Combined General and Regional Anesthesia for a Patient With Duchenne Muscle Dystrophy With an Implanted Left Ventricular Assisted Device Undergoing Orthopedic Surgery.

Duchenne muscular dystrophy (DMD) is an X-linked inherited dystrophinopathy, with an incidence of 1 in 3,600 - 5,000 male live-born infants. The leading cause of death is often cardiomyopathy-related heart failure. Given the progressive nature of the disorder with involvement of skeletal muscle, respiratory and cardiac function, perioperative care remains challenging with an increased incidence of perioperative morbidity and mortality. Perioperative care can be challenging due to life-threatening perioperative adverse events related to associated end-organ effects, as well as sensitivity to various anesthetic agents, rhabdomyolysis, hyperkalemia, hyperthermia, and cardiac arrest. We present a 22-year-old DMD patient with left ventricular assisted device (LVAD), who presented for repair of both left distal femur and tibial diaphysis fractures. Anesthetic care included the unique combination of total intravenous anesthesia with dexmedetomidine and remimazolam combined with regional anesthesia including a supra-inguinal fascia iliaca block, saphenous nerve block, and popliteal nerve block. The basics of dystrophinopathies are presented, perioperative concerns discussed, and previous reports of the use of regional anesthesia as an adjunct to general anesthesia in adult and pediatric patients with DMD are reviewed.

Preliminary Experience With Remimazolam for Procedural Sedation and as an Adjunct to General Anesthesia During Diagnostic and Interventional Cardiac Procedures.

Background: Remimazolam is a benzodiazepine which, like midazolam, has sedative, anxiolytic, and amnestic properties. Ester metabolism results in a half-life of 5 - 10 min, a limited context sensitive half-life, and rapid recovery when the infusion is discontinued. Methods: Following the Institutional Review Board (IRB) approval, we performed a retrospective chart review of patients who received remimazolam in the cardiac catheterization, cardiac magnetic resonance imaging (MRI), and electrophysiology suites. The primary objective was to assess efficacy and safety. The secondary objective was to describe bolus and infusion dosing of remimazolam and the need for adjunctive agents to optimize procedural sedation conditions. Results: The study cohort included 26 patients with a median age of 18 years and a total of 33 anesthetic encounters. The most common procedures were endomyocardial biopsy or isolated hemodynamic assessment (right or left heart catheterization). Remimazolam was the primary agent for sedation in 82% of the procedures. The majority of cases (25 encounters, 76%) included a bolus dose of remimazolam prior to the start of an infusion. For those patients who received a starting bolus dose, dosing typically ranged between 30 and 110 µg/kg. Continuous infusion rates of remimazolam varied from 5 to 20 µg/kg/min. No adverse hemodynamic or respiratory effects were noted. Midazolam, fentanyl, and dexmedetomidine were the most frequently used adjunctive agents. One patient required transition to general anesthesia due to the need for a surgical intervention based on the findings of the cardiac catheterization. All other patients were effectively sedated. Conclusions: Our preliminary experience demonstrates that remimazolam effectively provided sedation for diagnostic and therapeutic cardiovascular procedures. Future studies are needed to further define dosing parameters for both bolus dosing and continuous infusion as well as to compare remimazolam to other commonly used for procedural sedation in patients with congenital and acquired heart disease.

Use of a Novel Buffered Hypertonic Saline Solution for Fluid Replacement and Resuscitation During Spinal Surgery in Adolescents.

Background: During major orthopedic procedures, such as posterior spinal fusion (PSF), isotonic fluids, colloids, starches, or gelatins are commonly used to replace the preoperative fluid deficit and provide ongoing fluid resuscitation. Given recent concerns regarding the potential adverse physiologic effects of albumin solutions, we have modified our intraoperative practice to include the use of a novel 2% buffered hypertonic saline solution during major orthopedic procedures. We present our preliminary clinical experience with this novel fluid for intraoperative resuscitation and its impact on limiting the use of 5% albumin. Methods: A retrospective review was performed to identify patients who received 2% buffered hypertonic saline during PSF. The intraoperative course of these patients was compared to case-matched control patients who received standard care with isotonic fluids plus 5% albumin as an adjunct for intravascular resuscitation. Results: The study cohort included 23 patients who received 2% buffered hypertonic saline and 25 in the case-matched control group. There was no difference in the volume of intraoperative isotonic crystalloid fluids, estimated blood loss, and urine output between the two groups. In the control cohort, 19 of 25 patients (76%) received 5% albumin compared to only six of 23 patients (26%, P = 0.0005) in the 2% buffered hypertonic saline group. The final pH was higher in the patients that received 2% buffered hypertonic saline than in the control group (7.40 ± 0.03 versus 7.36 ± 0.06, P = 0.0131). Additionally, the starting and final serum sodium values were higher in the patients that received 2% buffered hypertonic saline, although no difference was noted in the mean change from the starting value (average increase of 2 mEq/L in both groups). Conclusion: Use of a novel 2% buffered hypertonic saline solution for intraoperative resuscitation during major orthopedic procedures decreases the need for 5% albumin while avoiding the development of hyperchloremic metabolic acidosis which may occur with standard sodium chloride solutions.

Where have all the pediatric anesthesiology fellows gone in the USA? Anesthesiology fellowship trends.

BACKGROUND: Recent consternation over the number of unfilled Pediatric Anesthesiology fellowship positions in the United States compelled us to assess the change in the ratio of Pediatric Anesthesiology fellows to the number of graduating anesthesiology residents over the 14-year period between 2008 and 2022. We also sought to report the total ratio of anesthesiology fellows to graduating residents and trends in the annual number of fellowship applicants relative to the number of Accreditation Council for Graduate Medical Education (ACGME)-accredited anesthesiology fellowship positions by specialty. METHODS: We used publicly available resources, including ACGME Data Resource Books, National Resident Matching Program (NRMP) data, San Francisco (SF) Match data, and American Board of Medical Specialties (ABMS) data, to determine the ratio of anesthesiology fellows to graduating anesthesiology residents and to compare the number of fellowship applicants to fellowship positions for Adult Cardiothoracic Anesthesiology, Critical Care Anesthesiology, Obstetric Anesthesiology, Pain Medicine and Pediatric Anesthesiology. RESULTS: Since 2008, the ratio of ACGME-accredited anesthesiology fellows to graduating residents increased from 0.36 in 2008 (2007 residency graduates) to 0.59 in 2022 (2021 residency graduates) and the ratio of Pediatric Anesthesiology fellows to graduating residents remained relatively stable from 0.10 to 0.11. The number of unmatched positions in Pediatric Anesthesiology increased from 17 in 2017 to 86 in 2023, and all ACGME-accredited fellowships had more positions available than applicants in 2023. CONCLUSION: In the USA, while the ratio of Pediatric Anesthesiology fellowship graduates to anesthesiology residency graduates remained relatively constant from 2008 to 2022, this is likely a lagging indicator that has not yet accounted for the recent decrease in fellowship applicants. These findings refute prior estimates for a surplus in Pediatric Anesthesia supply in the USA and have significant implications for the future.

A ROTEM-guided algorithm aimed to reduce blood product utilization during neonatal and infant cardiac surgery.

BACKGROUND: Neonates and infants undergoing cardiac surgery tend to receive high volumes of blood products. The use of rotational thromboelastometry (ROTEM®) has been shown to reduce the administration of blood products in adults after cardiac surgery. We sought to develop a targeted administration of blood products based on ROTEM® to reduce blood product utilization during and after neonatal and infant cardiac surgery. METHODS: We conducted a retrospective review of data from a single center for neonates and infants undergoing congenital cardiac surgery using cardiopulmonary bypass (CPB) from September 2018-April 2019 (control group). Then, using a ROTEM® algorithm, we collected data prospectively between April-November 2021 (ROTEM group). Data collected included age, weight, gender, procedure, STAT score, CPB time, aortic cross-clamp time, volume, and type of blood products administered in the operating room and cardiothoracic intensive care unit (CTICU). In addition, ROTEM® data, coagulation profile in CTICU, chest tube output at 6 and 24 hours, use of factors concentrate, and thromboembolic complications were recorded. RESULTS: The final cohort of patients included 28 patients in the control group and 40 patients in the ROTEM group. The cohort included neonates and infants undergoing the following procedures: arterial switch, aortic arch augmentation, Norwood procedure, and comprehensive stage II procedure. There were no differences in the demographics or procedure complexity between the two groups. Patients in the ROTEM® group received fewer platelets (36 ± 12 vs. 49 ± 27 mL/kg, p 0.028) and cryoprecipitate (8 ± 3 vs. 15 ± 10 mL/kg, p 0.001) intraoperatively when compared to the control group. CONCLUSION: The utilization of ROTEM® may have contributed to a significant reduction in some blood product administration during cardiac surgery for infants and neonates. ROTEM® data may play a role in reducing blood product administration in neonatal and infant cardiac surgery.

Optic nerve ultrasound and cardiopulmonary bypass: A pilot study.

Introduction: Despite advances in surgical, anesthetic, perfusion, and postoperative care, adverse neurological consequences may occur following cardiac surgery and cardiopulmonary bypass (CPB). Consequences of the physiologic effects of CPB may alter the blood-brain barrier, autoregulation, and intracranial pressure (ICP) in the immediate postoperative period. Methods: We evaluated the effects of cardiac surgery and CPB on the central nervous system by measuring the optic nerve sheath diameter (ONSD) by using ultrasound as a surrogate marker of ICP. ONSD was measured after anesthetic induction and endotracheal intubation (time 1), after separation from CPB (time 2), and at the completion of the surgical procedure prior to leaving the OR (time 3). Results: The study cohort included 14 patients, ranging in age from newborn to 6 years. When comparing the Fontan group (n = 5) to the non-Fontan group (n = 9), four elevated ONSD observations were recorded for the Fontan patients during the study period, including one at time 1, one at time 2, and two at time 3. In Fontan versus non-Fontan patients, ONSD was greater at all three time points compared to non-Fontan. The change in the ONSD from time 1 to time 2 was greater (+0.2 mm vs. -0.1 mm), and the mean value at time 2 was significantly higher (4.2 vs. 3.5 mm, P = 0.048). Conclusions: Patients with Fontan physiology may be more prone to higher levels of baseline intracranial pressure due to elevated systemic venous pressure and decreased cardiac output. Alternatively, the chronically high central venous pressures may artificially elevate ONSD without clinical changes in ICP, necessitating the development of separate normative values based on the type of congenital heart disease.

Risk Factors and Consequences of Acute Kidney Injury After Noncardiac Surgery in Children.

BACKGROUND: Postoperative acute kidney injury (AKI) is a serious complication that is associated with prolonged hospital stay, high risk of short-term postsurgical mortality, need for dialysis, and possible progression to chronic kidney disease. To date, very little data exist on the risk of postoperative AKI among children undergoing noncardiac surgical procedures. We used data from a large multicenter cohort to determine the factors associated with AKI among children who underwent inpatient noncardiac surgical procedures and its impact on the postoperative course. METHODS: We utilized the National Surgical Quality Improvement Program Pediatric participant user files to identify a cohort of children who underwent inpatient surgery between 2012 and 2018 (n = 257,439). We randomly divided the study population into a derivation cohort of 193,082 (75%) and a validation cohort of 64,357 (25%), and constructed a multivariable logistic regression model to identify independent risk factors for AKI. We defined AKI as the occurrence of either acute renal failure or progressive renal insufficiency within the 30 days after surgery. RESULTS: The overall rate of postoperative AKI was 0.10% (95% confidence interval [CI], 0.09-0.11). In a multivariable model, operating times longer than 140 minutes, preexisting hematologic disorder, and preoperative sepsis were the strongest independent predictors of AKI. Other independent risk factors for AKI were American Society of Anesthesiologists (ASA) physical status ≥III, preoperative inotropic support, gastrointestinal disease, ventilator dependency, and corticosteroid use. The 30-day mortality rate was 10.1% in children who developed AKI and 0.19% in their counterparts without AKI ( P < .001). Children who developed AKI were more likely to require an extended hospital stay (≥75th percentile of the study cohort) relative to their peers without AKI (77.4% vs 21.0%; P < .001). CONCLUSIONS: Independent preoperative risk factors for AKI in children undergoing inpatient noncardiac surgery were hematologic disorder, preoperative sepsis, ASA physical status ≥III, inotropic support, gastrointestinal disease, ventilator dependency, and steroid use. Children with AKI were 10 times more likely to die and nearly 3 times more likely to require an extended hospital stay, relative to their peers without AKI.

Impact of the COVID-19 pandemic on the 2020 pediatric anesthesiology fellowship application cycle: A survey of program directors.

BACKGROUND: The COVID-19 pandemic created a situation with an urgent need to produce a virtual system for the 2019-2020 pediatric anesthesiology fellowship cycle. With fellowship interviews beginning in April 2020, there was minimal time for programs to adapt. Each program rapidly developed its own platform, expectations, materials, and process for interviews-all while under the stress of managing the unfolding patient care, financial, and leadership crises of the unfolding pandemic. AIMS: The aim of this survey-based study was to help identify changes compared with previous traditional cycles, obstacles encountered, and program director attitudes toward this, and possible future, virtual application cycles. We separately report the results of an applicant-based survey about the 2020 virtual interview cycle. METHODS: A 50-question survey was developed utilizing Qualtrics. An anonymous survey link was sent to all pediatric anesthesiology program directors with an invitation for one program leader (either the program director or assistant/associate program director but not both) from each program to complete the voluntary survey. RESULT: Thirty respondents completed the survey, for a response rate of 50% based on the 60 ACGME-approved pediatric anesthesiology fellowships. Compared to previous traditional cycles, almost half of respondents (14/29, 48.3%) reported no increase in the number of applications received, and a majority of respondents (16/29, 55.2%) reported that they offered the same number of interview spots for the year. The virtual interview process appears to have gone smoothly, as a majority of programs reported they never or rarely had technical problems across a number of different domains. Importantly, the majority of respondents were either somewhat satisfied or extremely satisfied (21/28, 75%) with the overall virtual interview process. Given the choice of preferred interview format going forward, half of the respondents (14/28) would offer a combination of traditional and virtual interviews. CONCLUSIONS: These results demonstrate that virtual interviews are a viable alternative to traditional interviews and can be completed without many technological complications. PDs were overall satisfied with virtual interviews, despite not having appropriate time to plan and coordinate, and would be interested in continuing this option into the future. There are areas where improvements can be made and with appropriate planning could look to mitigate some of the areas where virtual interviews fall short of traditional interviews. In combination with our previously published survey of applicants (Paediatr Anaesth. 2021;31(9):968-976), these data form a more complete picture of virtual interview best practices going forward.

The impact of the COVID-19 pandemic on the 2020 pediatric anesthesiology fellowship application cycle: A survey of applicants.

BACKGROUND: The COVID-19 pandemic created a situation with an urgent need to produce a virtual system for the 2019-2020 pediatric anesthesiology fellowship cycle. With fellowship interviews beginning in April 2020, there was minimal time to adapt. Each program rapidly developed its own platform, expectations, materials, and process for interviews, and applicants were exposed to a wide array of variability in the process-all while under the stress of interviewing for fellowship positions. AIMS: The aim of this survey-based study was to obtain input from applicants to help guide program decisions about "best practice" for the future for both pediatric anesthesiology and other graduate medical education matches. METHODS: A 28-question survey was developed utilizing Qualtrics. An anonymous link was sent to all pediatric anesthesiology program directors for distribution of the survey link to all recently matched applicants. Incoming fellows who were accepted outside of the match process were also invited to respond. RESULTS: Fifty respondents completed the survey, for a response rate of 30% based on the 167 matched fellowship positions nationwide (50/167). A majority of the respondents reported they felt virtual interviews allowed them to learn the following things equally as well compared with a traditional interview about fellowship programs: salary and benefits, available academic opportunities, available clinical opportunities, clinical schedule of the fellowship, mentorship opportunities, clinical experience and training of the fellowship, and expected work-life balance during fellowship. Respondents report that the most important factors in making their rank list were perceived goodness of fit, desired geographic location, and perception of program leadership. Additionally, respondents ranked the types of information and interactions that they found most helpful to make decisions. All respondents reported the benefit of cost savings compared to a traditional application cycle, with the most commonly reported estimated savings being $3,000-$5,000 per respondent. CONCLUSIONS: These results allow recommendations for "best practices" for virtual interviews to include programs providing an electronic packet of information prior to the interview day, providing dedicated time for applicants to interact with current fellows, providing applicants an understanding of the city/region of the location of the program, and offering a completely optional postinterview visit, when possible. Based on the results of this survey, we recommend that programs continue to offer virtual interviews as a penalty-free option for applicants, even when in-person interviews may be feasible.

An Advanced Boot Camp for Pediatric Anesthesiology Fellows.

BACKGROUND: Managing pediatric crises necessitates the acquisition of unique skills and confidence in its execution. Our aim was to develop and assess a curriculum based on the constructivist learning environment to enhance learning, orientation, and preparation of graduating pediatric anesthesiology fellows. METHODS: Fifty pediatric anesthesiology fellows from 9 academic institutions in the United States were recruited for an advanced boot camp over a 2-year period. Training stations were developed using high-fidelity simulation, standardized patients, self-reflection modules, and facilitated discussions. The curriculum was evaluated using an anonymous survey that assessed knowledge, self-confidence, appropriateness of case-scenario complexity, and usefulness for transitioning into an independent practitioner on a Likert scale (1 = strongly disagree to 5 = strongly agree). Data points were expressed as the median and interquartile range (IQR). RESULTS: Ninety-eight percent of the fellows completed a survey. Fellow perceptions of the advanced boot camp was positive. The median scores (IQR) for knowledge, self-confidence, appropriateness of case complexity, and usefulness for transition in 2017 were 5 (3,5), 4.5 (3,5), 5 (3,5), and 5 (3,5), respectively, and 5 (3,5), 4.5 (3,5), 5 (4,5), and 5 (3,5), respectively, in 2018. The IQR in the assessment for an appropriate level of complexity for their level of training, narrowed in 2018 (4,5), when compared with 2017 (3,5). CONCLUSIONS: Fellow responses support the idea that the advanced boot camp provided tools and strategies for their transition. A narrowed IQR regarding the appropriate level of complexity of scenarios in 2018, when compared with 2017, might suggest an improvement in the curriculum.

The otolaryngologist's and anesthesiologist's collaborative role in a pandemic: A large quaternary pediatric center's experience with COVID-19 preparation and simulation.

There has been a rapid global spread of a novel coronavirus, the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), which originated in Wuhan China in late 2019. A serious threat of nosocomial spread exists and as such, there is a critical necessity for well-planned and rehearsed processes during the care of the COVID-19 positive and suspected patient to minimize transmission and risk to healthcare providers and other patients. Because of the aerosolization inherent in airway management, the pediatric otolaryngologist and anesthesiologist should be intimately familiar with strategies to mitigate the high-risk periods of viral contamination that are posed to the environment and healthcare personnel during tracheal intubation and extubation procedures. Since both the pediatric otolaryngologist and anesthesiologist are directly involved in emergency airway interventions, both specialties impact the safety of caring for COVID-19 patients and are a part of overall hospital pandemic preparedness. We describe our institutional approach to COVID-19 perioperative pandemic planning at a large quaternary pediatric hospital including operating room management and remote airway management. We outline our processes for the safe and effective care of these patients with emphasis on simulation and pathways necessary to protect healthcare workers and other personnel from exposure while still providing safe, effective, and rapid care.

Ultrasound-Guided, Continuous Brachial Plexus Blockade in a Neonate With Upper Extremity Limb Ischemia: A Case Report.

Regional anesthetic blocks, especially in-dwelling catheters, are infrequently used in neonates and infants. The following report describes a neonate with a gangrenous right upper extremity requiring multiple painful debridements over several weeks. A brachial plexus catheter was placed using ultrasound guidance, and a continuous infusion of a local anesthetic was used to provide postoperative pain control. After the initial procedures, bolus doses of a local anesthetic agent provided surgical anesthesia for dressing changes, thus obviating the need for multiple general anesthetics. This case demonstrates the potential efficacy of regional techniques to both treat pain and limit anesthetic exposures in neonates.

A Multidisciplinary Approach to a Pediatric Difficult Airway Simulation Course.

Objective To design and assess an advanced pediatric airway management course, through simulation-based team training and with multiple disciplines, to emphasize communication and cooperation across subspecialties and to provide a common skill set and knowledge base. Methods Trainees from anesthesiology, emergency medicine, critical care, pediatric surgery, and otolaryngology at a tertiary children's hospital participated in a 1-day workshop emphasizing airway skills and complex airway simulations. Small groups were multidisciplinary to promote teamwork. Participants completed pre- and postworkshop questionnaires. Results Thirty-nine trainees participated over the 3-year study period. Compared with their precourse responses, participants' postcourse responses indicated either agreement or strong agreement that the multidisciplinary format (1) helped in the development of team communication skills and (2) was preferred over single-discipline training. Improvement in confidence in managing critical airway situations and in advanced airway management skills was significant ( P < .05). Eighty-one percent of participants had improved confidence in following the hospital's critical airway protocol, and 64% were better able to locate advanced airway management equipment. Discussion Multiple subspecialists manage pediatric respiratory failure, where successful care requires complex handoffs and teamwork. Multidisciplinary education to teach advanced airway management, teamwork, and communication skills is practical and preferred by learners and is possible to achieve despite differences in experience. Future study is required to better understand the impact of this course on patient care outcomes. Implications for Practice Implementation of a pediatric difficult airway course through simulation-based team training is feasible and preferred by learners among multiple disciplines. A multidisciplinary approach exposes previously unrecognized knowledge gaps and allows for better communication and collaboration among the fields.

A Novel Technique for the Administration of Sub-Ambient Oxygen in the Operating Room.

Hypoplastic left heart syndrome (HLHS) is a common form of congenital heart disease with abnormal development of left-sided structures of the heart. As excessive pulmonary blood flow is common prior to palliative surgical procedures, therapeutic maneuvers may be required to decrease pulmonary blood flow and augment systemic cardiac output. Respiratory manipulations to optimize the ratio of pulmonary to systemic blood flow may include techniques to induce hypercarbia or the delivery of sub-ambient concentrations of oxygen (FiO2 less than 0.21). We present a neonate with HLHS who required intraoperative care during a stage I hybrid procedure. Options for the intraoperative administration of a sub-ambient concentration of oxygen are presented.

Double-Blind Randomized Placebo-Controlled Trial of Single-Dose Intravenous Acetaminophen for Pain Associated With Adenotonsillectomy in Pediatric Patients With Sleep-Disordered Breathing.

OBJECTIVES: Adequate pain control is an important component in the postoperative outcome for pediatric adenotonsillectomy patients with sleep-disordered breathing (SDB). Intravenous acetaminophen appears to be a favorable analgesic adjunct owing to its predictable pharmacokinetics and opioid-sparing effects; however, its role in pediatric adenotonsillectomy pain management remains unclear. METHODS: In this prospective, randomized, double-blinded, controlled study, subjects with the diagnosis of SDB, aged 2 to 8 years, who required extended postoperative admission, received intravenous acetaminophen (15 mg/kg) or saline placebo intraoperatively in addition to morphine (0.1 mg/kg) for postoperative surgical analgesia. Pain scores in the postanesthesia care unit (PACU) using the FLACC (Faces, Leg, Activity, Cry, Consolability) score were used to determine the need for supplemental analgesic agents in the PACU. The PACU time and time to the first request for pain medication on the inpatient ward were also measured. RESULTS: A total of 239 patients were included in the final data analysis (118 in the intravenous acetaminophen group and 121 in the saline placebo group). The 2 groups did not differ in the proportion of patients reaching FLACC scores = 4 in the PACU (p = 0.223); mean FLACC scores in the PACU (p = 0.336); mean PACU time (p = 0.883); or time to requesting pain medication on the inpatient ward (p = 0.640). CONCLUSIONS: A single intraoperative dose of intravenous acetaminophen did not alter the postoperative course of pediatric patients with SDB following adenotonsillectomy.

Tracheal extubation practices following adenotonsillectomy in children: effects on operating room efficiency between two institutions.

BACKGROUND: Adenotonsillectomy is one of the most commonly performed operative procedures in children. It is imperative to find the most efficient and cost-effective methods of practice to facilitate operating room management while maintaining patient safety. We investigated the efficiency of two different approaches of tracheal extubation in pediatric patients following adenotonsillectomy at two tertiary care pediatric hospitals with large surgical volumes. The primary aim of the study was to determine the difference in the operating room time according to the institutional practice of tracheal extubation in the postanesthesia care unit (PACU) as compared to the operating room. METHODS: After obtaining IRB approval, a retrospective chart review was performed over a 12-month period at two large, tertiary care children's hospitals including the first hospital, where patients undergo tracheal extubation in the operating room after completion of the surgical procedure and a second hospital, where patients are brought directly to the PACU and undergo tracheal extubation in the PACU by nurses, with immediate availability of the pediatric anesthesiology faculty. Patients ≤12 years of age undergoing adenotonsillectomy were eligible for inclusion in the study. Patients with significant cardiopulmonary disease or scheduled for recovery in the critical care unit were excluded. Patient demographics, total time in the operating room, surgical time, total time in the PACU, and, when applicable, time until tracheal extubation, were noted. RESULTS: The study cohort included 672 patients from the first hospital and 700 patients from the second hospital. Average operating room time was 17 min shorter at the first hospital than at the other, with most of the difference due to a reduction in the time between surgery end and transport from the operating room. PACU times were also 26 min shorter at the first hospital than at the second children's hospital. CONCLUSION: Tracheal extubation in the PACU is an efficient use of operating room time and resources.

General anesthesia with a native airway for patients with mucopolysaccharidosis type III.

BACKGROUND: Mucopolysaccharidosis type III is a progressive disease with worsening airway, pulmonary, and cardiac involvement that may complicate anesthetic care. AIM: To prospectively evaluate the incidence of airway issues and complications during magnetic resonance imaging (MRI) and lumbar puncture (LP) during general anesthesia with a native airway for patients with mucopolysaccharidosis type III. METHOD: The study was a part of the natural history study. Anesthesia was induced with sevoflurane, which was discontinued after intravenous access was obtained. General anesthesia with a native airway was provided by dexmedetomidine and propofol. Dexmedetomidine (0.5 µg·kg-1 ) was administered over 5 min followed by a continuous infusion at 0.5 µg·kg-1 ·h-1 . A continuous infusion of propofol was started at 150 µg·kg-1 ·min-1 . A bolus dose of propofol (1 mg·kg-1 ) was administered and the propofol infusion was increased as needed. Airway management and vital signs were recorded for the entire procedure until discharge. RESULTS: Twenty-five patients (6.9 ± 3.1 years) received total of 43 MRI and LP procedures in the cohort. No patient failed sedation. Although mask induction with sevoflurane was not clinically problematic, upper airway obstruction was noted during 14 procedures (33%). This required the application of continuous positive airway pressure, temporary oral airway placement, jaw thrust, or shoulder roll. Airway dynamics improved once the anesthesia was transitioned to intravenous anesthetic agents. Although a small shoulder roll was needed to improve airway patency for 11 cases (26%), a large shoulder roll tended to make the upper airway obstruction worse. Oxygen desaturation (≤90%) was noted during MRI in three cases (7%). CONCLUSION: A combination of dexmedetomidine and propofol provided effective general anesthesia with a native airway during the procedures. Although upper airway obstruction was noted, it resolved with simple airway maneuvers without further airway intervention.

Learning From Experience: Improving Early Tracheal Extubation Success After Congenital Cardiac Surgery.

OBJECTIVES: The many advantages of early tracheal extubation following congenital cardiac surgery in young infants and children are now widely recognized. Benefits include avoiding the morbidity associated with prolonged intubation and the consequences of sedation and positive pressure ventilation in the setting of altered cardiopulmonary physiology. Our practice of tracheal extubation of young infants in the operating room following cardiac surgery has evolved and new challenges in the arena of postoperative sedation and pain management have appeared. DESIGN: Review our institutional outcomes associated with early tracheal extubation following congenital cardiac surgery. PATIENTS: Inclusion criteria included all children less than 1 year old who underwent congenital cardiac surgery between October 1, 2010, and October 24, 2013. MEASUREMENTS AND MAIN RESULTS: A total of 416 patients less than 1 year old were included. Of the 416 patients, 234 underwent tracheal extubation in the operating room (56%) with 25 requiring reintubation (10.7%), either immediately or following admission to the cardiothoracic ICU. Of the 25 patients extubated in the operating room who required reintubation, 22 failed within 24 hours of cardiothoracic ICU admission; 10 failures were directly related to narcotic doses that resulted in respiratory depression. CONCLUSIONS: As a result of this review, we have instituted changes in our cardiothoracic ICU postoperative care plans. We have developed a neonatal delirium score, and have adopted the "Kangaroo Care" approach that was first popularized in neonatal ICUs. This provision allows for the early parental holding of infants following admission to the cardiothoracic ICU and allows for appropriately selected parents to sleep in the same beds alongside their postoperative children.