Clowns for the prevention of preoperative anxiety in children: a randomized controlled trial

Objective:  To determine if specially trained professional clowns allayed preoperative anxiety and resulted in a smooth anesthetic induction compared to the use of midazolam or no intervention.
Methods:  This was a randomized, controlled, and blinded study conducted with children 3–8 years of age undergoing general anesthesia and elective outpatient surgery. Patients were assigned to one of three groups: Group 1 did not receive midazolam or clown presence; group 2 received 0.5 mg·kg⁻¹ oral midazolam 30 min before surgery up to a maximum of 15 mg; and group 3 had two specially trained clowns present upon arrival to the preoperative holding area and throughout operating room (OR) entrance and mask application for inhalation induction of anesthesia. The children were videotaped for later grading.
Results:  The clown group had a statistically significant lower modified-Yale Preoperative Anxiety Scale score in the preoperative holding area compared to the control and midazolam group. The clowns' effect on anxiety reduction continued when the children entered the OR but was equal at this point to the midazolam group. Upon application of the anesthesia mask no significant differences were detected between the groups.
Conclusions:  This study found that the use of preoperative medically trained clowns for children undergoing surgery can significantly alleviate preoperative anxiety. However, clowns do not have any effect once the anesthesia mask is introduced.     

Pulse oximetric thresholds for tonsillectomy and adenotomy in children: significance of 1–2% decline in oxyhemoglobin saturation

Objectives:  We aimed to establish optimal overnight pulse oximetric thresholds for determining the indication of tonsillectomy and adenotomy (TA) in children by revising the definition of 'desaturation'.
Methods:  One hundred and thirty four children scheduled for TA (TA group, 5.3 ± 1.4 years old) and 112 otherwise healthy children scheduled for elective minor surgery (control group, 5.4 ± 1.5 years old) were enrolled into this prospective study. Data were recorded and stored every 10 s using Nellcor N-395. Desaturation/resaturation events were defined as x % change ( x  = 1–4) of SpO₂ (oxyhemoglobin saturation by pulse oximetry) in 10 s. The desaturation/resaturation indices were calculated as events per hour of total sleeping time. For each index, a wide range of temporary thresholds was set. The optimal thresholds for TA were the ones that maximized the weighted average for sensitivity, specificity (based on whether the index improved or not after TA), and the percentage of the control children whose indices were below the threshold.
Results:  For all the indices, the optimal thresholds that fulfilled the above condition were determined. Compared with the x  = 3–4% results, the application of x  = 1–2% approximately doubled the TA patients whose preoperative 'positive' indices improved after TA, with the weighted averages of 84.3–92.3% as described above.
Conclusions:  By defining desaturation/resaturation as a 1–2% change in SpO₂ from the preceding value, children with adenotonsillar hypertrophy whose pulse oximetric indices are expected to improve after TA can be detected by pulse oximetry with relatively high sensitivity and specificity.     

Implementation of the scientific evidence into daily practice – example from fast-track colonic cancer surgery

Objective  To report the implementation and results of fast-track surgery for colonic cancer in the daily routine.
Method  A total of 131 consecutive patients scheduled for elective colonic cancer resections entered a fast-track perioperative course after thorough information. The regimen contained: no preoperative bowel cleansing, transverse and small abdominal incisions, no dains nor tubes, mobilization and normal meal the evening on the day of surgery, epidural analgesia, oral laxatives, and a planned discharge on postoperative day 3.
Results  Median number of days postoperative in hospital were 4 days (range 1–46). Eighty-nine per cent experienced an uncomplicated course, 3% were readmitted within 30 days, and the 30-day mortality was 3.8%.
Conclusion  Fast-track surgery is feasible in an unselected patient population scheduled for elective colon cancer resections without compromising quality.     

A comparison of the STORZ video laryngoscope and standard direct laryngoscopy for intubation in the Pediatric airway – a randomized clinical trial

Introduction:  Direct laryngoscopy can be challenging in infants and neonates. Even with an optimal line of sight to the glottic opening, the viewing angle has been measured at 15°. The STORZ DCI video laryngoscope (Karl Storz, Tuttlingen, Germany) incorporates a fiberoptic camera in the light source of a standard laryngoscope of variable sizes. The image is displayed on a screen with a viewing angle of 80°. We studied the effectiveness of the STORZ DCI as an airway tool compared to standard direct laryngoscopy in children with normal airway.
Methods:  In this prospective, randomized study, 56 children (ages 4 years or younger) undergoing elective surgery with the need for endotracheal intubation were divided into two groups: children who underwent standard direct laryngoscopy using a Miller 1 or Macintosh 2 blade (DL) and children who underwent video laryngoscopy using the STORZ DCI video laryngoscope with a Miller 1 blade (VL). Time to best view (TTBV), time to intubate (TTI), Cormack–Lehane (CL), and percentage of glottis opening seen (POGO) score were recorded.
Results:  TTBV in DL was 5.5 (4–8) s and 7 (4.2–9) s in VL. TTI in DL was 21 (17–29) s and in VL 27 (22–37) s ( P  = 0.006). The view as assessed by POGO score was 97.5% (60–100%) in DL and 100% (100–100%) in the VL ( P  = 0.003). Data are presented as median and interquartile range and analyzed using t -test.
Discussion:  This study demonstrates that the STORZ DCI video laryngoscope provides an improved view to the glottis in children with normal airway anatomy, but requires a longer time for intubation.     

Laparoscopic dismembered pyeloplasty for ureteropelvic junction obstruction in children

Objectives:   To present our initial experience with laparoscopic pyeloplasty and to evaluate the safety and short-term outcome of this technique in children.
Methods:   Thirteen kidney units in twelve children underwent laparoscopic dismembered pyeloplasty for the management of ureteropelvic junction obstruction (UPJO) at our institution between 2005 and 2008. Patient age at surgery was 18–177 months (mean 89.8 months). There were six boys and six girls. Ten had unilateral UPJO with a normal contralateral kidney, one had bilateral UPJO and one had UPJO of a solitary kidney. We used 3- and 5-mm instruments for grasping, blunt dissection, incising and suturing to facilitate safe and precise surgery. The outcome was measured by the operative time and resolution of obstruction and symptoms.
Results:   Median operative time was 275 min (range 154–420). There was a slight relationship between age and operative time. No major perioperative complications occurred in any cases. Median renal pelvic anterior–posterior diameter at ultrasonography significantly decreased from 8.6 cm (range 3.8–22.0) preoperatively to 3.9 cm (1.0–8.9) postoperatively ( P  < 0.05). The median pre- and postoperative split renal function on diuretic renography in unilateral cases was 37.3% (range 29.7–46.4) and 39.5% (27.8–48.0), respectively. Overall, successful resolution of UPJO was observed in 12 of 13 kidneys (92.3%).
Conclusions:   Laparoscopic pyeloplasty represents a safe and effective option in the surgical treatment of children with UPJO.     

Diagnostic accuracy of anesthesiology evaluation timing: the 'One-Stop Anesthesia' in pediatric day-surgery

Objective:  Assessing timing efficacy of anesthetic evaluation in pediatric day-surgery by a diagnostic accuracy study.
Aim:  Lowering hospital visits in patients with negative medical history.
Background:  Pediatric patients scheduled for day-surgery procedures can be categorized, according to their history, in two groups. One, the largest, includes healthy patients and the other includes those with medical conditions that necessitate further evaluation.
Materials and methods:  Clinical data are collected by the pediatric surgeons of our department and reviewed by an anesthetist who then selects the timing of anesthesiology evaluation, which will take place in the same day of the procedure (One-Stop Anesthesia), or some days before it, in a dedicated setting (Pre-Admission Clinic). In 2008, 332 children, older than 12 months, screened by that method, underwent surgical procedures in general anesthesia.
Results:  Our data were examined using Bayesian Statistical Analysis. In the 'One-Stop Anesthesia' group, true positive were 290 (87.4%) and false positive 4 (1.2%). Of the 38 patients assessed by our Pre-Admission Clinic, true negative were 30 (9%) and false negative 8 (2.4%). Sensibility (97.3%), specificity (88.2%), positive predictive value (98.6%), negative predictive value (78.9%), diagnostic accuracy (96.4%), likelihood positive (8.3), and likelihood negative (0.03) were calculated.
Conclusions:  Timing the preoperative anesthesiologist's evaluation avoided 88% of hospital visits, usually to the Pre-Admission Clinic, and thus, it was cost effective, reducing direct and indirect costs of healthcare providers.     

The changing impact of age on colorectal cancer surgery. A trend analysis

Objective  The aim of the study was to evaluate the changing influence of age on the outcomes of colorectal cancer surgery in a retrospective trend analysis.
Methods  Data on 985 patients undergoing colorectal cancer surgery were collected during 1975–1984 and 1995–2004. Variables and outcomes of patients aged < 65, 65–74, 75–84 and 85+ years were compared with intra- and interdecade analyses. Endpoints of the study were postoperative mortality, 5-year overall and cancer-related survivals.
Results  The rate of elderly patients undergoing colorectal cancer surgery increased significantly from 1975–1984 to 1995–2004. Distribution of American Society of Anesthesiology score and cancer stage remained unchanged over time. The rate of palliative procedures decreased over time, most significantly in the older age groups. In 1995–2004 the palliation rate was similar across all age groups. The rate of emergency surgery also decreased, but it remained higher in older age groups. Operative mortality rate decreased over time across all age groups, but age-related differences were still observed in the 1995–2004 series. Cancer-related survival after curative surgery increased from 58% in 1975–1984 to 64% in 1995–2004 in 75+ years patients, while it increased from 56% to 78% in patients aged 74 years or younger.
Conclusions  Elderly patients with colorectal cancer benefited substantially from healthcare progress during the last 30 years. The reduction of palliative procedures and the decline in operative mortality document the efficacy of not restricting the access to radical surgery for these patients.     

Single injection paravertebral block for renal surgery in children

Background:  Continuous paravertebral block (PVB) has been successfully used for postoperative analgesia in children. However, data regarding the efficacy of a single injection technique for major renal surgery are still lacking.
Methods:  Following the ethics committee approval and parent informed consent, 24 children (median 10.3 months; range: 2.9–26.8) undergoing major renal surgery were included in a prospective observational pilot study. Following a standardized general anesthetic the patients were administered a single injection low thoracic PVB (loss-of-resistance technique; 0.5 ml·kg⁻¹ of levobupivacaine 2.5 mg·ml⁻¹ with epinephrine 5 μg·ml⁻¹) at the end of surgery. Postoperative pain was assessed by Face, Legs, Activity, Cry, Consolability (FLACC) score at predetermined time points and in case of apparent patients' discomfort during the first 12 postoperative hours. The duration of postoperative analgesia was defined as the interval between PVB and the first supplemental administration of a rescue opioid analgesic. The incidence of complications and postoperative vomiting (POV) was also recorded.
Results:  A successful PVB was achieved in 23/24 patients (95.8%). The median duration of the block was 600 min (range: 180–720 min) with 10 children not requiring any supplemental analgesia during the 12-h observation period. Vascular puncture was observed in 2/24 children (8.3%) and POV occurred in 4/24 children (16.7%). All complications were considered minor and did not influence recovery.
Conclusions:  Single injection PVB provided clinically relevant postoperative analgesia in children undergoing major renal surgery.     

Salbutamol premedication in children with a recent respiratory tract infection

Background :  Premedication with β-2 agonists (e.g. salbutamol) is effective in preventing increases in total respiratory resistance and in decreasing the incidence of perioperative bronchospasm in asthmatic children. Because children with recent respiratory tract infection (RTI) exhibit bronchial hyperreactivity similar to that observed in asthmatic children, the use of salbutamol in children with RTI has become popular among pediatric anesthetists for the prevention of perioperative respiratory adverse events (PRAE). In a prospective observational study, we therefore assessed the usefulness of salbutamol premedication on the occurrence of PRAE.
Methods :  Results from 600 children (0–16 years) undergoing general anesthesia were analyzed: 200 children with a recent RTI who received preoperative salbutamol 10–30 min prior to surgery, 200 children with a recent RTI without salbutamol premedication, and 200 children without a RTI during the last 4 weeks. All PRAE (laryngospasm, bronchospasm, oxygen desaturation [<95%], severe coughing) were recorded.
Results :  Children with a recent RTI who received salbutamol demonstrated a significantly reduced incidence of perioperative bronchospasm (5.5% vs 11%, P  = 0.0270) and severe coughing (5.5% vs 11.5%, P  = 0.0314) compared with children who had an RTI but did not receive salbutamol. However, healthy children presented with the lowest rate (bronchospasm 1.5%, severe coughing 4.5%) of respiratory complications compared with children with a recent RTI independent whether or not they received salbutamol preoperatively.
Conclusions :  The results from this audit suggest that children with a history of a recent RTI have significantly less PRAE following a premedication with salbutamol compared with no premedication. Therefore, premedication with salbutamol might be considered in children with recent RTI.     

The effect of postoperative fasting on vomiting in children and their assessment of pain

Background:  Mandatory postoperative food intake has been shown to increase nausea and vomiting, and so postoperative fasting has become common practice even if patients request food or drink.
Objective:  We sought to investigate whether postoperative fasting reduces the incidence of postoperative vomiting in children when compared with a liberal regimen in which they are allowed to eat and drink upon request.
Methods:  One hundred forty-seven children scheduled for outpatient surgery were randomized to one of two groups. After anesthesia, patients in the 'fasting' group were expected to fast for 6 h. The children in the 'liberal' group were allowed to eat and drink according to their own needs. The incidence of vomiting and the children's well-being were recorded at several time points over a 24-hour period. Parents were also asked to rate, on a scale of 0–6, how much their children were bothered by fasting, pain, and nausea/vomiting.
Results:  Age (4.8 ± 2.6 years), weight (20 ± 9 kg) and gender (73% boys) were comparable between the groups. The incidence of vomiting was 15% in the liberal and 22% in the fasting group ( P  = 0.39) and, between 1 and 12 h after extubation, children in the liberal group were significantly happier ( P  < 0.001). Children in the liberal group were significantly less bothered by their pain than those in the fasting group ( P  < 0.001).
Conclusion:  Postoperative fasting did not reduce the incidence of vomiting after general anesthesia in children when compared with a liberal regimen. Furthermore, the ability to eat and drink at will decrease the bothersome aspects of pain and lead to happier patients.     

Internal jugular vein diameter in pediatric patients: are the J‐shaped guidewire diameters bigger than internal jugular vein? An evaluation with ultrasound

Aim:  This study investigates whether the diameters of right internal jugular vein (RIJV) are suitable for the use of 'big radius curved J-tip' Seldinger wires in pediatric patients.
Methods:  One-hundred and thirty-five children, 1 month to 15 years of age, scheduled for pediatric surgery were divided into four subgroups according to their age (0–12 months, 1–2 years, 2–6 years old, and >6 years). Patients in the 0–12 months group were further divided into two groups as 0–6 months and 7–12 months of age to evaluate RIJV characteristics in detail. Following anesthesia induction, depth, diameter, and area of RIJV were measured with ultrasound at the level of cricoid cartilage and sterno-clavicular junction in supine and Trendelenburg position.
Results:  Infants in the 0–6 months of age group had the least mean diameter of RIJV at both the cricoid cartilage and the sternoclavicular junction level (0.484 ± 0.132 and 0.499 ± 0.136 cm). The aforementioned diameter was significantly lower than the values of other age groups ( P  < 0.05). Trendelenburg position did not increase RIJV diameter in children below 6 and cross-sectional area below 2 years old. Correlations between age, height, weight, head circumference and RIJV diameter, cross-sectional area, depth from the skin were weak.
Conclusion:  The diameter of the IJV in pediatric patients, especially infants, is often smaller than the diameter of the J-tip guidewire curve. We speculate that this may lead to impeded guidewires and failed cannulation. It must also be kept in mind that the Trendelenberg position might not facilitate IJV cannulation in children <2 years of age.     

Paediatric propofol pharmacokinetics: a multicentre study

Introduction:  Schuttler and Imhsens propofol pharmacokinetic (PK) model (1) based on pooled adult and paediatric data lacked information for the smallest patients. We conducted a pooled population analysis of available neonatal and paediatric propofol PK data. The variable clinical circumstances of the individual studies allowed us to explore health status as a PK model covariate.
Methods:  We combined raw propofol blood/plasma concentration vs time data, dosing information and demographic data from eight paediatric studies conducted by six research groups, with our data (2,3). The pooled data set comprised 197 individuals (2315 observations), aged 0.02–12.25 years (2.75–60.5 kg, median 15 kg). In this preliminary population PK analysis using NONMEM, the basic model structure was established before all model parameters were allometrically scaled to body weight. The influence of health status on paediatric propofol PK was explored.
Results:  In this 3-compartment preliminary model, postcardiac surgery patients have significantly reduced metabolic clearance rates (31–45% less when compared with healthy children or noncardiac PICU patients). The volume of the deep peripheral compartment in critically ill and postcardiac surgery children is 319% and 205% larger, respectively, than in healthy children, see Table 1 .  

  Table 1  PK values for a child weighing 15 kg     

13.

Plasma and renal clearances of lactated Ringer's solution in pediatric and adult patients just before anesthesia is induced     

YUHONG LI PhD  ROBERT G. HAHN PhD  †  YAOQIN HU MD  ‡  YAN XIANG MD    SHENGMEI ZHU MD 《Paediatric anaesthesia》2009,19(7):682-687

Background:  Lactated Ringer's solution is most widely used in children, but little is known about how children who are scheduled for surgery handle a fluid load when compared to adults. This study explores whether a more cautious regimen for the administration of lactated Ringer's is warranted in children awaiting minor surgery when compared to adults.
Methods:  Plasma dilution (based on hemoglobin), urinary excretion, and volume kinetics were used to assess the disposition of an i.v. infusion of 10 ml·kg⁻¹ of lactated Ringer's solution over 20 min in 14 pediatric patients (4 years of age, average body weight 15 kg) and in 14 adult patients scheduled for similar minor pelvic surgery. Experiments were performed after premedication, but before anesthesia was induced.
Results:  Plasma dilution was less pronounced in the pediatric patients ( P  <   0.03) who also had excreted more of the infused fluid within 90 min than the adults (43% vs 18%, P  <   0.03). After correction for body weight, their plasma clearance was 4 times higher ( P  <   0.02) and the renal clearance of lactated Ringer's solution 7 times higher ( P  <   0.001) than those of the adults. The more rapid turnover of fluid in the children might be explained by a shorter period of preoperative fasting (6 vs 10 h) and/or by physiological differences attributable to age.
Conclusion:  The plasma and renal clearances of lactated Ringer's solution were higher in children with a body weight of about 15 kg in comparison with adults. Therefore, children in this age group may receive at least the same amounts of fluid per kilo body weight during preparation for surgery as the amounts recommended for adults.     

14.

Intrathecal ropivacaine 5 mg/ml for outpatient knee arthroscopy: a comparison with lidocaine 10 mg/ml     

G. FANELLI  G. DANELLI  M. ZASA  M. BACIARELLO  S. DI CIANNI  S. LEONE 《Acta anaesthesiologica Scandinavica》2009,53(1):109-115

Purpose: The aim of this prospective, randomised, blind study was to compare the evolution of spinal block produced with 50 mg lidocaine 10 mg/ml and 10 mg ropivacaine 5 mg/ml for outpatient knee arthroscopy.
Methods: Thirty outpatients undergoing knee arthroscopy received 50 mg of lidocaine 10 mg/ml ( n =15) or 10 mg of ropivacaine 5 mg/ml ( n =15) intrathecally. The evolution of spinal block was recorded until home discharge, while the occurrence of transient neurologic symptoms (TNS) was evaluated through phone-call follow-ups.
Results: The median onset time was 15 (10–21) min with lidocaine and 24 (11–37) min with ropivacaine ( P =0.109). Spinal lidocaine resulted in a faster resolution of sensory block [148 (130–167) min vs. 188 (146–231) ( P =0.022)], unassisted ambulation with crutches [176 (144–208) min vs. 240 (179–302) min ( P =0.014)], and voiding [208 (163–254) min vs. 293 (242–343) min ( P =0.001)] than ropivacaine. Recovery of motor function required 113 (95–131) min with lidocaine and 135 (87–183) with ropivacaine ( P =0.219). Six lidocaine patients reported TNS (40%) as compared with no patient receiving ropivacaine (0%) ( P =0.005).
Conclusions: Spinal block produced with 10 mg ropivacaine 5 mg/ml is as effective as that produced by 50 mg of lidocaine 10 mg/ml. Recovery of unassisted ambulation and spontaneous voiding occurred earlier with lidocaine, but this was associated with a markedly higher incidence of TNS.     

15.

Training in pediatric anesthesia for registrars – UK National survey     

KRISHNAN MELARKODE MBBS MD DNB FRCA  AMR ABDELAAL FRCA MD  †  SAM BASS LLM BSc MBBS FRCA MFFLM  † 《Paediatric anaesthesia》2009,19(9):872-878

Background:  The aim of this National survey was to review the training provided in pediatric anesthesia to all registrars across all deaneries in the United Kingdom. The Royal College of Anaesthetists (RCA) recognizes training in pediatric anesthesia as an important training module for specialist registrars in years 1 and 2 of their training and recommends that this training should be delivered in 1–3-month blocks.
Methods:  This was a simple online survey ( http://www.esurveyspro.com ). We aimed to contact all registrars via the Association of Paediatric Anaesthetists of Great Britain and Ireland and the RCA.
Results:  Our survey indicated that there is wide variation in the duration of modular training across all deaneries. Three hundred and sixty-two registrars (65.5%) thought that the implementation of the European working time directives (EWTD) would hamper training in this specialty. One hundred and sixty-seven trainees (42.7%) spent more than 75% of their time doing pediatric anesthesia during their training module. Only 34 trainees (6.4%) had the opportunity to anesthetize children every week in District General Hospitals (DGHs), while 280 trainees (53.03%) said they did not have regular pediatric lists in DGHs.
Conclusions:  It will be necessary to increase the duration of modular training with the implementation of EWTD. Modular training in pediatric anesthesia should be provided as a dedicated and protected module. Training opportunities in DGHs are limited. There is also a need for new guidelines, as current guidelines regarding pediatric anesthesia training will be outdated with the implementation of EWTD.     

16.

Intraoperative hyponatremia during craniofacial surgery     

K. RANDO MD    G. ZUNINI MD    A. NEGROTO MD 《Paediatric anaesthesia》2009,19(4):358-363

     

17.

Fasting times in caregivers of children presenting for ambulatory surgery     

Farooq M  Tan K  Crowe S 《Paediatric anaesthesia》2008,18(9):820-822

Background:  It has been the anecdotal experience in this unit that many parents and guardians of children presenting for day-case surgery also fast along with their child for prolonged periods of time. There have been several episodes of parents feeling dizzy or nauseated on leaving the anesthetic room after induction of anesthesia, and many incidents of fainting in recovery when collecting their child. Our purpose was to investigate this theme further, by auditing the fasting times of caregivers coming to the induction room over a 3-month period. This information has not been previously described in the literature.
Methods:  We carried out a prospective audit of current practice. Data were collected by questionnaire, which caregivers were requested to complete in the holding area, after the child was checked in for theatre.
Results:  Two hundred and fifty-seven caregivers fasted for 0–6 h and 223 fasted for >6 h. One hundred and fourteen caregivers fasted for 7–12 h and 109 caregivers fasted between 13 and 19 h.
Conclusions:  A large proportion of parents choose to fast with their children. Some caregivers fast for long periods. In general, this does not cause any ill effects, although some parents missed routine medications while fasting.     

18.

Exhaled carbon monoxide screening for environmental tobacco smoke exposure in preanesthetic children     

DANIELLE DUKELLIS BS    JEANNIE ZUK PHD    ZHAOXING PAN PHD    JOHN E. MORRISON MD    ROBERT H. FRIESEN MD 《Paediatric anaesthesia》2009,19(9):848-853

Objective:  Exposure to environmental tobacco smoke (ETS) is associated with an increased risk of perioperative adverse events in children. The purpose of this study was to evaluate exhaled carbon monoxide (CO) as a preoperative ETS screening tool in children.
Methods:  Five hundred and one children aged 6–15 years were enrolled. The child's guardian completed a questionnaire that surveyed environmental exposures to CO and ETS. A preoperative urine sample was obtained from children who assented and were able to void, and urine cotinine values were measured. Exhaled CO was measured using the EC50-Micro Smokerlyzer^® (Bedfont Scientific Ltd, UK).
Results:  Four hundred and fifty-one subjects completed the study, and urine samples were obtained from 83. 25% of subjects were classified as exposed to ETS based on questionnaire results. Exhaled CO values did not correlate with either the qualitative (questionnaire) or quantitative (urine cotinine) measurements of ETS exposure. Exhaled CO predicted a urine cotinine/creatinine ratio >10 with a sensitivity of 10% and a specificity of 85%.
Conclusion:  Exhaled CO measured by this device is not a useful preoperative screening tool for ETS exposure in children. Because exhaled CO has been used successfully to monitor ETS exposure in adolescents, we believe that its failure in our population is as a result of the limited ability of small children to perform vital capacity maneuvers in order to provide an adequate endtidal sample.     

19.

The thermal benefit of prewarming in children     

B.  Hullett  N. Chambers  J Preuss†‡  I. Zamudio  J. Lange†‡  E. Pascoe§¶  T. Ledowski†‡ 《Paediatric anaesthesia》2009,19(5):556-556

     

20.

Pediatric airway management: comparing the Berci–Kaplan Video Laryngoscope with direct laryngoscopy     

DAVID MACNAIR MB ChB FRCA    DAN BARACLOUGH MBChB  FRCA    GRAHAM WILSON MB ChB FRCA    MARK BLOCH MB ChB FRCA    THOMAS ENGELHARDT MD PhD FRCA 《Paediatric anaesthesia》2009,19(6):577-580

Objectives:  To assess the utility of the Berci–Kaplan Video Laryngoscope (VL) in pediatric anesthesia.
Background:  The VL is designed to improve visualization of the glottis during tracheal intubation of normal and difficult airways in adults. This study was designed to assess the visual quality and the ease of tracheal intubation in children using the VL when compared with direct laryngoscopy (DL).
Methods:  Sixty children, aged 2–16 years requiring tracheal intubation, were enrolled in this prospective, randomized clinical trial. Following induction of anesthesia and muscle paralysis, the first laryngoscopy method, using either a DL or the VL, was performed by one anesthetist, and the laryngoscopic view was graded according to the Cormack–Lehane scale. Laryngoscopy and grading of the view in the second method were then performed by a second anesthetist. Tracheal intubation was completed following the second laryngoscopy, and time to intubation was recorded.
Results:  The average age and weight were 8.9 ± 3.6 years and 34.9 ± 16.0 kg respectively. Videolaryngoscopy improved 8/11 grade 2 views to grade 1 ( P  =   0.02), and one grade 3 to a grade 2. Three grade 2 views remained unchanged from DL to VL. 4/30 VL intubations required two attempts, and 1/30 failed after two attempts, but was easily intubated with DL. Median time (range) was 16.0 s (14.0–20.0 s) and 22.5 s (17.8–35.0 s) for DL and VL respectively ( P  <   0.001).
Conclusion:  Videolaryngoscopy provides better views than DL at the expense of time to intubate. Although the time taken to intubate is increased with the VL, it is clinically acceptable.     

Plasma and renal clearances of lactated Ringer's solution in pediatric and adult patients just before anesthesia is induced

Background:  Lactated Ringer's solution is most widely used in children, but little is known about how children who are scheduled for surgery handle a fluid load when compared to adults. This study explores whether a more cautious regimen for the administration of lactated Ringer's is warranted in children awaiting minor surgery when compared to adults.
Methods:  Plasma dilution (based on hemoglobin), urinary excretion, and volume kinetics were used to assess the disposition of an i.v. infusion of 10 ml·kg⁻¹ of lactated Ringer's solution over 20 min in 14 pediatric patients (4 years of age, average body weight 15 kg) and in 14 adult patients scheduled for similar minor pelvic surgery. Experiments were performed after premedication, but before anesthesia was induced.
Results:  Plasma dilution was less pronounced in the pediatric patients ( P  <   0.03) who also had excreted more of the infused fluid within 90 min than the adults (43% vs 18%, P  <   0.03). After correction for body weight, their plasma clearance was 4 times higher ( P  <   0.02) and the renal clearance of lactated Ringer's solution 7 times higher ( P  <   0.001) than those of the adults. The more rapid turnover of fluid in the children might be explained by a shorter period of preoperative fasting (6 vs 10 h) and/or by physiological differences attributable to age.
Conclusion:  The plasma and renal clearances of lactated Ringer's solution were higher in children with a body weight of about 15 kg in comparison with adults. Therefore, children in this age group may receive at least the same amounts of fluid per kilo body weight during preparation for surgery as the amounts recommended for adults.     

Intrathecal ropivacaine 5 mg/ml for outpatient knee arthroscopy: a comparison with lidocaine 10 mg/ml

Purpose: The aim of this prospective, randomised, blind study was to compare the evolution of spinal block produced with 50 mg lidocaine 10 mg/ml and 10 mg ropivacaine 5 mg/ml for outpatient knee arthroscopy.
Methods: Thirty outpatients undergoing knee arthroscopy received 50 mg of lidocaine 10 mg/ml ( n =15) or 10 mg of ropivacaine 5 mg/ml ( n =15) intrathecally. The evolution of spinal block was recorded until home discharge, while the occurrence of transient neurologic symptoms (TNS) was evaluated through phone-call follow-ups.
Results: The median onset time was 15 (10–21) min with lidocaine and 24 (11–37) min with ropivacaine ( P =0.109). Spinal lidocaine resulted in a faster resolution of sensory block [148 (130–167) min vs. 188 (146–231) ( P =0.022)], unassisted ambulation with crutches [176 (144–208) min vs. 240 (179–302) min ( P =0.014)], and voiding [208 (163–254) min vs. 293 (242–343) min ( P =0.001)] than ropivacaine. Recovery of motor function required 113 (95–131) min with lidocaine and 135 (87–183) with ropivacaine ( P =0.219). Six lidocaine patients reported TNS (40%) as compared with no patient receiving ropivacaine (0%) ( P =0.005).
Conclusions: Spinal block produced with 10 mg ropivacaine 5 mg/ml is as effective as that produced by 50 mg of lidocaine 10 mg/ml. Recovery of unassisted ambulation and spontaneous voiding occurred earlier with lidocaine, but this was associated with a markedly higher incidence of TNS.     

Training in pediatric anesthesia for registrars – UK National survey

Background:  The aim of this National survey was to review the training provided in pediatric anesthesia to all registrars across all deaneries in the United Kingdom. The Royal College of Anaesthetists (RCA) recognizes training in pediatric anesthesia as an important training module for specialist registrars in years 1 and 2 of their training and recommends that this training should be delivered in 1–3-month blocks.
Methods:  This was a simple online survey ( http://www.esurveyspro.com ). We aimed to contact all registrars via the Association of Paediatric Anaesthetists of Great Britain and Ireland and the RCA.
Results:  Our survey indicated that there is wide variation in the duration of modular training across all deaneries. Three hundred and sixty-two registrars (65.5%) thought that the implementation of the European working time directives (EWTD) would hamper training in this specialty. One hundred and sixty-seven trainees (42.7%) spent more than 75% of their time doing pediatric anesthesia during their training module. Only 34 trainees (6.4%) had the opportunity to anesthetize children every week in District General Hospitals (DGHs), while 280 trainees (53.03%) said they did not have regular pediatric lists in DGHs.
Conclusions:  It will be necessary to increase the duration of modular training with the implementation of EWTD. Modular training in pediatric anesthesia should be provided as a dedicated and protected module. Training opportunities in DGHs are limited. There is also a need for new guidelines, as current guidelines regarding pediatric anesthesia training will be outdated with the implementation of EWTD.     

Fasting times in caregivers of children presenting for ambulatory surgery

Background:  It has been the anecdotal experience in this unit that many parents and guardians of children presenting for day-case surgery also fast along with their child for prolonged periods of time. There have been several episodes of parents feeling dizzy or nauseated on leaving the anesthetic room after induction of anesthesia, and many incidents of fainting in recovery when collecting their child. Our purpose was to investigate this theme further, by auditing the fasting times of caregivers coming to the induction room over a 3-month period. This information has not been previously described in the literature.
Methods:  We carried out a prospective audit of current practice. Data were collected by questionnaire, which caregivers were requested to complete in the holding area, after the child was checked in for theatre.
Results:  Two hundred and fifty-seven caregivers fasted for 0–6 h and 223 fasted for >6 h. One hundred and fourteen caregivers fasted for 7–12 h and 109 caregivers fasted between 13 and 19 h.
Conclusions:  A large proportion of parents choose to fast with their children. Some caregivers fast for long periods. In general, this does not cause any ill effects, although some parents missed routine medications while fasting.     

Exhaled carbon monoxide screening for environmental tobacco smoke exposure in preanesthetic children

Objective:  Exposure to environmental tobacco smoke (ETS) is associated with an increased risk of perioperative adverse events in children. The purpose of this study was to evaluate exhaled carbon monoxide (CO) as a preoperative ETS screening tool in children.
Methods:  Five hundred and one children aged 6–15 years were enrolled. The child's guardian completed a questionnaire that surveyed environmental exposures to CO and ETS. A preoperative urine sample was obtained from children who assented and were able to void, and urine cotinine values were measured. Exhaled CO was measured using the EC50-Micro Smokerlyzer^® (Bedfont Scientific Ltd, UK).
Results:  Four hundred and fifty-one subjects completed the study, and urine samples were obtained from 83. 25% of subjects were classified as exposed to ETS based on questionnaire results. Exhaled CO values did not correlate with either the qualitative (questionnaire) or quantitative (urine cotinine) measurements of ETS exposure. Exhaled CO predicted a urine cotinine/creatinine ratio >10 with a sensitivity of 10% and a specificity of 85%.
Conclusion:  Exhaled CO measured by this device is not a useful preoperative screening tool for ETS exposure in children. Because exhaled CO has been used successfully to monitor ETS exposure in adolescents, we believe that its failure in our population is as a result of the limited ability of small children to perform vital capacity maneuvers in order to provide an adequate endtidal sample.     

Pediatric airway management: comparing the Berci–Kaplan Video Laryngoscope with direct laryngoscopy

Objectives:  To assess the utility of the Berci–Kaplan Video Laryngoscope (VL) in pediatric anesthesia.
Background:  The VL is designed to improve visualization of the glottis during tracheal intubation of normal and difficult airways in adults. This study was designed to assess the visual quality and the ease of tracheal intubation in children using the VL when compared with direct laryngoscopy (DL).
Methods:  Sixty children, aged 2–16 years requiring tracheal intubation, were enrolled in this prospective, randomized clinical trial. Following induction of anesthesia and muscle paralysis, the first laryngoscopy method, using either a DL or the VL, was performed by one anesthetist, and the laryngoscopic view was graded according to the Cormack–Lehane scale. Laryngoscopy and grading of the view in the second method were then performed by a second anesthetist. Tracheal intubation was completed following the second laryngoscopy, and time to intubation was recorded.
Results:  The average age and weight were 8.9 ± 3.6 years and 34.9 ± 16.0 kg respectively. Videolaryngoscopy improved 8/11 grade 2 views to grade 1 ( P  =   0.02), and one grade 3 to a grade 2. Three grade 2 views remained unchanged from DL to VL. 4/30 VL intubations required two attempts, and 1/30 failed after two attempts, but was easily intubated with DL. Median time (range) was 16.0 s (14.0–20.0 s) and 22.5 s (17.8–35.0 s) for DL and VL respectively ( P  <   0.001).
Conclusion:  Videolaryngoscopy provides better views than DL at the expense of time to intubate. Although the time taken to intubate is increased with the VL, it is clinically acceptable.