Risk Of Respiratory Adverse Events Research Articles

Application of Bispectral Index System (BIS) Monitor to Ambulatory Pediatric Dental Patients under Intravenous Deep Sedation.

Purpose Intravenous sedation has been well accepted to allow dental restoration in uncooperative children while avoiding aspiration and laryngospasm; however, intravenous anesthetics such as propofol may lead to undesired effects such as respiratory depression and delayed recovery. The use of the bispectral index system (BIS), a monitoring system reflective of the hypnotic state, is con-troversial in the reduction in the risk of respiratory adverse events (RAEs), recovery time, the in-travenous drug dosage, and post-procedural events. The aim of the study is to evaluate whether BIS is advantageous in pediatric dental procedures. Methods A total of 206 cases, aged 2-8 years, receiving dental procedures under deep sedation with propofol using target-controlled infusion (TCI) technique were enrolled in the study. BIS level was not monitored in 93 children whereas it was for 113 children, among which BIS values were maintained between 50-65. Physiological variables and adverse events were recorded. Statistical analysis was conducted using Chi-square, Mann Whitney U, Independent Samples t and Wilcoxon signed tests, with a p value of <0.05 considered to be statistically significant. Results Although no statistical significance in the post-discharge events and total amount of propofol used was observed, a clear significance was identified in periprocedural adverse events (hypoxia, apnea, and recurrent cough, all p value < 0.05) and discharge time (63.4 ± 23.2 vs. 74.5 ± 24.0 min, p value < 0.001) between these two groups. Conclusions The application of BIS in combination with TCI may be beneficial for young children undergoing deep sedation for dental procedures.

Association of adverse respiratory events with sodium-glucose cotransporter 2 inhibitors versus dipeptidyl peptidase 4 inhibitors among patients with type 2 diabetes in South Korea: a nationwide cohort study

BackgroundImpaired respiratory function remains underrecognized in patients with type 2 diabetes (T2D), despite common pulmonary impairment. Meanwhile, there is little data available on the respiratory effects of sodium glucose cotransporter 2 inhibitors (SGLT2i). Hence, we examined the association between SGLT2i use and the risk of adverse respiratory events in a real-world setting.MethodsWe conducted a population-based, nationwide cohort study using an active-comparator new-user design and nationwide claims data of South Korea from January 2015 to December 2020. Among individuals aged 18 years or older, propensity score matching was done to match each new user of SGLT2is with dipeptidyl peptidase 4 inhibitors (DPP4is), with patients followed up according to an as-treated definition. The primary outcome was respiratory events, a composite endpoint of acute pulmonary edema, acute respiratory distress syndrome (ARDS), pneumonia, and respiratory failure. Secondary outcomes were the individual components of the primary outcome and in-hospital death. Cox models were used to estimate hazard ratios (HRs) and 95% CIs.ResultsOf 205,534 patient pairs in the propensity score matched cohort, the mean age of the entire cohort was 53.8 years and 59% were men, with a median follow-up of 0.66 years; all baseline covariates achieved balance between the two groups. Incidence rates for overall respiratory events were 4.54 and 7.54 per 1000 person-years among SGLT2i and DPP4i users, respectively, corresponding to a rate difference of 3 less events per 1000 person-years (95% CI − 3.44 to − 2.55). HRs (95% CIs) were 0.60 (0.55 to 0.64) for the composite respiratory endpoint, 0.35 (0.23 to 0.55) for acute pulmonary edema, 0.44 (0.18 to 1.05) for ARDS, 0.61 (0.56 to 0.66) for pneumonia, 0.49 (0.31 to 0.76) for respiratory failure, and 0.46 (0.41 to 0.51) for in-hospital death. Similar trends were found across individual SGLT2is, subgroup analyses of age, sex, history of comorbidities, and a range of sensitivity analyses.ConclusionsThese findings suggest a lower risk of adverse respiratory events associated with patients with T2D initiating SGLT2is versus DPP4is. This real-world evidence helps inform patients, clinicians, and guideline writers regarding the respiratory effects of SGLT2i in routine practice.

THE IMPORTANCE OF OBSTRUCTIVE SLEEP APNEA SCORE AND END-TIDAL CO2 LEVEL IN ADOLESCENT CHILDREN WHO UNDERWENT OROPHARYNGEAL SURGERY

Aim Children with obstructive sleep apnea have an increased postoperative risk of adverse respiratory events. In our study, we calculated Obstructive Sleep Apnea Scores using the modified STOP-Bang questionnaire in children undergoing oropharyngeal surgery. The groups determined according to this score were compared in terms of mask ventilation levels in the intraoperative period, postoperative complications and postoperative ETCO2 levels. Methods A total of 90 patients, aged 7-15 years, who will undergo oropharyngeal surgery, classified as ASA I-II, and who have undergone a modified STOP-Bang questionnaire at the preoperative examination, were included in the study. Obstructive sleep apnea score (OSAs) was determined according to the modified STOP-Bang questionnaire, and the patients were divided into 3 groups as low, medium, and high-risk. Difficult mask ventilation level was noted in the intraoperative period. At the end of the operation, end-tidal carbon dioxide concentration (ETCO2) values at 0, 3, 5, 10, and 15 minutes after the patient was extubated and whether the patient had spasms were recorded. Results Among the 8 parameters in the modified STOP-Bang questionnaire, it was found that there was a significant difference between the groups for the other 6 parameters except for snoring and learning disability. Diffucult mask ventilation increased significantly from Group I to Group III. There is a significant difference between Group I and II, Group II and III, and Group I and Group III (p= 0.001). Although there were small differences within the groups and between the measurements of ETCO2 at different minutes, these differences were not statistically significant (p≥0.05) Conclusion In conclusion, associations between the results of the modified STOP-Bang questionnaire and the level of intervention required for difficult mask ventilation, this information could serve as a useful indicator for a higher level of care in the perioperative period for future patients

Measuring Success of Patient Safety Initiatives: The 2023 American Society of Anesthesiologists Practice Guidelines for Monitoring and Antagonism of Neuromuscular Blockade

Measuring Success of Patient Safety Initiatives: The 2023 American Society of Anesthesiologists Practice Guidelines for Monitoring and Antagonism of Neuromuscular Blockade

Periodontal Diseases: A Covert Focus of Inflammation in Pulmonary Diseases

Pulmonary diseases have known to exert significant human sufferings with high death toll globally. The association between periodontitis and pulmonary diseases is still in its infancy and needs attention. Poor oral health has shown to influence pulmonary health as well as the course of the diseases associated with this system. Numerous studies have emphasized that resident microorganisms of lungs are primarily the habitants of oral cavity. It could be due to the aspiration of oral periodontopathic bacteria into the lungs, thereby initiating the inflammatory process. Added to this, the inflammatory mediators elaborated from the inflamed periodontium in case of periodontal diseases may spread via blood to other organs such as lungs causing infections. Numerous studies have highlighted the beneficial role of periodontal therapy in improving lung function with a decreased frequency of exacerbations, reduced risk of adverse respiratory events, and morbidity, especially in chronic obstructive pulmonary disease patients. Medically compromised dentate patients admitted in intensive care units owing to their inability to maintain oral hygiene properly have increased propensity of acquiring respiratory infections. The present review focuses on emphasizing the relationship between periodontitis and pulmonary diseases with the available published literature utilizing PubMed and Google Scholar databases in the last four decades.

This Month in Anesthesiology

This Month in Anesthesiology

Impact of supplemental anesthesia in preterm infants undergoing inguinal hernia repair under spinal anesthesia : Aretrospective analysis.

In preterm infants, spinal anesthesia (SpA) is recognized as an alternative to general anesthesia for inguinal hernia repair (IHR); however, some patients require supplemental anesthesia during surgery. The purpose of this study was to investigate the frequency and impact of supplemental anesthesia on perioperative care and adverse respiratory and hemodynamic events. A retrospective study of preterm infants undergoing IHR at Heidelberg University Hospital within the first year of life between 2009 and 2018 was carried out. In total, 230 patients (255 surgeries) were investigated. Among 189 procedures completed using SpA 24patients received supplemental anesthesia. Reasons for supplemental anesthesia included loss of anesthetic effect, returning motor response, and respiratory complications. Compared to SpA alone, no differences were found concerning hemodynamic parameters; however, patients requiring supplemental anesthesia displayed higher rates of postoperative oxygen supplementation and unexpected admission to the intensive care unit. The rate of perioperative apnea was 2.7%. Apneic events exclusively occurred after supplemental anesthesia. Bilateral IHR and duration of surgery were associated with the need for supplemental anesthesia. Whereas SpA might be favorable when compared to general anesthesia for IHR, the data indicate that particular caution is required in patients receiving supplemental anesthesia due to the possible risk for adverse respiratory events.

Wildfire Smoke Exposure Is Associated with Adverse Respiratory Events under General Anesthesia in At-risk Pediatric Patients.

Increasing wildfire activity worldwide has led to exposure to poor air quality and numerous detrimental health impacts. This study hypothesized an association between exposure to poor air quality from wildfire smoke and adverse respiratory events under general anesthesia in pediatric patients. This was a single-center retrospective double-cohort study examining two significant wildfire events in Northern California. Pediatric patients presenting for elective surgery during periods of unhealthy air quality were compared with those during periods of healthy air quality. The primary exposure, unhealthy air, was determined using local air quality sensors. The primary outcome was the occurrence of an adverse respiratory event under anesthesia. Secondary analysis included association with other known risk factors for adverse respiratory events. A total of 625 patients were included in the analysis. The overall risk of a respiratory complication was 42.4% (265 of 625). In children without a history of reactive airway disease, the risk of adverse respiratory events did not change during unhealthy air periods (102 of 253, 40.3%) compared with healthy air periods (95 of 226, 42.0%; relative risk 0.96 [0.77 to 1.19], P = 0.703). In children with a history of reactive airway disease, the risk of adverse respiratory events increased from 36.8% (25 of 68) during healthy air periods to 55.1% (43 of 78) during periods with unhealthy air (1.50 [1.04 to 2.17], P = 0.032). The effect of air quality on adverse respiratory events was significantly modified by reactive airways disease status (1.56 [1.02 to 2.40], P = 0.041). Pediatric patients with underlying risk factors for respiratory complications under general anesthesia had a greater incidence of adverse respiratory events during periods of unhealthy air quality caused by wildfire smoke. In this vulnerable patient population, postponing elective anesthetics should be considered when air quality is poor.

Association between oxygen saturation level during bronchoscopy and post-bronchoscopy adverse events: a retrospective cohort study

BackgroundFlexible bronchoscopy is widely used to diagnose and treat various respiratory diseases. However, caution is warranted for post-bronchoscopy adverse events. Although desaturation frequently occurs during bronchoscopy, its clinical impact and the optimal oxygen saturation level during the procedure remain unclear. This study aimed to investigate whether the percutaneous oxygen saturation (SpO2) level during bronchoscopy is associated with the development of post-bronchoscopy respiratory adverse events.MethodsIn this single-center retrospective cohort study conducted from March 2020 to February 2021, 569 patients were classified into high or low oxygen saturation groups based on the SpO2 level during bronchoscopy. The primary outcome was post-bronchoscopy respiratory adverse events, and secondary outcomes were other post-bronchoscopy adverse events and clinical outcomes.ResultsAmong 569 patients, 458 and 111 patients were classified into the high oxygen saturation (SpO2 > 96%) and low oxygen saturation (SpO2 ≤ 94%) groups, respectively. After propensity score matching, the low oxygen saturation group had more post-bronchoscopy respiratory and febrile adverse events than the high oxygen saturation group. In the multivariable regression analysis, low SpO2 level during bronchoscopy was an independent risk factor for post-bronchoscopy respiratory adverse events (odds ratio = 3.16 [95% confidence interval 1.37–7.30]). In the low oxygen saturation group, the high-risk subgroups for post-bronchoscopy respiratory adverse events were the elderly, women, current smokers, and patients with chronic obstructive pulmonary disease or acute decompensated heart failure before bronchoscopy. There was no significant difference in the length of hospital stay, intensive care unit admission, or mortality between the high and low oxygen saturation groups.ConclusionsClose monitoring is recommended for patients with SpO2 ≤ 94% during bronchoscopy due to the increased risk of respiratory adverse events after the procedure.

Postoperative respiratory adverse events in children after endoscopic laryngeal cleft repair

Due to the serious nature of respiratory adverse events, understanding their incidence can help in decisions regarding safe postoperative disposition. There have been no studies, however, evaluating the risk of postoperative respiratory adverse events (PRAEs) in children undergoing endoscopic laryngeal cleft (LC) repair, which is the primary objective of this study. We conducted a retrospective chart review of all patients who underwent LC repair at a large tertiary children's hospital from 2015 to 2020. PRAEs were defined as having at least one of the following: remained intubated, required reintubation, required positive pressure ventilation, required high flow O2 nasal cannula, or required more than one dose of racemic epinephrine. Univariate analyses compared demographic, preoperative characteristics, and intraoperative characteristics between those with and without a PRAE. Overall, 8/26 (31%) patients had a PRAE and there were no differences between patients who did and did not have a PRAE and most comorbidities. Younger age (p = 0.03), being male (p = 0.07), and being admitted preoperatively (p = 0.07) were potentially associated with PRAEs. Need for intraoperative intubation for any reason or duration was associated with increased incidence of PRAEs (p = 0.02). The overall 31% incidence of postoperative respiratory adverse events reaffirms the appropriateness of PICU disposition for a large proportion of children undergoing endoscopic LC repair. Further studies with increased sample sizes are needed to tease apart patient or procedure-specific factors that significantly increase the risk of respiratory adverse events to have more definitive evidence regarding safe postoperative disposition.

Periodontal Diseases: Major Exacerbators of Pulmonary Diseases?

Periodontal diseases are a range of polymicrobial infectious disorders, such as gingivitis and periodontitis, which affect tooth-supporting tissues and are linked to playing a role in the exacerbation of several pulmonary diseases. Pulmonary diseases, such as pneumonia, chronic obstructive pulmonary disease (COPD), asthma, tuberculosis, COVID-19, and bronchiectasis, significantly contribute to poor quality of life and mortality. The association between periodontal disease and pulmonary outcomes is an important topic and requires further attention. Numerous resident microorganisms coexist in the oral cavity and lungs. However, changes in the normal microflora due to oral disease, old age, lifestyle habits, or dental intervention may contribute to altered aspiration of oral periodontopathic bacteria into the lungs and changing inflammatory responses. Equally, periodontal diseases are associated with the longitudinal decline in spirometry lung volume. Several studies suggest a possible beneficial effect of periodontal therapy in improving lung function with a decreased frequency of exacerbations and reduced risk of adverse respiratory events and morbidity. Here, we review the current literature outlining the link between the oral cavity and pulmonary outcomes and focus on the microflora of the oral cavity, environmental and genetic factors, and preexisting conditions that can impact oral and pulmonary outcomes.

Preemptive analgesic effectiveness of single dose intravenous ibuprofen in infants undergoing cleft palate repair: a randomized controlled trial

BackgroundCorrection surgery for cleft palate is recommended between 9 and 18 months of age. Patients suffer from acute pain after palatoplasty. Clinicians are hesitant to use opioids for analgesia concerning the potential high risk of respiratory adverse events. Intravenous ibuprofen perhaps be a suitable adjuvant to pain relief. We try to assess whether preoperative administration of intravenous ibuprofen can decrease opioid requirements following cleft palate repair in infants.MethodsThis single center prospective randomized clinical trial was performed from February to April 2021 at Department of Anesthesiology in Shanghai Children’s Medical Center. Forty patients ASA I-II, aged 9–24 months with isolated cleft palate and undergoing palatoplasty were randomized in a 1:1 ratio to receive either a single dose of 10 mg/kg ibuprofen intravenously or normal saline at induction. Children and infants postoperative pain scale (CHIPPS) was used for pain assessment. Those patients CHIPPS pain score equal or higher than 4 received analgesic rescue with titrating intravenous fentanyl 0.5 μg/kg and repeated in 10 min if required. The primary outcome was the amount of postoperative fentanyl used for rescue analgesia in postanesthesia care unit (PACU).ResultsPatients (n = 20 in each group) in IV-Ibuprofen group required less postoperative fentanyl than those in placebo group (p<0.001). There was no significant difference between two groups in first rescue analgesia time (p = 0.079) and surgical blood loss (p = 0.194). No incidence of obvious adverse events had been found within the first 24 h after surgery in both groups.ConclusionsPreemptive intravenous administration ibuprofen 10 mg/kg at induction had a significant opioid sparing effect in early postoperative period without obvious adverse effects in infants undergoing palatoplasty.Trial registrationCHICTR, CTR2100043718, 27/02/2021 http://www.chictr.org.cn/showproj.aspx?proj=122187

Efficacy and safety of e-cigarette use for smoking cessation: a systematic review and meta-analysis of randomized controlled trials

Abstract Background Quitting smoking substantially reduces the risk of developing cardiovascular disease. Smokers are increasingly turning to electronic cigarettes (e-cigarettes) to help them quit smoking combustible cigarettes. However, the efficacy and safety of e-cigarettes for smoking cessation remain controversial. Purpose To examine the efficacy and safety of e-cigarette use for smoking cessation. Methods We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing nicotine and non-nicotine e-cigarettes (alone, or in combination with behavioural and/or pharmacological interventions) to conventional smoking cessation therapies (pharmacological, behavioural, or both). We systematically searched MEDLINE, Embase, and the Cochrane Libraries. Inclusion was restricted to RCTs that reported biochemically validated abstinence at six months or greater. The primary comparison was nicotine e-cigarettes versus any (non-e-cigarette) conventional smoking cessation therapy. Count data were pooled using DerSimonian and Laird random-effects models with inverse variance weighting to obtain relative risks (RRs) and 95% confidence intervals (CIs). Results A total of six RCTs (n=3,401) were included, with maximum follow-up durations ranging from six to 12 months. Compared with conventional smoking cessation therapies, point estimates favoured nicotine e-cigarettes for the most rigorous criterion of abstinence, continuous abstinence, and point prevalence abstinence, although findings were inconclusive due to wide 95% CIs (Table 1). Similar trends were observed when comparing non-nicotine e-cigarettes to traditional smoking cessation therapies. Compared with non-nicotine e-cigarettes, nicotine e-cigarettes increased abstinence as defined by the most rigorous criterion. Although there was a signal suggesting a potential increased risk of respiratory adverse events with nicotine e-cigarettes versus traditional therapies, the 95% CI is wide. Conclusion E-cigarettes appear to be more efficacious than conventional nicotine pharmacotherapies and behavioural smoking cessation therapies. Although currently available safety data are inconclusive, e-cigarettes may be considered for smoking cessation given the established long-term health consequences of continued smoking. Funding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): Mr. Levett is supported by an Ivan Racheff Scholarship, funded through the McGill University Faculty of Medicine and Health Sciences Research Bursary Program. Dr. Filion is supported by a Senior Research Scholar award from the Fonds de recherche du Québec – Santé and a William Dawson Scholar award from McGill University.

Implementing Perioperative Evidence-Based Interventions for OSA: Increasing Risk Awareness, Enhancing Patient Care

<h3>Introduction</h3> The majority of Obstructive Sleep Apnea (OSA) cases are reported to be undiagnosed, including surgery patients. Perioperative nurses are in a unique position to recognize OSA not diagnosed in the perianesthesia period. <h3>Identification of the problem</h3> OSA has been identified as a factor for prolonging PACU stays and, more importantly, a contributing factor to respiratory compromise for those receiving opioids postoperatively. This population has an increased risk for adverse respiratory events once discharged. Implementing and sustaining interventions to safely discharge the patient can be a challenge. <h3>EBP Question/Purpose</h3> . <h3>PICO question. Databases utilized</h3> Can increasing nursing knowledge of OSA risk and perioperative nursing interventions optimize perioperative care for surgical patients with diagnosed and undiagnosed OSA? The American Society of Anesthesiologist published guidelines for perioperative management of patients with OSA in 2006. Since then, the ASPM published guidelines for monitoring opioid induced sedation in 2011 and in 2012 ASPAN published practice recommendation for obstructive sleep apnea in the adult patient. Various literature has been published on implementing these guidelines. <h3>Methods/Evidence</h3> Initial data showed patients with oxygen desaturation less than 92%, had STOPBANG scores of 4-8 52%. A pre-survey was distributed to nurses working in the pre-op and post-op area to assess their knowledge of OSA, OSA risk identification, and interventions to initiate with OSA and at-risk populations. Education was then given regarding identification of undiagnosed sleep apnea, recognition of post-operative hypoventilation and apneic events, and implementation of enhanced monitoring and nursing interventions. OSA screening information was added to electronic documentation, including assessments of at home CPAP/BiPAP use. A literature review identified post-anesthesia patient education points for patient diagnosed with or at risk for OSA. Educational points were incorporated into discharge teaching and discharge documents. A post survey was completed. <h3>Significance of Findings/Outcomes</h3> The initial desaturation data was thought to be skewed as nurses were unwilling to document low saturations on their patients, waiting to document until the patient was encouraged to take deep breaths, repositioned the airway, or provided other interventions. <h3>Implications for perianesthesia nurses and future research</h3> Encourage frontline nurses to recognize the significance of respiratory compromise and improve quality of care with resources and increased knowledge of interventions.

Low-Dose Ketamine Infusion for Perioperative Pain Management in Patients Undergoing Laparoscopic Gastric Bypass: A Prospective Randomized Controlled Trial.

Introduction Obesity is a common comorbidity seen in the perioperative setting and is associated with many diseases including cardiovascular disease and obstructive sleep apnea. Laparoscopic Roux-en-Y gastric bypass is the gold standard surgical treatment for patients whose weight is refractory to diet and exercise. Caring for these patients perioperatively presents unique challenges to anesthesiologists and is associated with an increased risk of adverse respiratory events. In our study, we hypothesize that a low-dose perioperative ketamine infusion will reduce opioid consumption and improve analgesia when compared to standard therapy. Methods This is a single-center, prospective randomized controlled study enrolling 35 patients in total. Patients were randomized equally into the ketamine and control group. Preop, intraop, and postop management regimens were standardized. The ketamine group received a 0.3 mg/kg ideal body weight ketamine bolus after induction followed by a 0.2 mg/kg/hr ketamine infusion continued into the postop setting for up to 24 hours. Data collected included total perioperative opioids used converted to oral morphine equivalents (ME), pain scores, side effects, hospital length of stay, and patient satisfaction captured via postoperative questionnaires. Results The use of perioperative opioid consumption was significantly lower in the ketamine group when compared with the control group (179.9 ME versus 248.7 ME, P=0.03). There was no statistically significant difference in pain scores or hospital length of stay postoperatively between the two groups. There were also no reported adverse respiratory events, prolonged sedation, agitation, or other side effects reported in either group. The patient satisfaction questionnaires showed a significant difference with the ketamine group reporting lower maximum pain scores, a decrease in how pain limited activities of daily living once discharged, and increased hospital pain management satisfaction scores. Conclusions Perioperative low-dose ketamine infusions significantly reduced opioid consumption in morbidly obese patients undergoing laparoscopic gastric bypass surgery.

Identification of the risk factors in perioperative respiratory adverse events in children under general anesthesia and the development of a predictive model.

BackgroundThis study explored the risk factors of perioperative respiratory adverse events in children under 12 years old undergoing general anesthesia surgery. A prediction model was constructed according to the related risk factors to provide a basis for timely clinical intervention and decision-making.MethodsChildren under 12 years old who underwent general anesthesia in our hospital between January 2016 and December 2020 were included in this study. The clinical data, including age, gender, weight, American Society of Anesthesiologists (ASA) grade classification, operation season, preoperative hospital stay, anesthesia time, and postoperative pain score, were collated. Continuous variables were converted to categorical variables. Logistic regression analysis was used to screen independent risk factors and a nomogram was constructed to predict the probability of adverse events. Fitting curves and receiver operating characteristic (ROC) curves were utilized to verify the model.ResultsLogistic regression analyses demonstrated that age [odds ratio (OR) =1.32, 95% confidence interval (CI): 1.08 to 1.49], body weight (OR =1.49, 95% CI: 1.21 to 1.84), anesthesia time (OR =1.61, 95% CI: 1.32 to 1.78), and surgery season (OR =1.12, 95% CI: 1.07 to 1.39) were independent risk factors for respiratory adverse events in children undergoing general anesthesia (P<0.05). The risk of respiratory-related adverse events increased in children with grade II ASA classification compared to children with grade I ASA classification (P<0.05). Similarly, the risk of respiratory adverse events increased in children with level III pain scores compared to children with level I pain scores (P<0.05). The calibration curve showed that the predicted curve was consistent with the actual curve. The area under the ROC curve (AUC) was 0.707, indicating that model showed great predictive ability.ConclusionsAge, weight, anesthesia time, operation season, ASA grade, and pain score were identified as independent risk factors for respiratory adverse events in children undergoing general anesthesia. Using the above risk factors, a nomogram was established to predict the risk of respiratory system-related adverse events. The predicted results were highly consistent with the actual risk, and the false positive rate was within a reasonable range.

Reducing pediatric exposure to environmental tobacco smoke: The effects of pediatric exposure to environmental tobacco smoke and the role of pediatric perioperative care.

Exposure to environmental tobacco smoke (ETS) has deleterious effects on a child's general health and their perioperative risk; specifically, it doubles a child's perioperative risk of adverse respiratory events, particularly laryngospasm. It increases the risk of sudden infant death syndrome, bacterial meningitis, middle ear infection, asthma, and lower respiratory tract infection. The preoperative assessment of children presenting for procedures under general anesthesia is an opportune moment to screen for exposure to ETS and give information about the risks and cessation support (if applicable). This can be described as a "teachable moment"; there is a documented need for this public health education and it aligns with the NHS Long Term Plan, aiming to embed public health information into every consultation a patient or family has with a healthcare practitioner. The period preceding and following surgery is a time when patients or their families are motivated to make a behavioral change. It has been shown that parents who smoke are more likely to attempt smoking cessation if their child has had recent surgery but not to maintain their abstinence; however, we know that subsequent quit attempts increase the likelihood that a smoker will succeed in permanently abstaining so aiming for a quit attempt rather than permanent abstinence is a valid aim. A suggested screening method would be to firstly ask all parents or carers in the preoperative health screening questionnaire about their child's exposure to ETS, accepting this lacks both the sensitivity and specificity of a valid screening tool. This can be augmented by measuring exhaled carbon monoxide in any child who is able to comply with the test; exhaled carbon monoxide has been shown to be a valid screening tool for exposure to ETS in adolescents but not children under 12years of age, perhaps because smaller children may not be able to cooperate with the test which requires a vital capacity maneuver to provide an adequate endtidal sample. A suggested model for smoking cessation intervention is called Very Brief Advice and comprises three parts: Ask about a child's exposure to ETS with/without exhaled carbon monoxide measurement Advise about the risks to the child's general and perioperative health and the health of the smoker and wider family plus the benefits of smoking cessation Act on the response by referring to local smoking cessation support. Referral to local smoking cessation services should be along established pathways. Thus, recording a household smoking status and referring to local smoking cessation services targets a public health measure with benefits beyond the individual patient and planned anesthetic. There is no evidence in the literature of the effect of environmental exposure to electronic cigarettes ("vaping") on a child's perioperative health. Further research is needed to establish if preoperative reduction in or removal from exposure to ETS reduces the risk of respiratory adverse events in the child.

Think Before You Administer: Is Routine Benzodiazepine Premedication Before Endoscopy in Adults Necessary?

Think Before You Administer: Is Routine Benzodiazepine Premedication Before Endoscopy in Adults Necessary?

Airway management and perioperative adverse events in children with mucopolysaccharidoses and mucolipidoses: A retrospective cohort study.

Children suffering from mucopolysaccharidoses (subtypes I, II, III, IV, VI, and VII) or mucolipidoses often require anesthesia, but are at high risk for perioperative adverse events. However, the impact of the disease subtype and the standard of care for airway management are still unclear. This study aimed to assess independent risk factors for perioperative adverse events in individuals with mucopolysaccharidoses/mucolipidoses and to analyze the interaction with the primary airway technique implemented. This retrospective study included individuals with mucopolysaccharidoses/mucolipidoses who underwent anesthesia at two high-volume centers from 2002 to 2016. The data were analyzed in a multivariate hierarchical model, accounting for repeated anesthesia procedures within the same patient and for multiple events within a single anesthesia. Of 141 identified inpatients, 67 (63 mucopolysaccharidoses and 4 mucolipidoses) underwent 269 anesthesia procedures (study cases) for 353 surgical or diagnostic interventions. At least one perioperative adverse event occurred in 25.6% of the cases. The risk for perioperative adverse events was higher in mucopolysaccharidoses type I (OR 8.0 [1.5-42.7]; P=.014) or type II (OR 8.8 [1.3-58.6]; P=.025) than in type III. Fiberoptic intubation through a supraglottic airway was associated with the lowest risk for perioperative adverse events and lowest conversion rate. Direct laryngoscopy was associated with a significantly higher risk for airway management problems than indirect techniques (estimated event rates 47.8% vs 10.1%, OR 24.05 [5.20-111.24]; P<.001). The risk for respiratory adverse events was significantly higher for supraglottic airway (22.6%; OR 31.53 [2.79-355.88]; P=.001) and direct laryngoscopy (14.8%; OR 14.70 [1.32-163.44]; P=.029) than for fiberoptic intubation through a supraglottic airway (2.1%). The disease subtype and primary airway technique were the most important independent risk factors for perioperative adverse events. Our findings indicate that in MPS/ML children with predicted difficult airway indirect techniques should be favored for the first tracheal intubation attempt.

The mask or the needle? Which induction should we go for?

This review summarizes the current evidence available to guide anaesthetists along the decision-making process between inhalational and intravenous anaesthesia when caring for paediatric patients. A recent large randomized controlled trial in children with risk factors demonstrated a significant benefit of intravenous induction over inhalational induction with regards to respiratory adverse events. This difference is particularly pronounced in those with respiratory symptoms. For children scheduled for elective surgery, intravenous induction has significant advantages with regards to reduced respiratory adverse events and for less postoperative behavioural disturbances, it may be associated with more anxiety at the time of induction. The anaesthetist in charge of the patient needs to weigh up the balance between the clinical risk of respiratory adverse events, the 'veins on offer', the level of anxiety and previous experiences of the child and his/her parents.