Preoperative evaluation in infants and children: recommendations of the Italian Society of Pediatric and Neonatal Anesthesia and Intensive Care (SARNePI).

BACKGROUND: The preoperative assessment involves the process of evaluating the patient's clinical condition, which is intended to define the physical status classification, eligibility for anesthesia and the risks associated with it, thus providing elements to select the most appropriate and individualized anesthetic plan. The aim of this recommendation was provide a framework reference for the preoperative evaluation assessment of pediatric patients undergoing elective surgery or diagnostic/therapeutic procedures. METHODS: We obtained evidence concerning pediatric preoperative evaluation from a systematic search of the electronic databases MEDLINE and Embase between January 1998 and February 2012. We used the format developed by the Italian Center for Evaluation of the Effectiveness of Health Care's scoring system for assessing the level of evidence and strength of recommendations. RESULTS: We produce a set of consensus guidelines on the preoperative assessment and on the request for preoperative tests. A review of the existing literature supporting these recommendations is provided. In reaching consensus, emphasis was placed on the level of evidence, clinical relevance and the risk/benefit ratio. CONCLUSION: Preoperative evaluation is mandatory before any diagnostic or therapeutic procedure that requires the use of anesthesia or sedation. The systematic prescription of complementary tests in children should be abandoned, and replaced by a selective and rational prescription, based on the patient history and clinical examination performed during the preoperative evaluation.

Update of recommendations for Analgosedation in pediatric intensive care unit.

Effective and adequate therapy to control pain and stress are essential in managing children in Pediatric Intensive Care Unit (PICU) undergoing painful invasive procedures, this should be, but is not yet, one of our main aims. Aware that this difficult mission must be pursued in a systematic, multimodal and multitasking way, the Studying Group on Analgosedation in PICU from the Italian Society of Neonatal and Paediatric Anesthesia and Intensive Care (SARNePI) is providing its recommendations.

Congenital diaphragmatic hernia repair during whole body hypothermia for neonatal hypoxic ischemic encephalopathy.

Major malformations, surgery and persistent pulmonary hypertension (PHT) have been considered contraindications to therapeutic hypothermia (TH) in newborns with hypoxic-ischemic encephalopathy (HIE). We report two patients with undiagnosed congenital diaphragmatic hernia (CDH) who developed HIE after birth. Diagnosis of moderate HIE was formulated based on clinical, laboratory and electroencephalographic criteria. The patients were treated with whole body hypothermia (33.5 °C) for 72 h. During hypothermia the patients underwent surgical repair with regular perioperative course. Ventilatory support with high-frequency oscillatory ventilation, oxygen requirements and inotropic support remained stable during hypothermia. Serial echocardiographic evaluations did not demonstrate any change in pulmonary pressure values. In our experience TH did not increase the risk of hemodynamic instability, PHT or bleeding. Hypothermia may be considered in patients with HIE and CDH or other surgical conditions with favorable prognosis.

Parental role in the Intensive Care Unit for children affected by Werdnig Hoffmann disease.

AIM: The aim of this study was to determine the role of parents after extubation of their children affected by Spinal Muscular Atrophy Type 1 (SMA1) in the Pediatric Intensive Care Unit. Currently, children affected by SMA1 are often treated with non-invasive mechanical ventilation and mechanical support of cough. During the first two or three years of life they frequently present severe respiratory failure requiring intubation. Extubation may be at severe risk of failure even because of inadequate care. METHODS: Parents of SMA1 children were offered an early education on the most critical aspects and a training in non-invasive respiratory support after diagnosis. They were asked and allowed to stay as longer as possible with their child after extubation. Quality and quantity of care given by parents during the first 24 hours after extubation were recorded. RESULTS: All parents participated to the success of the weaning procedure: they gave continuous care and all children could be extubated. CONCLUSION: The presence of parents after extubation of SMA1 patients is important for the success of the procedure; otherwise, the presence of a skilled nurse is needed, with a nurse-patient ratio of 1:1.

Ropivacaine vs bupivacaine in major surgery in infants.

PURPOSE: To assess and compare the onset time and duration of neuroblockade obtained after ropivacaine or bupivacaine in infants undergoing major abdominal surgery. We also evaluated the efficacy and safety of employing ropivacaine instead of bupivacaine to provide operative anesthesia and postoperative analgesia. METHODS: In a prospective double blind study 28 infants, aged 1-12 months, undergoing elective major abdominal surgery, were randomly allocated to receive, after induction of general anesthesia, either 0.7 ml x kg(-1) bupivacaine 0.25% (group B) or ropivacaine 0.2% (group R) via lumbar epidural block. The onset time, total surgical time and duration of analgesia were recorded. RESULTS: No differences were noted in demographic data, hemodynamic variables or duration of surgery. The onset time for sensory blockade was 13.1 min +/- 2.1 (group B) and 11.7 +/- 2.4 min (group R). The duration of analgesia was 491 +/- 291 (group R) and 456 min +/- 247 (group B). Eight patients in group B and six in group R needed codeine and acetaminophen rescue on at least one occasion during the 24 hr study period. No major side effects were noted in either groups. CONCLUSIONS: In infants undergoing major abdominal surgery under combined epidural/light general anesthesia, ropivacaine 0.2% produces sensory and motor blockade similar in onset, duration of action and efficacy to that obtained from an equal volume, 0.7 ml x kg(-1), of bupivacaine 0.25%.

Comparison of ropivacaine with bupivacaine for paediatric caudal block.

In a double-blind, multicentre study 245 children aged 1-10 yr undergoing elective minor surgery as inpatients were randomly allocated to receive a single caudal extradural injection of 1 ml kg-1 of either 0.25% bupivacaine or 0.2% ropivacaine after induction of light general anaesthesia. The groups were comparable for age, weight, vital signs and duration of surgery. The onset time was similar for ropivacaine and bupivacaine (9.7 vs 10.4 min). Further analgesia was not required in 40% of children. The mean time to first analgesia in the remainder was 233 min in the bupivacaine group and 271 min in the ropivacaine group. No motor block was measurable in either group. Ropivacaine 2 mg kg-1 was as effective as bupivacaine 2.5 mg kg-1 for caudal analgesia in children.

[The effects of a dose of epidural clonidine combined with intrathecal morphine for postoperative analgesia]. / Effetti di una dose di clonidina epidurale associata a morfina intratecale sull'analgesia postoperatoria.

OBJECTIVE: To evaluate the effectiveness of a single bolus of epidural (ED) clonidine (C) associated with intrathecal morphine (M) on postoperative analgesia after cesarean section (CS). DESIGN: Prospective double-blind randomized study. SETTING: Obstetric department. PATIENTS: Fourty patients ASA 1-2 submitted to combined spinal-epidural block (CSE) for CS. INTERVENTIONS: A needle through needle set for CSE was used. The intrathecal block was induced with 2.7-3 ml of isobaric 0.5% bupivacaine (B) and 250 micrograms of M. After ED test with 0.5% B, a single bolus of C 150 micrograms in NS 10 ml (group C, n 20) or NS 10 ml as placebo (group P, n 20) was given through the ED catheter. METHODS: The observation for 36 hours evaluated analgesia (VAS until the first dose of additional analgesic, total amount of analgesic and time of first analgesic request) and side effects (variations of arterial pressure and heart rate, motor block, sedation, nausea, vomiting, itching, respiratory depression). Groups were statistically compared. RESULTS: In group C lower analgesic request (significantly between 12th and 18th hour) and significant delay of first request (22.5 +/- 4.1 h) were registered. VAS showed significant trend to opposite sign variations (downwards in group C, upwards in group P) at 1, 2 and 12 hours. In group C lower sistolic arterial pressure at 1 and 4 hours, denser motor block at 2 and 4 hours and mild sedation were observed. CONCLUSIONS: A single ED bolus of C 150 micrograms after CS significantly enhances and prolongs the analgesic effect of M 250 micrograms without important side effects.

Plasma levels of clonidine following epidural bolus injection in children.

BACKGROUND: The use of clonidine as an adjunct to epidural administration of local anesthetics in children has been reported to substantially improve the duration and quality of postoperative analgesia. The aims of the present study were to determine the pharmacokinetic profile and to investigate the interaction between postoperative sedation and analgesia after epidurally administered clonidine in children. METHODS: Plasma levels of clonidine (0-10 h postop) and assessment of postoperative analgesia and sedation (0-24 h postop) were performed at predetermined intervals following lumbar epidural administration of bupivacaine 2.0 mg/kg and clonidine 2 mg/kg in 8 children undergoing ureteral re-implantation surgery using general anesthesia (age range: 1-9 yr, weight range: 9-41 kg). Plasma levels of clonidine were analyzed by radioimmunoassay, and sedation and analgesia were assessed by previously described scoring systems. RESULTS: The venous plasma pharmacokinetics of clonidine following epidural administration showed a considerable interindividual variation. Cmax and Tmax values of clonidine were found to be within the 0.45-0.77 ng/mL and 48-193 min range, respectively. The time to absorb 95% of the clonidine dose from the epidural space into plasma varied between 36 min and 7.6 h. In 6 of the 8 patients postoperative analgesia substantially outlasted the duration of sedation (> or = 2 h). Sedation could not be detected in any patients at plasma concentrations below 0.3 ng/mL. CONCLUSIONS: The pharmacokinetic profile associated with epidural clonidine administration in children (1-9 y) was similar to that previously reported in adults. The postoperative analgesia seen after administration of epidural bupivacaine-clonidine during general anesthesia in children cannot only be explained by residual postoperative sedation.

Ropivacaine in paediatric surgery: preliminary results.

In a double blind study 40 patients, aged 1-9 years, undergoing elective minor surgery were examined and randomly divided in two groups (20 children each). After light general anaesthesia Group 1 received caudal injection of bupivacaine 0.25% 2 mg.kg-1 while Group 2 received 0.2% ropivacaine 2 mg.kg-1. No differences were observed in demographic data, HR, BP and duration of surgery; the onset time of anaesthesia was 12 min and 9 min in Group 1 and 2 respectively. Ten patients in Group 1 received paracetamol in the first 24 h after surgery while only two children in Group 2 needed analgesic; even the duration of analgesia in the patients requiring paracetamol was superior in group 2 (520 min vs 253 min). No motor block was apparent at awakening in either group and no side effect was noticed. In conclusion ropivacaine seems to be an effective and safe drug in paediatric regional anaesthesia.

Peripheral neuropathy in angioimmunoblastic lymphadenopathy with dysproteinaemia.

A case of angioimmunoblastic lymphadenopathy with dysproteinaemia complicated by a subacute peripheral neuropathy is described. Clinically the neuropathy was mainly motor, but pain and paraesthesiae in the legs were also present. Sural nerve biopsy indicated decreased numbers of myelinated fibres, mainly the largest, without actual signs of degeneration or regeneration. However, the occurrence of denervation bands indicated that degeneration had led to loss of myelinated fibres.