Pediatric Anesthesia最新文献

Aromatic l-amino acid decarboxylase (AADC) deficiency is a rare autosomal recessive disorder that results in a lack of the monoamine neurotransmitters dopamine, serotonin, norepinephrine, and epinephrine. Patients present with a wide spectrum of symptoms, including motor and autonomic dysfunction, hypotonia, and developmental delay, often before the age of one. Until recently, treatment options were limited to symptom control, but the recent approval of the first gene therapy for AADC deficiency in Europe and the UK has provided an alternative to treating symptoms for this disease. Eladocagene exuparvovec is a one-time gene therapy, administered bilaterally to the putamen by magnetic resonance imaging-guided stereotactic neurosurgery. While administration of the gene therapy itself is minimally invasive, the anesthetic management of patients with AADC deficiency is challenging due to the absence of sympathetic regulation secondary to the lack of adrenergic neurotransmitters. Optimal anesthetic management requires an understanding of the complex and heterogeneous nature of the disease. Hemodynamic instability, temperature dysregulation, and hypoglycemia are of primary concern, but there are also challenges regarding intravenous access and airway management. A thorough preoperative assessment is essential and should be guided by the patient's history. Advanced planning is necessary regarding the timing of the procedure schedule and operative plan; meticulous preparation, simulation for the operating room, as well as communication with all perioperative staff members, are crucial. Intraoperatively, utmost care must be taken to protect the skin, maintain body temperature, and to prepare for inotropic and/or glycemic support as needed. Postoperative intensive care management is necessary for consideration of postoperative extubation and provision of supportive care. With careful planning, preparation, and vigilance, patients with AADC deficiency can safely undergo anesthesia.

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.

Endotracheal tubes (ETTs) are life-supporting devices that are designed to maintain a patent airway in patients who are unable to sustain an airway due to illness or injury. Patients with small airways, such as neonates and pediatrics, have unique structural and functional features, making it essential that ETT design considers and executes on these particular needs. Though uncuffed ETTs have historically been preferred for patients younger than eight years of age, advances in cuffed ETT design and construction can be utilized to manufacture ETTs that are optimized for the smallest, most fragile airways. The purpose of this article is to discuss certain design features of cuffed ETTs in respect to small airways.

Background: Despite known disparities in pediatric perioperative outcomes, few studies have examined factors associated with the use of regional anesthesia for pediatric orthopedic surgery.

Aims: This investigation aimed to determine if minority and developmental disability status were associated with the allocation of peripheral nerve blocks in calcaneal osteotomy.

Methods: We conducted a single-center, retrospective study of records of patients <18 years who underwent calcaneal osteotomy from 2013 to 2023. Regional technique was classified into three groups: popliteal-sciatic single-shot block, popliteal-sciatic catheter, and no block. Patients were classified as either nonminority (white, non-Hispanic) or minority. Developmental disability status was defined based on medical history and classified as binary. Anesthesiologists were classified as "regional" or "nonregional" based on clinical expertise. A Bayesian hierarchical multinomial model with random intercepts for patients and surgeons was used to investigate the association of minority status, developmental disability, and anesthesiologist expertise with block selection.

Results: We analyzed 287 cases in 225 patients; of these, 55% occurred in minority patients and 28% occurred in patients with developmental disability. Catheters were placed in 45% of cases, single shot blocks in 41%, and no block in 14%. Minority and nonminority patients had a similar likelihood of receiving of any block. Patients with developmental disability had a -22% absolute difference of receiving any block (95% credible interval [-38%, -7%]) compared to those without developmental disability (55% vs. 77%), an effect primarily driven by a lower rate of catheter placement in these children. Regional anesthesiologists were more likely to place catheters (23% absolute increase; 36% vs. 13%) and more likely to perform any block in children with developmental disability (30% absolute increase; 67% vs. 37%) than nonregional anesthesiologists.

Conclusions: Decision-making surrounding the placement of regional anesthesia techniques is complex. In this study, developmental disability status and anesthesiologist experience were associated with a difference in the use of regional anesthesia in patients undergoing calcaneal osteotomy.

Introduction: The Society for Pediatric Anesthesia Quality and Safety Committee developed the Pediatric Regional Anesthesia Time-Out Checklist, consisting of 14 safety items intended to be reviewed by an anesthesia team prior to a regional anesthetic. Primarily, we hypothesized that use of this Checklist would increase the number of safety items performed compared with no checklist, evaluating the usefulness of this tool. Secondarily, we hypothesized that, after checklist training, subjects would show better clinical judgment by electing to perform a regional anesthetic in scenarios in which no programmed error existed and electing to not perform a regional anesthetic in scenarios in which a programmed error did exist.

Methods: Each anesthesia attending/trainee pair participated in 12 different randomized video-recorded medium-fidelity regional anesthesia simulation scenarios, receiving checklist training after half of the scenarios had been completed by each pair. In four of the scenarios, subjects were expected to decline to perform the regional anesthetic because of an error programmed into the scenario. Two errors consisted of a maximum dose of local anesthetic given by the surgeon immediately prior to the planned regional anesthetic and two errors consisted of coagulation issues prior to neuraxial block (1 with a low platelet count and 1 receiving low molecular weight heparin). Scenarios were scored for the number of safety items identified and performed by the subjects. Additionally, the team's choice to perform the regional anesthetic or abort was recorded.

Results: One-hundred and thirty-two scenarios were performed by 22 physicians. A greater number of safety items were completed after training on the Pediatric Regional Anesthesia Time-Out Checklist, for each of 11 individual groups and when data from all groups was pooled, p < 0.001, 95% CI (0.33, 0.41). Overall, 78% of safety items studied were performed after checklist training compared to 41% of safety items performed prior to training. The team's choice to perform or abort the regional anesthetic occurred as expected more often (92% of scenarios) after Checklist training, compared to before checklist training (77% of scenarios), t = 3.41; p = 0.001, 95% CI (0.03, 0.27). Teams chose to perform the regional anesthetic despite a programmed error in three scenarios (0.05%) prior to Checklist training and no scenarios (0%) after Checklist training.

Conclusion: Pediatric Regional Anesthesia Time-Out Checklist training led to an increased number of safety items performed prior to a simulated anesthetic.

Background: After-hours pediatric anesthesia may pose increased risks, with a heightened potential for sudden cardio-respiratory decline. While mortality rates are low in Australia and New Zealand, critical events and morbidity occur more frequently and present ongoing challenges. However, little is known about how trainees are supervised during these high-risk periods.

Methods: An anonymized online survey of members of the Society for Pediatric Anesthesia in New Zealand and Australia (SPANZA) was conducted to explore supervising anesthetists attitudes towards after-hours supervision. The survey examined the influence of patient age, medical history, trainee experience, and surgery type on supervision practices.

Results: Respondents identified age and physical status as key risk factors but reported providing less direct supervision than recommended by international studies, especially for non-complex surgeries in healthy children. Trainee experience was a significant factor in supervision decisions.

Conclusion: Pediatric anesthetists in Australia and New Zealand recognize major risk factors but tend to supervise more remotely after-hours. Further research is needed to evaluate the effects of these supervision practices on outcomes.

Background: Neonatal resuscitation airway training can be difficult as there is no feedback on the face mask technique. "JUNO" is a training respiratory function monitor that provides feedback on mask leak, ventilatory rate, and tidal volume.

Objective: To evaluate whether the use of the JUNO improves face mask ventilation techniques in manikin models.

Methods: We conducted an observational cross-over study with our unit staff. Following instructions, each participant performed a single-person technique, followed by a two-person technique with no JUNO feedback. This was repeated with JUNO feedback visible. A similar sequence was performed both in term and preterm manikins, giving a total of 8 sequences. Each participant was instructed to perform 1 min of positive pressure ventilation providing 30 inflations/minute for all of the simulations. Each of the simulation data underwent a data cleaning process.

Results: Thirty-eight subjects provided a total of 304 sequences of positive pressure ventilation. A total of 13 354 inflations were analyzed. The feedback group had significantly lower rates of inflations with leak >60%, lower rates of excessive tidal volumes, lower mean leak percentage, and a lower mean inspiratory tidal volumes. When analyzed based on the technique (single person and two-person), similar positive results were noted in the "feedback group", across all the strata of staff. All of the staff reported that JUNO improved their ventilation technique and would recommend it for staff training.

Conclusions: The use of JUNO significantly improved mask ventilation consistently across manikin types, staff roles, and techniques (either single- or two-person).

Background: Trauma-induced coagulopathy (TIC) is associated with negative outcomes. Pediatric TIC has been described most often in older children. Children undergo normal developmental hemostasis, but it is unknown how this process impacts the risk of TIC across childhood.

Aims: To understand variations in coagulation testing and TIC across pediatric age groups.

Methods: We evaluated testing patterns of coagulation studies at presentation and over the first 72 h of hospitalization by pediatric age group at a large, Level I trauma center, 2015-2020. The frequency of TIC was determined using published, age-specific reference ranges and controlling for injury severity. We performed subgroup analyses of those with isolated severe traumatic brain injury (TBI) and those who presented directly from the scene of injury.

Results: Data from 2409 pediatric patients were available; 333 patients had isolated severe TBI. Children <1 year were least likely to be tested for TIC at presentation and over the first 72 h, even among the most injured. Fibrinogen testing was uncommon, regardless of injury severity. TIC was common: 22% of patients had TIC at presentation and 35% by 72 h. Greater injury severity was associated with TIC. Children 1-4 and 5-9 years had a higher frequency of TIC at presentation and over 72 h compared to older children in the least injured cohort. We saw no difference in frequency of TIC between age groups in the subset with isolated severe TBI. Using age-specific criteria, patients most often met TIC criteria by INR/PT, followed by platelet count, and least commonly by aPTT. The presence of TIC was associated with in-hospital mortality (OR 4.10, 95% CI 2.06-8.17).

Conclusions: Significant sampling bias exists in clinical data collection among injured children and adolescents. Contrary to previous reports and using age-specific TIC criteria, younger children are not at lower risk of TIC than older children when controlling for injury severity.