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 survey of practice in the anesthetic management of adolescent idiopathic scoliosis spine fusion by the North American Pediatric Spine Anesthesiologists Collaborative.

BACKGROUND: Adolescent Idiopathic Scoliosis (AIS) affects 2%-4% of the general pediatric population. While surgical correction remains one of the most common orthopedic procedures performed in pediatrics, limited consensus exists on the perioperative anesthetic management. AIMS: To examine the current state of anesthetic management of typical AIS spine fusions at institutions which have a dedicated pediatric orthopedic spine surgeon. METHODS: A web-based survey was sent to all members of the North American Pediatric Spine Anesthesiologists (NAPSA) Collaborative. This group included 34 anesthesiologists at 19 different institutions, each of whom has a Harms Study Group surgeon performing spine fusions at their hospital. RESULTS: Thirty-one of 34 (91.2%) anesthesiologists completed the survey, with a missing response rate from 0% to 16.1% depending on the question. Most anesthesia practices (77.4%; 95% confidence interval [CI], 67.7-93.4) do not have patients come for a preoperative visit prior to the day of surgery. Intravenous induction was the preferred method (74.2%; 95% CI 61.3-89.9), with the majority utilizing two peripheral IVs (93.5%; 95% CI 90.3-100) and an arterial line (100%; 95% CI 88.8-100). Paralytic administration for intubation and/or exposure was divided (51.6% rocuronium/vecuronium, 45.2% no paralytic, and 3.2% succinylcholine) amongst respondents. While tranexamic acid was consistently utilized for reducing blood loss, dosing regimens varied. When faced with neuromonitoring signal issues, 67.7% employ a formal protocol. Most anesthesiologists (93.5%; 95% CI 78.6-99.2) extubate immediately postoperatively with patients admitted to an inpatient floor bed (77.4%; 95% CI 67.7-93.3). CONCLUSION: Most anesthesiologists (87.1%; 95% CI 80.6-99.9) report the use of some form of an anesthesia-based protocol for AIS fusions, but our survey results show there is considerable variation in all aspects of perioperative care. Areas of agreement on management comprise the typical vascular access required, utilization of tranexamic acid, immediate extubation, and disposition to a floor bed. By recognizing the diversity of anesthetic care, we can develop areas of research and improve the perioperative management of AIS.

Blood pressure nomograms for children undergoing general anesthesia, stratified by age and anesthetic type, using data from a retrospective cohort at a tertiary pediatric center.

Reference values for non-invasive blood pressure (NIBP) are available for children undergoing general anesthesia, but have not been analyzed by type of anesthetic. This study establishes age-specific pediatric NIBP reference values, stratified by anesthetic type: inhalational anesthesia (IHA), total intravenous anesthesia (TIVA), and mostly intravenous anesthesia (MIVA, an inhalational induction followed by intravenous maintenance of anesthesia). NIBP measurements were extracted from a de-identified vital signs database for children < 19 years undergoing anesthesia between Jan/2013-Dec/2016, excluding cardiac surgery. We automatically rejected artifacts and randomly sampled 20 NIBP values per case. Anesthetic phase (induction/maintenance) was identified using operating room booking times for procedure start, and anesthetic types were identified based on intraoperative minimum alveolar concentration values in the different phases of the anesthetic. From 36,347 cases in our operating room booking system, we matched 24,457 cases with available vital signs. Of these, 20,613 (84%) had valid NIBP data and could be assigned to one anesthetic type: TIVA 11,819 [57%], IHA 4,752 [23%], and MIVA 4,042 [20%]. Mean NIBP during anesthesia increased with age, from median values of 48 mmHg (TIVA), 45 mmHg (IHA), and 41 mmHg (MIVA) in neonates, to 70 mmHg (TIVA), 68 mmHg (IHA), and 64 mmHg (MIVA) in 18-year-olds, respectively. In children < 1 year, mean NIBP values were 4 mmHg higher with TIVA than IHA (p < 0.001). These pediatric NIBP reference values contribute to ongoing debate about alarm limits based on age and anesthetic type, and may motivate prospective studies into the effects of different anesthesia regimes on vital signs.

The Effect of Carbetocin Dose on Transmural Dispersion of Myocardial Repolarization in Healthy Parturients Scheduled for Elective Cesarean Delivery Under Spinal Anesthesia: A Prospective, Randomized Clinical Trial.

BACKGROUND: QT interval prolongation is associated with torsade de pointes but remains a poor predictor of drug torsadogenicity. Increased transmural dispersion of myocardial repolarization (TDR), measured as the time interval between the peak and end of the T wave (Tp-e), is a more reliable predictor. Carbetocin is recommended as an uterotonic in patients undergoing cesarean delivery (CD), but its effect on Tp-e is unknown. We evaluated the effect of carbetocin dose on Tp-e and Bazett-corrected QT intervals (QTc) during elective CD under spinal anesthesia. METHODS: On patient consent, 50 healthy parturients undergoing elective CD with a standardized spinal anesthetic and phenylephrine infusion were randomized to receive an intravenous (IV) bolus of carbetocin 50 µg (C50) or 100 µg (C100) via an infusion pump over 1 minute. A 12-lead electrocardiogram (ECG) was obtained at baseline, 5 minutes after spinal anesthesia, then 5 and 10 minutes after carbetocin administration. A cardiologist blinded to group and timing of ECGs measured QTc and Tp-e using Emori's criteria. Primary outcome was the change in Tp-e at 5 minutes after carbetocin administration between the C50 and C100 groups and within each group compared to baseline values. Secondary outcomes included occurrence of arrhythmias, changes in QTc at 5 and 10 minutes after carbetocin, changes in both QTc and Tp-e after spinal anesthesia compared to baseline between and within groups. RESULTS: Data from 41 parturients with a mean (standard deviation [SD]) age of 39.0 (0.7) years and weight of 75.0 (12.0) kg were analyzed. Between groups, at 5 minutes after carbetocin administration, Tp-e in C100 was 4.1 milliseconds longer compared to C50 (95% confidence interval [CI], 0.8-7.5; P = .01). Within groups, at 5 minutes after carbetocin administration, C50 did not significantly increase Tp-e compared to baseline (mean difference [MD] 1.9 milliseconds; 95% CI, -0.95 to 4.81 milliseconds; P = .42) but C100 did (MD 5.1 milliseconds; 95% CI, 2.1-8.1; P = .003). QTc increased significantly within C50 and C100 groups at 5 and 10 minutes after carbetocin administration (all P < .001), with no between-group differences. There were no arrhythmias. CONCLUSIONS: Tp-e was unaffected by C50 IV given after CD in healthy parturients under spinal anesthesia, but minimally prolonged by C100. The increase in QTc after carbetocin administration was statistically significant, but with no apparent dose-dependent effect. The minimal Tp-e prolongation at the higher dose is unlikely to have any clinically significant impact on TDR and therefore the risk of inducing torsade de pointes is low.

Association of dexmedetomidine with recovery room and hospital discharge times: A retrospective cohort analysis.

BACKGROUND: Dexmedetomidine is a useful anesthetic adjunct, increasingly popular during pediatric surgery and procedural sedation. Its half-life of 2-3 hours might prolong recovery and discharge times when compared with an un-supplemented propofol anesthetic. This may create an additional burden in a busy post-anesthetic care unit (PACU). AIM: To investigate whether intraoperative adjuvant dexmedetomidine delays PACU discharge in patients undergoing propofol anesthesia for day surgery or procedural investigations with minimal anticipated post-procedural pain. METHODS: We conducted a retrospective review of outpatient procedures performed during a six-month period including pediatric patients, ASA physical status I-III, who underwent intravenous anesthesia with propofol and remifentanil for magnetic resonance imaging (MRI), strabismus repair, upper gastrointestinal endoscopy, or combined upper/lower gastrointestinal endoscopy. Patients receiving a sedative premedication, long-acting opioids, or volatile anesthetics for maintenance of anesthesia, were excluded. Duration of PACU stay was compared for patients who did or did not receive intraoperative dexmedetomidine in the four procedure groups. RESULTS: Charts were reviewed for 359 patients; 130 (36%) received dexmedetomidine. Median differences in duration of PACU stay for dexmedetomidine versus non-dexmedetomidine cases were: 5 minutes (95%CI 0 to 10, p=0.037) for MRI; 5 minutes (95%CI -3 to 15, p=0.258) for strabismus surgery; 7 minutes (95%CI 3 to 10, p<0.001) for upper endoscopy; and 5 minutes (95%CI 1 to 12, p=0.021) for combined upper/lower endoscopy. Linear regression (F=61.1, adjusted R2 =0.40) indicated a significant relationship between dexmedetomidine dose (estimate 14.6 minutes per µg/kg, 95%CI 8.2 to 21.1, p<0.001) and duration of PACU stay. CONCLUSION: We found evidence for a small association of intraoperative dexmedetomidine with duration of recovery from propofol anesthesia for a set of common outpatient procedures, with a potential dose relationship equivalent to approximately 15 minutes delay per µg/kg dexmedetomidine administered. Future research into the benefits of dexmedetomidine in pediatric anesthesia should further evaluate this relationship.

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.

A systematic review of outcomes reported inpediatric perioperative research: A report from the Pediatric Perioperative Outcomes Group.

The Pediatric Perioperative Outcomes Group (PPOG) is an international collaborative of clinical investigators and clinicians within the subspecialty of pediatric anesthesiology and perioperative care which aims to use COMET (Core Outcomes Measures in Effectiveness Trials) methodology to develop core outcome setsfor infants, children and young people that are tailored to the priorities of the pediatric surgical population.Focusing on four age-dependent patient subpopulations determined a priori for core outcome set development: i) neonates and former preterm infants (up to 60 weeks postmenstrual age); ii) infants (>60 weeks postmenstrual age - <1 year); iii) toddlers and school age children (>1-<13 years); and iv) adolescents (>13-<18 years), we conducted a systematic review of outcomes reported in perioperative studies that include participants within age-dependent pediatric subpopulations. Our review of pediatric perioperative controlled trials published from 2008 to 2018 identified 724 articles reporting 3192 outcome measures. The proportion of published trials and the most frequently reported outcomes varied across pre-determined age groups. Outcomes related to patient comfort, particularly pain and analgesic requirement, were the most frequent domain for infants, children and adolescents. Clinical indicators, particularly cardiorespiratory or medication-related adverse events, were the most common outcomes for neonates and infants < 60 weeks and were the second most frequent domain at all other ages. Neonates and infants <60 weeks of age were significantly under-represented in perioperative trials. Patient-centered outcomes, heath care utilization, and bleeding/transfusion related outcomes were less often reported. In most studies, outcomes were measured in the immediate perioperative period, with the duration often restricted to the post-anesthesia care unit or the first 24 postoperative hours. The outcomes identified with this systematic review will be combined with patient centered outcomes identified through a subsequent stakeholder engagement study to arrive at a core outcome set for each age-specific group.

Effects of Dexmedetomidine on Myocardial Repolarization in Children Undergoing General Anesthesia: A Randomized Controlled Trial.

BACKGROUND: Dexmedetomidine is a highly selective α2-adrenergic agonist, which is increasingly used in pediatric anesthesia and intensive care. Potential adverse effects that have not been rigorously evaluated in children include its effects on myocardial repolarization, which is important given that the drug is listed as a possible risk factor for torsades de pointes. We investigated the effect of 3 different doses of dexmedetomidine on myocardial repolarization and transmural dispersion in children undergoing elective surgery with total IV anesthesia. METHODS: Sixty-four American Society of Anesthesiologists I-II children 3-10 years of age were randomized to receive dexmedetomidine 0.25 µg/kg, 0.5 µg/kg, 0.75 µg/kg, or 0 µg/kg (control), as a bolus administered over 60 seconds, after induction of anesthesia. Pre- and postintervention 12-lead electrocardiograms were recorded. The interval between the peak and the end of the electrocardiogram T wave (Tp-e; transmural dispersion) and heart rate-corrected QT intervals (myocardial repolarization) were measured by a pediatric electrophysiologist blinded to group allocation. Data were analyzed using an analysis of covariance regression model. The study was powered to detect a 25-millisecond difference in Tp-e. RESULTS: Forty-eight children completed the study, with data analyzed from 12 participants per group. There were no instances of dysrhythmias. Tp-e values were unaffected by dexmedetomidine administration at any of the studied doses (F = 0.09; P = .96). Mean (99% CI) within-group differences were all <2 milliseconds (-5 to 8). Postintervention, corrected QT interval increased in the control group, but decreased in some dexmedetomidine groups (F = 7.23; P < .001), specifically the dexmedetomidine 0.5 and 0.75 µg/kg doses. Within groups, the mean (99% CI) differences between pre- and postintervention corrected QT interval were 12.4 milliseconds (-5.8 to 30.6) in the control group, -9.0 milliseconds (-24.9 to 6.9) for dexmedetomidine 0.25 µg/kg, -18.6 milliseconds (-33.7 to -3.5) for dexmedetomidine 0.5 µg/kg, and -14.1 milliseconds (-27.4 to -0.8) for dexmedetomidine 0.75 µg/kg. CONCLUSIONS: Of the bolus doses of dexmedetomidine studied, none had an effect on Tp-e and the dexmedetomidine 0.5 and 0.75 µg/kg doses shortened corrected QT intervals when measured at 1 minute after dexmedetomidine bolus injection during total IV anesthesia. There is no evidence for an increased risk of torsades de pointes in this context.

Effects of Dexmedetomidine on Blood Glucose and Serum Potassium Levels in Children Undergoing General Anesthesia: A Secondary Analysis of Safety Endpoints During a Randomized Controlled Trial.

BACKGROUND: Dexmedetomidine is a highly selective α2-adrenergic agonist, which is increasingly used in pediatric anesthesia and intensive care. Potential adverse effects that have not been rigorously evaluated in children include its effects on blood glucose and serum potassium concentrations, which are relevant due to the associations of derangements of both parameters with undesired outcomes. We investigated the effects of 3 different doses of dexmedetomidine on these outcomes in a randomized controlled trial in children undergoing elective surgery. METHODS: Sixty-four American Society of Anesthesiologists I-II children were randomized to receive either dexmedetomidine 0.25 µg/kg, dexmedetomidine 0.5 µg/kg, dexmedetomidine 0.75 µg/kg, or 0 µg/kg (control), as a bolus administered over 60 seconds after induction of anesthesia. Changes in plasma glucose and serum potassium concentrations were measured in venous blood sampled before and at 15 and 30 minutes after study drug administration. Data were plotted within and between groups and analyzed using a constrained longitudinal data approach. RESULTS: Forty-nine children completed the study. Mean glucose levels at 15 and 30 minutes were elevated with estimated changes from baseline of 0.37 mmol/L (95% CI, 0.29-0.45 mmol/L) and 0.05 mmol/L (95% CI, 0.00-0.10 mmol/L), respectively. At 15 minutes, there was a linear dose-response relationship (1.07 mmol/L/µg/kg [95% CI, 0.57-1.58 mmol/L/µg/kg]), but there was no appreciable effect of dexmedetomidine at 30 minutes (0.15 mmol/L/µg/kg [95% CI, -0.40 to 0.70 mmol/L/µg/kg]). Potassium levels were depressed relative to baseline, with a mean difference at 15 minutes of -0.20 mEq/L (95% CI, -0.28 to -0.12 mEq/L) and at 30 minutes of -0.12 mEq/L (95% CI, -0.15 to -0.08 mEq/L), but there was no appreciable effect of dexmedetomidine at either time. CONCLUSIONS: Small elevations in glucose and decreases in potassium were observed after induction of anesthesia in children. The elevation in glucose at 15 minutes depended on the dose of dexmedetomidine administered. These preliminary data warrant further investigation.

Integrating intraoperative physiology data into outcome analysis for the ACS Pediatric National Surgical Quality Improvement Program.

BACKGROUND: The Pediatric National Surgical Quality Improvement Program (P-NSQIP) samples surgical procedures for benchmarking and quality improvement. While generally comprehensive, P-NSQIP does not collect intraoperative physiologic data, despite potential impact on outcomes. AIMS: The aims of this study were (a) to describe a methodology to augment P-NSQIP with vital signs data and (b) demonstrate its utility by exploring relationships that intraoperative hypothermia and hypotension have with P-NSQIP outcomes. METHODS: Vital signs from 2012 to 2016 were available in a research databank. Episodes of hypotension and hypothermia were extracted and recorded alongside local P-NSQIP data. Multivariable regression analyses were performed to explore associations with undesired outcomes, including: surgical site infection, wound disruption, unplanned return to the operating room, and blood transfusion. Model variables were selected with the Akaike information criterion using 2012-2014 as the training set and validated with receiver operating characteristics analysis using 2015-2016 as the testing set. RESULTS: Data from 6737 patients were analyzed, with 43.9% female, median [interquartile range] age 5.8 [1.3-12.4] years, undergoing procedures lasting 118 [75-193] minutes. Hypothermia, observed in 45% of cases, was associated with wound disruption (odds ratio 1.75, 95% CI 1.1-2.83). Hypotension, observed in 60% of cases, was associated with unplanned returns (odds ratio 1.58, 95% CI 1.02-2.51), and transfusions (odds ratio 1.95, 95% CI 1.14-3.52). Surgical site infection, wound disruption, unplanned return, and transfusion models had areas under the receiver operating characteristic curve of 0.69/0.67, 0.59/0.63, 0.78/0.79, and 0.92/0.93 for validation models including hypothermia/hypotension respectively. CONCLUSION: Adding intraoperative vital signs to P-NSQIP data allowed identification of two modifiable risk factors: hypothermia was associated with increased wound disruption, and hypotension with increased blood transfusions and unplanned returns to the operating room. These findings may motivate prospective studies and prompt other centers and P-NSQIP to augment outcome data with intraoperative physiological data.

Using physiological monitoring data for performance feedback: an initiative using thermoregulation metrics.

BACKGROUND: Feedback of performance data can improve professional practice and outcomes. Vital signs are not routinely used for quality improvement because of their limited access. Intraoperative hypothermia has been associated with deleterious effects, including surgical site infections and bleeding. We speculated that providing feedback could help keep temperature monitoring and management a priority in the anesthesiologist's mind, thereby improving perioperative temperature management. We hypothesized that feedback on thermoregulation metrics, without changes in policy, could reduce temperature-monitoring delays at the start of scoliosis correction surgery. METHODS: Although our tertiary pediatric centre does not have an anesthesia information management system, vital signs for all surgical cases are recorded in real time. Temperature data from children undergoing spine surgery are extracted from a vital signs databank and analyzed using MATLAB. Spine team anesthesiologists are provided with both team and individualized feedback regarding two variables: the percentage of time that patients are hypothermic and the time delay from the start of the case to the first temperature monitoring (our primary outcome). These data are shared every six months as run charts for the entire group and as anonymized (coded) box-and-whisker plots for each anesthesiologist. RESULTS: This feedback of temperature-delay data reduced the median [interquartile range] delay from 39.0 [18.7-61.5] min to 14.4 [10.8-22.9] min (median reduction, 21.8 min; 95% confidence interval, 14.9 to 28.2; P < 0.001). It did not, however, further reduce the percentage of time patients remained hypothermic beyond the improvements already achieved with prewarming. CONCLUSION: Feedback of intraoperative thermoregulation management improved both group and individual performances as measured by significant, sustained reductions in temperature-monitoring delays. Thus, intraoperative vital signs data may improve the quality of, and reduce the variability in, anesthetic practice.

Preoperative warming and undesired surgical and anesthesia outcomes in pediatric spinal surgery-a retrospective cohort study.

BACKGROUND: Underbody forced air warming is a method commonly used for intraoperative temperature maintenance in children. We previously reported that preoperative forced air warming of children undergoing spinal surgery substantially reduces the incidence and duration of intraoperative hypothermia (<36°C). OBJECTIVE: The aim of this study was to evaluate the effects of preoperative warming before spinal deformity surgery on surgical site infection rate, length of hospitalization, and bleeding (estimated blood loss and incidence of cell salvaged and/or allogeneic packed red blood cell transfusions). METHODS: Demographic, anesthetic, and surgical data of all patients who underwent spinal deformity surgery between December 2009 and December 2012 were obtained by retrospective chart review. Temperature data were abstracted from an existing repository; the incidence and duration of hypothermic episodes were identified. For each outcome, logistic regression models and propensity score analysis were used to estimate the effect of prewarming, adjusted for potential confounders. The issue of missing data was handled by a multiple imputation method. Data from 334 procedures were used in modeling and propensity score stratification. RESULTS: Adjusted odds ratios for the effects of prewarming were 0.47 (95% CI 0.15-1.49) for surgical site infections; 0.89 (95% CI 0.55-1.41) for cell salvaged blood transfusion; 0.43 (95% CI 0.22-0.83) for allogeneic packed red blood cell transfusion; and 1.24 (95% CI 0.77-1.99) for a length of hospitalization >6 days. Adjusted mean decrease in estimated blood loss for prewarming was 72 (95% CI -29 to 173) ml. CONCLUSION: In this study, prewarming was associated with a reduction in allogeneic packed red blood cell transfusion. However, no causal relationship between prewarming and reduced allogeneic blood transfusion should be assumed. Prewarming was not associated with reductions in estimated blood loss, length of hospitalization, or the incidence of surgical site infection.

Changes in QTc associated with a rapid bolus dose of dexmedetomidine in patients receiving TIVA: a retrospective study.

BACKGROUND: Clinical indications for the perioperative use of dexmedetomidine in pediatric anesthesia are accumulating. However, in 2013, dexmedetomidine was added to the list of medications with possible risk of prolonging the QT interval and/or inducing Torsades de Pointes. Unfortunately, current evidence for dexmedetomidine-induced QT prolongation is sparse and somewhat contradictory. OBJECTIVE: The purpose of this study was to evaluate temporal changes in corrected QT interval (QTc) after a rapid bolus administration of dexmedetomidine under total intravenous anesthesia (TIVA) with a standardized propofol and remifentanil administration. METHODS: Electrocardiography (ECG) and corresponding trend data were extracted from automated electronic data capture of physiological monitoring. Ten-second epochs of ECG data were extracted in 1-min intervals for 12 min, starting 1 min before dexmedetomidine bolus administration, and ending 10 min after. QT intervals were extracted using an automated routine in MATLAB, and corrected for heart rate (HR) using Bazett's (QTcB) and Fridericia's formulas (QTcF). QTcB and QTcF were compared using Wilcoxon signed-rank test between baseline measurements and the subsequent four interval values. RESULTS: Data from 21 subjects (17 male) with median (range) age 7.1 (5.4-9.5) yr, weight 23.6 (16.2-36.7) kg, and height 121 (103-140) cm were analyzed. Bolus administration of dexmedetomidine reduced HR in all subjects (median 22%), and caused transient reduction of QT interval, with its peak at 1-min postbolus administration: QTcB (median reduction 30.7 ms, P < 0.001) or QTcF (median reduction 15.4 ms, P = 0.001); QT shortening became statistically insignificant 4 min following dexmedetomidine bolus administration for QTcB and 2 min for QTcF. CONCLUSION: In this study, a rapid bolus of dexmedetomidine transiently shortened corrected QT intervals. However, these effects are confounded by dexmedetomidine-induced bradycardia. These findings should be confirmed in pediatric studies without concomitant TIVA administration and with optimized correction of baseline HR.

The safety of modern anesthesia for children with long QT syndrome.

BACKGROUND: Patients with long QT syndrome (LQTS) may experience a clinical spectrum of symptoms, ranging from asymptomatic, through presyncope, syncope, and aborted cardiac arrest, to sudden cardiac death. Arrhythmias in LQTS are often precipitated by autonomic changes. This patient population is believed to be at high risk for perioperative arrhythmia, specifically torsades de pointes (TdP), although this perception is largely based on limited literature that predates current anesthetic drugs and standards of perioperative monitoring. We present the largest multicenter review to date of anesthetic management in children with LQTS. METHODS: We conducted a multicentered retrospective chart review of perioperative management of children with clinically diagnosed LQTS, aged 18 years or younger, who received general anesthesia (GA) between January 2005 and January 2010. Data from 8 institutions were collated in an anonymized database. RESULTS: One hundred three patients with LQTS underwent a total of 158 episodes of GA. The median (interquartile range) age and weight of the patients at the time of GA was 9 (3-15) years and 30.3 (15.4-54) kg, respectively. Surgery was LQTS-related in 81 (51%) GA episodes (including pacemaker, implantable cardioverter-defibrillator, and loop recorder insertions and revisions and lead extractions) and incidental in 77 (49%). ß-blocker therapy was administered to 76% of patients on the day of surgery and 47% received sedative premedication. Nineteen percent of patients received total IV anesthesia, 30% received total inhaled anesthesia, and the remaining 51% received a combination. No patient received droperidol. There were 5 perioperative episodes of TdP, all in neonates or infants, all in surgery that was LQTS-related, and none of which was overtly attributable to anesthetic regimen. Thus the incidence (95% confidence interval) of perioperative TdP in incidental versus LQTS-related surgery was 0/77 (0%; 0%-5%) vs 5/81 (6.2%; 2%-14%). CONCLUSIONS: With optimized perioperative management, modern anesthesia for incidental surgery in patients with LQTS is safer than anecdotal case report literature might suggest. Our series suggests that the risk of perioperative TdP is concentrated in neonates and infants requiring urgent interventions after failed first-line management of LQTS.

Usability and performance characteristics of the pediatric air-Q® intubating laryngeal airway.

PURPOSE: The air-Q® intubating laryngeal airway (ILA) is a supraglottic device (SGD) designed specifically to function as both a primary airway and a bridging device and conduit for fibreoptic intubation in difficult airway scenarios. This observational study evaluated the usability and performance characteristics of pediatric air-Q ILA sizes 1.0, 1.5, 2.0, and 2.5 when used as a primary airway. METHODS: One hundred ten children, American Society of Anesthesiologists physical status I-III and undergoing elective surgery, received a weight-appropriate air-Q ILA following induction of anesthesia. The evaluation criteria included ease of insertion, quality of ventilation, presence of gastric insufflation, oropharyngeal leak pressures (OLPs) and maximum tidal volumes (VT max) in five different head positions, and fibreoptic view of the glottis. RESULTS: For sizes 1.0, 1.5, 2.0, and 2.5, the median [P25,P75] neutral OLPs (cm H2O) were 23.0 [20.0,30.0], 16.5 [15.0,20.8], 14.0 [10.0,17.8], and 14.0 [11.3,16.8], respectively. The median [P25,P75] neutral VT max values (mL · kg(-1)) were 17.4 [14.3,19.7], 20.3 [16.8,25.5], 17.8 [14.5,22.1], and 14.0 [11.6,16.0], respectively. Median [P25,P75] ease of insertion scores (0-10; 0 = easiest ever, 10 = most difficult ever) were 1 [1,2], 2 [2,3], 2 [1,2.8], and 2 [2,3] respectively. Ventilation was adequate in 108/110 cases, and a fibreoptic view of the vocal cords was obtained in 102/110 cases. CONCLUSIONS: The air-Q ILA functions acceptably as a primary SGD in infants and children. The OLPs are lower than published values for the ProSeal laryngeal mask airway (LMA ProSeal™), the current pediatric SGD of choice, but adequate tidal volumes are readily achievable. The fibreoptic views of the glottis portend well for fibreoptic intubation through the device. (This trial was registered at clinicaltrials.gov number, NCT00885911).

A retrospective audit to examine the effectiveness of preoperative warming on hypothermia in spine deformity surgery patients.

BACKGROUND: Hypothermia (core body temperature <36°C) during surgery has been associated with surgical site infection, a major risk in all spine deformity surgeries. Forced air warming is an important method of intraoperative temperature maintenance in children. In mid-2010, we empirically introduced preoperative warming as a strategy to reduce intraoperative hypothermia. OBJECTIVE: We report the prevalence and extent of hypothermia during spine deformity surgeries at our institution and evaluate the effect of the introduction of preoperative warming. METHODS: We performed a retrospective audit of temperature data in children who underwent spine deformity surgeries during two-seven-month periods: November 2011 to June 2012 and 2 years prior to this period (before preoperative warming implementation). Specifically, the following data were obtained: (i) case duration; (ii) first measured temperature; (iii) last measured temperature; (iv) percentage of case spent hypothermic; (v) number of hypothermic episodes per case, and (vi) delay between case start and time of first temperature measured. Data were compared visually and using the Mann-Whitney U-test. Confidence intervals (CI) were obtained using the Hodges-Lehmann estimator. RESULTS: Preoperative warming reduced the percentage of case duration spent hypothermic by a median of 111.1 min (P < 0.001, 95% CI 77.1-139.9 min). Additionally, it increased the first measured temperature by a median of 0.5°C (P < 0.001, 95% CI 0.3-0.7°C). The last temperature at the end of the case remained unchanged (P = 0.57, 95% CI -0.2-0.1°C). CONCLUSION: Preoperative warming of children undergoing spine deformity surgery significantly reduces the percentage of case spent hypothermic, thereby potentially reducing risk of perioperative complications.

An Individualized Postoperative Pain Risk Communication Tool for Use in Pediatric Surgery: Co-Design and Usability Evaluation.

BACKGROUND: Risk identification and communication tools have the potential to improve health care by supporting clinician-patient or family discussion of treatment risks and benefits and helping patients make more informed decisions; however, they have yet to be tailored to pediatric surgery. User-centered design principles can help to ensure the successful development and uptake of health care tools. OBJECTIVE: We aimed to develop and evaluate the usability of an easy-to-use tool to communicate a child's risk of postoperative pain to improve informed and collaborative preoperative decision-making between clinicians and families. METHODS: With research ethics board approval, we conducted web-based co-design sessions with clinicians and family participants (people with lived surgical experience and parents of children who had recently undergone a surgical or medical procedure) at a tertiary pediatric hospital. Qualitative data from these sessions were analyzed thematically using NVivo (Lumivero) to identify design requirements to inform the iterative redesign of an existing prototype. We then evaluated the usability of our final prototype in one-to-one sessions with a new group of participants, in which we measured mental workload with the National Aeronautics and Space Administration (NASA) Task Load Index (TLX) and user satisfaction with the Post-Study System Usability Questionnaire (PSSUQ). RESULTS: A total of 12 participants (8 clinicians and 4 family participants) attended 5 co-design sessions. The 5 requirements were identified: (A) present risk severity descriptively and visually; (B) ensure appearance and navigation are user-friendly; (C) frame risk identification and mitigation strategies in positive terms; (D) categorize and describe risks clearly; and (E) emphasize collaboration and effective communication. A total of 12 new participants (7 clinicians and 5 family participants) completed a usability evaluation. Tasks were completed quickly (range 5-17 s) and accurately (range 11/12, 92% to 12/12, 100%), needing only 2 requests for assistance. The median (IQR) NASA TLX performance score of 78 (66-89) indicated that participants felt able to perform the required tasks, and an overall PSSUQ score of 2.1 (IQR 1.5-2.7) suggested acceptable user satisfaction with the tool. CONCLUSIONS: The key design requirements were identified, and that guided the prototype redesign, which was positively evaluated during usability testing. Implementing a personalized risk communication tool into pediatric surgery can enhance the care process and improve informed and collaborative presurgical preparation and decision-making between clinicians and families of pediatric patients.

Tracheal inflammatory myofibroblastic tumor presenting as an obstructive pediatric foreign body.

We describe an unusual presentation of a suspected pediatric foreign body (FB) aspiration which was found to be an occlusive inflammatory myofibroblastic tumor (IMT) of the distal trachea. These are rarely reported entities, with the potential for significant airway bleeds. Multidisciplinary discussion and involvement allowed for a safe patient outcome.