bluuebunny/crossref_metadata_2025 huggingface dataset:
Free and total bupivacaine plasma concentrations after continuous epidural anaesthesia in infants and children
Authors: Luz  , Wieser  , Innerhofer  , Frischhut  , Ulmer  , Benzer
Published: March 2003

We measured free and total venous bupivacaine plasma concentrations in fourteen infants and children aged 6 days (2800 g) to 9 years (27 kg) undergoing epidural anaesthesia. An initial bolus of 0.5 ml·kg−1 bupivacaine 0.25% was followed by a continuous infusion administered one h after bolus over a period of seven h (first hour 0.25 ml·kg−1·h−1 0.25%; then reduced to 0.125%). Although total bupivacaine plasma concentrations were within acceptable limits (<1.5 μg·ml−1), four of the seven infants showed adverse reactions. Maximum plasma concentrations of free bupivacaine were significantly higher in infants (P<0.05) than in older children. We conclude that toxicity may be underestimated when only measuring total bupivacaine concentrations. In young infants the bupivacaine dose administered for continuous epidural anaesthesia should be further lowered below recommended concentrations and the patients closely observed for possible adverse reactions.
The Alagille's syndrome and its anaesthetic considerations
Authors: CHOUDHRY DINESH , REHMAN MOHAMMED , SCHWARTZ ROY , PICCOLI DAVID
Published: March 2003

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.
Development of a selection and monitoring protocol for safe sedation of children
Authors: MORTON N. , OOMEN G.
Published: March 2003

A protocol was developed for children undergoing diagnostic and therapeutic procedures under sedation to try to raise the standards of patient selection, preparation, monitoring and management to those of children undergoing general anaesthesia. The principles underlying the protocol design were that informed consent should be obtained; fasting guidelines as for general anaesthesia should be implemented; contraindications to sedation should be actively sought; monitoring should be commenced from the time of administration of sedation until recovery and should be maintained during patient transport; personnel trained in monitoring and resuscitation of children should have as their sole duty the monitoring of the sedated child and should not take part in the procedure; the minimum monitoring standard should comprise regular assessments of the level of sedation, oxygen saturation by pulse oximetry, respiratory rate and pulse rate supplemented by temperature, ECG and blood pressure for infants, for prolonged procedures or where verbal contact with the child is lost.
The intravascular migration of an epidural catheter
Authors: Dickson M.A.s , Doyle E
Published: March 2003

The intravascular migration of an endhole epidural catheter in a child is described. We suggest measures to reduce the risk of inadvertent intravenous administration of local anaesthetic and means of reducing the effects of this with particular relevance to paediatric practice.
Pulmonary atelectasis during paediatric anaesthesia: CT scan evaluation and effect of positive endexpiratory pressure (PEEP)
Authors: Serafini G , Cornara G , Cavalloro F , Mori A , Dore R , Marraro G , Braschi A
Published: March 2003

The case series consisted of ten children, ranged in age from one to three years (median 1.8 yrs), and in body weight from 10.2 to 13.5 kg (median 11.7 kg), in ASA class 1 or 2, all without lung disease. Having undergone general anaesthesia for cranial or abdominal CT scans, the patients were studied for pulmonary morphology. The first pulmonary CT scan was taken five min after induction of general inhalational anaesthesia; preoxygenation was avoided and an intraoperative FiO2≤0.4 was used. Densities in dependent regions of both lungs were observed in all children. After ventilation with PEEP of 5 cmH2O, all the observed densities disappeared without impairment of heart rate, blood pressure, haemoglobin saturation and endtidal CO2 (PECO2). We conclude that the appearance in children of atelectasis cannot be explained by a reabsorption of O2 mechanism and by denitrogenation. However, a PEEP of 5 cmH2O is able both to recruit all the available alveolar units, and to induce the disappearance of atelectasis in dependent lung regions.
Extrapyramidal side‐effects from droperidol mixed with morphine for patient‐controlled analgesia in two children
Authors: Habre W. , Wilson D. , Johnson C.M.
Published: March 2003

We report two cases of extrapyramidal reactions occurring in children following the use of droperidol in combination with morphine for patient‐controlled analgesia (PCA). Symptoms appeared 38 and 27 h, respectively, after commencement and after a total dose of 0.14 mg·kg−1 and 0.17 mg·kg−1, respectively. Although effective and safe in adult patients, we recommend caution with the use of droperidol‐morphine mixtures for PCA in paediatric patients.
Postal survey of the anaesthetic techniques used for paediatric tonsillectomy surgery
Authors: Hatcher I.S. , Stack C.G.
Published: March 2003

A postal survey of anaesthetic techniques used for tonsillectomy surgery in children (age 3–16 years) was performed with particular reference to the use of the reinforced laryngeal mask airway and the use of suxamethonium. From 110 questionnaires despatched, replies were obtained from 88 consultant anaesthetists with commitments to otolaryngologic (ENT) anaesthesia (response rate 80%). In paediatric practice, the reinforced laryngeal mask airway was routinely used by 14 (16%) respondents from the 88 who replied. Thirteen (33%) respondents out of 39 respondents who replied saying that they had used the reinforced laryngeal mask airway at some point, reported problems with its use. Suxamethonium was used routinely by 40 consultants (45%) for tonsillectomy surgery. Severe problems with its use had been encountered by 26 (30%) respondents
Remifentanil infusion for major abdominal surgery in small infants
Authors: Wee L. H. , Moriarty A. , Cranston A. , Bagshaw O.
Published: March 2003

Neonates are known to be sensitive to volatile anaesthetic agents which may lead to prolonged recovery. In this study, a remifentanil infusion was used in conjunction with an infusion of epidural ropivacaine and isoflurane anaesthesia for major abdominal surgery in small infants. This led to a short recovery time for infants aged 7 days to 3 months but a prolonged recovery in those under the age of 7 days. Good perioperative analgesia was achieved.
Comparison of morphine sulphate and codeine phosphate in children undergoing adenotonsillectomy
Authors: SEMPLE D. , RUSSELL S. , DOYLE E. , ALDRIDGE L.M.
Published: March 2003

We undertook a double‐blind study to evaluate equianalgesic doses of intramuscular morphine sulphate (0.15 mg??kg−1) and codeine phosphate (1.5 mg??kg−1) in 40 healthy children undergoing adenotonsillectomy. There were no significant differences in pain scores, analgesic requirements or sedation scores between the two groups over the following 24 h. More children vomited in the morphine group (60%) than the codeine group (30%) between one and six h after the procedure (P<0.05). Codeine phosphate is associated with less postoperative vomiting than morphine sulphate while providing comparable postoperative analgesia for adenotonsillectomy.
Jugular bulb temperature compared with non‐invasive temperatures and cerebral arteriovenous oxygen saturation differences during open heart surgery
Authors: SANDSTRÖM KERSTIN , NILSSON KRISTER , ANDRÉASSON SVENERIK , LARSSON LARS E.
Published: March 2003

Limited information is available about the correlation between cerebral temperature and routine temperature measurements during cardiopulmonary bypass in infants. Nasopharyngeal, tympanic membrane and rectal temperatures were compared with jugular bulb temperature in ten infants operated on with moderate or deep hypothermia. The cerebral arteriovenous saturation differences were correlated with the temperatures at the four measurement sites. The jugular bulb and nasopharyngeal temperatures showed the most rapid response during cooling and rewarming. The tympanic temperature response varied in an unpredictable way. Rectal temperature, which was the target for rewarming, lagged behind during both cooling and rewarming. Overwarming at the end of cardiopulmonary bypass, seen as jugular bulb and nasopharyngeal temperatures exceeding 38??C, was common after deep hypothermia. A high correlation was found between the cerebral arteriovenous oxygen saturation differences and the jugular bulb temperature (r=0.81) and the nasopharyngeal and the tympanic temperature (r=0.79), whereas the correlation with rectal temperature was weaker (0.66).
Propofol and pain on induction: the effect of injectate temperature in children
Authors: Pickford Alison , Burden John , Lewis Ian
Published: March 2003

A prospective, randomized, double‐blind study was conducted to determine whether cooled intravenous propofol reduces the incidence of pain on induction of anaesthesia in children. Seventy patients aged 3–10 years, ASA I or II, were randomized to receive 1% propofol plus 0.05% lidocaine either at room temperature (20–23°C) or cooled to 4C. Pain was assessed by a blinded observer using a behavioural scale. Data from 69 patients were analysed. The incidence of pain was 9/34 (26%, 95% confidence intervals 11–41%) in the room temperature injectate group and 5/35 (14%, 95% confidence intervals 3–26%) in the cold injectate group. These differences were not statistically significant (P=0.21, chi‐squared test). Pain scores were similar in both groups.
The Newton valve revisited: an in‐vitro study of ventilator circuit dead space
Authors: Wongprasartsuk P. , Mason David G.
Published: March 2003

A laboratory study was conducted to investigate the volume (length) of the ventilator circuit dead space (VCD) tubing at which dilution of an inspired gas by ventilator driving gas first occurs using three lung models. Various lengths of two VCD tubing materials [Portex (Sims Portex Ltd, Kent, UK) 10 mm bore smooth‐walled silicon and Intersurgical (Wokingham, Berks, UK) 22 mm corrugated plastic] were interposed between a T‐piece circuit and Nuffield 200 ventilator (Penlon, Abingdon, Oxon, UK) with a Newton valve attached. Dilution of inspired gas by the ventilator driving gas was first detected during ventilation of infant and child lung models when the VCD was 7 ml (6 cm) and 77 ml (102 cm), respectively, using Portex tubing, and 24 ml (6.5 cm) and 105 ml (29 cm), respectively, using Intersurgical tubing. No dilution occurred using the neonatal model. Dilution of the inspired anaesthetic gases by ventilator driving gas may occur in paediatric practice if the VCD volume (length) is inadequate. This risk is greatest in the child.
The feasibility of pain treatment at home after adenoidectomy with ketoprofen tablets in small children
Authors: Kokki Hannu , Nikanne Elina , Ahonen Riitta
Published: March 2003

In this study, we investigated the feasibility of pain treatment using ketoprofen 25 mg tablets (5 mg·kg–1·day–1) at home in children after daycase adenoidectomy. We also determined the adverse events and the incidence of postoperative bleeding during the first week after surgery. Initially, we studied 611 children aged 1–9 years. The study design was prospective, longitudinal, and open. The final data consisted of 555 (91%) children, and 522 children who received ketoprofen at home. The parents administered four (1–10, median with 10th and 90th percentiles) ketoprofen tablets to their children during the first week. A total of 20% of the parents experienced problems in administering tablets, and problems were three times more common in children under 48 months compared to older children. The main problems were swallowing difficulties and the unpleasant taste of the tablet. Neither serious adverse events, nor clinically significant bleeding occurred. Ketoprofen at the dose of 5 mg·kg–1·day–1 proved to be a safe analgesic in children for short‐term use after adenoidectomy.
Combination propofol–ketamine anaesthesia in sick neonates
Authors: Golden Samuel
Published: March 2003

Two critically ill, opioid‐tolerant neonates were anaesthetized using pancuronium and a mixture of propofol (PROP) and ketamine (KET). Three mg of KET were added per ml (10 mg) of PROP in a single syringe and infused at a rate of 100–150 μg·kg−1·min−1 of the PROP component (30–45 μg·kg−1·min−1 KET). Total doses of 12–15 and 3.6–4.5 mg·kg−1 of PROP and KET, respectively, were administered. Both patients remained haemodynamically stable throughout their surgical procedures. PROP‐KET is a rational and effective combination for intravenous anaesthesia in critically ill neonates who are likely to be opioid‐tolerant when an anaesthesia vaporizer is not readily available.
Morphine with or without a local anaesthetic for postoperative intrathecal pain treatment after selective dorsal rhizotomy in children
Authors: Hesselgard K. , Strömblad L.G. , Reinstrup P.
Published: March 2003

Selective dorsal rhizotomy is a surgical procedure with a selective division of posterior spinal nerve rootlets to treat spasticity in children. The extensive surgical procedure with multilevel laminectomies and the nerve root manipulation result in intense pain postoperatively. Two intrathecal (IT) regimes of pain treatment were compared in these children, concerning their pain relief and possible side‐effects. In a prospective study, 12 children (3–6 years of age) with six in each group, received either intermittent IT morphine (5 μg·kg−1 four times a day) or continuous infusion of a mixture of bupivacaine (40 μg·kg−1·h−1) and morphine (0.6 μg·kg−1·h−1). Pain score was lower in the bupivacaine/morphine group (0.2 ± 1.1) compared to intermittent morphine (2 ± 2.4) on a scale from 0 to 6 (P ≤ 0.0001). Bupivacaine/morphine resulted in a lower, but not significant, difference in pruritus and lower muscle spasm. Haemodynamic and ventilatory parameters did not differ between the groups. Intrathecal continuous infusion of bupivacaine and morphine was superior to intermittent morphine in the treatment of pain after selective dorsal rhizotomy operations.
Anaesthetic management for a patient with Dejerine‐Sottas disease and asthma
Authors: Huang Jianhong , Soliman Iris
Published: March 2003

Dejerine‐Sottas disease is a very uncommon degenerative disease of the peripheral nervous system. The details of perioperative anaesthetic management are discussed including the use of epidural anaesthesia, with supplemental intravenous anaesthesia and an LMA.
A comparison of the respiratory effects of high concentrations of halothane and sevoflurane
Authors: Walpole R. , Olday J. , Haetzman M. , Drummond G.B. , Doyle E.
Published: March 2003

We studied the respiratory effects of the administration of either 5% halothane or 8% sevoflurane in 70% nitrous oxide (N2O) for 5 min in 21 boys aged 1–5 years. A similar degree of ventilatory depression was noted with both agents. Minute volume fell by approximately 50% as a result of a reduction in tidal volume despite an increase in respiratory rate.
Mediastinal mass obscured by a large pericardial effusion in a child: a potential cause of serious anaesthetic morbidity
Authors: Dilworth K.E. , McHugh K. , Stacey S. , Howard R.F.
Published: March 2003

Anaesthesia in the presence of a mediastinal mass is known to be hazardous. We report a case of a 5‐year‐old boy with a presumed postviral pericardial effusion presenting for pericardiocentesis under general anaesthesia. Cardiorespiratory collapse following induction of anaesthesia occurred due to an undiagnosed mediastinal tumour. The reasons for misdiagnosis, mechanisms for perioperative complications and optimal management are discussed. Mediastinal masses and underlying malignancy should always be considered in patients with large pericardial effusions.
Review of ethics in paediatric anaesthesia: research issues
Authors: Edgar J. , Morton N. S. , Pace N. A.
Published: March 2003

This is the second of a series of three articles reviewing the recent changes in the law in relation to ethics and the practice of paediatric anaesthesia. The review covers, in a practical question and answer format, the topics of consent, research, intensive care issues and organ donation in children.
Determination of the median effective concentration (EC50) of propofol during oesophagogastroduodenoscopy in children
Authors: Hammer Gregory B. , Litalien Catherine , Wellis Vinit , Drover David R.
Published: March 2003

Background: Propofol is commonly used to provide anaesthesia for children undergoing oesophagogastroduodenoscopy (OGD). Despite this, the plasma concentration–response relationships for propofol used in this setting have not been established.

Methods: In order to determine the EC50 of propofol during OGD, we studied 12 children aged 3–10 years. No premedication was given. Propofol was administered via a target‐controlled infusion system using the STANPUMP software based on a paediatric pharmacokinetic model. The ‘up‐and‐down’ method described by Dixon was used to determine the EC50. Accordingly, the target plasma propofol concentration for each patient, beginning with the second subject, was determined by the response of the previous patient. A patient was considered a ‘responder’ if there was minimal movement and the heart rate (HR) and blood pressure (BP) remained ≤ 120% of baseline during the procedure. Patients who moved excessively, i.e. requiring more than gentle restraint, or who manifest HR and BP >120% of baseline, were considered ‘nonresponders’.

Results: The EC50 of propofol during OGD was 3.55 μg·ml–1 in this study.

Conclusions: The plasma propofol concentration associated with adequate anaesthesia for OGD in 50% of unpremedicated children is 3.55 μg·ml–1. This concentration is higher than that required for OGD in adult patients.
Management of general anaesthesia in infants and children with a history of idiopathic pulmonary haemorrhage
Authors: Tripi Paul A. , Thomas Susan , Dearborn Dorr G.
Published: March 2003

Background: Idiopathic pulmonary haemorrhage in infants is a rare disorder that is endemic to metropolitan Cleveland, Ohio. Since 1993, 32 infants with this disorder were diagnosed and treated at our institution, one of them after developing pulmonary haemorrhage during induction of anaesthesia. Of this population, five patients have undergone a total of 10 general anaesthetics at some time after the initial diagnosis of pulmonary haemorrhage.

Methods: We performed a retrospective chart review of these cases to identify whether any risk factors for anaesthesia‐related morbidity were present, to review the anaesthetic technique and to identify morbidity related to residual underlying pulmonary disease.

Results: No patients experienced any anaesthesia related complication nor any perioperative respiratory problem.

Conclusions: These data may be useful to anaesthesiologists in other geographical locations since this disorder has been reported in other parts of the USA, and presumably may exist in other areas of the world.
The introduction of a paediatric anaesthesia information leaflet: an audit of its impact on parental anxiety and satisfaction
Authors: BELLEW M. , ATKINSON K.R. , DIXON G. , YATES A.
Published: March 2003

Background: A paediatric anaesthesia information leaflet was produced to address preoperative parental anxiety and to facilitate informed parental consent.

Methods: An audit was undertaken to assess the impact of introducing the leaflet. This addressed the information needs and expectations of parents of children undergoing anaesthesia, parental satisfaction with information provision and parental preoperative anxiety.

Results: The audit revealed that parents expect to be provided with information, although not necessarily in written form. However, the majority who received the information leaflet concluded that verbal information alone would not have been sufficient. The information leaflet was found to be accessible, informative and useful and those who received it reported greater satisfaction with information provision than a control group. Many parents perceived that it resulted in lower levels of preoperative anxiety.

Conclusions: A decision was therefore undertaken that routine use of the leaflet would continue on all of the paediatric surgical wards. However, the study also indicated that leaflets should not replace verbal communication with nursing and medical staff, who remain important sources of information.
Ilioinguinal and iliohypogastric nerve block revisited: single shot versus double shot technique for hernia repair in children
Authors: Lim Suan‐Ling , SB Agnes NG , Tan Geok‐Mui
Published: March 2003

Background: We attempted to determine the efficacy of a one plane ilioinguinal and iliohypogastric nerve block with a single shot and double shot techniques.

Methods: In a randomized single blind study, 90 children, aged 2–12 years, received a single shot (SS) or a double shot (DS) technique for ilioinguinal and iliohypogastric (IG–IH) nerve block for inguinal hernia repair. In the SS group, 0.25 ml·kg–1 of 0.25% bupivacaine was given one fingerbreadth medial to the anterior superior iliac spine under the external oblique aponeurosis. In the DS group, one‐third of the total dose of bupivacaine was given as for the SS group. The remaining two‐thirds was deposited 0.5 cm above and lateral to the mid‐inguinal point deep to the external oblique aponeurosis.

Results: The success rates of both techniques were similar, at 72%, although the presence of local anaesthetic in the inguinal canal was significantly higher with the DS technique. The incidence of femoral nerve block was 4.5% with the SS and 9% with the DS technique (P > 0.05). Parental satisfaction with postoperative pain relief was high, at 94%.

Conclusions: The DS technique, while technically more difficult, does not improve the success rate of the IG–IH nerve block compared with the SS technique.
An unexpected difficult laryngoscopy
Authors: De Beer D.A.H. , Williams D.G. , Mackersie A.
Published: March 2003

Summary A case of unexpected difficult laryngoscopy in a patient with gross hydrocephalus and generalized hypertonus is described. The 30‐month‐old girl had no antecedent history of such difficulty, having had two recent uneventful anaesthetics. We suggest that the reason for our inability to open the patient's mouth was a result of contracture of the temporalis muscle. The patient was managed using a laryngeal mask airway with controlled ventilation.
Venous air embolus during arthrography in a child: vital signs changes illustrated by the automated data recording system
Authors: KEIDAN ILAN , GIVON URI , BERKENSTADT HAIM , PEREL AZRIEL
Published: March 2003

We describe an 18‐month‐old boy who suffered venous air embolism during an arthrogram. Dangers associated with air injection are emphasized, illustrating the importance of careful monitoring to detect adverse events. We recommend caution when employing this method of hip joint evaluation.
Epidural anaesthesia in a child with possible spinal muscular atrophy
Authors: Veen A. , Molenbuur B. , Richardson F.J.
Published: March 2003

Spinal muscular atrophy (SMA) is a rare lower motor neurone disease in which anaesthetic management is often difficult as a result of muscle weakness and hypersensitivity to neuromuscular blocking agents. Neuraxial anaesthesia is controversial in these patients; however, some cases have been reported in which neuraxial anaesthesia has been used without neurological sequelae. We describe a 7‐year‐old patient with possible SMA scheduled for a Grice‐arthrodesis. Because of previous prolonged postoperative drowsiness and poor oral intake, we decided to use an epidural technique with sevoflurane sedation and spontaneous ventilation to avoid the use of muscle relaxants and systemic opioids and consequently admission to the intensive care unit. After 3 days, the epidural analgesia was stopped and the patient regained her preoperative motor function within 5 h. Despite the controversy surrounding the use of neuraxial techniques in neuromuscular disease, we found no well‐founded basis for this in patients with SMA in the literature.
Severe anaphylactic shock without exanthema in a case of unknown latex allergy and review of the literature
Authors: Hollnberger H. , Gruber E. , Frank B.
Published: March 2003

We describe a case of severe anaphylactic shock without exanthema in an 8‐year‐old boy who was undergoing elective surgery for an ileostomy. The boy had a history of four anorectal operations in the newborn period, but no history of allergies. Sudden, profund bronchospasm and cardiorespiratory collapse occurred 30 min after the beginning of the operation. No signs of exanthema or urticaria were seen. The patient was resuscitated successfully and remained ventilated for 25 h. During this time, he needed epinephrine in dosages of 0.3–0.05 μg·kg−1·min−1. Radioallergosorbent (RAST) tests for the patient were positive Cap Class 3 and 4, and specific immunoglobulin E was highly positive, suggesting a natural rubber latex allergy as the cause of the anaphylactic shock. Ethylene oxide was negative. Eleven days later, a further operation was performed with a strict latex‐free protocol in the presence of histamine 1 and 2 receptor antagonists. On this occasion, the intraoperative course was uneventful. Incidence of anaphylactic reactions, prevalence of latex sensitization, special risk groups and management are discussed.
Prediction of tracheal tube size in children using multiple variables
Authors: Eck John B. , De Lisle Dear Guy , Phillips‐Bute Barbara G. , Ginsberg Brian
Published: March 2003

Background: Tracheal tube (TT) size selection in children is important to avoid complications. Formulae utilizing age and physical characteristics to predict appropriate tube size are not entirely predictive.

Methods: Using an automated anaesthesia record keeper database, the anaesthetic records of 8504 children, aged up to 7 years, who required tracheal intubation, were reviewed. Age, height and weight data were related to TT size. The total number of patients whose age, height and weight were independently available was 8396, 3929 and 7823, respectively. The number having all three variables was 3814. A linear regression analysis was performed for patients with all three variables and for each variable individually.

Results: Tracheal tube size is best predicted using multivariate analysis and, for any child aged up to 7 years, is represented by the formula: 2.44 + (age × 0.1) + (height × 0.02) + (weight × 0.016). Formulae utilizing these variables individually are also reviewed.

Conclusons: Prediction of TT size is best accomplished using multiple variables. Further prospective study is suggested.
Mivacurium infusion requirement and spontaneous recovery of neuromuscular transmission in children anaesthetized with nitrous oxide and fentanyl, halothane, isoflurane or sevoflurane
Authors: Woloszczuk‐Gebicka B.
Published: March 2003

Background: Forty children, aged 3–11 years, ASA I or II, were allocated at random to receive N2O/O2–fentanyl or 1 MAC halothane, isoflurane or sevoflurane–N2O/O2 anaesthesia. Mivacurium was used for muscle relaxation.

Methods: Electromyographic response of the adductor pollicis to train‐of‐four (TOF) stimulation, 2 Hz for 2 s, applied to the ulnar nerve at 10‐s intervals was recorded using the Relaxograph (Datex, Helsinki, Finland). An intubating dose of mivacurium, 0.2 mg·kg–1 was given, and when T1 returned to 5%, muscle relaxation was maintained by continuous infusion of mivacurium, adjusted manually to maintain a stable 90–99% block.

Results: Halothane, isoflurane and sevoflurane groups had lower infusion requirements for mivacurium than the N2O–fentanyl group (P=0.000083). Mivacurium requirement was 18.8 ± 6.8, 10.8 ± 4.2, 6.9 ± 3.9 and 9.6 ± 5.6 μg·kg–1·min–1 for children receiving N2O/O2–fentanyl, halothane, isoflurane and sevoflurane anaesthesia, respectively.

Conclusions: Spontaneous recovery from T1=10% to TOF ratio=0.7 was insignificantly prolonged from 6.3 to 12.5 min in the fentanyl group to 7–16.5 min in children anaesthetized with inhalational anaesthetics.
Effect of ilioinguinal nerve block on the catecholamine plasma levels in orchidopexy: comparison with caudal epidural block
Authors: Somri Mostafa , Gaitini Luis A. , Vaida Sonia J. , Yanovski Boris , Sabo Edmond , Levy Nurit , Greenberg Avital , Liscinsky Sofia , Zinder Oren
Published: March 2003

Summary Background: Both caudal epidural and ilioinguinal/iliohypogastric nerve blocks have been used to provide effective intra‐ and postoperative analgesia. Stress response hormone levels can be used as an objective method to assess the analgesic efficacy of the anaesthetic techniques used in infraumbilical surgery in children. In this study, we compared catecholamine blood levels in children undergoing these two different supplementary analgesic/anaesthetic techniques.

Methods: Thirty male paediatric patients undergoing orchidopexy, ASA I, received inhalation general anaesthesia, and were randomly allocated to one of two groups: a caudal group (n = 15) and an ilioinguinal/iliohypogastric nerve block group (n = 15). Plasma epinephrine and norepinephrine concentrations were measured at the induction time, at the end of surgery, and in the postanaesthesia care unit. Postoperative pain score was also assessed in the postanaesthesia care unit.

Results: In both groups, there was a substantial decrease in the catecholamine blood levels; however, there were significantly higher levels of epinephrine in the ilioinguinal group at the end of surgery (P = 0.008) and in the recovery room (P = 0.02) and a significant higher level of norpinephrine in the recovery room (P = 0.008).

Conclusions: The result of this study revealed that caudal epidural block was more effective than ilioinguinal block in suppressing the stress response as reflected in epinephrine and norepinephrine blood levels in orchidopexy patients.
Anaesthetic management of children with tuberous sclerosis
Authors: Shenkman Ze'ev , Rockoff Mark A. , Eldredge Elizabeth A. , Korf Bruce R. , Black Peter Mch. L. , Soriano Sulpicio G.
Published: March 2003

Summary Background: Tuberous sclerosis (TS) is a hamartomatous disease that usually presents with cutaneous and intracranial lesions, but can also affect other organ systems.

Methods: In this report, we retrospectively reviewed the perioperative course of 24 children with TS who had medically intractable seizures as the primary disease process.

Results: Cardiac rhabdomyoma was detected in 11 of 18 patients who had a cardiac evaluation, and coexisting congenital heart defects were diagnosed in six. Ten of 17 patients who had a renal evaluation were diagnosed with renal TS, presenting with azotaemia in one and hypertension in four. The major perioperative complications in the 52 anaesthetics, included death (a neonate after cardiac rhabdomyoma resection), seizures (five patients) and bradyarrhythmias (two patients).

Conclusions: Patients with TS and neurological disorders frequently have coexisting cardiac and renal disease as well. Patients with TS should be evaluated for these organ specific disorders prior to surgery.
Risk factors for airway complications during general anaesthesia in paediatric patients
Authors: Bordet Fabienne , Allaouchiche Bernard , Lansiaux Sabine , Combet Sylvie , Pouyau Agnes , Taylor Patricia , Bonnard Corinne , Chassard Dominique
Published: March 2003

Summary Background: Although airway complications are a frequent problem during paediatric anaesthesia, no study has prospectively identified risk factors for adverse respiratory events during airway management when LMA™ (laryngeal mask airway), face mask (FM) or a tracheal tube (TT) are used.

Methods: A prospective study was performed at a university hospital's paediatric centre. Preoperative information included recent history of respiratory infection and type of surgery. Intraoperative information included the identification of the device user, the duration of anaesthesia and the type of airway device used. Adverse respiratory events during the perioperative and postoperative periods were registered. One thousand nine hundred and ninety‐six patients were included (mean age 6.45 ± 2.9 years).

Results: Airway complications occurred in 10.2% of the patient for LMA (72/704), 4.7% for FM (19/401) and 7.4% (66/891) for TT. Using a stepwise logistic regression, three independent risk factors were identified: age < 6 years, odds ratio (OR) 1.84, 95% CI (1.21–2.80); use of LMA, OR 2.32, 95% CI (1.29–4.17); presence of respiratory infections (RI) before the procedure, OR 3.72, 95% CI (2.3–5.99).

Conclusions: Age < 6 years, recent RI and the use of the LMA were identified as independent factors associated with an increased risk of airway complications.
Remifentanil vs fentanyl/morphine for pain control during paediatric cardiac surgery
Authors: Bell G.T. , Dickson U. , Arana A. , Marshall C. , Robinson D. , Morton N.S.
Published: March 2003

Introduction  Remifentanil is a potent synthetic opioid that does not accumulate after infusion or repeated bolus doses. It may be rapidly titrated to the requirements of individual patients. Remifentanil has potential advantages for paediatric cardiac surgery in being able to provide potent analgesia required to blunt the stress response in theatre and a lack of prolonged sedative affects that may delay progress in intensive care.

Methods  After approval by the local ethics committee, 18 patients were randomised to receive a titrated infusion of remifentanil (0–1 mcg.kg.min−1) or a standard dose of fentanyl (30 mcg.kg−1) pre‐bypass with morphine (1 mg.kg−1) on rewarming. The anaesthetic technique aside from analgesia was that normally used by the consultant anaesthetist responsible for the case. Blood samples for glucose and cortisol were taken at regular intervals from induction through bypass and into the first 24 hours of postoperative intensive care. Urine samples taken over the same period were analysed for 3 methythistidine:creatinine ratios. In addition to biochemical indicators of the stress response we recorded baseline haemodynamic parameters and any acute physiological events.

Results  Statistical analysis is not yet complete – initial analysis shows that both techniques obtunded the stress response to a very similar extent.

Ten patients were randomised to receive morphine and eight to receive remifentanil (there were late cancellations in the remifentanil group). One patient was withdrawn from the remifentanil group for a protocol violation.

There were two incidences of inadequate analgesia in the remifentanil group one related to rapid haemodilution going onto cardiopulmonary bypass and a second as a consequence of an infusion line kinking.

Discussion and conclusions  Although it was our original intention to continue remifentanil up to 24 hours postoperatively, this was only achieved in four out of the seven remifentanil patients due either to discharge to the ward or to difficulty in titration of an appropriate dose for spontaneously breathing patients in intensive care. In our unit it became appropriate to start a morphine infusion to replace remifentanil within the first few hours of PICU admission.

The episode of inadequate analgesia going on to bypass occurred when remifentanil was infusing at 1 mcg.kg.min−1 which illustrates high inter‐individual variation. The other episode when a peripheral line kinked emphasises the importance of line patency and we would recommend that infusions are given centrally to help ensure adequate delivery.
Comparison of the work of breathing imposed by three anaesthetic breathing systems in children
Authors: Shenoy V. , Meakin G.H. , Masterson J.J.
Published: March 2003

Introduction  There is concern that the resistance of the valves in circle systems may impose an unacceptable respiratory load in children (1). In this study we compared the work of breathing imposed by the Bain, Jackson Rees and the circle systems in anaesthetised spontaneously breathing children.

Methods  Following local ethics committee approval and the written informed consent of a parent, 12 children, aged 2–6 years, ASA grades I–II scheduled for routine genital surgery (e.g. circumcision) were recruited [Weight 14.4 ± 2.9 kg and age 3.02 ± 1.3 years (meant SD)]. Patients were premedicated with midazolam 0.5 mg·kg−1. Anaesthesia was induced by inhalation of 66% N2O in O2 and sevoflurane 8%, and the trachea was intubated. Caudal analgesia was provided using bupivacaine 0.25% in a dose of 0.5 mg·kg−1. Anaesthesia with spontaneous ventilation was maintained with 66% N2O in O2, and sevoflurane 2–4%. Routine monitoring consisted of ECG, pulse oximetry, capnography and non‐invasive blood pressure.

When anaesthesia had been stable for at least 15 min, the patients were attached to three different breathing systems in random succession for 10 min: 1, a Circle (Draeger Julian); 2, a Bain; 3, a Jackson Rees system. At the end of these 10 min periods, work of breathing was measured using a computerised, portable respiratory monitor (CP‐100 Pulmonary Monitor, Bear Medical). Work of breathing (W) was calculated by measuring the area enclosed in the oesophageal pressure‐volume loop (2). Oesophageal pressure was measured using a disposable balloon catheter (Smartcath, Bear Medical) and flow was measured using a disposable flow transducer (Varflex, Bear Medical). All equipment was calibrated in accordance with the manufacturers instructions prior to use.

The total work of breathing (W) was expressed as Joules per litre of ventilation (J·l−1). This was compared between breathing systems using anova. P < 0.05 was considered statistically significant.

Results  The results are presented in Table 1.

Direct measurements and calculated variables (mean ± SD)

Circle
Bain
Jackson – Rees

Work of breathing  (J·l−1)
0.34 ± 0.1
0.36 ± 0.07
0.34 ± 0.09

Peak inspiratory flow rate  (l·s−1)
0.19 ± 0.03
0.20 ± 0.04
0.20 ± 0.04

Peak expiratory flow rate  (l·s−1)
0.16 ± 0.03
0.14 ± 0.03
0.16 ± 0.03

Δ Poes(cmH2O)
5.5 ± 2.71
6.3 ± 1.49
5.9 ± 1.83

Minute ventilation  (l·min−1)
2.9 ± 0.6
2.8 ± 0.7
2.9 ± 0.6

End‐tidal CO2 (kPa)
7.8 ± 0.9
7.7 ± 0.9
7.0 ± 2.4

Δ Poes = difference between end‐expiratory oesophageal pressure and lowest oesophageal pressure.

Conclusions  Our results indicate that there was no difference in the total work of breathing in children attached to a circle system compared to a Bain or Jackson Rees systems.

Acknowledgements  This work was supported by a grant from Draeger UK Ltd.
Anaesthetic management in McKusick–Kaufman syndrome
Authors: Tekin Idil , Ok Gulay , Genc Abdulkadir , Tok Demet
Published: March 2003

Summary The cardinal features of McKusick–Kaufman syndrome (MKS) are polydactyly and hydrometrocolpos. Sometimes, this abdominopelvic mass may restrict pulmonary function and decrease the oxygenation of the newborn. We present a case of MKS and review the clinical features and appropriate anaesthetic management. A 45‐day‐old girl, weighing 4450 g, born at term, presented to our Paediatric Surgery Department with abdominal distention, diarrhoea and vomiting, which started on the 15th day of life. On physical examination, peripheral cyanosis, tachycardia and tachypnoea were found. A prominent mass was palpated in the lower abdomen. There was vaginal atresia and a sixth digit was found on her left foot. There was a large cystic mass extending from the pelvis to the level of L1 displacing the diaphragm, and bilateral hydroureteronephrosis were seen on plain abdominal X‐ray, ultrasonography and computerized tomography. In the preanaesthetic assessment, the patient was evaluated for multiple congenital anomalies. Our management of anaesthesia, for a neonate with severe hydrometrocolpos compressing the diaphragm, consisted of gastric decompression and preoxygenation before tracheal intubation, routine and airway pressure monitoring, periodic analyses of blood gases and maintenance of anaesthesia with a low concentration of volatile agent, together with an opioid.
Functional MRI as a tool to assess vision in dogs: the optimal anesthetic
Authors: Willis Craig K. R. , Quinn Richard P. , McDonell Wayne M. , Gati Joseph , Parent Joane , Nicolle David
Published: March 2003

Functional magnetic resonance imaging (fMRI) is a recent advance in neuroimaging that provides a picture of brain activity with excellent spatial resolution. Current methods used to evaluate canine vision are poorly standardized and vulnerable to bias. Functional MRI may represent a valuable method of testing vision in dogs if the impacts of anesthesia on fMRI are understood. Six dogs were scanned during visual stimulation, each under three different anesthetic protocols (isoflurane, propofol, fentanyl/midazolam) to address the questions: (1) Can visually evoked fMR signals be reliably recorded in anesthetized dogs? and (2) Which anesthetic agent permits the least suppression of visually induced fMR signal in dogs? This study confirms that visual stimuli reliably elicit neural activity and fMR signal change in anesthetized dogs. No significant differences in images acquired under the three anesthetics were found, and there was no significant relationship between anesthetic dose and brain activity, within the range of doses used in this study. Images obtained during isoflurane anesthesia were more consistent between dogs than those obtained with the other two agents. This reduced variation may reflect the fact that inhalant anesthesia is more easily controlled than intravenous anesthesia under conditions associated with high field fMRI.
Respiratory function and extraocular muscle paralysis following administration of pancuronium bromide in dogs
Authors: Sullivan T.C. , Hellyer P.W. , Lee D.D. , Davidson M.G.
Published: March 2003

Pancuronium bromide, a neuromuscular blocking agent, was evaluated in canine cataract surgical patients under general anesthesia to determine its effects on respiratory function and globe position. Two paralytic, anesthetic regimes were studied: one using a standard dosage of 0.066 mg kg−1 pancuronium bromide, given intravenously while providing the patient with ventilatory support, and one using a dosage of 0.022 mg kg−1 in which no ventilatory support was provided. Eye position and anterior vitreal position/displacement were recorded by a surgeon who was blinded as to treatment group. Physiological parameters indicative of respiratory function were monitored. Both dosages of pancuronium produced comparable, neutral globe position within 30 s following administration which lasted for 20–30 min. All patients in the standard dose group experienced uneventful anesthetic episodes with physiological parameters well within the normal ranges. Within 5 min after administration, all patients in the low‐dose group developed a pronounced respiratory acidosis (mean arterial pH = 7.07 ± 0.08; mean PaCO2 = 79.8 ± 10.7 mmHg), which exceeded a set of predetermined safety limits, and subsequently these dogs received ventilatory support. We conclude that 0.022 mg kg−1 pancuronium rapidly produces an unacceptable level of respiratory acidosis and, as a result, patients receiving neuromuscular blocking agents should routinely receive ventilatory support.
Use of nested polymerase chain reaction (PCR) for detection of retroviruses from formalin‐fixed, paraffin‐embedded uveal melanomas in cats
Authors: Stiles  , Bienzle  , Render  , Buyukmihci  , Johnson
Published: March 2003

Thirty‐six formalin‐fixed, paraffin‐embedded enucleated globes from cats with a diagnosis of diffuse anterior uveal melanoma were obtained. Sections of tumor were excised, deparaffinized, and subjected to nested polymerase chain reaction (PCR) to identify proviral DNA sequences from the feline leukemia virus (FeLV)–feline sarcoma virus (FeSV; 36 eyes), and the feline immunodeficiency virus (FIV; 18 eyes). All samples tested were negative for FIV DNA. Three samples were positive for FeLV–FeSV DNA. This is the first reported evidence of a possible link between naturally occurring feline anterior uveal melanoma and the presence of FeLV–FeSV DNA.
Bacterial and fungal pathogens isolated from corneal ulcerations in domesticated elephants (Elephas maximus maximus) in Sri Lanka
Authors: Kodikara  , De Silva  , Makuloluwa  , De Silva  , Gunatilake
Published: March 2003

Infective corneal diseases are common among the domesticated elephants in Sri Lanka, causing morbidity including blindness leading to loss of revenue to their owners. From 140 elephants of different ages and both sexes, 36 animals (25.7%) had evidence of keratitis, corneal ulcers, corneal opacities, and some had foreign bodies in their eyes. Nine elephants (6.4%) had lesions in both eyes (6.41%). Cultures for both bacteria and fungi were obtained from 26 corneal ulcers, including the nine elephants with bilateral lesions. The other 10 animals could not be restrained for sample collection. Swabs from the normal corneas of an additional 20 elephants without signs of any ophthalmic diseases were also collected. Twenty‐three of the 35 (65.71%) samples from affected corneas yielded bacterial pathogens, and 14 (40%) also had fungal isolates. None of them yielded a fungal isolate alone. The predominant bacteria isolated were Staphylococcus aureus, beta hemolytic streptococci and coliforms. Fusarium, Cladosporium, Curvularia and Aspergillus species were the primary fungal isolates. No bacteria or filamentous fungi were isolated from the eyes with the normal corneas. Microbial identification including fungal isolations is suggested in the management of infective corneal diseases in elephants.
Lipogranulomatous conjunctivitis: clinical findings from 21 eyes in 13 cats
Authors: Read Robert A , Lucas Julia
Published: March 2003

Objective The clinical and, where available, histologic features of lesions fitting a previous description of lipogranulomatous conjunctivitis were reviewed retrospectively from a series of cats.

Animals studies

Thirteen cats (21 eyes) with lesions consistent with a diagnosis of lipogranulomatous conjunctivitis were seen over a 4‐year period in a referral practice in southern Australia. Affected cats ranged in age from 6 to 16 years (mean 11.2 ± 3.6 years).

Results

Twelve cats were domestic shorthair or longhair cats and one was a British shorthair cat. Five cats were white, four were bicolor, two were orange tabby and two were dilute orange tabby. Lesions were always found in the palpebral conjunctiva, adjacent to the eyelid margin. They affected upper eyelids only in five cases, and upper plus lower eyelids in eight cases. Lesions were bilateral in eight cases. Lesions were excised in eight cases, with resolution of associated irritation and no signs of lesion recurrence during a 4‐ to 21‐month follow‐up period.

Histologic features of tissues excised from surgically treated cases were consistent with a previous report of lipogranulomatous conjunctivitis and with descriptions of chalazia. A possible role of actinic radiation in the etiopathogenesis of lesions is discussed.
Treatment of granulomatous meningoencephalomyelitis in a dog
Authors: Nuhsbaum M. Tanja , Powell Cynthia C. , Gionfriddo Juliet R. , Cuddon Paul A.
Published: March 2003

The clinical work‐up, diagnosis and follow‐up of an 8‐year‐old, female‐spayed Shih Tzu with diffuse, granulomatous meningoencephalomyelitis (GME)‐causing visual deficits is reported. The use of cytosine arabinoside as an alternative treatment for GME is discussed.