Melissa Wheeler

MANAGEMENT STRATEGIES FOR THE DIFFICULT PEDIATRIC AIRWAY

Strategies for managing the difficult pediatric airway can be divided into two broad categories: the anticipated difficult airway and the unexpected difficult airway. The unexpected difficult airway can be subdivided into the nonemergency (can ventilate/cannot intubate) and emergency pathways (cannot ventilate/cannot intubate). These classifications, however, are not static. Either the anticipated difficult airway or the nonemergency pathway of the unexpected difficult airway can degrade during the course of management into the emergency pathway. The best strategies are designed to avoid this scenario but still provide a contingency plan should this occur. The suggested management strategies are based on the American Society of Anesthesiologists (ASA) practice guidelines, 1 clinical case reports of management of the pediatric patient with the difficult airway, and clinical experience; the lists provide an overview. A detailed discussion of options and techniques is provided in the text. Although broad, this is not an all-inclusive discussion, and other approaches may be appropriate. The division of the tasks into categories is an organizational tool for presentation and a guide in developing a reasonable approach to the pediatric patient with a difficult airway. Some tasks have overlapping concerns and some may be undertaken simultaneously.

Patient-controlled Epidural Analgesia in Children: Can They Do It?

Extensive clinical experience and many studies support the use of IV patient-controlled analgesia (IV PCA) and regional anesthesia techniques for the treatment of postoperative pain in children. In contrast, little has been reported about the ability of children to use patient-controlled epidural analgesia (PCEA) or about the efficacy of this technique. We report a descriptive analysis of prospectively recorded data in 128 children (132 procedures) in whom PCEA was used for acute postoperative pain control. Satisfactory analgesia was obtained in 119 patients (90.1%) for up to 103 h with no episodes of desaturation and without clinical evidence of toxicity or serious adverse effects. Analgesia was satisfactory with the initial settings in 89 patients; in 38 others, this was achieved with changes in PCEA settings or solution. Five patients were switched to IV PCA because of inadequate analgesia. Eight patients with satisfactory analgesia were converted to IV PCA because of adverse effects. Children as young as 5 yr had the cognitive ability to understand and the willingness to use PCEA, consistent with reported use of IV PCA. Careful attention should be paid to the total hourly local anesthetic dose to avoid exceeding the recommended limits. Our prospectively collected data demonstrate that PCEA provides satisfactory analgesia with a small incidence of adverse side effects in children and should be considered along with other strategies in pediatric postoperative pain management.

Practical pediatric regional anesthesia

In children, regional anesthetic techniques are safe and effective adjuncts to general anesthesia and for postoperative pain relief. Application of the techniques described in this article will contribute to improved care for pediatric patients undergoing surgical procedures. The judicious choice of local anesthetics, along with the blockades of targeted nerves, decrease the need for supplemental analgesics in the recovery phase.

Age-stratified pharmacokinetics of ketorolac tromethamine in pediatric surgical patients

Published data suggest that ketorolac pharmacokinetics are different in children than in adults. We sought to better characterize ketorolac pharmacokinetics in children. Thirty-six children, aged 1–16 yr, were stratified into four age groups: 1–3 yr, 4–7 yr, 8–11 yr, and 12–16 yr. Each child received 0.5 mg/kg of ketorolac tromethamine IV after completion of elective surgery. A maximum of 16 venous blood samples (mean, 13 ± 2) were collected at predetermined times up to 10 h after drug administration. Plasma ketorolac concentrations were measured by high-performance liquid chromatography after solid-phase extraction. Individual concentration-versus-time relationships were best fit to a two-compartment pharmacokinetic model by using SAAM II. Body weight-normalized pharmacokinetic variables did not differ among the age groups and were similar to those reported for adults, including a volume of distribution at steady state of 113 ± 33 mL/kg (mean ± sd) and an elimination clearance of 0.57 ± 0.17 mL · min−1 · kg−1. Our study demonstrates that a single dose of ketorolac (0.5 mg/kg) results in plasma concentrations in the adult therapeutic concentration range for 6 h in most children. Our data provide no evidence that children require either larger weight-adjusted doses or shorter dosing intervals than adults to provide similar plasma drug concentrations.

ProSealTM laryngeal mask airway in 120 pediatric surgical patients: a prospective evaluation of characteristics and performance

Background:  The ProSealTM LMA (PLMATM) has recently been introduced in pediatric sizes (1.5, 2, 2.5, 3). Limited pediatric data have been published.

Intravenous ondansetron in established postoperative emesis in children

Background In pediatric postsurgical patients, postoperative vomiting is a common occurrence that can delay recovery and result in unplanned hospital admissions after outpatient surgery. This randomized, double‐blind, placebo‐controlled, multicenter study evaluated the efficacy and safety of ondansetron in the control of established postoperative emesis in outpatients aged 2–12 yr. Methods Screened for the study were 2,720 ASA physical status 1–3 children undergoing outpatient surgery during general anesthesia, which included nitrous oxide. Children experiencing two emetic episodes within 2 h of discontinuation of nitrous oxide were given intravenous ondansetron (n = 192; 0.1 mg/kg for children weighing less or equal to 40 kg; 4 mg for children weighing > 40 kg) or placebo (n = 183). Results The proportion of children with no emetic episodes and no use of rescue medication was significantly greater (P < 0.001) in the ondansetron group compared with placebo for both 2‐ and 24‐h periods after study drug administration (78% of the ondansetron group and 34% of the placebo group for 2 h; 53% of the ondansetron group and 17% of the placebo group for 24 h). Among patients with at least one emetic episode or with rescue medication use, the median time to onset of emesis or rescue was 127 min in the ondansetron group compared with 58 min in the placebo group (P < 0.001). The median time from study drug administration until discharge was significantly shorter (P < 0.01) in the ondansetron group (153 min, range 44–593 min) compared with the placebo group (173 min, range 82–622 min). The incidence of potentially drug‐related adverse events was similar in the ondansetron (3% of patients) and the placebo (4% of patients) groups. Conclusion A single dose of ondansetron (0.1 mg/kg up to 4 mg) is effective and well tolerated in the prevention of further episodes of postoperative emesis in children after outpatient surgery. Administration of ondansetron also may result in a shorter time to discharge.

Premedication of pediatric tonsillectomy patients with oral transmucosal fentanyl citrate

We assessed the safety and efficacy of oral transmucosal fentanyl citrate (Fentanyl Oralet[registered sign]; Abbott Laboratories, Abbott Park, IL), administered preoperatively to provide both preoperative sedation and postoperative analgesia, in a randomized, double-blind, placebocontrolled study in 40 children, 2-10 yr of age, scheduled for tonsillectomy. In the preoperative holding area, one group (Group O) received Fentanyl Oralet[registered sign] (fentanyl 10-15 micro g/kg), and the other (Group IV) received only the candy matrix. Patients in Group O received an IV injection of saline, and those in Group IV received an IV injection of fentanyl (2 micro g/kg) after removal of the first tonsil. Except for the opioid, patients received a standard anesthetic. Preoperative sedation and cooperation were assessed. Postoperative pain was evaluated using an objective pain scale. Patients in Group O were more sedated but no more cooperative at the induction of anesthesia compared with those in Group IV. No patient vomited preoperatively or experienced preoperative or postoperative desaturation. Time to postanesthesia care unit (PACU) discharge was not different between groups. There was no significant difference in the number of patients requiring morphine in the PACU (6 of 21 in Group O versus 10 of 19 in Group IV). Plasma fentanyl concentrations were not a reliable indicator of the need for postoperative morphine. Among the patients who required morphine postoperatively, there was an 11-fold variation in plasma fentanyl concentrations at the time of morphine administration. Derived pharmacokinetic parameters were similar to those previously reported in children; bioavailability of the fentanyl in Fentanyl Oralet[registered sign] was 0.33. We conclude that premedication with Fentanyl Oralet[registered sign] did not differ with IV fentanyl in regard to the induction of anesthesia and postoperative analgesia. Implications: In this double-blind, randomized study, we studied the efficacy of Fentanyl Oralet[registered sign] (10-15 micro g/kg) preoperatively for providing postoperative analgesia in children undergoing tonsillectomy. We found no incidence of preoperative desaturation or vomiting in any patient. This is in contrast to other studies, in which there was a longer time interval between Fentanyl Oralet[registered sign] completion and induction of anesthesia. The bioavailability of the fentanyl in Fentanyl Oralet[registered sign] was estimated to be 33%, which is less than that reported in adults (approximately 50%). There was no difference in postoperative opioid requirements between patients who received 2 micro g/kg of fentanyl IV and those who received Fentanyl Oralet[registered sign].

Uptake pharmacokinetics of the Fentanyl Oralet® in children scheduled for central venous access removal: implications for the timing of initiating painful procedures

Summary Background: The Fentanyl Oralet® (Abbott Laboratories, Abbott Park, IL, USA) is an oral transmucosal drug delivery system. We previously examined pharmacokinetic parameters of children who had completed consumption of the Fentanyl Oralet®. The present study was designed to clarify pharmacokinetic parameters during the consumption phase to determine if there is an optimal administration time before painful procedures.

Do latex precautions in children with myelodysplasia reduce intraoperative allergic reactions

Children with myelodysplasia have an increased incidence of latex allergy, which can lead to severe intraoperative allergic reactions. Despite widespread recommendations to avoid intraoperative latex exposure, little evidence exists to support the efficacy of this practice. We examined the incidence of intraoperative allergic reactions in children with myelodysplasia who underwent 1,025 operations in a 36-month period before and after institution of a standardized latex-avoidance protocol. Risk factors for an intraoperative reaction were found to be a history of latex allergy (p = 0.001) and surgery performed before institution of the latex-avoidance protocol (p = 0.01). The estimate of increased risk for allergic reaction was 3.09 times higher in cases performed without latex avoidance. Recognized violation of the protocol after its institution led to severe allergic reactions in three patients. Our experience suggests that a latex-avoidance protocol reduces intraoperative allergic reactions in children with myelodysplasia. Development of severe allergic reactions with violation of the protocol reinforces the importance of vigilance on the part of all operating room personnel in its implementation.

Case series: IV regional anesthesia with ketorolac and lidocaine: Is it effective for the management of complex regional pain syndrome 1 in children and adolescents?

IMPLICATIONS We report our experience with ketorolac/lidocaine IV regional anesthesia (Bier block) (IVRA) in two adolescents with complex regional pain syndrome 1. IVRA resulted in complete resolution of symptoms.