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Acta Anaesthesiol Scand 2002 Aug;46(7):887-95
Department of Paediatric Research, the National Hospital, Oslo, Norway. hanne.storm@klinmed.uio.no
BACKGROUND: Skin conductance (SC) as a measure of emotional state or arousal may be a tool for monitoring surgical stress in anaesthesia. When an outgoing sympathetic nervous burst occurs to the skin, the palmar and plantar sweat glands are filled up, and the SC increases before the sweat is removed and the SC decreases. This creates a SC fluctuation. The purpose of this study was to measure SC during laparoscopic cholecystectomy with propofol and remifentanil anesthaesia and to evaluate whether number and amplitude of SC fluctuations correlate with perioperative stress monitoring. METHODS: Eleven patients were studied nine times before, during and after anaesthesia. SC was compared to changes in stress measures such as blood pressure, heart rate, norepinephrine and epinephrine levels. SC was also compared to changes in Bispectral index (BIS). RESULTS: The blood pressure, epinephrine levels and norepinephrine levels were positively correlated with both the number (P < 0.001) and amplitude (P < 0.01) of the SC fluctuations. Moreover, the BIS was positively correlated with the number (P < 0.001) and amplitude (P < 0.001) of the SC fluctuations. Furthermore, during tracheal intubation, the mean levels of the number of SC fluctuations from the 11 patients had the same stress response as measured in changes of the mean levels of norepinephrine. The mean BIS did not show any stress response during tracheal intubation. CONCLUSION: Number of SC fluctuations may be a useful method for monitoring the perioperative stress.
PMID: 12139547, UI: 22135066
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Acta Anaesthesiol Scand 2002 Aug;46(7):882-6
Department of Orthopaedics, Sabbatsberg Hospital, Stockholm, Sweden.
BACKGROUND: The auditory evoked potential (AEP) is sensitive to the depth of anesthesia. The A-line monitor is a novel device that processes the amplitude and latency of the AEP during the mid-latency time window to provide a simple numerical index, the AAItrade mark-index. The hypothesis of the present study was that titration of anesthetic depth (desflurane) by means of the AAItrade mark-index could decrease the consumption of the main anesthetic and shorten emergence times. METHODS: Thirty ASA I-II patients scheduled for elective open spine surgery under general anesthesia were randomly allocated to two groups. Group I (n=15), the main anesthetic, desflurane, was titrated with a target AAItrade mark-index of 20+/-5. Group II (n=15), desflurane was titrated according to routine clinical signs, including heart rate, blood pressure, sweating and tears. No fixed MAC-multiple was sought. The primary study variable was desflurane consumption; and secondary study variables were time to extubation and orientation. RESULTS: All patients had an uncomplicated course and no patients showed signs of awareness or had any recall postoperatively. AAItrade mark-index guidance reduced desflurane consumption by 29% and improved emergence. Time until extubation and orientation and ability to state name and date of birth was significantly shortened among AAItrade mark-index titrated patients. CONCLUSION: Titrating depth of desflurane anesthesia using AAItrade mark-index guidance decreased main anesthetic consumption and improved emergence during spine surgery.
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PMID: 12139546, UI: 22135065
Acta Anaesthesiol Scand 2002 Aug;46(7):831-5
Department of Anesthesiology, National Defense Medical College, Tokorozawa, Saitama, Japan.
BACKGROUND: Effects of propofol on human cerebral blood flow (CBF), cerebral metabolic rate of oxygen (CMRO2), and blood flow-metabolism coupling have not been fully evaluated. We therefore assessed the effects of propofol on total-CBF and CMRO2 in patients without noxious stimuli and neurologic disorders. METHODS: General anesthesia was induced with midazolam (0.2 mg/kg) and fentanyl (5 microg/kg) in 10 patients (ASA physical status I) undergoing knee joint endoscopic surgery. Epidural anesthesia was also performed to avoid noxious stimuli during surgery. Cerebral blood flow (CBF) and cerebral arteriovenous oxygen content difference (a-vDO2) was measured using the Kety-Schmidt method with 15% N2O as a tracer before and after propofol infusion (6 mg/kg/h for 40 min), and the CMRO2 was also calculated. RESULTS: CBF decreased following propofol infusion from 34.4 ml/100 g/min (range 28.4-52.0) to 30.0 ml/100 g/min (range 20.2-42.4) (P=0.04). Although there was no significant change in a-vDO2, CMRO2 decreased following propofol infusion from 2.7 ml/100 g/min (range 2.2-4.3) to 2.2 ml/100 g/min (range 1.4-3.0) (P=0.04). There was a strong linear correlation between CBF and CMRO2 (r=0.90). CONCLUSION: Propofol proportionally decreased CBF and CMRO2 without affecting a-vDO2 in humans, suggesting that normal cerebral circulation and metabolism are maintained.
PMID: 12139539, UI: 22135058
Acta Anaesthesiol Scand 2002 Aug;46(7):827-30
Pain Relief Unit, Academic Medical Center, University of Amsterdam, the Netherlands. j.h.vranken@amc.uva.nl
Pancreatic cancer has a very poor prognosis resulting in the death of 98% of patients. Pain may be severe and difficult to treat. Management of pain includes chemotherapy, radiotherapy, pharmacologic treatment, and neurolytic celiac plexus block. Recent reviews of the efficacy of neurolytic celiac plexus block however, have reached conflicting conclusions. In this paper, we present two patients with severe pancreatic cancer pain resistant to pharmacologic treatment. Analgesic effect following repeated neurolytic celiac plexus blocks with alcohol was limited in time. Post-mortem neurohistopathologic examination of the celiac plexus revealed an abnormal celiac architecture with a combination of abnormal neurons with vacuolization and normal looking neuronal structures (ganglionic structures and nerve fibers) embedded in fibrotic hyalinized tissue. Our results show that a neurolytic celiac plexus block with alcohol is capable of partially destroying the celiac plexus. These findings may explain the significant but short-lasting analgesic effect following neurolytic celiac plexus block with alcohol.
PMID: 12139538, UI: 22135057
Acta Anaesthesiol Scand 2002 Aug;46(7):821-6
Department of Anesthesia, Woo-Kyung Kim, College of Medicine, Korea University, Korea University Guro Hospital, Seoul, South Korea. iloklee@hotmail.com
BACKGROUND: Ketamine can enhance anesthetic and analgesic actions of a local anesthetic via a peripheral mechanism. The authors' goal was to determine whether or not ketamine added to ropivacaine in interscalene brachial plexus blockade prolongs postoperative analgesia. In addition, we wanted to determine the incidence of adverse-effects in patients undergoing hand surgery. METHODS: Sixty adults scheduled for forearm or hand surgery under the interscalene brachial plexus block were prospectively randomized to receive one of the solutions of the study. Group P received 0.5% ropivacaine 30 ml, group K received 0.5% ropivacaine 30 ml with 30 mg ketamine, and group C received 0.5% ropivacaine with 30 mg ketamine i.v. Loss of shoulder abduction, elbow flexion, wrist flexion and loss of pinprick in the C4-7 sensory dermatomes were assessed at 1-min intervals. Adverse-effects were assessed every 5 min. The duration of the sensory and motor blocks was assessed after operation. Adverse-effects were also recorded. RESULTS: The onset time of sensory or motor blockade and the duration of sensory or motor blockade were similar in all groups. Adverse-effects occurred in 44% of patients in group K and 94% of group C. CONCLUSION: This study suggests that 30 mg ketamine added to ropivacaine in the brachial plexus block does not improve the onset or duration of sensory block, but it does cause a relatively high incidence of adverse-effects. These two findings do not encourage the use of ketamine with local anesthetics for brachial plexus blockade.
PMID: 12139537, UI: 22135056
Acta Anaesthesiol Scand 2002 Aug;46(7):815-20
Department of Medical Intensive Care Unit, Albert Szent-Gyorgyi Medical University, Szeged, Hungary. szili@card.azr.nl
BACKGROUND: The combination of laser Doppler flowmetry and non-invasive blood pressure monitoring allows the continuous observation of cutaneous vascular resistance (CVR). Continuous recording of unmodulated skin blood flow (SBF) is very sensitive to artefacts, rendering the method unreliable. In contrast, intermittent short lasting challenges of the CVR by cardiovascular autonomic reflexes may provide information about the responsiveness of the sympathetic nervous system in the skin. METHODS: Eleven patients with below-wrist hand surgery (six males and five females; aged 35.2+/-7.1 years) performed Valsalva maneuver following axillary blockade. Skin blood flow was continuously monitored on the forearm of the side axillary blockade, as well as on the contra-lateral forearm, which was used as the control. The responses were expressed as changes compared with the baseline level derived from a resting period of 30 s. The maximal change in CVR was determined during the late strain phase of the Valsalva maneuver on both sides. For numerical comparison the change in CVR on the axillary blockade and control sides were simultaneously calculated. RESULTS: During the Valsalva maneuver a significant increase in CVR was observed on the control side with a maximum value during the late strain phase (baseline 0.18+/-0.1 and late strain phase 0.42+/-0.2 relative units; P<0.01). In contrast, only minimal changes were detected on the side of axillary blockade in CVR (baseline 0.17+/-0.8 and late strain 0.16+/-0.2 relative units; P=NS). CONCLUSIONS: Our findings support the disputed hypothesis that the human skin microvasculature is involved in baroreflex regulation under thermoneutral conditions. The determination of baroreflex stimulus-induced microvascular responses may serve as a feasible method for monitoring the effectiveness of sympathetic blockade.
PMID: 12139536, UI: 22135055
Acta Anaesthesiol Scand 2002 Aug;46(7):806-14
Department of Anesthesiology and Intensive Care, Orebro University Hospital, Sweden. igor.dobrydnjov@orebroll.se
BACKGROUND: The purpose of the present study was to evaluate the postoperative analgesic and adverse effects of equal doses of oral or intrathecal clonidine in spinal anaesthesia with bupivacaine plain. METHODS: Forty-five ASA I-III orthopaedic patients scheduled for osteosynthesis of a traumatic femur fracture were randomised in a double-blind fashion to one of 3 groups. Patients received 15 mg of plain bupivacaine intrathecally (group B) or an intrathecal mixture of bupivacaine 15 mg and clonidine 150 mg (group CIT). In group CPO oral clonidine 150 mg was administered 60 min before intrathecal injection of bupivacaine 15 mg. RESULTS: Oral and intrathecal clonidine prolonged the time until the first request for analgesics, 313 +/- 29 and 337 +/- 29 min, respectively, vs. 236 +/- 27 min in group B (P < 0.01). The total 24- h PCA morphine dose was significantly lower in group CIT(19.3 +/- 1.3 mg) compared to groups B and CPO(33.4 +/- 2.0 and 31.2 +/- 3.1 mg). MAP was decreased significantly during the first hour after intrathecal clonidine(14%) and during the first 5 h after oral clonidine(14-19%). HR decreased in CIT during the 5th and 6th postoperative hours(7-9%) and during the first 2 h(9%) in CPO (P < 0.01). The degree of sedation was more pronounced in group CPO during the first 3 h. Four patients had pruritus in group B. CONCLUSIONS: Addition of intrathecal clonidine prolonged analgesia and decreased morphine consumption postoperatively more than oral clonidine. Hypotension was more pronounced after oral than after intrathecal clonidine. Intrathecal clonidine is therefore recommended.
PMID: 12139535, UI: 22135054
Acta Anaesthesiol Scand 2002 Aug;46(7):794-8
Department of Anesthesiology and Intensive Care, Kuopio University Hospital, Finland.
BACKGROUND: In some patients spinal puncture (SP) is followed by postdural puncture headache (PDPH). When the symptoms of PDPH are severe and are not relieved within a few days an epidural blood patch (EBP) might be performed. The aim of this survey was to review requests for EBPs and to evaluate the effectiveness of EBP in patients aged 13-18 years during a 6.5 year period ending in June 2001. METHODS: The Information System Patient Measures Database was interrogated to identify patients who were referred for EBP. After identification, the patients' medical records were reviewed in detail for the characteristics of PDPH and other symptoms, and for the effectiveness of the EBP. RESULTS: Forty-two EBPs were performed after 40 SPs on 37 patients (24 girls, 13 boys). Epidural blood patches were performed twice in five patients. The reasons for repeating the procedure were repeat SP with new PDPH in three patients and an unsatisfactory effect in two patients. Twenty-eight of the 40 spinal punctures (70%) had been performed for diagnostic use and 10 (25%) for spinal anesthesia. Two patients (5%) developed PDPH after inadvertent dural puncture with an epidural needle. In 37 cases the criteria for PDPH were fulfilled, and one patient had a cerebrospinal fluid fistula headache. Two-thirds of the girls had associated symptoms of headache compared with one-third of the boys. Epidural blood patch was performed 1-22 days after SP with 0.2 ml/kg (mean) of autologous blood injected into the epidural space. The success rate of the first injection was 37 out of 40 EBP (93%), and the second injection was effective in both patients with recurred PDPH. CONCLUSION: Epidural blood patch seems to be an effective and safe procedure in adolescents for treating severe and persistent PDPH.
PMID: 12139533, UI: 22135052
Acta Anaesthesiol Scand 2002 Aug;46(7):789-93
Department of Anesthesia and Intensive Care, Center of Head and Orthopedics, Copenhagen University Hospital, Rigshospitalet, Denmark. zjkn@rh.dk
BACKGROUND: Ambulatory axillary block by multiple nerve stimulation (MNS) is effective and time efficient, but may be rejected by patients because of block pain. This prospective study assessed patients' anxiety and acceptance of this block, identified which of the components of blocking procedure is most painful (i.v. line insertion, repeated needle passes, local anesthetic injection, or electrical stimulation) and recorded patients' anesthetic preferences for the future hand surgery. METHODS: Upon arrival at the day unit, 100 unpremedicated adult patients without previous experience of peripheral nerve stimulation indicated on the visual analog scale (VAS; 0-100) their anxiety about the block. The blocking procedure was then explained step-by-step. After inserting the i.v. line and freezing the skin in axilla, four terminal nerves (musculocutaneous, median, ulnar, radial) were electrolocated using an initial current of 2 mA and a target current of 0.1-0.5 mA. Pain caused by the individual components of blocking procedure was assessed on VAS before the start of surgery. On the day after the operation, the patients reassessed their anxiety for the next axillary block and indicated which anesthetic method (block alone, block plus sedation, or general anesthesia) they would prefer for the future hand surgery. RESULTS: Before the block, 59 patients admitted being anxious about regional block (median anxiety VAS=27), compared with 42 patients (anxiety VAS=10) postoperatively: P<0.01. Median intensity of electrical stimulation pain was significantly higher (VAS=16) than pain of local anesthetic injections (VAS=8), i.v. line insertion (VAS=6) and multiple needle passes (VAS=5). However, only 53 patients categorized electrolocation as painful. Twenty-seven reported discomfort but not pain, and 20 patients described the sensation as 'funny' or 'strange'. None of the patients had surgical pain during operation. Mean duration of surgery was 77 min, and of hospital stay 166 min. Ninety-eight patients would choose the same block for the future hand surgery, 13 of which would like sedation before the block, and two patients did not wish to be awake during any surgery. Ninety-five patients were satisfied with fast-tracking. CONCLUSIONS: Fear of block pain is diminished after experiencing the blocking procedure. Electrical stimuli was perceived as painful by 53% of patients, and this pain was more intense than with other block components. The majority of our patients would choose axillary block without sedation for future hand surgery and are satisfied with fast-tracking.
PMID: 12139532, UI: 22135051
Anaesthesia 2002 Oct;57(10):1046
Senior House Officer and Consultant, Department of Anaesthetics and Intensive Care, Dumfries and Galloway Royal Infirmary, Bankend Road, Dumfries, DG1 4AP, UK; Assistant Director, Robertson Centre for Biostatistics, Boyd Orr Building, Glasgow University, University Avenue, Glasgow, G12 8QQ.
[Record supplied by publisher]
PMID: 12358987
Anaesthesia 2002 Oct;57(10):1038-1039
PMID: 12358976
Anaesthesia 2002 Oct;57(10):1012-5
Specialist Registrar and Consultant, Magill Department of Anaesthesia, Intensive Care & Pain Management, Chelsea & Westminster Hospital, 369 Fulham Road, London SW10 9NH, UK.
[Medline record in process]
We investigated the attitudes of 96 patients and 163 anaesthetists to the need for obtaining informed consent before specialist airway techniques. Participants were asked to score six questions using a numerical scale, as to whether they thought consent was necessary before specific procedures, particularly in relation to fibreoptic intubtion used for teaching or maintaining skills. Significant differences in opinion were found between patients and anaesthetists despite a wide range of views. Overall, patients felt that specific consent was required for non-routine techniques, whilst anaesthetic respondents felt this was unnecessary, even if teaching. We conclude that guidance in obtaining consent is needed to support anaesthetists wishing to practice or teach fibreoptic intubation.
PMID: 12358960, UI: 22246010
Anaesthesia 2002 Oct;57(10):995-8
Assistant Professor, Resident, Biomedical Engineer, Senior Electrical Technician, Departments of Anaesthesia and Biomedical Engineering, American University of Beirut Medical Center, Beirut, Lebanon.
This newly designed peripheral nerve stimulator allows the scrubbed anaesthetist performing a nerve block to adjust the electrical current output needed for localisation of the target nerve without the need for an assistant.
PMID: 12358957, UI: 22246007
Anaesthesia 2002 Oct;57(10):984-94
Consultant Anaesthetist, The Norfolk and Norwich University Hospitals Healthcare Trust, Norwich, UK.
The administration of general anaesthesia in the UK has generally been carried out by medically qualified staff but there have been instances where this has not been the case. This article describes the role of the 'Sister Anaesthetists' who made a significant contribution to the delivery of anaesthesia services at the Norfolk and Norwich Hospital from the end of the First World War until the introduction of the National Health Service in 1948.
PMID: 12358956, UI: 22246006
Anesthesiology 2002 Oct;97(4):1042
PMID: 12357196, UI: 22243727
Anesthesiology 2002 Oct;97(4):1041
*Shackleton Department of Anesthesia, Southampton General Hospital, Southampton, Hampshire, United Kingdom. patrickjbcoleman@hotmail.com
PMID: 12357195, UI: 22243726
Anesthesiology 2002 Oct;97(4):1039-40
Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts. mayfield@etherdome.mgh.harvard.edu
PMID: 12357193, UI: 22243724
Anesthesiology 2002 Oct;97(4):1036
PMID: 12357189, UI: 22243720
Anesthesiology 2002 Oct;97(4):1032-3
*Hospital for Sick Children and University of Toronto, Toronto, Ontario. jlerman@rogers.com
PMID: 12357186, UI: 22243717
Anesthesiology 2002 Oct;97(4):1027
*Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri. kara-nikm@notes.wustl.edu
PMID: 12357182, UI: 22243713
Anesthesiology 2002 Oct;97(4):1025-6
*Department of Surgical Gastroenterology, Hvidovre University Hos-pital, Hvidovre, Denmark. henrik.kehlet@hh.hosp.dk
PMID: 12357179, UI: 22243710
Anesthesiology 2002 Oct;97(4):1015-9
Department of Anesthesia, Children's National Medical Center, George Washington University, Washington, DC, USA. zquezado@nih.gov
PMID: 12357175, UI: 22243706
Anesthesiology 2002 Oct;97(4):1005-6
* Professor Emeritus.
The cerebral metabolic effects of a massive dose of thiopental (177 mg/kg) were investigated in seven dogs. The systemic circulation was supported with an extracorporeal circuit. At an infusion rate of 2 mg/kg/min, cerebral oxygen consumption (CMR ) decreased progressively until cerebral electrical silence was produced. This occurred after a mean dose of 72 mg/kg, which caused a mean decrease in CMR to 58% of the control value (measured at 1.5% halothane inspired). Thereafter, despite continued at 4 mg/kg/min, CMR did not decrease further. The oxygen-glucose index never changed during the infusion period and, at the termination of the infusion, brain assays for ATP, phosphocreatine, lactate, and pyruvate revealed normal concentrations. It is concluded that there was no alteration in normal cerebral metabolic pathways, that cerebral metabolic effects of thiopental are secondary to functional effects, that thiopental would provide no cerebral protection during hypoxia sufficient to abolish cerebral function, and that thiopental does not uncouple oxidative phosphorylation.(O2) (O2) (O2)
PMID: 12357170, UI: 22243701
Anesthesiology 2002 Oct;97(4):921-30
* Postgraduate Researcher, dagger Associate Professor.
BACKGROUND (human ether-a-gogo related gene) encodes the cardiac rapidly activating delayed rectifier potassium currents (I ), which play an important role in cardiac action potential repolarization. General anesthetics, like halothane, can prolong Q-T interval, suggesting that they act on myocellular repolarization, possibly involving channels. Evidence for direct modulation of channels by halothane is still lacking. To gain insight on channel modulation by halothane the authors recorded macroscopic currents expressed in oocytes and conducted non-stationary noise analysis to evaluate single channel parameters modified by the anesthetic.(kr)METHODS Macroscopic currents were recorded in 120 mm K internal-5 mm K external solutions with the cut open oocyte technique. Macropatch recordings for non-stationary noise analysis of tail currents were made in symmetrical 120 mm K solutions. Pulse protocols designed for current recording were elicited from a holding potential of -80 mV. Halothane was delivered gravity-fed perfusion.RESULTS Halothane (0.7%, 1.5%, and 3%) decreased macroscopic currents in a concentration-dependent manner (average reduction by 14%, 22%, and 35% in the range of -40 mV to 40 mV) irrespective of potential. currents had slower activation and accelerated deactivation and inactivation. Non-stationary noise analysis revealed that halothane, 1.5%, decreased channel P by 27%, whereas single-channel current amplitudes and number of channels in the patch remained unchanged.(o)CONCLUSIONS Halothane inhibits currents expressed in oocytes in a concentration-dependent manner. It slowed down activation and accelerated deactivation and inactivation of channels. The authors' results demonstrate that halothane decreased currents by modulating kinetic properties of channels, decreasing their open probability. Partial block of I currents could contribute to delayed myocellular repolarization and altered cardiac electrophysiology.(kr)
PMID: 12357160, UI: 22243691
Anesthesiology 2002 Oct;97(4):786-93
West Australian Sleep Disorders Research Institute, Department of Pulmonary Physiology, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia. eastwood@cygnus.uwa.edu.au
BACKGROUND: The unprotected upper airway tends to obstruct during general anesthesia, yet its mechanical properties have not been studied in detail during this condition. METHODS: To study its collapsibility, pressure-flow relationships of the upper airway were obtained at three levels of anesthesia (end-tidal isoflurane = 1.2%, 0.8%, and 0.4%) in 16 subjects while supine and spontaneously breathing on nasal continuous positive airway pressure. At each level of anesthesia, mask pressure was transiently reduced from a pressure sufficient to abolish inspiratory flow limitation (11.8 +/- 2.7 cm H(2)O) to pressures resulting in variable degrees of flow limitation. The relation between mask pressure and maximal inspiratory flow was determined, and the critical pressure at which the airway occluded was recorded. The site of collapse was determined from simultaneous measurements of nasopharyngeal, oropharyngeal, and hypopharyngeal and esophageal pressures. RESULTS: The airway remained hypotonic (minimal or absent intramuscular genioglossus electromyogram activity) throughout each study. During flow-limited breaths, inspiratory flow decreased linearly with decreasing mask pressure (r(2) = 0.86 +/- 0.17), consistent with Starling resistor behavior. At end-tidal isoflurane of 1.2%, critical pressure was 1.1 +/- 3.5 cm H O; at 0.4% it decreased to -0.2 +/- 3.6 cm H(2)O ( < 0.05), indicating decreased airway collapsibility. This decrease was associated with a decrease in end-expiratory esophageal pressure of 0.6 +/- 0.9 cm H(2)O ( < 0.05), suggesting an increased lung volume. Collapse occurred in the retropalatal region in 14 subjects and in the retrolingual region in 2 subjects, and did not change with anesthetic depth. CONCLUSIONS: Isoflurane anesthesia is associated with decreased muscle activity and increased collapsibility of the upper airway. In this state it adopts the behavior of a Starling resistor. The decreased collapsibility observed with decreasing anesthetic depth was not a consequence of neuromuscular activity, which was unchanged. Rather, it may be related to increased lung volume and its effect on airway wall longitudinal tension. The predominant site of collapse is the soft palate.
PMID: 12357141, UI: 22243672
Anesthesiology 2002 Oct;97(4):5A-6A
PMID: 12357136, UI: 22243667
Paediatr Anaesth 2002 Sep;12(7):641-4
Department of Anesthesia and Critical Care, St Christopher's Hospital for Children, Philadelphia, PA, USA.
Morquio's syndrome is an inherited disorder characterized by excessive excretion of keratan sulphate in the urine. The anaesthetic care of these patients should take into consideration respiratory, craniofacial, cardiac, skeletal, ocular and hepatic abnormalities. We report the case of a child with Morquio's syndrome who presented for stabilization of the cervical spine, and discuss the issues relevant to the anaesthesiologist.
PMID: 12358664, UI: 22247495
Paediatr Anaesth 2002 Sep;12(7):632-6
Department of Anesthesia, Thomas Jefferson University Hospital, Philadelphia, PA and Department of Anesthesiology and Critical Care Medicine, Wilmington, DE, USA.
Larsen syndrome is a complex syndrome with genetic heterogeneity, and with both autosomal dominant and autosomal recessive patterns of inheritance. It is characterized by congenital dislocation of joints, flat faces and complicated by issues relating to respiratory, cardiac, musculoskeletal and central nervous systems. This report describes the anaesthetic management of two patients with Larsen syndrome. The first case is a 4-year-old patient who had cervical cord compression secondary to cervical instability and who was scheduled for anterior corpectomy with fusion of cervical vertebrae and placement of halo frame. This patient had transient loss of evoked potentials during positioning and a stormy postoperative course requiring reintubation and a prolonged stay in the intensive care unit. The second case is a 22-month-old child who was scheduled for a repeat posterior cervical spinal fusion due to failure of her initial fusion procedure. This patient had an uneventful perioperative course. Relevant anaesthetic issues in patients with Larsen syndrome are discussed.
PMID: 12358662, UI: 22247493
Paediatr Anaesth 2002 Sep;12(7):629-31
Department of Anaesthesia and Radiology, Great Ormond Street Hospital for Children, London, UK.
We present a case of a 3-year-old child who underwent hepatic artery chemoembolization. The anaesthetic management, prophylaxis of tumour lysis syndrome, nausea and vomiting and the management of perioperative pain relief are all discussed.
PMID: 12358661, UI: 22247492
Paediatr Anaesth 2002 Sep;12(7):604-9
Departments of Anesthesiology and Pediatrics, Children's National Medical Center and George Washington University Medical Center, Washington, DC, USA.
Background: The aim of the study was to determine if concurrent use of short-acting sedatives would decrease the incidence of emergence agitation associated with desflurane while preserving rapid recovery. Methods: Sixty-nine children, aged 2-9 years, who were undergoing adenotonsillectomy, were randomly assigned to three groups: (i) intravenous midazolam 0.1 mg.kg-1; (ii) propofol 2 mg.kg-1; and (iii) control. An observer blind to anaesthetic technique assessed emergence times and behaviour. Data were compared using chi-squared and ANOVA. Results: Midazolam initially decreased the incidence of emergence agitation but, in the postanaesthesia care unit, significant agitation was seen in all three groups. Emergence and complete recovery were delayed in groups 1 and 2. Conlusions: The concurrent use of midazolam or propofol did not reduce the incidence of emergence agitation but did delay emergence and recovery. These agents are not recommended for reducing emergence agitation in children receiving desflurane.
PMID: 12358656, UI: 22247487
Paediatr Anaesth 2002 Sep;12(7):589-93
Department of Anaesthesia, Royal Hospital for Sick Children, Glasgow, UK.
Background: The aim of this study was to evaluate the ease of use and efficacy of the Paedfusor, a computer controlled propofol infusion device with software appropriate for children down to the age of 6 months and weighing 5 kg. Methods: Thirty ASA I children, aged 6 months to 16 years, who were scheduled for elective surgery, were anaesthetized using the Paedfusor, programmed for the child's age and weight. Vital signs were recorded at 1-min intervals during induction and every 3 min thereafter. Patients breathed spontaneously through a laryngeal mask airway (LMATM) and perioperative analgesia was provided by a regional block. Target plasma and calculated effector site propofol readings were recorded on insertion of the LMA, insertion of regional block, surgical incision and on removal of LMA. Results: A target plasma propofol level of 8 micro g.ml-1 universally induced sleep within 1 min. Spontaneous respiration was maintained in the majority of patients with no cases of laryngospasm. Mean calculated effector site concentration was 4.29 micro g.ml-1 for insertion of the LMA and 2.78 micro g.ml-1 for LMA removal. Fifty-seven percent moved on insertion of the local anaesthetic block and 30% responded to surgical stimulation. Mean heart rates increased slightly after each stimulus, returning thereafter to baseline values. Blood pressure remained stable. No relationship between the duration of infusion, total propofol requirements and time to patient awakening was found. The average total propofol dose was high, being highest in the youngest groups. Vital signs were within acceptable safety limits throughout. Conclusions: This open study confirms the ease of use, clinical efficacy and absence of adverse effects of the Paedfusor for the induction and maintenance of anaesthesia in healthy children aged over 6 months undergoing elective surgery.
PMID: 12358653, UI: 22247484
Paediatr Anaesth 2002 Sep;12(7):579-84
Department of Paediatric Anaesthesia, Women's and Children's Hospital, Adelaide, South Australia.
Background: Oxygenation and gas exchange are impaired after induction of general anaesthesia. A timed re-expansion inspiratory manoeuvre (TRIM) improves pulmonary compliance and reverses haemoglobin oxygen desaturation rapidly in lambs. Methods: Twenty children of less than 2 years of age were given a standardized ventilated general anaesthetic. After 15 min of anaesthesia they were randomized to receive either a TRIM or 100% oxygen for 3 min. Dynamic pulmonary compliance and airway resistance were measured. Results: Pulmonary compliance fell by 12% and airway resistance rose by 12% during 15 min of ventilated general anaesthesia. 100% oxygen caused a further fall of 9% in compliance (P=0.016), whilst TRIM resulted in a 30% increase in compliance (P < 0.01). The changes in airway resistance with 100% oxygen and TRIM were not statistically significant. Conclusions: This study shows that TRIM increases pulmonary compliance during standardized ventilated general anaesthesia.
PMID: 12358651, UI: 22247482
Paediatr Anaesth 2002 Sep;12(7):569-578
Department of Anesthesia, Children's Hospital, Harvard Medical School, Boston, MA, USA, Department of Anesthesiology and Critical Care, The Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, USA, Department of Anesthesia and Critical Care, The Hospital of the University of Pennsylvania, University of Pennsylvania School of Medicine, Philadelphia, PA, USA.
PMID: 12358650
Paediatr Anaesth 2002 Sep;12(7):567-8
Department of Paediatric Anaesthesia and Pain Management, Royal Children's Hospital, Melbourne, Australia.
PMID: 12358649, UI: 22247480
Paediatr Anaesth 2002 Jul;12(6):559-60
PMID: 12139601, UI: 22136207
Paediatr Anaesth 2002 Jul;12(6):519-25
Department of Anesthesia, Children's Hospital, Boston and Harvard Medical School, MA 02115, USA. mccann@tch.harvard.edu
BACKGROUND: Bispectral index (BIS) is a signal processing device that potentially is a pharmacodynamic measure of the effects of anaesthesia on the central nervous system. METHODS: In this prospective blinded study, we investigated the pharmacodynamic relationship between BIS, haemodynamic changes during anaesthesia and endtidal nonsteady state concentrations of sevoflurane in 30 children, mean age 3.3 +/- 1.1 years, who were undergoing tonsillectomy and adenoidectomy. A standardized anaesthetic technique was used and included induction and maintenance with sevoflurane, nitrous oxide and oxygen. BIS, heart rate, mean arterial pressure (MAP) and endtidal sevoflurane (ETsevo) concentrations were continuously recorded and specifically noted at the time of intubation, placement of Dingman gag, incision of adenoid, adenoid out, incision of tonsil, tonsil one out, tonsil two out, last agent off, first spontaneous movement, first eye opening and extubation. The anaesthetist was blinded to BIS throughout the procedure. RESULTS: Using a Spearman correlation analysis, there was significant negative correlation between BIS and ETsevo concentrations (r=- 0.888, P < 0.01) and a pharmacodynamic relationship with EC50 (ETsevo at which BIS=50) of 1.48% (95% confidence interval 0.84-2.11). There was a weak negative correlation between sevoflurane and MAP (r=- 0.391, P < 0.01) but no significant correlation between sevoflurane and heart rate. CONCLUSIONS: In preschool children undergoing sevoflurane anaesthesia for tonsillectomy and adenoidectomy, endtidal sevoflurane concentrations are more closely correlated with BIS than with MAP or heart rate.
PMID: 12139593, UI: 22136199
Paediatr Anaesth 2002 Jul;12(6):507-10
Institute for Anesthesiology, University Medical Center, Nijmegen, the Netherlands. jj.driessen@anes.azn.nl
BACKGROUND: The time-course of the neuromuscular effects of rocuronium 0.3 mg.kg-1 during nitrous oxide-halothane anaesthesia in children with and without renal failure is unknown. This study compared the neuromuscular blocking effects in these groups. METHODS: The study was approved by the Hospital Ethical Committee. In the control group, 14 healthy children without renal disease were scheduled for various elective surgical procedures. Sixteen children with endstage renal failure, 14 of whom were already on renal dialysis, were scheduled for (re)placement of dialysis catheters (n=14) or for renal transplantation (n=2). Anaesthesia was induced and maintained with halothane and nitrous oxide in oxygen. Acceleromyographic thumb adduction after supramaximal ulnar nerve stimulation was recorded using train-of-four stimulation every 15 s. The onset time, the time to recovery of the first twitch to 25% or 75% and to recovery of a train-of-four ratio of 0.7 after rocuronium 0.3 mg.kg-1 were measured. Statistical analysis was performed with Student's t-test. P < 0.05 was considered statistically significant. RESULTS: The onset time was longer in children with renal failure (139 s, SD=71) than in control children (87 s, SD=43) (P=0.02). There were no significant differences in the duration of action of rocuronium between children without renal failure and in 15 out of 16 children with renal failure. CONCLUSIONS: In children with renal failure, aged over 1 year, a single bolus dose of rocuronium 0.3 mg.kg-1 does not cause a prolonged block, but has a slower onset than in healthy children.
PMID: 12139591, UI: 22136197
Paediatr Anaesth 2002 Jul;12(6):473-7
PMID: 12139586, UI: 22136192
Other Formats: Links:
Pediatrics 2002 Oct;110(4):758-61
Departments of Nursing. Pharmacy. Rehabilitation Therapies. Pediatrics, Children's Hospital of Iowa with University of Iowa Health Care, Iowa City, Iowa.
OBJECTIVES: Children view needle sticks as the worst source of pain and fear in the hospital setting. In an effort to minimize the pain of needle sticks, the use of eutectic mixture of lidocaine and prilocaine (EMLA) has become standard practice in many children's hospitals. Unfortunately, EMLA requires at least 60 minutes to be fully effective and reportedly may cause vasoconstriction, leading to difficult vein cannulation. A newly available local anesthetic (ELA-Max) may require less time and cause less vasoconstriction. The purpose of this randomized crossover study was to investigate the anesthetic equivalence of EMLA and ELA-Max. METHODS: Thirty well children (14 girls and 16 boys) who were between the ages of 7 and 13 years volunteered to have EMLA applied to the dorsal aspect of 1 hand for 60 minutes and ELA-Max applied to the other hand for 30 minutes. Right and left hands were randomized to treatment type and order of intravenous (IV) insertion. Clinical Research Center nurses, blind to the anesthetic randomization, attempted to insert a 22-gauge Teflon IV catheter into a vein in each hand. The children rated pain during IV insertion on the Oucher scale, and the nurse rated the difficulty of the insertion. RESULTS: There was no significant difference in pain ratings for hands that were treated with EMLA (mean: 20.5) or with ELA-Max (mean: 24), and there was no difference for the difficulty of vein cannulation. Children's preprocedure state anxiety was positively associated with pain ratings. CONCLUSIONS: ELA-Max, applied for 30 minutes before IV cannulation, has an anesthetic effectiveness similar to EMLA applied for 60 minutes. Some children rated IV insertion pain fairly high for both hands (eg, 60 on a 0- to 100-point scale) despite anesthetic treatment. Preprocedural anxiety may affect the perception and/or rating of pain. There were no differences between hands that were treated with EMLA or with ELA-Max for success of IV insertion.
PMID: 12359791, UI: 22247524
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