Measuring negative behavior change: a pilot study determining feasibility and baseline rate in measures of quality of life and behavior of children after day case ENT surgery and anesthesia

Aim: To determine the feasibility and baseline rate in measures of quality of life and behavior of children after day case ENT surgery and anaesthesia. Background: Negative behavior change post anesthesia has been reported in previous studies to varying degrees [1–3]. Variation may be because of the scales used to measure change. The Post Hospitalization Behavior Questionnaire (PHBQ) [4] has been commonly used to detect these behavior changes. Another scale, the Pediatric Quality of Life Inventory Generic Core Scales version 4.0 (pedsql ) [5] is a validated quality of life questionnaire. It may prove superior in measuring behavior change post anesthesia but has not been used in this context. The comparative feasibility of using the scales and baseline rates of behavior is yet to be determined in this setting. Methods: The population was pediatric ENT day surgeries. After informed consent, demographic and medical data were collected. Questionnaires were performed preoperatively (Baseline), and postoperatively (Day 7 and 30). Results: Neither scale found evidence for substantial negative behavior change, with some negative changes in anxiety domains on the PHBQ and negative changes on the functional domains of the pedsql . Surprisingly, many children showed improvement in behavior. Both scales were equally feasible. Overall return rate was <50%. Conclusion: This pilot data can provide some baseline rates and data on feasibility to plan future intervention studies. In these studies, the anxiety domain of PHBQ may be the best scale to use but small changes indicate large numbers would be needed and particular strategies would be needed to increase follow‐up. References 1 Kotiniemi LH, Ryhanen PT, Moilanen IK. Behavioural changes in children following day‐case surgery: a 4‐week follow‐up of 551 children. Anaesthesia 1997; 52(10) : 970‐6. 2 Kain ZN, Caldwell‐Andrews AA, Maranets I, McClain B, Gaal D, Mayes LC et al. Preoperative anxiety and emergence delirium and postoperative maladaptive behaviors. Anesthesia & Analgesia. 2004 of contents, 2004; 99(6) : 1648‐54. 3 Stargatt R, Davidson AJ, Huang GH, Czarnecki C, Gibson MA, Stewart SA et al. A cohort study of the incidence and risk factors for negative behavior changes in children after general anesthesia. Paediatric Anaesthesia 2006; 16(8) : 846‐59. 4 Vernon DT, Schulman JL, Foley JM. Changes in children's behavior after hospitalization. Some dimensions of response and their correlates. American Journal of Diseases of Children 1966; 111(6) : 581‐93. 5 Varni JW, Seid M, Knight TS, Uzark K, Szer IS. The PedsQL 4.0 Generic Core Scales: sensitivity, responsiveness, and impact on clinical decision‐making. Journal of Behavioral Medicine 2002; 25(2) : 175‐93.     

A cohort study of the incidence and risk factors for negative behavior changes in children after general anesthesia

BACKGROUND: Hospitalization and anesthesia can have a substantial psychological impact on children, which may be manifested by negative behavioral change. The primary aims of this study were to estimate the incidence of negative behavior change postanesthesia in a large cohort of children, and to identify the possible risk factors. METHODS: One thousand two hundred and fifty children aged from 3 to 12 years scheduled for anesthesia for a variety of procedures were enrolled. The absolute version of the Vernon Post Hospitalization Behavior Questionnaire (PHBQ) was used to assess behavior change at 3 and 30 days postanesthesia. Deterioration in seven or more items of behavior was defined to be a significant negative behavior change. Demographic data, anesthesia details, type and extent of preparation, details of procedure and length of hospitalization were recorded. Child temperament, child anxiety and parental anxiety were also measured. RESULTS: Twenty-four percent of children had significant negative behavior change at day 3 and 16% at day 30. After logistic regression, factors associated with significant negative behavior change at 3 days were increased parental state anxiety, younger age, overnight admission, lower birth order and preparation via having a discussion with the anesthetist. At day 30, longer hospitalization, younger age, reading the anesthesia preparation book and a previous difficult anesthesia experience were associated with significant negative behavior change. Also at day 30, reading the anesthesia preparation book was strongly associated with negative behavior change in children having short procedures, but not longer procedures. However, at both 3 and 30 days, the amount of variability explained by factors included in the models was low. CONCLUSIONS: Significant negative behavior change can occur in children after anesthesia. It is difficult to precisely predict in which children this will occur, however, some individual, family and procedural variables are associated with significant negative behavior change. If used, preparation should be considered according to level of surgical complexity.     

Premedication in children: hypnosis versus midazolam

BACKGROUND: The main objectives of premedication in children are to facilitate the separation from the parents, to reduce preoperative anxiety, to smooth the induction of anesthesia and to lower the risk of postoperative behavioral disorders. The most common technique is sedative premedication with midazolam. Hypnosis enables a state of relaxation to be achieved and has never been evaluated as a premedication technique. The aim of the present study was to evaluate the efficacy of hypnosis on anxiety and perioperative behavioral disorders versus midazolam. METHODS: Fifty children from 2 to 11 years of age were randomized into two groups: group H received hypnosis as premedication; group M were given 0.5 mg x kg(-1) midazolam orally, 30 min before surgery. Preoperative anxiety was evaluated using the Modified Yale Preoperative Anxiety Scale (mYPAS) score when arriving in the department (T1), when entering the operating room (T2), and when fitting the facemask (T3). Postoperative behavioral disorders were evaluated using the Posthospitalization Behavioral Questionnaire (PHBQ) at days 1, 7 and 14. RESULTS: The two groups showed no significant difference preoperatively with the PHBQ: (M) 21 (17-25) vs (H) 20 (8-25) and mYPAS score: (M) 28 (23-75) vs (H) 23 (23-78). The number of anxious children was less during induction of anesthesia in the hypnosis group (T3: 39% vs 68%) (P < 0.05). Postoperatively, hypnosis reduced the frequency of behavior disorders approximately by half on day 1 (30% vs 62%) and day 7 (26% vs 59%). CONCLUSIONS: Hypnosis seems effective as premedication in children scheduled for surgery. It alleviates preoperative anxiety, especially during induction of anesthesia and reduces behavioral disorders during the first postoperative week.     

Postconcussive symptoms in children with mild closed head injuries.

OBJECTIVE: To examine the incidence and neuropsychological, behavioral, and neuroimaging correlates of postconcussive symptoms (PCS) in children with mild closed head injuries (CHI). DESIGN: 26 Children with mild CHI and 8 of their uninjured siblings, from 8 to 15 years old, were recruited prospectively and assessed at baseline (ie, within 7 days of injury) and at 3 months postinjury. Parents rated PCS, motivation and affective lability, and behavioral adjustment. Baseline ratings assessed premorbid functioning retrospectively, and follow-up ratings assessed postinjury status. On both occasions, children completed neuropsychological testing, and those with mild CHI also underwent magnetic resonance imaging (MRI). RESULTS: Children with mild CHI did not differ from siblings in baseline ratings of premorbid PCS but displayed higher ratings on several PCS at 3 months postinjury. Thirty-five percent of children with mild CHI showed increases in PCS, compared with baseline premorbid ratings, but none of the siblings did so. Children with mild CHI whose PCS increased from premorbid levels showed poorer neuropsychological functioning at baseline than did children whose PCS did not increase, although the differences had partially resolved by 3 months. They also displayed decreased motivation over time. Their behavioral adjustment was poorer and they had smaller white matter volumes on MRI, but the latter differences were present at baseline and did not change over time, suggesting that they existed prior to the injury. CONCLUSION: Postinjury increases in PCS occur in a sizable minority of children with mild CHI and more often than among uninjured siblings. Increases in PCS following mild CHI are associated with premorbid neurological and psychosocial vulnerability, but also with postinjury decrements in neuropsychological and neurobehavioral functioning.     

Sleeping characteristics of children undergoing outpatient elective surgery

BACKGROUND: A significant number of children undergoing anesthesia and surgery exhibit new-onset sleep-related problems postoperatively. The aim of this longitudinal cohort study was to expand previous research in this area by using a new objective technology. METHODS: This study compared children undergoing general anesthesia and outpatient surgery (n = 92) to a community-based control group of children (n = 77). Data regarding coping, temperament, anxiety, surgical procedures, and postoperative pain were collected. Subjects underwent actigraphy sleep monitoring for at least 3 nights before surgery and 5 postoperative days (POD). Sleep assessment was performed with actigraphy sleep monitoring and the Post Hospitalization Behavioral Questionnaire (PHBQ). RESULTS: Forty-three children (47%) in the surgery group experienced postoperative sleeping disturbances as determined by either the actigraphy or the PHBQ. Only 13 children (14.4%), however, experienced a decrease of at least 1 SD in percentage sleep as assessed by actigraphy. Postoperative pain scores on POD 1 and POD 2 were significantly higher among children who exhibited sleep problems as diagnosed by actigraphy (F = 4.283; P= 0.047). Also, children who exhibited actigraph-based sleep problems scored lower sociability-temperament (14.1 +/- 4.3 vs. 17.5 +/- 3.4; P= 0.04) scores compared with the community group and had a higher rate of change in their perioperative anxiety levels (group x time interaction, F = 5.1; P= 0.03). CONCLUSION: A significant number of children undergoing outpatient surgery experience postoperative sleep-related problems. The clinical significance of this finding, however, is unclear.     

Sleeping Characteristics of Children Undergoing Outpatient Elective Surgery

Background: A significant number of children undergoing anesthesia and surgery exhibit new-onset sleep-related problems postoperatively. The aim of this longitudinal cohort study was to expand previous research in this area by using a new objective technology.

Methods: This study compared children undergoing general anesthesia and outpatient surgery (n = 92) to a community-based control group of children (n = 77). Data regarding coping, temperament, anxiety, surgical procedures, and postoperative pain were collected. Subjects underwent actigraphy sleep monitoring for at least 3 nights before surgery and 5 postoperative days (POD). Sleep assessment was performed with actigraphy sleep monitoring and the Post Hospitalization Behavioral Questionnaire (PHBQ).

Results: Forty-three children (47%) in the surgery group experienced postoperative sleeping disturbances as determined by either the actigraphy or the PHBQ. Only 13 children (14.4%), however, experienced a decrease of at least 1 SD in percentage sleep as assessed by actigraphy. Postoperative pain scores on POD 1 and POD 2 were significantly higher among children who exhibited sleep problems as diagnosed by actigraphy (F = 4.283;P = 0.047). Also, children who exhibited actigraph-based sleep problems scored lower sociability-temperament (14.1 +/- 4.3 vs. 17.5 +/- 3.4;P = 0.04) scores compared with the community group and had a higher rate of change in their perioperative anxiety levels (group x time interaction, F = 5.1;P = 0.03).     

The health-related quality of life of children with an extremity fracture: a one-year follow-up study

PURPOSE: To document the health-related quality of life (HRQOL) of children with an extremity fracture at 3 and 12 months postinjury and to determine whether it varies significantly by fracture region and site. METHODS: Children hospitalized for an extremity fracture at 4 pediatric trauma centers were studied. A baseline, 3-month, and 12-month telephone interview were completed by a primary caregiver to measure the child's HRQOL using the Pediatric Quality of Life Inventory (PedsQL). HRQOL was modeled as a function of injury, patient, and family characteristics using a longitudinal regression model. RESULT: Of the 100 children enrolled, 52 sustained a lower extremity fracture (LEF) and 48 an upper extremity fracture (UEF). Postinjury HRQOL scores were significantly poorer than preinjury scores for all subjects (P = 0.05). In addition, a significant proportion of subjects reported impaired physical and psychosocial HRQOL at 3 (44% and 46%, respectively) and 12 months (23% and 33%, respectively) postinjury. At 3 months postinjury, children with an LEF had significantly poorer HRQOL outcomes compared to children with a UEF. By 12 months postinjury, the physical function of children with a tibia and/or fibula fracture remained significantly lower than children with a UEF (P < or = 0.05). CONCLUSIONS: Children hospitalized for an extremity fracture suffered dramatic declines in physical and psychosocial well-being during the first 3 months postinjury. By 1 year postinjury, most children recovered; however, children with a tibia and/or fibula fracture still reported significantly poorer physical functioning.     

不同麻醉方式对全身麻醉患儿术后行为改变的影响

目的 评价不同的麻醉方式对全身麻醉下行扁桃体、腺样体切除术患儿术后行为改变的影响. 方法 将90例全身麻醉下行扁桃体、腺样体切除术患儿采用随机数字表法分为3组(每组30例):吸入麻醉组(S组)、全凭静脉组(P组)、静吸复合组(SP组).根据术后行为量表(post hospitalization behavior questionnaire,PHBQ),在术后1、3、7、15d及3个月评估3组患儿消极术后行为改变(negative postoperative behavioural changes,NPOBCs)的发生. 结果 与S组比较,SP组术后7、15 d发生NPOBCs的患儿(18例、10例)及3个月来平均每例患儿NPOBCs发生的总次数[(11±8)次]均较低,差异有统计学意义(P＜0.05);P组术后3、7、15 d发生NPOBCs的患儿数(20例、16例及8例)及3个月来平均每例患儿NPOBCs发生的总次数[(6±6)次]也均较低,差异有统计学意义(P＜0.05);与SP组比较,P组患儿术后NPOBCs发生率差异无统计学意义(P＞0.05),但平均每例患儿NPOBCs发生的总次数明显较少,差异有统计学意义(P＜0.05). 结论 相比吸入麻醉和静吸复合麻醉,全凭静脉麻醉可减少小儿患者NPOBCs的发生.     

Quality of Life after Pediatric Intestinal Transplantation: The Perception of Pediatric Recipients and Their Parents

The objective was to examine the perception of physical and psychosocial functioning of pediatric intestinal transplant recipients who are beyond the perioperative period and compare these with normal and chronically ill children. Child and parent forms of the Child Health Questionnaire were administered to all 29 pediatric intestinal transplant recipients between the ages of 5 and 18 years who had had a small bowel transplantation 1 year previous and had a functional allograft. Comparison was made with published norms and scores for pediatric patients on hemodialysis. Intestinal transplant recipients (on average 5 years after intestinal transplantation and at a mean age 11 years) reported similar scores in all domains compared with normal children. Parents of intestinal transplant recipients noted decreased function in several domains related to their child's general health, physical functioning, and the impact of the illness on parental time, emotions and family activities. Intestinal transplant recipients beyond the perioperative period perceive their physical and psychosocial functioning as similar to normal school children. Parental proxy assessments differ from the recipients, with the parent's perception of decreased general health and physical functioning for intestinal transplant recipients compared with norms.     

Postoperative behavioral changes following anesthesia with sevoflurane

BACKGROUND: Behavioral disturbance following hospitalization is a relatively frequent event, some children still having negative behavioral changes (NBC) 1 month following their operation. Sevoflurane has a propensity to induce 'excitement' during induction of anaesthesia, and delirium in the immediate postoperative phase. The aim of this study was to evaluate whether this translates into prolonged behavioral change. METHODS: A total of 120 children presenting for daycase surgical procedures under anesthesia were included in the study. Children were randomized to induction and maintenance of anesthesia with sevoflurane or halothane. No additional sedative drugs were administered. Postoperative behavioral change was assessed using the Post-Hospital Behavior Questionnaire (PHBQ) on postoperative days 1, 7 and 30. RESULTS: The Sevoflurane group (n = 63) were more distressed on emergence of anesthesia than the Halothane group (n = 57) (P < 0.05). About 58.3, 46.8 and 38.3% of all children exhibited NBC on postoperative days 1, 7 and 30, respectively. There was no association between anesthetic agent and behavior. There was a significant relationship between decreasing age and NBC (P < 0.005). CONCLUSIONS: Children anesthetized with sevoflurane exhibit more immediate postoperative distress than those anesthetized with halothane. This difference is not carried over into the longer posthospital period. Negative behavioral changes occur more frequently with decreasing age.     

Perioperative growth hormone treatment and functional outcome after major abdominal surgery: a randomized, double-blind, controlled study

OBJECTIVE: To evaluate short- and long-term effects of perioperative human growth hormone (hGH) treatment on physical performance and fatigue in younger patients undergoing a major abdominal operation in a normal postoperative regimen with oral nutrition. SUMMARY BACKGROUND DATA: Muscle wasting and functional impairment follow major abdominal surgery. METHODS: Twenty-four patients with ulcerative colitis undergoing ileoanal J-pouch surgery were randomized to hGH (12 IU/day) or placebo treatment from 2 days before to 7 days after surgery. Measurements were performed 2 days before and 10, 30, and 90 days after surgery. RESULTS: The total muscle strength of four limb muscle groups was reduced by 7.6% in the hGH group and by 17.1% in the placebo group at postoperative day 10 compared with baseline values. There was also a significant difference between treatment groups in total muscle strength at day 30, and at the 90-day follow-up total muscle strength was equal to baseline values in the hGH group, but still significantly 5.9% below in the placebo group. The work capacity decreased by approximately 20% at day 10 after surgery, with no significant difference between treatment groups. Both groups were equally fatigued at day 10 after surgery, but at day 30 and 90 the hGH patients were less fatigued than the placebo patients. During the treatment period, patients receiving hGH had reduced loss of limb lean tissue mass, and 3 months after surgery the hGH patients had regained more lean tissue mass than placebo patients. CONCLUSIONS: Perioperative hGH treatment of younger patients undergoing major abdominal surgery preserved limb lean tissue mass, increased postoperative muscular strength, and reduced long-term postoperative fatigue.     

Perioperative cardiac arrests in children between 1988 and 2005 at a tertiary referral center: a study of 92,881 patients

BACKGROUND: The objective of this study was to determine the incidence and outcome of perioperative cardiac arrest (CA) in children younger than 18 yr undergoing anesthesia for noncardiac and cardiac procedures at a tertiary care center. METHODS: After institutional review board approval (Mayo Clinic, Rochester, Minnesota), all patients younger than 18 yr who had perioperative CA between November 1, 1988, and June 30, 2005, were identified. Perioperative CA was defined as a need for cardiopulmonary resuscitation or death during anesthesia care. A cardiac procedure was defined as a surgical procedure involving the heart or great vessels requiring an incision. RESULTS: A total of 92,881 anesthetics were administered during the study period, of which 4,242 (5%) were for the repair of congenital heart malformations. The incidence of perioperative CA during noncardiac procedures was 2.9 per 10,000, and the incidence during cardiac procedures was 127 per 10,000. The incidence of perioperative CA attributable to anesthesia was 0.65 per 10,000 anesthetics, representing 7.5% of the 80 perioperative CAs. Both CA incidence and mortality were highest among neonates (0-30 days of life) undergoing cardiac procedures (incidence: 435 per 10,000; mortality: 389 per 10,000). Regardless of procedure type, most patients who experienced perioperative CA (88%) had congenital heart disease. CONCLUSION: The majority of perioperative CAs were caused by factors not attributed to anesthesia, in distinction to some recent reports. The incidence of perioperative CA is many-fold higher in children undergoing cardiac procedures, suggesting that definition of case mix is necessary to accurately interpret epidemiologic studies of perioperative CA in children.     

Continuous peripheral nerve block for postoperative pain control at home: a prospective feasibility study in children

BACKGROUND AND OBJECTIVES: We assessed the feasibility and efficacy of postoperative pain control by continuous peripheral nerve blockade (CPNB) in children after early home discharge under parental surveillance. METHODS: All children scheduled for primary elective ankle or foot surgery under sciatic popliteal CPNB and general anesthesia were evaluated. After obtaining the surgeon's consent, the children were discharged on either the day (D) of surgery (D0), or on postoperative D1 or D2 (depending on whether they needed a plaster cast or a suction drainage). The CPNB was continuously infused, using an elastomeric pump. Before the procedure, the parents were taught how to assess their children's pain, to use rescue analgesia, and to manage an infusion elastomeric pump device, and when to call the hospital in case of emergency. The children returned to the hospital for catheter removal and the recording of any postoperative event. RESULTS: Forty-seven children were entered into this observational study. Two were discharged home on the same day, 30 were discharged home 1 day after surgery, and 15 were discharged home 2 days after surgery. The mean duration of infusion elastomeric pump at home was 3 days (range, 2 to 4 days). Analgesia was rated as excellent or good in 89% of the cases, and the quality of sleep was always good, except for three patients. Some minor untoward effects were recorded. Two children returned to the hospital because of accidental disconnection of the infusion elastomeric pump from the catheter. Four patients presented skin redness at the puncture site, but no infection was observed, and all catheters remained sterile. No parents called the hospital. The children's quality of life was rated as excellent or as satisfactory overall, by both the children and their parents. CONCLUSIONS: Shortening hospital stays with the use of at-home CPNB under sole parental supervision is feasible, after selecting children with a suitable family environment.     

The severity and duration of postoperative pain and analgesia requirements in children after tonsillectomy, orchidopexy, or inguinal hernia repair

Objectives: To provide parents of children with accurate information regarding postoperative pain, its management, and functioning following common surgical procedures. Background: The increasing prevalence of pediatric day‐case procedures demands a more thorough understanding of the recovery profiles associated with these operations. Aim: To document postdischarge pain profiles, analgesia requirements, and functional limitation in children following tonsillectomy, orchidopexy, or inguinal hernia repair (IHR). Methods: Following hospital discharge, parents were asked to record their children’s pain levels, analgesia consumption, and degree of functional limitation each day until complete recovery. Pain and functional limitation were measured using the Parents’ Postoperative Pain Measurement (PPPM) scale and Functional Activity Score, respectively. Significant pain was defined as PPPM ≥ 6. Results: One hundred and five patients (50, tonsillectomy; 24, orchidopexy; and 31, IHR) were recruited. Median PPPM was always <6 after IHR, ≥6 only on day 1 after orchidopexy and persisted through to day 8 after tonsillectomy. Mild or severe functional limitation was observed after all surgeries and persisted for 4, 5, and 4 days after median PPPM < 6 after IHR, orchidopexy, and tonsillectomy, respectively. Combination analgesia was commonly administered after orchidopexy and tonsillectomy but less so after IHR. The general practitioner consultation rate following tonsillectomy was 54%. Conclusions: After tonsillectomy, children experience significant pain and severe functional limitation for 7 days after surgery. For many children, pain and functional limitation persists throughout the second postoperative week. In children undergoing orchidopexy, paracetamol and ibuprofen provide adequate analgesia. Pain begins to subside after the first postoperative day, and normal activity resumes after 7 days. After IHR, children experience mild pain that can be treated with paracetamol and return to normal functioning after 4 days.     

Second‐hand smoking and carboxyhemoglobin levels in children: a prospective observational study

Aim: To establish baseline noninvasive carboxyhemoglobin (COHb) levels in children and determine the influence of exposure to environmental sources of carbon monoxide (CO), especially environmental tobacco smoke, on such levels. Background: Second‐hand smoking may be a risk factor for adverse outcomes following anesthesia and surgery in children (1) and may potentially be preventable. Patients and Methods: Parents and their children between the ages of 1–12 were enrolled on the day of elective surgery. The preoperative COHb levels of the children were assessed noninvasively using a CO‐Oximeter (Radical‐7 Rainbow SET Pulse CO‐Oximeter; Masimo, Irvine, CA, USA). The parents were asked to complete an environmental air‐quality questionnaire. The COHb levels were tabulated and correlated with responses to the survey in aggregate analysis. Statistical analyses were performed using the nonparametric Mann–Whitney and Kruskal–Wallis tests. P < 0.05 was statistically significant. Results: Two hundred children with their parents were enrolled. Children exposed to parental smoking had higher COHb levels than the children of nonsmoking controls. Higher COHb values were seen in the youngest children, ages 1–2, exposed to parental cigarette smoke. However, these trends did not reach statistical significance, and confidence intervals were wide. Conclusions: This study revealed interesting trends of COHb levels in children presenting for anesthesia and surgery. However, the COHb levels measured in our patients were close to the error margin of the device used in our study. An expected improvement in measurement technology may allow screening children for potential pulmonary perioperative risk factors in the future.     

Perioperative complications in children with Apert syndrome: a review of 509 anesthetics

Objectives: To perform a retrospective, anesthesia case note review in children with Apert Syndrome. Aim: To identify perioperative complications in this group of patients. Background: Apert syndrome is a rare autosomal dominant disorder characterized by craniosynostosis, craniofacial anomalies, and severe symmetrical syndactyly (cutaneous and bony fusion) of the hands and feet. Children with this syndrome require general anesthetics for a number of different operations and procedures. Our institution has records of 71 children with Apert syndrome. Analysis of their general anesthetic records was undertaken, and the incidence of perioperative complications was investigated. Methods: A retrospective case note review was performed on 61 children with Apert syndrome over a 14‐year period. There were a total of 509 general anesthetics administered to these children during this period of time. Results: There were a total of 31 perioperative respiratory complications occurring in 21 patients (6.1% of the total cases). Twenty‐three of these complications were supraglottic airway obstruction (4.5% of total cases). Conclusions: We found there to be a low incidence of major perioperative major complications in this group of patients. Nevertheless, a significant proportion of these children have obstructive sleep apnoea and may develop supraglottic airway obstruction on induction and emergence from anesthesia due to the associated mid‐face anatomical abnormalities.     

Anesthesia for children with hyperleukocytosis a retrospective review

Background: Hyperleukocytosis (a white cell count in peripheral blood >100 × 10⁹ l^?1) is a well‐recognized medical emergency. Rates of morbidity associated with anesthesia in hyperleukocytotic patients have not been previously described. This retrospective study describes the perioperative morbidity and mortality of children who present acutely with hyperleukocytosis. Methods: All patients under 17 years of age with leukemia complicated by hyperleukocytosis and who received general anesthesia as part of their acute care at the Children’s Hospital in Westmead from July 1999 to June 2008 were included. Data describing perioperative adverse events within 48 h of anesthesia were collected using a systematic chart review. Results: Over the 8‐ year period, 60 children were admitted with hyperleukocytosis related to a new diagnosis of leukemia. Fifty‐two children had general anesthesia within 48 h of their admission. Eleven children required two separate general anesthetics within this same time frame. Two deaths were recorded within 48 h of anesthesia; one child died from neurological complications of her disease, and the second died from multi‐organ failure. Three children had serious respiratory adverse events requiring postanesthesia intensive care. Thirteen children had notable but less serious adverse events. These were typically respiratory in nature and required supplemental oxygen for more than 2 h after anesthesia. Conclusion: Children with leukemia‐related hyperleukocytosis often require general anesthesia at the time of presentation and are at significant perioperative risk. Respiratory adverse events are very common and mandate close postanesthesia care.     

Anesthesia can be safely provided for children in a high-field intraoperative magnetic resonance imaging environment

Objectives: To describe the challenges associated with providing safe anesthesia and perioperative care for children in a remote intraoperative magnetic resonance (iMR) operating room (OR) and to identify perioperative anesthesia outcomes, including adverse events related to the iMR environment. Background: Increasingly, children undergo neurosurgical procedures in a high‐field iMR OR. We describe a 10‐year experience of providing anesthesia for children in this environment with a mobile 1.5‐Tesla magnet. Methods: A 10‐year retrospective analysis was conducted of children who underwent neurosurgical procedures in a high‐field mobile iMR OR. Primary outcomes related to perioperative adverse events and recovery profiles. Results were expressed as mean ± sd or median (range), as appropriate. Results: One hundred and five procedures were performed on 98 children, aged 4 months–18 years, weighing 6–112 kg. The commonest two diagnostic categories were tumor (n = 52) and seizures (n = 27). Median anesthetic time was 439 (185–710) mins. There were no significant adverse events related to the iMR environment. The mean postanesthetic care unit admission temperature was 37 ± 0.9°C and the mean modified Aldrete Score at 30 mins was 7.2 ± 0.9. Two patients experienced seizures in the immediate postoperative period, readily controlled with propofol. There was one breach of MR safety protocol, and no adverse events related to patient transport. Conclusions: Anesthesia and perioperative care of children in an iMR setting were associated with a very low incidence of complications, despite the duration of the procedures involved. Such success depends upon a cohesive team‐based approach.     

Ingestion of stimulant medications does not alter bispectral index or clinical depth of anesthesia at 1 MAC sevoflurane in children

Background/Aim: Children treated with stimulant medications for the behavioral management of attention deficit hyperactivity disorder (ADHD) may present for elective surgery. Stimulant medication is often continued until the morning of surgery to optimize perioperative behavior. It is unknown whether such stimulant drug ingestion can affect cerebral arousal and alter depth of anesthesia. A clinically relevant alteration in measured depth of anesthesia could form the basis for an evidence‐based recommendation that children taking stimulant medications require a change in the amount of anesthetic delivered or that they require routine monitoring of depth of anesthesia. Materials and Methods: Thirty‐four ASA 1 and 2 children aged between 5 and 16, presenting for elective day case surgery, were recruited. Seventeen had a diagnosis of ADHD and had taken stimulant medication on the day of surgery, and 17 were controls. A standard inhalational induction of anesthesia using air, oxygen, and sevoflurane by facemask was performed and maintained for 10 min at 1 MAC endtidal sevoflurane. During this time, no other stimulus was applied to the patient. Bispectral index (BIS) and other markers of depth of anesthesia were recorded after 10 min. Results: Children in both groups were of similar ages and weights. There were a higher percentage of boys in the stimulants group. Baseline physiological parameters were similar in both groups. After induction and equilibration for 10 min of anesthesia at 1 MAC endtidal sevoflurane, there was no significant difference in BIS or clinical markers of depth of anesthesia. Conclusions: Children taking stimulant medication for ADHD, and who ingest medication on the day of surgery, do not appear to have altered BIS or depth of anesthesia at 1 MAC of sevoflurane. These results do not support a recommendation for a change in anesthetic practice for children having ingested stimulants up to the day of surgery, either in terms of increasing the amount of anesthetic given or monitoring of depth.     

Effect of nicotine replacement therapy on stress and smoking behavior in surgical patients

BACKGROUND: Many surgical patients are dependent on nicotine. Smoke-free policies in healthcare facilities mandate abstinence from smoking, which could contribute to psychological stress in the perioperative period. The authors tested the hypothesis that nicotine replacement therapy decreases psychological stress in cigarette smokers scheduled to undergo elective surgery and determined whether nicotine replacement therapy affects postoperative smoking behavior, even when not specifically prescribed to promote abstinence. METHODS: In this double-blind, placebo-controlled trial, 121 smokers, of whom 116 received a study intervention, were randomly assigned to receive either active (nicotine-containing) or placebo patches, beginning on the morning of surgery and continuing for up to 30 days after discharge from the hospital. Outcomes included the Perceived Stress Score, the Nicotine Withdrawal Score, and subject self-report of smoking behavior. RESULTS: The Perceived Stress Score and the Nicotine Withdrawal Score did not change significantly from baseline over the immediate perioperative period and did not differ between active or placebo patch groups (all P > 0.19). The percentage of placebo versus active patch subjects reporting 7-day abstinence at 30 days postoperatively (30% vs. 39%; P = 0.29) did not differ significantly between groups. At 30 days postoperatively, subjects in both groups significantly reduced their cigarettes smoked per day from baseline, but those receiving active patches reported a greater decrease (a mean decrease of 11 +/- 11 vs. 15 +/- 7 cigarettes/day in placebo and active groups; P = 0.045). CONCLUSION: Routine nicotine replacement therapy is not indicated in smokers undergoing surgery for the purposes of managing nicotine withdrawal and stress but can modify some aspects of postoperative smoking behavior.