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Background Thoracic bioreactance is a noninvasive and continuous method of cardiac output ( CO) measurement that is being developed in adult patients. Very little information is available on thoracic bioreactance use in children. Objective The aim of the study was to evaluate the ability of a bioreactance device ( NICOM®; Cheetah Medical, Tel Aviv, Israel) to estimate CO and to track changes in CO induced by volume expansion (VE) in children. Methods Cardiac output values obtained using the NICOM® device ( CONICOM) and measured by trans-thoracic echocardiography ( COTTE) were compared in pediatric neurosurgical patients during the postoperative period. Results Seventy-three pairs of measurements of CO obtained in 30 children were available for analysis. The bias (lower and upper limits of agreement) between CONICOM and COTTE was −0.11 (−1.4 to 1.2) l·min−1. The percentage error (PE) was 55%. The precision of the NICOM® device was 45%. A significant correlation was observed between the CO values obtained using the two methods ( r = 0.89, <0.001). The concordance percentage between changes in COTTE and CONicom induced by VE was 84% following exclusion of patients with changes in CO <15% ( n = 5). Conclusions The PE observed is too large, and the limits of agreement too wide, to enable us to comment on the equivalence of the two techniques of CO measurements. However, the NICOM® device performs well in tracking changes in CO following VE. [ABSTRACT FROM AUTHOR]

Background Few data are available in the literature on risk factors for postoperative vomiting ( POV) in children. Objective The aim of the study was to establish independent risk factors for POV and to construct a pediatric specific risk score to predict POV in children. Methods Characteristics of 2392 children operated under general anesthesia were recorded. The dataset was randomly split into an evaluation set ( n = 1761), analyzed with a multivariate analysis including logistic regression and backward stepwise procedure, and a validation set ( n = 450), used to confirm the accuracy of prediction using the area under the receiver operating characteristic curve ( ROCAUC), to optimize sensitivity and specificity. Results The overall incidence of POV was 24.1%. Five independent risk factors were identified: stratified age (>3 and <6 or >13 years: adjusted OR 2.46 [95% CI 1.75-3.45]; ≥6 and ≤13 years: a OR 3.09 [95% CI 2.23-4.29]), duration of anesthesia (a OR 1.44 [95% IC 1.06-1.96]), surgery at risk (a OR 2.13 [95% IC 1.49-3.06]), predisposition to POV (a OR 1.81 [95% CI 1.43-2.31]), and multiple opioids doses (a OR 2.76 [95% CI 2.06-3.70], P < 0.001). A simplified score was created, ranging from 0 to 6 points. Respective incidences of POV were 5%, 6%, 13%, 21%, 36%, 48%, and 52% when the risk score ranged from 0 to 6. The model yielded a ROCAUC of 0.73 [95% CI 0.67-0.78] when applied to the validation dataset. Conclusions Independent risk factors for POV were identified and used to create a new score to predict which children are at high risk of POV. [ABSTRACT FROM AUTHOR]

Background Little information is available on the titration of morphine postoperatively in children. This observational study describes the technique in terms of the bolus dose, the number of boluses required, the time to establish analgesia, and side effects noted. Methods Morphine was administered if pain score ( VAS or FLACC) was >30. Patients weighing less than 45 kg received a 50 μg·kg−1 bolus of morphine with subsequent boluses of 25 μg kg−1 as required. Patients weighing over 45 kg received boluses of 2 mg. Pain and Ramsay scores were recorded up to 90 min after the end of the titration and any side effect or complication was noted. Data are presented as the median [interquartile Q1-Q3 range]. Results Overall, 103 children were studied. The median age was 4.2 years [0.8-12.2 years]. The median weight was 15.5 kg [8.2-35.0 kg]. The protocol was effective for pain control with a significant decrease in pain scores over time. The median pain score ( VAS or FLACC) was 70 [50-80] prior to the initial bolus and 0 [0-10] 90 min after the last bolus. Median Ramsay score was 1 [1-2] before the initial bolus administration and 4 [2-4] at 90 min. The median total dose of morphine was 100 [70-140] μg·kg−1, and the median number of boluses was 3 [2-5]. Side effects were observed in 17% of cases. No serious complications were observed. Conclusions Our study of morphine titration for children shows that our protocol was effective for pain control with a significant decrease in pain scores over time. No serious complications were encountered. More studies on larger cohorts of patients are needed to confirm the efficacy and safety of this protocol. [ABSTRACT FROM AUTHOR]

There are so far no existing consensus guidelines regarding red blood cell transfusion during pediatric surgery, and there is a little information regarding red blood cell transfusion policy among pediatric anesthesiologists. To determine the transfusion threshold and the volumes of packed red blood cell (PRBC) transfusion among French-speaking pediatric anesthesiologists. A questionnaire of case scenarios was sent to active members of the French Language Society of Pediatrics Anesthesiologists (ADARPEF). Of the 324 active members of the ADARPEF, 175 (54%) completed the questionnaire. The threshold for blood transfusion varied from 6 to 12 g·dl depending on the scenario. The hemoglobin threshold for blood transfusion and the volume of blood transfused vary among ADARPEF physicians, for the same class of patients. The median [95% CI] hemoglobin threshold for starting blood transfusion was 7.9 [6.9-8.9], 7.3 [6.4-8.2], and 8.1 [7.0-9.2] g·dl in the pre-, intra-, and postoperative phase, respectively. The median [95% CI] PRBC volume transfused was 11.7 [6.6-16.8] ml·kg, and the median hemoglobin target was 11.3 [9.8-12.8] g·dl. Physicians ranked age (79%), clinical tolerance of anemia (99%), underlying medical conditions (95%), hemodynamic instability (89%), hemostasis disorder (86%), and sepsis (79%) as the most significant factors affecting their transfusion decisions. Most pediatric anesthesiologists (89%) measure the hemoglobin level before PRBC transfusion. This survey identifies significant differences in transfusion practice patterns among pediatric anesthesiologists with a median transfusion threshold of 7.6 [6.6-8.6] g·dl and a median PRBC volume transfusion of 11.7 [16.8-6.6] ml·kg. [ABSTRACT FROM AUTHOR]

The article examines the arguments for and against the use of cuffed and uncuffed tubes in pediatric anesthesia from the perspective of two experts. It highlights issues that are to be resolved with anesthetists who are considering altering their practice of intubation in pediatric patients. It notes that the application of cuffed tube is still commonly used in general pediatric anesthesia practice.

Background: The correct size of cuffed endotracheal tube (CET) limits the risk of postintubation tracheal damage. The aim of this study was to compare the size of the CET used in children with the size predicted by the Khine formula [age (years)/4 + 3]. Methods: After ethical committee approval, 204 children aged 1 day–15 years were included prospectively in the study. The choice of the size of the CET was made at the discretion of the attending anesthesiologist. The main criterion of judgment was the comparison of the leak before and after inflating the cuff at a pressure of 20 cm·H2O. Demographic data, tracheal tube size used and that predicted by Khine’s formulae and side-effects were recorded. Results: Overall, 21% of the CET were in accordance with the size predicted by the Khine formula. In the remaining patients, 72% were oversized and 7% undersized. In 12 cases, the size of CET chosen initially was modified: for a larger size in eight children and for a smaller size in four others. Six children (2.9%) presented with minor postoperative complications. Conclusions: Our data suggest that Khine’s formula for predicting the appropriate tracheal tube size underestimates optimal size by 0.5 mm. We therefore recommend the use of the following formula: internal diameter of the CET = [age/4 + 3.5] in children >1 year of age which may be applied without increased risk of complications. The rate of tracheal reintubation as well as the detected leaks supports these recommendations. [ABSTRACT FROM AUTHOR]

The surgical correction of craniosynostosis may be associated with extensive blood loss and transfusion. The aim of this study was to compare the efficacy of the perioperative use of the continuous autotransfusion system (CATS group) and of the postoperative use of the CBCII ConstaVac® system (CV group) to reduce homologous transfusion in infants during repair of craniosynostosis. Two groups of consecutive infants, weighing <10 kg, and scheduled for the surgical correction of craniosynostosis, were compared retrospectively according to the blood salvaging system used: CATS group and CV group. The primary endpoint was the comparison of the total volume of homologous blood transfused. There was no significant difference between the CV ( n = 69) and the CATS ( n = 135) groups with regard to physical, preoperative and postoperative data, except for the type of craniosysnostosis with more scaphocephaly in the CV group ( P = 0.03). No significant difference in blood loss and homologous transfusion was observed between the two groups during the perioperative period. Two subgroups of patients were also compared: a subgroup including patients operated on with a linear craniectomy for scaphocephaly, and a subgroup including all other patients. There was also no significant difference in blood loss and homologous transfusion between the CV and the CATS groups for these two subgroups of patients. Our results suggest that the postoperative use of the CBCII ConstaVac® system is as efficient as the perioperative use of the CATS® system for reducing homologous blood transfusion during repair of craniosynostosis in infants weighing <10 kg. [ABSTRACT FROM AUTHOR]

Investigates the criteria in the selection of tubes used for pediatric tracheal intubation. Advantages of cuffed tracheal tubes (CTT); Accounts on the limited use of CTT; Methods used by anesthesiologists for tracheal tube sizing.

A letter to the editor is presented in response to the article about bispectral index (BIS)-guided pediatric anesthesia by N. Bhardwaj and S. Yaddanapudi in the previous issue.

Abstract: In pediatric patients, pain remains the most common complaint after surgery. This French multicenter epidemiological study (AlgoDARPEF) aimed to evaluate the use of a smartphone application (App) to assess the duration and severity of pain experienced by children undergoing outpatient surgery. Children younger than 18 years scheduled for an elective outpatient procedure in one of the participating centers were eligible. Parents were invited to provide daily information for 10 days regarding their child's pain and comfort through a smartphone App using the Parents' Postoperative Pain Measure-Short-Form (PPPM-SF). Children older than 6 years could also provide self-assessments of pain using a numerical rating scale (NRS)-11. Data regarding pain medication, preoperative anxiety, postoperative nausea and vomiting, and parent satisfaction were also analyzed. Repeated-measures analyses of variances (ANOVAs) were used to compare the self-assessments and hetero-assessments of pain. Eleven centers participated in the study, and 1573 patients were recruited. Forty-nine percentage of parents (n = 772) actually used the App at least once. In all surgeries, the average pain rating on the PPPM-SF scale did not exceed 3/10 throughout the follow-up period, as well as for 4 main surgical specialties. Age, visceral surgery, and preoperative anxiety ≥ 4/10 were identified as independent risk factors for experiencing at least 1 episode of pain ≥4/10 during the first 48 postoperative hours. Although these findings indicated that postoperative pain management seems to be satisfactory in the families who used the App, some improvements in anxiety management are suggested. This study shows that inviting parents to use a smartphone App to assess and report the quality of postoperative management in pediatric patients provides useful information. A continuous report regarding pain and adverse events over a 10-day postoperative period by a self-reporting or parent's contribution is possible. Future studies should investigate the ability of live data collection using an App to ensure fast, efficient interactions between patients and physicians. [ABSTRACT FROM AUTHOR]

Background: Because of the renewed interest in intubation in children without relaxants, over a period of 1 month, the anaesthesiologists of five paediatric universitary teaching hospitals were asked to complete a questionnaire each time they performed a tracheal intubation without muscle relaxant. Methods: Intubating conditions were assessed with five items. Each item was graded on a four-point scale. Intubating conditions were judged acceptable when all items scored 2 or less. Episodes of oxygen desaturation and failed intubations were noted. Data are expressed as mean ± SD (extremes). Results: Five hundred and two questionnaires were completed during the study period. Children were aged 61 ± 50 (1-180) months old. Induction of anaesthesia was performed with sevoflurane for 62.6% of the children (endtidal concentration 5.9 ± 1.5%) and propofol for 28.9% (dose 5.8 ± 4.2 mg·kg[sup -1]). Opioids were associated with these hypnotics in 53.2% of the children. Tracheal intubation was successful in 87.1% of the children. Sevoflurane produced better intubating conditions than propofol. Sevoflurane requirements for tracheal intubation may be higher in infants aged less than 6 months old than in older children. A severe decrease in SpO[sub 2] (≤ 90%) was observed in 15.9% of the infants aged less than 1 year old and in 1.7% of the children, respectively (P < 0.0001). Conclusions: Sevoflurane is the most commonly used agent for tracheal intubation without relaxants with higher doses being required in infants aged less than 6 months. Propofol, even with opioids, was not so successful. [ABSTRACT FROM AUTHOR]

• General anesthesia for surgery during childhood is a recurring phenomenon. • Anesthesia neurotoxicity is still debated. • A rich preclinical literature describes a wide range of neurotoxicity mechanisms. • The clinical literature about anesthesia neurotoxicity is controversial. • Translational research will open up new avenues of research about anesthesia neurotoxicity. In 2017, the Food and Drug Administration published a safety recommendation to limit the exposure to general anesthesia as much as possible below the age of three. Indeed, several preclinical and clinical studies have questioned the possible toxicity of general anesthesia on the developing brain. Since then, recent clinical studies tried to mitigate this alarming issue. What is true, what is false? Contrary to some perceptions, the debate is not over yet. Only stronger translational research will allow scientists to provide concrete answers to this public health issue. In this review, we will provide and discuss the more recent data in this field, including the point of view of preclinical researchers, neuropsychologists and pediatric anesthesiologists. Through translational research, preclinical researchers have more than ever a role to play to better understand and identify long-term effects of general anesthesia for pediatric surgery on brain development in order to minimize it. [ABSTRACT FROM AUTHOR]

Background Several studies have highlighted the importance of critical incident (CI) reporting in order to enhance patient safety. We have implemented an anonymous procedure for CI reporting in our department of paediatric anaesthesia. This study aims at analysing those CIs so as to improve patient care and risk management. Material and methods CIs were reported by the anaesthetic team using the World Health Organization classification and analysed using the ORION methodology. CIs were classified according to type, surgery and complications. Risk factors and consequences for patients and for the institution were analysed. Risk factors with high degree of harm for the patient were identified using a univariate analysis and odds ratios (OR). Results Over an 18-month period, 114 CIs were reported for 103 patients (median age: 7.0 years [95% CI: 3.6–9.8]). We found that 29.9% of reported CIs had consequences for the patients and 76.3% were considered preventable. The two main types of CI were “respiratory” (28.8%) and “drug-related” (22.8%) incidents. The main risk factor was ‘human error’ (42.3%). Several consequences for the patient and the hospital were identified. An ASA score ≥ 3 (OR: 2.52; [95% CI: 1.10–5.78]) was an independent risk factor for a high degree of patient harm. Conclusion Improving quality of care must be a priority for paediatric anaesthesiologists as most of the CIs observed are preventable and have consequences for the patient and the institution. [ABSTRACT FROM AUTHOR]

Focuses on the issues related to pediatric anesthesia. Use of the laryngeal mask airway in mucopolysaccharidosis; Importance of cuffed tubes in pediatric anesthesia; Increase amount of air in the abdominal cavity.