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People with alternating hemiplegia of childhood undergoing general anesthesia are at risk for severe complications including critical bradycardia and hemiplegic incidents. We performed a 10-year historical cohort study and completed a subgroup analysis of patients who specifically underwent general anesthesia. Patients with ATP1A3 positive variants were compared with those without such variants. The 14 patients reviewed underwent general anesthesia a combined total of 39 times. Two patients had a short QTc documented prior to anesthesia and presented with bradycardia in the recovery room. Two other patients experienced a suspected seizure and hemiplegic incident; one of those patients received no facility-administered medications prior to experiencing a hemiplegic incident, and the other experienced a hemiplegic incident on emergence from anesthesia with subsequent cardiac arrest and successful resuscitation. No apparent association was identified between type of anesthesia and the development of bradycardia or hemiplegic incidences. Of the four patients experiencing critical events, three had the ATP1A3-D801N variant. Although additional research is necessary to confirm such associations, patients with alternating hemiplegia of childhood, specifically the ATP1A3-D801N variant, appear to be at elevated risk for complications associated with general anesthesia, suggesting the need for an increased anticipation of complications for this population., Competing Interests: Name: Emily M. Funk DNP, CRNA Contribution: This author made significant contributions to the conception, synthesis, writing, and final editing and approval of the manuscript to justify inclusion as an author; she is the corresponding author for this article. Disclosures: None. Name: Guy de L. Dear, MB, FRCA Contribution: This author made significant contributions to the conception, synthesis, writing, and final editing and approval of the manuscript to justify inclusion as an author. Disclosures: None. Name: Mary E. Moya-Mendez, MD, MHS, MS Contribution: This author made significant contributions to the conception, synthesis, writing, and final editing and approval of the manuscript to justify inclusion as an author. Disclosures: None. Name: Andrew P. Landstrom, MD, PhD Contribution: This author made significant contributions to the conception, synthesis, writing, and final editing and approval of the manuscript to justify inclusion as an author. Disclosures: None. Name: Andrew Breglio, MD, DPhil Contribution: This author made significant contributions to the conception, synthesis, writing, and final editing and approval of the manuscript to justify inclusion as an author. Disclosures: None Name: Lauren E. Parker, BS Contribution: This author made significant contributions to the conception, synthesis, writing, and final editing and approval of the manuscript to justify inclusion as an author. Disclosures: None Name: April Boggs, RN Contribution: This author made significant contributions to the conception, synthesis, writing, and final editing and approval of the manuscript to justify inclusion as an author. Disclosures: None. Name: Lyndsey Prange, MSN, CPNP Contribution: This author made significant contributions to the conception, synthesis, writing, and final editing and approval of the manuscript to justify inclusion as an author. Disclosures: None. Name: Loraine Barstow DNP, CRNA Contribution: This author made significant contributions to the conception, synthesis, writing, and final editing and approval of the manuscript to justify inclusion as an author. Disclosures: None. Name: Mohamad A. Mikati, MD Contribution: This author made significant contributions to the conception, synthesis, writing, and final editing and approval of the manuscript to justify inclusion as an author; he is the senior author for this article Disclosures: This author has intellectual property interest in gene therapy of ATP1A3-related disease. The authors did not discuss off-label use within the article. Disclosure statements are available upon request., (Copyright © 2025 by the American Association of Nurse Anesthesiology.)

Background: Precise anesthesia delivery helps ensure amnesia, analgesia, and immobility. Conventionally, the end-tidal anesthetic concentration is maintained through manual adjustment of the fresh gas flow and anesthetic vaporizer output. Some anesthesia delivery systems can deliver and maintain clinician-selected end-tidal anesthetic agent (EtAA) concentration using a modified closed-loop system. We evaluated the performance of an End-tidal Control (EtC) system on the Aisys CS 2 anesthesia machine (GE HealthCare). We hypothesized EtC anesthetic delivery would be noninferior to manually controlled anesthetic delivery., Methods: The Multi-site Anesthesia randomized controlled STudy of End-tidal control compared to conventional Results (MASTER) Trial evaluated anesthetic delivery in 210 adult patients receiving inhaled anesthesia. Patients were randomized to either EtC or manual control (MC) anesthetic delivery. The primary objective was to determine whether, compared to conventional anesthesia practice, EtC achieves and maintains clinician-specified EtAA and end-tidal oxygen (Et o2 ) concentrations within defined noninferiority limits. Noninferiority was concluded if the lower limit of the 95% confidence interval (CI) of the difference between the percent duration within the acceptable range (5% of steady state or a margin of ~10% of each agent's minimum alveolar concentration) for EtC and MC was ≥ -5% for both EtAA and Et o2 . Secondary objectives included performance measures: response time: time required to attain 90% of the first desired EtAA, overshoot: amount the controller (or vaporizer delivery) exceeded the desired EtAA, and accuracy: average deviation from the desired EtAA., Results: EtC achieved and sustained targeted EtAA and Et o2 concentrations within the noninferiority threshold. The EtAA was within 5% of the desired value 98% ± 2.05% of the time with EtC compared to 45.7% ± 31.7% of the time with MC (difference 52.3% [95% CI, 45.9%-58.6%], P < .0001). For Et o2 , EtC was within the noninferiority limit 86.3% ± 22.8% of the time compared with MC at 41% ± 33.3% ( P < .0001, difference 45.3% [95% CI, 36.1%-54.5%]). The median response time for achieving 90% of the initial EtAA desired value was 75 seconds with EtC and 158 seconds with MC ( P = .0013). EtC exhibited a median overshoot of 6.64% of the selected EtAA concentration, whereas MC often failed to reach the clinician's desired value. The difference in median percent deviation from desired EtAA value was 15.7% ([95% CI, 13.5%-19.0%], P < 0001)., Conclusions: EtC achieves and maintains the EtAA and Et o2 concentration in a manner that is noninferior to manually controlled anesthesia delivery., Competing Interests: Conflicts of Interest, Funding: Please see DISCLOSURES at the end of this article., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the International Anesthesia Research Society.)

Introduction: Intraoperative neuromonitoring (IONM) is commonly used during surgery of the spine and spinal cord for early surveillance of iatrogenic injury to the central and peripheral nervous system. However, for infants and young children under 3 years of age, the use of IONM is challenging due to incomplete central and peripheral myelination., Case Presentation: We report a case of a T4-T6 dermal sinus tract (DST) that was resected on day of life 23, with the successful use of IONM., Conclusion: To our knowledge, this is the youngest reported case of the use of IONM in the surgical correction of a DST in a neonatal patient. This case demonstrates the potential efficacy of IONM in neonatal spine surgery and the techniques used to adapt the technology to an immature nervous system., (© 2022 S. Karger AG, Basel.)

Background Pathogenic variation in the ATP1A3 -encoded sodium-potassium ATPase, ATP1A3, is responsible for alternating hemiplegia of childhood (AHC). Although these patients experience a high rate of sudden unexpected death in epilepsy, the pathophysiologic basis for this risk remains unknown. The objective was to determine the role of ATP1A3 genetic variants on cardiac outcomes as determined by QT and corrected QT (QTc) measurements. Methods and Results We analyzed 12-lead ECG recordings from 62 patients (male subjects=31, female subjects=31) referred for AHC evaluation. Patients were grouped according to AHC presentation (typical versus atypical), ATP1A3 variant status (positive versus negative), and ATP1A3 variant (D801N versus other variants). Manual remeasurements of QT intervals and QTc calculations were performed by 2 pediatric electrophysiologists. QTc measurements were significantly shorter in patients with positive ATP1A3 variant status ( P <0.001) than in patients with genotype-negative status, and significantly shorter in patients with the ATP1A3-D801N variant than patients with other variants ( P <0.001). The mean QTc for ATP1A3-D801N was 344.9 milliseconds, which varied little with age, and remained <370 milliseconds throughout adulthood. ATP1A3 genotype status was significantly associated with shortened QTc by multivariant regression analysis. Two patients with the ATP1A3-D801N variant experienced ventricular fibrillation, resulting in death in 1 patient. Rare variants in ATP1A3 were identified in a large cohort of genotype-negative patients referred for arrhythmia and sudden unexplained death. Conclusions Patients with AHC who carry the ATP1A3-D801N variant have significantly shorter QTc intervals and an increased likelihood of experiencing bradycardia associated with life-threatening arrhythmias. ATP1A3 variants may represent an independent cause of sudden unexplained death. Patients with AHC should be evaluated to identify risk of sudden death.

Study Objective: To determine how much money patients are willing to pay to avoid postoperative muscle pains associated with succinylcholine., Design: Observational study with survey instrument., Setting: University-affiliated metropolitan hospital., Patients: Eighty-eight adult patients, 43 men and 45 women, who were scheduled to undergo surgery with general anesthesia and who completed a preoperative questionnaire (median age range, 41-50 y; median income, US$45,000-60,000)., Interventions and Measurements: Patients completed a computerized, interactive questionnaire preoperatively. They were asked about demographics and previous experiences with muscle pain and postoperative myalgia. With the use of the willingness-to-pay model, the value that they would be willing to pay for a hypothetical muscle relaxant that avoided postoperative myalgia was determined., Main Results: Eighty-nine percent of patients considered avoiding postoperative myalgia as important. Patients were willing to pay a median (interquartile range) of $33 ($19-$50) out of pocket for a muscle relaxant that was not associated with postoperative myalgia, a figure that increased to $40 if the insurance company paid for the drug (P < 0.0001). Willingness to pay was influenced by patients' income but not by prior experience with postoperative myalgia., Conclusion: Patients consider avoidance of postoperative myalgia important and are willing to pay $33 out of pocket for a muscle relaxant that is not associated with this side effect.

Study Objective: To determine if 450 micrograms/kg (1.5 times the ED95) of rocuronium would result in a comparable onset with a shorter duration of action when compared with 600 micrograms/kg (2 times the ED95)., Design: Randomized, single-blind study., Setting: Teaching hospital., Patients: 85 ASA physical status I and II children ages 2 through 12, undergoing elective surgery with an inhalation induction using halothane., Interventions: Group 1 received 600 micrograms/kg rocuronium, and Group 2 received 450 micrograms/kg rocuronium., Measurements and Main Results: The two groups were compared using a Student's t-test, with p < 0.05 significant. The time of onset, or time to 95% suppression of neuromuscular twitch with standard errors, was 140 +/- 13 seconds (range 46 to 365 sec) in Group 1 and 148 +/- 13 seconds (range 82 to 345 sec) in Group 2 (NS = not significant). The times to 25% return of twitch from baseline (T25) in Groups 1 and 2 were 28 +/- 1.5 minutes (range 14 to 45 min) and 26 +/- 1.6 minutes (range 10 to 55 min), respectively (NS). The differences between these two doses in onset of, and recovery from, block were not found to be statistically significant. The results, however, excluded 5% of the higher dose group and 31% of the lower dose group who did not achieve 95% suppression of twitch. Time to maximal suppression of neuromuscular blockade, however, was not statistically significant for the 85 patients with a time of 270 +/- 28 seconds (range 91 to 605 sec) with a mean maximal suppression of 98.7% in Group 1 and 313 +/- 25 seconds (range 91 to 899 sec) with a mean maximal suppression of 93.1% in Group 2., Conclusion: The two doses of rocuronium did not differ statistically in onset or duration. Rocuronium at 600 micrograms/kg offers more reliability than 450 micrograms/kg in achieving adequate muscle relaxation, and the lower dose may result in a significantly large number of patients who may have inadequate intubating conditions.

In a randomized controlled trial at Duke University and University of North Carolina Hospitals, 143 two to six year old children undergoing elective ambulatory surgery were randomized into a control group who received routine preoperative teaching or an intervention group who received an interactive teaching book. Changes in behaviour were measured by a Vernon behavioural questionnaire preoperatively and again two weeks postoperatively. A Global Mood Score was assessed in the preoperative holding area, at arrival into the operating room, and at the time of mask induction. The children in the control group were significantly more aggressive postoperatively than the intervention group (P < 0.05). Children who received the interactive teaching book exhibited higher levels of anxiety on the day of surgery, but fewer behavioural changes two weeks following surgery. Parents in the intervention group reported that preoperative teaching helped their child (87%) and themselves (83%).

Background: Although approximately 2,000 medical practice guidelines have been proposed, few have been successfully implemented and sustained. We hypothesized that we could develop and institute practice guidelines to promote more appropriate use of costly anesthetics, to generate and sustain widespread compliance from a large physician group, and to decrease costs without adversely affecting clinical outcomes., Methods: A prospective before and after comparison study was performed at a tertiary care medical center. Clinical outcomes data and times indicative of perioperative patient flow were collected on the first of two sets of patients 1 month before discussion of practice guidelines. Practice guidelines were developed by the physicians and their associated care team for the intraoperative use of anesthetic drugs. A drug distribution process was developed to aid compliance. Clinical outcomes data and times indicative of perioperative patient flow were collected on the second set of patients 1 month after institution of practice guidelines. Hospital drug costs and adherence to guidelines were noted throughout the study period and for each of the following 9 months by querying the database of an automated anesthesia record keeper., Results: A total of 1,744 patients were studied. Drug costs decreased from 56 dollars per case to 32 dollars per case as a result of adherence to practice guidelines. Perioperative patient flow was minimally affected. Time (mean +/- SD) from end of surgery to arrival in the post-anesthesia care unit (PACU) increased from 11 +/- 7 min before the authors instituted practice guidelines to 14 +/- 8 min after practice guidelines (P < 0.0001). Admission of inpatients to the PACU receiving monitored anesthesia care increased from 6.5 to 12.9% (P < 0.02). Perioperative patient flow and clinical outcomes were not otherwise adversely affected. Compliance and cost savings have been sustained., Conclusions: This study is an example of a successful physician-directed program to promote more appropriate utilization of health care resources. Cost savings were obtained without any substantial changes in clinical outcomes. Institution of similar practice guidelines should result in pharmaceutical savings in the range of 50% at tertiary care centers around the country, with a slightly smaller degree of savings expected at institutions with more ambulatory surgery.

Background: Medical informatics provide a new way to evaluate the practice of medicine. Anesthesia automated record keepers have introduced anesthesiologists to computerized medical records. To derive useful information from the stored data requires programming that is not currently commercially available. The authors describe how they custom-programmed an automated record keeper's database to perform cost calculations, how they validated the programming, and how they used the data in a successful pharmaceutical cost-containment program., Methods: The Arkive (San Diego, CA) automated record keeper database was programmed at Duke University Medical Center as an independent noncommercial project to calculate costs according to standard formulae and to follow adherence to Duke University Department of Anesthesiology's prescribing guidelines for anesthetic drugs. Validation of that programming (including analysis of discarded drugs) was accomplished by comparing database calculated costs with actual pharmacy distribution of drugs during a 1-month period., Results: Validation data demonstrated a 99% accuracy rate for total costs of the drugs studied (atracurium, vecuronium, rocuronium, propofol, midazolam, fentanyl, and isoflurane). The study drugs represented approximately 67% of all drug costs for the period studied., Conclusions: Programming of an anesthesia automated record keeper's database yields essential information for management of an anesthetic practice. Accurate economic evaluation of anesthetic drug use is now possible. In the future, as definitive identification of best anesthetic practices that yield optimal patient outcomes and higher measures of patient satisfaction is pursued, large numbers of patients should be studied. This is only possible through database analysis and complete computerization of the perioperative medical record.

Background: This study determined the accuracy of previously defined adult fentanyl pharmacokinetics in children having surgery; from this population, the pharmacokinetics of fentanyl were characterized in children when administered via a computerized assisted continuous-infusion device., Methods: Twenty children between the ages of 2.7 and 11 y scheduled to undergo elective noncardiac surgery were studied. After induction, anesthesia was maintained with 60% nitrous oxide in oxygen supplemented with fentanyl (n = 10) or fentanyl plus isoflurane (n = 10). Fentanyl was administered via computerized assisted continuous-infusion to target concentrations determined by clinical requirements. Plasma fentanyl concentrations were measured and used to evaluate the performance of the fentanyl pharmacokinetics and then to determine a new set of pharmacokinetic parameters and the variance in the context-sensitive half-times simulated for these patients., Results: The original adult fentanyl pharmacokinetics resulted in a positive bias (10.4%), indicating that measured concentrations were mostly greater than predicted. A two-compartment model with age and weight as covariates provided the optimal pharmacokinetic parameters. These resulted in a residual performance error of -1.1% and a median absolute performance error of 17.4%. The context-sensitive times determined from this pediatric population were considerably shorter than the context-sensitive times previously published for adults., Conclusions: The pharmacokinetics of fentanyl administered by computerized assisted continuous-infusion differ between adults and children. The newly derived parameters are probably more suitable to determine infusion schemes of up to 4 h in children between the ages of 2 and 11 y.

Gas exchange occurring in the abdominal cavity during laparoscopy, using carbon dioxide as the insufflating gas, was investigated in 25 female patients being ventilated with 66.6% nitrous oxide and 33.3% oxygen. The gas remaining in the abdomen at the end of the procedure was collected and measurements were made using an infrared spectrometer, a paramagnetic analyser and a mass spectrometer. The mean duration of the laparoscopy was 9.5 minutes and the mean volume of carbon dioxide delivered was 6.8 litres. Nitrous oxide concentration in the abdomen was found to increase significantly with the duration of the procedure, varying from 1.4% to 12.8% with a mean of 4.3% (s.d. +/- 2.4). Oxygen concentration measured from 0.1 to 1.8% with a mean of 0.7% (s.d. +/- 0.4). Nitrogen concentration varied from zero to 1.8%, having a mean concentration of 0.8% (s.d. +/- 0.5). Carbon dioxide content was from 85.7 to 99.6% with a mean concentration of 94.2% (s.d. +/- 3.1).