Development and Validation of a Risk Scale for Emergence Agitation After General Anesthesia in Children: A Prospective Observational Study.

BACKGROUND: Emergence agitation (EA) is a common complication in children after general anesthesia. The goal of this 2-phase study was (1) to develop a predictive model (EA risk scale) for the incidence of EA in children receiving sevoflurane anesthesia by performing a retrospective analysis of data from our previous study (phase 1) and (2) to determine the validity of the EA risk scale in a prospective observational cohort study (phase 2). METHODS: Using data collected from 120 patients in our previous study, logistic regression analysis was used to predict the incidence of EA in phase 1. The optimal combination of the predictors was determined by a stepwise selection procedure using Akaike information criterion. The ß-coefficient for the selected predictors was calculated, and scores for predictors determined. The predictive ability of the EA risk scale was assessed by a receiver operating characteristic (ROC) curve, and the area under the ROC curve (c-index) was calculated with a 95% confidence interval (CI). In phase 2, the validity of the EA risk scale was confirmed using another data set of 100 patients (who underwent minor surgery under general anesthesia). The ROC curve, the c-index, the best cutoff point, and the sensitivity and specificity at the point were calculated. In addition, we calculated the gray zone, which ranges between the two points where sensitivity and specificity, respectively, become 90%. RESULTS: In phase 1, the final model of the multivariable logistic regression analysis included the following 4 predictors: age (logarithm odds ratios [OR], -0.38; 95% CI, -0.81 to 0.00), Pediatric Anesthesia Behavior score (logarithm OR, 0.65; 95% CI, -0.09 to 1.40), anesthesia time (logarithm OR, 0.60; 95% CI, -0.18 to 1.19), and operative procedure (logarithm OR, 2.53; 95% CI, 1.30-3.75 for strabismus surgery and logarithm OR, 2.71; 95% CI, 0.99-4.45 for tonsillectomy). The EA risk scale included these 4 predictors and ranged from 1 to 23 points. In phase 2, the incidence of EA was 39%. The c-index of phase 1 was 0.84 (95% CI, 0.74-0.94), and the c-index of phase 2 was 0.81 (95% CI, 0.72-0.89). The best cutoff point for the EA risk scale was 11 (sensitivity = 87% and specificity = 61%). The gray zone ranged from 10 to 13 points, and included 38% of patients. CONCLUSIONS: We developed and validated an EA risk scale for children receiving sevoflurane anesthesia. In our validation cohort, this scale has excellent predictive performance (c-index > 0.8). The EA risk scale could be used to predict EA in children and adopt a preventive strategy for those at high risk. This score-based preventive approach should be studied prospectively to assess the safety and efficacy of such a strategy.

Electrical stimulation of the heart 7 acupuncture site for preventing emergence agitation in children: A randomised controlled trial.

BACKGROUND: Emergence agitation is common in children recovering from general anaesthesia. The prevention of emergence agitation remains an important challenge in the field of paediatric anaesthesia. OBJECTIVE: We aimed to examine the effectiveness of electrically stimulating the heart 7 (HT7) acupuncture site with a peripheral nerve stimulator (PNS) during surgery, for preventing emergence agitation in paediatric patients recovering from general anaesthesia. DESIGN: A double-blind, randomised, controlled, parallel-group trial. SETTING: Kanagawa Children's Medical Centre, Yokohama, Japan. PATIENTS: One hundred and twenty patients aged 18 to 96 months (American Society of Anesthesiologists physical status I or II) undergoing minor elective surgery under general anaesthesia with sevoflurane. INTERVENTION: Patients were randomly assigned to either undergo bilateral stimulation of HT7 with two PNS devices (1 Hz, 50 mA) during surgery (Group HT7) or a control group that did not undergo electrical stimulation of HT7 during surgery. MAIN OUTCOME MEASURES: The primary outcome was the incidence of emergence agitation evaluated in the postanaesthesia care unit (PACU) using the Paediatric Anaesthesia Emergence Delirium scale. The secondary outcomes were the time from operation completion to tracheal extubation, PACU stay duration and postoperative pain scores. RESULTS: The incidence of emergence agitation was significantly lower in the HT7 group compared with the control group (31.7 vs. 56.7%, respectively; P = 0.010). The risk ratio was 0.56 (95% confidence interval 0.36 to 0.86) and the number needed to treat was 4 (95% confidence interval 3 to 13). There were no statistically significant differences between groups in time from operation completion to tracheal extubation, PACU stay duration or postoperative pain. CONCLUSION: Bilateral electrical stimulation of HT7 using two PNS devices significantly decreases the incidence of emergence agitation. TRIAL REGISTRATION: UMIN Clinical Trial Registry (registry number: UMIN000011704).

Inadequate spinal anesthesia in a patient with marfan syndrome and dural ectasia.

Lumbosacral dural ectasia is frequently observed in patients with Marfan syndrome. Although neuraxial anesthesia is often used in peripartum anesthetic management, few reports describe the effects of dural ectasia on the spread and duration of neuraxial anesthesia. We report a case of combined spinal-epidural anesthesia for a cesarean delivery in a patient with Marfan syndrome in whom complications probably related to dural ectasia occured.

[Airway management in children with vallecular cyst: review of 25 cases--can we predict difficult intubation?].

BACKGROUND: Vallecular cysts frequently cause difficult intubation due to poor glottic visualization during direct laryngoscopy. The appropriate way of airway management and predictive factors of difficult intubation are unknown. METHODS: We reviewed anesthetic induction and airway management in 25 cases of vallecular cysts for the past 11 years. We collected the following data of 24 cases in 20 children who were intubated under direct laryngoscopy: age (month), height (cm), weight (kg), cyst-diameter (mm), cyst-diameter to patient-height ratio, and clinical symptoms. These data were compared between difficult intubation group (group A) and easy or slightly difficult intubation group (group B). RESULTS: In the majority of cases, anesthesia was induced with spontaneous ventilation maintained. Group A and B consisted of 6 and 18 cases, respectively. All cases of group A required assistive devices such as stylets or tube introducers. Cyst-diameter to patient-height ratios were significantly higher in group A than in group B (0.26 vs. 0.18, P = 0.03). CONCLUSIONS: Because children with vallecular cysts have a risk of difficult airway, we need to prepare for difficult airway management. The cyst-diameter to patient-height ratio could be useful as a predictor of difficult intubation.

Functional-food constituents in the fruiting bodies of Stropharia rugosoannulata.

Nine compounds (1-9) were isolated from the fruiting bodies of Stropharia rugosoannulata. Compounds 1-5, 8, and 9 suppressed the formation of osteoclast. Compounds 2 and 5 showed anti-fungal activity, and their MIC were 250 µM and 500 µM respectively. Compounds 2-6 showed inhibitory effects on thapsigargin toxicity.

Anesthetic management of a child with Aicardi syndrome undergoing laparoscopic Nissen's fundoplication: a case report.

Aicardi syndrome (AS) is a rare congenital syndrome and is characterized by the triad of infantile spasm, agenesis of the corpus callosum, and anomaly of chorioretinal lacunae. We here report a case of a patient with AS under general anesthesia. Although there is no report in which muscle relaxants were used in AS patients, vecuronium bromide was used for artificial pneumoperitoneum in this case. Careful management is important for AS patients during an operation that significantly affects respiratory function. In addition, it is possible that muscle relaxants be administered safely in AS patients. Careful monitoring such as epileptiform electroencephalogram and bispectral index monitors may be needed for the early detection of epileptic activities.

[Anesthetic management for laryngoscopic evaluation of upper airway stenosis using our modified endoscopic mask].

Young children are at increased risk for hypoxaemia and hypercapnea during flexible laryngoscopy due to the small size and increased collapsibility of their airways. To evaluate upper airway stenosis of a 5-year-old girl presenting with retractive inspiratory breathing, we developed a modified endoscopy mask consisting of a regular face mask where the original port for endoscope was replaced by a disposable rubber dam. This setting allows a leak-free passage of both nasal and oral endoscopy and enables emergent endoscopic intubation through a small hole of a rubber dam. Using this airtightly sealed modified mask, we successfully managed diagnostic endoscopy of laryngomalacia and evaluated infolding of arytenoids under spontaneous ventilation with 100% oxygen.

The carina is not a landmark for central venous catheter placement in neonates.

BACKGROUND: Cardiac tamponade is rare but one of the most serious complications in relation to central venous catheters (CVC). The tip of the CVC should be placed outside the pericardium to avoid tamponade. In adults, the carina is always located above the pericardium; therefore, the carina is a reliable landmark for CVC placement. We examined whether the carina could also be an adequate landmark for CVC placement in neonates. METHODS: The study was conducted using nine fresh neonatal cadavers. The longitudinal distance between the carina and the pericardium as it transverses the superior vena cava (the pericardial reflection: PR) was measured. RESULTS: The median postconceptional age (gestational age in weeks + weeks after delivery) at autopsy was 35 (range: 23-42) weeks. The PR was located at a distance of 4 mm above to 5 mm below the carina. Unlike in adults, the position of the PR varies in relation to the carina in neonates. In seven of the nine subjects, the location of the PR was above the carina. CONCLUSIONS: In neonates, the carina is not always located above the pericardium, as it is in adults; therefore, the carina is not an appropriate landmark for CVC placement.

[Anesthetic management for a child with pompe disease].

Pompe or glycogen storage disease type II is a genetic disorder affecting the cardiac and skeletal muscle. A 4-year-old boy with this disease was scheduled to undergo an orthopedic operation for clubbed foot. He had cardiomyopathy and skeletal muscle weakness; but his cardiac function was normalized by the long-term enzyme replacement therapy. General anesthesia was slowly induced with oxygen, nitrous oxide, and sevoflurane, and tracheal intubation was achieved without any muscle relaxants. In combination with a caudal blockade with 6 ml of 0.375% ropivacaine, general anesthesia was successfully maintained with oxygen, nitrous oxide, and sevoflurane. We did not use muscle relaxants to avoid prolonged respiratory depression. The perioperative course was uneventful and no complication was observed.

[The management of the difficult pediatric airway].

BACKGROUND: We are faced sometimes with the difficult pediatric airway due to congenital abnormalities. However, there has been no systematic examination for the management of the difficult pediatric airway. METHODS: We retrospectively examined the incidence of difficult airway in 13,557 pediatric patients who had undergone general anesthesia with tracheal intubation. The difficulties of the intubation were classified into grade 1 to 4; grade 1: intubated one time, grade 2: two times, grade 3: three times or more, grade 4: changed to another way. We defined grade 3 and 4 as "difficult airway". RESULTS: Twenty-five patients (0.17%) are "difficult airway" among 13,557 patients in which 21 patients (0.15%) are classified as grade 3, and 4 patients (0.02%) are grade 4. The difficulties were significantly different among the syndromes (P< 0.001). The rate of the incidence in the difficulty is high in Treacher Collins syndrome, arthrogryposis multiprex congenita and first and second brachial arch syndrome, but few is in Pierre-Robin syndrome, Crouzon syndrome and Apert syndrome which are known to accompany difficult airway. CONCLUSIONS: We demonstrated that the incidence of difficult airway is different among the syndromes.

A comparison of five techniques for detecting cardiac activity in infants.

BACKGROUND: The new guidelines for cardiopulmonary resuscitation recommend that laypersons should begin chest compressions without checking for a pulse because the pulse check has serious limitations in accuracy. We determined the efficacy of the most suitable method to search for cardiac activity in infants. METHODS: Twenty-eight nurses tried to detect infants' cardiac activity and determined their heart rates with five different techniques: palpation of brachial pulse, carotid pulse, femoral pulse, apical impulse and auscultation of apical impulse with the naked ear (direct auscultation technique). RESULTS: The mean time interval required to find the pulse within 30 s in the auscultation, the apical, the brachial, the carotid and the femoral were 2.4 +/- 1.2, 3.5 +/- 2.7, 4.0 +/- 2.7, 9.9 +/- 7.0 and 9.1 +/- 5.9 s, respectively. The required time was significantly shorter in the auscultation method than in the palpation of carotid and femoral pulses. The percentage and 95% confidence intervals (95% CI) of pulses identified within 10 s (= the number of the correct identified within 10 s/the number of all cases) in auscultation, apical, brachial, carotid and femoral palpations were 100.0% (95% CI 51.8, 100), 75.0% (95% CI 28.9, 89.3), 73.1% (95% CI 52.2, 88.4), 50.0% (95% CI 30.6, 69.4) and 42.9% (95% CI 24.5, 62.8), respectively. These values were greater in the auscultation method than in all the palpation methods. CONCLUSIONS: The direct auscultation technique was more rapid and accurate than any other techniques to determine cardiac activity without instruments. It is suggested that direct a auscultation technique is also superior to the palpation of brachial artery in cardiopulmonary resuscitation in infants.

Higher airway seal does not imply adequate positioning of laryngeal mask airways in paediatric patients.

BACKGROUND: It has been generally accepted that a higher airway seal pressure indicates adequate positioning of the laryngeal mask airway (LMA) in adult patients. The present study was undertaken to clarify whether a higher airway seal pressure correlates with an adequate positioning of the LMA in paediatric patients. METHODS: One hundred and eighty-one healthy children, aged 6-121 months, weighing 7.0-30.0 kg, managed with size 1.5-2.5 LMAs during elective surgery, were enrolled in this study. LMAs were inserted without using muscle relaxants, and patients breathed spontaneously during surgery. At the end of surgery, we documented oropharyngeal sealing pressure and fibreoptic aperture views of the LMA. We used a new fibreoptic score evaluating the anatomical relationship between LMA aperture and epiglottis: 1, the aperture view covered with anterior epiglottis completely, but the airway staying open; 2, anterior epiglottis seen for more than two-thirds of the aperture view in diameter; 3, anterior epiglottis seen for more than one-third, but less than two-thirds of the aperture view in diameter; and 4, anterior epiglottis seen for less than one-third of the aperture view in diameter. RESULTS: The oropharyngeal sealing pressures for each fibreoptic position, scores 1 to 4, were 17.0 +/- 6.4, 17.9 +/- 4.2, 20.1 +/- 7.3 and 17.1 +/- 6.1 cm H2O, respectively. There were no significant differences in sealing pressure between the four groups (P=NS). CONCLUSIONS: A higher airway seal is believed to be one of the clinical signs correlating with the correct position of an LMA. We found no relationship between oropharyngeal sealing pressure and LMA cuff position in paediatric patients.