Pediatric Anesthesia Practice Research Articles

Landmark papers in pediatric cardiac anesthesia: documenting the history of the specialty.

Pediatric cardiac anesthesia has developed over the past eight decades into a specialty delivering complex clinical care and contributing remarkable scientific progress. The history of this development can be traced through journal articles that mark the strides of the specialty. This article discusses journal articles, chosen by the author, that he considers had a significant impact on the practice of pediatric cardiac anesthesia or are of historical interest.

Place of rapid sequence induction in paediatric anaesthesia

### Key points Stept and Safar1 introduced the concept of rapid sequence induction (RSI) in 1970 after Snow and Nunn had found that the commonest cause of anaesthesia-related deaths in 1958 were because of aspiration.2 The perceived benefit of RSI in reducing the risk of aspiration, in high-risk patients, has led to it becoming the standard level of care, despite the lack of quality evidence.3 The development of the RSI technique is based upon adult practice. In children a ‘classical’ RSI may not always be the correct choice because of psychological, anatomical, and physiological differences. A survey of UK anaesthetists found that only around 50% would routinely perform an RSI for a child with a presumed full stomach despite having comparable aspiration risk as an adult.4 This article examines the evidence for the use of ‘classical’ RSI and its place in contemporary paediatric anaesthetic practice. Pulmonary aspiration of gastric contents under anaesthesia was not described as a problem until Mendelson famously described its deleterious effects in 1946. However, practice at that time included many risks for aspiration: no routine fasting combined with placing patients in a 20° head down position, undoubtedly increased the number who suffered from passive regurgitation. The first neuromuscular blocking agent, tubocurarine, was invented in the early 1940s. Although not used widely in 1946, it is only fully effective after 2–3 min, thereby allowing a prolonged period without protective airway reflexes. Despite the consideration of fasting times and gastric emptying taking a more prominent place since the 1940s and the invention …

Pediatric transport medicine and the dawn of the pediatric anesthesiology and critical care medicine subspecialty: an interview with pioneer Dr. Alvin Hackel

Dr. Alvin 'Al' Hackel (1932-) Professor Emeritus of Anesthesiology, Perioperative and Pain Medicine, and Pediatrics at the Stanford University School of Medicine, has been an influential pioneer in shaping the scope and practice of pediatric anesthesia. His leadership helped to formally define the subspecialty of pediatric anesthesiology ('who is a pediatric anesthesiologist?') and the importance of specialization and regionalization of expertise in both patient transport and perioperative care. His enduring impact on pediatric anesthesia and critical care practice was recognized in 2006 by the American Academy of Pediatrics when it bestowed upon him the profession's highest lifetime achievement award, the Robert M. Smith Award. Of his many contributions, Dr. Hackel identifies his early involvement in the development of pediatric transport medicine as well as the subspecialty of pediatric anesthesiology as his defining contribution. Based on a series of interviews held with Dr. Hackel between 2009 and 2014, this article reviews the early development of transportation medicine and the remarkable career of a pioneering pediatric anesthesiologist.

Is Anesthesia Safe for My Child?

FOR YEARS, WE HAVE ANSWERED this common parental question with a resounding “Yes”—as data pointed to overwhelming safe and effective outcomes of pediatric anesthesia after implementation of intraoperative and early postoperative monitoring. However, a growing number of studies have raised concerns that anesthetics may actually be neurotoxic to the developing brain, leading to long-term changes in memory and cognition that cannot be identified during the perioperative period. These concerns have been highlighted in recent editorials in The New England Journal of Medicine, 1 Rappaport B.A. Suresh S. Hertz S. Evers A.S. Orser B.A. Anesthetic neurotoxicity—Clinical implications of animal models. N Engl J Med. 2015; 372: 796-797 Crossref PubMed Scopus (244) Google Scholar The Journal of the American Medical Association, 2 Psaty B.M. Platt R. Altman R.B. Neurotoxicity of generic anesthesia agents in infants and children: An orphan research question in search of a sponsor. JAMA. 2015; 313: 1515-1516 Crossref PubMed Scopus (44) Google Scholar and in the lay press. 3 Grady D. Researchers warn on anesthesia, unsure of risk to children. The New York Times. Febuary 25, 2015. Google Scholar Not surprisingly, parents are more frequently asking surgeons and anesthesiologists “Will anesthesia hurt my child's brain?” Furthermore, nearly half of anesthesiologists in a recent survey have been asked about this important topic by their nonanesthesia colleagues, including pediatricians, surgeons, and radiologists. 4 Ward C.G. Hines S.J. Maxwell L.G. McGowan F.X. Sun L.S. Neurotoxicity, general anesthesia in young children, and a survey of current pediatric anesthesia practice at US teaching institutions. Paediatr Anaesth. 2016; 26: 60-65 Crossref Scopus (16) Google Scholar Although we do not know how often perioperative nurses are asked this question, it is important that we understand what is known and unknown about anesthetic neurotoxicity and be prepared to answer parental concerns in a knowledgeable and supportive manner. Terri Voepel-Lewis, PhD, RN, Associate Research Scientist, University of Michigan Medical School, Department of Anesthesiology, Section of Pediatrics, Ann Arbor, MI Shobha Malviya, MD, Professor of Anesthesiology, Department of Anesthesiology, University of Michigan, Ann Arbor, MI

Efficacy of paediatric anaesthetic trolleys: A call for a basic standard and layout.

Providing safe anaesthesia to children especially in emergency situations goes hand in hand with instant availability of appropriately sized equipment and monitoring. This is best achieved using a designated paediatric anaesthetic trolley containing essential equipment. Guidance for the contents of such trolleys is neither explicit nor standard. We used a survey and a qualitative enquiry to develop a checklist suitable for standardisation of contents and layout of paediatric anaesthetic trolleys. We conducted an observational study of our current practice and paediatric anaesthetic trolleys in a tertiary care hospital. We also performed a qualitative enquiry from experienced paediatric anaesthetists and operating department practitioners.We developed an empirical checklist to ensure the minimum 'essential' equipment is available on these trolleys and implemented a standard layout to facilitate its use. We identified 11 areas in our hospital where anaesthesia is provided to children, each with a designated paediatric anaesthetic trolley. There were considerable deficiencies of items in all areas with no standard pattern or layout. Different types of trolleys contributed to the confusion. In addition, overstocking of inappropriate items hindered its efficient use. Standardising the contents and layout of the paediatric anaesthetic trolley is an essential pre-requisite for safer paediatric anaesthetic practice.

Neurotoxicity, general anesthesia in young children, and a survey of current pediatric anesthesia practice at US teaching institutions.

Recent articles in both scholarly journals and the lay press about the topic of anesthetic related neurotoxicity have increased the awareness and discussion of this topic with parents and other pediatric medical specialties (i.e., surgeons, radiologists, and pediatricians). The purpose of the present study was to survey how a subset of pediatric anesthesia departments in the US have responded to the issue of anesthetic related neurotoxicity in terms of clinical practice, training and communication with other medical specialties, and the frequency and timing of discussions with families. A survey consisting of 22 questions was sent to PALC (Pediatric Anesthesia Leadership Council) & PAPDA (Pediatric Anesthesia Program Directors Association) via SurveyMonkey. The survey was divided into sections on Anesthesia Faculty/Trainees, Parents and Non-Anesthesia Providers. Responses to the survey were solicited via email to PALC and PAPDA, and then followed up with reminders to individual emails using the mailing lists of both organizations. The results of this survey demonstrate that pediatric anesthesia programs around the US do not have a consistent approach in managing the topic of anesthesia-related neurotoxicity with pediatric anesthesiologists, anesthesiology residents, pediatric anesthesiology fellows and their non-anesthesia medical and surgical colleagues, as well as the discussion of this topic with parents. A significant need exists to provide information to other pediatric professionals and parents. A consistent message from all providers that includes what is known, and indeed more importantly what is not known may be a useful approach.

Is there a role for codeine in paediatric anaesthetic practice?

Is there a role for codeine in paediatric anaesthetic practice?

The state of UK pediatric anesthesia: a survey of National Health Service activity.

This secondary analysis of the 2013 United Kingdom National Health Service (NHS) Anaesthesia Activity Survey of the Fifth National Audit Project (of the Royal College of Anaesthetists and Association of Anaesthetists of Great Britain and Ireland) shows pediatric anesthesia activity in detail. A local coordinator (LC) in every NHS hospital collected data on patients undergoing any procedure managed by an anesthetist. Questionnaires had 30 question categories. Each LC was randomized to a 2-day period. The pediatric age groups were infants, (<1 year), preschool age (1-5 year), and school age children (6-15 year). The median questionnaire return rate was 98%. The annual caseload was estimated to be 486 900 children: 36 500 infants, 184 700 preschool age, and 265 800 school age children. Almost 90% of children (1-15 year) were ASA 1 or 2 and the substantial majority underwent routine nonurgent ear nose and throat, dental, orthopaedics, or general surgery procedures; 65% were 'day cases'. One in six children were managed outside operating theater sites compared with one in 12 adults. Forty one per cent was in district general hospitals. Almost all ASA 4 and 5 children (89%) and infants (92%) were managed in specialist hospitals. 'Awake' cases and sedation accounted for only 2% of cases. There were notable differences in demography and anesthetic care compared with adults and between different age groups of children. These data enable analysis of the current state of UK pediatric anesthetic practice and highlight differences between pediatric and adult services.

Development of a computerized monitoring program to identify narcotic diversion in a pediatric anesthesia practice.

Development of an operational reporting dashboard designed to correlate data from multiple sources to help detect potential drug diversion by automated dispensing cabinet (ADC) users is described. A commercial business intelligence platform was used to create a dashboard tool for rapid detection of unusual patterns of ADC transactions by anesthesia service providers at a large pediatric hospital. By linking information from the hospital's pharmacy information management system (PIMS) and anesthesia information management system (AIMS) in an associative data model, the "narcotic reconciliation dashboard" can generate various reports to help spot outlier activity associated with ADC dispensing of controlled substances and documentation of medication waste processing. The dashboard's utility was evaluated by "back-testing" the program with historical data on an actual episode of diversion by an anesthesia provider that had not been detected through traditional methods of PIMS and AIMS data monitoring. Dashboard-generated reports on key metrics (e.g., ADC transaction counts, discrepancies in dispensed versus reconciled amounts of narcotics, PIMS-AIMS documentation mismatches) over various time frames during the period of known diversion clearly indicated the diverter's outlier status relative to other authorized ADC users. A dashboard program for correlating ADC transaction data with pharmacy and patient care data may be an effective tool for detecting patterns of ADC use that suggest drug diversion.

Malignant hyperthermia in the early days of pediatric anesthesia: an interview with anesthesiology pioneer, Dr. John F. Ryan.

Dr. John F. Ryan (1935 - ), Associate Professor of Anaesthesia at the Harvard Medical School, influenced the careers of hundreds of residents and fellows-in-training while instilling in them his core values of resilience, hard work, and integrity. His authoritative textbook, A Practice of Anesthesia for Infants and Children, remains as influential today as it did when first published decades ago. Although he had had many accomplishments, he identified his experiences caring for patients with malignant hyperthermia and characterizing the early discovery of this condition as his defining contribution to medicine. Based on a series of interviews with Dr. Ryan, this article reviews a remarkable career that coincides with the dawn of modern pediatric anesthetic practice.

Update on Airway Devices

There has been a number of newer airway devices aimed to improve airway management for children. Cuffed tracheal tubes (TT), videolaryngoscopes (VLs) and supraglottic airways (SGAs) have all been used successfully in the clinical practice of pediatric anesthesia. The purpose of this review article is to present the current evidence regarding the use of the Microcuff TT, alternative devices for direct laryngoscopy (fiberoptic bronchoscopes and VLs) and newer SGAs (LMA Supreme, i-gel, and air-Q) in infants and children.

Perioperative Care of an Infant With an Open Safety Pin in the Hypopharynx

In the practice of pediatric anesthesia, foreign body (FB) aspiration represents a commonly encountered surgical emergency, which may lead to morbidity and mortality if not handled in a timely and effective fashion. We present a 12-month-old infant who was found to have a sharp FB lodged in the hypopharynx at the level of the glottis, leading to a unique clinical challenge, both from the standpoint of airway management and removal technique. We discuss the symptoms and radiographic manifestations of FB aspiration. Options for anesthetic management are presented and potential complications are reviewed. J Med Cases. 2015;6(4):146-149 doi: http://dx.doi.org/10.14740/jmc2017w

Managing the difficult airway in the syndromic child

A difficult airway as defined by the ASA Task Force on Management of the Difficult Airway is ‘the clinical situation in which a conventionally trained anaesthesiologist experiences difficulty with facemask ventilation of the upper airway, difficulty with tracheal intubation, or both’. In a retrospective review of 11 219 paediatric procedures, the risk of difficult laryngoscopy was estimated as 1.35%. The risk was found to be higher in neonates and infants, children who are underweight, ASA physical status III and IV, or have Mallampati score III and IV. 1 However, the reliability of the Mallampati score in predicting difficult airway management in the paediatric population has been questioned and some clinicians prefer the Colorado Pediatric Airway Score (COPUR), since it uses a detailed scoring system and is therefore possibly more reliable. 2 Cooperation for airway assessment in children is not always easy and the availability of a score which accounts for a number of different aspects of the airway is more thorough. (See Table 1 for details.) Data pertaining to the real incidence of difficult airway management in children are sparse, but they are thought to be lower than in the adult population. Certain features predicting potential difficulties with airway management are often present in a number of syndromic children seen in paediatric anaesthesia practice. Predictors of difficult intubation include the presence of dysmorphic features, limited neck extension due to fusion of cervical vertebrae as found in Klippel‐ Feil syndrome, limited mouth opening, and restricted mobility of temporo-mandibular joints, a large tongue (macroglossia) such as found in Beckwith‐Wiedemann syndrome, limited submandibular space (retrognathia, micrognathia, mandibular hypoplasia or dysplasia) as found in Pierre Robin syndrome and Treacher Collins syndrome, and the presence of structural abnormalities in the laryngo-tracheal passage. Other predictors include soft tissue tumours, storage diseases such as mucopolysaccharidoses, and arteriovenous or lymphatic malformations involving the airway. In neonates and infants, the lateral profile may be more useful in eliciting the subtle signs of mandibular hypoplasia which are easily missed. (Refer to Table 2 for the anatomical site predominantly causing the airway problem in these syndromes.) This review focuses on some common syndromes predominantly seen in paediatric anaesthesia practice that are associated with potentially difficult airway management and highlights the related relevant features. A broader discussion of difficult intubation in the paediatric population has been published elsewhere and is beyond the scope of this review. 34

Perioperative Care of an Infant With an Open Safety Pin in the Hypopharynx

In the practice of pediatric anesthesia, foreign body (FB) aspiration represents a commonly encountered surgical emergency, which may lead to morbidity and mortality if not handled in a timely and effective fashion. We present a 12-month-old infant who was found to have a sharp FB lodged in the hypopharynx at the level of the glottis, leading to a unique clinical challenge, both from the standpoint of airway management and removal technique. We discuss the symptoms and radiographic manifestations of FB aspiration. Options for anesthetic management are presented and potential complications are reviewed. J Med Cases. 2015;6(4):146-149 doi: http://dx.doi.org/10.14740/jmc2017w

Controversies in Pediatric Perioperative Airways.

Pediatric airway management is a challenge in routine anesthesia practice. Any airway-related complication due to improper procedure can have catastrophic consequences in pediatric patients. The authors reviewed the current relevant literature using the following data bases: Google Scholar, PubMed, Medline (OVID SP), and Dynamed, and the following keywords: Airway/s, Children, Pediatric, Difficult Airways, and Controversies. From a summary of the data, we identified several controversies: difficult airway prediction, difficult airway management, cuffed versus uncuffed endotracheal tubes for securing pediatric airways, rapid sequence induction (RSI), laryngeal mask versus endotracheal tube, and extubation timing. The data show that pediatric anesthesia practice in perioperative airway management is currently lacking the strong evidence-based medicine (EBM) data that is available for adult subpopulations. A number of procedural steps in airway management are derived only from adult populations. However, the objective is the same irrespective of patient age: proper securing of the airway and oxygenation of the patient.

The development of pediatric anesthesia and intensive care in Scandinavia.

The initiation and development of pediatric anesthesia and intensive care have much in common in the Scandinavian countries. The five countries had to initiate close relations and cooperation in all medical disciplines. The pediatric anesthesia subspecialty took its first steps after the Second World War. Relations for training and exchange of experiences between Scandinavian countries with centers in Europe and the USA were a prerequisite for development. Specialized pediatric practice was not a full-time position until during the 1950s, when the first pediatric anesthesia positions were created. Scandinavian anesthesia developed slowly. In contrast, Scandinavia pioneered both adult and certainly pediatric intensive care. The pioneers were heavily involved in the teaching and training of anesthetists and nurses. This was necessary to manage the rapidly increasing work. The polio epidemics during the 1950s initiated a combination of clinical development and technical innovations. Blood gas analyses technology and interpretation in combination with improved positive pressure ventilators were developed in Scandinavia contributing to general and pediatric anesthesia and intensive care practice. Scandinavian specialist training and accreditation includes both anesthesia and intensive care. Although pediatric anesthesia/intensive care is not a separate specialty, an 'informal accreditation' for a specialist position is obtained after training. The pleasure of working in a relatively small group of devoted colleagues and staff has persisted from the pioneering years. It is still one of the most inspiring and pleasant gifts for those working in this demanding specialty.

Total intravenous anesthesia will supercede inhalational anesthesia in pediatric anesthetic practice.

Inhalational anesthesia has dominated the practice of pediatric anesthesia. However, as the introduction of agents such as propofol, short-acting opioids, midazolam, and dexmedetomidine a monumental change has occurred. With increasing use, the overwhelming advantages of total intravenous anesthesia (TIVA) have emerged and driven change in practice. These advantages, outlined in this review, will justify why TIVA will supercede inhalational anesthesia in future pediatric anesthetic practice.

Perioperative pulmonary aspiration is infrequent and low risk in pediatric anesthetic practice.

Recent studies have reported perioperative pulmonary aspiration in pediatric practice to be an uncommon problem associated with low morbidity and mortality. This paper examines the recent publications in both the adult and pediatric literature and looks at some of the potential risk factors involved, both patient and anesthetic, in the development of aspiration of gastric contents. We also look at the risk of severe morbidity following pulmonary aspiration and speculate on possible reasons behind the assertion that pulmonary aspiration in pediatric anesthetic practice is rare and a low-risk event.

Rapid sequence induction has no use in pediatric anesthesia.

(Classic) rapid sequence induction and intubation (RSII) has been considered fundamental to the provision of safe anesthesia. This technique consists of a combination of drugs and techniques and is intended to prevent pulmonary aspiration of gastric content with catastrophic outcomes to the patient. This review investigates aspects of this technique and highlights dangers and frauds if this technique is transferred directly into pediatric anesthesia practice. The author recommends a controlled anesthesia induction by trained pediatric anesthesiologist with suitable equipment for the children considered at risk of pulmonary aspiration. RSSI is a dangerous technique if adopted without modification into pediatric anesthesia and has in its 'classic' form no use.

Effects of sevoflurane versus other general anaesthesia on emergence agitation in children.

Effects of sevoflurane versus other general anaesthesia on emergence agitation in children.