Diego Neuhaus

Semi‐elective intraosseous infusion after failed intravenous access in pediatric anesthesia

Background:  Intraosseous (IO) infusion is a well‐established intervention to obtain vascular access in pediatric emergency medicine but is rarely used in routine pediatric anesthesia.

Controlled rapid sequence induction and intubation - an analysis of 1001 children.

Classic rapid sequence induction puts pediatric patients at risk of cardiorespiratory deterioration and traumatic intubation due to their reduced apnea tolerance and related shortened intubation time. A ‘controlled’ rapid sequence induction and intubation technique (cRSII) with gentle facemask ventilation prior to intubation may be a safer and more appropriate approach in pediatric patients. The aim of this study was to analyze the benefits and complications of cRSII in a large cohort.

Fasting times and gastric contents volume in children undergoing deep propofol sedation--an assessment using magnetic resonance imaging

Aim:  To investigate the effect of fasting times for clear fluids and solids/non‐clear fluids on gastric content volume using magnetic resonance imaging (MRI).

Intraosseous infusion. An important technique also for paediatric anaesthesia

Timely establishment of venous access in infants and toddlers can prove a particularly challenging task. Since the 1940s the technique of intraosseous infusion has established itself as a valuable alternative means for rapid, efficient and safe delivery of drugs and fluids to critically ill children. Whereas international guidelines for paediatric emergency medical care have assigned intraosseous infusion a high priority, most anaesthetists utilize this well-proven technique with great reluctance. This article describes the technique of intraosseous infusion, introduces two different cannulation systems, and discusses its potential indications in paediatric anaesthesia, based on current emergency medical care guidelines as well as some of our own case studies. In particular, children with acutely life-threatening conditions, such as circulatory arrest, laryngospasm, acute airway haemorrhage, hypovolaemic shock or hypothermia secondary to extensive burns, should receive an intraosseous cannula if intravenous access cannot be rapidly established. Future discussion may reveal whether a transiently inserted intraosseous infusion would also be indicated if the child with difficult or impossible venous access presents without acute life-threatening conditions for anaesthesia. Successful application of the intraosseous infusion technique requires immediate access to the necessary equipment, intensive education, continuous training and clear guidelines for its application in an anaesthesia department.ZusammenfassungDie zeitgerechte Etablierung eines venösen Zugangs kann insbesondere bei Säuglingen und Kleinkindern eine große Herausforderung sein. Hier hat sich die intraossäre Infusionstechnik seit den 1940er Jahren als schnelle, effiziente und sichere Alternativmethode zur Schaffung eines Gefäßzugangs bewährt, um einem vitalgefährdeten Kind dringend benötigte Medikamente und Flüssigkeiten zu applizieren. Während in den internationalen Leitlinien zur pädiatrischen Notfallmedizin der intraossären Infusion eine hohe Priorität eingeräumt wird, greifen die meisten Anästhesisten nur sehr zögerlich auf diese langjährig bewährte Punktionstechnik zurück. Die vorliegende Arbeit beschreibt die intraossäre Infusionstechnik, stellt zwei unterschiedliche Kanülierungssysteme vor und diskutiert, basierend auf den aktuellen notfallmedizinischen Leitlinien sowie anhand von eigenen Fallbeispielen, potenzielle Indikationen für die Kinderanästhesie. Demnach sollten insbesondere akut vital-gefährdete Kinder mit Kreislaufstillstand, Laryngospasmus, akuter Atemwegsblutung, hypovolämischem Schock oder Hypothermie bei ausgedehnten Verbrennungen ohne liegenden bzw. rasch anzulegenden venösen Zugang mit einer intraossären Kanüle versorgt werden. Inwieweit die intraossäre Infusion auch beim nichtakut vital-gefährdeten Kind mit schwierigem oder unmöglichem peripheren Venenzugang in der Anästhesie überbrückend und zeitlich begrenzt eingesetzt werden sollte, wird die zukünftige Diskussion zeigen. Die erfolgreiche Anwendung der intraossären Infusionstechnik in der Kinderanästhesie verlangt die unmittelbare Verfügbarkeit der entsprechenden Ausrüstung, die umfassende Schulung und das regelmäßige Training sowie eine klare Regelung für ihre Anwendung innerhalb der Anästhesieabteilung.AbstractTimely establishment of venous access in infants and toddlers can prove a particularly challenging task. Since the 1940s the technique of intraosseous infusion has established itself as a valuable alternative means for rapid, efficient and safe delivery of drugs and fluids to critically ill children. Whereas international guidelines for paediatric emergency medical care have assigned intraosseous infusion a high priority, most anaesthetists utilize this well-proven technique with great reluctance. This article describes the technique of intraosseous infusion, introduces two different cannulation systems, and discusses its potential indications in paediatric anaesthesia, based on current emergency medical care guidelines as well as some of our own case studies. In particular, children with acutely life-threatening conditions, such as circulatory arrest, laryngospasm, acute airway haemorrhage, hypovolaemic shock or hypothermia secondary to extensive burns, should receive an intraosseous cannula if intravenous access cannot be rapidly established. Future discussion may reveal whether a transiently inserted intraosseous infusion would also be indicated if the child with difficult or impossible venous access presents without acute life-threatening conditions for anaesthesia. Successful application of the intraosseous infusion technique requires immediate access to the necessary equipment, intensive education, continuous training and clear guidelines for its application in an anaesthesia department.

Pediatric Epstein-Barr Virus Carriers With or Without Tonsillar Enlargement May Substantially Contribute to Spreading of the Virus

BACKGROUND Human-to-human transmission of the persistent infection establishing Epstein-Barr virus (EBV) occurs via saliva. Tonsils act as important portal of entry and exit of EBV. The contagiousness of pediatric EBV carriers and the role played by tonsillar enlargement (TE) are not known. METHODS We compared EBV shedding in mouthwash samples from pediatric EBV carriers with or without TE to that in mouthwash samples from pediatric patients with infectious mononucleosis (IM), the symptomatic form of primary infection if delayed after the age of 5 years. EBV DNA was quantified by polymerase chain reaction, and contagiousness was assessed using the cord lymphocyte transformation assay. RESULTS EBV carriers with TE shed EBV DNA at an almost similar frequency (although in lower amounts) as pediatric patients with acute IM but more frequently (P <.001) and in higher amounts (P = .038) than EBV carriers without TE. EBV DNA levels in mouthwash samples from EBV carriers with TE mirrored levels in tonsils and gradually declined after tonsillectomy. Almost half of the mouthwash samples from pediatric EBV carriers contained infectious EBV. CONCLUSIONS Pediatric EBV carriers--in particular, those with TE-may considerably contribute to the spreading of EBV in industrialized countries.

Correspondence: Incidence of complications associated with rapid sequence induction (RSI) in children – it is a matter of age and technique

children without ADHD. As Dr. Kira points out, while increased salivary cortisol levels may well contribute to the uncooperative induction behavior of children with ADHD, the observation by Blomqvist et al. (2) that children with ADHD undergoing dental procedures have lower cortisol levels compared with children without ADHD yet are harder to manage ‘muddies the waters’ somewhat. As our hypothesis did not include the role of cortisol levels in the expression of perioperative behaviors in children with and without ADHD, we can only conclude that the observed differential response to the stress of anesthesia and surgery is likely multifactorial and, as such, perhaps an interesting platform for future research. A L A N R. T A I T T E R R I V O E P E L-L E W I S The Department of Anesthesiology, University of Michigan Health System, Ann Arbor, MI, USA (email: atait@umich.edu)

Incidence of complications associated with rapid sequence induction (RSI) in children - it is a matter of age and technique.

children without ADHD. As Dr. Kira points out, while increased salivary cortisol levels may well contribute to the uncooperative induction behavior of children with ADHD, the observation by Blomqvist et al. (2) that children with ADHD undergoing dental procedures have lower cortisol levels compared with children without ADHD yet are harder to manage ‘muddies the waters’ somewhat. As our hypothesis did not include the role of cortisol levels in the expression of perioperative behaviors in children with and without ADHD, we can only conclude that the observed differential response to the stress of anesthesia and surgery is likely multifactorial and, as such, perhaps an interesting platform for future research. A L A N R. T A I T T E R R I V O E P E L-L E W I S The Department of Anesthesiology, University of Michigan Health System, Ann Arbor, MI, USA (email: atait@umich.edu)

Correspondence: Incidence of complications associated with rapid sequence induction (RSI) in children - it is a matter of age and technique: CORRESPONDENCE

children without ADHD. As Dr. Kira points out, while increased salivary cortisol levels may well contribute to the uncooperative induction behavior of children with ADHD, the observation by Blomqvist et al. (2) that children with ADHD undergoing dental procedures have lower cortisol levels compared with children without ADHD yet are harder to manage ‘muddies the waters’ somewhat. As our hypothesis did not include the role of cortisol levels in the expression of perioperative behaviors in children with and without ADHD, we can only conclude that the observed differential response to the stress of anesthesia and surgery is likely multifactorial and, as such, perhaps an interesting platform for future research. A L A N R. T A I T T E R R I V O E P E L-L E W I S The Department of Anesthesiology, University of Michigan Health System, Ann Arbor, MI, USA (email: atait@umich.edu)