safety of invasive monitoring in infants and children: Complications of central venous access

In critically ill pediatric patients, central venous access may serve many objectives including the administration of life-saving medications, a secure source of vascular access, and a site for monitoring central venous pressure and obtaining intermittent blood samples. As with any invasive procedure, the risk-benefit ratio must be considered. Although a CVC may be used to provide life-saving therapies, complications and adverse effects may occur. These complications may occur during catheter placement or with its subsequent use. The two factors that have provided the most dramatic impact in decreasing complications include the use of ultrasound for CVC placement and the placement checklist recommended by Dr. Pronovost. Ultrasound has been shown to increase the success rate and decrease the complication rate by helping the clinical avoid inadvertent carotid puncture and excessive depth of needle insertion which may result in pneumothorax. With ongoing use in the ICU setting, a daily reassessment of the need for central venous access should be included into the rounding checklist so that consideration regarding removal of the line is discussed on a daily basis

Sugammadex and fast-track anesthesia for pediatric cardiac surgery in a developing country

Objective: There are several physiologic advantages to early tracheal extubation and spontaneous ventilation following surgery for congenital heart disease [CHD]. In order for early tracheal extubation to be feasible, effective reversal of neuromuscular blockade is mandatory. Sugammadex reverses neuromuscular blockade with a mechanism that differs from acetylcholinesterase inhibitors. We aimed to study the effect of sugammadex on the fast track extubation

Methodology: We retrospectively reviewed our experience with the use of sugammadex to reverse neuromuscular blockade following cardiac surgery for CHD in infants and children, during a pediatric cardiac surgical trip of Heart Care International to Tuxtla, Mexico. Demographic data collected included age, weight, type of CHD, and the surgical procedure. Intraoperative data included sugammadex dose, outcome [successful tracheal extubation], and adverse effects, which could be attributed to sugammadex. Sugammadex was administered to 14 patients, who ranged in age from 1 to 16 years of age and in weight from 7.6 to 57.7 kilograms. Statistical analysis was done

Results: All 14 patients underwent successful tracheal extubation in the operating room within 15 min of completion of the surgical procedure. No patient required reintubation of the trachea during the postoperative course. No adverse effects related to sugammadex were noted

Conclusions: Our preliminary experience demonstrates that sugammadex effectively reverses neuromuscular blockade and allows for early tracheal extubation in pediatric patients following surgery for repair of CHD. Prompt and effective reversal of neuromuscular blockade allows for effective fasttracking with early tracheal extubation

Perioperative management of a patient with glutaric aciduria: a case report and literature review

Glutaric aciduria type-1 [GA-1] is an autosomal recessive metabolic disorder due to the deficiency of the enzyme glutaryl-CoA dehydrogenase. The enzymatic defect leads to secondary damage to the central nervous system due to the accumulation of glutaric acid. Progressive neurologic effects with spasticity and orthopedic deformities necessitate frequent surgical and anesthetic care. We present a 13-year-old girl with glutaric academia type-1 who required anesthetic care for posterior spinal fusion. Previous reports of anesthetic care for these patients are reviewed, the end-organ involvement discussed, and options for anesthetic care presented

Dye extravasation during radiography for branchial cleft sinus compromising airway in an infant

Branchial cleft anomalies are common congenital head and neck lesions in the pediatric population. Their close proximity to laryngeal structures may lead to airway complications during the diagnosis and management of the lesion. We present an unusual cause of airway compromise secondary to dye extravasation during an interventional radiology procedure for evaluation of a branchial cleft sinus. The diagnosis and treatment of branchial cleft anomalies are reviewed and options presented for the management of airway compromise related to interventions for these anomalies

Caudal epidural blockade for major orthopedic hip surgery in adolescents

There continues to be a significant focus on the value of regional and neuraxial anesthesia techniques for adjunctive use when combined with general anesthesia. The reported advantages include decreased patient opiate exposure, decreased medication-related adverse effects, decreased postanesthesia recovery room time and hospital stay, and increased patient satisfaction. The authors present a case-controlled series evaluating the use of a single caudal epidural injection prior to incision as an adjunct to general anesthesia for the open repair of slipped capital femoral epiphysis. Opiate consumption, pain scores, and hospital stay were compared between the two cohorts of 16 adolescent patients. All patients received a demand-only patient-controlled opiate delivery system. Although the failed block rate was high [31%], there was decreased opioid use in the perioperative arena as well as during the first 24 postoperative hours in patients who had a successful caudal epidural block. Furthermore, discharge home was possible in 27% of patients who received a caudal epidural block compared to 0% of patients who did not receive a caudal block. The potential utility of caudal epidural block as an adjunct to general anesthesia during major hip surgery in adolescents is presented. Factors resulting in a failed block in this patient population as well as the use of the ultrasound as an added modality to increase block success are reviewed

proactive risk assessment by utilizing 'Healthcare Failure Mode and Effect Analysis' [HFMEA] for safe implementation of peripheral nerve catheters in pediatric patients

In 2011, Nationwide Children's Hospital began using peripheral nerve catheters [PNC] to provide postoperative analgesia to patients undergoing select orthopedic and abdominal surgeries. While PNCs provide a significant improvement in the quality of care that our patients receive, introducing this new technology and process within our hospital presents an inherent risk. In order to assure that our patients received the safest care, we assembled a multi-disciplinary team to complete a proactive risk assessment by utili2ing Healthcare Failure Mode and Effect Analysis [HFMEA]. HFMEA was designed by the VA National Center for Patient Safety to identify potential failure modes within systems, and to study the consequences the failure modes have on customers. The result of this process identified and evaluated 96 failure modes and therefore 19 specific interventions were developed and deployed. The HFMEA process gives us confidence that new pain management techniques and tfieir related processes can be safely and effectively implemented in order to provide the safest and highest quality care to our patients

Peripheral regional anesthesia in infants and children: an update

Peripheral regional anesthesia in children has had a recent surge in popularity among pediatric anesthesia providers. The increased prevalence is at least in part explained by the proliferation of ultrasonography in the perioperative arena. Ultrasound-guided peripheral nerve block techniques have given pediatric anesthesiologists confidence to approach the diminutive structures that are in close approximation to sensitive areas. The three major categories of pediatric peripheral nerve blocks are upper extremity, truncal, and lower extremity. The indications, ultrasound anatomy, ultrasound-guided technique, and potential complications of the nerve blocks in each category are reviewed

An update on airway management in infants and children

'Anesthesia is nothing, but airway management' or 'Anesthesia is nothing without airway management', perhaps both are true. Airway anatomy and physiology in infants and small children differs markedly from the adults, and so are the problems associated with it. We have to adopt protocols, methods and techniques, specifically for this population. This special article is an overview of the current trends with a special reference to the future perspective in infant and pediatric airway management

retrospective review of interscalene nerve blockade for shoulder surgery in the pediatric population

To retrospectively investigate the efficacy of interscalene nerve blockade in reducing postoperative pain and minimizing inpatient hospital admission after shoulder surgery in the pediatric population. Thirty-four consecutive patients undergoing shoulder surgery under general anesthesia both with and without the addition of an interscalene nerve block were included in the study. After induction of general anesthesia, those patients receiving regional anesthesia had an interscalene nerve block placed using real-time ultrasonographic guidance with the deposition of 20-30 mL of local anesthetic solution into the interscalene groove. Postoperative pain scores, the use of supplemental analgesic medications, post-anesthesia care unit [PACU] length of stay, hospital course, and any acute or non-acute complications were recorded and evaluated. There were no cardiac events, neuropathies, seizures, pneumothoraoes, or other major complications. There was a statistically significant reduction in the pain scores in patients who received an interscalene nerve block versus those who did not. There was also a significant difference found in the need for postoperative inpatient hospital admission. Eleven of the 14 patients [79%] who received a combined general and regional anesthetic technique were discharged home on the day of surgery versus 9 of 20 patients [45%] who did not receive an interscalene block [p = 0.036]. Postoperative opioid requirements were significantly reduced in patients receiving an interscalene block within the first six hours of inpatient hospital admission [p = 0.035]. There was no difference in PACU length of stay or adverse effects [postoperative nausea and vomiting] between the groups. Interscalene nerve block offers a safe and effective method of providing superior postoperative analgesia and minimizing inpatient hospital admissions in pediatric patients undergoing shoulder surgery

Neonatal resuscitation: an update

International guidelines on neonatal resuscitation were published in 2010 based on the best availabl evidence. While many of these guidelines remain unchanged, subtle refinements have evolved with recent evidence. The aim of this review is to distill these recommendations, to provide updates wher appropriate, and to condense them into a framework that is useful for the clinician. Birth depressioi is a common event, caused by both maternal and neonatal conditions. Prompt initiation of the moj appropriate support is essential for achieving best outcomes. While ventilation of the small airways i the most important intervention in the neonatal resuscitation algorithm, progression to the next ste is based on the simultaneous assessment of both heart rate and respirations. Serial clinical assessmer of the response to interventions is fundamental to a successful resuscitation. Pulse oximetry should b used for assessing oxygenation when resuscitation is required. And generally speaking, term and neaj term infants should be resuscitated using room air, while preterm infants should be resuscitated with the lowest concentration of oxygen needed to maintain normal oxygen saturations. Decisions regardin respiratory support should be individualized, but the lowest peak inspiratory pressure needed to achie clinical improvement is advocated in neonatal resuscitation. The use of end-expiratory pressure reduce the need for invasive respiratory support, and support of spontaneous respirations with continuoi positive airway pressure [CPAP] has been shown to result in improved long-term outcomes in pretem but not term infants. Finally, circulatory support is rarely indicated in neonatal resuscitation scenario but is recommended in circumstances of presumed volume loss, persistent or prolonged bradycardia, or a persistent, suboptimal response to resuscitative efforts

Perioperative care of an adolescent with Charcot-Marie-Tooth disease with placement of a caudal epidural catheter as an adjunct to general anesthesia

First described in 1886, Charcot-Marie-Tooth [CMT] disease is an inherited peripheral neuropathy which was originally termed peroneal progressive muscular atrophy. Given the invariable involvement of the neuromuscular system, anesthetic care is frequently required during surgical procedures aimed at correcting the orthopedic sequelae of the disorder. The authors present a 13-year-old boy with CMT who presented for anesthetic care during triple arthrodesis to treat pes cavus deformity of the foot. The perioperative considerations of patients with CMT are discussed with particular emphasis on the feasibility and safety of using regional anesthetic techniques

Caudal epidural blockade in adolescents

Various options are available for the provision of analgesia following major surgical procedures including systemic opioids and regional anesthetic techniques. Regional anesthetic techniques offer the advantage of providing analgesia while avoiding the deleterious adverse effects associated with opioids including nausea, vomiting, sedation and respiratory depression. Although used commonly in infants and children, there is a paucity of experience with the use of caudal epidural blockade in adolescents. We retrospectively reviewed the perioperative care of adolescents undergoing major urologic or orthopedic surgical procedures for whom a caudal epidural block was placed for postoperative analgesia. The cohort for the study included 5 adolescents, ranging in age from 13 to 18 years and in weight from 42 to 71 kilograms. Caudal epidural analgesia was accomplished after the induction of anesthesia and prior to the start of the surgical procedure using 20-25 mL of either 0.25% bupivacaine or 0.2% ropivacaine with clonidine [1 micro g/kg]. The patients denied pain the recovery room. The time to first request for analgesia varied from 12 to 18 hours with the patients requiring 1-3 doses of analgesic agents during the initial 24 postoperative hours. Our preliminary experience demonstrates the efficacy of caudal epidural block in providing analgesia following major urologic and orthopedic surgical procedures. The applications of this technique as a means of providing postoperative analgesia are discussed

Medication errors: a matter of serious concern

The incidence of medications errors is increasing and the exact incidence is likely greatly underestimated and under-reported. Although the majority of these errors occur due to lack of knowledge of or failure to follow accepted protocols, look alike medication containers are the primary cause in many cases of drug error related morbidity or even mortality. With the number of drugs and the number of pharmaceutical companies manufacturing the same drug on an increase, the incidence is likely to increase. It is a universal problem that can be found in any operating room throughout the world, as demonstrated by the multi-national representation of many reports on this subject in the literature. This editorial supplements a case report, the 'Clinipics' Registered page and a special article on the topic of hazards of look-alike drug containers published in this issue of Anaesthsia, Pain and Intensive Care. The authors also attempt to present strategies to reduce these medication errors. The development of a non-blame environment where errors are openly reported and discussed and regulations for labeling the drug containers, vials and ampoules is stressed

Dexmedetomidine and the perioperative care in Riley-Day syndrome: a case report and literature review

Familial dysautonomia [FD], also known as Riley-Day syndrome, is a disorder of the autonomic nervous system that results in loss of demyelinated nerve fibers of sensory, sympathetic and parasympathetic neurons. Individuals with FD have variable clinical symptoms that may include insensitivity to pain, inability to produce tears, poor oral intake during infancy, repeated vomiting, failure to thrive, wide fluctuations in body temperature, and episodic hypertension and hypotension. These paroxysmal crises are due to dysfunction of the autonomic system with an elevation of both norepinephrine and dopamine levels. Clonidine, an alpha 2-adrenergic agonist, has been previously demonstrated to be an effective pharmacological agent in the treatment of dysautonomic crises related to FD. Dexmedetomidine is an alpha 2-adrenergic agonist with an alpha 2:alpha 1 specificity that is almost 8 times that of clonidine. The authors present the perioperative use of dexmedetomidine in a patient with FD. Previous reports of the use of dexmedetomidine in patients with FD are reviewed and the beneficial physiologic effects discussed

Dexmedetomidine and ketamine sedation for a patient with presumed mitochondrial disease and malignant hyperthermia

Mitochondrial disorders and malignant hyperthermia are two co-morbid conditions which present their own anesthetic difficulties. However, the combination of both pathologies in one patient presents a particularly unique problem with regards to anesthetic management and perioperative care. We present the case of a 20-year-old with both a mitochondrial disorder and malignant hyperthermia history. The perioperative implications of these disorders are discussed and options for anesthetic care reviewed

Monitored anesthesia care with dexmedetomidine and remifentanil during cardiac catheterization in a patient with Duchenne muscular dystrophy and malignant hyperthermia susceptibility

Sedation during invasive procedures is frequently required not only to provide appropriate humanitarian care, but also to facilitate the completion of invasive procedures. Although the current sedative agents are generally safe and effective, adverse effects may occur especially in patients with co-morbid diseases. We present the successful use of a combination of dexmedetomidine and remifentanil to provide sedation [monitored anesthesia care] during cardiac catheterization and coronary angiography in an 11 years old patient with Duchenne muscular dystrophy. Co-morbid conditions included depressed myocardial function, a recent concern of coronary artery insufficiency, a family history of malignant hyperthermia, and impaired respiratory function. Dexmedetomidine was administered as an infusion starting at 0.7 [ig/ kg/hour without a loading dose, while remifentanil was administered as an infusion of 0.1 microg/kg/min. There was no patient response to local infiltration of the groin or placement of the arterial catheter for coronary angiography. The patient tolerated the procedure well without adverse effects. The combination of dexmedetomidine and remifentanil for monitored anesthesia care in the pediatric patient is discussed and the potential efficacy of this combination for procedural sedation is reviewed

Extracorporeal life support for acute respiratory distress syndrome

The morbidity and mortality of acute respiratory distress syndrome remain to be high. Over the last 50 years, the clinical management of these patients has undergone vast changes. Significant improvement in the care of these patients involves the development of mechanical ventilation strategies, but the benefits of these strategies remain controversial. With a growing trend of extracorporeal support for critically ill patients, we provide a historical review of extracorporeal membrane oxygenation [ECMO] including its failures and successes as well as discussing extracorporeal devices now available or nearly accessible while examining current clinical indications and trends of ECMO in respiratory failure

Perioperative care of a patient with neuronal ceroid lipofuscinoses

The neuronal ceroid lipofuscinoses [NCL] are a group of inherited, autosomal recessive, and progressive neurodegenerative diseases, which result from an enzymatic defect or the deficiency of a transmembrane protein, leading to the accumulation of lipopigments [lipofuscin] in various tissues. NCL results in the impairment of function in several end-organs including the central nervous system with loss of cognitive and motor function, myoclonus, and intractable seizures. Additional involvement includes the cardiovascular system with arrhythmias and bradycardia as well as impairment of thermoregulation leading to perioperative hypothermia. Given the complexity of the end-organ involvement and the progressive nature of the disorder, the anesthetic care of such patients can be challenging. Till date, there are a limited number of reports regarding the anesthetic management of patients with NCL. We present an 18-year-old patient with NCL who required anesthetic care during replacement of a vagal nerve stimulator. Previous reports of anesthetic care for these patients are reviewed, the end-organ involvement of NCL discussed, and options for anesthetic care presented