Effect of perioperative administration of ropivacaine with epinephrine on postoperative pediatric adenotonsillectomy recovery.

OBJECTIVES: To determine whether perioperative administration of ropivacaine hydrochloride with epinephrine decreases postoperative pain following adenotonsillectomy and to determine the pharmacokinetics of ropivacaine following injection. DESIGN: Prospective, randomized, double-blind clinical trial. SETTING: University pediatric ambulatory center. PARTICIPANTS: A total of 130 children, aged 2 to 12 years, undergoing adenotonsillectomy. INTERVENTION: Patients received injections, in the tonsillar fossae, of isotonic sodium chloride solution or 0.5% ropivacaine hydrochloride with epinephrine immediately following tonsillectomy. MAIN OUTCOME MEASURES: Modified objective pain score, time to 100 mL of oral intake, serial plasma ropivacaine levels, use of analgesics, incidence of retching and emesis, and other symptoms. RESULTS: Fifty-three patients (80%) in the ropivacaine group had detectable plasma levels in at least 3 of the 4 measurement time periods. The mean +/- SD peak concentration (C(max)) was 0.71 +/- 0.33 micro g/mL and the half-life was 0.96 hours. The average modified objective pain scores over all time points favored the placebo group (P =.06 test of between-subjects effects). Similarly, the average behavior score over time favored the placebo group (P =.046 test of between-subjects effects). Neck pain was better in the placebo group when averaged over postoperative days 1, 3, 7, and 14 (P =.04). The percentage of patients who had retching in the recovery room was greater in the ropivacaine group (41% vs 19%, P =.006). CONCLUSIONS: The injection of 0.5% ropivacaine with epinephrine immediately following adenotonsillectomy results in a measurable plasma level. Ropivacaine with epinephrine injection does not reduce pain postoperatively and adversely affects behavior scores, neck pain scores, and retching frequency compared with placebo. Ropivacaine with epinephrine injection for postoperative analgesia is not recommended for this patient population.

Anesthetic and recovery profiles of lidocaine versus mepivacaine for spinal anesthesia in patients undergoing outpatient orthopedic arthroscopic procedures.

STUDY OBJECTIVE: To compare isobaric lidocaine and mepivacaine in outpatient arthroscopic surgery. DESIGN: Prospective, randomized, double-blinded study. SETTING: Ambulatory surgery center affiliated with an academic tertiary-care hospital. PATIENTS: 84 adult, ASA physical status 1, 2, and 3 ambulatory patients, age 18-70 years, undergoing arthroscopic knee surgery. INTERVENTION: Patients were randomized to receive a combination spinal-epidural anesthetic using 80 mg of either isobaric 2% mepivacaine or isobaric 2% lidocaine. Patients also received a femoral 3-in-1 block with 0.5% bupivacaine applied to the affected extremity. MEASUREMENTS: Demographic data and level and duration of the block were recorded. The use of supplemental epidural anesthesia was noted along with frequency of bradycardia, hypotension, and episodes of nausea and vomiting. Duration of block and times to ambulation and voiding were recorded. Delayed variables, including fatigue, difficulty urinating, back pain, and transient neurologic symptoms (TNS) were obtained. MAIN RESULTS: No demographic differences were noted between groups, and surgical duration was similar. Satisfactory anesthesia was achieved in all cases, with no differences noted in hypotension, bradycardia, nausea, or vomiting. Onset of sensory and motor block was similar. Duration of block before epidural supplementation was 94 ± 21 minutes with lidocaine versus 122 ± 23 minutes for mepivacaine (P < 0.011). Times to ambulation and voiding were longer in patients receiving mepivacaine but did not affect PACU stay. Twenty-four and 48-hour recovery was similar with no TNS symptoms reported. CONCLUSION: No major differences were noted between lidocaine and mepivacaine spinal anesthesia. Time to ambulation and voiding were longer in patients who received mepivacaine as was time to first dose of epidural catheter. Neither group had TNS symptoms. Lidocaine and mepivacaine are both appropriate spinal anesthetics for ambulatory orthopedic lower extremity procedures.

The effect of propofol/remifentanil rapid-induction technique without muscle relaxants on intraocular pressure.

STUDY OBJECTIVE: To evaluate the effect of propofol (two mg/kg)/remifentanil (4 µg/kg) on intraocular pressure (IOP) when used for rapid-sequence induction. DESIGN: Randomized, double-blinded trial. SETTING: Ambulatory surgery center. PATIENTS: 47 adult, ASA physical status I and II patients (ages 18-75 yrs), undergoing outpatient, elective, nonophthalmologic surgery. INTERVENTIONS: After premedication with midazolam (two mg) and glycopyrrolate (0.2 mg), standard monitors and a bispectral index (BIS) monitor were applied. Patients underwent rapid-sequence induction with intravenous (IV) propofol two mg/kg and either remifentanil 4 µg/kg IV or succinylcholine 1.5 mg/kg IV. An experienced anesthesiologist, blinded to patient group assignment, performed intubation after 60 seconds. MEASUREMENTS: IOP, heart rate (HR), blood pressure, BIS scores, intubating conditions, and response to intubation (coughing or moving) were recorded at baseline, immediately after completion of induction, one minute after intubation, and three minutes after intubation. Time to return of spontaneous ventilation was also measured. MAIN RESULTS: Remifentanil produced a 39% decrease in IOP immediately after induction, which remained unchanged by laryngoscopy and intubation (P < 0.001). IOP remained below baseline even in patients who coughed or moved in response to intubation. Remifentanil caused a significant decrease in mean arterial pressure of 24% to 31% but no significant change in HR, and it blocked the hemodynamic response to laryngoscopy and intubation while providing intubating conditions comparable to those of succinylcholine. CONCLUSIONS: Propofol/remifentanil induction provides adequate intubating conditions, prevents an increase in IOP, and controls the hemodynamic stress response to laryngoscopy and intubation.

Ondansetron and dolasetron provide equivalent postoperative vomiting control after ambulatory tonsillectomy in dexamethasone-pretreated children.

UNLABELLED: In this prospective, randomized, double-blinded, placebo-controlled study, we compared the incidence of emesis and 48-h recovery profiles after a single dose of preoperative ondansetron versus dolasetron in dexamethasone-pretreated children undergoing ambulatory tonsillectomy. One-hundred-forty-nine children, 2-12 yr old, ASA physical status I and II, completed the study. All children received standardized perioperative care, including premedication, surgical and anesthetic techniques, IV fluids, analgesics, and rescue antiemetic medications. Patients were randomized to receive ondansetron 0.15 mg/kg, maximum 4 mg (Group 1); dolasetron 0.5 mg/kg, maximum 25 mg (Group 2); or saline placebo (Group 3) IV before the initiation of surgery. In addition, all patients received dexamethasone 1 mg/kg (maximum 25 mg). Rescue antiemetics were administered for two or more episodes of retching/vomiting. The incidence of retching/vomiting before home discharge did not differ between the ondansetron and dolasetron groups and was significantly less frequent compared with the placebo group (10%, Group 1; 8%, Group 2; 30%, Group 3). Similar results were obtained at 24-48 h after discharge (6%, Groups 1 and 2; 18%, Group 3). The need for rescue antiemetics administered after the second retching/vomiting episode was significantly less in Groups 1 (4%) and 2 (6%) compared with Group 3 (22%) before home discharge. The complete response rate, defined as no retching/vomiting and no antiemetic for 48 h, was significantly increased in Groups 1 (76%) and 2 (74%) compared with Group 3 (44%). The antiemetic efficacy of prophylactic ondansetron and dolasetron was comparable in dexamethasone-pretreated children undergoing ambulatory tonsillectomy. IMPLICATIONS: The efficacy of a single dose of prophylactic ondansetron versus dolasetron in conjunction with dexamethasone was studied on posttonsillectomy retching/vomiting and 48-h recovery in children 2-12 yr old. Compared with placebo, ondansetron and dolasetron produced comparable reductions in the incidence of retching/vomiting and the need for rescue antiemetics.

Postoperative analgesia in children undergoing myringotomy and placement equalization tubes in ambulatory surgery.

UNLABELLED: We enrolled 120 children undergoing bilateral myringotomy and tube placement in this prospective, randomized, observer-blinded study. Patients were randomized into one of four groups: Group 1 (control) was plain acetaminophen 10 mg/kg orally, Group 2 was acetaminophen 10 mg/kg with 1 mg/kg of codeine orally, Group 3 was transnasal butorphanol 25 micro g/kg given immediately after the induction of anesthesia, and Group 4 was ketorolac 1 mg/kg given IM immediately after the induction of anesthesia. All children received oral midazolam (0.6 mg/kg) before surgery. A nurse blinded to the analgesic technique used assessed the child's behavior at the induction of anesthesia and in the postanesthesia care unit using a 4-point scale. Analgesic effectiveness was determined by assessing the child's pain at 5-min intervals using a modified 10-point objective pain scale. In the postanesthesia care unit, rescue pain medication was administered for an objective pain scale >or=4 or a behavior score >or=3. Our data suggest that IM ketorolac is a promising analgesic to be used in this surgical population. Time to first rescue analgesic was longest in the ketorolac group, and there was no associated postoperative vomiting or nausea. IM ketorolac given during surgery was the best analgesic regimen for these procedures. IMPLICATIONS: We compared four different analgesics in the management of pain after placement of pressure equalization tubes during myringotomy in children and demonstrated that ketorolac or butorphanol provided superior analgesia when compared with acetaminophen with codeine or plain acetaminophen. Children who received ketorolac versus butorphanol had less vomiting in the 24 h after surgery.