BACKGROUND:Accurate blood pressure monitoring is essential in many clinical scenarios for adults and children and, when continuous measurement is critical, necessitates the insertion of an arterial line. A novel continuous non-invasive arterial pressure monitoring device using a pulse contour algorithm (Pulse Decomposition Analysis), Vitalstream™, is approved by the United States Food and Drug Administration for use in adults. In this study the performance and accuracy of the device compared to intraarterial blood pressure monitoring were assessed in children ages 2-17 undergoing major surgeries. We report the results using comparison to aspects of the recently published ISO 81060-3:2022 standard for continuous automated blood pressure measurement. METHODS:31 children ages 2-17 years scheduled for major surgery requiring invasive arterial blood pressure monitoring were consented to participate. Systolic, diastolic, and mean arterial blood pressure readings were obtained from both systems during at least thirty minutes of simultaneous monitoring during hemodynamically stable periods of the surgical procedure and statistically compared. RESULTS:The correlations of systolic and, diastolic, and mean arterial pressures were, respectively, 0.77, 0.68 and 0.7. The Bland-Altman comparisons yielded bias of -3.79 (9.74) mmHg, 1.72 (8.45) mmHg and 2.41 (8.75) mmHg respectively, for systolic, diastolic, and mean arterial pressures, (p < 0.001 for all comparisons). Concordances for systole, diastole and MAP were, respectively, 0.82, 0.85 and 0.83. CONCLUSIONS:Most values fell within +/-20mmhg of the corresponding arterial line values. While this meets the basic requirement for such devices published by professional societies, clinicians will need to be aware of the potential variances and make clinical decisions accordingly. The Vitalstream™ may offer low risk, accurate continuous pressure monitoring in children ages 2-17. CLINICAL TRIALS:gov: NCT04817137 The trial was registered at clinicaltrials.gov (NCT048I7173).

Pediatric arterial thromboembolism is an extremely rare and serious complication, especially rare when it is noncatheter-related. Most of the literature describes venous and catheter-related thromboembolism. We report a case of a 10-year-old boy with hereditary multiple exostosis who developed acute limb ischemia following deformity correction and Ilizarov ring fixation for limb lengthening. This case highlights two issues: the role of Point of Care Ultrasound (POCUS) and the management of an epidural catheter amidst unanticipated anticoagulation. It also demonstrates the importance of a multidisciplinary team-based approach for optimum management at each level.

Background/importance Despite over 30 years of use by pediatric anesthesiologists, standardized dosing rates, dosing characteristics, and cases of toxicity of truncal nerve catheters are poorly described. Objective We reviewed the literature to characterize dosing and toxicity of paravertebral and transversus abdominis plane catheters in children (less than 18 years). Evidence review We searched for reports of ropivacaine or bupivacaine infusions in the paravertebral and transversus abdominis space intended for 24 hours or more of use in pediatric patients. We evaluated bolus dosing, infusion dosing, and cumulative 24-hour dosing in patients over and under 6 months. We also identified cases of local anesthetic systemic toxicity and toxic blood levels. Findings Following screening, we extracted data from 46 papers with 945 patients. Bolus dosing was 2.5 mg/kg (median, range 0.6–5.0; n=466) and 1.25 mg/kg (median, range 0.5–2.5; n=294) for ropivacaine and bupivacaine, respectively. Infusion dosing was 0.5 mg/kg/hour (median, range 0.2–0.68; n=521) and 0.33 mg/kg/hour (median, range 0.1–1.0; n=423) for ropivacaine and bupivacaine, respectively, consistent with a dose equivalence of 1.5:1.0. A single case of toxicity was reported, and pharmacokinetic studies reported at least five cases with serum levels above the toxic threshold. Conclusions Bolus doses of bupivacaine and ropivacaine frequently comport with expert recommendations. Infusions in patients under 6 months used doses associated with toxicity and toxicity occurred at a rate consistent with single-shot blocks. Pediatric patients would benefit from specific recommendations about ropivacaine and bupivacaine dosing, including age-based dosing, breakthrough dosing, and intermittent bolus dosing.

Background Inconsistent nomenclature and anatomical descriptions of regional anesthetic techniques hinder scientific communication and engender confusion; this in turn has implications for research, education and clinical implementation of regional anesthesia. Having produced standardized nomenclature for abdominal wall, paraspinal and chest wall regional anesthetic techniques, we aimed to similarly do so for upper and lower limb peripheral nerve blocks. Methods We performed a three-round Delphi international consensus study to generate standardized names and anatomical descriptions of upper and lower limb regional anesthetic techniques. A long list of names and anatomical description of blocks of upper and lower extremities was produced by the members of the steering committee. Subsequently, two rounds of anonymized voting and commenting were followed by a third virtual round table to secure consensus for items that remained outstanding after the first and second rounds. As with previous methodology, strong consensus was defined as >= 75% agreement and weak consensus as 50%-74% agreement. Results A total of 94, 91 and 65 collaborators participated in the first, second and third rounds, respectively. We achieved strong consensus for 38 names and 33 anatomical descriptions, and weak consensus for five anatomical descriptions. We agreed on a template for naming peripheral nerve blocks based on the name of the nerve and the anatomical location of the blockade and identified several areas for future research. Conclusions We achieved consensus on nomenclature and anatomical descriptions of regional anesthetic techniques for upper and lower limb nerve blocks, and recommend using this framework in clinical and academic practice. This should improve research, teaching and learning of regional anesthesia to eventually improve patient care.

Background Accurate blood pressure monitoring is essential in many clinical scenarios for adults and children. A novel continuous non-invasive arterial pressure monitoring device using a pulse contour algorithm (pulse decomposition analysis), Vitalstream™, was recently cleared by the United States Food and Drug Administration for use in patients 18 years of age and older. Recently published ISO 81060–3:2022 standards for continuous automated blood pressure measurement were used to determine the accuracy (bias) and precision (repeatability) of the device in children ages 2–17 undergoing major surgeries compared to intraarterial blood pressure monitoring. Accuracy and precision are defined as acceptable if bias is within 6 mmHg and standard deviation within 10 mmHg. Methods A sample of 31 children ages 2–17 years scheduled for major surgery requiring invasive arterial blood pressure monitoring were consented to participate. Each patient was monitored with a radial arterial catheter and a Vitalstream™ monitor. Hemodynamic measures obtained from both systems during at least thirty minutes of simultaneous monitoring during the surgical procedure were analyzed using Pearson correlation coefficients as well as Bland-Altman and 4Q plot trend analyses. Results The correlations of systolic and diastolic arterial pressures were, respectively, 0.77 and 0.68. The Bland-Altman comparisons yielded bias (standard deviation) of 3.79 (9.74) mmHg and − 1.72 (8.45) mmHg for, respectively, systolic, and diastolic arterial pressures, (p < 0.001 for all comparisons). Concordances for systole and diastole were, respectively, 0.82 and 0.85. Conclusions In this study, continuous, beat by beat blood pressure measured using the non-invasive Vitalstream™ device correlated well with invasive arterial catheter measurements in the children. Most patients exhibited good agreement between methods, and the results were within established ISO limits for the validation of continuous automatic arterial pressure monitoring. The Vitalstream™ may offer low risk, accurate blood pressure monitoring in children ages 2–17. The trial was registered at clinicaltrials.gov (NCT04817137)

Background and objectives Documentation is important for quality improvement, education, and research. There is currently a lack of recommendations regarding key aspects of documentation in regional anesthesia. The aim of this study was to establish recommendations for documentation in regional anesthesia. Methods Following the formation of the executive committee and a directed literature review, a long list of potential documentation components was created. A modified Delphi process was then employed to achieve consensus amongst a group of international experts in regional anesthesia. This consisted of 2 rounds of anonymous electronic voting and a final virtual round table discussion with live polling on items not yet excluded or accepted from previous rounds. Progression or exclusion of potential components through the rounds was based on the achievement of strong consensus. Strong consensus was defined as ≥75% agreement and weak consensus as 50%–74% agreement. Results Seventy-seven collaborators participated in both rounds 1 and 2, while 50 collaborators took part in round 3. In total, experts voted on 83 items and achieved a strong consensus on 51 items, weak consensus on 3 and rejected 29. Conclusion By means of a modified Delphi process, we have established expert consensus on documentation in regional anesthesia.

Background Caudal epidural analgesia is the most common regional anesthetic performed in infants. Dural puncture, the most common serious complication, is inversely proportional to age. Measuring the distance from the sacrococcygeal membrane to the dural sac may prevent dural puncture. This study measures the sacrococcygeal membrane to dural sac distance using ultrasound imaging to determine feasibility of imaging and obtaining measurements. Methods Sacral ultrasound imaging of 40 preterm neonates was obtained in left lateral decubitus, a typical position for caudal blockade. No punctures were made. The sacrococcygeal membrane and termination of the dural sac were visualized, and the distance measured. The spinal levels of the conus medullaris and dural sac termination were recorded. Results 20 males and 20 females former preterm neonates with an average weight (SD; range) of 1740 (290; 860-2350) g and average age (SD; range) of 35.0 (1.35; 32.2-39) weeks gestational age at the time of imaging. The average sacrococcygeal membrane to distal dural sac distance (SD; range) was 17.4 (3.1; 10.6-26.3) mm. Overall, the weights correlated positively with the distance but the coefficient of variation was large at 23%. The conus medularis terminated below the L3 level and dural sac below the S3 level in 20% and 10% of subjects respectively with hip flexion. Conclusion Ultrasound can be used to measure the sacrococcygeal membrane to dura distance in preterm neonates prior to needle insertion when performing caudal block and demonstrates large variability. Ultrasound imaging may identify patients at risk for dural puncture. When ultrasound is not available, needle insertion less than 3 mm/kg beyond the puncture of the sacrococcygeal membrane should prevent dural contact in 99.9% of neonates.

The opioid epidemic is a major public health issue in the United States. Exposure of opioid naïve-patients to opioids in the perioperative period is a well-documented source of continued use with one in 20 opioid-naïve surgical patients continuing to use opioids beyond 90 days. There is no association with magnitude of surgery, major versus minor, and the strongest predictor of continued use is surgical exposure. Causal factors include over reliance on opioids for intraoperative and postoperative analgesia and excessive ambulatory opioid prescribing. Opioid-induced hyperalgesia can paradoxically result from intraoperative (anesthesia controlled) opioid administration. Increasing size of initial prescription is a strong predictor of continued use necessitating procedure specific supplies limited to under 3-days. Alternative multimodal pain management (non-opioid medications and regional anesthesia) that limit opioid use must be a high priority with opioids reserved for severe breakthrough pain. Barriers to implementation of opioid-sparing pathways include reluctance to adopt protocols and apprehension about opioid elimination. Considering the number of surgeries performed annually in the United States, perioperative physicians must aggressively address modifiable factors in surgical patients. Patient care pathways need to be constructed collaboratively by surgeons and anesthesiologists with continuing feedback to optimize patient outcomes including iatrogenic opioid dependence.

Following the placement of lumbar plexus and parasacral sciatic catheters for complex lower extremity surgery, a 19-kg child had dense sensory and motor blockades in the postanesthesia care unit. The surgical team felt obligated to exclude anatomically modifiable compression of the sciatic nerve and planned for surgical reexploration. Using an insulated short, beveled needle, direct electrical nerve stimulation distal to the parasacral sciatic block and proximal to the surgical site elicited tibial nerve motor function and confirmed nerve integrity. Peripheral nerve stimulation can be used to differentiate between the etiologies of motor blockade in time-critical situations.

Point-of-care ultrasound (POCUS) is a critical skill for all regional anesthesiologists and pain physicians to help diagnose relevant complications related to routine practice and guide perioperative management. In an effort to inform the regional anesthesia and pain community as well as address a need for structured education and training, the American Society of Regional Anesthesia and Pain Medicine Society (ASRA) commissioned this narrative review to provide recommendations for POCUS. The recommendations were written by content and educational experts and were approved by the guidelines committee and the Board of Directors of the ASRA. In part II of this two-part series, learning goals and objectives were identified and outlined for achieving competency in the use of POCUS, specifically, airway ultrasound, lung ultrasound, gastric ultrasound, the focus assessment with sonography for trauma exam, and focused cardiac ultrasound, in the perioperative and chronic pain setting. It also discusses barriers to POCUS education and training and proposes a list of educational resources. For each POCUS section, learning goals and specific skills were presented in the Indication, Acquisition, Interpretation, and Medical decision-making framework.

Pediatric AnesthesiaVolume 31, Issue 4 p. 501-501 CORRESPONDENCE Isolated t-wave morphology changes during caudal injection in an infant Cheryl Sook Lai Chooi, Corresponding Author cheryl.chooi@childrens.harvard.edu orcid.org/0000-0001-5480-9890 Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA, USA Correspondence Cheryl Chooi, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, 300 Longwood Ave, Boston, MA 02115, USA. Email: cheryl.chooi@childrens.harvard.eduSearch for more papers by this authorCarolyn Butler, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA, USASearch for more papers by this authorKaren Boretsky, orcid.org/0000-0003-2799-9902 Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA, USASearch for more papers by this author Cheryl Sook Lai Chooi, Corresponding Author cheryl.chooi@childrens.harvard.edu orcid.org/0000-0001-5480-9890 Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA, USA Correspondence Cheryl Chooi, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, 300 Longwood Ave, Boston, MA 02115, USA. Email: cheryl.chooi@childrens.harvard.eduSearch for more papers by this authorCarolyn Butler, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA, USASearch for more papers by this authorKaren Boretsky, orcid.org/0000-0003-2799-9902 Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA, USASearch for more papers by this author First published: 27 March 2021 https://doi.org/10.1111/pan.14116Citations: 1Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinked InRedditWechat Citing Literature Volume31, Issue4April 2021Pages 501-501 RelatedInformation

Transthoracic focused cardiac ultrasound imaging in the operating room is typically performed using phased array transducers.1,2 We present the portable ultrasound imaging of a 1.1-kg neonate in a short-axis parasternal view to demonstrate curvilinear transducer use for parasternal imaging, which provided clear structure resolution (left) and excessive artifact in near-field targets using a typical phased array transducer (right). The heart structure including the right (RV) and left ventricle (LV) is clear on the left (54 × 10 mm curvilinear transducer [2 to 9 MHz]), whereas the speckle artifact rendered the right image (26 × 20 mm phased array transducer [1 to 5 MHz]) uninterpretable.3Focused cardiac ultrasound imaging provides information for the management of critical situations in children and adults.1,2 In most operating rooms, a single phased array transducer is available for focused cardiac ultrasound imaging.1,2 Phased array transducers are small-footprint (2.0 to 2.6 cm), low-frequency (1 to 5 MHz) transducers for deep imaging (greater than 6 cm) through narrow rib spaces. Low-frequency curvilinear transducers (1 to 9 MHz) have large footprints (5.4 to 8 cm) and are not considered suitable for imaging between ribs.2The infant’s superficial targets and small size create imaging challenges owing to interference of returning wave scatter noise (speckle artifact) prominent in the near field3 and narrow rib spaces. Curvilinear transducer for imaging infants in subcostal windows when a phased array is unavailable is reported.2 In this case, the phased array was available but produced poor images. The lack of infant rib ossification creates an acoustic window for curvilinear imaging. Although both the convex and phased array transducers are considered low frequency, this convex transducer oscillates at slightly higher frequencies and provided better near-field resolution in this infant.The authors declare no competing interests.

BackgroundThere is heterogeneity in the names and anatomical descriptions of regional anesthetic techniques. This may have adverse consequences on education, research, and implementation into clinical practice. We aimed to produce standardized nomenclature for abdominal wall, paraspinal, and chest wall regional anesthetic techniques.MethodsWe conducted an international consensus study involving experts using a three-round Delphi method to produce a list of names and corresponding descriptions of anatomical targets. After long-list formulation by a Steering Committee, the first and second rounds involved anonymous electronic voting and commenting, with the third round involving a virtual round table discussion aiming to achieve consensus on items that had yet to achieve it. Novel names were presented where required for anatomical clarity and harmonization. Strong consensus was defined as ≥75% agreement and weak consensus as 50% to 74% agreement.ResultsSixty expert Collaborators participated in this study. After three rounds and clarification, harmonization, and introduction of novel nomenclature, strong consensus was achieved for the names of 16 block names and weak consensus for four names. For anatomical descriptions, strong consensus was achieved for 19 blocks and weak consensus was achieved for one approach. Several areas requiring further research were identified.ConclusionsHarmonization and standardization of nomenclature may improve education, research, and ultimately patient care. We present the first international consensus on nomenclature and anatomical descriptions of blocks of the abdominal wall, chest wall, and paraspinal blocks. We recommend using the consensus results in academic and clinical practice.

BACKGROUND:Caudal epidural anesthesia is a frequently performed regional anesthesia block in infants and young children. Traditional landmark-based blind needle insertion remains the norm with no immediate, objective method to determine the presence of local anesthetic in the epidural space. Increasingly, ultrasound-imaging is used in pediatric regional anesthesia with demonstrated improvements in block efficacy and efficiency. The value of ultrasound-imaging in confirming success rate of traditional caudal placement is not well defined.AIM:To assess the success rate of conventional landmark-based caudal technique using ultrasound-imaging.METHODS:Prospective observational study of 30 children ages 1 month to 7 years undergoing surgical procedures with consent for caudal blockade. Provider success rate of caudal blockade placed by landmark technique was measured using ultrasound-imaging of needle tip and local anesthetic flow in the epidural space.RESULTS:Ultrasound-imaging demonstrated 80% success to correct positioning of the needle tip and local anesthetic in the epidural space. Failure was associated with decreasing experience and presence of anatomic variances. All improperly positioned needles were subsequently successfully positioned using real-time ultrasound-imaging. Mean time for confirmatory ultrasound-imaging (SD; range) was 1 minute (0.3; 1-3).CONCLUSION:The use of ultrasound-imaging can be used to identify proper needle placement in the sacral epidural canal and facilitate subsequent corrected placement.