Karin Becke

European consensus statement for intraoperative fluid therapy in children.

The intraoperative infusion of isotonic solutions with 1-2.5% glucose in children is considered well established use in Europe and other countries. Unfortunately, a European marketing authorisation of such a solution is currently missing and as a consequence paediatric anaesthetists tend to use suboptimal intravenous fluid strategies that may lead to serious morbidity and even mortality because of iatrogenic hyponatraemia, hyperglycaemia or medical errors. To address this issue, the German Scientific Working Group for Paediatric Anaesthesia suggests a European consensus statement on the composition of an appropriate intraoperative solution for infusion in children, which was discussed during a working session at the 2nd Congress of the European Society for Paediatric Anaesthesiology in Berlin in September 2010. As a result, it was recommended that an intraoperative fluid should have an osmolarity close to the physiologic range in children in order to avoid hyponatraemia, an addition of 1-2.5% instead of 5% glucose in order to avoid hypoglycaemia, lipolysis or hyperglycaemia and should also include metabolic anions (i.e. acetate, lactate or malate) as bicarbonate precursors to prevent hyperchloraemic acidosis. Thus, the underlying intention of this consensus statement is to facilitate the granting of a European marketing authorisation for such a solution with the ultimate goal of improving the safety and effectiveness of intraoperative fluid therapy in children.

Intraoperative low‐dose S‐ketamine has no preventive effects on postoperative pain and morphine consumption after major urological surgery in children

Background : Clinical studies suggest low‐dose ketamine may have preemptive effects on postoperative pain in adults. The objective of this study was to determine whether intraoperative low‐dose S‐ketamine reduces postoperative pain and morphine consumption in children undergoing major urological surgery.

Anesthesia and the developing brain: a way forward for clinical research.

It is now well established that many general anesthetics have a variety of effects on the developing brain in animal models. In contrast, human cohort studies show mixed evidence for any association between neurobehavioural outcome and anesthesia exposure in early childhood. In spite of large volumes of research, it remains very unclear if the animal studies have any clinical relevance; or indeed how, or if, clinical practice needs to be altered. Answering these questions is of great importance given the huge numbers of young children exposed to general anesthetics. A recent meeting in Genoa brought together researchers and clinicians to map a path forward for future clinical studies. This paper describes these discussions and conclusions. It was agreed that there is a need for large, detailed, prospective, observational studies, and for carefully designed trials. It may be impossible to design or conduct a single study to completely exclude the possibility that anesthetics can, under certain circumstances, produce long‐term neurobehavioural changes in humans; however , observational studies will improve our understanding of which children are at greatest risk, and may also suggest potential underlying etiologies, and clinical trials will provide the strongest evidence to test the effectiveness of different strategies or anesthetic regimens with respect to better neurobehavioral outcome.

Metamizole for postoperative pain therapy in 1177 children: A prospective, multicentre, observational, postauthorisation safety study.

BACKGROUND Due to possible serious adverse drug reactions (ADRs), the use of metamizole for postoperative pain therapy in children is a subject of debate. Safety studies with large sample sizes have not been published as yet. OBJECTIVE The aim of this study was to evaluate the use of metamizole in children aged up to 6 years undergoing surgery with a particular focus on serious ADRs such as haemodynamic, anaphylactic or respiratory reactions and agranulocytosis. DESIGN A multicentre, prospective, noninterventional, observational postauthorisation safety study (PASS). SETTING The study was conducted in six different paediatric centres from September 2013 to September 2014. PATIENTS One thousand one hundred and seventy-seven children aged up to six years (American Society of Anesthesiologists’ physical status class I to III) receiving a single dose of metamizole for postoperative pain therapy were enrolled. MAIN OUTCOME MEASURES Patient demographics, main and secondary diagnoses, surgical procedures performed, metamizole dose, haemodynamic data, use of other analgesics and regional blocks, results of pain measurement (Children and Infants Postoperative Pain Scale, ChIPPS) and ADR incidence were documented using a standardised case report form. RESULTS Of the 1177 children observed at six paediatric centres, 1145 were included for analysis [age 35.8 ± 18.1 (0.1 to 72) months]. The mean metamizole dose was 17.3 ± 2.9 (8.3 to 29.4) mg kg−1. Mean arterial pressure (MAP) remained stable during metamizole infusion [baseline 55.7 ± 11.3 (25 to 98) and after infusion 56.6 ± 11.3 (25 to 99) mmHg; P < 0.01]. Pruritus, swelling and exanthema were observed in one patient each (total 0.3%). No respiratory adverse events directly related to the metamizole administration and no clinical signs of agranulocytosis were reported. All data are mean ± SD (range). CONCLUSION Single intravenous doses of metamizole used for the prevention or treatment of postoperative pain were well tolerated in more than 1000 children aged up to 6 years. The probability of serious ADRs (haemodynamic, anaphylactic or respiratory reactions) is lower than 0.3%. The sample size and follow-up was not sufficient to detect episodes of agranulocytosis.

Perioperative intravenous fluid therapy in children: guidelines from the Association of the Scientific Medical Societies in Germany

This consensus‐ based S1 Guideline for perioperative infusion therapy in children is focused on safety and efficacy. The objective is to maintain or re‐establish the childs normal physiological state (normovolemia, normal tissue perfusion, normal metabolic function, normal acid‐ base‐ electrolyte status). Therefore, the perioperative fasting times should be as short as possible to prevent patient discomfort, dehydration, and ketoacidosis. A physiologically composed balanced isotonic electrolyte solution (BS) with 1–2.5% glucose is recommended for the intraoperative background infusion to maintain normal glucose concentrations and to avoid hyponatremia, hyperchloremia, and lipolysis. Additional BS without glucose can be used in patients with circulatory instability until the desired effect is achieved. The additional use of colloids (albumin, gelatin, hydroxyethyl starch) is recommended to recover normovolemia and to avoid fluid overload when crystalloids alone are not sufficient and blood products are not indicated. Monitoring should be extended in cases with major surgery, and autotransfusion maneuvers should be performed to assess fluid responsiveness.

What's new in pediatric acute pain therapy?

Purpose of review This review highlights the current trends of efficient and safe perioperative pediatric pain therapy in the context of a multimodal pain therapy concept. Recent findings A multimodal pain therapy concept should be easy to apply and safe regarding the occurrence of side-effects. The administration of nonopioid analgesics should be obligatory, regional anesthesia techniques – under ultrasound guidance – should be performed whenever possible, opioids should be given immediately and sufficiently whenever necessary, the administration of co-analgesics like lidocaine, dexamethasone or ketamine should be considered, and most importantly, each pain therapy should be performed according to pain assessment and long enough until adequate pain relief. Summary Safe and simple pediatric pain management in the perioperative period combines not only easy to apply and safe stepwise pain therapy itself, but also adequate pain assessment and the implementation of continuous hospital quality improvement strategies.

The OrphanAnaesthesia project.

Orphan diseases are rare diseases with a prevalence in Europe of less than five in 10 000. Many are caused by genetic, infectious or auto-immune disorders, but in most cases, their origin is unknown. To date, approximately 7000 orphan diseases have been found, described and investigated. Most are serious chronic diseases and may lead to life-threatening medical conditions. Each orphan disease is characterised by an individual time of onset, heterogenous organ manifestations and different clinical signs. Some diseases can easily be diagnosed when typical signs become apparent at birth or in childhood, for example Treacher–Collins syndrome with its unique cranial dysmorphism, but others appear later, during adulthood, at first without specific symptoms, like the non-specific muscular weakness seen with amyotrophic lateral sclerosis.

Incidence of complications associated with rapid sequence induction (RSI) in children - it is a matter of age and technique.

children without ADHD. As Dr. Kira points out, while increased salivary cortisol levels may well contribute to the uncooperative induction behavior of children with ADHD, the observation by Blomqvist et al. (2) that children with ADHD undergoing dental procedures have lower cortisol levels compared with children without ADHD yet are harder to manage ‘muddies the waters’ somewhat. As our hypothesis did not include the role of cortisol levels in the expression of perioperative behaviors in children with and without ADHD, we can only conclude that the observed differential response to the stress of anesthesia and surgery is likely multifactorial and, as such, perhaps an interesting platform for future research. A L A N R. T A I T T E R R I V O E P E L-L E W I S The Department of Anesthesiology, University of Michigan Health System, Ann Arbor, MI, USA (email: atait@umich.edu)

Etiquette, competence, and professionalism: the profile of the ‘ideal pediatric anesthesiologist’

Competence is defined as the ability to perform a job properly; this includes knowledge, skills, and appropriate behavior. Professionalism is a wider term; it is the detailed description of the ideal caregiver’s profile including all aspects, especially of social interactions, too. In this issue, in a qualitative study, Lockman et al. tried to define professionalism in pediatric anesthesiology by asking relevant stakeholder groups, pediatric anesthesiologists, nurses, parents, and surgeons, what they believe are the qualities of an ideal ‘professional’ anesthesiologist (1). Without surprise, the different groups attached weight to different aspects. However, all aspects are important and this may well be worth some thoughts. The physical image, the behavior including dress, manners, body language, and eye contact are important. This was pointed out in a landmark editorial entitled ‘Etiquette-based medicine’ by Kahn in the New England Journal of Medicine (2). The author proposed a simple checklist, which was acknowledged in subsequent publications (3). A correct etiquette opens the social space for future interactions and creates the first impression about a specific person. In a wider sense, etiquette includes also basic rules in everyday life, for instance, email correspondence which should be polite, formal, and also brief and to the point (4) and phone etiquette with taking a call as quickly as possible, identifying yourself with full name and title and showing willingness to listen intently to the other party. Etiquette may also include maintaining poise in difficult situations, e.g., when exposed to disruptive behavior of the other party, it is essential not to react in the same manner (5). A correct etiquette is the basis for every pediatric anesthesiologist like the posture and sheet music for a piano player. This is just the indispensable prerequisite for every high-level performance on the scene. Fortunately, training an etiquettebased approach is feasible and even easy by using a very clear checklist. A novice can practice it without problems already and it can simply be tested. As always, success is most granted when the teachers are trained first and then the trainees. Parents and children, however, expect much more than a correct etiquette from the pediatric anesthesiologist. They desire to have a compassionate doctor, who is able to recognize the suffering of the child and to understand the whole family. Some people believe that this belongs exclusively to the category of attitudes, like honesty or reliability. To some extent, with respect to attitudes, trainees are thought to be unteachable. However, this is only partly true and some aspects can be coached, e.g., following up a patient postoperatively or avoiding handovers whenever possible. Surprisingly, specialty expertise, procedural, and clinical competence is not a significant area of discussion in this paper (1). It is simply taken as implicitness by parents, nurses, and surgeons. Nevertheless, it is an important issue because a pediatric anesthesiologist has to be able to provide good and safe patient’s care and hence, to master the most difficult clinical situations. Happily, already today, common training programs focus on this goal to achieve an optimal clinical performance. A pediatric anesthesiologist should be dedicated to his profession and always be trying to perform at the highest possible level. Every step should be carried out in a perfect way, and every detail counts, even if it seems to be unimportant at first glance. Apparently, today, we can improve the outcome only by the aggregation of marginal gains. Like in sports such as cycling, where when everything is improved even only by a small amount, one can finally end up as the winner (6). Best possible care of children can be achieved when individual competence and institutional expertise go hand in hand in a sustainable manner, including lifelong learning and sincere safety culture. What reflects good practice today may not be any more correct tomorrow. With the intention to give some precise advice, this editorial concludes with the words of the senior German anesthesiologist, Bernd Landauer, presuming that the keys for a successful professional life and probably, more in general, for a successful private life too, include the following points:

Metamizole for Postoperative Pain Therapy in Infants Younger than 1 Year.

Background Due to possible serious adverse drug reactions (ADRs), the use of metamizole for postoperative pain therapy in infants is a subject of debate. Safety studies with large sample sizes are missing. Aim This prospective multicenter observational study was conducted to evaluate the use of metamizole in infants younger than 1 year undergoing surgery with a particular focus on possible serious ADRs (e.g., hemodynamic, anaphylactic or respiratory reactions, and agranulocytosis). Methods Infants aged up to 1 year (American Society of Anesthesiologists [ASA] I‐III) receiving a single dose of metamizole for postoperative pain therapy were enrolled. Patient demographics, main and secondary diagnosis, surgical procedures performed, metamizole dose, hemodynamic data, use of other analgesics and regional blocks, results of pain measurement, and incidence of ADRs were documented using a standardized case report form. Results A total of 316 infants observed at five pediatric centers were included for analysis (age 4.4 ± 3.7 [0.06‐12] months). Mean metamizole dose was 17.8 ± 3.1 (9.2‐29.8) mg·kg‐1. Mean arterial pressure (MAP) remained stable during metamizole infusion (MAP before infusion 45 ± 9.5 [25‐95] and after infusion 45 ± 9.2 [25‐99] mm Hg). Erythema was observed in one patient (ADRs total: 0.3%, 95% confidence interval: 0.27‐0.32). No respiratory adverse events directly related to the metamizole administration and no clinical signs of agranulocytosis were reported. Conclusion Single intravenous doses of metamizole used for prevention or treatment of postoperative pain were safe in more than 300 infants younger than 1 year. The statistical probability of serious ADRs (e.g., hemodynamic, anaphylactic or respiratory reactions) was lower than 1%. The sample size and follow‐up were not sufficient to detect agranulocytosis.