Charles R. Schrock

The dose of caudal epidural analgesia and duration of postoperative analgesia

Background: Single dose caudal epidural is commonly utilized for postoperative analgesia in children. Previous studies have determined the optimal concentration of local anaesthetic, and the minimal volume to produce a desired dermatomal distribution. However, none has sought the optimal volume to administer. The specific aim of this study was to determine whether the volume of caudal epidural local anaesthetic influenced the duration of postoperative analgesia.

Peri‐operative pain management in children with cerebral palsy: comparative efficacy of epidural vs systemic analgesia protocols

Selective Dorsal Rhizotomy (SDR) is the only surgical intervention with class I evidence supporting permanent reduction in spasticity for children with cerebral palsy (Paediatr Anaesth, 12, 2002, 296; Neurosurg Focus, 21, 2006, e2). Postoperatively, adequate analgesia can be difficult to achieve (J Neurosurg, 105, 2006, 8; Childs Nerv Syst, 17, 2001, 556; Pediatr Neurosurg, 43, 2007, 107; Anesth Analg, 79, 1994, 340; Reg Anesth Pain Med, 24, 1999, 438; Pediatr Anesth, 19, 2009, 1213). This study examines a novel regimen utilizing the combination of epidurally infused ropivacaine – hydromorphone and scheduled ketorolac. This regimen was compared to a protocol utilizing systemic fentanyl and diazepam.

Difficult airway consultation service for children: steps to implement and preliminary results

Failed airway management remains one of the most common causes of cardiopulmonary arrest in the pediatric population. Practice guidelines addressing the difficult airway (DAW) in adults provide anesthesiologists a framework for managing the airway during the perioperative period; however, similar consensus guidelines are lacking in the pediatric population. Many of the adverse events associated with difficult pediatric airway management occur outside the perioperative setting and often result in worse outcomes. The lower frequency of DAW management required in children, lesser awareness of pediatric health care professionals about DAW management, and the need for guiding principles led us to develop a DAW consultative service. This report outlines the steps to establish the Difficult Airway Service (DAS) and the initial experiences with this new consultation service.

Images in Anesthesiology: Transient Paraplegia after Anesthesia for Magnetic Resonance Imaging

AN 8-yr-old girl developed kyphosis and myelopathy after treatment for Ewing sarcoma. Her thoracic kyphosis (144°) had resulted in myelopathy, gait disturbance, and urinary incontinence (fig.). Halo traction had been instituted 3 months before preparing for C7–T11 posterior spinal fusion. The magnetic resonance imaging (MRI) findings are marked kyphosis of the thoracic spine, with marked narrowing of the spinal canal over the kyphotic deformity, worst at the apex at the T5–T6 level (arrow). To obtain the MRI, halo-gravity traction was discontinued in the hours before the study. She was sedated with propofol and received supplemental oxygen by nasal cannula. Spontaneous ventilation was maintained without airway instrumentation. Blood pressures were within 85% of awake measures during the 90-min MRI. She complained of paralysis on emergence. Examination revealed flaccid lower-extremity paralysis. She did not respond to painful toe touch. She had no light touch sensation of the legs and lower abdomen. Halo traction was reestablished, and within 2 h, motor and sensory effects returned to baseline. A posterior spinal fusion was performed the day after the MRI, and her myelopathy continued to improve throughout her 2-week hospitalization. Children with thoracic kyphosis are at increased risk of experiencing myelopathy and neurologic deficits during correction surgery when compared with children with other forms of scoliosis. The discontinuation of halo traction, positioning during the MRI procedure, or hemodynamic changes associated with propofol anesthesia could all potentially contribute to the transient deficit. Maintaining halo traction with a nonferromagnetic device during MRI might have reduced the likelihood of the transient paralysis, but the pins still can transmit thermal and vibratory energy, leading to scalp burns. The potential for neurologic injury in children with kyphosis requires vigilance and attention to those factors that may be associated with neurologic deterioration, such as the release of halo traction, patient positioning, and maintaining hemodynamic stability.