Teleconsultation in pediatric anesthesia: First assessment of feasibility, quality, and satisfaction in France.

INTRODUCTION: The COVID-19 pandemic has prompted the development of anesthesia teleconsultation in many countries. In pediatric anesthesia, data about anesthesia teleconsultation are scarce. The main objective of this prospective descriptive study was to provide an evaluation of the feasibility of pediatric anesthesia teleconsultation. Perception of the safety and quality, parental and medical satisfaction were also assessed. METHODS: From September to December 2020, patients undergoing a pediatric anesthesia teleconsultation in Toulouse University Hospital, using the TeleO™ dedicated teleconsultation platform were prospectively included. Feasibility was defined as the rate of anesthesia teleconsultations successfully performed using the TeleO™ platform alone. Questionnaires regarding the quality, safety, and satisfaction were filled in by physicians and families. RESULTS: A total of 114 children (3 months-17 years) were included in the study. Feasibility was 82%, failure was mainly caused by technical issues. Physicians estimated that the safety and quality of anesthetic preparation were optimal in 100% of cases. Anesthetists were satisfied (VAS ≥70/100) with the medical, technical, and relational (child/parents) aspects of anesthesia teleconsultation in 91%, 64%, and 84%/90% of cases respectively. Almost all parents (97%) stated that they would agree to anesthesia teleconsultation for a future procedure. CONCLUSION: In this first assessment, pediatric anesthesia teleconsultation appears to be feasible, with high rates of medical and parental satisfaction. Physicians' perception of the safety and quality of this process were positive. Improving the technical process might be a key determinant to promote further development of pediatric anesthesia teleconsultation.

A follow-up of pain reported by children undergoing outpatient surgery using a smartphone application: AlgoDARPEF multicenter descriptive prospective study.

ABSTRACT: In pediatric patients, pain remains the most common complaint after surgery. This French multicenter epidemiological study (AlgoDARPEF) aimed to evaluate the use of a smartphone application (App) to assess the duration and severity of pain experienced by children undergoing outpatient surgery. Children younger than 18 years scheduled for an elective outpatient procedure in one of the participating centers were eligible. Parents were invited to provide daily information for 10 days regarding their child's pain and comfort through a smartphone App using the Parents' Postoperative Pain Measure-Short-Form (PPPM-SF). Children older than 6 years could also provide self-assessments of pain using a numerical rating scale (NRS)-11. Data regarding pain medication, preoperative anxiety, postoperative nausea and vomiting, and parent satisfaction were also analyzed. Repeated-measures analyses of variances (ANOVAs) were used to compare the self-assessments and hetero-assessments of pain. Eleven centers participated in the study, and 1573 patients were recruited. Forty-nine percentage of parents (n = 772) actually used the App at least once. In all surgeries, the average pain rating on the PPPM-SF scale did not exceed 3/10 throughout the follow-up period, as well as for 4 main surgical specialties. Age, visceral surgery, and preoperative anxiety ≥ 4/10 were identified as independent risk factors for experiencing at least 1 episode of pain ≥4/10 during the first 48 postoperative hours. Although these findings indicated that postoperative pain management seems to be satisfactory in the families who used the App, some improvements in anxiety management are suggested. This study shows that inviting parents to use a smartphone App to assess and report the quality of postoperative management in pediatric patients provides useful information. A continuous report regarding pain and adverse events over a 10-day postoperative period by a self-reporting or parent's contribution is possible. Future studies should investigate the ability of live data collection using an App to ensure fast, efficient interactions between patients and physicians.

Ventilation in pediatric anesthesia: A French multicenter prospective observational study (PEDIAVENT).

INTRODUCTION: Protective ventilation is now a standard of care in adults. However, management of ventilation is heterogeneous in children and little is known regarding the mechanical ventilation parameters actually used during pediatric anesthesia. AIM: The aim of the study was to assess current ventilatory practices during pediatric anesthesia in France and to compare them with pediatric experts' statements, with a specific focus on tidal volume. PATIENTS AND METHODS: We conducted a prospective multicenter observational study, regarding the ventilatory management and the mechanical ventilation parameters, over two days (21 and 22 June 2017) in 29 pediatric centers in France. All children undergoing general anesthesia during these 2 days were eligible; those who required extracorporeal circulation or one-lung ventilation were excluded. RESULTS: A total of 701 children were included; median [IQR] age was 60 [24-120] months. Among the patients in whom controlled ventilation was used, 254/515 (49.3%) had an expired tidal volume >8 mL/kg and 44 children (8.8%) an expired tidal volume ≥10 mL/kg. Lower weight and use of a supraglottic airway device were significantly associated with provision of a tidal volume ≥10 mL/kg (odds ratio 0.94, 95% confidence interval [0.92; 0.97], P < .001 and 2.28 [1.20; 4.31], P = .012, respectively). The positive end-expiratory pressure was set at a median [IQR] of 4 [3-5] cmH2 O; it was <3 cmH2 O in 15.7% of children and not used in 56/499 (9.3%). Among intubated children, 57 (18.3%) received a tidal volume < 10 mL/kg with a positive end-expiratory pressure ≥3 cmH2 O in association with recruitment maneuvers. CONCLUSIONS: Ventilatory practices in children were heterogenous, and a large proportion of children were not ventilated as it is currently recommended by some experts.

Management of the child's airway under anaesthesia: The French guidelines.

OBJECTIVE: To provide French guidelines about "Airway management during paediatric anaesthesia". DESIGN: A consensus committee of 17 experts from the French Society of Anaesthesia and Intensive Care Medicine (Société Française d'Anesthésie-Réanimation, SFAR) and the Association of French speaking paediatric anaesthesiologists and intensivists (Association Des Anesthésistes Réanimateurs Pédiatriques d'Expression Francophone, ADARPEF) was convened. The entire process was conducted independently of any industry funding. The authors followed the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to assess the quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasised. Few recommendations were not graded. METHODS: The panel focused on 7 questions: 1) Supraglottic Airway devices 2) Cuffed endotracheal tubes 3) Videolaryngoscopes 4) Neuromuscular blocking agents 5) Rapid sequence induction 6) Airway device removal 7) Airway management in the child with recent or ongoing upper respiratory tract infection. Population, intervention, comparison, and outcomes (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. The analysis of the literature and the redaction of the recommendations were then conducted according to the GRADE® methodology. RESULTS: The SFAR Guideline panel provides 17 statements on "airway management during paediatric anaesthesia". After two rounds of discussion and various amendments, a strong agreement was reached for 100% of the recommendations. Of these recommendations, 6 have a high level of evidence (Grade 1 ± ), 6 have a low level of evidence (Grade 2 ± ) and 5 are experts' opinions. No recommendation could be provided for 3 questions. CONCLUSIONS: Substantial agreement exists among experts regarding many strong recommendations for paediatric airway management.

Development and validation of a risk score to predict the probability of postoperative vomiting in pediatric patients: the VPOP score.

BACKGROUND: Few data are available in the literature on risk factors for postoperative vomiting (POV) in children. OBJECTIVE: The aim of the study was to establish independent risk factors for POV and to construct a pediatric specific risk score to predict POV in children. METHODS: Characteristics of 2392 children operated under general anesthesia were recorded. The dataset was randomly split into an evaluation set (n = 1761), analyzed with a multivariate analysis including logistic regression and backward stepwise procedure, and a validation set (n = 450), used to confirm the accuracy of prediction using the area under the receiver operating characteristic curve (ROCAUC ), to optimize sensitivity and specificity. RESULTS: The overall incidence of POV was 24.1%. Five independent risk factors were identified: stratified age (>3 and <6 or >13 years: adjusted OR 2.46 [95% CI 1.75-3.45]; ≥6 and ≤13 years: aOR 3.09 [95% CI 2.23-4.29]), duration of anesthesia (aOR 1.44 [95% IC 1.06-1.96]), surgery at risk (aOR 2.13 [95% IC 1.49-3.06]), predisposition to POV (aOR 1.81 [95% CI 1.43-2.31]), and multiple opioids doses (aOR 2.76 [95% CI 2.06-3.70], P < 0.001). A simplified score was created, ranging from 0 to 6 points. Respective incidences of POV were 5%, 6%, 13%, 21%, 36%, 48%, and 52% when the risk score ranged from 0 to 6. The model yielded a ROCAUC of 0.73 [95% CI 0.67-0.78] when applied to the validation dataset. CONCLUSIONS: Independent risk factors for POV were identified and used to create a new score to predict which children are at high risk of POV.

[Allowing parents to enter the recovery room]. / Accueillir les parents en salle de surveillance postinterventionnelle.

At Necker-Enfants malades hospital, the presence of the parents alongside the child during the immediate postoperative period has been allowed and encouraged for a number of years. In order to standardise the practices in terms of allowing parents to enter post-anaesthetic recovery rooms, nurses have drawn up a procedure to follow. In parallel, a study and a satisfaction survey have been carried out in order to measure the benefits of this approach for parents and for the child undergoing the operation.

Neonatal outcome of gastroschisis is mainly influenced by nutritional management.

OBJECTIVE: The aim of the study was to evaluate early minimal enteral feeding (MEF) and gradual enteral nutrition increment on neonatal outcome of gastroschisis. PATIENTS AND METHODS: An intervention group was prospectively assessed and compared with an observational historical control group. The prospective study relied on a new protocol of enteral nutrition. According to the new protocol, MEF was initiated 5 days after bowel reintegration and milk amounts were increased 12 mL/kg/day. In the control group, enteral nutrition was delayed until resolution of postoperative ileus, and increment of feeding was not systematized. RESULTS: Twenty-two patients were included in the MEF group and compared with 51 control patients. Infants in the control group had lower gestational age (36 vs 35 gestational weeks [GW], P=0.03) and birth weight (2465 vs 2200 g, P=0.05). Time to first enteral nutrition (5 vs 11.5 days, P=0.0005) was significantly shorter in the MEF group. All patients in this group were fully enteral fed at day 60, though 30.4% of patients in the control group still needed parenteral nutrition at day 60 (P=0.004). Incidence of nosocomial infection was reduced (9% of patients vs 40%, P=0.016) and hospital stay tended to be shorter in the MEF group (40 vs 54.5 days, P=0.08). In the univariate analysis, factors influencing the length of parenteral nutrition during the 2 periods were the severity of perivisceritis and new nutritional protocol. In the multivariate analysis, only nutritional protocol was significantly associated with the length of parenteral nutrition (P=0.038). CONCLUSIONS: Early MEF and controlled increase of nutritional elements after bowel reintegration significantly improved outcome of gastroschisis in newborns.

Intestinal transplantation for total intestinal aganglionosis: a series of 12 consecutive children.

BACKGROUND: Management of patients with total intestinal aganglionosis (TIA) is a medical challenge because of their dependency on parenteral nutrition (PN). Intestinal transplantation (ITx) represents the only alternative treatment for patients with irreversible intestinal failure for achieving intestinal autonomy. METHODS: Among 66 patients who underwent ITx in our center, 12 had TIA. They received either isolated ITx (n = 4) or liver-ITx (LITx, n = 8) after 10 to 144 months of total PN. All grafts included the right colon. RESULTS: After a median follow-up of 57 months, the survival rate was 62.5% in the LITx group and 100% in the ITx patients. The graft survival rate was 62.5% in the LITx group and 75% in the ITx group. All the surviving patients were fully weaned from total PN, after a median of 57 days. Pull through of the colon allograft was carried out in all patients. Fecal continence is normal in all but one of the surviving children. CONCLUSION: These results suggest that ITx with colon grafting should be the preferred therapeutic option in TIA. Early referral to a transplantation center after diagnosis of TIA is critical to prevent PN-related cirrhosis and thereby to permit ITx, which is associated with a good survival rate.