Gillian R. Lauder

Total intravenous anesthesia will supercede inhalational anesthesia in pediatric anesthetic practice

Inhalational anesthesia has dominated the practice of pediatric anesthesia. However, as the introduction of agents such as propofol, short‐acting opioids, midazolam, and dexmedetomidine a monumental change has occurred. With increasing use, the overwhelming advantages of total intravenous anesthesia (TIVA) have emerged and driven change in practice. These advantages, outlined in this review, will justify why TIVA will supercede inhalational anesthesia in future pediatric anesthetic practice.

Confronting the challenges of effective pain management in children following tonsillectomy

Tonsillectomy is an extremely common surgical procedure associated with significant morbidity and mortality. The post-operative challenges include: respiratory complications, post-tonsillectomy hemorrhage, nausea, vomiting and significant pain. The present model of care demands that most of these children are managed in an ambulatory setting. The recent Federal Drug Agency (FDA) warning contraindicating the use of codeine after tonsillectomy in children represents a significant change of practice for many pediatric otolaryngological surgeons. This introduces a number of other safety concerns when deciding on a safe alternative to codeine, especially since most tonsillectomy patients are managed by lay primary caregivers at home. This review outlines the safety issues and proposes, based on currently available evidence, a preventative multi-modal strategy to manage pain, nausea and vomiting without increasing the risk of post-tonsillectomy bleeding.

Defining the reliability of sonoanatomy identification by novices in ultrasound-guided pediatric ilioinguinal and iliohypogastric nerve blockade.

BACKGROUND: The ilioinguinal (II)/iliohypogastric (IH) nerve block is a safe, frequently used block that has been improved in efficacy and safety by the use of ultrasound guidance. We assessed the frequency with which pediatric anesthesiologists with limited experience with ultrasound-guided regional anesthesia could correctly identify anatomical structures within the inguinal region. Our primary outcome was to compare the frequency of correct identification of the transversus abdominis (TA) muscle with the frequency of correct identification of the II/IH nerves. We used 2 ultrasound machines with different capabilities to assess a potential equipment effect on success of structure identification and time taken for structure identification. METHODS: Seven pediatric anesthesiologists with <6 mo experience with ultrasound-guided regional anesthesia performed a total of 127 scans of the II region in anesthetized children. The muscle planes and the II and IH nerves were identified and labeled. The ultrasound images were reviewed by a blinded expert to mark accuracy of structure identification and time taken for identification. Two ultrasound machines (Sonosite C180plus and Micromaxx, both from Sonosite, Bothell, WA) were used. RESULTS: There was no difference in the frequency of correct identification of the TA muscle compared with the II/IH nerves (&khgr;2 test, TA versus II, P = 0.45; TA versus IH, P = 0.50). Ultrasound machine selection did show a nonsignificant trend in improving correct II/IH nerve identification (II nerve &khgr;2 test, P = 0.02; IH nerve &khgr;2 test, P = 0.04; Bonferroni corrected significance 0.17) but not for the muscle planes (&khgr;2 test, P = 0.83) or time taken (1-way analysis of variance, P = 0.07). A curve of improving accuracy with number of scans was plotted, with reliability of TA recognition occurring after 14–15 scans and II/IH identification after 18 scans. CONCLUSIONS: We have demonstrated that although there is no difference in the overall accuracy of muscle plane versus II/IH nerve identification, the muscle planes are reliably identified after fewer scans of the inguinal region. We suggest that a reliable end point for the inexperienced practitioner of ultrasound-guided II/IH nerve block may be the TA/internal oblique plane where the nerves are reported to be found in 100% of cases.

A smartphone version of the Faces Pain Scale-Revised and the Color Analog Scale for postoperative pain assessment in children.

Effective pain assessment is essential during postoperative recovery. Extensive validation data are published supporting the Faces Pain Scale‐Revised (FPS‐R) and the Color Analog Scale (CAS) in children. Panda is a smartphone‐based application containing electronic versions of these scales.

Intrathecal infusion of bupivacaine and clonidine provides effective analgesia in a terminally ill child

The intrathecal infusion of drugs to provide analgesia for terminally ill children with refractory pain is a rarely utilized but very effective technique. A number of pharmacological agents, most commonly opioids and local anesthetics, have been administered intrathecally for this purpose. However, tachyphylaxis and neuraxial opioid‐related side effects can limit their utility. The alpha‐2 agonist clonidine is commonly used to augment local anesthetic techniques for postsurgical pain in children and for the management of refractory cancer pain in adults, but there is only a single report of the use of clonidine intrathecally in a terminally ill child. We present the case of the youngest reported child to have received intrathecal analgesia for terminal care: a 3‐year‐old boy with advanced pelvic rhabdomyosarcoma, whose refractory pain was managed effectively with an intrathecal infusion of bupivacaine and preservative‐free clonidine.

Dexmedetomidine and hydromorphone: A novel pain management strategy for the oncology ward setting during anti‐GD2 immunotherapy for high‐risk neuroblastoma in children

Treatment of neuroblastoma with targeted immunotherapy using chimeric anti‐GD2 monoclonal antibodies (ch14.18) is associated with significant pain requiring management with a high‐dose opioid infusion. We present a case series of six children, for whom dexmedetomidine and hydromorphone infusions safely and effectively reduced the pain of ch14.18 therapy in the oncology ward setting.

Developing an objective method for analyzing vital signs changes in neonates during general anesthesia.

Commonly used general anesthetics are considered to be neurotoxic to the developing rodent brain, leading to poor long‐term outcome. However, it is unclear whether these rodent studies can be extrapolated to the human neonate. Given that anesthesia for urgent neonatal surgery cannot be avoided, it is vitally important to assess other factors that may impact neurological outcome following anesthesia and surgery.

Oral morphine dosing predictions based on single dose in healthy children undergoing surgery

Oral morphine has been proposed as an effective and safe alternative to codeine for after‐discharge pain in children following surgery but there are few data guiding an optimum safe oral dose.

In-hospital usability and feasibility evaluation of Panda, an app for the management of pain in children at home.

Postoperative pain in children is often poorly managed at home, leading to slower functional recovery, poor oral intake, sleep disturbances, and behavioral changes. Panda is a smartphone application (app) designed to support parents in assessing their childs pain and managing medications.