Pediatric Anesthesia最新文献

Background: Despite advances in medical care, noncardiac surgery in children with congenital heart disease (CHD) remains associated with considerable perioperative morbidity and mortality. This study evaluates trends in postoperative outcomes after noncardiac surgery in children with and without CHD across two time periods.

Aims: We aimed to determine and compare the incidence of adverse outcomes following noncardiac surgery in a large cohort of children without CHD, in children with minor CHD, major CHD, and severe CHD, across two time periods (2012-2016 and 2017-2022, excluding 2020).

Methods: Children undergoing noncardiac surgery from 2012 to 2022 were identified from the ACS-NSQIP Pediatric database, excluding 2020. Patients were stratified by CHD severity (none, minor, major, severe) and by era (2012-2016 vs. 2017-2022). Outcomes included 30-day mortality, cardiac arrest, reintubation, reoperation, and readmission. Multivariable logistic regression was used to compare outcomes across eras, adjusting for demographic, clinical, and procedural variables.

Results: Among 1 023 638 children, there were 88.3% patients with no CHD and 11.7% with CHD (5.9% minor, 5.2% major, 0.6% severe). Improvements were seen across all CHD subgroups, particularly in reintubation and readmission rates. The most consistent improvement was in reintubation, including in severe CHD (aOR 0.69; 95% CI: 0.53, 0.89; p = 0.005).

Conclusion: These findings demonstrate meaningful improvements in postoperative outcomes over time, notably reduced rates of 30-day mortality, reintubation, and readmission in the non-CHD group. Patients with minor and major CHD experienced significant declines in reintubation and readmission, while those with severe CHD showed reduced reintubation. Despite rising CHD prevalence and complexity, improvements likely reflect advances in perioperative care, risk stratification, and multidisciplinary management at specialized centers for children undergoing noncardiac surgery.

There exists, across the world, significant variation in pre-operative pediatric fasting guidance for breast, formula, and cow's milk. Alongside recent shifts toward liberal clear liquid intake in response to prolonged fasts, there is also a trend emerging toward more liberal milk fasts. This narrative review aims to shed light on the following questions on the topic of pre-operative fasting of milks in children: What current published guidelines exist, what do they recommend and why? What benefits might reduced fasting times provide? Is there evidence that shorter fasting rules are as safe as longer fasting rules? What is the physiology of gastric emptying for milks? What is the evidence that gastric emptying differs for cow's, formula, or breast milk, and does age have an influence? The extent to which we are currently able to answer these questions aims to both better inform those formulating perioperative fasting guidelines and to stimulate standardized research into gastric emptying and pre-operative fasting of milk in children.

Background: Effective pain management during peripherally inserted central catheter placement in neonates and pediatric patients remains challenging, often leading to procedural distress and suboptimal outcomes.

Aim: This randomized controlled trial aimed to evaluate the analgesic efficacy of brachial plexus block compared to local infiltration anesthesia during peripherally inserted central catheter placement.

Methods: Seventy patients were randomized into two groups: brachial plexus block (Group B) and local infiltration anesthesia (Group C). Procedural pain was assessed using the Comfort Neo Scale at T = 0 min (puncture) and T = 30 min (30 min after the procedure). Secondary outcomes included the first-attempt success rate, procedure time, number of puncture attempts, and rescue analgesic use. All interventions were performed under ultrasonographic guidance. Continuous data are expressed as medians [interquartile range (IQR)].

Results: The median Comfort Neo Scale scores at T = 0 were significantly lower in Group B (6 [6-6]) than in Group C (30 [30-30]; difference: -24, 95% CI: -24 to -24, p < 0.0001). At T = 30, the scores remained lower in Group B (6 [6-6]) than in Group C (22 [12-30]; difference: -16, 95% CI: -19 to -10, p < 0.0001). Group B also demonstrated shorter procedure times (30 [20-30] vs. 40 [30-50] min; difference: -10 min, 95% CI: -20 to -10, p < 0.0001), higher first-attempt success rates (61% vs. 38%; odds ratio: 0.08, 95% CI: 0.03-0.26, p < 0.0001), and fewer puncture attempts (1 [1-2] vs. 2 [1-3]; difference: -1, 95% CI: -2 to 0, p < 0.001). Rescue analgesic use and pain-related movements were significantly reduced in Group B (odds ratio for pain-related movement: ∞, 95% CI: 109-∞, p < 0.0001).

Conclusions: Brachial plexus block provides superior pain relief and procedural outcomes compared to local infiltration anesthesia during peripherally inserted central catheter placement in neonates and pediatric patients. Its adoption as a standard pain management approach can enhance patient comfort, improve efficiency, and reduce procedural distress. Future studies should explore the broad applicability and long-term benefits of this approach.

Trial registration: Japan Registry of Clinical Trials (jRCT): jRCT1010220045.

Background: Safe and effective anesthesia is critical for the care of pediatric patients with congenital heart disease undergoing cardiac catheterization. Over the past two decades, there has been a significant transition from primarily diagnostic procedures to complex interventional cases, accompanied by a shift from operator-managed sedation to anesthesia administered by a trained anesthesiologist.

Aims: The aim of our study is to explore the incidence of high severity anesthesia related adverse events (ARAE) and whether these rates correlate with Procedural Risk in Congenital Cardiac Catheterization (PREDIC³T) case-type risk categories. Higher risk categories have been shown to correlate with high severity procedural related adverse events.

Methods: A multicenter, retrospective cohort study utilized data collected prospectively in the Congenital Cardiac Catheterization Project on Outcomes (C3PO). This study, encompassing 18 contributing institutions, analyzed data from January 1, 2019 to December 31, 2023. Rates of 17 specific ARAE were stratified via PREDIC³T category.

Results: During the study period, 38, 021 cardiac catheterizations were included in this analysis. A total of 321 ARAE of any severity (level 1-5) were recorded, for an overall rate of 0.8% (CI, 0.7%-0.9%). Of these 321 ARAE, 160 were high severity (level 3bc/4/5), yielding a rate of 0.4%. Rates of high severity ARAE by PREDIC³T risk category (0,1, 2, 3, 4, 5) were found to be 0.2%. 0.4%, 0.5%, 0.3%. 0.8%, and 0.7%, respectively. Multivariable logistic regression analyses identified weight under 10 kg, hemodynamic vulnerability score (HVS) ≥ 1, and PREDIC³T risk category 5 procedures as factors associated with higher odds of experiencing a high severity ARAE.

Conclusions: The overall rate of ARAE, including high severity ARAE, was found to be increased in higher PREDIC³T risk category procedures. Both patient and procedural factors contribute to ARAE in the congenital cardiac catheterization laboratory.

Clinical trial number and registry: Not applicable.

Introduction: Neonates undergoing cardiac surgery face a high risk of neurological injury and neurodevelopmental complications. Transcranial Doppler monitoring is used and validated in adults to measure cerebral blood flow and can provide valuable insights into cerebral perfusion in neonates. Nevertheless, it has not been widely introduced in neonatal cardiac surgery.

Aims: This study aims to evaluate the feasibility of continuous bilateral transcranial Doppler monitoring for assessing cerebral perfusion during neonatal cardiac surgery.

Methods: Continuous transcranial Doppler monitoring was employed during neonatal cardiac surgery with a commercially available transcranial Doppler system and fixation materials. Cerebral blood flow velocity, invasive arterial blood pressure, and other key physiological parameters were measured throughout the procedures.

Results: A total of 44 procedures were monitored. Four were excluded due to storage problems (n = 2), inadequate time to apply the probes (n = 1), and subject drop-out due to lower surgery severity (n = 1). Bilateral sufficient signal quality was obtained in all patients at the start. Unilateral signal deterioration occurred in 1 (2.5%) of left middle cerebral artery measurements and in 3 (7.5%) of right middle cerebral artery measurements. Mean (SD) left/right MCA CBFV were: pre-bypass 17.2 (6.4)/15.4 (6.8) cm/s, during bypass 10.8 (4.0)/10.2 (4.3) cm/s, and post-bypass 18.4 (5.9)/16.1 (5.1) cm/s. Mean (SD) ABP was 38.1 (4.4) mmHg pre-bypass, 38.0 (5.1) mmHg during bypass, and 47.8 (4.7) mmHg post-bypass.

Conclusions: This study demonstrates that bilateral transcranial Doppler monitoring is feasible during neonatal cardiac surgery when performed within the recommended operational safety limits. Transcranial Doppler provides real-time information on cerebral blood flow, complementing existing tools.

Trial registration: ClinicalTrials.gov identifier: NCT04713605.

Background: Telemedicine has emerged as a valuable tool in healthcare, especially in the wake of the COVID-19 pandemic, showcasing high satisfaction rates across various medical fields. But its potential benefits for pre-anesthetic evaluation in children have not been widely studied.

Method: This pilot randomized controlled trial involves 70 pediatric patients aged 3-12 years compares telemedicine (Group T) with conventional, that is, in-person assessments (Group C), with the primary outcome being the number of visits required for pre-anesthetic checkup, while secondary outcomes include cancellation rates on the day of surgery, duration of consultation, parent/guardian satisfaction rates and concordance of pre-anesthesia checkups between anaesthesiologists.

Result: Telemedicine demonstrated comparable effectiveness to in-person assessments, with no statistically significant difference in the number of visits required for anesthesia clearance (mean visits: 1.54; 95% CI: 1.27-1.81 in group T vs. 1.69; 95% CI: 1.42-1.96 in group C). Surgical cancellations or delays occurred in fewer than one case per group. The duration required for primary anesthesia clearance during the initial session in Group T took longer (17 min 22 s; 95% CI: 15 min 25 s-19 min 20s) than in Group C (13 min 19 s; 95% CI: 11 min 47 s-14 min 50s). This difference may be attributed to parental/guardian unfamiliarity with Zoom and the challenges of home-based assessments, but high satisfaction scores (mean total 5-point likert satisfaction score = 20.74 ± 1.93 out of 25) suggest acceptance among parents/guardians. Concordance rates between anaesthesiologists for medical history, investigations, documentation, ASA status, and anesthesia plan were high (> 85% of cases) using telemedicine except for airway assessment as it was in agreement in only 45.7% of cases.

Conclusion: Telemedicine is offering similar clinical outcomes, high parental satisfaction, and greater accessibility and thus underscores its potential to enhance accessibility and convenience in pediatric pre-anesthesia evaluations without compromising clinical quality.

Trial registration: Clinical trial number: CTRI/2022/11/047193.

Introduction: Pediatric musculoskeletal and cancer surgeries often lead to significant postoperative pain. Augmented reality (AR), a non-pharmacological approach to pain modulation, has been insufficiently studied for its potential role in reducing opioid use following major surgery in children.

Methods: In this pilot trial, we randomly assigned pediatric patients undergoing major surgery, in a 1:1 ratio, to an AR versus non-AR scavenging game postoperatively. Randomization was stratified according to the study site. The primary endpoint was the rate of persistent opioid use measured at 90 days after hospital discharge. Secondary endpoints included pain intensity, opioid use, inpatient ambulation or "out of bed", movement, length of stay, and adverse events. We considered the trial a success if the rate of opioid use at 90 days postoperatively was significantly lower in the AR arm than in the non-AR arm.

Results: A total of 66 patients underwent randomization (n = 33 in each arm). The median age of each group was 12 years old. There were more females (72.7%) in the AR group than in the non-AR group (48.5%). Most patients (80%) had undergone oncological surgeries. The primary endpoint was met in over 95% of the patients. The overall rate of opioid use was low in both groups of patients (AR: 6.1% and non-AR: 9.7%) and did not reach statistical significance (p = 0.667). There were no statistically significant differences in secondary outcomes.

Conclusion: In conclusion, this pilot study does not support the use of AR aimed at reducing the rate of persistent opioid use following pediatric surgery.

Pediatric total intravenous anesthesia (TIVA) with propofol is well-established, safe, and offers advantages over volatile anesthesia. Nevertheless, its use remains limited because of inadequate training and knowledge, lack of confidence, perceived complexity, and uncertainty or limited awareness of its benefits. This error traps article explores key principles for the safe and effective use of pediatric TIVA, including pharmacological principles, the role of adjunct agents, practical aspects of drug delivery, electroencephalography-based monitoring, and the use of TIVA in specific populations.

Background: Pain in children is undertreated. An assessment scale co-designed with children, parents, and health care professionals could lead to more effective pain assessments and treatment strategies aimed at reducing pain and pain-related symptoms. There are analogue scales validated for self-report of pain in children, but today, children regularly use digital technology, which healthcare should align with. The newly developed electronic Faces Thermometer Scale is a digital assessment scale that needs further validation before it may be recommended for self-reporting pain intensity.

Aims: The study aimed to determine the convergent and discriminant validity of a new digital pain assessment scale in a pediatric postoperative setting.

Methods: The study was performed at a pediatric surgery department in southern Sweden. A total of 88 children were included, generating 716 assessments. Convergent validity was established by comparing the well-validated Colored Analogue Scale and Faces Pain Scale Revised with the electronic Faces Thermometer Scale. Pain assessments were conducted at three different time points: one before surgery, one once the participant became alert and aware, and one 30-45 min after the second time point. A p-value of 0.05 was considered statistically significant. Discriminant validity was established by comparing a potential non-painful situation with a painful situation using the electronic Faces Thermometer Scale.

Results: The agreement between the scales at different time points, as well as across different ages and gender, showed a statistically significant correlation: Kendall's Tau B correlation coefficient varied between 0.61 and 0.79 at different time points. The electronic Faces Thermometer Scale was able to discriminate pain across different age groups and genders. There was a statistically significant difference between pre- and postoperative assessments, and the Clopper-Pearson proportion ranged from 0.70 to 0.90.

Conclusions: The electronic Faces Thermometer Scale provides a valid digital scale for self-report of pain within pediatric postoperative care.