Association Of Paediatric Anaesthetists Research Articles

Abstracts of the Best Oral Free Paper Presentations at the Annual Scientific Meeting of the Association of Paediatric Anaesthetists of Great Britain & Ireland (APAGBI), Torquay, 2011

Abstracts of the Best Oral Free Paper Presentations at the Annual Scientific Meeting of the Association of Paediatric Anaesthetists of Great Britain & Ireland (APAGBI), Torquay, 2011

1364 Peri-Operative Assessment and Management of Pain in Children

Aim: To review peri-operative assessment of pain, documentation practices, management interventions, psychological preparation and followup in children. Methods: A retrospective audit at the Homerton university hospital over a 12 month period from 1st Feb 2008 - 31st Jan 2009. All children operated on as elective day cases were included in the cohort. Patients who were transferred out postoperatively and those admitted post trauma were excluded. Results: Total of 132 children were included in the audit. 107 (81%) had their pain assessed, of which 59 (44%) had it documented.39 children had nerve blocks, 27 of which were caudals, 7 had penile block, 2 were given rectus sheath block while 3 received ilio-inguinal block.33% of the patients who received nerve blocks required intra-operative opioids while 25% needed it postoperatively. 85% of blocks provided good pain relief. 25 patients, all under the age of five underwent lower abdominal surgeries. 22 were given caudal blocks while one received a penile block. One from the above group received both intra and post-op opioid. Conclusions: • Majority of patients' pain is being managed appropriately. Caudal blocks appear to be adequate for analgesia for sub-umbilical surgeries. Training of junior doctors in procedural skills does not necessary impact on efficient delivery of care as shown in our cohort of successful caudal epidurals. Most of these were performed by a junior doctor under supervision from a senior consultant anaesthetist. Pain is not being assessed and documented as per recommendation by the Association of Paediatric Anaesthetists.

APA national audit of pediatric opioid infusions

A prospective audit of neonates, infants, and children receiving opioid infusion techniques managed by pediatric acute pain teams from across the United Kingdom and Eire was undertaken over a period of 17 months. The aim was to determine the incidence, nature, and severity of serious clinical incidents (SCIs) associated with the techniques of continuous opioid infusion, patient-controlled analgesia, and nurse-controlled analgesia in patients aged 0-18. The audit was funded by the Association of Paediatric Anaesthetists (APA) and performed by the acute pain services of 18 centers throughout the United Kingdom. Data were submitted weekly via a web-based return form designed by the Document Capture Company that documented data on all patients receiving opioid infusions and any SCIs. Eight categories of SCI were identified in advance, and the reported SCIs were graded in terms of severity (Grade 1 (death/permanent harm); Grade 2 (harm but full recovery and resulting in termination of the technique or needing significant intervention); Grade 3 (potential but no actual harm). Data were collected over a period of 17 months (25/06/07-25/11/08) and stored on a secure server for analysis. Forty-six SCIs were reported in 10 726 opioid infusion techniques. One Grade 1 incident (1 : 10,726) of cardiac arrest occurred and was associated with aspiration pneumonitis and the underlying neurological condition, neurocutaneous melanosis. Twenty-eight Grade 2 incidents (1 : 383) were reported of which half were respiratory depression. The seventeen Grade 3 incidents (1 : 631) were all drug errors because of programming or prescribing errors and were all reported by one center. The overall incidence of 1 : 10,000 of serious harm with opioid infusion techniques in children is comparable to the risks with pediatric epidural infusions and central blocks identified by two recent UK national audits (1,2). Avoidable factors were identified including prescription and pump programming errors, use of concurrent sedatives or opioids by different routes and overgenerous dosing in infants. Early respiratory depression in patients with specific risk factors, such as young age, neurodevelopmental, respiratory, or cardiac comorbidities, who are receiving nurse-controlled analgesia or continuous opioid infusion suggests that closer monitoring for at least 2 h is needed for these cases. As a result of this audit, we can provide parents with better information on relative risks to help the process of informed consent.

How do pediatric anesthesiologists define intraoperative hypotension?

Although blood pressure (BP) monitoring is a recommended standard of care by the ASA, and pediatric anesthesiologists routinely monitor the BP of their patients and when appropriate treat deviations from 'normal', there is no robust definition of hypotension in any of the pediatric anesthesia texts or journals. Consequently, what constitutes hypotension in pediatric anesthesia is currently unknown. We designed a questionnaire-based survey of pediatric anesthesiologists to determine the BP ranges and thresholds used to define intraoperative hypotension (IOH). Members of the Society of Pediatric Anesthesia (SPA) and the Association of Paediatric Anaesthetists (APA) of Great Britain and Ireland were contacted through e-mail to participate in this survey. We asked a few demographic questions and five questions about specific definitions of hypotension for different age groups of patients undergoing inguinal herniorraphy, a common pediatric surgical procedure. The overall response rate was 56% (483/860), of which 76% were SPA members. Majority of the respondents (72%) work in academic institutions, while 8.9% work in institutions with fewer than 1000 annual pediatric surgical caseload. About 76% of respondents indicated that a 20-30% reduction in baseline systolic blood pressure (SBP) indicates significant hypotension in children under anesthesia. Most responders (86.7%) indicated that they use mean arterial pressure or SBP (72%) to define IOH. The mean SBP values for hypotension quoted by SPA members was about 5-7% lower across all pediatric age groups compared to values quoted by APA members (P = 0.001 for all age groups). There is great variability in the BP parameters used and the threshold used for defining and treating IOH among pediatric anesthesiologists. The majority of respondents considered a 20-30% reduction from baseline in SBP as indicative of significant hypotension. Lack of a consensus definition for a common clinical condition like IOH could have implications for patient care as well as future clinical research.

Pediatric DNAR orders in the perioperative period

Do not attempt resuscitation (DNAR) orders are a formal expression of the intention to refrain from resuscitation. Since their inception in 1974, such orders have become widely accepted within the hospital setting. However, their acceptance in theatres where anesthesia may cause cardiovascular instability, outcomes from cardiac arrest are improved and when there is a cross-over of techniques between anesthetic practice and resuscitation, has been more problematic. In order to ascertain the opinions on DNAR orders in the perioperative period, a questionnaire was sent to all consultant members of the Association of Paediatric Anaesthetists of Great Britain and Ireland, which asked about DNAR orders, resuscitation under anesthesia and included a number of case studies. Of the 280 respondents, 160 (57.1%) agreed that an anesthetist could alter the order in the perioperative period with 41 (14.6%) stating that they would always suspend such an order. Most anesthetists agreed that they would discuss DNAR orders during their preoperative assessment but could not agree as to which interventions constituted normal anesthetic practice as opposed to resuscitation. At present, there is variation in practice between pediatric anesthetists over suspension of DNAR orders in the perioperative period and no specific guidelines to refer to. We suggest that guidelines be produced and that these should take into account the work that has already taken place and guidelines published by other anesthetic communities.

A survey of paediatric caudal extradural anaesthesia practice

Introduction: Caudal extradural anaesthesia (CEA) is a common technique with wide application in paediatric anaesthesia [1]. An ‘on line’ World Wide Web survey of paediatric anaesthetists was undertaken to delineate any differences in the practice of this procedure. Methods: A web based questionnaire was devised to survey the practice of caudal extradural anaesthesia in children by anaesthetists who were members of the Association of Paediatric Anaesthetists of Great Britain and Ireland (APAGBI). The questionnaire was designed to collect information on the experience of the anaesthetist, techniques employed, drugs used and the use of the caudal extradural catheter technique for continuous extradural anaesthesia and analgesia. Results: E-mails were sent to 600 anaesthetists and there were 366 useable on-line replies. The majority of respondents had greater than 5 years of paediatric anaesthetic experience and performed up to ten caudal extradural procedures a month. The commonest device used was a cannula (69.7%) with 68.6% using a 22G device. Those with less than 15 years experience tended to employ a cannula while anaesthetists with greater than 15 years experience favoured a needle technique. Most anaesthetists (91.5%) did not believe that there was a clinically significant risk of implantation of dermoid tissue into the caudal extradural space. The majority of anaesthetists used a combination of clinical methods to confirm correct placement of a needle or cannula and injection of local anaesthetic into the caudal extradural space. Only 27 respondents indicated that they used ultrasound. The local anaesthetic agents used were bupivacaine (43.4%), levobupivacaine (41.7%), ropivacaine (13.4%) and lignocaine (1.5%). A total of 104 anaesthetists used more than one type of local anaesthetic. Drug additives used included clonidine (42.3%), ketamine (37.5%) and opioids (18.1%). The caudal catheter technique was used by 43.6% of anaesthetists. For a single shot caudal injection most anaesthetists (74%) used gloves only with fewer adopting the ‘no touch’ technique (15.2%) or use of glove, gown and mask (10.8%). Anaesthetists with greater than 10 years experience tended to use a ‘no touch’ technique. Discussion: Caudal extradural anaesthesia is an extremely common technique among those surveyed. Most anaesthetists use a cannula to access the caudal space which is in variance with the description of the technique in the peer review literature. However, the needle technique still tends to be used by anaesthetists with more than 15 years of experience. The majority of anaesthetists concur with the lack of evidence that there is a risk of implantation of dermoid tissue into the caudal extradural space. The anaesthetists surveyed tended to use a combination of simple clinical methods to identify correct placement of local anaesthetic in the caudal space. Ultrasound is rarely used. This may change when ultrasound become more readily available. Despite the greater safety margin of levobupivacaine, bupivacaine is used slightly more frequently. This may be due to cost. Ketamine and clonidine are the most commonly used additives. The caudal extradural catheter technique is used by a large proportion of anaesthetists despite there being few commercially available sets of equipment [2]. While most anaesthetists wear gloves for asepsis some still employ a more traditional no-touch technique. Conclusion: To our knowledge this is the first electronic large scale survey of anaesthetists who perform caudal extradural anaesthesia in children. The findings of this survey provides a snap shot of current practice and act as a useful reference for the development of enhanced techniques and new equipment to improve safety and efficacy in the future.

National survey of pediatric breathing systems use in the UK*

To determine current practice in the use of pediatric breathing systems in the UK. Whilst the Ayres T-Piece has been used extensively in pediatric anesthesia for nearly six decades, the circle system has undergone recent modifications. These have enhanced its suitability for pediatric use. A postal questionnaire was sent to all consultant members of the Association of Paediatric Anaesthetists (APA). This asked about standard breathing systems for induction, maintenance, and ventilation during anesthesia in three groups of children (neonates, infants, and older children less than 20 kg). Additional questions included if anesthetic rooms were used and scavenging routinely employed. Replies were received from 337 members, giving a response rate of 75%. The T-Piece was the predominant breathing system for induction in all age groups but the circle appears popular for maintenance, particularly in older children. Anesthetic rooms were used by 97% for induction and scavenging used by only 60% when using a T-Piece. Despite significant improvements to the pediatric circle system and its practical advantages, the T-Piece remains the commonest breathing system used in smaller children by UK members of the APA.

Tonsillectomy and adenoidectomy in children with sleep related breathing disorders: consensus statement of a UK multidisciplinary working party

During 2008, ENT-UK received a number of professional enquiries from colleagues about the management of children with upper airway obstruction and uncomplicated obstructive sleep apnoea (OSA). These children with sleep-related breathing disorders (SRBDs) are usually referred to paediatricians and ENT surgeons. In some district general hospitals, (DGHs) where paediatric intensive care (PICU) facilities to ventilate children were not avail able, paediatrician and anaesthetist colleagues were expressing concern about children with a clinical diagnosis of OSA having routine tonsillectomy, with or without adenoidectomy. As BAPO President, I was asked by the ENT-UK President, Professor Richard Ramsden, to investigate the issues and rapidly develop a working consensus statement to support safe but local treatment of these children. The Royal Colleges of Anaesthetists and Paediatrics and Child Health and the Association of Paediatric Anaesthetists nominat ed expert members from both secondary and tertiary care to contribute and develop a consensus statement based on the limit ed evidence base available. Our terms of reference were to produce a statement that was brief, with a limited number of references, to inform decisionmaking at the present time. With patient safety as the first priority, the working party wished to support practice that facilitated referral to a tertiary centre of those children who could be expected, on clinical assessment alone, potentially to require PICU facilities. In contrast, the majority of children who could be safely managed in a secondary care setting should be managed closer to home in a DGH. BAPO, ENT-UK, APA, RCS-CSF and RCoA have endorsed the consensus statement; the RCPCH has no mechanism for endors ing consensus statements, but the RCPCH Clinical Effectiveness Committee reviewed the statement, concluding it was a ‘concise, accurate and helpful document’. The consensus statement is an interim working tool, based on level-five evidence. It is intended as the starting point to catalyze further development towards a fully structured, evidence-based guideline; to this end, feedback and comment are welcomed. This and the constructive feedback from APA and RCPCH will be incorporated into a future guideline proposal. This consensus statement is also being published by all the working party host organisations and will appear in the RCoA Bulletin, Clinical Otolaryngology and on the RCPCH website

European Conference on Paediatric Anaesthesia Organized By the FEAPA and the Dutch Association of Paediatric Anaesthetists (SKA) Amsterdam, September 27–29th 2007: Results of the best free papers competition

European Conference on Paediatric Anaesthesia Organized By the FEAPA and the Dutch Association of Paediatric Anaesthetists (SKA) Amsterdam, September 27–29th 2007: Results of the best free papers competition

34th Annual Scientific Meeting of the Association of Paediatric Anaesthetists of Great Britain and Ireland, 8?10 March 2007, Manchester. Runner up for trainee prize Optimal spectral irradiance for laryngoscopy

Introduction: Changing the colour of light produced by laryngoscopes may improve the view at laryngoscopy and facilitate intubation. This could be crucial in children with anatomically difficult airways and in acute airway emergencies. Infra red light has been shown to be detrimental to optimal laryngoscopy (1). Anaesthetists have expressed a preference for blue/white light output to facilitate intubation (2). Blue light corresponds to peak haemoglobin absorption (415 nm) and therefore enhances the view of capillary vessels within the surface mucosa.(3) Green light defines deeper structures more clearly (3). Specific combinations of blue and green light spectra may provide the best conditions for intubation. Light Emitting Diodes (LEDs) have the advantage of producing light in a more appropriate part of the spectrum. LEDs are not currently used in laryngoscopes available in the UK. The aim of this study was to compare the spectral irradiance of the ProAct Miller 1 Paediatric blade laryngoscope (containing an incandescent bulb) with a custom-made laryngoscope containing an LED. Methods: The light spectral irradiance from the laryngoscope blades was measured under standardised conditions using the Bentham spectroradiometer. Blackout conditions were applied to eliminate background light. The tip of each laryngoscope blade was placed in contact with the sample port of the spectroradiometer. A mains voltage supply was set at 3 V for the Miller 1 blade (A) and 3.6 V for the blade with the LED (B), as specified by the manufacturers. Results: The Miller 1 paediatric blade produced spectral irradiance mainly in the infrared region (>660 nm) in contrast with the LED which produced most irradiance in the blue/green region of the spectrum (400–550 nm). (1) [ Spectral irradiance from the Miller 1 blade (A) and the blade with the LED (B). ] Discussion and conclusions: Paediatric laryngoscopes with LEDs may provide superior intubating conditions than that currently available with incandescent light sources. LEDs can be further modified to emit the optimal spectral irradiance required for laryngoscopy. This may prove invaluable when presented with a difficult airway. References 1 Crosby E, Cleland M. An assessment of the luminance and light field characteristics of used direct laryngoscopes. CanJ Anesth 1999; 46: 792–796. 2 Scholz A, Farnum N, Wilkes AR et al. Minimum and optimum light output of Mackintosh size 3 laryngoscopy blades: a manikin study. Anaesthesia 2007; 62: 163–168. 3 Watanabe A, Tsujie H, Taniguchi M, Hosokawa M, Fujita M, Sasaki S. Laryngoscopic detection of pharyngeal carcinoma in situ with narrow band imaging. Laryngoscope 2006; 116: 650–654.

34th Annual Scientific Meeting of the Association of Paediatric Anaesthetists of Great Britain and Ireland, 8?10 March 2007, Manchester. Spread of local anaesthetic solution in epidural space visualisation with ultrasound in single shot caudals

Background: Ultrasonography is becoming an important adjunct in paediatric neuraxial blockade. Ultrasound guidance helps in visualisation of relevant neuraxial structures, predicting depth of epidural space from skin, reduction in bony contact and faster epidural placement. The visibility of neuraxial structures declines in patients as age increases. To date, there are no studies looking at the extent of spread of local anaesthetic solution in the epidural space and its correlation to the volume used, under ultrasound guidance. We report the results of our audit on spread of local anaesthetic solution in the epidural space in single shot caudal blocks. This abstract is based on the first 17 patients, the presentation will be based on all 50 patients. Methods: This audit was approved by the local audit committee. We aimed to follow the extent of the spread of local anaesthetic within the epidural space with real time ultrasonography. Patients were selected when the planned anaesthetic included a single shot caudal block. The anaesthetists performing the anaesthetic and the caudal block consented to our ultrasound visualisation. All patients were below 5 years of age. No attempt was made to standardise the technique, the dose, or the speed of injection. After the placement of the caudal cannula by the primary anaesthetist involved in patient care, a separate anaesthetist, experienced in using ultrasound, visualised the neuraxial structures and subsequent spread of the local anaesthetic solution with real time ultrasound. The spread was followed during the injection and for 10 s after the completion of the injection. A 5 cm 7.5–12 MHz linear array was used longitudinally with either midline or paramedian approach. Results: We are reporting the preliminary results from 17 patients. Patients were aged between 1 day and 1 year 10 months. They weighed between 3.3 kg and 14.6 kg. Either 22 gauge Jelco or Abbocath were used to perform the procedure; 0.25% or 0.20% L-bupivacaine was used on all occasions. The volume administered per kg ranged between 0.33 and 1.27 ml. The visibility of neuraxial structures was good on all occasions. On calculating the Spearmans correlation coefficient, the extent of spread of local anaesthetic in the epidural space was positively correlated with the volume used by a correlation coefficient of 0.64, with a P value of 0.008. The postoperative pain score in recovery was 0 in 16 out of the 17 cases. The one failure occurred when the observed spread would not have been expected to provide analgesia for the performed operation. Conclusions: Among children below 5 years of age, there seems to be a positive correlation between the volume of local anaesthetic injected into the epidural space and the extent of its spread. This needs to be further investigated by a prospective randomised control trial. The utility of real time ultrasound to allow a reliable achievement of a desired level of sensory block, should be investigated i.e, whether the volume used in achieving a desired level of local anaesthetic spread, as guided by ultrasound, provides superior analgesia and fewer adverse effects compared with the volume calculated using the Armitage regimen. References 1 Rapp HJ, Folger A, Grau T. Ultrasound guided epidural catheter insertion in children. Anesth Analg 2005; 101: 333–339. 2 Willschke H, Marhofer P, Bosenberg A, et al. Epidural catheter placement in children: comparing a novel approach using ultrasound guidance and a standard loss of resistance technique. Br J Anaesth 2006; 97: 200–207. 3 Marhofer P, Bosenberg A, Sitzwohl C et al. Pilot study of neuraxial imaging by ultrasound in infants and children. Pediatr Anesth 2005; 15: 671–676.

34th Annual Scientific Meeting of the Association of Paediatric Anaesthetists of Great Britain and Ireland, 8?10 March 2007, Manchester. Paediatric propofol pharmacokinetics: a multicentre study

Introduction: Schuttler and Imhsens propofol pharmacokinetic (PK) model (1) based on pooled adult and paediatric data lacked information for the smallest patients. We conducted a pooled population analysis of available neonatal and paediatric propofol PK data. The variable clinical circumstances of the individual studies allowed us to explore health status as a PK model covariate. Methods: We combined raw propofol blood/plasma concentration vs time data, dosing information and demographic data from eight paediatric studies conducted by six research groups, with our data (2,3). The pooled data set comprised 197 individuals (2315 observations), aged 0.02–12.25 years (2.75–60.5 kg, median 15 kg). In this preliminary population PK analysis using NONMEM, the basic model structure was established before all model parameters were allometrically scaled to body weight. The influence of health status on paediatric propofol PK was explored. Results: In this 3-compartment preliminary model, postcardiac surgery patients have significantly reduced metabolic clearance rates (31–45% less when compared with healthy children or noncardiac PICU patients). The volume of the deep peripheral compartment in critically ill and postcardiac surgery children is 319% and 205% larger, respectively, than in healthy children, see Table 1. Table 1. PK values for a child weighing 15 kg Parameter Typical Value 95% Confidence Interval CL (l·min-1) Healthy 0.614 0.563–0.665 PICU 0.767 0.628–0.906 PICU cardiac 0.421 0.366–0.476 Q2 (l·min-1) 0.839 0.703–0.975 Q3 (l·min-1) 0.252 0.221–0.283 V1 (l) 7.76 6.33–9.19 V2 (l) 14.4 12.8–16.0 V3 (l) Healthy 83.9 61.4–106 PICU 268 183–353 PICU cardiac 172 117–227

34th Annual Scientific Meeting of the Association of Paediatric Anaesthetists of Great Britain and Ireland, 8?10 March 2007, Manchester. Paediatric total intravenous anaesthetic use: a nationwide study

Introduction: Propofol is widely used for induction and maintenance of anaesthesia in paediatric patients. Following the initial reports of deaths following prolonged high dose infusions on intensive care (1), the propofol infusion syndrome was described (2). The exact cause of this is still uncertain but consistent biochemical abnormalities have been described (3, 4). Initially the cases were all in children on intensive care units, but more recently cases have been reported in adults. Of greater concern to paediatric anaesthetists are the reports of deaths following propofol infusions in theatre (5, 6). We set out to define the current use of propofol infusions by Paediatric Anaesthetists within the UK. Methods: A list of names and addresses of paediatric anaesthetists was composed by contacting anaesthetic departments at the hospitals by telephone and asking for the names of their paediatric anaesthetists. An 18 question survey with an enclosed stamped, addressed envelope was posted to 388 consultant paediatric anaesthetists in 51 hospitals throughout the UK. The survey was re-submitted once to consultants who had not initially replied. The results were tabulated onto a database and analysed. Results: We received a total of 242 replies (63% of surveyed population), 240 of which regularly anaesthetised children. Within the last year 13% had used propofol infusions on children under 1, 31% in children 1–5 years, 41% in children 5–10 years and 46% in the over 10 s. The two most common surgical specialties with which propofol TIVA was used were ENT (n = 66), and orthopaedics (n = 53), the most common operations stated being middle ear surgery, muscle biopsy and scoliosis surgery. The reasons for using propofol in these patients were broad and included both anaesthetic and surgical considerations. 60 consultants questioned used propofol infusions in children at least monthly, 98 rarely and 72 never. Over 50% of replies believed that propofol infusions reduced the rate of postoperative nausea and vomiting in respect to inhalational techniques, less agreed that there was faster recovery time or time to discharge. Remifentanil was commonly used with propofol infusions but target controlled infusion devices were uncommonly used. The longest time anyone considered using propofol for was 72 h, although the mode of all positive responses was 6 h. The majority of people failed to give a maximum infusion rate. Conclusions: Propofol infusions are used widely throughout the UK for their perceived anaesthetic and surgical benefits. Given that there are well documented catastrophic, albeit rare side effects, it is surprising that there are no guidelines for infusions in theatre. Further work is required to elucidate the exact mechanism of propofol infusion syndrome to guide future anaesthetic practice. References 1 Parke TJ, Stevens JE, Rice AS et al. Metabolic acidosis and fatal myocardial failure after propofol infusion in children: five case reports. Br Med J 1992; 305: 613–616. 2 Bray RJ. Propofol infusion syndrome in children. Paediatr Anaes 1998; 8: 491–499. 3 Wolf AR, Weir P, Segar P, et al. Impaired fatty acid oxidation in propofol infusion syndrome. Lancet 2001; 357: 606–607. 4 Wolf AR, Potter F. Propofol infusion in children: when does an anesthetic tool become an intensive care liability? Paediatr Anaesth 2004; 14: 435–438. 5 Mehta N, DeMunter C, Habibi P et al. Short-term propofol infusions in children. Lancet 1999; 354: 866–867. 6 Kill C, Leonhardt A, Wulf H. Lacticacidosis after short-term infusion of propofol for anaesthesia in a child with osteogenesis imperfecta. Paediatr Anaesth 2003; 13: 823–826.

34th Annual Scientific Meeting of the Association of Paediatric Anaesthetists of Great Britain and Ireland, 8?10 March 2007, Manchester. A comparison of the laryngeal mask airway with facemask and oropharyngeal airway for manual ventilation by critical care nurses in children

Introduction: The European Resuscitation Council recommends the laryngeal mask airway (LMA) for manual ventilation in adult resuscitation if the skills required for the placement of a tracheal tube are unavailable or intubation proves impossible (1). This followed concerns about the ability of inexperienced personnel to provide manual ventilation using traditional facemask and oropharyngeal airway (FM/OA). If inadequate FM/OA ventilation also occurs in children, the LMA may improve airway management during resuscitation. Methods: Local ethical approval was obtained. We trained 19 nurses, experienced in paediatric intensive care, emergency medicine or anaesthetics in the use of the LMA on manikins. They all had prior experience in FM/OA ventilation. Children undergoing elective surgery were studied. Anaesthesia was induced with propofol (3–5 mg·kg−1) or sevoflurane (8% in oxygen/nitrous oxide) followed by a continuous infusion of propofol/remifentanil to produce apnoea. Standard monitoring was applied and an ultrasound sensor placed above the xiphisternum to measure anterior posterior (AP) chest expansion. The consultant paediatric anaesthetist manually ventilated the lungs using FM/OA. The AP chest expansion achieved was defined as the gold standard. The nurse then inserted each airway device in random order and chest expansion was compared with the gold standard. A maximum of three attempts was allowed for each airway device. Prior to the study commencing adequate ventilation was defined as successful if 60% or more of the ‘gold standard’ AP chest expansion was achieved. Results: The 60 children studied had a median age of 4 years (range 7 months–8 years), and median weight of 17 kg (range 8–41 kg). Using an LMA the nurses achieved successful ventilation in 78% of children compared with 71% in the FM/OA group (P = 0.39, chi-squared test). The LMA was inserted successfully at the 1st attempt in 60%, 2nd attempt in 11% and 3rd attempt in 6% of children. Median time to first successful breath was 38 s (range 11–147 s) for the LMA and 24 s (range 15–48 s) for the FM/GA. (Figure 1). Figure 1. A cumulative frequency plot of the time to first successful ventilation using the laryngeal mask airway or face mask and oropharyngeal airway. Download figure to PowerPoint Discussion: Critical care nurses can be trained to provide successful ventilation in 78% of children using an LMA. Similar studies in adults have shown a higher proportion of successful LMA insertions than this but the proportion of children successfully ventilated using FM/OA (70%) was higher than in adult studies. This may be because FM/OA ventilation is easier in children. Time to successful ventilation was faster in the FM/OA group than the LMA group, similar to adult studies. In this group of nurses the LMA may not usefully improve the proportion of children ventilated successfully compared with FM/OA. Acknowledgements: This study received funding from the Resuscitation Council (UK). Reference 1 Baskett P. Guidelines for the advanced management of the airway and ventilation during resuscitation. A statement by the Airway and Ventilation Management of the Working Group of the European Resuscitation Council. Resuscitation 1996: 31: 201–230.

New maintenance fluid guidelines for children: is 0.9% sodium chloride with 5% glucose a good choice?

New maintenance fluid guidelines for children: is 0.9% sodium chloride with 5% glucose a good choice?

Use of nonsteroidal anti-inflammatory drugs in infants. A survey of members of the Association of Paediatric Anaesthetists of Great Britain and Ireland

Use of nonsteroidal anti-inflammatory drugs in infants. A survey of members of the Association of Paediatric Anaesthetists of Great Britain and Ireland

Breathing system filters for paediatric practice

We wish to draw attention to the discussion section of the paper from Cann and colleagues comparing breathing system filters [1] which contains the following comment: ‘Optimal performance is especially pertinent to the paediatric setting where there are additional considerations like increased dead space. However, the AAGBI recommends that filters are not used for paediatric patients; rather, the breathing system is replaced between each case. This recommendation is endorsed by the Association of Paediatric Anaesthetists’. In fact, the Association of Paediatric Anaesthetists (APA) has not endorsed this recommendation and our position is set out clearly in a statement issued jointly by the APA and the AAGBI [2]. This statement followed a meeting between both organisations and a senior scientific officer from the MHRA to address issues arising from an evaluation of breathing filters by the MHRA published in March 2004 [3]. The MHRA evaluation suggested that some paediatric filters were less efficient than adult filters because they allowed greater penetrance of saline particles during in vitro testing. It was therefore concluded that they did not afford the same degree of protection for the breathing system as adult filters. Subsequently, it was recommended that circuits used for paediatric anaesthesia should be disposed of after use [4]; however, we note that this stipulation is not contained in the latest guidelines on checking equipment. Most of the paediatric filters with higher measured penetration values were designed for use in small infants and were tested with a gas flow of 15 l.min−1, which is disproportionately high when compared with the adult test flow (30 l.min−1). The APA therefore considered that further information obtained at lower, more appropriate flows was required before recommending a significant change in practice. Furthermore, in older children it is common practice to use larger filters together with a variety of adult breathing systems, including circle systems. Therefore, a blanket recommendation to change circuits between each paediatric case is inappropriate. Taking account of these considerations, the AAGBI and the APA issued a joint statement, which included ‘At present there is insufficient evidence to recommend a wholesale change in practice. In order to underpin future recommendations, it has been agreed that further work is required to examine the performance of filters manufactured for use in infants and small children. In the meantime, in order to protect individual anaesthetists, anaesthetic departments should review their practice and policies. There should be a local policy, agreed by the local clinical governance structure, concerning the use of single use items of equipment and filters that takes account of the size of the patient and the existing evidence’[2]. We welcome the presentation of a paper at the recent Annual Scientific Meeting of the Association of Paediatric Anaesthetists by Dr Wilkes and colleagues which reported useful additional information on the performance of infant filters at lower gas flows. We hope that the paper will be published shortly; this should provide further clarification and, together with the original MHRA report, help departments draw up a policy on the safe and rational use of circuits and filters in the paediatric population, which is appropriate to their needs.

A reply

We would like to thank Drs Bennett and Bingham for their interest in our work. They highlighted a section of our paper where, they claim, we mistakenly suggested that the Association of Paediatric Anaesthetists (APA) had endorsed previous guidance published by the Association of Anaesthetists of Great Britain and Ireland (AAGBI) on the re-use of breathing systems with paediatric patients. We apologise for this error, but feel that this, which was written after consultation with some our paediatric anaesthetist colleagues, highlights that there is still confusion in this area. The original guidance published by the AAGBI was that ‘In paediatric practice where the use of a filter would increase dead space and/or resistance unacceptably, filters should not be used but the breathing system should be changed between patients’[1]. The deleterious effects of the increase in deadspace [2] and resistance to gas flow [3] by adding a filter continue to be highlighted for this particularly vulnerable group of patients and reference continues to be made to the original guidance [4-6]. It could be inferred from the joint statement by Drs Bennett and Bingham that the original guidelines had not been replaced. However, we acknowledge that many anaesthetists do use paediatric breathing systems for more than one patient [7, 8], though the situation is probably different if the patient weighs less than 3 kg; perhaps there is a case to publish separate guidelines for these two groups of paediatric patients. Maybe it is worth emphasising that many manufacturers still label breathing systems intended for use with paediatric patients as ‘single-use’. An individual who re-uses such a breathing system takes on full responsibility for its safety and effectiveness [9]. Because of this, to quote Grant: ‘An injured patient does not have to prove it was your fault. You have to show that is was not your fault’[10]. The guidance on the re-use of medical device marked for single-use is therefore quite explicit. The recent discussion on the use of filters in paediatric patients arose from the work carried out for the Medicines and Healthcare products Regulatory Agency (MHRA) [11], which indicated that the performance of filters intended for use with paediatric patients was not as always as good as that of filters intended for use with adults [5]. It is perhaps worth stating that, even if the performance of filters intended for use with small infants was similar to that of adult filters when tested at lower flows, the absence of any published minimum level of performance makes interpretation of the results rather difficult. However, our study, on which Drs Bennett and Bingham commented, concentrated on another, separate, aspect; namely, how easily water can pass through different filters. We hope that our article has added to the debate on the use of these devices, and possibly help during the formulation of guidelines and policies for the use of these devices.

Epidural analgesia in children. A survey of current opinions and practices amongst UK paediatric anaesthetists.

Despite the widespread use of epidural analgesia in children its place in paediatric pain management has not been clearly established. In order to investigate the current practice of paediatric epidural analgesia in the UK paediatric anaesthetists and paediatric pain management teams were surveyed. Questionnaires were sent to the members of the Association of Paediatric Anaesthetists (APA) working within the UK and to lead clinicians and clinical nurse specialists for acute pain in the 26 designated major paediatric centres. The response rate was 72%. There was little consensus regarding drugs and drug combinations used for epidural analgesia. A total of 36% of paediatric centres did not audit their epidural practice, and of those that did the reported incidences of side-effects showed wide variation. Important differences in practice were also identified in the areas of patient selection, informed consent, the use of epidural test doses, drug delivery systems, monitoring and the management of side-effects. Twelve per cent of specialist paediatric hospitals did not have an acute pain team and elsewhere the provision was often limited to staff with few or no specialist skills. There is wide variation in the practice of paediatric epidural analgesia in the UK. Inconsistencies are likely to be related to the poor evidence base available to guide clinical decision making and the lack of a specialized paediatric acute pain service in some centres. More research is required to determine the optimal management of epidural analgesia, and suitable clinical support for paediatric pain control should be more widely available.

Annual Scientific Meeting of the Association of Paediatric Anaesthetists of Great Britain and Ireland

Annual Scientific Meeting of the Association of Paediatric Anaesthetists of Great Britain and Ireland