Pediatric Anesthesia

Induction Technique Among Infants and Neonates Undergoing Pyloromyotomy

The decline is Succinylcholine use has been expedited by the arrival of Sugammadex. Succinylcholine is often still preferred where the risk of aspiration is deemed higher.

This study compared rapid sequence induction (RSI) with modified rapid sequence induction (mRSI) in infants.

The conclusion found mRSI acceptable practice: “In infants presenting for pyloromyotomy, anesthetic induction with mRSI compared with RSI was associated with significantly less hypoxemia without an observed increase in aspiration events. In addition, the need for multiple intubation attempts was a strong predictor of hypoxemia. The increased risk of hypoxemia associated with RSI and multiple intubation attempts was even more pronounced in neonatal patients.”

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Assessment of Common Criteria for Awake Extubation in Infants and Young Children

This study assessed the value of commonly used predictors of fitness for extubation in predicting successful extubation following emergence from general anesthesia with a volatile anesthetic in young children.

Their conclusions:

“Conjugate gaze, facial grimace, eye opening, purposeful movement, and tidal volume greater than 5 ml/kg were each individually associated with extubation success in pediatric surgical patients after volatile anesthetic. Further, the use of a multifactorial approach using these predictors, may lead to a more rational and robust approach to successful awake extubation.”

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Spinal anesthesia compared with general anesthesia for neonates with hypertrophic pyloric stenosis

This retrospective study surveyed general vs. spinal anesthesia for infants with pyloric stenosis. While it may not be in the comfort zone for some practitioners, it was shown that it was a viable alternative to general anesthesia, reducing the respiratory morbidity associated with the latter, significantly reducing apneic episodes and desaturation.

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Hypoxemia, Bradycardia, and Multiple Laryngoscopy Attempts during Anesthetic Induction in Infants

This retrospective study is cause for concern in Pediatric and Neonatal Anesthesia.

In a quaternary pediatric academic center, 16% of healthy infants undergoing routine tracheal intubations had multiple laryngoscopies with a 35% hypoxia incidence, and 9% bradycardia incidence.

Multiple laryngoscopies were associated with hypoxia and while this population has airway challenges, there is a need to do better with training and equipment.

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Reducing pain in infants, children, and adolescents

This Cochrane Special Collection highlights the evidence for reducing both chronic and acute pain in infants, children, and adolescents.

Some areas are still devoid of good evidence, but this review includes links to a large number of topics. Chronic pain topics include the use of antidepressants, anti-epileptics, NSAIDS, acetaminophen, and opioids in non-cancer pain. A list of reviews of different opioids for cancer pain is included. Various opioids as well as psychological interventions are surveyed in acute pain management.

The list is comprehensive and full text is available at:

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Thiamine to Treat Persistent Hyperlactatemia in Pediatric Septic Shock

Numerous studies have advocated combinations of Thiamine, Vitamin C and Steroids in septic shock in adults, but randomized studies have yet to convince majority opinion on outcome improvement.

This Pediatric study used Thiamine and reported improvements in Lactate clearance, but again this is a surrogate outcome measure and does not demonstrate mortality improvement, nor does it prove causation. So it re-emphasizes the need for further randomized controlled studies.

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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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