Mohamed A. Rehman

The Use of Lidocaine for Preventing the Withdrawal Associated with the Injection of Rocuronium in Children and Adolescents

UNLABELLED We designed this study to examine the incidence and degree of movement after the administration of rocuronium in children and adolescents and to measure the treatment effect of lidocaine for its prevention. One hundred patients (aged 5-18 yr) were randomly assigned to two groups. After general anesthesia was induced with 5 mg/kg thiopental sodium and manual occlusion of venous outflow was performed, one group of patients received 0.1 mL/kg 1% lidocaine i.v.. A second group received 0.1 mL/kg of isotonic sodium chloride solution as a placebo control. Venous outflow occlusion was held for 15 s, released, and immediately followed by the administration of rocuronium 1 mg/kg i.v.. The patients response to rocuronium injection was graded using a 4-point scale. We observed that the incidence of withdrawal was 84% in the placebo group and was significantly decreased to 46% in patients pretreated with lidocaine (P < 0.001). This study demonstrates that the i.v. injection of rocuronium is commonly associated with a withdrawal reaction in anesthetized pediatric patients and that this reaction can be attenuated or eliminated by pretreatment with i.v. lidocaine. IMPLICATIONS Pain on injection of rocuronium in pediatric patients can be alleviated by pretreatment with i.v. lidocaine.

Pulse pressure variation: where are we today?

In the present review we will describe and discuss the physiological and technological background necessary in understanding the dynamic parameters of fluid responsiveness and how they relate to recent softwares and algorithms’ applications. We will also discuss the potential clinical applications of these parameters in the management of patients under general anesthesia and mechanical ventilation along with the potential improvements in the computational algorithms.

Airway management complications in children with difficult tracheal intubation from the Pediatric Difficult Intubation (PeDI) registry: a prospective cohort analysis

BACKGROUND Despite the established vulnerability of children during airway management, remarkably little is known about complications in children with difficult tracheal intubation. To address this concern, we developed a multicentre registry (Pediatric Difficult Intubation [PeDI]) to characterise risk factors for difficult tracheal intubation, establish the success rates of various tracheal intubation techniques, catalogue the complications of children with difficult tracheal intubation, and establish the effect of more than two tracheal intubation attempts on complications. METHODS The PeDI registry consists of prospectively collected tracheal intubation data from 13 childrens hospitals in the USA. We established standard data collection methods before implementing the secure web-based registry. After establishing standard definitions, we collected and analysed patient, clinician, and practice data and tracheal intubation outcomes. We categorised complications as severe or non-severe. FINDINGS Between August, 2012, and January, 2015, 1018 difficult paediatric tracheal intubation encounters were done. The most frequently attempted first tracheal intubation techniques were direct laryngoscopy (n=461, 46%), fibre-optic bronchoscopy (n=284 [28%]), and indirect video laryngoscopy (n=183 [18%]) with first attempt success rates of 16 (3%) of 461 with direct laryngoscopy, 153 (54%) of 284 with fibre-optic bronchoscopy, and 101 (55%) of 183 with indirect video laryngoscopy. Tracheal intubation failed in 19 (2%) of cases. 204 (20%) children had at least one complication; 30 (3%) of these were severe and 192 (19%) were non-severe. The most common severe complication was cardiac arrest, which occurred in 15 (2%) patients. The occurrence of complications was associated with more than two tracheal intubation attempts, a weight of less than 10 kg, short thyromental distance, and three direct laryngoscopy attempts before an indirect technique. Temporary hypoxaemia was the most frequent non-severe complication. INTERPRETATION More than two direct laryngoscopy attempts in children with difficult tracheal intubation are associated with a high failure rate and an increased incidence of severe complications. These results suggest that limiting the number of direct laryngoscopy attempts and quickly transitioning to an indirect technique when direct laryngoscopy fails would enhance patient safety. FUNDING None.

Anesthesia Information Management System Implementation: A Practical Guide

Anesthesia Information Management Systems (AIMS) display and archive perioperative physiological data and patient information. Although currently in limited use, the potential benefits of an AIMS with regard to enhancement of patient safety, clinical effectiveness and quality improvement, charge capture and professional fee billing, regulatory compliance, and anesthesia outcomes research are great. The processes and precautions appropriate for AIMS selection, installation, and implementation are complex, however, and have been learned at each site by trial and error. This collaborative effort summarizes essential considerations for successful AIMS implementation, including product evaluation, assessment of information technology needs, resource availability, leadership roles, and training.

A Review of Analytics and Clinical Informatics in Health Care

Federal investment in health information technology has incentivized the adoption of electronic health record systems by physicians and health care organizations; the result has been a massive rise in the collection of patient data in electronic form (i.e. “Big Data”). Health care systems have leveraged Big Data for quality and performance improvements using analytics—the systematic use of data combined with quantitative as well as qualitative analysis to make decisions. Analytics have been utilized in various aspects of health care including predictive risk assessment, clinical decision support, home health monitoring, finance, and resource allocation. Visual analytics is one example of an analytics technique with an array of health care and research applications that are well described in the literature. The proliferation of Big Data and analytics in health care has spawned a growing demand for clinical informatics professionals who can bridge the gap between the medical and information sciences.

The efficacy of the Storz Miller 1 video laryngoscope in a simulated infant difficult intubation.

BACKGROUND: Several studies have shown video laryngoscopy to be a useful technique in the management of patients in whom glottic exposure by direct laryngoscopy is difficult. We conducted this study as a preliminary investigation comparing the Storz DCI Miller 1 video laryngoscope (VL, Karl Storz GmbH, Tuttlingen, Germany) and direct laryngoscopy with a Miller 1 laryngoscope (DL) in an infant manikin model simulating difficult direct laryngoscopy. We hypothesized that compared with DL, VL would provide a better glottic view but would be associated with a longer time to intubation because of the different skill set required when using video intubation. METHODS: A Laerdal® infant airway management training manikin (Laerdal Medical, Wappingers Falls, NY) was adapted using cloth tape to limit cervical spine mobility. Thirty-two attending pediatric anesthesiologists attempted tracheal intubation of the infant manikin using VL and DL in randomized order. The best laryngeal view with each laryngoscope and time to intubation were documented. RESULTS: There was a significant difference in the distributions of laryngoscopy grades between VL and DL (P < 0.001), with the VL giving a better laryngeal view. Forty percent of anesthesiologists reported a Grade 3 or 4 view with DL; all of which were converted to Grades 1 and 2 with VL. The median grade with interquartile range was two (2-3) for DL and one (1-2) for VL (P < 0.001). Seventy-eight percent of participants reported an improvement of at least one grade in laryngeal view with VL compared with DL. There were two failed intubations using DL and none using VL. Time to intubation was similar between the two techniques. CONCLUSIONS: The Storz Miller 1 VL blade improved glottic exposure in a simulated difficult laryngoscopy compared with direct laryngoscopy with a standard Miller 1 blade without increasing the time to intubation.

Bradycardia During Induction of Anesthesia with Sevoflurane in Children with Down Syndrome

BACKGROUND: Bradycardia is a complication associated with inhaled induction of anesthesia with halothane in children with Down syndrome. Although bradycardia has been reported after anesthetic induction with sevoflurane in these children, the incidence is unknown. OBJECTIVES: In this study we compared the incidence and characteristics of bradycardia after induction of anesthesia with sevoflurane in children with Down syndrome to healthy controls. METHODS: We reviewed electronic anesthetic records of 209 children with Down syndrome and 268 healthy control patients who had inhaled induction of anesthesia with sevoflurane over an 8-year period. Data extracted from the medical record included demographics, history of congenital heart disease, heart rate, oxyhemoglobin saturation, expired sevoflurane concentrations, arterial blood pressure, and any treatment of bradycardia during the first 360 seconds after the start of induction of anesthesia. Bradycardia and hypotension were defined as heart rate and arterial blood pressure below the critical limits recommended for activating a pediatric rapid response team to the bedside of a hospitalized child for quick intervention. Factors associated with bradycardia were identified in a univariate analysis. A step-wise backward multiple logistic regression model was used to identify independent factors. Differences between the 2 groups were computed using Fishers exact test or &khgr;2 tests for categorical data and t tests for continuous data. RESULTS: Univariate analysis demonstrated that Down syndrome, low ASA physical status, congenital heart disease, and mean sevoflurane concentrations were factors associated with bradycardia. However, multivariate analysis showed that only Down syndrome and low ASA physical status remained as independent factors associated with bradycardia. CONCLUSION: Bradycardia during anesthetic induction with sevoflurane was common in children with Down syndrome, with and without a history of congenital heart disease.

Anesthetic management of living liver donors.

PurposeLiving organ donation is being performed with increasing frequency to overcome the shortage of organs for transplantation. Our experience in the anesthetic management of donors with relevant issues is discussed and complications encountered are recorded.MethodsData were collected retrospectively and analyzed on all 22 left lateral hepatectomies performed at our institution between 1993 to 1997 for transplantation.ResultsMajor ethical concern was the risk to the donors and anesthetic issues were those of a major abdominal procedure. All except four donors were parents (mother/father). Average blood loss was 805 ± 479 ml and only two donors required blood transfusion. Mean operative time was 8.2 ± 1.5 hr. Thoracic epidural analgesia was the most commonly adopted mode of pain relief. Average time to return of bowel sound postoperatively was 3.1 ± 1.0 days and was not influenced by the postoperative analgesic technique used. Total duration of hospital stay was 8.4 ± 1.1 days. Three donors developed minor postoperative complications atrial fibrillation and retained JP drain; left lower lobe pneumonia; and incisional hernia. All patients recovered uneventfully.ConclusionLiving organ donors contribute towards decreasing the shortage of organs for transplantation. Minimizing the discomfort associated with the surgical intervention and providing a complication-free perioperative course will positively influence the continued availability of such donations. On review of the first 22 left lateral hapatectomies performed, we observed only minor complications. Postoperative pain was a serious problem and thoracic epidural provided satisfactory analgesia.RésuméObjectifLe don d’organe vivant se fait de plus en plus souvent en raison du manque d’organes pour la transplantation. Notre expérience de l’anesthésie des donneurs ainsi que les questions qui y sont pertinentes sont examinées et les complications qui surviennent sont présentées.MéthodeUne collecte rétrospective suivie d’une analyse des données des 22 hépatectomies latérales gauches réalisées pour la transplantation entre 1993 et 1997 à notre institution.RésultatsNotre principale souci éthique a été celui du risque encouru par les donneurs, et nos choix anesthésiques, ceux d’une intervention abdominale majeure. Les donneurs, sauf quatre, étaient des parents (mère/père). La perte sanguine moyenne a été de 805 ± 479 ml, et deux donneurs ont eu besoin de transfusion. Le temps moyen de l’opération a été de 8,2 ± 1,5 h. Lanalgésie épidurale thoracique a été privilégiée comme traitement de la douleur. Le temps moyen nécessaire au retour des bruits intestinaux postopératoires a été de 3,1 ± 1,0 jours peu importe la technique analgésique postopératoire utilisée. La durée totale du séjour hospitalier a été de 8,4 ± 1,1 jours. Trois donneurs ont développé des complications postopératoires mineures de fibrillation auriculaire et de rétention du drain de Jackson-Pratt, de pneumonie du lobe inférieur gauche et de hernie au site de l’incision. Tous les patients se sont rétablis sans incidents.ConclusionLes dons d’organe vivant permettent de palier le manque d’organes pour la transplantation. En réduisant l’inconfort associé à l’intervention chirurgicale et en procurant un environnement périopératoire sans complications, nous pourrons assurer le maintien de dons semblables. Lors de la révision des 22 premières hépatectomies latérales gauches, nous n’avons relevé que des complications mineures. La douleur postopératoire a été un problème sérieux que l’analgésie épidurale thoracique nous a permis de régler de façon satisfaisante.

Big data and visual analytics in anaesthesia and health care

Advances in computer technology, patient monitoring systems, and electronic health record systems have enabled rapid accumulation of patient data in electronic form (i.e. big data). Organizations such as the Anesthesia Quality Institute and Multicenter Perioperative Outcomes Group have spearheaded large-scale efforts to collect anaesthesia big data for outcomes research and quality improvement. Analytics--the systematic use of data combined with quantitative and qualitative analysis to make decisions--can be applied to big data for quality and performance improvements, such as predictive risk assessment, clinical decision support, and resource management. Visual analytics is the science of analytical reasoning facilitated by interactive visual interfaces, and it can facilitate performance of cognitive activities involving big data. Ongoing integration of big data and analytics within anaesthesia and health care will increase demand for anaesthesia professionals who are well versed in both the medical and the information sciences.

Telemedicine consultation and monitoring for pediatric liver transplant.

Telemedicine provides the opportunity to bring medical expertise to the bedside, even if the medical expert is not physically near the patient. Internet technology has facilitated telemedicine allowing for voice, video and other data to be exchanged between remote locations. To date, applications of telemedicine to anesthesia (Teleanesthesia) have been limited. Previous work by Cone et al., (Anesth Analg 2006;1463-7) demonstrated the ability to direct an anesthetic in a remote location using satellite communication. In this report, we describe the use of telemedicine to support two cases of elective living related pediatric liver transplants performed at the Narayana Hrudayalaya Institute of Medical Sciences in Bangalore, India with preoperative and intraoperative consultation provided by physicians at the Childrens Hospital of Philadelphia.