Linda J. Mason

Complications in paediatric anaesthesia.

Purpose of review Many regional anaesthesia techniques as well as central venous access in paediatric patients are still described insufficiently. This review article describes the basics in small part ultrasonography and highlights new developments in ultrasonographic-guided regional anaesthetic techniques and vascular access. Recent findings Ultrasonographic guidance for regional anaesthesia and vascular access has been shown to be suitable for paediatric anaesthesia. Particular neonates and babies may profit from direct ultrasonographic visualization of anatomical structures during invasive procedures. Advantages of ultrasonographic-guided regional anaesthesia are high success rates, improved block qualities and well tolerated avoidance of complications. Ultrasonographic guidance for vascular access in children is clearly recommended by the National Institute for Clinical Excellence guidelines. Summary Regional anaesthesia and vascular access under ultrasonographic guidance offers significant advantages and improved safety. Additional education and hand skills, extensive experience and adequate equipment are necessary for the effective implementation of these methods in the daily clinical practice.

Brain temperature: heat production, elimination and clinical relevance

Neurological insults are a leading cause of morbidity and mortality, both in adults and especially in children. Among possible therapeutic strategies to limit clinical cerebral damage and improve outcomes, hypothermia remains a promising and beneficial approach. However, its advantages are still debated after decades of use. Studies in adults have generated conflicting results, whereas in children recent data even suggest that hypothermia may be detrimental. Is it because brain temperature physiology is not well understood and/or not applied properly, that hypothermia fails to convince clinicians of its potential benefits? Or is it because hypothermia is not, as believed, the optimal strategy to improve outcome in patients affected with an acute neurological insult? This review article should help to explain the fundamental physiological principles of brain heat production, distribution and elimination under normal conditions and discuss why hypothermia cannot yet be recommended routinely in the management of children affected with various neurological insults.

Airway management in two of newborns with Pierre Robin Sequence : the use of disposable vs multiple use LMA for fiberoptic intubation

In this article, we discuss the use of LMAs as a conduit to intubate the trachea of two Pierre Robin Sequence infants. Multiple use LMAs will admit larger diameter tracheal tubes (TT) than their disposable counterparts. Increased friction with the surface of the TT makes passing even small diameter tubes through the lumen of the disposable LMA difficult.

An update on the etiology and prevention of anesthesia‐related cardiac arrest in children

The etiology of cardiac arrest in the pediatric patient has changed over the past 20 years as practice has evolved in the care of these patients. The Pediatric Closed Claims Study in 1993 showed respiratory events were the most common category accounting for 43% of claims with inadequate ventilation seen in half of the respiratory events. The typical profile in this category of inadequate ventilation were healthy, nonobese children breathing halothane spontaneously whose arrest was preceded by hypotension or bradycardia. These children were difficult to resuscitate successfully, 70% died and 30% had permanent central nervous system impairment. Pulse oximetry was used in 7% of the Closed Claim cases and capnometry in 5% (1).

Pediatric cardiac emergencies.

Successful management of pediatric cardiac emergencies requires an accurate diagnosis to institute an appropriate plan of therapy. The diagnosis, however, is not always straightforward, as evidenced by the nonspecific clinical picture that can be presented by congenital heart defects. Entertaining the possibility of a cardiac problem in neonates with pulmonary symptoms unresponsive to standard therapies is crucial for successful management of patients with congenital heart disease. In addition to ventilatory support, prostaglandin E1 infusions or emergency interventional cardiac catheterization is often a life-saving initial measure in patients with acutely decompensated congenital cardiac lesions that require a patent ductus arteriosus for survival. Pericardial tamponade is associated with various acquired and iatrogenic causes. Emergent pericardiocentesis is mandatory when cardiovascular compromise occurs. The goal of anesthetic management is to maintain cardiac output. With the increasing use of central venous catheters in neonatal ICUs and the high mortality rate for central venous catheter-related cardiac tamponade, the diagnosis must be considered in any patient with a central venous catheter in situ who acutely develops unexplained hypotension, bradycardia, and diminished pulses. Arrhythmias also can cause hemodynamic instability in infants and children. Supraventricular tachycardia is by far the most common emergently presenting arrhythmia in the pediatric population. Unstable patients require immediate intravenous adenosine or synchronized cardioversion. Complete heart block is rare, but it can lead to congestive heart failure and occasionally to cardiovascular collapse and sudden death. Emergency treatment of complete heart block includes pharmacologic support and temporary or permanent pacemaker placement as indicated. In infants, congestive heart failure usually is related to congenital heart disease, whereas in older children, it tends to be secondary to an acquired cause. Supportive measures, fluid restriction, and inotropic support are the principles of initial treatment. Prompt recognition and initiation of appropriate therapy in pediatric cardiac emergencies are essential for favorable outcomes.

Preoperative Evaluation, Premedication, and Induction of Anesthesia

Abstract Adequate preparation of children for anesthesia allows optimization of medical conditions and leads to decreased morbidity. The medical history and laboratory testing obtained preoperatively aid the anesthesiologist in determining readiness for the planned surgery. Preparedness begins with adherence to a preoperative fasting schedule for elective surgery, selecting appropriate premedication, formulating an anesthetic plan and anticipating postoperative concerns. There are a variety of techniques for inducing general anesthesia. The technique used depends on a number of factors including the childs developmental age, understanding and ability to cooperate, previous experiences, the presence of a parent and the interaction of these factors with the childs underlying medical or surgical conditions. This chapter discusses special problems encountered in the pediatric population that require additional considerations from anesthesiologists. The preoperative period can be a stressful time for the fearful child and for those with autism spectrum disorders thus requiring the anesthesiologist to tailor the approach to meet the childs needs. Other challenges that pediatric patients present include respiratory system conditions such as obstructive sleep apnea syndrome, bronchopulmonary dysplasia, difficult airway, upper respiratory tract infections and apnea in former preterm infants. Additional conditions that are discussed include diabetes, seizure disorders, and sickle cell disease. Finally, the detection of a cardiac murmur, anemia or a fever before elective surgery will present a dilemma whether to proceed. The preoperative visit is an essential component of identifying the pediatric patients needs and devising a plan that leads to a superior patient experience, a decrease in the number of cancellations and improved outcomes.

Challenges in paediatric ambulatory anesthesia.

PURPOSE OF REVIEW Clinical studies and new guidelines are frequently being published in the area of preoperative fasting. A growing population of patients with obstructive sleep apnea is being referred for outpatient procedures including adenotonsillectomy. RECENT FINDINGS Recently published preoperative fasting guidelines for pediatric patients are covered along with studies comparing gastric volume following different fasting intervals. Pediatric obstructive sleep apnea is discussed. Clinical presentation, severity, perioperative risks, and controversies as whether outpatient procedures are suitable for these patients are presented. New data covering different perioperative aspects are presented. SUMMARY A more liberal preoperative intake is encouraged with fasting for 2 h for clear liquids, 4  h for breast milk, 6  h for formula and light meals, and 8  h for heavy meals is widely accepted. Interpersonal variation in residual gastric volume exists. Children with obstructive sleep apnea under 3 years of age and those with severe obstructive sleep apnea and comorbidities are not candidates for ambulatory surgery. Polysomnography has specific preoperative indications. Dexmedetomidine can decrease emergence agitation and has an opioid-sparing effect. Intravenous acetaminophen is presented as an opioid-sparing analgesic. Dexamethasone is effective in preventing postoperative nausea without increased risk of bleeding. Surgical techniques may affect postoperative pain.

Analgesic effectiveness of acetaminophen for primary cleft palate repair in young children: a randomized placebo controlled trial

Clefting of the lip, palate, or both is a common congenital abnormality. Inadequate treatment for pain in children may result from concerns over opioid‐related adverse effects. Providing adequate pain control with minimal adverse effects remains challenging in children.

Effects of hemodilution after traumatic brain injury in juvenile rats

Background:  Normovolemic hemodilution (HD) in adult animal studies has shown exacerbation of traumatic brain injury (TBI) lesion volumes. Similar studies in juvenile rats have not been reported and outcomes are likely to be different. This study investigated the effects of normovolemic hemodilution (21% hematocrit) in a juvenile TBI (jTBI) model.

CHAPTER 4 – Preoperative Evaluation, Premedication, and Induction of Anesthesia

clear fluids from the stomach is approximately 15 minutes (Fig. 4.1); as a result, 98% of clear fluids exit the stomach in children by 1 hour. Clear liquids include water, fruit juices without pulp, carbonated beverages, clear tea, and black coffee. Although fasting for 2 hours after clear fluids ensures nearly complete emptying of the residual volume, extending the fasting interval to 3 hours introduces flexibility in the operative schedule. The potential benefits of a 2-hour fasting interval after clear fluids include a reduced risk of hypoglycemia, which is a real possibility in children who are debilitated, have chronic disease, are poorly nourished, have metabolic dysfunction, or are preterm or formerly preterm infants. Additional benefits include decreased thirst, decreased hunger (and thus reduced temptation that the fasting child will “steal” another child’s food), decreased risk for hypotension during induction, and improved child cooperation. A scheduled operation on a preterm infant or neonate may occasionally be delayed, thus extending the period of fasting to a point that could be potentially dangerous (i.e., from hypoglycemia or hypovolemia). In this circumstance, the infants should be given glucose-containing intravenous (IV) maintenance fluids before induction of anesthesia. Alternatively, if the period may be protracted, the infant should be offered clear fluids orally until 2 hours before induction. Breast milk, which can cause significant pulmonary injury if aspirated, has a very high and variable fat content (determined by maternal diet), which will delay gastric emptying. Breast milk should not be considered a clear liquid. Two studies estimated the gastric emptying times after clear fluids, breast milk, or formula in full-term and preterm neonates. The emptying times for Preparation of Children for Anesthesia