Comparison of train-of-four count by anesthesia providers versus TOF-Watch® SX: a prospective cohort study.

PURPOSE: Qualitative monitoring of neuromuscular blockade using the train-of-four (TOF) count is widely used to determine the timing and dose of reversal agents for neuromuscular blockade. We compared TOF count measured manually by anesthesia providers with that determined by TOF-Watch® SX. METHODS: This prospective observational cohort study included patients who were American Society of Anesthesiologists physical status III or less and undergoing elective surgery. During recovery from an intubating dose of rocuronium or vecuronium, the TOF count was measured every 15 sec using TOF-Watch SX. Anesthesia providers assessed the TOF count twice at each level of TOF-count, 15 sec after the TOF-Watch SX count increased to the next level and then two to five minutes later. RESULTS: In 75 patients, 687 observations were collected. There was agreement between the TOF-Watch SX and the subjective assessment by the provider in 386 (56%) of these observations. The agreement was 87% at TOF counts of 0 and 4. In the 409 observations at TOF counts 1, 2, and 3, the agreement was 36%. Among the 264 observations with disagreement at these TOF counts, providers assessed a higher TOF count in 254 (96%) observations and a lower count in 10 (4%) observations compared with the TOF-Watch SX. CONCLUSION: Anesthesia providers report higher values of TOF count compared with the TOF-Watch SX, especially at intermediate levels of neuromuscular blockade. Since the dosing guidelines for the timing and dose of reversal agents are based on the TOF count derived from the TOF-Watch SX, a manually assessed TOF count may lead to inadequate dosing and/or premature administration of reversal agents.

Ventilation by mask before and after the administration of neuromuscular blockade: a pragmatic non-inferiority trial.

BACKGROUND: Test ventilating prior to administration of neuromuscular blockade (NMB) in order to avoid a cannot intubate-cannot ventilate situation is a classic anesthesia teaching. The primary aim of our study was to show that facemask ventilation (FMV) after NMB was not inferior to FMV prior to NMB with respect to exhaled gas volumes before and after their administration. METHODS: This study was approved by the University of Washington Human Subjects Division (Seattle, Washington, USA). Written informed consent was obtained from all patients. Measurements of tidal volume (Vte) as well as other respiratory parameters during FMV were made for 60 s after induction of anesthesia and again after NMB. Difficult, impossible, inadequate, and dead-space only mask ventilation was graded using published definitions. Difficult intubation was defined as >2 attempts at intubation. The primary outcome was non-inferiority in Vte during both study periods defined as a mean difference of <50 mL. Multivariate analysis was performed to assess for interaction between operator experience, patient risk factors for difficult mask ventilation, exhaled volumes, and use of airway adjuncts. RESULTS: Two-hundred and ten patients were studied. Overall, FMV improved after NMBD. The mean (SD) Vte in mL/breath increased from 399 (169) to 428 (166) (mean dif. 30 mL, p = 0.001) and the minute ventilation in L/min from 5.6 (2.5) to 6.3 (2.5) (mean dif. 0.6, p < 0.001). No patient who was difficult to ventilate after induction became impossible after NMB. DISCUSSION: In patients at risk for or judged to be a difficult FMV by clinical grading scales, tidal volumes improved after administration of NMBDs. None of these patients exhibited a decline in ventilation or became impossible to ventilate after NMBDs. Several limitations are noted, including the use of hand-delivered breaths and inability to account for time-related changes in ventilation conditions independent of NMBDs. CONCLUSION: We conclude that FMV is no worse after NMB than before and is likely to improve airway conditions. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02237443 . Registered August 28, 2014.

Intraoperative neuromuscular monitoring site and residual paralysis.

BACKGROUND: Residual paralysis is common after general anesthesia involving administration of neuromuscular blocking drugs (NMBDs). Management of NMBDs and reversal is frequently guided by train-of-four (TOF) monitoring. We hypothesized that monitoring of eye muscles is associated with more frequent residual paralysis than monitoring at the adductor pollicis. METHODS: This prospective cohort study enrolled 180 patients scheduled for elective surgery with anticipated use of NMBDs. Collected variables included monitoring site, age, gender, weight, body mass index, American Society of Anesthesiologists physical status class, type and duration of surgery, type of NMBDs, last and total dose administered, TOF count at time of reversal, dose of neostigmine, and time interval between last dose of NMBDs to quantitative measurement. Upon postanesthesia care unit admission, we measured TOF ratios by acceleromyography at the adductor pollicis. Residual paralysis was defined as a TOF ratio less than 90%. Multivariable logistic regression was used to account for unbalances between the two groups and to adjust for covariates. RESULTS: 150 patients received NMBDs and were included in the analysis. Patients with intraoperative TOF monitoring of eye muscles had significantly greater incidence of residual paralysis than patients monitored at the adductor pollicis (P < 0.01). Residual paralysis was observed in 51/99 (52%) and 11/51 (22%) of patients, respectively. The crude odds ratio was 3.9 (95% CI: 1.8-8.4), and the adjusted odds ratio was 5.5 (95% CI: 2.1-14.5). CONCLUSIONS: Patients having qualitative TOF monitoring of eye muscles had a greater than 5-fold higher risk of postoperative residual paralysis than those monitored at the adductor pollicis.

S-100ß and Antioxidant Capacity in Cerebrospinal Fluid during and after Thoracic Endovascular Aortic Repair.

BACKGROUND: Thoracic Endovascular Aortic Repair (TEVAR) has substantially decreased the mortality and major complications from aortic surgery. However, neurological complications such as spinal cord ischemia may still occur after TEVAR. S-100ß is a biomarker of central nervous system injury, and oxidant injury plays an important role in neurological injury. In this pilot study, we examined the trends of S-100ß and antioxidant capacity in the CSF during and after TEVAR. METHODS: We recruited 10 patients who underwent elective TEVAR. CSF samples were collected through a lumbar catheter at the following time points: before the start of surgery (T0) and immediately (T1) and 24 (T2) and 48 hours (T3) after the deployment of the aortic stent. S-100ß and CSF antioxidant capacity were analyzed with the use of commercially available kits. RESULTS: We observed that the level of S-100ß in all of the subjects at 24 hours after the deployment of the aortic stent (T2) increased. However, the levels of S-100ß at T1 and T3 were comparable to the baseline value. The antioxidant capacity remained unchanged. No patient had a clinical neurologic complication. CONCLUSIONS: Our observations may indicate biochemical/subclinical central nervous system injury attributable to the deployment of the aortic stent.

Perioperative and intensive care management of pediatric tracheal tear.

Management of tracheal tears can prove to be challenging in the perioperative setting. This is a rare condition that can be life threatening. Here, we present a case of seven-year-old boy involved in a high-speed motor vehicle collision. The child sustained multiple injuries including a near fatal head injury, multiple facial fractures, and a tracheal injury associated with pneumomediastinum. Due to the imminent threat of brainstem herniation while being imaged in the CT scanner, the patient underwent an emergent craniotomy to evacuate his evolving intracranial bleed. Imaging prior to the craniectomy suggested a possible tracheal injury, given the extensive pneumomediastinum. However, initial perioperative ventilation was without any difficulty. After stabilization of intracranial pressure (ICP) and hemodynamics, on hospital day 4, the patient returned to the operating room to diagnose and repair his tracheobronchial injury. This is a unique polytrauma case in which a tracheal tear was managed in the midst of other life-threatening injuries.

Pediatric neurotrauma.

Traumatic brain injury (TBI) is the leading cause of death and disability in children over 1 year of age. Knowledge about the age-specific types of injury and how to manage children with neurotrauma is essential to understanding and recognizing the extent and degree of injury and to optimize outcomes. In this article, we review the epidemiology, pathophysiology, and clinical management of pediatric neurotrauma.

Rapid-sequence intubation and cricoid pressure.

Airway management is the most important clinical skill for anesthesiologist, emergency physician, and other providers who are involved in oxygenation and ventilation of the lungs. Rapid-sequence intubation is the preferred method to secure airway in patients who are at risk for aspiration because it results in rapid unconsciousness (induction) and neuromuscular blockade (paralysis). Application of cricoid pressure (CP) for patients undergoing rapid-sequence intubation is controversial. Multiple specialty societies have recommended that CP is not effective in preventing aspiration; rather it may worsen laryngoscopic view and impair bag-valve mask ventilation. Some experts think that CP should be applied in trauma and patients at risk for aspiration; however CP, if necessary, should be altered or removed to facilitate intubation.

Pediatric airway management.

Securing an airway is a vital task for the anesthesiologist. The pediatric patients have significant anatomical and physiological differences compared with adults, which impact on the techniques and tools that the anesthesiologist might choose to provide safe and effective control of the airway. Furthermore, there are a number of pathological processes, typically seen in the pediatric population, which present unique anatomical or functional difficulties in airway management. The presence of one of these syndromes or conditions can predict a "difficult airway." Many instruments and devices are currently available which have been designed to aid in airway management. Some of these have been adapted from adult designs, but in many cases require alterations in technique to account for the anatomical and physiological differences of the pediatric patient. This review focuses on assessment and management of pediatric airway and highlights the unique challenges encountered in children.

Extraglottic airway devices: A review.

Extraglottic airway devices (EAD) have become an integral part of anesthetic care since their introduction into clinical practice 25 years ago and have been used safely hundreds of millions of times, worldwide. They are an important first option for difficult ventilation during both in-hospital and out-of-hospital difficult airway management and can be utilized as a conduit for tracheal intubation either blindly or assisted by another technology (fiberoptic endoscopy, lightwand). Thus, the EAD may be the most versatile single airway technique in the airway management toolbox. However, despite their utility, knowledge regarding specific devices and the supporting data for their use is of paramount importance to patient's safety. In this review, number of commercially available EADs are discussed and the reported benefits and potential pitfalls are highlighted.

Pre-hospital care of pediatric patients with trauma.

Prehospital pediatric care is an important component in the treatment of the injured child, as the prehospital responders are the first medical providers performing life saving and directed medical care. Traumatic injuries are the leading cause of morbidity and mortality in the pediatric patient population. Nevertheless, for most prehospital provider it is a rare event to treat pediatric trauma patients and there is a still existing gap between the quality of care for pediatric patients compared to adults. To improve pediatric prehospital trauma care more provider need to be trained in identifying the specific differences between adult and pediatric patients.

Pediatric burn injuries.

Pediatric burns comprise a major mechanism of injury, affecting millions of children worldwide, with causes including scald injury, fire injury, and child abuse. Burn injuries tend to be classified based on the total body surface area involved and the depth of injury. Large burn injuries have multisystemic manifestations, including injuries to all major organ systems, requiring close supportive and therapeutic measures. Management of burn injuries requires intensive medical therapy for multi-organ dysfunction/failure, and aggressive surgical therapy to prevent sepsis and secondary complications. In addition, pain management throughout this period is vital. Specialized burn centers, which care for these patients with multidisciplinary teams, may be the best places to treat children with major thermal injuries. This review highlights the major components of burn care, stressing the pathophysiologic consequences of burn injury, circulatory and respiratory care, surgical management, and pain management of these often critically ill patients.

Vascular access, fluid resuscitation, and blood transfusion in pediatric trauma.

Trauma care in the general population has largely become protocol-driven, with an emphasis on fast and efficient treatment, good team communication at all levels of care including prehospital care, initial resuscitation, intensive care, and rehabilitation. Most available literature on trauma care has focused on adults, allowing the potential to apply concepts from adult care to pediatric care. But there remain issues that will always be specific to pediatric patients that may not translate from adults. Several new devices such as intraosseous (IO) needle systems and techniques such as ultrasonography to cannulate central and peripheral veins have become available for integration into our pre-existing trauma care system for children. This review will focus specifically on the latest techniques and evidence available for establishing intravenous access, rational approaches to fluid resuscitation, and blood product transfusion in the pediatric trauma patient.

Sedation and analgesia for the pediatric trauma patients.

The number of children requiring sedation and analgesia for diagnostic and therapeutic procedures has increased substantially in the last decade. Both anesthesiologist and non-anesthesiologists are involved in varying settings outside the operating room to provide safe and effective sedation and analgesia. Procedural sedation has become standard of care and its primary aim is managing acute anxiety, pain, and control of movement during painful or unpleasant procedures. There is enough evidence to suggest that poorly controlled acute pain causes suffering, worse outcome, as well as debilitating chronic pain syndromes that are often refractory to available treatment options. This article will provide strategies to provide safe and effective sedation and analgesia for pediatric trauma patients.

Initial assessment and management of pediatric trauma patients.

Injury is the leading cause of death and disability in children. Each year, almost one in six children in the United States require emergency department (ED) care for the treatment of injuries, and more than 10,000 children die from injuries. Severely injured children need to be transported to a facility that is staffed 24/7 by personnel experienced in the management of children, and that has all the appropriate equipment to diagnose and manage injuries in children. Anatomical, physiological, and emotional differences between adults and children mean that children are not just scaled-down adults. Facilities receiving injured children need to be child and family friendly, in order to minimize the psychological impact of injury on the child and their family/carers. Early recognition and treatment of life-threatening airway obstruction, inadequate breathing, and intra-abdominal and intra-cranial hemorrhage significantly increases survival rate after major trauma. The initial assessment and management of the injured child follows the same ATLS(®) sequence as adults: primary survey and resuscitation, followed by secondary survey. A well-organized trauma team has a leader who designates roles to team members and facilitates clear, unambiguous communication between team members. The team leader stands where he/she can observe the entire team and monitor the "bigger picture." Working together as a cohesive team, the members perform the primary survey in just a few minutes. Life-threatening conditions are dealt with as soon as they are identified. Necessary imaging studies are obtained early. Constant reassessment ensures that any deterioration in the child's condition is picked up immediately. The secondary survey identifies other injuries, such as intra-abdominal injuries and long-bone fractures, which can result in significant hemorrhage. The relief of pain is an important part of the treatment of an injured child.

Trends in trauma transfusion.

Trauma is the leading cause of death in young adults and acute blood loss contributes to a large portion of mortality in the early post-trauma period. The recognition of lethal triad of coagulopathy, hypothermia and acidosis has led to the concepts of damage control surgery and resuscitation. Recent experience with managing polytrauma victims from the Iraq and Afghanistan wars has led to a few significant changes in clinical practice. Simultaneously, transfusion practices in the civilian settings have also been extensively studied retrospectively and prospectively in the last decade. Early treatment of coagulopathy with a high ratio of fresh frozen plasma and platelets to packed red blood cells (FFP:platelet:RBC), prevention and early correction of hypothermia and acidosis, monitoring of hemostasis using point of care tests like thromoboelastometry, use of recombinant activated factor VII, antifibrinolytic drugs like tranexamic acid are just some of the emerging trends. Further studies, especially in the civilian trauma centers, are needed to confirm the lessons learned in the military environment. Identification of patients likely to need massive transfusion followed by immediate preventive and therapeutic interventions to prevent the development of coagulopathy could help in reducing the morbidity and mortality associated with uncontrolled hemorrhage in trauma patients.

Pediatric procedural sedation and analgesia outside the operating room: anticipating, avoiding and managing complications.

In the new millennium, there has been a huge surge in the numbers of procedures performed under sedation in pediatric patients outside the operating room. Traditionally, these were performed by anesthesiologists. Increasingly, other specialists, such as emergency room physicians, pediatricians and radiologists, are involved in the management of procedural sedations under elective or emergency situations. Professional organizations such as the American Society of Anesthesiologists, American Academy of Pediatrics, Joint Commission on Accreditation of Healthcare Organizations and other organizations are working continuously to make procedural sedation for children safe, economical and tailored to the needs of the child and the diagnostic/therapeutic procedure being performed. Multi-institutional databases have been set up to investigate the complications related to procedural sedation and lessons are being learned from the analysis of these data. This article reviews these data and describes strategies to prevent and manage common adverse events following procedural sedation in children outside the operating room.

Trauma care today, what's new?

Injury is the fourth leading cause of death in the US, and the leading cause of death in younger age. Trauma is primarily a disease of the young and accounts for more years of productive life lost than any other illness. Consequently, almost every health care provider encounters trauma patients from time to time. Many of these patients are critically ill and pose several challenges in the acute phase, including airway and ventilation, fluid management, intracranial pressure control, etc. In the last decade, several strategies and treatment options have been studied in trauma care along with improvement in technologies. In this review, we will discuss a few of the new developments and updates in trauma care.

Current trends and update on injury prevention.

Injuries are a major and growing public health problem, a leading cause of death and disabilities among people aged 1-44 years around the world. Each year, 5.8 million people die from injuries, accounting for 10% of the world's deaths. Road traffic injuries (RTIs), self-inflicted injuries and violence are the top three leading causes of all injury deaths, while RTIs, falls and drowning are the top three leading causes of unintentional injury death. In many high-income countries, trends of injury death have been decreasing as a result of prevention measures. In contrast, trends in low- and middle-income countries have been rising. In this article, we review the prevention strategies for RTIs, violence, falls and drowning developed over decades to disseminate the knowledge and inform health care providers, especially acute care physicians, about the importance of injury prevention.

Propofol infusion syndrome in a super morbidly obese patient (BMI = 75).

Propofol infusion syndrome (PRIS) is a rare but often fatal complication as a result of large doses of propofol infusion (4-5 mg/kg/hr) for a prolonged period (>48 h). It has been reported in both children and adults. Besides large doses of propofol infusion, the risk factors include young age, acute neurological injury, low carbohydrate and high fat intake, exogenous administration of corticosteroid and catecholamine, critical illness, and inborn errors of mitochondrial fatty acid oxidation. PRIS manifestation include presence of metabolic acidosis with a base deficit of more than 10 mmol/l at least on one occasion, rhabdomyolysis or myoglobinuria, acute renal failure, sudden onset of bradycardia resistant to treatment, myocardial failure, and lipemic plasma. The pathophysiology of PRIS may be either direct mitochondrial respiratory chain inhibition or impaired mitochondrial fatty acid metabolism mediated by propofol. We report a case of supermorbidly obese patient who received propofol infusion by total body weight instead of actual body weight and developed PRIS.

Analgesia and sedation for children undergoing burn wound care.

Standard care of burn wounds consists of cleaning and debridement (removing devitalized tissue), followed by daily dressing changes. Children with burns undergo multiple, painful and anxiety-provoking procedures during wound care and rehabilitation. The goal of procedural sedation is safe and efficacious management of pain and emotional distress, requiring a careful and systematic approach. Achieving the best results needs understanding of the mechanisms of pain and the physiologic changes in burn patients, frequent evaluation and assessment of pain and anxiety, and administration of suitable pharmacological and nonpharmacological therapies. Pharmacological therapies provide the backbone of analgesia and sedation for procedural pain management. Opioids provide excellent pain control, but they must be administered judiciously due to their side effects. Sedative drugs, such as benzodiazepines and propofol, provide excellent sedation, but they must not be used as a substitute for analgesic drugs. Ketamine is increasingly used for analgesia and sedation in children as a single agent or an adjuvant. Nonpharmacological therapies such as virtual reality, relaxation, cartoon viewing, music, massage and hypnosis are necessary components of procedural sedation and analgesia for children. These can be combined with pharmacological techniques and are used to limit the use of drugs (and hence side effects), as well as to improve patient participation and satisfaction. In this article, we review the pathophysiologic changes associated with major thermal injury in children, the options available for sedation and analgesia for wound care procedures in these children and our institutional guidelines for procedural sedation.