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Peroral endoscopic myotomy, or POEM, is currently the most successful realization of natural orifice transluminal endoscopic surgery (NOTES). The procedure is a treatment option for achalasia, a primary motility disorder of the esophagus caused by neuromuscular dysfunction at the esophagogastric junction. Achalasia though rare in both adult and pediatric populations has profound life-long morbidity. POEM has rapidly become an alternative surgical treatment option to laparoscopic Heller myotomy owing to its low complication rates and promising long-term outcomes. As more POEM programs are implemented in children’s hospitals, pediatric anesthesiologists will need to become familiar with this advanced endoscopic procedure in order to provide safe anesthesia. To date, no clear recommendations exist for anesthetic management of pediatric patients undergoing POEM and guidance is extrapolated from limited adult literature. The efficacy and safety of the POEM procedure have been demonstrated in a number of pediatric patients by reviewing the surgical literature. An understanding of the procedural steps, an awareness of known intraoperative complications, and a review of management strategies will help avoid rare but catastrophic adverse events.

The foundation of neonatal anesthesia lies in the understanding of neonatal physiology and the challenges of the neonatal transition from fetal physiology. A thorough preoperative assessment of the neonate is essential prior to any surgery, including a history, physical exam, and any necessary studies. The neonatal airway is notable for being smaller, more anterior, and more cephalad in comparison to adults and should be examined for features of a difficult airway. A comprehensive review of airway management, respiratory physiology, and cardiovascular physiology is imperative to the intraoperative and postoperative management of the neonate. The fundamentals of neonatal physiology establish the basis for successfully guiding a neonate through the perioperative period.

Minimally invasive surgery (MIS) is a surgical approach that has rapidly changed the world of surgery in the last few decades. Its use in pediatric populations has increased with technological improvements and greater surgeon experience. However, an open approach remains a valuable option in many pediatric patients. Discussion of the pros and cons of each approach, especially to anesthesiologists, depends on a strong understanding of the physiologic effects of insufflation with MIS. Furthermore, outcomes data for pediatric specific surgeries is significant in the comparison of MIS vs open surgical approaches.

Tracheoesophageal fistula (TEF) with and without esophageal atresia (EA) is one of the most challenging and relatively common congenital anomalies (Knottenbelt et al., Best Pract Res Clin Anaesthesiol 24:387–401, 2010). It is heterogenous in nature, involving both genetic and environmental factors. Given the large proportion of TEF neonates with other major congenital anomalies, most notably VACTERL association, identification of these defects should be a primary focus. Ideal surgical management of TEF includes division of the fistula and primary esophageal repair in one operation (Healey et al., Arch Surg 133:552–556, 1998). Thoracoscopic repair has been performed with increasing frequency and success over the last two decades. Anesthetic management poses many intraoperative challenges, the most common of which is interference with ventilation. For a successful outcome, the postoperative care should continue with the surgical team working closely with neonatal intensivists, nurses, and parents regarding plans for airway support, intravenous fluids, antibiotics, parenteral nutrition, and pain management.

Vascular access has been an important component of medical therapy for patients throughout the history of medicine. The first documented intravenous (IV) therapy attempt was in 1492 by a doctor caring for Pope Innocent VIII in Rome, followed by IV experiments with opium on dogs at Oxford University in the seventeenth century [1]. However, it wasn’t until the cholera outbreak that technology for IV therapy developed from the works of Dr. Thomas Latta, which was further developed in the 1930s by Hirschfeld, Hyman, and Wanger with the invention of the micro-dripper. The use of vascular access for IV therapy was further solidified and made available to the public in the 1950s with the invention of the plastic catheter we use daily by the Mayo Clinic [1].

Necrotizing enterocolitis is one of the most common gastrointestinal emergencies in neonatal intensive care units and one of the most serious diseases because of its associated long-term morbidity and significant mortality. In this chapter, we describe the pathophysiology and epidemiology along with the anesthesia management and care challenges of patients with necrotizing enterocolitis and short bowel syndrome.

Median arcuate ligament syndrome (MALS) has been described for over a century, yet the etiology and pathophysiology are not well understood. Interestingly, postural orthostatic tachycardia syndrome (POTS) has been observed to be associated with MALS, with approximately 5% of POTS patients having the diagnosis of MALS also. Based on the most current literature available, this chapter will discuss the etiology, epidemiology, clinical features, diagnostic findings, therapeutic options, and anesthetic considerations for patients with POTS and MALS. The laparoscopic approach is now widely accepted as the standard for surgical treatment. The anesthetic management of these patients must include several unique considerations in the preoperative, intraoperative, and postoperative phases.

The practice of pediatric anesthesia, especially when performed for pediatric airway disorders, has evolved remarkably over the past century. This chapter will cover the interesting story of the evolution of anesthesia beginning with ether and later development of mask, endotracheal tube, LMA and TIVA, and current state of the art and highlight current areas of controversy regarding pediatric airway management.

Critical for successful management of the child undergoing anesthesia is the preoperative assessment of the child. In this era of cost containment, even complex patients undergo procedures on an ambulatory basis. This has mitigated the opportunities anesthesiologists may have had in the years past to see patients while hospitalized the night before surgery. As such, assessments either in an outpatient anesthesia clinic or in the preoperative holding area need to be incisive and precise. Undoubtedly, consideration of key factors is necessary for avoiding predictable difficulties. This introductory chapter will discuss these specific considerations in the preoperative assessment of children undergoing surgery for pediatric airway pathologies.

Summary Background: We sought to characterize the airway responses to desflurane during maintenance of and emergence from anesthesia in children whose airways were supported with laryngeal mask airways (LMAs). Methods/Materials: Four hundred healthy children were randomized in a 3 : 1 ratio to either desflurane or isoflurane (reference group) during anesthetic maintenance. After induction of anesthesia, anesthesia was maintained with the designated anesthetic. The investigator chose the airway (LMA and facemask), ventilation strategy and when to remove the LMA. The incidence of airway events during maintenance, emergence and recovery was recorded. Results: Ninety percent of children received LMAs. The frequency of major airway events after desflurane (9%) was similar to that after isoflurane (4%) (number needed to harm [NNH] 20), although the frequency of major events after the LMA was removed during deep desflurane anesthesia (15%) was greater than during awake removal (5%) (NNH 10) (P

There is increased awareness of the need for effective postoperative analgesia in infants and young children. A multi-modal approach to preventing and treating pain usually is used. Mild analgesics, local and regional analgesia, and opioids when indicated, frequently are combined to minimize adverse effects of individual drugs or techniques.

Background A randomized, double-blinded trial was performed to evaluate the efficacy and safety of the S-Caine Patch (ZARS, Inc., Salt Lake City, UT), a eutectic mixture of lidocaine and tetracaine, for pain relief during venipuncture in children. Methods With institutional review board approval, parental consent, and patient assent, 64 children who were scheduled for medically indicated vascular access at two centers were randomly assigned (2:1) to receive either an S-Caine Patch or a placebo patch for 20 min before venipuncture procedures. The primary outcome measure was the child's rating of pain during venipuncture using the Oucher pain scale. Additional measures of efficacy included the blinded investigator's and an independent observer's four-point categorical scores. Variables were compared between treatments using Mantel-Haenszel summary chi-square tests or Pearson chi-square tests. Results The S-Caine Patch produced significantly greater pain relief compared with placebo (median Oucher scores of 0 vs. 60; P < 0.001). Fifty-nine percent of the children in the S-Caine Patch group reported no pain compared with 20% of the children in the placebo patch group. The investigator estimated that 76% of the children in the S-Caine Patch group experienced no pain during venipuncture versus 20% in the placebo patch group (P = 0.001). Independent observer ratings also favored the S-Caine Patchtrade mark (P < 0.001). Mild skin erythema (< 38%) and edema (< 2%) occurred with similar frequencies between the groups. Conclusion This study demonstrated that a 20-min application of the S-Caine Patch is effective in lessening pain associated with venipuncture procedures. Adverse events after S-Caine Patch application were mild and transient.

A child with emergence delirium (ED) is in a ‘dissociated state of consciousness in which the child is irritable, uncompromising, uncooperative, incoherent, and inconsolably crying, moaning, kicking, or thrashing’. ED can disrupt the surgical repair, be distressing for parents and staff and may cause parental dissatisfaction with their child’s care. Many scales have been proposed to evaluate the incidence and severity of ED, and a variety of scales are used in clinical practice and for research purposes. Agitation due to pain is a significant confounding factor for the evaluation of the presence or measurement of the degree of ED. The Cravero scale (Table 1) has five steps from obtunded and unresponsive to wild thrashing behaviour requiring restraint. A score of 4 (from crying and difficult to console to wild thrashing) for a 5 or more min duration despite active calming efforts is regarded as indicative of ED. The Paediatric Anaesthesia Emergence Delirium (PAED) scale (Table 2) is validated but is difficult to use in routine clinical practice. The Watcha scale (Table 3) is a simpler tool to use in clinical practice and may have a higher overall sensitivity and specificity than the PAED and Cravero scales. It is more practical to use a simple scale to detect delirium and then use the PAED scale to measure its degree.

UNLABELLED In this study, we examined the effectiveness of caudal blocks and correlated it with the laxity of the patients' anal sphincter before emergence from anesthesia in 178 children undergoing inguinal and/or penile surgery. Bupivacaine 0.25% in a volume of 0.6-1.25 mL/kg was used in all patients. The presence of a lax anal sphincter at the end of surgery correlated significantly with the reduced administration of narcotics intraoperatively and in the postanesthesia care unit (P < 0.001). The sensitivity of the sphincter tone test was 98.1% with a 95% confidence interval (CI) ranging from 94.3% to 99.6%. The specificity of the test was 94.4% with a 95% CI of 72.0%-100%. The positive predictive value of this test in predicting adequate caudal block was excellent (99.4%) with a 95% CI of 96.1%-100%. The negative predictive value was better than average (85%) with a 95% CI of 62.9%-95.4%. We conclude that a lax anal sphincter can predict the effectiveness of analgesia after pediatric caudal blockade. A tight sphincter may suggest the need to repeat the block before the child awakens, or consider alternate methods of postoperative analgesia. IMPLICATIONS A lax anal sphincter in children undergoing inguinal and/or penile surgery can predict the effectiveness of analgesia after pediatric caudal blockade.

We calculated the effects of the simulated Valsalva (V), liver (L) compression, and Trendelenburg (T) position on the cross-sectional area (CSA) of the right internal jugular vein by using planimetry (Aloka ultrasound machine) in 84 infants and young children. Eight combinations of positions and interventions were studied for each patient, with the patient supine, in the T position, during the simulated V maneuver, with L compression and a combination of maneuvers. Data were analyzed by using Friedman's chi(2) test and Wilcoxon's signed rank test. An increase of25% in the CSA of the internal jugular vein was considered significant. In infants, the maximal mean increase achieved with the combination of all 3 maneuvers was only 17.4% +/- 16.1%. As a single maneuver, the simulated V was the most effective (11.6% +/- 11.5%). In children, the combination of all 3 maneuvers performed simultaneously produced a mean 65.9% (SD +/- 44.7%) increase in the CSA, which was larger than the increase by all other maneuvers alone or in a single combination (Friedman's test, P0.001 and Wilcoxon's test, P0.002). As a single maneuver, V produced the most increase (40.4% +/- 32.2%) compared with L compression (14.3% +/- 18.9%) or T position (24.3% +/- 27.1%).The combinations of simulated Valsalva, liver compression, and Trendelenburg maneuvers produce the maximal mean increase in the size of the internal jugular vein in infants and young children, with the Valsalva maneuver being the most effective single maneuver. This increase is significant in young children, but negligible in infants.

POST-TONSILLECTOMY BLEEDING Tonsillectomy, whether accompanied by adenoidectomy or not, is one of the most commonly performed surgical procedure^.^ Post-tonsillectomy bleeding is considered a surgical emergency. It can occur within the first 24 hours (i.e., primary) or 5 to 10 days after surgery when the eschar covering the tonsillar bed retracts (i.e., secondary)." Primary bleeding is more serious than secondary bleeding, because it usually is more brisk and profuse. The incidence has been reported to be less than 1% in a large series of 9409 cases performed by using mechanical dissection.ls The management of anesthesia can be challenging, even in the hands of an experienced pediatric anesthesiologist. It often requires dealing with anxious parents; upset surgeons; and frightened, anemic, hypovolemic children with stomachs full of blood.

Pediatric cardiopulmonary bypass (CPB) results in increased total body water and capillary permeability. Ultrafiltration has been effective in removing this excess water. The con ventional method of ultrafiltration is restricted by the vol ume in the venous reservoir and therefore is inefficient in smaller children and neonates, whose blood volume is dis proportionately smaller than the circuit volume. Modified ultrafiltration, performed in the immediate post-CPB period, is more effective in these patients. Blood from the aorta is pumped through the ultrafilter, and warm concentrated blood is returned to the right atrium. This removes excess water from the patient and provides a method of salvaging volume from the circuit. Modified ultrafiltration results in consistent improvements in systolic blood pressure, cardiac index, and lung compliance, as well as a reduction in pul monary vascular resistance. Removal of various inflamma tory mediators, such as tumor necrosis factor a, interleu kin-6, and interieukin-8, has been reported after modified ultrafiltration. Other advantages include an increase in he matocrit, colloid osmotic pressure, and coagulation factors, resulting in decreased bleeding and a decreased need for transfusions. In the animal model, improvement in cerebral recovery after deep hypothermic circulatory arrest has been reported. The disadvantages of this technique include the risk of air entrapment, delay in heparin reversal, and poten tial for cooling.

Background Percutaneous cannulation of the internal jugular vein in infants is technically more difficult and carries a higher risk of carotid artery puncture than in older children and adults. In this prospective study, the authors tested their hypothesis that using an ultrasound scanner would increase the success of internal jugular cannulation and decrease the incidence of carotid artery puncture in infants. Methods After approval from the institutional review board and receipt of written informed parental consent, 95 infants scheduled for cardiac surgery were randomized prospectively into two groups. In the landmarks group, the patients' internal jugular veins were cannulated using the traditional method of palpation of carotid pulsation and identification of other anatomic landmarks. In the ultrasound group, cannulation was guided using an ultrasound scanner image. The cannulation time, number of attempts, success rate, and incidence of complications were compared for the two groups. Results There were no significant differences between the two groups with regard to weight, age, and American Society of Anesthesiologists physical status classification. The success rate was 100% in the ultrasound group, with no carotid artery punctures, and 77% in the landmarks group, with a 25% incidence of carotid artery punctures. Both differences were significant (P > 0.0004). The cannulation time was less, the number of attempts was fewer, and the failure rate was significantly lower in the ultrasound group than in the landmark group. Conclusion Ultrasonographic localization of the internal jugular vein was superior to the landmarks technique in terms of overall success, speed, and decreased incidence of carotid artery puncture.

It has been estimated that 0.8% of children born in the United States will be diagnosed to have some form of congenital heart disease. (CHD) Many of these children will require surgery for noncardiac conditions that are commonly encountered during childhood (e.g. inguinal hernia, dental caries, or chronic tonsillitis). Moreover, many children with CHD have other associated noncardiac (e.g. orthopedic or genitourinary) congenital anomalies that require surgical repair. Many of these procedures are performed in general hospitals by noncardiac anesthesiologists. It is therefore essential that the anesthesiologist be knowledgeable, not only of the basics of pediatric anesthesia, but also of the pathophysiology of the cardiac lesions. Knowledge of the physiological consequences of shunting or obstruction is essential to understanding the hemodynamic consequences of any congenital heart deformity. Application of these physiologic concepts permits the anesthesiologist to design a rational management plan for the child with CHD.

To provide clinicians with an evidence-based overview of all topics related to ultrasound vascular access. An international evidence-based consensus provided definitions and recommendations. Medical literature on ultrasound vascular access was reviewed from January 1985 to October 2010. The GRADE and the GRADE-RAND methods were utilised to develop recommendations. The recommendations following the conference suggest the advantage of 2D vascular screening prior to cannulation and that real-time ultrasound needle guidance with an in-plane/long-axis technique optimises the probability of needle placement. Ultrasound guidance can be used not only for central venous cannulation but also in peripheral and arterial cannulation. Ultrasound can be used in order to check for immediate and life-threatening complications as well as the catheter’s tip position. Educational courses and training are required to achieve competence and minimal skills when cannulation is performed with ultrasound guidance. A recommendation to create an ultrasound curriculum on vascular access is proposed. This technique allows the reduction of infectious and mechanical complications. These definitions and recommendations based on a critical evidence review and expert consensus are proposed to assist clinicians in ultrasound-guided vascular access and as a reference for future clinical research.

Summary A prospective study of otherwise healthy unpremedicated children scheduled for outpatient surgery was undertaken to determine the relationship between preoperative anxiety and gastric fluid volume and acidity in children. The anxiety level of the child, using a six point anxiety scale, was determined in the preoperative holding area 15–30 min before surgery. After induction of anaesthesia and tracheal intubation, a multi-port large bore catheter was inserted orally to aspirate gastric contents. Gastric fluid volume was measured and its pH was determined by an Accumet® 915 pH meter. One hundred and fifty patients, between 2 and 10 years of age (mean 5.3 ± 3.0 yrs), weighing 11.2–69.0 kg (mean 22.3 ± 15.4) were studied. Gastric contents could only be aspirated in 101 out of 150 patients. Gastric fluid volume averaged 0.41 ± 0.31 ml·kg−1 in these 101 patients. The average pH was 1.54 ± 0.40. Thirty two patients (21%) had gastric fluid volume > 0.4 ml·kg−1 and pH

Objectives/Hypothesis: To evaluate and describe airway complications in pediatric adenotonsillectomy. Study Design: Retrospective case-control study. Methods: A chart review of patients that underwent adenotonsillectomy between 2006 and 2010 was performed. Perioperative complications, patient characteristics, and surgeon and anesthesia technique were recorded. Results: A total of 682 charts were reviewed. Eleven cases (1.6%) of laryngospasm were identified: one was preoperative, seven occurred in the operating room postextubation, and three occurred in the recovery area. Four patients were given succinylcholine, one was reintubated, and the other cases were managed conservatively. Mean age of patients with laryngospasm was 5.87 years (standard deviation [SD], 4.01; 1.9–15.8 years). There were 12 cases (1.8%) of bronchospasm; all were treated with nebulized albuterol. Mean age of patients with bronchospasm was 5.81 years (SD, 4.17; 1.8–14.1 years). Overall, 22 patients required antiemetics (3.3%), 19 required albuterol (2.9%), and five required racemic epinephrine (0.8%). Compared to the children without airway complications, there was no difference in age, weight, American Society of Anesthesiologists status, length of surgery, need for admission, and anesthesia technique in those that had laryngospasm. Patients with bronchospasm, compared to the patients without complications, had faster surgeries (P < .05), were more likely to have underlying asthma (P < .05), and were more likely to be admitted (P < .05). There were no unexpected admissions or other morbidities. Conclusions: The rates of laryngospasm (1.6%) and bronchospasm (1.8%) are significantly lower than reported in the literature, reflecting refinements in modern anesthesia/surgical technique. Knowledge of at-risk patients can facilitate planning to potentially reduce the incidence of perioperative airway complications during adenotonsillectomy.

There are multiple modalities by which trauma occurs to the neck. One of these includes minor suction trauma which usually results in a superficial bruising of the skin. While this usually self-resolves, patients with hemophilia are at higher risk for the development of bleeding from such trauma. Hematomas of the head and neck in patients with hemophilia have seldom been reported. We report a unique case of expanding bilateral neck hematomas secondary to suction trauma in a patient with Hemophilia A with high-titer inhibitor and highlight the importance of a multidisciplinary approach in the management of this complex patient.

Plastic bronchitis or "Bronchitis Plastica" is a rare disease characterized by the formation of thick, tenacious, arborizing mucofibrinous tracheobronchial casts that result in life-threatening airway obstruction and pulmonary failure. We review three children who developed recurrent plastic bronchitis after undergoing a Fontan procedure for single ventricle physiology. Case series of three patients with plastic bronchitis at a tertiary referral children's hospital. All patients required repeated bronchoscopies, one requiring four separate ones over a week's period, for removal of the rigid casts. Extra-corporal membrane oxygenation (ECMO) was needed in two children because of severe respiratory failure. All were also managed with adjunctive intensive medical support. Pulmonary function returned to normal in all children, but recurred 2 months later in one who subsequently expired due to pulmonary failure. Plastic bronchitis is an unusual condition of unknown cause that occurs in multiple clinical settings, but especially in those children who have undergone a Fontan operation. Management of this distressing situation is difficult and early diagnosis and aggressive measures to remove rigid casts combined with intensive medical care are necessary. The intrinsic cardiopulmonary physiology of children with Fontan procedures, including the risk of arrhythmias, hypo-oxygenation, and pulmonary hypertension make this condition even more complex.

We performed orotracheal intubation in 153 consecutive pediatric patients undergoing cardiac catheterization. Auscultation of bilateral breath sounds was confirmed. By fluoroscopy, the tip of the endotracheal tube (ETT) was seen in the right mainstem bronchus in 18 patients (11.8%) and in a low position, defined as within 1 cm above the carina, in 29 patients (19.0%). All of the 18 patients with right mainstem intubation were children

Cannulation of the radial artery percutaneously or by cut down is frequently used to monitor blood pressure in infants and children undergoing cardiopulmonary bypass. When radial artery cannulation is difficult because of previous cannulation attempts, and/or surgical cut downs, posterior tibial artery cannulation is sometimes undertaken. We describe a child in whom the left internal mammary artery (LIMA) was chosen for monitoring arterial blood pressure because of malfunction of the existing posterior tibial arterial pressure line after cardiopulmonary bypass. This line was used for more than 3 weeks postoperatively in the intensive care unit for monitoring and for sampling. There were no complications with the placement and/or the removal of this arterial line on the 25th postoperative day. When standard arterial monitoring sites are not accessible, internal mammary artery cannulation can provide reliable access for prolonged arterial blood pressure monitoring in the postoperative period in children.

SummaryBackground: We prospectively studied the effects of intramuscular (i.m.) ketamine alone, or combined with midazolam, on mask acceptance and recovery in young children who were uncooperative during induction of anaesthesia. Methods: The Institutional Review Board (IRB) approval was obtained to study 80 children, 1–3 years, scheduled for bilateral myringotomies and tube insertion (BMT). Mask induction was attempted in all the children. Those who were uncooperative were randomly assigned to one of the four preinduction treatment groups: group I, ketamine 2 mg·kg−1; group II, ketamine 2 mg·kg−1 combined with midazolam 0.1 mg·kg−1; group III, ketamine 2 mg·kg−1 with midazolam 0.2 mg·kg−1; or group IV, ketamine 1 mg·kg−1 with midazolam 0.2 mg·kg−1. Anaesthesia was continued with nitrous oxide and halothane by facemask. Results: Children in all treatment groups achieved satisfactory sedation in less than 3 min following the administration of the preinduction drug(s). Compared with patients who received halothane induction (comparison group), the use of ketamine alone did not significantly (P > 0.0167, a Bonferroni corrected significance level) delay recovery and discharge times (18.8 ± 2.5 and 82.5 ± 30.7 min vs 12.6 ± 4.6 and 81.0 ± 33.8 min, P = 0.030 and P = 0.941, respectively). Patients who received ketamine/midazolam combinations, however, had significantly longer recovery and discharge times vs halothane (32.3 ± 14.0 and 128.0 ± 36.6 min, P = 0.001, P = 0.007, respectively). These times were so clinically unacceptable, that the study had to be terminated with only 17 patients receiving study drugs. Conclusions: It is concluded that ketamine/midazolam combination is not appropriate for preinduction of anaesthesia in paediatric ambulatory patients because of unacceptably prolonged recovery and delayed discharge times.

UNLABELLED In this study we compared the intensity and level of caudal blockade when two different volumes and concentrations of a fixed dose of bupivacaine were used. Fifty children, 1-6 yr old, undergoing unilateral orchidopexy received a caudal block with a fixed 2 mg/kg dose of bupivacaine immediately after the induction. Group 1 (n = 23) received 0.8 mL/kg of 0.25% bupivacaine, whereas Group 2 (n = 27) received 1.0 mL/kg of 0.2% bupivacaine. Epinephrine 1:400,000 and 0.1 mL of sodium bicarbonate per 10 mL of local anesthetic solution were added. There were no statistically significant differences between the two groups in their anesthesia, surgery, recovery, and discharge times. Fifteen patients (65.2%) in Group 1 required an increase in inspired halothane concentration to block hemodynamic and/or ventilatory response during spermatic cord traction, as compared with 8 patients (29.6%) in Group 2 (P = 0.022). In the recovery room, four (17.4%) patients in Group 1 required rescue treatment with fentanyl, versus two (7.4%) in Group 2 (P = 0.372). In children undergoing orchidopexy, a caudal block with a larger volume of dilute bupivacaine is more effective than a smaller volume of the standard 0.25% solution in blocking the peritoneal response during spermatic cord traction, with no change in the quality of postoperative analgesia. IMPLICATIONS In children undergoing orchidopexy, a caudal block with a larger volume of dilute bupivacaine is more effective than a smaller volume of the more concentrated solution in blocking the peritoneal response during spermatic cord traction, with no change in the quality of postoperative analgesia.

This study was designed to determine the feasibility and benefits of fast-tracking children after ambulatory surgery. One-hundred-fifty-five healthy children undergoing surgical procedures lasting90 min were studied in a randomized manner. After surgery, children who met predefined recovery criteria in the operating room were entered into one of the study groups. Seventy-one patients (control) were first admitted to the postanesthesia care unit (PACU) and then to the second-stage recovery unit (SSRU). Eighty-four children bypassed the PACU and were directly admitted to the SSRU (Fast-Track group). The demographic data, airway management, and surgical procedures were similar in both groups of patients. During the recovery phase, 62.0% of the PACU group patients and 40.5% of the Fast-Track patients received analgesics (P = 0.01). The total recovery time was 79.1 +/- 48.3 min in the Fast-Track group and 99.4 +/- 48.6 min in the Control group (P = 0.008). A larger percentage of parents in the Fast-Track group (31% vs 16%) reported that their child was restless on arrival at the SSRU (P = 0.037). There were no clinically significant adverse events. However, adequate pain control must be provided before transfer to SSRU. In conclusion, fast-tracking children after ambulatory surgery is feasible and beneficial when specific selection criteria are used.The results of this study show that the total recovery time is shorter in children who are fast-tracked (bypass the postanesthesia care unit) after ambulatory surgery. A higher percentage of parents of the Fast-Track group felt that their child was restless on arrival at the second-stage recovery unit. Fast-tracking children after ambulatory surgery is feasible and beneficial when specific selection criteria are used.

Central venous cannulation allows accurate monitoring of right atrial pressure and infusion of drugs during the anaesthetic management of infants undergoing cardiopulmonary bypass. In this prospective, randomized study, we compared the success and speed of cannulation of the internal jugular vein in 45 infants weighing less than 10 kg using three modes of identification: auditory signals from internal ultrasound (SmartNeedle, SM), external ultrasound imaging (Imaging Method, IM) and the traditional palpation of the carotid pulsation and other landmarks (Landmarks Method, LM). The cannulation time, number of attempts with LM and SM techniques were greater than those with IM technique. The incidence of carotid artery puncture and the success rate were not significantly different among the three groups. In infants, a method based on visual ultrasound identification (IM) of the internal jugular vein is more precise and efficient than methods based on auditory (SM) and tactile perception (LM).

Susan T Verghese, Raafat S HannallahThe George Washington University Medical Center, Division of Anesthesiology, Children’s National Medical Center, Washington, DC, USAAbstract: The greatest advance in pediatric pain medicine is the recognition that untreated pain is a significant cause of morbidity and even mortality after surgical trauma. Accurate assessment of pain in different age groups and the effective treatment of postoperative pain is constantly being refined; with newer drugs being used alone or in combination with other drugs continues to be explored. Several advances in developmental neurobiology and pharmacology, knowledge of new analgesics and newer applications of old analgesics in the last two decades have helped the pediatric anesthesiologist in managing pain in children more efficiently. The latter include administering opioids via the skin and nasal mucosa and their addition into the neuraxial local anesthetics. Systemic opioids, nonsteroidal anti-inflammatory agents and regional analgesics alone or combined with additives are currently used to provide effective postoperative analgesia. These modalities are best utilized when combined as a multimodal approach to treat acute pain in the perioperative setting. The development of receptor specific drugs that can produce pain relief without the untoward side effects of respiratory depression will hasten the recovery and discharge of children after surgery. This review focuses on the overview of acute pain management in children, with an emphasis on pharmacological and regional anesthesia in achieving this goal.Keywords: pediatric pain treatment, pain medication in children, pediatric regional anesthesia, pca and pcea in children, epidural additives