Charles H. Lockhart

Seizures occurring in pediatric patients receiving continuous infusion of bupivacaine.

ontinuous infusion of local anesthetics through regional techniques has recently C gained popularity for the treatment of postoperative pain; however, information on the appropriate safe and effective doses and infusion rates for use in children is still limited. The following two case reports illustrate bupivacaine toxicity manifested by seizures in the absence of cardiovascular problems caused by the cumulative effect of a continuous infusion. Although different sites (intrapleural in case 1 and epidural in case 2) were used, the blood levels at the time of the seizures are remarkably similar.

Oral transmucosal fentanyl citrate for preanesthetic medication of pediatric day surgery patients with and without droperidol as a prophylactic anti-emetic

he safety and efficacy of oral transmucosal fentanyl citrate (OTFC) as a preanesthetic medication and the efficacy of droperidol as a prophylactic anti-emetic were evaluated in 100 children aged 2-8 yr undergoing general anesthesia for outpatient surgery. Patients were randomly assigned to one of four groups and managed in a double-blinded manner: 1) placebo lozenge 45 min preoperatively and placebo (normal saline) injected intravenously after induction of anesthesia; 2) placebo lozenge 45 min preoperatively and 50 micrograms/kg droperidol intravenously after induction; 3) 15-20 micrograms/kg OTFC lozenge 45 min preoperatively and placebo intravenously after induction; and 4) 15-20 micrograms/kg OTFC lozenge 45 min preoperatively and droperidol 50 micrograms/kg intravenously after induction. Anesthesia was induced and maintained with halothane and nitrous oxide in oxygen. Heart rate, respiratory rate, blood pressure, and hemoglobin oxygen saturation (SpO2) were monitored throughout the study. Scoring systems were used to evaluate sedation, anxiety, cooperation, and ease and quality of anesthetic induction. Emergence, recovery, and discharge times were recorded. Nausea, vomiting, and adverse effects were noted. Preoperatively, children receiving OTFC had significantly greater sedation, slower respiratory rates, lower SpO2, and less excitement during induction. Postoperative nausea and vomiting occurred significantly more frequently after OTFC than after placebo. Prophylactic droperidol did not significantly reduce the incidence of nausea and vomiting. The authors conclude that, in pediatric surgical outpatients, OTFC reliably induces preoperative sedation and facilitates inhalation induction of anesthesia, but it is associated with significant decreases in respiratory rate and SpO2 and a high incidence of postoperative nausea and vomiting that is not significantly reduced by prophylactic droperidol.

Advances in diabetic management : Implications for anesthesia

The past 20 yr have seen an explosion in advances for the management of Type I diabetes mellitus. Not only new delivery systems, such as the continuous subcutaneous insulin pump, but also better and more stable types of insulin with predictable pharmacokinetics and pharmacodynamics have been developed. An artificial pancreas is now on the horizon. This progress has had a significant impact on modern perioperative care of the diabetic patient.

Postoperative quadriplegia after spinal fusion for scoliosis with intraoperative awakening

Neurologic complications, although rare, may follow scoliosis correction by spinal fusion (1,2). The incidence of acute neurologic complications during spine fusion may vary, with the population treated and the procedure performed, from 0.7% to 5.0% (2,3). The etiology of cord damage during spinal fusion remains unclear, but may involve vascular compromise associated with mechanical deformation (1,4-6). Intraoperative monitoring of spinal cord function during scoliosis correction has been recommended as a means of detecting early neurologic deficits that can be reversed by reduction of vertebral distraction or removal of supporting rods (3,6-11). Wake-up techniques and recording of somatosensory evoked potentials (SSEPs) are the only current means for monitoring spinal cord integrity during scoliosis surgery (3,6-12). Recently, postoperative paraplegia has been observed despite the recording of normal intraoperative SSEPs. As SSEP monitoring continues to be a research tool that is not universally available, intraoperative awakening has remained an important modality for testing cord integrity after scoliosis correction since its introduction in 1973 (11). Permanent quadriplegia after successful intraoperative awakening during spine fusion for scoliosis is now reported.

Hypotensive Anaesthesia for Craniectomy in Infancy

Deliberate hypotension using halothane and controlled ventilation without positive end-expiratory pressure was employed in 18 of 30 patients undergoing craniectomy for unilateral or bilateral craniosynostosis over a 3-yr period. The technique was simple, resulted in good control of arterial pressure and diminished blood loss, and did not involve extensive monitoring or the use of potentially toxic adjuvant drugs. In the hypotensive group mean systolic arterial pressure was decreased from 92.5 to 65.0 mm Hg. Estimated blood loss was decreased from 111 to 89 ml (mean) for all ages and from 133 to 72 ml (mean) for infants between 8 and 32 weeks of age compared with the normotensive control group.