A prospective randomized comparative trial of pediatric C-MAC D-blade video laryngoscope with McCoy direct laryngoscope for intubation in children posted for elective surgical procedures under general anesthesia.

BACKGROUND: Pediatric airway management requires careful clinical evaluation and experienced execution due to anatomical, physiological, and developmental considerations. Video laryngoscopy in pediatric airways is a developing area of research, with recent data suggesting that video laryngoscopes are better than standard Macintosh blades. Specifically, there is a paucity of literature on the advantages of the C-MAC D-blade compared to the McCoy direct laryngoscope. METHODS: After Ethics Committee approval, 70 American Society of Anesthesiologists physical status 1 and 2 children aged 4-12 years scheduled for elective surgery under general anesthesia were recruited. Patients were randomly allocated to intubation using a C-MAC video laryngoscope size 2 D-blade (Group 1) and a McCoy laryngoscope size 2 blade (Group 2). The Intubation Difficulty Scale (IDS) for ease of intubation was the primary outcome, while Cormack-Lehane grades, duration of laryngoscopy and intubation, hemodynamic responses, and incidence of any airway complications were secondary outcomes. RESULTS: Both groups were comparable in terms of patient characteristics. The median (IQR) Intubation Difficulty Scale (IDS) score was better but was statistically nonsignificant with C-MAC (0 [0-0] vs. 0 [0-2], p = .055). The glottic views were superior (CL grade I in 32/35 vs. 23/35, p = .002), and the time to best glottic view (6 s [5-7] vs. 8.0 s [6-10], p = .006) was lesser in the C-MAC D-blade group while the total duration of intubation was comparable (20 s [16-22] vs. 18 s [15-22], p = .374). All the patients could be successfully intubated on the first attempt. None of the patients had any complications. CONCLUSION: The C-MAC video laryngoscope size 2 D-blade provided faster and better glottic visualization but similar intubation difficulty compared to McCoy size 2 laryngoscope in children. The shorter time to achieve glottic view demonstrated with the C-MAC failed to translate into a shorter total duration of intubation when compared to the McCoy laryngoscope attributable to a pronounced curvature of the D-blade.

Evaluation of parental anxiety following three methods of pre-anesthesia counseling: Video, brochure and verbal communication.

BACKGROUND: The purpose of this study is to provide comprehensive and efficient pre-anesthesia counseling (PAC) utilizing audiovisual aids and to examine their effect on parental anxiety. METHODS: For this prospective, controlled study, 174 parents were recruited and randomized into three groups of 58 (Group A: video, Group B: brochure, and Group C: verbal). During pre-anesthesia counseling, the parent was provided with a detailed explanation of preoperative preparation, fasting instructions, transport to the operating room, induction, the emergence of anesthesia, and nursing in the post-anesthesia care unit based on their assigned group. We evaluated parental anxiety using Spielberger's State-Trait Anxiety Inventory before and after the pre-anesthesia counseling. RESULTS: The results of our study show a statistically significant difference in the final mean STAI scores among the three groups (Group A: 34.69 ± 5.31, Group B: 36.34 ± 8.59, and Group C: 43.59 ± 3.39; p < .001). When compared to the brochure and verbal groups, the parents in the video group have the greatest difference in mean baseline and final Spielberger's State-Trait Anxiety Inventory scores (12.207 ± 5.291, p .001). CONCLUSION: The results of our study suggest that pre-anesthesia counseling by video or a brochure before the day of surgery is associated with a higher reduction in parental anxiety when compared to verbal communication.

Anesthetic Considerations in Multisystem Inflammatory Syndrome in Children: A Case Series.

Multisystem inflammatory syndrome in children (MIS-C) is an immune response inciting multiorgan dysfunction and a shock-like state which is typically seen in children 2 to 6 weeks after either a coronavirus disease-19 infection or exposure. When such a child comes for any surgery, perioperative anesthetic management demands multidisciplinary involvement and individualized case-based decision-making. Due to the novelty of the condition, there are limited data on anesthetic implications in these patients. Anesthetic management in the affected children is dynamic depending on the organ systems involved and the progression of the disease state. Though the long-term effects of the syndrome are largely unknown, we hope that awareness of the MIS-C-associated complications may help anesthesiologists involved in childcare. Herein, we put forward challenges and clinical dilemmas we faced during the anesthetic management of three children with MIS-C presenting for emergency and elective surgery.

Clinical Evaluation of Two Different Doses of Clonidine as an Adjuvant to Bupivacaine in Ultrasound-Guided Supraclavicular Brachial Plexus Block for Pediatric Upper Limb Surgeries - A Randomized Trial.

Background: Clonidine as an adjuvant to local anesthetic for regional anesthesia in upper limb surgeries has been extensively studied in adults, but there is a paucity of data regarding the dose of clonidine which is effective and safe as an adjuvant in children. Aims: To find the dose of clonidine that prolongs the duration of analgesia without prolonging the side effects. Settings and Design: Prospective, randomized, double-blind study. Materials and Methods: After taking informed consent from the parents/guardian, 42 children aged 3-12 years who were scheduled to undergo unilateral upper limb surgeries below the elbow were randomized into two groups of 21 each. Group A was given 0.5 µg.kg-1 of clonidine in addition to 0.5 mL.kg-1 of 0.25% bupivacaine and Group B received 1 µg.kg-1 of clonidine added to the same volume and concentration of local anesthetic for supraclavicular brachial plexus block under general anesthesia using ultrasound guidance. The drug administration and the recording of the observations were done by an investigator blinded to the dose of clonidine. Statistical Analysis Used: Statistical testing was conducted with the Statistical Package for the Social Sciences system version SPSS 17.0. Results: The demographic parameters and baseline hemodynamic parameters were similar in the two groups. The block failed in one child in Group A. One patient in Group A required tramadol postoperatively while none of the patients in Group B required tramadol. The mean duration of analgesia (11.35 ± 1.54 h vs. 9.94 ± 1.04 h, P < 0.001) and the duration of motor block (8.86 ± 1.0 h vs. 7.77 ± 0.55 h, P < 0.001) were significantly higher in group B. Sedation scores were higher in the recovery room in Group B. Deep sedation, bradycardia, and respiratory depression were not observed in any of the cases. Conclusions: Clonidine 1 µg.kg-1 when added as an adjuvant to bupivacaine for pediatric supraclavicular brachial plexus block prolongs the duration of analgesia and motor block as compared to the dose of 0.5 µg.kg-1. However, this was at the cost of increased duration of motor block and sedation. Considering the clinical equivalence of the effect, a lower dose of clonidine would be preferable to avoid the undesirable effects.

Videolaryngoscopy Bails us out of Difficult Intubation Scenarios in Syndromic Children: A Case Series.

Airway management in children with craniofacial anomalies can be complicated and may require multiple attempts with conventional direct laryngoscopy (DL). Videolaryngoscopes (VLs) have a well-established role in difficult airway management in adults; however, their role remains to be fully elucidated in paediatric age group. There is a relative paucity in the literature regarding the role of VLs in cases of syndromic children, and it is not clear whether they should be used as an initial option or as a rescue device. Herein, we report a series of cases of children with Pierre Robin sequence, Beckwith-Wiedemann syndrome, and Hurler's syndrome wherein VLs proved beneficial after multiple failed DL attempts. Following initial failed attempts to intubate using DL, these children were subsequently intubated using VLs. Therefore, VLs should be used for initial intubation attempts in syndromic children with potential difficult airways.

Anesthesia Challenges in the Management of Freeman-Sheldon Syndrome: Report of Two Cases and Literature Review.

Freeman-Sheldon syndrome is a congenital myopathy with a reported prevalence of less than 1 per 1 million. Also known as craniocarpotarsal dysplasia, this syndrome is characterized by muscle contractures and soft-tissue dysplasia of the face, hands, and feet. The resulting musculoskeletal deformities may require multiple orthopedic, ocular, and plastic reconstructive surgeries. The anesthetic challenges include a potentially difficult airway and intravenous access, susceptibility to malignant hyperthermia, and an unpredictable response to muscle relaxants. This report of the anesthetic management of 2 children with Freeman-Sheldon syndrome emphasizes the anesthetic considerations for the successful management of patients with this syndrome.

Delayed Onset and Prolonged Horner Syndrome in Two Children After Single-Shot UltrasoundGuided Infraclavicular and Subclavian Perivascular Brachial Plexus Blocks for Upper Extremity Surgery: Case Reports.

Horner syndrome is a known complication of cervical approaches to brachial plexus blocks due to local anesthetic-induced oculosympathetic paresis. It has rarely been described in relation to ultrasound-guided brachial plexus blocks in children. This syndrome is usually self-limiting but may cause apprehension to the child, parents, and the treating physicians until its resolution. We report delayed manifestations of Horner syndrome in 2 children following ultrasound-guided infraclavicular and subclavian perivascular blocks.

Comparative evaluation of CMAC and Truview picture capture device for endotracheal intubation in neonates and infants undergoing elective surgeries: A prospective randomized control trial.

BACKGROUND: Videolaryngoscopy has an established role in difficult airway management in adults. However, there is limited literature to support their efficacy in children. The Truview Picture Capture Device has shown promising results for endotracheal intubation in infants in the past. The CMAC videolaryngoscope has launched its novel infant Miller blade, but its performance has not been assessed clinically for routine intubation in infants and neonates. We hypothesized that the CMAC videolaryngoscope would reduce the total time to intubation as compared to the Truview Picture Capture Device in neonates and infants. METHODS: After parental informed consent, 80 prospective infants posted for surgical procedures under general anesthesia were randomized to undergo intubation with either of the two. The two videolaryngoscopes were also compared in terms of time required for glottis view and intubation (primary outcome), modified Cormack and Lehane grade, first attempt and overall success rate, ease of intubation, number of attempts, and any complications. RESULTS: The CMAC significantly reduced the time required for glottic view [8 s (5.25-9) vs 9 s (6.5-12); P = 0.02] and intubation [22 s (18-26) vs 26 s (21.5-32); P = 0.003]. The median difference (95% CI) for time to tracheal intubation and time to glottic view was 4 s (1-7) and 1 (0-4). It also improved the ease of intubation, the Cormack-Lehane grades, and first attempt success rate. Intubation with the CMAC was possible in 100% cases, whereas only 92.5% of patients could be intubated with the Truview. The failed intubations with the Truview could be successfully intubated with the CMAC. CONCLUSION: The CMAC Miller blade reduced the total time taken for tracheal intubation and intubation difficulty as compared to the Truview Picture Capture Device and may be a better tool for intubation in infants.

Combined Spinal-Epidural Anesthesia With Dexmedetomidine-Based Sedation for Multiple Corrective Osteotomies in a Child With Osteogenesis Imperfecta Type III: A Case Report.

Osteogenesis imperfecta (OI) is a rare disabling genetic connective tissue disorder. General anesthesia in these patients is associated with increased risks. Regional anesthesia is favored wherever feasible, but there are limited reports of use of a sole regional technique in OI in pediatric patients. Moreover, combined spinal-epidural anesthesia has never been described previously. We are reporting the use of combined spinal-epidural anesthesia for a prolonged surgery (multiple osteotomies) of lower limbs in a 10-year-old wheelchair-bound child with OI type III. Preoperative counseling, ultrasonography guidance, titrated local anesthetic dosage, and dexmedetomidine sedation helped establish optimum surgical conditions.

Anaesthetic management of a child with stone man syndrome: Look before you leap!

Stone Man syndrome or fibrodysplasia ossificans progressiva (FOP) is an extremely rare (1 in 2 million) genetic disorder characterised by ectopic ossification of the skeletal and connective tissues leading to progressive fusion of axial and appendicular skeleton. Surgery and anaesthesia-induced trauma can lead to disease flare-up if due precautions are not taken and disable the patient further. However, rarity of the disease may lead to its common misdiagnosis and anaesthesiologist may be caught unaware. There is relative paucity of literature regarding anaesthetic management of children with FOP. Videolaryngoscopes (VLs) provide a non-line-of-sight view and require less anterior force to visualise the glottis, may provide an alternative to fibreoptic intubation for airway management in such cases. Use of VL has only been reported once in an adult with FOP for nasotracheal intubation. We describe the successful anaesthetic management of an 11-year-old child with FOP and anticipated difficult airway.

Inadvertent Massive Overdose of Lidocaine in an Infant With Arthrogryposis Multiplex Congenita Treated Successfully With Lipid Emulsion.

Severe local anesthetic toxicity is potentially life threatening and is often refractory to standard resuscitative measures. Infants are a particularly susceptible population in this regard because of their unique physiologic features. Recently, 20% intravenous (IV) lipid emulsion (Intralipid) has been proposed as a "one-stop solution" to toxicity related to all commonly used amide local anesthetics. There is an abundance of literature describing its uses in association with regional blocks in adults. However, there is a scarcity of reports describing its application in children, and use of 10% IV lipid emulsion (Intralipid) has not been described in children for rescue therapy, to our knowledge. We report a case of accidental life-threatening overdose of IV lidocaine (lignocaine) in an infant, which was successfully managed with 10% lipid emulsion.

Successful management of malignant hyperpyrexia syndrome in a pediatric patient: What to do when dantrolene is not available?

Malignant hyperpyrexia syndrome (MHS) is a rare entity and may not be encountered by the anaesthesiologists throughout their professional career. Whenever it manifests can be a challenging task to manage and prove to be fatal when a timely diagnosis and required therapeutic measures are not taken. Althoughthe dantrolene should be available wherever anaesthesia is practiced, considering the rarity of the syndrome this may not be the scenario always. We are reporting a case of MHS in a pediatric patient to highlight the facts that prompt clinical diagnosis, ongoing supportive treatment, discontinuation of all the anaesthetic agents and and stringent perioperative monitoring along with postoperative oral dantrolene may provide an answer to the MHS crisis in the face of an unavailability of the IV dantrolene; as may be the case in many rural and developing set-ups.

Cancellation of elective cases in pediatric surgery: An audit.

AIM: To determine the main reasons for cancellation of elective cases on scheduled date of surgery in pediatric patients. MATERIALS AND METHODS: The audit was conducted in a 216 beds tertiary care pediatric super-specialty hospital. Two operation theatres (OT) provide elective surgical services to pediatric surgery, orthopedics, ophthalmology and otorhinolaryngology. The audit included all those patients who were posted for elective surgery over a period of one year. Cancelled cases were identified from predesigned OT utilization formats and the reasons for cancellation were evaluated. RESULTS: A total of 2473 cases were posted for the elective surgery in the year 2009 and 189 (7.64%) patients had their surgery cancelled. The main reasons for cancellation were upper respiratory infections (30.68%) and shortage of time (29%). Other reasons were medically unfit patients (15.34%), precedence of emergency cases (3.7%); non-availability of ventilator and intensive care bed (4.7%); no-show by patient (4.76%); non-availability of blood (4.2%); incomplete work up (2.64%); administrative reasons (1.58%); patient not fasting (1.58%) and unspecified reasons (2.1%). Overall, 38.6% causes were preventable. CONCLUSIONS: Elective surgery cancellation is a significant problem with multifactorial etiology. Most common reasons for cancellation of planned surgery were sudden onset of respiratory tract infection in the admitted patient and shortage of time. It suggests that on many occasions, surgeons take more time than anticipated for performing the procedure.