Jenny Thomas

Pharmacokinetics and efficacy of ropivacaine for continuous epidural infusion in neonates and infants.

Introduction:  The primary objective of this noncomparative study was to evaluate the pharmacokinetics of ropivacaine during a 48–72‐h continuous epidural infusion of ropivacaine in children under 1 year. The secondary objectives were to assess efficacy and safety.

The efficacy of caudal ropivacaine 1, 2 and 3 mg·ml−1 for postoperative analgesia in children

Background: The aim of this double blind, randomized, comparative study was to assess the analgesic efficacy and incidence of motor block after caudal block using three different concentrations of ropivacaine, 1, 2 and 3 mg·ml–1, in children 4–12‐year‐old.

Validation of a six-graded faces scale for evaluation of postoperative pain in children

Background: The faces pain scales are often used for self‐report assessment of paediatric pain. The aim of this study was to evaluate the validity of a six‐graded faces pain scale after surgery by comparing the level of agreement between the childrens report of faces pain scores and experienced nurses’ assessment of pain by observation of behaviour. The faces pain scores before, at and after administration of analgesics were analysed. The study was performed in two South African hospitals, one with a mainly rural population and the other with an urban population.

Conjoined twins – the anaesthetic management of 15 sets from 1991–2002

The Red Cross War Memorial Childrens Hospital, Cape Town, South Africa is the only dedicated childrens hospital in sub‐Saharan Africa and, as such, is the referral hospital for complex procedures from this region.

Challenges associated with paediatric pain management in Sub Saharan Africa

The African child is particularly vulnerable to disease and injury, and subsequently, to pain and suffering. Factors such as inadequate training, language barriers, cultural diversity, limited resources and the burden of disease prevents sick and injured children from receiving basic pain care. This situation can only be rectified by providing pre and post graduate training on the safe use of analgesic preparations, the availability of drugs and government support.

Reducing the risk in neonatal anesthesia

Neonatal anesthesia is fraught with potential risk for the patient and stress for the anesthesiologist. Where possible, recognition of these risks, avoidance of, and being able to manage them appropriately, must impact positively on perioperative outcomes in this vulnerable group of patients. Good communication with the parents, as well as with other healthcare providers, is crucial to safe and successful anesthetic care.

Intraoperative neurophysiological monitoring for the anaesthetist

Abstract The use of intraoperative neurophysiological monitoring (INM) during spinal orthopaedic and neurosurgical procedures provides a challenge to the attending anaesthesiologist. Since all anaesthetic agents affect synaptic function, the choice of agent will be determined by the type of surgery and the INM modality employed. Halogenated volatile agents decrease evoked potential (EP) amplitude and increase latency, and should be avoided in modalities that pass through cortical tracts. The effect on EPs is apparent at minimum alveolar concentrations of 0.3–0.5. Intravenous agents affect EPs in a dose-dependent manner, and should be titrated to response. Total intravenous anaesthesia with propofol and remifentanyl is the preferred technique. The risk of propofol infusion syndrome has not been shown to affect the choice of this agent. Compound muscle action potentials are abolished by barbiturates, and should be avoided during motor-evoked potential (MEP) monitoring. Although somatosensory-evoked potentials are unaffected by muscle relaxants, they prevent the monitoring of MEPs and should be avoided during multimodal use. When paralysis is required to ensure patient safety, the train-of-four ratio should be kept at 2/4 twitches and a T1 response at 10–20% of baseline, with use of a closed-loop system.

Intraoperative neurophysiological monitoring for the anaesthetist Part 1: A review of the theory and practice of intraoperative neurophysiological monitoring

Abstract Intraoperative neurophysiological monitoring (IONM) has become the gold standard for the monitoring of functional nervous tissue and mapping of eloquent brain tissue during neurosurgical procedures. The multimodal use of somatosensory-evoked potentials and motor-evoked potentials ensures adequate monitoring of anterior sensory and dorsal motor pathways. The use of IONM during spinal orthopaedic surgery has drastically reduced the incidence of postoperative neurological deficit and allowed radical resection of brain tumours. Evoked potentials (EPs) are analysed for increased latency (> 1 millisecond) and decreased amplitude (< 50%). Special considerations have to be made in the paediatric population who present with decreased myelination and morphological changes to the EPs. A thorough knowledge of the physics and physiology behind these techniques will ensure better outcomes and successful implementation in neurosurgical centres. In this two-part article series, we will provide a review of the most recent available literature on IONM. The different modalities that are available, their indications and application are presented in Part 1, while the different anaesthetic options that exist will be discussed and the basic approach to the planning of a successful anaesthetic outlined in Part 2.

Epidermolysis bullosa in children: pathophysiology, anaesthesia and analgesia

“Few conditions are more devastating to the physical, emotional, and social health of an infant or child than epidermolysis bullosa. The disease is actually a group of congenital abnormalities of the skin, and it encompasses a variety of genetic abnormalities of proteins that mediate adhesion of the skin. These abnormalities result in fragile skin that blisters, causing pain, deformity, social and emotional disability, susceptibility to infection and cancer, and shortened life. Children with epidermolysis bullosa require lifelong support and understanding from physicians (both specialists and g eneralists), from clinical support personnel, and most important, from their families.”1

Endotracheal tubes in paediatric anaesthesia: the cuffed versus uncuffed debate

The paediatric airway demands respect, and appropriate and safe management of this delicate structure is of utmost importance. With development of polyvinyl chloride (PVC) in the 1960s, uncuffed endotracheal tubes (ETTs) replaced tracheostomies for long-term intubation and ventilation in the intensive care unit (ICU). Since then, uncuffed ETTs have traditionally been used in infants and children under the age of eight (or even ten) years for both short- and long-term intubation in theatre and ICU. Cuffed ETTs were not considered appropriate in this age group, and until fairly recently many manufacturers of ETTs did not produce cuffed sizes smaller than a 5 mm internal diameter (ID). However, debate in the literature over the last decade questions this teaching, some saying that the routine use of uncuffed ETTs in infants and children is not based on scientific evidence. It is clear that the strongly emerging role of cuffed ETTs in the paediatric population has come to the fore.