Sedation Practices for Lumbar Punctures in Patients With Acute Lymphoblastic Leukemia: A Multicenter Retrospective Study Using Pediatric Health Information Systems.

BACKGROUND: Sedation is often used to reduce pain and anxiety in pediatric patients with acute lymphoblastic leukemia (ALL) undergoing lumbar punctures (LPs). There is a potential for long-term effects on neurocognition with repeat sedative exposures in young children. The purpose of this study is to determine the practice habits regarding sedation for LPs in pediatric patients with ALL among multiple institutions. METHODS: This is a retrospective study of 48 hospitals in the Pediatric Health Information Systems (PHIS) between October 2015 and December 2019. Children 1 to 18 years old with ALL who received intrathecal chemotherapy in an outpatient setting were included. We analyzed the prevalence of anesthesia usage and the types of anesthetics used. RESULTS: Of the 16,785 encounters with documented use of anesthetic medications, intravenous and inhaled anesthetics were used in 16,486 (98.2%) and local anesthetics alone in 299 (1.8%). The most commonly used medications used for sedation were propofol (n=13,279; 79.1%), midazolam (n=4228; 25.2%), inhaled fluranes (n=3169; 18.9%), and ketamine (n=2100; 12.5%). CONCLUSION: The majority of children's hospitals in the United States use intravenous and inhaled anesthetics for routine therapeutic LPs in pediatric patients with ALL. Propofol is one of the most common medications used for sedation.

A retrospective review of femoral nerve block for postoperative analgesia after knee surgery in the pediatric population.

BACKGROUND: To investigate the outcomes of pediatric patients receiving a femoral nerve block (FNB) in addition to general anesthesia for arthroscopic knee surgery compared with those receiving general anesthesia alone. METHODS: This retrospective review included all patients undergoing arthroscopic knee surgery from January 2009 to January 2011 under general anesthesia both with and without a FNB. After the induction of general anesthesia, those patients selected for regional anesthesia received a FNB using real-time ultrasound or nerve stimulator guidance. For the FNB, 0.2 to 0.4 mL/kg of local anesthetic solution was injected around the femoral nerve at the level of the inguinal crease. Intra-articular injection of bupivacaine (0.25%, 10 mL) was administered by the surgeon for all patients not receiving a FNB. Additional analgesic medications, PACU length of stay, duration of hospitalization, hospital course, and any acute or nonacute complications were recorded and evaluated. RESULTS: There were no adverse effects related to the FNB. Using a 0 to 10 visual analogue scale (0=no pain), there was a statistically significant difference in both the high (4.0 ± 4.0 vs. 5.3 ± 3.1, P=0.0004) and low (1.5 ± 1.8 vs. 2.1 ± 2.0, P=0.002) pain scores in patients who received a FNB versus those who did not with the scores being lower in those who had received a FNB. There was a decreased need for the use of opioids postoperatively (61% vs. 71%, P=0.04) and a decreased duration of postoperative stay in patients who were admitted to the hospital (11.7 ± 8.1 vs. 15.8 ± 10 h, P=0.044) in individuals who had a FNB. There was a significantly lower admission rate in patients undergoing anterior cruciate ligament repair in the FNB group (72% vs. 95%, P=0.001). There was no difference in the incidence of postoperative nausea and vomiting between the groups. CONCLUSION: After arthroscopic knee surgery in pediatric patients, a FNB shortens hospital stay, reduces opioid requirements, and decreases postoperative pain scores. For anterior cruciate ligament repairs, FNB lowers postoperative admission rates. CLINICAL EVIDENCE: Level III.

Phenobarbital use in an infant requiring extracorporeal membrane life support.

Over the past two decades, there has been an increased use of extracorporeal membrane life support (ECLS) for critically ill neonates and infants. Approximately 20% of these children will experience seizures as a complication of ECLS or the comorbid condition which necessitated extracorporeal support. While phenobarbital is one of the most common drugs used to treat seizures in children, little is known about its dosing while on ECLS. We present a 3-month-old girl who required ECLS after cardiac arrest in the postoperative period following surgery for complex congenital heart disease. The patient subsequently developed seizure activity, which was treated with phenobarbital. Following an initial loading dose of 30 mg/kg, the serum concentration was 47.9 mcg/ml. A supplementary loading dose of 10 mg/kg was administered 8 h later with an increase of the maintenance dose to 8 mg/kg/day. The phenobarbital serum concentrations were 65.9 and 72.8 mcg/ml on the subsequent days. Despite therapeutic levels of phenobarbital, the patient continued to exhibit clinical and electroencephalographic evidence of seizure activity and a midazolam infusion was started at 0.3 mg/kg/h. Because of continued seizure activity, the patient ultimately required titration of midazolam to 1.2 mg/kg/h by day 7 of ECLS to control seizure activity. Due to severe intracerebral bleeding on day 9, ECLS was withdrawn and the patient expired. Our experience demonstrates some of the challenges of medication titration during ECLS. Previous reports of phenobarbital dosing during ECLS are reviewed and considerations for the dosing of anticonvulsant medications during extracorporeal support are discussed.

Hemodynamic and Respiratory Effects of Regadenoson During Radiologic Imaging in Infants and Children.

BACKGROUND: Myocardial perfusion imaging using radionuclides is a well-validated, noninvasive method to aid in the diagnosis of patients with suspected or known myocardial ischemia. To increase the sensitivity of the technique, pharmacologic agents which induce coronary vasodilatation are administered. Regadenoson is a novel selective A2A receptor agonist that has similar efficacy to adenosine for cardiac magnetic resonance imaging (MRI) with a more favorable adverse effect profile and is the most widely used pharmacologic stress agent. While widely used in adults, there is limited experience with it in pediatrics, particularly young children. METHODS: The current study retrospectively reviews our experience with stress cardiac MRI using regadenoson in children requiring general anesthesia. The study cohort included eight patients, all male, ranging in age from 2 to 6.2 years (mean age of 4.2 years) and in weight from 10 to 30.5 kg (mean weight of 18.5 kg). All patients received general anesthesia with endotracheal intubation and a volatile anesthetic agent. RESULTS: Heart rate 1 min prior to regadenoson was 99 ± 19.2 (mean ± standard deviation (SD)) beats per minute. Peak heart rate was achieved at an average of 4 min post regadenoson administration with a mean heart rate of 122 ± 15 beats per minute. The average of the mean arterial pressure 1 min prior to regadenoson was 53.4 ± 5.2 mm Hg. Mean arterial pressure nadir was noted at 6 min post regadenoson with a value of 44.1 ± 6.3 mm Hg. Blood pressure support with phenylephrine was required in four of the eight (50%) of patients. No adverse respiratory events were noted. Only one of the eight (13%) patients had a perfusion defect but had preserved ventricular function and recovered without incident. CONCLUSIONS: Use of regadenoson in pediatric patients requiring general anesthesia is safe and feasible.

The otolaryngologist's and anesthesiologist's collaborative role in a pandemic: A large quaternary pediatric center's experience with COVID-19 preparation and simulation.

There has been a rapid global spread of a novel coronavirus, the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), which originated in Wuhan China in late 2019. A serious threat of nosocomial spread exists and as such, there is a critical necessity for well-planned and rehearsed processes during the care of the COVID-19 positive and suspected patient to minimize transmission and risk to healthcare providers and other patients. Because of the aerosolization inherent in airway management, the pediatric otolaryngologist and anesthesiologist should be intimately familiar with strategies to mitigate the high-risk periods of viral contamination that are posed to the environment and healthcare personnel during tracheal intubation and extubation procedures. Since both the pediatric otolaryngologist and anesthesiologist are directly involved in emergency airway interventions, both specialties impact the safety of caring for COVID-19 patients and are a part of overall hospital pandemic preparedness. We describe our institutional approach to COVID-19 perioperative pandemic planning at a large quaternary pediatric hospital including operating room management and remote airway management. We outline our processes for the safe and effective care of these patients with emphasis on simulation and pathways necessary to protect healthcare workers and other personnel from exposure while still providing safe, effective, and rapid care.

Pulmonary Hemorrhage During Computed Tomography-Guided Percutaneous Lung Biopsy: A Case Report and Review of the Literature.

Percutaneous lung biopsy represents a minimally invasive method of obtaining lung tissue to aid in the diagnosis of various pulmonary diseases. Although the technique has major advantages, including being less invasive and having a more rapid recovery than open thoracotomy, complications such as bleeding may occur. To date, there is limited information regarding the complications and their treatment associated with this procedure. We describe a 22-year-old man with chronic granulomatous disease who experienced a pulmonary hemorrhage after percutaneous lung biopsy using computed tomography guidance while he was under general endotracheal anesthesia. Potential treatment algorithms and strategies are presented.

Pulse Pressure Analysis to Guide Intraoperative Phlebotomy Prior to Cardiac Surgery.

BACKGROUND: The aim of this study was to evaluate the response of the LiDCO-rapid™ during intraoperative phlebotomy in anesthetized children prior to surgery for congenital heart disease. METHODS: After the induction of general anesthesia and endotracheal intubation, baseline vital signs were recorded, along with pulse pressure variability (PPV) and stroke volume variability (SVV) from the LiDCO-rapid™ and cerebral oxygenation (rSO2) using near-infrared spectroscopy (NIRS). Phlebotomy was performed over 5 - 10 min with the volume of blood removed calculated to achieve a hematocrit of 24-28% on cardiopulmonary bypass. The primary outcome was a decline in rSO2 ≥ 5 between the baseline value and the end of phlebotomy. At that time, the correlation of the starting and ending values of SVV and PPV with the NIRS was determined. RESULTS: The study cohort included 30 patients (mean age of 21 ± 11 years). Statistically significant changes during the study period were observed in rSO2, but not in the LiDCO-rapid™ parameters. In analysis of continuous NIRS data, the change in NIRS did not correlate with either baseline (r = 0.10, P = 0.644) or final (r = 0.02, P = 0.914) SVV. Likewise, the change in NIRS did not correlate with baseline (r = 0.01, P = 0.953) or final (r = 0.00, P = 0.982) PPV. CONCLUSION: Baseline values as well as changes in the PVV and SVV from the LiDCO-rapid™ did not predict or correlate with changes in cerebral oxygenation measured by NIRS during intraoperative phlebotomy. Our preliminary data suggest that these parameters (PVV and SVV) are not useful in monitoring patient stability or the need for volume replacement during intraoperative phlebotomy prior to cardiac surgery.

Intraoperative Anaphylactic Reaction: Is it the Floseal?

When hemodynamic or respiratory instability occurs intraoperatively, the inciting event must be determined so that a therapeutic plan can be provided to ensure patient safety. Although generally uncommon, one cause of cardiorespiratory instability is anaphylactic reactions. During anesthetic care, these most commonly involve neuromuscular blocking agents, antibiotics, or latex. Floseal is a topical hemostatic agent that is frequently used during orthopedic surgical procedures to augment local coagulation function and limit intraoperative blood loss. As these products are derived from human thrombin, animal collagen, and animal gelatin, allergic phenomenon may occur following their administration. We present 2 pediatric patients undergoing posterior spinal fusion who developed intraoperative hemodynamic and respiratory instability following use of the topical hemostatic agent, Floseal. Previous reports of such reactions are reviewed, and the perioperative care of patients with intraoperative anaphylaxis is discussed.

Caudal epidural blockade for major orthopedic hip surgery in adolescents.

BACKGROUND: There continues to be a significant focus on the value of regional and neuraxial anesthesia techniques for adjunctive use when combined with general anesthesia. The reported advantages include decreased patient opiate exposure, decreased medication-related adverse effects, decreased postanesthesia recovery room time and hospital stay, and increased patient satisfaction. MATERIALS AND METHODS: The authors present a case-controlled series evaluating the use of a single caudal epidural injection prior to incision as an adjunct to general anesthesia for the open repair of slipped capital femoral epiphysis. Opiate consumption, pain scores, and hospital stay were compared between the two cohorts of 16 adolescent patients. All patients received a demand-only patient-controlled opiate delivery system. RESULTS: Although the failed block rate was high (31%), there was decreased opioid use in the perioperative arena as well as during the first 24 postoperative hours in patients who had a successful caudal epidural block. Furthermore, discharge home was possible in 27% of patients who received a caudal epidural block compared to 0% of patients who did not receive a caudal block. CONCLUSION: The potential utility of caudal epidural block as an adjunct to general anesthesia during major hip surgery in adolescents is presented. Factors resulting in a failed block in this patient population as well as the use of the ultrasound as an added modality to increase block success are reviewed.

A case report of a retained and knotted caudal catheter.

Caudal catheters advanced to the lumbar and thoracic regions can be used to provide excellent analgesia for pre-term neonates undergoing major abdominal and thoracic procedures. Despite their frequent use, attention to detail is mandatory to avoid complications related to the medications used or the placement technique. We present a 2-day-old, 2 kg, pre-term infant who was born at 32 weeks gestational age with a tracheoesophageal fistula. Following anesthetic induction, a caudal epidural catheter was placed with the intent of threading it to the mid-thoracic level. The intraoperative and post-operative courses were uneventful with the epidural catheter providing adequate analgesia without the need for supplemental intravenous opioids. During catheter removal, resistance was noted and it could not be easily removed. With repositioning and various other maneuvers, the catheter was removed with some difficulty. On examination of the catheter, a complete knot was noted. Options for catheter advancement from the caudal space to the thoracic dermatomes are reviewed and techniques discussed for removal of a retained epidural catheter.

Plethysmography variability index response to isovolemic hemodilution in children prior to surgery for congenital heart disease.

The aim of this study was to evaluate the response of pleth variability index (PVI) to phlebotomy in anesthetized children prior to surgery for congenital heart disease. After induction of general anesthesia and prior to surgical incision, approximately 10 mL/kg of blood was removed from 40 mechanically ventilated children over a 5-10 min period. The PVI was continuously monitored. Additionally, the volume of crystalloid required to ensure hemodynamic and near infrared spectroscopy stability was recorded. There was no difference between the pre-phlebotomy PVI (13% ± 6.2) and the post-phlebotomy PVI (16.4% ± 9.6) (P = 0.55). Patients who had a starting PVI ≤14% had a significant increase in PVI after phlebotomy from 9.1% ± 3 to 14.3% ± 7.2 (P = 0.0014). Although, patients with a pre-phlebotomy PVI of >14% required more crystalloid replacement (11 ± 9.4 mL/kg) than those with a PVI ≤14% (5.3 ± 4.7 mL/kg), this was not significant (P = 0.06). In patients who received less crystalloid replacement during phlebotomy, PVI did show a significant increase. Additionally, the data suggests that patients with a pre-phlebotomy PVI >14% required greater fluid replacement than those with a PVI < 14%. Further research is needed to better delineate the utility of PVI in this unique group of patients.

Caudal epidural blockade in adolescents.

BACKGROUND: Various options are available for the provision of analgesia following major surgical procedures including systemic opioids and regional anesthetic techniques. Regional anesthetic techniques offer the advantage of providing analgesia while avoiding the deleterious adverse effects associated with opioids including nausea, vomiting, sedation and respiratory depression. Although used commonly in infants and children, there is a paucity of experience with the use of caudal epidural blockade in adolescents. METHODS: We retrospectively reviewed the perioperative care of adolescents undergoing major urologic or orthopedic surgical procedures for whom a caudal epidural block was placed for postoperative analgesia. RESULTS: The cohort for the study included 5 adolescents, ranging in age from 13 to 18 years and in weight from 42 to 71 kilograms. Caudal epidural analgesia was accomplished after the induction of anesthesia and prior to the start of the surgical procedure using 20-25 mL of either 0.25% bupivacaine or 0.2% ropivacaine with clonidine (1 µg/kg). The patients denied pain the recovery room. The time to first request for analgesia varied from 12 to 18 hours with the patients requiring 1-3 doses of analgesic agents during the initial 24 postoperative hours. CONCLUSIONS: Our preliminary experience demonstrates the efficacy of caudal epidural block in providing analgesia following major urologic and orthopedic surgical procedures. The applications of this technique as a means of providing postoperative analgesia are discussed.

Phenylephrine to Treat Hypoxemia during One-Lung Ventilation in a Pediatric Patient.

To improve surgical visualization and facilitate the procedure, one-lung ventilation (OLV) is frequently used during thoracic surgery. Although generally well tolerated, the ventilation-perfusion inequality induced by OLV may lead to a decrease in oxygenation and, at times, hypoxemia. Effective treatment algorithms and strategies are necessary for the treatment of hypoxemia during OLV to ensure that the technique can be continued without interruption and allow for completion of the surgical procedure. Treatment strategies may include applying positive end expiratory pressure to the nonoperative lung, continuous positive airway pressure or low flow oxygen insufflation to the operative lung, decreasing anesthetic agents that interfere with hypoxic pulmonary vasoconstriction (HPV), or switching to total intravenous anesthesia. Although less commonly employed, α-adrenergic agonists may also improve oxygenation during OLV by augmenting HPV. We present a 12-year-old girl who developed hypoxemia during OLV, which was not corrected by the usual maneuvers. Hypoxemia was successfully treated with a phenylephrine infusion. The potential applications of α-adrenergic agonists such as phenylephrine in the treatment of hypoxemia during OLV are discussed and its physiologic basis reviewed.

Impact of aprotinin and renal function on mortality: a retrospective single center analysis.

BACKGROUND: An estimated up to 7% of high-risk cardiac surgery patients return to the operating room for bleeding. Aprotinin was used extensively as an antifibrinolytic agent in cardiac surgery patients for over 15 years and it showed efficacy in reducing bleeding. Aprotinin was removed from the market by the U.S. Food and Drug Administration after a large prospective, randomized clinical trial documented an increased mortality risk associated with the drug. Further debate arose when a meta-analysis of 211 randomized controlled trials showed no risk of renal failure or death associated with aprotinin. However, only patients with normal kidney function have been studied. METHODS: In this study, we look at a single center clinical trial using patients with varying degrees of baseline kidney function to answer the question: Does aprotinin increase odds of death given varying levels of preoperative kidney dysfunction? RESULTS: Based on our model, aprotinin use was associated with a 3.8-fold increase in odds of death one year later compared to no aprotinin use with p-value = 0.0018, regardless of level of preoperative kidney dysfunction after adjusting for other perioperative variables. CONCLUSIONS: Lessons learned from our experience using aprotinin in the perioperative setting as an antifibrinolytic during open cardiac surgery should guide us in testing future antifibrinolytic drugs for not only efficacy of preventing bleeding, but for overall safety to the whole organism using long-term clinical outcome studies, including those with varying degree of baseline kidney function.