Risk prediction models for emergence delirium in paediatric general anaesthesia: a systematic review.

Objectives: Emergence delirium (ED) occurs in approximately 25% of paediatric general anaesthetics and has significant adverse effects. The goal of the current systematic review was to identify the existing literature investigating performance of predictive models for the development of paediatric ED following general anaesthesia and to determine their usability.

Design: Systematic review using the Prediction model study Risk Of Bias Assessment Tool (PROBAST) framework.

A practical guide to acute pain management in children.

In the pediatric population, pain is frequently under-recognized and inadequately treated. Improved education and training of health care providers can positively impact the management of pain in children. The purpose of this review is to provide a practical clinical approach to the management of acute pain in the pediatric inpatient population.

Patient-Controlled Analgesia Plus Background Opioid Infusion for Postoperative Pain in Children: A Systematic Review and Meta-Analysis of Randomized Trials.

Background: Bolus administration of opioids via a patient-controlled analgesia (PCA) device is widely used in the postoperative pediatric population. PCA devices have been shown to provide superior analgesia and greater patient satisfaction compared with intermittent administration. Studies comparing the efficacy of PCA with and without a background infusion for postoperative analgesia in children vary considerably in terms of dosing and methodologic quality, making it difficult for practitioners to derive clinically useful information.

Association Between Intermittent Hypoxemia or Bradycardia and Late Death or Disability in Extremely Preterm Infants.

Importance: Extremely preterm infants may experience intermittent hypoxemia or bradycardia for many weeks after birth. The prognosis of these events is uncertain.

Objective: To determine the association between intermittent hypoxemia or bradycardia and late death or disability.

Analgesic effects of gabapentin after scoliosis surgery in children: a randomized controlled trial.

Background: Postoperative pain remains an important challenge after scoliosis surgery in children. Opioids are the mainstay of treatment, and adult studies demonstrate gabapentin as a useful adjunct to opioids in the management of postoperative pain.

Method: Adolescent patients undergoing idiopathic scoliosis surgery were randomized to receive a single preoperative dose of gabapentin 600 mg or placebo.

Inhaled nitric oxide use in newborns.

Inhaled nitric oxide (iNO) is a pulmonary vasodilator that plays a major role in regulating vascular muscle tone. It has emerged as a treatment for hypoxemic respiratory failure in newly born infants that is associated with persistent high pulmonary vascular pressure and resultant right-to-left shunting of blood (persistent pulmonary hypertension of the newborn). Current evidence shows that iNO improves oxygenation and decreases the combined outcome of death or need for extracorporeal membrane oxygenation in infants ≥35 weeks' gestational age at birth.

Abnormal fatty acid metabolism in spinal muscular atrophy may predispose to perioperative risks.

A 15 year old boy with SMA type II underwent spinal fusion and suffered a mitochondrial Reye-like catabolic crisis 4 days postop with hypoketotic hypoglycemia, lactic acidaemia, hyperammonemia and liver failure, with 90% coagulative necrosis and diffuse macro- and microvesicular steatosis, requiring orthotopic liver transplantation. This crisis responded in part to mitochondrial therapy and anabolic rescue. He made a dramatic sustained neurological recovery, though his post-transplant liver biopsies revealed micro- and macrosteatosis.

Influence of lumbar epidural injection volume on pain relief for radicular leg pain and/or low back pain.

Background Context: Epidural injections are commonly used to treat low back disorders. It has been proposed that in addition to the anti-inflammatory effects, injected material displaces the dura forward and inward, producing a stretch of the nerve roots that leads to lysis of neural adhesions. Despite this, there are no controlled trials investigating the effect of volume injected with pain as an independent outcome.

Early inhaled nitric oxide therapy for term and near-term newborn infants with hypoxic respiratory failure: neurodevelopmental follow-up.

Objective: To report the neurodevelopmental outcome of infants enrolled in a randomized multicenter trial of early inhaled nitric oxide (iNO) in term and near-term neonates with hypoxic respiratory failure and pulmonary hypertension.

Study Design: Neonates born at > or = 34 weeks gestation who required assisted ventilation and had an oxygenation index > or = 15 and < 25 were randomized to an early iNO group or a control group. A comprehensive neurodevelopmental assessment of survivors was performed at age 18 to 24 months.

The Premature Infants in Need of Transfusion (PINT) study: a randomized, controlled trial of a restrictive (low) versus liberal (high) transfusion threshold for extremely low birth weight infants.

Objective: To determine whether extremely low birth weight infants (ELBW) transfused at lower hemoglobin thresholds versus higher thresholds have different rates of survival or morbidity at discharge.

Study Design: Infants weighing <1000 g birth weight were randomly assigned within 48 hours of birth to a transfusion algorithm of either low or high hemoglobin transfusion thresholds. The composite primary outcome was death before home discharge or survival with any of either severe retinopathy, bronchopulmonary dysplasia, or brain injury on cranial ultrasound.

Ototoxic drugs and sensorineural hearing loss following severe neonatal respiratory failure.

Aim: To determine relationships between ototoxic drugs and 4-y sensorineural hearing loss (SNHL) in near-term and term survivors of severe neonatal respiratory failure.

Methods: All 81 survivors of the Canadian arm of the Neonatal Inhaled Nitric Oxide Study (mortality 32, loss to follow-up 9) received loop diuretics, aminoglycosides, and neuromuscular blockers (NMB), and 50 received vancomycin as neonates. Prospective, longitudinal secondary outcome using audiological tests diagnosed late-onset, progressive SNHL in 43 (53%); not flat (sloping) in 29, flat (severe to profound) in 14.

Actuarial survival of a large Canadian cohort of preterm infants.

Background: The increased survival of preterm and very low birth weight infants in recent years has been well documented but continued surveillance is required in order to monitor the effects of new therapeutic interventions. Gestation and birth weight specific survival rates most accurately reflect the outcome of perinatal care. Our aims were to determine survival to discharge for a large Canadian cohort of preterm infants admitted to the neonatal intensive care unit (NICU), and to examine the effect of gender on survival and the effect of increasing postnatal age on predicted survival.

A randomized trial of early versus standard inhaled nitric oxide therapy in term and near-term newborn infants with hypoxic respiratory failure.

Objective: Inhaled nitric oxide (iNO) reduces the use of extracorporeal membrane oxygenation (ECMO)/incidence of death in term and near-term neonates with severe hypoxic respiratory failure. We conducted a randomized, double masked, multicenter trial to determine whether administration of iNO earlier in respiratory failure results in additional reduction in the incidence of these outcomes.

Methods: Neonates who were born at > or =34 weeks' gestation were enrolled when they required assisted ventilation and had an oxygenation index (OI) > or =15 and <25 on any 2 measurements in a 12-hour interval.

Inhaled nitric oxide inhibits the release of matrix metalloproteinase-2, but not platelet activation, during extracorporeal membrane oxygenation in adult rabbits.

Background/purpose: In neonates receiving extracorporeal membrane oxygenation (ECMO), platelet activation and dysfunction occur with the release of matrix metalloproteinase (MMP)-2, which stimulates platelet aggregation. Because inhaled nitric oxide (NO) reduces pulmonary hypertension and inhibits platelet aggregation, the authors examined the effects of inhaled NO on platelet activation induced by ECMO.

Methods: Ten adult white New Zealand rabbits were instrumented for ECMO and assigned randomly to receive either inhaled NO at 40 ppm or 30% oxygen for 1 hour before ECMO and continued for 4 hours after starting ECMO.

Late-onset, progressive sensorineural hearing loss after severe neonatal respiratory failure.

Objectives: To determine the prevalence of sensorineural hearing loss (SNHL) at the age of 4 years among survivors of severe neonatal respiratory failure with and without congenital diaphragmatic hernia and to document the occurrence of late-onset or progressive SNHL among the survivors.

Design: Prospective, longitudinal secondary outcome study.

Setting: Multicenter Canadian study in 9 tertiary referral centers.

Variations in intraventricular hemorrhage incidence rates among Canadian neonatal intensive care units.

Objectives: To examine the variation in intraventricular hemorrhage (IVH) incidence among neonatal intensive care units and identify potentially modifiable risk factors.

Study Design: Multiple logistic regression analysis was used to examine variations in > or =grade 3 IVH, adjusting for baseline population risk factors, admission illness severity, and therapeutic risk factors. Subjects were born at <33 weeks' gestational age, admitted within 4 days of life to 1 of 17 participating Canadian NICU network sites in 1996-97, and had neuroimaging in the first 2 weeks of life.

Prolonged use of pancuronium bromide and sensorineural hearing loss in childhood survivors of congenital diaphragmatic hernia.

Sensorineural hearing loss (SNHL) is a significant neurologic morbidity in survivors of neonatal congenital diaphragmatic hernia (CDH), with a reported incidence of up to 60%. In a historical cohort study of 37 neonates with CDH, we investigated the use of pancuronium bromide (PB) and common ototoxic drugs during the neonatal period and their relationship to SNHL in childhood survivors. Survivors with SNHL (n = 23) had significantly higher cumulative dose of PB administered during the neonatal illness than survivors without SNHL (n = 14).

The Edmonton experience with venovenous extracorporeal membrane oxygenation.

Background/purpose: Despite the proven effectiveness of venovenous extracorporeal membrane oxygenation (VV ECMO) in the treatment of neonates with severe respiratory failure, this technique is not widely used. The purpose of this study was to assess the authors' policy of preferred use of VV ECMO with a cephalad catheter and to compare the results with those of the Extracorporeal Life Support Organization (ELSO) Registry.

Methods: Charts of neonatal ECMO candidates were reviewed retrospectively.

The outcome of very low birth weight neonates (

Although inhaled nitric oxide (INO) improves oxygenation in critically ill neonates, the neurodevelopmental outcome of premature neonates with severe hypoxemic respiratory failure treated with INO has not been reported. Mortality and prospective neurodevelopmental assessment in early childhood were studied in a cohort of 24 very low birth weight neonates ( View Article and Find Full Text PDF

Congenital diaphragmatic hernia: developing a protocolized approach.

Background/purpose: The purpose of this study was to evaluate the evolving outcome of newborns who have congenital diaphragmatic hernia (CDH) using a protocolized approach to management, which includes extracorporeal membrane oxygenation (ECMO) and to present the details of such a management protocol.

Methods: A retrospective chart review was conducted of the neonatal outcome of near-term (>34 weeks' gestation) newborns with CDH all referred to the Royal Alexandra Hospital either before or after delivery. A protocol was developed that included antenatal assessment, the use of antenatal steroids, planned delivery, use of prophylactic surfactant, pressure limited gentle ventilation, permissive hypercarbia and hypoxia, and venovenous ECMO, if indicated.

Inhaled nitric oxide improves oxygenation in piglets with meconium aspiration.

We hypothesized that nitric oxide (NO) inhalation in a model of meconium aspiration in newborn piglets would decrease pulmonary vascular resistance. Seven neonatal piglets were obtained at less than 48 hr of age and instrumented under fentanyl anesthesia. Inhaled NO (40 parts per million) was administered during normoxia and again after hypoxia was induced by reducing FiO2 to 0.

Congenital diaphragmatic hernia: associated malformations--cystic adenomatoid malformation, extralobular sequestration, and laryngotracheoesophageal cleft: two case reports.

Two infants with unusual bronchopulmonary malformations associated with congenital diaphragmatic hernia (CDH) are presented. One infant had extralobular sequestration and cystic adenomatoid malformation of the lower lobe, in addition to a left-sided CDH. The second infant had a laryngotracheoesophageal cleft extending to the carina (type III) in addition to a left-sided CDH.