Ultrasound-guided mid point-transverse process to pleura block versus thoracic paravertebral block in pediatric open-heart surgery: A randomized controlled non-inferiority study.

STUDY OBJECTIVE: The mid point-transverse process to pleura block (MTPB) is a new variant of thoracic paravertebral block (TPVB). This study aimed to compare TPVB and MTPB with respect to intraoperative attenuation of the hemodynamic stress response to surgery and postoperative analgesia in pediatric open heart surgery with midline sternotomy. DESIGN: A single-center, randomized, controlled, double-blind, non-inferiority study. SETTING: Tertiary care children's university hospital. PATIENTS: We recruited 83 children aged 2-12 years of both sexes with American Society of Anesthesiologists (ASA) physical status class II who were scheduled for elective open cardiac surgeries with midline sternotomy for the repair of simple noncyanotic congenital heart defects. INTERVENTIONS: Eligible participants were randomized into either the TPVB or MTPB groups at a ratio of 1:1. In the TPVB group, patients were bilaterally injected with 0.4 ml/kg of 0.25% bupivacaine in the paravertebral space at T4 and T5. In the MTPB group, patients were bilaterally injected with 0.4 ml/kg of 0.25% bupivacaine mid-transverse process and pleura just posterior to superior costotransverse ligament at the level of T4 and T5. MEASUREMENTS: The primary outcome was the hemodynamic responses to sternotomy incision, including heart rate (HR) and invasive mean arterial pressure (MAP), recorded before and after the induction of anesthesia, after skin incision, after sternotomy, 15 min after cardiopulmonary bypass (CPB), and after the closure of the sternum. The secondary outcomes were time needed to perform the bilateral block, intraoperative fentanyl consumption, postoperative fentanyl consumption, modified objective pain score (MOPS) measured at 1, 2, 6, 12, 18, and 24 h after extubation, extubation time, intensive care unit (ICU) discharge time, and the incidence of non-surgical complications (postoperative pruritus, postoperative vomiting, pneumothorax, hematoma or local anesthetic toxicity). MAIN RESULTS: There were no significant differences in HR and MAP in the TPVB group compared with the MTPB group at the following time points: baseline, after induction, after skin incision, after sternotomy, 15 min after CPB, and after sternal closure. Intergroup comparisons of HR and MAP did not reveal significant differences between the groups. The median (IQR) time needed to perform bilateral MTPB (7[6-8] min) was significantly (p < 0.001) shorter than that of TPVB (12[10-13] min). Intraoperative fentanyl consumption and fentanyl consumption in the first postoperative 24 h after extubation were similar in the TPVB and MTPB groups (4[2-4] vs 4[2-4] and 4.66 ± 0.649 vs 4.88 ± 1.082 µg/kg), respectively. Extubation time and ICU discharge time were comparable in the TPVB and MTPB groups (2[1-3] vs 2[1-3] h and 21.2 ± 2.5 vs 20.8 ± 2.6 h), respectively. Measurements of MOPS pain scores at 1, 2, 6, 12, 18, and 24 h after extubation were similar in both groups. The incidence of nonsurgical complications was similar in both groups. CONCLUSIONS: MTPB is non-inferior to TPVB in attenuating the intraoperative hemodynamic stress response to noxious surgical stimuli and in reducing perioperative opioid consumption, extubation time, and ICU discharge time. Moreover, MTPB is technically easier than TPVB and requires less time to perform. Clinical trial registration number The clinical trial registration was prospectively performed at the Pan African Clinical Trials Registry (PACTR202204901612169, approval date 01/04/2022, URL https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=22602).

Comparison of the Outcomes of Oral Versus Nasal Endotracheal Intubation in Neonates and Infants Undergoing Cardiac Surgery: A Randomized Controlled Study.

OBJECTIVE: The choice of oral or nasal endotracheal intubation in children undergoing cardiac surgery is affected by several factors. This study compared the outcomes of oral versus nasal intubation in neonates and infants who underwent open cardiac surgery. DESIGN: A randomized, controlled, open-labeled study. SETTING: At a university hospital. PARTICIPANTS: A total of 220 infants and neonates who underwent cardiac surgery. INTERVENTIONS: Patients were allocated randomly to oral or nasal intubation. MEASUREMENTS AND MAIN RESULTS: The primary outcome measure was postoperative fentanyl consumption (µg/kg/h) by intubated patients. Secondary outcome measures were the increase in heart rate (HR) from baseline during intubation, the time consumed for intubation, accidental intraoperative extubation, the occurrence of epistaxis, time to extubation, the onset of full oral feeding, intensive care unit (ICU) and hospital lengths of stay, and the incidence of postoperative complications (the need for reintubation, stridor, pneumonia, wound infection). The mean (SD) postoperative fentanyl consumption of intubated patients (the primary outcome) was significantly lower (p < 0.001) in the nasal intubation group (0.53 ± 0.48) µg/kg/h compared with the oral intubation group (0.82 ± 0.20) µg/kg/h. The median (IQR) time needed for the intubation (31.5, 27-35 v 16, 14.8-18 seconds) was significantly (p < 0.001) longer, and the mean (SD) increase in HR (beats/min) from baseline during intubation (18 ± 5 v 26 ± 7) was significantly (p < 0.001) lower in the nasal intubation group compared to the oral intubation group. The incidence of inadvertent intraoperative extubation was significantly (p = 0.029) higher in the oral (n = 6, 6.1%) than in the nasal (n = 0, 0%) intubation group. The median (IQR) time to extubation (14, 12.6-17.2 v 20.5, 16.4-25.4 hours) and the ICU length of stay (27, 26-28 v 30, 28-34 hours) were significantly (p < 0.05) shorter in the nasal group compared to the oral group. The median (IQR) time to onset of full oral feeding was significantly (p = 0.031) shorter in the nasal intubation group (3, 1-6 days) compared to the oral intubation group (4, 2-7 days). There were no significant differences between the oral and nasal groups in the duration of hospital stay and the indices for reintubation, postintubation stridor, pneumonia, and surgical wound infection. CONCLUSIONS: The nasal route for intubation is associated with less postoperative fentanyl consumption, earlier extubation, lower incidence of accidental extubation, and earlier full oral feeding than oral intubation. The nasal route is not associated with an increased risk of postoperative pneumonia or surgical wound infection.

Bilateral Ultrasound-Guided Mid-Point Transverse Process to Pleura Block for Perioperative Analgesia in Pediatric Cardiac Surgery: A Randomized Controlled Study.

OBJECTIVE: Mid-point transverse process to pleura (MTP) block is a new regional analgesia technique. This study aimed to assess the perioperative analgesic effects of MTP block in children undergoing open-heart surgery. DESIGN: A single-center, randomized, double-blinded, controlled, superiority study. SETTING: At a University Children's Hospital. PARTICIPANTS: Fifty-two patients aged 2 to 10 years who underwent open-heart surgery. INTERVENTIONS: Patients were randomized to receive either bilateral MTP block or no block (control). MEASUREMENTS AND MAIN RESULTS: The primary outcome was fentanyl consumption in the first postoperative 24 hours. The secondary outcomes were intraoperative fentanyl consumption, modified objective pain score (MOPS) measured at 1, 4, 8, 16, and 24 hours after extubation, and the duration of stay in the intensive care unit (ICU). The mean (SD) postoperative fentanyl consumption (µg/kg) in the first 24 hours was significantly reduced in the MTP block group (4.4 ± 1.2) compared to the control group (6.0 ± 1.4, p < 0.001). The mean (SD) intraoperative fentanyl requirement (µg/ kg) was significantly reduced in the MTP block group (9.1 ± 1.9) compared to the control group (13.0 ± 2.1, p < 0.001). The MOPS was significantly reduced in the MTP block group compared to the control group at 1, 4, 8, and 16 hours after extubation but was comparable in both groups at 24 hours. The mean (SD) duration of ICU stay (hours) was significantly reduced in the MTP block group (25.0 ± 2.9) compared to the control group (30.7 ± 4.2, p < 0.001). CONCLUSIONS: Single-shot bilateral ultrasound-guided MTP block in children undergoing cardiac surgery reduced the mean fentanyl consumption in the first postoperative 24 hours, intraoperative fentanyl requirements, pain score at rest, time to extubation, and duration of ICU stay.

Recovery Profile of Sugammadex versus Neostigmine in Pediatric Patients Undergoing Cardiac Catheterization: A Randomized Double-Blind Study.

Background: Sugammadex is a selective reversal agent which has the ability to reverse deep neuromuscular blockade. However, there are still controversial results as regard sugammadex effects on the quality of recovery. We hypothesized that Sugammadex may have better recovery profile compared to neostigmine in pediatric patients with congenital heart diseases undergoing cardiac catheterization. Patients and Methods: This prospective randomized double-blind study included 50 pediatric patients aged <2 years who were divided into two groups according to the reversal agent used; Group S (Sugammadex) and Group N (Neostigmine). Both groups received the same anesthetic technique during cardiac catheterization, and basic hemodynamic monitoring was ensured in both groups. After the procedure, reversal was done using 4 mg.kg‒1 sugammadex or 0.04 mg. kg‒1 neostigmine plus 0.02 mg. kg‒1 atropine according to the group allocation. Recovery time and side effects were recorded. Results: The two groups showed comparable findings regarding demographics. Nonetheless, the total time of anesthesia had mean values of 91.06 and 101.25 min in the two groups, respectively (P = 0.003), while recovery time had mean values of 1.61 and 9.23 min in the same groups, respectively (P < 0.001). Hemodynamic profile (heart rate and mean arterial pressure) was better after reversal with sugammadex. Blood sugar levels and side effects showed no significant difference between both groups. Conclusion: Sugammadex can be a more rapid and effective alternative to neostigmine for reversal of rocuronium-induced neuromuscular blockade in pediatric patients undergoing cardiac catheterization.