Background: Mechanical ventilation impairs oxygenation and increases intrapulmonary shunt. Positive end-expiratory pressure (PEEP) slows derecruitment, improves lung function but can compromise hemodynamics. Objectives: To asses slow PEEP titration effect on intrapulmonary shunt, oxygenation and hemodynamics in preschool children on mechanical ventilation under general anesthesia. Methods: This was a single tertiary care center an open-label, randomized parallel group controlled clinical trial. Study included 70 children, 3-7 years, ASA I and II, under general anesthesia for non-cardiothoracic surgery. Children were randomly allocated either to receive PEEP titration 5-11 cmH2O 20 minutes before the end of anesthesia (intervention group) or to be ventilated until the end of anesthesia with constant positive end-expiratory pressure of 3 cmH2O (control group). Main outcome measures were changes in oxygenation index (PaO2/FiO2) and alveolar-arterial gradient (P(A-a)O2) between and within groups and changes in systolic blood pressure (SBP), mean arterial pressure (MAP) and heart rate (HR) in interventional group during PEEP trial. Results: Seventy children were recruited and analyzed. P(A-a)O2 and PaO2/FiO2 improved in interventional group comparing to control as consequence of PEEP titration (∆PaO2/FiO2-30.3 vs. 0.52; P < 0.001; ∆P(A-a)O2 6.7 vs.-1.0; P < 0.001) and within interventional group before and after PEEP titration (PaO2/FiO2 522.0 vs. 552.3; P < 0.01; P(A-a)O2 20.1 vs. 13.3; P < 0.001). Hypotension and bradycardia were not documented. Conclusions: Slow PEEP titration up to 11 cmH2O improves oxygenation, reduces intrapulmonary shunt without causing hemodynamic instability in preschool children during general anesthesia.

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Moebiusov sindrom je redak i kompleksan sindrom koji zbog kliničke ekspresije predstavlja veliki izazov za pedijatrijskog anesteziologa. Kao najznačajniji problem za anesteziju, zbog izraženih kraniofacijalnih malformacija, ističe se otežano obezbeđivanje sigurnog disajnog puta. Potreba za anestezijom nameće se još u uzrastu novorođenčeta i kasnije u detinjstvu zbog izvođenja neophodnih dijagnostičkih i hirurških procedura. Prikazujemo slučaj dvomesečnog odojčeta sa Moebiusovim sindromom, potencijalne anesteziološke implikacije kao i bezbednu primenu kaudalnog bloka kao anesteziološke tehnike zbog operacije Ahilovih tetiva i korekcije urođenih deformiteta oba stopala.

Objective − To compare the effectiveness and safety of wound instillation with levobupivacaine with a placebo, in children who underwent inguinal hernia repair, for pain relief. The secondary objective was to examine the frequency of postoperative analgesic mixture (paracetamol/ibuprofen) use. Methods − Single center randomized placebo-controlled trial. Paediatric teaching hospital in Belgrade, Serbia. This study included 100 children who underwent elective surgery for unilateral inguinal hernia. Children were randomized by simple randomization into two groups (N=50 in the experimental group, N=50 in the control group). A solution of 0.5% levobupivacaine, 0.5 mg/kg (0.1 ml/kg) was instilled into the wounds of children in the experimental group before suturing the abdominal fascia. The same amount of 0.9% saline was administered to the children in the control group. The primary outcome was the level of postoperative pain after coming round from general anesthesia (t0) and at 2h, 6h, 12h, 18h and 24h after surgery. The FLACC (Face, Legs, Activity, Cry, Consolability) scale was used to assess the level of pain. The secondary outcome was the frequency of paracetamol/ibuprofen use for pain relief after surgery. Results − Out of the total number of children (100), 70% were boys (70) and 30% were girls (30), and their average age was 3.5±1.9 years. The average duration of surgical intervention in both groups was 31.6±4.2 minutes. Significantly fewer children in the experimental group reported pain (FLACC ≥1) at 2h (P=0.032) and 6h (P=0.001) after surgery, compared to the children in the control group (8 vs. 17 at 2h after surgery; 4 vs. 14 at 6h after surgery). Significantly fewer children in the control group reported sensations of pain that required administration of analgesics 6h after surgery (FLACC >3) compared to the control group (P=0.001) (1 vs. 14). Overall, significantly fewer children in the experimental group received a paracetamol/ibuprofen mixture for pain relief after surgery, compared to the children in the control group (P<0.001) (4 vs. 50). The average daily amount of acetaminophen in the experimental group was 28±127 mg/kg/day and ibuprofen 5.6±1.8 mg/kg/day, while in control group, acytaminophen 42.5±7.7 mg/kg/day and ibprofen 11.5±4 mg/kg/day. The total amount of analgesics was highly statistically significantly lower in the experimental group (P<0.001). Conclusion − Instillation of levobupivacaine before wound suturing in children who had undergone elective inguinal hernia surgery repair was effective in postoperative pain relief. Children who received levobupivacaine also received less of the paracetamol/ibuprofen mixture to relieve their pain over 24 hours after surgery.

Background: Intraoperative application of positive end-end-expiratory pressure (PEEP) is recommended in mechanically ventilated children since it improves lung mechanics. However, inadequate level of applied pressure can increase risk of barotrauma. Objectives: To assess the impact of titrated PEEP on lung mechanics in mechanically ventilated children under general anaesthesia. Methods: This was an open label, single Tertiary Centre randomized controlled clinical trial. The study population included 70 preschool children, ASA I and II, scheduled for orthopaedic, reconstructive, abdominal or urological surgery. Children with upper respiratory tract infection, allergic to chosen anaesthetics, cardiorespiratory comorbidities were excluded. Patients were randomly assigned either to receive intraoperative PEEP titration form 5 - 11 cmH2O 20 minutes before the end of anaesthesia (intervention group) or to be ventilated until the end of anaesthesia conventionally with a positive end-expiratory pressure of 3 cmH2O (control group). Main outcomes: changes in dynamic lung compliance (Cdyn), peak airway pressure (PIP), mean airway pressure (Paw) between groups at the end of surgery; changes in PIP and Paw during PEEP titration and desaturation in interventional group during PEEP titration. Results: Seventy preschool children were recruited and analysed. Intraoperative positive end-expiratory pressure titration improved Cdyn in the intervention group comparing to control (ΔCdy -3.2 vs. 0.63; P < 0.001). PIP and Paw were higher in interventional group (ΔPIP -0.57vs. 0.11; P < 0.001, and ΔPaw -0.63 vs. 0.0; P < 0.001) and desaturation was not observed in interventional group. Conclusions: Stepwise titration of PEEP up to 11 cmH2O improves subsequent lung mechanics without causing of barotrauma.