Incidence of Emergence Delirium in the Pediatric PACU: Prospective Observational Trial.

Emergence delirium (ED) is a postoperative complication in pediatric anesthesia characterized by perception and psychomotor disorder and has a negative impact on morbidity in the form of maladaptive behavior, which can last weeks after anesthesia. Patients with developed ED present with psychomotor anxiety, agitation, and are at higher risk of unintentional extraction of an intravenous cannula, self-harm and nausea and vomiting. The described incidence of ED varies between 25−80%, with a higher prevalence among children younger than 6 years of age. We aimed to determine the incidence of ED in pediatric patients (>1 month) after general anesthesia in the post-anesthesia care unit (PACU), using Paediatric Anaesthesia Emergence Delirium (PAED) score, Watcha score and Richmond agitation and sedation scale (RASS). The incidence of ED was the highest in the PAED score with cutoff ≥10 points (89.0%, n = 1088). When using PAED score >12 points, ED incidence was 19.3% (n = 236). The lowest incidence was described by Watcha and RASS scores, 18.8% (n = 230) vs. 18.1% (n = 221), respectively. The threshold for PAED ≥10 points seems to give false-positive results, whereas the threshold >12 points is more accurate. RASS scale, although intended primarily for estimation of the depth of sedation, seems to have a good predictive value for ED.

Videolaryngoscopy vs. Direct Laryngoscopy for Elective Airway Management in Paediatric Anaesthesia: A prospective randomised controlled trial.

BACKGROUND: The indirect visualisation of the glottic area with a videolaryngoscope could improve intubation conditions which may possibly lead to a higher success rate of the first intubation attempt. OBJECTIVE: Comparison of videolaryngoscopy and direct laryngoscopy for elective airway management in paediatric patients. DESIGN: Prospective randomised controlled trial. SETTINGS: Operating room. PARTICIPANTS: 535 paediatric patients undergoing elective anaesthesia with tracheal intubation. 501 patients were included in the final analysis. INTERVENTIONS: Patients were randomly allocated to the videolaryngoscopy group (n  = 265) and to the direct laryngoscopy group (n  = 269) for the primary airway management. MAIN OUTCOME MEASURES: The first attempt intubation success rate was assessed as the primary outcome. The secondary outcomes were defined as: the time to successful intubation (time to the first EtCO2 wave), the overall intubation success rate, the number of intubation attempts, the incidence of complications, and the impact of the length of the operator's clinical practice. RESULTS: The study was terminated after the planned interim analysis for futility. There were no significant demographic differences between the two groups. The first attempt intubation success rate was lower in the videolaryngoscopy group; 86.8% (n  = 211) vs. 92.6% (n  = 239), P = 0.046. The mean time to the first EtCO2 wave was longer in the videolaryngoscopy group at 39.0 s ±â€Š36.7 compared to the direct laryngoscopy group, 23.6 s ±â€Š24.7 (P < 0.001). There was no difference in the overall intubation success rate, in the incidence of complications nor significant difference based on the length of the clinical practice of the operator. CONCLUSIONS: The first attempt intubation success rate was lower in the videolaryngoscopy group in comparison to the direct laryngoscopy group. The time needed for successful intubation with videolaryngoscopy was longer compared with direct laryngoscopy. TRIAL REGISTRATION: Clinicaltrials.gov identifier: NCT03747250.

Rapid sequence induction: An international survey.

BACKGROUND: Rapid sequence induction (RSI) is a standard procedure, which should be implemented in all patients with a risk of aspiration/regurgitation during anaesthesia induction. OBJECTIVE: The primary aim was to evaluate clinical practice in RSI, both in adult and paediatric populations. DESIGN: Online survey. SETTINGS: A total of 56 countries. PARTICIPANTS: Members of the European Society of Anaesthesiology. MAIN OUTCOME MEASURES: The aim was to identify and describe the actual clinical practice of RSI related to general anaesthesia. RESULTS: From the 1921 respondents, 76.5% (n=1469) were qualified anaesthesiologists. When anaesthetising adults, the majority (61.7%, n=1081) of the respondents preoxygenated patients with 100% O2 for 3 min and 65.9% (n=1155) administered opioids during RSI. The Sellick manoeuvre was used by 38.5% (n=675) and was not used by 37.4% (n=656) of respondents. First-line medications for a haemodynamically stable adult patient were propofol (90.6%, n=1571) and suxamethonium (56.0%, n=932). Manual ventilation (inspiratory pressure <12 cmH2O) was used in 35.5% (n=622) of respondents. In the majority of paediatric patients, 3 min of preoxygenation (56.6%, n=817) and opioids (54.9%, n=797) were administered. The Sellick manoeuvre and manual ventilation (inspiratory pressure <12 cmH2O) in children were used by 23.5% (n=340) and 35.9% (n=517) of respondents, respectively. First-line induction drugs for a haemodynamically stable child were propofol (82.8%, n=1153) and rocuronium (54.7%, n=741). CONCLUSION: We found significant heterogeneity in the daily clinical practice of RSI. For patient safety, our findings emphasise the need for international RSI guidelines. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT03694860.

Post-myringotomy oto-liquorrhea in children - A case study and literature review.

Myringotomy is a surgical incision of tympanic membrane used mainly as therapy for acute otitis media. It is a safe and simple procedure; however possible complications must be considered. In this article is described a case study of a 2-and-a-half-year-old girl with a massive oto-liquorrhea following myringotomy.

Laryngeal mask airway Unique™ position in paediatric patients undergoing magnetic resonance imaging (MRI): prospective observational study.

BACKGROUND: Laryngeal mask UNIQUE® (LMAU) is supraglottic airway device with good clinical performance and low failure rate. Little is known about the ideal position of the LMAU on the magnetic resonance imaging (MRI) and whether radiological malposition can be associated with clinical performance (audible leak) in children. The primary aim of the study was to evaluate incidence of the radiologic malposition of the LMAU according to size. The secondary outcome was the clinical performance and associated complications (1st attempt success rate, audible leak) in LMAUs in correct position vs. radiologically misplaced LMAUs. METHODS: In prospective observational study, all paediatric patients undergoing MRI of the brain under general anaesthesia with the LMAU were included (1.9.2016-16.5.2017). The radiologically correct position: LMAU in hypopharynx, proximal cuff opposite to the C1 or C2 and distance A (proximal cuff end and aditus laryngis) ≤ distance B (distal cuff end and aditus laryngis). Malposition A: LMAU outside the hypopharynx. Malposition B: proximal cuff outside C1-C2. Malposition C: distance A ≥ distance B. We measured distances on the MRI image. Malposition incidence between LMAU sizes and first attempt success rate in trainees and consultant groups was compared using Fisher exact test, difference in incidence of malpositions using McNemar test and difference in leakage according to radiological position using two-sample binomial test. RESULTS: Overall 202 paediatric patients were included. The incidence of radiologically defined malposition was 26.2% (n = 53). Laryngeal mask was successfully inserted on the 1st attempt in 91.1% (n = 184) cases. Audible leak was detected in 3.5% (n = 7) patients. The radiologically defined malposition was present in 42.9% (n = 3) cases with audible leak. The rate of associated complications was 1.5% (n = 3): laryngospasm, desaturation, cough. In 4.0% (n = 8) the LMAU was soiled from blood. Higher incidence of radiological malposition was in LMAU 1.0, 1.5 and LMAU 3, 4 compared to LMAU 2 or LMAU 2.5 (p < 0.001). CONCLUSION: Malposition was not associated with impaired clinical performance (audible leak, complications) of the LMAU or the need for alternative airway management. TRIAL REGISTRATION: Clinicaltrials.gov  (NCT02940652) Registered 18 October 18 2016.

Ischemic stroke in paediatrics - narrative review of the literature and two cases.

Stroke is a rare condition in childhood with an estimated incidence of between 1.3-13/100.000 patients. Clinical manifestation and risk factors for paediatric stroke are different from those of adults. The uncommon incidence, age-associated difference and plethora of clinical symptoms make the diagnosis of such strokes extremely difficult and often delayed. The history and clinical examination should point to diseases or predisposing factors. Neuroimaging (DWI MR) is the golden standard for diagnosis of paediatric stroke and other investigations can be considered according to the clinical condition. Despite advances in paediatric stroke research and clinical care, questions remain unanswered regarding acute treatment, secondary prevention and rehabilitation. The treatment recommendations are mainly extrapolated from studies on adult populations. In the review authors summarized the clinical characteristics and diagnostic steps for stroke in children/adolescents based on the most recent international guidelines and practical directions for recognising and managing the child/adolescent with stroke in paediatric emergency. In the two case reports, we describe the clinical course in both stroke patients.

Controversies in Pediatric Perioperative Airways.

Pediatric airway management is a challenge in routine anesthesia practice. Any airway-related complication due to improper procedure can have catastrophic consequences in pediatric patients. The authors reviewed the current relevant literature using the following data bases: Google Scholar, PubMed, Medline (OVID SP), and Dynamed, and the following keywords: Airway/s, Children, Pediatric, Difficult Airways, and Controversies. From a summary of the data, we identified several controversies: difficult airway prediction, difficult airway management, cuffed versus uncuffed endotracheal tubes for securing pediatric airways, rapid sequence induction (RSI), laryngeal mask versus endotracheal tube, and extubation timing. The data show that pediatric anesthesia practice in perioperative airway management is currently lacking the strong evidence-based medicine (EBM) data that is available for adult subpopulations. A number of procedural steps in airway management are derived only from adult populations. However, the objective is the same irrespective of patient age: proper securing of the airway and oxygenation of the patient.

An unusual reason for severe bradycardia leading to cardiac arrest during general anaesthesia: a case report.

BACKGROUND: Takotsubo cardiomyopathy also known as transient balooning syndrome is an increasingly reported phenomenon characterized by acute reversible apical or midventricular dysfunction. This stress- induced cardiomyopathy mimics myocardial infarction, but without significant coronary artery disease, and rarely presents in perioperative period. METHODS AND RESULTS: We report a case of postmenopausal woman scheduled to undergo elective cholecystectomy, with no history of coronary artery disease. She presented perioperatively with Takotsubo cardiomyopathy by unique manifestation-asystoly. This uncommon cause of cardiac arrest during anaesthesia was possibly induced by preoperative emotional stress. There was full recovery thanks to intensive management. In Takotsubo cardiomyopathy related cardiogenic shock we used the calcium sensitiser levosimendan successfully. CONCLUSION: Takotsubo cardiomyopathy has an excellent long-term prognosis and nearly all patients have full recovery of left ventricular function. We emphasize the importance of heavy premedication by stress compromised patients and the need of sufficiently deep anaesthesia and analgesia during surgeries.