Experience of Remifentanil in Extremely Low-birth-weight Babies Undergoing Laparotomy

Premature babies experience pain and require adequate analgesia for any painful procedure. Fentanyl and morphine resulted in safe and effective anesthesia in the past; however, their pharmacokinetics may be impaired in preterm babies with multiorgan failure. Remifentanil, despite the absence of available pharmacokinetic data in preterm infants and few reports in newborns, demonstrated its advantages in children undergoing either major surgery or minor painful procedures and has been shown to be useful even in neonates, because its elimination is independent of organ function. We report two cases of babies born at 26 weeks’ and 27 weeks’ gestation, weighing 580g and 400g, respectively, undergoing laparotomy for necrotizing enterocolitis. Both received midazolam bolus and remifentanil infusion at high doses. This technique seems to be an advantageous alternative even in extremely low-birth-weight prematures. Furthermore, it becomes a technique of choice in these babies because the available ventilators are often not equipped with halogenated vaporizers. Particularly in intensive care, where there are no scavenger systems, it could allow to operate without moving out the preterm babies and avoiding stress and hypothermia

Peri-operative red blood cell transfusion in neonates and infants: NEonate and Children audiT of Anaesthesia pRactice IN Europe: A prospective European multicentre observational study

BACKGROUND: Little is known about current clinical practice concerning peri-operative red blood cell transfusion in neonates and small infants. Guidelines suggest transfusions based on haemoglobin thresholds ranging from 8.5 to 12 g dl-1, distinguishing between children from birth to day 7 (week 1), from day 8 to day 14 (week 2) or from day 15 (≥week 3) onwards. OBJECTIVE: To observe peri-operative red blood cell transfusion practice according to guidelines in relation to patient outcome. DESIGN: A multicentre observational study. SETTING: The NEonate-Children sTudy of Anaesthesia pRactice IN Europe (NECTARINE) trial recruited patients up to 60 weeks' postmenstrual age undergoing anaesthesia for surgical or diagnostic procedures from 165 centres in 31 European countries between March 2016 and January 2017. PATIENTS: The data included 5609 patients undergoing 6542 procedures. Inclusion criteria was a peri-operative red blood cell transfusion. MAIN OUTCOME MEASURES: The primary endpoint was the haemoglobin level triggering a transfusion for neonates in week 1, week 2 and week 3. Secondary endpoints were transfusion volumes, 'delta haemoglobin' (preprocedure - transfusion-triggering) and 30-day and 90-day morbidity and mortality. RESULTS: Peri-operative red blood cell transfusions were recorded during 447 procedures (6.9%). The median haemoglobin levels triggering a transfusion were 9.6 [IQR 8.7 to 10.9] g dl-1 for neonates in week 1, 9.6 [7.7 to 10.4] g dl-1 in week 2 and 8.0 [7.3 to 9.0] g dl-1 in week 3. The median transfusion volume was 17.1 [11.1 to 26.4] ml kg-1 with a median delta haemoglobin of 1.8 [0.0 to 3.6] g dl-1. Thirty-day morbidity was 47.8% with an overall mortality of 11.3%. CONCLUSIONS: Results indicate lower transfusion-triggering haemoglobin thresholds in clinical practice than suggested by current guidelines. The high morbidity and mortality of this NECTARINE sub-cohort calls for investigative action and evidence-based guidelines addressing peri-operative red blood cell transfusions strategies. TRIAL REGISTRATION: ClinicalTrials.gov, identifier: NCT02350348

Capnography and the Bispectral Index—Their Role in Pediatric Sedation: A Brief Review

Sedation in children is increasingly emerging as a minimally invasive technique that may be associated with local anaesthesia or diagnostic and therapeutic procedures which do not necessarily require general anaesthesia. Standard monitoring requirements are not sufficient to ensure an effective control of pulmonary ventilation and deep sedation. Capnography in pediatric sedation assesses the effect of different drugs on the occurrence of respiratory failure and records early indicators of respiratory impairment. The Bispectral index (BIS) allows the reduction of dose requirements of anaesthetic drugs, the reduction in the time to extubation and eye opening, and the reduction in the time to discharge. In the field of pediatric sedation, capnography should be recommended to prevent respiratory complications, particularly in spontaneous ventilation. The use of the BIS index, however, needs further investigation due to a lack of evidence, especially in infants. In this paper, we will investigate the role of capnography and the BIS index in improving monitoring standards in pediatric sedation

Experience of Remifentanil in Extremely Low-birth-weight Babies Undergoing Laparotomy

Premature babies experience pain and require adequate analgesia for any painful procedure. Fentanyl and morphine resulted in safe and effective anesthesia in the past; however, their pharmacokinetics may be impaired in preterm babies with multiorgan failure. Remifentanil, despite the absence of available pharmacokinetic data in preterm infants and few reports in newborns, demonstrated its advantages in children undergoing either major surgery or minor painful procedures and has been shown to be useful even in neonates, because its elimination is independent of organ function. We report two cases of babies born at 26 weeks’ and 27 weeks’ gestation, weighing 580 g and 400 g, respectively, undergoing laparotomy for necrotizing enterocolitis. Both received midazolam bolus and remifentanil infusion at high doses. This technique seems to be an advantageous alternative even in extremely low-birth-weight prematures. Furthermore, it becomes a technique of choice in these babies because the available ventilators are often not equipped with halogenated vaporizers. Particularly in intensive care, where there are no scavenger systems, it could allow to operate without moving out the preterm babies and avoiding stress and hypothermia

Mydriasis induced by sub-Tenon's ropivacaine: injection in patients undergoing strabismus surgery

PURPOSE:To investigate the effects of sub-Tenon's capsule ropivacaine injection on pupillary diameter in strabismus surgery. METHODS: A total of 16 patients were randomly assigned to 2 groups. The ropivacaine group (R) received sub-Tenon's ropivacaine 1% (2.5-3 mL) injections. In the control group (C), general anesthesia was induced and a saline solution (2.5-3 mL) was injected in the sub-Tenon's capsule. Pupillary diameter was measured at baseline and 2 and 5 minutes from the injections. The effects of the injections were expressed as a ratio of final (5 minutes) versus basal diameter. RESULTS: A significant mydriasis occurred in the ropivacaine group when compared with the control group (Group R vs Group C ratio = 2.32, p < 0.0001) or with unoperated fellow eye (R vs unoperated eye ratio = 2.29, p < 0.0001). CONCLUSIONS: Ropivacaine in the sub-Tenon's capsule induces a mydriasis probably related to a pharmacological ciliary ganglion block. Copyright 2010 American Association for Pediatric Ophthalmology and Strabismus. Published by Mosby, Inc. All rights reserved

State of the Art in Pediatric Anesthesia: A Narrative Review about the Use of Preoperative Time

This review delves into the challenge of pediatric anesthesia, underscoring the necessity for tailored perioperative approaches due to children’s distinctive anatomical and physiological characteristics. Because of the vulnerability of pediatric patients to critical incidents during anesthesia, provider skills are of primary importance. Yet, almost equal importance must be granted to the adoption of a careful preanesthetic mindset toward patients and their families that recognizes the interwoven relationship between children and parents. In this paper, the preoperative evaluation process is thoroughly examined, from the first interaction with the child to the operating day. This evaluation process includes a detailed exploration of the medical history of the patient, physical examination, optimization of preoperative therapy, and adherence to updated fasting management guidelines. This process extends to considering pharmacological or drug-free premedication, focusing on the importance of preanesthesia re-evaluation. Structural resources play a critical role in pediatric anesthesia; components of this role include emphasizing the creation of child-friendly environments and ensuring appropriate support facilities. The results of this paper support the need for standardized protocols and guidelines and encourage the centralization of practices to enhance clinical efficacy

Pediatric robotic surgery: issues in management-expert consensus from the Italian Society of Pediatric and Neonatal Anesthesia and Intensive Care (SARNePI) and the Italian Society of Pediatric Surgery (SICP).

Background: Pediatric robotic-assisted surgeries have increased in recent years; however, guidance documents are still lacking. This study aimed to develop evidence-based recommendations, or best practice statements when evidence is lacking or inadequate, to assist surgical teams internationally. Methods: A joint consensus taskforce of anesthesiologists and surgeons from the Italian Society of Pediatric and Neonatal Anesthesia and Intensive Care (SARNePI) and the Italian Society of Pediatric Surgery (SICP) have identified critical areas and reviewed the available evidence. The taskforce comprised 21 experts representing the fields of anesthesia (n = 11) and surgery (n = 10) from clinical centers performing pediatric robotic surgery in the Italian cities of Ancona, Bologna, Milan, Naples, Padua, Pavia, Perugia, Rome, Siena, and Verona. Between December 2020 and September 2021, three meetings, two Delphi rounds, and a final consensus conference took place. Results: During the first planning meeting, the panel agreed on the specific objectives, the definitions to apply, and precise methodology. The project was structured into three subtopics: (i) preoperative patient assessment and preparation; (ii) intraoperative management (surgical and anesthesiologic); and (iii) postoperative procedures. Within these phases, the panel agreed to address a total of 18 relevant areas, which spanned preoperative patient assessment and patient selection, anesthesiology, critical care medicine, respiratory care, prevention of postoperative nausea and vomiting, and pain management. Conclusion: Collaboration among surgeons and anesthesiologists will be increasingly important for achieving safe and effective RAS procedures. These recommendations will provide a review for those who already have relevant experience and should be particularly useful for those starting a new program