Pediatric anesthesia in North America.

BACKGROUND AND OBJECTIVES: This educational review outlines the current landscape of pediatric anesthesia training, care delivery, and challenges across Canada, Barbados, and the United States. DESCRIPTIONS AND CONCLUSIONS: Approximately 5% of Canadian children undergo general anesthesia annually, administered by fellowship-trained pediatric anesthesiologists in children's hospitals, general anesthesiologists in community hospitals, or family practice anesthesiologists in underserved regions. In Canada, the focus is on national-level evaluation and accreditation of pediatric anesthesia fellowship training, addressing challenges arising from workforce shortages, particularly in remote areas. Barbados, a Caribbean nation, lacks dedicated pediatric hospitals but has provided pediatric anesthesia since 1972 through anesthetists with additional training. Challenges in its development, common to low-middle-income countries, include inadequate infrastructure and workforce shortages. Increased awareness of pediatric anesthesia as a sub-specialty could enhance perioperative care for Barbadian children. Pediatric anesthesia encompasses various specialties in the United States, with pediatric anesthesiologists playing a foundational role. Challenges faced include recruitment and retention difficulties, supply-chain shortages, and the proliferation of anesthesia sites, all impacting the delivery of modern, high-quality, and cost-effective patient care. Collaborative efforts at national and organizational levels strive to improve the quality and safety of pediatric anesthesia care in the United States.

A Multi-Site Survey Study on the Association Between the COVID-19 Pandemic and United States Anesthesiology Residents' Mental Health.

BACKGROUND:  At the onset of the coronavirus disease 2019 (COVID-19) pandemic, anesthesiology residency programs were impacted differently due to various factors such as the local severity of COVID-19, exposure to patient suffering, and inability to complete rotations. We sought to investigate the impact of local-level pandemic severity on the well-being of anesthesiology residents. METHODS:  This multi-site study surveyed postgraduate year two residents from 15 United States (US) anesthesiology programs using the Perceived Stress Scale, Mini-Z, Patient Health Questionnaire-9,WHO-5 Well-Being Index,and the Multidimensional Scale of Perceived Social Support before the pandemic (baseline survey) and during the first COVID-19 surge (post survey). RESULTS:  A total of 144 (65%) residents responded to the initial baseline survey; 73 (33%) responded to the post survey, and 49 (22%) completed both surveys. There was not a statistically significant difference in any well-being outcomes of participants between the surveys, nor was there a significant difference based on the severity of COVID-19 impact at the program's hospital. Male participants had higher perceived stress scores (ß = 4.05, 95%CI: 0.42, 7.67, P = 0.03) and lower social support from family (ß = -6.57, 95%CI: -11.64, -1.51, P = 0.01) at the post survey compared to female participants after controlling for baseline scores. Additionally, married participants or those with domestic partners reported higher perceived social support in the post survey (ß = 5.79, 95%CI: -0.65, 12.23, P = 0.03). CONCLUSION:  The local COVID-19 severity at a residency program did not disproportionately impact well-being scores among anesthesiology residents. Those most vulnerable to diminished well-being appeared to be male and single participants. As a result, targeted well-being interventions, including those aiming to increase social support, to higher-risk resident groups may be indicated. Future work is needed to assess the longstanding COVID-19 pandemic impacts on resident well-being.

Genetically Confirmed Malignant Hyperthermia in a Six-Week-Old Infant: A Case Report.

A six-week-old 3.9-kg infant presented for microlaryngoscopy and diaphragmatic hernia repair. While positioning for laparoscopy after microlaryngoscopy, the infant developed muscle rigidity, worsening hypercarbia, tachycardia, and early hyperthermia. Sevoflurane was discontinued, and the clinical picture indicating malignant hyperthermia (MH) resolved without dantrolene. Subsequent genetic testing revealed that both the patient and his father carried a mutation in the RYR1 gene that is diagnostic for MH. This is the second youngest genetically confirmed case of MH. This case adds to a limited body of evidence regarding MH presentation and diagnosis in neonates and infants.

Assessing Caudal Block Concentrations of Bupivacaine With and Without the Addition of Intravenous Fentanyl on Postoperative Outcomes in Pediatric Patients: A Retrospective Review.

Caudal blocks are a significant and efficacious aspect of pediatric anesthesia, especially in urologic and many general surgery cases. This type of regional anesthesia is common because it has a high success rate and provides between 6 and 8 hours of postoperative pain control. The aim of this study was to determine whether the concentration of bupivacaine or the addition of intravascular (i.v.) fentanyl affected the postanesthesia care unit (PACU) discharge time. A retrospective cohort study comparing the outcomes in pediatric patients who have received varying caudal concentrations with and without the addition of i.v. fentanyl was performed. A total of 849 consecutive patients undergoing hypospadias repairs or circumcisions were reviewed and placed in one of the following 3 groups: 0.125% bupivacaine (group 1), 0.25% bupivacaine (group 2), or one of these concentrations of bupivacaine + i.v. fentanyl intraoperatively (group 3). Total PACU time for each group was 46.1 minutes (group 1), 48.9 minutes (group 2), and 49.7 minutes (group 3). Our results revealed that there is no statistically significant difference between concentrations of bupivacaine administered in a caudal block with or without i.v. fentanyl with regard to the outcome of PACU duration (P = 0.16). Overall, based on the retrospective cohort design, there is no difference in primary and secondary outcomes based on the concentration of bupivacaine, when administered at a volume of 1 mL/kg.

Moyamoya disease: a review of the disease and anesthetic management.

Moyamoya disease is a rare chronic cerebrovascular disease seen both in children and adults. It has a progressive course, but may have a variable clinical presentation. The disease causes ischemic stroke, intracranial hemorrhage, headache, seizures, and transient ischemia attack in children and in adults. Although the pathogenesis of the disease remains unknown, research suggests a genetic predisposition. There are also undefined systemic processes involved in this vasculopathy. Better noninvasive diagnostic techniques for diagnosis of the Moyamoya disease have been developed, but medical treatment can still be challenging. However, various surgical revascularization procedures have shown to provide symptomatic benefit in a majority of these patients. In addition, the anesthetic management of these patients has evolved over the years with an increased understanding of the disease. These have specifically resulted from the identification of risk factors for perioperative complications and outcomes related to the use of anesthetic agents. Finally, research in the last 3 decades has led to the recognition of the importance of pain control, the increased use of regional anesthesia, and better monitoring techniques in providing high quality and safe patient care to patients with Moyamoya disease. This article will provide a comprehensive review of the disease and its anesthetic management.

Acute-recurrent subcutaneous emphysema after ventriculopleural shunt placement.

Ventriculopleural shunts are one of the alternatives to ventriculoperitoneal shunts for draining cerebrospinal fluid. They are used in patients who have failed multiple ventriculoperitoneal shunts because of peritonitis, loculated ascites, or pseudocyst formation, or those who are not optimal candidates for vascular shunts. A case of acute recurrent subcutaneous emphysema around the incision of a ventriculopleural shunt is presented.

Successful anesthetic management of a child with an extensive facial hemangioma and high output cardiac failure for placement of a central venous catheter.

A two-and-a-half-year-old female with an extensive facial and lingual hemangioma, associated high output cardiac failure, and a history of difficult intubation presented for central venous catheter (CVC) placement for vincristine chemotherapy. Anesthetic management of this complex case is presented and the complicating medical conditions are discussed.

Caring for the patients with cervical spine injuries: what have we learned?

PURPOSE: Anesthesiologists are often involved in the early management and resuscitation of patients who have sustained cervical spine injuries (CSIs). The most crucial step in managing a patient with suspected CSI is the prevention of further insult to the cervical spine (C-spine). In this review, important factors related to initial management, diagnosis, airway and anesthetic management of patients with CSI are presented. SOURCE: Medline search was performed to seek out the English-language literature using the following phrases and keywords: spine trauma; cervical spine; airway management after CSI. PRINCIPAL FINDINGS: Cervical spine injury occurs in up to 3% to 6% of all patients with trauma. The initial management of a patient with potential spine injury requires a high degree of suspicion for CSI so that early stabilization of the spine can be used to prevent further neurological damage. Diagnostic radiology has a critical role to play; however, clinical evaluation is equally important in excluding CSI in a conscious and cooperative patient. Although in-line stabilization reduces the movement at C-spine, traction causes clinically significant distraction and should be avoided. CONCLUSION: A high level of suspicion and anticipation are the major components of decision making and management in a patient with CSI. Endotracheal intubation using the Bullard laryngoscope may have some advantages over other techniques as it causes less head and C-spine extension than the conventional laryngoscope, and this results in a better view. However, the current opinion is that oral intubation using a Macintosh blade after intravenous induction of anesthesia and muscle relaxation along with inline stabilization is the safest and quickest way to achieve intubation in a patient with suspected CSI. In summation caution, close care and maintenance of spinal immobilization are more important factors in limiting the risk of secondary neurological injury than any particular technique.

Hyperkalemic cardiac arrest following succinylcholine administration: The use of extracorporeal membrane oxygenation in an emergency situation.

We report an 11-year-old male with undiagnosed myopathy, who developed cardiac arrest secondary to severe rhabdomyolysis and hyperkalemia following succinylcholine administration. The patient required extracorporeal membrane oxygenation support from which he was eventually weaned successfully. He died eleven days after the cardiac arrest as a result of apparent ischemic brain injury.