Off-label use of medications in paediatric anaesthesia is common practice, owing to the relative paucity of evidence-based dosing regimens in children. Well-performed dose–finding studies, especially ...in infants, are rare and urgently needed. Unanticipated effects can result when paediatric dosing is based on adult parameters or local traditions. A recent dose–finding study on ephedrine highlights the uniqueness of paediatric dosing in comparison with adult dosing. We discuss the problems of off-label medication use and the lack of evidence for various definitions of hypotension and associated treatment strategies in paediatric anaesthesia. What is the aim of treating hypotension associated with anaesthesia induction: restoring the MAP to awake baseline values or elevating it above a provisional hypotension threshold?
Post-operative brain injury in neonates may result from disturbed cerebral perfusion, but accurate peri-operative monitoring is lacking. High-frame-rate (HFR) cerebral ultrasound could visualize and ...quantify flow in all detectable vessels using spectral Doppler; however, automated quantification in small vessels is challenging because of low signal amplitude. We have developed an automatic envelope detection algorithm for HFR pulsed wave spectral Doppler signals, enabling neonatal brain quantitative parameter maps during and after surgery.
HFR ultrasound data from high-risk neonatal surgeries were recorded with a custom HFR mode (frame rate = 1000 Hz) on a Zonare ZS3 system. A pulsed wave Doppler spectrogram was calculated for each pixel containing blood flow in the image, and spectral peak velocity was tracked using a max-likelihood estimation algorithm of signal and noise regions in the spectrogram, where the most likely cross-over point marks the blood flow velocity. The resulting peak systolic velocity (PSV), end-diastolic velocity (EDV) and resistivity index (RI) were compared with other detection schemes, manual tracking and RIs from regular pulsed wave Doppler measurements in 10 neonates.
Envelope detection was successful in both high- and low-quality arterial and venous flow spectrograms. Our technique had the lowest root mean square error for EDV, PSV and RI (0.46 cm/s, 0.53 cm/s and 0.15, respectively) when compared with manual tracking. There was good agreement between the clinical pulsed wave Doppler RI and HFR measurement with a mean difference of 0.07.
The max-likelihood algorithm is a promising approach to accurate, automated cerebral blood flow monitoring with HFR imaging in neonates.
Pediatric anesthesia is large part of anesthesia clinical practice. Children, parents and anesthesiologists fear anesthesia because of the risk of acute morbidity and mortality. Modern anesthesia in ...otherwise healthy children above 1 year of age in developed countries has become very safe due to recent advance in pharmacology, intensive education, and training as well as centralization of care. In contrast, anesthesia in these children in low-income countries is associated with a high risk of mortality due to lack of basic resources and adequate training of health care providers. Anesthesia for neonates and toddlers is associated with significant morbidity and mortality. Anesthesia-related (near) critical incidents occur in 5% of anesthetic procedures and are largely dependent on the skills and up-to-date knowledge of the whole perioperative team in the specific needs for children. An investment in continuous medical education of the perioperative staff is required and international standard operating protocols for common procedures and critical situations should be defined.
•Mortality after anesthesia in older healthy children in developing countries is low.•Mortality after anesthesia in neonates and toddlers is high, namely in low-income countries.•Critical (near) incidents, particular in younger children, are common.•Investment in continuous medical education of all perioperative staff is required.•International standard operating protocols should be defined and implemented.
BACKGROUND:Although noninvasive blood pressure (NIBP) monitoring during anesthesia is a standard of care, reference ranges for blood pressure in anesthetized children are not available. We developed ...sex- and age-specific reference ranges for NIBP in children during anesthesia and surgery.
METHODS:In this retrospective observational cohort study, we included NIBP data of children with no or mild comorbidity younger than 18 yr old from the Multicenter Perioperative Outcomes Group data set. Sex-specific percentiles of the NIBP values for age were developed and extrapolated into diagrams and reference tables representing the 50th percentile (0 SD), +1 SD, −1 SD, and the upper (+2 SD) and lower reference ranges (−2 SD).
RESULTS:In total, 116,362 cases from 10 centers were available for the construction of NIBP age- and sex-specific reference curves. The 0 SD of the mean NIBP during anesthesia varied from 33 mmHg at birth to 67 mmHg at 18 yr. The low cutoff NIBP (2 SD below the 50th percentile) varied from 17 mmHg at birth to 47 mmHg at 18 yr old.
CONCLUSIONS:This is the first study to present reference ranges for blood pressure in children during anesthesia. These reference ranges based on the variation of values obtained in daily care in children during anesthesia could be used for rapid screening of changes in blood pressure during anesthesia and may provide a consistent reference for future blood pressure–related pediatric anesthesia research.
Purpose
The purpose of this international study was to investigate prescribing practices of dexmedetomidine by paediatric anaesthesiologists.
Methods
We performed an online survey on the prescription ...rate of dexmedetomidine, route of administration and dosage, adverse drug reactions, education on the drug and overall experience. Members of specialist paediatric anaesthesia societies of Europe (ESPA), New Zealand and Australia (SPANZA), Great Britain and Ireland (APAGBI) and the USA (SPA) were consulted. Responses were collected in July and August 2019.
Results
Data from 791 responders (17% of 5171 invitees) were included in the analyses. Dexmedetomidine was prescribed by 70% of the respondents (ESPA 53%; SPANZA 69%; APAGBI 34% and SPA 96%), mostly for procedural sedation (68%), premedication (46%) and/or ICU sedation (46%). Seventy-three percent had access to local or national protocols, although lack of education was the main reason cited by 26% of the respondents not to prescribe dexmedetomidine. The main difference in dexmedetomidine use concerned the age of patients (SPA primarily < 1 year, others primarily > 1 year). The dosage varied widely ranging from 0.2–5 μg kg
−1
for nasal premedication, 0.2–8 μg kg
−1
for nasal procedural sedation and 0–4 μg kg
−1
intravenously as adjuvant for anaesthesia. Only ESPA members (61%) had noted an adverse drug reaction, namely bradycardia.
Conclusion
The majority of anaesthesiologists use dexmedetomidine in paediatrics for premedication, procedural sedation, ICU sedation and anaesthesia, despite the off-label use and sparse evidence. The large intercontinental differences in prescribing dexmedetomidine call for consensus and worldwide education on the optimal use in paediatric practice.
Organization of healthcare strongly differs between European countries and results in country‐specific requirements in postgraduate medical training. Within the European Union (EU), the European ...Board of Anaesthesiology has set recommendations of training for the Specialty of Anaesthesiology including standards for Postgraduate Medical Specialist training including a description for providing service in pediatric anesthesia. However, these standards are advisory and not mandatory. Here we aimed to review the current state and associated challenges of pediatric anesthesia training in Europe. We report an important country‐specific variability both in training and regulations of practice of pediatric anesthesia in the EU and in the United Kingdom. The requirements for training in pediatric anesthesia varies between nothing specified (Belgium) or providing anesthesia with direct supervision to a minimum of 50 cases below 5 years of age (Germany) to 3–6 month clinical practice in a specialized pediatric hospital (France). Likewise, the regulations for providing anesthesia to children varies from no regulations at all (Belgium) to age specific requirements and centralization of all children below 4 years of age to specified centers (United Kingdom). Officially recognized pediatric anesthesia fellowship programs are not available in most countries of Europe. It remains unclear if and how country‐specific differences in pediatric anesthesia training are associated with clinical outcomes in pediatric perioperative care. There is converging interest and support for the establishment of a European pediatric anesthesia curriculum.
Blood pressure is a basic feature of monitoring during anaesthesia. However, it is very unclear what blood pressures are normal during anaesthesia in children. Furthermore, the clinical consequences ...of low blood pressure are also uncertain. Similarly, it is unclear when to initiate therapy for hypotension during anaesthesia. This review summarizes the most recent development on the interpretation of blood pressure measurements in children and the relation of low blood pressure to clinical outcome.
Recently published (multicentre) database studies show that alleged complications of intraoperative hypotension (brain ischaemia, kidney dysfunction, myocardial ischaemia and multiple organ dysfunction) are very rare in children after anaesthesia noncardiac procedures. Furthermore, other studies show that a considerable number of patients have blood pressure lower than a threshold according to the current standards treatment of Paediatric Life Support.
The recently published reference tables can guide anaesthesiologist in daily practice to define intraoperative hypotension. However, there are situations in which a higher blood pressure is recommendable and an individual approach is required.
Summary
Background
The incidence, type and severity of anesthesia‐related critical incidents during the perioperative phase has been investigated less in children than in adults.
Aim
The aim of the ...study was to identify and analyze anesthesia‐related critical incidents in children to identify areas to improve current clinical practice, and to propose a specialized anesthesia‐related critical incidence registration for children.
Method
All reported pediatric anesthesia‐related critical incidents reported on a voluntary reporting based on a 20‐item complication list of the Dutch Society of Anesthesiology between January 2007 and August 2013 were analyzed. An anesthesia‐related critical incident was defined as ‘any incident that affected, or could have affected, the safety of the patient while under the care of an anesthetist’. As the 20‐item complications list was too crude for detailed analyses, all critical incidents were reclassified into the more detailed German classification lists with the adjustment of specific items for children (in total 10 categories with 101 different subcategories).
Results
During the 6‐year period, a total of 1214 critical incidents were reported out of 35 190 anesthetics (cardiac and noncardiac anesthesia cases). The most frequently reported incidents (46.5%) were related to the respiratory system. Infants <1 year, children with ASA physical status III and IV, and emergency procedures had a higher rate of adverse incidents.
Conclusion
Respiratory events were the most reported commonly critical incidents in children. Both the Dutch and German existing lists of critical incident definitions appeared not to be sufficient for accurate classification in children. The present list can be used for a new registration system for critical incidents in pediatric anesthesia.
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