bluuebunny/crossref_metadata_2025 huggingface dataset:
Oesophageal perforation presenting as oesophageal atresia in a premature neonate following difficult intubation
Authors: Seefelder C. , Elango S. , Rosbe K.W. , Jennings R.W.
Published: March 2003

Iatrogenic oesophageal perforation in neonates is well recognized in the medical and surgical literature with intubation injury listed as a possible contributing mechanism besides nasogastric tube placement and suctioning. Diagnosis can be difficult and sometimes confused with other entities. With early diagnosis, nonsurgical management often leads to complete resolution in neonates. We report the case of a 1‐day‐old premature neonate who was brought to the operating room with the preliminary diagnosis of proximal oesophageal atresia with stump perforation and distal tracheo‐esophageal fistula. His intubation for respiratory distress at birth had been difficult due to Pierre–Robin sequence with micrognathia. Oesophagoscopy in the operating room revealed a patent oesophagus but perforations in the pharynx and in the proximal oesophagus with the nasogastric tube entering the pharyngeal perforation. Oesophageal perforation and the limitations of the difficult airway algorithm in small neonates are discussed.
Parental perceptions of comfort during mechanical ventilation
Authors: Playfor Stephen D. , Thomas David A. , Choonara Imti , Collier Jacqueline , Jarvis Anita
Published: March 2003

There are no reports of the parental perceptions of comfort during the mechanical ventilation of children. We have assessed the quality of sedation in 28 mechanically ventilated children and compared these results to an overall parental assessment of comfort, obtained by postal questionnaire. There was no correlation between the parental assessment of comfort and the paediatric intensive care unit (PICU) staff satisfaction with the level of sedation. Parental assessment of comfort was positively correlated with the duration of ventilation, whilst PICU staff satisfaction was positively correlated with the age of the child. Parents appear to become more satisfied with the degree of comfort of their children as the duration of mechanical ventilation increases, which is an effect that may have an important bearing on communication between parents and health professionals. Our results also suggest that the commonly used sedation regime of midazolam and morphine is less effective in younger children.
Postoperative epidural analgesia with bupivacaine and fentanyl: hourly pain assessment in 348 paediatric cases
Authors: Lejus Corinne , Surbled Marielle , Schwoerer Didier , Renaudin Mariette , Guillaud Christian , Berard Luc , Pinaud Michel
Published: March 2003

Background: The objective of this prospective study was the evaluation of the analgesia provided by an epidural infusion of bupivacaine and fentanyl after different types of surgery in children.

Methods: Data were collected from 348 epidural analgesia in 87 children below 2 years of age, in 80 children between 2 and 6 years and 181 above 6 years of age, for a median duration of 43 postoperative hours. Bupivacaine (mean concentration 0.185%) and fentanyl (5 μg·kg−1·day−1) were administered on the surgical ward.

Results: Pain control was considered excellent in 86% of the 11 072 pain hourly assessments. Analgesia was found to be better for children older than 2 years, and the overall quality of their night’s sleep was better than that of older children. Higher pain scores were noted for Nissen fundoplication surgery and club foot repairs. Early discontinuation rarely occurred, and only because of technical problems with the epidural catheter (4%) or insufficient analgesia (6%). Complications were minor (nausea/vomiting 14%, pruritus 0.6%, urinary retention 17%) and easily reversed.

Conclusions: This combination of bupivacaine–fentanyl provides safe analgesia after major surgery in children with frequent clinical monitoring. Regular pain assessments of intensity and duration are useful to improve the quality of postoperative analgesia.
A study of epidural pressures in infants
Authors: Vas Lakshmi , Raghavendran Shreekrishna , Hosalkar Hetal , Patil Bharati
Published: March 2003

Background: The pressures exerted on fragile structures in the infant during epidural injections have never been studied previously.

Methods: We measured the pressure changes in the epidural space of 20 infants during injection of local anaesthetic solutions. The pressures developed during passage of the epidural needle through the ligaments of spine and in the epidural space during the injection of 1 ml at two rates of injection, over 1 and 2 min and the residual pressure 1 and 2 min after each injection were studied.

Results: The mean pressure while the needle was being advanced through the ligamentum flavum was 69.14 ± 36.95 mmHg. The epidural pressure after needle had just penetrated the ligament without eliciting the loss of resistance was 1 ± 9.759 mmHg. A distinct pulsatile waveform identical to the pulse waveform was observed as soon as the epidural space was entered. The pressure rise varied according to the rate of injection. The pressures were 27.79 mmHg when the rate of injection was 1 ml·min–1, with a residual pressure after 1 min of 12 ± 5.53 mmHg and 10.14 ± 5.53 mmHg after 2 min of injection. When the rate of injection was 1 ml·2 min–1, the pressures were 15.66 ± 9.48 mmHg with a residual pressure after 1 min of 14.79 ± 5.15 mmHg and 12.93 ± 5.46 mmHg after 2 min of injection.

Conclusions: The residual pressures seem to vary more with the volume injected than the rate of injection or the pressures developed during the injection. The relationship between the rate of injection and pressures is significant when compared with adults where the pressures have been measured after an injection rate of 1 ml·s–1 and 1 ml·5 s–1. This is a very fast rate compared with our rates of injection of 1 ml over 1 and 2 min. Based on the findings of this study, we recommend a rate of 1 ml·2 min–1 in infants. In neonates, a slower rate of injection would be preferable.
Anaesthetic management and high frequency oscillatory ventilation
Authors: Tobias Joseph D. , Burd Randall S.
Published: March 2003

In an effort to decrease morbidity and mortality, newer modes of mechanical ventilation have been introduced into the critical care arena. One such technique, high frequency oscillatory ventilation (HFOV) relies on respiratory rates greater than 150 b·min−1, small tidal volumes, and the maintenance of a constant distending pressure thereby limiting peak inflating pressure and potentially the incidence of barotrauma. Despite the frequent application of this technique in the ICU setting, there is limited information concerning its intraoperative use. We present three infants who represent the perioperative applications of HFOV: (i) elective preoperative use to minimize lung movement and interference with surgical exposure during thoracotomy and PDA ligation; (ii) intraoperative application when progressive alterations in respiratory compliance led to ineffective intraoperative ventilation/oxygenation; and (iii) anaesthetic care for a neonate already receiving HFOV. The techniques of HFOV and previous reports of perioperative use are reviewed.
Complicated airway management in a child with prune‐belly syndrome
Authors: Bariş Sibel , Karakaya Deniz , Üstün Emre , Tür Ayla , Rizalar Riza
Published: March 2003

We describe a 15‐month‐old boy with prune‐belly syndrome (PBS) in whom airway management was complicated. Following an inhalation induction using sevoflurane, tracheal intubation by direct laryngoscopy proved impossible after repeated attempts. A laryngeal mask airway (LMA™) was inserted and the child had an uneventful anaesthetic course.
Difficult airway management of a child impaled through the neck
Authors: Melillo Edward P. , Hawkins David J. , Lynch Liam , Macnamara Aiden
Published: March 2003

We report the difficult airway management of a child impaled through the neck by a wooden plant support. The various options are discussed and the involvement of experienced personnel together with a clear preformulated plan of action is stressed.
A technique for maintenance of airway access in infants with a difficult airway following tracheal extubation
Authors: Hammer Gregory B. , Funck Natasha , Rosenthal David N. , Feinstein Jeffrey A.
Published: March 2003

Tracheal extubation of patients with a difficult airway represents a challenge to anaesthesiologists and intensive care physicians. While a variety of techniques designed to maintain access to the airway in case of the need for tracheal reintubation have been described in adults, no reports have been published in infants and young children. We describe an approach to this issue in a young child with severe micrognathia.
Prevention of vomiting after strabismus surgery in children: dexamethasone alone versus dexamethasone plus low‐dose ondansetron
Authors: Splinter William M.
Published: March 2003

Background: Postoperative vomiting is a common complication after strabismus surgery. The combination of dexamethasone and ondansetron decreases vomiting after strabismus surgery, while dexamethasone alone decreases vomiting after tonsillectomy in children. We compared the effect of dexamethasone alone to ondansetron plus dexamethasone on postoperative vomiting among children undergoing strabismus surgery.

Methods: Healthy children, aged 2–14 years, who were undergoing strabismus surgery were entered into this randomized, blocked and stratified study. Patients were administered 0.5 mg·kg−1 midazolam p.o., 20–30 min preoperatively when indicated. The patients had an intravenous induction with 2.5–3.5 mg·kg−1 propofol or an inhalation induction of anaesthesia with halothane and N2O. All patients were given 20 μg·kg−1 atropine i.v. Study drugs were administered in a double‐blind fashion. Both groups received 150 μg·kg−1 dexamethasone i.v. Group D patients received placebo and group OD received 50 μg·kg−1 of ondansetron i.v. Anaesthesia was maintained with halothane and N2O. Postoperative fluid, vomiting and pain management were standardized. Patients were followed for 24 h. We studied 193 patients with 111 patients in the OD group. Demographic data were similar.

Results: The overall incidence of vomiting was 23%; in group D and 5%; in group OD (P < 0.001). Each episode of vomiting increased the in‐hospital length of stay by 29 min (P < 0.001).

Conclusions: There was a remarkably low incidence of postoperative vomiting of 5%; with the combination of dexamethasone plus a low‐dose of ondansetron which more effectively decreased vomiting after strabismus surgery in children when compared with dexamethasone alone.
Use of albumin, blood transfusion and intraoperative glucose by APA and ADARPEF members: a postal survey
Authors: Söderlind M. , Salvignol G. , Izard P. , Lönnqvist P.A.
Published: March 2003

Background and methods: A postal survey was mailed to the members of Association of Paediatric Anaesthetists of Great Britain and Ireland (APA) (n=187) and French‐Language Society of Paediatric Anaesthesiologists (ADARPEF) (n=220) to primarily investigate the impact of a recently published Cochrane report on the clinical use of albumin solutions in paediatric anaesthetic practice. At the same time, information regarding blood transfusion strategies and the use of intraoperative glucose containing maintenance solutions was gathered.

Results: The response rate of the survey was 38% and 25% for APA and ADARPEF members, respectively. Forty‐one percent of APA members reported a reduced use of albumin containing solutions following the publication of the Cochrane report compared to eight percent in the ADARPEF group (P < 0.0001). Albumin continues to be the most frequently used plasma expander in premature babies and neonates, whereas many colleagues use alternative colloids in infants and older children. A clear difference was observed in the 1–12‐year‐old age group between APA members favouring the use of gelatines and ADARPEF members who instead frequently use hetastarch solutions. ADARPEF members appeared to have a slightly more restrictive attitude towards blood transfusion and also reported more widespread use of erythropoetin (56% versus 9%, P < 0.0001) and predilution techniques (40% versus 23%, P < 0.04) compared with APA members. Regarding intraoperative maintenance solutions, a large proportion of both APA and ADARPEF members still use high concentrations of glucose intraoperatively, even in older children.
A comparison of prilocaine and lidocaine for intravenous regional anaesthesia for forearm fracture reduction in children
Authors: DAVIDSON ANDREW J. , EYRES ROBERT L. , COLE WILLIAM G.
Published: March 2003

Background: In this prospective blinded randomized study, we compared prilocaine and lidocaine for intravenous regional anaesthesia for forearm fracture reduction in children.

Methods: Two hundred and seventy‐nine children, aged 3–16 years, were enrolled and randomly assigned to receive 3 mg·kg−1 of either prilocaine or lidocaine. The severity of fracture was classified according to the displacement of the radius (i.e., no radial fracture, angulated, partly displaced or completely displaced). Pain during the procedure was assessed as none, minimal, moderate or severe.

Results: There was no significant difference between agents in the proportion of patients with a successful reduction (prilocaine 94%, lidocaine 92%). Compared with less severe fractures, successful reduction was less common in the completely displaced fractures (P < 0.001) but there was no significant difference in this category between anaesthetic agents (successful reduction: prilocaine, 84%; lidocaine, 78%). Analgesia was superior in the lidocaine group with more patients having no or minimal pain (prilocaine, 78%; lidocaine, 90%, P < 0.05).

Conclusions: Both agents are effective for forearm fracture reduction in children with a high incidence of successful reductions, particularly in the minimally or nondisplaced fractures. Lidocaine provided superior analgesia.
Airway management in a baby with femoral hypoplasia–unusual facies syndrome
Authors: IOHOM GABRIELLA , LYONS BARRY , CASEY WILLIAM
Published: March 2003

We report the successful fibreoptic intubation through a laryngeal mask airway (LMATM) while maintaining spontaneous respiration in an anaesthetized 3‐month‐old female infant with femoral hypoplasia–unusual facies syndrome, in whom direct laryngoscopy and intubation proved impossible.
The size 1.5 Laryngeal Mask Airway (LMATM) in paediatric anaesthetic practice
Authors: BAGSHAW O.
Published: March 2003

Background: The recently introduced size 1.5 laryngeal mask airway (LMATM) is specifically designed for use in children weighing 5–10 kg. Methods: We prospectively evaluated its use in 68 patients, mean age 8.7 months, who were undergoing a variety of routine surgical procedures.

Results: The overall incidence of complications was high (42%) and was significantly more common in younger patients. Most of these related to poor positioning of the LMA, or airway problems such as obstruction or laryngospasm. Critical incidents occurred in seven patients, and all but one of these was related to the use of an LMA.

Conclusions: The size 1.5 LMA is a useful addition to the range available, although the overall complication rate is considerable and is inversely related to the age of the child.
Precise localization of a recurrent tracheo‐oesophageal fistula using retrograde guide wire placement
Authors: Hotta Yukako , Uezono Shoichi , Segawa Osamu , Muto Ayako , Nishiyama Keiko , Nagata Osamu , Ozaki Makoto
Published: March 2003

A 4‐month‐old‐infant was presented with a presumptive diagnosis of a recurrent tracheo‐oesophageal fistula. Preoperative bronchoscopy failed to reveal any defects on the tracheal lumen; however, combined oesophagoscopy and bronchoscopy successfully identified the tracheal orifice of the fistula, which facilitated surgical identification of the recurrent fistula and proper placement of the tracheal tube.
The addition of antiemetics to the morphine solution in patient controlled analgesia syringes used by children after an appendicectomy does not reduce the incidence of postoperative nausea and vomiting
Authors: Munro F.J. , Fisher S. , Dickson U. , Morton N.
Published: March 2003

Summary Background: We studied the effect of intraoperative ondansetron 0.1 mg·kg–1 or droperidol 0.01 mg·kg–1, followed by the same dose of the antiemetic agent added to the morphine solution during patient controlled analgesia (PCA) on the incidence of nausea and vomiting in children following an appendicectomy.

Methods: Sixty children, aged 5–13 years, were recruited and randomly allocated to receive no prophylactic antiemetic, the control group (group C), ondansetron (group O) or droperidol (group D). The PCA pump was programmed to deliver a bolus dose of 20 μg·kg–1 of morphine.with a 5‐min lockout period and a background infusion of 4 μg·kg–1·h–1.

Results: Postoperatively, the three groups were compared for nausea, vomiting and sedation scores for 24 h. The incidence of postoperative nausea and vomiting was 33% for group C, 44% for group O and 41% for group D. There was no increase in sedation scores in the droperidol group.

Conclusions: We were unable to show any significant benefit from the prophylactic administration of ondansetron or droperidol to children using morphine PCA devices following appendicectomy in the doses we employed.
Cardiac surgery in a child with sacral and intrasacral haemangioma
Authors: Sarkar Molly , Odegard Kirsten , Laussen Peter
Published: March 2003

A 23‐month‐old female with giant sacral (S1–S5) and intrasacral (L4–S5) haemangioma, lipomyeloschisis and a tethered cord presented for correction of a sinus venosus atrial septal defect. Angiography revealed a large perisacral hypervascular mass with large veins and an intraspinal extension. The patient had a neurogenic bladder and left extremity weakness due to spinal cord compression. The potential for additional neurological injury secondary to bleeding, venous congestion, ischaemia and steal phenomenon during cardiopulmonary bypass is discussed.
Postintubation tracheal stenosis in an 11‐year‐old boy: a surgical and anaesthetic challenge
Authors: Aguilera I.M. , Walker R.W.M. , Dearlove O.R.
Published: March 2003

Summary We present a case of postintubation tracheal stenosis in an 11‐year‐old boy occurring after a relatively short period of intubation. He had been intubated and ventilated in a paediatric intensive care unit after a road traffic accident. Clinical symptoms manifested by oxygen desaturation and wheeziness, finally leading to deterioration of the level of consciousness, occurred a few hours after the first attempt at extubation after 48 h requiring reintubation. Endoscopic examination performed a few weeks later revealed a tracheal stenosis. Consequently, he underwent an initial period of conservative treatment consisting of balloon dilatation and intralesional injection of steroids, followed by a tracheal resection and reconstruction. The anaesthetic management of patients with tracheal stenosis presenting for laryngo‐tracheobronchoscopy and balloon dilatation is discussed.
Perioperative management of a child with glycogen storage disease type III undergoing cardiopulmonary bypass and repair of an atrial septal defect
Authors: Mohart David , Russo Pierantonio , Tobias Joseph D.
Published: March 2003

Summary The glycogen storage diseases (GSD) are a heterogenous group of inherited disorders involving one of the several steps of glycogen synthesis or degradation. Type III GSD, also known as Cori's or Forbe's disease, results from a deficiency of the enzyme, amylo‐1,6‐glucosidase, which is responsible for the breakdown or debranching of the glycogen molecule during catabolism. As a result of this deficiency, inadequate glycogen breakdown occurs, resulting in hypoglycaemia during periods of fasting or stress, as well as storage of excessive glycogen, predominantly in the liver. Glycogen accumulation in the liver leads to hepatogmegaly and, in some instances, hepatic dysfunction with cirrhosis in the third and fourth decades of life. Additionally, deficiency of the enzyme in skeletal and cardiac muscle can lead to skeletal muscle weakness and cardiomyopathy. We present a 28‐month‐old girl who presented for anaesthetic care for cardiopulmonary bypass and closure of an atrial septal defect. The potential perioperative implications of GSD type III are discussed.
QT prolongation under sevoflurane in infants
Authors: Maier S. , Kleinsasser A. , Keller C. , Kühbacher G. , Löckinger A.
Published: March 2003

Introduction  QT interval prolongation may cause the potentially lethal tachyarrhythmia torsades de pointes (1). The cause of the QT interval prolongation may be a congenital mutation in genes encoding cardiac potassium and sodium channels (2) or be acquired following drug administration (3) or metabolic disorders (4). Among a few other drugs volatile anaesthetics prolong the QT interval. During the last few years sevoflurane has become the most used volatile anaesthetic for the induction of anaesthesia in infants.

Methods  This investigation, on infants aged from 1 to 6 months, was approved by the institutional ethic committee. Thirty‐six otherwise healthy infants due to elective surgery were included in our study The patients were randomly assigned to one of two treatment groups. Group S (n = 24) was anaesthetised with sevoflurane, Group H was anaesthetised with halothane. ECG recordings were taken before the anaesthesia onset, 15 min after the first contact with the volatile anaesthetic and 60 min after the ending of the volatile gas exposition. QTc interval was calculated using the Bazett's formula (5).

Results  QTc interval was significantly (P < 0.0002) (Table 1) lengthened 15 min after anaesthesia induction with sevoflurane as well as 60 min (P < 0.01) after the ending of the gas exposition without any difference in age and gender. The QTc interval in patients anaesthetised with halothane did not show any significant change.

Baseline
+ 15 min
60 min post

QT (ms)

Sevotlurane
250 ± 23
301 ± 19†‡
279 ± 22*‡

Halothane
260 ± 20
274 ± 23
258 ± 22

QTc (ms)

Sevoflurane
409 ± 20
473 ± 19†‡
433 ± 15†‡

Halothane
417 ± 22
418 ± 20
407 ± 34

P < 0.05,

P < 0.01 in intergroup comparison;

P < 0.01 in comparison to baseline value. Data are mean ± SD.

Conclusion  Usually no preoperative ECG recording, genetic or metabolic examination is performed in infants prior to elective surgical intervention. Physicians should be aware that sevoflurane induction and anaesthesia significantly lengthens the QTc interval in infants.
Modelling paracetamol urine metabolites
Authors: Van Der Marel C. , Anderson B.J. , Tibboel D. , Holford N.H.G.
Published: March 2003

Introduction  Glucuronidation is immature in neonates and sulphation is the dominant metabolic pathway (glucuronide/sulphate 0.34). Adult glucuronide/sulphate ratios (+2) are believed to occur at 12 years (1). Different UDP‐glucuronosyltransferases, the rate‐limiting enzyme in neonates, mature at different rates: that responsible for bilirubin metabolism, for example, within the first 3 months of life. These enzymes are regulated not only by ontogenic, but also by genetic processes. Paracetamol clearance approaches adult rates at 1 year, when standardised to an allometric 3/4 power model (2). Urinary metabolites in 11‐month‐old children were investigated to determine metabolic pathway predominance at this age for paracetamol.

Methods  Ethical committee approval was granted and informed consent from parents/caregivers was obtained for each study child. Children (n = 158) nursed in PICU after craniosyntosis surgery were given regular paracetamol (LD 40 mg/kg, MD 20 mg·kg−1 6–8 h over 24 h). Serial serum concentrations were measured in 150 children (3). Urine was collected at 3 h intervals for 24 h and assayed for paracetamol, paracetamol glucuronide and paracetamol sulphate in 15 children.

Data were analysed using differential equations for a 7 compartment model with the first order conditional estimate method using ADVAN 6, Tol = 5 of NONMEM V. Data were pooled with another study (2) to characterise oral bioavailability.

Results  Children had a mean age 11.8 SD 2.6 months and weight 9.1 SD 1.9 kg. Oral paracetamol bioavailability was low compared to rectal. due to nasogastric loss and vomiting. Sulphate metabolite clearance was 2.85 l·h−1·70kg−1 while glueuronide metabolite clearance was 6.07 l·h−1·70kg−1. Unmetabolised paracetamol urinary clearance (3.65 l·h−1·70kg−1) was unexpectedly large and was related to urine production with an exponential function. We were unable to estimate other metabolite (e.g. mercaptopurine/cysteine metabolites from glutathione) clearances.

Discussion  The glucuronide/sulphate ratio of approximately 2 that is described in children aged 12 years (1) was reached by the age of 1 year. Earlier reports suggested that this ratio be attained slowly during childhood. Our data suggests that maturation of the glucuronide system for paracetamol is more rapid during the first year than previously assumed.
The braun thermoscan thermometer: validation of normal ranges in a paediatric practice
Authors: Streets C.A. , Carr A.S.
Published: March 2003

Introduction  Pyrexia is a common cause of operative cancellation in paediatric practice, and so the accurate determination of temperature is of paramount importance. Recently the Braun ThermoScan infrared aural thermometer has been introduced to Derriford Hospital as a safe and non‐invasive technique for measuring temperature. Initially the published upper limits of normal for this technique appeared to be higher than expected. Initial experiences with the thermometer in Derriford Hospital produced high temperature readings in children who were otherwise clinically well. The aim of this study was to compare the manufacturer's published normal ranges with those obtained from a general paediatric population.

Methods  Ethics Committee approval was obtained. The study was conducted between July and November 2001. Patients less than 16 years of age, and admitted to either the Day Surgical Unit or the general paediatric wards for elective surgery were included. Each child had its temperature measured on admission using the Braun ThermoScan aural thermometer. The ages and temperatures were recorded, and the values compared with the manufacturer's normal ranges using standard error of the means.

Results  Preliminary data are reported from 248 children: 1–2 years (n = 30), 3–10 years (n = 159), and 11–15 years (n = 59). The table demonstrates that there is no significant statistical difference between the manufacturer's ranges and those of the Derriford Hospital paediatric elective surgical population.

Discussion  The Braun ThermoScan infrared aural thermometer is considered to be a safe, hygienic, and convenient technique for measuring temperature. Despite initial misgivings that a temperature approaching 38°C could not be considered normal, this study has confirmed that the manufacturer's published normal ranges are indeed compatible with those obtained from a district general hospital paediatric population.

Conclusion  This study validates the manufacturer's published normal range for the Braun ThermoScan thermometer. This therefore leaves a clinical dilemma – does a child with a temperature of 37.9°C have a pyrexia or not?
Tramadol for pain relief in children undergoing tonsillectomy. A comparison with morphine
Authors: Engelhardt T. , Steel E. , Johnston G.
Published: March 2003

Introduction  Pain control for paediatric patients undergoing tonsillectomy remains problematic. The combination of intra‐operative morphine and rectal diclofenac results in a high incidence of post‐operative nausea and vomiting as well further analgesic requirements. Tramadol is reported to be an effective analgesic and have a side effect profile similar to morphine. It is not classed as a controlled drug and is available in tablet, suppository and injection form. It is currently not licensed for paediatric use in the UK.

Methods  We conducted a prospective, double blind, randomised controlled trial in children scheduled for elective tonsillectomy or adenotonsillectomy at the Royal Aberdeen Children Hospital. Following local ethics committee approval and obtaining a drug exemption certificate from the Medicines Licensing Agency for an unlicensed drug in paediatrics we recruited 60 patients into three groups: morphine (0.1 mg·kg−1), tramadol (1 mg·kg−1) and tramadol (2 mg·kg−1). These drugs were given as a single injection following induction of anaesthesia. In addition, all patients received diclofenac (1 mg·kg−1) rectally. The post‐operative analgesic requirements, sedation scores, signs of respiratory depression and nausea and vomiting as well as antiemetic requirements were noted at 4 hourly intervals until discharge. Statistical analysis was performed using chi‐square, Kruskal–Wallis and one‐way anova tests as appropriate. P < 0.05 was considered statistically significant.

Results  There were no statistical significant differences in age, weight, type of operation or induction of anaesthesia, 4 hourly sedation and pain scores and further analgesic requirements. There were no incidences of respiratory depression. Morphine was associated with a significantly higher incidence of vomiting following discharge to the wards (75% vs 40%, P = 0.03) when compared to both tramadol groups. The differences in anti‐emetic requirements did not reach statistically significant difference (P = 0.078).

Conclusions  We conclude that tramadol has similar analgesic properties and side effects when compared with morphine. The pharmaceutical presentation and the availability as a non‐controlled substance may make it a useful addition to paediatric anaesthesia if it becomes licensed for paediatric anaesthesia in the UK.
Laryngotracheo‐oesophageal cleft in an infant: airway management during bronchoscopy
Authors: Singh Baljit , Balasubramaniam Sangeeta , Choudhury Roy
Published: March 2003

Summary A case of laryngotracheo‐oesophageal cleft scheduled for bronchoscopy and repair is described. The authors highlight the difficulties of bronchoscopy in such a patient and suggest simple manoeuvres to negotiate the rigid bronchoscope into the trachea.
A comparison of remifentanil and fentanyl for fast track paediatric cardiac anaesthesia
Authors: Friesen Robert H. , Veit Andrew S. , Archibald David J. , Campanini Rafael S.
Published: March 2003

Summary Background: Fast track anaesthetic protocols for cardiac surgical patients have been developed to facilitate early tracheal extubation. We compared anaesthetics based on either remifentanil or fentanyl for fast track paediatric cardiac anaesthesia.

Methods: Fifty patients with atrial septal defect or simple ventricular septal defect who were deemed suitable for fast track anaesthetic management were randomly assigned to group R (remifentanil) or group F (fentanyl). After sevoflurane induction, patients received either R infusion or F bolus. Following intubation, isoflurane 0.5 MAC was administered to all patients. Blood pressure (BP) and heart rate (HR) were recorded at baseline and pre‐ and postinduction, intubation, skin incision and sternotomy. Other parameters measured included time to extubation, reintubation rate and requirements for postoperative analgesia, ondansetron, and nitroprusside in the paediatric intensive care unit.

Results: BP decreased similarly from baseline in both groups. Decreases in HR over time were significantly greater in group R. Haemodynamic response to incision/sternotomy was low and similar in both groups. There were no significant differences in extubation time, reintubation incidence, postoperative narcotic requirements, postoperative hypertension or postoperative nausea/vomiting.

Conclusions: The remifentanil based anaesthetic was associated with a significantly slower HR than the fentanyl based anaesthetic. The clinical implications of the slower HR during remifentanil anaesthesia could be important and should be investigated.
Comparison of fentanyl–bupivacaine or midazolam–bupivacaine mixtures with plain bupivacaine for caudal anaesthesia in children
Authors: Baris Sibel , Karakaya Deniz , Kelsaka Ebru , Güldogus Fuat , Ariturk Ender , Tür Ayla
Published: March 2003

Summary Background: The aim of this study was to evaluate the intensity and effectiveness of 0.75 ml·kg−1 bupivacaine 0.25% with the addition of fentanyl or midazolam for caudal block in children undergoing inguinal herniorrhaphy.

Methods: Seventy‐five children were allocated randomly to three groups to receive a caudal block with either 0.25% bupivacaine with fentanyl 1 µg·kg −1 (group BF) or with midazolam 50 µg·kg−1 (group BM) or bupivacaine alone (group B) after induction of anaesthesia. Haemodynamic parameters, degree of pain, additional analgesic requirements and side‐effects were evaluated.

Results: The mean systolic arterial pressure at 10, 20, 30 min after caudal block was higher in group B compared with groups BF and BM. Mean intraoperative heart rate was lower in group BF than the other groups. Adequate analgesia was obtained in all patients (100%) in group BF, 23 patients (92%) in group BM and 21 patients (84%) in group B (P > 0.05). The time to recovery to an Aldrete score of 10 was significantly shorter in group B than group BM (P < 0.05). Although not significant, it was also shorter in group B than group BF. There was no difference in additional analgesic requirements between the groups in the first 24 h. Sedation score was higher in the midazolam group at 60 and 90 min postoperatively than the other groups.

Conclusions: Caudal block with 0.75 ml·kg−1 0.25% bupivacaine and 50 µg·kg−1 midazolam or 1 µg·kg−1 fentanyl provides no further analgesic advantages to bupivacaine alone when administered immediately after induction of anaesthesia in children undergoing unilateral inguinal herniorrhaphy.
Efficacy and safety of caudal injection of levobupivacaine, 0.25%, in children under 2 years of age undergoing inguinal hernia repair, circumcision or orchidopexy
Authors: Taylor R. , Eyres R. , Chalkiadis G.A. , Austin S.
Published: March 2003

Summary Background: Levobupivacaine is the S(–)‐enantiomer of racemic bupivacaine. Evidence suggests that it is less cardiotoxic than racemic bupivacaine and the R(+)‐enantiomer, dexbupivacaine, while retaining similar local anaesthetic properties and potency to racemic bupivacaine.

Methods: This was an open study designed to assess the efficacy and safety of 0.25% levobupivacaine administered as a caudal injection at a dose of 2 mg·kg‐1 to 49 paediatric patients aged less than 2 years old undergoing circumcision (group 1), or hernia repair or orchidopexy (group 2).

Results: Adequate analgesia (an increase of <20% in pulse or respiratory rate compared with baseline and an absence of gross movement on application of surgical stimulus) was achieved in 43/48 patients evaluable for afficacy (89.6%). All 22 Patients in the circumcision group had adequate analgesia, and two of these patients did not require addit

Conclusions: Levobupivacaine is a promising new local anaesthetic agent for pain management in paediatric patients and appears to offer similar anaesthetic efficacy to racemic bupivacaine with a potetially improved tolerability profile.
Description of ciliary body anatomy and identification of sites for transscleral cyclophotocoagulation in the equine eye
Authors: Miller Tammy L. , Willis A. Michelle , Wilkie David A. , Hoshaw‐Woodard Stacy , Stanley James R. L.
Published: March 2003

Objective

To determine the most appropriate anatomical location for diode laser probe placement to accurately photoablate the equine ciliary body using a contact, transscleral approach.

Design

Original research.

Procedures

Forty‐two freshly enucleated adult equine eyes were evaluated. The horizontal, medial vertical, central vertical, and lateral vertical lengths of the cornea were measured from limbus to limbus. Needles were inserted perpendicular to the sclera at specific distances posterior to the external limbus at the 1, 2, 4, 5, 6, 7, 8, 10, 11 and 12 o’clock positions. The per cent frequency that needles penetrated internal anatomical regions (lens, lens zonules, pars plicata, anterior, middle, and posterior pars plana, ora ciliaris retinae, or retina), when inserted at 2, 4, 6, and 8 mm posterior to the limbus, were calculated for all eyes combined, for right vs. left, for males vs. females, and for three age groups. The internal distance from the limbus to the anterior pars plana, and from the anterior pars plana to the ora ciliaris retinae were also measured in six of the horses (12 eyes). Mean distances and standard deviations were computed for all parameters.

Results

Average corneal sizes and standard deviations were: 30.24 mm ± 1.53 (horizontal); 24.69 mm ± 1.52 (central vertical); 22.79 mm ± 1.49 (medial vertical); and 19.79 mm ± 1.55 (lateral vertical). Internal distances of the pars plicatas ranged from 5.33 mm ± 0.49 to 10.67 mm ± 1.15. Internal distances of the pars planas ranged from 0.33 mm ± 0.49 to 3.17 mm ± 0.39. High probabilities of penetrating the pars plicata correspond to positions 4 mm posterior to the external limbus dorsotemporal 10, 11 o’clock (OD), and 1, 2 o’clock (OS), dorsonasal 1 o’clock (OD) and 11 o’clock (OS), and ventrotemporal 5–7 o’clock (OU). Low probabilities of penetrating the pars plicata correspond to positions ventronasal 4 o’clock (OD), 8 o’clock (OS) and dorsonasal 2 o’clock (OD), 10 o’clock (OS) at 4 and 6 mm posterior to the external limbus as well as ventrotemporal 4 o’clock (OS), 8 o’clock (OD) at 6 mm posterior to the external limbus.

Conclusions

Transscleral cyclophotocoagulation may be a viable alternative to medical therapy for control of intraocular pressure in horses with glaucoma. Overall, the most accurate anatomical position on the sclera for cyclophotocoagulation of the equine eye is 4–6 mm posterior to the limbus, avoiding the nasal quadrants. Accurate transscleral cyclophotocoagulation should optimize the therapeutic outcome and minimize potential side‐effects such as retinal detachment and cataract formation.
Carprofen inhibition of flare in the dog measured by laser flare photometry
Authors: Krohne S.G. , Blair M.J. , Bingaman D. , Gionfriddo J.R.
Published: March 2003

The purpose of this study was to determine whether oral carprofen (Rimadyl®) treatment in dogs could prevent or decrease the breakdown of the blood–aqueous barrier. The topical pilocarpine irritative model was used to induce breakdown and cause flare. Pilocarpine was instilled in both eyes of seven dogs at time zero and again 5 h later. At 7 h, laser flare photometry was used to measure the flare concentration in each eye using the Kowa FC‐1000 laser flare cell meter. All treatments were then discontinued. Two days later, carprofen was administered to the same dogs for a total of three doses. After the last dose of carprofen, pilocarpine treatments and flare measurements were repeated. Carprofen pretreatment resulted in a 68% inhibition of flare, which was highly significant (P< 0.01). The pilocarpine group had a mean of 16.1 photon counts per millisecond (PC ms−1) ± 2.2 SE, and the carprofen group had a mean of 7.0 PC/ms ± 1.2 SE. These results compare favorably with previous studies measuring increased protein or fluorescein concentrations in the aqueous humor after blood–aqueous barrier breakdown in the dog. These results suggest that carprofen may be effectively used as a systemically administered ocular anti‐inflammatory drug. Carprofen has the added benefit of fewer reported side effects.
Intraocular pressure in normal dairy cattle
Authors: Gum G.G. , Gelatt K.N. , Miller D.N. , Mackay E.O.
Published: March 2003

Intraocular pressure (IOP) was measured in normal dairy cows by applanation tonometry. In the first study of 15 Holstein and 17 Jersey cows the mean IOP by Mackay‐Marg tonometry was 27.5 ± 4.8 mmHg (range 16–39 mmHg); no significant differences (P< 0.92) were observed between the Holstein and Jersey breeds. In the second study of 15 Holstein and 12 Jersey cows, the mean IOPs by Mackay‐Marg and TonoPen‐XL tonometry were 28.2 ± 4.6 mmHg (range 19–39 mmHg) and 26.9 ± 6.7 mmHg (range 16–42 mmHg), respectively. Comparisons of the Mackay‐Marg and TonoPen tonometers indicated no significant differences (P< 0.16). The mean and range of IOP in normal dairy cows within 2 SD (95% of the population) is 27 mmHg with a range of 16–36 mmHg.
Heterochromia iridis in water buffaloes (	Bubalus bubalis)
Authors: Misk  , Semieka  , Fathy
Published: March 2003

This study included 45 unaffected animals and 593 animals affected with heterochromia irides, and 85 enucleated eyeballs with heterochromia irides. The classification of heterochromia irides, morphology of normal and heterochromic irides, and the histology, ultrastructure, and scanning electron microscopy are presented. The incidence of heterochromia irides in water buffaloes was 7.62% affecting either one or both eyes. Both complete and partial heterochromia irides occurred. Complete heterochromia iridis is more frequent than the partial form in either bilateral or unilateral cases. The pupil has a dumb‐bell‐shape appearance. Granula iridica occurred at the upper (100%) and lower (30%) pupillary margins and originated from the posterior pigmented epithelium. In heterochromia irides, the melanocytes is absent in the anterior border and stromal layers, and iridal thickness appeared thinner than that of normal eyes.
Golden Retriever uveitis: 75 cases (1994–1999)
Authors: Sapienza J.S. , Simó F.J. , Prades‐Sapienza A.
Published: March 2003

ObjectiveTo document the presenting ocular signs and the clinical course of Golden Retriever dogs with a progressive anterior uveitis, often associated with the histologic presence of iridociliary cysts.

Animals studiedSeventy‐five Golden Retriever dogs (142 affected eyes) referred to a private practice referral ophthalmology clinic between 1994 and 1999.

ProceduresComplete ophthalmic evaluation with slit‐lamp biomicroscopy, indirect ophthalmoscopy, applanation tonometry, and gonioscopy. Hematology, serum biochemical evaluations, and serologic titers for endemic infectious agents were also used in selected cases.

ResultsThe age range of affected dogs was 4.5–14.5 years, with a mean age of 8.6 ± 2.1 years. The majority of the dogs (n = 66) were affected in both eyes at first presentation. The sex distribution included 4 intact males, 32 neutered males, and 39 spayed females. Hematology, serum biochemical evaluations, and serologic titers for endemic infectious agents failed to demonstrate any underlying disorder. The ophthalmic hallmark of this syndrome was the appearance of pigment on the anterior lens capsule, often in a radial orientation. This capsular pigment was seen both with and without associated uveal cysts. Although single to multiple iridociliary cysts were noted clinically in only 13.3% of the cases, cysts were common on histopathology of advanced glaucomatous, blind eyes. Fibrin was observed in the anterior chamber of 37% of the cases, and often was a precursor for glaucoma. Cataract formation (37%) and glaucoma (46%) were frequent sequelae to the uveitis. Posterior synechiae formation occurred in 50% of the cases. Histopathologic analysis of four enucleated eyes and the eviscerated specimens from 14 glaucomatous eyes demonstrated thin‐walled iridociliary epithelial cysts in 3/4 and 12/14 cases, respectively. Microscopically, little to no uveal inflammatory infiltration was commonly noted.

ConclusionThe overall prognosis for this progressive uveitis in Golden Retriever dogs is guarded, with 46% of the eyes becoming blind due to glaucoma. Iridociliary cysts in Golden Retriever dogs may lead to the development of glaucoma in this breed.
Immunohistochemical studies of cone photoreceptors and cells of the inner retina in feline rod‐cone degeneration
Authors: Narfström Kristina , Ehinger Berndt , Bruun Anitha
Published: March 2003

Previous studies using electroretinography and immunohistochemistry have shown normal cone function and structure in early stages of hereditary rod‐cone degeneration of Abyssinian cats. To further investigate the cone photoreceptors and the inner retina of dystrophic cats, antibodies against green‐ and blue‐sensitive cones and specific cell types of inner retina were used in seven cats with the recessively inherited rod‐cone degeneration, and three normal European short‐haired cats. There was a reduction in number of both types of cones early in the disease. Changes at early stages of disease also occurred among horizontal cells in which there was an extension and a thickening of their lateral processes. The regular configuration of bipolar cells was changed in the more advanced stages of disease and their apical dendrites were lost. Abnormalities were not observed in the amacrine cells and in the ganglion cell layer in any of the present cases. This study shows that the cone system is morphologically abnormal in young cats at an earlier stage of disease than previously shown. The present findings also support the assumption that the inner retina is largely preserved throughout the disease process.
Preservation of hymenopteran specimens for subsequent molecular and morphological study
Authors: Quicke D. L. J. , Lopez‐Vaamonde C. , Belshaw R.
Published: March 2003

Some guidelines are presented for long‐term preservation of insects for non‐traditional systematic studies such as DNA sequencing and internal anatomical research. The main criteria for good DNA preservation appear to be the rapidity with which the DNA is protected from enzymatic and chemical breakdown, and subsequent storage conditions. The immediate post mortem treatment of specimens appears particularly important to the preservation of amplifiable DNA. For storage we recommend 70–100% ethanol at low temperature, deep freezing, and critical point or chemical drying direct from alcohol. For internal anatomy, traditional fixatives, 70% ethanol in a refrigerator, critical point drying or chemical drying are recommended. Cold‐storage in 70% ethanol with or without subsequent critical point drying or chemical drying using hexamethyldisilazane allow both molecular and morphological study.
Models of analysis for molecular datasets for the reconstruction of basal hymenopteran relationships
Authors: Dowton Mark , Austin Andrew D.
Published: March 2003

We previously reported analyses of basal hymenopteran relationships using fragments of the COI and 16S rDNA mitochondrial genes, employing models of analysis that ate considered contentious by some. For the COI protein‐coding gene, we assessed non‐synonymous changes only, while for the 16S rDNA fragment, we analysed all positions, but down‐weighted AT‐transversions. In the present study, we describe and justify in greater detail these models of analysis.