Evolving outcomes of surgery for retinal detachment in retinopathy of prematurity: the need for a national service in the United Kingdom : An audit of surgery for acute tractional retinal detachment complicating ROP in the UK.

OBJECTIVES: To audit the structural and functional outcomes of surgery for acute tractional retinal detachment due to retinopathy or prematurity between 2004 and 2014 in Oxford UK. METHODS: Consecutive operations were identified from a surgical log. Clinical data including demography, perioperative data, and retinal outcomes were extracted into a spreadsheet and compared against two international data sets referenced in the method section. Nonparametric tests (Fisher's exact, and the Mann-Whitney U-tests) were used for statistical analysis with a p-value < 0.05 considered significant. RESULTS: Twenty-nine eyes of 19 babies underwent surgery. The mean age (SD) at final follow-up was 6.4 (3.7) years of age and comparable to the reference data sets. The mean birth weight and gestational age of babies matched the ETROP data set referenced in the method section. Anatomical success was obtained in 16/29 (55.2%) of eyes and more likely with stage 4 ROP than stage 5 disease (p < 0.05). Thirteen of 29 eyes (44.8%) obtained form vision post-operatively. All instances of macular retinal reattachment during follow up were verified with post-operative OCT. CONCLUSIONS: Surgery for stage 5 ROP is not worthwhile. For stage 4 ROP it yielded better visual outcomes than ETROP but registration for visual impairment was not prevented. Innovation such as endoscopic vitrectomy could yield better outcomes. Earlier detection of vitreoretinal fibrosis could result in timelier referral. A formally funded national service is needed to ring-fence resource to avoid delays in access to surgery, which has a narrow surgical window.

A clinical evaluation of the I-gel ™ supraglottic airway device in children.

BACKGROUND: The i-gel(TM) is one of the latest commercially available, second-generation supraglottic airway devices (SADs). Specific features include a distal cuff made of a thermoplastic elastomer gel that does not require inflation and a gastric side channel to allow passage of a gastric tube, venting of gas from the stomach, and an early indication of regurgitation. Previous studies in older children and adults have shown that it is a reliable, efficient, and safe device for airway management. METHODS: We evaluated the i-gel(TM) in sizes ranging from 1 to 2.5 in children considered suitable for a supraglottic device. We assessed successful rates of insertion, airway leak pressure, position confirmed by fiberoptic laryngoscopy, gastric tube placement, manipulations required, and complications. RESULTS: The i-gel(TM) was used in 154 children over a period of 12 months. The median age [interquartile range (IQR)] was 4 years 11 months (2-7 years), median weight (IQR) 19 kg (13-26), and median (IQR) duration of procedure 29 (30-45) min. First insertion attempt was successful in 93.5% of patients, and second attempt in 5.8%. The median (IQR) time to insertion was 14 (13-16) s. The median (IQR) leak pressure was 20 (15-25) cmH(2) 0. Gastric tube placement was successful in 90% of cases. On fiberoptic examination, the vocal cords were visible in 97% of patients. Complications arose in 20% of patients, but the majority were minor. Anesthetists commented that the device had a tendency to displace upward out of the mouth and that extension toward the forehead and flexion toward the feet of the proximal tube altered the quality of the airway. Overall, in seven (4.5%) patients, the device was abandoned and an alternative airway was used. CONCLUSIONS: Pediatric i-gel(TM) sizes 1.5-2.5 provided a satisfactory airway during anesthesia for spontaneously breathing infants and children. However, to ensure a clear airway, considerable vigilance is required when fixing the device in the mouth and to avoid the negative effects of flexion of the proximal tubing. The i-gel(TM) is more expensive than first-generation devices. Whether this additional cost for the potential benefit of greater airway protection is considered acceptable will depend on longer-time evaluation and surveillance to establish overall safety.

A survey of pediatric caudal extradural anesthesia practice.

BACKGROUND: Caudal extradural blockade is one of the most commonly performed procedures in pediatric anesthesia. However, there is little information available on variations in clinical practice. OBJECTIVES: To perform a survey of members of the Association of Paediatric Anaesthetists of Great Britain and Ireland who undertake caudal anesthesia. METHODS: An 'online' World Wide Web questionnaire collected information on various aspects of clinical practice. The survey ran from April to June 2008. RESULTS: There were 366 questionnaires completed. The majority of respondents had >5 years of pediatric experience and performed up to ten caudal extradural procedures a month. The commonest device used was a cannula (69.7%) with 68.6% using a 22G device. There was a trend toward the use of a cannula in those anesthetists with <15 years experience, while those with >15 years experience tended to use a needle. Most anesthetists (91.5%) did not believe that there was a significant risk of implantation of dermoid tissue into the caudal extradural space. The majority used a combination of clinical methods to confirm correct placement. Only 27 respondents used ultrasound. The most popular local anesthetics were bupivacaine (43.4%) and levobupivacaine (41.7%). The most common additives were clonidine (42.3%) and ketamine (37.5%). The caudal catheter technique was used by 43.6%. Most anesthetists (74%) wear gloves for a single shot caudal injection. CONCLUSIONS: This survey provides a snapshot of current practice and acts a useful reference for the development of enhanced techniques and new equipment in the future.