Fast-track recovery after day case surgery.

BACKGROUND: Fast-track recovery processes are implemented for pediatric day case surgery. We conducted a prospective study to evaluate postoperative comfort and parental satisfaction of children included in this process to improve quality of care. METHODS: We included all children scheduled for superficial procedures or dental treatment outside the operating room. A questionnaire was explained to parents before hospital discharge to evaluate the first night at home. Postoperative comfort evaluation included postoperative pain score (FLACC scale), incidence of postoperative nausea and vomiting, and postoperative behavior disorders. Incidence of posthospital behavior disturbance was evaluated measuring postoperative agitation at home, and disinterest with toys and games. Parental satisfaction was evaluated with a four-point Likert scale (1 = not satisfied at all, 2 = not satisfied, 3 = satisfied, 4 = very satisfied). RESULTS: One hundred and forty-three questionnaires were returned to hospital. Despite reduced length of stay in short-stay unit after anesthesia (28 ± 34 min), we did not report serious complications, and global parental satisfaction was good about the care process. Pain scores (FLACC >3) were higher in the group scheduled for dental procedures, but were very low for the other superficial surgery. With an odd ratio of 5.8 (95% confidence interval 2-17; P = 0.001), postoperative behavior modification (agitation or disinterest with toys or games) was the strongest variable that can predict parental dissatisfaction. CONCLUSION: Optimal pain management, better parental information about risks of postoperative behavior disturbances, and program integrating parent and child preparation should improve quality of care and global satisfaction in the fast-track recovery process.

Sevoflurane anesthesia and brain perfusion.

OBJECTIVE/AIM: To assess the impact of sevoflurane and anesthesia-induced hypotension on brain perfusion in children younger than 6 months. BACKGROUND: Safe lower limit of blood pressure during anesthesia in infant is unclear, and inadequate anesthesia can lead to hypotension, hypocapnia, and low cerebral perfusion. Insufficient cerebral perfusion in infant during anesthesia is an important factor of neurological morbidity. In two previous studies, we assessed the impact of sevoflurane anesthesia on cerebral blood flow (CBF) by transcranial Doppler (TCD) and on brain oxygenation by NIRS, in children ≤2 years. As knowledge about consequences of anesthesia-induced hypotension on cerebral perfusion in children ≤6 months is scarce, we conducted a retrospective analysis to compare the data of CBF and brain oxygenation, in this specific population. METHODS: We performed a retrospective analysis of data collected from our two previous studies. Baseline values of TCD or NIRS were recorded and then during sevoflurane anesthesia. From a database of 338 patients, we excluded all patients older than 6 months. Then, we compared physiological variables of TCD and NIRS population to ensure that the two groups were comparable. We compared rSO2 c and TCD measurements variation according to MAP value during sevoflurane anesthesia, using anova and Student-Newman-Keuls for posthoc analysis. RESULTS: One hundred and eighty patients were included in the analysis. TCD and NIRS groups were comparable. CBF velocities (CBFV) or rSO2 c reflects a good cerebral perfusion when MAP is above 45 mmHg. When MAP is between 35 and 45 mmHg, CBFV variation reflects a reduction of CBF, but rSO2 c increase is the consequence of a still positive balance between CMRO2 and O2 supply. Below 35 mmHg of MAP during anesthesia, CBFV decrease and rSO2 c variation from baseline is low. For each category of MAP and for the two groups, etCo2 and expired fraction of sevoflurane (FeSevo) were comparable (anova P > 0.05). CONCLUSION: In a healthy infant without dehydration, with normal PaCO2 and hemoglobin value, scheduled for short procedures, MAP is a good proxy of cerebral perfusion as we found that CBF assessed by CBFV and rSO2 c decreased proportionally with cerebral perfusion pressure. During 1 MAC sevoflurane anesthesia, maintaining MAP beyond 35 mmHg during anesthesia is probably safe and sufficient. But when MAP decreases below 35 mmHg, CBF decreases and rSO2 c variation from baseline is low despite CMRO2 reduction. In this situation, cerebral metabolic reserve is low and further changes of systemic conditions may be poorly tolerated by the brain.

Impact of sevoflurane anesthesia on brain oxygenation in children younger than 2 years.

OBJECTIVE/AIM: To assess the impact of sevoflurane and anesthesia-induced hypotension on brain oxygenation in children younger than 2 years. BACKGROUND: Inhalational induction with sevoflurane is the most commonly used technique in young children. However, the effect of sevoflurane on cerebral perfusion has been only studied in adults and children older than 1 year. The purpose of this study was to assess the impact of sevoflurane anesthesia on brain oxygenation in neonates and infants, using near-infrared spectroscopy. METHODS: Children younger than 2 years, ASA I or II, scheduled for abdominal or orthopedic surgery were included. Induction of anesthesia was started by sevoflurane 6% and maintained with an expired fraction of sevoflurane 3%. Mechanical ventilation was adjusted to maintain an endtidal CO2 around 39 mmHg. Brain oxygenation was assessed measuring regional cerebral saturation of oxygen (rSO2 c), measured by NIRS while awake and 15 min after induction, under anesthesia. Mean arterial pressure (MAP) variation was recorded. RESULTS: Hundred and ninety-five children were included. Anesthesia induced a significant decrease in MAP (-27%). rSO2 c increased significantly after induction (+18%). Using children age for subgroup analysis, we found that despite MAP reduction, rSO2 c increase was significant but smaller in children ≤ 6 months than in children >6 months (≤ 6 months: rSO2 c = +13%, >6 months: rSO2 c = +22%; P < 0.0001). Interindividual comparison showed that, during anesthesia at steady-state with comparable CMRO2, rSO2 c values were significantly higher when MAP was above 36 mmHg. And the higher the absolute MAP value during anesthesia was, the higher the rSO2 c was. We observed a rSO2 c variation ≤ 0 in 21 patients among the 195 studied, and the majority of these patients were younger than 6 months (n = 19). No increase or decrease of rSO2 c during anesthesia despite reduction of CMRO2 can be explained by a reduction of oxygen supply. Using the ROC curves, we determined that the threshold value of MAP under anesthesia, associated with rSO2 c variation ≤ 0%, was 39 mmHg in all the studied population (AUC: 0.90 ± 0.02; P < 0.001). In children younger than 6 months, this value of MAP was 33 mmHg, and 43 mmHg in children older than 6 months. CONCLUSION: Despite a significant decrease of MAP, 1 MAC of sevoflurane induced a significant increase in regional brain oxygenation. But subgroup analysis showed that MAP decrease had a greater impact on brain oxygenation, in children younger than 6 months. According to our results, MAP value during anesthesia should not go under 33 mmHg in children ≤6 months and 43 mmHg in children >6 months, as further changes in MAP, PaCO2 or hemoglobin during anesthesia may be poorly tolerated by the brain.

Ondansetron for the prevention and treatment of nausea and vomiting following pediatric strabismus surgery.

BACKGROUND: Neither droperidol nor ondansetron has been proven completely effective, and there are conflicting data comparing the efficacy of the two agents. The purpose of this study was to compare the efficacy, safety and cost of a combination of ondansetron administered intravenously in the operating room followed by oral ondansetron treatment at home with the more commonly used treatment of intravenous droperidol therapy and oral dimenhydrinate therapy, for the prevention and treatment of postoperative nausea and vomiting in children undergoing strabismus surgery. METHODS: Double-blind randomized clinical trial with parallel comparison groups. All patients aged 6 months to 18 years who underwent strabismus surgery at a pediatric hospital in Montreal between Nov. 13, 2000, and June 12, 2001, were included. The exclusion criteria were nausea or vomiting, or use of antiemetics or narcotics in the 24 hours preceding surgery, and past history of hepatic, gastric or renal disease. The outcome measures were frequency of nausea and vomiting, severity of nausea and adverse effects in hospital, during transportation home and during the first 24 hours at home. Data were obtained through nursing notes and through a telephone interview conducted 24 to 48 hours after discharge. RESULTS: Of the 208 eligible patients, 172 were randomly assigned to the study groups (88 to the ondansetron group and 84 to the droperidol/dimenhydrinate group). We found no statistically significant difference in the incidence of nausea and vomiting in hospital or at home between the two groups (25.3% vs. 31.6%, p = 0.371). There was a significant difference between the two groups in the rate of vomiting during transportation home (3.6% vs. 12.6%, p = 0.044). The incidence of severe nausea was 14.4% with ondansetron and 15.4% with droperidol, a nonsignificant difference (p = 1.00). No significant difference was observed between the two groups in the incidence of any nausea (p = 0.434) or adverse effects (p = 0.220). We calculated that the combination of droperidol and dimenhydrinate was seven times less costly than the ondansetron regimen. INTERPRETATION: In this study, the efficacy and safety of intravenous administration of droperidol followed by oral use of dimenhydrinate did not differ from that of intravenous followed by oral use of ondansetron in children undergoing strabismus surgery. Since treatment with ondansetron is much more costly than the combination of droperidol and dimenhydrinate, at this time the use of ondansetron in the prevention and treatment of vomiting and nausea in this population may not be beneficial on a cost basis if all other variables are considered.