Eugene B. Freid

Tracheal extubation of deeply anesthetized pediatric patients: a comparison of desflurane and sevoflurane.

In this study, we examined the emergence characteristics of children tracheally extubated while deeply anesthetized with desflurane (Group D) or sevoflurane (Group S). Forty-eight children were randomly assigned to one of the two groups. At the end of the operation, all subjects were tracheally extubated while breathing 1.5 times the minimal effective concentration of assigned inhaled anesthetic. Recovery characteristics and complications were noted. Group D patients had higher arousal scores on arrival to the postanesthesia care unit than Group S patients. Later arousal scores were not significantly different. No serious complications occurred in either group. Coughing episodes and the overall incidence of complications after extubation were more frequent in Group D. Readiness for discharge and actual time to discharge were not significantly different between groups. Emergence agitation was common in both groups (33% overall, 46% for Group D, and 21% for Group S). Narcotic administration in the postanesthesia care unit occurred more frequently in Group D (10 of 24 patients) versus Group S (3 of 24 patients). Premedication with oral midazolam resulted in significantly longer emergence times regardless of the potent inhaled anesthetic administered.

Epidural fentanyl infusion with patient-controlled epidural analgesia for postoperative analgesia in children☆

Abstract The use of epidural fentanyl infusion with patient-controlled epidural analgesia (PCEA) is becoming popular for postoperative analgesia in adults. Its use has not been reported in the pediatric population. We report our initial experience with this technique in pediatric patients. The charts of all children who received epidural fentanyl infusions for postoperative analgesia between June 1991 and February 1992, were reviewed. Thirty-one patients, ages 6 to 17 years (mean ± SD, 13.2 ± 2.7) received epidural fentanyl infusion with PCEA for 36 operative procedures. Epidural catheters were either inserted in the lumbar (n = 14) or thoracic (n = 22) epidural space at a level based on the surgery. A fentanyl bolus of 1.38 ± 0.43 μg/kg was delivered via epidural catheter just prior to the conclusion of surgery. A continuous infusion of fentanyl (0.56 ± 0.18 μg/kg/h) with a PCEA bolus (0.53 ± 0.17 μg/kg) available every 15 minutes was initiated in the recovery room and was utilized for 8 to 110 hours (59 ± 27 hours). Pain and sedation were assessed by verbal descriptive scales, and side effects were noted. Alterations in dosing regimen were made for inadequate analgesia or side effects. Analgesia was assessed as excellent or good in 78% of the patients, 91% in the thoracic catheter group and 57% in the lumbar catheter group (P

What is taught, what is tested: Findings and competency-based recommendations of the Undergraduate Medical Education Committee of the Society of Critical Care Medicine

Introduction:Addressing an unexpected shortfall of intensivists requires early identification and training of appropriate personnel. The purpose of this study was to determine how U.S. medical students are currently educated and tested on acute care health principles. Hypothesis/Methods:A survey of critical care education with telephone follow-up was mailed to the deans of all 126 medical schools. Web site review of medical school curricula for critical care education was performed. Upon invited request, four members of the Undergraduate Medical Education Committee (UGMEC) reviewed 1,200 pool questions of step II of the U.S. Medical Licensing Examination (USMLE) given to graduating medical students for critical care content. Descriptive statistics are employed. Results:Survey response rate was 49% and 88% by the second mailing with Web site review. Forty-five percent of U.S. medical schools responding had formal undergraduate critical care didactic curricula averaging 12 ± 3 hrs: 60% were elective, 60% taught in the 4th year. Eighty percent of clinical ICU rotations offered were elective. Sixty percent of schools taught 11 key critical care procedures in the 3rd or 4th year; 17% required them to graduate. Nineteen percent of Step II USMLE questions had critical care content; 58% dealt with pulmonary or cardiac disease. Conclusions:Graduating medical students are tested (and licensed accordingly) on critical care knowledge, despite an inconsistent exposure to the discipline in medical school. The UGMEC has drafted competency-based recommendations for acute health care delivery that encourage mandatory didactic and procedural critical care training. The UGMEC recommends that critical care rotations with didactic curricula be required for undergraduate education and that acute care procedural skills be an important component of these curricula.

Epidural morphine combined with epidural or intravenous butorphanol for postoperative analgesia in pediatric patients

We performed a prospective, randomized, double-blinded study in 60 postoperative pediatric patients aged 6 wk to 7 yr to compare the efficacy of butorphanol given epidurally or intravenously in preventing the side effects of epidural morphine. Three groups of patients received 60 micrograms/kg epidural morphine; 20 patients also received epidural butorphanol 30 micrograms/kg, and 20 patients also received 30 micrograms/kg intravenous butorphanol. All patients were evaluated for analgesia, sedation, vomiting, urinary retention, pruritus, and respiratory depression for 24 h postoperatively. Although the overall incidence of side effects was not different in the three groups, the epidural butorphanol group had a significant decrease in severity of pruritus. Sedation was seen more frequently in the groups receiving butorphanol, but was most pronounced in the epidural butorphanol group. We conclude that butorphanol has little or no effect on the side effects of epidural morphine.

Artificial surfactant for therapy in hydrocarbon-induced lung injury in sheep

OBJECTIVE To document the effect of administering artificial surfactant into the trachea, either by instillation or aerosolization, on acute lung injury experimentally induced with kerosene in sheep. DESIGN Randomized, prospective, controlled study. SETTING Research laboratory. SUBJECTS Sheep (n = 24), weighing 8.5 to 25.2 kg (average 16.6). INTERVENTIONS In anesthetized, tracheally intubated sheep with pulmonary and femoral artery catheters inserted, lung injury was induced by instilling kerosene (0.3 mL/kg) into the trachea. After 15 mins of spontaneous breathing, mechanical ventilation was instituted with a uniform F10(2) and a tidal volume of 10 mL/kg. Sheep were then assigned randomly to one of four regimens as follows: exogenous surfactant or saline (5 mL/kg each) was administered as a bolus intratracheally or by aerosolization for 6 hrs. MEASUREMENTS AND MAIN RESULTS Arterial and mixed venous blood gases, pH, airway pressure, and static respiratory system compliance were measured and compared between aerosol saline and aerosol surfactant and between bolus saline and bolus surfactant. For all variables except static respiratory system compliance, the hourly rate of change from 15 mins, 1 hr, and 6 hrs after kerosene instillation was determined for each animal, and group rank sums of hourly rates of change were compared. For static respiratory system compliance, the slope of the pressure-volume curve with volumes of 100, 200, 300, 400, and 500 mL was computed for each animal at baseline and at 3 and 6 hrs after kerosene instillation. Group rank sums for static respiratory system compliance at 3 and 6 hrs were compared. Also, the 3- and 6-hr static respiratory system compliance values at each of the volumes were compared. With saline, six of eight sheep died; with surfactant, no sheep died (p = .001). When compared with saline at 15 mins, 1 hr, and 6 hrs after kerosene instillation, surfactant, regardless of whether administered by aerosol or bolus, significantly increased rate of change of arterial oxygen saturation, mixed venous oxygen saturation, and PO2. CONCLUSIONS In the present animal study, artificial surfactant was an effective treatment for hydrocarbon aspiration. Aerosolized surfactant achieved results similar to instilled surfactant but at a lower total dose.

The effects of isoflurane and desflurane titrated to a bispectral index of 60 on the cortical somatosensory evoked potential during pediatric scoliosis surgery

In this study, we compared the effect of isoflurane and desflurane on the posterior tibial somatosensory evoked potential recorded by scalp electrodes during correction of idiopathic scoliosis in pediatric patients. Depth of sedation was controlled by maintaining bispectral index (BIS) at 60 throughout the study. Comparison of patients breathing desflurane and isoflurane showed an evoked cortical amplitude (N37-P45) of 0.53 ± 0.3 &mgr;V versus 1.3 ± 0.8 &mgr;V (P = 0.014), respectively. In addition to this comparison, a crossover design was included whereby the desflurane or isoflurane received in the first part of the study was changed to the other anesthetic. Substituting one anesthetic for another confirmed our initial finding that the cortical evoked amplitude is greater with isoflurane than with desflurane. No differential effect was found between desflurane and isoflurane on the evoked subcortical (N31-P34) amplitude or the P37 latency.

Withdrawal after narcotic therapy : A survey of neonatal and pediatric clinicians

Pharmacists at the 1995 American College of Clinical Pharmacy Pediatric Practice and Research Network meeting volunteered to act as coordinators at their sites and survey pediatric and neonatal nurses, pharmacists, and physicians regarding dependency in neonatal and pediatric patients after therapeutic administration of narcotics. Thirteen (60%) of 21 coordinators returned 244 surveys. Primary symptoms of withdrawal reported by clinicians were agitation (100%), irritability (100%), inconsolability (100%), crying (99%), tremors (98%), high heart rate (98%), fidgets (98%), high blood pressure (97%), less sleep (96%), and sweating (94%). Most clinicians considered narcotic withdrawal to be a problem (74%) that should be treated (87%). A dependency scale is being developed and will include symptoms reported by more than 75% of respondents.

Integration of the Human Patient Simulator into the Medical Student Curriculum

To date, the main educational thrust of anesthesia (human patient) simulators has been on learning and practice in the operating room environment. The utility of anesthesia simulators in medical practice outside the operating room is just recently being realized. The human patient simulator has a number of attributes that make it useful in teaching, and possibly evaluating, the skills necessary to care for the acutely ill patient. As critical care itself developed as an extension of the operating room environment, the use of simulation in critical care education is an expected evolution of this technology.