Paediatric anaesthesia最新文献

Aims: The aim of this study was to investigate whether respiratory variations in carotid and aortic blood flows measured by Doppler ultrasonography could accurately predict fluid responsiveness in critically ill children.

Methods: This was a prospective single-center study including mechanically ventilated children who underwent fluid replacement at the discretion of the attending physician. Response to fluid load was defined by a stroke volume increase of more than 15%. Maximum and minimum values of velocity peaks were determined over one controlled respiratory cycle before and after volume expansion. Respiratory changes in velocity peak of the carotid (∆Vpeak_Ca) and aortic (∆Vpeak_Ao) blood flows were calculated as the difference between the maximum and minimum values divided by the mean of the two values and were expressed as a percentage.

Results: A total of 30 patients were included, of which twelve (40%) were fluid responders and 18 (60%) non-responders. Before volume expansion, both ∆Vpeak_Ca and ∆Vpeak_Ao were higher in responders than in non-responders (17.1% vs 4.4%; p < .001 and 22.8% vs 6.4%; p < .001, respectively). ∆Vpeak_Ca could effectively predict fluid responsiveness (AUC 1.00, 95% CI 0.88-1.00), as well as ∆Vpeak_Ao (AUC 0.94, 95% CI 0.80-0.99). The best cutoff values were 10.6% for ∆Vpeak_Ca (sensitivity, specificity, positive predictive value and negative predictive value of 100%) and 18.2% for ∆Vpeak_Ao (sensitivity, 91.7%; specificity, 88.9%; positive predictive value, 84.6%; negative predictive value, 94.1%). Volume expansion-induced changes in stroke volume correlated with the ∆Vpeak_Ca and ∆Vpeak_Ao before volume expansion (ρ of 0.70 and 0.61, respectively; p < .001 for both).

Conclusions: Analysis of respiratory changes in carotid and aortic blood flows are accurate methods for predicting fluid responsiveness in children under invasive mechanical ventilation.

Background: Videolaryngoscopes improve tracheal intubation in adult patients, but we currently do not know whether they are similarly beneficial for children. We designed this ranking systematic review to compare individual video and direct laryngoscopes for efficacy and safety of orotracheal intubation in children.

Methods: We searched PubMed and five other databases on January 27, 2021. We included randomized clinical trials with patients aged ≤18 years, comparing different laryngoscopes for the outcomes: failed first intubation attempt; failed intubation within two attempts; failed intubation; glottic view; time for intubation; complications. In addition, we assessed the quality of evidence according to GRADE recommendations.

Results: We included 46 studies in the meta-analyses. Videolaryngoscopy reduced the risk of failed first intubation attempt (RR = 0.43; 95% CI: 0.31-0.61; p = .001) and failed intubation within two attempts (RR = 0.33; 95% CI: 0.33-0.33; p < .001) in children aged <1 year. Videolaryngoscopy also reduced the risk of major complications in both children aged <1 year (RR = 0.33; 95% CI: 0.12-0.96; p = .046) and children aged 0-18 years (RR = 0.40; 95% CI: 0.25-0.65; p = .002). We did not find significant difference between videolaryngoscopy and direct laryngoscopy for time to intubation in children aged <1 year (MD = -0.95 s; 95% CI: -5.45 to 3.57 s; p = .681), and children aged 0-18 years (MD = 1.65 s; 95% CI: -1.00 to 4.30 s; p = .222). Different videolaryngoscopes were associated with different performance metrics within this meta-analysis. The overall quality of the evidence ranged from low to very low.

Conclusion: Videolaryngoscopes reduce the risk of failed first intubation attempts and major complications in children compared to direct laryngoscopes. However, not all videolaryngoscopes have the same performance metrics, and more data is needed to clarify which device may be better in different clinical scenarios. Additionally, care must be taken while interpreting our results and rankings due to the available evidence's low or very low quality.

Congenital insensitivity to pain with anhidrosis (CIPA) is a rare disease also known as hereditary sensory and autonomic neuropathy. CIPA is characterized by a lack of pain sensitivity and impaired development of sweat glands. Surgery is required for patients with self-mutilation and skeletal developmental disorders. Due to the disease's rarity and intricacy, anesthesia poses its challenges. Although there have been a few cases of CIPA patients receiving surgery and anesthesia, the number is very limited. Here, we report a case of a child with CIPA who underwent open-heart surgery and discuss the anesthetic considerations. We conclude that patients with CIPA undergoing open-heart surgery require some opioids, that muscle relaxants and volatile anesthetics should be used with extreme caution, and that airway management and temperature control require special attention.

Background: Fluid administration in children undergoing surgery requires precision, however, determining fluid responsiveness can be challenging. Ultrasound has been used widely in the emergency department and intensive care units as a noninvasive, bedside manner of determining volume status, but the intraoperative period presents unique challenges as often the chest and abdomen are inaccessible for ultrasound. We investigate whether carotid artery ultrasound, specifically carotid flow time, can be used to determine fluid responsiveness in children under general anesthesia.

Methods: Prospective observational study of 87 children ages 1-12 years who were scheduled for elective noncardiac surgery. Ultrasound of the carotid artery and heart was performed at three time points: (1) after inhalational induction of anesthesia with the subject spontaneously breathing, (2) during positive pressure ventilation through endotracheal tube or supraglottic airway with tidal volume set at 8 ml/kg with PEEP of 10 cmH₂ O, and (3) after a 10 ml/kg fluid bolus. Carotid flow time and cardiac output were measured from saved images.

Results: Corrected carotid flow time (FTc) increased with initiation of positive pressure ventilation in both fluid responders and nonresponders (352.7 vs. 365.3 msec, p = .005 in fluid responders; 348.3 vs. 365.2 msec, p = .001 in nonresponders). FTc increased after fluid bolus in both responders and nonresponders (365.3 vs. 397.6 msec, p < .001 in fluid responders; 365.2 vs. 397.2 msec, p < .001 in nonresponders). However, baseline FTc during spontaneous ventilation or positive pressure ventilation prior to fluid bolus was not associated with fluid responsiveness.

Discussion: Flow time increases with initiation of positive pressure ventilation and after administration of a fluid bolus. FTc may serve as an indicator of fluid status but does not predict fluid responsiveness in children under general anesthesia.

Background: Fluid boluses are frequently utilized in children. Despite their frequency of use, there is little objective data regarding the utility of fluid boluses, who they benefit the most, and what the effects are.

Aims: This study aimed to conduct pooled analyses to identify those who may be more likely to respond to fluid boluses as well as characterize clinical changes associated with fluid boluses.

Methods: A systematic review of the literature and meta-analysis was conducted to identify pediatric studies investigating the response to fluid boluses and clinical changes associated with fluid boluses.

Results: A total of 15 studies with 637 patients were included in the final analyses with a mean age of 650 days ± 821.01 (95% CI 586 to 714) and a mean weight of 10.5 kg ± 7.19 (95% CI 9.94 to 11.1). The mean bolus volume was 12.14 ml/kg ± 4.09 (95% CI 11.8 to 12.5) given over a mean of 19.55 min ± 10.16 (95% CI 18.8 to 20.3). The following baseline characteristics were associated with increased likelihood of response [represented in mean difference (95% CI)]: greater age [207.2 days (140.8 to 273.2)], lower cardiac index [-0.5 ml/min/m² (-0.9 to -0.3)], and lower stroke volume [-5.1 ml/m² (-7.9 to -2.3)]. The following clinical parameters significantly changed after a fluid bolus: decreased HR [-5.6 bpm (-9.8 to -1.3)], increased systolic blood pressure [7.7 mmHg (1.0 to 14.4)], increased mean arterial blood pressure [5.5 mmHg (3.1 to 7.8)], increased cardiac index [0.3 ml/min/m² (0.1 to 0.6)], increased stroke volume [4.3 ml/m² (3.5 to 5.2)], increased central venous pressure [2.2 mmHg (1.1 to 3.3)], and increased systemic vascular resistance [2.1 woods units/m² (0.1 to 4.2)].

Conclusion: Fluid blouses increase arterial blood pressure or cardiac output by 10% in approximately 56% of pediatric patients. Fluid blouses lead to significant decrease in HR and significant increases in cardiac output, stroke volume, and systemic vascular resistance. Limited published data are available on the effects of fluid blouses on systemic oxygen delivery.

Background: The validity of current tools for intraoperative objective assessment of nociception/antinociception balance during anesthesia in young and very young surgery children is unknown.

Aim: Primary aim of the study was to test the hypothesis that the Newborn Infant Parasympathetic Evaluation (NIPE) index performs better in indicating nociception in anesthetized children below 2 years than changes in heart rate. Secondary aims were to evaluate associations between intraoperative changes in NIPE index values and postoperative pain and emergence delirium.

Methods: Fifty-one children aged <2 years who underwent surgery were included in this prospective observational study. Patients were assigned to either group 1 (healthy children, n = 31) or group 2 (critically ill, ventilated premature infants and neonates, n = 20). The NIPE index and heart rate in response to three defined nociceptive stimuli were continuously recorded. Two different scales, Kindliche Unbehagens- und Schmerzskala (KUS) and Pediatric Anesthesia Emergence Delirium (PAED) as well as a Pain Questionnaire were used to assess postoperative pain levels and emergence delirium.

Results: In total, 110 nociceptive events were evaluated. The analysis revealed a statistically significant association between a decrease in the NIPE index and all nociceptive stimuli, with a sensitivity of 92% and a specificity of 96%. The mean percentage decrease ranged from approx. 15%-30% and was highly statistically significant in both groups and for each of the nociceptive events except for venous puncture (p = .004). In contrast, no consistent change in heart rate was demonstrated. The KUS and PAED scale scores were significantly associated with the duration of anesthesia (p = .04), but not with intraoperative NIPE depression.

Conclusion: The NIPE index was reliable for assessing intraoperative nociception in children aged <2 years and was more reproducible for detecting specific nociceptive stimuli during general anesthesia than heart rate. An effect on postoperative outcome is still elusive.

Background: Because the unanticipated arousal or hemodynamic instability during anesthesia may adversely affect the physical and emotional welfare of children, adequate management of the anesthesia depth is required. We aimed to compare Bispectral Index (BIS) and Patient State Index (PSI) in children during sevoflurane anesthesia and evaluate PSI as depth of anesthesia monitor in children aged 6 months-12 years.

Methods: In this prospective observational study, children aged 6 months-12 years old scheduled for elective surgery under sevoflurane anesthesia were enrolled from November 2018 to June 2019. We monitored BIS and PSI at different sevoflurane concentrations. The primary outcome was the correlation between BIS and PSI. The correlation between BIS and PSI at different sevoflurane concentrations (at 1, 1.5, and 2 MACs) and at different age groups (6 months-2 years, 2-7 years, and 8-12 years) was also investigated.

Results: Bispectral index and PSI showed a fair correlation (r = .430; 95% confidence interval [CI], 0.297-0.546; p < .001). Two values were fairly correlated at 1, 1.5, and 2 MAC (r = .544; 95% CI, 0.314-0.716; p < .001, r = .509; 95% CI, 0.283-0.699; p < .001, and r = .315; 95% CI, 0.047-0.522; p = 0.007). BIS and PSI values showed a fair correlation in 6 months - 2 year and 8-12 year groups (r = .696; 95% CI, 0.519-0.813; p < .001 and r = .297; 95% CI, -0.017 to 0.543; p < .021), but there was not significant correlation in 2-7 years group (r = .190; 95% CI, -0.015 to 0.374; p = .052).

Conclusions: There was a fair correlation between BIS and PSI in children under sevoflurane anesthesia. The use of BIS and PSI as an indicator for anesthesia depth by sevoflurane is not reliable in pediatric patients.