John B. Eck

Pediatric regional anesthesia: beyond the caudal.

P ediatric regional anesthesia has gone through significant development in recent years with advances in safety information, pharmacology, and block techniques. There is an increasing interest in regional anesthesia in pediatrics beyond the common caudal, epidural, or spinal. With improvements in equipment that are specific to children and the addition of ropivacaine as a proven local anesthetic, pediatric regional anesthesia, and specifically peripheral nerve blockade, should continue to gain popularity. The last literature reviews in major anesthesia journals on pediatric regional anesthesia were published more than a decade ago (1,2). The popularity of regional anesthesia as a supplement to general anesthesia in children has grown out of recognition of its advantages beyond simple avoidance of general anesthesia. Suggested benefits include the decreased intraoperative requirement for general anesthetics, less of a need for the use of parenteral opioids thereby limiting the incidence of respiratory depression, and limitation of stress hormone responses (1,3,4). Improved postoperative analgesia and shortened recovery for outpatient surgery have provided further impetus for refinement of techniques that can be used safely in combination with general anesthesia in children. The goal of these techniques that specifically and peripherally target the location of the surgery is to minimize the undesirable side effects of central blocks such as urinary retention, hypotension, and muscle weakness in unaffected areas. Additionally, when compared with central regional blockade, peripheral nerve blocks may be associated with a decreased incidence of serious sequelae as demonstrated in a largescale study by the French-Language Society of Pediatric Anesthesiologists, which led the authors to suggest that peripheral blocks be used more often in place of central blocks when appropriate (5). The following review will discuss the safety and the unique differences between adults and children that influence the anesthetics and techniques of peripheral nerve blockade in children.

Anaesthetic management of infants with glycogen storage disease type II: a physiological approach.

Pompe or Glycogen Storage Disease type II (GSD‐II) is a genetic disorder affecting both cardiac and skeletal muscle. Historically, patients with the infantile form usually die within the first year of life due to cardiac and respiratory failure. Recently a promising enzyme replacement therapy has resulted in improved clinical outcomes and a resurgence of elective anaesthesia for these patients. Understanding the unique cardiac physiology in patients with GSD‐II is essential to providing safe general anaesthesia.

Use of remifentanil in infants.

We describe the use of remifentanil in three infants with complex medical issues (hepatic failure, cyanotic heart disease and renal compromise). The short duration of opioid effect even after a long period of drug infusion (18 h) suggests this drug may be useful in some infants. Continued study is warranted.

Prediction of tracheal tube size in children using multiple variables

Background: Tracheal tube (TT) size selection in children is important to avoid complications. Formulae utilizing age and physical characteristics to predict appropriate tube size are not entirely predictive.

Teaching Successful Central Venous Cannulation in Infants and Children: Audio Doppler Versus Anatomic Landmarks

OBJECTIVE To determine if vein localization with an audio Doppler increases successful central venous cannulation and decreases complications in infants and children when performed by inexperienced operators, compared with vein localization by anatomic landmarks (ALs). DESIGN A prospective cohort of infants and children undergoing central venous cannulation for cardiac surgery. SETTING A university-affiliated childrens hospital with a pediatric anesthesia fellowship program. PARTICIPANTS All infants and children undergoing cardiac surgery between July 1, 1996, and January 1, 1997. INTERVENTIONS Subjects had central venous catheters (CVCs) placed by an anesthesia fellow by either ALs or audio-Doppler localization of the veins. MEASUREMENTS AND MAIN RESULTS Eighty-four children were studied. Internal jugular vein (IJV) cannulation was attempted in 71 (85%) children and femoral vein cannulation in 13 (15%) children. Time to catheter insertion, number of needle passes, and artery puncture were noted. Sixty-one of 63 (97%) children had successful central venous cannulation by an anesthesia fellow using audio-Doppler vein localization. This was significantly greater than the 13 of 21 (62%) successful cannulations among children who had veins localized by ALs. Time to insertion did not differ by method of vein localization; however, the number of needle passes was significantly greater in the AL group. Artery puncture did not differ significantly by method of vein localization. CONCLUSION Vein localization by audio Doppler significantly increases the rate of successful central venous cannulation and decreases the number of needle passes in pediatric patients when used by inexperienced operators.

Neuromuscular effects of rapacuronium in pediatric patients during nitrous oxide-halothane anesthesia: comparison with mivacurium.

Purpose: To describe neuromuscular effects of rapacuronium in pediatric patients during N2 O-halothane anesthesia and compare them with mivacurium in children.Methods: 103 pediatric patients, seven days- 12 yr, received rapacuronium or mivacurium during N2 O-halothane anesthesia. Onset and recovery of block were measured using EMG (Datex). Block was compared between groups based on drug treatment and age. Children < two years received 1 or 2 mg·kg−1 rapacuronium: 2 – 12 yr received either 2 mg·kg−1 or 3 mg·kg−1 rapacuronium, or 0.2 mg·kg−1 mivacurium.Results: There were no differences in onset (1.7±1.8 min) or maximum block (T1 2.4±8%) among neonates, infants, and toddlers after either dose of rapacuronium. There was no difference between 1 and 2 mg·kg−1 of rapacuronium block at 60 sec. Train-of-four ratio (T4/T1)>0.7 occurred later after 2 mg·kg−1 than 1 mg·kg−1 in these patients (P<0.05). There was no difference in T25 among neonates, infants and toddlers for 1 mg·kg−1 or 2 mg·kg−1 doses. Rapacuronium, 3 mg·kg−1, produced maximum block 1.5 min earlier than did mivacurium, 0.2 mg·kg−1 (P<0.001). There was no difference in block at 60 sec, maximum block or time to maximum block between 2 and 3 mg·kg−1 rapacuronium for children > two years of age. Maximum block occurred 1.0±0.5 min after 2 or 3 mg·kg−1 when T1 was 0.2±1.1% of baseline. T25 and T4/T1>0.7 occurred 10 to 11 min later after this dose of rapacuronium than after mivacurium.Conclusion: Rapacuronium produces block earlier than mivacurium. Recovery from rapacuronium block is dose related and slower than that following mivacurium during halothane anesthesia.RésuméObjectif: Décrire les effets neuromusculaires du rapacuronium pendant l’anesthésie avec N2O et halothane et les comparer avec ceux du mivacurium chez des enfants.Méthode: Cent trois enfants, de 7 jrs à 12 ans, ont reçu du rapacuronium ou du mivacurium pendant une anesthésie avec N2O et halothane. Le début et la fin du bloc ont été mesurés à l’aide de l’EMG (Datex). Le bloc a été comparé sur la base du traitement médicamenteux et de l’âge. Les enfants <2 ans ont reçu 1 ou 2 mg·kg−1 de rapacuronium; ceux de 2–12 ans ont reçu 2 ou 3 mg·kg−1 de rapacuronium, ou 0,2 mg·kg−1 de mivacurium.Résultats: Le rapacuronium, peu importe la dose administrée et l’âge des patients, n’a pas présenté de différence quant au début d’action (1,7±1,8 min) du bloc ou au temps du bloc maximal (T1 2,4±8%). À 60 s, les blocs provoqués par 1 et 2 mg·kg−1 de rapacuronium étaient semblables. Le rapport du train-de-quatre (T4/T1)>0,7 s’est produit plus tard après 2 mg·kg−1 qu’après 1 mg·kg−1 (P<0,05). Aucune différence non plus au T25 entre les doses de 1 ou 2 mg·kg−1. La dose de 3 mg·kg−1 de rapacuronium a produit le bloc maximal 1,5 min plus tôt que celle de 0,2 mg·kg−1 (P<0,001) de mivacurium. Il n’y a pas eu de différence de bloc à 60 s, de temps pour le bloc maximal ou de temps pour atteindre ce bloc maximal chez les enfants >2 ans qui ont reçu 2 et 3 mg·kg−1 de rapacuronium. Le bloc maximal a été noté 1,0±0,5 min après 2 ou 3 mg·kg−1 quand T1 était à 0,2±1,1% de la mesure de base. T25 et T4/T1>0,7 sont survenus de 10–11 min plus tard après cette dose de rapacuronium qu’après le mivacurium.Conclusion: Le rapacuronium agit plus rapidement que le mivacurium. Pendant l’anesthésie avec de l’halothane, le renversement du bloc suivant l’utilisation de rapacuronium est relié à la dose et est plus lent que celui qui suit le mivacurium.

Office-based anesthesia for children

The use of office-based surgery and anesthesia will continue to grow. The anesthesia community has embraced the opportunity to become a driving force of office-based surgery and has organized into rapidly growing groups that promote safe practice in the office setting. The Society for Office-Based Anesthesia was developed to continuously improve patient safety and outcomes in office surgery. This group has an active Web site (www.soba.org) that allows for online discussions and widespread participation in working toward the societys stated goal. This Web site may be used as a reference for physicians in the process of considering the move to office-based anesthesia. The advantages of office-based anesthesia are numerous. The financial incentives are tremendous and the convenience to the patient and surgeon is important. For office anesthesia to be successful in children, patient safety, proof of improved outcomes, and family and surgeon satisfaction must be the goals. Anesthesia providers must continue to take active roles in organizing the office environment to ensure that safety is paramount. As the field grows, additional ways to study and improve the overall care children receive in the office should be sought. In the near future, office practice for surgery and anesthesia for children undergoing minor procedures should be a safe and effective alternative to current practices.

The association between caudal anesthesia and increased risk of postoperative surgical complications in boys undergoing hypospadias repair

Recent reports have suggested that caudal anesthesia may be associated with an increased risk of postoperative surgical complications. We examined our experience with caudal anesthesia in hypospadias repair to evaluate for increased risk of urethrocutaneous fistula or glanular dehiscence.