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Background Remote ischemic preconditioning involves providing a brief ischemia–reperfusion event to a tissue to create subsequent protection from a more severe ischemia–reperfusion event to a different tissue/organ. The few pediatric remote ischemic preconditioning studies in the literature show conflicting results. Aim We conducted a pilot randomized controlled trial to determine the feasibility of conducting a larger trial and to gather provisional data on the effect of early and late remote ischemic preconditioning on outcomes of infants after surgery for congenital heart disease. Methods This single-center, double-blind randomized controlled trial of remote ischemic preconditioning vs control (sham-remote ischemic preconditioning) in young infants going for surgery for congenital heart disease at the Stollery Children's Hospital. Remote ischemic preconditioning was performed at 24–48 h preoperatively and immediately prior to cardiopulmonary bypass. Remote ischemic preconditioning stimulus was performed with blood pressure cuffs around the thighs. Primary outcomes were feasibility and peak blood lactate level on day 1 postoperatively. Results Fifty-two patients were randomized but seven patients became ineligible after randomization leaving 45 patients included in the study. In the included patients, 7 (15%) had protocol deviations (five infants did not have the preoperative intervention and two did not receive the intervention in the operating room). From a comfort point of view, only one subject in the control group and two in the Remote ischemic preconditioning group received sedation during the preoperative intervention. There were no study-related adverse events and no complications to the limbs subjected to preconditioning. There were no significant differences between the Remote ischemic preconditioning group and the control group in the highest blood lactate level on day 1 postoperatively (mean difference, 1.28; 95%CI, −0.22, 2.78; P-value = 0.093). Conclusion In infants who underwent surgery for congenital heart disease, our pilot randomized controlled trial on early and late remote ischemic preconditioning proved to be feasible but did not find any significant difference in acute outcomes. A larger trial may be necessary.

Objective Our primary objective was to determine the maximum depth of sedation achieved, as measured by the bispectral (BIS) index monitor, for pediatric patients undergoing procedural sedation in a pediatric emergency department. Methods This prospective, blinded, observational study was conducted in a tertiary pediatric emergency department. Procedural sedation and analgesia were performed in the standard manner, with the addition of blinded BIS index monitoring. In addition, both the sedating physician and the procedural physician recorded their clinical impression of the maximum depth of sedation. Results A convenience sample of 50 patients was enrolled. The median age was 9.2 years (range, 3-15 y). The mean nadir BIS index was 43.1 ± 17.4 (SD), with a 95% confidence interval from 37.8 to 48.4. This was significantly lower than the BIS index value that is considered to reflect general anesthesia ( 0.0001). Almost 80% of the analyzed patient sedations were classified as having achieved general anesthesia. When comparing the sedating physician and the procedural physician's clinical assessment of maximal depth of sedation with the nadir BIS index value, there was only slight agreement between the 2 groups (κ statistics, 0.19 and 0.057, respectively). Ninety-three percent of the sedating physicians and 88% of the procedural physicians underestimated the maximum depth of sedation of their patients. Conclusions This study suggests that most pediatric procedural sedation patients spend at least a period in a general anesthetic state. During most procedural sedation, the physicians involved are likely underestimating the maximal depth of sedation for their patients.

UNLABELLED We examined the success of inserting epidural catheters via the caudal route in infants by using electrocardiographic guidance. A case series of 20 patients with thoracic epidural analgesia was studied. After the induction of general anesthesia, an 18-gauge IV catheter was inserted into the caudal space to allow threading of a 20-gauge epidural catheter. The electrocardiogram (ECG) tracings via the epidural catheter, as well as the surface ECG at the target spine level, were recorded simultaneously with a modified two-channel five-lead ECG system. The epidural catheter was advanced from the caudal space until the tip reached the target level as demonstrated by a match in the configuration of the epidural ECG tracing to that of the surface ECG tracing at the target level. The catheter tip location was verified by postoperative radiographs. All catheter tips were located within two vertebrae of the target level, and satisfactory intraoperative epidural anesthesia was achieved in all subjects. IMPLICATIONS Epidural electrocardiography may be used to guide the positioning of the thoracic epidural catheter tip via the caudal approach to the appropriate dermatome for optimum analgesia.

We designed this study to determine the threshold current for nerve stimulation of an insulated needle in the epidural space. The intended dermatome was identified using the bony landmarks of the spine. An 18-gauge insulated Tuohy needle was inserted perpendicularly to the skin and advanced until "loss of resistance" was felt. A nerve stimulator was then connected to the insulated needle. Twenty patients were studied using an insulated Tuohy needle and one patient was studied using a noninsulated Tuohy needle. Muscle twitch was elicited with a current of 11.1 +/- 3.1 mA (mean +/- sd) in all patients in which an insulated needle was used. Muscle twitches were within 2 myotomes of the intended level (based on bony landmarks). Muscle twitch was not elicited with a noninsulated needle. After catheter threading, positive stimulation tests were elicited via epidural catheters in all patients (4.9 +/- 2.3 mA). Postoperative radiograph confirmed all catheter placements within 2 myotomes of the muscle twitches. Electrical stimulation may be a useful adjuvant tool to loss of resistance for confirming proper thoracic epidural needle placement. The threshold current criteria for an insulated needle (6-17 mA) would be higher than the original Tsui test criteria described for an epidural catheter (1-10 mA) in the epidural space.