Ramona Kearney

Thoracic Epidural Analgesia Via the Caudal Approach in Pediatric Patients Undergoing Fundoplication Using Nerve Stimulation Guidance

IMPLICATIONS Epidural catheter placement using electrical stimulation guidance is an alternative approach for positioning the catheter into the thoracic region via the caudal space. This easily performed clinical assessment provides optimization of catheter tip positioning for achieving effective pain control.

Thoracic and lumbar epidural analgesia via the caudal approach using electrical stimulation guidance in pediatric patients: a review of 289 patients.

BackgroundNerve stimulation guidance (Tsui test) has been reported to be an effective alternative to radiographic imaging for proper catheter placement. The purpose of this study was to examine the success rate and complications of continuous caudal epidural analgesia since the implementation of routine use of the Tsui test at the authors’ institution. MethodsThe authors examined prospectively collected data in their pediatric pain service database from 289 children who had attempted caudal placement of a lumbar or thoracic catheter between 1999 and 2002. ResultsIn five patients (aged 5 months–1.6 yr), the catheter did not thread to the desired level and was abandoned in the operating room (technical success rate, 98.2%). Of the remaining 284 patients, the overall analgesic success rate of all caudal route epidural analgesia procedures was 84.9%. There was no significant difference in adequate pain control (success) in infants (aged 1 day–1 yr) versus older children (aged younger than 1 yr). The most common adverse effects were pruritus (26.1%) and nausea and vomiting (16.9%). Of the patients in our study, 57.7% had urinary catheters in situ; of those who did not have a catheter placed, 20.8% experienced urinary retention. The incidence of respiratory depression was 4.2%, but the administration of naloxone for severe respiratory depression was never necessary. Three percent of catheters were removed because of suspected contamination, but no epidural abscesses or systemic infection were noted. ConclusionsThe results of this study suggest that epidural catheter placement via the caudal approach using the Tsui test is an effective and reasonable alternative to direct lumbar and thoracic epidural analgesia in pediatric patients.

Propofol total intravenous anesthesia for MRI in children.

Background:  The aim of this study was to assess clinical signs of airway patency, airway intervention requirements and adverse events in 100 children receiving propofol total intravenous anesthesia for magnetic resonance imaging, with spontaneous ventilation and oxygenation via nasal prongs.

A rapid precurarization technique using rocuronium

PurposeTo evaluate a rapid and time-saving precurarization technique using rocuronium to prevent succinylcholine-induced myalgia.MethodIn a prospective, double blind randomized study, 42 ASA 1–2 patients were assigned to one of three pretreatment groups: 0.01 ml · kg−1 normal saline, 0.1 mg · kg−1 atracurium, and 0.1 mg · kg−1 rocuronium. Anaesthesia commenced with 1.5 μg · kg−1 fentanyl and 0.5 mg · kg−1 lidocaine at time zero. Pretreatment was administered 60 sec later, followed by 2.5 mg · kg−1 propofol. At 90 sec, 1.5 mg · kg−1 succinylcholine was injected and 30 sec later, the trachea was intubated and the ease of intubation was graded. The patient was observed for the presence and severity of fasciculations. Myalgias were recorded on postoperative days 1, 2 and 7.ResultsThe incidence of fasciculations in the rocuronium group (21.4%) was lower (P < 0.001) than atracurium (78.5%) or placebo (92.8%) groups. On postoperative day 1, the incidence of postoperative myalgia in the rocuronium group (14.2%) was less than the placebo group (78.2%;P < 0.002) and atracurium group (85.7%;P < 0.001). The incidence of myalgia in the rocuronium group (7.1%) was lower than in the placebo group (78.5%;P < 0.001) but not different from the atracurium group (42.8%;P = 0.077) on postoperative day 2. On postoperative day 7, there was no difference among the three groups. Fasciculations were related to post-operative myalgia. There was no difference in intubating conditions among the three groups.ConclusionRocuronium pretreatment given just before induction of anaesthesia with propofol reduces fasciculations and succinylcholine-induced myalgia.RésuméObjectifÉvaluer une technique de précurarisation rapide à base de rocuronium pour prévenir les myalgies causées par la succinylcholine, tout en sauvant du temps.MéthodeDans une étude prospective, à double insu et aléatoire, 42 patients de classe ASA I et 2 ont été répartis en 3 groupes selon le prétraitement reçu: 0.01 ml · kg−1 de NaCl 0,9%, 0.1 ml · kg−1 d’atracurium et 0.1 mg · kg de rocuronium. Au temps zéro de l’anesthésie, les patients ont reçu 1.5 mg · kg−1 de fentanyl et 0,5 mg · kg−1 de lidocaïne. Soixante secondes plus tard, on a administré le prétraitement suivi de 2.5 mg · kg−1 de propofol. À 90 secondes, on a injecté 1.5 mg · kg−1 de succinylcholine et 30 secondes plus tard la trachée a été intubée et on a évalué la facilité de l’intubation. On a recherché chez les patients la présence de fasciculations, dont on a évalué la sévérité. On a évalué les myalgies en postopératoire aux jours 1, 2 et 7.RésultatsLincidence de fasciculations a été plus faible dans le groupe rocuronium (21,4%,P 0,001) que dans le groupe atracurium (78,5%) ou le groupe placebo (92,8%). Au jour 1, l’incidence des myalgies était plus faible dans le groupe rocuronium (14.2%) que dans le groupe placebo (78.2%,P 0,002) et dans le groupe atracurium (85,7%,P 0,001). Au jour 2, l’incidence des myalgies dans le groupe rocuronium demeurait plus faible que dans le groupe placebo (78.5%,P 0.001) mais n’était pas différente du groupe atracurium (42,8%,P = 0,077). Au jour 7, il n’existait plus de différence entre les 3 groupes. Les myalgies postopératoires étaient en relation avec les fasciculations. On n’a constaté aucune différence dans les conditions d’intubation.ConclusionLe prétraitement avec le rocuronium administré immédiatement avant une induction au propofol réduit les fasciculations et les myalgies provoquées par la succinylcholine.

Anesthesia for magnetic resonance imaging in children: a survey of Canadian pediatric centres

To the Editor: We recently conducted a telephone survey of pediatric anesthesia departments in 11 Canadian university centres. Department chiefs (or designates) were asked to identify current anesthesia practice and concerns for pediatric magnetic resonance imaging (MRI). In all 11 centres, care was provided by pediatric anesthesiologists, with ten centres having MRI compatible machines available. All centres routinely used capnography and pulse oximetry. Eight centres routinely used non-invasive blood pressure monitoring. Five centres routinely used electrocardiogram (ECG) monitoring, and two centres had no MRI compatible ECG available. In seven centres the anesthesiologists were located in the control room during scanning. Staff were more likely to remain in the scanning room if a slave monitor was unavailable in the control room. Six centres predominantly used a propofol total iv anesthesia technique (TIVA), with the other five centres using a volatile technique more frequently or exclusively. Centres predominantly using TIVA were less likely to instrument the airway (Table). Propofol induction and maintenance dose estimates ranged from 2 to 6 mg·kg–1 (mean 3.7) and 100 to 250 μg·kg–1·min–1 (mean 165) respectively, with one centre using boluses as required rather than an infusion. Three centres routinely using TIVA had no MRI compatible infusion pump available; instead using a remote pump with a hydraulic interface, or a manual method calculating drops per minute. Propofol sedation techniques have been well described previously, although often with lower doses of propofol than we found in this survey. Centres not routinely using TIVA had concerns about maintaining and monitoring the airway if nasal prongs or a face mask were used. Annual caseload estimates ranged from 20 to 1,400 children. Many centres noted increasing demand from radiology departments for anesthesia services, with one centre commenting that anesthesia out of the operating room currently accounts for greater than 30% of the department workload. Most centres felt that seven to eight years was the age at which children more reliably tolerated scanning without anesthesia. The mean daily caseload for centres predominantly using TIVA was 9.2 (5–12) vs 7.2 (5–10) for other centres, possibly due to shorter induction and emergence periods as the airway is instrumented less often. We conclude that anesthesia for MRI accounts for a significant workload for pediatric anesthesiologists. Some centres remain concerned about the safety of TIVA using nasal prongs or face mask despite the suggestion it may decrease anesthesia time.

The research productivity of Canadian physicians: how the timing of obtaining a PhD has an influence.

Purpose To determine whether the sequence of training to obtain MD and PhD degrees is associated with different career paths for physicians who have their PhD before medical school and those who obtain it after their MD, and to explore the factors that encourage or dissuade Canadian dual-degree physicians in pursuing a research career. Method In 2003, questionnaires from the University of Alberta, Edmonton, Canada, were sent to all 734 Canadian physicians having MDs and PhDs, identified through the Canadian Medical Directory. Data collected were gender; year and country of MD; sequence of obtaining degrees; portion of time on clinical, research, teaching, and administrative duties; number of publications and currently held grant amounts; and perceived incentives and disincentives to research careers. Two focus groups were held with a subset of physicians to further explore themes. Results The response rate was 64%. On the basis of the timing of the PhD relative to the MD, physicians were designated early PhDs (26%), concurrent PhDs (12%), or late PhDs (62%). Late PhDs spent more time in research and less time on clinical practice than the other two groups and spent more time teaching and had published more papers than the early PhDs. Grant amounts were highest for late PhDs. Lack of time and resources were the major disincentives to research, and noteworthy incentives were the opportunity for intellectual challenge and creativity, and previous research experience. Conclusions Physicians who obtain a PhD after an MD have a more research-focused career than those who enter medical school with a PhD.