Characterization of the Difficult Peripheral IV in the Perioperative Setting: A Prospective, Observational Study of Intravenous Access for Pediatric Patients Undergoing Anesthesia.

Background: Various criteria exist for defining difficult intravenous access (DIVA) in infants and children. The current study evaluated the factors associated with DIVA in a prospective cohort of over 1000 infants and children presenting for anesthetic care. Methods: This was a prospective, observational study of patients aged 0 to 18 years undergoing elective surgical or radiologic procedures under general anesthesia. Prior to the initial attempt at peripheral intravenous (PIV) cannulation, the anticipated difficulty of PIV catheter placement was determined by the provider using a visual analogue scale (VAS) from 1 to 10. The number of attempts was recorded as well as the time required to achieve PIV access. DIVA was defined as requiring three or more attempts. After successful cannulation, the actual difficulty of the PIV placement was assessed by the provider and recorded using the same VAS. Patient characteristics, including age, race, body mass index (BMI), American Society of Anesthesiologists (ASA) physical classification, and history of difficult PIV placement, were evaluated as covariates. Results: In our cohort of 1002 pediatric patients, 78% of patients were successfully cannulated in a single attempt and 91% of patients were successfully cannulated in two or fewer attempts. Factors associated with requiring three or more PIV attempts included younger age (OR 8.73; 95% CI: 3.38, 22.6 for age <1 year and OR 4.93; 95% CI: 2.05, 11.8 for age 1-3 years), higher ASA physical classification (OR 1.95; 95% CI: 1.10, 3.46 for ASA II), and prior history of difficult PIV placement (OR 3.46; 95% CI: 1.70, 7.08). BMI, racial category or gender were not independent predictors of DIVA. Conclusion: We found that approximately 9% of patients required three or more attempts at IV placement in the operating room. Patients that required multiple PIV attempts were more likely to be younger, have a higher ASA classification or a history of difficult PIV placement.

Ultrasound assessment of the inferior vena cava in children: A comparison of sub-xiphoid and right lateral coronal views.

OBJECTIVES: The inferior vena cava collapsibility index (IVCCI) has been used to assess the respiratory variation of the inferior vena cava (IVC) diameter and hence intravascular volume. The sub-xiphoid view (SXV) is the standard view to evaluate the IVC. The right lateral transabdominal view (RLV) has been shown in adults to be an alternative view to evaluate the IVC when the SXV is not feasible. The aim of the study was to compare IVC dimensions from these two views and thus determine whether the RLV view can be used instead of the SXV in pediatric patients. METHODS: We conducted a single-center prospective observational crossover study. Study subjects were ASA physical status 1-2 children, 1-12 years of age scheduled for elective surgery under general anesthesia. Anesthesia was maintained by mask with spontaneous ventilation with end-tidal sevoflurane at 2%-5% after the induction of anesthesia. IVCCI was measured using M-mode in both the SXV and RLV. RESULTS: The study cohort included 50 children with a mean age of 5.1 years. The median value for the IVCCI-sx was 0.45 (IQR: 0.28-0.70) while the IVCCI-rl was 0.30 (0.19-0.5). The mean difference between the two groups was 0.12 (95% CI: 0.177-0.066, p < .001, two-tailed paired t-test). Spearman's rank correlation coefficient was 0.66. The univariate linear regression model was IVCCIsx = 0.21 + 0.77 × IVCCIrl. CONCLUSIONS: IVCCIrl was lower than IVCCIsx. IVCCI measured from the right lateral view tended to overestimate the patient's fluid-responsiveness and therefore these two values are not interchangeable.

Use of cuffed endotracheal tubes in infants less than 5 kilograms: A retrospective cohort study.

BACKGROUND: Improved understanding of airway anatomy and refinement of equipment have led to the increased use of cuffed endotracheal tubes (ETTs) in infants and children. Despite expanded evidence on the potential advantages of cuffed ETTs in pediatric patients, there remains limited data on their use in infants less than 5 kilograms (kg). The current study retrospectively evaluates the perioperative use of cuffed ETTs in infants weighing 2-5 kg. METHODS: This is a retrospective study from a tertiary care children's hospital involving a 3-year period. Data regarding anesthetic care, airway management, and postoperative course were retrospectively retrieved from the electronic medical record. RESULTS: The study cohort included 1162 patients, 1086 of whom had their tracheas intubated with a cuffed ETT and 76 with an uncuffed ETT. Patients were divided into two groups for analysis: 2 to <3 kg and 3 to 5 kg. In both weight groups, cuffed ETTs resulted in a decreased need for more than one laryngoscopy and a change in ETT size with no increase in postoperative airway effects including stridor. CONCLUSIONS: These data provide additional information regarding the efficacy and safety of cuffed ETTs in neonates and infants.

Clinical Outcomes of a Modified Laryngeal Mask Airway (LMA® Gastro™ Airway) During Esophagogastroduodenoscopy in Children and Adolescents: A Randomized Study.

INTRODUCTION: During esophagogastroduodenoscopy (EGD), general anesthesia (GA) may be provided using a laryngeal mask airway (LMA) with the endoscope inserted behind the cuff of the LMA into the esophagus. Passage of the endoscope may increase the intracuff of the LMA. We evaluated a newly designed LMA (LMA® Gastro™ Airway) which has an internal channel exiting from its distal end to facilitate EGD. The current study compared the change of LMA cuff pressure between this new LMA and a standard clinical LMA (Ambu® AuraOnce™) during EGD. METHODS: Patients less than 21 years of age and weighing more than 30 kg were randomized to receive airway management with one of the two LMAs during EGD. After anesthetic induction and successful LMA placement, the intracuff pressure of the LMAs was continuously monitored during the procedure. The primary outcome was the change of intracuff pressure of the LMAs. RESULTS: The study cohort included 200 patients (mean age 13.6 years and weight 56.6 kg) who were randomized to the LMA® Gastro™ Airway (n=100) or the Ambu® AuraOnce™ LMA (n=100). Average intracuff pressures during the study period (before and after endoscope insertion) were not different between the two LMAs. Ease of the procedure was slightly improved with the LMA® Gastro™ Airway (p<0.001). DISCUSSION: The LMA® Gastro™ Airway blunted, but did not prevent an increase in intracuff pressure during EGD when compared to the Ambu® AuraOnce™ LMA. Throat soreness was generally low, and complications were infrequent in both groups. The ease of the procedure was slightly improved with the LMA® Gastro™ Airway compared to the Ambu® AuraOnce™ LMA.

Heart Rate Changes Following the Administration of Sugammadex to Infants and Children With Comorbid Cardiac, Cardiovascular, and Congenital Heart Diseases.

BACKGROUND: Sugammadex is a novel, rapidly-acting pharmacologic agent to reverse steroidal neuromuscular blocking agents with demonstrated advantages over acetylcholinesterase inhibitors. However, anecdotal reports have noted rare instances of bradycardia and even cardiac arrest. The current study examined heart rate (HR) changes in infants and children with comorbid cardiac, cardiovascular, and congenital heart diseases. METHODS: Patients less than 18 years of age, who had a comorbid cardiac, cardiovascular, or congenital heart disease and were to receive sugammadex, were included in this prospective observational study. After sugammadex administration, HR was continuously monitored and recorded every minute for the first 15 min, and then every 5 min for the next 15 min or until the patient was transferred from the operating room. The primary outcome, bradycardia, was defined as HR below the fifth percentile for age. Secondary outcomes included greatest decrease in HR from baseline for each patient and interventions required for bradycardia. RESULTS: The study cohort included 99 patients (58 male and 41 female) with a median age of 3 years. Bradycardia was noted in 20 of 99 patients (20%); however, six of these patients were bradycardic prior to the administration of sugammadex. Older patients, male patients, and patients with higher body weight were the most likely to experience bradycardia. None of the patients required treatment for bradycardia. CONCLUSIONS: The incidence of bradycardia following the administration of sugammadex was low, even in patients with congenital heart disease. Bradycardia was not associated with clinically significant hemodynamic changes and no treatment was required.

Choosing endotracheal tube size in children: Which formula is best?

OBJECTIVES: Various formulae have been suggested to calculate the appropriate sized endotracheal tube in children. The current study prospectively compares three commonly used formulae for selection of cuffed endotracheal tubes in children. METHODS: Patients were randomized to one of three formulae (Duracher, Cole, or Khine) to determine the size of the cuffed endotracheal tube for endotracheal intubation. The fit of the tube was noted and intracuff pressure was measured using a manometer. The postoperative incidence of stridor, throat pain/soreness, and hoarseness was noted in the post-anesthesia care unit at 2, 4 and 24 h after the procedure. RESULTS: The study cohort included 135 patients less than or equal to 8 years, equally divided into three groups based on age, weight, and gender. There was no difference in the intracuff pressure, the volume required to seal the airway, or the number of times in which the intracuff pressure was greater than or equal to 20 or 30 cm H2O among the three groups. Six tube changes were required in the Cole group while no tube changes were required in the Duracher group (p < 0.05). The postoperative incidence of adverse events (throat pain, hoarseness, and stridor) at 0-2 h, 2-4 h, and 24 h was higher in the Cole group when compared to the Duracher group. CONCLUSION: When using an endotracheal tube with a polyurethane cuff, the Duracher formula provided the best estimate for choosing the correct size.

Perioperative Administration of Emend® (Aprepitant) at a Tertiary Care Children's Hospital: A 12-Month Survey.

INTRODUCTION: Aprepitant (Emend®) is a novel antiemetic agent that works through antagonism of neurokinin-1 (NK-1) receptors. To date, there are limited data regarding its use to prevent postoperative nausea and vomiting (PONV) in children. We retrospectively reviewed our initial 12-months experience with aprepitant after it was made available for perioperative use. METHODS: The anesthetic records of patients who received aprepitant were retrospectively reviewed and demographic, surgical, and medication data retrieved. RESULTS: The study cohort included 31 patients (15 male and 16 female) ranging in age from 4 to 27 years (15.7 ± 7.4 years) and in weight from 14.4 to 175.7 kilograms (59.3 ± 30.2 kgs). Most of the patients (30 of 31) received the capsule form and 1 received the liquid. The average dose of aprepitant administered was 0.9 ± 0.6 mg/kg; however, only one patient received dosing expressed as mg/kg, and the majority received a 40 mg capsule. All of the patients in the cohort had either a previous history of PONV or risk factors for PONV. PONV occurred in the PACU in 1 patient and during the first 24 postoperative hours in 3 additional patients. No adverse effects related to aprepitant use were noted. CONCLUSION: Aprepitant was easily added to the preoperative regimen for pediatric patients who may require it. Our approach limited overuse and subsequent cost concerns. Future studies with a comparator group and a greater sample size are needed to demonstrate its efficacy, especially in comparison to time-honored agents such as ondansetron. No adverse effects were noted in our limited study cohort.

Safety of Same-Day Discharge Compared to Overnight Observation Following Laparoscopic Appendectomy in the Pediatric-Aged Patient: A National Surgical Quality Improvement Program Project.

Background: Previous studies regarding same-day discharge (SDD) after laparoscopic appendectomy for pediatric patients have been limited by the cohort size and lack of specificity regarding the definition of SDD. Our study evaluates the safety of appendectomy performed with SDD in pediatric patients when compared to appendectomy followed by an overnight stay, using a large nationwide database and a strict definition of SDD by using hospital length of stay (LOS). Methods: Using the National Surgical Quality Improvement Program-Pediatric (NSQIP-P) registry, we identified patients younger than 18 years of age who underwent outpatient laparoscopic appendectomy, with SDD (n = 2647) or overnight stay (n = 5045). One-to-one propensity score matching was performed to compare 30-day readmission rates and postsurgical complications. Results: Non-Hispanic black race was associated with a higher likelihood of overnight stay after laparoscopic appendectomy. In the propensity score-matched analysis (N = 2443 pairs), SDD was not associated with an increased risk of 30-day unplanned readmission (odds ratio [OR] = 0.9, 95% confidence interval [CI] = 0.6-1.4; P = .667) or any 30-day complication (OR = 0.8, 95% CI: 0.6-1.1; P = .258). Conclusion: SDD after laparoscopic appendectomy in pediatric patients was not associated with an increased risk of 30-day hospital admission or complication rate. Protocols to expedite perioperative care, including standardization of intraoperative care, may facilitate same-day hospital discharge, resulting in a decrease in health care costs.

Intracuff pressure during one-lung ventilation in infants and children.

OBJECTIVE: We prospectively evaluated intracuff pressure (IP) during one-lung ventilation (OLV) to characterize potential risk associated with overinflation of the cuff used for OLV. DESIGN: Prospective observational study over a 2-year period, in infants and children undergoing thoracic surgery. The IPs of the tracheal and bronchial balloon were measured using a manometer and compared to a previously recommended threshold of 30 cmH2O. Data were compared by the device type used to achieve OLV. SETTING: Freestanding tertiary-care pediatric hospital. PARTICIPANTS: Patients ≤18 years of age undergoing thoracic procedures requiring OLV. INTERVENTIONS: Measurement of IP. MEASUREMENTS AND MAIN RESULTS: Thirty patients were enrolled (age 5 months-18 years) with a median weight of 28 kg. Median tracheal and bronchial IPs were 32 cmH2O (range: 11, 90) and 44 cmH2O (range: 10, 100), respectively. The tracheal and bronchial IPs exceeded 30 cmH2O in 13 of 20 patients (65%) and 21 of 30 patients (70%), respectively. CONCLUSIONS: IP was high and in excess of recommended levels in most children undergoing OLV. Continuous monitoring of IP may be indicated during OLV to address the risks involved and ensure the prevention of complications related to high IP. TYPE OF STUDY: Prospective comparative study. LEVEL OF EVIDENCE: Level II.

Predictors of Referral to a Pediatric Outpatient Chronic Pain Clinic.

OBJECTIVES: The main objectives of this study were to retrospectively characterize the rate of referrals to an outpatient chronic pain clinic among adolescents with chronic pain, and to identify factors associated with referral. MATERIALS AND METHODS: Adolescents, 13 to 18 years of age seen in 2010 to 2015 at outpatient clinics associated with Nationwide Children's Hospital (NCH) and diagnosed with chronic pain were included if they lived near NCH and had not been previously referred to the NCH outpatient chronic pain clinic. Subsequent referrals to the pain clinic were tracked through December 2017 using a quality improvement database. Factors predicting referral were assessed at the initial encounter in another outpatient clinic and analyzed using multivariable logistic regression. RESULTS: The analysis included 778 patients (569 female; median age, 15 y), of whom 96 (12%) were subsequently referred to the chronic pain clinic, after a median period of 3 months. Generalized chronic pain (adjusted odds ratio, 1.8; 95% confidence interval, 1.1-3.1; P=0.023) and regional pain syndromes (adjusted odds ratio, 3.1; 95% confidence interval, 1.5-6.7; P=0.003) were associated with increased likelihood of referral. The referral was also more likely among female patients and among patients with a mental health comorbidity or recent surgery or hospitalization. DISCUSSION: Referrals to our chronic pain clinic were more likely for adolescents with generalized chronic pain, regional pain syndromes, and patients with mental health comorbidities. Recent hospitalization or surgery, but not recent emergency department visits, were associated with pain clinic referral. The multivariable analysis did not find disparities in referral by race or socioeconomic status.

An Enhanced Recovery Protocol that Facilitates Same-day Discharge for Simple Laparoscopic Appendectomies.

Acute appendicitis is the most common gastrointestinal condition requiring urgent operation in the pediatric population with laparoscopic appendectomy (LA) being the current surgical technique. We describe the implementation of a standardized protocol to reduce postoperative nausea and vomiting (PONV) and facilitate same-day discharge after LA. METHODS: A multidisciplinary team developed this protocol to facilitate same-day discharge after observing high rates of overnight stay due to PONV among simple appendectomies performed in 2011-2012. The protocol was implemented in November 2014 and underwent a revision in June 2016. Following the implementation of the protocol, we monitored the patients undergoing an LA at Nationwide Children's Hospital between November 2014 and August 2017. RESULTS: We identified 691 patients (255 female) who underwent a simple LA at Nationwide Children's Hospital between November 2014 and August 2017. The patient population had a median age of 11 years (interquartile range: 9, 14). Among these patients, 514 (74%) were discharged on the day of surgery, and 387 (56%) were protocol compliant. The rate of same-day discharge was higher for compliant cases (79%) than noncompliant cases (69%, P = 0.003). Multivariable statistical analysis associated compliance with an increased likelihood of same-day discharge (Odds ratio [OR] = 1.7, 95% CI: 1.2, 2.4, P = 0.002). CONCLUSIONS: Implementation of the LA protocol to reduce PONV demonstrated a significant increase in the rate of same-day discharge from the hospital among compliant patients. Also, the adoption of a protocol to select patients for early discharge after LA has shown results with a 45% reduction in the need for inhospital beds.

Caudal epidural block instead of general anesthesia in an adult with Duchenne muscular dystrophy.

Duchenne muscular dystrophy (DMD), first described in 1834, is an X-linked dystrophinopathy, leading to early onset skeletal muscle weakness. Life expectancy is reduced to early adulthood as a result of involvement of voluntary skeletal muscles with respiratory failure, orthopedic deformities, and associated cardiomyopathy. Given its multisystem involvement, surgical intervention may be required to address the sequelae of the disease process. We present a 36-year-old adult with DMD, who required anesthetic care during surgical debridement of an ischial pressure sore. Given his significant respiratory muscle involvement, ultrasound-guided caudal epidural anesthesia was used instead of general during the surgical procedure. The technique and its applications are discussed, with particular emphasis on the feasibility and safety of using regional anesthetic techniques in patients with DMD.