Intraoperative dextrose rate during exploratory laparotomies in neonates and the incidence of postoperative hyperglycemia: A retrospective observational study.

INTRODUCTION: Compared with the older pediatric population, neonates have greater perioperative morbidity and mortality. Difficulty with glucose regulation may be a contributing modifiable risk factor during perioperative anesthetic management. To mitigate the risk of hyperglycemia in neonates, some providers empirically halve the preoperative rate of dextrose-containing infusions during surgery. AIM: To assess the association between halving the preoperative maintenance dextrose rate and postoperative euglycemia in neonatal intensive care unit patients undergoing exploratory laparotomies. METHODS: Neonatal intensive care unit patients who underwent exploratory laparotomy under general anesthesia from 1/1/2014 to 11/21/2019 were included in this analysis. Hyperglycemia and hypoglycemia were defined as >150 mg/dL and <46 mg/dL. A calculated dextrose ratio was utilized to categorize patients into full and half intraoperative dextrose rate cohorts. Univariate analyses were performed with Fisher's exact test, the Wilcoxon rank sum test, or Spearman's correlation. Multivariable analyses with regression models were conducted after graphical evaluation of a predetermined set of independent variables. RESULTS: 107 patients were included in the full dextrose rate cohort and 96 patients in the half dextrose rate cohort with postoperative hyperglycemia occurring in 47 and 28 patients, respectively. On univariate analysis, halving the preoperative dextrose rate was associated with decreased postoperative hyperglycemia (odds ratio: 0.53; 95% CI: 0.28-0.98, P = 0.041). This association continued in the regression model (adjusted odds ratio: 0.49; 95% CI: 0.25-0.80, P = 0.008) after controlling for preoperative dextrose rate, preoperative serum glucose, preoperative pH, surgical duration, postmenstrual age at surgery, and the presence of necrotizing enterocolitis. Only one patient was hypoglycemic postoperatively, and they were in the full dextrose cohort. CONCLUSION: Halving of preoperative dextrose rates intraoperatively during exploratory laparotomy in neonatal intensive care unit patients was associated with a decreased risk of postoperative hyperglycemia without substantially increasing the occurrence of postoperative hypoglycemia. The practice of halving preoperative dextrose rates may be an effective empirical approach for intraoperative glucose management in the high-risk neonatal population when blood glucose monitoring is challenging.

Prolonged neuromuscular block after rocuronium administration in laparoscopic pyloromyotomy patients: A retrospective bayesian regression analysis.

BACKGROUND: Infants undergoing pyloromyotomy are at a high risk of aspiration, making rapid sequence induction the preferred method of induction. Since succinylcholine use in infants can be associated with complications, rocuronium is frequently substituted despite its prolonged duration of action. AIMS: To examine the likelihood of non-reversibility to neostigmine at the end of surgery in laparoscopic pyloromyotomies and its correlation to both rocuronium dose and out of operating room time. METHODS: Patients who underwent laparoscopic pyloromyotomy for infantile hypertrophic pyloric stenosis, received rocuronium, and were reversed with neostigmine were included. Bayesian multivariable logistic regression was utilized to determine the probability of non-reversibility, and Bayesian multivariable median regression was performed to ascertain the correlation between out of operating room time and non-reversibility. RESULTS: 306 patients were analyzed with a median surgical duration of 19 min (interquartile range 16 to 23). 74% received succinylcholine for intubation followed by rocuronium, and the remaining received rocuronium alone. The median rocuronium dose was 0.41 mg/kg (interquartile range 0.27 - 0.56 mg/kg). Prolonged block occurred in 68 (22.2%) patients. There was a non-trivial probability of prolonged block with low rocuronium doses, and each 0.1 mg/kg increase in total rocuronium dose was associated with an odds ratio of 1.36 (95% credible interval: 1.17-1.58) of neostigmine non-reversibility at the end of surgery. Non-reversibility was correlated with a substantial increase in median out of operating room time (13.4 min, 95% credible interval: 5.5-20.8 min), which was compounded by high rocuronium dosing (2.2 min increase per 0.1 mg/kg for doses greater than 0.5 mg/kg, 95% credible interval: 0.7-3.6 min). CONCLUSION: Prolonged blockade can occur from rocuronium administration in infants undergoing pyloromyotomy even at low doses. Therefore, consideration of appropriate rocuronium dosing or the use of sugammadex should be considered.