Pediatric Anesthesiology 2018 Reviews

Friday Session I

Reviewed by Echo Rowe, MD
Clinical Assistant Professor
Stanford Children’s Health/Lucile Packard Hospital

Anesthesia and Concussion

Monica S. Vavilala, MD
Director for Harborview Injury Prevention and Research Center
Professor of Anesthesiology and Pediatrics, University of Washington

Concussion and how it relates to anesthesia is a topic receiving increasing attention.  Questions relating to should anesthesiologists be screening for concussion, how soon after a concussion is elective surgery okay, should the anesthetic plan be altered in someone with a concussion showed a variable audience response.  This may in part be due to the fact that only three PubMed articles with both ‘concussion and anesthesia’ exist, so clearly there is much work to be done in this arena.

There are nearly two million children with just sports related concussion per year, making the overall head impact exposure while the brain is still undergoing development a huge topic for consideration.  In one small study looking at number of children with concussion symptoms scheduled for time sensitive surgery, the prevalence ranged from 2.7-11%.

Concussion is defined as a brain injury induced by biomechanical forces that may or may not include loss of consciousness, and typically results in a rapid onset of short-lived impairment of neurological function with no abnormalities on standard structural neuroimaging studies. This is essentially a mild traumatic brain injury with symptoms including headache, cognitive impairment, and emotional lability.  Other signs may be amnesia, irritability, slowed reaction times, drowsiness or insomnia.  Current treatment is primarily symptomatic and involves mostly rest, both physically and cognitively until symptoms resolve.

There are some tools available to help diagnose concussions including the concussion symptom checklist from the CDC and the sports concussion assessment tool (SCAT3). Recently, the FDA has approved blood biomarkers of astrocyte and neuronal damage, GFAP and UCHL-1 but these are not widely used at this time.

Animal models suggest that some of the behavioral effects are associated with Tau tangling and myelin changes, reduced connectivity, and altered cerebral perfusion and autoregulation, especially in the first five days. These changes may take up to two weeks to recover.  Certainly, there is a lot more research that needs to be done on understanding how anesthetic agents may impact the injured brain and this research ties directly into work exploring anesthetic neurotoxicity.

Based on what is presently known, Dr. Vavilala’s recommendations for secondary injury prevention include screening (and documentation) for concussion in elective surgery using SCAT checklist and delaying anesthesia until at baseline when possible. If patient remains symptomatic at ten days refer to a concussion clinic or neurologist. Other considerations include anesthetic type, medication choices, altering hemodynamic goals, and additional brain monitoring but there is currently no consensus, which begs the questions of whether a SPA consensus statement is needed.

Who Fails Non-Operative Management of Pediatric Blunt Abdominal Trauma and Why

David Notrica, MD
Trauma Medical Director, Phoenix Children’s Hospital
Associate Professor of Surgery, Mayo Clinic College of Medicine
Associate Professor, University of Arizona College of Medicine

The purpose of this topic is to:

• Recognize the characteristics associated with failure of non-operative management of blunt liver and/or spleen injury,
• Understand the timing of failure
• Emphasize the detrimental role of crystalloid in trauma patients.

Nonoperative management has become the standard in pediatric trauma; however, looking at who fails and where they fail gives some interesting clues.  Overall failure is just 5% in pediatric centers, but is between 9-15% nationally.  The highest failure rate occurs in those with pancreatic injury, followed by spleen and then liver and kidney.

The ATOMAC study was a prospective study conducted at 10 Level 1 Pediatric trauma centers and included 1000 patients with spleen or liver injury. The overall nonoperative failure rate was 7% with none of these occurring in isolated spleen injuries, and 3.8% in isolated liver injuries, usually high grade.  The mechanism of injury is also relevant with bicycle crashes significantly increasing failure rate, falls much less likely, and motor vehicle accident, sports and assaults having an average likelihood of nonoperative failure. Age and gender had no impact.

There are a number of other risk factors that increase likelihood of requiring an operation.  These include CT contrast extravasation, hypotension at admission, transfusion requirements (especially if needed early), higher grade injuries to liver and spleen, multiple injuries, peritonitis, initial hemoglobin less than 8.5, and large hemoperitoneum.  One key concept Dr. Notrica emphasized is distinguishing between a patient who bled and one who is still bleeding.  Observing patient response to transfusion in the trauma bay is the clue to distinguish these.

Kidney injuries are a bit different in looking at the predictive factors that lead to nonoperative failure.  An absence of contrast material in the ipsilateral ureter, large separation of upper and lower poles, multiple areas of extravasation or need for transfusion are all positive predictors of needing surgical intervention.

In comparing adults vs children, children tend to fail very early, usually 50% within three hours from hospital arrival and 75% by 12 hours.  However, there is a major discrepancy in failure rate depending on where the child is treated.  Just looking at pediatric spleen injuries, the risk of splenectomy is much higher in non-trauma centers, non-children’s hospitals and adult general surgeons.  This statistic is supported in a JAMA study that found risk of splenectomy 5X higher at adult vs children’s hospitals.

The most common causes for going to the operating room are shock, peritonitis and continued bleeding, with intestinal, pancreatic and diaphragm injury being less common causes.  Keep in mind that continued splenic bleeding is probably more common than true delayed splenic bleeding.  Most intestinal injuries are less emergent and can be treated in first 24-48 hours, and pancreatic injury may need operative management to minimize loss of pancreas for reconstruction.

In closing, Dr. Notrica made a few key points in pediatric blunt abdominal trauma. First using evidence-based guidelines such as those in the ATOMAC study and comparing against benchmarks is beneficial in deciding operative vs nonoperative management.  Using the algorithm of: First give 20 ml/kg, if not responsive up to 40 ml/kg crystalloid or 20ml/kg PRBCs. If not responsive, proceed to the OR.  Avoid large crystalloid volume and instead advocate for early transfusion.

ATLS Update

Graciela Argote-Romero, MD
Department of Anesthesiology and Pain Medicine, Ohio State University
Nationwide Children’s Hospital

This is the 40-year anniversary of ATLS guidelines with new guidelines just recently published.  There are over 9500 pediatric deaths from traumatic injury annually, which equates to one child dying every hour.  Two thirds of those deaths involve unintentional injuries and over half are motor vehicle accidents.

It is important to know that a child has a 25% less chance of dying if they go to a level 1 trauma center.  This is partly because care starts before getting to hospital, as well as preparation by the receiving team. Having a pre-arrival huddle to identify roles, collaboration amongst emergency and intensive care physician, surgeons, anesthesiologists, as well as additional resources such as respiratory therapy, blood bank and social workers can be extremely helpful. It may be useful to use My ATLS app, which includes primary and secondary survey instructions, as well as other helpful tips including medication adjustments for rapid sequence intubation.

There are a few key concepts that Dr. Romero emphasized. First, having a coordinated trauma team approach. Second, securing access in 90 seconds whether that is intravenous or intraosseous.  Third, restrictive use of crystalloids (20 ml/kg), before moving onto PRBCs for damage control resuscitation.  Damage control resuscitation refers to avoiding the death triad of acidosis, hypothermia and coagulopathy by:

• Stopping the bleeding
• Minimizing crystalloids
• Massive transfusion protocols in place for bleeding greater than 40 ml/kg to control coagulopathy
• Correcting acidosis
• Avoiding surgical delays
• Maintaining normothermia

The role of tranexamic acid (TXA) in pediatric trauma management is still being defined but is gaining traction. The CRASH 2 study has shown that TXA is associated with decreased mortality and did not show any adverse reactions. The TXA dose in pediatric trauma is 15mg/kg over 10 min then 2mg/kg/hr infusion over eight hours or until bleeding stops.  Additional pediatric studies support the use of TXA in trauma requiring massive transfusion.