Harshad Gurnaney

Malignant hyperthermia and muscular dystrophies.

BACKGROUND: Patients with muscular dystrophy have been reported to experience a variety of life-threatening complications during and after general anesthesia. We performed a systematic analysis to define the spectrum of anesthetic-related complications in patients with muscular dystrophy, with an emphasis on malignant hyperthermia susceptibility. METHODS: A literature search was undertaken using multiple search engines and the appropriate articles were reviewed by the authors to determine anesthetic-associated complications in patients with muscular dystrophy. Of all the types of muscular dystrophy, Duchenne muscular dystrophy (DMD) and Becker dystrophy (BD) represent nearly all the anesthesia-related reports. RESULTS: Anesthetic complications in patients with DMD and BD include intraoperative heart failure, inhaled anesthetic-related rhabdomyolysis (absence of succinylcholine), and succinylcholine-induced rhabdomyolysis and hyperkalemia. CONCLUSION: We did not find an increased risk of malignant hyperthermia susceptibility in patients with DMD or BD compared with the general population. However, dystrophic patients who are exposed to inhaled anesthetics may develop disease-related cardiac complications, or rarely, a malignant hyperthermia-like syndrome characterized by rhabdomyolysis. This latter complication may also occur postoperatively. Succinylcholine administration is associated with life-threatening hyperkalemia and should be avoided in patients with DMD and BD.

A Prospective Randomized Equivalence Trial of the GlideScope Cobalt ® Video Laryngoscope to Traditional Direct Laryngoscopy in Neonates and Infants

Background: Intubation in children is increasingly performed using video laryngoscopes. Many pediatric studies examine novice laryngoscopists or describe single patient experiences. This prospective randomized nonblinded equivalence trial compares intubation time for the GlideScope Cobalt® video laryngoscope (GCV, Verathon Medical, Bothell, WA) with direct laryngoscopy with a Miller blade (DL, Heine, Dover, NH) in anatomically normal neonates and infants. The primary hypothesis was that intubation times with GCV would be noninferior to DL. Methods: Sixty subjects presenting for elective surgery were randomly assigned to intubation using GCV or DL. Intubation time, time to best view, percentage of glottic opening score, and intubation success were documented. We defined an intubation time difference of less than 10 s as clinically insignificant. Results: There was no difference in intubation time between the groups (GCV median = 22.6 s; DL median = 21.4 s; P = 0.24). The 95% one-sided CI for mean difference between the groups was less than 8.3 s. GCV yielded faster time to best view (median = 8.1 s; DL 9.9 s; P = 0.03). Endotracheal tube passage time was longer for GCV (median = 14.3 s; DL 8.5 s; P = 0.007). The percentage of glottic opening score was improved with GCV (median 100; DL 80; P < 0.0001). Conclusions: Similar intubation times and success rates were achieved in anatomically normal neonates and infants with the GCV as with DL. The GCV yielded faster time to best view and better views but longer tube passage times than DL.

Prospective randomized observer-blinded study comparing the analgesic efficacy of ultrasound-guided rectus sheath block and local anaesthetic infiltration for umbilical hernia repair

BACKGROUND Umbilical hernia repair, a common day-surgery procedure in children, is associated with considerable postoperative discomfort. Possible modes of postoperative analgesia for umbilical hernia repair are rectus sheath block (RSB) and local anaesthetic infiltration of the surgical site (LAI). METHODS We undertook an observer-blinded, randomized, prospective, observational study to compare the efficacy of ultrasound-guided RSB and LAI in providing postoperative analgesia for umbilical hernia repair. Our primary objective was to compare the use of opioid medication between patients who receive RSB and those who receive LAI. Our secondary objectives were to compare the duration of analgesia based on time to first rescue analgesic, to compare the quality of analgesia based on revised FACES scale, and to determine the incidence of side-effects. RESULTS Fifty-two patients (26 in each group) completed the study. There was a statistically significant difference in the perioperative opioid medication consumption between the LAI group [mean: 0.13 mg kg(-1), confidence interval (0.09-0.17 mg kg⁻¹)] and the RSB group [mean: 0.07 mg kg⁻¹, confidence interval (0.05-0.09 mg kg⁻¹)] (P=0.008). When we compared the postoperative opioid consumption between the LAI group [mean: 0.1 mg kg⁻¹, 95% confidence interval (0.07-0.13 mg kg⁻¹)] and the RSB group [mean: 0.07 mg kg(-1), 95% confidence interval (0.05-0.09 mg kg⁻¹)] (P=0.09), there was a trend towards statistical significance between the two groups. The difference in time to rescue analgesic administration between the RSB group [49.7 (36.9) min] and the LAI group [32.4 (29.4) min] was not statistically significant (P=0.11). CONCLUSIONS This study demonstrates that ultrasound-guided RSB provides superior analgesia in the perioperative period compared with infiltration of the surgical site after umbilical hernia repair. In comparing only the postoperative period, analgesia provided by an ultrasound-guided RSB showed a trend towards statistically significant improvement compared with infiltration of the surgical site.

The efficacy of the Storz Miller 1 video laryngoscope in a simulated infant difficult intubation.

BACKGROUND: Several studies have shown video laryngoscopy to be a useful technique in the management of patients in whom glottic exposure by direct laryngoscopy is difficult. We conducted this study as a preliminary investigation comparing the Storz DCI Miller 1 video laryngoscope (VL, Karl Storz GmbH, Tuttlingen, Germany) and direct laryngoscopy with a Miller 1 laryngoscope (DL) in an infant manikin model simulating difficult direct laryngoscopy. We hypothesized that compared with DL, VL would provide a better glottic view but would be associated with a longer time to intubation because of the different skill set required when using video intubation. METHODS: A Laerdal® infant airway management training manikin (Laerdal Medical, Wappingers Falls, NY) was adapted using cloth tape to limit cervical spine mobility. Thirty-two attending pediatric anesthesiologists attempted tracheal intubation of the infant manikin using VL and DL in randomized order. The best laryngeal view with each laryngoscope and time to intubation were documented. RESULTS: There was a significant difference in the distributions of laryngoscopy grades between VL and DL (P < 0.001), with the VL giving a better laryngeal view. Forty percent of anesthesiologists reported a Grade 3 or 4 view with DL; all of which were converted to Grades 1 and 2 with VL. The median grade with interquartile range was two (2-3) for DL and one (1-2) for VL (P < 0.001). Seventy-eight percent of participants reported an improvement of at least one grade in laryngeal view with VL compared with DL. There were two failed intubations using DL and none using VL. Time to intubation was similar between the two techniques. CONCLUSIONS: The Storz Miller 1 VL blade improved glottic exposure in a simulated difficult laryngoscopy compared with direct laryngoscopy with a standard Miller 1 blade without increasing the time to intubation.

Bradycardia During Induction of Anesthesia with Sevoflurane in Children with Down Syndrome

BACKGROUND: Bradycardia is a complication associated with inhaled induction of anesthesia with halothane in children with Down syndrome. Although bradycardia has been reported after anesthetic induction with sevoflurane in these children, the incidence is unknown. OBJECTIVES: In this study we compared the incidence and characteristics of bradycardia after induction of anesthesia with sevoflurane in children with Down syndrome to healthy controls. METHODS: We reviewed electronic anesthetic records of 209 children with Down syndrome and 268 healthy control patients who had inhaled induction of anesthesia with sevoflurane over an 8-year period. Data extracted from the medical record included demographics, history of congenital heart disease, heart rate, oxyhemoglobin saturation, expired sevoflurane concentrations, arterial blood pressure, and any treatment of bradycardia during the first 360 seconds after the start of induction of anesthesia. Bradycardia and hypotension were defined as heart rate and arterial blood pressure below the critical limits recommended for activating a pediatric rapid response team to the bedside of a hospitalized child for quick intervention. Factors associated with bradycardia were identified in a univariate analysis. A step-wise backward multiple logistic regression model was used to identify independent factors. Differences between the 2 groups were computed using Fishers exact test or &khgr;2 tests for categorical data and t tests for continuous data. RESULTS: Univariate analysis demonstrated that Down syndrome, low ASA physical status, congenital heart disease, and mean sevoflurane concentrations were factors associated with bradycardia. However, multivariate analysis showed that only Down syndrome and low ASA physical status remained as independent factors associated with bradycardia. CONCLUSION: Bradycardia during anesthetic induction with sevoflurane was common in children with Down syndrome, with and without a history of congenital heart disease.

Ambulatory continuous peripheral nerve blocks in children and adolescents: a longitudinal 8-year single center study.

BACKGROUND:Although the role of regional anesthesia in pediatric patients has been increasing over the last few years, there are only a few small case series that describe the use of ambulatory continuous peripheral nerve blocks (CPNBs) in this patient population. In this report, we describe our experience with the use of ambulatory CPNBs in 1285 children. METHODS:Data were collected for consecutive children who had a CPNB placed between January 2005 and December 2011 at The Children’s Hospital of Philadelphia from the departmental regional anesthesia database. Data collected included demographics, the site of catheter placement and technique of nerve block, presence of sensory/motor blockade, use of perioperative opioids, and any complications related to CPNBs. RESULTS:Continuous infusions of local anesthetics were administered via the catheters in 1285 outpatients. The mean duration of the CPNB was 50.7 ± 14.4 hours (mean ± SD). Among patients discharged home with the CPNBs, 969 (75.4%) of the patients required either no supplemental opioids or oral opioids only on an “as needed” basis in the postoperative period (confidence interval, 73.0%–77.8%). Two patients were readmitted for IV pain management after they were discharged home with the CPNB catheters. No neurological deficit related to the CPNBs was identified in any of the patients at their 6-month follow-up with the orthopedic surgeon (confidence interval, 0%–0.29%). CONCLUSION:This audit of 1285 children shows ambulatory CPNBs can provide postoperative analgesia and may reduce the need for inpatient parenteral opioid therapy.

Anesthetic management of children with an anterior mediastinal mass

STUDY OBJECTIVE To review the anesthetic management and perioperative course of children with an anterior mediastinal mass. DESIGN Retrospective review. SETTING University-affiliated childrens hospital. MEASUREMENTS The records of 46 children presenting with an anterior mediastinal mass between October 1, 1998 and October 1, 2006 were studied. Preoperative symptoms, diagnostic imaging and physical examination findings, anesthetic techniques, and perioperative complications were recorded. MAIN RESULTS Spontaneous ventilation was maintained in 21 of 46 cases. Five patients had mild intraoperative complications, including upper airway obstruction, mild oxyhemoglobin desaturation, wheezing, partial airway obstruction, and a pneumothorax after mediastinal mass biopsy. There were no serious complications or perioperative deaths. CONCLUSIONS Children with a symptomatic anterior mediastinal mass underwent general anesthesia without serious complications. Spontaneous ventilation was preferred for all patients with severe airway compression.

The effects of oral ondansetron disintegrating tablets for prevention of at-home emesis in pediatric patients after ear-nose-throat surgery.

BACKGROUND: Tonsillectomy and adenoidectomy are associated with a frequent incidence of vomiting, both in the hospital and at home. We evaluated the effects of oral ondansetron disintegrating tablets (ODT) on the incidence of at-home emesis in children undergoing tonsillectomy with and without adenoidectomy and with and without bilateral myringotomy and tube insertion. METHODS: All patients underwent inhaled mask induction with nitrous oxide, oxygen, and sevoflurane. Morphine, dexamethasone, and ondansetron were administered to all patients intraoperatively. Postoperative pain was treated with fentanyl or acetaminophen with codeine. Rescue antiemetics in the postanesthesia care unit or same day surgery unit were administered for three emetic episodes within 15 min, or upon patient or parent request. Patients were randomized for at-home administration of five doses of either ondansetron ODT or a placebo. All patients were followed for the first 3 days after surgery. At-home emesis was the primary outcome variable. RESULTS: Two hundred and twenty-one patients were entered into the study, yielding 200 evaluable subjects. At-home emesis occurred in 15 (14.5%) of the 103 children who received ODT, and 31 (32%) of the 97 children in the placebo group, P = 0.004. Subgroup analysis demonstrated efficacy in patients who did not require rescue medication for nausea and vomiting while in the hospital, but did not demonstrate efficacy for patients who required rescue medication. CONCLUSIONS: At-home use of ODT may prevent emesis in children during the first 3 days after tonsillectomy in children. Patients who require rescue after prophylactic treatment for nausea and vomiting in the hospital may not respond to prophylactic ondansatron ODT at home.

Dermabond decreases pericatheter local anesthetic leakage after continuous perineural infusions.

To the Editor Continuous perineural infusions (CPNIs) of local anesthetic provide sustained postoperative analgesia, opioid sparing, and facilitate early discharge from the hospital. One common problem with CPNIs is pericatheter leakage that can compromise the sterile dressing, increase the risk of dislodgement of the perineural catheter, and, as a result, decrease patient satisfaction. Frequent dressing changes are also associated with increased risk of perineural catheter insertion site colonization and infections. One technique described in a case series to secure the CPNI catheters is using 2-octyl cyanoacrylate glue (Dermabond Topical Skin Adhesive; Ethicon, Somerville, NJ) to secure the site of the continuous peripheral nerve block catheter. The sterile liquid once applied to the skin polymerizes within minutes, forming a waterproof bond with the keratin in the epidermis. Since August 2008, we have applied Dermabond at the CPNI insertion site after catheter placement and before injecting a bolus of local anesthetic. After injection of local anesthetic, we place a sterile transparent dressing over the Dermabond-catheter complex at the catheter entry site. We provide written instructions to the family and a member of the nursing staff explains the process to the family. Most of the CPNI catheters are removed by a family member on postoperative day 2 at home. We also explain to the family that we use Dermabond, which may be associated with increased resistance when catheter withdrawal is attempted. However, we have had no problems related to removal of the catheters. We compared the incidence of local anesthetic leakage and CPNI catheter dislodgement between CPNI catheters placed before using Dermabond and those after using Dermabond. In 896 patients in whom catheters had been implanted and the injection site sealed with Dermabond, a leak occurred in 5 cases (0.56%) resulting in removal of 3 catheters (0.33%) because of leakage, and in 8 cases (0.89%), the catheters dislodged spontaneously before the planned removal. When Dermabond was not used (before August 2008), of the 748 patients, a leak occurred in 29 cases (3.87%) of which 9 (1.2%) were removed because of heavy leakage, and in 26 cases (3.48%), the catheters dislodged before the planned removal. These data suggest that Dermabond may be useful in preventing pericatheter leakage and may also reduce the incidence of premature dislodgement of the catheter.

A prospective randomized observer-blinded study to assess postoperative analgesia provided by an ultrasound-guided bilateral thoracic paravertebral block for children undergoing the Nuss procedure.

Background and Objectives This prospective, randomized, single-blinded study evaluates the effectiveness of the ultrasound-guided bilateral thoracic paravertebral (BTPV) block for providing postoperative pain control in children undergoing the Nuss procedure. Methods Thirty American Society of Anesthesiologists I–II children with pectus excavatum, scheduled for the Nuss procedure, were enrolled at West China Hospital of Sichuan University. The patients were randomly allocated into the BTPV block group or the control group. In the BTPV group, 0.25% ropivacaine 0.5 mL/kg with 1:200,000 epinephrine was injected under ultrasound guidance on each side at the level of the fifth thoracic vertebra. Postoperative pain was evaluated in both groups for the first 48 hours. Total opioid administered and cumulative attempts on the patient/parent-controlled intravenous analgesia (PCA) pump were recorded. Postoperative negative behavioral changes in the children were evaluated on postoperative days 1, 7, and 30, respectively, using the posthospital behavior questionnaire. Results The pain scores were significantly reduced in the postanesthesia care unit and for the first 48 hours postoperatively in the BTPV group compared to the control group (P < 0.01). The sufentanil use in the postanesthesia care unit was significantly greater in the control group [mean (SD), 0.2 (0) mcg/kg] compared to the BTPV group [mean (SD), 0.05 (0.06) mcg/kg] (P < 0.01). The postoperative sufentanil use was significantly higher in the control group during the first 24 hours (P < 0.01). Numbers of attempts on the PCA pump were significantly greater in the control group (P < 0.01). The posthospital behavior questionnaire score was lower in the BTPV group on day 1, day 7, and 1 month, respectively (P < 0.01). Conclusions Ultrasound-guided BTPV block provides improved postoperative analgesia for children undergoing the Nuss procedure as compared with intravenous PCA and decreases the incidence of postoperative behavioral disturbance.