Dinesh K. Choudhry

The Use of Lidocaine for Preventing the Withdrawal Associated with the Injection of Rocuronium in Children and Adolescents

UNLABELLED We designed this study to examine the incidence and degree of movement after the administration of rocuronium in children and adolescents and to measure the treatment effect of lidocaine for its prevention. One hundred patients (aged 5-18 yr) were randomly assigned to two groups. After general anesthesia was induced with 5 mg/kg thiopental sodium and manual occlusion of venous outflow was performed, one group of patients received 0.1 mL/kg 1% lidocaine i.v.. A second group received 0.1 mL/kg of isotonic sodium chloride solution as a placebo control. Venous outflow occlusion was held for 15 s, released, and immediately followed by the administration of rocuronium 1 mg/kg i.v.. The patients response to rocuronium injection was graded using a 4-point scale. We observed that the incidence of withdrawal was 84% in the placebo group and was significantly decreased to 46% in patients pretreated with lidocaine (P < 0.001). This study demonstrates that the i.v. injection of rocuronium is commonly associated with a withdrawal reaction in anesthetized pediatric patients and that this reaction can be attenuated or eliminated by pretreatment with i.v. lidocaine. IMPLICATIONS Pain on injection of rocuronium in pediatric patients can be alleviated by pretreatment with i.v. lidocaine.

Bispectral Index Monitoring: A Comparison Between Normal Children and Children with Quadriplegic Cerebral Palsy

We performed this study to compare the correlation of bispectral index (BIS) values with different sevoflurane concentrations between normal children and those with quadriplegic cerebral palsy with mental retardation (CPMR). Twenty children with CPMR (Group I) and 21 normal children (Group II) between 2 and 14 yr of age were studied. Anesthesia was induced and maintained with sevoflurane and 66% N2O/O2. Bispectral values were recorded on an Aspect Medical Systems (Natick, MA) monitor, and sevoflurane concentrations were measured with an Ohmeda (Hanover, MA) inhaled anesthetic monitor. The BIS values were recorded after midazolam premedication; after the induction of anesthesia; at end-tidal sevoflurane concentrations of 1%, 3%, and again at 1%; and after emergence from the anesthetic. Both groups were similar in age and sex distribution, but children in Group I weighed less than those in Group II (P < 0.05). The BIS values were significantly lower in Group I compared with Group II after sedation, at 1% sevoflurane concentrations, and after emergence. No difference was observed between the two groups at anesthesia induction (8%) and at 3% sevoflurane concentration. We conclude that, in children with CPMR, BIS values exhibit a pattern of change similar to that observed in normal children. However, absolute BIS values obtained in such children are lower than those in normal children while awake and at different sevoflurane concentrations.

Anesthetic management of living liver donors.

PurposeLiving organ donation is being performed with increasing frequency to overcome the shortage of organs for transplantation. Our experience in the anesthetic management of donors with relevant issues is discussed and complications encountered are recorded.MethodsData were collected retrospectively and analyzed on all 22 left lateral hepatectomies performed at our institution between 1993 to 1997 for transplantation.ResultsMajor ethical concern was the risk to the donors and anesthetic issues were those of a major abdominal procedure. All except four donors were parents (mother/father). Average blood loss was 805 ± 479 ml and only two donors required blood transfusion. Mean operative time was 8.2 ± 1.5 hr. Thoracic epidural analgesia was the most commonly adopted mode of pain relief. Average time to return of bowel sound postoperatively was 3.1 ± 1.0 days and was not influenced by the postoperative analgesic technique used. Total duration of hospital stay was 8.4 ± 1.1 days. Three donors developed minor postoperative complications atrial fibrillation and retained JP drain; left lower lobe pneumonia; and incisional hernia. All patients recovered uneventfully.ConclusionLiving organ donors contribute towards decreasing the shortage of organs for transplantation. Minimizing the discomfort associated with the surgical intervention and providing a complication-free perioperative course will positively influence the continued availability of such donations. On review of the first 22 left lateral hapatectomies performed, we observed only minor complications. Postoperative pain was a serious problem and thoracic epidural provided satisfactory analgesia.RésuméObjectifLe don d’organe vivant se fait de plus en plus souvent en raison du manque d’organes pour la transplantation. Notre expérience de l’anesthésie des donneurs ainsi que les questions qui y sont pertinentes sont examinées et les complications qui surviennent sont présentées.MéthodeUne collecte rétrospective suivie d’une analyse des données des 22 hépatectomies latérales gauches réalisées pour la transplantation entre 1993 et 1997 à notre institution.RésultatsNotre principale souci éthique a été celui du risque encouru par les donneurs, et nos choix anesthésiques, ceux d’une intervention abdominale majeure. Les donneurs, sauf quatre, étaient des parents (mère/père). La perte sanguine moyenne a été de 805 ± 479 ml, et deux donneurs ont eu besoin de transfusion. Le temps moyen de l’opération a été de 8,2 ± 1,5 h. Lanalgésie épidurale thoracique a été privilégiée comme traitement de la douleur. Le temps moyen nécessaire au retour des bruits intestinaux postopératoires a été de 3,1 ± 1,0 jours peu importe la technique analgésique postopératoire utilisée. La durée totale du séjour hospitalier a été de 8,4 ± 1,1 jours. Trois donneurs ont développé des complications postopératoires mineures de fibrillation auriculaire et de rétention du drain de Jackson-Pratt, de pneumonie du lobe inférieur gauche et de hernie au site de l’incision. Tous les patients se sont rétablis sans incidents.ConclusionLes dons d’organe vivant permettent de palier le manque d’organes pour la transplantation. En réduisant l’inconfort associé à l’intervention chirurgicale et en procurant un environnement périopératoire sans complications, nous pourrons assurer le maintien de dons semblables. Lors de la révision des 22 premières hépatectomies latérales gauches, nous n’avons relevé que des complications mineures. La douleur postopératoire a été un problème sérieux que l’analgésie épidurale thoracique nous a permis de régler de façon satisfaisante.

Continuous chest wall ropivacaine infusion for analgesia in children undergoing Nuss procedure: a comparison with thoracic epidural

Pain following Nuss procedure is severe and its management is challenging. Many different pain treatment modalities are currently being used, but none of them have been found to be ideal.

The Alagille's syndrome and its anaesthetic considerations

Alagilles syndrome is an inherited disorder affecting multiple organ systems. Most characteristic is the paucity of the interlobular bile ducts with cholestasis. The anaesthetic plan for these patients should be based on careful preoperative preparation and attention to the issues involving hepatobiliary, cardiac, neurodevelopmental, nutritional, haematological, ocular and facial abnormalities. We report the case of a five‐and‐a‐half‐year old patient with Alagilles syndrome who sustained a pathological fracture of the femur and was scheduled for closed reduction and application of a hip spica cast. Relevant anaesthetic issues are discussed.

One lung anaesthesia for video assisted thoracoscopic lung biopsy in a paediatric patient

Introduction followed by an oxygen/nitrous oxide/halothane inhalation induction. Pancuronium was utilized for Video Assisted Thoracoscopic Surgery (VATS) is muscle relaxation. A direct laryngoscopy with a being used with increasing frequency in children. Miller no. two blade was performed and a size 4 F Single lung ventilation (SLV) is essential during VATS. Fogarty arterial embolectomy catheter was passed In older children, a double lumen tube is used for through the vocal cords until the 20 cm mark was at SLV. In infants, alternative techniques need to be the lips. This was followed immediately by a 4.5 oral used (1–8, 10). We report a case of a successful SLV tracheal tube which was secured at 13 cm. (Prior to in a 17-month-old undergoing VATS for a lung biopsy. insertion of the Fogarty catheter, it was ascertained A brief description of the procedure with practical that it would require about 1 ml of normal saline suggestions is also included. rather than the 0.75 ml of air mentioned on the package insert to fully inflate the balloon.) After the tracheal tube was positioned in the mid trachea, a Case report Pentax paediatric fibreoptic scope (2.5 outer A 17-month-old 11 kg male with a past medical diameter) was passed through a swivel connector to history significant for histiocytosis X and partial confirm the position of the Fogarty catheter. On diabetes insipidus (DI) presented for a lung biopsy inspection, the Fogarty catheter was found to be lying for evaluation of a diffuse reticular nodular infiltrate at the level of the carina. With a gentle twisting on his chest x-ray. The patient had received a course motion, the catheter was passed into the left main of chemotherapy for his histiocytosis, which included bronchus and the balloon was advanced well into methotrexate, mercaptopurine, velban, prednisone, the lumen of the main bronchus. During this time, and cyclosporine. The patient was brought to the the patient was ventilated with oxygen and operating room and routine monitors (EKG, pulse isoflurane. After confirming the position of the oximetry, axillary temperature probe, blood pressure bronchial blocker, the fibreoptic scope was removed. The Fogarty balloon was inflated with 1 ml of normal cuff with a Doppler probe) were placed. The right saline after removal of the stylet. On inflation of the subclavian Broviac catheter was accessed and the balloon, it was confirmed that the left sided breath patient was pretreated with atropine 0.2 mg IV sounds disappeared without any change on the right side. Correspondence to: Dr Mohamed Rehman, Department of Desaturation with pulse oximeter reading (SpO2) Anesthesia and Critical Care, Erie Avenue at Front Street, Philadelphia, PA, USA. in the upper 80 s was noticed. When the balloon was

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.

Outpatient outcomes and satisfaction in pediatric population: data from the postoperative phone call

Quality and patient/parent satisfaction are goals for pediatric perioperative services. As part of the implementation of our operating room electronic medical record (EMR), a postoperative phone call questionnaire was developed to assess patients discharged after outpatient surgery. The goal of this initiative was to determine the rate of common postoperative complications and understand reasons for patient/parent dissatisfaction.

Electrocardiographic artefact with SSEP monitoring unit during scoliosis surgery

A case of somatosensory evoked potential (SSEP) induced electrocardiographic artefact simulating supraventricular tachycardia (SVT) is described in a three year old girl with Goldenhar syndrome, during anterior thoracoscopic discectomy with posterior spinal fusion for scoliosis. Adenosine was administered for this misinterpreted EKG with coincidental cessation of SVT like trace.

Effect of 90° counterclockwise rotation of the endotracheal tube on its advancement through the larynx during nasal fiberoptic intubation in children: a randomized and blinded study.

Resistance to the passage of the endotracheal tube (ETT) is frequently encountered in children as it is advanced over the fiberoptic scope for placement into the trachea because it gets hung up at the laryngeal inlet. Literature in adults indicates that a 90° counterclockwise rotation (CCR) of the ETT before advancing results in smooth passage. We found no literature in children.