Caroline A. Pasquariello

Determining optimum operating room utilization

Economic considerations suggest that it is desirable to keep operating rooms fully used when staffed, but the optimum utilization of an operating room (OR) is not known. We created a simulation of an OR to define optimum utilization. We set operational goals of having cases start within 15 min of the scheduled time and of having the cases end no more than 15 min past the scheduled end of the day. Within these goals, a utilization of 85% to 90% is the highest that can be achieved without delay or running late. Increasing the variability of case duration decreases the utilization that can be achieved within these targets.

Rapacuronium and the risk of bronchospasm in pediatric patients.

We conducted this study to determine the risk factors for the development of bronchospasm after the administration of rapacuronium and to determine if children with bronchospasm on induction of anesthesia were more likely to have received rapacuronium compared with other muscle relaxants. In a retrospective cohort study, all anesthetic records in which rapacuronium was administered were reviewed to determine which patients developed bronchospasm during induction of anesthesia. Two-hundred-eighty-seven patients were identified, of whom 12 (4.2%; 95% confidence interval [CI], 2.2%–7.2%) developed bronchospasm during induction of anesthesia. Significant risk factors for the development of bronchospasm with administration of rapacuronium included rapid sequence induction (relative risk [RR], 17.9; 95% CI, 2.9–∞) and prior history of reactive airways disease (RR, 4.6; 95% CI, 1.5–14.3). In a case-control study, all cases of bronchospasm during induction of anesthesia in the 5-mo time period that rapacuronium was available for clinical use were identified. Aside from the 12 cases of bronchospasm with rapacuronium, 11 additional cases of bronchospasm were associated with the use of other muscle relaxants. Four controls were randomly selected for each of the 23 cases of bronchospasm. Children with bronchospasm during induction of anesthesia were several times more likely (odds ratio, 10.1; 95% CI, 3.5–28.8) for having received rapacuronium compared with other muscle relaxants.

Analgesia for venepuncture in a paediatric surgery centre.

To establish an effective and efficient method of painless venepuncture in children 8 years and older in an ambulatory paediatric surgery centre.

Plasma cholinesterase deficiency in a neonate

We report a two-day-old infant who had a period of apnoea lasting six hours following the intravenous administration of succinylcholine (Sch). The results of her plasma cholinesterase level and dibucaine number indicate a congenital absence of plasma cholinesterase (PChE) enzyme, although both parents and siblings had normal cholinesterase levels and dibucaine numbers. This is believed to be the youngest reported case of prolonged apnoea after the administration of succinylcholine.RésuméNous rapportons le cas d’un bébé de deux jours qui présente une période d’apnée de six heures après l’administration intraveineuse de succinylcholine. Les résultats du dosage de la cholinestérase plasmatique et de l’épreuve à la dibucaïne montrent une absence congénitale de cholinestérase plasmatique (PChE), malgré des dosage normaux chez les parents et la fratrie. Nous croyons qu’il s’agit là du plus jeune cas d’apnée prolongée après administration de succinylcholine.

Early intravenous cannulation in children during inhalational induction of anaesthesia

Intravenous cannulation is obtained in almost all patients scheduled for operative intervention under anaesthesia. In our practice, inhalational induction precedes cannulation in children in order to avoid pain and discomfort, and cannulation is delayed until the child is adequately anaesthetized in fear of precipitating laryngospasm due to painful stimulus of venepuncture in the light stage of anaesthesia. This study was performed on 150 patients between two to eight years of age to determine if there is a difference in the incidence of untoward incidents, if cannulation is performed when children are lightly anaesthetized (Early, Group E), as compared to when they are deeply anaesthetized (Late, Group L). In patients randomized to early cannulation, the results showed that there was a significantly shorter time from induction to venous cannulation, the halothane concentration was lower at the time of cannulation, there was a greater incidence of movement on cannulation and a greater incidence of changes in heart rate, blood pressure, and respiratory rate. There was no significant differences in the incidence of laryngospasm or in the success rate of intravenous cannulation between the two groups. We conclude that venous cannulation can be safely performed during the light stages of anaesthesia.

Bacterial endocarditis prophylaxis: What is recommended and what is practiced?

STUDY OBJECTIVE To determine how often pediatric anesthesiologists follow the American Heart Association (AHA) recommendations for the administration of prophylactic antibiotics to prevent bacterial endocarditis (BE). DESIGN Questionnaires mailed to all members of the Society for Pediatric Anesthesia regarding their use of antibiotics to prevent BE. SETTING Anesthesia department at a university-affiliated childrens hospital. MEASUREMENTS AND MAIN RESULTS 898 questionnaires were mailed, and 465 questionnaires were returned, yielding a response rate of 52%. When anesthesiologists administer BE prophylaxis intravenously (IV), they perform an inhalation anesthetic 76% of the time prior to establishing IV access. Ninety percent of the respondents stated that if administration of antibiotics occurs after a mask induction, they do not delay incision or instrumentation for 30 minutes. Therefore, respondents do not follow AHA recommendations for BE prophylaxis 55% of the time. Of the 465 respondents, only 4 recalled pediatric patients who developed perioperative BE. CONCLUSIONS The majority of anesthesiologists responding to this survey routinely do not follow the current AHA recommendations for BE prophylaxis when caring for children. Since there are no studies demonstrating that administering antibiotics 30 minutes prior to invasive procedures is more effective than administering antibiotics immediately prior to invasive procedures, it may be appropriate to follow a time sequence that is more comfortable and convenient for pediatric patients. We believe that a reconsideration of the current AHA recommendations for BE prophylaxis is warranted.

Intrathecal morphine for pediatric renal transplant recipients

Many pediatric renal transplant recipients have significant discomfort in the early postoperative period despite opioid administration. Intrathecal morphine is safe and effective for pain control in children. We examined our results with the use of intrathecal morphine for postoperative analgesia in renal transplant recipients at our institution. The morphine was administered while the patients were under general anesthesia. Seventeen of 22 patients received excellent pain control and there were few minor and no major complications. Intrathecal morphine is beneficial for postoperative analgesia in pediatric renal transplant recipients.

An Additional Sign of Correct Needle Placement When Performing a Caudal Block in Pediatric Patients

We appreciate I. Malagon’s comments about the statistical analysis in Table 2 of our recent investigation concerning the effects of nimodipine on regional blood flow in the heart and brain during cardiopulmonary resuscitation (CPR) in pigs. We fully agree that nonparametric tests would have been more appropriate given that several groups of data in this table do not follow a normal distribution. However, although the use of Student’s t-test was not an ideal choice in this case, it did not produce misleading results. This can be explained by the fact that Student’s t-test is not very susceptible to deviations from a normal distribution. Malagon is especially concerned about the possibility that by using a nonparametric test statistically significant differences in blood flow in the heart and brain between the nimodipineand placebo-treated pigs would already exist before drug treatment. To test this possibility, we used the Mann-Whitney U-test for comparisons of blood flow in the heart and brain between the two groups and found no significant differences before drug treatment at baseline and at 5 min of CPR between the two groups or between successfully and unsuccessfully resuscitated animals. In addition, the pattern of significances during the observation period as reported in Table 2 has been, in general, robust to the application of a nonparametric test. Concerning the number of animals in Table 2, we would like to point out that this table contains the successfully resuscitated animals. We stated in the Discussion section of our paper that each animal that was successfully resuscitated lived throughout the observation period. Therefore, at baseline and at 240 min after CPR, the same numbers of animals were available for measurement. We apologize for not stating this more clearly in our article.

Univent tube: a simple method for avoiding a potentially disastrous complication.

To the beginning anesthesiologist, the approach to the treatment of malignant hyperthermia is confusing and cumbersome. In particular, the emphasis on rapid detection and institution of treatment in this infrequent disease is stressful to the inexperienced and may affect recall of the malignant hyperthermia protocol. The following mnemonic is offered as an aid to teaching the essential steps in the initial treatment of a case of malignant hyperthermia.