Pediatric Anesthesia

Pediatric Risk Stratification: Patient Comorbidities and Intrinsic Surgical Risk

A retrospective study of the Pediatric NSQIP delineated the impact of intrinsic surgical risk with patient co-morbidities, informing how intrinsic surgical risk can add to mortality prediction.

“Surgical procedures identified by specialty are not independent risk factors for perioperative mortality in pediatric patients. However, in multivariable predictive algorithms, the interaction of patient comorbidities with the intrinsic risk of the surgical procedure strongly predicts 30-day mortality.”

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Nasal High-Flow Therapy for Newborn Infants

High flow nasal oxygen has become a popular alternative to non-invasive ventilation and as a means of apneic oxygenation during airway management.

This neonatal study did not replicate its advantages described in other studies:

“Nasal high-flow therapy was not shown to be noninferior to CPAP and resulted in a significantly higher incidence of treatment failure than CPAP when used in nontertiary special care nurseries as early respiratory support for newborn infants with respiratory distress. ”

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Opioid Sparing in Pediatric Adenotonsillectomy

This QI project identified an opioid sparing anesthesia approach for pediatric tonsillectomy and adenotonsillectomy that moved away from morphine and acetaminophen, though Dexmedetomidine plus Ibuprofen, and finally on to the most effective regime consisting of Dexmedetomidine plus Ketorolac.

The study highlights both the move away from opioid based anesthesia as well as the increasing use of Intraoperative Dexmedetomidine.

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Monitored anaesthesia care for gastrointestinal endoscopy in children

An observational study to identify the prevalence and predictors of adverse events during sedation for paediatric endoscopy. The incidences of adverse events and adverse respiratory events were 3.4 and 3.3%, respectively.

12 independent predictors: age, children’s size for example underweight/overweight, morbid obesity, presence of respiratory comorbidities, recent respiratory infection, neurological comorbidities, upper gastrointestinal endoscopy, propofol co-administration with ketamine or after sevoflurane induction, and propofol induction dose.

Posthoc secondary analyses revealed a significantly higher risk of adverse events and also significantly more respiratory comorbidities and respiratory infections in children aged less than 2 years when compared with children aged at least 2 years. No cardiovascular events were observed.

Adverse events were rare but predictable and pediatric endoscopy is safe in experienced hands.

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Pediatric Temperament and Postoperative Pain

The influence of psychological, psychiatric and emotional factors on pain postoperatively has been well described. Recent studies have shown the negative effects of anxiety, depression, sleep disturbance, and even parental anxiety on postoperative pain in adults as well as children.

This study shows “preoperative temperament characteristics may differentially influence pediatric post‐operative pain experience in children. Specifically, children with high levels of positive and negative emotionality may exhibit more post‐surgical pain behaviors”.

The novel approach looked at broader temperament analysis; positive excitability clusters as well as the more well known negative attitudes are a factor to consider for pain prediction.

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Anesthetic Neurotoxicity in Children

This article discusses the issues raised by many studies of potential neurotoxicity of anesthetics in infants, toddlers and children.

It attempts to address varying results of different studies, and to synthesize animal evidence with pediatric studies, different times of exposure and number of anesthetics.

The authors note that test batteries may not have sufficient ability to detect subtle changes in IQ, behavioural issues and academic performance, and argue for a redirecting of testing to identify potentially subtle effects that could be related to anesthesia.

There are still no studies that show overwhelmingly that anesthesia causes harm in pediatric anesthesia and at this time no practice change is felt to be warranted for performing necessary surgeries in children

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Oxygen Saturation Index Vs. Oxygenation Index in Neonates

Beyond the PaO2/FiO2 ratio in hypoxic respiratory failure, the Oxygenation Index (OI) is used in neonates, with 15/25/40 representing mild, moderate and severe illness. This retrospective study compared invasive with non-invasive measures of severity of respiratory failure.

OI = MAP × Fio2 × 100 / Pao2, where MAP indicates mean airway pressure.

Oxygen Saturation Index (OSI), a non-invasive counterpart is defined as OSI = MAP × Fio2 × 100 / Spo2

OI and OSI showed a strong correlation. Derived OI from OSI was in good agreement and strongly predictive of clinically relevant OI cutoffs from 5 to 25.

More studies in different disease severity are needed but OSI may provide a useful non-invasive alternative to OI in this setting.

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Perioperative Opioids in Children Guidelines

The Society for Pediatric Anesthesiology issues guidelines for perioperative opioid use. Many of the recommendations are not that different to adults in terms of assessing pain, safety/monitoring, patient controlled analgesia, outpatient analgesia, side effects, adjunctive agents/regional anesthesia…

Caution is advised with the potential seizure activity of both Meperidine (Pethidine) and Tramadol, and Codeine is advised against once again due to unpredictable metabolism.

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Children’s Pain Memory

Negative pain experiences can colour children’s response to pain in the long term.

This study showed that parent, but not child, anxiety before surgery contributed to the development of negative biases in children’s memories for pain-related fear 1 month later. “Specifically, higher levels of parent trait anxiety led to children recalling higher levels of pain-related fear than they initially reported”.

Children who initially reported higher levels of pain intensity and pain-related fear tended to recall higher levels pain intensity and pain-related fear. Children who developed negatively biased memories of pain-related fear had higher postsurgical pain after surgery (ie, 3 days after discharge).

The message is to target parental anxiety as well as manage pain early and for the first few days after surgery.

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Transfontanelle Ultrasound to Predict Fluid Responsiveness in Infants

Studies have found a relationship between fluid responsiveness and respiratory variation in the arterial blood flow peak velocity in the ascending aorta.

This was a prospective observational study of 30 infants undergoing cardiac surgery. Before and after the administration of 10ml · kg–1 crystalloid, established measures – respiratory variation of the aorta blood flow peak velocity, pulse pressure variation, and central venous pressure were obtained. The respiratory variation of the internal carotid artery blood flow peak velocity was measured using transfontanelle ultrasound.

In this study the respiratory variation of the internal carotid artery blood flow peak velocity as measured using transfontanelle ultrasound predicts an increase in stroke volume in response to an intravenous fluid bolus.

Cutoffs for respiratory variation were different than aortic velocity and further larger studies are needed in diverse populations before this potentially useful non-invasive fluid responsiveness assessment modality can be more widely recommended in infants.

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