A retrospective study about cerebral near-infrared spectroscopy monitoring during paediatric cardiac surgery and intra-operative patient blood management.

OBJECTIVES: Cerebral non-invasive monitoring of oxygen saturation by near-infrared spectroscopy (rSO2) during paediatric cardiac surgery is supposed to decrease the risk of neurological complications. Since haemoglobin level is one of the factors changing rSO2, we aimed to explore if rSO2 monitoring influences intra-operative RBC (red blood cell) transfusion threshold and volumes, as well as the duration of ICU stay. METHODS: The design was a retrospective analysis involving 91 children less than 2 years of age (including 16 neonates) with a congenital heart disease requiring surgical treatment with or without cardiopulmonary bypass from January 2006 to August 2009. Systematic rSO2 monitoring was introduced after September 2007 (n=56). The independent factors associated with the intra-operative transfusion threshold haemoglobin (Hb) level>9.5g/dL, total volume of intra-operative RBC transfusion<30mL/kg and ICU stay<6 days were identified by multivariate analysis logistic regression. Data were expressed as medians (25-75%). RESULTS: Cardiac malformations and demographic characteristics were similar in both periods. Two independent factors, weight and rSO2 monitoring, were identified as independent factors associated with the three end-points. The transfusion threshold, total transfusion volume and ICU stay with and without rSO2 were 9.8 (8.9 to 10.3) versus 8.7 (8.2 to 9.6) g/dL (P<0.0001), 20 (14-49) versus 36 (22.5-51.5) mL/kg (P=0.0165) and 5 (3-8) versus 7 (5-10.7) days (P=0.0084), respectively. CONCLUSION: rSO2 monitoring changed our transfusion strategy with an earlier transfusion but a reduced total RBC volume and decreased the length of ICU stay.

An opioid-free anaesthetic using nerve blocks enhances rapid recovery after minor hand surgery in children.

BACKGROUND AND OBJECTIVE: The aim of this prospective randomized study was to evaluate the quality of analgesia, postoperative comfort and subsequent duration of hospitalization after distal hand surgery and peripheral nerve block at the wrist for paediatric outpatients. METHODS: Sixty consecutive ASA I or II children were randomly assigned to the following groups: in group B (block), intraoperative and postoperative analgesia was provided by peripheral nerve block; and in group O (opioids), intraoperative and postoperative analgesia was provided by intravenous opioids. The patients' age, sex and type of surgery were recorded as were the postoperative pain management and postoperative vomiting. Time to discharge from the recovery room, the postoperative ward and the time to discharge home were also noted. RESULTS: The two groups were similar with respect to age, sex, ASA physical status, weight, height and types of injuries. The incidence of postoperative pain (CHEOPS score >or=7) and the incidence of postoperative vomiting were significantly higher in group O than in group B: 26.6 versus 3.3%; P = 0.025, and 33.3 versus 6.6%; P = 0.011, respectively. The time before oral intake was significantly longer in group O than in group B [187 (75-265) min versus 60 (32-125) min, respectively, P = 0.0002]. The time to meet discharge home criteria was 277 (230-330) min in group O versus 210 (145-260) min in group B (P = 0.0039). CONCLUSION: The present study demonstrates for the first time that, after distal hand surgery in children, peripheral nerve block improves pain management, opioid analgesia-induced side effects and provides a shorter postoperative recovery time than systemic analgesia with opioids.

Single-breath vital capacity rapid inhalation induction with sevoflurane: feasibility in children.

BACKGROUND: Single-breath vital capacity technique is currently administered for inhalation induction of anesthesia with sevoflurane in adults. Because sevoflurane is used in children, the aim of this open nonrandomized trial was to explore the feasibility and acceptance of this technique in midazolam premedicated patients aged from 4 to 15 years old. METHODS: A pediatric population (n = 118) was instructed in the vital capacity technique after their arrival in the induction room in a standardized and playful manner. Induction was performed with a circle-absorber breathing circuit, primed with sevoflurane 7% in 100% O2. Success of the single-breath vital capacity, delay of induction, hemodynamic and airway tolerance, acceptance by the children and side effects were analyzed. A multivariate logistic regression model was used to identify independent risk factors associated with the failure of the vital capacity technique. RESULTS: Single-breath vital capacity technique was achieved by 57% of the children. The success rate highly correlated with age and ranged from 10% in 4-5 years old to 75% at 11 years and 95% by 14 years. Other factors for success were cooperation and understanding. The need for more than two explanations of the technique was predictive of failure. Delays in the loss of the eyelash reflex and central pupil myosis were obtained in 34 s (18-50) and 242 s (145-278), respectively [median (interquartile ranges)]. Hemodynamic tolerance was good with few airway complications. CONCLUSION: Rapid anesthesia induction using a single-breath technique with 7% sevoflurane is effective and well tolerated in children, particularly in those above 9 years of age, and in fact, success rate was markedly lower in the young age groups.

Is haemostasis biological screening always useful before performing a neuraxial blockade in children?

BACKGROUND: Because of the lack of controlled studies, there is no consensus of opinion about the practice of routine haemostasis tests before neuraxial blockade in children. The purpose of this study was to compare the influence of two different strategies of coagulation evaluation on the incidence of diagnosed coagulopathies leading to a modification of the preoperative or anaesthetic management in children who were scheduled for caudal, epidural or intrathecal block. METHODS: For a 24-month period (period 1, retrospective study, n=751), haemostasis screening was undertaken only after family and personal history and physical examination in all patients. For the following 24 months (period 2, prospective study, n=958), a standardized questionnaire was used. In addition, routine tests (prothrombin, partial thromboplastin time, platelet count) were performed in children who where not yet walking. In older children, coagulation tests were undertaken as in period 1. RESULTS: Overall, 26 significant abnormalities were diagnosed. Coagulation tests were performed in 16.2% (period 1) and 78.2% (period 2) of the children, who were not yet walking. Routine tests did not improve the diagnosis of haemostasis abnormalities justifying a modification of the preoperative and anaesthetic management (2.2% from 406 children in period 1 vs 4.1% from 266 children in period 2). The predictive positive value of routine tests (period 2) was 19%, vs 45% for specific tests (period 1) (P < 0.001). In older children, the use of a standardized form increased the number of haemostasis screenings without improvement of diagnosis leading to modified preoperative management (0.3% from 315 children in period 1 vs 0.5% from 628 children in period 2). CONCLUSIONS: When routine testing is performed in nonwalking children, the screening number increases without leading to a higher number of anaesthetic management changes, suggesting that routine testing does not seem to provide much extra information in the absence of a positive history.