Association of dexmedetomidine with recovery room and hospital discharge times: A retrospective cohort analysis.

BACKGROUND: Dexmedetomidine is a useful anesthetic adjunct, increasingly popular during pediatric surgery and procedural sedation. Its half-life of 2-3 hours might prolong recovery and discharge times when compared with an un-supplemented propofol anesthetic. This may create an additional burden in a busy post-anesthetic care unit (PACU). AIM: To investigate whether intraoperative adjuvant dexmedetomidine delays PACU discharge in patients undergoing propofol anesthesia for day surgery or procedural investigations with minimal anticipated post-procedural pain. METHODS: We conducted a retrospective review of outpatient procedures performed during a six-month period including pediatric patients, ASA physical status I-III, who underwent intravenous anesthesia with propofol and remifentanil for magnetic resonance imaging (MRI), strabismus repair, upper gastrointestinal endoscopy, or combined upper/lower gastrointestinal endoscopy. Patients receiving a sedative premedication, long-acting opioids, or volatile anesthetics for maintenance of anesthesia, were excluded. Duration of PACU stay was compared for patients who did or did not receive intraoperative dexmedetomidine in the four procedure groups. RESULTS: Charts were reviewed for 359 patients; 130 (36%) received dexmedetomidine. Median differences in duration of PACU stay for dexmedetomidine versus non-dexmedetomidine cases were: 5 minutes (95%CI 0 to 10, p=0.037) for MRI; 5 minutes (95%CI -3 to 15, p=0.258) for strabismus surgery; 7 minutes (95%CI 3 to 10, p<0.001) for upper endoscopy; and 5 minutes (95%CI 1 to 12, p=0.021) for combined upper/lower endoscopy. Linear regression (F=61.1, adjusted R2 =0.40) indicated a significant relationship between dexmedetomidine dose (estimate 14.6 minutes per µg/kg, 95%CI 8.2 to 21.1, p<0.001) and duration of PACU stay. CONCLUSION: We found evidence for a small association of intraoperative dexmedetomidine with duration of recovery from propofol anesthesia for a set of common outpatient procedures, with a potential dose relationship equivalent to approximately 15 minutes delay per µg/kg dexmedetomidine administered. Future research into the benefits of dexmedetomidine in pediatric anesthesia should further evaluate this relationship.

Environmentally sustainable perioperative medicine: simple strategies for anesthetic practice.

PURPOSE: This continuing professional development module aims to inform anesthesiologists about the magnitude of healthcare-related waste and its contribution to global warming, as well as providing general strategies to improve environmental sustainability in daily anesthesia practice in a Canadian context. PRINCIPAL CONSIDERATIONS: Global warming is considered to be the biggest global health threat of the 21st century. Healthcare is not only adversely impacted by but also a significant contributor to global warming and environmental degradation. Healthcare provision produces 4.6% of the total national greenhouse gas emissions in Canada, while healthcare waste has increased unabated in recent years, largely because of increased use of disposable medical supplies. Operating rooms are highly energy-intensive and produce up to 33% of total hospital waste. Increasingly, attention in healthcare is being focused on environmental sustainability by exploring evidence-based approaches to more sustainable delivery of healthcare. Key to environmental sustainability research is the life-cycle assessment methodology, which measures the cradle-to-grave impact of products on various environmental outcomes and empowers purchasing departments to make environmentally conscious decisions. By using the "reduce, reuse, recycle" hierarchy of waste reduction, several easily implementable evidence-based strategies are proposed to reduce the environmental footprint of everyday anesthesia practice. These recommendations focus on informed decisions on volatile anesthetic use, reduced drug waste, limited use of single-use devices, and meticulous waste segregation and recycling strategies. CONCLUSIONS: Anesthesiologists have a unique opportunity to be champions of environmental sustainability through evidence-based practices, while simultaneously reaping significant synergistic health, cost, and quality co-benefits.

RéSUMé: OBJECTIF: Ce module de développement professionnel continu a pour objectif de conscientiser les anesthésiologistes quant à l'ampleur du gaspillage et des déchets liés aux soins de santé et leur contribution au réchauffement climatique, ainsi que de proposer des stratégies générales pour améliorer la durabilité environnementale dans la pratique quotidienne de l'anesthésie dans un contexte canadien. CONSIDéRATIONS PRINCIPALES: Le réchauffement climatique est considéré comme la plus importante menace en matière de santé mondiale au XXIe siècle. D'un côté, les soins de santé sont victimes des impacts négatifs du réchauffement climatique et de la dégradation de l'environnement, mais de l'autre, ils y contribuent également de façon significative. La fourniture de soins de santé produit 4,6 % des émissions nationales totales de gaz à effet de serre au Canada, alors que les déchets médicaux ne cessent d'augmenter depuis quelques années ­ augmentation due en grande partie à l'utilisation accrue de matériels médicaux jetables. Les salles d'opération sont particulièrement énergivores et produisent jusqu'à 33 % des déchets hospitaliers totaux. Dans les soins de santé, l'attention se tourne de plus en plus vers la durabilité en explorant des approches fondées sur des données probantes pour une fourniture plus écologique des soins de santé. La méthodologie d'analyse du cycle de vie est un élément crucial de la recherche en durabilité : cette méthodologie mesure l'impact d'un produit, de sa création à son élimination, sur différents résultats environnementaux. Elle permet aux services d'approvisionnement d'être mieux outillés pour prendre des décisions écoresponsables. En s'appuyant sur la hiérarchie des 3 R « réduire, réutiliser, recycler ¼ pour la réduction des déchets, nous proposons plusieurs stratégies fondées sur des données probantes et faciles à mettre en œuvre afin de réduire l'empreinte environnementale de la pratique quotidienne de l'anesthésie. Ces recommandations mettent l'emphase sur des stratégies concernant divers aspects promouvant une plus grande durabilité, soit : la gestion de l'utilisation des anesthésiques volatils, la réduction du gaspillage médicamenteux, l'utilisation restreinte des dispositifs à usage unique, le tri méticuleux des déchets et les stratégies de recyclage. CONCLUSION: Les anesthésiologistes ont une occasion unique de devenir des leaders en durabilité grâce à des pratiques fondées sur des données probantes, tout en récoltant d'importants avantages concomitants et synergiques en matière de santé, de coûts et de qualité.

Usability and performance characteristics of the pediatric air-Q® intubating laryngeal airway.

PURPOSE: The air-Q® intubating laryngeal airway (ILA) is a supraglottic device (SGD) designed specifically to function as both a primary airway and a bridging device and conduit for fibreoptic intubation in difficult airway scenarios. This observational study evaluated the usability and performance characteristics of pediatric air-Q ILA sizes 1.0, 1.5, 2.0, and 2.5 when used as a primary airway. METHODS: One hundred ten children, American Society of Anesthesiologists physical status I-III and undergoing elective surgery, received a weight-appropriate air-Q ILA following induction of anesthesia. The evaluation criteria included ease of insertion, quality of ventilation, presence of gastric insufflation, oropharyngeal leak pressures (OLPs) and maximum tidal volumes (VT max) in five different head positions, and fibreoptic view of the glottis. RESULTS: For sizes 1.0, 1.5, 2.0, and 2.5, the median [P25,P75] neutral OLPs (cm H2O) were 23.0 [20.0,30.0], 16.5 [15.0,20.8], 14.0 [10.0,17.8], and 14.0 [11.3,16.8], respectively. The median [P25,P75] neutral VT max values (mL · kg(-1)) were 17.4 [14.3,19.7], 20.3 [16.8,25.5], 17.8 [14.5,22.1], and 14.0 [11.6,16.0], respectively. Median [P25,P75] ease of insertion scores (0-10; 0 = easiest ever, 10 = most difficult ever) were 1 [1,2], 2 [2,3], 2 [1,2.8], and 2 [2,3] respectively. Ventilation was adequate in 108/110 cases, and a fibreoptic view of the vocal cords was obtained in 102/110 cases. CONCLUSIONS: The air-Q ILA functions acceptably as a primary SGD in infants and children. The OLPs are lower than published values for the ProSeal laryngeal mask airway (LMA ProSeal™), the current pediatric SGD of choice, but adequate tidal volumes are readily achievable. The fibreoptic views of the glottis portend well for fibreoptic intubation through the device. (This trial was registered at clinicaltrials.gov number, NCT00885911).

Total intravenous anesthesia and spontaneous respiration for airway endoscopy in children--a prospective evaluation.

INTRODUCTION: Inhalational anesthesia with spontaneous respiration is traditionally used to facilitate airway endoscopy in children. The potential difficulties in maintaining adequate depth of anesthesia using inhalational anesthesia and the anesthetic pollution of the surgical environment are significant disadvantages of this technique. We report our institutional experience using total intravenous anesthesia (TIVA) and spontaneous respiration. METHODS: We prospectively studied 41 pediatric patients undergoing 52 airway endoscopies and airway surgeries. Following induction of anesthesia, a propofol infusion was titrated to a clinically adequate level of anesthesia, guided by the Bispectral Index (BIS), and a remifentanil infusion was titrated to respiratory rate. ECG, BP, pulse oximetry, BIS level, transcutaneous CO(2) (TcCO(2)), respiratory rate, and drug infusion rates were recorded. Adverse events and the response to these events were also recorded. RESULTS: Forty-one children underwent 52 airway procedures; 17 rigid bronchoscopies and 35 micro-laryngobronchoscopies, including 18 LASER treatments, were performed. The mean (sd) age was 6.9 (5.8) years and weight 26.9 (21.2) kg. The mean induction time was 13 (6) min, and anesthesia duration was 49 (30) min. The mean highest TcCO(2) recorded during the procedures was 62.8 +/- 15.3 mmHg. Coughing occurred in 14 (27%) patients, requiring additional topical anesthesia (3), a bolus of propofol (4) or remifentanil (1), or removal of the bronchoscope (1). Desaturation below 90% occurred in 10 (19%) cases; only three required intervention in the form of temporary assisted ventilation (2) or inhaled bronchodilators (1). No laryngospasm, stridor, or arrhythmias were observed. CONCLUSION: TIVA and spontaneous respiration is an effective technique to manage anesthesia for airway endoscopy and surgery in children.

The effect of age on the dose of remifentanil for tracheal intubation in infants and children.

INTRODUCTION: This study aimed to determine the age-specific bolus dose of remifentanil (ED(50)) to facilitate tracheal intubation without the use of neuromuscular blocking agents. METHODS: ASA 1-2 subjects were recruited into three groups of 0-3 months (group I), 4-12 months (group II), and 1-3 years (group III) of age. A sequential up-and-down design determined the remifentanil bolus dose, which was initially started at 3 mcg x kg(-1) and adjusted in 1 mcg x kg(-1) increments (range 1-6 mcg x kg(-1)). Following pretreatment with glycopyrrolate 10 microg x kg(-1) and an induction dose of propofol 5 mg x kg(-1), remifentanil was administered with a blinded study investigator commencing tracheal intubation after 60 s. After tracheal intubation, the time to return of spontaneous ventilation was measured. Logistic regression was used to predict the ED(50) and ED(95) of remifentanil. RESULTS: Sixty-four subjects were recruited. Tracheal intubation was successful at first attempt in over 90% of subjects in each age group. Satisfactory intubating conditions were achieved in 85%, 63%, and 75% of subjects in groups I, II, and III, respectively. The logistic regression results for ED(50) (95% CI) were 3.1 (2.5-3.8), 3.7 (2.0-5.4), and 3.0 (2.1-3.9) mcg x kg(-1), and ED(95) (95% CI) were 5.0 (3.0-7.0), 9.4 (1.5-17.4), and 5.6 (2.9-8.4) mcg x kg(-1) in groups I, II, and III, respectively. Infants aged 4-12 months (group II) showed a marked variability in dose response; however, the mean ED(50) and ED(95) were not different to groups I and III. Older children had a longer duration of apnea than infants, 331 vs 180 s (P < 0.05). DISCUSSION: The ED(50) of remifentanil for tracheal intubation was higher in all age groups than previously reported. Ideal intubating conditions were achieved in 50% of subjects with remifentanil doses of 3.1-3.7 mcg x kg(-1). Higher doses will be required for higher success rates and with anticholinergic pretreatment, doses of up to 6 mcg x kg(-1) were tolerated, without adverse effects, in two patients. Further investigation of the variability in dose response in infants and assessment of the safety this technique is warranted.

Caudal and Intravenous Anesthesia Without Airway Instrumentation for Laparoscopic Inguinal Hernia Repair in Infants: A Case Series.

We report a series of 20 neonates and infants (18 born preterm) who underwent laparoscopic inguinal hernia repair with caudal anesthesia, oxygen via nasal cannula, and intravenous anesthesia. Surgery was successful in all cases without airway instrumentation or intraoperative complications. Sedation was provided with dexmedetomidine, propofol, and remifentanil. Two patients had apnea in the following 24 hours. There were no unplanned intensive care admissions. Laparoscopy allowed unplanned bilateral repair in 2 cases. Caudal with intravenous anesthesia without airway instrumentation is a viable technique for laparoscopic inguinal hernia repair. Avoiding general endotracheal anesthesia may reduce perioperative complications and influence postoperative disposition.

Intravenous Ketamine Infusion as an Adjuvant to Morphine in a 2-Year-Old With Severe Cancer Pain From Metastatic Neuroblastoma.

A 2.8-year-old female patient (11.6 kg) was admitted to the hospital for uncontrolled pain and swelling in the left leg relating to a metastatic neuroblastoma. Initially, her pain was managed with oral morphine 2 mg (approx. 0.2 mg/kg) every 4 hours. Because she was quite somnolent but still in significant pain, analgesia was then changed to methadone 1 mg orally every 6 hours (approximately 0.1 mg/kg/dose) and was eventually increased over 36 hours to 2 mg every 6 hours (approximately 0.2 mg/kg/dose). She received oral methadone 0.6 mg (approximately 0.05 mg/kg) every 4 hours as needed for breakthrough pain. She continued to have severe pain and experienced side effects, including respiratory depression, sedation, visual hallucinations, and vomiting. An intravenous ketamine infusion was started at 100 µg/kg/hour. Regular opioid administration was ceased, but she was given intravenous morphine 0.5 to 0.75 mg for breakthrough pain. She required only zero to three doses of breakthrough morphine per day, initially. After starting the ketamine infusion, her pain control improved and her symptoms of opioid toxicity abated. She was more alert and able to partake in limited activities. As a result of pain from progressive disease, the ketamine infusion was increased to 200 µg/kg/hour after 6 days with positive results. Her condition continued to deteriorate. An intravenous morphine infusion was initiated 2 weeks after starting the ketamine infusion and was eventually increased to 50 µg/kg/hour. One week later, she died with reasonable pain control. This case illustrates the use of ketamine as an effective analgesic in an adjuvant setting in a pediatric patient with advanced poorly controlled cancer pain. Ketamine not only eased the child's suffering while preserving life but also improved her quality of life by maintaining the child's ability to communicate and engage in activities.

Cranial conjoined twins: surgical and anesthetic challenges for a routine procedure: adenoidectomy and examination of ears.

Craniopagus conjoined twins have long been the subject of interest because of the rarity and peculiarity of their juxtaposition. We present the surgical, airway and anesthetic challenges in craniopagus conjoined twins, in which one of the twins underwent adenoidectomy for obstructive sleep breathing disorder. The surgical procedure required a special setting from an anesthetic perspective whereby both children needed anesthesia due to the complex physiology of their brains and cardiovascular systems. As well, we took the opportunity to do bilateral ear examinations of both twins.

Relationship between age and spontaneous ventilation during intravenous anesthesia in children.

BACKGROUND: Maintaining spontaneous ventilation in children, using total intravenous anesthesia (TIVA), is often desirable, particularly for airway endoscopy. The aim of this study was to evaluate the effect of age on the dose of remifentanil tolerated during spontaneous ventilation under anesthesia maintained with infusions of propofol and remifentanil and to provide guidelines for the administration of remifentanil and propofol to maintain spontaneous ventilation in children. METHODS: Forty-five children scheduled for strabismus surgery were divided by age into three groups (group I: 6 months-3 years, group II: 3 years-6 years, and group III: 6 years-9 years). The propofol infusion was titrated using State Entropy as a pharmacodynamic endpoint and remifentanil infused, using a modified up-and-down method, with respiratory rate depression as a pharmacodynamic endpoint. A respiratory rate of just greater than 10, stable for 10 min, determined the final remifentanil infusion rate. The group mean was estimated from the final remifentanil infusion rate tolerated (RD(50)). RESULTS: The RD(50) of groups I, II, and III were 0.192 (0.08), 0.095 (0.04), and 0.075 (0.03) microg x kg(-1) x min(-1) respectively. Pair-wise comparisons between the groups for the rate of remifentanil tolerated revealed a statistically significant increase in the RD(50) in children less than 3 years of age compared with older children in groups II and III (P < 0.001). The relationship between remifentanil dose and age, weight or height was not linear. CONCLUSIONS: Younger children, especially those aged less than 3 years, tolerate a higher dose of remifentanil while still maintaining spontaneous respiration. TIVA with spontaneous ventilation is readily achieved in younger children and infants.

Intravenous nalbuphine 50 microg x kg(-1) is ineffective for opioid-induced pruritus in pediatrics.

PURPOSE: This investigation evaluated the efficacy of nalbuphine in treating postoperative opioid-induced pruritus (Pr) in pediatric patients. METHODS: After Ethics Board approval, the dual site, tertiary care teaching centre study recruited 212 subjects, age > or = seven years, who received opioid analgesia postoperatively. A modified, self-report colour analogue scale (CAS) scored pruritus intensity (PrI). Subjects who reported PrI score > or = 5/10 were randomized to treatment with nalbuphine 50 microg x kg(-1) iv (max 5 mg) or saline placebo. A pruritus intensity difference (PrID) > or = 50% was considered a positive outcome. RESULTS: Of 260 subjects approached, 212 consented and 184 received opioids. Median age was 13 yr (range 7-19) and median weight was 51 kg (range 19.6-134.8 kg). Pruritus intensity > or = 5/10 occurred in 37 (20.1%) subjects. Intravenous morphine [patient-controlled analgesia (PCA)/continuous infusion] was associated with Pr in 68% of subjects over a wide dose range (9.4-63.2 mug.kg(-1).hr(-1)). Pruritus occurred in 36% of patients in the PCA group compared to continuous opioid infusion (27%) and epidural administration (27%). Pruritus intensity difference > or = 50% was achieved in 55.6% of nalbuphine and 57.9% of saline-treated subjects. CONCLUSION: This preliminary report suggests that nalbuphine 50 microg x kg(-1) iv is not effective in treating postoperative opioid-induced pruritus in pediatric patients. The modified CAS score and PrID warrant further investigation.

Intravenous nalbuphine 50 µg·kg(-1) is ineffective for opioid-induced pruritus in pediatrics.

PURPOSE: This investigation evaluated the efficacy of nalbuphine in treating postoperative opioid-induced pruritus (Pr) in pediatric patients. METHODS: After Ethics Board approval, the dual site, tertiary care teaching centre study recruited 212 subjects, age ≥ seven years, who received opioid analgesia postoperatively. A modified, self-report colour analogue scale (CAS) scored pruritus intensity (PrI). Subjects who reported PrI score ≥ 5/10 were randomized to treatment with nalbuphine 50 µg·kg(-1) iv (max 5 mg) or saline placebo. A pruritus intensity difference (PrID) ≥ 50% was considered a positive outcome. RESULTS: Of 260 subjects approached, 212 consented and 184 received opioids. Median age was 13 yr (range 7-19) and median weight was 51 kg (range 19.6-134.8 kg). Pruritus intensity ≥ 5/10 occurred in 37 (20.1%) subjects. Intravenous morphine [patient-controlled analgesia (PCA)/continuous infusion] was associated with Pr in 68% of subjects over a wide dose range (9.4-63.2 µg·kg(-1)·hr(-1)). Pruritis occurred in 36% of patients in the PCA group compared to continuous opioid infusion (27%) and epidural administration (27%). Pruritus intensity difference ≥ 50% was achieved in 55.6% of nalbuphine and 57.9% of saline-treated subjects. CONCLUSION: This preliminary report suggests that nalbuphine 50 µg·kg(-1) iv is not effective in treating postoperative opioidinduced pruritus in pediatric patients. The modified CAS score and PrID warrant further investigation. OBJECTIF: Évaluer l'efficacité de la nalbuphine contre le prurit (Pr) postopératoire induit par les opioïdes chez des patients pédiatriques. MéTHODE: Nous avons recruté 212 sujets de ≥ sept ans qui ont reçu une analgésie opioïde postopératoire. Une échelle analogique de couleur (EAC) modifiée pour l'auto-évaluation a mesuré les scores d'intensité du prurit (IPr). Répartis au hasard, les sujets dont les scores d'IPr étaient ≥ 5/10 ont reçu de la nalbuphine à 50 µg·kg(-1) iv (5 mg maximal) ou un placebo salin. Une différence d'intensité de prurit (DIPr) ≥50% était considérée positive. RéSULTATS: Des 260 sujets rencontrés, 212 ont participé à l'étude et 184 ont reçu des opioïdes. L'âge moyen a été de 13 ans (7-19) et le poids moyen de 51 kg (19,6-134,8 kg). Un prurit ≥ 5/10 a été noté chez 37 (20,1 %) des sujets. De la morphine intraveineuse [en analgésie auto-contrôlée (AAC) ou en perfusion continue] a été associée à du Pr chez 68 % des sujets pour un grand éventail de doses (9,4-63,2 µg·kg(-1)·h(-1)). Le prurit s'est manifesté chez 36 % des patients avec l'AAC comparée à la perfusion d'opioïde continue (27 %) et à l'administration péridurale (27 %). Une différence d'intensité du prurit ≥ 50 % a été atteinte chez 55,6 % des sujets qui recevaient la nalbuphine et 57,9 % de ceux qui avaient le placebo. CONCLUSION: La nalbuphine iv à 50 µg·kg(-1) n'est pas efficace pour traiter le prurit postopératoire induit par les opioïdes chez des patients pédiatriques. Le score modifié à l'EAC et la DIPr devront être étudiés plus à fond.

Inadvertent cervical epidural catheter placement via the caudal route using electrical stimulation.

Inadvertent placement of an epidural catheter in the cervical region via the caudal route is described in an infant who underwent revision of a fundoplication. We attempted electrical stimulation (the Tsui test) via the epidural catheter to confirm correct placement and positioning of the catheter tip. In this case, the epidural catheter was inadvertently advanced to the cervical region, resulting in stimulation of the phrenic nerve. These diaphragmatic twitches were misinterpreted as chest wall twitches, and it was incorrectly assumed that the catheter was in the thoracic region. To avoid misinterpretation of the stimulation level, the catheter should be continuously stimulated while it is advanced. We also recommend that the catheter length be estimated before insertion (although doing so did not help in this case) and that the catheter position be radiographically confirmed after surgery.

Reversal of an unintentional spinal anesthetic by cerebrospinal lavage.

UNLABELLED: In this case report, we describe the use of cerebrospinal fluid lavage as a successful treatment of an inadvertent intrathecally placed epidural catheter in a 14-yr-old girl who underwent a combination of epidural anesthesia and general anesthesia for orthopedic surgery. In this case, a large amount of local anesthetic was injected (the total possible intrathecal injection was 200 mg of lidocaine and 61 mg of bupivacaine), resulting in apnea and fixed dilated pupils in the patient at the end of surgery. Twenty milliliters of cerebrospinal fluid was replaced with 10 mL of normal saline and 10 mL of lactated Ringer's solution from the "epidural" catheter. Spontaneous respiration returned 5 min later, and the patient was tracheally extubated after 30 min. No signs of neurological deficit or postdural puncture headache were noted after surgery. IMPLICATIONS: Cerebrospinal lavage may be a helpful adjunct to the conventional supportive management of patients in the event of an inadvertent total spinal.

Intravenous ketamine infusion as an adjuvant to morphine in a 2-year-old with severe cancer pain from metastatic neuroblastoma.

A 2.8-year-old female patient (11.6 kg) was admitted to the hospital for uncontrolled pain and swelling in the left leg relating to a metastatic neuroblastoma. Initially, her pain was managed with oral morphine 2 mg (approx. 0.2 mg/kg) every 4 hours. Because she was quite somnolent but still in significant pain, analgesia was then changed to methadone 1 mg orally every 6 hours (approximately 0.1 mg/kg/dose) and was eventually increased over 36 hours to 2 mg every 6 hours (approximately 0.2 mg/kg/dose). She received oral methadone 0.6 mg (approximately 0.05 mg/kg) every 4 hours as needed for breakthrough pain. She continued to have severe pain and experienced side effects, including respiratory depression, sedation, visual hallucinations, and vomiting. An intravenous ketamine infusion was started at 100 microg/kg/hour. Regular opioid administration was ceased, but she was given intravenous morphine 0.5 to 0.75 mg for breakthrough pain. She required only zero to three doses of breakthrough morphine per day, initially. After starting the ketamine infusion, her pain control improved and her symptoms of opioid toxicity abated. She was more alert and able to partake in limited activities. As a result of pain from progressive disease, the ketamine infusion was increased to 200 microg/kg/hour after 6 days with positive results. Her condition continued to deteriorate. An intravenous morphine infusion was initiated 2 weeks after starting the ketamine infusion and was eventually increased to 50 microg/kg/hour. One week later, she died with reasonable pain control. This case illustrates the use of ketamine as an effective analgesic in an adjuvant setting in a pediatric patient with advanced poorly controlled cancer pain. Ketamine not only eased the child's suffering while preserving life but also improved her quality of life by maintaining the child's ability to communicate and engage in activities.

The incidence of laryngospasm with a "no touch" extubation technique after tonsillectomy and adenoidectomy.

UNLABELLED: In this case series, we evaluated the incidence of laryngospasm using a clearly defined awake tracheal extubation technique in 20 children undergoing elective tonsillectomy with or without adenoidectomy. This technique required patients to be turned to the recovery position at the end of the procedure before discontinuing the volatile anesthetics. No further stimulation, besides continuous oximetry monitoring, was allowed until the patients spontaneously woke up ("no touch" technique). The incidence of laryngospasm, oxygen saturation, and coughing was recorded. No cases of laryngospasm, oxygen desaturation, or severe coughing occurred in our patient population. IMPLICATIONS: This study re-emphasizes the importance of a sound anesthetic technique in tracheally extubating pediatric patients.