Clinical Outcomes Associated With Intranasal Dexmedetomidine Sedation in Children.

OBJECTIVES: We aimed to describe the quality of sedation and additional clinically-meaningful outcomes associated with different intranasal dexmedetomidine-based regimens in children undergoing nonpainful procedures. METHODS: A multicenter prospective observational study of children aged 2 months to 17 years undergoing intranasal dexmedetomidine sedation for MRI, auditory brainstem response testing, echocardiogram, EEG, or computed tomography scan. Regimens varied by dose of dexmedetomidine and use of adjunct sedatives. Quality of sedation was assessed using the Pediatric Sedation State Scale and by determining proportion of children who achieved an acceptable sedation state. Procedure completion, time-based outcomes, and adverse events were assessed. RESULTS: We enrolled 578 children across 7 sites. Median age was 2.5 years (interquartile range 1.6-3) and 37.5% were female. The most common procedures were auditory brainstem response testing (54.3%) and MRI (22.8%). The most common dose was 3 to 3.9 mcg/kg (55%), with 25.1% and 14.2% of children receiving oral or intranasal midazolam, respectively. Acceptable sedation state and procedure completion was achieved in 81.1% and 91.3% of children, and mean time to onset of sedation and total sedation time were 32.3 and 114.8 minutes, respectively. Twelve interventions were performed in 10 patients in response to an event; no patients required a serious airway, breathing, or cardiovascular intervention. CONCLUSIONS: Intranasal dexmedetomidine-based regimens can achieve acceptable sedation states and high rates of procedure completion in children undergoing sedation for nonpainful procedures. Our findings delineate clinical outcomes associated with intranasal dexmedetomidine-based sedation that can be used to guide the implementation and optimization of such regimens.

Anesthesia and pain management of pediatric cytoreductive surgery with hyperthermic intraperitoneal chemotherapy.

BACKGROUND: Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy has shown to improve survival in patients with extensive or refractory abdominal tumors of many different histologies. Postoperative pain control can be challenging as the surgical procedure is performed through a midline laparotomy incision from xiphoid to symphysis pubis, and patients are usually nothing by mouth for the first 8-10 postoperative days. AIMS: We present the anesthetic management and postoperative pain control strategies for cytoreductive surgery with hyperthermic intraperitoneal chemotherapy using a multimodal, opioid-sparing, and total intravenous anesthetic technique with a tunneled thoracic epidural. METHODS: A single institution retrospective review of anesthetic management, intraoperative fluid and blood administration, and postoperative pain control for pediatric patients undergoing cytoreductive surgery with hyperthermic intraperitoneal chemotherapy between July 2018 and December 2020 was conducted. We employed a novel anesthetic and analgesia protocol consisting of premedication with gabapentin followed by intraoperative infusions of propofol, dexmedetomidine, ketamine, and cisatracurium. A tunneled thoracic epidural catheter was placed for management of pain. RESULTS: We reviewed and analyzed the first 25 patient records. The most common diagnosis was desmoplastic small round cell tumor (n = 12). Median age of patients was 14 years (range 21 months-22 years). All patients were extubated in the operating room and no patients required reintubation. There were no incidences of acute kidney injury. Epidural infusions were used for a median of 8 days (range 2-14 days). Median postoperative intravenous opioid use (morphine equivalent) through postoperative day 10 was 0.02 mg/kg/day (range 0-0.86 mg/kg/day) administered for a median of 2 days (range 0-17 days). Nine patients (36%) did not require any intravenous opioids in the postoperative period. CONCLUSIONS: Utilizing a multimodal, opioid-sparing, total intravenous anesthetic technique in conjunction with a tunneled thoracic epidural catheter, we were able to avoid the need for postoperative mechanical ventilation and minimize both intraoperative and postoperative opioid requirements.

Anesthesia for Global General Thoracic Surgery.

Anesthesia in low-to-middle income countries (LMICs) is often provided by nonphysician anesthetists. The training and resources for anesthesia in LMICs are limited, and this must be evaluated when starting or expanding a thoracic surgery program in LMICs. The ability to access a patient's baseline pulmonary and cardiovascular status is often based on rudimentary studies and a thorough history and physical. Advance studies, such as echocardiograms, cardiovascular stress test, cardiac catherizations, pulmonary function tests, and MRIs, are often not available. Careful assessment of both preoperative patient selection, intraoperative ability to provide one-lung ventilation, and postoperative critical care management must be considered when surgical planning is occurring.

Virtual Reality after Surgery-A Method to Decrease Pain After Surgery in Pediatric Patients.

BACKGROUND: Virtual Reality (VR) is used as an effective tool for distraction and as an adjunct for pain management. This study was conducted to compare VR to standard iPad use after surgery and examine its effect on pain score and opioid consumption. METHODS: This was a randomized controlled study, with stratification by surgery type, age group (7-12yo, 13-18yo) and gender. Pain and anxiety were assessed with validated scales (STAI, FACES, VAS, FLACC) and outcomes were compared between each group. RESULTS: 50 of the 106 enrolled patients used the VR device. After adjusting for age, gender, and STAI, patients had a decreased FLACC score while using the VR device compared to the iPad group (odds ratio 2.95, P = .021). The younger patients were found to have lower FLACC scores while using the VR device (odds ratio 1.15, p=0.044); this finding was most significant when patients used the VR device for 20-30 minutes (odds ratio 1.67, P = .0003). Additionally, after adjusting for treatment group, gender, and STAI, the younger patients had higher odds of withdrawal or exclusion from the study (odds ratio 1.18, P = .021). No significant difference in opioid consumption between the groups was found. DISCUSSION: Virtual reality was well tolerated and more effective in decreasing pain during the immediate postoperative period than iPad use. Despite a slightly higher withdrawal rate, younger patients benefited more from the intervention.

High-dose dexmedetomidine for noninvasive pediatric procedural sedation and discharge readiness.

BACKGROUND: The University of North Carolina's (UNC) Pediatric Sedation Service adopted a noninvasive procedural sedation protocol that uses dexmedetomidine in children based on review of literature that reported fast recovery times and low morbidity. This study aimed to compare dexmedetomidine discharge readiness times observed at UNC with those previously published with a hypothesis that the discharge times at UNC are longer than those previously published. A secondary aim was to evaluate the safety profile of the protocol. METHODS: Pediatric outpatients (6 months-18 years) who received dexmedetomidine per protocol for a noninvasive procedure or study from January 2011 through April 2012 were included in this retrospective chart review. A total of 615 patient encounters were evaluated. Patients received bolus doses of 2 µg·kg(-1) over 10 min for up to three doses followed by a 1 µg·kg(-1) ·h(-1) infusion (group 1) or a 1.5 µg·kg(-1) ·h(-1) infusion (group 2). Primary outcomes included time to sedation, time to arousal, and time to discharge. RESULTS: No significant differences between the dosing groups were noted. Time to discharge was significantly shorter for group 1 (79 min) than for group 2 (101 min). The range of discharge times at UNC was 78.7-100.9 min compared to previous studies that report recovery times of 24.8-35.2 min. CONCLUSION: Dexmedetomidine arousal and discharge times observed at UNC were longer than anticipated when compared to literature. The safety profile of the drug was comparable to prior studies.