Complications Associated With Removal of Airway Devices Under Deep Anesthesia In Children: An Analysis of The Wake Up Safe Database

Background: Previous studies examining removal of endotracheal tubes and supraglottic devices under deep anesthesia were underpowered to identify rare complications. This study sought to report all adverse events associated with this practice found in a large national database of pediatric anesthesia adverse events.Methods: An extract of an adverse events database created by the Wake Up Safe database, a multi-institutional pediatric anesthesia quality improvement initiative, was performed for this study. It was screened to identify anesthetics with variables indicating removal of airway devices under deep anesthesia. Three anesthesiologists screened the data to identify events where this practice possibly contributed to the event. Event data was extracted and collated. Results: 102 events met screening criteria and 66 met inclusion criteria. Two cardiac etiology events were identified, one of which resulted in the patient’s demise. The remaining 97% of events were respiratory in nature (64 events), including airway obstruction, laryngospasm, bronchospasm and aspiration. Some respiratory events consisted of multiple distinct events in series. Nineteen respiratory events resulted in cardiac arrest (29.7%) of which 15 (78.9%) were deemed preventable by local anesthesiologists performing independent review. Respiratory events resulted in intensive care unit admission (37.5%), prolonged intubation and temporary neurologic injury but no permanent harm. Provider and patient factors were root causes in most events. Upon investigation, areas for improvement identified included improving patient selection, ensuring monitoring, availability of intravenous access, and access to emergency drugs and equipment until emergence.Conclusions: Serious adverse events have been associated with this practice, but no respiratory events were associated with long-term harm.

Sleep quality and emergence delirium in children undergoing strabismus surgery: a comparison between preschool- and school-age patients

Background Emergence delirium (ED) is common in pediatric patients undergoing general anesthesia with sevoflurane. Preoperative sleep quality is associated with the risk factors for ED. However, research on the relationship between sleep quality and ED is limited. We aimed to investigate the relationship between ED and preoperative sleep quality in pediatric patients undergoing strabismus surgery. Methods This clinical trial included pediatric patients aged 4–12 years who underwent elective strabismus surgery. The patients and their parents were questioned about the patients’ preoperative sleep quality using the Pittsburgh Sleep Quality Index (PSQI) questionnaire. For anesthesia induction, thiopental (5 mg/kg) and rocuronium (0.6 mg/kg) were used, and anesthesia was maintained with sevoflurane (minimum alveolar concentration, 1–1.5). After administration of a reversal drug, extubation was performed, and the patients were transferred to a post-anesthesia recovery unit. At 10 min after extubation, the degree of ED was measured using the pediatric anesthesia emergence delirium (PAED) and Watcha scale scores. Results Of the 62 enrolled patients, three pediatric patients were excluded. The overall incidence of ED was 22%. A total of 59 patients were divided into the two groups. The ED group and the non-ED group comprised 13 and 46 patients. Age, height and weight were significantly lower in the ED group than in the non-ED group. Preoperative PSQI and Watcha scale score were significantly higher in the ED group than in the non-ED group. Multivariate analysis showed that age (adjusted OR [95% CI]: 0.490 [0.290–0.828], p = 0.008) and preoperative PSQI score (adjusted OR [95% CI]: 2.149[1.224–3.771], p = 0.008) was associated with ED. In sub-group analysis, PAED scale and Watcha scale scores showed a moderate correlation with preoperative sleep quality in preschool-age patients. Conclusion In conclusion, the incidence of ED tended to be higher in younger age and poorer preoperative sleep quality in pediatric patients. In particular, the poorer sleep quality score was associated with higher incidence of ED in the preschool-age. Large-scale clinical studies and long-term follow-up studies on ED and sleep quality are required. Trial registration This study was registered with Clinicaltrials.gov (NCT03332407) at November 5th 2017.

Effects of different doses of dexmedetomidine on postsurgical emergence agitation and oxidative stress in children

Purpose: To study the effects of various dexmedetomidine (DEX) doses on post-surgical emergence agitation (EA) and oxidative stress in children.Methods: At various times, mean arterial pressure (MAP) and heart rate (HR) were measured: prior to anesthesia (T0), during intubation (T1), at onset of operation (T2), and at the end of surgery (T3). The incidence of post-surgical EA was estimated, and the extent of agitation were determined based on pediatric anesthesia emergence delirium (PAED). Post-surgical pain was determined using facial pain scale (FPS). Serum levels of cortisol (Cor), epinephrine (E), and norepinephrine (NE) were quantified at T0 and T3. Extubation time and awakening time, as well as postoperative complications were recorded.Results: At T1, T2 and T3, levels of HR and MAP were significantly increased in all three groups, when compared to the corresponding values at T0, with group C having peak values, followed by A and B. Group B had a lower incidence of EA than groups A and C, but EA incidence was lower in group A than in group C. The lowest scores for PAED and FPS were in group B (p < 0.05). Blood levels of Cor, E and NE at T0 were comparable amongst the three groups. However, at T3, serum levels of these parameters were lower in group B than in each of the other 2 groups.Conclusion: At a dose of 0.5 μg/kg, DEX effectively reduces the incidence of post-surgical EA, improves hemodynamics, and alleviates oxidative stress responses in pediatric anesthesia.