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Sbaraglia F, Cuomo C, Della Sala F, Festa R, Garra R, Maiellare F, Micci DM, Posa D, Pizzo CM, Pusateri A, Spano MM, Lucente M, Rossi M. State of the Art in Pediatric Anesthesia: A Narrative Review about the Use of Preoperative Time. J Pers Med 2024; 14:182. [PMID: 38392615 PMCID: PMC10890671 DOI: 10.3390/jpm14020182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Revised: 02/05/2024] [Accepted: 02/05/2024] [Indexed: 02/24/2024] Open
Abstract
This review delves into the challenge of pediatric anesthesia, underscoring the necessity for tailored perioperative approaches due to children's distinctive anatomical and physiological characteristics. Because of the vulnerability of pediatric patients to critical incidents during anesthesia, provider skills are of primary importance. Yet, almost equal importance must be granted to the adoption of a careful preanesthetic mindset toward patients and their families that recognizes the interwoven relationship between children and parents. In this paper, the preoperative evaluation process is thoroughly examined, from the first interaction with the child to the operating day. This evaluation process includes a detailed exploration of the medical history of the patient, physical examination, optimization of preoperative therapy, and adherence to updated fasting management guidelines. This process extends to considering pharmacological or drug-free premedication, focusing on the importance of preanesthesia re-evaluation. Structural resources play a critical role in pediatric anesthesia; components of this role include emphasizing the creation of child-friendly environments and ensuring appropriate support facilities. The results of this paper support the need for standardized protocols and guidelines and encourage the centralization of practices to enhance clinical efficacy.
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Affiliation(s)
- Fabio Sbaraglia
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Christian Cuomo
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Filomena Della Sala
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Rossano Festa
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Rossella Garra
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Federica Maiellare
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Daniela Maria Micci
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Domenico Posa
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Cecilia Maria Pizzo
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Angela Pusateri
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Michelangelo Mario Spano
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Monica Lucente
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Marco Rossi
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
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Karam C, Zeeni C, Yazbeck-Karam V, Shebbo FM, Khalili A, Abi Raad SG, Beresian J, Aouad MT, Kaddoum R. Respiratory Adverse Events After LMA® Mask Removal in Children: A Randomized Trial Comparing Propofol to Sevoflurane. Anesth Analg 2023; 136:25-33. [PMID: 35213484 DOI: 10.1213/ane.0000000000005945] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND The removal of the laryngeal mask airway (LMA®) in children may be associated with respiratory adverse events. The rate of occurrence of these adverse events may be influenced by the type of anesthesia. Studies comparing total intravenous anesthesia (TIVA) with propofol and sevoflurane are limited with conflicting data whether propofol is associated with a lower incidence of respiratory events upon removal of LMA as compared to induction and maintenance with sevoflurane. We hypothesized that TIVA with propofol is superior to sevoflurane in providing optimal conditions and improved patient's safety during emergence. METHODS In this prospective, randomized, double-blind clinical trial, children aged 6 months to 7 years old were enrolled in 1 of 2 groups: the TIVA group and the sevoflurane group. In both groups, patients were mechanically ventilated. At the end of the procedure, LMAs were removed when patients were physiologically and neurologically recovered to a degree to permit a safe, natural airway. The primary aim of this study was to compare the occurrence of at least 1 respiratory adverse event, the prevalence of individual respiratory adverse events, and the airway hyperreactivity score following emergence from anesthesia between the 2 groups. Secondary outcomes included ease of LMA insertion, quality of anesthesia during the maintenance phase, hemodynamic stability, time to LMA removal, and incidence of emergence agitation. RESULTS Children receiving TIVA with propofol had a significantly lower incidence (10.8.% vs 36.2%; relative risk, 0.29; 95% CI [0.14-0.64]; P = .001) and lower severity ( P = .01) of respiratory adverse outcomes compared to the patients receiving inhalational anesthesia with sevoflurane. There were no statistically significant differences in secondary outcomes between the 2 groups, except for emergence agitation that occurred more frequently in patients receiving sevoflurane ( P < .001). CONCLUSIONS Propofol induction and maintenance exerted a protective effect on healthy children with minimal risk factors for developing perioperative respiratory complications, as compared to sevoflurane.
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Affiliation(s)
- Cynthia Karam
- From the Department of Anesthesiology and Pain Management, American University of Beirut Medical Center, Beirut, Lebanon
| | - Carine Zeeni
- From the Department of Anesthesiology and Pain Management, American University of Beirut Medical Center, Beirut, Lebanon
| | - Vanda Yazbeck-Karam
- Department of Anesthesiology, Lebanese American University Medical Center-Rizk Hospital, Beirut, Lebanon
| | - Fadia M Shebbo
- From the Department of Anesthesiology and Pain Management, American University of Beirut Medical Center, Beirut, Lebanon
| | - Amro Khalili
- From the Department of Anesthesiology and Pain Management, American University of Beirut Medical Center, Beirut, Lebanon
| | - Sarah G Abi Raad
- From the Department of Anesthesiology and Pain Management, American University of Beirut Medical Center, Beirut, Lebanon
| | - Jean Beresian
- From the Department of Anesthesiology and Pain Management, American University of Beirut Medical Center, Beirut, Lebanon
| | - Marie T Aouad
- From the Department of Anesthesiology and Pain Management, American University of Beirut Medical Center, Beirut, Lebanon
| | - Roland Kaddoum
- From the Department of Anesthesiology and Pain Management, American University of Beirut Medical Center, Beirut, Lebanon
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Analysis of National Outcomes for Simple Versus Complex Nasal Dermoid Cyst Excision. J Craniofac Surg 2020; 32:e281-e283. [PMID: 33278252 DOI: 10.1097/scs.0000000000007160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Nasal dermoid cysts represent a spectrum of complexity from dermal sacs to multiloculated sinus tracts with intracranial extension with treatments ranging from outpatient excision to transcranial procedures involving dissection of the dermoid from the dura mater. In this study, the authors examined national outcomes across the spectrum utilizing the NSQIP database. Interestingly, complication rates were uniformly low at 1.2% even though those requiring transcranial excision required significantly longer surgical procedures (P = 0.001), and were significantly more likely to be admitted as inpatients (P < 0.001). Risk factors for longer surgery included patients with comorbidities (P = 0.006), patients requiring rhinoplasty (P = 0.001), and patients requiring a craniotomy (P = 0.023). While uncommon (0.3%), infectious complications remain primary drivers of postoperative morbidity. The NSQIP database does not allow for calculation of recurrence risk, likely a driver of poorer long-term outcomes, and efforts to quantify recurrence risk will be the subject of future research.
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Becke-Jakob K, Eich C, Röher K. Präoperative Vorbereitung in der Kinderanästhesie. Monatsschr Kinderheilkd 2020. [DOI: 10.1007/s00112-020-01040-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Inhalational versus Intravenous Induction of Anesthesia in Children with a High Risk of Perioperative Respiratory Adverse Events: A Randomized Controlled Trial. Anesthesiology 2018; 128:1065-1074. [PMID: 29498948 DOI: 10.1097/aln.0000000000002152] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Limited evidence suggests that children have a lower incidence of perioperative respiratory adverse events when intravenous propofol is used compared with inhalational sevoflurane for the anesthesia induction. Limiting these events can improve recovery time as well as decreasing surgery waitlists and healthcare costs. This single center open-label randomized controlled trial assessed the impact of the anesthesia induction technique on the occurrence of perioperative respiratory adverse events in children at high risk of those events. METHODS Children (N = 300; 0 to 8 yr) with at least two clinically relevant risk factors for perioperative respiratory adverse events and deemed suitable for either technique of anesthesia induction were recruited and randomized to either intravenous propofol or inhalational sevoflurane. The primary outcome was the difference in the rate of occurrence of perioperative respiratory adverse events between children receiving intravenous induction and those receiving inhalation induction of anesthesia. RESULTS Children receiving intravenous propofol were significantly less likely to experience perioperative respiratory adverse events compared with those who received inhalational sevoflurane after adjusting for age, sex, American Society of Anesthesiologists physical status and weight (perioperative respiratory adverse event: 39/149 [26%] vs. 64/149 [43%], relative risk [RR]: 1.7, 95% CI: 1.2 to 2.3, P = 0.002, respiratory adverse events at induction: 16/149 [11%] vs. 47/149 [32%], RR: 3.06, 95% CI: 1.8 to 5. 2, P < 0.001). CONCLUSIONS Where clinically appropriate, anesthesiologists should consider using an intravenous propofol induction technique in children who are at high risk of experiencing perioperative respiratory adverse events. VISUAL ABSTRACT An online visual overview is available for this article at http://links.lww.com/ALN/B725.
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An update on the perioperative management of children with upper respiratory tract infections. Curr Opin Anaesthesiol 2017; 30:362-367. [DOI: 10.1097/aco.0000000000000460] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Armoni Domany K, Gut G, Yakir BE, Sivan Y. Variability in anesthesiologists' approach to the preoperative management of asthmatic children. J Clin Anesth 2016; 35:62-69. [PMID: 27871597 DOI: 10.1016/j.jclinane.2016.07.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Revised: 06/19/2016] [Accepted: 07/05/2016] [Indexed: 12/22/2022]
Abstract
OBJECTIVE No consensus guidelines exist for the preoperative treatment of asthmatic children referred for elective surgery. We investigated the attitude of pediatric anesthesiologists to this issue. DESIGN A questionnaire survey was conducted. SETTING National survey. SUBJECTS Certified Israeli pediatric anesthesiologists from all 24 general hospitals in Israel. MEASUREMENT Twenty-one questions regarding the approach to preoperative management of asthmatic children including 6 case scenarios with a variety of clinical situations and treatments of asthmatic children. The results were compared with the attitude of pediatric pulmonologists recently published using a similar methodology. MAIN RESULTS Forty-four pediatric anesthesiologists from all 24 general hospitals in Israel responded. Twenty-five percent of pediatric anesthesiologists answered that, in addition to pediatric anesthesiologists, the primary pediatrician should be consulted, and 70% believed that a pediatric pulmonologists should also be consulted. Overall, results showed a wide variability between responders especially for preschool children and unstable school-aged asthmatic children for both disciplines. The variability referred to the use of any treatment, bronchodilators, inhaled corticosteroids and their combination, addition of systemic corticosteroids, and the length of preoperative treatment. Compared with pediatric pulmonologists, a better within-discipline agreement was observed by the pediatric anesthesiologists for stable school-aged asthmatic children with a lower inclination to augment preoperative treatment (P< .001). No difference was observed for the preschool children with asthma and for the unstable school-aged asthmatic child. CONCLUSIONS A wide variability exists in pediatric anesthesiologists' approach to the preoperative management of asthmatic children for most common case scenarios. This is probably explained by the heterogeneity of asthma, the type of surgery, the lack of guidelines, and the paucity of data. Similarities as well as differences exist between pediatric anesthesiologists and pulmonologists. Further studies and implementation of consensus guidelines are needed.
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Affiliation(s)
- Keren Armoni Domany
- Department of Pediatric Pulmonology, Critical Care and Sleep Medicine, Dana Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv University Sackler Faculty of Medicine, Israel.
| | - Guy Gut
- Department of Pediatric Pulmonology, Critical Care and Sleep Medicine, Dana Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv University Sackler Faculty of Medicine, Israel
| | - Bat-El Yakir
- Department of Pediatric Pulmonology, Critical Care and Sleep Medicine, Dana Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv University Sackler Faculty of Medicine, Israel
| | - Yakov Sivan
- Department of Pediatric Pulmonology, Critical Care and Sleep Medicine, Dana Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv University Sackler Faculty of Medicine, Israel
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Anesthesia and ventilation strategies in children with asthma: part II - intraoperative management. Curr Opin Anaesthesiol 2014; 27:295-302. [PMID: 24686320 DOI: 10.1097/aco.0000000000000075] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW As asthma is a frequent disease especially in children, anesthetists are increasingly providing anesthesia for children requiring elective surgery with well controlled asthma but also for those requiring urgent surgery with poorly controlled or undiagnosed asthma. This second part of this two-part review details the medical and ventilatory management throughout the perioperative period in general but also includes the perioperative management of acute bronchospasm and asthma exacerbations in children with asthma. RECENT FINDINGS Multiple observational trials assessing perioperative respiratory adverse events in healthy and asthmatic children provide the basis for identifying risk reduction strategies. Mainly, animal experiments and to a small extent clinical data have advanced our understanding of how anesthetic agents effect bronchial smooth muscle tone and blunt reflex bronchoconstriction. Asthma treatment outside anesthesia is well founded on a large body of evidence.Perioperative prevention strategies have increasingly been studied. However, evidence on the perioperative management, including mechanical ventilation strategies of asthmatic children, is still only fair, and further research is required. SUMMARY To minimize the considerable risk of perioperative respiratory adverse events in asthmatic children, perioperative management should be based on two main pillars: the preoperative optimization of asthma treatment (please refer to the first part of this two-part review) and - the focus of this second part of this review - the optimization of anesthesia management in order to optimize lung function and minimize bronchial hyperreactivity in the perioperative period.
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Armoni-Domany K, Gut G, Soferman R, Sivan Y. Pediatric pulmonologists approach to the pre-operative management of the asthmatic child. J Asthma 2014; 52:391-7. [PMID: 25405359 DOI: 10.3109/02770903.2014.986742] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE No consensus guidelines exist for the respiratory treatment of asthmatic children referred for elective surgery. The aim of this study was to evaluate the attitude of pediatric pulmonologists regarding the pre-operative management of these children. METHODS A survey of pre-operative management of asthmatic children was conducted. All 48 certified pediatric pulmonologists in Israel completed a questionnaire that comprised 20 questions regarding their approach to pre-operative management including six case scenarios with a variety of clinical situations and treatments of children with asthma. RESULTS Response rate was 100%. All believed that pre-operative treatment should be considered in all asthmatic children. Almost 50% suggested that a pediatric pulmonologist should be consulted in all pre-operative assessments. 50% recommended consultation only in individual cases. Overall, results showed a very wide variability between responders especially in pre-school and poorly controlled school children. The variability referred to the use of bronchodilators, inhaled corticosteroids and their combination during the pre-operative days, the addition of systemic CS and the length of pre-operative treatment. Almost all participants suggested either the initiation or augmentation of pre-operative treatment in high risk situations. CONCLUSIONS This data demonstrate an important variability among pediatric pulmonologists in Israel regarding the practice of pre-operative treatment of infants and children with asthma especially for the less controlled and high risk children. This is most probably explained by the paucity of evidence-based data and the lack of established guidelines. Consensus guidelines for the pre-operative management of asthmatic children are needed.
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Affiliation(s)
- Keren Armoni-Domany
- Sackler Faculty of Medicine, Department of Pediatric Pulmonology, Critical Care and Sleep Medicine, Dana Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv University , Tel Aviv , Israel
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