Perioperative use of glucose containing solutions in infants less than 6 months of age: A clinical practice survey among US academic centers.

BACKGROUND: Although there is a wide breadth of literature on glucose homeostasis in infants, standardization of perioperative hypoglycemia diagnosis and management is lacking. AIMS: Survey of academic pediatric anesthesiology departments across the USA to evaluate institutional policies regarding the perioperative use of glucose containing solutions in infants less than 6 months of age. METHODS: A questionnaire was sent to 20 United States university affiliated academic pediatric anesthesiology departments. RESULTS: The responses suggest that, in the centers surveyed, glucose administration in infants is largely practitioner dependent. Two respondents (10%) claim to have a departmental policy regarding glucose administration in infants less than 6 months of age. In premature infants, 75% of respondents administer glucose. When administering glucose, 75% of physicians surveyed replete infants at their maintenance intravenous fluid rate. There was discrepancy among practitioners regarding initiation of hypoglycemia treatment, 35% treat infants at a blood glucose level of 70 mg/dl, 30% at BG 60 mg/dl, 25% at 50 mg/dl, and 10% are unsure. DISCUSSION: This survey highlights the lack of consensus, at least among pediatric anesthesiologists working in US academic centers, regarding blood glucose management in infants less than 6 months of age. There is a need to define the indications for using glucose containing solutions in infants during the perioperative period, their ideal content, the appropriate thresholds for hypo- and hyperglycemia as well as the optimal point-of care glucose monitoring intervals.

Development of a new biochip array for APOE4 classification from plasma samples using immunoassay-based methods.

BACKGROUND: Apolipoprotein E (APOE) is a key player in lipid transport and metabolism and exists in three common isoforms: APOE2, APOE3 and APOE4. The presence of the E4 allelic variant is recognized as a major genetic risk factor for dementia and other chronic (neuro)degenerative diseases. The availability of a validated assay for rapid and reliable APOE4 classification is therefore advantageous. METHODS: Biochip array technology (BAT) was successfully applied to identify directly the APOE4 status from plasma within 3 h, through simultaneous immunoassay-based detection of both specific APOE4 and total APOE levels. RESULTS: Samples (n=432) were first genotyped by polymerase chain reaction (PCR), and thereafter, using BAT, the corresponding plasma was identified as null, heterozygous or homozygous for the E4 allele by calculating the ratio of APOE4 to total APOE protein. Two centers based in Austria and Ireland correctly classified 170 and 262 samples, respectively, and achieved 100% sensitivity and specificity. CONCLUSIONS: This chemiluminescent biochip-based sandwich immunoarray provides a novel platform to detect rapidly and accurately an individual's APOE4 status directly from plasma. The E4 genotype of individuals has been shown previously to affect presymptomatic risk, prognosis and treatment response for a variety of diseases, including Alzheimer's disease. The biochip's potential for being incorporated in quantitative protein biomarker arrays capable of analyzing disease stages makes it a superior alternative to PCR-based APOE genotyping and may deliver additional protein-specific information on a variety of diseases in the future.

Feasibility and Analgesic Efficacy of Thoracolumbar Dorsal Ramus Nerve Block Using Multiorifice Pain Catheters for Scoliosis Surgery: A Prospective Cohort Study.

BACKGROUND: Approximately 38,000 scoliosis surgery correction operations are performed annually in the United States; these operations are associated with considerable postoperative pain which can be difficult to manage. This is largely attributed to an incision spanning multiple vertebral segments with paraspinal muscle dissection and retraction to facilitate the implantation of segmental hardware and rods. Frequently utilized analgesic modalities include intravenous patient-controlled analgesia and epidural analgesia, often in combination. We sought to ascertain the feasibility and analgesic efficacy of continuous thoracolumbar dorsal ramus nerve (TDRN) block using surgically placed multiorifice catheters. METHODS: Forty-two patients diagnosed with idiopathic scoliosis who underwent a posterior spinal fusion (PSF) were enrolled after consent was obtained. Patients were managed utilizing a standardized Enhanced Recovery After Surgery) protocol including a perioperative opioid-sparing regimen. Data were collected at specified time intervals during the recovery period. These data points included pain scores using the Numeric Rating Scale. Parenteral or both oral and parenteral opioid consumption doses were also collected every 4 hours. Any significant postoperative adverse events were recorded as well. RESULTS: A total of 42 patients had surgically placed TDRN catheters, and 40 patients were included in this study. The patients all reported low to moderate pain scores with low opioid consumption postoperatively, while the TDRN catheter delivery of local anesthetic analgesics did not result in significant complications. CLINICAL RELEVANCE: A regional technique utilizing TDRN catheters could be a valuable component of the postoperative pain management protocols for PSF surgery, and additional studies are warranted. CONCLUSION: This study evaluated the feasibility and analgesic efficacy of TDRN catheters for postoperative pain control following multilevel PSF for idiopathic scoliosis. Continuous local anesthetic delivery through TDRN catheters is a feasible and safe technique for postoperative pain control in these patients. Selective blockade of the dorsal rami might have benefits over epidural analgesia or other regional techniques.

Failed Emergence After Pediatric Epilepsy Surgery: Is Propofol-Related Infusion Syndrome to Blame?

Propofol infusion syndrome was first reported in the literature by Bray in 1998. He described a series of fatal outcomes after a presenting constellation of symptoms observed in pediatric patients who had received prolonged propofol infusions. Profound metabolic acidosis and bradycardia are the disease's hallmark features, which can further develop expeditiously to rhabdomyolysis, renal failure, and heart failure. It has been subsequently theorized that a triggering mechanism or a precipitating factor sets up the progressive physiologic spiral which can ensue. The name of the disease was expanded to Propofol Related Infusion Syndrome (PRIS), as propofol alone was no longer considered the culprit. The disease process is rare and can present with an insidious onset in some cases, causing much speculation of whether there is a proper grasp of the disease entity in its entirety as currently reported. The case discussed in this article depicts an adverse neurologic outcome following a craniotomy for temporal lobectomy in a child with lesional epilepsy. Since there was no obvious causative factor for these findings, PRIS became a diagnosis that was robustly discussed among the involved services.

Anesthetic Management of a Patient with Harlequin Ichthyosis.

Harlequin ichthyosis is a severe and often fatal form of congenital ichthyosis caused by defective lipid transport which results in a dysfunctional skin barrier. Patients who survive the neonatal period are predisposed to skin infections, sepsis, impaired thermoregulation, and dehydration. The unique skin characteristics can present significant anesthetic challenges. We highlight the relevant anesthetic considerations in a 3-year-old presenting for syndactyly release of the right second and fourth digits. We describe the steps to ensure protection of the fragile skin barrier during establishment of intravenous access and airway management, therefore providing guidance for care of this vulnerable patient population.

Derivation and validation of a simple perioperative sleep apnea prediction score.

BACKGROUND: Obstructive sleep apnea (OSA) is a largely underdiagnosed, common condition, which is important to diagnose preoperatively because it has implications for perioperative management. Our purpose in this study was to identify independent clinical predictors of a diagnosis of OSA in a general surgical population, develop a perioperative sleep apnea prediction (P-SAP) score based on these variables, and validate the P-SAP score against standard overnight polysomnography. METHODS: A retrospective, observational study was designed to identify patients with a known diagnosis of OSA. Independent predictors of a diagnosis of OSA were derived by logistic regression, based on which prediction tool (P-SAP score) was developed. The P-SAP score was then validated in patients undergoing overnight polysomnography. RESULTS: The P-SAP score was derived from 43,576 adult cases undergoing anesthesia. Of these, 3884 patients (7.17%) had a documented diagnosis of OSA. Three demographic variables: age > 43 years, male gender, and obesity; 3 history variables: history of snoring, diabetes mellitus Type 2, and hypertension; and 3 airway measures: thick neck, modified Mallampati class 3 or 4, and reduced thyromental distance were identified as independent predictors of a diagnosis of OSA. A diagnostic threshold P-SAP score > or = 2 showed excellent sensitivity (0.939) but poor specificity (0.323), whereas for a P-SAP score > or = 6, sensitivity was poor (0.239) with excellent specificity (0.911). Validation of this P-SAP score was performed in 512 patients with similar accuracy. CONCLUSION: The P-SAP score predicts diagnosis of OSA with dependable accuracy across mild to severe disease. The elements of the P-SAP score are derived from a typical university hospital surgical population.

Anesthesia induction, emergence, and postoperative behaviors in children with attention-deficit/hyperactivity disorders.

BACKGROUND/AIM: Given the increasing prevalence of attention-deficit and attention-deficit hyperactivity disorders (ADHD), anesthesiologists are now presented with a greater number of children who are diagnosed with these conditions. This prospective, observational study was designed to compare anesthesia induction, emergence, and postoperative behaviors in children with and without ADHD. METHODS/MATERIALS: The sample included 268 children, 4-17 years of age undergoing elective surgery with a confirmed diagnosis of ADHD. A cohort of children without ADHD, matched for age, gender, and procedure served as controls. Preoperative cooperation, induction, and emergence behaviors were measured using established scales. Postoperative maladaptive behaviors were measured using a modified Post-Hospital Behavioral Questionnaire that was administered via telephone 1 week after surgery. RESULTS: Children with ADHD were significantly less cooperative at induction of anesthesia compared with controls (20.9% vs 10.6% respectively, P = 0.001). Although some control children exhibited an increase in maladaptive behaviors postoperatively, these behaviors were significantly greater among children with ADHD. In particular, relative to their normal behaviors, children with ADHD had greater difficulties in concentration and decision-making; were more disobedient, impulsive, fidgety, had poor appetite; were difficult to talk to; and exhibited an increase in temper tantrums following surgery. CONCLUSIONS: This is the first prospective study to our knowledge that has examined the perioperative and postoperative behaviors of children with ADHD compared to those without this disorder. These results are important in alerting anesthesiologists, parents, and teachers to the potential for difficulties during induction of anesthesia and postoperative behavioral problems at home and in school, respectively.