Publications by authors named "Carolyne Pehora"

22 Publications

  • Page 1 of 1

Predicting Perioperative Respiratory Adverse Events in Children With Sleep-Disordered Breathing.

Anesth Analg 2021 04;132(4):1084-1091

From the Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada.

Background: No evidence currently exists to quantify the risk and incidence of perioperative respiratory adverse events (PRAEs) in children with sleep-disordered breathing (SDB) undergoing all procedures requiring general anesthesia. Our objective was to determine the incidence of PRAEs and the risk factors in children with polysomnography-confirmed SDB undergoing procedures requiring general anesthesia.

Methods: Retrospective review of all patients with polysomnography-confirmed SDB undergoing general anesthesia from January 2009 to December 2013. Demographic and perioperative outcome variables were compared between children who experienced PRAEs and those who did not. Generalized estimating equations were used to build a predictive model of PRAEs.

Results: In a cohort of 393 patients, 51 PRAEs occurred during 43 (5.6%) of 771 anesthesia encounters. Using generalized estimating equations, treatment with continuous positive airway pressure or bilevel positive airway pressure (odds ratio, 1.63; 95% confidence interval [CI], 1.05-2.54; P = .031), outpatient (odds ratio, 1.37; 95% CI, 1.03-1.91; P = .047), presence of severe obstructive sleep apnea (odds ratio, 1.63; 95% CI, 1.09-2.42; P = .016), use of preoperative oxygen (odds ratio 1.82; 95% CI, 1.11-2.97; P = .017), history of prematurity (odds ratio, 2.31; 95% CI, 1.33-4.01; P = .003), and intraoperative airway management with endotracheal intubation (odds ratio, 3.03; 95% CI, 1.79-5.14; P < .001) were associated with PRAEs.

Conclusions: We propose the risk factors identified within this cohort of SDB patients could be incorporated into a preoperative risk assessment tool that might better to identify the risk of PRAE during general anesthesia. Further investigation and validation of this model could contribute to improved preoperative risk stratification, decision-making (postoperative admission and level of monitoring), and health care resource allocation.
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http://dx.doi.org/10.1213/ANE.0000000000005195DOI Listing
April 2021

Surgical Closure of Atrial Septal Defects in Young Children-A Review of Anesthesia Care in Sternotomy and Thoracotomy Approaches.

J Cardiothorac Vasc Anesth 2021 Jan 9;35(1):123-127. Epub 2020 Jul 9.

Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Canada; University of Toronto, Toronto, Canada. Electronic address:

Objectives: To review and compare the anesthetic management of atrial septal defect (ASD) closures via mini lateral thoracotomy and sternotomy approaches.

Design: Retrospective analysis.

Setting: Single- center pediatric quaternary care hospital.

Participants: Patients aged <8 years of age undergoing ASD closure.

Intervention: None.

Measurements And Main Results: Outcome measures included anesthetic technique, total amount and type of analgesics, pain scores, procedure duration, complications, blood transfusion requirements, and duration of stay. Each group had 15 patients. All patients in the sternotomy group received 0.25% bupivacaine subcutaneous infiltration. Eleven of the 15 thoracotomy patients received a fascial plane block, including serratus anterior and erector spinae blocks, and 3 received subcutaneous infiltration. There was no difference in opioid consumption intraoperatively or in the first 24 hours after surgery (0.28 ± 0.24 mg/kg morphine equivalents in thoracotomy group and 0.21 ± 0.12 mg/kg in sternotomy group). Duration of procedure and cardiopulmonary bypass duration were longer in the thoracotomy group. There was no difference in cross-clamp duration between groups. There was no difference in intensive care unit or hospital stay.

Conclusions: The authors reviewed perioperative pain management strategies used in surgical ASD closures. Different fascial plane blocks were used. This study has paved way to design a randomized control trial to compare various regional techniques for cardiac surgeries and identified opportunities for improved pain assessment scoring in children after cardiac surgery.
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http://dx.doi.org/10.1053/j.jvca.2020.07.023DOI Listing
January 2021

Dexamethasone as an adjuvant to peripheral nerve block.

Cochrane Database Syst Rev 2017 Nov 9;11:CD011770. Epub 2017 Nov 9.

Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, Canada, M5G 1X8.

Background: Peripheral nerve block (infiltration of local anaesthetic around a nerve) is used for anaesthesia or analgesia. A limitation to its use for postoperative analgesia is that the analgesic effect lasts only a few hours, after which moderate to severe pain at the surgical site may result in the need for alternative analgesic therapy. Several adjuvants have been used to prolong the analgesic duration of peripheral nerve block, including perineural or intravenous dexamethasone.

Objectives: To evaluate the comparative efficacy and safety of perineural dexamethasone versus placebo, intravenous dexamethasone versus placebo, and perineural dexamethasone versus intravenous dexamethasone when added to peripheral nerve block for postoperative pain control in people undergoing surgery.

Search Methods: We searched the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, DARE, Web of Science and Scopus from inception to 25 April 2017. We also searched trial registry databases, Google Scholar and meeting abstracts from the American Society of Anesthesiologists, the Canadian Anesthesiologists' Society, the American Society of Regional Anesthesia, and the European Society of Regional Anaesthesia.

Selection Criteria: We included all randomized controlled trials (RCTs) comparing perineural dexamethasone with placebo, intravenous dexamethasone with placebo, or perineural dexamethasone with intravenous dexamethasone in participants receiving peripheral nerve block for upper or lower limb surgery.

Data Collection And Analysis: We used standard methodological procedures expected by Cochrane.

Main Results: We included 35 trials of 2702 participants aged 15 to 78 years; 33 studies enrolled participants undergoing upper limb surgery and two undergoing lower limb surgery. Risk of bias was low in 13 studies and high/unclear in 22. Perineural dexamethasone versus placeboDuration of sensory block was significantly longer in the perineural dexamethasone group compared with placebo (mean difference (MD) 6.70 hours, 95% confidence interval (CI) 5.54 to 7.85; participants1625; studies 27). Postoperative pain intensity at 12 and 24 hours was significantly lower in the perineural dexamethasone group compared with control (MD -2.08, 95% CI -2.63 to -1.53; participants 257; studies 5) and (MD -1.63, 95% CI -2.34 to -0.93; participants 469; studies 9), respectively. There was no significant difference at 48 hours (MD -0.61, 95% CI -1.24 to 0.03; participants 296; studies 4). The quality of evidence is very low for postoperative pain intensity at 12 hours and low for the remaining outcomes. Cumulative 24-hour postoperative opioid consumption was significantly lower in the perineural dexamethasone group compared with placebo (MD 19.25 mg, 95% CI 5.99 to 32.51; participants 380; studies 6). Intravenous dexamethasone versus placeboDuration of sensory block was significantly longer in the intravenous dexamethasone group compared with placebo (MD 6.21, 95% CI 3.53 to 8.88; participants 499; studies 8). Postoperative pain intensity at 12 and 24 hours was significantly lower in the intravenous dexamethasone group compared with placebo (MD -1.24, 95% CI -2.44 to -0.04; participants 162; studies 3) and (MD -1.26, 95% CI -2.23 to -0.29; participants 257; studies 5), respectively. There was no significant difference at 48 hours (MD -0.21, 95% CI -0.83 to 0.41; participants 172; studies 3). The quality of evidence is moderate for duration of sensory block and postoperative pain intensity at 24 hours, and low for the remaining outcomes. Cumulative 24-hour postoperative opioid consumption was significantly lower in the intravenous dexamethasone group compared with placebo (MD -6.58 mg, 95% CI -10.56 to -2.60; participants 287; studies 5). Perinerual versus intravenous dexamethasoneDuration of sensory block was significantly longer in the perineural dexamethasone group compared with intravenous by three hours (MD 3.14 hours, 95% CI 1.68 to 4.59; participants 720; studies 9). We found that postoperative pain intensity at 12 hours and 24 hours was significantly lower in the perineural dexamethasone group compared with intravenous, however, the MD did not surpass our pre-determined minimally important difference of 1.2 on the Visual Analgue Scale/Numerical Rating Scale, therefore the results are not clinically significant (MD -1.01, 95% CI -1.51 to -0.50; participants 217; studies 3) and (MD -0.77, 95% CI -1.47 to -0.08; participants 309; studies 5), respectively. There was no significant difference in severity of postoperative pain at 48 hours (MD 0.13, 95% CI -0.35 to 0.61; participants 227; studies 3). The quality of evidence is moderate for duration of sensory block and postoperative pain intensity at 24 hours, and low for the remaining outcomes. There was no difference in cumulative postoperative 24-hour opioid consumption (MD -3.87 mg, 95% CI -9.93 to 2.19; participants 242; studies 4). Incidence of severe adverse eventsFive serious adverse events were reported. One block-related event (pneumothorax) occurred in one participant in a trial comparing perineural dexamethasone and placebo; however group allocation was not reported. Four non-block-related events occurred in two trials comparing perineural dexamethasone, intravenous dexamethasone and placebo. Two participants in the placebo group required hospitalization within one week of surgery; one for a fall and one for a bowel infection. One participant in the placebo group developed Complex Regional Pain Syndrome Type I and one in the intravenous dexamethasone group developed pneumonia. The quality of evidence is very low due to the sparse number of events.

Authors' Conclusions: Low- to moderate-quality evidence suggests that when used as an adjuvant to peripheral nerve block in upper limb surgery, both perineural and intravenous dexamethasone may prolong duration of sensory block and are effective in reducing postoperative pain intensity and opioid consumption. There is not enough evidence to determine the effectiveness of dexamethasone as an adjuvant to peripheral nerve block in lower limb surgeries and there is no evidence in children. The results of our review may not apply to participants at risk of dexamethasone-related adverse events for whom clinical trials would probably be unsafe.There is not enough evidence to determine the effectiveness of dexamethasone as an adjuvant to peripheral nerve block in lower limb surgeries and there is no evidence in children. The results of our review may not be apply to participants who at risk of dexamethasone-related adverse events for whom clinical trials would probably be unsafe. The nine ongoing trials registered at ClinicalTrials.gov may change the results of this review.
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http://dx.doi.org/10.1002/14651858.CD011770.pub2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6486015PMC
November 2017

A randomized controlled trial of amitriptyline versus gabapentin for complex regional pain syndrome type I and neuropathic pain in children.

Scand J Pain 2016 Oct 16;13:156-163. Epub 2016 Jun 16.

Pain Innovations Inc., London, Ontario, Canada.

Background: Treatment of neuropathic pain in children is challenging, and requires a multimodal approach of pharmacologic, physical, and psychological therapies; however there is little evidence to guide practice. Amitriptyline and gabapentin are first-line drugs for treating neuropathic pain in adults, yet no studies have examined their efficacy, or compared them directly, to determine which might be better for pain relief and sleep disturbance in children.

Methods: After informed consent was obtained, 34 patients aged 7-18 years diagnosed with complex regional pain syndrome type I (CRPS I) or a neuropathic pain condition were randomly allocated to receive either amitriptyline or gabapentin. Patients were followed for 6 weeks and assessed for pain intensity, sleep quality and adverse events. We blinded study personnel, including health-care providers, participants, parents, the research coordinator and the data analyst. Patients then completed quantitative sensory testing (QST) and a psychosocial pain assessment with the team psychologist, within 1-3 days of the start of the trial.

Results: At the end of the 6-week trial, patients on both drugs had important reductions in pain, having surpassed the minimally important difference (MID) of 1. The difference between the groups however was not statistically significant. For the secondary outcomes, we found no statistically significant difference between the two drugs in sleep score or adverse events suggesting that both drugs improve sleep score to a similar degree and are equally safe.

Conclusions: Amitriptyline and gabapentin significantly decreased pain intensity scores and improved sleep. There were no significant differences between the two drugs in their effects on pain reduction or sleep disability.

Implications: Although larger, multi-centred trials are needed to confirm our findings, including long-term follow-up, both drugs appear to be safe and effective in treating paediatric patients in the first-line treatment of CRPS I and neuropathic pain over 6-weeks.
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http://dx.doi.org/10.1016/j.sjpain.2016.05.039DOI Listing
October 2016

L-carnitine reduces susceptibility to bupivacaine-induced cardiotoxicity: an experimental study in rats.

Can J Anaesth 2017 Mar 28;64(3):270-279. Epub 2016 Dec 28.

Department of Anesthesia and Pain Medicine, The Hospital For Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada.

Background: The primary aim of this study was to evaluate the effect of acute administration of L-carnitine 100 mg·kg iv on susceptibility to bupivacaine-induced cardiotoxicity in rats.

Methods: In the first of two experiments, L-carnitine 100 mg·kg iv (n = 10) or saline iv (n = 10) was administered to anesthetized and mechanically ventilated Sprague-Dawley rats following which an infusion of bupivacaine 2.0 mg·kg·min iv was given until asystole occurred. The primary outcome was the probability of survival. Secondary outcomes included times to asystole, first dysrhythmia, and to 50% reductions in heart rate (HR) and mean arterial pressure (MAP). To determine whether the same dose of L-carnitine is effective in treating established bupivacaine cardiotoxicity, we also conducted a second experiment in which bupivacaine 20 mg·kg iv was infused over 20 sec. Animals (n = 10 per group) received one of four iv treatments: 30% lipid emulsion 4.0 mL·kg, L-carnitine 100 mg·kg, 30% lipid emulsion plus L-carnitine, or saline. The primary outcome was the return of spontaneous circulation (ROSC) during resuscitation.

Results: In the first study, L-carnitine 100 mg·kg increased the probability of survival during bupivacaine infusion (hazard ratio, 12.0; 95% confidence interval, 3.5 to 41.5; P < 0.001). In L-carnitine-treated animals, the times to asystole, first dysrhythmia, and to 50% reductions in HR and MAP increased by 33% (P < 0.001), 65% (P < 0.001), 71% (P < 0.001), and 63% (P < 0.001), respectively. In the second study, no animal in the control or L-carnitine alone groups achieved ROSC when compared with the lipid emulsion groups (P < 0.01).

Conclusion: These findings suggest that acute administration of L-carnitine 100 mg·kg decreases susceptibility to bupivacaine cardiotoxicity, but is ineffective during resuscitation from bupivacaine-induced cardiac arrest.
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http://dx.doi.org/10.1007/s12630-016-0797-5DOI Listing
March 2017

A retrospective review of pediatric difficult airways: once easy, not always easy.

Can J Anaesth 2016 Jun 14;63(6):776-7. Epub 2016 Jan 14.

Department of Anesthesiology and Pain Medicine, The Hospital for Sick Children, Toronto, ON, Canada.

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http://dx.doi.org/10.1007/s12630-016-0586-1DOI Listing
June 2016

Are Parents Getting it Right? A Survey of Parents' Internet Use for Children's Health Care Information.

Interact J Med Res 2015 Jun 22;4(2):e12. Epub 2015 Jun 22.

The Hospital for Sick Children, Department of Anesthesia and Pain Medicine, Toronto, ON, Canada.

Background: The use of the Internet to search for medical and health-related information is increasing and associated with concerns around quality and safety.

Objective: We investigated the current use and perceptions on reliable websites for children's health information by parents.

Methods: Following institutional ethics approval, we conducted a survey of parents/guardians of children presenting for day surgery. A 20-item survey instrument developed and tested by the investigators was administered.

Results: Ninety-eight percent of respondents reported that they used the Internet to search for information about their child's health. Many respondents reported beginning their search at public search engines (80%); less than 20% reported starting their search at university/hospital-based websites. Common conditions such as colds/flu, skin conditions and fever were the most frequently searched, and unique conditions directly affecting the child were second. Despite low usage levels of university/hospital-based websites for health information, the majority of respondents (74%) regarded these as providing safe, accurate, and reliable information. In contrast, only 24% of respondents regarded public search engines as providing safe and reliable information. Fifty percent of respondents reported that they cross-checked information found on the internet with a family physician.

Conclusions: An unprecedented majority of parents and guardians are using the Internet for their child's health information. Of concern is that parents and guardians are currently not using reliable and safe sources of information. Health care providers should begin to focus on improving access to safe, accurate, and reliable information through various modalities including education, designing for multiplatform, and better search engine optimization.
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http://dx.doi.org/10.2196/ijmr.3790DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4526953PMC
June 2015

The construction and implementation of a novel postburn pruritus scale for infants and children aged five years or less: introducing the Toronto Pediatric Itch Scale.

J Burn Care Res 2015 Jan-Feb;36(1):44-9

From the *Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, Toronto, Ontario; †Department of Anesthesia, University of Toronto, Ontario; ‡Holland Bloorview Kids Rehabilitation Hospital, Toronto, Ontario; and §Department of Plastic Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada.

The authors' objectives were to design, refine, validate and implement a behavior-anchored postburn pruritus scale for children aged 5 years or less. We engaged a range of professionals involved in the care of children with burns. We used Q-methodology in interprofessional team exercises to identify and stratify itch behaviors into categories of increasing severity, and then iteratively refined these into a draft scale. We used a range of quantitative and qualitative techniques to assess the utility, feasibility, and validity of the scale and refined it accordingly. During the implementation phase we collected some preliminary reliability data. We generated a 4-point scale of itch severity with simple descriptors of each score. We also designed a separate guidance note and example behaviors that could be used to orientate new users without the need for rater training. End-user interviews revealed high levels of feasibility and content validity. The reliability data showed moderate inter-observer agreement, with a Cohen's kappa of 0.52 (P < .001). We have developed and implemented a behavioral post-burn pruritus scale for use in children aged less than 5 years and have demonstrated its utility, feasibility, validity, and reliability. The development of a validated symptom scoring scales will allow for the conduct of high-quality quantitative clinical trials and the subsequent implementation of evidence-based management protocols.
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http://dx.doi.org/10.1097/BCR.0000000000000129DOI Listing
October 2015

Early postoperative patient-controlled analgesia ratio predicts 24-hour morphine consumption and pain in children undergoing scoliosis surgery.

J Opioid Manag 2014 Jan-Feb;10(1):39-45

Department of Anesthesia and Pain Medicine, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.

Background: The identification of patients at risk for developing severe postoperative pain and/or opioid-related side effects is difficult due to a lack of sensitive indicators. The patient-controlled analgesia (PCA) ratio of demands to deliveries is a potential tool for early identification of patients who experience severe postoperative pain. The authors hypothesized that the PCA ratio is able to predict morphine requirement in the first 24 hours after scoliosis surgery.

Methods: The authors performed a retrospective study of adolescents who had surgery for idiopathic scoliosis. They collected data describing PCA demands and deliveries, morphine consumption, numerical rating scale (NRS) pain scores, opioid related side effects, and duration of hospital stay. Spearman rank analysis assessed association among 4-hour PCA ratios, NRS pain score, and 24-hour morphine consumption. Patients were divided into groups on the basis of PCA ratios <1.5 and ≥1.5. Univariate analysis and multiple regression were used to identify independent factors predictive for increased 24-hour morphine. Mann-Whitney rank-sum and Fisher exact tests were used to compare data. p < 0.05 was considered statistically significant.

Results: One hundred forty-seven patients were included in the analysis, mean (SD) age and weight were 15 (1.8) years and 55 (27) kg, respectively. There was a significant positive correlation between the 4-hour PCA ratio and initial 24-hour cumulative morphine consumption (r = 0.33, p = 0.0002). Patients with a 4-hour PCA ratio ≥1.5 demonstrated a significantly greater initial 24-hour morphine consumption (p = 0.0002), greater pain scores at 24 hours after surgery (p = 0.02), a greater incidence of at least one opioid-related side effect within the initial 24 hours after surgery, and a longer duration of hospital stay (p = 0.04) compared with those patients with a 4-hour PCA ratio <1.5. PCA ratio ≥1.5, age, and patient sex were predictive for 24-hour morphine consumption.

Conclusions: The authors have demonstrated that a PCA ratio of demands/deliveries ≥1.5 is predictive of increased opioid requirements and is associated with greater pain scores in the initial 24 hours after surgery, an increased incidence of opioid-related side effects, and duration of hospital stay.
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http://dx.doi.org/10.5055/jom.2014.0190DOI Listing
May 2014

Effectiveness of preoperative screening for sickle cell disease in a population with a newborn screening program: a cohort study.

Can J Anaesth 2013 Jan 27;60(1):54-9. Epub 2012 Oct 27.

Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, University of Toronto, ON, Canada.

Purpose: Published clinical practice guidelines recommend that all patients from ethnic groups with a high prevalence of sickle cell disease (SCD) undergo preoperative screening for this hemoglobinopathy. Newborn Screening Ontario initiated a universal sickle hemoglobinopathy screening program in 2006 as part of its regional newborn screening program. The primary objective of this study was to determine the effectiveness of selective preoperative screening for SCD based on at-risk ethnicity in Ontario, a region that has a universal newborn sickle hemoglobinopathy screening program.

Methods: The hematology laboratory database at our hospital was searched to identify all children who underwent preoperative sickle cell screening in the 42-month period starting in November 2006 (when the newborn sickle hemoglobinopathy screening program was introduced) and ending in April 2010. Medical records of all children testing positive on hemoglobin analysis were reviewed to determine perioperative outcomes.

Results: Our search strategy identified 710 children who were born after the introduction of newborn screening and who underwent preoperative screening. Thirty-five of these children had abnormal sickle solubility tests - one (0.14%) was a new diagnosis (not identified by newborn screening), one had been diagnosed previously, and 33 (4.65%) were identified as having sickle cell trait. Sixty children had more than one preoperative screening test performed (range, 2-4). Six of the 35 children with abnormal sickle solubility results underwent repeated testing.

Conclusions: Preoperative screening based on at-risk ethnicity alone is an ineffective method of identifying additional children with SCD in Ontario, a population with universal newborn sickle hemoglobinopathy screening. In an effort to avoid unnecessary repeat testing, we propose an algorithm to help physicians decide whether to initiate preoperative sickle cell screening for children.
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http://dx.doi.org/10.1007/s12630-012-9807-4DOI Listing
January 2013

PCA-derived factors that may be predictive of postoperative pain in pediatric patients: a possible role for the PCA ratio.

J Opioid Manag 2012 Jan-Feb;8(1):39-44

Department of Anesthesia & Pain Medicine, Hospital for Sick Children, University of Toronto, Toronto, Ontario.

Objective: No method exists to reliably predict which patients will develop severe postoperative pain. The authors hypothesized that data derived from patient-controlled analgesia (PCA) pumps (specifically the ratio of patient demands to pump deliveries) may predict which patients would develop severe pain after scoliosis repair.

Setting: Quaternary, university-affiliated, pediatric hospital.

Patients And Participants: Forty American Society of Anesthesiologists I-Il pediatric patients who had undergone elective scoliosis repair and had consented to recruitment to a randomized clinical trial investigating the effects of early morphine administration on remifentanil-induced hyperalgesia.

Interventions: To test the hypothesis of the current study, the authors calculated the PCA ratio of demand to delivery at every 4 hours throughout the first 24 hours after surgery for all the patients recruited to the original study.

Main Outcome Measures: The authors compared calculated PCA ratios, numeric rating scale pain scores, and cumulative morphine consumption for those patients who developed severe postoperative pain and met the criteria for opioid rotation versus those patients who did not.

Results: Seven patients required opioid rotation from PCA morphine to PCA hydromorphone. Eight hours after surgery, the median PCA ratio for those seven patients (2.5[range, 1.8-4.3]) was significantly greater than that for all other recruited patients (1.3 [range, 0-2.7]; p < 0.001).

Conclusions: Patients who developed severe postoperative pain and met the criteria for opioid rotation demonstrated significantly increased PCA ratios of demand to delivery as early as 8 hours after surgery.
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April 2012

Cardiac arrest upon induction of anesthesia in children with cardiomyopathy: an analysis of incidence and risk factors.

Paediatr Anaesth 2011 Sep 8;21(9):951-7. Epub 2011 Jul 8.

Our Lady's Children's Hospital, Crumlin, Dublin, Ireland.

Introduction: It is thought that patients with cardiomyopathy have an increased risk of cardiac arrest on induction of anesthesia, but there is little available data. The purpose of this study was to identify the incidence and potential risk factors for cardiac arrest upon induction of anesthesia in children with cardiomyopathy in our institution.

Methods: A retrospective chart review was performed. Eligible patients included patients admitted between 1998 and 2008 with the International Statistical Classification of Disease code for cardiomyopathy (ICD-9 code 425) who underwent airway intervention for sedation or general anesthesia in the operating room, cardiac diagnostic and interventional unit (CDIU) or intensive care unit. Patients undergoing emergency airway intervention following cardiovascular collapse were excluded. For each patient, we recorded patient demographics, disease severity, anesthesia location, and anesthetic technique.

Results: One hundred and twenty-nine patients with cardiomyopathy underwent a total of 236 anesthetic events, and four cardiac arrests were identified. One was related to bradycardia (HR<60), two were attributed to bradycardia in association with severe hypotension (systolic blood pressure<45), and the fourth arrest was related to isolated severe hypotension. Two occurred in the operating suite and two in the CDIU. There was no resulting mortality. One patient progressed to heart transplantation. Multiple combinations of anesthetic drugs were used for induction of anesthesia.

Conclusion: We performed a review of the last 10 years of anesthesia events in children with cardiomyopathy. We report four cardiac arrests in two patients and 236 anesthetic events (1.7%). To the best of our knowledge, this is the largest review of these patients to date but is limited by its retrospective nature. The low cardiac arrest incidence prevents the identification of risk factors and the development of a cardiac arrest risk predictive clinical tool.
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http://dx.doi.org/10.1111/j.1460-9592.2011.03645.xDOI Listing
September 2011

The use of NSAIDs in pediatric scoliosis surgery - a survey of physicians' prescribing practice.

Paediatr Anaesth 2009 Aug;19(8):756-63

Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada.

Background: Pediatric scoliosis surgery is associated with considerable postoperative pain requiring opioids for analgesia. Nonsteroidal antiinflammatory drugs (NSAIDs) can be used as adjuvants for analgesia; however, the potential of these agents to affect bone healing raises concerns. No large-scale prospective studies have been performed to evaluate the benefit-to-risk ratio of NSAID use after pediatric scoliosis surgery. Given the lack of evidence in the literature, a survey of practice patterns of anesthesiologists from around the world was conducted with respect to the use of NSAIDs after pediatric spinal fusion surgery for scoliosis.

Methods: One hundred and fourteen anesthesiologists from international academic pediatric hospitals were asked to complete an online survey. After 1 month, nonresponders were sent a second e-mail asking for their participation. All questions were developed specifically for this study.

Results: Out of 80 anesthesiologists who responded 61 were included in the final analysis. Fifty-nine percent routinely use NSAIDs, the most common agents being intravenous ketorolac and oral ibuprofen. The majority of respondents begin to administer NSAIDs within the first three postoperative days for a duration of four or more days. The primary reason for not routinely prescribing NSAIDs was the risk of bone nonunion.

Conclusions: This survey demonstrates that the practice patterns of pediatric anesthesiologists from around the world with respect to the administration of NSAIDs for the management of postoperative pain after pediatric spinal fusion reflects the conflicting evidence in the literature and the lack of high-quality studies in humans.
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http://dx.doi.org/10.1111/j.1460-9592.2009.03060.xDOI Listing
August 2009

Drug-induced acute pancreatitis in children receiving chemotherapy for acute leukemia: does propofol increase the risk?

Anesth Analg 2009 Aug;109(2):379-81

Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.

Background: The use of propofol is controversial in patients with a history of acute pancreatitis or those taking drugs, including certain chemotherapeutic drugs, that are associated with pancreatitis.

Methods: To investigate this issue, we reviewed the medical records of all children who were diagnosed with pancreatitis while receiving chemotherapy for acute leukemia during a 5-year period.

Results: A temporal relationship between propofol use and development of acute pancreatitis could not be established.

Conclusion: Propofol can be considered for general anesthesia in children who are receiving chemotherapeutic drugs that are themselves associated with acute pancreatitis or those who have a history of chemotherapy-induced pancreatitis.
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http://dx.doi.org/10.1213/ane.0b013e3181ac13edDOI Listing
August 2009

Preparation of the Dräger Fabius GS workstation for malignant hyperthermia-susceptible patients.

Can J Anaesth 2009 Jul 28;56(7):497-501. Epub 2009 Apr 28.

Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada.

Purpose: In order to establish guidelines for the preparation of the Dräger Fabius GS premium anesthetic workstation for malignant hyperthermia-susceptible patients, the authors evaluated the effect of the workstation's exchangeable and autoclavable components on the washout of isoflurane.

Methods: A Dräger Fabius GS workstation was primed with 1.5% isoflurane, and exchangeable components were replaced as follows: Group 1: no replacement (control); Group 2: autoclaved ventilator diaphragm and ventilator hose; Group 3: flushed ventilator diaphragm and ventilator hose; Group 4: autoclaved compact breathing system. The fresh gas flow (FGF) was set at 10 L . min(-1), and the concentration of isoflurane in the inspiratory limb of the circle breathing circuit was recorded every minute until an endpoint of 5.0 parts per million (ppm) was achieved, at which time the FGF was reduced to 3 L . min(-1). Six experiments were conducted in each of the four groups.

Results: The time to achieve an isoflurane concentration of 5.0 ppm decreased in the following order: Group 1 (151 +/- 17 min) > Group 3 (137 +/- 7 min) > Group 4 (122 +/- 11 min) > Group 2 (42 +/- 6 min) (P < 0.01 vs control). Isoflurane concentration increased approximately fivefold when the FGF was reduced to 3 L . min(-1).

Conclusion: Anesthetic washout from the Dräger Fabius GS is relatively slow. Although washout was accelerated when the Dräger Fabius GS was equipped with autoclaved components, the reduction in washout time may be less than that required for this technique to be accepted into clinical practice. A dedicated vapor-free workstation may be preferable for rapid turnover between cases.
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http://dx.doi.org/10.1007/s12630-009-9097-7DOI Listing
July 2009

Dose-dependent suppression of the electrically elicited stapedius reflex by general anesthetics in children undergoing cochlear implant surgery.

Anesth Analg 2009 May;108(5):1480-7

Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.

Background: Cochlear implants stimulate the auditory nerve to enable hearing. Determining appropriate upper and lower limits of stimulation is essential for successful cochlear implantation. The intraoperative evoked stapedius reflex threshold (ESRT) and evoked compound action potential (ECAP) are commonly used to determine the limits of implant stimulation. In this study, we evaluated the dose-related effects of sevoflurane, desflurane, isoflurane, and propofol on the intraoperative ESRT and ECAP.

Methods: Forty-four children aged 6 mo to 17 yr undergoing cochlear implantation were recruited. Each child was randomly assigned to receive sevoflurane, desflurane, isoflurane, or propofol. Evoked responses were measured by a blinded investigator at end-tidal anesthetic concentrations corresponding to 0, 0.75, and 1.5 age-adjusted minimum alveolar concentration administered in random sequence and at targeted blood concentrations of propofol of 0, 1.5, and 3.0 microg/mL. Data were analyzed using one-way repeated-measures analysis of variance. P < 0.05 was considered statistically significant.

Results: The ESRT increased dose dependently with increasing volatile anesthetic concentration (P < 0.01). The stapedius reflex was completely abolished by volatile anesthesia in more than half of children. Propofol minimally affected the ESRT. In contrast, the ECAP was unaffected by anesthesia.

Conclusions: Volatile anesthetics suppress the stapedius reflex in a dose-dependent manner, suggesting that ESRT measurements acquired during volatile anesthesia will overestimate the maximum comfort level, which may cause discomfort postoperatively and adversely affect the child's adaptation to the implant. We advise against the use of volatile anesthetics for measurement of the stapedius reflex threshold during cochlear implant surgery.
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http://dx.doi.org/10.1213/ane.0b013e31819bdfd5DOI Listing
May 2009

Pre-treatment with morphine does not prevent the development of remifentanil-induced hyperalgesia.

Can J Anaesth 2008 Dec;55(12):813-8

Department of Anesthesia, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada.

Purpose: Remifentanil, an ultra short-acting opioid commonly used to supplement general anesthesia, is associated with the development of hyperalgesia that manifests clinically as an increase in postoperative analgesic requirement. This study involving adolescents undergoing scoliosis surgery evaluated whether pre-treatment with morphine prior to commencing remifentanil infusion would decrease the initial 24-hr morphine consumption and pain scores.

Methods: Forty ASA I-II pediatric patients undergoing surgical correction of idiopathic scoliosis were recruited in a prospective, randomized, double-blind fashion to receive 150 microg x kg(-1) morphine or an equal volume saline prior to commencing remifentanil by infusion. The primary outcome was the initial 24-hr postoperative morphine consumption. Numeric rating scale (NRS) pain scores at rest and on coughing were recorded, as were scores for nausea, vomiting, and sedation and incidences of pruritus.

Results: The groups were demographically similar. No differences were observed between groups vis-à-vis the initial 24-hr morphine consumption, NRS pain scores, sedation, nausea, or vomiting.

Conclusion: Pre-treatment with 150 microg x kg(-1) morphine did not decrease the initial 24-hr morphine consumption in adolescents who received remifentanil by infusion for surgical correction of idiopathic scoliosis.
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http://dx.doi.org/10.1007/BF03034052DOI Listing
December 2008

The experience of conducting Mortality and Morbidity reviews in a pediatric interventional radiology service: a retrospective study.

J Vasc Interv Radiol 2009 Jan 29;20(1):77-86. Epub 2008 Oct 29.

Department of Medical Imaging, University of British Columbia, British Columbia, Canada.

Purpose: To review the experience and impact of conducting multidisciplinary Morbidity and Mortality (M&M) reviews in pediatric interventional radiology (IR) and describe issues, lessons, and recommendations.

Materials And Methods: A dedicated functionality of an existing database was developed to retrospectively analyze pediatric IR M&M issues. Patient demographics, sedation/anesthesia, and procedure type were recorded. M&M issues were assigned to at least one of 10 categories and graded as major or minor per Society of Interventional Radiology (SIR) guidelines. Issues could result in recommendations, which were divided into six categories; each was classified as implemented or not implemented.

Results: Of 31,983 patient encounters over a period of 10 years, 516 patient events (1.6%) were discussed at M&M reviews. A total of 772 categories were assigned; they related to the procedure (34%), patient comorbidity (20%), processes (15%), device (10%), management (8%), sedation/anesthesia (4%), medication (2%), ethical issues (1%), "near-misses" (1%), and other (5%). A total of 292 issues (57%) were graded as minor (SIR class A, n = 202; class B, n = 90) and 224 (43%) as major (SIR class C, n = 42; class D, n = 151; class E, n = 6; class F, n = 27). Twenty-seven deaths were reviewed. Of 397 recommendations made, 80% were fully implemented, 11% partially implemented, and 9% not implemented. Recommendations made related to process improvements (49%), technical changes (20%), interdisciplinary discussions (15%), educational endeavors (9%), contacting manufacturers (6%), and other issues (1%).

Conclusions: As a result of regular multidisciplinary M&M reviews being conducted, a large number of practical recommendations were made for improvements in quality of care, and implemented over a 10-year period. M&M reviews provide a useful forum for team discussions and are a vehicle for change and potential improvement in the delivery of care in a pediatric IR service.
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http://dx.doi.org/10.1016/j.jvir.2008.09.013DOI Listing
January 2009

Coadministration of propofol and remifentanil for lumbar puncture in children: dose-response and an evaluation of two dose combinations.

Anesthesiology 2008 Oct;109(4):613-8

Department of Anesthesia, The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario, Canada.

Background: The combination of propofol and remifentanil may be particularly suitable for short-duration procedures such as lumbar puncture. The authors undertook a two-part study to evaluate coadministration of propofol and remifentanil as an anesthetic technique for lumbar puncture in children.

Methods: The first part was a sequential allocation dose-finding study to determine the minimum effective dose of remifentanil when coadministered with 2.0 or 4.0 mg/kg propofol. The second was a randomized double-blind study to compare the intraoperative and recovery characteristics of 2.0 or 4.0 mg/kg propofol coadministered with the corresponding effective dose of remifentanil.

Results: Effective doses of remifentanil in 98% of children were 1.50 +/- 1.00 and 0.52 +/- 1.06 microg/kg when coadministered with 2.0 and 4.0 mg/kg propofol, respectively. The duration of apnea was longer (median, 110 vs. 73 s; P < 0.05) and the time to awakening was shorter (median, 10 vs. 23 min; P < 0.05) after 2.0 mg/kg propofol plus 1.5 microg/kg remifentanil compared with 4.0 mg/kg propofol plus 0.5 microg/kg remifentanil. No child experienced hypotension or postprocedure nausea or vomiting after either dose combination.

Conclusions: Both dose combinations (2.0 mg/kg propofol plus 1.5 microg/kg remifentanil and 4.0 mg/kg propofol plus 0.5 microg/kg remifentanil) provide effective anesthesia for lumbar puncture in children. However, the intraoperative and recovery characteristics of the two dose combinations differ in that the duration of apnea increases whereas recovery time decreases as the dose of remifentanil is increased and that of propofol is decreased.
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http://dx.doi.org/10.1097/ALN.0b013e31818629f3DOI Listing
October 2008

Intraoperative low-dose ketamine does not prevent a remifentanil-induced increase in morphine requirement after pediatric scoliosis surgery.

Anesth Analg 2008 Oct;107(4):1170-5

Department of Anesthesia, The Hospital for Sick Children, University of Toronto, 555 University Ave., Toronto, Ontario, Canada M5G 1X8.

Background: Remifentanil-based anesthesia is commonly used to facilitate neurophysiologic monitoring during pediatric scoliosis surgery. Acute opioid tolerance and/or hyperalgesia resulting from remifentanil-based anesthesia may involve activation of N-methyl-D-aspartate systems. We hypothesized that low-dose intraoperative infusion of the N-methyl-d-aspartate antagonist ketamine would suppress the development of tolerance and thereby decrease postoperative morphine consumption in children receiving remifentanil-based anesthesia for scoliosis surgery.

Methods: Thirty-four adolescents aged 12-18 yr scheduled for scoliosis surgery were randomly assigned to receive intraoperative low-dose ketamine (bolus dose of 0.5 mg/kg followed by continuous infusion of 4 microg.kg(-1).min(-1)) or an equal volume of saline during propofol/remifentanil anesthesia. Cumulative morphine consumption was assessed using a patient-controlled analgesia device for 72 h after surgery. Postoperative morphine consumption, pain scores at rest and during cough, and sedation scores were recorded by a blinded investigator every hour for the first 4 h, every 4 hours for 20 h, and then every 12 hours for 72 h.

Results: Cumulative morphine consumption at 24, 48, and 72 h after surgery did not differ significantly between groups (ketamine group: 1.57+/-0.56, 3.05+/-1.14, and 4.46+/-1.53 mg/kg; saline group: 1.60+/-0.53, 2.87+/-1.05, and 4.11+/-1.71 mg/kg, respectively). No differences in pain or sedation scores were found. The duration of anesthesia was similar in the two groups.

Conclusions: These data do not support the use of intraoperative low-dose ketamine to prevent the development of remifentanil-induced acute opioid tolerance and/or hyperalgesia during pediatric scoliosis surgery.
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http://dx.doi.org/10.1213/ane.0b013e318183919eDOI Listing
October 2008

Effect of low-dose ketamine on voltage requirement for transcranial electrical motor evoked potentials in children.

Spine (Phila Pa 1976) 2007 Oct;32(22):E627-30

Department of Anesthesia, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.

Study Design: Randomized controlled trial. OBJECTIVE.: To determine the effect of low-dose ketamine on the voltage needed to elicit maximal amplitude of the motor-evoked response to transcranial electrical stimulation during propofol/remifentanil anesthesia in children undergoing scoliosis surgery.

Summary Of Background Data: Motor-evoked potentials (MEPs) are increasingly used to assess the integrity of motor pathways during surgery. Whereas most general anesthetics depress MEP amplitude, the effect of ketamine has been variable, ranging from little or no reduction to an increase in amplitude, suggesting that ketamine may be useful as an agent to facilitate MEP monitoring. We tested the hypothesis that low-dose ketamine would reduce the voltage required to elicit maximal amplitude of the motor-evoked response to transcranial electrical stimulation during propofol/remifentanil anesthesia.

Methods: Thirty-four patients 12 to 16 years of age undergoing posterior instrumentation for correction of idiopathic scoliosis were randomly assigned to receive low-dose ketamine (0.5 mg/kg bolus, followed by 4 microg/kg/min infusion) or an equal volume of saline. Anesthesia was maintained using a mixture of 30% oxygen in air, continuous infusion of propofol at a rate of 100 to 150 microg/kg per min, and continuous infusion of remifentanil. Myogenic motor-evoked responses to transcranial electrical stimulation of the motor cortex were recorded. The minimum voltage required to elicit maximal amplitude of the MEP response was determined. Voltage requirements were compared using the Mann-Whitney U rank sum test. P < 0.05 was considered statistically significant.

Results: No significant difference was found in the minimal voltage needed to elicit maximum amplitude of the MEP response. Median (range) voltage requirements in the ketamine and control groups were 227 V (range, 160-350 V) and 215 V (range, 150-300 V), respectively.

Conclusion: Addition of low-dose ketamine to propofol/remifentanil anesthesia does not significantly reduce the voltage needed to elicit maximum amplitude of the motor-evoked response to transcranial electrical stimulation.
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http://dx.doi.org/10.1097/BRS.0b013e3181573eb4DOI Listing
October 2007