Acupressure-acupuncture antiemetic prophylaxis in children undergoing tonsillectomy.

BACKGROUND: Acupuncture or acupressure at the Nei-Guan (P.6) point on the wrist produces antiemetic effects in awake but not anesthetized patients. The authors studied whether a combined approach using preoperative acupressure and intra- and postoperative acupuncture can prevent emesis following tonsillectomy in children. METHODS: Patients 2-12 yr of age were randomly assigned to study or placebo groups. Two Acubands with (study) and two without (placebo) spherical beads were applied bilaterally on the P.6 points; non-bead- and bead-containing Acubands, respectively, were applied on the sham points. All Acubands were applied before any drug administration. After anesthetic induction, acupuncture needles were substituted for the beads and remained in situ until the next day. All points were covered with opaque tape to prevent study group identification. A uniform anesthetic technique was used; postoperative pain was managed initially with morphine and later with acetaminophen and codeine. Emesis, defined as retching or vomiting, was assessed postoperatively. Ondansetron was administered only after two emetic episodes at least 2 min apart. Droperidol was added if emesis persisted. RESULTS: One hundred patients were enrolled in the study. There were no differences in age, weight, follow-up duration, or perioperative opioid administration between groups. Retching occurred in 26% of the study patients and in 28% of the placebo patients; 51 and 55%, respectively, vomited; and 60 and 59%, respectively, did either. There were no significant differences between the groups. Redness occurred in 8.5% of acupuncture sites. CONCLUSION: Perioperative acupressure and acupuncture did not diminish emesis in children following tonsillectomy.

Preoperative fasting practices in pediatrics.

BACKGROUND: The purpose of this study was to determine current practice patterns for preoperative fasting at major pediatric hospitals. METHODS: Fasting guidelines for children at each of the hospitals listed in the second edition of the Directory of Pediatric Anesthesiology Fellowship Programs were solicited and analyzed. RESULTS: Fifty-one institutions were surveyed, and 44 responded. In 50%, clear fluids were permitted up to 2 h prior to anesthesia for all children. Breast milk was restricted to 4 h for children younger than 6 months in 61% of hospitals. Institutions were equally divided (39% each) between a 4-h and a 6-h fast for formula in infants younger than 6 months; for infants older than 6 months, 50% of hospitals restricted formula feeding to 6 h. There was no consensus for solid feeding in children younger than 3 yr, but 50% of hospitals agree that solids should be restricted after midnight in children older than 3 yr. CONCLUSIONS: There is no uniform fasting practice for children before elective surgery in the United States and Canada. However, there is agreement among most institutions that ingestion of clear fluids 2-3 h prior to general anesthesia is acceptable. Most also accept a 4-h restriction for breast milk and a 6-h restriction for nonhuman formula. There is great diversity among institutions regarding fasting for solids in children, with many restricting intake after midnight. There is little agreement about whether infant formula should be treated in the same way as solid food or how to categorize breast milk.

Single-dose ondansetron prevents postoperative vomiting in pediatric outpatients.

UNLABELLED: This randomized, double-blind, parallel-group, multicenter study evaluated the safety and efficacy of ondansetron (0.1 mg/kg to 4 mg intravenously) compared with placebo in the prevention of postoperative vomiting in 429 ASA status I-III children 1-12 yr old undergoing outpatient surgery under nitrous oxide- and halothane-based general anesthesia. The results show that during both the 2-h and the 24-h evaluation periods after discontinuation of nitrous oxide, a significantly greater percentage of ondansetron-treated patients (2 h 89%, 24 h 68%) compared with placebo-treated patients (2 h 71%, 24 h 40%) experienced complete response (i.e., no emetic episodes, not rescued, and not withdrawn; P < 0.001 at both time points). Ondansetron-treated patients reached criteria for home readiness one-half hour sooner than placebo-treated patients (P < 0.05). The age of the child, use of intraoperative opioids, type of surgery, and requirement to tolerate fluids before discharge may also have affected the incidence of postoperative emesis during the 0- to 24-h observation period. Use of postoperative opioids did not have any effect on complete response rates in this patient population. We conclude that the prophylactic use of ondansetron reduces postoperative emesis in pediatric patients, regardless of the operant influential factors. IMPLICATIONS: Postoperative nausea and vomiting often occur after surgery and general anesthesia in children and are the major reason for unexpected hospital admission after ambulatory surgery. Our study demonstrates that the prophylactic use of a small dose of ondansetron reduces postoperative vomiting in pediatric patients.

Tubeless spontaneous respiration technique for pediatric microlaryngeal surgery.

BACKGROUND: Tubeless spontaneous respiration technique for pediatric microlaryngeal surgery may be accomplished using different anesthetic protocols. Two methods, inhalation of volatile anesthetic agents alone and in combination with intravenous propofol, are reviewed with regard to intraoperative airway stability, post-operative morbidity, recovery room course, and halothane concentration required during maintenance anesthesia. DESIGN: Retrospective case series. SETTING: Otolaryngology referral hospital. PATIENTS AND METHODS: Twenty-nine microlaryngeal procedures were performed using tubeless spontaneous respiration technique in children ranging from 2 weeks to 11 years of age. The following 2 anesthetic protocols were used: inhaled volatile anesthetic agents alone in 18 procedures and in combination with intravenous propofol in 11. Anesthesia, surgery, and recovery room times were documented. Specific characteristics of anesthetic maintenance, including total anesthetic gas flow (liters per minute), variations of halothane concentration (percentage), and duration of halothane administration (minutes) were also recorded to calculate the mean concentration of halothane (percentage) delivered to each patient. RESULTS: No statistical differences were observed between the 2 protocols in terms of anesthesia and surgical outcomes. Adjusting for differences in patient age, weight, maintenance duration, and total anesthetic gas flow, the introduction of propofol allowed a statistically significant reduction in the mean concentration of halothane required during maintenance anesthesia. CONCLUSIONS: Both tubeless spontaneous respiration technique protocols proved successful in this study. However, the addition of propofol allowed a significant reduction in the halothane requirement during anesthesia maintenance. This has the potential benefit of decreasing the exposure of operating room personnel to volatile anesthetics during tubeless spontaneous respiration technique.

The use of the laryngeal mask airway in children with bronchopulmonary dysplasia.

Airway maintenance with the laryngeal mask airway (LMA) was evaluated and compared to the endotracheal (ET) tube in 27 former premature infants and children with bronchopulmonary dysplasia (BPD) during second stage open-sky vitrectomy. The children were randomly assigned to a study group and anesthetized with halothane in N2O:O2. The airway was maintained with the LMA (n = 13) or the ET tube (n = 14). Respiratory and hemodynamic variables were recorded. Intraoperative and postoperative complications were noted. The respiratory rate and the end-tidal CO2 were significantly higher in the LMA group as compared with the ET tube group (P < 0.01); however, the pulse rate and both systolic and diastolic blood pressures throughout the surgical procedure were lower in the LMA group (P < 0.05). The incidence of coughing, with and without desaturation, wheezing, and hoarseness in the postoperative period was higher in the ET tube group. Awakening, after discontinuation of the anesthetic (P < 0.01) was more rapid, and home discharge time (P < 0.002) was shorter in the LMA group (P < 0.0025), although our study design could not isolate the use of the LMA as the factor responsible for this. This study in patients with mild chronic lung disease demonstrated that the LMA can maintain a satisfactory airway during minor surgical procedures in children with bronchopulmonary dysplasia and result in fewer respiratory adverse effects than with the ET tube.

Metoclopramide reduces the incidence of vomiting after tonsillectomy in children.

The efficacy of intravenous metoclopramide in controlling vomiting in children after tonsillectomy was determined in a prospective randomized, double-blind investigation. One hundred two unpremedicated, ASA physical status I or II children between the ages of 1 and 15 yr who were undergoing surgical removal of the tonsils, with or without adenoidectomy, were studied. Anesthesia was induced either with halothane, nitrous oxide, and oxygen by mask or by intravenous thiopental and was maintained with halothane, nitrous oxide, oxygen, and intravenous morphine (0.1 mg/kg). Each child randomly received either 0.15 mg/kg of metoclopramide or saline solution placebo intravenously after transfer to the postanesthesia care unit. All episodes of vomiting were recorded for 24 h after completion of surgery. The incidence of vomiting in the saline solution group was 70%, compared with 47% in the metoclopramide group (P = 0.026). The authors conclude that the administration of intravenous metoclopramide in a dose of 0.15 mg/kg on arrival in the postanesthesia care unit significantly decreases the incidence of vomiting in children after tonsillectomy.

A comparison of propofol, midazolam, and methohexital for sedation during retrobulbar and peribulbar block.

STUDY OBJECTIVE: To compare the efficacy of propofol, methohexital, and midazalom in providing adequate sedation during administration of retrobulbar block and satisfactory postoperative amnesia. DESIGN: Retrospective chart review over a 4-month period. SETTING: Ambulatory patients in the main operating room of a university-affiliated hospital. PATIENTS: One hundred forty-seven ambulatory patients undergoing ophthalmologic surgery of less than 2 hours' duration under regional anesthesia consisting of retrobulbar or peribulbar block and intravenous (IV) sedation. INTERVENTIONS: One of three drugs--propofol 0.47 +/- 0.06 mg/kg, midazolam 0.02 +/- 0.005 mg/kg, or methohexital 0.45 +/- 0.16 mg/kg--was administered IV. Patients were observed for a minimum of 60 seconds or until adequate sedation was achieved, after which a retrobulbar or peribulbar block was performed. MEASUREMENTS AND MAIN RESULTS: Blood pressure, electrocardiogram, and oxygen saturation were monitored and recorded. Patients were observed for apnea, hiccups, pain on injection, excitement, tremor, grimacing, or verbal response during the block. The requirement for additional sedation intraoperatively was noted. Patients were questioned postoperatively in the ambulatory recovery room for recall of needle insertion or discomfort during the block, as well as about their satisfaction with the overall experience. CONCLUSIONS: Grimacing or verbal response during the retrobulbar or peribulbar block did not predict or correlate with patient recall. Propofol was equal to both midazolam and methohexital in providing adequate sedation and postoperative amnesia but possesses the added advantages of reduced postoperative vomiting, lower intraocular pressure, and earlier return-to-home readiness.

General anesthesia prior to treatment of anterior mediastinal masses in pediatric cancer patients.

Many children with malignant diseases who present with an anterior mediastinal mass must undergo general anesthesia for tissue diagnosis or tumor resection. One hundred sixty-three pediatric patients over a period of 6 yr were admitted to Memorial Sloan-Kettering Cancer Center with a diagnosis of anterior mediastinal mass. Forty four of these patients required surgery and their records were reviewed. In recent years perioperative radiation therapy has been advocated for this patient group prior to their receiving general anesthesia. If a tissue diagnosis has not been made, preoperative radiation therapy may distort histologic findings and prevent accurate diagnosis. All patients with an anterior mediastinal mass who must receive general anesthesia in our institution do so prior to treatment with radiation or chemotherapy even in the presence of cardiovascular or respiratory symptoms. No patient died or sustained permanent injury as a result of their anesthetic or operative experience. Two patients who experienced difficulty on induction of anesthesia required tracheal intubation with a rigid bronchoscope. Two patients developed airway obstruction during anesthetic maintenance that was corrected with changes in patient position. Four patients were unable to have their tracheas extubated at the conclusion of surgery and one patient required tracheal reintubation in the immediate postoperative period. These patients were treated with radiation therapy and chemotherapy after tissue for diagnosis had been obtained. The authors conclude that in the absence of life-threatening preoperative airway obstruction and severe clinical symptoms general anesthesia may be safely induced prior to radiation therapy.

Anterior mediastinal mass in a pregnant patient: anesthetic management and considerations.

Patients with anterior mediastinal masses are recognized to be at risk for cardiorespiratory compromise when general anesthesia is induced. Likewise, pregnancy has a widely known constellation of potential complications that confront the anesthesiologist. The combination of both problems in a single patient presents an unusual anesthetic challenge. The following is a case report of a pregnant patient with a large, symptomatic anterior mediastinal mass who required general anesthesia for a diagnostic procedure before definitive therapy could be initiated.

[Old and new in obstetrics radiodiagnosis (author's transl)]. / Vecchio e nuovo in radiodiagnostica ostetrica.

After recalling the techniques in use prior to the sixties, the possibilities of employing teleradiopelvimetry and echography are reported. Amniography and its therapeutic applications is discussed in detail.

Classification and radiographic features of uterine malformations: hysterosalpingographic study.

A series of 13470 hysterosalpingographic investigations demonstrated congenital uterine malformations in 1160 cases (8.6%). Uterus arcuatus and uterine hypoplasia, the latter ranking as a malformation on embryological grounds, together accounted for two-thirds of the cases, uterus unicornis unicollis and uterus bicornis unicollis together for over a quarter and the others, uterine didelphys, uterus bicornis bicollis and uterus septus/subseptus, for much smaller percentages. Each malformation is described and illustrated by typical hysterosalpingograms. In addition to its decisive importance in diagnosis, hysterosalpingography it also valuable in planning surgical correction in many cases.