Robin G. Cox

Patient selection in ambulatory anesthesia — An evidence-based review: part II

PurposeTo identify and characterize the evidence supporting decisions made in the care of patients with selected medical conditions undergoing ambulatory anesthesia and surgery. Conditions highlighted in this review include: the elderly heart transplantation, hyper-reactive airway disease, coronary artery disease, and obstructive sleep apnea.SourceA structured search of MEDLINE ( 1966–2003) was performed using keywords for ambulatory surgery and patient condition. Selected articles were assigned a level of evidence using Centre for Evidence Based Medicine (CEBM) criteria. Recommendations were also graded using CEBM criteria.Principal findingsThe elderly may safely undergo ambulatory surgery but are at increased risk for hemodynamic variation in the operating room. The heart transplant recipient is at increased risk of coronary artery disease and renal insufficiency and should undergo careful preoperative evaluation. The patient with reactive airway disease is at increased risk of minor respiratory complications and should be encouraged to quit smoking. The patient with coronary artery disease and recent myocardial infarction may undergo ambulatory surgery without stress testing if functional capacity is adequate. The patient with obstructive sleep apnea is at increased risk of difficult tracheal intubation but the likelihood of airway obstruction and apnea following ambulatory surgery is unknown.ConclusionAmbulatory anesthesia is infrequently associated with adverse outcomes, however, knowledge regarding specific patient conditions is of generally low quality. Few prospective trials are available to guide management decisions.RésuméObjectifIdentifier et caractériser la preuve à l’appui des décisions prises sur les soins à donner aux patients qui présentent des pathologies médicales ciblées et qui subissent une anesthésie en chirurgie ambulatoire. Les situations sélectionnées dans cette revue comprennent : la vieillesse, la transplantation cardiaque, l’affection respiratoire hyper-réactionnelle, la coronaropathie et l’apnée obstructive du sommeil.SourceUne recherche structurée dans MEDLINE (1966–2003) a été réalisée selon les mots dés pour la chirurgie ambulatoire et l’état du patient. Les articles choisis ont été cotés selon le niveau de preuve des critères du Centre for Evidence Based Medicine (CEBM). Les recommandations ont aussi été graduées selon les critères du CEBM.Constatations principalesLes personnes âgées peuvent subir une opération ambulatoire en toute sécurité, mais sont plus à risque de variation hémodynamique en salle d’opération. Les greffés cardiaques sont plus à risque de coronaropathie et d’insuffisance rénale et doivent avoir une évaluation préopératoire minutieuse. Les cas d’affection respiratoire réactionnelle sont plus à risque de complications respiratoires mineures et doivent être encouragés à cesser de fumer. Le patient atteint de coronaropathie, victime récente d’infarctus myocardique, peut être vu en chirurgie ambulatoire sans épreuve d’effort si la capacité fonctionnelle est adéquate. En cas d’apnée obstructive du sommeil, il y a plus de risque de difficulté d’intubation trachéale, mais la possibilité d’obstruction des voies aériennes et d’apnée à la suite d’une opération ambulatoire n’est pas connue.ConclusionLanesthésie ambulatoire n’est pas souvent associée à des complications, même si la connaissance de pathologies spécifiques est peu développée en général. Il existe peu d’études prospectives permettant de guider les décisions thérapeutiques.

Evidence-based clinical update: Does premedication with oral midazolam lead to improved behavioural outcomes in children?

PurposeThe purpose of this evidence-based clinical update was to identify the best evidence to determine if behavioural outcomes are improved in children after oral midazolam premedication.MethodsA literature search was conducted using both PubMed and OVID programs, utilizing the terms ‘midazolam’, and either ‘premedication’ or ‘preoperative treatment’. Search limits that were employed included randomized controlled trials (RCTs), English language, human studies, children aged 0–18 yr, and publication dates 1990 — present (January 2006). A review of the 171 abstracts obtained was undertaken and, of these, 30 papers were identified that concerned oral midazolam in children prior to general anesthesia, and that involved a RCT with a placebo or control arm. These studies were assigned levels of evidence, and grades of recommendation were made according to Centre for Evidence-Based Medicine criteria.ResultsOral midazolam premedication in children was found to reduce the anxiety associated with separation from parents/ guardians, and with induction of anesthesia. Recovery times are not significantly delayed. There is no consistent evidence to suggest a reduction in the phenomenon of emergence agitation. Evidence suggesting an improvement in behavioural outcomes at home is also inconsistent.ConclusionPremedication with midazolam 0.5 mg·kg−1 po administered 20–30 min preoperatively, is effective in reducing both separation and induction anxiety in children (grade A recommendation), with minimal effect on recovery times. However improved postoperative behavioural outcomes in the postanesthesia care unit, or at home cannot be predicted on a consistent basis.RésuméObjectifL’objectif de cette mise à jour basée sur des données probantes est d’évaluer les meilleures données sur l’amélioration du comportement des enfants après une prémédication au midazolam.MéthodesUne recherche d’articles a été effectuée avec les programmes PubMed et OVID, en utilisant les termes « midazolam », ainsi que « premedication » ou « preoperative treatment ». On a limité la recherche aux études contrôlées randomisées, en langue anglaise, sur des êtres humains, sur des sujets de 0 à 18 ans, publiées de 1990 à maintenant (janvier 2006). Après examen des 171 résumés obtenus, on a retenu 30 articles qui portaient sur le midazolam par voie orale chez les enfants avant une anesthésie générale et qui comportaient une randomisation avec un groupe placebo ou témoin. Les études ont été évaluées selon le niveau de preuve et on leur a donné une cote selon le barème du « Centre for Evidence-Based Medicine ».RésultatsOn a trouvé que midazolam par voie orale diminuait l’anxiété survenant à la séparation des parents ou tuteurs et à l’induction de l’anesthésie. Les temps de récupération n’étaient pas prolongés significativement. Il n’y a pas de données solides qui suggéreraient une diminution du phénomène d’agitation à l’émergence. De même, les données sur l’amélioration du comportement au retour à la maison sont contradictoires.ConclusionUne prémédication avec du midazolam 0,5 mg·kg−1 administré par voie orale 20–30 min avant la chirurgie est efficace pour diminuer l’anxiété liée à la séparation et à l’induction (recommandation de niveau A) avec peu d’effets sur le temps de récupération. Toutefois, on ne peut pas prédire avec certitude les comportements à la salle de réveil ou au retour à la maison.

Photorefractive keratectomy in children

Purpose: To evaluate photorefractive keratectomy (PRK) in pediatric patients who fail traditional methods of treatment for myopic anisometropic amblyopia and high myopia. Setting: Nonhospital surgical facility with follow‐up in a hospital clinic setting. Methods: Photorefractive keratectomy was performed in 40 eyes of 27 patients. The patients were divided into 4 groups based on the type of myopia: myopic anisometropic amblyopia (15 eyes/13 patients), bilateral high myopia (20 eyes/10 patients), high myopia post‐penetrating keratoplasty (3 eyes/2 patients), and combined corneal scarring and anisometropic amblyopia (2 eyes/2 patients). All procedures were performed under general anesthesia using the VISX 20/20 B laser and a multizone, multipass ablation technique. Appropriate corneal fixation was achieved with appropriate head positioning (turn and tilt) and an Arrowsmith fixation ring. Myopia was as high as −25.00 diopter (D) spherical equivalent (SE), but no treatment was for more than −17.50 D SE. Results: The mean SE decreased from −10.68 D to −1.37 D at 1 year, a mean change of −9.31 D. At 1 year, the mean best corrected visual acuity improved from 20/70 to 20/40 in the entire group. Forty percent of eyes were within ±1.0 D of the targeted refraction. There was no haze in 59.5% of eyes. Three eyes initially had 3+ haze; 1 improved to 2+ and 2 required repeat PRK with significant haze reduction. Five eyes (3 patients) with greater than −17.00 D SE myopia before PRK (range −17.50 to −25.00 D) had 3.42 D more effect than predicted (range 0.50 to 5.50 D). A functional vision survey demonstrated a positive effect on the childrens ability to function in their environments after the laser treatment. Conclusion: Photorefractive keratectomy in children represents another method of providing long‐term resolution of bilateral high myopia and myopic anisometropic amblyopia.

Comparison of laryngeal mask airway (LMA)-Proseal™ and the LMA-Classic™ in ventilated children receiving neuromuscular blockade

Purpose: To determine whether a functional difference exists between the size 2 laryngeal mask airway (LMA)-Classic™ (CLMA) and LMA-Proseal™ (PLMA) in anesthetized children who have received neuromuscular blockade. Airway leak during intermittent positive pressure ventilation (IPPV) and adequacy of fibreoptic laryngeal view were the primary study outcomes.Methods: A randomized, controlled, single-blinded study of 51 ASA I or II children weighing 10–20 kg was undertaken. The anesthetic technique was standardized. Following insertion of the LMA and cuff inflation to 60 cm H2O, we measured oropharyngeal leak pressure and gastric insufflation and leak fraction during IPPV, and evaluated the adequacy of fibreoptic view.Results: Oropharyngeal leak pressure measured by neck auscultation was higher for the PLMA compared to the CLMA (23.7vs 16.5 cm H2O,P=0.009) but, when measured by the inspiratory hold maneuver was not significantly different (24.8vs 20.3 cm H2O, respectively,P=0.217). Leak fraction values were similar for the CLMA and the PLMA (21.2%.vs 13.3%, respectively,P=0.473). A satisfactory view of the larynx was obtained more frequently in the PLMA group (21/25vs 10/25,P=0.003). Gastric insufflation during leak determination was more common with the CLMA (12/26vs 2/25 CLMAvs PLMA, respectively,P=0.006).Conclusion: In children undergoing IPPV with neuromuscular blockade, the size 2 PLMA is associated with a higher leak pressure by auscultation and less gastric insufflation compared to the CLMA. Leak pressures assessed by manometric stability are similar with these two devices. The improved fibreoptic view of the larynx through the PLMA may be advantageous for bronchoscopy.RésuméObjectif: Déterminer s’il existe une différence fonctionnelle entre les masques laryngés (LMA)-Classic™ (CLMA) et LMA-ProSeal™ (PLMA) de taille 2 chez les enfants anesthésiés lors d’un bloc neuromusculaire. Les fuites du masque pendant la ventilation à pression positive intermittente (VPPI) et une bonne vision laryngée par fibre optique constituaient les résultats principaux recherchés par cette étude.Méthode: Une étude randomisée contrôlée en aveugle portant sur 51 enfants ASA I ou II et pesant entre 10 et 20 kg a été menée. La technique anesthésique utilisée a été standardisée. Après avoir inséré le LMA et gonflé le ballonnet à 60 cm H2O, nous avons mesuré la pression de fuite oropharyngienne, l’insufflation gastrique et la fraction de fuite pendant la VPPI, et avons évalué la qualité de la vision par fibre optique.Résultats: La pression de fuite oropharyngienne mesurée par auscultation du cou était plus élevée lors de l’utilisation du PLMA que du CLMA (23,7 vs 16,5 cm H2O, P=0,009) ; toutefois, lorsque celle-ci a été mesurée par manœuvre de retenue respiratoire, il n’y a pas eu de différence significative (24,8 vs 20,3 cm H2O, respectivement, P=0,217). Les valeurs de fraction de fuite étaient semblables avec le CLMA et le PLMA (21,2 % vs 13,3 %, respectivement, P=0,473). Une vision satisfaisante du larynx a été plus fréquemment obtenue dans le groupe PLMA (21/25 vs 10/25, P=0,003). L’insufflation gastrique pendant la détermination de la fuite a été plus fréquemment observée dans le groupe CLMA (12/26 vs 2/25 CLMA vs PLMA, respectivement, P=0,006).Conclusion: Chez les enfants subissant une VPPI lors d’un bloc neuromusculaire, le PLMA de taille 2 est associé à une pression de fuite plus élevée par auscultation et moins d’insufflation gastrique par rapport à une utilisation du CLMA. Les pressions de fuite évaluées par stabilité manométrique sont semblables avec les deux appareils. Une vision par fibre optique améliorée du larynx avec le PLMA pourrait s’avérer utile pour la bronchoscopie.

The prone position is associated with a decrease in respiratory system compliance in healthy anaesthetized infants.

Ten healthy (ASA I or II) anaesthetized infants undergoing clubfoot surgery were studied. General anaesthesia included rocuronium, nitrous oxide and isoflurane. Volume controlled ventilation (12 ml·kg−1) was delivered via a coaxial Mapleson‐D (Bain) system and a Datex AS/3 ventilator. Pulmonary mechanics were measured sequentially in the supine and prone positions using a Bicore CP‐100 pulmonary function monitor. Subjects had a mean age of 6 (± 2) months and a mean weight of 8.3 (± 1.4) kg. Dynamic compliance (CDYN) and static compliance (CSTAT) were both significantly lower in the prone position than in the supine position (P < 0.0005). Mean CDYN decreased from 14.9 ± 4.9 ml·cmH2O–1 (supine) to 11.6 ± 3.5 ml·cmH2O–1 (prone). Mean CSTAT decreased from 10.2 ± 2.8 ml·cmH2O–1 (supine) to 8.9 ± 2.3 ml·cmH2O–1 (prone). No clinically significant differences in gas exchange were noted, however, on repositioning.

Hypoxaemia and hypotension after intravenous codeine phosphate

This report describes a case of accidental intravenous administration of codeine phosphate (1 mg · kg−1) to a previously healthy five-year-old boy, who was undergoing strabismus surgery. Hypoxaemia (SpO2 85% with FiO2 of 1) and hypotension (systolic BP 65 mmHg) resulted, which responded to resuscitation with lactated Ringers (20 ml · kg−1) and phenylephrine (2 μg · kg−1). The degree of hypoxaemia observed in this case was severe, but was not associated with clinical evidence of bronchospasm. Possible mechanisms for this reaction might have included direct myocardial depression and histamine release. This case adds further support to the recommendation that codeine phosphate should never be administered intravenously.RésuméCette observation décrit l’injection intraveineuse accidentelle de phosphate de codéine (1 mg · kg−1) à un garçon de cinq ans jusque-là bien portant soumis à une correction chirurgicale de strabisme. Il est apparu une hypoxémie (SpO2 85% avec une FiO2 = 1,0) et une l’hypotension (PAS 65 mmHg) qui ont bien répondu à l’administration de lactate de Ringer (20 ml · kg−1) et de phényléphrine (2 μg · kg−1). Dans le cas présent, le degré d’hypoxémie était grave mais n’était de toute évidence pas causé par un bronchospasme. Une dépression myocardique directe accompagnée d’histamino-libération pourrait constituer le mécanisme plausible de cette réaction. Cette observation endosse une fois plus la recommandation selon laquelle on ne doit jamais administrer de phosphate de codéine par la voie intraveineuse.

The ankle clonus test is not a clinically useful measure of spinal cord integrity in children.

PurposeBilateral flexion-induced ankle clonus has been proposed as a test of spinal cord integrity during anesthesia for scoliosis surgery. The purpose of this study was to establish the reliability of this test in normal children emerging from volatile anesthesia. A secondary objective was to determine if there was a difference in the validity of this test with either sevoflurane or isoflurane anesthesia.MethodsIn a randomized, prospective blinded clinical trial, 32 healthy children aged three to 13 yr, were randomized to receive either isoflurane (Group I,n = 15) or sevoflurane (Group S,n = 17) for maintenance of anesthesia during dental restorative surgery. During emergence, an observer, blinded to group allocation, recorded ankle clonus scores (number of beats to a maximum of 5 on each side) at 60-sec intervals until tracheal extubation. End-tidal anesthetic concentration was measured contemporaneously.ResultsNon-sustained ankle clonus was elicited in a majority of children during emergence: 13 (87%) patients in Group I and 15 (88%) in Group S demonstrated at least non-sustained or unilateral clonus. However, bilateral sustained (> 5 beats·min-1) ankle clonus occurred in only four (27%) patients in Group I and four (24%) patients in Group S (P = 0.83).ConclusionWe conclude that the specificity of the ankle clonus test is too low to be clinically useful as a measure of spinal cord integrity in children, both when isoflurane and sevoflurane are used as the primary anesthetic agent.RésuméObjectifLe clonus du pied bilatéral induit par la flexion a été proposé comme test de l’intégrité de la moelle épinière pendant l’anesthésie pour une opération de scoliose. Le but de notre étude était d’établir la fiabilité de ce test chez des enfants normaux au réveil d’une anesthésie avec agent volatil. Un objectif secondaire était de déterminer s’il y avait une différence de validité du test avec l’anesthésie au sévoflurane ou à l’isoflurane.MéthodeDans une étude clinique randomisée, prospective aveugle, 32 enfants de 3 à 13 ans ont été répartis au hasard et ont reçu de l’isoflurane (Groupe I, n = 15) ou du sévoflurane (Groupe S, n = 17) pour le maintien de l’anesthésie pendant une restauration dentaire chirurgicale. Pendant le retour à la conscience, un observateur impartial a enregistré les scores de clonus du pied (nombre de battements jusqu’à un maximum de 5 de chaque côté) à intervalles de 60 s jusqu’à l’extubation endotrachéale. La concentration télé-expiratoire d’anesthésique a été mesurée aux mêmes moments.RésultatsUn clonus non soutenu a été obtenu chez la majorité des enfants pendant le retour à la conscience : 13 (87 %) patients du Groupe I et 15 (88 %) du Groupe S ont présenté au moins un clonus non soutenu ou unilatéral. Cependant, un clonus bilatéral soutenu (> 5 battements·min-1) est survenu chez seulement 4 (27 %) patients du Groupe I et 4 (24 %) du Groupe S (P= 0,83).ConclusionLa spécificité du test de clonus du pied est trop faible pour être cliniquement significative comme mesure de l’intégrité de la moelle épinière chez les enfants, autant avec l’isoflurane qu’avec le sévoflurane comme anesthésique principal.

Repair of incarcerated inguinal hernia in an infant with acute viral bronchiolitis

PurposeTo describe the anesthetic concerns and management options in an infant with acute viral bronchiolitis who required emergency surgery.Clinical featuresA 12-week-old infant presented to the emergency department with an incarcerated right inguinal hernia. The history was complicated by concurrent acute bronchiolitis. As the hernia was irreducible, emergency surgery was required. General endotracheal anesthesia, following a rapid sequence induction, was supplemented with a caudal epidural block. Inhaled salbutamol and suctioning for thick tracheal secretions were required and were found to be clinically useful. The baby made agood postoperative recovery.ConclusionsA variety of techniques may be used to anesthetize the infant with concurrent acute bronchiolitis. In this case a good outcome was achieved with combined general and regional anesthesia, together with the use of inhaled salbutamol.RésuméObjectifDécrire les problèmes anesthésiques et tes solutions possibles entourant le cas d’un enfant atteint de bronchiolite virale aiguë qui doit être opéré d’urgence.Éléments cliniquesUn bébé de 12 sem, amené à l’urgence, présentait une hernie inguinale droite incarcérée qui nécessitait une opération d’urgence. Le portrait clinique se compliquait d’une bronchiolite aiguë. L’anesthésie endotrachéale générale, réalisée à la suite d’une séquence d’induction rapide, a été complétée par un bloc péridural caudal. L’inhalation de salbutamol et l’aspiration de sécrétions trachéales épaisses ont été nécessaires et utiles. Le bébé s’est très bien rétabli de l’opération.ConclusionDiverses techniques anesthésiques peuvent être utiles dans le cas d’un bébé atteint de bronchiolite aiguë concomitante. De bons résultats ont été obtenus en combinant l’anesthésie générale et régionale avec l’inhalation de salbutamol.

Are children just little adults when it comes to propofol injection pain

thetic agent in pediatric practice, with the well-known benefits of smooth induction characteristics, antiemetic effect, rapid recovery and pleasant emergence. The drug appears to have a wide margin of safety and is less likely to cause significant hypotension than in the elderly population. With the exception of concerns that have been raised with its use for long-term sedation in the pediatric critical care environment,1 there appear to be few safety issues to unduly concern the anesthesiologist. Minor complications are a different issue. Most of these, such as excitatory events upon induction, are generally of a trivial nature, but the troublesome issue of pain on injection still remains and has never been consistently eradicated.2 Consider the following scenario. A happy little fellow arrives with doting parents for his hernia repair. A preoperative tour some days previously has helped reassure the family and the child is orientated to the hospital by child-life workers. On the day of surgery, local anesthetic cream is applied to the child’s hand. The family meets with the anesthesiologist and it is planned to have a parent present for the induction. Everyone is happy and the anesthesiologist impresses everyone, including him/herself, by painlessly introducing the iv catheter into the appropriate vein. When the propofol starts to run in, however, the child lets out a piercing scream and complains loudly about the “big owee!” in his arm. No one is that impressed any more. Will the child remember this event? Quite possibly. The parent will certainly remember. Fortunately, this type of event is not that common, as most anesthesiologists administer lidocaine, either prior to the propofol with venous occlusion, or mixed with the propofol solution. There are some details of technique that seem to be important. Picard’s large meta-analysis3 would suggest that lidocaine is most efficacious when given in advance of the propofol and by applying a tourniquet for up to 120 sec. Although a total of 6,246 patients were included in this analysis, most of the patients were adult. In practice, many children, particularly in the younger age group, object to a tourniquet being applied for this length of time. Whilst a circumferential squeeze with a pair of warm hands may be somewhat less threatening to the child, the reliability of this as a tourniquet may be questionable. Many pediatric anesthesiologists therefore add lidocaine to propofol and have good success with this mixture. Important points seem to be to add the lidocaine just prior to injection and to use an adequate amount of lidocaine.4 Morton5 has reported complete abolition of pain with a freshly prepared mixture of propofol (3 mg·kg–1) and lidocaine (1 mg·kg–1). This brief report was conducted in 50 unpremedicated children and the injections were made via a vein on the dorsum of the hand. The only concern with this mixture is that some children require higher doses of propofol (4–5 mg·kg–1) for induction, particularly if used as a sole agent. When the induction dose is high, therefore, the lidocaine dose increases and toxicity becomes a concern. Can other strategies reduce the pain on injection of propofol more than the appropriate use of lidocaine? Many approaches have been tried in the past, with mixed success. Two techniques are evaluated and presented in this month’s Canadian Journal of Anesthesia. Rachel Pollard and colleagues, from B.C. Children’s Hospital, Vancouver, have compared the effect of lidocaine and thiopental when added to propofol.6 The incidence of injection pain in the propofol/thiopental (P/T) group was 14%, compared to 35% in the propofol/lidocaine (P/L) group. Some questions arise from this study. Firstly, it is not clear why the incidence of pain in the P/L group was as high as 35%. Morton, using the same dose of lidocaine 1016 EDITORIAL

Alternative therapies and postoperative vomiting

In this volume of Pediatric Anesthesia, Moeen describes a randomized controlled trial of acupuncture vs dexamethasone for the prevention of postoperative vomiting (POV) in children undergoing tonsillectomy (1). This well-designed study adds to the body of literature suggesting that acupuncture may have a role in the prevention of POV. Essentially, no difference was shown between a specific acupuncture method and a singleagent antiemetic prophylaxis with dexamethasone (0.15 mg kg ) in the prevention of POV for the first 24 h post tonsillectomy in children. Some features of the technique used by Moeen are worthy of note. The acupuncture method involved needling in three locations—P6 (at both wrists) and CV13 (between the umbilicus and the xiphisternum). Manual rotation of all three needles was required every 5 min for a total of 20 min. Sham acupuncture was given to the dexamethasone group, with the needles inserted slightly away from the described acupuncture points, and at a shallower depth. Although not stated in the paper, it is assumed that manual rotation of the sham needles was not performed. Acupuncture as a therapeutic technique has likely been around for several thousand years, although the exact origin of the practice remains a subject of debate. Needle-shaped stones have been found in China dating back some 8000 years, but whether they were used for acupuncture or some other purpose is unclear. Clearly documented Chinese descriptions of acupuncture have been found within the past 2000 years. In twentieth century China, acupuncture had its ups and downs; the practice was outlawed in 1929, but was reinstated under communist rule in the 1950s, together with other aspects of traditional Chinese medicine. Since then, acupuncture has been become integrated with Western medicine in Chinese health care institutions. In the West, acupuncture has also found a degree of acceptance, at least for some conditions and symptoms, although the traditional concept of meridians has been questioned. In Alberta, Canada, acupuncturists are regulated under the Health Disciplines Act, along with midwives and emergency medical technicians. Postoperative nausea and vomiting (PONV) is a symptom that has been found to be amenable to prevention by the use of acupuncture. A Cochrane Review, updated in 2015, examined the effectiveness of PC6 (the same point as P6 or Nei Guan) acupuncture for the prevention of PONV (2). Fifty-nine studies were identified, of which seven included children. This review determined that there was evidence for the superiority of acupuncture over sham acupuncture in preventing PONV; it was recommended that no further sham trials are required. When studies that compared acupuncture with antiemetic drugs were examined, it was found that, overall, acupuncture was as effective as a variety of antiemetic drugs in the prevention of PONV; the evidence was rated as moderate for this conclusion. When it came to comparing acupuncture alone with a combination of acupuncture and antiemetic drugs, the review determined that the evidence was inconclusive and that further high-quality studies are needed. How does this Cochrane Review relate to the study by Moeen? Although instructive, it must be recognized that the Cochrane review only contained seven studies that included children, and they were of variable quality; they also examined the PC6 acupuncture point only. We also know that antiemetic drugs vary in their effectiveness, and that for a high-risk procedure such as tonsillectomy, at least two antiemetics are currently recommended. An interesting study would therefore be to compare dexamethasone combined with a 5-HT3 antagonist (the gold standard) vs acupuncture. Another question that remains is whether the CV13 point is required or whether bilateral P6 stimulation alone would be as effective. Despite these questions, Moeen does add to the sparse pediatric literature on this topic and provides evidence for the three location (P6 and CV13) acupuncture points. Dexamethasone has many benefits for the child undergoing tonsillectomy. These go beyond the prevention of POV, and include analgesia, earlier return to a normal diet, and a reduction in the need for medical attention in the postoperative period (3). These varied outcomes have been addressed at least in part by Moeen. The time to first oral intake was no different between dexamethasone and acupuncture, however, the pain scores were slightly higher in the acupuncture group at 12 and 18 h postoperatively (1). It can be said that the jury is still out when it comes to the broader anti-inflammatory benefits of dexamethasone for the tonsillectomy patient, as compared with acupuncture. Although seemingly attractive in terms of providing relatively safe antiemetic therapy with acupuncture, Moeen’s study does raise certain practical issues. How many hospital departments in a Western setting have practitioners well trained in the art and science of acupuncture? In Alberta, acupuncturists train for 4 years before being licensed, however, physicians may