A randomized trial of the glottic views with the classic Miller, Wis-Hipple and C-MAC (videolaryngoscope and direct views) straight size 1 blades in young children.

STUDY OBJECTIVE: The Miller and Wis-Hipple size 1 blades are widely used for laryngoscopy in children and the C-MAC straight blade is used increasingly in young children, although the glottic views with these blades have not been compared. To determine whether the glottic views with these blades are equivalent. DESIGN: Equivalent study. SETTING: Operating room. PATIENTS: 96 children <2 years, ASA 1 or 2, elective surgery requiring orotracheal intubation. INTERVENTIONS: Direct laryngoscopy with the Miller and Wis-Hipple or C-MAC (videolaryngoscope and direct view) straight blades size 1; photographs of the glottic opening. MEASUREMENTS: Percent of glottic opening (POGO) was measured using a standardized scale by a blinded investigator. Heart rate, systolic blood pressure and hemoglobin oxygen saturation were measured before and after laryngoscopy. RESULTS: The POGO scores with the four blades/views were equivalent (fewer than 20% of the views yielded POGO scores <80). However, a post hoc comparison of the POGO scores yielded significant differences (P = 0.0001); the C-MAC videolaryngoscope view yielded significantly better scores than the Miller, Wis-Hipple and direct C-MAC views (P = 0.0009, 0.0002 and 0.0001 respectively). The POGO score with the Miller blade was superior to that with the direct C-MAC view (P = 0.024). No adverse events or complications occurred. CONCLUSION: The four blades/glottic views were equivalent, although a post hoc analysis demonstrated that the glottic view with the C-MAC videolaryngoscope was superior overall and the view with the Miller size 1 was superior to that with the direct C-MAC view.

Do small doses of atropine (<0.1 mg) cause bradycardia in young children?

OBJECTIVE: To determine the heart rate response to atropine (<0.1 mg) in anaesthetised young infants. DESIGN: Prospective, observational and controlled. SETTING: Elective surgery. PATIENTS: Sixty unpremedicated healthy infants less than 15 kg were enrolled. Standard monitoring was applied. Anaesthesia was induced by mask with nitrous oxide (66%) and oxygen (33%) followed by sevoflurane (8%). INTERVENTIONS: Intravenous (IV) atropine (5 µg/kg) was flushed into a fast flowing IV. The ECG was recorded continuously from 30 s before the atropine until 5 min afterwards. MAIN OUTCOME MEASURES: The incidence of bradycardia and arrhythmias was determined from the ECGs by a blinded observer. RESULTS: The median (IQR) age was 6.5 (4-12) months and the mean (95% CI) weight was 8.6 (8.1 to 9.1) kg. The mean (95% CI) dose of atropine was 40.9 (37.3 to 44) µg. Bradycardia did not occur. Two infants developed premature atrial contractions and one developed a premature ventricular contraction. When compared with baseline values, heart rate increased by 7% 30 s after atropine, 14% 1 min after atropine and 25% 5 min after atropine. Twenty-nine infants (48%) experienced tachycardia (>20% above baseline rate) after atropine lasting 222.7 s (range 27.9-286). The change in heart rate 5 min after atropine was inversely related to the baseline heart rate. CONCLUSIONS: The upper 95% CI for the occurrence of bradycardia in the entire population of infants based on a zero incidence in this study is 5%. These results rebut the notion that atropine <0.1 mg IV causes bradycardia in young infants. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov #NCT01819064.

Noise level measurement, a new method to evaluate effectiveness of sedation in pediatric dentistry.

OBJECTIVES: Pediatric dentists perform moderate sedation frequently to facilitate dental treatment in uncooperative children. Assessing the depth and quality of sedation is an important factor in the clinical utilization of moderate sedation. We aimed to determine if the level of noise, created by the children who are undergoing moderate sedation during dental procedures, could be used as a nonsubjective measurement of the depth of sedation and compare it to the Ohio State Behavior Rating Score (OSBRS). METHODS: Following Institutional Review Board approval and after receiving informed consent, we studied 51 children with a mean age of 4.2 years and average weight of 18.5 kg, who were undergoing restorative or extractive dental procedures, requiring moderate sedation. Sedation efficacy was assessed using OSBRS at several stages of the procedure. The noise level was measured by using a NoisePRO logging device to record the noise level at a rate of every second throughout the procedure. RESULTS: The depth of sedation assessed by OSBRS during the operative procedure was significantly correlated with noise level. The act of administering the local anesthesia and the operative procedure itself were two phases of the encounter that were significantly associated with higher OSBRS as well as noise levels. CONCLUSION: Measurement of noise level can be used as an effective guide to quantify the depth of sedation at different stages of the dental procedure. It is a nonsubjective and continuous measurement, which could be useful in clinical practice for the administration of moderate sedation during dental procedures. By using noise level analysis we are able to determine successful, poor, and failed sedation outcome.