Postoperative nausea and vomiting (PONV) and pain are two of the major concerns for patients presenting for surgery. The causes of PONV are multifactorial and can largely be categorized as patient risk factors, anaesthetic technique, and surgical procedure. Antiemetics work on several different receptor sites to prevent or treat PONV. This is probably why numerous studies have now demonstrated that using more than one antiemetic is usually more effective and results in fewer side-effects than simply increasing the dose of a single antiemetic. A multimodal approach to PONV should not be limited to drug therapy alone but should involve a holistic approach starting before operation and continuing intraoperatively with risk reduction strategies to which are added prophylactic antiemetics according to the assessed patient risk for PONV. With the increasing understanding of the pathophysiology of acute pain, especially the occurrence of peripheral and central hypersensitization, it is unlikely that a single drug or intervention is sufficiently broad in its action to be adequately effective, especially with moderate or greater pain. Although morphine and its congeners are usually the foundation of pain management regimens, as their dose increases so does the incidence of side-effects. Thus, the approach for the management of acute postoperative pain is to use multiple drugs or modalities (e.g. regional anaesthesia) to maximize pain relief and reduce side-effects.

The prevalence of diabetic retinopathy was 17.6% among the self-reported rural population with diabetes. The prevalence of referable (sight threatening) retinopathy was 5.3%. Risk factors associated with the development of any DR were male gender (OR= 1.37), longer duration of diabetes (per year, OR= 1.07), lean body mass index (OR= 1.30), higher systolic blood pressure (per 10 mm Hg, OR= 1.18), and insulin treatment (OR= 1.34; P P CONCLUSION: The study identified risk factors associated with DR in the rural population with diabetes. The results suggested that there was a need for formulating effective preventive strategies to minimize avoidable blindness due to diabetes, in rural areas.

Point-of-care ultrasound (POCUS) has found many relevant applications in pediatric anesthesia and critical care medicine. Specifically, the cardiac and pulmonary POCUS examinations provide a wealth of information from physical examination assistance to diagnostic evaluation and assessment of treatment response. However, as with any adjunct, potentially dangerous pitfalls exist when POCUS is performed, interpreted, and applied by the novice sonographer. Using case illustrations, we highlight the clinical application of POCUS in addition to potential dangers. Additionally, suggestions for learning POCUS, assessing competency and credentialing are reviewed. K E Y W O R D S anesthesiology, cardiac, critical care, perioperative, point-of-care ultrasound, pulmonary, ultrasound | 791 ADLER Et AL. S U PP O RTI N G I N FO R M ATI O N Additional supporting information may be found online in the Supporting Information section at the end of the article. How to cite this article: Adler AC, Brown KA, Conlin FT, Thammasitboon S, Chandrakantan A. Cardiac and lung point-of-care ultrasound in pediatric anesthesia and critical care medicine: Uses, pitfalls, and future directions to optimize pediatric care. Pediatr Anesth. 2019;29:790-798.

Aim: End-tidal CO 2 (Et CO2 ) is the standard in operative care along with pulse oximetry for ventilation assessment. It is known to be less accurate in the infant population than in adults. Many neonatal intensive care units (NICU) have converted to utilizing transcutaneous CO 2 (tcP CO2 ) monitoring. This study aimed to compare perioperative Et CO2 to tcP CO2 in the pediatric perioperative population specifically below 10 kg, which encompasses neonates and some infants. Methods: After IRB approval and parental written informed consent, we enrolled neonates and infants weighing less than 10 kg, who were scheduled for elective surgery with endotracheal tube under general anesthesia. P CO2 was monitored with Et CO2 and with tcP CO2 . Venous blood gas (Pv CO2 ) samples were drawn at the end of the anesthetic. We calculated a mean difference of Et CO2 minus Pv CO2 (Delta Et CO2 ), and tcP CO2 minus Pv CO2 (Delta tcP CO2 ) from end-of-case measurements. The mean differences in the NICU and non-NICU patients were compared by t-tests and Bland–Altman analysis. Results: Median age was 10.9 weeks, and median weight was 4.4 kg. NICU (n=6) and non-NICU (n=14) patients did not differ in Pv CO2 . Relative to the Pv CO2 , the Delta Et CO2 was much greater in the NICU compared to the non-NICU patients (−28.1 versus −9.8, t=3.912, 18 df, P =0.001). Delta tcP CO2 was close to zero in both groups. Although both measures obtained simultaneously in the same patients agreed moderately with each other (r =0.444, 18 df, P =0.05), Bland–Altman plots indicated that the mean difference (bias) in Et CO2 measurements differed significantly from zero ( P <0.05). Conclusions: Et CO2 underestimates Pv CO2 values in neonates and infants under general anesthesia. TcP CO2 closely approximates venous blood gas values, in both the NICU and non-NICU samples. We, therefore, conclude that tcP CO2 is a more accurate measure of operative Pv CO2 in infants, especially in NICU patients.

BACKGROUND: Caudal block, the most common regional anesthetic in children, is predominantly performed using palpation to determine placement. The efficacy of the palpation technique is unknown with respect to block success. While ultrasound has been suggested for use during caudal block, its use is infrequent. METHODS: A single-blinded prospective observational trial was performed evaluating provider success rate of caudal blocks placed by palpation alone. After needle insertion and partial local anesthetic injection, an ultrasound was performed to confirm correct location. RESULTS: A total of 109 caudal blocks were performed during the prospective observational study. Success rate for caudal blocks done by palpation alone was 78.9% as confirmed by ultrasound. In 21.1% of caudal blocks, the provider incorrectly judged the needle to be in the caudal space as confirmed with ultrasound. CONCLUSIONS: Real-time ultrasound visualization of local anesthetic injection provides reliable and immediate confirmation during caudal block in children.