Clinical Use of the Pictorial Baxter Retching Faces Scale for the Measurement of Postoperative Nausea in Children.

BACKGROUND: Because nausea is difficult to evaluate in children, vomiting is used as the objective clinical end point in managing pediatric postoperative nausea and vomiting and postdischarge nausea and vomiting (PDNV). The recently developed pictorial Baxter Retching Faces (BARF) scale has content, construct, and convergent validity in quantifying pediatric nausea intensity. We determined its clinical usefulness in assessing pediatric postoperative nausea and vomiting and PDNV, establishing the lowest age associated with consistently reliable use, the score at which patients identify a need for therapy, and the minimum clinically relevant change in scores, and examined its test-retest reliability. METHODS: We obtained subject ratings of the severity of their nausea using the BARF and visual analog scales in the preoperative, postanesthesia care unit and postdischarge phases. Changes in nausea were rated on a 5-point Likert scale, along with responses to queries of a need for rescue antiemetics at these time points. RESULTS: Children ≥6 years of age had a consistently reliable ability to use the BARF scale (132/132 [100%] vs 59/76 [77.6%] for children ≥6 and <6 years of age, respectively, Fisher exact test, P < .001). The BARF scale had excellent performance in predicting patient-perceived need for antiemetics, with a score of 4 having 80.0% sensitivity and 85.6% specificity. The minimum clinically relevant difference in BARF scores was 1.47 (95% confidence interval, 0.84-2.1). The intraclass correlation coefficient was 0.56 (95% confidence interval, 0.34-0.73).The BARF scale identified 60 of 192 (31.3%) children as having postoperative nausea in the postanesthesia care unit, with severe nausea (score >6) in 13 (6.7%). Emesis occurred in 8 (4.1%). Rescue antiemetics were administered to 16 (8.3%), including 2 with severe emesis (≥3 episodes) but in only 2 of 11 (18.2%) with severe nausea without vomiting. PDNV was reported in 39 of the 99 who returned diaries (39.4%), with nausea in 34 (34.3%), severe nausea in 15 (15.2 %), and emesis in 16 (16.2%). CONCLUSIONS: The pictorial BARF scale is easy to use in the clinical setting by children ≥6 years of age, has a minimum clinically relevant difference of 1.47, with scores of 4 or higher associated with a patient-identified need for rescue antiemetics. Assessment of postoperative nausea by the BARF scale has shown that clinically significant nausea occurs frequently in children but is not always treated unless accompanied by vomiting.

A comparison of the Truview PCD and the GlideScope Cobalt AVL video-laryngoscopes to the Miller blade for successfully intubating manikins simulating normal and difficult pediatric airways.

BACKGROUND: Video-laryngoscopes provide better glottic visualization, but tracheal intubation times are longer, compared to conventional direct laryngoscopy in adult patients with normal airways. The objective of this randomized crossover study was to compare times to successful tracheal intubation with video-laryngoscope and direct laryngoscopy in manikins simulating infants with normal and abnormal airways. METHODS: Thirty experienced pediatric anesthesia practitioners performed tracheal intubation in three distinct manikins simulating infants with (i) a normal airway (ii), an anterior larynx, and (iii) the Pierre Robin sequence anatomy. These were performed using a standard Miller #1 blade, the GlideScope Cobalt AVL, and the Truview PCD video-laryngoscope, first in a normal neck and then an unstable cervical spine scenario (18 intubations/subject). The specific assigned order of devices and manikins for each participant was based on a three by three Latin square design to minimize carryover effects between the model and the device. Predefined times to intubation were analyzed by Cox regression model and Kaplan-Meier survival curves. RESULTS: Intubation times were shorter and success rates were higher with the Miller blade compared to either the GlideScope or the Truview videoscope in all three manikins in both scenarios, but did not differ between the GlideScope and the Truview devices. Improved intubation times and success rates in the unstable cervical spine scenario compared to the normal neck were attributed to learning effects with sequential intubation. CONCLUSION: Higher success rates and shorter intubation times with the Miller blade compared to either video-laryngoscope may reflect greater experience with direct laryngoscopy, need for more video-laryngoscopy training, or result from the manikin design. Individual practitioners may differ in their preference of device for intubating a child with anticipated difficult airway based on their previous experiences, self-assessment of their skills, and evaluation of the child's airway anatomy.

Retrospective Comparison of Intranasal Dexmedetomidine and Oral Chloral Hydrate for Sedated Auditory Brainstem Response Exams.

OBJECTIVE: Satisfactory conditions for auditory brainstem responses (ABR) screening tests for pediatric hearing loss are usually achieved with oral chloral hydrate (CH) sedation. When the US manufacture of this drug was discontinued for business reasons, we developed an alternative sedation regimen using intranasal dexmedetomidine (IN DEX) 4 µg/kg. This institutional review board-approved retrospective study compared the efficacy and adverse effect profiles of these 2 sedative regimens. METHODS: Medical records of children receiving oral CH or IN DEX for ABR were surveyed for demographic data and times from sedative administration to start and completion of the ABR procedure and recovery times. We also noted if the examination was completed with or without interruptions, failed for inadequate sedation, and if predefined cardiorespiratory adverse events occurred. RESULTS: In the IN DEX cohort, the examination could be completed more frequently with a single dose of medication (P = .002). Satisfactory sedation in these patients permitted an earlier start of both the ABR examination and recovery to the awake status (P < .001 and < .045, respectively). Hypoxia requiring oxygen therapy was more frequent in the CH group. CONCLUSIONS: This retrospective study found that IN DEX provides effective sedation for ABR examinations, with the benefits of an ability to begin the test sooner and complete the examination with a single dose, in addition to a decreased incidence of hypoxemia. A randomized controlled trial should test the hypothesis that the IN DEX technique is superior to the well-established standard oral CH regimen.

A prospective, randomized, double-blind trial of intranasal dexmedetomidine and oral chloral hydrate for sedated auditory brainstem response (ABR) testing.

BACKGROUND: Dexmedetomidine is increasingly used by various routes for pediatric sedation. However, there are few randomized controlled trials comparing the efficacy of dexmedetomidine to other commonly used sedatives. AIM: To compare the efficacy of sedation with intranasal dexmedetomidine to oral chloral hydrate for auditory brainstem response (ABR) testing. METHODS: In this double-blind, double-dummy study, children undergoing ABR testing were randomized to receive intranasal dexmedetomidine 3 mcg · kg(-1) plus oral placebo (Group IN DEX) or oral chloral hydrate 50 mg · kg(-1) plus intranasal saline placebo (Group CH). We recorded demographic data, times from sedative administration to start and completion of testing, quality of sedation, occurrence of predefined adverse events, discharge times, and return to baseline activity on the day of testing. RESULTS: Testing completion rates with a single dose of medication were higher in the IN DEX group (89% vs 66% for CH, odds ratio with 95% confidence intervals 4.04 [1.3-12.6], P = 0.018). The median [95% CI)] time to successful testing start was shorter (25 [20-29] min vs 30 [20-49] min for IN DEX and CH, respectively, log rank test P = 0.02) and the proportion of children whose parents reported a return to baseline activity on the day of testing was greater for the IN DEX than the CH group (89% vs 64%, OR [95% CI] 4.71 [1.34-16.6], P = 0.02). There were no major adverse events in either group and no significant differences in the incidence of minor events. CONCLUSION: Intranasal dexmedetomidine is an effective alternative to oral chloral hydrate sedation for ABR testing, with the advantages of a higher incidence of testing completion with a single dose, shorter time to desired sedation level, and with significantly more patients reported to return to baseline activity on the same day.

Prenatal Identification of Pierre Robin Sequence: A Review of the Literature and Look towards the Future.

Fetal ultrasonography is an important tool used to prenatally diagnose many craniofacial conditions. Pierre Robin sequence (PRS) is a rare congenital deformation characterized by micrognathia, glossoptosis, and airway obstruction. PRS can present as a perinatal emergency when the retropositioned tongue obstructs the airway leading to respiratory compromise. More predictable and reliable diagnostic studies could help the treating medical team as well as families prepare for these early airway emergencies. The medical literature was reviewed for different techniques used to prenatally diagnose PRS radiologically. We have reviewed these techniques and suggested a possible diagnostic pathway to consistently identify patients with PRS prenatally.

Comparison of pediatric perioperative risk assessment by ASA physical status and by NARCO-SS (neurological, airway, respiratory, cardiovascular, other-surgical severity) scores.

BACKGROUND: ASA-PS is a widely used perioperative health assessment method, but with poor reproducibility. A novel objective, pediatric-specific risk classification system based on Neurological, Airway, Respiratory, Cardiovascular, Other categories and Surgical Severity (NARCO-SS) has been validated in only one US center. OBJECTIVE: Independent external validation of the NARCO-SS and comparison with the ASA-PS in predicting perioperative outcomes. METHODS: Preoperative ASA-PS and NARCO-SS scores were assigned to 387 children by pediatric anesthesia consultants at a tertiary care center in India and predefined perioperative adverse events and escalation of care recorded. Spearman's correlations determined the relationship between outcomes and scores and kappa statistics for interobserver reliability. The predictive performance of the ASA-PS and NARCO-SS was evaluated by the area under the receiver operating characteristics curves (AUC-ROC) for discrimination and Pearson's chi-square for calibration. RESULTS: NARCO-SS and ASA scores had significant Spearman's correlation coefficients with perioperative outcomes and moderate interobserver reliability. The NARCO-SS showed greater discrimination than the ASA-PS (AUC-ROC 0.778 vs 0.710 for escalation of care and 0.822 vs 0.724 for adverse events, P < 0.01). However, both scores had poor calibration (Pearson's chi-square, P < 0.0001). Individual NARCO-SS categories for neurological and airway lacked statistically significant Spearman's correlations. CONCLUSIONS: NARCO-SS is a valid risk stratification tool that is better than the ASA-PS in discriminating children with adverse perioperative outcomes. The poor calibration of both scores suggests neither can reliably predict perioperative outcomes in individual patients. Modification of neurological and airway categories may improve the predictive accuracy of the NARCO-SS.

Perioperative respiratory complications following awake and deep extubation in children undergoing adenotonsillectomy.

BACKGROUND: Perioperative respiratory complications after adenotonsillectomy (T&A) are common and have been described to occur more frequently in children below 3 years of age, those with cranio-facial abnormalities, Down syndrome, obstructive sleep apnea, morbid obesity, and failure to thrive. AIMS: To investigate the association between awake vs deep tracheal extubation and perioperative respiratory conditions. RESULTS: The primary outcome was any perioperative respiratory complication. Major complications included the need for airway reinstrumentation, continuous or bi-level positive airway pressure (CPAP or BiPAP) and ventilation, or pharmacologic intervention for managing airway obstruction. Minor respiratory complications included persistent hypoxemia defined as oxygen saturation (SpO2 ) <92% for ≥30 s or postoperative oxygen dependence for hypoxemia for ≥15 min. There was no statistically significant difference in the incidence of any perioperative respiratory complication in children undergoing an awake vs deep extubation (18.5% and 18.9% for awake and deep extubation, respectively (P = 0.93)). Only low weight (≤14 kg) was associated with increased perioperative respiratory complications (P = 0.005). In this study, factors found not to be statistically significant with perioperative respiratory complications included age; presence of Down syndrome, cranio-facial abnormality, or cerebral palsy; obstructive sleep apnea confirmed by polysomnography; diagnosis of obstructive sleep apnea by clinical history; presence of an upper respiratory tract infection (URI) within 2 weeks of presentation; history of reactive airway disease; status at extubation; endtidal sevoflurane and carbon dioxide concentrations at extubation; total intraoperative opioids administered in morphine equivalents (mg·kg(-1) ); administration of propofol at extubation; and intraoperative administration of an anticholinergic drug. CONCLUSIONS: There was no difference in the incidence of perioperative respiratory complications in children undergoing a T&A following an awake vs deep extubation. Only weight ≤14 kg was associated with increased perioperative respiratory complications.

A multicenter, randomized, double-blind placebo-controlled, single dose trial of the safety and efficacy of intravenous ibuprofen for treatment of pain in pediatric patients undergoing tonsillectomy.

BACKGROUND: Tonsillectomy is one of the most common pediatric procedures in the United States. An optimal perioperative pain control regimen remains a challenge. Intravenous ibuprofen administered at induction of anesthesia may be a safe and efficacious option for postoperative tonsillectomy pain. OBJECTIVES: To determine whether preoperative administration of intravenous ibuprofen (IV-ibuprofen) can significantly decrease the number of doses of postoperative fentanyl when compared with placebo in pediatric tonsillectomy surgical patients. METHODS: This was a multicenter, randomized, double-blind placebo-controlled trial conducted at six hospitals in the United States. A total of 161 pediatric patients aged 6-17 years undergoing tonsillectomy were randomized to receive either a single preoperative dose of 10 mg·kg(-1) IV-ibuprofen or placebo (normal saline). Postoperative pain was managed with intravenous fentanyl (0.5 µg·kg(-1)) on an as needed basis when the visual analog scale (VAS) was >30 mm and deemed appropriate by recovery room nurse/physician. The primary endpoint was the number of doses and amount of postoperative fentanyl administered postoperatively for rescue analgesia. RESULTS: There was a significant reduction in the number of postoperative doses and the amount of fentanyl administered after surgery in the IV-ibuprofen group compared with the placebo group (P = 0.021). There were no differences in the time to first analgesia request or the number of patients who required postoperative analgesia. There were no significant differences in the incidence of serious adverse events, surgical blood loss (P = 0.662), incidence of postoperative bleeding, or a need for surgical re-exploration between the treatment groups. CONCLUSION: Administration of IV-ibuprofen, 10 mg·kg(-1) , significantly reduced fentanyl use in pediatric tonsillectomy patients.

A retrospective study of multimodal analgesic treatment after laparoscopic appendectomy in children.

BACKGROUND: Laparoscopic appendectomy is a common emergency pediatric surgery procedure accompanied by substantial pain (pain scores >4 for >60% of the time) in 33% of these patients. We introduced a bundle of pain management interventions including local anesthetic infiltration at the incision site, intravenous (IV) opioids by patient-controlled analgesia (PCA), and scheduled doses of IV ketorolac and oral acetaminophen/hydrocodone. OBJECTIVES: To evaluate the effect of these pain management interventions on pain control after laparoscopic appendectomy. METHODS: We retrospectively studied pain in 206 children above 7 years of age undergoing laparoscopic appendectomy from December 2011 to February 2012 at our institution. We extracted data on patient demographics, duration of anesthesia and surgery, intraoperative opioids, local anesthetic infiltration, surgical procedure reports, along with pain scores, postoperative PCA use, and opioid-related complications and hospital stays. Patients were divided into two groups - simple appendicitis without peritonitis and appendicitis with generalized peritonitis. RESULTS: The incidence of substantial pain when the multimodal regimen was used was 12%, which is significantly lower than earlier reports (Fisher's exact test P < 0.001). Patients with generalized peritonitis experienced more pain, consumed more opioids, had more unmet PCA demands, and a higher incidence of respiratory depression compared with those with simple appendicitis. CONCLUSION: The multimodal regimen of local anesthetic infiltration, opioid by PCA, NSAIDs, and oral acetaminophen/hydrocodone reduced the incidence of substantial pain. Additional studies are required to identify subgroups of patients with minimal opioid requirements who can benefit from modifications of this regimen.

Comparison of the development of performance skills in ultrasound-guided regional anesthesia simulations with different phantom models.

BACKGROUND: Ultrasound-guided regional anesthesia (UGRA) skills are traditionally obtained by supervised performance on patients, but practice on phantom models improves success. Currently available models are expensive or use perishable products, for example, olive-in-chicken breasts (OCB). We constructed 2 inexpensive phantom (transparent and opaque) models with readily available nonperishable products and compared the process of learning UGRA skills by novice practitioners on these models with the OCB model. METHODS: Three experts first established criteria for a satisfactory completion of the simulated UGRA task in the 3 models. Thirty-six novice trainees (<20 previous UGRA experience) were randomly assigned to perform a UGRA task on 1 of 3 models-the transparent, opaque, and OCB models, where the hyperechoic target was identified, a needle was advanced to it under ultrasound guidance, fluid was injected, and images were saved. We recorded the errors during task completion, number of attempts and needle passes, and the time for target identification and needle placement until the predetermined benchmark of 3 consecutive successful UGRA simulations was accomplished. RESULTS: The number of errors, needle passes, and time for task completion per attempt progressively decreased in all 3 groups. However, failure to identify the target and to visualize the needle on the ultrasound image occurred more frequently with the OCB model. The time to complete simulator training was shortest with the transparent model, owing to shorter target identification times. However, trainees were less likely to agree strongly that this model was realistic for teaching UGRA skills. CONCLUSIONS: Training on inexpensive synthetic simulation models with no perishable products permits learning of UGRA skills by novices. The OCB model has disadvantages of containing potentially infective material, requires refrigeration, cannot be used after multiple needle punctures, and is associated with more failures during simulated UGRA. Direct visualization of the target in the transparent model allows the trainee to focus on needle insertion skills, but the opaque model may be more realistic for learning target identification skills required when UGRA is performed on real patients in the operating room.

Postoperative analgesic and behavioral effects of intranasal fentanyl, intravenous morphine, and intramuscular morphine in pediatric patients undergoing bilateral myringotomy and placement of ventilating tubes.

BACKGROUND: Bilateral myringotomy and placement of ventilating tubes (BMT) is one of the most common pediatric surgical procedures in the United States. Many children who undergo BMT develop behavioral changes in the postanesthesia care unit (PACU) and require rescue pain medication. The incidence of these changes is lower in children receiving intraoperative opioids by the nasal, IM, or IV route compared with placebo. However, there are no data to indicate which route of administration is better. Our study was designed to compare the immediate postoperative analgesic and behavioral effects of 3 frequently used intraoperative techniques of postoperative pain control for patients undergoing BMT under general anesthesia. METHODS: One hundred seventy-one ASA physical status I and II children scheduled for BMT were randomized into 1 of 3 groups: group 1-nasal fentanyl 2 µg/kg with IV and IM saline placebo; group 2-IV morphine 0.1 mg/kg with nasal and IM placebo; or group 3-IM morphine 0.1 mg/kg with nasal and IV placebo. All subjects received a standardized general anesthetic with sevoflurane, N(2)O, and O(2) and similar postoperative care. The primary end point of the study was the pain scores measured by the Faces, Legs, Activity, Cry, and Consolability (FLACC) scale in the PACU. RESULTS: There were no significant differences in peak FLACC pain among the 3 groups (mean [95% CI] 2.0 [1.2-2.8] for intranasal fentanyl, 2.7 [1.7-3.6] for IV morphine, and 2.9 [2.1-3.7] for IM morphine, respectively). There were no differences in the scores on the Pediatric Anesthesia Emergence Delirium (PAED) scale, incidence of postoperative emergence delirium (PAED score ≥ 12), emesis, perioperative hypoxemia, or need for airway intervention, and postoperative rescue analgesia. There were also no differences in the duration of PACU stay or parental satisfaction among the groups. CONCLUSION: In this double-blind, double-dummy study, there was no difference in the efficacy of intranasal fentanyl, IM and IV morphine in controlling postoperative pain and emergence delirium in children undergoing BMT placement. The IM route is the simplest and avoids the potential for delays to establish vascular access for IV therapy and the risks of laryngospasm if intranasal drugs pass through the posterior nasopharynx and irritate the vocal cords.

The effect of obesity on the ED(95) of propofol for loss of consciousness in children and adolescents.

INTRODUCTION: Anesthesiologists face a dilemma in determining appropriate dosing of anesthetic drugs in obese children. In this study we determined the dose of propofol that caused loss of consciousness in 95% (ED(95)) of obese and nonobese children as determined by loss of eye lash reflex. METHODS: Forty obese (body mass index [BMI] > 95th percentile for age and gender) and 40 normal weight (BMI 25th to 84th percentile) healthy ASA 1 to 2 children ages 3 to 17 years presenting for surgical procedures were studied using a biased coin design. The primary endpoint was loss of lash reflex at 20 seconds after propofol administration. The first patient in each group received 1.0 mg/kg of IV propofol, and subsequent patients received predetermined propofol doses based on the lash reflex response in the previous patient. If the lash reflex was present, the next patient received a dose increment of 0.25 mg/kg. If the lash reflex was absent, the next patient was randomized to receive either the same dose (95% probability) or a dose decrement of 0.25 mg/kg (5% probability). The ED(95) and 95% confidence intervals (CI) were calculated using isotonic regression and bootstrapping methods respectively. RESULTS: The ED(95) of propofol for loss of lash reflex was significantly lower in obese pediatric patients (2.0 mg/kg, approximate 95% CI, 1.8 to 2.2 mg/kg) in comparison with nonobese patients (3.2 mg/kg, approximate 95% CI, 2.7 to 3.2 mg/kg), P ≤ 0.05. DISCUSSION: A simple approach to deciding what dose of propofol should be used for induction of anesthesia in children ages 3 to 17 years is to first establish the child's BMI on readily available gender-specific charts. Obese children (BMI >95th percentile for age and gender) require a lower weight-based dose of propofol for induction of anesthesia, than do normal-weight children.

Development and validation of a pictorial nausea rating scale for children.

OBJECTIVE: The lack of a widely used, validated measure limits pediatric nausea management. The goal of this study was to create and validate a pictorial scale with regular incremental levels between scores depicting increasing nausea intensity. METHODS: A pictorial nausea scale of 0 to 10 with 6 faces (the Baxter Retching Faces [BARF] scale) was developed in 3 stages. The BARF scale was validated in emergency department patients with vomiting and in healthy patients undergoing day surgery procedures. Patients were presented with visual analog scales for nausea and pain, the pictorial Faces Pain Scale-Revised, and the BARF scale. Patients receiving opioid analgesics or antiemetic agents had their pain and nausea assessed before and 30 minutes after therapy. Spearman's ρ correlation coefficients were calculated. A Wilcoxon matched-pair rank test compared pain and nausea scores before and after antiemetic therapy. RESULTS: Thirty oncology patients and 15 nurses participated in the development of the scale, and 127 patients (52, emergency department; 75, day surgery) ages 7 to 18 years participated in the validation. The Spearman ρ correlation coefficient of the first paired BARF and visual analog scale for nausea scores was 0.93. Visual analog scales for nausea and BARF scores were significantly higher in patients requiring antiemetic agents (P = .0001) and decreased significantly after treatment (P = .0002), while posttreatment VAS (P = .20) and FPSR scores (P =.47) for patients receiving only antiemetic agents did not [corrected]. CONCLUSIONS: We describe the development of a pictorial scale with beginning evidence of construct validity for a self-report assessment of the severity of pediatric nausea. The scale had convergent and discriminant validity, along with an ability to detect change after treatment.

Pediatric obesity: observed impact in the ambulatory surgery setting.

More obese children are presenting for surgery, reflecting an increase in comorbidities requiring surgery or an increased prevalence in the community. The objectives of this study were to determine the prevalence of obesity in our pediatric surgery patient population, detect ethnic disparities amongst this cohort of obese patients and also to determine any increase in pediatric obesity related comorbidities requiring surgery. Day surgery patients between ages 3 and 17 years were prospectively studied over a 3-month period. The proportion of obese children, demographics, and surgical procedures were determined. Of the 1559 patients analyzed, 312 (20%) were obese. Close to half of this subset of children were of Hispanic descent. Adenotonsillectomy was the most common surgery; however, the case distribution of this cohort was similar to our operating room database. Prevalence of pediatric obesity in our day surgery patients therefore reflects that of the community and has not resulted in an increase in related comorbidities requiring surgery. Longitudinal studies to assess the incidence of pediatric obesity related complications will be beneficial.

Bradycardia during induction of anesthesia with sevoflurane in children with Down syndrome.

BACKGROUND: Bradycardia is a complication associated with inhaled induction of anesthesia with halothane in children with Down syndrome. Although bradycardia has been reported after anesthetic induction with sevoflurane in these children, the incidence is unknown. OBJECTIVES: In this study we compared the incidence and characteristics of bradycardia after induction of anesthesia with sevoflurane in children with Down syndrome to healthy controls. METHODS: We reviewed electronic anesthetic records of 209 children with Down syndrome and 268 healthy control patients who had inhaled induction of anesthesia with sevoflurane over an 8-year period. Data extracted from the medical record included demographics, history of congenital heart disease, heart rate, oxyhemoglobin saturation, expired sevoflurane concentrations, arterial blood pressure, and any treatment of bradycardia during the first 360 seconds after the start of induction of anesthesia. Bradycardia and hypotension were defined as heart rate and arterial blood pressure below the critical limits recommended for activating a pediatric rapid response team to the bedside of a hospitalized child for quick intervention. Factors associated with bradycardia were identified in a univariate analysis. A step-wise backward multiple logistic regression model was used to identify independent factors. Differences between the 2 groups were computed using Fisher's exact test or χ(2) tests for categorical data and t tests for continuous data. RESULTS: Univariate analysis demonstrated that Down syndrome, low ASA physical status, congenital heart disease, and mean sevoflurane concentrations were factors associated with bradycardia. However, multivariate analysis showed that only Down syndrome and low ASA physical status remained as independent factors associated with bradycardia. CONCLUSION: Bradycardia during anesthetic induction with sevoflurane was common in children with Down syndrome, with and without a history of congenital heart disease.

The effect of intraoperative dexmedetomidine on postoperative analgesia and sedation in pediatric patients undergoing tonsillectomy and adenoidectomy.

BACKGROUND: The immediate postoperative period after tonsillectomy and adenoidectomy, one of the most common pediatric surgical procedures, is often difficult. These children frequently have severe pain but postoperative airway edema along with increased sensitivity to the respiratory-depressant effects of opioids may result in obstructive symptoms and hypoxemia. Opioid consumption may be reduced by nonsteroidal antiinflammatory drugs, but these drugs may be associated with increased bleeding after this operation. Dexmedetomidine has mild analgesic properties, causes sedation without respiratory depression, and does not have an effect on coagulation. We designed a prospective, double-blind, randomized controlled study to determine the effects of intraoperative dexmedetomidine on postoperative recovery including pain, sedation, and hemodynamics in pediatric patients undergoing tonsillectomy and adenoidectomy. METHODS: One hundred nine patients were randomized to receive a single intraoperative dose of dexmedetomidine 0.75 microg/kg, dexmedetomidine 1 microg/kg, morphine 50 microg/kg, or morphine 100 microg/kg over 10 minutes after endotracheal intubation. RESULTS: There were no significant differences among the 4 groups in patient demographics, ASA physical status, postoperative opioid requirements, sedation scores, duration of oxygen supplementation in the postanesthetic care unit, and time to discharge readiness. The median time to first postoperative rescue analgesic was similar in patients receiving dexmedetomidine 1 microg/kg and morphine 100 microg/kg, but significantly longer compared with patients receiving dexmedetomidine 0.75 microg/kg or morphine 50 microg/kg (P < 0.01). In addition, the number of patients requiring >1 rescue analgesic dose was significantly higher in the dexmedetomidine 0.75 microg/kg group compared with the dexmedetomidine 1 microg/kg and morphine 100 microg/kg groups, but not the morphine 50 microg/kg group. Patients receiving dexmedetomidine had significantly slower heart rates in the first 30 minutes after surgery compared with those receiving morphine (P < 0.05). There was no significant difference in sedation scores among the groups. CONCLUSIONS: The total postoperative rescue opioid requirements were similar in tonsillectomy patients receiving intraoperative dexmedetomidine or morphine. However, the use of dexmedetomidine 1 microg/kg and morphine 100 microg/kg had the advantages of an increased time to first analgesic and a reduced need for additional rescue analgesia doses, without increasing discharge times.

Effect of age and sedative agent on the accuracy of bispectral index in detecting depth of sedation in children.

OBJECTIVE: This study evaluated age- and sedative agent-related differences in bispectral index across observed sedation levels in a large sample of children < 18 years of age. PATIENTS AND METHODS: With institutional review board approval and waiver of consent, data from 4 independently conducted studies were combined in a secondary analysis of 3373 observations from 248 children aged 1 month to 18 years. In these studies, bispectral index values of sedated children were recorded in a blinded fashion, and sedation depth was scored using the University of Michigan Sedation Scale (UMSS). Bispectral index was evaluated across UMSS scores for several age groups and during use of each sedative agent (with/without opioids). RESULTS: There was a moderate inverse correlation between bispectral index and UMSS for all age groups. There were significant differences in bispectral index across UMSS and between each sedation level except UMSS 3 to 4 in all the age groups and UMSS 0 to 1 in infants. The mean bispectral index and the cutoff values on the receiver-operating-characteristic curve for mild, moderate, and deep sedation were significantly lower in infants < or = 6 months compared with older children at each sedation level. Bispectral index was reasonably sensitive and specific in differentiating mild (UMSS 0-1) from deeper (UMSS 3-4) levels of sedation but poorly differentiated between moderate and deep levels of sedation in all age groups. There was a moderate correlation between bispectral index and UMSS during the use of chloral hydrate, pentobarbital, propofol, and midazolam but poor correlation during ketamine or opioid use. Bispectral index values were significantly lower during deep sedation with propofol and pentobarbital compared with midazolam and chloral hydrate. CONCLUSIONS: Our findings suggest that, although bispectral index may differentiate light from deep sedation in most children, bispectral index must be interpreted cautiously in sedated children, with particular consideration given to patient age and use of sedative agents.

Validation of the bispectral index monitor for measuring the depth of sedation in children.

The Bispectral Index (BIS) is an empirically calibrated number derived from adult electroencephalograph data that correlates with the depth of sedation in adults. We tested the hypothesis that the BIS score is a valid measure of the depth of pediatric sedation in a study designed to avoid limitations of a previously published report. BIS values from 96 healthy ASA physical status I-II children aged 1-12 yr undergoing sedation were continually recorded and electronically transferred to a computer. Two independent observers blinded as to BIS score evaluated sedation using the Observer's Assessment of Alertness/Sedation (OAA/S) and the University of Michigan Sedation Scale (UMSS) at 3-5 min intervals. There was a significant correlation between BIS and UMSS and between BIS and OAA/S by both the Spearman's rank correlation test and by prediction probability (P < 0.001). In children <6 yr, there was a significant correlation between BIS and the clinical sedation scores for subgroups undergoing invasive and noninvasive procedures (P < 0.001). There was also good agreement between the 2 independent observers who assessed clinical sedation scores (kappa = 0.51, P < 0.001). We conclude that the BIS monitor is a quantitative, nondisruptive and easy to use depth of sedation monitor in children.

Blood glucose control during selective arterial stimulation and venous sampling for localization of focal hyperinsulinism lesions in anesthetized children.

Surgical management of congenital hyperinsulinism is improved by accurate localization of small, focal dysregulated pancreatic lesions using the arterial stimulation and venous sampling (ASVS) test, which can demonstrate increased hepatic venous insulin concentrations after selective arterial injections of calcium. However, anesthesia-related increases in blood glucose can induce insulin secretion, making it difficult to interpret ASVS test data. In this retrospective study, we examined the effect of anesthetic interventions on blood glucose concentrations in 68 children undergoing ASVS testing. We considered only the glucose concentrations observed before calcium stimulation in the final analysis. The choice of drugs for induction (sevoflurane, propofol, or thiopentone), maintenance inhaled anesthetics (sevoflurane, desflurane, or isoflurane), and the use of caudal epidural bupivacaine were not associated with significant differences in the mean blood glucose concentration before ASVS. However, patients receiving remifentanil infusions had smaller mean glucose concentrations (80 +/- 18 versus 100 +/- 44 mg x dl(-1), P = 0.01). These concentrations were also significantly smaller if tracheal intubation was delayed for at least 10 min after induction while patients received inhaled anesthetics via a face mask along with remifentanil infusions (79 +/- 14 for delayed intubation versus 95 +/- 39 mg x dl(-1) for early intubation, respectively, P = 0.03). The percentage increase in glucose concentrations from preintubation values was significantly smaller in these subjects (3.7% +/- 21.9% for delayed intubation versus 31.7% +/- 60.4% for early intubation, P = 0.02). We conclude that the anesthetic management protocol for these patients should include the use of remifentanil infusions and the administration of inhaled anesthetics and remifentanil infusions for a minimum of 10 min to establish a deep plane of anesthesia before tracheal intubation.

Epidural versus general anesthesia for twin-twin transfusion syndrome requiring fetal surgery.

OBJECTIVES: This paper describes our experiences with epidural and general anesthesia for selective fetoscopic laser photocoagulation (SFLP) of placental vascular anastomoses in patients with severe twin-twin transfusion syndrome (TTTS). METHODS: Retrospective review of 29 anesthetic and surgical operative records of 28 women undergoing SFLP at The Children's Hospital of Philadelphia from July 1996 to June 2001. RESULTS: Patients with anterior placentas were more likely to receive a general anesthetic. Patients receiving an epidural anesthetic received significantly more intravenous (i.v.) crystalloid but less i.v. fentanyl than those receiving a general or combined technique. CONCLUSIONS: The advantages of general anesthesia include increased ability of the patient to tolerate extreme positions and the surgical manipulation of the uterus (required in the technically more difficult cases), greater uterine relaxation, decreased use of i.v. fluids, but increased fentanyl requirements. Epidural anesthesia avoids the risks of failed tracheal intubation in pregnant women but may not reduce fetal responses to surgical stimuli unless the mother receives supplemental intravenous drugs. However, this may increase the risk of respiratory depression. The choice of anesthetic technique for SFLP in patients with severe TTTS must be made after careful consideration of maternal and fetal factors.