Week in review June 19-23, 2023
Myron Yaster MD
Ketorolac use in neonates and young infants: Lots of anecdotes and opinions not a lot of data
Rita Agarwal MD, FAAP, FASA and Lynne G. Maxwell MD
Original articles
Nicole A McElroy, Anna Bustin, Sarah Gattoline. Evaluation of the Safety of Ketorolac in Postsurgical Infants Less Than Six Months of Age. Pediatr Pharmacol Ther. 2022;27(4):347-351.
PMID: 35558356 PMCID: PMC9088443
Stone SB. Ketorolac in Postoperative Neonates and Infants: A Systematic Review. J Pediatr Pharmacol Ther. 2021;26(3):240-247. PMID: 33833624; PMCID: PMC8021237
Ziesenitz VC, Welzel T, van Dyk M, Saur P, Gorenflo M, van den Anker JN. Efficacy and Safety of NSAIDs in Infants: A Comprehensive Review of the Literature of the Past 20 Years. Paediatr Drugs. 2022 Nov;24(6):603-655. doi: 10.1007/s40272-022-00514-1. Epub 2022 Sep 2. PMID: 36053397; PMCID: PMC9592650
The use of ketorolac in neonates and infants < 6 months has really not been studied well. How, or if to use it, is very physician and institution specific. These articles provide some limited guidance.
We have a problem
Myron Yaster MD, Lynne G. Maxwell MD, and Odinakachukwu Ehie MD FASA
Editorial
Sandberg WS, Davidson A. "People, We Have a Problem". Anesthesiology. 2023 Jun 1;138(6):581-584. PMID: 37158650
Original article
White RS, Andreae MH, Lui B, Ma X, Tangel VE, Turnbull ZA, Jiang SY, Nachamie AS, Pryor KO; Multicenter Perioperative Outcomes Group Collaborators. Antiemetic Administration and Its Association with Race: A Retrospective Cohort Study. Anesthesiology. 2023 Jun 1;138(6):587-601. PMID: 37158649
In a large retrospective cohort study from the Multicenter Perioperative Research Group (MPOG) database, White et al. found that Black patients receive perioperative antiemetic administration at a lower rate than White patients. This provocative data cannot be ignored nor its shameful, shocking implications.
Through the glass, darkly: variability in GA use for MRI by race
Bishr Haydar MD, Lynne G, Maxwell MD, and Myron Yaster MD
Original article
Ziyu Gan, Julia M Rosenbloom, Elizabeth De Souza, T Anthony Anderson. Racial/Ethnic Variability in Use of General Anesthesia for Pediatric Magnetic Resonance Imaging. Anesth Analg. 2023 Jun 1;136(6):1189-1197. PMID: 36857212
Using an insurance database Gan et al. found that use of general anesthesia for MRI in children varies by race. We had a lot of issues with this study but believe it gives us an opportunity to reflect on the biases we carry and how they may influence how you provide anesthesia to your patients.
Alpha-1-acid glycoprotein and local anesthetics in the neonate
Myron Yaster MD and Lynne G. Maxwell MD
Original article
Linnarsson, C, Bartocci, M, Larsson, BA, Eksborg, S, von Horn, H, Olofsson, MA. Alpha-1-acid glycoprotein and its potential impact on local anesthetic dose in neonates. Pediatr Anaesth. 2023; 33: 571- 576. doi:10.1111/pan.14672
Amide local anesthetics bind to alpha-1 acid glycoproteins (AAGP). Newborns have less AAGP than older children and adults allowing more free unbound local anesthetics in the circulation which may result in toxicity. The authors found that AAGP levels are higher than previously reported. Nevertheless, we would take a conservative approach and not recommend changing current practice and we would urge you to continue to use lower doses of amides in neonates either for single or continuous infusions.
Reader response
Myron Yaster MD
Vikas O'Reilly-Shah, MD, PhD, FASA from the Seattle Children’s Hospital commented on racial disparities in treating PONV. Drs. Mihir Parikh and Ethan Sanford from UT Southwestern commend on Congenital diaphragmatic hernia, ECMO and continuous EEG monitoring