Pediatric Anesthesia

Pediatric Regional Anesthesia Complications

A somewhat reassuring study on pediatric anesthesia regional anesthesia that included both peripheral nerve and neuraxial blocks finds: “In a prospective multicenter cohort of more than 100,000 blocks in children, there were no cases of permanent neurologic deficit associated with regional anesthesia. The rate of transient neurologic deficit was low at 2.4 per 10,000, and the incidence of local anesthesia toxicity was also low at 0.76 per 10,000”.

There was only one epidural abscess, and one epidural hematoma in a paravertebral block. Transient neurological deficits did not differ between peripheral and neuraxial blocks. Importantly, no additional risk was observed with placing blocks under general anesthesia.

The most common adverse events were benign catheter-related failures (4%).

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Air vs. Oxygen for category II fetal heart tracings in labor

The entrenched practice of applying oxygen for intrauterine resuscitation with category II fetal heart tracings in labor may be another needless practice. This study found no difference with room air, measuring umbilical artery lactate, as well as no difference in mode of delivery. We avoid neonatal hyperoxia and this may well apply before birth also (as well as a myriad of adult conditions where oxygen should be used only for measured hypoxia).

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Morbidity after Pediatric ARDS

An analysis of pediatric patients following ARDS and mechanical ventilation reveals some important figures.

13% in-hospital mortality.

Discharge to rehabilitation rate was 24.5% and associated with new morbidity.

In survivors to hospital discharge, new morbidity was seen in 23%.

One- and Three-year mortality of survivors was 5.5% and 8% and was associated with baseline Functional Status Scale, immunocompromised status, Pediatric Risk of Mortality III, and organ failures at pediatric acute respiratory distress syndrome onset, but not with pediatric acute respiratory distress syndrome severity.

Survivor morbidity should be an important metric in future studies.

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Inhaled Nitric Oxide and Pediatric ARDS

Inhaled Nitric Oxide has been one of those agents in search of an indication, good in theory but disappointing in terms of hard outcomes. Improved oxygenation is a surrogate outcome. A retrospective cohort study finds: “Treatment with inhaled nitric oxide in pediatric acute respiratory distress syndrome is not associated with improvement in either mortality or ventilator-free days and may be associated with harm”. More prospective trials are needed to confirm whether this is a pointless expensive intervention.

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Neonatal Inguinal Hernia Repair

A study highlights the issues of neonates and respiratory depression or apnea. Careful use and titration of opioids and neuromuscular blocking agents is needed. The issue is more critical in premature and ex-premature infants. Risk factors for increased PACU stay included postmenstrual age <45 weeks, prematurity, general anaesthesia, and postoperative opioid administration (nalbuphine). In contrast, they found that both use of regional anaesthesia alone and the use of intraoperative regional anaesthesia reduced PACU stay.

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Nebulized Dexmedetomidine Sedation

A study compared nebulized Dexmedetomidine 2mcg/kg, Ketamine 2mg/kg and Midazolam 0.2mg/kg for sedation in children 3 – 7 year olds prior to GA for bone marrow aspiration.  “Preschool children premedicated with nebulised dexmedetomidine had more satisfactory sedation, shorter recovery time, and less postoperative agitation than those who received nebulised ketamine or midazolam“.

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Preoperative carbohydrate loading

In addition to more liberal guidelines for clear fluids in recent years, preoperative carbohydrate drinks have become popular and perhaps ahead of the evidence but seem to improve well being, speed of recovery and insulin sensitivity. A Cochrane review ( link ) found positive benefits.

This Pediatric study showed reduced nausea and gastric content (but not vomiting) after gastroscopy under GA with preoperative carbohydrate drinks.

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Cricoid Pressure in PICU

Cricoid Pressure, once a holy grail of emergency intubation, has been increasingly questioned for effectiveness. Inadequate and improper application frequently occurs, as well as interference with ventilation or intubation. It was also removed from the AHA ACLS recommendations during bag and mask ventilation.  This was a retrospective study which found:  “Cricoid pressure during induction and mask ventilation before tracheal intubation in the current ICU practice was not associated with a lower regurgitation rate after adjusting for previously reported confounders. Further studies are needed to determine whether cricoid pressure for specific indication with proper maneuver would be effective in reducing regurgitation events”.

A good example of entrenched dogma meeting evidence based medicine!

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Preterm Oxygen Saturation and Outcome

In this study on extremely preterm infants (less than 28 weeks)  there was no significant difference between a lower Spo2target range of 85-89%  compared with a higher Spo2 target range 91-95% on the primary composite outcome of death or major disability at a corrected age of 18 to 24 months. The lower Spo2 target range was associated with a higher risk of death and necrotizing enterocolitis, but a lower risk of retinopathy of prematurity treatment – but not blindness.  Higher oxygen saturations than 95% are certainly not needed.

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