Graham Wilson

Are you hungry? Are you thirsty? – fasting times in elective outpatient pediatric patients

Objective:  This study assessed the duration of pre‐operative fasting in children and its impact on the subjective feeling of hunger and thirst prior to elective outpatient anesthesia.

Pediatric airway management: comparing the Berci–Kaplan Video Laryngoscope with direct laryngoscopy

Objectives:  To assess the utility of the Berci–Kaplan Video Laryngoscope (VL) in pediatric anesthesia.

Management of invasive meningococcal disease in children and young people: summary of SIGN guidelines

Despite the successful introduction of immunisation with meningococcal group C conjugate vaccine in 1999,1 invasive meningococcal disease continues to cause substantial morbidity and mortality.2 Most deaths occur in the first 24 hours, often before specialist care starts. The challenge therefore is to identify those patients who will progress rapidly from non-specific early presentation to life threatening disease.3 Major changes to the organisation of health care in the United Kingdom, particularly in the provision of resuscitation and paediatric intensive care, have been associated with dramatically improved outcomes over recent decades.4 5 However, lack of high quality evidence to inform changes in clinical practice has been a particular challenge in developing this evidence based guideline. This article summarises the most recent guidance from the Scottish Intercollegiate Guidelines Network (SIGN) on the management of invasive meningococcal disease in children and young people.6 SIGN recommendations are based on systematic reviews of best available evidence. The strength of the evidence is graded as A, B, C, or D (fig 1⇓), but the grading does not reflect the clinical importance of the recommendations. Recommended best practice (“good practice points”), based on the clinical experience of the guideline development group, is also indicated (as GPP). Fig 1 Explanation of SIGN grades of recommendations ### Signs and symptoms Invasive meningococcal disease has an early, non-specific stage with signs such as fever, lethargy, irritability, nausea, and poor feeding. These signs are commonly found in children with self limiting viral illnesses, so a confident differential diagnosis at an early stage is very difficult. Observational studies have associated leg pain, cold extremities, and abnormal skin colour with developing invasive meningococcal disease.7 This non-specific early stage commonly lasts for several hours before invasive meningococcal disease progresses rapidly to three general disease patterns8:

Who needs an IV? Retrospective service analysis in a tertiary pediatric hospital

Aims:  The question if it is possible and safe to anesthetize children for short procedures without intravenous (IV) access provokes strong opinions among pediatric anesthetists. However, only limited data are available to support either side of the arguments. This pediatric university hospital provides anesthesia to a community dental service, led by staff anesthesiologists. A rapid turnover system based on inhalational induction and maintenance of anesthesia without mandatory IV access has been employed since 2005.

Caudal additives do not improve the analgesia afforded by levobupivacaine after hypospadias repair.

Background: Caudal analgesia is commonly employed to provide excellent intra- and postoperative analgesia for primary hypospadias repair in children. Several additives to local anesthetics are commonly employed to increase the block duration, although these have uncertain benefits. Objectives: This study investigated whether, in caudal analgesia with levobupivacaine 0.25%, the addition of S (+)-ketamine, clonidine, or both agents combined, would prolong postoperative analgesia in patients undergoing primary hypospadias repair. Patients and Methods: We conducted a retrospective chart analysis for all patients who underwent hypospadias repair with caudal analgesia over a consecutive 3-period at this institution. The study examined four patient groups, classified according to the analgesia used: No additive, levobupivacaine alone Levobupivacaine and S (+)-ketamine Levobupivacaine and clonidine Levobupivacaine, S (+)-ketamine, and clonidine Primary outcome measures were as follows: time to the first postoperative request for analgesia, total first 24-hour postoperative analgesia, and time to hospital discharge. Results: The 87 patients included had a mean ± SD age of 21.4 ± 13.5 months and weight of 11.9 ± 2.4 kg. The median doses of levobupivacaine, S (+)-ketamine, and clonidine were 0.7 mg/kg (range, 0.4–1.3), 0.5 mg/kg (0.2–1.1), and 1.8 μg/kg (0.8–2.3), respectively. The addition of S(+)-ketamine, clonidine, or both did not increase the time to first oral analgesia request. Neither did it reduce the total first 24-hour postoperative analgesia requirements or alter hospital discharge time. However, the additive drugs in combination did increase postoperative sedation. Conclusions: The addition of S (+)-ketamine or clonidine to levobupivacaine 0.25% in caudal analgesia for hypospadias repair appears to be of no benefit. However, use of the additives in combination increased postoperative sedation.

Equipment and Monitoring ? What is in the Future to Improve Safety?

There have been a number of recent developments in the practice of anesthesia and intensive care aimed at improving outcome in terms of reducing both morbidity and mortality, as well as other less‐defined factors, such as quality of service provision. Significant advances have been made in airway devices such as pediatric tracheal tube designs, Microcuff® tracheal tubes, and new laryngoscopes. Noninvasive monitoring devices, including continuous hemoglobin analysis and near infrared spectrometry, are being increasingly used in pediatric anesthesia. Other, ‘scaled‐down’ versions from adult anesthesia care, however, have not universally been shown to result in improved safety and outcomes in pediatric anesthesia.

The anatomic relationship between the internal jugular vein and the carotid artery in children after laryngeal mask insertion. An ultrasonographic study.

Background:  Central venous cannulation, although challenging in children and prone to complications, is frequently required for total parenteral nutrition and infusion of drugs.

Comparison of landmark technique and ultrasound guidance for localisation of long saphenous vein in infants and children

Study objective The long saphenous vein (LSV) is commonly used in small children to obtain venous access, and is usually cannulated at the ankle using the anatomical landmark technique. This is a ‘blind’ technique, which frequently requires multiple attempts, and may be associated with complications and failure. This study compared ultrasound guidance and landmark technique for localisation of the LSV in infants and small children. Methods 40 children aged 6 months to 2 years scheduled for elective surgery were included in this prospective clinical observational study. The anticipated puncture site of the LSV at the ankle was marked by either a consultant paediatric anaesthetist or a trainee anaesthetist using anatomical landmarks. A Sono-site Micromaxx 13–6 MHz SLA transducer was then used to determine the distance between the mark and the LSV. The diameter of the LSV was also measured. Results Mean LSV diameters were 2.60±0.68 mm and not significantly different between consultant and trainee groups (p=0.34). The mean distance of the anticipated puncture site from the middle of the vein was 3.14 mm (± 2.78 mm). The use of anatomical landmarks would have resulted in failure to cannulate the LSV in 58 of 79 (73%) attempts. Consultant anaesthetists were more likely to be successful (14 of 42 (33%) attempts, mean distance from LSV 2.6±2.6 mm) when compared with trainees (8 of 37 attempts (22%), mean distance from LSV 3.7±2.9 mm, p=0.034). Conclusion Ultrasound guidance is superior to the anatomical landmark technique for localisation of LSV and may reduce the number of cannulation attempts in infants and small children.

Ultrasound guided rectus sheath blockade compared to peri-operative local anesthetic infiltration in infants undergoing supraumbilical pyloromyotomy

Background: Provision of appropriate analgesia for supraumbilical pyloromyotomy in infants is limited by concerns about sensitivity to opioids and other medication groups, due to immature metabolism. Local anesthetic infiltration and ultrasound guided rectus sheath blockade are two techniques commonly employed to provide perioperative analgesia. The aim of this review was to compare the quality of post-operative analgesia afforded by these two techniques. Materials and Methods: A retrospective chart analysis of hospital records of all patients who underwent supraumbilical pyloromyotomy at a tertiary pediatric hospital between March 2009 and February 2011. Analysis of the anesthetic technique employed and post-operative acetaminophen requirements were performed. Additional information as to time to first post-operative feed, any complications and time of discharge from the hospital were collected by reviewing the post-operative nursing notes. Results: A total of 30 patients underwent supraumbilical pyloromyotomy during this period. A total of 18 received local anesthetic infiltration at the end of the procedure and 12 patients underwent ultrasound guided pre-incisional rectus sheath block for post-operative analgesia. Patients who had post-operative local anesthetic infiltration had a median (range) of 2 (1-3) doses of acetaminophen in the first 24 h. In the group of patients who received a rectus sheath block, the median (range) number of doses of acetaminophen in the first 24 h was also 2 (1-3). There were no differences in time to first feed and time to hospital discharge between the groups. The volume of local anesthetic administered was significantly smaller in the group receiving analgesia via rectus sheath block. Conclusion: Local anesthetic infiltration and pre-incisional ultrasound guided rectus sheath block provide similar degrees of post-operative analgesia. There were no differences between the two groups in time for first post-operative feed and time to hospital discharge.

Useful in acute upper airway obstruction in children

Ashworth argues that mobile phone video footage is useful when treating sick children.1 We know of two recent cases in which such video footage provided by parents was valuable in the diagnosis and treatment of upper airway obstruction. A previously healthy 2.5 year old boy was …