After nectarine: how should we provide anesthesia for neonates?

Airway management may influence postoperative ventilation need in preterm infants after laser eye treatment

BACKGROUND

Retinopathy of prematurity is treated with laser photocoagulation under general anaesthesia with intubation using endotracheal tube (ETT), which carries a risk for postoperative mechanical ventilation (MV). Laryngeal mask airway (LMA) may provide a safe alternative. We assessed the need for postoperative MV in preterm infants who received LMA versus ETT.

METHODS

In this single-centre, retrospective cohort study, preterm infants who underwent laser photocoagulation between 2014-2021 were enroled. For airway management, patients received either LMA (n = 224) or ETT (n = 47). The outcome was the rate of postoperative MV.

RESULTS

Patients' age were 37 [35;39] weeks of postmenstrual age, median bodyweight of Group LMA was higher than Group ETT's (2110 [1800;2780] g versus 1350 [1230;1610] g, respectively, p < 0.0001). After laser photocoagulation, 8% of Group LMA and 74% of Group ETT left the operating theatre requiring MV. Multiple logistic regression revealed that the use of LMA and every 100 g increase in bodyweight significantly decreased the odds of mechanical ventilation (OR 0.21 [95% CI 0.07-0.60], and 0.73 [95% CI 0.63-0.84], respectively). Propensity score matching confirmed that LMA decreased the odds of postoperative MV (OR 0.30 [95% CI 0.11-0.70]).

CONCLUSION

The use of LMA is associated with a reduced need for postoperative MV.

IMPACT

Using laryngeal mask airway instead of endotracheal tube for airway management in preterm infants undergoing general anaesthesia for laser photocoagulation for treating retinopathy of prematurity could significantly decrease the postoperative need for mechanical ventilation. According to our current understanding, this has been the largest study investigating the effect of laryngeal mask airway during general anaesthesia in preterm infants. Our study suggests that the use of laryngeal mask airway is a viable alternative to intubation in the vulnerable population of preterm infants in need of laser treatment.

Current anesthesia practice for preterm infants undergoing surgery for necrotizing enterocolitis: A European survey

STUDY OBJECTIVE

Necrotizing enterocolitis (NEC) is a life-threatening intestinal illness mostly affecting preterm infants, which commonly requires surgery. Anesthetic care for these patients is challenging, due to their prematurity and critical illness with hemodynamic instability. Currently, there are no guidelines for anesthetic care for these vulnerable patients. Therefore, this study aimed to describe current anesthesia practices across Europe for infants undergoing surgery for NEC.

DESIGN

Cross-sectional survey study.

PARTICIPANTS

Anesthesiologists working in centers where surgery for NEC is performed across Europe.

MEASUREMENTS

A 46-item questionnaire assessing protocols for anesthesia practice, preoperative care, intraoperative care, postoperative care, and the respondent's opinion on the adequacy of anesthetic care for patients with NEC in their center.

MAIN RESULTS

Out of the 173 responding anesthesiologists from 31 countries, approximately a third had a written standard protocol for anesthetic care in infants. Three quarters of the respondents screened all patients with NEC preoperatively, and a third structurally performed preoperative multidisciplinary consultation. For induction of general anesthesia, most respondents opted for intravenous anesthesia (n = 73, 43%) or a combination of intravenous and inhalation anesthesia (n = 57, 33%). For intravenous induction, they mostly used propofol (n = 58, 44%), followed by midazolam (n = 43, 33%) and esketamine (n = 42, 32%). For maintenance of anesthesia, inhalation anesthetic agents were more commonly used (solely: n = 71, 41%; in combination: n = 37, 22%), almost exclusively with sevoflurane. Postoperative analgesics mainly included paracetamol and/or morphine. Sixty percent of the respondents (n = 104) considered their anesthetic care for patients with NEC adequate. Suggestions for further improvement mainly revolved around monitoring, protocols, and collaboration.

CONCLUSIONS

Anesthesia practice for infants undergoing surgery for NEC was highly variable. Most respondents considered the provided anesthetic care for patients with NEC adequate, but also recognized opportunities for further improvement, especially with regards to monitoring, protocols, and interdisciplinary collaboration.

Lessons learned from big data (APRICOT, NECTARINE, PeDI)

Big data in paediatric anaesthesia allows the evaluation of morbidity and mortality of anaesthesia in a large population, but also the identification of rare critical events and of their causes. This is a major step to focus education and design clinical guidelines. Moreover, they can help trying to determine normative data in a population with a wide range of ages and body weights. The example of blood pressure under anaesthesia will be detailed. Big data studies should encourage every department of anaesthesia to collect its own data and to benchmark its performance by comparison with published data. The data collection processes are also an opportunity to build collaborative research networks and help researchers to complete multicentric studies. Up to recently, big data studies were only performed in well developed countries. Fortunately, big data collections have started in some low and middle income countries and truly international studies are ongoing.

State of the Art in Pediatric Anesthesia: A Narrative Review about the Use of Preoperative Time

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.

The Role of Erythropoietin in Preventing Anemia in the Premature Neonate

Recombinant human erythropoietin (rhEPO) treatment is an alternative to red blood cell (RBC) transfusions in neonates presenting anemia of prematurity (AOP). This study assesses the impact of early rhEPO administration on AOP (any stage) incidence, as well as the incidence of individual AOP stages and RBC transfusions. Out of 108 preterm neonates, 49 were administered rhEPO and compared to the remaining group using univariate and multivariate analyses. Univariately, gestational age (GA), birth weight (BW), hemoglobin (Hb), hematocrit (HCT), RBC levels, and iron administration were significantly associated with AOP (p < 0.05 each); however, only the latter remained significant following multivariate analysis (AOR: 2.75, 95% CI, 1.06-7.11). Multinomial analysis revealed rhEPO treatment was associated with a near three-fold reduction in moderate AOP incidence (OR: 0.36, 95% CI, 0.15-0.89). Furthermore, ANCOVA revealed positive correlations between rhEPO administration and 21-day Hb (p < 0.01), HCT (p < 0.05), and EPO (p < 0.001) levels. The results confirm previously reported benefits of rhEPO treatment, such as reduced moderate AOP incidence and increased Hb, HCT, and serum EPO levels.

"Emerging Topics in Pain Medicine": Advancing Research and Patient-Centered Health Strategies

Pain, in all its various forms and manifestations, impacts the lives of millions worldwide [...].

Outcome following anaesthesia in infancy in the Nordic countries: Subgroup analysis of the NECTARINE study

INTRODUCTION

The neonate and children audit of anaesthesia practice in Europe (NECTARINE) prospective observational study reported an incidence of 35.2% of critical events requiring intervention during 6542 anaesthetics in 5609 infants up to 60 weeks postmenstrual age (PMA) from 165 centres in 31 European countries.

METHODS

Sub-analysis of the cohort from the Nordic countries (8% of the entire cohort) was conducted. Secondary aims were to describe the Nordic countries' anaesthetic practices and compare morbidity and mortality with the overall European cohort.

RESULTS

Eleven Nordic centres recruited 447 infants (66% males, 37.3% born preterm and 45% had congenital anomalies) undergoing anaesthesia for 530 surgical or non-surgical procedures at 25-60 weeks PMA. Perioperative critical events triggered interventions in 228/530 (43%) cases. Hypotension (12.6%) or hypoxaemia (11.7%) were more common in younger patients and those with co-morbidities. Hypo/hypercapnia occurred in 1.5%/4.7% of cases. More than two attempts for intubation were required in 13 (2.9%) infants (max three attempts). Distribution of ASA-Physical Status Scores was similar to the total European cohort (40% was ASA > 2). A total of 236/530 (44.5%) patients were admitted to the postoperative intensive care unit. Thirty-day morbidity (complications in 87/447 = 19.5%) and mortality (8/447, 1.8%) did not differ from the overall European cohort. Hospital re-admissions were significant up to 90 days (98/447 = 21.9%).

CONCLUSIONS

In Nordic countries, anaesthesia in young infant children is resource-demanding, and perioperative critical events and co-morbidities are common. Thirty-day morbidity and mortality data in the Nordic countries did not differ from the overall European cohort.

Preventing difficult facemask ventilation in children: all is well that starts well

Difficult facemask ventilation at induction of general anaesthesia can trigger hypoxaemia and inadequate ventilation if not immediately identified and adequately treated. For this reason, identification of predisposing conditions before induction of anaesthesia and causes of poor facemask ventilation are critical to avoid the subsequent complications. In a recently published secondary analysis of the Paediatric Difficult Intubation (PeDI) registry, the incidence and risk factors for difficult facemask ventilation in children with difficult tracheal intubation was described, as highlighted in the editorial.

Evaluation of Nociception during Pediatric Surgery: A Topical Review

The association between intraoperative nociception and increased patient's morbidity is well established. However, hemodynamic parameters, such as heart rate and blood pressure, may result in an inadequate monitor of nociception during surgery. Over the last two decades, different devices have been marketed to "reliably" detect intraoperative nociception. Since the direct measure of nociception is impractical during surgery, these monitors measures nociception surrogates such as sympathetic and parasympathetic nervous systems responses (heart rate variability, pupillometry, skin conductance), electroencephalographic changes, and muscular reflex arc. Each monitor carries its own advantages and disadvantages. The manuscript aims to give an overview of the most up-to-date information available in the literature on current nociceptor monitors available in clinical practice, with particular focus on their applications in pediatrics.