Glossopharyngeal nerve block for pain relief after pediatric tonsillectomy: retrospective analysis and two cases of life-threatening upper airway obstruction from an interrupted trial.

A regional anesthetic technique formerly used in adults for tonsillectomy was adapted to provide posttonsillectomy pain relief in children. Injection of 3-10 mL of 0.25%-0.5% bupivacaine into each lateral pharyngeal space appeared to provide good postsurgical analgesia. A retrospective chart review failed to link the technique to airway-related complications. A prospective, randomized, double-blind, placebo-controlled trial comparing the analgesic effectiveness and postsurgical complications in patients undergoing tonsillectomy and receiving either bupivacaine or placebo was begun after institutional approval and informed consent. The study was terminated after eight children had been enrolled because two of four children receiving bupivacaine developed severe upper airway obstruction (UAO) after extubation of the trachea. We conclude that the volume and concentration of bupivacaine were sufficient to block the vagus nerves proximal to the take off of the recurrent laryngeal nerves and/or the hypoglossal nerves, resulting in severe UAO. The short distance between the hyoid and jugular foramen would predispose children and adults with a short neck to the development of this complication. In conclusion, bilateral local anesthetic injection into the lateral pharyngeal space may result in severe UAO and loss of protective reflexes.

Acetaminophen or ketorolac for post myringotomy pain in children? A prospective, double-blinded comparison.

Myringotomy with tube placement (BMT) is the most frequent surgical procedure performed in children. The purpose of this prospective, double-blinded study was to determine if 15 mg.kg-1 of acetaminophen (paracetamol) provides analgesia similar to that provided by ketorolac, 1 mg.kg-1, at a lower cost. One-hundred-and-thirty-two children, ages six months to nine years, scheduled for elective BMT were randomized to receive oral acetaminophen or ketorolac 30 min preoperatively. An Objective Pain Scale score was assessed upon arrival to the PACU and at five, ten and 20 min. Time of awakening, time of PACU and day surgery discharge and incidence of vomiting were recorded. Groups were comparable in demographics, side effects and time to discharge. Median pain scores were lower in the ketorolac group at five and ten min but no differences were seen at discharge nor in postdischarge analgesic requirements. Is ten min of better analgesia worth the cost of ketorolac? We conclude that the slight analgesic benefit from ketorolac does not justify its cost in this setting.

Effect of ketorolac on bleeding time and postoperative pain in children: a double-blind, placebo-controlled comparison with meperidine.

STUDY OBJECTIVE: To determine whether ketorolac 0.75 mg/kg would provide a comparable degree of analgesia to that of meperidine 1 mg/kg in terms of postoperative opioid requirements and pain scores in children undergoing surgeries associated with mild to moderate postsurgical discomfort. DESIGN: Randomized, prospective, placebo-controlled, double-blinded study of the initial 6 postsurgical hours. SETTING: University affiliated teaching hospital. PATIENTS: 90 healthy ASA status I and II children scheduled for elective general, orthopedic, or genitourinary procedures associated with mild to moderate postsurgical pain. Extensive surgical procedures associated with a significant risk of bleeding were excluded. INTERVENTIONS: Ketorolac 0.75 mg/kg, meperidine 1 mg/kg, or placebo (normal saline) was administered intramuscularly (IM) at the beginning of surgery. MEASUREMENTS AND MAIN RESULTS: Bleeding times were measured prior to and 180 minutes after study drug administration. Time to first rescue medication, total opioid requirement, pain scores, incidence of vomiting and length of stay were evaluated. Placebo-treated patients were rescued earlier (p < 0.0001) and required twice the rescue dosage (p = 0.013) when compared with either the ketorolac or meperidine groups. The ketorolac and meperidine groups did not differ with regard to time until first rescue, cumulative proportion requiring rescue, or the number of rescue doses required. A single dose of IM ketorolac prolonged bleeding time by 53 +/- 75 seconds (p = 0.006). CONCLUSIONS: Ketorolac provided analgesia comparable to that of meperidine and significantly reduced opioid requirements. Since ketorolac was not associated with a reduction in postoperative vomiting or length of stay, and in view of the uncertain risk of bleeding, it offers no advantage over meperidine in the management of mild to moderate acute postsurgical pain.

Maternal and fetal effects of laparoscopic insufflation in the gravid baboon.

STUDY OBJECTIVE: To test the hypothesis that intraabdominal pressures (IAP) associated with abdominal insufflation for laparoscopic procedures can alter pulmonary and hemodynamic values in the pregnant baboon and hemodynamic values in the fetus. DESIGN: A descriptive physiologic study. SETTING: Animal research facility at Scott and White Memorial Hospital, Temple, TX. PARTICIPANTS: Four pregnant baboons at 120 +/- 7 days' gestation. INTERVENTIONS: The baboons underwent general anesthesia, Swan-Ganz and arterial catheter placement, and abdominal insufflation at 10 and 20 mm Hg IAP for 20-minute intervals at each pressure. The following end points were measured: maternal heart rate (MHR), mean arterial pressure (MAP), cardiac output (CO), pulmonary capillary wedge pressure (PCWP), pulmonary artery pressures (PAP), central venous pressure (CVP), systemic vascular resistance (SVR), ventilator rate (VR), oxygen saturation, and end-tidal carbon dioxide (CO2). Fetal heart rate and fetal growth values were measured, and umbilical artery Doppler flow studies were performed. MEASUREMENTS AND MAIN RESULTS: The PCWP (p <0.026), CVP (p <0.0012), and PAP (p <0.046) were significantly increased at 20 mm Hg IAP; CO decreased as IP increased. The MAP, MHR, and SVR did not change significantly with increased IAP. The only significant change in pulmonary values was the increase in peak airway pressure (p <0.001). The VR was increased from an average of 18 to 41 breaths/minute in an attempt to maintain adequate oxygen saturation and to normalize end-tidal CO2 when IAP was increased to 20 mm Hg. Respiratory acidosis (pH <7. 35, partial pressure of carbon dioxide >50 torr) was demonstrated in three of four animals within 20 minutes at an IAP of 20 mm Hg. Results of Doppler flow studies on the effects of the fetuses were unaltered immediately after this procedure compared with baseline measurements. Normal interval growth was demonstrated 2 weeks after the procedure. CONCLUSION: The baboon mothers and fetuses had no adverse effects at an IAP of 10 mm Hg, but may have significant cardiovascular and respiratory alterations associated with IAP of 20 mm Hg.