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Intravenous fluids for perioperative infusion therapy should be isotonic to maintain the body fluid homeostasis in children. Modified fluid gelatin 4% in a balanced electrolyte solution has a theoretical osmolarity of 284 mosmol LWe thus hypothesized that the infusion of gelatin would be expected to decrease plasma osmolality. We performed an in-vitro experiment and an in-vivo study to evaluate the impact of gelatin on the osmolality in children.In the in-vitro experiment, full blood samples were diluted with gelatin 4% or albumin (50 g LIn the in-vitro experiment, 65 gradually diluted blood samples from five volunteers (age 25-55 years) were analyzed. The dilution with gelatin caused no significant changes in osmolality between 0% and 100%. Compared with gelatin, the osmolality in the albumin group was significantly lower between 50% and 100% dilution (p .05). In the in-vivo study, 221 children (age 21.4 ± 30 months) were included. After gelatin infusion, the osmolality increased significantly (mean change 4.3 ± 4.8 [95% CI 3.7-4.9] mosmol kg HGelatin in a balanced electrolyte solution has isotonic characteristics in-vitro and in-vivo, despite the low theoretical osmolarity, probably caused by the (unmeasured) negative charges in the gelatin molecules contributing to the plasma osmolality. For a better evaluation of the (real) tonicity of gelatin-containing solutions, we suggest to calculate the osmolality (mosmol kg HClinicalTrials.gov (ID: NCT02495285).

In our institution, a modified WHO surgical safety checklist was implemented more than ten years ago. In retrospect, we noticed that pediatric anesthesia was underrepresented in our surgical safety checklist modification. Therefore, we added a standardized team briefing (pedSOAP-M) immediately before induction of anesthesia and hypothesized that the use of this checklist was effective to detect relevant errors with potentially harmful consequences.The primary aim was to assess the incidence and characteristics of the detected errors, and the secondary aim was to identify factors influencing error detection.This prospective observational study was performed between November 2020 and October 2021 in five operation rooms at the Children's Hospital of Hannover Medical School, Germany. The subcategories of the pedSOAP-M checklist were suction, oxygen, airway, pharmaceuticals, and monitoring. Demographic and procedure-related data and the briefing results were documented anonymously and undated, using a standardized case report form.We enrolled 1030 and analyzed 1025 patients (aged 0-18 years). Relevant errors were detected in 111 (10.8%) cases (suction 2.5%, oxygen 3.0%, airway 0.2%, pharmaceuticals 2.4%, monitoring 3.0%). In the pharmaceuticals subcategory, the most common error was entering a wrong patient weight into the perfusor syringe pumps. Experienced anesthetists detected significantly more errors than less experienced ones.The briefing tool pedSOAP-M was effective in detecting relevant errors with potentially harmful consequences. The presence of an experienced anesthetist was associated with a higher efficacy of the briefing. Particular attention should be given to entering patient weight into the anesthesia workstation and the perfusor syringe pumps.

Background Postoperative bleeding is a major problem in children undergoing complex pediatric cardiac surgery. The primary aim of this prospective observational study was to evaluate the effect of an institutional approach consisting of early preventive fibrinogen, prothrombin complex and platelets administration on coagulation parameters and postoperative bleeding in children. The secondary aim was to study the rate of re-intervention and postoperative transfusion, the occurrence of thrombosis, length of mechanical ventilation, ICU stay and mortality. Methods In fifty children (age 0–6 years) with one or more predefined risk factors for bleeding after cardiopulmonary bypass (CPB), thrombelastography (TEG) and standard coagulation parameters were measured at baseline (T1), after CPB and reversal of heparin (T2), at sternal closure (T3) and after 12 h in the ICU (T4). Clinical bleeding was evaluated by the surgeon at T2 and T3 using a numeric rating scale (NRS, 0–10). Results After CPB and early administration of fibrinogen, prothrombin complex and platelets, the clinical bleeding evaluation score decreased from a mean value of 6.2 ± 1.9 (NRS) at T2 to a mean value of 2.1 ± 0.8 at T3 (NRS; P P r = 0.70, P − 1) correlated significantly with weight (r = − 0.42, P = 0.002), priming volume as percentage of estimated blood volume (r = 0.30, P = 0.034), minimum CPB temperature (r = − 0.30, P = 0.033) and the change in clinical bleeding evaluation from T2 to T3 (r = 0.71, P 10% of estimated blood volume) was 8%. No child required a surgical re-intervention, and no cases of thrombosis were observed. Hospital mortality was 0%. Conclusion In this observational study of children with an increased risk of bleeding after CPB, an early preventive therapy with fibrinogen, prothrombin complex and platelets guided by clinical bleeding evaluation and TEG reduced bleeding and improved TEG and standard coagulation parameters significantly, with no occurrence of thrombosis or need for re-operation. Trial registration German Clinical Trials Register DRKS00018109 (retrospectively registered 27th August 2019).

Modified fluid gelatin 4% is approved for use in children, but there is still a surprising lack of clinical studies including large numbers of pediatric patients. Therefore, we performed a European prospective noninterventional multicenter study to evaluate the use of a modified fluid gelatin 4% in saline (sal-GEL) or an acetate-containing balanced electrolyte solution (bal-GEL) in children undergoing major pediatric surgery.The primary aim was to assess the indications and dosing of modified fluid gelatin, and the secondary aim was to assess the safety and efficacy, focusing, in particular, on routinely collected clinical parameters.Children aged up to 12 years with ASA risk scores of I-III receiving sal-GEL or bal-GEL were followed perioperatively. Demographic data, surgical procedures performed, anesthesia, hemodynamic and laboratory data, adverse events, and adverse drug reactions were documented using a standardized case report form.601 children that were investigated at 13 European pediatric centers from May 2015 to March 2020 (sal-GEL 20.1%, bal-GEL 79.9%; mean age 29.1 ± 38.6 (range 0-144) months; body weight 12.1 ± 10.5 (1.4-70) kg) were included in the analysis. The most frequent indications for GEL infusion were hemodynamic instability without bleeding (76.0%), crystalloids alone not being sufficient for hemodynamic stabilization (55.7%), replacement of preoperative deficit (26.0%), and significant bleeding (13.0%). Mean infused GEL volume was 13.0 ± 5.3 (2.4-37.5) ml kgModerate doses up to 20 ml kg

Background Neonates and infants with congenital heart disease undergoing general anesthesia have an increased risk for critical cardiovascular events. Etomidate produces very minimal changes in hemodynamic parameters in older children with congenital heart disease. There is a lack of studies evaluating the effect of etomidate on systemic and regional cerebral perfusion in neonates and infants with congenital heart disease. Aim The aim of this prospective observational study was to evaluate the effect of etomidate on systemic and regional cerebral perfusion in neonates and infants with congenital heart disease. Methods In fifty infants aged 0-11 months (24% neonates n = 12) with congenital heart disease, mean arterial blood pressure, cardiac index using electrical cardiometry, and regional cerebral oxygen saturation using near-infrared spectroscopy were measured at baseline and 1, 3, 5, and 10 minutes after induction by 0.4 mg kg-1 etomidate. Hypotension was defined as a mean arterial blood pressure under 35 mm Hg and cerebral desaturation as a regional cerebral oxygen saturation of less than 80% of baseline. Results Mean arterial blood pressure, cardiac index, and regional cerebral oxygen saturation remained stable above the predefined limits. Mean arterial blood pressure decreased slightly within a physiological range after 3 minutes (P = .005, 95% CI:-5.9 to -1.0). No significant change in cardiac index could be observed. Conclusion Etomidate 0.4mg kg-1 does not impair systemic or regional cerebral perfusion in neonates or infants with congenital heart disease.

Background The amplitude-integrated EEG (aEEG) is a widely used monitoring tool in neonatology / pediatric intensive care. It takes into account the amplitudes, but not the frequency composition, of the EEG. Advantages of the aEEG are clear criteria for interpretation and time compression. During the first year of life, the electroencephalogram (EEG) during sedation / anesthesia changes from a low-differentiated to a differentiated EEG; higher-frequency waves develop increasingly. There are few studies on the use of aEEG during pediatric anesthesia. A systematic evaluation of the aEEG in defined EEG stages during anesthesia / sedation is not yet available. Parameters of pediatric EEGs (power, median frequency, spectral edge frequency) recorded during anesthesia and of the corresponding aEEGs (upper and lower value of the aEEG trace) should be examined for age-related changes. Furthermore, it should be examined whether the aEEG can distinguish EEG stages of sedation / anesthesia in differentiated EEGs. Methods In a secondary analysis of a prospective observational study EEGs and aEEGs (1-channel recordings, electrode positions on forehead) of 50 children (age: 0–18 months) were evaluated. EEG stages: A (awake), Slow EEG, E2, F0, and F1 in low-differentiated EEGs and A (awake), B0–2, C0–2, D0–2, E0–2, F0–1 in differentiated EEGs. Results Median and spectral edge frequency increased significantly with age (p p 1 to E1 (p = 0.04, or less), and the upper and lower values of the aEEG trace increased with age (p 1 to E1 were assigned to the original EEG stage in only 19.3% of the cases. When age was added as the third variable, the rate of correct reclassifications was 28.5%. Conclusions The aEEG was not suitable for distinguishing EEG stages above the burst suppression range. For this purpose, the frequency composition of the EEG should be taken into account.

BACKGROUND Trigger-free anaesthesia is required for patients who are susceptible to malignant hyperthermia. Therefore, all trace of volatile anaesthetics should be removed from anaesthetic machines before induction of anaesthesia. Because the washout procedure is time consuming, activated charcoal filters have been introduced, but never tested under minimal flow conditions. OBJECTIVE To investigate performance of activated charcoal filters during long duration (24 h) simulated ventilation. DESIGN A bench study. SETTING A Primus anaesthesia machine (Drager) was contaminated with either 4% sevoflurane or 8% desflurane by ventilating a test lung for 90 min. The machine was briefly flushed according to manufacturer instructions, activated charcoal filters were inserted and a test lung was ventilated in a 24 h test. Trace gas concentrations were measured using a closed gas loop high-resolution ion mobility spectrometer with gas chromatographic preseparation. During the experiment reduced fresh gas flows were tested. At the end of each experiment the activated charcoal filters were removed and the machine was set to standby for 10 min to test for residual contamination within the circuit. The activated charcoal filters were reconnected into the circuit to test their ability to continue removing volatile anaesthetics (functional test) from the gas. Control experiments were conducted without activated charcoal filters. MAIN OUTCOME MEASURES Absolute concentrations of desflurane and sevoflurane. RESULTS The concentration of volatile anaesthetics dropped to less than 5 ppm (parts per million) following insertion of activated charcoal filters. In the desflurane experiments at least 1 l min FGF was needed to keep the concentration below an acceptable level (

Background Infants are likely to develop anuria during laparoscopy which is uncommon in older patients. The reason for this susceptibility remains unknown. We compared the impact of CO2 pneumoperitoneum on renal perfusion and urine production in piglets compared with adolescent pigs. We furthermore investigated the effects of different resuscitation strategies. Materials and Methods Male piglets (n = 21) were divided into four groups: (a) infant controls (n = 5), (b) infants with crystalloid restitution (n = 6), (c) infants with colloidal restitution (n = 5), and (d) adolescents with crystalloid restitution (n = 5). Animals were ventilated, the central vessels and ureters were cannulated, and the animals were subjected to a 3-hour, 10 mm Hg CO2 pneumoperitoneum followed by 2-hour resuscitation. Renal perfusion was assessed by fluorescent microspheres and the rate of urine flow was measured. Results Urine production significantly decreased after insufflation only in the infant crystalloid and adolescent group, but not in controls or infants treated with colloids. In the infant crystalloid group, urine production remained at levels below 20% of baseline throughout the experiment. In this group, the renal perfusion dropped significantly after the beginning of the capnoperitoneum and remained significantly reduced throughout the experiment. Conclusion Our data indicates that capnoperitoneum impairs renal perfusion and urine production in infants. In moderate-pressure capnoperitoneum, this effect cannot be compensated by application of crystalloids but with colloids.

OBJECTIVES Current guidelines recommend 6 h of fasting for solids before anaesthesia. However, prolonged fasting may lead to discomfort, hunger, thirst, misbehaviour and lipolysis. To prevent this, a more liberal fasting regimen has been empirically implemented in our children's hospital, allowing a shorter fasting time of 4 h for a standardised light breakfast. AIM The aim of this study was to determine the gastric emptying time after a standardised light breakfast in healthy children. DESIGN A prospective observational noninterventional study. METHODS After fasting overnight, the children had a standardised light breakfast. Before and afterwards, ultrasound examinations of the gastric antrum were performed hourly to determine the gastric antral area (GAA), which is a surrogate parameter for gastric volume in children in the right lateral position (RLP). Demographic data and fasting times are presented as mean ± SD (range) and GAA as median (interquartile range). RESULTS Twenty-two children aged 7.8 (2.5 to 13.6) years volunteered for this study. After fasting overnight [735 ± 120 (467 to 930) min], the initial GAA was 3.06 (2.35 to 4.03) cm in RLP. After the light breakfast, GAA in RLP initially increased and decreased subsequently. After 4 h, GAA in RLP was lower than the initial value (median of differences -0.54, 95% confidence interval -1.00 to -0.07, P

Background Exhaled propofol concentrations correlate with propofol concentrations in adult human blood and the brain tissue of rats, as well as with electroencephalography (EEG) based indices of anesthetic depth. The pharmacokinetics of propofol are however different in children compared to adults. The value of exhaled propofol measurements in pediatric anesthesia has not yet been investigated. Breathing system filters and breathing circuits can also interfere with the measurements. In this study, we investigated correlations between exhaled propofol (exP) concentrations and the Narkotrend Index (NI) as well as calculated propofol plasma concentrations. Methods A multi-capillary-column (MCC) combined with ion mobility spectrometry (IMS) was used to determine exP. Optimal positioning of breathing system filters (near-patient or patient-distant) and sample line (proximal or distal to filter) were investigated. Measurements were taken during induction (I), maintenance (M) and emergence (E) of children under total intravenous anesthesia (TIVA). Correlations between ExP concentrations and NI and predicted plasma propofol concentrations (using pediatric pharmacokinetic models Kataria and Paedfusor) were assessed using Pearson correlation and regression analysis. Results Near-patient positioning of breathing system filters led to continuously rising exP values when exP was measured proximal to the filters, and lower concentrations when exP was measured distal to the filters. The breathing system filters were therefore subsequently attached between the breathing system tubes and the inspiratory and expiratory limbs of the anesthetic machine. ExP concentrations significantly correlated with NI and propofol concentrations predicted by pharmacokinetic models during induction and maintenance of anesthesia. During emergence, exP significantly correlated with predicted propofol concentrations, but not with NI. Conclusion In this study, we demonstrated that exP correlates with calculated propofol concentrations and NI during induction and maintenance in pediatric patients. However, the correlations are highly variable and there are substantial obstacles: Without patient proximal placement of filters, the breathing circuit tubing must be changed after each patient, and furthermore, during ventilation, a considerable additional loss of heat and moisture can occur. Adhesion of propofol to plastic parts (endotracheal tube, breathing circle) may especially be problematic during emergence. Trial Registration The study was registered in the German registry of clinical studies (DRKS-ID: DRKS00015795).

Background Despite well-defined recommendations, prolonged fasting times for clear fluids and solids are still common before elective surgery in adults. Extended fasting times may lead to discomfort, thirst, hunger and physiological dysfunctions. Previous studies have shown that prolonged fasting times are frequently caused by patients being misinformed as well as inadequate implementation of the current guidelines by medical staff. This study aimed to explore how long elective surgery patients fast in a German secondary care hospital before and after the introduction of an educational note for patients and re-training for the medical staff. Methods A total of 1002 patients were enrolled in this prospective, non-randomised interventional study. According to the power calculation, in the first part of the study actual fasting times for clear fluids and solids were documented in 502 consecutive patients, verbally instructed as usual regarding the recommended fasting times for clear fluids (2 h) and solids (6 h). Subsequently, we implemented additionally to the verbal instruction a written educational note for the patients, including the recommended fasting times. Furthermore, the medical staff was re-trained regarding the fasting times using emails, newsletters and employee meetings. Thereafter, another 500 patients were included in the study. We hypothesised, that after these quality improvement procedures, actual fasting times for clear fluids and solids would be more accurate on time. Results Actual fasting times for clear fluids were in the median 11.3 (interquartile range 6.8–14.3; range 1.5–25.5) h pre-intervention, and were significantly reduced to 5.0 (3.0–7.2; 1.5–19.8) h after the intervention (median difference (95%CI) − 5.5 (− 6.0 to − 5.0) h). The actual fasting times for solids also decreased significantly, but only from 14.5 (12.1–17.2; 5.4–48.0) h to 14.0 (12.0–16.3; 5.4–32.0) h after the interventions (median difference (95%CI) − 0.52 (− 1.0 to − 0.07) h). Conclusions The study showed considerably extended actual fasting times in elective adult surgical patients, which were significantly reduced by simple educational/training interventions. However, the actual fasting times still remained considerably longer than defined in recommended guidelines, meaning further process optimisations like obligatory fluid intake in the early morning are necessary to improve patient comfort and safety in future. Trial registration German registry of clinical studies (DRKS-ID: DRKS 00020530, retrospectively registered).

Purpose Ketogenic diets (KDs) are used to treat epilepsies resistant to pharmacotherapy or some inborn errors of metabolism. For prolonged anesthesia, use of balanced electrolyte solutions (BESs) supplemented with 0.5% glucose has been advocated to maintain ketosis while preventing hypoglycemia. Unfortunately, there is no BES containing 0.5% glucose available from pharmacies. In a laboratory study, we investigated the physical and chemical stability of different BES mixtures containing 0.5% glucose. Methods In total, six approaches were chosen to create a BES with 0.5% glucose: three different glucose-free BESs were supplemented with glucose. Additionally, commercially available BES containing 1% glucose was diluted with three different glucose-free BESs to obtain a solution containing 0.5% glucose. Turbidity, pH, electrical conductivity, and macroscopic appearance of these solutions were measured immediately, at 24 hours, and after 7 days, and were compared with the original BES. Results Turbidity, pH, and electrical conductivity, as well as macroscopic appearance did not exceed the changes of the controls. Conclusions No signs of incompatibility reactions could be observed in a 1-week time period. Our study supports the stability of the examined BES containing 0.5% glucose for prolonged anesthesia in patients on KD. Clinical studies are needed to evaluate if BES containing 0.5% glucose is superior in patients on KDs.

BACKGROUND 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. AIMS Based on this and before implementation of a more liberal preoperative clear fluid fasting policy for children, we studied gastric emptying time of clear fluids in children and hypothesized that the mean gastric emptying time would be 1 hour. METHODS Between March and December 2019, children scheduled for general anesthesia at our University Children's Hospital were enrolled in this prospective observational study. After overnight fasting, gastric emptying was examined by sonographic measurements of the gastric antral area before and 5, 15, 30, 45, and 60 minutes after intake of water or fruit juice. RESULTS Twenty-six children were enrolled in this study, and 24 aged 11 (range 4-17) years were included for statistical analysis. The median ingested fluid volume was 4.7 (range 1.8-11.8) mL kg-1 . The gastric antral area of the children initially increased and subsequently decreased after intake of clear fluids and correlated significantly with fasting time (r = -0.55, P 5 mL kg-1 . There was no difference in the gastric antral area between water and fruit juice. Using a linear regression model, the calculated mean gastric emptying time of clear fluids was 52 minutes. CONCLUSION This study showed that the gastric emptying time of children after intake up to 5 mL kg-1 clear fluids was

Background Infants undergoing general anaesthesia have an increased risk of severe respiratory and cardiovascular critical events. Awake caudal anaesthesia is an alternative for small infants undergoing minor lower abdominal surgery. While clinical experience has shown stable intra-operative haemodynamic conditions, there are no studies evaluating systemic and regional cerebral perfusion during such a procedure. Objectives The purpose of this study was to evaluate the effects of awake caudal anaesthesia on systemic and regional cerebral perfusion in small infants. Design A prospective observational cohort study. Setting Clinic of Anaesthesiology, University Children's Hospital, between November 2017 and June 2018. Patients Twenty small infants (postmenstrual age 36 to 54 weeks, weight 1800 to 5700 g) scheduled for lower abdominal surgery under awake caudal anaesthesia were enrolled in this study. Intervention Standard monitoring was expanded to include cardiac index using electrical velocimetry and regional cerebral oxygen saturation using near infrared spectroscopy. The caudal block was performed with 0.3% ropivacaine 1 ml kg Hypotension was defined as mean arterial blood pressure (BP) less than 35 mmHg and regional cerebral desaturation as regional cerebral oxygen saturation less than 80% of baseline. Main outcomes Mean arterial BP, cardiac index and regional cerebral oxygen saturation parameters under awake caudal anaesthesia. Results Mean arterial BP, cardiac index and regional cerebral oxygen saturation remained above the predefined lower limits. No episodes of hypotension or regional cerebral desaturation were observed. Operation time was 35 ± 13 (range 20 to 71) min. The infants were discharged to the neonatal ward after the end of surgery, and milk was fed 22 ± 15 (range 6 to 55) min thereafter. Five preterm infants experienced self-limiting episodes of apnoea intra-operatively. Conclusion The current study shows that awake caudal anaesthesia does not impair systemic and regional cerebral perfusion in small infants. Trial registration German registry of clinical studies (DRKS-ID: 800015742).

Background Volatile anaesthetics are a potential hazard during occupational exposure, pregnancy or in individuals with existing disposition to malignant hyperthermia. Anaesthetic waste gas concentration in postanaesthesia care units (PACU) has rarely been investigated. Objective(s) The current study aims to assess concentrations of volatile anaesthetics in relation to room size, number of patients and ventilator settings in different PACUs. Design A prospective observational study. Setting Two different PACUs of the Hannover Medical School (Hannover, Germany) were evaluated in this study. The rooms differed in dimensions, patient numbers and room ventilation settings. Patients During the observation period, sevoflurane anaesthesia was performed in 65 of 140 patients monitored in postanaesthesia unit one and in 42 of 70 patients monitored in postanaesthesia unit two. Main outcome measures Absolute trace gas room concentrations of sevoflurane measured with a compact, closed gas loop high-resolution ion mobility spectrometer. Results Traces of sevoflurane could be detected in 805 out of 970 samples. Maximum concentrations were 0.96 ± 0.20 ppm in postanaesthesia unit one, 0.82 ± 0.07 ppm in postanaesthesia unit two. Median concentration was 0.12 (0.34) ppm in postanaesthesia unit one and 0.11 (0.28) ppm in postanaesthesia unit two. Conclusion Low trace amounts of sevoflurane were detected in both PACUs equipped with controlled air exchange systems. Occupational exposure limits were not exceeded.

Background: During cardiopulmonary bypass (CPB) in children, anesthesia maintained by sevoflurane administered via the oxygenator is increasingly common. Anesthetic uptake and requirement may be influenced by the non-physiological conditions during hypothermic CPB. Narcotrend-processed EEG monitoring may, therefore, be useful to guide the administration of sevoflurane during this phase. Objective: The objective of this prospective, clinical, observational study was to assess the correlation between body temperature, Narcotrend Index (NI) and administered sevoflurane in children during CPB. Methods: Forty-four children aged 0 to 10 years undergoing hypothermic cardiac surgery were studied. On bypass, anesthesia was maintained with sevoflurane administered via the oxygenator of the heart-lung machine. Nasopharyngeal temperature, NI and minimum alveolar concentration (MAC) of sevoflurane were recorded in intervals of 10 minutes. Expiratory gas was sampled from the oxygenator’s sole expiratory port via a separate connecting line and the MAC was measured by the agent analyzer of the anesthesia machine. Results: Raw (r = 0.74) and corrected (r = 0.73) r-values show that narcosis depth (as indicated by NI) can primarily be explained by the interaction of MAC and temperature. The analysis of variance (without the interaction term) confirms the significant and independent association of both factors, MAC (pConclusion: Perfusionists and anesthetists should be aware of the results of processed electroencephalograph (EEG) monitoring during CPB. Sevoflurane requirements differ inter-individually; they may decrease during cooling and increase during rewarming. Therefore, it seems reasonable to include the results of processed EEG monitoring when administering sevoflurane during CPB in children, but further studies are necessary to confirm this thesis.

SummaryBackground In current guidelines, 6 hours of fasting is recommended for solids to limit the risk of pulmonary aspiration during anesthesia in children. Ultrasonography has recently been introduced to evaluate gastric volumes in children in the context of preanesthetic fasting. Therefore, in this study, we firstly evaluated the precision of ultrasound assessment of gastric volume in an experimental setting and secondly studied gastric emptying times after a normal breakfast in healthy preschool children using ultrasound. Methods In a preliminary experiment, a pear-shaped elastic balloon was filled and emptied in 50 mL steps from 0 to 500 mL with water. After each step, the balloon antral area was measured using ultrasonography. Thereafter, gastric emptying was examined in healthy preschool children after normal breakfast by sonographic measurements of the gastric antral area in right lateral decubitus position at two consecutive timepoints. Correlation coefficients (Pearson, 95% CI) between the balloon antral area and the balloon volume or gastric antral area and fasting time were calculated and gastric emptying time was extrapolated by linear regression. Data are presented as mean (range). Results In the balloon experiment, the balloon volume correlated significantly with the balloon antral area (63 measurements, r=.96, P

BACKGROUND Sevoflurane induction followed by intravenous anesthesia is a widely used technique to combine the benefits of an easier and less traumatic venipuncture after sevoflurane inhalation with a recovery with less agitation, nausea, and vomiting after total intravenous anesthesia (TIVA). Combination of two different anesthetics may lead to unwanted burst suppression in the electroencephalogram (EEG) during the transition phase. OBJECTIVE The objective of this prospective clinical observational study was to identify the optimal initial propofol bolus dose for a smooth transition from sevoflurane induction to TIVA using the EEG Narcotrend Index (NI). METHODS Fifty children aged 1-8 years scheduled for elective pediatric surgery were studied. After sevoflurane induction and establishing of an intravenous access, a propofol bolus dose range 0-5 mg·kg-1 was administered at the attending anesthetist's discretion to maintain a NI between 20 and 64, and sevoflurane was stopped. Anesthesia was continued as TIVA with a propofol infusion dose of 15 mg·kg-1 ·h-1 for the first 15 min, followed by stepwise reduction according to McFarlan's pediatric infusion regime, and remifentanil 0.25 μg·kg-1 ·min-1 . Endtidal concentration of sevoflurane, NI, and hemodynamic data were recorded during the whole study period using a standardized case report form. Propofol plasma concentrations were calculated using the paedfusor dataset and a TIVA simulation program. RESULTS Median endtidal concentration of sevoflurane at the time of administration of the propofol bolus was 5.1 [IQR 4.7-5.9] Vol%. The median propofol bolus dose was 1.2 [IQR 0.9-2.5] mg·kg-1 and median NI thereafter was 33 [IQR 23-40]. Nine children presented with a NI 13-20 and three children with burst suppression in the EEG (NI 0-12); all of them received an initial propofol bolus dose >2 mg·kg-1 . Regression equation demonstrated that NI 20-64 was achieved with a 95% probability when using a propofol bolus dose of 1 mg·kg-1 after sevoflurane induction. Decrease in mean arterial blood pressure correlated significantly with propofol bolus dose (P = 0.038). After 25 min of TIVA, children younger than 2 years had a higher NI (median difference 14.0, 95%CI: 6.0-20.0, P = 0.001), higher deviations from the expected Narcotend Index (median difference 4.1, 95%CI: 3.9-4.2, P < 0.001) and lower calculated propofol plasma concentrations (median difference 0.2 μg·ml-1 , 95% CI: 0.1-0.3 μg·ml-1 , P < 0.001) than older children. CONCLUSION After sevoflurane induction, a reduced propofol bolus dose of 1 mg·kg-1 followed by TIVA according to McFarlan's regime resulted in a NI within the recommended range in children aged 1-8 years. During the course of TIVA, children younger than 2 years displayed higher NI values and more pronounced interindividual variation. Processed EEG monitoring is recommended to find adequate individual age-dependent doses.

BACKGROUND In paediatric anaesthesia, pre-operative fasting should be short to prevent discomfort, hunger, thirst and metabolic disorders. Current European guidelines recommend pre-operative fasting times of 4 h for breast milk and 6 h for formula milk in infants, whereas some national guidelines allow both until 4 h before anaesthesia. OBJECTIVE We evaluated the gastric emptying times of preterm infants after breast milk and formula milk, hypothesising that the mean gastric emptying time would be less than 4 h. DESIGN A prospective, observational, noninterventional cohort study. SETTING Neonatal ICU of a university hospital from August to September 2017. PATIENTS Twenty-two infants with a postmenstrual mean ± SD (range) age of 35 ± 2 (32 to 40) weeks were included. Based on their prescription plan, 10 infants received breast milk and 12 received formula milk with a total volume of 50 ± 16 (24 to 70) ml. INTERVENTIONS Gastric emptying was examined by sonographic measurements of the gastric antral area (GAA) before (FT0) and hourly after breast milk or formula milk feeding (FT1 to FT3). MAIN OUTCOME MEASURES Estimated gastric emptying time after enteral feeding with breast milk and formula milk in preterm infants. RESULTS The GAA of the preterm infants initially increased and subsequently decreased after feeding. GAA correlated significantly with fasting time (r = -0.53, P

Transpulmonary ultrasound dilution (TPUD) method, a novel indicator dilution (ID) technique for cardiac output measurement, detects and quantifies shunts, both in children and adults. However, its accuracy and reproducibility in cardiac right-to-left-shunt (RLS) detection have not been investigated. In a prospective observational study, we assessed the validity of TPUD algorithm for RLS detection in children with congenital heart disease (CHD) and proven RLS in comparison with controls without shunts between February 2010 and October 2011. As TPUD algorithm was unknown, we tested ID curve morphology, appearance time (AT) and central blood volume index (CBVI) as diagnostic criteria. TPUD identified RLS correctly in all 16 RLS subjects [median age (range): 18 months (1 month–15 years 6 months)] and excluded RLS in all 26 controls [74 months (8 months to 17 years 4 months)]. AT was significantly shorter in RLS (P

Background Due to possible serious adverse drug reactions (ADRs), the use of metamizole for postoperative pain therapy in infants is a subject of debate. Safety studies with large sample sizes are missing. Aim This prospective multicenter observational study was conducted to evaluate the use of metamizole in infants younger than 1 year undergoing surgery with a particular focus on possible serious ADRs (e.g., hemodynamic, anaphylactic or respiratory reactions, and agranulocytosis). Methods Infants aged up to 1 year (American Society of Anesthesiologists [ASA] I–III) receiving a single dose of metamizole for postoperative pain therapy were enrolled. Patient demographics, main and secondary diagnosis, surgical procedures performed, metamizole dose, hemodynamic data, use of other analgesics and regional blocks, results of pain measurement, and incidence of ADRs were documented using a standardized case report form. Results A total of 316 infants observed at five pediatric centers were included for analysis (age 4.4 ± 3.7 [0.06–12] months). Mean metamizole dose was 17.8 ± 3.1 (9.2–29.8) mg·kg−1. Mean arterial pressure (MAP) remained stable during metamizole infusion (MAP before infusion 45 ± 9.5 [25–95] and after infusion 45 ± 9.2 [25–99] mm Hg). Erythema was observed in one patient (ADRs total: 0.3%, 95% confidence interval: 0.27–0.32). No respiratory adverse events directly related to the metamizole administration and no clinical signs of agranulocytosis were reported. Conclusion Single intravenous doses of metamizole used for prevention or treatment of postoperative pain were safe in more than 300 infants younger than 1 year. The statistical probability of serious ADRs (e.g., hemodynamic, anaphylactic or respiratory reactions) was lower than 1%. The sample size and follow-up were not sufficient to detect agranulocytosis.

Summary Objectives Despite serious renal side effects in critically ill adult patients, artificial colloids are still fundamental components of perioperative fluid therapy in infants and children, although the impact of 6% hydroxyethyl starch (HES) and 4% gelatin (GEL) on renal function during pediatric surgery has not been identified yet. Aim To determine the impact of high doses of artificial colloids on renal function, we conducted an experimental animal study and hypothesized that neither the infusion of HES nor of GEL would have a serious impact on renal function. Methods Fifteen sedated piglets were randomly assigned to receive an infusion of either 50 ml·kg−1 HES or GEL, or a balanced electrolyte solution (crystalloid group). Before and 1 week after infusion, serum and urine renal function tests were recorded and renal biopsies were taken. Results Serum and urine renal function tests revealed no increase after administration of HES and GEL, and only a discrete increase in serum creatinine (median 9.8 μmol·l−1, 95% CI 4.0–19.1) in the crystalloid group. Histopathological examination indicated a sparsely, multifocal infiltration of mononuclear cells in all groups and an unspecific pyelectasia of one animal in the GEL group. Conclusions After high doses of HES or GEL in piglets, no relevant impact on renal function could be found. These results confirm that AKI after HES or GEL is very unlikely in hemodynamically stable perioperative patients with normal renal function.

BACKGROUND In contrast to preoperative fasting guidelines in paediatric anaesthesia, actual fasting times are often too long. OBJECTIVE The objective of this study was to evaluate the effect of preoperative fasting on glucose concentration, ketone bodies and acid-base balance in children. DESIGN A prospective, noninterventional, clinical observational study. SETTING A single-centre trial, study period from June 2014 to November 2014. PATIENTS One hundred children aged 0 to 36 months scheduled for elective paediatric surgery. MAIN OUTCOME MEASURES Patient demographics, fasting times, haemodynamic data, glucose and ketone body concentrations, and acid-base parameters after induction of anaesthesia were documented using a standardised case report form. RESULTS Mean fasting period was 7.8 ± 4.5 (3.5 to 20) h, and deviation from guideline (ΔGL) was 3.3 ± 3.2 (-2 to 14) h. Linear regression showed a significant correlation between fasting times and ketone bodies, anion gap, base excess, osmolality as well as bicarbonate (for each, P < 0.05), but not glucose or lactate. In children with ΔGL more than 2 h (54%), ketone bodies, osmolality and anion gap were significantly higher and base excess significantly lower than children with ΔGL less than 2 h (for each, P < 0.05). CONCLUSION After prolonged preoperative fasting, children younger than 36 months can present with ketoacidosis and (low) normal blood glucose concentrations. Actual fasting times should be optimised according to existing guidelines. In small infants, deviations from fasting guidelines should be as short as possible and not longer than 2 h.

Background: In older children, different electroencephalogram-based algorithms for measuring depth of anesthesia displayed a similar performance as in adults, but in infants they have not displayed the same reliability so far. According to the individual developmental state, the Narcotrend distinguishes "differentiated" electroencephalograms, which can be classified using the full Narcotrend Index scale, from "undifferentiated" electroencephalograms, which are classified using a scale with fewer stages. Objective: The objective of this prospective clinical observational study was to assess the feasibility and performance of the Narcotrend monitor in children

Summary Objectives Neonates and infants are at the highest risk of developing perioperative hypothermia. A number of methods to prevent hypothermia during pediatric anesthesia are in use, and despite the fact that conventional forced-air warmers are the most effective devices, they are not always sufficient enough to maintain body temperature. Therefore, recently a new forced-air warming system with an increased warm air flow was introduced to the market. Aim The aim of this study was to evaluate this new forced-air warming system in neonates and infants during pediatric anesthesia. We hypothesized that the new blanket alone is sufficient enough to prevent neonates and infants from intraoperative hypothermia. Methods Neonates and infants (body weight

Summary Background In pediatric anesthesia, preoperative fasting guidelines are still often exceeded. Objective The objective of this noninterventional clinical observational cohort study was to evaluate the effect of an optimized preoperative fasting management (OPT) on glucose concentration, ketone bodies, acid–base balance, and change in mean arterial blood pressure (MAP) during induction of anesthesia in children. Methods Children aged 0–36 months scheduled for elective surgery with OPT (n = 50) were compared with peers studied before optimizing preoperative fasting time (OLD) (n = 50) who were matched for weight, age, and height. Results In children with OPT (n = 50), mean fasting time (6.0 ± 1.9 h vs 8.5 ± 3.5 h, P 2 h 8% vs 70%), ketone bodies (0.2 ± 0.2 mmol·l−1 vs 0.6 ± 0.6 mmol·l−1, P < 0.001), and incidence of hypotension (MAP

Summary Background Acetate-containing balanced electrolyte solutions are frequently used for fluid therapy in pediatric anesthesia, but no studies investigating the compatibility with common anesthetic drugs are available. Aim To reveal possible incompatibilities between common anesthetic drugs and the acetate-containing balanced electrolyte solutions BS (Sterofundin ISO; B.Braun Melsungen AG, Melsungen, Germany) and BS-G1 (E148G1 Pad; Serumwerk Bernburg AG, Bernburg, Germany), with normal saline (NS) as control. Methods All tested infusion solutions were mixed 1 : 1 with 28 common anesthetic drugs in concentrations used in daily clinical practice. Electrical conductivity, pH, and turbidimetric light diffusion at 405 nm were measured. Macroscopic changes such as gross precipitation, change in color, or bubble formation were also assessed. All measurements were performed immediately after mixing as well as 30 and 60 min after. Results The vast majority of drugs showed no significant change in pH, electric conductivity, turbidimetric detectable light diffusion, or macroscopic appearance after mixing with BS, BS-G1, and NS. Phenytoin immediately precipitated in response to all tested solutions as did diazepam. Thiopental precipitated after mixing with BS only. Conclusions Most of the tested drugs did not show any signs or evidence of incompatibility reactions. However, phenytoin and diazepam should not be in contact with the three tested solutions, including NS. Thiopental should be used with caution because it can precipitate in solutions with a low pH (e.g., BS).

Summary Objective: This prospective clinical observational study was conducted to investigate the effects of contrast medium on acid–base balance, electrolyte concentrations, and osmolality in children. Background: For pediatric cardiac catheterization, high doses of nonionic hyperosmolar contrast medium are widely used. Methods: Forty pediatric patients (age 0–16 years) undergoing cardiac angiography with more than 3 ml·kg−1 of nonionic hyperosmolar contrast medium (Iomeprol) were enrolled, and the total amount of the contrast agent given was documented. Before and after contrast medium administration, a blood sample was collected to analyze electrolytes, acid–base parameters, osmolality, hemoglobin, and hematocrit. Results: After cardiac catheterization, pH, hemoglobin, hematocrit, bicarbonate, base excess, sodium, chloride, calcium, anion gap and strong ion difference decreased, whereas osmolality increased significantly (base excess −1.8 ± 1.8 vs −3.4 ± 2.3, sodium 138 ± 2.9 vs 132 ± 4.1 mm, osmolality 284 ± 5.7 vs 294 ± 7.6 mosmol·kg−1, P

Summary Background: Neonates have a higher metabolic rate and an increased risk of perioperative hypoglycemia and lipolysis, but during anesthesia, both oxygen consumption and metabolic rate are decreased, and this may lead to reduced intraoperative glucose requirements. Objective: The objective of this prospective multicentre observational postauthorisation safety study was to evaluate the intraoperative use of a novel isotonic balanced electrolyte solution with a low glucose concentration of 1% (BS-G1) in neonates with a particular focus on changes in acid-base, electrolyte, and glucose concentrations. Methods: Following the local ethics committee approval, neonates with a postmenstrual age under 45 weeks and an ASA risk score of I–IV undergoing intraoperative administration of BS-G1 were enrolled. Patient demographics, the performed procedure, adverse drug reactions, hemodynamic data, and the results of blood gas analysis before and after infusion were documented with a focus on changes in acid-base, electrolyte, and glucose concentrations. Results: In 66 neonates (ASA I–IV; postmenstrual age 38 ± 4, range 25–45 weeks; body weight 2.9 ± 0.9, range 0.65–4.6 kg), the mean infusion rate was 10.4 ± 3.2 (range 4.5–19.6) ml·kg−1·h−1 BS-G1. During the infusion, hemoglobin, hematocrit, bicarbonate, base excess, anion gap, strong ion difference, and calcium decreased, and chloride and glucose increased significantly within the physiological range. All other measured parameters including sodium and lactate remained stable. Neither hypoglycemia (glucose 10 mm) was documented after BS-G1 infusion. No adverse drug reactions were reported. Conclusion: The study shows that the intraoperative use of an isotonic balanced electrolyte solution with 1% glucose and a mean infusion rate of 10 ml·kg−1·h−1 helps to avoid acid-base dysbalance, hyponatraemia, hypoglycemia, ketoacidosis, and hyperglycemia in surgical neonates. A careful intraoperative monitoring and adaptation of the infusion rate as needed is crucial because the glucose and fluid requirements may vary widely between subjects.

This prospective clinical observational study was conducted to investigate the effects of contrast medium on acid-base balance, electrolyte concentrations, and osmolality in children.For pediatric cardiac catheterization, high doses of nonionic hyperosmolar contrast medium are widely used.Forty pediatric patients (age 0-16 years) undergoing cardiac angiography with more than 3 ml·kg(-1) of nonionic hyperosmolar contrast medium (Iomeprol) were enrolled, and the total amount of the contrast agent given was documented. Before and after contrast medium administration, a blood sample was collected to analyze electrolytes, acid-base parameters, osmolality, hemoglobin, and hematocrit.After cardiac catheterization, pH, hemoglobin, hematocrit, bicarbonate, base excess, sodium, chloride, calcium, anion gap and strong ion difference decreased, whereas osmolality increased significantly (base excess -1.8 ± 1.8 vs -3.4 ± 2.3, sodium 138 ± 2.9 vs 132 ± 4.1 mm, osmolality 284 ± 5.7 vs 294 ± 7.6 mosmol·kg(-1), P0.01). Seventy-eight percent of the children developed hyponatremia (sodium135 mm). No changes were seen in pCO(2) , lactate, and potassium levels.Regarding the differential diagnosis of metabolic disturbances after pediatric cardiac catheterization, low-anion gap metabolic acidosis and hyponatremia should be considered as a possible side effect of the administered contrast medium.

Neonates have a higher metabolic rate and an increased risk of perioperative hypoglycemia and lipolysis, but during anesthesia, both oxygen consumption and metabolic rate are decreased, and this may lead to reduced intraoperative glucose requirements.The objective of this prospective multicentre observational postauthorisation safety study was to evaluate the intraoperative use of a novel isotonic balanced electrolyte solution with a low glucose concentration of 1% (BS-G1) in neonates with a particular focus on changes in acid-base, electrolyte, and glucose concentrations.Following the local ethics committee approval, neonates with a postmenstrual age under 45 weeks and an ASA risk score of I-IV undergoing intraoperative administration of BS-G1 were enrolled. Patient demographics, the performed procedure, adverse drug reactions, hemodynamic data, and the results of blood gas analysis before and after infusion were documented with a focus on changes in acid-base, electrolyte, and glucose concentrations. In 66 neonates (ASA I-IV; postmenstrual age 38 ± 4, range 25-45 weeks; body weight 2.9 ± 0.9, range 0.65-4.6 kg), the mean infusion rate was 10.4 ± 3.2 (range 4.5-19.6) ml·kg(-1) ·h(-1) BS-G1. During the infusion, hemoglobin, hematocrit, bicarbonate, base excess, anion gap, strong ion difference, and calcium decreased, and chloride and glucose increased significantly within the physiological range. All other measured parameters including sodium and lactate remained stable. Neither hypoglycemia (glucose3 mm) nor hyperglycemia (glucose10 mm) was documented after BS-G1 infusion. No adverse drug reactions were reported.The study shows that the intraoperative use of an isotonic balanced electrolyte solution with 1% glucose and a mean infusion rate of 10 ml·kg(-1) ·h(-1) helps to avoid acid-base dysbalance, hyponatraemia, hypoglycemia, ketoacidosis, and hyperglycemia in surgical neonates. A careful intraoperative monitoring and adaptation of the infusion rate as needed is crucial because the glucose and fluid requirements may vary widely between subjects.