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.

Anaesthesia for the paediatric outpatient.

PURPOSE OF REVIEW: The aim of this review was to discuss recent developments in paediatric anaesthesia, which are particularly relevant to the practitioner involved in paediatric outpatient anaesthesia. RECENT FINDINGS: The use of a pharmacological premedication is still a matter of debate. Several publications are focussing on nasal dexmedetomidine; however, its exact place has not yet been defined. Both inhalational and intravenous anaesthesia techniques still have their advocates; for diagnostic imaging, however, propofol is emerging as the agent of choice. The disappearance of codeine has left a breach for an oral opioid and has probably worsened postoperative analgesia following tonsillectomy. In recent years, a large body of evidence for the prevention of postoperative agitation has appeared. Alpha-2-agonists as well as the transition to propofol play an important role. There is now some consensus that for reasons of practicability prophylactic antiemetics should be administered to all and not only to selected high-risk patients. SUMMARY: Perfect organization of the whole process is a prerequisite for successful paediatric outpatient anaesthesia. In addition, the skilled practitioner is able to provide a smooth anaesthetic, minimizing complications, and, finally, he has a clear concept for avoiding postoperative pain, agitation and vomiting.

Regional anaesthesia in neonates, infants and children: an educational review.

Prophylactic analgesia with local anaesthesia is widely used in children and has a good safety record. Performing regional blocks in anaesthetised children is a safe and generally accepted practice. When compared with adults, lower concentrations of local anaesthetics are sufficient in children; the onset of a block occurs more rapidly but the duration is usually shorter. Local anaesthetics have a greater volume of distribution, a lower clearance and a higher free (non-protein-bound) fraction. The recommended maximum dose has to be calculated for every individual. Peripheral blocks provide analgesia restricted to the site of surgery, and some of them have a very long duration of action. Abdominal wall blocks, such as transverse abdominis plane or ilio-inguinal nerve block, should be performed with the aid of ultrasound. Caudal anaesthesia is the single most important technique. Ropivacaine 0.2% or levobupivacaine 0.125 to 0.175% at roughly 1 ml  kg⁻¹ is adequate for most indications. Clonidine and morphine can be used to prolong the duration of analgesia. Ultrasound is not essential for performing caudal blocks, but it may be helpful in case of anomalies suspected at palpation and for teaching purposes. The use of paediatric epidural catheters will probably decline in the future because of the potential complications.

[Regional anaesthesia in children--caudal anaesthesia and trunk blocks]. / Kinderanästhesie--Regionalanästhesie bei Kindern: Kaudalanästhesie und Bauchwandblockaden.

In children, elective surgery is often performed in the trunk region. Regional anaesthetic techniques allow good analgesia with reduced opioid consumption, and enhance rapid discharge of the small patients. This review focuses on indication, anatomic structures, puncture techniques and potential complications of caudal anaesthesia, transversus abdominis plane block, ilioinguinal/iliohypogastric nerve block and rectus sheath block.

Pro con debate: the use of regional vs systemic analgesia for neonatal surgery.

In recent years the inclusion of regional techniques to pediatric anesthesia has transformed practice. Simple procedures such as caudal anesthesia with local anaesthetics can reduce the amounts of general anesthesia required and provide complete analgesia in the postoperative period while avoiding large amounts of opioid analgesia with potential side effects that can impair recovery. However, the application of central blocks (epidural and spinal local anesthesia) via catheters in the younger infant, neonate and even preterm neonate remains more controversial. The potential for such invasive maneuvers themselves to augment risk, can be argued to outweigh the benefits, others would argue that epidural analgesia can reduce the need for postoperative ventilation and that this not only facilitates surgery when intensive care facilities are limited, but also reduces cost in terms of PICU stay and recovery profile. Currently, opinions are divided and strongly held with some major units adopting this approach widely and others maintaining a more conservative stance to anesthesia for major neonatal surgery. In this pro-con debate the evidence base is examined, supplemented with expert opinion to try to provide a balanced overall view.

[Generous use of opioids is advantageous for infants and children--Contra]. / Grosszügiger Einsatz von Opioiden bei Säuglingen und Kleinkindern--Contra.

Opioids are important as medication against postoperative pain in infants and children too. However, intraoperatively given opioids increase the analgesic demand in the postoperative period without an improvement of the postoperative pain. Nausea, vomiting, respiratory depression and gastroparesis develop. The apparent benefit of a stable anaesthetic has to be bought with relevant drawbacks. Modern concepts heavily rely on local anaesthetics and nonsteroidals for postoperative analgesia.

Ear surgery in infants under one year of age: its risks and implications for cochlear implant surgery.

OBJECTIVE: Neonatal hearing screening programs allow early identification of infants with congenital severe hearing impairment. Increasing evidence suggests that early cochlear implantation (CI) facilitates auditory rehabilitation and bilateral implantation exceeds the benefit of unilateral CI fitting. Elective surgery before the age of 12 months has, therefore, become increasingly popular. A team approach between the surgeon and the anesthesia team is required to guarantee the safety for the patient. The implanting surgeon should also be aware of the special constraints relevant at this age group. STUDY DESIGN: Our personal experience at a tertiary children's hospital and a review of the German and English literature published on this subject between 1980 and 2007. SETTING: Tertiary referral otology and skull base center with affiliated children's hospital. PATIENTS: Patients younger than 1 year of age undergoing CI surgeries were analyzed concerning surgical techniques, and anesthesiological aspects of elective surgeries in small infants were evaluated. INTERVENTIONS AND OUTCOME MEASURES: The main focus was on CI surgeries in very young infants. Risk factors involving the surgical planning, intervention, and perioperative anesthesia care were evaluated. RESULTS: The age of the patient and the pediatric experience of the anesthesiologist, but not the duration of the surgery, are relevant risk factors. This review article is intended to highlight the surgical and anesthesiological considerations when performing CI surgery in very young infants and anticipates familiarizing the implanting surgeon with important aspects of hemostasis, pharmacokinetics, and cardiopulmonary reserves in small pediatric patients. CONCLUSION: Elective ear surgery in infants below 1 year of age should be performed in institutions where a continuous experience with this type of patient exists and all the facilities of pediatric perioperative anesthesia care are readily available.

Psoas compartment block in children: Part I--description of the technique.

BACKGROUND: Until recently only small series of psoas compartment blocks (PCB) in children have been reported. A high incidence of epidural spread as an important side effect was noted. A series of 100 consecutive blocks using new standardized landmarks is reported. METHODS: In 100 consecutive children (5.9-106 kg) PCB was performed using a nerve stimulator. In the lateral position, the needle was inserted between the medial 2/3 and the lateral 1/3 on a line from the spinous process of L4 to the posterior superior iliac spine. The blocks were performed by residents in training under supervision of one specific designated pediatric anesthetist. RESULTS: All blocks were clinically successful. In 64% only one attempt was necessary, in 26 patients two attempts were necessary and in 10 patients more than two attempts were necessary. In 16% a vascular puncture occurred. In one patient with a dense unilateral block a partial epidural spread occurred. No serious complications were observed during the perioperative period. CONCLUSIONS: The described new technique has a very high success rate with no relevant side effects. Although only one case of epidural spread occurred, PCB remains an invasive technique with the potential for serious complications.

Psoas compartment block (PCB) in children: Part II--generation of an institutional learning curve with a new technique.

BACKGROUND: Literature concerning institutional learning processes for anesthesia procedures in pediatric anesthesia is rare. Until recently only small series of psoas compartment blocks (PCB) in children have been reported. We report on a series of 100 consecutive blocks using new landmarks and the institutional learning process. METHODS: In 100 consecutive children (5.9-106 kg) PCB was performed using a nerve stimulator. In the lateral position, the needle was inserted between the medial 2/3 and the lateral 1/3 on a line from the spinous process of L4 to the posterior superior iliac spine. Residents unfamiliar with PCB were instructed by one single staff member without manual intervention. Failure was defined as a bloody tap, more than one skin perforation with the needle or relinquishing the procedure to senior staff. To evaluate the institutional learning process the cumulative sum (CUSUM) statistical technique was used. CUSUM analysis was performed using an acceptable failure rate of 10%. A learning curve using a bootstrap technique and a least square fit model was also used. RESULTS: Although all blocks were clinically successful, only in 64% was a single attempt sufficient. In 16% vascular puncture occurred. Surprisingly the CUSUM analysis showed a clear institutional learning phenomenon. Applying a strict definition for a successful block, more than 100 PCB in an institution may be necessary. Using the generated learning curve, for a success rate of 70% a case load of at least 55 attempts is required. CONCLUSIONS: Although the described new technique had a very high success rate with a low complication rate, PCB in children is not easily implemented into clinical practice when strict criteria of success were used, despite a well-controlled environment. Training programs could use CUSUM to track the progress of their institutional learning in order to guarantee adequate experience.

Regional anaesthetic techniques for neonatal surgery: indications and selection of techniques.

The goal of neonatal care is to optimise the outcome of term and preterm infants with minimal suffering. Neonates are rare patients for the anaesthetist, therefore personal and even global experiences are limited. This chapter focuses on strategies for dealing with common clinical situations, e.g. heel lancing, obtaining vascular access, circumcision, hernia repair and pyloric stenosis, as well as major neonatal surgery. With the exception of heel lancing, regional techniques are useful in all cases. However, a careful risk-benefit analysis is mandatory, especially when considering more invasive techniques such as epidural catheters.