Abstract Background Rapid‐sequence tracheotomy and scalpel‐bougie tracheotomy are two published approaches for establishing emergency front‐of‐neck access in infants. It is unknown whether there is a difference in performance times and success rates between the two approaches. Aims The aim of this cross‐over randomized control trial study was to investigate whether the two approaches were equivalent for establishing tracheal access in rabbit cadavers. The underlying hypothesis was that the time to achieve the tracheal access is the same with both techniques. Methods Between May and September 2022, thirty physicians (pediatric anesthesiologists and intensivists) were randomized to perform front‐of‐neck access using one and then the other technique: rapid‐sequence tracheotomy and scalpel‐bougie tracheotomy. After watching training videos, each technique was practiced four times followed by a final tracheotomy during which study measurements were obtained. Based on existing data, an equivalence margin was set at ∆ = ±10 s for the duration of the procedure. The primary outcome was defined as the duration until tracheal tube placement was achieved successfully. Secondary outcomes included success rate, structural injuries, and subjective participant self‐evaluation. Results The median duration of the scalpel‐bougie tracheotomy was 48 s (95% CI: 37–57), while the duration of the rapid‐sequence tracheotomy was 59 s (95% CI: 49–66, p = .07). The difference in the median duration between the two approaches was 11 s (95% CI: −4.9 to 29). The overall success rate was 93.3% (95% CI: 83.8%–98.2%). The scalpel‐bougie tracheotomy resulted in significantly fewer damaged tracheal rings and was preferred among participants. Conclusions The scalpel‐bougie tracheotomy was slightly faster than the rapid‐sequence tracheotomy and favored by participants, with fewer tracheal injuries. Therefore, we propose the scalpel‐bougie tracheostomy as a rescue approach favoring the similarity to the adult approach for small children. The use of a comparable equipment kit for both children and adults facilitates standardization, performance, and logistics. Trial Registration ClinicalTrials.gov identifier: NCT05499273.
Summary Background The use of isotonic electrolytic solutions for the intraoperative fluid management in children is largely recognized, but the exact composition still needs to be defined. Objectives The primary objective of this randomized controlled open trial was to compare the changes in chloride plasma concentration using two intraoperative isotonic fluid regimens (Sterofundin vs normal saline, both added with 1% of glucose) in children undergoing major surgery. Secondary objectives were to compare changes in other electrolytes, renal function, and the occurrence of hypoglycemia. Methods Children aged between 1 and 36 months, scheduled for major surgery, were randomized to receive Sterofundin or saline during the intraoperative time. Children with preoperative electrolyte abnormalities, hemodynamic instability, and severe renal or hepatic dysfunction were excluded. The primary outcome was the Δ of Cl − (Δ = change in plasma concentration between post‐ and pre‐infusion), and secondary outcomes included Δ of other electrolytes and intraoperative hypoglycemia. Results A total of 240 patients were included in the two study sites and randomized to receive Sterofundin plus 1% glucose or normal saline plus 1% glucose, in a open fashion (229 were finally analyzed). Δ of Cl − and Mg ++ was statistically less relevant in patients who received intraoperative Sterofundin, and Δ of the other electrolytes was comparable between the two study groups. Relative risk of hyperchloremia was significantly higher when large volumes were infused (over than 46.7 ml·kg −1 ), regardless of type of crystalloid infused. Hypoglycemia occurred in two of 229 patients. Conclusions Sterofundin is safer than normal saline in protecting young children undergoing major surgery against the risk of increasing plasma chlorides and the subsequent metabolic acidosis.
In the last 20 years, data from studies of laboratory animals, including nonhuman primates, have provided ample evidence that general anaesthetic drugs cause pathological changes in developing central nervous system (neurotoxicity). Recently, a new area of research has been developed in order to recognize any possible actions that can attenuate anaesthetics neurotoxicity. This review aims to provide an overview of the recent literature on neuroprotection.Neuroprotection includes a variety of actions that aim to preserve neuronal structures and/or function against insults caused by sedative and anaesthetic agents. Neuroprotective solutions include prevention of damage, such as postponing procedure, and counterbalance the damage. Mitigation of the neurotoxicity can be obtained through pharmacological protection, reducing cumulative dose or promoting neuroplasticity. Moreover, surgery and pain themselves might interfere with normal neurodevelopment in children and, in particular, treatment of pain plays a key role in preserving cortical activity and brain development.Recent literature largely explores a variety of solutions in order to preserve and reduce the damage caused by anaesthetic agents. At the moment, none of the presented solutions regarding neuroprotection is applicable in clinical setting. Further research studies are needed.
Summary Background: Clonidine has the potential to significantly prolong the duration of caudal epidural anesthesia. We investigated the effect of the addition of clonidine to the MLAC of levobupivacaine in a randomized controlled dose–response trial. Methods: A group of 120 children aged <6 years of age received caudal anesthesia with levobupivacaine and 1, 2, or 3 μg·kg −1 of clonidine. The MLAC was determined according to a Dixon‐Massey protocol. The primary outcome was effective surgical anesthesia. Secondary outcomes were the duration of postoperative analgesia, postoperative pain scores, clonidine side effects, and time to hospital discharge. Results: The MLAC of caudal levobupivacaine was 0.106%, 0.077%, and 0.035% with 1, 2, and 3 μg·kg −1 of clonidine, respectively. There were significant dose‐dependent increases in median duration of analgesia. The incidence of delayed discharge, somnolence, and PONV was significantly increased in the 3 μg·kg −1 of clonidine group. Conclusions: Clonidine produces a local anesthetic sparing effect with a dose‐dependent decrease in levobupivacaine MLAC for caudal anesthesia. In addition, there is a dose‐dependent prolongation of postoperative analgesia following lower abdominal surgery in children. A dose of 2 μg·kg −1 of clonidine provides the optimum balance between improved analgesia and minimal side effects.
Introduction: Cryoanalgesia has been recently described as alternative technique for immediate and persistent pain treatment after pectus excavatum repair. Cryoanalgesia has the potentiality to reduce analgesic consumption and length of hospitalization. However, cryoanalgesia has not been standardized yet: the previous reports describe different techniques and systems and include only small series. In Europe, no reports on cryoanalgesia for pectus repair have been published so far. Materials and Methods: This is a prospective single center pilot study performed in adolescents undergoing minimally invasive pectus excavatum repair with a new cryoanalgesia system, using a probe designed specifically for thoracoscopy. This new double lumen probe has the theoretical advantage of freezing only in its tip, so reducing the risk of complications. Results: Seven patients undergoing pectus excavatum repair were treated with cryoanalgesia performed with the new probe. No complications of cryoanalgesia were reported. Total consumption of morphine during hospital stay was between 0.1 and 0.35 mg/kg, with no side effects reported. Mean time to discharge was 2.4 days. All patients reported a good pain control with a fair need of rescue medications for pain relief during the first week after discharge, and a very good pain control without need of rescue medications during following weeks. Conclusions: Our pilot study showed that the new cryoanalgesia device is efficacious in terms of pain control, hospital stay and resumption of post-operative activities. The cryoprobe designed allowed an easy and safe maneuver. A prospective trial is needed to better define the risks and benefits of this technique.
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