Anesthesia In Young Children Research Articles

Combination of Silver Diamine Fluoride and Hall Technique for Caries Management in Primary Molars: A Randomized Controlled Trial.

Combination of different noninvasive caries arresting approaches may improve the effectiveness and success rate of individual procedures for caries management. The purpose of this study was to evaluate clinical and radiographic success rate of a combination of 38% silver diamine fluoride (SDF) application and Hall technique (HT) for the management of dentinal caries in primary molars and compare it with conventional stainless steel crown (SSC) restoration. Children aged 4-8 years, having carious primary molars with the International Caries Detection and Assessment System (ICDAS) score of 5 or 6, were randomly assigned to treatment group A or B. Treatment group A (n = 25) received 38% SDF application and Hall crown, while group B (n = 25) received conventional SSC restoration. Follow-up was done at 1 month, 3, 6, 12, 24, and 30 months intervals. There was one case of major failure in group A (93.5% successful) while no case of major failure in group B (100% successful) and the difference was not statistically significant (p > 0.05). For minor failure (loss of SSC), the success rate was 91.3% in group B and 84.2% in group A, wherein the difference was not statistically significant (p > 0.05). Conservative management of dentinal carious lesions with SDF and HT showed a similar success rate as compared to conventional operative procedures. This protocol can help reduce the clinical chair time and the need for deep sedation/general anesthesia in young children suffering from deep carious lesions with reversible pulpitis. CTRI/2020/07/026877, Clinical Trial Registry-India. Mittal M, Chopra R, Kumar A, et al. Combination of Silver Diamine Fluoride and Hall Technique for Caries Management in Primary Molars: A Randomized Controlled Trial. Int J Clin Pediatr Dent 2024;17(10):1114-1120.

A novel approach to calculate the required volume of air for bronchial blockers in young children.

Bronchial blocker balloons inflated with small volumes of air increase balloon pressure, involving a risk of airway injury especially in young children. However, there are no established guidelines regarding the appropriate volumes of air required to provide safe bronchial occlusion. This study aimed to introduce a novel method for calculating the amount of air required for safe bronchial blocker balloon occlusion for one lung anesthesia in young children. We included 79 pediatric patients who underwent video-assisted thoracoscopic surgery at our hospital. Preoperatively, the balloon pressure and corresponding diameter of 5F bronchial blockers inflated with different volumes of air were measured. Intraoperatively, bronchial diameters measured by computerized tomographic scans were matched to the exvivo measured balloon diameters. The quality of lung isolation, incidence of balloon repositioning, and airway injury were documented. Postoperatively, airway injury was evaluated through fiberoptic bronchoscopy. Balloon pressure and balloon diameter showed linear and nonlinear correlations with volume, respectively. The median lengths of the right and left mainstem bronchi were median (interquartile range) range: 5.3 mm (4.5-6.3) 2.7-8.15 and 21.8 (19.6-23.4) 14-29, respectively. Occluding the left mainstem bronchus required <1 mL of air, with a balloon pressure of 27 cm H2O. The isolation quality was high with no case of mucosal injury or displacement. Occluding the right mainstem bronchus required a median air volume of 1.3 mL, with a median balloon pressure of 44 cm H2O. One patient had poor lung isolation due to a tracheal bronchus and another developed mild and transient airway injury. The bronchial blocker cuff should be regarded as a high-pressure balloon. We introduced a new concept for safe bronchial blocker balloon occlusion for one-lung ventilation in small children.

Quantitative Liver Imaging in Children.

In children and adults, quantitative imaging examinations determine the effectiveness of treatment for liver disease. However, pediatric liver disease differs in presentation from liver disease in adults. Children also needed to be followed for a longer period from onset and have less control of their bodies, showing more movement than adults during imaging examinations, which leads to a greater need for sedation. Thus, it is essential to appropriately tailor and accurately perform noninvasive imaging tests in these younger patients. This article is an overview of updated imaging techniques used to assess liver disease quantitatively in children. The common initial imaging study for diffuse liver disease in pediatric patients is ultrasound. In addition to preexisting echo analysis, newly developed attenuation imaging techniques have been introduced to evaluate fatty liver. Ultrasound elastography is also now actively used to evaluate liver conditions, and the broad age spectrum of the pediatric population requires caution to be taken even in the selection of probes. Magnetic resonance imaging (MRI) is another important imaging tool used to evaluate liver disease despite requiring sedation or anesthesia in young children because it allows quantitative analysis with sequences such as fat analysis and MR elastography. In addition to ultrasound and MRI, we review quantitative imaging methods specifically for fatty liver, Wilson disease, biliary atresia, hepatic fibrosis, Fontan-associated liver disease, autoimmune hepatitis, sinusoidal obstruction syndrome, and the transplanted liver. Lastly, concerns such as growth and motion that need to be addressed specifically for children are summarized.

Feasible Removal of Facial Hemangiomas Under Local Anesthesia in Young Children.

Facial Hemangiomas are often recommended to be removed exclusively in the operating room under general anesthesia, especially for children under the age of 4. Assumed parental and patient anxiety and possible blood loss pushes surgeons away from attempting excision under local anesthesia. A review was conducted to assess the outcomes of children who underwent excision of facial hemangiomas under local anesthesia alone by 1 plastic surgeon with a minimum of 3 months follow-up. Complications and hemangioma recurrence were recorded. A survey was given 3 to 6 months after treatment to assess parental satisfaction, anxiety, and thought process about anesthesia. Eighteen children (9 males and 9 females) underwent in-office excision between 2020 and 2021. The mean age of this cohort was 12 months ( ranging 2-52m). The average facial hemangioma size was 2.088cm (ranging 1.0-3.2cm). Ten patients experienced complete resolution (56%) at 12-month follow-up. There were no hospitalizations or cases of significant (>10mL) blood loss, infection, dehiscence, hematoma, or scar hypertrophy. The average level of parental anxiety before the procedure was 3.3/10, and 1.6/10 after the procedure. Total 13/14 parents gave 4/4 ratings for satisfaction with the quality of care, team responsiveness, pain management, and management of expectations. Facial hemangioma removal under local anesthesia alone is a safe and feasible alternative treatment method for patients younger than 4 years of age.

PET/MR of pediatric bone tumors: what the radiologist needs to know.

Integrated 2-deoxy-2-[fluorine-18]fluoro-D-glucose (18F-FDG) positron emission tomography (PET)/magnetic resonance (MR) imaging can provide "one stop" local tumor and whole-body staging in one session, thereby streamlining imaging evaluations and avoiding duplicate anesthesia in young children. 18F-FDG PET/MR scans have the benefit of lower radiation, superior soft tissue contrast, and increased patient convenience compared to 18F-FDG PET/computerized tomography scans. This article reviews the 18F-FDG PET/MR imaging technique, reporting requirements, and imaging characteristics of the most common pediatric bone tumors, including osteosarcoma, Ewing sarcoma, primary bone lymphoma, bone and bone marrow metastases, and Langerhans cell histiocytosis.

Possibilities of magnetic resonance imaging in the diagnosis of acute aseptic sacroilitis in children

INTRODUCTION: Children and adolescents with juvenile spondyloarthritis (JSA) are at risk of developing sacroiliitis. MRI is the most preferred method of diagnosing sacroiliitis in adults over radiography and computed tomography. However, in the case of diagnosing childhood sacroiliitis, there is little information about the capabilities of MRI, and the reliability of the results in studies varies.OBJECTIVE: To show the possibilities of MRI in the diagnosis of infectious-allergic sacroiliitis.MATERIALS AND METHODS.: In this report, we present an analysis of data from 16 patients with aseptic (infectious-allergic) sacroiliitis only. Boys and girls aged 6 to 17 years (mean age 12.2±4.9) were equally divided. Magnetic resonance imaging, including contrast-enhanced imaging (used in 14 patients out of the total), was performed on a 3 T scanner (Achieva dStream Phillips) using a standard protocol that included multiplanar 3D T1-, T2WI, FLAIR and STIR with oblique coronal projection, diffusion-weighted images (DWI).RESULTS: MRI in all 16 patients revealed changes, even in those cases when X-ray and CT did not reveal pathological changes in bone or the changes were on the verge of normal (n=15). Of the 16 children, 10 (62.5%) had unilateral changes (50% on the right, 50% on the left) and six (37.5%) had bilateral changes. The bone marrow edema affected the sacrum in 10 patients, the ilium in three, and both bones of the joint in three patients. On DWI (10 children), increased diffusion was observed in five patients, on the right — in three, and on the left — in two patients.CONCLUSION: Currently, the best imaging modality for suspected acute sacroiliitis is MRI, which is more sensitive and specific, allowing early diagnosis of the disease and, accordingly, initiation of treatment, improving the prognosis. Disadvantages of MRI are long scan times, susceptibility to motion artifacts that require sedation or anesthesia in young children.

Impact of Pediatric Radiation Oncology With Movie Induced Sedation Effect (PROMISE) on Patient Movement and General Anesthesia Use in Pediatric Radiation Therapy

Pediatric radiation therapy (RT) often requires daily anesthesia to ensure precise immobilization for safe and accurate treatment. Unfortunately, repeated anesthesia can be detrimental to patient health and quality of life, and provides significant logistical and financial burden. PROMISE (Pediatric Radiation Oncology with Movie Induced Sedation Effect) is an interactive incentive-based movie system that allows for real time monitoring of patient motion and automatic shutting off of the beam and video if the patient moves outside of defined parameters. We hypothesize that PROMISE will result in minimal patient movement during RT and an overall decrease in the need for general anesthesia in young children (ages 3-7).PROMISE integrates a movie system involving wireless video streaming to a low attenuation screen directly in front of the patient with a video surveillance gating module (AlignRT) for real time monitoring and behavior training. Starting in the beginning of 2020, this system was available for all children < 12 years old undergoing RT at our institution. For patients treated with PROMISE, AlignRT monitoring data was collected and analyzed to determine patient motion. We compared frequency of anesthesia use after implementation of PROMISE to the 2 years' prior at our institution to estimate reduction in anesthesia use per age group.PROMISE was successfully implemented in 21 children, the majority (76%) who were 7 years or younger and most likely would have otherwise required daily anesthesia. Patient movement during RT with PROMISE was minimal, with in-treatment variation of ∼1.2 mm (0.8 mm standard deviation) from the reference baseline. Prior to implementation of PROMISE (2018-19), 100% of kids below the age of 3 (6/6), 70% of kids ages 3-7 (14/20), and 14% of kids ages 8 to 11 (4/28) needed general anesthesia. After PROMISE implementation (2020), 100% of kids below the age of 3 (5/5), 40% of kids ages 3-7 (8/20), and 8% of kids ages 8-11 (1/13) needed general anesthesia. When analyzed per fraction, after PROMISE, 100% below the age of 3 (76/76), 29% ages 3-7 (90/315), and < 1% ages 8-11 (1/221) required general anesthesia. On per patient comparison, PROMISE resulted in a 30% absolute benefit in those 3-7 years old, with 70% previously requiring anesthesia to only 40% after the implementation of PROMISE.PROMISE resulted in a 30% absolute reduction in general anesthesia use for children ages 3-7. Further, patient movement during RT with PROMISE was minimal, within acceptable standards. The real time motion monitoring with automatic safety shutoff and behavioral training make PROMISE a unique and attractive alternative to general anesthesia. Further prospective clinical data is necessary to prove the safety and efficacy of PROMISE in pediatric RT.

The use of intraoperative neurophysiological monitoring in dorsal resection of hemivertebrae

BACKGROUND: Congenital disorders of vertebrae formation are a common pathology in children. Intraoperative neurophysiological monitoring is a mandatory procedure, although it may not be effective enough due to the immature neural structures and the use of inhalation anesthetics in young children.&#x0D; AIM: To study aims to investigate the characteristic features of intraoperative neurophysiological monitoring in children with a congenital deformity of the spine during dorsal resection of the hemivertebrae.&#x0D; MATERIALS AND METHODS: 42 patients aged 117 years with a congenital deformity of the spine underwent 46 resections of the abnormal vertebra from an isolated dorsal approach (egg-shell technique). Intraoperative neurophysiological monitoring at the stages of the operation included a muscle relaxant test (TOF), transcranial electrical stimulation of the motor cortex (TCeMEP), control of the approach to the nerve (N. Proxy), correct placement of the pedicle screw (Screw Integrity), and EMG recording of the electromyogram. The accuracy of the screw placement was assessed by the Gerzbien method, and the presence of neurological disorders was tested by the Frenkel scale. The effect of inhalation anesthetic (sevoran) on motor evoked potentials was monitored by regulating its delivery, and the dependence on the age of patients was evaluated.&#x0D; RESULTS: The average age of patients was 7.7 4.5 years, and the TOF value was 80.5 17%. In 41 patients, the N. Proxy test was unremarkable, while in one patient, the 812 mA value did not require a change in the trajectory of the screws. From the beginning of sevoran and intraoperatively, motor evoked potentials from all tested muscles were recorded in 54.8% of patients; in children over 8 years old, this was observed in 92.8%, in children under 8 years old in 35.7% of cases in their age groups. In other patients, motor evoked potentials were most often not recorded from the muscles of the thigh and lower leg after sevoran administration. In children over 8 years old in 7.2%, under 8 years old in 83.3% of patients; Interestingly, in 7.2% of patients who are under 8 years of age, motor evoked potentials were not initially recorded from any muscle. Withdrawal of sevorane in 30.9% of patients allowed intraoperative motor evoked potentials to be obtained from all tested muscles in 100% of cases. For adequate management of anesthesia, 5 patients (50%) 14 years old and one patient 6 years old (5.6%) did not receive sevoran, and motor evoked potentials were recorded from the abdominal muscles. This allowed to assess the conduction only at the thoracic level and are required increased vigilance of surgeons when carrying out any corrective manipulations.&#x0D; CONCLUSIONS: Intraoperative neurophysiological monitoring with dorsal hemivertebra resection is an effective method that allows controlling the neurological complications during manipulations on the spine.

Update on the safety of anesthesia in young children presenting for adenotonsillectomy.

Tonsillectomy with and without adenoidectomy is a frequently performed surgical procedure in children. Although a common procedure, it is not without significant risk. It is critical for anesthesiologists to consider preoperative, intraoperative, and postoperative patient factors and events to optimize safety, especially in young children. In the majority of cases, the indication for adenotonsillectomy in young children is obstructive breathing. Preoperative evaluation for patient comorbidities, especially obstructive sleep apnea, risk factors for a difficult airway, and history of recent illness are crucial to prepare the patient for surgery and develop an anesthetic plan. Communication and collaboration with the otolaryngologist is key to prevent and treat intraoperative events such as airway fires or hemorrhage. Postoperative analgesia planning is critical for safe pain control especially for those patients with a history of obstructive sleep apnea and opioid sensitivity. In young children, it is important to also consider the impact of anesthetic medications on the developing brain. This is an area of continuing research but needs to be weighed when planning for surgical treatment and when discussing risks and benefits with patients’ families.

Parental Decision-Making for Surgery and Anesthesia in Young Children.

Millions of young children undergo surgery and anesthesia each year, yet there is a lack of scientific consensus about the safety of anesthesia exposure for the developing brain. Also poorly understood is parental anesthesia-related decision-making and how neurotoxicity information influences their choices. The theoretical model of parental decision-making generated in this research explicates this process. Interviews with 24 mothers yielded a theoretical framework based on their narratives developed using a qualitative grounded theory analysis. Five major themes emerged from these interviews: emotional processing, cognitive processing, relationships as resources, the mother/child dyad, and the health care context. Mothers described a non-linear, iterative process; they moved fluidly through emotional and cognitive processing supported by relationships as resources and influenced by the health care context. A key element was the subtheme of the medical translator, an individual who provided context and information. The mother/child dyad grounded the model in the relationship with the child.

Особенности проведения анестезии при офтальмологических вмешательствах у детей с перинатальными поражениями центральной нервной системы

Purpose. To study the frequency and severity of hypertensive-hydrocephalic syndrome in children planning to undergo ophthalmic surgery, to assess the adequacy of the anesthesia performed. Material and methods. The clinical material was selected by the method of continuous sampling from 4 637 children. Of these, two age groups were formed. The 1st group consisted of 220 children under the age of 6 years, to whom the induction of anesthesia was carried out with the drug «Sevoran». Group 2 included 56 older children (from 7 to 17 years old), who received anesthesia induction with propofol or sodium thiopental. Both groups were comparable in terms of the severity of the hypertensive-hydrocephalic syndrome. Results. Throughout the entire operating period, no complications arose in any case. Within 1–3 hours after waking up, 32 children of the 1st group and 6 children of the 2nd group complained of an isolated headache. Postoperative nausea and vomiting were observed in 22 children of the 1st group and 6 children of the 2nd group. In 30% of cases in children of the 1st group, postoperative reactions were expressed by aggressive behavior, disorientation in place and time, violation of behavioral reactions. In group 2, such reactions were detected only in 10% of cases. All negative manifestations were arrested by parenteral administration of midazolam at a dose of 3–5 mg. Conclusion. For the induction of anesthesia in young children with the presence of hypertensive-hydrocephalic syndrome, the optimal use of the drug «Sevoran». The drugs of choice for anesthesia in children over 6 years of age are propofol and sodium thiopental. The use of artificial ventilation in a moderate hyperventilation mode avoids an increase in intracranial pressure. Adequate analgesia avoids many adverse reactions. Keywords: hypertensive-hydrocephalic syndrome, general inhalation anesthesia, ophthalmic surgery.

Repeated measurements of ERGs and VEPs using chloral hydrate sedation and propofol anesthesia in young children.

Sedation with chloral hydrate or anesthesia using propofol allow ocular examination and testing in young children, but these drugs may affect electrophysiologic recordings. We compared the flash and pattern ERGs and VEPs recorded with each drug in a cohort of young children enrolled in a prospective study of optic nerve hypoplasia (ONH) syndrome. ERGs and VEPs to light-adapted, standard, full-field flashes, to standard and steady-state pattern-reversal (PR) were recorded with cycloplegia in 9 participants. Age range at the first session, with chloral hydrate was 8-23 mo; at the second session with propofol it was 20-29 mo. Examiners masked to the drug and clinical conditions measured the waveforms for longitudinal, paired comparisons between the sessions. Flash ERG amplitudes did not differ between sessions; peak times were longer at the second session (propofol) by clinically insignificant amounts (< 2ms, p = 0.002). Standard PERGs had larger amplitudes and later peaks in the second session (propofol) than with chloral hydrate (P50 2.9 vs 4.7μV, p = 0.016 and 43 vs 52ms, p < 0.001; N95 4.0 vs 6.1μV, p = 0.003 and 91 vs 98.5ms p = 0.034.). These differences were present for those with an interval of > 10 mo between sessions (n = 5, 10 eyes) but not for those with a shorter inter-test interval (< 8 mo, p > 0.05, n = 4). Magnitudes of the steady-state PERGs did not differ between tests but the waveforms had earlier peaks at the second test with propofol. Flash VEP waveforms were present in 10/18 eyes and showed 72% agreement for recordability between sessions. Standard pattern VEPs were recordable in only a few eyes in this cohort with ONH. Light-adapted flash ERG waveforms were generally similar with chloral hydrate and with propofol. Larger PERGs with later peaks, found in the second session (propofol) could reflect maturation of the PERG generators, as the differences found were associated with a greater age difference between the sessions, but we do not rule out that small differences in the waveforms may be drug-related. There are insufficient VEP data from these children with ONH to identify drug-related or maturational effects on VEPs.

Effects of neonatal isoflurane anesthesia exposure on learning-specific and sensory systems in adults

Millions of children undergo general anesthesia each year, and animal and human studies have indicated that exposure to anesthesia at an early age can impact neuronal development, leading to behavioral and learning impairments that manifest later in childhood and adolescence. Here, we examined the effects of isoflurane, a commonly-used general anesthetic, which was delivered to newborn rabbits. Trace eyeblink classical conditioning was used to assess the impact of neonatal anesthesia exposure on behavioral learning in adolescent subjects, and a variety of MRI techniques including fMRI, MR volumetry, spectroscopy and DTI captured functional, metabolic, and structural changes in key regions of the learning and sensory systems associated with anesthesia-induced learning impairment. Our results demonstrated a wide array of changes that were specific to anesthesia-exposed subjects, which supports previous studies that have pointed to a link between early anesthesia exposure and the development of learning and behavioral deficiencies. These findings point to the need for caution in avoiding excessive use of general anesthesia in young children and neonates.

Acetyl-l-carnitine does not prevent neurodegeneration in a rodent model of prolonged neonatal anesthesia

Many studies have shown that prolonged or repeated use of general anesthesia early in life can cause an increase in neurodegeneration and lasting changes in behavior. While short periods of general anesthesia appear to be safe, there is a concern about the neurotoxic potential of prolonged or repeated general anesthesia in young children. Unfortunately, the use of general anesthesia in children cannot be avoided. It would be a great benefit to develop a strategy to reduce or reverse anesthesia mitigated neurotoxicity.The mechanisms behind anesthesia related neurotoxicity are unknown, but evidence suggests that mitochondrial dysfunction and abnormal energy utilization are involved. Recent research suggests that a class of compounds known as carnitines may be effective at preventing anesthesia related neurotoxicity by influencing fatty acid metabolism in the mitochondria. However, it is unknown if carnitines can provide protection against changes in behavior associated with early life exposure to anesthesia. Accordingly, we evaluated the neuroprotective potential of acetyl-l-carnitine in 7-day old rats. Rat pups were exposed to 6 h of general anesthesia with sevoflurane or a control condition, with and without acetyl-l-carnitine. The oxygenation level of animals was continuously monitored during sevoflurane exposure, and any animal showing signs of hypoxia was removed from the study.Animals exposed to sevoflurane showed clear signs of neurodegeneration 2 h after sevoflurane exposure. The hippocampus, cortex, thalamus, and caudate putamen all had elevated levels of Fluoro-Jade C staining. Despite the elevated levels of Fluoro-Jade C, few behavioral changes were observed in an independent cohort of animals treated with sevoflurane. Furthermore, acetyl-l-carnitine had little impact on levels of Fluoro-Jade C staining in animals treated with sevoflurane. These data suggest that acetyl-l-carnitine may offer little protection again anesthesia related neurotoxicity in fully oxygenated animals.

Reducing preoperative anxiety with Child Life preparation prior to intravenous induction of anesthesia: A randomized controlled trial.

Induction of anesthesia can be stressful: Up to 60% of children suffer significant anxiety immediately before surgery. Anxiety is associated with higher postoperative analgesia requirements, higher incidence of emergence delirium, and detrimental effects on sleep and behavior. Child Life preparation includes role-play, expectation-setting, and teaching coping strategies. AIM: The aim of this trial was to determine whether preoperative Child Life preparation reduces anxiety prior to intravenous induction of anesthesia. Children aged 3-10years, with no known preexisting anxiety and no preoperative anxiolytics, undergoing elective day surgery lasting≤2hours, were enrolled in a randomized controlled trial. Each child's baseline anxiety was assessed in the anesthetic care unit, using the modified Yale Preoperative Anxiety Scale-Short Form (mYPAS-SF, observational scores from 22.9, minimal anxiety, to 100, maximal anxiety) as the primary outcome. The child was randomly assigned to intervention (minimum 15minutesChild Life preparation) or control (standard practice withoutChild Life preparation). Participants entered the operating room with one parent. A researcher (blinded to group allocation) scored the child's operating room anxiety using mYPAS-SF, up to the first attempt at intravenous cannulation. Fifty-nine children completed the study, aged median [interquartile range] 5 [3-7] years. Baseline mYPAS-SF anxiety was 29.2 [22.9-37.5] for all children, and operating room anxiety was 29.2 [22.9-49.0]. Operating room anxiety was higher than baseline in 16/31 (52%) children in the control group and 6/28 (21%) in the Child Life preparationgroup. ANCOVA revealed a significant effect of baseline mYPAS-SF anxiety and group on operating room anxiety (F=10.31, P<.001, adjusted R2 =.24); individual parameter estimates indicated thatChild Life preparation reduced operating room anxiety by 13.8 (95% CI 4.4-23.1) points compared to control, P=.005. A brief, targeted Child Life preparationsession had a statistically significant effect on reducing preoperative anxiety prior to intravenous induction of anesthesia in young children, with no known preexisting anxiety. This effect may be clinically important and suggests that Child Life can be a valuable component of pediatric surgical care. Further research is required in specific populations.

Self-induced soft-tissue injuries following dental anesthesia in children with and without intellectual disability. A prospective study.

Self-induced soft-tissue injuries (SSI) are reported as local anesthesia complications, particularly in children. The purpose of the study was to evaluate the frequency of SSI following dental anesthesia in children with and without intellectual disability. 241 children receiving dental treatments with local anesthesia were divided into 2 groups: A, children without intellectual disability (159 individuals, 299 injections); B, children with intellectual disability (82 individuals, 165 injections). Each group was divided into subgroups according to age, injection technique and dental treatment. Two days after the dental procedure, a phone survey was conducted to determine the presence of SSI. The frequency of SSI in group B was 19%, with no differences in relation to gender and age. In group A the frequency of SSI was significantly lower (9%; p = 0.002; Chi-square test); the children in the ≤ 6years-old subgroup experienced a higher frequency of SSI (p = 0.002). The lower arch was at major risk of SSI in both groups (p = 0.002). According to a multilevel approach group (p = 0.001) and injection technique (p = 0.0001) significantly influenced SSI; no influence of dental treatment is evidenced. SSI are common complications of local anesthesia in young children and individuals with intellectual disability.

Surgical treatment of inguinal hernia in neonates and infants: Early surgery or elective surgery?

PURPOSE: The surgical technique for inguinal hernia repair is well established. However, the safety of this procedure in young children still remains under debate because of risks of general anesthesia in young children. We assessed the indications for inguinal hernia repair in neonates and infants. PATIENTS AND METHODS: Between 2007 and 2017, laparoscopic hernia repair was performed in 408 patients at our institution. We reviewed the data from their medical records, including their sex, age at surgery, and incidence of asymptomatic patent processus vaginalis (PPV) during the surgery. RESULTS: The incidence of asymptomatic contralateral PPV in the female neonates/infants in whom the original hernia was on the left side was 75% and higher as compared to the frequency in other subpopulations. The incidence of bilateral inguinal hernia repair in female neonates/infants was 68.8% and higher as compared to that in other subpopulations. CONCLUSION: The incidence of an asymptomatic contralateral PPV and of a bilateral inguinal hernia repair was higher in female neonates/infants as compared to the corresponding frequencies in other subpopulations. In some infants of this group, the PPV on the contralateral side could potentially close as the children grew older. Therefore, girls with inguinal hernia under 1 year of age should be treated by elective surgery after they become at least 1 year old.

The Effects of Propofol on the Human Blood Brain Barrier

Background and Hypothesis: Recently, the safety of repeated and lengthy anesthesia in young children has been called into question. Previous studies have shown propofol, an anesthetic, can diminish blood-brain barrier (BBB) properties. However, the underlying cellular mechanisms are relatively unknown. The BBB is critical in ensuring that potentially harmful circulating factors are impermeable to the brain. Previous animal studies models have shown that propofol increases the levels of matrix metalloproteinases (MMPs), which have independently been shown to degrade the extracellular matrix and breakdown tight junctions, a critical component of the BBB. Hypothesis: Propofol exposure to a human induced pluripotent stem cell (iPSC)-derived BBB model increases MMP activity ultimately contributing to a leaky barrier phenotype.&#x0D; Experimental Design or Project Methods: This study utilized human iPSCs differentiated into brain microvascular endothelial cells (BMECs), the barrier forming cell type of the BBB. iPSC-derived BMECS were exposed to propofol (50μM) for three hours and barrier properties were monitored. Barrier tightness was monitored using trans-endothelial electrical resistance (TEER) and sodium fluorescein permeability assays. Tight junction localization was determined with immunocytochemistry. MMP activity was determined with SensoLyte assay kits. To determine the role of MMPs, a broad spectrum MMP inhibitor, GM6001, was utilized and barrier properties were monitored.&#x0D; Results: Propofol treatment significantly reduced TEER and increased sodium fluorescein permeability, indicative of a leaky barrier. Propofol treatment increased levels of MMP-2 activity but not MMP-9 when compared to non-treated BMECs. Inhibition of MMPs by GM6001 prior to propofol treatment appeared to partially restore barrier integrity as monitored by sodium fluorescein permeability.&#x0D; Conclusion and Potential Impact: These results indicate that increased MMP-2 activity levels could be in part responsible for diminished BBB properties. Inhibition of MMPs protected barrier integrity from propofol treatment. A further understanding of the underlying mechanisms of anesthetic-induced damage can potentially improve anesthesia safety.&#x0D;

Sedation and the Food and Drug Administration Warning: What a Pediatric Gastroenterologist, Hepatologist, and Pancreatologist Should Know.

Pediatric gastroenterologists recommend and perform a range of procedures requiring sedation and anesthesia in young children. A recent warning from the US Food and Drug Administration (FDA) states that "repeated or lengthy use of general anesthetics and sedation drugs during surgeries or procedures in children younger than 3 years or in pregnant women during their third trimester may affect the development of children's brains." 1 As it relates to time, the FDA warning details risks of "procedures lasting longer than 3 hours or if multiple procedures are required." Pediatric gastroenterologists and related specialists should be aware of the warning and its relevance to their patients.

Effect of Albuterol Premedication vs Placebo on the Occurrence of Respiratory Adverse Events in Children Undergoing Tonsillectomies

Tonsillectomy is a common pediatric procedure for the treatment of sleep-disordered breathing and chronic tonsillitis. Up to half of children having this procedure experience a perioperative respiratory adverse event. To determine whether inhaled albuterol sulfate (salbutamol sulfate) premedication decreases the risk of perioperative respiratory adverse events in children undergoing anesthesia for tonsillectomy. A randomized, triple-blind, placebo-controlled trial (the Reducing Anesthetic Complications in Children Undergoing Tonsillectomies [REACT] trial) was conducted at Perth Children's Hospital (formerly Princess Margaret Hospital for Children), the only tertiary pediatric hospital in Western Australia. Participants included 484 children aged 0 to 8 years who were undergoing anesthesia for tonsillectomy. The study was conducted between July 15, 2014, and May 18, 2017. Participants were randomized to receive either albuterol (2 actuations, 200 μg) or placebo before their surgery. Occurrence of perioperative respiratory adverse events (bronchospasm, laryngospasm, airway obstruction, desaturation, coughing, and stridor) until discharge from the postanesthesia care unit. Of 484 randomized children (median [range] age, 5.6 [1.6-8.9] years; 285 [58.9%] boys), 479 data sets were available for intention-to-treat analysis. Perioperative respiratory adverse events occurred in 67 of 241 children (27.8%) receiving albuterol and 114 of 238 children (47.9%) receiving placebo. After adjusting for age, type of airway device, and severity of obstructive sleep apnea in a binary logistic regression model, the likelihood of perioperative respiratory adverse events remained significantly higher in the placebo group compared with the albuterol group (odds ratio, 2.8; 95% CI, 1.9-4.2; P < .001). Significant differences were seen in children receiving placebo vs albuterol in laryngospasm (28 [11.8%] vs 12 [5.0%]; P = .009), coughing (79 [33.2%] vs 27 [11.2%]; P < .001), and oxygen desaturation (54 [22.7%] vs 36 [14.9%]; P = .03). Albuterol premedication administered before tonsillectomy under general anesthesia in young children resulted in a clinically significant reduction in rates of perioperative respiratory adverse events compared with the rates in children who received placebo. Premedication with albuterol should be considered for children undergoing tonsillectomy. Australian New Zealand Clinical Trials Registry identifier: ACTRN12614000739617.