Gordana Vlajkovic

Emergence Delirium in Children: Many Questions, Few Answers

The introduction of a new generation of inhaled anesthetics into pediatric clinical practice has been associated with a greater incidence of ED, a short-lived, but troublesome clinical phenomenon of uncertain etiology. A variety of anesthesia-, surgery-, patient-, and adjunct medication-related factors have been suggested to play a potential role in the development of such an event. Restless behavior upon emergence causes not only discomfort to the child, but also makes the caregivers and parents feel unhappy with the quality of recovery from anesthesia. Although the severity of agitation varies, it often requires additional nursing care, as well as treatment with analgesics or sedatives, which may delay discharge from hospital. To reduce the incidence of this adverse event, it is advisable to identify children at risk and take preventive measures, such as reducing preoperative anxiety, removing postoperative pain, and providing a quiet, stress-free environment for postanesthesia recovery. More clinical trials are needed to elucidate the cause as well as provide effective treatment.

The addition of fentanyl to local anesthetics affects the quality and duration of cervical plexus block: a randomized, controlled trial.

BACKGROUND: Cervical plexus block is frequently associated with unsatisfactory sensory blockade. In this randomized, double-blind, placebo-controlled trial, we examined whether the addition of fentanyl to local anesthetics improves the quality of cervical plexus block in patients undergoing carotid endarterectomy (CEA). METHODS: Seventy-seven consecutive adult patients scheduled for elective CEA were randomized to receive either fentanyl 1 mL (50 &mgr;g) or saline placebo 1 mL in a mixture of 10 mL bupivacaine 0.5% and 4 mL lidocaine 2% for deep cervical plexus block. Superficial cervical plexus block was performed using a mixture of 10 mL bupivacaine 0.5% and 5 mL lidocaine 2%. Pain was assessed using the verbal rating scale (0–10; 0 = no pain, 10 = worst pain imaginable), and propofol in 20-mg IV bolus doses was given to patients reporting verbal rating scale >3 during the procedure. Rescue medication consumption during surgery and analgesia requirements over the next 24 hours, as well as onset of sensory blockade, were recorded. A P value <0.05 was regarded as statistically significant. RESULTS: Fewer patients in the fentanyl group (4 of 38, 10.5%) required propofol compared with the placebo group (26 of 39, 66.7%; P < 0.001). In comparison with the placebo group, the fentanyl group consumed less propofol (median 0 [0–60] vs 60 [0–160] mg, respectively; P < 0.001), required postoperative analgesia less frequently (22 of 38 patients, 57.9% vs 35 of 39 patients, 89.7%, respectively; P = 0.002), and requested the first analgesic after surgery later (median 5.8 [1.9–15.6] vs 3.1 [1.0–11.7] hours, respectively; P < 0.001), whereas the onset time of sensory blockade was similar in both groups (median 12 [9–18] vs 15 [9–18] minutes, respectively; P = 0.18). CONCLUSIONS: The addition of fentanyl to local anesthetics improved the quality and prolonged the duration of cervical plexus block in patients undergoing CEA.

Cervical plexus block versus general anesthesia in carotid surgery: single center experience.

Introduction Carotid endarterectomy may be performed under general (GA) or regional anesthesia (RA). The aim of this study was to evaluate the influence of anesthetic techniques on perioperative mortality and morbidity in patients undergoing carotid surgery. Material and methods This prospective study included 1098 consecutive patients operated on between 2003 and 2009 (773 underwent cervical plexus block and 325 underwent general anesthesia). Results There were 6 deaths, 3 (0.9%) after GA and 3 (0.4%) after RA (p = 0.272). Neurological complication rates were not significantly different (GA 2.1% vs. RA 1.1%, p = 0.212). Incidence of myocardial infarction was similar (GA 0.31% vs. LA 0.39%, p = 0.840). Shunt placement rate was the same in both groups, 11.1%. Total operating time and carotid clamping time were significantly shorter in RA patients (RA: 92 min vs. GA: 106 min; p < 0.001 and RA: 18 min vs. GA: 19 min; p = 0.040). There was no significant difference in number of reinterventions (RA: 1.0% vs. GA: 0.6%; p = 0.504). Pulmonary complications were common in the GA group (RA: 0 vs. GA 0.9%; p = 0.007). Time to first postoperative analgesic was significantly shorter in the GA group (RA: 226 min vs. GA: 139 min; p < 0.001). Conclusions Type of anesthesia does not affect the outcome of surgical treatment of carotid disease. However, it should be stressed that fewer respiratory complications, later requirement for first postoperative analgesic, and an awake patient who can continue oral therapy early after surgery, give priority to regional techniques of anesthesia.

Comparison of postoperative pain and satisfaction after dacryocystorhinostomy in patients operated on under local and general anesthesia

Summary Background There has been only 1 study on postoperative pain after external dacryocystorhinostomy (DCR) that compared pain between 2 groups of patients; 1 group received local anesthesia and the other received general anesthesia. To further characterize the relationship between these 2 types of anesthesia and postoperative pain, we designed a study in which a single patient received these 2 different anesthesia modalities for a short interval on 2 different sides. Material/Methods There were 50 participants in this study. External DCR was performed on the same participant on both sides using local anesthesia on 1 side and general anesthesia on the other. Postoperative pain was measured using the visual analogue scale (VAS), and localization and timing of pain were reported by the participants. Postoperative nausea and vomiting (PONV) were documented if present. Results Pain levels were significantly higher with general anesthesia 3 hours post-surgery, and 6 hours post-surgery the pain remains higher following general anesthesia but is borderline insignificant (p=0.051). However, 12 hours post-surgery, there is no significant difference in the pain level (p=0.240). There was no significant difference in the localization of pain with local and general anesthesia. Postoperative nausea is significantly more frequent after general anesthesia, and vomiting only occurs with general anesthesia. Local anesthesia was preferred by 94% of the participants (47 out of 50). Conclusions The vast majority of patients in our study who have undergone both GA and LA DCR would choose LA again, providing a compelling case for use of the LA technique.

Pain Associated with Carotid Artery Surgery Performed under Carotid Plexus Block: Preemptive Analgesic Effect of Ketorolac

Carotid artery surgery (CAS) performed under cervical plexus block is frequently associated with significant intra- and postoperative pain. To evaluate whether preoperative administration of ketorolac may improve analgesia in this type of surgery, 80 patients scheduled for CAS under cervical plexus block were randomly allocated to receive intravenously either 30 mg of ketorolac or placebo 30 minutes before surgery. Verbal rating scale pain scores during surgery and 3 and 6 hours after surgery, the number of patients requiring additional analgesia, and the total analgesic consumption both during and within 6 hours after surgery were significantly lower, whereas the time to first postoperative analgesia was significantly shorter in the ketorolac group than in the control group. The results of this prospective, randomized, double-blind study show that a single 30 mg dose of ketorolac administered intravenously 30 minutes before surgery reduces intraoperative pain and preempts postoperative pain in patients undergoing CAS under carotid plexus block.

Pain during external dacryocystorhinostomy with local anesthesia.

Summary Background External dacryocystorhinostomy (DCR) is often performed under local anesthesia (LA) without adequate knowledge of the pain experienced by the patient. Material/Methods We subdivided our surgical technique into stages easily understood by the patients (introducing cotton tipped applicators, performing parabulbar injection, creating the incision, bone cracking (opening the ostium), manipulating the nose, intubating, closing the wound, and packing with gauze). A total of 50 patients ranging in age from 31 to 83 years of age (63.64±9.64) underwent external DCR. Each patient was asked 30 minutes after surgery to indicate the intensity of pain experienced at each stage of the surgery and during intramuscular (IM) injection of an antibiotic using a visual analog scale (VAS). Results Analysis of the VAS-based pain scores indicated 3 statistically equal occurrences of pain coinciding with the opening of the ostium, and receiving both parabulbar anesthetic and IM antibiotic injections. Conclusions The level of pain experienced during the most unpleasant stage of external DCR (ostium opening) was similar to the pain experienced from an IM injection. Patients can be informed that pain during external DCR with local anesthesia is comparable to receiving an IM gluteal injection.

Use of Propofol in Combination with Remifentanil for Plastic and Reconstructive Surgery.

We have read the recent study by Sanatkar et al. with great interest [1]. The authors evaluated the effects of a mixture of propofol and two different concentrations of ketamine on sedation in adult patients undergoing plastic and reconstructive surgery. In addition to ketamine, midazolam and fentanyl were administered for premedication, and 2 % lidocaine with epinephrine 1/200,000 was used for local anesthesia. The results of the study demonstrated satisfactory levels of hemodynamic and respiratory stability as well as adequate sedation and analgesia. Low doses of ketamine can be useful for analgesia and sedation [1, 2] but may also be associated with a variety of adverse effects including increased oral secretion, nausea and vomiting, hemodynamic instability, and postoperative hallucinations [3]. This may limit the use of ketamine, particularly in patients with cardiovascular, respiratory, neurological, psychological, and other diseases, which was shown in the study [1]. Considering that an increasing number of elderly patients with some of the aforementioned comorbidities are seeking aesthetic surgery, the routine use of ketamine for procedural sedation may not be appropriate in clinical settings. We propose administration of a mixture of propofol and remifentanil for similar or longer surgical procedures (e.g., facial plastic surgery), which is an anesthetic technique widely used at our institution. In most cases, satisfactory levels of sedation and analgesia are produced by application of target-controlled infusion (TCI) to achieve effectsite concentration of propofol (0.4–0.8 mcg/ml) and remifentanil (0.5–1 ng/ml) [4]. Local anesthesia is provided by a mixture of 1 % lidocaine and 0.25 % levobupivacaine with epinephrine (1/200,000). The patients are encouraged to take oral anxiolytics as well as antiemetic medication prior to admission. Before surgery, premedication is administered using midazolam (2 mg) and atropine (0.5 mg) i.v. In addition to adequate sedation and analgesia levels, this anesthetic technique enhances patient comfort without compromising hemodynamic stability or respiratory function during surgery. However, close monitoring of vital signs is required during and after the procedure to avoid potentially serious adverse cardiovascular and respiratory events.