Safeguarding children: why an issue for pediatric anesthetists?

Child maltreatment and the responsibility of heath care professionals to assist in prevention and diagnosis is currently center stage in the United Kingdom. This subject has a very large literature base. Anesthetists were one of the first groups to have specific guidance on this subject, and key competencies are now part of the core curriculum for our trainees. This article seeks to briefly define maltreatment and provide statistics that outline the scale of the problem, and includes discussion of risk factors and recognition. We have focused on physical abuse and have provided a separate section on abusive head trauma, which is of particular importance to anesthetists. We also discuss the process of management, with some detail around Child Death Review procedures.     

全麻苏醒期患儿躁动风险预测模型的建立与验证

目的 建立与验证全麻苏醒期患儿躁动风险列线图预测模型,为识别躁动高风险患儿提供评估工具。方法 收集全麻手术的1～6岁患儿651例,随机分为建模组(n=459)和验证组(n=192),利用多因素logistic回归分析确定建模组全麻苏醒期患儿躁动的危险因素,构建列线图预测模型,分别使用建模组和验证组数据集对模型进行验证。结果 苏醒期发生躁动160例(建模组113例,验证组47例),躁动发生率24.58%。多因素logistic回归显示,年龄、手术科室、身体约束、麻醉方式、镇痛治疗、留置尿管是全麻苏醒期患儿躁动的影响因素(均P<0.05)。基于6个危险因素构建列线图预测模型,模型验证的校正曲线显示模型准确度良好,建模组ROC曲线下面积为0.767,验证组为0.827。结论 全麻苏醒期患儿躁动风险列线图预测模型具有良好的准确度和区分度,可为临床筛查术后躁动高危患儿提供评估工具。     

Blood pressure and flow in pediatric anesthesia: An educational review

During recent years, a lot of interest has been focused on blood pressure in the context of pediatric anesthesia, trying to define what is normal in relation to age and what numeric values that should be regarded as hypotension, needing active intervention. However, blood pressure is mainly measured as a proxy for flow, that is, cardiac output. Thus, just focusing on specific blood pressure numbers may not necessarily be very useful or appropriate. The aim of this educational review is to put the issue of intraoperative blood pressure in the context of pediatric anesthesia in further perspective.     

Consensus statement on clear fluids fasting for elective pediatric general anesthesia

Pediatric anesthetic guidelines for the management of preoperative fasting of clear fluids are currently 2 hours. The traditional 2 hours clear fluid fasting time was recommended to decrease the risk of pulmonary aspiration and is not in keeping with current literature. It appears that a liberalized clear fluid fasting regime does not affect the incidence of pulmonary aspiration and in those who do aspirate, the sequelae are not usually severe or long‐lasting. With a 2‐hour clear fasting policy, the literature suggests that this translates into 6‐7 hours actual duration of fasting with several studies up to 15 hours. Fasting for prolonged periods increases thirst and irritability and results in detrimental physiological and metabolic effects. With a 1‐hour clear fluid policy, there is no increased risk of pulmonary aspiration and studies demonstrate the stomach is empty. There is less nausea and vomiting, thirst, hunger, and anxiety, if allowed a drink closer to surgery. Children appear more comfortable, better behaved and possibly more compliant. In children less than 36 months this has positive physiological and metabolic effects. It is practical to allow children to drink until 1 hour prior to anesthesia on the day of surgery. In this joint consensus statement, the Association of Paediatric Anaesthetists of Great Britain and Ireland, the European Society for Paediatric Anaesthesiology, and L'Association Des Anesthésistes‐Réanimateurs Pédiatriques d'Expression Française agree that, based on the current convincing evidence base, unless there is a clear contraindication, it is safe and recommended for all children able to take clear fluids, to be allowed and encouraged to have them up to 1 hour before elective general anesthesia.     

Careful physical examination is essential in the preoperative assessment of children for dental extractions under general anesthesia

Background : Physical examination is routinely carried out for the preoperative assessment of children, but is it of value in day stay community dental surgery? Methods : A prospective survey of new diagnoses made on children presenting for community dental extractions and compared with children having nondental surgery. Results : Five of 216 children for dental extractions were seen with new diagnoses made, with a variety of conditions including patent ductus arteriosus, aortic stenosis, ventricular septal defect and obstructive sleep apnea. No new diagnoses were made in 294 nondental children in the same period. Conclusions : Physical examination provides a useful adjunct to the history in children undergoing community dental extraction. There is potentially significant morbidity undiagnosed in apparently fit children presenting for dental surgery.     

Laryngeal reflex responses in pediatric anesthesia

Laryngeal and respiratory reflexes are vitally important defense mechanisms against foreign body aspiration, safeguarding airway patency, and ventilation. These highly preserved automatisms easily overrule external influences like willpower or (anesthetic) medication. Prevention and anticipation are, therefore, the essential strategies to avoid adverse events and damage, and treatment is most effective in the early stage of the reflex response. The physiology and pathophysiology of the various defensive reflexes as well as a comprehensive anesthetic approach to prevention and treatment are outlined in this review.     

An optimum time for intravenous cannulation after induction with sevoflurane in children

Background: It is a common practice to perform inhalational induction with sevoflurane followed by intravenous cannulation in children. However, there is little information regarding the time at which the intravenous cannulation can be attempted safely after sevoflurane induction. Aim: To determine the optimal time for safe intravenous cannulation in children induced with sevoflurane. Methods: Pediatric patients aged 4–10 years receiving sevoflurane inhalational induction for elective cases were recruited. General anesthesia was induced with sevoflurane and oxygen via mask, then intravenous cannulation was attempted. The time for intravenous cannulation was determined by the use of up‐and‐down method using 30 s as a step size. Intravenous cannulation without any movement, coughing, or laryngospasm was considered successful. The up‐and‐down sequences were analyzed by the probit test. Results: The time for effective intravenous cannulation in 50% patients was 1.90 min (95% confidence limits, 1.24–2.41 min). The time for effective cannulation in 95% of patient population was 3.32 min (95% confidence limits, 2.68–6.77 min). Conclusion: We recommend an optimal time of 3.5 min for attempting intravenous cannulation after the loss of eyelash reflex with sevoflurane induction.     

Risk factors for laryngospasm in children during general anesthesia

Background:  Laryngospasm is a common and often serious adverse respiratory event encountered during anesthetic care of children. We examined, in a case control design, the risk factors for laryngospasm in children.
Material and Methods:  The records of 130 children identified as having experienced laryngospasm under general anesthesia were examined. Cases were identified from those prospectively entered into the Mayo Clinic performance improvement database between January 1, 1996 and December 31, 2005. Potential demographic, patient, surgical and anesthetic related risk factors were determined in a 1 : 2 case–control study.
Results:  No individual demographic factors were found to be significantly associated with risk for laryngospasm. However, multivariate analysis demonstrated significant associations between laryngospasm and intercurrent upper respiratory infection (OR 2.03 P  =   0.022) and the presence of an airway anomaly (OR   =   3.35, P  =   0.030). Among those experiencing laryngospasm during maintenance or emergence, the use of a laryngeal mask airway was strongly associated even when adjusted for the presence of upper respiratory infection and airway anomaly ( P  =   0.019). Ten patients experienced postoperatively one or more complications whereas only three complications were observed among controls ( P  =   0.008). No child required cardiopulmonary resuscitation and there were no deaths in either study cohort.
Conclusions:  In our pediatric population, the risk of laryngospasm was increased in children with upper respiratory tract infection or an airway anomaly. The use of laryngeal mask airway was found to be associated with laryngospasm even when adjusted for the presence of upper respiratory tract infection and airway anomaly.     

Multidrug intravenous anesthesia for children undergoing MRI: a comparison with general anesthesia

BACKGROUND: We used a multidrug intravenous anesthesia regimen with midazolam, ketamine, and propofol to provide anesthesia for children during magnetic resonance imaging (MRI). This regimen was compared with general anesthesia in a randomized comparative study. Outcome measures were safety, side effects and recovery variables in addition to adverse events in relation to age strata. METHODS: The children received either general anesthesia with propofol, vecuronium and isoflurane [general endotracheal anesthesia (GET) group; n=313] or intravenous anesthesia with midazolam, ketamine, and propofol [intravenous anesthesia (MKP) group; n=342]. Treatment assignment was randomized based on the date of the MRI. Physiological parameters were monitored during anesthesia and recovery. Desaturation (SpO2<93%), airway problems, and the need to repeat the scan were recorded. The discharge criteria were stable vital signs, return to baseline consciousness, absence of any side effects, and ability to ambulate. RESULTS: With the exception of two children (0.6%) in the MKP group, all enrolled children completed the scan. A significantly greater number (2.3%) required a repeat scan in the MKP group (P<0.05) and were sedated with a bolus dose of propofol. The total incidence of side effects was comparable between the MKP (7.7%) and GET groups (7.0%). Infants below the age of 1 year showed a significantly higher incidence of adverse events compared with the other age strata within each group. Within the MKP group, risk ratio was 0.40 and 0.26 when comparing infants aged below 1 year with the two older age strata, respectively. Recovery characteristics were comparable between both groups. CONCLUSIONS: Intravenous midazolam, ketamine and propofol provides safe and adequate anesthesia, comparable with that obtained from general endotracheal anesthesia, for most children during MRI.     

A comparison of emergence delirium scales following general anesthesia in children

Background: Emergence delirium (ED) is of increasing interest since the introduction of short‐acting volatiles such as sevoflurane. Methods: We compared the Pediatric Anesthesia Emergence Delirium (PAED), Watcha and Cravero scales for assessing the presence of ED in 117 of 118 consecutive children <18 years recovering from general anesthesia. The primary measure was the worst score for ED as assessed on each scale and for each patient during their PACU stay. An experienced anesthetist observer also made a subjective assessment of the presence of ED. Results: A PAED score of ≥10 detected ED in 37 children (32%), while the Watcha detected 30 (26%) and Cravero 41 (35%). Twenty‐five patients (21%) fulfilled criteria for ED in all three scales as did all eight patients assessed by the experienced pediatric anesthetist observer. Median PAED scores (interquartile ranges) for patients assessed as having ED or not respectively were for Watcha, 12 (11,14), 7 (4,8); for Cravero, 11 (9,13), 7 (4,8); and for the experienced anesthetist observer, 14.5 (13.5,16.5), 7 (6,10). Conclusions: All three scales correlated reasonably well with each other but have individual limitations in their potential to assess whether ED is present. In the absence of developing an improved research tool to assess ED, a PAED score >12 appears to provide greater sensitivity and specificity than a PAED score ≥10. However, the Watcha scale is a simpler tool to use in clinical practice and may have a higher overall sensitivity and specificity than the other scales.     

A survey of pediatric caudal extradural anesthesia practice

Background:  Caudal extradural blockade is one of the most commonly performed procedures in pediatric anesthesia. However, there is little information available on variations in clinical practice.
Objectives:  To perform a survey of members of the Association of Paediatric Anaesthetists of Great Britain and Ireland who undertake caudal anesthesia.
Methods:  An 'online' World Wide Web questionnaire collected information on various aspects of clinical practice. The survey ran from April to June 2008.
Results:  There were 366 questionnaires completed. The majority of respondents had >5 years of pediatric experience and performed up to ten caudal extradural procedures a month. The commonest device used was a cannula (69.7%) with 68.6% using a 22G device. There was a trend toward the use of a cannula in those anesthetists with <15 years experience, while those with >15 years experience tended to use a needle. Most anesthetists (91.5%) did not believe that there was a significant risk of implantation of dermoid tissue into the caudal extradural space. The majority used a combination of clinical methods to confirm correct placement. Only 27 respondents used ultrasound. The most popular local anesthetics were bupivacaine (43.4%) and levobupivacaine (41.7%). The most common additives were clonidine (42.3%) and ketamine (37.5%). The caudal catheter technique was used by 43.6%. Most anesthetists (74%) wear gloves for a single shot caudal injection.
Conclusions:  This survey provides a snapshot of current practice and acts a useful reference for the development of enhanced techniques and new equipment in the future.     

全身麻醉患儿术后恢复期保温措施研究

目的探讨非气管插管全身麻醉患儿术后转入麻醉恢复室的最佳保温方法。方法选择非气管插管全身麻醉手术后转入麻醉恢复室患儿120例,按随机数字表法分为S1组、S2组和C组各40例。S1组采用加温系统实施主动保温,温度调节为38℃;S2组采用加温毯实施主动保温,温度调节为38℃;C组采用常规盖棉被保暖。观察三组生命体征变化、意识恢复时间、在麻醉恢复室停留时间、低体温及并发症发生率的差异。结果三组不同时间体温和心率比较,干预效应、时间效应均P0.05,交互效应均P0.05。三组术后意识恢复时间、恢复室停留时间、低体温和寒战发生率比较,差异有统计学意义(P0.05,P0.01),S1组各项指标更优。结论对非气管插管全麻手术后患儿在麻醉恢复室实施加温系统主动保温,可以降低术后低体温发生率,有助于患儿尽快恢复。     

Complications during rapid sequence induction of general anesthesia in children: a benchmark study

Objectives: Determine incidence of complications such as difficult or failed intubation, hypoxemia, hypotension, and bradycardia in children undergoing rapid sequence intubation (RSI) in a pediatric anesthesia department in a tertiary care children’s hospital. Aim: To establish a benchmark to be used by other institutions and nonanesthesiologists performing RSI in children. Background: RSI is being increasingly performed in the nonoperating room setting by nonanesthesiologists. No published studies exist to establish a benchmark of intubation success or failure and complications in this patient population. Methods/Materials: Retrospective cohort analysis of children aged 3–12 undergoing RSI from 2001 to 2006. Results: One thousand seventy children underwent RSI from 2001 to 2006. Twenty (1.9%) developed moderate hypoxemia (SpO₂ 80–89%), 18 (1.7%) demonstrated severe hypoxemia (SpO₂ < 80%), 5 (0.5%) developed bradycardia (heart rate <60), and 8 (0.8%) developed hypotension (systolic blood pressure <70 mmHg). One patient had emesis of gastric contents but no evidence of pulmonary aspiration or hypoxemia. Eighteen (1.7%) children were noted to be difficult to intubate and required more than one intubation attempt. All were eventually intubated without significant complications. Patients between 10 and 19 kg had a higher incidence of severe hypoxemia when compared with older children (P < 0.001). There was no association between choice of muscle relaxant and any complication. Conclusions: In our cohort of 1070 children who underwent RSI, difficult intubation was encountered in 1.7% and transient oxyhemoglobin desaturation occurred in 3.6%. Severe hypoxemia was more likely in children <20 kg. There were no children who could not be intubated, and there were no long‐term or permanent complications.     

Regional versus general anesthesia in high-risk surgical patients: The need for a clinical trial

Regional anesthesia is often preferred over general anesthesia for patients with cardiovascular disease because of presumed decreased risk of perioperative myocardial ischemia. However, few studies have addressed this issue directly. To determine whether the type of anesthesia is independently associated with myocardial ischemia, records of 134 patients undergoing peripheral vascular grafting under general or regional anesthesia were examined. There were no significant differences preoperatively between groups in ASA class, age, sex, or prevalence of angina, diabetes, or hypertension. Twelve patients developed myocardial ischemia or infarction within 7 days of operation; 11 of these 12 patients had received regional anesthesia (p < 0.015). The association between anesthetic approach and perioperative myocardial ischemia or infarction remained after adjustment for preoperative factors associated with ischemia or with type of anesthesia. General anesthesia does not appear to be associated with increased risk of myocardial ischemia, and stringent recommendations to avoid it in this population may be unfounded. A clinical trial is needed to define more clearly the risks and benefits of different types of anesthesia in high-risk patients.