Ethnicity and parental report of postoperative behavioral changes in children.

OBJECTIVES: To examine the role of ethnicity and language in parent report of children's postoperative behavioral recovery. AIM: To compare incidence of new onset negative behavior change in English- and Spanish-speaking White and Hispanic children following outpatient surgery. BACKGROUND: Postoperative behavioral change in children is common; however, it is unknown whether cultural variables including ethnicity and language may influence parent report of children's behavioral recovery. METHODS/MATERIALS: Participants included 288 parents (English-speaking White, English-speaking Hispanic, Spanish-speaking Hispanic parents) of children undergoing outpatient elective surgery. Parents completed the post-hospitalization behavior questionnaire (PHBQ) and parents' postoperative pain measure (PPPM) on postoperative days one, three, and seven at home. RESULTS: Most parents (83%) reported onset of new negative behavioral change in children postoperatively. Generalized estimating equations revealed significant group differences in overall behavior change [Wald χ(2)(12) = 375.69, P < 0.0001] after controlling for demographic and socioeconomic differences. At all three postoperative days, Spanish-speaking Hispanic (SSH) parents reported lower negative behavioral changes in their children compared to English-speaking White (ESW) parents (day 1: P < 0.01; day 3: P < 0.001; day 7: P < 0.10). On postoperative days one and three, SSH parents also reported lower total PHBQ scores than English-speaking Hispanic (ESH) parents [day 1: χ(2)(1) = 6.72, P = 0.01; day 3: χ(2)(1) = 7.98, P = 0.005]. CONCLUSION: The present study provides evidence that parent report of children's postoperative behavioral recovery may be influenced by cultural variables, such as ethnicity and language. The present results contribute to a growing body of evidence that highlights the need for culturally sensitive assessment and care of families in the medical setting. The findings may reflect differences in cultural values such as stoicism; however, future studies would benefit from examination of the factors that may account for the differences in reported behavior change after surgery (i.e., report bias, cultural values).

Clinical assessment incorporating a personal genome.

BACKGROUND: The cost of genomic information has fallen steeply, but the clinical translation of genetic risk estimates remains unclear. We aimed to undertake an integrated analysis of a complete human genome in a clinical context. METHODS: We assessed a patient with a family history of vascular disease and early sudden death. Clinical assessment included analysis of this patient's full genome sequence, risk prediction for coronary artery disease, screening for causes of sudden cardiac death, and genetic counselling. Genetic analysis included the development of novel methods for the integration of whole genome and clinical risk. Disease and risk analysis focused on prediction of genetic risk of variants associated with mendelian disease, recognised drug responses, and pathogenicity for novel variants. We queried disease-specific mutation databases and pharmacogenomics databases to identify genes and mutations with known associations with disease and drug response. We estimated post-test probabilities of disease by applying likelihood ratios derived from integration of multiple common variants to age-appropriate and sex-appropriate pre-test probabilities. We also accounted for gene-environment interactions and conditionally dependent risks. FINDINGS: Analysis of 2.6 million single nucleotide polymorphisms and 752 copy number variations showed increased genetic risk for myocardial infarction, type 2 diabetes, and some cancers. We discovered rare variants in three genes that are clinically associated with sudden cardiac death-TMEM43, DSP, and MYBPC3. A variant in LPA was consistent with a family history of coronary artery disease. The patient had a heterozygous null mutation in CYP2C19 suggesting probable clopidogrel resistance, several variants associated with a positive response to lipid-lowering therapy, and variants in CYP4F2 and VKORC1 that suggest he might have a low initial dosing requirement for warfarin. Many variants of uncertain importance were reported. INTERPRETATION: Although challenges remain, our results suggest that whole-genome sequencing can yield useful and clinically relevant information for individual patients. FUNDING: National Institute of General Medical Sciences; National Heart, Lung And Blood Institute; National Human Genome Research Institute; Howard Hughes Medical Institute; National Library of Medicine, Lucile Packard Foundation for Children's Health; Hewlett Packard Foundation; Breetwor Family Foundation.

Beyond pain: predictors of postoperative maladaptive behavior change in children.

UNLABELLED: OBJECTIVES & AIM: Using well-validated measures and controlling for potential confounding variables such as pain and surgical and anesthetic technique, the goal of this project was to identify the incidence of and risk factors for the development of behavior change in children after surgery. BACKGROUND: Although researchers have described maladaptive behavior change following surgery, many previous studies are limited by potential confounding variables, including postoperative pain, type of surgery, and surgical and anesthetic procedure. METHODS: Participants included 260 children undergoing tonsillectomy and adenoidectomy. Baseline and demographic data were collected prior to surgery and pain and behavioral recovery were recorded for 2 weeks following surgery. A standardized approach to anesthesia and surgical procedure was implemented and well-validated assessment measures were used. RESULTS: On the first day at home following surgery, 80.4% of children exhibited negative behavior change. Nearly one-third of children continued to exhibit behavior changes 2 weeks after surgery. Logistic regression analyses that controlled for pain severity identified several predictors of behavior change: preexisting somatic and anxious/depressed problems predicted new onset postoperative general anxiety, chi(2) (8) = 20.10, P = 0.010; younger age predicted separation anxiety, chi(2) (4) = 20.41, P < 0.01; and inhibited temperament predicted postoperative sleep disturbance, chi(2) (2) = 9.19, P = 0.010. CONCLUSIONS: Individual child factors above and beyond pain predict maladaptive postoperative behavior change; identification of these predictors may be helpful in both preventing and ameliorating difficulties with behavioral recovery following surgery.

The place of premedication in pediatric practice.

Behind the multiple arguments for and against the use of premedication, sedative drugs in children is a noble principle that of minimizing psychological trauma related to anesthesia and surgery. However, several confounding factors make it very difficult to reach didactic evidence-based conclusions. One of the key confounding issues is that the nature of expectations and responses for both parent and child vary greatly in different environments around the world. Studies applicable to one culture and to one hospital system (albeit multicultural) may not apply elsewhere. Moreover, the study of hospital-related distress begins at the start of the patient's journey and ends long after hospital discharge; it cannot be focused completely on just the moment of anesthetic induction. Taking an example from actual practice experience, the trauma caused by the actual giving of a premedication to a child who absolutely does not want it and may struggle may not be recorded in a study but could form a significant component of overall effect and later psychological pathology. Clearly, attitudes by health professionals and parents to the practice of routine pediatric premedication, vary considerably, often provoking strong opinions. In this pro-con article we highlight two very different approaches to premedication. It is hoped that this helps the reader to critically re-evaluate a practice, which was universal historically and now in many centers is more selective.

Preoperative melatonin and its effects on induction and emergence in children undergoing anesthesia and surgery.

BACKGROUND: Studies conducted in adults undergoing surgery reported a beneficial effect of oral melatonin administered before surgery. There is a paucity of such data in children undergoing anesthesia and surgery. METHODS: Children undergoing surgery were randomly assigned to receive preoperatively oral midazolam 0.5 mg/kg or oral melatonin 0.05 mg/kg, 0.2 mg/kg, or 0.4 mg/kg. The primary outcome of the study was preoperative anxiety (Yale Preoperative Anxiety Scale). The secondary outcomes were the children's compliance with induction (Induction Compliance Checklist), emergence behavior (Keegan scale), and parental anxiety (State-Trait Anxiety Inventory). RESULTS: Repeated measures ANOVA showed that children who received melatonin at any of the three doses were more anxious compared with children who received midazolam (P < 0.001). Parental anxiety did not differ on the basis of the experimental condition (P = ns). The melatonin groups showed a dose-response effect on emergence behavior. Children who received melatonin developed less emergence delirium compared with those who received midazolam (P < 0.05), and the effect was dose related; the incidence after 0.05 mg/kg melatonin was 25.0%, incidence after 0.2 mg/kg melatonin was 8.3%, and incidence after 0.4 mg/kg melatonin was 5.4%. CONCLUSIONS: Midazolam is more effective than melatonin in reducing children's anxiety at induction of anesthesia. Melatonin showed a direct dose-dependent effect on emergence delirium.

Novel portable device measures preoperative patient metabolic gas exchange.

BACKGROUND: Indirect calorimetry (IC), the measurement of airway CO2 elimination (VCO2), O2 [corrected] uptake (VO2) [corrected], and respiratory exchange ratio (RER = VCO2/VO2), is a noninvasive modality for the assessment of body metabolism. In anesthesia, IC can signal critical events and onset of acute metabolic derangements. We have previously demonstrated the accuracy and precision of a new IC measurement system designed for mechanically ventilated patients, comprised of a new clinical bymixer, fast response humidity and temperature sensor, and a flowmeter. However, measurement of IC during spontaneous breathing is challenging because of unstable tidal volume, frequency, and functional residual capacity (FRC). METHODS: A new device for IC measurements, designed specifically for spontaneous breathing, was validated against a metabolic lung simulator bench setup. In a second study, the same device was used to conduct preoperative measurements of VCO2 and VO2 in 15 patients. RESULTS: Our measurements showed excellent correlation and agreement with metabolic lung simulator values: The average (+/-SD) percent error for airway VCO2 was -4.7% +/- 3.31%; the average (+/-SD) percent error for airway VO2 was -0.30% +/- 5.25%. Average values of VCO2 and VO2 in the patient study (3.01 +/- 0.56 and 3.44 +/- 0.69 mL x kg(-1) x min(-1), respectively) were in agreement with previously reported values. CONCLUSION: We have shown that the new, portable bymixer-flow device, using a bymixer and a fast response humidity sensor, provided accurate and convenient bedside measurement of VCO2 and VO2. We believe that it can contribute in the future to preoperative assessment and baseline reference value for perioperative management.

Bymixer system can measure O2 uptake and CO2 elimination in the anesthesia circle circuit.

BACKGROUND: The ability to measure carbon dioxide elimination (Vco(2)), oxygen uptake (Vo(2)), and R (respiratory exchange ratio, Vco(2)/Vo(2)) during anesthesia may help the non-invasive detection of critical events (e.g., abrupt decrease in cardiac output) and metabolic upset (e.g., onset of anaerobic metabolism). METHODS: We have developed a new clinical bymixer (inline mixing chamber) that can measure mixed inspired and expired gas fractions in the anesthesia circle circuit. The addition of a standard anesthesia gas analyzer and flowmeter, and a new airway temperature and humidity sensor, allow determinations of Vco(2) and Vo(2) at the airway opening of the circle circuit. Over a range of tidal volume and frequency, Vco(2) and Vo(2) were compared to reference values generated by the combustion of metered liquid ethanol in a new metabolic lung simulator. RESULTS: By linear regression, bymixer-flow measurements of Vco(2) (slope = 1.02, Y-intercept = -5.31, coefficient of determination, R(2) = 0.998) and Vo(2) (slope = 1.05, Y-intercept = -4.34, R(2) = 0.993) correlated closely to the reference values generated by the metabolic lung simulator. Limits of agreement analysis generated percent errors (mean +/- 1.96 SD) of -1.2 +/- 7.2% for Vco(2) and 2.5 +/- 9.8% for Vo(2). CONCLUSIONS: The new clinical bymixer is compact, lightweight, disposable, inexpensive, and has a fast and adjustable response time (time constant about 14 sec). Anesthesia circle circuit integrity is maintained. Bymixer-flow measurements of Vco(2) and Vo(2) are accurate and may add to clinical monitoring under anesthesia and surgery.

Novel, adjustable, clinical bymixer measures mixed expired gas concentrations in anesthesia circle circuit.

UNLABELLED: We have introduced a novel, parallel design into a new clinical bymixer (patent pending), named for the bypass of a constant fraction of total flow through a mixing chamber. Over a wide range of tidal volumes (300-1200 mL), frequency (6-20 breaths/min), and PCO(2) (6-50 mm Hg), the bymixer provided accurate measurement of mixed expired gas fractions in the ventilation circuit compared with an expired gas collection in a metabolic lung bench setup (average slope, 1.00; average y intercept, -0.01; average coefficient of determination, R(2) = 0.9988). Simple changes in mixing chamber volume provided adjustable bymixer response times. The fast bymixer response (time constant, 6.4 s) should allow measurements to be updated every 20 s (where 95% response occurs by three time constants). The new clinical bymixer is constructed from standard anesthesia circuit components, attaches easily to the anesthesia machine inspired outlet and expired inlet ports, is simple to clean and sterilize, and has no reservoir to trap condensed water vapor from expired gas. The new clinical bymixer may facilitate indirect calorimetry (CO(2) elimination, VCO(2), and oxygen uptake, VCO(2)) during anesthesia and the noninvasive detection of metabolic upset (e.g., onset of anaerobic metabolism) and critical events (e.g., pulmonary embolism). IMPLICATIONS: A new clinical bymixer (inline mixing chamber) provides a fast response and accurate measurements of mixed expired gas fractions in the anesthesia circle circuit. A novel parallel design facilitates adjustable response, easy cleaning, and construction from standard airway circuit components. The new clinical bymixer may facilitate widespread introduction of indirect calorimetry during anesthesia.