Efficacy of Infrared Vein Visualization versus Standard Technique for Peripheral Venous Cannulation in Infant and Toddler Populations: A Randomized Study.

Establishing intravenous (IV) access in younger patient populations via the traditional cannulation technique for procedures requiring anesthesia is often challenging. Infrared (IR) vein visualization is a modality that aids venous cannulation; however, few reports of this technique exist in the infant and toddler population. The primary aim of this study was to compare the efficacy of IR vein visualization to the standard cannulation technique for obtaining peripheral IV access in infant and toddler populations. Following Institutional Review Board (IRB) approval and written informed consent, children were randomly assigned to either a standard cannulation technique group or an IR vein visualization device group for venous cannulation. The primary outcome variable was the success rate of IV cannulation, and the secondary variables were the total number of attempts and the time to successful cannulation. No difference was noted between either group for first-attempt success rate (standard versus IR: 61.25% vs. 54.4%; p = 0.4) or time to establish IV cannulation (standard versus IR: median [interquartile range], 40 s [24-120] vs. 53 s [26-106]; p = 0.55). The anesthesiologist's grading of the anticipated difficulty of IV cannulation was a significant predictor of cannulation success (p = 0.0016). Our study demonstrated no significant benefit in utilizing the IR vein visualization device in terms of the overall success rate, number of attempts, and time to establish successful IV cannulation when compared to the standard technique. However, in difficult IV access situations, this device proved to be a valuable rescue adjunct.

Addition of Local Anesthetic Epidural Infusion Catheter to Intravenous Opioid Analgesia for Postoperative Pain Control in Children Undergoing Video Assisted Thoracoscopic Surgery (VATS).

PURPOSE: Postoperative analgesia following minimally invasive video assisted thoracoscopic surgery (VATS) in pediatric patients may involve intravenous opioid analgesics and continuous local anesthetic infusions via an epidural infusion catheter. The use of epidural catheters may avoid systemic side effects of intravenous opioids in this vulnerable population. DESIGN: Our primary aim was to compare total morphine equivalents (MEQ) required, and pain scores between local anesthetic epidural infusion catheters combined with intravenous opioids, versus intravenous opioids alone in pediatric patients following VATS procedure. METHODS: Following Institutional Review Board approval, we performed a retrospective chart review of children (ages 1 month to 18 years) who underwent VATS procedure for noncardiac thoracic surgery. Based on the postoperative analgesic technique used, the study population was divided into two groups that is, epidural group and nonepidural group. Both groups received intravenous systemic opioids. The primary outcome variables were total MEQ required and pain scores in the perioperative period. FINDINGS: Ninety-two patients were included in the study. Of these, 22 patients belonged to the epidural group versus 70 patients to the nonepidural group. There was no statistical difference in MEQ requirements or pain scores between the groups intraoperatively (P = .304), in the postanesthesia care unit (P = .166), or at postoperative time intervals of 24 hours (P = .805) and 48 hours (P = .844). The presence of infection or empyema was a significant factor for the avoidance of epidural placement by providers (P = .003). CONCLUSIONS: There was no significant difference in the perioperative MEQ or postoperative pain scores between the epidural catheter group and the nonepidural group. More research is necessary to determine if this could be due to epidural catheter malposition and/or inadequate dermatomal coverage of surgical chest tubes.

Recovery Characteristics in Neonates Following General Anesthesia: A Retrospective Chart Review.

Introduction Preterm babies increasingly survive the neonatal period as a result of advanced care practices. Accordingly, anesthesiologists are likely to encounter these patients with greater frequency. Ex-premature infants and term neonates are known to have an increased risk of post-operative apneas following surgery and anaesthesia. Methods Following approval from the Institutional Review Board, we performed a retrospective chart review of neonates 0-28 days of age who underwent general anaesthesia procedures over two years. Data collected included age days, sex, weight, gestational age, American Society of Anaesthesiologists (ASA) physical status, type of anaesthetic (general/regional/spinal), airway management, surgical procedure, intraoperative adverse events, duration of anaesthesia, medications administered, post-operative recovery location, the occurrence of apneic events, medical co-morbidities, duration of post anaesthesia care unit (PACU) admission, a requirement for neonatal intensive care unit (NICU) admission, and duration of hospital admission. Results A total of 239 charts were reviewed from January 1, 2015, to December 31, 2016. Ninety-five cases were excluded for required postoperative mechanical ventilation. For the remaining 144 cases, the mean age was 12.8 days, 65% male, 35% female, mean gestational age 38.6 weeks, mean post-menstrual age 40.5 weeks, mean ASA status 3.5, and mean weight 3.46 kg. Post-operative apnea was observed in two neonates (1.4%). Risk factors for postoperative apnea included lower gestational age at birth (median 37.5 vs. 39.1 weeks, p=0.26), lower post-menstrual age (median 38.5 vs. 41.0 weeks, p=0.18), and lower weight (median 2.8 vs. 3.5kg, p=0.27), respectively. ASA classification, preoperative anaemia, and known pathology were all significant risk factors for apnea (p<0.05). Significant factors from the bivariate analysis were preoperative anaemia, known pathology, age, duration of anaesthesia, weight, intraoperative fentanyl, and amount of neuromuscular blocker. Age and preoperative anaemia were significant predictors for recovery location. The odds of going to PACU vs NICU/PICU for post-operative recovery were 7.4 times greater for every two weeks greater age (95% CI=(2.80-19.31), p<0.001).  Conclusion This study corroborates previous findings of predictive risk factors for post-anaesthesia apnea in preterm and term neonates. Previously reported risk factors, including low gestational/post-menstrual age, lower weight, and intraoperative narcotic use, were likely contributors to one of the apneic events in our study. A larger sample size is warranted to confirm a valid predictive model. Standardized universal guidelines would be useful in eliminating local variation in PACU monitoring and discharge criteria in this vulnerable age group.

Cytokine Panels and Pediatric Acute Respiratory Distress Syndrome: A Translational Investigation.

OBJECTIVES: To identify and compare serum and lower respiratory tract fluid biomarkers of lung injury using well-characterized mouse models of lung injury. To explore the relationship between these preclinical biomarkers and clinical outcomes in a discovery cohort of pediatric patients with acute respiratory failure from pneumonia. DESIGN: Prospective, observational cohort study. SETTING: A basic science laboratory and the PICU of a tertiary-care children's hospital. PATIENTS: PICU patients intubated for respiratory failure from a suspected respiratory infection. INTERVENTIONS: Prospective enrollment and collection of lower respiratory tract fluid samples. MEASUREMENTS AND MAIN RESULTS: C57BL6/J mice were intranasally inoculated with escalating doses of influenza A virus or toll-like receptor agonists to simulate varying degrees of lung injury. Serum and bronchoalveolar lavage fluid were measured for the presence of cytokines using commercially available multiplex cytokine assays. Elevated levels of C-C motif chemokine ligand 7 at the peak of inflammation in both bronchoalveolar lavage fluid and serum correlated with lethality, with the bronchoalveolar lavage fluid ratio of C-C motif chemokine ligand 7:C-C motif chemokine ligand 22 providing the best prediction in the mouse models. These preclinical biomarkers were examined in the plasma and lower respiratory tract fluid of a discovery cohort of pediatric patients with acute respiratory failure from pneumonia. The primary clinical outcome measure was ventilator-free days, with secondary outcomes of pediatric acute respiratory distress syndrome severity and mortality. Elevation in peak lower respiratory tract fluid C-C motif chemokine ligand 7:C-C motif chemokine ligand 22 ratios demonstrated a significant negative correlation with ventilator-free days (r = -0.805; p < 0.02). CONCLUSIONS: This study provides evidence that lung immune profiling via lower respiratory tract fluid cytokine analysis is feasible and may provide insight into clinical outcomes. Further validation of markers, including the C-C motif chemokine ligand 7:C-C motif chemokine ligand 22 ratio in this limited study, in a larger cohort of patients is necessary.

Torsades de Pointes During Myringotomy in a Child with Congenital Long QT Syndrome: A Case Report.

BACKGROUND Long QT syndrome (LQTS) is an arrhythmogenic heart condition that can be congenital or acquired. Prolonged ventricular repolarizations in individuals with the disorder can cause fatal arrhythmias. Abnormal functioning of cardiac ion channels leads to arrhythmias such as torsades de pointes (TdP) and may be triggered by stress or medications. Many medications used in the perioperative period are triggers for the arrythmia. CASE REPORT A 7-year-old patient with known congenital LQTS type 2 presented for bilateral myringotomy and tube placement. The patient was otherwise healthy and taking propranolol daily. Preoperative midazolam was administered for anxiolysis, and induction of anesthesia was uneventful. He sustained an episode of TdP immediately following general anesthetic induction after failure of an in situ automatic implantable cardioverter-defibrillator (AICD). External defibrillation succeeded, and the patient was stabilized in the Postanesthesia Recovery Unit before transfer to the Pediatric Intensive Care Unit. Interrogation of the AICD revealed several undelivered defibrillation attempts. A chest X-ray showed an area suggestive of an epicardial electrode fracture. The following day, the AICD was replaced with no arrythmias noted. The patient had an uneventful recovery. CONCLUSIONS In patients with a known history of LQTS, preparation and prevention are cornerstones of anesthesia care. Minimizing the use of triggering medications and emotional stress in the perioperative period, combined with ready equipment and medications to respond to arrythmias, are essential. In children, there is a greater chance of lead fracture and resulting device failure. Preoperative history of device function or interrogation of the AICD and possibly a chest X-ray are essential to ensure the integrity of the leads.

A Model for a Standardized and Sustainable Pediatric Anesthesia-Intensive Care Unit Hand-Off Process.

BACKGROUND AND OBJECTIVES: The hand-off process between pediatric anesthesia and intensive care unit (ICU) teams involves the exchange of patient health information and plays a major role in reducing errors and increasing staff satisfaction. Our objectives were to (1) standardize the hand-off process in children's ICUs, and (2) evaluate the provider satisfaction, efficiency and sustainability of the improved hand-off process. METHODS: Following multidisciplinary discussions, the hand-off process was standardized for transfers of care between anesthesia-ICU teams. A pre-implementation and two post-implementation (6 months, >2 years) staff satisfaction surveys and audits were conducted to evaluate the success, quality and sustainability of the hand-off process. RESULTS: There was no difference in the time spent during the sign out process following standardization-median 5 min for pre-implementation versus 5 and 6 min for post-implementation at six months and >2 years, respectively. There was a significant decrease in the number of missed items (airway/ventilation, venous access, medications, and laboratory values pertinent events) post-implementation compared to pre-implementation (p ≤ 0.001). In the >2 years follow-up survey, 49.2% of providers felt that the hand-off could be improved versus 78.4% in pre-implementation and 54.2% in the six-month survey (p < 0.001). CONCLUSION: A standardized interactive hand-off improves the efficiency and staff satisfaction, with a decreased rate of missed information at the cost of no additional time.

Acute Postoperative Pain Management After Major Limb Amputation in a Pediatric Patient: A Case Report.

PURPOSE: Although total prevention of phantom pain is difficult, pediatric patients requiring amputation benefit from an individualized combination of analgesic techniques for phantom pain reduction using a multimodal and interprofessional approach. This is especially useful in the event a single therapy is ineffective for total pain reduction, and may ultimately lead to a reduction in chronic pain development. DESIGN: Case report with multimodal and interprofessional approach. METHODS: A 16-year-old patient with synovial sarcoma underwent a right hemipelvectomy and hip disarticulation. The patient had significant preoperative cancer pain requiring high-dose opioid analgesics prior to surgery. An interprofessional multimodal pain management strategy was used for acute and long-term reduction of postoperative phantom pain. FINDINGS: Although our patient developed acute phantom pain, multimodal therapy reduced immediate pain with resolution by 2 years follow-up. CONCLUSIONS: An individualized plan using interprofessional teamwork before surgery may provide optimal results in alleviating phantom pain after amputation for pediatric patients.

Perioperative thrombotic complications associated with pediatric liver transplantation: a UNOS database evaluation.

BACKGROUND: This retrospective UNOS database evaluation analyzes the prevalence of preoperative portal vein thromboses (PVT), and postoperative thromboses leading to graft failure in pediatric patients undergoing liver transplantation (LT). METHODS: The evaluation was performed in three age groups: I (0-5), II (6-11), III (12-18) years old. Factors predictive of pre- and postoperative thromboses were analyzed. RESULTS: Between 2000 and 2015, 8982 pediatric LT were performed in the US. Of those, 390 patients had preoperative PVT (4.3%), and 396 (4.4%) had postoperative thromboses. The prevalence of both types of thromboses was less in Group III than in the other two groups (3.20% vs 4.65%, p = 0.007 and 1.73% vs. 5.13%, p < 0.001, respectively). The prevalence of postoperative thromboses was significantly higher in Group I than in the other two groups (5.49% vs. 2.51%, p < 0.001). Preoperative PVT was independently associated with postoperative thromboses (OR = 1.7, p = 0.02). Children less than 5 years of age were more likely to develop postoperative thromboses leading to graft failure (OR = 2.9, p < 0.001). CONCLUSION: Younger children undergoing LT are prone to pre-and postoperative thrombotic complications. Preoperative PVT at the time of transplantation was independently associated with postoperative thromboses. Perioperative antithrombotic therapy should be considered in pediatric patients undergoing LT.

Allergic Reaction Caused by a Lip Balm-Flavored Facemask Used During Inhalational Induction: A Case Report.

Flavoring a facemask with a lip balm for inhalational induction in children is a common practice. However, most anesthesia providers are unaware of potential complications and the management of allergic reactions caused by lip balm. We describe the occurrence of allergic reaction to lip balm-flavored facemask in a child who underwent an inhalational anesthetic induction. The facial rash resolved completely without complications after administration of an antihistamine and steroid.

Postoperative Pain and Analgesia in Children Undergoing Palatal Surgery: A Retrospective Chart Review.

PURPOSE: Pediatric patients undergoing palatal surgery may experience significant postoperative pain. Undertreatment of acute postoperative pain may impact postoperative bleeding and recovery. The primary objectives of this study were to evaluate the severity of acute postoperative pain scores, analgesia management, and discharge times after palatal surgery. DESIGN AND METHODS: A retrospective chart review was performed for all patients aged <18 years, born with cleft palate who underwent palatal surgery over a 1-year period. The primary outcome variable was the highest pain score recorded by the nursing staff at various time frames postoperatively. FINDINGS: Overall, the infant/toddler group demonstrated higher postoperative pain scores throughout the first 24 hours (1- to 6-hour period, P = .015). The duration of hospital stay was significantly greater in the infant/toddler age group (P < .001). CONCLUSION: The results of our study indicate that frequent pain monitoring, multimodal approach, and "round-the-clock" analgesics may be warranted in this vulnerable patient population.

Phenylephrine infusion for spinal-induced hypotension in elective cesarean delivery: Does preload make a difference?

BACKGROUND AND AIMS: Patients undergoing elective cesarean delivery (CD) have a high-risk of spinal-induced hypotension (SIH). We hypothesized that a colloid preload would further reduce SIH when compared with a crystalloid preload. MATERIAL AND METHODS: Eighty-two healthy parturients undergoing elective CD were included in the study. Patients were randomly assigned to two groups (41 patients in each group) to receive either Lactated Ringer's solution (1500 ml) or hydroxyethyl starch (6% in normal saline, 500 ml) 30 min prior to placement of spinal anesthesia. All patients were treated with a phenylephrine infusion (100 mcg/min), titrated during the study. RESULTS: There was no statistical difference between groups with regards to the incidence of hypotension (10.8% in the colloid group vs. 27.0% in the crystalloid group, P = 0.12). There was also no difference between groups with respect to bradycardia, APGAR scores, and nausea and vomiting. Significantly less phenylephrine (1077.5 ± 514 mcg) was used in the colloid group than the crystalloid group (1477 ± 591 mcg, P = 0.003). CONCLUSION: The preload with 6% of hydroxyethyl starch before CD might be beneficial for the prevention of SIH.

A quality improvement project to reduce hypothermia in infants undergoing MRI scanning.

BACKGROUND: Hypothermia prevention strategies during MRI scanning under general anesthesia in infants may pose a challenge due to the MRI scanner's technical constraints. Previous studies have demonstrated conflicting results related to increase or decrease in post-scan temperatures in children. We noted occurrences of post-scan hypothermia in anesthetized infants despite the use of routine passive warming techniques. OBJECTIVE: The aims of our quality improvement project were (a) to identify variables associated with post-scan hypothermia in infants and (b) to develop and implement processes to reduce occurrence of hypothermia in neonatal intensive care unit (NICU) infants undergoing MRI. MATERIALS AND METHODS: One hundred sixty-four infants undergoing MRI scanning were prospectively audited for post-scan body temperatures. A multidisciplinary team identified potential variables associated with post-scan hypothermia and designed preventative strategies: protocol development, risk factor identification, vigilance and use of a vacuum immobilizer. Another audit was performed, specifically focusing on NICU infants. RESULTS: In the initial phase, we found that younger age (P = 0.002), lower weight (P = 0.005), lower pre-scan temperature (P < 0.01), primary anesthetic technique with propofol (P < 0.01), advanced airway devices (P = 0.02) and being in the NICU (P < 0.01) were associated with higher odds for developing post-scan decrease in body temperature. Quality improvement processes decreased the occurrence of hypothermia in NICU infants undergoing MRI scanning from 65% to 18% (95% confidence interval for the difference, 26-70%, P < 0.001). CONCLUSION: Several variables, including being in the NICU, are associated with a decrease in post-scan temperature in infants undergoing MRI scanning under sedation/general anesthesia. Implementation of strategies to prevent hypothermia in infants may be challenging in the high-risk MRI environment. We were able to minimize this problem in clinical practice by applying quality improvement principles.

Case Report: Genetic analysis and anesthetic management of a child with Niemann-Pick disease Type A.

A 14-month-old child, recently diagnosed with Niemann-Pick disease type A, presented for a laparoscopic placement of a gastrostomy tube under general anesthesia. The disease was confirmed and further characterized by genetic testing, which revealed evidence of the presence of two known pathogenic mutations in the SMPD1 gene, and enzyme studies showed a corresponding very low level of enzymatic activity of acidic sphingomyelinase. The anesthetic management involved strategies to manage an anticipated difficult intubation and avoid post-operative ventilation.

Comparison of 2 techniques of laryngeal tube exchange in a randomized controlled simulation study.

BACKGROUND: Laryngeal tubes (LT) are often used as rescue airway devices. Among prehospital medical personnel, the success rates are high and significantly faster compared to an endotracheal tube (ETT). Therefore, LTs are increasingly used in the prehospital setting. The exchange of an LT for an ETT may often be desirable. Two fiberoptic bronchoscope-facilitated techniques have been described to exchange an LT for an ETT: an intraluminal technique using an Aintree intubating catheter and an extraluminal technique using a nasal route alongside the LT. In this randomized cross-over mannequin study, we compared the intraluminal with the extraluminal exchange technique. The primary outcome was time to achieve an effective airway through an ETT. We hypothesized that the intraluminal technique would be significantly faster. METHODS: Thirty anesthesia providers were recruited to the study. Each participant attempted both techniques in an intubation simulation model. The tube exchange time was recorded from picking up the fiberoptic bronchoscope until confirmation of ventilation with the ETT. RESULTS: Four participants in each group had a failed attempt at intubation. Time to establish an endotracheal intubation was significantly shorter with the intraluminal technique vs the extraluminal technique (77.5 vs 140 seconds; P=.03). CONCLUSION: Based on the results of our study, we suggest that the intraluminal technique may be a suitable alternative for a fiberoptic-guided rapid exchange of an LT for an ETT to establish an effective airway in a challenging situation.

Safety of the breast-feeding infant after maternal anesthesia.

There has been an increase in breast-feeding supported by the recommendations of the American Academy of Pediatrics and the World Health Organization. An anesthesiologist may be presented with a well-motivated breast-feeding mother who wishes to breast-feed her infant in the perioperative period. Administration of anesthesia entails acute administration of drugs with potential for sedation and respiratory effects on the nursing infant. The short-term use of these drugs minimizes the possibility of these effects. The aim should be to minimize the use of narcotics and benzodiazepines, use shorter acting agents, use regional anesthesia where possible and avoid agents with active metabolites. Frequent clinical assessments of the nursing infant are important. Available literature does suggest that although the currently available anesthetic and analgesic drugs are transferred in the breast milk, the amounts transferred are almost always clinically insignificant and pose little or no risk to the nursing infant.

Analysis of acute pain scores and skin conductance measurements in infants.

BACKGROUND: Skin conductance (SC) has been previously used to measure acute post-operative pain in adults and older children (>1year old).We have investigated the ability of SC to predict the severity of post-operative pain scores in the exclusively infant population. METHODS: Infants (ages 6-12months) scheduled for elective surgery were recruited for the study. Data for behavioral pain scores and SC values - frequency of electrodermal responses per second (EDR/s), peak and basal levels, were recorded in the post-anesthesia care unit (PACU). Blood samples were collected for genomic studies, including single nucleotide polymorphisms (SNP) in morphine opioid receptor (MOR) A118G and the catechol-O-methyltransferase (COMT) G1947A genes. RESULTS: 31 infants, mean age 8.9months (±1.9); mean weight 8.5kg (±1.1) were included in the final study analysis. With every 0.1 unit increase in peak values noted on SC, the odds of higher pain scores were found to be 5% greater (p=0.03). For predictability of moderate to severe pain, the area under the curve, sensitivity and specificity were 0.64, 90.9% and 51.4% respectively for peak values and 0.66, 54.5% and 79.4% respectively for EDR/s values. Genotyping performed in 16 out of 31 infants demonstrated that the carriers of MOR 118G allele had consistently higher basal SC values in the PACU. CONCLUSION: Peak SC values may serve as indicators of unmitigated pain. Further studies are needed to fully investigate the effect of MOR A118G SNP on the post operative pain scores and SC values in the larger infant population in order to validate both the clinical significance of the skin conductance for routine pain assessment in infants and the observed genetic effect.