Agarwal, Rita, MD
NOTHING TO DISCLOSE
PEDIATRIC ANESTHESIA UPDATE
LEAVING DENVER
OPTIMAL RESOURCES FOR THE SURGICAL
CARE OF CHILDREN IN THE US
Pediatric Anesthesia Update
CRASH 2015  Moved to California
Rita A gar wal MD  Working at Stanford
Clinical Professor of and Lucille Packard
Anesthesiology
Stanford School of
Children’s Hospital
 This is my last year as
Medicine
CRASH Program
Director
 Can’t ski cause I broke
my wrist
 Please encourage next
year’s organizer’s to
invite me back 
OBJECTIVES:
Surgical Environment
Codeine
Anesthesia and neurodevelopment
PRAN Update
Lidocaine and laryngospasm
Clotting-differences in children
Machine washout
AMERICAN PEDIATRIC SURGICAL ASSOCIATION
American College of Surgeons
Society for Pediatric Anesthesia
American Academy of Pediatrics
Children’s Hospital Association
Created task force in 2012
Met in 2012, 13, 14
Develop “consensus recommendations”
 Agarwal, Rita, MD Pediatric Anesthesia Update

OPTIMAL RESOURCES FOR CHILDREN’S SURGICAL

AMBULATORY SURGERY RECOMMENDATIONS
CARE
 Currently a “mismatch”
 ?suboptimal care 1.Pediatric Anesthesiologist for children < 1 year of age
 35% of neonates in 2009 complex surgery at non-specialty 2.Dedicated area for pre and post
institutions/units
3.Special needs for emotional well being
 “Appropriate pediatric anesthesia expertise, including both relevant
training and an adequate level of ongoing clinical pediatric practice, 4.Anesthesia and resuscitation equipment readily available
was judged to be critical” 5.One + PALS certified person available
6.Admission and monitoring for neonates and Ex=premature
infants
7.Formal transfer agreements

NOV 2014
 Agarwal, Rita, MD Pediatric Anesthesia Update

DEFINITIONS

HOPEFULLY YOU ARE NOT STEAMING HOT OR FEELING

OPTIMAL RESOURCES
LIKE YOU’RE ABOUT

Information being widely

disseminate
Plan to start voluntary
reviews
Administered by
American College of
Surgeons
Agarwal, Rita, MD Pediatric Anesthesia Update

Anesthesia & Analgesia:

June 2014 - Volume 118 - Issue 6 - p 1157–1159
doi: 10.1213/ANE.0b013e31829ec1e6
Editorials: Editorial
The Elephant in the Room: Lethal Apnea at Home after Adenotonsillectomy
Brown, Karen A. MD*; Brouillette, Robert T. MD†

APRIL 2014 WHAT SHOULD WE USE INSTEAD?

Hyrocodone
Oxycodone
Ibuprofen
Acetaminophen
Tramadol
Diclofenac

SUMMER 2014
 Agarwal, Rita, MD Pediatric Anesthesia Update

ANESTHESIA AND NEURO DEVELOPMENT ANESTHESIA AND NEUROTOXICIT Y

New FDA statement coming soon

 Much Stronger Warning

VOLATILE AND OTHER ANESTHETICS OF MICE AND MEN

Over-inhibition Mice •Humans

All volatile anesthetics, Brain Growth Spurt: first •Brain Growth Spurt:
midazolam, propofol and 1-2 weeks of life prenatal-24 months
ketamine have been Anesthetized for 5-6 •Equivalent to
implicated hours several days-months
Many species including •Monitored
Many unmonitored •Pain and surgical stress
primates
Pain and surgical stress are harmful
So far opioids seem to be are harmful
OK

Ta b le 1 . C h a r a c t e r is t i c s o f e l i g i b l e s t u d i e s f o r m e t a- a n a l y s is .

PLoS One. 2014 Jan

20;9(1):e85760.

Wang X, Xu Z, Miao C-H (2014) Current Clinical Evidence on the Effect of General Anesthesia on Neurodevelopment in Children: An Updated Systematic Review with Meta-Regression.
PLoS ONE 9(1): e85760. doi:10.1371/journal.pone.0085760
http://www.plosone.org/article/info:doi/10.1371/journal.pone.0085760
 Agarwal, Rita, MD Pediatric Anesthesia Update

RESULTS

All children undergoing pyloric stenosis b/w 1986-1990 in Pyloric Stenosis No Pyloric Stenosis

Denmark % male 80 51.6

Compared with 5% age matched sample Parental Age similar similar
Parental Education slightly lower
9 th grade standardized educational test
Mean Birth Weight (g) 3345 3434
Small % of Danish children do NOT take these tests Age at time of surgery 40 days
Variables: sex, birth weight, parental education and age. Congenital malformations 6.8% 4.4%

Exclusions: congenital malformation, hyperbilirubinemia, Non-attainment-boys 22% 16%

OR=1.37
neonatal jaundice Non-attainment-girls 13% 10%

CONCLUSION

Mean test scores similar

once low birth weight and
congenital malformation are
excluded
Higher incidence of test Non-
Attainment in exposed
patients boys > girls

100 children who had surgery < 1yr of age

Performance on “high stakes” test at age 12
Diagnosis of “learning disability”
Phone surveys
Slightly higher incidence of “learning disabilities”
 Agarwal, Rita, MD Pediatric Anesthesia Update

PROBLEMS WITH THE STUDY

Small
Retrospective
GA group was 90% male
Maternal education slightly
lower
Learning disabilities not
defined

ING ET.AL. ANESTHESIOLOGY 2014

Data sets derived from children born between 1989-1992

Extensive and repeated individual neurodevelopmental tests
ICD 9 diagnoses of “ADHD”
Neuropsychological test
Group Academic tests
No difference in group tests
Neuropsych testing and ICD diagnosis alterations

FLICK EDITORIAL
Most studies with negative results used were large and reviewed
group tests of achievements
Most positive studies were small and looked at individual
cognitive evaluation
Use of ICD-9 codes for ADHD are controversial and inaccurate
 Anesthesia & Analgesia:
June 2014 - Volume 118 - Issue 6 - p 1284–
1292
Pediatric Neuroscience: Research Report
Subclinical Carbon Monoxide Limits Apoptosis in
the Developing Brain After Isoflurane Exposure
Cheng, Ying; Levy, Richard J. MD
Agarwal, Rita, MD Pediatric Anesthesia Update

F IGURE 2 F IGURE 3
S ubclinical C arbon M onoxide L i mits S ubclinical C arbon M onoxide L i mits
A poptosis i n t he D eveloping B rain A fter A poptosis i n t he D eveloping B rain A fter
I soflurane E xposure I soflurane E xposure

Cheng, Ying; Levy, Richard J. Cheng, Ying; Levy, Richard J.

Anesthesia & Analgesia. 118(6):1284- Anesthesia & Analgesia. 118(6):1284-
1292, June 2014. 1292, June 2014.
doi: 10.1213/ANE.0000000000000030 doi: 10.1213/ANE.0000000000000030

Copyright © 2014 International Anesthesia Research Society. Published by Lippincott Williams & Wilkins. 43 Copyright © 2014 International Anesthesia Research Society. Published by Lippincott Williams & Wilkins. 44

F IGURE 4
S ubclinical C arbon M onoxide L i mits
A poptosis i n t he D eveloping B rain A fter
I soflurane E xposure

Cheng, Ying; Levy, Richard J.

Anesthesia & Analgesia. 118(6):1284-
1292, June 2014.
doi: 10.1213/ANE.0000000000000030

Anesthesia & Analgesia:

Figure 4. Cytoc hrome c per oxidase
June 2014 - Volume 118 - Issue 6 - p 1160–
activity after carbon monoxide (CO)
e xp os ure w i t h a n d w i t h out i s o f lur ane .
S t e a d y-st at e c yt o chrome c p e r oxi das e
1162
ac tivity immediately after 1-hour
exposure is shown. Values are expressed
as means plus standard error. N = 5
Editorials: Editorial
animals per cohort. *P < 0.05 vs 0 ppm
CO – isoflurane, P < 0.001 vs 5 ppm CO –
isoflurane, vs 100 ppm CO – isoflurane. Good Gas, Bad Gas: Isoflurane, Carbon
†P < 0.01 vs 0 ppm CO – isoflurane. ‡P <
0.001 vs 0 ppm CO – isoflurane. ^P <
0.05 vs 5 ppm CO – isoflurane. @P < 0.01
Monoxide, and Which Is Which?
vs 5 ppm CO – isoflurane. #P < 0.05 vs
100 ppm CO – isoflurane.?P < 0.01 vs 0
ppm CO + isoflurane. $P < 0.01 vs 5 ppm
CO + isoflurane. %P < 0.001 vs 0 ppm CO
Jevtovic-Todorovic, Vesna MD, PhD, MBA
+ isoflurane.

Copyright © 2014 International Anesthesia Research Society. Published by Lippincott Williams & Wilkins. 45

PROTECTORS SELECTED REFERENCES

Subclinical carbon monoxide  Pre-administration of curcumin prevents neonatal sevoflurane exposure-induced

neurobehavioral abnormalities in mice. Ji MH, Qiu LL, Yang JJ, Zhang H, Sun XR, Zhu
Dexmedetomidine SH, Li WY, Yang JJ. Neurotoxicology. 2014 Nov 15
 Neuroprotective effect of dexmedetomidine on hyperoxia-induced toxicity in the
Erythropoetin neonatal rat brain.Sifringer M, von Haefen C, Krain M, Paeschke N, Bendix I, Bührer
Magnesium C, Spies CD, Endesfelder S. Oxid Med Cell Longev. 2015;2015
 Dexmedetomidine provides neuroprotection: impact on ketamine-induced
Lithium neuroapoptosis in the developing rat brain.Duan X, Li Y, Zhou C, Huang L, Dong Z.
Xingnaojing Acta Anaesthesiol Scand. 2014 Oct;58(9):1121-6.
 Dexmedetomidine provides cor tical neuroprotection: impact on anaesthetic-induced
Curcumin neuroapoptosis in the rat developing brain. Sanders RD, Sun P, Patel S, Li M, Maze
M, Ma D. Acta Anaesthesiol Scand. 2010 Jul;54(6):710-6
 Agarwal, Rita, MD Pediatric Anesthesia Update

SELECTED REFERENCES SHOULD WE WAIT?

 Er ythropoietin protects newborn rat against sevoflurane-induced neurotoxicity. What should we tell
Pellegrini L, Bennis Y, Velly L, Grandvuillemin I, Pisano P, Bruder N, Guillet B.
Paediatr Anaesth. 2014 Jul;24(7):749-59. families?
 Dual effects of ketamine: neurotoxicity versus neuroprotection in anesthesia for the Informed consent?
developing brain.Yan J, Jiang H. J Neurosurg Anesthesiol. 2014 Apr;26(2):155-60
 Mol Med Rep. 2015 Mar;11(3):1615-22. doi: 10.3892/mmr.2014.2934. Epub 2014 Are some medication
Nov 13.Pre-treatment with a Xingnaojing preparation ameliorates sevoflurane- better?
induced neuroapoptosis in the infant rat striatum. Yang ZJ 1 , Wang YW 1 , Li CL 1 , Ma
LQ 1 , Zhao X 1 Can anything help?

UPDATE FROM PEDIATRIC

REGIONAL ANESTHESIA
NETWORK

CAUDAL
 Agarwal, Rita, MD Pediatric Anesthesia Update

CAUDALS

Mean dose 1.4 mg/kg bupivacaine + epi

>4000 received more than 2mg/kg
Almost 1000 received more than 2.5mg
Dosing variability
Decreasing use of ultrasound

• Almost 19,000 patients and no temporary or

permanent sequelae
• A great deal of dosing variability with the only
2 cases of possible systemic toxicity
occurring at doses well below currently
recommended doses

INTERSCALENE BLOCKS

7.7 % with Anatomic landmarks

88% with U/S
13% with nerve stimulation
No postoperative neurologic symptoms (PONS)
No local anesthetic systemic toxicity (LAST)
One post-op infection
One intravascular punsture
 Agarwal, Rita, MD Pediatric Anesthesia Update

ASLEEP VS. AWAKE

TAP BLOCKS TAP BLOCKS

1994 patients
Dosing Variability-median 1mg/kg
2 complications-blood aspiration and peritoneal
puncture
Most performed under GA with U/S

MORE ON TAP BLOCKS

Suresh et al (Ped Anesth 2014) compared 2.5 vs.1.25

mg/kg bup→ longer duration
Lorenzo et.al (j Urol 2014) TAP vs, field infiltration by
surgeon
Review of the Effectiveness and Complications of Continuous Peripheral Nerve Catheters
TAP not better in Ambulatory Setting: A Two Year Retrospective Analysis
Tariq M. Malik, M.D., Sehar S. Gafoor, M.D.
A&A Case Reports University of Chicago, Chicago, Illinois, United States

2013: Cardiac Arrest from TAP+ field infiltration-failure to

communicate
2014: TAP for VP shunts
 Agarwal, Rita, MD
MORE ON CLOTTING
• Anesthesia & Analgesia:
• March 2014 - Volume 118 - Issue 3 - p 628–636
• Pediatric Anesthesiology: Review Article
• The Efficacy of Antifibrinolytic Drugs in Children
Undergoing Noncardiac Surgery: A Systematic Review of
the Literature
• Faraoni, David MD, FCCP*; Goobie, Susan M. MD, FRCPC†
• TXA and EACA seem to decrease blood loss in spine fusion patients
• Most studies small and retrospective
Pediatric Anesthesia Update
AMICAR ABSTRACT FROM ASA
Pharmacokinetics of Aminocaproic Acid in Adolescents
Undergoing Posterior Spinal Fusion Surgery
Paul Stricker,Devika Singh,John Fiadjoe, et.al
Children's Hospital of Philadelphia,
• EACA clearance increased with weight and age.
• weight < 25 kg: 100 mg/kg loading dose and 40 mg/kg/hr infusion;
• 25 kg ≤ weight < 50 kg: 100 mg/kg loading dose and 35 mg/kg/hr
infusion, and
• weight ≥ 50 kg: 100 mg/kg loading dose and 30 mg/kg/hr infusion.
Br J Anaesth. 2015 Jan 13. pii: aeu459. [Epub ahead of
print]
 Agarwal, Rita, MD Pediatric Anesthesia Update

ASA 2014 ABSTRACTS Capnography Fails as a Continuous Respiratory Monitor in

Pediatric Patients Treated with IVPCA Opioids
Myron Yaster, M.D., Karen M. Miller, B.A., Andrew Y. Kim, B.S., Elizabeth
Improving Outcomes After Neuromuscular Scoliosis Surgery: White, R.N., Constance L. Monitto, M.D., Sapna R. Kudchadkar, M.D.,
Have We Learned From Massive Transfusion Protocols? James Fackler, M.D.
Kesavan Sadacharam, M.D., Bruce R. Brenn, M.D et.al
Alfred I. duPont Hospital for Children Children treated with IV PCA did not tolerate
continuous monitoring of respiration using
capnography. Until better, kid friendly monitors
are available, guidelines and recommendations
….preliminary results …show that patients who received high
geared to adult patients cannot be extended to
ratio FFP and PRBC and less crystalloid had less total blood children
loss, less percentage of blood volume loss and better urine
output suggesting better outcomes

Survey Says: What Do Pediatric Clinicians Really Know About the “Sedation or
Anesthesia” Required When Ordering an MRI “With Sedation”?
Glenn E. Mann, M.D., Scott Lipson, M.D., Jerry Chao, M.D., Terry-Ann Chambers, M.D.,
Madelyn Kahana, M.D.
Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, United
States  Anesth Analg. 2014 Sep;119(3):651-60. doi:
10.1213/ANE.0000000000000288.
 Cognitive outcome af ter spinal anesthesia and surgery during infancy.
 Williams RK 1 , Black IH, Howard DB, Adams DC, Mathews DM, Friend AF,
Meyers HW.
 Conclusion:  We found no link between duration of surger y with infant SA and scores
on academic achievement testing in elementary school. We also found no
A majority of pediatric care providers do not appreciate the
differences between the depths of anesthesia required to relationship between infant SA and surger y with VPAA on elementary
per form MRIs in children. In addition, they are unaware of the school testing
possible need for intubation and apnea associated with cer tain
MRI studies.

 Anesthesia & Analgesia:

July 2014 - Volume 119 - Issue 1 - p 67–75
 Anesthesia & Analgesia:
Technology, Computing, and Simulation:
 July 2014 - Volume 119 - Issue 1 - p 9–10
Research Report
 Editorials: Editorial
The Sevoflurane Washout Profile of Seven  How Will We Ever Know if Our Machine Is Adequately Flushed?
Recent Anesthesia Workstations for Malignant  Mar tin, Timothy W. MD, MBA * ; Block, Frank E. Jr MD †
Hyperthermia-Susceptible Adults and Infants: A
Bench Test Study
Cottron, Nicolas MD; Larcher, Claire MD;
Sommet, Agnès MD, PhD; Fesseau, Rose MD;
Alacoque, Xavier MD; Minville, Vincent MD, PhD;
Fourcade, Olivier MD, PhD; Kern, Delphine MD,
PhD
 Agarwal, Rita, MD Pediatric Anesthesia Update

PREVENTING LARYNGOSPASM

 Propofol
 Deep vs Awake extubation
 Remifentanil
 Magnesium sulphate
 Lidocaine

LIDOCAINE AND ITS ROLE IN LARYNGOSPASM TOPICAL LIDOCAINE STUDY

Ped Anaesth. 2012 Apr;22(4):345-50

TECHNIQUE FOR SIMULATING AIRWAY REFLEXES

 Sevo induction
 LMA
 FOB with 20G epidural catheter
 0.25 cc sterile water
 Video taped and obser ved
 3 times points
 Agarwal, Rita, MD Pediatric Anesthesia Update

INTRAVENOUS LIDOCAINE STUDY

Anaesthesia. 2013 Jan;68(1):13-20.

Anaesthesia. 2014 Dec;69(12):1388-96. doi: 10.1111/anae.12788. Epub

IV LIDOCAINE 2014 Jul 3.
The efficacy of lidocaine to prevent laryngospasm in children: a systematic
review and meta-analysis.
Mihara T1, Uchimoto K, Morita S, Goto T.

Meta-analysis says yes:

9 studies, 787 patients
Decreased incidence of laryngospasm at 2mins, not so
Topical and IV lidocaine help
much at 10 minutes

SELECTED REFERENCES
LARYNGOSPASM-TREATMENT
 Risk factors for lar yngospasm in children during general anesthesia.Flick RP, Wilder
 100% oxygen + Fink maneuver RT, Pieper SF, van Koeverden K, Ellison KM, Marienau ME, Hanson AC, Schroeder DR,
(painful jaw thrust) Sprung J. Paediatr Anaesth. 2008 Apr;18(4):289-96
 Positive pressure ventilation to  Screening by pulse CO-oximetr y for environmental tobacco smoke exposure in
PIP of 20cm H20 preanesthetic children.Cardwell K, Pan Z, Boucher R, Zuk J, Friesen RH.Paediatr
 Propofol 0.0.5 -1mg.kg Anaesth. 2012 Sep;22(9):859-64
 Risk assessment for respirator y complications in paediatric anaesthesia: a
 Lidocaine
prospective cohor t study.von Ungern-Sternberg BS, Boda K, Chambers NA, Rebmann
 Sux 10-20% of intubating dose C, Johnson C, Sly PD, Habre W.Lancet. 2010 Sep 4;376(9743):773-83
 Magnesium Sulphate ?
Agarwal, Rita, MD Pediatric Anesthesia Update