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Established noninvasive pharmacologic means of alleviating pain and anxiety in children undergoing intravenous cannulation are time-consuming, and thus impractical for routine use in the emergency department. Vapocoolant sprays provide transient skin anesthesia within seconds of application. We compared the effect of a new vapocoolant spray to placebo on pain due to intravenous cannulation in children. In this double-blind randomized controlled trial, which we conducted between June 1 and Sept. 12, 2006, 80 children aged 6-12 years received either vapocoolant spray or placebo before cannulation. Children rated their pain using a 100-mm colour visual analogue scale. Secondary outcomes included success rate on first attempt at cannulation and pain ratings by the children's parents, nurses and child life specialists. We found a modest but significant reduction in pain with the use of vapocoolant spray (mean difference 19 mm, 95% confidence interval [CI] 6-32 mm; p < 0.01). Cannulation on first attempt was more often successful with the use of vapocoolant spray (85.0%) than with placebo (62.5%) (mean difference 22.5%, 95% CI 3.2%-39.9%; p = 0.03). The number needed to treat to prevent 1 cannulation failure was 5 (95% CI 3-32). Parents (p = 0.04), nurses (p = 0.01) and child life specialists (p < 0.01) considered the children's pain to be reduced with the use of vapocoolant spray. The vapocoolant spray in our study quickly and effectively reduced pain due to intravenous cannulation in children and improved the success rate of cannulation. It is an important option to reduce childhood procedural pain in emergency situations, especially when time precludes traditional interventions. (http://ClinicalTrials.gov trial register no. NCT00130650.).

Champlain BASE™ (Building Access to Specialists through eConsultation) is a web-based asynchronous electronic communication service that allows primary-care- practitioners (PCPs) to submit \"elective\" clinical questions to a specialist. For adults, PCPs have reported improved access and timeliness to specialist advice, averted face-to-face specialist referrals in up to 40% of cases and high provider satisfaction. To determine whether the expansion of eConsult to a pediatric setting would result in similar measures of improved healthcare system process and high provider acceptance reported in adults. Prospective observational cohort study. Single Canadian tertiary-care academic pediatric hospital (June 2014-16) servicing 1.2 million people. 1. PCPs already using eConsult. 2.Volunteer pediatric specialists provided services in addition to their regular workload. 3.Pediatric patients (< 18 years-old) referred for none-acute care conditions. Specialty service utilization and access, impact on PCP course-of-action and referral-patterns and survey-based provider satisfaction data were collected. 1064 eConsult requests from 367 PCPs were answered by 23 pediatric specialists representing 14 specialty-services. The top three specialties represented were: General Pediatrics 393 cases (36.9%), Orthopedics 162 (15.2%) and Psychiatry 123 (11.6%). Median specialist response time was 0.9 days (range <1 hour-27 days), most consults (63.2%) required <10minutes to complete and 21/21(100%) specialist survey-respondents reported minimal workload burden. For 515/1064(48.4%) referrals, PCPs received advice for a new or additional course of action; 391/1064(36.7%) referrals resulted in an averted face-to-face specialist visit. In 9 specialties with complete data, the median wait-time was significantly less (p<0.001) for an eConsult (1 day, 95%CI:0.9-1.2) compared with a face-to-face referral (132 days; 95%CI:127-136). The majority (>93.3%) of PCPs rated eConsult as very good/excellent value for both patients and themselves. All specialist survey-respondents indicated eConsult should be a continued service. Similar to adults, eConsult improves PCP access and timeliness to elective pediatric specialist advice and influences their care decisions, while reporting high end-user satisfaction. Further study is warranted to assess impact on resource utilization and clinical outcomes.

Purpose The aim of this study was to describe the changes in respiratory system compliance and other measures of respiratory mechanics associated with peritoneal insufflation (12 mmHg pressure) with carbon dioxide (PNP12) and 20° Trendelenburg positioning (TDG20) in pediatric patients undergoing laparoscopic surgery for abdominal cryptorchidism. Methods Twelve subjects with abdominal cryptorchidism undergoing orchiopexy were enrolled in the study. General anesthesia was conducted with sevoflurane/O 2 /air, fentanyl, and rocuronium. Pressure-controlled ventilation with a peak inspiratory pressure (PIP) of 10-15 cm H 2 O and a positive end-expiratory pressure of 5 cm H 2 O was titrated to achieve a tidal volume (VT/kg) of 6-10 mL·kg −1 and end-tidal carbon dioxide (EtCO 2 ) of 35-40 mmHg. Adjustments of PIP and respiratory rate (RR) were made to maintain the initial VT/kg and EtCO 2  < 50 mmHg. Measurements of weight-corrected dynamic compliance (Cdyn/kg), VT/kg, and EtCO 2 were recorded at baseline, after PNP12, at TDG20, and again after deflation and return to the level position. Results Adjustments in PIP were required in all subjects to maintain the target VT/kg. The Cdyn/kg decreased 42% (95% confidence interval [CI]: 30 to 51; P  < 0.001) after PNP12, and it remained below baseline until deflation. The TDG20 caused only minimal additional reductions in Cdyn/kg (10% decrease; 95% CI: 0 to 19; P  = 0.048). The VT/kg decreased 42% (95% CI: 31 to 52; P  = 0.048) with PNP12, and after TDG20, it decreased a further 10% (95% CI: 4 to 19; P  = 0.038). After deflation, the VT/kg increased by 56% (95% CI: 28 to 90; P  = 0.001) and was then adjusted back to the initial values. Conclusion The PNP12 significantly decreases Cdyn/kg and VT/kg in pediatric patients. The use of TDG20 produces a relatively minor additional impact in respiratory mechanics. This study emphasizes the need to adjust ventilator settings to maintain normal gas exchange during this procedure.

Purpose of ReviewGood pain management in children, especially those at end of life, is a crucial component of palliative medicine. The current review assesses some of the new and/or innovative ways to manage pain in children. The article focuses on some recent medications/pharmaceutical options such as cannabinoids and also innovative ways to administer medication to children, such as intranasal and inhalation.Recent FindingsCurrent approaches to pain management now include (1) new uses of old drugs such as ketamine and lidocaine, (2) use of new drugs/medications such as cannabinoids, and (3) creative use of old technology such as atomizers, intranasal drops, and inhalation.SummaryTypically, novel approaches to care rarely start in pediatrics or palliative care. The current review has presented some new and old drugs being utilized in new and old ways.

In some species males increase their reproductive success by forcing females to copulate with them, usually by grasping the female or pinning her to the ground to prevent her from escaping. Here we report an example of males coercing copulation by trapping a female in a confined space. During mate-searching, female Uca mjoebergi fiddler crabs visit males and choose whether or not to enter their burrow for inspection. Males typically enter the burrow first and we found that 71% of females will follow him down and 54% decide to stay and mate. However, some males use an alternative tactic where he will wait for the female to enter the burrow first, after which he traps her inside. Although a significantly lower percentage of females will enter a burrow following this behaviour (41%), upon entry 79% females that enter will become trapped and almost all of these females (90%) produce a clutch of eggs. Our observations suggest that males are able to gain fertilisations from females that may not have remained in the burrow by trapping them and coercing them to mate.

Purpose Somatic paravertebral block (SPVB) appears to provide effective and prolonged nerve block in children; however, study of its use in this population is limited. We compared SPVB with no block in children undergoing appendectomy. Methods Thirty-six children aged 3-16 yr undergoing open appendectomy were involved in this prospective randomized controlled study. Anesthesia was induced with propofol and maintained with isoflurane in N 2 O/oxygen. All subjects received fentanyl, acetaminophen and ketorolac during anesthesia. Group I (SPVB) subjects received a right SPVB at T 11 , T 12 , and L 1 using 0.2% ropivacaine 0.25 mL·kg −1 with epinephrine 1:200,000 preoperatively. Group II (Control) had only bandaids applied to skin. Both groups were given morphine 0.05 mg·kg −1 iv every 2 hr if pain scores reached 5/10 on a visual analogue scale. Acetaminophen was administered postoperatively every 6 hr to both groups. Time to first dose of morphine, total dose of morphine in 24 hr, and any adverse effects up to 24 hr after surgery were recorded. Results Group I (SPVB) subjects required significantly less morphine than Group II (Control) patients (0.12 ± 0.07 vs 0.34 ± 0.15 mg·kg −1 , respectively; P  < 0.001), and time to their first dose was significantly longer (7.1 ± 4.4 vs 2.5 ± 1.6 hr, respectively; P  < 0.001). Incidence of vomiting was 11% with Group I and 27% with Group II ( P  = 0.21). No other adverse effects were observed in either group. Conclusions In children undergoing appendectomy, SPVB provides better pain relief than no block and reduces opioid requirements. Side effects were not statistically different between groups.

Validation of the bispectral index (BIS) in children requires correlating BIS with several levels of sedation, hypnosis and anesthesia. Our purpose was to compare BIS values with objective assessments of the level of hypnosis in children. We postulated that BIS predicted the level of anesthesia during induction and emergence in children. In a prospective observational study, we evaluated the BIS monitor in 87 children (ages: 0.3 to 14 yr) ASA physical status I-II undergoing general surgery under sevoflurane and nitrous oxide. Clinical signs of inhalational anesthesia (CSA), the motor response to surgical incision and signs of arousal were used as indicators of the depth of anesthesia. CSA and BIS measurements were paired every minute during induction and emergence until arousal. CSA scores decreased during induction and increased during emergence (P < 0.001) and correlated with changes in sevoflurane concentrations (r = -0.46; P < 0.001). BIS was associated with changes in CSA scores during induction (r = 0.49; P < 0.01) and emergence (r = 0.62; P < 0.01), but the ranges of individual BIS values overlapped several levels of hypnosis. A BIS value greater than 50 had a positive predictive value of 25% for distinguishing between responders and non-responders to surgical incision. A BIS score equal or greater than 72 had a predictive value of 63% for discriminating between pre-arousal and arousal. BIS correlates with several levels of hypnosis during inhalational induction and emergence in children, but individual BIS values show large inter-individual variability. The BIS monitor identified the physiological changes associated with arousal and distinguished the effects of preoperative sedation during emergence. The use of movement as an endpoint of hypnosis during surgical stimulation does not correlate with BIS values in children. The large inter-individual variability of BIS at different levels of anesthetic depth may limit the applicability of BIS to pediatric anesthesia.

PurposePatients with adolescent idiopathic scoliosis undergoing corrective surgery are at risk for iatrogenic spinal cord injury and subsequent new neurologic deficits (NNDs). Intraoperative neurophysiologic monitoring (IONM) has been used to identify spinal cord injury; however, available data showing that IONM leads to improved clinical outcomes are inconclusive. This exploratory study aimed to examine the incidence of NNDs after idiopathic scoliosis surgery in two pediatric institutions in Canada with a focus on IONM use.MethodsCharts of pediatric patients (10–18 yr) with adolescent idiopathic scoliosis who underwent scoliosis correction surgery were retrospectively identified from the operating room database. Data regarding incidence and severity (mild [isolated sensory deficit] vs severe [any motor deficit]) of NNDs as well as demographic and clinical characteristics were extracted.ResultsOf 547 patients reviewed, 359 (66%) underwent IONM and 186 (34%) underwent wake-up test. Neuromonitoring data were missing in two patients. Total incidence of NNDs was 4.9% (95% confidence interval [CI], 3.1 to 6.8). Compared with the wake-up test, patients undergoing IONM were less likely to develop NNDs (unadjusted odds ratio, 0.39; 95% CI, 0.18 to 0.86; P = 0.02). Nevertheless, subgroup analysis did not reveal a statistical difference in severity of those deficits (mild vs severe) with IONM vs wake-up test. Combined anterior and posterior approach was also significantly associated with increased risk of such deficits.ConclusionThis exploratory study revealed that IONM was associated with a reduced overall incidence of NNDs in idiopathic scoliosis correction; however, its impact on the severity of those deficits is questionable. As we were unable to adjust for confounding variables, further research is needed to determine the impact of IONM on NNDs.