Lynne R. Ferrari

General Anesthesia Prior to Treatment of Anterior Mediastinal Masses in Pediatric Cancer Patients

Many children with malignant diseases who present with an anterior mediastinal mass must undergo general anesthesia for tissue diagnosis or tumor resection. One hundred sixty-three pediatric patients over a period of 6 yr were admitted to Memorial Sloan-Kettering Cancer Center with a diagnosis of anterior mediastinal mass. Forty four of these patients required surgery and their records were reviewed. In recent years perioperative radiation therapy has been advocated for this patient group prior to their receiving general anesthesia. If a tissue diagnosis has not been made, preoperative radiation therapy may distort histologic findings and prevent accurate diagnosis. All patients with an anterior mediastinal mass who must receive general anesthesia in our institution do so prior to treatment with radiation or chemotherapy even in the presence of cardiovascular or respiratory symptoms. No patient died or sustained permanent injury as a result of their anesthetic or operative experience. Two patients who experienced difficulty on induction of anesthesia required tracheal intubation with a rigid bronchoscope. Two patients developed airway obstruction during anesthetic maintenance that was corrected with changes in patient position. Four patients were unable to have their tracheas extubated at the conclusion of surgery and one patient required tracheal reintubation in the immediate postoperative period. These patients were treated with radiation therapy and chemotherapy after tissue for diagnosis had been obtained. The authors conclude that in the absence of life-threatening preoperative airway obstruction and severe clinical symptoms general anesthesia may be safely induced prior to radiation therapy.

Metoclopramide reduces the incidence of vomiting after tonsillectomy in children.

The efficacy of intravenous metoclopramide in controlling vomiting in children after tonsillectomy was determined in a prospective randomized, double-blind investigation. One hundred two unpremedicated, ASA physical status I or II children between the ages of 1 and 15 yr who were undergoing surgical removal of the tonsils, with or without adenoidectomy, were studied. Anesthesia was induced either with halothane, nitrous oxide, and oxygen by mask or by intravenous thiopental and was maintained with halothane, nitrous oxide, oxygen, and intravenous morphine (0.1 mg/kg). Each child randomly received either 0.15 mg/kg of metoclopramide or saline solution placebo intravenously after transfer to the postanesthesia care unit. All episodes of vomiting were recorded for 24 h after completion of surgery. The incidence of vomiting in the saline solution group was 70%, compared with 47% in the metoclopramide group (P = 0.026). The authors conclude that the administration of intravenous metoclopramide in a dose of 0.15 mg/kg on arrival in the postanesthesia care unit significantly decreases the incidence of vomiting in children after tonsillectomy.

Acupressure-Acupuncture Antiemetic Prophylaxis in Children Undergoing Tonsillectomy

BACKGROUND Acupuncture or acupressure at the Nei-Guan (P.6) point on the wrist produces antiemetic effects in awake but not anesthetized patients. The authors studied whether a combined approach using preoperative acupressure and intra- and postoperative acupuncture can prevent emesis following tonsillectomy in children. METHODS Patients 2-12 yr of age were randomly assigned to study or placebo groups. Two Acubands with (study) and two without (placebo) spherical beads were applied bilaterally on the P.6 points; non-bead- and bead-containing Acubands, respectively, were applied on the sham points. All Acubands were applied before any drug administration. After anesthetic induction, acupuncture needles were substituted for the beads and remained in situ until the next day. All points were covered with opaque tape to prevent study group identification. A uniform anesthetic technique was used; postoperative pain was managed initially with morphine and later with acetaminophen and codeine. Emesis, defined as retching or vomiting, was assessed postoperatively. Ondansetron was administered only after two emetic episodes at least 2 min apart. Droperidol was added if emesis persisted. RESULTS One hundred patients were enrolled in the study. There were no differences in age, weight, follow-up duration, or perioperative opioid administration between groups. Retching occurred in 26% of the study patients and in 28% of the placebo patients; 51 and 55%, respectively, vomited; and 60 and 59%, respectively, did either. There were no significant differences between the groups. Redness occurred in 8.5% of acupuncture sites. CONCLUSION Perioperative acupressure and acupuncture did not diminish emesis in children following tonsillectomy.

Endoscopic repair of laryngeal cleft type I and type II: When and why?

To evaluate the clinical features of children with type I and type II laryngeal cleft and the role of conservative monitoring versus endoscopic repair in their management.

Perioperative management of pediatric surgical patients with diabetes mellitus

Pediatric patients with diabetes are managed with increasingly complex regimens. To optimally manage these patients during the perioperative period, pediatric anesthesiologists must carefully consider the pathophysiology of the disease, patient-specific methods of treatment, status of glycemic control, and the type of surgery proposed. Important pediatric issues, including body size, pubertal development, and ability to tolerate nil per os status, must be considered. To keep pace with the array of options for treating diabetes in children, the perioperative plan should be developed in consultation with a pediatric endocrinologist. We present an algorithm that was developed at Children’s Hospital Boston for the management of pediatric patients with either type 1 or type 2 diabetes mellitus presenting for surgery and general anesthesia. This collaborative effort between the pediatric anesthesia and endocrine services represents one example of a standardized approach to these patients that should facilitate care and improve management. Differences from previously published recommendations are highlighted, as are expected changes caused by the continued evolution of pediatric diabetes care.

Single-Dose Ondansetron Prevents Postoperative Vomiting in Pediatric Outpatients

This randomized, double-blind, parallel-group, multicenter study evaluated the safety and efficacy of ondansetron (0.1 mg/kg to 4 mg intravenously) compared with placebo in the prevention of postoperative vomiting in 429 ASA status I-III children 1-12 yr old undergoing outpatient surgery under nitrous oxide- and halothane-based general anesthesia. The results show that during both the 2-h and the 24-h evaluation periods after discontinuation of nitrous oxide, a significantly greater percentage of ondansetron-treated patients (2 h 89%, 24 h 68%) compared with placebo-treated patients (2 h 71%, 24 h 40%) experienced complete response (i.e., no emetic episodes, not rescued, and not withdrawn; P < 0.001 at both time points). Ondansetron-treated patients reached criteria for home readiness one-half hour sooner than placebo-treated patients (P < 0.05). The age of the child, use of intraoperative opioids, type of surgery, and requirement to tolerate fluids before discharge may also have affected the incidence of postoperative emesis during the 0- to 24-h observation period. Use of postoperative opioids did not have any effect on complete response rates in this patient population. We conclude that the prophylactic use of ondansetron reduces postoperative emesis in pediatric patients, regardless of the operant influential factors. Implications: Postoperative nausea and vomiting often occur after surgery and general anesthesia in children and are the major reason for unexpected hospital admission after ambulatory surgery. Our study demonstrates that the prophylactic use of a small dose of ondansetron reduces postoperative vomiting in pediatric patients. (Anesth Analg 1997;85:538-45)

The use of the laryngeal mask airway in children with bronchopulmonary dysplasia.

Airway maintenance with the laryngeal mask airway (LMA) was evaluated and compared to the endotracheal (ET) tube in 27 former premature infants and children with bronchopulmonary dysplasia (BPD) during second stage open-sky vitrectomy. The children were randomly assigned to a study group and anesthetized with halothane in N2 O:O2. The airway was maintained with the LMA (n = 13) or the ET tube (n = 14). Respiratory and hemodynamic variables were recorded. Intraoperative and postoperative complications were noted. The respiratory rate and the end-tidal CO (2) were significantly higher in the LMA group as compared with the ET tube group (P < 0.01); however, the pulse rate and both systolic and diastolic blood pressures throughout the surgical procedure were lower in the LMA group (P < 0.05). The incidence of coughing, with and without desaturation, wheezing, and hoarseness in the postoperative period was higher in the ET tube group. Awakening, after discontinuation of the anesthetic (P < 0.01) was more rapid, and home discharge time (P < 0.002) was shorter in the LMA group (P < 0.0025), although our study design could not isolate the use of the LMA as the factor responsible for this. This study in patients with mild chronic lung disease demonstrated that the LMA can maintain a satisfactory airway during minor surgical procedures in children with bronchopulmonary dysplasia and result in fewer respiratory adverse effects than with the ET tube. (Anesth Analg 1995;81:310-3)

Laryngeal cleft: Evaluation and management

OBJECTIVES Review the latest diagnostic and treatment modalities for laryngeal and laryngotracheoesophageal clefts as they can be a major cause of respiratory and feeding morbidity in the infant and pediatric population. METHODS Literature review of published reports. RESULTS The presentation of laryngeal cleft usually involves respiratory symptoms, such as stridor, chronic cough, aspiration, and recurrent respiratory infections. Clefts of the larynx and trachea/esophagus can occur in isolation, as part of a syndrome (Opitz-Frias, VATER/VACTERL, Pallister Hall, CHARGE), or with other associated malformations (gastrointestinal, genitourinary, cardiac, craniofacial). This publication reviews the presenting signs/symptoms, diagnostic options, prognosis, and treatment considerations based on over a decade of experience of the senior author with laryngeal clefts. CONCLUSIONS Type I laryngeal clefts can be managed medically or surgically depending on the degree of morbidity. Types II, III, and IV require endoscopic or open surgery to avoid chronic respiratory and feeding complications.

Perioperative management of diabetes insipidus in children.

Managing children with diabetes insipidus (DI) in the perioperative period is complicated and frequently associated with electrolyte imbalance compounded by over- or underhydration. In this study the authors developed and prospectively evaluated a multidisciplinary approach to the perioperative management of DI with a comparison to 19 historical control children. Eighteen children either with preoperative DI or undergoing neurosurgical operations associated with a high risk for developing postoperative DI were identified and managed using a standardized protocol. In all patients in whom DI occurred during or after surgery, a continuous intravenous infusion of aqueous vasopressin was initiated and titrated until antidiuresis was established. Intravenous fluids were given as normal saline and restricted to two thirds of the estimated maintenance rate plus amounts necessary to replace blood losses and maintain hemodynamic stability. In all children managed in this fashion, perioperative serum sodium concentrations were generally maintained between 130 and 150 mEq/L, and no adverse consequences of this therapy developed. In the 24-hour period evaluated, the mean change in serum sodium concentrations between the historical controls was 17.6 ± 9.2 mEq/L versus 8.36 ± 6.43 mEq/L in those children managed by the protocol. Hyponatremia occurred less frequently in the children managed with this protocol compared with historical controls.

Preoperative evaluation of pediatric surgical patients with multisystem considerations

Fewer and fewer patients spend time in the hospital in advance of a surgical or interventional procedure requiring anesthesia care. As a result, there is increasing reliance on a thorough preoperative evaluation directed toward identifying anesthetic risks. For this to occur, each medical institution must have a clear and comprehensive system that processes patients during the preoperative period. There are specific and unique personnel and system requirements for the accumulation of multidisciplinary information in the pediatric patient population. The justification for the cost of this type of program is the savings realized by the decrease in wasted operating room time due to inadequate or incomplete patient preparation. The following is a description of a successful perioperative evaluation and preparation process that has been in place for 7 yr in a major pediatric academic institution.