Pediatric Anesthesia

Middle Finger Length and Pediatric Tube Size

Age based formulae for pediatric uncuffed tracheal tube size are non-linear so these authors propose a new formula: ‘middle finger length (cm) (round up to nearest 0.5) = internal diameter of uncuffed tracheal tube (mm)’ – may be an improvement compared with age formulae for selecting uncuffed tracheal tubes in children.

The study was small and needs validation. It included children up to 12 years old, but skewed to less than 5 year olds. The backdrop to this is the shift in practice to cuffed microcuff tubes for many pediatric anesthesiologists ( link ), and the study may not apply.

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Dural Sac Extent in Neonatal Caudal Block

An anatomic study in neonates sought to determine how close the dural sac was to the apex of the sacral hiatus, as this may lead to unintended spinal injection. Average distance in males was 10.9mm and 9.6mm in females; it increased with greater neonate length. Range was 4.9 -26.3mm.

“Anesthesiologists should be aware of the short distance between the sacral hiatus and the dural sac when performing caudal blocks, the shortest distance was 4.94 mm. Armed with this knowledge, caudal techniques should be modified to improve the safety and reduce the risk of complications, such as dural puncture.”

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Gastric Volume/Content in Elective Pediatric Surgery

This prospective cohort study aimed to identify “at risk” stomachs – with solid content or more than 1.25ml/kg in elective pediatric surgery. Median duration of fasting was 4 hours for liquids and >13 hours for solids. They found only 1% of elective children had potentially increased risk for pulmonary aspiration, but none had solid contents

While the overall findings are reassuring, they also draw attention to the often prolonged fasting times in pediatric surgery.

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Transversus Abdominis Plane Block in Children

“In children, quality of postoperative pain control provided by transversus abdominis plane (TAP) block using levobupivacaine 0.4 mg·kg−1 administered as either 0.2% or 0.4% did not differ and was associated with a very low risk of local anesthetic systemic toxicity”. The study involved inguinal day surgery and about 70% did not require any postoperative opioids. However the study only compared the two concentrations, there being no comparison with a control group not given the TAP block.

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Transfusion in Pediatric ARDS

The Pediatric Critical Care Transfusion and Anemia Expertise Initiative issues consensus recommendations on red cell transfusion in critically ill pediatric ARDS. The guidelines are in keeping with the widespread trend of restrictive blood policies.

“Transfusion of RBCs in children with respiratory failure with an hemoglobin level less than 5 g/dL was strongly recommended. It was strongly recommended that RBCs not be systematically administered to children with respiratory failure who are hemodynamically stable and who have a hemoglobin level greater than or equal to 7 g/dL. Experts could not make a recommendation for children with hemodynamic instability, with severe hypoxemia and/or with an hemoglobin level between 5 and 7 g/d”.

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Peripherally Inserted Central Venous Lines

Although peripherally inserted central lines may intuitively appear less invasive, this study finds that “Rates of central line–associated blood stream infection and venous thromboembolism were higher in hospitalized pediatric patients with peripherally inserted central catheters as compared to central venous catheters”.

This was a retrospective study but clearly further study is needed as to the optimal route of central venous lines in  both pediatric and adult patients.

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Neonatal Circumcision Analgesia

A randomized study compares analgesic methods for neonatal circumcision. Options that were better than EMLA alone were EMLA in combination with a) oral sucrose, b) penile ring block, or c) dorsal penile nerve block.

The most effective analgesia of those tested was EMLA + sucrose + penile ring block. Multimodal wins again. It seems reasonable to add a block, although they were performed here by a Pediatric Urologist.

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Pediatric and Neonatal Airway Management

Issues of concern in the area of Pediatric and Neonatal ICU in airway management are highlighted in the UK in this survey study.

Compared with adult ICU, there was less airway policies, difficult airway carts, checklists, videolaryngoscopy and way less capnography. This was more pronounced in the Neonatal area.

The authors conclude “major gaps in optimal airway management provision exist in UK paediatric intensive care units and especially in UK neonatal intensive care units“.

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