Cardiocirculatory intraoperative assessment during single-shot caudal anaesthesia in children: comparison between levobupivacaine and ropivacaine.

BACKGROUND: Caudal block with levobupivacaine or ropivacaine is the most commonly used regional anaesthesia in children. METHODS: The aim of study was to compare the cardiocirculatory profile induced in two matched groups of young patients, submitted to caudal anaesthesia with levobupivacaine or ropivacaine for an elective subumbilical surgery. Sixty children were enrolled: thirty received levopubivacaine 0.25% and thirty ropivacaine 0.2%. Intraoperative heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP) were monitored at following times: Ta0 (after anaesthesia induction), Tal (after caudal anaesthesia), Ta2 (five minutes later), Ta3 (ten minutes later), Ts1 (at surgical incision), Ts2, Ts3, Ts4, Ts5 (every 10 minutes during surgery), Taw (at the awakening). RESULTS: In both groups the cardiocirculatory trend remained within normal ranges at all times considered, demonstrating the safety of the method with both drugs. Both groups showed a similar trend at the different monitoring times: low decrease in HR, SBP and DBP after caudal block, slight increase in parameters after skin incision, slight decrease during surgery, increase at awakening. Regarding SBP and DBP, the levobupivacaine group children generally showed higher levels compared to the ropivacaine group, especially for DBP. CONCLUSIONS: Paediatric caudal anaesthesia is an effective method with an very infrequent complication rate. Possible hypotheses for differing haemodynamic behaviour could include a stronger vasoconstriction reflex of innervated areas during caudal anaesthesia with levobupivacaine and a lower levobupivacaine induced block of the sympathetic fibers, related to different pharmacokinetic profile of low concentrations of the local anaesthetics used in paediatric epidural space.

Increase of plasmatic beta-endorphin immunoreactive material in children in the perioperative period: the influence of the site of surgery.

BACKGROUND: The primary aim of the study was to confirm the increase of plasmatic IR beta-endorphin material during the perioperative period in children. The second was to search for the factors responsible for this increment. METHODS: Seventy-two consecutive children undergoing a surgical procedure were recruited. Pre-anaesthesia and anaesthesia were standardised. Plasmatic IR beta-endorphin material was measured at three timepoints: at baseline (t (0)), before induction (t (1)), and at the end of anaesthesia (t (2)). Two general linear models were set up to analyse the influence of demographics and clinics on the IR beta-endorphin variation between t (0) and t (1). A third model was established to process the possible surgical factors contributing to the IR beta-endorphin variation between t (1) and t (2). RESULTS: ANOVA showed that IR beta-endorphin concentrations increased significantly across the three timepoints (p < 0.0001). Wilcoxon test proved that the difference was significant both for t (0) vs. t (1) and for t (1) vs. t (2). None of the factors taken into account in the pre-operative period influenced the increase in IR beta-endorphin between t (0) and t (1). Of the factors taken into account in the surgical period, only the type of procedure was significant (p = 0.005). The t-test showed that IR beta-endorphin significantly increased during spermatic and epigastric anastomosis (p = 0.000), orchidopexy (p = 0.02), Van der Meulen urethroplasty (p = 0.004), and Duckett urethroplasty (p = 0.003). CONCLUSION: Plasmatic beta-endorphin increases during the perioperative period in children. The site of surgery is responsible for this increment during intervention.

Protocols to manage postoperative pain in neonates and children hospitalized in a surgical ward. Methodological issues and cultural background.

The authors describe the cultural background and methods they adopted to construct protocols for analgesia in newborns and children hospitalized in a surgical ward. Drugs and dosages are reported in the Appendix, whereas scales for pain measurement and cut off ratings for rescue doses (or otherwise relevant) are described respectively in Tables 2 and 3. Genetics and cognitive structures play a crucial role in pain and analgesia. Protocols have a critical role, however their application must be tailored to the single child.

A pain educational program for pediatric nurses: topics and key points.

The undertreatment of pain in children may lead to severe consequences. Basic knowledge about pain in this category of patients may improve pain assessment and its management. In line with the Project established by the Italian Ministry of Health, authors planned an educational program devoted to the pediatric nurses. The concept of brain and of cognitive development, the methodological bases of the pain measurement and the cognition of long-term consequences on pain have been the key points of the program. The course was efficacious and highly appreciated by nurses. The improvement of practice standards will be the true indicator of its efficacy.

Exposure of personnel to sevoflurane during paediatric anaesthesia: influence of professional role and anaesthetic procedure.

BACKGROUND AND OBJECTIVE: This study was performed to determine the individual exposure of paediatric operating theatre personnel to sevoflurane and to evaluate the impact of inhalation induction and various airway approaches on exposure to airborne sevoflurane. METHODS: Mean individual environmental (workplace air) exposure to sevoflurane and a biomarker of exposure (urinary sevoflurane) were monitored in 36 subjects (10 anaesthetists, 10 surgeons, 12 nurses and 4 auxiliary personnel) working in two paediatric operating rooms. RESULTS: Environmental and urinary values were significantly greater in anaesthetists compared with other groups, with median values of 0.65ppm (interquartile range 1.36; 95th percentile 4.36) for breathing zone sevoflurane and 2.1 microgL(-1) urine (interquartile range 2.6; 95th percentile 7.6) for urinary sevoflurane. Anaesthetists exceeded the 2ppm maximum allowed environmental concentration recommended by the National Institute for Occupational Safety and Health in 4 of 22 cases (18.1%). A positive correlation was found between the number of patients undergoing inhalational induction each day and mean values of breathing zone and urinary sevoflurane. An increase in the number of daily laryngeal mask insertions, or the use of rigid bronchoscopy, are statistically related to higher environmental and urinary values (P < 0.01 and <0.00001 for breathing zone sevoflurane, P < 0.05 and <0.01 for urinary sevoflurane, respectively). CONCLUSIONS: Anaesthesia with sevoflurane can pose a hazard of chronic exposure with anaesthetists having the highest risk. Endotracheal intubation offers considerable protection against exposure. Routine anaesthesia using a standard facemask, a laryngeal mask or rigid bronchoscopy are risk factors for increased anaesthetic exposure.

Peripherally inserted central venous catheters in preterm newborns: two unusual complications.

This report describes the case of two newborns who suffered unusual complications after peripheral insertion of a central venous catheter. In one baby a fragment of the catheter tip became embolized in a peripheral branch of the left pulmonary artery. In the other baby, the catheter perforated a peripheral branch of the pulmonary artery, giving rise to chemical pneumonitis with extensive pleural effusion. The outcome was positive for both babies. A large clinical series is necessary to establish the complications of this procedure, their prevention and management.

[In-hospital pediatric cardiopulmonary resuscitation]. / Emergenze intraospedaliere pediatriche.

Between 0,7-3% of pediatric patients may require resuscitation during hospital stay. The physicians of the Pediatric Intensive Care Unit of the C.O.U. Anesthesia and Intensive Care-Baroncini developed a plan for the management of pediatric emergencies inside the Department of Pediatric Medical and Surgical Sciences. The plan consisted of: the drawing up of a PI 34-Procedure; the preparation and implementation of a training course for doctors and nurses; the purchase of 12 emergency-trolleys according to the Broselow Pediatric Resuscitation Measuring Tape and the implementation of a specific system for the emergency-call. Precise duty for anesthesiologists and intensivists is the emergency- planning and management, in order to diffuse the medical knowledge needed to assist patients requiring vital functions support. The management of the intra-hospital pediatric emergencies is strictly dependent on the training of the staff, based on a specific support algorithm, and specific equipment for the different ages.

[Inhalation of foreign bodies]. / Inalazione di corpi estranei nelle vie aeree.

Accidental aspiration of a foreign body (FB) is an event which is reasonably frequent and dramatic in children and is still today one of the main causes of death due to accidents at home in children up to three-four years of age. The severity of the clinical picture varies according to the size, shape, type and site of arrest of the material aspirated and can be associated with both severe asphyxial forms and forms with insidious and vague symptoms which are difficult to diagnose correctly. A late diagnosis is however a fairly common event in literature. An anamnesis suggesting probable aspiration in a child under the age of 3 should direct doctors towards diagnostic and operative endoscope examinations of the patient, even where there is a negative clinical and radiological picture. Organic material, mainly peanuts, represented 60-75% of the findings, particularly in the 0-3 year age-band. In the other of cases inorganic material was extracted from school-age children. Aspiration of a FB exposes the patient to risk of serious complications and sequelae. Antibiotic, dexamethasone therapy and the ventilation support in the CPAP helped to avoid post-extractive sequelae. Prevention should in any case be the primary aim as regards to aspiration of foreign bodies in children. This should be stimulated by appropriate educational campaigns to raise awareness. The study included 62 child patients observed in the Department of Anesthesia and Intensive Care of the S.Orsola-Malpighi Hospital of Bologna over the last 11 years who were admitted for suspected FB aspiration.

Individual pain history and familial pain tolerance models: relationships to post-surgical pain.

OBJECTIVES: (a) To investigate the influence of previous pain experience and familial pain tolerance models on postsurgical pain; (b) to investigate the effect of personality traits on vicarious learning. DESIGN: Before surgery, the patients completed the Minnesota Multiphasic Personality Inventory (MMPI), Eysenck Personality Inventory (EPI), and State-Trait Anxiety Inventory (STAI) personality tests. They also underwent a semi-structured interview to collect information on familial pain tolerance models and their own pain history. Postthoracotomy pain was assessed by measuring its latency (h), intensity (VAS 0-10), and duration (days). SETTING: A unique protocol to minimize the use of pain killers and encourage the adoption of coping strategies to face postsurgical pain was in use in the Thoracic Department. PATIENTS: A total of 126 patients who were free from chronic pain and undergoing thoracic surgery entered the study. OUTCOME: Most patients recalled a history of surgical or medical pain and good pain tolerance models in their original family. An almost equal number denied pain or had good pain tolerance models in their present family. Only a few patients reported poor tolerance models. RESULTS: Patients who had previously been subjected to medical pain experienced a greater intensity of pain. In addition, those who had reported poor tolerance in the original family experienced both earlier and more severe pain. Some patients' personality traits were related to familial pain tolerance models. CONCLUSIONS: We conclude that knowledge of an individual's pain history and familial pain tolerance models can be useful in predicting and managing post-surgical pain.

Self-control expectancy and postsurgical pain: relationships to previous pain, behavior in past pain, familial pain tolerance models, and personality.

The importance of self-control expectancy on postsurgical pain was studied in 126 patients enrolled in a particular clinical setting. The contribution of previous pain experiences, past behaviors, vicarious experiences, and personality traits to self-control expectancy reported by patients was also investigated. To collect this information, a specific questionnaire and a semistructured interview were given before surgery. Minnesota Multiphasic Personality Inventory (MMPI), Eysenck Personality Inventory (EPI), and State-Trait Anxiety Inventory (STAI) personality tests were also administered. Postsurgical pain was assessed by measuring intensity (Visual Analogue Scale, VAS), latency (hr), and duration (days). Results show that expected emotional coping response is crucially related to the whole pain experience (intensity, latency, and duration). Self-control expectancy is associated with mastery behaviors in previous pains, vicarious experiences, and personality traits. These findings suggest that the knowledge of patients' beliefs about their ability to acquire and maintain control over impending pain is useful in predicting and managing postsurgical pain.

Intensity, latency and duration of post-thoracotomy pain: relationship to personality traits.

The relationship between personality traits and post-surgical pain was studied in 126 patients submitted to a particular set of procedures. The personality was studied by MMPI, STAI, EPI tests before surgery. After surgery, pain intensity was positively related to duration, and pain latency negatively related to both intensity and duration. According to multiple regression analysis, pain intensity was found to be predictable from both the state anxiety and psychoasthenia scales, pain latency from state anxiety and masculinity/femininity, pain duration from aggressivity and hysteria. Results suggest that personality traits constitute strong modulatory factors of the overall pain experience.