Hamish M. Munro

Risk factors for perioperative adverse respiratory events in children with upper respiratory tract infections

Background Anesthesia for the child who presents for surgery with an upper respiratory infection (URI) presents a challenge for the anesthesiologist. The current prospective study was designed to determine the incidence of and risk factors for adverse respiratory events in children with URIs undergoing elective surgical procedures. Methods The study population included 1,078 children aged 1 month to 18 yr who presented for an elective surgical procedure. Parents were given a short questionnaire detailing their child’s demographics, medical history, and presence of any symptoms of a URI. Data regarding the incidence and severity of perioperative respiratory events were collected prospectively. Adverse respiratory events (any episode of laryngospasm, bronchospasm, breath holding > 15 s, oxygen saturation < 90%, or severe cough) were recorded. In addition, parents were contacted 1 and 7 days after surgery to determine the child’s postoperative course. Results There were no differences between children with active URIs, recent URIs (within 4 weeks), and asymptomatic children with respect to the incidences of laryngospasm and bronchospasm. However, children with active and recent URIs had significantly more episodes of breath holding, major desaturation (oxygen saturation < 90%) events, and a greater incidence of overall adverse respiratory events than children with no URIs. Independent risk factors for adverse respiratory events in children with active URIs included use of an endotracheal tube (< 5 yr of age), history of prematurity, history of reactive airway disease, paternal smoking, surgery involving the airway, the presence of copious secretions, and nasal congestion. Although children with URIs had a greater incidence of adverse respiratory events, none were associated with any long-term adverse sequelae. Conclusions The current study identified several risk factors for perioperative adverse respiratory events in children with URIs. Although children with acute and recent URIs are at greater risk for respiratory complications, these results suggest that most of these children can undergo elective procedures without significant increase in adverse anesthetic outcomes.

Use of the laryngeal mask airway in children with upper respiratory tract infections: a comparison with endotracheal intubation.

Several studies suggest that placement of an endotracheal tube (ETT) in a child with an upper respiratory infection (URI) increases the risk of complications.However, the development of the laryngeal mask airway (LMA) has provided anesthesiologists with an alternative means of airway management. This study was therefore designed to evaluate the use of the LMA in children with URIs and to compare it with the ETT. The study sample consisted of 82 pediatric patients (3 mo to 16 yr of age) who presented for elective surgery with an URI. Patients with URIs were randomly allocated to receive either an ETT (n = 41) or a LMA (n = 41) and were followed for the appearance and severity of any perioperative complications. The two groups were similar with respect to age, gender, anesthesia and surgery times, number of attempts at tube placement, and presenting URI symptoms. There were no differences between groups in the incidence of cough, breath-holding, excessive secretions, or arrhythmias. Although one patient in the ETT group required a muscle relaxant for laryngospasm, the overall incidence of laryngospasm was similar between the two groups. There was, however, a significantly greater incidence of mild bronchospasm in the ETT group compared with the LMA group (12.2% vs 0%, P < 0.05). The incidence of major arterial oxygen desaturation events (Spo2 <90%) during placement of the airway device was also significantly increased in the ETT group (12.5% vs 0%, P < 0.05). Furthermore, the total number of all episodes of respiratory complications, i.e., breath-holding, laryngospasm, bronchospasm, and major oxygen desaturation, was significantly greater in the ETT group (35 vs 19, P < 0.05). Despite this, all respiratory complications were easily managed, and there were no adverse sequelae. Although the risks associated with anesthetizing a child with an URI remain controversial, results from this study suggest that the LMA offers a suitable alternative to the ETT for use in children with URIs. Implications: This study compares the use of the laryngeal mask airway with the endotracheal tube for airway management in children with upper respiratory infections. Results suggest that if the decision is made to proceed with anesthesia for the child with an upper respiratory infection, then the laryngeal mask airway provides a suitable alternative to the endotracheal tube. (Anesth Analg 1998;86:706-11)

Cancellation of pediatric outpatient surgery: Economic and emotional implications for patients and their families

Abstract Study Objective: To determine the cause and timing of case cancellation in a pediatric outpatient surgical population, and to examine the economic and emotional impact of such cancellations on patients and their families. Design: Questionnaire survey. Setting: Outpatient surgery unit of a large university childrens hospital. Participants: 127 parents of children whose elective outpatient surgery had been cancelled. Interventions: A total of 200 questionnaires were mailed to the parents of children who had their outpatient surgery cancelled. Measurements and Main Results: Of those children whose surgery had been cancelled, 34.6% were due to upper respiratory infections (URIs), 30.7% for other medical reasons, and the balance for scheduling errors, because the child had not fasted, or for difficulties with transportation. The majority of surgeries (58.3%) were cancelled prior to their scheduled surgery date. However, 18.9% were cancelled on the day of surgery prior to leaving for the hospital and 22.8% were cancelled on arrival at the outpatient surgery clinic. Of those patients whose surgeries were not cancelled until they arrived at the hospital, 38.5% of mothers and 50.0% of fathers missed a day of work and, of these, 53.3% and 42.1%, respectively, went unpaid for the work day missed. The mean number of miles driven (round trip) to the hospital for a cancelled operation was 158.8 miles (range 8 to 1,350 miles). Additional testing and new appointments were ordered in 25.2% of the cancelled cases. 45% of parents and 16% of children were disappointed by the cancellation; 16% of parents were frustrated by the cancellation and 3.3% were angry. Conclusions: This study suggests that last-minute cancellation of surgery has an important impact on patients and their families and suggests a need to review present protocols for screening patients prior to surgery.

Pain management in children with and without cognitive impairment following spine fusion surgery

Background: We compared pain assessment and management practices in children with and without cognitive impairment (CI) undergoing spine fusion surgery.

Propofol infusion and the incidence of emesis in pediatric outpatient strabismus surgery.

A prospective, randomized, double-blind study was conducted to examine the effect of a propofol infusion on the incidence of postoperative emesis in children undergoing outpatient strabismus surgery. Seventy-eight children, aged 3-12 yr, were allocated randomly to receive either nitrous oxide and halothane or nitrous oxide and a propofol infusion for the maintenance of anesthesia. The overall incidence of vomiting during the first 24 h was 64% in those receiving halothane and 41% in those receiving the propofol infusion; this difference was statistically significant (P < 0.05). In children who received no opioids postoperatively, the incidence of vomiting in the first 24 h was 71% in the halothane group and 24% in the propofol group; this difference was also significant (P = 0.001). We conclude that propofol was effective in reducing the incidence of postoperative emesis in pediatric outpatient strabismus surgery.

Low-dose ketorolac improves analgesia and reduces morphine requirements following posterior spinal fusion in adolescents

PurposeTo determine if low-dose ketorolac would improve analgesia while minimizing unwanted side effects in adolescents following posterior spinal fusion (PSF).MethodsA prospective randomized double-blind placebo-controlled trial assessed the analgesic effects of low-dose ketorolac following PSF. Thirty-five adolescents aged 11–17 yr were randomly assigned to receive placebo or 0.5 mg·kg−1 ketorolac (maximum of 15 mg) six hourly postoperatively for 36 hr in conjunction with standard morphine patient controlled analgesia (PCA). Pain and sedation were assessed twice daily for the first three postoperative days (POD). The incidence of side effects related to both non-steroidal anti-inflammatory agents and opioids were recorded.ResultsAdolescents in the ketorolac group received an average dose of 0.2 mg·kg−1 (average exposure 1.2 mg·kg−1), had lower pain scores on POD one and two (P < 0.05) and consumed less morphine in the postanesthesia care unit and on POD two. There was no difference in the incidence of pruritus, nausea, vomiting or constipation, but patients in the ketorolac group tolerated activity better on POD one (P < 0.05). There were no differences between groups with regard to postoperative blood loss or transfusion requirements. Fourteen patients were followed for two years and the incidence of curve progression, hardware failure or back pain at final follow-up was not different.ConclusionLow-dose ketorolac in conjunction with morphine PGA improved the quality of analgesia and reduced morphine requirements following PSF compared to placebo without increasing the incidence of non-steroidal anti-inflammatory side effects.RésuméObjectifDéterminer si une faible dose de kétorolac améliore l’analgésie tout en réduisant les effets secondaires chez des adolescents qui ont subi une spondylodèse postérieure (SDP).MéthodeUn essai à double insu, randomisé et contrôlé contre placebo a permis d’évaluer les effets analgésiques d’une faible dose de kétorolac administrée après une SDR Trente-cinq adolescents de 11–17 ans ont été répartis de manière aléatoire et ont reçu, soit un placebo, soit 0,5 mg·kg−1 de kétorolac (maximum de 15 mg) toutes les six heures après l’opération et ce, pendant 36 h en conjonction avec de la morphine normale en analgésie autocontrôlée (AAC). La douleur et la sédation ont été évaluées deux fois par jour pour les trois premiers jours postopératoires (JPO). L’incidence d’effets secondaires reliés aux anti-inflammatoires non stéroïdiens (AINS) et aux opioïdes a été notée.RésultatsLes sujets qui ont eu du kétorolac ont reçu une dose moyenne de 0,2 mg·kg−1 (exposition moyenne de 1,2 mg·kg−1), ont présenté des scores de douleur plus faibles aux JPO un et deux (P < 0,05) et ont pris moins de morphine à la salle de réveil et au deuxième JPO. Lincidence de prurit, nausées, vomissements ou constipation était comparable dans les deux groupes, mais les mouvements étaient mieux tolérés avec le kétorolac au premier JPO (P < 0,05). La perte sanguine postopératoire et les besoins de transfusion ont été comparables. Quatorze patients ont été suivis pendant deux ans et l’incidence de la progression de la courbe, de la défaillance du matériel ou de la douleur au dos n’était pas différente au dernier examen de suivi.ConclusionUne faible dose de kétorolac, administrée avec de la morphine en AAC, améliore la qualité de l’analgésie et réduit les besoins de morphine à la suite d’un SDP, en comparaison avec un placebo, et sans augmenter l’incidence d’effets secondaires des AINS.

Parents’ preferences for participation in decisions made regarding their child’s anaesthetic care

Background: The traditional paternalistic approach to medical decision‐making is moving towards a climate of greater patient and/or surrogate involvement. Despite this, there is considerable debate regarding patient preferences for participation in medical decision‐making and its effect on patient satisfaction and outcome. This study was designed to examine parents’ preferences for participation in decisions regarding their child’s anaesthetic care and to determine if active participation is associated with greater parental satisfaction.

Pain relief in children following outpatient surgery

STUDY OBJECTIVE To evaluate perioperative analgesia, prescription patterns, pain relief, and parental care of children undergoing outpatient surgery. DESIGN Prospective data collection and parental interview. SETTING Large tertiary care, university-based medical center. PATIENTS 471 children aged between 10 months and 18 years who underwent an outpatient surgical procedure expected to be associated with pain. MEASUREMENTS AND MAIN RESULTS All perioperative data regarding analgesia, antiemetics, postoperative pain scores, and discharge prescriptions were recorded. Parents were telephoned 24 hours following surgery, and data concerning their childs pain relief, analgesic and antiemetic usage, and their ability to care for their child were obtained. Of the 460 patients questioned, 97% were described by their parents as having adequate, good, or very good pain relief (acceptable) during the first 24 hours postoperatively, whereas only 15 (3%) had poor pain relief (unacceptable). All patients received some form of analgesia intraoperatively. The children with poor pain relief were more likely to have experienced postoperative nausea and vomiting (p = 0.01) and were more difficult to care for at home (p < 0.0001). In a subset of 185 patients who had genitourinary procedures, those who received regional analgesia reported better pain relief (p = 0.05). CONCLUSIONS Despite a wide range of surgical procedures being performed on children on an ambulatory basis, current selection of patients for outpatient surgery is appropriate given the ability of the parents to manage their childrens pain and to care for their children at home.

Oral granisetron for strabismus surgery in children.

PurposeTo determine the efficacy of oral granisetron in preventing postoperative vomiting (POV) following strabismus repair in children.MethodsIn a randomized, double-blind, placebo-controlled trial, 73 pediatric patients received either placebo, 20 μg·kg−1 or 40 μg·kg−1 granisetronpo 20 min before induction of anesthesia. No premedication was given, induction was with halothane and all children breathed spontaneously via a laryngeal mask airway. Maintenance was with isoflurane without the use of opioids. Ketorolac and acetaminophen were used for analgesia. The number of episodes and the severity of vomiting and retching were recorded for the first 24 hr postoperatively, as was the use of rescue antiemetics.ResultsGranisetron 20 μ·kg−1 and 40 μg·kg−1 were more effective than placebo in reducing the incidence of POV during the first 24 hr (29% in both the granisetron groupsvs 84% in the placebo group,P < 0.05). In addition, the number of children experiencing severe vomiting (≥ 3 episodes) was reduced in the granisetron 20 μg·kg−1 and 40 μg·kg−1 groups compared with placebo (4%, 8% and 48% respectively,P < 0.05). Patients in the granisetron group were discharged home earlier ( 105 min vs 124 min,P = 0.04). There was no difference in the incidence of POV between the two granisetron groups.ConclusionPreoperative oral granisetron in a dose of 20 μg·kg−1 provided effective prophylaxis against POV in children undergoing stabismus repair.RésuméObjectifDéterminer l’efficacité du granisétron, administré par voie orale, à prévenir les vomissements postopératoires (VPO) suivant la correction du strabisme chez des enfants.MéthodeLors d’un essai contre placebo, en double aveugle, 73 patients pédiatriques ont reçu soit un placebo, soit 20 μg·kg−1 ou 40 μg·kg−1 de granisétronpo 20 min avant l’induction de l’anesthésie. Aucune prémédication n’a été administrée, l’induction s’est faite avec de l’halothane et l’anesthésie a été maintenue chez tous les enfants en utilisant la ventilation spontanée au moyen d’un masque laryngé. On a maintenu l’anesthésie avec de l’isoflurane sans employer d’opioïdes. Les analgésiques étaient du kétorolac et de l’acétaminophène. Le nombre et la sévérité des épisodes de vomissements et de haut-le-coeur ont été notés, pendant les vingt-quatre premières heures postopératoires, de même que le recours à des antiémétiques.RésultatsLe granisétron à 20 μg·kg−1 et à 40 μg·kg−1 a été plus efficace que le placebo en réduisant l’incidence des VPO pendant les vingt-quatre premières heures (29 % dans les deux groupes qui ont reçu du granisétron vs 84 % dans le groupe qui a reçu le placebo, P < 0,05). De plus, le nombre d’enfants qui ont eu des vomissements sévères (≥ 3 épisodes) était réduit dans les groupes recevant du granisétron en doses de 20 μg·kg−1 et de 40 μg·kg−1 à comparer au groupe recevant le placebo (4 %, 8% et 48 % respectivement,P < 0,05). Les patients du groupe granisétron ont reçu leur congé plus tôt ( 105 min vs 124 min,P = 0,04). Il n’y a pas eu de différence entre les deux groupes qui ont reçu du granisétron concernant l’incidence des VPO.ConclusionLadministration orale préopératoire de granisétron en doses de 20 μg·kg−1 prévenait de façon efficace les VPO chez les enfants ayant subi une correction de strabisme.

Pro: The routine use of aprotinin during pediatric cardiac surgery is a benefit

ORE THAN HALF of the children undergoing cardiopulmonary bypass (CPB) in North America are younger than 1 year old, and neonates comprise approximately 36% of this group. 1 Many of these children undergo multiple-stage reconstructive procedures as well as repeat operations to replace conduits and valves, which are often performed at low temperatures with long bypass times. Bleeding complications are common and are secondary to increased tissue friability, extensive suture lines, and increasingly complicated surgical repairs. In addition, clotting mechanisms are incompletely developed in infants, and they tolerate hemorrhage and tamponade poorly. These issues underscore the need to develop therapeutic modalities directed at the attenuation of the inflammatory reaction and coagulation cascade initiated by CPB. Several studies in children suggest that aprotinin is beneficial for pediatric patients during cardiac surgery. Aprotinin, isolated in 1930, is a serine protease inhibitor that has been used in numerous clinical settings, including acute pancreatitis, adult respiratory distress syndrome, trauma, and septic shock. In the 1960s, aprotinin was used in adult cardiac surgery in an attempt to reduce excessive blood loss thought to be due to increased fibrinolysis. By 1984, the benefits of aprotinin in pediatric CPB were being studied, and decreases in postoperative blood loss and fibrin split products were demonstrated. 2 Attention has turned to aprotinins potential as a kallikrein inhibitor to attenuate the inflammatory response associated with CPB. Numerous studies have demonstrated a reduction in blood loss associated with aprotinin use in pediatric CPB. Herynkopf et aP noted that homologous donor exposure was decreased by about half in the patients who received aprotinin. A study of children undergoing repair of tetralogy of Fallot showed significant decreases in the total volume of blood loss and blood transfused. 4 Penkoske et al 5 showed similar decreases in blood loss, volume of transfusion, and number of units transfused. In pediatric lung transplants, Jaquiss et al6 demonstrated that high-risk patients receiving aprotinin bled less than, or similar to, low-risk transplant patients who had not received aprotinin. In a study at this institution, aprotinin decreased the number of