Perioperative management of pediatric surgical patients with diabetes mellitus

Pediatric patients with diabetes are managed with increasingly complex regimens. To optimally manage these patients during the perioperative period, pediatric anesthesiologists must carefully consider the pathophysiology of the disease, patient-specific methods of treatment, status of glycemic control, and the type of surgery proposed. Important pediatric issues, including body size, pubertal development, and ability to tolerate nil per os status, must be considered. To keep pace with the array of options for treating diabetes in children, the perioperative plan should be developed in consultation with a pediatric endocrinologist. We present an algorithm that was developed at Children's Hospital Boston for the management of pediatric patients with either type 1 or type 2 diabetes mellitus presenting for surgery and general anesthesia. This collaborative effort between the pediatric anesthesia and endocrine services represents one example of a standardized approach to these patients that should facilitate care and improve management. Differences from previously published recommendations are highlighted, as are expected changes caused by the continued evolution of pediatric diabetes care. IMPLICATIONS: The evolution of diabetes care for children has made the management of perioperative blood glucose levels a greater challenge for pediatric anesthesiologists. A standardized algorithm for the perioperative management of pediatric patients with type 1 or type 2 diabetes mellitus os presented.     

Pediatric neuroanesthesia

The perioperative management of pediatric neurosurgical patients presents many challenges to neurosurgeons and anesthesiologists. Many conditions are unique to pediatrics. Thorough preoperative evaluation and open communication between members of the health care team are important. A basic understanding of age-dependent variables and the interaction of anesthetic and surgical procedures are essential in minimizing perioperative morbidity and mortality.     

Anesthesia and perioperative medical management of children with spinal muscular atrophy

Objective:  To describe the perioperative medical care, anesthetic considerations, and the risk of postanesthetic respiratory failure in patients with pediatric spinal muscular atrophy (SMA).
Methods:  There is a retrospective chart review carried out at an urban, tertiary care pediatric hospital. All patients with ICD-9 codes corresponding to SMA diagnoses were identified, and records screened for anesthetic and perioperative medical management. Medical records were reviewed for demographic, clinical, and outcome data.
Main results:  Twenty-five children with SMA (10 type I, 8 type II, 7 type III) accounted for 56 general and regional anesthetic cases. Twenty-one (38%) cases had preexisting ventilator dependence. Total intravenous anesthesia with nitrous oxide was provided in 14 (25%) cases, balanced anesthesia with inhalational agents and epidural or systemic opioids were used in 41 (84%) cases, and one infant received a spinal anesthesia. Intraoperative and postoperative complications occurred in 2 (4%) and 2 (4%) cases respectively. One case required an unplanned postanesthetic intensive care unit admission, and there were two late deaths with redirection of care.
Conclusions:  Perioperative care can be provided for children with SMA safely and effectively with total intravenous or inhaled anesthetics along with the judicious use of opioids to improve patient comfort without increased morbidity. Further prospective studies of standardized anesthetic and perioperative respiratory medical management in this population are required to minimize the decompensation of tenuous preoperative respiratory function.     

Anästhesiologisches Management bei Korrekturen von Lippen-Kiefer-Gaumenspalten bei Kindern

We have developed a modern strategy for the anesthetic management of pediatric cleft lip and cleft palate repair using anesthetic drugs such as sevoflurane, desflurane, acetaminophen, remifentanil, and pirtitramide together with new techniques. It provides best conditions for the surgeon and maximum safety for the pediatric patient. A team of pediatricians, neonatologists, pediatric surgeons, and pediatric anesthetists have tackled the problem of management of children with craniofacial abnormalities such as cleft lip and cleft palate. The best and safest anesthetic techniques are outlined and the most frequent complications are discussed, e.g. management of the difficult airway, the airway in patients with complex craniofacial abnormalities, fiberoptic endotracheal intubation through a laryngeal mask, intraoperative dislocation of the endotracheal tube, postoperative airway obstruction and perioperative bleeding.     

Anesthesia-related cardiac arrest in children. An update

The improvement in mortality rates for anesthetized children over the past 50 years reflects the many improvements that have been made in pediatric perioperative care. The modern pediatric anesthesiologist is better trained than the predecessors of half a century ago, and has a vastly improved arsenal of monitoring devices and anesthetic agents from which to choose. The modern pediatric perioperative environment is better equipped to meet the unique needs of children. Techniques practiced by surgeons, nurses, radiologists, and pharmacologists help create a far more sophisticated infrastructure than existed 50 years ago. Given these changes, it is not surprising that outcomes for patients have improved.     

A framework for the management of the pediatric airway

Critical airway incidents in children are a frequent problem in pediatric anesthesia and remain a significant cause of morbidity and mortality. Young children are at particular risk in the perioperative period. Delayed management of airway obstruction can quickly lead to serious complications due to the short apnea tolerance in children. A simple, time critical, and pediatric‐specific airway management approach combined with dedicated teaching, training, and frequent practice will help to reduce airway‐related pediatric morbidity and mortality. There is currently no pediatric‐specific universal framework available to guide practice. Current algorithms are modifications of adult approaches which are often inappropriate because of differences in age‐related anatomy, physiology, and neurodevelopment. A universal and pragmatic approach is required to achieve acceptance across diverse pediatric clinicians, societies, and groups. Such a framework will also help to establish minimum standards for pediatric airway equipment, personnel, and medications whenever pediatric airway management is required.     

人工智能在小儿麻醉中的应用进展

人工智能技术已逐步应用到临床麻醉中,在小儿麻醉中的应用及研究日益增多。人工智能可以在术前预警小儿围术期高危事件风险(如围术期死亡和气道不良事件),辅助气道诊断/评估和围术期输血预测;在术中辅助超声显像、小儿气道管理和呼吸监测,帮助实现麻醉的精准自动化闭环控制;在术后自动监测小儿呼吸模式等。本文总结了医学领域常用的人工智能模型,回顾了目前人工智能应用于小儿麻醉围术期各个阶段的临床研究。人工智能的发展及其在小儿麻醉领域的应用为麻醉科医师在改善患儿的围术期麻醉管理方面提供了思路,有助于预测临床结局,降低围术期风险。     

儿童围术期晶体和胶体液的管理:我们从哪里来又如何到这里?

自从HoSday和Segar在50多年前发表了一篇关于住院儿童补液的成分与比例的标志性文章(Pediarics,1957；19:823-32)以来,临床大部分围术期的补液治疗都以此为参考.但是现今对于儿科手术患者来说,糖、电解质以及血管内扩容的需要量都与原先的描述大不一样了.因此,使用传统的Holliday和Segar...     

Pediatric tracheomalacia and the perioperative anesthetic management of thoracoscopic posterior tracheopexy

Tracheomalacia is a broad term used to describe an abnormally compliant trachea that can lead to exaggerated collapse and obstruction with expiration. We describe the perioperative management of a complex pediatric patient undergoing a posterior tracheopexy which is a relatively new surgical treatment, with a novel surgical approach—thoracoscopy. This procedure has competing surgical and anesthetic needs and presents unique challenges to the physicians involved in caring for these patients. We also review the current literature on pediatric tracheomalacia and examine the newest treatment options to highlight the potential anesthetic challenges and pitfalls associated with management.     

Pediatric obstructive sleep apnea: Preoperative and neurocognitive considerations for perioperative management

Obstructive sleep apnea (OSA) affects up to 7.5% of the pediatric population and is associated with a variety of behavioral and neurocognitive sequelae. Prompt diagnosis and treatment is critical to halting and potentially reversing these changes. Depending on the severity of the OSA and comorbid conditions, different treatment paradigms can be pursued, each of which has its own unique risk:benefit ratio. Adenotonsillectomy is first‐line recommended surgical treatment for pediatric OSA. However, it carries its own perioperative risks and the decision regarding surgical timing is therefore made in the context of procedural risk versus patient benefit. This article presents the seminal perioperative and neurocognitive risks from pediatric OSA to aid with perioperative management.     

Patients with malignant osteopetrosis are at high risk of anesthetic morbidity and mortality.

The anesthetic literature contains no focused discussion of the perioperative management and risks of children with malignant autosomal recessive osteopetrosis (osteopetrosis). We retrospectively analyzed the perioperative morbidity and mortality rates encountered in the anesthetic management of children with osteopetrosis. We compared the perioperative mortality rate for this patient population with that for other pediatric patients in our institution and that reported in the literature for children and other high-risk patients. We also investigated the inability to intubate the tracheas of children with osteopetrosis compared with other pediatric patients in our institution. Using Fisher's exact test, patients with osteopetrosis were found to have a higher likelihood of perioperative mortality compared with other children or all ASA physical status III, but not ASA physical status IV, patients (P < 0.05). Finally, we discovered that children with osteopetrosis were more likely to have tracheas that could not be intubated than other pediatric patients in our institution. We conclude that children with osteopetrosis are at risk of adverse respiratory events and mortality associated with these adverse events. IMPLICATIONS: Osteopetrosis is a rare disease that increases perioperative morbidity and mortality. By performing a retrospective chart review, we found that this increased perioperative morbidity and mortality is primarily related to airway and respiratory factors. Anesthetic management strategies should consider the factors that cause the high frequency of adverse airway events in this patient population.     

Role of echocardiography in the assessment of right ventricular function in the pediatric population

This review article summarizes the use of echocardiography in the evaluation of the right ventricle with special emphasis on pediatric patients. After reading this article, anesthesiologists will develop a better understanding of the anatomy and echocardiographic parameters for hemodynamic and functional assessment of the right ventricle. This knowledge will assist with the perioperative management of patients with cardiopulmonary disorder.     

可弯曲喉罩在患儿气道管理中的应用进展

可弯曲喉罩是患儿麻醉领域常用的气道管理工具,其具有可曲折、抗压缩的长通气端导管,固定方便且可充分暴露手术视野,不妨碍外科操作。患儿舌体大、声门高等解剖因素增加了可弯曲喉罩置入及对位的难度,可弯曲喉罩较低的密封压也增加了术中喉罩漏气及反流误吸的风险。本文就可弯曲喉罩在患儿气道管理中的临床应用进展作一综述,为优化围术期气道管理提供思路,以提高手术安全性并减少术后并发症。     

多学科合作快速康复外科理念在腹腔镜腹股沟疝修补术围手术期的应用

目的:探讨以多学科团队(MDT)合作为基础的快速康复外科(ERAS)在腹腔镜腹股沟疝修补术围手术期应用的可行性及有效性。方法:将782例行择期腹腔镜腹股沟疝修补术的患者按入院顺序随机分为ERAS组(392例)和对照组(390例)。对照组接受常规治疗护理;ERAS组接受MDT合作ERAS理念的治疗护理,主要干预措施包括住院模式选择,医护一体化健康教育,饮食要求,胃肠道准备,尿潴留预防,术后早期活动,伤口疼痛预防,麻醉前给药,防止术中低温,围手术期补液管理,术后恶心、呕吐预防及1个月患者舒适度评价等。比较两组患者术后疼痛、恢复情况、并发症与应激反应发生率、术后舒适度等。结果:与对照组比较,ERAS组术后次日清晨NRS疼痛评分降低,恢复正常饮食时间、下床活动时间、住院时间均减少,术后满意率增加,血清肿、尿潴留、伤口感染等并发症与不适感、恶心反应的发生率降低,术后1个月中位腹股沟疼痛调查表评分降低(均P0.05)。结论:在腹腔镜腹股沟疝修补术患者围手术期中采用MDT合作ERAS理念可以减轻患者不适,加速康复,缩短住院时间,提高患者满意度及舒适度。     

The year in cardiothoracic and vascular anesthesia: selected highlights from 2010

The aortic valve treatment revolution continues with the maturation of aortic valve repair and the dissemination of transcatheter aortic valve implantation. The recent publication of comprehensive multidisciplinary guidelines for diseases of the thoracic aorta has assigned important roles for the cardiovascular anesthesiologist and perioperative echocardiographer. Although intense angiotensin blockade improves outcomes in heart failure, it might further complicate the maintenance of perioperative systemic vascular tone. Ultrafiltration as well as intensive medical management guided by the biomarker brain natriuretic peptide improves outcomes in heart failure. Continuous-flow left ventricular assist devices have further improved outcomes in the surgical management of heart failure. Major risk factors for bleeding in the setting of these devices include advanced liver disease and acquired von Willebrand syndrome. The metabolic modulator perhexiline improves myocardial diastolic energetics to achieve significant symptomatic improvement in hypertrophic cardiomyopathy. A landmark report was also published recently that outlines the major areas for future research and clinical innovation in this disease. Landmark trials have documented the outcome importance of perioperative cerebral oxygen saturation monitoring as well as the outcome advantages of the Sano shunt over the modified Blalock-Taussig shunt in the Norwood procedure. Furthermore, the development and evaluation of pediatric-specific ventricular assist devices likely will revolutionize the mechanical management of pediatric heart failure. A multidisciplinary review has highlighted the priorities for future perioperative trials in congenital heart disease. These pervasive developments likely will influence the future training models in pediatric cardiac anesthesia.     

Perioperative considerations for the food‐allergic pediatric patient

Patients with a history of food allergy and food intolerance are common in the pediatric population and are encountered frequently in the perioperative setting by pediatric anesthesiologists. Perioperatively, food allergy can present on a spectrum ranging from minor acute urticaria to more severe hypovolemia and anaphylactic shock. Allergy to foods including fruits, fish, egg, soy, and peanut are most concerning for their potential to cross‐react with perioperative medications. There is little in the anesthesia literature that focuses on the perioperative management of children with food allergies. This educational review will provide a brief overview of classic immunoglobulin E (IgE)‐mediated food allergies, less common non‐IgE food allergies, and present perioperative considerations for these patients. An audio summary of this topic is included as Supplementary Audio S1 .     

Perioperative intravenous lidocaine use in children

Perioperative pain management impacts patient morbidity, quality of life, and hospitalization cost. In children, it impacts not only the child, but the whole family. Adjuncts for improved perioperative analgesia continue to be sought to minimize adverse side effects associated with opioids and for those in whom regional or neuraxial anesthesia is not suitable. The use of ketamine and alpha agonists may be useful in these settings but have noted adverse effects including hallucinations, hemodynamic instability, and excessive sedation. One alternative is intravenous lidocaine. Despite its off-label use, intravenous lidocaine has demonstrated anti-neuropathic, anti-hyperalgesic, and anti-inflammatory actions and is an emerging technique. Multiple studies in adults have demonstrated beneficial effects of perioperative intravenous lidocaine including improved perioperative analgesia with reduced postoperative opioid use, improved gastrointestinal function, earlier mobilization, and reduction in hospital length of stay. Despite the limited pediatric literature, some of these findings have been replicated. Large-scale trials providing evidence for the pediatric pharmacokinetics and high-quality safety data with respect to intravenous lidocaine are still however lacking. To date, dose ranges studied in the pediatric population have not been associated with serious side effects and current data suggests perioperative intravenous lidocaine in a subgroup of pediatric surgical patients seems well-tolerated and beneficial.     

Perioperative management in children with chronic pain

Children with chronic pain often undergo surgery and effective perioperative management of their pain can be challenging. Identification of the pediatric chronic pain patient preoperatively and development of a perioperative pain plan may help ensure a safer and more comfortable perioperative course. Successful management usually requires multiple different classes of analgesics, regional anesthesia, and adjunctive nonpharmacological therapies. Neuropathic and oncological pain can be especially difficult to treat and usually requires an individualized approach.     

Pediatric ventricular assist devices: Bridge to a new era of perioperative care

Pediatric ventricular assist devices (VADs) are evolving as a standard therapy for end stage heart failure in children. Major recent developments include the increased use of continuous flow (CF) devices in children and increased experience with congenital heart disease (CHD) and outpatient management. In the current and future era anesthesiologists will encounter more children presenting for VAD implantation, subsequent procedures and heart transplantation. Successful perioperative management requires an understanding of the interaction between the patient's physiology and the device and a framework to troubleshoot problems. This review focuses on CF devices, VAD support for CHD and perioperative management of pulsatile and CF devices in the pediatric population.