Total Intravenous Anesthesia and Spontaneous Ventilation for Foreign Body Removal in Children
Bibliographic record
Abstract
To the Editor In a recent study, Chen et al.1 compared the risk factors for hypoxia when using 4 different anesthetic techniques for removal of foreign bodies in children younger than 5 years old. The fact that the authors found that patients breathing spontaneously and receiving total IV anesthesia (TIVA) had more movement, breath holding, and a lower success rate with foreign body removal is not surprising and is, in our opinion, attributable to the too small doses of propofol and remifentanil administered. Subjects received a bolus of propofol (3\N5 mg/kg) and remifentanil (1 μg/kg) followed by infusions of propofol (100\N150 μg/kg/min) and remifentanil (0.1 μg/kg/min). Simulations (TIVATrainer®) of the doses described would have produced near steady-state (15 minutes) effect-site concentration of propofol of 2.9 μg/mL based on the Paedfusor model2 and remifentanil of 0.55 μg/mL based on the Rigby-Jones model.3 These concentrations would be considered low even in adults. Moreover, most children will tolerate larger does of remifentanil (and propofol) while maintaining spontaneous respiration.4 Our institutional practice is to use TIVA with remifentanil and propofol for most of our patients undergoing airway endoscopy. In a prospective study, we found the mean remifentanil dose to be 0.21 (SD 0.31) μg/kg/min and propofol infusion rate to be 368 (SD 103) μg/kg/min.5 The wide interindividual variability dictates that drugs are titrated to clinical effect within a wide dose range. The greater incidence of laryngospasm in the TIVA group might also reflect the too small dose of the drugs. Reflex laryngeal responses occur less frequently and of shorter duration with propofol anesthesia compared with sevoflurane,6 and propofol is often used for treatment of mild laryngospasm. We conclude that the increased complication rate seen in the group using TIVA and spontaneous ventilation may have been due to the low doses used and not a result of the technique selected. Stephan Malherbe, MBBCh, FFA(SA), MMed, FRCP J. Mark Ansermino, MBBCh, MSc(Inf), FFA(SA), FRCPC Department of Pediatric Anesthesia British Columbia Children's Hospital Vancouver, British Columbia, Canada [email protected]
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.002 | 0.013 |
| Meta-epidemiology (narrow) | 0.001 | 0.001 |
| Meta-epidemiology (broad) | 0.001 | 0.001 |
| Bibliometrics | 0.001 | 0.001 |
| Science and technology studies | 0.001 | 0.001 |
| Scholarly communication | 0.002 | 0.002 |
| Open science | 0.002 | 0.001 |
| Research integrity | 0.006 | 0.008 |
| Insufficient payload (model declined to judge) | 0.003 | 0.001 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".