Feasibility and pharmacokinetics of caudal blockade in children and adolescents with 30–50 kg of body weight

Summary

Background

Caudal blockade, although an important technique of pediatric regional anesthesia, is rarely used in children heavier than 30 kg. This reservation is due to anatomical concerns and lack of pharmacokinetic data. We therefore set out to evaluate, in pediatric patients weighing 30−50 kg, the feasibility of ultrasound-guided caudal blockade and the pharmacokinetics of caudally administered ropivacaine.

Methods

Twenty consecutive children were included. General anesthesia was used to ensure a secured airway. For the caudal punctures, we applied the same clinical standards as in smaller children, administering ropivacaine 3.1 mg·ml^-1 for a volume of 1 ml·kg⁻¹ via ultrasound guidance. Pharmacokinetic analysis was based on total plasma ropivacaine levels and included maximum concentration (C_max), time to C_max (t_max), terminal elimination half-life, area under the concentration–time curve for the 4-h sampling period, apparent total body clearance, and apparent volume of distribution.

Results

In all 19 cases of successful puncture, we identified the relevant anatomical structures (sacral cornua, sacral hiatus, dura mater) and verified correct administration of the local anesthetic by visualizing its cranial spread. Surgical blockade was successful in 18 of 20 cases (90%; one puncture was technically not possible and one child received intraoperatively 50 μg fentanyl). The pharmacokinetic profile of the administered ropivacaine 3.1 mg·ml⁻¹ indicated plasma levels within safe ranges in pediatric patients weighing 30−50 kg.

Conclusions

Based on our pharmacodynamic and pharmacokinetic results, we suggest that the body weight of 50 kg it is feasible to perform effective and safe caudal blockade in children up to 50 kg body weight.

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Early childhood exposure to short periods of sevoflurane is not associated with later, lasting cognitive deficits

Summary

Background

A detrimental effect of commonly used anesthetics on the neurodevelopmental and behavioral parameters has long been shown in young animals subjected to early childhood anesthesia. Epidemiologic studies suggest the possibility of a modestly elevated risk of adverse neurodevelopmental outcomes in children exposed to anesthesia during early childhood. However, these results are still preliminary and inconclusive.

Aim

To further elucidate the probability of occurrence of such adverse outcomes, we evaluated cognitive performance of children who underwent general anesthesia early in their childhood.

Method

One hundred and fifteen children aged 5‒16 years with established glaucoma were included in the study. Of these, 68 children had a history of at least one general anesthesia with sevoflurane before age 3. Phonemic and semantic verbal fluency, and forward and backward digit span tests were performed to evaluate cognitive function in the study subjects.

Results

The two-way anova revealed that all these variables showed significant changes in various age groups, but they were comparable among subjects with no, single, or multiple childhood anesthesia.

Conclusion

It can be concluded that brief periods of anesthesia with single anesthetic sevoflurane may be safe for children under age 3.

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Pain after discharge following head and neck surgery in children

Summary

Background

It is well established that children experience significant pain for a considerable period following adenotonsillectomy. Less is known, however, about pain following other common head and neck operations.

Aim

The aim of this study was to describe the severity and duration of postoperative pain experienced by children undergoing elective head and neck procedures (primary outcomes). Behavioral disturbance, nausea and vomiting, parental satisfaction, and medical reattendance rates were also measured (secondary outcomes).

Method

Parents of children (0–18 years) undergoing common head and neck operations were invited to participate. Pain scores on the day of surgery and each day post discharge were collected via multiple telephone interviews. Data collected included pain levels, analgesia prescribed and given, behavioral disturbance rates, and nausea and vomiting scores. Follow-up was continued until pain resolved.

Results

Two hundred and fifty-one patients were analyzed (50 adenoidectomy, 51 adenotonsillectomy, 19 myringoplasty, 52 myringotomy, 43 strabismus, and 36 tongue tie divisions). On the day of surgery myringoplasty, strabismus surgery, and adenotonsillectomy patients on average had moderate pain, whereas adenoidectomy, tongue tie, and myringotomy patients had mild pain. Adenotonsillectomy patients continued to have moderate pain for several days with pain lasting on average 9 days. From day 1 postoperatively mild pain was experienced in the other surgical groups with the average duration of pain varying from 1 to 3 days depending on the surgery performed. Frequency of behavioral issues closely followed pain scores for each group. Analgesic prescribing and regimes at home varied widely, both within and between the different surgical groups. Rates of nausea and vomiting following discharge were low in all groups. The overall unplanned medical reattendance rate was 16%.

Conclusion

Adenotonsillectomy patients represent the biggest challenge in postoperative pain management of the head and neck surgeries evaluated. The low rates of pain, nausea, and vomiting reported in the days following surgery for the other procedures suggests that children can be cared for at home with simple analgesia. Discharge information and analgesia prescribing on discharge should be tailored to the operation performed.

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The Paradox of Painless Periodontal Disease

Abstract

Periodontal diseases, primarily gingivitis and periodontitis, are characterised by progressive inflammation and tissue destruction. However, they are unusual in that they are not also accompanied by the pain commonly seen in other inflammatory conditions. This suggests that interactions between periodontal bacteria and host cells create a unique environment in which the pro-algesic effects of inflammatory mediators and factors released during tissue damage are directly or indirectly inhibited. In this review we summarise the evidence that periodontal disease is characterised by an accumulation of classically pro-algesic factors from bacteria and host cells. We then discuss several mechanisms by which inflammatory sensitisation of nociceptive fibres could be prevented through inactivation or inhibition of these factors. Further studies are necessary to fully understand the molecular processes underlying the endogenous localised hypoalgesia in human periodontal disease. This knowledge might provide a rational basis to develop future therapeutic interventions, such as host modulation therapies, against a wide variety of other human pain conditions.

This article is protected by copyright. All rights reserved.

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Invited Commentary: PET-CT Surveillance versus Neck Dissection in Advanced Head and Neck Cancer

Abstract

Squamous cell carcinoma of the head and neck region (HNSCC) including oral cavity, oropharynx, larynx and hypopharynx is the 6^th most common cancer in the world. In 2012, 690.000 new cases of head neck cancer were diagnosed worldwide thus accounting for 4.9% of all malignant tumors (Braakhuis et al., 2014). Recent estimates showed 100.000 new cases of cancer of the oral cavity and the pharynx in Europe every year (Ferlay et al., 2013).

This article is protected by copyright. All rights reserved.

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BacterioFiles 259 - Fluke Froth Fosters Fester Fixing

This episode: I converse with Dr. Michael Smout about a liver fluke parasite could help heal chronic wounds more quickly!

(13.4 MB, 14.6 minutes)

Show notes: 

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BacterioFiles 259 - Fluke Froth Fosters Fester Fixing

This episode: I converse with Dr. Michael Smout about a liver fluke parasite could help heal chronic wounds more quickly!

(13.4 MB, 14.6 minutes)

Show notes: 

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BacterioFiles 259 - Fluke Froth Fosters Fester Fixing

This episode: I converse with Dr. Michael Smout about a liver fluke parasite could help heal chronic wounds more quickly!

(13.4 MB, 14.6 minutes)

Show notes: 

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Pain after discharge following head and neck surgery in children

Summary

Background

It is well established that children experience significant pain for a considerable period following adenotonsillectomy. Less is known, however, about pain following other common head and neck operations.

Aim

The aim of this study was to describe the severity and duration of postoperative pain experienced by children undergoing elective head and neck procedures (primary outcomes). Behavioral disturbance, nausea and vomiting, parental satisfaction, and medical reattendance rates were also measured (secondary outcomes).

Method

Parents of children (0–18 years) undergoing common head and neck operations were invited to participate. Pain scores on the day of surgery and each day post discharge were collected via multiple telephone interviews. Data collected included pain levels, analgesia prescribed and given, behavioral disturbance rates, and nausea and vomiting scores. Follow-up was continued until pain resolved.

Results

Two hundred and fifty-one patients were analyzed (50 adenoidectomy, 51 adenotonsillectomy, 19 myringoplasty, 52 myringotomy, 43 strabismus, and 36 tongue tie divisions). On the day of surgery myringoplasty, strabismus surgery, and adenotonsillectomy patients on average had moderate pain, whereas adenoidectomy, tongue tie, and myringotomy patients had mild pain. Adenotonsillectomy patients continued to have moderate pain for several days with pain lasting on average 9 days. From day 1 postoperatively mild pain was experienced in the other surgical groups with the average duration of pain varying from 1 to 3 days depending on the surgery performed. Frequency of behavioral issues closely followed pain scores for each group. Analgesic prescribing and regimes at home varied widely, both within and between the different surgical groups. Rates of nausea and vomiting following discharge were low in all groups. The overall unplanned medical reattendance rate was 16%.

Conclusion

Adenotonsillectomy patients represent the biggest challenge in postoperative pain management of the head and neck surgeries evaluated. The low rates of pain, nausea, and vomiting reported in the days following surgery for the other procedures suggests that children can be cared for at home with simple analgesia. Discharge information and analgesia prescribing on discharge should be tailored to the operation performed.

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Feasibility and pharmacokinetics of caudal blockade in children and adolescents with 30–50 kg of body weight

Summary

Background

Caudal blockade, although an important technique of pediatric regional anesthesia, is rarely used in children heavier than 30 kg. This reservation is due to anatomical concerns and lack of pharmacokinetic data. We therefore set out to evaluate, in pediatric patients weighing 30−50 kg, the feasibility of ultrasound-guided caudal blockade and the pharmacokinetics of caudally administered ropivacaine.

Methods

Twenty consecutive children were included. General anesthesia was used to ensure a secured airway. For the caudal punctures, we applied the same clinical standards as in smaller children, administering ropivacaine 3.1 mg·ml^-1 for a volume of 1 ml·kg⁻¹ via ultrasound guidance. Pharmacokinetic analysis was based on total plasma ropivacaine levels and included maximum concentration (C_max), time to C_max (t_max), terminal elimination half-life, area under the concentration–time curve for the 4-h sampling period, apparent total body clearance, and apparent volume of distribution.

Results

In all 19 cases of successful puncture, we identified the relevant anatomical structures (sacral cornua, sacral hiatus, dura mater) and verified correct administration of the local anesthetic by visualizing its cranial spread. Surgical blockade was successful in 18 of 20 cases (90%; one puncture was technically not possible and one child received intraoperatively 50 μg fentanyl). The pharmacokinetic profile of the administered ropivacaine 3.1 mg·ml⁻¹ indicated plasma levels within safe ranges in pediatric patients weighing 30−50 kg.

Conclusions

Based on our pharmacodynamic and pharmacokinetic results, we suggest that the body weight of 50 kg it is feasible to perform effective and safe caudal blockade in children up to 50 kg body weight.

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Chemoselective Transesterification of Acrylate Derivatives for Functionalized Monomer Synthesis Using a Hard Zinc Alkoxide Generation Strategy

A new practical method for the synthesis of functionalized acrylate derivatives with the view to prepare functional polymers was explored. Hard zinc alkoxide generation enabled the highly chemoselective transesterification of acrylate derivatives over the undesired conjugate addition, which caused polymerization. The combined use of the catalytic zinc cluster Zn₄(OCOCF₃)₆O and 4-(dimethylamino)pyridine delivered various functionalized acrylate derivatives through the transesterification of commercially available methyl acrylate derivatives with functionalized alcohols under mild conditions.

We develop a highly chemoselective transesterification of acrylate derivatives by using a hard zinc alkoxide generation strategy. High functional group compatibility, including the hydrophilic ether functionality, clearly demonstrates the utility of the present zinc catalysis for the synthesis of functionalized monomers.

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An Efficient Multi-Component Synthesis of Highly Functionalized Calix[4]arenes with Pronounced Binding Affinity toward β-Lactoglobulin

A facile and convenient approach for the synthesis of multi-functionalized calix[4]arenes through multi-component reactions is described. A series of five new calix[4]arene-hexaamide derivatives were synthesized, and their structures were elucidated by means of spectroscopic data. The value of this method lies in its operational simplicity, mild reaction conditions, structural diversity of products, and good yields. Furthermore, fluorescence studies demonstrated considerable binding affinity of these new calix[4]arenes toward β-lactoglobulin protein.

A new class of highly functionalized calix[4]arenes was synthesized by multi-component reactions in good yields (70–86 %). Protein-binding studies carried out with fluorescence spectroscopy revealed that these compounds bind strongly to β-lactoglobulin.

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FRET Pairs with Fixed Relative Orientation of Chromophores

Synthetic routes to different oligospirothioketal (OSTK) Förster resonance energy transfer (FRET) constructs are described and the photophysics of these constructs were explored in different solvents. The FRET efficiencies were determined from the experimental data and compared with theoretical values. The influence of the outstanding rigidity of the novel OSTK compounds on the FRET is discussed.

FRET pairs with a fixed relative orientation of chromophores have been synthesized by combining fluorophores with oligospirothioketal (OSTK) rods. Their photophysical properties have been investigated and are described herein.

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Early childhood exposure to short periods of sevoflurane is not associated with later, lasting cognitive deficits

Summary

Background

A detrimental effect of commonly used anesthetics on the neurodevelopmental and behavioral parameters has long been shown in young animals subjected to early childhood anesthesia. Epidemiologic studies suggest the possibility of a modestly elevated risk of adverse neurodevelopmental outcomes in children exposed to anesthesia during early childhood. However, these results are still preliminary and inconclusive.

Aim

To further elucidate the probability of occurrence of such adverse outcomes, we evaluated cognitive performance of children who underwent general anesthesia early in their childhood.

Method

One hundred and fifteen children aged 5‒16 years with established glaucoma were included in the study. Of these, 68 children had a history of at least one general anesthesia with sevoflurane before age 3. Phonemic and semantic verbal fluency, and forward and backward digit span tests were performed to evaluate cognitive function in the study subjects.

Results

The two-way anova revealed that all these variables showed significant changes in various age groups, but they were comparable among subjects with no, single, or multiple childhood anesthesia.

Conclusion

It can be concluded that brief periods of anesthesia with single anesthetic sevoflurane may be safe for children under age 3.

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Perioperative morbidity in children with elastin arteriopathy

Summary

Background

Children with elastin arteriopathy (EA), the majority of whom have Williams–Beuren syndrome, are at high risk for sudden death. Case reports suggest that the risk of perioperative cardiac arrest and death is high, but none have reported the frequency or risk factors for morbidity and mortality in an entire cohort of children with EA undergoing anesthesia.

Aim

The aim of this study was to present one institution's rate of morbidity and mortality in all children with EA undergoing anesthesia and to examine patient characteristics that pose the greatest risk.

Methods

We reviewed medical records of children with EA who underwent anesthesia or sedation for any procedure at our institution from 1990 to 2013. Cardiovascular hemodynamic indices from recent cardiac catheterization or echocardiography were tabulated for each child. The incidence, type, and associated factors of complications occurring intraoperatively through 48 h postoperatively were examined.

Results

Forty-eight patients with confirmed EA underwent a total of 141 anesthetics. There were seven cardiac arrests (15% of patients, 5% of anesthetics) and nine additional intraoperative cardiovascular complications (15% of patients, 6% of anesthetics). Extracorporeal life support was initiated in five cases. There were no perioperative deaths. All children having a cardiac arrest or complication were <3 years old and had biventricular outflow tract obstruction (BVOTO). Subgroup analysis demonstrated high rates of cardiac arrest in two groups: children with BVOTO (44%) and age <3 years old (21%).

Conclusions

We have confirmed that the rate of cardiac arrest and complications is significantly elevated in children with EA undergoing anesthesia. Children <3 years old and with BVOTO were at the greatest risk in our population.

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Respiratory depression detected by capnography among children in the postanesthesia care unit: a cross-sectional study

Summary

Background

Children are at risk for respiratory depression while recovering from anesthesia. Currently, monitoring children in the postanesthesia care unit (PACU) with pulse oximetry is recommended. However, pulse oximetry does not reliably recognize hypoventilation or apnea, particularly in the presence of supplemental oxygen. Capnography is a sensitive monitor of ventilation that is not often used in the PACU.

Aim

To determine the frequency of hypoventilation and apnea as detected by capnography among children in the PACU.

Methods

In a cross-sectional study, capnography monitoring was applied to healthy children of age 1–17 years in the PACU of a tertiary care hospital. Staff was blinded to the capnography monitor; alarms were disabled. Staff provided routine care and monitoring with pulse oximetry to all patients. Vital signs, patient interventions, and medication administration were recorded by a research assistant every 30 s until all monitoring was discontinued by staff. Outcome measures included frequency of hypoventilation and apnea as measured by capnography and oxygen desaturations as measured by pulse oximetry, as well as staff interventions for these events.

Results

Data from 194 children were analyzed. Capnography detected hypoventilation or apnea in 45.5% (95% CI 38.5%, 52.5%) of patients. Oxygen desaturations occurred in 19% (95% CI 13%, 24%) of patients. Interventions occurred in 9% (95% CI 5%, 13%) of patients. Patients who received narcotic medications were more likely to experience hypoventilation (OR 2.3, 95% CI 1.02, 5.3) and apnea (OR 2.7, 95% CI 1.1, 7). Hypoventilation was seen more often among children who received supplemental oxygen (OR 3.1, 95% CI 1.1, 12).

Conclusions

Hypoventilation and apnea are common among children in the PACU; however, few interventions occur to address these events. Routine monitoring with capnography may improve recognition of respiratory depression and enhance patient safety in the PACU.

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An Efficient Multi-Component Synthesis of Highly Functionalized Calix[4]arenes with Pronounced Binding Affinity toward β-Lactoglobulin

A facile and convenient approach for the synthesis of multi-functionalized calix[4]arenes through multi-component reactions is described. A series of five new calix[4]arene-hexaamide derivatives were synthesized, and their structures were elucidated by means of spectroscopic data. The value of this method lies in its operational simplicity, mild reaction conditions, structural diversity of products, and good yields. Furthermore, fluorescence studies demonstrated considerable binding affinity of these new calix[4]arenes toward β-lactoglobulin protein.

A new class of highly functionalized calix[4]arenes was synthesized by multi-component reactions in good yields (70–86 %). Protein-binding studies carried out with fluorescence spectroscopy revealed that these compounds bind strongly to β-lactoglobulin.

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Chemoselective Transesterification of Acrylate Derivatives for Functionalized Monomer Synthesis Using a Hard Zinc Alkoxide Generation Strategy

A new practical method for the synthesis of functionalized acrylate derivatives with the view to prepare functional polymers was explored. Hard zinc alkoxide generation enabled the highly chemoselective transesterification of acrylate derivatives over the undesired conjugate addition, which caused polymerization. The combined use of the catalytic zinc cluster Zn₄(OCOCF₃)₆O and 4-(dimethylamino)pyridine delivered various functionalized acrylate derivatives through the transesterification of commercially available methyl acrylate derivatives with functionalized alcohols under mild conditions.

We develop a highly chemoselective transesterification of acrylate derivatives by using a hard zinc alkoxide generation strategy. High functional group compatibility, including the hydrophilic ether functionality, clearly demonstrates the utility of the present zinc catalysis for the synthesis of functionalized monomers.

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FRET Pairs with Fixed Relative Orientation of Chromophores

Synthetic routes to different oligospirothioketal (OSTK) Förster resonance energy transfer (FRET) constructs are described and the photophysics of these constructs were explored in different solvents. The FRET efficiencies were determined from the experimental data and compared with theoretical values. The influence of the outstanding rigidity of the novel OSTK compounds on the FRET is discussed.

FRET pairs with a fixed relative orientation of chromophores have been synthesized by combining fluorophores with oligospirothioketal (OSTK) rods. Their photophysical properties have been investigated and are described herein.

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Perioperative morbidity in children with elastin arteriopathy

Summary

Background

Children with elastin arteriopathy (EA), the majority of whom have Williams–Beuren syndrome, are at high risk for sudden death. Case reports suggest that the risk of perioperative cardiac arrest and death is high, but none have reported the frequency or risk factors for morbidity and mortality in an entire cohort of children with EA undergoing anesthesia.

Aim

The aim of this study was to present one institution's rate of morbidity and mortality in all children with EA undergoing anesthesia and to examine patient characteristics that pose the greatest risk.

Methods

We reviewed medical records of children with EA who underwent anesthesia or sedation for any procedure at our institution from 1990 to 2013. Cardiovascular hemodynamic indices from recent cardiac catheterization or echocardiography were tabulated for each child. The incidence, type, and associated factors of complications occurring intraoperatively through 48 h postoperatively were examined.

Results

Forty-eight patients with confirmed EA underwent a total of 141 anesthetics. There were seven cardiac arrests (15% of patients, 5% of anesthetics) and nine additional intraoperative cardiovascular complications (15% of patients, 6% of anesthetics). Extracorporeal life support was initiated in five cases. There were no perioperative deaths. All children having a cardiac arrest or complication were <3 years old and had biventricular outflow tract obstruction (BVOTO). Subgroup analysis demonstrated high rates of cardiac arrest in two groups: children with BVOTO (44%) and age <3 years old (21%).

Conclusions

We have confirmed that the rate of cardiac arrest and complications is significantly elevated in children with EA undergoing anesthesia. Children <3 years old and with BVOTO were at the greatest risk in our population.

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Feasibility and pharmacokinetics of caudal blockade in children and adolescents with 30–50 kg of body weight

Summary

Background

Caudal blockade, although an important technique of pediatric regional anesthesia, is rarely used in children heavier than 30 kg. This reservation is due to anatomical concerns and lack of pharmacokinetic data. We therefore set out to evaluate, in pediatric patients weighing 30−50 kg, the feasibility of ultrasound-guided caudal blockade and the pharmacokinetics of caudally administered ropivacaine.

Methods

Twenty consecutive children were included. General anesthesia was used to ensure a secured airway. For the caudal punctures, we applied the same clinical standards as in smaller children, administering ropivacaine 3.1 mg·ml^-1 for a volume of 1 ml·kg⁻¹ via ultrasound guidance. Pharmacokinetic analysis was based on total plasma ropivacaine levels and included maximum concentration (C_max), time to C_max (t_max), terminal elimination half-life, area under the concentration–time curve for the 4-h sampling period, apparent total body clearance, and apparent volume of distribution.

Results

In all 19 cases of successful puncture, we identified the relevant anatomical structures (sacral cornua, sacral hiatus, dura mater) and verified correct administration of the local anesthetic by visualizing its cranial spread. Surgical blockade was successful in 18 of 20 cases (90%; one puncture was technically not possible and one child received intraoperatively 50 μg fentanyl). The pharmacokinetic profile of the administered ropivacaine 3.1 mg·ml⁻¹ indicated plasma levels within safe ranges in pediatric patients weighing 30−50 kg.

Conclusions

Based on our pharmacodynamic and pharmacokinetic results, we suggest that the body weight of 50 kg it is feasible to perform effective and safe caudal blockade in children up to 50 kg body weight.

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Early childhood exposure to short periods of sevoflurane is not associated with later, lasting cognitive deficits

Summary

Background

A detrimental effect of commonly used anesthetics on the neurodevelopmental and behavioral parameters has long been shown in young animals subjected to early childhood anesthesia. Epidemiologic studies suggest the possibility of a modestly elevated risk of adverse neurodevelopmental outcomes in children exposed to anesthesia during early childhood. However, these results are still preliminary and inconclusive.

Aim

To further elucidate the probability of occurrence of such adverse outcomes, we evaluated cognitive performance of children who underwent general anesthesia early in their childhood.

Method

One hundred and fifteen children aged 5‒16 years with established glaucoma were included in the study. Of these, 68 children had a history of at least one general anesthesia with sevoflurane before age 3. Phonemic and semantic verbal fluency, and forward and backward digit span tests were performed to evaluate cognitive function in the study subjects.

Results

The two-way anova revealed that all these variables showed significant changes in various age groups, but they were comparable among subjects with no, single, or multiple childhood anesthesia.

Conclusion

It can be concluded that brief periods of anesthesia with single anesthetic sevoflurane may be safe for children under age 3.

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Pain after discharge following head and neck surgery in children

Summary

Background

It is well established that children experience significant pain for a considerable period following adenotonsillectomy. Less is known, however, about pain following other common head and neck operations.

Aim

The aim of this study was to describe the severity and duration of postoperative pain experienced by children undergoing elective head and neck procedures (primary outcomes). Behavioral disturbance, nausea and vomiting, parental satisfaction, and medical reattendance rates were also measured (secondary outcomes).

Method

Parents of children (0–18 years) undergoing common head and neck operations were invited to participate. Pain scores on the day of surgery and each day post discharge were collected via multiple telephone interviews. Data collected included pain levels, analgesia prescribed and given, behavioral disturbance rates, and nausea and vomiting scores. Follow-up was continued until pain resolved.

Results

Two hundred and fifty-one patients were analyzed (50 adenoidectomy, 51 adenotonsillectomy, 19 myringoplasty, 52 myringotomy, 43 strabismus, and 36 tongue tie divisions). On the day of surgery myringoplasty, strabismus surgery, and adenotonsillectomy patients on average had moderate pain, whereas adenoidectomy, tongue tie, and myringotomy patients had mild pain. Adenotonsillectomy patients continued to have moderate pain for several days with pain lasting on average 9 days. From day 1 postoperatively mild pain was experienced in the other surgical groups with the average duration of pain varying from 1 to 3 days depending on the surgery performed. Frequency of behavioral issues closely followed pain scores for each group. Analgesic prescribing and regimes at home varied widely, both within and between the different surgical groups. Rates of nausea and vomiting following discharge were low in all groups. The overall unplanned medical reattendance rate was 16%.

Conclusion

Adenotonsillectomy patients represent the biggest challenge in postoperative pain management of the head and neck surgeries evaluated. The low rates of pain, nausea, and vomiting reported in the days following surgery for the other procedures suggests that children can be cared for at home with simple analgesia. Discharge information and analgesia prescribing on discharge should be tailored to the operation performed.

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BacterioFiles 259 - Fluke Froth Fosters Fester Fixing

This episode: I converse with Dr. Michael Smout about a liver fluke parasite could help heal chronic wounds more quickly!

(13.4 MB, 14.6 minutes)

Show notes: 

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BacterioFiles 259 - Fluke Froth Fosters Fester Fixing

This episode: I converse with Dr. Michael Smout about a liver fluke parasite could help heal chronic wounds more quickly!

(13.4 MB, 14.6 minutes)

Show notes: 

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BacterioFiles 259 - Fluke Froth Fosters Fester Fixing

This episode: I converse with Dr. Michael Smout about a liver fluke parasite could help heal chronic wounds more quickly!

(13.4 MB, 14.6 minutes)

Show notes: 

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Pain after discharge following head and neck surgery in children

Summary

Background

It is well established that children experience significant pain for a considerable period following adenotonsillectomy. Less is known, however, about pain following other common head and neck operations.

Aim

The aim of this study was to describe the severity and duration of postoperative pain experienced by children undergoing elective head and neck procedures (primary outcomes). Behavioral disturbance, nausea and vomiting, parental satisfaction, and medical reattendance rates were also measured (secondary outcomes).

Method

Parents of children (0–18 years) undergoing common head and neck operations were invited to participate. Pain scores on the day of surgery and each day post discharge were collected via multiple telephone interviews. Data collected included pain levels, analgesia prescribed and given, behavioral disturbance rates, and nausea and vomiting scores. Follow-up was continued until pain resolved.

Results

Two hundred and fifty-one patients were analyzed (50 adenoidectomy, 51 adenotonsillectomy, 19 myringoplasty, 52 myringotomy, 43 strabismus, and 36 tongue tie divisions). On the day of surgery myringoplasty, strabismus surgery, and adenotonsillectomy patients on average had moderate pain, whereas adenoidectomy, tongue tie, and myringotomy patients had mild pain. Adenotonsillectomy patients continued to have moderate pain for several days with pain lasting on average 9 days. From day 1 postoperatively mild pain was experienced in the other surgical groups with the average duration of pain varying from 1 to 3 days depending on the surgery performed. Frequency of behavioral issues closely followed pain scores for each group. Analgesic prescribing and regimes at home varied widely, both within and between the different surgical groups. Rates of nausea and vomiting following discharge were low in all groups. The overall unplanned medical reattendance rate was 16%.

Conclusion

Adenotonsillectomy patients represent the biggest challenge in postoperative pain management of the head and neck surgeries evaluated. The low rates of pain, nausea, and vomiting reported in the days following surgery for the other procedures suggests that children can be cared for at home with simple analgesia. Discharge information and analgesia prescribing on discharge should be tailored to the operation performed.

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Feasibility and pharmacokinetics of caudal blockade in children and adolescents with 30–50 kg of body weight

Summary

Background

Caudal blockade, although an important technique of pediatric regional anesthesia, is rarely used in children heavier than 30 kg. This reservation is due to anatomical concerns and lack of pharmacokinetic data. We therefore set out to evaluate, in pediatric patients weighing 30−50 kg, the feasibility of ultrasound-guided caudal blockade and the pharmacokinetics of caudally administered ropivacaine.

Methods

Twenty consecutive children were included. General anesthesia was used to ensure a secured airway. For the caudal punctures, we applied the same clinical standards as in smaller children, administering ropivacaine 3.1 mg·ml^-1 for a volume of 1 ml·kg⁻¹ via ultrasound guidance. Pharmacokinetic analysis was based on total plasma ropivacaine levels and included maximum concentration (C_max), time to C_max (t_max), terminal elimination half-life, area under the concentration–time curve for the 4-h sampling period, apparent total body clearance, and apparent volume of distribution.

Results

In all 19 cases of successful puncture, we identified the relevant anatomical structures (sacral cornua, sacral hiatus, dura mater) and verified correct administration of the local anesthetic by visualizing its cranial spread. Surgical blockade was successful in 18 of 20 cases (90%; one puncture was technically not possible and one child received intraoperatively 50 μg fentanyl). The pharmacokinetic profile of the administered ropivacaine 3.1 mg·ml⁻¹ indicated plasma levels within safe ranges in pediatric patients weighing 30−50 kg.

Conclusions

Based on our pharmacodynamic and pharmacokinetic results, we suggest that the body weight of 50 kg it is feasible to perform effective and safe caudal blockade in children up to 50 kg body weight.

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Chemoselective Transesterification of Acrylate Derivatives for Functionalized Monomer Synthesis Using a Hard Zinc Alkoxide Generation Strategy

A new practical method for the synthesis of functionalized acrylate derivatives with the view to prepare functional polymers was explored. Hard zinc alkoxide generation enabled the highly chemoselective transesterification of acrylate derivatives over the undesired conjugate addition, which caused polymerization. The combined use of the catalytic zinc cluster Zn₄(OCOCF₃)₆O and 4-(dimethylamino)pyridine delivered various functionalized acrylate derivatives through the transesterification of commercially available methyl acrylate derivatives with functionalized alcohols under mild conditions.

We develop a highly chemoselective transesterification of acrylate derivatives by using a hard zinc alkoxide generation strategy. High functional group compatibility, including the hydrophilic ether functionality, clearly demonstrates the utility of the present zinc catalysis for the synthesis of functionalized monomers.

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An Efficient Multi-Component Synthesis of Highly Functionalized Calix[4]arenes with Pronounced Binding Affinity toward β-Lactoglobulin

A facile and convenient approach for the synthesis of multi-functionalized calix[4]arenes through multi-component reactions is described. A series of five new calix[4]arene-hexaamide derivatives were synthesized, and their structures were elucidated by means of spectroscopic data. The value of this method lies in its operational simplicity, mild reaction conditions, structural diversity of products, and good yields. Furthermore, fluorescence studies demonstrated considerable binding affinity of these new calix[4]arenes toward β-lactoglobulin protein.

A new class of highly functionalized calix[4]arenes was synthesized by multi-component reactions in good yields (70–86 %). Protein-binding studies carried out with fluorescence spectroscopy revealed that these compounds bind strongly to β-lactoglobulin.

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FRET Pairs with Fixed Relative Orientation of Chromophores

Synthetic routes to different oligospirothioketal (OSTK) Förster resonance energy transfer (FRET) constructs are described and the photophysics of these constructs were explored in different solvents. The FRET efficiencies were determined from the experimental data and compared with theoretical values. The influence of the outstanding rigidity of the novel OSTK compounds on the FRET is discussed.

FRET pairs with a fixed relative orientation of chromophores have been synthesized by combining fluorophores with oligospirothioketal (OSTK) rods. Their photophysical properties have been investigated and are described herein.

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Early childhood exposure to short periods of sevoflurane is not associated with later, lasting cognitive deficits

Summary

Background

A detrimental effect of commonly used anesthetics on the neurodevelopmental and behavioral parameters has long been shown in young animals subjected to early childhood anesthesia. Epidemiologic studies suggest the possibility of a modestly elevated risk of adverse neurodevelopmental outcomes in children exposed to anesthesia during early childhood. However, these results are still preliminary and inconclusive.

Aim

To further elucidate the probability of occurrence of such adverse outcomes, we evaluated cognitive performance of children who underwent general anesthesia early in their childhood.

Method

One hundred and fifteen children aged 5‒16 years with established glaucoma were included in the study. Of these, 68 children had a history of at least one general anesthesia with sevoflurane before age 3. Phonemic and semantic verbal fluency, and forward and backward digit span tests were performed to evaluate cognitive function in the study subjects.

Results

The two-way anova revealed that all these variables showed significant changes in various age groups, but they were comparable among subjects with no, single, or multiple childhood anesthesia.

Conclusion

It can be concluded that brief periods of anesthesia with single anesthetic sevoflurane may be safe for children under age 3.

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Perioperative morbidity in children with elastin arteriopathy

Summary

Background

Children with elastin arteriopathy (EA), the majority of whom have Williams–Beuren syndrome, are at high risk for sudden death. Case reports suggest that the risk of perioperative cardiac arrest and death is high, but none have reported the frequency or risk factors for morbidity and mortality in an entire cohort of children with EA undergoing anesthesia.

Aim

The aim of this study was to present one institution's rate of morbidity and mortality in all children with EA undergoing anesthesia and to examine patient characteristics that pose the greatest risk.

Methods

We reviewed medical records of children with EA who underwent anesthesia or sedation for any procedure at our institution from 1990 to 2013. Cardiovascular hemodynamic indices from recent cardiac catheterization or echocardiography were tabulated for each child. The incidence, type, and associated factors of complications occurring intraoperatively through 48 h postoperatively were examined.

Results

Forty-eight patients with confirmed EA underwent a total of 141 anesthetics. There were seven cardiac arrests (15% of patients, 5% of anesthetics) and nine additional intraoperative cardiovascular complications (15% of patients, 6% of anesthetics). Extracorporeal life support was initiated in five cases. There were no perioperative deaths. All children having a cardiac arrest or complication were <3 years old and had biventricular outflow tract obstruction (BVOTO). Subgroup analysis demonstrated high rates of cardiac arrest in two groups: children with BVOTO (44%) and age <3 years old (21%).

Conclusions

We have confirmed that the rate of cardiac arrest and complications is significantly elevated in children with EA undergoing anesthesia. Children <3 years old and with BVOTO were at the greatest risk in our population.

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Respiratory depression detected by capnography among children in the postanesthesia care unit: a cross-sectional study

Summary

Background

Children are at risk for respiratory depression while recovering from anesthesia. Currently, monitoring children in the postanesthesia care unit (PACU) with pulse oximetry is recommended. However, pulse oximetry does not reliably recognize hypoventilation or apnea, particularly in the presence of supplemental oxygen. Capnography is a sensitive monitor of ventilation that is not often used in the PACU.

Aim

To determine the frequency of hypoventilation and apnea as detected by capnography among children in the PACU.

Methods

In a cross-sectional study, capnography monitoring was applied to healthy children of age 1–17 years in the PACU of a tertiary care hospital. Staff was blinded to the capnography monitor; alarms were disabled. Staff provided routine care and monitoring with pulse oximetry to all patients. Vital signs, patient interventions, and medication administration were recorded by a research assistant every 30 s until all monitoring was discontinued by staff. Outcome measures included frequency of hypoventilation and apnea as measured by capnography and oxygen desaturations as measured by pulse oximetry, as well as staff interventions for these events.

Results

Data from 194 children were analyzed. Capnography detected hypoventilation or apnea in 45.5% (95% CI 38.5%, 52.5%) of patients. Oxygen desaturations occurred in 19% (95% CI 13%, 24%) of patients. Interventions occurred in 9% (95% CI 5%, 13%) of patients. Patients who received narcotic medications were more likely to experience hypoventilation (OR 2.3, 95% CI 1.02, 5.3) and apnea (OR 2.7, 95% CI 1.1, 7). Hypoventilation was seen more often among children who received supplemental oxygen (OR 3.1, 95% CI 1.1, 12).

Conclusions

Hypoventilation and apnea are common among children in the PACU; however, few interventions occur to address these events. Routine monitoring with capnography may improve recognition of respiratory depression and enhance patient safety in the PACU.

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An Efficient Multi-Component Synthesis of Highly Functionalized Calix[4]arenes with Pronounced Binding Affinity toward β-Lactoglobulin

A facile and convenient approach for the synthesis of multi-functionalized calix[4]arenes through multi-component reactions is described. A series of five new calix[4]arene-hexaamide derivatives were synthesized, and their structures were elucidated by means of spectroscopic data. The value of this method lies in its operational simplicity, mild reaction conditions, structural diversity of products, and good yields. Furthermore, fluorescence studies demonstrated considerable binding affinity of these new calix[4]arenes toward β-lactoglobulin protein.

A new class of highly functionalized calix[4]arenes was synthesized by multi-component reactions in good yields (70–86 %). Protein-binding studies carried out with fluorescence spectroscopy revealed that these compounds bind strongly to β-lactoglobulin.

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Chemoselective Transesterification of Acrylate Derivatives for Functionalized Monomer Synthesis Using a Hard Zinc Alkoxide Generation Strategy

A new practical method for the synthesis of functionalized acrylate derivatives with the view to prepare functional polymers was explored. Hard zinc alkoxide generation enabled the highly chemoselective transesterification of acrylate derivatives over the undesired conjugate addition, which caused polymerization. The combined use of the catalytic zinc cluster Zn₄(OCOCF₃)₆O and 4-(dimethylamino)pyridine delivered various functionalized acrylate derivatives through the transesterification of commercially available methyl acrylate derivatives with functionalized alcohols under mild conditions.

We develop a highly chemoselective transesterification of acrylate derivatives by using a hard zinc alkoxide generation strategy. High functional group compatibility, including the hydrophilic ether functionality, clearly demonstrates the utility of the present zinc catalysis for the synthesis of functionalized monomers.

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FRET Pairs with Fixed Relative Orientation of Chromophores

Synthetic routes to different oligospirothioketal (OSTK) Förster resonance energy transfer (FRET) constructs are described and the photophysics of these constructs were explored in different solvents. The FRET efficiencies were determined from the experimental data and compared with theoretical values. The influence of the outstanding rigidity of the novel OSTK compounds on the FRET is discussed.

FRET pairs with a fixed relative orientation of chromophores have been synthesized by combining fluorophores with oligospirothioketal (OSTK) rods. Their photophysical properties have been investigated and are described herein.

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Perioperative morbidity in children with elastin arteriopathy

Summary

Background

Children with elastin arteriopathy (EA), the majority of whom have Williams–Beuren syndrome, are at high risk for sudden death. Case reports suggest that the risk of perioperative cardiac arrest and death is high, but none have reported the frequency or risk factors for morbidity and mortality in an entire cohort of children with EA undergoing anesthesia.

Aim

The aim of this study was to present one institution's rate of morbidity and mortality in all children with EA undergoing anesthesia and to examine patient characteristics that pose the greatest risk.

Methods

We reviewed medical records of children with EA who underwent anesthesia or sedation for any procedure at our institution from 1990 to 2013. Cardiovascular hemodynamic indices from recent cardiac catheterization or echocardiography were tabulated for each child. The incidence, type, and associated factors of complications occurring intraoperatively through 48 h postoperatively were examined.

Results

Forty-eight patients with confirmed EA underwent a total of 141 anesthetics. There were seven cardiac arrests (15% of patients, 5% of anesthetics) and nine additional intraoperative cardiovascular complications (15% of patients, 6% of anesthetics). Extracorporeal life support was initiated in five cases. There were no perioperative deaths. All children having a cardiac arrest or complication were <3 years old and had biventricular outflow tract obstruction (BVOTO). Subgroup analysis demonstrated high rates of cardiac arrest in two groups: children with BVOTO (44%) and age <3 years old (21%).

Conclusions

We have confirmed that the rate of cardiac arrest and complications is significantly elevated in children with EA undergoing anesthesia. Children <3 years old and with BVOTO were at the greatest risk in our population.

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Feasibility and pharmacokinetics of caudal blockade in children and adolescents with 30–50 kg of body weight

Summary

Background

Caudal blockade, although an important technique of pediatric regional anesthesia, is rarely used in children heavier than 30 kg. This reservation is due to anatomical concerns and lack of pharmacokinetic data. We therefore set out to evaluate, in pediatric patients weighing 30−50 kg, the feasibility of ultrasound-guided caudal blockade and the pharmacokinetics of caudally administered ropivacaine.

Methods

Twenty consecutive children were included. General anesthesia was used to ensure a secured airway. For the caudal punctures, we applied the same clinical standards as in smaller children, administering ropivacaine 3.1 mg·ml^-1 for a volume of 1 ml·kg⁻¹ via ultrasound guidance. Pharmacokinetic analysis was based on total plasma ropivacaine levels and included maximum concentration (C_max), time to C_max (t_max), terminal elimination half-life, area under the concentration–time curve for the 4-h sampling period, apparent total body clearance, and apparent volume of distribution.

Results

In all 19 cases of successful puncture, we identified the relevant anatomical structures (sacral cornua, sacral hiatus, dura mater) and verified correct administration of the local anesthetic by visualizing its cranial spread. Surgical blockade was successful in 18 of 20 cases (90%; one puncture was technically not possible and one child received intraoperatively 50 μg fentanyl). The pharmacokinetic profile of the administered ropivacaine 3.1 mg·ml⁻¹ indicated plasma levels within safe ranges in pediatric patients weighing 30−50 kg.

Conclusions

Based on our pharmacodynamic and pharmacokinetic results, we suggest that the body weight of 50 kg it is feasible to perform effective and safe caudal blockade in children up to 50 kg body weight.

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Early childhood exposure to short periods of sevoflurane is not associated with later, lasting cognitive deficits

Summary

Background

A detrimental effect of commonly used anesthetics on the neurodevelopmental and behavioral parameters has long been shown in young animals subjected to early childhood anesthesia. Epidemiologic studies suggest the possibility of a modestly elevated risk of adverse neurodevelopmental outcomes in children exposed to anesthesia during early childhood. However, these results are still preliminary and inconclusive.

Aim

To further elucidate the probability of occurrence of such adverse outcomes, we evaluated cognitive performance of children who underwent general anesthesia early in their childhood.

Method

One hundred and fifteen children aged 5‒16 years with established glaucoma were included in the study. Of these, 68 children had a history of at least one general anesthesia with sevoflurane before age 3. Phonemic and semantic verbal fluency, and forward and backward digit span tests were performed to evaluate cognitive function in the study subjects.

Results

The two-way anova revealed that all these variables showed significant changes in various age groups, but they were comparable among subjects with no, single, or multiple childhood anesthesia.

Conclusion

It can be concluded that brief periods of anesthesia with single anesthetic sevoflurane may be safe for children under age 3.

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Pain after discharge following head and neck surgery in children

Summary

Background

It is well established that children experience significant pain for a considerable period following adenotonsillectomy. Less is known, however, about pain following other common head and neck operations.

Aim

The aim of this study was to describe the severity and duration of postoperative pain experienced by children undergoing elective head and neck procedures (primary outcomes). Behavioral disturbance, nausea and vomiting, parental satisfaction, and medical reattendance rates were also measured (secondary outcomes).

Method

Parents of children (0–18 years) undergoing common head and neck operations were invited to participate. Pain scores on the day of surgery and each day post discharge were collected via multiple telephone interviews. Data collected included pain levels, analgesia prescribed and given, behavioral disturbance rates, and nausea and vomiting scores. Follow-up was continued until pain resolved.

Results

Two hundred and fifty-one patients were analyzed (50 adenoidectomy, 51 adenotonsillectomy, 19 myringoplasty, 52 myringotomy, 43 strabismus, and 36 tongue tie divisions). On the day of surgery myringoplasty, strabismus surgery, and adenotonsillectomy patients on average had moderate pain, whereas adenoidectomy, tongue tie, and myringotomy patients had mild pain. Adenotonsillectomy patients continued to have moderate pain for several days with pain lasting on average 9 days. From day 1 postoperatively mild pain was experienced in the other surgical groups with the average duration of pain varying from 1 to 3 days depending on the surgery performed. Frequency of behavioral issues closely followed pain scores for each group. Analgesic prescribing and regimes at home varied widely, both within and between the different surgical groups. Rates of nausea and vomiting following discharge were low in all groups. The overall unplanned medical reattendance rate was 16%.

Conclusion

Adenotonsillectomy patients represent the biggest challenge in postoperative pain management of the head and neck surgeries evaluated. The low rates of pain, nausea, and vomiting reported in the days following surgery for the other procedures suggests that children can be cared for at home with simple analgesia. Discharge information and analgesia prescribing on discharge should be tailored to the operation performed.

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Respiratory depression detected by capnography among children in the postanesthesia care unit: a cross-sectional study

Summary

Background

Children are at risk for respiratory depression while recovering from anesthesia. Currently, monitoring children in the postanesthesia care unit (PACU) with pulse oximetry is recommended. However, pulse oximetry does not reliably recognize hypoventilation or apnea, particularly in the presence of supplemental oxygen. Capnography is a sensitive monitor of ventilation that is not often used in the PACU.

Aim

To determine the frequency of hypoventilation and apnea as detected by capnography among children in the PACU.

Methods

In a cross-sectional study, capnography monitoring was applied to healthy children of age 1–17 years in the PACU of a tertiary care hospital. Staff was blinded to the capnography monitor; alarms were disabled. Staff provided routine care and monitoring with pulse oximetry to all patients. Vital signs, patient interventions, and medication administration were recorded by a research assistant every 30 s until all monitoring was discontinued by staff. Outcome measures included frequency of hypoventilation and apnea as measured by capnography and oxygen desaturations as measured by pulse oximetry, as well as staff interventions for these events.

Results

Data from 194 children were analyzed. Capnography detected hypoventilation or apnea in 45.5% (95% CI 38.5%, 52.5%) of patients. Oxygen desaturations occurred in 19% (95% CI 13%, 24%) of patients. Interventions occurred in 9% (95% CI 5%, 13%) of patients. Patients who received narcotic medications were more likely to experience hypoventilation (OR 2.3, 95% CI 1.02, 5.3) and apnea (OR 2.7, 95% CI 1.1, 7). Hypoventilation was seen more often among children who received supplemental oxygen (OR 3.1, 95% CI 1.1, 12).

Conclusions

Hypoventilation and apnea are common among children in the PACU; however, few interventions occur to address these events. Routine monitoring with capnography may improve recognition of respiratory depression and enhance patient safety in the PACU.

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An Efficient Multi-Component Synthesis of Highly Functionalized Calix[4]arenes with Pronounced Binding Affinity toward β-Lactoglobulin

A facile and convenient approach for the synthesis of multi-functionalized calix[4]arenes through multi-component reactions is described. A series of five new calix[4]arene-hexaamide derivatives were synthesized, and their structures were elucidated by means of spectroscopic data. The value of this method lies in its operational simplicity, mild reaction conditions, structural diversity of products, and good yields. Furthermore, fluorescence studies demonstrated considerable binding affinity of these new calix[4]arenes toward β-lactoglobulin protein.

A new class of highly functionalized calix[4]arenes was synthesized by multi-component reactions in good yields (70–86 %). Protein-binding studies carried out with fluorescence spectroscopy revealed that these compounds bind strongly to β-lactoglobulin.

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Chemoselective Transesterification of Acrylate Derivatives for Functionalized Monomer Synthesis Using a Hard Zinc Alkoxide Generation Strategy

A new practical method for the synthesis of functionalized acrylate derivatives with the view to prepare functional polymers was explored. Hard zinc alkoxide generation enabled the highly chemoselective transesterification of acrylate derivatives over the undesired conjugate addition, which caused polymerization. The combined use of the catalytic zinc cluster Zn₄(OCOCF₃)₆O and 4-(dimethylamino)pyridine delivered various functionalized acrylate derivatives through the transesterification of commercially available methyl acrylate derivatives with functionalized alcohols under mild conditions.

We develop a highly chemoselective transesterification of acrylate derivatives by using a hard zinc alkoxide generation strategy. High functional group compatibility, including the hydrophilic ether functionality, clearly demonstrates the utility of the present zinc catalysis for the synthesis of functionalized monomers.

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FRET Pairs with Fixed Relative Orientation of Chromophores

Synthetic routes to different oligospirothioketal (OSTK) Förster resonance energy transfer (FRET) constructs are described and the photophysics of these constructs were explored in different solvents. The FRET efficiencies were determined from the experimental data and compared with theoretical values. The influence of the outstanding rigidity of the novel OSTK compounds on the FRET is discussed.

FRET pairs with a fixed relative orientation of chromophores have been synthesized by combining fluorophores with oligospirothioketal (OSTK) rods. Their photophysical properties have been investigated and are described herein.

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Perioperative morbidity in children with elastin arteriopathy

Summary

Background

Children with elastin arteriopathy (EA), the majority of whom have Williams–Beuren syndrome, are at high risk for sudden death. Case reports suggest that the risk of perioperative cardiac arrest and death is high, but none have reported the frequency or risk factors for morbidity and mortality in an entire cohort of children with EA undergoing anesthesia.

Aim

The aim of this study was to present one institution's rate of morbidity and mortality in all children with EA undergoing anesthesia and to examine patient characteristics that pose the greatest risk.

Methods

We reviewed medical records of children with EA who underwent anesthesia or sedation for any procedure at our institution from 1990 to 2013. Cardiovascular hemodynamic indices from recent cardiac catheterization or echocardiography were tabulated for each child. The incidence, type, and associated factors of complications occurring intraoperatively through 48 h postoperatively were examined.

Results

Forty-eight patients with confirmed EA underwent a total of 141 anesthetics. There were seven cardiac arrests (15% of patients, 5% of anesthetics) and nine additional intraoperative cardiovascular complications (15% of patients, 6% of anesthetics). Extracorporeal life support was initiated in five cases. There were no perioperative deaths. All children having a cardiac arrest or complication were <3 years old and had biventricular outflow tract obstruction (BVOTO). Subgroup analysis demonstrated high rates of cardiac arrest in two groups: children with BVOTO (44%) and age <3 years old (21%).

Conclusions

We have confirmed that the rate of cardiac arrest and complications is significantly elevated in children with EA undergoing anesthesia. Children <3 years old and with BVOTO were at the greatest risk in our population.

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Feasibility and pharmacokinetics of caudal blockade in children and adolescents with 30–50 kg of body weight

Summary

Background

Caudal blockade, although an important technique of pediatric regional anesthesia, is rarely used in children heavier than 30 kg. This reservation is due to anatomical concerns and lack of pharmacokinetic data. We therefore set out to evaluate, in pediatric patients weighing 30−50 kg, the feasibility of ultrasound-guided caudal blockade and the pharmacokinetics of caudally administered ropivacaine.

Methods

Twenty consecutive children were included. General anesthesia was used to ensure a secured airway. For the caudal punctures, we applied the same clinical standards as in smaller children, administering ropivacaine 3.1 mg·ml^-1 for a volume of 1 ml·kg⁻¹ via ultrasound guidance. Pharmacokinetic analysis was based on total plasma ropivacaine levels and included maximum concentration (C_max), time to C_max (t_max), terminal elimination half-life, area under the concentration–time curve for the 4-h sampling period, apparent total body clearance, and apparent volume of distribution.

Results

In all 19 cases of successful puncture, we identified the relevant anatomical structures (sacral cornua, sacral hiatus, dura mater) and verified correct administration of the local anesthetic by visualizing its cranial spread. Surgical blockade was successful in 18 of 20 cases (90%; one puncture was technically not possible and one child received intraoperatively 50 μg fentanyl). The pharmacokinetic profile of the administered ropivacaine 3.1 mg·ml⁻¹ indicated plasma levels within safe ranges in pediatric patients weighing 30−50 kg.

Conclusions

Based on our pharmacodynamic and pharmacokinetic results, we suggest that the body weight of 50 kg it is feasible to perform effective and safe caudal blockade in children up to 50 kg body weight.

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Early childhood exposure to short periods of sevoflurane is not associated with later, lasting cognitive deficits

Summary

Background

A detrimental effect of commonly used anesthetics on the neurodevelopmental and behavioral parameters has long been shown in young animals subjected to early childhood anesthesia. Epidemiologic studies suggest the possibility of a modestly elevated risk of adverse neurodevelopmental outcomes in children exposed to anesthesia during early childhood. However, these results are still preliminary and inconclusive.

Aim

To further elucidate the probability of occurrence of such adverse outcomes, we evaluated cognitive performance of children who underwent general anesthesia early in their childhood.

Method

One hundred and fifteen children aged 5‒16 years with established glaucoma were included in the study. Of these, 68 children had a history of at least one general anesthesia with sevoflurane before age 3. Phonemic and semantic verbal fluency, and forward and backward digit span tests were performed to evaluate cognitive function in the study subjects.

Results

The two-way anova revealed that all these variables showed significant changes in various age groups, but they were comparable among subjects with no, single, or multiple childhood anesthesia.

Conclusion

It can be concluded that brief periods of anesthesia with single anesthetic sevoflurane may be safe for children under age 3.

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