Rapid induction of anesthesia with high concentrations of halothane or sevoflurane in children.

STUDY OBJECTIVE: To compare the characteristics of the rapid induction of anesthesia in pediatric patients with high concentrations of sevoflurane or halothane, and to determine the ability of anesthesiologists to correctly identify the anesthetic drug when administered in this fashion. DESIGN: Randomized, prospective, open-label study. SETTING: Academic university hospital. PATIENTS: 78 ASA physical status I and II healthy children scheduled for brief surgical procedures with general anesthesia and medicated with midazolam. INTERVENTIONS: Assessments were made by 5 pediatric anesthesiologists and 18 anesthesiology residents. Sevoflurane or halothane was randomly selected for anesthetic induction. The anesthetic circuit was primed with the drug (8% sevoflurane or 4% halothane) in 50% nitrous oxide and oxygen. The anesthesiologists were blinded as to the anesthetics being administered. After completion of anesthetic induction, the anesthesiologists were asked to identify the anesthetic and to assess the quality and speed of induction. MEASUREMENT AND MAIN RESULTS: The pediatric anesthesiologists correctly identified the anesthetic in 55 of 78 assessments (70.5%). This figure is statistically better than what could be achieved by random guessing (p < 0.001). The residents correctly identified the anesthetic in only 46 of 78 assessments (60.0%). Statistically, this figure is no better than what could be achieved by random guessing (p = 0.06). Speed of induction was subjectively felt to be faster with sevoflurane than halothane but there were no differences in actual induction time (sevoflurane group, 3.7 +/- 2.7 min; halothane group, 3.7 +/- 2.6 min). There were no differences in the quality of induction or the incidence of airway complications. The perceived incidence of tachycardia was significantly higher with sevoflurane than halothane(sevoflurane group, 74%; halothane group 20%). CONCLUSION: The induction of anesthesia with high concentrations of either halothane or sevoflurane can be safely accomplished. Pediatric anesthesiologists can differentiate between halothane and sevoflurane when either drug is given in high initial concentrations. The presence of tachycardia may have served as the primary clue in determining which drug was being used.

Anesthetic management for patients with arthrogryposis multiplex congenita and severe micrognathia: case reports.

Arthrogryposis multiplex congenita (AMC) is a spectrum syndrome of multiple persistent limb contractures often accompanied by associated anomalies, including cleft palate, genitourinary defects, gastroschisis, and cardiac defects. Pediatric patients with AMC frequently present for multiple surgeries requiring general endotracheal anesthesia. We describe our anesthetic experience with the laryngeal mask airway and endotracheal tube in two neonates with AMC and severe micrognathia. We discuss AMC and outline the problems encountered in difficult airway management.

Low-dose caudal morphine for postoperative analgesia in infants and children: a report of 500 cases.

STUDY OBJECTIVE: To determine the effectiveness of morphine 0.03 mg/kg or 0.04 mg/kg administered caudally to children for postoperative pain relief. DESIGN: Retrospective chart review. SETTING: University-affiliated hospital. PATIENTS: The charts of 500 children who had undergone various surgical procedures and who were given caudal morphine 0.03 mg/kg or 0.04 mg/kg either prior to the surgical procedure or immediately at the conclusion of the surgical procedure. MEASUREMENTS AND MAIN RESULTS: Parameters of respiratory rate, oxygen saturation, nausea and vomiting, voiding problems, and pruritus were recorded for each patient. There was no respiratory depression noted in the review of the 500 patients; 23% had nausea and vomiting, 3% had voiding problems needing bladder catheterization, and 7% reported pruritus, which was treated with either diphenhydramine or naloxone. CONCLUSION: Statistically there were no differences between morphine 0.03 mg/kg and morphine 0.04 mg/kg in all the study parameters. There was no respiratory depression in the 500 cases reviewed. The postoperative pain relief ranged from 6 hours to over 24 hours. This method of immediate postoperative pain management proved to be effective and safe.

Anesthesia in a child with Rett syndrome: a case report and literature review.

Rett syndrome is an increasingly diagnosed syndrome in young children who appear normal at birth and develop normally until 6 to 18 months of age, when developmental milestones fail to be reached. The syndrome appears only in girls and therefore it is thought to be an X-linked dominant trait that is lethal in the male. This is a case report and literature review of anesthesia in a child with Rett syndrome.

Intraoperative fluid and electrolyte management in the pediatric surgical patient.

A comprehensive plan for intraoperative fluid and electrolyte maintenance in the pediatric surgical patient should be made before the start of anesthesia and carried out carefully but aggressively by the surgeon and anesthesiologist. There must be careful assessment of intraoperative blood loss, accurate calculation of the volume of clear fluids given, and frequent measurement of electrolyte levels, blood gas levels, and hematocrit values, particularly during long operative procedures. Tabulated are maintenance fluid requirements, suggested fluid replacement schedules, and formulas for determining blood volume and allowable blood loss, plus a regimen for blood replacement.

Cardiac arrest following administration of vancomycin.

A two-year-old female child status post-bilateral nephrectomies sustained a cardiac arrest following the central intravenous administration of vancomycin chloride. This report reviews the literature concerning the problems associated with the use of vancomycin chloride in the perioperative period.

Anaesthesia for a child with progeria.

The Hutchinson-Gilford syndrome, commonly referred to as progeria, is a rare childhood syndrome that results in premature ageing. We focus on two anaesthetics administered to a child with progeria and a review of the available literature.

Evaluation of the premature infant at risk for postoperative complications.

We reviewed anaesthetic records of 35 infants with a history of prematurity, who presented for elective herniorrhaphy. We applied a scoring system to help evaluate risk of postoperative complications. Six patients experienced postoperative complications. All six patients had a score of five or more and gave history of either apnoea or a history of moderate bronchopulmonary dysplasia. A preoperative history of apnoea and/or moderate bronchopulmonary dysplasia appear to be valuable markers for postoperative complications. A conceptual age of 40 weeks is an acceptable lower limit of age providing there is no history of apnoea or pulmonary disease.

Malignant hyperthermia during repair of a cleft lip in a 6-month-old infant, with survival.

The case history is given of a 6-month-old girl who survived an attack of malignant hyperthermia that occurred during the repair of a cleft lip. We believe that this is the youngest such patient reported to date. The current concepts of the mechanisms of excessive heat production and muscular rigidity are presented. The need for constant awareness, early recognition, and prompt and proper treatment on the part of both the operating surgeon and the anesthesiologist are stressed to avoid a fatal outcome. Unfortunately, as yet there is no conclusive, consistent screening test available to identify those who will experience such an episode. Because a patient has once undergone general anesthesia uneventfully does not mean that malignant hyperthermia will not occur during a subsequent procedure or even during use of some amide local anesthetics.

Anaesthesia for the achondroplastic dwarf.

Over the past three years, 36 anaesthetics were administered to 27 patients with achondroplastic dwarfism. Twenty-four patients underwent craniectomy for foramen magnum stenosis. Sixteen of the operations were undertaken in the sitting position with nine incidents of venous air embolism (VAE), all of which occurred in patients under 12 years of age. Six major complications occurred: two C-1 level spinal cord infarctions, two brachial plexus palsies, one severe macroglossia, and one accidental extubation. Intravenous access in the small child with achondroplastic dwarfism is made difficult because of the excess, lax skin and subcutaneous tissue. Airway management and laryngoscopy were not difficult and we found that endotracheal tube size was best predicted by the patient's weight and not age. Blood loss was 38 +/- 9 mg X kg-1 in the prone position (n = 8) and 18 +/- 4 mg X kg-1 in the sitting position (n = 16), and was related to the surgical procedure rather than to dwarfism. Our data indicate that complications are more likely to occur in the sitting position, and that these complications are of a serious nature, and every precaution should be taken to avoid their occurrence.