{"title":"In this issue September 2020.","authors":"A. Davidson","doi":"10.1111/pan.14003","DOIUrl":"https://doi.org/10.1111/pan.14003","url":null,"abstract":"","PeriodicalId":281130,"journal":{"name":"Paediatric anaesthesia","volume":"209 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2020-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"123065284","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
One of the most widely used options for minimal/moderate sedation in pediatric patients is oral midazolam, as it presents an alternative to less well‐accepted routes of administration (eg, intravenous or intranasal) of this well‐known efficacious and well‐tolerated short‐acting benzodiazepine. A systematic review of the literature was conducted in order to identify clinical studies evaluating the effectiveness of oral midazolam for sedation in pediatric patients in the context of premedication before anesthesia or during diagnostic/treatment procedures. The percentage of responders (response rate) after single administration of oral midazolam was evaluated and compared versus placebo in a subset of placebo‐controlled studies. The range of oral midazolam doses providing effective sedation in the different pediatric age subsets was analyzed in order to assess optimum dosing strategies. A total of 25 pediatric clinical studies, utilizing a variety of measures of sedation effectiveness, were selected. These studies included a total of 1472 patients (aged 4 months‐18 years) treated with midazolam (0.25‐1.5 mg/kg) and 138 patients treated with placebo. The response rates [95% confidence interval] with oral midazolam ranged from 36.7% [21.6%, 54.9%] to 97.8% [86.1%, 99.7%], while with placebo response rates ranged from 4.0% [0.6%, 23.5%] to 41.0% [29.4%, 53.6%]. When considering the 4 placebo‐controlled studies, the odds ratios [95% confidence interval] for the comparison of midazolam vs. placebo ranged from 13.4 [5.0, 36.0] to 25.9 [6.7, 100.6]. The analysis of subgroups by context of sedation showed response rates [95% confidence interval] with oral midazolam ranging from 36.7% [21.6%, 54.9%] to 97.0% [94.8%, 98.3%] for anesthetic premedication and from 56.1% [43.1%, 68.4] to 97.8% [86.1%, 99.7%] for medical procedures. The efficacy of midazolam for pediatric minimal/moderate sedation from a dose of 0.25 mg/kg and above was demonstrated. The probability of occurrence of adverse events and over‐sedation increases with increasing doses.
{"title":"Efficacy of oral midazolam for minimal and moderate sedation in pediatric patients: A systematic review","authors":"M. Manso, C. Guittet, F. Vandenhende, L. Granier","doi":"10.1111/pan.13747","DOIUrl":"https://doi.org/10.1111/pan.13747","url":null,"abstract":"One of the most widely used options for minimal/moderate sedation in pediatric patients is oral midazolam, as it presents an alternative to less well‐accepted routes of administration (eg, intravenous or intranasal) of this well‐known efficacious and well‐tolerated short‐acting benzodiazepine. A systematic review of the literature was conducted in order to identify clinical studies evaluating the effectiveness of oral midazolam for sedation in pediatric patients in the context of premedication before anesthesia or during diagnostic/treatment procedures. The percentage of responders (response rate) after single administration of oral midazolam was evaluated and compared versus placebo in a subset of placebo‐controlled studies. The range of oral midazolam doses providing effective sedation in the different pediatric age subsets was analyzed in order to assess optimum dosing strategies. A total of 25 pediatric clinical studies, utilizing a variety of measures of sedation effectiveness, were selected. These studies included a total of 1472 patients (aged 4 months‐18 years) treated with midazolam (0.25‐1.5 mg/kg) and 138 patients treated with placebo. The response rates [95% confidence interval] with oral midazolam ranged from 36.7% [21.6%, 54.9%] to 97.8% [86.1%, 99.7%], while with placebo response rates ranged from 4.0% [0.6%, 23.5%] to 41.0% [29.4%, 53.6%]. When considering the 4 placebo‐controlled studies, the odds ratios [95% confidence interval] for the comparison of midazolam vs. placebo ranged from 13.4 [5.0, 36.0] to 25.9 [6.7, 100.6]. The analysis of subgroups by context of sedation showed response rates [95% confidence interval] with oral midazolam ranging from 36.7% [21.6%, 54.9%] to 97.0% [94.8%, 98.3%] for anesthetic premedication and from 56.1% [43.1%, 68.4] to 97.8% [86.1%, 99.7%] for medical procedures. The efficacy of midazolam for pediatric minimal/moderate sedation from a dose of 0.25 mg/kg and above was demonstrated. The probability of occurrence of adverse events and over‐sedation increases with increasing doses.","PeriodicalId":281130,"journal":{"name":"Paediatric anaesthesia","volume":"55 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2019-10-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"125083627","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-10-01DOI: 10.1093/med/9780198755791.003.0012
S. Roberts
Pain is amongst the most frequently occurring problems anaesthetists are confronted with in paediatric clinical settings and can be due to trauma, illness, surgery, or procedures. It remains one of the most challenging issues that clinicians have to manage during hospital admission. Despite the significant strides made over the last 30 years, pain management practices continue to fall short of exemplary and children continue to experience needless moderate to severe pain in hospital. ‘Child’ refers to any individual between birth and eighteen years of age. Within this age range there are broad variations in cognitive, physical and socio-emotional development that significantly impact and influence pain assessment and pain management strategies. Effective pain management requires adaptation and tailoring of treatment strategies for each individual rather than a rigid application of formulae, and while it is not always possible or feasible to eradicate all pain, practitioners should endeavour to reduce it to a tolerable level. This chapter aims to provide trainees with a highly practical and easy-to-access overview of pain management strategies that are appropriate and effective. It contain core information that will enable anaesthetic trainees to identify the most appropriate pain management therapies for paediatric patients. The information presented is brief and succinct, providing an essential up-to-date, rational, and logical approach to pain management in children.
{"title":"Pain and sedation","authors":"S. Roberts","doi":"10.1093/med/9780198755791.003.0012","DOIUrl":"https://doi.org/10.1093/med/9780198755791.003.0012","url":null,"abstract":"Pain is amongst the most frequently occurring problems anaesthetists are confronted with in paediatric clinical settings and can be due to trauma, illness, surgery, or procedures. It remains one of the most challenging issues that clinicians have to manage during hospital admission. Despite the significant strides made over the last 30 years, pain management practices continue to fall short of exemplary and children continue to experience needless moderate to severe pain in hospital. ‘Child’ refers to any individual between birth and eighteen years of age. Within this age range there are broad variations in cognitive, physical and socio-emotional development that significantly impact and influence pain assessment and pain management strategies. Effective pain management requires adaptation and tailoring of treatment strategies for each individual rather than a rigid application of formulae, and while it is not always possible or feasible to eradicate all pain, practitioners should endeavour to reduce it to a tolerable level. This chapter aims to provide trainees with a highly practical and easy-to-access overview of pain management strategies that are appropriate and effective. It contain core information that will enable anaesthetic trainees to identify the most appropriate pain management therapies for paediatric patients. The information presented is brief and succinct, providing an essential up-to-date, rational, and logical approach to pain management in children.","PeriodicalId":281130,"journal":{"name":"Paediatric anaesthesia","volume":"8 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2019-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"122141230","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-10-01DOI: 10.1093/med/9780198755791.003.0002
Thomas M. Engelhardt
Differences in pharmacokinetics and pharmacodynamics are important in small children. This chapter provides an overview of essential pharmacokinetic parameters and developmental aspects. Intravenous anaesthetic agents, including total intravenous anaesthesia models, are described. An overview of commonly used inhalational anaesthetic agents, sedatives, and neuromuscular blockers is given. The analgesic sections describe opioids, simple analgesics, and local anaesthetic agents. Paediatric indications, common side effects, and dosing are included for each agent. A fundamental understanding of developmental differences is key to the safe and effective use of anaesthetic drugs in children.
{"title":"Pharmacology and fluids","authors":"Thomas M. Engelhardt","doi":"10.1093/med/9780198755791.003.0002","DOIUrl":"https://doi.org/10.1093/med/9780198755791.003.0002","url":null,"abstract":"Differences in pharmacokinetics and pharmacodynamics are important in small children. This chapter provides an overview of essential pharmacokinetic parameters and developmental aspects. Intravenous anaesthetic agents, including total intravenous anaesthesia models, are described. An overview of commonly used inhalational anaesthetic agents, sedatives, and neuromuscular blockers is given. The analgesic sections describe opioids, simple analgesics, and local anaesthetic agents. Paediatric indications, common side effects, and dosing are included for each agent. A fundamental understanding of developmental differences is key to the safe and effective use of anaesthetic drugs in children.","PeriodicalId":281130,"journal":{"name":"Paediatric anaesthesia","volume":"1 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2019-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"129595430","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-10-01DOI: 10.1093/med/9780198755791.003.0019
E. Carver, DOUG J.G. Johnson
Maxillofacial surgery in paediatrics ranges from straightforward oral surgery to complex reconstructive surgery of the maxilla and mandible in cases of congenital or acquired abnormality. Craniofacial surgery is undertaken in supra-regional units and involves a multidisciplinary team of maxillofacial, neuro, and plastic surgeons. Much of craniofacial surgery in paediatrics is for craniosynostosis (premature fusion of one or more sutures of the skull) and can involve significant blood loss. Cleft lip and palate surgery in the UK is undertaken in a small number of regional centres, mainly by plastic surgeons. Anaesthesia for these specialities requires clear understanding of the procedure to be undertaken and readiness for potential perioperative complications. All these areas of practice need a good knowledge of, and ability in, the management of the difficult airway.
{"title":"Maxillofacial, craniofacial, and cleft surgery","authors":"E. Carver, DOUG J.G. Johnson","doi":"10.1093/med/9780198755791.003.0019","DOIUrl":"https://doi.org/10.1093/med/9780198755791.003.0019","url":null,"abstract":"Maxillofacial surgery in paediatrics ranges from straightforward oral surgery to complex reconstructive surgery of the maxilla and mandible in cases of congenital or acquired abnormality. Craniofacial surgery is undertaken in supra-regional units and involves a multidisciplinary team of maxillofacial, neuro, and plastic surgeons. Much of craniofacial surgery in paediatrics is for craniosynostosis (premature fusion of one or more sutures of the skull) and can involve significant blood loss. Cleft lip and palate surgery in the UK is undertaken in a small number of regional centres, mainly by plastic surgeons. Anaesthesia for these specialities requires clear understanding of the procedure to be undertaken and readiness for potential perioperative complications. All these areas of practice need a good knowledge of, and ability in, the management of the difficult airway.","PeriodicalId":281130,"journal":{"name":"Paediatric anaesthesia","volume":"198 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2019-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"132964103","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-10-01DOI: 10.1093/med/9780198755791.003.0026
A. Moores
It is not uncommon for a child or infant to present with a congenital syndrome or condition that may have specific implications for the conduct of their anaesthesia. There are many thousands of such syndromes in existence. This chapter focuses on a few of the more commonly known syndromes and conditions, with emphasis on their clinical features, anaesthetic management, and potential problems that may arise during the perioperative period.
{"title":"Comorbidities and syndromes","authors":"A. Moores","doi":"10.1093/med/9780198755791.003.0026","DOIUrl":"https://doi.org/10.1093/med/9780198755791.003.0026","url":null,"abstract":"It is not uncommon for a child or infant to present with a congenital syndrome or condition that may have specific implications for the conduct of their anaesthesia. There are many thousands of such syndromes in existence. This chapter focuses on a few of the more commonly known syndromes and conditions, with emphasis on their clinical features, anaesthetic management, and potential problems that may arise during the perioperative period.","PeriodicalId":281130,"journal":{"name":"Paediatric anaesthesia","volume":"14 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2019-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"115091869","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-10-01DOI: 10.1093/med/9780198755791.003.0028
P. Murphy, S. Stibbards
This chapter provides the reader with a simple approach to managing the sick child who needs medical stabilization and then transfer to a tertiary centre. The dangers of transferring a patient and a joint approach by referring and receiving centres is discussed. A pre-transfer checklist is included to promote safe practice in an often stressful and unfamiliar environment. The chapter also briefly covers some of the issues of air transfer with these patients.
{"title":"Stabilizing and transferring the critically ill child in a general hospital","authors":"P. Murphy, S. Stibbards","doi":"10.1093/med/9780198755791.003.0028","DOIUrl":"https://doi.org/10.1093/med/9780198755791.003.0028","url":null,"abstract":"This chapter provides the reader with a simple approach to managing the sick child who needs medical stabilization and then transfer to a tertiary centre. The dangers of transferring a patient and a joint approach by referring and receiving centres is discussed. A pre-transfer checklist is included to promote safe practice in an often stressful and unfamiliar environment. The chapter also briefly covers some of the issues of air transfer with these patients.","PeriodicalId":281130,"journal":{"name":"Paediatric anaesthesia","volume":"66 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2019-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"133854572","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-10-01DOI: 10.1093/med/9780198755791.003.0001
Thomas M. Engelhardt
Children who undergo general anaesthesia have an increased perioperative risk of morbidity and mortality compared with adults. This is due to differences in anatomy and reduced physiological reserves. A clear understanding of neonatal and paediatric anatomy and physiology is therefore essential to provide safe paediatric perioperative care. This chapter outlines major anatomical and physiological differences of the paediatric and neonatal airway, including causes and treatment of airway obstruction. Essential aspects of the respiratory, cardiovascular, CNS, and hepatorenal systems are discussed. Important considerations of fluid and thermal control are described that form the basis of safe paediatric anaesthesia practice.
{"title":"System-based anatomy and physiology","authors":"Thomas M. Engelhardt","doi":"10.1093/med/9780198755791.003.0001","DOIUrl":"https://doi.org/10.1093/med/9780198755791.003.0001","url":null,"abstract":"Children who undergo general anaesthesia have an increased perioperative risk of morbidity and mortality compared with adults. This is due to differences in anatomy and reduced physiological reserves. A clear understanding of neonatal and paediatric anatomy and physiology is therefore essential to provide safe paediatric perioperative care. This chapter outlines major anatomical and physiological differences of the paediatric and neonatal airway, including causes and treatment of airway obstruction. Essential aspects of the respiratory, cardiovascular, CNS, and hepatorenal systems are discussed. Important considerations of fluid and thermal control are described that form the basis of safe paediatric anaesthesia practice.","PeriodicalId":281130,"journal":{"name":"Paediatric anaesthesia","volume":"47 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2019-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"114711118","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Marieke Voet, A. Nusmeier, J. Lerou, J. Luijten, M. Cornelissen, J. Lemson
A living‐donor (adult) kidney transplantation in young children requires an increased cardiac output to maintain adequate perfusion of the relatively large kidney. To achieve this, protocols commonly advise liberal fluid administration guided by high target central venous pressure. Such therapy may lead to good renal outcomes, but the risk of tissue edema is substantial.
{"title":"Cardiac output‐guided hemodynamic therapy for adult living donor kidney transplantation in children under 20 kg: A pilot study","authors":"Marieke Voet, A. Nusmeier, J. Lerou, J. Luijten, M. Cornelissen, J. Lemson","doi":"10.1111/pan.13705","DOIUrl":"https://doi.org/10.1111/pan.13705","url":null,"abstract":"A living‐donor (adult) kidney transplantation in young children requires an increased cardiac output to maintain adequate perfusion of the relatively large kidney. To achieve this, protocols commonly advise liberal fluid administration guided by high target central venous pressure. Such therapy may lead to good renal outcomes, but the risk of tissue edema is substantial.","PeriodicalId":281130,"journal":{"name":"Paediatric anaesthesia","volume":"9 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2019-08-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"125618677","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-08-01DOI: 10.1093/med/9780198755791.003.0004
Barry G Lambert, N. Masip
This chapter covers the preparation of the child and carers for general anaesthesia. It starts with a review of the developmental stages of childhood, and how the child can be expected to behave. Thereafter, preoperative methods to decrease anxiety are discussed, including the involvement of play therapist and psychologist. The fasting of children is reviewed and both standard and liberal guidelines provided. Consent for general anaesthesia as pertains to English law is described, followed by a concise overview of safeguarding. Details regarding the various forms of topical anaesthesia are also provided.
{"title":"Preoperative preparation","authors":"Barry G Lambert, N. Masip","doi":"10.1093/med/9780198755791.003.0004","DOIUrl":"https://doi.org/10.1093/med/9780198755791.003.0004","url":null,"abstract":"This chapter covers the preparation of the child and carers for general anaesthesia. It starts with a review of the developmental stages of childhood, and how the child can be expected to behave. Thereafter, preoperative methods to decrease anxiety are discussed, including the involvement of play therapist and psychologist. The fasting of children is reviewed and both standard and liberal guidelines provided. Consent for general anaesthesia as pertains to English law is described, followed by a concise overview of safeguarding. Details regarding the various forms of topical anaesthesia are also provided.","PeriodicalId":281130,"journal":{"name":"Paediatric anaesthesia","volume":"72 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2019-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"121826994","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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