Checking the basis of intraosseous access-Radiological study on tibial dimensions in the pediatric population.

BACKGROUND: Malposition of intraosseous needles in pediatric patients is frequently reported. Incorrect needle length and penetration depth related to the puncture site and level are possible causes. AIMS: Aim of this study was to analyze anatomic dimensions of the proximal tibia in the pediatric population with respect to intraosseous needle placement and needle tip position. METHODS: Plain lower leg radiographs of children aged from birth to 16 years of age were analyzed. Pretibial tissue layer, cortical bone thickness, and the diameter of the medullary cavity were measured at two different puncture levels. Data were analyzed as descriptive statistics and by polynomial regression plots and set in context to commonly used EZ-IO® needle lengths of 15 and 25 mm. RESULTS: Radiographs from 190 patients (104 boys/86 girls) were included. When fully inserted to skin level, up to 10.5% of needles do not reach medullary cavity at one and 18.5% at two patient's fingerbreadths distal to tibial tuberosity. The opposite cortical wall is touched or penetrated in 16% and 25%, respectively. Up to 96% of too deep needle tip positions occur in children younger than 24 months, as do too superficial tip positions in 59%. CONCLUSIONS: Puncture level and needle length have a great influence on potential needle tip positions. Infants and toddlers are at highest risk for malpositioning. Due to relevant growth-related differences in tibial anatomy, an age-related and well-reflected approach is crucial to successfully establish intraosseous access.

Patient- and Physician-Reported Outcome of Combined Fractional CO2 and Pulse Dye Laser Treatment for Hypertrophic Scars in Children.

BACKGROUND: Hypertrophic scars are commonly seen in children and associated with pruritus, pain, functional impairment, and aesthetic disfigurement. Ablative fractional CO2 and pulse dye laser are emerging techniques to improve scar quality. Only limited data are available on children, nonburn scars, and patient-reported outcome. We aimed to investigate safety and outcome of repeated laser therapy for hypertrophic scars originating from burns and other conditions by means of patient- and physician-reported outcome measures. METHODS: This was a retrospective before-after analysis of laser treatments in children with hypertrophic scars. Outcome was measured using Patient and Observer Scar Assessment Scale, Vancouver Scar Scale and Itch Man Scale. With respect to safety, laser- and anesthesia-related complications were analyzed. RESULTS: Seventeen patients, aged 11.37 ± 4.82 years with 27 scars, underwent 102 distinct laser treatments, mainly combined CO2 and pulse dye laser (94%), with few CO2 only (6%). Vancouver Scar Scale total score before the first and after the first session decreased significantly from 7.65 ± 2.12 to 4.88 ± 1.73; Patient and Observer Scar Assessment Scale observer overall opinion also dropped from 5.88 ± 1.57 to 4.25 ± 1.70. Pruritus improved significantly. Patient age and timing of laser intervention did not have an impact on treatment response. Complications related to laser treatment were seen in 2% (wound infection, n = 2) and to anesthesia in 4% (insignificant n = 2, minor n = 1). CONCLUSIONS: Combined laser therapy significantly improves quality, pain, and pruritus of hypertrophic scars in children. When provided by experienced laser and anesthesia teams, it is safe with a low rate of complications.

Intraosseous infusion in elective and emergency pediatric anesthesia: when should we use it?

PURPOSE OF REVIEW: Difficulties to establish a venous access may also occur in routine pediatric anesthesia and lead to hazardous situations. Intraosseous infusion is a well tolerated and reliable but rarely used alternative technique in this setting. RECENT FINDINGS: According to recent surveys, severe complications of intraosseous infusion stay a rare event. Minor complications and problems in getting an intraosseous infusion started on the other side seem to be more common than generally announced. The EZ-IO intraosseous infusion system has received expanded EU CE mark approval for an extended dwell time of up to 72 h and for insertion in pediatric patients in the distal femur. Key values of blood samples for laboratory analysis can be obtained with only 2 ml of blood/marrow waste and do also offer reliable values using an I-Stat point-of-care analyzer. SUMMARY: Most problems in using an intraosseous infusion are provider-dependent. In pediatric anesthesia, the perioperative setting should further contribute to reduce these problems. Nevertheless, regular training, thorough anatomical knowledge and prompt availability especially in the pediatric age group are paramount to get a seldom used technique work properly under pressure. More longitudinal data on large cohorts were preferable to further support the safety of the intraosseous infusion technique in pediatric patients.

Controlled rapid sequence induction and intubation - an analysis of 1001 children.

BACKGROUND: Classic rapid sequence induction puts pediatric patients at risk of cardiorespiratory deterioration and traumatic intubation due to their reduced apnea tolerance and related shortened intubation time. A 'controlled' rapid sequence induction and intubation technique (cRSII) with gentle facemask ventilation prior to intubation may be a safer and more appropriate approach in pediatric patients. The aim of this study was to analyze the benefits and complications of cRSII in a large cohort. METHODS: Retrospective cohort analysis of all patients undergoing cRSII according to a standardized institutional protocol between 2007 and 2011 in a tertiary pediatric hospital. By means of an electronic patient data management system, vital sign data were reviewed for cardiorespiratory parameters, intubation conditions, general adverse respiratory events, and general anesthesia parameters. RESULTS: A total of 1001 patients with cRSII were analyzed. Moderate hypoxemia (SpO2 80-89%) during cRSII occurred in 0.5% (n = 5) and severe hypoxemia (SpO2 <80%) in 0.3% of patients (n = 3). None of these patients developed bradycardia or hypotension. Overall, one single gastric regurgitation was observed (0.1%), but no pulmonary aspiration could be detected. Intubation was documented as 'difficult' in two patients with expected (0.2%) and in three patients with unexpected difficult intubation (0.3%). The further course of anesthesia as well as respiratory conditions after extubation did not reveal evidence of 'silent aspiration' during cRSII. CONCLUSION: Controlled RSII with gentle facemask ventilation prior to intubation supports stable cardiorespiratory conditions for securing the airway in children with an expected or suspected full stomach. Pulmonary aspiration does not seem to be significantly increased.

Fasting times and gastric contents volume in children undergoing deep propofol sedation--an assessment using magnetic resonance imaging.

AIM: To investigate the effect of fasting times for clear fluids and solids/non-clear fluids on gastric content volume using magnetic resonance imaging (MRI). METHODS: Pediatric patients undergoing diagnostic MRI under deep propofol sedation, with the stomach located within the area of diagnostic study, were included in this clinical observational study. According to standard institutional guidelines, children were allowed to eat/drink until 4 h and to drink clear fluids until 2 h before scheduled induction time of anesthesia. Gastric content volume per kg body weight (GCV(w)) was determined using MRI and compared with actual fasting times prior to induction. RESULTS: Overall 68 patients aged from 0.3 to 19.6 (2.8) years were investigated. Fasting time for clear fluids ranged from 1.1 to 15.5 (5.5) h, for non-clear fluids/solids from 4.0 to 20.2 (6.7) h. GCV(w) ranged from 0.2 to 6.3 (0.75) ml·kg(-1) and showed no significant negative correlation to fasting times for clear fluids (r = -0.07, P = 0.60) and non-clear fluids/solids (r = -0.08, P = 0.51). CONCLUSIONS: Based on this preliminary data, GCV(w) showed considerable variation but did not correlate with fasting times in children and adolescent patients. Recommended fasting times were often exceeded.

Pediatric epstein-barr virus carriers with or without tonsillar enlargement may substantially contribute to spreading of the virus.

BACKGROUND: Human-to-human transmission of the persistent infection establishing Epstein-Barr virus (EBV) occurs via saliva. Tonsils act as important portal of entry and exit of EBV. The contagiousness of pediatric EBV carriers and the role played by tonsillar enlargement (TE) are not known. METHODS: We compared EBV shedding in mouthwash samples from pediatric EBV carriers with or without TE to that in mouthwash samples from pediatric patients with infectious mononucleosis (IM), the symptomatic form of primary infection if delayed after the age of 5 years. EBV DNA was quantified by polymerase chain reaction, and contagiousness was assessed using the cord lymphocyte transformation assay. RESULTS: EBV carriers with TE shed EBV DNA at an almost similar frequency (although in lower amounts) as pediatric patients with acute IM but more frequently (P <.001) and in higher amounts (P = .038) than EBV carriers without TE. EBV DNA levels in mouthwash samples from EBV carriers with TE mirrored levels in tonsils and gradually declined after tonsillectomy. Almost half of the mouthwash samples from pediatric EBV carriers contained infectious EBV. CONCLUSIONS: Pediatric EBV carriers--in particular, those with TE-may considerably contribute to the spreading of EBV in industrialized countries.

Semi-elective intraosseous infusion after failed intravenous access in pediatric anesthesia.

BACKGROUND: Intraosseous (IO) infusion is a well-established intervention to obtain vascular access in pediatric emergency medicine but is rarely used in routine pediatric anesthesia. METHODS: In this observational study, we report on a series of 14 children in whom semi-elective IO infusion was performed under inhalational anesthesia after peripheral intravenous (IV) access had failed. Patient and case characteristics, technical details, and estimated timings of IO infusion as well as associated complications were reviewed. Data are median and range. RESULTS: IO infusion was successfully established in fourteen children [age: 0.1-6.00 years (median 0.72 years); weight: 3.5-12.0 kg (median 7.0 kg)]. The majority suffered from chronic cardiac, metabolic, or dysmorphic abnormalities. Estimated time taken from inhalational induction of anesthesia until insertion of an intraosseous needle was 26.5 min (15-65 min). The proximal tibia was cannulated in all patients. The automated EZIO IO system was used in eight patients and the manual COOK system in six patients. Drugs administered included hypnotics, opioids, neuromuscular blocking agents and reversals, cardiovascular drugs, antibiotics, and IV fluids. The IO cannulas were removed either in the operating theatre (n = 5), in the recovery room (n = 5), or in the ward (n = 4), after 73 min (19-225 min) in situ. There were no significant complications except one accidental postoperative dislocation. CONCLUSIONS: IO access represents a quick and reliable alternative for pediatric patients with prolonged difficult or failed IV access after inhalational induction of anesthesia.