Ultrasound assessment of gastric volume in the fasted pediatric patient undergoing upper gastrointestinal endoscopy: development of a predictive model using endoscopically suctioned volumes.

BACKGROUND: Aspiration of gastric contents can be a serious anesthetic-related complication. Gastric antral sonography prior to anesthesia may have a role in identifying pediatric patients at risk of aspiration. We examined the relationship between sonographic antral area and endoscopically suctioned gastric volumes, and whether a 3-point qualitative grading system is applicable in pediatric patients. METHODS: Fasted patients presenting to a pediatric hospital for upper gastrointestinal endoscopy were included in the study. Sonographic measurement of the antral cross-sectional area (CSA) in supine (supine CSA) and right lateral decubitus (RLD CSA) position was completed, and the antrum was designated as empty or nonempty. Gastric contents were endoscopically suctioned and measured. Multiple regression analysis was used to fit a mathematical model to estimate gastric volume. RESULTS: One hundred patients (aged 11-216 months) were included. The gastric antrum was measured in 94% and 99% of patients in the supine and RLD positions, respectively. Gastric antral CSA correlated with total gastric volume in both supine (ρ = 0.63) and RLD (ρ = 0.67) positions. A mathematical model incorporating RLD CSA and age (R(2)  = 0.60) was determined as the best-fit model to predict gastric volumes. Increasing gastric antral grade (0-2) was associated with increasing gastric fluid volume. CONCLUSION: The results suggest that sonographic assessment of the gastric antrum provides useful information regarding gastric content (empty versus nonempty) and volume (ml·kg(-1) ) in pediatric patients. Results suggest that the three-point grading system may be a valuable tool to assess gastric 'fullness' based on a qualitative exam of the antrum.

Effect of dexamethasone on postoperative morbidity after dental rehabilitation in children.

PURPOSE: Dexamethasone reduces postoperative morbidity after adenotonsillectomy, strabismus surgery, and third molar extraction. Our hypothesis was that dexamethasone would reduce pain and other morbidity in children undergoing dental surgery for up to 24 hr postoperatively. METHODS: A triple-blinded, randomized, controlled trial was carried out on 200 children undergoing prolonged dental rehabilitation under general anesthesia. Subjects were randomized into two groups: group D, given dexamethasone 0.3 mg·kg(-1); group S, given normal saline. The primary outcome measure was pain over 24 hr as evaluated by a parental 0-10 numerical rating scale (NRS). Key secondary outcomes included oral intake on a four-point scale at 24 hr and the overall incidence of postoperative vomiting (POV). Analysis for the primary outcome consisted of comparison of means in the NRS with the Wilcoxon rank sum test and for occurrence of POV with Fisher's test. RESULTS: After eliminating 22 subjects for protocol violations and withdrawals, 178 subjects were analyzed. There was no significant difference in pain scores (NRS) at 24 hr or the worst NRS experienced over the preceding 24 hr. There was no difference in the quality of oral intake between the groups. There was a significant difference in the percentage of patients who vomited during the first 24 hr: eight of 91 in group S and one of 87 in group D. Therefore, 7.74% more vomited in group S (P = 0.045), with a 95% confidence interval of 0.32 to15.16 for the difference in percentages. CONCLUSIONS: Dexamethasone, 0.3 mg·kg(-1), did not reduce pain over 24 hr in healthy children undergoing dental rehabilitation under general anesthesia. The quality of oral intake was also unaffected by dexamethasone at 24 hr. Dexamethasone did produce a significant reduction in postdischarge vomiting, beyond the incidence found with ondansetron alone.

The effects of parental presence in the postanesthetic care unit on children's postoperative behavior: a prospective, randomized, controlled study.

BACKGROUND: The effects on children of parental presence in the postanesthesia care unit (PACU) have not been extensively studied. The few published studies are retrospective, nonrandomized, or lack adequate controls. They suggest that parental presence in the PACU decreases crying and negative behavior change postoperatively. We performed this prospective, randomized, controlled study to determine whether the presence of a parent affected crying behaviors in the PACU and behavior change 2 weeks postoperatively. METHODS: Randomly selected patients, aged 2.0 to 8 years 11 months, ASA physical status I or II, and scheduled for elective outpatient surgery with an anticipated PACU stay of >10 minutes were randomly assigned to the parent present group (n = 150) or parent absent group (n = 150) in the PACU. All parents underwent the same preparation program. Reunification occurred once children's eyes had opened for the parent present group. In the PACU, crying was scored each minute after eye opening using a 5-point scale. Negative behavior change 2 weeks after discharge was determined using the Post Hospitalization Behavior Questionnaire. Because the anesthesia technique to be used was not determined a priori, data on the technique used were collected to ensure that groups were similar. Multiple and logistic regression techniques were used to determine predictors of crying in the PACU and behavior change 2 weeks postoperatively. RESULTS: Parental presence in the PACU made no difference in crying in the PACU. Negative behavior change 2 weeks postoperatively occurred more frequently in the parent absent group than the parent present group (45.8% vs 29.3%; P = 0.007). Multiple regression identified the following significant factors as predictive of larger proportion of time spent crying in the PACU (R(2) = 0.256, F[5, 273] = 15.66, P < 0.001): age <5 years (P < 0.001) and higher Children's Hospital of Eastern Ontario Pain Scale score at 15 minutes after arrival in day surgery (P < 0.001). Parental presence or absence from the PACU was not predictive of crying in the PACU, and neither were socioeconomic status nor intraoperative opioid analgesia. Logistic regression identified the following factors (chi(2)[4] = 26.62, P < 0.001) as predictive of negative behavior change at 2 weeks postoperatively: being younger than 5 years (P < 0.001) and being in the parent absent group (P = 0.003). CONCLUSION: For fit healthy children undergoing outpatient surgery, parental presence in the PACU decreases negative behavior change at 2 weeks postoperatively but makes no difference in crying in the PACU. Future studies of behavior change postoperatively should consider parental presence in the PACU a factor and determine whether the effect persists with other interventions.

Evidence-based clinical update: Which local anesthetic drug for pediatric caudal block provides optimal efficacy with the fewest side effects?

PURPOSE: The purpose of this evidence-based clinical update is to identify the best evidence when selecting a long-acting local anesthetic agent for single-shot pediatric caudal anesthesia in children. METHODS: A structured literature search was conducted using PubMed and Medline (OVID) using the terms "caudal" and combinations of at least two of "bupivacaine", "ropivacaine", and "levobupivacaine". The search limits included "randomized controlled trials" (RCTs), "meta-analysis", "evidence-based reviews" or "reviews", "human", and "all child: 0-18 yr". Seventeen RCTs were identified that concerned single-shot pediatric caudal anesthesia with at least two of the three drugs in question. Data were extracted for the areas of clinical efficacy and side effects. Study findings were assigned levels of evidence, and grades of recommendation were made according to Centre for Evidence-Based Medicine criteria. RESULTS: The three drugs investigated were found to be equivalent in terms of efficacy. Evidence showed bupivacaine with the highest incidence of motor block and ropivacaine with the lowest. Adverse effects were rare and unrelated to the choice of drug. There were no serious adverse events. CONCLUSION: None of the three agents was shown to be superior in terms of efficacy. Bupivacaine is preferred if motor block is desired, ropivacaine is preferred if motor block is to be minimized. Adverse effects in human studies are rare, mild, and unrelated to the choice of drug. Despite encountering the absence of serious adverse events in each of the studies reviewed, it is noted that animal studies suggest a safer profile with ropivacaine or levobupivacaine than with bupivacaine.

[Comparison of laryngeal mask airway (LMA)- Proseal and the LMA-Classic in ventilated children receiving neuromuscular blockade].

PURPOSE: To determine whether a functional difference exists between the size 2 laryngeal mask airway (LMA)-Classic (CLMA) and LMA-Proseal (PLMA) in anesthetized children who have received neuromuscular blockade. Airway leak during intermittent positive pressure ventilation (IPPV) and adequacy of fibreoptic laryngeal view were the primary study outcomes. METHODS: A randomized, controlled, single-blinded study of 51 ASA I or II children weighing 10-20 kg was undertaken. The anesthetic technique was standardized. Following insertion of the LMA and cuff inflation to 60 cm H(2)O, we measured oropharyngeal leak pressure and gastric insufflation and leak fraction during IPPV, and evaluated the adequacy of fibreoptic view. RESULTS: Oropharyngeal leak pressure measured by neck auscultation was higher for the PLMA compared to the CLMA (23.7 vs 16.5 cm H(2)O, P = 0.009) but, when measured by the inspiratory hold maneuver was not significantly different (24.8 vs 20.3 cm H(2)O, respectively, P = 0.217). Leak fraction values were similar for the CLMA and the PLMA (21.2%. vs 13.3%, respectively, P = 0.473). A satisfactory view of the larynx was obtained more frequently in the PLMA group (21/25 vs 10/25, P = 0.003). Gastric insufflation during leak determination was more common with the CLMA (12/26 vs 2/25 CLMA vs PLMA, respectively, P = 0.006). CONCLUSION: In children undergoing IPPV with neuromuscular blockade, the size 2 PLMA is associated with a higher leak pressure by auscultation and less gastric insufflation compared to the CLMA. Leak pressures assessed by manometric stability are similar with these two devices. The improved fibreoptic view of the larynx through the PLMA may be advantageous for bronchoscopy.