Safety and efficacy of aprotinin versus tranexamic acid for reducing absolute blood loss and transfusion in pediatric patients undergoing craniosynostosis surgery: a randomized, double-blind, three-arm controlled trial.

OBJECTIVE: Craniosynostosis surgery is associated with considerable blood loss and need for transfusion. Considering the lower estimated blood volume (EBV) of children compared to adults, excessive blood loss may quickly lead to hypovolemic shock. Therefore, reducing blood loss is important in craniosynostosis surgery. This study was conducted to evaluate the efficacy of aprotinin or tranexamic acid (TXA) in blood loss reduction in these patients. METHODS: In the current randomized controlled trial, 90 eligible pediatric patients with craniosynostosis were randomly divided into three groups to receive either aprotinin, TXA, or no intervention. The absolute blood loss and transfusion amount were assessed for all patients both intraoperatively and 2 and 8 hours postoperatively. RESULTS: Although crude values of estimated blood loss were not significantly different between groups (p = 0.162), when adjusted to the patient's weight or EBV, the values reached the significance level (p = 0.018), particularly when the aprotinin group was compared to the control group (p = 0.0154). The EBV losses 2 hours and 8 hours postoperatively significantly dropped in the TXA and aprotinin groups compared to the control group (p = 0.001 and p < 0.001, respectively). Rates of postoperative blood transfusion were significantly higher in the control group (p = 0.024). Hemoglobin and hematocrit 8 hours postoperatively were lower in the control group than in the TXA or aprotinin treatment groups (p < 0.002 and p < 0.001, respectively). There were no serious adverse events associated with the interventions in this study. CONCLUSIONS: Aprotinin and TXA can reduce blood loss and blood transfusion without serious complications and adverse events in pediatric patients undergoing craniosynostosis surgery.

A randomized-controlled, double-blind study to evaluate the efficacy of caudal midazolam, ketamine and neostigmine as adjuvants to bupivacaine on postoperative analgesic in children undergoing lower abdominal surgery.

• Background: Caudal epidural is the most commonly used technique for the management of postoperative pain in children. The aim of the present study was to assess and compare the efficacy of caudal bupivacaine as a postoperative analgesic alone or combined with midazolam, ketamine, and neostigmine in pediatric patients undergoing lower abdominal surgery. METHODS: Eighty pediatric patients categorized under the American Society of Anesthesiologists Physical Status I and II Classification System, who have been scheduled to undergo lower abdominal surgery were randomly designated into four groups to receive caudal block with either 1 ml/kg of 0.25% caudal bupivacaine for group B, 1 ml/kg of 0.25% caudal bupivacaine mixed with 2 µg/kg neostigmine for group BN, 1 ml/kg of 0.25% caudal bupivacaine mixed with 0.5 mg/kg ketamine for group BK or 1 ml/kg of 0.25% caudal bupivacaine mixed with 50 mcg/kg midazolam for group BM. Postoperative analgesia was examined by a blinded anesthetist utilizing a Revised Faces Pain Scale.Consumption of the total amount of rescue analgesic each 24 h, postoperative time to requirement of the first dose and any adverse effects were noted. RESULTS: The four groups were comparable as regards age, sex, weight, duration of surgery, heart rate, blood pressure and the time from induction of anesthesia to response to voice. The Revised Faces Pain Scale was 2.6±1.5 in group BN, 3.1±1.8 in group BM, 4.4±2.4 in group BK, and 5.6±1.3 in group B (p=0.005). Postoperative duration of analgesia was 433±68 min, 769±118 min, 1097±126 min and 1254±176 min in groups B, BK, BM and BN respectively (P=0.001). The dose of rescue analgesic within 24 h in group B was significantly higher than those of the other three groups (P<0.05). CONCLUSION: Addition of either neostigmine, midazolam, or ketamine to caudal bupivacaine extended analgesia time and decreased rescue analgesic compared to bupivacaine alone in children who underwent lower abdominal surgery.

Skin Temperature Over the Carotid Artery, an Accurate Non-invasive Estimation of Near Core Temperature.

BACKGROUND: During anesthesia, continuous body temperature monitoring is essential, especially in children. Anesthesia can increase the risk of loss of body temperature by three to four times. Hypothermia in children results in increased morbidity and mortality. Since the measurement points of the core body temperature are not easily accessible, near core sites, like rectum, are used. OBJECTIVES: The purpose of this study was to measure skin temperature over the carotid artery and compare it with the rectum temperature, in order to propose a model for accurate estimation of near core body temperature. PATIENTS AND METHODS: Totally, 124 patients within the age range of 2 - 6 years, undergoing elective surgery, were selected. Temperature of rectum and skin over the carotid artery was measured. Then, the patients were randomly divided into two groups (each including 62 subjects), namely modeling (MG) and validation groups (VG). First, in the modeling group, the average temperature of the rectum and skin over the carotid artery were measured separately. The appropriate model was determined, according to the significance of the model's coefficients. The obtained model was used to predict the rectum temperature in the second group (VG group). Correlation of the predicted values with the real values (the measured rectum temperature) in the second group was investigated. Also, the difference in the average values of these two groups was examined in terms of significance. RESULTS: In the modeling group, the average rectum and carotid temperatures were 36.47 ± 0.54°C and 35.45 ± 0.62°C, respectively. The final model was obtained, as follows: Carotid temperature × 0.561 + 16.583 = Rectum temperature. The predicted value was calculated based on the regression model and then compared with the measured rectum value, which showed no significant difference (P = 0.361). CONCLUSIONS: The present study was the first research, in which rectum temperature was compared with that of skin over carotid artery, to find a safe location with easier access and higher accuracy for estimating near core body temperature. Results obtained in this study showed that, using a model, it is possible to evaluate near core body temperature in children, by measuring skin temperature over carotid artery.

Acupressure using ondansetron versus metoclopramide on reduction of postoperative nausea and vomiting after strabismus surgery.

OBJECTIVE: To compare the clinical efficacy of acupressure with treatment induced by ondansetron and metoclopramide on reduction of the severity of postoperative nausea and vomiting (PONV) after strabismus surgery. METHODS: There were 200 patients with ASA classes I-II, ages 10 to 60 years old, who underwent strabismus surgery that were included in this randomized, prospective, double-blind, placebo-controlled trial. Group I was the control, group II received metoclopramide 0.2 mg/kg, and group III received ondansetron 0.15 mg/kg intravenously immediately prior to anesthesia induction. In Group IV, acupressure wristbands were applied at the P6 points. Acupressure wrist bands were not placed appropriately for subjects of groups I-III. The acupressure wrist bands were applied 30 minutes before anesthesia induction and removed six hours after surgery completion. Anesthesia was standardized. PONV was evaluated within 0 - 2 hours and 2 - 24 hours after surgery by a blinded observer. Results were analyzed by the Chi-square or Fisher exact test. A P value of <0.05 was considered significant. RESULTS: The incidence of PONV was not significantly different among acupressure, metoclopramide and ondansetron groups during 24 hours. Also, the severity of PONV was not significantly different between acupressure, metoclopramide, and ondansetron in the recovery and ward. CONCLUSION: Acupressure at the P6 point causes a significant reduction in the incidence and severity of PONV 24 hours after strabismus surgery as well as metoclopramide (0.2 mg/kg) and ondansetron (0.15 mg/kg) intravenous for patients aged 10 or older. (Irct ID: IRCT138807152556N1).