Association of anesthetic and surgical risk factors with outcomes of initial diagnostic biopsies in a current cohort of children with anterior mediastinal masses.

Background: Diagnostic biopsies of pediatric anterior mediastinal masses (AMMs) are high-risk procedures in which general anesthesia (GA) is traditionally avoided. However, awareness of historically recognized risk factors and corresponding perioperative management have improved over time and may now no longer strictly preclude the use of GA. Therefore, in this study, we examined the association of anesthetic and surgical risk factors and modalities with resulting procedural and survival outcomes in a current patient cohort. Methods: We retrospectively reviewed charts of 35 children with AMMs who underwent initial diagnostic biopsies between January 2001 and August 2019, and determined tracheal compression and deviation from archival CT scans and procedural and disease outcomes. Results: Twenty-three (65%) patients underwent GA while 12 (35%) received sedation. Among patients with available CT measurements, 13 of 25 (52%) had >50% anteroposterior tracheal diameter reduction. Patients with >50% anteroposterior tracheal compression received sedation more frequently (p=0.047) and were positioned upright (p=0.015) compared with patients with ≤50% compression, although 4 of 13 and 9 of 12, respectively, still received GA. Intraoperative adverse events (AEs) occurred in four (11.4%) patients: three received GA, and all were positioned supine or lateral. AEs were not associated with radiographic airway risk factors but were significantly associated with morphine and sevoflurane use (p<0.001) and with thoracoscopic biopsies (p=0.035). There were no on-table mortalities, but four delayed deaths occurred (three related to disease and one from late procedural complications). Conclusions: In a current cohort of pediatric AMM biopsies, patients with >50% anteroposterior tracheal compression were more frequently managed with a conservative perioperative management strategy, though not completely excluding GA. The corresponding reduction in frequency of procedural AEs in this traditionally high-risk group suggests that increased awareness of procedural risk factors and appropriate risk-guided perioperative management choices may obviate the procedural mortality historically associated with pediatric AMM biopsies.

High detection rates and genetic diversity of picobirnaviruses (PBVs) in pigs on St. Kitts Island: Identification of a porcine PBV strain closely related to simian and human PBVs.

We report here high rates (75.38%, 49/65) of detection of genogroup I (GI) PBVs in diarrheic pigs on the Caribbean island of St. Kitts. High quality gene segment-2 sequences encoding a significant region (~350 amino acid (aa) residues) of the putative RNA-dependent RNA polymerase (RdRp) were obtained for 23 PBV strains. The porcine PBV strains from St. Kitts exhibited high genetic diversity among themselves (deduced aa identities of 56-100%) and with other PBVs (maximum deduced aa identities of 64-97%), and retained the three domains that are conserved in putative RdRps of PBVs. The nearly complete gene segment-2 sequence (full-length minus partial 3'- untranslated region) of a porcine PBV strain (strain PO36 from St. Kitts) that is closely related (deduced aa identities of 96-97%) to simian and human GI PBVs was determined using a combination of the non-specific primer-based amplification method and conventional RT-PCR. The complete putative RdRp sequence of strain PO36 preserved the various features that are maintained in PBVs from various species. For the first time, several co-circulating PBV strains from pigs were characterized for a significant region (~350 aa) of the putative RdRp, providing important insights into the genetic diversity of PBVs in a porcine population. Taken together, these observations corroborated growing evidence that PBVs can be highly prevalent and show limited correlation globally with host species or geography. This is the first report on detection of PBVs in pigs from the Caribbean region.

A simplified approach for anaesthetic management of diagnostic procedures in children with anterior mediastinal mass.

INTRODUCTION: Children with an anterior mediastinal mass (AMM) need general anaesthesia (GA) or deep sedation for diagnostic procedures more often than adult patients. Anaesthetic management to prevent such complications includes maintenance of spontaneous ventilation (SV) and prebiopsy corticosteroids/radiotherapy. METHODS: We reviewed the medical records of children with AMM who were brought to the operating theatre for diagnostic procedures (prior to chemotherapy) between 2001 and 2013. Our aim was to describe the clinical features, radiological findings and anaesthetic management, as well as determine any association with complications. RESULTS: 25 patients (age range 10 months-14 years) were identified during the study period. Corticosteroid therapy was started before the biopsy for one patient. All 25 patients had GA/sedation. A senior paediatric anaesthesiologist was involved in all procedures. Among 13 high-risk patients, SV was maintained in 11 (84.6%) patients, ketamine was used as the main anaesthetic in 8 (61.5%) patients, 6 (46.2%) patients were in a sitting position and no airway adjunct was used for 7 (53.8%) patients. There were 3 (12.0%) minor complications. CONCLUSION: Based on our results, we propose a simplified workflow, wherein airway compression of any degree is considered high risk. For patients with high-risk features, multidisciplinary input should be sought to decide whether the child would be fit for a procedure under GA/sedation or considered unfit for any procedure. Recommendations include the use of less invasive methods, involving experienced anaesthesiologists to plan the anaesthetic technique and maintaining SV.

Singapore Paediatric Resuscitation Guidelines 2016.

We present the revised 2016 Singapore paediatric resuscitation guidelines. The International Liaison Committee on Resuscitation's Pediatric Taskforce Consensus Statements on Science and Treatment Recommendations, as well as the updated resuscitation guidelines from the American Heart Association and European Resuscitation Council released in October 2015, were debated and discussed by the workgroup. The final recommendations for the Singapore Paediatric Resuscitation Guidelines 2016 were derived after carefully reviewing the current available evidence in the literature and balancing it with local clinical practice.

Detection of picobirnaviruses in vervet monkeys (Chlorocebus sabaeus): Molecular characterization of complete genomic segment-2.

During 2014-2015, 270 fecal samples were collected from non-diarrheic, captive and wild African green monkeys (AGMs) on the island of St. Kitts, Caribbean region. By RNA-PAGE, picobirnaviruses (PBVs) were detected in sixteen captive AGMs. By RT-PCR and sequencing of partial gene segment-2, PBVs in 15 of these 16 samples were assigned to genogroup-I. The full-length nucleotide (nt) sequence of gene segment-2 of one of the genogroup-I PBV strains, strain PBV/African green monkey/KNA/016593/2015, was obtained using a non-specific primer-based amplification method with modifications. Gene segment-2 of strain 016593 was 1707bp long, and encoded a putative RNA-dependent RNA polymerase (RdRp) of 538aa. Furthermore, the nearly complete gene segment-2 sequences of three other AGM PBV strains were determined using primers designed from gene segment-2 sequence of 016593. The gene segment-2 of the 4 AGM PBV strains were almost identical to each other, and exhibited a high degree of genetic diversity (maximum nt and deduced aa sequence identities of 66.4% and 65.3%, respectively) with those of PBVs from other host species. The 5'- and 3'- (except for one mismatch) end nt sequences and the three domains of RdRps were retained in the AGM PBV strains. To our knowledge, this is the first report on detection, and molecular characterization of complete gene segment-2 of PBVs in vervet monkeys. PBVs were detected for the first time from the Caribbean region.

The effects of active (hot-seat) versus observer roles during simulation-based training on stress levels and non-technical performance: a randomized trial.

BACKGROUND: Active 'hands-on' participation in the 'hot-seat' during immersive simulation-based training (SBT) induces stress for participants, which is believed to be necessary to improve performance. We hypothesized that observers of SBT can subsequently achieve an equivalent level of non-technical performance as 'hot-seat' participants despite experiencing lower stress. METHODS: We randomized 37 anaesthesia trainees into two groups to undergo three consecutive SBT scenarios. Eighteen 'hot-seat' trainees actively participated in all three scenarios, and 19 'observer' trainees were directed to observe the first two scenarios and participated in the 'hot-seat' only in scenario 3. Salivary cortisol (SC) was measured at four time points during each scenario. Primary endpoint for stress response was the change in SC (ΔSC) from baseline. Performance was measured using the Anaesthetist's Non-Technical Skills (ANTS) Score. RESULTS: Mean SC increased in all participants whenever they were in the 'hot-seat' role, but not when in the observer role. Hot-seat ΔSC (mcg/dL) for scenarios 1, 2, and 3 were 0.122 (p = 0.001), 0.074 (p = 0.047), and 0.085 (p = 0.023), respectively. Observers ΔSC (mcg/dL) for scenarios 1, 2, and 3 were -0.062 (p = 0.091), 0.010 (p = 0.780), and 0.144 (p = 0.001), respectively. Mean ANTS scores were equivalent between the 'hot-seat' (40.0) and 'observer' (39.4) groups in scenario 3 (p = 0.733). CONCLUSIONS: Observers of SBT achieved an equivalent level of non-technical performance, while experiencing lower stress than trainees repeatedly trained in the 'hot-seat'. Our findings suggest that directed observers may benefit from immersive SBT even without repeated 'hands-on' experience and stress in the hot-seat. The directed observer role may offer a less stressful, practical alternative to the traditional 'hot-seat' role, potentially rendering SBT accessible to a wider audience. TRIAL REGISTRATION: ClinicalTrials.gov Identifier NCT02211378, registered August 5, 2014, retrospectively registered.

Neonatal and Paediatric Extracorporeal Membrane Oxygenation (ECMO) in a Single Asian Tertiary Centre.

INTRODUCTION: Extracorporeal membrane oxygenation (ECMO) is a cardiopulmonary bypass technique (CPB) which provides life-saving support in patients with refractory cardiorespiratory failure until cardiopulmonary recovery or organ replacement. MATERIALS AND METHODS: This is a single centre retrospective study reporting the largest series of paediatric patients in Singapore who received ECMO support over an 11-year period from January 2002 to December 2012. The objective is to describe the characteristics of the patients and to report the survival to hospital discharge, complications during ECMO and other long-term complications. RESULTS: Forty-eight patients received ECMO during the study period. ECMO was initiated for myocarditis in majority of the paediatric patients whereas postoperative low cardiac output state was the most common indication in the neonatal population. The overall survival rate to hospital discharge was 45.8%. Survival was highest in the neonates with respiratory failure (75%). Haematological and cardiac complications were most common during ECMO. Age group, gender, duration of ECMO, need for renal replacement therapy, acute neurological complications were not associated with mortality. Those needing inotropic support during ECMO had poorer survival while those with hypertension requiring vasodilator treatment had a higher survival rate. The survival rates for ECMO patients more than doubled from the initial 6 years of 23% to 54% in the last 5 years of the study period. Long-term complications encountered included neurological, respiratory and cardiac problems. CONCLUSION: ECMO is a life-saving modality for neonatal and paediatric patients with cardiopulmonary failure from diverse causes. Patients with persistent need for inotropes during ECMO had poorer outcome. Centre experience had an impact on ECMO outcome.

Audits and critical incident reporting in paediatric anaesthesia: lessons from 75,331 anaesthetics.

INTRODUCTION: This study reports our experience of audit and critical incidents observed by paediatric anaesthetics from 2000 to 2010 at a paediatric teaching hospital in Singapore. METHODS: Data pertaining to patient demographics, practices and critical incidents during anaesthesia and in the perioperative period were prospectively collected via an audit form and retrospectively analysed thereafter. RESULTS: A total of 2,519 incidents were noted at the 75,331 anaesthetics performed during the study period. There were nine deaths reported. The majority of incidents reported were respiratory critical incidents (n = 1,757, 69.8%), followed by cardiovascular incidents (n = 238, 9.5%). Risk factors for critical incidents included age less than one year, and preterm and former preterm children. CONCLUSION: Critical incident reporting has value, as it provides insights into the system and helps to identify active and system errors, thus enabling the formulation of effective preventive strategies. By creating and maintaining an environment that encourages reporting, we have maintained a high and consistent reporting rate through the years. The teaching of analysis of critical incidents should be regarded by all clinicians as an important tool for improving patient safety.

Retrospective review of ilioinguinal-iliohypogastric nerve block with general anesthesia for herniotomy in ex-premature neonates.

OBJECTIVES AND AIMS: We examine the efficacy and complications of general anesthesia with ilioinguinal-iliohypogastric nerve block performed on ex-premature neonates undergoing inguinal herniotomy. BACKGROUND: The ex-premature neonate has many co-morbidities and is at risk of postoperative apnea and bradycardia. Anesthesia techniques aimed to provide good surgical conditions include general anesthesia and central neuroaxial techniques. There are still significant complications after these techniques and none is superior. METHODS/MATERIALS: A retrospective search of our department's computer database was conducted on ex-premature neonates, post-menstrual age of 48 weeks and under, who received general anesthesia and ilioinguinal-iliohypogastric nerve block for bilateral inguinal herniotomy from 1997 to 2009. RESULTS: Eighty-two neonates were selected. All medical notes were traced and information including the demographics, co-morbidities and perioperative data were obtained. The mean gestational age was 30.3 weeks (sd ± 3.2) and the mean post-conception age was 40.0 weeks (sd ± 3.1). Mean birth weight was 1284 g (sd ± 518) and mean weight at the time of surgery was 2795 g (sd ± 958). Thirty-two (39.0%) neonates had apnea of prematurity, which required caffeine treatment. Thirty-five (42.7%) neonates required intubation for ventilatory support preoperatively. There was a good success rate of the ilioinguinal-iliohypogastric nerve block in 73 (89.0%) patients. They were deemed successful clinically by the attending anesthesiologist. No perioperative rescue opioid was required. Four neonates had postoperative apnea requiring intervention. CONCLUSION: Ilioinguinal-iliohypogastric nerve block has a success rate similar to other techniques and when combined with general anesthesia, provides a viable alternative technique of anesthesia in these high-risk patients.

Evaluation of emergence delirium in Asian children using the Pediatric Anesthesia Emergence Delirium Scale.

BACKGROUND: Emergence delirium (ED) is a common problem in children recovering from general anesthesia. ED causes disruption in the postanesthetic care unit, making nursing and monitoring more difficult, and is potentially dangerous to the child. The greatest hindrance to understanding ED was the lack of a standardized tool to assess it. The Pediatric Anesthesia Emergence Delirium (PAED) Scale was recently described to measure the degree of ED in children. In this prospective observational study, we sought to evaluate the incidence of ED by grading emergence behavior using the PAED Score in healthy Asian children undergoing outpatient surgery. METHODS: Three hundred sixteen children aged 2-12 years undergoing general anesthesia for elective outpatient surgery were included. No premedication was administered. Induction behavior was graded using the induction compliance checklist, and the presence of any excitation on induction documented. Emergence behavior was recorded using the PAED Scale, and the children were separately assessed for clinical agitation. RESULTS: One hundred and thirty-six children (43%) had PAED Scores >0 and 33 (10.4%) had PAED Scores of >or=10. Only 28 children (8.9%) had clinical agitation consistent with ED, the rest were agitated for other reasons. A score of >or=10 on the PAED Scale was the best discriminator between presence and absence of clinical agitation. The area under the receiver operating characteristic curve for PAED Score of >or=10 was 0.98, with a true-positive rate (sensitivity) of 0.85 and a false-positive rate (1-specificity) of 0.041. Four factors were found to be predictive of ED. These include young age, poor compliance at induction, lack of intraoperative fentanyl use and rapid time to awakening. CONCLUSIONS: The incidence of ED is approximately 10% in our population of healthy, unpremedicated Asian children undergoing day surgery. Young age, poor compliance at induction, lack of intraoperative fentanyl use and rapid time to awakening were predictive risk factors for ED in our population. A PAED Score of >or=10 was correlated with clinically significant ED and appeared to be the ideal cutoff score for ED.

Contemporary management of aggression in an inner city mental health service.

OBJECTIVES: From 2002 to mid 2003, Royal Brisbane and Women's Hospital Mental Health experienced increased patient - staff aggression and staff injury which resulted in staff conflict and recruitment difficulties. Strategies introduced to reduce the frequency and impact of aggression in the mental health service were evaluated. METHOD: By mid 2003, incident data indicated increasing aggressive incidents. Based on this, an aggression management strategy was developed which included improved staff communication, new acute pharmacological treatment protocols, mandatory staff aggression management training, personal alarms and aggression risk assessment tools. RESULTS: Following the introduction of the strategy in early 2004, there was a reduction of 40% in aggressive incidents and a 56% reduction in staff injuries in 2005 compared to 2003 levels. A more assertive approach to tranquillisation was not associated with an increased adverse event rate for patients. CONCLUSIONS: A co-ordinated strategy can contain and reduce aggressive incidents in acute inpatient mental health settings. These strategies are transferable to other health settings including Emergency Departments.

A comparison between single- and double-breath vital capacity inhalation induction with 8% sevoflurane in children.

BACKGROUND: This study was conducted to determine if a double-breath (DB) vital capacity (VC) rapid inhalation induction using immediate high-inspired concentration of sevoflurane is as well tolerated as a single-breath (SB) technique and if it results in a shorter induction time. METHODS: A total of 104 children, ASA I-II, 6 year and above, undergoing elective surgery were randomly assigned to two groups: SB VC inhalation induction or DB VC inhalation induction with 8% sevoflurane in 66% nitrous oxide. The induction time, complications (cough, laryngospasm, breath-hold, movement, salivation) and level of satisfaction were documented. RESULTS: Induction was significantly faster in the DB group (41 +/- 9 s) compared with the SB group (50 +/- 14 s). DB inhalation induction was associated with fewer complications (15.4%) than the SB technique (50%). CONCLUSIONS: Double-breath VC inhalation induction with 8% sevoflurane is as well tolerated as a SB technique and results in a faster onset of anaesthesia.

Effective reduction of anxiety and pain during venous cannulation in children: a comparison of analgesic efficacy conferred by nitrous oxide, EMLA and combination.

BACKGROUND: EMLA cream is the current technique of choice to reduce pain during venous cannulation in most paediatric practice. Its use is limited by logistic arrangements and failure to improve cooperation and allay anxiety. Nitrous oxide (N2O) would appear to be an effective alternative. A combination technique may be useful in selected patients. METHODS: One hundred and twenty unpremedicated ASA 1 and 2 day surgery patients, aged 8-15 years were randomized into group 1 (EMLA + air/O2), group 2 (50% N2O/50% O2) and group 3 (EMLA + 50% N2O/50% O2). All patients underwent cannulation on the dorsum of the hand with a 22-G intravenous catheter. Pain behaviour before cannulation was assessed by an observer with Children's Hospital of Eastern Ontario Pain Scale (CHEOPS). Pain during cannulation was evaluated with CHEOPS by an observer and Visual Analogue Scale (VAS) (0-100 mm) by the patient. Satisfaction score (0-100%) for the experience were reported by the patient. Degree of ease of cannulation, time for cannulation were assessed. Heart rate, oxygen saturation were compared before, during and after cannulation. RESULTS: The self-reported VAS for group 3 (10.10 +/- 14.99) was significantly lower than group 1 (26.13 +/- 27.59) and group 2 (18.35 +/- 18.11) (P = 0.003). No significant difference existed between VAS for group 1 and 2. There were also significantly more patients with VAS = 0 in group 3 (23/40) versus group 2 (11/40) versus group 1 (10/40), P = 0.004. The satisfactory score in group 3 (93 +/- 9.96) was significantly higher (P = 0.039) than group 1 (81.13 +/- 24.61) and group 2 (84 +/- 22.02). The increase in CHEOPS from before to during cannulation was significant only in group 1 (P = 0.002). There was no significant difference between frequency of patients with side-effects, ease of cannulation and time taken for cannulation in the three groups. CONCLUSIONS: EMLA and 50% N2O are equally effective for pain reduction while a combination technique provides superior analgesia and satisfaction. N2O has an advantage over EMLA in reduction of pain related behaviour in older children.

Difficult paediatric intubation when fibreoptic laryngoscopy fails.

We report an unusual problem with fibreoptic bronchoscopy in an 8-year-old girl with Negar syndrome. She had a history of difficult airway since birth, and had undergone mandibular distraction for severe obstructive sleep apnoea when she was aged 2 years. Nagar syndrome is a Treacher-Collins like syndrome with normal intelligence, conductive bone deafness and problems with articulation. The patients have malar hypoplasia with down slanting palpebral fissures, high nasal bridge, micrognathia, absence of lower eyelashes, low set posteriorly rotated ears, preauricular tags, atresia of external ear canal, cleft palate, hypoplasia of thumb, with or without radius, and limited elbow extension. Protracted attempts with a fibreoptic bronchoscope failed to visualize the glottis, and this was only possible when the tube was guided to the larynx by blind nasal intubation. Apparently, the healing of the wounds for the mandibular distraction in the mandibular space on the inside of the rami of the mandible had caused differential fibrosis on either side of the hyoid, leading to a triplane distortion of the larynx with a left shift, clockwise rotation to a 2-8 o'clock direction and a slight tilt towards the left pharyngeal wall. The large epiglottis overlying this had precluded a view of the larynx. Finally, the older technique of breathguided intubation facilitated fibreoptic bronchoscopy to achieve tracheal intubation.