Mark S. Schreiner

Ingestion of liquids compared with preoperative fasting in pediatric outpatients

The preoperative fast is often an unpleasant preoperative experience that might be alleviated by allowing children to drink clear liquids. The authors compared gastric fluid volume and pH in two groups of children, one of whom was permitted clear liquids until 2 h before surgery (study group) and the other followed routine preoperative fasting orders (control group). The study group was not limited in the quantity of clear liquid allowed with the exception that the last intake prior to surgery was limited to 8 ounces. The study group (n = 53) averaged 5.9 +/- 5 yr and weighed 23.6 +/- 17 kg, while the control group averaged 7.3 +/- 4.6 yr and weighed 29 +/- 17.7 kg (P = NS). Gastric contents were aspirated following induction of anesthesia. Gastric fluid volume averaged 0.44 +/- 0.51 ml/kg for study group and 0.57 +/- 0.51 ml/kg in the control group (P = 0.12). Of the study patients, 48% had a measured gastric fluid volume greater than or equal to 0.4 ml/kg compared with 58% of the control patients (P = 0.77). Eighty three patients had sufficient gastric fluid for pH determination; of these 34/35 (97%) in the study group and 44/48 (92%) in the control group had a gastric fluid pH less than or equal to 2.5. Using a linear analog scale parents rated the children in the study group to be less irritable (P less than 0.001) and to have had a better overall preoperative experience (P less than 0.01) compared with the control patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Do Children Who Experience Laryngospasm Have an Increased Risk of Upper Respiratory Tract Infection

Background Laryngospasm is the most frequently reported respiratory complication associated with upper respiratory infection and general anesthesia in retrospective studies, but prospective studies have failed to demonstrate any increase in risk. Methods A case-control study was performed to examine whether children with laryngospasm were more likely to have an upper respiratory infection on the day of surgery. The parents of all patients (N = 15,183) who were admitted through the day surgery unit were asked if their child had an active or recent (within 2 weeks of surgery) upper respiratory infection and were questioned about specific signs and symptoms to determine if the child met Tait and Knights definition of an upper respiratory infection. Control subjects were randomly selected from patients whose surgery had occurred within 1 day of the laryngospasm event. Results Patients who developed laryngospasm (N = 123) were 2.05 times (95% confidence interval 1.21-3.45) more likely to have an active upper respiratory infection as defined by their parents than the 492 patients in the control group (P less or equal to 0.01). The development of laryngospasm was not related to Tait and Knights definition for an upper respiratory infection or to recent upper respiratory infection. Children with laryngospasm were more likely to be younger (odds ratio = 0.92, 95% confidence interval 0.87-0.99), to be scheduled for airway surgery (odds ratio = 2.08, 95% confidence interval 1.21-3.59), and to have their anesthesia supervised by a less experienced anesthesiologist (odds ratio = 1.69, 95% confidence interval 1.04-2.7) than children in the control group. Conclusion Laryngospasm was more likely to occur in children with an active upper respiratory infection, children who were younger, children who were undergoing airway surgery, and children whose anesthesia were supervised by less experienced anesthesiologists. Understanding the risk factors and the magnitude of the likely risk should help clinicians make the decision as to whether to anesthetize children with upper respiratory infection.

Lighted Stylet Tracheal Intubation: A Review

Tracheal intubation is older than the recognized his-tory of general anesthesia itself. In the late 18th cen-tury, The Royal Humane Society of London used tra-cheal intubation for resuscitating the near-drowned.Approximately 100 years later, MacEwan (1) per-formed a digital tracheal intubation in an awake pa-tient before a chloroform and air general endotrachealanesthetic for the resection of a tongue tumor, and in1928, Magill (2) incorporated blind nasal tracheal in-tubation as a part of a general anesthetic. Althoughlaryngoscopes were invented in the 19th century, tra-cheal intubation under direct visualization was greatlyenhanced by the development of a special laryngo-scope blade by Macintosh (3) in 1943.The first reported use of a lighted stylet used tofacilitate intubation came in 1957 when (by now SirRobert) Macintosh (4) described an 18-inch illumi-nated tracheal tube introducer, which was designed tostiffen the tube and better illuminate the cords bysupplementing the light of the laryngoscope. Berman(5) described a similar device in 1959 and said it wasuseful “when the fickle light of the laryngoscope hasgone out at the most inopportune time.” In the sameyear, Yamamura et al. (6) described a light bulb-tippedwire that was inserted into the tracheal tube beforeblind nasal intubation in awake patients. The tubeposition was then determined by the medial transillu-mination of the external throat and neck.In 1977, Foster (7) used a transilluminating fiberop-tic bundle to facilitate tracheal intubation in a youngchild with trismus, and Ducrow (8), in the followingyear, used a flexible surgical light (Flexi-lum™, Con-cept Corporation, Clearwater, FL) to achieve the sameend by first passing a guide (two plastic suction cath-eters connected end-to-end) into the trachea followedby passage of the tracheal tube over the guide. In acorrespondence to the latter article, Rayburn (9) com-mented that the Flexi-lum™ could be positioned in-side the tracheal tube, thereby shortening the intuba-tion sequence and claimed that the technique,nicknamed “lightwand intubation,” had been used forsome years at the Brooke Army Medical Center.

Practice guidelines for postanesthetic care: an updated report by the American Society of Anesthesiologists Task Force on Postanesthetic Care.

RACTICE Guidelines are systematically developed recommendations that assist the practitioner and patient in making decisions about health care. These recommendations may be adopted, modified, or rejected according to clinical needs and constraints, and are not intended to replace local institutional policies. In addition, Practice Guidelines developed by the American Society of Anesthesiologists (ASA) are not intended as standards or absolute requirements, and their use cannot guarantee any specific outcome. Practice Guidelines are subject to revision as warranted by the evolution of medical knowledge, technology, and practice. They provide basic recommendations that are supported by a synthesis and analysis of the current literature, expert and practitioner opinion, open forum commentary, and clinical feasibility data. This document updates the “Practice Guidelines for Postanesthetic Care: A Report by the American Society of Anesthesiologists Task Force on Postanesthetic Care,” adopted by the ASA in 2001 and published in 2002.*

Variation in Standards of Research Compensation and Child Assent Practices: A Comparison of 69 Institutional Review Board–Approved Informed Permission and Assent Forms for 3 Multicenter Pediatric Clinical Trials

OBJECTIVE. To systematically compare standards for compensation and child participant assent in informed permission, assent, and consent forms (IP-A-CFs) approved by 55 local institutional review boards (IRBs) reviewing 3 standardized multicenter research protocols. METHOD. Sixty-nine principal investigators participating in any of 3 national, multicenter clinical trials submitted standardized research protocols for their trials to their local IRBs for approval. Copies of the subsequently IRB-approved IP-A-CFs were then forwarded to an academic clinical research organization. This collection of IRB-approved forms allowed for a quasiexperimental retrospective evaluation of the variation in informed permission, assent, and consent standards operationalized by the local IRBs. RESULTS. Standards for compensation and child participant assent varied substantially across 69 IRB-approved IP-A-CFs. Among the 48 IP-A-CFs offering compensation, monetary compensation was offered by 33 as reimbursement for travel, parking, or food expenses, whereas monetary or material compensation was offered by 22 for subject inconvenience and by 13 for subject time. Compensation ranged widely within and across studies (study 1,

An evaluation of the efficacy and tolerability of oral tramadol hydrochloride tablets for the treatment of postsurgical pain in children.

180–1425; study 2,

Preoperative fasting in children.

0–500; and study 3,

A Single Dose of Morphine Sulfate Increases the Incidence of Vomiting after Outpatient Inguinal Surgery in Children

0–100). Regarding child participant assent, among the 57 IP-A-CFs that included a form of assent documentation, 33 included a line for assent on the informed permission or consent form, whereas 35 included a separate form written in simplified language. Of the IP-A-CFs that stipulated the documentation of assent, 31 specified ≥1 age ranges for obtaining assent. Informed permission or consent forms were addressed either to parents or child participants. CONCLUSION. In response to identical clinical trial protocols, local IRBs generate IP-A-CFs that vary considerably regarding compensation and child participant assent.

Preoperative oral dextromethorphan does not reduce pain or analgesic consumption in children after adenotonsillectomy.

In this double-blinded, randomized, multicenter study, we examined analgesic efficacy and tolerability of tramadol in postoperative pediatric patients. Eighty-one postsurgical ASA physical status I and II patients ages 7–16 yr received oral tramadol (approximately 1 or 2 mg/kg) for postoperative analgesia when they were ready to transition from morphine patient-controlled analgesia to oral analgesics. Rescue analgesia consisted of morphine patient-controlled analgesia or an oral equivalent dose of oxycodone. Patients rated their pain just before the administration of tramadol and at regular intervals for 8 h afterwards using the Wong-Baker Faces Pain Rating Scale. The 2-mg/kg group required approximately half as much rescue analgesia as the 1-mg/kg group (P = 0.006). Parents rated the larger dose more favorably. Adverse events were generally mild to moderate in severity (vomiting [10%], nausea [9%], pruritus [7%], rash [4%]) and similar between the two treatment groups. There were no significant changes in hemodynamic variables, respiratory rate, or Spo2 percentages between the two treatment groups or in all patients compared with pretreatment values.

A comparison of awake versus paralyzed tracheal intubation for infants with pyloric stenosis

Children undergo a preoperative fast in an attempt to minimize the fluid and solid food component of gastric contents. The importance of a preoperative fast was acknowledged early in the evolution of anesthesia as a discipline of medicine. In response to concerns about the aspiration of gastric contents, a prolonged fast presumably came into vogue. With this practice, it was not unusual to have hungry, irritable children who were prone to hypoglycemia after fasts of 8 ‐12 h or even longer. The purpose of this article is to provide the reader with a narrative review of the literature pertaining to preoperative fasting in children. This article is primarily focused on randomized controlled trials (RCTs), but when not available, literature of lesser intensity was used. We present the physiology of gastric emptying with an emphasis on studies focusing on children in the perioperative period. These studies of gastric emptying were, when possible, divided into studies involving solid food and those involving clear fluids. We then present preoperative fasting of children, which was subdivided by age (neonates, infants, toddlers, and adolescents) and by health (elective versus emergent surgery and healthy versus medically compromised patients). In the concluding portions of this review, we present recommendations for the management of perioperative fasting and recommendations with respect to the need for more research, as more questions remain unanswered than those that have been answered. During preparation of this article, we accepted several links. The linkage between gastric fluid volume and aspiration pneumonia for healthy patients has recently been examined by an ASA taskforce, which concluded that the available data were insufficient to confirm or deny a relationship. Although this means that gastric fluid volume is a surrogate end point for aspiration pneumonia, virtually all studies examining preoperative feeding practices have gastric residual volume as their primary end point. For the purpose of this review, we focus on the end point of gastric residual volume, which is the almost exclusive choice of numerous peer-reviewed investigations. Furthermore, in the practice of anesthesia, patients undergoing emergency surgery have increased gastric contents and are at increased risk of aspiration pneumonia. This is an established link, and if we were to refute it, we would deny the need for rapid-sequence induction plus appropriate airway management during general anesthesia for emergency surgery. Although increased gastric contents increase the risk of aspiration pneumonia, there is no known gastric fluid volume that places a particular patient at clinically relevant risk or eliminates all risk.