Paediatric anaesthesia
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Total intravenous anesthesia (TIVA) using a mixture of propofol and remifentanil in the same syringe has become an accepted technique in Pediatric Anesthesia. A survey by a group of respected UK anesthetists demonstrated a low incidence of serious complications, related to the pharmacology and dose of the drugs. However, a current guideline for the safe use of TIVA recommends against this practice. ⋯ The medicolegal considerations are stark. In UK and EU Law, mixing propofol and remifentanil creates a new, unlicensed drug and the person mixing takes on the responsibilities of manufacturer. If a patient receiving anesthesia in the form of a mixed propofol-remifentanil infusion suffered a critical incident or actual harm, the clinician's practice may come under scrutiny and criticism, potentially involving a legal challenge and the Medical Regulator.
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Paediatric anaesthesia · Dec 2020
An approach to using pharmacokinetics and electroencephalographyforpropofol anesthesia for surgery in infants.
Safe and effective techniques for propofol total intravenous anesthesia (TIVA) in infants are not well imbedded into clinical practice, resulting in practitioner unfamiliarity and potential for over- and under-dosing. In this education article, we describe our approach to TIVA dosing in infants and toddlers (birth to 36 months) which combines the use of pharmacokinetic models with EEG multi-parameter analysis. Pharmacokinetic models describe propofol and remifentanil effect site concentrations (Ce) over time in different age groups for a given dosing regimen. ⋯ In our practice, we use a "lookup table" of age-based dosing regimens or target-controlled infusion (TCI) based on the pharmacokinetic models to deliver a target propofol Ce and co-administer remifentanil and/or regional technique for analgesia. We analyze Electroencephalogram (EEG) waveforms, SEF, and DSA to adjust the propofol dose or TCI target concentration to the individual infant. EEG analysis mitigates against biological variability inherent in the pharmacokinetic models and has improved our experience with TIVA for infants.
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Paediatric anaesthesia · Dec 2020
Review Meta AnalysisEfficacy of caudal versus intravenous administration of α2 adrenoceptor agonists to prolong analgesia in pediatric caudal block: A systematic review and meta-analysis.
α2 adrenoceptor agonists have been proposed as adjuncts to prolong analgesia in pediatric caudal block. The aim of this meta-analysis was to compare the analgesic efficacy of caudal vs intravenous α2 adrenoceptor agonists during pediatric caudal block. ⋯ Caudal α2 adrenoceptor agonists as adjuncts to local anesthetic during pediatric caudal block are more effective than intravenous injection. However, the results were affected by small sample size and significant heterogeneity.
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Paediatric anaesthesia · Dec 2020
Observational StudyUltrasound assessment of gastric emptying time after intake of clear fluids in children scheduled for general anesthesia - a prospective observational study.
While many clinics have changed their local regimen toward a more liberal policy regarding clear fluid fasting for general anesthesia, there is a lack of studies evaluating gastric emptying time in a clinical setting. ⋯ This study showed that the gastric emptying time of children after intake up to 5 mL kg-1 clear fluids was <1 hour in a clinical setting. These results support the more liberal fasting regimen favoring a 1-hour fasting time and suggest 5 mL kg-1 as an upper limit for clear fluids (eg, water, sugared water or tea or diluted fruit juice) from 2 hours to 1 hour before induction of anesthesia in children.
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Paediatric anaesthesia · Dec 2020
Observational StudyRoutine Chest X-Ray Following Ultrasound-Guided Internal Jugular Veins Catheterization in Critically Ill Children: A Prospective Observational Study.
Recent studies in adults have shown that routine chest X-ray following ultrasound-guided central venous catheter insertion through the internal jugular vein is unnecessary due to a low rate of complications. ⋯ In this critically ill pediatric cohort, all central venous catheters inserted under ultrasound guidance could have been used with safety prior to acquiring chest X-ray. Overall chest X-ray impacted patient management in only 1% of cases. Our results do not support delaying urgent central venous catheter use pending chest X-ray completion in critically ill children.