Christopher Heard

Complications in Pediatric Tracheostomies

Objective To examine complications of pediatric tracheostomy.

A Comparison of Dexmedetomidine-Midazolam with Propofol for Maintenance of Anesthesia in Children Undergoing Magnetic Resonance Imaging

BACKGROUND:Dexmedetomidine is an &agr;2 agonist that is currently being investigated for its suitability to provide anesthesia for children. We compared the pharmacodynamic responses to dexmedetomidine-midazolam and propofol in children anesthetized with sevoflurane undergoing magnetic resonance imaging (MRI). METHODS:Forty ASA 1 or 2 children, 1–10 yr of age, were randomized to receive either dexmedetomidine-midazolam or propofol for maintenance of anesthesia for MRI after a sevoflurane induction. Dexmedetomidine was administered as an initial loading dose (1 &mgr;g/kg) followed by a continuous infusion (0.5 &mgr;g · kg−1 · h−1). Midazolam (0.1 mg/kg) was administered IV when the infusion commenced. Propofol was administered as a continuous infusion (250–300 &mgr;g · kg−1 · min−1). Recovery times and hemodynamic responses were recorded by one nurse who was blinded to the treatments. RESULTS:We found that the times to fully recover and to discharge from the ambulatory unit after dexmedetomidine administration were significantly greater (by 15 min) than those after propofol. Analysis of variance demonstrated that heart rate was slower and systolic blood pressure was greater with dexmedetomidine than propofol. Respiratory indices for the two treatments were similar. During recovery, hemodynamic responses were similar. Cardiorespiratory indices during anesthesia and recovery remained within normal limits for the children’s ages. No adverse events were recorded. CONCLUSION:Dexmedetomidine-midazolam provides adequate anesthesia for MRI although recovery is prolonged when compared with propofol. Heart rate was slower and systolic blood pressure was greater with dexmedetomidine when compared with propofol. Respiratory indices were similar for the two treatments.

Methadone dosage for prevention of opioid withdrawal in children

Background Opioids are frequently used for sedation in the Paediatric Intensive Care Unit (PICU). With time the dosing often increases because of tolerance. On cessation of the sedation there is a risk of the opioid withdrawal syndrome. The aim of our study was to evaluate methadone dosing as a risk factor for opioid withdrawal and to determine optimal dose and efficacy of methadone to prevent withdrawal.

Dexmedetomidine for pediatric MRI sedation: a review of a series of cases

Background:  The aim of this review was to determine whether dexmedetomidine alone provided satisfactory conditions for children undergoing magnetice resonance imaging (MRI).

Oral midazolam premedication for paediatric day case patients

Forty‐nine children having day‐stay surgical procedures were randomly assigned to receive oral midazolam 0.75 mg·kg−1 or placebo in a double blind fashion. The childs level of anxiety was assessed before premedication using parental, child and observer scales. The child and observer anxiety scores were repeated in the anaesthetic room. Most children presented for anaesthesia in a calm state, irrespective of whether they had received midazolam. Parents tended to overestimate their childs level of anxiety. Observer anxiety scores reliably predicted behaviour during induction of anaesthesia in the absence of a sedative. Observer scores decreased in the midazolam group (P<0.02), but not in the placebo group, children below six years having the greatest decrease with midazolam. The median time to discharge from hospital was delayed by 30 min in the midazolam group (P<0.01). Children do not require routine sedative premedication for day case procedures, but oral midazolam is useful in producing calm behaviour in those children with high observer anxiety scores.

Fiberoptic-guided endotracheal intubation via the laryngeal mask airway in pediatric patients: a report of a series of cases.

The laryngeal mask airway is increasingly being used in pediatric anesthesia (1-3). The placement of the laryngeal mask airway in children results in an acceptable airway in more than 90% of patients (1) on the first attempt and in almost 100% on subsequent attempts. Experience in its use has increased to a degree where it is now being used for patients in whom airway management is difficult, with no untoward effects reported in previously published case reports (4-10). In some of these cases, the laryngeal mask airway has been used instead of endotracheal intubation (5,10), but this may not always be possible and an endotracheal tube may be required. There have been case reports of the laryngeal mask airway being used to facilitate endotracheal tube placement using guides such as catheters (4) or light stylets (6). These were placed blindly and hence had a risk of not being correctly positioned. The problem-free use of a fiberoptic bronchoscope through a laryngeal mask has been described for diagnostic bronchoscopy in children (7) ; it has also been used with a guide wire to assist endotracheal intubation (8). In our cases, we assessed a technique using a laryngeal mask airway to facilitate the use of a fiberoptic bronchoscope to position a guide wire under direct visualization for directing the placement of an endotracheal tube (Fig. 1). This technique allows for the maintenance of both oxygenation and inhalational anesthesia during the positioning of the bronchoscope via the laryngeal mask airway, up to the moment of passing the endotracheal tube over the guide wire.

Continuous Remifentanil for Pediatric Neurosurgery Patients

Objective: Remifentanil hydrochloride is a new titratable opioid agonist with rapid onset and offset of action. We present 2 cases of intracranial mass lesions in whom remifentanil was used to obtain serial neurological examinations. Methods: Patients received bolus doses of remifentanil 1 µg/kg followed by continuous infusions of 0.1–0.5 µg/kg/min, titrated to effect. After the clinical examination, the remifentanil was restarted to the desired effect. Conclusion: The ultra-short duration of action of remifentanil makes it ideally suited for selected pediatric neurosurgical patients in whom frequent, serial neurological examinations are necessary. There were no side effects associated with the use of remifentanil.

Intranasal flumazenil and naloxone to reverse over-sedation in a child undergoing dental restorations.

We describe a 3‐year‐old child who became over‐sedated after receiving intranasal (IN) midazolam (0.53 mg·kg−1) and IN sufentanil (1 mcg·kg−1) for dental restorations in the dental office. Desaturation was attributed to laryngospasm, which was managed with positive pressure ventilation and oxygen. The sedation was reversed with a combination of IN flumazenil and naloxone.

Transport for paediatric intensive care. Measuring the performance of a specialist transport service

Fifty children were referred for transport to a paediatric intensive care unit (PICU). Two scoring systems were used for the transfer process. A physiology score derived from the paediatric risk of mortality (PRISM) score was performed at referral, before transfer and on arrival on PICU. An interventions score based on the therapeutic intervention scoring system (TISS) was performed for interventions by the referring staff and by the transport team before and during transfer. Critical events during transport were recorded. Three children died at the referring hospital. Forty‐seven were transported by the PICU team. No child died or suffered a major physiological deterioration or equipment related problem in transit. Physiology scores did not deteriorate during transfer. Referral physiology scores did not reliably predict the need for major therapeutic interventions by the transport team before transfer. Critically ill children may be transported safely by a specialist team.

Neonatal tracheal intubation: an imbroglio unresolved

We wish to publish a corrigendum to our recent editorial (1) in which we misquoted Cook-Sather et al. (2). We incorrectly quoted Cook-Sather et al. suggesting that awake intubation was associated with more desaturation than intubation during anesthesia. In truth, their results demonstrated more attempts at and more prolonged tracheal intubations when they were performed awake compared with anesthetized; the severity and frequency of the desaturations however did not differ between the treatments. We apologize for the misquote.