Epidural Abscess Complicating Tunneled Caudal Epidural Catheter in an Infant for Postoperative Pain Management of Open Abdominal Surgery

Journal of Medical Cases · 2024 · 1 citations

• Medicine
• Surgery
• Anesthesia

Regional anesthesia is being used more frequently in pediatric anesthesia practice, including the perioperative care of neonates and infants. Adverse effects may be encountered during epidural needle placement, with catheter advancement, or subsequently during infusion of local anesthetic agents. Despite applying standard practice of care regarding placement of epidural catheter, epidural catheter-related infections may still occur. We present the rare occurrence of an epidural abscess in a 4-month-old infant after placement and subsequent use of a tunneled caudal epidural catheter for postoperative pain management following abdominal surgery. Magnetic resonance imaging (MRI) was the gold standard diagnostic imaging modality and was used to identify the abscess. Management included intravenous antibiotic therapy as well as hemilaminectomy with evacuation of the epidural abscess and hematoma. The patient continued to progress well with no deficits noted on neurological examination. There were no other postoperative concerns. When there is a concern for epidural catheter-related infection, the catheter should be removed immediately. The epidural catheter tip as well as any purulent discharge from the insertion site should be sent for culture and sensitivity. Urgent neurosurgical and infectious disease consultation is suggested to provide opinions regarding surgical intervention and antibiotic therapy.

Continuous Erector Spinae Plane Block for Pain Management Following Thoracotomy for Aortic Coarctectomy

Journal of Medical Cases · 2024-01-01 · 1 citations

Pain following thoracotomy is one of the most severe forms of postoperative pain. Post-thoracotomy pain may increase the risk of post-surgical pulmonary complications, postoperative mortality, prolong hospitalization, and increase utilization of healthcare resources. To mitigate these effects, anesthesia providers commonly employ continuous epidural infusions, paravertebral blocks, and systemic opioids for pain management and improvement of pulmonary mechanics. We report the use of a continuous erector spinae plane block (ESPB) via a peripheral nerve catheter for postoperative pain management of an 18-year-old patient who underwent complex aortic coarctation repair via lateral thoracotomy, aided by cardiopulmonary bypass. Continuous ESPB proved to be an acceptable alternative for postoperative pain control, producing a substantial multi-dermatomal sensory block, resulting in adequate pain control, reduced opioid consumption, and a potentially shorter hospital stay.

Sugammadex Vial Wastage: Implications for the Cost of Anesthesia Care in Children: Research Letter

Anesthesiology · 2023-04-07 · 3 citations

Although pharmaceutical costs account for approximately 15% of the overall cost of anesthetic care, these expenses are frequently assumed to be due to the choice of anesthetic technique (general vs. regional) or the choice of medications used for anesthetic care.1 Seldom addressed in measures to control care-related expenditures is the issue of medication wastage that occurs when a medication vial is opened but not used.1 This waste represents a potential cost saving if the drug was not discarded, because unadministered drugs account for more than 25% of the anesthesia medication budget.1One of the more expensive medications used in anesthetic care is sugammadex, which is currently supplied in 200 mg/2 ml or 500 mg/5 ml vials. Because sugammadex vials are labeled single-dose or single-use only, the standard of care is that partially used or unadministered opened vials are discarded.2 Medication vial wastage is particularly common in pediatric anesthesia because of the variability in patient weights and the fact that medications are administered on a milligram per kilogram body weight basis.1The present study had two objectives. First, we examined the longitudinal trends in sugammadex administration in a national pediatric surgical population, and second, we estimated the proportion of drug wastage and its economic implications based on the minimum sugammadex vial size of 200 mg/2 ml. After institutional review board approval from the Nationwide Children’s Hospital (Columbus, Ohio), we identified 1,550,894 administrations of either rocuronium or vecuronium during induction of anesthesia among children 18 yr or younger across 49 children’s hospitals reporting to the Pediatric Health Information System between January 1, 2017, and September 31, 2022. We then examined the longitudinal trends in sugammadex administration for reversal of neuromuscular blockade across all study centers. We finally performed a budget impact analysis of the amount of wasted drug based on the minimum sugammadex vial size of 200 mg/2 ml. We defined drug wastage as documented less than 100 mg administration because such instances signify partial vial use, consistent with the Centers for Disease Control and Prevention (Atlanta, Georgia) recommendation.2 We calculated the 2022 inflation-adjusted cost saving, if a sugammadex vial size of 100 mg/1 ml were available, by multiplying the frequency of 100 mg or less administered to $49.87 (half of the acquisition cost of 200 mg/2 ml sugammadex).We identified 400,838 sugammadex administrations during the study period between January 1, 2017, through the third quarter of 2022. Sugammadex administration increased by 43% by the end of the study period. Drug wastage occurred in almost 3 of 5 administered doses (59.2%, n = 237,092). If sugammadex vial size of 100 mg/ml were available and it cost roughly half that of a 200-mg vial, or if vials were split, then an estimated $14,000,000 worth of drug would not have been discarded during the study period. By the third quarter of 2022, the quarterly average cost saving in the absence of medication wastage was $40,235 (fig. 1).Sugammadex is one of many expensive medications where the minimum vial contains quantities larger than the amount needed for pediatric patients. Two other commonly used medications with similar concerns are acetaminophen (1,000 mg/100 ml) and dexmedetomidine (100 mcg/2 ml). Previous research has proposed cost-saving solutions to reduce or eliminate the cost associated with drug wastage.3 These solutions include regulations to require manufacturers to identify vials that match doses commonly used in the pediatric population (e.g., 50-mg or 100-mg vials). Another solution would be the adoption of certified disposal and a virtual return system that would require manufacturers to refund the cost of leftover drugs. Finally, there is the option of not using sugammadex for neuromuscular blockade reversal given the recent findings that its use is not associated with reduced incidence of perioperative respiratory adverse events.4 Studies in adults have shown mixed results about the cost-effectiveness of neostigmine in comparison with sugammadex.5 Given the unique dosage requirements in children, further research is needed to determine whether using neostigmine is associated with cost reductions compared with sugammadex, given currently available vial sizes.The Centers for Disease Control and Prevention has published formal guidelines regarding vial repackaging that should be performed under USP Pharmaceutical Compounding Compendium, as well as the manufacturer’s recommendations about the safe storage of medications outside their original containers. Vial repackaging should be performed by a trained pharmacist or pharmacy technician under a sterile hood. The new vial or syringe must be labeled with pertinent information regarding the medication, including its name, medication concentration, total volume, and expiration date.2 Research is needed to describe current vial-splitting practices and explore any missed opportunity to maximize their safety (e.g., medication contamination).Certain limitations of this report must be acknowledged. Some pharmacies may report the total cost of vials instead of the administered dose. However, if this were to happen, it would only underestimate the magnitude of the total potential cost saving. In conclusion, we observed increasing trends of sugammadex administration, most of which were associated with drug wastage. The financial implications of such drug wastage underline an urgent need for pharmaceutical companies to produce vials appropriate for pediatric anesthesia and for hospitals to consider repackaging strategies in the short term.The authors declare no competing interests.

Association of Sugammadex or Neostigmine With Major Postoperative Pulmonary Complications in Children

Anesthesia & Analgesia · 2022-01-12 · 18 citations

BACKGROUND: Recent data in adult patients indicate that the use of sugammadex compared to neostigmine for reversal of neuromuscular block (NMB) was associated with a significant reduction in the risk of composite postoperative pulmonary complications. Despite the clinical significance of pulmonary complications in children, studies exploring the role of NMB reversal in the risk of these complications are currently unavailable. METHOD: We performed a propensity score-matched retrospective study using the Pediatric Health Information System (PHIS) dataset spanning the years 2016 and 2020. We studied children <18 years who underwent elective, inpatient, noncardiac surgical procedures and received either neostigmine or sugammadex for reversal of NMB. Our primary outcome was major postoperative pulmonary complication, which we defined as the occurrence of either postoperative pneumonia or respiratory failure. RESULTS: Our study included a study population of 33,819 children, of whom 23,312 (68.9%) received neostigmine and 10,507 (31.1%) received sugammadex. After propensity score matching (10,361 matched from each group), we found no evidence of a statistically significant association between the NMB reversal agent and the incidence of pulmonary complications (3.1% vs 3.1%; odds ratio [OR], 0.90; 95% confidence interval [CI], 0.78-1.05; P = .19). The components of pulmonary complications, including respiratory failure and pneumonia, were not statistically associated with the choice of NMB reversal agent. CONCLUSIONS: Choice of NMB reversal agent does not appear to impact the incidence of major postoperative pulmonary complications. Further research is needed to determine whether our results carry forth across subpopulations defined by surgical specialty, the presence of complex chronic conditions, and anesthesia technique.

Ambulatory spinal anesthesia in infants ≤ six months of age: A retrospective review of outcomes and safety

Journal of Clinical Anesthesia · 2022-07-01 · 7 citations

Use of a Spinal-Caudal Epidural Technique for Abdominal Surgery in a Newborn With Noonan Syndrome and Severe Hypertrophic Cardiomyopathy

A&A Practice · 2022-08-01

Features of Noonan syndrome include a distinctive facial appearance, short stature, a broad or webbed neck, congenital heart disease, bleeding problems, skeletal malformations, and developmental delay. Although pulmonary stenosis is most commonly reported, up to 20% of patients have hypertrophic cardiomyopathy (HCM). We report the use of a combined spinal-caudal epidural anesthesia technique during urologic surgery (pyeloplasty) in an 8-week-old infant with Noonan syndrome and HCM. A spinal-caudal epidural technique provides favorable hemodynamic conditions, avoids the need for airway instrumentation, and may serve as an alternative to general anesthesia in these high risk patients.

Intermittent Cerebrospinal Leak After Inadvertent Dural Puncture During Epidural Catheter Placement for Postoperative Analgesia

Journal of Medical Cases · 2022-07-01 · 2 citations

Regional anesthesia is being used more frequently in pediatric anesthesia practice, including the perioperative care of neonates and infants. Adverse effects may be encountered during epidural needle placement, with catheter advancement, or subsequently during infusion of local anesthetic agents. We present the rare occurrence of a persistent cerebrospinal fluid (CSF) leak following inadvertent dural puncture (wet tap) during attempted placement of an epidural catheter in a 6-year-old child. Potential adverse effects of epidural anesthesia in children are discussed, and options for treatment of a persistent CSF leak after inadvertent dural puncture are reviewed.

Adverse Events in Infants Less Than 6 Months of Age After Ambulatory Surgery and Diagnostic Imaging Requiring Anesthesia

Pediatric Quality and Safety · 2022-07-01 · 4 citations

Introduction: AAP guidelines recommend infants less than 6 months of age are monitored for at least 2 hours following surgery. This retrospective study evaluated if adherence to the 2-hour monitoring guideline decreased the risk of adverse events associated with ambulatory procedures in infants younger than 6 months. Methods: We queried the hospital’s electronic medical record to identify patients younger than 6 months of age who received anesthetic care from January 2015 to March 2020. Demographic data, intraoperative adverse events, and returns to the emergency department (ED) or urgent care within 7 days were captured for each patient. We calculated the number and frequency for categorical data and median and interquartile range (IQR) for continuous data. Chi-square or Fisher’s exact test were used to compare patients who experienced an adverse event to those that did not. Results: One thousand one hundred seventy-seven patients who had 1,261 unique anesthetic encounters were analyzed. Forty-four adverse events were identified, 20 (1.6%) before discharge, including 3 unplanned admissions, and 24 (1.9%) returns to the ED/UC within 7 days postoperatively. We did not observe differences in postoperative recovery time in patients who experienced an adverse event and those who did not (88 min vs. 77 min, respectively, P = 0.078). None of the ED/UC returns would have been avoided by a longer PACU stay. Conclusions: With the appropriate patient selection, once physiological discharge readiness is met, adherence to a strict 2-hour time-based discharge criteria does not increase safety for infants younger than 6 months of age after ambulatory procedures.

Characterization of the Difficult Peripheral IV in the Perioperative Setting: A Prospective, Observational Study of Intravenous Access for Pediatric Patients Undergoing Anesthesia

Pediatric Health Medicine and Therapeutics · 2022-05-01 · 7 citations

Background: Various criteria exist for defining difficult intravenous access (DIVA) in infants and children. The current study evaluated the factors associated with DIVA in a prospective cohort of over 1000 infants and children presenting for anesthetic care. Methods: This was a prospective, observational study of patients aged 0 to 18 years undergoing elective surgical or radiologic procedures under general anesthesia. Prior to the initial attempt at peripheral intravenous (PIV) cannulation, the anticipated difficulty of PIV catheter placement was determined by the provider using a visual analogue scale (VAS) from 1 to 10. The number of attempts was recorded as well as the time required to achieve PIV access. DIVA was defined as requiring three or more attempts. After successful cannulation, the actual difficulty of the PIV placement was assessed by the provider and recorded using the same VAS. Patient characteristics, including age, race, body mass index (BMI), American Society of Anesthesiologists (ASA) physical classification, and history of difficult PIV placement, were evaluated as covariates. Results: In our cohort of 1002 pediatric patients, 78% of patients were successfully cannulated in a single attempt and 91% of patients were successfully cannulated in two or fewer attempts. Factors associated with requiring three or more PIV attempts included younger age (OR 8.73; 95% CI: 3.38, 22.6 for age <1 year and OR 4.93; 95% CI: 2.05, 11.8 for age 1-3 years), higher ASA physical classification (OR 1.95; 95% CI: 1.10, 3.46 for ASA II), and prior history of difficult PIV placement (OR 3.46; 95% CI: 1.70, 7.08). BMI, racial category or gender were not independent predictors of DIVA. Conclusion: We found that approximately 9% of patients required three or more attempts at IV placement in the operating room. Patients that required multiple PIV attempts were more likely to be younger, have a higher ASA classification or a history of difficult PIV placement.

Continuous epidural chloroprocaine after abdominal surgery is associated with lower postoperative opioid exposure in NICU infants

Journal of Pediatric Surgery · 2021-05-29 · 13 citations