Robert D. Valley

Caudal morphine for postoperative analgesia in infants and children: a report of 138 cases.

Epidural narcotics have been shown to provide effective postoperative analgesia in pediatric patients (16). Caudal administration of morphine is perhaps the most widely used epidural narcotic technique in children. Although a number of studies have appeared in the literature describing dosing techniques, quality of analgesia, and side effects, these have all been from relatively small series of patients and have excluded patients under 1 yr of age (1-7). Since first utilizing caudal narcotics for postoperative analgesia at our institution we have performed more than 250 such blocks in infants as young as 1 day old. The purpose of this retrospective study is to report our early experience with this technique.

Tracheal extubation of deeply anesthetized pediatric patients: a comparison of desflurane and sevoflurane.

In this study, we examined the emergence characteristics of children tracheally extubated while deeply anesthetized with desflurane (Group D) or sevoflurane (Group S). Forty-eight children were randomly assigned to one of the two groups. At the end of the operation, all subjects were tracheally extubated while breathing 1.5 times the minimal effective concentration of assigned inhaled anesthetic. Recovery characteristics and complications were noted. Group D patients had higher arousal scores on arrival to the postanesthesia care unit than Group S patients. Later arousal scores were not significantly different. No serious complications occurred in either group. Coughing episodes and the overall incidence of complications after extubation were more frequent in Group D. Readiness for discharge and actual time to discharge were not significantly different between groups. Emergence agitation was common in both groups (33% overall, 46% for Group D, and 21% for Group S). Narcotic administration in the postanesthesia care unit occurred more frequently in Group D (10 of 24 patients) versus Group S (3 of 24 patients). Premedication with oral midazolam resulted in significantly longer emergence times regardless of the potent inhaled anesthetic administered.

Epidural fentanyl infusion with patient-controlled epidural analgesia for postoperative analgesia in children☆

Abstract The use of epidural fentanyl infusion with patient-controlled epidural analgesia (PCEA) is becoming popular for postoperative analgesia in adults. Its use has not been reported in the pediatric population. We report our initial experience with this technique in pediatric patients. The charts of all children who received epidural fentanyl infusions for postoperative analgesia between June 1991 and February 1992, were reviewed. Thirty-one patients, ages 6 to 17 years (mean ± SD, 13.2 ± 2.7) received epidural fentanyl infusion with PCEA for 36 operative procedures. Epidural catheters were either inserted in the lumbar (n = 14) or thoracic (n = 22) epidural space at a level based on the surgery. A fentanyl bolus of 1.38 ± 0.43 μg/kg was delivered via epidural catheter just prior to the conclusion of surgery. A continuous infusion of fentanyl (0.56 ± 0.18 μg/kg/h) with a PCEA bolus (0.53 ± 0.17 μg/kg) available every 15 minutes was initiated in the recovery room and was utilized for 8 to 110 hours (59 ± 27 hours). Pain and sedation were assessed by verbal descriptive scales, and side effects were noted. Alterations in dosing regimen were made for inadequate analgesia or side effects. Analgesia was assessed as excellent or good in 78% of the patients, 91% in the thoracic catheter group and 57% in the lumbar catheter group (P

Safety and Feasibility of High-pressure Transvenous Limb Perfusion With 0.9% Saline in Human Muscular Dystrophy

We evaluated safety and feasibility of the transvenous limb perfusion gene delivery method in muscular dystrophy. A dose escalation study of single limb perfusion with 0.9% saline starting with 5% of limb volume was carried out in adults with muscular dystrophies under intravenous analgesia/anesthesia. Cardiac, vascular, renal, muscle, and nerve functions were monitored. A tourniquet was placed above the knee with inflated pressure of 310 mm Hg. Infusion was carried out with a clinically approved infuser via an intravenous catheter inserted in the saphenous vein with a goal infusion rate of 80 ml/minute. Infusion volume was escalated stepwise to 20% limb volume in seven subjects. No subject complained of any post procedure pain other than due to needle punctures. Safety warning boundaries were exceeded only for transient depression of limb tissue oximetry and transient elevation of muscle compartment pressures; these were not associated with nerve, muscle, or vascular damage. Muscle magnetic resonant imaging (MRI) demonstrated fluid accumulation in muscles of the perfused lower extremity. High-pressure retrograde transvenous limb perfusion with saline up to 20% of limb volume at above infusion parameters is safe and feasible in adult human muscular dystrophy. This study will serve as a basis for future gene transfer clinical trials.

Epidural morphine combined with epidural or intravenous butorphanol for postoperative analgesia in pediatric patients

We performed a prospective, randomized, double-blinded study in 60 postoperative pediatric patients aged 6 wk to 7 yr to compare the efficacy of butorphanol given epidurally or intravenously in preventing the side effects of epidural morphine. Three groups of patients received 60 micrograms/kg epidural morphine; 20 patients also received epidural butorphanol 30 micrograms/kg, and 20 patients also received 30 micrograms/kg intravenous butorphanol. All patients were evaluated for analgesia, sedation, vomiting, urinary retention, pruritus, and respiratory depression for 24 h postoperatively. Although the overall incidence of side effects was not different in the three groups, the epidural butorphanol group had a significant decrease in severity of pruritus. Sedation was seen more frequently in the groups receiving butorphanol, but was most pronounced in the epidural butorphanol group. We conclude that butorphanol has little or no effect on the side effects of epidural morphine.

Acute Horner syndrome due to thoracic epidural analgesia in a paediatric patient

A 4‐year‐old boy with coarctation of the aorta underwent surgical aortic arch repair with general anaesthesia and thoracic epidural analgesia. In the immediate postoperative period, the child developed a unilateral Horner syndrome which appeared to be related to the epidural infusion rate. Management of this patient as well as alternate aetiologies of Horner syndrome are described. Horner syndrome is a rare complication of epidural catheters and is often unrecognized, especially in children.

The effects of isoflurane and desflurane titrated to a bispectral index of 60 on the cortical somatosensory evoked potential during pediatric scoliosis surgery

In this study, we compared the effect of isoflurane and desflurane on the posterior tibial somatosensory evoked potential recorded by scalp electrodes during correction of idiopathic scoliosis in pediatric patients. Depth of sedation was controlled by maintaining bispectral index (BIS) at 60 throughout the study. Comparison of patients breathing desflurane and isoflurane showed an evoked cortical amplitude (N37-P45) of 0.53 ± 0.3 &mgr;V versus 1.3 ± 0.8 &mgr;V (P = 0.014), respectively. In addition to this comparison, a crossover design was included whereby the desflurane or isoflurane received in the first part of the study was changed to the other anesthetic. Substituting one anesthetic for another confirmed our initial finding that the cortical evoked amplitude is greater with isoflurane than with desflurane. No differential effect was found between desflurane and isoflurane on the evoked subcortical (N31-P34) amplitude or the P37 latency.

Wet forced-air warming blankets are ineffective at maintaining normothermia.

Background:  Forced‐air warming systems have proven effective in preventing perioperative hypothermia. To date, reported adverse events relate primarily to overheating and thermal injuries. This study uses a simple model to show that forced‐air warming blankets become ineffective if they get wet.

High-Pressure Transvenous Perfusion of the Upper Extremity in Human Muscular Dystrophy: A Safety Study with 0.9% Saline

We evaluated safety and feasibility of high-pressure transvenous limb perfusion in an upper extremity of adult patients with muscular dystrophy, after completing a similar study in a lower extremity. A dose escalation study of single-limb perfusion with 0.9% saline was carried out in nine adults with muscular dystrophies under intravenous analgesia. Our study demonstrates that it is feasible and definitely safe to perform high-pressure transvenous perfusion with 0.9% saline up to 35% of limb volume in the upper extremities of young adults with muscular dystrophy. Perfusion at 40% limb volume is associated with short-lived physiological changes in peripheral nerves without clinical correlates in one subject. This study provides the basis for a phase 1/2 clinical trial using pressurized transvenous delivery into upper limbs of nonambulatory patients with Duchenne muscular dystrophy. Furthermore, our results are applicable to other conditions such as limb girdle muscular dystrophy as a method for delivering regional macromolecular therapeutics in high dose to skeletal muscles of the upper extremity.

Anaesthetic management of infants requiring endobronchial argon laser surgery

Small infants with endobronchial lesions primarily due to traumatic suction catheter injuries are now undergoing argon laser surgery to remove obstructive tissue. Providing an anaesthetic for these infants can be challenging because of the small airways involved which must be shared by the anaesthetist and the surgeon. We have performed 30 argon laser endobronchial surgeries in nine infants. The lungs of the majority of patients were ventilated through a tracheostomy intraoperatively, while the surgeon passed the argon laser fibre through the suction port of a fibreoptic bronchoscope which was passed transnasally. Three infants were too small to allow passage of the fibreoptic bronchoscope past an artificial airway. In these patients surgery and ventilation were accomplished through a rigid bronchoscope. Three larger patients without tracheostomies were managed with a modified nasal airway for intraoperative ventilation in conjunction with the fibreoptic bronchoscope.RésuméLes lésions endobronchiques chez le nourrisson sont dues principalement à des traumatismes causés par des cathéters de succion trachéale. La chirurgie avec laser à l’argon permet l’exérèse de ces lésions lorsqu’elles causent de l’obstruction. L’anesthésie pour ce type d’intervention représente un défi dû à la difficulté d’accès aux petites voies aériennes devenues à la fois le champ de travail de l’anesthésiste et du chirurgien. Nous avons réalisé 30 chirurgies au laser à l’argon pour exérèse de lésions endobronchiques chez neuf nourrissons. La majorité des patients avaient une trachéostomie permettant la ventilation pulmonaire pendant la chirurgie. La fibre du laser à l’argon etait passée par l’orifice de succion d’un bronchoscope flexible à fibres optiques introduit par le nez. Chez trois patients trop petits, il fut impossible d’introduire le bronchoscope flexible en présence du tube de trachéostomie. La chirurgie et la ventilation ont alors été faites à l’aide d’un bronchoscope rigide. Chez trois patients plus grands sans trachéostomie, la ventilation et l’introduction du bronchoscope flexible furent réalisées à l’aide d’une canule nasale modifiée.