Peter Hole

Laryngeal mask airway guided tracheal intubation in a neonate with the Pierre Robin syndrome

Endotracheal intubation in infants with the Pierre Robin syndrome may sometimes be impossible to accomplish by conventional means. To aid difficult tracheal intubation many different techniques have been described.

A One Year Health Economic Model Comparing Transdermal Fentanyl with Sustained-Release Morphine in the Treatment of Chronic Noncancer Pain

A Markov model was constructed to simulate the resource use and health outcomes of one year of treatment comparing the fentanyl transdermal therapeutic system (fentanyl-TTS) with oral sustained-release (SR) morphine in outpatients with noncancer pain in Denmark. Effectiveness was assessed in terms of days of good pain control and days on initial treatment. Costs included those of baseline pain management, including breakthrough pain; co-medication costs; and control of adverse events. Fentanyl-TTS was more effective than SR-morphine in achieving good pain control (99 vs. 64 days, respectively) and the incremental cost-effectiveness of fentanyl-TTS was US

Epidural morphine for postoperative pain relief in children

10.26 per extra day of good pain control. Patients treated with fentanyl-TTS remained considerably longer on initial treatment compared with those treated with SR-morphine (166 days vs. 117 days, respectively). The results of this study suggest that fentanyl-TTS is a competitive therapeutic and economic choice for the treatment of chronic noncancer pain.

Spinal anaesthesia with glucose–free 2% lignocaine. Effect of different volumes

Epidural morphine for postoperative pain relief is in general use, and has proved to be very efficient in adults. The epidural technique and the use of epidural morphine are much less frequent in children. For 2 years we have prospectively followed 76 children who had epidural morphine for postoperative pain relief after major abdominal surgery. The age distribution was from newborn to 13 years, with a median age of 12 months. It was estimated that 94% of the patients had good analgesia for the first 24 postoperative hours and no other opioids were given. The side effects were few, but one case of respiratory depression was seen and 20% of the children had pruritus. There were four dural punctures and three catheters slipped out accidentally, but otherwise the treatment was continued as long as it was considered necessary (1–11 days). The use of postoperative ventilatory support decreased during the investigation. We observed a change in the sleeping pattern with an increased number of sleep–induced myoclonia during the administration of epidural morphine. In conclusion, the use of epidural morphine in children for postoperative pain relief is very efficient. The minimal effective dose has not been established as yet, but 50 Hg/kg every 8 h, supplemented with small doses of bupivacaine, provides excellent analgesia in the immediate postoperative period after major abdominal surgery. The side effects are few, but the risk of respiratory depression is always present and observation in the intensive care unit or recovery for the first 24 h is strongly recommended.

Electric Spinal Cord Stimulation (SCS) in the Treatment of Angina Pectoris: A Cost-Utility Analysis

Spinal anaesthesia with 2, 3 or 4 ml of glucose–free 2% lignocaine was studied in 64 patients undergoing transurethral surgery of the bladder. Cephalad spread of analgesia, onset time, duration of analgesia, duration of motor block, quality of analgesia, and the cardiovascular effects were assessed. Two ml of 2% lignocaine was insufficient to produce reliable analgesia. Three ml provided sufficient analgesia in most of the patients, but 4 ml was needed to guarantee sufficient analgesia in all patients. Onset times for analgesia and motor block were 10–20 min. After 4 ml the median and interquartile values were: maximum cephalad spread: T8, (T10–T5); time from injection to regression of analgesia to T11: 84 min, (60–103 min); duration of complete motor block: 90 min, (60–120 min). All patients in the 3–ml and 4–ml groups developed complete motor block. There was a positive correlation between the dose and the duration of analgesia and motor block. A positive correlation, although weaker, was also seen between the dose and the maximum cephalad spread of analgesia. There was an inverse relationship between the cephalad spread of analgesia and the duration of motor block. Falls in systolic blood pressure > 30% were noted in seven patients in whom the cephalad spread of analgesia was higher than in the rest of the patients. Spinal anaesthesia with glucose–free 2% lignocaine in doses of 3–4 ml provides reliable analgesia for transurethral surgery of the bladder.

Haemolytic Uraemic Syndrome and Accumulation of Haemoglobin-Haptoglobin Complexes in Plasma in Serum Sickness Caused by Penicillin Drugs

For the last 15 years electric spinal cord stimulation (SCS) has been employed in patients with confirmed ischemic heart disease who suffer from refractory angina pectoris despite maximum medical/surgical treatment. The purpose of this investigation was to assess not only the economic consequences of SCS treatment (cost‐utility analysis) but also altered quality of life in SCS patients. The retrospective study includes 18 consecutive patients, six women and 12 men, with an average age of 56.5 years (range 50–68), submitted to implantation of a SCS system at Odense University Hospital. Before implantation of the SCS system, the patients were in a transcutaneous electric nerve stimulation (TENS) treatment 2–11 months. At the submission all patients were in New York Heart Association functional group III/IV. The results are based on cost data from the year prior to start of TENS treatment compared with the year after implantation of the SCS system. Medical records of the patients were examined and data concerning use of general practitioners and emergency services were collected from a nationwide database. Quality of life data were collected using identical questionnaires (perception of pain, mobility, function in daily life, and physical activity) related to the period immediately before start of the TENS treatment and one year after SCS implant. Savings were found at hospital level (reduction in number of admissions) and for non‐hospital related expenses (such as medication and visits at general practitioners). In addition, improvements were registered in all respects which constituted assessment of the quality of life of the patients. The study is a repetition of a similar analysis with identical results made in 1990 and including the 16 first angina pectoris patients treated with SCS at Odense University Hospital. SCS is effective in reducing hospital and non‐hospital related expenses and improving quality of life of the patients. SCS is a simple treatment for the patient to use. The implantation technique is not more invasive than permanent cardiac pacing. The decisive part of the procedure is the insertion of the electrode and follow‐up with support and adjustments of the stimulation.

Durability of central venous catheters. A randomized trial in children with malignant diseases

2 patients treated with penicillin and ampicillin, respectively, suffered from haemorrhagic diathesis, haemolysis, cerebral symptoms and renal insufficiency, resembling a haemolytic-uraemic syndrome. Their plasma was red due to the presence during several days of haemoglobin-haptoglobin complexes, the P-haemoglobin being 2.8 and 1.6 g/l, respectively. Coagulation tests showed an unusual pattern with prolonged activated partial thromboplastin times, an extremely long thrombin time and very high levels of fibrinogen degradation products. Repeated transfusion had no effect. The patients were considered to have developed a drug-induced serum sickness associated with insufficient function of the reticuloendothelial system, and secondary to this an accumulation of haemoglobin-haptoglobin complexes in plasma. When the penicillin drugs were discontinued, all measured variables rapidly normalised and the patients recovered completely. Thus, the haemolyticuraemic syndrome seemed to be caused by the serum sickness, possibly via circulating or cell-associated immune complexes. The possibility of a type III allergic reaction should be considered in patients with haemolytic-uraemic-like syndromes.

Arterial Carbon Dioxide Tensions during Anaesthesia with Manual Ventilation A Descriptive Study of the Effects of Various Non-Polluting Circuits

In a prospective randomized study the durability of tunnelled and non‐tunnelled central venous catheters was investigated in children with malignant diseases. Twenty children were included in the study but four (two in each group) had to be excluded; three because the entry criteria turned out not to be fulfilled and one because of lack of data. The median duration of the tunnelled catheters was 224 days with a range of 25–846 days which was significantly longer than that of conventional catheters (39.5 days, range 9–228 days). In addition six of eight conventional catheters were accidentally removed whereas all catheters in the tunnelled group had to be removed via a small incision. Three cases of catheter related sepsis, two in the tunnelled group and one in the conventional group, were registered. The corresponding number of infections per catheter days were 1 in 1189 days and 1 in 522 days, respectively. In conclusion cuffed, tunnelled central venous catheters are less prone to displacement than traditional percutaneous central venous catheters when used in children with malignant diseases.

Method for continuous measurement of carbon dioxide output during anesthesia. An assessment.

In 660 supine, intubated and anaesthetized, healthy patients scheduled for various elective surgical procedures, the distribution of arterial carbon dioxide tension (Paco2) was investigated during manual non‐monitored ventilation. The study comprised six equal groups: group I: ventilation with a circle circuit absorber system; group 2: ventilation with the Hafnia A circuit using a total fresh gas flow (FGF) of 100 ml.kg‐1 min‐1; groups 3–6: ventilation with a Hafnia D circuit with fresh gas flows of 100, 80, 70 and 60 ml.kg‐1 min‐1, respectively. The mean Pacos of the first three groups were situated in the lower range of normocapnia (the observations in the first group having the greatest total range), whereas the rebreathing (Hafnia A and D) circuits resulted in a clustering of observed data. Employing the rebreathing circuits, protection against hypocapnia can be achieved by lowering the fresh gas flow. The most satisfying result was obtained with the Hafnia D circuit with a fresh gas flow of 70 ml.kg‐1 min‐1, resulting in normocapnia with a modest and limited spread towards hypo‐ and hypercapnia. FGF in excess of this level must be considered as wasted. The study indicates that corrections of fresh gas flows for age are superfluous. Use of relaxants and type of surgery had no influence on the observations.

Postoperative pain management in children

Employing the Mapleson D circuit, a modified closed‐circuit flow‐through technique for the continuous measurement of carbon dioxide production (Vco2) was tested for accuracy and precision in a lung model. The recovery of carbon dioxide production was found to be between 90 and 1lo%, the maximized errors for a single estimate of carbon dioxide production were between ± 4 and ± 28%, with the highest errors at high gas flows and low carbon dioxide inputs. Accepting arbitrarily chosen limits of maximized errors of ± 10%, it could be shown that the system did not work acceptably when the mean carbon dioxide concentration was below 1.5 vol.% within the fresh gas flow rates (2.2–7.7 1 min‐1) and the range of minute ventilation (4–10 1 min‐1) employed. The half‐life of carbon dioxide washout varied between 41 and 138 s, thus limiting the suitability of the system for detecting changes in carbon dioxide output. The method may be used as an approximate monitor of VCo2 in anaesthetized patients, but cannot be regarded as sufficient for research purposes.