Central venous catheter tip positioning using ultrasound in pediatric patients-A prospective observational study.

BACKGROUND: In children, central venous catheter (CVC) placement is usually performed under ultrasound guidance for optimal visualization of vessels and reduction of puncture-related complications. Nevertheless, in many cases, additional radiographic examinations are performed to check the position of the catheter tip. AIM: The primary objective of this observational feasibility study was to determine the number of ultrasound-guided central venous catheter tips that can be identified in a subsequent position check using ultrasonography. Furthermore, we investigated the optimal ultrasound window, time expenditure, and success rate concerning puncture attempts and side effects. In addition, we compared the calculated and real insertion depths and analyzed the position of the catheter tip on postoperative radiographs with the tracheal bifurcation as a traditional landmark. METHODS: Ninety children with congenital heart defects who required a central venous line for cardiac surgery were included in this single-center study. After the insertion of the catheter, the optimal position of its tip was controlled using one of four predefined ultrasound windows. A chest radiograph was obtained postoperatively in accordance with hospital standards to check the catheter tip position determined by ultrasonography. RESULTS: The children had a median (IQR) age of 11.5 (4.0, 58.8) months and a mean (SD) BMI of 15.3 (2.91) kg/m2 Ultrasound visualization of the catheter tip was successful in 86/90 (95.6%) children (95% confidence interval [CI]: 91.3%, 99.8%). Postoperative radiographic examination showed that the catheter tip was in the desired position in 94.4% (95% CI: 89.7%, 99.2%) of the cases. None of the children needed the catheter tip position being corrected based on chest radiography. CONCLUSION: Additional radiation exposure after the placement of central venous catheters can be avoided with the correct interpretation of standardized ultrasound windows, especially in vulnerable children with cardiac disease.

European Pediatric Cardiac Anesthesia Fellowship Program: A First Proof of Concept.

The Pediatric Cardiac Anesthesia (PCA) fellowship is a demanding training program in Europe and the United States. Successful completion of the program requires years of training in anesthesiology, a thorough understanding of cardiovascular anatomy and physiology, and extensive experience in the perioperative management of neonates and children with heart disease. In the context of the first candidate to successfully complete the PCA program in Europe, this article presents excerpts from the design and structure of the European PCA program. The PCA program is evaluated critically by both external and internal reviewers, and points are highlighted that could be included in the next version of the program.

Pediatric anesthesia in Europe: Variations within uniformity.

Organization of healthcare strongly differs between European countries and results in country-specific requirements in postgraduate medical training. Within the European Union (EU), the European Board of Anaesthesiology has set recommendations of training for the Specialty of Anaesthesiology including standards for Postgraduate Medical Specialist training including a description for providing service in pediatric anesthesia. However, these standards are advisory and not mandatory. Here we aimed to review the current state and associated challenges of pediatric anesthesia training in Europe. We report an important country-specific variability both in training and regulations of practice of pediatric anesthesia in the EU and in the United Kingdom. The requirements for training in pediatric anesthesia varies between nothing specified (Belgium) or providing anesthesia with direct supervision to a minimum of 50 cases below 5 years of age (Germany) to 3-6 month clinical practice in a specialized pediatric hospital (France). Likewise, the regulations for providing anesthesia to children varies from no regulations at all (Belgium) to age specific requirements and centralization of all children below 4 years of age to specified centers (United Kingdom). Officially recognized pediatric anesthesia fellowship programs are not available in most countries of Europe. It remains unclear if and how country-specific differences in pediatric anesthesia training are associated with clinical outcomes in pediatric perioperative care. There is converging interest and support for the establishment of a European pediatric anesthesia curriculum.

Effect of Extracerebral Contamination on Near-infrared Spectroscopy as Revealed during Organ Donation: A Prospective Observational Study in Brain-dead Organ Donors.

BACKGROUND: Near-infrared spectroscopy (NIRS) has been utilized widely in anesthesia and intensive care to monitor regional cerebral oxygen saturation (rScO2). A normal oxygenation of extracerebral tissues may overlay and thereby mask cerebral desaturations, a phenomenon known as extracerebral contamination. The authors investigated the effect of a cessation of extracerebral tissue perfusion on rScO2 in patients with anoxic brains. METHODS: In a single-center, prospective, observational study, brain-dead adults undergoing organ donation were investigated. rScO2 was measured bifrontally using the INVOS 5100C/7100 as well as the ForeSight Elite system. To achieve an efficient conservation of organs and to prevent a redistribution of the perfusion fluid to other tissues, the aorta was clamped before organ perfusion. rScO2 was monitored until at least 40 min after aortic clamping. The primary outcome was the amount of extracerebral contamination as quantified by the absolute decrease in rScO2 after aortic clamping. Secondary outcomes were the absolute rScO2 values obtained before and after clamping. RESULTS: Twelve organ donors were included. Aortic clamping resulted in a significantly (P < 0.001) greater absolute decrease in rScO2 when comparing the INVOS (43.0 ± 9.5%) to the ForeSight (27.8 ± 7.1%) monitor. Before aortic clamping, near-normal rScO2 values were obtained by the INVOS (63.8 ± 6.2%) and the ForeSight monitor (67.7 ± 6.5%). The rScO2 significantly (P < 0.001) dropped to 20.8 ± 7.8% (INVOS) and 39.9 ± 8.1% (ForeSight) 30 min after clamping, i.e., a condition of a desaturation of both extracerebral and cerebral tissues. CONCLUSIONS: The abrupt end of extracerebral contamination, caused by aortic clamping, affected both NIRS monitors to a considerable extent. Both the INVOS and the ForeSight monitor were unable to detect severe cerebral hypoxia or anoxia under conditions of normal extracerebral oxygenation. While both NIRS monitors may guide measures to optimize arterial oxygen supply to the head, they should not be used with the intention to detect isolated cerebral desaturations.

Digital Online Patient Informed Consent for Anesthesia before Elective Surgery-Recent Practice in Europe.

BACKGROUND: Digitalization in the health system is a topic that is rapidly gaining popularity, and not only because of the current pandemic. As in many areas of daily life, digitalization is becoming increasingly important in the medical field amid the exponential rise in the use of computers and smartphones. This opens up new possibilities for optimizing patient education in the context of anesthesia. The main aim of this study was to assess the implementation of remote consent in Europe. METHODS: An online survey entitled "Digital online Patient Informed Consent for Anesthesia before Elective Surgery. Recent practice in Europe," with a total of 27 questions, was sent by the European Society of Anesthesiology and Intensive Care (ESAIC) to their members in 47 European countries. To assess the effect of the economy on digitalization and legal status with regard to anesthesia consent, data were stratified based on gross domestic product per capita (GDPPC). RESULTS: In total, 23.1% and 37.2% of the 930 participants indicated that it was possible to obtain consent online or via telephone, respectively. This observation was more often reported in countries with high GDPPC levels than in countries with low GDPPC levels. Furthermore, 27.3% of the responses for simple anesthesia, 18.7% of the responses for complex anesthesia, and 32.2% of the responses for repeated anesthesia indicated that remote consent was in accordance with the law, and this was especially prevalent in countries with high GDPPC. Concerning the timing of consent, patients were informed at least one day before in 67.1% of cases for simple procedures and in 85.2% of cases for complex procedures. CONCLUSION: Even European countries with high GDPPC use remote informed consent only in a minority of cases, and most of the time for repeated anesthetic procedures. This might reflect the inconsistent legal situation and inhomogeneous medical technical structures across Europe.

Ideal endotracheal intubation depth at the vocal-cord level to avoid single-lung intubation using the percentage ratio of the tracheal length to body height.

INTRODUCTION: Our previous study revealed racial differences in the tracheal length of cardiac paediatric patients between Germany and Japan. The current study was conducted in two stages, aiming to determine whether the tracheal length differs between cardiac and non-cardiac paediatric patients and whether the results could also be generalised to adults. MATERIAL AND METHODS: The first stage was a retrospective observational evaluation of 335 cardiac and 275 non-cardiac paediatric patients in Japan. The tracheal length, the distance between the vocal cords and carina tracheae, was measured on preoperative chest radiographs taken in the supine position. The second stage was a validation process including 308 Japanese patients. Endotracheal intubation was performed based on the results of the first-stage investigation. RESULTS: It was revealed that the tracheal length ranged from 7 to 11% of the body height in both the cardiac and non-cardiac Japanese paediatric patients. None of 308 Japanese paediatric and adult patients underwent single-lung intubation after the endotracheal tube was inserted at a depth of 7% of the body height at the vocal-cord level, corresponding to the minimum tracheal length for Japanese patients. The distance between the endotracheal tube tip and carina tracheae on postoperative chest radiographs was generally less than 4% of the body height across all paediatric and adult Japanese patients. CONCLUSIONS: The current study demonstrated that endotracheal intubation avoiding single-lung intubation can be achieved by inserting endotracheal tubes to the minimum tracheal length for a specific ethnic group at the vocal-cord level in paediatric patients, including neonates and premature infants, as well as adults.

Quality comparison of remote anesthetic consultation versus on-site consultation in children with sedation for a magnetic resonance imaging examination-A randomized controlled trial.

BACKGROUND: In the course of the corona pandemic, digital media has increasingly been used in many areas of medical practice to reduce personal contact. As it is of interest whether this can be practiced in the context of anesthesia consultations without loss of quality, we interviewed parents whose children received a cardiac or neuro magnetic resonance imaging (MRI) under sedation. Parents either received an on-site or a remote consultation conducted by an anesthesiologist. Both parents and anesthesiologist were asked to indicate their satisfaction with the respective consultation procedure in a questionnaire. AIM: The aim of this study was to investigate if remote pre-anesthesia consultation, supported by an online video, for parents whose children are receiving MRI examinations under sedation can replace the commonly performed on-site consultation, without decreasing its quality. METHODS: In this randomized trial, a total of 200 patients were included, one half received pre-anesthesia consultation on-site and the other half was given a link to a video and pre-anesthesia consultation was conducted by phone. As a primary analysis, we compared the level of satisfaction for the general procedure, the quality of the pre-anesthesia consultation and the contact to the anesthesiologists (or parents). We further investigated the frequency of complications and the preference for a possible next informed consent. RESULTS: Both groups showed high levels of satisfaction. Some anesthesiologists and parents were less satisfied with the quality of on-site pre-anesthesia consultation than with the remote. In our patient cohort, there was no evidence for higher risk of complications when information was provided by telephone. Further, parents as well as anesthesiologists clearly favored the combined form of telephone information and online video. Overall, 61.2% of parents and 64% of anesthesiologists would choose this form of pre-anesthesia consultation for repeat anesthesia. CONCLUSIONS: We did not observe that combined telephone and video decreased the quality of pre-anesthesia consultation. A remote version seems feasible for simple procedures such as sedation for MRI. Further research on this topic in other areas of anesthesia would be beneficial.

Regional anesthesia as part of enhanced recovery strategies in pediatric cardiac surgery.

PURPOSE OF REVIEW: The purpose of this review article was to highlight the enhanced recovery protocols in pediatric cardiac surgery, including early extubation, rapid mobilization and recovery, reduction of opioid-related side effects, and length of pediatric ICU and hospital stay, resulting in decreased costs and perioperative morbidity, by introducing recent trends in perioperative anesthesia management combined with peripheral nerve blocks. RECENT FINDINGS: Efficient postoperative pain relief is essential for realizing enhanced recovery strategies, especially in pediatric patients. It has been reported that approaches to perioperative pain management using additional peripheral nerve blocks ensure early extubation and a shorter duration of ICU and hospital stay. This article provides an overview of several feasible musculofascial plane blocks to achieve fast-track anesthesia management for pediatric cardiac surgery. SUMMARY: Recent remarkable advances in combined ultrasound techniques have made it possible to perform various peripheral nerve blocks. The major strategy underlying fast-track anesthesia management is to achieve good analgesia while reducing perioperative opioid use. Furthermore, it is important to consider early extubation not only as a competition for time to extubation but also as the culmination of a qualitative improvement in the outcome of treatment for each patient.

Ultrasound-guided supraclavicular cannulation of left brachiocephalic versus right internal jugular vein: Comparative analysis of central venous catheter-associated complications.

AIMS: Central venous catheters are essential for the management of pediatric cardiac surgery patients. Recently, an ultrasound-guided access via a supraclavicular approach to the brachiocephalic vein has been described. Central venous catheters are associated with a relevant number of complications in pediatric patients. In this study, we evaluated the frequency of complications of left brachiocephalic vein access compared with right internal jugular vein standard access in children undergoing cardiac surgery. METHODS: Retrospective analysis of all pediatric cases at our tertiary care university hospital over a two-year period receiving central venous catheters for cardiac surgery. PRIMARY ENDPOINT: Frequency of complications associated with central venous catheters inserted via the left brachiocephalic vein vs. right internal jugular vein. Complications were defined as: chylothorax, deep vein thrombosis, sepsis, or delayed chest closure. Secondary endpoints: Evaluation of the insertion depth of the catheter using a height-based formula without adjustment for side used. RESULTS: Initially, 504 placed catheters were identified. Following inclusion and exclusion criteria, 480 placed catheters remained for final analysis. Overall complications were reported in 68/480 (14.2%) cases. There was no difference in the frequency of all complications in the left brachiocephalic vein vs. the right internal jugular vein group (15.49% vs. 13.65%; OR = 1.16 [0.64; 2.07]), nor was there any difference considering the most relevant complications chylothorax (7.7% vs. 8.6%; OR = 0.89 [0.39; 1.91]) and thrombosis (5.6% vs. 4.5%; OR = 1.28 [0.46; 3.31]). The mean deviation from the optimal insertion depth was left brachiocephalic vein vs. right internal jugular vein 5.38 ± 13.6 mm and 4.94 ± 15.1 mm, respectively. CONCLUSIONS: Among children undergoing cardiac surgery, there is no significant difference between the supraclavicular approach to the left brachiocephalic vein and the right internal jugular vein regarding complications. For both approaches, a universal formula can be used to determine the correct insertion depth.

[Safe and Appropriate Pharmacotherapy in Paediatric Anaesthesia]. / Sichere und passende Pharmakotherapie in der Kinderanästhesie.

Safe and appropriate pharmacotherapy in children requires knowledge of age-group-specific features regarding pharmacology and drug dosing. In addition, aspects of medication safety must be considered. This review highlights basic principles and discusses key facts; further research in paediatric databases is recommended (www.kinderformularium.de).

Effects of on-Table Extubation after Pediatric Cardiac Surgery.

Background: Enhanced recovery after surgery (ERAS) protocols are utilizing a multidisciplinary approach, reassessing physiology to improve clinical outcomes, reducing length of hospital stay (LOS) stay, resulting in cost reduction. Since its introduction in colorectal surgery. the concept has been utilized in various fields and benefits have been recognized also in adult cardiac surgery. However, ERAS concepts in pediatric cardiac surgery are not yet widely established. Therefore, the aim of the present study was to assess the effects of on-table extubation (OTE) after pediatric cardiac surgery compared to the standard approach of delayed extubation (DET) during intensive care treatment. Study Design and Methods: We performed a retrospective analysis of all pediatric cardiac surgery cases performed in children below the age of two years using cardiopulmonary bypass at our institution in 2021. Exclusion criteria were emergency and off pump surgeries as well as children already ventilated preoperatively. Results: OTE children were older (267.3 days vs. 126.7 days, p < 0.001), had a higher body weight (7.0 ± 1.6 kg vs. 4.9 ± 1.9 kg, p < 0.001), showed significantly reduced duration of ICU treatment (75.9 ± 56.8 h vs. 217.2 ± 211.4 h, p < 0.001) and LOS (11.1 ± 10.2 days vs. 20.1 ± 23.4 days; p = 0.001) compared to DET group. Furthermore, OTE children had significantly fewer catecholamine dependencies at 12-, 24-, 48-, and 72-h post-surgery, while DET children showed a significantly increased intrafluid shift relative to body weight (109.1 ± 82.0 mL/kg body weight vs. 63.0 ± 63.0 mL/kg body weight, p < 0.001). After propensity score matching considering age, weight, bypass duration, Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery Mortality (STATS)-Score, and the outcome variables, including duration of ICU treatment, catecholamine dependencies, and hospital LOS, findings significantly favored the OTE group. Conclusion: Our results suggest that on-table extubation after pediatric cardiac surgery is feasible and in our cohort was associated with a favorable postoperative course.

[Hemodynamic monitoring in pediatric anesthesia]. / Hämodynamisches Monitoring in der Kinderanästhesie.

Perioperative mortality and morbidity in childhood essentially depend on the quality of the anesthesia. The Safe Anesthesia for every Tot (SafeTots) initiative takes this into account and has defined normotension, normovolemia and normal heart rate as quality criteria in pediatric anesthesia. Appropriate monitoring of pediatric hemodynamics is necessary to fulfil these criteria. This article provides an overview of currently used methods and techniques for instrumental and non-instrumental cardiovascular monitoring in children. The current study situation, recommendations and guidelines on the application as well as practical aspects of the measurement methods are explained as far as possible. For a better understanding, procedures not routinely used in clinical practice are described in more detail.

Femoral Artery Cannulation Timing for a Pediatric Aortic Arch Repair.

We have previously introduced a blood delivery method via femoral artery cannulation to provide perfusion to the organs in the lower part of the body during pediatric aortic arch repair surgeries. In the original procedure, the femoral artery cannulation was performed after the patient had been covered with a sterile drape. Here, we suggest that the femoral artery cannulation should be performed before the patient is draped to allow optimal visibility of the target artery and puncture needle via aseptic real-time ultrasound-guided technique by reducing the inclusions between the patient's skin and ultrasound probe which attenuate the ultrasound beam.

Comparison of the Newborn Infant Parasympathetic Evaluation (NIPE™) index to changes in heart rate to detect intraoperative nociceptive stimuli in healthy and critically ill children below 2 years: An observational study.

BACKGROUND: The validity of current tools for intraoperative objective assessment of nociception/antinociception balance during anesthesia in young and very young surgery children is unknown. AIM: Primary aim of the study was to test the hypothesis that the Newborn Infant Parasympathetic Evaluation (NIPE) index performs better in indicating nociception in anesthetized children below 2 years than changes in heart rate. Secondary aims were to evaluate associations between intraoperative changes in NIPE index values and postoperative pain and emergence delirium. METHODS: Fifty-one children aged <2 years who underwent surgery were included in this prospective observational study. Patients were assigned to either group 1 (healthy children, n = 31) or group 2 (critically ill, ventilated premature infants and neonates, n = 20). The NIPE index and heart rate in response to three defined nociceptive stimuli were continuously recorded. Two different scales, Kindliche Unbehagens- und Schmerzskala (KUS) and Pediatric Anesthesia Emergence Delirium (PAED) as well as a Pain Questionnaire were used to assess postoperative pain levels and emergence delirium. RESULTS: In total, 110 nociceptive events were evaluated. The analysis revealed a statistically significant association between a decrease in the NIPE index and all nociceptive stimuli, with a sensitivity of 92% and a specificity of 96%. The mean percentage decrease ranged from approx. 15%-30% and was highly statistically significant in both groups and for each of the nociceptive events except for venous puncture (p = .004). In contrast, no consistent change in heart rate was demonstrated. The KUS and PAED scale scores were significantly associated with the duration of anesthesia (p = .04), but not with intraoperative NIPE depression. CONCLUSION: The NIPE index was reliable for assessing intraoperative nociception in children aged <2 years and was more reproducible for detecting specific nociceptive stimuli during general anesthesia than heart rate. An effect on postoperative outcome is still elusive.

European association of cardiothoracic anesthesiology and intensive care pediatric cardiac anesthesia fellowship curriculum: first edition

ABSTRACT: Pediatric cardiac anesthesia is a subspecialty of cardiac and pediatric anesthesiology dedicated to the perioperative care of patients with congenital heart disease. Members of the Congenital and Education Subcommittees of the European Association of Cardiothoracic Anaesthesiology and Intensive Care (EACTAIC) agreed on the necessity to develop an EACTAIC pediatric cardiac anesthesia fellowship curriculum. This manuscript represents a consensus on the composition and the design of the EACTAIC Pediatric Cardiac Anesthesia Fellowship program. This curriculum provides a basis for the training of future pediatric cardiac anesthesiologists by clearly defining the theoretical and practical requirements for fellows and host centers.

Digital Online Anaesthesia Patient Informed Consent before Elective Diagnostic Procedures or Surgery: Recent Practice in Children-An Exploratory ESAIC Survey (2021).

BACKGROUND: One undisputed benefit of digital support is the possibility of contact reduction, which has become particularly important in the context of the COVID-19 pandemic. However, to the best of our knowledge, there is currently no study assessing the Europe-wide use of digital online pre-operative patient information or evaluation in the health sector. The aim of this study was to give an overview of the current status in Europe. METHODS: A web-based questionnaire covering the informed consent process was sent to members of the European Society of Anaesthesia and Intensive Care Medicine (ESAIC) in 47 European countries (42,433 recipients/930 responses). Six questions related specifically to the practice in paediatrics. RESULTS: A total of 70.2% of the respondents indicated that it was not possible to obtain informed consent via the Internet in a routine setting, and 67.3% expressed that they did not know whether it is in line with the legal regulations. In paediatric anaesthesia, the informed consent of only one parent was reported to be sufficient by 77.6% of the respondents for simple interventions and by 63.8% for complex interventions. Just over 50% of the respondents judged that proof of identity of the parents was necessary, but only 29.9% stated that they ask for it in clinical routine. In the current situation, 77.9% would favour informed consent in person, whereas 60.2% could imagine using online or telephone interviews as an alternative to a face-to-face meeting if regulations were changed. Only 18.7% participants reported a change in the regulations due to the current pandemic situation. CONCLUSION: Whether informed consent is obtained either online or on the telephone in the paediatric population varies widely across Europe and is not currently implemented as standard practice. For high-risk patients, such as the specific cohort of children with congenital heart defects, wider use of telemedicine might provide a benefit in the future in terms of reduced contact and reduced exposure to health risks through additional hospital stays.