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Background Intraoperative magnetic resonance imaging (iMRI) has been recognized as a useful adjunct for brain tumor surgery in pediatric patients. There is minimal data on the use of an offsite intraoperative magnetic resonance imaging operating theater (iMRI OT), whereby vehicle transfer of patients is involved. The primary aim of this study is to validate the feasibility of perioperative patient transfer to use an offsite iMRI OT for patients with pediatric brain tumor. Secondary objectives include the assessment of tumor resection efficacy and perioperative outcomes in our patient cohort. Methods This is a retrospective, single-institution clinical study of prospectively collected data from Singapore's largest children hospital. Variables of interest include issues encountered during interhospital transfer, achievement of surgical aims, length of stay in hospital, and postoperative complications. Our findings were compared with results of related studies published in the literature. Results From January 1, 2009 to December 31, 2018, a total of 35 pediatric operative cases were performed in our offsite iMRI OT. Within this cohort, 24 of these were brain tumor surgery cases. For all the patients in this study, use of the iMRI OT influenced intraoperative decisions. Average ambulance transport time from parent hospital to the iMRI OT was 30.5 minutes, and from iMRI OT back to the parent hospital after surgery was 27.7 minutes. The average length of hospitalization stay was 7.9 days per patient. There were no ferromagnetic accidents during perioperative iMRI scanning and no airway/hemodynamic incidents in patients encountered during interhospital transfer. Conclusions In our local context, the use of interhospital transfers for access to iMRI OT is a safe and feasible option in ensuring good patient outcomes for a select group of patients with pediatric brain tumors.

Background Self-made Y-connector jet-oxygenation devices with wide-bore expiratory port have been described but not evaluated in infant models. Little is known about the effect of oxygen flow rates on jet oxygenation via transtracheal cannula. Aims The aim of this study was to compare two self-made Y-connector jet-oxygenation devices against the ENK oxygen flow modulator™, and the effects of three different oxygen flow rates based on body weight, in both unobstructed and obstructed airways, on the time to re-oxygenate in a rabbit infant model. The aim was also to assess the effectiveness of an oxygen flow rate of 1 L/min, for re-oxygenation using ENK oxygen flow modulator™. Methods Nine rabbits were grouped in threes: Group 1 had a Y-connector attached to an intravenous infusion tubing, Group 2 the same Y-connector attached to a perfusion oxygenator tubing and Group 3, ENK oxygen flow modulator™. From oxygen saturations of 75%, the rabbits were jet oxygenated using their assigned device for 10 minutes at each flow rate of 1 L/kg/min, 1.5 L/kg/min and 2 L/kg/min with their airways unobstructed and later, obstructed. Group 3 had additional experiments involving an absolute oxygen flow rate of 1 L/min. Results All devices resulted in rapid re-oxygenation within 40 seconds at flow rates of 1 L/kg/min. Oxygen flow rates beyond 1 L/kg/min in obstructed airways resulted in high airway pressures. All rabbits in Group 3 with obstructed airways died from barotrauma when jet oxygenated at a flow rate of 1.5 L/kg/min. When an oxygen flow rate of 1 L/min was used in Group 3, there was a failure to re-oxygenate to SpO2 90% within 120 seconds in some rabbits. Conclusion Our animal model results suggest that self-made Y-connector jet-oxygenation devices with wide-bore expiratory port are efficacious and perhaps safer than ENK oxygen flow modulator™ in obstructed airways, and jet oxygenation with minimal oxygen flow rates starting at 1 L/kg/min or (age [years] + 4) L/min, whichever lower, should be considered.

a) To evaluate the effect of adding 1.25 mg of bupivacaine to intrathecal fentanyl on the duration of analgesia in an Asian population and b) to examine if the baricity of the local anesthetic at this dose has any bearing on the duration and quality of block.Forty-eight parturients in early labour received combined spinal epidural (CSE) analgesia to evaluate a) the effect of adding 1.25 mg of bupivacaine to intrathecal (IT) fentanyl 25 microg on the duration of analgesia and b) the effect of baricity of intrathecal local anesthetic on the duration and quality of the block. Patients were randomly allocated to receive: IT fentanyl 25 microg plus normal saline (Group f, n=16), IT fentanyl 25 microg plus plain bupivacaine 1.25 mg (Group f+pb, n=16) and IT fentanyl 25 microg plus heavy bupivacaine 1.25 mg (Group f+hb, n=16). The two components of the IT injectate (total of 2.25 mL) were given sequentially.Group f+hb had the lowest sensory dermatomal block (T7 vs T4 (Group f), T5 (Group f+pb), P0.01). There were no differences in the duration of analgesia and incidence of side effects among the groups.We found no advantage of adding 1.25 mg bupivacaine to fentanyl 25 microg. At this dose, the baricity of bupivacaine has no effect on the duration of analgesia.

Caudal epidural block in a conscious infant is a recognised technique that allows the avoidance of general anaesthesia and risks associated with it. It is also technically easier to perform reliably compared with an awake subarachnoid block in skilled hands.(1) While local anaesthetic systemic toxicity is a rare complication of caudal anaesthesia, this case illustrates the potential for caudal anaesthesia done awake in enhancing patient safety through early recognition of local anaesthetic systemic toxicity.

Summary Emergence delirium is a significant problem in children regaining consciousness following general anaesthesia. We compared the emergence characteristics of 120 patients randomly assigned to receive a single intravenous dose of dexmedetomidine 0.3 μg.kg−1, propofol 1 mg.kg−1, or 10 ml saline 0.9% before emerging from general anaesthesia following a magnetic resonance imaging scan. Emergence delirium was diagnosed as a score of 10 or more on the Paediatric Anaesthesia Emergence Delirium scale. The incidence of emergence delirium was 42.5% in the dexmedetomidine group, 33.3% in the propofol group and 41.5% in the saline group (p = 0.671). Three patients in the dexmedetomidine group, none in the propofol group and two in the saline group required pharmacological intervention for emergence delirium (p = 0.202). Administration of neither dexmedetomidine nor propofol significantly reduced the incidence, or severity, of emergence delirium. The only significant predictor for emergence delirium was the time taken to awaken from general anaesthesia, with every minute increase in wake-up time reducing the odds of emergence delirium by 7%.

The study was aimed primarily at comparing the duration of analgesia produced by intrathecal fentanyl 25 microg with sufentanil 5 microg when added to bupivacaine 1.25 mg as the initial component of the combined spinal epidural (CSE) technique in early labour.Forty healthy parturients were randomly assigned into two groups to receive either intrathecal sufentanil 5 microg plus bupivacaine 1.25 mg (Group S) or intrathecal fentanyl 25 microg plus bupivacaine 1.25 mg (Group F). Apart from the duration of analgesia, pain scores and side effects were also evaluated.There was no significant difference in the duration of analgesia (mean 109 +/- SD 49 min in Group F vs 118 +/- 54 min in Group S, P=0.9). Group F had a more rapid onset of analgesia (P0.05) and a higher cephalad block (median T4 vs T7, P0.05) in the first 30 min after the block. No difference in the side effects was detected.Fentanyl 25 microg is a good alternative to sufentanil 5 microg when added to bupivacaine 1.25 mg for early labour analgesia.

We report our anesthetic management of a neonate who presented with complete persistent buccopharyngeal membrane and unilateral choanal atresia, and underwent examination under anesthesia. Maintaining airway patency and spontaneous respiration were our priority. Intravenous propofol was used to maintain adequate anesthetic depth for flexible laryngotracheoscopy and nasotracheal intubation through the only patent passage. We encountered problems of bradycardia and hypotension. Tracheostomy was performed. Definitive management of the persistent buccopharyngeal membrane was carried out on day 14.

Background Active ‘hands-on’ participation in the ‘hot-seat’ during immersive simulation-based training (SBT) induces stress for participants, which is believed to be necessary to improve performance. We hypothesized that observers of SBT can subsequently achieve an equivalent level of non-technical performance as ‘hot-seat’ participants despite experiencing lower stress. Methods We randomized 37 anaesthesia trainees into two groups to undergo three consecutive SBT scenarios. Eighteen ‘hot-seat’ trainees actively participated in all three scenarios, and 19 ‘observer’ trainees were directed to observe the first two scenarios and participated in the ‘hot-seat’ only in scenario 3. Salivary cortisol (SC) was measured at four time points during each scenario. Primary endpoint for stress response was the change in SC (ΔSC) from baseline. Performance was measured using the Anaesthetist’s Non-Technical Skills (ANTS) Score. Results Mean SC increased in all participants whenever they were in the ‘hot-seat’ role, but not when in the observer role. Hot-seat ΔSC (mcg/dL) for scenarios 1, 2, and 3 were 0.122 (p = 0.001), 0.074 (p = 0.047), and 0.085 (p = 0.023), respectively. Observers ΔSC (mcg/dL) for scenarios 1, 2, and 3 were −0.062 (p = 0.091), 0.010 (p = 0.780), and 0.144 (p = 0.001), respectively. Mean ANTS scores were equivalent between the ‘hot-seat’ (40.0) and ‘observer’ (39.4) groups in scenario 3 (p = 0.733). Conclusions Observers of SBT achieved an equivalent level of non-technical performance, while experiencing lower stress than trainees repeatedly trained in the ‘hot-seat’. Our findings suggest that directed observers may benefit from immersive SBT even without repeated ‘hands-on’ experience and stress in the hot-seat. The directed observer role may offer a less stressful, practical alternative to the traditional ‘hot-seat’ role, potentially rendering SBT accessible to a wider audience. Trial registration ClinicalTrials.gov Identifier NCT02211378, registered August 5, 2014, retrospectively registered. Electronic supplementary material The online version of this article (doi:10.1186/s41077-017-0040-7) contains supplementary material, which is available to authorized users.