Procedural sedation and analgesia in pediatric diagnostic and interventional radiology: An expert DELPHI consensus document developed by the ITALIAN scientific society of anesthesia, analgesia, resuscitation and intensive care (SIAARTI).

BACKGROUND: Children undergoing diagnostic and interventional radiology procedures often require sedation to achieve immobility and analgesia if the procedure is painful. In the past decades, leading scientific organizations have developed evidence-based guidelines for procedural sedation and analgesia in children outside of the operating room. Their recommendations are being applied to procedural sedation in radiology. However, some questions remain open regarding specific aspects contextualized to the radiology setting, such as elective prone sedation, the urgency of the procedure, when venous access or airway protection is required, and others. AIMS: To address the unresolved issues of procedural sedation and analgesia in pediatric diagnostic and interventional radiology. METHODS: An expert panel of pediatricians, pediatric anesthesiologists, intensivists, and neuroradiologists selected topics representative of current controversies and formulated research questions. Statements were developed by reviewing the literature for new evidence, comparing expertise and experience, and expressing opinions. Panelists' agreement with the statements was collected anonymously using the DELPHI method. RESULTS: Twelve evidence-based or expert opinion incorporate are presented, considering risks, benefits, and applicability. CONCLUSIONS: This consensus document, developed by a multidisciplinary panel of experts involved in the field, provides statements to improve the quality of decision-making practice in procedural sedation and analgesia in pediatric radiology.

Children and neonates anesthesia in magnetic resonance environment in Italy: an active call survey.

BACKGROUND: Pediatric anesthesia care in the Magnetic Resonance Imaging is a challenge for clinicians. The recent debate about the role of anesthetic agent on neural development, encouraged an evaluation of their actual activity in this environment. In this active call survey, the authors sought to delineate the Italian situation regarding national centers, staff involved, monitoring tools available and sedation techniques. METHODS: A complete sample of all national centers performing almost a pediatric discharge in the 2014 was obtained from Health Ministry registers. All Institutions were contacted for a prospective phone investigation and a three-section survey was fill out with the Physician in charge. A descriptive and exploratory analyzes about the organization setting of the Centers were performed. RESULTS: Among 876 Institution screened, only 106 (37%) met minimal criteria for inclusion. Children are managed by anesthesiologists in the 95% of cases, while neonates in the 54%. A dedicated nurse is present in 74% of centers. While a pulse oximetry is present in 100% of centers, the rate of prevalence of other monitoring is lower. A specific MRI-compatible ventilator is available in the 95% of Centers, but many tools are not equally homogenously distributed. Pharmacological approach is preferred in pediatric age (98%), but its use for newborns is reduced to 43%. CONCLUSIONS: We found significant heterogeneity in the daily clinical practice of sedation in MRI. Our results could be a starting point to evaluate the further evolution of approach to children and neonates in magnetic resonance setting. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT04775641.

Perioperative management of children with neuromuscular disorders based on a common protocol: A prospective, national study in Italy.

BACKGROUND: Children with neuromuscular diseases (NMDs) often display respiratory muscle weakness which increases the risk of postoperative pulmonary complications (PPCs) after general anaesthesia. Non-invasive ventilation (NIV) associated with mechanical insufflation-exsufflation (MI-E) can reduce the incidence and severity of PPCs. The aim of this study was to report our experience with a shared perioperative protocol that consists in using NIV combined with MI-E to improve the postoperative outcome of NMD children (IT-NEUMA-Ped). METHOD: We conducted a multicentre, observational study on 167 consecutive paediatric patients with NMDs undergoing anaesthesia from December 2015 to December 2018 in a network of 13 Italian hospitals. RESULTS: We found that 89% of the 167 children (mean age 8 years old) were at high risk of PPCs, due to the presence of at least one respiratory risk factor. In particular, 51% of them had preoperative ventilatory support dependence. Only 14 (8%) patients developed PPCs, and only two patients needed tracheostomy. Average hospital length of stay (LOS) was 6 (2-14) days. The study population was stratified according to preoperative respiratory devices dependency and invasiveness of the procedure. Patients with preoperative ventilatory support dependence showed significantly higher intensive care unit (ICU) admission rate and longer hospital LOS. CONCLUSION: Disease severity seems to be more related to the outcome of this population than invasiveness of procedures. NIV combined with MI-E can help in preventing and resolve PPCs.

Prevention of post-operative hyperalgesia in a heroin-addicted patient on methadone maintenance.

WHAT IS KNOWN AND OBJECTIVE: The exponential increase in chronic opioid consumers resulted in more challenges regarding post-operative pain management. Considering the usual hyperalgesic response to pain and the increased opioid-tolerance, a multidrug approach should be desirable. CASE DESCRIPTION: We described the strategy in pain management of a patient receiving methadone maintenance treatment, who underwent surgery associated with moderate post-operative pain. The combination of balanced general anaesthesia and intraoperative continuous low-dose infusion of ketamine assured an appropriate control of post-operative pain without increasing opioid consumption. Besides, it was not associated with psychomimetic effects. WHAT IS NEW AND CONCLUSION: Ketamine can effectively reduce opioid requirements in chronic opioid users on methadone maintenance therapy and should therefore be considered promptly as part of a multimodal perioperative analgesia management in this category of patients.

Follow-up to Age 4 Years of Treatment of Type 1 Retinopathy of Prematurity Intravitreal Bevacizumab Injection versus Laser: Fluorescein Angiographic Findings.

PURPOSE: To compare structural outcome at age 4 years of eyes treated with intravitreal injection of bevacizumab with fellow eyes treated with conventional laser photoablation in type 1 retinopathy of prematurity (ROP). DESIGN: Single, randomized, controlled trial. PARTICIPANTS: All inborn babies with type 1 zone 1 ROP at the Neonatal Intensive Care Unit of the Catholic University, Rome, from September 1, 2009, to March 31, 2012. METHODS: In 21 infants (42 eyes), 1 eye was randomized to receive an intravitreal injection of 0.5 mg bevacizumab; the fellow eye underwent conventional laser photoablation. Digital retinal imaging and fluorescein angiography (FA) were performed at an average of 4 years after treatment in follow-up after these studies performed at treatment and 9 months. MAIN OUTCOME MEASURES: Fluorescein angiograms were examined by 2 experts to document retinal and choroidal findings. RESULTS: Among the 20 bevacizumab-treated eyes available at 4 years of age, all showed abnormalities at the periphery (avascular area, vessel leakage, shunts, abnormal vessel branching, and tangles) or the posterior pole (hyperfluorescent lesions, absence of foveal avascular zone). These lesions were not observed in the majority of the lasered eyes. Among the 19 laser-treated eyes, leakage was noted in 1 eye, shunts and tangles were noted in 3 eyes, and macular abnormalities were noted in 3 eyes. CONCLUSIONS: Fluorescein angiography has shown potentially serious and long-term ocular effects that are present more commonly after treatment with bevacizumab for acute-phase ROP than after laser.

Phenylephrine eye drops in pediatric patients undergoing ophthalmic surgery: incidence, presentation, and management of complications during general anesthesia.

BACKGROUND: Phenylephrine eye drops are widely used as mydriatic agent to reach the posterior segment of the eye. In literature, many reports suggest a systemic absorption of this agent as a source of severe adverse drug reactions. Hence, we reviewed our experience with topical phenylephrine in ophthalmic surgery. METHODS: In May 2006, following US guidelines publication, a standard operating procedure was issued in our operating rooms to standardize the use of phenylephrine eye drops in our practice. Two years later, after the occurrence of a cluster of serious adverse drug reactions in infants undergoing surgery, a review of phenylephrine safety and systemic complications incidence was performed. RESULTS: We observed 451 pediatric patients, and 187 met the inclusions criteria: Among them, 4 experienced hemodynamic complications due to phenylephrine eye drops. The incidence of major complications was 2.1%. CONCLUSIONS: Two different patterns of side effects occurred. The first one was a cardiovascular derangement with severe hypertension and heart rate alterations; the other one involved exclusively pulmonary circuit causing early edema. These clinical manifestations, their duration, and treatment responses are all explainable by alfa1-adrenergic action of phenylephrine. This hypothetic pathogenesis has been confirmed also by the usefulness of direct vasodilators (anesthetic agents) and by the negative outcome occurred in the past with the use of beta-blockers.

Driving pressure: A useful tool for reducing postoperative pulmonary complications.

The operating room is a unique environment where surgery exposes patients to non-physiological changes that can compromise lung mechanics. Therefore, raising clinicians' awareness of the potential risk of ventilator-induced lung injury (VILI) is mandatory. Driving pressure is a useful tool for reducing lung complications in patients with acute respiratory distress syndrome and those undergoing elective surgery. Driving pressure has been most extensively studied in the context of single-lung ventilation during thoracic surgery. However, the awareness of association of VILI risk and patient positioning (prone, beach-chair, park-bench) and type of surgery must be raised.

Focus on the Role of Non-Invasive Respiratory Support (NRS) during Palliative Care in Patients with Life-Limiting Respiratory Disease.

The management of patients with life-threatening respiratory disease in the ICU and at home has become increasingly of interest over the past decades. Growing knowledge supports the use of NRS, aimed at improving patient comfort and improving quality of life. However, its role during palliative care is not well defined, and evidence of support remains limited. The aim of this narrative review is to examine the recent evidence relating to the use of non-invasive respiratory support at the end of life, in order to clarify who benefits and when. The literature research was conducted on PubMed, using MeSH words. A review of the relevant literature showed that non-invasive respiratory support techniques for patients with life-limiting respiratory disease vary (from high-flow oxygen therapy to conventional oxygen therapy, from CPAP to NPPV) and each has precise indications. To date, from the hospital to the home setting, the monitoring and application of these respiratory support techniques have varied widely. In conclusion, the choice of respiratory support in this category of patients should be based on the technique that will optimize the comfort of the patient and improve the quality of their life. On the other hand, regarding monitoring, both telemedicine and ultrasound diagnostics help to satisfy the patient's wish to spend the last period of his life in the home environment, to avoid inappropriately aggressive diagnostic interventions, and to reduce the high costs of hospitalized procedures in this category of patients.

Clinical Evaluation of Oral Midazolam Containing Cyclodextrin in Pediatric Magnetic Resonance: A Retrospective Cohort Study.

BACKGROUND: Reducing a child's level of anxiety before magnetic resonance imaging (MRI) procedures allows for better behavioral outcomes. The aim of this retrospective study was to evaluate anxiolytic efficacy of Midazolam/γ-cyclodextrin oral formulation. METHODS: We retrospectively reviewed 100 medical charts of children who, between 1 February and 31 July 2022, underwent MRI under general anesthesia with or without premedication with midazolam/γ-cyclodextrin. Primary outcome was comparison of behavior to facemask positioning, while secondary endpoints were degree of drugs acceptance, anxiolytic effect evaluation, child's behavior on separation, and sevoflurane need. RESULTS: Facemask positioning was accepted by 58% of the midazolam/γ-cyclodextrin group compared to 22% of children in the control group. The rate of acceptance was >90%. At the moment of separation from parent, none of the premedicated children needed to be restrained compared to 18% in the control group. A lower percentage of sevoflurane was needed for eye-closure at induction of anesthesia and for anesthesia maintenance. At emergence from anesthesia, 46% of children in the premedicated group compared to 66% of children in the control group showed transient agitation. CONCLUSIONS: Midazolam/γ-cyclodextrin showed a good profile of acceptance, satisfactory anxiolytic properties, and reduced need for anesthetics when administered to children before MRI under general anesthesia.

Myocardial Work by Speckle-Tracking Echocardiography in Heart Transplant Recipients: Association Between Global Work Efficiency and Coronary Allograft Vasculopathy.

Coronary allograft vasculopathy (CAV) is a leading cause of morbidity and mortality after heart transplantation. CAV is often diagnosed in later stages or during routine screening in asymptomatic subjects. Myocardial work (MW), calculated using left ventricular global longitudinal strain (LV-GLS) and systemic blood pressure, may be associated with the presence of CAV and outperform conventional echocardiographic parameters. In this retrospective observational study, heart transplant recipients who underwent regular follow-up at our institution between May 2022 and September 2023 were enrolled. All included patients underwent speckle-tracking echocardiography, including MW indexes. CAV was classified according to invasive coronary angiography or computed tomography performed within 12 months of index echocardiography. We collected all available clinical and echocardiographic parameters and evaluated the potential association with CAV. CAV was detected in 29 of 93 patients (31%) (CAV+). Of the MW indexes, the mean global work efficiency (GWE) was 90 ± 6% and was significantly lower in CAV+ than CAV- subjects (86 ± 7% vs 91 ± 4%, p <0.001). GWE (OR 0.86, CI 0.77 to 0.94, p = 0.002), E/e' ratio (OR 1.27, CI 1.08 to 1.52, p = 0.006), and left ventricular ejection fraction (OR 0.90; CI 0.81 to 0.98, p = 0.017) were independently associated with the presence of CAV. GWE (GWE vs LV-GLS, delta area under the curve 0.154, p = 0.047) and the proposed model (GWE+E/e' vs LV-GLS, delta area under the curve 0.198, p = 0.004) were significantly superior in stratifying the incremental risk for CAV compared with LV-GLS. In conclusion, GWE was observed to be independently associated with the presence of CAV. MW could represent a novel noninvasive screening method for CAV in heart transplant recipients. Larger and prospective studies are needed to confirm this hypothesis.

State of the Art in Pediatric Anesthesia: A Narrative Review about the Use of Preoperative Time.

This review delves into the challenge of pediatric anesthesia, underscoring the necessity for tailored perioperative approaches due to children's distinctive anatomical and physiological characteristics. Because of the vulnerability of pediatric patients to critical incidents during anesthesia, provider skills are of primary importance. Yet, almost equal importance must be granted to the adoption of a careful preanesthetic mindset toward patients and their families that recognizes the interwoven relationship between children and parents. In this paper, the preoperative evaluation process is thoroughly examined, from the first interaction with the child to the operating day. This evaluation process includes a detailed exploration of the medical history of the patient, physical examination, optimization of preoperative therapy, and adherence to updated fasting management guidelines. This process extends to considering pharmacological or drug-free premedication, focusing on the importance of preanesthesia re-evaluation. Structural resources play a critical role in pediatric anesthesia; components of this role include emphasizing the creation of child-friendly environments and ensuring appropriate support facilities. The results of this paper support the need for standardized protocols and guidelines and encourage the centralization of practices to enhance clinical efficacy.

St. Jude Trifecta versus Carpentier-Edwards Perimount Magna valves for the treatment of aortic stenosis: comparison of early Doppler-echocardiography and hemodynamic performance.

OBJECTIVE: Aim of this study was to compare the hemodynamic profiles of 2 aortic valve bioprostheses: the Carpentier Edwards Perimount Magna (CEPM) valve and the Trifecta valve. METHODS: 100 patients who underwent AVR for severe symptomatic AS between September 2011 and October 2012 were analyzed by means of standard trans-thoracic Doppler-echocardiography. RESULTS: Mean and peak gradients were significantly lower for the 21 mm Trifecta vs CEPM (11 +/- 4 vs 15 +/- 4 mmHg, and 20 +/- 6 vs 26 +/- 7 mmHg, respectively; all p < 0.05) and the 23 mm Trifecta vs CEPM (8 +/- 2 vs 14 +/- 4 mmHg, and 17 +/- 6 vs 25 +/- 9 mmHg; all p < 0.05). Effective orifice area tended to be slightly higher for the Trifecta valve. CONCLUSION: The new bioprosthetic valve Trifecta has an excellent hemodynamic profile, and lower trans-prosthesic gradients when compared to CEPM valve.

Real Evidence and Misconceptions about Malignant Hyperthermia in Children: A Narrative Review.

Malignant hyperthermia is a rare but life-threatening pharmacogenetic disorder triggered by exposure to specific anesthetic agents. Although this occurrence could affect virtually any patient during the perioperative time, the pediatric population is particularly vulnerable, and it has a five-fold higher incidence in children compared to adults. In the last few decades, synergistic efforts among leading anesthesiology, pediatrics, and neurology associations have produced new evidence concerning the diagnostic pathway, avoiding unnecessary testing and limiting false diagnoses. However, a personalized approach and an effective prevention policy focused on clearly recognizing the high-risk population, defining perioperative trigger-free hospitalization, and rapid activation of supportive therapy should be improved. Based on epidemiological data, many national scientific societies have produced consistent guidelines, but many misconceptions are common among physicians and healthcare workers. This review shall consider all these aspects and summarize the most recent updates.

Morbidity and mortality after anesthesia in early life in Italy. A subgroup analysis of the NECTARINE Trial.

BACKGROUND: Recent literature on neonatal anesthesia focuses on the importance of keeping physiology within the ranges of normality to improve the long-term neurological outcome. The Neonate and Children audit of Anesthesia pRactice IN Europe (NECTARINE) showed a derangement of one or more than one physiological parameters during anesthesia needing a medical intervention in 35.2% of 6592 anesthesia procedure performed in infants up to 60 weeks postmenstrual age. METHODS: Subanalysis of the Italian NECTARINE cohort providing a snapshot of anesthesia management, incidence of clinical events requiring intervention during anesthesia, and morbidity and mortality at 30 and 90 days. Secondary aim was to compare outcomes between Italy and Europe. RESULTS: Twenty-three Italian centers recruited 501 patients (63% male, 37% female) undergoing 611 procedures (441 surgical and 170 non-surgical) with a mean gestational age at birth of 38 weeks. Events requiring a medical intervention during anesthesia occurred in 177 cases (28.9%), lower than those reported in Europe (35.3%). The majority of events concerned episodes of cardiovascular instability, most commonly due to hypotension. The incidence of mortality at 30 days was 2.7%, consistent with the European incidence. CONCLUSIONS: Anesthetizing neonates is challenging. It is crucial that neonatal anesthesia practice is performed in specialized centers to maximize the potential positive outcome. We recommend a certification of quality for Institutions providing care for very young patients.

Safety and Feasibility of Analgosedation for Electrochemotherapy of Liver Lesions.

Interventional Oncology treatments grant low-risk mini-invasive alternatives to surgery for cancer patients. Percutaneous ablative therapies represent a cornerstone for treatment of liver cancer patients. Among these, a newly emerging one is represented by electrochemotherapy. Improvements in analgesia and sedation can nowadays offer optimal support for ablative procedures, serving as a valid alternative to general anesthesia. The intention of this retrospective monocentric study is to report our preliminary experience on feasibility and safety of electrochemotherapy for treatment of complex liver tumors unfit for thermal ablation, using analgosedation instead of general anesthesia. Five patients were enrolled in the study, undergoing electrochemotherapy under analgosedation. Mean procedural time and hospitalization time were recorded. Immediate post-procedural cone-beam CT showed complete coverage of the lesion without complications. One-month CT examination showed an overall response rate of 100% (four complete responses, one partial response). Electrochemotherapy under analgosedation seems to be a safe, feasible, and effective option for liver cancer patients not amenable to other ablative techniques.

Erector spinae plane block in children: a narrative review.

The erector spinae plane block (ESPB) is a novel technique used in both adult and pediatric patients. Its use in children has mostly been described in terms of perioperative pain management for various types of surgery. After its introduction, anesthesiologists began using ESPBs in various surgical settings. As adequate analgesia along with a low complication rate were reported, interest in this technique dramatically increased. Many studies in adults and children, including randomized controlled trials, have been published, resulting in the emergence of different clinical indications, with various technical and pharmacological approaches currently evident in the literature. This narrative review aims to analyze the current evidence in order to guide practitioners towards a more homogeneous approach to ESPBs in children, with a major focus on clinical applications. The ESPB is an efficient, safe, and relatively easy technique to administer. It can be applied in a wide range of surgeries, includes thoracic, abdominal, hip, and femur surgery. Its usefulness is evident in the context of enhanced recovery after surgery protocols and multimodal analgesia. Single-shot, intermittent bolus, and continuous infusion techniques have been described, and non-inferiority has been observed when compared with other locoregional techniques. Even though both the efficacy and safety of the procedure are widely accepted, current evidence is predominantly based on case reports, with very few well-designed observational studies. Consequently, the level of evidence is still poor, and more well-designed double-blind, randomized, placebo-controlled trials are needed to refine the procedure for different clinical applications in the pediatric population.

Pediatric anesthesia and achalasia: 10 years' experience in peroral endoscopy myotomy management.

BACKGROUND: Endoscopic treatment for achalasia (POEM) is a recently introduced technique that incorporates the concepts of natural orifice transluminal surgery. Although pediatric achalasia is rare, POEM has been episodically used in children since 2012. Despite this procedure entails many implications for airway management and mechanical ventilation, evidences about anesthesiologic management are very poor. We conducted this retrospective study to pay attention on the clinical challenge for pediatric anesthesiologists. We put special emphasis on the risk in intubation maneuvers and in ventilation settings. RESULTS: We retrieved data on children 18 years old and younger who underwent POEM in a single tertiary referral endoscopic center between 2012 and 2021. Demographics, clinical history, fasting status, anesthesia induction, airway management, anesthesia maintenance, timing of anesthesia and procedure, PONV, and pain treatment and adverse events were retrieved from the original database. Thirty-one patients (3-18 years) undergoing POEM for achalasia were analyzed. In 30 of the 31 patients, rapid sequence induction was performed. All patients manifested consequences of endoscopic CO2 insufflation and most of them required a new ventilator approach. No life-threatening adverse events have been detected. CONCLUSIONS: POEM procedure seems to be characterized by a low-risk profile, but specials precaution must be taken. The inhalation risk is actually due to the high rate of full esophagus patients, even if the Rapid Sequence Induction was effective in preventing ab ingestis pneumonia. Mechanical ventilation may be difficult during the tunnelization step. Future prospective trials will be necessary to individuate the better choices in such a special setting.