French current practice for ambulatory anesthesia in children: a survey among the French-speaking Pediatric Anesthesiologists Association (ADARPEF)

Background: This survey aims to describe current practice in ambulatory care among pediatric anesthesiologists in France. Methods: Members of the French‐speaking Pediatric Anesthesiologists Association (ADARPEF) were sent a questionnaire examining the proportion of pediatric ambulatory anesthesia practiced by each responder, the level of adherence to pediatric ambulatory Anesthesia guidelines, and responder consensus in decision making when faced with common case scenarios in pediatric ambulatory anesthesia. For the latter, consensus was defined as a > 80% opinion. Results: One hundred and forty‐five pediatric anesthesiologists replied (43%). Ambulatory anesthesia appears underused in France. Recent French pediatric ambulatory anesthesia guidelines are being applied. Postoperative pain is poorly managed. The choice of scheduling children for ambulatory anesthesia appears to be more heavily influenced by practitioners’ subjective evaluation than evidence from the literature. Conclusion: A better commitment for ambulatory care must be found among anesthesiologists. Further studies are required to improve coherence, safety, and efficiency of children selection for ambulatory anesthesia.     

Herbal medicine use by children presenting for ambulatory anesthesia and surgery

BACKGROUND: Herbal medicine use has become increasingly popular throughout the world. Some of these agents may have serious interactions with anesthetic drugs. Children may potentially be more vulnerable to such interactions because of altered drug handling. While the prevalence of herbal medicine use by children with some chronic illnesses has been estimated, the incidence of this in a population of otherwise healthy children admitted for minor ambulatory anesthesia and surgery is currently unknown. METHODS: Parents of 601 children presenting consecutively for ambulatory surgery were asked to complete a questionnaire detailing administration of herbal medicines to their child. RESULTS: This study identified that 6.4% of children were currently taking an herbal preparation; while a further 10.1% had taken an herbal medicine in the past. Echinacea and arnica were the commonest used herbal remedies. A significant number of children had taken agents which may interact with anesthesia and surgery: St John's Wort, valerian, garlic and gingko. Information on herbal medicines was mostly obtained by parents from nonmedical sources. CONCLUSIONS: A total of 16.6% of children had a current or past history of ingestion of herbal medicines. This finding may have implications for the perioperative management of children presenting for day-case surgery.     

A review of pediatric fasting guidelines and strategies to help children manage preoperative fasting

Fasting for surgery is a routine step in the preoperative preparation for surgery. There have however been increasing concerns with regard to the high incidence of prolonged fasting in children, and the subsequent psycho-social distress and physiological consequences that this poses. Additionally, the past few years have yielded new research that has shown significant inter-individual variation in gastric emptying regardless of the length of the fast, with some patients still having residual gastric contents even after prolonged fasts. Additionally, multiple large-scale studies have shown no long-term sequalae from clear fluid aspiration, although two deaths from aspiration have been reported within the large Wake Up Safe cohort. This has led to a change in the recommended clear fluid fasting times in multiple international pediatric societies; similarly, many societies continue to recommend traditional fasting times. Multiple fasting strategies exist in the literature, though these have mostly been studied and implemented in the adult population. This review hopes to summarize the recent updates in fasting guidelines, discuss the issues surrounding prolonged fasting, and explore potential tolerance strategies for children.     

Fasting times and gastric contents volume in children undergoing deep propofol sedation--an assessment using magnetic resonance imaging

Aim: To investigate the effect of fasting times for clear fluids and solids/non‐clear fluids on gastric content volume using magnetic resonance imaging (MRI). Methods: Pediatric patients undergoing diagnostic MRI under deep propofol sedation, with the stomach located within the area of diagnostic study, were included in this clinical observational study. According to standard institutional guidelines, children were allowed to eat/drink until 4 h and to drink clear fluids until 2 h before scheduled induction time of anesthesia. Gastric content volume per kg body weight (GCV_w) was determined using MRI and compared with actual fasting times prior to induction. Results: Overall 68 patients aged from 0.3 to 19.6 (2.8) years were investigated. Fasting time for clear fluids ranged from 1.1 to 15.5 (5.5) h, for non‐clear fluids/solids from 4.0 to 20.2 (6.7) h. GCV_w ranged from 0.2 to 6.3 (0.75) ml·kg^?1 and showed no significant negative correlation to fasting times for clear fluids (r = ?0.07, P = 0.60) and non‐clear fluids/solids (r = ?0.08, P = 0.51). Conclusions: Based on this preliminary data, GCV_w showed considerable variation but did not correlate with fasting times in children and adolescent patients. Recommended fasting times were often exceeded.     

肾积水患儿术前禁食禁饮多学科链式管理的实践

目的 探讨多学科协作模式下肾积水患儿术前禁食禁饮链式管理临床可行性、安全性和有效性.方法 将146例肾积水患儿按时间段分组,2018年4～12月78例患儿作为对照组,2019年1～9月68例患儿作为观察组.对照组采用传统的术前禁食禁饮管理方式,观察组采用多学科协作模式下术前禁食禁饮链式管理方式,评估记录两组禁食禁饮情况...     

Risk factors for perioperative adverse events in children with myotonic dystrophy

Background:  This study was conducted to identify patient-related, surgical, and anesthetic factors that would help predict adverse events and allow for better planning of perioperative care in children with myotonic dystrophy.
Methods:  This is a retrospective chart review from a large tertiary pediatric hospital. Data were collected on demographics, disease severity, surgical procedure, and anesthetic technique. Perioperative adverse events were recorded.
Results:  Records on 27 patients having 78 anesthetics over a 17.5-year period were reviewed. The overall frequency of postoperative respiratory complications was 10%. Significant risk factors were high muscular impairment rating scale (MIRS) grade ( P  = 0.007), at least 2300 cytosine, thymine, guanine (CTG) repeats on the protein kinase gene of chromosome 19q ( P  = 0.009), a longer duration of surgery (RR = 14.0 for surgery lasting at least 1 h; P  = 0.002), perioperative morphine use (RR = 7.7, 95% CI 2.2–12.8; P  = 0.005), intubation ( P  = 0.02), and the use of muscle relaxant without reversal (RR = 15.5, P  = 0.0002). Using a multivariate risk model, only MIRS grade and the use of muscle relaxant without reversal were shown to be significant independent risk factors (RR = 24.9, P  < 0.0001).
Conclusions:  The MIRS is a statistically significant and clinically useful tool for predicting high perioperative risk. Patients with a high MIRS grade should therefore be considered for postoperative intensive care. The use of muscle relaxant without reversal was also shown to be a significant risk factor. Patients who require morphine infusions postoperatively might also be most safely managed in a high dependency unit.     

Anaesthesia for microvascular surgery in children

Now Actays, microvascular reconstructions are performed with high success rate even in small children. The combination of general anaesthesia and axillary plexus block was used in this prospective study in order to achieve optimal surgical conditions in these challenging operations. Fifteen children under eight years of age (1–8 years) were anaesthetised with a standardised anaesthesia method using a combination of general anaesthesia and axillary plexus block for microvascular toe-to-hand transfer. The duration of anaesthesia varied between 7.5—14.5 hours (mean 11 h). The difference in peripheral skin temperature was used to indicate the difference in peripheral circulation. Due to plexus block, the mean skin temperature in the operated hand was 1.4 C higher than in the opposite extremity at the end of the operation. In the early postoperative phase the temperature difference increased to 4.8C ( P <0.01) due to vasoconstriction in the control hand. The mean temperature in the transplant was 33.3±2.4C at the end of the operation. Primary microvascular results were good in all but two children who needed reoperations. All of the transfers survived. The mean central temperature increased progressively during the operation from 36.2C to 37.6C. One 1-year-old child developed a moderate hyper-thermia of 39.1C. According to this study axillary plexus block can be combined with general anaesthesia in prolonged microvascular operations. When the effect of general anaesthesia ceased, the plexus block effectively increased peripheral circulation in the operated hand.     

Anesthesia for thoracic surgery in children in developing countries

Anesthesia for surgery on the lung and intra-thoracic structures requires a high level of expertise. In the developing world, patients are often poor, anemic and malnourished. They present late with a variety of diseases. Surgery is often mandated in spite of inadequate resources. Maintaining the safety of the patient while treating them within the limits of our resources is a continuing challenge.     

快速康复外科理念下择期手术婴幼儿术前禁食现状调查

目的 了解快速康复外科理念下择期手术患儿术前实际禁食情况,为针对性干预提供参考。 方法 对行择期手术的356例患儿采用自行设计的问卷调查术前实际禁食情况。 结果 术前禁食液体时间为4.92（3.68,9.38）h、禁食母乳为7.17（5.88,9.38）h、禁食配方奶、非母乳或淀粉类固体食物为10.33（8.34,12.50）h;因禁食哭闹140例（39.33%）;不同年龄、家长性别和文化程度患儿术前液体禁食时间差异有统计学意义（均P＜0.05）;患儿家长对术前禁食目的、术前禁食时间过长的危害认知不足,对各类食物术前禁食时间认知存在偏差。 结论 择期手术患儿各类食物术前实际禁食时间过长,导致部分患儿哭闹;患儿家长对术前禁食认知不足,需针对性干预,以促进术前正确禁食。     

Analgesia for appendectomy: comparison of fentanyl and alfentanil in children

During etomidate-N2O vecuronium anaesthesia for appendectomy, three groups of 13 children received fentanyl as a 10 micrograms.kg-1 loading dose and 2 micrograms.kg-1 increments in Group F, alfentanil as a 100 micrograms.kg-1 initial loading dose and either 20 micrograms.kg-1 increments in Group AB or 1 microgram.kg-1.min-1 continuous infusion in Group AI. On the basis of intraoperative heart rate changes, the opioid regimen was less efficient in Group AB (P less than 0.05). Based upon equianalgesic cumulative dosage, the alfentanil/fentanyl potency ratio was in the range of 1/10 to 1/13. The awakening time was similar in all groups, as were the duration of postoperative analgesia, the incidence of postoperative pain and the incidence of nausea and vomiting. We conclude that high-dose alfentanil is as efficient as fentanyl for intra and postoperative analgesia in children undergoing appendectomy.     

Perioperative anxiety in children

Objectives & Aim: The purpose of this investigation was to examine children’s anxiety across the perioperative setting. Background: Although several studies have examined preoperative anxiety in children, few researchers have illustrated perioperative anxiety; that is, anxiety in children throughout the pre and postoperative continuum. Methods: Participants were 261 children ages 2–12. Anxiety was rated prior to surgery, immediately after surgery, and for 2 weeks at home following surgery. Results: Low child sociability and high parent anxiety predicted perioperative anxiety. Perioperative anxiety was related to postoperative pain and negative postoperative behavioral change. Conclusions: Identification and prevention of anxiety in children can help prevent negative outcomes following surgery.     

Effect of minimizing preoperative fasting on perioperative blood glucose homeostasis in children

Two hundred healthy, unpremedicated children, ages 1–10 years, scheduled for elective outpatient surgery were studied in order to examine the effect of minimizing preoperative fasting on perioperative blood glucose concentrations in paediatric patients. None of the patients ingested solids after midnight. On the day of surgery, the children were assigned to one of two groups. Group A children (n= 113) were not allowed any liquids for at least 6 h prior to surgery (NPO). Children in Group B (n= 87) ingested 10 ml·kg^?1 of apple juice 2–4 h prior to the induction of anaesthesia. All patients received lactated Ringer's solution intraoperatively, unless BG at induction was < 50 mg·dl^?1 (2.8 m·mol·l^?1) in which case dextrose 2.5% in lactated Ringer's solution was administered. None of the patients who received apple juice was hypoglycaemic during induction of anaesthesia. However, two children in the NPO group had blood glucose values ± 50 mg·dl^?1 (2.8 m·mol·l^?1) at the time of induction of anaesthesia. Thirteen (11%) patients in Group A and 6 (7%) patients in Group B showed either no change or a further decrease in their postoperative BG concentration as compared with their induction values. Two of 43 patients in Group A and 2 of 41 patients in Group B had gastric fluid volumes > 0.4 ml/kg. All patients in both groups had gastric pH < 2.5. This study shows that gastric fluid volume and pH following a 2–4 h fast are not different from the values measured in children who were subjected to a traditional fasting period of 6 h or longer. Moreover, apple juice consumed 2–4 h prior to surgery neither buffers gastric pH nor does it modify intraoperative glucose homeostasis in children.     

A national survey of the anesthetic management of tonsillectomy surgery in children

Background: Tonsillectomy in children is a common procedure; however, there appears to be a significant degree of variability in anesthetic management. Thus far, there has been no large national survey looking at the perioperative care of these children. Objectives: We conducted a national survey with the aim of determining what represents common practice in the perioperative management of children undergoing tonsillectomy surgery. We compared the respondents’ management against evidence‐based practice. Methods: The survey took the form of a questionnaire, which was sent to members of The Association of Paediatric Anaesthetists (APAGBI) and to Royal College tutors. The questionnaire was sent in paper format to the College Tutors and in digital format to APAGBI members. Emphasis was placed upon preoperative preparation, induction technique, airway management, analgesia, postoperative nausea and vomiting strategy, fluid management and emergence from anesthesia. Results: Responses were obtained from 173 individuals representing a broad cross‐section of anesthetists from teaching and district general hospitals. Findings are as follows: the application of topical anesthetic cream is commonplace (93%), with Ametop^® being the primary preparation used; the intravenous route was preferred to induce anesthesia; most practitioners intubate the trachea to maintain the airway during anesthesia (79%); a muscle relaxant was employed to assist intubation of the trachea in 47% of respondents and the routine use of suxamethonium was reported to be uncommon (9%); the administration of prophylactic ondansetron and dexamethasone was reported by 79% and 70% of respondents respectively; and nonsteroidal anti‐inflammatory drugs (NSAIDs) are used by 77% of individuals either pre‐emptively or during the intraoperative period. Conclusions: Whilst there is individual variability in the management of these cases, the majority of anesthetists prefer the intravenous route for induction of anesthesia, after application of topical anesthetic cream. It is routine practice to intubate the trachea, administer paracetamol, NSAIDs, strong opiates and antiemetics.