Abstracts
Questa rubrica seleziona gli abstracts più interessanti nel campo dell'anestesia pediatrica e neonatale e viene costantemente aggiornata.
Pharmacokinetics of
levobupivacaine (2.5 mg/kg) after caudal administration in children younger
than 3 years.
Cortínez LI, Fuentes R, Solari S, Ostermann P, Vega M, Muñoz
HR. Anesth Analg. 2008 Oct;107(4):1182-4.Departamento de Anestesiología,
Hospital Clínico Universidad Católica, Marcoleta 367, Santiago,
Chile. licorti@med.puc.c
BACKGROUND: Caudal administration of levobupivacaine (2.5 mg/kg) in children is used frequently in some hospitals. However, no reports of levobupivacaine concentrations have been published with this dosing scheme. We report the results of a study on the pharmacokinetics of levobupivacaine (2.5 mg/kg) after caudal administration in children younger than 3 yr. METHODS: Ten children, aged 1-36 mo and scheduled for subumbilical surgery were studied under sevoflurane anesthesia. After caudal injection of 0.25% levobupivacaine (2.5 mg/kg), serial venous blood samples were taken for 3 h to measure total plasma concentration levels of levobupivacaine. Median (range) levobupivacaine Cmax and Tmax measured were 1.48 (0.62-2.40) microg/mL and 37 (10-60) min. The highest individual Cmax was observed in a 1-mo-old infant 30 min after caudal block. CONCLUSIONS: The highest Cmax reached in this study was close to the toxic threshold of adult patients. Although no adverse events have been reported, care must be taken, especially in small infants, after caudal administration of levobupivacaine (2.5 mg/kg).
Detecting awareness
in children by using an auditory intervention.
Davidson AJ, Sheppard SJ, Engwerda AL, Wong A, Phelan L, Ironfield CM,
Stargatt R. Anesthesiology. 2008 Oct;109(4):619-24. Department of Anaesthesia,
Royal Children's Hospital, Melbourne, Australia. andrew.davidson@rch.org.au
BACKGROUND: The incidence of awareness has been reported to be higher in children than in adults. Accurately assessing awareness in children is difficult, and the lack of a specific measure of awareness makes it difficult to determine exactly how many and why children are aware. The aim of this study was to determine the incidence and timing of awareness in children by using auditory stimuli applied during anesthesia. METHODS: Three easily identified animal noises were played repeatedly through headphones during three specific phases of anesthesia in 539 children aged 5-12 yr. Children were not told that this would happen. Awareness was determined with a structured interview on days 1 and 3 after the anesthetic. All positive responses were sent to four adjudicators for assessment, and awareness was defined as having occurred if all adjudicators agreed that the child was aware. RESULTS: Five hundred children were interviewed at least once after the anesthetic. Thirty-five reports were sent to the adjudicators, and one child was classified as aware. This child was deemed to be aware even though he did not report hearing an animal. CONCLUSIONS: The incidence of awareness in this study is less than reported previously.
Coadministration of
propofol and remifentanil for lumbar puncture in children: dose-response
and an evaluation of two dose combinations.
Hayes JA, Lopez AV, Pehora CM, Robertson JM, Abla O, Crawford MW. Anesthesiology.
2008 Oct;109(4):613-8 Department of Anesthesia, The Hospital for Sick
Children, 555 University Avenue, Toronto, Ontario, Canada. jason.hayes@sickkids.ca
BACKGROUND: The combination of propofol and remifentanil may be particularly suitable for short-duration procedures such as lumbar puncture. The authors undertook a two-part study to evaluate coadministration of propofol and remifentanil as an anesthetic technique for lumbar puncture in children. METHODS: The first part was a sequential allocation dose-finding study to determine the minimum effective dose of remifentanil when coadministered with 2.0 or 4.0 mg/kg propofol. The second was a randomized double-blind study to compare the intraoperative and recovery characteristics of 2.0 or 4.0 mg/kg propofol coadministered with the corresponding effective dose of remifentanil. RESULTS: Effective doses of remifentanil in 98% of children were 1.50 +/- 1.00 and 0.52 +/- 1.06 microg/kg when coadministered with 2.0 and 4.0 mg/kg propofol, respectively. The duration of apnea was longer (median, 110 vs. 73 s; P < 0.05) and the time to awakening was shorter (median, 10 vs. 23 min; P < 0.05) after 2.0 mg/kg propofol plus 1.5 microg/kg remifentanil compared with 4.0 mg/kg propofol plus 0.5 microg/kg remifentanil. No child experienced hypotension or postprocedure nausea or vomiting after either dose combination. CONCLUSIONS: Both dose combinations (2.0 mg/kg propofol plus 1.5 microg/kg remifentanil and 4.0 mg/kg propofol plus 0.5 microg/kg remifentanil) provide effective anesthesia for lumbar puncture in children. However, the intraoperative and recovery characteristics of the two dose combinations differ in that the duration of apnea increases whereas recovery time decreases as the dose of remifentanil is increased and that of propofol is decreased.
Determining the accuracy
of caudal needle placement in children: a comparison of the swoosh test
and ultrasonography.
Raghunathan K, Schwartz D, Connelly NR.Paediatr Anaesth. 2008 Jul;18(7):606-12.Click
here to read Department of Anesthesiology, Baystate Medical Center, Springfield,
MA, USA.
BACKGROUND: The aim of the present study was to compare two confirmatory tests - the 'swoosh' test (auscultation during caudal injection) and real time ultrasound imaging (both transverse 2D imaging and color flow Doppler imaging) in pediatric patients receiving a caudal epidural block. METHODS/MATERIALS: This was a retrospective observational study of caudal injections administered to 83 pediatric patients (0-11 years) presenting for elective surgery over a 4 month time period. While injecting small aliquots of local anesthetic, a standard stethoscope was placed over the lower lumbar spine to auscultate for the 'swoosh' test. An ultrasound machine (Sonosite Titan, Sonosite Inc., Bothell, WA, USA) was then utilized for real-time visualization of caudal injectate. Each test performed during the caudal injection (swoosh, turbulence on 2D imaging, or color flow on Doppler imaging) was recorded as positive, negative or equivocal. RESULTS: Eighty out of 83 patients (96.4%) had a successful caudal block based on minimal or no perioperative narcotic use, minimal or no response to surgical stimulation, the presence of motor blockade and patient comfort in the PACU. Ultrasound was significantly superior to 'swoosh' for sensitivity (96.3% vs 57.5%), negative predictive (40% vs 5.6 value) % and likelihood ratio (2.89 vs 1.73). Specificity and positive predictive value were not different between 'swoosh' and ultrasound. Of the ultrasound tests, turbulence was more sensitive than color flow Doppler (95.0% vs 78.8%). CONCLUSION: Ultrasonography is superior to the 'swoosh' test as an objective confirmatory technique during caudal block placement in children. We found the presence or absence of turbulence during injection within the caudal space to be the best single indicator of caudal success. We think ultrasonography should be used, if available, when teaching this technique.
Awareness in children: another two cases. Blussé Van Oud-Alblas HJ, Bösenberg AT, Tibboel D.Paediatr Anaesth. 2008 Jul;18(7):654-7. Epub 2008 May 8.Click here to readDepartment of Anaesthesiology and Department of Pediatric Surgery, Erasmus University Medical Centre - Sophia Children's Hospital, Rotterdam, The Netherlands. h.blussevanoudalblas@erasmusmc.nl
Intraoperative awareness is an anesthesia complication and occurs when a patient becomes conscious during a procedure performed under general anesthesia and subsequently has recall of these events. Awareness is well described phenomenon in adults, with an incidence of 0.1-0.2 % for low-risk surgical procedures. Recent studies have shown that awareness in children is more common than in adults. However, causes and the long-term psychological impact of awareness in children are unknown. We report on two cases of intraoperative awareness in children in an attempt to throw further light on this complex problem.
Single injection paravertebral block for renal surgery in children.
Berta E, Spanhel J, Smakal O, Smolka V, Gabrhelik T, Lönnqvist PA.Paediatr
Anaesth. 2008 Jul;18(7):593-7. Epub 2008 May 8.Click here to read Department
of Anaesthesia and Intensive Care, University Hospital Olomouc, Olomouc,
Czech Republic. e.berta@email.cz
BACKGROUND: Continuous paravertebral block (PVB) has been successfully used for postoperative analgesia in children. However, data regarding the efficacy of a single injection technique for major renal surgery are still lacking. METHODS: Following the ethics committee approval and parent informed consent, 24 children (median 10.3 months; range: 2.9-26.8) undergoing major renal surgery were included in a prospective observational pilot study. Following a standardized general anesthetic the patients were administered a single injection low thoracic PVB (loss-of-resistance technique; 0.5 ml.kg(-1) of levobupivacaine 2.5 mg.ml(-1) with epinephrine 5 mug.ml(-1)) at the end of surgery. Postoperative pain was assessed by Face, Legs, Activity, Cry, Consolability (FLACC) score at predetermined time points and in case of apparent patients' discomfort during the first 12 postoperative hours. The duration of postoperative analgesia was defined as the interval between PVB and the first supplemental administration of a rescue opioid analgesic. The incidence of complications and postoperative vomiting (POV) was also recorded. RESULTS: A successful PVB was achieved in 23/24 patients (95.8%). The median duration of the block was 600 min (range: 180-720 min) with 10 children not requiring any supplemental analgesia during the 12-h observation period. Vascular puncture was observed in 2/24 children (8.3%) and POV occurred in 4/24 children (16.7%). All complications were considered minor and did not influence recovery. CONCLUSIONS: Single injection PVB provided clinically relevant postoperative analgesia in children undergoing major renal surgery.
Dose-response study
of intrathecal fentanyl added to bupivacaine in infants undergoing lower
abdominal and urologic surgery.
Batra YK, Lokesh VC, Panda NB, Rajeev S, Rao KL.Paediatr Anaesth. 2008
Jul;18(7):613-9. Epub 2008 May 8.Click here to read Departments of Anaesthesia
and Intensive Care, Postgraduate Institute of Medical Education and Research,
Chandigarh, India. ykbatra@glide.net.in
BACKGROUND: Intrathecal (IT) adjuncts often are used to enhance the duration of spinal bupivacaine. Fentanyl is a spinal analgesic that could be a useful adjunct, and enhances the duration and quality of sensory block in adult surgical and obstetric population. However, no data exist to assess the dose-response characteristics of IT fentanyl when added to bupivacaine in infants. METHODS: Fifty-eight infants undergoing lower abdominal and urologic procedures were randomized into four groups to receive plain 0.5% hyperbaric bupivacaine F0 (<5 kg = 0.5 mg.kg(-1); 5-10 kg = 0.4 mg.kg(-1)). Groups F0.25, F0.5, and F1 groups received bupivacaine added with 0.25, 0.5, and 1 mug.kg(-1) of fentanyl, respectively. Duration of spinal anesthesia (SA) as assessed by the recovery of hip flexion in the postoperative period was the primary variable analyzed. In addition, the duration of analgesia in the postoperative period, rescue postoperative analgesic requirements and hemodynamic changes were recorded. RESULTS: Fifty-six infants were studied. The four groups were similar for age, weight, duration of surgery, onset of sensory, motor block, and the highest level of analgesia attained. The addition of 1 mug.kg(-1) fentanyl (F1) significantly increased the duration of SA (74.27 +/- 6.1 min) compared to the control group (51.21 +/- 5.2 min) (P = 0.001). Postoperative pain-free interval was prolonged (P = 0.004) and significantly less rescue analgesics were required after 1 mug.kg(-1) IT fentanyl (P = 0.032). These parameters did not show any significant difference among groups F0, F0.25, and F0.5. CONCLUSIONS: The addition of 1 mug.kg(-1) IT fentanyl to spinal bupivacaine prolonged the duration of spinal block in infants undergoing lower abdominal and urologic procedures.
A new formula of age-related
anatomical landmarks for blockade of the sciatic nerve in the popliteal
fossa in children using the posterior approach.
Bernière J, Schrayer S, Piana F, Vialle R, Murat I.Paediatr Anaesth.
2008 Jul;18(7):602-5. Epub 2008 May 8.Click here to read Department of
Anesthesiology, Armand Trousseau Hospital, Pierre et Marie Curie University,
Paris, France.
BACKGROUND: Anatomical landmarks for sciatic nerve blockade are poorly described in children. In adults, the site of puncture of the high approach is located at least 10 cm above the popliteal skin crease. METHODS: We hypothesized that correcting the adult landmarks (10 cm) by the ratio of the calculated child femoral shaft length over the adult femoral shaft length would provide adequate landmarks for needle introduction for popliteal nerve block in children. RESULTS: The theoretical landmarks were calculated and tested in 21 infants and children. In all cases, the sciatic nerve was easily located using the nerve stimulator when the needle was inserted at the calculated place and 29 catheters were successfully placed in these 21 children. CONCLUSION: These simple landmarks adapted to children age are expected to help the clinicians to perform safely sciatic blocks at the popliteal fossa in young patients.
Continuous infraclavicular
brachial plexus block: a modified technique to better secure catheter
position in infants and children.
Ponde VC. Anesth Analg. 2008 Jan;106(1):94-6, table of contents.Click
here to readDepartment of Anesthesiology, All India Institute of Physical
Medicine and Rehabilitation, Mumbai, India. vrushaliponde@yahoo.co.in
INTRODUCTION: The infraclavicular approach to the brachial plexus provides suitable anesthesia and also lends itself well to stabilizing and securing a catheter for a continuous infusion. We describe an approach for continuous infusions using an infraclavicular approach in children. METHODS: Twenty-five patients aged 8 mo to 3 yr, weighing 7-14 kg, scheduled for forearm and hand surgeries were studied. The infraclavicular brachial plexus was located using a nerve stimulator attached to a sheathed 19-gauge Touhy needle. The needle was inserted through the skin at 1 cm below and 1 cm lateral to the midpoint of the clavicle. The needle was advanced and directed toward the coracoid process maintaining an angle of 30 degrees with the skin. A 20-gauge epidural catheter was passed to the 5-7 cm mark through the Touhy needle. The Touhy needle was removed and the catheter left in place. Bupivacaine (1 mL/kg; 0.25%) was administered through the catheter. A continuous infusion of 0.25 mg/kg/h of bupivacaine (0.125%) was commenced near the end of surgery and continued on the first postoperative day. The continuous infusion was discontinued on the second postoperative day and intermittent boluses were administered every 4 to 6 h. In all patients the catheter was removed after 48 h. RESULTS: Twenty-four patients (96%) had a successful block. On the first postoperative day all patients were pain free (Children's Hospital Eastern Ontario Pain Scale score 4-6). On the second day, two children (8%) needed ibuprofen syrup along with a supplemental dose of local anesthesia. The catheter was passed with ease in all but four children. However, in these four patients, slight needle angulation and a bolus of 1-2 mL local anesthetic solution was required to overcome the resistance. None of the patients had catheter dislodgements or accidental removal, hemorrhagic tap, or pneumothorax. CONCLUSIONS: A modified technique for continuous infraclavicular brachial plexus block helps secure the catheter and provides effective intra- and postoperative pain relief in pediatric patients.
End-of-life decisions in pediatric intensive care. Recommendations of the Italian Society of Neonatal and Pediatric Anesthesia and Intensive Care (SARNePI).Giannini A, Messeri A, Aprile A, Casalone C, Jankovic M, Scarani R, Viafora C; SARNePI Bioethics Study Group.Paediatr Anaesth. 2008 Nov;18(11):1089-95.Click here to read Pediatric Intensive Care Unit, Fondazione IRCCS Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena, Milan, Italy. a.giannini@policlinico.mi.it
End-of-life decisions represent one of the most complex and challenging issues in pediatric intensive care. These recommendations aim to offer Italian pediatric intensive care unit (PICU) teams a framework for the end-of-life decision-making process. The paper proposes a process based on the principle that the use of a diagnostic or therapeutic tool must comply with a 'criterion of proportionality'. Appropriately informed parents, as natural interpreters and advocates of the best interests of their child, can contribute in assessing the burdensomeness of the treatment and determining its proportionality. The decision to limit, withdraw or withhold life-sustaining treatments considered disproportionate represents a clinically and ethically correct choice. This decision should be made (a) collectively by PICU team and the other caregivers, (b) with the explicit involvement of parents, and (c) noting in the patient's clinical record the decisions taken and the reasons behind them. The withdrawing or withholding of life support can never entail the abandonment of the patient nor the withdrawal of any therapy aimed at treating any form of suffering. No action aimed at deliberately hastening the death of the patient is ever acceptable. These recommendations advocate a decision as far as possible shared by patient (whenever feasible), parents and caregivers. Ensuring that all involved are kept fully informed and that there is open and timely communication between them is the key to achieving this. It is the physician in charge of the patient's care and the head of the unit who bear the main responsibility for the final decision.
The hemodynamic effects
of newborn caudal anesthesia assessed by transthoracic echocardiography:
a randomized, double-blind, controlled study.
Deng M, Wang X, Wang L, Zheng S.Paediatr Anaesth. 2008 Nov;18(11):1075-81.Click
here to read Department of Anesthesiology, Children's Hospital of Fudan
University, Shanghai, China. dengmeng05@163.com
BACKGROUND: Caudal anesthesia has been increasingly used in abdominal, urinary tract, and lower extremity surgery of infants. However, little was known about the hemodynamic effects of caudal anesthesia in them, especially in neonates. The purpose of this prospective study was designed to investigate the hemodynamic alterations by transthoracic echocardiography in newborn baby after caudal anesthesia with plain Bupivacaine or with epinephrine added Bupivacaine. METHODS: Thirty full-term newborn infants scheduled for lower abdominal or urinary tract surgery were randomly allocated into three groups (n = 10 each) as follows: (i) GA group: general anesthesia with sevoflurane; (ii) GA+CP group: GA with sevoflurane, combined with caudal anesthesia of plain Bupivacaine (1.25 ml x kg(-1) of 0.2%); (iii) GA+CA group: sevoflurane GA combined with caudal anesthesia of epinephrine-added Bupivacaine (1.25 ml x kg(-1) of 0.2% Bupivacaine plus 1/200,000 epinephrine). Cardiac output (CO), arterial blood pressure, and heart rate were measured before (T-5) and 5(T5), 10(T10), 15(T15) min after performance of caudal anesthesia. RESULTS: In GA group, no significant hemodynamic alteration was observed in comparison with T-5, except HR, which decreased by 7% at T15; In GA+CP group, compared with T-5, HR decreased significantly at T5, T10 and T15, respectively, by 6%, 7% and 10%. And also CO decreased significantly at T15 by 8% compared with T-5; In GA+CA group, no significant hemodynamic alteration was observed expect diastolic arterial blood, which decreased significantly at T15 by 10% compared with T-5; At T15, the larger decrease of systolic arterial blood in GA+CP group and GA+CA group vs (GA) group (P < 0.05). CONCLUSIONS: The study shows the stability of hemodynamic variables during caudal anesthesia with Bupivacaine and with epinephrine-added Bupivacaine in newborn infants.
Hemodynamic effects
of levobupivacaine after pediatric caudal anesthesia evaluated by transesophageal
doppler.
Galante D, Pellico G, Meola S, Caso A, De Capraris A, Milillo R, Mirabile
C, Olivieri M, Cinnella G, Dambrosio M.Paediatr Anaesth. 2008 Nov;18(11):1066-74.Click
here to readUniversity Department of Anesthesia and Intensive Care, University
Hospital Ospedali Riuniti of Foggia, Italy, University of Foggia, Italy.
dario.galante@tin.it
BACKGROUND: The aim of this study is to determine if there are significant differences in hemodynamic effects between combined general-regional anesthesia using levobupivacaine 0.25% 2 ml x kg(-1) via the caudal route in comparison with balanced general anesthesia using continuous infusion of remifentanil in young children undergoing genitourinary surgery. PATIENTS AND METHODS: 62 ASA I-II pediatric patients (12 female, 50 male) aged 6 months to 7 years undergoing genitourinary surgery were included in the study. Patients were randomly allocated into one of two groups of 31 patients each. Group Caud received caudal blockade with levobupivacaine 0.25% 2 mg x kg(-1) in combined general-regional anesthesia and Group Gen received balanced general anesthesia with remifentanil. The noninvasive hemodynamic parameters were measured in each group 5 min after induction of general anesthesia or caudal block (Tcaud), after further 5 min coincident with skin incision (Tsi), 10 min after skin incision (T10i), at the end of surgical procedure (Tend). The time between Tcaud and Tsi was 10 min and the measurements during the interval time T10i-Tend were performed every 15 min according to the duration of surgical procedures. RESULTS: There was a decrease in all measured hemodynamic parameters at skin incision. The decreases occurred in both groups with those in the caudal group occurring at skin incision and those in the balanced anesthesia group occurring at 10 min after skin incision. These variations showed no significant differences for any of the stated outcomes; neither between the groups at each time point nor in the caudal in comparison with baseline measurements. CONCLUSIONS: Using transesophageal Doppler no differences in hemodynamic parameters could be detected between balanced general anesthesia with either caudal levobupivacaine or remifentanil infusion. Both techniques showed good hemodynamic stability with only minor changes from baseline over time which are unlikely to be of clinical significance except possibly in patients with preexisting cardiovascular compromise. Other studies with noninvasive monitoring in a larger population are required to better understand the consequences of caudal blockade on CO and on regional blood flow in infants.
Effect of remifentanil on oculocardiac reflex in paediatric strabismus surgery. Chung CJ, Lee JM, Choi SR, Lee SC, Lee JH.Acta Anaesthesiol Scand. 2008 Oct;52(9):1273-7.Click here to read Department of Anaesthesia & Pain Medicine, Dong-A University Hospital, Busan, Korea. cjchung@dau.ac.kr
BACKGROUND: Rapidly acting narcotics enhance the degree of bradycardia due to the oculocardiac reflex (OCR) elicited by extraocular muscle (EOM) tension during strabismus surgery. We evaluated and compared the effects of remifentanil and sevoflurane on OCR during paediatric strabismus surgery. METHODS: One hundred and twenty children, 1-9 years old, undergoing elective strabismus surgery, were randomly assigned to receive sevoflurane or remifentanil. No anticholinergic prophylaxis was administered. Anaesthesia was induced using ketamine 1.0 mg/kg or midazolam 0.15 mg/kg with 66% N(2)O in O(2). Laryngeal mask airways were placed with rocuronium 0.5 mg/kg. Anaesthesia was maintained with sevoflurane 2.0-3.0 vol% with 66% N(2)O in O(2) or remifentanil 0.75 mug/kg over 1 min and followed by the continuous infusion of remifentanil 0.5 mug/kg/min with 66% N(2)O in O(2). Heart rate (HR) and blood pressure (BP) were measured and compared. OCR was defined as a reduction in HR of >20% induced by traction of an EOM. RESULTS: During anaesthesia, HR and BP were maintained at a lower level in the remifentanil group than in the sevoflurane group (each, P<0.05). The mean percent change in HR (-23.3+/-17.0% vs. -11.2+/-13.0%; P<0.05) and the incidence of OCR (58.3% vs. 28.3%; P<0.05) following traction of an EOM were higher in the remifentanil group than in the sevoflurane group. CONCLUSIONS: Remifentanil enhanced the degree of bradycardia due to OCR as compared with sevoflurane during paediatric strabismus surgery.
Intraoperative awareness during paediatric anaesthesia.Blussé van Oud-Alblas HJ, van Dijk M, Liu C, Tibboel D, Klein J, Weber F.Br J Anaesth. 2009 Jan;102(1):104-10. Epub 2008 Nov 5.Click here to read Department of Anaesthesiology.
BACKGROUND: /st> Previous studies indicate a higher incidence of awareness during anaesthesia in children than in adults, that is, around 1% vs 0.2%. In this prospective cohort study, we determined the incidence of intraoperative awareness in children undergoing elective or emergency surgery at a university children's hospital. METHODS: /st> Data from 928 consecutive paediatric patients, aged 5-18 yr, were collected prospectively over a 12 month period. Interviews using a structured questionnaire were scheduled at three time points: within 24 h after the operation, and 3-7 and 30 days after operation. Reports of suspected awareness were sent to four independent adjudicators. If they all agreed, the case was classified as a true awareness case. RESULTS: /st> The interviews generated 26 cases of suspected awareness. Six cases were judged to be true awareness, equalling a 0.6% incidence (95% confidence interval 0.03-1.40%). Auditory and sensory perceptions were the sensations most reported by these six children. Pain, anxiety, and paralysis were less often mentioned. The children in general did not report awareness as stressful. CONCLUSIONS: /st> The incidence of awareness in this study, in children undergoing general anaesthesia, is comparable with recent reports from other countries, and appears to be higher than that reported in adults.
MAC-awake of sevoflurane in children.Davidson AJ, Wong A, Knottenbelt G, Sheppard S, Donath S, Frawley G. Paediatr Anaesth. 2008 Aug;18(8):702-7.Click here to readDepartment of Anaesthesia & Pain Management, Royal Children's Hospital, Vic., Australia. andrew.davidson@rch.org.au
INTRODUCTION: Age influences the potency of anesthetic agents, but there is little information on how age influences MAC-awake. MAC-awake may be an important aspect of anesthesia potency for the prevention of awareness during anesthesia. The aim of this study was to measure MAC-awake in a range of ages in children. METHODS: After institutional ethics approval and informed parental consent 60 children were enrolled; 20 in each of three age groups (2 to <5, 5 to <8 and 8-12 years). Children were excluded if they had opioids, sedative premedication or a procedure likely to cause any residual discomfort. All children had sevoflurane anesthesia. At the end of the procedure the sevoflurane was decreased to the target concentration. Once the target endtidal concentration was achieved it was maintained for 10 min before a standard stimulus was applied and an observer determined if the child was awake. The Dixon up-down method was used to determine progression of subsequent concentrations and MAC-awake (ED50) for the three age groups were obtained using the probit model. RESULTS: This study found evidence for a difference in ED50 between age groups (P = 0.008). The MAC-awake was highest in the youngest group (0.66%) and similar in the older groups (0.45% and 0.43%). CONCLUSION: Although MAC-awake changes with age, in the ages where awareness has been reported, MAC-awake was found to be relatively low, and therefore it seems unlikely that age-specific changes to MAC-awake are a cause for awareness in children aged 5-12 years.
Ultrasound-guided serial
ilioinguinal nerve blocks for management of chronic groin pain secondary
to ilioinguinal neuralgia in adolescents.
Suresh S, Patel A, Porfyris S, Ryee MY. Paediatr Anaesth. 2008 Aug;18(8):775-8.Click
here to read Research & Chronic Pain Center, Children's Memorial Hospital
and Associate Professor of Anesthesiology & Pediatrics, Northwestern
University, Feinberg School of Medicine, Chicago, IL, USA. ssuresh@childrensmemorial.org
We examined the efficacy of serial ilioinguinal nerve blocks using ultrasound guidance for management of chronic inguinal pain secondary to persistent ilioinguinal neuralgia in adolescents. This case series consists of two adolescents who had persistent inguinal pain secondary to ilioinguinal neuralgia who were treated with conventional pain medications that did not relieve the pain. One patient had pain immediately following surgery while the other had pain several months after an injury. Serial ilioinguinal nerve blocks were performed with local anesthetic solution using ultrasound guidance in an outpatient setting. Both the adolescents had complete relief of pain symptoms and were able to resume normal activities. There were no adverse effects associated with the blocks. Performance of serial ilioinguinal nerve blocks using ultrasonography in an outpatient setting in adolescents and adolescents with ilioinguinal neuralgia may reduce pain and allow these adolescents to resume their normal activities.
The dynamic relationship
between end-tidal sevoflurane concentrations, bispectral index, and cerebral
state index in children.
Fuentes R, Cortínez LI, Struys MM, Delfino A, Muñoz H.Anesth
Analg. 2008 Nov;107(5):1573-8.Click here to readDepartamento de Anestesiología,
Hospital Clínico U. Católica, Marcoleta 367, Santiago, Chile.
BACKGROUND: To guide anesthetic administration with electroencephalogram monitors in children, an adequate characterization of the anesthetic effect measured by these monitors in this population is needed. We sought to quantify and compare the dynamic profile of sevoflurane's effect measured with the cerebral state index (CSI) and the bispectral index (BIS) in children. METHODS: Fifteen healthy children, aged 3-15 yr, scheduled to undergo minor surgery were prospectively studied. During the simultaneous recording of CSI and BIS, the sevoflurane vaporizer was set at 6 vol % for 5 min and then decreased. End-tidal concentrations (C(ET)) were measured. The C(ET)-sevoflurane effect-site concentration equilibration and pharmacodynamics were modeled. Goodness of fit between models was compared. Data are typical value (coefficient of variation). RESULTS: Within the anesthetic depth range studied, the rate of change of sevoflurane's effect expressed as the effect-site equilibration half-life (t(1/2) k(e0)) was slower with the CSI [2.0 (14) min] than with BIS [1.2 (53) min] (P < 0.05). The estimated baseline effect of BIS and CSI before sevoflurane administration (E(0)) was 84 (39) for CSI and 87 (7) for BIS (NS). The sensitivity to sevoflurane hypnotic effect expressed in the C(50) [steady-state C(ET) eliciting half of the maximum response (E(max))] was 2.1 (68) % with CSI and 2.1 (16)% with BIS (NS). The E(max) with CSI 45 (0) was higher than that with BIS 27 (39) (P < 0.05). The population prediction error was significantly better for BIS (-0.7 +/- 26.9) than for CSI (-3.0 +/- 178.6) (P < 0.05). CONCLUSIONS: In children, the t(1/2) k(e0) of sevoflurane and the pharmacodynamics of sevoflurane were quantified and the results were entirely dependent on the monitor used to measure its hypnotic effect. Within the anesthetic depth range studied, the rate of change of sevoflurane's effect was slower with the CSI. To adequately guide sevoflurane administration with these monitors in children, these differences should be considered.
Impact of anesthetic agents on cerebrovascular physiology in children.Szabó EZ, Luginbuehl I, Bissonnette B. Paediatr Anaesth. 2008 Nov 5. [Epub ahead of print]Department of Anaesthesia, University of Toronto, Toronto, ON, Canada.
Summary The role of the pediatric neuroanesthetist is to provide comprehensive care to children with neurologic pathologies. The cerebral physiology is influenced by the developmental stage of the child. The understanding of the effects of anesthetic agents on the physiology of cerebral vasculature in the pediatric population has significantly increased in the past decade allowing a more rationale decision making in anesthesia management. Although no single anesthetic technique can be recommended, sound knowledge of the principles of cerebral physiology and anesthetic neuropharmacology will facilitate the care of pediatric neurosurgical patients.
Hemodynamic effects of levobupivacaine after pediatric caudal anesthesia evaluated by transesophageal doppler.
Galante D, Pellico G, Meola S, Caso A, De Capraris A, Milillo R, Mirabile C, Olivieri M, Cinnella G, Dambrosio M.
Paediatr Anaesth. 2008 Nov;18(11):1066-74.
Ultrasound needle guidance in neonatal and infant caudal anesthesia.
Galante D.
Paediatr Anaesth. 2008 Aug 19. [Epub ahead of print] No abstract available.
Transesophageal Doppler probe and proseal laryngeal mask airway. A new technique for probe insertion in pediatric anesthesia.
Galante D.
Anesth Analg. 2008 Jul;107(1):348. No abstract available.
Anesthetic management of children with pulmonary arterial hypertension.
Galante D, Meola S, Pellico G, Tancredi ML, Milillo R.
Paediatr Anaesth. 2008 Jun;18(6):562-3; author reply 563-4. No abstract available.
Effects of remifentanil on propofol requirements for loss of consciousness in target-controlled infusion.
Galante D. Minerva Anestesiol. 2008 May;74(5):219. No abstract available.
ProSeal as an alternative to endotracheal intubation in pediatric laparoscopy.
Galante D, Katsanou A, Tancredi ML, Milillo R, Pellico G.
Paediatr Anaesth. 2008 Jan;18(1):83-4; author reply 84-5. No abstract available.
Intraoperative hypothermia. Relation between general and regional anesthesia, upper- and lower-body warming: what strategies in pediatric anesthesia?
Galante D.
Paediatr Anaesth. 2007 Sep;17(9):821-3. No abstract available.
New formulae for predicting tracheal tube length.
Galante D, Pellico G.
Paediatr Anaesth. 2007 Jul;17(7):710-1; author reply 711. No abstract available.
Cuffed tracheal tubes in children - things have changed.
Galante D, Pellico G.
Paediatr Anaesth. 2007 Jun;17(6):602; author reply 602-3. No abstract available.
Volatile agents and caudal block.
Galante D, Dambrosio M, Cinnella G, Pellico G, Federico A, Pugliese P, Sforza D.
Paediatr Anaesth. 2007 Apr;17(4):398-9; author reply 400. No abstract available.
Postextubation adverse events in children undergoing general anesthesia.
Galante D, Pellico G, Federico A, Schiraldi R, Matella M, Milillo R, Dambrosio M, Cinnella G.
Paediatr Anaesth. 2007 Feb;17(2):192; author reply 193. No abstract available.
Caudal block complication in a patient with trisomy 13.
Galante D, Pellico G.
Paediatr Anaesth. 2006 Sep;16(9):999-1000; author reply 1000. No abstract available.
A technique to improve the safety of laryngeal mask airway when used in lacrimal duct surgery.
Galante D, Pellico G.
Paediatr Anaesth. 2006 Aug;16(8):896. No abstract available.
Preoperative apnea in a preterm infant after caudal block with ropivacaine and clonidine.
Galante D.
Paediatr Anaesth. 2005 Aug;15(8):708-9. No abstract available.
Evaluation of the haemostasis before a central block in children: What is the French anaesthesiologist's attitude? Pajot S, Asehnoune K, Le Roux C, Léturgie C, Surbled M, Bazin V, Lejus C. Ann Fr Anesth Reanim. 2008 Dec 3 Service d'anesthésie et de réanimation chirurgicale, Hôtel-Dieu-hôpital Mère-Enfant, CHU de Nantes, place Alexis-Ricardeau, 44093 Nantes cedex 01, France.
OBJECTIVE: Because of the lack of controlled studies, there is no consensus regarding the practice of routine haemostasis tests before neuraxial blockade in children. The purpose of this study was to describe the French surgical practice about the preoperative evaluation of coagulation in children who were scheduled for paediatric neuraxial anaesthesia. STUDY DESIGN: Descriptive analysis of the practice. METHODS: A telephone survey for coagulation screening was conducted in French surgical paediatric units, known to perform paediatric neuraxial anaesthesia on a routine basis. The aim of the standardized questionnaire was to evaluate the expertise in performance of neuraxial block, the modalities of the preoperative haemostasis screening, and the indications of biological tests and to assess whether a standardized team procedure was used. RESULTS: Forty-two hospitals (27 universities, 10 general hospitals and five private institutions) were contacted; 61 anaesthesiologists with an expertise with central block answered the survey. Thirty-five institutions used a standardized procedure and 57,1% of them undertook routines tests only in children who are not walking. In the remaining 42,9%, the strategy was to screen systematically all patients whatever their age, familial and personal history as well as physical examination. However, only 54% of the anaesthesiologists performed an extensive physical examination in order to detect symptoms in favour of signs of haemostatic disorders. CONCLUSION: While numerous data suggest that routine testing does not to provide much extra information in the absence of a positive history, a systematic strategy is still widely applied in children. Guidelines need to be developed to insure the safety of oriented tests.
Comparison between sedation and general anesthesia for endoscopy in children.Abushahwan I, Lamontagne C, Murto K, Splinter B. Can J Anaesth. 2008 Jun;55 Suppl 1:463761.
Introduction: With the increasing safety of endoscopic examination, upper and lower gastrointestinal (G.I) endoscopy are being performed with increasing frequency in children. G.I endoscopy can be done with intravenous sedation or under general anesthesia. In many medical centers, the use of general anesthesia for upper and lower gastrointestinal endoscopy has been replaced by intravenous sedation. The aim of this study was to compare the safety and efficacy of general anesthesia and deep sedation in children undergoing gastrointestinal endoscopy. METHODS: After ethics committee approval, 125 children, 1 to 6 years of age, ASA I-III, undergoing elective upper and/or lower gastrointestinal endoscopy were enrolled. Children were divided into three groups. In Group 1 anesthesia was induced and maintained with a combination of air/oxygen/sevoflurane. In Group 2, anesthesia was induced with propofol 2 mg/kg and maintained with propofol 250-300 mcg/kg/min. In Group 3, anesthesia was induced with sevoflurane and maintained with a combination of propofol 80 mcg/kg/min and remifentanil 0.1 mcg/kg/min. Demographic data, hemoglobin oxygen saturation, respiratory rate, blood pressure, and heart rate were monitored continuously and recorded at baseline and every 5-minutes. Adverse effects, recovery time, and discharge time were also recorded RESULTS: 121 children completed the study. Hemodynamic stability was maintained in all children throughout the procedure. Respiratory depression was observed in two children in the GA group, and three children in the propofol group. No episodes of respiratory drepression were observed in the propofol/remifentanil group. Episodes of desaturation (SaO2 < 90 mmHg) were observed in 3 children in the GA group, two patients in the propofol group, and in one child of the propofol remifentanil group. Rescue bolus of propofol 1mg/kg was needed in two children in the propofol group and one patient in the propofol/remifentanil group due to excessive movement. All children had their eyes open within 5 min after arrival to the recovery area. No complications were recorded in the recovery period.Discussion: Based on the result of this study, this study show that deep sedation and general anesthesia are equally effective and safe anesthetic regimens in spontaneously breathing children undergoing gastrointestinal endoscopy.
Postoperative pain relief in infants undergoing myringotomy and tube placement: comparison of a novel regional anesthetic block to intranasal fentanyl--a pilot analysis. Voronov P, Tobin MJ, Billings K, Coté CJ, Iyer A, Suresh S. Paediatr Anaesth. 2008 Dec;18(12):1196-201. Pediatric Anesthesiology, Children's Memorial Hospital, Feinberg School of Medicine, Northwestern University, Chicago, IL 60614, USA.
AIM: The aim of this study was to investigate the use of a novel regional anesthetic technique for the management of pain in the postoperative period in infants and children undergoing myringotomy and tube placement. METHODS: After institutional review board (IRB) approval was obtained, 200 children were randomized in this double blind, prospective, randomized controlled trial to receive either a nerve block of the auricular branch of the Vagus (Nerve of Arnold) with 0.2 ml of 0.25% bupivacaine or receive intranasal fentanyl 2 mcg.kg(-1) after induction of general anesthesia. Patients were monitored in the recovery room for analgesia, need for additional analgesia, incidence of nausea and vomiting, and time to discharge from the hospital. Additional analgesics administered in the PACU, surgical short-stay unit as well as at home were also recorded. RESULTS: There was no difference in the pain scores between groups (P = 0.53); there was no difference in the amount of rescue medications between groups (P = 0.86); there was no difference in the incidence of nausea and vomiting between groups (P = 0.34); there was no difference in the time to discharge between groups (P = 0.5). CONCLUSIONS: This pilot study demonstrates the efficacy of a peripheral nerve block for management of postoperative pain in infants and children undergoing myringotomy and tube placement. This may be a viable alternative for postoperative pain control in this population. Future multi-center, randomized controlled trials may be necessary to validate the efficacy of this block in infants and children.
The effects of 45 degree head up tilt on the lumbar puncture success rate in children undergoing spinal anesthesia. Apiliogullari S, Duman A, Gok F, Ogun CO, Akillioglu I. Paediatr Anaesth. 2008 Dec;18(12):1178-82.Click here to read Department of Anesthesia and Intensive Care, Dr Faruk Sukan Obstetrics and Children's Hospital, Konya, Turkey. sapiliogullari@yahoo.com
BACKGROUND: There are few studies for procedural techniques of lumbar puncture (LP) for spinal anesthesia in children. There are no controlled studies on the effect of patient positioning. We designed this prospective, randomized study to compare the success rates of LP of the lateral decubitus and lateral decubitus position with a 45 degree head up tilt in children undergoing spinal anesthesia. METHODS: Study was conducted in 180 children aged between one month to twelve years. The LP was performed under general anesthesia using sevoflurane with a 26-gauge, atraumatic needle either in the standard lateral decubitus, knee-chest position (group I, n = 90) or lateral decubitus, knee-chest position with a 45 degree head up tilt (group II, n = 90). The free flow of clear cerebrospinal fluid (CSF) at first attempt was considered to evidence a successful LP. RESULTS: The two groups were similar in age and weight. Total LP success rate was higher in group II than in group I (P < 0.05). When the significance between the groups was evaluated according to age, the increase in LP success rate was significant in children aged <12 months of age but not significant in children older than 12 months of age. CONCLUSIONS: Because of higher success rate, lateral decubitus, knee-chest position with 45 degree head up tilt may be the preferred position for spinal anesthesia in infants.
Ultrasound-guided supraclavicular vs infraclavicular brachial plexus blocks in children. De José María B, Banús E, Navarro Egea M, Serrano S, Perelló M, Mabrok M. Paediatr Anaesth. 2008 Sep;18(9):838-44. Department of Paediatric Anaesthesiology, Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain. bdejosemaria@hsjdbcn.org
BACKGROUND: Supraclavicular brachial plexus blocks are not common in children because of risk of pneumothorax. However, infraclavicular brachial plexus blocks have been described in paediatric patients both with nerve stimulation and ultrasound (US)-guidance. US-guidance reduces the risk of complications in supraclavicular brachial plexus blocks in adults. OBJECTIVE: To compare the success rate, complications and time of performance of US-guided supraclavicular vs infraclavicular brachial plexus blocks in children. MATERIAL AND METHODS: Eighty children, 5-15 years old, scheduled for upper limb surgery were divided into two randomized groups: group S (supraclavicular), n = 40, and group I (infraclavicular), n = 40. All blocks performed were exclusively US-guided, by a senior anaesthesiologist with at least 6 months of experience in US-guided blocks. For supraclavicular blocks the probe was placed in coronal-oblique-plane in the supraclavicular fossa and the puncture was in-plane (IP) from lateral to medial. For infraclavicular blocks the probe was placed parallel and below the clavicle and the puncture was out-of-plane. Ropivacaine 0.5% was administered up to a maximum of 0.5 ml x kg(-1) until appropriate US-guided-spread was achieved. Block duration and volumes of ropivacaine used (mean+/-1SD) in the supraclavicular approach were recorded. Success rate (mean +/- 1 SD, 95%confidence interval), complications rate and time to perform the block (two-tailed Student's test) were recorded both for supraclavicular and infraclavicular approaches. RESULTS: In the US-guided supraclavicular brachial plexus blocks, the duration of the sensory block was 6.5 +/- 2 h and of the motor block was 4 +/- 1 h. The volume of ropivacaine used in this group was 6 +/- 2 ml. In group I, 88% of blocks achieved surgical anaesthesia without any supplemental analgesia compared with 95% in group S (P = 0.39; difference=7%; 95% CI: -10% to 24%). Failures in group I were because of arterial puncture and insufficient ulnar or radial sensory block. Failures in group S were because of insufficient ulnar sensory block. No pneumothorax or Horner's syndrome was recorded in either group. The mean time (SD) to perform the block was in group I: 13 min (range 5-16) and in group S: 9 min (range 7-12); the 95% CI for this difference was 2-6 min and was statistically significant (P < 0.05). CONCLUSIONS: (i) Ultrasound-guided supraclavicular and infraclavicular brachial plexus blocks are effective in children. (ii) There has been no pneumothorax in 40 US-guided supraclavicular brachial plexus blocks performed by anaesthesiologists already trained in US-guided regional anaesthesia using an IP technique in children > or =5 years old. (iii) In this study, the supraclavicular approach of the brachial plexus was faster to perform than the infraclavicular one.
The optimum concentration of levobupivacaine for intra-operative caudal analgesia in children undergoing inguinal hernia repair at equal volumes of injectate. Yao YS, Qian B, Chen BZ, Wang R, Tan L. Anaesthesia. 2009 Jan;64(1):23-6. Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China.
Probit analysis was used to predict the median effective concentration (EC(50)) and the 95% effective concentration (EC(95)) values of levobupivacaine for caudal analgesia in children at equal volumes of injectate. Sixty children scheduled for inguinal herniorrhaphy were recruited. Anaesthesia was induced with sevofurane and nitrous oxide. Then caudal block (total volume of local anaesthetic 1 ml.kg(-1)) was performed. Patients randomly received one of six concentrations (0.08%, 0.10%, 0.12%, 0.14%, 0.16% or 0.18%) of levobupivacaine. Thereafter, inhalational anaesthetics were discontinued and intravenous midazolam 0.1 mg.kg(-1) was administered to maintain sedation. The effective caudal analgesia was defined as an absence of gross movements and a haemodynamic (heart rate or blood pressure) reaction < 20% compared with baseline in response to surgical incision. Our data indicated that the EC(50) and EC(95) values of levobupivacaine for caudal analgesia were 0.109% (95% confidence intervals 0.098-0.120%) and 0.151% (95% confidence intervals 0.135-0.193%) when using the same volume (1 ml.kg(-1)), respectively.
A national survey of the anesthetic management of tonsillectomy surgery in children. Allford M, Guruswamy V. Paediatr Anaesth. 2008 Dec 18.Department of Anaesthesia, Leeds General Infirmary, Leeds, UK.
Summary Background: Tonsillectomy in children is a common procedure; however, there appears to be a significant degree of variability in anesthetic management. Thus far, there has been no large national survey looking at the perioperative care of these children. Objectives: We conducted a national survey with the aim of determining what represents common practice in the perioperative management of children undergoing tonsillectomy surgery. We compared the respondents' management against evidence-based practice. Methods: The survey took the form of a questionnaire, which was sent to members of The Association of Paediatric Anaesthetists (APAGBI) and to Royal College tutors. The questionnaire was sent in paper format to the College Tutors and in digital format to APAGBI members. Emphasis was placed upon preoperative preparation, induction technique, airway management, analgesia, postoperative nausea and vomiting strategy, fluid management and emergence from anesthesia. Results: Responses were obtained from 173 individuals representing a broad cross-section of anesthetists from teaching and district general hospitals. Findings are as follows: the application of topical anesthetic cream is commonplace (93%), with Ametop((R)) being the primary preparation used; the intravenous route was preferred to induce anesthesia; most practitioners intubate the trachea to maintain the airway during anesthesia (79%); a muscle relaxant was employed to assist intubation of the trachea in 47% of respondents and the routine use of suxamethonium was reported to be uncommon (9%); the administration of prophylactic ondansetron and dexamethasone was reported by 79% and 70% of respondents respectively; and nonsteroidal anti-inflammatory drugs (NSAIDs) are used by 77% of individuals either pre-emptively or during the intraoperative period. Conclusions: Whilst there is individual variability in the management of these cases, the majority of anesthetists prefer the intravenous route for induction of anesthesia, after application of topical anesthetic cream. It is routine practice to intubate the trachea, administer paracetamol, NSAIDs, strong opiates and antiemetics.
Does epidural analgesia delay the diagnosis of lower limb compartment syndrome in children? Johnson DJ, Chalkiadis GA.Paediatr Anaesth. 2008 Dec 15. Department of Anaesthesia and Pain Management, Royal Children's Hospital, Parkville, Vic., Australia.
Summary One of the cardinal symptoms of compartment syndrome is pain. A literature review was undertaken in order to assess the association of epidural analgesia and compartment syndrome in children, whether epidural analgesia delays the diagnosis, and to identify patients who might be at risk. Evidence was sought to offer recommendations in the use of epidural analgesia in patients at risk of developing compartment syndrome of the lower limb. Increasing analgesic use, increasing/breakthrough pain and pain remote to the surgical site were identified as important early warning signs of impending compartment syndrome in the lower limb of a child with a working epidural. The presence of any should trigger immediate examination of the painful site, and active management of the situation (we have proposed one clinical pathway). Avoidance of dense sensory or motor block and unnecessary sensory blockade of areas remote to the surgical site allows full assessment of the child and may prevent any delay in diagnosis of compartment syndrome. Focusing on excluding the diagnosis of compartment syndrome rather than failure of analgesic modality is vital. In the pediatric cases reviewed there was no clear evidence that the presence of an epidural had delayed the diagnosis.
A national survey of the anesthetic management of tonsillectomy surgery in children. Allford M, Guruswamy V. Paediatr Anaesth. 2009 Feb;19(2):145-52.
Department of Anaesthesia, Jubilee Wing, Leeds General Infirmary, Leeds, UK. mark.allford@dsl.pipex.com
BACKGROUND: Tonsillectomy in children is a common procedure; however, there appears to be a significant degree of variability in anesthetic management. Thus far, there has been no large national survey looking at the perioperative care of these children. OBJECTIVES: We conducted a national survey with the aim of determining what represents common practice in the perioperative management of children undergoing tonsillectomy surgery. We compared the respondents' management against evidence-based practice. METHODS: The survey took the form of a questionnaire, which was sent to members of The Association of Paediatric Anaesthetists (APAGBI) and to Royal College tutors. The questionnaire was sent in paper format to the College Tutors and in digital format to APAGBI members. Emphasis was placed upon preoperative preparation, induction technique, airway management, analgesia, postoperative nausea and vomiting strategy, fluid management and emergence from anesthesia. RESULTS: Responses were obtained from 173 individuals representing a broad cross-section of anesthetists from teaching and district general hospitals. Findings are as follows: the application of topical anesthetic cream is commonplace (93%), with Ametop being the primary preparation used; the intravenous route was preferred to induce anesthesia; most practitioners intubate the trachea to maintain the airway during anesthesia (79%); a muscle relaxant was employed to assist intubation of the trachea in 47% of respondents and the routine use of suxamethonium was reported to be uncommon (9%); the administration of prophylactic ondansetron and dexamethasone was reported by 79% and 70% of respondents respectively; and nonsteroidal anti-inflammatory drugs (NSAIDs) are used by 77% of individuals either pre-emptively or during the intraoperative period. CONCLUSIONS: Whilst there is individual variability in the management of these cases, the majority of anesthetists prefer the intravenous route for induction of anesthesia, after application of topical anesthetic cream. It is routine practice to intubate the trachea, administer paracetamol, NSAIDs, strong opiates and antiemetics.
A cohort evaluation of the pediatric ProSeal laryngeal mask airway in 100 children. Kelly F, Sale S, Bayley G, Cook T, Stoddart P, White M.Paediatr Anaesth. 2008 Oct;18(10):947-51
Department of Anaesthesia, Bristol Royal Hospital for Children, Bristol, UK.
BACKGROUND: The ProSeal laryngeal mask airway (PLMA) has been available in pediatric sizes in the UK since 2007. Although several non-UK studies have evaluated PLMAs in children, there are little published data regarding their use in this country. Having decided to introduce the pediatric PLMA into our practice, we chose to prospectively audit the first 100 uses as part of our clinical governance. METHODS: We studied children undergoing elective surgery who were considered suitable for a supraglottic airway. We recorded patient, surgical and insertion details, device performance data and complications. Patient management was not altered by inclusion in this audit. RESULTS: Twenty size 1.5, 55 size 2.0, 15 size 2.5 and 10 size 3.0 PLMAs were inserted in 100 consecutive children [median age 2 years (range 2 months to 10 years) and median weight 15 kg (range 4.9-60 kg)]. The overall first attempt success rate was 93% (size 1.5, 100%; size 2.0, 100%; size 2.5, 87%; size 3.0, 90%) and overall successful insertion rate was 99%. Median leak pressure was 25 cmH(2)O. Outright failure was seen in one patient; complications were seen in another six patients (partial airway obstruction in five patients and mild laryngospasm in one patient), all of whom were transient and none of whom required intubation. No episodes of regurgitation were recorded. CONCLUSIONS: Even without prior experience and using nonconventional insertion, pediatric PLMAs (including size 1.5) can be easily inserted and provide an effective airway.
Muscle relaxant use for tracheal intubation in pediatric anaesthesia: a survey of clinical practice in Germany. Nauheimer D, Fink H, Fuchs-Buder T, Geldner G, Hofmockel R, Ulm K, Wallek B, Blobner M.Paediatr Anaesth. 2009 Mar;19(3):225-31 Klinik für Anästhesiologie, Intensiv-, Notfallmedizin und Schmerztherapie, Klinikum Ludwigsburg, Germany. nauhdi01@kliniken-lb.de
OBJECTIVES: Aim of this Germany-wide study was to evaluate the use and application customs of neuromuscular blocking drugs (NMBDs) for tracheal intubation in children of age 5 years or younger. MATERIAL AND METHODS: In the year 2005, a total of 3260 questionnaires were sent out to all heads of anesthesia departments at all types of hospitals as well as ambulatory anesthesia centers in Germany. The fields covered by the questionnaire were regarding institutional size, amount of general anesthesia and specifically pediatric cases, number of intubations and NMBDs used, frequency of use of the individual relaxants and techniques utilized when administering muscle relaxants. RESULTS: Of the sent-out questionnaires 66.9% could be analyzed: 82% of hospitals use 1-3 muscle relaxants in children; 91% of the ambulatory anesthesia centers use a repertoire of 1-2 neuromuscular blockers for pediatric cases. However, general anesthesia with tracheal intubation in children is often induced without using any NMBD at all. Mivacurium is the predominantly used NMBD for pediatric intubation in Germany. In contrast, the use of succinylcholine is far less in ambulatory anesthesia centers than in hospitals. Despite controversial discussion, precurarization, priming, and timing are still utilized in German anesthesia practice. CONCLUSION: In Germany, mivacurium, with its favorable pharmacologic profile for short cases, is the predominantly used NMBD for pediatric tracheal intubation. Despite the known adverse effects of intubation without muscle relaxation, this technique is also wide-spread, especially among German anesthetists in ambulatory anesthesia centers. Surveys like these are important to determine a status quo of use and application customs of NMBDs in pediatric anesthesia and provide a basis for numerous other studies.
Paediatric airway management: basic aspects. Holm-Knudsen RJ, Rasmussen L . Acta Anaesthesiol Scand. 2009 Jan;53(1):1-9.S.
Department of Anaesthesia, Center of Head and Orthopaedics, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark. rhk@rh.dk
Paediatric airway management is a great challenge, especially for anaesthesiologists working in departments with a low number of paediatric surgical procedures. The paediatric airway is substantially different from the adult airway and obstruction leads to rapid desaturation in infants and small children. This paper aims at providing the non-paediatric anaesthesiologist with a set of safe and simple principles for basic paediatric airway management. In contrast to adults, most children with difficult airways are recognised before induction of anaesthesia but problems may arise in all children. Airway obstruction can be avoided by paying close attention to the positioning of the head of the child and by keeping the mouth of the child open during mask ventilation. The use of oral and nasopharyngeal airways, laryngeal mask airways, and cuffed endotracheal tubes is discussed with special reference to the circumstances in infants. A slightly different technique during laryngoscopy is suggested. The treatment of airway oedema and laryngospasm is described.
Airway management in children: ultrasonography assessment of tracheal intubation in real time? Marciniak B, Fayoux P, Hébrard A, Krivosic-Horber R, Engelhardt T, Bissonnette B .Anesth Analg. 2009 Feb;108(2):461-5. Pôle d'Anesthésie Réanimation, Hôpital Jeanne de Flandre, CHRU, Rue Eugène Aviné, 59037 Lille Cedex France. bmarciniak@chru-lille.fr
BACKGROUND: Pediatric tracheal intubation requires considerable expertise and can represent a challenge to many anesthesiologists. Confirmation of correct tracheal tube position relies on direct visualization or indirect measures, such as auscultation and capnography. These methods have varying sensitivity and specificity, especially in the infant and young child. Ultrasonography is noninvasive and is becoming more readily available to the anesthesiologist. In this study, we investigated the characteristic real-time ultrasonographic findings of the normal pediatric airway during tracheal intubation and its suitability for clinical use. METHODS: Thirty healthy children with normal airways requiring tracheal intubation were studied. Ultrasonographic measurements of the pediatric airway during tracheal intubation under deep inhaled anesthesia were performed using a Sonosite Titan (Sonosite, Bothell, WA) scanner while recording characteristic images during this process. Correct tracheal tube placement was further confirmed using auscultation and satisfactory end-tidal capnography. RESULTS: The mean (+/- sd) age of studied patients was 48 +/- 37 mo, weight was 19.7. +/- 8.6 kg and the sex ratio (m/f) was 1:2. Successful tracheal intubation was verified using the following criteria: 1) identification of the trachea and tracheal rings, 2) visualization of vocal cords, 3) widening of glottis as the tracheal tube passes through, and 4) tracheal tube position above carina and demonstration of movement of the chest wall visceroparietal pleural interface (i.e., sliding sign) after manual ventilation of the lungs. One esophageal intubation was readily recognized by visualization of the tube in the left paratracheal space. CONCLUSION: This study describes characteristic ultrasonographic findings of the pediatric airway during tracheal intubation. It suggests that ultrasonography may be useful for airway management in children.
Anesthesia for major general surgery in neonates with complex cardiac defects. Walker A, Stokes M, Moriarty A.Paediatr Anaesth. 2009 Feb;19(2):119-25
Birmingham Children's Hospital NHS Foundation Trust, Birmingham, West Midlands, UK. amywalker@doctors.org.uk
Centers with large cardiac workloads may be presented with neonates who need major general surgery before correction or palliation of a serious cardiac defect. This is still a rare situation with only three short case reports available in the medical literature (1-3). We have reviewed the anesthetic and analgesic regimens of 18 such neonates who presented to the Birmingham Children's Hospital in the 4-year period 2004-2007. These children require meticulous preoperative evaluation and although it might be anticipated that they would pose a serious challenge to anesthetists, in reality with thorough investigation, preparation, and careful management, they tolerate general anesthesia well. These children may be transferred to centers of specialist pediatric cardiac anesthesia to be benefited from experience obtained there.
Relative analgesic potencies of levobupivacaine and ropivacaine for caudal anesthesia in children. Ingelmo P, Frawley G, Astuto M, Duffy C, Donath S, Disma N, Rosano G, Fumagalli R, Gullo A.Anesth Analg. 2009 Mar;108(3):805-13 Department of Perioperative Medicine and Intensive, A.O. San Gerardo, Monza, Italy.
BACKGROUND: Comparing relative potency of new local anesthetics, such as levobupivacaine and ropivacaine, by the minimum local analgesic concentration model has not been described for caudal anesthesia. Therefore, we performed a prospective, randomized, double-blind study to determine the minimum local analgesic concentrations of a caudal single shot of ropivacaine and levobupivacaine in children and to describe the upper dose-response curve. METHODS: We performed a two-stage prospective, randomized, double-blind study comparing the dose-response curves of caudal ropivacaine and levobupivacaine in children. In phase 1, 80 boys were randomized to receive either ropivacaine or levobupivacaine. In the second phase a further 32 patients were randomly allocated to receive caudal anesthesia with doses designed to delineate the upper dose-response range (the 50% effective dose [ED(50)]-ED(95) range). RESULTS: There were no significant differences in ED(50) values for caudal ropivacaine and levobupivacaine. The ED(50) for levobupivacaine estimated from the Dixon Massey method was 0.069% (95% CI 0.056%-0.082%) and for ropivacaine was 0.075% (95% CI 0.058%-0.092%). Estimated by isotonic regression the ED(50) and ED(95) respectively of levobupivacaine were 0.068 (0.04-0.09) and 0.20% (95% CI 0.16%-0.24%). For ropivacaine ED 50 and ED95 were 0.066 (0.033-0.098) and 0.225% (95% CI 0.21%-0.24%). CONCLUSIONS: In children receiving one minimum alveolar anesthetic concentration of sevoflurane, there were no significant differences in the ED(50) for caudal levobupivacaine and ropivacaine. The potency ratio at ED(50) was 0.92 and 0.89 at ED(95), indicating that caudal levobupivacaine and ropivacaine have a similar potency.
The incidence and nature of adverse events during pediatric sedation/anesthesia with propofol for procedures outside the operating room: a report from the Pediatric Sedation Research Consortium. Cravero JP, Beach ML, Blike GT, Gallagher SM, Hertzog JH; Pediatric Sedation Research Consortium. Anesth Analg. 2009 Mar;108(3):795-804 Department of Anesthesiology and Pediatrics, Dartmouth Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH 03756-0001, USA. Joseph.Cravero@Hitchcock.Org
OBJECTIVE: We used a large database of prospectively collected data on pediatric sedation/anesthesia outside the operating room provided by a wide range of pediatric specialists to delineate the nature and frequency of adverse events associated with propofol-based sedation/anesthesia care. PATIENTS AND METHODS: Data were collected by the Pediatric Sedation Research Consortium, a collaborative group of institutions dedicated to improving sedation/anesthesia care for children internationally. Members prospectively enrolled consecutive patients receiving sedation or sedation/anesthesia for procedures. The primary inclusion criterion was the need for some form of sedation/anesthesia to perform a diagnostic or therapeutic procedure outside the operating room. There were no exclusion criteria. Data on demographics, primary illness, coexisting illness, procedure performed, medications used, procedure and recovery times, medication doses outcomes of anesthesia, airway interventions and adverse events were collected and reported using web-based data collection tool. For this study, we evaluated all instances where propofol was used as the primary drug in the sedation/anesthesia technique. RESULTS: Thirty-seven locations submitted data on 49,836 propofol sedation/anesthesia encounters during the study period from July 1, 2004 until September 1, 2007. There were no deaths. Cardiopulmonary resuscitation was required twice. Aspiration during sedation/anesthesia occurred four times. Less serious events were more common with O(2) desaturation below 90% for more than 30 s, occurring 154 times per 10,000 sedation/anesthesia administrations. Central apnea or airway obstruction occurred 575 times per 10,000 sedation/anesthesia administrations. Stridor, laryngospasm, excessive secretions, and vomiting had frequencies of 50, 96, 341, and 49 per 10,000 encounters, respectively. Unexpected admissions (increases in levels of care required) occurred at a rate of 7.1 per 10,000 encounters. In an unadjusted analysis, the rate of pulmonary adverse events was not different for anesthesiologists versus other providers. CONCLUSIONS: We report the largest series of pediatric propofol sedation/anesthesia for procedures outside the operating room. The data indicate that propofol sedation/anesthesia is unlikely to yield serious adverse outcomes in a collection of institutions with highly motivated and organized sedation/anesthesia services. However, the safety of this practice is dependent on a system's ability to manage less serious events. We propose that our data suggest variables for training and credentialing providers of propofol sedation/anesthesia and the system characteristics that promote safe use of this drug.
Remifentanil in paediatric anaesthetic practice. Marsh DF, Hodkinson B. Anaesthesia. 2009 Mar;64(3):301-8
Department of Anaesthesia, Queen Alexandra Hospital, Portsmouth, UK. debbie.marsh@porthosp.nhs.uk
Remifentanil is a synthetic opioid, first introduced into clinical practice in 1996. Its unique pharmacokinetic profile has resulted in a gradual increase in its popularity in paediatric anaesthesia. It is an opioid of high potency and rapid clearance, consequently lacking problems of accumulation. These characteristics give it a high degree of predictability and it has become an attractive choice for a wide variety of anaesthetic challenges, from premature neonates to the elderly. Neonates and infants have a higher clearance than older children and, as a result, remifentanil has additional benefits in this group. Remifentanil can be described as the only consistently predictable opioid in paediatric practice.
Ketamine or alfentanil administration prior to propofol anaesthesia: the effects on ProSeal laryngeal mask airway insertion conditions and haemodynamic changes in children. Begec Z, Demirbilek S, Onal D, Erdil F, Ilksen Toprak H, Ozcan Ersoy M. Anaesthesia. 2009 Mar;64(3):282-6 Inonu University, School of Medicine, Malatyam Turkey. zozpolat@inonu.edu.tr
This study was designed to compare the effects of ketamine and alfentanil administered prior to induction of anaesthesia with propofol, on the haemodynamic changes and ProSeal laryngeal mask airway (PLMA) insertion conditions in children. Eighty children, aged between 3-132 months, were randomly allocated to receive either alfentanil 20 microg.kg(-1) (alfentanil group) or ketamine 0.5 mg.kg(-1) (ketamine group) before induction of anaesthesia. Ninety seconds following the administration of propofol 4 mg.kg(-1), a PLMA was inserted. In the ketamine group, heart rate and mean arterial pressure were higher during the study period compared with the alfentanil group (p < 0.05). The time for the return of spontaneous ventilation was prolonged in the alfentanil group (p = 0.004). In conclusion, we found that the administration of ketamine 0.5 mg.kg(-1) with propofol 4 mg.kg(-1) preserved haemodynamic stability, and reduced the time to the return of spontaneous ventilation, compared with alfentanil 20 microg.kg(-1) during PLMA placement. In addition, the conditions for insertion of the PLMA with ketamine were similar to those found with alfentanil.
Subtenon block compared to intravenous fentanyl for perioperative analgesia in pediatric cataract surgery. Ghai B, Ram J, Makkar JK, Wig J, Kaushik S. Anesth Analg. 2009 Apr;108(4):1132-8.Click here to read Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India.
BACKGROUND: General anesthesia with opioids provides good operative conditions for ocular surgery in children; however, postoperative pain management remains a significant problem. Regional anesthesia is commonly used as an adjunct to general anesthesia in children. We compared the efficacy and safety of subtenon block (SB) versus IV fentanyl for perioperative analgesia in pediatric cataract surgery. We hypothesized that perioperative analgesia using SB may reduce the requirement of postoperative rescue analgesia compared with fentanyl. METHODS: This was a prospective, randomized, controlled, double-blind trial. One hundred fourteen ASA I and II children (6 mo-6 yr) undergoing elective cataract surgery in one eye under general anesthesia were studied. Children were randomly allocated to one of the two groups, i.e., Group SB (n = 58) or Group F (n = 56) after securing the airway. Children in Group SB received SB with 0.06-0.08 mL/kg of 2% lidocaine and 0.5% bupivacaine (50:50) mixture and simultaneous 0.2 mL/kg normal saline IV, whereas children in Group F received 1 microg/kg (0.2 mL/kg of 5 microg/kg) of fentanyl IV and simultaneous subtenon injection with normal saline (0.06-0.08 mL/kg). Surgery started after 5 min of study drug administration. Postoperative assessment for pain, sedation, and nausea/vomiting was done at 0.5, 1, 2, 3, 4, and 24 h. The primary outcome was number of patients requiring rescue analgesia during the 24-h study period. Secondary outcomes assessed were pain and sedation scores, time to first rescue analgesia, incidence of occulocardiac reflex, and nausea/vomiting. RESULTS: The number of patients requiring rescue analgesia during the 24 h was significantly less in Group SB (n = 17/58, 29.3%) compared with Group F (n = 39/56, 69.6%, P < 0.001). The postoperative pain scores were statistically lower in Group SB at all time intervals. The median (range) time to first analgesic requirement was significantly prolonged in Group SB (16 [2-13] vs 4 [0.5-8.5] h in Group F) (P < 0.001). Sedation scores at (1/2) h were comparable, after which significantly more children were anxious or crying in Group F compared with Group SB in which more children were calm, sitting, or lying with eyes open and relaxed (P < 0.05). A significantly higher incidence of oculocardiac reflex was recorded in Group F versus Group SB (P = 0.019). No complication related to SB was noticed. CONCLUSIONS: SB is a safe and superior alternative to IV fentanyl for perioperative analgesia in pediatric cataract surgery.
Clinical evaluation of a pressure release valve for paediatric cuffed tracheal tubes Fertl S, Bernet V, Schmitz A, Woitzek K, Weiss M. Anästhesieabteilung, Universitäts-Kinderkliniken Zürich, Steinwiesstr. 75, Zürich, Schweiz.
OBJECTIVE: The safe use of cuffed tracheal tubes for children necessitates a cuff pressure limitation at 20-25 cmH2O. The aim of the study was to evaluate the reliability and benefit of a new cuff pressure release valve (opening pressure 20 cmH2O) for children intubated with a cuffed tracheal tube. METHODS: In a prospective, observational trial cuff pressure was recorded in paediatric and adolescent patients intubated with a cuffed tracheal tube during sevoflurane/nitrous oxide anaesthesia. The cuff pressure release valve was interposed between the cuff manometer and the pilot balloon. In 25 patients measurements were started at the initial opening pressure (group A) and in a further 25 patients measurements were started at the minimal sealing cuff pressure (group B). RESULTS: A total of 50 patients, aged from 0.4 to 17.8 years (median 7.4 years) were enrolled in the study. The opening pressure measured (group A) was 19.7+/-0.8 cmH(2)O and the cuff sealing pressure (group B) was 11.7+/-2.9 cmH2O (range 6-16 cmH2O). Mean cuff pressure values in group A were 20.4+/-1.6 cmH2O and 16.5+/-3.3 cmH2O in group B. In one patient (group A) the cuff pressure exceeded 25 cmH2O and was manually decreased to 20 cmH2O. In total, 24 filling procedures (group A 14; group B 10) were required during 103.1 h of investigation because of cuff pressure drop and audible air leakage, mainly caused by cuff pressure increases and consequent releases during patient positioning. CONCLUSION: Our data demonstrate that the tested cuff pressure release valve was useful and reliable to limit cuff pressure in tracheal intubated children and adolescents within an acceptable pressure range.
Intrathecal neostigmine with bupivacaine for infants undergoing lower abdominal and urogenital procedures: dose response.
Batra YK, Rajeev S, Panda NB, Lokesh VC, Rao KL. Acta Anaesthesiol Scand. 2009 Apr;53(4):470-5. Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India. ykbatra@glide.net.in
BACKGROUND: Intrathecal (IT) neostigmine produces dose-dependent analgesia in adults. However, the dose of spinal neostigmine has not been investigated in infants. The purpose of this study was to assess spinal anesthesia (SA) duration provided by four doses of spinal neostigmine added to bupivacaine for lower abdominal and urogenital procedures in infants. METHODS: Seventy-five infants were randomized into five groups. The control group B received IT plain 0.5% hyperbaric bupivacaine. Groups BN.25, BN.50, BN.75, and BN1.0 received bupivacaine with 0.25, 0.5, 0.75, and 1 microg/kg of neostigmine, respectively. The primary variable was the duration of anesthesia assessed by recovery of hip flexion. Postoperative pain with facial expression, leg activity, arm activity, crying and consolability scale score, and rescue analgesic requirements were the secondary variables measured, and the side effects were noted. RESULTS: Seventy-three infants completed the study. There was a significant linear increase in SA duration with IT neostigmine to 65.2 (4.3) min with 0.5 microg/kg (P<0.01), 88.2 (5.1) with 0.75 microg/kg (P<0.001) and 92 (4.3) with 1 microg/kg (P<0.001) from 52.4 (4.3) min with bupivacaine alone. SA duration showed no significant difference between plain bupivacaine and BN.25 (P=0.100) or between groups BN.75 and BN1.0 (P=0.451). Groups BN.75 and BN1.0 had significantly reduced pain scores, and the median duration before the first dose rescue analgesic was requested prolonged significantly (P<0.001) compared with the other three groups. CONCLUSIONS: IT neostigmine at a dose of 0.75 microg/kg added to bupivacaine significantly prolonged SA duration with reduced postoperative pain scores and rescue analgesic requirements in infants undergoing lower abdominal and urogenital procedures. No additional benefits were provided on increasing it to 1 microg/kg.
Growth rates in pediatric diagnostic imaging and sedation.Wachtel RE, Dexter F, Dow AJ.Anesth Analg. 2009 May;108(5):1616-21
Department of Anesthesia, University of Iowa, Iowa City, Iowa 52242, USA.
BACKGROUND: Workload has increased greatly over the past decade for anesthesia providers administering general anesthesia and/or sedation for pediatric diagnostic imaging. METHODS: Data from an academic medical center were studied over a 12-yr period. Growth in the number of children 0-17 yr of age undergoing magnetic resonance imaging (MRI) and/or computerized tomography (CT) scans who received care from anesthesia providers was compared with the increase in the total number of MRI and CT procedures performed in children. Anesthesia providers included anesthesiologists, residents, Certified Registered Nurse Anesthetists, and student Certified Registered Nurse Anesthetists. Toward the end of the study, a team of sedation nurses was employed by the hospital to administer moderate sedation. They provided an alternative to anesthesia providers from the anesthesia department, who usually administered general anesthesia. Use of sedation nurses versus anesthesia providers, and the relationship to scan duration and patient age, were studied over a 6-mo period. RESULTS: The number of children receiving care from anesthesia providers for MRI and CT scans grew at the same 8%-9% annual rate as the number of scans performed. The percentage of children receiving anesthesia care did not change over the 12 yr. Creation of a nurse sedation team that provided moderate sedation did not alter the number of children receiving care from anesthesia providers but did increase the total number of children receiving hypnotics. Anesthesia was rarely used for scans shorter than 30 min in duration. Increases in scan duration were associated with increased utilization of anesthesia providers for both MRI and CT after stratifying by age. An age of 3-5 yr was associated with the highest rates of anesthesia care. CONCLUSIONS: Future workload for anesthesia providers administering general anesthesia and/or sedation for pediatric diagnostic imaging will depend on trends in the total number of scans performed. Workload may also be sensitive to factors that increase scan duration or alter the percentage of patients in the 3-5 yr age group. It may additionally depend on reimbursements from insurance companies.
Ultrasound versus landmark-based technique for ilioinguinal-iliohypogastric nerve blockade in children: the implications on plasma levels of ropivacaine. Weintraud M, Lundblad M, Kettner SC, Willschke H, Kapral S, Lönnqvist PA, Koppatz K, Turnheim K, Bsenberg A, Marhofer P.Anesth Analg. 2009 May;108(5):1488-92. Department of Anesthesia, Intensive Care Medicine and Pain Therapy, Medical University of Vienna, Vienna, Austria.
BACKGROUND: Ilioinguinal-iliohypogastric nerve blockade (INB) is associated with high plasma concentrations of local anesthetics (LAs) in children. Ultrasonographic guidance enables exact anatomical administration of LA, which may alter plasma levels. Accordingly, we compared plasma levels of ropivacaine after ultrasonographic versus landmark-based INB. METHODS: After induction of general anesthesia, 66 children (8-84 mo) scheduled for inguinal hernia repair received INB with 0.25 mL/kg of ropivacaine 0.5% (1.25 mg/kg) either by a landmark-based (n = 31) or by an ultrasound-guided technique (n = 35). Ropivacaine plasma levels were measured before (0) and 5, 10, 20, and 30 min after the LA injection, using high-performance liquid chromatography. Maximum plasma concentrations (C(max)), time to C(max) (t(max)), the absorption rate constant (k(a)), the speed of rise of the plasma concentration at Time 0 (dC(0)/dt), and area under the curve value (AUC) were determined. RESULTS: The ultrasound-guided technique resulted in higher C(max) (sd), k(a), dC(0)/dt, and AUC values and shorter t(max) compared with the landmark-based technique (C(max): 1.78 [0.62] vs 1.23 [0.70] microg/mL, P < 0.01; k(a): 14.4 [10.7] vs 11.7 [11.4] h(-1), P < 0.05; dC(0)/dt: 0.26 [0.12] vs 0.15 [0.03] microg/mL . min, P < 0.01; AUC: 42.4 [15.9] vs 27.2 [18.1] microg . 30 min/mL, P < 0.001; t(max): 20.4 [8.6] vs 25.3 [7.6] min, P < 0.05). CONCLUSIONS: The pharmacokinetic data indicate faster absorption and higher maximal plasma concentration of LA when ultrasound was used as a guidance technique for INB compared with the landmark-based technique. Thus, a reduction of the volume of LA should be considered when using an ultrasound-guided technique for INB.
Pediatric laryngeal dimensions: an age-based analysis. Dalal PG, Murray D, Messner AH, Feng A, McAllister J, Molter D.Anesth Analg. 2009 May;108(5):1379-81. Department of Anesthesiology, Penn State Milton S Hershey Medical Center, Hershey, Pennsylvania 17033, USA. pdalal@hmc.psu.ed
BACKGROUND: In children, the cricoid is considered the narrowest portion of the "funnel-shaped" airway. Growth and development lead to a transition to the more cylindrical adult airway. A number of airway decisions in pediatric airway practice are based on this transition from the pediatric to the adult airway. Our primary aim in this study was to measure airway dimensions in children of various ages. The measures of the glottis and cricoid regions were used to determine whether a transition from the funnel-shaped pediatric airway to the cylindrical adult airway could be identified based on images obtained from video bronchoscopy. METHODS: One hundred thirty-five children (ASA physical status 1 or 2) aged 6 mo to 13 yr were enrolled for measurement of laryngeal dimensions, including cross-sectional area (G-CSA), anteroposterior and transverse diameters at the level of the glottis and the cricoid (C-CSA), using the video bronchoscopic technique under general anesthesia. RESULTS: Of the 135 children enrolled in the study, seven patients were excluded from the analysis mainly because of poor image quality. Of the 128 children studied (79 boys and 49 girls), mean values (+/-standard deviation) for the demographic data were age 5.9 (+/-3.3) yr, height 113.5 (+/-22.2) cm and weight 23.5 (+/-13) kg. Overall, the mean C-CSA was larger than the G-CSA (48.9 +/- 15.5 mm(2) vs 30 +/- 16.5 mm(2), respectively). This relationship was maintained throughout the study population starting from 6 mo of age (P < 0.001, r = 0.45, power = 1). The mean ratio for C-CSA: G-CSA was 2.1 +/- 1.2. There was a positive correlation between G- and the C-CSA versus age (r = 0.36, P < 0.001; r = 0.27, P = 0.001, respectively), height (r = 0.34, P < 0.001; r = 0.29, P < 0.001, respectively), and weight (r = 0.35, P < 0.001; r = 0.25, P = 0.003, respectively). No significant gender differences in the mean values of the studied variables were observed. CONCLUSION: In this study of infants and children, the glottis rather than cricoid was the narrowest portion of the pediatric airway. Similar to adults, the pediatric airway is more cylindrical than funnel shaped based on these video bronchoscopic images. Further studies are needed to determine whether these static airway measurements in anesthetized and paralyzed children reflect the dynamic characteristics of the glottis and cricoid in children.
Prospective, randomized comparison of ProSealTM and ClassicTM laryngeal mask airways in anaesthetized neonates and infants.
Micaglio M, Bonato R, De Nardin M, Parotto M, Trevisanuto D, Zanardo V, Doglioni N, Ori C.Br J Anaesth. 2009 May 19. Institute of Anesthesia and Intensive Care, Department of Pharmacology and Anesthesiology.
BACKGROUND: /st> When compared with the Classic laryngeal mask airway (cLMA), the recently introduced ProSeal laryngeal mask airway (PLMA) has modified features to produce higher airway seal pressures and enable ventilation in circumstances where the cLMA might fail. The first neonatal size 1 PLMA recently became available. This study was designed to compare the effectiveness of the size 1 cLMA and PLMA during positive pressure ventilation in anesthetized neonates and infants. METHODS: /st> Forty-six consecutive patients undergoing elective cardiac surgical procedures were randomized for initial airway management with the cLMA or PLMA. Insertion time (IT), number of placement attempts, ease of placement, quality of the initial airway, maximum tidal volume (TV(max)), and airway pressure at which an audible leak in the mouth (P(leak)) occurred were collected. All data were recorded before performing tracheal intubations. RESULTS: /st> IT and success rate were similar for both LMAs. The initial quality of the airway was significantly better for the PLMA (P<0.05). TV(max) and P(leak) were significantly higher for PLMA (77 vs 58 ml, P<0.02 and 29.8 vs 24.4 cm H(2)O, P<0.02). No adverse events were recorded during the study. CONCLUSIONS: /st> The size 1 PLMA forms a more effective seal than size 1 cLMA in neonates. This might allow the PLMA to be used in those newborn infants requiring high airway pressures for ventilation.
Pressure volume curves of paediatric laryngeal mask airways. Wallace CJ, Chambers NA, Erb TO, von Ungern-Sternberg BS.Anaesthesia. 2009 May;64(5):527-31. Department of Anaesthesia, Princess Margaret Hospital for Children, Perth, Australia.
Hyperinflation of the laryngeal mask airway cuff may exert high pressure on pharyngeal and laryngeal structures. In vitro data show that high intra cuff pressures may occur when inflated to only 30% of the manufacturer's recommended maximum inflation volume. We prospectively assessed the pressure volume curves of paediatric sized laryngeal mask airways (size 1-3) in 240 consecutive children (0-15 years). Following laryngeal mask airway insertion the cuff was inflated with 1-ml increments of air up to the maximum recommended by the manufacturer. After each ml cuff pressure was measured. At the end all cuff pressures were adjusted to 55 cmH(2)O. The maximum recommended volume resulted in high intracuff pressures in all laryngeal mask airway brands and sizes studied. Approximately half the maximum volume produced a cuff pressure > or = 60 cmH(2)O. This occurred in all brands and all sizes studied. We recommend that cuff manometers should be used to guide inflation in paediatric laryngeal mask airways.
Does ultrasound guidance improve the success rate of infraclavicular brachial plexus block when compared with nerve stimulation in children with radial club hands?
Ponde VC, Diwan S. Anesth Analg. 2009 Jun;108(6):1967-70. Department of Anesthesiology, All India institute of physical Medicine and Rehabilitation, Mumbai, Maharashtra, India. vrushaliponde@yahoo.co.in
BACKGROUND: The classical response to nerve stimulation may be altered in cases of radial club hand. Ultrasound guidance may prove to be a useful tool in such situations. In this study, we compared the success rate of ultrasound-guided infraclavicular brachial plexus block with nerve stimulation for children undergoing radial club hand repair. METHODS: Fifty children, aged 1-2 yr, undergoing radial club hand repair were randomly assigned to receive infraclavicular brachial plexus block guided by nerve stimulator (Group NS) or ultrasound (Group U) in combination with light general anesthetic. Bupivacaine 0.5 mL/kg of 0.5% was injected in both groups. Pain response to surgical stimulus was considered as block failure. The Children's Hospital Eastern Ontario Pain Scale pain score was recorded at 1, 4, 6, 8, and 10 postoperative hours. RESULTS: In Group NS, the blocks were successful in 16 of 25 patients (64%), whereas in Group U, 24 of 25 patients had successful blocks (P = 0.0053). There was no difference in the time to first analgesia or analgesic consumption in the 10-h study period. CONCLUSION: Ultrasound-guided infraclavicular brachial plexus block improves the success rate in patients with radial club hands when compared with nerve stimulation in patients undergoing radial club hand correction.
Are peripheral and neuraxial blocks with ultrasound guidance more effective and safe in children? Rubin K, Sullivan D, Sadhasivam S. Paediatr Anaesth. 2009 Feb;19(2):92-6. Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA.
BACKGROUND AND AIMS: The efficacy and safety of ultrasound guided (USG) pediatric peripheral nerve and neuraxial blocks in children have not been evaluated. In this review, we have looked at the success rate, efficacy and complications with USG peripheral nerve blocks and compared with nerve stimulation or anatomical landmark based techniques in children. METHODS: All suitable studies in MEDLINE, EMBASE Drugs and Cochrane Evidence Based Medicine Reviews: Cochrane Database of Systemic Reviews databases were identified. In addition, citation review and hand search of recent pediatric anesthesia and surgical journals were done. All three authors read all selected articles independently and a consensus was achieved. All randomized controlled trials (RCTs) comparing USG peripheral and neuraxial blocks with other techniques in children were included. RESULTS: Ultrasound guidance has been demonstrated to improve block characteristics in children including shorter block performance time, higher success rates, shorter onset time, longer block duration, less volume of local anesthetic agents and visibility of neuraxial structures. CONCLUSION: Clinical studies in children suggest that US guidance has some advantages over more traditional nerve stimulation-based techniques for regional block. However, the advantage of US guidance on safety over traditional has not been adequately demonstrated in children except ilio-inguinal blocks.
The addition of fentanyl to 1.5 mg/ml ropivacaine has no advantage for paediatric epidural analgesia.Cho JE, Kim JY, Hong JY, Kil HK. Acta Anaesthesiol Scand. 2009 Jun 30
Background: Epidural opioids are frequently combined with local anaesthetics for an additive antinociceptive effect. We investigated the efficacy of epidural fentanyl to 1.25 or 1.5 mg/ml ropivacaine for post-operative epidural analgesia in children. Methods: One hundred and eight children undergoing hypospadias repair were randomized to receive 1.25 mg/ml ropivacaine (R(1.25) group), 1.25 mg/ml ropivacaine with 0.2 mcg/kg/h of fentanyl (R(1.25)F group), 1.5 mg/ml ropivacaine (R(1.5) group) or 1.5 mg/ml ropivacaine with 0.2 mcg/kg/h of fentanyl (R(1.5)F group) for post-operative epidural analgesia. The epidural catheter was threaded caudally through the L4-5 interspace. The face, legs, activity, cry, consolability (FLACC) score was assessed at every hour and at FLACC score >4, an epidural bolus of 0.5 ml/kg of ropivacaine 1.5 mg/ml was given as the rescue analgesia. The incidence of side effects such as hypoxia, sedation, pruritus, nausea and/or vomiting was recorded. Results: The need for rescue analgesia was higher in the R(1.25) group compared with that in the other three groups (all P<0.05). The incidence of side effects was higher in the R(1.5)F group compared with that in the R(1.25) and R(1.5) groups (both P=0.010). Conclusion: The addition of 0.2 mcg/kg/h fentanyl to 1.5 mg/ml ropivacaine increased the incidence of side effects without improvement of analgesia in infants and children undergoing hypospadias repair. The use of plain 1.25 mg/ml ropivacaine increased the need for rescue analgesia and this could be compensated by addition of fentanyl.
Ultrasound-guided transversus abdominis plane block for neonatal abdominal surgery.Fredrickson MJ, Seal P. Anaesth Intensive Care. 2009 May;37(3):469-72.
This paper describes four neonates having abdominal procedures with intraoperative and early postoperative analgesia provided by a transversus abdominis plane regional block. Analgesia for neonatal upper and mid-abdominal surgery usually involves regional anaesthesia and/or systemic opioid. All these analgesia techniques have problems specific to the neonatal period. Neonates are sensitive to the respiratory depressant effects of systemic opioid, while the low threshold for local anaesthetic toxicity limits regional anaesthesia/analgesia, which in neonatal upper abdominal surgery is often limited to local anaesthetic infiltration. The transversus abdominis plane block has been shown to provide effective analgesia following a variety of abdominal surgeries in both adults and children. We report four neonates who underwent minor or major abdominal surgery under general anaesthesia supplemented by ultrasound-guided transversus abdominis plane block. Perioperative opioids were administered to one neonate who required postoperative ventilation. Ultrasound-guided transversus abdominis plane bock is a technically feasible alternative to local anaesthetic wound infiltration in the neonate and warrants further evaluation.
Pediatric airway foreign body retrieval: surgical and anesthetic perspectives.Zur KB, Litman RS.Paediatr Anaesth. 2009 Jul;19(s1The Pediatric Airway):109-117.
Airway foreign body aspiration most commonly occurs in young children and is associated with a high rate of airway distress, morbidity, and mortality. The presenting symptoms of foreign body aspiration range from none to severe airway obstruction, and may often be innocuous and nonspecific. In the absence of a choking or aspiration event, the diagnosis may be delayed for weeks to months and contribute to worsening lung disease. Radiography and high resolution CT scan may contribute to the eventual diagnosis. Bronchoscopy is used to confirm the diagnosis and retrieve the object. The safest method of removing an airway foreign body is by utilizing general anesthesia. Communication between anesthesiologist and surgeon is essential for optimal outcome. The choice between maintenance of spontaneous and controlled ventilation is often based on personal preference and does not appear to affect the outcome of the procedure. Complications are related to the actual obstruction and to the retrieval of the impacted object. The localized inflammation and irritation that result from the impacted object can lead to bronchitis, tracheitis, atelectasis, and pneumonia.
Diagnostic accuracy of anesthesiology evaluation timing: the 'One-Stop Anesthesia' in pediatric day-surgery. Mangia G, Presutti P, Antonucci A, Bianco F, Bonomo R, Ferrari P. Department of Anaesthesiology, San Camillo Hospital, Rome, Italy. mangia.giovanni@fastwebnet.i. Paediatr Anaesth. 2009 Aug;19(8):764-9.
OBJECTIVE: Assessing timing efficacy of anesthetic evaluation in pediatric day-surgery by a diagnostic accuracy study. AIM: Lowering hospital visits in patients with negative medical history. BACKGROUND: Pediatric patients scheduled for day-surgery procedures can be categorized, according to their history, in two groups. One, the largest, includes healthy patients and the other includes those with medical conditions that necessitate further evaluation. MATERIALS AND METHODS: Clinical data are collected by the pediatric surgeons of our department and reviewed by an anesthetist who then selects the timing of anesthesiology evaluation, which will take place in the same day of the procedure (One-Stop Anesthesia), or some days before it, in a dedicated setting (Pre-Admission Clinic). In 2008, 332 children, older than 12 months, screened by that method, underwent surgical procedures in general anesthesia. RESULTS: Our data were examined using Bayesian Statistical Analysis. In the 'One-Stop Anesthesia' group, true positive were 290 (87.4%) and false positive 4 (1.2%). Of the 38 patients assessed by our Pre-Admission Clinic, true negative were 30 (9%) and false negative 8 (2.4%). Sensibility (97.3%), specificity (88.2%), positive predictive value (98.6%), negative predictive value (78.9%), diagnostic accuracy (96.4%), likelihood positive (8.3), and likelihood negative (0.03) were calculated. CONCLUSIONS: Timing the preoperative anesthesiologist's evaluation avoided 88% of hospital visits, usually to the Pre-Admission Clinic, and thus, it was cost effective, reducing direct and indirect costs of healthcare providers.
A retrospective analysis of anesthesiologic complications in pediatric neurosurgery. Aleksic V, Radulovic D, Milakovic B, Nagulic M, Vucovic D, Antunovic V, Djordjevic M. Department of Anesthesia and Reanimation, Institute for Neurosurgery, Clinical Center of Serbia, Koste Todorovica 8, Belgrade, Serbia.Paediatr Anaesth. 2009 Jul 13.
Summary Background and objective: Different clinical and surgical factors can influence the occurrence of anesthesiologic complications in pediatric neurosurgery. Preoperative knowledge of these factors is of great importance in the application of safe anesthetics and a favorable surgical outcome. The objective was to establish the importance of clinical and surgical risk factors on the frequency of anesthesia complications in pediatric neurosurgery. Data and method: The research, from 1996 to 2000, involved 705 children, aged from <1 year to 15 years, who underwent surgery for elective neurosurgical pathology and severe head injuries. We analysed the influence that: age, the preoperative neurologic diagnosis, the urgency of the operation, additional disorders, the surgical position, and the duration of anesthesia had on the frequency of anesthesia complications. To test the statistical relevance and to confirm the hypothesis, the Pearson's chi-square test, Mann-Whitney U-test, and univariate and multivariate logistic regressions were used. Results: Anesthesia complications (cardiovascular, respiratory, air embolism, allergic reactions) were present in 68/705 (9.6%) patients. Their frequency was statistically greater in children for whom the surgery was >240 min, who were in the sitting position and when comorbidity was evident. Neither age nor the urgency of the operation or reoperation had any significant influence on the occurrence of anesthetic complications. Conclusion: The duration of anesthesia, the sitting position of the patient, and the presence of comorbidities significantly increase the risk of anesthesia complications in pediatric neurosurgery.
Anesthetic experience of 100 pediatric tracheostomies.Wrightson F, Soma M, Smith JH. Department of Anaesthesia, Great Ormond Street Hospital, London, UK. Paediatr Anaesth. 2009 Jul;19(7):659-66.
BACKGROUND: Tracheostomy is more hazardous in the pediatric population than in adults (Paediatr Nurs, 17, 2005, 38; Int J Pediatr Otorhinolaryngol, 67, 2003, 7; J R Soc Med, 89, 1996, 188). Airway management in these children and infants is potentially challenging. Previous case series of pediatric tracheostomy published in the surgical journals make little mention of anesthetic techniques used and do not describe airway management. The aim of this study was to review the anesthetic, and in particular the airway management of children undergoing tracheostomy at Great Ormond Street Hospital (GOSH). METHODS: Between September 2004 and December 2007, the ENT surgical database showed that 109 children had a surgical tracheostomy performed at GOSH. We were only able to locate the notes of 100 of these cases. The anesthetic records of these 100 patients undergoing tracheostomy were analyzed retrospectively. RESULTS: Ninety-four percent (94/100) of tracheostomies were elective, and 6% (6/100) were emergency. In this study, 26% (26/100) of children were recorded as difficult to intubate. These difficult airways were managed as follows: 10/26 used a laryngeal mask airway (LMA), 5/26 were managed with facemask alone, 3/26 had fiber-optic intubation, 5/26 had surgical intubation and 2/26 were intubated with the aid of a bougie and cricoid pressure. CONCLUSIONS: This case series demonstrates that intubation is difficult in up to 26% of children presenting for tracheostomy. While intubation of the trachea remains the preferred option when anesthetizing children for tracheostomy, the LMA or facemask can provide a successful airway where intubation is not possible. The use of the LMA or facemask may therefore be life saving in the unintubatable child.
PTwo different doses of caudal neostigmine co-administered with levobupivacaine produces analgesia in children.aediatr Karaaslan K, Gulcu N, Ozturk H, Sarpkaya A, Colak C, Kocoglu H. Department of Anesthesiology, Abant Izzet Baysal University, Faculty of Medicine, Bolu, Turkey. Anaesth. 2009 May;19(5):487-493.
SUMMARY BACKGROUND: This study was aimed to evaluate the analgesic efficacy duration of analgesia, and side effects of two different doses of caudal neostigmine used with levobupivacaine in children. METHODS: Sixty boys, between 5 months and 5 years, undergoing genitourinary surgery were allocated randomly to one of three groups (n =20 each). Group I patients received caudal 0.25% levobupivacaine (1 ml.kg(-1)) alone. Groups II and III patients received neostigmine (2 and 4 microg.kg(-1) respectively) together with levobupivacaine used in the same does as Group I. Pain scores were assessed using Children's and Infant's Postoperative Pain Scale (CHIPPS) at 15th (t(1)) min after arrival to postanesthetic care unit, and 1st (t(2)), 2nd (t(3)), 3rd (t(4)), 4th (t(5)), 8th (t(6)), 16th (t(7)), and 24th (t(8)) hour postoperatively. Duration of analgesia, amount of additional analgesic (paracetamol), score of motor blockade and complications were recorded for 24 h postoperatively, and compared between groups. RESULTS: CHIPPS scores were higher during t(2), t(3), t(6), t(7), and t(8) periods, duration of analgesia was shorter, and total analgesic consumption was higher in Group I compare to neostigmine groups (P < 0.05). Duration of postoperative analgesia and total analgesic consumption were similar in Groups II and III (P > 0.05). Adverse effects were not different between three groups. CONCLUSIONS: Caudal neostigmine in doses of 2 and 4 microg.kg(-1) with levobupivacaine extends the duration of analgesia without increasing the incidence of adverse effects, and 2 microg.kg(-1) seems to be the optimal dose, as higher dose has no further advantages.
A randomized study of a new landmark-guided vs traditional para-carotid approach in internal jugular venous cannulation in infants.Xiao W, Yan F, Ji H, Liu M, Li L. Cardiovascular Institute & Fuwai Cardiovascular Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100037, China. Paediatr Anaesth. 2009 May;19(5):481-6.
BACKGROUND: Central venous catheterization is more difficult in infants than in adults. Ultrasound-guided internal jugular venous cannulation may improve the accuracy of localization of the internal jugular vein (IJV), but ultrasound equipment is not universally available. The landmark technique remains essential in daily practice. METHODS: One hundred and forty infants, aged 3-12 months, who were scheduled to undergo surgery for congenital heart disease, were randomly assigned to a new landmark-guided group or traditional para-carotid group. In the new landmark-guided group, at the level of the cricoid cartilage, the carotid artery was marked, and the apex of the triangle formed by the two heads of the sternocleidomastoid muscle and the clavicle was also marked. The needle was inserted at the midpoint of the two marked points and advanced in the direction of the ipsilateral nipple. Seven cardiac anesthesia fellows participated in this study, and each fellow performed 10 central catheterizations in each group. The times to successful catheterization of the IJV were measured. Attempts at needle punctures for successful catheterization and procedural complications were counted. RESULTS: The IJV was successfully punctured within three attempts in 74% of infants in the para-carotid group, compared with 94% in the new landmark-guided group (P = 0.001). The time to successful catheterization was significantly shorter in the new landmark-guided group (P < 0.01). The incidence of arterial punctures in the para-carotid group was 11%, compared with 3% in the new landmark-guided group (P < 0.05). CONCLUSIONS: Compared with traditional para-carotid approach, the new landmark-guided approach for access of the IJV during teaching central catheterization significantly reduced carotid arterial puncture, provided a higher success rate and minimized procedure time in infants aged 3-12 months.
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