An effective procedure for skin stiffness measurement to improve Paediatric Burn Care

BackgroundThe objective evaluation of scar quality plays a crucial role in improving burn surgery and scar rehabilitation. Suction-based skin measurements were proposed as a method to objectively determine the mechanical properties of scars, yet their use is limited, in particular for paediatric burn care. A new device was developed which provides essential advantages for scar assessment. The aim of this study was to assess its reliability, intra- and interobserver variability.MethodsThe new device, “Nimble”, consists of a lightweight probe that measures the negative pressure needed to obtain a predefined tissue elevation, revealing information on the stiffness of the tissue. 29 former paediatric burn patients were included. Three observers measured the tissue stiffness of a predefined location on the scar and on healthy skin using the Nimble, and the established suction device, the Cutometer^®. The reliability of both instruments in distinguishing between healthy skin and scar was assessed by means of the intraclass correlation coefficient.ResultsThe Nimble successfully differentiated between scar tissue and healthy skin in 92%, the Cutometer in 80% of the patients (p < 0.05). Inter- and intraobserver variability of the Nimble (ICCs) were excellent. For the majority of the calculated ICC values the Nimble exceeded the Cutometer^®.ConclusionThe new device enables reliable and safe measurement of the stiffness of scars. Measurements are less susceptible to patient non-compliance and observer dependency. The Nimble might therefore constitute an easy to use tool for the systematic assessment of scars, thus supporting decision-making in paediatric burn care.     

A survey of the use of 2D ultrasound guidance for insertion of central venous catheters by UK consultant paediatric anaesthetists

BACKGROUND AND OBJECTIVE: National Institute for Clinical Excellence guidance states that 2D imaging ultrasound guidance should be used when inserting internal jugular venous lines in adults and children in the elective situation and should be considered in most clinical circumstances requiring central venous catheter insertion. This survey explored the availability, training and use of ultrasound devices by consultant paediatric anaesthetists in the UK. METHODS: A questionnaire was distributed to UK members of the Association of Paediatric Anaesthetists of Great Britain and Ireland. RESULTS: There was a response rate of 63% and of those responding, 212 (81%) inserted paediatric central venous catheters. Ultrasound devices were available in the workplace of 216 (82%) and the average number of devices available per department was two. For elective paediatric theatre cases, 26% of paediatric anaesthetists with access to an ultrasound device always used it when inserting an internal jugular central venous line. The majority (74%) of respondents had received training in the use of 2D ultrasound. CONCLUSIONS: National Institute for Clinical Excellence guidance on the use of ultrasound locating devices for placing central venous catheters is not universally adhered to. Among the reasons for this are problems with availability of equipment, lack of training in the use of ultrasound and non-acceptance of the guidelines.     

Postal survey of cuffed or uncuffed tracheal tubes used for paediatric tracheal intubation

A postal survey of the use of cuffed or uncuffed tracheal tubes for tracheal intubation in children and infants was performed to investigate the criteria used for deciding the choice of tube and the manner of inflating the cuff in the case of use of a cuffed tracheal tube (CTT). From 200 questionnaires despatched, replies were received from 130 paediatric anaesthesiologists (response rate 65%). In paediatric practice, the CTT was routinely used by 25% of respondents for more than 80% of their patients, while more than 37% of respondents use them in less than 20% of the cases. The three main criteria used for inflating a cuff were: (i) the presence of a leak, (ii) the type of surgery associated with the presence of a leak and (iii) the patient's age associated with the type of surgery and the presence of a leak. These criteria were specified, respectively, by 32%, 24% and 18% of the respondents. The cuff was inflated in response to a leak in 18% of the cases and as a response to a pressure manometer in 15% of the cases. Few paediatric anaesthesiologists use a cuffed tracheal tube routinely for tracheal intubation in children, and fewer actually use a pressure monitoring device, while it is suggested that the cuff pressure should be monitored in case of CTT.     

Experimental and Preliminary Clinical Studies of a Method of Reducing Anaesthetic Gas Contamination

Long-term exposure to low concentrations of anaesthetic gases is potentially hazardous. In spite of efforts to reduce the exposure of personnel by increased air conditioning, by scavenging of excess circuit gases and by improvements in anaesthetic equipment, high concentrations of gases have still been measured. Problems arise during mask induction, in paediatric anaesthesia, and in certain situations with unavoidable leaks, especially in small rooms but also in recovery rooms. Experimental and preliminary clinical studies have shown that nitrous oxide pollution can be considerably reduced by using a separate close scavenging system in the area where high gas concentrations occur. The geometrical and flow dimensions of a close scavenging device used in paediatric. anaesthesia are described.     

Is adenoidectomy in children safer with laryngeal mask airway or with tracheal intubation?

Adenoidectomy in paediatric outpatient surgery is assumed to require tracheal intubation (TT). The laryngeal mask airway (LMA) commonly used for general paediatric surgery has never been previously studied for adenoidectomy. We therefore prospectively compared in a randomized manner, the incidence of complications with TT and LMA in 56 children undergoing adenoidectomy. Preoperative, intraoperative and the lowest SPO₂ values after removal of either TT or LMA were recorded. The respiratory complications, cough, stridor and/or laryngospasm, were recorded intraoperatively and after removal of the airway device. The oxygen saturation levels were significantly higher in the laryngeal mask airway group both intraoperatively and after removal of the respiratory device (P<0.05). The incidence of respiratory complications was lower in the LMA group. In conclusion we have shown that the laryngeal mask airway with a flexometallic tube is a satisfactory alternative to tracheal intubation for outpatient paediatric adenoidectomy.     

Evaluation of a new paediatric scavenging valve

BACKGROUND: Prolonged exposure to anaesthetic gases may be associated with adverse effects. Scavenging is in widespread use in adult anaesthesia but it has been more difficult to find a satisfactory solution for use in paediatric anaesthesia. The Exeter Paediatric T-piece Scavenging (Exeter PTS) valve has been designed for use with a modified Jackson-Rees system to allow connection to an active or passive Approved Gas Scavenging System. METHODS: Use of the Exeter PTS valve was evaluated in 35 spontaneously breathing paediatric patients (mean age 4.7 years, mean weight 16.7 kg) using each patient as their own control. Atmospheric pollution was measured using a Miran 1B infrared spectrophotometer. RESULTS: When using a modified Jackson-Rees breathing system with an open-ended bag, pollution levels of isoflurane exceeded the Occupational Exposure Standard of 50 p.p.m. When the Exeter PTS valve and an active scavenging system were used, pollution was significantly reduced to below 5% of the recommended limit. CONCLUSIONS: We conclude that there is a need to reduce atmospheric pollution when using a modified Jackson-Rees system in spontaneously breathing patients and that this can be achieved by use of the Exeter PTS valve.     

ASSESSMENT OF A SCAVENGING DEVICE FOR USE IN PAEDIATRIC ANAESTHESIA

We describe a scavenging device, primarily for use during inhalationinduction of anaesthesia in children; it was designed to optimizethe often conflicting requirements of clinical acceptabilityand adequate gas collection. The performance was assessed inthree ways. The device reduced the nitrous oxide concentrationin the breathing zone of the anaesthetist during inhalationinduction to about 100 p.p.m. We also describe a method to measurethe direct catchment of nitrous oxide expressed as a percentageof the total nitrous oxide used. In 46 patients the mean percentagecollection was 82%. Using personal sampling devices, we foundthat comprehensive scavenging in paediatric anaesthesia canreduce the average exposure of anaesthetists to about 130 p.p.m.of nitrous oxide.     

A comparison of the laryngeal mask airway with facemask and oropharyngeal airway for manual ventilation by critical care nurses in children

The laryngeal mask airway is included as a first line airway device during adult resuscitation by first responders. However, there is little evidence for its role in paediatric resuscitation. Using anaesthetised children as a model for paediatric cardiopulmonary arrest, we compared the ability of critical care nurses to manually ventilate the anaesthetised child via the laryngeal mask airway compared with the facemask and oropharyngeal airway. The airway devices were inserted in random order and chest expansion was measured using an ultrasound distance transducer. The critical care nurses were able to place the laryngeal mask airway and achieve successful ventilation in 82% of children compared to 70% using the facemask and oropharyngeal airway, although the difference was not statistically significant (p = 0.136). The median time to first successful breath using the laryngeal mask airway was 39 s compared to 25 s using the facemask (p < 0.001). In this group of nurses, we did not show a difference in ventilation via a laryngeal mask airway or facemask, although facemask ventilation was achieved more quickly.     

The use of the cuffed oropharyngeal airway in paediatric patients

BACKGROUND: The cuffed oropharyngeal airway (COPA) is a device which has already been demonstrated to be suitable for anaesthetized adult patients undergoing either spontaneous or mechanical ventilation. There are few reports on the use of the COPA in children. In this study, the authors assessed the COPA in paediatric patients undergoing minor surgery. METHODS: The same anaesthesiologist inserted the COPA in 40 consecutive paediatric patients, ASA I and II, aged 1.8-15.3 years. (7.4 +/- 3.9), after induction of anaesthesia with N2O/O2/sevoflurane. COPA size was chosen by measuring the distal tip of the device at the angle of the jaw with the COPA perpendicular to the patient's bed. The proper positioning of the COPA was assessed by observing thoracoabdominal movements, regular capnograph trace, the reservoir bag movements and SpO2 > 94% with a fraction of inspired oxygen of 0.5. Anaesthesia was maintained with 1 MAC halothane, sevoflurane, or isoflurane in N2O/O2 (50%) and the patients were spontaneously breathing. The stability of the COPA following changes in head, neck and body position was tested. We recorded the duration time for COPA insertion, the side-effects of placement of the COPA and during the intraoperative period, the number of attempts, the type of manipulation in order to provide an effective airway and postoperative symptoms, such as the presence of blood on the device, sore throat, neckache, jaw pain and PONV. RESULTS: Successful COPA insertion at the first attempt was 90% and at the second attempt in the remaining 10%. The most frequent airway manipulations were head tilt in 27.5% (obtained by a pillow under shoulders) and chin lift in 5%. No complications both at COPA placement nor during the intraoperative period were observed. On the basis of weight and age, the COPA size was no. 8 in 50%, no. 9 in 30%, no. 10 in 12.5%, and no. 11 in 7.5%. The COPA demonstrated stability after changes in head, neck and body position. Postoperative complications were the presence of blood stains in one case and PONV in six cases (15%). CONCLUSIONS: The COPA is an extratracheal airway device suitable in paediatric patients undergoing general anaesthesia with spontaneous ventilation for minor surgery and other painful procedures. This study shows that for paediatric patients: (i) complications seem to be rare; (ii) the COPA allows hands free anaesthesia; (iii) specific indication for the COPA could be obese patients with a small mouth; and (iv) COPA sizing can be easily established by the weight or age of the patients.     

A DEVICE FOR MECHANICAL VENTILATION SUITABLE FOR NEWBORN AND INFANTS DURING ANAESTHESIA

A simple device for converting the Cyclator, an adult ventilator,to paediatric use with an infant anaesthetic circuit has beendescribed. This improvisation works on the principle of an adjustableleak introduced in the patient's circuit as recommended by Mushin,Mapleson and Lunn (1962). Present address: Hackney Hospital, London, E.9.     

Initial experience with a wire-guided endobronchial blockade to achieve one-lung ventilation

We report our initial experience with a wire-guided endobronchial blockade, which is a new method to achieve one-lung ventilation with a conventional endotracheal tube. The strong points of this device are its ease of use and the fast training, the possibility of setting it up after the patient was positioned in lateral decubitus position or in the course of intervention as well as the maintenance of ventilation during insertion. Its weak points are the lack of a paediatric model and the quality of the lung collapse which requires a particular operation to be perfect.     

The utilisation of intraosseous infusion in the resuscitation of paediatric major trauma patients

Intraosseous lines are a reliable and rapid tool for obtaining vascular access in emergency situations, particularly in children. Their use is recommended when intravenous access cannot be easily secured and there is a need for fluid or pharmacological resuscitation. Training in this technique is included in the Advanced Trauma Life Support (ATLS) and Advanced Paediatric Life Support course (APLS) provider courses. The objective of this study is to analyse the national use of intraosseous lines in paediatric trauma in England and Wales. Data has been collected from the Trauma Audit and Research Network (TARN) group longitudinally over 14 years from 1988 to 2002. From 23,489 paediatric trauma cases, intraosseous lines were used in only 129 patients. Compared with the remainder of the paediatric data, we found that these were the younger (1-6 years), more severely injured patients (higher ISS, lower GCS, higher head, thorax, and abdominal AIS). The mortality of these patients was high at 64% compared with 4% overall. IO line use was greater in general than in Paediatric hospitals, perhaps due to good intravenous access skills in paediatric centres. We recommend that intraosseous line use should be a skill available to everybody involved in paediatric trauma resuscitation, particularly those who may not have refined paediatric intravenous cannulation skills.     

Inter-observer and intra-observer reliability in the radiographic measurements of paediatric forefoot alignment

BackgroundFoot bones in children have more rounded shapes in radiograms than adults. Thus, the goal of this work was assessing inter- and intra-observer reliability in paediatric forefoot angle measurements.Material and methodsSix forefoot angles in 34 AP standing paediatric foot radiographs were measured by 5 researchers. A classic statistical analysis with use of IBM SPSS Statistics 25 was performed and a new method with two-way analysis of variance was applied.ResultsResults of statistical analysis revealed the properties of a subjective assessment related to specific angles. Kilmartin’s angle, calcaneus-fifth metatarsal angle and first ray angle are the most reliable; metatarsus adductus angle should be used with great caution in pediatric population. Engel’s angle is the most difficult for measuring and measurement error is the highest.ConclusionThe power of paediatric forefoot measurements is various. Several angles are reliable, while Engle’s angle is the most doubtful.     

Infrared technology to improve efficacy of venous access in burns population

Background

Obtaining venous access in the burn population is challenging both in the acute and elective surgical settings. In paediatric burns, this is further compounded by smaller veins, thicker subcutaneous fat and poor cooperation. The introduction of infrared technology (Accuvein®) to identify veins up to 10 mm deep has been shown to increase efficacy. It has been promoted in challenging cases. We aim to ascertain whether Accuvein® is a useful clinical tool in the context of burns population.

Methods

A formal service evaluation of the device was carried out prospectively during a 6-week period. User feedback questionnaires were circulated. We reviewed patient demographics, indication of use, number of attempts and skin quality. We rated user satisfaction using visual analogue scales and a free text comment section.

Results

Twenty-eight questionnaires were returned. We noted inclination for use of device in paediatric patients compared to adults. Ethnicity included Caucasian, Asians, Afro-Caribbean and Hispanic. Skin quality in majority was described as normal; only four patients had poor quality skin (burn scars, friable thin skin). Fifteen patients had successful first attempts. Ninety-six percent of practitioners felt that the device was useful, although 59 % required assistance initially. We noted that it was not useful in detecting veins through grafted burn sites.

Conclusions

Accuvein® is a useful adjunct for venous access particularly in the paediatric population. By reducing the number of attempts to obtain venous access, this saves time and improve efficacy of care. However, we noted that it is not helpful over grafted burn sites. This could be attributable to the nature of the initial burn surgery (tangential excision) rather than the thickness of overlying skin.Level of Evidence: Level IV, risk/prognostic study.

     

Maschinelle Autologe Transfusion (MAT) während orthopädischer Eingriffe bei Kindern Ist der Einsatz der Maschinellen Autotransfusion auch bei kinderchirurgischen Eingriffen möglich?

The use of autotransfusion devices is an established method of reducing the need for homologous transfusions in surgery [3, 11, 13], but technical factors still contraindicate the washing and concentration of blood volumes smaller than 300 ml. Therefore, haemoconcentration of small volumes of salvaged blood, as usually found in paediatric surgery, is considered to be a complicated and questionable practice [5]. Whereas these amounts of blood loss are easily tolerated by adults, they may necessitate homologous transfusions in paediatric surgery. In a prospective study, we investigated whether a simple technical modification in the processing of salvaged blood could facilitate the use of autotransfusion devices, especially in children. Patients and methods. Intraoperative blood salvage was performed in children 6 months to 10 years old undergoing surgery for hip dysplasia. Autotransfusion (Dideco STAT) was started when the blood loss was estimated to be more than 20% of the total blood volume (TBV). As a reference, we used a formula based on body weight [10]: for children up to the age of 6 years 80 ml/kg blood volume and for children up to 10 years 75 ml/kg. The total volume of salvaged fluid including blood, anticoagulant solution, and surgical irrigation was collected in a reservoir and transferred to the autotransfusion set, after which the reservoir was rinsed with 500 ml 0.9% saline solution in order to save the remaining blood. After processing, the blood was stored in the retransfusion bag. By adding the same volume of plasma expander (6% hydroxyethyl starch [HES], molecular weight 450000), spontaneous sedimentation of the washed autologous erythrocytes (RBCs) for 10–15 min led to a concentrate of RBCs. After 10 μ filtration, the RBC suspension was retransfused (Figs.?1–3). Results. Within 12 months, autotransfusion was performed during 6 out of 15 surgical procedures according to the method described above. The calculated blood loss averaged 25.6% of TBV, of which 21.4% (=272 ml) could be processed by the autotransfusion device (Table?3). The mean values of 2.6 g/dl haemoglobin (Hb) and 6.8% haematocrit (HCt) in the salvaged blood increased to 9.4 g/dl and 27.3% in the processed RBC concentrates. After adding 6% HES solution, spontaneous sedimentation of the RBCs led to values of Hb 22.1 g/dl and HCt 59.8%. An average of 59.5 ml (22–99 ml) sedimented RBCs was retransfused to the patients, including 11.6 ml 6% HES solution (Table 4). In this manner, the need for homologous transfusions could be avoided in these patients both during and after surgery. Conclusions. This study shows that the use of blood salvaging in paediatric surgery is indicated under certain conditions. With the aid of the simple modification described above, we solved the main problem in paediatric autotransfusion by concentrating RBC suspensions with low Hb and Hct values after using the autotransfusion device.     

Epidural analgesia in children. A survey of current opinions and practices amongst UK paediatric anaesthetists

BACKGROUND: Despite the widespread use of epidural analgesia in children its place in paediatric pain management has not been clearly established. In order to investigate the current practice of paediatric epidural analgesia in the UK paediatric anaesthetists and paediatric pain management teams were surveyed. METHODS: Questionnaires were sent to the members of the Association of Paediatric Anaesthetists (APA) working within the UK and to lead clinicians and clinical nurse specialists for acute pain in the 26 designated major paediatric centres. RESULTS: The response rate was 72%. There was little consensus regarding drugs and drug combinations used for epidural analgesia. A total of 36% of paediatric centres did not audit their epidural practice, and of those that did the reported incidences of side-effects showed wide variation. Important differences in practice were also identified in the areas of patient selection, informed consent, the use of epidural test doses, drug delivery systems, monitoring and the management of side-effects. Twelve per cent of specialist paediatric hospitals did not have an acute pain team and elsewhere the provision was often limited to staff with few or no specialist skills. CONCLUSION: There is wide variation in the practice of paediatric epidural analgesia in the UK. Inconsistencies are likely to be related to the poor evidence base available to guide clinical decision making and the lack of a specialized paediatric acute pain service in some centres. More research is required to determine the optimal management of epidural analgesia, and suitable clinical support for paediatric pain control should be more widely available.     

Risk factors for airway complications during general anaesthesia in paediatric patients

BACKGROUND: Although airway complications are a frequent problem during paediatric anaesthesia, no study has prospectively identified risk factors for adverse respiratory events during airway management when LMA trade mark (laryngeal mask airway), face mask (FM) or a tracheal tube (TT) are used. METHODS: A prospective study was performed at a university hospital's paediatric centre. Preoperative information included recent history of respiratory infection and type of surgery. Intraoperative information included the identification of the device user, the duration of anaesthesia and the type of airway device used. Adverse respiratory events during the perioperative and postoperative periods were registered. One thousand nine hundred and ninety-six patients were included (mean age 6.45 +/- 2.9 years). RESULTS: Airway complications occurred in 10.2% of the patient for LMA (72/704), 4.7% for FM (19/401) and 7.4% (66/891) for TT. Using a stepwise logistic regression, three independent risk factors were identified: age < 6 years, odds ratio (OR) 1.84, 95% CI (1.21-2.80); use of LMA, OR 2.32, 95% CI (1.29-4.17); presence of respiratory infections (RI) before the procedure, OR 3.72, 95% CI (2.3-5.99). CONCLUSIONS: Age < 6 years, recent RI and the use of the LMA were identified as independent factors associated with an increased risk of airway complications.     

A randomised comparison of the single use LMA Flexible with the reusable LMA Flexible in paediatric dental day-case patients

In this study we compared the performance of the single use flexible laryngeal mask airway (LMA Flexible^™) with the original reusable LMA Flexible^™ in paediatric dento-alveolar day-case surgery. The aim of the study was to determine whether these two supraglottic airway devices were clinically equivalent when used for simple dental extractions in children under general anaesthesia. This randomised comparative trial in 100 healthy children used first attempt airway insertion success as its primary outcome measure. Secondary outcomes included the adequacy of ventilation, incidence of airway obstruction and the requirement for device manipulation and the incidence of adverse airway outcomes during recovery from anaesthesia. No difference was found between the devices in first attempt insertion success rate (94% with reusable LMA Flexible and 90% with single use LMA Flexible, p = 0.358), and ease of insertion was also similar (p  =  0.5). Both devices performed equally well during surgery, with no significant differences in episodes of intra-operative airway compromise (p  =  0.387), and both the single use and reusable LMA Flexible displayed excellent recovery characteristics, with no occurrences of emergence airway obstruction. No blood was discovered within the inner LMA tube shaft in either device, implying that both protected against tracheobronchial soiling. We conclude therefore that the single use LMA Flexible is an acceptable alternative to the reusable LMA Flexible.     

Arterial desaturation in healthy children during transfer to the recovery room

The oxygen saturation in 71 healthy paediatric patients (3.5 months to 16.7 years) was measured by pulse oximetry during transfer from the operating room to the recovery room. These measurements were recorded continuously while the patients breathed room air. Of the patients studied, 28.1 per cent exhibited significant arterial desaturation of less than or equal to 90 per cent. The corresponding PO2 for this saturation level is less than or equal to 58 mmHg. In only 45 per cent of these desaturated patients was the desaturation recognized clinically by the presence of cyanosis. Age, type of anaesthetic, the use or avoidance of narcotics, and the use of controlled or spontaneous respiration had no significant relationship to the incidence of desaturation. Since more than a one quarter of all patients studied desaturated significantly, and since cyanosis can be difficult to detect clinically during the transfer period, the use of supplemental oxygen during transfer should be considered by the anaesthetist at the end of every paediatric general anaesthetic.     

An evaluation of the filtration performance of paediatric breathing system filters using sodium chloride particles at low flows

Introduction:  A minimum standard has yet to be set for paediatric breathing system filters. An evaluation of adult, paediatric and neonatal filters suggested that paediatric filters may have greater penetrance than adult filters at preset flows (1). Hence, it has been suggested that paediatric filters may be less efficient in the prevention of transmission of infective agents (2). While evaluations have been carried out at flows set by the British Standards Institution (3), concern has been expressed that these are not representative of the flows encountered in clinical practice. The use of more appropriate flows would allow the development of more reliable performance criteria. This study evaluated the pressure drop and penetrance of five filters at flows of 3 and 15 l·min^-1.
Methods:  The pressure drop across 15 unused samples of five different filters was measured at a flow of 15 l·min^-1 (RT-200 Calibration Analyser, Timeter Corp, St Louis, USA). The penetration of sodium chloride particles through five samples of each filter was measured at a flow of 15 l·min^-1 using a 'Moore's' Test Rig (CEN Bench Rig, SFP Services, Christchurch, UK) (2). Subsequently, two groups of five of the same filters were tested in parallel using a flow of 15 l·min^-1, thus each filter was tested at a flow of 3 l·min^-1.
Results: