Postoperative complications after tonsillectomy and adenoidectomy in children with Down syndrome.

OBJECTIVE: To compare the postoperative course and complications after tonsillectomy or tonsillectomy and adenoidectomy in children with Down syndrome (group 1) with the postoperative course and complications in children in a control group (group 2). DESIGN: Retrospective review of medical records for the period January 1, 1986, through March 30, 1996. SETTING: Tertiary care children's hospital. PATIENTS: The study included 87 children in group 1 and 64 children in group 2 matched for age, sex, and year of surgery. INTERVENTION: Tonsillectomy and adenoidectomy (group 1, 79 children; group 2, 57 children) and tonsillectomy (group 1, 8 children; group 2, 7 children). MAIN OUTCOME MEASURES: Length of hospitalization and postoperative complications. RESULTS: The length of hospitalization was significantly increased for the children in group 1 compared with that of children in group 2 (1.6 vs 0.80 days; P=.001, Mann-Whitney U test). Twenty-two children (25%) in group 1 required airway management or observation in the pediatric intensive care unit compared with no children in group 2 who required such care (P<.001, Fisher exact test). None of the children in either group required reintubation, continuous positive airway pressure, or tracheotomy. Respiratory complications requiring intervention were 5 times more likely in group 1 (22 [25%] vs 3 [5%]; P<.001, Fisher exact test). The median time until intake of clear liquids and duration of intravenous therapy were significantly increased in group 1 compared with group 2 (5.0 vs 4.0 hours, P=.03; 23.5 vs 16.0 hours, P=.001, respectively; Mann-Whitney U test). CONCLUSIONS: Although tonsillectomy and adenoidectomy can be performed safely in children with Down syndrome, the rate of postoperative respiratory complications is higher and the duration until adequate oral intake is resumed is longer. We therefore recommend that children with Down syndrome be admitted to the hospital overnight after undergoing tonsillectomy and adenoidectomy.

Jet ventilation for laser laryngeal surgery in children. Modification of the Saunders jet ventilation technique.

In our clinical series, 40-50% O2 and 50-60% N2O (regulated by a blender and delivered by manual jet ventilation (MJV] and residual halothane from induction provided satisfactory supralaryngeal anesthesia. Fentanyl, N2O, atracurium, and lidocaine administered i.v. effectively blunted laryngeal stimulation, allowed control of respiration, and minimized vocal cord motion. Wide unobstructed surgical access to the entire endolarynx is provided. Atracurium (an intermediate-acting non-depolarizing muscle relaxant administered in a single bolus or by constant infusion) achieves the needed level of blockade and permits the anesthesiologist to focus on the pattern of respiration rather than the degree of neuromuscular blockade. Its duration of action seems to be well matched to the average duration of this surgical procedure. Because its reversal is prompt (35-45 min from i.v. injection to 25% recovery by neuromuscular transmission monitor) (Brandom et al., Clinical pharmacology of atracurium in paediatric patients, Br. J. Anaesth., 55 (1983) 117S-121S) children can be discharged safely from the recovery room to home after an appropriate period of observation in the short-stay unit. Our report confirms and extends another recent report supporting supraglottic jet ventilation (Scamman, F.L. and McCabe, B.F., Supraglottic jet ventilation for laser surgery of the larynx in children, Ann. Otol. Rhinol. Laryngol., 95 (1986) 142-145). We believe that the MJV technique is advantageous in children, particularly for outpatient surgery. Attention to detail and careful communication between a skilled anesthesiologist and surgeon are essential. Dangerous barotrauma can occur and skill and monitoring are essential.

Pulmonary aspiration in pediatric patients during general anesthesia: incidence and outcome.

STUDY OBJECTIVES: To determine the incidence of, outcome of, and risk factors for anesthesia-related pulmonary aspiration in the predominantly pediatric population receiving anesthesia care. DESIGN: Using a clinical concurrent quality assessment system we developed, we used data stored in a custom-designed computerized database to initiate a retrospective review. Statistical relationships were analyzed by Fisher's exact test and binary logistic regression with commercially available software. SETTING: University-affiliated pediatric hospital. PATIENTS: All patients receiving anesthesia (n = 50,880) between April 1, 1988, and March 31, 1993. MEASUREMENTS AND MAIN RESULTS: Aspiration occurred in 52 (0.10% or 10.2 per 10,000) of the 50,880 general anesthesia cases. Aspirate was food or gastric contents in 25 cases (0.049% or 4.9 per 10,000), blood in 13 (0.026% or 2.6 per 10,000), and unknown material in 14 (0.0275% or 2.76 per 10,000). There were no deaths attributable to aspiration. Morbidity was confined to unanticipated hospital admission (n = 12), cancellation of the surgical procedure (n = 4), and intubation, with or without ventilation (n = 15). Aspiration occurred significantly more often in patients with greater severity of underlying illness (ASA physical status III or IV) (p = 0.0015), intravenous induction (p = 0.0054), and age equal to or greater than 6.0 years and less than 11.0 years (p = 0.0029). Emergency procedures had a marginally significant increased aspiration risk (p = 0.0527). CONCLUSIONS: The overall incidence of anesthesia-related aspiration in our series (0.10%) was twice that reported in studies of adults, and four times (0.25%) higher for those at highest risk (ASA physical status III or IV vs. physical status I or II). Anesthesia-related pulmonary aspiration was proven to be a rare event in this tertiary pediatric center and its consequences relatively mild. Because of the very low frequency and the lack of serious outcome after aspiration in ASA physical status I and II pediatric patients, it appears that routine prophylactic administration of histamine blockers or propulsive drugs in healthy pediatric patients is unwarranted.

Allometric determination of the distance from the central venous pressure port to wedge position of balloon-tip catheters in pediatric patients.

Position of the CVP port on a flow-directed balloon-tip pulmonary arterial catheter affects the accuracy of both thermodilution cardiac output determinations and CVP measurements. Systemic allometry (the study of the growth of a part in relation to the total organism) has been used to determine an easily measured independent variable that would predict this position. Sixty-one pediatric patients (aged 0 to 165 months) were studied either at autopsy or at the time of cardiac catheterization. The distance from the central venous port to the wedge position was best predicted by nonlinear manipulation of age.

Airway management for CO2 laser surgery on the larynx: Venturi jet ventilation and alternatives.

Supralaryngeal Venturi jet ventilation provides superb surgical visualization and access to the larynx, including the anterior and posterior commissure. When VJV is delivered through a metal cannula and laryngoscope or all-metal endotracheal tube or bronchoscope, there is no inorganic combustible material in the surgical field, making supralaryngeal VJV a safe as well as effective technique for CO2 laser surgery on the airway.

Anesthesia considerations for orthotopic liver transplantation.

An institutionwide commitment is necessary for the success of a liver transplantation program. Although the number of people available to manage anesthesia for such surgery may vary, a minimally staffed transplantation team must include a staff anesthesiologist, an anesthesia resident, one or two certified nurse-anesthetists, and a nonprofessional to obtain and run specimens to the laboratory and blood bank; the operating room must be connected by intercom and telephone to support services. Another technician may be present to collect specimens and data for research purposes. Additional staff anesthesiologists, certified nurse-anesthetists, and anesthesia residents should be on call for other emergency surgery. The staff of laboratory and blood bank facilities must participate wholeheartedly to meet ongoing requirements during a liver transplantation. Enormous quantities of packed red cells (up to 250 units), fresh-frozen plasma, platelets, and occasionally cryoprecipitate must be immediately available. In addition, the donor pool and the supply of on-hand blood must be large enough to prevent shortages of blood for other emergency or routine surgery. Liver transplantation procedures last an average of 12 hours and cannot easily be accommodated in a busy operating room schedule. It is not reasonable to expect other patients, other surgeons, the anesthesiology department, and the hospital to postpone routine or other emergency surgery while a liver transplantation is being performed. Thus, the hospital must provide facilities to accommodate such a program either by new construction or by remodeling or reassigning operating space.

Anesthesia for pediatric orthotopic liver transplantation.

The anesthetic management of 68 liver transplantations in 50 pediatric patients is described. The surgical technique is briefly reviewed. The selection of an anesthetic technique was not as important as management of numerous intra-operative problems. Citrate intoxication secondary to massive blood transfusion in the hypothermic anhepatic patient is a major problem, as are coagulation deficiencies. Hyperkalemic cardiac arrest, also a significant hazard, produced the only intraoperative death.

Intraoperative coagulation changes in children undergoing liver transplantation.

Intraoperative changes in blood coagulation were observed in eight children undergoing liver transplantation using a simplified coagulation profile (prothrombin time [PT], activated partial thromboplastin time [aPTT], and platelet count) and thrombelastography. Preoperatively, PT and aPTT were moderately prolonged (1.5 times control), and platelet count was greater than 100,000/mm3 in all patients but one (91,000/mm3). During the preanhepatic and anhepatic stages, PT, aPTT, reaction time, and coagulation time improved toward normal values, but platelet count and maximum amplitude did not change. Significant changes in coagulation occurred on reperfusion of the grafted liver: PT, aPTT, reaction time, and coagulation time were prolonged, and platelet count, maximum amplitude, and clot formation rate decreased. A heparin effect, which did not require treatment, was seen on reperfusion in four patients. Fibrinolysis occurred during the operation in five patients and was treated with Epsilon-aminocaproic acid (EACA) in one. Blood coagulation improved slowly, and values were close to baseline 90 min after reperfusion. In general, the coagulation changes seen in these children are similar to those in adults but less severe, possibly because of the preponderance of cholestatic disease in children compared with the more common hepatocellular disease in adults.

Mivacurium infusion requirements in pediatric surgical patients during nitrous oxide-halothane and during nitrous oxide-narcotic anesthesia.

We were interested in determining the infusion rate of mivacurium required to maintain approximately 95% neuromuscular blockade during nitrous oxide-halothane (0.8% end-tidal) or nitrous oxide-narcotic anesthesia. Neuromuscular blockade was monitored by recording the electromyographic activity (Datex NMT) of the adductor pollicis muscle resulting from supramaximal stimulation of the ulnar nerve at 2 Hz for 2 s at 10-s intervals. Mivacurium steady-state infusion requirements averaged 315 +/- 26 micrograms.m-2.min-1 during nitrous oxide-halothane anesthesia and 375 +/- 19 micrograms.m-2.min-1 (mean +/- SEM) during nitrous oxide-narcotic anesthesia. Higher levels of pseudocholinesterase activity were generally associated with a higher mivacurium infusion requirement. During both anesthetics, younger age was associated with a higher infusion requirement when the infusion requirement was calculated in terms of micrograms.kg-1.min-1. This difference was not present when the infusion rate was calculated in terms of micrograms.m-2.m-1. There was no evidence of cumulation during prolonged mivacurium infusion. There was no difference in the rates of spontaneous or reversal-mediated recovery between anesthetic groups. After the termination of the infusion, spontaneous recovery to T4/T1 greater than or equal to 0.75 occurred in 9.8 +/- 0.4 min, with a recovery index, T25-75, of 4.0 +/- 0.2 min (mean +/- SEM). In summary, pseudocholinesterase activity is the major factor influencing mivacurium infusion rate in children during nitrous oxide-narcotic or nitrous oxide-halothane (0.8% end-tidal) anesthesia.