Effect of caudal block using different volumes of local anaesthetic on optic nerve sheath diameter in children: a prospective, randomized trial.

BACKGROUND: Caudal block is commonly administered for postoperative analgesia in children. Although caudal block with 1.5 ml kg -1 local anaesthetic has been reported to reduce cerebral oxygenation in infants, the effect of caudal block on intracranial pressure (ICP) in children has not been well investigated. Optic nerve sheath diameter (ONSD) correlates with degree of ICP. This study aimed to estimate the effects of caudal block on ICP according to volume of local anaesthetic using ultrasonographic measurement of ONSD in children. METHODS: Eighty patients, 6- to 48-months-old, were randomly allocated to the high-volume (HV) or low-volume (LV) groups for caudal block with ropivacaine 0.15%, 1.5 ml kg -1 or 1.0 ml kg -1 , respectively. Measurement of ONSD was performed before (T0), immediately after (T1), and 10 min (T2) and 30 min (T3) after caudal block. RESULTS: The two groups exhibited significant differences in ONSD according to time ( P Group x Time =0.003). The HV group exhibited significantly greater changes in ONSD from T0 to T2 and T3 than the LV group. However, in both groups, ONSDs at T1, T2 and T3 were significantly greater compared with those at T0, with the highest values at T2. CONCLUSIONS: Caudal block with a high volume of local anaesthetic can cause a greater increase in ICP than caudal block with a low volume of local anaesthetic. However, caudal block with 1.0 ml kg -1 of local anaesthetic can also result in a significant increase in ICP. CLINICAL TRIAL REGISTRATION: NCT02768493.

Manual vs. pressure-controlled facemask ventilation for anaesthetic induction in paralysed children: a randomised controlled trial.

BACKGROUND: During anaesthetic induction with a facemask, the inconsistent inspiratory flow with manual ventilation (MV) raises the peak airway pressure (PAP), which can be significantly higher than PAP during pressure-controlled ventilation (PCV). In this study, PAP was compared between MV and PCV at the same tidal volume of 8-10 ml/kg during facemask ventilation for anaesthetic induction in children. The occurrence of gastric insufflation (GI) was evaluated with ultrasonography and stethoscopic auscultation. METHODS: Forty-eight children, aged 0.5-7 years, undergoing elective urologic surgery were randomly allocated into either Group MV or Group PCV. Under light sedation with thiopental iv., ultrasonography (US) was performed and the gastric antrum was identified. After additional thiopental and rocuronium administration, facemask ventilation with a tidal volume of 8-10 ml/kg was performed for 3 min, whereas respiratory parameters were recorded at 1 min intervals. Real-time US and stethoscopic auscultation were performed for evaluation of GI. RESULTS: In the MV group, PAP was higher at all the time points compared with the PCV group (14 vs. 9.5, 15 vs. 10 and 15 vs. 9 cmH2 O, all P < 0.05). However, there was no difference in the GI occurrence between Group MV and Group PCV (7 vs. 3, P = 0.284). There was no difference between PAP in patients with GI and without GI (P > 0.05). Ultrasonography was more sensitive in detecting GI than the stethoscopic auscultation (10 vs. 5). Gastric antral area was expanded after facemask ventilation in both groups, but there were no intergroup differences. CONCLUSION: Although PCV provided lower PAP than MV at the same tidal volume, the risk of GI may not be eliminated during facemask ventilation in paralysed small children.

Impact of caudal block on postoperative complications in children undergoing tubularised incised plate urethroplasty for hypospadias repair: a retrospective cohort study.

This study aimed to assess the association between caudal block and postoperative complications after tubularised incised plate urethroplasty. The medical records of 388 paediatric patients who underwent urethroplasty at a tertiary medical centre were analysed retrospectively. Among the 342 patients included, 216 patients received a caudal block and 72 (21.1%) patients suffered surgical complications. The number of patients having surgical complications was significantly greater among patients who received a caudal block than among patients who did not receive a caudal block (53 (24.5%) versus 19 (15.1%), respectively, p = 0.04). Based on multivariate logistic regression analysis, duration of surgery, caudal block and hypospadias types were independent risk factors for the surgical complications. Patients with caudal block had an odds ratio of 2.1 (95% CI, 1.14-3.81, p = 0.018) for the development of postoperative complications compared with patients without caudal block. This analysis demonstrates that caudal block is associated with surgical complications after tubularised incised plate urethroplasty.

Ultrasound measurement of subglottic diameter and an empirical formula for proper endotracheal tube fitting in children.

BACKGROUND: The appropriate endotracheal tube (ETT) size is commonly determined using age-based formula; ETT size determination based on ultrasound (US) measurement of subglottic diameter (SD), the narrowest portion of the paediatric upper airway, may provide a better method for accurate fit. We aimed to validate ETT size determination using US measures of SD before intubation to establish an empirical formula for ETT fitting based on SD and biographic parameters. METHODS: We included 215 children aged 1-72 months undergoing general anaesthesia. US was performed on the anterior neck to measure SD during mask ventilation under anaesthesia. Endotracheal intubation was performed with a cuffed ETT selected by age-based recommendation; the transverse outer diameter (OD) of the ETT within the trachea at the subglottis level (OD-ETT at SD) was measured. RESULTS: The OD-ETT at SD was correlated with the actual OD-ETT outside the trachea (R(2) = 0.635), showing the validity of ultrasonographic measurement; moreover, the US-measured SD revealed strong correlation with the actual OD-ETT (R(2) = 0.834). US-measured SD and biographic data (age, height and weight) showed little correlation in children less than 12 months but good correlation (age, height) in children older than 12 months (P < 0.01). CONCLUSIONS: US-measured OD-ETT at SD was in good agreement with the actual OD-ETT, suggesting that US-measured SD helps in choosing the appropriate ETT diameter for children. In children older than 12 months, the equation 'OD (mm) = 0.01 × age (months) + 0.02 × height (cm) + 3.3' may help select the appropriate ETT.

Preoperative anxiety and pain sensitivity are independent predictors of propofol and sevoflurane requirements in general anaesthesia.

BACKGROUND: Psychological factors are thought to drive inter-patient variations in anaesthetic and analgesic requirements. This cross-sectional study investigated whether preoperative psychological factors can predict anaesthetic requirements and postoperative pain. METHODS: Before total thyroidectomy, 100 consecutive women completed the Spielberger's State-Trait Anxiety Inventory (STAI) and the pain sensitivity questionnaire (PSQ). Target-controlled propofol was administered for induction of anaesthesia, and sevoflurane-oxygen-air was given to maintain equal depths of anaesthesia, as determined by bispectral index (BIS) monitoring. RESULTS: Patients with higher anxiety scores (state and trait) required greater amounts of propofol to reach light (BIS=85) and moderate (BIS=75) levels of sedation, but only trait anxiety was significantly associated with propofol requirements in reaching a deep level of sedation (BIS=65). The MAC-hour of sevoflurane was significantly correlated only with PSQ scores. The postoperative pain intensity was significantly correlated with both STAI and PSQ. CONCLUSIONS: Preoperative anxiety and pain sensitivity are independent predictors of propofol and sevoflurane requirements in general anaesthesia. Anaesthetic and analgesic doses could be modified based on the patient's preoperative anxiety and pain sensitivity.

Ultrasonography reveals a high prevalence of lower spinal dysraphism in children with urogenital anomalies.

BACKGROUND: Lower spinal dysraphism is frequently reported in anorectal anomaly combined with urogenital anomalies. The prevalence of the spinal dysraphism has not been comprehensively studied in children with simple urogenital anomalies. We evaluated the prevalence of the spinal dysraphism using ultrasound data of the lumbosacral area in children with urogenital anomalies. METHODS: Lumbosacral ultrasound images of 259 children who underwent urological surgery with simple urogenital anomalies were reviewed by an ultrasound-specialized radiologist. The primary outcome measures were the conus medullaris (CM) level and the thickness of the filum terminale. The spinal ultrasonographic findings that were assessed in children showed abnormal spinal findings compared with the other children having normal findings. Two years later, the follow-up telephone interviews were made with the parents of the children with abnormal findings. RESULTS: Eighteen children were differentiated as the abnormal finding group. They were suspected of spinal cord tethering. The level of CM was lower, and the filum terminale was thicker compared to the normal group [L2(lower (L)) vs. L1(L), 2.2 mm vs. 0.8 mm]. Of eighteen children, four were confirmed as tethered spinal cord with lipoma on magnetic resonance imaging by the time of surgery, and two were strongly suspected of occult spinal dysraphism (OSD) based on ultrasound findings and follow-up interviews. CONCLUSIONS: The prevalence of OSD in children under 24 months of age with simple urogenital anomaly was higher than what was reported for the general population. Ultrasound examination of spinal structures before caudal block in children with urogenital anomaly should be considered.

Venous flow dynamics during spinal block in normotensive and hypertensive elderly patients: a duplex ultrasonographic study.

BACKGROUND: Spinal block induces hyperkinetic change in lower extremity blood flow. We compared the venous flow dynamic responses to spinal block in normotensive and hypertensive elderly patients. METHODS: Following spinal block using 10 mg 0.5% (w/v) bupivacaine, we measured changes in blood pressure, heart rate, and venous flow dynamics of the popliteal vein by duplex ultrasonography in 20 normotensive (NBP group) and 18 hypertensive (HIBP group) patients. RESULTS: Spinal block caused significant decreases in blood pressure in both groups; similar rates of hypotension were observed. At baseline, peak velocity, time-averaged maximum velocity, and time-averaged mean velocity were higher in the HIBP than in the NBP group. During spinal block, peak velocity increased in both groups, and the between-group differences were no longer significant. At baseline, volume flow in the two groups was similar and increased by 141.5% in the NBP and 131.7% in the HIBP group during spinal block. CONCLUSIONS: Blood pressure and flow dynamics in the popliteal vein showed similar changes during spinal anaesthesia in elderly patients taking antihypertensive medication and normotensive patients, despite differences in baseline values.

Effects of intravenous dexmedetomidine on low-dose bupivacaine spinal anaesthesia in elderly patients.

BACKGROUND: Dexmedetomidine (DMT) has been shown to prolong spinal anaesthesia. We evaluated the effects of intravenous DMT on low-dose bupivacaine spinal anaesthesia in elderly patients. METHODS: Fifty-one elderly patients undergoing transurethral resection of the prostate were randomized into two groups receiving either 1.0 µg/kg DMT (DMT group, n = 26) or normal saline (control group n = 25) intravenously prior to spinal anaesthesia with 1.2 ml of bupivacaine, 5 mg/ml. RESULTS: The mean time to two-segment regression (39 min vs. 78 min for cold, 41 min vs. 61 min for pinprick) and that to motor regression (23 min vs. 46 min) were longer in the DMT group than in the control group. The atropine-requiring bradycardia was more frequent in the DMT group than in the control group (24.0% vs. 3.8%). The median sedation scores (ranges) during surgery were 4 (2-6) in the DMT group and 2 (1-3) in the control group (P < 0.001). Two patients in the DMT group showed oxygen desaturation (peripheral oxygen saturation < 90%) during surgery. The duration of post-operative care unit stay was longer in the DMT group than in the control group (58 min vs. 96 min). Post-operative pain intensity was lower and the mean time to first request for post-operative analgesia was longer in the DMT group compared to the control group (6.6 h vs. 2.1 h). CONCLUSION: Intravenous DMT prolonged the duration of spinal anaesthesia and improved post-operative analgesia. However, more profound sedation with desaturation was observed with more frequent bradycardia, and delayed recovery should be considered in elderly patients.

Evaluation of radial and ulnar blood flow after radial artery cannulation with 20- and 22-gauge cannulae using duplex Doppler ultrasound.

This study evaluated ulnar and radial artery blood flow after radial artery cannulation during general anaesthesia using Doppler ultrasound. A total of 80 patients were randomly assigned to receive radial artery cannulation with either a 20-G or 22-G cannula. Arterial diameter, peak systolic velocity, end-diastolic velocity, resistance index and mean volume flow were measured at four time points in both arteries: before anaesthesia; 5 min after intubation; immediately after cannulation; and 5 min after cannulation. After radial artery cannulation, ulnar diameters and blood flow were significantly increased, and persisted until 5 min after cannulation. Radial blood flow was decreased immediately after cannulation and recovered to pre-cannulation values 5 min after cannulation. There were no statistical differences between groups at each time point. Radial artery cannulation causes compensatory increase in ulnar artery blood flow, and the difference in cannula size has minimal effect on this change.

Epidural ropivacaine and sufentanil and the perioperative stress response after a radical retropubic prostatectomy.

BACKGROUND: The effects of an epidural opioid and a local anesthetic on the perioperative stress responses have not been fully investigated in elderly patients undergoing cancer surgery. We hypothesized that the stress response after a radical retropubic prostatectomy (RRP) would be attenuated by epidural ropivacaine and sufentanil. METHODS: In this randomized, double-blinded study, we included patients above 65 years of age who were scheduled for a RRP. In addition to general anesthesia, they received either epidural saline continuously (5 ml/h) (C group, n=20); 0.3% ropivacaine (R group, n=20); or 0.3% ropivacaine combined with 1 µg/ml sufentanil (RS group; n=20). We determined the concentrations of glucose, insulin, cortisol, epinephrine, norepinephrine, and prolactin before, during, and up to 48 h after surgery. RESULTS: The concentrations of glucose and insulin increased in all the groups. The cortisol level increased in the C group while it decreased significantly in the RS group. Epinephrine and norepinephrine concentrations increased significantly after surgery in the C group, but not in the R and RS groups. The prolactin concentration increased in all the groups, and was higher in the RS group than in the other groups (P=0.002). Post-operative pain scores and analgesic requirement were lower in the R and RS groups. CONCLUSION: Epidural ropivacaine blunted the perioperative stress responses in elderly patients undergoing a RRP. The combination of epidural ropivacaine and sufentanil was associated with the most pronounced attenuation of the stress response. ClinicalTrial.gov registration number: NCT01086956.

Ketorolac or fentanyl continuous infusion for post-operative analgesia in children undergoing ureteroneocystostomy.

BACKGROUND: children undergoing ureteroneocystostomy suffer from post-operative pain due to the surgical incision and bladder spasm. A single-shot caudal block is a common technique for paediatric analgesia, but a disadvantage is the limitation of a short duration in spite of the additives co-administered. A few clinical trials have shown that ketorolac provides an effective post-operative analgesia and reduces the bladder spasms after ureteral implantation in children. We compared the efficacy of a continuous infusion of ketorolac and fentanyl in post-operative analgesia and bladder spasm in children who underwent ureteroneocystostomy. METHODS: fifty-two children were allocated to the ketorolac group (Group K, n=26) and fentanyl group (Group F, n=26). After general anaesthesia, a caudal block was performed with 1.5 ml/kg of 0.15% ropivacaine. At the beginning of surgery, an infusion was started after the bolus injection of ketorolac 0.5 mg/kg or fentanyl 1 microg/kg. An infusion device was programmed to deliver ketorolac 83.3 microg/kg/h or fentanyl 0.17 microg/kg/h for 48 h. RESULTS: two of Group F and three of Group K were excluded from the study. Post-operative pain scores were similar between the two groups. One of Group K (4%) and seven of Group F (30.4%) experienced bladder spasms. The rescue analgesic requirements were significantly less in Group K. CONCLUSIONS: a Continuous infusion of ketorolac provided effective analgesia after operation in children who underwent ureteroneocystostomy as well as a low dosage of fentanyl. Ketorolac was more effective in reducing the frequency of bladder spasms and rescue analgesic requirements.

Optimal dose of propofol for intubation after sevoflurane inhalation without neuromuscular blocking agent in children.

BACKGROUND: This study was designed to determine the optimal dose of propofol for excellent intubating conditions in children without neuromuscular blockade at various alveolar concentrations of sevoflurane. METHODS: Sixty-three children, aged 0.5-5 years, were randomized to three groups of end-tidal sevoflurane concentration (ETsevo) 3%, 3.5%, and 4%. Inhalation anesthesia was started with sevoflurane 7% in 100% oxygen. When the patients became unconscious, inspired concentration was adjusted to obtain the target ETsevo for each group. When ETsevo reached the target concentration, a predetermined dose of propofol was given and tracheal intubation was performed. The proper dose of propofol was determined using the 'up-and-down' method. RESULTS: The median dose (95% confidence intervals) of propofol for excellent tracheal intubating conditions in 50% of children were 1.25 mg/kg (0.84-1.75) at ETsevo of 3%, 0.76 mg/kg (0.35-1.21) at 3.5%, and 0.47 mg/kg (0.26-1.09) at 4%. The frequency of adverse effects was not different between groups during induction and recovery. CONCLUSION: Propofol 1.5-2 mg/kg provides excellent intubating conditions at 3-4% ETsevo in children without using any neuromuscular blocking agent.

Effect of dexamethasone in combination with caudal analgesia on postoperative pain control in day-case paediatric orchiopexy.

BACKGROUND: Dexamethasone has a powerful anti-inflammatory action and has demonstrated reduced morbidity after surgery. The aim of this study was to examine the effects of a single i.v. dose of dexamethasone in combination with caudal block on postoperative analgesia in children. METHODS: Seventy-seven children (aged 1-5 yr) undergoing day-case orchiopexy were included in this prospective, randomized, double-blinded study at a single university hospital. After inhalation induction of general anaesthesia, children received either dexamethasone 0.5 mg kg(-1) (maximum 10 mg) (n=39) or the same volume of saline (n=38) i.v. A caudal anaesthetic block was then performed using 1.5 ml kg(-1) of ropivacaine 0.15% in all patients. After surgery, rescue analgesic consumption, pain scores, and adverse effects were evaluated for 24 h. RESULTS: Significantly, fewer patients in the dexamethasone group required fentanyl for rescue analgesia (7.9% vs 38.5%) in the post-anaesthetic care unit or acetaminophen (23.7% vs 64.1%) after discharge compared with the control group. The time to first administration of oral acetaminophen was significantly longer in the dexamethasone group (646 vs 430 min). Postoperative pain scores were lower in the dexamethasone group and the incidence of adverse effects was similar in both groups. CONCLUSIONS: Intravenous dexamethasone 0.5 mg kg(-1) in combination with a caudal block augmented the intensity and duration of postoperative analgesia without adverse effects in children undergoing day-case paediatric orchiopexy. TRIAL REGISTRATION: ClinicalTrials.gov. The number of registration: NCT01041378.

Incidence of venous gas embolism during robotic-assisted laparoscopic radical prostatectomy is lower than that during radical retropubic prostatectomy.

BACKGROUND: Robotic-assisted laparoscopic radical prostatectomy (RALRP) is gaining popularity as a less traumatic and minimally invasive alternative to open radical retropubic prostatectomy (RRP). The aim of this study was to evaluate the incidence and grade of venous gas embolism (VGE) during RALRP compared with those during RRP using transoesophageal echocardiography (TOE). METHODS: Fifty-two patients undergoing RRP (n=26) or RALRP (n=26) were consecutively enrolled. TOE was continuously applied during surgery and VGE was graded by an independent researcher. RESULTS: The total incidence of VGE (proportion, 95% CI) in the RRP group was higher than that in the RALRP group [20/25 (0.80, 0.60-0.92) and 10/26 (0.38, 0.22-0.58), respectively]. Most VGE in the RALRP group occurred during the transection of the deep dorsal venous complex. There was no difference in the incidence of severe VGE between the two groups. No patients with cardiorespiratory instabilities even with severe VGE were observed in this study. CONCLUSIONS: In contrast to general belief, VGE occurred less frequently during RALRP. Although the VGE in this study did not cause any cardiorespiratory instability, close monitoring for possibly fatal VGE must be considered during both types of radical prostatectomy because those who undergo radical prostatectomy frequently have cardiopulmonary co-morbidities.

Spread of ropivacaine by a weight-based formula in a pediatric caudal block: a fluoroscopic examination.

BACKGROUND: Caudal block is the most common regional technique to provide post-operative analgesia in pediatric infra-umbilical surgery. This study was designed to define how many spinal segments would be covered by the weight-based dosage of caudally administered 0.2% ropivacaine in children using the fluoroscopic method. METHODS: After an approval from the institutional human research review board, in 83 ASA I boys undergoing day-case urological surgery, the distribution of ropivacaine mixed with a radioactive dye in relation to the volume injected caudally was studied. Three groups were studied: for perineal surgery 0.5 ml/kg (group C(0.5)), for inguinal hernia repair 1 ml/kg (group C(1.0)), and for orchiopexy 1.25 ml/kg (group C(1.25)). The dose of 0.2% ropivacaine containing radiopaque dye at a ratio of 1 : 4 was injected at a rate of 1 ml 3 s(-1). Fluoroscopic examination was performed immediately to define the level of the drug spread within the extradural space. RESULTS: The highest spinal levels [median with ranges] of spread were L2 [L4-T12] in group C(0.5), T12 [L1-T8] in group C(1.0), and T10 [L2-T7] in group C(1.25). Analysis by age distribution (infants: <12 months; toddlers: 12-36 months; and children: >36 months) revealed a larger spread in younger patients. CONCLUSIONS: Based on the fluoroscopic findings, the weight-based doses for caudally administered 0.2% bupivacaine suggested by Armitage are also useful for ropivacaine to block the spinal level required for the different types of surgeries studied.

The relative position of ilioinguinal and iliohypogastric nerves in different age groups of pediatric patients.

BACKGROUND: Ilioinguinal nerve (IIN) and iliohypogastric nerve (IHN) blocks provide good perioperative pain relief for children undergoing inguinal procedures such as inguinal hernia repair, orchiopexy, and hydrocelectomy. The aim of this ultrasound imaging study is to compare the relative anatomical positions of IIN and IHN in different age groups of pediatrics. METHODS: Two-hundred children (aged 1-82 months, ASA I or II) undergoing day-case surgery were consecutively included in this study. Following the induction of general anesthesia, an ultrasonographic exam was performed using a high-frequency linear probe that was placed on an imaginary line connecting the anterior superior iliac spine (ASIS) to the umbilicus. RESULTS: There were significant differences in ASIS-IIN (distance from ASIS to IIN), ASIS-IHN (distance from the ASIS to the IHN), and IIN-IHN (distance between IIN and IHN) between the age groups: <12 months (n=84), 12-36 months (n=80), and >37 months (n=36). However, IIN-Peritoneum (distances from IIN to peritoneum), skin-IIN, and skin-IHN (depth of IIN and IHN relative to skin) were similar in three groups. ASIS-IIN and ASIS-IHN showed significantly positive correlations with age. CONCLUSIONS: Age should be considered when placing a needle in landmark techniques for pediatric II/IH nerve blocks. However, needle depth should be confirmed by the fascial click due to the lack of predictable physiologic factors.

Titrated propofol induction vs. continuous infusion in children undergoing magnetic resonance imaging.

BACKGROUND: Propofol is the popular intravenous (i.v.) anaesthetic for paediatric sedation because of its rapid onset and recovery. We compared the efficacy and safety of a single dose and conventional infusion of propofol for sedation in children who underwent magnetic resonance imaging (MRI). METHODS: This was a double-blind, randomized-controlled study. One hundred and sixty children were assigned to group I (single dose) or II (infusion). Sedation was induced with i.v. propofol 2 mg/kg, and supplemental doses of propofol 0.5 mg/kg were administered until adequate sedation was achieved. After the induction of sedation, we treated patients with a continuous infusion of normal saline at a rate of 0.3 ml/kg/h in group I and the same volume of propofol in group II. In case of inadequate sedation, additional propofol 0.5 mg/kg was administered and the infusion rate was increased by 0.05 ml/kg/h. Induction time, sedation time, recovery time, additional sedation and adverse events were recorded. RESULTS: Recovery time was significantly shorter in group I compared with group II [0 (0-3) vs. 1 (0-3), respectively, P<0.001]. Group I (single dose) had significantly more patients with recovery time 0 compared with group II (infusion) (65/80 vs. 36/80, respectively, P<0.001). Induction and sedation times were not significantly different between groups. There was no significant difference in the frequency of additional sedation and adverse events between groups. CONCLUSION: A single dose of propofol without a continuous infusion can provide appropriate sedation in children undergoing MRI for <30 min.

Comparison of intrathecal fentanyl and sufentanil in low-dose dilute bupivacaine spinal anaesthesia for transurethral prostatectomy.

BACKGROUND: The administration of low-dose bupivacaine can limit the distribution of spinal block to reduce adverse haemodynamic effects. Intrathecal opioids can enhance analgesia in combination with subtherapeutic doses of local anaesthetics. We aimed at comparing the efficacy of intrathecal fentanyl and sufentanil with low-dose diluted bupivacaine for transurethral prostatectomy (TURP) in elderly patients. METHODS: Seventy patients undergoing TURP were randomly allocated into two groups. Group F (n=35) received fentanyl 25 microg+bupivacaine 0.5% (0.8 ml)+normal saline 0.3 ml and Group S (n=35) received sufentanil 5 microg+bupivacaine 0.5% (0.8 ml)+normal saline 0.7 ml--in total, bupivacaine 0.25% (1.6 ml) intrathecally. Onset and duration of the sensory block, the degree of the motor block, side-effects, and the perioperative analgesic requirements were assessed. RESULTS: The median peak level of the sensory block was significantly higher in Group S than in Group F (P=0.049). Group S required fewer perioperative analgesics than Group F (P=0.008). The time to the first analgesic request was longer in Group S (P=0.025). There were no differences between the groups for the onset and recovery time of the sensory block, degree of the motor block, quality of anaesthesia, or adverse effects. CONCLUSIONS: Low-dose diluted bupivacaine with fentanyl 25 microg or sufentanil 5 microg can provide adequate anaesthesia without haemodynamic instability for TURP in elderly patients. However, sufentanil was superior to fentanyl in the quality of the spinal block produced.

The addition of fentanyl to 1.5 mg/ml ropivacaine has no advantage for paediatric epidural analgesia.

BACKGROUND: Epidural opioids are frequently combined with local anaesthetics for an additive antinociceptive effect. We investigated the efficacy of epidural fentanyl to 1.25 or 1.5 mg/ml ropivacaine for post-operative epidural analgesia in children. METHODS: One hundred and eight children undergoing hypospadias repair were randomized to receive 1.25 mg/ml ropivacaine (R1.25 group), 1.25 mg/ml ropivacaine with 0.2 mcg/kg/h of fentanyl (R1.25F group), 1.5 mg/ml ropivacaine (R1.5 group) or 1.5 mg/ml ropivacaine with 0.2 mcg/kg/h of fentanyl (R1.5F group) for post-operative epidural analgesia. The epidural catheter was threaded caudally through the L4-5 interspace. The face, legs, activity, cry, consolability (FLACC) score was assessed at every hour and at FLACC score >4, an epidural bolus of 0.5 ml/kg of ropivacaine 1.5 mg/ml was given as the rescue analgesia. The incidence of side effects such as hypoxia, sedation, pruritus, nausea and/or vomiting was recorded. RESULTS: The need for rescue analgesia was higher in the R1.25 group compared with that in the other three groups (all P<0.05). The incidence of side effects was higher in the R1.5F group compared with that in the R1.25 and R1.5 groups (both P=0.010). CONCLUSION: The addition of 0.2 mcg/kg/h fentanyl to 1.5 mg/ml ropivacaine increased the incidence of side effects without improvement of analgesia in infants and children undergoing hypospadias repair. The use of plain 1.25 mg/ml ropivacaine increased the need for rescue analgesia and this could be compensated by addition of fentanyl.

Effects of reverse Trendelenburg position and inguinal compression on femoral vein cross-sectional area in infants and young children.

This study evaluated the effects of the reverse Trendelenburg position and additional inguinal compression on the cross-sectional area of the femoral vein in paediatric patients. Seventy subjects were allocated to two groups: the infants group and the children group. Cross-sectional area of the femoral vein was measured just below the inguinal ligament using ultrasound. Three measurements were obtained for each patient: (i) supine, (ii) reverse Trendelenburg position and (iii) reverse Trendelenburg position with inguinal compression. In the infants group, femoral vein cross-sectional area increased by a mean (SD) of 21.1 (15.2) % in the reverse Trendelenburg position and by 60.7 (30.8) % in the reverse Trendelenburg position with inguinal compression; whereas in the children group, femoral vein cross-sectional area increased by 24.7 (15.8) % in the reverse Trendelenburg position and by 100.3 (50.7) % in the reverse Trendelenburg position with inguinal compression. Inguinal compression in the reverse Trendelenburg position offers a useful means of increasing femoral vein cross-sectional area in paediatric patients.