Miller, J; Ding, L; Gunter, J; Lam, J; Lin, E; Paquin, J; Li, B; Spaeth, J; Kreeger, R; Divanovic, A; Mahmoud, M; Loepke, A. Comparison of Intranasal Dexmedetomidine and Oral Pentobarbital Sedation for Transthoracic Echocardiography in Infants and Toddlers: A Prospective, Randomized, Double-Blind Trial. Anesthesia and Analgesia. 2018; 126(6):2009-2016.
The research presented in this paper is one of the most rigorous, prospective, CONSORT trials to date, providing a solid foundation for the use of intranasal dexmedetomidine for pediatric sedation, even in the presence of congenital heart disease. Children with congenital heart disease receive repeated exposure to sedatives and anesthetics that may affect brain development. Dexmedetomidine, which in animals alters brain structure to a lesser degree, may offer advantages in this vulnerable population. This study compares the effectiveness and adverse effects of intranasal dexmedetomidine sedation to that of oral pentobarbital in 280 patients aged 3 – 24 months at Cincinnati Children’s Hospital Medical Center from 2014 to 2017. The researchers found that intranasal dexmedetomidine is not inferior to oral pentobarbital sedation for infant transthoracic echocardiography sedation and does not increase the risk of clinically significant adverse events. The use of intranasal dexmedetomidine sedation could change practice to use of a potentially less neurotoxic sedative for non-painful diagnostic procedures.
Moore, D. Opioid Omission Is Not Opioid Sparing. Response to "Surgery-Induced Opioid Dependence: Adding Fuel to the Fire?" Anesthesia and Analgesia. 2018; 126(5):1789-1790.
This editorial provides a very personal insight into the challenges of providing adequate pain management in the midst of the opioid crisis. A Cincinnati Children's anesthesiologist and pain specialist who has treated hundreds of patients in his 18 years of practice experienced surgery, anesthesia, and pain management through the eyes of a patient - his wife. He compared and contrasted her two very different experiences with two very similar surgeries, one before, and one after the rise of the "Opioid Epidemic". This prompted several questions about our new “opiate-sparing” mentality. There needs to be a balance between efforts to reduce or eliminate their use and providing safe and effective pain relief. The ever-increasing incidence of opioid misuse, abuse, overdose and deaths need addressed. But, our well-meaning desire to limit opioids may have gone too far - opioid omission is NOT opioid sparing.
Olbrecht, V; Skowno, J; Marchesini, V; Ding, L; Jiang, Y; Ward, C; Yu, G; Liu, H; Schurink, B; Vutskits, L; de Graaff, J; Jr, M; von Ungern-Sternberg, B; Kurth, C; Davidson, A. An International, Multicenter, Observational Study of Cerebral Oxygenation during Infant and Neonatal Anesthesia. Anesthesiology. 2018; 128(1):85-96.
This study aimed to determine if anesthesia in neonatal surgery causes neurological development issues by determining the incidence of low cerebral oxygenation and associated factors during general anesthesia in infants. Potential risk factors of anesthesia during infancy include exposure to toxic substances that disrupt the function of the nervous system, or neurotoxicity, surgical disease, and injury to the brain through lack of oxygen, or cerebral hypoxia-ischemia. These are all mechanisms that can lead to neurocognitive development issues. This study tested 453 infants less than 6 months old who were undergoing general anesthesia for thirty minutes or more. The study found that mild and moderate low cerebral saturation occurred frequently, but severe desaturation was uncommon. Additionally, low mean arterial pressure although common was not associated with low cerebral saturation. Unrecognized severe desaturation lasting three minutes or longer in infants seems unlikely to explain the subsequent development of neurocognitive abnormalities.
Ross, J; Queme, L; Lamb, J; Green, K; Ford, Z; Jankowski, M. Interleukin 1 beta inhibition contributes to the antinociceptive effects of voluntary exercise on ischemia/reperfusion-induced hypersensitivity. Pain. 2018; 159(2):380-392.
This paper describes one way that voluntary, but not forced, exercise can regulate the inflammatory response to ischemic injuries and potentially produce pain relief. Peripheral circulation issues may be an underlying cause of musculoskeletal pain in many conditions, including sickle cell anemia and peripheral vascular disease. Exercise is commonly recommended as a treatment strategy, but recent studies have had mixed results, and in some myalgias, robust exercise may even be detrimental. Targeting IL1β may be an effective treatment strategy for this insidious type of muscle pain. Researchers found protective effects of two days of voluntary wheel running prior to ischemia and reperfusion (I/R) injury of the forelimb in affected mice. They showed that two days of voluntary exercise (wheel running), but not forced exercise (treadmill) completely blocked injury-induced IL1β enhancement and development of ischemic myalgia-like pain related behaviors, similar to systemic injection of an IL1 receptor antagonist during I/R. Interleukin 1 receptor antagonist treatment prevented the I/R-induced changes in mechanical and chemical sensitivity of individual primary muscle afferents. Altogether, these data strengthen the evidence that transient I/R injury sensitizes group III and IV muscle afferents via increased IL1β in the muscles to stimulate ischemic myalgia development.
Du, T; Hill, L; Ding, L; Towbin, A; DeJonckheere, M; Bennett, P; Hagerman, N; Varughese, A; Pratap, J. Gastric emptying for liquids of different compositions in children. British Journal of Anaesthesia. 2017; 119(5):948-955.
Children are routinely required to fast before procedures that require sedation or general anesthesia in order to reduce aspiration risk, but infants and very young children especially need to avoid unnecessary fasting. The desire to have an empty stomach during induction of anesthesia must balance against the deleterious effects of prolonged fasting. Surgical patients are increasingly encouraged to take nutrition late before surgery as part of ‘Enhanced Recovery After Surgery’ protocols. In recent years, new drinks (e.g. Ensure Clear) are available that are optically clear but with more protein than standard clear fluids, however, the appropriate place of such drinks within the existing fasting schedule remain uncertain. This paper compares the gastric emptying profiles of a novel clear high protein drink (Ensure Clear), a traditional clear fluid (apple juice), and a non-clear fluid (2% milk) in 48 healthy volunteers using a non-invasive ultrasonographic methodology. Despite early differences, clearance from the stomach was similar for all three fluids at the terminal phase, which is the period of greatest relevance to preoperative fasting recommendations. Research showed the stomach is essentially clear by 3-3.5 h for all three drinks studied. The differentiation between liquids in current guidelines is not supported by this study.