Perioperative Management Of Pediatric Patients Research Articles

Accuracy of a Dual-Sensor Heat-Flux (DHF) Non-Invasive Core Temperature Sensor in Pediatric Patients Undergoing Surgery.

Accurate temperature measurement is crucial for the perioperative management of pediatric patients, and non-invasive thermometry is necessary when invasive methods are infeasible. A prospective observational study was conducted on 57 patients undergoing elective surgery. Temperatures were measured using a dual-sensor heat-flux (DHF) thermometer (Tcore™) and a rectal temperature probe (TRec), and the agreement between the two measurements was assessed. The DHF measurements showed a bias of +0.413 °C compared with those of the TRec. The limits of agreement were broader than the pre-defined ±0.5 °C range (-0.741 °C and +1.567 °C). Although the DHF sensors tended to overestimate the core temperature compared to the rectal measurements, an error grid analysis demonstrated that 95.81% of the DHF measurements would not have led to a wrong clinical decision, e.g., warming or cooling when not necessary. In conclusion, the low number of measurements that would have led to incorrect decisions suggests that the DHF sensor can be considered an option for continuous temperature measurement when more invasive methods are infeasible.

FEATURES OF PERIOPERATIVE MANAGEMENT OF PEDIATRIC PATIENTS WITH CONGENITAL HEART DEFECTS

The paper analyzes the features of perioperative management of pediatric patients with congenital heart defects. The authors note that the perioperative period is the period starting from the moment of the beginning of the operation and ending with the moment of transfer of the patient to the ward after the operation. This period is very important for the recovery of children after surgery for a heart defect. In the perioperative period, indicators such as blood pressure, pulse, oxygen saturation, respiratory rate and other indicators are monitored to make sure that the patient is in a stable condition and there are no complications. In the perioperative period, measures are taken to prevent complications such as infections, bleeding, thrombosis, etc. Doctors also monitor the balanced administration of fluids and electrolytes to maintain the stability of the patient, and try to minimize the time of surgery to reduce stress for the patient and reduce the risk of complications. During the period under review, procedures are also carried out to support the postoperative period, such as the administration of medications and infusion solutions, maintaining body temperature and other procedures. In general, the perioperative period is of critical importance for the recovery of children after surgery for a heart defect. Proper monitoring of health indicators, prevention of complications, proper anesthesia and other procedures help children recover faster after surgery and reduce the risk of complications.

Perioperative management of pediatric patients undergoing juvenile angiofibroma resection. A case series and educational review highlighting patient blood management.

Juvenile nasopharyngeal angiofibromas are one of the most enigmatic, bloody tumors encountered by otorhinolarygnologists, head and neck surgeons, neurosurgeons, and anesthesiologists. Juvenile nasopharyngeal angiofibromas are rare, benign, highly vascular tumors with a propensity towards aggressive local invasion. Surgery, open or endoscopic, to remove the growth is the primary treatment of choice for Juvenile nasopharyngeal angiofibromas. Historically, surgical resection was associated with massive, rapid blood loss, traditionally managed by blood product transfusion and deliberate hypotension. Preventative management employing multimodal blood conservation strategies should be an essential standard of perioperative care for patients with Juvenile nasopharyngeal angiofibromas. We describe a contemporary and comprehensive approach in the management of patients with high grade Juvenile nasopharyngeal angiofibromas. This includes surgical strategies such as preemptive external carotid artery embolization, endoscopic surgical approach, and staged operations, as well as anesthetic strategies including antifibrinolytic therapy and acute normovolemic hemodilution. These surgeries, once synonymous with massive transfusion, may potentially be performed without allogeneic blood transfusion, or deliberate hypotension. Using a case series, the authors introduce a contemporary approach to multimodal, multidisciplinary blood conservation strategies for Juvenile nasopharyngeal angiofibromas surgery. Here in the authors report on an updated contemporary perioperative clinical approach to patients with Juvenile nasopharyngeal angiofibromas. From an anesthetic perspective, we describe the successful use of normal hemodynamic goals, restrictive transfusion strategy, antifibrinolytic therapy, autologous normovolemic hemodilution, and early extubation in the care of three adolescent males with highly invasive tumors. We demonstrate that new surgical and anesthetic strategies have yielded a significant decrease in intraoperative blood loss and eliminated the need for transfusion of autologous red blood cells, which enable improved outcomes. The perioperative approach to elective surgery for Juvenile nasopharyngeal angiofibromas management is presented from a multidisciplinary patient blood management perspective.

Machine Learning–Based Prediction of Acute Kidney Injury Following Pediatric Cardiac Surgery: Model Development and Validation Study

Cardiac surgery-associated acute kidney injury (CSA-AKI) is a major complication following pediatric cardiac surgery, which is associated with increased morbidity and mortality. The early prediction of CSA-AKI before and immediately after surgery could significantly improve the implementation of preventive and therapeutic strategies during the perioperative periods. However, there is limited clinical information on how to identify pediatric patients at high risk of CSA-AKI. The study aims to develop and validate machine learning models to predict the development of CSA-AKI in the pediatric population. This retrospective cohort study enrolled patients aged 1 month to 18 years who underwent cardiac surgery with cardiopulmonary bypass at 3 medical centers of Central South University in China. CSA-AKI was defined according to the 2012 Kidney Disease: Improving Global Outcomes criteria. Feature selection was applied separately to 2 data sets: the preoperative data set and the combined preoperative and intraoperative data set. Multiple machine learning algorithms were tested, including K-nearest neighbor, naive Bayes, support vector machines, random forest, extreme gradient boosting (XGBoost), and neural networks. The best performing model was identified in cross-validation by using the area under the receiver operating characteristic curve (AUROC). Model interpretations were generated using the Shapley additive explanations (SHAP) method. A total of 3278 patients from one of the centers were used for model derivation, while 585 patients from another 2 centers served as the external validation cohort. CSA-AKI occurred in 564 (17.2%) patients in the derivation cohort and 51 (8.7%) patients in the external validation cohort. Among the considered machine learning models, the XGBoost models achieved the best predictive performance in cross-validation. The AUROC of the XGBoost model using only the preoperative variables was 0.890 (95% CI 0.876-0.906) in the derivation cohort and 0.857 (95% CI 0.800-0.903) in the external validation cohort. When the intraoperative variables were included, the AUROC increased to 0.912 (95% CI 0.899-0.924) and 0.889 (95% CI 0.844-0.920) in the 2 cohorts, respectively. The SHAP method revealed that baseline serum creatinine level, perfusion time, body length, operation time, and intraoperative blood loss were the top 5 predictors of CSA-AKI. The interpretable XGBoost models provide practical tools for the early prediction of CSA-AKI, which are valuable for risk stratification and perioperative management of pediatric patients undergoing cardiac surgery.

The Perioperative Anesthetic Management of the Pediatric Patient with Special Needs: An Overview of Literature.

The perioperative management of pediatric patients with psycho-physical disorders with related relational and cognitive problems must be carefully planned, in order to make the entire hospitalization process as comfortable and as less traumatic as possible. This article reports an overview of the anesthetic management of non-cooperative patients between 6 and 14 years old. The pathologies most frequently responsible for psycho-physical disorders can be summarized into three groups: (1) collaboration difficulties (autism spectrum disorders, intellectual impairment, phobia); (2) motor dysfunction (cerebral palsy, epilepsy, other brain pathologies, neuromuscular disorders), and (3) craniofacial anomalies (Down syndrome, other genetic syndromes). Anesthesia can be performed safely and successfully due to careful management of all specific problems of these patients, such as a difficult preoperative evaluation (medical history, physical examination, blood sampling, evaluation of vital parameters and predictive indices of difficult airway) and the inapplicability of a “standard” perioperative path (timing and length of the hospitalization, anesthetic premedication, postoperative management). It is necessary to ensure a dedicated perioperative process that is safe, comfortable, tailored to specific needs, and as less traumatic as possible. At the same time, all necessary precautions must be taken to minimize possible complications.

Systematic Review and Guidelines for Perioperative Management of Pediatric Patients Undergoing Major Plastic Surgery Procedures, with a Focus on Free Tissue Transfer.

Microsurgical free tissue transfer has been successfully implemented for various reconstructive applications in children. The goal of this study was to identify the best available evidence on perioperative management of pediatric patients undergoing free tissue transfer and to use it to develop evidence-based care guidelines. A systematic review was conducted in the PubMed, Embase, Scopus, and Cochrane Library databases. Because a preliminary search of the pediatric microsurgical literature yielded scant data with a low level of evidence, pediatric anesthesia guidelines for healthy children undergoing major operations were also included. Exclusion criteria included vague descriptions of perioperative care, case reports, and studies of syndromic or chronically ill children. Two hundred four articles were identified, and 53 met inclusion criteria. Management approaches specific to the pediatric population were used to formulate recommendations. High-quality data were found for anesthesia, analgesia, fluid administration/blood transfusion, and anticoagulation (Level I Evidence). Lower quality evidence was identified for patient temperature (Level III Evidence) and vasodilator use (Level IV Evidence). Key recommendations include administering sevoflurane for general anesthesia, implementing a multimodal analgesia strategy, limiting preoperative fasting, restricting blood transfusions until hemoglobin level is less than 7 g/dl unless the patient is symptomatic, and reserving chemical venous thromboembolism prophylaxis for high-risk patients. Pediatric-specific guidelines are important, as they acknowledge physiologic differences in children, which may be overlooked when extrapolating from adult studies. These evidence-based recommendations are a key first step toward standardization of perioperative care of pediatric patients undergoing plastic surgical procedures, including free tissue transfer, to improve outcomes and minimize complications.

Perioperative Management of Pediatric Patients with Moyamoya Arteriopathy.

Pediatric patients with moyamoya arteriopathy are at high risk for developing new onset transient or permanent neurologic deficits secondary to cerebral hypoperfusion, particularly in the perioperative period. It is therefore essential to carefully manage these patients in a multidisciplinary, coordinated effort to reduce the risk of new permanent neurologic deficits. However, little has been published on perioperative management of pediatric patients with moyamoya, particularly in the early postoperative period during intensive care unit admission. Our pediatric neurocritical care team sought to create a multidisciplinary periprocedural evidence- and consensus-based care pathway for high-risk pediatric patients with moyamoya arteriopathy undergoing anesthesia for any reason to decrease the incidence of periprocedural stroke or transient ischemic attack (TIA). We reviewed the literature to identify risk factors associated with perioperative stroke or TIA among patients with moyamoya and to gather data supporting specific perioperative management strategies. A multidisciplinary team from pediatric anesthesia, neurocritical care, nursing, child life, neurosurgery, interventional neuroradiology, neurology, and hematology created a care pathway for children with moyamoya undergoing anesthesia, classifying them as either high or standard risk, and applying an individualized perioperative management plan to high-risk patients. The incidence of neurologic sequelae before and after pathway implementation will be compared in future studies.

Practice patterns of perioperative insulin pump management in pediatric diabetes.

Perioperative management of children with diabetes is complex.1-3 Insulin pumps are increasingly used by children with type 1 diabetes (T1D), and anesthesiologists are likely to encounter them in practice. However, there is limited data on the experience of using insulin pumps in the perioperative management of pediatric patients.

Perioperative Management of Pediatric Patients with Osteogenesis Imperfecta Undergoing Orthopedic Procedures

Osteogenesis imperfecta (OI) is a predominantly autosomal dominant inherited condition involving connective tissue associated with not only bone fragility, but multi-system involvement with perioperative implications. The perioperative management of patients with OI undergoing orthopedic procedures is high risk for anatomical and physiological reasons. We performed a retrospective analysis of 13 years of data covering the perioperative management of 146 pediatric patients with OI for 280 operative procedures involving up to five bones each by two fellowship-trained pediatric orthopedic surgeons and a team of pediatric anesthesiologists. The purpose of the review was to describe updated perioperative anesthetic management based on over a decade of experience in a pediatric hospital specializing in the management of OI patients.

Perioperative management of pediatric en-bloc combined heart-liver transplants: a case series review.

Combined heart and liver transplantation (CHLT) in the pediatric population involves a complex group of patients, many of whom have palliated congenital heart disease (CHD) involving single ventricle physiology. The purpose of this study was to describe the perioperative management of pediatric patients undergoing CHLT at a single institution and to identify management strategies that may be used to optimize perioperative care. We did a retrospective database review of all patients receiving CHLT at a children's hospital between 2006 and 2014. Information collected included preoperative characteristics, intraoperative management, blood transfusions, and postoperative morbidity and mortality. Five pediatric CHLTs were performed over an 8-year period. All patients had a history of complex CHD with multiple sternotomies, three of whom had failing Fontan physiology. Patient age ranged from 7 to 23 years and weight from 29.5 to 68.5 kg. All CHLTs were performed using an en-bloc technique where both the donor heart and liver were implanted together on cardiopulmonary bypass (CPB). The median operating room time was 14.25 h, median CPB time was 3.58 h, and median donor ischemia time was 4.13 h. Patients separated from CPB on dopamine, epinephrine, and milrinone infusions and two required inhaled nitric oxide. All patients received a massive intraoperative blood transfusion post CPB with amounts ranging from one to three times the patient's estimated blood volume. The patient who required the most transfusions was in decompensated heart and liver failure preoperatively. Four of the five patients received an antifibrinolytic agent as well as a procoagulant (prothrombin complex concentrate or recombinant activated Factor VII) to assist with hemostasis. There were no 30-day thromboembolic events detected. Postoperatively the median length of mechanical ventilation, ICU stay and stay to hospital discharge was 4, 8, and 37 days, respectively. All patients are alive and free from allograft rejection at this time. Combined heart and liver transplantation in the pediatric population involves a complex group of patients with unique perioperative challenges. Successful management starts with thorough preoperative planning and communication and involves strategies to deal with massive intraoperative hemorrhage and coagulopathy in addition to protecting and supporting the transplanted heart and liver and meticulous surgical technique. An integrated multidisciplinary team approach is the cornerstone for successful outcomes.

Perioperative management of pediatric patients on mechanical cardiac support

The population of children with end-stage heart failure requiring mechanical circulatory support is growing. These children present for diagnostic imaging studies, various interventions and noncardiac surgical procedures that require anesthetic care. This article is a review of the population demographics of children on mechanical cardiac support, the alternative devices available, and the important concepts for safe perioperative management of these patients. The discussion will be limited to devices for short- and long-term cardiac support, excluding extracorporeal membrane oxygenation (ECMO) for respiratory support.

Syndromes: Rapid Recognition and Perioperative Implications.

University of Toronto, Toronto, Ontario, Canada. joan.bevan@utoronto.caSyndromes: Rapid Recognition and Perioperative Implications. Edited by Bruno Bissonette, M.D., Igor Luginbuehl, M.D., Bruno Marciniak, M.D., and Bernard Dalens, M.D. New York, McGraw-Hill Medical Publishing Division, 2006. Pages: 953. Price: $89.95.Pediatric anesthesiologists have long recognized that children with classic groups of symptoms that characterize common eponymous syndromes, such as Down syndrome, often present for surgery with difficult airways for intubation and cardiac anomalies. Less frequently, they encounter a rare congenital syndrome, or some sporadic nonsyndromal disorder, that is complex in nature and presents challenging management problems. As neonatal survival from life-threatening conditions has improved, anesthesiologists now treat children with syndromes in day-care surgical settings and intensive care units. It would be a daunting task to remain knowledgeable about the many new syndromes that are being identified at an unprecedented rate after the completion of the Human Genome Project. So, there is a clear need for a readily available resource of information on syndromes to consult when dealing with these cases.Bruno Bissonette and his coeditors have compiled an encyclopedic reference text to more than 2,000 syndromes that confound the perioperative management of pediatric patients. The main body of the text provides an alphabetical listing of these syndromes, with an easy cross-referencing system to synonyms, variations, and closely related conditions. Illustrations of many common or rare conditions allow a rapid diagnosis to be confirmed. Each entry is a well-organized description of the syndrome under 14 standardized headings. Typically, important clinical features for recognition of the syndrome are presented with a brief historic note about early descriptions. The incidence and prevalence in specific populations is estimated, and the likely pathophysiologic mechanisms underlying the medical condition are discussed. Diagnostic tests to aid in the differential diagnosis are listed, and attention is drawn to those organ systems that are most likely to be involved and need further investigation. Recommendations for preoperative management and anesthetic considerations follow logically from these considerations. The inclusion of current information about the genetic basis of the syndrome and updated references is valuable for those who want to pursue the topic further, either for interest or as an adjunct to family counseling in the perioperative period.This book makes fascinating reading. Using closure of a cleft palate as an example of a routine surgical procedure, it describes an alarming range of possible associations with syndromes that may confront the unsuspecting anesthesiologist. Juberg-Hayward syndrome is a very rare inherited disorder that includes microcephaly with thumb and limb deformities. There are only 250 known cases of ectrodactyly, ectodermal dysplasia, and clefting (EEC) syndrome, but they are associated with difficult intubation, mental retardation, hearing loss, and renal dysplasia. McPherson-Clemens syndrome is an autosomal recessive disorder complicated by hypertelorism, bifid thumbs, malrotation of the intestine, and complex congenital heart defects. CCGE syndrome is a synonym for cleft palate, cardiac defect, genital anomalies, and ectrodactyly, an extremely rare inherited disorder for which anesthesia has not been described.Rosseli-Gulienetti syndrome is another example of an autosomal recessive condition that manifests with ectodermal dysplasia, hand and foot deformities, and mental retardation. These are only five of the many syndromes with which cleft palate, an eminently correctable condition that will necessitate repeated anesthesia, may coexist.When a syndrome has been diagnosed in infancy, there will be warning of potential problems and, often, a history of previous anesthetic experiences. The specter of unexplained cardiac arrest as the presenting feature of Duchenne muscular dystrophy in apparently healthy young boys is still real. However, after a diagnosis has been made, the concise, complete information presented here allows such cases to be approached with confidence. It explains that Duchenne muscular dystrophy affects 1:3,500 boys as a result of a spontaneous mutation or X-recessive inheritance in a gene mapped to the short arm of the X chromosome at position 21 (Xp21). The absence of dystrophin disrupts sarcolemma function and results in progressive muscular, respiratory, and cardiac disease. Recommendations for cardiorespiratory function tests preoperatively and avoidance of succinylcholine and halogenated inhalational agents, while remaining prepared for hyperkalemic cardiac arrest, are valuable cautionary reminders.This is a wonderful book. Its publication is timely in filling a void that medical advances have created. As the number of older and newer syndromes identified becomes overwhelming for anesthesiologists, this resource will contribute to improvements in the perioperative care of children. However, it could be argued that a Web-based interactive platform, rather than the traditional hardback book format, would make the material even more useful, accessible, and easier to keep up-to-date. In the meantime, this book should be readily available to all pediatric anesthesiologists in the perioperative and intensive care environments.University of Toronto, Toronto, Ontario, Canada. joan.bevan@utoronto.ca

Perioperative management of pediatric patients with diabetes mellitus

近年来,儿童1型和2型糖尿病的发病率逐渐上升.由于其发病年龄及病情程度的特殊性和复杂性,因此围手术期的处理至关重要.现从术前、术中和术后各阶段综述了以美国波士顿大学儿童医院各学科众多权威学者牵头制定的一项相对比较完整的处理准则,希望能够进一步指导和增强麻醉科医师的处理能力。

Thirteenth Annual Meeting of the Society for Pediatric Anesthesia, Dallas, Texas, October 8, 1999

Thirteenth Annual Meeting of the Society for Pediatric Anesthesia, Dallas, Texas, October 8, 1999

Pediatrics for anesthesiologists

Complex pediatric cases will more and more often be undertaken by general anesthesiologists. However, keeping up with the pediatric literature can be difficult. In this brief review, we examine the most recent information on the perioperative management of pediatric patients with sickle cell disease, and look at the recent utilization of aprotinin to control blood loss in children of Jehovah's Witnesses. We review the encouraging results of intestinal transplantations recently performed at the University of Nebraska, and we look at the tremendous potential for umbilical cord blood transplantation to treat malignant and nonmalignant diseases in children successfully.

Perioperative problems in pediatric anesthesia

Perioperative management of pediatric patients has significant impact on children's overall hospital experience. Recent investigations have focused on the need for, agents used for, and mode of delivery of preanesthetic medications; liberalizing the preoperative fast; increasing parental presence at the time of anesthetic induction; and prophylaxis and treatment of postoperative nausea and vomiting.