Editor's picks for the pediatric anesthesia article of the day: June 2024
Melissa Brooks Peterson MD, Justin L. Lockman MD, MSEd, Myron Yaster MD
As previously announced, the PAAD has entered into a partnership with the journal Pediatric Anesthesia in which we provide the journal with our top 4-5 PAADs of the month which the journal then posts with short summaries and a hyperlink on their website. We repost this for those of you who may have missed the PAADs when originally posted and/or to refresh your memories for those of you who read the PAADs when first posted. Today’s PAAD are the highest opened articles with the most reader responses in the month of June 2024….(Brooks Peterson M, Yaster M, Lockman JL. Editor's picks for the pediatric anesthesia article of the day: June 2024. Pediatr Anesth. 2024; 34: 1289-1290. doi:10.1111/pan.15008 )
TITLE: Look at that caudal go!
LINK: https://ronlitman.substack.com/p/look-at-that-caudal-go
Kim HJ, Kim H, Lee S, Koh WU, Park SS, Ro Y. Reconsidering injection volume for caudal epidural block in young pediatric patients: a dynamic flow tracking experimental study. Reg Anesth Pain Med. 2024 May 7;49(5):355–360. doi: 10.1136/rapm-2023-104 409. PMID: 37429622.
When performing a caudal what's the volume of drug you need to inject to obtain maximal spread and success? Kim et al. “aimed to estimate the cephalad spread of injection volume by caudal route using dynamic ultrasound imaging in 40 young (6-24 months) pediatric patients undergoing foot surgery. Unfortunately, the visualization of sonographic local anesthetic spread was not correlated to either SENSORY or MOTOR blockade because the patients were anesthetized with a vapor anesthetic.”
TITLE: Beyond the 5 Hs and Ts
LINK: https://ronlitman.substack.com/p/beyond-the-5-hs-and-ts
Meng L, Rasmussen M, Abcejo AS, Meng DM, Tong C, Liu H. Causes of Perioperative Cardiac Arrest: Mnemonic, Classification, Monitoring, and Actions. Anesth Analg. 2024 Jun 1;138(6):1215–1232. doi: 10.1213/ANE.0000000000006664. Epub 2023 Oct 3. PMID: 37788395.
A common mnemonic used in perioperative cardiac arrest (POCA) event and in the Society for Pediatric Anesthesia's Pedi crisis app and in the American Heart Association Pediatric Advanced Life Support (PALS) courses is the 5 Hs and Ts: Hypoxia, Hypovolemia, Hydrogen ions (acidosis), Hypo-/Hyperkalemia, and Hypothermia (Hs) and Toxins (anesthetic drug overdose), Tamponade (cardiac), Tension pneumothorax, Thrombosis (pulmonary), and Thrombosis (coronary) (Ts). Meng et al. propose a modification to assess “preload-contractility-afterload-rate and rhythm (PCARR)” by relying heavily on the use of echocardiography, electrocardiography, pulse oxygen saturation, end-tidal carbon dioxide, and blood pressure to identify clues to the underlying cause of POCA.
TITLE: Successful return to work in anesthesia after maternity leave: a qualitative study
LINK: https://ronlitman.substack.com/p/successful-return-to-work-in-anesthesia
Allen KJ, Chiavaroli N, Reid KJ. Successful return to work in anesthesia after maternity leave: a qualitative study. Anesthesia. 2024 Jan 4. doi: 10.1111/anae.16231. Epub ahead of print. PMID: 38177064.
Maternity leave is the most common reason for extended leave longer than 3 months, with leave duration varying significantly from country to country and among institutions. The authors of this study sought to qualitatively interview anesthetists/anesthesiologists who had at least 3 months of maternity leave and had successfully re-entered the workforce at least 6 months ago at a minimum of 0.1 FTE to do public hospital work in Australia or Aotearoa, New Zealand. The study identified 5 dominant themes from their interviews: Leave duration, planning for re-entry, workplace culture, career impact, and emotional impact. The authors found planning a graded re-entry, rostering considerations, and breastfeeding arrangements to be among the most supportive interventions, with negative attitudes toward re-entry to be among the most challenging.
TITLE: Suprazygomatic Maxillary Nerve Blocks for pediatric T&A
LINK: https://ronlitman.substack.com/p/suprazygomatic-maxillary-nerve-blocks
Lin C, Abboud S, Zoghbi V, Kasimova K, Thein J, Meister KD, Sidell DR, Balakrishnan K, Tsui BCH. Suprazygomatic Maxillary Nerve Blocks and Opioid Requirements in Pediatric Adenotonsillectomy: A Randomized Clinical Trial. JAMA Otolaryngol Head Neck Surg. 2024 May 23:e241011. doi: 10.1001/jamaoto.2024.1011. Epub ahead of print. PMID: 38780948; PMCID: PMC11117150.
Adenotonsillectomy is among the most common and painful procedures performed in children and opioid-based analgesia has historically been the norm. Opioid-sparing and opioid-free analgesic techniques are currently being investigated to avoid the many opioid-related complications including PONV, respiratory depression and chronic opioid abuse. In this prospective, (mostly) blinded, randomized controlled trial, patients were divided into 2 groups. The experimental group received the suprazygomatic nerve block (ropivacaine 0.5%, 1 mg/kg) under ultrasound guidance after induction of anesthesia while the control group did not. The block group had less pain and had modest decreases in opioid consumption. Because ultrasound was used it added 17 minutes of extra OR time to achieve these modest results.
TITLE: More on Video versus Direct Laryngoscopy for Urgent Intubation of Newborn Infants
LINK: https://ronlitman.substack.com/p/more-on-video-versus-direct-laryngoscopy
Geraghty LE, Dunne EA, Ní Chathasaigh CM, Vellinga A, Adams NC, O'Currain EM, McCarthy LK, O'Donnell CPF. Video versus Direct Laryngoscopy for Urgent Intubation of Newborn Infants. N Engl J Med. 2024 May 30;390(20):1885–1894. doi: 10.1056/NEJMoa2402785. Epub 2024 May 5. PMID: 38709215.
In this prospective randomized trial, Geraghty et al. nce again demonstrate in a single center study that “among neonates undergoing urgent endotracheal intubation in the delivery room or NICU, video laryngoscopy resulted in a greater number of successful intubations on the first attempt than direct laryngoscopy.” Some key features: the video laryngoscope was a C-MAC, Karl Storz with size/age-appropriate Miller straight blades. Hyper-angulated blades were not used. The intubators were pediatric residents and neonatology fellows. Medication to facilitate intubation in the NICU (NOT in the Delivery Room) included: intravenous fentanyl (2 mcg/kg), atropine (20 mcg/kg), and succinylcholine (2 mg/kg). Supplemental Oxygen WAS NOT GIVEN DURING during the intubation attempts.
TITLE: Halothane…. Yes halothane!
LINK: https://ronlitman.substack.com/p/halothaneyes-halothane
Friesen RH. The halothane era in pediatric anesthesia: The convergence of a cardiac depressant anesthetic with the immature myocardium of infancy. Paediatr Anaesth. 2024 Jul;34(7):592–596. doi: 10.1111/pan.14840. Epub 2024 Jan 17. PMID: 38231007.
Ndikontar Kwinji R. Halothane: Why we still use it. Paediatr Anaesth. 2024 Jul;34(7):590–591. doi: 10.1111/pan.14900. Epub 2024 Apr 15. PMID: 38619502.
Halothane has largely been removed from most anesthesia machines in high income countries but continues to be a mainstay of general anesthesia In low and moderate income countries because it is so inexpensive. The history and pharmacology of halothane are reviewed as well as tips on how to use halothane safely.
