Randomised controlled trial of dexmedetomidine sedation vs general anaesthesia for inguinal hernia surgery on perioperative outcomes in infants.

BACKGROUND: Neonates and infants undergoing general anaesthesia for hernia surgery are at risk of perioperative cardiorespiratory adverse events. The use of regional anaesthesia with dexmedetomidine preserves airway tone and may potentially avoid these complications. This study compares the perioperative conditions and adverse events between dexmedetomidine sedation with caudal block and general anaesthesia with caudal block for inguinal hernia surgery in infants. METHODS: A randomised controlled trial was conducted in a tertiary hospital in Singapore involving 104 infants younger than 3 months, who were randomised to receive either dexmedetomidine sedation (DEX) with caudal block or general sevoflurane anaesthesia with tracheal intubation and caudal block (GA) for inguinal hernia surgery. Perioperative conditions, haemodynamics and adverse events were compared between groups. RESULTS: Fifty-one infants received DEX and 48 infants received GA. In the DEX group, 46 infants (90.2%) had their operations completed solely under this technique, two (3.9%) were converted to general anaesthesia with intubation, and three (5.9%) required brief administration of nitrous oxide or low-dose sevoflurane. Overall, 96.1% of infants in the DEX group did not require intubation. Perioperative conditions were similar in both groups. The DEX group had significantly lower heart rates and higher mean arterial pressures intraoperatively. Two infants in the DEX group (3.9%) required postoperative intensive care admission compared with six infants (12.5%) in the GA group. CONCLUSIONS: Dexmedetomidine sedation with caudal block provides a feasible alternative to general anaesthesia in infants undergoing hernia surgery. This technique avoids the need for tracheal intubation, which may be beneficial in neonates. CLINICAL TRIAL REGISTRATION: NCT02559102.

A pilot study of dexmedetomidine sedation and caudal anesthesia for inguinal hernia repair in infants.

BACKGROUND: Recent concerns regarding possible long-term effects of early anesthesia exposure on neurodevelopment in children have provided an impetus to explore alternative anesthetic techniques using potentially neuroprotective agents. Dexmedetomidine has not been implicated in anesthesia-induced neurotoxicity and has been shown to be neuroprotective in preclinical studies. We describe a case series of 50 neonates and infants who received dexmedetomidine sedation with caudal anesthesia instead of general endotracheal anesthesia for inguinal hernia surgery. METHODS: We conducted a retrospective chart review on all neonates and infants who underwent inguinal hernia surgery with dexemetomidine sedation and caudal anesthesia in our institution. We started exploring this technique since October 2011 and established a protocol of administering dexmedetomidine 2 mcg·kg(-1) over 10 min, followed by 1 mcg·kg(-1) over the next 10 min. This led to satisfactory conditions for caudal placement in 20 min, with minimal need for airway intervention during surgery. RESULTS: The median gestational age of the infants was 31.4 (28.7, 36.0) weeks and median postconceptual age was 39.7 weeks (IQR 37.8, 45.7) at time of surgery. Of patients, 86% had surgery successfully completed under this technique alone. Seven patients required sevoflurane or nitrous oxide due to failed caudal block (n = 1) or difficult or prolonged surgery (n = 6). After establishing the sedation protocol and excluding patients with large or complicated hernias, the success rate was 96%. Transient intra-operative apnea or hypoventilation occurred in five patients and postoperative apnea in two patients. All respiratory events were easily reversed and no patient developed significant bradycardia or required intubation. CONCLUSIONS: Dexmedetomidine sedation with caudal anesthesia is a feasible alternative to spinal or general anesthesia in selected infants undergoing uncomplicated hernia surgery. It avoids the need for endotracheal intubation and may be potentially beneficial in avoiding the unknown effects of general anesthesia on neurodevelopment.

Intraoperative pediatric electroencephalography monitoring: an updated review.

Intraoperative electroencephalography (EEG) monitoring under pediatric anesthesia has begun to attract increasing interest, driven by the availability of pediatric-specific EEG monitors and the realization that traditional dosing methods based on patient movement or changes in hemodynamic response often lead to imprecise dosing, especially in younger infants who may experience adverse events (e.g., hypotension) due to excess anesthesia. EEG directly measures the effects of anesthetics on the brain, which is the target end-organ responsible for inducing loss of consciousness. Over the past ten years, research on anesthesia and computational neuroscience has improved our understanding of intraoperative pediatric EEG monitoring and expanded the utility of EEG in clinical practice. We now have better insights into neurodevelopmental changes in the developing pediatric brain, functional connectivity, the use of non-proprietary EEG parameters to guide anesthetic dosing, epileptiform EEG changes during induction, EEG changes from spinal/regional anesthesia, EEG discontinuity, and the use of EEG to improve clinical outcomes. This review article summarizes the recent literature on EEG monitoring in perioperative pediatric anesthesia, highlighting several of the topics mentioned above.

Evaluation of emergence delirium in Asian children using the Pediatric Anesthesia Emergence Delirium Scale.

BACKGROUND: Emergence delirium (ED) is a common problem in children recovering from general anesthesia. ED causes disruption in the postanesthetic care unit, making nursing and monitoring more difficult, and is potentially dangerous to the child. The greatest hindrance to understanding ED was the lack of a standardized tool to assess it. The Pediatric Anesthesia Emergence Delirium (PAED) Scale was recently described to measure the degree of ED in children. In this prospective observational study, we sought to evaluate the incidence of ED by grading emergence behavior using the PAED Score in healthy Asian children undergoing outpatient surgery. METHODS: Three hundred sixteen children aged 2-12 years undergoing general anesthesia for elective outpatient surgery were included. No premedication was administered. Induction behavior was graded using the induction compliance checklist, and the presence of any excitation on induction documented. Emergence behavior was recorded using the PAED Scale, and the children were separately assessed for clinical agitation. RESULTS: One hundred and thirty-six children (43%) had PAED Scores >0 and 33 (10.4%) had PAED Scores of >or=10. Only 28 children (8.9%) had clinical agitation consistent with ED, the rest were agitated for other reasons. A score of >or=10 on the PAED Scale was the best discriminator between presence and absence of clinical agitation. The area under the receiver operating characteristic curve for PAED Score of >or=10 was 0.98, with a true-positive rate (sensitivity) of 0.85 and a false-positive rate (1-specificity) of 0.041. Four factors were found to be predictive of ED. These include young age, poor compliance at induction, lack of intraoperative fentanyl use and rapid time to awakening. CONCLUSIONS: The incidence of ED is approximately 10% in our population of healthy, unpremedicated Asian children undergoing day surgery. Young age, poor compliance at induction, lack of intraoperative fentanyl use and rapid time to awakening were predictive risk factors for ED in our population. A PAED Score of >or=10 was correlated with clinically significant ED and appeared to be the ideal cutoff score for ED.