Pediatric Anesthesia

Pressure Controlled Ventilation for Pediatric Facemask

From an early view study in Pediatric Anesthesia: At an inspiratory pressure of 13 cmH2O, pressure‐controlled ventilation may be more effective than manual ventilation in preventing gastric insufflation while providing stable ventilation in children.

This is also a useful maneuver to free both hands to maintain a patent airway without needing another staff member to squeeze the breathing bag, and could usefully be further studied in adults in difficult mask-ventilation scenarios. Modern anesthesia machines provide such modes as Pressure Control and Pressure Control-Volume Guaranteed.

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Clear Fluid Fasting in Elective Pediatric Anesthesia

The European Society of Anaesthesiology endorses 1 hour clear fluid fasting for elective pediatric anesthesia. It joins previous consensus statements from the Association of Paediatric Anaesthetists of Great Britain and Ireland, the European Society for Paediatric Anaesthesiology, and L’Association Des Anesthésistes‐Réanimateurs Pédiatriques d’Expression Française ( link ).

Unless, as always, there is a clear contraindication!

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Hydrocortisone and Bronchopulmonary Dysplasia

Concern regarding the longer term effects of Dexamethasone for bronchopulmonary dysplasia in premature infants despite its efficacy in reducing mortality. This has led to Hydrocortisone being used instead.

This randomized trial does not support that practice, showing no difference from placebo. “These findings do not support the practice of initiating hydrocortisone between 7 and 14 days after birth to reduce the risk of the composite outcome of death or bronchopulmonary dysplasia in mechanically ventilated very preterm infants“.

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Low flow Sevoflurane Pediatric Induction

A study supports reducing fresh gas flow to 1L/min after priming with 8% Sevoflurane for 30secs at 6L/min in pediatric inhalational anesthesia induction.

Despite the tendency to maximize gas flow for a presumably faster induction, it was found that anesthesia induction at low‐fresh gas flow using a circle system significantly reduces sevoflurane consumption, without compromising the quality of induction or increasing induction time.

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Oliguria and Acute Renal Injury in Pediatric Critical Care

Post hoc analysis of Assessment of Worldwide Acute Kidney Injury, Renal Angina, and Epidemiology study: it draws attention to the fact that oliguria is as or more important than Creatinine. It concluded: “Nearly one in five critically ill children with acute kidney injury do not experience increase in serum creatinine. These acute kidney injury events, which are only identified by urine output criteria, are associated with comparably poor outcomes as those diagnosed by changes in creatinine. Children meeting both criteria had worse outcomes than those meeting only one”.

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Epidural Analgesia for Pediatric Thoraco-Lumbar Spine Surgery

This Cochrane review compared postoperative systemic analgesia with epidural analgesia for spine surgery in children and adolescents.

They found a small advantage in that there is moderate‐ and low‐quality evidence that there may be a small additional reduction in pain up to 72 hours after surgery with epidural analgesia compared with systemic analgesia.

The findings are somewhat underwhelming but there may be an added advantage in earlier return of bowel function. No meaningful data on time to ambulation or length of stay is provided. Patients were more satisfied with epidurals.

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Hypertonic Saline and ICP in Pediatric Head Trauma

Hypertonic saline has become favoured by many centres rather than mannitol for raised intracranial pressure reduction. Some evidence suggests continuous infusion may be more effective. It is however unclear if head injury outcomes are improved.

This pediatric chart review study showed that use of 23.4% hypertonic saline with children admitted for severe traumatic brain injury is associated with a statistically significant decrease in intracranial pressure within 1 hour of use. A randomized study is needed to ascertain how outcome may be improved.

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Platelet-Transfusion Thresholds in Neonates

In preterm (<34 weeks) infants with severe thrombocytopenia, two thresholds for platelet transfusion were compared. Those randomly assigned to receive platelet transfusions at a platelet-count threshold of 50,000 per cubic millimeter had a significantly higher rate of death or major bleeding within 28 days compared to 25,000 per cubic millimeter. The accompanying New England journal editorial puts it: less is more.

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High Volume Fluid and Pediatric Colectomy Outcome

Restrictive fluid administration has become the standard of care in major abdominal surgery in adults as part of ERAS (enhanced recovery); the RELIEF trial sounded the only caution in terms of renal risk ( link ).

This pediatric paper extends the doctrine in that high volume fluids were associated with increased length of stay, longer time to first meal, and longer need for supplemental oxygen.

The conclusion is that high volume fluid administration during colectomy for pediatric patients is associated with worsened postoperative outcomes suggestive of impaired recovery.

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Intranasal Ketamine for Extremity Injuries in Children

A small non-inferiority study on children aged 8- 17 with extremity injuries (mostly fractures) compared intranasal Ketamine 1.5 mg/kg with Fentanyl 2 mcg/kg.

Ketamine produced effective analgesia that was non-inferior to Fentanyl, but did have more what are characterized as minor side effects, eg. dizziness or somnolence; these were short-lived. No serious adverse events, such as respiratory or hemodynamic, occurred.

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