Effect of Inhaled Sevoflurane on Pediatric Cerebrospinal Fluid Pressure During Lumbar Puncture; Implications for Intracranial Hypertension.

Objective: To determine influence of sevoflurane on changes in cerebrospinal fluid pressure in children presenting for lumbar puncture. Methods: Cerebrospinal fluid pressure, end tidal carbon dioxide, and end tidal sevoflurane concentration measurements were obtained at 2-minute intervals for a total of 10 minutes (T0 to T5). Because of concerns regarding patient safety and comfort, the study measurements were completed at the end of the lumbar procedure, starting with the closing pressure and when sevoflurane was stopped. Results: As end tidal sevoflurane concentration decreased, cerebrospinal fluid pressure initially increased up to T2 before decreasing back to around the initial point. There was no significant correlation between sevoflurane level and cerebrospinal fluid pressure. Both weight status and presence or absence of optic edema did not have a significant impact on pressure over time. However, there was a statistically significant difference in the cerebrospinal fluid pressure over time between those with spontaneous respirations compared to those without. Conclusions: There was no significant correlation between the end tidal sevoflurane concentration and cerebrospinal fluid pressure. Assisted ventilation did produce a statistically significant increase in cerebrospinal fluid pressure and suggests that the most accurate measurements are in those with spontaneous respirations.

The effects of oral ondansetron disintegrating tablets for prevention of at-home emesis in pediatric patients after ear-nose-throat surgery.

BACKGROUND: Tonsillectomy and adenoidectomy are associated with a frequent incidence of vomiting, both in the hospital and at home. We evaluated the effects of oral ondansetron disintegrating tablets (ODT) on the incidence of at-home emesis in children undergoing tonsillectomy with and without adenoidectomy and with and without bilateral myringotomy and tube insertion. METHODS: All patients underwent inhaled mask induction with nitrous oxide, oxygen, and sevoflurane. Morphine, dexamethasone, and ondansetron were administered to all patients intraoperatively. Postoperative pain was treated with fentanyl or acetaminophen with codeine. Rescue antiemetics in the postanesthesia care unit or same day surgery unit were administered for three emetic episodes within 15 min, or upon patient or parent request. Patients were randomized for at-home administration of five doses of either ondansetron ODT or a placebo. All patients were followed for the first 3 days after surgery. At-home emesis was the primary outcome variable. RESULTS: Two hundred and twenty-one patients were entered into the study, yielding 200 evaluable subjects. At-home emesis occurred in 15 (14.5%) of the 103 children who received ODT, and 31 (32%) of the 97 children in the placebo group, P = 0.004. Subgroup analysis demonstrated efficacy in patients who did not require rescue medication for nausea and vomiting while in the hospital, but did not demonstrate efficacy for patients who required rescue medication. CONCLUSIONS: At-home use of ODT may prevent emesis in children during the first 3 days after tonsillectomy in children. Patients who require rescue after prophylactic treatment for nausea and vomiting in the hospital may not respond to prophylactic ondansatron ODT at home.

Cardiac arrest under anesthesia in a pediatric patient with Williams syndrome: a case report.

Serial cardiac arrests occurred during the induction of a 3-year-old boy for elective 1-sided orchiopexy surgery and evaluation under anesthesia of previously placed ear tympanoplasty tubes. The child's history included Williams syndrome along with hypercalcemia and mild supravalvular aortic stenosis. The initial arrests included significant ST wave changes along with profound brodycardia, hypotension, and pulseless electrical activity requiring full resuscitation twice. The patient was transferred on an emergency basis to the intensive care unit (the surgery was cancelled), and a heart catheterization was scheduled for the following morning. The patient experienced several cardiac arrests during the cardiac catheterization procedure, necessitating emergency extracorporeal membrane oxygenation cannulation and immediate transfer to the operating room for emergency cardiac surgery. A thorough preoperative cardiac workup, including cardiac catheterization, electrocardiogram, and echocardiogram, may decrease mortality and morbidity in patients with Williams syndrome. However, cardiac catheterization has been associated with increased risk in this patient population.

Pain management following myringotomy and tube placement: intranasal dexmedetomidine versus intranasal fentanyl.

PURPOSE: Despite the brevity of the procedure, bilateral myringotomy and tympanostomy tube placement (BMT) can result in significant postoperative pain and discomfort. As the procedure is frequently performed without intravenous access, non-parenteral routes of administration are frequently used for analgesia. The current study prospectively compares the efficacy of intranasal (IN) dexmedetomidine with IN fentanyl for children undergoing BMT. METHODS: This prospective, double-blinded, randomized clinical trial included pediatric patients undergoing BMT. The patients were randomized to receive either IN dexmedetomidine (1 µg/kg) or fentanyl (2 µg/kg) after the induction of general anesthesia with sevoflurane. All patients received rectal acetaminophen (40 mg/kg) and the first 50 patients also received premedication with oral midazolam. Postoperative pain and recovery were assessed using pediatric pain and recovery scales, and any adverse effects were monitored for. RESULTS: The study cohort included 100 patients who ranged in age from 1 to 7.7 years and in weight from 8.6 to 37.4 kg. They were divided into 4 groups with 25 patients in each group: (1) midazolam premedication+IN dexmedetomidine; (2) midazolam premedication+IN fentanyl; (3) no premedication+IN dexmedetomidine; and (4) no premedication+IN fentanyl. Pain scores were comparable when comparing groups 2, 3 and 4, but were higher in group 1 (midazolam premedication with IN dexmedetomidine). There was no difference in total time in the post-anesthesia care unit (PACU) or time from arrival in the PACU until hospital discharge between the 4 groups. The heart rate (HR) was significantly lower in group 3 when compared to the other groups at several different times after arrival to the PACU. No clinically significant difference was noted in blood pressure. CONCLUSION: Following BMT, when no premedication is administered, there was no clinical advantage when comparing IN dexmedetomidine (1 µg/kg) to IN fentanyl (2 µg/kg). The addition of oral midazolam as a premedication worsened the outcome measures particularly for children receiving IN dexmedetomidine.