Transnasal Humidified Rapid Insufflation Ventilatory Exchange Augments Oxygenation in Children With Juvenile Onset Recurrent Respiratory Papillomatosis During Surgery
A Prospective Randomized Crossover Controlled Trial
Anesthesia Analgesia
Submitted December 2023 by Dr Chris Brasher
Read by 113 Journal Watch subscribers
Children undergoing suspension laryngoscopy for papillomatosis surgery were randomised to either THRIVE or room air during apnoea. All patients were paralysed and intubated/ventilated periodically. No laser was used. Apnoea time to desaturation on air was 3.8 minutes, on THRIVE it 8.9 minutes. The increase in transcutaneous CO2 measurements was also significantly lower. Of note, the study design was to intubate at eight minutes of apnoea, and 26 of 28 patients in the THRIVE group were still saturating at 100% at eight minutes.
This study is a good demonstration of the difference between THRIVE and room air in paralysed apnoeic paediatric patients. THRIVE will predictably provide over 8 minutes of oxygenation in paediatric patients.
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Anesthesia and Sedation Exposure and Neurodevelopmental Outcomes in Infants Undergoing Congenital Cardiac Surgery
A Retrospective Cohort Study
Anesthesiology
Submitted December 2023 by Dr Rebecca McIntyre
Read by 107 Journal Watch subscribers
The authors of this retrospective study hypothesized that greater exposure to sedation and anaesthesia in children undergoing complex cardiac surgery is associated with lower neurodevelopmental scores at 18 months. They found the use of ketamine was associated with lower neurodevelopmental scores.
This is a retrospective cohort study involving a secondary analysis of a patient cohort that had been recruited for a prospective observational study. The authors looked at the records of 41 single ventricle and 69 two ventricle patients who underwent surgery with cardiopulmonary bypass at Children’s Hospital of Philadelphia before 44 weeks post-conceptual age.
Total exposure – in the operating theatre and in ICU - to volatile anaesthetic agents, opioids, benzodiazepines, dexmedetomidine and ketamine was calculated. At 18 months all children underwent developmental evaluation using the Bayley Scale of Infant and Toddler Development 3rd edition (Bayley III).
Analysis of the data included adjusting for potentially confounding patient characteristics, including presence of a genetic anomaly, patient sex and race, birth weight, maternal education level, exposure to ECMO, first admission length of stay; all of which had an impact on Bayley III scores.
No statistically significant association was found between volatile anaesthetic exposure and Bayley III scores (in contrast to previous studies by Andropoulos and by Diaz which found associations between exposure to volatiles and worse neurodevelopmental outcomes). Opioid, benzodiazepine and dexmedetomidine exposure were not associated with lower Bayley III scores.
Ketamine exposure was associated with a reduction in Bayley III motor scores, after adjusting for confounders. Each mg/kg increase in ketamine exposure was associated with a 0.34 point decrease in Bayley III motor scores (95% CL = -0.64 to -0.05, p=0.0242)
It is also notable – though perhaps not surprising – that single ventricle patients and patients that required ECMO had lower neurodevelopmental scores at 18 months compared to two ventricle patients and those who did not require ECMO.
The authors conclude that ketamine use in these patients should be avoided, and that factors other than volatile anaesthetic exposure should be considered as more impactful to neurodevelopment in these patients.
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The role of volatile capture technology in desflurane disposal from decommissioned vaporisers
Anaesthesia
Submitted December 2023 by Dr Rebecca McIntyre
Read by 729 Journal Watch subscribers
This letter outlines a pilot project examining a method for capturing retained desflurane from decommissioned desflurane vaporizers in the UK. As part of the NHS’s drive to be more environmentally friendly, desflurane has been withdrawn from Scotland this year, and it will be withdrawn from England in 2024. The retained desflurane in the decommissioned vaporizers needs to be disposed of responsibly. In this letter, the authors describe their evaluation of a volatile capture technology (SageTech SID-Dock). When used in combination with a standard anaesthetic machine, the circuit was flushed at 3 different FGFs and desflurane concentrations, and the mass transfer from the vaporizer to the SageTech SID-Dock was measured. They found an average of 94% efficiency of mass transfer, and conclude that it is an effective method of capturing unused desflurane.
They do not deal with the problem of how to responsibly dispose of the captured desflurane, but suggest potential solutions include high temperature incineration, chemical processing and photolytic destruction.
It is heartening to read that people are thinking about and actively working on solutions to the problem of greenhouse gas emissions in the healthcare system.
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