Pediatric Anesthesia最新文献

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: 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: 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: 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: Satisfying ethical principles of voluntary consent within workflow constraints can be challenging, particularly for anesthesia research, where patients are met on the day of surgery. For parents, the added burden of being a surrogate decision maker may impact willingness to be approached for research on the day of surgery. Our aims were to determine parental attitudes to day of surgery approach for research consent and if study type had any influence.

Methods: We iteratively developed a questionnaire using stakeholder interviews regarding day of surgery approach for research consent. Particular attention was given to (a) research study designs, (b) previous research experience, and (c) types of surgeries. Participants were stratified according to a child's age, child's previous surgical experience, and any family research experience. Enrolment continued until saturation was reached. Interviews were transcribed and analyzed for themes. The final questionnaire included questions designed to determine parental perceptions of the appropriateness of the same day approach, and whether ethical principles would be satisfied if approached on the day of surgery. The second section presented a series of scenarios describing different study types designed to determine if studies with increasing levels of perceived risk would impact parental perception.

Results: Most parents reported that this approach would satisfy ethical principles for voluntary informed consent. Study type was not a determinant except for RCTs, where only half felt a day of surgery approach would be appropriate. The most cited reason for reluctance for RCTs was insufficient time to review details. Parents of younger children (61.1% infants, 56.2% toddlers) were more likely to prefer an alternative time of approach compared to teenagers (36%).

Conclusions: The results of this study are reassuring for pediatric researchers, identifying majority acceptance for day of surgery research consent approaches for most studies. We identified subgroups who preferred alternative timing for approach. Alternate strategies are advised to target these subgroups.

Trial registration: ClinicalTrials.gov identifier: NCT04613505.

Background: Retinoblastoma (RB) is the most common intraocular malignancy diagnosed in early childhood. Treatment is extensive, requiring multiple general anesthetics to facilitate eye examinations. However, little is known how repeated exposure to general anesthesia in early childhood affects cognitive function in RB survivors.

Purpose: The purpose of this cross-sectional study was to examine the effects of anesthesia exposure on cognition in 14- to 26-year-old RB survivors compared with those in healthy controls.

Methods: Patients who previously received care for RB (n = 98) were recruited and compared to a cohort of healthy subjects (n = 97). Participants' cognitive functioning was assessed using the Montreal Cognitive Assessment (MoCA). MoCA scores were compared between groups using Wilcoxon rank-sum tests. Relationships between MoCA scores and anesthesia exposure were assessed using Spearman's rank correlation coefficients. Multiple regression was used to evaluate the effect of anesthesia (both before the age of three and throughout childhood) on cognition.

Results: RB patients scored significantly lower than controls on the MoCA and several of its subscales (Naming, Attention, Language, and Abstraction; adjusted ps < 0.05). Total childhood anesthesia exposure was negatively associated with MoCA total scores (ρ = -0.19, p = 0.009) and some subscale scores. In regression models adjusted for covariates, each time anesthesia was administered before the age of three (β = -0.06, p = 0.02) or throughout childhood (β = -0.04, p = 0.005) was associated with a small but statistically significant decrease in cognition. Hollingshead socioeconomic status (β = 0.04, p = 0.001) and public insurance (β = -1.75, p < 0.0001) were stronger predictors of MoCA total scores than anesthesia exposure.

Conclusion: Despite any effects of repeated anesthesia exposure in early childhood on cognition, MoCA scores for RB survivors were in the normal range. These findings add to the developing research on neurocognitive effects of anesthesia in early childhood in a population with large anesthesia exposure and minimal confounding factors. Future research should include additional measures of neurodevelopmental functioning and focus on the at-risk low socioeconomic status population. Continued follow-up and assessment of visual function in bilateral survivors are imperative.