Guidelines to the Practice of Anesthesia: Revised Edition 2023.

OVERVIEW: The Guidelines to the Practice of Anesthesia Revised Edition 2023 (the Guidelines) were prepared by the Canadian Anesthesiologists' Society (CAS), which reserves the right to determine their publication and distribution. The Guidelines are subject to revision and updated versions are published annually. The Guidelines to the Practice of Anesthesia Revised Edition 2023 supersede all previously published versions of this document. Although the CAS encourages Canadian anesthesiologists to adhere to its practice guidelines to ensure high-quality patient care, the CAS cannot guarantee any specific patient outcome. Anesthesiologists should exercise their own professional judgment in determining the proper course of action for any patient's circumstances. The CAS assumes no responsibility or liability for any error or omission arising from the use of any information contained in its Guidelines to the Practice of Anesthesia.

RéSUMé: Le Guide d'exercice de l'anesthésie, version révisée 2023 (le Guide), a été préparé par la Société canadienne des anesthésiologistes (SCA), qui se réserve le droit de décider des termes de sa publication et de sa diffusion. Le Guide est soumis à révision et des versions mises à jour sont publiées chaque année. Le Guide d'exercice de l'anesthésie, version révisée 2023, remplace toutes les versions précédemment publiées de ce document. Bien que la SCA incite les anesthésiologistes du Canada à se conformer à son guide d'exercice pour assurer une grande qualité des soins dispensés aux patients, elle ne peut garantir les résultats d'une intervention spécifique. Les anesthésiologistes doivent exercer leur jugement professionnel pour déterminer la méthode d'intervention la mieux adaptée à l'état de leur patient. La SCA n'accepte aucune responsabilité ou imputabilité de quelque nature que ce soit découlant d'erreurs ou d'omissions ou de l'utilisation des renseignements contenus dans son Guide d'exercice de l'anesthésie.

Clinical Case Complexity in Occupational Health: Contributing Factors and a Proposed Conceptual Framework Model.

OBJECTIVES: Clinical case complexity is an inherent factor in occupational health (OH), yet it is poorly defined and understood. Our aim was to identify the multiple sources of complexity in OH and propose a conceptual complexity framework model for clinical OH practice. METHODS: Through a scoping review, expert panel consensus, and content analysis of OH clinical case reports, we identified relevant complexity-contributing factors (CCFs) specifically tailored to the OH setting, which we defined and validated. RESULTS: The proposed model consists of three primary domains (PDs); health factors, workplace factors and biopsychosocial factors. Twenty-seven CCFs are described and defined within these PDs. CONCLUSIONS: This work lays the foundation for improved understanding, identification, and assessment of complexity in OH. This is imperative for ensuring high quality clinical practice standards, identifying training needs and appropriate triaging/resource allocation.

Pediatric anesthesia training to early career stage: Opportunities for firm foundations.

Attaining professional contentment can be challenging for many. Academic success, psychosocial support, and the confidence to provide excellent clinical care at the workplace are key pillars that can help build a sense of meaning in a career. The role of mentorship in facilitating these key pillars at different stages of pediatric anesthesia training and new independent practice is instrumental. For mentees aspiring for a career in pediatric anesthesia, there are several points of focus. Mentees should seek out mentors early in training, build on these relationships, and explore opportunities for peer mentorship as they advance in their career. For mentors, introducing mentees to the clinical and academic aspects of pediatric anesthesia and setting the foundation for the mentee to advance in their career can be both gratifying and stimulating. In this article, we explore the development and progression of a mentor-mentee relationship through training to the early career stage and its role in developing a meaningful career in pediatric anesthesia.

Opioid-related harm in a quaternary pediatric hospital: A 5-year review.

BACKGROUND: Opioid therapy in pediatrics may be particularly prone to error, yet the incidence of opioid-related medication error and harm has not yet been described in the pediatric inpatient setting. METHODS: We reviewed a prospectively compiled medication safety database from November 1, 2012 to October 31, 2017. Reports originated from voluntary reporting, hospital code events, naloxone administrations, and reports of unexpected experiences of patient pain. Time, location, error characteristics, drug, route, prescription, error phase, mechanisms, harm, and outcome were collected for all reports. Error and harm were classified by the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) system. RESULTS: Over 697 opioid medication safety reports were included during the study period. Opioids were administered at a rate of 79.26 administrations per 100 patient bed days, with morphine and hydromorphone administered at 62 versus 15 administrations per 100 bed days, respectively. Overall error rate was 0.94 errors per 103 patient days. Although the absolute rate of error reporting was greater for morphine (0.65 errors reported per 103 opioid administrations) than for hydromorphone, the adjusted incidence of harm was 0.211 per 103 hydromorphone administrations compared to 0.086 per 103 morphine administrations. 47 opioid errors resulted in harm, and administration errors (29) were almost twice as common as prescribing errors (15). CONCLUSIONS: We report and aim to establish a comparative reference point for incidence of opioid-related error and harm adjusted for both hospital bed days and total opioid administrations within the pediatric hospital inpatient setting based on the above findings.

The Antidepressant-Like Effects of a Clinically Relevant Dose of Ketamine Are Accompanied by Biphasic Alterations in Working Memory in the Wistar Kyoto Rat Model of Depression.

Major depressive disorder (MDD) is the leading cause of disability worldwide. The majority of antidepressant drugs require several weeks or months of treatment to demonstrate efficacy and a subset of patients are resistant to such interventions. Ketamine demonstrates rapid and long-lasting antidepressant effects in treatment resistant patients; however, side effects may limit its widespread clinical utility. The pharmaceutical industry is engaged in developing novel rapid-acting antidepressant drugs and the establishment of clinically relevant assays are needed to advance this process. Wistar Kyoto (WKY) rats are a valuable model of many of the characteristics of MDD and their resistance to selective serotonin reuptake inhibitors (SSRIs) in several behavioral paradigms emulates treatment resistance in clinical populations. Here, we confirmed the depressive-like phenotype of WKY rats in comparison to Sprague Dawley rats, characterized by increased immobility in the forced swim test, decreased locomotor activity and entries to the centre in the open field test, anhedonia in the female urine sniffing test and working memory deficits in the delayed non-match to position task. Single subcutaneous administration of 5 mg/kg ketamine in WKY rats mirrored the plasma exposure produced by the antidepressant dose in the clinic and rescued depressive-like behaviors. The same dose induced transient side effects, including decreased locomotor activity and reduced positive affect-associated vocalizations. Furthermore, ketamine acutely impaired working memory but induced pro-cognitive effects at a later time point. These data confirm the WKY rat as a preclinical model of depression. Ketamine's efficacy in recovering this depressive-like phenotype while inducing transient dissociative-like effects supports this as a translational model suitable for investigating novel antidepressant drugs.

Ultrasound-guided techniques for peripheral intravenous placement in children with difficult venous access.

Peripheral intravenous placement in children can be challenging. Different techniques have been used to improve first pass success rates in children with known history of difficult venous access including surface landmarking, local warming, transillumination, ultrasonography, epidermal nitroglycerin, central venous access, intraosseous placement, and venous cutdown. Among these, ultrasound guidance has garnered the most interest among anesthesiologists. The cumulative literature surrounding the utility of ultrasound-guided peripheral intravenous placement in children with and without difficult venous access has shown mixed results. Literature on the utility of ultrasound guidance for peripheral intravenous placement in children under deep sedation or anesthesia is limited but encouraging. This review summarizes the overall evidence for ultrasound-guided peripheral intravenous placement in children with difficult venous access under deep sedation or general anesthesia. Furthermore, five subtly varying approaches to ultrasound-guided peripheral intravenous placement with their advantages and disadvantages will be discussed. One of these five approaches is Dynamic Needle Tip Positioning. Utilizing a short axis out of plane ultrasound view, this promising technique allows for accurate needle tip localization and may increase the success rate of peripheral intravenous placement, even in small children, under deep sedation, or general anesthesia.

Neuronal glutamatergic changes and peripheral markers of cytoskeleton dynamics change synchronically 24 h after sub-anaesthetic dose of ketamine in healthy subjects.

Ketamine acts as a rapid-acting antidepressant by restoring glutamatergic deficits and activating synaptic plasticity processes, with peak activity 24 h after infusion. Microtubule dynamics are known to play a key role in modulation of cytoskeleton and synaptic plasticity, as well as in signalling events in peripheral blood cells. Here, we correlated ketamine-induced change in glutamate/creatinine (Glu/Cr) levels in the pregenual anterior cingulate cortex (pgACC) with peripheral markers of microtubule dynamics, namely acetylated α-tubulin (Acet-Tub), with particular attention to gender specificity. Eighty healthy controls (age = 25.89 ± 5.29, 33 women) were administered intravenous infusion of either ketamine (0.5 mg/kg) or placebo (saline). Blood samples were obtained at baseline and 24 h after infusion and plasma levels of Acet-Tub and transferrin (TRF; loading control) were measured via infrared western blotting. Glu/Cr levels were measured via high-field (7 T) proton magnetic resonance spectroscopy [1H-MRS] in the pgACC at the same time points. Gender differences were observed in baseline Acet-Tub/TRF levels (p < 0.001), and an interaction of time by treatment by gender (F = 5.13, p = 0.027) was found, with a significant increase in Acet-Tub/TRF for ketamine group in females only (p = 0.038). Ketamine-induced gender-independent Glu/Cr changes at 24 h (F(1, 69) = 4.08, p = 0.047), and changes in the pgACC were negatively correlated with the Acet-Tub/TRF expression (r= -0.464, p = 0.010) in the ketamine group, in which, separated by sex, only women showed significant correlation. Our findings indicate a temporal association between changes in central ketamine-induced glutamatergic effects and peripheral markers of cytoskeleton reorganization, particularly in females.

Knowledge translation and process improvement interventions increased pain assessment documentation in a large quaternary paediatric post-anaesthesia care unit.

BACKGROUND: Due to inadequate pain assessment documentation in our paediatric post-anaesthetic care unit (PACU), we were unable to monitor pain intensity, and target factors contributing to moderate and severe postoperative pain in children. The purpose of this study was to improve pain assessment documentation in PACU through a process improvement intervention and knowledge translation (KT) strategy. The study was set in a PACU within a large university affiliated paediatric hospital. Participants included PACU and Acute Pain Service nursing staff, administrative staff and anaesthesiologists. METHODS: The Plan-Do-Study-Act method of quality improvement was used. Benchmark data were obtained by chart review of 99 patient medical records prior to interventions. Data included pain assessment documentation (pain intensity score, use of validated pain intensity measure) during PACU stay. Repeat chart audit took place at 4, 5 and 6 months after the intervention. INTERVENTION: Key informant interviews were conducted to identify barriers to pain assessment documentation. A process improvement was implemented whereby the PACU flowsheets were modified to facilitate pain assessment documentation. KT strategy was implemented to increase awareness of pain assessment documentation and to provide the knowledge, skill and judgement to support this practice. The KT strategy was directed at PACU nursing staff and comprised education outreach (educational meetings for PACU nurses, discussions at daily huddles), reminders (screensavers, bedside posters, email reminders) and feedback of audit results. RESULTS: The proportion of charts that included at least one documented pain assessment was 69%. After intervention, pain assessment documentation increased to >90% at 4 and 5 months, respectively, and to 100% after 6 months. CONCLUSION: After implementing process improvement and KT interventions, pain assessment documentation improved. Additional work is needed in several key areas, specifically monitoring moderate to severe pain, in order to target factors contributing to significant postoperative pain in children.

Evaluating the effects of general anesthesia on sleep in children undergoing elective surgery: an observational case-control study.

Study Objectives: Previous research has suggested that general anesthetics can disturb postoperative sleep patterns by affecting the sleep-wake cycle. The objective was to identify the effects of general anesthetics on sleep quality and related behavioral changes in children. Methods: This was a prospective, observational case-control study with children, aged 18 months to 8 years, undergoing general anesthesia for elective surgery. Participants wore an actigraph for 7 days on three occasions: prior to surgery, the immediate postoperative period, and 3 months after surgery. Data regarding behavior patterns were collected using behavioral assessments at baseline, the first postoperative week, and 3 months following surgery. Results: Thirty-one participants (mean age 4.8 ± 2.0 years, 81% male) underwent urologic or otolaryngologic surgery. The median (interquartile range) anesthetic duration was 132.0 (80.0-184.0) min. No significant differences were found in sleep efficiency, total sleep time, wake time after sleep onset, or sleep onset latency between baseline, 7 day postoperative period, and the 3 month follow-up. No significant differences were found in sleep-related behavioral metrics including internalizing and externalizing behaviors, and executive functioning. Data were compared with a control group of 18 participants (mean age 5.3 ± 1.8 years, 61% male). No significant differences were found in sleep patterns and related behavioral metrics between both groups. Conclusions: In this study, general anesthesia did not result in disturbed sleep or associated negative behavioral changes in otherwise healthy children undergoing elective surgeries of low complexity. Physicians can advise parents that a child's surgery and associated general anesthetic exposure may not result in significant changes in postoperative sleep patterns.

Dual Motor-Cognitive Virtual Reality Training Impacts Dual-Task Performance in Freezing of Gait.

Freezing of gait (FOG), an episodic gait disturbance characterized by the inability to generate effective stepping, occurs in more than half of Parkinson's disease patients. It is associated with both executive dysfunction and attention and becomes most evident during dual tasking (performing two tasks simultaneously). This study examined the effect of dual motor-cognitive virtual reality training on dual-task performance in FOG. Twenty community dwelling participants with Parkinson's disease (13 with FOG, 7 without FOG) participated in a pre-assessment, eight 20-minute intervention sessions, and a post-assessment. The intervention consisted of a virtual reality maze (DFKI, Germany) through which participants navigated by stepping-in-place on a balance board (Nintendo, Japan) under time pressure. This was combined with a cognitive task (Stroop test), which repeatedly divided participants' attention. The primary outcome measures were pre- and post-intervention differences in motor (stepping time, symmetry, rhythmicity) and cognitive (accuracy, reaction time) performance during single- and dual-tasks. Both assessments consisted of 1) a single cognitive task 2) a single motor task, and 3) a dual motor-cognitive task. Following the intervention, there was significant improvement in dual-task cognitive and motor parameters (stepping time and rhythmicity), dual-task effect for those with FOG and a noteworthy improvement in FOG episodes. These improvements were less significant for those without FOG. This is the first study to show benefit of a dual motor-cognitive approach on dual-task performance in FOG. Advances in such virtual reality interventions for home use could substantially improve the quality of life for patients who experience FOG.

Early postoperative patient-controlled analgesia ratio predicts 24-hour morphine consumption and pain in children undergoing scoliosis surgery.

BACKGROUND: The identification of patients at risk for developing severe postoperative pain and/or opioid-related side effects is difficult due to a lack of sensitive indicators. The patient-controlled analgesia (PCA) ratio of demands to deliveries is a potential tool for early identification of patients who experience severe postoperative pain. The authors hypothesized that the PCA ratio is able to predict morphine requirement in the first 24 hours after scoliosis surgery. METHODS: The authors performed a retrospective study of adolescents who had surgery for idiopathic scoliosis. They collected data describing PCA demands and deliveries, morphine consumption, numerical rating scale (NRS) pain scores, opioid related side effects, and duration of hospital stay. Spearman rank analysis assessed association among 4-hour PCA ratios, NRS pain score, and 24-hour morphine consumption. Patients were divided into groups on the basis of PCA ratios <1.5 and ≥1.5. Univariate analysis and multiple regression were used to identify independent factors predictive for increased 24-hour morphine. Mann-Whitney rank-sum and Fisher exact tests were used to compare data. p < 0.05 was considered statistically significant. RESULTS: One hundred forty-seven patients were included in the analysis, mean (SD) age and weight were 15 (1.8) years and 55 (27) kg, respectively. There was a significant positive correlation between the 4-hour PCA ratio and initial 24-hour cumulative morphine consumption (r = 0.33, p = 0.0002). Patients with a 4-hour PCA ratio ≥1.5 demonstrated a significantly greater initial 24-hour morphine consumption (p = 0.0002), greater pain scores at 24 hours after surgery (p = 0.02), a greater incidence of at least one opioid-related side effect within the initial 24 hours after surgery, and a longer duration of hospital stay (p = 0.04) compared with those patients with a 4-hour PCA ratio <1.5. PCA ratio ≥1.5, age, and patient sex were predictive for 24-hour morphine consumption. CONCLUSIONS: The authors have demonstrated that a PCA ratio of demands/deliveries ≥1.5 is predictive of increased opioid requirements and is associated with greater pain scores in the initial 24 hours after surgery, an increased incidence of opioid-related side effects, and duration of hospital stay.

Partial liquid ventilation for the prevention of mortality and morbidity in paediatric acute lung injury and acute respiratory distress syndrome.

BACKGROUND: Acute lung injury and acute respiratory distress syndrome are syndromes of severe respiratory failure. Children with acute lung injury or acute respiratory distress syndrome have high mortality and the survivors have significant morbidity. Partial liquid ventilation is proposed as a less injurious form of respiratory support for these children. Uncontrolled studies in adults have shown improvements in gas exchange and lung compliance with partial liquid ventilation. A single uncontrolled study in six children with acute respiratory syndrome showed some improvement in gas exchange during three hours of partial liquid ventilation. This review was originally published in 2004, updated in 2009 and again in 2012. OBJECTIVES: To assess whether partial liquid ventilation reduces mortality or morbidity, or both, in children with acute lung injury or acute respiratory distress syndrome. SEARCH METHODS: In this updated review, we searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 11); CINAHL (Cumulative Index to Nursing & Allied Health Literature) via Ovid (1982 to November 2011); Ovid MEDLINE (1950 to November 2011); and Ovid EMBASE (1982 to November 2011). The search was last performed in August 2008. SELECTION CRITERIA: We included randomized controlled trials (RCTs) which compared partial liquid ventilation with other forms of ventilation in children (aged 28 days to 18 years) with acute lung injury or acute respiratory distress syndrome. Trials had to report one or more of the following: mortality; duration of mechanical ventilation, respiratory support, oxygen therapy, stay in the intensive care unit, or stay in hospital; infection; long-term cognitive impairment, neurodevelopmental progress, or other long-term morbidities. DATA COLLECTION AND ANALYSIS: We independently evaluated the quality of the relevant studies and extracted the data from the included studies. MAIN RESULTS: Only one study enrolling 182 patients (reported as an abstract in conference proceedings) was identified and found eligible for inclusion; the authors reported only limited results. The trial was stopped prematurely and was, therefore, under-powered to detect any significant differences and at high risk of bias. The only available outcome of clinical significance was 28-day mortality. There was no statistically significant difference between groups, with a relative risk for 28-day mortality in the partial liquid ventilation group of 1.54 (95% confidence interval 0.82 to 2.9). AUTHORS' CONCLUSIONS: There is no evidence from RCTs to support or refute the use of partial liquid ventilation in children with acute lung injury or acute respiratory distress syndrome. Adequately powered, high quality RCTs are still needed to assess its efficacy. Clinically relevant outcome measures should be assessed (mortality at discharge and later, duration of both respiratory support and hospital stay, and long-term neurodevelopmental outcomes). The studies should be published in full.

PCA-derived factors that may be predictive of postoperative pain in pediatric patients: a possible role for the PCA ratio.

OBJECTIVE: No method exists to reliably predict which patients will develop severe postoperative pain. The authors hypothesized that data derived from patient-controlled analgesia (PCA) pumps (specifically the ratio of patient demands to pump deliveries) may predict which patients would develop severe pain after scoliosis repair. SETTING: Quaternary, university-affiliated, pediatric hospital. PATIENTS AND PARTICIPANTS: Forty American Society of Anesthesiologists I-Il pediatric patients who had undergone elective scoliosis repair and had consented to recruitment to a randomized clinical trial investigating the effects of early morphine administration on remifentanil-induced hyperalgesia. INTERVENTIONS: To test the hypothesis of the current study, the authors calculated the PCA ratio of demand to delivery at every 4 hours throughout the first 24 hours after surgery for all the patients recruited to the original study. MAIN OUTCOME MEASURES: The authors compared calculated PCA ratios, numeric rating scale pain scores, and cumulative morphine consumption for those patients who developed severe postoperative pain and met the criteria for opioid rotation versus those patients who did not. RESULTS: Seven patients required opioid rotation from PCA morphine to PCA hydromorphone. Eight hours after surgery, the median PCA ratio for those seven patients (2.5[range, 1.8-4.3]) was significantly greater than that for all other recruited patients (1.3 [range, 0-2.7]; p < 0.001). CONCLUSIONS: Patients who developed severe postoperative pain and met the criteria for opioid rotation demonstrated significantly increased PCA ratios of demand to delivery as early as 8 hours after surgery.

Redesigning a morbidity and mortality program in a university-affiliated pediatric anesthesia department.

BACKGROUND: The concept of the morbidity and mortality (M&M) review is almost 100 years old, yet no standards describe "good practice" of M&M in clinical departments. Few reports measure output and impact of M&M reviews. The M&M activities were developed in a university-affiliated pediatric anesthesia department as part of a departmental quality improvement (QI) initiative. The process was designed to identify problems within the M&M program and to introduce interventions and actions to increase the program's efficiency and impact. METHODS: Through a series of interviews and consultation with hospital management, existing problems and inefficiencies were identified, a framework for developing the M&M program was established, and reportable outcome measures, such as increased meeting attendance, participation, self-reporting, and change to practice, were developed. Through appointment of specific M&M personnel, appointment ofa specific departmental M&M coordinator, meeting more regularly, stressing the review of system errors and close calls, and encouraging anonymous reporting, the department's M&M activities were redesigned. RESULTS: From the (July 1) 2001-(June 30) 2006 to (July 1) 2006-(June 30) 2009 periods, case reviews and case presentations increased from a mean of 1.9 to 3.4 cases presented per M&M meeting. Meeting attendance increased from a mean of 5.1 to 25, and self-reporting from a mean of 22% of all safety reports received to 40%. Findings and recommendations were effectively disseminated throughout the department and hospital, reflecting the unique structure of the M&M program and personnel's efforts. DISCUSSION: M&M QI with respect to data gathering, case review, and ongoing medical education is an efficient way to demonstrate quality assurance and creative professional development.

Pharmacotherapy in pediatric critical illness: a prospective observational study.

BACKGROUND AND OBJECTIVES: Pharmacotherapy is an under-evaluated element of critical care medicine. In order to better understand pharmacotherapy in pediatric critical illness, we evaluated a cohort of emergency admissions to a university-affiliated pediatric intensive care unit (PICU). METHODS: A prospective, observational study was performed. Eligible patients were admitted to this medical-surgical ICU for at least 24 hours. The primary outcomes were the number of drug orders written, the number of different medications ordered, and the number of drug administrations. Multiple regression analyses were used to identify factors independently associated with each primary outcome. RESULTS: We studied 100 patients with a median age of 40 months (interquartile range [IQR] 9-82), who were admitted for a total of 851 ICU days. These patients received 4419 drug orders and 11 911 intermittent dose-administrations of 241 different medications. Each patient received a median of 29.5 (IQR 16.5-48.5) drug orders, 14 (IQR 9-18.5) different medications, and 58 (IQR 28-129) drug administrations while in the ICU. The most frequent orders were for morphine 457 (10.6%), furosemide (frusemide) 337 (7.8%), potassium 237 (5.5%), lorazepam 226 (5.2%), and albuterol (salbutamol) 158 (3.7%). The duration of PICU stay and severity of illness were independently associated with all primary outcomes. CONCLUSIONS: Pharmacotherapy is an active component in the practice of pediatric critical care medicine. We demonstrated that increasing numbers of ordered medications, drug orders, and drug administrations were associated with increasing duration of ICU therapies and the length of ICU stay. These data underscore the potential importance of improved safety and efficacy of medicines used to treat critically ill children.

Pre-treatment with morphine does not prevent the development of remifentanil-induced hyperalgesia.

PURPOSE: Remifentanil, an ultra short-acting opioid commonly used to supplement general anesthesia, is associated with the development of hyperalgesia that manifests clinically as an increase in postoperative analgesic requirement. This study involving adolescents undergoing scoliosis surgery evaluated whether pre-treatment with morphine prior to commencing remifentanil infusion would decrease the initial 24-hr morphine consumption and pain scores. METHODS: Forty ASA I-II pediatric patients undergoing surgical correction of idiopathic scoliosis were recruited in a prospective, randomized, double-blind fashion to receive 150 microg x kg(-1) morphine or an equal volume saline prior to commencing remifentanil by infusion. The primary outcome was the initial 24-hr postoperative morphine consumption. Numeric rating scale (NRS) pain scores at rest and on coughing were recorded, as were scores for nausea, vomiting, and sedation and incidences of pruritus. RESULTS: The groups were demographically similar. No differences were observed between groups vis-à-vis the initial 24-hr morphine consumption, NRS pain scores, sedation, nausea, or vomiting. CONCLUSION: Pre-treatment with 150 microg x kg(-1) morphine did not decrease the initial 24-hr morphine consumption in adolescents who received remifentanil by infusion for surgical correction of idiopathic scoliosis.

Management of priapism in a child with sickle cell anemia; successful outcome using epidural analgesia.

PURPOSE: To describe the successful management of priapism secondary to sickle cell anemia in a child using neuraxial analgesia provided via an epidural catheter. CLINICAL FEATURES: A seven-year-old male presented with chest crisis and priapism which, following hemoglobin electrophoresis led to a new diagnosis of sickle cell anemia. Epidural management was attempted as an alternative to surgery after failure of more conventional medical and surgical methods to treat the priapism. The patient's clinical condition improved with this intervention and together with further conservative therapy resulted in complete resolution of the priapism. CONCLUSIONS: Priapism is a well described complication of sickle cell anemia that is painful and difficult to manage. Surgical intervention is the last therapeutic resort and often results in significant long-term morbidity. This case highlights how select cases of priapism can be successfully managed with epidural neuraxial blockade which not only provides superior analgesia for the often painful conservative treatments, but may also per se impart a direct and salutary therapeutic benefit.