Postoperative complications associated with extubation strategies following palatoplasty: a single-center retrospective analysis.

PURPOSE: Palatoplasty carries a high risk of airway obstruction as a postoperative complication. Since 2007, the protocol in our hospital has been to leave an endotracheal tube in place after surgery while the patient is moved to the pediatric intensive care unit. Extubation is then performed after achievement of hemostasis and recovery of consciousness. We compared the cases over the 5-year periods before and after the introduction of this revised postsurgical management plan to investigate its effect on postoperative complications. METHODS: This was a retrospective cohort study involving a single pediatric hospital. The subjects were 199 children aged 1-3 years, who underwent palatoplasty between January 2002 and July 2012. Changes in the incidence rates of postoperative complications were statistically examined. RESULTS: There were significantly more postoperative complications among the patients who were extubated in the operating room than among those extubated in the intensive care unit (operating room group, 22/94 cases; intensive care unit group, 10/105 cases; P < 0.01). Serious complications, such as hypoxemia and airway obstruction, also occurred more frequently in the operating room group. CONCLUSION: Extubation in an intensive care unit was possibly associated with a reduction in postoperative complications.

[Anesthetic management of a patient with Fontan circulation with pacemaker failure].

We describe the anesthetic management of a 23-year-old female patient with severe bradycardia due to pacemaker lead disconnection. The pacemaker had been placed due to complete AV block following an extracardiac Fontan operation. She was scheduled for lead repair under general anesthesia. The preoperative HR was only 37 beats x min(-1) of idioventricular rhythm. As further bradycardia was a major concern, we prepared a percutaneous cardiac pacemaker and the catheterization laboratory for transatrial cardiac pacing. After placement of transcutaneous cardiac pacing pads on the chest, we administered isoproterenol at 0.01 microg x kg(-1) x min(-1). We confirmed an increase in HR to 50 beats x min(-1) and induced anesthesia, after which isoproterenol was administered at 0.015 microg x kg(-1) x min(-1). No bradycardia was observed perioperatively. Transvenous cardiac pacing, part of the last step in the ACLS bradycardia algorithm, is inappropriate except in patients with anatomic Fontan circulation. Furthermore, in the case of bradycardia, percutaneous or transesophageal cardiac pacing can be used; however, these are not always effective. Transatrial cardiac pacemakers are probably most effective for bradycardia with Fontan circulation but they should be placed by a catheter specialist, and emergency placement can be difficult. As described here, a special management protocol is necessary to control bradycardia in the face of Fontan circulation.

[Risk management in pediatric regional anesthesia].

Although regional analgesia exerts beneficial effects not only for reducing the stress responses during surgery but also for pain relief after surgery, adverse incidents have occurred even at a low rate. Severe complications such as spinal penetration during epidural block can devastate not only patients, families but also our staffs and we have to avoid such disastrous result absolutely. Retrospective and prospective studies are seldom able to register the precise incident rate of severely injured complication related to regional blocks because the rate is very low. Therefore we have to glean any information from case reports and studies as much as possible. A study has clarified that more epidural cases might be able to reduce the rate of injuring and younger age group is apt to be injured especially in the thoracic region. The report of five cases of severe injuring during epidural blocks from Giaufré's study gave us some important advices. We should not perform epidural blocks in the very young age group and not use air while confirming epidural space by loss of resistance technique and local anesthetics containing even low concentrations of epinephrine. We have to select patients carefully and balance the risk and benefits with the patients.

[Case of spinal anesthesia for pyrolomyotomy in a former preterm infant with chronic lung disease].

A former premature infant (1,795 g) with chronic lung disease underwent pyrolomyotomy under spinal anesthesia. She had been managed with artificial ventilation for 2 months after birth and had developed chronic lung disease. She showed frequent apnea with desaturation several times per day and 21 x min(-1) of oxygen had been administered. She began projectile vomiting 1 month after extubation and then was diagnosed as hypertrophic pyrolic stenosis by ultrasonography. She was transferred to our hospital to have pyrolomyotomy. After admission to pediatric intensive care, she was managed with nasal-DPAP to prevent apnea. Surgery was completed on the second day after admission under spinal anesthesia using 1.0 mg x kg(-1) of hyperbaric bupivacaine. Spinal puncture was accomplished with 19 mm of 27 G needle after removal of lidocaine patch which had been applied 1 hour before. After the outflow of clear CSF was confirmed, the anesthetics was administered. After we confirmed the anesthesia level up to T5, surgery was commenced. She was managed with mask CPAP to prevent deasaturation under spontaneous respiration during surgery. She required nasal-CPAP to prevent apnea after surgery and she was transferred back to the referred hospital on the 3rd postoperative day without any sequela.

[Spinal anesthesia for a inguinal hernia repair in a small child with laryngeal stenosis].

We experienced spinal anesthesia for inguinal hernia repair in combination with general anesthesia in a 4-year-old child with functional laryngeal stenosis and tendency of laryngeal edema. His airway was managed without endotracheal tube or laryngeal mask airway because these devices could worsen the upper airway stenosis. Spinal anesthesia offered reliable and potent analgesia leading to safe anesthetic management under spontaneous breathing. Although spinal anesthesia in combination with general anesthesia is not common in pediatric patients, it is effective and safe to apply for a case requiring more reliable and potent analgesia with understanding anatomical and physiological characteristics in children.

The effective time and concentration of nitrous oxide to reduce venipuncture pain in children.

STUDY OBJECTIVE: To investigate the time of administration and concentration of inhaled nitrous oxide (N(2)O) needed to reduce the pain associated with intravenous (i.v.) cannulation in children. DESIGN: Prospective, randomized study. SETTING: Operating room of a children's hospital. PATIENTS: 73 ASA physical status I and II children, aged 6-15 years, scheduled for elective day or non-day surgery. INTERVENTIONS: Children were randomly allocated to one of 4 groups prior to i.v. insertion of a 24-gauge catheter in the dorsum of the hand: Group 1 (n = 18): 50% N(2)O in O(2) for three minutes; Group 2 (n = 18): 50% N(2)O in O(2) for 5 minutes; Group 3 (n = 18): 70% N(2)O in O(2) for three minutes; or Group 4 (n = 19): 70% N(2)O in O(2) for 5 minutes. MEASUREMENTS: Just after the venous cannulation, degree of pain was assessed by examining the faces of the patient by the parent and an operating room nurse. MAIN RESULTS: Pain scores obtained from parents of children in Groups 3 and 4 were significantly lower than from those in Groups 1 and 2. Pain scores from the nurse in Group 3 was significantly lower than those in Group 1. However, there was no significant difference in pain score between Group 3 and Group 4. Frequency of side effects was similar among the 4 groups. CONCLUSIONS: Seventy percent N(2)O in O(2) given for three minutes was effective for reducing venipuncture pain in children.