Ludmyla Kachko

Complex regional pain syndromes in children and adolescents

Background: The purpose of the present paper was to assess efficiency of treatment and long‐term functional outcome of complex regional pain syndromes (CRPS) in children who were treated in the chronic pain clinic at a major tertiary hospital in Israel.

Spinal anesthesia in neonates and infants - A single-center experience of 505 cases

Background:  Our aim was to assess the safety and efficacy of spinal anesthesia (SA) in newborns and infants undergoing surgery appropriate for this technique.

A vein entry indicator device for facilitating peripheral intravenous cannulation in children: a prospective, randomized, controlled trial.

BACKGROUND: Vascular access is often technically difficult in children because of the small caliber and impalpability of the veins. In this study, we sought to determine if use of the Vein Entry Indicator Device (VEID™) in children facilitates peripheral venous access. METHODS: Two-hundred-two healthy (ASA grade I and II) children scheduled for same-day surgery at a major tertiary hospital in Israel were randomly allocated to undergo VEID-assisted or standard peripheral venous cannulation. All cases involved the insertion of a 22-gauge cannula into an upper limb vein. Primary outcome measures were number of attempts to successful cannulation, rate of success at first attempt, and time required for insertion. The data were presented as mean (sd). Analyses of variance and Pearson &khgr;2 test or Fisher’s exact test were used to compare the groups; forward stepwise logistic regression was used to identify the three variables (age, vein assessment category, use of the VEID) significantly associated with a successful first attempt. A P value of ≤0.05 was considered significant. RESULTS: Successful cannulation was achieved at the first attempt in the majority of patients in both groups. Two attempts were needed in 8% of the VEID group and 28% of the control group, and 3 attempts were needed in 1% and 3%, respectively (P < 0.01). Analysis by vein assessment category yielded a similar rate of successful first-attempt cannulations in the two groups for easy veins. However, for the difficult and intermediate categories, the rate was 89.7% in the VEID group compared to 23.3% in the control group (P < 0.001). The fewer number of attempts in the study group was associated with a shorter time from the start of the search for an appropriate vein to successful cannulation (9.1 s versus 22.5 s in the control group). CONCLUSIONS: The VEID facilitates the insertion of peripheral venous cannulas in healthy children with intermediate/difficult veins undergoing same-day surgery, reducing the number of attempts and the overall time required.

Impact of spinal anesthesia for open pyloromyotomy on operating room time

PURPOSE When pyloromyotomy for hypertrophic pyloric stenosis (HPS) is performed under general anesthesia, metabolic abnormalities and fluid deficits coupled with residual anesthetics may increase the risk of postoperative apnea, thereby, prolonging operating room time and delaying extubation. Spinal anesthesia has been found to reduce the rate of postoperative apnea in high-risk infants. The aim of the study was to evaluate the effect of spinal vs general anesthesia on operating room time in infants undergoing open pyloromyotomy. METHODS Data for 60 infants who underwent pyloromyotomy under spinal (n = 24) or general (n = 36) anesthesia at a tertiary pediatric medical center were derived from the computerized database. Primary outcome measures were total operating room time, procedure duration, anesthesia release time, wake-up time, and anesthesia control time (anesthesia release plus wake-up). Nonparametric Mann-Whitney test was used for statistical analysis, and Levenes test was used to assess the equality of variances in samples; P <or= .05 was considered significant. RESULTS Mean total operating room time was 50.9 (12.1) minutes in the spinal anesthesia group and 69.5 (26.8) minutes in the general anesthesia group (P = .001). Corresponding values for mean wake-up time were 3.6 (2.9) and 17.2 (25.3) minutes (P < .001), and for mean anesthesia control time, 13.2 (6.7) and 28.5 (24.6) minutes (P < .001). There were no between-group differences in procedure duration or anesthesia release time. On Levenes test, between-group differences were significant for total operating time and wake-up time (P = .01 for both). CONCLUSIONS The use of spinal anesthesia for open pyloromyotomy in infants with HPS shortens the operating room time by reducing the wake-up time.

Spinal anesthesia for noncardiac surgery in infants with congenital heart diseases

Objective/Aim:  To compare hemodynamic parameters in infants with congenital heart disease (CHD) undergoing noncardiac surgery (NCS) under awake spinal anesthesia (SA) with controls without CHD also undergoing SA.Spinal anesthesia (SA) in pediatrics began to be used in the late nineteenth century in multiple procedures, with priority for high-risk and former preterm infants, for its suggested protective role compared to the development of postoperative apnea with general anesthesia (GA). In children, higher doses of local anesthetics are required with a shorter duration of action and a greater hemodynamic stability compared to adults. The puncture must be performed in the L4-L5 or L5-S1 spaces to prevent spinal injuries. The practice of SA in pediatric patients requires skill and experience; failure rates of up to 28% have been reported. The drugs most commonly used for SA are tetracaine and bupivacaine alone or with adjuvants. SA complications are rare and often without consequences, except for postdural puncture headaches and backaches. Although SA is today considered safe and effective for pediatric patients, it remains relatively underutilized compared to GA.

Spinal anesthesia in infants with ventriculoperitoneal shunt: report of five cases and review of literature

We describe five cases of children with ventriculoperitoneal shunt who underwent abdominal and perineal procedures under spinal anesthesia. Four of them had been born prematurely, and all had suffered from severe neonatal complications. All of our patients suffered from severe respiratory impairment, that had required mechanical ventilation, and three of them suffered additionally from apnea of prematurity. Four patients had ventriculoperitoneal shunt inserted because of obstructive hydrocephalus and one because of congenital central nervous system anomalies. Two underwent subsequently shunt revision. The benefits of spinal anesthesia in this high‐risk population are described. The risks of spinal anesthesia in the presence of a ventricular shunt device, especially infection and dural leakage, are discussed, and the literature about this topic briefly reviewed.

Neuropathic pain other than CRPS in children and adolescents: incidence, referral, clinical characteristics, management, and clinical outcomes

Chronic pain in children and adolescents is common, but proportion of neuropathic pain (NP), a heterogeneous group of diseases with major impact on health‐related quality of life, significant economic burden, and limited treatment options, is unclear. Many studies have focused only on complex regional pain syndrome (CRPS). Our aim was to examine the incidence, clinical features, management, and outcome of non‐CRPS NP in patients referred to a chronic pediatric pain clinic (CPPC) at a tertiary‐care hospital.

Sub-Tenon’s Ropivacaine Block for Pain Relief After primary Strabismus Surgery

Purpose: Pain is the main cause of patient distress/dissatisfaction after strabismus surgery. The aim of the study was to evaluate the effect of sub-Tenon’s block with ropivacaine at the end of strabismus surgery on post-operative pain. Methods: A prospective trial was conducted in 79 patients (age 1.0–65 years) scheduled for outpatient primary strabismus surgery with fixed sutures under general anesthesia (GA) at a major tertiary hospital. Half the patients were randomly allocated to receive sub-Tenon’s block with ropivacaine 0.2% at conclusion of the operation. Primary outcome measures were visual analog scale (VAS) scores at arrival to the post-anesthesia care unit (PACU), at discharge 3 hr later, 12–16 hr post-operatively, and 24 hr post-operatively. Supplemental analgesia requirements and patient satisfaction were recorded as well. Data were presented as median (range). Mann–Whitney test, Pearson χ2-test or Fisher’s exact test was used for statistical analysis; p ≤ 0.05 was considered significant. Results: There were no between-group differences in median VAS scores at arrival to the PACU and at discharge, with a borderline difference at 24 hr post-operatively (p = 0.06). At 12–16 hr post-operatively, the median score was 0.0 (range 0–5) in the study group and 4.0 (range 0–6) in the controls (p < 0.001). The lower VAS score in the study group was associated with a lower rate of supplemental analgesia use (21.9% versus 57.9%, p = 0.001), fewer doses of supplemental analgesia (10 doses versus 35, p = 0.03), and higher patient satisfaction (p < 0.001). Conclusions: Sub-Tenon’s block with ropivacaine 0.2% at the completion of outpatient primary strabismus surgery with fixed sutures under GA reduces pain 12–16 hr post-operatively and analgesia requirements 4–23 hr post-operatively.

Postoperative respiratory complications in Joubert syndrome

SIR—Joubert syndrome (JS) is a rare autosomal recessive disorder whose main clinical signs are hypotonia, ataxia, mental retardation, abnormal eye movements and a respiratory pattern of alternating hyperpnea-apnea during the first months of life (1). Although most cases are sporadic, in some families JS appears to be inheritated via a recessive gene, called AHI1, encoding jouberin, whose locus is on chromosome 6 (2,3). Children with JS who present with retinal degeneration seem more prone to develop renal disease, nephronophthisis or cystic dysplastic kidney, causing renal failure and a high mortality. Partial or complete agenesis of the cerebellar vermis is the most significant neuropathological finding (1). The diagnosis is confirmed by magnetic resonance imaging, which reveals a pathognomonic neuroradiological sign, the ‘molar tooth sign’ (4). Some of the clinical features of JS that are relevant to anesthesia include palate malformations, a large or protruding tongue, laryngomalacia and micrognathia. The characteristic respiratory irregularities of JS may also present problems during and after anesthesia. Past reports of anesthesia care have been limited to infants with normal renal function (5–7). The advanced treatment of renal failure permits prolongation of life, so that JS children grow up and may require surgery and anesthesia as adults. This is the first reported case of anesthesia management of a young adult with JS and subsequent complications. A 19-year-old young man was scheduled for Tenckhoff catheter removal and Permacath insertion. He suffered from JS manifesting as severe mental retardation, physical impairment, a seizure disorder and endstage renal failure from nephronophthisis. Renal insufficiency began at the age of 16 years and 2 years later a Tenckhoff catheter was inserted for peritoneal dialysis. He was given 0.05 mgÆkg IV morphine and the anesthesia management of the procedure and postoperative course were uneventful. Ten months later, Tenckhoff catheter removal and insertion of the Permacath for hemodialysis were planned, because of local peritonitis. On admission the patient (weight 56 kg, height 153 cm) was conscious and afebrile. Blood pressure (BP) was 115/75 mmHg, heart rate (HR) 90 bÆmin, and SpO2 98% in room air. Preoperative clinical examination revealed normal respiratory patterns. With the exception of high values of urea and creatinine, 42 mmolÆl(117 mgÆdl) and 725 lmolÆl(8.2 mgÆdl), respectively, blood analysis and electrolytes were within normal range. Urinary output was approximately 1000 ml per 24 h. Current medications consisted of valproic acid 1 g daily, sodium bicarbonate, calcium, vitamins B and D, folic acid and erythropoietin and also vancomycin and garamycin for treatment of peritonitis. Premedication consisted of oral midazolam 15 mg administered 45 min before surgery. Following placement of routine monitors and preoxygenation with 100% oxygen, induction of anesthesia was accomplished with propofol 1.7 mgÆkg and fentanyl 1 lgÆkg, followed by atracurium 0.5 mgÆkg for facilitation of tracheal intubation and maintained with 1% isoflurane in nitrous oxide in 50% oxygen with controlled ventilation. Additional opioids were avoided. The surgical procedure, performed under fluoroscopy, lasted 70 min. BP and HR remained within normal values. At the end of the procedure the surgeon performed local infiltration of the incision sites with 10 ml of 0.2% ropivacaine. After reversal of muscle relaxation (confirmed using a nerve stimulator) the patient met clinical criteria for extubation, which was performed in the operating room. Approximately 1 min after extubation the patient suddenly became apneic and was ventilated manually with 100% oxygen without difficulty via facemask. After termination of the apnea, which lasted nearly 2 min, the patient started to breath spontaneously and was transferred to the postoperative area in full consciousness. During this episode his cardiovascular parameters remained stable. Five minutes after arrival in the recovery room (RR), hyperpneic pattern of breathing (nearly 50 brÆmin) were recorded. The patient remained conscious and did not express pain sensation verbally or behaviorally. BP was 110/70 mmHg, HR 80 bÆmin and SpO2 100% on oxygen 6 lÆmin. On auscultation, breath sounds were equal without wheezing. A chest X-ray performed to exclude pneumothorax or pulmonary edema was within normal limits. This episode of hyperpnea lasted for 10 min and terminated as suddenly as it commenced. The patient was discharged to the ward fully recovered with pulses oximetry monitoring overnight. No respiratory complications were later recorded in the ward. Joubert syndrome is a rare (1 : 10 000) but well documented congenital disease that was first described in 1969 by Marie Joubert et al. (1) and involves malformation of the areas of the brain controlling balance and coordination. Psychomotor activity is slowed and there are abnormal eye Pediatric Anesthesia 2006 16: 799–808

Anesthesia for the child with Zellweger syndrome: a case report

97–99%. A preconfigured styleted LMA can be successfully used in pediatric-burned patients with a fixed neck flexion deformity and limited mouth opening with an upsidedown technique. Rashid M. Khan M D Vijayata Verma M B B S Ashutosh Bhradwaj M B B S Gaurav Dwivedi M B B S Meher F. Ahson M B B S Meraj Ahmed M B B S Shahryar A. K. Suri M B B S Department of Anaesthesiology, J.N. Medical College, A.M.U., Aligarh, U.P., India