Fatis Altintas

The efficacy of pre- versus postsurgical axillary block on postoperative pain in paediatric patients.

We compared the effects of pre‐ and postsurgical axillary block on pain after hand and forearm surgery in 55 children in a double‐blind randomized study. The successful blocks are reported here (n=49). Children aged 1–11 years and ASA I or II were allocated randomly to receive axillary block with 2 mg.kg−1 of 0.25% bupivacaine, either after induction but before the surgery (presurgical group, n=25) or immediately after surgery, before the end of anaesthesia (postsurgical, n=24). In all patients, a standard general anaesthesia technique was used. The Faces Pain Scale (FPS) and analgesic requirements were recorded for 24 h at various times after operation. Eight patients (32%) in the presurgical group and 20 patients (83.33%) in the postsurgical group did not require additional analgesic within the first 24 h after operation (P< 0.05). In patients who had pain during the observation period, the pain started 13.66±2.61 h in the presurgical group and 13.14±2.34 h in the postsurgical group after performing block (P> 0.05). The FPS scores were similar in both groups during the first 8 h in the postoperative period (P> 0.05). There was a significant difference at 10 h after surgery (P< 0.05). Cumulative FPS score was higher in the presurgical group (10.50±1.06) than in the postsurgical group (9.45±1.28) (P< 0.05), but both groups had effective analgesia overall, the mean FPS score being less than 2. Additional analgesic consumption was similar in these patients in both groups. A lower isoflurane concentration was used in the presurgical group (0.68%vs 1.72%, P< 0.001). We did not demonstrate the superiority of preemptive analgesia, but our results indicate that presurgical axillary block with 0.25% bupivacaine allows the use of inhalational anaesthetics at lower concentrations while providing a reasonably painless postoperative period.

Systemic stress response during operations for acute abdominal pain performed via laparoscopy or laparotomy in children

We compared the endocrine and metabolic changes during acute emergency abdominal surgery performed using either laparoscopy or laparotomy in children. Twenty‐nine children aged 1.5–14 years were assigned to undergo laparoscopy (n = 15) or laparotomy (n = 14) with a standard anaesthesia technique. Arterial blood gases and blood prolactin, cortisol, interleukin‐6, glucose, insulin, lactic acid and epinephrine levels were determined 5 min after the induction of anaesthesia, 30 min into surgery and at the end of surgery. Intra‐operative heart rate and mean arterial pressure were stable in both groups. In the laparoscopy group, slight respiratory acidosis occurred during surgery (p < 0.01) but there were no changes in the laparotomy group. Insulin, cortisol, prolactin, epinephrine, lactate and blood glucose levels increased in both groups (p < 0.05) although there was no difference between the groups. The surgical stress and trauma imposed by laparoscopy seems similar to that caused by laparotomy in children undergoing emergency abdominal surgery.

Interscalene brachial plexus block with bupivacaine and ropivacaine in patients with chronic renal failure: diaphragmatic excursion and pulmonary function changes.

In this randomized, double-blind study, we compared the anesthetic characteristics and pulmonary function changes of 0.33% bupivacaine and 0.33% ropivacaine used for interscalene brachial plexus (IBP) anesthesia in patients with chronic renal failure. Forty-two patients undergoing IBP anesthesia for creation of arteriovenous fistulas were randomly allocated to receive either 30 mL of 0.33% bupivacaine (Group B) or 0.33% ropivacaine (Group R). Block onset time, diaphragmatic excursion (ultrasonographic evaluation), and free plasma concentrations of bupivacaine and ropivacaine were evaluated. Negative motion or immobility of the ipsilateral hemidiaphragm and a decrease of >10 mm in positive motion were defined as diaphragmatic paresis. The pulmonary function variables were measured by bedside spirometry equipment. Seven patients needed supplemental local anesthetic, one with total spinal block; these patients were excluded from the study. The success rate was 80.9%. Block quality was similar in the two groups. Ipsilateral hemidiaphragmatic excursion was decreased in both groups compared with baseline values (P < 0.05). Diaphragmatic paresis was identified in 10 of 16 patients and 8 of 18 patients in Groups B and R, respectively (P > 0.05). Pulmonary function significantly decreased from baseline in both groups (forced vital capacity (FVC) 30%, forced expiratory volume at 1 second (FEV1) 32%, and peak expiratory flow (PEF) 31% in Group B and FVC 17%, FEV1 17%, and PEF 5% in Group R) (P < 0.001). The decreases in Group B were larger than those in Group R (P < 0.05). Three patients in Group B and one in Group R had mild respiratory problems (P > 0.05). Concentrations of bupivacaine and ropivacaine were below toxic levels rather than “normal range.” We conclude that pulmonary function decreased more after IBP with 0.33% bupivacaine than with 0.33% ropivacaine.

The cardiorespiratory effects of laparoscopic procedures in infants

We assessed the cardiorespiratory effects of laparoscopic procedures in 27 infants aged between 36 and 365 days. Infants were monitored and anaesthetised in a standardised manner. Heart rate, mean arterial pressure, end‐tidal carbon dioxide and oxygen saturation were recorded, and blood gases were measured at 5 min after intubation, 15 and 30 min after carbon dioxide pneumoperitoneum, 5 min after desufflation and after extubation. The pH, Pao2, base excess, Sao2 and Spo2 decreased, and Pco2 increased by insufflation of carbon dioxide intraperitoneally, and improved following deflation. Changes in pH and Pao2 during the study were statistically significant (p < 0.0001). The increase in Paco2 30 min after pneumoperitoneum was statistically significant when compared with initial values. Transient arrhythmias were observed in 10 infants 1 min after pneumoperitoneum. There were no statistically significant alterations in heart rate and systolic blood pressure.

Anesthetic management of a child with Rubinstein–Taybi syndrome

SIR—The Rubinstein–Taybi syndrome is a rare congenital syndrome characterized by several morphological abnormalities and clinical features (1,2). We describe the anesthetic management of a 13-month-old girl with Rubinstein–Taybi syndrome using general anesthesia in combination with an epidural block, requiring above knee amputation for hemangioendothelioma. The patient weighed 9.5 kg. She was born at term, following an uncomplicated pregnancy and Apgar scores were normal. The manifestations of Rubinstein–Taybi syndrome in this patient were mental retardation, broad thumbs, and great toes, a small mouth with high-arched palate, antimongoloid slant of the palpebral fissures, short neck, beaked nose, and hypoplastic nasal alae. On physical examinations, she had also a prominent forehead with high hairline and pectus excavatum. Deep tendon reflexes were normal and she had no acousticofacial reflex. In this particular case, there was no congenital heart disease, which is reported to occur in one-third of cases (3). There was no evidence of cardiac dysfunction, but breath sounds were harsh on oscultation. The blood and urine analyses were normal except for leukocytosis (27 · 10 l). She tested positive for hepatitis C. She was scheduled for above knee amputation because of the hemangioendothelioma. We decided to use general anesthesia in combination with epidural anesthesia. Anesthesia was induced by face mask with 50% N2O/O2/sevoflurane (7–8%). Following atracurium 0.5 mgÆkg, the trachea was intubated. We paid special attention to the possibility of difficulty in airway management and the risks of aspiration pneumonia. We made sure that equipment necessary to manage a difficult airway, including fiberoptic bronchoscope was available, but tracheal intubation was not difficult. Maintenance of anesthesia was with sevoflurane 1% and 50% N2O in O2. The lungs were ventilated with volume controlled mechanical ventilation (Cicero, Draeger, Lübech, Germany). Ventilator settings were: expiratory/inspiratory time ratio 1 : 2, tidal volume 8 mlÆkg, and respiratory rate 18 bÆmin. After tracheal intubation, she was placed in the lateral decubitus and epidural puncture was performed at the L3–4 interspace with a 19-G Tuohy needle, the epidural space was at 2.5 cm and a 21-G catheter was inserted. An epidural bolus injection of morphine 1 mg and bupivacaine 20 mg in 10 ml saline was given which provided good intraoperative analgesia. Anaesthesia was uneventful and lasted for 3 h. Throughout the procedure, the patient remained hemodynamically stable. No complications were observed in the perioperative period. Postoperatively, adequate analgesia was achieved with 0.5 mgÆh of morphine via the epidural catheter. Anesthesiologists should be aware of the possibility of difficulty in airway management, the risks of aspiration pneumonia and of cardiovascular dysfunction in Rubinstein–Taybi syndrome. There is also a high risk of apnea, respiratory obstruction and respiratory failure postoperatively (1). Twigg and Cook predicted difficult intubation in an adult patient and ventilated via a ProSeal laryngeal mask airway (3). Tokarz et al. anesthetized and intubated an infant without muscle relaxants using propofol and remifentanil. We used atracurium for neuromuscular blockade to avoid adverse effects of succinylcholine, Stirt reported cardiac arrest after the use of succinylcholine in these children (4). Although a laryngeal mask airway (LMA) was found to be suitable in a patient with Rubinstein–Taybi syndrome, we used a tracheal tube to prevent aspiration as did Critchley et al. (5). Although our patient had a small mouth with high-arched palate and short neck, tracheal intubation was not difficult. Critchley et al. described anesthetic management of a 5-month-old infant using general anesthesia in combination with caudal block (5). Spinal anesthesia has been recommended as the sole anesthetic technique for high-risk pediatric patients especially those with a history of respiratory problems (6). We preferred the combination of general anesthesia and lumbar epidural block to provide a fast recovery and postoperative analgesia. Fatis Altintas* Serpil Cakmakkaya*† *Department of Anaesthesiology Cerrahpaşa Medical School Istanbul University Istanbul, Turkey †Cevizlibag, Tercuman sitesi A4 blok daire: 78 Zeytinburnu Istanbul, Turkey (Email: sercakmakkaya@hotmail.com)

Effects of systemic and epidural morphine on antidiuretic hormone levels in children.

Background: Although the use of opioids during general anaesthesia suppresses stress response to surgery and pain, the effects on antidiuretic hormone (ADH) are controversial. The aim of this study was to find the effects of morphine with either intravenous infusion or epidural route on ADH and other stress hormones.

General anesthesia for a child with Goldenhar syndrome

SIR—Goldenhar, in 1952, described the classical triad of epibulbar dermoids, preaurical tags and blind fistulas and vertebral anomalies (1). Difficulty in tracheal intubation may result from a combination of mandibular hypoplasia, craniovertebral anomalies, and hemifacial microsomia. Radiological evaluation for mandibular deformity and craniovertebral anomalies is recommended (2). We describe the anesthetic management of a child with Goldenhar syndrome. A 4.5-year-old, 18 kg, girl previously diagnosed with Goldenhar’s Syndrome was scheduled for ectropion surgery. The manifestation of Goldenhar’s syndrome were right sided maxillofacial hypoplasia, mandibular hypoplasia, right microtia, right epibulbar demoid. She had no vertebral abnormalities or cardiac disease. Blood tests and chest radiography were normal. The patient had been operated 2 years previously because of right epibulbar dermoids. There was no information about difficulty in tracheal intubation in this operation. Mouth opening was limited because of the mandibular hypoplasia. Because we suspected that tracheal intubation would be difficult, we decided to anesthetize and intubate the patient without muscle relaxants using propofol and remifentanil. Special attention was paid to the possibility of difficulties in airway management. After preoxygenation, a continuous infusion of remifentanil 1 lÆkgÆmin was started. Anesthesia was induced with propofol 2.0 mgÆkg and maintained with sevoflurane 1% in oxygen. Lung ventilation was achieved via a facemask. Laryngoscopy was performed using a Macintosh 2 blade. First attempt at visualization of the larynx and oral intubation of the trachea was unsuccessful. After the first attempt, it was decided to exchange the curved blade for straight (Miller) blade and use a stylet for a blind technique. A 4.5 mm tracheal tube with a curved stylet was guided in the presumed direction of the glottis. The tube slid off the stylet but would not pass into the trachea. We exchanged the tube for 4.0 mm and the intubation was performed successfully at the next attempt, confirmed by auscultation and capnometry. Anesthesia was maintained with sevoflurane 1 and 50% O2/N2O and the lungs ventilated with volume controlled mechanical ventilation (Cicero, Draeger, Lübeck, Germany). The remifentanil infusion was maintained at 0.15 lÆkgÆmin. Muscle relaxants were not required. Anesthesia, which was uneventful, lasted for 160 min, after which the patient was extubated. The postoperative course was uneventful. Anesthesiologists should be aware of the possibility of difficulty in airway management, cardiovascular and renal disorders and neuromusculer problems in Goldenhar’s syndrome. Evaluation of upper and lower airway obstruction, pulmonary function, laryngeal, renal, cardiac and neurological function is recommended (2). There are previous reports of anesthesia in patient with Goldenhar’s syndrome pointing out difficulties with airway management. A retrograde intubation method was used successfully in a 5-month-old infant with Goldenhar’s syndrome by Cooper and Murray–Wilson (3). Bahk et al. described four different cases of difficult airway including one with Goldenhar’s syndrome. They reported use of a laryngeal mask airway and fiberoptic intubation via the laryngeal mask (4). Sculerati et al. assessed airway management in children with major craniofacial anomalies in a retrospective study (5). They found craniofacial synostosis patients (Crouzon, Pfeifer, or Apert syndrome) had the highest rate of tracheostomy (48%), mandibulofacial dysostoses patients (Treacher collins or Nager syndrome) had the next highest rate (41%) but patients with oculo-auriculovertebral sequence were less likely to undergo tracheostomy (22%). Before anesthetizing this patient, we anticipated that tracheal intubation might be difficult, avoided using muscle relaxants and expected a rapid return of spontaneous ventilation if intubation had failed. Awakening time from remifentanil based anesthesia is significantly faster than inhalational anesthesia alone (6). This method could be considered if there is possibility of difficulty in airway management. Fatis Altintas Ozlem S. Cakmakkaya Department of Anaesthesiology and Reanimation, Cerrahpasa Medical School, University of Istanbul, Istanbul, Turkey (email: sercakmakkaya@hotmail.com or serpilcakmakkaya@yahoo.com)

Effectiveness of morphine via thoracic epidural vs intravenous infusion on postthoracotomy pain and stress response in children

Background : Thoracotomy causes severe pain in the postoperative period. The aim was to evaluate effectiveness of two pain treatment methods with morphine on postthoracotomy pain and stress response.

Anesthetic management of a child with Arnold–Chiari malformation and Klippel–Feil syndrome

1 Tariq M, Beg MH. A foreign body in the bronchus still presents problems. Int J Clin Pract 1999; 53: 81–82. 2 Brett CM, Zwass MS. Eyes ears nose throat and dental surgery. In: Gregory GA, ed. Pediatric Anesthesia, 4th edn. Philadelphia, PA: Churchill Livingstone, 2002: 663–705. 3 Bossoe HH, Boe J. Broken tracheostomy tube as a foreign body. Lancet 1960; 1: 1006–1007. 4 Sood RK. Fractured tracheostomy tube. J Laryngol Otol 1973; 87: 1033–1034. 5 Kemper BI, Rosica N, Myers EN et al. Migration of the inner cannula. An unusual foreign body. Eye Ear Nose Throat Mon 1972; 51: 257–258. 6 Kakar PK, Saharia PS. An unusual foreign body in the tracheobronchial tree. J Laryngol Otol 1972; 86: 1155–1157. 7 Ward CF, Benumof JL. Anesthesia for airway foreign body extraction in children. Anesth Rev 1977; 4: 13.

Anesthetic management in a child with deletion 9p syndrome

1.69 lgÆkgÆh and 1.23 lgÆkgÆh of fentanyl for the patient receiving wound infiltration only and for the patient receiving caudal morphine with local infiltration, respectively. In summary, we present this case of pediatric liver transplantation with local anesthetic wound infiltration for postoperative pain control, and compare it with a previous report of caudal morphine with local anesthetic infiltration of the wound. Early extubation aids in early mobilization and graft perfusion, and may improve the overall success of the operation (4). No conclusions can be drawn regarding the superiority of caudal morphine vs local wound infiltration alone, but supplemental analgesic techniques in pediatric liver transplant patients may allow for reduced administration of narcotics and help facilitate early extubation and recovery. The decision to use supplemental local anesthetics must take into consideration the viability of the donor liver, potential for toxicity, coagulation status and whether the child is a candidate for early extubation. Tae W. Kim* Calvin C. Chan† *Department of Anesthesiology and Pediatrics, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX, USA †The University of Texas, Health Science Center, Houston, TX, USA (email: twkim@bcm.tmc.edu).