Electroencephalographic markers of brain development during sevoflurane anaesthesia in children up to 3 years old.

BACKGROUND: General anaesthetics generate spatially defined brain oscillations in the EEG that relate fundamentally to neural-circuit architecture. Few studies detailing the neural-circuit activity of general anaesthesia in children have been described. The study aim was to identify age-related changes in EEG characteristics that mirror different stages of early human brain development during sevoflurane anaesthesia. METHODS: Multichannel EEG recordings were performed in 91 children aged 0-3 yr undergoing elective surgery. We mapped spatial power and coherence over the frontal, parietal, temporal, and occipital cortices during maintenance anaesthesia. RESULTS: During sevoflurane exposure: (i) slow-delta (0.1-4 Hz) oscillations were present in all ages, (ii) theta (4-8 Hz) and alpha (8-12 Hz) oscillations emerge by ∼4 months, (iii) alpha oscillations increased in power from 4 to 10 months, (iv) frontal alpha-oscillation predominance emerged at ∼6 months, (v) frontal slow oscillations were coherent from birth until 6 months, and (vi) frontal alpha oscillations became coherent ∼10 months and persisted in older ages. CONCLUSIONS: Key developmental milestones in the maturation of the thalamo-cortical circuitry likely generate changes in EEG patterns in infants undergoing sevoflurane general anaesthesia. Characterisation of anaesthesia-induced EEG oscillations in children demonstrates the importance of developing age-dependent strategies to monitor properly the brain states of children receiving general anaesthesia. These data have the potential to guide future studies investigating neurodevelopmental pathologies involving altered excitatory-inhibitory balance, such as epilepsy or Rett syndrome.

Stable plasma concentrations of unbound ropivacaine during postoperative epidural infusion for 24-72 hours in children.

BACKGROUND AND OBJECTIVES: The aim of this open, non-controlled, multi-centre study was to evaluate the pharmacokinetics and safety of a 24-72 h continuous epidural ropivacaine infusion in children aged 1-9 yr. METHODS: After induction of general anaesthesia, 29 ASA I-II children, scheduled for major surgery in dermatomes below T10 had lumbar epidural catheters placed. A bolus of ropivacaine, 2 mg kg(-1), was given over 4 min, followed immediately by an infusion of 2 mg mL(-1) ropivacaine 0.4 mg kg(-1) h(-1) for the next 24-72 h. RESULTS: Plasma concentrations of total ropivacaine (mean 0.83 and 1.06 mg L(-1) at 16-31 and 59-72 h, respectively) and alpha1-acid-glucoprotein (mean 13 and 25 micromol L(-1) at baseline and 59-72 h) increased over the course of the infusion. Plasma concentrations of unbound ropivacaine were stable throughout the epidural infusion (mean 0.021 range 0.011-0.068 and mean 0.016 range 0.009-0.023 mg L(-1) at 16-31 and 59-72 h, respectively) and were well below threshold levels associated with central nervous system toxicity in adults (0.35 mg L(-1)). Apparent unbound clearance (mean 346, range 86-555 mL min(-1) kg(-1)) showed no age-dependency. No signs of systemic toxicity or cardiovascular effects were observed. All patients received additional analgesics with morphine. CONCLUSION: Following a 24-72 h epidural infusion of ropivacaine 0.4 mg kg(-1) h(-1) in 1-9-yr-old children, the plasma concentrations of unbound ropivacaine were stable over time with no age-dependency.

Activation of purified 3-hydroxy-3-methylglutaryl-CoA reductase by phospholipids.

3-Hydroxy-3-methylglutaryl-CoA reductase (HMG-CoA reductase), the enzyme that catalyzes the rate-limiting step in cholesterol biosynthesis, has been purified by two previously reported procedures. Enzyme purified by the method of Heller, R. and Shrewsbury, M. (1976) J. Biol. Chem. 251, 3815-3822) shows up to 3-fold enhancement of activity by various types of lipid dispersions while the enzyme purified by the procedure of Tormanen et al. ((1976) Biochem. Biophys. Res. Commun. 68, 754-762) shows no activation. These results suggest that interaction with microsomal membrane lipids may be important in determining the activity of this enzyme. Analysis of bound lipid showed that enzyme prepared by the procedure of Tormanen contained at last 50 times as much phospholipid on a weight basis as enzyme prepared by Heller and Shrewsbury. Analysis of both preparations by gel-electrophoresis indicates that enzyme activities of the two comigrate, but in neither case does activity coincide with the major protein species.

Glutamate-induced sensitization of rat masseter muscle fibers.

In rats, intradermal or intraarticular injection of glutamate or selective excitatory amino acid receptor agonists acting at peripheral excitatory amino acid receptors can decrease the intensity of mechanical stimulation required to evoke nocifensive behaviors, an indication of hyperalgesia. Since excitatory amino acid receptors have been found on the terminal ends of cutaneous primary afferent fibers, it has been suggested that increased tissue glutamate levels may have a direct sensitizing effect on primary afferent fibers, in particular skin nociceptors. However, less is known about the effects of glutamate on deep tissue afferent fibers. In the present study, a series of experiments were undertaken to investigate the effect of intramuscular injection of glutamate on the excitability and mechanical threshold of masseter muscle afferent fibers in anesthetized rats of both sexes. Injection of 1.0 M, but not 0.1 M glutamate evoked masseter muscle afferent activity that was significantly greater than that evoked by isotonic saline. The mechanical threshold of masseter muscle afferent fibers, which was assessed with a Von Frey hair, was reduced by approximately 50% for a period of 30 min after injection of 1.0 M glutamate, but was unaffected by injections of 0.1 M glutamate or isotonic saline. Injection of 25% dextrose, which has the same osmotic strength as 1.0 M glutamate, did not evoke significant activity in or decrease the mechanical threshold of masseter muscle afferent fibers. Magnetic resonance imaging experiments confirmed that injection of 25% dextrose and 1.0 M glutamate produced similar edema volumes in the masseter muscle tissue. Co-injection of 0.1 M kynurenate, an excitatory amino acid receptor antagonist, and 1.0 M glutamate attenuated glutamate-evoked afferent activity and prevented glutamate-induced mechanical sensitization. When male and female rats were compared, no difference in the baseline mechanical threshold or in the magnitude of glutamate-induced mechanical sensitization of masseter muscle afferent fibers was observed; however, the afferent fiber activity evoked by injection of 1.0 M glutamate into the masseter muscle was greater in female rats. The results of the present experiments show that intramuscular injection of 1.0 M glutamate excites and sensitizes rat masseter muscle afferent fibers through activation of peripheral excitatory amino acid receptors and that glutamate-evoked afferent fiber activity, but not sensitization, is greater in female than male rats.

High sensitivity quantification of RNA from gels and autoradiograms with affordable optical scanning.

To increase sensitivity and to improve normalization of RNA levels in Northern blot analysis, a comparatively inexpensive optical scanner was utilized for digitizing photonegatives of ethidium bromide stained gels and autoradiograms. The optical scanner captures the image with a maximum resolution of 300 dots per inch by assigning one of 256 gray levels (8-bit) to each dot in the image. With the use of the public domain NIH Image program (requires a Macintosh II and an 8-bit video card), gel or autoradiogram bands in the digitized image are selected and their average gray scale density measured. We found that the digitized image of a photonegative of a TAE (Tris-acetate/EDTA) agarose gel, loaded incrementally with 50-1500 ng total RNA, produced a linear response over a 4-fold range down to 100 ng (R2 greater than 0.950). In utilizing "quantification" gels like this, RNA samples that are too dilute or too small for traditional spectrophotometric techniques can be normalized and loaded uniformly onto subsequent Northern gels. Results from autoradiogram scans demonstrate highly linear gray scale responses over a 4-fold range of total RNA (R2 greater than 0.950) that are reproducible with different blots and probe types (e.g., riboprobe, cDNA and oligonucleotide). In addition, we describe a normalization technique using a 30-mer oligonucleotide probe for rat 28S ribosomal RNA as a measure of total RNA loaded per gel lane. Altogether, this scanning, ribosomal RNA normalization system allows the measurement of relative changes between 20% and 400% using standard autoradiographic methods.

Midazolam for conscious sedation during pediatric oncology procedures: safety and recovery parameters.

Multiple bone marrow aspirations or biopsies and lumbar punctures are a necessary part of the diagnosis and treatment of many pediatric cancer patients. Pharmacologic sedation may decrease the distress associated with these procedures. Midazolam (MDZ, Versed) is a water-soluble, rapid-onset, short-duration benzodiazepine that has not been studied widely in children. We prospectively evaluated safety and recovery parameters for intravenous MDZ used for conscious sedation by oncologists (without an anesthesiologist in attendance) for 70 procedures (bone marrow aspirations, lumbar punctures, or bone marrow aspirations plus lumbar punctures) in 24 ambulatory pediatric cancer patients, aged 1.5 to 15.5 years. MDZ was used alone or in combination with morphine or fentanyl. Respiratory rate, oxygen saturation, blood pressure, and heart rate were monitored. Sedation, anxiolysis, and recovery were assessed with a behavior score and a modified recovery room discharge score. Restraint was not required in 45% of the procedures. In no case was a respiratory rate less than 12 observed. In nine procedures (13%), an oxygen saturation less than or equal to 90 occurred, all within 10 minutes after the last dose of MDZ. Ten procedures (14%) required verbal stimulation to take deeper breaths. Two patients did not respond immediately to verbal stimulation and received face-mask oxygen. Hypoxemia was not correlated with opioid use. Hypoxemia appears to be related to total MDZ dose and may occur with normal respiratory rates; all cases resolved with verbal stimulation or face-mask oxygen without specific airway maneuvers or assisted ventilation. Heart rate and blood pressure remained stable in all 70 procedures.(ABSTRACT TRUNCATED AT 250 WORDS)

Chronic pain in cystic fibrosis.

OBJECTIVE: The objective of this study was to examine the incidence and therapy of chronic pain in a group of older patients with cystic fibrosis (CF). PATIENTS: We identified two groups of patients followed at the CF Center at Children's Hospital (Boston); the first group consisted of all patients above the age of 5 years who died between 1984 and 1993, and the second was a cohort of 23 additional CF patients who had been referred to the Pain Treatment Service. DESIGN: Medical charts were reviewed for the etiology and therapy of all pain episodes requiring medical intervention. RESULTS: The incidence of chronic pain in this population increased sharply in the last 6 months of life. Headaches (55% of patients) and chest pain (65%) were frequently reported, although back pain (19%), abdominal pain (19%), and limb pain (16%) were also reported. In patients with headache, the main etiologies were hypercarbia or hypoxia, migraine, and sinusitis. The majority of chest pain was musculoskeletal, with pleuritis, pneumothorax, and rib fracture also reported as the cause of chest pain. INTERVENTIONS: A variety of nonpharmacological and pharmacological therapies were reported. Forty-one patients (53%) had pain severe enough to require opioid treatment, and 10 patients (13%) received opioids for more than 3 months. In eight patients with more severe pain, regional analgesia was found to be particularly effective. CONCLUSIONS: Chronic pain is a common problem in CF, particularly as the patient population ages. When administered with caution, opioids have proven to be effective and safe in this population; regional anesthesia can be used to preserve pulmonary toilet while adequately treating severe pain.

Regional analgesia on pediatric medical and surgical wards.

Regional anesthetic approaches to pain management were examined in 72 children and young adults (ages 3 weeks to 31 years) who were observed on the surgical or medical wards of a children's hospital separate from intensive care areas. A protocol was devised to permit safe conduct of these techniques on the ward. Full resuscitation supplies were kept at each bedside. All patients receiving epidural narcotics had an apnea monitor, hourly counting of respiratory rates, and restriction of systemic analgesics. All bolus re-injections into the catheters were performed by an anesthesiologist who monitored the patient for 20 min. Minor side-effects, including pruritus, nausea, and urinary retention were common, but manageable. Significant complications included: one case of decubitus ulcers requiring skin-grafting, one episode of mild hypotension in a patient with terminal malignancy, requiring ephedrine and phenylephrine, and one mild toxic reaction on test dosing due to presumed intravascular migration of a lumber sympathetic catheter. Regional analgesic techniques can provide excellent analgesia on the wards for selected children and young adults, provided precautions are taken. Further study is required to define specific indications, risks and benefits relative to simpler techniques.

Dextroamphetamine or methylphenidate as adjuvants to opioid analgesia for adolescents with cancer.

The doses of opioid analgesics required to control pain in patients with cancer may result in somnolence and reduced interaction with family members. Psychostimulants such as dextroamphetamine (DA, Dexedrine) or methylphenidate (MP, Ritalin) have been used in adults to counteract the sedation of opioid analgesia. We retrospectively reviewed our experience using these agents at Children's Hospital. Eleven patients (age 12-20 years) received DA or MP, and decreased somnolence or improved interaction was noted in five patients. Adverse effects potentially related to DA or MP were noted in two patients, none of which resulted in discontinuance of the stimulant. Further prospective, controlled studies are needed to assess the safety and efficacy of DA and MP in counteracting the sedation of opioid analgesia in children and adolescents.

Intravenous amitriptyline in pediatrics.

Oral amitriptyline has been used as an analgesic in a wide range of pain settings. Despite long-term availability of a parenteral form, the few reports about this formulation have been limited to pharmacokinetic studies in normal volunteers, trials in depressed patients, and analyses of electroencephalogram (EEG) activation. We retrospectively reviewed our experience using intravenous (IV) amitriptyline at Children's Hospital, Boston and at Children's Hospital at Stanford. Eight children (aged 5-16.6 years), who were unable to tolerate medications by the oral route, received IV amitriptyline for a variety of indications, including neuropathic pain, depression, sleep disturbance, and as an adjuvant agent for opioid analgesia. One patient experienced an extrapyramidal reaction temporally related to the administration of IV amitriptyline, which was successfully managed with diphenhydramine. Further prospective, controlled studies are needed to further assess the safety, efficacy and tolerability of this novel use of amitriptyline.

Discordance between self-report and behavioral pain measures in children aged 3-7 years after surgery.

This study examined concurrent self-reports of pain intensity and behavioral responses in 25 children aged 3-7 yr. Behavioral (Children's Hospital of Eastern Ontario Pain Scale, CHEOPS) and self-report (the Oucher and Analogue Chromatic Continuous Scale) measures of pain were obtained following major surgery. The two self-report measures were strongly and significantly correlated, and the pattern of scores over the 36-hr observation period was as expected. There was little relationship between the scores for the self-report and the behavioral measures. Many children who reported severe pain manifested few of the behavioral indicators of distress used in the CHEOPS. This behavioral response pattern may occur commonly in children experiencing pain after surgery and may limit the applicability of current behavioral scales as sole measures of pain intensity in younger children.

Reflex sympathetic dystrophy in children. Clinical characteristics and follow-up of seventy patients.

We report on the experience with our first seventy patients who had reflex sympathetic dystrophy and were less than eighteen years old (average age, 12.5 years). In our series, the patients were predominantly girls (male to female ratio, 11:59) and the lower extremity was involved most often (sixty-one of the seventy patients). The average time from the initial injury to the diagnosis was one year, which indicates that the syndrome remains under-recognized in patients in this age-group. Conservative treatment with physical therapy, transcutaneous electrical nerve stimulation, psychological therapies including cognitive-behavioral management and relaxation training, and tricyclic anti-depressants was effective in improving the average scores for pain and function for forty patients. Sympathetic blocks were helpful for twenty-eight of thirty-seven patients. Thirty-eight of the seventy patients in the series continued to have some degree of residual pain and dysfunction. Reflex sympathetic dystrophy in children differs in presentation and clinical course from the syndrome in adults. It is best treated in a multidisciplinary fashion.

Monitoring intravenous fat emulsions in neonates with the fatty acid/serum albumin molar ratio.

Weekly determinations of the fatty acid/albumin molar ratio (FA/SA) were obtained 136 times on 50 neonates (birthweight range, 675-4300 grams; median, 1360 grams) to determine if our use of intravenous fat (IVF) was putting these newborns at risk for kernicterus. The FA/SA was measured using a convenient spectrophotometric technique which we have previously described (Berde CB, Kerner JA, Johnson JD: Clin Chem 26:1173-1177, 1980). Twenty-nine infants received IVF with doses from 0.5 to 3.3 gram/kilogram/day (mean 1.5 gram/kilogram/day), given over 24 hours whenever possible, most commonly begun in the second week of life when the bilirubin level was less than one half of the potential exchange level. Twenty-one infants received no IVF. Previous studies show that fatty acids do not begin to displace bilirubin from albumin until the FA/SA is greater than 6 in vivo, and greater than 4 in vitro. All our infants had safe values with mean FA/SA values of approximately 1.0. Continuous IVF as we administer it does not place neonates at risk for kernicterus. Centers administering IVF in the first week of life or by bolus should consider close monitoring of their infants with the FA/SA.

Pediatric postoperative pain management.

This article reviews methods to relieve postoperative pain in most children. It also discusses the major barriers to treatment and considers the provision of opioids via a painless route as an alternative to the more usual intramuscular (and painful) route.

Pharmacologic management of pain in children and adolescents.

In the management of chronic pain conditions, the combination of pharmacologic measures with physical and psychologic modalities becomes even more important. A pain clinic and pain consultation service are one model that facilitates this combined approach. Initial management of mild to moderate pain begins with nonopioid analgesics such as acetaminophen and NSAIDs. Persistent severe pain of a neuropathic character merits careful trials of antidepressants or anticonvulsants. Traditionally, use of opioids for chronic pain not due to cancer has been discouraged for adults as well as children. Recently, this view was challenged by reports by Portenoy and Foley and by Taub, who followed a group of adults with chronic pain due to a variety of conditions. They found that the majority of these patients, if managed with opioids on a regular schedule as part of an overall treatment program, could be made comfortable and were able to increase their level of functioning for several years. In general, dosage escalation and compulsive drug-seeking behaviors were not seen. Since this report was retrospective and did not involve children, caution must be applied in extrapolating these findings to children. For example, remarkably little is known about the effects of chronic opioid administration in childhood on growth and development. Certainly, this issue deserves further study before general recommendations can be made. It seems prudent to emphasize the importance of maximizing nonpharmacologic and nonopioid approaches in the management of chronic pain in children prior to embarking on long-term use of opioids.

Effects of adrenergic agonists and antagonists on tetrodotoxin-induced nerve block.

BACKGROUND AND OBJECTIVES: The relative contributions of alpha(1)-, alpha(2)-, and beta-adrenergic receptors to adrenergic agonists' prolongation of nerve block by tetrodotoxin (TTX) are unknown. We investigated which receptor agonists prolong TTX block, and whether delayed injection of antagonists can interrupt prolonged blocks after coinjection of TTX and agonists. METHODS: Rats received percutaneous sciatic nerve block with 120 micromol/L TTX with and without adrenergic agonists and antagonists. Block duration was assessed by a modified hot-plate test. Functional deficits in the uninjected leg were used to assess systemic distribution of TTX. Data were expressed as medians with 25th and 75th percentiles. RESULTS: Coinjection of 5.5 micromol/L phenylephrine (alpha(1)-specific), 10 micromol/L clonidine (alpha(2)-specific), and 1.1 micromol/L epinephrine (mixed alpha- and beta-agonist) prolonged TTX nerve block, but 5.5 micromol/L isoproterenol (mixed beta-agonist) did not. Yohimbine inhibited TTX block prolongation by clonidine (median inhibitory concentrations, IC(50) = 130 nmol/L); phentolamine similarly inhibited epinephrine (IC(50) = 45 nmol/L). Adrenergic antagonists did not inhibit the prolongation of TTX block by agonists when injected 3 or 6 hours after the initial block. Subcutaneous injection of adrenergic agonists at a remote site did not prolong TTX block, except for a modest prolongation by clonidine. CONCLUSION: TTX block can be prolonged by alpha(1)- and alpha(2)-, but not beta-adrenergic agonists via locally mediated events of relatively brief duration. Delayed injection of adrenergic antagonists does not interrupt the prolonged blocks produced by coinjection of TTX and adrenergic agonists unless administered soon after block is established. Reg Anesth Pain Med 2001;26:239-245.

The local anesthetic properties and toxicity of saxitonin homologues for rat sciatic nerve block in vivo.

BACKGROUND AND OBJECTIVES: Saxitoxin and its homologues are naturally occurring compounds that block the sodium channel with high potency. They have the potential for providing prolonged duration local anesthesia when coinjected with vasoconstrictors or conventional local anesthetics and are devoid of local neurotoxicity. Here, we compare sciatic nerve block with saxitoxin to those with neosaxitoxin, decarbamoyl saxitoxin, and tetrodotoxin (TTX), in a search for even safer compounds. METHODS: Rats received percutaneous sciatic nerve block with toxins. The compounds were compared in terms of lethality, onset and duration of action for thermal analgesia (hot-plate testing), and motor block (weight-bearing). Data were expressed as medians with 25th and 75th percentiles, and median effective concentrations were determined. RESULTS: The median concentrations at which analgesia of 60 minutes duration was achieved were neosaxitoxin, 34+/-2 micromol/L; saxitoxin, 58+/-3 micromol/L; TTX, 92+/-5 micromol/L; and decarbamoyl saxitoxin, 268+/-8 micromol/L. Similar trends were observed for other measures of effectiveness (block duration of 90 minutes, maximal block), and for lethality so that the therapeutic indices were similar. No toxin had a marked predominance of sensory or motor block. The potency of TTX was intermediate between those of the saxitoxins, and its therapeutic index was slightly better. No difference was observed in time to onset of nerve blockade among the toxins. CONCLUSIONS: Substitutions on the saxitoxin nucleus result in large differences in incidence and duration of block, and toxicity. The therapeutic indices of the saxitoxins are similar; that of TTX is slightly better.

Prolonged local myometrial blockade prevents preterm labor after fetal surgery in a leporine model.

BACKGROUND/PURPOSE: Postoperative premature labor remains the foremost limiting factor to the development of fetal surgery. Most attempts at controlling this complication have involved the use of drugs delivered systemically to the mother. This study assessed the effects of prolonged local anesthetic blockade of the myometrium on preterm delivery after open fetal surgery. METHODS: Eighteen New Zealand rabbits at 23 days' gestation (term, 31 to 33 days) were divided in three groups. In group I (n = 6), the most proximal fetuses of both uterine horns were submitted to open amputation of a forelimb; in a few animals, one of the uterine horns was empty, hence, only one fetus was manipulated. In groups II (n = 5) and III (n = 7), an identical surgical procedure was performed. In group II, immediately before hysterotomy, the myometrium was injected with 0.5 mL of 0.5% bupivacaine along the incision line. In group III, only saline was injected. In group II, before uterine closure, the incised area of the myometrium was injected with 1.5 mL of a novel suspension of biodegradable polylactic-co-glycolic acid microspheres loaded with 75% w/w bupivacaine and 0.05% w/w dexamethasone. This suspension previously has been shown to provide peripheral nerve blockade for approximately 5 days. In group III, microspheres without any drug were injected. RESULTS: Abortion rates were significantly different among the groups: 83.3% (five of six) for the does in group I, zero in group II, and 71.4% (five of seven) in group III (P < .05). The absence of abortions observed in group II occurred despite the fact that the fetal mortality rate was significantly higher in this group (87.5%, seven of eight fetuses) than in groups I (0) and III (33.3%, 4 of 12 fetuses, P < .05). CONCLUSIONS: Prolonged local blockade of the myometrium with bupivacaine inhibits preterm labor after fetal surgery in rabbits. The high fetal mortality rate observed in this study may be caused by "transplacental" transfer of the local anesthetic to the fetus. Notably, the abortifacient effect of a dead fetus was completely suppressed by the local blockade. Studies using microspheres with local anesthetics that do not cross the placenta, in animal models with longer gestational periods, are warranted.

Continuous caudal anesthesia for inguinal hernia repair in former preterm infants.

STUDY OBJECTIVE: To determine the feasibility of continuous caudal anesthesia with 2-chloroprocaine in conscious former preterm infants undergoing inguinal hernia repair. DESIGN: Prospective study. SETTING: University-affiliated children's hospital. PATIENTS: Ten former preterm infants, ASA physical status II and III, who were 35 to 49.5 weeks postconceptional age at the time of surgery. INTERVENTIONS: Caudal anesthesia was administered via an indwelling catheter using a loading dose of 1 ml/kg (30 mg/kg) of 3% 2-chloroprocaine, followed by incremental doses of 0.3 ml/kg (9 mg/kg) to achieve a level of T4 to T2. The block was maintained by a minimum infusion rate of 30 mg/kg/hr (1 ml/kg/hr) of the same local anesthetic solution. MEASUREMENTS AND MAIN RESULTS: The mean cumulative dose of 2-chloroprocaine was 2.8 +/- 1.0 ml/kg/hr (84 +/- 30 mg/kg/hr) infused over a mean duration of 95 +/- 35 minutes. Serum cholinesterase concentration and plasma 2-chloroprocaine concentration were measured in five infants. CONCLUSIONS: Three percent 2-chloroprocaine can be used effectively for continuous caudal anesthesia in conscious, former preterm infants for inguinal hernia and penoscrotal surgical procedures lasting 85 to 170 minutes.

Management of tracheobronchial and esophageal foreign bodies in children: a survey study.

STUDY OBJECTIVE: To assess the current anesthetic management for aspiration of a foreign body into the airway and esophagus of a young child. DESIGN: Questionnaire study. MEASUREMENTS AND MAIN RESULTS: A questionnaire regarding choice of induction technique in a variety of foreign body clinical scenarios was sent to 1,342 anesthesiologists, all members of the Society for Pediatric Anesthesia. The foreign body, either a coin (penny) or a safety pin (open), was positioned on radiography in a variety of anatomic locations. Depending on the foreign body location, the patient was either asymptomatic or exhibited symptoms. Participants indicated their choice of induction for each situation. Of the 1,342 questionnaires mailed, there were 838 respondents (62.4%). Coins and pins in the gastroesophageal tract were managed mostly by a rapid-sequence induction (p < 0.001). Coins and pins at all levels in the tracheobronchial tree were managed most often by a mask induction with no cricoid pressure (p < 0.001). Although 14.5% of respondents chose awake and sedated technique for a foreign body in the supraglottic area, few chose this technique for a foreign body in other locations. The type of object did not affect the choice of drugs for induction of anesthesia in most anatomic locations. Respondents with limited pediatric anesthesia experience used inhalation induction much less often than did those with more experience. Multiple-logistic regression analysis showed that both number of years in practice and type of practice (university, private, hybrid) were predictors for the induction. CONCLUSIONS: These data indicate that inhalation induction is favored most often for removal of foreign bodies in the airway, while intravenous induction is preferred for removal of foreign bodies in the gastroesophageal tract. In addition, practice type, greater percentage of time spent in pediatric anesthesia, and greater experience are related to a higher likelihood of inhalation induction.