Error traps in patients with congenital heart disease undergoing noncardiac surgery.

Patients with congenital heart disease are living longer due to improved medical and surgical care. Congenital heart disease encompasses a wide spectrum of defects with varying pathophysiology and unique anesthetic challenges. These patients often present for noncardiac surgery before or after surgical repair and are at increased risk for perioperative morbidity and mortality. Although there is no singular safe anesthetic technique, identifying potential error traps and tailoring perioperative management may help reduce morbidity and mortality. In this article, we discuss five error traps based on the collective experience of the authors. These error traps can occur when providing perioperative care to patients with congenital heart disease for noncardiac surgery and we present potential solutions to help avoid adverse outcomes.

Perioperative Staff's Experiences of Premedication for Children.

PURPOSE: Providing perioperative care for children who express anxiety or react with negative anxiety-associated consequences can be a challenge. The use of premedication is established as an important intervention for young children before surgery, yet research into care providers' experiences of premedication is limited. The aim of this study was to explore perioperative staff's experiences of premedication for preschool-age children. DESIGN: A descriptive inductive qualitative study was performed based on focus group discussions. METHODS: A purposive sample of a team from the operating department with experience in anesthetizing and caring for children in the perioperative period was interviewed in small focus groups: five preoperative and postoperative care nurses, five nurse anesthetists, and five anesthesiologists. The transcribed text was categorized using qualitative content analysis. FINDINGS: The content analysis revealed three themes: a matter of time, do not wake the sleeping bear, and on responsive tiptoes. CONCLUSIONS: Care providers must adapt their work to the child's emotional state of mind and needs, allowing time for the child to trust and accept the premedication and for the premedication to reach its peak effect. Premedication provides light sleep preoperatively, which requires careful treatment of the child to avoid emotional reactions, and the postoperative path is most peaceful when the premedication supports a long duration of sedation. Our findings highlight the need for safety precautions and a permissive and flexible organization with the goal of achieving a smooth and safe journey for the child in the perioperative path.

Emergence delirium: an overview with an emphasis on the use of electroencephalography in its management.

Emergence delirium remains a clinically significant issue, which often leads to distress among pediatric patients, parents, and staff in the short term; and may also result in postoperative maladaptive behaviors persisting for weeks to months. Although several diagnostic tools are available, the Pediatric Anesthesia Emergence Delirium Scale is most often utilized. Many risk factors contributing to the likelihood of a pediatric patient developing emergence delirium have been identified; however, its accurate prediction remains challenging. Recently, intraoperative electroencephalographic monitoring has been used to improve the prediction of emergence delirium. Similarly, it may also prevent emergence delirium if the anesthesiologist ensures that the at-risk patient rouses only after the onset of appropriate electroencephalogram patterns, thus indicating a change to natural sleep. Prediction of at-risk patients is crucial; preventing emergence delirium may begin early during patient preparation by using non-pharmacological methods (i.e., the ADVANCE program). Intraoperative electroencephalographic monitoring can predict emergence delirium. This review also discusses a range of pharmacological treatment options which may assist the anesthesiologist in preventing emergence delirium among at-risk patients.

Pediatric anesthesia training in Israel and Palestine: Realities versus expectations.

Israel is a young country with a rather young system of medical education. This educational review serves to illuminate the similarities and differences in the training of a pediatric Anesthesiologist in both Israel and Palestine.

Postdural Puncture Headaches in Pediatric Patients: A Review of Options When Repeated Epidural Blood Patches Do Not Work.

We present the case of an adolescent with refractory postdural puncture headache (PDPH), whose symptoms resolved with a sphenopalatine ganglion (SPG) nerve block using a J-tip style catheter. Our patient was treated with multiple modalities, including conservative and medical management, multiple epidural blood patches, and different nerve blocks. We discussed different treatments for the PDPH, why each modality did not work, and why our SPG block with a J-tip catheter possibly provided a better sympathetic block in a patient with intractable PDPH for two weeks.

The endocrinologist gap: Managing diabetes patients in absence of a specialist.

The treatment of pediatric patients with diabetes is frequently orchestrated within a multidisciplinary framework at tertiary, specialized institutions. In situations where emergent surgery is indicated or when a procedure is scheduled in a facility devoid of an endocrinology service, the onus of managing perioperative glycemic levels may rest with the attending anesthesiologist. The objective of this review is to furnish a comprehensive examination of the anesthetic considerations and perioperative governance of pediatric patients with diabetes. Furthermore, this paper delineates a streamlined protocol for perioperative glycemic control, tailored to both major and minor surgical interventions.

Incidence of complications after nonoperating room anesthesia in children in a low- and middle-income country: A prospective and observational study.

INTRODUCTION: Nonoperating room anesthesia is a growing field of medicine that can have an increased risk of complications, particularly in low- and middle-income countries. AIMS: The aim of this study was to describe the incidence of complications after pediatric nonoperating room anesthesia and investigate its risk factors. METHODS: In this prospective observational study, we included all children aged less than 5 years who were sedated or anesthetized in the radiology setting of a university hospital in a low- and middle-income country. Patients were divided into two groups: complications or no-complications groups. Then, we compared both groups, and univariable and multivariable logistic regression models were used to investigate the main risk factors for complications. RESULTS: We included 256 children, and the incidence of complications was 8.6%. The main predictors of nonoperating room anesthesia-related morbidity were: critically-ill children (aOR = 2.490; 95% CI: 1.55-11.21), predicted difficult airway (aOR = 5.704; 95% CI: 1.017-31.98), and organization insufficiencies (aOR = 52.6; 95% CI:4.55-613). The preanesthetic consultation few days before NORA protected against complications (aOR = 0.263; 95%CI: 0.080-0.867). CONCLUSIONS: The incidence of complications during NORA among children in our radiology setting remains high. Investigating predictors for morbidity allowed high-risk patient selection, which allowed taking precautions. Several improvement measures were taken to address the organization's insufficiencies.

Virtual parental presence with coaching for reducing preoperative anxiety in children: a feasibility and pilot randomized controlled trial.

BACKGROUND: Preoperative anxiety in children causes negative postoperative outcomes. Parental presence at induction is a non-pharmacological strategy for relieving anxiety; nevertheless, it is not always possible or effective, namely when parents are overly anxious. Parental presence via video has been demonstrated to be useful in other contexts (divorce, criminal court). This study reports the feasibility of a randomized controlled trial to investigate the effect of video parental presence and parental coaching at induction on preoperative anxiety. METHODS: The study was a randomized, 2 × 2 factorial design trial examining parental presence (virtual vs. physical) and coaching (provided vs. not provided). Feasibility was assessed by enrollment rate, attrition rate, compliance, and staff satisfaction with virtual method with the NASA-Task Load Index (NASA-TLX) and System Usability Scale (SUS). For the children's anxiety and postoperative outcomes, the modified Yale Preoperative Anxiety Scale (mYPAS) and Post-Hospitalization Behavioral Questionnaire (PHBQ) were used. Parental anxiety was evaluated with the State-Trait Anxiety Inventory (STAI) questionnaire. RESULTS: A total of 41 parent/patient dyads were recruited. The enrollment rate was 32.2%, the attrition rate 25.5%. Compliance was 87.8% for parents and 85% for staff. The SUS was 67.5/100 and 63.5/100 and NASA-TLX was 29.2 (21.5-36.8) and 27.6 (8.2-3.7) for the anesthesiologists and induction nurses, respectively. No statistically significant difference was found in mYPAS, PHBQ and STAI. CONCLUSION: A randomized controlled trial to explore virtual parental presence effect on preoperative anxiety is feasible. Further studies are needed to investigate its role and the role of parent coaching in reducing preoperative anxiety.

Temporomandibular Joint Ankylosis in a Three-Year-Old Female: Anaesthesia, Airway Management, and Mandibular Distraction Osteogenesis.

Temporomandibular joint (TMJ) ankylosis is generally characterised by a complex aetiology, with several contributing causes, including infections, autoimmune diseases, trauma, and congenital anomalies. This case report describes a three-year-old female suffering from traumatic temporomandibular ankylosis with retrognathia, severe mouth-opening restriction, and obstructive sleep apnea (OSA). The present case highlights the difficulties with TMJ ankylosis, especially when access to healthcare is sought out late and delayed diagnosis is prevalent. Mandibular distraction osteogenesis and awake fiberoptic intubation were used in the surgical and anaesthetic management of this case, with the otorhinolaryngology team on standby to perform a tracheostomy if required, highlighting the necessity of a multidisciplinary approach in such cases. Patients with TMJ ankylosis have significant life-altering changes, including psychological stress, chewing difficulty, speech difficulties, facial distortion, and speech impediment. When OSA progresses, it also presents more health risks. For the purpose of treating TMJ ankylosis, avoiding serious problems, and enhancing patient well-being, prompt diagnosis and therapy are crucial. In order to optimise patient results, this case study highlights the need for knowledge and research in the treatment of TMJ ankylosis as well as the requirement of medical professionals working together in a synergistic way.

Comparison of the HugeMed video laryngoscope with the Macintosh direct laryngoscope for nasotracheal tracheal intubation in children undergoing dental treatment: a randomized controlled clinical study.

OBJECTIVES: The aim of this study was to compare the performance of the HugeMed® videolaryngoscope with a direct Macintosh laryngoscope for nasotracheal intubation. METHODS: Eighty-eight children aged 4-10 years were randomly assigned to either the HugeMed® videolaryngoscope (HVL) or the Macintosh direct laryngoscope (MDL) group. Intubation difficulty, glottic view grade, time-to-intubation, number of tracheal intubation attempts, use of external laryngeal manipulation and Magill forceps, recovery time, pediatric-anesthesia-delirium-scale (PAEDS) scores, pain due to tracheal intubation, and laryngeal bleeding were evaluated. RESULTS: Easy tracheal intubation incidence was higher in the HVL group than that in the MDL group (p = 0.001). Glottic view was better in the HVL group as compared to the MDL group (p = 0.027). There was no difference between the groups in terms of time-to-tracheal intubation, number of tracheal intubation attempts, Magill forceps usage, pain, and bleeding due to tracheal intubation. The need for external laryngeal manipulation (p = 0.004) and PAEDS scores (p = 0.006) were higher in the MDL group than those in the HVL group. CONCLUSION: HugeMed® videolaryngoscope may provide easier tracheal intubation, create a better glottic view, and significantly reduce the need for additional manipulation compared to the Macintosh direct laryngoscope, for nasotracheal intubation. CLINICAL TRIAL REGISTRATION: www.clinicaltrial.gov identifier is NCT05121597.

Current anesthesia practice for preterm infants undergoing surgery for necrotizing enterocolitis: A European survey.

STUDY OBJECTIVE: Necrotizing enterocolitis (NEC) is a life-threatening intestinal illness mostly affecting preterm infants, which commonly requires surgery. Anesthetic care for these patients is challenging, due to their prematurity and critical illness with hemodynamic instability. Currently, there are no guidelines for anesthetic care for these vulnerable patients. Therefore, this study aimed to describe current anesthesia practices across Europe for infants undergoing surgery for NEC. DESIGN: Cross-sectional survey study. PARTICIPANTS: Anesthesiologists working in centers where surgery for NEC is performed across Europe. MEASUREMENTS: A 46-item questionnaire assessing protocols for anesthesia practice, preoperative care, intraoperative care, postoperative care, and the respondent's opinion on the adequacy of anesthetic care for patients with NEC in their center. MAIN RESULTS: Out of the 173 responding anesthesiologists from 31 countries, approximately a third had a written standard protocol for anesthetic care in infants. Three quarters of the respondents screened all patients with NEC preoperatively, and a third structurally performed preoperative multidisciplinary consultation. For induction of general anesthesia, most respondents opted for intravenous anesthesia (n = 73, 43%) or a combination of intravenous and inhalation anesthesia (n = 57, 33%). For intravenous induction, they mostly used propofol (n = 58, 44%), followed by midazolam (n = 43, 33%) and esketamine (n = 42, 32%). For maintenance of anesthesia, inhalation anesthetic agents were more commonly used (solely: n = 71, 41%; in combination: n = 37, 22%), almost exclusively with sevoflurane. Postoperative analgesics mainly included paracetamol and/or morphine. Sixty percent of the respondents (n = 104) considered their anesthetic care for patients with NEC adequate. Suggestions for further improvement mainly revolved around monitoring, protocols, and collaboration. CONCLUSIONS: Anesthesia practice for infants undergoing surgery for NEC was highly variable. Most respondents considered the provided anesthetic care for patients with NEC adequate, but also recognized opportunities for further improvement, especially with regards to monitoring, protocols, and interdisciplinary collaboration.

The Safety of the Laryngeal Mask Airway in Adenotonsillectomy: A Systematic Review and Meta-Analysis.

BACKGROUND: Adenotonsillectomy is one of the most common surgical procedures worldwide. The current standard for securing the airway in patients undergoing adenotonsillectomy is endotracheal tube (ETT) intubation. Several studies have investigated the use of the laryngeal mask airway (LMA) in this procedure. We conducted a systematic review and meta-analysis to compare the safety and efficacy of the LMA versus ETT in adenotonsillectomy. METHOD: Databases were searched from inception to 2022 for randomized controlled trials and comparative studies. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. The primary outcome is the rate of perioperative respiratory adverse events (PRAEs). Secondary outcomes included the rate of conversion to ETT, desaturations, nausea/vomiting, and surgical time. A subgroup analysis, risk of bias, publication bias, and Grading of Recommendations Assessment, Development, and Evaluation (GRADE) assessments were also performed. RESULTS: Twelve studies were included in the analysis (4176 patients). The mean overall conversion to ETT was 8.36% [95% confidence interval (CI) = 8.17, 8.54], and for the pediatric group 8.27% (95% CI = 8.08, 8.47). The mean rate of conversion to ETT secondary to complications was 2.89% (95% CI = 2.76, 3.03) while the rest was from poor surgical access. Overall, there was no significant difference in PRAEs [odds ratio (OR) 1.16, 95% CI = 0.60, 2.22], desaturations (OR 0.79, 95% CI = 0.38, 1.64), or minor complications (OR 0.89, 95% CI = 0.50, 1.55). The use of LMA yielded significantly shorter operative time (mean difference -4.38 minutes, 95% CI = -8.28, -0.49) and emergence time (mean difference -4.15 minutes, 95% CI = -5.63, -2.67). CONCLUSION: For adenotonsillectomy surgery, LMA is a safe alternative to ETT and requires less operative time. Careful patient selection and judgment of the surgeon and anesthesiologist are necessary, especially given the 8% conversion to ETT rate.

Anatomical Studies Evaluating Pediatric Regional Anesthesia: A Scoping Review.

BACKGROUND: Pediatric regional anesthesia has been driven by the gradual rise in the adoption of opioid-sparing strategies and the growing concern over the possible adverse effects of general anesthetics on neurodevelopment. Nonetheless, performing regional anesthesia studies in a pediatric population is challenging and accounts for the scarce evidence. This study aimed to review the scientific foundation of studies in cadavers to assess regional anesthesia techniques in children. METHODS: We searched the following databases MEDLINE, EMBASE, and Web of Science. We included anatomical cadaver studies assessing peripheral nerve blocks in children. The core data collected from studies were included in tables and comprised block type, block evaluation, results, and conclusion. RESULTS: The search identified 2409 studies, of which, 16 were anatomical studies on the pediatric population. The techniques evaluated were the erector spinae plane block, ilioinguinal/iliohypogastric nerve block, sciatic nerve block, maxillary nerve block, paravertebral block, femoral nerve block, radial nerve block, greater occipital nerve block, infraclavicular brachial plexus block, and infraorbital nerve block. CONCLUSION: Regional anesthesia techniques are commonly performed in children, but the lack of anatomical studies may result in reservations regarding the dispersion and absorption of local anesthetics. Further anatomical research on pediatric regional anesthesia may guide the practice.

Assessment of risk factors for adverse events in analgosedation for pediatric endoscopy: A 10-year retrospective analysis.

OBJECTIVES: Data regarding the occurrence of complications specifically during pediatric anesthesia for endoscopic procedures is limited. By evaluating such data, factors could be identified to assure proper staffing and preparation to minimize adverse events and improve patient safety during flexible endoscopy. METHODS: This retrospective cohort study included children undergoing anesthesia for gastroscopy, colonoscopy, bronchoscopy, or combined endoscopic procedures over 10-year period. The primary study aim was to evaluate the incidence of complications and identify risk factors for adverse events. RESULTS: Overall, 2064 endoscopic procedures including 1356 gastroscopies (65.7%), 93 colonoscopies (4.5%), 235 bronchoscopies (11.4%), and 380 combined procedures (18.4%) were performed. Of the 1613 patients, 151 (7.3%) patients exhibited an adverse event, with respiratory complications being the most common (65 [3.1%]). Combination of gastrointestinal endoscopies did not lead to an increased adverse event rate (gastroscopy: 5.5%, colonoscopy: 3.2%). Diagnostic endoscopy as compared to interventional had a lower rate. If bronchoscopy was performed, the rate was similar to that of bronchoscopy alone (19.5% vs. 20.4%). Age < 5.8 years or body weight less than 20 kg, bronchoscopy, American Society of Anesthesiologists status ≥ 2 or pre-existing anesthesia-relevant diseases, and urgency of the procedure were independent risk factors for adverse events. For each risk factor, the risk for events increased 2.1-fold [1.8-2.4]. CONCLUSIONS: This study identifies multiple factors that increase the rate of adverse events associated anesthesia-based endoscopy. Combined gastrointestinal procedures did not increase the risk for adverse events while combination of bronchoscopy to gastrointestinal endoscopy showed a similar risk as bronchoscopy alone.

Delayed Sequence Intubation in Children, Why Not?

Tracheal intubation in pediatric patients is a clinical scenario that can quickly become an emergency. Complication rates can potentially reach up to 60% in rapid sequence intubation. An alternate to this is delayed sequence intubation, which may reduce potential complications-mostly hypoxemia-and can be especially useful in non-cooperative children. This technique consists of the prior airway and oxygenation optimization. This is done through sedation using agents that preserve ventilatory function and protective reflexes and continuous oxygen therapy-prior and after the anesthetic induction-using nasal prongs. The objective of this narrative review is to provide a broader perspective on delayed sequence intubation by defining the concept and indications; reviewing its safety, effectiveness, and complications; and describing the anesthetic agents and oxygen therapy techniques used in this procedure.