Incidence Of Respiratory Adverse Events Research Articles

Presurgical fentanyl vs caudal block and the incidence of adverse respiratory events in children after orchidopexy

There is controversy about the etiology of early postoperative hypoxemia. Age, weight, intubation, surgical procedure, use of muscle relaxants, and/or administration of opioids may affect the incidence of early postoperative hypoxemia. In this prospective, randomized, and single-blinded study, we evaluated whether the administration of caudal analgesia vs i.v. fentanyl affected the number of children who develop postextubation adverse upper airway respiratory events, (upper airway obstruction, laryngospasm) and/or early postoperative hypoxemia. Institutional approval and written parental informed consents were obtained. Thirty-eight healthy outpatient boys, aged 1-6 years, scheduled for elective orchidopexy were randomized to receive pain relief either with a presurgical caudal block or by i.v. fentanyl. The primary outcome of the study was the number of children who developed postextubation adverse upper airway respiratory events and/or early postoperative hypoxemia. The number of boys who developed postextubation adverse upper airway respiratory events and/or early postoperative hypoxemia in the caudal group was less compared with those in the fentanyl group (P = 0.04). Compared to fentanyl, placement of a presurgical caudal block in boys scheduled for orchidopexy was associated with a lower incidence of postextubation adverse upper airway respiratory events and/or early postoperative hypoxemia.

Antagonism of non‐depolarising neuromuscular block: current practice

There is now mounting evidence that even small degrees of postoperative residual neuromuscular block increases the incidence of adverse respiratory events in the Post Anaesthesia Care Unit and may increase longer-term morbidity as well. In the absence of quantitative neuromuscular monitoring, residual block is easily missed. A very strong case can be made for the routine administration of a non-depolarising antagonist unless it can be objectively demonstrated that complete recovery has occurred spontaneously. However, the use of acetylcholinesterase inhibitors is associated with the potential for cardiovascular and respiratory side-effects, so there are cogent reasons for using low doses when the level of neuromuscular block is not intense. As little as 0.015-0.025 mg.kg(-1) of neostigmine is required at a train-of-four count of four with minimal fade, whereas 0.04-0.05 mg.kg(-1) is needed at a train-of-four count of two or three. If only a single twitch or none at all can be evoked, neostigmine should not be expected to promptly reverse neuromuscular block, and antagonism is best delayed till a train-of-four-count of two is achieved.

Laryngeal Mask Airway Is Associated with an Increased Incidence of Adverse Respiratory Events in Children with Recent Upper Respiratory Tract Infections

Laryngeal Mask Airway Is Associated with an Increased Incidence of Adverse Respiratory Events in Children with Recent Upper Respiratory Tract Infections

Laryngeal Mask Airway Is Associated with an Increased Incidence of Adverse Respiratory Events in Children with Recent Upper Respiratory Tract Infections

Laryngeal Mask Airway Is Associated with an Increased Incidence of Adverse Respiratory Events in Children with Recent Upper Respiratory Tract Infections

Intraoperative Acceleromyographic Monitoring Reduces the Risk of Residual Neuromuscular Blockade and Adverse Respiratory Events in the Postanesthesia Care Unit

Incomplete recovery from neuromuscular blockade in the postanesthesia care unit (PACU) may contribute to adverse postoperative respiratory events. This study determined the incidence and degree of residual neuromuscular blockade in patients randomized to conventional qualitative train-of-four (TOF) monitoring or quantitative acceleromyographic monitoring. The incidence of adverse respiratory events in the PACU was also evaluated. One hundred eighty-five patients were randomized to intraoperative acceleromyographic monitoring (acceleromyography group) or qualitative TOF monitoring (TOF group). Anesthetic management was standardized. TOF patients were extubated when standard criteria were met and no fade was observed during TOF stimulation. Acceleromyography patients had a TOF ratio of greater than 0.80 as an additional extubation criterion. Upon arrival in the PACU, TOF ratios of both groups were measured with acceleromyography. Adverse respiratory events during transport to the PACU and during the first 30 min of PACU admission were also recorded. A lower frequency of residual neuromuscular blockade in the PACU (TOF ratio < or = 0.9) was observed in the acceleromyography group (4.5%) compared with the conventional TOF group (30.0%; P < 0.0001). During transport to the PACU, fewer acceleromyography patients developed arterial oxygen saturation values, measured by pulse oximetry, of less than 90% (0%) or airway obstruction (0%) compared with TOF patients (21.1% and 11.1%, respectively; P < 0.002). The incidence, severity, and duration of hypoxemic events during the first 30 min of PACU admission were less in the acceleromyography group (all P < 0.0001). Incomplete neuromuscular recovery can be minimized with acceleromyographic monitoring. The risk of adverse respiratory events during early recovery from anesthesia can be reduced by intraoperative acceleromyography use.

Laryngeal Mask Airway Is Associated With an Increased Incidence of Adverse Respiratory Events in Children With Recent Upper Respiratory Tract Infections

Survey of Anesthesiology: June 2008 - Volume 52 - Issue 3 - p 130-131 doi: 10.1097/01.SA.0000307881.44919.90

Is Propofol a Safe Alternative to Pentobarbital for Sedation during Pediatric Diagnostic CT?

To prospectively compare the incidence of adverse respiratory events, the need for airway interventions, and the recovery time after propofol sedation with similar data from a retrospective review of data obtained in patients who underwent pentobarbital sedation. This HIPAA-compliant study was conducted with institutional review board approval and parental informed consent. The hospital sedation committee approved a 2-month pilot program of propofol sedation as a potential alternative to pentobarbital sedation. Parents were given the choice of having their child sedated with intravenously administered propofol or pentobarbital. Fifty-two patients (18 female, 34 male; mean age, 2.9 years +/- 2.4 [standard deviation]) received propofol. An equal number of patients (21 female, 31 male; mean age, 2.5 years +/- 1.7) who previously received pentobarbital were included. The sample sizes provided 80% power to detect differences in airway manipulations, adverse respiratory events, and recovery time between the groups by using the Fisher exact test and the Student t test. A two-tailed P value of less than .05 indicated a significant difference. Patients sedated with propofol underwent significantly more airway manipulations to relieve obstruction than did patients sedated with pentobarbital (23% vs 0%, P < .001). More adverse respiratory events occurred in the propofol group than in the pentobarbital group (12% vs 0%, P = .03). Patients in the propofol group had a faster recovery profile than did patients in the pentobarbital group (34 minutes +/- 17 vs 100 minutes +/- 30, P < .001). Propofol is associated with a significantly greater incidence of adverse respiratory events than is pentobarbital.

Addition of ketamine to propofol for initiation of procedural anesthesia in children reduces propofol consumption and preserves hemodynamic stability

There is no ideal anesthesia protocol to perform short invasive procedures in pediatric oncology. The combination of propofol and ketamine may offer advantages over propofol alone. In a prospective, randomized, double-blind study, we analyzed 63 consecutive procedures performed in 47 oncology children. All patients received 1 mug/kg fentanyl, followed by propofol 1 mg/kg in group P (n=33) or propofol 0.5 mg/kg and ketamine 0.5 mg/kg in group PK (n=30) for the initiation of anesthesia. The need for supplementation with propofol and/or fentanyl to maintain an adequate level of anesthesia was recorded. The hemodynamic and respiratory profile, recovery time and the occurrence of side effects were compared. Significantly more children required propofol (100% vs. 83.3%) and fentanyl (75.5% vs. 43.3%) rescue doses, and developed hypotension (63.6% vs. 23.4%) and bradycardia (48.5 vs. 23.4%) in group P compared with group PK, with a comparable incidence of respiratory adverse events and recovery times. However, 40% of children in group PK were agitated following recovery compared with 6% in group P. The combination of propofol and ketamine for invasive procedures in pediatric oncology resulted in reduced propofol and fentanyl consumption and preserved hemodynamic stability, but more children in the combination group recovered with agitation.

Laryngeal Mask Airway Is Associated with an Increased Incidence of Adverse Respiratory Events in Children with Recent Upper Respiratory Tract Infections

The laryngeal mask airway (LMA) has been advocated as an alternative technique to tracheal intubation for airway management of children with recent upper respiratory tract infections (URIs). The authors determined the occurrence of adverse respiratory events and identified the associated risk factors to assess the safety of LMA in children. During a period of 5 months, parents of children scheduled to undergo general anesthesia with an LMA were asked to fill out a questionnaire regarding their child's medical history and potential symptoms of URI. In addition, all episodes of adverse respiratory events in the perioperative period (laryngospasm, bronchospasm, coughing, airway obstruction, and oxygen desaturation) as well as details of anesthesia management were recorded. Among the 831 children included in the study, 27% presented with a history of a recent URI within the last 2 weeks before anesthesia. The presence of a recent URI doubled the incidence of laryngospasm (odds ratio, 2.6; 95% confidence interval, 1.3-5.0), coughing (odds ratio, 2.7; 95% confidence interval, 1.7-4.3), and oxygen desaturation (odds ratio, 1.9; 95% confidence interval, 1.2-2.8). This incidence was even higher in young children; in those undergoing ear, nose, and throat surgery; and when there were multiple attempts to insert the LMA. An LMA used in children with recent URIs was associated with a higher incidence of laryngospasm, cough, and oxygen desaturation compared with healthy children. However, the overall incidence of adverse respiratory events was low, suggesting that if anesthesiologists allow at least a 2-week interval after a URI, they can safely proceed with anesthesia using an LMA.

Removal of the laryngeal tube in children: anaesthetized compared with awake

Laryngeal tube (LT) is a useful airway device in children, but there is no objective evidence that removal of LT in awake state is better than in anaesthetized state. So, we compared the incidence of respiratory adverse events after the removal of LT, either under anaesthesia or on awakening. Seventy healthy children between 1 and 12 yr of age were enrolled in this study. Anaesthesia was induced and maintained with sevoflurane. After induction of anaesthesia, patients were randomized into two groups: removal of LT in anaesthetized state (Group A: 2% sevoflurane) and in awake state (Group B). During and within 1 min of the removal of LT, airway complications such as upper airway obstruction, cough, vomiting, teeth clenching, hypersalivation, desaturation <90%, and laryngospasm were recorded. Cough (37.1 vs 2.9%), hypersalivation (28.6 vs 5.7%), desaturation (20 vs 0%), and LT dislocation during emergence relating to the patient's movement (26.5 vs 0%) occurred more frequently in Group B (P < 0.05). Upper airway obstruction occurred more frequently (68.6 vs 31.4%) in Group A, and it was easily resolved by chin or jaw lifting. LT removal in anaesthetized state reduced cough, hypersalivation, and prevented tube displacement and hypoxia. Upper airway obstruction in the anaesthetized state should be predicted and managed with chin or jaw lifting.

Does the use of fentanyl in epidural solutions for postthoracotomy pain management in neonates affect surgical outcome?

Background/Purpose Continuous epidural analgesia is routinely used to manage pain in infants undergoing resection of a congenital cystic adenomatoid malformation (CCAM) of the lung. Our aim was to determine if there is a difference in the length of stay (LOS), supplemental analgesic requirements, pain control, and the incidence of adverse respiratory events in infants receiving the 2 standard epidural solutions commonly used: bupivacaine 0.1% and bupivacaine 0.1% with fentanyl 2 to 5 μg/mL. Methods We retrospectively reviewed the charts of infants who received epidural infusions containing bupivacaine 0.1% (n = 18) and bupivacaine 0.1% with fentanyl 2 to 5 μg/mL (n = 10) after CCAM resection during a 12-month period. LOS, rescue opioid, and nonopioid analgesic use, incidence of respiratory depression, and pain scores were recorded. Results The LOS in patients receiving fentanyl in their epidural solution was 1 day longer than those receiving plain bupivacaine (median 4 vs 3 days, respectively). Nonopioid analgesic and rescue opioid use was greater in patients who did not have fentanyl in their epidural solutions. Pain ratings were not significantly different. The incidence of respiratory depression was greater in patients receiving epidural infusions containing fentanyl (50% vs 17%, respectively). Conclusion The addition of fentanyl to epidural infusions of bupivacaine in infants undergoing thoracotomy for resection of CCAM may prolong recovery and increase the incidence of adverse respiratory events without providing a significant analgesic benefit.

Incidence and risk factors of perioperative respiratory adverse events in children undergoing elective surgery.

Adverse respiratory events remain one of the major causes of morbidity during anaesthesia, especially in children. The purpose of this prospective study was to determine the incidence of perioperative respiratory adverse events (PRAE) during elective paediatric surgery and to identify the risk factors for these events. Potential risk factors (atopy, eczema, rhinitis, food allergy, previous allergic tests, pollens or animal allergy, passive smoking, obstructive sleep disorders) were assessed using the International Society on Allergy and Asthma (ISAAC) questionnaire, which was submitted to the parents during preoperative anaesthetic assessment. Anaesthetic and surgical conditions were systematically recorded. A multivariate logistic regression explaining PRAE was developed in 800 children. The intraoperative incidence of respiratory adverse events was 21% and the incidence in the postanesthetic care unit was 13%. According to the multivariate analysis, children not anaesthetized by a specialist paediatric anaesthesiologist have 1.7 increased risk to present PRAE (95% CI = 1.13-2.57). Children anaesthetized for ear, nose, throat (ENT) surgery had a 1.57-fold higher risk of PRAE compared with other procedures (95% CI = 1.01-2.44). Furthermore, there was a synergistic interaction when two risk factors: residents and ENT surgery, were concomitant: the odds ratio (OR) of PRAE during non-ENT surgical procedures was 1.43 (95% CI = 0.91-2.24), but increased to 2.74-fold (95% CI = 1.15-4.32) for ENT surgery. The risk of PRAE was significantly lower when the anaesthetic technique included tracheal intubation with relaxants (OR = 0.6, 95% CI = 0.45-0.95) and decreased by 8% with each increasing year of age. This study demonstrates a high incidence of PRAE in paediatric surgical patients without respiratory tract infections, which appears to be primarily determined by the age of the child and the anaesthetic care rather than by the child's medical history.

Risk for respiratory events in a cohort of patients receiving inhaled zanamivir: A retrospective study

Background: Inhaled zanamivir is indicated for treatment of uncomplicated acute illness due to influenza A and B viruses in patients aged ≥12 years who have been symptomatic for no more than 2 days. Objective: The primary objective of this study was to estimate the incidence of adverse respiratory events among zanamivir-treated patients under conditions of usual care. Methods: The Ingenix research database includes insurance claims for all dispensations, inpatient and outpatient services, and procedures including the associated diagnoses and costs for a subset of all enrolled UnitedHealthcare members. We identified all persons with a dispensation of zanamivir recorded between October 1, 1999, and April 30, 2000. We captured medical and pharmaceutical claims data for the 6 months before the dispensation to obtain information about comorbidities, overall health status, and respiratory events. Medical and hospital record abstraction and clinical review served to confirm inpatient/emergency department (ED) events. We also examined the records of an ∼ 10% random sample of patients treated for a potential respiratory event in an outpatient/physician office visit during the 10-day follow-up period. Respiratory events not sufficiently severe to result in medical care were not captured in this study. Results: A total of 5498 eligible zanamivir dispensations contributed by 5450 patients (2911 females, 2539 males; mean age, 38.8 years), with 40 confirmed inpatient/ED respiratory events, were included in the study. Of these 40 events, 31 were pneumonia, bronchitis, or exacerbations of existing chronic respiratory disease; none required intubation or ventilation. No events occurred on the dispensation date. The overall risk for an inpatient/ED respiratory event was 0.7 per 100 episodes (95% CI, 0.5–1.0). Seven events of wheezing or shortness of breath were not an obvious extension of the original influenza-like illness or of a complicating bronchitis ( risk = 0.13 per 100 episodes; 95% CI, 0.06–0.26). Conclusions: No immediate or severe bronchoconstrictive responses occurred among 5498 zanamivir dispensations. The overall risk for any respiratory event was low, and none was sufficiently severe to suggest respiratory failure.