 observational), including 9070 patients, met the eligibility criteria. On-table extubation was associated with lower reintubation rates in most studies, though findings were not consistent across all. Mortality rates were generally comparable between groups. ICU and hospital LOS were consistently shorter in the on-table group. Postoperative blood gas analyses showed a better arterial pH, lactate, and PaCO₂ profile in the on-table group. The risk of bias was elevated between observational studies.

Limitations: Selection bias was present, as the majority of studies were observational, and the decision for on-table extubation was largely based on clinician assessment of suitability and stability at the end of surgery. High heterogeneity across studies limited meta-analysis feasibility.

Conclusion: Although this systematic review suggests that on-table extubation may be associated with potentially better outcomes following pediatric cardiac surgery, no safe conclusions can be drawn about its benefit due to the high heterogeneity and potential high risk of bias of most included studies. Well-designed RCTs are needed to confirm the benefits and safety of on-table extubation and to guide appropriate patient selection.

Trial registration: International Prospective Register of Systematic Reviews (PROSPERO): CRD42025644238.

Background and objective: Endoscopic strip craniectomy is a minimally invasive surgical technique offered to infants for craniosynostosis repair. We examine our institution's experience with infants undergoing this surgery with respect to perioperative physiological parameters, transfusion rates, complications, and length of hospital stay.

Methods: We performed an observational retrospective review of all infants undergoing endoscopic strip craniectomy at Great Ormond Street Hospital, UK from 2019 to 2024. Data were collected via the digital health record system EPIC (Epic Systems Corporation [2023], USA) and analyzed in Microsoft Excel.

Results: One hundred and eleven patients were included in the study undergoing single or multicranial suture repair: metopic (n = 67), unicoronal (n = 27), sagittal (n = 9), frontosphenoidal (n = 2), bicoronal (n = 4), and multisuture (n = 2). We present a mean age of 4.4 months (±1.05 SD), weight 6.95 kg (±1.05 SD), male (n = 66) population predominance, and ASA score from 1 to 3. Surgical procedure time was 73 min (±23 SD) across all sutures, with multisuture repair requiring a longer operative time of 96 min (±15 SD). The overall red cell transfusion rate was 1 in 5 children, with a higher incidence in those undergoing metopic suture repair (18/67, 26%). Mean preoperative and postoperative hemoglobin in the single suture repair group was 114 g/L (±11 g/L SD) and 87 g/L (±13 g/L SD) resulting in a mean reduction in hemoglobin of 26 g/L (±15 g/L SD). Mean preoperative and postoperative hemoglobin in the bilateral or multisuture repair group was 118 g/L (±7.17 g/L SD) and 85.5 g/L (±14.29 g/L SD) resulting in a mean reduction in hemoglobin of 35 g/L (±15 g/L SD). One hundred and six infants (95%) were discharged on Day 1 postoperatively, and no children required high dependency care. Complications reported were inadvertent extubation on positioning (n = 2), laryngospasm (n = 1), and a minor transfusion reaction (n = 1).

Conclusion: Endoscopic strip craniectomy is a well-established minimally invasive surgical technique. Anesthesia for this procedure is typically performed in young infants who may be at greater risk of perioperative anesthetic complications and clinically significant blood loss and blood transfusion. We report a > 20% transfusion rate in our infant cohort mostly with metopic repairs.

Introduction: Optimal positioning of the endotracheal tube is a crucial step in the airway management of neonates. Short airway length creates a narrow margin of safety and thus a higher chance of ETT malpositioning. Published literature reports airway length of 5-7.5 cm, which is primarily based on autopsy and radiologic studies. We decided to measure the airway length in neonates undergoing surgeries using flexible fiberoptic bronchoscopy (FFOB).

Methodology: Sixty full-term neonates, scheduled for surgery under general anesthesia with endotracheal intubation, were included in the study. Neonates with airway anomalies and anticipated difficult airways were excluded. Airway length was measured using FFOB.

Results: Sixty neonates were included in the study. The mean airway length ± SD was 3.85 ± 0.71 cm. The mean ± SD length in males was 3.87 ± 0.63 cm, and in females was 3.82 ± 0.86 cm. The Spearman rank correlation coefficient of airway length (cm) with age was 0.139, and for weight was 0.130.

Conclusion: Airway length is much smaller in neonates as compared to that reported in the literature. Airway dimensions need reassessment in this population in order to improve safety and effectiveness of neonatal intubation practices.

Background: It is recognized that the perioperative anesthetic management of children with long QT syndrome may be complex, as they are at risk of life-threatening arrhythmias such as ventricular tachycardia, torsades des pointes, ventricular fibrillation, or severe bradycardia. There is uncertainty regarding the incidence of complications as well as which techniques might be acceptable or preferable in this group of patients.

Aims: In collaboration with the Congenital Cardiac Anesthesia Network, we conducted a prospective audit of the anesthetic management, complications, and outcomes of children with long QT syndrome.

Methods: Following receipt of ethics committee approval and an extensive process of communication within the Congenital Cardiac Anesthesia Network and elsewhere, over approximately a two-year period in the United Kingdom we prospectively collected fully anonymized data relating to the anesthetic management of children with long QT syndrome using an online secure reporting portal.

Results: 90 episodes of anesthesia for cardiac/cardiological (44) and non-cardiac (46) procedures were reported in 81 patients, with a median age of 6 years and a median weight of 22 kg. 59% were male. In 57 patients (70%), the diagnosis of long QT syndrome had been confirmed by genotyping. Where available, the QTc on a preoperative ECG ranged from 340 to 650 milliseconds. 14 patients had a history of previous out-of-hospital cardiac arrest, and 18 patients had an in situ cardiac pacing/defibrillation system. Three patients had a previous history of major complications under anesthesia, including ventricular tachycardia or ventricular fibrillation. Three patients experienced a significant complication, including intermittent atrioventricular block, ventricular tachycardia, changes in QRS morphology on the electrocardiograph, and bradycardia necessitating cardiopulmonary resuscitation. Both intravenous and inhalational agents were used perioperatively. No patient required unplanned admission to an intensive care unit. In every case, the patient was anesthetized by a consultant.

Conclusions: This complex group of patients has a significant complication rate under general anesthesia. Perioperative management of such patients should be delivered by experienced anesthetists, and in the majority of cases, it is appropriate for this to take place in centers where there is relevant additional cardiological expertise.

Background: There is difficulty completing outpatient procedures in children with complex developmental and behavioral diagnoses. These visits may require increased personnel and incur delays.

Aims: We sought to evaluate if an interdisciplinary team of providers, nurses, and a clinical pharmacist dedicated to advanced preparation (e.g., discussing patient, reviewing concerns with procedure completion, understanding medication needs) and the development of a pre-appointment plan can streamline outpatient visits.

Methods: Pediatric patients with complex behavioral disorders requiring a procedure at an outpatient visit were evaluated retrospectively using pre- and post-implementation data. Outcomes assessed were duration of outpatient appointment and procedural sedation times, procedure success, and description of pharmacist interventions as part of the team. Data are reported descriptively.

Results: Thirty-five patients were included: 17 pre- and 18 post-implementation of the team. Median appointment and sedation times were reduced in the post- compared to the pre-implementation group, 133 min (IQR 98-178) vs. 173 min (IQR 153-190) (p = 0.08) and 40 min (IQR 30-54) vs. 75 min (IQR 45-100) (p = 0.02), respectively. There was no difference in procedure success, and 15 pharmacist interventions were made in six patients in the post-implementation group related to drug-drug interactions, premedication selection, and dose recommendations.

Conclusions: An interdisciplinary sedation team focused on pre-appointment planning for complex pediatric behavioral patients requiring a procedure in the outpatient setting was associated with reduced appointment and sedation times, a clinically and statistically significant finding, respectively. Future studies should focus on resource utilization and patient and caregiver satisfaction.

Background: High-flow oxygen in children prolongs the apnea time. The exact mechanism remains unclear.

Aims: This study investigated whether low- and high-flow nasal oxygen are non-inferior to very high-flow oxygen in preventing lung volume loss during apnoea in children under general anesthesia. We also examined whether early onset oxygen using the Optiflow Switch cannula reduces lung volume loss compared to conventional late-onset application. Finally, we assessed the timing and regional distribution of lung volume changes using electrical impedance tomography (EIT).

Methods: We conducted a single center randomized controlled non-inferiority trial. After Ethics Committee approval and informed consent, we recruited 108 children (ASA1 and 2, 10-20 kg) undergoing elective general anesthesia. The primary endpoint was the normalized reduction in lung volume in relation to body weight (mL kg^-1) after termination of facemask ventilation from start to end of apnoea measured with EIT. After induction of anesthesia and neuromuscular blockade, patients were left apnoeic for 5 min receiving humidified and heated oxygen with a high-flow system at different flow rates: (1) Low-flow 0.2 L min^-1 kg^-1; (2) High-flow 2 L min^-1 kg^-1; (3) Very high-flow 4 L min^-1 kg^-1(control group); (4) Early onset of high-flow 2 L min^-1 kg^-1 with Optiflow Switch. Normalization of impedance change to 6-8 mL kg^-1 in relation to body weight and changes in lung volume from start to end of apnoea were measured.

Results: 89/108 children were analyzed (low-flow n = 20, high-flow n = 24, very high-flow n = 21 and early onset high-flow n = 24.). The estimated mean (95% CI) reduction in lung volume was: low-flow 5.9 (5.3-7.8) mL kg^-1, high-flow 6.5 (5.3-7.8) mL kg^-1, very high-flow (control) 5.7 (4.4-7.0) mL kg^-1, and early onset high-flow 6.7 (5.5-7.9) mL kg^-1. Non-inferiority could be demonstrated only for the low-flow group compared to the control group.

Conclusions: Apnoeic oxygenation with low-flow is non-inferior to very high-flow regarding lung volume loss in children. An early onset of apnoeic oxygenation after facemask ventilation may delay lung volume loss during apnoea.