Recovery characteristics of propofol anaesthesia, with and without nitrous oxide: a comparison with halothane/nitrous oxide anaesthesia in children.
Crawford MW. Lerman J. Sloan MH. Sikich N. Halpern L. Bissonnette B.
Department of Anaesthesia, Hospital for Sick Children, University of Toronto, Ontario, Canada.
Few studies have examined whether nitrous oxide influences the recovery characteristics of propofol anaesthesia. The present study examined the effect of nitrous oxide on the recovery characteristics of propofol anaesthesia, and compared these data with those for halothane/nitrous oxide anaesthesia. Sixty children aged 3-12 years were assigned at random to receive one of three maintenance regimens: propofol with or without nitrous oxide (70%) or halothane/nitrous oxide (70%). During propofol/N2O anaesthesia, the infusion rate of propofol (180 +/- 39 micrograms.kg-1.min-1) required to maintain the mean arterial pressure and heart rate within 20% of the baseline values was significantly less than that during propofol/O2 (220 +/- 37 micrograms.kg-1.min-1; P < 0.005). The time from discontinuation of anaesthesia to eye-opening (11 +/- 6 min), to response to commands (12 +/- 6 min), and to return of full wakefulness (21 +/- 10 min) after propofol/N2O were similar to those after propofol/O2, but significantly less (by approximately 30%) than those after halothane (P < 0.05). The overall incidence of emesis after propofol/N2O (53%) was greater than that after propofol/O2 (17%, P < 0.05) and comparable to that after halothane/N2O (58%). These data suggest that N2O has little effect on the rate of recovery after propofol, but significantly increases the incidence of postoperative emesis, thereby attenuating one of the main attributes of propofol anaesthesia.
Hepatopulmonary syndrome and liver transplantation: a review of the peroperative management of seven paediatric cases.
Van Obbergh LJ. Carlier M. De Kock M. Otte JB. Moulin D. Veyckemans F.
Department of Anaesthesiology, Catholic University of Louvain Medical School, Brussels, Belgium.
Until recently, hypoxaemia was considered as a relative contraindication for liver transplantation. The hepatopulmonary syndrome associated with a right to left shunt of blood through the lungs is reversible in adults and children after correction of the cirrhosis by liver transplantation. However, concerns have been raised regarding the risks of anaesthesia in such hypoxaemic patients. Since the peroperative management of children undergoing liver transplantation and suffering from hepatopulmonary syndrome and severe hypoxemia has never been described, we report here our experience in seven children. Despite the fact that severe arterial desaturation was recorded throughout the procedure, no major complications were recorded peroperatively. The postoperative intubation time was 58 +/- 21 h, five children being extubated while still hypoxaemic. All seven patients reversed their hepatopulmonary syndrome after a mean postoperative period of 24 +/- 10 weeks. This shows that liver transplantation can be successfully achieved in severely hypoxaemic children and that postoperative correction of the right to left shunt is then obtained.
The Alagilles syndrome and its anaesthetic considerations.
Choudhry DK. Rehman MA. Schwartz RE. Piccoli DA.
Department of Anaesthesia and Critical Care, St. Christopher's Hospital for Children, Philadelphia, PA 19134-1095, USA.
Alagille's syndrome is an inherited disorder affecting multiple organ systems. Most characteristic is the paucity of the interlobular bile ducts with cholestasis. The anaesthetic plan for these patients should be based on careful preoperative preparation and attention to the issues involving hepatobiliary, cardiac, neurodevelopmental, nutritional, haematological, ocular and facial abnormalities. We report the case of a five-and-a-half-year old patient with Alagille's syndrome who sustained a pathological fracture of the femur and was scheduled for closed reduction and application of a hip spica cast. Relevant anaesthetic issues are discussed.
Prophylactic therapy with granisetron in the prevention of vomiting after paediatric surgery. A randomized, double-blind comparison with droperidol and metoclopramide.
Fujii Y. Tanaka H.
Department of Anaesthesiology, Toride Kyodo General Hospital, Ibaraki, Japan.
The antiemetic efficacy of droperidol, metoclopramide and granisetron was compared with placebo in the reduction of vomiting after paediatric surgery (the extremities; inguinal hernia; and phimosis) during general inhalational anaesthesia. One hundred children, ASA physical status I, 4-10 years of age, were enrolled in a prospectively, randomized, double-blind investigation and assigned to one of four treatment regimens: placebo (saline, n = 25), droperidol (50 micrograms.kg1, n = 25), metoclopramide (0.25 mg.kg-1, n = 25) or granisetron (40 micrograms.kg-1, n = 25). These drugs were administered intravenously (i.v.) after inhalation induction of anaesthesia. A complete response, defined as no emesis and no need for another rescue antiemetic during the first 24 h after anaesthesia, occurred in 60%, 76%, 68% and 88% of patients who had received placebo, droperidol, metoclopramide and granisetron, respectively (P < 0.05; overall Fisher's exact probability test). The incidence of adverse events postoperatively was not different among the treatment groups. In conclusion, granisetron 40 micrograms.kg-1 is a better antiemetic than droperidol and metoclopramide when compared to placebo for the prevention of postoperative emesis in children.
Anaesthetic management of a prematurely born infant with Cantrells pentalogy.
Laloyaux P. Veyckemans F. Van Dyck M.
Department of Anesthesiology, Cliniques Universitaires St Luc, Catholic University of Louvain Medical School, Brussels, Belgium.
Cantrell's pentalogy (CP) is a rare congenital syndrome combining a defect of the supraumbilical abdominal wall, the agenesis of the lower part of the sternum and of the anterior portion of the diaphragm, the absence of the diaphragmatic part of the pericardium, and a cardiac malformation. It was first described by Cantrell in 1958 (1,2). We report the case of a prematurely born infant with CP and Wolff-Parkinson-White (WPW) syndrome who required surgery first for bilateral inguinal hernia repair and later for Blalock-Taussig shunt. During these two procedures, our anaesthetic plan was to preserve the fragile equilibrium of both the pulmonary and the cardiovascular systems.
Stridor in the neonate and infant. Implications for the paediatric anaesthetist. Prospective description of 155 patients with congenital and acquired stridor in early infancy.
Holzki J. Laschat M. Stratmann C.
Department of Paediatric Anaesthesia, Children's Hospital Cologne, Germany.
One hundred-and-fifty-five neonates and infants up to the sixth month of postnatal age were investigated to reveal the cause of clinically relevant stridor. In 100 patients congenital stridor was found, in 55 children the stridor was considered to be acquired. A curled, soft epiglottis, almost synonymously used with the diagnosis of congenital stridor, was found in 7% only, indicating different methods of investigation and different selection of patients compared to previous years. In acquired stridor the majority of infants showed laryngeal and tracheal trauma, mostly due to the use of too large tracheal tubes.
Comparison of granisetron and droperidol in the prevention of vomiting after strabismus surgery or tonsillectomy in children.
Fujii Y. Saitoh Y. Tanaka H. Toyooka H.
Department of Anaesthesiology, University of Tsukuba Institute of Clinical-Medicine, Ibaraki, Japan.
This prospective, randomized, double-blinded study evaluated the antiemetic efficacy of granisetron and droperidol in 80 ASA physical status I children, aged 4-10 years, undergoing strabismus surgery or tonsillectomy with or without adenoidectomy. After anaesthetic induction, the patients received either granisetron (40 micrograms.kg-1, n = 40) or droperidol (50 micrograms.kg-1, n = 40) intravenously. The incidence of vomiting during the first 24h after anaesthesia was 15% and 38% after administering granisetron and droperidol, respectively (P = 0.02). The requirement for rescue antiemetic therapy for the treatment of two or more episodes of vomiting was 0% with granisetron and 18% with droperidol (P = 0.001). In conclusion, granisetron was superior to droperidol in reducing the incidence and frequency of postoperative vomiting in paediatric patients.
Diagnosis and anaesthesia management of haemophilia during the neonatal period.
Baujard C. Gouyet L. Murat I.
Department of Anaesthesia, Hopital d'enfants Armand Trousseau, Paris, France.
We report here the case of a newborn infant admitted to our hospital for moderate gastro-intestinal bleeding. Despite abnormal value for aPTT, diagnosis of moderate haemophilia A was only made preoperatively when surgery was deemed necessary to treat pyloric stenosis. Clinical circumstances of the diagnosis and anaesthesia management of haemophilia during the neonatal period are discussed.
Anaesthesia and mitochondrial disease.
Wallace JJ. Perndt H. Skinner M.
Royal Hobart Hospital, Tasmania, Australia.
Mitochondrial diseases, or encephalomyopathies, are an uncommon, heterogeneous group of disorders with variable clinical course and presentation. Many of these patients present for surgery, or undergo anaesthesia in the course of investigation of their illness. Unfortunately, little information exists on their management in anaesthetic texts and the literature. We report on the anaesthetic management of a paediatric patient with mitochondrial disease, and briefly discuss the pathophysiology and anaesthetic implications of these disorders.