Predictors of paediatric difficult intubation according to the experience of a university hospital in a low- and middle-income country: A prospective observational study.

BACKGROUND: Difficult airway management is one of the main challenges in paediatric anaesthesia, particularly in low- and middle-income countries. AIMS: The aim of this study was to investigate the main predictors of difficult paediatric intubation. METHODS: In this observational study, we included all children aged less than five years undergoing intra-abdominal surgery with endotracheal intubation. Patients were divided into two groups according to the incidence of difficult intubation. Then, we investigated predictors for difficult paediatric intubation. RESULTS: We included 217 children, and difficult intubation was observed in 10% of them. Predictors were as follows: Mallampati III-IV class (adjusted odds ratio = 2.21; 95% confidence interval = 1.1-6.4), limited mouth opening (adjusted odds ratio = 2.4; 95% confidence interval = 1.8-3.5), facial dysmorphia (adjusted odds ratio = 2.6; 95% confidence interval = 1.32-7.4) and anaesthesia without muscle relaxant (adjusted odds ratio = 1.8; 95% confidence interval = 1.0-5.1) or without opioids during crash inductions (adjusted odds ratio = 1.7; 95% confidence interval = 1.01-4.8). CONCLUSION: Facial dysmorphia and limited mouth opening were predictors of difficult intubation in children. Furthermore, it seems that Mallampati class and anaesthesia technique may also predict challenging intubation, which may guide us to change our perioperative practice.

Lateral versus supine position for tracheal extubation among infants after intraabdominal surgery: A randomised controlled trial.

In this prospective randomised controlled trial, we compared the impact of the lateral versus supine position for tracheal extubation among infants aged two months to two years after intraabdominal surgery on the incidence of respiratory adverse events that may occur after extubation. The anaesthesia protocol was standardised. Among the 120 infants included (60 in each group), the demographic and perioperative data were comparable between both groups. The incidence of perioperative respiratory adverse events after tracheal extubation was 21.6% and 5% in the supine and lateral position groups, respectively, with p = 0.007 and odds ratio = 3.87; 95% confidence interval: 1.18-12.6. Lateral position also reduced the incidence of airway obstruction with p = 0.004 and odds ratio = 11.8; 95% confidence interval: 1.46-95.3 and oxygen desaturation below 92% with p = 0.008 and odds ratio = 11.8; 95% confidence interval: 1.46-95. The lateral position seems to be practical and beneficial for tracheal extubation among infants.

Incidence of complications after nonoperating room anesthesia in children in a low- and middle-income country: A prospective and observational study.

INTRODUCTION: Nonoperating room anesthesia is a growing field of medicine that can have an increased risk of complications, particularly in low- and middle-income countries. AIMS: The aim of this study was to describe the incidence of complications after pediatric nonoperating room anesthesia and investigate its risk factors. METHODS: In this prospective observational study, we included all children aged less than 5 years who were sedated or anesthetized in the radiology setting of a university hospital in a low- and middle-income country. Patients were divided into two groups: complications or no-complications groups. Then, we compared both groups, and univariable and multivariable logistic regression models were used to investigate the main risk factors for complications. RESULTS: We included 256 children, and the incidence of complications was 8.6%. The main predictors of nonoperating room anesthesia-related morbidity were: critically-ill children (aOR = 2.490; 95% CI: 1.55-11.21), predicted difficult airway (aOR = 5.704; 95% CI: 1.017-31.98), and organization insufficiencies (aOR = 52.6; 95% CI:4.55-613). The preanesthetic consultation few days before NORA protected against complications (aOR = 0.263; 95%CI: 0.080-0.867). CONCLUSIONS: The incidence of complications during NORA among children in our radiology setting remains high. Investigating predictors for morbidity allowed high-risk patient selection, which allowed taking precautions. Several improvement measures were taken to address the organization's insufficiencies.

Percutaneous infraclavicular subclavian vein catheters in paediatric cancer patients in comparison with critically ill children: a one-year experience from a Tunisian hospital.

BACKGROUND: Paediatric cancer and critically ill patients frequently require central venous catheters for prolonged intravenous therapy. The aim of this study is to compare the difficulty of catheter insertion and the morbidity related to this procedure in these two populations and to investigate risk factors for complications. METHODS: This prospective observational study was conducted at the Hedi Chaker University Hospital in Sfax, Tunisia, from July 2021 to July 2022. We included all patients aged three months to 14 years who required an infraclavicular subclavian vein catheterization. Patients were divided into two groups: Group 1 included children with malignancies; and Group 2 included critically ill paediatric patients. Then, we compared the demographic data, the difficulty of the catheterization procedure, and catheter-related complications. We also investigated risk factors for complications using a logistic regression model. The significance level was P<0.05. RESULTS: We included 65 infants and children requiring central venous access, 28 of whom suffered from malignancies. The demographic parameters were comparable. However, the time for the procedure and the number of attempts were higher in the malignancy group with P<0.001. Central venous catheter complications were present 46.4% of the time in Group 1 compared to 21.6% in Group 2 (P=0.032). Malignancies were associated with an increased risk of complications (aOR = 2.95; 95%CI: 0.63-13.8). CONCLUSIONS: This study showed increased difficulty and higher morbidity related to infraclavicular subclavian vein catheterization among infants and children suffering from cancer.

Early versus late removal of the I-Gel in paediatric patients with mild upper respiratory tract symptoms undergoing ambulatory ilioinguinal surgery: A prospective observational study.

The optimal timing of I-Gel removal in children with mild respiratory symptoms remains controversial. Consequently, we tried to assess the impact of early versus late I-Gel removal on the incidence of perioperative respiratory adverse events among children aged one to five years undergoing ambulatory surgery under general anaesthesia with I-Gel airway ventilation. The anaesthesia protocol was the same for all patients. Children were divided into two groups according to the approach of I-Gel removal (early versus late). The incidence of perioperative respiratory adverse events after the I-Gel removal was the main outcome, and a multivariable regression was performed to investigate the implication of the I-Gel removal in perioperative respiratory adverse events. According to our study, the incidence of perioperative respiratory adverse events was not correlated to the timing of I-Gel removal. However, prolonged postoperative oxygen support can be seen when the I-Gel is removed in anaesthetized children.

Airway management in a rare case of congenital palate teratoma with a cleft palate: A case report.

Airway management in neonates is difficult because of the risk of rapid hypoxia. It presents a challenge even for an experienced anesthesiologist. Oral tumors in neonates can obstruct the airway or feeding problems in the newborn. Surgical excision is the treatment of choice but these tumors can seriously worsen the conditions of intubation. To surmount these difficulties, a particular multidisciplinary approach and special precautions are needed. We describe the airway management and precautions taken in the anesthesia for surgical removal of a case of large congenital palate teratoma associated with a wide cleft palate in a 25-day-old girl. Impossible intubation was predicted on magnetic resonance imaging. The difficult airway management cart as well as an otorhinolaryngologist skilled in performing emergency tracheostomies in neonates were available. The patient was intubated by conventional laryngoscopy under sevoflurane inhalation anesthesia. The tumor was successfully resected. This case poses a challenge for managing the airway because of the possibility of obstruction of the airway and the difficulty of the airway that radiological exams have allowed us. So, a multidisciplinary team effort is needed for successful neonatal airway management.

Management of COVID-19-Associated Guillain-Barré Syndrome in a Full-Term Pregnant Woman: A Case Report.

Guillain-Barré syndrome (GBS) can occur after viral infections. Its occurrence after COVID-19 infection in the peripartum period is a very rare co-occurrence. Therefore, there are no guidelines for the management of these patients. We report the case of a 32-year-old pregnant woman who developed COVID-19-associated GBS with aspiration pneumonia, motor weakness, and ascending paralysis at 39 weeks of gestation. Preoperative plasmatic exchange (plasmapheresis) and oxygen support were very effective and allowed for a rapid recovery within five days. Because of foetal distress during labor, the patient had a caesarean section under spinal anaesthesia with no maternal complications or adverse foetal outcomes.

Spontaneous bladder rupture after non-traumatic vaginal delivery: a rare case report.

Spontaneous bladder rupture (SBR) is a rare condition and often missed diagnosis, especially after a non traumatic vaginal delivery. A 32-year-old para 3 woman, consulted for abdominal pain and anuria two days after instrumental vaginal delivery with forceps for foetal distress in second sate of labour. Blood tests were suggestive of an acute renal failure. An abdominocentesis revealed a clear fluid looking like ascites. The ultrasound and computed tomography (CT) scan showed a large abdominal effusion. An exploratory laparoscopy revealed a bladder perforation which was sutured after laparotomy. SRB is extremely rare after a non traumatic vaginal delivery. It is associated with significant morbidity and mortality. Symptoms are mostly non-specific. It is suspected when post partum abdominal pain is associated with an effusion and renal failure signs. If suspected, the uroscanner remains the gold standard for diagnostic. Laparotomy is the standard surgical approach in this condition. Abdominal pain with elevated serum creatinine should be suspicious of SBR in post-partum.

Predictors of perioperative respiratory adverse events among children with upper respiratory tract infection undergoing pediatric ambulatory ilioinguinal surgery: a prospective observational research.

Objectives: Anesthesia for children with an upper respiratory tract infection (URI) has an increased risk of perioperative respiratory adverse events (PRAEs) that may be predicted according to the COLDS score. The aims of this study were to evaluate the validity of the COLDS score in children undergoing ilioinguinal ambulatory surgery with mild to moderate URI and to investigate new predictors of PRAEs. Methods: This was a prospective observational study including children aged 1-5 years with mild to moderate symptoms of URI who were proposed for ambulatory ilioinguinal surgery. The anesthesia protocol was standardized. Patients were divided into two groups according to the incidence of PRAEs. Multivariate logistic regression was performed to assess predictors for PRAEs. Results: In this observational study, 216 children were included. The incidence of PRAEs was 21%. Predictors of PRAEs were respiratory comorbidities (adjusted OR (aOR)=6.3, 95% CI 1.19 to 33.2; p=0.003), patients postponed before 15 days (aOR=4.3, 95% CI 0.83 to 22.4; p=0.029), passive smoking (aOR=5.31, 95% CI 2.07 to 13.6; p=0.001), and COLDS score of >10 (aOR=3.7, 95% CI 0.2 to 53.4; p=0.036). Conclusions: Even in ambulatory surgery, the COLDS score was effective in predicting the risks of PRAEs. Passive smoking and previous comorbidities were the main predictors of PRAEs in our population. It seems that children with severe URI should be postponed to receive surgery for more than 15 days.

Complications and its risk factors of percutaneous subclavian vein catheters in pediatric patients: enhancing the outcomes of a university hospital in a low-income and middle-income country.

Objective: Assessing central venous catheter-related complications with regular feedback and investigating risk factors are mandatory to enhance outcomes. The aim of this study is to assess our experience in the management of pediatric subclavian vein catheters (SVCs) and to investigate the main risk factors for complications. Methods: In this prospective observational study, we included children aged 3 months to 14 years who underwent infraclavicular subclavian vein catheterization consecutively using the anatomic landmark technique. Patients were divided into two groups: group 1 included complicated catheters and group 2 included non-complicated catheters. The management protocol was standardized for all patients. After comparing the two groups, univariate and multivariate logistic regression were used to investigate the risk factors for complications. Results: In this study, we included 134 pediatric patients. The rate of complications was 32.8%. The main complications were central line-associated bloodstream infection (63.6%), bleeding and/or hematoma (22.7%), mechanical complications (13.6%), and vein thrombosis (13.6%). After adjustment for confounding factors, predictors of catheter-related complications were difficult insertion procedure (adjusted odds ratio (aOR)=9.4; 95% confidential interval (CI): 2.32 to 38.4), thrombocytopenia (aOR=4.43; 95% CI: 1.16 to 16.86), comorbidities (aOR=2.93; 95% CI: 0.58 to 14.7), and neutropenia (aOR=5.45; 95% CI: 2.29 to 13.0). Conclusions: High rates of complications were associated with difficult catheter placement and patients with comorbidities and severe thrombocytopenia. To reduce catheter-related morbidity, we suggest an ultrasound-guided approach, a multidisciplinary teaching program to improve nursing skills, and the use of less invasive devices for patients with cancer.

Risk factors of early mortality after neonatal surgery in Tunisia.

BACKGROUND: Research concerning factors of death after neonatal surgery is scarce. Insight into mortality might improve perioperative care. This study aimed to identify predictive factors of mortality after neonatal surgery in a low income country (LIC). METHODS: Charts of all newborn patients who underwent surgical procedures under general anesthesia during the neonatal period in our department of pediatric surgery between January 2010 and December 2017 were reviewed. We used univariate and multivariate analysis to evaluate perioperative variables potentially predictive of early postoperative mortality. RESULTS: One hundred eighty-two cases were included in the study: 41 newborns (28.6%) were premature (<37 weeks of gestation) and 52 (22.5%) weighed less than 2.5 kg. The most commonly diagnosed conditions were esophageal atresia (24%) and bowel obstruction (19%). Forty-four patients (24%) died during hospitalization. The highest rate of mortality was observed for congenital diaphragmatic hernia. Univariate analysis showed that perinatal predictive variables of mortality were prematurity, low birth weight, the necessity of preoperative intubation, and duration of surgery more than 2 h. Logistic regression showed three independent risk factors, which are the duration of surgery, low birth weight and the necessity of preoperative intubation. CONCLUSION: The overall mortality in infants undergoing neonatal surgery is still high in LICs. Knowledge of independent risk factors of early mortality may help clinicians to more adequately manage the high-risk population. TYPE OF THE STUDY: Clinical research paper. LEVEL OF EVIDENCE: III.

[Reaction to Mohamed Said Nakhli et al. concerning the article: "When the axillary block remains the only alternative in a 5 year old child". The Pan African Medical Journal. 2015;21:36]. / Réaction à Mohamed Said Nakhli et al. à propos de l'article: "Quand le bloc axillaire reste la seule alternative chez un enfant de 5 ans". The Pan African Medical Journal. 2015;21:36.

Axillary block is an easy and recommended technique in children. Its use in children with acute hepatitis A is not risk free especially when associated with sedation using remifentanil and propofol. Similarly, the presence of a single hydatid cyst allows general anesthesia with mono-pulmonary ventilation.

Postoperative analgesia in children when using clonidine in addition to fentanyl with bupivacaine given caudally.

The aim of the study was to evaluate the efficacy of clonidine in association with fentanyl as an additive to bupivacaine 0.25% given via single shot caudal epidural in pediatric patients for postoperative pain relief. In the present prospective randomized double blind study, 40 children of ASA-I-II aged 1-5 years scheduled for infraumblical surgical procedures were randomly allocated to two groups to receive either bupivacaine 0.25% (1 ml/kg) with fentanyl 1 µg/kg and clonidine 1µg/kg (group I) or bupivacaine 0.25% (1 ml/kg) with fentanyl 1 µg/kg (group II). Caudal block was performed after the induction of general anesthesia. Postoperatively patients were observed for analgesia, sedation, hemodynamic parameters, and side effects or complications. Both the groups were similar with respect to patient and various block characteristics. Heart rate and blood pressure were not different in 2 groups. Significantly prolonged duration of post-operative analgesia was observed in group I (P<0.05). Side effects such as respiratory depression, vomiting and bradycardia were similar in both groups. The adjunction of clonidine to fentanyl as additives to bupivacaine in single shot caudal epidural in children may provide better and longer analgesia after infraumblical surgical procedures.

Near-infrared spectrometry in pregnancy: progress and perspectives, a review of literature.

Near-infrared spectroscopy (NIRS) allows continuous noninvasive monitoring of in vivo oxygenation in selected tissues. It has been used primarily as a research tool for several years, but it is seeing wider application in the clinical arena all over the world. It was recently used to monitor brain circulation in cardiac surgery, carotid endarteriectomy, neurosurgery and robotic surgery. According to the few studies used NIRS in pregnancy, it may be helpful to assess the impact of severe forms of preeclampsia on brain circulation, to evaluate the efficacy of different treatments. It may also be used during cesarean section to detect earlier sudden complications. The evaluation of placental function via abdominal maternal approach to detect fetal growth restriction is a new field of application of NIRS.

Subarachnoid morphine versus TAP blocks for enhanced recovery after caesarean section delivery: A randomized controlled trial.

INTRODUCTION: Subarachnoid morphine is widely used for pain relief in enhanced recovery program after cesarean section in spite of its side effects. However, the role of TAP block is still controversial. The aim of our study was to compare the impact of these analgesic techniques (subarachnoid morphine and TAP block) on enhanced recovery after cesarean section. MATERIALS AND METHODS: In this randomized controlled trial, we included patients scheduled for cesarean delivery under spinal anesthesia. Patients were randomized in two groups. Group I: received spinal anesthesia with 100µg of subarachnoid morphine. Group II: received spinal anesthesia without subarachnoid morphine followed by an ultrasound-guided TAP block. We assessed the time required for mobilization, for re-establishment of gastrointestinal transit and for breast-feeding. RESULTS: TAP block allowed earlier postoperative mobilization. Time required for getting up was significantly lower in group II (9.4h versus 6.9h; P=0.024) as well as time required for walking (12.4h versus 7.4h; P=0.001). TAP block allowed earlier re-establishment of gastrointestinal transit (11.2h in group I versus 8.1h in group II; P<0.001). CONCLUSIONS: TAP block seems to be suitable with enhanced recovery programs.

[Kinetics, diagnostic and prognostic value of procalcitonin after cardiac surgery]. / Cinétique et intérêt diagnostique et pronostique de la procalcitonine après chirurgie cardiaque.

Cardiac surgery with cardiopulmonary bypass (CPB) can cause a systemic inflammatory response (SIRS) making difficult the interpretation of inflammatory markers. Procalcitonin (PCT) is a marker of inflammation that appears to be a good early marker of infection after cardiac surgery. To study the kinetics of PCT after cardiac surgery with CPB and to determine its diagnostic and prognostic value. This is a prospective observational study including 40 adult patients consecutively operated for a coronary or valve surgery with CPB, so programmed or semi-urgent. The anesthetic protocol was standardized for all patients. A determination of PCT and CRP was performed before the CEC, at the decision of the CEC (H0), 4 hours after (H4), then H24, H48, H72 and H96. The rate of PCT and CRP increased significantly from the H4 until 4(th) day compared to baseline. (p<0.05). The concentration of PCT increased at the end of CPB, reaching its peak on 1(st) day (0.96±1.00 ng/mL) and then declined rapidly to J2, J3 and J4. CRP showed a slower kinetics with a peak on day 2 (204±81 mg/L) and decreased more slowly. PCT levels showed no significant variation depending on the type of surgery and they were significantly increased in cases of severe SIRS, late postoperative infection and postoperative renal dysfunction (PORD). However, the rates of CRP were not correlated with these complications. According to ROC curve analysis, a threshold value of 0.958 ng/mL PCT measured on the 1(st) day after surgery had a sensitivity of 85% and a specificity of 95% for the prediction of severe SIRS with organ dysfunction. For a threshold of 1.2 ng/mL measured at day 1 postoperatively, the PCT has a sensitivity of 100% and a specificity of 96% for predicting late infection. For a threshold value of 0.475 ng/mL measured at the decision of the CPB, the PCT has a sensitivity of 80% and a specificity of 69% for predicting PORD. PCT levels were correlated with severity scores. They were also correlated with length of stayin ICU. According to ROC curve analysis, a cutoff of 0.737 ng/mL measured at 1(st )postoperative day, the PCT has a sensitivity of 76% and a specificity of 91% for the prediction of an ICU stay of more 3 days with AUC=0.818. The PCT is a marker that has a fast kinetics and can early predict severe SIRS, and late postoperative infection as well as PORD.