Perioperative hypersensitivity in children: A prospective multidisciplinary study

BACKGROUND

There are few studies of perioperative hypersensitivity reactions in children. The diagnosis of perioperative hypersensitivity reactions may be under estimated because it is difficult to recognize the reactions. Anaphylaxis may go unnoticed because of patient unconsciousness. Urticaria may be missed due to sterile drapes. The aim of this study was to prospectively evaluate perioperative hypersensitivity reactions.

METHODS

In this prospective study, patients with suspected perioperative hypersensitivity reactions aged 0-18 years who underwent surgery at the Department of Pediatric Surgery, Cerrahpasa Faculty of Medicine, between 2019 and 2021 were investigated. Suspected reactions in the perioperative period were graded according to the Ring and Messmer scale. Patients with suspected reactions were examined 4-6 weeks after the reaction. If necessary, specific IgE and basophil activation tests were performed. Reactions of grades III-IV were considered anaphylaxis. If one test modality was strongly positive and there was a relevant time point or repeated allergic reactions, or at least two test modalities were positive, hypersensitivity was confirmed. In all patients, serum tryptase levels were analyzed at the time of the reaction, 2 h after the reaction, and 4-6 weeks after the reaction as part of the allergic evaluation.

RESULTS

A total of 29 patients (8 female, 21 male) suspected of having an intraoperative reaction during the study were included in the analysis. Perioperative hypersensitivity reactions were noted in 1 patient. The incidence of perioperative hypersensitivity reactions was reported to be 0.03% (n = 1/2861). While anaphylaxis was confirmed in 1 patient, 5 patients were considered possible anaphylaxis cases.

CONCLUSION

Perioperative hypersensitivity reactions can be life-threatening and may recur with further administration. Collaboration between pediatric surgeons, anesthesiologists, and allergists can prevent further reactions. All suspected cases should be evaluated by an experienced allergist soon after the initial reaction.

Effect of paediatric caudal injection volume on optic nerve sheath diameter and regional cerebral oximetry: A randomised trial

BACKGROUND

Caudal injections commonly used for neuraxial anaesthesia in children can displace cerebrospinal fluid cranially causing safety concerns in terms of raised intracranial pressure. Optic nerve sheath diameter (ONSD) is a noninvasive surrogate for the measurement of intracranial pressure. Regional cerebral oximetry (CrSO 2 ) can monitor brain oxygenation, which may decrease by a reduction in cerebral flow due to increased intracranial pressure.

OBJECTIVES

Comparing how caudal injection volumes of 0.8 and 1.25 ml kg -1 influence ONSD and CrSO 2 within the first 30 min after injection.

DESIGN

Prospective, randomised and parallel group trial.

SETTING

Operating room.

PATIENTS

Fifty-eight elective paediatric surgical patients between ages 1 and 7 years old, ASA class I or II, without previous intracranial or ocular pathology and surgery appropriate for single - shot caudal anaesthesia.

INTERVENTION

Single-shot caudal anaesthesia with 0.8 ml kg -1 (group L, n  = 29) and 1.25 ml kg -1 (group H, n  = 29) of 2 mg kg -1 bupivacaine solution.

MAIN OUTCOME MEASURES

Optic nerve sheath diameter measured with ultrasonography and regional cerebral oximetry measured by near - infrared spectroscopy before (NIRS), immediately after, 10, 20 and 30 min after the block.

RESULTS

Mean ONSD values increased from a baseline of 4.4 ± 0.2 mm to a maximum of 4.5 ± 0.2 mm 20 min after injection in group L and from a baseline of 4.5 ± 0.3 mm to a maximum of 4.8 ± 0.3 mm 10 min after injection in group H. Eight of 29 patients in group H and none in group L had an ONSD increase by more than 10%. Both groups had a reduction of less than 2.5% in CrSO 2 .

CONCLUSION

Caudal injection with 1.25 ml kg -1 increased ONSD, an indirect measurement of ICP, more than 0.8 ml kg -1 and neither volume caused a clinically important reduction in CrSO 2 .

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04491032.

Pudendal nerve block for circumcision of pediatric patient with Pierre Robin Sequence: case report

Pierre Robin Sequence (PRS) is a congenital condition characterized by micrognathia, glossoptosis, and cleft palate that presents with airway obstruction and developmental delay with or without other congenital anomalies. These patients' anesthesia management is challenging because of difficult ventilation and intubation. Regional anesthesia methods should be considered for these patients on a case-by-case basis. This report presents primary use of regional anesthesia for circumcision of a 9-year-old boy with PRS.

Pudendal Nerve Block Versus Penile Nerve Block in Children Undergoing Circumcision

PURPOSE

Penile nerve block is the most popular nerve block for the circumcision in pediatric patients. This study aimed to compare the analgesic efficiency of penile nerve block and the pudendal nerve block on postoperative pain and additional analgesic requirements in children undergoing circumcision.

MATERIAL AND METHODS

This prospective randomized double-blind study enrolled 85 children, aged 1 to10 years, undergoing circumcision. The patients were randomly divided into two groups either receiving dorsal penile block group (PNB-Group) or pudendal nerve block (PDB-Group). In the PNB-Group, 0.3 ml/kg 0.25 % bupivacaine was used; and, in the PDB-Group, 0.3 ml/kg bupivacaine was applied with nerve stimulator at a concentration of 0.25%. In the postoperative period, the modified CHEOPS pain scale scoring and additional analgesic demand were evaluated at the 5th and 30th minutes and at the 1st and 2nd hours. The subsequent pain evaluations were made by the parents at home, at the postoperative 6th, 12th, 18th and 24th hours.

RESULTS

Seven patients were excluded from the study, and seventy eight patients were evaluated for analysis. Patients in PDB-Group had significantly lower postoperative pain intensity and lower mCHEOPS scores (3.83 ± 0.98) when compared to the PNB-Group (6.47 ± 0.91) (P < .01) at all measurement times and none of patients in PDB-Group had additional analgesic requirements up to 24 hours. Patients in the PNB-Group had significantly more analgesic requirements at all measurements times except at the 1st, 2nd, 24th hours. 3.8%, 30.8%, 46.2% and 59% of the patients in the PNB group needed additional analgesia respectively at 5th, 6th, 12th and 18th hours.

CONCLUSION

Pudendal nerve block provided additional analgesic free period and had better analgesic efficiency compared to the penile nerve block lasting until 24 hours after operation.

Complications during esophageal endoscopy with or without baloon dilation under general anesthesia in pediatric patients: a prospective and observational study

BACKGROUND

Complications can occur during esophagoscopy as a result of applied procedure in children, especially during dilation techic. Our aim was to identify cardio-respiratory alterations during esophagoscopy with or without baloon dilation under anesthesia in children, and to investigate the postoperative complications.

METHODS

Prospective, observational study of endoscopic procedures in patients 0-16 years. The patients were divided into two groups: the endoscopy-dilation group (Group ED: endoscopy and balloon dilation due to esophageal stricture) and endoscopy without dilation (Group E: endoscopy for diagnostic reasons, control esophagoscopy or sclerotherapy). Hemodynamic and ventilatory parameters alterations and complications during endoscopy, dilation and two-hours follow-up time in the postoperative recovery room were recorded.

RESULTS

102 procedures in 60 patients were included. Peak inspiratory pressure (PIP) values significantly increased after endoscopy in both groups (p<0.001). There was a significant increase in mean PIP values in the dilation group during the procedure (p<0,001). The difference in PIP values before and after the endoscopy was negatively correlated with age in both groups. When the groups were subdivided taking two years of age as a cut-off point in comparing PIP difference before-after endoscopy, PIP increase was statistically significant in both groups under two-years old. In the dilation group, statistically significant increase of HR was detected during the procedure (p<0,001).

CONCLUSION

During endoscopy PIP increased in patients with or without baloon dilation especially in the dilation group. PIP increase was higher in younger children. Severe respiratory and cardiovascular complications during balloon dilation under general anesthesia should be carefully observed and managed.

Laryngotracheal edema due to thermal injury: A complication after thyroidectomy in children

Postoperative respiratory insufficiency is a serious complication of total thyroidectomies which can be multifactorial, especially in children. We report two siblings who had undergone thyroidectomy with subsequent respiratory distress. Electrothermal bipolar and harmonic scalpel were used during thyroid dissections. Both patients had early postoperative respiratory problems. The older one suffered from mild respiratory distress for 24 hours and then he spontaneously recovered. The younger one was extubated but then she had serious stridor accompanied with abdominal and intercostal retractions. She was re-intubated and admitted to ICU for mechanical ventilatory support, where she stayed for 14 days due to multiple failed extubation attempts. The symptoms were more severe in the younger child probably due to softer tracheal wall and weaker tracheal cartilages. We should keep in mind the probable postoperative respiratory complications due to thermal injury or inappropriate surgical technique after thyroid surgeries.

The anaesthetic consideration of tracheobronchial foreign body aspiration in children

Cases of tracheobronchial foreign body aspiration are frequently encountered emergency cases of childhood; and, delays in its recognition and treatment do result in serious morbidity and mortality. Diagnosis mainly relies on taking history which should indicate what the foreign body is, when it has been aspirated and where it is located. Belated consultation can cause misdiagnosis with the mixing of the symptoms and data with those of other pathologies common to childhood and further delays in the correct diagnosis. Bronchoscopy is required for the differential diagnosis of suspected tracheobronchial foreign body aspiration in order to eliminate other common pediatric respiratory concerns. Given the shared use of the airways by the surgeon and the anaesthesiologist, bronchoscopy is a challenging procedure requiring experienced teams with an efficient method of intercommunication, and also well planning of the anaesthesia and bronchoscopy ahead of the procedures. Despite the recent popularisation of the fiberoptic brochoscopes, the rigid bronchoscopy remains to be used commonly and is regarded to provide the gold standard technique. There have been reports in the literature on the uses of inhalation and/or intravenous (IV) anaesthesia and spontaneous or controlled ventilation methods without any demonstration of the superiority of one technique over the other. The most suitable methods of anaesthesia and ventilation would be those that reduce the risks of complications, morbidity and mortality; and, preventive measures should be taken with priority against childhood cases of tracheobronchial foreign body aspiration.

Transversus Abdominis Plane (TAP) block for postoperative analgesia in neonates and young infants: retrospective analysis of a case series. TAP blocks in neonates and young infants

BACKGROUND

The effectiveness of the TAP block in children has been well characterized in literature. However, there are only few reports about TAP block in the neonates and low birth weight groups. This is a retrospective observational analysis of ultrasound - assisted TAP blocks in neonates and young infants. The aim of this study to analyze retrospectively the analgesic effectiveness of TAP block in neonates and infants undergoing abdominal and inguinal surgeries.

METHODS

Thirty-four cases of neonates and infants with (whom) applied TAP block were retrospectively analyzed. The TAP block was performed postoperatively in supraumbilical surgeries and preoperatively in infraumbilical surgeries. The TAP block was applied with 0.8 ml/kg-1 of 0.25% bupivacaine in unilateral approach and 1.6 mlkg-1 of 0.125% bupivacaine in bilateral approach. The CRIES Pain Scale was used for postoperative pain measurement of neonates.

RESULTS

The patient's age ranged from 2 to 88 day-old with a mean (SD) of 36.2(24.2). Eleven of them were premature babies. The weight ranged from 1.6 to 5.8 with a mean (SD) of 3.7kg (1.1). Twenty-nine patients were extubated at the end of the surgery and the other patients within 12 hours. 67.7% infants required no additional postoperative analgesic in 24 hours and none of them required narcotic analgesics.

CONCLUSIONS

Our conclusion is that the use of TAP blocks results in low analgesic requirements and a low incidence of postoperative intubation and mechanical ventilation in neonates and infants. It should be considered in this age group of child for postoperative analgesia.

Anaphylaxis after administration of amikacin containing sodium metabisulfite in a premature newborn

Anaphylaxis is a serious systemic hypersensitivity reaction that is rapid in onset and can cause death. Premature newborns, whose immunological system is immature, are less likely to develop anaphylaxis. Administration of amikacin, containing sodium metabisulfite, to a 3-day-old premature newborn, induced a near fatal anaphylaxis. After suspicion of sepsis, the baby was started on amikacin. Clinical improvement was observed after initiation of treatment. On the third day of treatment with amikacin, the newborn suddenly developed tachypnea, tachycardia, angioedema and cyanosis. Anaphylaxis was diagnosed and treated. Latent reaction occurred after one hour of clinical improvement. The baby was intubated immediately. Anaphylaxis is a medical emergency; therefore the clinicians should have a rapid and careful assessment about this potentially fatal reaction. Even after successful treatment of anaphylaxis, the patient should be under observation for 72 hours because of the possibility of a biphasic reaction.

Emergency bronchoscopy for foreign-body aspiration in a child with type I mucopolysaccharidosis: a challenging airway management experience

The mucopolysaccharidosis (MPS) is a rare lysosomal storage disease. Glycosaminoglycans (GAG) accumulate in musculoskeletal system, connective tissues. Enlarged tongue, short immobile neck, and limited mobility of the cervical spine and temporomandibular joints render the airway management potentially risky. MPS children have high anesthetic risks, especially in airway management of emergency situations. The foreign-body aspiration requiring intervention with rigid bronchoscopy is an urgent and risky clinical situation. We present our experience with a challenging airway management with a three-year-old child with MPS who needed emergency bronchoscopy due to peanut aspiration.

Results of a Two-stage Technique for Treatment of Proximal Hypospadias with Severe Curvature: Creation of a Urethral Plate Using a Vascularized Preputial Island Flap

PURPOSE

To present the results of a two-stage technique used for the treatment of proximal hypospadias with severe curvature.

MATERIALS AND METHODS

The medical records of children with proximal hypospadias and severe curvature were retrospectively analyzed. A 2-stage procedure was performed in 30 children. In the first stage, the release of chordee was performed, and a well-vascularized preputial island flap was created. The vascularized island flap was brought anteriorly and sutured over the ventral surface of the glans and degloved penile shaft. The second stage was performed 6-8 months later. A neourethra was reconstructed by the tubularization of the preputial-urethral plate utilizing the principles of Duplay technique. All surgical procedures were performed between 2005 and 2011.

RESULTS

The mean age of the patients was 4.4 years (1-17 years). The mean duration of urethral catheterization was 6 days after the first stage and 10 days following the second stage. The flaps were viable in all of the children. There was no residual chordee. Following the second stage (n = 30), complications developed in 11 children (36%), namely, a fistula in 7, a pinpoint fistula in 3, and a diverticulum formation in 1. The cosmetic outcome was satisfactory. Uroflowmetry measurements were evaluated, and only one patient had a diverticulum formation at the late follow-up.

CONCLUSION

Vascularized preputial island flap is an alternative to free grafts for the reconstruction of the urethra. The main advantage of this flap technique is the creation of a thick, healthy and well-vascularized urethral plate. The advantages of this technique include better aesthetic appearance, an acceptable complication rate, and a very low rate of diverticula formation.

Chronic neurological deficits in mice after perinatal hypoxia and ischemia correlate with hemispheric tissue loss and white matter injury detected by MRI

We investigated the effects of perinatal hypoxia-ischemia (HI) on brain injury and neurological functional outcome at postnatal day (P)30 through P90. HI was induced by exposing P9 mice to 8% O(2) for 55 min using the Vannucci HI model. Following HI, mice were treated with either vehicle control or Na(+)/H(+) exchanger isoform 1 (NHE1) inhibitor HOE 642. The animals were examined by the accelerating rotarod test at P30 and the Morris water maze (MWM) test at P60. T(2)-weighted MRI was conducted at P90. Diffusion tensor imaging (DTI) was subsequently performed in ex vivo brains, followed by immunohistochemical staining for changes in myelin basic protein (MBP) and neurofilament protein expression in the corpus callosum (CC). Animals at P30 after HI showed deficits in motor and spatial learning. T(2) MRI detected a wide spectrum of brain injury in these animals. A positive linear correlation was observed between learning deficits and the degree of tissue loss in the ipsilateral hemisphere and hippocampus. Additionally, CC DTI fractional anisotropy (FA) values correlated with MBP expression. Both FA and MBP values correlated with performance on the MWM test. HOE 642-treated mice exhibited improved spatial learning and memory, and less white matter injury in the CC. These findings suggest that HI-induced cerebral atrophy and CC injury contribute to the development of deficits in learning and memory, and that inhibition of NHE1 is neuroprotective in part by reducing white matter injury. T(2)-weighted MRI and DTI are useful indicators of functional outcome after perinatal HI.

Inhibition of Na+/H+ exchanger isoform 1 is neuroprotective in neonatal hypoxic ischemic brain injury

We investigated the role of Na(+)/H(+) exchanger isoform 1 (NHE-1) in neonatal hypoxia/ischemia (HI). HI was induced by unilateral ligation of the left common carotid artery in postnatal day 9 (P9) mice, and subsequent exposure of animals to 8% O(2) for 55 min. A pre/posttreatment group received a selective and potent NHE-1 inhibitor HOE 642 (0.5 mg/kg, intraperitoneally) 5 min before HI, then at 24 and 48 h after HI. A posttreatment group received HOE 642 (0.5 mg/kg) at 10 min, 24 h, and 48 h after HI. Saline injections were used as vehicle controls. The vehicle-control brains at 72 h after HI exhibited neuronal degeneration in the ipsilateral hippocampus, striatum, and thalamus, as identified with Fluoro-Jade C positive staining and loss of microtubule-associated protein 2 (MAP2) expression. NHE-1 protein was upregulated in glial fibrillary acidic protein-positive reactive astrocytes. In HOE 642-treated brains, the morphologic hippocampal structures were better preserved and displayed less neurodegeneration and a higher level of MAP2 expression. Motor-learning deficit was detected at 4 weeks of age after HI in the vehicle control group. Inhibition of NHE-1 in P9 mice not only reduced neurodegeneration during the acute stage of HI but also improved the striatum-dependent motor learning and spatial learning at 8 weeks of age after HI. These findings suggest that NHE-1-mediated disruption of ionic homeostasis contributes to striatal and CA1 pyramidal neuronal injury after neonatal HI.