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[Monitoring airway pressure in pediatric anesthesia: an experimental model of intratracheal medication and pressure-volume loops]. / Monitorización de las presiones de la vía aérea en anestesia pediátrica. Presentación de un modelo experimental de medición intratraqueal y bucles presión/volumen.

BACKGROUND: In the monitoring of anesthesia, airway pressure is measured in the ventilator or at the closest possible connection to the endotracheal tube. OBJECTIVE: To compare the airway pressures and pressure-volume loops obtained before connection to the endotracheal tube with those obtained in the trachea. MATERIAL AND METHODS: We carried out a single-blind prospective observational study on ASA 1 patients between the ages of 7 and 12 years ventilated in volume-control mode with an inspiration-to-expiration ratio of 1:2. Intratracheal and extratracheal peak and plateau pressures and pressure-volume loops were recorded. A special device was designed to monitor intratracheal pressure. Both sensors were connected to the same spirometric analysis system. The variables were measured on intubation and 5, 10, 15, 20, 30, 40, 50, and 60 minutes after intubation. The recorded pressures were compared using the t test, the Pearson product moment correlation coefficient (r), and the Spearman rank correlation coefficient (p), and regression models were fit to the data. RESULTS: Seventy-one patients were enrolled. The mean (SD) pressure difference between the 2 systems was 3.5 (0.35) cm H2O (P < .01) and no differences between the endotracheal peak pressures and the plateau pressures were observed. The intratracheal areas of the pressure-volume loops were 15% lower than the extratracheal areas. The value of r for the correlation between the intratracheal peak and plateau pressures was 0.998 (P < .01). The value of r for the correlation between the intratracheal and extratracheal peak pressures was 0.981 (P < .01). Analysis of variance confirmed the linear relationship. CONCLUSIONS: The difference between the intratracheal and extratracheal pressure measurements is due to the different locations at which the measurements are taken.

[Monitoring airway gas in pediatric anesthesia: an experimental model for endotracheal gas measurement]. / Monitorización de los gases de la vía aérea en anestesia pediátrica. Presentación de un modelo experimental de medición endotraqueal de gases.

BACKGROUND: We designed an endotracheal probe for measuring inspired and expired gas fractions during pediatric general anesthesia. OBJECTIVE: To compare the gas fractions measured by means of intratracheal and extratracheal monitoring. MATERIAL AND METHODS: The study included ASA 1 patients between the ages of 7 and 12 years under inhaled anesthesia with mechanical ventilation. The following parameters were recorded inside and outside the trachea: inspired and expired oxygen, nitric oxide (N2O) and sevoflurane fractions; the expired and inspired fraction gradients; PaCO2; and end-tidal carbon dioxide (ETCO2). Measurements were taken by an airflow sensor (Pedi-Lite) in the circuit before the point of connection to the endotracheal tube and by an intratracheal probe placed between the tube and the carina. Both sensors were connected to the same monitor. Measurements were taken on intubation and 5, 10, 15, 20, 30, 40, 50, and 60 minutes thereafter. PaCO2 was recorded at the same time. The recorded values were analyzed using the t test and the Pearson product moment correlation coefficient (r), and regression models were constructed using analysis of variance. RESULTS: Seventy-one patients were enrolled in the study. The mean difference (SD) ETCO2 was 5 (3) mm Hg higher according to endotracheal measurement (P < .005), and that measurement was almost identical (+/-13 mm Hg) to the PaCO2 (P < or = .5). The inspired/expired gradients of endotracheal measurement of oxygen and N2O were 3 (2) points higher (P < .05) than the gradients of extratracheal measurements. In the case of sevoflurane gradients, however, the extratracheal values were higher (mean difference, 0.6 [0.2] points, P < .05). The inspired/expired oxygen and N2O gradients became equal after 18 (3) minutes; the sevoflurane gradients became equal after 8 (2) minutes. CONCLUSIONS: Intratracheal and extratracheal measurements of the inspired and expired fractions of mixed gases provide different results.

Monitorización de las presiones de la vía aérea en anestesia pediátrica. Presentación de un modelo experimental de medición intratraqueal y bucles presión/volumen / Monitoring airway pressure in pediatric anesthesia: an experimental model of intratracheal medication and pressure-volume loops

INTRODUCCIÓN: En la monitorización anestésica, lapresión de la vía aérea se mide en el respirador o en laconexión más proximal posible al tubo endotraqueal.OBJETIVOS: Comparar las presiones en vía aérea ybucles presión/volumen obtenidos antes del tubo endotraqueal con los obtenidos intratraquealmente.MATERIAL Y MÉTODOS: Estudio prospectivo observacionalsimple. Pacientes de 7-12 años; ASA I; ventilados envolumen control, I:E (1:2). Medición de las presiones pico y plateau, y bucles presión/volumen, en el interior de la tráquea y extratraqueales. Se diseñó un dispositivo especial para monitorizar presiones endotraqueales. Ambas sondas conectadas al mismo sistema de análisis espirométrico. Las variables se analizaron en inicio, 5’, 10’, 15’, 20’, 30’, 40’, 50’ y 60 minutos tras intubación. Se realizó comparación de medias (T Student), coeficiente de correlación de Pearson(r) y de Spearman (ρ) para las presiones obtenidas; y sedeterminó existencia de modelos de regresión.RESULTADOS: Incluimos 71 pacientes. Las presiones,presentaron un diferencial entre ambos sistemas de 3,5 ±0,35 cm H2O (p < 0,01); no existiendo diferencias entrepresión máxima y presión plateau endotraqueales. Lasáreas intratraqueales de los bucles presión/volumen fueron un 15% inferiores a las extratraqueales. La r entre presión pico y plateau intratraqueal fue de 0,998(p < 0,01). La r entre presión pico intratraqueal y extratraqueal fue de 0,981 (p < 0,01). Aplicando ANOVA seconfirmó un modelo de regresión lineal.CONCLUSIONES: La diferencia de las mediciones de laspresiones dentro de la tráquea y extratraqueales, son debidas a los diferentes lugares donde se realiza la medición

BACKGROUND: In the monitoring of anesthesia, airwaypressure is measured in the ventilator or at the closest possible connection to the endotracheal tube.OBJECTIVE: To compare the airway pressures and pressure-volume loops obtained before connection to the endotracheal tube with those obtained in the trachea.MATERIAL AND METHODS: We carried out a single-blindprospective observational study on ASA 1 patients betweenthe ages of 7 and 12 years ventilated in volume-control mode with an inspiration-to-expiration ratio of 1:2. Intratracheal and extratracheal peak and plateau pressures and pressurevolume loops were recorded. Aspecial device was designed to monitor intratracheal pressure. Both sensors were connected to the same spirometric analysis system. The variables weremeasured on intubation and 5, 10, 15, 20, 30, 40, 50, and 60 minutes after intubation. The recorded pressures were compared using the t test, the Pearson product moment correlation coefficient (r), and the Spearman rank correlation coefficient (ρ), and regression models were fit to the data.RESULTS: Seventy-one patients were enrolled. The mean(SD) pressure difference between the 2 systems was 3.5(0.35) cm H2O (P < .01) and no differences between theendotracheal peak pressures and the plateau pressureswere observed. The intratracheal areas of the pressurevolume loops were 15% lower than the extratracheal areas. The value of r for the correlation between the intratracheal peak and plateau pressures was 0.998 (P < .01). The value of r for the correlation between the intratracheal and extratracheal peak pressures was 0.981 (P < .01). Analysis of variance confirmed the linear relationship.CONCLUSIONS: The difference between the intratrachealand extratracheal pressure measurements is due to the different locations at which the measurements are taken

Monitorización de los gases de la vía aérea en anestesia pediátrica. Presentación de un modelo experimental de medición endotraqueal de gases / Monitoring airway gas in pediatric anesthesia: an experimental model for endotracheal gas measurement

INTRODUCCIÓN: Diseñamos una sonda endotraqueal para medir fracciones inspiradas y espiradas de los gases de la mezcla durante anestesia general pediátrica. OBJETIVOS: Comparar los gases analizados en el circuito, mediante monitorización intra y extratraqueal, y comprobar sus posibles diferencias. MATERIAL Y MÉTODOS: Pacientes de 7 a 12 años; ASA I; bajo anestesia inhalatoria en ventilación mecánica. Se analizan dentro y fuera de la tráquea, fracciones inspiradas (Fi) y espiradas (Fe) de O2/N2O/Sevoflurano; la relación Fe/Fi; presión arterial de CO2 (PaCO2); y end tidal CO2 (ETCO2); mediante medición previa al tubo endotraqueal (TET) desde pedi-lite, y mediante sonda en tráquea, anterior a la carinay posterior al TET. Ambos dispositivos fueron conectadosal mismo monitor. Se realizaron mediciones en inicio, 5’,10’, 15’, 20’, 30’, 40’, 50’ y 60 minutos tras ntubación, y de PaCO2 en los mismos tiempos. Se compararon valoresmedios (T Student), coeficiente correlación de Pearson (r), y se determinaron modelos de regresión (ANOVA).RESULTADOS: Incluimos 71 pacientes. La diferencia media (DE) de ETCO2 fue 5(±3) mmHg superior para la medición endotraqueal (p < 0,005), casi coincidente (±1,3 mmHg) con la PaCO2 (p ≤ 0,5). Los gradientes (DE) de Fi-Fe O2/N2O fueron 3 (±2) puntos superiores en la mediciónendotraqueal (p < 0,05). Sin embargo, sevoflurano presentódiferencia media extratraqueal superior 0,6 (±0,2) puntos(p < 0,05). Conforme avanza el tiempo anestésico, losgradientes Fi-Fe O2/N2O, se equiparan transcurridos 18(±3) minutos, para sevoflurano esto sucede en 8 (±2) minutos. CONCLUSIONES: Las fracciones inspiradas y espiradas de los gases de la mezcla son distintos, según se realice la medición intra o extratraqueal (AU)

BACKGROUND: We designed an endotracheal probe for measuring inspired and expired gas fractions during pediatric general anesthesia. OBJECTIVE: To compare the gas fractions measured by means of intratracheal and extratracheal monitoring. MATERIAL AND METHODS: The study included ASA 1 patients between the ages of 7 and 12 years under inhaled anesthesia with mechanical ventilation. The following parameters were recorded inside and outside the trachea: inspired and expired oxygen, nitric oxide (N2O) and sevoflurane fractions;the expired and inspired fraction gradients; PaCO2; andend-tidal carbon dioxide (ETCO2). Measurements were takenby an airflow sensor (Pedi-Lite) in the circuit before the point of connection to the endotracheal tube and by an intratracheal probe placed between the tube and the carina. Both sensors were connected to the same monitor. Measurements were taken on intubation and 5, 10, 15, 20, 30, 40, 50, and 60 minutes thereafter. PaCO2 was recorded at the same time. The recorded values were analyzed using the t test and the Pearson product moment correlation coefficient (r), and regression models were constructed using analysis of variance. RESULTS: Seventy-one patients were enrolled in the study. The mean difference (SD) ETCO2 was 5 (3) mm Hg higher according to endotracheal measurement (P < .005), and that measurement was almost identical (±1.3 mm Hg) to the PaCO2 (P ≤ .5). Theinspired/expired gradients of endotracheal measurement of oxygen and N2O were 3 (2) points higher (P< .05) than the gradients of extratracheal measurements. In the case of sevoflurane gradients, however, the extratracheal values were higher (mean difference, 0.6 [0.2] points, P < .05). The inspired/expired oxygen and N2O gradients became equal after 18 (3) minutes; the sevoflurane gradients became equal after 8 (2) minutes. CONCLUSIONS: Intratracheal and extratracheal measurements of the inspired and expired fractions of mixed gases provide different results (AU)

[Levobupivacaine versus racemic bupivacaine for thoracic and upper lumbar epidural anesthesia-analgesia in children]. / Levobupivacaína versus bupivacaína racémica para anestesia/analgesia epidural toráicica y lumbar alta en niños.

OBJECTIVES: We compared levobupivacaine to bupivacaine for epidural analgesia for thoracic or upper abdominal surgery in children. Our working hypothesis was that at equivalent doses levobupivacaine and bupivacaine behave in the same way. MATERIAL AND METHODS: ASA 1-4 patients between the ages of 5 and 16 years were randomized to a levobupivacaine or a bupivacaine group. After general anesthesia was induced, we inserted a thoracic or upper lumbar epidural catheter and administered a dose of 0.25% bupivacaine or levobupivacaine (1 mgxkg(-1)) while maintaining general anesthesia. Analgesia was provided with an epidural infusion of 0.125% bupivacaine or levobupivacaine with fentanyl. Fentanyl was used as a perioperative rescue analgesic and metamizole magnesium as a postoperative rescue analgesic. The epidural infusion was reduced by 25% each day beginning on the second day. We analyzed hemodynamic and respiratory variables, rescue analgesia, time until extubation and discharge from the recovery unit, complications associated with the technique, adverse effects, and degree of comfort achieved. RESULTS: We studied 64 patients; 33 received levobupivacaine and 31 bupivacaine. Mean (SD) duration of recovery unit stay was significantly longer in the bupivacaine group (4.2 [0.99] days) than in the levobupivacaine group (35 [0.6] days; P<.05). Significantly more patients needed perioperative rescue analgesia in the levobupivacaine group (n=6 [18.18%]) than in the bupivacaine group (n=3 [9.67%]; P<.01). After 48 hours, the need for postoperative rescue analgesia was significantly lower with levobupivacaine (P<.01). Motor block was significantly greater with bupivacaine (P<05). Adverse effects and complications included 2 cases of persistent bradycardia and 1 case of dural puncture with no subsequent clinical manifestations. CONCLUSIONS: This experience with epidural anesthesia for thoracic and upper abdominal surgery showed levobupivacaine and racemic bupivacaine to have similar profiles. Levobupivacaine, which is less toxic, could be used to replace bupivacaine in children.

Levobupivacaína versus bupivacaína racémica para anestesia/analgesia epidural torácica y lumbar alta en niños / Levobupivacaine versus racemic bupivacaine for thoracic and upper lumbar epidural anesthesia–analgesia in children

OBJETIVOS: Se compara levobupivacaína versus bupivacaínaen niños para analgesia epidural torácica oabdominal alta. Hipótesis: levobupivacaína se comportade igual modo que bupivacaína a dosis equivalentes.MATERIALY MÉTODOS: Pacientes distribuidos aleatoriamenteen Grupo I (levobupivacaína) y Grupo II (bupivacaína),ASA I-IV, entre 5-16 años. Tras anestesia general, se colocócatéter epidural torácico o lumbar alto; administramos boloanestésico epidural de bupivacaína versus levobupivacaína0,25% (1 mg kg–1), manteniéndose anestesia general. Realizamosanalgesia con perfusión epidural de bupivacaína o levobupivacaína0,125% con fentanilo, y rescate con fentaniloperioperatorio, y metamizol magnésico postoperatorio. Se disminuyóla perfusión epidural un 25% cada día desde el 2º día.Se analizó: perfil hemodinámico y respiratorio; analgesia derescate; tiempos para extubación y alta de Reanimación, complicacionesde la técnica, efectos adversos y confort obtenido.RESULTADOS: Estudiamos 64 pacientes, Grupo I (n = 33)y Grupo II (n = 31). Diferencias significativas en: estanciaen Reanimación (p < 0,05), mayor para Grupo II (4,2 ± 0,99días) que para Grupo I (3,5 ± 0,6 días); analgesia de rescateperioperatoria (p < 0,01), Grupo I mayor que Grupo II[n = 6 (18,18%) y n = 3 (9,67%)]; analgesia de rescate postoperatoria(p < 0,01), Grupo I menor que Grupo II a partirde las 48 h. Bloqueo motor (p < 0,05), Grupo II mayorque Grupo I. Los efectos adversos y las complicaciones fueron,dos bradicardias persistentes y una punción dural sinmanifestaciones clínicas posteriores.CONCLUSIONES: En nuestra experiencia en anestesia epiduraltorácica y abdominal alta, levobupivacaína tiene unperfil muy parecido a bupivacaína racémica. Levobupivacaína,menos tóxica, podría sustituir a bupivacaína en niños

OBJECTIVES: We compared levobupivacaine to bupivacaine for epidural analgesia for thoracic or upper abdominal surgery in children. Our working hypothesis was that at equivalent doses levobupivacaine and bupivacaine behave in the same way. MATERIALAND METHODS: ASA1-4 patients between the ages of 5 and 16 years were randomized to a levobupivacaine or a bupivacaine group. After general anesthesia was induced, we inserted a thoracic or upper lumbar epidural catheter and administered a dose of 0.25% bupivacaine or levobupivacaine (1 mg·kg-1) while maintaining general anesthesia. Analgesia was provided with an epidural infusion of 0.125% bupivacaine or levobupivacaine with fentanyl. Fentanyl was used as a perioperative rescue analgesic and metamizole magnesium as a postoperative rescue analgesic. The epidural infusion was reduced by 25% each day beginning on the second day. We analyzed hemodynamic and respiratory variables, rescue analgesia, time until extubation and discharge from the recovery unit, complications associated with the technique, adverse effects, and degree of comfort achieved. RESULTS: We studied 64 patients; 33 received levobupivacaine and 31 bupivacaine. Mean (SD) duration of recovery unit stay was significantly longer in the bupivacaine group (4.2 [0.99] days) than in the levobupivacaine group (3.5 [0.6] days; P<.05). Significantly more patients needed perioperative rescue analgesia in the levobupivacaine group (n=6 [18.18%]) than in the bupivacaine group (n=3 [9.67%]; P<.01). After 48 hours, the need for postoperative rescue analgesia was significantly lower with levobupivacaine (P<.01). Motor block was significantly greater with bupivacaine (P<.05). Adverse effects and complications included 2 cases of persistent bradycardia and 1 case of dural puncture with no subsequent clinical manifestations. CONCLUSIONS: This experience with epidural anesthesia for thoracic and upper abdominal surgery showed levobupivacaine and racemic bupivacaine to have similar profiles. Levobupivacaine, which is less toxic, could be used to replace bupivacaine in children

Transverse myelitis following general and epidural anaesthesia in a paediatric patient.

A 13-year-old girl developed transverse myelitis 2 weeks after an uncomplicated, combined general and epidural anaesthetic for orthopaedic surgery. Since epidural anaesthesia had been used, a causal relationship might have been assumed. We review the aetiology and pathogenesis of acute transverse myelitis and the role of anaesthesia in this disorder. Although a causal relationship cannot be assumed and regional anaesthesia in children is considered safe, we would like to re-emphasise the management principles and practices that may improve the benefit-to-risk ratio of these techniques.

[Efficacy of the EMLA cream in the reduction of pain caused by venipuncture in children premedicated with oral midazolam]. / Eficacia de la crema EMLA en la disminución del dolor a la venopunción en niños premedicados con midazolam oral.

OBJECTIVE: EMLA cream, a lidocaine-prilocaine mixture, penetrates skin easily. Our aim was to compare EMLA and placebo to assess the efficacy of EMLA in decreasing the pain of venipuncture in children premedicated with oral midazolam 0.5 mg/kg. PATIENTS AND METHODS: This was a prospective study enrolling 100 children 3 to 9 years of age (5.6 +/- 2) randomly distributed in 2 groups of 50. EMLA cream was applied in group 1 while placebo was applied in group 2 (control group). All were premedicated with oral midazolam. Either EMLA or placebo was applied at least 30 minutes before transfer to the operating theater and the area was covered with a transparent dressing. Parameters recorded upon arrival in the operating room and upon hand puncture with a 22-G needle were systolic and diastolic arterial pressures (SAP and DAP) and heart rate (HR). Pain was assessed on a behavior scale, a visual analog scale evaluated by the anesthesiologist (VAS-anesthesiologist) and a VAS evaluated by a nurse (VAS-nurse). Adverse events were also recorded. A Student t-test and a Mann-Whitney U-test were used for statistical analysis; the level of significance was p < 0.05. RESULTS: There were no significant differences in mean age or weight between the 2 groups. In the area EMLA was applied, 2 children presented erythema and 2 pruritus. Mean scores on the pain scales were lower in the EMLA group (p < 0.05) than in the control group: behavior scale 1.8 +/- 1.3 versus 3.2 +/- 1.7; VAS-anesthesiologist 2.8 +/- 2.3 versus 5.1 +/- 2.7; VAS-nurse 2.7 +/- 2.1 versus 5.9 +/- 1.9. HR increased in both groups (with placebo from 105 +/- 16 to 118 +/- 19, and with EMLA from 99 +/- 19 to 109 +/- 21), but the increase in SAP was statistically significant only in the placebo group, in which it rose from 113 +/- 11 to 125 +/- 16. CONCLUSION: EMLA cream decreases the pain of hand venipuncture in children premedicated with oral midazolam.

[Hemodynamic repercussion of epidural bupivacaine in thoracic injuries]. / Repercusión hemodinámica de la bupivacaína epidural en los traumatismos torácicos.

Systemic and pulmonary hemodynamic effects of 8 to 10 ml of 0.25% bupivacaine containing 1:200,000 adrenaline administered at the midthoracic level were prospectively assessed in 20 patients (aged 45 +/- 16 years) with thoracic trauma presenting 6 +/- 2 rib fractures and pulmonary contusion of different extent and radiologic density. The study was carried out at comparable evolving times, 24 h after trauma, during the second or third day of treatment, and when the hemodynamic stability of the patient was achieved. Hemodynamic measurements were performed before and 30 min after administration of the analgesic agent using a Swan-Ganz catheter. The results indicate that administration of moderate doses of epidural bupivacaine at the middle thoracic level in patients with normovolemic thoracic traumatism were not followed by alterations in the hemodynamic function except for a slight decrease in systemic arterial and pulmonary pressure. The mean arterial pressure decreased by 8% (p less than 0.05), the cardiac index showed a 4% reduction (p = 0.05), and the mean pulmonary pressure experienced a 14% decrease (p less than 0.05).