Pediatric anesthetists have an important role to play in the management of patients suspected or confirmed to have COVID‐19. In many institutions, the COVID‐19 intubation teams are staffed with ...anesthetists as the proceduralists working throughout the hospitals also in the ICU and Emergency Departments. As practitioners who perform aerosol generating procedures involving the airway, we are at high risk of exposure to the virus SARS‐CoV‐2 and need to ensure we are well prepared and trained to manage such cases. This article reviews the relevant pediatric literature surrounding COVID‐19 and summarizes the key recommendations for anesthetists involved in the care of children during this pandemic.
Background
Hypoactive delirium is present when an awake child is unaware of his or her surroundings, is unable to focus attention, and appears quiet and withdrawn. This condition has been ...well‐described in the intensive care setting but has not been extensively studied in the immediate post‐anesthetic period.
Aim
To determine if hypoactive emergence delirium occurs in the recovery unit of a pediatric hospital, and if so, what proportion of emergence delirium is hypoactive in nature.
Methods
We conducted an observational study using the Cornell Assessment of Pediatric Delirium in a cohort of 4424 children recovered at a tertiary pediatric hospital. The incidence of emergence delirium detected using the Pediatric Anesthetic Emergence Delirium (PAED) scale was also recorded for comparison.
Results
There were 74 cases of emergence delirium detected during the study period using the Cornell Assessment of Pediatric Delirium (1.7%). Only 57 cases were detected using the Pediatric Anesthetic Emergence Delirium scale. The additional 17 cases detected using the Cornell Assessment of Pediatric Dlirium represent cases of hypoactive delirium. In this cohort of pediatric patients, 23% of all cases of emergence delirium were hypoactive in nature.
Conclusion
The significance of hypoactive delirium in this population is unknown; however, previous studies have shown that emergence delirium can result in post‐operative behavior changes and may affect compliance with future episodes of care. However, hypoactive delirium is often missed without active screening. The prevalence detected in this study therefore suggests hypoactive delirium warrants further investigation.
Background
Barrier techniques, such as plastic sheets or intubation boxes, are purported to offer additional protection for healthcare workers.
Aims
To assess the functionality, perceived safety, ...droplet protection, and aerosol protection of several barrier techniques.
Methods
Firstly, a simulation study with 12 different laryngoscopists was conducted to assess the time taken to perform an intubation (via direct laryngoscopy, via video laryngoscopy, and via a bougie) with four different barrier techniques (personal protective equipment only, a plastic sheet, a tented plastic sheet, and an intubation box). Secondly, a cough at the time of intubation was simulated using ultraviolet dye to assess the spread of droplets; and thirdly, smoke was used to assess the spread of aerosols.
Results
Intubation time using the box was noninferior to using no barrier. Based on subjective ratings by the laryngoscopists, the most functional technique was no barrier followed by the intubation box, then the tented sheet, and then the plastic sheet. The technique that conferred the highest feeling of safety to the laryngoscopists was the intubation box, followed by the tented sheet, then no barrier, and then the plastic sheet. All the barriers prevented the ultraviolet dye contaminating the head and torso of the laryngoscopist. Smoke remained within the intubation box if plastics sheets were used to cover the openings and suction was ineffective at clearing it. With no barrier in place, smoke was effectively cleared away from the patient in a theater with laminar flow but tended to spread up toward the laryngoscopist in a room without laminar flow.
Conclusions
A well‐designed intubation box is an effective barrier against droplets and is noninferior to no barrier in relation to intubation time. However, a box interferes with laminar flow in theaters with formal ventilation systems and may result in accumulation of aerosols if it is completely enclosed.
Background
A contemporary, well‐validated instrument for the measurement of behavior change in children after general anesthesia is lacking. The Post Hospitalization Behavior Questionnaire for ...Ambulatory Surgery (PHBQ‐AS) has been developed as an updated version of the original Post Hospitalization Behavior Questionnaire (PHBQ) to better reflect the current patient population and modern anesthetic practices.
Aims
To assess the reliability of the PHBQ‐AS and determine concurrent validity with another measure of child behavior, the Strength and Difficulties Questionnaire (SDQ).
Methods
We compared the PHBQ‐AS with the SDQ in 248 children presenting for day‐case surgery. A baseline SDQ measurement was taken prior to surgery, and then, both scales were administered on days 3, 14, and 28 postsurgery.
Results
The PHBQ‐AS demonstrated good reliability in terms of internal consistency with a Cronbach's alpha of 0.79 and split‐half correlation with Spearman Brown adjustment of 0.85. There was weak correlation with the SDQ on day 3 postoperatively (Pearson's r = 0.201), moderate correlation on day 14 (Pearson's r = 0.421), and weak‐to‐moderate correlation on day 28 (Pearson's r = 0.340). A cut‐off score of 3.2 on the PHBQ‐AS for the diagnosis of negative behavior demonstrated equivalence with the SDQ results; however, the SDQ results remained relatively constant throughout the study period and reflected the expected rate of increased risk of problem behavior in children.
Conclusions
The PHBQ‐AS showed good reliability but only had weak‐to‐moderate correlation with another measure of child behavior, the SDQ. Further validation is required before the PHBQ‐AS is used for the routine measurement of behavior change in children after anesthesia, or alternatively, a new instrument needs to be developed in order for research to advance in this area.
Background
Liver transplantation is conducted with strict oversight of organizational structure and clinical practice. However, specific regulations pertaining to the delivery of anesthetic services ...are lacking and consideration of departmental structure and mechanisms for quality control must occur at a local level. Busy centers collect and process sufficient data to guide this process but those with low case loads may not generate enough data for useful analysis. In Australia and New Zealand, pediatric liver transplants are performed at only four locations. As these operations are not equally distributed geographically or temporally there are periods of low activity at some centers. As anesthesia affects patient outcome, quality assurance activities are important in this setting.
Aims
Provide a global overview of the structure and function of liver transplantation networks. Identify issues related to provision of pediatric anesthetic services with specific reference to Australasia. Examine anesthetic data from a single pediatric center to illustrate benefits and limitations of such activity.
Methods
Pediatric liver transplant centers from Australia and New Zealand were surveyed to determine the organizational and logistical issues related to a liver transplant service. An audit of 15 years of liver transplants from a single center was conducted for benchmarking purposes and to identify changes in anesthetic practice over time.
Results
Pediatric liver transplants performed in Queensland from January 2005 to December 2019 were reviewed. Changes in transfusion practice reflected international trends. Morbidity and mortality were comparable to international data. Important complications such as hepatic artery and portal vein thrombosis were uncommon and did not generate enough data for further analysis.
Conclusions
Combining the anesthetic liver transplant data from all sites in a single registry would expand data collection and generate broadly applicable findings. We propose the establishment of an Australasian pediatric anesthetic liver transplant database.
Background
Early and delayed behavioral changes are well recognized after anesthesia. Intravenous anesthesia may prevent emergence delirium. However, it has not been evaluated as a preventive ...strategy for delayed postoperative behavior changes.
Aims
We aimed to determine whether intravenous anesthesia is effective at reducing postoperative behavior changes in children undergoing ambulatory endoscopic procedures when compared to inhalation anesthesia.
Methods
This randomized, double‐blinded controlled trial was approved by the local IRB. Children aged 1–12 years who underwent ambulatory endoscopic procedures were recruited. Preoperative anxiety was evaluated through the modified Yale Preoperative Anxiety Scale. All children underwent face mask inhalation induction with sevoflurane. After a peripheral line was placed, each child was allocated to sevoflurane or propofol maintenance. Emergence delirium was evaluated through the Pediatric Anesthesia Emergence Delirium scale. The child was discharged home, and behavioral changes were assessed through the Posthospitalization Behavior Questionnaire for Ambulatory Surgery on Days 1, 7, and 14.
Results
Overall, 175 children were enrolled. On Day 1 after the procedure, 57 children presented at least one negative behavior. On Days 7 and 14, 49 and 44 children presented at least one negative behavior, respectively. The median number of negative behaviors was similar between the groups. Post hoc analyses showed a moderate correlation between emergence delirium and negative postoperative behavior on Day 7 (r = .34; p = <.001) and an increase of 3.31 (95% CI 1.90; 4.36 p < .001) points in the mean summed score of new negative behaviors for individuals with emergence delirium.
Conclusion
The incidence of postoperative behavior changes in children undergoing ambulatory endoscopic procedures was similar when comparing intravenous with inhalation anesthesia. Children who experience emergence delirium might show a greater incidence of negative postoperative behavior changes.
PDF
