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.

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.

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.

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.

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.

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.

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.