David H. Corddry

Comparison of cuffed and uncuffed endotracheal tubes in young children during general anesthesia

Background Uncuffed endotracheal tubes are routinely used in young children. This study tests a formula for selecting appropriately sized cuffed endotracheal tubes and compares the use of cuffed versus uncuffed endotracheal tubes for patients whose lungs are mechanically ventilated during anesthesia. Methods Full‐term newborns and children (n = 488) through 8 yr of age who required general anesthesia and tracheal intubation were assigned randomly to receive either a cuffed tube sized by a new formula [size(mm internal diameter) = (age/4) + 3], or an uncuffed tube sized by the modified Coles formula [size(mm internal diameter) = (age/4) + 4]. The number of intubations required to achieve an appropriately sized tube, the need to use more than 21 [center dot] min sup ‐1 fresh gas flow, the concentration of nitrous oxide in the operating room, and the incidence of croup were compared. Results Cuffed tubes selected by our formula were appropriate for 99% of patients. Uncuffed tubes selected by Coles formula were appropriate for 77% of patients (P < 0.001). The lungs of patients with cuffed tubes were adequately ventilated with 2 1 [center dot] min sup ‐1 fresh gas flow, whereas 11% of those with uncuffed tubes needed greater fresh gas flow (P < 0.001). Ambient nitrous oxide concentration exceeded 25 parts per million in 37% of cases with uncuffed tubes and in 0% of cases with cuffed tubes (P < 0.001). Three patients in each group were treated for croup symptoms (1.2% cuffed; 1.3% uncuffed). Conclusions Our formula for cuffed tube selection is appropriate for young children. Advantages of cuffed endotracheal tubes include avoidance of repeated laryngoscopy, use of low fresh gas flow, and reduction of the concentration of anesthetics detectable in the operating room. We conclude that cuffed endotracheal tubes may be used routinely during controlled ventilation in full‐term newborns and children during anesthesia.

Ondansetron reduces the incidence and severity of poststrabismus repair vomiting in children

This prospective, randomized, placebo-controlled, double-blinded study evaluated the antiemetic efficacy of ondansetron and metoclopramide in 90 ASA physical status I or II children, 2-17 yr of age, undergoing strabismus repair. After anesthetic induction and prior to eye muscle manipulation, subjects received normal saline 0.3 mL/kg (Group 1), metoclopramide 0.25 mg/kg (Group 2), or ondansetron 0.15 mg/kg (Group 3), intravenously. There were no differences between groups with respect to age, weight, gender, fluids received, number of eye muscles repaired, anesthetic technique, or time in the operating room. The incidence of vomiting in Groups 1, 2, and 3 was 50%, 27%, and 10% prior to discharge, and 67%, 53%, and 30% during the 24 h after surgery, respectively. The number of children vomiting prior to discharge and within 24 h of surgery was significantly reduced in Group 3 compared with Group 1 (P < 0.003 and P < 0.015, respectively). The number of vomiting episodes per patient in Groups 1, 2, and 3 was 1.1, 0.5, and 0.1 prior to discharge, and 4.5, 2.6, and 1.2 during the 24 h after surgery (P < 0.0005 and P < 0.004, respectively). Ondansetron 0.15 mg/kg intravenously after the induction of anesthesia reduces the incidence and severity of vomiting after strabismus repair both prior to discharge from the hospital and during the 24 h after surgery.

A Study of Desmopressin and Blood Loss during Spinal Fusion for Neuromuscular Scoliosis A Randomized, Controlled, Double-Blinded Study

Background: Studies examining the use of desmopressin acetate (DDAVP) have shown variable results in DDAVPs efficacy for reducing blood loss. Studies of adults having cardiac surgery and of children having spinal fusion have suggested that patients with complicated medical histories and complex surgical procedures may benefit from use of DDAVP. Therefore, this study was designed to examine the homeostatic effects of DDAVP in children with severe cerebral palsy undergoing spinal fusion. Methods: A randomized, double‐blinded, and placebo‐controlled trial of DDAVP was designed to enroll 40 patients. However, termination of the study was advised by the Institutional Review Board after 21 patients were enrolled. All patients had spastic quadriplegic‐type cerebral palsy and were randomly assigned to one of two groups. The DDAVP group received 0.3 micro gram/kg DDAVP in 100 ml normal saline, and the placebo group received normal saline alone. All patients were anesthetized with nitrous oxide, oxygen, isoflurane, and fentanyl. Factor VIIIC and von Willebrands factor (vWF) concentrations were measured in blood drawn before DDAVP infusion and 1 h after infusion. Blood pressure was maintained at a systolic pressure of less than 100 mmHg. Use of crystalloids, packed erythrocytes, platelets, and fresh frozen plasma were based on criteria established by protocol. Estimated blood loss was assessed by weighing sponges and measuring suctioned blood from canisters. Results: Estimated blood loss (intraoperative and postoperative) and amount of packed erythrocytes transfused were similar for the DDAVP and placebo groups. Concentrations of both factor VIIIC and vWF were significantly greater after DDAVP infusion when compared with concentrations after placebo infusion. Conclusions: In the children who had complex spinal fusion, there was no difference in estimated blood loss between those who received DDAVP and those who received a placebo. Administration of DDAVP significantly increased factor VIIIC and vWF levels.

Preoperative Oral Ondansetron for Pediatric Tonsillectomy

This prospective, randomized, double-blind, placebo-controlled study evaluated the antiemetic efficacy of preoperative oral ondansetron, 0.075 mg/kg or 0.15 mg/kg, in 136 preadolescent children premedicated with midazolam 0.5 mg/kg per os and dexamethasone 0.1 mg/kg intravenously prior to undergoing tonsillectomy with isoflurane anesthesia. The incidence of vomiting during the 24 h after tonsillectomy was significantly reduced (P < 0.04) by ondansetron 0.15 mg/kg compared with placebo and ondansetron 0.075 mg/kg (15%, 38%, and 36%, respectively). There was a significant reduction (P < 0.03) in the mean number of vomiting episodes per patient during the 24 h immediately after tonsillectomy in the ondansetron 0.15 mg/kg group compared with the placebo and ondansetron 0.075 mg/kg study groups (0.2 +/- 0.6, 0.8 +/- 1.3, and 0.8 +/- 1.3, respectively). The need for antiemetic rescue therapy (ondansetron 0.15 mg/kg intravenously after three episodes of emesis prior to discharge) was significantly greater in children who received placebo compared with the ondansetron 0.15 mg/kg study group (13% vs 0%, P < 0.05). We conclude that ondansetron 0.15 mg/kg, administered orally prior to tonsillectomy, is associated with reduced postoperative vomiting in preadolescent children. In addition, the preoperative oral administration of ondansetron 0.075 mg/kg is no more effective than placebo in preventing posttonsillectomy vomiting in preadolescent children. (Anesth Analg 1996;82:558-62)

Does Pediatric ICU (PICU) Residency Curriculum Match General Pediatric Practice (GP) Needs

Does Pediatric ICU (PICU) Residency Curriculum Match General Pediatric Practice (GP) Needs?

THE MISMATCH BETWEEN ATTENDING (ATTND) AND RESIDENT (RES) DESIRED EDUCATION DELIVERY STYLES IN PEDIATRIC INTENSIVE CARE (PICU) |[dagger]| 1774

PICU program directors must decide on the best educational delivery process to implement resident educational guidelines as published by the American Board of Pediatrics and the Society of Critical Care. Our goal was to evaluate both RES and ATTND determinations of the optimal RES (PL-2) rotation in an intensivist directed, non-fellow PICU. METHOD: Using an orthogonal array design, a survey was constructed which included 9 unique 4-factor-3-intensity educational delivery profiles. Factors and intensities included: RES CLINICAL supervision [structured, flexible, independent], RES PROCEDURE supervision [structured, flexible, independent], ATTND TEACHING STYLE [interactive, formal lectures, RES independent study], and EVALUATION OF RES [standardized test, oral interview, RES formal presentation]. Conjoint analysis (using SYSTAT) evaluated the utility score (0-9), importance (%total utility range for each factor) and variability (intergroup utility range differences) of factors and intensities. RESULTS: The educational delivery factor of highest utility and importance for RES (n=34) was CLINICAL(flexible) (6.0, 34%) but for ATTND (n=23) was PROCEDURE (flexible) (5.8, 39%). The educational delivery factor of least utility and importance for RES was PROCEDURE (structured) (4.7, 10%) but for ATTND was EVALUATION OF RES(test) (4.7, 13%). When analyzed by RES year, TEACHING STYLE (44%) and EVALUATION OF RES (24%) importance showed the highest variability. ATTND response did not significantly vary by specialty type nor yrs of experience. CONCLUSION: There is a mismatch between RES and ATTND in terms of preferred allowed flexibility in performing procedures. ATTND are least concerned with the evaluation of the RES performance. RES value most the clinical interactive nature of a PICU rotation. RES PICU rotations should be designed to maximize their utility for both RES and ATTND and require reevaluation if RES composition or ATTND teaching opportunity time decreases.