Local Anesthesia With General Anesthesia for Pediatric Bone Marrow Procedures.

BACKGROUND: Pediatric patients with cancer undergo repeated painful procedures, including bone marrow aspirations and biopsies (BMABs). Optimal management of procedure-related pain can reduce discomfort, anxiety, and distress. METHODS: Children with neuroblastoma were randomly assigned to 1 of 2 arms on a prospective, single-blind, crossover trial conducted at Memorial Sloan Kettering Cancer Center from October 2016 to January 2018 (www.clinicaltrials.gov, identifier NCT02924324). Participants underwent 2 sequential BMABs: one with general anesthesia (GA) alone, the other with GA plus local anesthesia (LA) (GA + LA). The objective was to assess procedure-related pain and its interference with quality of life (QoL) with GA versus GA + LA. Primary outcome was percentage of participants requiring postprocedural opioids. Secondary outcomes were total opioid and nonopioid analgesics, pain scores, time to first analgesic, QoL, and toxicity. Management of postprocedural pain was standardized. RESULTS: Of 56 participants randomly assigned (3-16.5 years old), 46 completed both procedures. There was no significant difference in percentage of participants requiring opioids with GA versus GA + LA (24% vs 20%, P = .5). Pain scores in the recovery room were significantly lower for GA + LA versus GA (median [IQR]: 0 [0-2] vs 2 [0-4], P = .002). There were no statistically significant differences in total opioid or nonopioid analgesic, 6- and 24-hour pain scores, median time to first analgesic, or pain interference. No adverse events occurred. CONCLUSIONS: LA was associated with significant improvement in pain scores in the immediate recovery period. LA did not reduce postprocedural opioid use, nor did it improve QoL for patients undergoing BMAB with GA.

Ultrasonography-guided bilateral rectus sheath block vs local anesthetic infiltration after pediatric umbilical hernia repair: a prospective randomized clinical trial.

IMPORTANCE: Regional anesthetic techniques can be used to alleviate postoperative pain in children undergoing pediatric surgical procedures. Use of ultrasonographic guidance for bilateral rectus sheath block (BRSB) has been shown to improve immediate pain scores and reduce use of postoperative analgesia in the postanesthesia care unit (PACU). OBJECTIVE: To compare efficacy of ultrasonography-guided BRSB and local anesthetic infiltration (LAI) in providing postoperative analgesia after pediatric umbilical hernia repair. DESIGN: Prospective, observer-blinded, randomized clinical trial. SETTING: Tertiary-referral urban children's hospital. PARTICIPANTS: Eligible children 3 to 12 years of age undergoing elective umbilical hernia repair from November 16, 2009, through May 31, 2011. INTERVENTIONS: Ropivacaine hydrochloride administered at the conclusion of surgery as LAI by the surgeon (n = 25) or as ultrasonography-guided BRSB by the anesthesiologist (n = 27). MAIN OUTCOMES AND MEASURES: Scores on the FACES Pain Rating Scale measured at 10-minute intervals and all use of analgesic medications in the PACU. RESULTS: Median FACES scores in the PACU were lower in the BRSB group compared with the LAI group at 10 minutes (0 vs 1; P = .04), 30 minutes (0 vs 1; P = .01), and 40 minutes or later (0 vs 1; P = .03). Fewer doses of opioid and nonopioid medications were given to the BRSB group compared with the LAI group (5 vs 11 doses for opioids; 5 vs 10 for nonopioids). CONCLUSIONS AND RELEVANCE: In the PACU, ultrasonography-guided BRSB after umbilical hernia repair in children is associated with lower median FACES scores and decreased use of opioid and nonopioid medications compared with LAI. Future studies could examine the use of longer-acting anesthetic agents with ultrasonography-guided BRSB. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01015053.

Parent presence during complex invasive procedures and cardiopulmonary resuscitation: a systematic review of the literature.

We conducted a systematic review of the literature on parent presence during complex invasive pediatric procedures and/or resuscitation. We identified 15 studies that met our inclusion criteria. All studies were summarized chronologically according to level of evidence. The studies all demonstrated that parents prefer to have the choice about whether they remain at their child's side during complex invasive procedures and resuscitation, but they also revealed that apprehensions and controversy abound among clinicians regarding this practice. Despite the endorsements of the American Academy of Pediatrics and the Society of Critical Care Medicine and the recommendations of the American Heart Association, few pediatric institutions have drafted guidelines, conducted clinical education, or committed sufficient staff resources to fully support this practice. We present this review not only to illustrate the various perspectives of parents/guardians, clinicians, and pediatric patients themselves that have been reported to date but also to encourage more research so that the practice can be performed safely and benefit parents, their children, and clinicians alike.

The use of a laryngeal mask airway for emergent airway management in a prone child.

A 5-yr-old girl with Arnold-Chiari Malformation, Type 1, was accidentally tracheally extubated while positioned prone in a Mayfield neurosurgical headrest during a decompressive craniectomy and cervical laminectomy. While preparations were being made to return the patient to the supine position for reintubation, we placed a laryngeal mask airway (LMA) without difficulty. The child was kept in the prone position with the LMA in place using positive-pressure ventilation for the remainder of the operation. This case report emphasizes the practical, emergent use of a LMA to secure the airway of a pediatric patient in the prone position after accidental extubation.