An open label pilot study of a dexmedetomidine-remifentanil-caudal anesthetic for infant lower abdominal/lower extremity surgery: The T REX pilot study.

BACKGROUND: Concern over potential neurotoxicity of anesthetics has led to growing interest in prospective clinical trials using potentially less toxic anesthetic regimens, especially for prolonged anesthesia in infants. Preclinical studies suggest that dexmedetomidine may have a reduced neurotoxic profile compared to other conventional anesthetic regimens; however, coadministration with either anesthetic drugs (eg, remifentanil) and/or regional blockade is required to achieve adequate anesthesia for surgery. The feasibility of this pharmacological approach is unknown. The aim of this study was to determine the feasibility of a remifentanil/dexmedetomidine/neuraxial block technique in infants scheduled for surgery lasting longer than 2 hours. METHODS: Sixty infants (age 1-12 months) were enrolled at seven centers over 18 months. A caudal local anesthetic block was placed after induction of anesthesia with sevoflurane. Next, an infusion of dexmedetomidine and remifentanil commenced, and the sevoflurane was discontinued. Three different protocols with escalating doses of dexmedetomidine and remifentanil were used. RESULTS: One infant was excluded due to a protocol violation and consent was withdrawn prior to anesthesia in another. The caudal block was unsuccessful in two infants. Of the 56 infants who completed the protocol, 45 (80%) had at least one episode of hypertension (mean arterial pressure >80 mm Hg) and/or movement that required adjusting the anesthesia regimen. In the majority of these cases, the remifentanil and/or dexmedetomidine doses were increased although six infants required rescue 0.3% sevoflurane and one required a propofol bolus. Ten infants had at least one episode of mild hypotension (mean arterial pressure 40-50 mm Hg) and four had at least one episode of moderate hypotension (mean arterial pressure <40 mm Hg). CONCLUSION: A dexmedetomidine/remifentanil neuraxial anesthetic regimen was effective in 87.5% of infants. These findings can be used as a foundation for designing larger trials that assess alternative anesthetic regimens for anesthetic neurotoxicity in infants.

Intraoperative neurophysiological monitoring team's communiqué with anesthesia professionals.

BACKGROUND AND AIMS: Intraoperative neurophysiological monitoring (IONM) is the standard of care during many spinal, vascular, and intracranial surgeries. High-quality perioperative care requires the communication and cooperation of several multidisciplinary teams. One of these multidisciplinary services is intraoperative neuromonitoring (IONM), while other teams represent anesthesia and surgery. Few studies have investigated the IONM team's objective communication with anesthesia providers. We conducted a retrospective review of IONM-related quality assurance data to identify how changes in the evoked potentials observed during the surgery were communicated within our IONM-anesthesia team and determined the resulting qualitative outcomes. MATERIAL AND METHODS: Quality assurance records of 3,112 patients who underwent surgical procedures with IONM (from 2010 to 2015) were reviewed. We examined communications regarding perioperative evoked potential or electroencephalography (EEG) fluctuations that prompted neurophysiologists to alert/notify the anesthesia team to consider alteration of anesthetic depth/drug regimen or patient positioning and analyzed the outcomes of these interventions. RESULTS: Of the total of 1280 (41.13%) communications issued, there were 347 notifications and 11 alerts made by the neurophysiologist to the anesthesia team for various types of neuro/orthopedic surgeries. Prompt communication led to resolution of 90% of alerts and 80% of notifications after corrective measures were executed by the anesthesiologists. Notifications mainly related to limb malpositioning and extravasation of intravenous fluid. CONCLUSION: Based on our institutions' protocol and algorithm for intervention during IONM-supported surgeries, our findings of resolution in alerts and notifications indicate that successful communications between the two teams could potentially lead to improved anesthetic care and patient safety.

Comparison of dexmedetomidine and chloral hydrate sedation for transthoracic echocardiography in infants and toddlers: a randomized clinical trial.

BACKGROUND: Procedural sedation using chloral hydrate is used in many institutions to improve the quality of transthoracic echocardiograms (TTE) in infants and young children. Chloral hydrate has limited availability in some countries, creating the need for alternative effective sedatives. OBJECTIVE: The aim of our study was to compare the effectiveness of two doses of intranasal dexmedetomidine vs oral chloral hydrate sedation for transthoracic echocardiography. METHODS: This is a randomized, prospective study of 150 children under the age of 3 years with known or suspected congenital heart disease scheduled for transthoracic echocardiography with sedation. Group CH received oral chloral hydrate 70 mg · kg(-1), group DEX2 received 2 µg · kg(-1) intranasal dexmedetomidine, and group DEX3 received 3 µg · kg(-1) intranasal dexmedetomidine. Acceptance of drug administration, sedation onset and duration, heart rate, and oxygen saturation, sonographer and parent satisfaction were recorded. RESULTS: All patients were successfully sedated for TTE. A second sedative dose (rescue) for failed single-dose sedation was required for 4% of patients after CH, none of the patients after DEX2, and 4% of patients after DEX3. Patients in group CH had an average heart rate decline of 22% during sedation, while group DEX2 decreased 27%, and group DEX3 23% (P = 0.2180). Mean time from administration of the sedative to final patient discharge was 96 min after CH, 83 min after DEX2, and 94 min after DEX3 (P = 0.1826). CONCLUSION: Intranasal dexmedetomidine 2 and 3 µg · kg(-1) were found to be as effective for TTE sedation as oral chloral hydrate with similar sedation onset and recovery time and heart rate changes in this study population.

Comparison of propofol and dexmedetomedine techniques in children undergoing magnetic resonance imaging.

BACKGROUND: Propofol (PRO) and dexmedetomidine (DEX) are commonly used to produce anesthesia and sedation for routine MRI procedures. Children with complex conditions often require much lengthy MRI for multi-body-part scans with frequent scanner coil changes and patient body reposition. This study compared PRO and DEX techniques on outcomes for the particular MRI setting with longer than 1 h duration. METHODS: 95 children, aged from 1 to 7 years, scheduled for MRI >75 min were randomly assigned to PRO or DEX group. After induced with sevoflurane, a loading dose of PRO (2 mg·kg(-1)) was administrated and followed by continuous infusion (200 µg·kg(-1) ·min(-1)); a loading dose of DEX (2 µg·kg(-1)) was administrated and followed by continuous infusion (2 µg·kg(-1) ·h(-1)). Patients received O(2) by nasal cannula. The observed outcomes were times for induction, MRI, emergence, and recovery, and total time (induction to discharge); MRI pauses from patient movement; incidence of technique failure and critical events; emergence and behavior in postanesthesia care unit (PACU); parental satisfaction; and arterial pressure (BP) and heart rate (HR) during anesthesia. RESULTS: PRO compared with DEX showed significantly less time for anesthesia induction (16.3 versus 24.2 min), emergence (21.2 versus 39.9 min), PACU (35.7 versus 62.5 min), and total time (135 versus 173 min) (all P < 0.001). There were significantly fewer pauses during MRI and lower failure rate to complete MRI in PRO versus DEX (0.22 versus 0.81, P = 0.01 and 1 versus 15, P < 0.001), less behavioral disturbances in PACU, and higher parental satisfaction in PRO versus DEX (P < 0.01). There were no critical events in either group: In PRO, mean BP during MRI (from 52 ± 8 to 58 ± mmHg) was significantly less than before anesthesia (80 ± 12 mmHg), while HR remained relatively constant (range of 97-103) at its baseline of 108 ± 21, but in DEX, mean BP remained unchanged (from 76 ± 12 to 78 ± 15) during anesthesia compared with before anesthesia (79 ± 14 mmHg), while HR decreased (74 ± 16 to 78 ± 15) during anesthesia from its baseline (102 ± 17). CONCLUSION: For children undergoing lengthy multicomponent MRI, the propofol technique yielded overall better outcomes than the dexmedetomedine technique in terms of timeliness, PACU emergence characteristics, and parental satisfaction.

Implementing checklists in the operating room.

Checklists have established themselves as a key safety process in the operating room environment. This paper describes the background and context of how checklists have evolved in medicine. It also highlights ongoing challenges with particular attention to the importance of nontechnical skills or human factors training with relation to checklist design, testing and implementation and ongoing coaching.

A comparison of inhalational inductions for children in the operating room vs the induction room.

BACKGROUND: There has been debate about the use of an induction room (IR) compared with an operating room (OR) for inhalational induction in children. The quality of the anesthesia induction between these two physical environments has not been studied previously. We sought to compare child distress, OR utilization and efficiency, and parental satisfaction and safety, between an IR and an OR. METHODS: In a prospective observational study, we studied 501 developmentally appropriate children ages 1-14 years, American Society of Anesthesiologists (ASA) physical status I-III, presenting for the inhalational induction of anesthesia, undergoing outpatient or outpatient-admit ENT surgery. Inductions were performed in an IR (IR group) or OR (OR group) with parent(s) present. Child behavioral compliance was assessed using the Induction Compliance Checklist (ICC), a validated observational scale from 0 to 10 consisting of 10 behaviors; an ICC score ≥4 was considered poor behavioral compliance. Times for transport, anesthesia start, ready for surgery, surgery finish, out of OR, and total case process times were recorded. OR utilization and OR efficiency was derived using these times. Data on number and experience of clinical providers were also collected. Parent satisfaction with the induction was measured using a satisfaction survey. Safety was measured by recording respiratory complications during induction. The chi-squared test was conducted to determine whether induction location was associated with level of behavioral compliance. A multivariable proportional odds model was used to control for risk factors. OR utilization and efficiency were analyzed using the Wilcoxon-Mann-Whitney test. RESULTS: There were no significant differences in ICC scores between the groups (P-value = 0.12). Anesthesia, nonoperative, and transport time were statistically less in the OR group when compared with the IR group, although total case process times were similar in both groups. While OR efficiency was significantly higher for the OR group (P-value = 0.0096), OR utilization did not differ between groups (P-value = 0.288). The OR group had a significantly higher number of anesthesia providers and a more experienced surgical team. Parents in the two groups were equally satisfied with their experience during induction, and none of the subjects had respiratory complications during the anesthesia induction. CONCLUSIONS: We found no differences in child distress, parent satisfaction, and respiratory complications between inductions conducted in the IR vs the OR. Differences in utilization, efficiency, and turnover were minimal and not operationally significant. Capital equipment, space, and staffing strategies should be key drivers in considerations for the use of IRs, and in the design of ORs with IRs.

Effect of increasing depth of dexmedetomidine anesthesia on upper airway morphology in children.

OBJECTIVE: This prospective study examines the dose-response effects of dexmedetomidine on upper airway morphology in children with no obstructive sleep apnea (OSA). AIM: To determine the effect of increasing doses of dexmedetomidine on static and dynamic magnetic resonance (MR) images of the upper airway in spontaneously breathing children with no OSA. BACKGROUND: General anesthetics and sedatives attenuate upper airway muscle activity, rendering the airway vulnerable to obstruction. Dose-response effects of dexmedetomidine on upper airway of children are not known. We prospectively examined the dose-response effects of dexmedetomidine on upper airway morphology in children. METHODS/MATERIALS: Increasing doses of dexmedetomidine was administered to 23 children scheduled for MR imaging of the brain while breathing spontaneously via the native airway. Static axial and dynamic sagittal midline MR ciné images of the upper airway were obtained during low (1 mcg.kg(-1).h(-1)) and high (3 mcg.kg(-1).h(-1)) doses of dexmedetomidine. The airway anteroposterior diameter, transverse diameter, and cross-sectional areas were measured manually by two independent observers. Static airway measurements were taken at the level of the nasopharyngeal airway (sagittal images) and retroglossal airway (RGA) (sagittal and axial images). Dynamic change in cross-sectional area of airway between inspiration and expiration was considered a measure of airway collapsibility. RESULTS: Static axial measurements of RGA did not change with increasing dose of dexmedetomidine. Most sagittal airway dimensions demonstrated clinically modest, although statistically significant, reductions with high dose compared to low dose dexmedetomidine. Although, the dynamic changes in nasopharyngeal and retroglossal area with respiration were marginally greater for high dose than for low dose dexmedetomidine, no subject exhibited any clinical evidence of airway obstruction. CONCLUSION: Upper airway changes associated with increasing doses of dexmedetomidine in children with no OSA are small in magnitude and do not appear to be associated with clinical signs of airway obstruction. Even though these changes are small, all precautions to manage airway obstruction should be taken when dexmedetomidine is used for sedation.