Due to their low reserves, hypoxia and cardiac arrest occur rapidly in children. The continuous securing of the airway as well as maintenance of oxygenation and ventilation are of prior importance in ...paediatric anaesthesia. For this purpose, bag-mask ventilation and the opening of the upper airway must be trained and mastered in particular. As the most important supraglottic device, the laryngeal mask has been evaluated for patients of all ages.
Purpose
Trauma is the leading cause of death in children. In adults, blood transfusion and fluid resuscitation protocols changed resulting in a decrease of morbidity and mortality over the past 2 ...decades. Here, transfusion and fluid resuscitation practices were analysed in severe injured children in Germany.
Methods
Severely injured children (maximum Abbreviated Injury Scale (AIS) ≥ 3) admitted to a certified trauma-centre (TraumaZentrum DGU®) between 2002 and 2017 and registered at the TraumaRegister DGU® were included and assessed regarding blood transfusion rates and fluid therapy.
Results
5,118 children (aged 1–15 years) with a mean ISS 22 were analysed. Blood transfusion rates administered until ICU admission decreased from 18% (2002–2005) to 7% (2014–2017). Children who are transfused are increasingly seriously injured. ISS has increased for transfused children aged 1–15 years (2002–2005: mean 27.7–34.4 in 2014–2017). ISS in non-transfused children has decreased in children aged 1–15 years (2002–2005: mean 19.6 to mean 17.6 in 2014–2017). Mean prehospital fluid administration decreased from 980 to 549 ml without affecting hemodynamic instability.
Conclusion
Blood transfusion rates and amount of fluid resuscitation decreased in severe injured children over a 16-year period in Germany. Restrictive blood transfusion and fluid management has become common practice in severe injured children. A prehospital restrictive fluid management strategy in severely injured children is not associated with a worsened hemodynamic state, abnormal coagulation or base excess but leads to higher hemoglobin levels.
Anesthetic equipment, including breathing circuits, has evolved over time. The T‐piece circuit, in its various forms, was designed to meet the needs of its time. As equipment and techniques have ...moved on, it is timely to consider the place of the T‐piece in modern pediatric anesthetic practice. Today the circle system is a ubiquitous part of anesthesia. When integrated with a modern anesthetic machine it offers precise control of ventilation together with continuous monitoring of airway pressure and flow: but at the cost of complexity. In comparison the T‐piece offers a simple cheap lightweight design, so ergonomic in use that it almost becomes part of the anesthetist: but lacks the control and the barriers to unsafe use of more sophisticated systems. In addition, it requires high fresh gas flow adding to cost and environmental pollution. This pro‐con debate discusses whether there remains a case for continuing to use the T‐piece circuit in preference over other options. Possible indications for the T‐Piece are discussed together with alternative strategies. The limitations of the circle system, the T‐piece, and other alternative (such as self‐inflating resuscitator bag) are discussed with respect to pediatric anesthetic practice.
Traumatic brain injury (TBI) is associated with high rates of long-term disability and mortality. Our aim was to investigate the effects of thoracic trauma on the in-hospital course and outcome of ...patients with TBI.
We performed a matched pair analysis of the multicenter trauma database TraumaRegisterDGU® (TR-DGU) in the 5-year period from 2012 to 2016. We included adult patients (≥18 years of age) with moderate to severe TBI (abbreviated injury scale (AIS)= 3-5). Patients with isolated TBI (group 1) were compared to patients with TBI and varying degrees of additional blunt thoracic trauma (AIS
= 2-5) (group 2). Matching criteria were gender, age, severity of TBI, initial GCS and presence/absence of shock. The χ
-test was used for comparing categorical variables and the Mann-Whitney-U-test was chosen for continuous parameters. Statistical significance was defined by a p-value < 0.05.
A total of 5414 matched pairs (10,828 patients) were included. The presence of additional thoracic injuries in patients with TBI was associated with a longer duration of mechanical ventilation and a prolonged ICU and hospital length of stay. Additional thoracic trauma was also associated with higher mortality rates. These effects were most pronounced in thoracic AIS subgroups 4 and 5. Additional thoracic trauma, regardless of its severity (AIS
≥2) was associated with significantly decreased rates of good neurologic recovery (GOS = 5) after TBI.
Chest trauma in general, regardless of its initial severity (AIS
= 2-5), is associated with decreased chance of good neurologic recovery after TBI. Affected patients should be considered "at risk" and vigilance for the maintenance of optimal neuro-protective measures should be high.
Transfusion of red blood cell concentrate can be life-saving, but requires accurate dose calculations in children.
We tested the hypothesis that cognitive aids would improve identification of the ...correct recommended volumes and products, according to the German National Transfusion guidelines, in pediatric transfusion scenarios.
Four online questionnaire-based scenarios, two with hemodynamically stable and two with hemodynamically unstable children, were sent to German and international pediatric anesthetists for completion. In the two stable scenarios, participants were given pre-filled tables that contained all required information. For the two emergency scenarios, existing algorithms were used and required calculation by the user. The results were classified into three categories of deviations from the recommended values (DRV): DRV120 (<80% or >120%), as the acceptable variation; DRV 300 (<33% or >300%), the deviation of concern for potential harm; and DRV 1000 (<10% or >1000%), the excessive deviation with a high probability of harm.
A total of 1.458 pediatric anesthetists accessed this simulation questionnaire, and 402 completed questionnaires were available for analysis. A pre-filled tabular aid, avoiding calculations, led to a reduction in deviation rates in the category of DRV120 by 60% for each and of DRV300 by 17% and 20%, respectively. The use of algorithms as aids for unstable emergencies led to a reduction in the deviation rate only for DRV120 (20% and 15% respectively). In contrast, the deviation rates for DRV300 and DRV1000 rose by 37% and 16%, respectively. Participants used higher transfusion thresholds for the emergency case of a 2-year-old compromised child than for the stable case with a patient of the same age (on average, 8.6 g/dL, 95% CI 8.5-8.8 versus 7.1 g/dL, 95% CI 7.0-7.2,
< 0.001) if not supported by our aids. Participants also used a higher transfusion threshold for unstable children aged 3 months than for stable children of the same age (on average, 8.9 g/dL, 95% CI 8.7-9.0 versus 7.9 g/dL, 95% CI 7.7-8.0,
< 0.001).
The use of cognitive aids with precalculated transfusion volumes for determining transfusion doses in children may lead to improved adherence to published recommendations, and could potentially reduce dosing deviations outside those recommended by the German national transfusion guidelines.
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