Mary Ann Gurkowski

Lumbar and thoracic epidural analgesia via the caudal approach for postoperative pain relief in infants and children

Thirty infants scheduled for a variety of gastrointestinal, genitourinary and thoracic surgical procedures were selected for insertion of lumbar or thoracic epidural catheters via the caudal approach using either an Intracath® or a Burron® continuous brachial plexus kit. The catheters were inserted with ease by residents in training and no catheter-related complications were encountered. Lidocaine 0.5 per cent with 1:200,000 epinephrine was then injected to assure proper placement of the catheter before narcotics were administered. Postoperative analgesia was adequate in all patients using preservative-free morphine 0.05 mg · kg− 1. The mean dosing interval was 15 hr and no episodes of nausea, vomiting, hypotension or histamine release were noted. Urinary retention occurred in two infants and one infant became apnoeic three hours after epidural morphine administration but responded to naloxone and pulmonary ventilation with bag and mask. In conclusion, epidural catheters placed via the caudal approach are a safe and effective means of providing postoperative pain control in infants using preservative-free morphine. However, the use of epidural narcotics in infants less than two years of age is restricted to those who will receive intensive care unit monitoring postoperatively so that if apnoea occurs, rapid intervention can be taken by-skilled nursing personnel.RésuméTrente enfants cédulés pour une variété de chirurgies thoraciques gastrointestinales ou génito-urinaires ont été choisis pour l’insertion de cathéters épiduraux, lombaires ou thoraciques par voie caudate utilisant soil l’Intracath® ou un kit pour bloc continu du plexus brachial Burron®. Les cathéters ont été insérés facilement par des résidents en entraînment et aucune complication reliée au cathéter fut notée. De la lidocaîne 0,5 pour cent avec 1:200,000 d’épinéphrine était injectée afin d’assurer un bon positionnement du cathéter avant l’administration des narcotiques. L’analgésic postopératoire fut adéquate chez tous les patients utilisant de la morphine 0,05 mg · kg− 1 sans préservatif. L’intervalle moyen pour ces doses était de 15 heures et aucune épisode de nausée, vomissement, hypotension ou histamino libération ne fut noté. La rétention urinaire et survenue chez deux enfants alors qu’un autre est devenu apnéique trois heures après l’administration de morphine épidurale mais a répondu au naloxane et à la ventilation au masque. En conclusion, des cathéters épiduraux placés par voie caudale sont sécuritaires et efficaces pour soulager la douleur postopératoire chez les enfants lorsqu’on utilise la morphine sans aucun préservatif. Cependant, l’utilisation de narcotiques par voie épidurale chez les enfants âgés de moins de deux ans est réservée strictement à ceux qui doivent recevoir une surveillance postopératoire intensive afin d’intervenir rapidement en cas d’apnée.

Lung transplantation: Historical perspective, current concepts, and anesthetic considerations

E ND-STAGE LUNG disease (ESLD) is a major cause of death in western civilization. In 1985, chronic obstructive pulmonary disease (COPD), with more than 75,000 deaths, was the fifth leading cause of death in the United States. Idiopathic pulmonary fibrosis is another form of ESLD that has a high mortality, and once the diagnosis is made, the 5-year mortality varies from 40% to 80%. c~-1-Antitrypsin deficiency is found in approximately one of every 1,500 to 5,000 live births and accounts for approximately 40,000 patients in the United States. Cystic fibrosis (CF), another congenital disease, occurs in one of every 2,000 live births. There is currently very little that medicine can offer these patients. For many, lung transplantation is the only hope for survival, let alone recovery of independent function. Lung transplantation, actually a family of operations, includes single-lobe transplantation in the pediatric patient, single-lung transplantation (SLTx), double-lung (DLTx) with carina (en bloc), bilateral sequential single-lung (BSSLTx), and heart-lung block transplantation (HLTx). Various operations are proposed for different patient conditions, and some are more widely accepted than others. Bolton and Weiman I have attempted to describe precise physiological mechanisms of lung function elicited by different thoracic incisions and parenchyma resections to more scientifically choose appropriate transplantation operations. By far, most lung transplantations are SLTx or BSSLTx. Heart-lung transplantations and en bloc double-lung transplantations are now being performed less frequently than in the past.