Effectiveness of training before unsedated MRI scans in young children: a randomized control trial.

BACKGROUND: Young children requiring clinical magnetic resonance imaging (MRI) may be given general anesthesia. General anesthesia has potential side effects, is costly, and introduces logistical challenges. Thus, methods that allow children to undergo awake MRI scans are desirable. OBJECTIVES: To compare the effectiveness of mock scanner training with a child life specialist, play-based training with a child life specialist, and home book and video preparation by parents to allow non-sedated clinical MRI scanning in children aged 3-7 years. MATERIALS AND METHODS: Children (3-7 years, n=122) undergoing clinical MRI scans at the Alberta Children's Hospital were invited to participate and randomized to one of three groups: home-based preparation materials, training with a child life specialist (no mock MRI), or training in a mock MRI with a child life specialist. Training occurred a few days prior to their MRI. Self- and parent-reported functioning (PedsQL VAS) were assessed pre/post-training (for the two training groups) and pre/post-MRI. Scan success was determined by a pediatric radiologist. RESULTS: Overall, 91% (111/122) of children successfully completed an awake MRI. There were no significant differences between the mock scanner (89%, 32/36), child life (88%, 34/39), and at-home (96%, 45/47) groups (P=0.34). Total functioning scores were similar across groups; however, the mock scanner group had significantly lower self-reported fear (F=3.2, P=0.04), parent-reported sadness (F=3.3, P=0.04), and worry (F=3.5, P=0.03) prior to MRI. Children with unsuccessful scans were younger (4.5 vs. 5.7 years, P<0.001). CONCLUSIONS: Most young children can tolerate awake MRI scans and do not need to be routinely anesthetized. All preparation methods tested, including at-home materials, were effective.

Pediatric Airway Management in COVID-19 Patients: Consensus Guidelines From the Society for Pediatric Anesthesia's Pediatric Difficult Intubation Collaborative and the Canadian Pediatric Anesthesia Society.

The severe acute respiratory syndrome coronavirus 2 (coronavirus disease 2019 [COVID-19]) pandemic has challenged medical systems and clinicians globally to unforeseen levels. Rapid spread of COVID-19 has forced clinicians to care for patients with a highly contagious disease without evidence-based guidelines. Using a virtual modified nominal group technique, the Pediatric Difficult Intubation Collaborative (PeDI-C), which currently includes 35 hospitals from 6 countries, generated consensus guidelines on airway management in pediatric anesthesia based on expert opinion and early data about the disease. PeDI-C identified overarching goals during care, including minimizing aerosolized respiratory secretions, minimizing the number of clinicians in contact with a patient, and recognizing that undiagnosed asymptomatic patients may shed the virus and infect health care workers. Recommendations include administering anxiolytic medications, intravenous anesthetic inductions, tracheal intubation using video laryngoscopes and cuffed tracheal tubes, use of in-line suction catheters, and modifying workflow to recover patients from anesthesia in the operating room. Importantly, PeDI-C recommends that anesthesiologists consider using appropriate personal protective equipment when performing aerosol-generating medical procedures in asymptomatic children, in addition to known or suspected children with COVID-19. Airway procedures should be done in negative pressure rooms when available. Adequate time should be allowed for operating room cleaning and air filtration between surgical cases. Research using rigorous study designs is urgently needed to inform safe practices during the COVID-19 pandemic. Until further information is available, PeDI-C advises that clinicians consider these guidelines to enhance the safety of health care workers during airway management when performing aerosol-generating medical procedures. These guidelines have been endorsed by the Society for Pediatric Anesthesia and the Canadian Pediatric Anesthesia Society.

Ultrasound assessment of gastric volume in the fasted pediatric patient undergoing upper gastrointestinal endoscopy: development of a predictive model using endoscopically suctioned volumes.

BACKGROUND: Aspiration of gastric contents can be a serious anesthetic-related complication. Gastric antral sonography prior to anesthesia may have a role in identifying pediatric patients at risk of aspiration. We examined the relationship between sonographic antral area and endoscopically suctioned gastric volumes, and whether a 3-point qualitative grading system is applicable in pediatric patients. METHODS: Fasted patients presenting to a pediatric hospital for upper gastrointestinal endoscopy were included in the study. Sonographic measurement of the antral cross-sectional area (CSA) in supine (supine CSA) and right lateral decubitus (RLD CSA) position was completed, and the antrum was designated as empty or nonempty. Gastric contents were endoscopically suctioned and measured. Multiple regression analysis was used to fit a mathematical model to estimate gastric volume. RESULTS: One hundred patients (aged 11-216 months) were included. The gastric antrum was measured in 94% and 99% of patients in the supine and RLD positions, respectively. Gastric antral CSA correlated with total gastric volume in both supine (ρ = 0.63) and RLD (ρ = 0.67) positions. A mathematical model incorporating RLD CSA and age (R(2)  = 0.60) was determined as the best-fit model to predict gastric volumes. Increasing gastric antral grade (0-2) was associated with increasing gastric fluid volume. CONCLUSION: The results suggest that sonographic assessment of the gastric antrum provides useful information regarding gastric content (empty versus nonempty) and volume (ml·kg(-1) ) in pediatric patients. Results suggest that the three-point grading system may be a valuable tool to assess gastric 'fullness' based on a qualitative exam of the antrum.

Effect of dexamethasone on postoperative morbidity after dental rehabilitation in children.

PURPOSE: Dexamethasone reduces postoperative morbidity after adenotonsillectomy, strabismus surgery, and third molar extraction. Our hypothesis was that dexamethasone would reduce pain and other morbidity in children undergoing dental surgery for up to 24 hr postoperatively. METHODS: A triple-blinded, randomized, controlled trial was carried out on 200 children undergoing prolonged dental rehabilitation under general anesthesia. Subjects were randomized into two groups: group D, given dexamethasone 0.3 mg·kg(-1); group S, given normal saline. The primary outcome measure was pain over 24 hr as evaluated by a parental 0-10 numerical rating scale (NRS). Key secondary outcomes included oral intake on a four-point scale at 24 hr and the overall incidence of postoperative vomiting (POV). Analysis for the primary outcome consisted of comparison of means in the NRS with the Wilcoxon rank sum test and for occurrence of POV with Fisher's test. RESULTS: After eliminating 22 subjects for protocol violations and withdrawals, 178 subjects were analyzed. There was no significant difference in pain scores (NRS) at 24 hr or the worst NRS experienced over the preceding 24 hr. There was no difference in the quality of oral intake between the groups. There was a significant difference in the percentage of patients who vomited during the first 24 hr: eight of 91 in group S and one of 87 in group D. Therefore, 7.74% more vomited in group S (P = 0.045), with a 95% confidence interval of 0.32 to15.16 for the difference in percentages. CONCLUSIONS: Dexamethasone, 0.3 mg·kg(-1), did not reduce pain over 24 hr in healthy children undergoing dental rehabilitation under general anesthesia. The quality of oral intake was also unaffected by dexamethasone at 24 hr. Dexamethasone did produce a significant reduction in postdischarge vomiting, beyond the incidence found with ondansetron alone.

The effects of parental presence in the postanesthetic care unit on children's postoperative behavior: a prospective, randomized, controlled study.

BACKGROUND: The effects on children of parental presence in the postanesthesia care unit (PACU) have not been extensively studied. The few published studies are retrospective, nonrandomized, or lack adequate controls. They suggest that parental presence in the PACU decreases crying and negative behavior change postoperatively. We performed this prospective, randomized, controlled study to determine whether the presence of a parent affected crying behaviors in the PACU and behavior change 2 weeks postoperatively. METHODS: Randomly selected patients, aged 2.0 to 8 years 11 months, ASA physical status I or II, and scheduled for elective outpatient surgery with an anticipated PACU stay of >10 minutes were randomly assigned to the parent present group (n = 150) or parent absent group (n = 150) in the PACU. All parents underwent the same preparation program. Reunification occurred once children's eyes had opened for the parent present group. In the PACU, crying was scored each minute after eye opening using a 5-point scale. Negative behavior change 2 weeks after discharge was determined using the Post Hospitalization Behavior Questionnaire. Because the anesthesia technique to be used was not determined a priori, data on the technique used were collected to ensure that groups were similar. Multiple and logistic regression techniques were used to determine predictors of crying in the PACU and behavior change 2 weeks postoperatively. RESULTS: Parental presence in the PACU made no difference in crying in the PACU. Negative behavior change 2 weeks postoperatively occurred more frequently in the parent absent group than the parent present group (45.8% vs 29.3%; P = 0.007). Multiple regression identified the following significant factors as predictive of larger proportion of time spent crying in the PACU (R(2) = 0.256, F[5, 273] = 15.66, P < 0.001): age <5 years (P < 0.001) and higher Children's Hospital of Eastern Ontario Pain Scale score at 15 minutes after arrival in day surgery (P < 0.001). Parental presence or absence from the PACU was not predictive of crying in the PACU, and neither were socioeconomic status nor intraoperative opioid analgesia. Logistic regression identified the following factors (chi(2)[4] = 26.62, P < 0.001) as predictive of negative behavior change at 2 weeks postoperatively: being younger than 5 years (P < 0.001) and being in the parent absent group (P = 0.003). CONCLUSION: For fit healthy children undergoing outpatient surgery, parental presence in the PACU decreases negative behavior change at 2 weeks postoperatively but makes no difference in crying in the PACU. Future studies of behavior change postoperatively should consider parental presence in the PACU a factor and determine whether the effect persists with other interventions.

Evidence-based clinical update: Which local anesthetic drug for pediatric caudal block provides optimal efficacy with the fewest side effects?

PURPOSE: The purpose of this evidence-based clinical update is to identify the best evidence when selecting a long-acting local anesthetic agent for single-shot pediatric caudal anesthesia in children. METHODS: A structured literature search was conducted using PubMed and Medline (OVID) using the terms "caudal" and combinations of at least two of "bupivacaine", "ropivacaine", and "levobupivacaine". The search limits included "randomized controlled trials" (RCTs), "meta-analysis", "evidence-based reviews" or "reviews", "human", and "all child: 0-18 yr". Seventeen RCTs were identified that concerned single-shot pediatric caudal anesthesia with at least two of the three drugs in question. Data were extracted for the areas of clinical efficacy and side effects. Study findings were assigned levels of evidence, and grades of recommendation were made according to Centre for Evidence-Based Medicine criteria. RESULTS: The three drugs investigated were found to be equivalent in terms of efficacy. Evidence showed bupivacaine with the highest incidence of motor block and ropivacaine with the lowest. Adverse effects were rare and unrelated to the choice of drug. There were no serious adverse events. CONCLUSION: None of the three agents was shown to be superior in terms of efficacy. Bupivacaine is preferred if motor block is desired, ropivacaine is preferred if motor block is to be minimized. Adverse effects in human studies are rare, mild, and unrelated to the choice of drug. Despite encountering the absence of serious adverse events in each of the studies reviewed, it is noted that animal studies suggest a safer profile with ropivacaine or levobupivacaine than with bupivacaine.

Safety and efficacy of tranexamic acid in bleeding paediatric trauma patients: a systematic review protocol.

INTRODUCTION: Trauma is the leading cause of death among children aged 1-18. Studies indicate that better control of bleeding could potentially prevent 10-20% of trauma-related deaths. The antifibrinolytic agent tranexamic acid (TxA) has shown promise in haemorrhage control in adult trauma patients. However, information on the potential benefits of TxA in children remains sparse. This review proposes to evaluate the current uses, benefits and adverse effects of TxA in the bleeding paediatric trauma population. METHODS AND ANALYSIS: A structured search of bibliographic databases (eg, MEDLINE, EMBASE, PubMed, CINAHL, Cochrane CENTRAL) has been undertaken to retrieve randomised controlled trials and cohort studies that describe the use of TxA in paediatric trauma patients. To ensure that all relevant data were captured, the search did not contain any restrictions on language or publication time. After deduplication, citations will be screened independently by 2 authors, and selected for inclusion based on prespecified criteria. Data extraction and risk of bias assessment will be performed independently and in duplicate. Meta-analytic methods will be employed wherever appropriate. ETHICS AND DISSEMINATION: This study will not involve primary data collection, and formal ethical approval will therefore not be required. The findings of this study will be disseminated through a peer-reviewed publication and at relevant conference meetings. TRIAL REGISTRATION NUMBER: CRD42016038023.

[Comparison of laryngeal mask airway (LMA)- Proseal and the LMA-Classic in ventilated children receiving neuromuscular blockade].

PURPOSE: To determine whether a functional difference exists between the size 2 laryngeal mask airway (LMA)-Classic (CLMA) and LMA-Proseal (PLMA) in anesthetized children who have received neuromuscular blockade. Airway leak during intermittent positive pressure ventilation (IPPV) and adequacy of fibreoptic laryngeal view were the primary study outcomes. METHODS: A randomized, controlled, single-blinded study of 51 ASA I or II children weighing 10-20 kg was undertaken. The anesthetic technique was standardized. Following insertion of the LMA and cuff inflation to 60 cm H(2)O, we measured oropharyngeal leak pressure and gastric insufflation and leak fraction during IPPV, and evaluated the adequacy of fibreoptic view. RESULTS: Oropharyngeal leak pressure measured by neck auscultation was higher for the PLMA compared to the CLMA (23.7 vs 16.5 cm H(2)O, P = 0.009) but, when measured by the inspiratory hold maneuver was not significantly different (24.8 vs 20.3 cm H(2)O, respectively, P = 0.217). Leak fraction values were similar for the CLMA and the PLMA (21.2%. vs 13.3%, respectively, P = 0.473). A satisfactory view of the larynx was obtained more frequently in the PLMA group (21/25 vs 10/25, P = 0.003). Gastric insufflation during leak determination was more common with the CLMA (12/26 vs 2/25 CLMA vs PLMA, respectively, P = 0.006). CONCLUSION: In children undergoing IPPV with neuromuscular blockade, the size 2 PLMA is associated with a higher leak pressure by auscultation and less gastric insufflation compared to the CLMA. Leak pressures assessed by manometric stability are similar with these two devices. The improved fibreoptic view of the larynx through the PLMA may be advantageous for bronchoscopy.

Delayed rises in serum S100B levels and adverse neurological outcome in infants and children undergoing cardiopulmonary bypass.

BACKGROUND: The protein S100B is a marker of brain injury. Early after cardiopulmonary bypass (CPB), serum S100B levels are artefactually high. We investigated whether delayed (48 h) rise in S100B levels may have a role in detecting brain injury after CPB. METHODS: Data from 43 children were analysed in this study. Samples were collected at preincision and 30 min, 24 and 48 h postbypass and then analysed by using a commercially available radioimmunoassay (Sangtec100). Charts were reviewed at 3-5 months for evidence of neurological injury. RESULTS: S100B levels were high preoperatively in neonates and universally high immediately postbypass. In 36 children, samples were available for all time points. Compared with preoperative levels, rises occurred at both 24 and 48 h in three patients, only at 24 h in four patients and only at 48 h in three patients. Two patients had evidence of neurological injury. A rise at 48 h was associated with neurological injury (odds ratio 33.9, P < 0.03, 95% CI 1.39-827). There was no association between neurological injury and S100B levels at 24 h. Both the patients with neurological injury had rises at 48 h that were significantly higher than patients with rises at 48 h without injury. CONCLUSIONS: The results of this study suggest that monitoring S100B levels in the late postoperative period may still have a role in detecting neurological injury after cardiac surgery in children. Consistent with previous observations, S100B is high preoperatively in neonates and early postbypass in all patients.