Analgesic use and favourable patient-reported outcome measures after paediatric surgery: an analysis of registry data.

BACKGROUND: Pain after paediatric appendectomy and tonsillectomy is often undertreated. Benchmarking of hospitals could reveal which measures are associated with improved patient- or parent-reported pain-related outcomes. METHODS: A total of 898 anonymised cases from 11 European hospitals participating in PAIN OUT infant were analysed. The children completed a questionnaire on patient-reported outcomes (PROs) 24 h after surgery. According to a composite PRO measure, including pain intensity and pain-related interference, hospitals were allocated to Group I (favourable results), II (average results), and III (unfavourable results). Benchmarking of hospital groups was performed investigating process variables (dosing of non-opioid analgesics, opioids, and dexamethasone) associated with PROs, side-effects, and children's perception of care. Variables associated with PROs were analysed using multinomial regression analysis with the PRO score-related hospital group as a dependent variable (estimated odds ratios [OR], 95% confidence interval [CI]). RESULTS: During the first 24 h after surgery, 1.2 (1.1-1.3) full daily doses of non-opioid analgesics (non-steroidal anti-inflammatory drug [NSAID], paracetamol, metamizole) were administered in group I and 0.7 (0.6-0.8) in group III (P<0.001). Intraoperative dexamethasone was administered to 70.1 and 52.6% of the children in Group I and Group III, respectively (P<0.001). A lower number of full daily doses of non-opioid analgesics: 0.22 [0.15-0.31]), less dexamethasone (0.49 [0.33-0.71]), fewer non-opioid analgesics before the end of surgery (0.37 [0.22-0.62]) and higher opioid doses were associated with hospital allocation to group III vs group I (Nagelkerke's R2=0.433). CONCLUSIONS: The results indicated substantial deficits in the concept, application, and dosing of analgesics in paediatric patients after surgery. Timely administration of adequate analgesic doses can easily be introduced into daily clinical practice. CLINICAL TRIAL REGISTRATION: clinicaltrials.gov NCT02083835.

High-flow nasal cannula therapy and apnea time in laryngeal surgery.

In small children, high-flow nasal cannula therapy may prolong apnea time even when an inspiratory oxygen fraction below 100% is used. This will be beneficial in prolonged intubation attempts, but especially during procedures requiring prolonged apnea time, leading to fewer airway manipulations and markedly enhanced surgical conditions.

Blind intubation of anaesthetised children with supraglottic airway devices AmbuAura-i and Air-Q cannot be recommended: A randomised controlled trial.

BACKGROUND: Paediatric supraglottic airway devices AmbuAura-i and Air-Q were designed as conduits for tracheal intubation. Although fibreoptic-guided intubation has proved successful, blind intubation as a rescue technique has never been evaluated. OBJECTIVE: Evaluation of blind intubation through AmbuAura-i and Air-Q. On the basis of fibreoptic view data, we hypothesised that the success rate with the AmbuAura-i would be higher than with the Air-Q. DESIGN: A randomised controlled trial. SETTING: University Childrens' Hospital; September 2012 to July 2014. PATIENTS: Eighty children, American Society of Anesthesiologists (ASA) class I to III, weight 5 to 50 kg. INTERVENTIONS: Tracheal intubation was performed through the randomised device with the tip of a fibrescope placed inside and proximal to the tip of the tracheal tube. This permitted sight of tube advancement, but without fibreoptic guidance (visualised blind intubation). MAIN OUTCOME MEASURES: Primary outcome was successfully visualised blind intubation; secondary outcomes included supraglottic airway device success, insertion times, airway leak pressure, fibreoptic view and adverse events. RESULTS: Personal data did not differ between groups. In contrast to our hypothesis, blind intubation was possible in 15% with the Air-Q and in 3% with the AmbuAura-i [95% confidence interval (95% CI) 6 to 31 vs. 0 to 13%; P = 0.057]. First attempt supraglottic airway device insertion success rates were 95% (Air-Q) and 100% (AmbuAura-i; 95% CI 83 to 99 vs. 91 to 100; P = 0.49). Median leak pressures were 18 cmH2O (Air-Q) and 17 cmH2O [AmbuAura-i; interquartile range (IQR) 14 to 18 vs. 14 to 19 cmH2O; P = 0.66]. Air-Q insertion was slower (27 vs. 19 s, P < 0.001). There was no difference in fibreoptic view, or adverse events (P > 0.05). In one child (Air-Q size 1.5, tube size 3.5), the tube dislocated during device removal. CONCLUSION: Ventilation with both devices is reliable, but success of blind intubation is unacceptably low and cannot be recommended for elective or rescue purposes. If intubation through a paediatric supraglottic airway device is desired, we suggest that fibreoptic guidance is used. TRIAL REGISTRATION: Clinicaltrials.gov identifier: NCT01692522.

Performance of the pediatric-sized i-gel compared with the Ambu AuraOnce laryngeal mask in anesthetized and ventilated children.

BACKGROUND: This prospective, randomized, controlled trial compares the performance of the pediatric i-gel (Intersurgical Ltd., Wokingham, United Kingdom) with the Ambu AuraOnce laryngeal mask (Ambu A/S, Ballerup, Denmark) in anesthetized and ventilated children. METHODS: With ethics committee approval and written informed consent, the authors included 208 children, aged 0-17 yr, scheduled for elective day-surgery under general anesthesia. The primary outcome variable was oropharyngeal leak pressure. Other outcome variables were first-attempt and overall success, time to sufficient ventilation, and adverse events. RESULTS: Demographic data did not differ between groups. The leak pressure of the i-gel was significantly higher than the leak pressure of the Ambu (mean ± SD: 22 ± 5 cm H2O vs. 19 ± 3, P < 0.01). First-attempt success was 91% for the i-gel and 93% for the Ambu (P = 0.50). Overall success was 93% for the i-gel versus 98% for the Ambu (P = 0.10). Successfully inserted i-gels needed to be secured by taping in place to ensure the seal in 44% (0% with the Ambu, P < 0.01). Insertion was faster with the Ambu (24 ± 8 s vs. 27 ± 11, P = 0.02). There were no major side effects with either device. CONCLUSIONS: The leak pressure of the i-gel was statistically but not clinically significantly higher than the leak pressure of the Ambu. Time to insertion was longer with the i-gel. Both airway devices are suitable for positive pressure ventilation with high success rates in infants and children. Because the i-gel is prone to sliding out, it must be taped in place to avoid loss of the airway.

Continuous subacromial bupivacaine infusion for postoperative analgesia after open acromioplasty and rotator cuff repair: preliminary results.

Shoulder surgery is often associated with severe postoperative pain. Previous results in which single or continuous subacromial infiltration of local anesthetics was used as a method of postoperative pain relief have been contradictory. This study was initiated to evaluate the postoperative analgesic effect of a subacromial continuous 0.25% bupivacaine infusion at a rate of 6 mL/h after elective open shoulder surgery. We hypothesized that this procedure would improve postoperative analgesia while reducing morphine requirements. By use of a prospective, double-blind, randomized study design, 50 consecutive patients undergoing acromioplasty and rotator cuff repair surgery received a multiorifice catheter placed in the subacromial space. Twenty patients received 0.25% bupivacaine (group 1), and twenty-two patients received saline solution (group 2). The primary endpoints in the two groups were total morphine consumption administered by patient-controlled analgesia and the patient's subjective pain level evaluated by a visual analog scale during the first 48 postoperative hours. No major technical or pharmacologic side effects were noticed, and the indwelling pain catheter was well tolerated by all patients. There was no statistically significant difference (P < .05) either in total cumulative morphine consumption microg/48 h (73.2 +/- 43.1 vs 60.9 +/- 35.9) or in subjective pain perception 10-point visual analog scale (3.2 +/- 1.4 vs 3.1 +/- 1.5) between the two study groups. The continuous subacromial infiltration of 0.25% bupivacaine at a rate of 6 mL/h is concluded to be ineffective in providing pain relief supplementary to patient-controlled analgesia after open rotator cuff repair and acromioplasty surgery.