Suprazygomatic Maxillary Nerve Block in Palatoplasty: A Retrospective Cohort Study of Perioperative Outcomes in Syndromic and Non-Syndromic Children.

OBJECTIVE: This study compares the impact of surgical site infiltration of local anesthesia alone to surgical site infiltration plus suprazygomatic maxillary nerve block (SMB) in non-syndromic and syndromic children undergoing primary palatoplasty. DESIGN: Retrospective cohort study of intra- and post-operative outcomes and opioid utilization in children undergoing palatoplasty by a single surgeon. SETTING: Urban, academic, tertiary care children's hospital. PATIENTS, PARTICIPANTS: Children 24 months or younger undergoing primary palatoplasty were included (n = 102). Exclusion criteria were concurrent painful procedures, history of neonatal abstinence syndrome, and nurse-controlled analgesia (n = 30). INTERVENTIONS: All patients received epinephrine-containing local anesthetic infiltrated at the surgical site. Fifty-seven also underwent placement of ultrasound-guided SMB. MAIN OUTCOME MEASURE(S): Intra-operative opioid requirement, duration of anesthesia, time to wake up, post-operative opioid requirement, hypoxemic episodes, need for respiratory support, FLACC scores, and length of stay. RESULTS: When controlling for syndromic status and cleft phenotype, SMB was associated with a 57% reduction in intraoperative opioid requirements (95% CI = 15-81%, p = 0.024) but also with a 29% (∼5-min) increase in wake-up time post-surgery (95% CI = 3-50%, p = 0.048). Postoperatively, SMB was linked to a 18% reduction in hospital stay length (95% CI = 2-31%, p = 0.027) and a 88% reduction in opioid requirements within 24 h after surgery (p = 0.006). Desaturations and new respiratory support requirements were unaffected by SMB. CONCLUSIONS: Compared to surgical site infiltration of local anesthetic alone, adding SMB reduces intra- and postoperative narcotic requirements and decreases length of stay. These benefits apply to both syndromic and non-syndromic children. SMB does not meaningfully affect respiratory outcomes.

Efficacy of regional anesthesia in hip preservation surgeries: a systematic review.

The purpose of this study was to review the current literature on perioperative pain management in hip arthroscopy, periacetabular osteotomy and surgical hip dislocation. A systematic review of the literature published from January 2000 to December 2022 was performed. Selection criteria included published randomized controlled trials, prospective reviews and retrospective reviews of all human subjects undergoing hip preservation surgery. Exclusion criteria included case reports, animal studies and studies not reporting perioperative pain control protocols. Thirty-four studies included hip arthroscopy in which peripheral nerve blocks were associated with a significant reduction in pain score (P = 0.037) compared with general anesthesia alone. However, no pain control modality was associated with a significant difference in postanesthesia care unit opioid use (P = 0.127) or length of stay (P = 0.251) compared with general anesthesia alone. Falls were the most common complication reported, accounting for 37% of all complications. Five studies included periacetabular osteotomy and surgical hip dislocation in which peripheral nerve blocks were associated with an 18% reduction in pain on postoperative Day 2, a 48% reduction in cumulative opioid use on postoperative Day 2 and a 40% reduction in hospital stay. Due to the low sample size of the periacetabular osteotomy and surgical hip dislocation studies, we were unable to determine the significant difference between the means. Due to significant between-study heterogeneity, additional studies with congruent outcome measures need to be conducted to determine the efficacy of regional anesthesia in hip arthroscopy, periacetabular osteotomy and surgical hip dislocation.

Ultrasound-guided spinal anesthesia in infants: a narrative review.

BACKGROUND/IMPORTANCE: Infant spinal anesthesia has many potential benefits. However, the delivery of infant spinal anesthesia is technically challenging. The landmark-based technique has not changed for over a century. Advancements in ultrasound technology may provide an opportunity to improve infant spinal procedures. OBJECTIVE: Our primary objective is to conduct a comprehensive review of the current literature on ultrasonography for spinal anesthesia in infants. Given the narrow scope of this topic, our secondary objective is to review the current literature on ultrasonography for lumbar puncture in infants. EVIDENCE REVIEW: We reviewed all papers related to the use of ultrasound for infant spinal anesthesia. Two large databases were searched with key terms. Eligibility criteria were full-text articles in English. For our secondary objective, we searched one large database for key terms relating to ultrasonography and infant lumbar puncture. Eligibility criteria were the same. FINDINGS: Our primary search retrieved six articles. These consisted of four review articles, one case report, and one retrospective observational study. Our secondary search retrieved fourteen articles. These consisted of five randomized control trials, four prospective studies, three retrospective studies, and two review papers. CONCLUSIONS: Ultrasound yields high-quality images of the infant spine. Most literature regarding ultrasound for infant spinal procedures arises from emergency medicine or interventional radiology specialties. The literature on ultrasound for infant spinal anesthesia is extremely limited, but shows promise. Future studies are needed in order to determine whether ultrasound can improve the success rate for delivery of infant spinal anesthesia.

Perioperative Pain Management After Primary Palate Repair: A 3-Surgeon Retrospective Study.

OBJECTIVE: Pain management strategies following palatoplasty vary substantially. Despite efforts to reduce narcotic utilization, specific analgesic regimens are typically guided by surgeon preference. Our aim was to define analgesic variables that affect postoperative narcotic use and time to resumption of oral intake. DESIGN: This is a retrospective review from 2015 to 2018. PATIENTS: Nonsyndromic patients undergoing primary palate repair. MAIN OUTCOMES MEASURES: Analgesic variables included: local anesthetic, pterygopalatine ganglion nerve block, palatal pack, and postoperative use of ketorolac, dexamethasone, and nursing-controlled analgesia (NCA) opioid dosing. Proxy measures for pain included time to resumption of oral intake and morphine equivalence (mg/kg/h) administered. RESULTS: Veau phenotypes for the 111 patients included were: I (28%), II (19%), III (33%), IV (16%), and submucous (4%). Age, weight, local anesthetic, and postoperative use of ketorolac, dexamethasone, and palatal pack had no effect on either proxy measure (P > .05). Postoperative narcotic usage was significantly lower in patients who had an intraoperative suprazygomatic peripheral nerve block and significantly higher when NCA was utilized (P < .05). Neither variable had a significant impact on time to resumption of oral intake (P > .05). CONCLUSION: Several perioperative analgesic strategies lead to comparable postoperative consumption of narcotic and time to resume oral intake. The authors advise careful consideration of NCA due to the potential for increased narcotic utilization that we found in our institution. Based on our promising findings, further studies are warranted to assess risks, benefits, and costs of performing peripheral nerve blocks at the time of palatoplasty.

Body Mass Index (BMI) Impact on Anesthetic Safety among Adolescents Undergoing Bilateral Reduction Mammaplasty.

Obesity is common in adolescents with macromastia seeking surgery, prompting concerns over anesthesia-related complications due to obesity. This may lead to weight-based surgical policies, despite limited research. This study's purpose is to examine the impact of obesity status on perioperative anesthetic-related adverse events/surgical complications in adolescents/young adults undergoing bilateral reduction mammaplasty. Methods: A medical record query was performed to retrospectively identify patients who underwent bilateral reduction mammaplasty at our institution between January 2021 and December 2021. Patient demographics and clinical/surgical data were obtained from medical records. Pearson's chi-square, Fisher exact, and Median tests were used to examine associations between body mass index (BMI) category and clinical/demographic data. Results: Two hundred patients were included in analyses, with a median age at surgery of 18.0 years. The majority of patients were obese (63.5%, n = 127), and none were underweight. The most common comorbidity was asthma (27.0%, n = 54). There were no anesthetic-related intraoperative complications or delayed waking. The following did not significantly differ by BMI category: proportion of patients who experienced oxygen desaturation (pre-, intra-, or postoperatively), frequency of postoperative complications, and length of postanesthesia care unit and total hospital stays (P > 0.05, all). Conclusions: While institutions may implement weight-based surgical policies due to anesthesia-related complication concerns in patients with obesity, our study showed that BMI category did not significantly impact anesthetic-related adverse events/surgical complications in our sample. This suggests that such policies are not warranted in all situations, and that decisions regarding their necessity be data-driven.

Unique Issues Related to Regional Anesthesia in Pediatric Orthopedics.

This article will narrow its focus largely to notable issues related to regional anesthesia in pediatrics. First, the controversy surrounding awake versus anesthetized block placement will be addressed. There will also be a discussion on the use of regional anesthetics in orthopedics cases and the risk of compartment syndrome. Subsequently, the concern for regional anesthetics in the setting of an instrumented spine (eg, following spine fusion, baclofen pump placement) will be reviewed as such can have significant ramifications for patients. Finally, this article will consider ambulatory regional catheters and their increasing use in pediatric orthopedic anesthesia. Their utilization during the COVD epidemic played a key role in facilitating procedures that would have been canceled due to the protracted hospital bed shortage.

Gastric Point-of-Care Ultrasound in Acutely and Critically Ill Children (POCUS-ped): A Scoping Review.

Introduction: Point-of-care ultrasound (POCUS) use is increasing in pediatric clinical settings. However, gastric POCUS is rarely used, despite its potential value in optimizing the diagnosis and management in several clinical scenarios (i.e., assessing gastric emptying and gastric volume/content, gastric foreign bodies, confirming nasogastric tube placement, and hypertrophic pyloric stenosis). This review aimed to assess how gastric POCUS may be used in acute and critically ill children. Materials and Methods: An international expert group was established, composed of pediatricians, pediatric intensivists, anesthesiologists, radiologists, nurses, and a methodologist. A scoping review was conducted with an aim to describe the use of gastric POCUS in pediatrics in acute and critical care settings. A literature search was conducted in three databases, to identify studies published between 1998 and 2022. Abstracts and relevant full texts were screened for eligibility, and data were extracted, according to the JBI methodology (Johanna Briggs Institute). Results: A total of 70 studies were included. Most studies (n = 47; 67%) were conducted to assess gastric emptying and gastric volume/contents. The studies assessed gastric volume, the impact of different feed types (breast milk, fortifiers, and thickeners) and feed administration modes on gastric emptying, and gastric volume/content prior to sedation or anesthesia or during surgery. Other studies described the use of gastric POCUS in foreign body ingestion (n = 6), nasogastric tube placement (n = 5), hypertrophic pyloric stenosis (n = 8), and gastric insufflation during mechanical ventilatory support (n = 4). POCUS was performed by neonatologists, anesthesiologists, emergency department physicians, and surgeons. Their learning curve was rapid, and the accuracy was high when compared to that of the ultrasound performed by radiologists (RADUS) or other gold standards (e.g., endoscopy, radiography, and MRI). No study conducted in critically ill children was found apart from that in neonatal intensive care in preterms. Discussion: Gastric POCUS appears useful and reliable in a variety of pediatric clinical settings. It may help optimize induction in emergency sedation/anesthesia, diagnose foreign bodies and hypertrophic pyloric stenosis, and assist in confirming nasogastric tube placement, avoiding delays in obtaining confirmatory examinations (RADUS, x-rays, etc.) and reducing radiation exposure. It may be useful in pediatric intensive care but requires further investigation.

Epidural Analgesia Versus Lumbar Plexus Blockade After Hip Reconstruction Surgery in Children With Cerebral Palsy and Intrathecal Baclofen Pumps: A Comparison of Safety and Efficacy.

BACKGROUND: Epidural analgesia is commonly used for pain control after reconstructive hip surgery, but its use is controversial in the presence of an intrathecal baclofen pump (ITB). The purpose of this retrospective study was to investigate the rate of serious anesthetic and postoperative complications as well as the efficacy of epidural analgesia compared with lumbar plexus blocks (LPBs) for pain management after neuromuscular hip reconstruction in children with cerebral palsy (CP) and ITB. METHODS: Pediatric patients with CP and ITB undergoing hip reconstructive surgery from 2010 to 2019 were retrospectively identified. Patients receiving epidural analgesia were compared with those receiving LPB. Morphine milligram equivalents per kilogram were used as a surrogate measure for pain-related outcomes, as pain scores were reported with wide ranges (eg, 0 to 5/10), making it unfeasible to compare them across the cohort. Postoperative complications were graded using the modified Clavien-Dindo classification. RESULTS: Forty-four patients (26/44, 59% male) underwent surgery at an average age of 10.3 years (SD=3.4 y, range: 4 to 17 y). The majority utilized LPB (28/44, 64%) while the remaining utilized epidural (16/44, 36%). There were no differences in rates of serious complications, including no cases of ITB malfunction, damage, or infection. During the immediate postoperative course, patients who received LPB had higher morphine milligram equivalents per kilogram requirements than patients who received epidural analgesia. CONCLUSIONS: In patients with CP undergoing hip reconstruction surgery with an ITB in situ, epidural anesthesia was associated with improved analgesia compared with LPB analgesia, with a similar risk for adverse outcomes. Epidural catheters placed using image-guided insertion techniques can avoid damage to the ITB catheter while providing effective postoperative pain control without increasing rates of complications in this complex patient population. LEVEL OF EVIDENCE: Level III.

Epidural catheter placement in children with baclofen pumps.

BACKGROUND: Children with cerebral palsy often suffer from increased tone, which can be treated with intrathecal baclofen via implanted pump. Additionally, they often require major orthopedic surgery for hip reconstruction; however, the presence of an intrathecal baclofen pump is a relative contraindication to regional anesthesia due to concerns about damaging the intrathecal baclofen pump system. AIMS: (a) To evaluate adverse events related to placing epidural catheters in children with intrathecal baclofen pumps and (b) describe our multidisciplinary approach to the care of these complex patients. METHODS: Children with cerebral palsy and intrathecal baclofen pump in situ who underwent hip reconstruction between 2010 and 2019 and had a perioperative epidural placed were reviewed retrospectively. Charts were assessed for adverse events or intrathecal baclofen complications. Fluoroscopic images were reviewed to evaluate the proximity between epidural and intrathecal baclofen catheters. The process of coordinating multiple services was examined. RESULTS: Sixteen children met the inclusion criteria. There were no major complications following epidural placement. Postoperative pump interrogation was normal for all patients. Fluoroscopy was utilized for 9/16 (56%) epidural procedures. Epidurogram was used to confirm 11/16 catheters (68%). Children with an intrathecal baclofen pump were identified by orthopedic surgeons at the time of surgical booking and referred to the regional anesthesia team for review. The neurosurgical, pain, and regional anesthesia teams determined the appropriateness and safety of approaching the neuraxis. Pain and/or regional anesthesiologists with competency in spine fluoroscopy were scheduled on the day of surgery for fluoroscopically guided epidural placement. Postoperatively, catheters were managed by the acute pain team. Intrathecal baclofen pumps were interrogated by the baclofen pump team prior to patient discharge. DISCUSSION: In this case series, not only was epidural placement feasible but also there were no observed complications. This work highlights the importance of a multidisciplinary approach to complex regional anesthetic techniques, as well as the importance of basic competency in spine fluoroscopy for regional anesthesiologists.

Bilateral Erector Spinae Blocks Decrease Perioperative Opioid Use After Pediatric Cardiac Surgery.

OBJECTIVE: The present study examined the feasibility and efficacy of continuous bilateral erector spinae blocks for post-sternotomy pain in pediatric cardiac surgery. DESIGN: Prospective cohort study; patients were retrospectively matched 1:2 to control patients. Conditional logistic regression was used to compare dichotomous outcomes, and generalized linear models were used for continuous measures, both accounting for clusters. SETTING: Quaternary children's hospital, university setting. PARTICIPANTS: The study comprised 10 children ages five-to-17 years undergoing elective cardiac surgery requiring cardiopulmonary bypass. INTERVENTIONS: Ultrasound-guided bilateral erector spinae blocks at the conclusion of the cardiac surgical procedure, with postoperative infusion of ropivacaine until chest tube removal. Postoperative management otherwise followed standardized guidelines. MEASUREMENTS AND MAIN RESULTS: Patient characteristics were similar in the two groups. The median time to completion of the bilateral blocks was 16.0 minutes (interquartile range [IQR] 14.8-19.3), and no major adverse events were identified. Pain scores were low in both groups. Postoperative opioid use at 48 hours, rendered as oral morphine equivalents, was significantly reduced in the patients receiving the blocks. Cluster-adjusted squared-root-transformed means ± standard error were 0.89 ± 0.06 mg/kg for patients receiving the blocks versus 1.05 ± 0.06 mg/kg for control patients (p = 0.04; raw medians 0.81 [IQR 0.41-1.04] v 1.10 [IQR 0.78-1.35] mg/kg, respectively). There were no differences in recovery metrics, length of stay, or complications. CONCLUSIONS: Bilateral erector spinae blocks were associated with a reduction in opioid use in the first 48 hours after pediatric cardiac surgery compared with a matched cohort from the enhanced recovery program. Larger studies are needed to determine whether this can result in an improvement in recovery and patient satisfaction.

Educational Perspectives: Anesthesia 101: What the Neonatologist Needs to Know About Anesthesiology.

As the complexity of medicine increases, so too do the challenges with multidisciplinary communication and coordinated patient care. Anesthesiology represents a field for which there is no required study for medical students, pediatric residents, or neonatal-perinatal medicine fellows in the United States, so a neonatologist may have never received any formal training in anesthesiology (and vice versa for pediatric anesthesiologists in neonatology). In this review, we address frequently asked questions of neonatologists to anesthesiologists to better frame common issues. These topics include thermal regulation, fluid management, airway management, and the field of regional anesthesiology. Finally, collaborative efforts between the surgical and medical fields, such as the American College of Surgeons Children's Surgery Verification Quality Improvement Program, and the American Academy of Pediatrics NICU Verification Program, are ongoing and robust; these programs represent important opportunities to significantly improve the perioperative care of infants. Our hope is that this summary can serve as a primer and reference for those caring for neonatal patients during any perioperative period, including seasoned neonatologists and those early in their training. It is our further desire that this review will lead to improved communication and collegiality between the specialties.

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.

A Case Report of Incidental Hepatic Cysts Found on Ultrasound Imaging: Implications for the Anesthesiologist.

Point-of-care ultrasound imaging is increasingly used by anesthesiologists to facilitate rapid clinical diagnosis and treatment in the perioperative period. With its growing popularity, inevitably, unfamiliar structures will be observed. We present a case of cystic liver lesions in a healthy model during a point-of-care workshop. We address the clinical, ethical, and legal implications of incidental findings in anesthesiology. We offer recommendations and an algorithmic approach to these occurrences.