Comparison of pediatric perioperative risk assessment by ASA physical status and by NARCO-SS (neurological, airway, respiratory, cardiovascular, other-surgical severity) scores.

BACKGROUND: ASA-PS is a widely used perioperative health assessment method, but with poor reproducibility. A novel objective, pediatric-specific risk classification system based on Neurological, Airway, Respiratory, Cardiovascular, Other categories and Surgical Severity (NARCO-SS) has been validated in only one US center. OBJECTIVE: Independent external validation of the NARCO-SS and comparison with the ASA-PS in predicting perioperative outcomes. METHODS: Preoperative ASA-PS and NARCO-SS scores were assigned to 387 children by pediatric anesthesia consultants at a tertiary care center in India and predefined perioperative adverse events and escalation of care recorded. Spearman's correlations determined the relationship between outcomes and scores and kappa statistics for interobserver reliability. The predictive performance of the ASA-PS and NARCO-SS was evaluated by the area under the receiver operating characteristics curves (AUC-ROC) for discrimination and Pearson's chi-square for calibration. RESULTS: NARCO-SS and ASA scores had significant Spearman's correlation coefficients with perioperative outcomes and moderate interobserver reliability. The NARCO-SS showed greater discrimination than the ASA-PS (AUC-ROC 0.778 vs 0.710 for escalation of care and 0.822 vs 0.724 for adverse events, P < 0.01). However, both scores had poor calibration (Pearson's chi-square, P < 0.0001). Individual NARCO-SS categories for neurological and airway lacked statistically significant Spearman's correlations. CONCLUSIONS: NARCO-SS is a valid risk stratification tool that is better than the ASA-PS in discriminating children with adverse perioperative outcomes. The poor calibration of both scores suggests neither can reliably predict perioperative outcomes in individual patients. Modification of neurological and airway categories may improve the predictive accuracy of the NARCO-SS.

Anesthetic Management of a Neonate with Coarctation of the Aorta and Duct-Dependent Circulation Posted for Tracheoesophageal Fistula Repair.

Coarctation of the aorta (CoA) is a congenital heart disease found in a newborn with an incidence of 6%. It presents a significant clinical challenge in neonates posted for major surgeries like tracheoesophageal fistula (TEF) repair. We report the case of anesthetic management of a 2-day-old infant with CoA and duct-dependent circulation posted for TEF repair. We describe how physiology affects its perioperative management and the role of maintaining balance in peripheral vascular resistance and systemic vascular resistance to maintain ductal flow.

Role of videolaryngoscope in the management of difficult airway in adults: A survey.

BACKGROUND AND AIMS: A number of videolaryngoscopes (VLs) have flooded the Indian market. As per All India Difficult Airway Association 2016 guidelines, all anaesthesiologists should have access to a VL and must be trained to use it. We conducted an electronic survey to know the perception of Indian anaesthesiologists, who are members of the Indian Society of Anaesthesiologists (Karnataka State Chapter) towards the role of VL in the management of difficult airway (DA) and factors governing their use. METHODS: An electronic survey was sent to 2580 ISA members to know the availability, use and attitude towards VLs in the management of DA in adults. The survey was open for a period of 2 months and responses analysed. RESULTS: The response rate was 25.8% (666 out of 2580). A total of 280 (42%) respondents had access to VL. The respondents rated VL as 4th preference for anticipated DA and 1st for unanticipated DA (if available). The most widely used VLs were C-MAC, Airtraq, and Kingvision. As per 133 respondents (20%), access to VL in institutes was restricted only to consultants and the main reason being cost. The clarity of the image was the most important factor the respondents expected in a VL. CONCLUSIONS: Less than half of respondents had access to VLs. Most of them having access to it worked in corporate hospitals. The high cost of the device and steep learning curve are still barriers against its widespread use. We conclude that low-cost devices, with increased clarity may make usage of VLs frequent and available to residents.

Challenges in Anaesthetic management of a child for thoracoscopic assisted oesophageal replacement.

The loss of oesophageal length or obliteration of oesophageal lumen due to stricture acquired by accidental caustic ingestion is more common in children that may require major operative reconstruction. A number of procedures have been developed for anatomic replacement of oesophagus of which thoracoscopic assisted gastric transposition has shown the best outcome in children. This demands an extensive pre-operative evaluation, preparation and anaesthetic management since this is challenging and prolonged procedure done under one lung ventilation (OLV). Though it is a minimally invasive procedure, providing OLV and management of complications associated with it are the anaesthetic challenges among these children. We report anaesthetic management of an 8-year-old boy with oesophageal stricture following corrosive injury posted for thoracoscopic assisted gastric transposition.