Pediatric Anesthesia

Educational Objectives

The goal of this program is to improve optimizing use of anesthesia in pediatric patients. After hearing and assimilating this program, the clinician will be better able to:

1. Evaluate the results of recent studies assessing the neurodevelopmental effects of anesthesia in young children and the validity of current nil per os guidelines.

Summary

Effect of anesthesia on neurodevelopmental outcomes: Davidson et al (2016) the GAS trial assessed neurodevelopmental outcomes after general anesthesia and awake regional anesthesia for hernia repair; patients underwent ≤1 hr of anesthesia; McCann et al (2019) published a follow-up study of neurodevelopmental outcomes in the same patients at 5 yr; the studies found no significant neurodevelopmental differences (eg, >5-point difference in intelligence quotient) with brief anesthetic exposure; parental concern about the impact of general anesthesia is one of the driving factors increasing spinal anesthesia for neonates and infants for small procedures below the umbilicus lasting <1 hr; Simpao et al (2023) evaluated the effects of anesthesia in infants undergoing congenital cardiac surgery; the Bayley Scale of Infant and Toddler Development was assessed at 18 mo of age (neurodevelopmental disability is the most common complication of this surgery); exposures to volatile anesthetics, opioids, benzodiazepines, dexmedetomidine, and ketamine in children <44 wk of conceptual age were analyzed; children with congenital cardiac abnormalities undergo prolonged diagnostic and surgical procedures and may incur multiple anesthetic exposures, sometimes for many hours; the only agent with a negative impact was ketamine

Nil per os (NPO) guidelines: in Europe, there is consideration of adjusting guidelines to a 1-hr wait for clear liquids and decreasing other waiting periods by 1 hr; however, recent American Society of Anesthesiologists preoperative guideline updates state that the literature does not support any waiting period <2 hr for clear liquids; there is no significant benefit reported for protein-containing clear liquids; avoid delaying anesthesia after gum chewing; the incidence of pulmonary aspiration following current guidelines is 0.02% to 0.13%; it is not recommended to prevent children from having clear liquids for >2 hr (ie, avoid prolonged fasting for children); study (Sarhan et al [2023]) compared the level of gastric fluid 1 and 2 hr after receiving ≈50 mL of clear fluids; clear fluid administration of 3 mL/kg did result in higher gastric volume (antral grade 2) on ultrasonography assessment at 1 hr; at 2 hr, the antrum was empty; the original cutoff was ≈0.8 mL/kg volume threshold to reduce the incidence of aspiration; the suggested new cutoff is ≤1.5 mL/kg, but this has not been verified; Aschkenasy et al (2023) used endoscopy to measure gastric fluid volume; the study found only a 5 mL difference between the people who had fluids 2 vs 18 hr ago; it is possible that clear fluid fasting times maybe shortened from 2 hr, but more study is needed; note that oral midazolam, oxycodone, acetaminophen, and ibuprofen are particulate suspensions, and procedures are not delayed if children have these <2 hr before

Readings

Aschkenasy G, Leder O, Pardes R, et al. Preoperative clear fluid fasting and endoscopy-measured gastric fluid volume in children. PaediatrAnaesth. 2023;33(7):532-538. doi:10.1111/pan.14662; Davidson AJ, Disma N, de Graaff JC, et al. Neurodevelopmental outcome at 2 years of age after general anaesthesia and awake-regional anaesthesia in infancy (GAS): an international multicentre, randomisedcontrolled trial [published correction appears in Lancet. 2016 Jan 16;387(10015):228]. Lancet. 2016;387(10015):239-250. doi:10.1016/S0140-6736(15)00608-X; McCann ME, de Graaff JC, Dorris L, et al. Neurodevelopmental outcome at 5 years of age after general anaesthesia or awake-regional anaesthesia in infancy (GAS): an international, multicentre, randomised, controlled equivalence trial [published correction appears in Lancet. 2019 Aug 24;394(10199):638]. Lancet. 2019;393(10172):664-677. doi:10.1016/S0140-6736(18)32485-1; Sarhan KA, Hasaneen H, Hasanin A, et al. Ultrasound assessment of gastric fluid volume in children scheduled for elective surgery after clear fluid fasting for 1 versus 2 hours: A randomized controlled trial. AnesthAnalg. 2023;136(4):711-718. doi:10.1213/ANE.0000000000006157; Simpao AF, Randazzo IR, Chittams JL, et al. Anesthesia and sedation exposure and neurodevelopmental outcomes in infants undergoing congenital cardiac surgery: A retrospective cohort study. Anesthesiology. 2023;139(4):393-404. doi:10.1097/ALN.0000000000004684.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Goeller was recorded at the 2023 Annual Convention and Conclave of the American Osteopathic College of Anesthesiologists, held September 30 to October 3, 2023, in St. Petersburg, FL, and presented by the American Osteopathic College of Anesthesiologists. For information on future CME activities from this presenter, please visit https://www.aocaonline.org/. Audio Digest thanks the speakers and the American Osteopathic College of Anesthesiologists for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0.50 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0.50 CE contact hours.

Lecture ID:

AN660902

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.