Comparison of cerebral oxygen desaturation events between children under general anesthesia and chloral hydrate sedation - a randomized controlled trial.

BACKGROUND: During pediatric general anesthesia (GA) and sedation, clinicians aim to maintain physiological parameters within normal ranges. Accordingly, regional cerebral oxygen saturation (rScO2) should not drop below preintervention baselines. Our study compared rScO2 desaturation events in children undergoing GA or chloral hydrate sedation (CHS). METHODS: Ninety-two children undergoing long auditory assessments were randomly assigned to two study arms: CHS (n = 40) and GA (n = 52). Data of 81 children (mean age 13.8 months, range 1-36 months) were analyzed. In the GA group, we followed a predefined 10 N concept (no fear, no pain, normovolemia, normotension, normocardia, normoxemia, normocapnia, normonatremia, normoglycemia, and normothermia). In this group, ENT surgeons performed minor interventions in 29 patients based on intraprocedural microscopic ear examinations. In the CHS group, recommendations for monitoring and treatment of children undergoing moderate sedation were met. Furthermore, children received a double-barreled nasal oxygen cannula to measure end-tidal carbon dioxide (etCO2) and allow oxygen administration. Chloral hydrate was administered in the parent's presence. Children had no intravenous access which is an advantage of sedation techniques. In both groups, recommendations for fasting were followed and an experienced anesthesiologist was present during the entire procedure. Adverse event (AE) was a decline in cerebral oxygenation to below 50% or below 20% from the baseline for ≥1 min. The primary endpoint was the number of children with AE across the study arms. Secondary variables were: fraction of inspired oxygen (FIO2), oxygen saturation (SpO2), etCO2, systolic and mean blood pressure (BP), and heart rate (HR); these variables were analyzed for their association with drop in rScO2 to below baseline (%drop_rScO2). RESULTS: The incidence of AE across groups was not different. The analysis of secondary endpoints showed evidence that %drop_rScO2 is more dependent on HR and FIO2 than on BP and etCO2. CONCLUSIONS: This study highlights the strong association between HR and rScO2 in children aged < 3 years, whereas previous studies had primarily discussed the role of BP and etCO2. Prompt HR correction may result in shorter periods of cerebral desaturation. TRIAL REGISTRATION: The study was retrospectively registered with the German Clinical Trials Registry (DRKS00024362, 04/02/2021).

In vitro performance evaluation of AnaConDaTM-100 and AnaConDaTM-50 compared to a circle breathing system for control and consumption of volatile anaesthetics.

To identify the better volatile anaesthetic delivery system in an intensive care setting, we compared the circle breathing system and two models of reflection systems (AnaConDa™ with a dead space of 100 ml (ACD-100) or 50 ml (ACD-50)). These systems were analysed for the parameters like wash-in, consumption, and wash-out of isoflurane and sevoflurane utilising a test lung model. The test lung was connected to a respirator (circle breathing system: Aisys CS™; ACD-100/50: Puriton Bennett 840). Set parameters were volume-controlled mode, tidal volume-500 ml, respiratory rate-10/min, inspiration time-2 sec, PEEP-5 mbar, and oxygen-21%. Wash-in, consumption, and wash-out were investigated at fresh gas flows of 0.5, 1.0, 2.5, and 5.0 l/min. Anaesthetic target concentrations were 0.5, 1.0, 1.5, 2.0, and 2.5%.  Wash-in was slower in ACD-100/-50 compared to the circle breathing system, except for fresh gas flows of 0.5 and 1.0 l/min. The consumption of isoflurane and sevoflurane in ACD-100 and ACD-50 corresponded to the fresh gas flow of 0.5-1.0 l/min in the circle breathing system. Consumption with ACD-50 was higher in comparison to ACD-100, especially at gas concentrations > 1.5%. Wash-out was quicker in ACD-100/-50 than in the circle breathing system at a fresh gas flow of 0.5 l/min, however, it was longer at all the other flow rates. Wash-out was comparable in ACD-100 and ACD-50. Wash-in and wash-out were generally quicker with the circle breathing system than in ACD-100/-50. However, consumption at 0.5 minimum alveolar concentration was comparable at flows of 0.5 and 1.0 l/min.

Pain in children undergoing tonsillotomy with alternating ibuprofen and paracetamol - a prospective observational study.

BACKGROUND: The optimal pain therapy for children undergoing tonsillotomy remains unknown. Our aim was to evaluate a standard pain therapy including the alternating application of ibuprofen and paracetamol. METHODS: Pain intensity of 81 in-patients after tonsillotomy aged 2-12 years was evaluated three times daily (mean observation 3.85 days) using the Children's and Infants' Postoperative Pain Scale (CHIPPS) in children <5 years, or with the Faces Pain Scale-Revised (FPS-R) in older children. Parents completed the Parents' Postoperative Pain Measure (PPPM-D) in addition. Exceeding the cut-off value in one of the scores implied the indication for an opioid rescue medication (RM). Endpoints were number of children with indication for the RM, course of pain, concordance between pain scales, and adverse events. RESULTS: Overall, 45.7% of children needed the RM either in the recovery room or on the ward. The rate of children having an indication for RM on the ward was 30.9%. The highest proportion of affected children was identified on the day of surgery (32.1%). Most indications were detected with the PPPM-D only. A comparison with an earlier study showed less affected children compared to ibuprofen monotherapy on the day of surgery and the first postoperative day. Eleven children (13.6%) developed fever. CONCLUSION: Although our pain therapy concept was effective from postoperative day 1 onwards, it needs improvement for the day of surgery. The overall concordance between the PPPM-D and CHIPPS or FPS-R was low. Fever might be a confounder for the pain intensity measurement with the PPPM-D.