Hina Walia

Sevoflurane and bradycardia in infants with trisomy 21: A case report and review of the literature

Various perioperative concerns have been reported in patients with trisomy 21 including associated congenital heart disease, atlantoaxial instability, tracheal and subglottic stenosis, a predisposition to respiratory complications, hypothyroidism, and macroglossia leading to sleep disordered breathing. The recent literature has also suggested a propensity for the development of significant bradycardia during inhalation induction with sevoflurane. We present a 2-year-old girl with trisomy 21 who developed the rapid onset of bradycardia during anesthetic induction with sevoflurane. Previous reports are reviewed, postulated mechanisms discussed, and preventative strategies presented.

Optimizing the securement of epidural catheters: an in vitro trial

Introduction Epidural anesthesia is frequently used to provide postoperative analgesia following major surgical procedures. Secure fixation of the epidural catheter is necessary to prevent premature dislodgment and loss of epidural analgesia. Using an in vitro model, the current prospective study evaluates different types of dressings for securement of an epidural catheter by quantifying the force in Newtons (N) required for dislodgment using a digital force gage. Methods Four methods of epidural catheter securement were used on a simulator mannequin: 1) Suresite® Window Clear Dressing, 2) Op-Site Post-Op® Visible Dressing, 3) Steri-Strips® and Suresite Window Clear Dressing, and 4) Steri-Strips and Op-Site Post-Op Visible Dressing. Each method of securement was assessed 10 times to calculate the mean force required to dislodge the catheter. Mean force of dislodgment for each method was compared using parametric tests. Results The force (mean ± SD) required for catheter dislodgment for the four methods was 14.0±2.9, 2, 10.7±1.5, 8.6±2.3, and 9.6±2.2 N, respectively. The pairwise difference showed that the Suresite Window Clear Dressing was the best securement method when compared with other methods. Conclusion Our study demonstrates the advantage of the Suresite Window Clear Dressing in securing the epidural catheter. Future clinical trials are needed to validate these findings.

Rapid fluid administration: an evaluation of two techniques

Objective Rapid administration of fluid remains a cornerstone in treatment of shock and when caring for trauma patients. A range of devices and technologies are available to hasten fluid administration time. While new devices may optimize fluid delivery times, impact on subjective experience compared to traditional methods is poorly documented. Our study evaluated administration time and provider experience using two unique methods for fluid administration. Materials and methods Prospective comparison of objective and subjective outcomes using a novel infusion device (LifeFlow® Rapid Infuser) and the traditional push–pull syringe method in a simulated model of rapid fluid infusion. Ten paired trials were conducted for each of three intravenous catheter gauges. Providers administered 500 mL of isotonic crystalloid through an intravenous catheter with both LifeFlow and a push–pull device. Administration time was compared between devices using paired t-tests. Participants’ subjective physical demand, effort, pain, and fatigue using each device were recorded using 21-point visual analog scales and compared between devices using sign-rank tests. Results Fluid administration time was significantly decreased with LifeFlow compared to the push–pull device with the 18-gauge catheter (2.5±0.8 vs 3.8±1.0 minutes; 95% CI of difference: 0.9, 1.8 minutes; P<0.001). Findings were similar for other catheter sizes. No improvements in subjective experience were noted with the LifeFlow device. Increased physical demand with the LifeFlow device was noted with 18 and 22 gauge catheters, and increased fatigue with the LifeFlow device was noted for all catheter sizes. Conclusion The LifeFlow device was faster than the push–pull syringe method in our simulated scenario. However, provider subjective experience was not improved with the LifeFlow device.

Caregivers’ knowledge and acceptance of complementary and alternative medicine in a tertiary care pediatric hospital

Background The use of complementary and alternative medicine (CAM) therapies has increased in children, especially in those with chronic health conditions. However, this increase may not translate into acceptance of CAM in the perioperative setting. We surveyed caregivers of patients undergoing surgery to determine their knowledge and acceptance of hypnotherapy, acupuncture, and music therapy as alternatives to standard medication in the perioperative period. Materials and methods An anonymous, 12-question survey was administered to caregivers of children undergoing procedures under general anesthesia. Caregivers reported their knowledge about hypnotherapy, music therapy, and acupuncture and interest in one of these methods during the perioperative period. CAM acceptance was defined as interest in one or more CAM methods. Results Data from 164 caregivers were analyzed. The majority of caregivers were 20–40 years of age (68%) and mothers of the patient (82%). Caregivers were most familiar with acupuncture (70%), followed by music therapy (60%) and hypnotherapy (38%). Overall CAM acceptance was 51%. The acceptance of specific CAM modalities was highest for music therapy (50%), followed by hypnotherapy (17%) and acupuncture (13%). In multivariable logistic regression, familiarity with music therapy was associated with greater odds of CAM acceptance (odds ratio=3.36; 95% CI: 1.46, 7.74; P=0.004). Conclusion Overall CAM acceptance among caregivers of children undergoing surgery was 51%, with music therapy being the most accepted CAM method. Familiarity with music therapy was the only factor that was independently associated with accepting CAM in the perioperative period. The low acceptance for acupuncture and hypnosis in the perioperative situation may be related to insufficient parental knowledge and information.

A pilot study on secondhand tobacco exposure: parental knowledge about health impact and feasibility of cessation

Introduction As the primary source of smoke exposure is in the home, the smoking behaviors of parents and other caregivers are key determinants of a child’s exposure to secondhand smoke. The perioperative period offers an opportunity to discuss smoking cessation strategies. Methods This prospective study included 97 parents or caregivers of patients undergoing dental surgery. Caregivers were surveyed in the dental waiting room during the preoperative phase. The primary aim was to determine the feasibility of using the preoperative encounter to offer smoking cessation resources to parents of pediatric patients. The secondary aim was to compare willingness to receive smoking cessation resources according to the knowledge of the risks of secondhand smoking (ie, being aware of secondhand smoking and knowing that it posed a risk to their child). Results Awareness of risks due to secondhand smoking was 65% in the overall cohort and 58% among current smokers (P=0.284 vs nonsmokers). Among smokers in our study, only a small percentage (12%) were interested in smoking cessation help. Knowledge of the risks of secondhand smoke may not be sufficient for smokers to express willingness to receive help. Conclusion The outpatient clinic may be a teaching opportunity for smoking cessation for caregivers. However, we found that only a small percentage of caregivers were interested in receiving information about smoking cessation. This was despite the fact they were aware of the potential adverse effects of secondhand smoke on their children.

An In Vitro Assessment of the Efficacy of Various IV Cannulas for the Rapid IV Fluid Administration

Objectives: The current study prospectively evaluates the administration of fluid through commonly used vascular cannulas of various length and diameter. Design: Observational, in vitro experiment. Setting: Not applicable. Subjects: No human subjects. Interventions: None. Measurements and Main Results: Fluid (500 mL) was administered via gravity flow and with pressure assistance (pressure bag set at 300 mm Hg) through various vascular cannulas including peripheral IV catheters (22 gauge, 1 inch; 20 gauge, 1.16 and 1.88 inch; and 18 gauge, 1.16 and 1.88 inch), 3-Fr central line lumens (lengths 50, 80, and 120 mm), and a 4-Fr, 10 cm Micropuncture catheter (Cook Medical, Bloomington, IN). During gravity flow, drain time decreased by approximately 50% when moving from a 22 to 20 to 18 gauge cannula and increased by approximately 20% as the catheter length increased from 50 to 80 to 120 cm. Flow rates were highest with the Micropuncture catheter, which achieved a drain time of 2.7 minutes for the 500 mL bag when infused with pressure assistance. Conclusions: In general, the delivery of crystalloid solutions through commonly used vascular cannulas was fastest with larger diameter and shorter length cannulas. Pressure-assisted flow was able to partially compensate for the increased resistance with smaller and longer catheters. The unique design of the tip of the Micropuncture catheter compensated for the increased length and allowed for rapid fluid delivery. This design may compensate for the increased length when longer catheters are needed for ultrasound-guided placement.

Rapid Response Team activation for pediatric patients on the acute pain service

Untreated pain or overly aggressive pain management may lead to adverse physiologic consequences and activation of the hospitals Rapid Response Team. This study is a quality improvement initiative that attempts to identify patient demographics and patterns associated with Rapid Response Team consultations for patients on the acute pain service.

Correlation of Lactic Acid and Base Deficit Values Obtained From Arterial and Peripheral Venous Samples in a Pediatric Population During Intraoperative Care

Lactic acid and base deficit (BD) values are frequently monitored in the intensive care unit and operating room setting to evaluate oxygenation, ventilation, cardiac output, and peripheral perfusion. Although generally obtained from an arterial cannula, such access may not always be available. The current study prospectively investigates the correlation of arterial and peripheral venous values of BD and lactic acid. The study cohort included 48 patients. Arterial BD values ranged from −8 to 4 mEq/L and peripheral venous BD values ranged from −8 to 4 mEq/L. Arterial lactic acid values ranged from 0.36 to 2.45 μmol/L and peripheral venous lactic acid values ranged from 0.38 to 4 μmol/L. The arterial BD (−0.4 ± 2.2 mEq/L) was not significantly different from the peripheral venous BD (−0.6 ± 2.2 mEq/L). The arterial lactic acid (1.0 ± 0.5 μmol/L) was not significantly different from the peripheral venous lactic acid (1.1 ± 0.6 μmol/L). Pearson correlation coefficients demonstrated a very high correlation between arterial and peripheral venous BD (r = .88, P < .001) and between arterial and peripheral venous lactic acid (r = .67, P < .001). Bland-Altman plots of both pairs of measures showed that the majority of observations fell within the 95% limits of agreement. Least-squares regression indicated that a 1-unit increase in arterial BD corresponded to a 0.9-unit increase in peripheral venous BD (95% confidence interval [CI]: 0.7-1.0; P < .001) and a 1-unit increase in arterial lactic acid corresponded to a 0.9-unit increase in peripheral venous lactic acid (95% CI: 0.6-1.2; P < .001). These data demonstrate that there is a clinically useful correlation between arterial and peripheral venous lactic acid and BD values.

Oxymetazoline Metered Dose Spray: Factors Affecting Delivery Volume.

OBJECTIVES The current study compared the amount of oxymetazoline delivered by various anesthesia providers when holding the bottle in the upright and inverted position. Additionally, the amount delivered from a full bottle and a half-full bottle was also investigated. METHODS Using an analytical balance that was calibrated to zero, we evaluated the impact the position of the bottle and the volume of oxymetazoline in the bottle had on the amount being delivered by both anesthesia staff and trainees. RESULTS When using both filled and half-filled bottles, the amount delivered increased significantly when comparing the upright versus inverted position. With a full bottle, the amount delivered when the bottle was inverted increased almost 10-fold from 62 ± 80 to 606 ± 366 μL (p < 0.0001). Similarly, even with a half-filled bottle, the amount delivered increased in the inverted positions from 41 ± 48 to 645 ± 393 μL. Regardless of the scenario, we also noted significant variation from provider to provider. CONCLUSIONS Our results demonstrate that several factors may affect the amount of oxymetazoline delivered for metered dose bottles. Given the potential for severe end-organ effects with excessive dosage, alternative means of delivery are needed for its perioperative use.

Safety and efficacy of nurse-controlled analgesia in patients less than 1 year of age.

Background The management of acute pain presents unique challenges in the younger pediatric population. Although patient-controlled devices are frequently used in patients ≥6 years of age, alternative modes of analgesic delivery are needed in infants. Objective To examine the safety and efficacy of nurse-controlled analgesia (NCA) in neonates less than 1 year of age. Methods Data from patients <1 year of age receiving NCA as ordered by the Acute Pain Service at our institution were collected over a 5-year period and reviewed retrospectively. The primary outcomes were activation of the institution’s Rapid Response Team (RRT) or Code Blue, signifying severe adverse events. Pain score after NCA initiation was a secondary outcome. Results Among 338 girls and 431 boys, the most common opioid used for NCA was fentanyl, followed by morphine and hydromorphone. There were 39 (5%) cases involving RRT or Code Blue activation, of which only one (Code Blue) was activated due to a complication of NCA (apnea). Multivariable logistic regression demonstrated morphine NCA to be associated with greater odds of RRT activation (OR=3.29, 95% CI=1.35, 8.03, P=0.009) compared to fentanyl NCA. There were no statistically significant differences in pain scores after NCA initiation across NCA agents. Conclusion NCA is safe in neonates and infants, with comparable efficacy demonstrated for the three agents used. The elevated incidence of RRT activation in patients receiving morphine suggests caution in its use and consideration of alternative agents in this population.