David R. Lardner

Comparison of laryngeal mask airway (LMA)-Proseal™ and the LMA-Classic™ in ventilated children receiving neuromuscular blockade

Purpose: To determine whether a functional difference exists between the size 2 laryngeal mask airway (LMA)-Classic™ (CLMA) and LMA-Proseal™ (PLMA) in anesthetized children who have received neuromuscular blockade. Airway leak during intermittent positive pressure ventilation (IPPV) and adequacy of fibreoptic laryngeal view were the primary study outcomes.Methods: A randomized, controlled, single-blinded study of 51 ASA I or II children weighing 10–20 kg was undertaken. The anesthetic technique was standardized. Following insertion of the LMA and cuff inflation to 60 cm H2O, we measured oropharyngeal leak pressure and gastric insufflation and leak fraction during IPPV, and evaluated the adequacy of fibreoptic view.Results: Oropharyngeal leak pressure measured by neck auscultation was higher for the PLMA compared to the CLMA (23.7vs 16.5 cm H2O,P=0.009) but, when measured by the inspiratory hold maneuver was not significantly different (24.8vs 20.3 cm H2O, respectively,P=0.217). Leak fraction values were similar for the CLMA and the PLMA (21.2%.vs 13.3%, respectively,P=0.473). A satisfactory view of the larynx was obtained more frequently in the PLMA group (21/25vs 10/25,P=0.003). Gastric insufflation during leak determination was more common with the CLMA (12/26vs 2/25 CLMAvs PLMA, respectively,P=0.006).Conclusion: In children undergoing IPPV with neuromuscular blockade, the size 2 PLMA is associated with a higher leak pressure by auscultation and less gastric insufflation compared to the CLMA. Leak pressures assessed by manometric stability are similar with these two devices. The improved fibreoptic view of the larynx through the PLMA may be advantageous for bronchoscopy.RésuméObjectif: Déterminer s’il existe une différence fonctionnelle entre les masques laryngés (LMA)-Classic™ (CLMA) et LMA-ProSeal™ (PLMA) de taille 2 chez les enfants anesthésiés lors d’un bloc neuromusculaire. Les fuites du masque pendant la ventilation à pression positive intermittente (VPPI) et une bonne vision laryngée par fibre optique constituaient les résultats principaux recherchés par cette étude.Méthode: Une étude randomisée contrôlée en aveugle portant sur 51 enfants ASA I ou II et pesant entre 10 et 20 kg a été menée. La technique anesthésique utilisée a été standardisée. Après avoir inséré le LMA et gonflé le ballonnet à 60 cm H2O, nous avons mesuré la pression de fuite oropharyngienne, l’insufflation gastrique et la fraction de fuite pendant la VPPI, et avons évalué la qualité de la vision par fibre optique.Résultats: La pression de fuite oropharyngienne mesurée par auscultation du cou était plus élevée lors de l’utilisation du PLMA que du CLMA (23,7 vs 16,5 cm H2O, P=0,009) ; toutefois, lorsque celle-ci a été mesurée par manœuvre de retenue respiratoire, il n’y a pas eu de différence significative (24,8 vs 20,3 cm H2O, respectivement, P=0,217). Les valeurs de fraction de fuite étaient semblables avec le CLMA et le PLMA (21,2 % vs 13,3 %, respectivement, P=0,473). Une vision satisfaisante du larynx a été plus fréquemment obtenue dans le groupe PLMA (21/25 vs 10/25, P=0,003). L’insufflation gastrique pendant la détermination de la fuite a été plus fréquemment observée dans le groupe CLMA (12/26 vs 2/25 CLMA vs PLMA, respectivement, P=0,006).Conclusion: Chez les enfants subissant une VPPI lors d’un bloc neuromusculaire, le PLMA de taille 2 est associé à une pression de fuite plus élevée par auscultation et moins d’insufflation gastrique par rapport à une utilisation du CLMA. Les pressions de fuite évaluées par stabilité manométrique sont semblables avec les deux appareils. Une vision par fibre optique améliorée du larynx avec le PLMA pourrait s’avérer utile pour la bronchoscopie.

Ultrasound assessment of gastric volume in the fasted pediatric patient undergoing upper gastrointestinal endoscopy: development of a predictive model using endoscopically suctioned volumes

Aspiration of gastric contents can be a serious anesthetic‐related complication. Gastric antral sonography prior to anesthesia may have a role in identifying pediatric patients at risk of aspiration. We examined the relationship between sonographic antral area and endoscopically suctioned gastric volumes, and whether a 3‐point qualitative grading system is applicable in pediatric patients.

The effects of parental presence in the postanesthetic care unit on children's postoperative behavior: a prospective, randomized, controlled study.

BACKGROUND:The effects on children of parental presence in the postanesthesia care unit (PACU) have not been extensively studied. The few published studies are retrospective, nonrandomized, or lack adequate controls. They suggest that parental presence in the PACU decreases crying and negative behavior change postoperatively. We performed this prospective, randomized, controlled study to determine whether the presence of a parent affected crying behaviors in the PACU and behavior change 2 weeks postoperatively. METHODS:Randomly selected patients, aged 2.0 to 8 years 11 months, ASA physical status I or II, and scheduled for elective outpatient surgery with an anticipated PACU stay of >10 minutes were randomly assigned to the parent present group (n = 150) or parent absent group (n = 150) in the PACU. All parents underwent the same preparation program. Reunification occurred once childrens eyes had opened for the parent present group. In the PACU, crying was scored each minute after eye opening using a 5-point scale. Negative behavior change 2 weeks after discharge was determined using the Post Hospitalization Behavior Questionnaire. Because the anesthesia technique to be used was not determined a priori, data on the technique used were collected to ensure that groups were similar. Multiple and logistic regression techniques were used to determine predictors of crying in the PACU and behavior change 2 weeks postoperatively. RESULTS:Parental presence in the PACU made no difference in crying in the PACU. Negative behavior change 2 weeks postoperatively occurred more frequently in the parent absent group than the parent present group (45.8% vs 29.3%; P = 0.007). Multiple regression identified the following significant factors as predictive of larger proportion of time spent crying in the PACU (R2 = 0.256, F[5, 273] = 15.66, P < 0.001): age <5 years (P < 0.001) and higher Childrens Hospital of Eastern Ontario Pain Scale score at 15 minutes after arrival in day surgery (P < 0.001). Parental presence or absence from the PACU was not predictive of crying in the PACU, and neither were socioeconomic status nor intraoperative opioid analgesia. Logistic regression identified the following factors (&khgr;2[4] = 26.62, P < 0.001) as predictive of negative behavior change at 2 weeks postoperatively: being younger than 5 years (P < 0.001) and being in the parent absent group (P = 0.003). CONCLUSION:For fit healthy children undergoing outpatient surgery, parental presence in the PACU decreases negative behavior change at 2 weeks postoperatively but makes no difference in crying in the PACU. Future studies of behavior change postoperatively should consider parental presence in the PACU a factor and determine whether the effect persists with other interventions.

Reply to Bouvet et al. regarding their comment 'How may a mathematical model using ultrasound measurement of antral area be predictive of the gastric volume?'.

1 Li Y, Zhang Y, Zhou Y et al. The effect of prophylactic methylprednisolone needs more evidences on postoperative outcomes. Pediatr Anesth 2015; 25: 649–650. 2 Fan PT, Yu DT, Clements PJ et al. Effect of corticosteroids on the human immune response: comparison of one and three daily 1 gm intravenous pulses of methylprednisolone. J Lab Clin Med 1978; 91: 625–634. 3 Cheigh JS, Stenzel KH, Riggio RR et al. Effects of intravenous methylprednisolone on mixed lymphocyte cultures in normal humans. Transplant Proc 1975; 7: 31–35. 4 Lee HS, Lee JM, Kim MS et al. Lowdose steroid therapy at an early phase of postoperative acute respiratory distress syndrome. Ann Thorac Surg 2005; 79: 405–410. 5 Mitsuta K, Shimoda T, Fukushima C et al. Preoperative steroid therapy inhibits cytokine production in the lung parenchyma in asthmatic patients. Chest 2001; 120: 1175–1183.

After hours surgery and mortality: the potential role of acute care surgery models as a factor accounting for results

We read with interest the article by Sheehan and colleagues[1][1] regarding hip fracture mortality varying by setting. We wondered whether it were possible to determine from their data if time of day of surgery, which is an important risk factor in morbidity and mortality, was a factor. Wang and

Reply to Schmitz et al. regarding ‘Ultrasound assessment of gastric volume in the fasted pediatric patient undergoing upper gastrointestinal endoscopy: development of a predictive model using endoscopically suctioned volumes’

the second stopcock is attached to a pressure gauge to measure the applied gas pressure. A similar, selfassembled device has also been reported for the administration of emergency jet ventilation in pediatric patients (3). We confirm that the CPAP-delivery device can be connected to the bronchoscope working channel or suction port. When delivering oxygen through this device, the plateau pressure, which is dominantly determined by the flow rate of supplied oxygen, did not increase even when the distal end of the system was occluded. Pressure delivered to the alveoli is strictly controlled, and therefore, complications such as alveolar rupture and subsequent tension pneumothorax can be avoided during a bronchoscopic procedure. As it is a challenge for anesthesiologists to maintain oxygenation during bronchoscopic procedures in pediatric patients, we should utilize as many methods as possible to insufflate oxygen to patients. Although oxygen supply without sufficient gas egress has a potential risk of barotrauma, wall source oxygen insufflation through a bronchoscope can still be used as a safe and efficient method by adding pressure-relief port to the oxygen supply system such as CPAP-delivery device.

Making needles less prickly

We read with great interest the article by Curtis and colleagues, in which the authors conclude that current evidence does not support investing in ultrasound or near-infrared imaging for routine intravenous (IV) catheterization in children.[1][1] We contend that such a broad conclusion is not