Carmelo Minardi

Emergence delirium in children: a comparison of sevoflurane and desflurane anesthesia using the Paediatric Anesthesia Emergence Delirium scale.

This randomized control trial was designed to evaluate the incidence of emergence delirium (ED) in preschool children receiving sevoflurane or desflurane anesthesia combined with an effective caudal block.

Unexplained seizures in an infant

In June, 2004, a girl was delivered by caesarean section, at 38 weeks, after the placenta became detached. When she was 2 months old, the girl was brought to hospital with generalised tonic-clonic seizures, tremors in arms and legs, hypo tonia, and inconsolable crying. Blood tests, EEG, and MRI of the head and spine showed nothing abnormal. The girl’s mother, a housewife (the father was a farmer) was pre scribed amitrip tyline for postnatal depression and tension head ache; we knew of no other family history of neuro logical illness. Concluding that the girl had epilepsy, doctors prescribed phenobarbital; the hypotonia was treated with physio therapy. However, in early 2005, the girl had two further episodes of seizures. Each time, she had serial seizures for 20 s, then cried inconsolably for 5–7 min, and slept for 8–12 h. On hospitalisation, she had similar episodes almost daily. Finding the presentation inexplicable and unusual, doctors consulted international experts, who suggested that the girl might have a rare genetic condition, or intermittent hemiplegia. Flunari zine was prescribed, but stopped after 3 days, because of extrapyramidal sideeff ects. Subsequently, the girl was admitted to hospital around once a month, with seizures, which resolved on treatment. After the girl was admitted to our paediatric ward in September, 2005, doctors witnessed a seizure lasting 20 s, and prescribed diazepam, then phenobarbital. Electro encephalography (EEG) showed focal seizure activity. After the seizure, doctors monitored the girl’s EEG and electro cardiogram (ECG). Around 30 min after the seizure, the ECG showed ventricular tachycardia, which developed into ventricular fi brillation. The girl was given cardio pulmonary resuscitation, and transferred to the intensive-care department, where she was defi brillated, and given epinephrine and lidocaine, as well as 0∙9% saline. Sinus rhythm returned. The girl was now haemodynamically stable; however, her Glasgowcoma-scale score was 8. Her pupils were reactive but dilated, and she had generalised hypotonia. We sedated the patient with midazolam, intubated her, and ventilated her mechanically. The next morning, the girl was breathing independently, moving all her limbs well, and speaking. After extubation, we told the mother that her child was getting better. The mother did not seem relieved; she almost insisted that the girl’s condition was unimproved. Finding this incongruous, we requested toxicological analysis of blood and urine samples from the infant. Concentrations of anticonvulsant drugs were in the therapeutic range. However, the serum concentration of amitriptyline was 350 μg/L; the serum concentration of nortriptyline (a metabolite of amitriptyline), and the urine concentrations of amitriptyline and nortryptyline, were higher than our laboratory could quantify. We contacted the police. The mother admitted that, since the child was 1 month old, she had been administering amitriptyline drops to her. The child was removed from the family home, to live with her maternal grandmother. Sub sequently, the girl has been seen every 3 months by a paediatrician and a neurologist. When last seen, in July, 2008, she was well, and well looked after. Poisoning is one of the most common medical emergencies of childhood; and tricyclic antidepressants are frequent causes of poisoning in adults and children. How ever, deliberate poisoning is quite rare. We were unable to interview the mother at length, so know little about her motivations for poisoning the child. However, our patient may have been a victim of factitious disorder by proxy, also known as Munchausen’s syndrome by proxy (panel). If our surmise is correct, the mother did not primarily intend to kill the child. Nonetheless, she could have done. In children, amitriptyline overdose commonly causes seizures and tachycardia, as well as lethargy, hyperglycaemia, and leucocytosis; in adults, a serum con centration of 1000 μg/L is associated with a high risk of death.

Remifentanil and worse patient-reported outcomes regarding postoperative pain management after thyroidectomy

BACKGROUND Intraoperative remifentanil has been associated with postoperative hyperalgesia, higher visual analogic pain scores, and increased postoperative morphine consumption. However, this has not been investigated from patients perspective by using a patient-reported outcomes (PROs) approach with a validated questionnaire. METHODS We joined the largest prospective observational study on postoperative pain, PAIN OUT Project (NCT02083835), and collected data for 2 years. We studied the effects of remifentanil (R+) vs nonremifentanil (R-) anesthesia on PROs regarding their pain management after elective thyroidectomy. We selected 5 primary PROs (worst pain experienced, time spent in severe pain, relief received by treatment, satisfaction about pain management, wish for more pain treatment) and five secondary PROs (drowsiness, itching, nausea, dizziness, waking up due to pain) from the validated International Pain Outcomes questionnaire. RESULTS The analysis included 317 patients, 208 in the R+ group (65.6%) and 109 in the R- group (34.4%), the latter receiving fentanyl as intraoperative opioid. Although the R+ group received more frequently intraoperative nonopioids (202/208, 97.1% vs 86/109, 78.9%; P < .0001) and opioids (184/208, 88.5% vs 38/109, 34.9%; P < .001), it reported higher worst pain (5.1±2.1 vs 4.3±2.1, P < .005), lower satisfaction (7.4±2.0 vs 8.1±2.1, P < .001), and worse results in 4 secondary PROs. A sensitivity analysis performed matching 67 couples of patients yielded similar results in primary PROs. CONCLUSIONS Our study suggests that remifentanil-based anesthesia is associated with worse pain-related PROs in patients undergoing thyroidectomy despite more frequent intraoperative analgesic administration. This study adds further evidence to the growing literature about opioid- and remifentanil-induced hyperalgesia.

Does the Italian pediatric anesthesia training program adequately prepare residents for future clinical practice? What should be done?

Background:  Pediatric anesthesia should be considered a subspecialty addressing the complete pediatric population (from preterm to teenager) and requiring particular anatomical, pathophysiological, pharmacological and anesthesiological knowledge. A survey was conducted to evaluate the training in pediatric anesthesia performed by Medical Schools of Anesthesia in Italy and to assess if the European Federation of Associations of Pediatric Anesthesia (FEAPA) guidelines for training in pediatric anesthesia had been adopted.

Sedation and Analgesia in Pediatric Intensive Care

Almost all children in the pediatric intensive care (PICU) need analgesia and/or sedation. Analgesics drugs are used to control pain from surgical incisions, drainages, vascular access or endotracheal suctioning. Sedatives are used to facilitate the delivery of nursing care, to facilitate mechanical ventilation, prevent self-extubation and to minimize patient discomfort. A therapeutic plan for analgesia and sedation should be established for each patient and regularly reviewed. The most often used sedation agents in PICU patients are Morphine or Fentanyl alone or in combination with Midazolam. Several other drugs should be helpful to manage PICU patients therefore techniques like regional anesthesia and patient controlled analgesia to decrease the use of intravenous analgesia and sedation and to reduce the incidence of withdrawal syndrome. The therapeutic plan for analgesia and sedation should be established for each patient and regularly reviewed. Doses of sedative agents should be titrated to produce the desired level of sedation. The level of sedation should be regularly assessed and documented using few validated sedation assessment tool. However, behavioral evaluation tools based on patient responsiveness, cannot be used during the administration of neuromuscular blocking agents. Under this conditions it could be difficult to interpret the degree of sedation. EEG derived Monitoring devices may represents an useful tools of assessing the level of sedation, but there is insufficient evidence to support the routine use of the BIS monitor in PICU.

Emergence Delirium: Assessment, Prevention, and Decision-Making

Agitation or delirium during early emergence from anesthesia was first described in the 1960s [1,2]. Smessaert and colleagues [1] described three types of recovery from anesthesia: (1) patients with a tranquil and uneventful recovery; (2) patients who showed a moderate degree of restlessness; and (3) patients who were markedly delirious and uncooperative, and who required special care and restraint. They also described two main causative factors for postanesthetic delirium. The first was related to the anesthetic (cyclopropane more so than ether or barbiturates) and surgical procedures (peripheral surgery less so than intrathoracic or intra-abdominal surgery), and the second was related to the individual characteristics of the patient (e.g., sex, age, and mental attitude). They finally hypothesized that emergence from surgical anesthesia was primarily influenced by the patient’s personality and that pain was not the essential factor causing delirium [1].

Dose-Response of Propofol for Tracheal Intubation in Children Correlated to Intubation Condition Score and Cerebral State Index. Randomized, Double-Blinded Trial

Background: Avoiding neuromuscular blocking drugs may prevent the potential complications of their use if they are not required for the planned procedure. This study was designed to estimate dose-response of propofol for tracheal intubation in children correlated to Intubation Condition Score and Cerebral State Index (CSI) without neuromuscular blocking drugs. Methods: 56 children (ages 3-8 years), ASA physical status I and II, weight 13-35 Kg, admitted for adenotonsillectomy were included. Children were randomly divided into four groups to receive propofol by Target Controlled Infusion (TCI) at different concentrations: 3.0 μg•ml-1, 3.5 μg•ml-1, 4.0 μg•ml-1, 4.5 μg•ml-1. At time T0 remifentanil infusion 0.5 μg•kg-1•min-1 was started. After 4 min, time T1, children received propofol according to their group. At time T2 (8 min after T0) tracheal intubation was carried out, Intubation Condition Score and CSI values at time T2 were assessed. Results: The results show that increasing propofol plasma concentrations from 3.0 μg•ml-1 to 4.5 μg•ml-1, the number of patients with acceptable intubating conditions, increased to 100%. There was a statistically significant difference with respect to Intubating Condition Score: 3.0 μg•ml-1 vs 4.5 μg•ml-1 and 3.0 μg•ml-1 vs 4.0 μg•ml-1. With reference to CSI values, a statistically significant difference was observed between 4.5 μg•ml-1 and the other 3 concentrations. We observed a significant difference in patients with CSI≤50 versus CSI>50 among the four propofol groups. Therefore, we detected a significant difference in the Intubation Condition Score between the CSI≤50 and CSI>50 groups. Conclusions: The administration of propofol at 4 and 4.5 μg•ml-1, coadministered with remifentanil 0.5 μg•kg-1•min-1, provided clinically acceptable conditions for tracheal intubation. In our opinion the use of CSI monitoring may be of practical value in producing acceptable intubating conditions in children.

Intraocular pressure during laparoscopic surgery in paediatric patients

Intraocular pressure (IOP) has recently received much attention during anaesthesia in children.1 The effect of anaesthetic procedures on IOP has been well documented during non-ophthalmic surgery, and is unrelated to changes in blood pressure or heart rate.2–4 Moreover, many studies have shown an increase in IOP during laparoscopic surgery in adults,2 5 but to date, there have not been any studies in a paediatric population. For this reason, we decided to perform a study to see if there is any correlation between IOP, anaesthesia and surgery technique in children. In our study, concerning children without any ocular pathologies, there were no IOP variations related to the premedication, anaesthesia technique …

Palliative Care in Pediatric Patients

Palliative medicine is the study and management of patients with discomfort present, progressive, and evolved, for whom the prognosis is limited. The goal of palliative care, is to achieve the best quality of life for patients and their relatives. Palliative care for children is a developing area of care that is not yet widely recognized as a specialty in its own right. Palliative care aims to support children with life-limiting conditions and their families to maintain quality of life. A life- threatening illness is one where there is a high probability of premature death due to severe illness, but there is also a chance for long-term survival to adulthood. Children’s palliative care differs from adult palliative care. Provision of pediatric palliative care around the world is scant. There are many reasons for this such as financial, lack of trained professionals, and a lack of general awareness by the public or policymakers. Despite these barriers, many countries have found ways to provide this care and these countries are both resource-rich and resource-poor. It is important for these countries to share their experience, which includes valuable information on how barriers were overcome and programs were developed and implemented. Only through information dissemination will countries with no programs be able to learn from others and to identify strategies that they can be used to help advance the pediatric palliative care movement worldwide.