Tracheal extubation of deeply anesthetized pediatric patients: a comparison of isoflurane and sevoflurane.

UNLABELLED: We studied the emergence characteristics of unpremedicated children tracheally extubated while deeply anesthetized ("deep extubation") with isoflurane or sevoflurane. Forty children were assigned to one of two groups, Group I or Group S. At the end of the operation, Group I patients were extubated while breathing 1.5 times the minimum alveolar anesthetic concentration (MAC) of isoflurane. Group S patients were tracheally extubated while breathing 1.5 times the MAC of sevoflurane. Recovery characteristics and complications were noted. Group S patients were arousable sooner than Group I patients (10.1 + 6.5 vs 16.3 + 9.9 min). Later arousal scores and times to discharge were the same. There were no serious complications in either group. Breath-holding was more common in Group I. We conclude that the overall incidence of airway problems and desaturation episodes was similar between groups. Emergency delirium was common in both groups (32% overall: 40% for Group I, 25% for Group S). IMPLICATIONS: Deep extubation of children can be safely performed with either isoflurane or sevoflurane. After deep tracheal extubation, airway problems occur but are easily managed. Return to an arousable state occurred more quickly with sevoflurane, although time to meeting discharge criteria was not different between the two groups. Emergence delirium occurs frequently with either technique.

Epidural morphine combined with epidural or intravenous butorphanol for postoperative analgesia in pediatric patients.

We performed a prospective, randomized, double-blinded study in 60 postoperative pediatric patients aged 6 wk to 7 yr to compare the efficacy of butorphanol given epidurally or intravenously in preventing the side effects of epidural morphine. Three groups of patients received 60 micrograms/kg epidural morphine; 20 patients also received epidural butorphanol 30 micrograms/kg, and 20 patients also received 30 micrograms/kg intravenous butorphanol. All patients were evaluated for analgesia, sedation, vomiting, urinary retention, pruritus, and respiratory depression for 24 h postoperatively. Although the overall incidence of side effects was not different in the three groups, the epidural butorphanol group had a significant decrease in severity of pruritus. Sedation was seen more frequently in the groups receiving butorphanol, but was most pronounced in the epidural butorphanol group. We conclude that butorphanol has little or no effect on the side effects of epidural morphine.

Epidural fentanyl infusion with patient-controlled epidural analgesia for postoperative analgesia in children.

The use of epidural fentanyl infusion with patient-controlled epidural analgesia (PCEA) is becoming popular for postoperative analgesia in adults. Its use has not been reported in the pediatric population. We report our initial experience with this technique in pediatric patients. The charts of all children who received epidural fentanyl infusions for postoperative analgesia between June 1991 and February 1992, were reviewed. Thirty-one patients, ages 6 to 17 years (mean +/- SD, 13.2 +/- 2.7) received epidural fentanyl infusion with PCEA for 36 operative procedures. Epidural catheters were either inserted in the lumbar (n = 14) or thoracic (n = 22) epidural space at a level based on the surgery. A fentanyl bolus of 1.38 +/- 0.43 micrograms/kg was delivered via epidural catheter just prior to the conclusion of surgery. A continuous infusion of fentanyl (0.56 +/- 0.18 micrograms/kg/h) with a PCEA bolus (0.53 +/- 0.17 micrograms/kg) available every 15 minutes was initiated in the recovery room and was utilized for 8 to 110 hours (59 +/- 27 hours). Pain and sedation were assessed by verbal descriptive scales, and side effects were noted. Alterations in dosing regimen were made for inadequate analgesia or side effects. Analgesia was assessed as excellent or good in 78% of the patients, 91% in the thoracic catheter group and 57% in the lumbar catheter group (P < .02). Patients with thoracic catheters were more likely to need their infusion and PCEA doses decreased, whereas those with lumbar catheters more often needed their doses increased (P < .05). No patient had respiratory depression.(ABSTRACT TRUNCATED AT 250 WORDS)

Anaesthetic management of infants requiring endobronchial argon laser surgery.

Small infants with endobronchial lesions primarily due to traumatic suction catheter injuries are now undergoing argon laser surgery to remove obstructive tissue. Providing an anaesthetic for these infants can be challenging because of the small airways involved which must be shared by the anaesthetist and the surgeon. We have performed 30 argon laser endobronchial surgeries in nine infants. The lungs of the majority of patients were ventilated through a tracheostomy intraoperatively, while the surgeon passed the argon laser fibre through the suction port of a fibreoptic bronchoscope which was passed trans-nasally. Three infants were too small to allow passage of the fibreoptic bronchoscope past an artificial airway. In these patients surgery and ventilation were accomplished through a rigid bronchoscope. Three larger patients without tracheostomies were managed with a modified nasal airway for intraoperative ventilation in conjunction with the fibreoptic bronchoscope.