Anesthesia in children with osteogenesis imperfecta: Retrospective chart review of 83 patients and 205 anesthetics over 7 years.

BACKGROUND: Osteogenesis imperfecta is the collective term for a heterogeneous group of connective tissue syndromes characterized by bone fragility with multisystem involvement and perioperative implications. AIMS: Literature review of anesthetic management of patients with osteogenesis imperfecta revealed a paucity of data on the incidence of perioperative challenges. We sought to determine the rates of these challenges in our study cohort. METHODS: Data were collected in a specialty orthopedic hospital from 2008 to 2015 for 83 osteogenesis imperfecta patients undergoing 205 surgeries: 203 orthopedic surgeries and 2 mid-face reconstructive surgeries. Airway management, intravenous access, surgical blood loss, use of peripheral nerve blockade and/or neuraxial techniques, presence of perioperative fracture, and peak intraoperative temperature were evaluated and analyzed. RESULTS: Difficult airway was encountered in 3/205 (1.5%) cases and perioperative fracture in 2/205 (1%) cases. Neuraxial anesthesia was attempted in 64/205 cases with an 87.5% success rate. All peripheral nerve block attempts (33/205 cases) were successful. Difficult intravenous catheter placement was noted in 8/205 (4%) cases. Estimated blood loss >10% of estimated blood volume was considered significant, and occurred in 35/205 (17%) cases. Significant blood loss occurred more often in severe osteogenesis imperfecta types: 18/76 (23.7%) in Type III and 11/65 (16.9%) in Type IV, whereas only 4/47 (8.5%) occurred in mild Type I. In our 205 case cohort, osteogenesis imperfecta Type III had 5.6 times the odds [(95% CI = 1.8-17.2) P = 0.003] of having an anesthetic complication as compared to osteogenesis imperfecta Type I. CONCLUSION: Patients with osteogenesis imperfecta undergo frequent anesthetic exposures, but anesthetic challenges in our series were uncommon. Odds of challenges are greater in severe osteogenesis imperfecta Type III, with significant blood loss and difficulty placing intravenous catheters more likely encountered in the more severe types.

A randomized equivalence trial comparing the i-gel and laryngeal mask airway Supreme in children.

BACKGROUND: The laryngeal mask airway Supreme (Supreme) is a new single-use supraglottic device with gastric access capability now available in all sizes for children. OBJECTIVES: To compare the i-gel with the Supreme in children for routine airway maintenance. MATERIALS/METHODS: One hundred and seventy children, aged 3 months to 11 years, 5-50 kg in weight, were randomly assigned to receive either the i-gel or the Supreme. The primary outcome measured was airway leak pressure. Secondary outcomes included the following: ease and time for insertion, insertion success rate, fiberoptic grade of view, ease of gastric tube placement, number of airway manipulations, quality of airway during anesthetic maintenance, and complications. RESULTS: A total of 168 patients were assessed for the outcomes. The median (IQR [range]) airway leak pressure for the i-gel was higher than with the Supreme, 20 (18-25 [9-40]) cm H(2)O vs 17 (14-22 [10-40]) cm H(2)O, respectively (P = 0.001). There were no differences in the time for device insertion, fiberoptic grade of view, quality of airway, and complications. Median (IQR[range]) time of successful insertion of a gastric tube was faster with the Supreme, 12 (9.2-14.3 [5.2-44.2]) s than with the i-gel, 14 (11.9-19 [6.9-75]) s; P = 0.01. The number of airway manipulations during placement was higher with the i-gel than with the laryngeal mask airway Supreme (12 vs 13 patients), P = 0.02. CONCLUSIONS: In infants and children, when a single-use supraglottic device with gastric access capabilities is required, the i-gel demonstrated higher airway leak pressures and can be a useful alternative to the Supreme.

Head and neck blocks in infants, children, and adolescents.

This review will discuss the use of peripheral nerve blocks of the head and neck and its application to the practice of pediatric anesthesia using simple, landmark based approaches.

Postoperative pain relief in infants undergoing myringotomy and tube placement: comparison of a novel regional anesthetic block to intranasal fentanyl--a pilot analysis.

AIM: The aim of this study was to investigate the use of a novel regional anesthetic technique for the management of pain in the postoperative period in infants and children undergoing myringotomy and tube placement. METHODS: After institutional review board (IRB) approval was obtained, 200 children were randomized in this double blind, prospective, randomized controlled trial to receive either a nerve block of the auricular branch of the Vagus (Nerve of Arnold) with 0.2 ml of 0.25% bupivacaine or receive intranasal fentanyl 2 mcg.kg(-1) after induction of general anesthesia. Patients were monitored in the recovery room for analgesia, need for additional analgesia, incidence of nausea and vomiting, and time to discharge from the hospital. Additional analgesics administered in the PACU, surgical short-stay unit as well as at home were also recorded. RESULTS: There was no difference in the pain scores between groups (P = 0.53); there was no difference in the amount of rescue medications between groups (P = 0.86); there was no difference in the incidence of nausea and vomiting between groups (P = 0.34); there was no difference in the time to discharge between groups (P = 0.5). CONCLUSIONS: This pilot study demonstrates the efficacy of a peripheral nerve block for management of postoperative pain in infants and children undergoing myringotomy and tube placement. This may be a viable alternative for postoperative pain control in this population. Future multi-center, randomized controlled trials may be necessary to validate the efficacy of this block in infants and children.

Head and neck blocks in children.

PURPOSE OF REVIEW: The present article will review the current technology and available literature regarding regional anesthesia in infants and children undergoing head and neck surgery. RECENT FINDINGS: Regional anesthesia can be utilized in a variety of surgical procedures on the head and neck. The reporting of multiple techniques along with prospective randomized trials that have looked into the efficacy of these blocks in children have led to a sweeping increase in their use in children for postoperative pain relief. SUMMARY: The trigeminal nerve, along with the cervical nerve roots, supplies most of the sensory supply to the head and neck. The knowledge and application of the anatomical distribution of this area can increase the utilization of these blocks for a variety of different settings. The increased use of these blocks can reduce the need for additional postoperative analgesic that could in turn lead to fast-tracking of these patients and decrease the incidence of nausea and vomiting in the postoperative period.

Infraorbital nerve block in children: a computerized tomographic measurement of the location of the infraorbital foramen.

BACKGROUND AND OBJECTIVES: Infraorbital nerve blocks are performed in children undergoing cleft-lip surgery and endoscopic sinus surgery. The nerve exits the maxilla at the level of the infraorbital foramen. A sensory block of the infraorbital nerve can be performed by use of an intraoral route or an extraoral route. The objective of this study was to derive a mathematical formula to determine the position of the infraorbital foramen. METHODS: Computerized tomographic (CT) scans of children who were admitted to our institution for various reasons were evaluated with the assistance of a pediatric neuroradiologist. The distance of the foramen from the midline was determined, and a mixed-effects linear-regression model was used (PROC MIXED in SAS 9.1) to ascertain whether the distance of the infraorbital foramen correlated linearly with the age of the patient. RESULTS: CT scans of 48 pediatric patients were evaluated. The age of the patient accounted for more than half of the variation in this model. Distance of the infraorbital foramen can be predicted by use of the following formula: [Distance of the infraorbital foramen (in mm) from midline = 21.3 + 0.5 x age (in years)]. CONCLUSIONS: Our study found a linear correlation with age to the distance of the infraorbital foramen. This anatomic knowledge of the location of the infraorbital foramen may facilitate correct positioning of the needle. Future studies on the use of this formula with anatomic coordinates should be performed to test the validity of this formula.

Apnea in a child after oral codeine: a genetic variant - an ultra-rapid metabolizer.

We present a case of a 29 months old previously healthy child who experienced apnea resulting in brain injury following a dose of acetaminophen and codeine 2 days after an uneventful anesthetic for tonsillectomy. A genetic polymorphism leading to ultra-rapid metabolism of codeine into morphine resulted in narcosis and apnea. This paper discusses the use of codeine for pain relief, obstructive sleep apnea, the alteration of the CYP2D6 gene and the resulting effect on drug metabolism.

Head and neck blocks in children: an anatomical and procedural review.

Children undergo a variety of neurosurgical, otorhinolaryngology and plastic surgery procedures to the head and neck. Although opioids are utilized for pain control, they are associated with adverse side effects including postoperative nausea and vomiting, respiratory depression, somnolence and itching. The utilization of peripheral nerve blocks provides analgesia while reducing the need for opioids. This review will provide a summary of a variety of commonly used head and neck nerve blocks in children with a brief anatomical and technical summary.