Summary
The use of regional anesthesia is increasingly common in pediatric practice. This review reports the complications and risks in pediatric regional anesthesia. Few large studies reported ...incidence of complications. However, the different studies have shown that regional anesthesia, when performed properly, carried a very low risk of morbidity in appropriately selected infants and children. In addition, the use of ultrasound‐guided peripheral nerve blockade has shown some promise toward increasing the safety profile of these already safe techniques.
Summary
Introduction
To optimize the care pathway for children scheduled for ambulatory surgery, a pediatric postanesthetic discharge scoring system (Ped‐PADSS) was developed from a score used in ...adults. The objective of this study was to evaluate this score prospectively on a cohort of children who had a day case surgical procedure.
Materials and methods
This was a single center prospective observational study. Inclusion criteria were predefined as follows: children aged 6 months–16 years at the time of the study, with a scheduled day surgery. Discharge was validated by Ped‐PADSS scores ≥9, obtained at one hour intervals, after the return from the operating room and with the agreement of the surgeon. The duration of postoperative hospitalization was compared with data collected before the implementation of the score using the Student's t‐test.
Results
From February to July 2012, 1060 children were included. One hour after the return from the operating room, 97.2% of children were dischargeable using Ped‐PADSS. Two hours after the return from the operating room, 99.8% of children were dischargeable. The median postoperative hospital stay (n = 1041) was reduced by 69 min compared to the median stay before using the output score (n = 150) (P < 0.01).
Conclusion
The Ped‐PADSS score allows for the majority of children to be discharged 1 h after their return from the postanesthesia care unit. Children who were discharged using the Ped‐PADSS score returned home in safe and optimal conditions.
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).
Aims
Knowledge about the impact of epinephrine on the outcome in venoarterial (VA) extracorporeal membrane oxygenation (ECMO) patients is limited, and existing data are conflicting.
Methods and ...results
We conducted a retrospective cohort study in a 1500 bed tertiary university hospital. Five hundred and eighty‐nine VA‐ECMO patients were analysed. The median age was 57 years 47–65, 68% of male. The major indications for ECMO were post‐cardiotomy cardiogenic shock (CS) (38%) and medical CS (36%). Two hundred and sixty‐two (44.5%) patients received epinephrine alone or associated with another catecholamine while on ECMO. Baseline factors significantly associated with epinephrine administration were younger age, higher sequential organ failure assessment score, cardiac arrest at implantation, and intra‐aortic balloon pump support at implantation, whereas medical CS and dobutamine administration were significantly associated with a lower risk of epinephrine administration. Epinephrine administration was independently associated with death hazard ratio = 1.68 (1.44–2.23); P < 0.01. A sensitivity analysis with propensity score inverse probability weighting in complete cases confirmed a significant association of epinephrine administration with death hazard ratio = 1.69 (1.43–2.00); P < 0.001.
Conclusions
Among patients who required VA‐ECMO, epinephrine administration was associated with an increased risk for death.
Acute pain is a common condition among prehospital patients and prompt management is pivotal. Opioids are the most frequently analgesics used in the prehospital setting. However, opioids are highly ...addictive, and some patients may develop opioid dependence, even when they are exposed to brief opioid treatments. Therefore, alternative non-opioid analgesia should be developed to manage pain in the prehospital setting. Used at subdissociative doses, ketamine, a noncompetitive N-methyl-D-aspartate and glutamate receptor antagonist, provides analgesic effects accompanied by preservation of protective airway reflexes. In this context, we will carry out a randomized controlled, open-label, multicenter trial to compare a subdissociative dose of ketamine to morphine to provide pain relief in the prehospital setting, in patients with traumatic and non-traumatic pain.
This will be a multicenter, single-blind, randomized controlled trial. Consecutive adults will be enrolled in the prehospital setting if they experience moderate to severe, acute, non-traumatic and traumatic pain, defined as a numeric rating scale score greater or equal to 5. Patients will be randomized to receive ketamine or morphine by intravenous push. The primary outcome will be the between-group difference in mean change in numeric rating scale pain scores measured from the time before administration of the study medication to 30 min later.
This upcoming randomized clinical trial was design to assess the efficacy and safety of ketamine, an alternative non-opiate analgesia, to manage non-traumatic and traumatic pain in the prehospital setting. We aim to provide evidence to change prescribing practices to reduce exposition to opioids and the subsequent risk of addiction.
ClinicalTrials.gov, ID: NCT03236805 . Registered on 2 August 2017.
Perioperative Use of Intravenous Lidocaine Beaussier, Marc; Delbos, Alain; Maurice-Szamburski, Axel ...
Drugs (New York, N.Y.),
08/2018, Volume:
78, Issue:
12
Journal Article
Peer reviewed
Lidocaine is an amide local anaesthetic initially used intravenously as an antiarrhythmic agent. At some point it was proposed that intravenous lidocaine (IVL) had an analgesic effect that could be ...potentially beneficial in perioperative settings. Since these preliminary reports, a large body of evidence confirmed that IVL had anti-inflammatory and opiate-sparing effects, a combination of characteristics leading to an array of effects such as a decrease in postoperative pain and opiate consumption, and a reduction in the duration of digestive ileus. Additional studies demonstrated IVL to possess antithrombotic, antimicrobial and antitumoral effects. Beneficial effects of IVL have been characterized in abdominal surgery but remain controversial in other types of surgeries. Because the quality of evidence was limited, due to inconsistency, imprecision and study quality, recent conclusions from meta-analysis pooling together all types of surgery stated the uncertainty about IVL benefits. Additional indications such as the prevention of propofol-induced injection pain, prevention of hyperalgesia, protection against bronchial reactivity by bronchotracheal relaxation during surgery, and the increase in depth of general anaesthesia have since emerged. IVL is rapidly distributed in the body and metabolized by the liver. With the commonly recommended doses, lidocaine's therapeutic index remains very high and the plasma concentrations stay largely below the cardiotoxic and neurotoxic threshold levels, a notion that may be used by clinicians to draw conclusions on the benefit-risk profile of IVL in comparison to other analgesic strategies. The purpose of this review is to address the pharmacokinetic and pharmacodynamic properties of lidocaine in healthy and pathological conditions.
Summary
Background: The main objectives of premedication in children are to facilitate the separation from the parents, to reduce preoperative anxiety, to smooth the induction of anesthesia and to ...lower the risk of postoperative behavioral disorders. The most common technique is sedative premedication with midazolam. Hypnosis enables a state of relaxation to be achieved and has never been evaluated as a premedication technique. The aim of the present study was to evaluate the efficacy of hypnosis on anxiety and perioperative behavioral disorders versus midazolam.
Methods: Fifty children from 2 to 11 years of age were randomized into two groups: group H received hypnosis as premedication; group M were given 0.5 mg·kg−1 midazolam orally, 30 min before surgery. Preoperative anxiety was evaluated using the Modified Yale Preoperative Anxiety Scale (mYPAS) score when arriving in the department (T1), when entering the operating room (T2), and when fitting the facemask (T3). Postoperative behavioral disorders were evaluated using the Posthospitalization Behavioral Questionnaire (PHBQ) at days 1, 7 and 14.
Results: The two groups showed no significant difference preoperatively with the PHBQ: (M) 21 (17–25) vs (H) 20 (8–25) and mYPAS score: (M) 28 (23–75) vs (H) 23 (23–78). The number of anxious children was less during induction of anesthesia in the hypnosis group (T3: 39% vs 68%) (P < 0.05). Postoperatively, hypnosis reduced the frequency of behavior disorders approximately by half on day 1 (30% vs 62%) and day 7 (26% vs 59%).
Conclusions: Hypnosis seems effective as premedication in children scheduled for surgery. It alleviates preoperative anxiety, especially during induction of anesthesia and reduces behavioral disorders during the first postoperative week.
Abstract In the axillary fossa, the musculocutaneous nerve (MC) is generally distant from the axillary artery and from the other brachial plexus nerves. In that way, MC requires a specific block. We ...observed that the location of MC is influenced by the position of the patient's arm and shoulder. Abduction of the shoulder significantly reduced the distance between the MC and the axillary artery. This change in the location of the MC is probably due to the moving of the nerve because of muscle rearrangements and the ability to achieve better proximity of the probe in the axillary fossae.
Microparticulate local anesthetics-loaded delivery systems are known to provide a controlled release of drug and to reduce systemic toxicity resulting from transient high plasma concentrations. The ...aim of this study was to evaluate epidural, intrathecal and plasma pharmacokinetics of ropivacaine following epidural administrations of repeated boluses or infusions and to compare them with the epidural administration of polylactide-co-glycolide ropivacaine-loaded microspheres.
In the first step, the epidural and intrathecal pharmacokinetics was evaluated in 3 Lacaunes ewes, receiving epidural continuous infusion of ropivacaine with increasing doses (20, 50 and 100
mg/h). Then, six animals received an epidural administration of ropivacaine-loaded microspheres (500
mg), three others received ropivacaine in epidural bolus (30
mg) followed by infusion (2
mg/ml during 6
h), and the last three animals received three successive epidural boluses of ropivacaine (50
mg) at 2
h interval. A simultaneous microdialysis technique was used to measure epidural and intrathecal concentrations of ropivacaine.
After epidural administration of ropivacaine-loaded microspheres, Cmax in plasma was around 100
ng/ml while epidural and intrathecal Cmax of ropivacaine were close to 600 and 150
μg/ml, respectively. The ratios of intrathecal to epidural AUC (AUCit/AUCepi) for bolus administration, bolus
+
infusion administration, and for microspheres were 13.4
±
2.4; 14.1
±
6.1 and 33.9
±
22.6%, respectively. This suggested that administration of ropivacaine as microspheres increased the transmeningeal passage of ropivacaine in comparison to other administration regimens.
Epidural administration of ropivacaine-loaded microspheres led to the sustained levels of ropivacaine in the intrathecal space compared to the boluses of ropivacaine solution. Moreover, epidural administration of microspheres resulted in the highest efficiency in intrathecal uptake of ropivacaine compared to administration in solution.
Dosage of local anesthetics (LAs) used for regional anesthesia in children is not well determined. In order to evaluate and come to a consensus regarding some of these controversial topics, The ...European Society of Regional Anaesthesia and Pain Therapy (ESRA) and the American Society of Regional Anesthesia and Pain Medicine (ASRA) developed a Joint Committee Practice Advisory on Local Anesthetics and Adjuvants Dosage in Pediatric Regional Anesthesia.
Representatives from both ASRA and ESRA composed the joint committee practice advisory. Evidence-based recommendations were based on a systematic search of the literature. In cases where no literature was available, expert opinion was elicited.
Spinal anesthesia with bupivacaine can be performed with a dose of 1 mg/kg for newborn and/or infant and a dose of 0.5 mg/kg in older children (>1 year of age). Tetracaine 0.5% is recommended for spinal anesthesia (dose, 0.07-0.13 mL/kg). Ultrasound-guided upper-extremity peripheral nerve blocks (eg, axillary, infraclavicular, interscalene, supraclavicular) in children can be performed successfully and safely using a recommended LA dose of bupivacaine or ropivacaine of 0.5 to 1.5 mg/kg. Dexmedetomidine can be used as an adjunct to prolong the duration of peripheral nerve blocks in children.
High-level evidence is not yet available to guide dosage of LA used in regional blocks in children. The ASRA/ESRA recommendations intend to provide guidance in order to reduce the large variability of LA dosage currently observed in clinical practice.
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