Paediatric day stay tonsillectomy service: development and audit.

Day stay paediatric tonsillectomy is well established in many parts of the world but not in Australia. This audit presents the protocol and results of the first one hundred and twenty-five patients managed this way at our hospital. Patients assessed as being at low risk of postoperative complications were offered the procedure as a day patient. All patients had a standardized relaxant anaesthetic technique with an intraoperative opioid and antiemetics. The patients were observed for six hours postoperatively in the Day Stay Unit and contacted the day following surgery to assess any problems. The overall incidence of postoperative vomiting was 15.6%. Two patients required overnight admission. One child was re-admitted on day four for delayed postoperative haemorrhage. Forty-four of the first forty-nine patients' parents were contacted four to six weeks later to assess their experiences of the process. Although approximately three-quarters of the parents rated their child's pain as moderate or severe at some stage, all but one felt the analgesic regimen was good or adequate. Eighty per cent were satisfied with having the surgery as a day stay procedure.

Efficacy of securing cannulae with different taping methods.

This study compared locally available adhesive tapes and dressings in a block randomized, blinded study to determine the force required to dislodge a cannula. In the first stage of the study, various tapes and taping methods were used to secure a cannula to a polyvinylchloride (PVC) pipe. The cannula was attached to a section of a giving set which in turn was attached to a dynamic force transducer. The force required to dislodge the cannula, together with the methods of dislodgement were recorded. In stage two the best taping technique for each type of tape was tested by attaching a cannula to the surface of the forearm of an adult male volunteer. Of the tapes tested we found Leukoplast to be the most effective tape for securing the cannula to the PVC model. On the adult forearm Sleek was as effective as Leukoplast. Orientating the tape parallel to the long axis of the cannula and taping the cannula hub-giving set connection both improved the adherence of the cannula. Under the conditions tested, sterile adhesive dressings and tapes were relatively ineffective in securing the cannulae.

Superior vena cava obstruction and liver transplantation in a child.

We report a case of superior vena cava obstruction in a child, which was probably secondary to long-term central venous cannulation. The obstruction was asymptomatic preoperatively, but became evident during liver transplantation, and complicated the intraoperative management. There is one other case report of this occurring in an adult in similar circumstances, and we believe that ours is the first report of such a presentation in the paediatric age group.

The effect of single dose intravenous dexamethasone in tonsillectomy in children.

A prospective, randomized, double-blinded, placebo-controlled clinical trial was conducted in 41 patients evaluating the effect of a single preoperative dose of intravenous dexamethasone on postoperative vomiting and pain in children undergoing elective tonsillectomy. Dexamethasone was found to significantly reduce the incidence of vomiting in the first 24 hours postoperatively (P = 0.02), the time to first intake of solids (P = 0.001), the need to administer a rescue antiemetic (P = 0.005) and intravenous fluid therapy requirements (P = 0.006) in the postoperative period. No significant difference was found between the dexamethasone and placebo groups in the time to first intake of fluids, pain scores or analgesic requirement postoperatively. These results indicate that dexamethasone substantially reduces morbidity after tonsillectomy in children.

Preoperative hypoglycaemia, propranolol and the Jervell and Lange-Nielsen syndrome.

The Jervell and Lange-Nielsen syndrome is an autosomal recessive trait characterized by deafness and electrocardiographic changes. These changes include prolongation of the QT interval and T-wave inversion. Treatment may include the use of beta-blockers to prevent the development of malignant ventricular arrhythmias and sudden death. We report a patient with this syndrome, who was receiving propranolol orally and who became hypoglycaemic during the preoperative fasting period prior to cochlear implantation.

Intraoperative transoesophageal echocardiography for paediatric cardiac surgery--an audit of 200 cases.

We report out initial experience with intraoperative transoesophageal echocardiography (TOE) in 200 patients undergoing repair of congenital heart disease. Complications associated with probe insertion precluded a full study in 11 patients (5.5%) and included airway obstruction (n = 6), inability to pass the probe (n = 4) and vascular compression (n = 1). The preoperative diagnosis was confirmed by TOE in 176 of 189 cases (93%) with minor variances in 12 (6.3%) and one major variance (additional large muscular ventricular septal defect (VSD)). Unexpected abnormalities not diagnosed preoperatively were found at surgery in four cases (2%) and were all of trivial operative significance. Postoperative studies showed no residual defect in 96 (51%) and trivial or mild residual defects in 72 patients (38%). There were moderate or severe residual defects in 21 cases (11%). Ten cases (5.3%) returned to bypass for further surgery, with eight achieving complete or adequate amelioration. In six of the 10 cases, return to bypass was prompted by the TOE examination alone. There was one re-operation in the postoperative period for a VSD patch dehiscence. Routine TOE offers significant advantages in the management of patients undergoing repair of congenital heart disease, particularly in postoperative assessment. Careful monitoring of perfusion and ventilation is required, particularly during probe insertion in children weighing 5 kg or less.

Acupuncture and postoperative vomiting in day-stay paediatric patients.

The stimulation of the acupuncture point P6 has been used to prevent nausea and vomiting in the adult population. It has, however, been subject to limited comparative evaluation in children. We proposed that stimulation of P6 and the analgesic point Li4 would reduce the incidence of postoperative vomiting. Eighty-four unpremedicated paediatric patients having day-stay surgery (circumcision or herniotomy/orchidopexy) were included in a randomized, double-blind, placebo-controlled study of transcutaneous stimulation of P6 and Li4, or no stimulation. The incidence of vomiting was recorded for 24 hours postoperatively. There was no statistically significant difference in total postoperative vomiting in those patients who were stimulated, compared with the control group (P = 0.909), or between any group for postoperative vomiting in the recovery ward, day-stay ward or at home. For all groups, vomiting was more common within the first four hours and more likely to occur in the day-stay ward.

Parental attitudes to presence at induction of paediatric anaesthesia.

Previous studies of parental presence at induction of anaesthesia in children have examined parental reaction to being present and the benefits gained from their presence. This study was undertaken specifically to assess parents' attitudes to being present at induction of their child's anaesthetic. A total of 154 questionnaires were distributed over a two-week period to parents of children presenting to the Day Stay Unit for procedures requiring general anaesthesia. Eighty-eight percent would have liked to be present at induction. Only 41% of parents expected to be present and only 40% of parents were actually present for their child's induction. Of those parents present, 94% felt it helpful to their child, 65% helpful to themselves and 41% helpful to the anaesthetist. No-one felt their presence to have been unhelpful. These results may provide an incentive for anaesthetists to review their current paediatric anaesthetic practices.

Anaesthesia for patients with arthrogryposis multiplex congenita: what is the risk of malignant hyperthermia?

Arthrogryposis multiplex congenita has been linked with malignant hyperthermia. A review of the anaesthetic experience at the Royal Alexandra Hospital for Children over a 32-year period revealed no episode of malignant hyperthermia occurring in patients with arthrogryposis multiplex congenita despite many and varied exposures to known triggering agents.

Effect of halothane on spinal somatosensory evoked potentials in sheep.

The effects of increasing concentrations of halothane on the morphology of spinal somatosensory evoked potentials (SEP) were studied in seven anaesthetized sheep. Anaesthesia was induced with thiopentone and maintained with nitrous oxide in oxygen. Ventilation was controlled throughout. Arterial pressure, temperature and end-tidal carbon dioxide tension were monitored. A lumbar laminectomy was performed, the sciatic nerve exposed and a baseline spinal SEP was recorded from the surface of the lumbar spinal cord. Halothane was introduced in incremental steps of 1% up to 3% and further SEP were recorded. These recordings revealed that the spinal SEP peak latencies and general waveform configuration were stable under halothane anaesthesia. Baseline SEP amplitude was similar to that obtained with 1% halothane; however, at concentrations of 2% halothane or greater, there was a significant (P less than 0.005) attenuation of all components of the spinal SEP. These findings have important anaesthetic implications for patients undergoing spinal cord monitoring using SEP, although interspecies differences may occur.

Acute epiglottitis in children.

The records of one hundred and sixty-one children with acute epiglottitis admitted to the Royal Alexandra Hospital for Children between January 1975 and June 1984 were reviewed. Forty-five complications occurred in thirty-four patients, including five deaths. The preferred method of airway management is direct laryngoscopy and nasotracheal intubation under general anaesthesia in the presence of skilled assistance. There should be no attempt to lie the child down prior to this, nor should awake laryngoscopy be attempted, as this may precipitate a respiratory arrest. Chloramphenicol (with or without ampicillin) should be commenced after blood cultures are obtained, as 20% of the sensitivities available demonstrated resistance to ampicillin.