Effect of leg lift on stroke volume index in children 11-17 years old before and after induction of general anesthesia.

BACKGROUND: Fluid administration in ERAS is one component which anesthesiologists have control. Change in stroke volume index (SVI) is used to assess fluid responsiveness. This study sought the effect of perioperative fluid responsiveness in pediatric patients. The Cheetah NICOM™ (noninvasive CO monitor) was employed because of correlation with other CO monitors. AIMS: The Cheetah NICOM™ is an FDA-approved device in adults. Its indications in children are unknown. 24 enrolled patients (age 11-17) were ASA 1 or 2 without cardiopulmonary disease. The study examined changes in SVI, HR, SBP, and DBP between the semi-recumbent and legs lifted positions, both awake and after anesthesia. METHODS: Each patient had baseline vital signs measured and fluid responsiveness determined with the Cheetah NICOM™ monitor. Stroke volume index (SVI) was measured in both the semi-recumbent position and after passive leg lift. Measurements were repeated immediately after induction of general anesthesia. Twenty-one of 24 patients received inhalation induction with sevoflurane and three patients received intravenous propofol followed by sevoflurane. Airway management included intubation in 19 of 24 and a laryngeal mask airway (LMA) in five of 24 patients. RESULTS: There was a 25% increase in SVI after leg lift from 54.8 ml/m2 to 68.0 ml/m2 in awake patients (p < 0.001). Diastolic pressure decreased by 15.4% from 67.9 mm Hg to 58.2 mm Hg from semi-recumbent position and leg lift, respectively (p = .004). No significant change in heart rate or SBP was found. Following induction, patient SVI increased with leg lift by 25.6% from 42.6 ml/m2 to 53.5 ml/m2 after leg lift (p = .003). Heart rate decreased by 9.3% and SBP increased 2.8% with leg lift. CONCLUSIONS: 96% of normal 11-17-year-old children were fluid responsive while awake and 79% after induction of general anesthesia.

Epidural Analgesia Decreases Narcotic Requirements in Patients with Low Level Spina Bifida Undergoing Urological Laparotomy for Neurogenic Bladder and Bowel.

PURPOSE: Concerns regarding anatomical anomalies and worsening neurological symptoms have prevented widespread use of epidural catheters in patients with low level spina bifida. We hypothesize that thoracic epidural placement in the T9 to T10 interspace is safe and decreases narcotic requirements following major open lower urinary tract reconstruction in patients with low level spina bifida. MATERIALS AND METHODS: We reviewed consecutive patients with low level spina bifida who underwent lower urinary tract reconstruction and received epidurals for postoperative pain control. Controls were patients with low level spina bifida who received single injection transversus abdominis plane blocks and underwent similar procedures. Complications of epidural placement, including changes in motor and sensory status, were recorded. Opioid consumption was calculated using equivalent intravenous morphine doses. Mean and maximum pain scores on postoperative days 0 to 3 were calculated. RESULTS: Ten patients with low level spina bifida who underwent lower urinary tract reconstruction with epidural were matched to 10 controls with low level spina bifida who underwent lower urinary tract reconstruction with transverse abdominis plane block. Groups were demographically similar. All patients had full abdominal sensation and functional levels at or below L3. No epidural complications or changes in neurological status were noted. The epidural group had decreased opioid consumption on postoperative days 0 to 3 (0.75 mg/kg vs 1.29 mg/kg, p = 0.04). Pain scores were similar or improved in the epidural group. CONCLUSIONS: Thoracic epidural analgesia appears to be a safe and effective opioid sparing option to assist with postoperative pain management following lower urinary tract reconstruction in individuals with low level spina bifida.

Endotracheal intubation versus laryngeal mask airway for esophagogastroduodenoscopy in children.

OBJECTIVES: The present study examined the safety and efficacy of a laryngeal mask airway (LMA), compared with an endotracheal tube (ETT), for children undergoing elective esophagogastroduodenoscopy (EGD). METHODS: A total of 84 American Society of Anesthesiologists (ASA) patients, status I to III, were randomly assigned to receive an ETT or LMA. All participants were premedicated with midazolam 0.5 mg/kg (up to 15 mg). Airway device placement occurred after induction with 8% sevoflurane and 100% oxygen, placement of an intravenous catheter, and intravenous lidocaine 2 mg/kg up to 100 mg. The following data were collected: time from induction of anesthesia to placement of the airway device, time from end of procedure to arrival in the postoperative acute care unit (PACU), time in the PACU, time from arrival in the operating room (OR) to discharge, vomiting after the procedure, nausea requiring medicine, lowest oxygen saturation, highest concentration of sevoflurane, highest pain, amount of pain medicine, adverse events, and satisfaction of doctor performing the EGD. RESULTS: Group ETT had higher time from room arrival to airway placement, mask to airway placement, room arrival time to discharge, mask placement to discharge, airway placement to discharge, and end of procedure to discharge. Group ETT had a higher proportion of patients with vomiting than group LMA. No statistical difference was noted in endoscopist satisfaction when comparing ETT and LMA. The ETT group had 3 adverse events, including laryngospasm (n=2) and asthma attack (n=1). CONCLUSIONS: The LMA appears to be an acceptable and safe alternative for otherwise healthy children undergoing routine EGD. Benefits appear to be decreased incidence of vomiting and overall decreased time spent in the hospital.

A multicenter study to evaluate the pharmacokinetics and safety of liposomal bupivacaine for postsurgical analgesia in pediatric patients aged 6 to less than 17 years (PLAY).

STUDY OBJECTIVE: To evaluate the pharmacokinetics and safety of liposomal bupivacaine in pediatric patients undergoing spine or cardiac surgery. DESIGN: Multicenter, open-label, phase 3, randomized trial (PLAY; NCT03682302). SETTING: Operating room. PATIENTS: Two separate age groups were evaluated (age group 1: patients 12 to <17 years undergoing spine surgery; age group 2: patients 6 to <12 years undergoing spine or cardiac surgery). INTERVENTION: Randomized allocation of liposomal bupivacaine 4 mg/kg or bupivacaine hydrochloride (HCl) 2 mg/kg via local infiltration at the end of spine surgery (age group 1); liposomal bupivacaine 4 mg/kg via local infiltration at the end of spine or cardiac surgery (age group 2). MEASUREMENTS: The primary and secondary objectives were to evaluate the pharmacokinetics (eg, maximum plasma bupivacaine concentrations [Cmax], time to Cmax) and safety of liposomal bupivacaine, respectively. MAIN RESULTS: Baseline characteristics were comparable across groups. Mean Cmax after liposomal bupivacaine administration was lower versus bupivacaine HCl in age group 1 (357 vs 564 ng/mL); mean Cmax in age group 2 was 320 and 447 ng/mL for spine and cardiac surgery, respectively. Median time to Cmax of liposomal bupivacaine occurred later with cardiac surgery versus spine surgery (22.7 vs 7.4 h). In age group 1, the incidence of adverse events (AEs) was comparable between liposomal bupivacaine (61% [19/31]) and bupivacaine HCl (73% [22/30]). In age group 2, 100% (5/5) and 31% (9/29) of patients undergoing spine and cardiac surgery experienced AEs, respectively. AEs were generally mild or moderate, with no discontinuations due to AEs or deaths. CONCLUSIONS: Plasma bupivacaine levels following local infiltration with liposomal bupivacaine remained below the toxic threshold in adults (~2000-4000 ng/mL) across age groups and procedures. AEs were mild to moderate, supporting the safety of liposomal bupivacaine in pediatric patients undergoing spine or cardiac surgery. Clinical trial number and registry URL: ClinicalTrials.gov identifier: NCT03682302.

Gene associated with seizures, autism, and hepatomegaly in an Amish girl.

A genetic defect causing autism and epilepsy involving the contactin associated protein-like 2 gene (CNTNAP2) has been discovered in a selected cohort of Amish children. These children were found to have focal seizures and autistic regression. Surgical biopsy of the anterior temporal lobe of two such children revealed cortical dysplasia and a single nucleotide polymorphism mutation of this gene. The present case is that of a related but geographically distant proband with a similar phenotype but a single-base-pair deletion in the CNTNAP2 gene. This patient exhibited the additional features of periventricular leukomalacia and hepatomegaly.