Martin Jöhr

Inhalational anesthesia vs total intravenous anesthesia (TIVA) for pediatric anesthesia

Despite extensive research and development within the speciality, inhalation anesthesia remains by far the most commonly used technique in pediatric anesthesia. Volatile agents have their drawbacks, but until quite recently, techniques such as total i.v. anesthesia remained largely in the research domain. The advent of improved drugs, better understanding of pharmacokinetic ⁄ pharmacodynamic interaction, and simpler, age specific delivery systems are beginning to challenge the dominance of inhalation techniques in specific situations. Whether the benefits of total intravenous anesthesia (TIVA) can be harnessed and developed further to become the routine technique of choice in the future remains to be seen. In this paper, we objectively examine the arguments for and against inhalation and TIVA and look at where both techniques could be better adapted in the pediatric population.

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.

Caudal blocks: Caudal blocks

Caudal anesthesia is the single most important pediatric regional anesthetic technique. The technique is relatively easy to learn (1), has a remarkable safety record (2), and can be used for a large variety of procedures. The technique has been reviewed in the English (3) and French (4) literature, as well as in German guidelines (5) and in pediatric anesthesia textbooks (6).

Fiberoptic intubation through the laryngeal mask airway (LMATM) as a standardized procedure

(spinal, epidural, caudal) versus general anaesthesia in preterm infants undergoing inguinal hernioraphy in early infancy. Cochrane Database Syst Rev 2003; 3: CD003669. 3 Sartorelli KH, Abajian JC, Kreutz JM, et al. Improved outcome utilizing spinal anesthesia in high-risk infants. J Pediatr Surg 1992; 27: 1022–1025. 4 William JM, Stoddart PA, Williams SA, et al. Post-operative recovery after inguinal herniotomy in ex-premature infants: comparison between sevoflurane and spinal anaesthesia. Br J Anaesth 2001; 86: 366–371.

Generating a learning curve for penile block in neonates, infants and children: an empirical evaluation of technical skills in novice and experienced anaesthetists

Background : Literature concerning learning curves for anaesthesiological procedures in paediatric anaesthesia is rare. The aim of this study was to assess the number of penile blocks needed to guarantee a high success rate in children.

Pro con debate: the use of regional vs systemic analgesia for neonatal surgery

In recent years the inclusion of regional techniques to pediatric anesthesia has transformed practice. Simple procedures such as caudal anesthesia with local anaesthetics can reduce the amounts of general anesthesia required and provide complete analgesia in the postoperative period while avoiding large amounts of opioid analgesia with potential side effects that can impair recovery. However, the application of central blocks (epidural and spinal local anesthesia) via catheters in the younger infant, neonate and even preterm neonate remains more controversial. The potential for such invasive maneuvers themselves to augment risk, can be argued to outweigh the benefits, others would argue that epidural analgesia can reduce the need for postoperative ventilation and that this not only facilitates surgery when intensive care facilities are limited, but also reduces cost in terms of PICU stay and recovery profile. Currently, opinions are divided and strongly held with some major units adopting this approach widely and others maintaining a more conservative stance to anesthesia for major neonatal surgery. In this pro‐con debate the evidence base is examined, supplemented with expert opinion to try to provide a balanced overall view.

Anaesthesia for the child with a full stomach.

Pulmonary aspiration Perioperative pulmonary aspiration of gastric contents can occur in paediatric patients [1,2], and is occasionally associated with significant morbidity. Overall, however, the sequelae appear less severe than those in adult surgical patients, among whom fatalities are reported in most series [3–5]. In a large series of 63 180 general anaesthetic procedures in paediatric patients, 24 cases of aspiration occurred (1 : 2632 anaesthetics), only nine of these patients developed symptoms, only five needed respiratory support, and no patient died [1]. Interestingly, and of practical clinical importance, no patient without signs of respiratory compromise at 2 h developed symptoms in the later postoperative course. Patients scheduled for emergency procedures are exposed to risk that is up to 10 times higher. Although catastrophic outcomes following pulmonary aspiration in children are rare, relevant morbidity can occur [6], and all necessary precautions must be taken to identify those patients who are at risk and to avoid this complication.

Regional anaesthesia in neonates, infants and children: an educational review.

Prophylactic analgesia with local anaesthesia is widely used in children and has a good safety record. Performing regional blocks in anaesthetised children is a safe and generally accepted practice. When compared with adults, lower concentrations of local anaesthetics are sufficient in children; the onset of a block occurs more rapidly but the duration is usually shorter. Local anaesthetics have a greater volume of distribution, a lower clearance and a higher free (non-protein-bound) fraction. The recommended maximum dose has to be calculated for every individual. Peripheral blocks provide analgesia restricted to the site of surgery, and some of them have a very long duration of action. Abdominal wall blocks, such as transverse abdominis plane or ilio-inguinal nerve block, should be performed with the aid of ultrasound. Caudal anaesthesia is the single most important technique. Ropivacaine 0.2% or levobupivacaine 0.125 to 0.175% at roughly 1 ml kg−1 is adequate for most indications. Clonidine and morphine can be used to prolong the duration of analgesia. Ultrasound is not essential for performing caudal blocks, but it may be helpful in case of anomalies suspected at palpation and for teaching purposes. The use of paediatric epidural catheters will probably decline in the future because of the potential complications.

Congenital laryngotracheo-oesophageal cleft: successful ventilation with the Laryngeal Mask AirwayTM

A congenital laryngotracheo‐oesophageal cleft is a rare airway malformation which results from incomplete separation of the larynx and trachea from the hypopharynx and oesophagus. Patients usually present with stridor, aspiration and cyanosis associated with feeding. For early diagnosis, a high index of suspicion is needed. Unless an appropriate diagnostic approach is taken, the diagnosis can be missed. The successful ventilation of a neonate with the Laryngeal Mask AirwayTM is described.

Psoas compartment block in children: Part I--description of the technique.

Background : Until recently only small series of psoas compartment blocks (PCB) in children have been reported. A high incidence of epidural spread as an important side effect was noted. A series of 100 consecutive blocks using new standardized landmarks is reported.