Effects of Carbon Dioxide Insufflation and Trendelenburg Position on Brain Oxygenation During Laparoscopy in Children.

PURPOSE: Laparoscopic appendectomy has become more popular compared with the open appendectomy in children, but there are limited data on the effects of pneumoperitoneum and Trendelenburg position on cerebral oxygenation. This study was designed to evaluate the changes in cerebral saturation using near-infrared spectroscope during laparoscopic surgery in children. METHODS: The children underwent laparoscopic (LAP Group, n=22) or open appendectomy (OPEN Group, n=22). Right and left cerebral oxygenation (RScO2-LScO2), heart rate (HR), mean arterial pressure (MAP), end-tidal CO2pressure (PETCO2), and peripheral oxygen saturations (SpO2) were recorded between anesthesia induction (T0, baseline), after induction (T1), after intubation (T2), 5 minutes after intubation (T3), 5 minutes after pneumoperitoneum-15th minute at OPEN (T4), 5 minutes after Trendelenburg-20th minute at OPEN (T5), 30 minutes after pneumoperitoneum-45th minute at OPEN (T6), 5 minutes after supine position-skin suturing at OPEN (T7), 5 minutes postextubation (T8). RESULTS: Groups were similar with respect to their demographic data. In LAP group, a significant increase in HR was recorded at T5. No significant difference was observed in the MAP, PETCO2, SpO2, RScO2, and LScO2 values between the groups. There was a significant increase in the perioperative T1 to T8 values compared with the T0 values in LScO2 of the LAP group. CONCLUSIONS: Our results suggest that pneumoperitoneum and Trendelenburg position does not alter the hemodynamic values and can be safely performed in children without altering regional brain oxygenation levels.

Effect of video-based education on anxiety and satisfaction of patients undergoing spinal anesthesia / Efeito de informações por meio de vídeo sobre a ansiedade e satisfação de pacientes submetidos à anestesia espinhal

Abstract Background: Providing sufficient information during a preanesthetic interview may help improve patient understanding and decrease anxiety related to spinal anesthesia. We investigated the effect of video-based education on anxiety and satisfaction in patients about to undergo spinal anesthesia. Methods: A total of 198 patients scheduled for minor elective surgery under spinal anesthesia were prospectively enrolled. The State-Trait Anxiety Inventory (State-Trait Anxiety Inventory/State and State-Trait Anxiety Inventory/Trait) questionnaires and visual analog scale were used to measure anxiety levels before the standard anesthesia evaluation was initiated. Then, 100 patients in Group 1 received written, verbal, and video-based education, whereas 98 patients in Group 2 received only written and verbal instructions regarding spinal anesthesia. Then all participants completed the State-Trait Anxiety Inventory/State and visual analog scale to evaluate anxiety. Finally, a 5-point Likert scale was used to measure satisfaction during postoperative period. Results: No differences were found in the State-Trait Anxiety Inventory/State, State-Trait Anxiety Inventory/Trait, or visual analog scale scores between the two groups before the information period. The State-Trait Anxiety Inventory/State scores evaluating anxiety during the post-information period were differed in both groups and they found as 36.5 ± 10.0 in Group 1 and 39.6 ± 8.6 in Group 2 (p = 0.033). The 5-point Likert scale scores to measure satisfaction were stated as 4.5 ± 0.6 in Group 1 and 3.5 ± 1.2 in Group 2 (p < 0.001). Conclusions: Providing video-based information during the preanesthetic interview alleviated anxiety and increased satisfaction in patients undergoing spinal anesthesia.

Resumo Justificativa: Fornecer informação suficiente durante uma consulta pré-anestesia pode aumentar a compreensão do paciente e diminuir a ansiedade relacionada à anestesia espinhal. Investigamos o efeito do fornecimento de informação via vídeo sobre a ansiedade e satisfação em pacientes prestes a serem submetidos à anestesia espinhal. Métodos: Foram inscritos prospectivamente 198 pacientes agendados para cirurgias eletivas de pequeno porte sob anestesia espinhal. Os questionários de avaliação de estado e traço de ansiedade (State-Trait Anxiety Inventory/State e State-Trait Anxiety Inventory/Trait) e uma escala visual analógica foram usados para medir os níveis de ansiedade antes de a avaliação-padrão da anestesia ter sido iniciada. Em seguida, 100 pacientes do Grupo 1 receberam informação por escrito, verbal e via vídeo, enquanto 98 pacientes do Grupo 2 receberam apenas informação por escrito e verbal sobre a anestesia espinhal. Em seguida, todos os participantes responderam os inventários de estado e traço de ansiedade e a escala visual analógica para avaliar a ansiedade. Por fim, a escala de Likert de 5 pontos foi usada para medir a satisfação durante o período pós-operatório. Resultados: Não houve diferença nos escores dos questionários de estado e traço de ansiedade e da escala visual analógica entre os dois grupos antes do período de informação. Os escores de estado e traço de ansiedade que avaliam a ansiedade durante o período pós-informação foram diferentes em ambos os grupos: 36,5 ± 10,0 no Grupo 1 e 39,6 ± 8,6 no Grupo 2 (p = 0,033). Os escores da escala Likert de 5 pontos para medir a satisfação foram: 4,5 ± 0,6 no Grupo 1 e 3,5 ± 1,2 no Grupo 2 (p < 0,001). Conclusão: Fornecer informação via vídeo durante a consulta pré-anestésica aliviou a ansiedade e aumentou a satisfação em pacientes submetidos à anestesia espinhal.

[Effect of video-based education on anxiety and satisfaction of patients undergoing spinal anesthesia]. / Efeito de informações por meio de vídeo sobre a ansiedade e satisfação de pacientes submetidos à anestesia espinhal.

BACKGROUND: Providing sufficient information during a preanesthetic interview may help improve patient understanding and decrease anxiety related to spinal anesthesia. We investigated the effect of video-based education on anxiety and satisfaction in patients about to undergo spinal anesthesia. METHODS: A total of 198 patients scheduled for minor elective surgery under spinal anesthesia were prospectively enrolled. The State-Trait Anxiety Inventory (State-Trait Anxiety Inventory/State and State-Trait Anxiety Inventory/Trait) questionnaires and visual analog scale were used to measure anxiety levels before the standard anesthesia evaluation was initiated. Then, 100 patients in Group 1 received written, verbal, and video-based education, whereas 98 patients in Group 2 received only written and verbal instructions regarding spinal anesthesia. Then all participants completed the State-Trait Anxiety Inventory/State and visual analog scale to evaluate anxiety. Finally, a 5-point Likert scale was used to measure satisfaction during postoperative period. RESULTS: No differences were found in the State-Trait Anxiety Inventory/State, State-Trait Anxiety Inventory/Trait, or visual analog scale scores between the two groups before the information period. The State-Trait Anxiety Inventory/State scores evaluating anxiety during the post-information period were differed in both groups and they found as 36.5±10.0 in Group 1 and 39.6±8.6 in Group 2 (p=0.033). The 5-point Likert scale scores to measure satisfaction were stated as 4.5±0.6 in Group 1 and 3.5±1.2 in Group 2 (p<0.001). CONCLUSIONS: Providing video-based information during the preanesthetic interview alleviated anxiety and increased satisfaction in patients undergoing spinal anesthesia.

Comparison of anesthetic agents on otoacoustic emissions in children: propofol vs ketamine.

BACKGROUND: Otoacoustic emission (OAE) tests are important evaluation tools for diagnosis of peripheral auditory pathology. Sedation or general anesthesia may be required for the performance of the OAE tests. The aim of this retrospective study was to compare the effects of anesthetic agents, propofol and ketamine, on OAEs in children. METHODS: Fifty healthy children who underwent tonsillectomy and/or adenoidectomy under general anesthesia were included in this study. Three anesthesia induction protocols were defined for this study and the anesthesiologist applied his or her own choice. Transient evoked otoacoustic emissions (TEOAEs) and distortion-product otoacoustic emissions (DPOAEs) were automatically recorded in both ears of each patient prior to anesthetic (predrug) and following the loss of consciousness 5 min later (postdrug) by an audiologist blinded to the method of anesthesia. Acceptable TEOAEs were defined as signal noise ratio (S/N) of above 3 dB SPL (decibel sound pressure level) and DPOAEs of 6 dB SPL or above. Between-group and within-group comparisons and correlations were performed for statistical analysis. RESULTS: Retrospective review of the anesthesia charts from 44 cases that completed the study showed that propofol, ketamine, and sevoflurane induction protocols were used in 21, 18, and 5 cases, respectively. Measurements of 36 ears in the propofol group and 34 ears in the ketamine group were included in the final analysis. Postdrug TEOAE and DPOAE amplitudes were significantly lower than predrug amplitudes except at 8 kHz in the ketamine group. There was no significant statistical difference in postdrug DPOAE measurements between propofol and ketamine groups but a significant difference was observed at 2 and 3 kHz of postdrug TEOAE measurements. TEOAE measurements were below 3 dB in 8 of 34 ears after ketamine and in 1 of 36 ears after propofol administration. There was a significant difference between the groups with respect to the incidence of successful measurements of TEOAEs. The DPOAE measurements were affected less by these drugs. CONCLUSION: DPOAE measurements were reduced similarly by propofol and ketamine anesthesia. Lower false outcome ratio in TEOAE measurements made propofol a better option than ketamine.

The effect of lidocaine, bupivacaine and ropivacaine in nasal packs on pain and hemorrhage after septoplasty.

We aimed to investigate the effects of local anesthetics soaked in Merocel nasal packs on hemorrhage and pain after septoplasty. The methodology includes a prospective double-blind study that was conducted in patients undergoing septoplasty because of nasal septal deviation. The study included 143 patients. The patients were divided into four groups. Each group received 1% lidocaine + 0.000625% adrenalin, 0.375% ropivacaine, 0.25% bupivacaine as study groups or 0.9% sodium chloride as a control group in their Merocel packs postoperatively. The local anesthetics or sodium chloride were reapplied at the eighth postoperative hour. Each patient was given a questionnaire where verbal analog score and amount of postoperative hemorrhage was noted. The statistical analysis was performed using two sided t test on each patient group at each time point. The results included the patients in the control group needing rescue drug most often. There was no statistically significant difference between bupivacaine and lidocaine plus adrenalin in the patients who requested rescue drug. The patients in the ropivacaine group requested rescue drug more frequently than the bupivacaine and lidocaine plus adrenalin groups. Bupivacaine group had significantly better pain scores versus control group at all intervals except for the first postoperative hour.The bupivacaine group had better pain scores versus ropivacaine and lidocaine plus adrenalin groups in the 4th, 8th and the 24th hours. The bupivacaine group had better pain scores versus lidocaine plus adrenalin in the 12th, 16th and the 20th hours. The ropivacaine group had significantly better pain scores versus control group in the 8th, 12th, 16th, 20th and 24th postoperative hours. The ropivacaine group scored better than lidocaine plus adrenalin group just in the 16th hour. The lidocaine plus adrenalin group had significantly better pain scores versus control group in 4th and 12th hours. There was no statistically significant difference between the study groups in terms of postoperative hemorrhage. We concluded that bupivacaine use in nasal surgery provides better analgesia at least in the first 8 h period and does not cause more bleeding. Topical bupivacaine application to nasal packs should be considered after septoplasty.

Effect of pneumoperitoneum on the level of plasma potassium.

The purpose of this study was to find out the impact of acute respiratory acidosis on serum potassium level during laparoscopy. The study was performed on ninety patients who underwent laparoscopic surgery. Ventilation parameters were kept constant throughout the study. Samples for assessment of blood gases were collected in the following sequence: before pneumoperitoneum, a the 20th minute of pneumoperitoneum, at the 60th minute of pneumoperitoneum, and after extubation. The systolic, diastolic pressures and heart rate were recorded simultaneously. Before pneumoperitoneum, heart rate, systolic and diastolic pressures were reduced according to baseline values. With the induction of pneumoperitoneum, both systolic and diastolic pressures returned to the baseline levels except the heart rate. There was a statistically significant increase in potassium level (Control: 3.49 mEq.L(-1), determined high level: 3.75 mEq.L(-1)). Electrolytes, especially potassium, should be monitored during laparoscopy utilizing CO2 pneumoperitoneum and when necessary, ventilatory parameters should be adjusted.

Premedication of the pediatric patient - anesthesia for the uncooperative child.

PURPOSE OF REVIEW: Inadequate handling of an uncooperative child preoperatively results in postoperative behavior problems. Premedication enables a calm induction and helps to decrease postoperative problems. Several premedicants will be covered in this review. RECENT FINDINGS: Questions raised about the effects of oral midazolam use in children for premedication are now finding answers. New agents (dexmedetomidine and atypical antipsychotic agents) can be alternatives in premedication, especially in severely uncooperative children. The current literature highlights the missing information about the rather older premedicants. SUMMARY: The benefits and disadvantages of new and older drugs should be weighed against each other, and decisions should be made according to the requirements of surgery, ward conditions and the severity of psychologic, developmental or mental disease. Further studies for the evaluation of the anxiolytic, sedative and antipsychotic drugs are still required.

Does tramadol wound infiltration offer an advantage over bupivacaine for postoperative analgesia in children following herniotomy?

BACKGROUND: It has been demonstrated that tramadol is an effective analgesic. We aimed to compare postoperative analgesic effects of wound infiltration with tramadol (T) or bupivacaine (B) and intramuscular tramadol (I) after herniotomy in children. METHODS: In this study, 75 children were randomly assigned to group T, group B and group I. Wound infiltration was performed to the patients in group T (2 mg.kg-1 tramadol in 0.2 ml.kg-1 saline) and group B (0.2 ml.kg-1 0.25% bupivacaine) into the surgical incision. Twenty minutes before the end of the surgery 2 mg.kg-1 tramadol was injected i.m. in group I. Faces pain scale was used for assessing pain severity. Patients with pain score>2 were treated with paracetamol. The frequency of side effects and analgesic use were recorded. Patients were discharged on the next day. RESULTS: No side effects were recorded in any group. The pain scores of the patients at the first, fourth and eighth hours were significantly higher in group B and group I than group T (P<0.05). The pain scores of the patients at the first hour were significantly higher in group I compared with group B (P<0.05). Average time to first analgesic requirement was significantly longer in group T (6.72+/-4.09 h after herniotomy than both group I (4.49+/-3.9 h) and group B (6.04+/-3.7 h) (P<0.05). CONCLUSIONS: Wound infiltration with tramadol may be a good choice for postoperative analgesia in children having inguinal herniotomy.

[Challenges in the treatment of pain in children with cancer and tunneling of epidural catheter for long term infusion]. / Cocukta kanser agrisi tedavisinde sorunlar ve uzun süreli epidural infüzyon için tünel uygulamasi.

The main differences of cancer pain in children from adults are predominance of tumor related pain, difficulties in pain assessment and rare use of regional blocks. A 2.5 years old girl with severe pain due to pelvic/sacro-cocygeal mass will be presented here. Pain assessment depended on the observations of other patients' parents in the ward, because the child's family was uncooperative. An epidural catheter was placed at T12-L1 level when the conventional methods were unsuccessful and tunneled 5 cm away from the insertion site. Infusion of bupivacain 0.2 mg/kg/hr + fentanyl 0.4 mg/kg/hr from the catheter provided pain relief. Another epidural catheter placed when intravenous morphine infusion (0.02 mg/kg/hr) became inefficient following accidental removal of the initial one. The patient was transferred to another hospital for chemotherapy on the 2nd week. The good interactions between the anesthesiologists accomplished the continuity of pain therapy. Tunneling epidural catheter is an invaluable technique in children who are resistant to conventional pain therapies.

Effects of intraperitoneal and extraperitoneal carbon dioxide insufflation on blood gases during the perioperative period.

The aim of this study was to evaluate the effects of intraperitoneal and extraperitoneal CO2 insufflation on blood gases during and after laparoscopic surgery. Forty patients were included in this study. Twenty patients underwent elective laparoscopic cholecystectomy with intraperitoneal insufflation (intraperitoneal group) and 20 patients underwent laparoscopic inguinal hernia repair with extraperitoneal insufflation (extraperitoneal group). Arterial blood gases were analyzed at four points: 10 minutes after induction, 10 minutes after insufflation, 10 minutes after desufflation, and 30 minutes after the operation in the recovery room. PaCO2 values in the intraperitoneal group at the four points were 36.8 +/- 4, 39.6 +/- 5.9, 40.7 +/- 4.4, and 42.3 +/- 4.8 mm Hg; in the extraperitoneal group, 35.8 +/- 3.9, 37.4 +/- 4, 42.8 +/- 6.6, and 46.2 +/- 5.9 mm Hg. In the extraperitoneal group, there was a significant increase in postoperative PaCO2 compared to the desufflation PaCO2. In our study, extraperitoneal CO2 insufflation caused increases in PaCO2 values that started perioperatively and continued in the postoperative period.

Effectiveness of morphine via thoracic epidural vs intravenous infusion on postthoracotomy pain and stress response in children.

BACKGROUND: Thoracotomy causes severe pain in the postoperative period. The aim was to evaluate effectiveness of two pain treatment methods with morphine on postthoracotomy pain and stress response. METHODS: Thirty-two children undergoing major thoracotomy for noncardiac thoracic surgery were allocated to receive either single dose of thoracic epidural morphine 0.1 mg x kg(-1) in 0.2 ml x kg(-1) saline (TEP group, n = 16) or morphine infusion at 0.02 mg x kg(-1) h(-1) (INF group, n = 16) following bolus dose of 0.05 mg x kg(-1) postinduction. Pain and sedation scores and incidence of complications were recorded for 24 h and cortisol, blood glucose, insulin and morphine serum levels were evaluated following induction, 1, 8, 12, and 24 h after initial morphine administration. RESULTS: Five patients in TEP and one in INF required rescue morphine. The cortisol, insulin and blood glucose increased during the study and returned to normal levels at 24th hour (P < 0.05), similarly in both groups (P > 0.05). The morphine levels were variable within and between groups (P < 0.05). A common complication was nausea and vomiting with both the techniques (P > 0.05). CONCLUSION: Single dose TEP morphine offers no advantage over INF for pain treatment for thoracotomy in children and neither technique provided suppression of stress hormones in the first 24 h postoperatively.

Hepatobiliary mucinous cystadenoma in a child.

The authors present a 4-year-old boy who had a large mucin-hypersecreting hepatobiliary cystadenoma. The tumor caused a hepato-colo-cutaneous fistula, which produced a large amount of external fluid loss. Total excision and the repair of the fistula could be possible after shrinkage of the tumor with the use of selective embolization of the feeding artery by interventional radiology.

Effects of systemic and epidural morphine on antidiuretic hormone levels in children.

BACKGROUND: Although the use of opioids during general anaesthesia suppresses stress response to surgery and pain, the effects on antidiuretic hormone (ADH) are controversial. The aim of this study was to find the effects of morphine with either intravenous infusion or epidural route on ADH and other stress hormones. METHODS: Fifty children aging (1-15 years) undergoing major genito-urinary or abdominal operations were included in this study. The patients were allocated randomly to two groups receiving either a single dose of epidural morphine 0.1 mg.kg-1 (EP group, n = 25) postinduction or morphine infusion (INF group; n = 25) at 0.02 mg.kg-1.h-1 following 0.05 mg.kg-1 bolus. Blood samples were withdrawn for plasma ADH, osmolality, glucose, cortisol, insulin and morphine level analysis following induction and 1, 5, 12 and 24 h after initial morphine administration. RESULTS: The two groups were similar in demographic factors, pain scores, sedation scores, and incidence of nausea and vomiting. The amount of morphine received was different between groups and the changes in serum levels of morphine were statistically significant in EP group ( P < 0.05). The changes in cortisol, blood glucose and insulin levels were insignificant in both groups (P > 0.05). The changes of ADH levels were significant at time-points in both groups, reaching control levels at the 24th hour (P < 0.05). CONCLUSION: Despite the effective pain therapy and suppression of cortisol and insulin response to surgical stimulus, the increase in ADH secretion is not effected by systemic or epidural morphine administration.

Arterial carbon dioxide markedly increases during diagnostic laparoscopy in portal hypertensive children.

UNLABELLED: Several factors are responsible for hypercarbia during laparoscopic procedures. This study was undertaken because we observed a sudden increase in PaCO(2) in children with portal hypertension (PHT), which was unusual in healthy children undergoing laparoscopic procedures. Fifty-seven children underwent laparoscopic procedures under general anesthesia and were mechanically ventilated. Arterial blood samples were obtained 5 min after intubation (T(0)), 15 min and 30 min after CO(2) pneumoperitoneum (T(15) and T(30)), 5 min after desufflation (T(end)), and 10 min after extubation (T(ext)) for blood gas analysis. The changes in PaCO(2), pH, and ETCO(2) were statistically significant during the study periods in both groups (P < 0.05). The percentage of PaCO(2) increase between T(0) and T(15) was 11.5% and 20.1%, respectively, in the control group and the PHT group (P < 0.05). This increase reached 36.8% at T(30) in the PHT group, whereas the control group had a 17.2% increase (P < 0.05). ETCO(2) presented similar changes. The variability in base excess, bicarbonate, PaO(2), arterial oxygen saturation, and SpO(2) was not significant in either group (P > 0.05). The PaCO(2) increased remarkably in children with PHT undergoing laparoscopy, with no difference in intrahepatic or extrahepatic origin. Limiting the duration of CO(2) pneumoperitoneum and intraabdominal pressure and adjusting ventilatory variables to accommodate hypercarbia are of the utmost importance for such cases. IMPLICATIONS: We compared children with portal hypertension with systemically healthy children during laparoscopy. The increase in arterial and end-tidal CO(2) was remarkable in children with portal hypertension, regardless of bicarbonate changes. Managing ventilation to accommodate hypercarbia is of the utmost importance for such cases.

Esophageal variceal bleeding secondary to portal hypertension: endoscopic sclerotherapy as the first-step treatment.

BACKGROUND: Variceal bleeding from the esophagus is an important cause of mortality and morbidity in children with portal hypertension (PHT). PATIENTS AND METHODS: A series of 69 PHT cases (41 intrahepatic, 28 extrahepatic) have been evaluated in our department since 1990. According to the Child-Pugh classification, 49 cases were in class A, 16 cases were in class B, and 4 cases were in class C at admission. In our protocol, endoscopic sclerotherapy is performed in all patients, and the diagnosis is achieved directly by diagnostic laparoscopy and fine-needle liver biopsy. The procedure is applied under general anesthesia, and 1% aethoxysclerol (polidocanol) is injected paravariceally and intravariceally with the use of a flexible endoscope. RESULTS: The Sugiura procedure was performed in nine patients who presented with recurrent bleeding episodes despite the strict sclerotherapy protocol. Liver transplantation was performed in two patients who were in Child class C. The total mortality rate in this series was 7% (5/69). CONCLUSION: Endoscopic sclerotherapy, as presented herein, decreases the need for additional surgical interventions in children with PHT.

The analgesic efficacy and neuroendocrine response in paediatric patients treated with two analgesic techniques: using morphine-epidural and patient-controlled analgesia.

BACKGROUND: Pain treatment is one of the main concerns of paediatric anaesthesiologists. The purpose of this study was to assess and compare the quality of analgesia and stress suppression by morphine when used [epidural (single shot) (EP) or with intravenous (i.v.) for patient-controlled analgesia (PCA) in children]. METHODS: Forty-four children, aged 5-15 years, and who were undergoing major genitourinary or lower abdominal surgery with a standardized general anaesthesia technique, were included in this study. In the EP group (n=24) 0.1 mg x kg(-1) morphine in 0.2 ml x kg(-1) saline were given epidurally at the L3-4 level and in the PCA group (n=20) 0.1 mg x kg-1 morphine was given i.v. immediately after intubation. Postoperative PCA bolus doses were 0.5 mg for patients weighing less than 20 kg, 1 mg for children weighing 20-30 kg and 1.5 mg for children weighing 30-40 kg. Blood samples were withdrawn following induction and at 1, 8, 12 and 24 h after morphine administration for measurement of blood glucose, insulin, cortisol and morphine levels. Patients were observed for 24 h postoperatively; heart rate, systolic blood pressure, respiratory rate, FACES pain scores, sedation scores and complications were recorded. RESULTS: The PCA group received 0.56 +/- 0.33 mg x kg(-1) x day(-1) morphine. The FACES pain scores, sedation scores, cortisol, blood glucose and insulin levels were similar in both groups. Haemodynamic and respiratory evaluations and cortisol levels were stable but blood glucose and insulin changes at certain time periods were significant (P < 0.05). Serum morphine levels and incidence of vomiting were different between groups (P < 0.05). Serum morphine levels were similar at the first hour. CONCLUSIONS: Both techniques provided sufficient pain relief and attenuated the hormonal response without life-threatening complications.