Intraosseous infusions: a review for the anesthesiologist with a focus on pediatric use.

Intraosseous (IO) access is used most frequently for emergency care of critically ill infants and children when IV access cannot be rapidly achieved. Despite its efficacy in such situations, applications outside of the emergency room or resuscitation scenario have been limited. Furthermore, although the technique is emphasized in the teaching of those caring for critically ill infants and children in the emergency room or critical care setting, there is limited emphasis on its potential use in the perioperative setting. When peripheral venous access cannot be achieved in the operating room, alternative means of securing vascular access such as central line placement or surgical cutdown are generally successful; however, these techniques may be time consuming. Anyone providing anesthesia care for infants and children may want to become facile with the use of IO infusions for selected indications. We present the history of IO infusions, review the anatomy of the bone marrow space, discuss the potential role of IO infusions in the perioperative period, and analyze its adverse effect profile.

Moderate sedation for MRI in young children with autism.

UNLABELLED: Autism is a pervasive neurodevelopmental disorder. Because of the deficits associated with the condition, sedation of children with autism has been considered more challenging than sedation of other children. OBJECTIVE: To test this hypothesis, we compared children with autism against clinical controls to determine differences in requirements for moderate sedation for MRI. MATERIALS AND METHODS: Children ages 18-36 months with autism (group 1, n = 41) and children with no autistic behavior (group 2, n = 42) were sedated with a combination of pentobarbital and fentanyl per sedation service protocol. The sedation nurse was consistent for all patients, and all were sedated to achieve a Modified Ramsay Score of 4. Demographics and doses of sedatives were recorded and compared. RESULTS: There were no sedation failures in either group. Children in group 1 (autism) were significantly older than group 2 (32.02+/-3.6 months vs 28.16+/-6.7 months) and weighed significantly more (14.87+/-2.1 kg vs 13.42+/-2.2 kg). When compared on a per-kilogram basis, however, group 1 had a significantly lower fentanyl requirement than group 2 (1.25+/-0.55 mcg/kg vs 1.57+/-0.81 mcg/kg), but no significant difference was found in pentobarbital dosing between groups 1 and 2, respectively (4.92+/-0.92 mg/kg vs 5.21+/-1.6 mg/kg). CONCLUSION: Autistic children in this age range are not more difficult to sedate and do not require higher doses of sedative agents for noninvasive imaging studies.

Paediatric regional anaesthesia--what makes a difference?

Regional anaesthetic techniques are useful for providing post-operative pain control for ambulatory surgery in children. This chapter focuses on unique features of paediatric anatomy and physiology that allow successful performance of these techniques. An overview of the effective use of long-acting local anaesthetics in children is presented. Combinations of local anaesthetics and adjunct medications that prolong caudal blockade, the most commonly performed paediatric block, are reviewed, with a goal of providing prolonged analgesia with minimal side-effects. An overview of the use of peripheral nerve blockade and specific recommendations for the use of these blocks in children is also presented.

Office-based anesthesia for children.

The use of office-based surgery and anesthesia will continue to grow. The anesthesia community has embraced the opportunity to become a driving force of office-based surgery and has organized into rapidly growing groups that promote safe practice in the office setting. The Society for Office-Based Anesthesia was developed to continuously improve patient safety and outcomes in office surgery. This group has an active Web site (www.soba.org) that allows for online discussions and widespread participation in working toward the society's stated goal. This Web site may be used as a reference for physicians in the process of considering the move to office-based anesthesia. The advantages of office-based anesthesia are numerous. The financial incentives are tremendous and the convenience to the patient and surgeon is important. For office anesthesia to be successful in children, patient safety, proof of improved outcomes, and family and surgeon satisfaction must be the goals. Anesthesia providers must continue to take active roles in organizing the office environment to ensure that safety is paramount. As the field grows, additional ways to study and improve the overall care children receive in the office should be sought. In the near future, office practice for surgery and anesthesia for children undergoing minor procedures should be a safe and effective alternative to current practices.