Does heart rate variability using the Newborn Infant Parasympathetic Evaluation index identify postsurgical pain levels and emergence delirium in toddlers? A prospective observational study.

PURPOSE: Children recovering from anesthesia commonly experience early postoperative negative behaviour, caused by pain and emergence delirium. Differentiating the two is challenging in young children. Perioperative pain influences the heart rate variability-derived Newborn Infant Parasympathetic Evaluation (NIPE) index and may also affect emergence delirium. We sought to investigate whether the perioperative NIPE index can discriminate between mild, moderate, or severe pain levels and can detect emergence delirium. METHODS: This prospective observational study enrolled children aged three years or younger undergoing elective adenotonsillectomy, tonsillectomy, or adenoidectomy. The NIPE index, the Faces, Legs, Activity, Cry, Consolability (FLACC) score, and the Pediatric Anesthesia Emergence Delirium (PAED) score were recorded in the postanesthesia care unit (PACU). The primary aim was to investigate the relationship between the postoperative NIPE index and postoperative pain severity. The secondary aims were to evaluate the association between the NIPE index and emergence delirium (PAED ≥ 10) and its delirium-specific (ED-I) and pain-specific (ED-II) components. RESULTS: Sixty-nine children were recruited. In the PACU, the mean (standard deviation [SD]) NIPE values in children experiencing moderate and severe pain were 50 (12) and 49 (14), respectively. These values were significantly lower than the mean (SD) value of 64 (13) observed in children with mild pain (mean difference moderate vs no/mild pain, -14; 95% confidence interval [CI], -17 to -11; P < 0.001, and mean difference severe vs no/mild pain, -17; 95% CI, -20 to -14; P < 0.001, respectively). The NIPE index was significantly lower in children experiencing pain-specific ED-II (mean [SD] NIPE instantaneous [NIPEi] for ED-II 49 [10] vs no ED-II 55 [13]; mean difference, -6; 95% CI, -11 to -2; P = 0.009). The NIPE index was unable to detect emergence delirium (mean [SD] NIPEi for ED, 54 [15] vs no ED, 51 [10]; mean difference, 3; 95% CI, -2 to 8; P = 0.23) or the delirium-specific component ED-I (mean [SD] NIPEi for ED-I, 55 [15] vs no ED-I, 51 [11]; mean difference, 4; 95% CI, 0 to 8; P = 0.06). CONCLUSION: The NIPE index can identify moderate and severe postoperative pain after adenotonsillectomy but not emergence delirium in children aged three years and younger. This discrimination can be valuable in the early postoperative phase when the differentiation between pain and emergence delirium is difficult. STUDY REGISTRATION: ClinicalTrials.gov ( NCT04909060 ); first submitted 26 May 2021.

RéSUMé: OBJECTIF: Les enfants qui se remettent d'une anesthésie font fréquemment preuve d'un comportement négatif en début de période postopératoire. Ce comportement est causé par la douleur et le délire d'émergence, mais il est difficile de les distinguer chez les jeunes enfants. La douleur périopératoire a un impact sur l'indice d'évaluation parasympathique du nouveau-né et du nourrisson (NIPE) dérivé de la variabilité de la fréquence cardiaque et peut également affecter le délire d'émergence. Nous avons cherché à déterminer si l'indice NIPE périopératoire permettait de différencier des niveaux de douleur légers, modérés ou sévères et de détecter le délire d'émergence. MéTHODE: Cette étude observationnelle prospective a recruté des enfants de trois ans ou moins ayant bénéficié d'une adéno-amygdalectomie, d'une amygdalectomie ou d'une adénoïdectomie non urgente. L'indice NIPE, le score FLACC (Faces, Legs, Activity, Cry, Consolability) et le score PAED (Pediatric Anesthesia Emergence Delirium) ont été enregistrés en salle de réveil. L'objectif principal était d'étudier la relation entre l'indice NIPE postopératoire et la sévérité de la douleur postopératoire. Les objectifs secondaires étaient d'évaluer l'association entre l'indice NIPE et le délire d'émergence (PAED ≥ 10) et ses composantes spécifiques au délire (ED-I) et à la douleur (ED-II). RéSULTATS: Nous avons recruté soixante-neuf enfants. En salle de réveil, les valeurs NIPE moyennes (écart type [ET]) chez les enfants souffrant de douleurs modérées et sévères étaient respectivement de 50 (12) et de 49 (14). Ces valeurs étaient significativement inférieures à la valeur moyenne (ET) de 64 (13) observée chez les enfants présentant une douleur légère (différence moyenne modérée vs pas de douleur ou douleur légère, −14; intervalle de confiance [IC] à 95 %, −17 à −11; P < 0,001, et différence moyenne entre douleur sévère vs pas de douleur ou douleur légère, −17; IC 95 %, −20 à −14; P < 0,001, respectivement). L'indice NIPE était significativement plus faible chez les enfants présentant un ED-II spécifique à la douleur (moyenne [ET] NIPE instantanée [NIPEi] pour ED-II, 49 [10] vs pas de ED-II, 55 [13]; différence moyenne, −6; IC 95 %, −11 à −2; P = 0,009). L'indice NIPE n'a pas été en mesure de détecter le délire d'émergence (NIPEi moyen [ET] pour le délire d'émergence, 54 [15] vs pas de délire d'émergence, 51 [10]; différence moyenne, 3; IC 95 %, −2 à 8; P = 0,23) ou la composante spécifique au délire de l'ED-I (NIPEi moyen [ET] pour ED-I, 55 [15] vs pas d'ED-I, 51 [11]; différence moyenne, 4; IC 95 %, 0 à 8; P = 0,06). CONCLUSION: L'indice NIPE permet d'identifier une douleur postopératoire modérée et sévère après une adéno-amygdalectomie mais pas le délire d'émergence chez les enfants de trois ans et moins. Cette discrimination peut être utile dans la phase postopératoire précoce lorsqu'il est difficile de différencier la douleur et le délire d'émergence. ENREGISTREMENT DE L'éTUDE: ClinicalTrials.gov ( NCT04909060 ); première soumission le 26 mai 2021.

The endocrinologist gap: Managing diabetes patients in absence of a specialist.

The treatment of pediatric patients with diabetes is frequently orchestrated within a multidisciplinary framework at tertiary, specialized institutions. In situations where emergent surgery is indicated or when a procedure is scheduled in a facility devoid of an endocrinology service, the onus of managing perioperative glycemic levels may rest with the attending anesthesiologist. The objective of this review is to furnish a comprehensive examination of the anesthetic considerations and perioperative governance of pediatric patients with diabetes. Furthermore, this paper delineates a streamlined protocol for perioperative glycemic control, tailored to both major and minor surgical interventions.

Advances in pediatric perioperative care using artificial intelligence.

PURPOSE OF THIS REVIEW: This article explores how artificial intelligence (AI) can be used to evaluate risks in pediatric perioperative care. It will also describe potential future applications of AI, such as models for airway device selection, controlling anesthetic depth and nociception during surgery, and contributing to the training of pediatric anesthesia providers. RECENT FINDINGS: The use of AI in healthcare has increased in recent years, largely due to the accessibility of large datasets, such as those gathered from electronic health records. Although there has been less focus on pediatric anesthesia compared to adult anesthesia, research is on- going, especially for applications focused on risk factor identification for adverse perioperative events. Despite these advances, the lack of formal external validation or feasibility testing results in uncertainty surrounding the clinical applicability of these tools. SUMMARY: The goal of using AI in pediatric anesthesia is to assist clinicians in providing safe and efficient care. Given that children are a vulnerable population, it is crucial to ensure that both clinicians and families have confidence in the clinical tools used to inform medical decision- making. While not yet a reality, the eventual incorporation of AI-based tools holds great potential to contribute to the safe and efficient care of our patients.

What we know and what we don't know about the perioperative use of methadone in children and adolescents.

Postoperative pain control is essential to optimizing patient outcomes, improving satisfaction, and allowing patients to resume their baseline functional activities. Methadone, a synthetic mu-opioid agonist, has multiple pharmacologic properties that may be optimal for perioperative use. Compared to other opioids, methadone has a longer duration of action, rapid onset, extended dosing intervals, high oral bioavailability, low cost, lack of active metabolites, and action on multiple receptors. The current literature examining the use of methadone in the perioperative care of children and adolescents is limited and most often reported within the context of spine or cardiothoracic surgery. Overall, these studies support the hypothesis that perioperative methadone in pediatric patients may decrease postoperative pain, opioid consumption, length-of-stay, and the incidence of some opioid-related side effects, like constipation and urinary retention. A variety of protocols for the perioperative use of methadone have been described, including a single intraoperative dose as well as multiple small doses within multimodal pain protocols. The superiority of these protocols has not been established. Like all opioids, methadone has a side effect profile which includes nausea, vomiting, reduced GI motility, sedation, and respiratory depression at high doses. There is also a concern that it can cause QTc prolongation in patients. The primary aim of this educational review is to examine the pharmacologic data, published perioperative protocols, dosing considerations, and risks and benefits associated with inclusion of methadone in analgesic regimens for surgical patients. A secondary aim is to introduce opportunities for research around the perioperative use of methadone in children and adolescents. Based on our review, we would prioritize establishing optimal procedure-specific methadone protocols, determining generalizability for use in routine pediatric surgeries, and investigating methadone safety and efficacy prospectively as the primary opioid for pain management in the postanesthesia care unit or postsurgical floors.

Genetic risk factors for chronic postsurgical pain in children: A narrative review.

Genetic risk factors for chronic postsurgical pain in adults have been established, but little is known whether the same associations exist in children. It is even less clear how much influence single nucleotide polymorphisms can exert on the phenotypic expression of chronic postsurgical pain in children in general. To this effect, a search was made for original articles which met the following criteria: evaluation of postsurgical pain in children with known genetic mutations or, conversely, evaluation of atypical pain trajectories of postsurgical children assessing for possible genetic mutations that may explain the phenotype. All titles and abstracts retrieved were reviewed for suitability for inclusion. The references of the selected articles were also checked for additional relevant papers. To assess the transparency and quality of the genetic studies both STrengthening the REporting of Genetic Association studies scores and Q-Genie scores were applied. Overall, there is a paucity of information regarding the link between genetic mutations and eventual chronic postsurgical pain development although there is some information on acute postoperative pain. Evidence has shown that the contribution of genetic risk factors to chronic postsurgical pain development appears to be minor, with its clinical relevance yet to be described. More advanced techniques in systems biology (proteomics, transcriptomics) suggest promising avenues for investigating the disease.

The spectrum of indomethacin-responsive headaches in children and adolescents.

BACKGROUND: Headaches with marked, specific response to indomethacin occur in children, but the phenotypic spectrum of this phenomenon has not been well-studied. METHODS: We reviewed pediatric patients with headache showing ≥80% improvement with indomethacin, from seven academic medical centers. RESULTS: We included 32 pediatric patients (16 females). Mean headache onset age was 10.9 y (range 2-16 y). Headache syndromes included hemicrania continua (n = 13), paroxysmal hemicrania (n = 10), primary stabbing headache (n = 2), short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (n = 1), primary exercise headache (n = 1) and primary cough headache (n = 1). Adverse events were reported in 13, most commonly gastrointestinal symptoms, which often improved with co-administration of gastro-protective agents. CONCLUSION: Indomethacin-responsive headaches occur in children and adolescents, and include headache syndromes, such as primary cough headache, previously thought to present only in adulthood. The incidence of adverse events is high, and patients must be co-treated with a gastroprotective agent.

Reflecting back to move forward: Lessons learned about COVID-19 safety protocols from pediatric anesthesiologists.

BACKGROUND: The COVID-19 pandemic brought about the immediate need for enhanced safety protocols in health care centers. These protocols had to evolve as knowledge and understanding of the disease quickly broadened. AIMS: Through this study, the researchers aimed to understand the experiences of pediatric anesthesiologists at the Montreal Children's Hospital and the Shriners' Hospital Canada as they navigated the first wave of COVID-19 at their institutions. METHODS: Nine participants from the Montreal Children's Hospital and the Shriners' Hospital were interviewed. Interviews were recorded, transcribed verbatim, and then analyzed using an applied philosophical hermeneutics approach. FINDINGS: Participants expressed their wish for simple and easy-to-apply protocols while recognizing the challenge of keeping up with evolving knowledge on the disease and its transmission. They pointed to some limitations and unintended consequences of the safety protocols and the system-wide flaws that the COVID-19 pandemic helped bring to light. They described their frustrations with some aspects of the safety protocols, which they at times felt could be more efficient or better suited for their daily practice. CONCLUSIONS: The findings of this study highlighted the importance of listening to and empowering anesthesiology staff working in the field during crises, the implications of shifting from patient-centered care to community-centered care, and the fine line between sharing as much emerging information as possible and overwhelming staff with information.

Long-term efficacy and adverse effects of outpatient procedural analgesia with nitrous oxide for a child with Epidermolysis Bullosa.

Epidermolysis Bullosa is a dermatologic condition characterized by skin fragility and the formation of painful blisters all over the body. The course of this chronic hereditary disorder involves multiple painful procedures for which adequate analgesia is an ongoing challenge. This case report follows a previously-described pediatric patient with the Dowling-Meara variant of Epidermolysis Bullosa who was treated with at-home nitrous oxide for daily procedural analgesia. We report on the long-term effectiveness of this treatment in addition to any side effects encountered as a result of this treatment.

Multimodal Analgesic Plan for Children Undergoing Chimeric 14.18 Immunotherapy.

Immunotherapy with the chimeric 14.18 anti-GD2 antibody (ch14.18) is associated with severe neuropathic pain. Different analgesic modalities have been employed, but pain management remains challenging and side effects such as desaturation, bradycardia, and hypotension have been reported. We retrospectively analyzed the efficacy of a multimodal regimen based on gabapentin, ketamine, and morphine in controlling pain during ch14.18 chemotherapy. In our cohort, the pain was low, desaturation and hypotension were infrequent, and no episode of bradycardia was reported. Morphine consumption was similar to other studies. Our results suggest that this regimen may be a valid analgesic option in children undergoing ch14.18 infusion.

Use of bisphosphonates in a retrospective case series of children and adolescents with complex regional pain syndrome.

BACKGROUND: There is increasing evidence for the use of bisphosphonates to treat Complex Regional Pain Syndrome in adults. However, there are scarce data for their use in children with Complex Regional Pain Syndrome. AIM: This retrospective case series aimed to analyze the effects of intravenous bisphosphonate use in children and adolescents with Complex Regional Pain Syndrome enrolled in a multidimensional pain treatment program. METHODS: We analyzed the data of 16 patients (15 females and 1 male, mean age 14 ± 3 years) who received infusions of zoledronic acid (0.015 ± 0.0044mg/kg), pamidronate (0.72 ± 0.17mg/kg), or both depending on their initial response between October 2014 and December 2019. The primary endpoint of the study was the patient's global impression of change. Secondary outcomes included pain intensity, physical function, role function (school attendance), need for pain medications, and adverse effects. RESULTS: Nine of 16 patients reported meaningful improvements (global impressions of change of 84% or higher) at a median follow-up time of 16 (8-21) months after their last infusion of bisphosphonates. There were also meaningful reductions in pain intensity and the need for pain medications. There was an increase in the proportion of patients with minimal or without physical disability, and almost all patients normalized their school activities. Thirteen patients (81%) reported adverse effects, mostly flu-like symptoms, for a few days after the infusion. CONCLUSION: The use of bisphosphonate infusions may represent an effective treatment option for children with Complex Regional Pain Syndrome, not responding to multidisciplinary pain treatment programs.

Endoscopic Versus Open Repair for Craniosynostosis in Infants Using Propensity Score Matching to Compare Outcomes: A Multicenter Study from the Pediatric Craniofacial Collaborative Group.

BACKGROUND: The North American Pediatric Craniofacial Collaborative Group (PCCG) established the Pediatric Craniofacial Surgery Perioperative Registry to evaluate outcomes in infants and children undergoing craniosynostosis repair. The goal of this multicenter study was to utilize this registry to assess differences in blood utilization, intensive care unit (ICU) utilization, duration of hospitalization, and perioperative complications between endoscopic-assisted (ESC) and open repair in infants with craniosynostosis. We hypothesized that advantages of ESC from single-center studies would be validated based on combined data from a large multicenter registry. METHODS: Thirty-one institutions contributed data from June 2012 to September 2015. We analyzed 1382 infants younger than 12 months undergoing open (anterior and/or posterior cranial vault reconstruction, modified-Pi procedure, or strip craniectomy) or endoscopic craniectomy. The primary outcomes included transfusion data, ICU utilization, hospital length of stay, and perioperative complications; secondary outcomes included anesthesia and surgical duration. Comparison of unmatched groups (ESC: N = 311, open repair: N = 1071) and propensity score 2:1 matched groups (ESC: N = 311, open repair: N = 622) were performed by conditional logistic regression analysis. RESULTS: Imbalances in baseline age and weight are inherent due to surgical selection criteria for ESC. Quality of propensity score matching in balancing age and weight between ESC and open groups was assessed by quintiles of the propensity scores. Analysis of matched groups confirmed significantly reduced utilization of blood (26% vs 81%, P < .001) and coagulation (3% vs 16%, P < .001) products in the ESC group compared to the open group. Median blood donor exposure (0 vs 1), anesthesia (168 vs 248 minutes) and surgical duration (70 vs 130 minutes), days in ICU (0 vs 2), and hospital length of stay (2 vs 4) were all significantly lower in the ESC group (all P < .001). Median volume of red blood cell administered was significantly lower in ESC (19.6 vs 26.9 mL/kg, P = .035), with a difference of approximately 7 mL/kg less for the ESC (95% confidence interval for the difference, 3-12 mL/kg), whereas the median volume of coagulation products was not significantly different between the 2 groups (21.2 vs 24.6 mL/kg, P = .73). Incidence of complications including hypotension requiring treatment with vasoactive agents (3% vs 4%), venous air embolism (1%), and hypothermia, defined as <35°C (22% vs 26%), was similar between the 2 groups, whereas postoperative intubation was significantly higher in the open group (2% vs 10%, P < .001). CONCLUSIONS: This multicenter study of ESC versus open craniosynostosis repair represents the largest comparison to date. It demonstrates striking advantages of ESC for young infants that may result in improved clinical outcomes, as well as increased safety.

Cervical instability in patients with Trisomy 21: The eternal gamble.

Patients with Trisomy 21 are particularly at risk of cervical instability due to ligamentous laxity and osseous abnormalities. Up to 30% of Trisomy 21 patients are affected by atlanto-axial or atlanto-occipital instability, but only 1%-2% of cases are symptomatic. The radiologic assessment of cervical instability is not unanimously considered mandatory. The dynamic cervical spine radiograph is the most common screening tool for ruling out cervical spine instability in patients with Trisomy 21, and it is often requested before surgery. Several measurements have been investigated to assess the presence and degree of cervical instability; however, no conclusive recommendations have been forthcoming. In daily practice, many anesthesiologists may provide anesthesia via such means as laryngoscopy and tracheal intubation during surgery, without any radiological investigations before surgery. This review focuses on the diagnostic and prognostic measures available to evaluate the presence and degree of cervical instability in patients with Trisomy 21 and to propose practical recommendations to be applied in clinical practice.

Interventional procedures in children and adolescents with chronic non-cancer pain as part of a multidisciplinary pain treatment program.

BACKGROUND: Interventional procedures are part of multidisciplinary pain treatment programs to treat chronic non-cancer pain conditions in children and adolescents. However, the real benefit of these interventions remains unclear. AIMS: The aim of this study was to analyze the potential benefits of the interventional procedures in children and adolescents with chronic non-cancer pain in the setting of a multidisciplinary pain treatment program. METHODS: We retrospectively reviewed the charts of 98 children and adolescents receiving 314 diagnostic or therapeutic interventional procedures. We applied the following definitions of efficacy Short-term positive therapeutic effect: block that produced a minimum of 50% reduction in pain intensity for at least 4 weeks. Long-term positive therapeutic effect: a patient with a minimum of 50% reduction in pain intensity for at least 6 months Full recovery: a patient free of pain, not taking analgesics with normal physical and role functioning 6 months after the last procedure. RESULTS: Seventy-six of 112 diagnostic blocks (68%) were associated with a 50% reduction in pain intensity for at least 4 weeks after the procedure. One hundred and sixty-six of 202 therapeutics blocks (82%) were associated with a short-term benefit. Seventy-two of 98 patients (73%) referred a 50% reduction in their pain intensity (17%) or had full recovery 6 months after the procedures (56%) and a MPTP. Psychiatric comorbidity and more advanced age were factors associated with failure to respond to interventional procedures. CONCLUSION: The use of interventional procedures may represent a valid therapeutic option, associated with positive clinical outcomes within a multidisciplinary program.

Acute pain management in children: challenges and recent improvements.

PURPOSE OF REVIEW: The evidence regarding the efficacy of analgesics available to guide postoperative pain treatment in pediatric patients is limited. Opioid medications are very often an important component of pediatric postoperative pain treatment but have been associated with perioperative complications. We will focus on initiatives aiming to provide effective treatment minimizing the use of opioids and preventing the long-term consequences of pain. RECENT FINDINGS: Interpatient variability in postoperative pain is currently managed by applying protocols or by trial and error, thus often leading to patients being either undertreated or overtreated. Few evidence-based reports are available to guide the use of opioid medications in children, including the prescription of opioids after hospital discharge. Using combinations of nonopioid analgesics in a multimodal approach may limit the need for opioids, thus decreasing the risk of toxicity and dose-related side effects. There is a lack of adequate research in this field, and more specifically on identifying which patient is at higher risk of poor postoperative pain management. SUMMARY: Treatment options have evolved in recent years, including the combinations of multimodal regimens and regional anesthetic techniques. Using combinations of nonopioid analgesics in a multimodal approach may limit the need for opioids.

Nitrous oxide for procedural analgesia at home in a child with epidermolysis bullosa.

Epidermolysis bullosa comprises a range of conditions characterized by fragile skin with painful blistering induced by minor trauma and friction. The Dowling-Meara variant is a severe form characterized by disseminated painful blistering requiring lifelong skin and wound care. The natural history of the disease is characterized by a chronic course that tends to improve with advancing age. Various multimodal analgesic strategies have been proposed for painful procedures in children with epidermolysis bullosa. In this case report, we describe the use of nitrous oxide for pain control at home of blister treatments in a 4-year-old child with the Dowling-Meara variant.

The implications of immunization in the daily practice of pediatric anesthesia.

PURPOSE OF REVIEW: Vaccination is an important prevention measure, but requires an intact immune system. Surgery and anesthesia suppress the immune system and may interfere with the benefits of immunization. Moreover, common vaccine side-effects may be misinterpreted as postsurgical complications. This review summarizes the essential basis of immunization and its potential interactions with anesthesia. RECENT FINDINGS: Vaccines have mild side-effects, such as fever, but may lead to serious complications in immunocompromised patients. Surgery and anesthesia may decrease the efficacy of a vaccine, or promote vaccine-related complications. It, therefore, reasonable to schedule surgery and anesthesia with a delay either before or after vaccine administration, but there is no consensus among anesthesiologists and pediatricians regarding this timing. SUMMARY: Inactive vaccines are generally well tolerated. Live vaccines provide an effective and long-lasting immunization, but may carry more serious complications. Elective operations should be postponed 1 week after an inactive vaccine and 3 weeks after immunization with a live vaccine. To avoid misinterpretation of vaccine-related side-effects, vaccination should be also delayed after surgery.