Perioperative Care Of Infants Research Articles

Abstract 4135745: Prematurity Predicts Neurodevelopmental Outcomes in Congenital Heart Disease

Background: Neurodevelopmental (ND) impairment is common in both prematurity and congenital heart disease (CHD). Preterm infants with CHD may have a “double hit,” with worse ND impairments than seen in prematurity or CHD alone. We analyzed whether gestational age (GA) at delivery predicted ND outcomes in children with CHD. Methods: We performed a single-institution retrospective study of children who underwent infant heart surgery from 2007-2020 and returned for ND evaluation after discharge. Exclusion criteria were 1) trisomy 21 and 2) PDA ligation alone. The Bayley Scales of Infant and Toddler Development, Third Edition (Bayley-III) assessed ND between ages 6-40 months. Patients were stratified into 4 GA groups: very/moderately preterm (≤33 weeks), late-preterm (34-36 weeks), early-term (37-38 weeks) or term/post-term (≥39 weeks). Hierarchical linear regression evaluated potential predictors of Bayley-III composite scores including GA category, demographic, medical, and surgical variables. Results: Among 1350 infants, 513 (38%) had a Bayley-III at median age 28 months [IQR 19, 34]. Of these, 448 (87%) were full-term and 65 (13%) preterm. In univariate analyses, children born preterm vs. full term had lower Bayley-III cognitive, language, and motor scores, explaining from 2.4% (language) to 6.2% (motor) of the variance in Bayley composite scores. In the final models, GA remained a strong independent predictor of motor and cognitive scores. Children with GA ≤33 weeks had the worst outcomes, with age-adjusted cognitive and motor composite scores 11 and 15 points lower, respectively, than those of term infants (Figure). Other significant risk factors included lower primary caregiver education, Black race, longer hospital length of stay, and genetic diagnosis. These models ultimately explained 17-26% of the variance in Bayley scores, with the highest explained variance in the motor domain. Conclusions: Adjusting for other patient and medical factors, preterm infants with CHD have worse cognitive and motor outcomes; risk is highest in those born at ≤33 weeks. Further work is needed to identify potentially modifiable factors to tailor prenatal, postnatal and perioperative care of infants with CHD born prematurely.

Simulation in pediatric anesthesiology: current state and visions for the future.

Simulation is a well established practice in medicine. This review reflects upon the role of simulation in pediatric anesthesiology in three parts: training anesthesiologists to care for pediatric patients safely and effectively; evaluating and improving systems of care for children; and visions for the future. Simulation continues to prove a useful modality to educate both novice and experienced clinicians in the perioperative care of infants and children. It is also a powerful tool to help analyze and improve upon how care is provided to infants and children. Advances in technology and computational power now allow for a greater than ever degree of innovation, accessibility, and focused reflection and debriefing, with an exciting outlook for promising advances in the near future. Simulation plays a key role in developing and achieving peak performance in the perioperative care of infants and children. Although simulation already has a great impact, its full potential is yet to be harnessed.

Educational Perspectives: Anesthesia 101: What the Neonatologist Needs to Know About Anesthesiology.

As the complexity of medicine increases, so too do the challenges with multidisciplinary communication and coordinated patient care. Anesthesiology represents a field for which there is no required study for medical students, pediatric residents, or neonatal-perinatal medicine fellows in the United States, so a neonatologist may have never received any formal training in anesthesiology (and vice versa for pediatric anesthesiologists in neonatology). In this review, we address frequently asked questions of neonatologists to anesthesiologists to better frame common issues. These topics include thermal regulation, fluid management, airway management, and the field of regional anesthesiology. Finally, collaborative efforts between the surgical and medical fields, such as the American College of Surgeons Children's Surgery Verification Quality Improvement Program, and the American Academy of Pediatrics NICU Verification Program, are ongoing and robust; these programs represent important opportunities to significantly improve the perioperative care of infants. Our hope is that this summary can serve as a primer and reference for those caring for neonatal patients during any perioperative period, including seasoned neonatologists and those early in their training. It is our further desire that this review will lead to improved communication and collegiality between the specialties.

Estudio APRICOT sobre la seguridad de los más pequeños

El manejo anestésico del paciente pediátrico requiere de una formación y unas estructuras específicas, debido a las situaciones adversas que se pueden producir. El estudio APRICOT (Anaesthesia PRactice In Children Obervational Trial) con una muestra de más de 30.000 pacientes de 33 países europeos y a través de un minucioso análisis observacional de cohortes prospectivo, recoge la naturaleza, la incidencia y los factores de riesgo de los evento críticos más comprometedores; desde los más comunes como el laringoespasmo o el broncoespasmo, la bradicardia hasta la parada cardiaca, pasando por fenómenos neurológicos, anafilaxia o errores de medicación. Obtiene unos resultados que distan en algunos aspectos de lo estudiado hasta ahora. La diversidad de los datos analizados permite identificar aquellos factores de riesgo relacionados con los eventos críticos, entre ellos el anestesista y el centro hospitalario. Pero sobre todo da pie a la necesidad de crear guías de manejo anestésico pediátrico encaminadas hacia una Anestesia más segura. ABSTRACT APRICOT report about our yougest´s safety The perioperative care of infants and children demands special training and facilities due to possible critical events. The APRICOT study (Anaesthesia PRactice In Children Obervational Trial) analyses more than 30.000 anaesthetic procedures from 33 different European countries. Through a detailed prospective observational cohort study, this trial identifies the incidence, the nature and the outcomes of severe critical events in children, including laryngospasm, bronchospasm, cardiovascular instability and cardiac arrest, neurological damage, anaphylaxis or drug errors. Some reported results differ from what was previously published in the literature. Large variation of the collected data allows to identify those risk factors contributing to the severe critical events, among them, the anaesthetist and the centre. This study especially motivates to create clinical practice guidelines of paediatric anaesthesia management for a safer Anaesthesia.

Vasopressin in perioperative management of congenital diaphragmatic hernia

Perioperative care of infants with diaphragmatic hernias can be a challenge because of pulmonary hypertension and systemic hypotension. The objective of this study was to report the usefulness of vasopressin infusion in improving pulmonary and systemic haemodynamics in an infant with congenital diaphragmatic hernia. Oxygenation failure, pulmonary hypertension and refractory systemic hypotension in infants with diaphragmatic hernia are managed by ventilation and conventional inotropes (dobutamine and dopamine). Vasopressin is a recent addition that exerts vasodilatory effects on the pulmonary circulation and vasotonic effects on the systemic circulation. The net effect is a reduction in pulmonary vascular resistance and improvement in cardiac output and reduced need for inotropes. This paradoxical response (vasodilation in some vascular beds) distinguishes it from other vasoconstrictor agents. The infant was administered intravenous vasopressin infusion for severe pulmonary hypertension that needed inhaled nitric oxide and for systemic hypotension that needed multiple inotropes under close echocardiographic monitoring. Informed parental consent and appropriate institutional ethics approval were obtained. Addition of vasopressin led to improved oxygenation and weaning off from nitric therapy. Improvement in cardiac output and blood pressure facilitated the weaning off from inotropes. Close echocardiographic monitoring was performed to ascertain the haemodynamic effects of vasopressin. Under echocardiographic monitoring, vasopressin is a useful adjunct for managing pulmonary and systemic perioperative haemodynamic instability in infants with diaphragmatic hernia.Keywords: congenital diaphragmatic hernia, echocardiography, vasopressin

Acetaminophen for analgesia following pyloromyotomy: does the route of administration make a difference?

BackgroundDuring the perioperative care of infants with hypertrophic pyloric stenosis, an opioid-sparing technique is often advocated due to concerns such as postoperative hypoventilation and apnea. Although the rectal administration of acetaminophen is commonly employed, an intravenous (IV) preparation is also currently available, but only limited data are available regarding IV acetaminophen use for infants undergoing pyloromyotomy. The objective of the current study was to compare the efficacy of IV and rectal acetaminophen for postoperative analgesia in infants undergoing laparoscopic pyloromyotomy.MethodsA retrospective review of the use of IV and rectal acetaminophen in infants undergoing laparoscopic pyloromyotomy was performed. The efficacy was assessed by evaluating the perioperative need for supplemental analgesic agents, postoperative pain scores, tracheal extubation time, time in the postanesthesia care unit, time to oral feeding, and time to hospital discharge.ResultsThe study cohort included 68 patients, of whom 34 patients received IV acetaminophen and 34 received rectal acetaminophen. All patients also received local infiltration of the surgical site with 0.25% bupivacaine. No intraoperative opioids were administered. There was no difference between the two groups with regard to postoperative pain scores, need for supplemental analgesic agents, time in the postanesthesia care unit, or time in the hospital. There was no difference in the number of children who tolerated oral feeds on the day of surgery or in postoperative complications.ConclusionOur preliminary data suggest that there is no clinical difference or advantage with the use of IV versus rectal acetaminophen in infants undergoing laparoscopic pyloromyotomy.

Perioperative care of infants with pyloric stenosis.

Pyloric stenosis (PS) is one of the most common surgical conditions affecting neonates and young infants. The definitive treatment for PS is surgical pyloromyotomy, either open or laparoscopic. However, surgical intervention should never be considered urgent or emergent. More importantly, emergent medical intervention may be required to correct intravascular volume depletion and electrolyte disturbances. Given advancements in surgical and perioperative care, morbidity and mortality from PS should be limited. However, either may occur related to poor preoperative resuscitation, anesthetic management difficulties, or postoperative complications. The following manuscript reviews the current evidence-based medicine regarding the perioperative care of infants with PS with focus on the preoperative assessment and correction of metabolic abnormalities, intraoperative care including airway management (particularly debate related to rapid sequence intubation), maintenance anesthetic techniques, and techniques for postoperative pain management. Additionally, reports of applications of regional anesthesia for either postoperative pain control or as an alternative to general anesthesia are discussed. Management recommendations are provided whenever possible.

Pro: Dexmedetomidine Should Be Used for Infants and Children Undergoing Cardiac Surgery

THE LANDMARK WORK OF Anand et al 1 Anand K.J. Sippell W.G. Aynsley-Green A. Randomised trial of fentanyl anaesthesia in preterm babies undergoing surgery: Effects on the stress response. Lancet. 1987; 1: 62-66 Abstract PubMed Scopus (395) Google Scholar , 2 Anand K.J. Hickey P.R. Halothane-morphine compared with high-dose sufentanil for anesthesia and postoperative analgesia in neonatal cardiac surgery. N Engl J Med. 1992; 326: 1-9 Crossref PubMed Scopus (688) Google Scholar has documented the potential impact of anesthetic practice on morbidity and mortality after surgery for congenital heart disease. Nearly 20 years later, the anesthetic management of pediatric patients with congenital heart lesions is a delicate balance between the successful ablation of the harmful perioperative stress responses and the potential untoward sequelae of effective analgesia and sedation including prolonged ventilator dependence, adverse end-organ effects, and iatrogenic tolerance and dependency syndromes. Anesthesiologists remain intimately involved in the perioperative care of children undergoing cardiac surgery and continue to seek new modalities of perioperative analgesia and sedation in an attempt to limit these complications. Dexmedetomidine increasingly has been used by anesthesiologists and intensive care physicians to provide effective pain relief, sedation, and anxiolysis in critically ill infants and children while mitigating the adverse effects of ventilator and opioid dependency. Given its beneficial physiologic effects and limited adverse effect profile, there may be several potential applications for dexmedetomidine in the perioperative care of infants and children with congenital heart disease.

Update on Randomized Clinical Trials Impacting Clinical Care in Pediatric Cardiac Intensive Care

Clinical trials addressing the management of infants and children with congenital heart disease are challenged by low numbers of patients with a similar diagnosis (inadequate power), variation in management strategies between institutions (difficulty developing multicentered protocols), a rapidly evolving field (equipoise), and insufficient funding. This article summarizes the challenges and the results of some single-center and multicenter trials evaluating perioperative care of infants and children undergoing surgery for congenital heart disease.

Anesthesia by the pediatric specialist.

There is increasing evidence that involvement of pediatric anesthesiologists in the perioperative care of infants and children can positively impact outcome. Considerable data have emerged in the past several years that clearly show that infants and small children experience untoward events at a much higher rate than do older children and adults. Herein the author presents some of this literature as well as data suggesting that anesthesiologists with interest and additional training in the care of infants and children can improve anesthesia outcomes. Even in these days of cost containment, it makes sense to provide the best pediatric team to care for the pediatric patient during the perioperative experience.