Pediatric Anesthesia

Cuffed Tracheal Tubes in Pediatrics

Traditional use of non-cuffed tracheal tubes in neonates and children is being replaced by low pressure cuffs such as micro-cuffed tubes. This study reviewed subglottic stenosis found on micro-laryngoscopy within 6 months of invasive ventilation.

The only cases requiring surgical correction were in fact ex-premature neonates initially intubated with non-cuffed tubes.

Conclusion: “The introduction of a policy of appropriate placement and maintenance of low‐pressure, high‐volume cuffed endotracheal tubes in the pediatric critical care unit was not associated with an increased rate of endotracheal tube‐related subglottic trauma”.

link

Dexmedetomidine & Anesthesia

Two encouraging studies on Dexmedetomidine. The first reviews the potential for less neurotoxicity on its own or when added to other anesthetics, although more study is needed to assess any long term effects in children.

The second study reviews its use in general anesthesia and finds less pain and opioid use in adults postoperatively.

PedAnes link

ClinJPain link

 

Management of Anesthesia for Sickle Cell Disease

An educational article on anaesthesia management for children with sickle cell disease.  End-organ damage like cerebrovascular disease, heart failure secondary to thrombotic disease or pulmonary hypertension is seen less frequently now as is chronic kidney disease caused by ischaemic damage and loss of renal tubules. Vaccination should be comprehensive. The most common acute complications are infection and vaso-occlusive episodes. “Multiple splenic microinfarcts secondary to sickling is an early complication, with 90% of affected children reported to have functional asplenia by age 6 yr. This leads to an increased risk of bacterial infections, most notably with S. pneumoniae in addition to atypical organisms”.

Sepsis is less common with vaccination. The most common postoperative complications are vaso-occlusive episodes and Acute Chest Syndrome, reported especially after appendectomy and Cesarean, but also high after umbilical hernia repair, cholecystectomy, and splenectomy. Stroke and death were reported more rarely.

Anesthesia goals are to maintain oxygenation and hydration, avoid acidosis, and maintain normocarbia, normotension, and normothermia, as well as adequate analgesia.

Bja link

 

Pediatric Maintenance Intravenous Fluids

The American Academy of Pediatrics issues a clinical practice guideline on maintenance intravenous fluids in children, also applying to postoperative settings. The long review highlights in particular the potentially lethal danger of hyponatremic encephalopathy from hypotonic fluids that were historically popular in children (and still advised in some textbooks). In brief, they state: “The AAP recommends that patients 28 days to 18 years of age requiring maintenance IVFs should receive isotonic solutions with appropriate potassium chloride (KCl) and dextrose because they significantly decrease the risk of developing hyponatremia”. 

They note for the purposes of this guideline, isotonic solutions have a sodium concentration similar to PlasmaLyte, or 0.9% NaCl. Recommendations are not made regarding the safety of lactated Ringer solution. Researchers in the majority of studies added dextrose (2.5%–5%) to the intravenous (IV) solution.

The review excluded patients with neurosurgical disorders, congenital or acquired cardiac disease, hepatic disease, cancer, renal dysfunction, diabetes insipidus, voluminous watery diarrhea, or severe burns; neonates who were younger than 28 days old or in the NICU.

guideline link

{Treatment guidelines for hyponatremic encephalopathy link }

 

ECMO Resuscitation in Pediatric Cardiac Arrest

Recent evidence in adults found benefit in using Extracorporeal Membrane Resuscitation in OR cardiac arrest in particular from hemorrhage ( link ).

This study in infants and children also found some positive outcomes after in-hospital cardiac arrest.  “About one third of children survived with good neurobehavioral outcome 1 year after receiving extracorporeal cardiopulmonary resuscitation for in-hospital arrest. Open-chest cardiac massage and minimum postarrest lactate were associated with survival with good neurobehavioral outcome at 1 year”.

link

 

Intranasal Pediatric Sedation

Young children undergoing trans-thoracic echocardiography were sedated with intranasal Dexmedetomidine 2mcg/kg plus Ketamine 1mg/kg.  Sedation was successful in 96%, onset being about 16 minutes. Cyanotic heart disease, history of sedation failure, history of congenital heart disease surgery, and fever were independent risk factors for sedation failure. There were no serious adverse cardiorespiratory side effects.

This non-opioid combination was found to be effective with an acceptable safety profile.

link

 

Acupuncture for Post-Operative Nausea and Vomiting

Acupuncture has long been used for nausea and vomiting in different scenarios using the P6 point on the anterior forearm above the wrist. Studies have always been lower quality, with study blinding issues and  sham acupuncture being potentially effective also. A Cochrane review nonetheless concluded it to be comparable  to anti-emetics ( link ).

This latest study finds a significant reduction in nausea (more than vomiting) in the recovery period even when added to anti-emetics. The study was in children 3-9 years of age undergoing adenotonsillectomy. All patients received Ondansetron and Dexamethasone. There was no difference after 24 hours.

P6 acupuncture appears a simple measure without significant side-effects to consider for post-operative nausea and vomiting prevention.

link

 

 

Anesthesia, Surgery and Child Development

The huge area of research into the potential neurotoxicity of anesthetics in Pediatric Anesthesia has yielded reassuring results on the whole but some suggestions that multiple or prolonged anesthesias may be harmful in terms of learning and behavioural issues.

This sibling-controlled cohort study used the Early Development Instrument (EDI) and population-based health and demographic administrative databases to try to account for the many confounding variables in child development, e.g. genetic, perinatal, familial, environmental, social, educational.

The authors found “no differences in the adjusted odds of early developmental vulnerability or performance in any major developmental domain between biological siblings after exposure to surgical procedures that require general anesthesia”. They suggest anesthesia is a marker of vulnerability and does not reflect a causative pathway for adverse child development.

As an observational study, it is not the final word, but its findings are somewhat reassuring. Further study is still important in terms of types and duration of anesthesia not defined here. The advice for now remains the same that needed surgery should not be delayed based on current evidence in Pediatric Anesthesia.

link

 

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.

link