A study of the dosage and duration for levobupivacaine infusion by the caudal-epidural route in infants aged 3-6 months.

BACKGROUND: The local anesthetic, levobupivacaine, is the safer enantiomer of racemic bupivacaine. Present protocols for levobupivacaine are based on studies and pharmacokinetic modeling with racemic bupivacaine. AIMS: The aim is to investigate total serum levobupivacaine concentrations after a caudalepidural loading dose followed by a maintenance infusion over 48 hours in infants aged 3-6 months. METHODS: The clinical trial was conducted in eight infants aged 3-6 months, undergoing bladder exstrophy repair. Pharmacokinetic modeling allowed optimization of clinical sampling to measure total levobupivacaine and α1 -acid glycoprotein and prediction of the effect of α1 -acid glycoprotein on levobupivacaine plasma protein binding. RESULTS: The observed median total levobupivacaine serum concentration was 0.30 mg/L (range: 0.20-0.70 mg/L) at 1 hour after the loading dose of 2 mg/kg. The median total levobupivacaine concentration after 47 hours of infusion, at 0.2 mg/kg/h, was 1.21 mg/L (0.07-1.85 mg/L). Concentrations of α1 -acid glycoprotein were found to rise throughout the study period. Pharmacokinetic modeling suggested that unbound levobupivacaine quickly reached steady state at a concentration of approximately 0.03 mg/L. CONCLUSION: The study allows the development of a pharmacokinetic model, combining levobupivacaine and α1 -acid glycoprotein data. Modeling indicates that unbound levobupivacaine quickly reaches steady state once the infusion is started. Simulations suggest that it may be possible to continue the infusion beyond 48 hours.

Cochlear implantation in children with congenital long QT syndrome: Introduction of an evidence-based pathway of care.

Congenital long QT syndrome (cLQTS) is an inherited cardiac ion channelopathy characterized by a long corrected-QT interval on the ECG, associated with a risk of syncope and sudden death as a result of arrhythmias. The archetypal arrhythmia associated with cLQTS is torsade de pointes which may degenerate into ventricular fibrillation. Children with Jervell and Lange-Neilsen syndrome have the combination of cLQTS and congenital sensorineural deafness and may present for cochlear implantation (CI). Sympathetic stimulation and administration of QT-prolonging medications may trigger arrhythmias in children with cLQTS and thus the perioperative period is a time of increased risk of adverse events, with deaths reported in the CI literature. Our Paediatric Cochlear Implant Programme had previously elected to discontinue offering CI to children with cLQTS following a perioperative death. However, subsequent demand for this service by parents led us to develop and introduce a multidisciplinary, evidence-based pathway of care. This pathway modifies the perioperative management of these children to reduce the associated risk. We present the cases of four children with cLQTS who underwent CI in our specialist children's hospital.

Perioperative complications and outcomes in children with cerebral palsy undergoing scoliosis surgery.

INTRODUCTION: Neuromuscular scoliosis is a known risk factor for postoperative complications after corrective spine surgery. Few studies have looked at the preoperative factors affecting postoperative complications in children with cerebral palsy. AIM: The aim of this study was to examine the factors that might influence postoperative course in patients with cerebral palsy undergoing spine surgery for scoliosis. METHODS: Nineteen case notes of children with cerebral palsy who had spine surgery (2008-2014) were reviewed retrospectively. Preoperative comorbidities and postoperative complications were noted and complications were classified as major and minor. RESULTS: Thirteen out of 19 (68.4%) patients had two or more systemic comorbidities. Most common comorbidities included reflux and seizure disorder. Nine patients (49%) had at least one major complication. About 5/19 patients had respiratory complications requiring ventilation and 4/19 had massive blood loss. A higher incidence of postoperative major complication was recorded in the group with two systemic comorbidities as compared to those with less than two systemic comorbidities (47% vs 16%). Both patients who had a single-stage anterior release and posterior fixation had a major complication. CONCLUSION: Presence of two or more comorbidities and thoracotomy are risk factors for perioperative complications in children with cerebral palsy undergoing surgery for scoliosis correction.

CT-guided lung biopsies in children: anesthesia management and complications.

We describe the anesthetic management of three children who underwent CT-guided lung biopsies and the complications associated with the procedure. We discuss the likely causes and recommend steps that would help decrease the risk of these complications during such a procedure.