The Incidence of Residual Neuromuscular Block in Pediatrics: A Prospective, Pragmatic, Multi-institutional Cohort Study.

Introduction Residual neuromuscular block, defined as a quantitatively measured train-of-four ratio (TOFr) <0.9, is common postoperatively. Using a pragmatic trial design, we hypothesized that qualitative and/or clinical assessment of neuromuscular block would inadequately detect residual block following antagonism with neostigmine or sugammadex. Method After IRB approval and written informed consent, 74 children (aged 2-17 years), undergoing elective surgery and receiving rocuronium, were prospectively enrolled in the study at Children's Hospital Colorado and Children's Healthcare of Atlanta. Routine clinical practice at both institutions consisted of clinical signs and/or qualitative assessment with peripheral nerve stimulators. Children at the Colorado hospital routinely received sugammadex antagonism; whereas children at the Atlanta hospital received neostigmine. Residual neuromuscular block was assessed postoperatively using quantitative electromyography. If TOFr was <0.9, patients received sugammadex until TOFr ≥0.9. Result Qualitative and clinical assessment failed to detect residual block in 29.7% of patients in the neostigmine reversal cohort (adjusted odds ratio (aOR) 29.8, 95% confidence interval (CI): 2.7 to 5,559.5, p-value = 0.002). No residual block was detected in the sugammadex reversal cohort. A correlation between increasing patient weight and incidence of postoperative residual block was observed in the neostigmine cohort (aOR 1.05, 95% CI: 1.02 to 1.10, p-value = 0.002). Conclusion Qualitative and/or clinical assessment of neuromuscular block inadequately detects residual block following neostigmine antagonism.

Utilization of immediate extubation in a multidisciplinary pathway for pediatric liver transplantation associated with improved postoperative outcomes.

BACKGROUND: Immediate extubation is becoming more common in liver transplantation. However, limited data exist on how to identify pediatric patients with potential for successful immediate extubation and how this intervention may affect recovery. METHODS: This retrospective review evaluated patients who underwent liver transplantation from 2015 to 2021 at Children's Healthcare of Atlanta. Preoperative status and intraoperative management were evaluated and compared. Outcomes comprised thrombosis, surgical reexploration, retransplantation, as well as reintubation, high flow nasal cannula (HFNC) usage, postoperative infection, the length of stay (LOS), and mortality. RESULTS: A total of 173 patients were analyzed, with 121 patients (69.9%) extubated immediately. The extubation group had older age (median 4.0 vs 1.25 years, p = .048), lower PELD/MELD (28 vs. 34, p = .03), decreased transfusion (10.2 vs. 41.7 mL/kg, p < .001), shorter surgical time (332 vs. 392 min, p < .001), and primary abdominal closure (81% vs. 40.4%, p < .001). Immediate extubation was associated with decreased HFNC (0.21 vs. 0.71 days, p = .02), postoperative infection (9.9% vs. 26.9%, p = .007), mortality (0% vs. 5.8%, p = .036), and pediatric intensive care unit LOS (4.7 vs. 11.4 days, p < .001). The complication rate was lower in the extubation group (24.8% vs. 36.5%), but not statistically significant. CONCLUSIONS: Approximately 70% of patients were able to be successfully extubated immediately, with only 2.5% requiring reintubation. Those immediately extubated had decreased need for HFNC, lower infection rates, shorter LOS, and decreased mortality. Our results show that with proper patient selection and a multidisciplinary approach, immediate extubation allows for improved recovery without increased respiratory complications after pediatric liver transplantation.

Neurotoxic Impact of Individual Anesthetic Agents on the Developing Brain.

Concerns about the safety of anesthetic agents in children arose after animal studies revealed disruptions in neurodevelopment after exposure to commonly used anesthetic drugs. These animal studies revealed that volatile inhalational agents, propofol, ketamine, and thiopental may have detrimental effects on neurodevelopment and cognitive function, but dexmedetomidine and xenon have been shown to have neuroprotective properties. The neurocognitive effects of benzodiazepines have not been extensively studied, so their effects on neurodevelopment are undetermined. However, experimental animal models may not truly represent the pathophysiological processes in children. Multiple landmark studies, including the MASK, PANDA, and GAS studies have provided reassurance that brief exposure to anesthesia is not associated with adverse neurocognitive outcomes in infants and children, regardless of the type of anesthetic agent used.

The Development of an Enhanced Recovery Protocol for Kasai Portoenterostomy.

Balancing post-operative adequate pain control, respiratory depression, and return of bowel function can be particularly challenging in infants receiving the Kasai procedure (hepatoportoenterostomy). We performed a retrospective chart review of all patients who underwent the Kasai procedure from a single surgeon at Children's Healthcare of Atlanta from 1 January 2018, to 1 September 2022. 12 patients received the Kasai procedure within the study period. Average weight was 4.47 kg and average age was 7.4 weeks. Most patients received multimodal pain management including dexmedetomidine and/or ketorolac along with intravenous opioids. A balance of colloid and crystalloids were used for all patients; 57% received blood products as well. All patients were extubated in the OR and transferred to the general surgical floor without complications. Return of bowel function occurred in all patients by POD2, and enteral feeds were started by POD3. One patient had a presumed opioid overdose while admitted requiring a rapid response and brief oxygen supplementation. Simultaneously optimizing pain control, respiratory safety, and bowel function is possible in infants receiving the Kasai procedure. Based on our experience and the current pediatric literature, we propose an enhanced recovery protocol to improve patient outcomes in this fragile population. Larger, prospective studies implementing an enhanced recovery protocol in the Kasai population are required for stronger evidence and recommendations.

Anesthetic Management of a Patient With S-Adenosylhomocysteine Hydrolase Deficiency: A Case Report.

S-adenosylhomocysteine hydrolase (AHCY) deficiency is a rare congenital disorder in methionine metabolism with minimal guidelines regarding anesthetic management. This case report describes a 19-year-old man presenting for a liver biopsy in interventional radiology due to a history of elevated aminotransferases and creatine kinase. He received dextrose-containing fluids and a total intravenous anesthetic to avoid rhabdomyolysis and hyperkalemia. Anesthetic goals for patients with AHCY deficiency should focus on avoiding rhabdomyolysis, minimizing postoperative ventilatory compromise, monitoring for potential coagulopathy, and providing anxiolysis.

Hypoglossal Nerve Stimulator Placement for Pediatric Trisomy 21 Patients with Refractory Obstructive Sleep Apnea: A Case Series.

BACKGROUND: Hypoglossal nerve stimulators (HNS) are an increasingly popular form of upper airway stimulation for obstructive sleep apnea (OSA) in adults who are unable to tolerate positive pressure treatment. However, HNS use is currently limited in the pediatric population. CASE PRESENTATION: We present a case series detailing the anesthetic management of three pediatric trisomy 21 patients receiving HNS for refractory obstructive sleep apnea. The patients tolerated the procedure well and experienced no complications. The average obstructive apnea-hypopnea index (AHI) change was 87.4% with the HNS. CONCLUSIONS: Proper anxiolysis, safe and controlled induction, multimodal analgesia, and minimization of post-operative respiratory compromise are all necessary to ensure anesthetic and surgical success. After a tailored anesthetic regimen, proper device placement and close follow-up, our patients had a marked improvement in obstructive symptoms.

Intraoperative Multipoint Acupuncture for Reducing Postoperative Nausea and Vomiting in High-Risk Children: A Case Series.

Acupuncture studies have demonstrated varying effects on pediatric postoperative nausea and vomiting (PONV). Unanswered questions include whether the type of therapy, number of points used, or timing of treatments vary the effect of acupuncture. We present a case series of intraoperative multipoint acupuncture treatments for high-risk pediatric patients. Fourteen patients were included, and 19 treatments were provided. Twelve patients (85.7%) had previous PONV. Patients who received intraoperative acupunctur e reported no early phase PONV, and 3 patients (15.8%) reported late-phase PONV. One patient required postoperative antiemetics. Intraoperative multipoint acupuncture may be a safe and efficacious adjunct for PONV in high-risk pediatric patients.

A Narrative Review: Actigraphy as an Objective Assessment of Perioperative Sleep and Activity in Pediatric Patients.

Sleep is an important component of pediatric health and is crucial for cognitive development. Actigraphy is a validated, objective tool to capture sleep and movement data that is increasingly being used in the perioperative context. The aim of this review is to present recent pediatric studies that utilized actigraphy in the perioperative period, highlight gaps in the literature, and provide recommendations for future research. A literature search was completed using OVID and PubMed databases and articles were selected for inclusion based on relevance to the topic. The literature search resulted in 13 papers that utilized actigraphic measures. Results of the review demonstrated that actigraphy has been used to identify predictors and risk factors for poor postoperative sleep, examine associations among perioperative pain and sleep patterns, and assess activity and energy expenditure in both inpatient and outpatient settings. We propose expansion of actigraphy research to include assessment of sleep via actigraphy to: predict functional recovery in pediatric populations, to study postoperative sleep in high-risk pediatric patients, to test the efficacy of perioperative interventions, and to assess outcomes in special populations for which self-report data on sleep and activity is difficult to obtain.

Recent trends in airway management.

Tracheal intubation remains a life-saving procedure that is typically not difficult for experienced providers in routine conditions. Unfortunately, difficult intubation remains challenging to predict and intubation conditions may make the event life threatening. Recent technological advances aim to further improve the ease, speed, safety, and success of intubation but have not been fully investigated. Video laryngoscopy, though proven effective in the difficult airway, may result in different intubation success rates in various settings and in different providers' hands. The rescue surgical airway remains a rarely used but critical skill, and research continues to investigate optimal techniques. This review highlights some of the new thoughts and research on these important topics.

Status Asthmaticus and Central Herniation: A Case for Multidisciplinary Critical Care.

A 24-year-old woman with history of asthma was intubated emergently for acute status asthmaticus triggered by acute respiratory syncytial virus infection and treated with permissive hypercapnia. Her ventilation was complicated by auto-positive end-expiratory pressure and elevated peak airway, plateau, and central venous pressures. On hospital day 2, she was noted to have anisocoria. Imaging showed diffuse cerebral edema with central herniation. Difficult ventilation and hypercapnia directly contributed to her severe cerebral edema. Comanagement between neurologic and medical/pulmonary intensivists enabled the management of the competing treatment requirements for status asthmaticus and cerebral edema. This case highlights the importance of balancing conflicting physiologic needs and collaboration between teams.

Associations between healthy lifestyle behaviors and complementary and alternative medicine use: integrated wellness.

BACKGROUND: Conventional medicine, lifestyle modification, and complementary and alternative medicine (CAM) are potential strategies to decrease the risk of late effects in pediatric cancer survivors. This study aimed to compare the characteristics and usage patterns of CAM and lifestyle therapies among survivors of childhood cancer. METHODS: We report the results of a cross sectional survey comparing usage patterns of CAM and lifestyle therapies among childhood cancer survivors. CAM therapies were defined by NCCAM classifications and lifestyle therapies were defined as dietary changes, conventional supplements with dietary reference intake values, and exercise. RESULTS: One hundred fifty-five (95%) patients approached in person and 45 (34%) patients approached by mail consented to participate. Sixty-eight used at least one lifestyle therapy and 58% used at least one CAM therapy. CAM users had 4.7 times the odds of using lifestyle therapies than non-CAM users (P < .0001); the odds of using dietary change and conventional supplements was greater in CAM users than non-CAM users (odds ratio [OR] = 3.55, P < .0001 and OR = 4.80, P < .0001 respectively). Use of the top three CAM therapies was associated with overall lifestyle therapy use (OR = 12.52 and P < .0001, OR = 7.071 and P = .0004, and OR = 2.925 and P = .0089 for juicing, yoga/movement, and touch therapies, respectively). Lifestyle therapies and CAM had similar perceived efficacy (92%-90%, respectively). CONCLUSIONS: This data reports a strong association between CAM and lifestyle therapies and may identify a population with commitment to general wellness. Use of one therapy may promote use of other therapies and this potential synergistic relationship can be targeted in future interventions.

Severe group a streptococcus surgical site infection after thyroid lobectomy.

BACKGROUND: Thyroidectomy is rarely complicated by a surgical site infection (SSI). Despite its low incidence, post-thyroidectomy SSI is especially concerning because of its proximity to vital head and neck structures and the very real potential for airway compromise and death. Severe SSIs frequently are caused by Group A Streptococcus (GAS) because of its potential for developing into necrotizing fascitis. No description of the surgical approach to a necrotizing soft-tissue infection after thyroid resection is available in the current literature. METHODS: Case report and review of the pertinent English-language literature. RESULTS: A 47-year-old male underwent a right thyroid lobectomy and isthmusectomy for a follicular neoplasm. On post-operative day 2, the patient presented to the emergency department with persistent pain, rapid onset of swelling, and airway compromise shown on computed tomography scan. Emergency incision and drainage revealed a severe soft tissue infection. Because of subsequent worsening erythema and soft-tissue swelling, the patient had to be re-explored. The infection, later identified as caused by GAS, might have been transmitted from the patient's daughter. CONCLUSION: To our knowledge, this is the first case reported of exposure to a family member with GAS pharyngitis. Successful treatment requires an appropriately high level of suspicion followed by emergent operative debridement and systemic antibiotics.