Comparison of sevoflurane and ketamine for anesthetic induction in children with congenital heart disease

Background:  Sevoflurane is widely used in pediatric anesthesia for induction. Ketamine has been preferred in pediatric cardiovascular anesthesia. Aim of this study was to compare the hemodynamic effects and the speed of ketamine and sevoflurane for anesthesia induction in children with congenital heart disease.
Materials and methods:  Children with congenital heart disease undergoing corrective surgery were included in the study. After oral premedication with midazolam (0.5 mg·kg⁻¹), anesthesia induction was started with 5 mg·kg⁻¹ intramuscular ketamine (group K). In the second group, induction was achieved with sevoflurane (group S); the first concentration was 3% and increased after every three breaths. Intravenous access time and intubation times were enrolled for each child. Hemodynamic data and oxygen saturation were recorded every 2 min and any event during induction period was also noted.
Results:  Forty-seven children were included in the study; 23 in group K and 24 in group S. Heart rates and oxygen saturation values were similar between groups during the study. No difference was found between intravenous access time and intubation times. However, blood pressure levels were significantly lower in group S after recording baseline values till the intubation time (at 4, 6, and 8 min). Respiratory complications observed during the study were mild and were less frequent in group K than in group S (4 vs 13).
Conclusion:  Ketamine appears a good alternative for induction in patients with congenital heart disease. It permits preservation of hemodynamic stability with minimal side effects.     

Postoperative analgesia with preoperative oral ibuprofen or acetaminophen in children undergoing myringotomy

Previous studies have shown over 70% of children require analgesics following bilateral myringotomy and tube placement (BM&T). This double-blind, placebo-controlled study compared the postoperative analgesic effects of preoperatively administered oral acetaminophen or ibuprofen. Forty three ASA I or II children age six months or older scheduled for elective BM&T were randomized to receive acetaminophen (paracetamol) 15 mg·kg⁻¹, ibuprofen 10 mg·kg⁻¹, or placebo. Postoperative pain was assessed using the Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) upon arrival to the PACU and at 5, 10, 15, 30, 45, and 60 min. CHEOP scores did not differ between the groups at any time. There was no difference in the number of children receiving rescue analgesia. This study showed no benefit of preoperatively administered oral ibuprofen 10 mg·kg⁻¹ or acetaminophen 15 mg·kg⁻¹ over placebo for the relief of postoperative pain in children undergoing BM&T.     

Comparison of diclofenac and tenoxicam for postoperative analgesia with and without fentanyl in children undergoing adenotonsillectomy or tonsillectomy

127 children scheduled for elective tonsillectomy or adenotonsillectomy were studied. Anaesthesia was induced with propofol and maintained with a volatile agent. At induction the child received either rectal diclofenac 1 mg·kg⁻¹ with or without fentanyl 0.75 μg·kg⁻¹ i.v., or intravenous tenoxicam 0.4 mg·kg⁻¹ with or without fentanyl 0.75 μg·kg⁻¹ i.v. Blood loss was measured peroperatively. Nausea and vomiting scores, sedation scores and pain scores were recorded in the recovery room, at one, two, four and eight h postoperatively and at discharge. There were no significant differences in blood loss between the groups or between nausea and vomiting scores. Pain scores in the tenoxicam without fentanyl group were significantly higher in recovery ( P <0.05) than the diclofenac group without fentanyl and both fentanyl groups. This group required supplemental analgesia earlier although this was not significant. The pain scores in the diclofenac with fentanyl group were significantly lower at one h and four h than the group receiving diclofenac alone ( P =0.008 and 0.02 respectively).     

Peritonsillar infiltration with bupivacaine and pethidine for relief of post-tonsillectomy pain: a randomised double-blind study

Previous studies of infiltration of local anaesthetics in children undergoing tonsillectomy resulted in conflicting results. The aim of this study was to evaluate the effect of the peritonsillar injection of bupivacaine and pethidine on postoperative pain in children undergoing snare-dissection tonsillectomy. In a double-blind study, 80 children (aged 7–15 years) were randomly divided into two groups receiving peritonsillar injection of either bupivacaine (1 mg.kg⁻¹) and pethidine (1 mg.kg⁻¹) in adrenaline 1 : 200 000 (treatment group) or an equivalent volume of saline (placebo group) pre-operatively. The time needed for first demand of analgesia and analgesic consumption to reduce the visual analogue scale (VAS) for resting throat pain to≤30, the VAS for pain on swallowing, drinking liquid and eating a soft diet, incidence of nausea and vomiting, and the need for rescue anti-emetics in the first 24 h after operation were compared in both groups. The combination of bupivacaine and pethidine could significantly decrease the consumption of analgesics for resting pain at 4, 6, 8, 12, and 24 h after operation but did not reduce pain on swallowing, drinking liquid and eating a soft diet. The times to demand of first dose of analgesic and to first oral intake were not significantly different. The overall satisfaction of patients in relation to relief of postoperative pain was not significantly different between the two groups. Although peritonsillar injection of pethidine and bupivacaine in children reduces the analgesic consumption, it does not affect the dynamic pain state in the first 24 h after snare-dissection tonsillectomy.     

The analgesic efficacy of an injectable prodrug of acetaminophen in children after orthopaedic surgery

The analgesic efficacy and safety of propacetamol, an injectable prodrug of acetaminophen, (paracetamol) were studied in 87 children (36 boys, 51 girls; age 6–13; mean age 9.5 years) immediately after limb surgery. Using a double-blind, randomized, parallel group design, the effects of a single IV infusion of 30 mg·kg⁻¹ propacetamol (i.e. 15 mg·kg⁻¹ acetaminophen) were compared with a single injection of placebo (PL). Efficacy was assessed on pain scores rated on a four-point verbal scale, a five-point visual scale (faces) and on a four-point relief verbal scale before administration (T0) and 0.25, 0.5, 1, 2, 3, 4, 5, 6 h after administration. At the end the global efficacy was rated by the physician on a five-point verbal scale. Propacetamol was statistically superior to placebo on all assessment criteria. Seven side-effects were recorded: five in the propacetamol group and two in the placebo group. 30 mg·kg⁻¹ propacetamol provided a significantly greater analgesic effect than placebo in children after orthopaedic surgery.     

The efficacy of intravenous or peritonsillar infiltration of ketamine for postoperative pain relief in children following adenotonsillectomy

BACKGROUND: A few previous studies have suggested the efficacy of i.v. ketamine for postoperative pain relief in children after adenotonsillectomy, but none has investigated the efficacy of peritonsillar infiltration of ketamine in these children. METHODS: This randomized, placebo-controlled study evaluated the effects of peritonsillar infiltration of ketamine in children undergoing adenotonsillectomy. Ninety ASA I-II children were randomized three groups of 30 each. Group I received: 2 ml i.v. saline, group II received i.v. ketamine (0.5 mgxkg(-1)) and group III received a local peritonsillar infiltration of ketamine (0.5 mgxkg(-1)). All medications were 2 ml in volume which was applied 1 ml per tonsil 3 min prior to tonsillectomy. Modified Hannallah pain scale [observational pain scores (OPS)], nausea, vomiting, bleeding, rescue analgesia, sedation and Aldrete scores were recorded at first, 15th, 30th and 60th min postoperatively. Patients were interviewed on the day after surgery to assess the postoperative pain, nightmares, hallucinations, vomiting and bleeding. RESULTS: Group I had higher OPS scores than group II and group III. Group II and group III had comparable scores, which were not statistically significant (P > 0.05). Group II had higher sedation score at 15th min (P = 0.015). Thirty-two children, 19 of whom were in group I had rescue analgesia in postanesthesia care unit (P < 0.05) and the time to first analgesic requirement was significantly shorter in group I than the other groups (P = 0.006). Group II and group III also had less pain than group I at home (P = 0.023). CONCLUSIONS: Low dose ketamine given i.v. or by peritonsillar infiltration perioperatively provides efficient pain relief without side-effects in children undergoing adenotonsillectomy.     

Ketamine or alfentanil administration prior to propofol anaesthesia: the effects on ProSeal™ laryngeal mask airway insertion conditions and haemodynamic changes in children

This study was designed to compare the effects of ketamine and alfentanil administered prior to induction of anaesthesia with propofol, on the haemodynamic changes and ProSeal laryngeal mask airway^® (PLMA) insertion conditions in children. Eighty children, aged between 3–132 months, were randomly allocated to receive either alfentanil 20 μg.kg⁻¹ (alfentanil group) or ketamine 0.5 mg.kg⁻¹ (ketamine group) before induction of anaesthesia. Ninety seconds following the administration of propofol 4 mg.kg⁻¹, a PLMA was inserted. In the ketamine group, heart rate and mean arterial pressure were higher during the study period compared with the alfentanil group (p < 0.05). The time for the return of spontaneous ventilation was prolonged in the alfentanil group (p = 0.004). In conclusion, we found that the administration of ketamine 0.5 mg.kg⁻¹ with propofol 4 mg.kg⁻¹ preserved haemodynamic stability, and reduced the time to the return of spontaneous ventilation, compared with alfentanil 20 μg.kg⁻¹ during PLMA placement. In addition, the conditions for insertion of the PLMA with ketamine were similar to those found with alfentanil.     

Paediatric laparoscopic surgery: anaesthetic management

Summary
Total intravenous anaesthesia (TIVA) has been performed in 54 paediatric patients undergoing laparoscopic surgery. A loading dose of propofol 2.5 mg·kg⁻¹ and fentanyl 2 μg·kg⁻¹ were used for induction while a continuous infusion of propofol 9 mg·kg⁻¹·h⁻¹ and atracurium 0.5 mg·kg⁻¹·h⁻¹ in O₂/Air were used for maintenance. Intraoperative cardiorespiratory stability, prompt recovery, painless postoperative period show that TIVA is a valid and safe technique for laparoscopic surgery in children.     

Oral transmucosal ketamine: an effective premedication in children

The oral cavity offers a simple, painless way of drug administration. For this reason, we used oral transmucosal ketamine (5–6 mg·kg⁻¹) for premedication in 15 children and compared it with intranasal ketamine (5–6 mg·kg⁻¹), placebo and intramuscular ketamine (5–6 mg·kg⁻¹). Oral transmucosal ketamine (OTK) provided effective sedation, facilitated i.v. line insertion and was accepted with pleasure by the patients (as lollipops). The lollipops produced a slight increase in gastric volumes but did not affect gastric pH. In conclusion OTK has been shown to be an effective, harmless preoperative medication in paediatric patients.     

Comparison of topical lignocaine gel and fentanyl for perioperative analgesia in children undergoing cataract surgery

Background:  Opioids continue to remain the primary analgesics in children undergoing ophthalmic surgery, and their use may be associated with adverse effects like vomiting and respiratory depression. Topical anesthesia avoids these adverse effects and also complications of regional blocks. We designed this study to verify whether topical anesthesia with lignocaine gel is a feasible alternative to intravenous (IV) fentanyl for pediatric cataract surgery.
Methods:  One hundred ASA I and II children aged 3–12 years, scheduled for cataract surgery were included in this study. After induction of anesthesia, children were randomized to Group F (fentanyl), who received 2 mcg·kg⁻¹ IV fentanyl for analgesia and Group G (lignocaine gel), who received 2% lignocaine gel applied over the cornea of the operative eye. Anesthesia was maintained with isoflurane and oxygen in nitrous oxide. All children received intramuscular ketorolac. Intraoperative supplementary analgesia was provided with 0.5 mcg·kg⁻¹ IV fentanyl to manage increases in heart rate or blood pressure of 20% above baseline. In the postoperative period, Aldrete score and objective pain score were assessed. Rescue analgesia was provided with fentanyl in the postanesthesia care unit and syrup ibuprofen in the ward.
Results:  Significantly more children in group F (8/48) required intraoperative supplementary fentanyl as compared with group G (1/48) ( P  = 0.0291). In the PACU, 7/48 children of group G needed fentanyl as compared with 5/48 children in group F. Time to reach Aldrete 10 was significantly longer in group F ( P  = 0.01).
Conclusions:  Topical lignocaine gel is an effective analgesic and may be used as an adjunct to fentanyl during cataract surgery in children.     

Anaesthesia for insertion of ear tubes in children: comparison of propofol, thiopentone and halothane

To determine the quality of anaesthesia and speed of recovery after propofol anaesthesia for myringotomy in children, 100 children 2–12 years were randomized to one of four anaesthetic regimens for induction/maintenance: thiopentone (STP) (5 mg·kg⁻¹)/halothane, propofol (3 mg·kg⁻¹)/halothane, halothane/halothane or propofol (3 mg·kg⁻¹)/propofol bolus (0.5 mg·kg⁻¹ every 3 min (10 mg·kg⁻¹·h⁻¹)). Nitrous oxide (70%) in oxygen (30%) was used to facilitate insertion of an intravenous catheter and was continued throughout the anaesthetic. We found that the incidence of intraoperative movement in response to surgical stimulation was significantly greater in the prop/prop group 32%, compared with the three other groups ( P <0.02). Although some recovery variables (time to response to questions, sit unaided, tolerate oral fluids, and discharge with fluids) were achieved more rapidly by the prop/prop group than the other three groups, the times to open eyes, obey commands and, most importantly, discharge from recovery without fluids did not differ between the prop/prop and the hal/hal groups. We conclude that there is little benefit in using propofol as an induction agent alone or in combination with a propofol maintenance anaesthetic for paediatric myringotomy and tube surgery.     

Efficacy of a low-dose spinal morphine with bupivacaine for postoperative analgesia in children undergoing hypospadias repair

Background:  Children undergoing hypospadias repair need to be protected from highly unpleasant sensory and emotional experiences during and after surgery. We designed a double-blinded, randomized, and placebo-controlled study to compare the efficacy of a low-dose (2 μg·kg⁻¹) of intrathecal morphine with placebo for postoperative pain control of children undergoing repair of hypospadias surgery with spinal anesthesia.
Methods:  Fifty-four children were randomly assigned to one of two spinal anesthesia groups. Group M ( n  = 27) received hyperbaric bupivacaine plus 2 μg·kg⁻¹ of preservative-free morphine and group P ( n  = 27) received hyperbaric bupivacaine plus 0.9% NaCl (placebo) under inhalation anesthesia. General anesthetics were discontinued subsequent to the block. The primary outcome was the presence of pain-requiring analgesics during the first 12 h after the spinal block. Side effects were also recorded. The analgesic effects were evaluated by using the Children's Hospital of Eastern Ontario Pain Scale.
Results:  Forty-nine patients completed the trial. Fifteen patients (60%) in group P received supplementary analgesics within the first 12 h compared to only four patients (16.7%) in group M ( P  = 0.005). Mean duration of analgesia was 480 ± 209 and 720 ± 190 min in group P and group M respectively ( P  = 0.009). The groups were similar in postoperative side effects.
Conclusion:  Spinal anesthesia provided by hyperbaric bupivacaine is adequate for distal hypospadias repair in children, but adding 2 μg·kg⁻¹ intrathecal morphine provides better postoperative pain control when compared to placebo in these children.     

Electroencephalographic Narcotrend Index monitoring during procedural sedation and analgesia in children

Background:  The electroencephalographic Narcotrend Index (NI) may potentially help to titrate sedative medication during diagnostic and therapeutic procedures in children.
Methods:  With local ethics committee approval and informed parental consent, 31 patients, aged 8.9 ± 4.3 years, scheduled for elective upper gastrointestinal endoscopy were enrolled in this prospective, double-blinded observational study. Initially, patients received a single dose of intravenous piritramide 0.1 mg·kg⁻¹, followed by propofol 2 mg·kg⁻¹ and, if necessary, additional propofol doses (0.5 mg·kg⁻¹) to achieve and maintain a level of deep sedation throughout the procedure. Sedation was assessed by the University of Michigan Sedation Scale (UMSS). We investigated the relationship between depth of sedation, and the NI, and the classical EEG parameters (cEEG), total EEG power (Power), spectral edge (SEF) and median frequency, and relative power in the beta, alpha, theta and delta bands. The performance of the NI and cEEG parameters was evaluated by prediction probability ( P _K), receiver operating characteristic (ROC) and Spearman rank order correlation analysis.
Results:  Mean P _K values for NI (0.88) vs UMSS were higher than for the other cEEG parameters, except for Power (0.82) and SEF(0.81). Spearman correlation analysis revealed superiority of the NI over all cEEG parameters. The area under the curve for the NI was 0.93, which was superior to all other EEG parameters beside Power (0.86) and relative power in alpha (0.82).
Conclusions:  The results of this study suggest that the NI may be an objective nondisruptive tool for assessment of hypnotic depth in children under propofol-induced procedural sedation.     

Effects of blood sample volume on hematocrit in critically ill children and neonates

Background:  There are no studies correlating the volume of blood taken from children and hematocrit (Hct) stability, relating those changes to duration of stay, severity of illness or weight. Earlier studies in neonates suggest that repeated sampling results in a drop in Hct.
Aim:  To characterize the changes in Hct in children of all ages admitted to intensive care over a 5-day period following routine blood volume sampling.
Methods:  We undertook an open prospective observational study. Eligible children were recruited sequentially and data recorded for 5 days following admission. The bedside nurse recorded the daily volume of blood samples taken and transfusions given. Daily Hct was noted from the routine full blood count. The relationship between changes in Hct and blood sample volume and transfusion requirement was studied.
Results:  There were no differences in mean Hct on admission at end of the study ( P  = 0.69, n  = 30) nor in the median blood volume sampled between transfused and nontransfused groups (7.5 ml·kg⁻¹ vs 7.9 ml·kg⁻¹, P  = 0.88). The largest blood sample volumes were taken on admission and from the smallest patients.
Conclusion:  We have quantitated the change in Hct and size of blood volume taken for routine laboratory studies. We suggest that children can tolerate 0.25 ml·kg⁻¹·day⁻¹ blood sampling without a fall in Hct and sampling can be tailored to the individual child according to the admission Hct.     

Rectal paracetamol dosing regimens: determination by computer simulation

A pharmacokinetic dynamic simulation model was used to predict rectal paracetamol dosing schedules which would maintain steady state plasma concentrations of 10–20 mg·l⁻¹. These plasma concentrations of paracetamol are known to reduce fever. The conventional dosing schedule of 15 mg·kg⁻¹ four hourly was unsatisfactory. Steady state concentrations of 8–12 mg·l⁻¹ were only reached after 16 h. A loading dose of 50 mg·kg⁻¹ followed by 30 mg·kg⁻¹ six hourly achieved plasma concentrations of 9–18 mg·l⁻¹. Paracetamol is a mild analgesic. A higher plasma paracetamol concentration of 25 mg·l⁻¹ is known to give satisfactory analgesia to 60% of children after tonsillectomy. This concentration can be reached after a loading dose of 70 mg·kg⁻¹ and a maintenance dose of 50 mg·kg⁻¹ 8 hourly. Doses above 150 mg·kg⁻¹·day⁻¹ have been reported to cause reversible liver toxicity after 2–8 days and should not be sustained.     

The optimal dose of ketamine for caudal epidural blockade in children

Sixty boys aged up to 9 years undergoing orchidopexy were randomly allocated to receive one of three solutions for caudal epidural injection: group A received 1 ml. kg⁻¹ of 0.25% bupivacaine with 0.25 mg. kg⁻¹of preservative-free ketamine, group B received 1 ml. kg⁻¹ of 0.25% bupivacaine with ketamine 0.5mg. kg⁻¹ and group C received 1 ml. kg⁻¹ of 0.25% bupivacaine with 1 mg. kg⁻¹ of ketamine. Postoperative pain was assessed by means of a modified Objective Pain Score and analgesia was administered if this score exceeded four. The median duration of caudal analgesia was 7.9h in group A, 11 h in group B and 16.5 h in group C. There were no differences between the groups in the incidence of motor block, urinary retention, postoperative vomiting or postoperative sedation. Group C had a significantly higher incidence of behavioural side effects, including slightly odd behaviour, vacant stares and abnormal effect than groups A and B.     

Intranasal ketamine preinduction of paediatric outpatients

A double-blinded, placebo-controlled study compared the outcomes of intranasal ketamine premedication with placebo in outpatients. Forty paediatric outpatients were assigned randomly in a prospective fashion to one of two separate study groups of equal size (20 patients per group). A placebo group received 2 ml of intranasal saline, 1 ml per naris. The study group received intranasal ketamine, 3 mg·kg⁻¹, diluted to 2 ml with saline, 1 ml per naris. Using a cooperation index, a play therapist scored resistance to nasal instillation, separation of the child from parents at ten min, and acceptance of anaesthesia monitors and face mask at 15 min. Differences in age, weight, episodes of vomiting, recovery and discharge times among the two groups were not significant. Intranasal ketamine, 3 mg·kg⁻¹, was asssociated with a significantly better ( P =0.013) cooperation index than intranasal placebo. Intranasal ketamine, permitted pleasant and rapid separation of children from their parents, cooperative acceptance of monitoring and of mask inhalation induction, and did not cause prolonged postanaesthetic recovery or delayed discharge home.     

Single injection paravertebral block for renal surgery in children

Background:  Continuous paravertebral block (PVB) has been successfully used for postoperative analgesia in children. However, data regarding the efficacy of a single injection technique for major renal surgery are still lacking.
Methods:  Following the ethics committee approval and parent informed consent, 24 children (median 10.3 months; range: 2.9–26.8) undergoing major renal surgery were included in a prospective observational pilot study. Following a standardized general anesthetic the patients were administered a single injection low thoracic PVB (loss-of-resistance technique; 0.5 ml·kg⁻¹ of levobupivacaine 2.5 mg·ml⁻¹ with epinephrine 5 μg·ml⁻¹) at the end of surgery. Postoperative pain was assessed by Face, Legs, Activity, Cry, Consolability (FLACC) score at predetermined time points and in case of apparent patients' discomfort during the first 12 postoperative hours. The duration of postoperative analgesia was defined as the interval between PVB and the first supplemental administration of a rescue opioid analgesic. The incidence of complications and postoperative vomiting (POV) was also recorded.
Results:  A successful PVB was achieved in 23/24 patients (95.8%). The median duration of the block was 600 min (range: 180–720 min) with 10 children not requiring any supplemental analgesia during the 12-h observation period. Vascular puncture was observed in 2/24 children (8.3%) and POV occurred in 4/24 children (16.7%). All complications were considered minor and did not influence recovery.
Conclusions:  Single injection PVB provided clinically relevant postoperative analgesia in children undergoing major renal surgery.     

Tracheal administration of atropine in children—effect on heart rate

Forty-one ASA I patients, aged 2–6 years, anaesthetized for elective ear, nose and throat surgery, were studied in a double blind and randomized fashion in order to examine the effect of tracheally administered atropine 0.02 mg·kg⁻¹ or saline 0.9% on heart rate. In patients receiving atropine heart rate increased 8.8 beats·min⁻¹ (8.7%) and 16.2 beats·min⁻¹ (16.0%) after 3 and 5 min respectively. No increase in heart rate was seen in the saline group. Because of the late onset of action and only moderate increase in heart rate it is concluded that tracheal administration of atropine 0.02 mg·kg⁻¹ to children is insufficient in emergency situations.     

Analgesia for adenotonsillectomy in children: a comparison of morphine, ketamine and tramadol

Background : Establishment of good analgesia is of major concern in the postoperative period following adenotonsillectomy. The aim of this study was to compare the effects of ketamine, morphine and tramadol on postoperative pain after adenotonsillectomy in children. Methods : Sixty children (age 5–12 years) scheduled for adenotonsillectomy were randomized into four groups to receive intravenously (i.v.) either 0.5 mg·kg^?1 ketamine hydrochloride (K), 0.1 mg·kg^?1 morphine hydrochloride (M), 1.5 mg·kg^?1 tramadol hydrochloride (T) or normal saline (S) in a volume of 4 ml during induction. After tracheal intubation 10 μg·kg^?1·min^?1 ketamine hydrochloride in group K and 0.6 ml·kg^?1·h^?1 saline i.v. in groups M, K and S were infused peroperatively. Postoperative analgesic requirements and side‐effects were recorded. Pain was assessed by the Numeric Rating Scale (NRS) and the Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) scores. Results : Heart rate increased significantly peroperatively only in group K. NRS at first and fifth minute in group M and at first minute in group T and K and CHEOPS score at first, fifth, 15th and 60th min in group M were found to be significantly lower than in the control group. The time to first analgesic requirement was significantly longer in group M compared with ketamine and the control group. Six children in group M, nine in group T, 11 in group K and 15 in group S needed additional analgesics. Conclusions : Morphine hydrochloride 0.1 mg·kg^?1 i.v. administered during induction of anaesthesia provides efficient pain relief in children undergoing adenotonsillectomy.