Perioperative critical events and morbidity associated with anesthesia in early life: Subgroup analysis of United Kingdom participation in the NEonate and Children audiT of Anaesthesia pRactice IN Europe (NECTARINE) prospective multicenter observational study.

BACKGROUND: The NEonate and Children audiT of Anaesthesia pRactice IN Europe (NECTARINE) prospective observational study reported critical events requiring intervention during 35.2% of 6542 anesthetic episodes in 5609 infants up to 60 weeks postmenstrual age. The United Kingdom (UK) was one of 31 participating countries. METHODS: Subgroup analysis of UK NECTARINE cases (12.8% of cohort) to identify perioperative critical events that triggered medical interventions. Secondary aims were to describe UK practice, identify factors more commonly associated with critical events, and compare 30-day morbidity and mortality between participating UK and nonUK centers. RESULTS: Seventeen UK centers recruited 722 patients (68.7% male, 36.1% born preterm, and 48.1% congenital anomalies) undergoing anesthesia for 876 surgical or diagnostic procedures at 25-60 weeks postmenstrual age. Repeat anesthesia/surgery was common: 17.6% patients prior to and 14.4% during the recruitment period. Perioperative critical events triggered interventions in 300/876 (34.3%) cases. Cardiovascular instability (16.9% of cases) and/or reduced oxygenation (11.4%) were more common in younger patients and those with co-morbidities or requiring preoperative intensive support. A higher proportion of UK than nonUK cases were graded as ASA-Physical Status scores >2 or requiring urgent or emergency procedures, and 39% required postoperative intensive care. Thirty-day morbidity (complications in 17.2%) and mortality (8/715, 1.1%) did not differ from nonUK participants. CONCLUSIONS: Perioperative critical events and co-morbidities are common in neonates and young infants. Thirty-day morbidity and mortality data did not demonstrate national differences in outcome. Identifying factors associated with increased risk informs preoperative assessment, resource allocation, and discussions between clinicians and families.

Insufflation in minimally invasive surgery: Is there any advantage in staying low?

AIM: Minimally invasive repair of esophageal atresia with tracheoesophageal fistula (EA/TEF) and congenital diaphragmatic hernia (CDH) is feasible and confers benefits compared to thoracotomy or laparotomy. However, carbon dioxide (CO2) insufflation can lead to hypercapnia and acidosis. We sought to determine the effect of lower insufflation pressures on patients' surrogate markers for CO2 absorption - arterial partial pressure of CO2 (PaCO2), end tidal CO2 (EtCO2) and pH. METHODS: Single center retrospective review, including neonates without major cardiac anomaly. Selected patients formed 2 groups: Historical pressure (HP) group and low pressure (LP) group. We reported on the patients' preoperative characteristics that potentially confound the degree of CO2 absorption or elimination. Outcome measures were perioperative PaCO2, EtCO2, arterial pH and anesthetic time. RESULTS: 30 patients underwent minimally invasive surgery for CDH and 24 patients for EA/TEF with similar distribution within the HP and LP group. For CDH patients as well as for EA/TEF patients, there were no significant differences in their preoperative characteristics or surgery duration comparing HP and LP groups. With a decrease in insufflation pressure in CDH patients, there were a significant decrease (p = 0.002) in peak PaCO2 and an improvement in nadir pH (p = 0.01). For the EA/TEF patients, the decrease in insufflation pressure was associated with a significant decrease (p = 0.03) in peak EtCO2. Considering all 54 patients, we found EtCO2 to be highly significantly inversely correlated with pH and positively correlated with intraoperative PaCO2 (p < 0.001). Baseline Hb was inversely correlated with mean EtCO2 (p < 0.001). CONCLUSION: With lower insufflation pressures, CDH patients had significantly improved hypercapnia and acidosis, while EA/TEF patients had significantly reduced EtCO2. EtCO2 was correlated with acidosis and hypercapnia. TYPE OF STUDY: Retrospective case control study. LEVEL OF EVIDENCE: Level III.

A multicenter audit of the use of bronchoscopy during open and thoracoscopic repair of esophageal atresia with tracheoesophageal fistula.

BACKGROUND: Esophageal atresia (EA) with tracheoesophageal fistula is usually repaired in the neonatal period. Preferential ventilation through the fistula can lead to gastric distension. Bronchoscopy has a role in defining the site and size of the fistula, and may be carried out by the surgeon or the anesthetist. The use of bronchoscopy varies across different institutions. METHODS: This is a multicenter case note review of infants with EA with tracheoesophageal fistula who underwent surgery between January 2010 and December 2015. This retrospective audit aims primarily to document the use of bronchoscopy during open and thoracoscopic repair at a selection of United Kingdom centers. Respiratory complications, that is relating to airway management, the respiratory system, and difficulty with ventilation, at induction and during surgery, are recorded. The range of techniques for anesthesia and analgesia in these centers is noted. RESULTS: Bronchoscopy was carried out in 52% of cases. The incidence of respiratory complications was 7% at induction and 21% during surgery. Thoracoscopic repair usually took longer. One center used high-frequency oscillatory ventilation, on an elective basis during thoracoscopic repair, to facilitate surgical access and address concerns about hypoxemia and hypercarbia. CONCLUSION: The use of bronchoscopy varies considerably between institutions. Infants undergoing tracheoesophageal fistula repair are at risk of perioperative respiratory morbidity. The advent of thoracoscopic repair has introduced further variation.

Metabolic changes during major craniofacial surgery.

OBJECTIVES: The purpose of this study was to document the degree and duration of perioperative metabolic disturbance during major craniofacial surgery in children. AIM: The aim was to quantify the degree and duration of perioperative metabolic disturbance and to determine the relationship between the metabolic changes and the duration of surgery and total volume of blood and colloid given during surgery. BACKGROUND: These patients have the potential for massive blood loss and significant metabolic acidosis. Routine perioperative monitoring includes the serial measurement of base deficit (BD) as a marker of metabolic disturbance. METHODS/MATERIALS: All patients undergoing elective major craniofacial surgery were prospectively studied over a 10-month period. BD from arterial blood gas analysis was measured at standardized intervals during the perioperative period. The duration of surgery and total volume of blood and colloid given intraoperatively were used as covariates in a multiple regression analysis. RESULTS: Maximum recorded BD ranged from -3 to -20 (median -9). Median time taken to return to normal was 9.25 h (range 0-18 h). Median duration of significant BD was 3.8 h (range 0-20 h). CONCLUSIONS: Children undergoing major craniofacial surgery develop a varying degree of perioperative metabolic acidosis persisting for several hours. The maximum BD appears to be related to the amount of intraoperative blood loss and replacement rather than duration of surgery. As it is difficult to predict the extent and duration of metabolic acidosis for an individual patient, this study confirmed our current practice that all patients should be admitted to a neurosurgical high-dependency unit postoperatively for overnight monitoring.

Anesthesia in children with mastocytosis--a case based review.

INTRODUCTION: Mastocytosis is a rare heterogeneous disease of bone marrow origin which arises as a consequence of abnormal growth and/or accumulation of clonal mast cells in one or more organs. Sixty-five percent of patients with mastocytosis are children in whom it usually regresses around puberty. Adult patients with mastocytosis have been identified as at high risk of widespread mast cell degranulation in the perioperative period, this finding has not been reported in pediatric patients. This information has been repeated in mastocytosis websites where it has the potential to cause disproportionate alarm in parents. METHODS: We considered our experience of six children with mastocytosis together with a review of the literature to examine other reports of anesthesia in children with mastocytosis. Our literature search found 57 general anesthetics in 39 children with mastocytosis. In addition, we searched for information about current consensus in diagnosis, classification and treatment of mastocytosis and in vitro and in vivo studies looking at mast cell behavior in response to drugs commonly used during anesthesia. DISCUSSION: The literature search revealed that general anesthesia has precipitated life threatening complications in adult patients with systemic mastocytosis (SM) but no such complications have been described in children with mastocytosis. Our own experience with children with mastocytosis is of uneventful anesthesia. Advances in the understanding of the genetic basis of mastocytosis suggest that pediatric cutaneous mastocytosis (CM) and SM are different entities. SM in children is extremely rare and is associated with elevated baseline serum tryptase. There are few reports of anesthesia in this group. CONCLUSION: The risks for most pediatric patients are overstated by mastocytosis websites. Most pediatric patients with CM do not appear to be at risk of widespread mast cell degranulation during anesthesia but because of the small number of cases reported, the risk cannot be ascertained with confidence. Children with SM and a high baseline serum tryptase (marker of mast cell burden) may merit extra precautions but experience in this subgroup is even more limited. Drugs which cause minimal histamine release can be selected from the range of drugs available in most pediatric centers without compromise to technique.

Repair of sinus venosus defect in a patient with untreated vein of Galen aneurysmal malformation.

The vein of Galen aneurysmal malformation (VGAM) is a rare cerebral arteriovenous shunt, which may be associated with a congenital cardiac defect. Embolisation of the VGAM may be undertaken in the neonatal period if necessary, but is safer in infancy. Recent advances in neuroradiology have changed the prognosis for this group with many patients achieving survival with normal development. This case report describes a patient with a sinus venosus defect (SVD) and a VGAM and considers both the optimal timing of treatment of the two malformations and the conduct of anaesthesia for open repair of the SVD in the presence of an untreated VGAM.