Anestesia Pediatrica e Neonatale

Management of the upper airway in spontaneously breathing children A challenge for the anaesthetist. von Ungern-Sternberg BS , Erb TO , Frei FJ ., Anaesthesist 2005 Oct 27 Departement Anasthesie, Universitatskinderspital beider Basel, UKBB, .

In unconscious, spontaneously breathing and anaesthetised children, a high incidence of partial or complete airway obstruction jeopardizes sufficient oxygenation. In this situation, the most important and efficient manoeuvre is to open up the upper airway. Chin lift, jaw thrust and continuous positive airway pressure (CPAP) are proven and effective methods for opening an obstructed upper airway. In addition to these simple airway manoeuvres, different techniques of body positioning (e.g., lateral positioning or supine position in combination with the "sniffing position") are effective to improve and maintain upper airway patency.

Effect of lateral positioning on upper airway size and morphology in sedated children. Litman RS , Wake N , Chan LM , McDonough JM , Sin S , Mahboubi S , Arens R ., Anesthesiology 2005 Sep;103(3):484-8. University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania 19104, USA.

BACKGROUND: Lateral positioning decreases upper airway obstruction in paralyzed, anesthetized adults and in individuals with sleep apnea during sleep. The authors hypothesized that lateral positioning increases upper airway cross-sectional area and total upper airway volume when compared with the supine position in sedated, spontaneously breathing children. METHODS: Children aged 2-12 yr requiring magnetic resonance imaging examination of the head or neck region using deep sedation with propofol were studied. Exclusion criteria included any type of anatomical or neurologic entity that could influence upper airway shape or size. T1 axial scans of the upper airway were obtained in the supine and lateral positions, with the head and neck axes maintained neutral. Using software based on fuzzy connectedness segmentation (3D-VIEWNIX; Medical Imaging Processing Group, University of Pennsylvania, Philadelphia, PA), the magnetic resonance images were processed and segmented to render a three-dimensional reconstruction of the upper airway. Total airway volumes and cross-sectional areas were computed between the nasal vomer and the vocal cords. Two-way paired t tests were used to compare airway sizes between supine and lateral positions. RESULTS: Sixteen of 17 children analyzed had increases in upper airway total volume. The total airway volume (mean +/- SD) was 6.0 +/- 2.9 ml in the supine position and 8.7 +/- 2.5 ml in the lateral position (P < 0.001). All noncartilaginous areas of the upper airway increased in area in the lateral compared with the supine position. The region between the tip of the epiglottis and vocal cords demonstrated the greatest relative percent change. CONCLUSIONS: The upper airway of a sedated, spontaneously breathing child widens in the lateral position. The region between the tip of the epiglottis and the vocal cords demonstrates the greatest relative percent increase in size.

Pilot study of neuraxial imaging by ultrasound in infants and children. Marhofer P , Bosenberg A , Sitzwohl C , Willschke H , Wanzel O , Kapral S ., Paediatr Anaesth. 2005 Aug;15(8):671-6. Department of Anaesthesia and Intensive Care Medicine, Medical University of Vienna, Vienna, Austria. peter.marhofer@meduniwien.ac.at

BACKGROUND: Ultrasonography is becoming an important adjunct in regional anesthesia. Epidural anesthesia may pose significant challenges in infants and children because of difficulties in identifying the epidural space. In addition, epidural catheters are sometimes difficult to advance. The present study was performed to evaluate an optimal ultrasound technique for direct visualization of neuraxial structures in children. METHODS: A total of 32 infants and children scheduled for minor surgery were prospectively included in a high-resolution ultrasound study. Scans were performed using either a sector or linear probe and views from a longitudinal paramedian, median and transversal angle at lumbar and thoracic levels of the spinal cord were analyzed. RESULTS: In all children investigated, the linear probe generated better images than the sector probe. Of the various scanning perspectives, the paramedian longitudinal approach offered the best views at both cord levels. Broken down by age groups, the best visibility was clearly obtained in neonates up to 3 months of age (P < 0.0001 Vs all other age groups). In older children, the quality of ultrasound decreased in an age-dependent manner. CONCLUSIONS: Paramedian longitudinal scans with linear probes are the most favorable method of imaging neuraxial anatomy at lumbar and thoracic cord levels in infants and children, with the best results in neonates up to 3 months of age. Based on these results, and using real time imaging, a practical technique for ultrasound-guided epidural anesthesia for neonates and infants at lumbar and thoracic levels of the spinal cord is planned.

Tolerance and analgesic efficacy of a new i.v. paracetamol solution in children after inguinal hernia repair. Murat I , Baujard C , Foussat C , Guyot E , Petel H , Rod B , Ricard C Paediatr Anaesth. 2005 Aug;15(8):663-70. Department of Anesthesia, Hopital d'Enfants Armand Trousseau, Paris, France.

BACKGROUND: A new intravenous (i.v.) formulation of paracetamol and propacetamol (prodrug of paracetamol) were compared to determine tolerance and relative analgesic efficacy during the first 6 h after inguinal hernia repair performed under general anesthesia combined with ilioinguinal block in children. METHODS: A total of 183 ASA I or II in-patients, aged 1-12 years, admitted for unilateral inguinal hernia repair were randomized to receive in a double-blind design either i.v. paracetamol 15 mg.kg(-1) (n = 95) or propacetamol 30 mg.kg(-1) (n = 88) for postoperative pain relief as soon as pain intensity was greater than 30 on a 100 mm visual analog scale. All patients were evaluated for efficacy and tolerance. Efficacy was evaluated between 15 min and 6 h after the start of the 15 min infusion. RESULTS: The most frequently reported adverse event was injection site pain, which was significantly reduced in the new formulation group (i.v. paracetamol 14.7% vs propacetamol 33.0% of children, P = 0.005). No significant difference was obtained between treatments on pain relief (PR), pain intensity difference (PAID) from baseline, and objective pain scale intensity difference (OPSD). Also, treatment effects did not differ significantly for maximum values and weighted sums of PR, PAID (investigator and child rated), OPSD, time to first request for rescue medication, proportion of children requesting rescue medication, and investigators' global treatment satisfaction. CONCLUSION: A single infusion of i.v. paracetamol 15 mg.kg(-1) produced analgesia similar to a single infusion of propacetamol 30 mg.kg(-1) following inguinal hernia repair in children. Paracetamol i.v. 15 mg.kg(-1) was better tolerated at the injection site than propacetamol.

Evaluation of relatively low dose of oral transmucosal ketamine premedication in children: a comparison with oral midazolam. Horiuchi T , Kawaguchi M , Kurehara K , Kawaraguchi Y , Sasaoka N , Furuya H ., Paediatr Anaesth.2005 Aug;15(8):643-7

Department of Anesthesiology, Nara Medical University, Kashihara, Nara, Japan.

BACKGROUND: Oral Transmucosal ketamine (lollipop) has been shown to be an effective, harmless preoperative medication for children. However, its efficacy was not compared with commonly used premedication drugs. We, therefore, compared the efficacy of oral transmucosal ketamine with oral midazolam for premedication in children. METHODS: Fifty-five children (2-6 years of age) were randomized to receive orally either a lollipop containing 50 mg of ketamine (the group K; n = 27) or syrup containing 0.5 mg.kg(-1) of midazolam (the group M; n = 28) before minor surgery. A five points-sedation score (1 = asleep to 5 = agitated; scores 2 and 3 were defined as 'effective') on arrival in the operating room and a three points-acceptance score of separation from the parents and a three points-mask cooperation score at induction of anesthesia (1 = easy to 3 = markedly resistant; score 3 was defined as 'poor') were used. RESULTS: Sedation scores in group K were significantly higher than those in group M (P = 0.012), and the incidence of 'effective' in sedation was significantly lower in group K than in group M (P = 0.036). The incidence of 'poor' at separation from the parents and for mask cooperation was significantly higher in group K than in group M (P = 0.017, P = 0.019, respectively). CONCLUSION: These results indicate that a relatively low dose of oral transmucosal ketamine premedication provides no benefits over oral midazolam in children.

Pharmacokinetics of levobupivacaine after caudal epidural administration in infants less than 3 months of age. Chalkiadis GA , Anderson BJ , Tay M , Bjorksten A , Kelly JJ ., Br J Anaesth. 2005 Oct;95(4):524-9. Epub 2005 Aug 12. Department of Anaesthesia and Pain Management, Royal Children's Hospital, Parkville, Victoria, Australia.

BACKGROUND: There are few data describing levobupivacaine pharmacokinetics in infants (<3 months) after caudal administration. METHODS: An open-label study was undertaken to examine the pharmacokinetics of levobupivacaine 2.5 mg ml(-1), 2 mg kg(-1) in children aged less than 3 months after single-shot caudal epidural administration. Plasma concentrations were determined at intervals from 0.5 to 4 h after injection. A population pharmacokinetic analysis of levobupivacaine time-concentration profiles (84 observations) from 22 infants with mean postnatal age (PNA) 2.0 (range 0.6-2.9) months was undertaken using non-linear mixed effects models (NONMEM). Time-concentration profiles were analysed using a one-compartment model with first-order input and first-order elimination. Estimates were standardized to a 70 kg adult using allometric size models. RESULTS: Population parameter estimates (between-subject variability) for total levobupivacaine were clearance (CLt) 12.8 [coefficient of variation (CV) 50.6%] litre h(-1) 70 kg(-1), volume of distribution (Vt) 202 (CV 31.6%) litre 70 kg(-1), absorption half-life (Tabs) 0.323 (CV 18.6%) h 70 kg(-1). Estimates for the unbound drug were clearance (CLfree) 104 (CV 43.5%) litre h(-1) 70 kg(-1), volume of distribution (Vfree) 1700 (CV 44.9%) litre 70 kg(-1), absorption half-life (Tabsfree) 0.175 (CV 83.7%) h 70 kg(-1). There was no effect attributable to PNA on CL or V. Time to peak plasma concentration (Tmax) was 0.82 (CV 18%) h. Peak plasma concentration (Cmax) was 0.69 (CV 25%) microg ml(-1) for total levobupivacaine and 0.09 (CV 37%) microg ml(-1) for unbound levobupivacaine. CONCLUSIONS: Clearance in infants is approximately half that described in adults, suggesting immaturity of P450 CYP3A4 and CYP1A2 enzyme isoforms that metabolize levobupivacaine in infants. This lower clearance delays Tmax, which was noted to occur approximately 50 min after administration of caudal epidural levobupivacaine.

New perspectives for simulator-based training in paediatric anaesthesia and emergency medicine. Eich C , Russo S , Timmermann A , Nickel EA , Graf BM .,
Anaesthesist. 2005 Nov 25; Lehr- und Simulationszentrum fur Anaesthesiologie, Rettungs- und Intensivmedizin , Georg-August-Universitat, Gottingen.

Anaesthesia and emergency medical care for infants and toddlers is often associated with high clinical demands and specific challenges. Nevertheless, a significant proportion of interventions is performed by anaesthetists and emergency physicians with no specialised paediatric training and little experience in the management of anaesthetic incidents and emergencies specific to these age groups. Extensive studies have demonstrated a close inverse correlation between the level of specialisation and perioperative morbidity and mortality. However, clinical circumstances and the relatively small number of paediatric cases at many institutions often hinder the establishment of improved training concepts. Recently, high-fidelity infant simulators have become available, which permit authentic exposure to a large spectrum of scenarios in paediatric anaesthesia and emergency medicine. A multimodular concept of training, including such simulator-based techniques, may relieve the widespread shortage in clinical expierience, and hence greatly facilitate improvement of quality of care and patient safety.

Clonidine treatment for agitation in children after sevoflurane anesthesia. Tesoro S , Mezzetti D , Marchesini L , Peduto VA ., Anesth Analg. 2005 Dec;101(6):1619-22. Section of Anesthesia, Analgesia and Intensive Care, Department of Clinical and Experimental Medicine, University of Perugia, Italy. simonettatesoro@virgilio.it

Clonidine is effective in treating sevoflurane-induced postanesthesia agitation in children. We conducted a study on 169 children to quantify the risk reduction of clonidine agitation in patients admitted to our day-surgery pediatric clinic. Children were randomly allocated to receive clonidine 2 mug/kg or placebo before general anesthesia with sevoflurane that was also supplemented with a regional or central block. An observer blinded to the anesthetic technique assessed recovery variables and the presence of agitation. Pain and discomfort scores were significantly decreased in the clonidine group; the incidence of agitation was reduced by 57% (P = 0.029) and the incidence of severe agitation by 67% (P = 0.064). Relative risks for developing agitation and severe agitation were 0.43 (95% confidence interval, 0.24-0.78) and 0.32 (0.09-1.17), respectively. Clonidine produces a substantial reduction in the risk of postsevoflurane agitation in children.

Airway protective reflexes evoked by laryngeal instillation of distilled water under sevoflurane general anesthesia in children. Ishikawa T , Isono S , Tanaka A , Tagaito Y , Nishino T . Anesth Analg. 2005 Dec;101(6):1615-8. Department of Anesthesiology (B1), Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba 260-8677, Japan. tishikawa@faculty.chiba-u.jp

To investigate how sevoflurane modifies airway protective reflexes in anesthetized children, we recruited patients younger than 12-yr-old for our study. Anesthesia was induced with inhaled sevoflurane in oxygen. The airway was managed with a laryngeal mask airway and the patient breathing spontaneously. Depending on the depth of anesthesia, the subjects were divided into two groups: Group 1 and Group 2 (1% and 2% of end-tidal sevoflurane concentration, respectively). Behaviors of the larynx were assessed mainly by the fiberscopic images of the larynx as well as respiratory flow and esophageal pressure. A small dose, 0.02 mL/kg of distilled water (minimum 0.2 mL) was instilled to the larynx through a channel of the scope to evoke an airway protective reflex from the larynx. The responses were categorized into passive (laryngeal closure, laryngospasm, and apnea) and active (cough, expiration reflex, and swallowing reflex) responses. Ten subjects were included in each group. In both groups, the primary responses were passive; however, in Group 1, active reflexes were also observed in 8 of 10 subjects; no subjects in Group 2 had active reflexes (P < 0.01). We concluded that, in children, the depth of general anesthesia with sevoflurane modified airway protective reflexes.

What are the changes in paediatric anaesthesia practice afforded by new anaesthetic ventilators? Odin I , Nathan N ., Ann Fr Anesth Reanim. 2005 Nov 23; Departement d'anesthesie-reanimation chirurgicale, CHU Dupuytren, 2, avenue Martin-Luther-King, 87042 Limoges, France.

Because of specific paediatric respiratory physiology (mainly decreased compliance and functional residual capacity, increased O(2) demand and CO(2) production), ventilators for paediatric anaesthesia need to be powerful and able to deliver small volumes at a high rate without compression volume loss. The compensation of compliance now available on every anaesthesia machine, compensates for the volume of gas lost by compression in the circuit tubing allowing the tidal volume to reach preset commands, even for bellow in box respirators. Preset tidal volume is then totally delivered to the lung by volume-controlled ventilation because it becomes independent of total pulmonary compliance and fresh gas flow. Increased precision of electronic flowmeters and better air-tightness of circuits allow reducing with precision fresh gas flow to values approaching children's O(2) consumption and N(2)O diffusion. New modes of ventilation are now available on anaesthesia machine. Pressure controlled mode, by increasing and maintaining mean airway pressures, ameliorates intrapulmonary gas distribution and compensates for the gas leak from uncuffed tracheal tubes. Unsteady tidal volume resulting from variation of total compliance, is the main drawback of pressure-controlled ventilation that may be overcome by using the "autoflow" mode (better described as a pressure controlled mode ensuring tidal volume) available with one of the last generation of ventilators. Increased accuracy and security of the mode "pressure assist" might increase the use of spontaneous ventilation in paediatric anaesthesia even for low weight children. However tidal volume remains variable with compliance and depth of anaesthesia, which may require several adjustments of ventilator's settings. The clinical conditions (mainly airway control) of pressure assist use for children less than 10 kg should be elucidated before recommending its use.

Preoperative information for paediatric patients. The anaesthesiologist point of view. Orliaguet G . , Ann Fr Anesth Reanim. 2005 Nov 23; Departement d'anesthesie-reanimation, hopital Necker-Enfants-malades, Assistance-publique-hopitaux-de-Paris, universite Rene-Descartes Paris-V, 149, rue de Sevres, 75743 Paris cedex 15, France.

Medical information is mandatory before any medical procedure, including pediatric anesthesia. Preoperative information covers many aspects, including medico-psychologic and judicial aspects. When the patient is a child, information must be delivered to the parents in priority. However, the French law has given a particular attention to the opinion of the child. In 70% of the cases, preoperative anxiety of the parents is more related to anesthesia than to the surgical procedure itself. We have to explain the most frequent adverse effects, as well as the more severe and well known complications to the parents, even though they are very infrequent. The only cases where preoperative information is not required are: emergency cases and refusal of the patient or the parents to be informed. While information is necessarily oral, it may be completed using a written document. The quality of the preoperative information directly influences the quality of the psychological preoperative preparation of the parents, and thereafter of the child. Preoperative preparation programs have been developed, but controversial results have been observed. The great majority of the studies on preoperative programs were performed in the USA, where the demand for preoperative information is very important. It is far from sure that the results of all these studies may be extrapolated to French parents, and French studies are needed.

Anaesthetic particularities for children with tumours. Lejus C . , Ann Fr Anesth Reanim. 2005 Nov 23, Service anesthesie-reanimation chirurgicale, Hotel-Dieu-hopital Mere-Enfant, CHU de Nantes, 44093 Nantes cedex, France.

Objectives. - To present the more frequent solid tumors, that require a general anaesthesia and to describe the particularities of the anaesthetic management. Data sources and extraction. - The PUBMED database was searched for articles (1990 - 2005) combined with references analysis of major articles on the topics. Data synthesis. - Neoplasma is the first cause of paediatric death. In children less than 5 years of age, neuroblastoma and nephroblastoma are the more frequent of the tumour. The incidence of each pathology is low. However a general anaesthesia is required in numerous situations: bone marrow aspiration and biopsy, central venous catheter insertion, various biopsies under computed tomography, ultrasound, thoracoscopy or laparoscopy, MRI scan, surgery and body radiation. The key points of successful anaesthetic management include complete preoperative evaluation together with the oncology paediatric team. Particularly, cardiotoxicity may result from chemotherapy and hypertension is frequently associated with neuroblastoma and nephroblastoma. Mediastinal location of lymphomas induced a significant risk of cardiopulmonary complications during induction of general anaesthesia. A peak expiratory flow rate or a tracheal cross-section area less than 50% of predicted values are contraindication to general anaesthesia. Cephalic rhabdomyosarcoma may be responsible of difficult airway management. Specific guidelines are available for platelet and red cell transfusion in paediatric oncology patients. Surgical antibioprophylaxis are adapted in immunodepressed children to a potential increased risk of postoperative infectious complications, according personal previous history, microbiological ecology and body bacterial flora. Dosage of anaesthetic agents takes into account denutrition, hydroelectrolytic disturbances and hypovolemia.

Caudal anesthesia in pediatric cardiac surgery: does it affect outcome? Leyvi G , Taylor DG , Reith E , Stock A , Crooke G , Wasnick JD . J Cardiothorac Vasc Anesth. 2005 Dec;19(6):734-8. Department of Anesthesiology, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY.

Objective: The purpose of this study was to examine the influence of caudal anesthesia on outcomes (pediatric intensive care unit [PICU] length of stay, hospital length of stay, ventilatory time, early extubation rate) in pediatric patients undergoing congenital heart disease repair requiring cardiopulmonary bypass (CPB). Design: Retrospective. Setting: University teaching hospital. Participants: Pediatric patients undergoing surgery to treat congenital heart disease between 1999 and 2002. Intervention: None. Measurements and Main Results: Thirty-four patients with atrial septal defect (ASD), 37 with ventricular septal defect, and 46 with tetralogy of Fallot (TOF) were included in the analysis. No differences were found in preoperative and intraoperative data between caudal and noncaudal group for each disorder. There was no difference between caudal and noncaudal groups in PICU and hospital stay. A statistically significant difference was found in the postoperative ventilatory time in patients with ASD and TOF between caudal and noncaudal groups. The early extubation rate was higher in the TOF caudal group compared with the noncaudal group. Conclusions: This retrospective study demonstrated that postinduction placement of caudal anesthesia does not affect PICU or hospital length of stay. A well-controlled prospective study is needed to confirm these findings.

Does dexmedetomidine prevent emergence delirium in children after sevoflurane-based general anesthesia? Shukry M , Clyde MC , Kalarickal PL , Ramadhyani U . Paediatr Anaesth. 2005 Dec;15(12):1098-104. Department of Anesthesiology, Tulane University, New Orleans, LA, USA.

Summary Background : Emergence agitation or delirium (ED) is a frequent phenomenon in children recovering from general anesthesia (GA). Dexmedetomidine, an alpha2 receptor agonist, has analgesic and sedative properties that might be helpful in the management of ED. We studied the effects of a continuous perioperative infusion of 0.2 mug.kg(-1).h(-1) dexmedetomidine on the incidence of ED in 50 children aged 1-10 years scheduled for sevoflurane-based GA. Methods : Following inhalation induction of GA, the children were randomly assigned into dexmedetomidine or placebo Groups D and S, respectively. The infusion of 0.2 mug.kg(-1).h(-1) dexmedetomidine or equal volume of saline was started after securing the airway. Depth of anesthesia was maintained by adjusting the concentration of sevoflurane to achieve a Bispectral Index Score of 40-60. Intraoperative hemodynamics were recorded every 5 min and the trachea was extubated at the end of the procedure. Perioperative pain management was determined by the blinded anesthesia team, and the study drug infusion was maintained for 15 min following the postanesthesia care unit (PACU) admission. ED and pain scores were evaluated by a blinded observer. Results : The incidence of ED was statistically significantly different between the two groups, 26% in Group D Vs 60.8% in Group S (P = 0.036). Additionally, the number of episodes of ED was lower in Group D (P < 0.017). Pain scores and the times to extubate and discharge from PACU were the same. Conclusions : The perioperative infusion of 0.2 mug.kg(-1).h(-1) dexmedetomidine decreases the incidence and frequency of ED in children after sevoflurane-based GA without prolonging the time to extubate or discharge.

CSF pressure measurement during anesthesia: an unreliable technique. Eidlitz-Markus T , Stiebel-Kalish H , Rubin Y , Shuper A . Paediatr Anaesth. 2005 Dec;15(12):1078-82. Department of Pediatrics E-Ambulatory Day Care Center, Schneider Children's Medical Center of Israel, Petah Tiqva, Israel.

Summary Background: The measurement of cerebrospinal fluid (CSF) pressure is necessary for many clinical indications. Its accuracy may be compromized in frightened or uncooperative children who find it difficult to relax sufficiently. The aim of the present study was to evaluate possible effects of general anesthesia on CSF pressure values. Methods: Lumbar puncture was performed under general anesthesia in 15 patients aged 4.5-20 years for the evaluation of headaches associated with a swollen optic nerve. Cerebrospinal fluid pressure was measured with a manometer when the patient was fully anesthetized (opening pressure) and then continuously recorded until the patient regained consciousness. The opening pressure was compared with the lowest pressure measured at the termination of the procedure (end-measurement pressure). Results: Seventeen pressure measurements were performed in 15 patients. In all but two measurements, differences were noted between the opening and end pressure, ranging from 5 to 13 cmH(2)O. The opening pressure was abnormally high in 16 measurements, and the end pressure was abnormally high in seven. The difference between the two measurements was highly significant (P < 0.001). Conclusions: Lumbar puncture performed under general anesthesia may yield two pressure measurements. Many factors, such as hypercarbia and the anesthetic agent used, may influence the results. Owing to the dynamic changes in CSF pressure, measurements made under anesthesia may be unreliable.

Clonidine added to bupivacaine in neonatal spinal anesthesia: a prospective comparison in 124 preterm and term infants. Rochette A , Troncin R , Raux O , Dadure C , Lubrano JF , Barbotte E , Capdevila X . Paediatr Anaesth. 2005 Dec;15(12):1072-1077. Department of Anesthesiology and Intensive Care Medicine 'A', University Hospital Lapeyronie, Montpellier, France.

Summary Background: Spinal anesthesia (SA) remains the 'gold standard' in neonatal anesthesia for inguinal herniorrhaphy but its short duration impedes its usefulness. We previously demonstrated that clonidine prolongs neonatal SA without immediate side effects. Methods: We conducted a prospective observational study of 124 infants undergoing herniorrhaphy under SA with bupivacaine and clonidine. Two cohorts, term (n = 57) and former preterm (n = 67) infants, were evaluated and compared with regard to episodes of apnea, desaturation, and bradycardia within 24 h of SA. Results: In both groups, postoperative desaturation episodes were unchanged after SA, compared with the 12 preoperative hours, despite significantly increased apnea (P < 0.003 and <0.011 respectively). Transient bradycardias occurred in former preterm infants (P < 0.014): they spontaneously resolved in all cases. Mean arterial pressure did not vary during the study. Upper sensory level of SA, sedation on entering the postanesthesia care unit (PACU) and duration of stay in the PACU were similar in both groups. Conclusions: The clinical significance of short apneas, recovering spontaneously without desaturation, remains debatable. It is concluded that addition of clonidine to neonatal SA results in acceptable side effects. Side effects must be compared with the potential advantages before future recommendations.

Anesthetic management of the neonate with congenital complete heart block: a 16-year review. Kussman BD , Madril DR , Thiagarajan RR , Walsh EP , Laussen PC . Paediatr Anaesth. 2005 Dec;15(12):1059-66. Department of Anesthesiology, Perioperative and Pain Medicine, Children's Hospital Boston, Boston, MA, USA.

Summary Background: Anesthesia for patients with complete heart block can be associated with significant hemodynamic instability. The aim of this study is to review our anesthetic experience of neonates with congenital complete heart block (CCHB) who underwent placement of either a temporary epicardial pacing system or a permanent epicardial pacemaker. Methods: The anesthetic management of neonates with CCHB who underwent pacemaker placement at a single institution over a 16-year period was reviewed. Results: Twenty-four neonates were identified, 17 with a structurally normal heart (NL) and seven with associated congenital heart defects (CHD). Median (range) gestational age was 36.9 (26-41) weeks, birth weight 2.9 (1.0-4.1) kg, and baseline heart rate 47 (38-80) b.min(-1). A temporary epicardial pacing system was placed in six patients (four CHD, two NL; P = 0.003) following institution of mechanical ventilation and inotropic support for a low cardiac output state, and a permanent epicardial pacemaker was placed in 18 patients. Atropine 0.02 mg.kg(-1) IV prior to induction (n = 5) increased heart rate less than 20%. Intraoperative hypotension was documented in nine neonates, five of seven with CHD and four of 17 with NL (P = 0.02). In four patients (44%) hypotension occurred despite concurrent inotropic support. Intraoperative cardiac arrest occurred in one neonate, necessitating institution of extracorporeal membrane oxygenation. Two patients (8.3%) died in hospital from complex CHD and complications of prematurity. Conclusions: Early institution of mechanical ventilation, inotropic support and pacing are necessary in the neonate with CCHB and poor hemodynamic function, particularly with coexisting CHD or prematurity.

A 15-year review of children with Kawasaki's Syndrome having general anesthesia or deep sedation. Morrison JE , Anderson M , Chan KC , Pietra B , Zuk J , Gnadinger P . Paediatr Anaesth. 2005 Dec;15(12):1053-8. Department of Anesthesiology, The Children's Hospital and University of Colorado Health Sciences Center, Denver, CO, USA.

Summary Background: Children with Kawasaki's syndrome (KS), also known as Kawasaki's disease or 'mucocutaneous lymph node syndrome', have approximately 20-25% incidence of developing coronary artery aneurysms (CAA), stenosis or obliteration if not appropriately diagnosed and treated. In addition some children have myocarditis, pericardial effusions and/or cardiac arrhythmias during the acute phase of KS. Even with current treatment protocols, 2-4% will still be at risk of coronary artery pathology and the long-term implications regarding future coronary artery disease are unknown. Many of these children present for surgical or diagnostic procedures requiring general anesthesia or deep sedation. Only sporadic case reports have been published on the anesthetic experiences of such patients. Methods: With Institutional Review approval, we reviewed the medical records of all children with discharge diagnosis of KS from 1985 to 2000 for those receiving general anesthesia or deep sedation. Data abstracted from the medical records included information on any surgical procedures performed any time after onset of KS symptoms, type of anesthetic, perioperative monitoring and presence or absence of operative or perioperative complications. Results: A total of 178 children with KS were identified of whom 47 (26.4%) received either general anesthesia (34) or deep sedation (13). There were no deaths; one child developed congestive heart failure in the immediate postoperative period associated with KS myocarditis. Five (15%) of those having general anesthesia initially were either not diagnosed as having KS or had no preoperative cardiac evaluations. None of the children having general anesthesia had ST segment analysis, invasive monitoring or troponin measurements perioperatively. Conclusions: The high incidence of serious myocardial complications attributable to KS reported in the pediatric literature is rarely noted in the anesthesia literature. We feel there is a potential for more serious perioperative complications among KS children, although we can only speculate why complications are not more frequently encountered. Anesthetists involved in pediatric services are encouraged to consider KS in their diagnosis of children presenting with febrile illnesses with rashes and to consider the possibility of KS myocardial compromise if they encounter unexpected deterioration perioperatively. Preoperative ultrasound examination and perioperative monitoring (e.g. ST segment analysis and troponin measurements) for myocardial compromise are encouraged if KS is suspected.

The evaluation of propofol dosage for anesthesia induction in children with cerebral palsy with bispectral index (BIS) monitoring. Saricaoglu F , Celebi N , Celik M , Aypar U .
Paediatr Anaesth. 2005 Dec;15(12):1048-52. Department of Anaesthesiology and Reanimation, Hacettepe University, Ankara, Turkey.

Summary Background: We designed a randomized prospective study to investigate whether developmentally delayed children with cerebral palsy (CP) need a lower dosage of propofol for induction than normal children using bispectral index (BIS) monitoring criteria. Methods: After approval by the University Ethical Committee and written informed consent obtained from parents, 20 children with noncommunicative/nonverbal CP and 20 normal children requiring general anesthesia for elective orthopedic surgery were enrolled in the study. The patients were not premedicated. BIS leads were placed before the induction of anesthesia. Propofol was administered at a rate of 20 mg.30 s(-1) (i.e. 40 mg.min(-1)).When BIS value had reached a steady number of 35-45, infusion was stopped. Results: There was no significant difference between Group N and Group CP in age and sex distribution (P > 0.05), however children in Group CP weighed less than Group N (P = 0.05). The propofol dosage for induction was significantly lower in Group CP than Group N (P = 0.03). There were no differences in propofol doses administered to children using anticonvulsants and those not on anticonvulsants in Group CP. BIS values were comparable between the two groups (i.e. Group N and Group CP) at baseline and after propofol administration. Conclusions: Our data suggest that noncommunicative/nonverbal children with CP require less propofol to obtain the same BIS values (i.e. 35-45) than do otherwise healthy children.

High success rate and low incidence of headache and neurological symptoms with two spinal needle designs in children. Kokki H , Turunen M , Heikkinen M , Reinikainen M , Laisalmi M . Acta Anaesthesiol Scand. 2005 Oct;49(9):1367-72. Department of Anaesthesiology and Intensive Care, Kuopio University Hospital, Kuopio, Finland. Hannu.Kokki@kuh.fi

BACKGROUND: In children, only a few trials have evaluated the use of spinal needles with special tip designs. In this study, we compared the success rate and incidence of post-dural puncture complaints of two small-gauge spinal needle designs used in children undergoing spinal anaesthesia (SA). METHODS: Three hundred and three children aged 9 months to 17 years presenting for subumbilical surgery were randomly assigned to have a 26G Atraucan (n = 156) or 27G Whitacre (n = 147) spinal needle for SA. The number of attempts to obtain successful cerebrospinal fluid (CSF) return and the success rate of SA were recorded. The first week of recovery was recorded by a diary. RESULTS: Both groups had a similar one-attempt success rate: 80% in the Atraucan group and 81% in the Whitacre group. Failure to obtain CSF occurred in one patient in the Atraucan group and in two patients in the Whitacre group. Paraesthesia was observed more commonly in the Whitacre group (10%) than in the Atraucan group (2%) (P = 0.004). The success rate of SA was 96%, with no differences between the two needles; one child was given general anaesthesia and 11 children (3%) a single dose of supplemental analgesia for the skin incision. Forty-one children (15%) developed a headache, 13 of which were classified as post-dural puncture headache (PDPH), seven cases (5%) in the Atraucan group and six (4%) in the Whitacre group; none of the children required a blood patch. Fifteen children (10%) in the Atraucan group and nine (7%) in the Whitacre group developed low back pain. Two children (1%) in the Atraucan group and four (3%) in the Whitacre group developed transient neurological symptoms (TNSs). CONCLUSION: Both needles were associated with a high success rate and a low incidence of complaints.

Jet ventilation for laryngotracheal surgery in an ex-premature infant. Koomen E , Poortmans G , Anderson BJ , Janssens MM . Paediatr Anaesth. 2005 Sep;15(9):786-9. Academisch Ziekenhuis Maastricht, Maastricht, The Netherlands. koomen-bijsterbosch@planet.nl

A 4-month-old ex-premature infant with severe airway obstruction from subglottic cysts presented for surgical cyst removal. Laryngeal and tracheal surgical procedures in children may present difficulties for the anesthetist because the airway is shared with the surgeon. We report the use of high-frequency jet ventilation (HFJV) to maintain ventilation and provide adequate surgical access. Anesthesia was induced using sevoflurane in oxygen and was maintained with intravenous infusions of propofol 7.5 mg.kg(-1).h(-1) and remifentanil 0.4 microg.kg(-1).min(-1). The suction channel of the ENT laryngoscope was used to introduce an 8-FG ureteric drainage catheter into the larynx and this catheter was used to provide HFJV. Obstruction to expiratory flow was a major concern and was dependent on good positioning of the rigid laryngoscope. Complications such as barotrauma, pneumopericardium, CO2-retention, necrotizing tracheobronchitis, and gastric rupture dictate a fastidious technique.

Perioperative management of a child with short-chain acyl-CoA dehydrogenase deficiency. Turpin B , Tobias JD . Paediatr Anaesth. 2005 Sep;15(9):771-7 College of Osteopathic Medicine, University of Health Sciences, Kansas City, MO, USA.

Short-chain acyl-CoA dehydrogenase (SCAD) is a mitochondrial enzyme that catalyzes the dehydrogenation of short chain fatty acids (4 to 6 carbons in length) thereby initiating the cycle of beta-oxidation. This process generates acetyl-CoA, the key substrate for hepatic ketogenesis or ATP production by the Kreb's cycle. A deficiency of SCAD results in the build-up of potentially cytotoxic metabolites including ethylmalonic acid, methylsuccinyl CoA and butyryl-carnitine. The end-organ involvement is heterogeneous, but most commonly includes hypotonia with possible lipid myopathy and developmental delay. Other reported complications include dysmorphic craniofacial features, hypoglycemia, seizures, scoliosis, hypertonia and hyperreflexia, cyclic vomiting and myocardial dysfunction. We present a 23-month-old girl with SCAD deficiency, who required posterior fossa decompression for type 1 Chiari malformation. The potential perioperative implications of SCAD deficiency are reviewed.

Single-dose dexmedetomidine reduces agitation and provides smooth extubation after pediatric adenotonsillectomy. Guler G , Akin A , Tosun Z , Ors S , Esmaoglu A , Boyaci A .
Paediatr Anaesth. 2005 Sep;15(9):762-6. Department of Anesthesiology, Erciyes University, Medical Faculty, Kayseri, Turkey. gulen@erciyes.edu.tr

BACKGROUND: Dexmedetomidine has shown sedative, analgesic, and anxiolytic effects after intravenous (IV) administration. Sevoflurane is associated with a high incidence of emergence agitation in preschool children. In this placebo-controlled study, we examined the effect of single dose dexmedetomidine on emergence agitation in children undergoing adenotonsillectomy. METHODS: In a double-blinded trial, 60 children (age 3-7 years) were randomly assigned to receive dexmedetomidine 0.5 microg.kg(-1) IV or placebo, 5 min before the end of surgery. All patients received a standardized anesthetic regimen. For induction and maintenance of anesthesia we used sevoflurane. After surgery, the incidence and severity of agitation was measured 2 h postoperatively. The incidence of untoward airway events after extubation, such as breath holding, severe coughing, or straining were recorded. After surgery, the children's behavior and pain were assessed with a 5-point scale. RESULTS: The agitation and pain scores in the dexmedetomidine group were better than those in the placebo group (P < 0.05). The incidence of severe agitation (a score of 4 or more), and severe pain (a score of 3 or more) were significantly less in the dexmedetomidine group (P < 0.05). The number of severe coughs per patient in the dexmedetomidine group was significantly decreased compared with the control group (P < 0.05). Postoperative vomiting was similar in both groups. Times to emergence and extubation were significantly longer in the dexmedetomidine group (P < 0.05). CONCLUSIONS: We conclude that 0.5 microg.kg(-1) dexmedetomidine reduces agitation after sevoflurane anesthesia in children undergoing adenotonsillectomy.

Pharmacokinetics and efficacy of ropivacaine for continuous epidural infusion in neonates and infants. Bosenberg AT , Thomas J , Cronje L , Lopez T , Crean PM , Gustafsson U , Huledal G , Larsson LE . Paediatr Anaesth. 2005 Sep;15(9):739-49. Department Anaesthesia, Faculty Health Sciences, University Natal, Durban, South Africa. bosie@cormack.uct.ac.za

INTRODUCTION: The primary objective of this noncomparative study was to evaluate the pharmacokinetics of ropivacaine during a 48-72-h continuous epidural infusion of ropivacaine in children under 1 year. The secondary objectives were to assess efficacy and safety. METHODS: Neonates and infants (ASA I-III, gestational age > or =37 weeks, > or =2.5 kg, scheduled for major abdominal or thoracic surgery) were included and separated into age groups: 0-30 (neonate), 31-90, 91-180, and 181-365 days. Ethics committee approval and informed parental consent were obtained before inclusion. An epidural catheter was introduced under general anesthesia at the appropriate dermatomal level. An initial bolus dose (0.9-2.0 mg.kg(-1) of ropivacaine 0.2%) was followed by an epidural infusion (0.2 mg.kg(-1).h(-1) for infants <180 days or 0.4 mg.kg(-1).h(-1) for infants >180 days). Plasma samples were collected every 12 h from 24 h, and on termination of the epidural infusion. Postoperative pain was evaluated using both the Objective Pain Scale and a four-graded descriptive scale. RESULTS: Forty-five infants, median age 116 (0-362) days, were included. Forty-three and 19 patients received an infusion for at least 48 and 72 h, respectively. Satisfactory analgesia was provided in the majority, only 20 patients were given supplementary medication during the infusion. In all age groups, plasma concentrations of unbound ropivacaine leveled at 24 h, without any further increase at 48 and 72 h. Because of lower clearance of unbound ropivacaine in neonates (mean 33 ml.min(-1).kg(-1)) than in infants above the age of 30 days (80, 124, and 163 ml.min(-1).kg(-1), respectively, in the age groups 31-90, 91-180, and 180-365 days), unbound ropivacaine concentrations at the end of infusion were higher in neonates [median 0.10 mg.l(-1) (0.04-0.21 mg.l(-1))] than in infants >30 days [median 0.03 mg.l(-1) (0.003-0.10 mg.l(-1))]. CONCLUSION: Epidural infusions (0.2-0.4 mg.kg(-1).h(-1) ropivacaine) provided satisfactory pain relief in neonates and infants under 1 year. As plasma concentrations of unbound ropivacaine were not influenced by the duration of the infusion, ropivacaine can be safely used for postoperative epidural infusion for 48-72 h. Levels of unbound ropivacaine were higher in the neonates than in the infants, but were below threshold concentrations for CNS toxicity in adults (> or =0.35 mg.l(-1)). This should not preclude the use of ropivacaine infusions in neonates but suggests a need for caution during the first weeks of life.

The correlation of the Narcotrend Index with endtidal sevoflurane concentrations and hemodynamic parameters in children. Weber F , Hollnberger H , Gruber M , Frank B , Taeger K . Paediatr Anaesth. 2005 Sep;15(9):727-32. Department of Anaesthesia, University of Regensburg, Regensburg, Germany. frank.weber@klinik.uni-regensburg.de

BACKGROUND: The Narcotrend Index (NI) of anesthetic depth is potentially a pharmacodynamic measure of the effects of sevoflurane on the brain. METHODS: In this prospective observational study of 30 pediatric surgical patients (1-11 years), we investigated the correlation between nonsteady-state endtidal sevoflurane (eT(Sevo)), NI, mean arterial pressure (MAP), and heart rate (HR). The performance of the Narcotrend for differentiation between consciousness and unconsciousness was evaluated using prediction probability (P(K)). RESULTS: Spearman correlation analysis showed significant correlations (P < 0.01) between eT(Sevo) and NI (r = -0.85) and MAP (r = -0.43). P(K)-values for differentiation between consciousness and unconsciousness were 1.0 for NI and <0.85 for MAP and HR. During the surgical procedure, NI-values showed a constant rise with each 0.5% step of lowering eT(Sevo) (P < 0.03), whereas MAP remained unaltered and HR showed a constant decline (P < 0.03), except between 1.5 and 1%. CONCLUSIONS: In children, nonsteady-state eT(Sevo) concentrations are more closely related with NI than with MAP or HR. In this study, only NI reliably differentiated consciousness from unconsciousness.

The safety and efficacy of spinal anesthesia for surgery in infants: the Vermont Infant Spinal Registry. Williams RK , Adams DC , Aladjem EV , Kreutz JM , Sartorelli KH , Vane DW , Abajian JC . Anesth Analg. 2006 Jan;102(1):67-71. Department of Anesthesia, University of Vermont, College of Medicine and Vermont Children's Hospital, Burlington, Vermont 05405, USA. robert.williams@vtmednet.org

Studies with modest numbers of patients have suggested that spinal anesthesia in infants is associated with a very infrequent incidence of complications, such as hypoxemia, bradycardia, and postoperative apnea. Although spinal anesthesia would seem to be a logical alternative to general anesthesia for many surgical procedures, it remains an underutilized technique. Since 1978, clinical data concerning all infants undergoing spinal anesthesia at the University of Vermont have been prospectively recorded. In all, 1554 patients have been studied. Anesthesia was performed by anesthesia trainees and attending anesthesiologists. The success rate for LP was 97.4%. An adequate level of spinal anesthesia was achieved in 95.4% of cases. The average time required to induce spinal anesthesia was 10 min. Oxygen hemoglobin desaturation to <90% was observed in 10 patients. Bradycardia (heart rate <100 bpm) occurred in 24 patients (1.6%). This study confirms the infrequent incidence of complications associated with spinal anesthesia in infants. Spinal anesthesia can be performed safely, efficiently, and with the expectation of a high degree of success. Spinal anesthesia should be strongly considered as an alternative to general anesthesia for lower abdominal and lower extremity surgery in infants.

Use of the ProSeal laryngeal mask airway for pressure-controlled ventilation with and without positive end-expiratory pressure in paediatric patients: a randomized, controlled study. Goldmann K , Roettger C , Wulf H . Br J Anaesth. 2005 Dec;95(6):831-4. Department of Anaesthesia and Intensive Care Therapy, Philipps University Marburg, 35033 Marburg, Germany. kaigoldmann1@aol.com

BACKGROUND: Tracheal intubation and positive end-expiratory pressure (PEEP) are frequently used in children to avoid airway closure and atelectasis during general anaesthesia. Also, the laryngeal mask airway (LMA(dagger)) is frequently used. However, one of the limitations with its use in children is that its low-pressure seal is often inadequate for positive pressure ventilation with PEEP. The ProSeal LMA (PLMA) has been shown to form a more effective seal than the Classic LMA. The ability to apply PEEP with the PLMA might improve gas exchange during positive pressure ventilation in children when the LMA is used. METHODS: Twenty anaesthetized, non-paralysed children aged 55 (range 27-89) months, weighing 18 (sd 3) kg, were randomly allocated into two groups. Anaesthesia management and positive pressure ventilation were standardized. Size 2 and 2(1/2) PLMA were used. Artificial ventilation in Group I was with pressure controlled ventilation (PCV) and PEEP=5 cm H(2)O, in Group II with PCV without PEEP. A Fi(o(2)) = 1.0 was used for 20 min during induction of anaesthesia. Sixty minutes after induction of anaesthesia an arterial blood gas sample was taken under a Fi(o(2)) = 0.3. RESULTS: Groups were comparable with respect to demographic data. Pa(o(2)) in Group I [22.1 (1.6) kPa] was significantly (P=0.001) higher

Central venous catheterization in infants and children--small caliber audio-Doppler probe versus ultrasound scanner. Arai T , Yamashita M . Paediatr Anaesth. 2005 Oct;15(10):858-61. Department of Anesthesiology, Ibaraki Children's Hospital, Futaba-dai Mito, Japan. tsmarai@nifty.com

BACKGROUND: Ultrasound guidance for cannulation of the internal jugular vein has been shown to increase the success rate and reduce the incidence of complications in infants and children. We compared the use of a small caliber audio-Doppler probe with an ultrasound scanner for cannulation of a central venous (CV) line via the right internal jugular vein in infants and children. METHODS: Fifty-two infants and 29 children scheduled for open-heart surgery were enrolled. Cannulation was guided using a small caliber audio-Doppler probe (the AU group, n = 42), or an ultrasound scanner image (the US group, n = 39). Ultimate success rate, success rate at the first attempt, success rate within 5 min, and complications were compared for the two groups. RESULTS: In children (>12 months), both methods were equally efficient. But in infants (<12 months), success rate at the first attempt using audio-Doppler was worse than the rate using an ultrasound scanner and there were more complications when audio-Doppler was used. CONCLUSIONS: We conclude that application of both the audio-Doppler and the ultrasound scanner is useful in children over 1 year of age for access to the internal jugular vein. However, in infants and neonates, the ultrasound scanner would be more useful than the audio-Doppler.

A comparison of three methods for estimating appropriate tracheal tube depth in children. Mariano ER , Ramamoorthy C , Chu LF , Chen M , Hammer GB . Paediatr Anaesth. 2005 Oct;15(10):846-51. Department of Anesthesia, University of California at San Diego School of Medicine, San Diego, CA 92103, USA. ermariano@ucsd.edu

BACKGROUND: Estimating appropriate tracheal tube (TT) depth following tracheal intubation in infants and children presents a challenge to anesthesia practitioners. We evaluated three methods commonly used by anesthesiologists to determine which one most reliably results in appropriate positioning. METHODS: After IRB approval, 60 infants and children scheduled for fluoroscopic procedures requiring general anesthesia were enrolled. Patients were randomly assigned to one of three groups: (1) deliberate mainstem intubation with subsequent withdrawal of the TT 2 cm above the carina ('mainstem' method); (2) alignment of the double black line marker near the TT tip at the vocal cords ('marker' method); or (3) placement of the TT at a depth determined by the formula: TT depth (cm) = 3 x TT size (mmID) ('formula' method). TT tip position was determined to be 'appropriate' if located between the sternoclavicular junction (SCJ) and 0.5 cm above the carina as determined by fluoroscopy. Risk ratios were calculated, and data were analysed by the chi-square test accepting statistical significance at P < 0.05. RESULTS: The mainstem method was associated with the highest rate of appropriate TT placement (73%) compared with both the marker method (53%, P = 0.03, RR = 1.56) and the formula method (42%, P = 0.006, RR = 2.016). There was no difference between the marker and formula methods overall (P = 0.2, RR = 1.27). Analysis of age-stratified data demonstrated higher success with the marker method compared with the formula method for patients 3-12 months (P = 0.0056, RR = 4.0). CONCLUSIONS: Deliberate mainstem intubation most reliably results in appropriate TT depth in infants and children.

Clown doctors as a treatment for preoperative anxiety in children: a randomized, prospective study. Vagnoli L , Caprilli S , Robiglio A , Messeri A . Pediatrics. 2005 Oct;116(4):e563-7. Pain Service-Department of Anesthesia and Intensive Care, Anna Meyer Children's Hospital, 50132 Florence, Italy.

BACKGROUND: The induction of anesthesia is one of the most stressful moments for a child who must undergo surgery: it is estimated that 60% of children suffer anxiety in the preoperative period. Preoperative anxiety is characterized by subjective feelings of tension, apprehension, nervousness, and worry. These reactions reflect the child's fear of separation from parents and home environment, as well as of loss of control, unfamiliar routines, surgical instruments, and hospital procedures. High levels of anxiety have been identified as predictors of postoperative troubles that can persist for 6 months after the procedure. Both behavioral and pharmacologic interventions are available to treat preoperative anxiety in children. OBJECTIVE: The aim of this study was to investigate the effects of the presence of clowns on a child's preoperative anxiety during the induction of anesthesia and on the parent who accompanies him/her until he/she is asleep. METHODS: The sample was composed of 40 subjects (5-12 years of age) who had to undergo minor day surgery and were assigned randomly to the clown group (N = 20), in which the children were accompanied in the preoperative room by the clowns and a parent, or the control group (N = 20), in which the children were accompanied by only 1 of his/her parents. The anxiety of the children in the preoperative period was measured through the Modified Yale Preoperative Anxiety Scale instrument (observational behavioral checklist to measure the state anxiety of young children), and the anxiety of the parents was measured with the State-Trait Anxiety Inventory (Y-1/Y-2) instrument (self-report anxiety behavioral instrument that measures trait/baseline and state/situational anxiety in adults). In addition, a questionnaire for health professionals was developed to obtain their opinion about the presence of clowns during the induction of anesthesia, and a self-evaluation form was developed to be filled out by the clowns themselves about their interactions with the child. RESULTS: The clown group was significantly less anxious during the induction of anesthesia compared with the control group. In the control group there was an increased level of anxiety in the induction room in comparison to in the waiting room; in the clown group anxiety was not significantly different in the 2 locations. The questionnaire for health professionals indicated that the clowns were a benefit to the child, but the majority of the staff was opposed to continuing the program because of perceived interference with the procedures of the operating room. The correlation between the scores of the form to self-evaluate the effectiveness of the clowns and of the Modified Yale Preoperative Anxiety Scale is significant for both the waiting room and induction room. CONCLUSIONS: This study shows that the presence of clowns during the induction of anesthesia, together with the child's parents, was an effective intervention for managing children's and parents' anxiety during the preoperative period. We would encourage the promotion of this form of distraction therapy in the treatment of children requiring surgery, but the resistance of medical personnel make it very difficult to insert this program in the activity of the operating room.

Maternal and Neonatal Effects of Remifentanil at Induction of General Anesthesia for Cesarean Delivery: A Randomized, Double-blind, Controlled Trial. Kee WD , Khaw KS , Ma KC , Wong AS , Lee BB , Ng FF . Anesthesiology. 2006 Jan;104(1):14-20.

BACKGROUND:: Use of remifentanil during general anesthesia for cesarean delivery has been described, but its maternal and neonatal effects have not been investigated by a controlled study. METHODS:: In a randomized, double-blind, controlled study, patients undergoing elective cesarean delivery received an intravenous bolus of 1 mug/kg remifentanil (n = 20) or saline (n = 20) immediately before induction of general anesthesia. The authors compared maternal hemodynamic changes and neonatal condition and measured plasma concentrations of remifentanil. RESULTS:: The maximum increase in systolic arterial pressure from baseline after induction was smaller in the remifentanil group (median, 9 [range, -17 to 31] mmHg) compared with the control group (42 [6-73] mmHg, median difference, 33 mmHg; 95% confidence interval of difference, 23-45 mmHg; P < 0.0001). Maximum recorded values were smaller in the remifentanil group compared with the control group for systolic and mean arterial pressure and maternal heart rate. Apgar scores and time to sustained respiration were similar between groups. Two neonates in the remifentanil group were considered clinically depressed at birth and were given a single dose of naloxone. Remifentanil crossed the placenta with an umbilical venous/maternal arterial concentration ratio of 0.73 (SD, 0.17) and an umbilical arterial/umbilical venous concentration ratio of 0.60 (0.23). CONCLUSIONS:: A single bolus of 1 mug/kg remifentanil effectively attenuated hemodynamic changes after induction and tracheal intubation. However, remifentanil crosses the placenta and may cause mild neonatal depression and thus should be used for clear maternal indications when adequate facilities for neonatal resuscitation are available.

Low flow desflurane and sevoflurane anaesthesia in children. Isik Y , Goksu S , Kocoglu H , Oner U . Eur J Anaesthesiol. 2006 Jan;23(1):60-4. University of Gaziantep, Faculty of Medicine, Department of Anesthesiology and Reanimation, Gaziantep, Turkey.

SummaryBackground and objective: Low flow desflurane and sevoflurane anaesthesia were administered to children and compared for haemodynamic response, renal and hepatic function, recovery time and postoperative nausea and vomiting. Methods: Eighty ASA I-II patients aged 5-15 yr were included in the study. Midazolam was given for premedication. Anaesthesia induction was performed with fentanyl, propofol and atracurium. After intubation, the first group received desflurane, oxygen and nitrous oxide at 6 L min-1 and the second sevoflurane, oxygen and nitrous oxide at 6L min-1. Ten minutes after induction the flow was decreased to 1L min-1 in both groups. Haemodynamic parameters, preoperative and postoperative renal and hepatic function, the times of operation and anaesthesia, and early recovery data were recorded. Modified Aldrete scores were noted at the 10th and 30th minutes postoperatively and postoperative nausea, and vomiting were assessed. Results: There were no significant differences in haemodynamic parameters, renal and hepatic functions, postoperative recovery and postoperative nausea and vomiting between groups. The recovery time was shorter in the desflurane group compared to the sevoflurane group. Conclusion: Low flow desflurane and sevoflurane anaesthesia do not adversely affect haemodynamic parameters, hepatic and renal function in children. Desflurane may be preferred when early recovery from anaesthesia is warranted.

Comparison of the effect of ketamine added to bupivacaine and ropivacaine, on stress hormone levels and the duration of caudal analgesia. Akbas M , Titiz TA , Ertugrul F , Akbas H , Melikoglu M. Acta Anaesthesiol Scand. 2005 Nov;49(10):1520-6. Department of Anaesthesiology, Akdeniz University Medical Faculty, Antalya, Turkey. akbasmert@akdeniz.edu.tr

BACKGROUND: The aim of this study was to compare bupivacaine 0.25% and ropivacaine 0.2%, singly and in combination with ketamine, for caudal administration in children. Duration of analgesia, the need for other analgesics and the stress response were measured. METHODS: Eighty children were randomized into four groups of twenty. The bupivacaine group received bupivacaine 0.25% and the ketamine/bupivacaine group received bupivacaine 0.25% plus 0.5 mg/kg ketamine. The ropivacaine group received ropivacaine 0.2%, and the ketamine/ropivacaine group received ropivacaine 0.2% plus 0.5 mg/kg ketamine. The duration of analgesia and analgesic requirements were recorded for each group, as were peri-operative and post-operative concentrations of the stress hormones insulin, glucose and cortisol. RESULTS: Ketamine, added to either bupivacaine or ropivacaine for caudal analgesia, gave a longer duration of analgesia (P < 0.05) than bupivacaine or ropivacaine alone. In all groups, blood insulin concentration was increased, and cortisol concentration reduced. Glucose concentration was significantly increased in all groups (P < 0.05). CONCLUSIONS: Ketamine can safely be added to ropivacaine 0.2% or bupivacaine 0.25% for caudal anesthesia in order to prolong duration of analgesia and reduce the need for additional analgesics. Stress hormone levels are partially attenuated.

Leigh syndrome: Anesthetic management in complicated endoscopic procedures. Gozal D , Goldin E , Shafran-Tikva S , Tal D , Wengrower D . Paediatr Anaesth. 2006 Jan;16(1):38-42. Department of Pediatric Sedation Service, Anesthesiology, Hadassah University Hospital, Jerusalem, Israel.

Background : Leigh's syndrome, a disorder of infancy and childhood, is characterized by gray matter degeneration and focal brainstem necrosis. It presents with special clinical features such as developmental delay, nervous system dysfunction, respiratory abnormalities, and hypertrophic cardiomyopathy that can be a real challenge to the anesthesiologist. Anesthesia or sedation has rarely been reported in patients with Leigh disease. We report our experience in sedating five children with Leigh syndrome in seven procedures undertaken in the endoscopy suite (outside the operating room). Methods : Five children with Leigh disease, three girls and two boys, have been referred to us for percutaneous endoscopic gastrostomy (PEG) insertion and or replacement (a total of seven procedures).The average age was 2.6 years with a range of 4 months to 6 years. Informed consent was obtained from the patient's parents or guardian. An anesthesia machine, scavenging system, O(2) source and routine monitoring were available. Sedation was accomplished with propofol intravenous (i.v.) (0.5-1 mg.kg(-1)) maintained with a propofol infusion (50-100 mug.kg(-1).min(-1)). The spontaneously breathing patients received oxygen through an oxygen facemask during the procedure and afterwards recovery was managed in the gastroenterology unit. Results : All the children underwent the procedure without complications. One patient developed transient desaturation (SpO(2) 80%) for a few seconds. Body temperature, heart rate, arterial blood pressure, O(2) saturation and endtidal CO(2) were stable during the endoscopies. No special postprocedure management was required; the patients woke up at the end of the endoscopy and were able to drink and eat as usual. Conclusions : This rare mitochondrial disease presents unique management problems to the anesthesiologist when using general anesthesia. Our patients were managed appropriately before endoscopy and underwent the procedure under deep sedation. No complications occurred. We concluded that deep sedation in the endoscopy suite was safe in this small series of patients with this rare disease.

Spinal anesthesia in children with isobaric local anesthetics: Report on 307 patients under 13 years of age. Paediatr Anaesth. 2006 Jan;16(1):43-8 Imbelloni LE , Vieira EM , Sperni F , Guizellini RH , Tolentino AP . Institute for Regional Anaesthesia, Hospital de Base da FAMERP, Sao Jose do Rio Preto, SP, Brazil.

Background: Spinal anesthesia in expert hands is an excellent method for children for appropriate surgery. The aim of this study was to evaluate the effects of spinal anesthesia with isobaric solutions in 307 consecutive cases from May 2001 to August 2002. Methods: In this prospective study, 307 patients from 0 to 12 years of age were scheduled for spinal anesthesia with enantiomeric mixture of bupivacaine (S75 : 25R) 0.5% or racemic bupivacaine 0.5% or lidocaine 2% without glucose, for surgery compatible with the technique. The following were assessed: latency of analgesia, motor block, maximum length and duration of sensory blockade, cardiovascular changes, incidence of headache or transient neurological symptoms and cost. Results: The onset of sensory block occurred at 2.36 +/- 0.95 min. Duration of surgery was 1.29 +/- 0.83 h and the duration of stay in the postanesthesia care unit was 39.72 +/- 26.84 min. The highest level of analgesia ranged from T(9) to T(4) (mean T(6)). Onset of motor block was <2 min in all children and each had a modified Bromage score of 3 at the beginning of the surgery. At the end of the surgery 9% had score 3, 16%, score 2, 46%, score 1 and 29%, zero. Seventy five percent of all patients recovered from motor block 1 or zero at the end of the surgery. Patients older than 1 year were able to walk in 3.79 +/- 0.73 h. There was no case of oxygen desaturation. Hypotension and bradycardia occurred in one patient. Spinal anesthesia failed in five patients. Three children developed postdural puncture headache (PDPH), the youngest aged 2 years. PDPH in all three was mild or moderate. Transient radicular symptoms were not observed. The final cost of the spinal anesthesia was R$49.00 compared with a mean cost of general anesthesia of R$105.00. Conclusions: Spinal anesthesia continues to gain acceptance as an alternative to general anesthesia in children. There has also been an increased use of spinal anesthesia for other surgical procedures including lower extremity orthopedic procedures as well as specific surgery procedures above the umbilicus and in patients past the neonatal period. Spinal anesthesia in children is a special method suitable for use only by anesthesiologists, expert in administering spinal anesthesia for adults. It was 54% less than the cost of general anesthesia.

Anesthetic implications of Jacobsen syndrome. Blaine Easley R , Sanders D , McElrath-Schwartz J , Martin J , Mark Redmond J . Paediatr Anaesth. 2006 Jan;16(1):66-71. Department of Anesthesiology and Critical Care, Johns Hopkins Medical Institute, Baltimore, MD, USA.

Jacobsen syndrome (JS), also known as 11q-syndrome, is a congenital disorder associated with a deletion of the long arm of chromosome 11. Patients with JS characteristically exhibit multiple dysmorphic features, developmental delay, cardiac anomalies, and platelet abnormalities. Anesthetic issues related to the care of patients with JS concern airway management secondary to short neck, abnormal mouth shape and micrognathia/retrognathia, a high incidence of cardiac anomalies, and platelet dysfunction. Importantly, platelet abnormalities affect 95% of reported JS patients and involve platelet number, size and function. Two children with JS who required open heart surgery are presented and anesthetic management issues discussed. These patients represent the first reports regarding the perioperative issues in caring for patients with JS.

Anesthesia management in a young child with aromatic l-amino acid decarboxylase deficiency. Vutskits L , Menache C , Manzano S , Haenggeli CA , Habre W . Paediatr Anaesth. 2006 Jan;16(1):82-4. Department of Anesthesiology, Pharmacology and Surgical Intensive Care, University Hospital of Geneva, Geneva, Switzerland.

Aromatic l-amino acid decarboxylase (AADC) deficiency is characterized by an almost complete absence of sympathetic autoregulation, because of very low levels of circulating catecholamines. Here, we report the successful management of four consecutive anesthesia procedures in a young child presenting with AADC deficiency. Our experience suggests that, with appropriate anticipation of the potential autonomic disturbances, anesthesia, at least for minor surgical and diagnostic procedures, can be conducted safely in patients with AADC deficiency.

Clonidine in paediatric anaesthesia: review of the literature and comparison with benzodiazepines for premedication. Bergendahl H , Lonnqvist PA , Eksborg S . Acta Anaesthesiol Scand. 2006 Feb;50(2):135-43 Department of Anaesthesia, Intensive, and Pain Care, Karolinska University Hospital, Huddinge, Sweden.

Background: Children undergoing anaesthesia and surgery can experience significant anxiety and distress during the peri-operative period, but whether routine premedication is necessary is currently debated. Benzodiazepines are the most frequently used drugs as premedication in paediatric anaesthesia. In the US, 50% of young children undergoing surgery receive premedication and midazolam is the most frequently used drug in this context (1). Nishina and coworkers (2) concluded in a review article in 1999 that clonidine, administered via an oral, rectal, or caudal route, is a promising adjunct to anaesthetics and analgesics to enhance quality of peri-operative management in infants and children. Later publications also support the use of clonidine for premedication (3-6). The aim of this communication is to review the use of clonidine in paediatric anaesthesia and to propose clonidine as a promising alternative to midazolam. Clonidine is associated with a number of beneficial effects in the context ofanaesthesia both in adults and children. Why clonidine is not routinely use in clinical practice despite the massive publication list is to a large extent due to the lack of marketing efforts from the pharmaceutical industry since multiplegeneric preparations are now readily available on most markets. Midazolam is also associated with a number of beneficial effects, but is far from an ideal premedicant in children, especially with regards to the amnesia, confusion and long term behavioural disturbances. Clonidine has contrary to midazolam no effect on respiration. We believe that clonidine is a good alternative to midazolam as premedication in infants and children.

A comparison of a needle-free injection system for local anesthesia versus EMLA for intravenous catheter insertion in the pediatric patient. Jimenez N , Bradford H , Seidel KD , Sousa M , Lynn AM . Anesth Analg. 2006 Feb;102(2):411-4. Department of Anesthesiology and Pain Medicine, Children's Hospital and Regional Medical Center, University of Washington School of Medicine, Seattle, WA 98105, USA. nathalia.jimenez@seattlechildrens.org

Placement of IV catheters is a painful and stressful procedure for children. J-Tip is a needle-less Food and Drug Administration approved injection system that can be used for delivery of local anesthetic before IV cannulation. In this study, we compared the effectiveness of J-Tip versus eutectic mixture of local anesthetics (EMLA) to facilitate IV cannulation and provide adequate analgesia before IV placement. Children 7-19 years of age (n = 116) were randomized to receive 0.25 mL of 1% buffered lidocaine with J-Tip (n = 57) or 2.5 g of EMLA (n = 59) before IV cannulation. Measurements of success of cannulation (number of attempts for IV placement) and pain (0-10 visual analog scale) at application of local anesthetic and at cannulation were performed. There was a significant (P = 0.0001) difference in pain ratings during IV cannulation between EMLA (median = 3) and the J-Tip (median = 0). Eighty-four percent of patients reported no pain at the time of J-Tip lidocaine application compared to 61% in the EMLA group at the time of dressing removal (P = 0.004). We did not find differences in the number of attempts for IV cannulation. J-Tip application of 1% buffered lidocaine before IV cannulation is not painful and has better anesthetic effectiveness compared with EMLA.

Desflurane anesthesia after sevoflurane inhaled induction reduces severity of emergence agitation in children undergoing minor ear-nose-throat surgery compared with sevoflurane induction and maintenance. Mayer J , Boldt J , Rohm KD , Scheuermann K , Suttner SW . Anesth Analg. 2006 Feb;102(2):400-4. Department of Anesthesia and Intensive Care Medicine, Klinikum Ludwigshafen, Ludwigshafen, Germany. j-mayer@gmx.de

Emergence agitation may occur after general anesthesia with volatile anesthetics in children. We designed this study to examine the emergence behavior of children undergoing ear-nose-throat surgery after sevoflurane induction and desflurane maintenance versus both sevoflurane induction and maintenance using a recently published Pediatric Anesthesia Emergence Delirium (PAED) scale. In 38 premedicated children aged 12 mo to 7 yr mask induction with sevoflurane was performed and they were randomly assigned to receive either sevoflurane (n = 19) or desflurane (n = 19) for maintenance of general anesthesia. Time to tracheal extubation, modified Aldrete score, emergence behavior, recovery complications, and pain scores were assessed. The PAED scale showed a significant advantage for desflurane (6 [0-15] versus 12 [2-20], maximum total score of 20 for severe agitation). Time to extubation was significantly shorter with desflurane than with sevoflurane (5.4 +/- 1.4 versus 13.4 +/- 1.8 min). The modified Aldrete score on arrival in the postanesthesia care unit (PACU) was significantly lower in children receiving sevoflurane for maintenance. Time to discharge from PACU to normal ward and the incidence of adverse effects were not significantly different between the groups. In conclusion, the use of desflurane for maintenance of anesthesia after sevoflurane induction in children is associated with less severe emergence agitation and faster emergence times.

Caudal regional anesthesia, ropivacaine concentration, postoperative analgesia, and infants. Khalil S , Lingadevaru H , Bolos M , Rabb M , Matuszczak M , Maposa D , Chuang A . Anesth Analg. 2006 Feb;102(2):395-9. Department of Anesthesiology, Department of Ophthalmology, The University of Texas Medical School at Houston, Houston, Texas 77030-1503, USA. samia.n.khalil@uth.tmc.edu

In this randomized, double-blind trial we evaluated the quality and duration of analgesia and motor effects after caudal block using 1 mL/kg of ropivacaine 0.1% (Group 1), 0.15% (Group 2), 0.175% (Group 3) compared to 0.2% (Group 4) in infants 1-12 mo old. Postoperatively, the number of infants who received pain medication differed among the groups (P < 0.0005). There were more infants in Groups 1 and 2 compared with Group 4 and there was no difference between Groups 3 and 4. In the postanesthesia care unit, infants in Groups 1 and 2 received more pain medication than did those in Group 4 (P = 0.0098). In the day surgery unit, there was a significant difference among the groups (P = 0.0326); infants in Groups 3 and 4 required no pain medication. The analgesia duration differed among the groups (P = 0.034). Infants in Groups 1 and 2 had a shorter duration, and there was no difference between Groups 3 and 4. Infants in Group 4 took longer to regain their motor power compared with those in Group 3 (P = 0.0347). We conclude that in infants, ropivacaine 0.175% provided postoperative analgesia and duration similar to that of ropivacaine 0.2%, whereas ropivacaine 0.1% and 0.15% did not, and it was associated with fewer motor effects.

Respiratory reflex responses of the larynx differ between sevoflurane and propofol in pediatric patients. Oberer C , von Ungern-Sternberg BS , Frei FJ , Erb TO . Anesthesiology. 2005 Dec;103(6):1142-8. Division of Anesthesiology, University Children's Hospital beider Basel, 8 Roemergasse, CH-4058 Basel, Switzerland.

BACKGROUND: The effects of anesthetics on airway protective reflexes have not been extensively characterized in children. The aim of this study was to compare the laryngeal reflex responses in children anesthetized with either sevoflurane or propofol under two levels of hypnosis using the Bispectral Index score (BIS). The authors hypothesized that the incidence of apnea with laryngospasm evoked by laryngeal stimulation would not differ between sevoflurane and propofol when used in equipotent doses and that laryngeal responsiveness would be diminished with increased levels of hypnosis. METHODS: Seventy children, aged 2-6 yr, scheduled to undergo elective surgery were randomly allocated to undergo propofol or sevoflurane anesthesia while breathing spontaneously through a laryngeal mask airway. Anesthesia was titrated to achieve the assigned level of hypnosis (BIS 40 +/- 5 or BIS 60 +/- 5) in random order. Laryngeal and respiratory responses were elicited by spraying distilled water on the laryngeal mucosa, and a blinded reviewer assessed evoked responses. RESULTS: Apnea with laryngospasm occurred more often during anesthesia with sevoflurane compared with propofol independent of the level of hypnosis: episodes lasting longer than 5 s, 34% versus 19% at BIS 40 and 34% versus 16% at BIS 60; episodes lasting longer than 10 s, 26% versus 10% at BIS 40 and 26% versus 6% at BIS 60 (group differences P < 0.04 and P < 0.01, respectively). In contrast, cough and expiration reflex occurred significantly more frequently in children anesthetized with propofol. CONCLUSION: Laryngeal and respiratory reflex responses in children aged 2-6 yr were different between sevoflurane and propofol independent of the levels of hypnosis examined in this study.

Postoperative pain, nausea and vomiting following paediatric day-case tonsillectomy. Ewah BN , Robb PJ , Raw M . Anaesthesia. 2006 Feb;61(2):116-22. Department of Anaesthesia, Epsom & St Helier University Hospitals NHS Trust, Epsom, Surrey, KT18 7EG, UK.

More than 30% of all surgical activity for children in England and Wales is accounted for by routine ENT operations. There is known to be a high incidence of postoperative pain, nausea and vomiting following paediatric tonsillectomy with or without adenoidectomy. This prospective study examined the incidence of these complications in 100 children admitted for routine, elective day-case tonsillectomy, with or without adenoidectomy. The children were anaesthetised in accordance with our standard paediatric day-case protocol. The incidence of vomiting on the day of surgery was significantly less in the group anaesthetised in accordance with the protocol, compared to those in previously published studies. Postoperative pain was well controlled, with 88% of the children having minimal pain on the day of surgery, and reporting a pain score of 0-2. Modifying the anaesthetic care to a protocol designed to reduce postoperative pain, nausea and vomiting achieved measurable improvements in the recovery of this group following surgery. It has enabled us to evolve from a 100% inpatient stay for these operations to 98% day-case discharge rate, with minimal post anaesthetic or surgical morbidity. We describe the protocol and discuss the implications of implementing such a protocol for children undergoing these common operations.

Upper airway collapsibility in anesthetized children. Litman RS , McDonough JM , Marcus CL , Schwartz AR , Ward DS . Anesth Analg. 2006 Mar;102(3):750-4. Department of Anesthesiology, University of Rochester, Rochester, New York, USA. Litmanr@email.chop.edu

We sought to establish the feasibility of measuring upper airway narrowing in spontaneously breathing, anesthetized children using dynamic application of negative airway pressure. A secondary aim was to compare differences in upper airway collapsibility after the administration of sevoflurane or halothane. Subjects were randomized to either drug for inhaled anesthetic induction. Each was adjusted to their 1 MAC value (0.9% for halothane and 2.5% for sevoflurane) and a blinded anesthesia provider held the facemask without performing manual airway opening maneuvers but with inclusion of an oral airway device. Inspiratory flows were measured during partial upper airway obstruction created by an adjustable negative pressure-generating vacuum motor inserted into the anesthesia circuit. Critical closing pressure of the pharynx (Pcrit) was obtained by plotting the peak inspiratory flow of the obstructed breaths against the corresponding negative pressure in the facemask and extrapolating to zero airflow using linear correlation. Fourteen children were enrolled, seven in each anesthetic group. Two children in the halothane group did not develop flow-limited airway obstruction despite negative pressures as low as -9 cm H2O. Pcrit for sevoflurane ranged from -6.7 to -11.6 (mean +/- sd, -9.8 +/- 1.9) cm H2O. Pcrit for halothane ranged from -8.1 to -33 (mean +/- sd, -19.4 +/- 9.3) cm H2O (sevoflurane versus halothane, P = 0.048). We conclude that when using dynamic application of negative airway pressure, halothane appears to cause less upper airway obstruction than sevoflurane at equipotent concentrations.

The size 1(1/2) ProSeal laryngeal mask airway in infants: a randomized, crossover investigation with the Classic laryngeal mask airway. Goldmann K , Roettger C , Wulf H . Anesth Analg. 2006 Feb;102(2):405-10. Attending Anesthesiologist, Department of Anaesthesia and Intensive Care Therapy, Philipps University Marburg, Marburg, Germany. Kaigoldmann1@aol.com

Many problems with the Classic laryngeal mask airway (CLMA) in infants are believed to be related to its inadequate cuff design. One of the main limitations of the CLMA is that the resulting low-pressure seal can be inadequate for positive pressure ventilation (PPV). The ProSeal LMA (PLMA), a new laryngeal mask airway with a modified cuff, has been shown to form a more effective seal than the CLMA in children. The first infant size PLMA, size 1(1/2), became available recently. We studied 30 anesthetized, nonparalyzed infants aged 15 mo (2-30 mo) and weighing 9 kg (5-12 kg). The CLMA and PLMA were inserted in random order into each patient. Airway leak pressure and maximum tidal volume were measured. Ease of insertion, quality of initial airway, and fiberoptic position were also determined. Gastric tube placement was assessed for the PLMA. The mean airway leak pressure in neutral head position (26.7 versus 18.9 cm H2O), maximum flexion (35.6 versus 28.2 cm H2O), and the mean maximum tidal volume (312 versus 260 mL) were significantly higher for the PLMA (P < 0.01). Air entered the stomach in eight patients with the CLMA but did not with the PLMA. Gastric tube placement was possible in all but one patient. In three patients, the use of the PLMA led to some degree of clinically relevant compression of the larynx. The size 1(1/2) PLMA seems to be a more suitable device for airway maintenance in infants than the same size CLMA. The ability to insert a gastric tube at the same time, and a significantly higher airway leak pressure than with the CLMA, may have important implications for its use for PPV in infants.

A comparison of observational and objective measures to differentiate depth of sedation in children from birth to 18 years of age. Malviya S , Voepel-Lewis T , Tait AR . Anesth Analg. 2006 Feb;102(2):389-94. Department of Anesthesiology, Section of Pediatrics, C.S. Mott Children's Hospital, University of Michigan Medical Center, Ann Arbor, Michigan 48109-0211, USA. smalviya@umich.edu

Several observational and objective methods are available to assess sedation depth; however, data regarding their accuracy in differentiating deep sedation are limited. In this study we compared 3 sedation tools in children from birth to 18 yr of age and determined their relative value in detecting deep levels of sedation. Bispectral index monitoring (BIS), Modified Maintenance of Wakefulness Tests (MMWT), and the University of Michigan Sedation Scale (UMSS) were used to assess sedation. Three-hundred-twenty-seven observations were recorded in 39 children. The overall validity of each measure was supported by appropriate changes after sedation administration through the observation period. There were moderate to high correlations between UMSS and BIS (rho = -0.73) and UMSS and MMWT (rho = -0.59; P < 0.01). The correlation between BIS and MMWT was significant but low (r = 0.36; P < 0.01). Measures of exact agreement supported the reliability of the UMSS and MMWT across the sedation continuum. There were significant decreases in BIS across UMSS scores except from scores 2-3. ROC curves suggested that BIS < or = 80 and MMWT < or = 14 min were most sensitive in delineating deep sedation. Our findings demonstrate the overall validity of these observational and objective measures of sedation depth in children <18 yr of age but show ongoing limitations distinguishing moderate from deep sedation

The efficacy of a subhypnotic dose of propofol in preventing laryngospasm following tonsillectomy and adenoidectomy in children. Batra YK , Ivanova M , Ali SS , Shamsah M , Al Qattan AR , Belani KG . Paediatr Anaesth. 2005 Dec;15(12):1094-7. Department of Anaesthesia and Intensive Care, Al Sabah Hospital, Kuwait. ykbatra@glide.net.in

BACKGROUND: Laryngospasm is a well-known problem typically occurring immediately following tracheal extubation. Propofol is known to inhibit airway reflexes. In this study, we sought to assess whether the empiric use of a subhypnotic dose of propofol prior to emergence will decrease the occurrence of laryngospasm following extubation in children. METHODS: After approval from the Institutional Ethics Committee and informed parental consent, we enrolled 120 children ASA physical status I and II, aged 3-14 years who were scheduled to undergo elective tonsillectomy with or without adenoidectomy under standard general anesthesia. Before extubation, the patients were randomized and received in a blinded fashion either propofol 0.5 mg.kg(-1) or saline (control) intravenously. Tracheal extubation was performed 60 s after administration of study drug, when the child was breathing regularly and reacting to the tracheal tube. RESULTS: Laryngospasm was seen in 20% (n = 12) of the 60 children in the control group and in only 6.6% (n = 4) of 60 children in the propofol group (P < 0.05). CONCLUSIONS: During emergence from inhalational anesthesia, propofol in a subhypnotic dose (0.5 mg.kg(-1)) decreases the likelihood of laryngospasm upon tracheal extubation in children undergoing tonsillectomy with or without adenoidectomy.

Postoperative shivering in children and causative factors. Akin A , Esmaoglu A , Boyaci A . Paediatr Anaesth. 2005 Dec;15(12):1089-93. Department of Anesthesiology, Erciyes University School of Medicine, Kayseri, Turkey. aaynur@erciyes.edu.tr

BACKGROUND: The aim of this study is to investigate the incidence of shivering in children and to reveal the causative factors as well as any possible clinical implications. METHODS: This study was conducted on 1507 children who underwent surgery under general anesthesia. The patients were admitted to the postanesthesia care unit after the operation and their body temperatures measured from the tympanic membrane. The type of operation, operative time, method of anesthesia induction, age, and number of cases in which caudal block had been used were recorded. RESULTS: Of the 1507 children, 53 (3.5%) experienced shivering. The use of intravenous induction agents, age older than 6 years, and prolonged duration of surgery were associated with shivering. The type of the operation and gender had no effect. The frequency of shivering was lower in children who underwent caudal block with a statistical significance (P < 0.05). CONCLUSIONS: The overall incidence of shivering in children is low (3.5%). Use of intravenous induction agents, age older than 6 years, and prolonged duration of surgery were associated with shivering; prophylaxis is not necessary in children, treatment is given only when shivering occurs.

Continuous epidural block versus continuous popliteal nerve block for postoperative pain relief after major podiatric surgery in children: a prospective, comparative randomized study. Dadure C , Bringuier S , Nicolas F , Bromilow L , Raux O , Rochette A , Capdevila X . Anesth Analg. 2006 Mar;102(3):744-9. Department of Anesthesia, Lapeyronie University Hospital, Montpellier, France. chdadure@yahoo.fr

Foot and ankle surgery in children is very painful postoperatively. Adverse effects from opioids and continuous epidural block (CEB) limit their use in children. Continuous popliteal nerve blocks (CPNB) have not been studied for this indication in children. In this prospective, randomized study we evaluated the effectiveness and adverse events of CPNB or CEB in children after podiatric surgery. Fifty-two children scheduled for foot surgery were separated into four groups by age and analgesia technique. After general anesthesia, 0.5 to 1 mL/kg of an equal-volume mixture of 0.25% bupivacaine and 1% lidocaine with 1:200000 epinephrine was injected via epidural or popliteal catheters. In the postoperative period, 0.1 mL x kg(-1) x h(-1) (group CPNB) or 0.2 mL x kg(-1) x h(-1) (group CEB) of 0.2% ropivacaine was administered for 48 h. Niflumic acid was routinely used. Adverse events were noted in each treatment group. Postoperative pain during motion was evaluated at 1, 6, 12, 18, 24, 36, and 48 h. Requirement for rescue analgesia (first-line propacetamol 30 mg/kg 4 times daily or second-line 0.2 mg/kg IV nalbuphine), and motor blockade were recorded. Parental satisfaction was noted at 48 h. Twenty-seven patients were included in the CEB groups and 25 in CPNB groups. There were 32 children 1 to 6 yr of age (CPNB = 15; CEB = 17) and 20 children 7 to 12 yr of age (CPNB = 10; CEB = 10). The demographic data were comparable among groups. Postoperative analgesia was excellent for the two continuous block techniques and in the two age groups. Motor block intensity was equal between techniques. Adverse events (postoperative nausea or vomiting, urinary retention, and premature discontinuation of local anesthetic infusion in the 1- to 6-yr-old group) were significantly more frequent in the CEB group (P < 0.05). Eighty-six percent of the parents in the CEB groups and 100% in the CPNB groups were satisfied. We conclude that although both CEB and CPNB resulted in excellent postoperative analgesia in this study, CPNB was associated with less urinary retention and nausea and vomiting. Therefore, we recommend CPNB as the ideal form of postoperative analgesia after major podiatric surgery in 1- to 12-yr-old children.

The effect of sevoflurane on cerebral autoregulation in young children as assessed by the transient hyperemic response. Wong GT , Luginbuehl I , Karsli C , Bissonnette B . Anesth Analg. 2006 Apr;102(4):1051-5. Department of Anesthesia, Hospital for Sick Children, Toronto, Ontario, Canada. gordontcwong@hotmail.com

The transient hyperemic response (THR) test is a simple, noninvasive technique to evaluate cerebral autoregulation using transcranial Doppler. It has not yet been used in studies involving children. In this study we evaluated this response in children undergoing general anesthesia using sevoflurane. Twenty ASA physical status I children undergoing elective urological surgery sequentially received sevoflurane at 0.5, 1.0, and 1.5 MAC in a randomized order. Analgesia was solely provided by caudal anesthesia. The right middle cerebral artery flow velocities before (F1), during (F2), and after (F3) a 10-s ipsilateral carotid artery compression were recorded. The THR ratios (THRR) (+/- sd) for 0.5 MAC, 1.0 MAC, and 1.5 MAC were 1.24 +/- 0.11, 1.16 +/- 0.09, and 1.13 +/- 0.07, respectively. The THRR was significantly different between 0.5 MAC versus 1.0 and 1.5 MAC, respectively (P < 0.05). However, no difference was detected between 1.0 and 1.5 MAC. A THRR of more than 1.09 has previously been accepted as the lower limit of a positive response. The results in this study suggest that THR is affected by sevoflurane in a dose-dependent fashion but is maintained at up to 1.5 MAC. This suggests cerebral autoregulation is preserved in children anesthetized with up to 1.5 MAC sevoflurane.

Emergence and recovery in children after desflurane and isoflurane anaesthesia: effect of anaesthetic duration. Nordmann GR , Read JA , Sale SM , Stoddart PA , Wolf AR . Br J Anaesth. 2006 Apr 13; [Epub ahead of print] Department of Anaesthesia, Bristol Royal Hospital for Children, Bristol, UK.

BACKGROUND: We hypothesized that increasing duration of inhalation anaesthesia is associated with slower emergence and recovery in children, and that this effect would be less marked with desflurane in comparison with isoflurane. METHODS: Fifty-four infants and children assigned in groups according to age and expected length of operation were prospectively randomized to receive either isoflurane (I) or desflurane (D) for anaesthesia. After standard induction, the anaesthesia was maintained using an age-related 1.0 minimum alveolar concentration (MAC) equivalent for either agent in air and oxygen. Local analgesia was used as appropriate. End-tidal volatile agent concentration was recorded until extubation. Clinical evaluation of recovery was made by observers, blinded to group allocation. RESULTS: For patients <4 yr of age, the median (95% CI) times in minutes to first movement [5.27 (D), 9.22 (I)], eye opening [9.42(D), 13.3(I)] and extubation [7.18 (D), 12.5 (I)] were significantly shorter (P<0.05) for desflurane. In the group >4 yr of age, the median (95% CI) times in minutes to first movement [4.42 (D), 11.6 (I)], eye opening [8.55(D), 18.0(I)] and extubation [7.08 (D), 16.7 (I)] were significantly shorter (P<0.001) for desflurane. Times to leave recovery were not significantly different for the group <4 yr of age, but were significantly shorter for desflurane in the group >4 yr of age (P<0.01). The isoflurane, but not desflurane, had a time-dependent effect on arousal. There were no significant differences in incidence of airway irritation or emergence delirium between the two agents. CONCLUSIONS: The rate of recovery in children after exposure to desflurane was faster than those patients receiving isoflurane; recovery from desflurane, but not isoflurane, was relatively unaffected by the duration of anaesthesia.

Acquired long QT syndrome and elective anesthesia in children. Curry TB , Gaver R , White RD . Paediatr Anaesth. 2006 Apr;16(4):471-8. Department of Anesthesiology, Mayo Clinic College of Medicine, Rochester, MN, USA.

Summary We present the case of a child who had had a previous episode of torsades de pointes (TdP) and who was scheduled for elective surgery under general anesthesia. The pathophysiology of this condition and the anesthesia concerns are discussed. An 8-year-old male with a history of osteogenic sarcoma had undergone an uneventful limb salvage procedure 2 years earlier. During a subsequent admission to the hospital, he had had a cardiopulmonary arrest with complete recovery. Telemetry electrocardiogram (ECG) rhythm recordings obtained during the event showed TdP that degenerated into ventricular fibrillation, which then terminated spontaneously. On a subsequent ECG, the QTc interval was 694 ms. The prolonged QT interval was attributed to homeopathic use of cesium chloride supplements and the QT interval normalized after cesium was stopped. He presented for an elective procedure and, with an anesthetic plan that emphasized medications without known effect on the QT interval, had an uneventful perioperative course. The optimal anesthesia plan for patients with prolonged QT or those suspected to be at risk for prolongation of the QT interval has not been well described. Available evidence suggests that using total intravenous anesthesia with propofol may be the safest and was used uneventfully in this case. Additionally, this case emphasizes the need to inquire about the use of supplements and naturopathic medications, even in children, that may have life-threatening side effects or interactions with anesthetic agents.

Measuring anesthesia in children using the EEG. Davidson AJ . Paediatr Anaesth. 2006 Apr;16(4):374-87. Department of Anaesthesia and Pain Management, Royal Children's Hospital, Parkville, Vic.; Department of Pharmacology, University of Melbourne, Melbourne, Vic., Australia; Murdoch Childrens Research Institute, Melbourne, Vic., Australia.

Advances in electroencephalogram (EEG) processing have produced new interest in measuring anesthesia using the EEG. There are a number of EEG-based anesthesia 'depth' monitors now available and their use in pediatric anesthesia is increasing. Although these monitors have been extensively studied in adults, there are relatively few studies examining their validity or use in children. To some extent we must rely on adult data. However, extrapolation of data from adults to children requires an in depth understanding of the physiology behind the data. The first question is what is being measured. What is anesthesia? A model of anesthesia has several components with arousal as a core component. Arousal can be linked to clinical observations, and correlates with anatomical and physiological studies. The EEG has characteristics that fairly consistently change with arousal during anesthesia, but the relationship between arousal and the EEG is imprecise and drug dependent. This relationship is the basis for using the EEG to measure anesthesia and provides only an indirect measure of consciousness and memory formation. A good understanding of how the EEG is related to anesthesia is essential when interpreting the EEG during anesthesia, and especially when extending the use of the EEG to measure anesthesia in children. Physiological studies in adults and children indicate that EEG-derived anesthesia depth monitors can provide an imprecise and drug-dependent measure of arousal. Although the outputs from these monitors do not closely represent any true physiological entity, they can be used as guides for anesthesia and in so doing have improved outcomes in adults. In older children the physiology, anatomy and clinical observations indicate the performance of the monitors may be similar to that in adults, although the clinical relevance of outcomes may be different. In infants their use cannot yet be supported in theory or in practice.

The prevention of emergence agitation with tropisetron or clonidine after sevoflurane anesthesia in small children undergoing adenoidectomy. Lankinen U , Avela R , Tarkkila P . Anesth Analg. 2006 May;102(5):1383-6. Department of Anesthesiology and Intensive Care Medicine, Helsinki University Hospital, Helsinki, Finland.

Postoperative agitation is a common problem after sevoflurane anesthesia in children. In the present study, we evaluated if tropisetron or clonidine could reduce the incidence of postoperative agitation after day case adenoidectomy in small children. We included 75 unpremedicated children aged 1-7 yr who were randomly assigned to receive either placebo, tropisetron (0.1 mg/kg) or clonidine (1.5 microg/kg) after anesthesia induction. Anesthesia was induced and maintained with sevoflurane. Patients also received alfentanil (20 microg/kg) and diclofenac (1 mg/kg). Postoperative pain was treated with IV oxycodone (0.05 mg/kg). Time to achieve discharge criteria was recorded. Modified pain/discomfort scale was used assess the postoperative behavior. The incidence of postoperative agitation was significantly less (32%, 8/25 patients) in the tropisetron group compared with placebo (62%, 16/26 patients), P < 0.05). Clonidine could not prevent agitation (incidence 54%, 13/24). No adverse effects were noted during the study. Discharge times were similar between the groups (between 80 and 99 min on average). In conclusion, tropisetron 0.1 mg/kg significantly reduced the incidence of postoperative agitation after sevoflurane anesthesia. Clonidine 1.5 microg/kg did not differ from placebo with respect to postoperative agitation.

Tramadol for pain relief in children undergoing herniotomy: a comparison with ilioinguinal and iliohypogastric blocks. Khosravi MB , Khezri S , Azemati S . Paediatr Anaesth. 2006 Jan;16(1):54-8. Department of Anesthesiology, Shiraz University of Medical Sciences, Shiraz, Iran. Khosravimb@sums.ac.ir

BACKGROUND: Prevention of postoperative pain in children is one of the most important objectives of the anesthesiologist. Preoperative ilioinguinal and iliohypogastric nerve blocks have been widely used to provide analgesia in children undergoing herniorrhaphy. Tramadol is an analgesic with micro-opioid and nonopioid activity. In this study we compared the usage of intravenous tramadol with ilioinguinal and iliohypogastric nerve blocks for control of post-herniorrhaphy pain in children aged 2-7 years. METHODS: Sixty patients were randomly allocated to two groups of thirty. One group received tramadol 1.5 mg.kg(-1) i.v. before induction of general anesthesia and the other had an ilioinguinal and iliohypogastric nerve block with 0.5% bupivacaine (0.25 ml.kg(-1)) before skin incision. We assessed pain using the Children's Hospital of Eastern Ontario Pain Scale and the Categorical Pain Scale. RESULTS: At 1, 4 and 24 h after surgery the two groups had identical pain scores. At 2 and 3 h after surgery the tramadol group experienced significantly less pain (P < 0.05). The rescue drug for residual pain, was used equally in the two groups. None of the 60 patients had respiratory depression but the tramadol group patients were found to have more episodes of nausea and vomiting (P < 0.05). CONCLUSIONS: We concluded that tramadol can have at least the same analgesic effect as that of ilioinguinal and iliohypogastric nerve blocks for post-herniorrhaphy pain in children, with even a superior effect at the time of maximal analgesia. We also highlight the troublesome side-effect of nausea and vomiting which brings into question the benefits of using this opioid that seems to lack respiratory depression.

Spectral entropy as a measure of hypnosis in children. Klockars JG , Hiller A , Ranta S , Talja P , van Gils MJ , Taivainen T . Anesthesiology. 2006 Apr;104(4):708-17.
Department of Anesthesiology and Intensive Care Medicine, Hospital for Children and Adolescents, University of Helsinki, Finland. jaakko.klockars@hus.fi

BACKGROUND: The Datex-Ohmeda S/5 Entropy Module (Datex-Ohmeda Division, Instrumentarium Corp., Helsinki, Finland), using time-frequency balanced Spectral Entropy, is a novel tool for monitoring the hypnotic state during anesthesia. The Entropy Module produces two values, State Entropy (SE) and Response Entropy (RE), and in adults, it has been shown to measure reliably the hypnotic effects of various drugs. In children, Spectral Entropy has been only preliminary studied. The authors' aim was to study Spectral Entropy as a marker of hypnotic state during general anesthesia in infants and children. METHODS: Twenty infants (aged 1 month-1 yr) and 40 children (aged 1-15 yr) were anesthetized for surgery using standardized sevoflurane-nitrous oxide-based anesthesia. The relationships between SE, RE, or Bispectral Index (BIS) and (1) a modified Observer's Assessment of Alertness/Sedation Scale, (2) non-steady state end-tidal concentration of sevoflurane, (3) steady state end-tidal concentration of sevoflurane, and (4) hemodynamic values were calculated using prediction probability, nonlinear regression, and correlation coefficients, as appropriate. The performances of SE, RE, and BIS were compared. RESULTS: The prediction probability values (+/- SEM) of SE, RE, and BIS versus the modified Observer's Assessment of Alertness/Sedation Scale in the induction phase were 0.83 +/- 0.06, 0.88 +/- 0.06, and 0.87 +/- 0.08 for children and 0.76 +/- 0.08,0.79 +/- 0.08, and 0.73 +/- 0.10 for infants; values in the emergence phase were 0.68 +/- 0.05, 0.74 +/- 0.04, and 0.64 +/- 0.05 for children and 0.64 +/- 0.07, 0.69 +/- 0.06, and 0.72 +/- 0.06 for infants, respectively. SE, RE, and BIS values were inversely proportionally related to the end-tidal concentration of sevoflurane for children, but for infants, the correlation was much less clear. No significant correlations were found between SE, RE, or BIS values and the hemodynamic values. CONCLUSIONS: Spectral Entropy may be a useful tool for measuring the level of hypnosis in anesthetized children and seems to perform as well as BIS. In infants, the clinical usefulness of both these electroencephalogram-derived methods must be evaluated in further controlled studies.

Two dimensional ultrasound guidance in central venous catheter placement; a postal survey of the practice and opinions of consultant pediatric anesthetists in the United Kingdom. Bosman M , Kavanagh RJ . Paediatr Anaesth. 2006 May;16(5):530-7. The Royal Alexandra Hospital for Sick Children, Dyke Road, Brighton, UK.

Summary Background : Recent guidelines from the UK National Institute for Clinical Excellence (NICE) recommend the use of ultrasound guidance for central venous catheter (CVC) insertion in children. We conducted a survey of pediatric anesthetists to determine current practice and opinion on the appropriate use of ultrasound guidance. Method : A confidential postal questionnaire was sent to all members of the Association of Paediatric Anaesthetists working in the UK. After 4 weeks a follow-up questionnaire was sent to nonrespondents. Members were questioned on availability and use of ultrasound, and its place in clinical practice and training. Results : A total of 250 questionnaires were returned, a response rate of 63%. Of those members who placed CVCs in children (n = 196), 85% had access to ultrasound, and 68% stated that they used ultrasound guidance. Thirty-nine percent of clinicians who used ultrasound did so routinely. The remaining 61% used either a landmark or an ultrasound technique depending on circumstances. Regarding its mandatory use, 76% of responders believed that ultrasound guidance was beneficial in certain circumstances but did not need to be used routinely. Seventy-five percent of responders agreed that all pediatric anesthetists should have training and access to ultrasound for CVC placement. Conclusions : In the UK most pediatric anesthetists placing CVCs in children currently have access to ultrasound guidance. Despite a lack of widespread support for its routine use, most agree ultrasound is a useful tool, and that all pediatric anesthetists should have access and training in the use of this technology.

Immunization and anesthesia - an international survey. Short JA , VAN DER Walt JH , Zoanetti DC . Paediatr Anaesth. 2006 May;16(5):514-22. Departments of Paediatric Anaesthesia, Leeds General Infirmary, West Yorkshire, UK.

Abstract Background : There is no direct evidence of any major interaction between immunization and commonly used anesthetic agents and techniques in children, but it is possible that immunosuppression caused by anesthesia and surgery may lead to decreased vaccine effectiveness or an increased risk of complications. In addition, diagnostic difficulty may arise if a recently immunized child suffers from postoperative pyrexia or malaise. Aim : The aim of this study was to ascertain anesthetists' attitudes and practices regarding anesthesia and immunization. Methods : We conducted an international survey of members of the Association of Paediatric Anaesthetists of Great Britain and Ireland (APAGBI) and the Society for Paediatric Anaesthesia of New Zealand and Australia (SPANZA). Results : Two hundred and ninety-six (52.1%) APAGBI and 86 (49.4%) SPANZA responses were analyzed. There was no consensus of approach to this theoretical risk among respondents. In total, 60% of respondents would anesthetize a child for elective surgery within 1 week of receiving a live attenuated vaccine, but 40% would not. Few hospitals have formal policies on this issue and government guidance is based on a lack of evidence for adverse events rather than positive evidence of safety. Conclusions : There is a theoretical risk associated with anesthesia and surgery in recently immunized children. An international postal survey failed to find a consensus to this risk among pediatric anesthetists. From a risk management perspective, a review of the available evidence suggests that it would be prudent to adopt a cautious approach where the timing of elective surgery is discretionary. We therefore recommend that elective surgery and anesthesia should be postponed for 1 week after inactive vaccination and 3 weeks after live attenuated vaccination in children.

Ultrasonographic-guided ilioinguinal/iliohypogastric nerve block in pediatric anesthesia: what is the optimal volume? Willschke H , Bosenberg A , Marhofer P , Johnston S , Kettner S , Eichenberger U , Wanzel O , Kapral S . Anesth Analg. 2006 Jun;102(6):1680-4. Medical University of Vienna, Department of Anaesthesia and Intensive Care Medicine, Waehringer Guertel 18-20, A-1090 Vienna, Austria.

Recently, our study group demonstrated the usefulness of ultrasonographic guidance in ilioinguinal/iliohypogastric nerve blocks in children. As a consequence, we designed a follow-up study to evaluate the optimal volume of local anesthetic for this regional anesthetic technique. Using a modified step-up-step-down approach, with 10 children in each study group, a starting dose of 0.2 mL/kg of 0.25% levobupivacaine was administered to perform an ilioinguinal/iliohypogastric nerve block under ultrasonographic guidance. After each group of 10 patients, the results were analyzed, and if all blocks were successful, the volume of local anesthetic was decreased by 50%, and a further 10 patients were enrolled into the study. Failure to achieve a 100% success rate within a group subjected patients to an automatic increase of half the previous volume reduction to be used in the subsequent group. Using 0.2 and 0.1 mL/kg of 0.25% levobupivacaine, the success rate was 100%. With a volume of 0.05 mL/kg of 0.25% levobupivacaine, 4 of 10 children received additional analgesia because of an inadequate block. Therefore, according to the protocol, the amount was increased to 0.075 mL/kg of 0.25% levobupivacaine, where the success rate was again 100%. We conclude that ultrasonographic guidance for ilioinguinal/iliohypogastric nerve blocks in children allowed a reduction of the volume of local anesthetic to 0.075 mL/kg.

Epidural analgesia in the surgery of congenital tracheal stenosis: slide tracheoplasty on cardiopulmonary bypass. Vila R , Marhuenda C , Goncalves A , Gil-Jaurena JM , Pellicer M , Suescum MC , Miro L . Paediatr Anaesth. 2006 Jun;16(6):693-6. Department of Anaesthesia, Hospital Infantil Vall d'Hebron, Autonomous University of Barcelona, Catalonia, Spain.

Epidural analgesia in children is highly effective and safe; however, it has not enjoyed great popularity in surgery that requires cardiopulmonary bypass. A major concern is the possibility of damage to blood vessels with the epidural needle or catheter and epidural hematoma formation. There seems to be a low incidence of epidural hematoma if certain guidelines are followed, so that in children, epidural analgesia can be used in selected patients, with safety, when surgical repair requires cardiopulmonary bypass. Epidural morphine has been used for clinical pain relief in pediatric cardiac surgery. Improved pulmonary function, suppressed hormonal and metabolic stress responses, easy early tracheal extubation, and good analgesia and sedation that allows neurological examination to alert any possibles hidden complications, are the advantages. A dedicated medical team is essential in the perioperative management to achieve maximum benefit for these patients.

Acute pancreatitis after anesthesia with propofol in a child with glycogen storage disease type IA. Bustamante SE , Appachi E . Paediatr Anaesth. 2006 Jun;16(6):680-3 Department of Pediatric Critical Care, The Children's hospital at the Cleveland Clinic Foundation, Cleveland, OH, USA.

Glycogen storage disorder type 1A (GSD 1A) is an inherited disorder of glycogen metabolism characterized by fasting hypoglycemia, lactic acidosis, hyperuricemia, and hyperlipidemia. These children have a higher risk of developing pancreatitis because of hypertriglyceridemia. Drug-induced pancreatitis accounts for a small proportion of cases of pancreatitis. The mechanism of drug-induced pancreatitis include hypersensitivity, direct toxic injury or indirectly by inducing hypertriglyceridemia. Propofol is often the drug of choice for induction of anesthesia in ambulatory surgical procedures. There are various reports in the literature describing pancreatitis induced by propofol. We present a 4-year-old girl with GSD 1A, who required tonsillectomy and adenoidectomy under general anesthesia. She developed acute pancreatitis in the postoperative period. Propofol was used as a general anesthetic and the postoperative incidence of pancreatitis is discussed.

The safety and effectiveness of a modified convection heating system for children during anesthesia. Cassey JG , Armstrong PJ , Smith GE , Farrell PT . Paediatr Anaesth. 2006 Jun;16(6):654-62. Department of Paediatric Surgery, John Hunter Hospital, Newcastle, Australia.

Background: Convection heating shows most promise in maintaining children's core temperatures under anesthesia. We have previously shown that a modified convection heating technique worked in a mannequin model and sought to establish its safety and effectiveness in a clinical study. Methods: Children were recruited who were having elective surgery under general anesthesia lasting >90 min. The children were anesthetized and maintained in a room temperature of 21 degrees C. Warming was performed by a 'Bair Hugger' attached to a heat dissipation box, producing turbulent air from multiple outlet holes on its face. A plastic sheet covered the child, was attached to the top of the box, tucked into the sides of the bed and left open at the head end. Temperatures at various sites (air, skin, and core) were continuously monitored using thermistors connected to a datalogger and laptop. Analysis was performed using Excel. Results: The study comprised 40 children ranging in age from 2 days to 12.5 years and weigh 2.5-73 kg. Operations were 'peripheral' (e.g. urethroplasty) lasting 90 min to major laparotomy lasting 590 min. Body surface area uncovered was 5-25%. Skin temperatures rose to a maximum of c. 40 degrees C. Core temperatures rose after a 12-min lag by 0.01-0.04 degrees C.min(-1). In children who became hyperthermic, cooling was readily achieved by turning the heating off and leaving the fan running. Conclusions: The technique is safe and effective for children throughout the pediatric range. The practice of increasing room temperature above 21 degrees C for elective cases should be abandoned. Continuous monitoring of core temperature is necessary to prevent hyperthermia.

Optimally fitted tracheal tubes decrease the probability of postextubation adverse events in children undergoing general anesthesia. Suominen P , Taivainen T , Tuominen N , Voipio V , Wirtavuori K , Hiller A , Korpela R , Karjalainen T , Meretoja O . Paediatr Anaesth. 2006 Jun;16(6):641-7. Department of Anaesthesia and Intensive Care, Hospital for Children and Adolescents, Helsinki University Central Hospital, Helsinki, Finland.

Background : The air leak test is recommended for assessing the appropriate size of an uncuffed tracheal tube (TT) in children. Our objectives were to determine whether there is a certain threshold air leak value beyond which a higher risk for adverse events after removal of TT can be predicted and to define other risk factors related to extubation. Methods : We enrolled 234 cases ranging from newborn to 9 years of age requiring tracheal intubation for elective or emergency surgery. General anesthesia was induced by a mask or intravenously. The TT size was calculated using the formula: [age (years)/4] + 4.5. After the induction of anesthesia, the patient's trachea was intubated and the correct position was confirmed. The attending anesthetist assessed the leak pressure. Incidences of adverse events (prolonged or barking cough, obstructed or prolonged inspiration or expiration, subcostal and sternal retractions, arterial desaturation, or laryngospasm) were recorded after removal of TT. Results : Ten patients were excluded from the study. A total of 218 children underwent 224 operations under general anesthesia. Children who had an absent air leak at 25 cmH(2)O pressure had 2.8 times more adverse events during emergence from anesthesia than those with an audible air leak. Adverse events after the removal of TT were 3.7 times more likely to occur in children whose anesthesia was provided by a less experienced anesthesia trainee. Conclusions : Adverse events after removal of TT were more likely to occur in children with an absent air leak at 25 cmH(2)O pressure and in children whose anesthesia was provided by a less experienced anesthetist.

Predicting which children benefit most from parental presence during induction of anesthesia. Kain ZN , Mayes LC , Caldwell-Andrews AA , Saadat H , McClain B , Wang SM . Paediatr Anaesth. 2006 Jun;16(6):627-634. Department of Anesthesiology, Center for the Advancement of Perioperative Health(R) Yale University School of Medicine, New Haven, CT, USA.

Background: The purpose of this large-scale prospective cohort study (n = 426) was to identify child and parent characteristics that are associated with low anxiety and good compliance during induction of anesthesia when parents are present. Methods: Outcome variables included child's anxiety and child's compliance during induction of anesthesia. Predictor variables included demographics, temperament, trait (baseline) anxiety, coping style, and locus of control. Results: Results of a linear regression model (overall proportion of variance accounted for equals 39.5%) showed that significant predictors of anxiety during induction of anesthesia while parents are present included: the child's age (DeltaR(2) = 0.315, P = 0.0001), behavior during previous medical visits (DeltaR(2) = 0.025, P = 0.001), child's activity level (DeltaR(2) = 0.016, P = 0.007), parent's state (contextual) anxiety (DeltaR(2) = 0.022, P = 0.001) and parent's locus of control (DeltaR(2) = 0.009, P = 0.036). A linear regression model that was constructed with compliance of the child as the outcome revealed similar findings. Conclusions: Children who benefit from parental presence are older, had lower levels of activity in their temperament, and had parents who were calmer and who valued preparation and coping skills for medical situations. The practical implications of these findings are discussed.

Awareness : A problem in paediatric anaesthesia?Johr M . Anaesthesist. 2006 Jun 2; Institut fur Anasthesie, Kantonsspital, 6000, Luzern 16, Schweiz, joehrmartin@bluewin.ch.

Intraoperative awareness has been reported to occur in 0.8-5.0% of paediatric patients undergoing anaesthesia and, therefore, seems to be more common than in adults (incidence 0.1-0.2%). In adult patients, the consequences of intraoperative awareness are well known and can be severe, in children, however, they have not yet been adequately studied. The causes for intraoperative awareness can be divided into three broad categories: First, no or only a light anaesthetic is given on purpose, second, an insufficient dose of an anaesthetic is given inadvertently, third, there is equipment malfunction or the anaesthesiologist makes an error. Unfortunately, especially in young children, painful interventions are still performed without adequate analgesia, e.g. awake intubation or fracture manipulation under midazolam sedation alone. The key issue is, however, that pharmacokinetics and pharmacodynamics change enormously from the 500 g preterm baby to the adolescent patient. Adequate dosing is much more difficult in paediatric patients compared to standard adult surgical patients. Solid knowledge of the pharmacokinetic and pharmacodynamic characteristics of commonly used drugs in different paediatric age groups, as well as aiming for perfection in daily care will help to reduce the incidence of awareness. Methods for monitoring the depth of hypnosis, e.g. the bispectral index, will be used increasingly, at least in children above 1 year of age. In addition to clinical parameters, they will hopefully help to further reduce the incidence of intraoperative awareness.

Use of the size 3 ProSeal laryngeal mask airway in children. Results of a randomized crossover investigation with the Classic laryngeal mask airway Goldmann K , Roettger C , Wulf H . Anaesthesist. 2006 Feb;55(2):148-53. Klinik fur Anasthesie und Intensivtherapie, Philipps-Universitat, Marburg. Kaigoldmann1@aol.com

BACKGROUND: The low-pressure airway seal of the Classic laryngeal mask airway (CLMA) can be inadequate for positive pressure ventilation (PPV) in children. The ProSeal laryngeal mask airway (PLMA) forms a more effective seal of the airway than the CLMA and facilitates gastric tube placement in adults. The size 3 PLMA can be used in adults and children. METHODS: The CLMA and PLMA were studied in random order -- crossover -- in 30 anaesthetized, non-paralysed children (average age 10.6 years, average body weight 39 kg). Airway leak pressure, maximum tidal volume, ease of insertion, quality of initial airway and fiberoptic position were determined. Gastric tube placement was assessed for the PLMA. RESULTS: The mean airway leak pressure in neutral head position (27.0 vs. 16.8 cm H(2)O), maximum flexion (38.3 vs. 26.2 cm H(2)O) and maximum extension (21.1 vs. 14.2 cm H(2)O) as well as the mean maximum tidal volume (1432 vs. 1062 ml) were significantly higher (p<0.001) for the PLMA. Air insufflation into the stomach occurred with the CLMA but not with the PLMA. Gastric tube placement was possible in all patients. CONCLUSIONS: The high reliability of g-tube placement and the significantly increased airway leak pressure seem to make the size 3 PLMA a more suitable device for PPV in children than the same size CLMA.

Remifentanil decreases sevoflurane requirements in children. Castanelli DJ , Splinter WM , Clavel NA . Can J Anaesth. 2005 Dec;52(10):1064-70. Department of Anesthesia, Monash Medical Centre, Clayton, Victoria, Australia.

PURPOSE: To establish the effect of increasing concentrations of remifentanil on sevoflurane requirements in children. METHODS: Fifty-eight healthy patients, ASA status I-II aged two to 12 yr, undergoing abdominal wall hernia or hydrocele repairs were serially assigned to one of four test groups to receive remifentanil 0.03 microg.kg(-1).min(-1), 0.06 microg.kg(-1).min(-1), 0.12 microg.kg(-1).min(-1), or 0.25 microg.kg(-1).min(-1) iv. Patients received a bolus of remifentanil 1 microg.kg(-1) iv before the infusion began. End-tidal sevoflurane concentration was adjusted according to a Dixon up-and-down approach. Ten minutes after starting the remifentanil infusion, the surgical incision was made. The patient was observed for one minute from the time of incision by a solitary blinded rater for either flexion or withdrawal of one or more extremities in response to skin incision. RESULTS: The mean minimum alveolar concentration of sevoflurane was 2.39 +/- 0.58 with 0.03 microg.kg(-1).min(-1) remifentanil, 1.91 +/- 0.36 with 0.06 microg.kg(-1).min(-1) remifentanil, and 0.92 +/- 0.11 with 0.12 microg.kg(-1).min(-1) remifentanil. Remifentanil 0.25 microg.kg(-1).min(-1) lead to the sevoflurane being decreased to a level associated with spontaneous patient awakening. The effective dose (ED(50)) values of sevoflurane were 2.44 [95% confidence interval (CI) 2.16-2.72], 2.00 (95% CI 1.78-2.22), and 1.18 (95% CI 0.99-1.36) for remifentanil infusion rates of 0.03 microg.kg(-1).min(-1), 0.06 microg.kg(-1).min(-1), and 0.12 microg.kg(-1).min(-1) respectively. CONCLUSION: The administration of remifentanil produced a dose-dependent decrease in the minimum alveolar concentration of sevoflurane necessary for inhibition of movement reaction in response to surgical incision. The use of remifentanil may allow for flexible analgesic control and rapid recovery in children anesthetized with sevoflurane.

Preoperative screening for sickle cell disease in children: clinical implications. Crawford MW , Galton S , Abdelhaleem M . Can J Anaesth. 2005 Dec;52(10):1058-63. Department of Anesthesia, The Hospital for Sick Children, Toronto, Ontario M5G 1X8, Canada. mark.crawford@sickkids.ca

PURPOSE: Preoperative screening of at-risk patients for sickle cell disease (SCD) is recommended as a method to decrease perioperative morbidity. However, the effectiveness of pre-operative screening in accomplishing this goal has never been demonstrated. We undertook a retrospective study to determine the prevalence of positive test results among those screened preoperatively at our institution and to determine whether amendments to present screening guidelines can be recommended. METHODS: The hematology laboratory database of a university teaching hospital was searched to identify all patients who underwent preoperative screening for SCD from October 1999 to October 2003. The medical records of those patients testing positive were reviewed. RESULTS: Of 1,906 children screened preoperatively, 79 (4.1%) were diagnosed as having sickle cell trait and three (0.16%) as having some form of SCD: one had homozygous hemoglobin S and two had sickle-hemoglobin C disease. Two of the three had a family history for SCD and none had a preoperative hemoglobin concentration < 10 g.dL(-1). No patient developed perioperative sickle-related complications. CONCLUSION: Preoperative screening of 1,906 children identified only one asymptomatic child with undiagnosed SCD and a negative family history, suggesting that routine preoperative screening for SCD is rarely of significant clinical value in our population. Had preoperative screening not been performed, no child requiring preoperative transfusion would have been missed, representing a long-run probability of at least 99.84% that no at-risk child would require transfusion. We recommend that preoperative screening for SCD be undertaken selectively, giving consideration to the risks and benefits of screening to the individual patient.

Thoracic epidural catheter in the management of a child with an anterior mediastinal mass: a case report and literature review. Soliman LM , Mossad EB . Paediatr Anaesth. 2006 Feb;16(2):200-5. Department of Cardiothoracic Anesthesia, Division of Anesthesia and Critical Care Medicine, Cleveland Clinic Foundation, Cleveland, OH 44195, USA.

We describe a case of an anterior mediastinal mass compressing the right main bronchus that required a biopsy through a thoracotomy incision. The anesthetic management of these patients is associated with several risks and challenges, including potential airway compression and cardiovascular collapse. Inhalation induction and maintenance of spontaneous respiration is recommended to preserve normal transpulmonary pressure gradient and improve flow through conducting airways. We placed a thoracic epidural catheter under general anesthesia as the main analgesic technique in order to maintain spontaneous breathing. The use of regional anesthesia, especially continuous epidurals in pediatric cardiothoracic anesthesia have many theoretical advantages including attenuation of the neuroendocrine response, facilitation of rapid extubation and improved ventilatory mechanics secondary to decreased narcotic requirements. The absolute risk of nerve injury and epidural hematoma for this procedure is unknown and hard to define in this patient population. We reviewed multiple studies and case reports addressing its safety and reported side effects. Finally, we emphasize that a thoracic epidural anesthesia is a reasonable choice that can be applied carefully in special situations even for children under general anesthesia.

Comparison of caudal ketamine with lidocaine or tramadol administration for postoperative analgesia of hypospadias surgery in children. Gunduz M , Ozalevli M , Ozbek H , Ozcengiz D . Paediatr Anaesth. 2006 Feb;16(2):158-63. Department of Anaesthesiology, Cukurova University Faculty of Medicine, Balcali, Adana, Turkey. hmurat@cu.edu.tr

BACKGROUND: This study was designed to investigate whether the addition of tramadol or lidocaine to ketamine would enhance the quality of intra- and postoperative analgesia for hypospadias surgery in children. METHODS: Sixty-two ASA PS I or II children, between 1 and 10 years of age, scheduled for hypospadias surgery were recruited. Anesthesia was induced with 6-8% sevoflurane and maintained with 0.5-2.5% sevoflurane-50% N2O in oxygen. Children were allocated randomly to receive one of two study drugs. Children in group KL received caudal ketamine (0.25 mg.kg(-1)) plus lidocaine (2%, 2 mg.kg(-1)) and in group KT ketamine (0.25 mg.kg(-1)) plus tramadol (1 mg.kg(-1)). Systemic blood pressure, heart rate, peripheral O2 saturation, sedation, and pain scores (CHEOPS) were recorded at 1, 5, 10, 15, 30, 45 min and 1, 2, 3 h following recovery from anesthesia. RESULTS: Duration of analgesia was similar in the two groups (P > 0.05). CHEOPS in group KL was lower than in group KT during the study period, except at first 15 min. Sedation scores were higher in group KL than group KT in the first 10 min (P < 0.05). Incidence of postoperative nausea and vomiting was similar in the two groups (P > 0.05) Sevoflurane concentration required was significantly lower in group KL than group KT peroperatively (P < 0.001). CONCLUSIONS: Caudal ketamine (0.25 mg.kg(-1)), plus lidocaine (2% 2 mg.kg(-1)) significantly reduced sevoflurane concentration compared with ketamine (0.25 mg.kg(-1)) + tramadol (1 mg.kg(-1)). We suggested that both ketamine + lidocaine and ketamine + tramadol provided very effective and long duration of analgesia, similarly. However, analgesia quality is superior in the ketamine-lidocaine group postoperatively.

Comparison of 'whoosh' and modified 'swoosh' test for identification of the caudal epidural space in children. Talwar V , Tyagi R , Mullick P , Gogia AR . Paediatr Anaesth. 2006 Feb;16(2):134-9. Department of Anaesthesia and Intensive Care, VMMC and Safdarjang Hospital, New Delhi, India. vandtal@yahoo.com

BACKGROUND: Caudal analgesia is widely used in pediatric anesthesia practice. The 'whoosh' test which uses air to identify the epidural space, has been recommended as a guide for successful needle placement. However, the use of air may be associated with an incidence of neurological complications. The 'swoosh' test avoids the injection of air and was originally performed using injection of a local anesthetic solution. A comparison was made between the 'whoosh' test and a modified 'swoosh' test using saline to identify the caudal epidural space in children. METHODS: We studied 60 children of either sex in the age group of 2-8 years undergoing inguinal herniotomy. During insertion of the caudal block, a stethoscope was placed over the lower lumbar spine to note the presence or absence of 'whoosh' or 'swoosh', by an independent observer who was blinded to the injection of 1 ml of air or saline which was given simultaneously by the operator into the caudal space. The operator's clinical impression of successful insertion of the needle was also recorded and correlated with the presence or absence of 'whoosh' or 'swoosh'. In addition, the need for supplemental intraoperative analgesia was noted. RESULTS: Overall success rate of caudal block using the 'whoosh' and modified 'swoosh' tests was found to be 96.6% and 93.3%, respectively as judged by the lack of supplementary perioperative analgesia. The sensitivity, specificity and positive predictive value of the 'whoosh' test and clinical predictors of caudal placement was found to be 100% whereas the modified 'swoosh' test had a sensitivity of 93%, specificity of 50% and a positive predictive value of 96%. However, statistically there was no significant difference between the clinical predictors, 'whoosh' and the modified 'swoosh' test for identification of the caudal epidural space. CONCLUSIONS: The modified 'swoosh' test is as reliable as the 'whoosh' test and we recommend it for identification of the caudal epidural space in children as it avoids injection of air into the caudal space.

Airway management in pediatric anesthesia. Hohne C , Haack M , Machotta A , Kaisers U . Anaesthesist. 2006 Jul;55(7):809-20. Kliniken fur Anasthesiologie und operative Intensivmedizin, Charite - Universitatsmedizin Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, 13353 , Berlin, claudia.hoehne@charite.de.

Airway management in newborns, infants, and children is a challenge to anesthesia practitioners due to the particular anatomic and physiological characteristics. The larynx is positioned more cephalad, the occiput is protuberant, and the neck is short, which makes a special position for anesthesia induction necessary. The high respiratory frequency due to high oxygen demand and carbon dioxide production has to be taken into consideration during manual as well as mechanical ventilation. Different devices are available for airway management. Simple mask ventilation can be improved by a Wendl tube. The classic laryngeal mask can be recommended as a safe airway device in many indications, specifically in children with an upper respiratory airway infection. If intubation is indicated, an optimal size and position of the endotracheal tube has to be provided. Fiberoptic endotracheal intubation is recommended if a difficult airway is known or anticipated due to a craniofacial syndrome.

Anesthetic management of surgery in term and preterm infants. Breschan C , Likar R . Anaesthesist. 2006 Jun 28; Abteilung fur Anasthesiologie, LKH, St. Veiterstrasse 47, 9020, Klagenfurt, Osterreich, breschan.ch@chello.at.

The physiology of the preterm and term neonate is characterized by a high metabolic rate, limited pulmonary, cardiac and thermoregulatory reserve and decreased renal function. Multisystem immaturity creates important developmental differences in drug administration and response when compared to older children. Specific monitoring techniques are required because the neonate is not physically accessible to the anesthetist during the operation. This contribution reviews the specific pathophysiological characteristics of the newborn with relevance to anesthesia and also provides robust guidelines for the anesthetic management of the most frequent non-cardiac procedures which need surgery during the neonatal period. Consideration will also be given to the anesthetic management of very low birth-weight infants with anesthetic key issues such as avoiding hyperoxia, keeping hemodynamic parameters as stable as possible and preventing hypothermia.

Effect of propofol anesthesia and continuous positive airway pressure on upper airway size and configuration in infants. Crawford MW , Rohan D , Macgowan CK , Yoo SJ , Macpherson BA. Anesthesiology. 2006 Jul;105(1):45-50. Department of Anesthesia, The Hospital for Sick Children, University of Toronto, Ontario, Canada. mark.crawford@sickkids.ca

BACKGROUND: Infants are prone to obstruction of the upper airway during general anesthesia. Continuous positive airway pressure (CPAP) is often used to prevent or treat anesthesia-induced airway obstruction. The authors studied the interaction of propofol anesthesia and CPAP on airway caliber in infants using magnetic resonance imaging. METHODS: Nine infants undergoing elective magnetic resonance imaging of the brain were studied. Head position was standardized. Spin echo magnetic resonance images of the airway were acquired at the level of the soft palate, base of the tongue, and tip of the epiglottis. Four sets of images were acquired in sequence: (1) during light propofol anesthesia at an infusion rate of 80 microg . kg(-1) . min(-1), (2) after increasing the depth of propofol anesthesia by administering a bolus dose (2.0 mg/kg) and increasing the infusion rate to 240 microg . kg(-1) . min(-1), (3) during continued infusion of 240 microg . kg(-1). min propofol and application of 10 cm H2O CPAP, and (4) after removal of CPAP and continued infusion of 240 microg . kg(-1). min propofol. RESULTS: Increasing depth of propofol anesthesia decreased airway caliber at each anatomical level, predominantly due to anteroposterior narrowing. Application of CPAP completely reversed the propofol-induced decrease in airway caliber, primarily by increasing the transverse dimension. CONCLUSIONS: Airway narrowing with increasing depth of propofol anesthesia results predominantly from a reduction in anteroposterior dimension, whereas CPAP acts primarily to increase the transverse dimension. Although airway caliber during deep propofol anesthesia and application of CPAP was similar to that during light propofol anesthesia, there were significant configurational differences.

Ultrasonography-guided rectus sheath block in paediatric anaesthesia--a new approach to an old technique. Willschke H , Bosenberg A , Marhofer P , Johnston S , Kettner SC , Wanzel O , Kapral S . Br J Anaesth. 2006 Aug;97(2):244-9. Department of Anaesthesia and Intensive Care Medicine, Medical University of Vienna Austria.

BACKGROUND: The purpose of this study was an anatomical and clinical evaluation of ultrasonography-guided rectus sheath blocks in children. Method. A total of 30 children were included in the sono-anatomical part of the study. The depth of the anterior and posterior rectus sheath was evaluated with a portable SonSite 180 plus ultrasound machine and a 5-10 MHz linear probe. In total, 20 consecutive children undergoing umbilical hernia repair were included in the clinical part of this study. After induction of general anaesthesia children received a rectus sheath block under real-time ultrasonographic guidance by placing 0.1 ml kg(-1) bilaterally in the space between the posterior aspect of the sheath and the rectus abdominis muscle. RESULTS: Ultrasonographic visualization of the posterior rectus sheath was possible in all children. The correlation between the depth of the posterior rectus sheath and weight (adjusted r(2)=0.175), height (adjusted r(2)=0.314) and body surface area (adjusted r(2)=0.241) was poor. The ultrasound-guided rectus sheath blockade provided sufficient analgesia in all children with no need for additional analgesia in the perioperative period. CONCLUSION: The bilateral placement of levobupivacaine 0.25% 0.1 ml kg(-1) in the space between the posterior aspect of the rectus sheath and the rectus abdominis muscle under real-time ultrasonographic guidance provides sufficient analgesia for umbilical hernia repair. The unpredictable depth of the posterior rectus sheath in children is a good argument for the use of ultrasonography in this regional anaesthetic technique in children.

Sedation during spinal anaesthesia in infants. Hermanns H , Stevens MF , Werdehausen R , Braun S , Lipfert P , Jetzek-Zader M . Br J Anaesth. 2006 Jul 1; Department of Anaesthesiology, University Hospital Dusseldorf, Germany.

BACKGROUND: Neuraxial anaesthesia in adults decreases the dose of i.v. or inhalational anaesthetic needed to reach a desired level of sedation. Furthermore, spinal anaesthesia alone has a sedative effect. The mechanism behind this phenomenon is presumed to be decreased afferent stimulation of the reticular activating system after sympatholysis. We hypothesized that this mechanism is equally active in infants undergoing spinal anaesthesia. METHODS: In total, 20 unpremedicated former preterm infants underwent surgery under spinal anaesthesia with hyperbaric bupivacaine 0.5% 1 mg kg(-1) with epinephrine 10 microg kg(-1). No additional sedatives or anaesthetics were administered. Sedation was evaluated using the bispectral index (BIS) score and the 95% spectral edge frequency (SEF95). RESULTS: After spinal anaesthesia, mean (SD) BIS began to decrease significantly from baseline 97.0 (1.1) to 83.9 (14.4) after 15 min (P=0.006). BIS decreased further, reaching the lowest values after 30 min [62.2 (14.0); P<0.00001]. Mean (SD) SEF95 declined from baseline 26.1 (1.8) Hz to 24.3 (3.1) after 5 min (P=0.02) and further to 9.9 (3.8) after 30 min (P<0.00001). Mean arterial pressure also decreased significantly from 66.5 (4.7) mm Hg within 10 min to 56.1 (5.6) after spinal anaesthesia (P=0.0002), while heart rate remained stable. CONCLUSIONS: These results suggest that sedation after spinal anaesthesia in infants is at least as pronounced as in adults. The sedative effect of spinal anaesthesia should be kept in mind when additional sedatives are administered, especially in former preterm infants.

Summary proceedings from the neonatal pain-control group. Anand KJ , Aranda JV , Berde CB , Buckman S , Capparelli EV , Carlo W , Hummel P , Johnston CC , Lantos J , Tutag-Lehr V , Lynn AM , Maxwell LG , Oberlander TF , Raju TN , Soriano SG , Taddio A , Walco GA . Pediatrics. 2006 Mar;117(3 Pt 2):S9-S22. Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA. anandsunny@uams.edu

Recent advances in neurobiology and clinical medicine have established that the fetus and newborn may experience acute, established, and chronic pain. They respond to such noxious stimuli by a series of complex biochemical, physiologic, and behavioral alterations. Studies have concluded that controlling pain experience is beneficial with respect to short-term and perhaps long-term outcomes. Yet, pain-control measures are adopted infrequently because of unresolved scientific issues and lack of appreciation for the need for control of pain and its long-term sequelae during the critical phases of neurologic maturation in the preterm and term newborn. The neonatal pain-control group, as part of the Newborn Drug Development Initiative (NDDI) Workshop I, addressed these concerns. The specific issues addressed were (1) management of pain associated with invasive procedures, (2) provision of sedation and analgesia during mechanical ventilation, and (3) mitigation of pain and stress responses during and after surgery in the newborn infant. The cross-cutting themes addressed within each category included (1) clinical-trial designs, (2) drug prioritization, (3) ethical constraints, (4) gaps in our knowledge, and (5) future research needs. This article provides a summary of the discussions and deliberations. Full-length articles on procedural pain, sedation and analgesia for ventilated infants, perioperative pain, and study designs for neonatal pain research were published in Clinical Therapeutics (June 2005).

Inhalation induction using sevoflurane in children: the single-breath vital capacity technique compared to the tidal volume technique*. Lejus C , Bazin V , Fernandez M , Nguyen JM ,Radosevic A , Quere MF , Le Roux C , Le Corre A , Pinaud M . Anaesthesia. 2006 Jun;61(6):535-40. Service of Anaesthesiology, Hotel-Dieu, CHU Nantes, France. corinne.lejus@chu-nantes.fr

The single-breath vital capacity technique is suitable for inhalation induction of anaesthesia, using sevoflurane in children aged > 5 years. The purpose of this randomised trial was to compare the single breath vital capacity technique with the conventional tidal volume technique. Seventy- three ASA 1 or 2 children were instructed during the pre-operative visit in the vital capacity technique. The main criterion measured was time to loss of the eyelash reflex. Induction was performed using a circle-absorber breathing circuit primed with sevoflurane 7% in 50% nitrous oxide/oxygen with 6 l.min(-1) fresh gas flow. Time required for induction, haemodynamic changes, airway tolerance and side-effects were recorded. The children's opinion on the technique used was scored using a visual analogue scale (0-100) and a Smiley scale (0-10). The time to loss of the eyelash reflex was found to be reduced in the vital capacity group compared to the tidal volume group. The time to central myosis, to achieve bispectral index values 60 and 40, haemodynamic changes, respiratory events and side-effect incidences were similar in both groups. However, we found that the vital capacity technique was preferred by the children to the tidal volume technique.

Intravenous midazolam-ketamine anaesthesia for closed reduction of forearm fractures in children : Impact of additional axillary plexus anaesthesia. Wissler M , Tomaske M , Stutz K , Schmitz A , Gerber A , Weiss M . Anaesthesist, 2006 Jul 11; Anasthesieabteilung, Universitats-Kinderkliniken, Steinwiesstrasse 75, 8032, Zurich, Schweiz, markus.weiss@kispi.unizh.ch.

BACKGROUND: The aim of this study was to compare ketamine requirements in children undergoing closed reduction of forearm fractures under midazolam-ketamine anaesthesia with or without axillary plexus anaesthesia.METHODS: With hospital ethical committee approval, we retrospectively analyzed the records of children who received midazolam-ketamine anaesthesia in the years 2000-2001 (group A) and midazolam-ketamine anaesthesia combined with axillary plexus anaesthesia in the years 2002-2004 (group B) for closed reduction of forearm fractures. Requirements for ketamine and postoperative analgesics were noted. Groups were compared with the Mann-Whitney U-test or T-test and the chi(2)-test (p<0.05).RESULTS: A total of 455 children (group A 225/group B 230) were included in this study. The total amounts of ketamine were not statistically different between the two groups (p=0.154). However, ketamine requirements became less if the time interval between start of axillary plexus anaesthesia and start of intervention became more than 15 min (p<0.05). Patients in group B requested fewer analgesics in the postoperative period (p<0.01).CONCLUSIONS: In the clinical routine of an emergency department the combination of midazolam-ketamine anaesthesia with axillary plexus anesthesia for closed reduction of forearm fractures in children did not result in lower requirements of ketamine.

The effect of age on motor evoked potentials in children under propofol/isoflurane anesthesia. Lieberman JA , Lyon R , Feiner J , Diab M , Gregory GA . Anesth Analg. 2006 Aug;103(2):316-21 Department of Anesthesia & Perioperative Care, Box 0648, Room L-008, University of California, San Francisco, San Francisco, California 94143-0648, USA. lieberman@anesthesia.ucsf.edu

Intraoperative transcranial motor evoked potential (MEP) monitoring may help prevent neurologic injury during spine surgery. This type of monitoring may be difficult in the pediatric population under general anesthesia. We retrospectively reviewed data from 56 children, aged 2 to 18 yr, who were to undergo surgical correction of idiopathic scoliosis with MEP monitoring. Under combined isoflurane-propofol general anesthesia, before incision, we examined the minimum stimulating threshold voltage required to achieve a 50-microvolt or greater MEP response amplitude. Younger age was associated with an increase in the threshold voltage needed to elicit a sufficient MEP response. In addition, younger age was associated with longer stimulating pulse trains and greater need to adjust stimulating scalp electrodes. Body surface area, height, weight, and body mass index were also significant factors, but they were not independent predictors, after adjusting for age. Younger children received significantly lower levels of isoflurane and comparable doses of propofol, compared with older patients. Stronger stimulation needed to produce MEP responses in younger patients may reflect immaturity of their central nervous system, specifically conduction by the descending corticospinal motor tracts. Greater attention must be given to optimizing physiologic variables, limiting depressant anesthetics, and selecting the most favorable stimulating conditions in children, especially those <10 yr old.

Ultrasound-guided subgluteal sciatic nerve blocks with stimulating catheters in children: a descriptive study. van Geffen GJ , Gielen M . Anesth Analg 2006 Aug;103(2):328-33 Institute for Anesthesiology, Medical Centre, Radboud University, PO Box 9101, 6500 HB Nijmegen, The Netherlands. G.vanGeffen@anes.umcn.nl

We describe our clinical experience of combining ultrasound guidance and nerve stimulation for the insertion of subgluteal sciatic catheters in children. Ten children scheduled for lower limb surgery with a combined general anesthetic and a subgluteal sciatic catheter placement for both operative anesthesia and postoperative pain relief were studied. Under ultrasonographic guidance the sciatic catheter was placed using an 17-gauge 50-mm Arrow continuous peripheral nerve block needle and a 19-gauge stimulating catheter (Stimucath). The minimal electrical current required for muscle contraction on the stimulating needle and catheter differed widely among patients. Based on the visualization of the spread of local anesthetic during injection through the catheter, a successful prediction for the sciatic block was made in all patients. All catheters were successfully placed and provided excellent postoperative pain relief without complications.

A single dose of fentanyl and midazolam prior to Cesarean section have no adverse neonatal effects. Frolich MA , Burchfield DJ , Euliano TY , Caton D . Can J Anaesth. 2006 Jan;53(1):79-85. Department of Anesthesiology, University of Alabama at Birmingham, 619 South 19th Street, Birmingham, AL 35249-6810, USA. froelich@uab.edu

PURPOSE: Analgesia and sedation, routinely used as adjunct medications for regional anesthesia, are rarely used in the pregnant patient because of concerns about adverse neonatal effects. In an effort to obtain more information about maternal analgesia and sedation we studied neonatal and maternal effects of iv fentanyl and midazolam prior to spinal anesthesia for elective Cesarean section. METHODS: In this double-blinded, randomized, placebo-controlled trial, 60 healthy women received either a combination of 1 microg x kg(-1) fentanyl and 0.02 mg x kg(-1) midazolam intravenously or an equal volume of iv saline at the time of their skin preparation for a bupivacaine spinal anesthetic. Sample size was based on a non-parametric power analysis (power > 0.80 and alpha = 0.05) for clinically important differences in Apgar scores. Fetal outcome measures included Apgar scores, continuous pulse oximetry for three hours, and neurobehavioural scores. Maternal outcomes included catecholamine levels, and recall of anesthesia and delivery. RESULTS: There were no between-group differences of neonatal outcome variables (Apgar score, neurobehavioural scores, continuous oxygen saturation). Mothers in both groups showed no difference in their ability to recall the birth of their babies. CONCLUSIONS: Maternal analgesia and sedation with fentanyl (1 microg x kg(-1)) and midazolam (0.02 mg x kg(-1)) immediately prior to spinal anesthesia is not associated with adverse neonatal effects.

High levels of impulsivity may contraindicate midazolam premedication in children. Finley GA , Stewart SH , Buffett-Jerrott S , Wright KD , Millington D . Can J Anaesth. 2006 Jan;53(1):73-8. IWK Health Centre, 5850 University Ave., P.O. Box 9700, Halifax, Nova Scotia B3K 6R8, Canada. allen.finley@dal.ca

PURPOSE: To investigate the effects of midazolam on emotional reactivity during induction of anesthesia in a pediatric day surgery setting. A secondary purpose was to determine if these effects were influenced by child temperament factors. METHODS: Forty children (age four to six years) scheduled for myringotomy were randomly assigned, in a double blind fashion, to receive either oral midazolam 0.5 mg.kg-1 mixed with acetaminophen suspension or acetaminophen alone. The Emotionality, Activity, Sociability, and Impulsivity (EASI) scale was used as a measure of child temperament. The modified Yale Preoperative Anxiety Scale (m-YPAS), an observer-rated measure of state anxiety, was employed to assess anxiety pre- and post-drug, and also at induction of anesthesia. RESULTS: Children who received midazolam reacted significantly less to induction of anesthesia than did children in the placebo control group, F (1, 38) = 7.46, P = 0.01. A significant positive association was observed between baseline levels of anxiety and observer-rated anxiety at anesthetic induction, but only in the placebo group, r = 0.58, P < 0.01. A significant positive association was observed between levels of impulsivity at baseline and observer-rated anxiety at anesthetic induction, but only in the midazolam group, r = 0.42, P < 0.05. CONCLUSIONS: Midazolam dampened adverse reactivity during anesthetic induction, particularly among children with high baseline levels of anxiety. Baseline level of impulsivity was positively associated with adverse reactions to anesthesia induction in the drug group, but not in the placebo group, suggesting that high levels of trait impulsivity may contraindicate the use of midazolam as a preoperative medication.

A survey of the use of 2D ultrasound guidance for insertion of central venous catheters by UK consultant paediatric anaesthetists. Tovey G , Stokes M . Eur J Anaesthesiol. 2006 Aug 8; 1-5 Birmingham Children's Hospital, Department of Anaesthesia, Birmingham, UK.

SummaryBackground and objective: National Institute for Clinical Excellence guidance states that 2D imaging ultrasound guidance should be used when inserting internal jugular venous lines in adults and children in the elective situation and should be considered in most clinical circumstances requiring central venous catheter insertion. This survey explored the availability, training and use of ultrasound devices by consultant paediatric anaesthetists in the UK. Methods: A questionnaire was distributed to UK members of the Association of Paediatric Anaesthetists of Great Britain and Ireland. Results: There was a response rate of 63% and of those responding, 212 (81%) inserted paediatric central venous catheters. Ultrasound devices were available in the workplace of 216 (82%) and the average number of devices available per department was two. For elective paediatric theatre cases, 26% of paediatric anaesthetists with access to an ultrasound device always used it when inserting an internal jugular central venous line. The majority (74%) of respondents had received training in the use of 2D ultrasound. Conclusions: National Institute for Clinical Excellence guidance on the use of ultrasound locating devices for placing central venous catheters is not universally adhered to. Among the reasons for this are problems with availability of equipment, lack of training in the use of ultrasound and non-acceptance of the guidelines

Inhalation induction with sevoflurane in paediatrics: what is new? Bordes M , Cros AM . Ann Fr Anesth Reanim. 2006 Apr;25(4):413-6. Departement d'anesthesie-reanimation IV, hopital Pellegrin-Enfants, 33096 Bordeaux, cedex, France.

The delay for loss of consciousness can be shortened by using high concentration sevoflurane > 6% and by adding N2O during inhalation induction with sevoflurane in paediatrics. Mean time for tracheal tube insertion is lower than 5 min in the majority of studies. This shorter delay is not associated with any significant increase in clinical side effects. However, recent studies have demonstrated the epileptogenic effect of high effect site sevoflurane concentration (occurrence of spike wave on the EEG). Inhalation induction with high alveolar sevoflurane concentration is questionable mainly when it is associated with hyperventilation. Positive pressure ventilation or pressure support ventilation make it possible to maintain normocapnia and to monitor FeSevo. Adding a narcotic decreases the target cerebral concentration required to perform tracheal intubation and consequently the risk of spike wave occurrence.

The effect of caudal block on functional residual capacity and ventilation homogeneity in healthy children. von Ungern-Sternberg BS , Regli A , Frei FJ , Hammer J , Schibler A , Erb TO . Anaesthesia. 2006 Aug;61(8):758-63. Division of Anaesthesia, University Children's Hospital, Basel, Switzerland. bvonungern@uhbs.ch

Caudal block results in a motor blockade that can reduce abdominal wall tension. This could interact with the balance between chest wall and lung recoil pressure and tension of the diaphragm, which determines the static resting volume of the lung. On this rationale, we hypothesised that caudal block causes an increase in functional residual capacity and ventilation distribution in anaesthetised children. Fifty-two healthy children (15-30 kg, 3-8 years of age) undergoing elective surgery with general anaesthesia and caudal block were studied and randomly allocated to two groups: caudal block or control. Following induction of anaesthesia, the first measurement was obtained in the supine position (baseline). All children were then turned to the left lateral position and patients in the caudal block group received a caudal block with bupivacaine. No intervention took place in the control group. After 15 min in the supine position, the second assessment was performed. Functional residual capacity and parameters of ventilation distribution were calculated by a blinded reviewer. Functional residual capacity was similar at baseline in both groups. In the caudal block group, the capacity increased significantly (p < 0.0001) following caudal block, while in the control group, it remained unchanged. In both groups, parameters of ventilation distribution were consistent with the changes in functional residual capacity. Caudal block resulted in a significant increase in functional residual capacity and improvement in ventilation homogeneity in comparison with the control group. This indicates that caudal block might have a beneficial effect on gas exchange in anaesthetised, spontaneously breathing preschool-aged children with healthy lungs.

Efficacy and plasma levels of ropivacaine for children: controlled regional analgesia following lower limb surgery. Duflo F , Sautou-Miranda V , Pouyau A , Taylor P , Combet S , Chotel F , Bleyzac N , Chassard D . Br J Anaesth. 2006 Aug;97(2):250-4. Departement d'Anesthesie-Reanimation, Hopital Debrousse, Lyon, France. frederic.duflo@chu-lyon.fr

BACKGROUND: Continuous regional analgesia (CRA) is considered a safe and efficacious technique for postoperative pain relief in children after lower limb surgery. We recently evaluated the feasibility of patient-controlled regional analgesia (PCRA) in a similar acute pain situation and we concluded that PCRA might be advantageous over CRA in terms of lower costs, risk of systemic toxicity while producing similarly adequate analgesia. We therefore prospectively compared both techniques in the paediatric population. METHODS: In total, 30 children undergoing lower limb orthopaedic surgery were randomized to receive PCRA or CRA with ropivacaine 0.2%. Visual analogue scale scores, rescue analgesia, overall satisfaction, motor blockade and plasma ropivacaine concentrations were recorded for 48 h. RESULTS: Adequate analgesia was achieved with both techniques. No significant difference was noted for rescue analgesia, overall satisfaction and motor blockade. In contrast, children in the PCRA group received significantly less local anaesthetics than those in the CRA group. In addition, total plasma concentrations of ropivacaine were significantly reduced in the PCRA group as compared with the CRA group during the 48 h postoperative period. CONCLUSIONS: Both techniques are efficacious and satisfactory. However, PCRA with ropivacaine 0.2% can provide adequate postoperative analgesia for paediatric orthopaedic procedures with smaller doses of ropivacaine than CRA.

Incidence and nature of adverse events during pediatric sedation/anesthesia for procedures outside the operating room: report from the pediatric sedation research consortium.
Cravero JP , Blike GT , Beach M , Gallagher SM , Hertzog JH , Havidich JE , Gelman B ; Pediatric Sedation Research Consortium . Pediatrics. 2006 Sep;118(3):1087-96. Department of Anesthesiology, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire 03756, USA. Joseph.Cravero@Hitchcock.org

OBJECTIVE: We sought to use a large database of prospectively collected data on pediatric sedation and/or anesthesia for diagnostic and therapeutic procedures to delineate the nature and the frequency of adverse events that are associated with sedation/anesthesia care for procedures that are performed outside the operating room in children. METHODS: Data were collected by the Pediatric Sedation Research Consortium, a collaborative group of 35 institutions that are dedicated to improving sedation/anesthesia care for children internationally. Members prospectively enrolled consecutive patients who were receiving sedation or anesthesia for procedures. Data on demographics, primary illness, coexisting illness, procedure performed, medications used, outcomes, airway interventions, and adverse events were collected and reported on a Web-based data collection tool. RESULTS: A total of 26 institutions submitted data on 30,037 sedation/anesthesia encounters during the study period from July 1, 2004, to November 15, 2005. Serious adverse events were rare in the institutions involved in this study; there were no deaths. Cardiopulmonary resuscitation was required once. Less serious events were more common with O2 desaturation below 90% for > 30 seconds, occurring 157 times per 10000 sedations. Stridor and laryngospasm both occurred in 4.3 per 10,000 sedations. Unexpected apnea, excessive secretions, and vomiting had frequencies of 24, 41.6, and 47.2 per 10,000 encounters, respectively. CONCLUSIONS: Our data indicate that pediatric sedation/anesthesia for procedures outside the operating room is unlikely to yield serious adverse outcomes in a collection of institutions with highly motivated and organized sedation services. However, the safety of this practice depends on the systems' ability to manage less serious events.

A comparative study of hemodynamic responses to orotracheal intubation with fiberoptic bronchoscope and laryngoscope in children. Xue FS , Zhang GH , Sun HT , Li CW , Li P , Liu KP , Xu YC , Liu Y , Liu J . Paediatr Anaesth. 2006 Jul;16(7):743-7. Department of Anesthesiology, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China. fruitxue@yahoo.com.cn

BACKGROUND: The purposes of this study were to further identify the hemodynamic responses to orotracheal intubation in children, using a fiberoptic bronchoscope (FOB) and a direct laryngoscope (DLS), and to validate whether the FOB can attenuate the hemodynamic response to orotracheal intubation compared with the DLS. METHODS: Forty-three children, ASA PS I-II scheduled for elective plastic surgery under general anesthesia requiring orotracheal intubation were randomly allocated to either the DLS group (n = 20) or the FOB group (n = 23). Noninvasive systolic blood pressure (SBP) and heart rate (HR) were recorded before (baseline values) and after anesthesia induction (postinduction values), at intubation and every minute for the first 5 min after intubation. The maximal values of SBP and HR during the observation were also recorded. The product of HR and SBP [rate pressure product (RPP)] at each time point was calculated. RESULTS: In the DLS group, SBP, HR, and RPP at intubation and 1 min after intubation were significantly higher than postinduction values, but did not exceed baseline values. In the FOB group, SBP, HR, and RPP at intubation increased significantly compared with baseline and postinduction values. In the two groups, the maximal values of SBP, HR, and RPP during the observation were significantly higher than baseline values. Except for the HR at intubation, there were no significant differences in other hemodynamic parameters during the observation and the time required to reach maximal values of SBP, HR, and RPP between the two groups. CONCLUSIONS: Orotracheal intubation using FOB and DLS in children may cause similar increases in SBP and HR. Compared with the DLS, the FOB had no advantage in attenuating the hemodynamic responses to orotracheal intubation.

Use of BIS monitor in a child with congenital insensitivity to pain with anhidrosis. Brandes IF , Stuth EA . Paediatr Anaesth. 2006 Apr;16(4):466-70. Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI 53201, USA.

We describe a case of a 14-year-old boy with congenital insensitivity to pain and anhidrosis (CIPA) who underwent tarsal tunnel release for tarsal tunnel syndrome. Because of abnormal pain perception, the patient's response to normally painful surgical stimuli is severely impaired and not adequately reflected in a corresponding rise in blood pressure or heart rate. This lack of autonomic feedback to pain stimuli may make it more difficult to assess whether anesthetic depth is adequate to prevent intraoperative awareness and thus to safely conduct anesthesia, especially if muscle paralysis is required for surgical indications. We describe for the first time the use of processed EEG monitoring with a BIS A-2000 monitor to gauge anesthetic depth in a patient with CIPA. Initial forehead bispectral index (BIS) values prior to induction were normal (98) and then ranged between 23 and 79 during the whole surgical procedure. Propofol and lidocaine were used for induction and deep extubation; isoflurane was used as the sole anesthetic for maintenance with concentrations ranging from 0.21% to 0.92% to maintain a target BIS of 40-60. Volatile anesthetic requirements remained low throughout the procedure and no narcotics were necessary during surgery. The BIS monitor served as an adequate tool to help avoid excessive use of volatile anesthetic while assuring a processed EEG consistent with unconsciousness and amnesia. After the patient had recovered and was oriented to place and time in the recovery room, he was asked whether he remembered anything about the surgery and the presence of a breathing tube in his mouth. He denied any recall of such events.

Intraoperative wake-up test in neonatal neurosurgery. Govindarajan R , Babalola O , Gad-El-Kareem M , Kodali NS , Aronson J , Abadir A . Paediatr Anaesth. 2006 Apr;16(4):451-3. Department of Anesthesiology, Brookdale University Hospital and Medical Center, Brooklyn, NY 11212, USA.

Intraoperative wake-up test (WPT) still remains the gold standard to monitor anterior spinal cord function during spinal surgery. However, the test requires patient cooperation and hence difficult to perform in very young children or mentally challenged. In this report, we describe a WPT in a newborn during surgical repair of a large myelomeningocele. We relied on mivacurium for intubation and the relaxant effect was allowed to wear-off to permit the use of intraoperative nerve stimulator. We used desflurane and propofol infusion for rapid titration of the anesthetic depth and BIS monitor to 'gauge' the 'wakefulness' of the child during the WPT. We employed lidocaine infusion to improve tolerance to the tracheal tube and to bestow beneficial effect on intracranial pressure during surgery and the WPT. The results of the WPT were judged to be satisfactory after confirming flexion and extension of the lower extremities at the hip and knee level, correlating it with the BIS values, and comparing it with the preoperative status. Frequently associated prematurity, higher possibility of remaining intubated in the immediate postoperative period and any new onset neurologic deficit not becoming apparent until after extubation makes intraoperative neuromonitoring relevant in this age group. Our methodology of management has permitted us to perform a delicate test safely and will allow us to repeat the WPT if needed during neonatal neurosurgery.

A pilot study of the rectus sheath block for pain control after umbilical hernia repair. Isaac LA , McEwen J , Hayes JA , Crawford MW . Paediatr Anaesth. 2006 Apr;16(4):406-9.
Department of Anesthesia, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada.

BACKGROUND: Umbilical hernia repair, a common day surgery procedure in children, is associated with significant postoperative discomfort. The rectus sheath block may offer improved pain management following umbilical hernia repair. In this pilot study, we compared the efficacy of the rectus sheath block with that of our current standard practice--local anesthetic infiltration into the surgical wound--for pain control after umbilical hernia repair in children. METHODS: Fourteen children, aged 1-8 years, undergoing umbilical hernia repair were randomly assigned to receive either a rectus sheath block or local anesthetic infiltration into the surgical wound at completion of surgery. Anesthetic management was standardized. Each analgesic technique was performed using 0.8 ml x kg(-1) of 0.25% bupivacaine with epinephrine 1:200,000. Postoperatively, an investigator who was blinded to the analgesic technique recorded the Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) scores and sedation scores every 10 min, and administered intravenous morphine 50 microg x kg(-1) for cases with CHEOPS scores > or = 8. Total morphine dose was recorded. Parents were telephoned the day after surgery to determine the overall satisfaction with pain control. RESULTS: Total postoperative morphine consumption did not differ significantly between groups, averaging 0.10 +/- 0.09 and 0.10 +/- 0.07 mg x kg(-1) for the local infiltration and rectus sheath groups, respectively. There were no significant differences in pain or sedation scores, and no complications related to either analgesic technique. DISCUSSION: Our results suggest that the rectus sheath block has no advantage over infiltration of local anesthetic into the surgical wound for postoperative pain management in children undergoing umbilical hernia repair.

Comparative evaluation of different doses of propofol preceded by fentanyl on intubating conditions and pressor response during tracheal intubation without muscle relaxants. Gupta A , Kaur R , Malhotra R , Kale S . Paediatr Anaesth. 2006 Apr;16(4):399-405. Department of Anaesthesia, Safdarjang Hospital, Delhi, India. dr_akhi1@rediffmail.com

BACKGROUND: The aim of our study was to determine the optimal dose of propofol preceded by fentanyl for successful tracheal intubation and to see its effectiveness in blunting pressor response in children aged 3-10 years. METHODS: This prospective, double blind, randomized study was conducted on 60 ASA grade I and II children, between 3 and 10 years undergoing elective surgery who were divided into three groups of 20 each. The children received different doses of propofol (group I, 2.5 mg x kg(-1); group II, 3.0 mg x kg(-1); group III, 3.5 mg x kg(-1)) preceded by a fixed dose of fentanyl (3.0 microg x kg(-1)) 3 min earlier. The tracheal intubating conditions were graded based on scoring system devised by Helbo-Hensen et al. with Steyn modification which includes five criteria; ease of laryngoscopy, degree of coughing, position of vocal cords, jaw relaxation, and limb movement and graded on a 4-point scale. Heart rate (HR), mean arterial pressure (MAP), and oxygen saturation changes were also noted. RESULTS: Tracheal intubating conditions were acceptable in 25% of the patients in group I, while significantly higher (P < 0.001) in group II (80%) and in group III (90%). The pressor response was not effectively blunted in group I (17% increase in HR), while effectively blunted in groups II and III. A fall in cardiac output was seen in group III indicated by a decrease in MAP (16%) and HR (11%). No airway complications were noted. CONCLUSIONS: Propofol 3 mg x kg(-1) (group II) preceded by fentanyl 3 microg x kg(-1) is the optimal dose combination in our study. It provides acceptable intubating conditions in 80% patients, blunts pressor response to intubation without significant cardiovascular depression.

Efficacy of three doses of tramadol with bupivacaine for caudal analgesia in paediatric inguinal herniotomy. Prakash S , Tyagi R , Gogia AR , Singh R , Prakash S . Br J Anaesth. 2006Sep;97(3):385-8. Department of Anaesthesia and Intensive Care, Vardhman Mahavir Medical College and Safdarjang Hospital New Delhi, India. drsunilprakash@rediffmail.com

BACKGROUND: This study was designed to evaluate the analgesic efficacy of three doses of tramadol, administered caudally with bupivacaine, in providing postoperative pain relief in children. METHODS: Eighty children, aged between 2 and 8 yr, undergoing inguinal herniotomy were randomly allocated to receive bupivacaine 0.25% 0.75 ml kg(-1) (Group B; n=20), bupivacaine 0.25% 0.75 ml kg(-1) with tramadol 1 mg kg(-1) (Group BT1; n=20), bupivacaine 0.25% 0.75 ml kg(-1) with tramadol 1.5 mg kg(-1) (Group BT1.5; n=20), or bupivacaine 0.25% 0.75 ml kg(-1) with tramadol 2 mg kg(-1) (Group BT2; n=20) by the caudal route immediately after induction of general anaesthesia. Heart rate, arterial pressure and oxygen saturation were monitored. Postoperative pain was assessed at regular intervals for 24 h using All India Institute of Medical Sciences pain score. Analgesia was supplemented whenever pain score was >or=4. Duration of analgesia and requirement for additional analgesics was noted. RESULTS: Duration of analgesia was longer in Group BT2 [(mean (SD) 12 (0.9) h] compared with Group B [4 (1) h], Group BT1 [8 (0.9) h], or Group BT1.5 [11 (1) h]; all P<0.001. Total consumption of rescue analgesic was significantly lower in group BT2 compared with other groups (P<0.001). There were no significant changes in heart rate, arterial pressure and oxygen saturation between groups. Adverse effects were not observed. CONCLUSIONS: Caudal tramadol 2 mg kg(-1), combined with bupivacaine 0.25% 0.75 ml kg(-1), provided longer duration of postoperative analgesia and reduced requirement for rescue analgesic compared with tramadol 1 mg kg(-1) or 1.5 mg kg(-1) in children undergoing inguinal herniotomy.

Determination of the optimal angle for needle insertion during caudal block in children using ultrasound imaging. Park JH , Koo BN , Kim JY , Cho JE , Kim WO , Kil HK . Anaesthesia 2006 Oct;61(10):946-9. Department of Anaesthesiology and Pain Medicine, Kangdong Sacred Heart Hospital, Hallym University, Seoul, Korea.

Using ultrasound imaging, the optimal angle for needle insertion during caudal epidural injection in children was estimated. After general anaesthesia, ultrasonography was performed at the sacral hiatus in 130 children aged 2-84 months positioned in the lateral position. The median [range] values for the intercornual, caudal space depth and the distance from skin to the posterior sacral bony surface were 17.0 [9.6-24] mm, 3.5 [1-8] mm and 21.0 [10-39] mm, respectively. The optimal angle showed no significant correlation with age, weight, height or body surface area. The median [range] calculated optimal angle for the needle was 21.0 [10-38] degrees. We conclude that the needle should be inserted at about 20 degrees to the skin to avoid puncture of the bone and potential intra-osseous injection.

Anesthesia management with short acting agents for bilateral pheochromocytoma removal in a 12-year-old boy. Bakan M , Kaya G , Cakmakkaya S , Tufanogullari B . Paediatr Anaesth 2006 Nov;16(11):1184-8. Cerrahpasa Medical Faculty, Department of Anesthesiology and Reanimation, Istanbul University, Istanbul, Turkey.

A 12-year-old boy with bilateral adrenal pheochromocytoma pretreated with furosemide, nifedipine, prazosin, and propranolol underwent surgical removal of the tumors. General anesthesia with desflurane, remifentanil infusion and thoracic epidural analgesia was performed. To control the blood pressure (BP), remifentanil up to 1 mug.kg(-1).min(-1) infusion rate, sodium nitroprusside, and esmolol infusions were administered successfully. Following the ligation of the adrenal veins, hemodynamic parameters were stable and neither inotropic support nor corticosteroid replacement was required. We concluded that remifentanil-based anesthesia combined with low-dose desflurane and thoracic epidural analgesia may reduce the need for vasoactive drugs in the anesthesia management of pheochromocytoma. This combination may not prevent the hemodynamic fluctuations during tumor manipulation, but appears to facilitate a rapid and stable postoperative recovery.

Emergence agitation in preschool children: double-blind, randomized, controlled trial comparing sevoflurane and isoflurane anesthesia. Bortone L , Ingelmo P , Grossi S , Grattagliano C , Bricchi C , Barantani D , Sani E , Mergoni M . Paediatr Anaesth. 2006 Nov;16(11):1138-43. Primo Servizio di Anestesia e Rianimazione, Azienda Ospedaliera di Parma, Parma, Italy.

Background: This randomized, double-blind controlled trial was conducted to determine whether the association of sevoflurane for induction and isoflurane for anesthesia maintenance resulted in a lower incidence of postoperative agitation compared with sevoflurane as single agent. Methods: After Institute Ethics Committee's approval and parental written informed consent, 128 unpremedicated children (1-6 years), ASA I-II, scheduled for elective subumbilical surgery were enrolled. After induction with 8% sevoflurane, patients were randomly allocated to receive sevoflurane or isoflurane 1-1.5 MAC as maintenance agent. The primary endpoint of the study was the incidence of postoperative agitation defined as a screaming and crying child and/or a child that required physical restraint during emergence. Results: Eighteen children were excluded because they received sedatives, analgesia or anesthesia or because of ineffective regional analgesia before randomization. Fifty-four patients receiving sevoflurane and 56 receiving isoflurane completed the study. Twenty-eight children (95% CI 38-66%) in the sevoflurane group presented with postoperative agitation compared with 18 (95% CI 20-46%) patients receiving isoflurane (P = 0.028). Fifteen minutes after awakening, 11/54 children receiving sevoflurane were agitated compared with 4/56 receiving isoflurane (P = 0.03). Thereafter, there was a gradual reduction in the incidence of postoperative agitation over time. Conclusions: The association of sevoflurane for induction and isoflurane for maintenance produced significant less postoperative agitation in preschool children receiving regional anesthesia during subumbilical surgery compared with sevoflurane for induction and maintenance.

Outpatient arthroscopic knee surgery under combined local and intravenous propofol anesthesia in children and adolescents. Maldini B , Miskulin M . Paediatr Anaesth. 2006 Nov;16(11):1125-32. Department of Anesthesia, Sveti Duh General Hospital, Zagreb, Croatia.

Background: This prospective observational study included a case series of children and adolescents receiving light intravenous propofol anesthesia combined with local anesthesia (LA) for arthroscopic knee procedures. The aim was to examine the merits of anesthesia, to discuss the indications for the procedure and to analyze recovery/discharge times from the postanesthesia care unit (PACU). Methods: A cohort of 147 children and adolescents (ASA 1 and 2) aged 12-18 years admitted for outpatient arthroscopic knee procedures between January 2004 and May 2005 were studied. After IV access in the operating theater, the patients received propofol (10 mg.ml(-1)). Arthroscopy was performed approximately 15 min after injecting local anesthetic (15 ml 2% lidocaine with epinephrine 1:200 000) partly at the site of insertion of the arthroscope and other instruments (5 ml), and the rest intra-articular. The following parameters were assessed: airway patency, propofol requirement, vital signs, procedure time, surgical operating conditions, patient satisfaction score, time to discharge, postoperative analgesia and adverse events. Results: Of 147 patients, 133 patients (90.5%) underwent arthroscopic knee surgery, whereas knee arthroscopy alone was performed in 14 patients (9.5%) without indication for operative treatment. The arthroscopy was well tolerated in 96.6% patients (no pain, movement or discomfort during the procedure) and only five patients required conversion to general anesthesia. Pain experienced during the injection of lidocaine was more severe than pain experienced during the surgical procedure itself (P < 0.001). The surgical evaluation of operative conditions (visualization and access to intra-articular structures) was generally satisfactory and completely acceptable. Almost 94% (138/147) of patients said they would have the same procedure again under the same type of anesthesia. The mean propfol induction dose was 1.4 mg.kg(-1) (range: 0.9-3.8) and mean propofol infusion rate 167 mug.kg(-1).min(-1) (range: 130-250). Movement was more likely at lower infusion rates (mean: 151 mug.kg(-1).min(-1)). The maximal decrease in respiratory rate was 5.9 +/- 5.1 br.min(-1) (27.2 +/- 21%) and no patient became hypoxic. Patients recovered to preoperative values at 9.8 +/- 7.5 min following infusion discontinuation. There were no respiratory or cardiovascular complications. The mean stay in PACU was 47 min (range: 32-150). As many as 71% (105/147) of patients required no analgesics during the first two postoperative hours. Conclusions: The combination of light intravenous propofol anesthesia combined with local anesthesia for arthroscopic knee procedures provided effective sedation, good preservation of upper airway patency, rapid recovery and pain relief without major side effects and offers a good alternative to the methods already available. The majority of patients did not require postoperative analgesia.

Ultrasonographic guidance in pediatric regional anesthesia. Part 2: techniques. Roberts S . Paediatr Anaesth. 2006 Nov;16(11):1112-24. Jackson Rees Department of Anaesthesia, Alder Hey Hospital, Royal Liverpool Children's NHS Trust, Liverpool, UK.

The benefits of regional anesthesia are well documented. The downsides of such techniques have been a significant failure rate and a potential for serious complications. Nearly, all regional blocks were first described as essentially 'blind' techniques. The development of high-resolution portable ultrasound (US) has made the use of US for regional anesthesia possible. Improved understanding of sonographic anatomy should lessen both the failure rate and the possibility of incurring serious complications. Natural caution has dictated that only a selection of blocks used in adults has been commonly used in pediatric practice, but with the aid of US, the repertoire of blocks for infants and children may be widened. The second part of this review will concentrate on the practice of both peripheral and central blocks.

Convection heating in pediatric general surgery - a comparison of warming alternatives in a mannequin study. Nightingale S , Wynne L , Cassey J . Paediatr Anaesth. 2006 Jun;16(6):663-8. Department of Paediatrics, John Hunter Hospital, NSW, Australia.

BACKGROUND: Numerous methods of patient warming are used to prevent intraoperative hypothermia in children. Commercially available forced air warming blankets are effective, but are single-use items. We tested a custom-designed heat dissipation unit (HDU) against one such commercially available blanket. METHODS: Air temperatures at various points around a mannequin under simulated operating conditions were recorded using thermistors and thermal imaging. The only variable changed was the heating method: a forced air blanket or a customized HDU with two draping techniques - cotton drapes with and without a plastic 'undersheet'. RESULTS: The three methods produced similar temperature increases and plateaux across the 11 thermistor points measured. There were no significant differences between temperatures at 1 h. A plastic sheet did not appear to enhance the effectiveness of the HDU in this study. Thermal imaging photography suggested more uniform heating of the mannequin with the HDU arrangements. CONCLUSIONS: The custom-built HDU compares favorably in our mannequin study with a Bair Hugger forced air warming blanket. As it is reusable, it offers considerable potential savings.

A comparison of nerve stimulator guided paravertebral block and ilio-inguinal nerve block for analgesia after inguinal herniorrhaphy in children. Naja ZM , Raf M , El-Rajab M , Daoud N , Ziade FM , Al-Tannir MA , Lonnqvist PA . Anaesthesia. 2006 Nov;61(11):1064-8. Department of Anaesthesia, Makassed General Hospital, Beirut, Lebanon.

The aim of this study was to compare the efficacy of nerve stimulator guided paravertebral block with ilio-inguinal nerve block in children undergoing inguinal herniorrhaphy. Eighty children were randomly allocated to receive either paravertebral block or ilio-inguinal nerve block. Each block was evaluated in terms of intra-operative haemodynamic stability, postoperative pain scores at rest, on movement and during activity, requirement for supplemental analgesia and parental satisfaction. Haemodynamic stability was maintained significantly better during sac traction in the paravertebral block group (p < 0.005). Pain scores and analgesic consumption were significantly lower in the paravertebral block group during the postoperative follow-up period (p < 0.05). Parental satisfaction (93%vs 69%) and surgeon satisfaction (93%vs 64%) were significantly higher in the paravertebral block group (p < 0.05). Paravertebral blockade improved and prolonged postoperative analgesia, and was associated with greater parental and surgeon satisfaction when compared to ilio-inguinal nerve block.

Impact of caudal block on functional residual capacity and ventilation distribution in anaesthetized preschool children. von Ungern-Sternberg BS , Frei FJ , Regli A , Hammer J , Erb TO . Paediatr Anaesth. 2006 Dec;16(12):1301. Department of Anaesthesia, University Hospital for Children Basel, Basel, Switzerland.

Introduction: In children, general anaesthesia is often performed in combination with regional anaesthesia and caudal block (CB) is probably the most commonly used central neuroaxial blockade. The administration of local anaesthetics results in a motor blockade. The impact of this motor blockade induced by CB on the functional residual capacity (FRC) and ventilation distribution is unknown. The aim of this study was to determine the impact of CB versus control on FRC and ventilation distribution in preschool children. We hypothesized that an effective CB would lead to an increase of FRC and ventilation distribution while these parameters would remain unchanged in the control group. Methods: After approval from the local Ethics Committee, 52 preschool children (15-30 kg, 3-8 years) without cardiopulmonary disease who were to undergo elective surgery requiring combined general/regional anesthesia with a CB, were randomly allocated into two groups: CB (n = 26) or control (n = 26). Anesthesia was standardized using a propofol TCI for children. All children were breathing spontaneously via a laryngeal mask airway. FRC and lung clearance index (LCI), a measure of ventilation distribution, were calculated using a sulfur-hexafluoride gas (SF(6)) multibreath washout technique. A blinded reviewer performed off-line analyses of the data. Following the first measurement in the supine position (baseline), all children were turned into the left-lateral position. The CB group received a CB (0.2 ml.kg(-1) bupivacaine 0.25% + epinephrine 1: 200 000 test dose and 0.8 ml.kg(-1) bupivacaine 0.175%), while in the control group no intervention took place. After 5 min in the lateral position, all children were turned back to the supine position. After 15 min, the effectiveness of the CB was tested by pinching the skin at the L1 level with any movement being taken as a noneffective block (n = 0), and the second FRC assessment was performed in both groups. Results: At baseline, FRC and LCI were similar for the two groups. In the CB group, FRC (mean +/- SD) increased from 17.0 +/- 4.3 ml.kg(-1) to 20.5 +/- 5.1 ml.kg(-1) (P < 0.0001) after an effective CB while FRC in the control group remained unchanged (17.2 +/- 4.9 ml.kg(-1) to 17.1 +/- 4.8 ml.kg(-1) (P = 0.0757). At the same time, the LCI decreased from 12.0 +/- 2.5 to 9.37 +/- 1.7 (P < 0.0001) in the CB group, while it remained constant in the control group (10.8 +/- 2.7 vs 10.7 +/- 2.6, P = 0.1515). Conclusions: CB resulted in a significantly increased FRC and ventilation distribution, whereas these parameters did not change in the control group. This indicates that a CB could have a major impact on respiratory function in anaesthetized, spontaneously breathing children. Additionally, the constant values for FRC and LCI in the control group showed that there was no 'over-time' effect on these two parameters during the assessed study period. Acknowledgement: The study was funded by the Department of Anaesthesia, University of Basel, Switzerland and by the Swiss Association of Anaesthesia and Reanimation (SGAR).

Prone equals prone? - impact of different techniques of body positioning on functional residual capacity and ventilation distribution in anaesthetised, paralysed preschool children. von Ungern-Sternberg BS , Frei FJ , Hammer J , Erb TO . Paediatr Anaesth. 2006 Dec;16(12):1299. Department of Anaesthesia, University Hospital for Children Basel, Basel, Switzerland.

Introduction: In children undergoing anesthesia or sedation, optimizing functional residual capacity (FRC) is of special importance, because they have smaller elastic retraction forces compared with adults and a lower relaxation volume that makes them more prone to airway collapse. Moreover, children are particularly vulnerable to hypoxaemia because of their higher oxygen demand per kilo body weight. Although the prone position is effectively used to improve oxygenation, its impact on FRC is controversial. Thus, additional confounding factors such as changes in ventilation distribution or differences in positioning techniques might be of importance. In fact, positioning techniques such as flat versus augmented prone position could exert different degrees of pressure on the abdominal contents and thus differences in the cephalic displacement of the diaphragm. The aim of this study was to determine the impact of two different prone positioning techniques on FRC and ventilation distribution in anesthetized, paralyzed preschool-aged children. We hypothesized that augmented prone positioning improves FRC and ventilation distribution compared with the supine or flat prone position. Methods: Following local Ethics Committee approval, 30 preschool children without cardiopulmonary disease undergoing elective surgery were studied. FRC and lung clearance index (LCI), a measure of ventilation distribution, were calculated using a sulfur-hexafluoride gas (SF(6)) multibreath washout technique. After intubation, the measurements were taken in the supine position and in random order in the flat prone and augmented prone position (gel pads supporting the pelvis and the upper thorax to ensure free movement of the abdomen). The position of the arms was kept constant and the head was turned to the side for all assessments. Measurements were taken 5 min after each positioning. Results: Mean (range) age was 48.5 (24-80) months, weight = 17.2 (10.5-26.9) kg. FRC (mean +/- SD) was 22.9 +/- 6.2 ml.kg(-1) in the supine position and 23.3 +/- 5.6 ml.kg(-1) in the flat prone position while LCI was 8.1 +/- 2.3 vs 7.9 +/- 2.3 in these two positions, respectively. In contrast, FRC increased to 27.6 +/- 6.5 ml.kg(-1) (P < 0.001) in the augmented prone position while at the same time the LCI decreased to 6.7 +/- 0.9 (P < 0.001). Conclusions: FRC and ventilation distribution were similar in the supine and flat prone positions, while these parameters improved significantly in the augmented prone position suggesting that the technique of prone positioning could have a major impact on respiratory function in anaesthetized, mechanically ventilated preschool children. Acknowledgement: The study was funded by the Department of Anaesthesia, University of Basel, Switzerland.

Epidural analgesia for tracheo-oesophageal fistula repair. Krishnan K , Marcus R . Paediatr Anaesth. 2006 Dec;16(12):1299-300. Department of Anaesthesia, Birmingham Children's Hospital, Birmingham, UK.

Introduction: Traditionally neonates undergoing surgical repair of tracheo-oesophageal fistula (TOF) would receive opioid analgesia and be returned ventilated to a neonatal intensive care unit (ICU). It has been shown that the use of epidural analgesia can reduce the need for postoperative ventilation (1). In recent years it has been the practice in our institution to use epidural analgesia for these neonates where possible. This is an audit of our recent experience. Methods: We retrospectively identified cases of TOF repair at our institution from January 2002 to September 2005. The notes of these neonates were reviewed for the following information: birth weight, gestational age, co-existing congenital anomalies, preoperative respiratory function, operation duration, postoperative analgesia, ICU admission and duration of stay in ICU. Results: Thirty-five TOF repairs were identified. One neonate was excluded as he had concomitant abdominal surgery. Of the 34 remaining, 30 sets of notes were reviewed. The outcome for these neonates is shown in the diagram. Of the 10 neonates who did not receive an epidural, a reason was found in eight cases: three were already ventilated, two had abnormal coagulation, two had coexisting congenital heart disease and one had recurrent apnoeas. Only three of the 20 neonates with an epidural required postoperative ventilation, one for metabolic acidosis, one for lung collapse and one for inadequate respiratory effort. All three remained on ICU for <24 h. The median PICU stay for those neonates who did not receive an epidural was 4 days (range 2-11 days). The group who received epidural analgesia was more mature (38.7 weeks c.f. 35.3 weeks gestational age) and heavier (2.9 kg c.f. 2.3 kg) than the group who did not. The mean operative time (including bronchoscopy and surgery) was 2.8 h in the epidural group and 3.3 h in the nonepidural group. Conclusion: Mature neonates presenting for TOF repair can be managed with epidural analgesia, usually removing the need for postoperative ventilation and an ICU bed. There is a group of smaller, less mature neonates that did not receive epidural analgesia, we cannot determine from this audit whether any of these would have benefited from epidural analgesia. Reference 1 Bosenberg AT, Wiersma R, Hadley GP. Esophageal atresia: caudo-thoracic epidural anesthesia reduces the need for post-operative ventilatory support. Pediatr Surg Int 1992; 7: 289-291.

Lidocaine pretreatment for the prevention of propofol-induced transient motor disturbances in children during anesthesia induction: a randomized controlled trial in children undergoing invasive hematologic procedures. Bilotta F , Ferri F , Soriano SG , Favaro R , Annino L , Rosa G . Paediatr Anaesth. 2006 Dec;16(12):1232-1237. Department of Anesthesiology, Intensive Care and Pain Medicine, University of Rome 'La Sapienza', Rome, Italy.

Background: We examined the effect of lidocaine pretreatment before propofol administration on the incidence of transient motor disturbances and on propofol requirements for anesthesia induction in infants and children undergoing repeated painful diagnostic and therapeutic hematological procedures. Methods: A series of 358 children subgrouped according to the presence of a peripheral-vein or central venous catheter were randomly assigned to receive an intravenous dose of 2% lidocaine (2.0 mg.kg(-1)) or an equivalent volume of saline, 1 min before propofol (1.5-3.5 mg.kg(-1)) injected for anesthesia induction. Results: The incidence of spontaneous movements was significantly lower in patients pretreated with lidocaine than in those receiving placebo (2.5% vs 29%; P < 0.001, by chi-square test), as was the propofol induction dose (1.6 +/- 0.2 mg.kg(-1) vs 2.2 +/- 0.3 mg.kg(-1); P < 0.001) and pain at the injection site in patients peripheral-vein catheter (12% vs. 54%; P < 0.001). Lidocaine administration also improved children's acceptance as reported by parents on the Observational Scale of Behavioral Distress administered 2 h after the procedure (6.5 +/- 2.5 vs. 9.4 +/- 3.3; P < 0.001). Bouts of coughing developed significantly more frequently after lidocaine pretreatment than after placebo (62.5% vs. 17.5%; P < 0.001). Conclusions: Because lidocaine pretreatment before the induction of propofol-based anesthesia decreases propofol-induced motor disturbances, lowers hypnotic requirements and reduces pain at the injection site, without inducing untoward events, thus improving children's and parental acceptance, it should become standard practice in infants and children undergoing repeated painful diagnostic and therapeutic hematological procedures.

Increase in skin temperature after spinal anesthesia in infants. Jetzek-Zader M , Hermanns H , Freynhagen R , Lipfert P , Stevens MF . Reg Anesth Pain Med. 2006 Nov-Dec;31(6):519-22. Department of Anesthesiology, University of Dusseldorf, Dusseldorf, Germany.

BACKGROUND AND OBJECTIVES: The relatively stable hemodynamics during spinal anesthesia in infants have been attributed to a less active sympathetic nervous system in comparison with adults. Thus, the authors evaluated sympathetic block primarily by measurement of skin temperature and secondarily by determination of noninvasive blood pressure as an indirect sign of sympatholysis. METHODS: In 15 infants (postconceptual age: 45.0 +/- 4.8 weeks; weight: 4.0 +/- 1.2 kg) scheduled for repair of inguinal hernia under spinal anesthesia, skin temperature at the T4 level and at the plantar foot was measured before and after spinal anesthesia. Spinal anesthesia was induced at the L4/L5 interspace with 0.5% hyperbaric bupivacaine 1 mg/kg with 10 mug/kg adrenaline added. RESULTS: Temperature at the plantar foot after spinal anesthesia rose significantly from 33.0 degrees C +/- 1.3 degrees C to 34.7 degrees C +/- 1.4 degrees C within 10 minutes and to 35.6 degrees C +/- 0.9 degrees C after 20 minutes (P < .0001), whereas the temperature at the thorax remained constant at 35 degrees C to 36 degrees C. Systolic and diastolic blood pressure decreased by 15.9 +/- 11.4 mm Hg and 9.0 +/- 9.2 mm Hg, respectively (P < .01), but remained within normal range in all cases. CONCLUSIONS: The authors found a significant increase in skin temperature of the feet within 10 minutes as a sign of sympatholysis, whereas trunk temperature remained constant. Blood pressure decreased but remained within the normal range, despite the observed sympatholysis.

The former preterm infant and risk of post-operative apnoea: recommendations for management. Walther-Larsen S , Rasmussen LS . Acta Anaesthesiol Scand. 2006 Aug;50(7):888-93. Department of Anaesthesia, Section 4013 Juliane Marie Centre, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, DK-2100 Copenhagen, Denmark. RH02090@RH.dk

The preterm infant presenting for anaesthesia during the first 6 months of life is a major anaesthetic challenge. One of the most serious post-operative complications is apnoea with or without bradycardia. For this review, we conducted a search of the current literature in order to formulate a set of evidence-based clinical guidelines to help clinicians in the management of the former preterm infant to avoid post-operative apnoea. Only a small number of patients have been enrolled into prospective, randomized, controlled studies. Based on the current literature, regional anaesthesia is strongly recommended, preferably neuraxial block, but general anaesthesia is also used and in this setting, opioids and muscle relaxants should be avoided. Infants with a post-conceptual age of less than 46 weeks should be admitted for continuous monitoring for at least 12 h post-operatively. In infants with a post-conceptual age (PCA) between 46 and 60 weeks, a careful assessment of the child is mandatory and 12 h of respiratory monitoring is recommended if the patient's history reveals episodes of apnoea at home, chronic lung disease (CLD), neurological disease or anaemia. The otherwise healthy infant could be scheduled for theatre as the first patient on the list and subsequently monitored in the post-anaesthetic care unit for 6 h. The risk of apnoea in former preterm infants can be further reduced by the administration of intravenous caffeine (10 mg/kg). All of these patients should be referred to a tertiary centre for anaesthesia and surgery.

Fentanyl reduces desflurane-induced airway irritability following thiopental administration in children. Lee J , Oh Y , Kim C , Kim S , Park H , Kim H . Acta Anaesthesiol Scand. 2006 Oct;50(9):1161-4. Department of Anesthesiology, Seoul National University, College of Medicine, Seoul, South Korea.

BACKGROUND: Airway irritation is a major drawback of desflurane anesthesia. This study was designed to evaluate the effect of intravenous fentanyl given before thiopental induction on airway irritation caused by a stepwise increase in desflurane in children. METHODS: Eighty children (2-8 years) were enrolled in a randomized, double-blind study. Forty received saline and 40 received 2 microg/kg of fentanyl intravenously; this was followed by thiopental sodium 5 mg/kg in both groups. Patients were assistant-ventilated with desflurane 1%, which was then increased by 1% every six breaths up to 10%. During this period, cough, secretion, excitation and apnea were graded and the desflurane concentration at which airway irritation symptoms first occurred was recorded. The results were analyzed using Pearson's chi-squared test. RESULTS: The incidence of typical airway irritation events was lower with fentanyl than with saline (cough, 2.5% vs. 42.5%; secretion, 27.5% vs. 82.5%; excitation, 10% vs. 82.5%; apnea, 20% vs. 65%; P < 0.05). The mean expired desflurane concentration at which the first airway irritation symptom occurred was greater with fentanyl than with saline (7.3% vs. 5.5%, P < 0.05). CONCLUSIONS: Intravenous fentanyl in children reduces airway complications caused by desflurane.

A prospective, double-blind, randomized trial of caudal block using ropivacaine 0.2% with or without fentanyl 1 microg kg-1 in children. Kawaraguchi Y , Otomo T , Ota C , Uchida N Taniguchi A , Inoue S . Br J Anaesth. 2006 Dec;97(6):858-61. Epub 2006 Sep 13. Department of Anaesthesia and Critical Care, Miyagi Children's Hospital, Sendai, Japan. kawaraguchi@bea.hi-ho.ne.jp

BACKGROUND: It has been reported that ropivacaine produces vasoconstriction in contrast to vasodilation produced by bupivacaine. It is possible that additives to ropivacaine can provide further analgesic advantages compared with bupivacaine. We thus evaluated whether the addition of fentanyl to ropivacaine prolonged the duration of analgesia after a single shot caudal block. METHODS: A total of 36 children undergoing surgical procedures below the umbilicus were randomly allocated to one of two groups: Group F received ropivacaine 0.2%, 1 ml kg(-1) with fentanyl 1 microg kg(-1) and Group S received ropivacaine 0.2%, 1 ml kg(-1) with saline. The analgesic effect of the caudal block was evaluated using the Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) and sedation was assessed using the Steward score at 30 min after extubation and at 1, 2, 4, 6, 12 and 24 h. The first analgesic requirement time and side-effects in a 24 h period were also recorded. RESULTS: There were no differences in characteristics between the groups. The end-tidal concentration of sevoflurane at extubation in Group F was significantly lower than in Group S. However, there was no significant difference in time from discontinuation of the volatile anaesthetics to tracheal extubation. No statistical differences were found in the CHEOPS and Steward score, and the time to first analgesia. The incidence of postoperative vomiting was not significantly different. CONCLUSION: We found that the addition of fentanyl 1 mug kg(-1) to ropivacaine 0.2% for caudal analgesia provides no further analgesic advantages over ropivacaine 0.2% alone.

Early peristalsis following epidural analgesia during abdominal surgery in an extremely low birth weight infant. Hoehn T , Jetzek-Zader M , Blohm M , Mayatepek E . Paediatr Anaesth. 2007 Feb;17(2):176-9. Neonatology and Pediatric Intensive Care Medicine, Department of General Pediatrics, Heinrich-Heine-Universiry, Dusseldorf, Germany.

The inhibiting effect of opioids on intestinal motility is a cause of particular concern in extremely low birth weight (ELBW; birth weight <1000 g) infants with decreased peristalsis. An ELBW infant (birth weight 740 g) born after 26 + 1 week of gestation had an uneventful clinical course during the first few days of life. Sudden deterioration occurred on day 8 with metabolic acidosis, hyperglycemia and frequent apnea with secondary bradycardia. A chest X ray demonstrated the presence of air beneath the diaphragm. Intestinal perforation was suspected and the infant was taken to theater for laparotomy. For pain management, a 22 G epidural catheter was inserted via the caudal approach and threaded to a mid-thoracic level. Epidural ropivacaine was administered intraoperatively and for 48 h postoperatively. The infant was extubated on the following day. Opioids were not required or given at any stage during or after surgery. Peristalsis was present on auscultation as early as 3 h after surgery, the first stool was passed on the same day. Enteral nutrition was resumed early and tolerated well, full enteral feeding was rapidly achieved. Our case shows that the technique of caudal anesthesia is feasible in ELBW infants. We speculate that intestinal motility and establishment of full enteral feedings may be achieved earlier by epidural ropivacaine in cases of abdominal surgery in ELBW infants.

Ropivacaine spinal anesthesia in neonates: a dose range finding study. Frawley G , Skinner A , Thomas J , Smith S . Paediatr Anaesth. 2007 Feb;17(2):126-32. Department of Paediatric Anaesthesia and Pain Management, Royal Children's Hospital, Melbourne, Vic., Australia.

Background: Our primary aim was to determine the minimum local anaesthetic dose (MLAD) defined as the median effective local anesthetic dose for spinal anesthesia in neonates. Secondary aims were to determine the dose-response curve for spinal anesthesia including the clinically relevant ED95 dose and to describe the duration of motor block following ropivacaine spinal anesthesia. Methods: Fifty neonates less than 55 weeks postmenstrual age (PMA) having inguinal hernia repair were enrolled. The study was performed in two stages. The MLAD dose of ropivacaine was determined by up-down sequential allocation. An expanded dose ranging study was then performed with dose escalation to doses predicted to fall in the ED50-95 range dose. Probit and logit analysis on all patients was used to compare ED50 with the value described by the Dixon-Massey method and to determine doses up to the ED95. Results: Fifty neonates with a mean PMA of 43 weeks and mean weight of 3.7 kg were enrolled. The motor block MLAD (95% confidence interval) determined by the Dixon-Massey method was 0.51 (0.38-0.64) mg.kg(-1). A logistic regression analysis of the results of all 50 patients confirmed the Dixon-Massey result. The ED50 (95% CI) was 0.50 (0.39-0.63) mg.kg(-1) with an estimated ED95 was 1.08 (0.70-1.67) mg.kg(-1). These values were confirmed by probit analysis. Overall the mean duration (95% confidence interval) of lower limb motor blockade was 60.0 min (51.5-68.5 min). The duration of anesthesia far exceeded surgical duration in all successful cases. Conclusions: Ropivacaine is an effective agent for spinal anesthesia in neonates at a recommended dose of 1.08 mg.kg(-1). The motor block duration, however, is significantly shorter than equivalent agents and highly variable in duration.

Atelectasis in children undergoing either propofol infusion or positive pressure ventilation anesthesia for magnetic resonance imaging. Lutterbey G , Wattjes MP , Doerr D , Fischer NJ , Gieseke J Jr , Schild HH . Paediatr Anaesth. 2007 Feb;17(2):121-5. Department of Radiology, University of Bonn, Bonn, Germany.

Background: Atelectasis because of anesthesia is a recognized problem but may be affected by the anesthetic technique. We compared magnetic resonance images of atelectasis in children undergoing two types of anesthesia. Methods: Children requiring anesthesia for magnetic resonance imaging (MRI) had additional lung imaging sequences at the beginning and the end of anesthesia. Children had either i.v. propofol infusion (PI) without an artificial airway (n = 26) or positive pressure ventilation (PPV) via a tracheal tube (n = 20); the technique was chosen for clinical reasons. The extent of atelectasis was scored by two independent radiologists. Results: The median ages (range) for PI and PPV groups were 45 months (1-77 months) and 18 months (2-74 months), respectively. The proportion of children with atelectasis was different in the first lung scan (42% vs 80%), but in the second scan atelectasis was seen frequently in both groups (82% vs 94%) with a greater extent in the PPV group. The atelectasis score was higher in young children, but all children had normal oxygen requirements and saturations. Conclusions: Many factors may influence the development of atelectasis but this study found less extensive atelectasis with PI than PPV. PI allows for sufficient motionlessness, required for high diagnostic image quality in pediatric MRI.

Bupivacaine caudal epidural anesthesia: assessing the effect of general anesthetic technique on block onset. Ingelmo PM , Bendall EJ , Frawley G , Locatelli BG , Milan B , Lodetti D , Fumagalli R . Paediatr Anaesth. 2007 Mar;17(3):255-62. Department of Anaesthesia and Intensive Care, A.O. San Gerardo, Monza, Italy.

Background : The primary objective of this prospective, randomized trial was to compare the effect of propofol and sevoflurane on effectiveness of regional anesthesia. As a secondary objective, we aimed at evaluating the influence of age on neuraxial block profile. Methods : One hundred and thirteen healthy children aged <10 years, scheduled for general or urological surgical procedures were randomly allocated to receive either propofol or sevoflurane induction and maintenance. Children received caudal or lumbar epidural block depending on their weight and expected surgery. Time to onset of surgical anesthesia, intraoperative analgesic effectiveness, residual motor blockade, postoperative pain, and adverse effects were evaluated. To assess the influence of age on these measures children were further divided into three age groups: 0-24, 25-60 and >60 months. Results : The mean time to onset of surgical anesthesia was significantly shorter in the sevoflurane group than the propofol group (3.1 vs 4.7 min, P < 0.01), independent of the type of regional technique employed. Distress on arousal in recovery was increased in children receiving sevoflurane (P = 0.03). There was no significant difference in residual motor blockade between the groups but children between 0 and 24 months receiving sevoflurane had a higher incidence of residual motor blockade 3 h after local anesthetic injection (P = 0.01). Conclusions : This study has demonstrated that general anesthesia with sevoflurane decreases the time to onset of surgical anesthesia relative to propofol anesthesia. This effect was most marked when sevoflurane anesthesia preceded caudal epidural blockade. The basis for this effect is most likely to be related to differential binding of the two anesthetic agents to receptors in the spinal cord that mediate immobility in response to surgical stimuli.

The circulatory responses to tracheal intubation in children: a comparison of the oral and nasal routes. Xue FS , Liao X , Liu KP , Liu Y , Xu YC , Yang QY , Li P , Li CW , Sun HT . Anaesthesia. 2007 Mar;62(3):220-6. Department of Anaethesiology, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Ba-Da-chu Road, Shi-Jing-shan District Beijing, People's Republic of China 100041. fruitxue@yahoo.com.cn

The circulatory responses to laryngoscopic tracheal intubation in 62 healthy children undergoing surgery requiring tracheal intubation were studied. They were randomly assigned to receive either the oral or nasal route for intubation. Baseline non-invasive blood pressure and heart rate were recorded following induction of anaesthesia, at intubation and then every minute for 5 min. The percentage changes of systolic blood pressure and heart rate during the measurement period were calculated. The results demonstrated that intubation time was significantly longer in the nasal group. Both oral and nasal intubation caused significant increases in blood pressure and heart rate compared to baseline and postinduction values. However, there were no significant differences found between the two groups in relation to blood pressure and heart rate. The two groups were similar with respect to the percentage changes of systolic blood pressure and heart rate during the observation period. It is concluded that oral and nasal intubation using a direct laryngoscopy can result in a similar circulatory response in anaesthetised children.

Perioperative analgesia with continuous peripheral nerve blocks in children] Dadure C , Capdevila X . Ann Fr Anesth Reanim. 2007 Feb;26(2):136-44. Epub 2006 Dec 15.
Département d'anesthésie et de réanimation A, centre hospitalier universitaire Lapeyronie, 371, avenue du Doyen-Giraud, 34295 Montpellier, France.

Recently, regional anaesthesia in children has generated increasing interest. But single injection techniques have a limited duration of postoperative analgesia. Then, continuous peripheral nerve blocks have taken an important position in the anaesthetic arsenal, allowing an effective, safe and prolonged postoperative pain management. As adults, indications for continuous peripheral nerve blocks depend on the analysis of individual benefits/risks ratio. Main indications are intense postoperative pain surgical procedures, with or without postoperative rehabilitation, and complex regional pain syndrome. Contraindications to these procedures are rather similar to those in adults, plus parental and/or children refusal. Continuous peripheral nerve blocks are usually performed under general anaesthesia or sedation in children, and require appropriate equipment in order to decrease the risk of nerve injury. New techniques, such as transcutaneous nerve stimulation or ultrasound guidance, appeared to facilitate nerve and plexus approach identification in paediatric patients. Nevertheless, continuous peripheral nerve block may theoretically mask a compartment syndrome after trauma surgical procedures. Finally, ropivacaine appears to be the most appropriate drug for continuous peripheral nerve blocks in children, requiring low flow rates and concentrations of local anaesthetic. These techniques may facilitate early ambulation by an improved pain management or even postoperative analgesia at home with disposable pumps. One might infer from the current review that excellent pain relief coupled with a reduction of side effects would contribute to improve the quality of life and to decrease the frequency of disabling behavioural modifications in children, sometimes psychologically injured by hospital stay and postoperative pain.

Ultrasound-guided umbilical nerve block in children: a brief description of a new approach. de Jose Maria B , Götzens V , Mabrok M . Paediatr Anaesth. 2007 Jan;17(1):44-50.
Department of Pediatric Anesthesiology, Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain. bdejosemaria@hsjdbcn.org

BACKGROUND: The most popular peripheral nerve blocks used in umbilical hernia repair are rectus sheath block and paraumbilical block. However, multiple anatomic variations have been described and some complications may occur. Ultrasonographic guidance of peripheral nerve blocks has reduced the number of complications and improved the quality of blocks. This case series describes a new ultrasound-guided puncture technique of the 10th intercostal nerve in pediatric umbilical surgery. METHODS: Ten children (age range: 2-5 years) scheduled for umbilical hernia repair were included. Following the induction of general anesthesia, the ultrasonographic anatomy of the umbilical region was studied with a 10-MHz linear probe. An ultrasound-guided peripheral block of the 10th intercostal nerve in the lateral edge of both rectus abdominis muscles (RMs) was performed (total of 20 punctures). Surgical conditions, intraoperative hemodynamic parameters, and postoperative analgesia by means of the modified CHEOPS scale were evaluated. RESULTS: Umbilical anatomy was clearly identified by ultrasound in all cases. The epigastric vessels were identified--above the umbilicus--within the depth of the muscular mass of the RM. The spread of local anesthetic was ultrasound-controlled in all cases. However, the intercostal nerve could not be visualized. All blocks were effective during the surgery. Postoperative analgesia was only required in two children in the second postoperative hour. There were no complications. CONCLUSIONS: Ultrasound guidance enables performance of an effective umbilical block in the lateral edge of RM. Further studies should be carried on to visualize the intercostal nerve and to compare this technique with the classical ones.

Effectiveness of Arndt endobronchial blockers in pediatric scoliosis surgery: a case series. Bird GT , Hall M , Nel L , Davies E , Ross O . Paediatr Anaesth. 2007 Mar;17(3):289-94. Department of Anaesthetics, St Thomas' Hospital, London, UK.

BACKGROUND: Pediatric scoliosis surgery may require single lung ventilation for surgical access. Current methods of lung isolation are inadequate for some or all of these children. The Arndt endobronchial blocker (EBB) has been described for use in pediatric thoracic surgery to enable single lung ventilation (SLV). There are few data on its use in pediatric spinal deformity surgery. We report the successful use of the Arndt EBB in a series of these patients. METHODS: Any patient undergoing surgical correction of scoliosis involving a lateral thoracotomy for an anterior approach was managed with an Arndt EBB (5, 7 and 9 Fr gauge) to facilitate SLV. All cases were undertaken by a pediatric anesthetist trained in pediatric bronchoscopy; a 2.2 or 2.8 mm pediatric fiberoptic scope was used for placement and positional confirmation. RESULTS: Patients' ages and weights ranged from 18 months to 18 years, and from 9.4 to 71 kg. All had idiopathic or congenital scoliosis; one underwent a vertical expansion prosthetic titanium rib (VEPTR) procedure. In all 20 patients, placement was easily and quickly achieved with no incorrect placements. There was one displacement after inflation, quickly corrected. Right upper lobe deflation proved difficult in one patient with high take-off of the right upper lobe bronchus. The surgical field was excellent in all cases. CONCLUSIONS: In our case series, Arndt EBB provided a safe and highly effective means of single lung isolation for children undergoing pediatric scoliosis surgery.

Rapid sequence intubation without a neuromuscular blocking agent in a 14-year-old female patient with myasthenia gravis. Politis GD , Tobias JD . Paediatr Anaesth. 2007 Mar;17(3):285-8. Department of Anesthesiology, University of Virginia Health System, Charlottesville, VA, USA. gdp8a@virginia.edu

The anesthesia care of a 14-year-old female patient with an acute exacerbation of myasthenia gravis (MG) and a full stomach who required emergency surgery for placement of a hemodialysis catheter is described. A nonventilated rapid sequence induction was successful with the use of propofol, lidocaine, remifentanil, cricoid pressure and no neuromuscular blocking agent. Although the use of combinations of i.v. anesthetic agents have been suggested for tracheal intubation without the need for neuromuscular blocking agents, none of these techniques has been advocated for rapid sequence intubation. We review existing literature on the topic of tracheal intubation using remifentanil and propofol without a neuromuscular blocking agent and on the topic of tracheal intubation of patients with MG using i.v. anesthesia and no neuromuscular blocking agents.

Impact of Trendelenburg positioning on functional residual capacity and ventilation homogeneity in anaesthetised children. Regli A , Habre W , Saudan S , Mamie C , Erb TO , von Ungern-Sternberg BS ; Swiss Paediatric Respiratory Research Group . Anaesthesia. 2007 May;62(5):451-5. Department of Anaesthesia, Pharmacology and Intensive Care, University Hospitals of Geneva, Geneva, Switzerland.

Trendelenburg positioning, a head-down tilt, is routinely used in anaesthesia when inserting a central venous catheter to increase the calibre of the jugular or subclavian veins and to prevent an air embolism. We investigated the impact of Trendelenburg positioning on functional residual capacity and ventilation homogeneity as well as the potential reversibility of these changes by repositioning and/or a recruitment manoeuvre in children with congenital heart disease. Functional residual capacity and ventilation homogeneity were assessed in 20 anaesthetised children between the ages of 3 months and 8 years who required central venous catheterisation before undergoing cardiac surgery. Functional residual capacity was measured (1) in the supine position, (2) in the Trendelenburg position, (3) after repositioning supine and (4) after a recruitment manoeuvre to total lung capacity which was performed by manually elevating the airway pressure to 40 cmH(2)O for ten consecutive breaths. Adopting the Trendelenburg position led to a significant decrease in functional residual capacity (median [range]- 12 (6-21)%) and increase in lung clearance index (12 (2-19)%). Baseline values were not reached after repositioning supine in any patient until after a standardised recruitment manoeuvre was performed.

Anesthesia management of a ganglioneuroma with seizures presenting as pheochromocytoma. Batra YK , Rajeev S , Rao KL . Paediatr Anaesth. 2007 May;17(5):479-83. Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India. ykbatra@glide.net.in

Ganglioneuromas (GN) are neural crest cell-derived tumors which may coexist with pheochromocytomas, secrete various neuropeptides or the symptoms may mimic that of a pheochromocytoma, producing hypertension or a hypotensive crisis during anesthesia for these tumors. We report here the case of a 7-year-old female child with an adrenal tumor suspected to be a pheochromocytoma, later confirmed by histology as a GN. This child presented with episodic headache, anxiety, palpitations and 3D helical (spiral) computed tomography of the abdomen revealed an adrenal tumor. In addition, the child was diagnosed to have a seizure disorder. She was managed as a pheochromocytoma. Although the child's preoperative catecholamine levels were normal, tumor manipulation caused a hypertensive crisis. We discuss the clinical characteristics of this unusual case, anesthesia management, and the postoperative course.

Influence of anesthesia on immune responses and its effect on vaccination in children: review of evidence. Siebert JN , Posfay-Barbe KM , Habre W , Siegrist CA . Paediatr Anaesth 2007 May;17(5):410-20. World Health Organization Collaborating Center for Neonatal Vaccinology, Departments of Pathology and Pediatrics, University of Geneva Medical School, Geneva, Switzerland. claire-anne.siegrist@medecine.unige.ch

Anesthesia and surgery exert immunomodulatory effects and some authors argue that they may exert additive or synergistic influences on vaccine efficacy and safety. Alternatively, inflammatory responses and fever elicited by vaccines may interfere with the postoperative course. There is a lack of consensus approach among anesthesiologists to the theoretical risk of anesthesia and vaccination. Few studies have assessed the influence of anesthesia and surgery on pediatric vaccine responses. We have undertaken an extensive review of articles published in English between 1970 and 2006 meeting the criteria: measurement of immune parameters following general anesthesia in children. By searching the major medical databases (OVID Medline, PubMed, ISI Web of Science) and references cited in the articles themselves, among 277 articles obtained none examined directly the influence of anesthesia/surgery on vaccine responses. Only 16 original reports assessed the influence of several anesthetic agents on various markers of immunity including lymphocyte numbers and functions. These results are reinterpreted here in view of our current understanding of the immune mechanisms underlying vaccine efficacy and adverse events. We conclude that the immunomodulatory influence of anesthesia during elective surgery is both minor and transient (around 48 h) and that the current evidence does not provide any contraindication to the immunization of healthy children scheduled for elective surgery. However, respecting a minimal delay of 2 days (inactivated vaccines) or 14-21 days (live attenuated viral vaccines) between immunization and anesthesia may be useful to avoid the risk of misinterpretation of vaccine-driven adverse events as postoperative complications.

Spread of local anaesthetic solution in epidural space visualisation with ultrasound in single shot caudals. Raghavan K , Arnold R . Paediatr Anaesth. 2007 Jun;17(6):608-9.
Department of Anaesthesia, University Hospital Lewisham, London, UK.

Background: Ultrasonography is becoming an important adjunct in paediatric neuraxial blockade. Ultrasound guidance helps in visualisation of relevant neuraxial structures, predicting depth of epidural space from skin, reduction in bony contact and faster epidural placement. The visibility of neuraxial structures declines in patients as age increases. To date, there are no studies looking at the extent of spread of local anaesthetic solution in the epidural space and its correlation to the volume used, under ultrasound guidance. We report the results of our audit on spread of local anaesthetic solution in the epidural space in single shot caudal blocks. This abstract is based on the first 17 patients, the presentation will be based on all 50 patients. Methods: This audit was approved by the local audit committee. We aimed to follow the extent of the spread of local anaesthetic within the epidural space with real time ultrasonography. Patients were selected when the planned anaesthetic included a single shot caudal block. The anaesthetists performing the anaesthetic and the caudal block consented to our ultrasound visualisation. All patients were below 5 years of age. No attempt was made to standardise the technique, the dose, or the speed of injection. After the placement of the caudal cannula by the primary anaesthetist involved in patient care, a separate anaesthetist, experienced in using ultrasound, visualised the neuraxial structures and subsequent spread of the local anaesthetic solution with real time ultrasound. The spread was followed during the injection and for 10 s after the completion of the injection. A 5 cm 7.5-12 MHz linear array was used longitudinally with either midline or paramedian approach. Results: We are reporting the preliminary results from 17 patients. Patients were aged between 1 day and 1 year 10 months. They weighed between 3.3 kg and 14.6 kg. Either 22 gauge Jelco or Abbocath were used to perform the procedure; 0.25% or 0.20% L-bupivacaine was used on all occasions. The volume administered per kg ranged between 0.33 and 1.27 ml. The visibility of neuraxial structures was good on all occasions. On calculating the Spearmans correlation coefficient, the extent of spread of local anaesthetic in the epidural space was positively correlated with the volume used by a correlation coefficient of 0.64, with a P value of 0.008. The postoperative pain score in recovery was 0 in 16 out of the 17 cases. The one failure occurred when the observed spread would not have been expected to provide analgesia for the performed operation. Conclusions: Among children below 5 years of age, there seems to be a positive correlation between the volume of local anaesthetic injected into the epidural space and the extent of its spread. This needs to be further investigated by a prospective randomised control trial. The utility of real time ultrasound to allow a reliable achievement of a desired level of sensory block, should be investigated i.e, whether the volume used in achieving a desired level of local anaesthetic spread, as guided by ultrasound, provides superior analgesia and fewer adverse effects compared with the volume calculated using the Armitage regimen. References 1 Rapp HJ, Folger A, Grau T. Ultrasound guided epidural catheter insertion in children. Anesth Analg 2005; 101: 333-339. 2 Willschke H, Marhofer P, Bosenberg A, et al. Epidural catheter placement in children: comparing a novel approach using ultrasound guidance and a standard loss of resistance technique. Br J Anaesth 2006; 97: 200-207. 3 Marhofer P, Bosenberg A, Sitzwohl C et al. Pilot study of neuraxial imaging by ultrasound in infants and children. Pediatr Anesth 2005; 15: 671-676.

Paediatric total intravenous anaesthetic use: a nationwide study. Hill M , Peat W , Courtman S . Paediatr Anaesth. 2007 Jun;17(6):606. Derriford Hospital, Plymouth Devon, UK.

Introduction: Propofol is widely used for induction and maintenance of anaesthesia in paediatric patients. Following the initial reports of deaths following prolonged high dose infusions on intensive care (1), the propofol infusion syndrome was described (2). The exact cause of this is still uncertain but consistent biochemical abnormalities have been described (3, 4). Initially the cases were all in children on intensive care units, but more recently cases have been reported in adults. Of greater concern to paediatric anaesthetists are the reports of deaths following propofol infusions in theatre (5, 6). We set out to define the current use of propofol infusions by Paediatric Anaesthetists within the UK. Methods: A list of names and addresses of paediatric anaesthetists was composed by contacting anaesthetic departments at the hospitals by telephone and asking for the names of their paediatric anaesthetists. An 18 question survey with an enclosed stamped, addressed envelope was posted to 388 consultant paediatric anaesthetists in 51 hospitals throughout the UK. The survey was re-submitted once to consultants who had not initially replied. The results were tabulated onto a database and analysed. Results: We received a total of 242 replies (63% of surveyed population), 240 of which regularly anaesthetised children. Within the last year 13% had used propofol infusions on children under 1, 31% in children 1-5 years, 41% in children 5-10 years and 46% in the over 10 s. The two most common surgical specialties with which propofol TIVA was used were ENT (n = 66), and orthopaedics (n = 53), the most common operations stated being middle ear surgery, muscle biopsy and scoliosis surgery. The reasons for using propofol in these patients were broad and included both anaesthetic and surgical considerations. 60 consultants questioned used propofol infusions in children at least monthly, 98 rarely and 72 never. Over 50% of replies believed that propofol infusions reduced the rate of postoperative nausea and vomiting in respect to inhalational techniques, less agreed that there was faster recovery time or time to discharge. Remifentanil was commonly used with propofol infusions but target controlled infusion devices were uncommonly used. The longest time anyone considered using propofol for was 72 h, although the mode of all positive responses was 6 h. The majority of people failed to give a maximum infusion rate. Conclusions: Propofol infusions are used widely throughout the UK for their perceived anaesthetic and surgical benefits. Given that there are well documented catastrophic, albeit rare side effects, it is surprising that there are no guidelines for infusions in theatre. Further work is required to elucidate the exact mechanism of propofol infusion syndrome to guide future anaesthetic practice. References 1 Parke TJ, Stevens JE, Rice AS et al. Metabolic acidosis and fatal myocardial failure after propofol infusion in children: five case reports. Br Med J 1992; 305: 613-616. 2 Bray RJ. Propofol infusion syndrome in children. Paediatr Anaes 1998; 8: 491-499. 3 Wolf AR, Weir P, Segar P, et al. Impaired fatty acid oxidation in propofol infusion syndrome. Lancet 2001; 357: 606-607. 4 Wolf AR, Potter F. Propofol infusion in children: when does an anesthetic tool become an intensive care liability? Paediatr Anaesth 2004; 14: 435-438. 5 Mehta N, DeMunter C, Habibi P et al. Short-term propofol infusions in children. Lancet 1999; 354: 866-867. 6 Kill C, Leonhardt A, Wulf H. Lacticacidosis after short-term infusion of propofol for anaesthesia in a child with osteogenesis imperfecta. Paediatr Anaesth 2003; 13: 823-826.

The effects of sevoflurane and desflurane anesthesia on QTc interval and cardiac rhythm in children. Aypar E , Karagoz AH , Ozer S , Celiker A , Ocal T . Paediatr Anaesth. 2007 Jun;17(6):563-7. Section of Pediatric Cardiology, Department of Pediatrics, Hacettepe University Faculty of Medicine, Ankara, Turkey.

BACKGROUND: Inhalational anesthetics may prolong QTc interval (QT interval corrected for heart rate) of the ECG and cause life-threatening arrythmias. The effects of desflurane on QTc interval and cardiac rhythm have not been reported previously in children. We assessed the effects of desflurane anesthesia on QTc interval and cardiac rhythm and compared them with sevoflurane anesthesia in children. METHODS: The study was performed on 20 children admitted for inguinal hernia repair, with normal QTc intervals. Anesthesia was induced with propofol and intubation was achieved with vecuronium. Anesthesia was maintained with 2% sevoflurane (group I, n = 11) or 6% desflurane (group II, n = 9) and 66% nitrous oxide in oxygen. Electrocardiogram recordings were obtained by Holter recorder. QTc intervals were measured at baseline, 5, 10, 15, and 30 min after inhalation. RESULTS: None of the patients had significant arrythmia with desflurane anesthesia. One patient in the sevoflurane group had single, bigemini and multiform ventricular extrasystoles. There was no statistically significant difference in the baseline QTc values of the groups. Desflurane significantly prolonged QTc interval 5 min after induction until 30 min of anesthesia compared with baseline values (P = 0.029), while no significant prolongation was observed with sevoflurane (P = 0.141). CONCLUSIONS: Use of 2% sevoflurane during maintenance of anesthesia does not significantly prolong QTc interval while 6% desflurane significantly prolonged QTc interval in children with normal QTc interval undergoing inguinal herniorrhaphy.

Safety and efficacy of patient controlled epidural analgesia following pediatric spine surgery. Saudan S , von Ungern-Sternberg BS , Ceroni D , Meyer PA , Kaelin A , Habre W . Paediatr Anaesth. 2007 Jun;17(6):610-1. Paediatric Anaesthesia Unit, Geneva Children's Hospital, Geneva, Switzerland.

Background: Patient controlled epidural analgesia (PCEA) is uncommon in paediatric anaesthesia particularly for extensive spinal surgery. Since PCEA has been shown to offer superior pain control compared with continuous epidural infusions in adults, we prospectively evaluated the analgesia efficacy and safety of PCEA in children and adolescents following extensive spinal surgery. Methods: Following approval of the local Ethics Committee, 100 consecutive children [age median (range) 14 (6-19) years] undergoing spinal surgery were included, and 98 children benefited from PCEA. One or two epidural catheters were set in place by the surgeon under direct vision based on the number of vertebral segments operated. The epidural solution consisted of bupivacaine 0.0625%, fentanyl 1 mug.ml(-1) and clonidine 0.6 mug.ml(-1), delivered at a rate of 0.2 ml.kg(-1).h(-1 )and a bolus of 0.1 ml.kg(-1).h(-1 )(max 2 per h). On the 4th postoperative day, PCEA was stopped and analgesia was continued with patient controlled analgesia with morphine (PCA). After surgery, all patients were followed by the paediatric anaesthesia acute pain team for the duration of the administration of the PCEA (day 1-4) and PCA morphine (day 4-7). Pain was assessed at rest every 6 h and during mobilization every 24 h by the means of the Revised Facial Scale (RFS). All patients were continuously monitored with pulse oximetry, and every 6 h the respiratory frequency was assessed. The Bromage scale was used to evaluate motor blockade (0 = no paralysis; 1 = inability to lift the thigh; 2 = inability to flex the knee; 3 = inability to move any joint in the legs). The occurrence of postoperative nausea and vomiting (PONV), pruritus, cardiac and pulmonary complications were reported. Results: During the PCEA regimen, the maximal scores of the revised facial scale were below four at rest with a very high satisfaction rate (>90%). Pain scores were higher during mobilization on the first postoperative day and when PCEA was switched to PCA (Table 1). The overall incidence of adverse events was low and consisted primarily in technical problems and postoperative nausea and vomiting (Table 2). Only two children experienced a complication requiring the discontinuation of the PCEA but there were no consequent adverse sequelae: One child with known childhood epilepsy presented with a focal epileptic episode and one child had a suspected leak of the anaesthetic solution into the spinal space. The switch from PCEA to PCA was associated with a significant increase in PONV values as well as a decrease in satisfaction rates from 98% to 83%. Conclusions: The present study demonstrates that PCEA provides excellent pain relief following extensive spinal surgery and is associated with a low incidence of adverse events. Therefore, the use of PCEA should be encouraged in children and adolescents following extensive spine surgery.

Spread of local anaesthetic solution in epidural space visualisation with ultrasound in single shot caudals. Raghavan K , Arnold R . Paediatr Anaesth. 2007 Jun;17(6):608-9.
Department of Anaesthesia, University Hospital Lewisham, London, UK.

Background: Ultrasonography is becoming an important adjunct in paediatric neuraxial blockade. Ultrasound guidance helps in visualisation of relevant neuraxial structures, predicting depth of epidural space from skin, reduction in bony contact and faster epidural placement. The visibility of neuraxial structures declines in patients as age increases. To date, there are no studies looking at the extent of spread of local anaesthetic solution in the epidural space and its correlation to the volume used, under ultrasound guidance. We report the results of our audit on spread of local anaesthetic solution in the epidural space in single shot caudal blocks. This abstract is based on the first 17 patients, the presentation will be based on all 50 patients. Methods: This audit was approved by the local audit committee. We aimed to follow the extent of the spread of local anaesthetic within the epidural space with real time ultrasonography. Patients were selected when the planned anaesthetic included a single shot caudal block. The anaesthetists performing the anaesthetic and the caudal block consented to our ultrasound visualisation. All patients were below 5 years of age. No attempt was made to standardise the technique, the dose, or the speed of injection. After the placement of the caudal cannula by the primary anaesthetist involved in patient care, a separate anaesthetist, experienced in using ultrasound, visualised the neuraxial structures and subsequent spread of the local anaesthetic solution with real time ultrasound. The spread was followed during the injection and for 10 s after the completion of the injection. A 5 cm 7.5-12 MHz linear array was used longitudinally with either midline or paramedian approach. Results: We are reporting the preliminary results from 17 patients. Patients were aged between 1 day and 1 year 10 months. They weighed between 3.3 kg and 14.6 kg. Either 22 gauge Jelco or Abbocath were used to perform the procedure; 0.25% or 0.20% L-bupivacaine was used on all occasions. The volume administered per kg ranged between 0.33 and 1.27 ml. The visibility of neuraxial structures was good on all occasions. On calculating the Spearmans correlation coefficient, the extent of spread of local anaesthetic in the epidural space was positively correlated with the volume used by a correlation coefficient of 0.64, with a P value of 0.008. The postoperative pain score in recovery was 0 in 16 out of the 17 cases. The one failure occurred when the observed spread would not have been expected to provide analgesia for the performed operation. Conclusions: Among children below 5 years of age, there seems to be a positive correlation between the volume of local anaesthetic injected into the epidural space and the extent of its spread. This needs to be further investigated by a prospective randomised control trial. The utility of real time ultrasound to allow a reliable achievement of a desired level of sensory block, should be investigated i.e, whether the volume used in achieving a desired level of local anaesthetic spread, as guided by ultrasound, provides superior analgesia and fewer adverse effects compared with the volume calculated using the Armitage regimen. References 1 Rapp HJ, Folger A, Grau T. Ultrasound guided epidural catheter insertion in children. Anesth Analg 2005; 101: 333-339. 2 Willschke H, Marhofer P, Bosenberg A, et al. Epidural catheter placement in children: comparing a novel approach using ultrasound guidance and a standard loss of resistance technique. Br J Anaesth 2006; 97: 200-207. 3 Marhofer P, Bosenberg A, Sitzwohl C et al. Pilot study of neuraxial imaging by ultrasound in infants and children. Pediatr Anesth 2005; 15: 671-676.

Paediatric total intravenous anaesthetic use: a nationwide study. Hill M , Peat W , Courtman S . Paediatr Anaesth. 2007 Jun;17(6):606. Derriford Hospital, Plymouth Devon, UK.

Introduction: Propofol is widely used for induction and maintenance of anaesthesia in paediatric patients. Following the initial reports of deaths following prolonged high dose infusions on intensive care (1), the propofol infusion syndrome was described (2). The exact cause of this is still uncertain but consistent biochemical abnormalities have been described (3, 4). Initially the cases were all in children on intensive care units, but more recently cases have been reported in adults. Of greater concern to paediatric anaesthetists are the reports of deaths following propofol infusions in theatre (5, 6). We set out to define the current use of propofol infusions by Paediatric Anaesthetists within the UK. Methods: A list of names and addresses of paediatric anaesthetists was composed by contacting anaesthetic departments at the hospitals by telephone and asking for the names of their paediatric anaesthetists. An 18 question survey with an enclosed stamped, addressed envelope was posted to 388 consultant paediatric anaesthetists in 51 hospitals throughout the UK. The survey was re-submitted once to consultants who had not initially replied. The results were tabulated onto a database and analysed. Results: We received a total of 242 replies (63% of surveyed population), 240 of which regularly anaesthetised children. Within the last year 13% had used propofol infusions on children under 1, 31% in children 1-5 years, 41% in children 5-10 years and 46% in the over 10 s. The two most common surgical specialties with which propofol TIVA was used were ENT (n = 66), and orthopaedics (n = 53), the most common operations stated being middle ear surgery, muscle biopsy and scoliosis surgery. The reasons for using propofol in these patients were broad and included both anaesthetic and surgical considerations. 60 consultants questioned used propofol infusions in children at least monthly, 98 rarely and 72 never. Over 50% of replies believed that propofol infusions reduced the rate of postoperative nausea and vomiting in respect to inhalational techniques, less agreed that there was faster recovery time or time to discharge. Remifentanil was commonly used with propofol infusions but target controlled infusion devices were uncommonly used. The longest time anyone considered using propofol for was 72 h, although the mode of all positive responses was 6 h. The majority of people failed to give a maximum infusion rate. Conclusions: Propofol infusions are used widely throughout the UK for their perceived anaesthetic and surgical benefits. Given that there are well documented catastrophic, albeit rare side effects, it is surprising that there are no guidelines for infusions in theatre. Further work is required to elucidate the exact mechanism of propofol infusion syndrome to guide future anaesthetic practice. References 1 Parke TJ, Stevens JE, Rice AS et al. Metabolic acidosis and fatal myocardial failure after propofol infusion in children: five case reports. Br Med J 1992; 305: 613-616. 2 Bray RJ. Propofol infusion syndrome in children. Paediatr Anaes 1998; 8: 491-499. 3 Wolf AR, Weir P, Segar P, et al. Impaired fatty acid oxidation in propofol infusion syndrome. Lancet 2001; 357: 606-607. 4 Wolf AR, Potter F. Propofol infusion in children: when does an anesthetic tool become an intensive care liability? Paediatr Anaesth 2004; 14: 435-438. 5 Mehta N, DeMunter C, Habibi P et al. Short-term propofol infusions in children. Lancet 1999; 354: 866-867. 6 Kill C, Leonhardt A, Wulf H. Lacticacidosis after short-term infusion of propofol for anaesthesia in a child with osteogenesis imperfecta. Paediatr Anaesth 2003; 13: 823-826.

The effects of sevoflurane and desflurane anesthesia on QTc interval and cardiac rhythm in children. Aypar E , Karagoz AH , Ozer S , Celiker A , Ocal T . Paediatr Anaesth. 2007 Jun;17(6):563-7. Section of Pediatric Cardiology, Department of Pediatrics, Hacettepe University Faculty of Medicine, Ankara, Turkey.

BACKGROUND: Inhalational anesthetics may prolong QTc interval (QT interval corrected for heart rate) of the ECG and cause life-threatening arrythmias. The effects of desflurane on QTc interval and cardiac rhythm have not been reported previously in children. We assessed the effects of desflurane anesthesia on QTc interval and cardiac rhythm and compared them with sevoflurane anesthesia in children. METHODS: The study was performed on 20 children admitted for inguinal hernia repair, with normal QTc intervals. Anesthesia was induced with propofol and intubation was achieved with vecuronium. Anesthesia was maintained with 2% sevoflurane (group I, n = 11) or 6% desflurane (group II, n = 9) and 66% nitrous oxide in oxygen. Electrocardiogram recordings were obtained by Holter recorder. QTc intervals were measured at baseline, 5, 10, 15, and 30 min after inhalation. RESULTS: None of the patients had significant arrythmia with desflurane anesthesia. One patient in the sevoflurane group had single, bigemini and multiform ventricular extrasystoles. There was no statistically significant difference in the baseline QTc values of the groups. Desflurane significantly prolonged QTc interval 5 min after induction until 30 min of anesthesia compared with baseline values (P = 0.029), while no significant prolongation was observed with sevoflurane (P = 0.141). CONCLUSIONS: Use of 2% sevoflurane during maintenance of anesthesia does not significantly prolong QTc interval while 6% desflurane significantly prolonged QTc interval in children with normal QTc interval undergoing inguinal herniorrhaphy.

Anaesthetic agents in children: risk or benefit? Constant I . Ann Fr Anesth Reanim. 2007 Jun;26(6):516-23. Epub 2007 May 22. Service d'anesthésie-réanimation, hôpital Armand-Trousseau, Paris, France. isabelle.constant@trs.aphp.fr <isabelle.constant@trs.aphp.fr>

The practice of paediatric anaesthesia has changed during the last 25 years, with a noticeable reduction of mortality and serious morbidity. This improvement results in part from the use of new anaesthetic agents which large therapeutic interval regarding cardiovascular effects. Parallel to this advance and following experimental or clinical studies in neurosciences, some new concerns have emerged regarding short and long time consequences of anaesthesia. Indeed, postoperative hyperalgesia due to opioids, emergence agitation and postoperative maladaptive behavioural changes are widely described in children, in the same way the potential epileptogenic effect of sevoflurane is demonstrated. Thus the hypothetical cerebral toxicity leads us to reconsider our practice. Basically, monitoring of cerebral cortical effects of hypnotics is now possible from automated devices based on EEG, allowing us to control the administration of hypnotic agents. The therapeutic interval of these agents, previously determined between movement at incision and deleterious cardiovascular effect, may be revisited with a cerebral approach, with the risk of memorisation for the lower limit and the risk of cerebral over dosage for the upper limit. Lastly, further experimental and clinical studies are required to analyse the effects of the anaesthetic agents on the brain of the neonate, and the interest of the cerebral monitoring in this population.

Spinal anesthesia in neonates and infants - a single-center experience of 505 cases. Kachko L , Simhi E , Tzeitlin E , Efrat R , Tarabikin E , Peled E , Metzner I , Katz J . Paediatr Anaesth. 2007 Jul;17(7):647-53. Department of Anesthesia, Schneider Children's Medical Center of Israel, Petah Tiqwa and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

Background: Our aim was to assess the safety and efficacy of spinal anesthesia (SA) in newborns and infants undergoing surgery appropriate for this technique. Methods: The files of 505 patients who underwent surgery under spinal anesthesia since 1998 at a major tertiary hospital in Israel were analyzed retrospectively. SA was performed with bupivacaine 5 mg.ml(-1) by attending pediatric anesthesiologists or an anesthesia resident. Demographic data, prematurity history, comorbidities, technical data, cardiovascular stability, complications and supplementary drugs were documented. The surgeon assessed the quality of anesthesia at the end of surgery. Results: Appropriate SA was achieved in 95.3% of cases; in 69.9% at the first attempt. The mean number of attempts per patient was 1.41 and mean dose of bupivacaine was 0.66 +/- 0.16 mg.kg(-1). Intravenous sedation, usually with midazolam (dose 0.1-0.2 mg.kg(-1)) was required in 28.1% of children because of crying/restlessness. Intraoperative conversion to general anesthesia was necessary in five patients (1.04%). The main side effect was bradycardia (<100 b.min(-1)) without desaturation which occurred in nine patients (1.8%). In three patients (0.62%), high spinal block occurred without bradycardia and hypotension. None of the patients had postoperative meningitis. Conclusions: SA is safe and effective in newborns and infants undergoing low abdominal, perineal and orthopedic surgery. In order to save time, our advice is to attempt SA after the surgeon is scrubbed, and minimize surgical teaching activity. The need to deal with a small and sometimes sick patient independent of the type of anesthesia requires the presence of an experienced pediatric anesthesiologist.

The transesophageal Doppler and hemodynamic effects of epidural anesthesia in infants anesthetized with sevoflurane and sufentanil. Monsel A , Salvat-Toussaint A , Durand P , Haas V , Baujard C , Rouleau P , El Aouadi S , Benhamou D , Asehnoune K . Anesth Analg. 2007 Jul;105(1):46-50. Service d'Anesthésie-Réanimation et Unité Propre de Recherche de l'Enseignement Supérieur-Equipe d'Accueil (UPRES-EA 392), Le Kremlin Bicêtre, France.

BACKGROUND: It is thought that pediatric epidural anesthesia (EA) provides hemodynamic stability in children. However, when compared with information relating to adults, little is known about the hemodynamic effects of epidural EA on cardiac output (CO) in infants. METHODS: Using transesophageal Doppler to monitor CO, we prospectively studied 14 infants <10 kg who were scheduled for abdominal surgery. During sevoflurane general anesthesia, CO transesophageal Doppler monitoring was performed before and after lumbar EA with 0.75 mL/kg of 0.25% bupivacaine and 1:200,000 adrenaline. CO, arterial blood pressure, and heart rate were measured before and 5, 15, and 20 min after performance of EA. RESULTS: In patients anesthetized with sevoflurane and sufentanil, EA resulted in an increase in stroke volume by 29% (P < 0.0001) and a decrease in heart rate by 13% (P < 0.0001). EA also induced a significant decrease in systolic, diastolic, mean arterial blood pressure, and systemic vascular resistance by 11%, 18%, 15%, and 25%, respectively. Conversely, CO remained unchanged. CONCLUSIONS: The increase in stroke volume observed is probably explained by optimization of afterload because of the sympathetic blockade induced by EA. These results confirm that EA provides hemodynamic stability in infants weighing <10 kg and supports the use of EA in this pediatric population.

Prepuncture ultrasound-measured distance: an accurate reflection of epidural depth in infants and small children. Kil HK , Cho JE , Kim WO , Koo BN , Han SW , Kim JY . Reg Anesth Pain Med. 2007 Mar-Apr;32(2):102-6. Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea. hkkil@yumc.yonsei.ac.kr

BACKGROUND AND OBJECTIVES: Epidural cannulation is technically difficult in children who have small anatomic structures. Ultrasound information regarding the distance of skin-to-ligament flavum may be useful, leading to an increase in success rate without dural puncture. This study was performed to assess whether ultrasound-measured, skin-to-ligament flavum distance would reflect the needle depth during epidural puncture in infants and children. METHODS: The study compromised 180 children, aged 2 to 84 months, undergoing urologic surgery. After induction of anesthesia, ultrasound images of the longitudinal median and transverse views were acquired from L4-L5 in lateral decubitus position. Measured distance of skin-to-ligament flavum in each view was compared with the perpendicular skin-to-epidural depth, which was obtained from needle depth and angle by use of a trigonometric ratio equation. Additionally, we evaluated the ultrasound visibility of the ligament flavum and dura mater, number of puncture attempts, and complications. RESULTS: The correlation coefficient between measured distance and perpendicular epidural depth was slightly higher in longitudinal median view (R2 = 0.848) than in transverse view (R2 = 0.788). The visibility of ligament flavum and dura mater was "good" in 91 and 170 of 180 patients, respectively, and "sufficient" in the remaining subjects. The epidural space was located on first puncture attempt in 179 of 180 cases (99.4%). No incidents of dural puncture or bloody tap occurred. CONCLUSIONS: Ultrasound, particularly in the longitudinal median view, provides accurate information on the distance of skin-to-ligament flavum in infants and children. With reference to the measured distance, epidural puncture can be performed with minimal risk of dural puncture (upper limit of 95% CI = 1.67%).

Ultrasonographic guidance for sciatic and femoral nerve blocks in children. Br J Anaesth. 2007 Jun;98(6):797-801. Epub 2007 Apr 21. Oberndorfer U , Marhofer P , Bösenberg A , Willschke H , Felfernig M , Weintraud M , Kapral S , Kettner SC . Department of Anaesthesia and Intensive Care Medicine, Medical University Vienna, Währinger Gürtel 18-20, A-1090 Vienna, Austria.

BACKGROUND: Recent studies have shown that ultrasound guidance for paediatric regional anaesthesia can improve the quality of upper extremity and neuraxial blocks. We therefore investigated whether ultrasound guidance for sciatic and femoral nerve blocks prolongs sensory blockade in comparison with nerve stimulator guidance in children. METHODS: Forty-six children scheduled for surgery of one lower extremity were randomized to receive a sciatic and femoral nerve block under either ultrasound or nerve stimulator guidance. After induction of general anaesthesia, the blocks were performed using an ultrasound-guided multiple injection technique until the nerves were surrounded by levobupivacaine, or by nerve stimulator guidance using a predefined dose of 0.3 ml kg(-1) of levobupivacaine. An increase in heart rate of more than 15% of baseline during surgery defined a failed block. The duration of the block was determined from the injection of local anaesthetic to the time when the patient received the first postoperative analgesic. RESULTS: Two blocks in the nerve stimulator group failed. There were no failures in the ultrasound group. The duration of analgesia was longer in the ultrasound group mean (sd) 508 (178) vs 335 (169) min (P < 0.05). The volume of local anaesthetic in sciatic and femoral nerve blocks was reduced with ultrasound compared with nerve stimulator guidance [0.2 (0.06) vs 0.3 ml kg(-1) (P < 0.001) and 0.15 (0.04) vs 0.3 ml kg(-1) (P < 0.001), respectively]. CONCLUSIONS: Ultrasound guidance for sciatic and femoral nerve blocks in children increased the duration of sensory blockade in comparison with nerve stimulator guidance. Prolonged sensory blockade was achieved with smaller volumes of local anaesthetic when using ultrasound guidance.

Superior anti-emetic efficacy of granisetron-dexamethasone combination in children undergoing middle ear surgery. Gombar S , Kaur J , Kumar Gombar K , Dass A , Singh A . Acta Anaesthesiol Scand. 2007 May;51(5):621-4. Department of Anaesthesia and Intensive Care, Government Medical College and Hospital, #1111, Sector 32B, Chandigarh 160031, India. dr_sgombar@rediffmail.com

AIM: To compare the effectiveness of granisetron and a granisetron-dexamethasone combination for the prevention of post-operative vomiting in children undergoing middle ear surgery. METHODS: Ninety ASA physical status I or II children, aged 3-12 years, were randomly assigned to three groups of 30 each to receive a single dose of placebo (normal saline), granisetron 40 microg/kg or a combination of granisetron 40 microg/kg and dexamethasone 150 microg/kg intravenously after the induction of anaesthesia. Peri-operative anaesthetic care was standardized in all children. Post-operatively, during the first 24 h after anaesthesia, the frequencies of retching and vomiting and the incidence of adverse events were recorded. Rescue anti-emetic was administered if two or more episodes of emesis occurred. Post-operative pain was treated with morphine intravenously, followed by acetaminophen orally. RESULTS: There were no differences between the treatment groups with regard to demographic data. A complete response (no retching/vomiting and no need for rescue anti-emetic) was achieved in 50%, 80% and 96.67% of children who received saline, granisetron and granisetron-dexamethasone, respectively (P < 0.05). Six children who received placebo and one who received granisetron alone required another rescue anti-emetic. The incidence of adverse events was comparable in the three groups. CONCLUSION: The prophylactic granisetron-dexamethasone combination was more effective than granisetron alone in the prevention of post-operative emesis during the first 24 h after anaesthesia in children undergoing middle ear surgery.

Propofol and remifentanil for deep sedation in children undergoing gastrointestinal endoscopy. Abu-Shahwan I , Mack D . Paediatr Anaesth. 2007 May;17(5):460-3. Department of Anesthesiology, Children's Hospital of Eastern Ontario, 401 Smyth Rd, University of Ottawa, Ottawa, ON, Canada K1H 8L1. iabushahwan@cheo.on.ca

PURPOSE: The aim of this study was to evaluate the safety and efficacy of a combination of propofol and remifentanil deep sedation in spontaneously breathing children less than 7 years of age undergoing upper and/or lower gastrointestinal endoscopy. METHODS: The effect of propofol and remifentanil sedation was prospectively studied in 42 unpremedicated children undergoing gastrointestinal endoscopy. Anesthesia was induced with a combination of sevoflurane, nitrous oxide and oxygen. Anesthesia was maintained with an infusion of propofol (50-80 microg x kg(-1) x min(-1)) and remifentanil (0.1 microg x kg(-1) x min(-1)). Demographic data, heart rate, blood pressure, respiratory rate, and oxygen saturation were recorded every 5 min for each child. In addition, recovery and discharge times were recorded. RESULTS: All 42 procedures were completed with no complications. The combination of propofol and remifentanil resulted in a decrease in heart rate, blood pressure, and respiratory rate. There was no respiratory depression or oxygen desaturation in any child. A bolus of propofol (1 mg x kg(-1)) was necessary in one child for excessive movement. No patient experienced any side effects in the recovery period. CONCLUSION: The combination of propofol and remifentanil for sedation in children undergoing gastrointestinal endoscopy can be considered safe, effective and acceptable.

AEP-monitor/2 derived, composite auditory evoked potential index (AAI-1.6) and bispectral index as predictors of sevoflurane concentration in children. Ironfield CM , Davidson AJ . Paediatr Anaesth. 2007 May;17(5):452-9. Department of Anaesthesia & Pain Management, Royal Children's Hospital, Melbourne, Australia.

BACKGROUND: Level of anesthesia may be predicted with the auditory evoked potential or with passive processed electroencephalogram (EEG) parameters. Some previous reports suggest the passive EEG does not reliably predict level of anesthesia in infants. The AAI-1.6 is a relatively new index derived from the AEP/2 monitor. It combines auditory evoked potentials and passive EEG parameters into a single index. This study aimed to assess the AAI-1.6 as a predictor of level of anesthesia in infants and children. METHODS: Four infants aged less than 1 year, and five older children aged between 2 and 11 years were enrolled. They all had uniform sevoflurane anesthesia for cardiac catheterization. The AAI-1.6 and bispectral index (BIS) were recorded after achieving equilibrium at 1.5%, 2% and 2.5% sevoflurane, and immediately prior to awakening. The prediction coefficient (Pk) for BIS and AAI-1.6 was calculated and compared within each age group. RESULTS: The Pk for the AAI-1.6 was low in both 0-1 and 2-11 years age groups. In the 2-12 years group, the Pk for BIS was significantly higher than the Pk for the AAI-1.6 (Pk for BIS: 0.89, Pk for AAI-1.6: 0.53, P < 0.01). In contrast in the 0-1 year age group there was no evidence for a difference between the Pk for BIS and the Pk for the AAI-1.6 (Pk for BIS: 0.74, Pk for AAI-1.6: 0.53, P = 0.25). CONCLUSIONS: This preliminary study suggests AAI-1.6 is a poor predictor of sevoflurane concentration in infants and children.

Clonidine 1 microg/kg is a safe and effective adjuvant to plain bupivacaine in spinal anesthesia in adolescents. Kaabachi O , Zarghouni A , Ouezini R , Abdelaziz AB , Chattaoui O , Kokki H . Anesth Analg. 2007 Aug;105(2):516-9. Department of Anesthesiology and Intensive Care, Kassab Orthopedic Institute, Tunis, Tunisia.

BACKGROUND: Spinal anesthesia is increasingly used in adolescents. However, the anesthesia provided by bupivacaine alone may be too short for the planned surgery. The addition of clonidine 2 microg/kg to bupivacaine provides a prolonged anesthetic action but may be associated with hypotension. In the present study, we investigated the efficacy and safety of intrathecal clonidine 1 mug/kg in adjunction to bupivacaine in spinal anesthesia in adolescents. METHODS: Eighty-three adolescents, 51 males, aged 10-15 yr, scheduled for orthopedic surgery were enrolled in this placebo-controlled, randomized study. Patients were given spinal anesthesia either with plain 0.5% isobaric bupivacaine 0.2-0.4 mg/kg or bupivacaine with clonidine 1 microg/kg. The duration of sensory block was the primary outcome measure. RESULTS: Clonidine prolonged the duration of both the sensory and motor block. The time to regression of sensory block by two dermatomes was 136 (mean) (sd, 56) min in the adolescents with clonidine versus 107 min (sd, 42) in the controls (95% CI for diff: 5-53 min, P = 0.02). The time to full recovery of motor block was 251 min (sd, 79) in the adolescents with clonidine versus 181 min (sd, 59) in the controls (95% CI: 39-103 min, P = 0.001). Time to the first dose of rescue analgesia was longer in the adolescents with clonidine, 461 min (sd, 147) versus 330 min (sd, 138) in the controls (95% CI: 53-207 min, P = 0.01). There was no difference in the frequency of hypotension or bradycardia between the groups. CONCLUSION: In adolescents, clonidine 1 microg/kg prolonged the duration of sensory block achieved with bupivacaine by 30 min and postoperative analgesia by 120 min without severe adverse events.

The anesthetic management of children with neonatal-onset multi-system inflammatory disease. Lauro CF , Goldbach-Mansky R , Schmidt M , Quezado ZM . Anesth Analg. 2007 Aug;105(2):351-7. Department of Anesthesia and Surgical Services, National Institutes of Health Clinical Center, National Institutes of Health, Bethesda, MD 20892-1512, USA.

BACKGROUND: Neonatal-onset multi-system inflammatory disease (NOMID), a rare autosomal dominantly inherited disease, belongs to a growing spectrum of autoinflammatory diseases, is characterized by urticarial rash, arthropathy, and chronic aseptic meningitis, and is associated with mutations in the cold-induced autoinflammatory gene, CIAS1, the gene that encodes the protein, cryopyrin. As little is known about the anesthetic considerations of the disease, we sought to identify the main features and respective anesthetic and perioperative implications of NOMID. METHODS: We examined perianesthetic records of children with NOMID who were anesthetized for invasive diagnostic and therapeutic interventions between 2003 and 2006. In addition, we conducted an extensive literature review of the genetic, clinical, and biochemical abnormalities of the disease. RESULTS: Seventeen children with NOMID (median age 8 yr, range 9 mo to 11 yr) were anesthetized for diagnostic and therapeutic procedures. All patients had neurological involvement, including increased intracranial pressure, chronic aseptic meningitis, and developmental delay; 7 had bony overgrowth, 15 ocular, and 14 otological manifestations of NOMID. Despite the complexity of the disease, the perioperative course was uncomplicated, and no serious adverse events were observed. CONCLUSIONS: This study is the first to investigate the anesthetic implications of NOMID, an autoinflammatory disease associated with arthropathy, recurrent fevers, urticarial rash, and chronic aseptic meningitis. While for the pediatric anesthesiologist, the presence of fever and aseptic meningitis might make the conduct of anesthetics for elective procedures less desirable, our findings suggest that without evidence of active infection, even in the presence of fever and chronic aseptic meningitis, general and regional anesthesia may be conducted in patients with NOMID without untoward complications.

BACKGROUND: The initial findings from the Pediatric Perioperative Cardiac Arrest (POCA) Registry (1994-1997) revealed that medication-related causes, often cardiovascular depression from halothane, were the most common. Changes in pediatric anesthesia practice may have altered the causes of cardiac arrest in anesthetized children. METHODS: Nearly 80 North American institutions that provide anesthesia for children voluntarily enrolled in the Pediatric Perioperative Cardiac Arrest Registry. A standardized data form for each perioperative cardiac arrest in children </=18 yr of age was submitted anonymously. We analyzed causes of anesthesia-related cardiac arrests and related factors in 1998-2004. RESULTS: From 1998 to 2004, 193 arrests (49%) were related to anesthesia. Medication-related arrests accounted for 18% of all arrests, compared with 37% from 1994 to 1997 (P < 0.05). Cardiovascular causes of cardiac arrest were the most common (41% of all arrests), with hypovolemia from blood loss and hyperkalemia from transfusion of stored blood the most common identifiable cardiovascular causes. Among respiratory causes of arrest (27%), airway obstruction from laryngospasm was the most common cause. Vascular injury incurred during placement of central venous catheters was the most common equipment-related cause of arrest. The cause of arrest varied by phase of anesthesia care (P < 0.01). Cardiovascular and respiratory causes occurred most commonly in the surgical and postsurgical phases, respectively. CONCLUSIONS: A reduction in the proportion of arrests related to cardiovascular depression due to halothane may be related to the declining use of halothane in pediatric anesthetic practice. The incidence of the most common remaining causes of arrest in each category may be reduced through preventive measures.

Does adding intravenous fentanyl to caudal block in children enhance the efficacy of multimodal analgesia as reflected in the plasma level of catecholamines? Somri M , Tome R , Teszler CB , Vaida SJ , Mogilner J , Shneeifi A , Nurit L , Avital G , Zinder O , Gaitini LA . Eur J Anaesthesiol. 2007 May;24(5):408-13. Epub 2006 Nov 7. Technion - Israel Institute of Technology, Bruce Rappaport Faculty of Medicine, Anaesthesiology Department, Bnai-Zion Medical Center, Haifa, Israel. somri_m@yahoo.com

BACKGROUND AND OBJECTIVE: Several studies showed that single analgesic modality management can attenuate perioperative stress, but little is known about the effect of multimodal analgesia on catecholamine responses to surgical trauma in children. METHODS: Fifty children (American Society of Anesthesiologists Grade I or II) were randomly allocated to one of two groups: one received general anaesthesia and a caudal block (control group), and one group was given general anaesthesia, caudal block and intravenous (i.v.) fentanyl 2 microg kg(-1) (fentanyl group). Plasma epinephrine and norepinephrine concentrations were measured three times during the perioperative period: at induction time (T(0)), at the end of surgery (T(1)) and when the children were fully awake in the postanaesthesia care unit (T(2)). RESULTS: There was a significant reduction in the catecholamine levels in the two groups when (T(1)) and (T(2)) were compared with T(0). When plasma epinephrine levels (at T(0), T(1) and T(2)) between the two groups were compared, a statistically significant reduction at T(2) was obtained in the fentanyl group, when compared with the control group. However, plasma norepinephrine levels showed no statistically significant difference between the two groups (at T(0), T(1) and T(2)). CONCLUSION: These findings suggest that the multimodal analgesic approach of adding i.v. low-dose fentanyl to a caudal block may decrease the plasma epinephrine release in children undergoing inguinal herniotomy.

Is a fall in baseline heart rate a reliable predictor of a successful single shot caudal epidural in children? Ghai B , Makkar JK , Behra BK , Rao KP . Paediatr Anaesth. 2007 Jun;17(6):552-6. Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India. ghaibabita@hotmail.com

BACKGROUND: This study was designed to investigate whether a fall in heart rate (HR) with injection of local anesthetic into the caudal space can be used as a predictor of correct needle placement. METHODS: Two hundred and twenty pediatric patients undergoing infraumbilical surgery were recruited to the study. After induction of general anesthesia, baseline HR was recorded and caudal block was performed using 0.75-1 ml x kg(-1) 0.25% bupivacaine, which was injected at a rate of 1 ml x 3 s(-1). The change in HR while injecting an initial 0.2 ml x kg(-1) of drug and during total drug injection was recorded. HR reduction of > or = 3 b x min(-1) was considered a positive test for correct needle placement. The success of block was judged by HR response to skin incision, endtidal halothane concentration required for maintenance of anesthesia and postoperative pain scores. RESULTS: Caudal block was successful in 209/220 (95%) patients. Mean HR following the initial drug injection (111 +/- 17.7, P < 0.01) and entire drug injection (108.8 +/- 17.2, P < 0.01) was significantly lower than baseline (116.2 +/- 17.5). HR reduction of > or = 3 b x min(-1) was present in 190/209 and 199/209 successful block following initial drug injection and total drug injection respectively. The analysis of study data showed that a fall in HR is a predictor of successful caudal block, with a sensitivity of 90.9%, specificity of 100% and a positive predictive value of 100% after initial injection of local anesthetic. CONCLUSIONS: We conclude that decrease in HR with drug injection is a simple, objective and reliable test to predict success of caudal block.

When to add supplemental rectal paracetamol for postoperative analgesia with caudal bupivacaine in children? A prospective, double-blind, randomized study. Mercan A , Sayin MM , Saydam S , Ozmert S , Tiryaki T . Paediatr Anaesth. 2007 Jun;17(6):547-51. Department of Anesthesiology, SSK Ankara Training Hospital, Ankara, Turkey. arzumercan@yeditepe.edu.tr

BACKGROUND: The aim of this study was to investigate whether a supplemental dose of rectal paracetamol at the third or fourth hour would enhance the quality of analgesia provided by caudal epidural blockade in children. METHODS: Two hundred and two ASA I patients aged 1-12 years undergoing inguinal surgery were randomized into three groups in the postanesthesia care unit by drawing lots. Patients in the control group did not receive any analgesic until they had a pain score of 5 or higher, patients in the group P3 received rectal paracetamol (20-25 mg x kg(-1)) at the third hour, and patients in the group P4 received the same dose of rectal paracetamol at the fourth hour after caudal epidural injection. Pain was assessed by VAS (Visual Analog Scale) and supplementary rescue analgesic need was recorded. RESULTS: There was no difference between the demographic data or the duration and variety of surgery among the groups. A significantly lower number of patients required rescue analgesia at the sixth postoperative hour in group P3 and also lower pain scores were again obtained in group P3 at the sixth and eighth postoperative hours. CONCLUSIONS: Supplemental rectal paracetamol at the third hour of caudal blockade enhances the quality of postoperative analgesia better than its addition at the fourth hour in children undergoing inguinal surgery.

Type 1 diabetes mellitus. Perioperative management of children and adolescents Herbst A , Kiess W . Anaesthesist. 2007 May;56(5):454-60 Zentrum für Kinderheilkunde, Klinikum Leverkusen, Am Gesundheitspark 11, 51375 Leverkusen, Deutschland. herbst@klinikum-lev.de

Patients with type 1 diabetes require continuous substitution of exogenous insulin due to their disability to produce insulin themselves. The insulin dosage required is individual-specific and may change dramatically during the perioperative period. The patient may be endangered by metabolic decompensation including hypoglycaemia and diabetic ketoacidosis. Thus, perioperative management should include frequent blood glucose measurements and frequent adjustment of the insulin and glucose administration. When planning the operation, an individual treatment regime should be drawn up and be made available to the medical team. In order to facilitate the challenging perioperative management of these patients, this article presents the current recommendations for the perioperative management of children and adolescents with type 1 diabetes mellitus (i.e. of the International Society for Pediatric and Adolescent Diabetes, ISPAD).

Perioperative management for surgical correction of frontoethmoidal encephalomeningocele in children: a review of 102 cases. Leelanukrom R , Wacharasint P , Kaewanuchit A . Paediatr Anaesth. 2007 Sep;17(9):856-62 Department of Anesthesiology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand. fmedrll@md2.md.chula.ac.th

BACKGROUND: Frontoethmoidal encephalomeningocele (FEEM) is a congenital neural tube defect characterized by herniation of brain and meninges through an anterior skull defect. The extruding mass results in a cutaneous expanding lesion and facial deformity. The objective of this study was to review perioperative management for surgical correction of this condition. METHODS: We reviewed the charts of FEEM children who were treated by surgical correction in King Chulalongkorn Memorial Hospital during 1995-2005. The collected data were categorized into preoperative, intraoperative and postoperative data. In addition, average blood loss was calculated. RESULTS: A total of 102 charts were reviewed. Preoperative data: The mean age of the patients was 4.62 years. Forty-six patients (45%) were smaller than average weight or height. Preoperative-associated abnormal conditions were found in 69 cases (68%). Intraoperative data: The mean duration of the anesthesia and surgery were 6.35 h and 5.51 h, respectively. The estimated mean red cell mass loss was 13.04 ml.kg(-1). There is one case of difficult intubation. No major anesthetic complication was found. Postoperative data: The average intensive care unit stay and hospital stay were 1.55 days and 11.51 days, respectively. The main postoperative complications were tonic-clonic seizure and serious infection including septic shock from wound infection and meningitis. CONCLUSIONS: We reported perioperative management in 102 FEEM children. Comprehensive care during preoperative, intraoperative and postoperative period is essential for successful outcome.

A randomised placebo-controlled trial of the effects of midazolam premedication on children's postoperative cognition. Millar K , Asbury AJ , Bowman AW , Hosey MT , Martin K , Musiello T , Welbury RR . Anaesthesia. 2007 Dec;62(12):1301. University of Glasgow, Section of Psychological Medicine, Gartnavel Royal Hospital, 1055 Great Western Road, Glasgow G12 0XH, UK. k.millar@clinmed.gla.ac.uk

This randomised, placebo-controlled study assessed the effects of midazolam premedication on children's postoperative cognition and physical morbidity. In all, 179 children aged 5-10 years were randomly assigned to receive buccal midazolam (0.2 mg x kg(-1)) or placebo before sevoflurane-nitrous oxide anaesthesia for multiple dental extractions. They performed tests of choice reaction time, attention, psychomotor co-ordination and memory pre-operatively (baseline), before discharge and at 48 h. The reaction time of both groups was significantly slower before discharge compared to baseline, with the midazolam group being significantly slower than placebo. Psychomotor co-ordination was also significantly impaired postoperatively after midazolam. Performance on both tests had recovered to baseline by 48 h. Midazolam was also associated with significant anterograde amnesia, both postoperatively and at 48 h, for information presented in the interval between premedication and surgery. The results show significant short-term impairment of children's cognitive function and amnesia enduring for 48 h after low-dose midazolam premedication.

Recurrence of focal seizure activity in an infant during induction of anaesthesia with sevoflurane. Rewari V , Sethi D . Anaesth Intensive Care. 2007 Oct;35(5):788-91. Department of Anaesthesiology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India.

A three-month-old male infant, previously diagnosed with seizures with a focal origin induced by hypocalcaemia secondary to hypoparathyroidism, presented for right cataract surgery. The hypocalcaemia and seizure activity had resolved with medical therapy, with normal calcium levels and no seizures for a month. Anaesthesia with halothane and isoflurane for left cataract surgery two days previously had been uneventful. During induction of anaesthesia with sevoflurane for the right cataract surgery, the patient had a focal seizure similar to those previously occurring when the patient was hypocalcaemic. The patient had normal calcium levels at the time of surgery. It appears likely that sevoflurane had triggered seizure activity in the apparently controlled focus. The potential for sevoflurane to induce epileptogenic activity in patients with reduced seizure threshold is discussed.

Midlatency auditory evoked potentials in children: effect of age and general anaesthesia. Daunderer M , Feuerecker MS , Scheller B , Pape NB , Schwender D , Kuhnle GE . Br J Anaesth. 2007 Dec;99(6):837-44. Epub 2007 Oct 17. Clinic for Anaesthesiology, Ludwig Maximilians University Munich, Nussbaumstr. 20, D-80336 Munich, Germany. dr.daunderer@web.de

BACKGROUND: Midlatency auditory evoked potentials (MLAEP) are a promising tool for monitoring suppression of sensory processing during anaesthesia and might help to avoid awareness. MLAEP in children are different to those in adults and the exact changes during general anaesthesia are unknown. METHODS: In 49 children of age between 2 and 12 yr, MLAEP were recorded before anaesthesia, during tracheal intubation, at steady-state balanced anaesthesia, and after extubation. RESULTS: MLAEP were recordable in all children in the awake (premedicated) state with latencies but not amplitudes dependent on children's age. MLAEP latencies significantly increased during tracheal intubation and steady-state anaesthesia. Changes in amplitudes were inconsistent. All MLAEP variables returned to near baseline values after extubation. CONCLUSIONS: The results of this study imply that MLAEP can successfully be recorded during anaesthesia in children above the age of 2 yr. Further studies are necessary before MLAEP might be applicable for monitoring purposes in paediatric anaesthesia.

Comparison of transmucosal midazolam with inhalation sedation for dental extractions in children. A randomized, cross-over, clinical trial. Wilson KE , Welbury RR , Girdler NM . Acta Anaesthesiol Scand. 2007 Sep;51(8):1062-7. Department of Sedation, Newcastle University School of Dental Sciences and Dental Hospital, Newcastle upon Tyne, UK. katherine.wilson@ncl.ac.uk

BACKGROUND: The transmucosal route for conscious sedation in children has been reported widely in the field of medicine, but less so in dental patients. The aim of this study was to evaluate the efficacy and safety profile of midazolam (0.2 mg/kg) administered by the buccal transmucosal route, in comparison with nitrous oxide/oxygen inhalation sedation, for orthodontic extractions in 10-16-year-old dental patients. METHODS: Each patient attended for two visits and was randomly allocated to receive buccal midazolam (0.2 mg/kg) or nitrous oxide/oxygen titrated to 30%/70% at the first visit, the alternative being used at the second visit. The patients' vital signs, sedation levels and behavioural scores were recorded throughout. Post-operatively, side-effects, recall of the visit and satisfaction levels were recorded via questionnaire. RESULTS: Thirty-six patients, with a mean age of 12.9 years, completed both arms of the trial. The maximum level of sedation was achieved with buccal midazolam in a mean time of 14.42 min, compared with 7.05 min with inhalation sedation. The vital signs with both types of sedation remained within acceptable limits and the reported side-effects were of no clinical significance. Buccal midazolam was found to be acceptable by 65.7%. Only 28.6% of cases preferred this technique, the main disadvantage being the taste of the solution. CONCLUSION: Buccal midazolam sedation (0.2 mg/kg) seems to be equally as safe and effective as nitrous oxide/oxygen for the extraction of premolar teeth in anxious children. However, further research is required to refine the midazolam vehicle to improve acceptability.

Effects of age and emotionality on the effectiveness of midazolam administered preoperatively to children. Kain ZN , MacLaren J , McClain BC , Saadat H , Wang SM , Mayes LC , Anderson GM . Anesthesiology. 2007 Oct;107(4):545-52. Center for the Advancement of Perioperative Health, Department of Anesthesiology, Yale University School of Medicine, New Haven, CT 06510, USA. kain@biomed.med.yale.edu

BACKGROUND: Multiple studies document the beneficial effect of midazolam on preoperative anxiety in children. Many clinicians report, however, that some children may in fact not benefit from the administration of this drug. METHODS: After screening for relevant exclusion criteria, children undergoing surgery were enrolled in the study (n = 262) and received 0.5 mg/kg oral midazolam at 20-40 min before induction of anesthesia. Personality instruments were administered to all children, and anxiety levels were evaluated before and after administration of midazolam as well as during induction of anesthesia. Blood was drawn during the induction process and later analyzed for midazolam levels. A priori definitions of responders and nonresponders to midazolam were established using a multidisciplinary task force, videotapes of induction, and a validated and reliable anxiety scale, the modified Yale Preoperative Anxiety Scale. RESULTS: While 57% of all children scored at the minimum of the modified Yale Preoperative anxiety scale, 14.1% of children fell in the a priori defined group of midazolam nonresponders. Midazolam blood levels (94 +/- 41 vs. 109 +/- 40 ng/ml) and timing between administration of midazolam and induction (28 +/- 9 vs. 29 +/- 8 min) did not differ between midazolam responders and nonresponders. In contrast, midazolam nonresponders were younger (4.2 +/- 2.3 vs. 5.9 +/- 2.0 yr), more anxious preoperatively (49.7 +/- 22.9 vs. 38.3 +/- 19.1), and higher in emotionality (13.6 +/- 3.6 vs. 11.3 +/- 3.8) as compared with responders (P < 0.05). CONCLUSIONS: Although midazolam is an effective anxiolytic for most children, 14.1% of children still exhibit extreme distress. This subgroup is younger, more emotional, and more anxious at baseline. Future studies are needed to determine the best strategy to treat these children.

Multidrug intravenous anesthesia for children undergoing MRI: a comparison with general anesthesia. Shorrab AA , Demian AD , Atallah MM . Paediatr Anaesth. 2007 Dec;17(12):1187-93. Department of Anesthesia, Faculty of Medicine, University of Mansoura, Mansoura, Egypt.

Background: We used a multidrug intravenous anesthesia regimen with midazolam, ketamine, and propofol to provide anesthesia for children during magnetic resonance imaging (MRI). This regimen was compared with general anesthesia in a randomized comparative study. Outcome measures were safety, side effects and recovery variables in addition to adverse events in relation to age strata. Methods: The children received either general anesthesia with propofol, vecuronium and isoflurane [general endotracheal anesthesia (GET) group; n = 313] or intravenous anesthesia with midazolam, ketamine, and propofol [intravenous anesthesia (MKP) group; n = 342]. Treatment assignment was randomized based on the date of the MRI. Physiological parameters were monitored during anesthesia and recovery. Desaturation (SpO(2) < 93%), airway problems, and the need to repeat the scan were recorded. The discharge criteria were stable vital signs, return to baseline consciousness, absence of any side effects, and ability to ambulate. Results: With the exception of two children (0.6%) in the MKP group, all enrolled children completed the scan. A significantly greater number (2.3%) required a repeat scan in the MKP group (P < 0.05) and were sedated with a bolus dose of propofol. The total incidence of side effects was comparable between the MKP (7.7%) and GET groups (7.0%). Infants below the age of 1 year showed a significantly higher incidence of adverse events compared with the other age strata within each group. Within the MKP group, risk ratio was 0.40 and 0.26 when comparing infants aged below 1 year with the two older age strata, respectively. Recovery characteristics were comparable between both groups. Conclusions: Intravenous midazolam, ketamine and propofol provides safe and adequate anesthesia, comparable with that obtained from general endotracheal anesthesia, for most children during MRI.

The optimum initial pediatric epidural bolus: a comparison of four local anesthetic solutions. Ingelmo P , Locatelli BG , Frawley G , Knottenbelt G , Favarato M , Spotti A , Fumagalli R . Paediatr Anaesth. 2007 Dec;17(12):1166-75 Department of Anaesthesia and Intensive Care, A.O San Gerardo, Monza and Dipartimento di medicina sperimentale ambientale e biotecnologie mediche, Università degli Studi Milano Bicocca, Milan, Italy.

Background: There is no consensus on the concentration or type of local anesthetic used for initiation of epidural anesthesia. The aim of this randomized, double-blind, controlled trial was to compare the clinical effectiveness of epidural administration of both levobupivacaine and bupivacaine in 0.2% and 0.25% concentrations in pediatric patients undergoing abdominal and urological surgery. Methods: One hundred and forty-one children scheduled for lower abdominal and urological surgery were randomized to receive 0.4-0.6 ml.kg(-1) epidural, 0.25% bupivacaine, 0.2% bupivacaine, 0.25% levobupivacaine or 0.2% levobupivacaine. Initial epidural volumes, onset times; hemodynamic consequences, postoperative pain scores and degree of residual postoperative motor block were all recorded. Results: There were no significant differences in the proportion of children with effective analgesia after incision [0.20% bupivacaine 97%, 0.25% bupivacaine 94%, 0.20% levobupivacaine 91%, 0.25% levobupivacaine 92% (P = 0.73)] when a median volume of 0.55 ml.kg(-1) was used. There was no association between the volume used for thoracic, lumbar, or sacral epidural anesthesia and the effectiveness of the agents used. There was a significantly greater incidence of pain on awakening with the 0.2% solutions compared with the 0.25% solutions, but no differences in the incidence of residual motor block between groups. Conclusions: While there is no difference in the proportion of effective surgical anesthesia, the lower incidence of pain and distress with the 0.25% solutions suggests that this concentration has clinical advantages over the 0.2% solutions for pediatric epidural anesthesia.

A deeper level of ketamine anesthesia does not affect functional residual capacity and ventilation distribution in healthy preschool children. von Ungern-Sternberg BS , Regli A , Frei FJ , Ritz EM , Hammer J , Schibler A , Erb TO . Paediatr Anaesth. 2007 Dec;17(12):1150-1155. Division of Anesthesia, University Children's Hospital, Basel, Swtizerland.

Background: Ketamine is commonly used in children in the emergency setting and while undergoing diagnostic and therapeutic interventions because of its combination of hypnotic and analgesic properties. Although studies comparing various levels of ketamine anesthesia are lacking, previous work suggests that lung mechanics might only be minimally affected by ketamine. Methods: After approval from the Ethics Committee, anesthesia was induced with 2 mg.kg(-1) racemic ketamine followed by a continuous infusion of ketamine 2 mg.kg(-1) h(-1) (level I) in 26 children (2-6 years of age), and after 5 min, the first set of measurements was performed. Then, a second bolus of ketamine 2 mg.kg(-1) followed by ketamine 4 mg.kg(-1) h(-1) was administered (level II) and after 5 min, the second set of measurements was performed. Functional residual capacity (FRC) and lung clearance index (LCI) were calculated using a multibreath analysis by a blinded observer. Results: Functional residual capacity and LCI did not change between the two levels (FRC 25.6 [4.3] ml.kg(-1) vs 25.5 [4.2] ml.kg(-1), P = 0.769, LCI 10.5 [1.2] vs 10.3 [1.1], P = 0.403). The minute ventilation was similar between the two levels of anesthesia. The University of Michigan Sedation Scale increased from 3 (3) to 4 (3-4) at the second level of ketamine anesthesia. Conclusions: A deeper level of anesthesia induced by ketamine does not affect FRC, ventilation distribution or minute ventilation suggesting that the depth of ketamine anesthesia has a minimal effect on pulmonary function.

Children who refuse anesthesia or sedation: a survey of anesthesiologists. Lewis I , Burke C , Voepel-Lewis T , Tait AR . Paediatr Anaesth. 2007 Dec;17(12):1134-1142. Department of Pediatric Anesthesiology, Mott Children's Hospital, Ann Arbor, MI 40109-0211, USA.

Background: Few articles have addressed the issue of the child who refuses anesthesia or sedation for surgery. A survey of members of the Society for Pediatric Anesthesia in the USA was conducted regarding their experience with pediatric refusal and assent for surgery. Methods: Structured response and open-end questions were used in a confidential postal survey to assess the following: details of cancellations, the use of, and attitudes to, physical restraint at induction, premedication, the management of a hypothetical case of child refusal and individual techniques used for uncooperative children. Results: Surveys were received from 453/852 anesthesiologists for a 57% response rate. Nine percent and 45% of respondents had cancelled one or more cases for child refusal in the past year and during their entire career respectively. Forty-four percent of respondents used restraint in the majority of children <1 year of age, whereas only 2% did so in children >11 years. Respondents were more uncomfortable with restraint in older children and less likely to proceed with induction. Twelve years was the median age when respondents would respect the child's refusal to proceed. Conclusions: Cancellation of planned surgery because of child refusal is not uncommon. It is important to recognize the potentially uncooperative child, particularly older children with developmental delay or a lack of understanding. Discussion with child and parents, selective use of premedication and different induction agents, distraction, play techniques, gentle restraint and the option of cancellation and review should all be considered.

A comparison of intranasal dexmedetomidine and oral midazolam for premedication in pediatric anesthesia: a double-blinded randomized controlled trial. Yuen VM , Hui TW , Irwin MG , Yuen MK . Anesth Analg. 2008 Jun;106(6):1715-21. Department of Anaesthesiology, University of Hong Kong, Queen Mary Hospital, Hong Kong. vtang131@hku.hk

BACKGROUND: Midazolam is the most commonly used premedication in children. It has been shown to be more effective than parental presence or placebo in reducing anxiety and improving compliance at induction of anesthesia. Clonidine, an alpha(2) agonist, has been suggested as an alternative. Dexmedetomidine is a more alpha(2) selective drug with more favorable pharmacokinetic properties than clonidine. We designed this prospective, randomized, double-blind, controlled trial to evaluate whether intranasal dexmedetomidine is as effective as oral midazolam for premedication in children. METHODS: Ninety-six children of ASA physical status I or II scheduled for elective minor surgery were randomly assigned to one of three groups. Group M received midazolam 0.5 mg/kg in acetaminophen syrup and intranasal placebo. Group D0.5 and Group D1 received intranasal dexmedetomidine 0.5 or 1 microg/kg, respectively, and acetaminophen syrup. Patients' sedation status, behavior scores, blood pressure, heart rate, and oxygen saturation were recorded by an observer until induction of anesthesia. Recovery characteristics were also recorded. RESULTS: There were no significant differences in parental separation acceptance, behavior score at induction and wake-up behavior score. When compared with group M, patients in group D0.5 and D1 were significantly more sedated when they were separated from their parents (P < 0.001). Patients from group D1 were significantly more sedated at induction of anesthesia when compared with group M (P = 0.016). CONCLUSIONS: Intranasal dexmedetomidine produces more sedation than oral midazolam, but with similar and acceptable cooperation.

General anesthetics induce apoptotic neurodegeneration in the neonatal rat spinal cord. Sanders RD , Xu J , Shu Y , Fidalgo A , Ma D , Maze M . Anesth Analg. 2008 Jun;106(6):1708-11. Department of Anaesthetics, Pain Medicine and Intensive Care, Imperial College London, Chelsea & Westerminster Hospital, London, UK.

BACKGROUND: Exposure to anesthetics triggers apoptotic neurodegeneration in the neonatal rat brain; whether neuronal apoptosis also occurs in the spinal cord, a crucial target for analgesic and anesthetic drugs, is unknown. METHODS: We exposed 7-day-old rats were exposed to air or 75% nitrous oxide + 0.75% isoflurane in oxygen for 6 h (n = 19 per group). Caspase-3 immunoreactivity was evaluated in the lumbar spinal cord at the end of the gas exposure (n = 3 per group). Developmental nociceptive responses were tested using tail flick latencies on postnatal days 8, 15, and 30 (n = 3 per group). Motor responses were evaluated using the rotarod on postnatal day 30 (n = 7 per group). RESULTS: Isoflurane plus nitrous oxide increased the numbers of caspase-3 positive neurons in the spinal cord (P < 0.01). Despite a preponderance of the injury in the ventral horn of the spinal cord, motor impairment did not occur (P > 0.05). No functional effect on nociception was observed at the three developmental stages tested (P > 0.05). CONCLUSIONS: Anesthesia induces apoptosis in the neonatal rat spinal cord; however, the functional consequences of this injury, if any, remain obscure. Neither motor nor nociceptive responses were affected by anesthetic treatment. Nonetheless, further investigation is required as regional anesthetic techniques may also trigger neuroapoptosis in the spinal cord with unknown potency.

Influence of the anaesthetic depth on the inhibition of the oculocardiac reflex during sevoflurane anaesthesia for paediatric strabismus surgery. Yi C , Jee D . Br J Anaesth. 2008 Aug;101(2):234-8. Epub 2008 Jun 3 Department of Anaesthesiology and Pain Medicine, Yeungnam University College of Medicine, Daemyung-Dong, Nam-Gu, Daegu 705-035, Republic of Korea.

BACKGROUND: It remains controversial whether the anaesthetic depth as assessed by bispectral index (BIS) influences the oculocardiac reflex (OCR) during strabismus surgery. We investigated whether BIS-guided sevoflurane titration may help to optimize the anaesthetic depth for inhibition of the OCR during paediatric strabismus surgery. METHODS: Eighty-four patients (aged 2-12 yr) undergoing strabismus surgery were randomly allocated to one of the three groups (n=28 for each) according to target BIS value of 40, 50, and 60. The end-tidal sevoflurane concentration with 50% N2O/O2 was adjusted towards target BIS. The incidence of OCR and the lowest heart rate (HR) were recorded in relation to the end-tidal sevoflurane concentration. RESULTS: The incidence of OCR was higher in Group BIS-60 (71.4%) than in Groups BIS-40 (10.7%) (P<0.001) or BIS-50 (32.1%) (P=0.003), with no difference between Group BIS-40 and Group BIS-50. The lowest HR [beats min(-1), mean (sd)] during traction on the extraocular muscle was lower in Group BIS-60 [112.3 (sd 17.8)] compared with Group BIS-40 [129.3 (11.2)] (P<0.001), with no difference between BIS-40 and BIS-50 [121.4 (16.3)], and between BIS-50 and BIS-60. The end-tidal sevoflurane concentration was different between the three groups (P=0.001). CONCLUSIONS: We confirmed that OCR is relevant to the depth of anaesthesia. BIS values of 40-50 seem adequate for the inhibition of OCR. The results suggest that BIS may be a valuable tool during sevoflurane anaesthesia for strabismus surgery in children.

The anaesthetic management of children with anterior mediastinal masses. Hack HA , Wright NB , Wynn RF . Anaesthesia. 2008 Jun 9 Royal Manchester Children's Hospital, Hospital Rd. Pendlebury, Manchester M27 4HA, UK.

Children with anterior mediastinal masses may experience serious complications during general anaesthesia. We retrospectively surveyed the records of children with an anterior mediastinal mass who had been admitted to our hospital over a 7 year period. The presence of pre-operative symptoms or signs, findings of any special investigations performed and the anaesthetic outcome were noted. All radiological investigations were studied and tracheal compression measured. The majority of patients presented with severe clinical signs. There was a poor relationship between clinical signs and size of tumour or tracheal compression on CT scan. Corticosteroids were used prior to diagnosis in 33% of patients, all of whom were considered high risk. A clear diagnosis was made in 95% of these patients. The overall complication rate was 20% and 5% of patients had a serious complication related to anaesthesia. Stridor was the only sign that predicted an anaesthetic complication. Peri-operative respiratory complications were confined to patients with an isolated tracheal cross-sectional area less than 30% normal or less than 70% and associated with bronchial compression.

Anaesthetic management of gastrochisis - a review of our practice over the past 5 years. Raghavan M , Montgomerie J . Paediatr Anaesth. 2008 Aug;18(8):731-5 Department of Anaesthesia, Birmingham Children's Hospital, Birmingham, UK. murali.raghavan@nhs.net

BACKGROUND: Surgical closure of gastrochisis has traditionally been performed under general anesthesia followed by admission to intensive care and postoperative ventilation. We reviewed the management of these neonates in our hospital over the past 5 years to identify the changes in practice and possible factors which affect the peri-operative course. METHODS: We retrospectively identified cases of gastrochisis undergoing repair from June 2002 to May 2007. Details of the demographic data, preoperative factors, intra-operative anesthetic and surgical management, and postoperative care were collected from the anesthetic chart, operative record, and patient notes. RESULTS: Forty-eight self-ventilating neonates underwent operative repair in theatre. A neuraxial local anesthetic block was performed as part of the anesthetic technique in 22 patients. There was a significant difference in the need for postoperative ventilation in this group (23%) when compared with a traditional opioid-based method of providing analgesia (88%, P < 0.05). This difference was seen in both term and preterm babies. CONCLUSION: Conclusions are difficult to make when analyzing retrospective data in patients with a heterogeneous variety of factors. The results suggest that anesthesia which includes a regional technique is a valid method in these cases. Traditional opioid analgesia when compared with regional techniques may be associated with increased need for postoperative ventilation.

Ketamine anesthesia in children--exploring infusion regimens. Dallimore D , Anderson BJ , Short TG , Herd DW . Paediatr Anaesth. 2008 Aug;18(8):708-14 Department of Anaesthesiology, Auckland City Hospital, Auckland, New Zealand.

AIM: We aimed to produce a racemic ketamine manual infusion regimen capable of maintaining a steady-state blood concentration associated with anesthesia in children aged 1.5-12 years. METHOD: The literature was searched for a ketamine blood concentration associated with anesthesia in humans. Pharmacokinetic parameter estimates were taken from published studies of infusion data in children and used in a pharmacokinetic simulation program to predict likely ketamine blood concentrations during infusions. A variability of 10% was allowed about the chosen target concentration. RESULTS: A target concentration of 3 mg.l(-1) was chosen for simulation modeling. This target is greater than that associated with anesthesia when supplemented by nitrous oxide or midazolam in adults. Arousal to light touch or voice appears to occur at a mean plasma concentration of 0.5 mg.l(-1) in both children and adults. A loading dose of 2 mg.kg(-1) followed by an infusion rate of 11 mg.kg(-1).h(-1) for the first 20 min, 7 mg.kg(-1).h(-1) from 20 to 40 min, 5 mg.kg(-1).h(-1) from 40 to 60 min and 4 mg.kg(-1).h(-1) from 1 to 2 h resulted in a steady-state target concentration of 3 mg.l(-1) in children 1.5-12 years. Arousal, either spontaneous or to speech, is anticipated 3 h 47 min after a 2 h infusion in an average 6-year-old child. The context sensitive half-time in children was shorter than in adults after 1.5 h, rising from 30 min at 1 h to 55 min at 5 h after an infusion of 3 mg.kg(-1).h(-1) in a 10 kg child. CONCLUSION: Children require higher infusion rates than adults to maintain steady-state concentrations of 3 mg.l(-1) and have shorter context sensitive half-times than adults after prolonged infusion. These differences can be attributed to age-related pharmacokinetics. We anticipate slow return to full consciousness after prolonged infusion, suggesting that a lower target concentration with supplementation from adjuvant short acting anesthetic drugs may be advantageous.

BACKGROUND: /st> The surgical stress index (SSI), derived from a combination of heart rate (HR) and photoplethysmographic amplitude (PPGA) time series, is a novel method for continuous monitoring of intraoperative stress and has been validated in adults. The applicability of SSI and its constituents to monitoring children has not been previously evaluated. METHODS: /st> In this controlled trial, 22 anaesthetized patients, aged 4-17 yr, undergoing strabismus surgery were randomized into two groups, Group LL and Group BSS. Patients in Group LL received topical conjunctival anaesthesia with a 1:1 mixture of lidocaine 2% and levobupivacaine 0.75%, and patients in Group BSS received balanced salt solution. RESULTS: /st> Endotracheal intubation (n=22) increased median (range) SSI from 39.2 (22.6-55.6) to 53.6 (35.8-63.3) (P<0.001), decreased PPGA from 5.62 (2.79-9.69) to 5.27 (2.59-7.54)% (P=0.001), and increased the difference of response entropy (RE) and state entropy (SE) of frontal biopotentials (RE-SE) from 3.1 (0.06-9.1) to 5.7 (0.6-9.4) (P=0.01). Conventional haemodynamic variables also increased, median (range) HR from 72.9 (56.7-113.8) to 84.2 (60.4-124.8) beats min(-1) (P<0.001), and systolic non-invasive arterial pressure (S-NIBP) from 87 (78-143) to 103 (79-125) (P=0.007). When 3 min baseline before surgery was compared with 12 min of surgery, median (range) SSI increased from 43.3 (31.2-58.0) to 49.9 (39.3-57.2) (P=0.042) vs from 46.6 (26.8-57.8) to 52.1 (31.7-60.1) (P=0.024) and PPGA decreased from 6.60 (3.10-8.24) to 5.80 (3.03-7.65)% (P<0.001) vs from 5.51 (3.25-9.84) to 5.06 (3.08-8.99)% (P=0.042), in Groups LL and BSS, respectively, but SSI or other indicators did not differ significantly between the groups. CONCLUSIONS: /st> SSI, PPGA, HR, NIBP, RE, and RE-SE detect autonomic responses to nociceptive stimuli in anaesthetized children undergoing strabismus surgery.

Abstracts

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