A novel approach to calculate the required volume of air for bronchial blockers in young children.

INTRODUCTION: Bronchial blocker balloons inflated with small volumes of air increase balloon pressure, involving a risk of airway injury especially in young children. However, there are no established guidelines regarding the appropriate volumes of air required to provide safe bronchial occlusion. METHODS: This study aimed to introduce a novel method for calculating the amount of air required for safe bronchial blocker balloon occlusion for one lung anesthesia in young children. We included 79 pediatric patients who underwent video-assisted thoracoscopic surgery at our hospital. Preoperatively, the balloon pressure and corresponding diameter of 5F bronchial blockers inflated with different volumes of air were measured. Intraoperatively, bronchial diameters measured by computerized tomographic scans were matched to the ex vivo measured balloon diameters. The quality of lung isolation, incidence of balloon repositioning, and airway injury were documented. Postoperatively, airway injury was evaluated through fiberoptic bronchoscopy. RESULTS: Balloon pressure and balloon diameter showed linear and nonlinear correlations with volume, respectively. The median lengths of the right and left mainstem bronchi were median (interquartile range) range: 5.3 mm (4.5-6.3) 2.7-8.15 and 21.8 (19.6-23.4) 14-29, respectively. Occluding the left mainstem bronchus required <1 mL of air, with a balloon pressure of 27 cm H2O. The isolation quality was high with no case of mucosal injury or displacement. Occluding the right mainstem bronchus required a median air volume of 1.3 mL, with a median balloon pressure of 44 cm H2O. One patient had poor lung isolation due to a tracheal bronchus and another developed mild and transient airway injury. CONCLUSION: The bronchial blocker cuff should be regarded as a high-pressure balloon. We introduced a new concept for safe bronchial blocker balloon occlusion for one-lung ventilation in small children.

Current Anesthesia Practices of Pediatric Cardiac Surgeries in Tertiary Maternity and Children's Hospitals in China: A National Survey.

OBJECTIVES: To describe the current development of Chinese pediatric cardiac anesthesia practices. DESIGN: Descriptive research study. SETTING: This study used electronic questionnaires. The authors searched the official website of the National Health Commission of the People's Republic of China for tertiary maternity and children's hospitals across the country. PARTICIPANTS: Tertiary maternity and children's hospitals. INTERVENTIONS: All representatives of the invited hospitals were asked to report the official statistics of their hospitals whenever possible. MEASUREMENTS AND MAIN RESULTS: The survey questions were related to the geographic distribution and caseloads of pediatric cardiac surgical resources, technical capacities, anesthetic regimens, monitoring practices, and qualification requirements of anesthesiologists. A total of 130 hospitals were confirmed, using the registration information of the National Health Commission of the People's Republic of China, and 108 hospitals agreed to participate in this study. All enrolled hospitals completed the questionnaires, of which 52 could perform cardiac surgeries and were located in provinces, autonomous regions, and municipalities across the country, except for the Inner Mongolia Autonomous Region, Ningxia Hui Autonomous Region, and Tibet Autonomous Region. The authors found that most hospitals' caseload of pediatric cardiac surgeries was relatively small (<500 cases per year). Hospitals capable of performing high-risk pediatric cardiac surgeries are mainly located in Eastern China. Most hospitals prefer total intravenous anesthesia in cardiac surgeries, and commonly used anesthetics include propofol, sufentanil, rocuronium, and cisatracurium. Except for the basic intraoperative monitoring items (including electrocardiography, invasive blood pressure, central venous pressure, pulse oxygen saturation, intake-output volume, and body temperature), bispectral index and near-infrared spectroscopy are relatively commonly used in some hospitals. Postoperative analgesia for children undergoing cardiac surgeries was provided in 38 hospitals, and an intravenous analgesia pump was the most widely used analgesia measure. In addition, the most frequently mentioned qualification requirements for pediatric cardiac anesthesiologists in these hospitals specializing in cardiac surgeries were a further study in domestic hospitals specializing in cardiac surgeries and the professional titles of the attending doctors. CONCLUSIONS: Pediatric cardiac medical resources are mainly concentrated in Eastern China, and most hospitals capable of performing high-risk cardiac surgeries are located in the eastern part of the country. The authors found that pediatric cardiac anesthesia practices varied widely among the hospitals, and the main problem with pediatric cardiac anesthesia in China is that there is no systemic fellowship training curriculum at present; therefore, there is an urgent need to develop a fellowship training curriculum to further improve the quality of Chinese pediatric cardiac anesthesia.

Isoelectric Electroencephalography in Infants and Toddlers during Anesthesia for Surgery: An International Observational Study.

BACKGROUND: Intraoperative isoelectric electroencephalography (EEG) has been associated with hypotension and postoperative delirium in adults. This international prospective observational study sought to determine the prevalence of isoelectric EEG in young children during anesthesia. The authors hypothesized that the prevalence of isoelectric events would be common worldwide and associated with certain anesthetic practices and intraoperative hypotension. METHODS: Fifteen hospitals enrolled patients age 36 months or younger for surgery using sevoflurane or propofol anesthetic. Frontal four-channel EEG was recorded for isoelectric events. Demographics, anesthetic, emergence behavior, and Pediatric Quality of Life variables were analyzed for association with isoelectric events. RESULTS: Isoelectric events occurred in 32% (206 of 648) of patients, varied significantly among sites (9 to 88%), and were most prevalent during pre-incision (117 of 628; 19%) and surgical maintenance (117 of 643; 18%). Isoelectric events were more likely with infants younger than 3 months (odds ratio, 4.4; 95% CI, 2.57 to 7.4; P < 0.001), endotracheal tube use (odds ratio, 1.78; 95% CI, 1.16 to 2.73; P = 0.008), and propofol bolus for airway placement after sevoflurane induction (odds ratio, 2.92; 95% CI, 1.78 to 4.8; P < 0.001), and less likely with use of muscle relaxant for intubation (odds ratio, 0.67; 95% CI, 0.46 to 0.99; P = 0.046]. Expired sevoflurane was higher in patients with isoelectric events during preincision (mean difference, 0.2%; 95% CI, 0.1 to 0.4; P = 0.005) and surgical maintenance (mean difference, 0.2%; 95% CI, 0.1 to 0.3; P = 0.002). Isoelectric events were associated with moderate (8 of 12, 67%) and severe hypotension (11 of 18, 61%) during preincision (odds ratio, 4.6; 95% CI, 1.30 to 16.1; P = 0.018) (odds ratio, 3.54; 95% CI, 1.27 to 9.9; P = 0.015) and surgical maintenance (odds ratio, 3.64; 95% CI, 1.71 to 7.8; P = 0.001) (odds ratio, 7.1; 95% CI, 1.78 to 28.1; P = 0.005), and lower Pediatric Quality of Life scores at baseline in patients 0 to 12 months (median of differences, -3.5; 95% CI, -6.2 to -0.7; P = 0.008) and 25 to 36 months (median of differences, -6.3; 95% CI, -10.4 to -2.1; P = 0.003) and 30-day follow-up in 0 to 12 months (median of differences, -2.8; 95% CI, -4.9 to 0; P = 0.036). Isoelectric events were not associated with emergence behavior or anesthetic (sevoflurane vs. propofol). CONCLUSIONS: Isoelectric events were common worldwide in young children during anesthesia and associated with age, specific anesthetic practices, and intraoperative hypotension.

Do COVID-19 pandemic-related behavior changes affect perioperative respiratory adverse events in children undergoing cardiac interventional catheterization?

BACKGROUND: The novel coronavirus disease (COVID-19) suddenly broke out in China in December 2019. Pandemic-related behavioral changes can cause perioperative respiratory adverse events in children with congenital heart disease (CHD). Here, we compared the incidence of perioperative respiratory adverse events (PRAEs) in CHD children with and without upper respiratory infection (URI) undergoing the cardiac catheterization before and during the COVID-19 pandemic. METHODS: This prospective observational single-center study was based at a tertiary care center in Shanghai, China. A total of 359 children with CHD with and without recent URI were included between January 2019 and March 2021. The overall incidence of PRAEs (laryngospasm, bronchospasm, coughing, airway secretion, airway obstruction, and oxygen desaturation) in non-URI and URI children undergoing elective cardiac catheterization was compared before and during the COVID-19 pandemic. A logistic regression model was fitted to identify the potential risk factors associated with PRAEs. RESULTS: Of the 564 children enrolled, 359 completed the study and were finally analyzed. The incidence of URIs decreased substantially during the COVID-19 pandemic (14% vs. 41%, P < 0.001). Meanwhile, the overall PRAEs also significantly declined regardless of whether the child had a recent URI (22.3% vs. 42.3%, P = 0.001 for non-URI and 29.2% vs. 58.7%, P = 0.012 for URI, respectively). Post-operative agitation in children without URI occurred less frequently during the pandemic than before (2.3% vs. 16.2%, P = 0.001). Behaviors before the COVID-19 pandemic (odds ratio = 2.84, 95% confidence interval [CI] 1.76-4.58) and recent URI (odds ratio = 1.79, 95% CI 1.09-2.92) were associated with PRAEs. CONCLUSIONS: COVID-19 pandemic-related behavioral changes were associated with a reduction in PRAEs in non-URI and URI children undergoing elective therapeutic cardiac catheterization.

Effects of advance exposure to an animated surgery-related picture book on preoperative anxiety and anesthesia induction in preschool children: a randomized controlled trial.

BACKGROUND: Our aim was to investigate whether early surgical preparation by reading an animated picture book about procedure-related events could reduce the preoperative anxiety in preschoolers. METHODS: 131 patients, aged 3-6 years and underwent elective minor surgery were randomized either to a control or a picture book group. Both groups received general information about surgery and anesthesia in pre-anesthesia clinic. Patients in study group also received a surgery-depicting picture book for them to read at home a week earlier before surgery. Child anxiety was evaluated with the modified Yale Preoperative Anxiety Scale Short Form in six observing time points before anesthesia induction, and the compliance of anesthesia induction was assessed with the Induction Compliance Checklist (ICC). RESULTS: There were significantly lower anxiety scores in picture book group than in control group at the time of ready for intravenous cannulation in operating room [51.9 (23.6) vs. 67.2 (22.0); mean difference 15.3; 95% confidence interval (CI) 6.4-24.1; P = 0.001] and at the time of pre-anesthesia visit [27.8 (7.6) vs. 33.2 (13.6); mean difference 5.3; 95%CI 0.93-9.8; P = 0.018]. No significant differences of anxiety levels were found between two groups at other observed time points: in the anesthesia outpatient clinic, in the holding area, at separation from parent to operating room (OR), and on entrance to OR (P = 0.584, 0.335, 0.228, 0.137, respectively). The percentage of children with poor induction compliance (i.e., ICC ≥ 6) was higher in control group compared with that in picture book group [38% vs.21%; odds ratio(95%CI): 0.78(0.61-0.99); P = 0.041]. CONCLUSIONS: Home-reading an animated picture book to get familiar with the perioperative events earlier prior to surgery could effectively reduce the preoperative anxiety level and increase the compliance during the induction of anesthesia in preschool children. TRIAL REGISTRATION: ChiCTR2000033583, 06/06/2020 www.chictr.org.cn .

Age-Related Changes in Cerebral Hemodynamics in Children Undergoing Congenital Cardiac Surgery: A Prospective Observational Study.

OBJECTIVE: To explore age-related cerebral hemodynamic characteristics before and after pediatric cardiac surgery. DESIGN: Prospective observational study. SETTING: Single-center study based at a tertiary care center in Shanghai, China. PATIENTS: Fifty-three children with congenital heart disease (CHD) aged zero-to-six years undergoing cardiac surgery with cardiopulmonary bypass were enrolled, and 44 children finally were analyzed. INTERVENTION: Cerebral hemodynamics were measured by transcranial color-coded duplex sonography in the right temporal window before and after surgery. The resistance index (RI), pulsatility index (PI), and cerebral blood flow velocity (CBFV), including time average maximum flow velocity (Vtamax), mean blood flow velocity (Vmean), and the peak systolic flow velocity (Vpeak), of the right middle cerebral artery (MCA) and regional cerebral oxygen saturation (rScO2) of the right frontal lobe were measured and analyzed. Heart rate and mean arterial pressure were also recorded during ultrasound. MEASUREMENTS AND MAIN RESULTS: RI and PI decreased exponentially with age before and after cardiac surgery. While PI remained unchanged after cardiac surgery, RI was significantly reduced. Furthermore, RI reduction after cardiac surgery was more significant in children >18 months compared to those ≤18 months. CBFV of the right MCA also showed exponential increase with age, but rScO2 linearly increased. Cardiac surgery significantly changed the cerebral hemodynamics, but it did not affect rScO2 in children regardless of age. CONCLUSIONS: Age-related cerebral hemodynamic changes exist in children with CHD. Cardiopulmonary bypass surgery led to greater cerebrovascular dilation in children aged ≤18 months than those >18 months.

Quality improvement and patient safety in China, present and future.

With continued political support and increased health financing, China has achieved great progress in medical and health quality during the two decades. The strategy to improve health in China is built on reliable cross-sectoral information and data sharing along with quality improvement science and safety analytics balancing equitability, accessibility, quality outcomes, and safety in healthcare for everyone. As part of the healthcare system, pediatric anesthesiology has made great efforts to align with the China healthcare strategy to achieve quality outcomes, accessibility, and patient safety, but it still faces many problems such as unbalanced regional development, lack of awareness and relevant knowledge, and increased workload due to insufficient number of anesthesiologists. To address these problems, the Chinese Society of Anesthesiology and Chinese Society for Pediatric Anesthesiology supported by the Chinese hospital associations are strengthening interregional cooperation and international collaboration. In our experience, quality improvement can be successfully implemented at major centers through collaboration with experienced international institutions. In turn, the major centers educate and collaborate with the district hospitals to empower local improvements in safety and quality. Since the science in QI and patient safety is relatively new to anesthesiology in China, such collaborations must be greatly scaled up to reach the large geography and patient population in China. While the future is promising, there is still a long way to go.

Paediatric preoperative sedation practices in tertiary maternity and children's hospitals in China: a questionnaire survey.

BACKGROUND: Preoperative anxiety is a common problem in the paediatric population, and several studies have reported that it is related to adverse events such as emergence delirium and postoperative psychological and behavioural changes. In recent years, increasing attention has been paid to paediatric preoperative anxiety in China. A variety of strategies, including sedatives, parental presence, and audio-visual interventions, have been used to relieve paediatric preoperative anxiety, but there is no well-recognised procedure for paediatric preoperative sedation. Therefore, this study aimed to investigate current paediatric preoperative sedation practices in tertiary children's hospitals in China. METHODS: All tertiary maternity and children's hospitals registered with the National Health Commission of the People's Republic of China were invited to participate in an electronic survey, which included information on the preoperative sedation caseload, sites where preoperative sedation was performed, preoperative sedation methods used in different age groups, choice of sedatives, contraindications for premedication, staff structure for sedative administration and monitoring, and patient-monitoring practices. RESULTS: All 81 hospitals participating in our study completed the survey, and 38 hospitals (46.9 %) provided their preoperative sedation protocols. Twenty-four hospitals performed fewer than 5,000 preoperative sedation cases annually, and 9 hospitals performed more than 10,000 cases annually. Preoperative sedation was performed in preoperative preparation areas, preoperative holding areas, and operation rooms in 47.4 %, 26.3 %, and 13.2 % of hospitals, respectively. Sedatives were the most used interventions for paediatric preoperative sedation in all age groups, and the most widely used sedatives were propofol (intravenous) and dexmedetomidine (intranasal). The most common contraindications were American Society of Anesthesiologists class ≥ 3, emergency operation, and airway infection within 2 weeks. Sedatives were administered mainly by anaesthesiologists (63.2 %), and children were monitored mainly by anaesthesiologists (44.7 %) and nurses (39.5 %) after administration. Pulse oximetry was the most widely used monitoring device. CONCLUSIONS: Fewer than half of the tertiary maternity and children's hospitals in China provide paediatric preoperative sedation service, and the service practices vary widely. Further improvements are required to ensure the quality of paediatric preoperative sedation services and establish standard operating procedures.

Comparison of the ED50 propofol requirements during the insertion of laryngeal mask airway Ambu AuraFlex with Ambu AuraOnce in children undergoing strabismus surgery.

WHAT IS KNOWN AND OBJECTIVE: Optimal airway management is crucial in strabismus surgery due to the inaccessibility of the airway throughout the procedure. Laryngeal mask airway offers advantages over tracheal intubation in ophthalmic surgery as it does not increase the intraocular pressure. The purpose of this study was to determine the median effective dose of propofol required, when combined with 0.2 µg/kg of sufentanil, for smooth insertion of Ambu AuraFlex in the first attempt in children undergoing strabismus surgery, and to compare it with that for Ambu AuraOnce. METHODS: Forty-three paediatric patients undergoing strabismus surgery under general anaesthesia were recruited. For induction, the initial dosage of propofol was 2 mg/kg in the AuraOnce group or 3 mg/kg in the AuraFlex group. In accordance with Dixon's up-and-down method, the dose of propofol for consecutive patients in each group was adjusted in increments or decrements of 0.25 mg/kg based on the previous patient's "three-point, six-category scale" response to the first attempt of insertion of the randomized device. Insertion of the device was attempted when the bispectral index was ≤60 for 5 s after propofol administration without the use of neuromuscular blocking agents. RESULTS AND DISCUSSION: The median effective dose (95% confidence interval) of propofol was significantly lower in the Ambu AuraOnce group than in the Ambu AuraFlex group (1.92 [1.50-2.32] mg/kg vs. 2.98 [2.49-3.94] mg/kg; p = 0.002). The incidence of dislodgement of the device was significantly higher with the use of the Ambu AuraOnce than with the use of AuraFlex (p = 0.023), whereas insignificant differences were observed between the two groups in the incidence of other perioperative adverse events. WHAT IS NEW AND CONCLUSION: Ambu AuraFlex requires a significantly higher dose of propofol for insertion and provides more effective and stable airway management in strabismus surgery than AuraOnce.

Effect of recorded maternal voice on emergence agitation in children undergoing bilateral ophthalmic surgery: A randomised controlled trial.

AIM: This study was designed to investigate whether the playing-back of the recorded maternal voice through the headphones to children undergoing bilateral ophthalmic surgery has clinical effects on the incidence of emergence agitation, and the anaesthesia recovery course. METHODS: In this prospective, blinded and randomised study, 127 children, aged 2-8 years and undergoing bilateral ophthalmic surgery were randomly allocated to one of the two groups: group T (treatment group, listening to recorded mother's voice via headphones) or group C (control group, wearing headphones without auditory stimuli). The primary outcome was the incidence of emergence agitation, and the secondary outcomes were the awakening time, and the post-anaesthesia care unit (PACU) stay time. RESULTS: Children in the group of listening recorded mother's voice exhibited significantly low incidence of emergence agitation compared with those in the control group (32.8 vs. 55.6%; odds ratio (95% confidence interval): 0.39(0.19-0.80); P = 0.010). The awakening time was shorter in group T as compared to that in group C (22.9 (10.4) vs. 27.3 (13.7); P = 0.048). As results, the group T had significantly less PACU stay time with early discharge than the group C did (29.7 (12.1) vs. 34.8 (14.1); P = 0.031). CONCLUSIONS: Recorded mother's voice is an efficient method to reduce emergence agitation in children undergoing bilateral ophthalmic surgery with sevoflurane anaesthesia. Also, patients woke faster and PACU stay time was shorter in the mother's voice group as compared with the control group.

Moderate and deep sedation for non-invasive paediatric procedures in tertiary maternity and children's hospitals in China: a questionnaire survey from China.

BACKGROUND: Moderate and deep sedation are well-established techniques in many developed countries, and several guidelines have been published. However, they have received attention in China only in recent years. The aim of this study is to investigate current paediatric sedation practices in tertiary children's hospitals and tertiary maternity and children hospitals in China. METHODS: All tertiary children's hospitals and tertiary maternity and children hospitals registered with the National Health Commission of the People's Republic of China were invited to participate in an electronic survey, which included information on the sedation caseload, facility availability, staff structure, clinical skill requirements for sedation providers, fasting guidelines, patient-monitoring practices, and choice of sedatives. RESULTS: Fifty-eight of the 63 hospitals that completed the survey (92.1%) provided moderate and deep sedation. Dedicated sedation rooms and post-sedation recovery rooms were found in 14 (24.1%) and 19 (32.8%) hospitals, respectively. Sedation for non-invasive procedures was primarily performed by anaesthesiologists (69.0%); however, 75.9% of the sedation providers had not received paediatric basic or advanced life-support training. Children were asked to fast from clear liquids for at least 2 h in 44.8% of hospitals and up to 6 h in 5.2% of hospitals; they were asked to fast from solid food/milk for at least 4 h in 27.6% of hospitals and more than 8 h in 1.7% of hospitals. The most commonly used sedative in all groups was chloral hydrate. For rescue, propofol was the most widely used sedative, particularly for children older than 4 years. CONCLUSIONS: Moderate and deep sedation practices vary widely in tertiary children's hospitals and tertiary maternity and children hospitals in China. Optimised practices should be established to improve the quality of moderate and deep sedation.

Intranasal dexmedetomidine premedication in children with recent upper respiratory tract infection undergoing interventional cardiac catheterisation: A randomised controlled trial.

BACKGROUND: Recent upper respiratory tract infection (URI) is a risk factor for the occurrence of peri-operative respiratory adverse events (PRAE). This risk may be higher in children with congenital heart disease (CHD), particularly in those undergoing interventional cardiac catheterisation. It is therefore essential to adapt the anaesthetic strategy in these children to prevent from the occurrence of PRAE. OBJECTIVE: To determine whether intranasal dexmedetomidine (DEX) premedication can reduce the incidence of PRAE in children with recent URI undergoing interventional cardiac catheterisation. DESIGN: Randomised controlled trial. SETTING: Single-centre study based at a tertiary care centre in Shanghai, China. PATIENTS: A total of 134 children with CHD aged 0 to 16 years with recent URI undergoing interventional cardiac catheterisation. INTERVENTIONS: Children were randomised to receive either intranasal DEX 1.5 µg kg (DEX group) or intranasal saline (Placebo group) 30 to 45 min before anaesthesia induction. MAIN OUTCOME MEASURES: The incidence of PRAE. RESULTS: Intranasal DEX significantly reduced the incidence of PRAE (P = 0.001), particularly oxygen desaturation (P = 0.012). Most PRAE were observed during the emergence phase. The incidence of PRAE was comparable among the three types of left-right shunt CHD children in both groups. In children aged less than 3 years, the incidence of PRAE was significantly lower in the DEX group (P = 0.003). In contrast, the incidence of PRAE was comparable between the two groups in children aged at least 3 years. No differences in the incidence of emergence agitation, fever and vomiting between the two groups were noted. CONCLUSION: Administration of intranasal DEX 1.5 µg kg 30 to 45 min before induction led to a reduction in the incidence of PRAE in children aged less than 3 years with recent URI undergoing interventional cardiac catheterisation. TRIAL REGISTRATION: chictr.org.cn identifier: ChiCTR-RRC-17012519.

Dilation of the cystic duct confluence in laparoscopic common bile duct exploration and stone extraction in patients with secondary choledocholithiasis.

BACKGROUND: Many options exist for the management of cholelithiasis and secondary choledocholithiasis. Among them, laparoscopic common bile duct exploration (LCBDE) with choledocotomy followed by laparoscopic cholecystectomy has gained popularity. However, efforts should be made to ensure minimally invasive or noninvasive management of the common bile duct (CBD). The purpose of this study was to explore the clinical experience of non-invasive surgical modality, i.e., laparoscopic transcystic dilation of the cystic duct confluence in CBD exploration (LTD-CBDE), including feasibility, safety, adverse events, and incidence. METHODS: In this retrospective analysis, 68 patients were offered the LTD-CBDE technique from December 2015 to April 2018 based on patient's own intention. During the surgery, the cystic duct confluence was dilated with separation forceps and/or a columnar dilation balloon. Subsequently, CBD exploration and stone extraction were performed with a choledochoscope. The entrance of the CBD was covered with a cystic duct stump wall and was subjected to primary closure at the end of surgery. RESULTS: Forty-nine females and 19 males with cholelithiasis and secondary choledocholithiasis were included. The mean age was 53 years old (18 to 72 year). Of these patients, 62 (91.2%) were successfully treated with the LTD-CBDE technique, and bile leakage was observed in 3 patients (4.4%). The mean operation time was 106 min, and the mean hospital stay was 5.9 days. Among the other 6 patients, 3 were converted to open cholecystectomy due to severe fibrosis, unclear anatomical structure at Calot's triangle (n = 2) or Mirizze syndrome (n = 1); LCBDE was performed in 3 patients due to cystic duct atresia (n = 2) and low level of flow from the gallbladder duct into the CBD (n = 1). These patients had a smooth postoperative course. In total, 43/68 of the patients presented no radiological evidence of retained CBD stones at the postoperative follow-up (40 patients treated with LTD-CBDE) 1 year later. CONCLUSIONS: The current work suggests that LTD-CBDE for the management of cholelithiasis and secondary choledocholithiasis is a feasible, safe and effective technique with a low complication rate. LTD-CBDE offers another alternative for surgeons to treat patients in similar scenarios. However, additional randomized, controlled studies are needed to demonstrate its efficacy, safety, and impact on CBD stenosis.

Modified Lung Ultrasound Examinations in Assessment and Monitoring of Positive End-Expiratory Pressure-Induced Lung Reaeration in Young Children With Congenital Heart Disease Under General Anesthesia.

OBJECTIVES: Lung ultrasound can reliably diagnose pulmonary atelectasis. The object of this study is to determine the most efficient region to assess changes in atelectasis in children with congenital heart disease under general anesthesia. DESIGN: Randomized controlled trial. SETTING: Operating room at university-affiliated children's hospital. PATIENTS: Children between 3 months and 3 years old, scheduled for elective congenital heart disease surgery under general anesthesia. INTERVENTIONS: Forty children with congenital heart disease were randomly allocated to either a 5 cm H2O positive end-expiratory pressure group or a standard therapy control group. MEASUREMENTS AND MAIN RESULTS: Preoperative lung ultrasound was performed twice in each patient-after 1 and 15 minutes of mechanical ventilation. Atelectatic areas and B-lines were compared between two examinations. Different ultrasound regions were evaluated using Bland-Altman plots. The occurrence rate of atelectasis was much higher in inferoposterior lung regions (Scans 4-6) than in anterior and lateral regions (Scans 1-3). The median (interquartile range) lung ultrasound scores were lower in the positive end-expiratory pressure group than in the control group after treatment: 8 (3.3-9.8) versus 13 (8.3-17.5; p < 0.001). The atelectatic area was significantly decreased after treatment in the positive end-expiratory pressure group: 128 mm (34.5.5-213.3 mm) versus 49.5 mm (5.3-75.5 mm; p < 0.001). Bland-Altman plots revealed concordance between measurements in Scans 1-6 and those in Scans 4-6. In the posterior axillary line regions, changes in atelectatic area were significantly larger in the positive end-expiratory pressure group than in the control group (p = 0.03, 0.007, and 0.018). CONCLUSIONS: Lung ultrasound in inferoposterior lung regions may be more likely to reflect changes in atelectasis and save examination time; 5 cm H2O positive end-expiratory pressure may be useful in lung reaeration and can reduce, but not eliminate, atelectasis in children with congenital heart disease.

Newborn infant parasympathetic evaluation (NIPE) as a predictor of hemodynamic response in children younger than 2 years under general anesthesia: an observational pilot study.

BACKGROUND: It is still unknown whether newborn infant parasympathetic evaluation (NIPE), based on heart rate variability (HRV) as a reflection of parasympathetic nerve tone, can predict the hemodynamic response to a nociception stimulus in children less than 2 years old. METHODS: Fifty-five children undergoing elective surgery were analyzed in this prospective observational study. Noninvasive mean blood pressure (MBP), heart rate (HR) and NIPE values were recorded just before and 1 min after general anesthesia with endotracheal intubation as well as skin incision. The predictive performance of NIPE was evaluated by receiver-operating characteristic (ROC) curve analysis. A significant hemodynamic response was defined by a > 20% increase in HR and/or MBP. RESULTS: Endotracheal intubation and skin incision caused HR increases of 22.2% (95% confidence interval [CI] 17.5-26.9%) and 3.8% (2.1-5.5%), MBP increases of 18.2% (12.0-24.4%) and 10.6% (7.7-13.4%), and conversely, NIPE decreases of 9.9% (5.3-14.4%) and 5.6% (2.1-9.1%), respectively (all P < 0.01 vs. pre-event value). Positive hemodynamic responses were observed in 32 patients (62.7%) during tracheal intubation and 13 patients (23.6%) during skin incision. The area under the ROC curve values for the ability of NIPE to predict positive hemodynamic responses at endotracheal intubation and skin incision were 0.65 (0.50-0.78) and 0.58 (0.44-0.71), respectively. CONCLUSIONS: NIPE reflected nociceptive events as well as anesthestic induction in children less than 2 years undergoing general anaesthetia. Nevertheless, NIPE may not serve as a sensitive and specific predictor to changes in hemodynamics. TRIAL REGISTRATION: This study was registered on May 3, 2018 in the Chinese Clinical Trail Registry; the registration number is ( ChiCTR1800015973 ).

Statistical Analysis Plan for "An international multicenter study of isoelectric electroencephalography events in infants and young children during anesthesia for surgery".

This Statistical Analysis Plan details the statistical procedures to be applied for the analysis of data for the multicenter electroencephalography study. It consists of a basic description of the study in broad terms and separate sections that detail the methods of different aspects of the statistical analysis, summarized under the following headings (a) Background; (b) Definitions of protocol violations; (c) Definitions of objectives and other terms; (d) Variables for analyses; (e) Handling of missing data and study bias; (f) Statistical analysis of the primary and secondary study outcomes; (g) Reporting of study results; and (h) References. It serves as a template for researchers interested in writing a Statistical Analysis Plan.

Selection of cuffed endotracheal tube for children with congenital heart disease based on an ultrasound-based linear regression formula.

It remains to be discovered whether a formula predicting the subglottic transverse diameter measured by ultrasound (SGDformula) for the selection of an appropriate endotracheal tube (ETT) for children without congenital heart disease (CHD) is useful for children with CHD. A formula for predicting SGD was established after assessing 60 children ≤ 8 years without CHD and validated on 60 children with CHD. We selected the cuffed ETT size based on the SGD by ultrasound (SGDultra). Subsequently, the fit of the ETT cuff in 60 children with CHD was examined via air-leak test. The maximum allowed difference between the SGDformula and the ETT size that fit was 0.2 mm. The agreement among and accuracy of SGDultra, SGDformula, and the ETT used in children was analyzed. For children without CHD, we adopted a linear formula, given by SGDformula (mm) = 0.4 × age + 5.3. For children with CHD, allometric formula was adopted, given by SGDformula (mm) = 5.4 × age0.18. A stronger agreement exists between SGDultra and ETT size compared to that between SGDformula and ETT size. And the mean bias (SGDformula-ETT size and SGDultra-ETT size) was 0.21 mm (95% confidence interval, - 0.59 to 1.01 mm) and 0.00 mm (- 0.79 to 0.84 mm). For the CHD group, the ultrasound-based method yielded a 78% success rate of ETT size choice, while the formula-based method permitted an appropriate ETT size in only 32% of subjects (P < 0.001). Our analysis showed that measuring the SGDultra was more accurate in predicting the correct OD of the ETT in children with CHD undergoing cardiovascular surgery, based on the correlation and agreement with ETT OD.

Environmental enrichment reduces adolescent anxiety- and depression-like behaviors of rats subjected to infant nerve injury.

BACKGROUND: Infant nerve injury causes delayed adolescent neuropathic pain, but whether it also leads to psychiatric illness is unknown. Environmental enrichment (EE) increases social communication and activity. Thus, our goal was to test anxiety- and depression-like behaviors after infant peripheral nerve injury and evaluate the effect of environmental enrichment on these models of affective disorders. METHODS: Open field, elevated plus maze, sucrose preference, and pain behaviors (paw withdrawal threshold, spontaneous guarding score, and cold response to acetone) were measured in rats that received infant spared nerve injury (SNI). Enzyme-linked immune absorbent assay of cytokines was performed to evaluate the inflammatory response in the brain. Then, the ability of intracerebroventricular (ICV) injection of a microglia inhibitor, minocycline (MIN), and EE (a free-running wheel, a staircase, a plastic tunnel, a raised platform, and various colored balls) to reverse the infant SNI effects on behaviors and cytokines was examined. RESULTS: Infant nerve injury resulted in adolescent anxiety- and depression-like behaviors. The medial prefrontal cortex, basolateral amygdala, and ventral hippocampus were skewed to a pro-inflammatory profile. ICV injection of MIN reduced anxiety- and depression-like behaviors without affecting pain behaviors. In addition, ICV MIN skewed the brain towards an anti-inflammatory profile. Finally, environmental enrichment improved anxiety- and depression-like behaviors, as well as pain behaviors. EE increased brain IL-10 and decreased IL-1ß and TNF-α. CONCLUSIONS: Infant nerve injury induces adolescent anxiety- and depression-like behaviors and central nervous inflammation. Environmental enrichment reduces these behaviors by normalizing the inflammation balance in the brain.

The prediction probabilities for emergence from sevoflurane anesthesia in children: A comparison of the perfusion index and the bispectral index.

BACKGROUND: Predicting recovery of consciousness is one of the most essential functions of anesthesia depth monitors in anesthesia practice. Perfusion index and bispectral index are 2 indicators of the anesthesia depth monitoring with different working principles. The progression of the anesthesia emergence stages reflected by those monitors has not been well understood, especially in pediatric patients. The goals of this study were to compare the prediction probabilities of perfusion index and bispectral index in predicting awakening and in differentiating the different levels of arousal during emergence after sevoflurane anesthesia in children undergoing open inguinal hernia repairs. METHODS: Forty-five patients, aged 1 to 5 years, ASA Status I or II and scheduled for elective open inguinal hernia repairs under general anesthesia were enrolled. The perfusion index and bispectral index were monitored simultaneously during anesthesia recovery. The University of Michigan Sedation Scale was applied to evaluate the clinical arousal levels during emergence. The prediction probability was used to assess the performance of perfusion index and bispectral index in predicting awakening and distinguishing different levels of arousal corresponding to the University of Michigan Sedation Scale during recovery. RESULTS: The prediction probability of perfusion index (PkPI-Awakening  = .81, 95% CI 0.73-0.89) in differentiating full consciousness from unconsciousness during recovery was comparable to that of bispectral index (PkBIS- Awakening  = .86, 95% CI 0.79-0.92) (P = .47). The prediction probability for perfusion index (PkPI-UMSS  = .61, 95% CI 0.55-0.73) and bispectral index (PkBIS-UMSS  = .64, 95% CI 0.53-0.69) had similar performance in distinguishing different University of Michigan Sedation Scale levels. CONCLUSION: Both the perfusion index and bispectral index performed comparably well in predicting awakening and different arousal levels when emerging from sevoflurane anesthesia in children.

Noradrenergic transmission in the central medial thalamic nucleus modulates the electroencephalographic activity and emergence from propofol anesthesia in rats.

At present, the mechanisms by which general anesthetics causing loss of consciousness remain unclear. The central medial thalamic nucleus (CMT) is a rarely studied component of the midline thalamic complex, which is deemed to be a part of the nonspecific arousal system. Although the CMT participates in modulating arousal and receives excitatory noradrenergic projections from locus coeruleus, it remains unknown whether the noradrenergic pathway in the CMT takes part in modulating the arousal system. Therefore, we hypothesized that noradrenergic transmission in the CMT is involved in modulating induction and emergence of propofol anesthesia. First, we infused norepinephrine (NE) into the CMT to observe the role of CMT noradrenergic pathway in modulating the anesthetic state induced by propofol. The results showed that microinjection of NE into the CMT accelerated emergence from propofol anesthesia, but had no impact on the induction of or sensitivity to propofol anesthesia in rats. In addition, infusion of NE into the CMT caused electroencephalography changes in the prefrontal cortex and the anterior cingulate cortex. Finally, we used a whole-cell patch clamp to examine the effects of NE on neuronal excitability and GABAergic transmission in the CMT. In the CMT slices, propofol suppressed neuronal excitability and enhanced GABAergic transmission, while application of NE partly reversed these effects. These findings support the hypothesis that the CMT noradrenergic pathway plays an important role in modulating the emergence from general anesthesia.