Biomedical subjects
Publications and source records attributed to S Malviya.
An unusual case of scorpion sting followed by multiple cerebral and cerebellar watershed infarctions is being reported. Myocarditis, hypotension and hypoperfusion infarction is being considered as the possible explanation for this pathology. Hypoperfusion leading to parieto-occipital infarction has been reported earlier, however cerebellar infarction in this context is extremely rare.
BACKGROUND: Safe care of sedated children requires ongoing assessment of the depth of sedation to permit early recognition of progression to over-sedation. This study evaluated the validity and reliability of the University of Michigan Sedation Scale (UMSS) as a measure of sedation during procedures. The UMSS is a simple observational tool that assesses the level of alertness on a five-point scale ranging from 1 (wide awake) to 5 (unarousable with deep stimulation). METHODS: Thirty-two children aged 4 months to 5 yr (mean 1.5 yr), sedated for computed tomography (CT), were studied prospectively. The CT nurse assessed sedation using the UMSS before sedative administration and every 10 min thereafter. The child was videotaped during each assessment, and segments were edited and their order was randomized. Four nurses blinded to sedative administration viewed the segments and scored sedation using the UMSS. One of these nurses also scored sedation using a visual analogue scale (VAS) and another using the Observer's Assessment of Alertness/Sedation Scale (OAAS). To examine the test-retest reliability, 75 randomly selected video segments were viewed and scored on a second occasion. RESULTS: Changes in scores from baseline to discharge supported construct validity (P<0.0001). Criterion validity was demonstrated by significant correlations between the UMSS and the VAS and OAAS. There was good interobserver agreement between blinded observers' scores for each level of sedation and at discharge, and between blinded observers and the CT nurse for scores of 0 and 1 (lighter levels of sedation), but less agreement for scores 2 and 3 (deeper sedation) and discharge scores. Test-retest reliability was supported by agreement in the observers' UMSS scores. CONCLUSION: The UMSS is a simple, valid and reliable tool that facilitates rapid and frequent assessment and documentation of depth of sedation in children.
PURPOSE: To evaluate the acceptance and effectiveness of 0.2 mg x kg(-1) of oral transmucosal midazolam as a premedicant in infants and preschool children. METHOD: In a randomized, prospective double-blind placebo controlled study, 44 healthy children, between the ages of eight months to six years, presenting for elective surgery were divided in two groups. The medicated group received 0.2 mg x kg(-1) of injectable midazolam mixed with an equal volume of strawberry syrup and the placebo group received plain syrup 0.08 ml x kg(-1). Medications were placed on the anterosuperior aspect of the child's tongue in 3-5 aliquots of 0.2-0.4 ml. A blinded observer assessed the acceptance of the medication by willingness to open the mouth for the next aliquot and the efficacy of the medication was assessed by ease of separation from the parent. RESULTS: Ninety-six percent of the children in the placebo group and 95% in the midazolam group willingly accepted the medication. Separation of children from parents was successful in 95% of the medicated children compared with 59% in the placebo group (P = 0.006). CONCLUSION: Oral midazolam in thick strawberry syrup, administered in small aliquots via the oral transmucosal route was well accepted and proved to be an effective premedicant in infants and preschool children.
BACKGROUND: The traditional paternalistic approach to medical decision-making is moving towards a climate of greater patient and/or surrogate involvement. Despite this, there is considerable debate regarding patient preferences for participation in medical decision-making and its effect on patient satisfaction and outcome. This study was designed to examine parents' preferences for participation in decisions regarding their child's anaesthetic care and to determine if active participation is associated with greater parental satisfaction. METHODS: Three hundred and eight parents of children scheduled to undergo elective surgical procedures were asked to complete a questionnaire detailing information regarding their preferences for participation in decisions made regarding their child's anaesthetic care. Parents were classified as being passive, shared, or active decision makers. RESULTS: Overall, parents evidenced a preference for shared decision-making with the anaesthetist. Parents preferred to be passive with respect to intraoperative pain management but active with respect to their presence when their child wakes up. There were no differences between active, shared and passive decision-makers with respect to their satisfaction with anaesthetic care and their participation in decision-making. However, 32.1% of parents stated that they would have preferred more involvement in decision-making. These parents were significantly less satisfied with their child's care than those who felt that their participation had been adequate. CONCLUSIONS: This study highlights specific areas in which parents would prefer a more active role in decision-making and, as such, may serve to focus anaesthetists' efforts to educate parents with respect to the various options available for their child's care.
BACKGROUND: We compared pain assessment and management practices in children with and without cognitive impairment (CI) undergoing spine fusion surgery. METHODS: The medical records of 42 children (19 with CI and 23 without) were reviewed and data related to demographics, surgery, pain assessment and management, and side-effects were recorded. RESULTS: Fewer children with CI were assessed for pain on postoperative days (POD) 0-4 compared to those without CI (P < 0.002). Self-report was used for 81% of pain assessments in children without CI, while a behavioural tool was used for 75% of assessments in cognitively impaired children. Children with CI received smaller total opioid doses on POD 1-3 compared to those without CI (P < or = 0.02). Furthermore, children without CI received patient/nurse-controlled analgesia for more postoperative days than children with CI (P=0.02). CONCLUSION: Our data demonstrate a discrepancy in pain management practices in children with and without CI following spine fusion.
BACKGROUND: Anesthesia for the child who presents for surgery with an upper respiratory infection (URI) presents a challenge for the anesthesiologist. The Current prospective study was designed to determine the incidence of and risk factors for adverse respiratory events in children with URTs undergoing elective surgical procedures. METHODS: The study population included 1,078 children aged 1 month to 18 yr who presented for an elective surgical procedure. Parents were given a short questionnaire detailing their child's demographics, medical history, and presence of any symptoms of a URT. Data regarding the incidence and severity of perioperative respiratory events were collected prospectively. Adverse respiratory events (any episode of laryngospasm, bronchospasm, breath holding > 15 s, oxygen saturation < 90%, or severe cough) were recorded. In addition, parents were contacted 1 and 7 days after surgery to determine the child's postoperative course. RESULTS: There were no differences between children with active URIs, recent URIs (within 4 weeks), and asymptomatic children with respect to the incidences of laryngospasm and bronchospasm. However, children with active and recent URIs had significantly more episodes of breath holding, major desaturation (oxygen saturation < 90%) events, and a greater incidence of overall adverse respiratory events than children with no URIs. Independent risk factors for adverse respiratory events in children with active URIs included use of an endotracheal tube (< 5 yr of age), history of prematurity, history of reactive airway disease, paternal smoking, surgery involving the airway, the presence of copious secretions, and nasal congestion. Although children with URIs had a greater incidence of adverse respiratory events, none were associated with any long-term adverse sequelae. CONCLUSIONS: The current study identified several risk factors for perioperative adverse respiratory events in children with lulls. Although children with acute and recent URIs are at greater risk for respiratory complications, these results suggest that most of these children can undergo elective procedures without significant increase in adverse anesthetic outcomes.
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In busy surgical outpatient settings, it is important to quickly yet thoroughly assess a child's preoperative needs to determine whether a premedication or perhaps a parent's presence is warranted to facilitate a smooth anesthetic induction. This observational study of 252 children evaluated factors related to separation and induction behaviors of children. Six percent of children had difficulty separating from their parents, and 22% were uncooperative with induction of general anesthesia via face mask. Logistic regression showed that parent prediction was the best indicator of separation behavior, whereas younger age and separation behavior were both predictive of induction behavior. Findings suggest that parents are good predictors of their child's preoperative behaviors and may, therefore, provide valuable input when perioperative nurses and anesthesiologists are making decisions about potential preoperative interventions.
This study examined the relationship between temperament and sedation failure during magnetic resonance imaging (MRI) and computerized tomography (CT). One hundred and two children (aged 3-7 years) who underwent MRI or CT with or without sedation were studied. Demographics, sedatives administered, efficacy of sedation, and adverse events were recorded. Parents completed the Behavioural Style Questionnaire for 3-7 years olds during their wait. Eight children underwent MRI successfully without sedation, 83 were successfully sedated, and 11 procedures were aborted. Children whose sedation failed were less adaptable than children whose sedation was successful (P =0.04). Children who underwent MRI without sedation were more persistent than children who were sedated (P =0.05), and more persistent and less active than those whose sedation failed (P =0.02 and 0.03, respectively). The child's underlying temperament may contribute to sedation outcomes during MRI and CT. A presedation assessment of the child's temperament may therefore assist in decisions regarding sedation.
Sedation/analgesia for diagnostic and therapeutic procedures in children has been associated with life-threatening adverse events. Reports of adverse events and recognition of wide variability in sedation practices has led to the development of guidelines and standards of care to ensure the safety of sedated children. The safety of sedated children can be enhanced by detailed presedation evaluation, careful patient selection, and the use of drugs with a wide margin of safety that are carefully titrated to desired depth of sedation by trained personnel. Once sedative drugs are administered, stringent monitoring, including continuous pulse oximetry and frequent assessment of vital signs and sedation depth, will permit early recognition of untoward drug effects and permit early intervention. Children with underlying medical conditions, such as airway abnormalities, may not be suitable subjects for sedation and may require consideration for general anesthesia to aid their procedure. Although significant strides have been made in recognition of the risks of sedation and in development of guidelinesfor safe sedation practices, further work must focus on development of newer sedation regimens with shorter-acting drugs and wider margins of safety.
The decision to cancel or proceed with elective surgery for the child with an upper respiratory tract infection (URI) has been a source of debate among pediatric anesthesiologists, nurse anesthetists, and perianesthesia nurses for many years. Although some studies suggest that anesthesia for the child with a URI increases the risk of perioperative respiratory complications, others suggest that these complications are easily managed and are not associated with any adverse sequelae. This article describes the pathogenesis of viral respiratory tract infections, reviews the literature regarding anesthesia and URIs, and discusses the assessment and management of the child who presents for elective surgery while harboring a URI. It is hoped that this information will be important to perianesthesia nurses and anesthesia providers in making decisions regarding proceeding or cancelling surgery for children with URIs and in optimizing their perioperative management.
Inadequate pain assessment in children may lead to an underestimation of pain, and consequently, undertreatment in this population. This article provides an overview of pain assessment and describes specific measurement tools that can be used with infants, children, and adolescents. Nationally published practice guidelines and standards recommend pain assessment at regular intervals with age-appropriate tools. Pain assessment must be integrated into perianesthesia nursing practice, and nurses must develop competency in the assessment and treatment of pain in children.
Quality assurance data were collected prospectively for children who were sedated (n = 922) or given general anaesthesia (n = 140) for magnetic resonance imaging (MRI) or computerized tomography (CT). The data included patient characteristics, concurrent medication, adequacy of sedation, adverse events and requirement for escalated care. The quality of scans was evaluated. Reasons for preselection of general anaesthesia included previously failed sedation (28%), potential for failed sedation (32%) and perceived medical risk (14%). Hypoxaemia occurred in 2.9% of sedated children, and was more common in children classified as ASA III or IV. Sedation was inadequate for 16% of children and failed in 7%. Failed sedation was associated with greater age (P = 0.009), higher ASA status (P = 0.04) and use of benzodiazepines as sole sedatives (P < 0.03). More of the children who underwent general anaesthesia were ASA III or IV than sedated children, yet the procedure was successful in all the children who underwent general anaesthesia, with one incident of laryngospasm. Excessive motion was noted in 12% of scans of sedated children and 0.7% of those completed with general anaesthesia. We conclude that sedation of children for MRI and CT is associated with risks of hypoxaemia and of inadequate or failed sedation. These adverse events were more likely to occur in older children, those with a higher ASA status and those in whom benzodiazepines had been used as sole sedatives. For a preselected high-risk group of children, general anaesthesia may make MRI and CT scans more successful with minimal adverse events.
UNLABELLED: We compared the incidence and duration of false alarms (FA)and the sensitivity of conventional pulse oximetry (CPO) with Masimo Signal Extraction Technology (Masimo SET; Masimo Corporation, Irvine, CA) in children in the postanesthesia care unit. Disposable oximeter sensors were placed on separate digits of one extremity. Computerized acquisition of synchronous data included electrocardiograph heart rate, SpO(2), and pulse rate via CPO and Masimo SET. Patient motion, respiratory, and other events were simultaneously documented. SpO(2) tracings conflicting with clinical observations and/or documented events were considered false. These were defined as 1) Data dropout, complete interruption in SpO(2) data; 2) False negative, failure to detect SpO(2) </= 90% detected by another device or based on observation/intervention; 3) FA, SpO(2) </= 90% considered artifactual; and 4) True alarm (TA), SpO(2) </= 90% considered valid. Seventy-five children were monitored for 35 +/- 22 min/patient (42 h total). There were 27 TAs, all of which were identified by Masimo SET and only 16 (59%) were identified by CPO (P < 0.05). There was twice the number of FAs with CPO (10 vs 4 Masimo SET; P < 0.05). The incidence and duration of data dropouts were similar between Masimo SET and CPO. Masimo SET reduced the incidence and duration of FAs and identified a more frequent incidence of TAs compared with CPO. IMPLICATIONS: Pulse oximetry that incorporates Masimo Signal Extraction Technology (Masimo Corporation, Irvine, CA) may offer an advantage over conventional pulse oximetry by reducing the incidence of false alarms while identifying a higher number of true alarms in children in the postanesthesia care unit.
OBJECTIVE: Although sedation-related adverse events in children in the hospital setting have been extensively reported, limited data are available regarding adverse events after discharge home. Despite nationally recommended discharge criteria, in busy outpatient settings, children may be sent home into the care of their parents after a brief recovery from sedation, placing them at risk for adverse events in an unmonitored setting. Previous studies have not addressed issues such as requirement for escalation of care after discharge (ie, emergency department visits or hospitalization), or parental satisfaction with their child's sedation experience. This study was undertaken to evaluate the recovery and delayed adverse events after discharge of children who received sedation for magnetic resonance imaging or computed tomography. METHODS: With approval from the institutional review board and written informed consent from a parent, children (<18 years old) sedated for magnetic resonance imaging or computerized tomography were studied. Sedative drugs were ordered at the discretion of the radiologist responsible for the procedure in accordance with institutional sedation guidelines and in consideration of the child's health status. Pediatric nurses in the diagnostic areas administered the sedative agent(s) and monitored children according to preestablished institutional guidelines. Demographics, sedative(s) administered, and adverse events including hypoxemia (decrease in SpO(2) by >/=10% of baseline) and sedation events such as inadequate, failed, or excessive sedation, were documented on the institutional quality assurance tool. Children were discharged from the hospital when they met the following preestablished discharge criteria: return to baseline vital signs, level of consciousness close to baseline, and the ability to maintain a patent airway. The following day, parents were telephoned and questioned regarding the child's alertness, side effects, and whether medical follow-up had been sought. Parents also rated their overall satisfaction with the sedation experience. RESULTS: Three hundred seventy six children comprised the sample. Eighty nine percent of children received chloral hydrate (CH; 64 +/- 13 mg/kg), and 11% midazolam (.15 +/-.13 mg/kg) as the primary sedative. There was an 8% incidence of failed sedation, and a 1.6% incidence of hypoxemia during the procedure. Three children required prolonged monitoring in the postanesthesia care unit before discharge; 1 child attributable to an allergic reaction, a second attributable to wheezing and oxygen desaturation, and the third attributable to prolonged sedation from CH and midazolam. These children were discharged home from the postanesthesia care unit without additional sequelae. Side effects after discharge included: motor imbalance (31%), gastrointestinal effects (23%), agitation (19%), and restlessness (14%). Agitation and restlessness lasted greater than 6 hours in more than one third of children who experienced these effects. CH was more commonly associated with imbalance compared with midazolam, and restlessness and prolonged imbalance were associated with younger age. Medical advice was sought after discharge for 15 (4%) children, 3 of whom required a visit to the emergency department for excessive or prolonged sedation. Each of these children had received CH as a sole sedative in recommended doses (61-77 mg/kg). In 1 of these cases, the procedure had been aborted because of inadequate sedation in the hospital, yet the child became difficult to arouse at home. Only 48% of children returned to baseline activity and behavior within 8 hours of the procedure; however, 89% were back to baseline status within 24 hours. Notably, 5% of all children did not return to baseline activity until the second day after the procedure. Although not statistically significant, infants <12 months old experienced delayed recovery (ie, >/=24 hours) more frequently compared with older c
Transcutaneous electrical nerve stimulation (TENS) has been shown to be an effective treatment modality in adults experiencing pain associated with a variety of conditions. Therapeutic measures that are effective with adults can often be used with children. However, the benefit of TENS for children has not been well established since few research or clinical data have been published in the literature. This case report of a 4-year-old female with open perineal skin lesions who received TENS as an adjuvant therapy for painful dressing changes illustrates that TENS can be an effective treatment in children. In addition to the pain reduction seen in our patient, TENS therapy also had an opioid-sparing effect.
STUDY OBJECTIVE: To evaluate perioperative analgesia, prescription patterns, pain relief, and parental care of children undergoing outpatient surgery. DESIGN: Prospective data collection and parental interview. SETTING: Large tertiary care, university-based medical center. PATIENTS: 471 children aged between 10 months and 18 years who underwent an outpatient surgical procedure expected to be associated with pain. MEASUREMENTS AND MAIN RESULTS: All perioperative data regarding analgesia, antiemetics, postoperative pain scores, and discharge prescriptions were recorded. Parents were telephoned 24 hours following surgery, and data concerning their child's pain relief, analgesic and antiemetic usage, and their ability to care for their child were obtained. Of the 460 patients questioned, 97% were described by their parents as having adequate, good, or very good pain relief (acceptable) during the first 24 hours postoperatively, whereas only 15 (3%) had poor pain relief (unacceptable). All patients received some form of analgesia intraoperatively. The children with poor pain relief were more likely to have experienced postoperative nausea and vomiting (p = 0.01) and were more difficult to care for at home (p < 0.0001). In a subset of 185 patients who had genitourinary procedures, those who received regional analgesia reported better pain relief (p = 0.05). CONCLUSIONS: Despite a wide range of surgical procedures being performed on children on an ambulatory basis, current selection of patients for outpatient surgery is appropriate given the ability of the parents to manage their children's pain and to care for their children at home.
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