Christopher Brasher

Ketamine for Perioperative Pain Management in Children.A Meta Analysis of Published studies.

Introduction:  Balanced analgesia, using both opioid and nonopioids agents, has become the standard care for postoperative pain management. Ketamine, a compound with analgesic and antihyperalgesic properties, has been shown to decrease postoperative pain and opioid requirements in adults. The goal of the present meta‐analysis was to investigate postoperative analgesic properties of ketamine in pediatric patients.

Intraoperative changes in blood pressure associated with cerebral desaturation in infants.

Intraoperative hypotension has been linked to poor postoperative neurological outcomes. However, the definition of hypotension remains controversial in children. We sought to determine arterial blood pressure threshold values associated with cerebral desaturation in infants.

Preoperative preparation workshop reduces postoperative maladaptive behavior in children

Postoperative maladaptive behaviors (POMBs) are common following pediatric anesthesia, and preoperative anxiety is associated with POMBs. A family‐centered preoperative preparation workshop was instituted with the aim of reducing the incidence of POMB and preoperative anxiety, and the study was constructed to evaluate its effectiveness.

Plethysmographic Variability Index (PVI) accuracy in predicting fluid responsiveness in anesthetized children

Plethysmographic Variability Index (PVI) has been shown to accurately predict responsiveness to fluid loads in adults. The goal of this study was to evaluate PVI accuracy when predicting fluid responsiveness during noncardiac surgery in children.

Postoperative Pain Management in Children and Infants: An Update

Many factors contribute to suboptimal pain management in children. Current evidence suggests that severe pain in children has significant long-lasting effects, even more so than in adults. In particular, recent evidence suggests a lack of optimal postoperative pain management in children, especially following ambulatory surgery. This review provides simple guidelines for the management of postoperative pain in children. It discusses the long-term effects of severe pain and how to evaluate pain in both healthy and neurologically impaired children, including neonates. Currently available treatment options are discussed with reference to the efficacy and side effects of opioid and non-opioid and regional analgesic techniques. The impact of preoperative anxiety on postoperative pain, and the efficacy of some nonpharmacological techniques such as hypnosis or distraction, are also discussed. Finally, basic organizational strategies are described, aiming to promote safer and more efficient postoperative pain management in children.

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.

Stomal prolapse in children with chronic intestinal pseudoobstruction: a frequent complication?

AIM The aim of the study was to evaluate the morbidity rate of stoma in children diagnosed with chronic intestinal pseudoobstruction (CIPO) and try to determine risk factors. MATERIAL AND METHODS Twenty-two children (65%) of 34 referred to our center between 1988 and 2008 had a stoma. They were compared with 22 other children referred for another pathology necessitating a stoma. RESULTS The incidence of stomal prolapse in CIPO children was 45% vs 9% in non-CIPO children (P = .01). Prolapse occurred between the first postoperative day and the 10th postoperative month, with a median of 2 months. Surgical management was required in 60%, with an intestinal necrosis rate of 20% leading to intestinal resection. No mortality was noted. No risk factors favoring prolapse in CIPO children were identified. CONCLUSION Children with CIPO have a high rate of stomal prolapse with an increased risk of intestinal necrosis. Careful management of the stoma is necessary to avoid the risk of intestinal resection, which may aggravate the underlying intestinal disorder.

Predictive factors of PACU stay after herniorraphy in infant: a classification and regression tree analysis.

Introduction:  Herniorraphy is a common surgical intervention in infants, particularly in those born prematurely. Prematurity and perioperative sedation have been shown to be risk factors for postoperative apnea. However, their influence upon PACU stay duration has not been evaluated. The goal of this study was to investigate predictive factors for PACU stay in infants undergoing herniorraphy.

Predicting postoperative morphine consumption in children.

BACKGROUND Morphine is the most commonly used postoperative analgesic for moderate to severe pain in paediatric patients, but there is little research into predictive factors correlating with postoperative morphine consumption. METHODS All patients undergoing surgery who received morphine postoperatively over eight months were prospectively enrolled. Data analysed included total morphine consumption to day 3, age, weight, type of surgery, ASA status, preoperative opioid administration, predicted postoperative pain intensity (according to French Society of Anaesthesiology and Intensive Care classification) and surgery duration. Two cohorts were constructed: the first over 6months to construct a statistical model and the second over 2months to validate the model. ANOVA univariate analyses and multivariate linear analysis were performed. RESULTS One hundred and fifty-three patients were included in the construct cohort and 40 in the validation cohort. Multivariate analysis demonstrated that total morphine consumption through postoperative day 3 was independently increased by a decreased age, female gender, an increased duration of surgery and an increased morphine titration in PACU. Overall, the model explained 57% of morphine requirement variability. When the model was applied to the validation cohort, a significant correlation was demonstrated between observed and predicted values: r=0.67, P<0.0001. CONCLUSION Age, gender, duration of surgery and doses of titrated morphine in PACU proved to be strong predictors of postoperative morphine consumption by day 3 during paediatric surgery. Knowledge of such factors may help clinicians to better manage postoperative pain in children.

Postoperative complications following neonatal and infant surgery: Common events and predictive factors.

BACKGROUND Data on major non-surgical postoperative complications following neonatal and infant surgery is lacking. The goal of the present study was to describe common major complications and their predictive factors. MATERIAL AND METHODS The study consisted of a retrospective review of medical charts of patients less than 6months of age operated in our institution over one calendar year, excluding herniorraphy surgery. The data collected included demographics, preoperative ICU bed status, ASA status, a history of cardiac malformation, hyaline membrane disease (HMD) or necrotizing enterocolitis (NEC), preoperative haemoglobin, emergent surgery status, surgery type and duration, duration of anaesthesia and the need for intraoperative fluid boluses. Complications were analysed until the 30th postoperative day. Analyses included descriptive statistics and the determination of factors associated with non-surgical complications using univariate and multivariate statistics. RESULTS The study included 168 patients. Their postnatal age was 48±48days. Overall, 37 patients experienced major postoperative non-surgical complications. The most common major complications were haemodynamic compromise (n=19, 11.3%), multiple organ dysfunction syndrome (MODS, n=8, 4.8%) and respiratory failure requiring ventilation (n=3, 1.8%). Surgical complications occurred in 8 cases (4.8%). Four factors were identified as being predictive of non-surgical complications: PCA<40 weeks, a history of cardiac malformation, HMD or NEC, preoperative ICU status and intraoperative fluid bolus administration. CONCLUSION This study describes common non-surgical postoperative complications in neonates and infants, and their risk factors. They were much more common than surgical complications. Further studies should focus on preventive strategies addressing these complications.