Oxygenation during general anesthesia in pediatric patients:A retrospective observational study

Study objective: Protocols are used in intensive care and emergency settings to limit the use of oxygen. However, in pediatric anesthesiology, such protocols do not exist. This study aimed to investigate the administration of oxygen during pediatric general anesthesia and related these values to PaO2, SpO2 and SaO2. Design: Retrospective observational study. Setting: Tertiary pediatric academic hospital, from June 2017 to August 2020. Patients:Patients aged 0–18 years who underwent general anesthesia for a diagnostic or surgical procedure with tracheal intubation and an arterial catheter for regular blood withdrawal were included. Patients on cardiopulmonary bypass or those with missing data were excluded. Electronic charts were reviewed for patient characteristics, type of surgery, arterial blood gas analyses, and oxygenation management.Interventions: No interventions were done. Measurements: Primary outcome defined as FiO2, PaO2 and SpO2 values were interpreted using descriptive analyses, and the correlation between PaO2 and FiO2 was determined using the weighted Spearman correlation coefficient. Main results: Data of 493 cases were obtained. Of these, 267 were excluded for various reasons. Finally, 226 cases with a total of 645 samples were analyzed. The median FiO2 was 36% (IQR 31 to 43), with a range from 20% to 97%, and the median PaO2 was 23.6 kPa (IQR 18.6 to 28.1); 177 mmHg (IQR 140 to 211). The median SpO2 level was 99% (IQR 98 to 100%). The study showed a moderately positive association between PaO2 and FiO2 (r = 0.52, p &lt; 0.001). 574 of 645 samples (89%) contained a PaO2 higher than 13.3 kPa; 100 mmHg. Conclusions: Oxygen administration during general pediatric anesthesia is barely regulated. Hyperoxemia is observed intraoperatively in approximately 90% of cases. Future research should focus on outcomes related to hyperoxemia.</p

Needle-free pharmacological sedation techniques in paediatric patients for imaging procedures:a systematic review and meta-analysis

Background: Sedation techniques and drugs are increasingly used in children undergoing imaging procedures. In this systematic review and meta-analysis, we present an overview of literature concerning sedation of children aged 0–8 yr for magnetic resonance imaging (MRI) procedures using needle-free pharmacological techniques. Methods: Embase, MEDLINE, Web of Science, and Cochrane databases were systematically searched for studies on the use of needle-free pharmacological sedation techniques for MRI procedures in children aged 0–8 yr. Studies using i.v. or i.m. medication or advanced airway devices were excluded. We performed a meta-analysis on sedation success rate. Secondary outcomes were onset time, duration, recovery, and adverse events. Results: Sixty-seven studies were included, with 22 380 participants. The pooled success rate for oral chloral hydrate was 94% (95% confidence interval [CI]: 0.91–0.96); for oral chloral hydrate and intranasal dexmedetomidine 95% (95% CI: 0.92–0.97); for rectal, oral, or intranasal midazolam 36% (95% CI: 0.14–0.65); for oral pentobarbital 99% (95% CI: 0.90–1.00); for rectal thiopental 92% (95% CI: 0.85–0.96); for oral melatonin 75% (95% CI: 0.54–0.89); for intranasal dexmedetomidine 62% (95% CI: 0.38–0.82); for intranasal dexmedetomidine and midazolam 94% (95% CI: 0.78–0.99); and for inhaled sevoflurane 98% (95% CI: 0.97–0.99). Conclusions: We found a large variation in medication, dosage, and route of administration for needle-free sedation. Success rates for sedation techniques varied between 36% and 98%.</p

Beta-blockers and health-related quality of life in patients with peripheral arterial disease and COPD

Yvette RBM van Gestel1, Sanne&amp;nbsp;E Hoeks1, Don D Sin2, Henk Stam3, Frans W Mertens3, Jeroen J Bax4, Ron T van Domburg5, Don Poldermans61Department of Anesthesiology, Erasmus Medical Center, Rotterdam, The Netherlands; 2Department of Medicine, University of British Columbia and The James Hogg iCAPTURe Center, St. Paul&amp;rsquo;s Hospital, Vancouver, Canada; 3Department of Pulmonology, Erasmus Medical Center, Rotterdam, The Netherlands; 4Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands; 5Department of Cardiology, Erasmus Medical Center, Rotterdam, The Netherlands; 6Department of Vascular Surgery, Erasmus Medical Center, Rotterdam, The NetherlandsBackground: Beta-blockers are frequently withheld in patients with cardiovascular disease who also have chronic obstructive pulmonary disease (COPD) because of concerns that they might provoke bronchospasm and cause deterioration in health status. Although beta1-selective beta-blockers are associated with reduced mortality in COPD patients, their effects on health status are unknown. The aim of this study was to investigate the relationship between beta-blockers and health-related quality of life (HRQOL) in patients with peripheral arterial disease and COPD.Methods: Of the original cohort of 3371 vascular surgery patients, 1310 had COPD of whom 469 survived during long-term follow-up. These COPD patients were sent the Short Form-36 (SF-36) health-related quality of life questionnaire, which was completed and returned by 326 (70%) patients.Results: No significant differences in any of the SF-36 domains were observed between COPD patients who did and did not use beta-blockers (p &amp;gt; 0.05 for all). Furthermore, beta-blockers were not associated with any impairment in HRQOL among patients with COPD.Conclusion: Beta-blockers had no material impact on the HRQOL of patients with peripheral arterial disease who also had COPD. This suggests that beta-blockers can, in most circumstances, be administered to patients with COPD without impairment in HRQOL. Keywords: beta-blockers, chronic obstructive pulmonary disease, vascular surgery, health-related quality of lif

Early sac shrinkage predicts a low risk of late complications after endovascular aortic aneurysm repair

Background Aneurysm shrinkage has been proposed as a marker of successful endovascular aneurysm repair (EVAR). Patients with early postoperative shrinkage may experience fewer subsequent complications, and consequently require less intensive surveillance. Methods Patients undergoing EVAR from 2000 to 2011 at three vascular centres (in 2 countries), who had two imaging examinations (postoperative and after 6-18 months), were included. Maximum diameter, complications and secondary interventions during follow-up were registered. Patients were categorized according to early sac dynamics. The primary endpoint was freedom from late complications. Secondary endpoints were freedom from secondary intervention, postimplant rupture and direct (type I/III) endoleaks. Results Some 597 EVARs (71·1 per cent of all EVARs) were included. No shrinkage was observed in 284 patients (47·6 per cent), moderate shrinkage (5-9 mm) in 142 (23·8 per cent) and major shrinkage (at least 10 mm) in 171 patients (28·6 per cent). Four years after the index imaging, the rate of freedom from complications was 84·3 (95 per cent confidence interval 78·7 to 89·8), 88·1 (80·6 to 95·5) and 94·4 (90·1 to 98·7) per cent respectively. No shrinkage was an independent risk factor for late complications compared with major shrinkage (hazard ratio (HR) 3·11; P < 0·001). Moderate compared with major shrinkage (HR 2·10; P = 0·022), early postoperative complications (HR 3·34; P < 0·001) and increasing abdominal aortic aneurysm baseline diameter (HR 1·02; P = 0·001) were also risk factors for late complications. Freedom from secondary interventions and direct endoleaks was greater for patients with major sac shrinkage. Conclusion Early change in aneurysm sac diameter is a strong predictor of late complications after EVAR. Patients with major sac shrinkage have a very low risk of complications for up to 5 years. This parameter may be used to tailor postoperative surveillance. Towards personalized surveillanc

Supervised exercise therapy and revascularization: Single-center experience of intermittent claudication management

Guidelines recommend supervised exercise therapy (SET) as first-line treatment for intermittent claudication. However, the use of revascularization is widespread. We addressed the effectiveness of preventing (additional) invasive revascularization after primary SET or revascularization based on lesion and patient characteristics. In this single-center, retrospective, cohort study, 474 patients with intermittent claudication were included. Patients with occlusive disease of the aortoiliac tract and/or common femoral artery (inflow) were primarily considered for revascularization, while patients with more distal disease (outflow) were primarily considered for SET. In total, 232 patients were referred for SET and 242 patients received revascularization. The primary outcome was freedom from (additional) intervention, analyzed by Kaplan–Meier estimates. Secondary outcomes were survival, critical ischemia, freedom from target lesion revascularization (TLR), and an increase in maximum walking distance. In the SET-first strategy, 71% of patients had significant outflow lesions. Freedom from intervention was 0.90 ± 0.02 at 1-year and 0.82 ± 0.03 at 2-year follow-up. In the primary revascularization group, 90% of patients had inflow lesions. Freedom from additional intervention was 0.78 ± 0.03 at 1-year and only 0.65 ± 0.04 at 2-year follow-up, despite freedom from TLR of 0.91 ± 0.02 and 0.85 ± 0.03 at 1- and 2-year follow-up, respectively. In conclusion, SET was effective in preventing invasive treatment for patients with mainly outflow lesions. In contrast, secondary intervention rates following our strategy of primary revascularization for inflow lesions were unexpectedly high. These findings further support the guideline recommendations of SET as first-line treatment for all patients with intermittent claudication irrespective of level of disease

Type D Personality and Health-Related Quality of Life in Vascular Surgery Patients

Background: This study evaluated the association of type D personality and health-related quality of life (HRQoL) and assessed the stability of type D personality in vascular surgery patients during the year after surgery. Method: In a prospective cohort study between 2008 and 2014, 294 patients were assessed with validated questionnaires preoperatively and at 1, 6, and 12 months after surgery. Associations between type D personality, depression, and HRQoL were analyzed by generalized estimating equation models. Type D personality was analyzed in its standard dichotomous form as well as continuous (z) scores of its two components, negative affectivity (NA) and social inhibition (SI), and their interaction term. Results: Prevalence of type D personality varied between 18% and 25%. However, only 9% of the complete responders were classified as type D personality at all four assessments, whereas one third changed between type D classifications. Continuous scores showed greater stability over time. Dichotomized type D personality measured over time was significantly associated with impaired HRQoL, but this was not the case if measured once at baseline, like in general use. The continuous NA score and depression were also significantly associated with impaired HRQoL over time. Conclusion: Type D personality was not a stable trait over time. Preoperative assessment of type D personality did not predict improvement in HRQoL after vascular surgery. However, the study revealed associations between the NA component of type D personality, depression, and lower HRQoL. This indicates that measures of overall negative affect should be taken into account when assessing HRQoL patient-reported outcomes in vascular surgery patients

Aneurysm Sac Dynamics and its Prognostic Significance Following Fenestrated and Branched Endovascular Aortic Aneurysm Repair

Objective: This study aimed to assess aneurysm sac dynamics and its prognostic significance following fenestrated and branched endovascular aneurysm repair (F/BEVAR). Methods: Patients undergoing F/BEVAR for degenerative complex aortic aneurysm from 2008 to 2020 at two large vascular centres with two imaging examinations (30 day and one year) were included. Patients were categorised as regression and non-regression, determined by the proportional volume change (&gt; 5%) at one year compared with 30 days. All cause mortality and freedom from graft related events were assessed using Kaplan–Meier methods. Factors associated with non-regression at one year and aneurysm sac volume over time were examined for FEVAR and BEVAR independently using multivariable logistic regression and linear mixed effects modelling. Results: One hundred and sixty-five patients were included: 122 FEVAR, of whom 34% did not regress at one year imaging (20% stable, 14% expansion); and 43 BEVAR, of whom 53% failed to regress (26% stable, 28% expansion). Following F/BEVAR, after risk adjusted analysis, non-regression was associated with higher risk of all cause mortality within five years (hazard ratio [HR] 2.56, 95% confidence interval [CI] 1.09 – 5.37; p = .032) and higher risk of graft related events within five years (HR 2.44, 95% CI 1.10 – 5.26; p = .029). Following multivariable logistic regression, previous aortic repair (odds ratio [OR] 2.56, 95% CI 1.11 – 5.96; p = .029) and larger baseline aneurysm diameter (OR/mm 1.04, 95% CI 1.00 – 1.09; p = .037) were associated with non-regression at one year, whereas smoking history was inversely associated with non-regression (OR 0.21, 95% CI 0.04 – 0.96; p = .045). Overall following FEVAR, aneurysm sac volume decreased significantly up to two years (baseline vs. two year, 267 [95% CI 250 – 285] cm 3 vs. 223 [95% CI 197 – 248] cm 3), remaining unchanged thereafter. Overall following BEVAR, aneurysm sac volume remained stable over time. Conclusion: Like infrarenal EVAR, non-regression at one year imaging is associated with higher five year all cause mortality and graft related events risks after F/BEVAR. Following FEVAR for juxtarenal aortic aneurysm, aneurysm sacs generally displayed regression (66% at one year), whereas after BEVAR for thoraco-abdominal aortic aneurysm, aneurysm sacs displayed a concerning proportion of growth at one year (28%), potentially suggesting a persistent risk of rupture and consequently requiring intensified surveillance following BEVAR. Future studies will have to elucidate how to improve sac regression following complex EVAR, and whether the high expansion risk after BEVAR is due to advanced disease extent.</p

Aneurysm Sac Dynamics and its Prognostic Significance Following Fenestrated and Branched Endovascular Aortic Aneurysm Repair

Objective: This study aimed to assess aneurysm sac dynamics and its prognostic significance following fenestrated and branched endovascular aneurysm repair (F/BEVAR). Methods: Patients undergoing F/BEVAR for degenerative complex aortic aneurysm from 2008 to 2020 at two large vascular centres with two imaging examinations (30 day and one year) were included. Patients were categorised as regression and non-regression, determined by the proportional volume change (&gt; 5%) at one year compared with 30 days. All cause mortality and freedom from graft related events were assessed using Kaplan–Meier methods. Factors associated with non-regression at one year and aneurysm sac volume over time were examined for FEVAR and BEVAR independently using multivariable logistic regression and linear mixed effects modelling. Results: One hundred and sixty-five patients were included: 122 FEVAR, of whom 34% did not regress at one year imaging (20% stable, 14% expansion); and 43 BEVAR, of whom 53% failed to regress (26% stable, 28% expansion). Following F/BEVAR, after risk adjusted analysis, non-regression was associated with higher risk of all cause mortality within five years (hazard ratio [HR] 2.56, 95% confidence interval [CI] 1.09 – 5.37; p = .032) and higher risk of graft related events within five years (HR 2.44, 95% CI 1.10 – 5.26; p = .029). Following multivariable logistic regression, previous aortic repair (odds ratio [OR] 2.56, 95% CI 1.11 – 5.96; p = .029) and larger baseline aneurysm diameter (OR/mm 1.04, 95% CI 1.00 – 1.09; p = .037) were associated with non-regression at one year, whereas smoking history was inversely associated with non-regression (OR 0.21, 95% CI 0.04 – 0.96; p = .045). Overall following FEVAR, aneurysm sac volume decreased significantly up to two years (baseline vs. two year, 267 [95% CI 250 – 285] cm 3 vs. 223 [95% CI 197 – 248] cm 3), remaining unchanged thereafter. Overall following BEVAR, aneurysm sac volume remained stable over time. Conclusion: Like infrarenal EVAR, non-regression at one year imaging is associated with higher five year all cause mortality and graft related events risks after F/BEVAR. Following FEVAR for juxtarenal aortic aneurysm, aneurysm sacs generally displayed regression (66% at one year), whereas after BEVAR for thoraco-abdominal aortic aneurysm, aneurysm sacs displayed a concerning proportion of growth at one year (28%), potentially suggesting a persistent risk of rupture and consequently requiring intensified surveillance following BEVAR. Future studies will have to elucidate how to improve sac regression following complex EVAR, and whether the high expansion risk after BEVAR is due to advanced disease extent.</p