BACKGROUND:This study was designed to assess the feasibility of dual closed-loop titration of propofol and remifentanil guided solely by the Bispectral Index (BIS) monitor in pediatric and adolescent ...patients during anesthesia.
METHODS:Children undergoing elective surgery in this single-blind randomized study were allocated into the closed-loop (auto) or manual (manual) group. Primary outcome was the percentage of time with the BIS in the range 40 to 60 (BIS40–60). Secondary outcomes were the percentage of deep (BIS<40) anesthesia and drug consumption. Data are presented as median (interquartile range) or number (%).
RESULTS:Twenty-three patients (12 10 to 14 yr) were assigned to the auto group and 19 (14 7 to 14 yr) to the manual group. The closed-loop controller was able to provide induction and maintenance for all patients. The percentage of time with BIS40–60 was greater in the auto group (87% 75 to 96 vs. 72% 48 to 79; P = 0.002), with a decrease in the percentage of BIS<40 (7% 2 to 17 vs. 21% 11 to 38; P = 0.002). Propofol (2.4 1.9 to 3.3 vs. 1.7 1.2 to 2.8 mg/kg) and remifentanil (2.3 2.0 to 3.0 vs. 2.5 1.2 to 4.3 μg/kg) consumptions were similar in auto versus manual groups during induction, respectively. During maintenance, propofol consumption (8.2 6.0 to 10.2 vs. 7.9 7.2 to 9.1 mg kg h; P = 0.89) was similar between the two groups, but remifentanil consumption was greater in the auto group (0.39 0.22 to 0.60 vs. 0.22 0.17 to 0.32 μg kg min; P = 0.003). Perioperative adverse events and length of stay in the postanesthesia care unit were similar.
CONCLUSION:Intraoperative automated control of hypnosis and analgesia guided by the BIS is clinically feasible in pediatric and adolescent patients and outperformed skilled manual control.
Summary
Background
Few data are available in the literature on risk factors for postoperative vomiting (POV) in children.
Objective
The aim of the study was to establish independent risk factors for ...POV and to construct a pediatric specific risk score to predict POV in children.
Methods
Characteristics of 2392 children operated under general anesthesia were recorded. The dataset was randomly split into an evaluation set (n = 1761), analyzed with a multivariate analysis including logistic regression and backward stepwise procedure, and a validation set (n = 450), used to confirm the accuracy of prediction using the area under the receiver operating characteristic curve (ROCAUC), to optimize sensitivity and specificity.
Results
The overall incidence of POV was 24.1%. Five independent risk factors were identified: stratified age (>3 and <6 or >13 years: adjusted OR 2.46 95% CI 1.75–3.45; ≥6 and ≤13 years: aOR 3.09 95% CI 2.23–4.29), duration of anesthesia (aOR 1.44 95% IC 1.06–1.96), surgery at risk (aOR 2.13 95% IC 1.49–3.06), predisposition to POV (aOR 1.81 95% CI 1.43–2.31), and multiple opioids doses (aOR 2.76 95% CI 2.06–3.70, P < 0.001). A simplified score was created, ranging from 0 to 6 points. Respective incidences of POV were 5%, 6%, 13%, 21%, 36%, 48%, and 52% when the risk score ranged from 0 to 6. The model yielded a ROCAUC of 0.73 95% CI 0.67–0.78 when applied to the validation dataset.
Conclusions
Independent risk factors for POV were identified and used to create a new score to predict which children are at high risk of POV.
Objective
To report routine practice of “perimortem” CT-scan imaging to determine the causes of death in children dying from severe accidental injuries within the first hours following hospital ...admission.
Settings
Trauma center of a University Pediatric Hospital.
Methods
A retrospective study was conducted in children (0 to 15 years old) referred for severe trauma (GCS ≤ 8) to a regional pediatric trauma center, presenting with at least spontaneous cardiac rhythm and dying within the first 12 h after admission. “Perimortem” CT-scan consisted in high-resolution, contrast-enhanced, full-body CT-scan imaging, performed whatever child’s clinical status. Lethal and associated lesions found were analyzed and classified according to validated scales. The comparison between clinical and radiological examinations and CT-scan findings evaluated the accuracy of clinical examination to predict lethal lesions.
Results
CT-scan performed in 73 children detected 132 potentially lethal lesions, at least 2 lesions in 63%, and 1 in 37% of the cases. More frequent lethal lesions were brain (43%), and chest injuries (33%), followed by abdominal (12%), and cervical spine injuries (12%). Clinical and minimal radiological examinations were poorly predictive for identifying abdominal/chest lesions. Clinical and imaging data provided to the medical examiner were considered sufficient to identify the cause of death, and to deliver early burial certificates in 70 children. Only three legal autopsies were commanded.
Conclusions
Perimortem CT imaging could provide an insight into the causes of death in traumatized children. Performed on an emergency basis near death, it eliminates the difficulties encountered in forensic radiology. It could be a possible alternative to full-scale forensic examination, at least regarding elucidation of the potential, or highly probable causes of death.
Initially described for colorectal surgery,1 the benefits of ERAS are now well demonstrated in several surgical specialties for adults.2 The application of ERAS guidelines is the key to reduce ...hospital length of stay and cost through early mobilization, early feeding and early discharge.3 The implementation of ERAS in adults is a success, but this is not yet the case in pediatric surgery. ...a study recently applied an 18-point ERAS program for colorectal pediatric elective surgery.8 Thanks to the ERAS protocol, the median number of assisted recovery procedures received per patient increased from 5 to 11, while the median length of stay significantly decreased from 5 to 3 days. The answer can be found within the peculiarities of pediatric surgery: (1) the predominance of outpatient surgery, (2) the low postoperative mortality rate, (3) the wide variety of populations ranging from newborns to young adults, as well as (4) the role of parents and child psychology in the success of this type of programs. ...a prospective implementation study of this protocol is currently underway in 18 hospitals (Clinical Trials number NCT04060303).
To describe the results of an integrated pre- and in-hospital approach to critical care in a large population of children with severe traumatic brain injury and to identify the early predictors of ...their outcome.
A 9-yr retrospective review of the data of a trauma data bank.
Level III pediatric trauma center.
All children (1 month to 15 yrs) with severe traumatic brain injury (Glasgow Coma Scale </=8) hospitalized in our trauma center and followed until death or for >/=6 months after discharge.
None.
Univariate and further multivariate analyses were performed to determine independent predictive factors of death and outcome at discharge and 6 months later. The Glasgow Outcome Scale was used to evaluate outcome; a poor outcome referred to Glasgow Outcome Scale >/=3. Receiver operating characteristic curves were drawn to determine the threshold values of predictors of death and outcome. Analysis concerned 585 children (67% male and 33% female). Mean age was 7 +/- 5 yrs. Predominant mechanisms of injury were road traffic accidents and falls. Mean values for Glasgow Coma Scale, Pediatric Trauma Score, and Injury Severity Score were 6 (3-8), 3 (-4,10), and 28 (4-75), respectively. Mortality rate was 22%; Glasgow Outcome Scale was <3 in 53% of the cases at discharge and 60% at 6 months. Multivariate analysis identified Glasgow Coma Scale, Injury Severity Score, and hypotension on arrival as independent predictors of death and poor outcome at discharge and at 6 months. Threshold values for death were 28 for Injury Severity Score and 5 for Glasgow Coma Scale. The same values were found for poor outcome, except for outcome at 6 months where threshold value for the Glasgow Coma Scale was 6.
Initial hypotension, Glasgow Coma Scale, and Injury Severity Score are independent predictors of outcome in children with traumatic brain injury. Threshold values can be calculated for predicting poor outcome. These variables can be easily and detected early in this population and used for quality assessment.
Summary
Background
Thoracic bioreactance is a noninvasive and continuous method of cardiac output (CO) measurement that is being developed in adult patients. Very little information is available on ...thoracic bioreactance use in children.
Objective
The aim of the study was to evaluate the ability of a bioreactance device (NICOM®; Cheetah Medical, Tel Aviv, Israel) to estimate CO and to track changes in CO induced by volume expansion (VE) in children.
Methods
Cardiac output values obtained using the NICOM® device (CONICOM) and measured by trans‐thoracic echocardiography (COTTE) were compared in pediatric neurosurgical patients during the postoperative period.
Results
Seventy‐three pairs of measurements of CO obtained in 30 children were available for analysis. The bias (lower and upper limits of agreement) between CONICOM and COTTE was −0.11 (−1.4 to 1.2) l·min−1. The percentage error (PE) was 55%. The precision of the NICOM® device was 45%. A significant correlation was observed between the CO values obtained using the two methods (r = 0.89, <0.001). The concordance percentage between changes in COTTE and CONicom induced by VE was 84% following exclusion of patients with changes in CO <15% (n = 5).
Conclusions
The PE observed is too large, and the limits of agreement too wide, to enable us to comment on the equivalence of the two techniques of CO measurements. However, the NICOM® device performs well in tracking changes in CO following VE.
The role of the hypovolemic component secondary to the microcirculatory changes in the onset of inaugural anaphylactic hypotension remains debated. We investigated the microcirculatory permeability ...in a model of anaphylactic shock using a fluorescence confocal microscopy imaging system.
Ovalbumin-sensitized anesthetized Brown Norway rats were randomly allocated into two groups (n = 6/group): control and anaphylaxis, respectively induced by intravenous saline or ovalbumin at time 0 (T0). The mesentery was surgically exposed. Macromolecular fluorescein isothiocyanate-dextran was intravenously injected (T0-5min) allowing in vivo visualization of the mesenteric microvascular network by fluorescence microscopy. After a period of stabilization of the contrast agent concentration, a 5-s movie was recorded to obtain baseline signal intensity. Following T0, 5-s movies were recorded every 30 s for 30 min. Capillary leakage of fluorescein isothiocyanate-dextran was assessed in interstitium and compared between groups. Data are expressed as mean ± SD.
Following anaphylactic shock onset, an early, progressive, and global signal intensity increase over time was detected in the interstitium. Mean index leakage differed between control and anaphylaxis (respectively 20 ± 11 vs. 170 ± 127%; P < 0.0001), starting at 2 min after shock onset and progressively increasing. Index leakage correlated with the drop in arterial blood pressure until T0 + 10 min (r = -0.75, P = 0.0001).
During anaphylaxis, interstitial capillary leakage occurs within minutes after shock onset. Compared with controls, the mesenteric microcirculation showed at least 8-fold-increased macromolecular capillary leakage. The inflammation-induced microcirculatory changes with subsequent intravascular fluid transfer might be involved in the onset of the inaugural hypotension during anaphylactic shock.
Summary
The management of critically ill children with traumatic brain injury (TBI) requires a precise assessment of the brain lesions but also of potentially associated extra‐cranial injuries. ...Children with severe TBI should be treated in a pediatric trauma center, if possible. Initial assessment relies mainly upon clinical examination, trans‐cranial Doppler ultrasonography and body CT scan. Neurosurgical operations are rarely necessary in these patients, except in the case of a compressive subdural or epidural hematoma. On the other hand, one of the major goals of resuscitation in these children is aimed at protecting against secondary brain insults (SBI). SBI are mainly because of systemic hypotension, hypoxia, hypercarbia, anemia and hyperglycemia. Cerebral perfusion pressure (CPP = mean arterial blood pressure – intracranial pressure: ICP) should be monitored and optimized as soon as possible, taking into account age‐related differences in optimal CPP goals. Different general maneuvers must be applied in these patients early during their treatment (control of fever, avoidance of jugular venous outflow obstruction, maintenance of adequate arterial oxygenation, normocarbia, sedation–analgesia and normovolemia). In the case of increased ICP and/or decreased CPP, first‐tier ICP‐specific treatments may be implemented, including cerebrospinal fluid drainage, if possible, osmotic therapy and moderate hyperventilation. In the case of refractory intracranial hypertension, second‐tier therapy (profound hyperventilation with PaCO2 < 35 mmHg, high‐dose barbiturates, moderate hypothermia, decompressive craniectomy) may be introduced, after a new cerebral CT scan.
Summary
Background
Little information is available on the titration of morphine postoperatively in children. This observational study describes the technique in terms of the bolus dose, the number of ...boluses required, the time to establish analgesia, and side effects noted.
Methods
Morphine was administered if pain score (VAS or FLACC) was >30. Patients weighing less than 45 kg received a 50 μg·kg−1 bolus of morphine with subsequent boluses of 25 μg kg−1 as required. Patients weighing over 45 kg received boluses of 2 mg. Pain and Ramsay scores were recorded up to 90 min after the end of the titration and any side effect or complication was noted. Data are presented as the median interquartile Q1–Q3 range.
Results
Overall, 103 children were studied. The median age was 4.2 years 0.8–12.2 years. The median weight was 15.5 kg 8.2–35.0 kg. The protocol was effective for pain control with a significant decrease in pain scores over time. The median pain score (VAS or FLACC) was 70 50–80 prior to the initial bolus and 0 0–10 90 min after the last bolus. Median Ramsay score was 1 1–2 before the initial bolus administration and 4 2–4 at 90 min. The median total dose of morphine was 100 70–140 μg·kg−1, and the median number of boluses was 3 2‐5. Side effects were observed in 17% of cases. No serious complications were observed.
Conclusions
Our study of morphine titration for children shows that our protocol was effective for pain control with a significant decrease in pain scores over time. No serious complications were encountered. More studies on larger cohorts of patients are needed to confirm the efficacy and safety of this protocol.
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