Maurizio Passariello

Premedication in children: a comparison of oral midazolam and oral clonidine

Background:  Oral premedication is widely used in pediatric anesthesia to reduce preoperative anxiety and ensure smooth induction. Midazolam is currently the most commonly used premedicant, but good results have also been reported with clonidine. The aim of the present study was to compare clinical effects of oral midazolam and oral clonidine.

Insertion characteristics, sealing pressure and fiberoptic positioning of CobraPLA in children

Background:  The CobraPLATM is a new supraglottic airway device designed for the use in spontaneously breathing and mechanically ventilated patients. In adults it has been found as effective as the LMA, but with better sealing qualities. The aim of the present study was to evaluate fit and sealing characteristics of CobraPLA size 1.5 and 2 in mechanically ventilated children.

Absorption pharmacokinetics of clonidine nasal drops in children.

Background:  The α2 agonist clonidine has become a popular drug for premedication in children. Effects and pharmacokinetics after oral, rectal, and intravenous administration are well known. The aim of this study was to investigate the absorption pharmacokinetics of clonidine nasal drops in children.

Anesthesia for a child with deletion 3q syndrome

SIR—Chromosome 3q deletion syndrome is a rare autosomal dominant disorder where part of the long arm (q) is deleted resulting in various abnormalities which are determined by the size of the deleted portion. Deletion of the long arm of chromosome 3 with a variable phenotype consists mainly of microcephaly, unusual facial appearance with eye abnormalities and deformed ears, and delay in growth and development (1). In the literature so far there are no reports of anesthetic management with these patients. We would like to present the anesthetic management carried out for a hernia repair in a boy with chromosome 3q deletion syndrome and associated Pierre–Robin sequence and Dandy–Walker malformation. The boy was born spontaneously at 41 weeks of gestation with a birth weight of 2160 g. Intrauterine growth retard had been noticed from the 20th week of pregnancy. Dysmorphic features were noticed at birth and the newborn was admitted to the neonatal unit for further diagnosis. Microcephaly, microretrognathia, cleft palate, abnormally large ears, broad nasal bridge, blepharophimosis, ptosis, epicanthus inversus, increased muscle tone, and a stridolous cry were noted. A brain MRI showed agenesis of the cerebellar vermis, a mega cisterna magna and enlargement of the fourth ventricle (Dandy–Walker syndrome). An echocardiography revealed a normal heart. Chromosome analysis was performed and an interstitial deletion in the long arm of chromosome 3 of bands q22.1–q25.2 was diagnosed. Poor sucking reflex and failure to thrive made prolonged tube feedings necessary. At the age of 3 months, the patient was operated for bilateral inguinal hernia. A right redo-hernia repair was performed at the age of 7 months. Both procedures were carried out at another hospital. At this time, a Cormack and Lehane grade IV view was reported and dental damage occurred during intubation. The boy suffered a respiratory arrest postoperatively and was transferred to ICU for resuscitation. At the age of 9 months, the child was admitted for the first time to our hospital with the diagnosis of recurrent aspiration pneumonia and relapse of right inguinal hernia. His weight was now 7.9 kg and he was still on tube feedings. His psychomotor development was at a 3 months level and he presented muscular hypertonia. The airway was partially obstructed by the tongue and the boy assumed an opisthotonus-like posture during sleep. A chest X-ray at admission showed signs of pneumonia of both inferior lobes and the upper right lobe. A CT scan of the head confirmed the Dandy–Walker malformation. There were no signs of raised intracranial pressure. A videofluoroscopy of deglutition function revealed laryngeal incompetence and absence of protective airway reflexes. Insertion of a percutaneous gastrostomy tube was proposed, but the parents did not give consent. Once pneumonia had resolved, a hernioplasty with patch insertion was planned for the relapse of right inguinal hernia. A difficult airway was anticipated due to Pierre–Robin sequence with facial dysmorphism and the formerly reported Mc Cormack and Lehane grade IV. Availability of an ICU bed for postoperative monitoring was assured. As soon as the patient arrived in theatre, an intravenous cannula was placed and atropine 10 mcgÆkg was given and standard monitoring was started. Inhalational induction with 8% sevoflurane in 100% oxygen was performed. A Guedel cannula was required to keep the airway patent during induction. When a sufficient depth of anesthesia was achieved, a conventional laryngoscopy was performed and a McCormack and Lehane grade III view was recorded. Intubation was not attempted, instead a fiberoptic intubation through a size 1.5 LMA was performed. A 4.0 mm endotracheal tube was railroaded over the bronchoscope (model FB-8V Pentax, Tokyo, Japan) and then a 3.5 mm endotracheal tube was used as an extender to hold the tracheal tube in place while removing the LMA. Adequate ventilation was confirmed by capnography and bilateral normal breathing sounds. A caudal block was performed with levobupivacaine 0.25% 8 ml and anesthesia was maintained with a mixture of sevoflurane, nitrous oxide and oxygen. As the spontaneous breathing pattern was irregular in a hick-up like manner, pressurecontrolled ventilation was started to assure oxygenation and normocarbia. No muscle relaxants were given. Surgery lasted for 2 h and vital signs remained stable throughout the entire procedure. At the end of surgery, sevoflurane was discontinued and the patient quickly resumed spontaneous ventilation. Extubation was performed with the child fully awake and a 14 Fr nasal cannula was inserted to keep the airway patent. Postextubation stridor was successfully treated with adrenaline nebulizer and the child was transferred to ICU for postoperative monitoring. He required 30% oxygen during the first postoperative hours to keep his saturation above 95%. The rest of his postoperative course was uneventful and the next day he was discharged to the surgical ward. Pediatric Anesthesia 2008 18: 789–807

Steal induction in preschool children: is melatonin as good as clonidine? A prospective, randomized study

To investigate whether melatonin would be an alternative drug to clonidine for performance of steal induction.

Perioperative fluid management in children: a survey of current practice in Italy.

1 Escobar V, Bixler D, Gleiser S et al. Multiplepterygium sybdrine. Am J Dis Child 1978; 132: 609–611. 2 Chen H, Chang C-H, Misra RP et al. Multiple ptergygium syndrome. Am J Med Genet 1980; 7: 91–102. 3 Kuzma PJ, Calkins MD, Kline MD et al. The anesthetic management of patients with multiple pterygium syndrome. Anesth Analg 1996; 83: 430–432. 4 Siddiqui MS-R, Kymer PJ, Mayhew JF. Anesthesia in a child with Escobar syndrome. Pediatr Anesth 2004; 14: 1. 5 Robinson LK, O’Brien C, Puckett MC et al. Multiple pterygium syndrome: a case complicated by malignant hyperthermia. Clin Genet 1987; 32: 5–9.

Anesthesia for a child with Menkes disease.

(PPV)? This is a somewhat controversial topic. It is common knowledge that instrumentation of the larynx, trachea or bronchi is a powerful stimulus and may easily elicit coughing, bucking, laryngospasm, gagging, dysrthythmias or hypertensive responses which may have serious consequences. All these can be avoided with general anaesthesia using muscle relaxation and PPV. However, on literature review, Vane et al. (1) prefer spontaneous ventilation because they consider that PPV can potentially force the foreign body deeper into the small airways. This may make retrieval of foreign body more difficult or potentially create a ball valve obstruction. On the contrary, Kosloske (2) advocated muscle paralysis and PPV. Litman et al. (3) in their analysis of 94 cases for foreign body removal in children found that, in some cases in which spontaneous breathing techniques were used initially, the switch was made during the procedure to PPV. Causes for change in ventilatory management were inadequate ventilation, patient movement and laryngospasm. Consequently, each technique can be argued for; so, the anesthetic should be tailored to each specific case and what is deemed the most advantageous method for each individual child at that time. The point worth noting in this case is that the child did not have any recollection of actually inhaling the nail, consequently presenting only with an irritating cough, leading to a delayed diagnosis. Thus, one must have a very high index of suspicion for foreign body inhalation in pediatric patients, particularly in the younger age groups where the history can be more unreliable. Susan Calderbank Howard Wakeling Department of Anaesthesia, Worthing Hospital, Sussex (email: susiecalderbank@hotmail.com)

Anesthesia for a child with Camurati–Engelmann disease

SIR—We have read with interest the article by Park Y et al. (1) that compared 6 lg kg 1 of ramosetron with 100 lg kg 1 of ondansetron in children after orthopedic surgery. They found ‘significantly less vomiting during the first 24-h and 6–24-h period after surgery in ramosetron group than in ondansetron group’ and concluded that ramosetron was more effective than ondansetron in preventing postoperative vomiting (POV) in children. One significant limitation of their study was that they studied only a single dose of ondansetron (i.e., 100 lg kg ) and did not examine the dose–response relationship. In adults, a previous randomized controlled trial by Ryu J et al. (2). comparing 0.3 mg of ramosetron, 4 mg of ondansetron, and 8 mg of ondansetron revealed that 4 mg of ondansetron was less effective than 0.3 mg of ramosetron but 8 mg of ondansetron was as effective as a prophylaxis of postoperative nausea and vomiting (PONV). Therefore, when comparing ramosetron with ondansetron, it is important to consider the dosage. Park Y et al. (1). referred the FDA alert about QT interval prolongation with high-dose ondansetron (3), which states that the use of a single 32 mg intravenous dose of ondansetron in adults should be avoided. The dose of 32 mg is equal to that of 400–500 lg kg 1 for adult patient who weighs approximately 70 kg. Moreover, this FDA alert states that ‘ondansetron can continue to be used in adults and children with chemotherapy-induced nausea and vomiting at the lower intravenous dose recommended in the drug label, a dose of 0.15 mg kg 1 administered every 4 h for three doses’. Therefore, after carefully considering the FDA alert, 100 lg kg 1 of ondansetron is not considered the maximum dose, although it is a recommended dose for prevention of PONV. Taken together, it would be premature to conclude that ramosetron is more effective than ondansetron for preventing PONV in children because it is possible that higher but safe doses of ondansetron (e.g., 150 lg kg ) have a similar effect on PONV in children compared with ramosetron. Further studies are needed to determine which of the two drugs is more effective in preventing PONV in children.

150 Intralesional Corticosteroid Injection Following Endoscopic Balloon Dilation in Stricturing Pediatric Crohn's Disease: A Prospective Randomized, DoubleBlind, Controlled Trial

Aim: 30% of patients hospitalized with severe UC prove steroid-refractory. We aimed to evaluate outcomes and predictors of response to infliximab as rescue therapy in severe pediatric UC. Methods: As part of a prospective multicenter study, we evaluated factors associated with immediate and 1-year response to infliximab in steroid-refractory severe pediatric UC. Data were recorded at admission, days 3 and 5, at introduction of infliximab, at discharge and 1-year thereafter, using standardized data collection forms. Disease activity was determined using the validated Pediatric UC Activity Index (PUCAI). Serum TNF alpha level was determined before infliximab treatment using a cytokine antibody panel (TransSignal, CA). Concurrently, fecal calprotectin and lactoferrin levels were ascertained using standard assays in a central laboratory. Results: Of 128 children admitted, 33 failed steroids and treated with infliximab within 10.5±6 days. Mean PUCAI score at introduction of infliximab was 66±13 points, indicating persistence of severe colitis. 25/33 children (76%) responded and were discharged within 5±4 days of infliximab therapy; 7 in complete clinical remission (PUCAI 0.2). CRP, ESR, albumin and hemoglobin were not predictive of response to infliximab. Neither fecal calprotectin nor lactoferrin values were predictive of response (area under ROC curve 0.61 and 0.63, respectively; P>0.2). Serum TNF-alpha level was similar between responders and non-responders (10.6pg/ml (IQR 4-30) vs. 8.3pg/ml (5.7-11); P=0.4). 8 of the 25 responders received only 3-dose induction, and the others continued maintenance therapy without concomitant immunomodulation. Cumulative 1-year sustained response rate was 55% (18/33). There were no deaths and only 1 patient stopped treatment due to infusion reaction. Conclusion: Infliximab is safe and effective in inducing and maintaining clinical remission in steroid-refractory pediatric UC. Serum TNF-alpha level and fecal biomarkers are not useful in predicting outcome, but higher disease severity, judged clinically, and new onset disease are associated with reduced response.