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Emergence agitation in preschool children: double-blind, randomized, controlled trial comparing sevoflurane and isoflurane anesthesia

Background:  This randomized, double‐blind controlled trial was conducted to determine whether the association of sevoflurane for induction and isoflurane for anesthesia maintenance resulted in a lower incidence of postoperative agitation compared with sevoflurane as single agent.

Randomized controlled trial comparing the laryngeal tube and the laryngeal mask in pediatric patients

Background:  The laryngeal tube (LT) is a supraglottic ventilatory device used in adults. However, there is limited information about LT use in pediatric patients. This randomized controlled study compares LT with laryngeal mask (LMA) for airway management during spontaneous or assisted ventilation and during fiberoptic laryngoscopy in children.

Emergence delirium in children: a comparison of sevoflurane and desflurane anesthesia using the Paediatric Anesthesia Emergence Delirium scale.

This randomized control trial was designed to evaluate the incidence of emergence delirium (ED) in preschool children receiving sevoflurane or desflurane anesthesia combined with an effective caudal block.

Caudal 0.2% ropivacaine is less effective during surgery than 0.2% levobupivacaine and 0.2% bupivacaine: a double-blind, randomized, controlled trial

Background : We hypothesized that without the analgesic effects of volatile anesthetics, caudal 0.20% ropivacaine would be less effective during surgical stimulation than 0.20% bupivacaine or 0.20% levobupivacaine. This trial was designed to examine whether the combination of a caudal block with 0.20% ropivacaine and i.v. anesthesia resulted in reduced analgesic efficacy during surgery compared with caudal 0.20% levobupivacaine or 0.20% bupivacaine in children.

Relative analgesic potencies of levobupivacaine and ropivacaine for caudal anesthesia in children.

BACKGROUND: Comparing relative potency of new local anesthetics, such as levobupivacaine and ropivacaine, by the minimum local analgesic concentration model has not been described for caudal anesthesia. Therefore, we performed a prospective, randomized, double-blind study to determine the minimum local analgesic concentrations of a caudal single shot of ropivacaine and levobupivacaine in children and to describe the upper dose-response curve. METHODS: We performed a two-stage prospective, randomized, double-blind study comparing the dose-response curves of caudal ropivacaine and levobupivacaine in children. In phase 1, 80 boys were randomized to receive either ropivacaine or levobupivacaine. In the second phase a further 32 patients were randomly allocated to receive caudal anesthesia with doses designed to delineate the upper dose-response range (the 50% effective dose [ED50]-ED95 range). RESULTS: There were no significant differences in ED50 values for caudal ropivacaine and levobupivacaine. The ED50 for levobupivacaine estimated from the Dixon Massey method was 0.069% (95% CI 0.056%-0.082%) and for ropivacaine was 0.075% (95% CI 0.058%-0.092%). Estimated by isotonic regression the ED50 and ED95 respectively of levobupivacaine were 0.068 (0.04-0.09) and 0.20% (95% CI 0.16%-0.24%). For ropivacaine ED 50 and ED95 were 0.066 (0.033-0.098) and 0.225% (95% CI 0.21%-0.24%). CONCLUSIONS: In children receiving one minimum alveolar anesthetic concentration of sevoflurane, there were no significant differences in the ED50 for caudal levobupivacaine and ropivacaine. The potency ratio at ED50 was 0.92 and 0.89 at ED95, indicating that caudal levobupivacaine and ropivacaine have a similar potency.

Bupivacaine caudal epidural anesthesia: assessing the effect of general anesthetic technique on block onset

Background : The primary objective of this prospective, randomized trial was to compare the effect of propofol and sevoflurane on effectiveness of regional anesthesia. As a secondary objective, we aimed at evaluating the influence of age on neuraxial block profile.

Changes in total plasma and serum N-glycome composition and patient-controlled analgesia after major abdominal surgery

Systemic inflammation participates to the complex healing process occurring after major surgery, thus directly affecting the surgical outcome and patient recovery. Total plasma N-glycome might be an indicator of inflammation after major surgery, as well as an anti-inflammatory therapy response marker, since protein glycosylation plays an essential role in the inflammatory cascade. Therefore, we assessed the effects of surgery on the total plasma N-glycome and the association with self-administration of postoperative morphine in two cohorts of patients that underwent major abdominal surgery. We found that plasma N-glycome undergoes significant changes one day after surgery and intensifies one day later, thus indicating a systemic physiological response. In particular, we observed the increase of bisialylated biantennary glycan, A2G2S[3,6]2, 12 hours after surgery, which progressively increased until 48 postoperative hours. Most changes occurred 24 hours after surgery with the decrease of most core-fucosylated biantennary structures, as well as the increase in sialylated tetraantennary and FA3G3S[3,3,3]3 structures. Moreover, we observed a progressive increase of sialylated triantennary and tetraantennary structures two days after surgery, with a concomitant decrease of the structures containing bisecting N-acetylglucosamine along with bi- and trisialylated triantennary glycans. We did not find any statistically significant association between morphine consumption and plasma N-glycome.

Sepsis after epidural catheterization in a child with chronic regional pain syndrome type I

obstructing two thirds of the tracheal diameter was found and removed (Figure 1b). Following the procedure, the child was asymptomatic. Most likely, this cast (Figure 1c,d) was stripped off the tracheal tube (Figure 1e) at the time of extubation 5 days earlier but only started to produce symptoms when it became partially dislodged. We believe that our patient presented many of the features of OFTP, a complication not previously described in children. It is unclear whether the subglottic fibrinous cast was caused by a local reaction of the trachea to the tracheal tube [as suggested for adult patients with OFTP (2)] or represented thickened secretions from the lower respiratory tract that could not be cleared from the trachea through the tracheal tube. We agree with Birch and Salkeld (1) that an upper airway endoscopy should be performed without delay in patients with an unusual presentation of postextubation stridor (i.e., unusual timing and/or failure to respond to usually effective therapies). As illustrated by our patient and described by Deslée et al. (2), when such casts become dislodged sudden acute and even lifethreatening upper airway obstruction can occur. Thomas M. Berger M D* Martin Jöhr M D† *Neonatal and Paediatric Intensive Care Unit, Children’s Hospital of Lucerne, Lucerne, Switzerland (email: thomas.berger@ksl.ch) †Department of Anaesthesia, Kantonsspital Lucerne, Lucerne, Switzerland

Perioperative Outcomes and Management in Pediatric Complex Cranial Vault Reconstruction: A Multicenter Study from the Pediatric Craniofacial Collaborative Group

Background: The Pediatric Craniofacial Collaborative Group established the Pediatric Craniofacial Surgery Perioperative Registry to elucidate practices and outcomes in children with craniosynostosis undergoing complex cranial vault reconstruction and inform quality improvement efforts. The aim of this study is to determine perioperative management, outcomes, and complications in children undergoing complex cranial vault reconstruction across North America and to delineate salient features of current practices. Methods: Thirty-one institutions contributed data from June 2012 to September 2015. Data extracted included demographics, perioperative management, length of stay, laboratory results, and blood management techniques employed. Complications and outlier events were described. Outcomes analyzed included total blood donor exposures, intraoperative and perioperative transfusion volumes, and length of stay outcomes. Results: One thousand two hundred twenty-three cases were analyzed: 935 children aged less than or equal to 24 months and 288 children aged more than 24 months. Ninety-five percent of children aged less than or equal to 24 months and 79% of children aged more than 24 months received at least one transfusion. There were no deaths. Notable complications included cardiac arrest, postoperative seizures, unplanned postoperative mechanical ventilation, large-volume transfusion, and unplanned second surgeries. Utilization of blood conservation techniques was highly variable. Conclusions: The authors present a comprehensive description of perioperative management, outcomes, and complications from a large group of North American children undergoing complex cranial vault reconstruction. Transfusion remains the rule for the vast majority of patients. The occurrence of numerous significant complications together with large variability in perioperative management and outcomes suggest targets for improvement.

Peritoneal nebulization of ropivacaine during laparoscopic cholecystectomy: Dose finding and pharmacokinetic study

Background. Intraperitoneal nebulization of ropivacaine reduces postoperative pain and morphine consumption after laparoscopic surgery. The aim of this multicenter double-blind randomized controlled trial was to assess the efficacy of different doses and dose-related absorption of ropivacaine when nebulized in the peritoneal cavity during laparoscopic cholecystectomy. Methods. Patients were randomized to receive 50, 100, or 150 mg of ropivacaine 1% by peritoneal nebulization through a nebulizer. Morphine consumption, pain intensity in the abdomen, wound and shoulder, time to unassisted ambulation, discharge time, and adverse effects were collected during the first 48 hours after surgery. The pharmacokinetics of ropivacaine was evaluated using high performance liquid chromatography. Results. Nebulization of 50 mg of ropivacaine had the same effect of 100 or 150 mg in terms of postoperative morphine consumption, shoulder pain, postoperative nausea and vomiting, activity resumption, and hospital discharge timing (>0.05). Plasma concentrations did not reach toxic levels in any patient, and no significant differences were observed between groups (P > 0.05). Conclusions. There is no enhancement in analgesic efficacy with higher doses of nebulized ropivacaine during laparoscopic cholecystectomy. When administered with a microvibration-based aerosol humidification system, the pharmacokinetics of ropivacaine is constant and maintains an adequate safety profile for each dosage tested.