Avoiding pain during propofol injection in pediatric anesthesia: Hypnoanalgesia of the hand versus intravenous lidocaine.

INTRODUCTION: Pain related to injection of propofol during induction of anesthesia decreases from 66.8% without prevention, to 22-31% of cases when lidocaine is associated. Hypnoanalgesia of the hand is currently used for painful procedures in children but has never been evaluated in this indication. The primary aim of this prospective randomized single-blind study was to evaluate the efficacy of hypnoanalgesia of the hand for the prevention of moderate to severe pain during intravenous injection of propofol alone in comparison to lidocaine admixture. The secondary aim was to compare the global satisfaction of children in both methods. PATIENTS AND METHODS: One hundred patients aged 7-14 years, ASA 1-2, admitted for scheduled surgery under general anesthesia were randomized into two groups. Group L received a mixture of 1% propofol (3 mg/kg) and 1% Lidocaine (0.3 mg/kg). Group H received 1% propofol (3 mg/kg) after hypnoanalgesia of the hand realized by a single experimented operator. A video was made in order to evaluate the pain related to propofol injection by a blinded observer using the 4-point score of Cameron (painful ≥ 2). The global satisfaction of children was evaluated in postanesthesia care unit and documented if visual analog score was <7/10. RESULTS: Ninety-six patients were analyzed. The rate of painful patients did not differ significantly between groups (8.5% in group H [n = 47] vs 6.1% in group L [n = 49], OR= 0.70; 95% CI [0.13-3.35], p = 0.65), nor did the rate of nonsatisfied patients (10.6 in group H vs. 12.2% in group L, OR = 0.85; 95% CI [0.19-3.65], p = 1). CONCLUSIONS: Our results suggest that hypnoanalgesia of the hand alone is effective to prevent the pain related to propofol injection in children. No significant difference was found in comparison with lidocaine admixture nor for pain or satisfaction.

Teleconsultation in pediatric anesthesia: First assessment of feasibility, quality, and satisfaction in France.

INTRODUCTION: The COVID-19 pandemic has prompted the development of anesthesia teleconsultation in many countries. In pediatric anesthesia, data about anesthesia teleconsultation are scarce. The main objective of this prospective descriptive study was to provide an evaluation of the feasibility of pediatric anesthesia teleconsultation. Perception of the safety and quality, parental and medical satisfaction were also assessed. METHODS: From September to December 2020, patients undergoing a pediatric anesthesia teleconsultation in Toulouse University Hospital, using the TeleO™ dedicated teleconsultation platform were prospectively included. Feasibility was defined as the rate of anesthesia teleconsultations successfully performed using the TeleO™ platform alone. Questionnaires regarding the quality, safety, and satisfaction were filled in by physicians and families. RESULTS: A total of 114 children (3 months-17 years) were included in the study. Feasibility was 82%, failure was mainly caused by technical issues. Physicians estimated that the safety and quality of anesthetic preparation were optimal in 100% of cases. Anesthetists were satisfied (VAS ≥70/100) with the medical, technical, and relational (child/parents) aspects of anesthesia teleconsultation in 91%, 64%, and 84%/90% of cases respectively. Almost all parents (97%) stated that they would agree to anesthesia teleconsultation for a future procedure. CONCLUSION: In this first assessment, pediatric anesthesia teleconsultation appears to be feasible, with high rates of medical and parental satisfaction. Physicians' perception of the safety and quality of this process were positive. Improving the technical process might be a key determinant to promote further development of pediatric anesthesia teleconsultation.

Ventilation in pediatric anesthesia: A French multicenter prospective observational study (PEDIAVENT).

INTRODUCTION: Protective ventilation is now a standard of care in adults. However, management of ventilation is heterogeneous in children and little is known regarding the mechanical ventilation parameters actually used during pediatric anesthesia. AIM: The aim of the study was to assess current ventilatory practices during pediatric anesthesia in France and to compare them with pediatric experts' statements, with a specific focus on tidal volume. PATIENTS AND METHODS: We conducted a prospective multicenter observational study, regarding the ventilatory management and the mechanical ventilation parameters, over two days (21 and 22 June 2017) in 29 pediatric centers in France. All children undergoing general anesthesia during these 2 days were eligible; those who required extracorporeal circulation or one-lung ventilation were excluded. RESULTS: A total of 701 children were included; median [IQR] age was 60 [24-120] months. Among the patients in whom controlled ventilation was used, 254/515 (49.3%) had an expired tidal volume >8 mL/kg and 44 children (8.8%) an expired tidal volume ≥10 mL/kg. Lower weight and use of a supraglottic airway device were significantly associated with provision of a tidal volume ≥10 mL/kg (odds ratio 0.94, 95% confidence interval [0.92; 0.97], P < .001 and 2.28 [1.20; 4.31], P = .012, respectively). The positive end-expiratory pressure was set at a median [IQR] of 4 [3-5] cmH2 O; it was <3 cmH2 O in 15.7% of children and not used in 56/499 (9.3%). Among intubated children, 57 (18.3%) received a tidal volume < 10 mL/kg with a positive end-expiratory pressure ≥3 cmH2 O in association with recruitment maneuvers. CONCLUSIONS: Ventilatory practices in children were heterogenous, and a large proportion of children were not ventilated as it is currently recommended by some experts.

The sevoflurane washout profile of seven recent anesthesia workstations for malignant hyperthermia-susceptible adults and infants: a bench test study.

BACKGROUND: Preoperative flushing of an anesthesia workstation is an alternative for preparation of the anesthesia workstation before use in malignant hyperthermia-susceptible patients (MHS). We studied in vitro, using a test lung, the washout profile of sevoflurane in 7 recent workstations during adult and, for the first time, pediatric ventilation patterns. METHODS: Anesthesia workstations were first primed with 3% sevoflurane for 2 hours and then prepared according to the recommendations of the Malignant Hyperthermia Association of the United States. The flush was done with maximal fresh gas flow (FGF) with a minute ventilation equal to 600 mL × 15, to reach a sevoflurane concentration of <5 parts per million. After flush, 2 clinical situations were simulated in vitro to test the efficiency of preparation: decrease of FGF from max to 10 L/min, or decrease of minute ventilation to 50 mL × 30, to simulate the ventilation of an MHS infant. RESULTS: We report washout delays for MHS patients for previously studied workstations (Primus®, Avance®, and Zeus®) and more interestingly, for machines not previously tested (Felix®, Flow-I®, Perseus®, and Leon®). An increase of sevoflurane concentration was observed when decreasing FGF (except for flow-I® and Leon®) and during simulation of MHS infant ventilation (except for Felix®). CONCLUSIONS: This descriptive study strongly suggests that washout profiles may differ for each anesthesia workstation. We advise the use of maximal FGF during preparation and anesthesia. Required flushing times are longer when preparing an anesthesia workstation before providing anesthesia for MHS infants.

An ADARPEF survey on respiratory management in pediatric anesthesia.

BACKGROUND: There have been recent changes with regard to tools and concepts for respiratory management of children undergoing general anesthesia. OBJECTIVES: To determine the practice of pediatric anesthetists concerning: preoxygenation, breathing systems, ventilation modes, anesthetic agent and airway device, strategies for a general anaesthetic of less than 30 min using spontaneous respiration, and opinion about technical aspects of ventilation. METHODS: Online questionnaire sent by e-mail to all the anesthetists registered on the mailing list of the French-speaking Pediatric Anesthetists and Intensivists Association (ADARPEF). RESULTS: 232 questionnaires (46%) were returned. More than 25% of anesthetists surveyed declared that they do not perform preoxygenation before induction for children <15 years old, apart from neonates and clinical specific situations. When performed, <65% chose a FiO2 higher than 80%. Inhalational induction with sevoflurane is the preferred mode of induction set at 6% or 8%, respectively, 69% [62-75] vs 25% [18-31]. For induction, the circle system was the most popular circuit used in all ages. The accessory breathing system-Mapleson B type-was predominantly used for neonates (44% [37-54]). For maintenance of an anesthesia lasting <30 min in spontaneous breathing, the use of laryngeal mask increased with age, and the endotracheal tube was reserved for neonates (40% [33-48]). Pressure support ventilation was rarely used from the beginning of induction but was widely used for maintenance, whatever the age-group. Results differed according to the type of institution. CONCLUSION: Ventilation management depends on the age and institutions in terms of circuit, airway device or ventilation mode, and specific differences exist for neonates.

Inside anesthesia breathing circuits: time to reach a set sevoflurane concentration in toddlers and newborns: simulation using a test lung.

We measured the time it takes to reach the desired inspired anesthetic concentration using the Primus (Drägerwerk, AG, Lübeck, Germany) and the Avance (GE Datex-Ohmeda, Munich, Germany) anesthesia machines with toddler and newborn ventilation settings. The time to reach 95% of inspired target sevoflurane concentration was measured during wash-in from 0 to 6 vol% sevoflurane and during wash-out from 6 to 0 vol% with fresh gas flows equal to 1 and 2 times the minute ventilation. The Avance was faster than the Primus (65 seconds [95% confidence interval (CI): 55 to 78] vs 310 seconds [95% CI: 261 to 359]) at 1.5 L/min fresh gas flow, tidal volume of 50 mL, and 30 breaths/min. Times were shorter by the same magnitude at higher fresh gas flows and higher minute ventilation rates. The effect of doubling fresh gas flow was variable and less than expected. The Primus is slower during newborn than toddler ventilation, whereas the Avance's response time was the same for newborn and toddler ventilation. Our data confirm that the time to reach the target-inspired anesthetic concentration depends on breathing circuit volume, fresh gas flow, and minute ventilation.

A follow-up of pain reported by children undergoing outpatient surgery using a smartphone application: AlgoDARPEF multicenter descriptive prospective study.

ABSTRACT: In pediatric patients, pain remains the most common complaint after surgery. This French multicenter epidemiological study (AlgoDARPEF) aimed to evaluate the use of a smartphone application (App) to assess the duration and severity of pain experienced by children undergoing outpatient surgery. Children younger than 18 years scheduled for an elective outpatient procedure in one of the participating centers were eligible. Parents were invited to provide daily information for 10 days regarding their child's pain and comfort through a smartphone App using the Parents' Postoperative Pain Measure-Short-Form (PPPM-SF). Children older than 6 years could also provide self-assessments of pain using a numerical rating scale (NRS)-11. Data regarding pain medication, preoperative anxiety, postoperative nausea and vomiting, and parent satisfaction were also analyzed. Repeated-measures analyses of variances (ANOVAs) were used to compare the self-assessments and hetero-assessments of pain. Eleven centers participated in the study, and 1573 patients were recruited. Forty-nine percentage of parents (n = 772) actually used the App at least once. In all surgeries, the average pain rating on the PPPM-SF scale did not exceed 3/10 throughout the follow-up period, as well as for 4 main surgical specialties. Age, visceral surgery, and preoperative anxiety ≥ 4/10 were identified as independent risk factors for experiencing at least 1 episode of pain ≥4/10 during the first 48 postoperative hours. Although these findings indicated that postoperative pain management seems to be satisfactory in the families who used the App, some improvements in anxiety management are suggested. This study shows that inviting parents to use a smartphone App to assess and report the quality of postoperative management in pediatric patients provides useful information. A continuous report regarding pain and adverse events over a 10-day postoperative period by a self-reporting or parent's contribution is possible. Future studies should investigate the ability of live data collection using an App to ensure fast, efficient interactions between patients and physicians.

Guidelines: Anaesthesia in the context of COVID-19 pandemic.

OBJECTIVES: The world is currently facing an unprecedented healthcare crisis caused by the COVID-19 pandemic. The objective of these guidelines is to produce a framework to facilitate the partial and gradual resumption of intervention activity in the context of the COVID-19 pandemic. METHODS: The group has endeavoured to produce a minimum number of recommendations to highlight the strengths to be retained in the 7 predefined areas: (1) protection of staff and patients; (2) benefit/risk and patient information; (3) preoperative assessment and decision on intervention; (4) modalities of the preanaesthesia consultation; (5) specificity of anaesthesia and analgesia; (6) dedicated circuits and (7) containment exit type of interventions. RESULTS: The SFAR Guideline panel provides 51 statements on anaesthesia management in the context of COVID-19 pandemic. After one round of discussion and various amendments, a strong agreement was reached for 100% of the recommendations and algorithms. CONCLUSION: We present suggestions for how the risk of transmission by and to anaesthetists can be minimised and how personal protective equipment policies relate to COVID-19 pandemic context.

Management of the child's airway under anaesthesia: The French guidelines.

OBJECTIVE: To provide French guidelines about "Airway management during paediatric anaesthesia". DESIGN: A consensus committee of 17 experts from the French Society of Anaesthesia and Intensive Care Medicine (Société Française d'Anesthésie-Réanimation, SFAR) and the Association of French speaking paediatric anaesthesiologists and intensivists (Association Des Anesthésistes Réanimateurs Pédiatriques d'Expression Francophone, ADARPEF) was convened. The entire process was conducted independently of any industry funding. The authors followed the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to assess the quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasised. Few recommendations were not graded. METHODS: The panel focused on 7 questions: 1) Supraglottic Airway devices 2) Cuffed endotracheal tubes 3) Videolaryngoscopes 4) Neuromuscular blocking agents 5) Rapid sequence induction 6) Airway device removal 7) Airway management in the child with recent or ongoing upper respiratory tract infection. Population, intervention, comparison, and outcomes (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. The analysis of the literature and the redaction of the recommendations were then conducted according to the GRADE® methodology. RESULTS: The SFAR Guideline panel provides 17 statements on "airway management during paediatric anaesthesia". After two rounds of discussion and various amendments, a strong agreement was reached for 100% of the recommendations. Of these recommendations, 6 have a high level of evidence (Grade 1 ± ), 6 have a low level of evidence (Grade 2 ± ) and 5 are experts' opinions. No recommendation could be provided for 3 questions. CONCLUSIONS: Substantial agreement exists among experts regarding many strong recommendations for paediatric airway management.

Investigation of the paradoxical painful sensation ('illusion of pain') produced by a thermal grill.

A paradoxical painful sensation can be elicited by the simultaneous application of innocuous warm and cold stimuli to the skin. In the present study, we analyzed the conditions of production of this unique experimental illusion of pain in 52 healthy volunteers (27 men, 25 women). The stimuli were produced by a thermode composed of six bars whose temperature was controlled by Peltier elements. The temperature of alternate (even- and odd-numbered) bars could be controlled independently to produce various patterns of the 'thermal grill'. After measuring the cold and heat pain thresholds, a series of combinations of warm and cold stimuli, whose distance to the thermal pain threshold was at least 4 degrees C, were applied on the palmar surface of the right hand during 30s. After each stimulus, the subjects had to describe and rate their sensations on visual analog scales. Paradoxical painful sensations, mostly described as burning, were reported by all the subjects but three. However, the phenomenon was less frequent in approximately one third of ('low responder') volunteers. The frequency and intensity of such painful sensations were directly related to the magnitude (i.e. 5-25 degrees C) of the difference of the temperature between the warm and cold bars of the grill. The combination of increasingly colder temperature to a given warm temperature induces similar effects as combining increasingly warmer temperature to a given cold temperature. These results suggest that pain can be the result of a simple addition of non-noxious warm and cold signals.

Relationships between the paradoxical painful and nonpainful sensations induced by a thermal grill.

The simultaneous application of innocuous cutaneous warm and cold stimuli with a thermal grill can induce both paradoxical pain and paradoxical warmth (heat). The goal of this study was to investigate further the relationships between these paradoxical sensations. Stimuli were applied to the palms of the right hands of 21 volunteers with a thermode consisting of 6 bars, the temperature of which was controlled by Peltier elements. We assessed the quality and intensity of the sensations evoked by series of stimuli consisting of progressively colder temperatures combined with a series of given warm temperatures. We applied a total of 116 series of stimuli, corresponding to 785 combinations of warm and cold temperatures. The 2 paradoxical phenomena were reported for most of the series of stimuli (n=66). In each of these series, the 2 phenomena occurred in the same order: paradoxical warmth followed by paradoxical pain. The difference between the cold-warm temperatures eliciting paradoxical warmth was significantly smaller than that producing paradoxical pain. The intensities of the warmth and unpleasantness evoked by the stimuli were directly related to the magnitude of the warm-cold differential. Our results suggest that there is a continuum between the painful and nonpainful paradoxical sensations evoked by the thermal grill that may share pathophysiological mechanisms. These data also confirm the existence of strong relationships between the thermoreceptive and nociceptive systems and the utility of the thermal grill for investigating these relationships.

Effects of morphine on the experimental illusion of pain produced by a thermal grill.

We compared the effects of systemic morphine on normal (heat and cold) pain and paradoxical burning pain evoked by the simultaneous application of innocuous warm and cold stimuli to the skin. Twelve healthy volunteers participated in a randomised, double-blind, cross-over study to compare the effects of intravenous administration of morphine (0.025 or 0.1mg/kg) or placebo (saline). Stimuli were applied to the palm of the right hand with a thermode ("thermal grill") composed of six bars, whose temperatures were controlled by Peltier elements. For each session, we measured the heat and cold pain thresholds and then successively measured the intensity of: (i) paradoxical pain evoked by a combination of non-noxious warm and cold stimuli; (ii) "normal" pain evoked by suprathreshold heat or cold stimuli; (iii) non-painful sensations evoked by warm or cold stimuli at temperatures used to produce paradoxical pain. Measurements were performed before 20min after the administration of morphine or placebo and 5min after the administration of the morphine antagonist, naloxone. The administration of 0.1mg/kg of morphine, but not 0.025mg/kg, induced a significant and naloxone-reversible reduction of paradoxical pain intensity, which was directly correlated with the reduction of normal cold pain. No differences were observed for non-painful thermal sensations. The paradoxical burning pain evoked by a thermal grill can be modified pharmacologically by analgesics and share some mechanisms with normal pain. This unique experimental "illusion of pain" may represent a new model to test analgesics in healthy volunteers.

Pharmacological dissection of the paradoxical pain induced by a thermal grill.

We investigated the role of the glutamatergic and endogenous opioidergic systems in the paradoxical pain evoked by the simultaneous application of innocuous warm and cold stimuli to the skin with a "thermal grill". Two parallel randomized, double-blind, cross-over studies, including two groups of 12 healthy volunteers, were carried out to compare the effects of i.v. ketamine or naloxone to those of placebo, on the sensations produced by a thermode (i.e. thermal grill) composed of six bars applied on the palmar surface of the right hand. The temperature of alternate (even- and odd-numbered) bars could be controlled independently by Peltier elements to produce various patterns of the grill. During each experimental session we measured the effects of ketamine, naloxone or placebo on the intensity of: (i) paradoxical pain; (ii) "normal" thermal (heat and cold) pain; and (iii) non-painful thermal (warm and cool) sensations. Ketamine administration resulted in a significant reduction of paradoxical pain intensity but did not alter normal pain or non-painful thermal sensations. By contrast, naloxone had no effect on paradoxical pain, normal pain or non-painful thermal sensations. This study demonstrates for the first time that the "thermal grill illusion of pain" can be modulated pharmacologically. This paradoxical pain, which involves the glutamatergic systems, acting through the NMDA receptors, but not the tonic endogenous opioids systems, might share some mechanisms with pathological pain.

The relationship between bispectral index and endtidal concentration of sevoflurane during anesthesia and recovery in spontaneously ventilating children.

BACKGROUND: Global inverse correlation between BIS (bispectral index) and depth of anesthesia using sevoflurane has been documented in children in several studies under experimental conditions and in steady-state conditions during mechanically controlled ventilation. Because sevoflurane mask anesthesia combined with a peripheral nerve block is widely used in children, we studied the relationship between BIS and endtidal concentration of sevoflurane (PE(sevo)) under these conditions during surgery and emergence. METHODS: In this prospective blinded study of 32 children, the relationship between BIS and PE(sevo) was studied during sevoflurane anesthesia via facemask combined with peripheral nerve block. The intraoperative phase was studied during steady-state conditions (fixed PE(sevo)) and the emergence phase was studied during fast alveolar washout (FAW). BIS and PE(sevo) data fitted using the E(max) model. Coefficients of variation of BIS and PE(sevo) during the two periods were compared. RESULTS: Fit was adequate with the simple E(max) model. Intraoperative variation in BIS was large (28.4%), and larger than at awakening (28.4% vs 8%). At awakening, BIS varied less than PE(sevo) (8% vs 28.5%). No difference was found between children younger and those older than 5 years. CONCLUSIONS: Caution is required for intraoperative titration based on BIS when spontaneous ventilation is maintained because of the wide variability compared with PE(sevo). During emergence using FAW, BIS varied significantly less than PE(sevo), but the clinical relevance of this point could be discussed during anesthesia without tracheal intubation.