Rashmi Madan

Prophylactic ondansetron in prevention of postoperative nausea and vomiting following pediatric strabismus surgery: a dose-response study.

Background: This study evaluated the antiemetic effectiveness, dose–response, and clinical usefulness of prophylactic ondansetron in the prevention of postoperative nausea and vomiting (PONV) in children undergoing strabismus repair. Method: The authors observed 180 children, American Society of Anesthesiologists physical status I or II, 2–12 yr of age, who were undergoing strabismus repair. After induction of anesthesia with halothane and nitrous oxide in oxygen or intravenous thiopental, children received either placebo (saline) or intravenous ondansetron in doses of 25, 50, 75, 100, and 150 &mgr;g/kg (n = 30). The trachea was intubated and ventilation was controlled. Perioperative analgesic and fluid requirements were standardized. Episodes of nausea and vomiting were recorded for the first 24 h postoperatively. Data such as nonsurrogate (parental satisfaction scores and duration of postanesthesia care unit stay) and therapeutic (numbers needed to prevent and harm) outcome measures were collected. Results: The incidences of PONV in the placebo and 25-, 50-, 75-, 100-, and 150-&mgr;g/kg ondansetron groups were 83, 77, 47, 30, 30, and 27%, respectively. The incidence was less in the 75- (P = 0.002), 100- (P = 0.002), and 150-&mgr;g/kg (P < 0.001) ondansetron groups compared with placebo. Duration of stay in the postanesthesia care unit was shorter in the 75-, 100-, and 150-&mgr;g/kg ondansetron groups (P < 0.002) compared with the placebo group. Parental assessment scores for the child’s perioperative experience and the positive number needed to prevent PONV were also better and favorable in the 75-, 100-, and 150-&mgr;g/kg ondansetron groups compared with the placebo group. The incidence (P > 0.99) and severity (P = 0.63) of PONV were similar in the 75- and 150-&mgr;g/kg ondansetron groups. Surrogate, nonsurrogate, and therapeutic outcome measures revealed that 75 &mgr;g/kg ondansetron provided the same benefits as did 100 and 150 &mgr;g/kg. Conclusion: The routine prophylactic use of ondansetron at a dose of 75 &mgr;g/kg is as effective as 150 &mgr;g/kg in preventing PONV and improving the “true” outcome measures after strabismus repair in children.

Epidural pentazocine for postoperative pain relief.

A number of recent reports have described the usefulness of the epidural injection of narcotics for the relief of postoperative pain (1-4). Narcotics used for this purpose have included morphine, meperidine, methadone, hydromorphone, and fentanyl. These reports have also shown, however, that the epidural injection of narcotics, while effective in relieving postoperative pain in many patients, may also be associated with side effects such as respiratory depression, urinary retention, vomiting, and itching (2,3,57). Thus the search for a better agent is justified. The epidural or intrathecal use of a narcotic agonist-antagonist, especially one with a high lipid solubility such as pentazocine (8), has not been reported. The present study was undertaken to evaluate the feasibility of pentazocine as an agent for postoperative pain relief when injected epidurally.

Prophylactic Dexamethasone for Postoperative Nausea and Vomiting in Pediatric Strabismus Surgery: A Dose Ranging and Safety Evaluation Study

In this double-blind, randomized, placebo-controlled study, we evaluated the efficacy and safety of different doses of prophylactic IV dexamethasone for postoperative nausea and vomiting (PONV) in 168 children (aged 2–15 yr) scheduled for strabismus surgery. Patients received IV dexamethasone 0.25 mg/kg (D 0.25), 0.5 mg/kg (D 0.5), 1.0 mg/kg (D 1), or saline (S) immediately after induction of general anesthesia. Patients were discharged 24 h after surgery. Nausea and vomiting were assessed at 0–2, 2–6, and 6–24 h after surgery. Blood glucose was measured preoperatively and at 4 h after study drug administration. Wound healing and infection were assessed after 1 wk. More patients in group S had vomiting at 0–2, 2–6, and 6–24 h (P = 0.001, P = 0.003, and P = 0.04, respectively) and required larger doses of rescue antiemetics compared with the dexamethasone groups. Fewer patients in the dexamethasone groups (6, 3, and 6 in D 0.25, D 0.5, and D 1, respectively) had severe PONV compared with group S (P = 0.001). No significant increase in postoperative blood glucose levels was observed and wound healing was satisfactory in all four groups. The results suggest that dexamethasone 0.25 mg/kg is more effective than saline and equally effective compared with larger doses for preventing PONV for pediatric strabismus surgery.

Combination of droperidol and ondansetron reduces PONV after pediatric strabismus surgery more than single drug therapy

Background: Pediatric strabismus surgery is associated with a very high incidence of postoperative nausea and vomiting [(PONV) 44–88%]. Droperidol (10–75 μg kg−1) and ondansetron (50–150 μg kg−1) have shown variable success in reducing the incidence and severity of PONV. Combination of these two drugs has shown promising results. This randomized, double‐blind, placebo‐controlled clinical trial was conducted to evaluate the efficacy and safety of the combination of these two drugs in reducing the incidence and severity of PONV in pediatric strabismus surgery.

A dose response study of clonidine with local anesthetic mixture for peribulbar block: a comparison of three doses.

Clonidine prolongs anesthesia and analgesia of local anesthetics in various neural blocks as well as the duration of retrobulbar block. We assessed the dose-response relationship of clonidine added to lidocaine in peribulbar block. Sixty patients undergoing cataract surgery were given peribulbar block with 7 mL of 2% lidocaine and hyaluronidase with either saline (Control) or clonidine in 0.5-&mgr;g/kg (0.5 Clon), 1.0-&mgr;g/kg (1.0 Clon), or 1.5-&mgr;g/kg (1.5 Clon) doses. The onset and duration of lid and globe akinesia, globe anesthesia and analgesia, postoperative analgesic requirement, and adverse effects (hypotension, bradycardia, hypoxia, sedation, and dizziness) were recorded. The success rate and onset of block were comparable in all groups. The duration of lid and globe akinesia, globe anesthesia and analgesia was significantly (P < 0.01) prolonged in patients receiving 1.0 and 1.5 &mgr;g/kg clonidine as compared with the Control group. Perioperative pain scores and analgesic requirement were significantly less in these groups. 0.5 &mgr;g/kg clonidine did not increase the duration of anesthesia and analgesia significantly. Hypotension and dizziness were observed more in patients receiving 1.5 &mgr;g/kg clonidine as compared with other groups. We conclude that 1.0 &mgr;g/kg clonidine with a mixture of lidocaine (2%) significantly prolonged the duration of anesthesia and analgesia after peribulbar block with limited side effects.

Intrathecal midazolam added to bupivacaine improves the duration and quality of spinal anaesthesia

Background:  The antinociceptive action of intrathecal midazolam is well documented. In this prospective study, we investigated the addition of midazolam to intrathecal bupivacaine on the duration and quality of spinal blockade.

Effects of peribulbar bupivacaine as an adjunct to general anaesthesia on peri-operative outcome following retinal detachment surgery.

Sixty premedicated, ASA physical status I or II patients weighing > 25 kg scheduled for elective retinal detachment repair were randomly assigned to receive either peribulbar block with 10 ml of 0.25% bupivacaine (block group) or intravenous morphine 150 µg.kg−1 (morphine group), prior to the induction of general anaesthesia (n = 30 in each group). Patients were evaluated for intra‐operative oculocardiac reflex , peri‐operative pain relief, recovery from anaesthesia and postoperative nausea and vomiting. Apart from significantly reducing the incidence of oculocardiac reflex (30% vs. 70%, p = 0.0019), peribulbar bupivacaine also attenuated the severity of the reflex. Postoperative pain relief was superior in the block group. More block group patients had the maximum recovery score in the immediate postoperative period (80% vs. 27%, p < 0.0001) and they achieved complete recovery significantly faster than the morphine group (17.3 (14.7) min vs. 66.7 (29.7) min, p < 0.0001). The incidence (40% vs. 77%, p = 0.004) and severity of postoperative nausea and vomiting were significantly less in the block group. In summary, peribulbar bupivacaine, when administered together with general anaesthesia, attenuated oculocardiac reflex, provided comparable intra‐operative and superior postoperative analgesia, resulted in significantly earlier and better recovery from anaesthesia, and significantly reduced the incidence and severity of postoperative nausea and vomiting.

Anaesthesia and the Sturge-Weber syndrome

We report a series of 13 patients with Sturge-Weber syndrome anaesthetised on 17 occasions. Anaesthesia management varied depending on the clinical manifestations which ranged from localized, superficial skin lesions to extensive systemic involvement. These patients tolerate anaesthesia well but anaesthetic management includes evaluation for associated anomalies. Difficulty with intubation may occur due to angiomas of the mouth and upper airway. Anaesthesia should be planned to avoid trauma to the haemangiomata and increases in intraocular and intracranial pressure.RésuméNous rapportons une série d’observations concernant des porteurs du syndrome de Sturge-Weber anesthésiés à 17 occasions. L’anesthésie a varié selon les manifestations cliniques qui allaient de la lésion superficielle localisée à l’atteinte systémique grave. Ces patients tolèrent bien l’anesthésie mais celle-ci nécessite une recherche des anomalies associées pour fin d’évaluation. La présence d’angiomes de la bouche et des voies respiratoires supérieures peut rendre l’intubation difficile. La planification de l’anesthésie doit inclure la prévention du traumatisme aux hémangiomes et de l’augmentation de la tension intraoculaire et cérébrale.

Goldenhar's syndrome: an analysis of anaesthetic management. A retrospective study of seventeen cases.

Seventeen patients with Goldenhars syndrome who had surgery 28 times are presented. Various authors have reported problems in the anaesthetic management of these patients, but we encountered significant difficulties in only one. Three anaesthetic techniques were used. A thorough pre‐operative assessment with back‐up facilities for difficult intubation are important. Additional cardiorespiratory and craniovertebral anomalies may necessitate modifications in the basic techniques.

Intra-ocular pressure and haemodynamic changes after tracheal intubation and extubation : a comparative study in glaucomatous and nonglaucomatous children

This prospective, controlled study was conducted to compare the effects of tracheal intubation and extubation on intra‐ocular pressure changes and haemodynamic parameters in paediatric patients with and without glaucoma. The children were scheduled for intra‐ocular surgery. Twenty children with normal intra‐ocular pressure and 15 with glaucoma were studied. A standardised general anaesthetic was administered to both groups. After 5 min of anaesthesia, intra‐ocular pressure, heart rate and noninvasive blood pressure were measured. These measurements were repeated 30 s and 2 min after tracheal intubation. Further measurements were taken before, and 30 s and 2 min after extubation. The increase in intra‐ocular pressure after intubation was greater in the glaucomatous group than in the normal group. The increase in intra‐ocular pressure was greater after extubation than intubation in both groups, but was similar in the two groups. However, because of the already increased intra‐ocular pressure in glaucomatous children, they may be at an increased risk of visual damage after intubation and extubation.