Pediatric preoperative blood ordering: when is a type and screen or crossmatch really needed? (Carmean)

Fernández AM, Cronin J, Greenberg RS, Heitmiller ES. Pediatric preoperative blood ordering: when is a type and screen or crossmatch really needed? Paediatr Anaesth. 2014 Feb;24(2):146-50.

BACKGROUND: Unnecessary testing for and ordering of blood products adds to overall healthcare costs.

OBJECTIVES: Determine intraoperative red blood cell (RBC) product utilization for pediatric procedures and costs associated with perioperative testing and ordering.

METHODS: A retrospective chart review captured perioperative blood testing and intraoperative transfusion data for patients <19 years of age who underwent noncardiac surgery over a 13-month period at one tertiary care hospital. The main outcome measure was cost associated with testing for blood products in patients undergoing procedures that had a zero rate of transfusion.

RESULTS: The intraoperative transfusion rate for 8620 noncardiac pediatric procedures was 2.78%. Of 8380 nontransfused patients, 707 (8.4%) had type and screen, and of those, 420 (5%) were crossmatched for RBC products in preparation for surgery. The 10 surgical procedures that had the highest perioperative blood testing but no instances of transfusion were as follows: colostomy or ileostomy takedown, spinal cord untethering, tunneled catheter placement, laparoscopic Nissen fundoplication, elbow reduction and fixation, lumbar puncture, suboccipital craniectomy, hip arthrogram, percutaneous intravascular central line, and tonsillectomy and adenoidectomy. Procedures with low transfusion probability and high crossmatch testing were ventriculoperitoneal shunt revision and growing rod distraction. For all nontransfused patients, the cost of obtaining type and screen was $31 815, and the cost for crossmatch was $25 200.

CONCLUSION: Patients may undergo preoperative type and screen or crossmatch for procedures rarely associated with transfusion. Historic transfusion probability may be used to predict need for transfusion for specific surgical procedures and reduce unnecessary perioperative testing and associated costs.

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A review of 5434 percutaneous pediatric central venous catheters inserted by anesthesiologists. (Kamat)

Malbezin S, Gauss T, Smith I, Bruneau B, Mangalsuren N, Diallo T, Skhiri A, Nivoche Y, Dahmani S, Brasher C. A review of 5434 percutaneous pediatric central venous catheters inserted by anesthesiologists. Paediatr Anaesth. 2013 Nov;23(11):974-979.

OBJECTIVE: To review the results of an anesthesiologist led pediatric percutaneous central venous access service.

METHODS: Prospective data on percutaneous pediatric central venous catheter (CVC) insertions were collected over 22 years. Data included age, gender, weight, previous central CVCs, venous thromboses, investigations for great vein patency, type of CVC, external diameter, previous CVC insertions, intended use, operator identity, and the vein into which the CVC was inserted. The default technique was internal jugular vein cannulation using landmark technique (LT). Complication was defined as the following: failure to cannulate any vein, hemothorax, pneumothorax, right atrial perforation, extravenous wire positioning or CVC position and whether the patient was taken back to theater for CVC repositioning.

RESULTS: Five thousand four hundred and thirty-four percutaneous CVC insertion procedures were performed on 3954 patients. One-third involved children <1 year of age (n = 1823: 34%). Five thousand one hundred and twenty-five CVCs (95.3%) were inserted into internal jugular veins. The majority were tunneled CVCs (n = 5190: 96.2%). The perioperative complication rate was 1.3%. Successful cannulation occurred in 99.5% of patients. Failure was more likely in children ❤ kg, during large bore hemodialysis CVC insertions and during the first 4 years of the service – the latter suggesting a learning curve. Ninety-nine percent of CVCs were inserted using LTs.

CONCLUSION: This study demonstrates a high success rate and low complication rate during pediatric percutaneous internal jugular vein CVC insertions by trained anesthesiologists using LTs. Smaller children, hemodialysis CVCs, and the team’s learning curve were identified as risk factors for insertion failure.

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Controlled rapid sequence induction and intubation – an analysis of 1001 children. (Pham)

Paediatr Anaesth. 2013 Aug;23(8):734-40. PMID: 23763293

BACKGROUND: Classic rapid sequence induction puts pediatric patients at risk of cardiorespiratory deterioration and traumatic intubation due to their reduced apnea tolerance and related shortened intubation time. A ‘controlled’ rapid sequence induction and intubation technique (cRSII) with gentle facemask ventilation prior to intubation may be a safer and more appropriate approach in pediatric patients. The aim of this study was to analyze the benefits and complications of cRSII in a large cohort.

METHODS: Retrospective cohort analysis of all patients undergoing cRSII according to a standardized institutional protocol between 2007 and 2011 in a tertiary pediatric hospital. By means of an electronic patient data management system, vital sign data were reviewed for cardiorespiratory parameters, intubation conditions, general adverse respiratory events, and general anesthesia parameters. RESULTS: A total of 1001 patients with cRSII were analyzed. Moderate hypoxemia (SpO2 80-89%) during cRSII occurred in 0.5% (n = 5) and severe hypoxemia (SpO2 <80%) in 0.3% of patients (n = 3). None of these patients developed bradycardia or hypotension. Overall, one single gastric regurgitation was observed (0.1%), but no pulmonary aspiration could be detected. Intubation was documented as ‘difficult’ in two patients with expected (0.2%) and in three patients with unexpected difficult intubation (0.3%). The further course of anesthesia as well as respiratory conditions after extubation did not reveal evidence of ‘silent aspiration’ during cRSII.

CONCLUSION: Controlled RSII with gentle face mask ventilation prior to intubation supports stable cardiorespiratory conditions for securing the airway in children with an expected or suspected full stomach. Pulmonary aspiration does not seem to be significantly increased.

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Comparison of low-dose ketamine to midazolam for sedation during pediatric urodynamic study. (Pham)

Paediatr Anaesth. 2013 May;23(5):415-21. PMID: 23061785

INTRODUCTION: Aim of sedation during pediatric urodynamic studies (UDS) is a calm and cooperative child while not affecting measurements. We compared the effectiveness of midazolam to low-dose ketamine infusion for sedation and their impact on urodynamics.

MATERIALS AND METHODS: ASA-I children undergoing UDS were randomly assigned to group K (ketamine) loading dose (0.25 mg·kg(-1) ) followed by infusion of 10-20 μg·kg(-1) ·min(-1) or group M (midazolam) loading dose of (0.02 mg·kg(-1) ) followed by 1-2 μg·kg(-1) ·min(-1) . The sedation scores and reactivity to catheterization were monitored by Children Hospital of Wisconsin Sedation Scale and Frankl Behavior Rating Scale, respectively. The UDS included two-channel filling cystometry in supine position followed by a free uroflowmetry in sitting position. The UDS was performed and interpreted in accordance with good urodynamic practice guidelines of International Continence Society (2002).

RESULTS: A total of 34 children were enrolled. Group K children (n = 17) attained sedation earlier 6.80 (±3.36) min vs. 9.40 (±2.82) min; (P = 0.03) than group M (n = 17) and also recovered earlier 11.60 (±3.13) min vs. 19.67 (±5.49) min (P = 0.01). Reactivity scores during urinary and rectal catheterization were lower in group K (P = 0.03 and 0.01), respectively. Historical UDS data of 21 participants were available for comparison with effect of medication. None of the study drugs affected UDS parameters significantly.

CONCLUSIONS: Midazolam or low-dose ketamine provide satisfactory sedation during pediatric UDS without impacting urodynamic values.

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