Clinician Monitoring.

Since the first public demonstration of general anesthesia in 1846, anesthesiology has seen major advancements as a specialty. These include both important technological improvements and the development and implementation of internationally accepted patient safety standards. Together, these ultimately resulted in the recognition of anesthesiology as the leading medical specialty advocating for patient safety. Modern-day anesthesiology faces a new challenge of automated anesthesia delivery. Despite evidence for a more refined and precise delivery of anesthesia through this platform, there is currently no substitute for the presence of an appropriately trained anesthesia clinician to manage the complex interplay of human factors and patient safety in the perioperative setting.

The Use of Regional Catheters in Children Undergoing Repair of Aortic Coarctation.

OBJECTIVE: The objective was to assess the effectiveness and safety of peripheral regional anesthesia in congenital cardiac surgical patients undergoing thoracotomy for aortic coarctation. DESIGN: A retrospective chart review of pediatric patients (<18 years) who underwent surgical repair of congenital heart diseases via thoracotomy between September 2013 and July 2018 was done. Among patients who underwent coarctation repair, a propensity score was used to match patients who received a regional catheter (C) versus traditional medical treatment only (M). SETTING: A single center children's hospital. PARTICIPANTS: The median age was 172 days (IQR 64-1315) in group C and 176 days (IQR 71-1146) in group M (SMD = 0.07). The median weight was 6.8 kg (IQR 4.8-13.6) in group C and 7.7 kg (4.6-17.4) in group M (SMD = 0.003). MEASUREMENTS AND MAIN RESULT: Outcomes assessed were postoperative hospital length of stay, median pain scores in the first 24 and 48 hours, and total morphine equivalent use in the first 24 and 48 hours. Complications related to the catheters were reviewed. The median oral morphine equivalent dose administered in the first 24 hours was lower in group C than group M (0.8 mg/kg, IQR 0.5-1.1 vs. 1.4 mg/kg, IQR 0.9-1.7, p = 0.019). There were no major complications related to the catheters, including hematoma. CONCLUSIONS: Peripheral regional catheters may be used to reduce opioid requirements in patients after CoA repair. Due to the low risk of these catheters, they should be considered as part of a pain management strategy for pediatric patients undergoing thoracotomy and should be incorporated into strategies to improve outcomes.

Distal Peripheral Nerve Stimulation Successfully Assesses Sciatic Nerve Integrity Following Parasacral Sciatic Motor Block: A Case Report.

Following the placement of lumbar plexus and parasacral sciatic catheters for complex lower extremity surgery, a 19-kg child had dense sensory and motor blockades in the postanesthesia care unit. The surgical team felt obligated to exclude anatomically modifiable compression of the sciatic nerve and planned for surgical reexploration. Using an insulated short, beveled needle, direct electrical nerve stimulation distal to the parasacral sciatic block and proximal to the surgical site elicited tibial nerve motor function and confirmed nerve integrity. Peripheral nerve stimulation can be used to differentiate between the etiologies of motor blockade in time-critical situations.

The synergistic effect of dexmedetomidine on propofol for paediatric deep sedation: A randomised trial.

BACKGROUND: Propofol and dexmedetomidine are used separately, and sometimes together, for paediatric deep sedation. Although their combination has been described in adults, the effect of dexmedetomidine as a potential synergist in children has not been studied before. OBJECTIVES: The primary objective was to compare the propofol requirements of children who receive propofol alone with those who receive it in combination with dexmedetomidine for deep sedation for upper and lower endoscopic gastrointestinal procedures. DESIGN: This was a prospective, open-label, randomised study comparing patients who received propofol alone (group P) with those who received dexmedetomidine and propofol (group DP). The depth of sedation was titrated to a target bispectral (BIS) index. SETTING: A Gastroenterology Procedure Unit at a single, tertiary care academic medical centre from April 2018 until December 2019. PATIENTS: Eligible patients were scheduled for upper endoscopy, lower endoscopy or both. A total of 39 patients were enrolled (20 DP) and (19 P). INTERVENTIONS: Patients in Group DP received dexmedetomidine 0.5 µg kg-1 administered over 1 min followed by an infusion of 0.15 µg kg-1 h-1. In both groups, intravenous propofol was given in bolus increments titrated to a BIS index of 40 to 50 and then a continuous infusion of propofol to maintain BIS at 40 to 50. MAIN OUTCOME MEASURES: The primary outcome measure was propofol requirement in each group. Secondary outcome measures were time to achieve the targeted sedation depth, time to achieve an Aldrete recovery score of 9, duration of sedation, mean BIS values, adverse events, 'PAED' scores and time to discharge from the postanaesthesia care unit (PACU). RESULTS: The median (range) total dose of propofol was 0.23 (0.10 to 0.50) mg kg-1 min-1 in group DP and 0.40 (0.20 to 0.50) mg kg-1 min-1 in group P (P = 0.0004). Time of discharge from the PACU was 60 (20 to 121) min in group DP and 63 (46 to 91) min in group P (P = 0.0409). CONCLUSION: The combination of dexmedetomidine and propofol for paediatric procedural sedation achieved a significant reduction in median propofol dose and a slightly shorter median time to discharge from PACU. Large-scale studies may determine whether this reduction decreases the risk of significant adverse events. TRIAL REGISTRATION: ClinicalTrials.gov identifier NCT02952222.

The Use of Bispectral Index Monitoring Does Not Change Intraoperative Exposure to Volatile Anesthetics in Children.

The exposure of infants and children to volatile anesthetics, such as sevoflurane, has been a topic of concern with respect to the potential risk for long term neurocognitive effects. The primary objective of this study was to determine whether the perioperative utilization of Bispectral Index (BIS) monitoring alters the sevoflurane delivery and exposure to children. This is a prospective randomized trial of two groups of healthy ambulatory day surgery patients (2 to 12 years). The patients in both groups had the BIS applied soon after the induction of general anesthesia, but only the anesthesiologists in the group randomized to BIS visible were able to see the BIS values. All of the patients received general anesthesia with sevoflurane. This study found no difference in the overall exposure to sevoflurane between both groups (mean end-tidal sevoflurane level of 1.8 in both groups, P = 084). The duration of time in the recovery room, the time to meet discharge criteria, the Pediatric Agitation Emergence Delirium (PAED) scores and the Face, Legs, Activity, Cry, Consolability (FLACC) scores were not statistically different between the groups. The application and utilization of intraoperative BIS monitoring does not alter the sevoflurane administration nor the discharge readiness nor the recovery profile in healthy ambulatory children.

Confirmation of success rate of landmark-based caudal blockade in children using ultrasound: A prospective analysis.

BACKGROUND: Caudal epidural anesthesia is a frequently performed regional anesthesia block in infants and young children. Traditional landmark-based blind needle insertion remains the norm with no immediate, objective method to determine the presence of local anesthetic in the epidural space. Increasingly, ultrasound-imaging is used in pediatric regional anesthesia with demonstrated improvements in block efficacy and efficiency. The value of ultrasound-imaging in confirming success rate of traditional caudal placement is not well defined. AIM: To assess the success rate of conventional landmark-based caudal technique using ultrasound-imaging. METHODS: Prospective observational study of 30 children ages 1 month to 7 years undergoing surgical procedures with consent for caudal blockade. Provider success rate of caudal blockade placed by landmark technique was measured using ultrasound-imaging of needle tip and local anesthetic flow in the epidural space. RESULTS: Ultrasound-imaging demonstrated 80% success to correct positioning of the needle tip and local anesthetic in the epidural space. Failure was associated with decreasing experience and presence of anatomic variances. All improperly positioned needles were subsequently successfully positioned using real-time ultrasound-imaging. Mean time for confirmatory ultrasound-imaging (SD; range) was 1 minute (0.3; 1-3). CONCLUSION: The use of ultrasound-imaging can be used to identify proper needle placement in the sacral epidural canal and facilitate subsequent corrected placement.

The effect of suprainguinal fascia iliaca block on the recovery of patients after arthroscopic hip surgery.

BACKGROUND: Adolescent and young adult patients undergoing arthroscopic hip surgery experience significant pain in the immediate postoperative period. There is a small body of evidence that indicates suprainguinal fascia iliaca blocks can improve comfort during recovery from this intervention. Our hypothesis was that patients undergoing hip surgery would consume fewer opioids and have less pain in the perioperative time frame if they received the block as part of their analgesic regimen. METHODS: In this study, we evaluated the outcomes of 716 patients, including 275 who received a suprainguinal fascia iliaca block, and 441 who did not have a block. Inclusion criteria included all age groups and American Society of Anesthesiologists, functional classes 1-2. Patients who received other concurrent procedures or those with incomplete data sets were excluded. We utilized a regional anesthesia database that combined data from various repositories into one web-based relational system. The primary outcomes were total opioid consumption and pain scores in the recovery room. Secondary outcomes included opioid side effects, block-related complications, and total recovery room time. Multivariable logistic regression analysis was used to evaluate opioid consumption, side effects, and total recovery times. Pearson chi-square was applied to assess the level of pain between the two groups. RESULTS: Total opioid consumption was significantly less in the block group compared to those not receiving a block (0.28 mg/kg vs 0.35 mg/kg, P < 0.001, 95% CI of difference in medians 0.04-0.10 mg/kg), but there was no statistical difference in pain scores. Patients with the regional block had a lower frequency of emesis in the PACU (0.7% vs 4.3%; P < 0.005, 95% CI of difference: 2-25) and shorter PACU times (93 vs 108 minutes, P < 0.001, 95% CI of difference: 8-23 minutes). CONCLUSION: Our study supports the clinical effectiveness of suprainguinal fascia iliaca blocks in young patients undergoing arthroscopic hip surgery.

Ultrasound-guided lumbar plexus block in children and adolescents using a transverse lumbar paravertebral sonogram: Initial experience.

BACKGROUND: The clinical reliability and reproducibility of ultrasound-guided lumbar plexus blocks is not established in pediatric populations. We present the results of a combined nerve stimulation ultrasound-guided lumbar plexus block using the vertebral body, transverse process, and psoas muscle as landmarks on a transverse lumbar paravertebral sonogram with mid-axillary transducer placement, "shamrock method," in children and adolescents. AIMS: Our primary objective was to determine the rate of achieving sensory changes in the lumbar plexus distribution. Secondary outcomes were performance time, reliability of echo-landmarks, measures of patient comfort, and complications. METHODS: We reviewed prospectively collected quality assurance data and electronic medical records of 21 patients having major orthopedic surgery with lumbar plexus block catheter for postoperative analgesia. RESULTS: Twenty-one patients were studied with mean age and weight (SD, range) of 13.6 years (3.8, 6-18) and 49.3 kg (18.6, 19.2-87.6). Surgical procedures included periacetabular osteotomy, pelvic osteotomy, and proximal femoral osteotomy. Mean volume of 0.5 mL/kg (0.05) 0.2% ropivacaine produced thermal sensory changes to femoral and lateral femoral cutaneous nerves in 20/21 (95% CI 0.76 to >0.99) and 19/21 (95% CI 0.70-0.99) patients. Identification of transverse process (TP), vertebral body (VB), and psoas muscle (PM): 21/21 (95% CI 0.86-1.0). Average block performance time was 9:08 minutes (2:09, 2-13). Average opioid consumption (SD) in operating room, postanesthesia care unit, 0-12 and 12-24-hour periods were 0.17 mg/kg (0.08), 0.08 mg/kg (0.06), 0.06 mg/kg (0.06), and 0.06 mg/kg (0.05). Median pain score by severity category in postanesthesia care unit: (0-3) 66.7%, (4-6) 28.5%, (>7) 4.8%; 0-12 hours: (0-3) 76.2%, (4-6) 19.0%, (>7) 4.8%; 12-24 hours: (0-3) 57.2%, (4-6) 42.8%, (>7) 0%. No complications were recorded. CONCLUSION: Ultrasound guidance using lateral imaging of transverse process, vertebral body, and psoas muscle allows practitioners to reach the nerves of the lumbar plexus and achieve sensory block in pediatric patients with a high success rate.