Propofol 2 mg/kg is superior to propofol 1 mg/kg for tracheal intubation in children during sevoflurane induction.

BACKGROUND: Propofol has been used to facilitate tracheal intubation within a short time of sevoflurane induction without a muscle relaxant in children. We compared as the primary outcome the incidence of excellent intubating conditions after 8% sevoflurane and propofol 1 or 2 mg/kg. METHODS: One hundred and four patients (2-7 years) were randomly assigned to receive propofol 1 mg/kg in group SP1 (n=53) or propofol 2 mg/kg in group SP2 (n=51) after inhalation induction using sevoflurane 8% in oxygen. Forty-five seconds after propofol and controlled ventilation, intubating conditions were assessed using a four-point scoring system based on ease of laryngoscopy, vocal cords position, coughing, jaw relaxation and limb movement. Heart rate and systolic blood pressure were measured as baseline, after sevoflurane induction, propofol, intubation and at 2 and 5 min following intubation. RESULTS: Three patients in group SP1 were excluded from analysis. Time from sevoflurane induction to intubation (248.9±71.3 s in group SP1 vs. 230.9±61.3 s in group SP2) and endtidal sevoflurane before intubation (5.6±1.6% in group SP1 vs. 5.2±1.5% in group SP2) did not differ between the two groups. The incidence of excellent intubating conditions was significantly higher in group SP2 compared with group SP1 [47/51 (92%) vs. 28/50 (56%)]. The incidence of acceptable intubating conditions was significantly higher in group SP2 compared with group SP1 [48/51 (94%) vs. 35/50 (70%)]. No hemodynamic difference was noted at any time point between the two groups. CONCLUSION: Propofol 2 mg/kg during 8% sevoflurane induction resulted in a higher proportion of excellent intubating conditions compared with propofol 1 mg/kg.

Ondansetron is as effective as diphenhydramine for treatment of morphine-induced pruritus after cesarean delivery.

BACKGROUND: Subarachnoid (SA) morphine, highly effective for the management of pain after a cesarean delivery, is associated with a significant incidence of pruritus in up to 80% of patients. No previous study has compared the effectiveness of ondansetron (5-HT(3) antagonist) vs. diphenhydramine (H(1) receptor blocker) for the treatment of this side effect. METHODS: In this randomized, double-blind study, 113 patients with a pruritus score 3 or 4 (1=absent; 2=mild, no treatment required; 3=moderate pruritus, treatment required; and 4=severe pruritus) after SA morphine 0.2 mg were assigned to group ondansetron, which received 4 mg intravenously (i.v.) ondansetron, and group diphenhydramine, which received 25 mg i.v. diphenhydramine. Patients who continued to have pruritus > or =3, 30 min after the study drug were considered treatment failures and were treated with naloxone 0.04 mg i.v. repeatedly, as well as patients who relapsed. Pain scores, nausea, vomiting, and sedation were determined before and 30 min after the study drugs were administered. Patients were followed up for 24 h. RESULTS: The success rate was comparable between the two groups [40/57 (70%) and 38/56 (70%), P=0.79, in group ondansetron and group diphenhydramine, respectively]. Among the successfully treated patients, the recurrence rates of moderate to severe pruritus were 11/40 (28%) in group ondansetron and 13/38 (35%) in group diphenhydramine, P=0.52. The side effect profile was similar between the two groups. CONCLUSION: Ondansetron is as effective as diphenhydramine in relieving pruritus caused by SA morphine in patients undergoing a cesarean delivery. However, up to 50% of patients required naloxone either for primary failure or for recurrence.

Comparison of three doses of epidural fentanyl followed by bupivacaine and fentanyl for labor analgesia.

BACKGROUND: Epidural fentanyl 100 microg after lidocaine-epinephrine test dose has been shown to provide adequate analgesia in early labor. This investigation determines the effect of three different bolus doses of epidural fentanyl on duration and quality of analgesia during early first stage of labor. METHODS: In this prospective, double-blind study, 103 laboring nulliparous at cervical dilation <5 cm were enrolled. After an epidural test dose of lidocaine (60 mg) with epinephrine (15 microg), parturients received, randomly, bolus of epidural fentanyl 50, 75, or 100 microg, followed by a continuous infusion of epidural bupivacaine 0.0625% and fentanyl 3 microg/ml at a rate of 10 ml/h. Pain scores and maternal sedation, pruritus, nausea, and vomiting were recorded 10, 20, and 30 min after fentanyl, and every 30 min thereafter until first request for additional analgesia. RESULTS: Adequate analgesia was achieved in 87% (28/32), 94% (35/38), and 94% (31/33) in the fentanyl 50, 75, and 100 microg groups within 20 min. Mean duration of analgesia before re-dosing was significantly longer in fentanyl 100 and 75 microg groups (185.6+/-82.9 and 188.5+/-82.2 min, respectively) as compared with fentanyl 50 microg group (133.6+/-46.2 min, P<0.016). There was no difference in the incidence of maternal side effects or neonatal Apgar scores among the three groups. CONCLUSION: After a test dose of lidocaine-epinephrine, the three epidural fentanyl doses produced similar effective labor analgesia. However, epidural fentanyl 75 microg followed by epidural infusion of dilute bupivacaine and fentanyl produced longer duration of analgesia than fentanyl 50 microg followed by the same infusion, with no further prolongation when the dose of fentanyl was increased up to 100 microg.

Addition of ketamine to propofol for initiation of procedural anesthesia in children reduces propofol consumption and preserves hemodynamic stability.

BACKGROUND: There is no ideal anesthesia protocol to perform short invasive procedures in pediatric oncology. The combination of propofol and ketamine may offer advantages over propofol alone. METHODS: In a prospective, randomized, double-blind study, we analyzed 63 consecutive procedures performed in 47 oncology children. All patients received 1 mug/kg fentanyl, followed by propofol 1 mg/kg in group P (n=33) or propofol 0.5 mg/kg and ketamine 0.5 mg/kg in group PK (n=30) for the initiation of anesthesia. The need for supplementation with propofol and/or fentanyl to maintain an adequate level of anesthesia was recorded. The hemodynamic and respiratory profile, recovery time and the occurrence of side effects were compared. RESULTS: Significantly more children required propofol (100% vs. 83.3%) and fentanyl (75.5% vs. 43.3%) rescue doses, and developed hypotension (63.6% vs. 23.4%) and bradycardia (48.5 vs. 23.4%) in group P compared with group PK, with a comparable incidence of respiratory adverse events and recovery times. However, 40% of children in group PK were agitated following recovery compared with 6% in group P. CONCLUSIONS: The combination of propofol and ketamine for invasive procedures in pediatric oncology resulted in reduced propofol and fentanyl consumption and preserved hemodynamic stability, but more children in the combination group recovered with agitation.

Haloperidol vs. ondansetron for the prevention of postoperative nausea and vomiting following gynaecological surgery.

BACKGROUND AND OBJECTIVE: Ondansetron is widely used for the prophylaxis of postoperative nausea and vomiting, while haloperidol is an antiemetic that lacks recent data on efficacy and adverse effects. METHODS: In this prospective, randomized, double-blinded study involving 93 females undergoing gynaecological procedures under general anaesthesia, we compared the efficacy and adverse effects of prophylactic haloperidol 1 mg intravenous and ondansetron 4 mg intravenous vs. placebo. RESULTS: During the overall observation period (0-24 h), in the haloperidol, ondansetron and placebo groups respectively, the incidence of nausea and/or vomiting was 40.7% (11/27), 48.2% (13/27) and 55.5% (15/27), and the need of rescue antiemetics was 22.2% (6/27), 44.4% (12/27) and 40.7% (11/27), with P values >0.05 among the three groups. During the early observation period (0-2 h), in the haloperidol, ondansetron and placebo groups respectively, the incidence of nausea and/or vomiting was 13.7% (4/29), 26.6% (8/30) and 43% (13/30), and the need for rescue antiemetics was 6.8% (2/29), 26.6% (8/30) and 36.6% (11/30). Between haloperidol and placebo groups, the P value was 0.04 for nausea and/or vomiting, and was 0.01 for rescue antiemetics, in addition to lower nausea scores (P = 0.03). During the late observation period (2-24 h), no significant difference was shown among the three groups. CONCLUSION: The prophylactic administration of 1 mg intravenous haloperidol or 4 mg ondansetron, in female patients undergoing gynaecological surgery, did not improve the overall incidence of nausea and/or vomiting vs. placebo. However, haloperidol 1 mg proved to be an effective antiemetic in the early observation period without significant adverse effects.

Propofol-remifentanil-based anaesthesia vs. sevoflurane-fentanyl-based anaesthesia for immediate postoperative ophthalmic evaluation following strabismus surgery.

BACKGROUND AND OBJECTIVE: Following strabismus surgery, immediate postoperative ophthalmic evaluation may be desired. Thus, an anaesthetic technique allowing rapid recovery of ocular motility is required. Saccadic eye movements is a biophysical monitor of ocular motility and may be used to assess recovery from anaesthesia. The aim of this study is to compare the time to the recovery of saccadic eye movements in patients, following one of two anaesthetic techniques: Propofol-remifentanil-based anaesthesia vs. sevoflurane-fentanyl-based anaesthesia. METHODS: Fifty adult patients undergoing strabismus surgery were randomly assigned to one of two groups: patients in Group R received induction and maintenance of anaesthesia with propofol and remifentanil, while patients in Group S received induction of anaesthesia with propofol and fentanyl and maintenance of anaesthesia with sevoflurane. Recovery from anaesthesia was measured from the time all anaesthetics were turned off and was assessed every 2 min. Recovery time was attained when patients were able to generate brisk saccadic eye movements. At recovery time, the ophthalmic evaluation was started. RESULTS: The mean recovery time of saccadic eye movements was significantly shorter in the Group R when compared to the Group S (12.1 +/- 4.3 min vs. 21.5 +/- 4.7 min, respectively, P < 0.0001). More patients in Group S experienced nausea and vomiting postoperatively as compared to Group R (9/25 vs. 2/25, respectively, P = 0.037). CONCLUSIONS: Propofol-remifentanil-based anaesthesia may be a useful technique in strabismus surgery when immediate postoperative ophthalmic evaluation is desired. When compared to sevoflurane maintenance of anaesthesia, it allows for a more rapid recovery from anaesthesia as judged by recovery of saccadic eye movements and a decreased incidence of postoperative nausea and vomiting.

Effect of low-dose dexmedetomidine or clonidine on the characteristics of bupivacaine spinal block.

BACKGROUND: The purpose of this study was to compare the onset and duration of sensory and motor block, as well as the hemodynamic changes and level of sedation, following intrathecal bupivacaine supplemented with either dexmedetomidine or clonidine. METHODS: In a prospective, double-blind study, 60 patients undergoing transurethral resection of prostate or bladder tumor under spinal anesthesia were randomly allocated to one of three groups. Group B received 12 mg of hyperbaric bupivacaine, group D received 12 mg of bupivacaine supplemented with 3 microg of dexmedetomidine and group C received 12 mg of bupivacaine supplemented with 30 microg of clonidine. The onset times to reach peak sensory and motor levels, and the sensory and motor regression times, were recorded. Hemodynamic changes and the level of sedation were also recorded. RESULTS: Patients in groups D and C had a significantly shorter onset time of motor block and significantly longer sensory and motor regression times than patients in group B. The mean time of sensory regression to the S1 segment was 303 +/- 75 min in group D, 272 +/- 38 min in group C and 190 +/- 48 min in group B (B vs. D and B vs. C, P < 0.001). The regression of motor block to Bromage 0 was 250 +/- 76 min in group D, 216 +/- 35 min in group C and 163 +/- 47 min in group B (B vs. D and B vs. C, P < 0.001). The onset and regression times were not significantly different between groups D and C. The mean arterial pressure, heart rate and level of sedation were similar in the three groups intra-operatively and post-operatively. CONCLUSIONS: Dexmedetomidine (3 microg) or clonidine (30 microg), when added to intrathecal bupivacaine, produces a similar prolongation in the duration of the motor and sensory block with preserved hemodynamic stability and lack of sedation.

Comparison of three modes of patient-controlled epidural analgesia during labour.

BACKGROUND AND OBJECTIVES: This study compares three modes of patient-controlled epidural analgesia in parturients during labour. METHODS: Eighty-four women were randomized to one of three groups. The epidural solution used in all the three groups was 0.1% bupivacaine with fentanyl 2 microg mL(-1). Patients were able to self administer a demand dose of 3 mL with a lockout interval of 6 min in Group A, 6 mL with a lockout interval of 12 min in Group B and 9 mL with lockout interval of 18 min in Group C. All patients received a background infusion at a rate of 6 mL h(-1). Visual analogue pain scores, pinprick analgesia and motor block were assessed hourly by a blinded observer. The physician-administered supplementation and the cumulative dose of bupivacaine were also compared between the three groups. RESULTS: Pain scores, sensory level and motor block were not different among the study groups. Patients' satisfaction was rated good to excellent with no difference among groups. The cumulative dose of bupivacaine was not significantly different. However, there was a trend towards a decreased need for rescue analgesia in Group C. Within each group, the physician-administered supplementations were significantly higher during the second stage of labour than during the first stage (P < 0.05). CONCLUSION: The three modes of patient-controlled epidural analgesia supplemented by a background infusion of 6 mL h(-1) were equally effective for labour analgesia with a trend for decreased rescue analgesia in the group with a larger bolus dose and a longer lockout interval.

Preoperative caudal block prevents emergence agitation in children following sevoflurane anesthesia.

BACKGROUND: The frequency of emergence agitation in children is increased following sevoflurane anesthesia. However, controversies still exist concerning the exact etiology of this postanesthetic problem. Although this phenomenon is present with adequate pain relief or even following pain-free procedures, pain is still regarded as a major contributing factor. METHODS: In a prospective, randomized, double-blind study, we enrolled 48 premedicated and calm 2-6-year-old children undergoing inguinal hernia repair. We assigned children to one of two groups: children assigned to the caudal group (n = 24) received a caudal block to supplement sevoflurane, while children assigned to the fentanyl group (n = 24) received a bolus injection of 1 microg kg(-1) intravenous fentanyl before skin incision to supplement sevoflurane. In the post anesthesia care unit, all children were received by their parent, and the incidence of emergence agitation and pain scores, as well as hemodynamic changes, were compared in both groups. RESULTS: Forty-four children completed the study. In the fentanyl group, 59% of the children were agitated following emergence from anesthesia as compared to 4.5% in the caudal group (P < 0.001). Also, pain scores, mean values of heart rate and blood pressure as well as morphine requirement were significantly higher in the post anesthesia care unit in the fentanyl group compared to the caudal group. CONCLUSION: Our results show that in children undergoing inguinal hernia repair, pain control with a preoperative caudal block as compared to intraoperative intravenous fentanyl significantly reduces the incidence of emergence agitation and pain scores following sevoflurane anesthesia.

Diclofenac and/or propacetamol for postoperative pain management after cesarean delivery in patients receiving patient controlled analgesia morphine.

BACKGROUND AND OBJECTIVES: A multimodal approach to postcesarean pain management may enhance analgesia and reduce side effects after surgery. This study evaluates the postoperative analgesic effects of propacetamol and/or diclofenac in parturients undergoing elective cesarean delivery under spinal anesthesia. METHODS: After randomization, 80 healthy parturients received the following: placebo (group M), 100 mg diclofenac rectally every 8 hours (group MD), 2 g propacetamol intravenously every 6 hours (group MP), or a combination of 2 g propacetamol and 100 mg diclofenac (group MDP) as described above. Drugs were administered for 24 hours after surgery. Postoperative pain was controlled with a patient controlled analgesia pump, using morphine. The visual analog scale (VAS) at rest and on coughing, as well as the morphine consumption, were evaluated at 2, 6, and 24 hours postoperatively. Also, the side effects experienced after undergoing the different regimens were compared. RESULTS: The patients' characteristics did not differ significantly between the 4 groups. VAS score at 2 hours, both at rest and on coughing were lower in group MDP and MD compared with group M (P <.05). At 24 hours, there was still a tendency toward lower pain scores in the groups MDP and MD; however, this difference was only statistically significant at rest between the MDP group and the MP and M groups. Morphine consumption at 2, 6, and 24 hours was lower in the MDP and MD groups compared with the MP and M groups (P <.05). The morphine-sparing effect was higher in groups MDP and MD compared with group MP (57% and 46%, respectively, v 8.2%, P <.05). The incidence of side effects was similar in all groups. However, the power of the study was too low to permit an evaluation of potential side effects. CONCLUSION: Diclofenac after cesarean delivery improves analgesia and has a highly significant morphine-sparing effect. We were unable to demonstrate significant morphine-sparing effect of propacetamol or additive effect of propacetamol and diclofenac in this group of patients.

The effect of dexamethasone on postoperative vomiting after tonsillectomy.

UNLABELLED: In this double-blinded, randomized, placebo-controlled study, we assessed the effect of dexamethasone 0.5 mg/kg IV administered preoperatively in 110 children 2-12 yr old, undergoing electrodissection adenotonsillectomy, using a standardized anesthetic technique. The incidence of early and late vomiting, the time to first oral intake, the quality of oral intake, the satisfaction scores, and the duration of IV hydration were compared in both groups. The overall incidence of vomiting, as well as the incidence of late vomiting, was significantly less in the Dexamethasone group as compared with the Saline group (23% and 19% vs 51% and 34%, respectively). The time to first oral intake and the duration of IV hydration were shorter in the Dexamethasone group compared with the Saline group (P < 0.05). The quality of oral intake and the satisfaction scores were better in the Dexamethasone group than in the Saline group (P < 0.05). This report confirms the beneficial effect of IV dexamethasone on both vomiting and oral intake in children undergoing electrodissection adenotonsillectomy. IMPLICATIONS: In this double-blinded, placebo-controlled study, we examined the efficacy of a single dose of dexamethasone 0.5 mg/kg IV on posttonsillectomy vomiting and oral intake in children 2-12 yr old. Dexamethasone significantly decreased the incidence of postoperative vomiting during the first 24 h, shortened the time to the first oral intake and the duration of IV hydration, and improved the quality of oral intake and the satisfaction scores of the patients.

Does pregnancy protect against intrathecal lidocaine-induced transient neurologic symptoms?

We investigated the incidence of transient neurologic symptoms (TNS) after the use of hyperbaric lidocaine as compared with hyperbaric bupivacaine in patients undergoing cesarean delivery under spinal anesthesia. Two hundred women scheduled for cesarean delivery were randomly allocated to receive spinal anesthesia with 75 mg hyperbaric lidocaine 5% (n = 100) or 12 mg hyperbaric bupivacaine 0.75% (n = 100). Spinal anesthesia was administered to all patients in the sitting position with a 25-gauge Whitacre needle. The level of sensory blockade, time to full recovery, and intraoperative hemodynamic profile were noted in all patients. The patients were interviewed postoperatively for three consecutive days to detect the occurrence of TNS. The incidence of TNS was zero (95% confidence interval 0%--3%) in both the Lidocaine and the Bupivacaine Groups. Our results indicate that the frequency of postoperative TNS does not exceed 3% in patients undergoing cesarean delivery at term using hyperbaric lidocaine 5% or hyperbaric bupivacaine 0.75%.

Hydroxyethylstarch 10% is superior to Ringer's solution for preloading before spinal anesthesia for Cesarean section.

PURPOSE: To compare the preloading effect of 500 ml hydroxyethylstarch (HES) 10% with 1 L Lactated Ringer's solution (LR). METHODS: In 40 healthy women undergoing elective Cesarean section HES, 500 ml (n = 20), or LR, IL (n = 20), was administered during 10 min before spinal anesthesia. The incidence of hypotension, (systolic blood pressure < 80% of baseline and < 100 mm Hg), and the amount of ephedrine used to treat it were compared. Also, the incidence of nausea and/or vomiting were recorded. Neonatal outcome was assessed using Apgar scores and umbilical venous and arterial blood gases. RESULTS: The incidence of hypotension was higher in the LR than in HES group (80% vs 40%). Mean minimum systolic blood pressure was lower in the LR than in the HES group (86.1 +/- 12.7 mm Hg vs 99.6 +/- 9.7 mm Hg P < 0.05). Systolic blood pressure < 90 mmHg occurred in two of 20 patients (10%) who received HES vs 11 of 20 patients (55%) who received LR (P < 0.05). More doses of ephedrine were required to treat hypotension in the LRthan in the HES group (35.3 +/- 18.4 mg vs 10.6 +/- 8.6 mg; P < 0.05). The incidence of nausea and/or vomiting was lower in the HES than in the crystalloid group. Neonatal outcome was good and similar in both groups. CONCLUSION: Preloading patients undergoing elective Cesarean section with 500 ml HES 10%, decreases the incidence and severity of spinal-induced hypotension more than preloading with 1 L of LR solution.

Preoxygenation: comparison of maximal breathing and tidal volume breathing techniques.

BACKGROUND: Preoxygenation with tidal volume breathing for 3-5 min is recommended by Hamilton and Eastwood. This report compares tidal volume preoxygenation technique with deep breathing techniques for 30-60 s. METHODS: The study was conducted in two parts on patients undergoing elective coronary bypass grafting. In the first group (n = 32), each patient underwent all of the following preoxygenation techniques: the traditional technique consisting of 3 min of tidal volume breathing at an oxygen flow of 5 l/min; four deep breaths within 30 s at oxygen flows of 5 l/min, 10 l/min, and 20 l/min; and eight deep breaths within 60 s at an oxygen flow of 10 l/min. The mean arterial oxygen tensions after each technique were measured and compared. In the second group (n = 24), patients underwent one of the following techniques of preoxygenation: the traditional technique (n = 8), four deep breaths (n = 8), and eight deep breaths (n = 8). Apnea was then induced, and the mean times of hemoglobin desaturation from 100 to 99, 98, 97, 96, and 95% were determined. RESULTS: In the first group of patients, the mean arterial oxygen tension following the tidal breathing technique was 392+/-72 mm Hg. This was significantly higher (P<0.05) than the values obtained following the four deep breath technique at oxygen flows of 5 l/min (256+/-73 mm Hg), 10 l/min (286+/-69 mm Hg), and 20 l/min (316+/-67 mm Hg). In contrast, the technique of eight deep breaths resulted in a mean arterial oxygen tension of 369+/-69 mm Hg, which was not significantly different from the value achieved by the traditional technique. In the second group of patients, apnea following different techniques of preoxygenation was associated with a slower hemoglobin desaturation in the eight-deep-breaths technique as compared with both the traditional and the four-deep-breaths techniques. CONCLUSION: Rapid preoxygenation with the eight deep breaths within 60 s can be used as an alternative to the traditional 3-min technique.

Haemostasis-altering drugs and central neuraxial block.

PURPOSE: The purpose of this article is to review the literature concerning the use of epidural and spinal anaesthesia in patient receiving haemostasis-altering drugs, and to provide clear guidelines concerning the safe use of those anaesthetic in this category of patients. SOURCE: Relevant articles identified via a medline search and recommendation issued from consensus conferences were consulted. PRINCIPLE FINDINGS: Bleeding in the spinal canal is a very rare occurrence which makes it difficult to conduct randomised studies. Analysis of published case reports provide insight concerning the associated risk factors that may increase the risk of spinal haematoma. Those risk factors are predominantly, anticoagulation and puncture difficulties. Although many studies are reassuring, zero events does not mean that the risk is zero. Caution is always advised because the consequences of a spinal haematoma are devastating. CONCLUSION: Central neuraxial block should be avoided in fully anticoagulated patients. In partially anticoagulated patient, strict delays should be respected according to the pharmacology of the anticoagulants used, before institution of the central neuraxial block. Manipulation of epidural catheters should not be done unless the level of anticoagulation is low.