Paediatric anaesthesia: Overview

Abstract
Background: Perioperative anaphylaxis (PA) is a rare life-threatening complication of anesthesia, with few descriptions of its diagnosis and outcomes in the pediatric population. Many agents can be potential culprits, and drug provocation testing (DPT) to confirm the diagnosis is limited by the nature of anesthetic drugs. PA diagnosis and culprit identification remain a challenge. For patients with limited drug options, desensitization has not been reported. This study evaluated the results of skin and laboratory testing for pediatric patients with PA and provides the protocol and outcome of the first desensitization to cisatracurium, a neuromuscular blocking agent (NMBA).

Methods: Patients ≤18 years old with PA from 2019 to 2024 were included, and medical records were retrospectively reviewed, which comprised serum tryptase levels, results of skin testing (ST), basophil activation testing (BAT), and outcomes.

Results: Eleven patients were included. Tryptase was elevated in seven of 10 (70%) tested patients. ST yielded positive results for nine of 10 (90%), and two of 11 (18.2%) had positive BAT.

Results: A culprit agent was identified in 10 of 11 (91%). The most common drugs were NMBAs (70%) and beta-lactam antibiotics (20%). One patient with a positive DPT to NMBAs and limited alternatives was successfully desensitized to cisatracurium with a 3-bag, 12-step protocol.

Conclusion: The most common drug culprits of PA in children were NMBAs and were identified by ST. Tryptase correlated with PA. BAT served as adjunctive diagnostic tests. Desensitization to cisatracurium was possible.

Abstract in English, French
Purpose: Emergence delirium (ED) impacts approximately 25% of pediatric patients undergoing general anesthesia and is associated with with concerning consequences, including injury to patients and health care personnel. Risk prediction models with good usability for pediatric ED are lacking. We aimed to identify published risk factors in this systematic review.

Methods: We conducted a systematic literature search of prospective observational studies and clinical trials through eight major databases from inception to 11 January 2023. We included prospective studies published in English that examined the pediatric population (< 18 yr old) undergoing general anesthesia for any surgical or imaging procedure, that measured the risk factor(s) for ED preoperatively/intraoperatively, and that reported the incidence of ED. We excluded studies investigating therapeutic or prophylactic interventions of ED. We assessed the quality of eligible articles according to a modified version of the Scottish Intercollegiate Guidelines Network quality checklists and rated them as high, acceptable, or low quality. Risk factors discovered were qualitatively evaluated and synthesized with the following levels of evidence: strong evidence, moderate evidence, inconclusive evidence, or lack of evidence.

Results: Thirty-one studies, comprising a total of 6,068 patients, met the inclusion criteria. The median incidence of ED was 32%. Twelve studies were rated as high quality, 15 as acceptable quality, and the remaining four as low quality. Younger age and agitated/excited induction behaviour with strong evidence, followed by sevoflurane with moderate evidence, were identified as risk factors for pediatric ED. Quantitative synthesis was not feasible as there were no more than two studies that explored the same risk factor with the same cut-off.

Conclusion: Although quantitative analyses were not feasible, the current systematic review qualitatively identified three risk factors for pediatric ED with robust evidence.

Abstract
Purpose: Postoperative nausea and/or vomiting (PONV/POV) following tonsillectomy occurs in up to 89% of children without antiemetic prophylaxis. Prior systematic reviews have not evaluated the relative efficacy of ondansetron and metoclopramide for PONV/POV, including their adverse effects.

Methods: A systematic search was conducted of five databases from their inceptions to June 19, 2024. Inclusion criteria were randomized controlled trials (RCTs) comparing ondansetron and metoclopramide in pediatric patients undergoing tonsillectomy or adenotonsillectomy. The primary outcome was incidence of PONV/POV. Secondary outcomes were length of hospital stay (LOS) and adverse events including postoperative extrapyramidal reactions and delayed hospital readmissions. Pooled risk ratios (RRs) or mean differences (MDs) and 95% confidence intervals (CIs) were calculated using random-effects meta-analysis. Adjusted RRs were calculated using random-effects meta-regression. Risk of bias and certainty of evidence were assessed using Cochrane RoB 2 and GRADE, respectively. This study was registered in PROSPERO (42,024,499,702).

Results: Five RCTs met all inclusion criteria, consisting of 861 patients. Ondansetron significantly reduced risk of PONV/POV by almost 50% (RR 0.48 95% CI 0.31-0.75, moderate quality evidence), compared to metoclopramide. Intraoperative opioid dose did not impact the RR. Ondansetron also significantly shortened LOS (MD - 26.92 min 95% CI - 47.24 min to - 6.60 min, moderate quality evidence). Only two RCTs addressed readmission rates or extrapyramidal reactions, although no events occurred in either study.

Conclusion: Ondansetron is more effective than metoclopramide for PONV/POV prophylaxis, decreasing the risk of PONV/POV as well as LOS. Continued surveillance for adverse effects may be recommended when using either medication.