Perioperative intravenous fluid therapy in children: guidelines from the Association of the Scientific Medical Societies in Germany.

This consensus- based S1 Guideline for perioperative infusion therapy in children is focused on safety and efficacy. The objective is to maintain or re-establish the child's normal physiological state (normovolemia, normal tissue perfusion, normal metabolic function, normal acid- base- electrolyte status). Therefore, the perioperative fasting times should be as short as possible to prevent patient discomfort, dehydration, and ketoacidosis. A physiologically composed balanced isotonic electrolyte solution (BS) with 1-2.5% glucose is recommended for the intraoperative background infusion to maintain normal glucose concentrations and to avoid hyponatremia, hyperchloremia, and lipolysis. Additional BS without glucose can be used in patients with circulatory instability until the desired effect is achieved. The additional use of colloids (albumin, gelatin, hydroxyethyl starch) is recommended to recover normovolemia and to avoid fluid overload when crystalloids alone are not sufficient and blood products are not indicated. Monitoring should be extended in cases with major surgery, and autotransfusion maneuvers should be performed to assess fluid responsiveness.

[The difficult venous access]. / Kinderanästhesie--Der schwierige Venenzugang.

Venipunctures in children are difficult. Some factors can hardly be influenced, for example, a well-developed subcutaneous fat tissue. Technical devices may help to identify invisible veins. With the help of ultrasound deep peripheral veins on the wrists and ankles can be presented and punctured. Stiff resistance of a child thwarts any successful puncture. Children should therefore be adequately sedated, if cannot be induced by mask. Missing practice venipuncture and inadequate knowledge of appropriate puncture sites can be met easily by practicing and reading.The possibility of intraosseous puncture today is standard of anesthesia care for children. Within in a few seconds, a secure access to the vein system can be created.

[Perioperative fluid management in infants and toddlers]. / Kinderanästhesie--Infusionstherapie bei Säuglingen und Kleinkindern.

The more than 50 years ago of Holiday and Segar created fundamentals of fluid therapy with sodium hypotonic solutions require revision. Hypotonic electrolyte solutions should not be longer used perioperatively. To maintain the water balance in the perioperative phase stable, children need balanced electrolyte solutions, corresponding to the composition of the extracellular space. Routine glucose supply is not required, only children with an increased risk of hypoglycemia, such as newborns, need a supply of glucose as well as a monitoring of serum glucose. The historic 4-2-1-rule should be replaced by a simpler approach. Fasting deficit and intraoperative maintenance requirement will be covered by an increased rate of infusion of a balanced electrolyte solution. Intraoperative losses and correction needs to be replaced according to clinical criteria. Balanced electrolyte solution with and without 1% glucose are very safe with respect to hyponatremia, hypo-and hyperglycemia, and accidental overinfusion.

European consensus statement for intraoperative fluid therapy in children.

The intraoperative infusion of isotonic solutions with 1-2.5% glucose in children is considered well established use in Europe and other countries. Unfortunately, a European marketing authorisation of such a solution is currently missing and as a consequence paediatric anaesthetists tend to use suboptimal intravenous fluid strategies that may lead to serious morbidity and even mortality because of iatrogenic hyponatraemia, hyperglycaemia or medical errors. To address this issue, the German Scientific Working Group for Paediatric Anaesthesia suggests a European consensus statement on the composition of an appropriate intraoperative solution for infusion in children, which was discussed during a working session at the 2nd Congress of the European Society for Paediatric Anaesthesiology in Berlin in September 2010. As a result, it was recommended that an intraoperative fluid should have an osmolarity close to the physiologic range in children in order to avoid hyponatraemia, an addition of 1-2.5% instead of 5% glucose in order to avoid hypoglycaemia, lipolysis or hyperglycaemia and should also include metabolic anions (i.e. acetate, lactate or malate) as bicarbonate precursors to prevent hyperchloraemic acidosis. Thus, the underlying intention of this consensus statement is to facilitate the granting of a European marketing authorisation for such a solution with the ultimate goal of improving the safety and effectiveness of intraoperative fluid therapy in children.

[Case Report: Failed epidural puncture for insertion of a catheter]. / Kasuistik: Perioperative Schmerztherapie - Fehllage eines thorakalen Periduralkatheters nach Punktion in Seitenlage.

We report on a failed epidural puncture for insertion of a catheter during chest wall correction by the minimally invasive procedure according to Nuss in a 16-year-old boy. After insertion of the catheter without any problem and establishment of a symmetrical thoracic analgesia and initiation of general anaesthesia, the catheter was surprisingly observed in the thoracic cavity upon insertion of the endoscopic camera. The catheter was then withdrawn under vision and the operation continued without any further incidents.

Semi-elective intraosseous infusion after failed intravenous access in pediatric anesthesia.

BACKGROUND: Intraosseous (IO) infusion is a well-established intervention to obtain vascular access in pediatric emergency medicine but is rarely used in routine pediatric anesthesia. METHODS: In this observational study, we report on a series of 14 children in whom semi-elective IO infusion was performed under inhalational anesthesia after peripheral intravenous (IV) access had failed. Patient and case characteristics, technical details, and estimated timings of IO infusion as well as associated complications were reviewed. Data are median and range. RESULTS: IO infusion was successfully established in fourteen children [age: 0.1-6.00 years (median 0.72 years); weight: 3.5-12.0 kg (median 7.0 kg)]. The majority suffered from chronic cardiac, metabolic, or dysmorphic abnormalities. Estimated time taken from inhalational induction of anesthesia until insertion of an intraosseous needle was 26.5 min (15-65 min). The proximal tibia was cannulated in all patients. The automated EZIO IO system was used in eight patients and the manual COOK system in six patients. Drugs administered included hypnotics, opioids, neuromuscular blocking agents and reversals, cardiovascular drugs, antibiotics, and IV fluids. The IO cannulas were removed either in the operating theatre (n = 5), in the recovery room (n = 5), or in the ward (n = 4), after 73 min (19-225 min) in situ. There were no significant complications except one accidental postoperative dislocation. CONCLUSIONS: IO access represents a quick and reliable alternative for pediatric patients with prolonged difficult or failed IV access after inhalational induction of anesthesia.

[Obesity in pediatric anesthesia]. / Adipositas in der Kinderanästhesie.

The incidence of overweight and obesity in children and adolescents who need an anesthesia is increasing. These children have a higher risk for perioperative complications. The review discusses definition and causes of obesity in children, gives information about relevant pathophysiological changes, and focuses anesthesiological management and complications.

External Validation Of The Surgical Mortality Probability Model (S-MPM) In Patients Undergoing Non-Cardiac Surgery.

BACKGROUND: Preoperative risk assessment is a key issue in the process of patient preparation for surgery and the control of quality improvement in health care and certification programs. Hence, there is a need for a prognostic tool, whose usefulness can be assessed only after validation in the center other than the home one. The aim of the study was to validate the Surgical Mortality Probability Model (S-MPM) for detecting deaths and complications in patients undergoing non-cardiac surgery and to assess its suitability for various surgical disciplines. METHODS: This retrospective study involved 38,555 adult patients undergoing non-cardiac surgery in a single center in 2012-2015. The observation period concerned in-hospital mortality. RESULTS: In-hospital mortality for the total population was 0.89%. Mortality in the S-MPM I class amounted to 0.26%, S-MPM II 2.51%, and in the S-MPM III class 22.14%. This result was in line with those obtained by the authors. The discriminatory power for in-hospital mortality was good (area under curve (AUC) = 0.852, 95% CI: 0.834-0.869, p = 0.0000). The scale was the most accurate in general surgery (AUC = 0.89, 95% CI: 0.858-0.922) and trauma (AUC = 0.89; 95% CI: 0.87-0.915). In the logistic regression analysis, the scale showed a perfect fit/goodness of fit in the cross-validation method (v-fold cross-validation): Hosmer-Lemeshow (HL) = 7.945; p = 0.159. This result was confirmed by the traditional derivation and validation data set method (1:3; 9712 vs 22.748 cases): HL test = 3.073 (p = 0.546) in the teaching derivation data set and 10.77 (p = 0.029) in the test sample (validation data set). CONCLUSION: The S-MPM scale by Glance et al has proven to be a useful tool to assess the risk of in-hospital death and can be taken into account when considering treatment indications, patient information, planning post-operative care, and quality control.

[Case report: severe hypothermia in a newborn infant - challenges in preclinical emergency medicine]. / Kasuistik interaktiv: Neugeborenes mit schwerer Hypothermie - Eine notärztliche Herausforderung.

On the basis of a case report the prehospital management of a newborn child with deep accidental hypothermia (22oC) is discussed. The child was found in a garbage can. The continuous resuscitation during the transport into the clinic is done in an incubator and the child survives without neurologic damages. The used measures of the resuscitation are discussed on the basis of the therapy.

[Perioperative fluid guideline in preterms, newborns, toddlers and infants]. / Perioperative Flüssigkeitstherapie bei Früh- und Neugeborenen, Säuglingen und Kleinkindern.

The purposes of perioperative fluid therapy are to balance deficits that have occurred preoperatively, to realize the continuous infusion of maintenance requirements referred to body weight an to effect a correction of the intraoperative losses of water, electrolytes and blood components. Premature and new-born infants as well as children at risk for hypoglycaemia should additionally receive glucose in order to stabilise the glucose concentration and metabolism. Full electrolyte solutions containing 1 % glucose are sufficient. In cases with larger volume requirements, the circulatory system can be stabilized by the additional infusion of a glucose-free full electrolyte solution. Also in the cases of small children, artificial colloids may also be administered additionally. The efficacy of fluid and volume therapy should be controlled by an appropriately adapted circulation monitoring and regular blood gas analyses, especially for major interventions.

Absorption and distribution of etoricoxib in plasma, CSF, and wound tissue in patients following hip surgery--a pilot study.

The perioperative administration of selective cyclooxygenase-2 (COX-2)-inhibitors to avoid postoperative pain is an attractive option: they show favorable gastro-intestinal tolerability, lack inhibition of blood coagulation, and carry a low risk of asthmatic attacks. The purpose of this study was to determine the cerebrospinal fluid (CSF), plasma, and tissue pharmacokinetics of orally administered etoricoxib and to compare it with effect data, i.e., COX-2-inhibition in patients after hip surgery. The study was performed in a blinded, randomized, parallel group design. A total of 12 adult patients were included who received 120 mg etoricoxib (n = 8) or placebo (n = 4) on day 1 post-surgery. Samples from plasma, CSF, and tissue exudates were collected over a period of 24 h post-dosing and analyzed for etoricoxib and prostaglandin E(2) (PGE(2)) using liquid chromatography-tandem mass spectrometry and immuno-assay techniques. CSF area under the curve (AUC) [AUCs((O-24h))] for etoricoxib amounted to about 5% of the total AUC in plasma (range: 2-7%). Individual CSF lag times with respect to (50%) peak plasma concentration were

Extrapleural, submuscular bars placed by bilateral thoracoscopy--a new improvement in modified Nuss funnel chest repair.

BACKGROUND: Thoracoscopic Nuss funnel chest repair still has a significant complication rate. Bar dislocation, pneumothorax, pleural effusions, and pericarditis seem to be caused mechanical irritation by the bar. We intended to reduce these problems by further technical modification of the Nuss technique. METHODS: Of 157 prospectively followed modified Nuss repairs, the last 57 patients had the bars placed in an extrapleural position and fixed by 10 to 14 pericostal sutures under bilateral thoracoscopy. RESULTS: Entirely, extrapleural bar position was feasible in 53 of 57 patients. Four patients had minor holes over one of the bars, predominantly on the left side of the thorax. Pleural effusions, pneumothorax, and pain were greatly reduced, so that we discontinued the so far routine use of bilateral pleural drainages. CONCLUSIONS: Extrapleural bar position is feasible in more than 90% of modified Nuss repairs. It reduces pleural secretion and pain, and seems to reduce pneumothorax, pulmonary bar adhesions, and pericardial effusions. The technique is easy and safe, and reduced the incidence of most complications in this early experience of 57 adolescent patients, although no sportive restrictions were imposed at all.