Abstracts

Questa rubrica seleziona gli abstracts più interessanti nel campo dell'anestesia pediatrica e neonatale e viene costantemente aggiornata.

The cerebrovascular response to hypocapnia in children receiving propofol. Karsli C, Luginbuehl I, Bissonnette B. Anesth Analg. 2004 Oct;99(4):1049-52, table of contents.

Hypocapnia is used to treat acute increases in intracranial pressure during neurosurgery. Cerebrovascular reactivity to carbon dioxide (CCO(2)R) is preserved above 35 mm Hg ETco(2) in children during propofol anesthesia; however, a plateau effect has been suggested below 35 mm Hg. To further delineate this phenomenon, we measured CCO(2)R by transcranial Doppler (TCD) sonography over small increments in ETco(2) in 27 healthy children. Anesthesia comprised a standardized propofol infusion and a caudal epidural block. A TCD probe was placed to measure middle cerebral artery blood flow velocity (V(mca)). ETco(2) was adjusted between 24 and 40 mm Hg at 1- 2 mm Hg increments using an exogenous source of CO(2). There was an exponential relationship between ETco(2) and V(mca) above an ETco(2) value of 30 mm Hg (r = 0.82). However, V(mca) did not change with ETco(2) less than 30 mm Hg (r = 0.06). There were no significant changes in heart rate or arterial blood pressure. We conclude that when contemplating methods to decrease brain volume and intracranial pressure, hyperventilation to ETco(2) values less than 30 mm Hg may not be necessary in children receiving propofol, as no further reduction in cerebral blood flow velocity will be achieved.

Comparison of the LMA-ProSeal and LMA-Classic in children. Shimbori H, Ono K, Miwa T, Morimura N, Noguchi M, Hiroki K. Br J Anaesth. 2004 Oct;93(4):528-31. Epub 2004 Aug 06.

BACKGROUND: The LMA-ProSeal is a new laryngeal mask airway with a rear cuff and drainage tube that allows a higher seal pressure than the LMA-Classic for the same intra-cuff pressure, and it permits drainage of gastric secretions and access to the alimentary tract. The LMA-ProSeal can be used in children but it does not have a rear cuff. This study compared the LMA-ProSeal and the LMA-Classic in children for ease of insertion, airway sealing pressure and fibre-optic visualization. METHODS: Sixty ASA I-II children undergoing herniorrhaphy, orchiopexy or myringotomy were included. The patients were randomly assigned to size 2 LMA-Classic trade mark or size 2 LMA-ProSeal groups for airway management. We assessed success rates at first attempt of insertion, airway sealing pressure, fibre-optic position, success rates of gastric tube placement and postoperative blood staining of the device, tongue-lip-dental trauma and hoarseness. RESULTS: There was no statistical difference between the two groups for the success rates at first attempt of insertion, airway sealing pressure and fibre-optic position. Gastric tube insertion was successful in 90% of cases in the LMA-ProSeal group. The LMA-Classic had a higher rate of postoperative blood staining, but there was no tongue-lip-dental trauma or hoarseness in either group. CONCLUSION: We conclude that ease of insertion and airway sealing pressure are similar between the LMA-ProSeal and the LMA-Classic in children.

Similar excitation after sevoflurane anaesthesia in young children given rectal morphine or midazolam as premedication. Malmgren W, Akeson J. Acta Anaesthesiol Scand. 2004 Nov;48(10):1277-82.

Background: Sevoflurane is a rapid-acting volatile anaesthetic agent frequently used in paediatric anaesthesia despite transient postoperative symptoms of cerebral excitation, particularly in preschool children. This randomised and investigator-blinded study was designed to evaluate whether premedication with an opioid might reduce non-divertible postoperative excitation more than premedication with a benzodiazepine in preschool children anaesthetized with sevoflurane. Methods: Ninety-two healthy two to six year-old children scheduled for nasal adenoidectomy were randomised to be given rectal atropine 0.02 mg kg(-1) together with either morphine 0.15 mg kg(-1) or midazolam 0.30 mg kg(-1) approximately 30 min before induction and maintenance of sevoflurane anaesthesia. The patient groups were compared pre- and postoperatively by repeated clinical assessments of cerebral excitation according to a modified Objective Pain Discomfort Scale, OPDS. Results: There were no statistically significant postoperative differences in incidence, extent or duration of excitation between children given morphine or midazolam for premedication, whereas morphine was associated with more preoperative excitation than was midazolam. The study groups did not differ significantly with respect to age, weight, duration of surgery and anaesthesia, and time from tracheal extubation to arrival in and discharge from the postoperative ward. Conclusion: In this study morphine for premedication in young children anaesthetized with sevoflurane was associated with similar postoperative and higher preoperative OPDS scores compared with midazolam. These findings indicate that substitution of morphine for midazolam is no useful way of reducing clinical excitation after sevoflurane anaesthesia.

Caudal neostigmine with bupivacaine produces a dose-independent analgesic effect in children. Mahajan R, Grover VK, Chari P. Can J Anaesth. 2004 Aug-Sep;51(7):702-6

PURPOSE: To evaluate the analgesic efficacy and duration of varying doses of caudal neostigmine with plain bupivacaine and its side effects in children undergoing genito-urinary surgery. METHODS: In a randomized double-blind prospective study 80 boys aged two to eight years scheduled for surgical repair of hypospadias were allocated randomly to one of four groups (n = 20 each) and received either only caudal 0.25% plain bupivacaine 0.5 mL.kg(-1) (Group I) or 0.25% plain bupivacaine 0.5 mL.kg(-1) with neostigmine (Groups II-IV) in doses of 2, 3 and 4 microg.kg(-1) respectively. Postoperative pain was assessed for 24 hr using an objective pain score. Blood pressure, heart rate, oxygen saturation, total amount of analgesic consumed and adverse effects were also recorded. RESULTS: The duration of postoperative analgesia in Group I (5.1 +/- 2.3 hr) was significantly shorter than in the other three groups (II -16.6 +/- 4.9 hr; III - 17.2 +/- 5.5 hr; IV - 17.0 +/- 5.8 hr; P < 0.05). Total analgesic (paracetamol) consumption was significantly more in Group I (697.6 +/- 240.7 mg) than in the groups receiving caudal neostigmine (II - 248.0 +/- 178.4; III - 270.2 +/- 180.8 and IV -230.6 +/- 166.9 mg; P < 0.05). Groups II, III and IV were comparable with regards to duration of postoperative analgesia and total analgesic consumption (P > 0.05). Incidence of nausea and vomiting were comparable in all four groups. No significant alteration in vital signs or any other adverse effects were observed. CONCLUSIONS: Caudal neostigmine (2, 3 and 4 microg.kg(-1)) with bupivacaine produces a dose-independent analgesic effect ( approximately 16-17 hr) in children as compared to those receiving caudal bupivacaine alone (approximately five hours) and a reduction in postoperative rescue analgesic consumption without increasing the incidence of adverse effects.

The effects of chin lift and jaw thrust while in the lateral position on stridor score in anesthetized children with adenotonsillar hypertrophy. Arai YC, Fukunaga K, Hirota S, Fujimoto S. Anesth Analg. 2004 Dec;99(6):1638-41.

Obstruction of the upper airway is a major challenge for anesthesiologists administering general anesthesia in spontaneously breathing patients, especially in pediatric anesthesia with adenotonsillar hypertrophy. Lateral positioning is a simple treatment for obstructive sleep apnea and also decreases collapsibility of the pharynx in anesthetized adults with obstructive sleep apnea. In this study, we examined the effects of body position shifting and common airway maneuvers, such as chin lift and jaw thrust, on airway patency (stridor score) in anesthetized children scheduled for adenotonsillectomy. Thirty children aged 1-10 yr were anesthetized with sevoflurane. During spontaneous breathing of 5% sevoflurane, stridor score was recorded. After baseline recording, chin lift and jaw thrust were performed on patients in both the supine and the lateral decubitus positions. Chin lift and jaw thrust improved the stridor score. Furthermore, lateral positioning dramatically enhanced the effects of these airway maneuvers on airway patency. Jaw thrust combined with lateral positioning provided easy airway management for the anesthesiologists. We conclude that lateral positioning combined with airway maneuvers significantly improved airway patency compared with the airway maneuvers alone for patients in the supine position.

Difficult intubation in pediatric cardiac anesthesia. Akpek EA, Mutlu H, Kayhan Z. J Cardiothorac Vasc Anesth. 2004 Oct;18(5):610-2.

Objective: The aim of this study was to investigate cases of difficult intubation in pediatric cardiac surgical patients and to evaluate the importance of associated congenital abnormalities. Design: Retrospective analysis Setting: Departments of Anesthesiology and Pediatric Cardiovascular Surgery of a tertiary university hospital Participants: All children undergoing congenital heart surgery Interventions: Patients who had difficult intubations according to their anesthetic charts were further evaluated from hospital files for demographic characteristics, associated congenital abnormalities, and perioperative airway and/or respiratory complications. Measurements and main results: A total of 1,278 pediatric patients with congenital heart disease were operated on from January 1999 to July 2002. Difficult intubation was encountered in 16 cases (1.25%). Two of these were newborns, 11 were infants, and 3 were in the pediatric age group. Anterior larynx was the most common reason for difficult intubation (7 cases, 43.7%). There were associated syndromes and/or other congenital abnormalities in 8 children (50%). Conclusion: The likelihood of difficult intubation during pediatric cardiac surgery, especially in cases with other congenital pathologies should be kept in mind, and the anesthetic approach must be planned accordingly.

Do-not-resuscitate orders for pediatric patients who require anesthesia and surgery.Fallat ME, Deshpande JK. Pediatrics. 2004 Dec;114(6):1686-92.

This clinical report addresses the topic of preexisting do-not-resuscitate (DNR) orders for children undergoing anesthesia and surgery. Pertinent issues addressed include the rights of children, surrogate decision-making, the process of informed consent, and the roles of surgeons and anesthesiologists. The reevaluation process of DNR orders called "required reconsideration" can be incorporated into the process of informed consent for surgery and anesthesia. Care should be taken to distinguish between goal-directed and procedure-directed approaches to DNR orders. By giving parents or other surrogates and clinicians the option of deciding from among full resuscitation, limitations based on procedures, or limitations based on goals, the child's needs are individualized and better served.

Effect of head posture on tracheal tube position in children. Olufolabi AJ, Charlton GA, Spargo PM. Anaesthesia. 2004 Nov;59(11):1069-72.

Changes in the tracheal tube tip to carina distance were measured by radiographic screening following various head postures in 45 children undergoing cardiac catheterisation under general anaesthesia who were intubated via nasal and oral routes. Extension of the head moved the tracheal tube away from the carina and flexion moved it towards the carina in both routes. Endobronchial intubation was noted during neck flexion in a significant proportion of children intubated orally but none occurred during nasal intubation. Extension produced greater upward movement of the tracheal tube tip in the oral route than the nasal route. In contrast, flexion produced greater downward movement in the nasal route in some patients. The direction of movement with lateral rotation and use of a shoulder roll was inconsistent.

Suspected central anticholinergic syndrome in a 6-week-old infant. Kulka PJ, Toker H, Heim J, Joist A, Jakschik J. Anesth Analg. 2004 Nov;99(5):1376-8; table of contents.

A 6-wk-old male infant became unresponsive after an uneventful general anesthetic for hernia repair. His symptoms were consistent with central anticholinergic syndrome. He appeared to awaken after treatment with IV physostigmine in a dose of 0.04 mg/kg. Because of the recurrence of sedation, a second physostigmine infusion was administered, which again led to transient arousal. Finally, the patient awoke spontaneously after 24 h and recovered uneventfully.

Review of pediatric sedation. Cravero JP, Blike GT. Anesth Analg. 2004 Nov;99(5):1355-64.

Sedating children for diagnostic and therapeutic procedures remains an area of rapid change and considerable controversy. Exploration of this topic is made difficult by the fact that the reports of techniques and outcomes for pediatric sedation appear in a wide range of subspecialty publications and rarely undergo comprehensive examination. In this review article, we will touch on many aspects of the topic of pediatric sedation from the perspective of the anesthesiologist. We begin with a review of the historical role of anesthesiologists in the development of the current standards for pediatric sedation. We also examine the current status of pediatric sedation as reflected in published studies and reports. A specific review of the issues surrounding safety of sedation services is included. Current trends in sedation practice, including the expanding role of potent sedative hypnotic drugs outside the field of anesthesiology, are noted. Finally, we suggest future areas for research and clinical improvement for sedation providers.

Vascular access in emergency paediatric anaesthesia. Jordi Ritz EM, Erb TO, Frei FJ. Anaesthesist. 2004 Dec 18

There is very little literature to guide the young practitioner in caring for a child that needs emergency surgery and has difficult venous access.Questionnaires were sent to 89 members of the Swiss Paediatric Anaesthesia Society and to the heads of Anaesthesia Departments of Swiss teaching hospitals. Two typical case records were presented, both of which were characterised by the fact that 2-3 peripheral venous cannulation attempts were unsuccessful. Case A: a young child with a fracture of the radius and case B an infant with upper gastrointestinal ileus. The anaesthetists were then questioned regarding their preferences for optimal treatment. The majority would proceed with further attempts and, if these still failed, intramuscular or inhalational induction of anaesthesia was suggested as a reasonable choice for case A. However, for case B, a femoral venous or intraosseous access to the venous system was judged to be the safest method. On the basis of our inquiry and a literature search, a priority list was developed to suggest the best possible techniques for vascular access and alternative anaesthesia induction techniques for emergency paediatric procedures.

Peripheral venous pressure is an alternative to central venous pressure in paediatric surgery patients. Anter AM, Bondok RS. Acta Anaesthesiol Scand. 2004 Oct;48(9):1101-4.

BACKGROUND: Peripheral venous pressure (PVP) is easily and safely measured. In adults, PVP correlates closely with central venous pressure (CVP) during major non-cardiac surgery. The objective of this study was to evaluate the agreement between CVP and PVP in children during major surgery and during recovery. METHODS: Fifty patients aged 3-9 years, scheduled for major elective surgery, each underwent simultaneous measurements of CVP and PVP at random points during controlled ventilation intraoperatively (six readings) and during spontaneous ventilation in the post-anaesthesia care unit (three readings). In a subset of four patients, measurements were taken during periods of hypotension and subsequent fluid resuscitation (15 readings from each patient). RESULTS: Peripheral venous pressure was closely correlated to CVP intraoperatively, during controlled ventilation (r=0.93), with a bias of 1.92 (0.47) mmHg (95% confidence interval = 2.16-1.68). In the post-anaesthesia care unit, during spontaneous ventilation, PVP correlated strongly with CVP (r = 0.89), with a bias of 2.45 (0.57) mmHg (95% confidence interval = 2.73-2.17). During periods of intraoperative hypotension and fluid resuscitation, within-patient changes in PVP mirrored changes in CVP (r = 0.92). CONCLUSION: In children undergoing major surgery, PVP showed good agreement with CVP in the perioperative period. As changes in PVP parallel, in direction, changes in CVP, PVP monitoring may offer an alternative to direct CVP measurement for perioperative estimation of volume status and guiding fluid therapy.

The Cardiff paediatric laryngoscope blade: a comparison with the Miller size 1 and Macintosh size 2 laryngoscope blades. Jones RM, Jones PL, Gildersleve CD, Hall JE, Harding LJ, Chawathe MS.Anaesthesia. 2004 Oct;59(10):1016-9.

The Cardiff paediatric laryngoscope blade is a single blade that has been designed for use in children from birth to adolescence. This open, randomised, crossover study compared the Cardiff blade with the straight, size 1, Miller laryngoscope blade in 39 infants under 1 years of age and the curved, size 2, Macintosh blade in 39 children aged 1-16 years. The same laryngoscopic view was obtained with the Cardiff and Miller blades in 26 patients; the view was better with the Cardiff blade in seven patients and better with the Miller blade in six (median (IQR [range]) grade of laryngoscopy 1 (1-2 [1-3]) vs. 1 (1-2 [1-3]), respectively; p = 0.405). The Cardiff blade was faster at gaining a view than the Miller blade (mean (SD) time 8.5 (2.9) s vs. 10.2 (3.5) s, respectively; 95% CI for difference -2.8 to -0.4; p = 0.009). The Cardiff and Macintosh blades produced the same view in 32 patients; the view was better with the Cardiff blade in seven patients (median (IQR [range]) grade of laryngoscopy 1 (1-1 [1-3]) vs. 1 (1-2 [1-3]), respectively; p = 0.008). There was no difference in time to gain these views: mean (SD) 8.7 (3.0) s vs. 9.3 (2.7) s, respectively (95% CI for difference -1.58 to 0.40; p = 0.237). The Cardiff paediatric laryngoscope blade compares favourably with these two established laryngoscope blades in children.

Isobaric ropivacaine 5 mg/ml for spinal anesthesia in children. Kokki H, Ylonen P, Laisalmi M, Heikkinen M, Reinikainen M. Anesth Analg. 2005 Jan;100(1):66-70.

In this clinical trial, we evaluated the clinical effects of ropivacaine for spinal anesthesia in children. An open, prospective study was performed on 93 children, aged 1-17 yr, undergoing elective lower abdominal or lower limb surgery. A plain solution of ropivacaine 5 mg/mL at a dose of 0.5 mg/kg body weight (up to 20 mg) was administered via the L3-4 or L4-5 interspace with the patient in the lateral decubitus position. After injection, the patients were placed supine. The spread and duration of sensory analgesia and the degree of motor block were recorded. Satisfactory surgical anesthesia was achieved in 92 of the 93 children. Three children received general anesthesia; in one child spinal anesthesia failed, and in two cases surgery outlasted the duration of the sensory block. Four children received supplemental analgesia for skin incision. The mean highest level of sensory block was T6 (range, T2 to T12), and the mean time to the regression of sensory block to T10 was 96 min (range, 34-210 min). One child developed transient bradycardia and one hypotension. After discharge four children developed mild transient radiating neurologic symptoms and one epidural blood patch was performed for persistent position-dependent headache. We conclude that the block performance of intrathecal isobaric ropivacaine in children (>1 yr) is similar to that obtained in adults but the safety of the larger dose used in children warrants further studies.

Anesthesia for the child with an upper respiratory tract infection: still a dilemma?Tait AR, Malviya S. Anesth Analg. 2005 Jan;100(1):59-65.

One of the most controversial issues in pediatric anesthesia has revolved around the decision to proceed with anesthesia and surgery for the child who presents with an upper respiratory tract infection (URI). In the past, doctrine dictated that children with URIs have their surgery postponed until the child was symptom free. This practice was based on the empirically supported premise that anesthesia increased the risk of serious complications and complicated the child's postoperative course. Although recent clinical data confirm that some children with URIs are at increased risk of perioperative complications, these complications can, for the most part, be anticipated, recognized, and treated. Although the child with a URI still presents a challenge, anesthesiologists are now in a better position to make informed decisions regarding the assessment and management of these children, such that blanket cancellation has now become a thing of the past.

The development and validation of a risk score to predict the probability of postoperative vomiting in pediatric patients. Eberhart LH, Geldner G, Kranke P, Morin AM, Schauffelen A, Treiber H, Wulf H. Anesth Analg. 2004 Dec;99(6):1630-7

Risk scores to predict the occurrence of postoperative vomiting (PV) or nausea and vomiting that were developed for adult patients do not fit for children, because several risk factors are difficult to assess or are usually not applicable in pediatric patients (e.g., smoking status). Thus, in the present study, we sought to develop and to validate a simple score to predict PV in children (POVOC-score). Development and validation of the new score was based on data from 4 independent institutions of 1257 children (aged 0-14 yr) undergoing various types of surgery under general anesthesia without antiemetic prophylaxis. Preoperatively, several potential risk factors were recorded. Postoperatively, the occurrence of PV was observed for up to 24 h. The dataset was randomly split into an evaluation set (n = 657) that was analyzed using a forward logistic regression technique and a validation set (n = 600) that was used to confirm the accuracy of prediction by means of the area under a receiver operating characteristic curve. Four independent risk factors for PV were identified in the final analysis: duration of surgery >/=30 min, age >/=3 yr, strabismus surgery, and a positive history of PV in the children or PV/postoperative nausea and vomiting in relatives (mother, father, or siblings). The incidence of PV was 9%, 10%, 30%, 55%, and 70% for 0, 1, 2, 3, and 4 risk factors observed. Using these incidences as cut-off values in the validation dataset, the area under the receiver operating characteristic curve was 0.72 (95% confidence interval: 0.68-0.77). Our data suggest that PV can be predicted with an acceptable accuracy using a four-item simplified risk score.

Spinal anesthesia in an extremely low birth weight infant. Nickel US, Meyer RR, Brambrink AM.Paediatr Anaesth. 2005 Jan;15(1):58-62.

 Summary. A case of spinal anesthesia in an extremely low birth weight male infant (body weight of 930 g at time of surgery) is presented. He was born prematurely at a gestational age of 27 weeks because of a placenta tumor and had to undergo inguinal herniotomy at 34 weeks postconceptional age. He had bronchopulmonary dysplasia and oxygen supply was still required because of frequent deterioration of oxygen saturation. Spinal anesthesia was performed successfully without any complications. Relevant aspects concerning the technique and management of spinal anesthesia in preterm infants are discussed.

Total spinal anesthesia during combined general-epidural anesthesia in a 7-year-old child. Kipnis E, Desoutter E, Dalmas S, Marciniak B. Paediatr Anaesth. 2005 Jan;15(1):54-7.

 Summary Total spinal anesthesia (TSA) is a rare complication of lumbar epidural anesthesia through inadvertent spinal injection of local anesthetics following an undiagnosed dural breach or spinal placement of the catheter. TSA has rarely been reported in children. TSA occurred during epidural anesthesia in a 7-year-old child undergoing abdominal surgery. Recent previous lumbar punctures and intrathecal chemotherapy for Burkitt's lymphoma at the same level may have facilitated dural breach. Epidural anesthesia should not be attempted at the same intervertebral level as prior recent lumbar punctures.

Spinal anesthesia for diagnostic cardiac catheterization in high-risk infants. Katznelson R, Mishaly D, Hegesh T, Perel A, Keidan I. Paediatr Anaesth. 2005 Jan;15(1):50-3.

Summary Background : The main goals of diagnostic cardiac catheterization (DCC) in infants are to evaluate the anatomy and physiology of congenital and acquired cardiac defects while maintaining normal respiratory and hemodynamic variables. The aims of anesthesia for infants undergoing DCC are to prevent pain and movement during the procedure. General anesthesia (GA) or deep sedation could have undesirable respiratory and hemodynamic effects for conducting such studies. Furthermore, GA is associated with increased risks, especially in high-risk infants. Spinal anesthesia (SA) is a successful alternative to GA in surgery on infants with a history of prematurity and respiratory problems, with minimal respiratory and hemodynamic changes. Methods : We studied whether those advantages were applicable to DCC, and used a predetermined SA protocol in a cohort of 12 infants with compromised respiratory status. Success rate, study completion, complications, hemodynamic and respiratory effects and recovery profile were recorded. Results : Failure rate was significantly higher in infants older than 6 months. There was no significant difference between baseline and intraprocedure hemodynamic and respiratory parameters. The time to discharge was relatively short (33 +/- 12 min). Conclusions : Spinal anesthesia apparently provides stable hemodynamics and respiratory variables, rapid recovery and discharge time, and may be a viable alternative to GA or deep sedation in high-risk infants <6 months old undergoing DCC.

Propofol total intravenous anesthesia for MRI in children. Usher AG, Kearney RA, TsuiBC.Paediatr Anaesth. 2005 Jan;15(1):23-8.

Summary Background: The aim of this study was to assess clinical signs of airway patency, airway intervention requirements and adverse events in 100 children receiving propofol total intravenous anesthesia for magnetic resonance imaging, with spontaneous ventilation and oxygenation via nasal prongs. Methods: Airway patency was clinically assessed and stepwise interventions were performed until a satisfactory airway was achieved. Propofol requirements, vital signs, procedure times and adverse events were also recorded. Results: Ninety-three per cent of children had no signs of airway obstruction when positioned with a shoulder roll only, two required a chin lift, four required an oral airway and one required lateral positioning. The mean propofol induction dose was 3.9 mg.kg(-1) (range 1.8-6.4 mg.kg(-1)). The mean propofol infusion rate was 193 mug.kg(-1).min(-1) (range 150-250 mug.kg(-1).min(-1)). The initial and final mean respiratory rates were 26 and 23 b.min(-1) (P < 0.05). Movement was more likely at lower infusion rates (mean 175 mug.kg(-1).min(-1)). There were no respiratory or cardiovascular complications (calculated risk: 95% CI = 0-3%). The mean time from end of scan to discharge home was 44 min. Conclusions: This study demonstrates good preservation of upper airway patency and rapid recovery using general anesthetic doses of propofol in children.

Experience with the Arndt paediatric bronchial blocker. Wald SH, Mahajan A, KaplanMB, Atkinson JB.Br J Anaesth. 2005 Jan;94(1):92-4. Epub 2004 Oct 14.

Previously reported techniques for single lung ventilation in children have failed to provide consistent, single lung ventilation with relative ease and reliability. We report our experience with the use of a new device, the Arndt 5 French (Fr) paediatric endobronchial blocker, for single lung ventilation in a series of 24 children. We were able to achieve single lung ventilation in 23 of the 24 patients (aged 2-16 yr). Placement required approximately 5-15 min. Attempts at placement were aborted in one patient who was unable to tolerate even short periods of apnoea because of lung pathology. Although it has some limitations, our experience suggests that the paediatric bronchial blocker can be used as a consistent, safe method of single lung ventilation in most young children.

Appropriate placement of intubation depth marks in a new cuffed paediatric tracheal tube. Weiss M, Gerber AC, Dullenkopf A. Br J Anaesth. 2005 Jan;94(1):80-7. Epub 2004 Oct 14.

BACKGROUND: The aim of this study was to evaluate the appropriateness of intubation depth marks on the new Microcuff paediatric tracheal tube. METHODS: With local Institutional Ethics Committee approval and informed parental consent, we included patients from birth (weighing > or =3 kg) to 16 yr who were undergoing general anaesthesia requiring orotracheal intubation. Tracheal intubation was performed using direct laryngoscopy, the intubation depth mark was placed between the vocal cords, and the tube was taped to the lateral corner of the mouth. The distance between the tube tip and the tracheal carina was assessed by flexible bronchoscopy with the patients in supine, and their head in neutral positions. Tube sizes were selected according to the formula: internal diameter (ID; mm)=(age/4)+3.5 in children > or =2 yr. In full-term newborns (> or =3 kg) to less than 1 yr ID 3.0 mm tubes were used and in children from 1 to less than 2 yr ID 3.5 mm tubes were used. Endoscopic examination was performed in 50 size ID 3.0 mm tubes, and in 25 tubes of each tube size from ID 3.5 to 7.0 mm. Tracheal length and percentage of the trachea to which the tube tip was advanced were calculated. RESULTS: 250 patients were studied (105 girls, 145 boys). The distance from the tube tip to the carina ranged from 1.4 cm in a 2-month-old infant (ID 3.0 mm) to 7.7 cm in a 14-yr-old boy (ID 7.0 mm). Mean tube insertion into the trachea was 53.2% (6.3) of tracheal length with a minimum of 40% and a maximum of 67.6%. CONCLUSIONS: The insertion depth marks of the new Microcuff paediatric tracheal tube allow adequate placing of the tracheal tube with a cuff-free subglottic zone and without the risk for endobronchial intubation in children from birth to adolescence.

Anaesthesia for correction of scoliosis in children. Gibson PR.Anaesth Intensive Care. 2004 Aug;32(4):548-59.

Surgical correction of spinal deformities in children presents a challenge to the anaesthetist because of the extensive nature of the surgery, the co-morbidities of the patients and the constraints on anaesthetic techniques of intraoperative neurophysiological monitoring of the spinal cord. Adolescent idiopathic scoliosis is the most common deformity. Patients with scoliosis secondary to neuromuscular conditions are at greatest risk of perioperative problems, particularly excessive blood loss and respiratory failure. The risk of spinal cord damage can be decreased by the use of intraoperative spinal cord monitoring, particularly monitoring of the lower limb compound muscle action potential evoked by transcranial electrical stimulation. Specific anaesthetic techniques are required for this monitoring to be reliable. Because of concerns about spinal cord perfusion there is now less reliance on induced hypotension and haemodilution to reduce blood loss, with emphasis on proper patient positioning, controlled haemodynamics and antifibrinolytic therapy. Effective postoperative pain management requires a multimodal approach.

Entropy and bispectral index during anaesthesia in children. Davidson AJ, Kim MJ, Sangolt GK.
Anaesth Intensive Care. 2004 Aug;32(4):485-93.

Entropy is a new EEG based technology developed as a measure of depth of anaesthesia. The Entropy algorithm quantifies the degree of disorder in the EEG. During anaesthesia the disorder of the EEG, or entropy, falls. Entropy is independent of absolute frequency or amplitude of the EEG. This may make it suitable for paediatric anaesthesia. In this prospective observational blinded study we recorded the Entropy and Bispectral Index in 23 children undergoing general anaesthesia with isoflurane and nitrous oxide, supplemented with peripheral nerve blockade. We recorded Entropy at several times during anaesthesia, pre-awakening and 1-minute post-awakening. Entropy pre-awakening and 1 minute after awakening was compared to a value during anaesthesia in three age groups; less than one-year-old (infants), one to five years (toddlers) and five to twelve years (children). The correlation between BIS and Entropy was also calculated. Entropy post-awakening was higher than during anaesthesia for all age groups. Entropy pre-awakening was higher than during anaesthesia for the children and toddlers. This was not as apparent in infants. There was a strong correlation between BIS and Entropy for children and toddlers. The correlation was less for infants. This study demonstrates that, in children, Entropy is lower during anaesthesia when compared to awake values. Further evaluation in the paediatric population is worthwhile.

Pressure Support Ventilation Versus Continuous Positive Airway Pressure Ventilation with the ProSealTM Laryngeal Mask Airway: A Randomized Crossover Study of Anesthetized Pediatric Patients. von Goedecke A, Brimacombe J, Hormann C, Jeske HC, Kleinsasser A, Keller C.
Anesth Analg. 2005 Feb;100(2):357-60.

Continuous positive airway pressure (CPAP) and pressure support ventilation (PSV) improve gas exchange in adults, but there are little published data regarding children. We compared the efficacy of PSV with CPAP in anesthetized children managed with the ProSealtrade mark laryngeal mask airway. Patients were randomized into two equal-sized crossover groups and data were collected before surgery. In Group 1, patients underwent CPAP, PSV, and CPAP in sequence. In Group 2, patients underwent PSV, CPAP, and PSV in sequence. PSV comprised positive end-expiratory pressure set at 3 cm H(2)O and inspiratory pressure support set at 10 cm H(2)O above positive end-expiratory pressure. CPAP was set at 3 cm H(2)O. Each ventilatory mode was maintained for 5 min. The following data were recorded at each ventilatory mode: ETco(2), Spo(2), expired tidal volume, peak airway pressure, work of breathing patient (WOB), delta esophageal pressure, pressure time product, respiratory drive, inspiratory time fraction, respiratory rate, noninvasive mean arterial blood pressure, and heart rate. In Group 1, measurements for CPAP were similar before and after PSV. In Group 2, measurements for PSV were similar before and after CPAP. When compared with CPAP, PSV had lower ETco(2) (46 +/- 6 versus 52 +/- 7 mm Hg; P < 0.001), slower respiratory rate (24 +/- 6 versus 30 +/- 6 min(-1); P < 0.001), lower WOB (0.54 +/- 0.54 versus 0.95 +/- 0.72 JL(-1); P < 0.05), lower pressure time product (94 +/- 88 versus 150 +/- 90 cm H(2)O s(-1)min(-1); P < 0.001), lower delta esophageal pressure (10.6 +/- 7.4 versus 14.1 +/- 8.9 cm H(2)O; P < 0.05), lower inspiratory time fraction (29% +/- 3% versus 34% +/- 5%; P < 0.001), and higher expired tidal volume (179 +/- 50 versus 129 +/- 44 mL; P < 0.001). There were no differences in Spo(2), respiratory drive, mean arterial blood pressure, and heart rate. We conclude that PSV improves gas exchange and reduces WOB during ProSealtrade mark laryngeal mask airway anesthesia compared with CPAP in ASA physical status I children aged 1-7 yr.

Anesthetic techniques and postoperative emesis in pediatric strabismus surgery. Chhabra A, Pandey R, Khandelwal M, Subramaniam R, Gupta S.Reg Anesth Pain Med. 2005 Jan-Feb;30(1):43-7

Background and objectives Postoperative emesis after pediatric strabismus surgery continues to be a problem, despite the use of antiemetics. The purpose of this study was to identify an anesthetic technique associated with the lowest incidence of vomiting after pediatric strabismus surgery. Methods A prospective, randomized, double-blind study was conducted to evaluate the effect of intravenous fentanyl, meperidine, or peribulbar block with propofol infusion on emesis in 105 pediatric patients undergoing strabismus surgery. Anesthesia was maintained with nitrous oxide, oxygen, and propofol infusion. Ketorolac 1.0 mg/kg -1 intramuscular was administered to all patients after induction. Patients were given either a peribulbar block, intravenous fentanyl 2 mug/kg -1 , or intravenous meperidine 1mg/kg -1 for perioperative analgesia. The emesis scores were observed for the first 24 hours postoperatively. Results The incidence of emesis was significantly lower (1 of 35; 2.9%) in the peribulbar group compared with the meperidine group (9 of 35; 25.6%) ( P < .01) in the first 24 hours. The fentanyl group had a higher incidence of postoperative vomiting (4 of 35; 11.4%) than did the peribulbar group; the difference, however, was not statistically significant. Conclusion Among the three techniques, peribulbar block with propofol-based anesthesia is the technique with the lowest incidence of postoperative emesis. Fentanyl-propofol is an equally acceptable alternative; however, meperidine-propofol is associated with a high incidence of postoperative emesis.


Continuous peripheral nerve blocks at home for treatment of recurrent complex regional pain syndrome I in children. Dadure C, Motais F, Ricard C, Raux O, Troncin R, Capdevila X. Anesthesiology. 2005 Feb;102(2):387-91.

BACKGROUND: Recurrent complex regional pain syndrome I is not rare in the pediatric population. The authors conducted this study to evaluate the efficacy of continuous peripheral nerve blocks with elastomeric disposable pumps associated with initial Bier blocks for the treatment of recurrent complex regional pain syndrome I in children. METHODS: After parental informed consent, 13 children who did not respond to conventional complex regional pain syndrome treatment were included (mean age, 13 yr; range, 9-16 yr). After general anesthesia, peripheral nerve block was performed using 0.5 ml/kg lidocaine, 1%, with epinephrine and 0.5% ropivacaine injected in the peripheral nerve block catheter. Then, a 20-min Bier block was performed using a tourniquet and 0.2 ml/kg lidocaine, 1%; 3 ml/kg hydroxyethyl starch 130/06; and 5 mg/kg buflomedil injected intravenously. A solution of 0.1 ml . kg . h continuous ropivacaine, 0.2%, was infused through the catheter using an elastomeric pump for 96 h. Need for rescue analgesia, occurrence of side effects, and status of motor and sensory block were recorded at hours 1, 6, 12, 24, 48, 72, and 96. Children and parents completed a satisfaction assessment. All of the children had follow-up visits after 2 months. RESULTS: Postoperative analgesia was excellent. The median pain score was 0 for each period studied. Motor blockade was minimal before 12 h (median, 1) and absent thereafter. One child needed rescue analgesia. All children were able to walk easily after the initial 24-h period (walking score, > 4). Children and parents were all satisfied. Children returned home under parental surveillance beginning in the 24th hour. Neither peripheral nerve block nor Bier block caused side effects. After 2 months, none of the children exhibited any clinical symptom of recurrent complex regional pain syndrome. CONCLUSION: Ambulatory continuous peripheral nerve block associated with an initial Bier block seems to be a significant and novel contribution to treat recurrent pediatric complex regional pain syndrome I. It allows complete pain relief, early mobilization, and rapid return home, representing a psychological advantage for these children.

Anesthesia for pediatric renal transplantation with and without epidural analgesia - a review of 7 years experience. Coupe N, O'brien M, Gibson P, Lima J. Paediatr Anaesth. 2005 Mar;15(3):220-8.

Summary Background : Few objective data exist describing current anesthesia practice for pediatric renal transplantation. We describe here, the experience from an Australian tertiary pediatric center that has continued an active pediatric renal transplantation program after relocation in 1995. Areas of interest include preoperative status, fluid management, hemodynamic stability, perioperative complications, and the use of epidural analgesia. In particular, the influence of perioperative epidural analgesia on hemodynamic stability is addressed. Methods : A retrospective review of anesthesia records of all patients undergoing pediatric renal transplantation performed at the Children's Hospital at Westmead (CHW), from November 1995 to October 2002 was carried out. Results : Fifty-three pediatric renal transplants were performed in 50 patients. Average age and weight were 10.2 years (range: 1-18 years) and 31.4 kg (range: 9-66 kg), respectively. A total of 14 recipients were less than or equal to 6 years of age. Twenty-four children were recipients of cadaveric transplants, 29 children received kidneys from living related donors. Few children presented with severe anemia (two patients) gross electrolyte abnormalities (three patients) or uncontrolled hypertension. Intraoperatively, all children had central venous pressure monitoring and only four had invasive arterial blood pressure monitoring. Average intraoperative fluid administration was 88 ml.kg(-1) (range: 30-190). Twenty-three children received blood transfusions intraoperatively. Postoperative analgesia was provided using an epidural infusion in 39 patients and an opioid infusion/patient controlled analgesia in the remainder. There was a tendency to greater hemodynamic stability in the group, which received intra-operative epidural analgesia. Half the patients who had epidural analgesia required parenteral opioid supplementation. Five patients had postoperative pulmonary edema. Minor postoperative adverse events included epidural associated motor block (three cases) and opioid related oversedation (one patient). No perioperative mortality or major morbidity was recorded. Conclusions : Anesthesia for renal transplantation in pediatric patients at CHW is safe and effective using a selected range of drugs and techniques. Pretransplant medical optimization, careful preoperative assessment, adequate monitoring and precise fluid management together with appropriate postoperative analgesia typify the perioperative care of CHW renal transplant recipients.

Pediatric sedation in North American children's hospitals: a survey of anesthesia providers.
Lalwani K, Michel M. Paediatr Anaesth. 2005 Mar;15(3):209-13.

Summary Background : Information about the existence and organization of pediatric sedation services in North America is not available. We conducted a survey to collect this information from anesthesiologists at pediatric institutions and to identify factors perceived as limiting the development of sedation services. Method : We electronically mailed a confidential survey about pediatric sedation practice to an attending anesthesiologist involved in pediatric sedation at 116 children's hospitals in the United States and Canada. We identified the institutions using Internet resources. Electronic mailing addresses were obtained from departmental websites, society membership directories and departmental administrators. Our follow-up for nonresponders was by a second e-mail and a telephone call. Results : A total of 54 completed questionnaires were received, a response rate of 47%. Forty-nine (91%) were received from US hospitals, and the remainder from Canadian. Fifty percent of hospitals had a formal pediatric sedation service. Fifty-four percent utilized a 'mobile' provider model. Hospital credentialing for nonanesthesiologist providers varied between 66 and 76% for 'deep' and 'conscious' sedation, respectively. A nurse-physician provider combination was the most common, utilized in 59% of hospitals. Anesthesiologists were the sole sedation providers in 26% of institutions. Propofol was used regularly by nonanesthesiologists for sedation of nonintubated (42%) and intubated (63%) patients. Eighty-seven percent of institutions reported barriers to development of pediatric sedation services. The most common barrier was a shortage of providers, particularly anesthesiologists. Conclusions : Propofol use by nonanesthesiologists is common. Addressing the shortage of providers, and allocating resources for credentialing providers will encourage further development of pediatric sedation practice.

Vertical infraclavicular brachial plexus block in children: a preliminary study. de Jose Maria B, Tielens LK. Paediatr Anaesth. 2004 Nov;14(11):931-5.

BACKGROUND: Brachial plexus blockade is a well-established technique in upper limb surgery. Among the infraclavicular approaches, the vertical infraclavicular brachial plexus (VIP) block is easy to perform and has a large spectrum of nerve blockade. The aim of this preliminary study was to determine the ease, effectiveness, safety, and duration of the VIP block in pediatric trauma surgery. METHODS: Fifty-five patients (ASA physical status I and II, age range 5-17 years old) scheduled for upper limb trauma surgery received a VIP block under light general anesthesia, using 0.5 ml x kg(-1) of ropivacaine 0.5%. The number of attempts and time to perform the block, the occurrence of a surgical response, the visual analogue score (VAS) scores, the incidence of complications and the duration of the block were evaluated. RESULTS: The brachial plexus was found easily at the first or second attempt in 85% (47 of 55) of the cases, in 15% (eight of 55) of the cases it was localized after three to four attempts. The mean time to perform the block was 3.35 +/- 3.37 min. Ninety-eight percentage (54 of 55) of the blockades were effective for surgery and in just one case was ineffective. The VAS scores at the end of the procedure in 100% (55 of 55) of the cases were <3. There were no cases with clinical signs of pneumothorax nor inadvertent puncture of major vessels. Two patients developed a Horner's syndrome and in one a mild superficial hematoma at the puncture site occurred. The mean sensory block duration was 8.45 +/- 1.71 h and the mean motor block duration was 6.52 +/- 2.50 h. CONCLUSIONS: In this preliminary study, the VIP block was easy to perform, effective and free of major complications for pediatric trauma surgery. With the doses of ropivacaine we used it was useful for intra- and postoperative analgesia.


Evaluation of genitofemoral nerve block, in addition to ilioinguinal and iliohypogastric nerve block, during inguinal hernia repair in children. Sasaoka N, Kawaguchi M, Yoshitani K, Kato H, Suzuki A, Furuya H.Br J Anaesth. 2005 Feb;94(2):243-6. Epub 2004 Nov 26.

BACKGROUND: Ilioinguinal and iliohypogastric (IG-IH) nerve block has been widely used in children undergoing inguinal hernia repair. This technique may provide insufficient analgesia for intraoperative management as the inguinal region may receive sensory innervation from genitofemoral nerve. We proposed that addition of a genitofemoral nerve block might improve the quality of analgesia. METHODS: Ninety-eight children undergoing inguinal hernia repair were assigned randomly to receive either IG-IH nerve block (Group I) or IG-IH and genitofemoral nerve blocks (Group II). Systolic arterial pressure (SAP) and heart rate (HR) were recorded before surgery (control), after skin incision, at sac traction and at the end of surgery. Postoperative analgesic requirements and incidence of complications were recorded until discharge. RESULTS: At sac traction, SAP and HR were significantly higher in Group I (P<0.05), and the incidence of episodes of increased HR was also significantly higher in Group II (29 vs 12%, respectively, P<0.05). There were no significant differences in SAP and HR at other time points, postoperative analgesic requirements or incidence of complications between the groups. CONCLUSIONS: The benefit of the additional genitofemoral nerve block to IG-IH nerve block was limited only to the time of sac traction without any postoperative effect. This suggests there is little clinical benefit in the addition of a genitofemoral nerve block.

Caudal neostigmine with bupivacaine produces a dose-independent analgesic effect in children. Mahajan R, Grover VK, Chari P. Can J Anaesth. 2004 Aug-Sep;51(7):702-6.

PURPOSE: To evaluate the analgesic efficacy and duration of varying doses of caudal neostigmine with plain bupivacaine and its side effects in children undergoing genito-urinary surgery. METHODS: In a randomized double-blind prospective study 80 boys aged two to eight years scheduled for surgical repair of hypospadias were allocated randomly to one of four groups (n = 20 each) and received either only caudal 0.25% plain bupivacaine 0.5 mL.kg(-1) (Group I) or 0.25% plain bupivacaine 0.5 mL.kg(-1) with neostigmine (Groups II-IV) in doses of 2, 3 and 4 microg.kg(-1) respectively. Postoperative pain was assessed for 24 hr using an objective pain score. Blood pressure, heart rate, oxygen saturation, total amount of analgesic consumed and adverse effects were also recorded. RESULTS: The duration of postoperative analgesia in Group I (5.1 +/- 2.3 hr) was significantly shorter than in the other three groups (II -16.6 +/- 4.9 hr; III - 17.2 +/- 5.5 hr; IV - 17.0 +/- 5.8 hr; P < 0.05). Total analgesic (paracetamol) consumption was significantly more in Group I (697.6 +/- 240.7 mg) than in the groups receiving caudal neostigmine (II - 248.0 +/- 178.4; III - 270.2 +/- 180.8 and IV -230.6 +/- 166.9 mg; P < 0.05). Groups II, III and IV were comparable with regards to duration of postoperative analgesia and total analgesic consumption (P > 0.05). Incidence of nausea and vomiting were comparable in all four groups. No significant alteration in vital signs or any other adverse effects were observed. CONCLUSIONS: Caudal neostigmine (2, 3 and 4 microg.kg(-1)) with bupivacaine produces a dose-independent analgesic effect ( approximately 16-17 hr) in children as compared to those receiving caudal bupivacaine alone (approximately five hours) and a reduction in postoperative rescue analgesic consumption without increasing the incidence of adverse effects.

Preoperative caudal block prevents emergence agitation in children following sevoflurane anesthesia. Aouad MT, Kanazi GE, Siddik-Sayyid SM, Gerges FJ, Rizk LB, Baraka AS. Acta Anaesthesiol Scand. 2005 Mar;49(3):300-4.

Background: The frequency of emergence agitation in children is increased following sevoflurane anesthesia. However, controversies still exist concerning the exact etiology of this postanesthetic problem. Although this phenomenon is present with adequate pain relief or even following pain-free procedures, pain is still regarded as a major contributing factor. Methods: In a prospective, randomized, double-blind study, we enrolled 48 premedicated and calm 2-6-year-old children undergoing inguinal hernia repair. We assigned children to one of two groups: children assigned to the caudal group (n = 24) received a caudal block to supplement sevoflurane, while children assigned to the fentanyl group (n = 24) received a bolus injection of 1 microg kg(-1) intravenous fentanyl before skin incision to supplement sevoflurane. In the post anesthesia care unit, all children were received by their parent, and the incidence of emergence agitation and pain scores, as well as hemodynamic changes, were compared in both groups. Results: Forty-four children completed the study. In the fentanyl group, 59% of the children were agitated following emergence from anesthesia as compared to 4.5% in the caudal group (P < 0.001). Also, pain scores, mean values of heart rate and blood pressure as well as morphine requirement were significantly higher in the post anesthesia care unit in the fentanyl group compared to the caudal group. Conclusion: Our results show that in children undergoing inguinal hernia repair, pain control with a preoperative caudal block as compared to intraoperative intravenous fentanyl significantly reduces the incidence of emergence agitation and pain scores following sevoflurane anesthesia.

Delayed emergence process does not result in a lower incidence of emergence agitation after sevoflurane anesthesia in children. Oh AY, Seo KS, Kim SD, Kim CS, Kim HS. Acta Anaesthesiol Scand. 2005 Mar;49(3):297-9.

Background: Emergence agitation (EA) is more frequent after sevoflurane anesthesia than other inhalational agents but the etiology remains unclear. We investigated whether the EA after sevoflurane anesthesia is related to rapid emergence. Methods: Eighty-five patients, aged 1-7 years, undergoing elective urology surgery were studied. After induction, anesthesia was maintained with 2.0-2.5% sevoflurane and 50% N(2)O. BIS was monitored continuously throughout surgery and emergence. At the end of surgery, the children were randomly assigned to one of two groups: group I, immediate cessation of sevoflurane; or group G, gradual decrease of sevoflurane with the rate of 0.1%.min(-1). Emergence agitation score was recorded during recovery. Results: Times from immediate cessation or start of decrease of sevoflurane to BIS 70, 80, 90 and extubation were significantly longer in group G. The incidence of severe agitation (score >/=3) was not significantly different between group I and group G: which were 35.7% and 32.6%, respectively. Conclusion: Prolonged recovery did not reduce the incidence of EA following sevoflurane anesthesia in children.

Impact of the AEP-Monitor/2-derived composite auditory-evoked potential index on propofol consumption and emergence times during total intravenous anaesthesia with propofol and remifentanil in children. Weber F, Seidl M, Bein T. Acta Anaesthesiol Scand. 2005 Mar;49(3):277-83.

Background: The composite auditory evoked potential index (cAAI), derived from the AEP Monitor/2 (version 1.6; Danmeter A/S, Odense, Denmark) is a measure of the hypnotic component of general anaesthesia. The purpose of this study was to evaluate the impact of cAAI guidance on propofol consumption and emergence times in children receiving total intravenous anaesthesia (TIVA) with propofol and remifentanil. Methods: Twenty children, aged 3-11 years, scheduled for strabismus repair under TIVA with propofol and remifentanil were enrolled. Remifentanil was given to all patients at a constant infusion rate of 0.3 microg kg(-1) min(-1) throughout the anaesthesia. Patients were randomly allocated to receive a continuous propofol infusion adjusted either according to a conventional clinical practice (Group C, n = 10) or guided by cAAI-monitoring (Group G, n = 10, target cAAI 25-35). All patients were connected to the AEP Monitor/2, but in group C the anaesthetist was blinded to cAAI values. Propofol consumption (mgkg(-1)h(-1)) and emergence times (min) were the primary and secondary outcome measures. Results: Propofol consumption and emergence times (mean +/- SD) were significantly lower in group G compared to group C (Propofol: G: 4.2 +/- 1.7 vs. C 6.4 +/- 1.3 mg kg(-1) h(-1); P < 0.01; emergence times: G: 5.1 +/- 3.7 vs. C 13.2 +/- 8.2 min; P < 0.01). Intraoperative cAAI values (median [interquartile range]) were significantly higher in group G (23.9 [18-29.7]) than in group C (18.4 [16.0-22.1]; P < 0.01). Haemodynamic variables remained stable within age-related limits, and there were no observations of adverse events, especially no clinical signs of intraoperative awareness in any patient. Conclusion: Composite auditory evoked potential index monitoring during propofol/remifentanil-TIVA in children results in reduced propofol consumption and faster emergence.

Canadian pediatric anesthesiologists prefer inhalational anesthesia to manage difficult airways: a survey: [Les anesthesiologistes pediatriques canadiens preferent l'anesthesie par inhalation dans les cas de problemes des voies aeriennes: une enquete]. Brooks P, Ree R, Rosen D, Ansermino M. Can J Anaesth. 2005 Mar;52(3):285-290.

PURPOSE: To survey Canadian pediatric anesthesiologists to assess practice patterns in managing pediatric patients with difficult airways. METHODS: Canadian pediatric anesthesiologists were invited to complete a web survey. Respondents selected their preferred anesthetic and airway management techniques in six clinical scenarios. The clinical scenarios involved airway management for cases where the difficulty was in visualizing the airway, sharing the airway and accessing a compromised airway. RESULTS: General inhalational anesthesia with spontaneous respiration was the preferred technique for managing difficult intubation especially in infants (90%) and younger children (97%), however, iv anesthesia was chosen for the management of the shared airway in the older child (51%) where there was little concern regarding difficulty of intubation. Most respondents would initially attempt direct laryngoscopy for the two scenarios of anticipated difficult airway (73% and 98%). The laryngeal mask airway is commonly used to guide fibreoptic endoscopy. The potential for complete airway obstruction would encourage respondents to employ a rigid bronchoscope as an alternate technique (17% and 44%). CONCLUSION: Inhalational anesthesia remains the preferred technique for management of the difficult pediatric airway amongst Canadian pediatric anesthesiologists. Intravenous techniques are relatively more commonly chosen in cases where there is a shared airway but little concern regarding difficulty of intubation. In cases of anticipated difficult intubation, direct laryngoscopy remains the technique of choice and fibreoptic laryngoscopy makes a good alternate technique. The use of the laryngeal mask airway was preferred to facilitate fibreoptic intubation.

Patient-controlled regional analgesia is effective in children: a preliminary report. Duflo F, Qamouss Y, Remond C, Pouyau A, Heilporn A, Taylor P, Paturel B, Combet S, Boselli E, Chotel F, Berard J, Chassard D. Can J Anaesth. 2004 Nov;51(9):928-30.

PURPOSE: To report a preliminary analysis of prospectively recorded data in 27 children in whom patient-controlled regional analgesia (PCRA) was used for postoperative pain control following lower limb surgery. METHODS: Under general anesthesia, perineural catheters (popliteal and fascia iliaca compartment block) were inserted and infused with ropivacaine 0.2% (0.02 mL.kg(-1).hr(-1)). Additional demand doses were left to the child's discretion (0.1 mL.kg(-1)and a 30-min lockout interval). RESULTS: The average total dose of ropivacaine administered was 4.9 +/- 2 mg.kg(-1)over 48 hr. Visual analogue scale and Children's Hospital of Eastern Ontario Pain Scale scores were always inferior to 5/10 and 6/13, respectively. Motor block was observed in two children and two children needed rescue analgesia. CONCLUSIONS: Our preliminary observations indicate that PCRA in children provides satisfactory postoperative pain relief following lower limb surgery.

Anesthetic management of pediatric cleft lip and cleft palate repair. Machotta A. Anaesthesist. 2005 Mar 12

We have developed a modern strategy for the anesthetic management of pediatric cleft lip and cleft palate repair using anesthetic drugs such as sevoflurane, desflurane, acetaminophen, remifentanil, and pirtitramide together with new techniques. It provides best conditions for the surgeon and maximum safety for the pediatric patient. A team of pediatricians, neonatologists, pediatric surgeons, and pediatric anesthetists have tackled the problem of management of children with craniofacial abnormalities such as cleft lip and cleft palate.The best and safest anesthetic techniques are outlined and the most frequent complications are discussed, e.g. management of the difficult airway, the airway in patients with complex craniofacial abnormalities, fiberoptic endotracheal intubation through a laryngeal mask, intraoperative dislocation of the endotracheal tube, postoperative airway obstruction and perioperative bleeding.

Invasive techniques in emergency medicine. III. Intraosseous punction--an alternative vascular access in paediatric emergencies. Helm M, Gries A, Fischer S, Hauke J, Lampl L. Anaesthesist. 2005 Jan;54(1):49-56.

There can be few more daunting challenges for the emergency physician than an infant or small child in shock or cardiac arrest. At the best of times, the combination of small veins and abundant subcutaneous tissue makes vascular access difficult or impossible, even in experienced hands. For these situations, the intraosseous vascular access is an easy, rapid and safe alternative. The intraosseous route is recommended for children < or =6 years of age, where conventional vascular access cannot be timely established. The preferred sites are the medial aspect of the proximal end of the tibia, just below the tibial tuberosity. Access should be obtained with a commercially available intraosseous needle. All emergency drugs and infusion fluids for intravenous usage can safely be infused via the intraosseous route (except hypertonic solutions) and it is not necessary to adjust drug dosage compared to the intravenous route. To avoid complications caused by the intraosseous needle, such as osteomyelitis, it should be replaced within 2 h by a conventional vascular access.

Recovery after anesthesia for short pediatric oncology procedures: propofol and remifentanil compared with propofol, nitrous oxide, and sevoflurane. Glaisyer HR, Sury MR. Anesth Analg. 2005 Apr;100(4):959-63.

Anesthesia techniques in children undergoing short painful oncology procedures should allow rapid recovery without side effects. We compared the recovery characteristics of two anesthetic techniques: propofol with sevoflurane and nitrous oxide and a total IV technique using propofol and remifentanil. Twenty-one children, undergoing two similar painful procedures within 2 wk were studied in a single-blind manner within patient comparison. The order of the techniques was randomized. Propofol and remifentanil involved bolus doses of both propofol 3-5 mg/kg and remifentanil 1-4 microg/kg. Propofol with sevoflurane and nitrous oxide involved propofol 3-5 mg/kg with 2%-8% sevoflurane and 70% nitrous oxide. The primary outcome variable was the time taken to achieve recovery discharge criteria; other recovery characteristics were also noted. The mean age of the children was 6.5 yr (range, 2.5-9.8 yr). Nineteen had lymphoblastic leukemia and two had lymphoma. All children had intrathecal chemotherapy and one had bone marrow aspiration. Most procedures lasted <4 min. The mean time to achieve recovery discharge criteria was appreciably shorter after propofol and remifentanil than propofol with sevoflurane and nitrous oxide by nearly 19 min (P = 0.001). All other time comparisons had similar trends and statistical differences. Seven parents expressed a preference for the propofol and remifentanil technique compared with one preferring propofol with sevoflurane and nitrous oxide. Children are apneic during the procedure and require respiratory support from an anesthesiologist. Discharge readiness from the recovery ward was achieved on average 19 min earlier after propofol with remifentanil compared with the combination of propofol, sevoflurane and nitrous oxide. Parents more often preferred propofol with remifentanil.


The endoscopically measured effects of airway maneuvers and the lateral position on airway patency in anesthetized children with adenotonsillar hypertrophy.
Arai YC, Fukunaga K, Ueda W, Hamada M, Ikenaga H, Fukushima K. Anesth Analg. 2005 Apr;100(4):949-52.

Obstruction of the upper airway is a major challenge for anesthesiologists administering general anesthesia in spontaneously breathing children with adenotonsillar hypertrophy. Lateral positioning is a simple treatment for obstructive sleep apnea. In this study, we examined the effects of body position shifting and common airway maneuvers such as chin lift and jaw thrust on airway patency (stridor score and upper airway dimensions by endoscopy) in anesthetized children scheduled for adenotonsillectomy. Eighteen children aged 1-11 yr were anesthetized with sevoflurane. During spontaneous breathing with 5% sevoflurane and 100% oxygen, upper airway dimensions and stridor score were recorded. After baseline recording, chin lift and jaw thrust were performed in both the supine and the lateral decubitus position. Chin lift, jaw thrust, and lateral position increased the airway dimensions and improved the stridor score. Moreover, lateral positioning enhanced the effects of these airway maneuvers on airway patency. We concluded that lateral positioning combined with airway maneuvers provided better airway patency for anesthetized children with adenotonsillar hypertrophy.

Evaluation of satisfaction level by parents and children following pediatric anesthesia. Iacobucci T, Federico B, Pintus C, Francisci G.

Summary Background: Research in the field of patient satisfaction first took place in the 1980s in the USA, and later in Europe, aimed at meeting competitive requirements in the field of health care. Very few studies of this type exist in regard to pediatric anesthesia. Our aim was to develop a rapidly interpretable questionnaire to measure the level of parental satisfaction when their children undergo surgery and provide information on those factors triggering anxiety in these children. Methods: Over a period of 18 months 179 parents of children in pediatric surgery responded to 214 questionnaires designed to investigate principally the emotional/behavioral spheres as well as the comfort provided. Results and conclusions: We found that parents generally expressed a high degree of satisfaction which was good and correlated significantly with environmental comfort and postoperative observations performed by anesthetists and nursing staff. In the children, lack of fear at the moment of being anesthetized, and lack of anxiety on the day preceding surgery, were attributed to the serenity transmitted by the anesthetist and nurses. Significant anxiety resulted from the fear of an unpleasant impact with the operating room.

Randomized, double-blind, phase III, controlled trial comparing levobupivacaine 0.25%, ropivacaine 0.25% and bupivacaine 0.25% by the caudal route in children. Locatelli B, Ingelmo P, Sonzogni V, Zanella A, Gatti V, Spotti A, Di Marco S, Fumagalli R. Br J Anaesth. 2005 Mar;94(3):366-71. Epub 2004 Dec 17.

BACKGROUND: The rationale for replacing racemic bupivacaine with the s-enantiomers levobupivacaine and ropivacaine is to provide a wider margin of safety with the same analgesic efficacy and less postoperative motor block. In a randomized, double-blind, phase III, controlled trial we compared the caudal administration of levobupivacaine 0.25% and ropivacaine 0.25% with bupivacaine 0.25% in children. METHODS: Ninety-nine ASA I-II children less than 10 yr old scheduled for elective sub-umbilical surgery were randomized to receive caudal block with bupivacaine 0.25%, ropivacaine 0.25% or levobupivacaine 0.25%. The primary outcome of the study was the clinical efficacy of the caudal block during the operation. Secondary outcome measures were analgesic onset time, pain relief after the operation and residual motor blockade. RESULTS: The proportion of children with effective analgesia during the operation was similar among groups. There were no significant differences in the analgesic onset time of the caudal block. Bupivacaine produced a significant incidence of residual motor block compared with levobupivacaine or ropivacaine at wake-up (P<0.01). There were no significant differences in the number of patients receiving rescue analgesia after surgery. However, analgesic block lasted significantly longer in patients receiving bupivacaine (P=0.03). CONCLUSION: During sub-umbilical surgery, caudal levobupivacaine, ropivacaine and bupivacaine provided comparable analgesic efficacy. Bupivacaine produced a higher incidence of residual motor blockade and a longer analgesic block than ropivacaine and levobupivacaine.

Anesthetic management of infants with palliated hypoplastic left heart syndrome undergoing laparoscopic nissen fundoplication. Mariano ER, Boltz MG, Albanese CT, Abrajano CT, Ramamoorthy C. Anesth Analg. 2005 Jun;100(6):1631-3.

The safety of laparoscopic surgery in infants with single ventricle physiology has been a subject of controversy despite potential benefits over open surgery. We present the anesthetic management of five infants with palliated hypoplastic left heart syndrome that underwent laparoscopic Nissen fundoplication. After anesthetic induction and tracheal intubation, an intraarterial catheter was placed for hemodynamic monitoring. Insufflation pressure was limited to 12 mm Hg and was well tolerated by all patients. There were no intraoperative or postoperative complications. In patients with hypoplastic left heart syndrome, laparoscopic Nissen fundoplication can be safely performed with careful patient selection and close intraoperative monitoring.

Postoperative analgesia after spinal blockade in infants and children undergoing cardiac surgery. Hammer GB, Ramamoorthy C, Cao H, Williams GD, Boltz MG, Kamra K, Drover DR. Anesth Analg. 2005 May;100(5):1283-8

The aim of this prospective, randomized, controlled clinical trial was to define the opioid analgesic requirement after a remifentanil (REMI)-based anesthetic with spinal anesthetic blockade (SAB+REMI) or without (REMI) spinal blockade for open-heart surgery in children. We enrolled 45 patients who were candidates for tracheal extubation in the operating room after cardiac surgery. Exclusion criteria included age <3 mo and >6 yr, pulmonary hypertension, congestive heart failure, contraindication to SAB, and failure to obtain informed consent. All patients had an inhaled induction with sevoflurane and maintenance of anesthesia with REMI and isoflurane (0.3% end-tidal). In addition, patients assigned to the SAB+REMI group received SAB with tetracaine (0.5-2.0 mg/kg) and morphine (7 mug/kg). After tracheal extubation in the operating room, patients received fentanyl 0.3 mug/kg IV every 10 min by patient-controlled analgesia for pain score = 4. Pain scores and fentanyl doses were recorded every hour for 24 h or until the patient was ready for discharge from the intensive care unit. Patients in the SAB+REMI group had significantly lower pain scores (P = 0.046 for the first 8 h; P =0.05 for 24 h) and received less IV fentanyl (P = 0.003 for the first 8 h; P = 0.004 for 24 h) than those in the REMI group. There were no intergroup differences in adverse effects, including hypotension, bradycardia, highest PaCO(2), lowest pH, episodes of oxygen desaturation, pruritus, and vomiting.


Caudal anesthesia for minor pediatric surgery: a prospective randomized comparison of ropivacaine 0.2% vs levobupivacaine 0.2%. Ivani G, DE Negri P, Lonnqvist PA, L'erario M, Mossetti V, Difilippo A, Rosso F. Paediatr Anaesth. 2005 Jun;15(6):491-4.

Summary Background : Previous published data comparing ropivacaine 0.2% with levobupivacaine 0.25% have suggested that ropivacaine might be associated with less early postoperative motor blockade compared with levobupivacaine. The aim of the present study was to further investigate this issue comparing equal concentrations (0.2%) of ropivacaine and levobupivacaine in children undergoing minor subumbilical surgery. Methods : Following induction of a standardized anesthetic, patients (1-7 years) were randomized in a double-blind manner to receive a caudal block with either ropivacaine 0.2% (group R, n = 30) or levobupivacaine 0.2% (group L, n = 30), total volume 1 ml.kg(-1). Motor blockade (modified Bromage scale; primary end-point) and analgesia [Children and Infants Postoperative Pain Scale (CHIPPS) score] were assessed at predetermined time points during the first 24-postoperative hours. Results : Motor blockade was only registered during the first postoperative hour with no significant differences between the groups (group R n = 5, group L n = 8). Postoperative CHIPPS scores were almost identical in both groups with only seven and six patients requiring supplemental analgesia (CHIPPS score >/=4) in the R and L groups, respectively. Conclusions : A 0.2% concentrations of ropivacaine or levobupivacaine are clinically very similar with regard to postoperative analgesia and unwanted postoperative motor blockade in children undergoing minor subumbilical surgery.

Comparison of a combination of midazolam and diazepam and midazolam alone as oral premedication on preanesthetic and emergence condition in children. Arai YC , Fukunaga K , Hirota S . Acta Anaesthesiol Scand. 2005 May;49(5):698-701

BACKGROUND: Preanesthetic anxiety and emergence agitation are major challenges for anesthesiologists in pediatric anesthesia. Thus, midazolam has been used as premedication for children. However, midazolam alone is not effective for emergence agitation. The present study tested the effect of a combination of midazolam and diazepam on the preanesthetic condition and emergence behavior in children. METHODS: Forty-two children were allocated to one of three groups: the NoPre group received no premedication; the Mi group received midazolam 0.5 mg kg(-1) orally; and the Mi + Di group received midazolam 0.25 mg kg(-1) and diazepam 0.25 mg kg(-1) orally. When anesthesia was induced with 7% sevoflurane in 100% oxygen, qualities of mask induction and sedation were rated. Anesthesia was maintained with sevoflurane (3-5%) in 100% oxygen. During emergence from anesthesia, the score of the child's emergence behavior was rated. RESULTS: Children in the Mi and Mi + Di groups were more sedated than those in the NoPre group. A combination of midazolam and diazepam provided a better quality of mask induction, when compared with no premedication. Also, the children in the Mi + Di group were less agitated than those in the other groups during the emergence. CONCLUSION: Children in the Mi + Di group were significantly more sedated at induction of anesthesia and less agitated during emergence from anesthesia.

A double-blind comparison of intravenous ondansetron and placebo for preventing postoperative emesis in 1- to 24-month-old pediatric patients after surgery under general anesthesia. Khalil SN , Roth AG , Cohen IT , Simhi E , Ansermino JM , Bolos ME , Cote CJ , Hannallah RS , Davis PJ , Brooks PB , Russo MW , Anschuetz GC , Blackburn LM
Anesth Analg. 2005 Aug;101(2):356-61

We assessed the efficacy and safety of ondansetron (0.1 mg/kg IV) prophylactically administered before surgery for prevention of postoperative vomiting (POV) in a double-blind, placebo-controlled study of 670 pediatric patients, 1- to 24-mo-old, undergoing elective surgery under general anesthesia. The study enrolled 335 children in each treatment group (ondansetron versus placebo). Significantly fewer children treated with ondansetron exhibited emesis or discontinued the study prematurely after surgery (ondansetron, 11%; placebo, 28%; odds ratio = 0.33; P < 0.0001). The number required to treat prophylactically with ondansetron to prevent POV was approximately six. Ondansetron treatment also resulted in fewer patients requiring rescue medication or assumed to have had rescue upon early discontinuation from the study during the postoperative period (ondansetron, 5%; placebo, 10%) and less emesis (0 of 6) after rescue medication when compared with placebo (7 of 21). The incidence of POV and other antiemetic effects of ondansetron were similar in children aged 1-12 mo and 13-24 mo and in children prospectively expected or not expected to require opioids as part of their anesthetic or analgesic management. Ondansetron was well tolerated; the incidence of adverse events considered possibly related to study drug was similar between treatment groups (ondansetron, 1.8%; placebo, 1.5%). IMPLICATIONS: This prospective, randomized, double-blind, placebo-controlled study establishes the efficacy and tolerability of IV ondansetron (0.1 mg/kg) in the prevention of postoperative emesis in 1- to 24-mo-old pediatric patients undergoing elective surgery under general anesthesia.

Postoperative analgesia in infants and children. Postoperative analgesia in infants and children. Lonnqvist PA , Morton NS . Br J Anaesth. 2005 Jul;95(1):59-68. Epub 2005 Jan 21.

Pain control with low-dose alfentanil in children undergoing minor abdominal and genito-urinary surgery. Leoni F , Benni F , Iacobucci T , de Francisci G . Eur J Anaesthesiol. 2004 Sep;21(9):738-42.

BACKGROUND AND OBJECTIVE: The aim of this study was to investigate the quality of intra- and postoperative analgesia obtained by alfentanil compared to that produced by peripheral blockade in children. METHODS: During sevoflurane-nitrous oxide atracurium anaesthesia for minor abdominal or genito-urinary surgery, three groups of children aged 0-8 yr received 25 microg kg(-1) alfentanil intravenously (n = 28), or peripheral nerve blockade using 1 mLkg(-1) ropivacaine 0.475% (n = 24), or 12.5 microg kg(-1) alfentanil intravenously with peripheral nerve blockade using 1 mL kg(-1) ropivacaine 0.475% (n = 30). Changes in blood pressure and heart rate were measured during the procedures. Postoperative pain was assessed using the face, legs, activity, cry, consolability (FLACC) observational tool for quantifying pain behaviour and a numerical scale scored by nurses, doctors, parents and children. RESULTS: There was no significant difference in intra- or postoperative analgesic efficacy among the three groups. Patients who received alfentanil had significantly lower heart rates than those who received nerve blockade only (96.0+/-15.6 vs. 115.9+/-23.2 beats min(-1), P < 0.001). FLACC and numerical scale scores did not differ among the groups. There were no significant differences in incidence of vomiting or use of pain medications. CONCLUSIONS: It was concluded that a low-dose, intravenous bolus of alfentanil may be an efficient alternative to peripheral nerve blockade in controlling pain during and after minor abdominal and genito-urinary surgery.

Caudal additives for postoperative pain management in children: S(+)-ketamine and neostigmine. Almenrader N , Passariello M , D'Amico G , Haiberger R , Pietropaoli P . Paediatr Anaesth. 2005 Feb;15(2):143-7.

BACKGROUND: The aim of the present pilot study was to compare the analgesic efficacy of S(+)-ketamine either alone or in combination with neostigmine for caudal blockade in pediatric surgery. METHODS: A total of 40 children were randomly assigned to receive after induction of general anesthesia either caudal S(+)-ketamine 1 mg.kg(-1) (group K, n = 20) or caudal S (+)-ketamine 0.5 mg.kg(-1) plus neostigmine 10 microg.kg(-1) (group KN, n = 20). Anesthesia was maintained with sevoflurane and a laryngeal mask airway (LMA), no additional analgesics were administered. Postoperative pain and sedation were assessed by the Children's Hospital of Eastern Ontario Pain Score and Ramsay scale for 24 h. RESULTS: No statistical difference in duration of analgesia and sedation was found. Mean duration of postoperative analgesia was 18 +/- 9.4 h in group K and 21.8 +/- 6.7 h in group KN. There was a significantly higher incidence of postoperative vomiting after administration of caudal ketamine with neostigmine (30% group KN Vs 0% group K; P < 0.05). CONCLUSIONS: This pilot study demonstrates equianalgesic effects on postoperative pain relief in children with both caudal S(+)-ketamine 1 mg.kg(-1) and caudal S(+)-ketamine 0.5 mg.kg(-1) plus neostigmine 10 microg.kg(-1). Further studies are required to confirm adoption of caudal neostigmine into routine clinical practice.

The optimal insertion length of central venous catheter via the femoral route for open-heart surgery in infants and children. Shinohara Y , Arai T , Yamasita M . Paediatr Anaesth. 2005 Feb;15(2):122-4.

BACKGROUND: The recommended insertion length of central venous (CV) catheter via the internal jugular or subclavian vein has been determined in infants and children. However, the insertion length via the femoral vein has not been well-studied. This study determined the optimal insertion length of CV catheter via the femoral vein. METHODS: Infants and children, who had undergone cardiac catheterization via the right femoral vein, were the subjects of the study. After routine cardiac catheterization, the distance from the femoral puncture site to the third lumbar vertebral body (L3) level, was measured and recorded. The femoral-L3 length was termed as the optimal insertion length. RESULTS: This length was measured in 78 infants and children (age: 1-101 months, weight: 3.1-33.8 kg). The body weight of the patient and the length correlated well: the optimal insertion length (cm) = 0.45 x body weight (kg) + 8.13, coefficient of determination (R2) = 0.84. CONCLUSIONS: It has been recommended to place the tip of the catheter below the level of renal veins to avoid blocking free flow of those veins. Therefore, we chose the mid-point, L3 level as the optimal tip position of the femoral venous catheter. The length derived from the above formula could be used as a guideline for CV catheter insertion via the femoral vein in infants and children.

Caudal additives in pediatrics: a comparison among midazolam, ketamine, and neostigmine coadministered with bupivacaine. Kumar P , Rudra A , Pan AK , Acharya A . Anesth Analg. 2005 Jul;101(1):69-73

Single-shot "kiddie caudal" with bupivacaine alone is losing popularity because of its duration of 4-8 h. In a prospective randomized double-blind clinical study, we assessed and compared the efficacy of ketamine, midazolam, and neostigmine coadministered with bupivacaine in a caudal epidural to provide intraoperative and postoperative pain relief. Eighty children (ASA status I) aged 5-10 yr undergoing unilateral inguinal herniotomy were allocated randomly in equal numbers (n = 20) into 4 groups to receive a caudal injection of 0.25% bupivacaine (1 mL/kg) with or without ketamine (0.5 mg/kg), midazolam (50 microg/kg), and neostig-mine (2 microg/kg), after the induction of standardized general anesthesia without premedication. Monitoring for pain, sedation, postoperative nausea/vomiting, dizziness, and pruritus was performed by anesthesiologists blinded to the study allocation. The time to first analgesic administration (paracetamol syrup) was longer (P < 0.05) in the bupivacaine-neostigmine group and the bupivacaine-midazolam group than in the other groups. Undesirable effects, such as emesis, pruritus, and dizziness, were comparable in all groups. However, the incidence of hallucination was more frequent in the bupivacaine-ketamine group compared with the other groups. This study shows that single-shot caudal coadministration of bupivacaine-neostigmine and bupivacaine-midazolam was associated with an extended duration of postoperative pain relief.

Melatonin vs. midazolam premedication in children: a double-blind, placebo-controlled study. Samarkandi A , Naguib M , Riad W , Thalaj A , Alotibi W , Aldammas F , Albassam A . Eur J Anaesthesiol. 2005 Mar;22(3):189-96.

BACKGROUND AND OBJECTIVE: Unlike midazolam, melatonin premedication is not associated with cognitive impairment in adults despite its anxiolytic properties. The use of melatonin as a premedicant in children has not been reported. This randomized, double-blind, placebo-controlled study compared the perioperative effects of different doses of melatonin and midazolam in children. METHODS: Seven groups of children (n = 15 in each) were randomly assigned to receive one of the following premedicants. Midazolam 0.1, 0.25 or 0.5 mg kg(-1) orally, melatonin 0.1, 0.25 or 0.5 mg kg(-1) orally each mixed in 15 mg kg(-1) acetaminophen, or placebo only (15 mg kg(-1) acetaminophen). Anxiety and temperament were evaluated before and after administration of the study drug, on separation from parents and on the introduction of the anaesthesia mask. At week 2 postoperatively, the behaviour of the children was measured by the Post Hospitalization Behaviour Questionnaire. RESULTS: Melatonin or midazolam each in doses of 0.25 or 0.5 mg kg(-1) were equally effective as premedicants in alleviating separation anxiety and anxiety associated with the introduction of the anaesthesia mask. A trend was noted for midazolam to prolong recovery times as the dosage increased. The use of melatonin was associated with a lower incidence (P = 0.049) of excitement at 10 min postoperatively, and a lower incidence (P = 0.046) of sleep disturbance at week 2 postoperatively than that observed with midazolam and control groups. No postoperative excitement was noted in the melatonin groups at 20, 30 and 45 min. DISCUSSION: Melatonin was not only as effective as midazolam in alleviating preoperative anxiety in children, but it was also associated with a tendency towards faster recovery, lower incidence of excitement postoperatively and a lower incidence of sleep disturbance at week 2 postoperatively.

Anaesthetic management of a neonate with congenital cyst adenoid malformation. Guruswamy V , Roberts S , Arnold P , Potter F . Br J Anaesth. 2005 Aug;95(2):240-2. Epub 2005 Jun 1. Jackson Rees Department of Anaesthesia, The Royal Liverpool Children's Hospital NHS Trust, Alder Hey, Eaton Road, Liverpool L12 2AP, UK. umavelu18@aol.com

We report the anaesthetic management of a male neonate with congenital cyst adenoid malformation (CCAM) of the lung who underwent thoracotomy for resection of CCAM 24 h after birth and again at 24 days. The initial operation involved a 10-day admission to a paediatric intensive care unit (PICU) requiring ventilation, and was complicated by a pneumothorax. This report concentrates on the anaesthetic management for the second thoracotomy. The combination of intra-operative remifentanil infusion and the use of ultrasound to confirm correct placement of epidural catheter allowed on-table tracheal extubation and a shorter stay in PICU. The use of one-lung ventilation (OLV) allowed for better surgical access and enabled complete resection of the lesion.

Improvement of motor-evoked potentials by ketamine and spatial facilitation during spinal surgery in a young child. Erb TO , Ryhult SE , Duitmann E , Hasler C , Luetschg J , Frei FJ . Anesth Analg. 2005 Jun;100(6):1634-6. Department of Pediatric Anesthesiology, University Children's Hospital Beider Basel, UKBB, Roemergasse 8, CH-4058 Basel, Switzerland.

Monitoring motor evoked potentials is desirable during spine surgery but may be difficult to obtain in small children. In addition, the recording of reliable signals is often hampered by the presence of various anesthetics. We report the case of a young child whose motor evoked potentials were successfully monitored using a ketamine-based anesthesia and a newly introduced stimulation technique consisting of combined spatial and temporal facilitation.

Bispectral Indextrade mark values are higher during halothane vs. sevoflurane anesthesia in children, but not in infants. Edwards JJ , Soto RG , Bedford RF . Acta Anaesthesiol Scand. 2005 Sep;49(8):1084-7.

Background: Previously, we have shown in adult patients that bispectral index score (BIS) values are significantly higher during halothane anesthesia (53-61 units) as compared with those observed during equipotent concentrations of sevoflurane (39-43 units). Because halothane is frequently used in the pediatric setting, we tested the hypothesis that BIS values observed in children might also be higher during general anesthesia with halothane than with sevoflurane. Methods: Forty-one healthy, unpremedicated pediatric patients scheduled for elective operations received either halothane or sevoflurane titrated as appropriate for surgical stimulation. Results: During maintenance sevoflurane anesthesia (n = 20), the mean BIS values and percent end-tidal concentrations were 44 +/- 14 and 2.1 +/- 0.6, respectively, whereas for the halothane group (n = 21) the corresponding values were 61 +/- 7 and 1.1 +/- 0.4, respectively. Conclusion: These findings suggest that BIS values are higher during halothane vs. sevoflurane anesthesia in children, but not in infants.

Single-lung ventilation for pulmonary lobe resection in a newborn. Schmidt C , Rellensmann G , Van Aken H , Semik M , Bruessel T , Enk D . Anesth Analg. 2005 Aug;101(2):362-4

The increasing frequency of video-assisted thoracoscopic interventions as well as open thoracic surgical procedures in children demands appropriate anesthetic techniques to provide single-lung ventilation. A fiberoptically directed, wire-guided 5F endobronchial blocker for use in small infants has recently been devised. We report on the very special aspects of airway management in a newborn 3000-g infant who presented a major anesthetic and surgical challenge because of congenital emphysema of the left upper pulmonary lobe. IMPLICATIONS: The special aspects of single-lung ventilation in a newborn 3000-g infant who presented a major anesthetic and surgical challenge because of congenital emphysema of the left upper pulmonary lobe are reported.

Ultrasound-guided epidural catheter insertion in children. Rapp HJ , Folger A , Grau T . Anesth Analg. 2005 Aug;101(2):333-9

Epidural catheters (EC) are often used in pediatric patients for intraoperative and postoperative pain relief. The small anatomical structures and catheter insertion under general anesthesia make it more difficult to perform EC and to prevent damage. In this study we investigated the use of ultrasound (US) in detecting neuraxial structures during insertion and placement of EC in children. ASA I-II children scheduled for elective surgery under combined general and epidural anesthesia were studied. Patients received balanced anesthesia using sevoflurane, opioids and rocuronium. Before EC insertion US examination in a lateral position was done to visualize and identify neuraxial structures. Quality of visualization and site and depth of structures were recorded. Using a sterile kit to hold the US probe in position and enable the visualization of the neuraxial structures, an epidural cannula was inserted, using the loss of resistance technique, as the EC passed under US control to the desired level. Of 25 children, 23 were evaluated. Epidural space, ligamentum flavum, and dural structures were clearly identified and the depth to skin level estimated in all patients. Loss of resistance was visualized in all patients with a lumbar epidural approach. Correlation of US measured depth and depth of loss of resistance was 0.88. In eight of 23 patients EC could be visualized during insertion and in 11 others it could be visualized with additional US planes. US is an excellent tool to identify neuraxial structures in both infants and children. The size and the incomplete ossification of the vertebra allow exact visualization and localization of the depth of the epidural space, the loss of resistance, and all relevant neuraxial structures. IMPLICATIONS: Epidural catheters in children are mostly inserted under sedation or general anesthesia. This study showed that the use of ultrasound could help visualize all relevant neuraxial structures and their site and depth from the skin.

Ultrasonography for ilioinguinal/iliohypogastric nerve blocks in children. Willschke H , Marhofer P , Bosenberg A , Johnston S , Wanzel O , Cox SG , Sitzwohl C , Kapral S .
Br J Anaesth. 2005 Aug;95(2):226-30.

BACKGROUND: The ilioinguinal/iliohypogastric nerve block is a popular regional anaesthetic technique for children undergoing inguinal surgery. The success rate is only 70-80% and complications may occur. A prospective randomized double-blinded study was designed to compare the use of ultrasonography with the conventional ilioinguinal/iliohypogastric nerve block technique. METHODS: One hundred children (age range, 1 month-8 years) scheduled for inguinal hernia repair, orchidopexy or hydrocele repair were included in the study. Following induction of general anaesthesia, the children received an ilioinguinal/iliohypogastric block performed either under ultrasound guidance using levobupivacaine 0.25% until both nerves were surrounded by the local anaesthetic or by the conventional 'fascial click' method using levobupivacaine 0.25% (0.3 ml kg(-1)). Additional intra- and postoperative analgesic requirements were recorded. RESULTS: Ultrasonographic visualization of the ilioinguinal/iliohypogastric nerves was possible in all cases. The amount of local anaesthetic used in the ultrasound group was significantly lower than in the 'fascial click' group (0.19 (SD 0.05) ml kg(-1) vs 0.3 ml kg(-1), P<0.0001). During the intraoperative period 4% of the children in the ultrasound group received additional analgesics compared with 26% in the fascial click group (P=0.004). Only three children (6%) in the ultrasound-guided group needed postoperative rectal acetaminophen compared with 20 children (40%) in the fascial click group (P<0.0001). CONCLUSIONS: Ultrasound-guided ilioinguinal/iliohypogastric nerve blocks can be achieved with significantly smaller volumes of local anaesthetics. The intra- and postoperative requirements for additional analgesia are significantly lower than with the conventional method.

Epidural abscess following epidural analgesia in pediatric patients. Lin YC , Greco C . Paediatr Anaesth. 2005 Sep;15(9):767-70.

Summary Epidural abscess following epidural analgesia is an unusual event especially in pediatric patients. Two patients presented with fever and local signs of infection without neurological deficit on day 4 after the initiation of epidural analgesia. Neuro-imaging studies revealed epidural abscess. Both pediatric patients were treated successfully with intravenous antibiotics. One of the patients' initial MRI was normal. However, the symptoms persisted and a followed-up scan revealed epidural abscess. The other patient presented with worsening local indurations over the epidural insertion site and positive blood culture with Hemolytic streptococcus. Our experience suggests that neuro-imaging study should be strongly considered to evaluate pediatric patients with suspicion of epidural abscess.

The temperature and humidity of inspired gases in infants using a pediatric circle system: effects of high and low-flow anesthesia. Hunter T , Lerman J , Bissonnette B . Paediatr Anaesth. 2005 Sep;15(9):750-4.

Summary Background: The effects of low-flow anesthesia on the temperature and humidity of the inspired gas in infants during mechanical ventilation is unknown. This study was designed to evaluate the temperature and humidity of the inspired gas in infants using a pediatric circle absorber system with high and low fresh gas flow (HFGF and LFGF) anesthesia. Methods: Twenty infants participated in this observational, sequential, cross-over study. Each infant was mechanically ventilated with a Kion Anesthesia Workstation, using a pediatric anesthesia circle circuit with both HFGF (6 l.min(-1)) and LFGF (0.6 l.min(-1)) technique. Airway temperature was recorded continuously at 16 sites throughout the breathing circuit. The relative humidity of the inspired gas was measured at the elbow connector adjacent to the CO(2) sampling line. Results: The mean airway temperatures of the inspired gas and the changes in mean airway temperatures throughout the breathing circuit during HFGF and LFGF did not differ significantly. The mean relative humidity of the inspired gas at steady state using a LFGF technique, 33.7 +/- 3.6%, was approximately threefold greater than it was with a HFGF technique, 11.9 +/- 5.1% (P < 0.05). Conclusions: Low-flow anesthesia with a pediatric circle system in infants neither increases the temperature of the inspired gas, nor achieves the minimum humidity of 50% reported to prevent ciliary damage, although the humidity during LFGF did increase threefold compared with HFGF. To maintain the temperature and humidity of the inspired gas during mechanical ventilation in infants, passive or active gas humidification should be used.

Dreaming during anaesthesia in children: incidence, nature and associations. Huang GH , Davidson AJ , Stargatt R Anaesthesia. 2005 Sep;60(9):854-61

Anaesthesia. 2005 Sep;60(9):854-61. Summary In previous studies, the incidence of dreaming during anaesthesia in children was reported to be between 9.7% and 19%. These limited studies were performed over 15 years ago using outmoded anaesthetic techniques. No recent studies have examined the nature of dreaming or its impact on children. In this prospective cohort study of 864 children, we determined the incidence, nature, predictors and behavioural consequences of children who reported dreaming during anaesthesia. Children aged 5-12 years who had undergone general anaesthesia were interviewed for dreaming on three occasions. Dreaming was reported by 10.4% of children. The content of the dreams was mostly pleasant and unrelated to their hospital experiences. Dreaming was more common in younger children and in children who had also experienced awareness during anaesthesia. No association was found between dreaming and the anaesthetic drugs used. Dreaming was not associated with an increased risk of behavioural disturbances postoperatively. Anaesthetists should be reassured that dreaming is a common occurrence that does not appear to distress children.

Hemodynamic Responses to Etomidate on Induction of Anesthesia in Pediatric Patients. Anesth Analg. 2005 Sep;101(3):645-650. Sarkar M , Laussen PC , Zurakowski D , Shukla A Kussman B , Odegard KC .

Etomidate is often used for inducing anesthesia in patients who have limited hemodynamic reserve. Using invasive hemodynamic monitoring, we studied the acute effects of a bolus of etomidate during induction of anesthesia in children. Twelve children undergoing cardiac catheterization were studied (mean age, 9.2 +/- 4.8 yr; mean weight, 33.4 +/- 15.4 kg); catheterization procedures included device closure of secundum atrial septal defects (n = 7) and radiofrequency catheter ablation procedures for supraventricular tachycardia (n = 5). Using IV sedation, a balloon-tipped pulmonary artery catheter was placed to measure intracardiac and pulmonary artery pressures and oxygen saturations. Baseline measurements were recorded and then re-peated after a bolus of IV etomidate (0.3 mg/kg). For the entire group, no significant changes in right atrial, aortic, or pulmonary artery pressure, oxygen saturations, calculated Qp:Qs ratio or systemic or pulmonary vascular resistance were detected after the bolus dose of etomidate. The lack of clinically significant hemodynamic changes after etomidate administration supports the clinical impression that etomidate is safe in children. Further research is needed to determine the hemodynamic profile of etomidate in neonates and in pediatric patients with severe ventricular dysfunction and pulmonary hypertension.


Midazolam premedication in children: a pilot study comparing intramuscular and intranasal administration. Lam C , Udin RD , Malamed SF , Good DL , Forrest JL . Anesth Prog. 2005 Summer;52(2):56-61.

The purpose of this study was to compare the effectiveness of intramuscular and intranasal midazolam used as a premedication before intravenous conscious sedation. Twenty-three children who were scheduled to receive dental treatment under intravenous sedation participated. The patients ranged in age from 2 to 9 years (mean age, 5.13 years) and were randomly assigned to receive a dose of 0.2 mg/kg of midazolam premedication via either intramuscular or intranasal administration. All patients received 50% nitrous oxide and 50% oxygen inhalation sedation and local anesthetic (0.2 mL of 4% prilocaine hydrochloride) before venipuncture. The sedation level, movement, and crying were evaluated at the following time points: 10 minutes after drug administration and at the times of parental separation, passive papoose board restraint, nitrous oxide nasal hood placement, local anesthetic administration, and initial venipuncture attempt. Mean ratings for the behavioral parameters of sedation level, degree of movement, and degree of crying were consistently higher but not significant in the intramuscular midazolam group at all 6 assessment points. Intramuscular midazolam was found to be statistically more effective in providing a better sedation level and less movement at the time of venipuncture than intranasal administration. Our findings indicate a tendency for intramuscular midazolam to be more effective as a premedication before intravenous sedation.

Nerve Stimulator-guided Paravertebral Blockade Combined with Sevoflurane Sedation versus General Anesthesia with Systemic Analgesia for Postherniorrhaphy Pain Relief in Children: A Prospective Randomized Trial. Naja ZM , Raf M , El Rajab M , Ziade FM , Al Tannir MA , Lonnqvist PA . Anesthesiology. 2005 Sep;103(3):600-605.

BACKGROUND:: Improvement of the duration of postoperative analgesia is desirable in children undergoing inguinal hernia repair. METHODS:: Fifty children aged 5-12 yr were prospectively randomized to receive either paravertebral nerve blockade or general anesthesia (sevoflurane-fentanyl-nitrous oxide-oxygen) combined with standardized postoperative systemic analgesia, both combined with light sevoflurane anesthesia, for inguinal hernia repair. RESULTS:: Mean pain scores were significantly lower in paravertebral nerve blockade patients compared with patients treated with systemic analgesia during the entire 48-h observational period (P < 0.05). Analgesic consumption was significantly higher in the systemic analgesia group (88%) compared with the paravertebral nerve blockade group (32%) (P < 0.001). Parental satisfaction was significantly higher (80 vs. 48%; P < 0.05) and same-day discharge was possible in a higher proportion of patients in the paravertebral blockade group (80% vs. 52%; P < 0.05). CONCLUSIONS:: Paravertebral nerve blockade was associated with improved postoperative pain relief; reduced analgesic consumption, and faster hospital discharge compared with a systemic analgesia protocol in children undergoing herniorrhaphy.

Fetal pain: a systematic multidisciplinary review of the evidence. Lee SJ , Ralston HJ , Drey EA , Partridge JC , Rosen MA . JAMA. 2005 Aug 24;294(8):947-54.

CONTEXT: Proposed federal legislation would require physicians to inform women seeking abortions at 20 or more weeks after fertilization that the fetus feels pain and to offer anesthesia administered directly to the fetus. This article examines whether a fetus feels pain and if so, whether safe and effective techniques exist for providing direct fetal anesthesia or analgesia in the context of therapeutic procedures or abortion. EVIDENCE ACQUISITION: Systematic search of PubMed for English-language articles focusing on human studies related to fetal pain, anesthesia, and analgesia. Included articles studied fetuses of less than 30 weeks' gestational age or specifically addressed fetal pain perception or nociception. Articles were reviewed for additional references. The search was performed without date limitations and was current as of June 6, 2005. EVIDENCE SYNTHESIS: Pain perception requires conscious recognition or awareness of a noxious stimulus. Neither withdrawal reflexes nor hormonal stress responses to invasive procedures prove the existence of fetal pain, because they can be elicited by nonpainful stimuli and occur without conscious cortical processing. Fetal awareness of noxious stimuli requires functional thalamocortical connections. Thalamocortical fibers begin appearing between 23 to 30 weeks' gestational age, while electroencephalography suggests the capacity for functional pain perception in preterm neonates probably does not exist before 29 or 30 weeks. For fetal surgery, women may receive general anesthesia and/or analgesics intended for placental transfer, and parenteral opioids may be administered to the fetus under direct or sonographic visualization. In these circumstances, administration of anesthesia and analgesia serves purposes unrelated to reduction of fetal pain, including inhibition of fetal movement, prevention of fetal hormonal stress responses, and induction of uterine atony. CONCLUSIONS: Evidence regarding the capacity for fetal pain is limited but indicates that fetal perception of pain is unlikely before the third trimester. Little or no evidence addresses the effectiveness of direct fetal anesthetic or analgesic techniques. Similarly, limited or no data exist on the safety of such techniques for pregnant women in the context of abortion. Anesthetic techniques currently used during fetal surgery are not directly applicable to abortion procedures.

Effects of subtenon anesthesia combined with general anesthesia on perioperative analgesic requirements in pediatric strabismus surgery. Steib A , Karcenty A , Calache E , Franckhauser J , Dupeyron JP , Speeg-Schatz C . Reg Anesth Pain Med. 2005 Sep-Oct;30(5):478-83.

BACKGROUND AND OBJECTIVES: Pediatric strabismus surgery leads to undesirable intraoperative and postoperative side effects that include pain, postoperative nausea and vomiting (PONV), and oculocardiac reflex (OCR). We hypothesized that subtenon anesthesia performed before the start of surgery and combined with general intravenous anesthesia would reduce these adverse effects. METHODS: Forty children (2.5 to 6 years of age, ASA status I to II) were prospectively randomized to receive either subtenon bupivacaine 0.5% or a saline injection before the beginning of surgery in a double-blind manner. Perioperative analgesic requirements, pain scores (CHEOPS scale), hemodynamics, and incidence of OCR and PONV were compared. RESULTS: Postoperative pain scores were lower (P < .001) at removal of the laryngeal mask and 30 minutes later in the bupivacaine group. Intraoperative and postoperative analgesic requirements were significantly reduced in this group (P < .01). The incidence of OCR and PONV were also significantly decreased (P < .01). Intraoperative values of blood pressure were significantly higher in the saline group at 20 minutes (P < .02). CONCLUSION: We conclude that preoperative subtenon bupivacaine 0.5% compared with a saline injection contributed to reduction of perioperative pain and undesirable side effects in pediatric strabismus surgery performed under general anesthesia.

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