Association of dexmedetomidine use with haemodynamics, postoperative recovery, and cost in paediatric anaesthesia: a hospital registry study.

BACKGROUND: Dexmedetomidine utilisation in paediatric patients is increasing. We hypothesised that intraoperative use of dexmedetomidine in children is associated with longer postanaesthesia care unit length of stay, higher healthcare costs, and side-effects. METHODS: We analysed data from paediatric patients (aged 0-12 yr) between 2016 and 2021 in the Bronx, NY, USA. We matched our cohort with the Healthcare Cost and Utilization Project-Kids' Inpatient Database (HCUP-KID). RESULTS: Among 18 104 paediatric patients, intraoperative dexmedetomidine utilisation increased from 51.7% to 85.7% between 2016 and 2021 (P<0.001). Dexmedetomidine was dose-dependently associated with a longer postanaesthesia care unit length of stay (adjusted absolute difference [ADadj] 19.7 min; 95% confidence interval [CI]: 18.0-21.4 min; P<0.001, median length of stay of 122 vs 98 min). The association was magnified in children aged ≤2 yr undergoing short (≤60 min) ambulatory procedures (ADadj 33.3 min; 95% CI: 26.3-40.7 min; P<0.001; P-for-interaction <0.001). Dexmedetomidine was associated with higher total hospital costs of USD 1311 (95% CI: USD 835-1800), higher odds of intraoperative mean arterial blood pressure below 55 mm Hg (adjusted odds ratio [ORadj] 1.27; 95% CI: 1.16-1.39; P<0.001), and higher odds of heart rate below 100 beats min-1 (ORadj 1.32; 95% CI: 1.21-1.45; P<0.001), with no preventive effects on emergence delirium requiring postanaesthesia i.v. sedatives (ORadj 1.67; 95% CI: 1.04-2.68; P=0.034). CONCLUSIONS: Intraoperative use of dexmedetomidine is associated with unwarranted haemodynamic effects, longer postanaesthesia care unit length of stay, and higher costs, without preventive effects on emergence delirium.

Sedation Research in Critically Ill Pediatric Patients: Proposals for Future Study Design From the Sedation Consortium on Endpoints and Procedures for Treatment, Education, and Research IV Workshop.

OBJECTIVES: Sedation and analgesia for infants and children requiring mechanical ventilation in the PICU is uniquely challenging due to the wide spectrum of ages, developmental stages, and pathophysiological processes encountered. Studies evaluating the safety and efficacy of sedative and analgesic management in pediatric patients have used heterogeneous methodologies. The Sedation Consortium on Endpoints and Procedures for Treatment, Education, and Research (SCEPTER) IV hosted a series of multidisciplinary meetings to establish consensus statements for future clinical study design and implementation as a guide for investigators studying PICU sedation and analgesia. DESIGN: Twenty-five key elements framed as consensus statements were developed in five domains: study design, enrollment, protocol, outcomes and measurement instruments, and future directions. SETTING: A virtual meeting was held on March 2-3, 2022, followed by an in-person meeting in Washington, DC, on June 15-16, 2022. Subsequent iterative online meetings were held to achieve consensus. SUBJECTS: Fifty-one multidisciplinary, international participants from academia, industry, the U.S. Food and Drug Administration, and family members of PICU patients attended the virtual and in-person meetings. Participants were invited based on their background and experience. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Common themes throughout the SCEPTER IV consensus statements included using coordinated multidisciplinary and interprofessional teams to ensure culturally appropriate study design and diverse patient enrollment, obtaining input from PICU survivors and their families, engaging community members, and using developmentally appropriate and validated instruments for assessments of sedation, pain, iatrogenic withdrawal, and ICU delirium. CONCLUSIONS: These SCEPTER IV consensus statements are comprehensive and may assist investigators in the design, enrollment, implementation, and dissemination of studies involving sedation and analgesia of PICU patients requiring mechanical ventilation. Implementation may strengthen the rigor and reproducibility of research studies on PICU sedation and analgesia and facilitate the synthesis of evidence across studies to improve the safety and quality of care for PICU patients.

Children with Congenital Heart Disease Show Increased Behavioral Problems Compared to Healthy Peers: A Systematic Review and Meta-Analysis.

Millions of children and adults are living with congenital heart disease (CHD). Their risk for behavioral problems has not been the subject of a meta-analysis. We performed a systematic review and meta-analysis of measures of behavioral problems in people born with CHD compared to peers without CHD. We searched Pubmed, CINAHL, Embase, PsycInfo, and the Cochrane Library from January 1, 1986 to November 15, 2021. We included studies that reported a measure of behavioral problems in patients with CHD in children and adults older than 3 years of age. We screened 26,343 search results, and 24 studies met inclusion criteria. The quality of evidence was generally low. Subjects with CHD had a small increase in internalizing problems [standardized mean difference (SMD): 0.198, p = 0.02] and total behavior problems (SMD: 0.287, p = 0.013), but no difference in externalizing behavioral problems. There was significant heterogeneity in all three domains of behavior problems analyzed, and it could not be explained by variables such as age, severity, assessor, or assessment tool. There are small increases in parent- and self-reported overall behavioral problems and internalizing problems in patients with CHD compared to healthy controls. Wide confidence intervals in the meta-analyses leave open the possibility that certain factors may increase the risk of behavioral problems in this group, and future studies with important attention paid to potential confounders may help identify risk factors.

Multireference configuration interaction study of the predissociation of C2 via its F1Πu state.

Photodissociation is one of the main destruction pathways for dicarbon (C2) in astronomical environments, such as diffuse interstellar clouds, yet the accuracy of modern astrochemical models is limited by a lack of accurate photodissociation cross sections in the vacuum ultraviolet range. C2 features a strong predissociative F1Πu-X1Σg + electronic transition near 130 nm originally measured in 1969; however, no experimental studies of this transition have been carried out since, and theoretical studies of the F1Πu state are limited. In this work, potential energy curves of excited electronic states of C2 are calculated with the aim of describing the predissociative nature of the F1Πu state and providing new ab initio photodissociation cross sections for astrochemical applications. Accurate electronic calculations of 56 singlet, triplet, and quintet states are carried out at the DW-SA-CASSCF/MRCI+Q level of theory with a CAS(8,12) active space and the aug-cc-pV5Z basis set augmented with additional diffuse functions. Photodissociation cross sections arising from the vibronic ground state to the F1Πu state are calculated by a coupled-channel model. The total integrated cross section through the F1Πu v = 0 and v = 1 bands is 1.198 × 10-13 cm2 cm-1, giving rise to a photodissociation rate of 5.02 × 10-10 s-1 under the standard interstellar radiation field, much larger than the rate in the Leiden photodissociation database. In addition, we report a new 21Σu + state that should be detectable via a strong 21Σu +-X1Σg + band around 116 nm.

Prospectively assessed neurodevelopmental outcomes in studies of anaesthetic neurotoxicity in children: a systematic review and meta-analysis.

BACKGROUND: Whether exposure to a single general anaesthetic (GA) in early childhood causes long-term neurodevelopmental problems remains unclear. METHODS: PubMed/MEDLINE, Embase, CINAHL, Web of Science, and the Cochrane Library were searched from inception to October 2019. Studies evaluating neurodevelopmental outcomes and prospectively enrolling children exposed to a single GA procedure compared with unexposed children were identified. Outcomes common to at least three studies were evaluated using random-effects meta-analyses. RESULTS: Full-scale intelligence quotient (FSIQ); the parentally reported Child Behavior Checklist (CBCL) total, externalising, and internalising problems scores; and Behavior Rating Inventory of Executive Function (BRIEF) scores were assessed. Of 1644 children identified, 841 who had a single exposure to GA were evaluated. The CBCL problem scores were significantly higher (i.e. worse) in exposed children: mean score difference (CBCL total: 2.3 [95% confidence interval {CI}: 1.0-3.7], P=0.001; CBCL externalising: 1.9 [95% CI: 0.7-3.1], P=0.003; and CBCL internalising problems: 2.2 [95% CI: 0.9-3.5], P=0.001). Differences in BRIEF were not significant after multiple comparison adjustment. Full-scale intelligence quotient was not affected by GA exposure. Secondary analyses evaluating the risk of these scores exceeding predetermined clinical thresholds found that GA exposure was associated with increased risk of CBCL internalising behavioural deficit (risk ratio [RR]: 1.47; 95% CI: 1.08-2.02; P=0.016) and impaired BRIEF executive function (RR: 1.68; 95% CI: 1.23-2.30; P=0.001). CONCLUSIONS: Combining results of studies utilising prospectively collected outcomes showed that a single GA exposure was associated with statistically significant increases in parent reports of behavioural problems with no difference in general intelligence.

Executive functions in children with heart disease: a systematic review and meta-analysis.

CONTEXT: People with CHD are at increased risk for executive functioning deficits. Meta-analyses of these measures in CHD patients compared to healthy controls have not been reported. OBJECTIVE: To examine differences in executive functions in individuals with CHD compared to healthy controls. DATA SOURCES: We performed a systematic review of publications from 1 January, 1986 to 15 June, 2020 indexed in PubMed, CINAHL, EMBASE, PsycInfo, Web of Science, and the Cochrane Library. STUDY SELECTION: Inclusion criteria were (1) studies containing at least one executive function measure; (2) participants were over the age of three. DATA EXTRACTION: Data extraction and quality assessment were performed independently by two authors. We used a shifting unit-of-analysis approach and pooled data using a random effects model. RESULTS: The search yielded 61,217 results. Twenty-eight studies met criteria. A total of 7789 people with CHD were compared with 8187 healthy controls. We found the following standardised mean differences: -0.628 (-0.726, -0.531) for cognitive flexibility and set shifting, -0.469 (-0.606, -0.333) for inhibition, -0.369 (-0.466, -0.273) for working memory, -0.334 (-0.546, -0.121) for planning/problem solving, -0.361 (-0.576, -0.147) for summary measures, and -0.444 (-0.614, -0.274) for reporter-based measures (p < 0.001). LIMITATIONS: Our analysis consisted of cross-sectional and observational studies. We could not quantify the effect of collinearity. CONCLUSIONS: Individuals with CHD appear to have at least moderate deficits in executive functions. Given the growing population of people with CHD, more attention should be devoted to identifying executive dysfunction in this vulnerable group.

Branching Ratios of the N(2D03/2) and N(2D05/2) Spin-Orbit States Produced in the State-Selected Photodissociation of N2 Determined Using Time-Sliced Velocity-Mapped-Imaging Photoionization Mass Spectrometry (TS-VMI-PI-MS).

Branching ratios for N(2D03/2) and N(2D05/2) produced by predissociation of state selected excited nitrogen molecules in the vacuum ultraviolet region have been measured for the first time. The quantum numbers of the excited nitrogen molecule are defined by selective excitation of the nitrogen molecule in the Franck-Condon region from the ground electronic, 1Σg+, vibrational, v″, and rotational, J″ state to an excited Eu', v', J' state with a tunable vacuum ultraviolet, VUV1, laser. The neutral atoms produced by predissociation from this excited state are then selectively ionized with a second tunable VUV2 laser. Measurement of the relative populations of these two atoms formed in their spin-orbit states defines the quantum states for the atomic products. This means that the wave functions of the initial state and knowledge of the relative yields define all the experimental parameters for this series of unimolecular reactions. The ions formed by VUV2 are mass analyzed with a time-of-flight mass spectrometer and detected with a time slice velocity ion imaging mass spectrometer. In this manner, we can determine the recoil velocity associated with the predissociation process. Two different techniques are used to determine the spin-orbit ratios, namely, resonant VUV photoionization (RVUV-PI) spectroscopy and total kinetic energy release (TKER) spectroscopy determined from the image produced when the atoms are selectively ionized by VUV2 in the interaction region. The TKER spectra obtained from the lines at 110 296.25 and 110 304.96 cm-1 that couple to a newly discovered autoionization line at 129 529.4255 ± 0.0015 cm-1 prove that the lines observed in this region originate from the N(2D03/2) and N(2D05/2) atoms. Two other lines in this region at 110 286.20 and 110 299.89 cm-1 originate from the nitrogen N(4S03/2) that is photoionized in a 1+ 1 VUV-UV resonant multiphoton ionization process. The spin-orbit branching ratios have been evaluated for valence and Rydberg electronic excited states from 104 129.4 to 118 772.1 cm-1, and it shows that they are independent of the rotational and vibrational quantum numbers. They are not appreciably affected by the symmetry properties of the wave function in the Franck-Condon region of the excited states. In the energy region below 117 153.8 cm-1 the pathways at long internuclear distances appear to determine [N(2D03/2)]/[N(2D05/2)] branching ratios of ∼0.38, ∼0.62, and ∼1.04. At higher energies, TKER and RVUV-PI spectroscopy have been used to show that the average fraction of the N(2D03/2) and N(2D05/2) atoms produced in the spin-allowed channels that produce two N(2D0J) is 0.85 versus 0.15 for spin-forbidden channels. The importance and need for this information for comparison with theory and applications in astrochemistry are briefly discussed.

Branching Ratio Measurements of the Predissociation of 12C16O by Time-Slice Velocity-Map Ion Imaging in the Energy Region from 106 250 to 107 800 cm-1.

Photodissociation of CO is a fundamental chemical mechanism for mass-independent oxygen isotope fractionation in the early Solar System. Branching ratios of photodissociation channels for individual bands quantitatively yield the trapping efficiencies of atomic oxygen resulting into oxides. We measured the branching ratios for the spin-forbidden and spin-allowed photodissociation channels of 12C16O in the vacuum ultraviolet (VUV) photon energy region from 106 250 to 107 800 cm-1 using the VUV laser time-slice velocity-map imaging photoion technique. The excitations to four 1Π bands and three 1Σ+ bands of 12C16O were identified and investigated. The branching ratios for the product channels C(3P) + O(3P), C(1D) + O(3P), and C(3P) + O(1D) of these predissociative states strongly depend on the electronic and vibrational states of CO being excited. By plotting the branching ratio of the spin-forbidden dissociation channels versus the excitation energy from 102 500 to 110 500 cm-1 that has been measured so far, the global pattern of the 1Π-3Π interaction that plays a key role in the predissociation of CO is revealed and discussed.

Polymorphism in the ADRB2 gene explains a small portion of intersubject variability in pain relative to cervical dilation in the first stage of labor.

BACKGROUND: Variability in labor pain has been associated with demographic, clinical, and psychological factors. Polymorphisms of the ß2-adrenergic receptor gene (ADRB2) influence sensitivity to experimental pain in humans and are a risk factor for chronic pain. The authors hypothesized that polymorphisms in ADRB2 may influence labor pain. METHODS: After Institutional Review Board approval and written informed consent, the authors prospectively obtained hourly pain reports from 233 nulliparous parturients during the first stage of labor, of which 199 were included in the current analysis. DNA from blood samples was genotyped at polymorphisms in the genes for the ß2-adrenergic receptor, the µ opioid receptor subtype 1, catechol-O-methyltransferase, fatty acid amide hydrolase, and the oxytocin receptor. Labor pain as a function of cervical dilation was modeled with previously described methods. Patient covariates, ADRB2 genotype, and obstetrical and anesthesia treatment were evaluated as covariates in the model. RESULTS: Labor pain more rapidly became severe in parturients heterozygous or homozygous for the G allele at rs1042714 in the ADRB2 gene. Labor pain increased more rapidly after artificial rupture of membranes, augmentation with oxytocin, and in younger women. Inclusion of covariates explained approximately 10% of the variability between subjects. ADRB2 genotype explained less than 1% of the intersubject variability. CONCLUSION: ADRB2 genotype correlates with labor pain but explained less than 1% of the intersubject variance in the model.

Photodissociation of CO2 between 13.540 eV and 13.678 eV.

Photodissociation of CO2 is investigated between 13.540 eV and 13.678 eV using the time-sliced velocity-mapped ion imaging (TSVMI) apparatus that is combined with one-color and two-color pump-probe VUV + VUV and VUV + UV detection schemes by probing oxygen fragments at different levels. Several CO2 dissociation channels are directly observed from the ion images, namely CO(X (1)Σ(+)) + O((1)D), CO(X (1)Σ(+)) + O((1)S), CO(a (3)Π) + O((3)P), CO(a (3)Π) + O((1)D), CO(a' (3)Σ(+)) + O((3)P), CO(d (3)Δ) + O((3)P) and CO(e (3)Σ(-)) + O((3)P), whereas no CO(X (1)Σ(+)) + O((3)P) production has been found. The product kinetic energy distributions of these channels are reported for the first time. Possible dissociation mechanisms have been discussed based upon the product vibrational and rotational distributions.

Branching ratio measurements for vacuum ultraviolet photodissociation of 12C16O.

The branching ratios for the spin-forbidden photodissociation channels of (12)C(16)O in the vacuum ultraviolet (VUV) photon energy region from 102,500 (12.709 eV) to 106,300 cm(-1) (13.180 eV) have been investigated using the VUV laser time-slice velocity-map imaging photoion technique. The excitations to three (1)Σ(+) and six (1)Π Rydberg-type states, including the progression of W(3sσ) (1)Π(v' = 0, 1, and 2) vibrational levels of CO, have been identified and investigated. The branching ratios for the product channels C((3)P) + O((3)P), C((1)D) + O((3)P), and C((3)P) + O((1)D) of these predissociative states are found to depend on the electronic, vibrational, and rotational states of CO being excited. Rotation and e/f-symmetry dependences of the branching ratios into the spin-forbidden channels have been confirmed for several of the (1)Π states, which can be explained using the heterogeneous interaction with the repulsive D'(1)Σ(+) state. The percentage of the photodissociation into the spin-forbidden channels is found to increase with increasing the rotational quantum number for the K(4pσ) (1)Σ(+) (v' = 0) state. This has been rationalized using a (1)Σ(+) to (1)Π to (3)Π coupling scheme, where the final (3)Π state is a repulsive valence state correlating to the spin-forbidden channel.

Communication: State-to-state photodissociation study by the two-color VUV-VUV laser pump-probe time-slice velocity-map-imaging-photoion method.

We demonstrate that combining two independently tunable vacuum ultraviolet (VUV) lasers and the time-slice velocity-map-imaging-photoion (VMI-PI) method allows the rovibronically state-selected photodissociation study of CO in the VUV region along with the state-selective detection of product C((3)P(0,1,2)) using the VUV-UV (1+1') resonance-enhanced photoionization and the VUV Rydberg autoionization methods. Both tunable VUV lasers are generated based on the two-photon resonance-enhanced four-wave mixing scheme using a pulsed rare gas jet as the nonlinear medium. The observed fine-structure distributions of product C((3)P(J)), J = 0, 1, and 2, are found to depend on the CO rovibronic state populated by VUV photoexcitation. The branching ratios for C((3)P0) + O((3)P(J)): C((3)P0) + O((1)D2), C((3)P1) + O((3)P(J)): C((3)P1) + O((1)D2), and C((3)P2) + O((3)PJ): C((3)P2) + O((1)D2), which were determined based on the time-slice VMI-PI measurements of C(+) ions formed by J-state selective photoionization sampling of C((3)P(0,1,2)), also reveal strong dependences on the spin-orbit state of C((3)P(0,1,2)). By combining the measured branching ratios and fine-structure distributions of C((3)P(0,1,2)), we have determined the correlated distributions of C((3)P(0,1,2)) accompanying the formation of O((1)D2) and O((3)P(J)) produced in the VUV photodissociation of CO. The success of this demonstration experiment shows that the VUV photodissociation pump-VUV photoionization probe method is promising for state-to-state photodissociation studies of many small molecules, which are relevant to planetary atmospheres as well as fundamental understanding of photodissociation dynamics.

Memory Problems in Children With Congenital Heart Disease: A Narrative Review.

INTRODUCTION: Care for congenital heart diseases (CHD) has improved significantly over the past several decades, and children with CHD are now surviving into adulthood. Cognitive and behavioral problems affect children with CHD more than healthy peers. A review of performance on neuropsychological memory tasks has not been reported. We aimed to summarize the published literature on memory problems in people with CHD. METHODS: We searched Pubmed, Medline, and PsycINFO from January 1, 1986 to March 22, 2022 to reflect modern care for people with CHD. Our inclusion criteria were randomized controlled trials or observational studies that included children with CHD older than age 3 years, which reported the results of at least 1 neuropsychological test of memory in the CHD group. Our exclusion criteria were studies that included heart transplant recipients and studies that included children who required extracorporeal membrane oxygenation. RESULTS: Thirty-one studies that met our inclusion criteria and avoided exclusion criteria were included in this review. Several studies reported deficits in the subdomains of short-term and long-term memory and visual and verbal memory, though we found substantial heterogeneity across studies. The most likely subdomain to be affected in children with CHD appears to be short-term visual memory. CONCLUSIONS: There is likely an increased risk of memory problems for children and adults with CHD. We were unable to quantify the risk of memory problems due to the heterogeneity of published studies. Future research should make efforts to account for confounding variables and standardize outcome measures.

Impact of Anesthetic Exposures on the Neurocognitive Profiles of Pediatric Brain Tumor Survivors: A New Direction for Research and Multidisciplinary Collaboration.

Primary brain tumors are the most commonly diagnosed solid tumors in children, and pediatric brain tumor survivors experience lasting, pervasive deficits of neurocognitive functioning. Repeated exposure to anesthetic drugs is a necessary component not only of surgical resection but also of multimodal cancer care for the youngest patients with brain tumors. The potential for anesthetic neurotoxicity to worsen neurocognitive outcomes in this vulnerable group, therefore, warrants our attention and further study through multi-disciplinary collaboration. This review discusses neurocognitive functioning in pediatric brain tumor survivors, highlighting the findings of a recent study of children with tumors of the posterior fossa which identified treatment-related risk factors for neurocognitive difficulties, with those undergoing multimodal therapies (eg, chemotherapy and irradiation) experiencing the greatest deficits compared with healthy controls. The role of anesthetic neurotoxicity in long-term outcomes among pediatric brain tumor survivors is also reviewed.

Oxytocin and catechol-O-methyltransferase receptor genotype predict the length of the first stage of labor.

OBJECTIVE: We aimed to identify genetic factors that influence the rate of the first stage of labor. STUDY DESIGN: We prospectively enrolled 233 laboring nulliparous parturients. Demographic, clinical, and genetic data were collected. We evaluated the influence of population and individual variability using a nonlinear mixed effects model. RESULTS: Parturients who were homozygous for "G" at oxytocin receptor gene rs53576 transitioned to active labor later and thus had slower labor. Catechol-O-methyltransferase rs4633 genotype TT was associated with slower latent phase labor. Labor induction with prostaglandin was associated with faster labor, and request for meperidine was associated with slower labor. Birthweight was related inversely to the rate of the active phase. CONCLUSION: There are demographic, clinical, and genetic factors that influence an individual's rate of labor progress. This information could be used in automated form to improve the prediction of the length of the first stage of labor.

Time-slice velocity-map ion imaging studies of the photodissociation of NO in the vacuum ultraviolet region.

The time-slice velocity-map ion imaging and the resonant four-wave mixing techniques are combined to study the photodissociation of NO in the vacuum ultraviolet (VUV) region around 13.5 eV above the ionization potential. The neutral atoms, i.e., N((2)D(o)), O((3)P(2)), O((3)P(1)), O((3)P(0)), and O((1)D(2)), are probed by exciting an autoionization line of O((1)D(2)) or N((2)D(o)), or an intermediate Rydberg state of O((3)P(0,1,2)). Old and new autoionization lines of O((1)D(2)) and N((2)D(o)) in this region have been measured and newer frequencies are given for them. The photodissociation channels producing N((2)D(o)) + O((3)P), N((2)D(o)) + O((1)D(2)), N((2)D(o)) + O((1)S(0)), and N((2)P(o)) + O((3)P) have all been identified. This is the first time that a single VUV photon has been used to study the photodissociation of NO in this energy region. Our measurements of the angular distributions show that the recoil anisotropy parameters (ß) for all the dissociation channels except for the N((2)D(o)) + O((1)S(0)) channel are minus at each of the wavelengths used in the present study. Thus direct excitation of NO by a single VUV photon in this energy region leads to excitation of states with Σ or Δ symmetry (ΔΩ = ±1), explaining the observed perpendicular transition.