Deidre R. Larrier

The Effect of Intraoperative Dexmedetomidine on Postoperative Analgesia and Sedation in Pediatric Patients Undergoing Tonsillectomy and Adenoidectomy

BACKGROUND: The immediate postoperative period after tonsillectomy and adenoidectomy, one of the most common pediatric surgical procedures, is often difficult. These children frequently have severe pain but postoperative airway edema along with increased sensitivity to the respiratory-depressant effects of opioids may result in obstructive symptoms and hypoxemia. Opioid consumption may be reduced by nonsteroidal antiinflammatory drugs, but these drugs may be associated with increased bleeding after this operation. Dexmedetomidine has mild analgesic properties, causes sedation without respiratory depression, and does not have an effect on coagulation. We designed a prospective, double-blind, randomized controlled study to determine the effects of intraoperative dexmedetomidine on postoperative recovery including pain, sedation, and hemodynamics in pediatric patients undergoing tonsillectomy and adenoidectomy. METHODS: One hundred nine patients were randomized to receive a single intraoperative dose of dexmedetomidine 0.75 &mgr;g/kg, dexmedetomidine 1 &mgr;g/kg, morphine 50 &mgr;g/kg, or morphine 100 &mgr;g/kg over 10 minutes after endotracheal intubation. RESULTS: There were no significant differences among the 4 groups in patient demographics, ASA physical status, postoperative opioid requirements, sedation scores, duration of oxygen supplementation in the postanesthetic care unit, and time to discharge readiness. The median time to first postoperative rescue analgesic was similar in patients receiving dexmedetomidine 1 &mgr;g/kg and morphine 100 &mgr;g/kg, but significantly longer compared with patients receiving dexmedetomidine 0.75 &mgr;g/kg or morphine 50 &mgr;g/kg (P < 0.01). In addition, the number of patients requiring >1 rescue analgesic dose was significantly higher in the dexmedetomidine 0.75 &mgr;g/kg group compared with the dexmedetomidine 1 &mgr;g/kg and morphine 100 &mgr;g/kg groups, but not the morphine 50 &mgr;g/kg group. Patients receiving dexmedetomidine had significantly slower heart rates in the first 30 minutes after surgery compared with those receiving morphine (P < 0.05). There was no significant difference in sedation scores among the groups. CONCLUSIONS: The total postoperative rescue opioid requirements were similar in tonsillectomy patients receiving intraoperative dexmedetomidine or morphine. However, the use of dexmedetomidine 1 &mgr;g/kg and morphine 100 &mgr;g/kg had the advantages of an increased time to first analgesic and a reduced need for additional rescue analgesia doses, without increasing discharge times.

Propranolol for the treatment of subglottic hemangiomas

INTRODUCTION Infantile subglottic hemangiomas are rare causes of airway obstruction. They begin to proliferate at 1-2 months of age and can cause biphasic stridor with or without respiratory distress. Diagnosis requires direct visualization by direct laryngoscopy and bronchoscopy. Various therapeutic options have been utilized for treatment, including tracheotomy, open surgical excision, laser ablation, intralesional steroid injection, systemic steroids, and now oral propranolol. METHODS We present a retrospective chart review of infantile subglottic hemangiomas over a 5-year span (January 2005-2010) at a tertiary care pediatric hospital. IRB approval was obtained, and charts were reviewed to find patients with subglottic hemangiomas, including patient characteristics, presentation, workup, medical and surgical management, and outcomes. A case presentation demonstrates diagnostic, management, and treatment strategies and dilemmas encountered. RESULTS Nine patients were found to have infantile subglottic hemangiomas. Six of nine patients were treated with laser excision, with five of the six having localized subglottic hemangiomas. In 2009, three of four patients were initiated on propranolol as first-line treatment; the fourth had comorbidities which precluded this. Of the three, two showed improvement, while a third, who also had bearded hemangioma, required tracheotomy. DISCUSSION Infantile subglottic hemangiomas are rare but essential in the differential diagnosis of biphasic stridor. Although propranolol has been effective in treating cutaneous and airway hemangiomas, our experience suggests that this is not consistent for subglottic hemangiomas. In an area where airway compromise can be lethal, we must extend caution and monitor these patients closely as they may require adjuvant therapy.

Advanced pediatric mastoiditis with and without intracranial complications

Recently, several groups have noticed an increase in cases of advanced pediatric mastoiditis and intracranial complications. The objective of this study was to review the bacteriology of advanced mastoiditis in pediatric patients, with the hypothesis that a difference in bacteriology might explain the development of an intracranial complication.

Postoperative analgesic and behavioral effects of intranasal fentanyl, intravenous morphine, and intramuscular morphine in pediatric patients undergoing bilateral myringotomy and placement of ventilating tubes.

BACKGROUND:Bilateral myringotomy and placement of ventilating tubes (BMT) is one of the most common pediatric surgical procedures in the United States. Many children who undergo BMT develop behavioral changes in the postanesthesia care unit (PACU) and require rescue pain medication. The incidence of these changes is lower in children receiving intraoperative opioids by the nasal, IM, or IV route compared with placebo. However, there are no data to indicate which route of administration is better. Our study was designed to compare the immediate postoperative analgesic and behavioral effects of 3 frequently used intraoperative techniques of postoperative pain control for patients undergoing BMT under general anesthesia. METHODS:One hundred seventy-one ASA physical status I and II children scheduled for BMT were randomized into 1 of 3 groups: group 1—nasal fentanyl 2 &mgr;g/kg with IV and IM saline placebo; group 2—IV morphine 0.1 mg/kg with nasal and IM placebo; or group 3—IM morphine 0.1 mg/kg with nasal and IV placebo. All subjects received a standardized general anesthetic with sevoflurane, N2O, and O2 and similar postoperative care. The primary end point of the study was the pain scores measured by the Faces, Legs, Activity, Cry, and Consolability (FLACC) scale in the PACU. RESULTS:There were no significant differences in peak FLACC pain among the 3 groups (mean [95% CI] 2.0 [1.2–2.8] for intranasal fentanyl, 2.7 [1.7–3.6] for IV morphine, and 2.9 [2.1–3.7] for IM morphine, respectively). There were no differences in the scores on the Pediatric Anesthesia Emergence Delirium (PAED) scale, incidence of postoperative emergence delirium (PAED score ≥12), emesis, perioperative hypoxemia, or need for airway intervention, and postoperative rescue analgesia. There were also no differences in the duration of PACU stay or parental satisfaction among the groups. CONCLUSION:In this double-blind, double-dummy study, there was no difference in the efficacy of intranasal fentanyl, IM and IV morphine in controlling postoperative pain and emergence delirium in children undergoing BMT placement. The IM route is the simplest and avoids the potential for delays to establish vascular access for IV therapy and the risks of laryngospasm if intranasal drugs pass through the posterior nasopharynx and irritate the vocal cords.

Anatomy of headache and facial pain

In this article we review the neural and vascular supply contributing to headache and facial pain. A detailed review of the neuroanatomy, particularly of the trigeminal contribution, was formulated. Emphasis was placed on outlining the dural, supratentorial, and facial structures innervated. A detailed review of the vascular anatomy is performed, with demonstration of the trigeminal innervation of key vascular structures. An outline of pain-sensitive cranial structures is also described. The pathways examined in this article serve as the basis on which concepts of headache and facial pain will build.

Cervical thymic anomalies--the Texas Children's Hospital experience.

To review the presentation and management of cervical thymic cysts and ectopic thymic tissue at Texas Childrens Hospital over the last 25 years.

Microbiology of third and fourth branchial pouch cysts.

To identify the most common pathogens involved in infections of third and fourth branchial pouch cysts. Third and fourth branchial pouch cyst infections are an uncommon cause of anterior neck abscesses often confused with other entities, such as thyroglossal duct cysts and thyroid abscesses leading to misdiagnosis, recurrence, and increased morbidity related to a delay in diagnosis and appropriate treatment.

Complications of Sinusitis

Complications of sinusitis arise mostly as a result of the sinuses being separated from key organ structures only by relatively thin pieces of bone. As a result, there is always the potential for the disease to spread from the sinuses into the orbital space, and intracranially.

Modification of the Laerdal MegaCode Kid Mannequin Head to Simulate Aspiration of Peritonsillar Abscess

Objectives: (1) Validate a low-fidelity mannequin model engineered to teach drainage of peritonsillar abscesses. (2) Pilot this mannequin model in instructing incoming otolaryngology residents on drainage of peritonsillar abscesses. Methods: A peritonsillar abscess (PTA) simulator was constructed through modification of the Laerdal MegaCode Kid Mannequin head using inexpensive components. Tonsils were constructed from Dermasol, and the peritonsillar abscess was simulated by placing a balloon filled with a mixture of water and body lotion behind the appropriate soft palate region. A feedback electrode was placed behind this to create an audible buzz if the needle went too far, simulating entrance into the carotid artery. The model was validated by a panel of experts through survey, and subsequently used to teach PTA drainage to PGY2 otolaryngology residents. Results: The expert panel unanimously agreed that they would use the device to teach PTA drainage to trainees. The model was then used to instruct a novice group (N = 6). The majority of this novice group reported that the session was a vital part of their training experience, and it was important to practice drainage of a PTA on a mannequin. Conclusions: We validated a mannequin task trainer for drainage of peritonsillar abscesses and successfully implemented it into a teaching session. Given the frequency of presentation of PTA, the need to become competent in the procedure early in residency, and the success demonstrated using our model, we believe the model could be inexpensively replicated at other institutions for more safely and effectively teaching the procedure.

Creating an Algorithm for Preoperative Cardiac Assessment of Adenotonsillectomy Patients with Obstructive Sleep Apnea

Objectives: Create guidelines in preoperative cardiac workup for obese pediatric patients with obstructive sleep apnea (OSA) undergoing adenotonsillectomy (T&A). Specific objectives include: 1) Correlate body mass index (BMI) with postoperative complications. 2) Correlate BMI with cardiac pathology on preoperative and/or postoperative studies. 3) Determine if severity of OSA based on polysomnography (PSG) testing can predict postoperative complications. Methods: We conducted a retrospective chart review of over 110 pediatric patients with a BMI ≥ 25 kg/m2 who underwent T&A for OSA at a tertiary care children’s hospital from January 2006 to December 2011, excluding syndromic features or pre-existing cardiopulmonary disorders. Postoperative complications were analyzed in conjunction with BMI and severity of OSA based on polysomnography. Results: Preliminary analyses of cardiopulmonary pathology revealed 6 patients with right ventricular hypertrophy or dilation, 18 with tricuspid regurgitation, and 1 with reactive airway disease. There were no severe postoperative complications. Thirty-four patients underwent a polysomnogram with a mean apnea-hypopnea index (AHI) of 37.1 and a mean oxygen nadir of 80.5%. Increasing BMI was significantly correlated with higher AHI (P = 0.01, r = 0.5) but did not predict postoperative complications (P = 0.91). Preoperative oxygen nadir on PSG more closely predicted cardiac pathology, though results did not approach significance (P = 0.15). Conclusions: No adverse cardiopulmonary events were experienced by obese pediatric patients undergoing T&A, and hence, current data suggest that preoperative cardiac evaluation for obese children solely for the purpose of undergoing T&A is not routinely warranted.