[Perioperative use of metamizole and other nonopioid analgesics in children : Results of a survey]. / Perioperative Anwendung von Metamizol und anderen Nichtopioidanalgetika bei Kindern : Ergebnisse einer Umfrage.

BACKGROUND: Nonopioid analgesics are frequently used for perioperative pain management in children. In many countries, the nonopioid metamizole (dipyrone) is administered as an alternative to paracetamol and traditional NSAIDs (nonsteroidal anti-inflammatory drugs), such as ibuprofen and diclofenac; however, concerns over possible life-threatening adverse events (agranulocytosis) have prompted a debate over the use of metamizole. OBJECTIVE: To investigate current practice and use of nonopioid analgesics, particularly of metamizole in children younger than 14 years, in the perioperative setting. Furthermore, metamizole-related side effects, safety and approaches used to inform patients were addressed. METHODS: A link to an online questionnaire on the perioperative use of nonopioid analgesics in children, with a specific focus on dipyrone, was sent by e­mail to members of the German Society of Anesthesiology and Intensive Care Medicine (DGAI) and to members of the German Pain Society. RESULTS: A total of 2284 anesthesiologists filled out the questionnaire. Of these, 1476 were involved in the perioperative care of children younger than 14 years. The majority of respondents worked in German hospitals (90.5%) but Austria, Switzerland and the Netherlands were also among the countries represented. Of the respondents, 99.1% reported using nonopioid analgesics in the perioperative setting. The NSAID, metamizole, paracetamol and COX-2 inhibitors were administered by 83.9%, 68.6%, 67.5% and 2% of the respondents, respectively. Intravenous metamizole was the preferred nonopioid analgesic during surgical procedures, but following surgery, NSAID, metamizole and paracetamol were given with the same frequency by anesthesiologists. Of the respondents, 49.3% reported using metamizole in combination with another nonopioid analgesic in cases of severe pain, 14.8% used it as the sole nonopioid analgesic, and 23.2% never used it at all. Nearly half of the respondents administered metamizole i.v. in doses of 15 mg/kg body weight or lower, whereas 26% administered doses of at least 16 mg/kg up to more than 20 mg/kg. Of the physicians, 298 (20.2%) restricted the duration of metamizole use, varying between one single administration (4.7%), administration for 1 day (27.5%), or for 1-2 weeks (29.2%). Of the anesthesiologists, 65.6% reported no metamizole-related adverse effects. Allergic reactions/anaphylaxis and a drop in blood pressure requiring intervention were observed by 3-4% of the respondents. No change in blood cell counts within the last 2 years was reported by 73.1% of the respondents, whereas 17 anesthesiologists (1.3%) had observed children with altered blood cell counts, with 2 (0.14%) reporting agranulocytosis. In most cases these were incidental findings. No severe sequelae or deaths were reported. Few respondents (5.5%) performed routine blood cell counts to monitor metamizole therapy. Furthermore, only a minority always (3.5%) or sometimes (6.1%) informed a child's parents of possible side effects of treatment with metamizole. CONCLUSION: The survey confirmed that metamizole is frequently used in children in the perioperative setting. Intravenous metamizole is the preferred nonopioid analgesic administered intraoperatively for pain prophylaxis. Clinical symptoms of agranulocytosis should be monitored and patients should be better informed about metamizole-related side effects.

Drug safety in paediatric anaesthesia.

Life-threatening drug errors are more common in children than in adults. This is likely to be because of their variations in age and weight, combined with the occasional exposure of most anaesthetists to paediatric patients. Drug administration in anaesthesia is mostly undertaken by a single operator and thus represents a potentially greater risk compared with other areas of medicine. This increased risk is believed to be offset by anaesthetists working with only a limited number of drugs on a very frequent and repetitive basis. However, high rates of errors continue to be reported. Paediatric anaesthesia practice requires individual age- and weight-specific drug dose calculations and is therefore without a 'familiar' or 'usual' dose. The aim of this narrative systematic review of existing recommendations and current evidence of preventive strategies is to identify measures to enhance the safety and quality of drug administration in paediatric anaesthesia. This review collates and grades the evidence of such interventions and recommendations and assesses their feasibility. Most highly effective available measures require low or limited costs and labour. The presented solutions should, therefore, achieve a high level of acceptance and contribute significantly to safety and quality of care in paediatric anaesthesia.

[Use of cognitive aids in pediatric emergency care : Interdisciplinary consensus statement]. / Anwendung kognitiver Hilfsmittel im Kindernotfall : Interdisziplinär konsentierte Stellungnahme.

Preclinical pediatric emergencies are rare events and are therefore often associated with stress and uncertainty for emergency medical service personnel. To ensure adequate treatment of pediatric patients a variety of different cognitive aids exist (e.g. books, apps, rulers, weight-adapted bag systems). Especially the size specifications of the medical equipment and the dosage of emergency medication are individually very different in children and are dependent on parameters, such as body height and weight. Therefore, cognitive aids often enable length measurement whereby it is possible to draw conclusions on body weight for calculating the child's medication dosage. These aids may help to avoid the wrong medication dose or the wrong therapy of children but uncritical and untrained usage of these aids carries a potential risk of mistakes. This recommendation gives an overview of the general requirements and different problems of cognitive aids and should help improve the general framework and the rational basis for the use and further development of cognitive aids in emergency medicine.

[Interdisciplinary consensus statement on alternative airway management with supraglottic airway devices in pediatric emergency medicine: Laryngeal mask is state of the art]. / Interdisziplinär konsentierte Stellungnahme zum Atemwegsmanagement mit supraglottischen Atemwegshilfen in der Kindernotfallmedizin: Larynxmaske ist State-of-the-art.

BACKGROUND: Airway management with supraglottic airway devices (SGA) in life-threatening emergencies involving children is becoming increasingly more important. The laryngeal mask (LM) and the laryngeal tube (LT) are devices commonly used for this purpose. This article presents a literature review and consensus statement by various societies on the use of SGA in pediatric emergency medicine. MATERIAL AND METHODS: Literature search in the database PubMed and classification of studies according to the criteria of the Oxford Centre for Evidence-based Medicine levels of evidence. RESULTS: The evidence for successful application of the various types of LM is significantly higher than for LT application. Reports of smaller series of successful applications of LT are currently limited to selected research groups and centers. Insufficient evidence currently exists for the successful application of the LT especially for children below 10 kg body weight and, therefore, its routine use cannot currently be recommended. SGAs used for emergencies should have a possibility for gastric drainage. DISCUSSION: Considering the scientific data and the large clinical experience with the LM in medical routine and emergency situations in children, currently only the LM can be recommended for alternative (i.e. non-intubation) airway management in children. If alternative airway management is part of a local emergency strategy, the LM should be provided in all pediatric sizes (1, 1.5, 2, 2.5, 3, 4 and 5) for prehospital and in-hospital emergency use and all users should be regularly trained in its application.

[Pediatric emergence agitation]. / Postoperative Agitation im Kindesalter.

BACKGROUND: The origin of emergence agitation in children remains unclear; however, an association between surgical procedure, patient age and anesthetic regimen and the incidence of postoperative agitation has been described in the literature. AIM: The aim of this survey performed between February and April 2014 was to collect data from the daily clinical practice by experienced pediatric anesthesiologists regarding documentation, premedication, anesthesia regimen and postoperative treatment with respect to children with emergence agitation. MATERIAL AND METHODS: An online questionnaire with 33 items was developed and sent to all 525 members of the scientific committee of pediatric anesthesia (WAKKA) of the German Society of Anesthesiology and Intensive Care (DGAI). Members were asked to respond within a time period of 1 month but no reminders were sent out via email or telephone. RESULTS: A total of 156 members participated in the survey and of these 143 questionnaires were fully completed and included in the final evaluation (27 %). Of the participants 77 % had more than 6 years professional experience in the field of pediatric anesthesia and for 87 % emergence agitation remains a relevant clinical problem. The estimated incidence of emergence agitation was given as 1-10 % and as high as 11-20 % by 56% and 20 % of the participants, respectively. The incidence of postoperative agitation is documented by only 11 % of the participants with a validated score, such as the pediatric anesthesia emergence delirium (PEAD) scale and 89 % of the participants use midazolam for premedication. As a preemptive intervention total intravenous anesthesia is performed by 56 % whereas clonidine is used as first line prevention by 30 %. Postoperative pharmacological treatment is performed by a bolus administration of propofol (56 %) and clonidine (26 %). Postoperative parental presence was considered beneficial by 82 %. CONCLUSION: Emergence agitation is still seen as a relevant clinical problem by experienced pediatric anesthesiologists. Propofol is first choice when it comes to pharmacological prevention and treatment of emergence agitation. Postoperative parental presence was considered beneficial by the majority of anesthesiologists.

[Complications in pediatric anesthesia]. / Komplikationen in der Kinderanästhesie.

As in adult anesthesia, morbidity and mortality could be significantly reduced in pediatric anesthesia in recent decades. This fact cannot conceal the fact that the incidence of anesthetic complications in children is still much more common than in adults and sometimes with a severe outcome. Newborns and infants in particular but also children with emergency interventions and severe comorbidities are at increased risk of potential complications. Typical complications in pediatric anesthesia are respiratory problems, medication errors, difficulties with the intravenous puncture and pulmonal aspiration. In the postoperative setting, nausea and vomiting, pain, and emergence delirium can be mentioned as typical complications. In addition to the systematic prevention of complications in pediatric anesthesia, it is important to quickly recognize disturbances of homeostasis and treat them promptly and appropriately. In addition to the expertise of the performing anesthesia team, the institutional structure in particular can improve quality and safety in pediatric anesthesia.

General anaesthetics and the developing brain: an overview.

Various experimental studies in animals have shown that general anaesthetics are potentially toxic to the developing brain. By inducing apoptosis or interfering with neurogenesis, anaesthetic exposure during a critical period of neuronal development can have significant impact on neurocognitive function later in life. It remains controversial whether these experimental results can be transferred to human beings and this is under intensive scientific evaluation. To gain more insight into possible neurotoxic effects on the human brain of infants and small children, a number of retrospective studies have been performed. At present, there is no clear evidence that exposure to anaesthesia up to the age of 3-4 years is associated with neurocognitive or behavioural deficits. Currently, the PANDA, MASK and GAS studies are underway to explore this relationship. Anaesthesia is not an end in itself, but necessary to facilitate surgical procedures. There is evidence that maintaining physiological conditions is important for the overall outcome following anaesthesia and surgery. Until proven otherwise, it can be recommended to keep anaesthesia and surgery as short as possible, to use short-acting drugs and/or a combination of general anaesthesia and multimodal pain therapy including systemic analgesics, and local or regional anaesthesia, to reduce the overall drug dosage.

[Pediatric anesthesia in ear nose throat (ENT) surgery]. / Anästhesie für HNO-Eingriffe bei Kindern.

ENT procedures are the most common surgeries in children - an optimal anesthetic management provides an uncomplicated, safe perioperative process with as little discomfort for the child as possible. Children at risk must already be identified preoperatively: the combination of ENT surgery, airway susceptibility and age below 3 years can increase the rate of perioperative respiratory adverse events. Postoperatively, it is important to prevent complications such as pain and PONV by dedicated prevention and treatment strategies, as well as to recognize and treat respiratory or circulatory complications competent. Interdisciplinary guidelines and agreements as well as the overall competence of the team have the potential to improve patient safety and outcome in children.

[Nalbuphine in pediatric anesthesia]. / Nalbuphin in der Kinderanästhesie.

Efficient and safe pediatric perioperative pain therapy in the context of a multimodal pain therapy concept requires a slight to moderate opioid analgesic. Nalbuphine is a nearly ideal opioid for this purpose due to its unique pharmacological properties as a µ-receptor antagonist/κ-receptor agonist and a high safety profile. Nalbuphine is used clinically primarily in postoperative pain therapy administered as a bolus, continuous infusion and patient-controlled analgesia. Furthermore, it is administered in different regimens for pediatric diagnostic and interventional sedation.

[Neurotoxicity of general anesthetics in childhood: does anesthesia leave its mark on premature babies, newborns and infants?]. / Neurotoxizität von Allgemeinanästhetika im Kindesalter: Hinterlässt Narkose Spuren beim Früh-, Neugeborenen und Kleinkind?

Many animal experiments have shown that anesthetics can have a neurotoxic effect on immature brains because they induce apoptosis and influence neurogenesis and synaptogenesis. In animal experiments this has substantial implications for the neurocognitive functions of animals in later life. Whether these results of animal experiments can be transferred to humans is currently the subject of intensive research. In several retrospective studies no clear association between anesthesia in premature babies, newborns or infants and the occurrence of learning disorders or behavioral problems could be found. The prospective studies GAS and PANDA are designed to obtain a deeper insight and if possible to clarify this problem. Because of the high relevance of this topic and in order to achieve more clarity for this problem when dealing with parents, the scientific working group for neuroanesthesia and pediatric anesthesia of the German Society for Anesthesiology and Intensive Care Medicine (DGAI) has formulated a position document on the basis of currently available data.

[Diagnostic and interventional operations in childhood: anesthesiology management]. / Diagnostische und interventionelle Eingriffe im Kindesalter : Anästhesiologisches Management.

Diagnostic and interventional procedures in children often need to be performed under sedation. This prevents pain and stress in children and provides optimal examination conditions. For complete immobilization and stress shielding the depth of sedation often corresponds with general anesthesia. Therefore, established safety standards need to be observed and a fundamental precondition is implementation by a skilled anesthesiologist who can handle the anesthesiology procedure and its possible complications. Organization, schedule, medication, equipment, monitoring and post-anesthesiology care should be institutionally defined. A professional anesthesiology management of pediatric patients is an important factor to increase the quality of care, patient safety and patient satisfaction.

[Fibre optic-assisted endotracheal intubation through the laryngeal mask in children]. / Fiberoptisch unterstützte endotracheale Intubation durch die Larynxmaske im Kindesalter.

Fibre optic-assisted tracheal intubation through the laryngeal mask airway is a simple and safe procedure for securing the airway in the paediatric patient with unexpected and known difficult tracheal intubation. Therefore, fibre optic-assisted tracheal intubation through the laryngeal mask airway represents a standard airway technique and must be part of clinical education and also regular training. However, the removal of the laryngeal mask airway over the tracheal tube is impaired by the short length of the tracheal tube, easily resulting in tube dislocation from the trachea. Among several techniques to overcome this problem, the Cook airway exchange catheter offers a reliable method not only for safe removal of the laryngeal mask over the tracheal tube but also for insertion of an adequate tracheal tube, particularly in paediatric patients. This is particularly important for cuffed tubes as the pilot balloon of the cuffed tube is too large to pass through laryngeal mask airway tubes size 2.5 and smaller. This presentation demonstrates fibre optic-assisted tracheal intubation through the laryngeal mask airway in children step-by-step and discusses its clinical implications. A list with compatible sizes of laryngeal mask airways, tracheal tubes and airway exchange catheters is also provided.

EEG variables as measures of arousal during propofol anaesthesia for general surgery in children: rational selection and age dependence.

BACKGROUND: Clinical benefits of measuring processed EEG during anaesthesia in adults, such as improved recovery and reduced risk of awareness, may also be valid in children. This study evaluated a rational selection of EEG variables as measures of arousal during surgical anaesthesia in children. METHODS: Sixty children undergoing surgical anaesthesia with propofol and remifentanil were enrolled. The performance of 33 single EEG variables and bispectral index (BIS) was assessed by simultaneous analysis of prediction probability (Pk) of Children's Hospital of Wisconsin Sedation Scores and their signal-to-noise ratio (SNR). Variables performing best in Pk and SNR analysis were selected as potential measures of arousal. Their performance was investigated in five age groups, 0-1, 1-2, 2-5, 5-8, and 8-13 yr. RESULTS: Single EEG variables such as relative power from frequency bands 13-20 and 20-26 Hz, SEF95, and approximate entropy performed best with Pk>0.59 and SNR>5.50. The Pk and SNR of BIS were 0.71 and 15.76, respectively. Their performance was significantly better in children aged 1-13 yr than in 0-1 yr. CONCLUSIONS: BIS may provide a measure of arousal during propofol anaesthesia in children, but its accuracy is less in infants younger than 12 months. Single EEG variables such as high-frequency components of EEG, SEF95, and approximate entropy may be of limited value to detect arousal in the individual paediatric patient.