Observation of early postoperative hypoxaemia in children undergoing elective plastic surgery

Efficacy and safety comparison of esketamine-propofol with nalbuphine-propofol for upper gastrointestinal endoscopy in children: a multi-center randomized controlled trial

Background and Aims

Anesthetics such as propofol, esketamine and nalbuphine are used during the upper gastrointestinal endoscopy to achieve and maintain the desired sedation level. The aim of the study was to evaluate the effectiveness and safety of propofol-nalbuphine and propofol-esketamine in children.

Methods

A multi-centered study was performed at three tertiary class-A hospitals. Children between 3 and 12 years old undergoing diagnostic painless upper gastrointestinal endoscopy were included and randomly divided into esketamine or nalbuphine group to estimate the primary outcome of successful endoscope insertion. The patients were given esketamine 0.5 mg/kg and propofol 2 mg/kg intravenously in esketamine group, with nalbuphine 0.2 mg/kg and propofol 2 mg/kg in the nalbuphine group. The primary outcome was success rate for the first attempt of endoscope insertion in each group. Secondary outcomes included the safety of both anesthesia regimens and gastroenterologist's satisfaction. We used the Face, Leg, Activity, Cry and Consolability (FLACC) scale to evaluate the level of pain before and during the procedure and the Pediatric Anesthesia Emergence Delirium (PAED) scale to assess the level of agitation and delirium after awakening from anesthesia.

Results

Among 246 patients, 200 were randomly included in the final intention-to-treat analysis, with 100 patients in each group. The success rate for the first attempt of endoscope insertion in the esketamine group was higher than the nalbuphine group (97% vs. 66%; P < 0.01). The heart rate and mean arterial pressure after intraoperative administration in the esketamine group were higher than those in the nalbuphine group, while the delirium incidence during awakening was higher in esketamine group (all P < 0.05).

Conclusion

The success rate for the first attempt of endoscope insertion of children undergoing upper gastrointestinal endoscopy in the esketamine group was higher than the nalbuphine group, propofol-related hemodynamic changes were reduced accordingly, while the incidence of esketamine-related adverse effects could be high.

Clinical Trial Registration

Chinese Clinical Trial Registry: ChiCTR2000040500.

Surgical Closure of the Cleft Palate Has a Transient Obstructive Effect on the Upper Airway in Children

OBJECTIVE

To prospectively investigate the occurrence of respiratory symptoms related to obstructive sleep apnea (OSA) following primary palatoplasty in children with cleft palate (CP).

METHOD

Fifty-six nonsyndromic children presenting CP with a previously repaired cleft lip (CL) or without CL were assessed before and after palate repair. Twenty nonsyndromic children with isolated CL were analyzed as controls before and after lip repair. Respiratory symptoms were investigated preoperatively, and at early and late postoperative periods. Based on the parent reports of "difficulty of breathing (D), apnea events (A) and/or snoring (S) during sleep, a validated OSA index (1.42D + 1.41A + 0.71S - 3.83) was used to predict absence of OSA, possible OSA, and presence of OSA, at the 3 periods analyzed.

RESULTS

Screening for OSA showed that the CP group exhibited an increased mean index at the early postoperative assessment, suggesting "possible OSA," and a higher frequency of snoring at the early and late postoperative assessments, as compared to the CL group (P < .05). Sleep apnea events were not reported.

CONCLUSIONS

Surgical closure of the palate has an obstructive effect on the upper airway in the short term, causing OSA-related respiratory symptoms, mostly transient. However, the high prevalence of snoring still observed in the long term indicate that children with a palatal cleft who undergo surgical repair are at risk for OSA. The results support the conclusion that OSA is underappreciated in this population.

Comparative study between dexmedetomidine and fentanyl for sedation during mechanical ventilation in post-operative paediatric cardiac surgical patients

AIMS AND OBJECTIVES

To compare the efficacy of sedation and time taken for extubation using dexmedetomidine and fentanyl sedation in post-operative paediatric cardiac surgical patients.

METHODS

A prospective randomized double-blind study involving 60 children undergoing open heart surgery was conducted. The patients were divided into two groups, each involving 30 patients. One group received fentanyl at 1 μg/kg/h (Group A) and the other received dexmedetomidine at 0.5 μg/kg/h (Group B) for post-operative sedation with intermittent rescue fentanyl 0.5 μg/kg bolus in either group as per requirement during suctioning. The efficacy of sedation was assessed using the Ramsay sedation score, paediatric intensive care unit sedation score and the tracheal suction score. The time taken for extubation from the stoppage of infusion was noted.

RESULTS

Haemodynamic parameters between the two groups were comparable. All sedation scores were comparable in the fentanyl and dexmedetomidine groups. Average time (in minutes) required for extubation was 131.0 (±51.06 SD) in the dexmedetomidine group compared with 373.0 (±121.4 SD) in the fentanyl group. The difference in mean time for extubation was statistically significant.

CONCLUSIONS

Dexmedetomidine facilitates adequate sedation for mechanical ventilation and also early extubation as compared with fentanyl.

Presurgical fentanyl vs caudal block and the incidence of adverse respiratory events in children after orchidopexy

BACKGROUND

There is controversy about the etiology of early postoperative hypoxemia. Age, weight, intubation, surgical procedure, use of muscle relaxants, and/or administration of opioids may affect the incidence of early postoperative hypoxemia. In this prospective, randomized, and single-blinded study, we evaluated whether the administration of caudal analgesia vs i.v. fentanyl affected the number of children who develop postextubation adverse upper airway respiratory events, (upper airway obstruction, laryngospasm) and/or early postoperative hypoxemia.

METHODS/MATERIALS

Institutional approval and written parental informed consents were obtained. Thirty-eight healthy outpatient boys, aged 1-6 years, scheduled for elective orchidopexy were randomized to receive pain relief either with a presurgical caudal block or by i.v. fentanyl. The primary outcome of the study was the number of children who developed postextubation adverse upper airway respiratory events and/or early postoperative hypoxemia.

RESULTS

The number of boys who developed postextubation adverse upper airway respiratory events and/or early postoperative hypoxemia in the caudal group was less compared with those in the fentanyl group (P = 0.04).

CONCLUSIONS

Compared to fentanyl, placement of a presurgical caudal block in boys scheduled for orchidopexy was associated with a lower incidence of postextubation adverse upper airway respiratory events and/or early postoperative hypoxemia.

[Retrospective study of postoperative complications in primary lip and palate surgery]

This retrospective study addressed the complications of primary lip and palate surgeries, and was carried out at Craniofacial Anomalies Rehabilitation Hospital at University of São Paulo. The present study aimed to identify the most frequent complications, as well as verifying the rela-tions between demographic variables and the complications observed. The sample comprised the records of 484 patients submitted to primary lip and palate surgery during the period of November 2000 to April 2001. The results demonstrated predominance of white male individuals with a median age of 12 months. The most frequent type of cleft was complete cleft lip and palate, and cheiloplasty was the most prevalent surgery. Of the 484 patients included in the study, 58.05% presented at least one or more postoperative complications. Pain was the most frequent problem in the evaluated group, followed by oxygen desaturation and tachycardia.

Pierre-Robin-Sequenz — postoperative Komplikationen nach Gaumenspaltverschluss

BACKGROUND

In a 25-year retrospective review of 1976-2000, the postoperative course after cleft palate surgery and pharyngeal flap surgery in 87 children with Pierre Robin sequence was studied.

PATIENTS AND METHODS

The study comprised 114 interventions with 87 primary palatoplasties; 17 patients required palatal fistulae repair and 10 children were treated with secondary pharyngoplasty procedures. All children were divided into three postnatal risk groups according to the severity of their symptoms at birth and in the course of the early months of life.

RESULTS

A direct correlation was seen between the incidence of early postnatal difficulties and the postoperative obstructive complications after cleft palate surgery and pharyngeal flap surgery. Thus, children experiencing obstructive problems at birth (high postnatal risk group) displayed more severe complications at the time after cleft palate repair. In children undergoing pharyngeal flap surgery not only early postoperative obstruction but also late obstructive sleep apnea can occur.

Risk factors in children having palatoplasty

Palatoplasty carries a relatively high risk of hypoxaemia. We prospectively evaluated 23 children having elective surgery for cleft palate. Intubation was uneventful in 15 patients and the lowest pulse oximetry levels (mean: 93% (range: 100-57)) were less affected than those at extubation (mean: 83% (range: 100-21)) which was uneventful in 10. Establishing a free airway was associated with increased difficulties in patients with Pierre Robin sequence (n = 4). All children who had had a recent airway infection or a parent who smoked (n = 8) had some degree of difficulty in intubation, or extubation, or in both. Increased attention paid to these latter, avoidable, factors may potentially reduce the anaesthetic hazards in this group of patients, who are at increased risk.

Identification of children at high anaesthetic risk at the time of primary palatoplasty

Closure of the palate is an operation with a higher risk of postoperative hypoxaemia than other plastic surgical procedures. An increase in anaesthetic complications was noticed among our children with a cleft palate who were operated on with a palatoplasty, and this was further investigated. The records of 154 patients operated on between 1979 and 1996 were eligible for the study. A total of 128 had isolated cleft palate (ICP), 19 had Pierre Robin syndrome (PRS), and seven had other identified syndromes (IS). The results showed that the risk of anaesthetic complications was four times greater when the operation was done when the child was less than 1 year old, and there was a sixfold increase when a more elaborate velopharyngoplasty technique was used. Children with Pierre Robin syndrome were further classified according to the degree of neonatal difficulties. The 12 children with most severe problems were at increased risk. When the diagnostic criteria as well as the type of operation were taken into account the incidence of anaesthetic complications was 7/11, which was the highest risk encountered in the present study. When the first operation on the palate in children with Pierre Robin syndrome is planned, it should be based on a classification of neonatal problems and an investigation of their clinical condition. In children at risk the palatoplasty procedure should be postponed until the age of 12-18 months.

Postoperative oxygen therapy

Much has been published in the medical literature concerning adverse events relating to the surgical patient. Among the notable disorders requiring the expertise of the postanesthesia care unit nurse are the diagnosis and management of respiratory dysfunction acutely attributable to the effects of surgery and anesthesia. Inhalational and/or intravenous anesthetic agents contribute to pathophysiological alterations that lend to the development of hypoxemia in the postoperative period. When patients present with preexisting respiratory disease, their care is frequently more complex and challenging. This review session will address the oxygenation component of respiration and the perioperative influences that alter it as well as treatment considerations for normalizing oxygenation.