Monica Siewert

Risk factors for perioperative adverse respiratory events in children with upper respiratory tract infections

Background Anesthesia for the child who presents for surgery with an upper respiratory infection (URI) presents a challenge for the anesthesiologist. The current prospective study was designed to determine the incidence of and risk factors for adverse respiratory events in children with URIs undergoing elective surgical procedures. Methods The study population included 1,078 children aged 1 month to 18 yr who presented for an elective surgical procedure. Parents were given a short questionnaire detailing their child’s demographics, medical history, and presence of any symptoms of a URI. Data regarding the incidence and severity of perioperative respiratory events were collected prospectively. Adverse respiratory events (any episode of laryngospasm, bronchospasm, breath holding > 15 s, oxygen saturation < 90%, or severe cough) were recorded. In addition, parents were contacted 1 and 7 days after surgery to determine the child’s postoperative course. Results There were no differences between children with active URIs, recent URIs (within 4 weeks), and asymptomatic children with respect to the incidences of laryngospasm and bronchospasm. However, children with active and recent URIs had significantly more episodes of breath holding, major desaturation (oxygen saturation < 90%) events, and a greater incidence of overall adverse respiratory events than children with no URIs. Independent risk factors for adverse respiratory events in children with active URIs included use of an endotracheal tube (< 5 yr of age), history of prematurity, history of reactive airway disease, paternal smoking, surgery involving the airway, the presence of copious secretions, and nasal congestion. Although children with URIs had a greater incidence of adverse respiratory events, none were associated with any long-term adverse sequelae. Conclusions The current study identified several risk factors for perioperative adverse respiratory events in children with URIs. Although children with acute and recent URIs are at greater risk for respiratory complications, these results suggest that most of these children can undergo elective procedures without significant increase in adverse anesthetic outcomes.

False Alarms and Sensitivity of Conventional Pulse Oximetry Versus the Masimo Set™ Technology in the Pediatric Postanesthesia Care Unit

We compared the incidence and duration of false alarms (FA)and the sensitivity of conventional pulse oximetry (CPO) with Masimo Signal Extraction Technology™ (Masimo SET™; Masimo Corporation, Irvine, CA) in children in the postanesthesia care unit. Disposable oximeter sensors were placed on separate digits of one extremity. Computerized acquisition of synchronous data included electrocardiograph heart rate, Spo2, and pulse rate via CPO and Masimo SET™. Patient motion, respiratory, and other events were simultaneously documented. Spo2 tracings conflicting with clinical observations and/or documented events were considered false. These were defined as 1) Data dropout, complete interruption in Spo2 data; 2) False negative, failure to detect Spo2 ≤ 90% detected by another device or based on observation/intervention; 3) FA, Spo2 ≤ 90% considered artifactual; and 4) True alarm (TA), Spo2 ≤ 90% considered valid. Seventy-five children were monitored for 35 ± 22 min/patient (42 h total). There were 27 TAs, all of which were identified by Masimo SET™ and only 16 (59%) were identified by CPO (P < 0.05). There was twice the number of FAs with CPO (10 vs 4 Masimo SET™;P < 0.05). The incidence and duration of data dropouts were similar between Masimo SET™ and CPO. Masimo SET™ reduced the incidence and duration of FAs and identified a more frequent incidence of TAs compared with CPO. Implications Pulse oximetry that incorporates Masimo Signal Extraction Technology™ (Masimo Corporation, Irvine, CA) may offer an advantage over conventional pulse oximetry by reducing the incidence of false alarms while identifying a higher number of true alarms in children in the postanesthesia care unit.

Risk Factors for Adverse Postoperative Outcomes in Children Presenting for Cardiac Surgery with Upper Respiratory Tract Infections

Background Otherwise healthy children who present for elective surgery with an upper respiratory infection (URI) may be at risk for perioperative respiratory complications. This risk may be increased in children with congenital heart disease who undergo cardiac surgery while harboring a URI because of their compromised cardiopulmonary status. Therefore, this study was designed to determine the incidence of peri- and postoperative complications in children undergoing cardiac surgery while harboring a URI. Methods The study population consisted of 713 children scheduled to undergo cardiac surgery. Of these, 96 had symptoms of URI, and 617 were asymptomatic. Children were followed prospectively from induction of anesthesia to discharge from the hospital to determine the incidence of postoperative respiratory, cardiovascular, neurologic, and surgical adverse events. Duration of postoperative ventilation, time in the intensive care unit (ICU), and length of hospital stay were also recorded. Results Children with URIs had a significantly higher incidence of respiratory and multiple postoperative complications than children with no URIs (29.2 vs. 17.3% and 25 vs. 10.3%, respectively;P < 0.01) and a higher incidence of postoperative bacterial infections (5.2 vs. 1.0%;P = 0.01). Furthermore, logistic regression indicated that the presence of a URI was an independent risk factor for multiple postoperative complications and postoperative infections in children undergoing open heart surgery. Children with URIs also stayed longer in the intensive care unit than children with no URIs (75.9 ± 89.8 h vs. 57.7 ± 63.8, respectively;P < 0.01). However, the overall length of hospital stay was not significantly different (8.4 vs. 7.8 days, URI vs. non-URI groups;P > 0.05). Conclusions The presence of a URI was predictive of postoperative infection and multiple complications in children presenting for cardiac surgery. Despite this, the presence of a URI does not appear to affect the patients overall length of hospital stay nor the development of long-term sequelae.

Prolonged recovery stay and unplanned admission of the pediatric surgical outpatient: an observational study

STUDY OBJECTIVE To determine the incidence of and reasons for prolonged length of stay in the postanesthesia care unit and unplanned hospital admissions of children scheduled for outpatient surgery. DESIGN Prospective, observational cohort study. SETTING C. S. Mott Childrens Hospital, a tertiary care setting. PATIENTS 168 ASA physical status I, II, and III children (birth to 18 years), 130 of whom experienced a prolonged length of stay and 61 who had an unplanned hospital admissions. MEASUREMENTS AND MAIN RESULTS 3.9% of annual outpatient population experienced a prolonged length of stay, and 1.9% had an unplanned outpatient admission. Prolonged length of stay was most commonly due to postoperative nausea and vomiting (19%) or respiratory complications (16%), whereas unplanned hospital admissions were primarily for respiratory or surgical reasons (32% and 30%, respectively). Higher ASA status had a significant direct relationship with the incidence of unplanned outpatient admission and respiratory complications. Although most families were satisfied with the length of their childs care, 28% of parents whose children were sent home after a prolonged length of stay would have preferred a short hospital admission, and 16% of parents of children with an unplanned hospital admission would have preferred a longer stay in recovery and discharge home. CONCLUSION Prolonged length of stay and unplanned hospital admissions were uncommon outcomes following pediatric outpatient surgery. However, the impact of such outcomes on hospital staffing and family convenience may have implications related to cost containment and patient satisfaction.

A comparison of continuous epidural infusion and intermittent intravenous bolus doses of morphine in children undergoing selective dorsal rhizotomy

BACKGROUND AND OBJECTIVES Selective dorsal rhizotomy (SDR) is associated with moderale to severe postoperative pain. Although the efficacy of epidural analgesia in this population has been demonstrated, it has not been compared with conventional intravenous (i.v.) analgesia. This prospective study compared the effects of epidural and i.v. morphine regarding postoperative analgesia, side effects, and outcomes in children following SDR. METHODS Twenty-seven children were randomized to receive either epidural or i.v. analgesia. Children in the epidural group had a catheter placed by the neurosurgeon and received preservative-free morphine (Duramorph) 30 microg/kg, followed by an infusion of 3 microg/kg/h for 3 days. Children in the i.v. group received morphine 0.05-0.1 mg/kg intraoperatively, followed by 0.02 mg/kg doses postoperatively administered by nurses via a patient-controlled analgesia device. RESULTS The epidural group experienced lower pain scores (P = .04) and fewer muscle spasms (P < or = .04), and tolerated activity better (P < or = .02) during the early postoperative period than the i.v. group. Side effects were similar between groups, with no respiratory depression in either group. Parents of children in both groups perceived an adequate level of comfort and were very satisfied with the analgesic technique. Additionally, parents believed that their childs postoperative pain was less than anticipated (P < or = .01). CONCLUSIONS Both techniques provided effective postoperative analgesia with a similar incidence of side effects; however, our findings suggest that continuous infusions of epidural morphine improved overall comfort with lower pain scores, fewer muscle spasms, and improved tolerance of activity during the initial postoperative period.

The relationship between extracorporeal circuit prime, albumin, and postoperative weight gain in children

OBJECTIVES This study evaluated postoperative weight gain in children who received albumin versus crystalloid prime for cardiopulmonary bypass (CPB). DESIGN A retrospective case-controlled study. Children whose extracorporeal (EC) circuit prime contained albumin (group 1) were matched with those whose prime contained only crystalloid (group 2) on the basis of age, weight, and surgical repair. SETTING A university-based medical center. PARTICIPANTS Seventy-six children (newborn to 4 years of age) who underwent CPB for correction of a congenital heart anomaly from 1993 to 1995. Group 1 underwent surgery from October 1994 to September 1995, and group 2 from February 1993 to September 1994. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Group 1 had less weight gain on postoperative days (PODs) 1, 2 and 3 compared with group 2 (p = 0.04 on POD 1). Albumin (grams per milliliter) prime and prime volume in milliliters per kilogram were the best predictors of weight gain (p < 0.004), with prime volume being the more important. Children who weighed less than 7.5 kg received more prime volume and had greater weight gain than children who weighed 7.5 kg or greater on PODs 1, 2, and 3 (p < 0.02). CONCLUSION Data suggest that adding albumin to the EC circuit prime and minimizing the prime volume will result in less postoperative weight gain. Further prospective study with a larger sample is warranted to determine whether albumin prime offers other clinical benefits.

Effects of anesthetic technique on side effects associated with fentanyl oralet premedication

STUDY OBJECTIVES To evaluate the efficacy of 5 to 10 micrograms/kg of oral transmucosal fentanyl citrate (OTFC) as an anesthetic premedication, and to determine whether propofol induction reduces postoperative nausea and vomiting (PONV) in pediatric patients premedicated with OTFC undergoing outpatient surgery. DESIGN Prospective, randomized, double-blinded study. SETTINGS University of Michigan Health Care Systems and University of Arizona. PARTICIPANTS 62 ASA physical status I and II children aged 4 to 14 years (8.9 +/- 0.5 years). INTERVENTIONS Subjects were randomly assigned to one of four groups: (1) OTFC premedication and halothane induction; (2) OTFC premedication and propofol induction; (3) placebo premedication and halothane induction; and (4) placebo premedication and propofol induction. OTFC or placebo was administered 30 minutes prior to induction, and activity (sedation), apprehension, and cooperation scores were recorded before, at 15 and 30 minutes after study drug, and on induction. All perioperative adverse events were recorded. MEASUREMENTS AND MAIN RESULTS Children who received OTFC became drowsier and had a significant change from baseline in combined activity, apprehension, and cooperation scores, whereas those who received placebo became less cooperative at induction. Patients who received OTFC experienced more adverse events overall (p < 0.001) than patients who received placebo. Additionally, OTFC patients experienced more vomiting (p < 0.001) and pruritus (p = 0.049) than controls. The incidence of PONV in patients who received OTFC and halothane induction was 50%, compared to 30% in patients receiving OTFC and a propofol induction (p = NS). CONCLUSIONS OTFC in doses of 5 to 10 micrograms/kg was effective in producing sedation and facilitating cooperation with induction; however, it was associated with significant PONV in our study. Although propofol induction did not significantly reduce PONV in our study, further study with a larger sample, and with propofol as the sole anesthetic, may be warranted.

Evaluation of simethicone for the treatment of postoperative abdominal discomfort in infants

STUDY OBJECTIVE To determine whether abdominal discomfort is a cause for distress symptoms in infants following administration of inhalational anesthesia, and to evaluate the effectiveness of simethicone in treating this discomfort. DESIGN Randomized, double-blinded study. SETTING Large tertiary care, university-based medical center. PATIENTS 175 ASA physical status I and II infants under 28 months of age who underwent an inhalational anesthetic for a variety of procedures that were expected to cause relatively little pain. INTERVENTIONS Children were assessed for the presence of postoperative abdominal discomfort, and, if evident, were randomly given either simethicone or placebo in a double-blinded fashion. MEASUREMENTS AND MAIN RESULTS Abdominal discomfort was measured using the Faces Legs Activity Cry and Consolability (FLACC) Behavioral Pain Scale. Scores were recorded pre-drug; at 10, 20, and 30 minutes following drug administration; and at discharge. If discomfort had not resolved within 15 minutes after the drug was given, routine analgesics or other medications were administered. Abdominal girth was measured preoperatively, on admission into the postanesthesia care unit (PACU), and at discharge. 21% of infants exhibited symptoms of abdominal discomfort postoperatively. Younger infants were at greater risk for this condition. 36 infants were given either placebo or simethicone, and of these, infants who received simethicone were comfortable earlier and required fewer rescue medications compared with placebo. There were no differences in ability to tolerate oral fluids prior to discharge or in the length of stay in the PACU. CONCLUSIONS Simethicone is a safe and inexpensive medication that may provide anesthesiologists with an effective treatment choice for suspected postoperative abdominal discomfort in infants.