Eleanor J. Reimer

Propofol anaesthesia reduces early post-operative emesis after paediatric strabismus surgery

Propofol anaesthesia may reduce postoperative emesis. The purpose of this study was to compare the incidence of emesis after propofol anaesthesia with and without nitrous oxide, compared with thiopentone and halothane anaesthesia, in hospital and up to 24 hr postoperatively, in outpatient paediatric patients after strabismus surgery. Seventy-five ASA class I or II, unpremedicated patients, aged 2–12 yr were randomly assigned to one of three groups: Thiopentone, 6.0 mg · kg− 1 iv induction followed by halothane and N2O/O2 for maintenance (T/H); propofol for induction, followed by propofol and oxygen for maintenance (P/O2); and propofol for iv induction, followed by propofol infusion and N2O/O2 for maintenance (P/N2O). All received vecuronium, controlled ventilation, and acetaminophen pr. Morphine was given as needed for postoperative analgesia. There were no differences in age, weight, number of eye muscles operated upon, duration of anaesthesia or surgery. The P/N2O group (255 ± 80 μg· kg− 1· min− 1) received less propofol than the P/O2 group (344 ± 60 μg · kg− 1· min− 1) (P ≤ 0.0001) and had shorter extubation (P < 0.001) and recovery (P < 0.01) times. Emesis in the hospital, in both the P/N2O (4.0%) and P/O2 group (4.0%) was less than in the T/H group (32%) (P < 0.01). Antiemetics were required in four patients in the T/H group (16.0%). Overall emesis after surgery was not different among the groups: T/H (48%), P/O2 (28%) and P/N2O (42%). The use of propofol anaesthesia with and without N2O decreased only early emesis. This supports the concept of a short-acting, specific antiemetic effect of propofol.RésuméOn attribue au propofol des propriété anti-émétiques postopératoires. Cette étude a pour objectif de comparer l’incidence des vomissements après l’anesthésie au propofol avec ou sans protoxyde d’azote, comparativement à l’anesthésie au thiopentone-halothane. Cette étude est réalisée à l’hôpital et jusqu’à 24 heures après l’opération chez des patients ambulatoires après chirurgie pour strabisme. Soixante-quinze patients ASA I et II, non prémédiqués, âgés de 2 à 12 ans sont assignés au hasard à un de trois groupes: induction au thiopentone, 6,0 mg· kg− 1 avec maintien à l’halothane-N2O, (T/ H); induction avec maintien au propofol-oxygène (P/O2) et induction au propofol avec maintien au protoxyde-oxygène (P/N2O). Tous reçoivent du vécuronium, une ventilation contrôlée et de l’acétaminophène rectal. De la morphine est administrée au besoin pour contrôler la douleur postopératoire. Il n’y a pas de différence d’âge, du poids, du nombre de muscles opérés et de durée anesthésique et chirurgicale. Les patients du groupe P/N2O (255 ± 80 μg· kg− 1· min− 1) reçoivent moins de propofol que le groupe P/O2 (344 ± 60 μg· kg− 1· min− 1, P < 0.001), sont intubés moins longtemps (P < 0.0001) et s’éveillent plus rapidement (P < 0.01). A l’hôpital, les vomissements dans les deux groupes P/N2O (4.0%) et P/O2 (4.0%) sont moins fréquents que dans le groupe T/H (32%). Des antiémétiques sont requis chez quatre patients du groupe T/H (16%). L’incidence générale des vomissements après la chirurgie est la même pour tous les groupes: T/H (48%), P/O2 (28%) et P/N2O(42%). L’utilisation du propofol en anesthésic avec ou sans N2O ne diminue que l’incidence des vomissements précoces, ce qui supporte le concept d’une activité anti-émétique brève et spécifique.

Residual Block after Mivacurium with or without Edrophonium Reversal in Adults and Children

Background The rapid recovery from mivacurium-induced neuromuscular block has encouraged omission of its reversal. The purpose of this study was to determine, in children and in adults, whether failure to reverse mivacurium neuromuscular block was associated with residual neuromuscular block on arrival in the postanesthesia care unit. Methods In 50 children, aged 2-12 yr, and 50 adults, aged 20-60 yr, anesthesia was induced and maintained with propofol and fentanyl, and neuromuscular block was achieved by an infusion of mivacurium, to maintain one or two visible responses to train-of-four (TOF) stimulation of the ulnar nerve. At the end of surgery, mivacurium infusion was stopped, and 10 min later, reversal was attempted with saline or 0.5 mg *symbol* kg sup -1 edrophonium by random allocation. On arrival in the postanesthesia care unit, a blinded observer assessed patients clinically and by stimulation of the ulnar nerve with a Datex electromyogram in the uncalibrated TOF mode. Results Children arrived in the postanesthesia care unit 8.2 +/-3.4 min after reversal of neuromuscular block and showed no sign of weakness, either clinically or by TOF stimulation. Although TOF ratio was greater in children who had received edrophonium (1.00 +/-0.05 vs. 0.93+/-0.01, P < 0.01), TOF was > 0.7 in all children. Adults arrived in the postanesthesia care unit 12.9+/- 5.3 min after reversal of neuromuscular block (P < 0.01 vs. children). Six in the saline group demonstrated weakness (two required immediate reversal of neuromuscular block, and TOF was < 0.7 in four others), compared with TOF < 0.7 in only one of the edrophonium group (P < 0.05). Conclusions This study demonstrated that, in adults, failure to reverse mivacurium neuromuscular block was associated with an increased incidence of residual block. Such weakness was not observed in children receiving similar anesthetic and neuromuscular blocking regimens.

Robust closed-loop control of induction and maintenance of propofol anesthesia in children

During closed‐loop control, a drug infusion is continually adjusted according to a measure of clinical effect (e.g., an electroencephalographic depth of hypnosis (DoH) index). Inconsistency in population‐derived pediatric pharmacokinetic/pharmacodynamic models and the large interpatient variability observed in children suggest a role for closed‐loop control in optimizing the administration of intravenous anesthesia.

The effectiveness of clonidine as an analgesic in paediatric adenotonsillectomy

PurposeTo compare the analgesic effects of preoperative oral clonidine with intraoperative intravenous fentanyl in children undergoing tonsillectomy or adenotonsillectomy.MethodsThis randomized, controlled, double-blind study of 36 ASA 1–11 children, age 7–12 yr undergoing adenotonsillectomy was conducted at a tertiary care paediatric teaching hospital. Either 4 μg·kg−1 clonidinepo was given 60–90 min preoperatively or 3 μg·kg−1 fentanyliv was given intraoperatively. Postoperatively visual analog pain scores (VAS) were recorded at rest and on swallowing every 10 min for the first 30 min and then every 15 min for two hours. Morphine 0.05 mg·kg−1iv was given for VAS ≥5. If > 3 doses were required, 1.5 mg·kg−1 codeinepo and 20 mg·kg−1 acetaminophenpo were given. Sedation and anxiety scores were recorded preoperatively. Haemodynamic changes, blood loss, recovery scores, and the incidence of vomiting, hypotension, and airway obstruction were recorded.ResultsChildren who received clonidine had a higher incidence of preoperative sedation (63%) than those receiving fentanyl (6%). Preinduction mean arterial pressure was lower in the clonidine group but required no intervention. VAS scores were similar throughout the observation period. There was no difference either in the number of morphine or codeine rescue doses administered or in the incidence of side effects.ConclusionOral clonidine is an effective analgesic and sedative for children undergoing tonsillectomy or adenotonsillectomy.RésuméObjectifComparer les effets analgésiques de l’administration orale de clonidine préopératoire et de fentanyl intraveineux peropératoire chez des enfants devant subir une amygdalectomie ou une adéno-amygdalectomie.MéthodeCette étude randomisée, contrôlée et à double insu a porté sur 36 enfants ASA 1–11, âgés de 7 à 12 ans, devant subir une adéno-amygdalectomie dans un hôpital universitaire de soins pédiatriques tertiaires. On a administré 4 ug·kg−1 de clonidinepo 60–90 min avant l’intervention ou 3 ug·kg−1 de fentanyliv au cours de l’intervention. Les niveaux de douleur ont été enregistrés après l’opération, à l’aide de l’échelle visuelle analogue (EVA), au repos et lors de la déglutition à toutes les 10 min pendant les 30 premières min et à toutes les 15 min pendant les deux heures suivantes. On a administré 0,05 mg·kg−1 de morphineiv pour des scores.-5 à l’EVA. Si plus de 3 doses étaient nécessaires, on a donné aussi 1,5 mg·kg−1 de codéinepo et 20 mg·kg−1 d’acétaminophènepo. Avant l’intervention, on a enregistré les niveaux de sédation et d’anxiété. Les changements hémodynamiques, les pertes sanguines, les niveaux de récupération et l’incidence de vomissements, d’hypotension et d’obstruction du conduit aérien ont été notés.RésultatsLes enfants qui ont reçu de la clonidine ont présenté une plus grande incidence de sédation préopératoire (63 %) que ceux qui ont reçu du fentanyl (6 %). Avant l’induction de l’anesthésie, la tension artérielle moyenne était plus basse dans le groupe qui avait reçu de la clonidine, mais cela n’a pas nécessité de traitement. Les valeurs de l’EVA ont été similaires tout au long de la période d’observation. Il n’y avait pas de différence non plus quant au nombre de doses de rattrapage de morphine ou de codéine administrées ou quant à l’incidence d’effets secondaires.ConclusionLa clonidine par voie orale est un analgésique et un sédatif efficace chez des enfants qui subissent une amygdalectomie ou une adéno-amygdalectomie.

Slower administration of propofol preserves adequate respiration in children

Background:  Propofol is a versatile anesthetic agent used in pediatric practice to facilitate investigational and interventional procedures. Propofol can cause significant respiratory depression, the management of which may require advanced airway management skills. This investigation aimed to increase the safety of propofol administration by developing a dosing schedule that would preserve spontaneous respiration in at least 95% of subjects.

Dose responses for neostigmine and edrophonium as antagonists of mivacurium in adults and children

BackgroundReversal of neuromuscular blockade induced with pancuronium, d-tubocurarine, or doxacurium is achieved using smaller doses of neostigmine in adults than in children. Also, pancuronium- and doxacurium-induced blockade is reversed with smaller doses of edrophonium in children than in adults.

Reversal of doxacurium and pancuronium neuromuscular blockade with neostigmine in children

Recovery after doxacurium and pancuronium neuromuscular blockade and their acceleration by neostigmine have not been compared in children. Therefore, 60 paediatric surgical patients aged 2–10 yr (ASA 1–2) were studied. They were randomized to receive doxacurium 30 μg · kg−1 or pancuronium 70 μg · kg−1 iv during propofol, fentanyl, isoflurane and nitrous oxide anaesthesia. Electromyographic (EMG) responses of the adductor pollicis to train-of-four (TOF) stimulation of the ulnar nerve were recorded every ten seconds using a Datex NMT monitor. Six patients in each relaxant group received neostigmine (0, 5, 10, 20 or 40 μg · kg−1) with atropine by random allocation when first twitch height (TI) had recovered to 25% of control. Spontaneous recovery after ten minutes was similar following doxacurium (mean ± SEM values of 45.0 ± 3.9 vs 49.5 ± 10.0 % for TI and 25.2 ± 3.8 vs 14.8 ± 3.6% for TOF ratios). Dose-responses to neostigmine were calculated from the log dose vs logit of TI or TOF ratio after ten minutes. Neostigmine-assisted recovery was not different in the two groups, with ED70 and ED90 doses for TI of 14.3 ± 1.8 and 25.7 ± 2.7 μg·kg−1 for doxacurium and 12.5 ± 1.7 and 25.3 ± 2.3 μg· kg−1 for pancuronium. Time to recovery of TOF ratio to 70% after neostigmine 40 ng · kg−1 was 2.3 ± 1.0 and 4.2 ± 1.7 min (P = NS) following pancuronium and doxacurium, respectively. Adjusted recovery due to neostigmine alone (spontaneous recovery subtracted from the total) required two to three times higher doses of neostigmine. Thus, in children, the spontaneous recovery and reversal of neuromuscular blockade is similar with doxacurium and pancuronium. However, compared with previous adult studies, they recover twice as quickly from doxacurium neuromuscular blockade and neostigmine antagonism is achieved at 25–50% of the adult doses.RésuméOn n’a jamais comparé chez l’enfant l’antagonisme du bloc neuromusculaire produit par le doxacurium avec celui du pancuronium et son accélération par la néostigmine. Dans ce but, 60 patients pédiatriques programmés pour la chirurgie sont étudiés. Ils sont répartis au hasard pour recevoir soit du doxacurium 30 μg · kg−1 ou du pancuronium 70 μg · kg−1 pendant une anesthésie générale au propofol, fentanyl, isoflurane et protoxyde d’azote. La réponse électromyographique à la stimulation par train de quatre (TOF) du nerf cubital est enregistrée toutes les dix secondes sur un moniteur NMT de Datex. Six patients dans chacun des groupes reçoivent néostigmine (0, 5, 10, 20 ou 40) avec de l’atropine au moment du retour de l’amplitude de la première secousse (TI) à 25% du contrôle. Après dix minutes, la décurarisation spontanée est identique après le doxacurium (moyenne ± SEM, 45.0 ± 3,9 vs 49,5 ± 10,0% pour le TI et 25,2 ± 3,8 vs 14,8 ± 3,6% pour le rapport TOF). Les relations dose-effet de la néostigmine sont calculées avec le log de la dose vs le logit de TI ou la rapport TOF après dix minutes. Avec des ED70 et ED90, la décurarisation assistée par la néostigmine ne diffère pas entre les deux groupes au regard du TI: de 14,3 ± 1,8 et 25,7 ± 2,7 μg · kg−1 pour le doxacurium et de 12,5 ± 1,7 et 25,3 ± 2,3 μg · kg−1 pour le pancuronium. Le délai de retour du rapport TOF à 70% après néostigmine 40 μg · kg−1 est de 2,3 ± 1,0 après le pancuronium et de 4,2 ± 1,7 min (P = NS) après le doxacurium. La décurarisation ajustée pour la néostigmine seule (la décurarisation spontanée soustraite du total) nécessite des doses de deux à trois fois plus importantes de néostigmine. Chez l’enfant, la décurarisation spontanée et l’antagonisme du bloc neuromusculaire sont identiques pour le doxacurium et le pancuronium. Cependant, comparativement aux adultes, les enfants récupèrent deux fois plus rapidement du bloc neuromusculaire produit par le doxacurium et l’antagonisme de la néostigmine est complet à doses de 25–50% inférieures à celles de l’adulte.

Dexmedetomidine for co‐analgesia in chemotherapy‐induced severe enterocolitis

SIR—We present the case of a 2 year-old female undergoing autologous stem cell transplant for stage four neuroblastoma, whose chemotherapy-induced enterocolitis and mucositis was managed with a dexmedetomidine infusion, as part of a multimodal pain regimen. A previously healthy 2 year-old girl was diagnosed with left sided adrenal neuroblastoma. Postadrenalectomy follow up revealed persistent disease in the left kidney and peri-aortic node involvement therefore she underwent left nephrectomy with further myeloablative chemotherapy and stem cell support. Following myeloablative chemotherapy she developed acute severe enterocolitis. Initial pain management strategy included intravenous hydromorphone boluses 15 lgÆkg every 4 h and hyoscine butylbromide, however her abdominal pain worsened and she was referred to the acute pain service (APS) for ongoing management. Acute pain service commenced a hydromorphone infusion, initially at 4 lgÆkgÆh, increasing to 8 lgÆ kgÆh over days 1–5 of APS care, with additional boluses of 15 lgÆkg as required. Despite this, she continued to show significant distress and severe sleep disruption. On day 6 of APS care the decision was made to commence a dexmedetomidine infusion. The infusion was started at 0.15 lgÆkgÆh, and then increased to a maximum rate of 0.2 lgÆkgÆh by APS day 7. From APS day 9 it was weaned gradually over 48 h as the enterocolitis resolved, coincident with white cell count recovery. Hydromorphone was initially continued at 8 lgÆkgÆh, with 4 lgÆkg boluses as required and subsequently weaned to 2 lgÆkgÆh. This progress is charted in Figure 1, along with vital signs and sedation scores. The patient received 1 : 1 nursing and frequent vital sign monitoring. No loading dose was administered, to minimise the risk of cardiovascular instability. There were no incidences of clinically significant hypotension or bradycardia. There was no respiratory depression. Sedation scores indicate an improved sleep-wake cycle from APS day 8 onwards. Fourteen questionnaires were completed by medical, nursing staff and parents describing their experience of

The effectiveness of standard pediatric daycare surgery discharge communication: A quality improvement gap analysis

Abstract The aim of this manuscript is to identify for the reader how communication gaps during handovers from hospital personnel to parents after pediatric day surgery can endanger patient safety. Variables analyzed include parent-reported quality of communication and hospital safety culture, medication safety, surgical wound care, and nausea and vomiting knowledge. Data are obtained via a 21-item questionnaire. The reader is informed of a technique for communication quality measurement that combines naturalistic observation of the discharge process, a theoretical model of discharge communication and safety domain modeling and analysis. The reader is informed via the discharge communication and safety domain model of the areas posing the most risk to patient safety in the post-discharge period.

Training in pediatric anesthesia: a canadian survey

Christine A. Vandebeek MBA*, Robert F. Seal FRCPC†, Ramona Kearney FRCPC†, Eleanor Reimer FRCPC*, Dilsheesh Purewal MD, J. Mark Ansermino FFA(SA)* *Department of Anesthesiology, British Columbia’s Children’s Hospital and University of British Columbia, Vancouver, British Columbia; † Department of Anesthesiology and Pain Medicine, Stollery Children’s Hospital, University of Alberta, Edmonton, Alberta;