Assessing the Safety of a Novel Neonatal Anesthesia Protocol: A Review of 101 Patients With Early Cleft Lip Repair.

PURPOSE: Our study introduces a novel anesthetic protocol for neonates without using volatile agents with the goal to minimize potentially neurotoxic and pro-apoptotic agents. The authors evaluated the short-term safety and efficacy of our anesthetic protocol in patients undergoing early cleft lip repair (ECLR). METHODS: A retrospective review of ECLR patients who underwent repair before 2.5 months of age within the last 4.3 years was performed. This sample was comprised of 2 groups, those who received either a standard volatile gas-based regimen or a dexmedetomidine-based neonatal anesthetic protocol (DBNAP). Patient demographics, medication dosing, anesthetic time (induction to extubation), major and minor complications, and medication side effects were compared between the 2 cohorts. RESULTS: A total of 101 patients underwent ECLR. All patients were American Society of Anesthesiologists class 1 or 2. Mean age at surgery was 31 ±â€Š13 days and mean anesthetic time was 179 ±â€Š36 minutes. DBNAP was used in 65 patients while the standard anesthetic protocol was used in 36 patients. Patient weight was significantly lower in the DBNAP group (4.01 ±â€Š0.61 versus 4.38 ±â€Š0.72 kg, P  = 0.007). There were no significant differences between the 2 cohorts when comparing anesthetic time, emergence time, complication rate, or medication side effects. CONCLUSION: For patients undergoing ECLR, DBNAP is perioperatively equivalent to the anesthetic standard of care, demonstrating no major complications and acceptable rates of minor complications and medication side effects.

Repeated measurements of ERGs and VEPs using chloral hydrate sedation and propofol anesthesia in young children.

PURPOSE: Sedation with chloral hydrate or anesthesia using propofol allow ocular examination and testing in young children, but these drugs may affect electrophysiologic recordings. We compared the flash and pattern ERGs and VEPs recorded with each drug in a cohort of young children enrolled in a prospective study of optic nerve hypoplasia (ONH) syndrome. METHODS: ERGs and VEPs to light-adapted, standard, full-field flashes, to standard and steady-state pattern-reversal (PR) were recorded with cycloplegia in 9 participants. Age range at the first session, with chloral hydrate was 8-23 mo; at the second session with propofol it was 20-29 mo. Examiners masked to the drug and clinical conditions measured the waveforms for longitudinal, paired comparisons between the sessions. RESULTS: Flash ERG amplitudes did not differ between sessions; peak times were longer at the second session (propofol) by clinically insignificant amounts (< 2 ms, p = 0.002). Standard PERGs had larger amplitudes and later peaks in the second session (propofol) than with chloral hydrate (P50 2.9 vs 4.7 µV, p = 0.016 and 43 vs 52 ms, p < 0.001; N95 4.0 vs 6.1 µV, p = 0.003 and 91 vs 98.5 ms p = 0.034.). These differences were present for those with an interval of  > 10 mo between sessions (n = 5, 10 eyes) but not for those with a shorter inter-test interval (< 8 mo, p > 0.05, n = 4). Magnitudes of the steady-state PERGs did not differ between tests but the waveforms had earlier peaks at the second test with propofol. Flash VEP waveforms were present in 10/18 eyes and showed 72% agreement for recordability between sessions. Standard pattern VEPs were recordable in only a few eyes in this cohort with ONH. CONCLUSIONS: Light-adapted flash ERG waveforms were generally similar with chloral hydrate and with propofol. Larger PERGs with later peaks, found in the second session (propofol) could reflect maturation of the PERG generators, as the differences found were associated with a greater age difference between the sessions, but we do not rule out that small differences in the waveforms may be drug-related. There are insufficient VEP data from these children with ONH to identify drug-related or maturational effects on VEPs.

A Case Report and Anesthetic Considerations in Subcutaneous Fat Necrosis of the Newborn.

Subcutaneous fat necrosis of the newborn (SCFN) is an uncommon, self-limiting panniculitis generally diagnosed in the first few weeks of extrauterine life in term or postterm infants subjected to perinatal physiologic stress. Hallmarks of the process include dramatic hypercalcemia without identifiable cause that may be associated with renal disease, seizures, and death. Herein, we describe the anesthetic approach in an 11-week-old infant, including perioperative laboratory testing, management of hypercalcemia, and intraoperative considerations.

Anesthesia for pediatric patients with anti-NMDA receptor encephalitis: A retrospective case series.

INTRODUCTION: Anti-N-methyl-D-aspartate receptor encephalitis is caused by auto-antibodies that target the N-methyl-D-aspartate receptor. Autonomic instability is a hallmark of the disease. The objective of this case series is to examine how anesthesia affects pediatric patients with this disease. METHODS: We performed a retrospective chart review of 28 records in 17 patients who underwent anesthesia. Our primary outcomes were hemodynamic changes during the perioperative period. Heart rate, systolic and diastolic blood pressures, respiratory rate, and oxygen saturation comprise our endpoints. A subgroup of patients, who underwent imaging with anesthesia, was then compared to controls. RESULTS: In anti-N-methyl-D-aspartate receptor encephalitis cases, there were significant percent changes from baseline in heart rate; median = -14.3%, 95% CI (-19.3, -9.0), p < .01 at 30 min and -15.7%, (-21.1, -9.8), p < .01 at 60 min; in systolic blood pressure, -19.4%, (-23.7, -14.8) at 30 min, p < .01, and -14.8%, (-19.7, -9.5) at 60 min, p < .01; in diastolic blood pressure, -41.9%, (-46.9, -36.3), p < .01 at 30 min, and -37.5%, (-43.4, -30.9), p < .01 at 60 min. When compared to controls, there were no significant differences between the two groups across time of anesthesia (baseline to 60 min) in heart rate (p = .24), systolic blood pressure (p = .30), and diastolic blood pressure (p = .11). No patients experienced hemodynamic lability under anesthesia. One patient, with severe symptoms, died within 24 h of anesthesia. CONCLUSION: Although pediatric patients with anti-N-methyl-D-aspartate receptor encephalitis experienced vital sign changes with anesthesia, they were not clinically significant and they behaved similarly to controls. Disease severity may be a risk factor for perioperative complications.

Transcutaneous CO2 Monitoring in Children Undergoing Tonsillectomy for Sleep Disordered Breathing.

OBJECTIVES/HYPOTHESIS: Children undergoing tonsillectomy for sleep-disordered breathing are at risk for respiratory compromise when narcotics are administered. Severe complications resulting from hypoxia can include neuro-devastation and death. The objective of this prospective study was to evaluate the feasibility, accuracy, and utility of transcutaneous carbon dioxide (tcPCO2) monitoring during and after adenotonsillectomy. STUDY DESIGN: Prospective, Observational study. METHODS: Twenty-nine children with sleep-disordered breathing scheduled for adenotonsillectomy were included in the study. Peri-operative measurements of tcPCO2 were compared against a single venous blood sample (PaCO2) and end-tidal (ET) CO2. The differences between ETCO2, tcPCO2 measures, and PaCO2 were examined using non-paired t-tests and linear regression. Parameters from PSG were recorded and associations with tcPCO2 values were performed using linear regression analysis. Group comparisons were made between pre-, intra-, and post-operative tcPCO2 measurements. RESULTS: Similar to ETCO2, there was good correlation of tcPCO2 to PaCO2. Children with lower oxygen (O2) saturation nadirs had higher peak CO2 levels during surgery and spent a greater proportion of time with CO2 > 50 mmHg in the recovery room (P < .01 and P < .08). Other PSG measures (apnea-hypopnea index, O2 desaturation index, and peak CO2) did not have any significant correlation. Frequent episodes of hypercapnia were noted intra- and post-operatively and mean tcPCO2 values during both periods were significantly higher than baseline (P < .001). CONCLUSIONS: tcPCO2 monitoring is viable in children undergoing adenotonsillectomy and can provide a good estimate of hypoventilation. tcPCO2 measurements may have particular benefit in the post-operative setting and may assist in identifying children at greater risk for respiratory complications. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:1410-1415, 2021.

Anesthetic Considerations in Saul-Wilson Syndrome, a Rare Skeletal Dysplasia: A Case Report.

Saul-Wilson syndrome, also known as microcephalic osteodysplastic dysplasia, is a rare type of dwarfism with significant anesthetic considerations. The genetic defect is associated with nearly uniform micrognathia, odontoid hypoplasia, and possible cervical spine instability that contribute to potentially increased risk of airway complications. Herein, we describe the anesthetic management of a 2-year-old child with Saul-Wilson syndrome.

Early Cleft Lip Repair Revisited: A Safe and Effective Approach Utilizing a Multidisciplinary Protocol.

BACKGROUND: The optimal timing for cleft lip repair has yet to be established. Advances in neonatal anesthesia, along with a growing body of literature, suggesting benefits of earlier cleft lip and nasal repair, have set the stage for a reexamination of current practices. METHODS: In this prospective study, cleft lip and nasal repair occurred on average at 34.8 days (13-69 days). Nasal correction was achieved primarily through molding the nasal cartilage without the placement of nasal sutures at the time of repair. A standardized anesthetic protocol aimed at limiting neurotoxicity was utilized in all cases. Anesthetic and postoperative complications were assessed. A 3-dimensional nasal analysis compared pre- and postoperative nasal symmetry for unilateral clefts. Surveys assessed familial response to repair. RESULTS: Thirty-two patients were included (27 unilateral and 5 bilateral clefts). In this study, the overall complication rate was 3.1%. Anthropometric measurements taken from 3-dimensional-image models showed statistically significant improvement in ratios of nostril height (preoperative mean, 0.59; postoperative mean, 0.80), nasal base width (preoperative mean, 1.96; postoperative mean, 1.12), columella length (preoperative mean, 0.62; postoperative mean, 0.89; and columella angle (preoperative mean, 30.73; postoperative mean, 9.1). Survey data indicated that families uniformly preferred earlier repair. CONCLUSIONS: We present evidence that early cleft lip and nasal repair can be performed safely and is effective at improving nasal symmetry without the placement of any nasal sutures. Utilization of this protocol has the potential to be a paradigm shift in the treatment of cleft lip and nasal deformity.

Mainstream capnography system for nonintubated children in the postanesthesia care unit: Performance with changing flow rates, and a comparison to side stream capnography.

INTRODUCTION: Monitoring of exhaled carbon dioxide (CO2 ) in nonintubated patients is challenging. We compared the precision of a mainstream mask capnography to side stream sampling nasal cannula capnography. In addition, we compared the effect of gas flow rates on the measured exhaled CO2 between mainstream mask and side stream nasal cannula capnography. METHODS: A mainstream mask capnography system (cap-ONE) was tested. Children (weight of 7-40 kg, ASA 1-2) following anesthesia for minor procedures were assigned randomly to side stream or mainstream sampling groups. The side stream group wore a nasal cannula with CO2 side port (NC). In the postanesthesia care unit, O2 flow was started at 5 l·min-1 , reduced to 2 and then 0.25 l·min-1 every 3 min. Capnogram analysis measuring heights of all the waveforms was performed for continuous 120 s from the end of recording at each O2 flow rate for each group. RESULTS: Fifty-eight children were enrolled and 39 were analyzed (18 side stream NC and 21 mainstream mask). There were two mouth breathing children excluded from study in side stream NC group due to failure to capture measurable CO2 waveforms. Peak CO2 values measured by mainstream mask system were normally (Gaussian) distributed with smaller standard deviation (sd) at each O2 flow than were those measured by side stream NC system which demonstrated irregular distributions with larger sd. Peak CO2 values measurement was less affected by a change in flow rate in mainstream mask group than in side stream NC group (P = 0.04 in 5-0.25 l·min-1 O2 flow change). CONCLUSION: A new mainstream mask system (cap-ONE) performed with greater precision than side stream NC monitoring regardless of mouth breathing. Measurement of peak CO2 values by mainstream mask system showed normal distribution with smaller standard deviation (sd) and was less affected by O2 flow change in predictable fashion.

Improving diagnostic accuracy: simple statistical nomograms to interpret medical literature.

BACKGROUND: Authors of medical diagnostic literature frequently report sensitivity and specificity as measures of the quality of an evaluative study. However, these representations are easily misinterpreted by clinicians to be indicative of the prospective value of a test as predictive of the presence (positive predictive value, PPV) or absence of disease (negative predictive value, NPV). Although these phenomena are related, the mathematical expression and, therefore, the conclusions are more complex. METHODS: Using algebraic methods, we derived simplified formulas to determine PPV, NPV, and accuracy (A). These general terms were solved by constraining individual variables, resulting in the development of curves that may be used routinely to analyze medical diagnostic literature. RESULTS: Equations for PPV, NPV, and A were generated by using sensitivity, specificity, and incidence/prevalence as the dependent variables. These equations have been employed to generate representative graphs of PPV, NPV, and A and to clarify trends in these features with respect to commonly reported data. DISCUSSION: These simplified equations allow clinicians to determine the utility of diagnostic studies in prospect, despite having only sensitivity, specificity, and incidence or prevalence of disease.

Should intraoperative hypercapnea or hypercarbia raise concern in neonates undergoing thoracoscopic repair of diaphragmatic hernia of Bochdalek?

BACKGROUND: Better understanding of cardiopulmonary physiology in children with congenital diaphragmatic hernia of Bochdalek (CDH) has facilitated improved survival. In addition, it has allowed surgeons to employ minimally invasive techniques to their repair under conditions that might result in hypercarbia and/or recurrent pulmonary hypertension. MATERIALS AND METHODS: Under institutional review board approval, the records of all neonates at a single institution who underwent thoracoscopic CDH (T-CDH) were reviewed with attention to the incidence of intraoperative hypercapnea (elevated end tidal CO(2)) or hypercarbia (increased PCO(2) by blood gas measurement) and any associated complications. RESULTS: From 2004 through 2007, 31 consecutive neonates, including those who had undergone extracorporeal membrane oxygenation, had T-CDH. CO(2) insufflation to 3 mm Hg was used until the viscera were reduced within the abdominal cavity. The operative technique and outcomes are described elsewhere. Preoperative analyses revealed a mean arterial PCO(2) of 53 +/- 11 torr and SaO(2) of 95 +/- 5%. The mean highest recorded intraoperative end-tidal CO(2) level was 64 +/- 13 and correlated poorly with the highest arterial PCO(2) (mean, 78 +/- 29 torr; range, 29-130). The mean lowest recorded intraoperative SaO(2) was 92 +/- 8% with only two values less than 88%. The average lowest intraoperative mean arterial blood pressure was 47 +/- 8 mm Hg (range, 34-70 mm Hg). No neonate received inhaled nitric oxide, intravenous buffer administration, or escalation of inotrope administration during the procedures nor did any experience recurrent pulmonary hypertension postoperatively. SUMMARY: Hypercapnea and hypercarbia are common phenomena during T-CDH but do not appear to correlate with one another nor result in clinically evident recurrent pulmonary hypertension, hypoxemia, hypotension, need for support with vasoactive medications, inhaled nitric oxide, or buffering agents.

A prospective randomized blinded study of the effect of intravenous fluid therapy on postoperative nausea and vomiting in children undergoing strabismus surgery.

BACKGROUND: Nausea and vomiting is a common postoperative complication that often necessitates the use of antiemetic agents. METHODS: In a prospective, randomized, double blind trial, the effect of perioperative fluid administration on postoperative adverse outcomes following anesthesia was studied. One hundred children undergoing strabismus repair were randomly assigned to receive 10 ml x kg(-1) x h(-1) (control group) or 30 ml x kg(-1) x h(-1) (superhydration group) of lactated Ringer's solution during the operation. During the first 24 h postoperatively, nausea and vomiting, thirst, pain, and fever were evaluated. RESULTS: Groups were similar with respect to demographic data, surgical procedures and baseline hemodynamic variables. In the first 24 h postoperatively, nausea and vomiting occurred in 27 patients (54%) of the control group and 11 (22%) of patients in the superhydration group (P = 0.001). Comparison of the superhydration group with the control group also showed a statistically significant benefit of superhydration on postoperative thirst (P = 0.0002) and fever (P = 0.02). The differences in nausea and vomiting, thirst, and fever remained significant after adjustment for age, gender, weight, and duration of surgery. There was no significant difference between the two groups in postoperative pain. CONCLUSIONS: Intravenous superhydration administration is an inexpensive and safe therapy for reducing postoperative nausea and vomiting and discomfort.

Blood-conservation techniques in craniofacial surgery.

Attempts at reducing exposure to allogeneic transfusions, using blood conservation techniques such as controlled hypotension and normovolemic hemodilution, have met with mixed results and are not always practical in small infants. Recombinant human erythropoietin (RHE), a hormone that stimulates RBC production, increases the hematocrit when administered to infants. A retrospective chart review of all patients undergoing fronto-orbital advancement for craniosynostosis by the same plastic surgeon between January 2002 and December 2002 was conducted. A subgroup of patients (10/19) received RHE as a blood-conservation strategy. Transfusion requirements were lower in the RHE group (5/10) versus the control group (9/9). Total volume of blood products transfused was statistically lower in the RHE group (154 mL RHE group versus 421 mL control) (P < 0.03). RHE combined with blood-conservation techniques was associated with a decreased need for blood transfusion, thus exposing the patient to fewer risks associated with allogeneic transfusion.