Lung ultrasound for early diagnosis of postoperative need for ventilatory support: a prospective observational study.
Dransart-Rayé O,Roldi E,Zieleskiewicz L,Guinot P G,Mojoli F,Mongodi S,Bouhemad B
Anaesthesia
Pulmonary complications have a significant impact on morbidity and mortality in patients after major surgery. Lung ultrasound can be used at the bed-side, and has gained widespread acceptance in the intensive care unit. We conducted a prospective study to evaluate whether lung ultrasound could be used as a predictive marker for postoperative ventilatory support in high-risk surgical patients. We included 109 patients admitted to the intensive care unit while having mechanical ventilation of the lungs following major surgery. The PaO /F O ratio was calculated on admission and an ultrasound examination performed, including: lung ('lung ultrasound score', number of consolidated lung areas); cardiac (mitral flow); and inferior vena cava imaging (diameter and respiratory variation). Respiratory outcomes included: the need for ventilation support (mechanical ventilation, non-invasive ventilation or high-flow nasal cannula oxygen therapy); acute respiratory distress syndrome; cardiogenic pulmonary oedema; and early or late pulmonary infection. Patients with a lung ultrasound score ≥ 10 had a lower PaO /F O ratio, and needed more postoperative ventilatory support, than patients with lung ultrasound score < 10. Twenty patients had acute respiratory distress syndrome, and 14 had cardiogenic pulmonary oedema. The presence of ≥ 2 areas of consolidated lung was associated with a lower PaO /F O ratio, postoperative ventilatory support, longer intensive care stay and episodes of ventilator-associated pneumonia requiring antibiotics. Our results suggest that at intensive care unit admission, lung ultrasound scoring and detection of atelectasis can predict postoperative pulmonary outcomes after major visceral surgery, and could enhance bed-side decision making.
10.1111/anae.14859
Effects of positive end-expiratory pressure on pulmonary atelectasis after paediatric laparoscopic surgery as assessed by ultrasound: A randomised controlled study.
Anaesthesia, critical care & pain medicine
INTRODUCTION:Positive end-expiratory pressure (PEEP) following alveolar recruitment manoeuvre (RM) can effectively prevent anaesthesia-induced atelectasis in children. We aimed to evaluate the individual effect of PEEP following RM on atelectasis at the end of laparoscopic surgery in infants and small children. METHODS:Children undergoing laparoscopic inguinal hernia repair aged 5 weeks to 2 years were randomly allocated to either the PEEP or control group. A progressive RM was performed after intubation in all cases. The PEEP group received PEEP of 5 cmHO until the end of mechanical ventilation, while the control group did not receive any PEEP. Lung ultrasonography was performed to compare the number of atelectatic regions between the two groups after anaesthesia induction, after RM, and at the end of surgery in 12 thoracic regions. RESULTS:Overall, 432 ultrasonographic images were acquired from 36 children. At the end of surgery, the number of atelectatic regions (median [interquartile range]) was significantly lower in the PEEP group compared to the control group (2.0 [1.0-3.0] versus 4.0 [3.0-4.0] out of 12 regions, respectively; p = 0.02). While no difference was observed between the number of atelectatic regions after induction and at the end of surgery in the control group (p = 0.30), a decrease was observed in the PEEP group (3.0 [2.0-4.0] to 2.0 [1.0-3.0], respectively; p = 0.02). CONCLUSION:RM followed by a PEEP of 5 cmHO can effectively reduce the regions of pulmonary atelectasis at the end of laparoscopic surgery in infants and small children.
10.1016/j.accpm.2022.101034
Perioperative Pulmonary Atelectasis: Part II. Clinical Implications.
Anesthesiology
The development of pulmonary atelectasis is common in the surgical patient. Pulmonary atelectasis can cause various degrees of gas exchange and respiratory mechanics impairment during and after surgery. In its most serious presentations, lung collapse could contribute to postoperative respiratory insufficiency, pneumonia, and worse overall clinical outcomes. A specific risk assessment is critical to allow clinicians to optimally choose the anesthetic technique, prepare appropriate monitoring, adapt the perioperative plan, and ensure the patient's safety. Bedside diagnosis and management have benefited from recent imaging advancements such as lung ultrasound and electrical impedance tomography, and monitoring such as esophageal manometry. Therapeutic management includes a broad range of interventions aimed at promoting lung recruitment. During general anesthesia, these strategies have consistently demonstrated their effectiveness in improving intraoperative oxygenation and respiratory compliance. Yet these same intraoperative strategies may fail to affect additional postoperative pulmonary outcomes. Specific attention to the postoperative period may be key for such outcome impact of lung expansion. Interventions such as noninvasive positive pressure ventilatory support may be beneficial in specific patients at high risk for pulmonary atelectasis (e.g., obese) or those with clinical presentations consistent with lung collapse (e.g., postoperative hypoxemia after abdominal and cardiothoracic surgeries). Preoperative interventions may open new opportunities to minimize perioperative lung collapse and prevent pulmonary complications. Knowledge of pathophysiologic mechanisms of atelectasis and their consequences in the healthy and diseased lung should provide the basis for current practice and help to stratify and match the intensity of selected interventions to clinical conditions.
10.1097/ALN.0000000000004009
The effect of ultra-fast track cardiac anaesthesia in infants and toddlers: a randomised trial.
Cardiology in the young
BACKGROUND:The usefulness of ultra-fast track cardiac anaesthesia may give great benefits to patients; however, its usefulness has not been completely evaluated in infants and toddlers, who are generally considered the most difficult group for ultra-fast track cardiac anaesthesia. METHOD:A total of 130 children were allocated randomly into to a ultra-fast track cardiac anaesthesia group (Group D) or a conventional anaesthesia group (Group C) (each n = 65). In Group D, dexmedetomidine was administrated at a dosage of 1 µg/kg/hour after induction. The patient- controlled intravenous analgesia was dexmedetomidine and sufentanil. In Group C, patients were infused with of the same volume of normal saline, and sufentanil alone for patient-controlled intravenous analgesia. The dosages of sufentanil, extubation time, haemodynamic parameters, postoperative hospitalisation conditions, pain and sedation scores, blood gas analysis, and inotropic scores were all recorded. RESULTS:The dosage of sufentanil (1.49 ± 0.05 vs. 3.81 ± 0.04 µg, p < 0.001) and extubation time (2.63 ± 0.52 vs. 436.60 ± 22.19 minutes, p < 0.001) in Group D were all significantly lower than those in Group C. Moreover, cardiac intensive care unit stay time, total hospital stay, hospitalisation costs, postoperative lactate levels, and inotropic scores were also significantly lower in Group D. CONCLUSIONS:Using of ultra-fast track cardiac anaesthesia in infants and toddlers is effective, it not only reduce the perioperative requirement for opioids and shorten the extubation time but also decreases the inotrope requirement and provide a better postoperative condition for young children.
10.1017/S1047951121003681
The impact of fluid optimisation before induction of anaesthesia on hypotension after induction.
Khan A I,Fischer M,Pedoto A C,Seier K,Tan K S,Dalbagni G,Donat S M,Arslan-Carlon V
Anaesthesia
Intra-operative hypotension is a known predictor of adverse events and poor outcomes following major surgery. Hypotension often occurs on induction of anaesthesia, typically attributed to hypovolaemia and the haemodynamic effects of anaesthetic agents. We assessed the efficacy of fluid optimisation for reducing the incidence of hypotension on induction of anaesthesia. This prospective trial enrolled 283 patients undergoing radical cystectomy and randomly allocated them to goal-directed fluid therapy (n = 142) or standard fluid therapy (n = 141). Goal-directed fluid therapy patients received fluid optimisation based on stroke volume response to passive leg raise before induction; those with positive passive leg raise received intravenous crystalloid fluid boluses until stroke volume was optimised. Baseline mean arterial pressure was measured on the morning of surgery and on arriving in the operating theatre. This post-hoc analysis defined haemodynamic instability as either a > 30% relative drop in mean arterial pressure compared with baseline or absolute mean arterial pressure < 55 mmHg, within 15 min of induction. Forty-two (30%) goal-directed fluid therapy patients underwent fluid optimisation after finding an intravascular fluid deficit via passive leg raise testing; 106 (75%) goal-directed fluid therapy and 112 (79%) standard fluid therapy patients met criteria for haemodynamic instability. There was no significant difference in the incidence of haemodynamic instability between the goal-directed fluid therapy and standard fluid therapy groups using absolute mean arterial pressure drop below 55 mmHg (p = 0.58) or using pre-surgical testing or pre-surgical mean arterial pressure values as baseline (p = 0.21, p = 0.89, respectively); however, the difference in the incidence of haemodynamic instability was significant using the operating theatre baseline mean arterial pressure (p = 0.004). We conclude that fluid optimisation before induction of general anaesthesia did not significantly impact haemodynamic instability.
10.1111/anae.14984
Regional anaesthesia quality indicators for adult patients undergoing non-cardiac surgery: a systematic review.
Anaesthesia
Improvement in healthcare delivery depends on the ability to measure outcomes that can direct changes in the system. An overview of quality indicators within the field of regional anaesthesia is lacking. This systematic review aims to synthesise available quality indicators, as per the Donabedian framework, and provide a concise overview of evidence-based quality indicators within regional anaesthesia. A systematic literature search was conducted using the databases MEDLINE, Embase, CINAHL and Cochrane from 2003 to present, and a prespecified search of regional anaesthesia society websites and healthcare quality agencies. The quality indicators relevant to regional anaesthesia were subdivided into peri-operative structure, process and outcome indicators as per the Donabedian framework. The methodological quality of the indicators was determined as per the Oxford Centre for Evidence-Based Medicine's framework. Twenty manuscripts met our inclusion criteria and, in total, 68 unique quality indicators were identified. There were 4 (6%) structure, 12 (18%) process and 52 (76%) outcome indicators. Most of the indicators were related to the safety (57%) and effectiveness (19%) of regional anaesthesia and were general in nature (60%). In addition, most indicators (84%) were based on low levels of evidence. Our study is an important first step towards describing quality indicators for the provision of regional anaesthesia. Future research should focus on the development of structure and process quality indicators and improving the methodological quality and usability of these indicators.
10.1111/anae.15311
Choosing Wisely in pediatric anesthesia: An interpretation from the German Scientific Working Group of Paediatric Anaesthesia (WAKKA).
Becke Karin,Eich Christoph,Höhne Claudia,Jöhr Martin,Machotta Andreas,Schreiber Markus,Sümpelmann Robert
Paediatric anaesthesia
Inspired by the Choosing Wisely initiative, a group of pediatric anesthesiologists representing the German Working Group on Paediatric Anaesthesia (WAKKA) coined and agreed upon 10 concise positive ("dos") or negative ("don'ts") evidence-based recommendations. (i) In infants and children with robust indications for surgical, interventional, or diagnostic procedures, anesthesia or sedation should not be avoided or delayed due to the potential neurotoxicity associated with the exposure to anesthetics. (ii) In children without relevant preexisting illnesses (ie, ASA status I/II) who are scheduled for elective minor or medium-risk surgical procedures, no routine blood tests should be performed. (iii) Parental presence during the induction of anesthesia should be an option for children whenever possible. (iv) Perioperative fasting should be safe and child-friendly with shorter real fasting times and more liberal postoperative drinking and enteral feeding. (v) Perioperative fluid therapy should be safe and effective with physiologically composed balanced electrolyte solutions to maintain a normal extracellular fluid volume; addition of 1%-2.5% glucose to avoid lipolysis, hypoglycemia, and hyperglycemia, and colloids as needed to maintain a normal blood volume. (vi) To achieve safe and successful airway management, the locally accepted airway algorithm and continued teaching and training of basic and alternative techniques of ventilation and endotracheal intubation are required. (vii) Ultrasound and imaging systems (eg, transillumination) should be available for achieving central venous access and challenging peripheral venous and arterial access. (viii) Perioperative disturbances of the patient's homeostasis, such as hypotension, hypocapnia, hypothermia, hypoglycemia, hyponatremia, and severe anemia, should not be ignored and should be prevented or treated immediately. (ix) Pediatric patients with an elevated perioperative risk, eg, preterm and term neonates, infants, and critically ill children, should be treated at institutions where all caregivers have sufficient expertise and continuous clinical exposure to such patients. (x) A strategy for preventing postoperative vomiting, emergence delirium, and acute pain should be a part of every anesthetic procedure.
10.1111/pan.13383
Pediatric anesthesia after APRICOT (Anaesthesia PRactice In Children Observational Trial): who should do it?
Habre Walid
Current opinion in anaesthesiology
PURPOSE OF REVIEW:This review highlights the requirements for harmonization of training, certification and continuous professional development and discusses the implications for anesthesia management of children in Europe. RECENT FINDINGS:A large prospective cohort study, Anaesthesia PRactice In Children Observational Trial (APRICOT), revealed a high incidence of perioperative severe critical events and a large variability of anesthesia practice across 33 European countries. Relevantly, quality improvement programs have been implemented in North America, which precisely define the requirements to manage anesthesia care for children. These programs, with the introduction of an incident-reporting system at local and national levels, could contribute to the improvement of anesthesia care for children in Europe. SUMMARY:The main factors that likely contributed to the APRICOT study results are discussed with the goal of defining clear requirement guidelines for anesthetizing children. Emphasis is placed on the importance of an incident-reporting system that can be used for both competency-based curriculum for postgraduate training as well as for continuous professional development. Variability in training as well as in available resources, equipment and facilities limit the generalization of some of the APRICOT results. Finally, the impact on case outcome of the total number of pediatric cases attended by the anesthesiologist should be taken into consideration along with the level of expertise of the anesthesiologist for complex pediatric anesthesia cases.
10.1097/ACO.0000000000000580
Fundamentals and innovations in regional anaesthesia for infants and children.
Heydinger G,Tobias J,Veneziano G
Anaesthesia
Regional anaesthesia in children has evolved rapidly in the last decade. Although it previously consisted of primarily neuraxial techniques, the practice now incorporates advanced peripheral nerve blocks, which were only recently described in adults. These novel blocks provide new avenues for providing opioid-sparing analgesia while minimising invasiveness, and perhaps risk, associated with older techniques. At the same time, established methods, such as infant spinal anaesthesia, under-utilised in the last 20 years, are experiencing a revival. The impetus has been the concern regarding the potential long-term neurocognitive effects of general anaesthesia in the young child. These techniques have expanded from single shot spinal anaesthesia to combined spinal/epidural techniques, which can now effectively provide surgical anaesthesia for procedures below the umbilicus for a prolonged period of time, thereby avoiding the need for general anaesthesia. Continuous 2-chloroprocaine infusions, previously only described for intra-operative regional anaesthesia, have gained popularity as a means of providing prolonged postoperative analgesia in epidural and continuous nerve block techniques. The rapid, liver-independent metabolism of 2-chloroprocaine makes it ideal for prolonged local anaesthetic infusions in neonates and small infants, obviating the increased risk of local anaesthetic systemic toxicity that occurs with amide local anaesthetics. Debate continues over certain practices in paediatric regional anaesthesia. While the rarity of complications makes comparative analyses difficult, data from large prospective registries indicate that providing regional anaesthesia to children while under general anaesthesia appears to be at least as safe as in the sedated or awake patient. In addition, the estimated frequency of serious adverse events demonstrates that regional blocks in children under general anaesthesia are no less safe than in awake adults. In infants, the techniques of direct thoracic epidural placement or caudal placement with cephalad threading each have distinct advantages and disadvantages. As the data cannot support the safety of one technique over the other, the site of epidural insertion remains largely a matter of anaesthetist discretion.
10.1111/anae.15283
Characteristics of children aged 2-17 years undergoing anaesthesia in Danish hospitals 2005-2015: a national observational study.
Strøm C,Lundstrøm L H,Afshari A,Lohse N
Anaesthesia
Provision of paediatric anaesthesia requires careful consideration of the child's cognitive state, unique body composition and physiology. In an observational cohort study, we describe the population characteristics and conduct of anaesthesia in children aged 2-17 years from 1 January 2005 to 31 December 2015. Children were identified from the Danish Anaesthesia Database. We recorded the following variables: age; sex; comorbidities; indications for anaesthesia; practice of anaesthesia; and complications. Results are presented for two age groups: 2-5 and 6-17 years. In total, 32,840 (61% male) children aged 2-5 years received 50,484 anaesthesia episodes and 91,418 (54% male) children aged 6-17 years received 141,082 anaesthesia episodes. The younger children, compared with the older children, were more frequently anaesthetised at a university hospital (50% vs. 36%) and for non-surgical procedures (24% vs. 8%). For both age groups, general anaesthesia was the primary choice of anaesthesia regardless of the reason for anaesthesia. For surgery, general anaesthesia using inhalational agents in addition to intravenous agents or alone was more frequently used in younger children (49% vs. 15%), whereas older children commonly received total intravenous anaesthesia (50% vs. 83%). Regional anaesthesia was infrequently utilised. Complications occurred in 3.3% of anaesthesia episodes among 2-5 year olds compared with 3.7% of anaesthesia episodes among children aged 6-17 years. In conclusion, we found younger children (aged 2-5), compared with older children (aged 6-17) were more frequently anaesthetised for non-surgical reasons, at a university hospital and using inhalational agents. Complications were rare.
10.1111/anae.14419
Characteristics of children less than 2 years of age undergoing anaesthesia in Denmark 2005-2015: a national observational study.
Strøm C,Afshari A,Lundstrøm L H,Lohse N
Anaesthesia
There are few data available that describe the current anaesthetic management of children. We have analysed anaesthetic practice and peri-operative complications for children in Denmark aged less than two years. We conducted a population-based observational cohort study using the Danish Anaesthesia Database to identify children who received anaesthesia in hospital from 1 January 2005 until 31 December 2015. Data were combined with that from the Danish National Patient Registry and the Danish Civil Registration System. Age, sex, height, weight, ASA physical status, days in hospital before anaesthesia, number of anaesthetics per child, indications for anaesthesia, methods of anaesthesia, airway management and complications were all recorded. A total of 17,436 children (64% of whom were male) received 27,653 anaesthetics during the study period. In 58% of cases, the child had an ASA physical status score of 1. Thirty-seven percent had a previous anaesthetic episode. Seventy-nine percent were anaesthetised at a university hospital. The indications for anaesthesia were surgery (70%), diagnostic radiology (16%), non-surgical care (11%) and other indications (3%). General anaesthesia combining intravenous and inhalational agents was the most common approach for surgery (68%) and diagnostic radiology (47%). For non-surgical care, general anaesthesia using inhalational agents was the most common method (42%). Neuraxial blocks were used infrequently. The most common regional anaesthetic nerve block was an infraclavicular brachial plexus block (11%). Peri-operative complications occurred in 1.71% of cases. A large proportion of anaesthetics were conducted in children with comorbidities. Non-surgical indications for anaesthesia were frequent and peri-operative complications were rare.
10.1111/anae.14298
Perioperative critical events and morbidity associated with anesthesia in early life: Subgroup analysis of United Kingdom participation in the NEonate and Children audiT of Anaesthesia pRactice IN Europe (NECTARINE) prospective multicenter observational study.
Paediatric anaesthesia
BACKGROUND:The NEonate and Children audiT of Anaesthesia pRactice IN Europe (NECTARINE) prospective observational study reported critical events requiring intervention during 35.2% of 6542 anesthetic episodes in 5609 infants up to 60 weeks postmenstrual age. The United Kingdom (UK) was one of 31 participating countries. METHODS:Subgroup analysis of UK NECTARINE cases (12.8% of cohort) to identify perioperative critical events that triggered medical interventions. Secondary aims were to describe UK practice, identify factors more commonly associated with critical events, and compare 30-day morbidity and mortality between participating UK and nonUK centers. RESULTS:Seventeen UK centers recruited 722 patients (68.7% male, 36.1% born preterm, and 48.1% congenital anomalies) undergoing anesthesia for 876 surgical or diagnostic procedures at 25-60 weeks postmenstrual age. Repeat anesthesia/surgery was common: 17.6% patients prior to and 14.4% during the recruitment period. Perioperative critical events triggered interventions in 300/876 (34.3%) cases. Cardiovascular instability (16.9% of cases) and/or reduced oxygenation (11.4%) were more common in younger patients and those with co-morbidities or requiring preoperative intensive support. A higher proportion of UK than nonUK cases were graded as ASA-Physical Status scores >2 or requiring urgent or emergency procedures, and 39% required postoperative intensive care. Thirty-day morbidity (complications in 17.2%) and mortality (8/715, 1.1%) did not differ from nonUK participants. CONCLUSIONS:Perioperative critical events and co-morbidities are common in neonates and young infants. Thirty-day morbidity and mortality data did not demonstrate national differences in outcome. Identifying factors associated with increased risk informs preoperative assessment, resource allocation, and discussions between clinicians and families.
10.1111/pan.14457