Background and Aims Ultrasound-guided regional anesthesia and peripheral nerve catheters for postoperative pain management is a relatively recent aspect of the field of pediatric anesthesia. The goal of this prospective, blinded study was to evaluate cardiovascular and respiratory safety, clinical efficacy, and recovery following orthopedic surgery performed in peripheral nerve blocks using dexmedetomidine and propofol for sedation with spontaneous breathing. Methods The study included 90 children aged 1 to 18 who were randomly assigned to the dexmedetomidine or propofol groups, ASA-PS scores of I to III, since January 2022. We analyzed baseline characteristics: gender, age, body weight, hemodynamic and respiratory stability, the depth of anesthesia was determined with a modified Ramsay sedation score, presence of peripheral nerve catheter, duration of operation and anesthesia, and awakening time from anesthesia. Results The operation time was longer in the dexmedetomidine group (t = -2.988, DF = 88, p <0.01). The time of anesthesia was longer in the dexmedetomidine group (t = -22.301, DF = 88, p <0.05). Awakening time from anesthesia was longer in the propofol group (t = 10,884, DF = 88, p <0.01). Patients with neuromuscular disorders had a longer awakening time from anesthesia in the propofol group (t = -4808, DF = 43, p<0.01). Conclusions Our research has shown that dexmedetomidine and propofol are effective and safe for sedation in pediatric patients undergoing orthopedic surgery under regional anesthesia. Due to the rapid awakening from anesthesia, dexmedetomidine is the sedative of choice for patients with neuromuscular disorders.

To summarise the story, procedural pain management does not only have humane aspect in paediatric population, but it also prevents numerous complications, child’s negative attitude in following contacts with medical staff, percentage of chronic pain suffering patients, as well as cost of the treatment itself. Good pain assessment contributes to the prevention and/or early recognition of pain as well as the effective management of pain.When managing procedural pain in infants, older children and adolescents, not only proven analgesic strategies are important, but also suitable preparatory measures that contribute to reduction in anticipatory and procedural anxiety. Families, play therapists, nursing staff, and other team members should be included.

Perineural catheters (PCs) provide prolonged effect of the peripheral nerve block, and through a percutaneously placed catheter, whose top is near the nerve or nerve plaxus, local anesthetic is titrated to the desired effect. Catheter placement is performed under the control of ultrasound and / or neurostimulator. After placement, tunneling is carried out to ensure the adequate position of the catheter. PCs can be placed on the upper extremities (an extended block of the brachial plexus using an interscalene, supra/infra-clavicular or axillary nerve approach), lower extremities (prolonged lumbosacral plexus block, femoral, ischiadic or popliteal block) and other perineural blocks (thoracic, ilioinguinal, paravertebral, tap etc.) PCs have an increasing implementation on pediatric patients with aim to provide intraoperative anesthesia, postoperative analgesia and chronic pain therapy. Numerous studies on pediatric patients have shown that perineural catheters improve control of postoperative pain and lead to reduced use of opioids, thereby reducing the risk of side effects. The most common use of PCs is in orthopedic surgeries, where they significantly regulate postoperative pain and allow early use of physical therapy, better post-operative recovery, and reduce time of hospitalization. With adequate training of parents, they can be used at home. Due to the small number of contraindications (allergic reaction to local anesthetics, infection on the site of placement, patient refusal), and improvements in clinical, economic and humanistic approach, PCs have an increasingly important application. PCs improve the control of post-operative pain, reduce the use of analgesics and opioids, reduce post-operative complications nausea and vomiting, reduce time spend in hospital, require less treatment costs and improve the satisfaction of children and their parents.

Patients cotrolled analgesia (PCA) pump is an analgesic system where the patient is being deliverd a continuous minimal basal infusion of analgesics (mostly opioids), and the patient can delivere himself an additional bolus of drug by pushing the button. PCA pump is used for moderate to severe pain which requires multiple doses of IV analgesia. It is said that as soon as a child can play computer games, he can use and understand the PCA system. PCA allows the patient to have better analgesia with less dose of drugs than when it is used around the clock. During the first 24 hours, low doses of continuous infusions (background) improve the quality of sleep in pediatric patients without increasing side effects PCA is most commonly used on children for analgesia after major surgery, trauma with preserved sensorium, burns, sickle cell disease, malignancy or painful consequences of chemo-therapy (pain due to mucositis) and in some cases of chronic pain. Patients are generally started on a morphine infusion. Opioid switching in children is strongly recommended in the presence of inadequate analgesic effect and intolerable side effects. The usual, safe dose of morphine that provides adequate postoperative analgesia is in pediatric patients 10–30 mcg/kg/h. In pediatric population for PCA, fentanyl continuous infusions (1 mcg/kg per hour) plus fentanyl boluses (1 mcg/kg) can be safely used. The advantage of PCA is that it eliminates the high peaks and low troughs by allowing the patient to press the demand bolus button when they begin to feel pain. Most of them are very satisfied that they have participated in their own pain management. PCA allows safe analgesia in pediatric patients and lowers frequency of side effects. Patient indicates that their pain level is at a level acceptable to them and that they are happy with this method of analgesia.

Background & Objectives: Ketamin and ketofol are routinely used for short duration anaesthesia. However, to our knowledge, there are no data which are comparing these two anaesthetics in children undergoing laser procedures. Materials & Methods: This prospective analysis was performed in 103 consecutive children patients with ASA physical status I-II, who were scheduled for pulse dye laser treatment in the Department of Plastic Surgery at the University Children’s Hospital in the January – June 2014. All patients after oral premedication were randomized by computer into two groups - group I intravenously received ketamine and fentanyl, while group II received ketofol and fentanyl. Cardiovascular and respiratory stability, length and duration of the laser intervention, was evaluated during anesthesia. The questionnaire was used to assess the postprocedural adverse effects and parents satisfaction. Exclusion criteria were allergic reactions to ketamin, propofol, egg or soy products, increased intracranial or intraocular pressure and liver diseases. Results: The laser intervention was completed successfully in all patients. The most common side effect was nystagmus. The frequency of nystagmus in the group that received ketamine was 35.5% (p<0.01) while the occurrence of this side effect in the group that received ketofol was 5% and this difference was highly statistically significant (p<0.001). Other statistically significant side (p<0.01) effects were: diplopia and hallucinations. Postprocedural nausea and vomiting was more frequent in the group that received ketamine than in the group that received ketofol (p <0.05). There were no statically significant differences between groups considering satisfaction of parents. Conclusion: Taking into account side effects, we recommend combination of ketofol and fentanyl for procedural sedation and analgesia in pediatric patients undergoing laser procedures. References: 1. Krauss B, Green SM. Procedural sedation and analgesia in children.Lancet.2006; 367:766-80. 2. Andolfatto G, Willman E. A prospective case series of pediatric procedural sedation and analgesia in the emergency department using single-syringe ketamine-propofol combination (ketofol) Acad. Emerg. Med. 2010; 17:194-201. Disclosure of Interest: None declared

To the Editor: Mulvihill–Smith syndrome (MSS) is a very rare disease with important anesthetic implications [1]. It is characterized by a short stature, senile face, small mouth opening, prognatio mandible, and atherosclerosis. This case illustrates the potential difficulties in airway management during major surgery in a child with MSS. We report a case of a 10-year-old female child with MSS and diabetes mellitus type 2 who underwent general anesthesia for hepatic tumor extraction. Mallampaty score was III with Cormarck–Lehane gradus 3. Neck extension was limited, and she had a small mouth opening. After premedication with atropine and midazolam, induction in anesthesia was performed with fentanyl, propofol, and vecuronium. We had some difficulties with mask ventilation, but we intubated the patient with a no. 1 Macintosh blade and orotracheal tube no. 4, 5, after the third attempt. A fiberoptic laryngoscope was available in the operating room. There are not many papers that discuss anesthetic management in patients with progeria. Establishing the airway is one of the problems, including a difficult airway with small mouth opening [2]. The anesthetic management and positioning of these patients may be difficult because of atherosclerosis, bone deformities, and arthritic changes of the joints [3, 4]. The anesthetic management was planned as if this patient were a geriatric case because these patients have physiological changes suggestive of old age despite being chronologically and psychologically young [3]. Although there were no complications in establishing the airway in our case, it is important to evaluate the airway before the induction of anesthesia and to be prepared for difficult airway management.

Neurotrauma is a leading cause of childhood mortality. Physicians are in a continuous search for means to decrease mortality and morbidity caused by head injury. Treatment of these patients requires familiarity with both cerebral pathophysiology and actions of anesthetic agents on brain. Early treatment of hypotension and hypoventilation would cut mortality rate by at least one third. Prevention of increased intracranial pressure is the best treatment for head injury. Anesthetist, neurosurgeon and radiologist should all be members of a team which can secure timely diagnosis and treatment of an injured child. Paying attention to every detail is of huge significance. Treatment of the child in a pediatric trauma center or an accident and emergencies center for adults with both personnel and equipment capable for handling pediatric patients offers greater probability of survival.

Neurotrauma is a leading cause of childhood mortality. Physicians are in a continuous search for means to decrease mortality and morbidity caused by head injury. Treatment of these patients requires familiarity with both cerebral pathophysiology and actions of anaesthetic agents on brain. Early treatment of hypotension and hypoventilation would cut mortality rate by at least one third. Prevention of increased intracranial pressure is the best treatment for head injury. Anaesthetist, neurosurgeon and radiologist should all be members of a team which can secure timely diagnosis and treatment of an injured child. Paying attention to every detail is of huge significance. Treatment of the child in a pediatric trauma center or an accident and emergencies center for adults with both personnel and equipment capable for handling paediatric patients offers greater probability of survival.

Anesthesiaology Department, Clinic for Pediatric Surgery and Orthopedics, Clinical Centre Nis, Serbia, Nis, Serbia

Anesthesiology Department, Clinic for Pediatric Surgery and Orthopedics, Clinical Centre Nis, Nis, Serbia

Massive hemorrhage is a formidable challenge for anesthesia care providers in the elective setting and poses even greater potential challenges in the trauma setting. In all this cases, the anesthesia care providers are faced with large-volume resuscitations that typically start with crystalloid and colloid and rapidly progress to blood and blood products. These large-volume replacement may cause coagulopathy, which can be difficult to manage in the setting of ongoing blood loss. Coagulopathy associated with massive transfusion is multifactorial event that results from hemodilution, hypothermia, the use of fractionated blood products and disseminated intravascular coagulation. Maintaining a normal body temperature is a first-line, effective strategy to improve hemostasis during massive transfusion. Treatment strategies include the maintenance of adequate tissue perfusion, the corection of anemia, and the use of hemostatic blood products.