Tropisetron plus subhypnotic propofol infusion is more effective than tropisetron alone for the prevention of vomiting in children after tonsillectomy.

This study evaluated the efficacy of tropisetron compared with tropisetron and a subhypnotic propofol infusion in preventing postoperative vomiting following tonsillectomy. One hundred and forty healthy children, aged four to 12 years, undergoing tonsillectomy were recruited in a randomised, double-blind study. After induction with sevoflurane, anaesthesia was maintained with sevoflurane and nitrous oxide. All patients received tropisetron (0.2 mg/kg up to 5 mg; intravenously) and fentanyl (2 microg/kg; intravenously) and were intubated after atracurium which was reversed with neostigmine (and atropine). The tropisetron-plus-propofol group received a single dose of propofol (1 mg/kg) before intubation and a continuous infusion of propofol throughout surgery at 15 microg/kg/min. Data for postoperative vomiting were grouped into zero to four and four to 24 hour time intervals. A P value of < 0.05 was considered statistically significant. The percentage of patients exhibiting a complete response (no retching or vomiting for 24 hours) was 47.1% (33/70) in the tropisetron-alone group and 72.8% (51/70) in the tropisetron-plus-propofol group (P = 0.002). The 0.257 absolute risk reduction of vomiting with the addition of propofol represents a number needed to treat of 3.87, and a risk ratio of 0.51 (95% CI 0.32 to 0.79). Significantly fewer patients vomited in the tropisetron-plus-propofol group than in the tropisetron-alone group during the zero to four post-surgery interval (P = 0.016), but the difference was not statistically significant for the four to 24 hour postoperative period (P = 0.116). Intraoperative subhypnotic propofol infusion combined with tropisetron is more effective than tropisetron alone in reducing postoperative vomiting after tonsillectomy in children.

Spinal anesthesia with sequential administration of plain and hyperbaric bupivacaine provides satisfactory analgesia with hemodynamic stability in cesarean section.

BACKGROUND: Hypotension during spinal anesthesia is one of the major concerns in cesarean section. To achieve adequate spinal anesthesia with less hypotension, we evaluated the viability of sequential subarachnoid injection of two different baricities of bupivacaine. We used plain bupivacaine 5mg to obtain dense anesthesia of the surgical site, followed by hyperbaric bupivacaine 5mg to achieve spread to T5 anesthesia to address visceral pain. METHODS: In this double-blind prospective study, 72 parturients undergoing cesarean section were randomized to receive either hyperbaric bupivacaine 10mg or 5mg each of plain and hyperbaric bupivacaine sequentially for spinal anesthesia. Loss of pinprick sensation to T6 was regarded as sufficient for cesarean section to proceed. Characteristics of anesthesia, episodes of hypotension, bradycardia and ephedrine use were assessed by blinded observers. RESULTS: Demographic data, characteristics of anesthesia, quality of intraoperative anesthesia and Apgar scores were similar in the two groups. Compared to hyperbaric bupivacaine, the combination of plain and hyperbaric bupivacaine provided a marked decrease in the incidence of hypotension (13.9% vs. 66.7%, P<0.001) and side effects related hypotension such as nausea and vomiting (13.9% vs.52.8%, P<0.001). The amount of ephedrine administered was significantly lower in the plain and hyperbaric bupivacaine group (2.2+/-1.0mg vs. 20.5+/-8.7 mg (P<0.001). CONCLUSIONS: Sequential subarachnoid injection of plain and hyperbaric bupivacaine for cesarean section can provide reliable spinal anesthesia with a lower incidence of hypotension and vomiting.

Effects of reduction of the caudal morphine dose in paediatric circumcision on quality of postoperative analgesia and morphine-related side-effects.

This study compared the efficacy and adverse effects of three low doses of morphine (10, 15 and 30 microg x kg(-1)) for caudal epidural analgesia in children undergoing circumcision. A total of 135 boys undergoing out-patient circumcision were randomly assigned to receive 10, 15 or 30 microg x kg(-1) of caudal morphine. Anaesthesia was induced and maintained with propofol. After induction, the morphine was added to 0.5 ml.kg(-1) 1% lignocaine solution with adrenaline 5 microg.ml(-1) and injected caudally. Anaesthesia quality, postoperative pain and adverse events in a 24-hour period were evaluated. Paracetamol (20 mg.kg(-1) orally) was used as rescue analgesia as required. No patient required paracetamol in the first eight hours after the caudal injections. In the first 24 hours postoperatively no further analgesia was required in 66.7%, 77.8% and 91.1% of the patients in the 10, 15 and 30 microg.kg(-1) groups, respectively (P=0.01 for 10 vs. 30 groups). All patients had excellent analgesia. No respiratory complications were observed. Nausea-vomiting occurred in 13.3%, 20% and 46.7% of the patients in the 10, 15 and 30 gg.kg(-1) groups (P=0.002 for 10 vs. 30 and 0.044 for 15 vs. 30). Pruritus occurred in 8.9%, 11% and 15.6% in the 10, 15 and 30 microg.kg(-1) groups but was localised and did not require treatment. This study was not powered to assess concerns that low dose epidural morphine may rarely be associated with delayed apnoea and is therefore considered unsuitable for outpatient use in many centres. Increases in caudal morphine dose above 10 microg.kg1 produce some 'paracetamol sparing' but no improvement in analgesia, some pruritus and a significant increase in nausea and vomiting.