Hemodynamic and pharmacokinetic analysis of oxymetazoline use during nasal surgery in children.

OBJECTIVES/HYPOTHESIS: Oxymetazoline is an α-adrenergic agonist that is commonly used as a topical hemostatic agent in the operating room during ear, nose, and throat surgery. There are limited data on oxymetazoline pharmacokinetics in children who undergo general anesthesia. We assessed the hemodynamic effects and systemic absorption of topically applied oxymetazoline in children undergoing various nasal procedures. STUDY DESIGN: Prospective trial. METHODS: Children ages 2 to 17 years undergoing functional endoscopic sinus surgery, turbinate resection, or adenoidectomy were enrolled. The surgeon placed oxymetazoline-soaked pledgets (1.5 mL of 0.05% solution) according to our usual clinical practice. Blood samples for oxymetazoline assay were drawn at 5, 10, 20, 45, 90, and 150 minutes, and hemodynamic data were recorded at 5-minute intervals. Data analysis included mixed-effects regression and population pharmacokinetic/pharmacodynamic modeling. RESULTS: The analysis included 27 patients, age 7 ± 4 years, who received between 2 and 12 pledgets (3-18 mL) of oxymetazoline. Relative bioavailability compared to the spray formulation was 2.3 (95% confidence interval [CI]: 1.6-3.2), with slow absorption from the mucosal surface (absorption half-life 64 minutes; 95% CI: 44-90). Mean arterial pressure did not increase with oxymetazoline instillation at the observed oxymetazoline serum concentrations (0.04-7.6 µg/L). CONCLUSIONS: Despite concerns regarding oxymetazoline administration to mucosal membranes, we found that hemodynamic changes were clinically negligible with our usual clinical use of pledgets soaked in oxymetazoline. Compared to data on oxymetazoline in spray formulation, bioavailability was increased twofold with pledgets, but systemic absorption was very slow, contributing to low serum concentrations and limited hemodynamic effects. LEVEL OF EVIDENCE: 1b. Laryngoscope, 129:2775-2781, 2019.

Progress to publication of survey research presented at anesthesiology society meetings.

BACKGROUND: Understanding how survey methodology and quality measures are associated with progress from abstract presentation to manuscript publication can help optimize the design of survey research in anesthesiology, and enhance respondents' confidence in the value of survey participation. AIMS: The aim of this study was to determine if adherence to survey method recommendations and attainment of high response rates are associated with faster progress to publication among abstracts initially presented at anesthesiology society meetings. METHODS: Abstracts from the American Society of Anesthesiologists' (ASA) Annual Meeting, Association of Anaesthetists of Great Britain and Ireland (AAGBI) Annual Congress, and the International Anesthesia Research Society (IARS) Annual Meeting from 2011-2014 were reviewed. Abstracts reporting original survey data collection were included in a systematic search for resulting publications in peer-reviewed academic journals. Cox proportional hazards regression was used to analyze progress to publication. RESULT: Ninety-nine ASA, 76 AAGBI, and 30 IARS abstracts met inclusion criteria. Among these abstracts, 43 (43%) from ASA, none from AAGBI, and 7 (23%) from IARS have been published as original research articles or brief reports. Surveying patients or caregivers, as opposed to medical professionals, was associated with increased likelihood of publication (hazard ratio [HR] = 4.4, 95% confidence interval [CI]: 1.6, 12.4, P = 0.005) as was a larger sample size (eg, >500 vs <100; HR = 12.9, 95% CI: 3.8, 43.6, P < 0.001). CONCLUSIONS: While abstract presentation facilitates rapid dissemination of survey research findings, the impact and utility of such studies may be limited until a full manuscript is published. In our review, 25% of abstracts presenting survey data at major anesthesiology meetings were eventually published. Larger sample sizes and a target population of patients or caregivers increased the likelihood of survey research being published in full form.

Current perioperative care of infants with pyloric stenosis: comparison of survey results.

BACKGROUND: Considerable variation in the perioperative management of infants with pyloric stenosis (PS) led the authors to undertake a survey of pediatric anesthesiologists to determine if consensus-based guidelines could be developed. MATERIALS AND METHODS: Physicians who are members of the Society for Pediatric Anesthesia or the Association of Pediatric Anaesthetists of Great Britain and Ireland completed an online questionnaire through SurveyMonkey regarding current management of patients with PS. RESULTS: There were significant differences in the use of anticholinergic premedication, the selection of induction technique, and the use of adjuvant regional analgesia between the members of both organizations. CONCLUSIONS: The authors recommend creating an international multiinstitutional registry to prospectively record and track perioperative management of patients with PS to facilitate the development of clinical practice guidelines.

Hemodynamic profile and behavioral characteristics during induction of anesthesia in pediatric patients with attention deficit hyperactivity disorder.

AIM: There is no consensus regarding the administration of stimulant drugs preoperatively, particularly in pediatric patients diagnosed with ADHD. The primary objective of the current study was to assess differences in blood pressure and heart rate before and after induction of anesthesia between patients on chronic amphetamine or methylphenidate therapy who receive their normal dose preoperatively compared to patients in whom the prescribed medication was withheld. Secondary objectives were to assess the anxiety level during the induction of anesthesia and the effect of premedication with midazolam. METHOD: Patients, ranging in age from 2 through 18 years, were enrolled if they were diagnosed with ADHD, were taking amphetamines or methylphenidate at any time in the 6 months prior to admission, and were undergoing an outpatient surgical or diagnostic procedure. The study cohort was divided into those who took their ADHD medications prior to surgery and those who did not take their medications preoperatively. The primary objective was addressed by comparing heart rate, systolic and diastolic BP, and mean arterial pressure before and during anesthetic induction between the two groups. Hypotension after anesthetic induction was defined as systolic blood pressure and mean arterial pressure <5th percentile for age. To address the secondary objectives, modified Yale Preoperative Anxiety Scale (mYPAS) scores assessed prior to induction and during induction were compared between groups. RESULTS: Fifty patients were enrolled, 14 of whom took their ADHD medication and 34 of whom did not take ADHD medication preoperatively. Two patients with unknown ADHD medication status were excluded from the primary analysis (stratification by medication withholding), but all 50 patients were used for the secondary analysis (stratification by midazolam use). There was no intraoperative hypotension in either group. Despite weak evidence for a difference in heart rate between the group receiving medication and the group with no medication (96.8 ± 14.0 vs 88.0 ± 14.0 beats/min; difference of means = 8.8; 95% CI of difference: 0.2, 17.7; P = 0.055), there was no evidence for differences between the groups in systolic BP, diastolic BP, or mean arterial pressure. There were no differences between groups in mYPAS at the two time periods assessed. CONCLUSION: The evidence suggests that continuing preoperative stimulant medication is not associated with cardiovascular instability in the pediatric population. The evidence suggests that withholding or allowing stimulant medication preoperatively does not improve behavior on anesthetic induction or reduce the need for anxiolytic medication. Research efforts should focus on perioperative management strategies that will decrease the likelihood of long-term behavioral issues.

Oxymetazoline Metered Dose Spray: Factors Affecting Delivery Volume.

OBJECTIVES: The current study compared the amount of oxymetazoline delivered by various anesthesia providers when holding the bottle in the upright and inverted position. Additionally, the amount delivered from a full bottle and a half-full bottle was also investigated. METHODS: Using an analytical balance that was calibrated to zero, we evaluated the impact the position of the bottle and the volume of oxymetazoline in the bottle had on the amount being delivered by both anesthesia staff and trainees. RESULTS: When using both filled and half-filled bottles, the amount delivered increased significantly when comparing the upright versus inverted position. With a full bottle, the amount delivered when the bottle was inverted increased almost 10-fold from 62 ± 80 to 606 ± 366 µL (p < 0.0001). Similarly, even with a half-filled bottle, the amount delivered increased in the inverted positions from 41 ± 48 to 645 ± 393 µL. Regardless of the scenario, we also noted significant variation from provider to provider. CONCLUSIONS: Our results demonstrate that several factors may affect the amount of oxymetazoline delivered for metered dose bottles. Given the potential for severe end-organ effects with excessive dosage, alternative means of delivery are needed for its perioperative use.

Perioperative care of infants with pyloric stenosis.

Pyloric stenosis (PS) is one of the most common surgical conditions affecting neonates and young infants. The definitive treatment for PS is surgical pyloromyotomy, either open or laparoscopic. However, surgical intervention should never be considered urgent or emergent. More importantly, emergent medical intervention may be required to correct intravascular volume depletion and electrolyte disturbances. Given advancements in surgical and perioperative care, morbidity and mortality from PS should be limited. However, either may occur related to poor preoperative resuscitation, anesthetic management difficulties, or postoperative complications. The following manuscript reviews the current evidence-based medicine regarding the perioperative care of infants with PS with focus on the preoperative assessment and correction of metabolic abnormalities, intraoperative care including airway management (particularly debate related to rapid sequence intubation), maintenance anesthetic techniques, and techniques for postoperative pain management. Additionally, reports of applications of regional anesthesia for either postoperative pain control or as an alternative to general anesthesia are discussed. Management recommendations are provided whenever possible.

SUBMUCOSAL DISSECTION OF THE RETROPHARYNGEAL SPACE DURING NASAL INTUBATION.

Various complications have been reported with nasal endotracheal intubation including bleeding, epistaxis, bacteremia, damage to intranasal structures, and even intracranial penetration. We present two cases that required general anesthesia for dental surgery. Submucosal dissection of the retropharyngeal tissues occurred during attempted nasal endotracheal intubation. Previous reports of this complication are reviewed, treatment strategies presented, and potential maneuvers to prevent this complication suggested.

Current practices regarding codeine administration among pediatricians and pediatric subspecialists.

Pharmacogenomic studies have revealed a wide variation in the metabolism of codeine to its active metabolite, morphine. A particular subset of patients, known as ultrarapid metabolizers, possesses multiple copies of the CYP2D6 gene responsible for codeine metabolism. This has been linked to serious morbidity and mortality in pediatric patients leading to considerable debate regarding the use of codeine for analgesia in the pediatric population. The current study surveyed the current practice of codeine prescription in pediatric health care providers from a single tertiary care pediatric hospital. Of the 298 responders, 43.3% (129 of 298) continue to prescribe codeine for pain management in children. The vast majority of codeine prescribers were primary health care providers (89.1%). Most of the primary care practitioners were in office-based (42.6%) or hospital-based (45.7%) group practices. There was no significant difference in codeine use based on years of experience. Given the risks associated with this practice, increased education targeting this group appears warranted.