Hiromi Kako

The relationship between head and neck position and endotracheal tube intracuff pressure in the pediatric population

Over the past few years, there has been a change in clinical practice with a transition to the use of cuffed instead of uncuffed endotracheal tubes (ETTs) in pediatric patients. These changes have led to concerns regarding unsafe intracuff pressures in pediatric patients, which may result in postoperative morbidity. To avoid these issues, it is generally suggested that the intracuff pressure be maintained at ≤30 cmH2O. The current study prospectively assesses the changes in intracuff pressure related to alterations in head and neck position in pediatric patients.

Accuracy of the CNAP™ monitor, a noninvasive continuous blood pressure device, in providing beat-to-beat blood pressure readings in pediatric patients weighing 20–40 kilograms

During perioperative care, the continuous measurement of blood pressure (BP) provides superior physiologic monitoring to intermittent techniques. However, such monitoring requires placement of an intraarterial catheter, which may be time‐consuming or associated with adverse events and technical difficulty. A noninvasive, continuous BP monitoring device has been studied in the adult population. This study prospectively assesses its accuracy in pediatric patients, weighing 20–40 kg.

Severe intraoperative hypertension after induction of anesthesia in a child with a neuroblastoma

Neuroblastomas are the most common, non-central nervous system tumor of childhood. Similar to pheochromocytomas, they are derived from neural crest cells and therefore retain the potential to synthesize catecholamines. Unlike pheochromocytomas, however, perioperative issues related to blood pressure instability with hypertension are uncommon. We report details of a 3-year-old child with a neuroblastoma who developed severe hypertension and end-organ effects after induction of anesthesia. The association of such problems with neuroblastoma is reviewed and options for perioperative care presented.

A Prospective, Open-Label Trial of Clevidipine for Controlled Hypotension During Posterior Spinal Fusion

OBJECTIVES Controlled hypotension is one means to limit or avoid the need for allogeneic blood products. Clevidipine is a short-acting, intravenous calcium channel antagonist with a half-life of 1 to 3 minutes due to rapid metabolism by non-specific blood and tissue esterases. To date, there are no prospective evaluations with clevidipine in the pediatric population. We prospectively evaluated the dosing requirements, efficacy, and safety of clevidipine for ontrolled hypotension during spinal surgery for neuromuscular scoliosis in the pediatric population. METHODS Patients undergoing posterior spinal fusion for neuromuscular scoliosis were eligible for inclusion. The study was an open label, observational study. Maintenance anesthesia included desflurane titrated to maintain a bispectral index at 40 to 60 and a remifentanil infusion. Motor and somatosensory evoked potentials were monitored intraoperatively. When the mean arterial pressure (MAP) was ≥ 65 mmHg despite remifentanil at 0.3 mcg/kg/min, clevidipine was added to maintain the MAP at 55 to 65 mmHg. Clevidipine was initiated at 0.25 to 1 mcg/kg/min and titrated up in increments of 0.25 to 1 mcg/kg/min every 3 to 5 minutes to achieve the desired MAP. RESULTS The study cohort included 45 patients. Fifteen patients (33.3%) did not require a clevidipine infusion to maintain the desired MAP range, leaving 30 patients including 13 males and 17 females for analysis. These patients ranged in age from 7.9 to 17.4 years (mean ± SD: 13.7 ± 2.2 years) and in weight from 18.9 to 78.1 kg (mean ± SD: 43.4 ± 14.2 kg). Intraoperatively, the clevidipine infusion was stopped in 6 patients as the surgeon expressed concerns regarding spinal cord perfusion and requested a higher MAP than the study protocol allowed. The data until that point were included for analysis. The target MAP was initially achieved at a mean time of 8.9 minutes. Sixteen of the 30 patients (53.3%) achieved the target MAP within 5 minutes. Heart rate (HR) increased from a baseline of 83 ± 16 to 86 ± 15 beats per minute (mean ± SD) (p=0.04) with the administration of clevidipine. No patient had a HR increase ≥ 20 beats per minute or required the administration of a β-adrenergic antagonist. The duration of the clevidipine administration varied from 8 to 527 minutes (mean ± SD: 160 ± 123 minutes). The maintenance infusion rate of clevidipine varied from 0.25 to 5.0 mcg/kg/min (mean ± SD: 1.4 ± 1.1 mcg/kg/min). Clevidipine was paused a total of 43 times in the 30 cases. In 18 of the 30 patients (60%), the clevidipine infusion was temporarily paused more than once due to a MAP < 55 mmHg. A fluid bolus was administered to only 1 patient to treat the low MAP. No patient required the administration of a vasoactive agent for hypotension. When the clevidipine infusion was discontinued as controlled hypotension was no longer required, the MAP returned to baseline or ≥ 65 mmHg within 10 minutes in 12 of the 30 patients (40%). CONCLUSIONS Clevidipine can be used to provide controlled hypotension during posterior spinal fusion. The response of the MAP, both the onset and duration of action, were rapid. Although titration of the infusion with occasional pauses of administration may be needed, excessive hypotension was not noted.

Caudal anesthesia in a patient with peritonitis: Is it safe??

Neuraxial anesthesia combined with general anesthesia has become a widely accepted method of providing effective postoperative analgesia and decreasing intraoperative anesthetic needs in the pediatric population. In clinical practice, there still appears to be hesitancy for the use of a neuraxial technique (spinal or epidural) in patients at risk for bacteremia or with an on-going systemic infection. However, evidence-based medicine lacks any data to support an increase in the risk of infectious complications following neuraxial anesthesia. We present two pediatric patients with intra-abdominal infectious processes who received caudal epidural blockade for postoperative operative analgesia. The use of neuraxial techniques in patients at risk for bacteremia is reviewed, evidence-based medicine regarding the risks of infection discussed, and the potential favorable effects of neuraxial blockade on the neurohumoral response to sepsis and the systemic inflammatory responses presented.

Reply to Adam Adler and Arvind Chandrakantan regarding their comment “Nursing initiated tracheal extubation in PACU, the risk of delegating critical anesthesiology tasks in the interest of speed”

Sir—We would like to thank Drs. Adler and Chandrakantan for their interest in our manuscript regarding tracheal extubation practices following adenotonsillectomy in children. Their first query concerns the unclear reasons for excluding some cases from the control institution when analyzing the duration of postanesthesia care unit (PACU) stay. As noted in our original manuscript, these patients were discharged home directly from the PACU and therefore their duration of PACU stay was exceptionally long compared to data from Nationwide Children’s Hospital where the patients were discharged to an individual room where they received discharge and home care instructions in quiet environment from the nurses prior to discharge. As PACU stay durations were also more skewed in the control institution, we used the data reported in our manuscript to calculate the median postoperative length of stay (LOS) as 69 minutes at Nationwide Children’s Hospital (interquartile range [IQR]: 55, 88) compared to 80 minutes at the control institution (IQR: 60, 111). The 95% confidence interval (CI) of this difference in medians was 6-14 (P < .001 on Wilcoxon rank-sum test). If we had added the 167 control institution cases excluded from our original analysis, median PACU LOS in the control institution would have increased to 95 minutes (IQR: 65, 229), and the 95% CI of the difference in medians would have become 22-35. Clearly, the exclusion described in our manuscript led to a conservative estimate of differences in PACU LOS between the 2 institutions. Aside from this consideration, PACU LOS was calculated from the arrival in the PACU for both groups. The PACU discharge criteria were not standardized in the 2 institutions, and as noted in our manuscript, this was one of the limitations of our retrospective study. Our primary objective was to determine differences in operating room (OR) time, especially time from completion of the surgical procedure to exit from the OR, according to the institutional practice of tracheal extubation. The primary analyses from our study hold even when the cases with unusually prolonged PACU stay in the control institution were excluded, due to variation in the practice of discharging patients directly from the PACU. Drs. Adler and Chandrakantan also expressed a concern regarding the patient safety implications of tracheal extubation in the PACU and that such a practice eliminates a key component of what an anesthesiologist does. As perioperative physicians, however, our role is much greater in the overall care of patients during the many phases of anesthetic care. Over the years, our role has grown from merely an intraoperative care provider to a consultant during the entire perioperative process. As anesthesiologists, one of our roles is to determine when and where it is appropriate to extubate the trachea and also, who should perform this task. If we deem a patient safe for tracheal extubation in the PACU with a well-trained nurse, whom we have personally trained, we believe that this remains consistent with the role of a perioperative physician. The mere task of tracheal extubation should not define us. Equally as important, is to ensure that we continue to perform tracheal extubation in the OR in specific patient populations. Tracheal extubation in the PACU does not mean sacrificing deliberate practice and patient safety to save money and gain speed. They can exist together. As Drs. Adler and Chandrakantan mentioned, production pressure has been shown to relate to perioperative medical errors and adverse events. By performing tracheal extubation in the PACU, we remove the production pressure in the OR, where we believe tracheal extubation at times is hurried and perhaps performed at an inappropriate plane of anesthesia. Tracheal extubation in the PACU allows the patient enough time to fully emerge without production pressure. As outlined in our article, the process of tracheal extubation must be deliberate, with clear policies and procedures including training and recredentialing of the nursing staff. We do not routinely allow parents in the PACU, thereby eliminating that source of distraction or concern. Finally, what Adler et al. called “PACU nursing driven extubation” is not without supervision and direction of the anesthesiology staff. We carry walkie-talkies for instant communication, ensuring rapid response times for all phases of recovery in the PACU. While tracheal extubation is a key time point in the postoperative process, it is well known that sudden adverse airway events may occur before or following tracheal extubation. This mandates our constant ability to respond to problems in the PACU. The process of PACU tracheal extubation is only one aspect of team-based anesthesia care where anesthesiologists and nurses work together to provide high-quality and safe perioperative care as well as efficiency.

Perioperative care of a patient with neuronal ceroid lipofuscinoses

The neuronal ceroid lipofuscinoses (NCL) are a group of inherited, autosomal recessive, and progressive neurodegenerative diseases, which result from an enzymatic defect or the deficiency of a transmembrane protein, leading to the accumulation of lipopigments (lipofuscin) in various tissues. NCL results in the impairment of function in several end-organs including the central nervous system with loss of cognitive and motor function, myoclonus, and intractable seizures. Additional involvement includes the cardiovascular system with arrhythmias and bradycardia as well as impairment of thermoregulation leading to perioperative hypothermia. Given the complexity of the end-organ involvement and the progressive nature of the disorder, the anesthetic care of such patients can be challenging. Till date, there are a limited number of reports regarding the anesthetic management of patients with NCL. We present an 18-year-old patient with NCL who required anesthetic care during replacement of a vagal nerve stimulator. Previous reports of anesthetic care for these patients are reviewed, the end-organ involvement of NCL discussed, and options for anesthetic care presented.