The severe acute respiratory syndrome coronavirus 2 (coronavirus disease 2019 COVID-19) pandemic has challenged medical systems and clinicians globally to unforeseen levels. Rapid spread of COVID-19 ...has forced clinicians to care for patients with a highly contagious disease without evidence-based guidelines. Using a virtual modified nominal group technique, the Pediatric Difficult Intubation Collaborative (PeDI-C), which currently includes 35 hospitals from 6 countries, generated consensus guidelines on airway management in pediatric anesthesia based on expert opinion and early data about the disease. PeDI-C identified overarching goals during care, including minimizing aerosolized respiratory secretions, minimizing the number of clinicians in contact with a patient, and recognizing that undiagnosed asymptomatic patients may shed the virus and infect health care workers. Recommendations include administering anxiolytic medications, intravenous anesthetic inductions, tracheal intubation using video laryngoscopes and cuffed tracheal tubes, use of in-line suction catheters, and modifying workflow to recover patients from anesthesia in the operating room. Importantly, PeDI-C recommends that anesthesiologists consider using appropriate personal protective equipment when performing aerosol-generating medical procedures in asymptomatic children, in addition to known or suspected children with COVID-19. Airway procedures should be done in negative pressure rooms when available. Adequate time should be allowed for operating room cleaning and air filtration between surgical cases. Research using rigorous study designs is urgently needed to inform safe practices during the COVID-19 pandemic. Until further information is available, PeDI-C advises that clinicians consider these guidelines to enhance the safety of health care workers during airway management when performing aerosol-generating medical procedures. These guidelines have been endorsed by the Society for Pediatric Anesthesia and the Canadian Pediatric Anesthesia Society.
Tranexamic acid (TXA) reduces blood loss and transfusion in paediatric craniosynostosis surgery. The hypothesis is that low-dose TXA, determined by pharmacokinetic modelling, is non-inferior to ...high-dose TXA in decreasing blood loss and transfusion in children.
Children undergoing craniosynostosis surgery were enrolled in a two-centre, prospective, double-blind, randomised, non-inferiority controlled trial to receive high TXA (50 mg kg−1 followed by 5 mg kg−1 h−1) or low TXA (10 mg kg−1 followed by 5 mg kg−1 h−1). Primary outcome was blood loss. Low dose was determined to be non-inferior to high dose if the 95% confidence interval (CI) for the mean difference in blood loss was above the non-inferiority margin of –20 ml kg−1. Secondary outcomes were transfusion, TXA plasma concentrations, and biological markers of fibrinolysis and inflammation.
Sixty-eight children were included. Values were non-inferior regarding blood loss (39.4 4.4 vs 40.3 6.2 ml kg−1 difference=0.9; 95% CI: –14.2, 15.9) and blood transfusion (21.3 1.6 vs 23.6 1.5 ml kg−1 difference=2.3; 95% CI: –2.1, 6.7) between high-dose (n=32) and low-dose (n=34) groups, respectively. The TXA plasma concentrations during surgery averaged 50.2 (8.0) and 29.6 (7.6) μg ml−1. There was no difference in fibrinolytic and inflammatory biological marker concentrations. No adverse events were observed.
Tranexamic acid 10 mg kg−1 followed by 5 mg kg−1 h−1 is not less effective than a higher dose of 50 mg kg−1 and 5 mg kg−1 h−1 in reducing blood loss and transfusion in paediatric craniosynostosis surgery.
NCT02188576.
To investigate the variation of poorly ventilated lung units (i.e., silent spaces) in children undergoing procedural sedation in a day-hospital setting, until discharge home from the Post-Anesthesia ...Care Unit (PACU).
Prospective, single-center, observational cohort trial.
This study was conducted at the radiology department and in PACU at Bern University Hospital (Switzerland), a tertiary care hospital.
We included 25 children (1–6 years, ASA I-III) scheduled for cerebral magnetic resonance imaging scan, spontaneously breathing under deep sedation. Children planned for tracheal intubation, supraglottic airway insertion, or with contraindication for propofol were excluded.
After intravenous or inhaled induction, deep sedation was performed with 10 mg/kg/h Propofol. All children received nasal oxygen 0.3 ml/kg/min.
The proportion of silent spaces and the global inhomogeneity index were determined at each of five procedural points, using electrical impedance tomography: before induction (T1); before (T2) and after (T3) magnetic resonance imaging; at the end of sedation before transport to the PACU (T4); and before hospital discharge (T5).
The median interquartile range (IQR) proportion of silent spaces at the five analysis points were: T1, 5% 2%–14%; T2, 10% 7%–14%; T3, 12% 5%–23%; T4, 12% 7%–24%; and T5, 3% 2%–11%. These defined significant changes in silent spaces over the course of sedation (p = 0.009), but no differences in silent spaces from before induction to before discharge from the PACU (T1 vs. T5; p = 0.29). Median IQR global inhomogeneity indices were 0.57 0.55–0.58, 0.56 0.53–0.59, 0.56 0.54–0.59, 0.57 0.54–0.60 and 0.56 0.54–0.57, respectively (p = 0.93). None of the children reported anesthesia-related complications.
Deep sedation results in significantly increased poorly ventilated lung units during sedation. However, this does not significantly affect ventilation homogeneity, which was fully resolved at discharge from the PACU.
Trial registration: clinicaltrials.gov, identifier NCT04507581
•In small children, sedation results in silent spaces as a surrogate for atelectasis.•Atelectasis are fully resolved about 2 h after anesthesia.•On the basis of our data, procedural deep sedation is confirmed as a safe anesthesia technique in small children.
Supplemental oxygen administration by apnoeic oxygenation during laryngoscopy for tracheal intubation is intended to prolong safe apnoea time, reduce the risk of hypoxaemia, and increase the success ...rate of first-attempt tracheal intubation under general anaesthesia. This systematic review examined the efficacy and effectiveness of apnoeic oxygenation during tracheal intubation in children.
This systematic review and meta-analysis included randomised controlled trials and non-randomised studies in paediatric patients requiring tracheal intubation, evaluating apnoeic oxygenation by any method compared with patients without apnoeic oxygenation. Searched databases were MEDLINE, Embase, Cochrane Library, CINAHL, ClinicalTrials.gov, International Clinical Trials Registry Platform (ICTRP), Scopus, and Web of Science from inception to March 22, 2023. Data extraction and risk of bias assessment followed the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) recommendation.
After initial selection of 40 708 articles, 15 studies summarising 9802 children were included (10 randomised controlled trials, four pre-post studies, one prospective observational study) published between 1988 and 2023. Eight randomised controlled trials were included for meta-analysis (n=1070 children; 803 from operating theatres, 267 from neonatal intensive care units). Apnoeic oxygenation increased intubation first-pass success with no physiological instability (risk ratio RR 1.27, 95% confidence interval CI 1.03-1.57, P=0.04, I
=0), higher oxygen saturation during intubation (mean difference 3.6%, 95% CI 0.8-6.5%, P=0.02, I
=63%), and decreased incidence of hypoxaemia (RR 0.24, 95% CI 0.17-0.33, P<0.01, I
=51%) compared with no supplementary oxygen administration.
This systematic review with meta-analysis confirms that apnoeic oxygenation during tracheal intubation of children significantly increases first-pass intubation success rate. Furthermore, apnoeic oxygenation enables stable physiological conditions by maintaining oxygen saturation within the normal range.
Protocol registered prospectively on PROSPERO (registration number: CRD42022369000) on December 2, 2022.
Background
Rapid‐sequence tracheotomy and scalpel‐bougie tracheotomy are two published approaches for establishing emergency front‐of‐neck access in infants. It is unknown whether there is a ...difference in performance times and success rates between the two approaches.
Aims
The aim of this cross‐over randomized control trial study was to investigate whether the two approaches were equivalent for establishing tracheal access in rabbit cadavers. The underlying hypothesis was that the time to achieve the tracheal access is the same with both techniques.
Methods
Between May and September 2022, thirty physicians (pediatric anesthesiologists and intensivists) were randomized to perform front‐of‐neck access using one and then the other technique: rapid‐sequence tracheotomy and scalpel‐bougie tracheotomy. After watching training videos, each technique was practiced four times followed by a final tracheotomy during which study measurements were obtained. Based on existing data, an equivalence margin was set at ∆ = ±10 s for the duration of the procedure. The primary outcome was defined as the duration until tracheal tube placement was achieved successfully. Secondary outcomes included success rate, structural injuries, and subjective participant self‐evaluation.
Results
The median duration of the scalpel‐bougie tracheotomy was 48 s (95% CI: 37–57), while the duration of the rapid‐sequence tracheotomy was 59 s (95% CI: 49–66, p = .07). The difference in the median duration between the two approaches was 11 s (95% CI: −4.9 to 29). The overall success rate was 93.3% (95% CI: 83.8%–98.2%). The scalpel‐bougie tracheotomy resulted in significantly fewer damaged tracheal rings and was preferred among participants.
Conclusions
The scalpel‐bougie tracheotomy was slightly faster than the rapid‐sequence tracheotomy and favored by participants, with fewer tracheal injuries. Therefore, we propose the scalpel‐bougie tracheostomy as a rescue approach favoring the similarity to the adult approach for small children. The use of a comparable equipment kit for both children and adults facilitates standardization, performance, and logistics.
Trial Registration
ClinicalTrials.gov identifier: NCT05499273.
BACKGROUND: Little is known about current clinical practice concerning peri-operative red blood cell transfusion in neonates and small infants. Guidelines suggest transfusions based on haemoglobin ...thresholds ranging from 8.5 to 12 g dl-1, distinguishing between children from birth to day 7 (week 1), from day 8 to day 14 (week 2) or from day 15 (≥week 3) onwards.
OBJECTIVE: To observe peri-operative red blood cell transfusion practice according to guidelines in relation to patient outcome.
DESIGN: A multicentre observational study.
SETTING: The NEonate-Children sTudy of Anaesthesia pRactice IN Europe (NECTARINE) trial recruited patients up to 60 weeks' postmenstrual age undergoing anaesthesia for surgical or diagnostic procedures from 165 centres in 31 European countries between March 2016 and January 2017.
PATIENTS: The data included 5609 patients undergoing 6542 procedures. Inclusion criteria was a peri-operative red blood cell transfusion.
MAIN OUTCOME MEASURES: The primary endpoint was the haemoglobin level triggering a transfusion for neonates in week 1, week 2 and week 3. Secondary endpoints were transfusion volumes, 'delta haemoglobin' (preprocedure - transfusion-triggering) and 30-day and 90-day morbidity and mortality.
RESULTS: Peri-operative red blood cell transfusions were recorded during 447 procedures (6.9%). The median haemoglobin levels triggering a transfusion were 9.6 IQR 8.7 to 10.9 g dl-1 for neonates in week 1, 9.6 7.7 to 10.4 g dl-1 in week 2 and 8.0 7.3 to 9.0 g dl-1 in week 3. The median transfusion volume was 17.1 11.1 to 26.4 ml kg-1 with a median delta haemoglobin of 1.8 0.0 to 3.6 g dl-1. Thirty-day morbidity was 47.8% with an overall mortality of 11.3%.
CONCLUSIONS: Results indicate lower transfusion-triggering haemoglobin thresholds in clinical practice than suggested by current guidelines. The high morbidity and mortality of this NECTARINE sub-cohort calls for investigative action and evidence-based guidelines addressing peri-operative red blood cell transfusions strategies.
TRIAL REGISTRATION: ClinicalTrials.gov, identifier: NCT02350348.
Background and Objectives
Children undergoing airway management during general anesthesia may experience airway complications resulting in a rare but life‐threatening situation known as “Can't ...Intubate, Can't Oxygenate”. This situation requires immediate recognition, advanced airway management, and ultimately emergency front‐of‐neck access. The absence of standardized procedures, lack of readily available equipment, inadequate knowledge, and training often lead to failed emergency front‐of‐neck access, resulting in catastrophic outcomes. In this narrative review, we examined the latest evidence on emergency front‐of‐neck access in children.
Methods
A comprehensive literature was performed the use of emergency front‐of‐neck access (eFONA) in infants and children.
Results
Eighty‐six papers were deemed relevant by . Finally, eight studies regarding the eFONA technique and simulations in animal models were included. For all articles, their primary and secondary outcomes, their specific animal model, the experimental design, the target participants, and the equipment were reported.
Conclusion
Based on the available evidence, we propose a general approach to the eFONA technique and a guide for implementing local protocols and training. Additionally, we introduce the application of innovative tools such as 3D models, ultrasound, and artificial intelligence, which can improve the precision, safety, and training of this rare but critical procedure.
Summary
Preclinical evidence suggests that anesthetic agents harm the developing brain thereby causing long‐term neurocognitive impairments. It is not clear if these findings apply to humans, and ...retrospective epidemiological studies thus far have failed to show definitive evidence that anesthetic agents are harmful to the developing human brain.
Aim
The aim of this systematic review was to summarize the preclinical studies published over the past decade, with a focus on methodological issues, to facilitate the comparison between different preclinical studies and inform better design of future trials.
Method
The literature search identified 941 articles related to the topic of neurotoxicity. As the primary aim of this systematic review was to compare methodologies applied in animal studies to inform future trials, we excluded a priori all articles focused on putative mechanism of neurotoxicity and the neuroprotective agents. Forty‐seven preclinical studies were finally included in this review.
Results
Methods used in these studies were highly heterogeneous—animals were exposed to anesthetic agents at different developmental stages, in various doses and in various combinations with other drugs, and overall showed diverse toxicity profiles. Physiological monitoring and maintenance of physiological homeostasis was variable and the use of cognitive tests was generally limited to assessment of specific brain areas, with restricted translational relevance to humans.
Conclusion
Comparison between studies is thus complicated by this heterogeneous methodology and the relevance of the combined body of literature to humans remains uncertain. Future preclinical studies should use better standardized methodologies to facilitate transferability of findings from preclinical into clinical science.
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