Pediatric hyperglycemia and Brain Trauma, Dr. H. Chang

Helen A. Chang, DO

Article:
“Incidence and Risk Factors for Perioperative Hyperglycemia in Children with Traumatic Brain Injury.” Anesthesia and Analgesia. Jan 2009: 108(1): 81-89. Deepak Sharma, MD, Jill Jelacic, MD et al. Departmet of Anesthesiology, University of Washington, Seattle, WA.

Summary:

This was a retrospective cohort study of children < 13 years old you underwent urgent or emergent craniotomy for traumatic brain injury (TBI) at Harborview Medical Center. Data from 105 children were included and the main outcome was the incidence of hyperglycemia, defined as serum glucose > 200mg/dl at any given point during the pre-/intra-/postoperative period. Aside from the primary injury insult to the pediatric brain, secondary injury occurs as result of hypotension, hypoxia, increased ICP and hyperglycemia. These all contribute to poor outcomes, the intensive care length of stay, and in-hospital mortality.

The group’s main findings included: 1) perioperative hyperglycemia was common, 2) the sampling frequency for the majority of children was less than one serum glucose per “anesthetic hour,” 3) intraoperative hyperglycemia was common but few patients were treated with insulin, and 4) intraoperative hypoglycemia occurred independent of insulin treatment and in fact not rare. Despite the lack of consensus regarding the definition of hyperglycemia threshold for TBI in pediatric patients, the value of 200 was utilized as it is current clinical practice. No specific glycemic control guidelines have been published for pediatric TBI when this article was accepted. The issue still looms whether transient hyperglycemia after TBI should be treated. It was also clearly stated that hypoglycemia can be equally detrimental to the outcome. The data supports that there is an underestimation of both hypo-/hyperglycemia and that continuous perioperative glucose monitoring in children specifically with TBI may be needed.

Does covering a child on induction impact body temp? Dr. Trivedi

Puja Trivedi, DO
 PGY-3 Resident at RCRMC who will do a Cardiac Anesthesia Fellowship at USC upon graduation

Does the covering of children during induction of anesthesia have an effect on body temperature at the end of surgery?

Due to anesthesia induced impairment of thermoregulation as well as the cold environment of the operating room, surgical patients are prone to disturbances of his/her body temperature. Hypothermia under anesthesia follows a characteristic pattern of a large drop in core temperature due to core to peripheral heat redistribution. This is followed by a slow linear regression as more body heat is lost than generated. A plateau ensues as a thermal steady state is reached. A benefit of hypothermia has been exploited in the care of patients who have suffered a catastrophic myocardial and traumatic brain injury. Complications of hypothermia are more devastating and include coagulopathy secondary to cold induced platelet dysfunction, delayed wound healing, myocardial infarction, hypermetabolism secondary to shivering, a catecholamine surge resulting in tachycardia and hypertension due to discomfort and longer recovery time. 

Neonatal and pediatric patients are especially vulnerable in developing hypothermia due to an immature thermoregulatory system and greater heat loss due to an increased surface area to body weight ratio.  Shukry et al from the Children’s Hospital of Oklahoma City investigated the effect of covering children during induction of anesthesia and end of surgery core body temperatures, measured at the temporal artery and rectally. 50 healthy (ASA 1 or 2) children ranging from the age of 6 months to 3.5 years undergoing simple urologic procedures were selected. The majority of urological patients received caudal blocks which the author estimates can take anywhere from 10-20 minutes. They were either covered with a blanket during induction or remained uncovered, but both groups were re warmed using a forced air blanket at 43 degrees after the blue drapes were placed. Shukry et al found no change in core temperature at the end of the surgical procedure between patients covered with a blanket during anesthesia induction and those that were not. Limitations include small sample size and a higher than normal ambient operating room temperature which has a greater influence on the patient’s body temperature.

                 

Laryngospasm in Children, Dr. Chang

Helen A. Chang, DO

Article:
Case Scenario: Perianesthetic Management of Laryngospasm in Children

Orliaguet, Gilles A., et al. Anesthesiology, February 2012. Vol 116, No 2, pgs 458-468.

Summary:

This article presented a case about a 10-year old male taken for an emergent incision and drainage for a fingertip abscess. Only remarkable history included a recent URI 4 weeks prior, but clear of symptoms at the time of surgery. The primary anesthetic utilized manual ventilation with 2% expired sevoflurane with a mixture of oxygen and nitrous oxide (50/50%). After a peripheral IV was established, sufentanil (1mcg) was administered for analgesia. Mask ventilation became difficult and respiratory stridor was noted. With rapidly developing hypoxia and bradycardia, jaw thrust maneuver, positive pressure ventilation with 100% oxygen, and two boluses of propofol (total 10mg) did not break the suspected laryngospasm. Atropine IV and succinylcholine (16mg) followed by tracheal intubation followed, which improved oxygenation.

Children are more prone to laryngospasm than adults (17.4/1000). Risk factors for perioperative laryngospasm include:

-        Sex: male > female

-        URI present at time of surgery, or within past 2 weeks

-        Wheezing during exercise, or > 3 events within past year

-        Nocturnal dry cough

-        Eczema present, or within past year

-        Family hx: at least 2 family members with asthma, atopy, eczema, or smoking

Possible ways to prevent and manage laryngospasm:

-        Delay elective surgery 2-3 weeks s/p URI

-        Although various studies do not provide a “gold standard” per se, generalized increased risk of laryngospasm (increasing rank) are: Mask > LMA > ETT

-        Sufficient depth of anesthesia important when placing or removing an airway device, regardless route of induction (i.e. intravenous versus inhalation)

-        Caution with negative pressure pulmonary edema

-        At emergence, provide adequate suctioning, check for residual paralysis (if muscle relaxant administered), limit stimulus in operating room setting until patient spontaneously opens eyes, and consider using “artificial cough technique”

-        If you suspect laryngospasm, be cognizant, act fast, and aggressive!