An observational study of gastric contents in pediatric patients with long bone fracture using gastric ultrasound.

BACKGROUND: The retention of gastric contents at surgery presentation is a risk factor for perioperative aspiration. A preoperative fasting (nil per os; NPO) interval is widely used to reduce this risk, but this approach is based on assumptions about the prevalence of typical gastric emptying rates. We assessed NPO guidelines' reliability with ultrasound (US) imaging and suction in pediatric patients presenting for single long-bone fracture repair after appropriate NPO intervals, when nearly all should have had empty stomachs. AIMS AND METHODS: This prospective cross-sectional observational study comprised 200 pediatric surgical patients. As their NPO times varied by food/drink type, we defined "weighted NPO units" as the lowest multiple of elapsed recommended NPO times between consumption and surgery for each type of food or drink. We used US to image the stomach and its contents before anesthesia induction, followed by gastric suction. We evaluated the relationships between weighted NPO units, US gastric contents grade, opioid analgesic dosage and timing, and suctioned volume. RESULTS: Despite meeting typical NPO standards (median 14 h fasting), many patients retained nontrivial quantities of gastric contents at surgery. Weighted NPO units did not exhibit statistically-significant relationships with either suctioned volume or US grade. However, suctioned volume did correspond well to US grade. CONCLUSION: NPO status may be a less reliable predictor of gastric contents at anesthesia induction in this patient population than has been assumed. Bedside US screening appears to provide more useful information for the planning of airway management.

Midazolam for Anesthetic Premedication in Children: Considerations and Alternatives.

Premedication in anesthesia has long been used to reduce patient anxiety, increase patient compliance, and supplement the overall anesthetic. In pediatric populations, premedication also has the indirect benefits of reducing parental anxiety as well as both the incidence and severity of emergence delirium. Oral midazolam, selected for its ease of administration, short duration of action, and reliable anxiolytic and amnestic effects, has been a favorite choice in this role for decades. The side effect profile of midazolam is also relatively benign, heavily dose-dependent, and easily managed in the perioperative setting. While midazolam appears to be an ideal adjunct in the anesthetic care of pediatric patients, there is a growing body of evidence suggesting prolonged benzodiazepine exposure causes neurodevelopmental changes in infants. This evidence, along with the 2017 Food and Drug Administration (FDA) warning labels for the use of select anesthetic medications, including midazolam in children under the age of three, has led to some debate in the anesthetic community over the continued use of this anesthetic for premedication in pediatric populations. This article aims to educate the reader on the history of midazolam as a premedication agent in pediatric populations and examine the evidence supporting and against its continued use in this role.

Rapid Evaluation of Gastric Content With Ultrasound: An Educational Tool.

Pulmonary aspiration is a severe complication in patients receiving anesthesia for surgical procedures. The risk and severity of aspiration are significantly higher in the presence of substantial gastric contents. Bedside ultrasound imaging of the gastric antrum is emerging as a rapid and valuable method to evaluate gastric contents before surgery. Rapid gastric ultrasound using a three-category grading system promotes timely decision-making to help in emergent or urgent surgeries by identifying patients with potentially high gastric volumes or solid food contents. In emergent cases with limited time, a single ultrasound view of the gastric antrum is still likely to yield helpful information. In this report, we argue that bedside ultrasound offers a more reliable assessment of gastric contents than assumptions based on time-based fasting guidelines.

Management of a Large Post-tonsillectomy Thrombus Obstructing the Laryngeal View: A Case Report.

Anesthetic management of children with a post-tonsillectomy hemorrhage can be challenging. The patients may be anemic and hypovolemic and are at increased risk of having a difficult airway due to active bleeding, vomiting, and anatomical issues. A clot may also interfere with viewing the larynx, further exacerbating the difficulty of intubation. We describe a pediatric post-tonsillectomy hemorrhage case complicated by a large obstructing clot that was removed with Magill forceps after the airway was successfully secured with an endotracheal tube during rapid sequence induction.

Utilizing Cohesive Bandage to Prevent Adverse Effects of Bleomycin Sclerotherapy: A Case Report.

Sclerotherapy with bleomycin can cause cosmetic complications, including flagellate dermatitis and hyperpigmentation, induced or exacerbated by microtrauma to the skin. We report a case of a 9-year-old pediatric patient with congenital vascular malformations in which a cohesive bandage (eg, 3M Coban) was utilized to prevent bleomycin-induced hyperpigmentation. Postoperatively and on follow-up, there were no signs of hyperpigmentation or dermatitis in our patient. This report highlights using skin protective measures during bleomycin sclerotherapy for improved postoperative outcomes. If a patient is undergoing bleomycin sclerotherapy, consider removing adhesive where possible and using cohesive bandage to secure lines, airway instruments, and monitoring equipment.

Anesthetic Management of a Patient With Mitochondrial Encephalomyopathy, Lactic Acidosis, and Stroke-Like Episodes Syndrome During Extensive Spinal Surgery With Both Motor Evoked Potentials and Somatosensory Evoked Potentials: A Case Report.

Mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes (MELAS) syndrome is a complex and infrequently encountered mitochondrial cytopathy. Patients with MELAS often present with multi-systemic manifestations, making their anesthetic management particularly challenging. In this case report, we describe in detail our anesthetic approach for a 19-year-old male with confirmed MELAS linked to an m.3243A>G mutation. The patient had been diagnosed with MELAS at age 12 following a stroke-like episode and presented with progressive spinal deformities. He exhibited a 70° thoracic spine curvature and an 80° kyphosis, requiring a T1-L2 posterior spinal fusion. The surgical plan included neuromonitoring with both somatosensory and motor evoked potentials. Intravenous anesthetics such as propofol are typically preferred in this context due to their reduced interference with neuromonitoring compared to volatile anesthetics. Anticipating a surgical duration of six to seven hours, however, we hesitated to rely on propofol for this extended period due to its potential risks of lactic acidosis in the context of MELAS. Given that propofol infusion for extended periods (>48 hours) or at high doses (≥5 mg·kg-1·hour-1) is known to induce propofol-related infusion syndrome, and coupled with our concerns about the risk of lactic acidosis in this patient, we were compelled to design an anesthetic plan that avoided propofol altogether without excessive use of volatile anesthetics. This proactive approach ensured the maintenance of consistent neuromonitoring signals and the patient's safety, especially given his underlying mitochondrial dysfunction. Our primary rationale in presenting this case report is to highlight the challenges posed by MELAS in the setting of extended surgery, with a focus on anesthetic considerations during neuromonitoring. For prolonged surgeries that typically rely heavily on intravenous anesthetics, which interfere less with neuromonitoring than volatile anesthetics, the use of propofol should be approached with caution in MELAS contexts due to its associated risk of lactic acidosis. To our knowledge, this is the first case report that described the anesthetic management of a patient with MELAS undergoing a procedure of such duration, requiring both somatosensory and motor evoked potential neuromonitoring. We believe our experiences will serve as a reference for anesthesiologists and perioperative teams faced with similar challenging clinical situations.

Successful Rescue Ventilation of an Infant With a Laryngeal Mask Airway After Accidental Extubation in the Prone Position During Open Calvarial Reconstruction of a Craniosynostosis: A Case Report.

In this case report, we present a critical situation during an open calvarial reconstruction involving an 11-month-old infant. The patient experienced accidental extubation, requiring immediate intervention while in the prone position. Approximately two hours post-incision, ventilation became increasingly difficult due to a significant leak detected in the system. On closer inspection, it was observed that both the rubber tourniquet responsible for securing the anesthesia circuit and the tape that held the endotracheal tube in place had become loosened. In response to this emergency, the decision was made to remove the displaced endotracheal tube. We successfully introduced a 1.5 laryngeal mask airway (LMA; Unique™, Teleflex Incorporated, Wayne, PA), which restored ventilation. The patient maintained stable oxygen levels throughout this emergency period, displaying no signs of desaturation. An hour post-intervention, the surgical procedure was completed. The process of removing the LMA was uneventful without any complications. In the setting of emergent airway management, especially for patients in the prone position during surgical procedures, accidental extubation presents a challenge for healthcare providers. This case highlights the importance of prompt decision-making and having alternative airway devices on hand, such as an LMA.

Successful Administration of Preoperative Botox for Giant Omphalocele Repair With Ultrasound Guidance.

We present a case of a four-year-old male with a history of giant omphalocele who underwent ultrasound-guided Botox injection to bilateral anterior abdominal wall musculature in preparation for definitive repair. Botox administration was successfully combined with preoperative subfascial tissue expanders to achieve definitive midline closure of the anterior abdominal wall defect. Our experience suggests that Botox can be safely used as part of the treatment plan for giant omphalocele repair.

Current role of uniportal video-assisted thoracic surgery for lung cancer treatment.

The use of video-assisted thoracic surgery (VATS) as an approach for early-stage lung cancer treatment has revealed benefits compared to open surgery by minimizing trauma to the patients. This trend has brought the evolution of VATS to less and less invasive methods, eventually leading to the development of Uniportal VATS (UniVATS) technique. This new approach has shown to be resourceful, proving its feasibility even for complex oncological procedures. Furthermore, data is starting to express some benefits over multiport VATS, thus spurring on its development towards newer and more complex procedures. It is also been adopted by the surgical community achieving fast evolution and worldwide diffusion. Here, we review the evolution of UniVATS, its current state of evidence, some basic technical aspects, the present role it has in lung cancer treatment and the ongoing development of the technique. RELEVANCE FOR PATIENTS: This article could help patients to understand how the UniVATS technique developed as part of the evolution of VATS, sharing its benefits and indications. Furthermore, patients would be able to understand technical aspects and the current applications of UniVATS for lung cancer treatment.

Transnasal Sphenopalatine Ganglion Block for Postdural Puncture Headache in an Adolescent: A Case Report.

We present a pediatric patient with postdural puncture headache after a lumbar puncture, who was successfully treated with a sphenopalatine ganglion block. An uneventful autologous epidural blood patch had been placed 2 days before, but the patient reported a recurrence of symptoms after about 5 hours. Sphenopalatine ganglion block is well described in the treatment of postdural puncture headache for the obstetric population, but examples of its use in the pediatric population are not described. To our knowledge, this is the first pediatric case of sphenopalatine ganglion block for postdural puncture headache reported in the literature.

Apneic nasal oxygenation and safe apnea time during pediatric intubations by learners.

BACKGROUND: Apneic nasal oxygenation (ApOx) prolongs the time to desaturation during intubation of adult patients, but there is limited prospective evidence for apneic oxygenation in pediatric patients. AIMS: We hypothesized that ApOx during operating room intubation of pediatric patients by inexperienced learners would prolong the interval before desaturation. METHODS: This prospective observational study compared intubation data for 196 pediatric surgical patients intubated by learners under baseline practice (no nasal cannula), to 160 patients enrolled after adoption of routine apneic nasal cannula oxygenation at 5 L/min. The primary outcome was elapsed time between anesthetic induction and pulse oximetry (SpO2 ) falling to 95, if ever. RESULTS: Nasal cannula oxygenation during intubation by learners delayed desaturation to SpO2 95 (risk ratio for this event before intubation 0.05, 95% CI 0.03-0.09; P < 0.0001). CONCLUSIONS: Apneic oxygenation via nasal cannula during intubation of pediatric surgical patients prolongs time before desaturation, thus extending the safe interval for airway management by learners.

Delayed Post Caudal Catheter Placement Pseudomeningocele: A Case Report.

We present a rare case of a 7-month-old infant who developed a pseudomeningocele 16 days after an uneventful caudal catheter placement. The patient did not exhibit neurological deficits or signs of infection, and the mass increased in size with Valsalva maneuver. Pseudomeningocele, an abnormal collection of cerebrospinal fluid around an opening in the dura mater, can be iatrogenic or traumatic. Regional anesthesia is rarely the cause. Recognizing diagnostic features such as the lack of infectious signs and mass compressibility can prevent misdiagnosis and inappropriate invasive treatment.

Endoscopic Versus Open Repair for Craniosynostosis in Infants Using Propensity Score Matching to Compare Outcomes: A Multicenter Study from the Pediatric Craniofacial Collaborative Group.

BACKGROUND: The North American Pediatric Craniofacial Collaborative Group (PCCG) established the Pediatric Craniofacial Surgery Perioperative Registry to evaluate outcomes in infants and children undergoing craniosynostosis repair. The goal of this multicenter study was to utilize this registry to assess differences in blood utilization, intensive care unit (ICU) utilization, duration of hospitalization, and perioperative complications between endoscopic-assisted (ESC) and open repair in infants with craniosynostosis. We hypothesized that advantages of ESC from single-center studies would be validated based on combined data from a large multicenter registry. METHODS: Thirty-one institutions contributed data from June 2012 to September 2015. We analyzed 1382 infants younger than 12 months undergoing open (anterior and/or posterior cranial vault reconstruction, modified-Pi procedure, or strip craniectomy) or endoscopic craniectomy. The primary outcomes included transfusion data, ICU utilization, hospital length of stay, and perioperative complications; secondary outcomes included anesthesia and surgical duration. Comparison of unmatched groups (ESC: N = 311, open repair: N = 1071) and propensity score 2:1 matched groups (ESC: N = 311, open repair: N = 622) were performed by conditional logistic regression analysis. RESULTS: Imbalances in baseline age and weight are inherent due to surgical selection criteria for ESC. Quality of propensity score matching in balancing age and weight between ESC and open groups was assessed by quintiles of the propensity scores. Analysis of matched groups confirmed significantly reduced utilization of blood (26% vs 81%, P < .001) and coagulation (3% vs 16%, P < .001) products in the ESC group compared to the open group. Median blood donor exposure (0 vs 1), anesthesia (168 vs 248 minutes) and surgical duration (70 vs 130 minutes), days in ICU (0 vs 2), and hospital length of stay (2 vs 4) were all significantly lower in the ESC group (all P < .001). Median volume of red blood cell administered was significantly lower in ESC (19.6 vs 26.9 mL/kg, P = .035), with a difference of approximately 7 mL/kg less for the ESC (95% confidence interval for the difference, 3-12 mL/kg), whereas the median volume of coagulation products was not significantly different between the 2 groups (21.2 vs 24.6 mL/kg, P = .73). Incidence of complications including hypotension requiring treatment with vasoactive agents (3% vs 4%), venous air embolism (1%), and hypothermia, defined as <35°C (22% vs 26%), was similar between the 2 groups, whereas postoperative intubation was significantly higher in the open group (2% vs 10%, P < .001). CONCLUSIONS: This multicenter study of ESC versus open craniosynostosis repair represents the largest comparison to date. It demonstrates striking advantages of ESC for young infants that may result in improved clinical outcomes, as well as increased safety.

Perioperative Outcomes and Management in Pediatric Complex Cranial Vault Reconstruction: A Multicenter Study from the Pediatric Craniofacial Collaborative Group.

BACKGROUND: The Pediatric Craniofacial Collaborative Group established the Pediatric Craniofacial Surgery Perioperative Registry to elucidate practices and outcomes in children with craniosynostosis undergoing complex cranial vault reconstruction and inform quality improvement efforts. The aim of this study is to determine perioperative management, outcomes, and complications in children undergoing complex cranial vault reconstruction across North America and to delineate salient features of current practices. METHODS: Thirty-one institutions contributed data from June 2012 to September 2015. Data extracted included demographics, perioperative management, length of stay, laboratory results, and blood management techniques employed. Complications and outlier events were described. Outcomes analyzed included total blood donor exposures, intraoperative and perioperative transfusion volumes, and length of stay outcomes. RESULTS: One thousand two hundred twenty-three cases were analyzed: 935 children aged less than or equal to 24 months and 288 children aged more than 24 months. Ninety-five percent of children aged less than or equal to 24 months and 79% of children aged more than 24 months received at least one transfusion. There were no deaths. Notable complications included cardiac arrest, postoperative seizures, unplanned postoperative mechanical ventilation, large-volume transfusion, and unplanned second surgeries. Utilization of blood conservation techniques was highly variable. CONCLUSIONS: The authors present a comprehensive description of perioperative management, outcomes, and complications from a large group of North American children undergoing complex cranial vault reconstruction. Transfusion remains the rule for the vast majority of patients. The occurrence of numerous significant complications together with large variability in perioperative management and outcomes suggest targets for improvement.

Vascular smooth muscle cell membrane depolarization after NOS inhibition hypertension.

Nitric oxide (NO) synthase (NOS) inhibition with N(omega)-nitro-L-arginine (L-NNA) produces L-NNA hypertensive rats (LHR), which exhibit increased sensitivity to voltage-dependent Ca(2+) channel-mediated vasoconstriction. We hypothesized that enhanced contractile responsiveness after NOS inhibition is mediated by depolarization of membrane potential (E(m)) through attenuated K(+) channel conductance. E(m) measurements demonstrated that LHR vascular smooth muscle cells (VSMCs) are depolarized in open, nonpressurized (-44.5 +/- 1.0 mV in control vs. -36.8 +/- 0.8 mV in LHR) and pressurized mesenteric artery segments (-41.8 +/- 1.0 mV in control vs. -32.6 +/- 1.4 mV in LHR). Endothelium removal or exogenous L-NNA depolarized control VSMCs but not LHR VSMCs. Superfused L-arginine hyperpolarized VSMCs from both the control and LHR groups and reversed L-NNA-induced depolarization (-44.5 +/- 1.0 vs. -45.8 +/- 2.1 mV). A Ca(2+)-activated K(+) channel agonist, NS-1619 (10 microM), hyperpolarized both groups of arteries to a similar extent (from -50.8 +/- 1.0 to -62.5 +/- 1.2 mV in control and from -43.7 +/- 1.1 to -55.6 +/- 1.2 mV in LHR), although E(m) was still different in the presence of NS-1619. In addition, superfused iberiotoxin (50 nM) depolarized both groups similarly. Increasing the extracellular K(+) concentration from 1.2 to 45 mM depolarized E(m), as predicted by the Goldman-Hodgkin-Katz equation. These data support the hypothesis that loss of NO activation of K(+) channels contributes to VSMC depolarization in L-NNA-induced hypertension without a change in the number of functional large conductance Ca(2+)-activated K(+) channels.