Pediatric Pain Screening Tool: A Simple 9-Item Questionnaire Predicts Functional and Chronic Postsurgical Pain Outcomes After Major Musculoskeletal Surgeries.

Reliable, clinic-friendly screening for Chronic postsurgical pain (CPSP) risk is unavailable. Within a prospective, observational study, we evaluated Pediatric Pain Screening Tool (PPST), a concise 9-item questionnaire, as a preoperative screening tool to identify those at higher risk for CPSP (Numerical Rating Scale > 3/10 beyond 3 months post-surgery) and poor function (disability/Functional Disability Inventory [FDI]/quality of life/ Pediatric Quality of Life) after spine fusion and Nuss procedures. Incidence of CPSP was 34.86% (38/109). We confirmed PPST scale stability, test re-test reliability (ICC = 0.68; P< .001); PPST measures were positively correlated with known CPSP risk factors (P< .001) preoperative pain (Pearson or Spearman Correlation Coefficient [SCC]:0.672), Child anxiety sensitivity index (SCC:0.357), Patient Related Outcome Measures Information System pain interference (SCC:0.569), Patient Related Outcome Measures Information System depression (SCC:0.501), Pediatric Quality of Life (SCC:-0.460) and insomnia severity index (SCC0.567). Preoperative PPST and PPST physical sub-scores (median(IQR) were higher in CPSP (2[0.5,4], 1[0,2]) compared to non-CPSP (1[0,3], 0[0,1.5]) groups (P= .026, P= .029) respectively. PPST scores/sub-scores positively correlated with higher FDI at 6 months but only PPST total and PPST psychosocial subscore correlated with higher FDI at 12 months. Based on ROC, optimal PPST cutoff for CPSP was 2 (63.9% sensitivity, 64.7% specificity). CPSP risk was high (48.94% risk) if PPST ≥ 2 (n = 47) and medium (22.81%) if PPST < 2 (n = 57) after spine/pectus surgery. General and risk-strata specific, targeted psychosocial non-pharmacological interventions, need to be studied. Findings need validation in diverse, larger cohorts. CLINICALTRIALS.GOV IDENTIFIER: NCT02998138. PERSPECTIVE: The article supports Pediatric Pain Screening Tool, a simple 9-item questionnaire, as a preoperative screening tool for CPSP and function 6-12 months after spine/pectus surgeries. PPST measures correlate with known risk factors for CPSP. Risk stratification and targeted preventive interventions in high-risk subjects are proposed.

First-attempt success rate of video laryngoscopy in small infants (VISI): a multicentre, randomised controlled trial.

BACKGROUND: Orotracheal intubation of infants using direct laryngoscopy can be challenging. We aimed to investigate whether video laryngoscopy with a standard blade done by anaesthesia clinicians improves the first-attempt success rate of orotracheal intubation and reduces the risk of complications when compared with direct laryngoscopy. We hypothesised that the first-attempt success rate would be higher with video laryngoscopy than with direct laryngoscopy. METHODS: In this multicentre, parallel group, randomised controlled trial, we recruited infants without difficult airways abnormalities requiring orotracheal intubation in operating theatres at four quaternary children's hospitals in the USA and one in Australia. We randomly assigned patients (1:1) to video laryngoscopy or direct laryngoscopy using random permuted blocks of size 2, 4, and 6, and stratified by site and clinician role. Guardians were masked to group assignment. The primary outcome was the proportion of infants with a successful first attempt at orotracheal intubation. Analysis (modified intention-to-treat [mITT] and per-protocol) used a generalised estimating equation model to account for clustering of patients treated by the same clinician and institution, and adjusted for gestational age, American Society of Anesthesiologists physical status, weight, clinician role, and institution. The trial is registered at ClinicalTrials.gov, NCT03396432. FINDINGS: Between June 4, 2018, and Aug 19, 2019, 564 infants were randomly assigned: 282 (50%) to video laryngoscopy and 282 (50%) to direct laryngoscopy. The mean age of infants was 5·5 months (SD 3·3). 274 infants in the video laryngoscopy group and 278 infants in the direct laryngoscopy group were included in the mITT analysis. In the video laryngoscopy group, 254 (93%) infants were successfully intubated on the first attempt compared with 244 (88%) in the direct laryngoscopy group (adjusted absolute risk difference 5·5% [95% CI 0·7 to 10·3]; p=0·024). Severe complications occurred in four (2%) infants in the video laryngoscopy group compared with 15 (5%) in the direct laryngoscopy group (-3·7% [-6·5 to -0·9]; p=0·0087). Fewer oesophageal intubations occurred in the video laryngoscopy group (n=1 [<1%]) compared with in the direct laryngoscopy group (n=7 [3%]; -2·3 [-4·3 to -0·3]; p=0·028). INTERPRETATION: Among anaesthetised infants, using video laryngoscopy with a standard blade improves the first-attempt success rate and reduces complications. FUNDING: Anaesthesia Patient Safety Foundation, Society for Airway Management, and Karl Storz Endoscopy.

Tracking tidal volume noninvasively in volunteers using a tightly controlled temperature-based device: A proof of concept paper.

INTRODUCTION: There is a paucity of noninvasive respiratory monitors for patients outside of critical care settings. The Linshom respiratory monitoring device is a novel temperature-based respiratory monitor that measures the respiratory rate as accurately as capnography. OBJECTIVES: Determine whether the amplitude of the Linshom temperature profile was an accurate, surrogate and qualitative metric of the tidal volume (VT ) that tracks VT in healthy volunteers. METHODS: Forty volunteers breathed room air spontaneously through a tight-fitting continuous positive airway pressure mask with a Linshom device mounted in the mask. VT was measured contemporaneously using a standalone Maquet Servo-i ICU ventilator. The amplitudes of the Linshom temperature profiles were paired with the contemporaneous VT measurements using least squares linear regression analysis and the coefficient of variation (R2 ) was determined. RESULTS: Forty volunteers completed the study. The data from 30 of the volunteers were analysed and are presented; data from 10 volunteers were not included due to protocol violations and/or technical issues unrelated to Linshom. The fluctuations in the amplitude of the Linshom temperature profiles mapped closely with the measured VT using least squares linear regression analyses yielding a mean R2 (95% CI) value of 0.87 (0.84-0.90). CONCLUSION: These results support the notion that the Linshom temperature profile is an accurate and reliable surrogate that tracks changes in VT in healthy volunteers. Further studies are warranted in patients in clinical settings to establish the effectiveness of this monitor.

Does intravenous acetaminophen reduce perioperative opioid use in pediatric tonsillectomy?

OBJECTIVE: Postoperative pain control is of significant interest in pediatric otolaryngology given the safety concerns with opioid use. We sought to determine if addition of intraoperative intravenous acetaminophen decreases perioperative morphine use in pediatric tonsillectomy. METHODS: This study is a retrospective cohort study performed at a tertiary care academic children's hospital. 166 pediatric patients (aged 1-16 years) who underwent tonsillectomy with or without adenoidectomy were for review. Seventy-four patients received intraoperative intravenous acetaminophen (intervention cohort), while ninety-two patients served as our control and did not receive any intraoperative intravenous acetaminophen. Perioperative (intraoperative and postoperative) morphine use was our primary outcome measure. Rate of adverse events in the post anesthesia care unit and time for discharge readiness were secondary outcome measures. Wilcoxon two-sample t-test approximation and Fisher's exact test were used for data analyses. RESULTS: Patients in the intravenous acetaminophen cohort received less morphine (mg/kg) intraoperatively (0.058 versus 0.070, p = 0.089) and in the post anesthesia care unit (0.034 versus 0.051, p = 0.034) than the control cohort. The median time to discharge readiness for the intravenous acetaminophen and control groups was 108.5 versus 105 min (p = 0.018). There was no adverse respiratory event (oxygen desaturation <92% lasting more than a minute, requiring bag mask ventilation or reintubation) in either group in the post anesthesia care unit. There were 5 (7%) episodes of postoperative vomiting in the IV APAP, while 2 (2%) were recorded in the control cohort (p = 0.244). CONCLUSION: Our findings suggest intraoperative intravenous acetaminophen use in pediatric tonsillectomy can decrease the perioperative use of opioid for optimal pain management.

Pre-medication before dental procedures: A randomized controlled study comparing intranasal dexmedetomidine with oral midazolam.

BACKGROUND: This study aimed to determine if intranasal dexmedetomidine is a superior pre-medication to oral midazolam in older, difficult children. METHODS: This was conducted as a prospective, single-blind randomized control trial in a tertiary care center. Seventy-five children, age >5 years and weight >20 kg, who needed general anesthesia for dental procedures were randomly assigned to be pre-medicated with either oral midazolam at a dose of 0.5 mg/kg (max 15 mg) or intranasal dexmedetomidine at a dose of 2 mcg/kg (max 100 mcg). The primary outcome studied was the patients' level of sedation when separated from their parents, which was assessed using a 5-point University of Michigan Sedation Scale. Secondary outcome studied was the level of anxiolysis assessed by the acceptance of mask induction using a 4-point scale. All assessments were made by one research person blinded to the study drug. RESULTS: The two groups were similar in age, sex, weight, pre-anesthetic behavior, time from pre-medication to anesthesia induction, and surgical time. A significantly higher proportion of patients who received dexmedetomidine had satisfactory sedation at separation from parents (69.4% vs 40.5%, P = .03) compared to those who received midazolam. There were no significant differences in the rate of acceptance of mask induction (80.6% vs 78.4%, P = 1.00). Intranasal dexmedetomidine was tolerated well when administered using a mucosal atomizer and without any clinically significant effect on heart rate or systolic blood pressure. CONCLUSIONS: Intranasal dexmedetomidine provides higher success rate in sedation and parental separation compared to oral midazolam, in older, difficult children.

Complications in Pediatric Regional Anesthesia: An Analysis of More than 100,000 Blocks from the Pediatric Regional Anesthesia Network.

WHAT WE ALREADY KNOW ABOUT THIS TOPIC: WHAT THIS ARTICLE TELLS US THAT IS NEW: BACKGROUND:: Complications in pediatric regional anesthesia are rare, so a large sample size is necessary to quantify risk. The Pediatric Regional Anesthesia Network contains data on more than 100,000 blocks administered at more than 20 children's hospitals. This study analyzed the risk of major complications associated with regional anesthesia in children. METHODS: This is a prospective, observational study of routine clinical practice. Data were collected on every regional block placed by an anesthesiologist at participating institutions and were uploaded to a secure database. The data were audited at multiple points for accuracy. RESULTS: There were no permanent neurologic deficits reported (95% CI, 0 to 0.4:10,000). The risk of transient neurologic deficit was 2.4:10,000 (95% CI, 1.6 to 3.6:10,000) and was not different between peripheral and neuraxial blocks. The risk of severe local anesthetic systemic toxicity was 0.76:10,000 (95% CI, 0.3 to 1.6:10,000); the majority of cases occurred in infants. There was one epidural abscess reported (0.76:10,000, 95% CI, 0 to 4.8:10,000). The incidence of cutaneous infections was 0.5% (53:10,000, 95% CI, 43 to 64:10,000). There were no hematomas associated with neuraxial catheters (95% CI, 0 to 3.5:10,000), but one epidural hematoma occurred with a paravertebral catheter. No additional risk was observed with placing blocks under general anesthesia. The most common adverse events were benign catheter-related failures (4%). CONCLUSIONS: The data from this study demonstrate a level of safety in pediatric regional anesthesia that is comparable to adult practice and confirms the safety of placing blocks under general anesthesia in children.

Who Needs a Pediatric Intensive Care Unit After Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis?

BACKGROUND: Hypotensive events (HEs) following posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) can lead to delayed neurologic postoperative deficits (DNPD). This study aimed to determine the incidence of HEs (mean arterial pressure [MAP] <60 mmHg) after PSF for AIS and identify predictors for HEs. METHODS: Medical records of 99 consecutive patients who had PSF for AIS were retrospectively reviewed (2011-2013). Perioperative data were collected. Patients were divided into two groups based on MAP readings by an arterial line in the pediatric intensive care unit immediately postoperatively into postoperative day one: Group 1 (MAP ≥60 mmHg) and Group 2 (multiple occurrences of MAPs <60 mmHg). Mean values were compared using the independent t test. Multiple logistic regression was used to estimate the association of preoperative and intraoperative parameters with multiple HEs. RESULTS: Group 1 had 68 patients (68.7%) and Group 2 had 31 patients (31.3%). None of the compared parameters were associated significantly with multiple HE. However, patients who did not exhibit HEs within the first four hours postoperatively remained stable throughout the rest of the postoperative period. Only those with HEs in the first four hours experienced subsequent HEs in the first 24 hours. There were no DNPD or other major complications. CONCLUSION: Results showed that the incidence of HEs after PSF in AIS can be as high as 31.3%. We did not find any significant risk factors. Although DNPD after PSF is a rare complication and we had none in this series, we suggest that these patients with multiple HEs may be at risk for DNPD as a result of hypotension and potential for cord ischemia. Therefore, all patients after PSF should be monitored in a pediatric intensive care unit-type environment or postanesthesia recovery room initially. If stable for, at least, the initial four hours, then patients should be good candidates for a less intensive environment. LEVEL OF EVIDENCE: Level 3.

Spinal epidural hematoma following a thoracic epidural in a child with sickle cell disease.

Acute liver dysfunction in the perioperative period may increase the risk of epidural hematoma in a patient with a neuraxial catheter. Coagulation testing needs to be carefully monitored in these patients. An epidural hematoma should be ruled out urgently by CT or MRI in cases of a persistent motor block.

Use of cuffed tracheal tubes in neonates, infants and children: A practice survey of members of the Society of Pediatric Anesthesia.

STUDY OBJECTIVE: This study aimed to characterize the current practice patterns with cuffed tracheal tubes (CTT) in neonates, infants, and children among members of the Society of Pediatric Anesthesia (SPA). DESIGN AND SETTING: An electronic mail survey was distributed using Survey Monkey to members of SPA between December 2013 and February 2014. Each member was permitted one response. PATIENTS/INTERVENTION/MEASUREMENTS: Not applicable as this is a practice survey study. MAIN RESULTS: A total of 805 (28%) of the 2901 members of the SPA responded. Of the respondents, 88% were from the US, 83% were fellowship trained, 82% practiced pediatric anesthesia >50% of the time, and 65% practiced in academic centers. Eighty-five percent used CTT >50% of the time in children >2 years and 60% used CTT in full-term neonates >50% of the time. Twenty-nine percent reported always using CTT whereas 5% reported never using CTT. Those in practice <5 years, who were fellowship trained or in academic practice used CTT more often in neonates compared with those in practice >20 years, not fellowship trained or in private practice (P< .0001, P= .0003 and P= .0005, respectively). The most common reason for avoiding CTT was concern about post-extubation stridor (39%). Almost 70% of respondents accept the TT if it passes the subglottis without resistance and has a leak at 15 to 20 cmH2O. More than 60% of respondents do not monitor cuff pressures in CTT. CONCLUSION: A majority of SPA members routinely use CTT in neonates, infants and children.

Linshom respiratory monitoring device: a novel temperature-based respiratory monitor.

PURPOSE: We sought to develop a temperature-based respiratory instrument to measure respiration noninvasively outside critical care settings. METHOD: Respiratory temperature profiles were recorded using a temperature-based noninvasive instrument comprised of three rapid responding medical-grade thermistors-two in close proximity to the mouth/nose (sensors) and one remote to the airway (reference). The effect of the gas flow rate on the amplitude of the tracings was determined. The temperature-based instrument, the Linshom Respiratory Monitoring Device (LRMD) was mounted to a face mask and positioned on a mannequin face. Respiratory rates of 5-40 breaths·min(-1) were then delivered to the mannequin face in random order using artificial bellows (IngMar Lung Model). Data from the sensors were collected and compared with the bellows rates using least squares linear regression and coefficient of determination. The investigators breathed at fixed rates of 0-60 breaths·min(-1) in synchrony with a metronome as their respiratory temperature profiles were recorded from sensors mounted to either a face mask or nasal prongs. The recordings were compared with a contemporaneously recorded sidestream capnogram from a CARESCAPE GEB450 Monitor. The extracted respiratory rates from the LRMD tracings and capnograms were compared using linear regression with a coefficient of determination and a Bland-Altman plot. RESULTS: The amplitude of the sensor tracings was independent of the oxygen flow rate. Respiratory rates from the new temperature-based sensor were synchronous and correlated identically with both the artificial bellows (r(2) = 0.9997) and the capnometer mounted to both the face mask and nasal prongs (r(2) = 0.99; bias = -0.17; 95% confidence interval, -2.15 to 1.8). CONCLUSIONS: Respiratory rates using the LRMD, a novel temperature-based respiratory instrument, were consistent with those using capnometry.

RéSUMé: OBJECTIF: Nous avons tenté de mettre au point un instrument respiratoire se fondant sur la température afin de mesurer la respiration de façon non invasive en dehors des unités de soins critiques. MéTHODE: Les profils de température respiratoire ont été enregistrés à l'aide d'un instrument non invasif se fondant sur la température et composé de trois thermistances de qualité médicale à réponse rapide ­ deux à proximité de la bouche et du nez (capteurs) et un troisième à l'écart des voies aériennes (référence). L'effet du débit gazeux sur l'amplitude des tracés a été déterminé. L'instrument fondé sur la température, nommément le dispositif de monitorage respiratoire Linshom (LRMD), a été fixé à un masque facial et positionné sur le visage d'un mannequin. Des fréquences respiratoires de 5-40 respirations·min−1 ont ensuite été livrées au visage du mannequin dans un ordre aléatoire à l'aide de soufflets artificiels (modèle de poumon IngMar). Les données des capteurs ont été colligées et comparées aux fréquences des soufflets à l'aide d'une méthode de régression linéaire des moindres carrés et d'un coefficient de détermination. Les chercheurs ont respiré à des fréquences fixes de 0-60 respirations·min−1 en synchronie avec un métronome pendant que leurs profils de température respiratoire étaient enregistrés par des capteurs fixés à un masque facial ou à des canules nasales. Les enregistrements ont été comparés à un tracé de capnogramme latéral enregistré simultanément par un moniteur CARESCAPE GEB450. Les fréquences respiratoires extraites des tracés du LRMD et des capnogrammes ont été comparées à l'aide d'une méthode de régression linéaire avec un coefficient de détermination et un graphique de Bland-Altman. RéSULTATS: L'amplitude des tracés des capteurs était indépendante du débit d'oxygène. Les fréquences respiratoires du nouveau capteur basé sur la température étaient synchrones et identiquement corrélées aux soufflets artificiels (r2 = 0,9997) et au capnomètre fixé au masque facial et aux canules nasales (r2 = 0,99; biais = −0,17; intervalle de confiance 95 %, −2,15 à 1,8). CONCLUSION: Les fréquences respiratoires mesurées à l'aide du LRMD, un nouvel instrument respiratoire fondé sur la température, étaient cohérentes à celles mesurées par capnométrie.

A Case of Freeman-Sheldon Syndrome: Anesthetic Challenges.

UNLABELLED: Patients with Freeman-Sheldon Syndrome (FSS) often need multiple surgical procedures. We present a case of FSS and discuss the anesthetic challenges associated with the case. CASE PRESENTATION: A 10-week-old female with FSS presented for elective Nissen fundoplication and gastrostomy tube insertion. She had a history of difficult intubation at birth. General anesthesia with inhalational anesthetic and spontaneous respirations technique was used. Fiber optic bronchoscope (FOB)-assisted nasal intubation was successful after failed attempts with a Miller blade, GlideScope, and intubation through a laryngeal mask airway (LMA). She did not exhibit any signs of malignant hyperthermia (MH) during or immediately after the procedure. DISCUSSION: Challenges to the anesthesiologist in a case with FSS include establishing IV access, intubating the trachea, risk of MH and MH-like symptoms, and postoperative pulmonary complications. Proper multidisciplinary preoperative planning is essential for optimum care of these patients, preferably in a tertiary care center.

Stridor in Neonates After Using the Microcuff® and Uncuffed Tracheal Tubes: A Retrospective Review.

BACKGROUND: We conducted a retrospective chart review to determine the frequency of stridor and contributing factors after the use of Microcuff® and uncuffed tracheal tubes (TTs) in neonates. METHODS: All neonates in our neonatal intensive care unit whose airways were intubated between May 2011 and June 2012 were included. Data were collected from the neonatal intensive care unit database and from the electronic anesthesia record. Extracted data included postmenstrual age (PMA) at birth, birth weight, TT size and type, duration of tracheal intubation, and number of reintubations. The use of racemic epinephrine, heliox, and/or dexamethasone postextubation was considered diagnostic of stridor. RESULTS: Of the 324 neonates whose data were reviewed, 27 (8.3%) developed postextubation stridor. Neonates who developed stridor were more premature (PMA at birth, 29.9 ± 5.8 vs 33.0 ± 4.8 weeks, P = 0.001), had a lower birth weight (1.56 ± 1.07 vs 2.02 ± 0.96 kg, P = 0.005), greater duration of intubation (median: 20 vs 3 days, P < 0.0001), and multiple reintubations (median: 2 vs 0, P < 0.0001). The frequency of stridor was 17.2% after using Microcuff TT and 7.5% after using uncuffed TTs (Fisher exact test, 2-sided P = 0.08 [95% confidence interval for difference in proportions: -9.4% to 28.7%]). In a multivariable logistic regression model, after adjusting for PMA, birth weight, duration of intubation, and number of reintubations, the use of a Microcuff TT was associated with increased odds of stridor (adjusted odds ratio = 9.27 [95% confidence interval: 1.88-45.67], P = 0.006). CONCLUSIONS: The use of the Microcuff TT is associated with increased odds of postextubation stridor in neonates compared with the use of uncuffed TT.