Comparison of blood pressure measurements in the upper and lower extremities versus arterial blood pressure readings in children under general anesthesia.

PURPOSE: To compare invasive blood pressure (IBP) readings obtained from an arterial cannula with non-invasive blood pressure (NIBP) measurements from oscillometric cuffs on the upper and lower extremities of infants and children under general anesthesia. PATIENTS AND METHODS: Patients under 10 years of age were enrolled in our study if they were to receive general anesthesia with planned placement of a radial arterial cannula. At 5 mins intervals, IBP was measured using a fluid-coupled pressure transducer and NIBP was measured with two oscillometers with appropriately sized cuffs placed on the upper arm and lower leg, for 10 readings per patient. RESULTS: The study enrolled 18 boys and 12 girls, ranging in age from 0 to 8 years. Across 300 data points, the absolute difference between the arm and invasive mean arterial pressure (MAP) measurements was 7±7 mmHg (range: 0-52 mmHg). The absolute difference between the leg and invasive MAP measurements was 8±8 mmHg (range: 0-52 mmHg). Although both non-invasive measurement sites demonstrated frequent deviation from invasive measurement, large deviations were more common when BP was measured at the leg (81 of 298 observations (27%) deviating by >10 mmHg) compared to the arm (60 of 300 observations (20%) deviating by >10 mmHg). CONCLUSION: The frequency of clinically significant NIBP deviation in children under general anesthesia supports the importance of IBP monitoring when hemodynamic fluctuations are likely and would be particularly detrimental. NIBP measured at the lower leg is more likely to result in clinically significant deviation from invasively measured MAP than NIBP values obtained from an upper arm.

The Impact of Transport Modality on Efficiency of Simulated Neonatal Endotracheal Intubation.

INTRODUCTION: Although the transport of neonates is generally safe, adverse events can occur where equipment is a contributing factor. The aims of the study were to explore how the types of neonatal intensive care unit bed in use could impact a simulated emergency endotracheal intubation and to identify future areas for training and education. METHODS: The efficiency of endotracheal intubation performed during simulated neonatal transport using 3 different transport modalities (closed incubator bed, open incubator bed, and open radiant warmer bed) was assessed. Twenty participants were enrolled. Outcomes included time to intubation, intubation success, and ease of mannequin access and were compared using Wilcoxon signed-rank tests and McNemar exact tests. RESULT: Median times to intubation were 59, 44, and 37 seconds with the incubator top closed, with the top open, and with the open radiant warmer bed, respectively. Intubation was slowest and subjective ease of access was most difficult with the incubator top closed. CONCLUSIONS: Experienced anesthesia providers had significantly greater difficulty with simulated emergency endotracheal intubation when performing neonatal transport with the incubator top closed compared with available alternative modes.

Association between anemia and postoperative complications in infants undergoing pyloromyotomy.

BACKGROUND: Although preoperative anemia has been suggested to predict postsurgical morbidity and mortality among infants <1 year of age, the data were drawn from heterogeneous patient cohorts including severely ill infants undergoing complex, high-risk procedures. We aimed to determine whether untreated preoperative anemia was associated with increased risk of postoperative complications in infants <1 year of age who underwent pyloromyotomy, a common and relatively simple surgery. METHODS: Infants <1 year of age undergoing pyloromyotomy were identified from the American College of Surgeons (ACS) National Surgical Quality Improvement Program-Pediatric database. Preoperative anemia was defined as a hematocrit ≤40% for infants 0-30 days of age and ≤30% for infants more than 30 days of age. Patients who received pre- or postoperative blood transfusions were excluded. RESULTS: We identified 2948 patients who met our inclusion criteria, of whom 843 were anemic (29%). The overall rate of complications in this cohort was 6%. The most common postoperative complications were readmission (97 cases), surgical site infection (43), reoperation (39), prolonged hospital stay (24), urinary tract infection (3), 30-day mortality (3) and cardiac arrest (2). We found no differences in the incidence of complications in anemic versus nonanemic patients on bivariate analysis or multivariable logistic regression (adjusted odds ratio = 1.2; 95% confidence interval: 0.8-1.7; P = 0.319). CONCLUSIONS: In relatively healthy infants undergoing pyloromyotomy, untreated preoperative anemia was not associated with postoperative compilations and should not be considered a significant risk factor. Level of evidence III.

Monitoring of Sugammadex Dosing at a Large Tertiary Care Pediatric Hospital.

INTRODUCTION: Anesthesiologists use sugammadex to reverse neuromuscular blockade (NMB) produced by rocuronium and vecuronium. Its mechanism involves encapsulation of the neuromuscular blocking agent. Sugammadex dosing is based on the depth of NMB, assessed by measuring the train-of-four (TOF). METHODS: We retrospectively reviewed procedures under general anesthesia in patients older than 1 year of age if they included sugammadex reversal of rocuronium-induced NMB. Documentation of TOF monitoring before and after reversal was noted, along with the dose of sugammadex administered. TOF was considered correctly documented if the anesthesia provider recorded the number of twitches before and after NMB reversal, or if they recorded 4 twitches before NMB reversal. We defined appropriate sugammadex dosing if it was within 10% of the recommended dose for the depth of NMB. We repeated this review after staff education and creating a reminder in the electronic health record system. RESULTS: We included 100 patients in the preintervention analysis, of whom 30% had correct TOF documentation. Among patients with TOF assessment before sugammadex administration, the dose was appropriate in 34 of 40 cases. In the postintervention analysis, we reviewed 75 cases and found that correct documentation improved to 45% (P = 0.024). Among postintervention cases with TOF documented before sugammadex administration, sugammadex dosing was appropriate in 62 patients. CONCLUSION: Documentation of TOF was low (30%) before intervention and improved to only 45% after the interventions, suggesting that additional interventions are needed. Even before the intervention, with or without TOF documentation, the dose of sugammadex was generally consistent with recommendations.

A comparison of supraglottic devices in pediatric patients.

BACKGROUND: When managing patients with a difficult airway, supraglottic airways (SGAs) have been used as rescue devices or to serve as a conduit for endotracheal intubation. The current study compares various clinical outcomes, including the bronchoscopic view of the glottis when using 2 SGAs, the Air-Q® laryngeal mask airway (LMA) and the i-gel® SGA, in pediatric patients. METHODS: Patients ≤18 years of age were prospectively randomized to receive either the Air-Q® LMA or the i-gel® SGA. Following SGA placement, a flexible fiberoptic bronchoscope was inserted through the SGA to visualize the glottis. Time taken to obtain the bronchoscopic view and place the SGA, and the ability to seal the airway at 20 cmH2O were compared. The bronchoscopic view obtained was graded as follows: 1) glottic aperture seen completely; 2) glottic aperture seen partially with visual obstruction <50%; 3) glottic aperture seen, but visual obstruction >50%; and 4) glottic aperture not seen. RESULTS: Fifty patients were enrolled and 48 (22/26 male/female) were included in the analysis. Median age was 13 years (IQR: 7, 16) and median weight was 49 kg (IQR: 25, 70). The Air-Q® LMA and i-gel® SGA groups did not differ in device placement time (median of 19 vs 21 seconds; 95% CI of difference in medians: - 2 to 7; P=0.331), the time to achieve fiberoptic view of the glottis (median of 25 vs 21 seconds; 95% CI of difference: - 9 to 8; P=0.489) or the grade of the bronchoscopic view of the airway. Eight Air-Q® and 6 i-gel® supraglottic devices sealed the airway at 20 cmH2O. DISCUSSION: The time required for successful placement of the SGA, the time required for bronchoscopic view, and the quality of bronchoscopic view through the Air-Q® LMA and the i-gel® SGA did not differ.

A study on the efficacy and safety of combining dental surgery with tonsillectomy in pediatrics.

PURPOSE: Few data exist on combining pediatric surgical procedures under a single general anesthetic encounter (general anesthesia). We compared perioperative outcomes of combining dental surgical procedures with tonsillectomy during one anesthetic vs separate encounters. METHODS: We classified elective tonsillectomy ± adenoidectomy and restorative dentistry as combined (group C) or separate (group S). Outcomes included anesthesia time, recovery duration, the need for overnight hospital stay, and postoperative complications. RESULTS: Patients aged 4±1 years underwent tonsillectomy and dental surgery in combination (n=7) or separately (n=27). No differences were noted in total anesthesia time (C: median: 150, interquartile range [IQR]: 99, 165 vs S: median: 109, IQR: 92, 132; 95% CI of difference in median: -58, +10 minutes; P=0.115) and total recovery time (C: median: 54, IQR: 40, 108 vs S: median: 72, IQR: 58, 109; 95% CI of difference in median: -16, +48 minutes; P=0.307). The need for overnight stay (C: 4 of 7, S: 20 of 27; P=0.394) did not differ between the groups. No postoperative complications were noted in either group. CONCLUSION: These preliminary data support the potential feasibility of combining dental procedures with tonsillectomy during a single anesthetic encounter. Such care may not only reduce costs but also limit parental work absences and increase convenience for patient families. When compared with procedures performed separately, combined procedures did not result in increased morbidity or significant changes in postoperative outcomes.