A Single Center's Experience With Spinal Anesthesia for Pediatric Patients Undergoing Surgical Procedures.

PURPOSE: To perform a single institution review of spinal instead of general anesthesia for pediatric patients undergoing surgical procedures. Spinal success rate, intraoperative complications, and postoperative outcomes including unplanned hospital admission and emergency department visits within seven days are reported. METHODS: Retrospective chart review of pediatric patients who underwent spinal anesthesia for surgical procedures from 2016 until 2022. Data collected included patient demographics, procedure and anesthetic characteristics, intraoperative complications, unplanned admissions, and emergency department returns. RESULTS: The study cohort included 1221 patients. Ninety-two percent of the patients tolerated their surgical procedure without requiring conversion to general anesthesia, and 78% of patients that had spinals placed successfully did not receive any sedation following lumbar puncture. The most common intraoperative event was systolic blood pressure below 60 mm Hg (14%), but no cases required administration of vasoactive agents, and no serious intraoperative adverse events were observed. Post-Anesthesia Care Unit Phase I was bypassed in 72% of cases with a median postoperative length of stay of 84 min. Forty-six patients returned to the emergency department following hospital discharge, but no returns were due to anesthetic concerns. CONCLUSIONS: Spinal anesthesia is a viable and versatile option for a diversity of pediatric surgical procedures. We noted a low incidence of intraoperative and postoperative complications. There remain numerous potential advantages of spinal anesthesia over general anesthesia in young pediatric patients particularly in the ambulatory setting. LEVEL OF EVIDENCE: IV. TYPE OF STUDY: Retrospective cohort treatment study.

Opioid-Sparing Anesthetic Technique for Pediatric Patients Undergoing Adenoidectomy: A Pilot Study.

INTRODUCTION: An opioid-sparing anesthetic involves a multi-modal technique with non-opioid medications targeting different analgesic pathways. Such techniques may decrease adverse effects related to opioids. These techniques may be considered in patients at higher risk for opioid-related adverse effects including obstructive sleep apnea or sleep disordered breathing. METHODS: A prospective, pilot study was performed in 10 patients (3-8 years of age), presenting for adenoidectomy. The perioperative regimen included oral dextromethorphan (1 mg/kg) and acetaminophen (15 mg/kg) plus single boluses of intraoperative dexmedetomidine (0.5 µg/kg) and ketamine (0.5 mg/kg). Pain scores were assessed in the post anesthesia care unit (PACU) using the FLACC (Face, Legs, Activity, Cry, Consolability) scale. Patients with a pain score >4 received fentanyl as needed. PACU time, pain scores, and parent satisfaction were recorded. Postoperatively, patients were instructed to use oral acetaminophen or ibuprofen every 6 hours as needed for pain. RESULTS: The study cohort included 10 patients, 3-8 years of age. All patients had opioid-free anesthetic care. PACU time ranged from 24 to 102 minutes (median: 56 minutes). FLACC pain scores were 0 for all PACU assessments. Nine patients were discharged home and 1 patient had a planned overnight admission. Following hospital discharge, the pain scores were satisfactory during the 72-hour study period and 90% of the patients' guardians were satisfied or highly satisfied with their child's pain control. CONCLUSION: This opioid-sparing approach provided safe and effective pain control as well as parental satisfaction following adenoidectomy in children. Additional prospective studies are needed to determine whether this regimen is effective in a larger cohort of patients with and for other otolaryngology procedures.

The otolaryngologist's and anesthesiologist's collaborative role in a pandemic: A large quaternary pediatric center's experience with COVID-19 preparation and simulation.

There has been a rapid global spread of a novel coronavirus, the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), which originated in Wuhan China in late 2019. A serious threat of nosocomial spread exists and as such, there is a critical necessity for well-planned and rehearsed processes during the care of the COVID-19 positive and suspected patient to minimize transmission and risk to healthcare providers and other patients. Because of the aerosolization inherent in airway management, the pediatric otolaryngologist and anesthesiologist should be intimately familiar with strategies to mitigate the high-risk periods of viral contamination that are posed to the environment and healthcare personnel during tracheal intubation and extubation procedures. Since both the pediatric otolaryngologist and anesthesiologist are directly involved in emergency airway interventions, both specialties impact the safety of caring for COVID-19 patients and are a part of overall hospital pandemic preparedness. We describe our institutional approach to COVID-19 perioperative pandemic planning at a large quaternary pediatric hospital including operating room management and remote airway management. We outline our processes for the safe and effective care of these patients with emphasis on simulation and pathways necessary to protect healthcare workers and other personnel from exposure while still providing safe, effective, and rapid care.

Postoperative Clinical Course and Opioid Consumption Following Repair of Congenital Diaphragmatic Hernia: Open Versus Thoracoscopic Techniques.

Introduction: Minimally invasive surgical (MIS) approaches for thoracic procedures in adults result in an improved postoperative course with less pain, but there are limited data on similar procedures in neonates. We aimed to evaluate postoperative opioid consumption and pain management practices in neonates and infants following MIS versus open repair of congenital diaphragmatic hernia (CDH). Materials and Methods: This was an IRB approved, retrospective study from 2012 to 2016. Demographic data, intraoperative analgesic regimen, total 7-day postoperative opioid consumption, and use of adjunctive pain medications were compared by surgery type (open versus MIS). Secondary measures included time to tracheal extubation, oral feeds, and discharge home. Results: The study cohort included 28 patients (13 female, median age 5 days, average gestational age 39 weeks, and weight 3 kg). MIS was performed in 8 patients. In the first 7 postoperative days, the median postoperative opioid consumption was 0.3 mg/kg of oral morphine equivalents (interquartile range [IQR] 0.2, 18.3) in the MIS group versus 32.3 mg/kg (IQR 9.9, 53.6) in the open group (95% CI of differences in medians: 8.2-42.9; P = .006). No difference was noted in intraoperative opioid administration. Among secondary outcomes, length of stay was significantly longer in the open group. Conclusions: Although several factors may impact the hospital course of neonates with CDH, we found that patients had a more than 100-fold difference in median opioid consumption following repair with MIS versus an open approach. The study also noted significant variation in analgesic regimens suggesting other avenues for improved care of postsurgical neonates.

Adenotonsillectomy and postoperative respiratory adverse events: A retrospective study.

OBJECTIVES: Postoperative respiratory adverse events (PRAEs) are known complications following adenotonsillectomy (AT). Clinical data at a single institution were reviewed to investigate the factors that may contribute to PRAEs in the postanesthesia care unit (PACU). The relationship between PRAEs in the PACU and escalation of care, defined as either an unplanned admission for outpatient surgery or unplanned pediatric intensive care unit (PICU) admission, was investigated. METHODS: The perioperative records for all patients who underwent AT from 2016 to 2018 were reviewed. The surgical procedure was performed at both the main campus and the ambulatory surgery center in accordance with the institutional obstructive sleep apnea (OSA) guidelines. Patient characteristics and intraoperative medications were compared. Categorical variables were summarized as counts with percentages and compared using chi-square tests or Fisher's exact tests. Continuous variables were summarized as medians with interquartile ranges and compared using rank-sum tests. Multivariable logistic regression was performed to evaluate the association of intraoperative dosing with the occurrence of PRAEs. RESULTS: The study cohort included 6110 patients. Ninety-three patients (2%) experienced PRAEs in the PACU. Of these 93 patients, 14 (15%) resulted in an escalation of care, nearly all of which were unplanned PICU admissions. PRAEs tended to occur in younger patients, non-Hispanic black patients, and those with a higher American Society of Anesthesiologists (ASA) status. CONCLUSIONS: PRAEs are infrequent after AT at a tertiary institution with OSA guidelines in place. However, when PRAEs do occur, escalation of care may be required. Risk factors include age, ethnic background, and ASA physical status. LEVEL OF EVIDENCE: III.

Impact of coblation versus electrocautery on acute post-operative outcomes in pediatric tonsillectomy.

OBJECTIVE: Based on previous studies in the pediatric population, it remains unclear whether there is a difference in postoperative pain between two widely used tonsillectomy techniques: coblation and bovie electrocautery. This large prospective study investigates whether postoperative pain scores differ between these two surgical techniques for tonsillectomy. METHODS: Prospective, non-randomized study of children aged 2-8 enrolled in a randomized controlled trial of single-dose intravenous acetaminophen for pain associated with adenotonsillectomy. Included procedures occurred between October 2012 and June 2015 at a tertiary referral center. Only patients whose operations exclusively used coblation or electrocautery and who required postoperative admission for extended observation were included. Follow-up period was the length of inpatient stay. Patients and nurses who recorded the pain scores were blinded to the tonsillectomy technique. RESULTS: A total of 183 patients were included: 117 coblation cases and 66 electrocautery cases. Pain scores in the surgical recovery unit and pain scores after admission to the floor unit were not significantly different between coblation and electrocautery, either before or after adjustment for patient age, body mass index, intravenous acetaminophen use, and surgeon. There was also no difference in length of stay, readmission rate, or post-tonsillectomy hemorrhage. CONCLUSIONS: Coblation and electrocautery tonsillectomy are associated with similar post-operative pain scores in the recovery and inpatient units in the pediatric population. As coblation is costlier, the results of this study may affect which tool is used by otolaryngologists from a cost-benefit perspective. LEVEL OF EVIDENCE: III.

Analgesic effects of methadone and magnesium following posterior spinal fusion for idiopathic scoliosis in adolescents: a randomized controlled trial.

PURPOSE: To provide optimal conditions for neurophysiological monitoring and rapid awakening, remifentanil is commonly used during pediatric spinal surgery. However, remifentanil may induce hyperalgesia and increase postoperative opioid requirements. We evaluated the potential of methadone or magnesium to prevent remifentanil-induced hyperalgesia. METHODS: Using a prospective, randomized, blinded design, adolescents presenting for posterior spinal fusion to treat idiopathic scoliosis were assigned to receive desflurane with remifentanil alone (REMI), remifentanil + methadone (MET) (0.1 mg/kg IV over 15 min), or remifentanil + magnesium (MAG) (50 mg/kg bolus over 30 min followed by 10 mg/kg/h). Primary outcomes were opioid requirements and postoperative pain scores. Secondary outcomes included intraoperative anesthetic requirements, neurophysiological monitoring conditions, and emergence times. RESULTS: Data analysis included 60 patients. Total opioid requirement (hydromorphone) in the REMI group (received perioperatively and on the inpatient ward) was 0.34 ± 0.11 mg/kg compared to 0.26 ± 0.10 mg/kg in the MET group (95% confidence interval (CI) of difference: - 0.14, - 0.01; p = 0.035). The difference in opioid requirements between the REMI and MET group was related to intraoperative dosing (0.04 ± 0.02 mg/kg vs. 0.02 ± 0.01 mg/kg; 95% CI of difference: - 0.01, - 0.02; p = 0.003). No difference was noted in pain scores, and no differences were noted when comparing the REMI and MAG groups. CONCLUSION: With the dosing regimens in the current study, the only benefit noted with methadone was a decrease in perioperative opioid requirements. However, given the potential for hyperalgesia with the intraoperative use of remifentanil, adjunctive use of methadone appears warranted.

General Anesthesia With Dexmedetomidine and Remifentanil in a Neonate During Oracotomy and Resection of a Congenital Cystic Adenomatoid Malformation.

Based on animal data, concern has been expressed regarding the potential deleterious neurocognitive effects of general anesthesia during infancy and early life. Although there are no definitive data to prove this effect, the neonatal period has been suggested to be the most vulnerable period. While various inhaled and intravenous anesthetic agents have been implicated, dexmedetomidine and the opioids may be devoid of such effects. However, there are limited data regarding the combination of these agents during neonatal surgery and anesthesia. We present the use of these agents in combination with epidural anesthesia for postoperative analgesia in a 1-day-old neonate during thoracotomy and excision of a congental cystic adenomatoid malformation. Previous reports of the use of this unique combination of agents are reviewed and their role in this scenario discussed.

The Utility of the Modified Yale Preoperative Anxiety Scale for Predicting Success in Pediatric Patients Undergoing MRI Without the Use of Anesthesia.

PURPOSE: MRI is a common modality for diagnostic imaging. In children, general anesthesia is often required to complete MRI examinations. Simulation training can reduce the need for anesthesia in some children. Reliable screening tools to select who could benefit from practice MRI sessions are lacking. This study evaluates the use of the modified Yale Preoperative Anxiety Scale (mYPAS) in effectively identifying patients who may benefit from simulation-based training. METHODS: Children aged 5 and older who were originally scheduled for MRI with anesthesia in 2015 to 2016 were prospectively recruited for simulation-based training. The mYPAS assessment was performed by trained certified child life specialists before and after practice MRI sessions. The primary outcome was whether mYPAS could predict completing an MRI examination without anesthesia. RESULTS: Eighty patients (43 boys and 37 girls, age 8.5 ± 3.0 years) were enrolled in the study. Eleven subjects (14%) required general anesthesia to complete the MRI examination despite participating in the simulation. In the overall cohort, mYPAS scores improved after simulation from 31 ± 11 to 27 ± 9 (95% confidence interval of difference, -6, -2; P < .001 by paired t test). Receiver operating characteristic curve analysis found that presimulation mYPAS had good utility for predicting anesthesia requirement for MRI completion (area under the curve = 0.81). A presimulation mYPAS score > 33 predicted need for anesthesia with 82% sensitivity and 78% specificity. CONCLUSIONS: The mYPAS is a quick screening tool to identify pediatric patients who could benefit from simulation training by being able to complete an MRI examination without anesthesia.

Implementation of a perioperative surgical home protocol for pediatric patients presenting for adenoidectomy.

INTRODUCTION: The perioperative surgical home (PSH) is a patient-centered model designed to improve health, streamline the delivery of health care, and reduce the cost of care. Following the national introduction of PSH in 2014 by the ASA, adult hospitals have reported success with this model, with studies validating the benefits of PSH including reducing length of stay, lowering costs, and improving patient satisfaction. METHODS: Eligible patients, ranging in age from 16-35 months of age, were identified by the pre-admission testing (PAT) registered nurses (RNs) and faculty anesthesiologists upon review of the patient history. Participation in Pediatric PSH (PPSH) was introduced to the families by the pediatric otolaryngologists. Either the patient's family or physician team could elect to decline participation in the PPSH model. On the day of surgery, the PPSH protocol included a paper checklist to ensure that all patients met eligibility standards. A standardized order-set was implemented in the electronic medical record (EMR) for pre-operative and post-operative nursing instructions and eligible medications. Patients received at least 3 hours of postoperative monitoring prior to discharge home to address postoperative issues. Prior to discharge, caregivers watched a standard teaching video, available on YouTube, which was developed in conjunction with the hospital educational and technical support staff. An attending anesthesiologist made a postoperative followup phone call on the evening of surgery to ensure no untoward events were experienced by the patient as well as elicit caregiver feedback concerning the discharge process. The protocol was discontinued if at any time family members, physicians, or nurses were uncomfortable with completing the protocol or felt that the patient did not meet discharge criteria. RESULTS: One hundred sixty-six patients were evaluated for PPSH inclusion. Forty patients were excluded (23 did not meet inclusion criteria, 5 had viral upper respiratory infections, and 10 for other non specified reasons such as tonsillectomy added, sibling with surgery, and incorrect documentation). Therefore, a total of 126 were eligible for PPSH (male/female = 69/57; age 22 ± 4 months). The comparison group included 1,029 children (male/female = 645/384; age 22 ± 7 months of age) undergoing adenoidectomy who were not evaluated for PPSH inclusion. Of the 126 PPSH participants included in the analysis, 27 were excluded at some point during the pathway. Nine cases experienced oxygen desaturation, laryngospasm, or required supplemental oxygen. Noncompliance with the protocol was noted in 5 cases, parental concerns were noted in 17 cases, and there were concerns from the pediatric anesthesiologist or otolaryngologist in 5 cases. In the comparison group, hospital length of stay was significantly longer than in the PSH group (p<0.001), with 524 (51%) patients discharged on the day of service compared to 99 (79%) in the PSH group. No major morbidity or mortality occurred. There was no difference between the two groups in return to the emergency department (ED) visits within 30 days (PSH: 7/126, 6%; control: 59/1,029, 6%; p=0.935). Within 14 days of the procedure, 4 PPSH patients visited urgent care or a primary care physician; 4 visited the ED; and 1 was readmitted to the hospital. Twenty families contacted the otorhinolaryngology triage phone line primarily related to pain and fever. CONCLUSION: We present our experience and success in developing a PPSH for patients, ranging in age from 16 to 35 months of age, undergoing adenoidectomy either alone or with tympanostomy tube insertion by protocolizing care, collaborating among care providers, and educating families. With this process in place, a significant percentage of these patients who were previously admitted were discharged home the same day of surgery.

Double-Blind Randomized Placebo-Controlled Trial of Single-Dose Intravenous Acetaminophen for Pain Associated With Adenotonsillectomy in Pediatric Patients With Sleep-Disordered Breathing.

OBJECTIVES: Adequate pain control is an important component in the postoperative outcome for pediatric adenotonsillectomy patients with sleep-disordered breathing (SDB). Intravenous acetaminophen appears to be a favorable analgesic adjunct owing to its predictable pharmacokinetics and opioid-sparing effects; however, its role in pediatric adenotonsillectomy pain management remains unclear. METHODS: In this prospective, randomized, double-blinded, controlled study, subjects with the diagnosis of SDB, aged 2 to 8 years, who required extended postoperative admission, received intravenous acetaminophen (15 mg/kg) or saline placebo intraoperatively in addition to morphine (0.1 mg/kg) for postoperative surgical analgesia. Pain scores in the postanesthesia care unit (PACU) using the FLACC (Faces, Leg, Activity, Cry, Consolability) score were used to determine the need for supplemental analgesic agents in the PACU. The PACU time and time to the first request for pain medication on the inpatient ward were also measured. RESULTS: A total of 239 patients were included in the final data analysis (118 in the intravenous acetaminophen group and 121 in the saline placebo group). The 2 groups did not differ in the proportion of patients reaching FLACC scores = 4 in the PACU (p = 0.223); mean FLACC scores in the PACU (p = 0.336); mean PACU time (p = 0.883); or time to requesting pain medication on the inpatient ward (p = 0.640). CONCLUSIONS: A single intraoperative dose of intravenous acetaminophen did not alter the postoperative course of pediatric patients with SDB following adenotonsillectomy.

MRI Utilization and the Associated Use of Sedation and Anesthesia in a Pediatric ACO.

BACKGROUND AND OBJECTIVES: MRI is commonly used in the pediatric population and often requires sedation or general anesthesia to complete. This study used data from a pediatric accountable care organization (ACO) to investigate trends in MRI utilization and in the requirement for anesthesia to complete MRI examinations. METHODS: The Partners for Kids (PFK) ACO claims database was queried for MRI examination encounters involving patients 0 to 18 years old from 2009 to 2014, with utilization expressed as encounters per 10,000 PFK members-months. Data were limited to 2011 to 2014 to ensure consistent billing of anesthesia services. Encounters were classified according to the presence of procedure codes for anesthesia or sedation. RESULTS: MRI utilization was approximately constant over the study period at 11 to 12 encounters per 10,000 member-months. The need for anesthesia increased from 21% to 28% of encounters over 2011 to 2014. The latter increase was shared across 1- to 6-year-old, 7- to 12-year-old, and 12- to 18-year-old subgroups. In multivariable regression analysis of monthly utilization, increasing need for anesthesia could not be attributed to secular trends in patient demographics or types of examinations ordered. Paid cost data were available for outpatient MRIs, and MRIs with sedation accounted for an increasing share of these costs (from 22% in 2011 to 33% in 2014). CONCLUSION: There was an increasing need for anesthesia services to complete MRI examinations in this pediatric population, resulting in increasing cost of MRI examinations and presenting a challenge to ACO cost containment.

Routine Bronchoscopy and Fogarty Catheter Occlusion of Tracheoesophageal Fistulas.

INTRODUCTION: Use of a Fogarty catheter for emergent occlusion of tracheoesophageal fistulas (TEFs) has been described for use in unstable neonates. Our purpose was to describe a case series of elective Fogarty catheter occlusion of the TEF. MATERIALS AND METHODS: A formal operative laryngoscopy and rigid bronchoscopy were performed with Fogarty catheter placement into the fistula before surgical intervention. The balloon was inflated and gentle traction provided occlusion of the tract. An endotracheal tube was then placed in a midtracheal location irrespective of fistulous tract location. The Fogarty catheter was removed at the time of fistula ligation. RESULTS: Six patients underwent Fogarty catheter occlusion of the TEF at the time of repair. The average gestational age was 38 ± 2 weeks and birth weight was 2499 ± 399 g. Associated anomalies or comorbidities were present in 2 of 6 patients (33%). Five patients (83%) had an esophageal atresia with distal TEF, all of whom underwent surgical intervention before day of life (DOL) 2. Of these patients, 3 were performed thoracoscopically, 1 was converted from thoracoscopic to open, and 1 was initiated as an open procedure. One patient had an H-type fistula, which was repaired through a cervical approach on DOL 48. Average time required for both bronchoscopy and Fogarty placement was 10 ± 2 minutes. There were no complications associated with Fogarty catheter placement and catheter dislodgement did not occur during any of the procedures. CONCLUSION: Elective Fogarty catheter occlusion of TEF can be performed safely and expeditiously, alleviating many perioperative challenges of TEF.

Acetaminophen for analgesia following pyloromyotomy: does the route of administration make a difference?

BACKGROUND: During the perioperative care of infants with hypertrophic pyloric stenosis, an opioid-sparing technique is often advocated due to concerns such as postoperative hypoventilation and apnea. Although the rectal administration of acetaminophen is commonly employed, an intravenous (IV) preparation is also currently available, but only limited data are available regarding IV acetaminophen use for infants undergoing pyloromyotomy. The objective of the current study was to compare the efficacy of IV and rectal acetaminophen for postoperative analgesia in infants undergoing laparoscopic pyloromyotomy. METHODS: A retrospective review of the use of IV and rectal acetaminophen in infants undergoing laparoscopic pyloromyotomy was performed. The efficacy was assessed by evaluating the perioperative need for supplemental analgesic agents, postoperative pain scores, tracheal extubation time, time in the postanesthesia care unit, time to oral feeding, and time to hospital discharge. RESULTS: The study cohort included 68 patients, of whom 34 patients received IV acetaminophen and 34 received rectal acetaminophen. All patients also received local infiltration of the surgical site with 0.25% bupivacaine. No intraoperative opioids were administered. There was no difference between the two groups with regard to postoperative pain scores, need for supplemental analgesic agents, time in the postanesthesia care unit, or time in the hospital. There was no difference in the number of children who tolerated oral feeds on the day of surgery or in postoperative complications. CONCLUSION: Our preliminary data suggest that there is no clinical difference or advantage with the use of IV versus rectal acetaminophen in infants undergoing laparoscopic pyloromyotomy.

Time to talk about work-hour impact on anesthesiologists: The effects of sleep deprivation on Profile of Mood States and cognitive tasks.

BACKGROUND: A physician's fatigue raises significant concerns regarding personal and patient safety. Effects of sleep deprivation on clinical performance and the quality of patient care are major considerations of today's health care environment. AIM: To evaluate the impact of partial sleep deprivation after a 17-h overnight call (3 pm-7 am) on the mood status and cognitive skills of anesthesiologists in an academic clinical hospital setting, as compared to these parameters during regular working hours. METHODS: Taking circadian rhythm into account, the following measures were assessed in 21 pediatric anesthesiologists at two time points over the course of the study; (i) between 7 and 8 am on a regular non call day, and (ii) between 7 and 8 am after a 17-h in-house call (3 pm-7 am). Six mood states were assessed using the Profile of Mood States. A Total Mood Disturbance (TMD) score was obtained as the sum of all mood scores minus vigor. The total score provides a global estimate of affective state. Simple cognitive tests were similarly administered to assess cognitive skills. A two-tailed paired t-test was used to compare data between regular and post call days. A P < 0.05 was used. RESULTS: The study cohort included 21 pediatric anesthesiologists at a tertiary care children's hospital. Tension, anger, fatigue, confusion, TMD, irritability, feeling jittery, and sleepiness were significantly affected (P < 0.05). A decrease in vigor, energy, and confidence was observed after a night call shift (P < 0.05). There was also a decrease in being "talkative" after the call shift (P < 0.05). CONCLUSION: Partial sleep deprivation affects the total mood status of anesthesiologists and impacts their cognitive skills. These findings are particularly relevant in a context of increased work expectation, particularly on clinical performance in our modern medical system. Such observations suggest that there may be changes that impact the safety of our patients and the quality of health care that is provided.

A prospective, open-label trial of clevidipine for controlled hypotension during posterior spinal fusion.

OBJECTIVES: Controlled hypotension is one means to limit or avoid the need for allogeneic blood products. Clevidipine is a short-acting, intravenous calcium channel antagonist with a half-life of 1 to 3 minutes due to rapid metabolism by non-specific blood and tissue esterases. To date, there are no prospective evaluations with clevidipine in the pediatric population. We prospectively evaluated the dosing requirements, efficacy, and safety of clevidipine for ontrolled hypotension during spinal surgery for neuromuscular scoliosis in the pediatric population. METHODS: Patients undergoing posterior spinal fusion for neuromuscular scoliosis were eligible for inclusion. The study was an open label, observational study. Maintenance anesthesia included desflurane titrated to maintain a bispectral index at 40 to 60 and a remifentanil infusion. Motor and somatosensory evoked potentials were monitored intraoperatively. When the mean arterial pressure (MAP) was ≥ 65 mmHg despite remifentanil at 0.3 mcg/kg/min, clevidipine was added to maintain the MAP at 55 to 65 mmHg. Clevidipine was initiated at 0.25 to 1 mcg/kg/min and titrated up in increments of 0.25 to 1 mcg/kg/min every 3 to 5 minutes to achieve the desired MAP. RESULTS: The study cohort included 45 patients. Fifteen patients (33.3%) did not require a clevidipine infusion to maintain the desired MAP range, leaving 30 patients including 13 males and 17 females for analysis. These patients ranged in age from 7.9 to 17.4 years (mean ± SD: 13.7 ± 2.2 years) and in weight from 18.9 to 78.1 kg (mean ± SD: 43.4 ± 14.2 kg). Intraoperatively, the clevidipine infusion was stopped in 6 patients as the surgeon expressed concerns regarding spinal cord perfusion and requested a higher MAP than the study protocol allowed. The data until that point were included for analysis. The target MAP was initially achieved at a mean time of 8.9 minutes. Sixteen of the 30 patients (53.3%) achieved the target MAP within 5 minutes. Heart rate (HR) increased from a baseline of 83 ± 16 to 86 ± 15 beats per minute (mean ± SD) (p=0.04) with the administration of clevidipine. No patient had a HR increase ≥ 20 beats per minute or required the administration of a ß-adrenergic antagonist. The duration of the clevidipine administration varied from 8 to 527 minutes (mean ± SD: 160 ± 123 minutes). The maintenance infusion rate of clevidipine varied from 0.25 to 5.0 mcg/kg/min (mean ± SD: 1.4 ± 1.1 mcg/kg/min). Clevidipine was paused a total of 43 times in the 30 cases. In 18 of the 30 patients (60%), the clevidipine infusion was temporarily paused more than once due to a MAP < 55 mmHg. A fluid bolus was administered to only 1 patient to treat the low MAP. No patient required the administration of a vasoactive agent for hypotension. When the clevidipine infusion was discontinued as controlled hypotension was no longer required, the MAP returned to baseline or ≥ 65 mmHg within 10 minutes in 12 of the 30 patients (40%). CONCLUSIONS: Clevidipine can be used to provide controlled hypotension during posterior spinal fusion. The response of the MAP, both the onset and duration of action, were rapid. Although titration of the infusion with occasional pauses of administration may be needed, excessive hypotension was not noted.

A preliminary study of volatile agents or total intravenous anesthesia for neurophysiological monitoring during posterior spinal fusion in adolescents with idiopathic scoliosis.

STUDY DESIGN: A prospective randomized controlled trial. OBJECTIVE: The purpose of this study was to prospectively compare the efficacy of neurophysiological monitoring during general anesthesia with either a total intravenous technique or with the volatile anesthetic agent, desflurane. SUMMARY OF BACKGROUND DATA: A total intravenous anesthetic technique is generally chosen when neurophysiological monitoring is used as it has been shown to facilitate such monitoring. Despite this, with prolonged infusions of propofol, prolonged awakening times may be seen, which may impact the time required for postoperative neurological assessment or more importantly result in significant delays, should a wake-up test become necessary. To date, there are no prospective trials comparing intravenous techniques with a volatile agent-based anesthetic technique and its effects on neurophysiological monitoring. METHODS: This prospective study compares somatosensory evoked potential and motor evoked potential monitoring during posterior spinal fusion in 30 adolescents. The patients were randomized to receive a total intravenous technique with propofol-remifentanil or a volatile agent-based technique with desflurane-remifentanil. RESULTS: The groups were similar with regard to age, weight, height, body mass index, Cobb angle, and distribution of Lenke classifications. No differences were noted in anesthesia time, surgery time, intraoperative fluids, or estimated blood loss between the 2 groups. Time to eye opening, time to following commands, and time to tracheal extubation were shorter in the volatile anesthesia group than the total intravenous anesthesia group. No clinically significant difference was noted in the amplitude or latency of somatosensory evoked potential monitoring. Although statistically significantly greater voltage amplitude was required to generate a motor evoked potential, the voltage amount was within a clinically acceptable range. CONCLUSION: Our data demonstrate that a volatile agent-based anesthetic regimen is feasible even during neurophysiological monitoring. Advantages include a more rapid awakening and the feasibility of a rapid wake-up test (<5 min) in the event that irreversible changes in neurophysiological monitoring are noted. LEVEL OF EVIDENCE: 2.

Clinical evaluation of a novel LMA with a color-coded pressure gauge.

BACKGROUND: Unintended hyperinflation of the cuff of a laryngeal mask airway (LMA) may be associated with increased airway morbidity and postoperative pain. While the manufacturers recommend a cuff pressure of ≤ 60 cmH(2)O, in usual clinical practice, there is no method used to determine the intracuff pressure. The purpose of this prospective study was to evaluate the accuracy of a newly designed LMA with a built in pressure gauge intended to alert the clinician to elevated intracuff pressures. The pressure gauge has a color code system intended to reflect the intracuff pressure with green being 40-60 cmH(2)O. METHODS: There was no change dictated in clinical practice for these patients. Per our usual practice, the LMA was removed from the package and inserted with the cuff partially inflated. Additional air was added to the cuff using a syringe as needed to ensure a seal during positive pressure ventilation to a peak inflating pressure (peak ventilating pressure) of 20-25 cmH(2)O. The clinicians placing the LMA did not use the pressure gauge for clinical feedback during cuff inflation. Immediately after LMA placement, the pressure in the cuff of the LMA was measured using a hand held manometer by an independent reviewer not part of the patient's anesthetic management. The color indicated on the pressure gauge (yellow, green or red) was recorded prior to pressure sampling. Additional data collected included the patient's demographic data (age, weight, and gender), the size of the LMA, and whether air was added to the cuff. RESULTS: The study cohort included 100 children, ranging in age from 3 months to 19 years and in weight from 5.4 to 80.1 kg. One patient was excluded due to malfunction of the pressure gauge and pilot balloon of the LMA. The intracuff pressure as measured by manometer correlated appropriately with the color coding of the pressure gauge in 94 of the 99 (95%) of the LMA's tested. CONCLUSIONS: Given the potential association of excessive intracuff pressures with postoperative sore throat and the inability to ensure acceptable intracuff pressures using clinical judgment, this new LMA may allow a simple means of achieving this goal without the use of costly devices (manometers) in every operating room. In 95% of the LMA's tested, the color reading correlated appropriately with the intracuff pressure.

Respiratory support including emergent extracorporeal membrane oxygenation as a bridge to airway dilatation following perioperative bronchial occlusion.

During the perioperative period, various factors may lead to intraoperative and postoperative respiratory failure including upper airway obstruction, bronchospasm, acid aspiration, laryngospasm, and pulmonary hypertension. Regardless of the etiology, prompt recognition with treatment of the inciting event is required to ensure a successful recovery. We report the intraoperative development of respiratory insufficiency and failure in a 17-year-old girl who was status post lung transplant undergoing bronchoscopy. During bronchoscopy, complete left main stem obstruction occurred due to a fibrinous mass near the bronchial anastomosis site. Various modalities were used to support the patient intraoperatively and then postoperatively including low tidal volume/high PEEP ventilation, inhaled nitric oxide (iNO), and high frequency oscillatory ventilation (HFOV). In the CTICU, emergent bedside venovenous extracorporeal membrane oxygenation (ECMO) was used as a bridge to the recovery of respiratory function which was achieved with removal of the occluding fibrinous airway tissue followed by balloon dilatation and stenting of the left main stem bronchus. The potential perioperative causes of respiratory failure are reviewed and support techniques including conventional ventilator strategies, iNO, HFOV and ECMO discussed.