Double-blind, placebo-controlled analgesic study of ibuprofen or rofecoxib in combination with paracetamol for tonsillectomy in children.

BACKGROUND: The analgesics used for paediatric tonsillectomy may be associated with side-effects such as sedation, respiratory depression and vomiting (opioids) or increased bleeding [non-steroidal anti-inflammatory drugs (NSAIDs)]. In our institution, we employ a combination of paracetamol, NSAID and opioid, although there is no published evidence of analgesic benefit from adding NSAIDs to paracetamol in children. METHODS: This randomized, double-blinded clinical study examined the analgesic effectiveness of combining paracetamol (20 mg kg(-1)) with rofecoxib (0.625 mg kg(-1)), ibuprofen (5 mg kg(-1)) or placebo as premedication for (adeno)tonsillectomy (n=98) in children aged 3-15 yr. Intravenous fentanyl 1-2 microg kg(-1) was given intraoperatively. Regular oral paracetamol (15 mg kg(-1), 4 hourly) was given after operation and could be supplemented on request from the child with oral ibuprofen 5 mg kg(-1) or oral codeine 1 mg kg(-1). The primary outcome variable was need for early supplementary analgesia (within 2 h after surgery). RESULTS: The addition of ibuprofen to paracetamol reduced the need for early analgesia from 72% to 38% of children (difference 34%; 95% confidence interval 4-64%). The addition of rofecoxib to paracetamol did not significantly alter the need for early analgesia (68 vs 72%). Pain scores were higher in those children who required early analgesia. There were no differences between the groups in operative blood loss or complications, total 24-h analgesic consumption, pain scores at 4 and 8 h, vomiting or antiemetic use. CONCLUSION: This study provides evidence to support the combination of ibuprofen (but not rofecoxib) with paracetamol for perioperative analgesia in children.

Analgesic efficacy of ketorolac 0.5% ophthalmic solution (Accular) in paediatric strabismus surgery.

This prospective double-blind study was designed to assess the analgesic efficacy of ketorolac 0.5% ophthalmic solution compared with placebo in 30 healthy children undergoing extraocular muscle recession for correction of strabismus. After paracetamol 20 mg.kg-1 preoperatively, a standard anaesthetic was given. There were no significant differences in Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) and faces pain scale (FPS) scores, requirement for supplementary analgesia or in postoperative vomiting between the two groups over the following 24 h. This study did not demonstrate improved postoperative analgesia when topical ketorolac eye drops were given in addition to paracetamol. This observed lack of efficacy may reflect difficulties in the use of CHEOPS and FPS in this age group with this pain model.

Decreased mivacurium requirements and delayed neuromuscular recovery during sevoflurane anesthesia in children and adults.

UNLABELLED: The purpose of this study was to compare the mivacurium infusion requirements and neuromuscular recovery in adults and children during propofol/opioid and sevoflurane anesthesia. Seventy-five adult and 75 pediatric patients were randomized to receive propofol/opioid 0.5 or 1.0 minimum alveolar anesthetic concentration (MAC) (age-related) sevoflurane anesthesia. Plasma cholinesterase (PChE) activity was measured. Neuromuscular blockade was monitored by train-of-four (TOF) stimulation every 10 s and adductor pollicis electromyography. A bolus of 2 x the 95% effective dose of mivacurium (0.25 mg/kg) was followed by an infusion titrated to maintain 90%-95% blockade. Mivacurium doses were recorded every 5 min. At the end of surgery, the infusion was stopped, and recovery from mivacurium was monitored until TOF > or =0.7. PChE concentrations were within the normal range (adults 4-12 KU/L, children 6-16 KU/L) and correlated with mivacurium dose. Mivacurium infusion rates were higher in children than in adults: at 30 min, the rates in children were 13.1 +/- 6.4, 8.1 +/- 4.7, and 5.2 +/- 2.9 microg x kg(-1) x min(-1) at 0, 0.5, and 1.0 MAC sevoflurane, respectively; the corresponding rates in adults were 5.9 +/- 3.1, 4.3 +/- 1.7, and 2.9 +/- 0.7 microg x kg(-1) x min(-1) (P < 0.01). Sevoflurane decreased mivacurium requirements, maximal decreases at 45 min in children and 10 min in adults, and delayed neuromuscular function recovery. Children recovered twice as quickly as adults, achieving TOF > or =0.7 at 9.8 +/- 2.5, 11.4 +/- 2.8, and 19.6 +/- 6.3 min compared with 19.9 +/- 5.4, 26.4 +/- 8.3, and 32.9 +/- 9.8 min in adults (P < 0.0001). In conclusion, mivacurium requirements were correlated with PChE, were greater in children than in adults, and were reduced by sevoflurane. Neuromuscular recovery occurred more rapidly in children and was delayed by sevoflurane. IMPLICATIONS: The mivacurium infusion requirement to maintain constant 90%-95% neuromuscular block during anesthesia is correlated with plasma cholinesterase activity. It is increased in children and reduced by the inhaled anesthetic sevoflurane. Despite the larger dose administered to children, recovery from block occurred more rapidly in children than in adults and was delayed by sevoflurane.

An analogue approach to audit in anaesthesia.

The predicted outcome of anaesthesia and surgery was compared with the immediate outcome in 508 patients by means of two 100 mm linear analogue scales. The results were used to obtain a statistically based rule by which the anaesthetist may consistently select three groups of patients for audit: group 1, patients in whom immediate outcome of anaesthesia and surgery is worse than predicted; group 2, patients whose outcome is better than predicted; and group 3, the remaining patients. The rule, which is simply adapted to departmental audit, does not necessarily need a computer but is suited to the computer as it is numerically based.

Plasma observations near neptune: initial results from voyager 2.

The plasma science experiment on Voyager 2 made observations of the plasma environment in Neptune's magnetosphere and in the surrounding solar wind. Because of the large tilt of the magnetic dipole and fortuitous timing, Voyager entered Neptune's magnetosphere through the cusp region, the first cusp observations at an outer planet. Thus the transition from the magnetosheath to the magnetosphere observed by Voyager 2 was not sharp but rather appeared as a gradual decrease in plasma density and temperature. The maximum plasma density observed in the magnetosphere is inferred to be 1.4 per cubic centimeter (the exact value depends on the composition), the smallest observed by Voyager in any magnetosphere. The plasma has at least two components; light ions (mass, 1 to 5) and heavy ions (mass, 10 to 40), but more precise species identification is not yet available. Most of the plasma is concentrated in a plasma sheet or plasma torus and near closest approach to the planet. A likely source of the heavy ions is Triton's atmosphere or ionosphere, whereas the light ions probably escape from Neptune. The large tilt of Neptune's magnetic dipole produces a dynamic magnetosphere that changes configuration every 16 hours as the planet rotates.

Plasma observations near uranus: initial results from voyager 2.

Extensive measurements of low-energy positive ions and electrons in the vicinity of Uranus have revealed a fully developed magnetosphere. The magnetospheric plasma has a warm component with a temperature of 4 to 50 electron volts and a peak density of roughly 2 protons per cubic centimeter, and a hot component, with a temperature of a few kiloelectron volts and a peak density of roughly 0.1 proton per cubic centimeter. The warm component is observed both inside and outside of L = 5, whereas the hot component is excluded from the region inside of that L shell. Possible sources of the plasma in the magnetosphere are the extended hydrogen corona, the solar wind, and the ionosphere. The Uranian moons do not appear to be a significant plasma source. The boundary of the hot plasma component at L = 5 may be associated either with Miranda or with the inner limit of a deeply penetrating, solar wind-driven magnetospheric convection system. The Voyager 2 spacecraft repeatedly encountered the plasma sheet in the magnetotail at locations that are consistent with a geometric model for the plasma sheet similar to that at Earth.

Plasma observations near saturn: initial results from voyager 2.

Results of measurements of plasma electrons and poitive ions made during the Voyager 2 encounter with Saturn have been combined with measurements from Voyager 1 and Pioneer 11 to define more clearly the configuration of plasma in the Saturnian magnetosphere. The general morphology is well represented by four regions: (i) the shocked solar wind plasma in the magnetosheath, observed between about 30 and 22 Saturn radii (RS) near the noon meridian; (ii) a variable density region between approximately 17 RS and the magnetopause; (iii) an extended thick plasma sheet between approximately 17 and approximately 7 RS symmetrical with respect to Saturn's equatorial plane and rotation axis; and (iv) an inner plasma torus that probably originates from local sources and extends inward from L approximately 7 to less than L approximately 2.7 (L is the magnetic shell parameter). In general, the heavy ions, probably O(+), are more closely confined to the equatorial plane than H(+), so that the ratio of heavy to light ions varies along the trajectory according to the distance of the spacecraft from the equatorial plane. The general configuration of the plasma sheet at Saturn found by Voyager 1 is confirmed, with some notable differences and additions. The "extended plasma sheet," observed between L approximately 7 and L approximately 15 by Voyager 1 is considerably thicker as observed by Voyager 2. Inward of L approximately 4, the plasma sheet collapses to a thin region about the equatorial plane. At the ring plane crossing, L approximately 2.7, the observations are consistent with a density of O(+) of approximately 100 per cubic centimeter, with a temperature of approximately 10 electron volts. The location of the bow shock and magnetopause crossings were consistent with those previously observed. The entire magnetosphere was larger during the outbound passage of Voyager 2 than had been previously observed; however, a magnetosphere of this size or larger is expected approximately 3 percent of the time.

Plasma observations near saturn: initial results from voyager 1.

Extensive measurements of low-energy plasma electrons and positive ions were made during the Voyager 1 encounter with Saturn and its satellites. The magnetospheric plasma contains light and heavy ions, probably hydrogen and nitrogen or oxygen; at radial distances between 15 and 7 Saturn-radii (Rs) on the inbound trajectory, the plasma appears to corotate with a velocity within 20 percent of that expected for rigid corotation. The general morphology of Saturn's magnetosphere is well represented by a plasma sheet that extends from at least 5 to 17 Rs, is symmetrical with respect to Saturn's equatorial plane and rotation axis, and appears to be well ordered by the magnetic shell parameter L (which represents the equatorial distance of a magnetic field line measured in units of Rs). Within this general configuration, two distinct structures can be identified: a central plasma sheet observed from L = 5 to L = 8 in which the density decreases rapidly away from the equatorial plane, and a more extended structure from L = 7 to beyond 18 Rs in which the density profile is nearly flat for a distance +/- 1.8 Rs off the plane and falls rapidly thereafter. The encounter with Titan took place inside the magnetosphere. The data show a clear signature characteristic of the interaction between a subsonic corotating magnetospheric plasma and the atmospheric or ionospheric exosphere of Titan. Titan appears to be a significant source of ions for the outer magnetosphere. The locations of bow shock crossings observed inbound and outbound indicate that the shape of the Saturnian magnetosphere is similar to that of Earth and that the position of the stagnation point scales approximately as the inverse one-sixth power of the ram pressure.

Plasma observations near jupiter: initial results from voyager 2.

The first of at least nine bow shock crossings observed on the inbound pass of Voyager 2 occurred at 98.8 Jupiter radii (R(J)) with final entry into the magnetosphere at 62 R(J). On both the inbound and outbound passes the plasma showed a tendency to move in the direction of corotation, as was observed on the inbound pass of Voyager 1. Positive ion densities and electron intensities observed by Voyager 2 are comparable within a factor of 2 to those seen by Voyager 1 at the same radial distance from Jupiter; the composition of the magnetospheric plasma is again dominated by heavy ions with a ratio of mass density relative to hydrogen of about 100/1. A series of dropouts of plasma intensity near Ganymede may be related to a complex interaction between Ganymede and the magnetospheric plasma. From the planetary spin modulation of the intensity of plasma electrons it is inferred that the plasma sheet is centered at the dipole magnetic equator out to a distance of 40 to 50 R(J) and deviates from it toward the rotational equator at larger distances. The longitudinal excursion of the plasma sheet lags behind the rotating dipole by a phase angle that increases with increasing radial distance.

Plasma observations near jupiter: initial results from voyager 1.

Extensive measurements of low-energy positive ions and electrons were made throughout the Jupiter encounter of Voyager 1. The bow shock and magneto-pause were crossed several times at distances consistent with variations in the upstream solar wind pressure measured on Voyager 2. During the inbound pass, the number density increased by six orders of magnitude between the innermost magnetopause crossing at approximately 47 Jupiter radii and near closest approach at approximately 5 Jupiter radii; the plasma flow during this period was predominately in the direction of corotation. Marked increases in number density were observed twice per planetary rotation, near the magnetic equator. Jupiterward of the Io plasma torus, a cold, corotating plasma was observed and the energylcharge spectra show well-resolved, heavy-ion peaks at mass-to-charge ratios A/Z* = 8, 16, 32, and 64.

Observations at mercury encounter by the plasma science experiment on mariner 10.

A fully developed bow shock and magnetosheath were observed near Mercury, providing unambiguous evidence for a strong interaction between Mercury and the solar wind. Inside the sheath there is a distinct region analogous to the magnetosphere or magnetotail of Earth, populated by electrons with lower density and higher temperature than the electrons observed in the solar wind or magnetosheath. At the time of encounter, conditions were such that a perpendicular shock was observed on the inbound leg and a parallel shock was observed on the outbound leg of the trajectory, and energetic plasma electron events were detected upstream from the outbound shock crossing. The interaction is most likely not atmospheric, but the data clearly indicate that the obstacle to solar wind flow is magnetic, either intrinsic or induced. The particle fluxes and energy spectra showed large variations while the spacecraft was inside the magnetosphere, and these variations could be either spatial or temporal.

Observations at venus encounter by the plasma science experiment on mariner 10.

Preliminary results from the rearward-looking electrostatic analyzer of the plasma science experiment during the Mariner 10 encounter with Venus are described. They show that the solar-wind interaction with the planet probably involves a bow shock rather than an extended exosphere, but that this is not a thin boundary at the point where it was crossed by Mariner 10. An observed reduction in the flux of electrons with energies greater than 100 electron volts is interpreted as evidence for somne direct interaction with the exosphere. Unusual intermittent features observed downstream of the planet indicate the presence of a comet-like tail hundreds of scale lengths in length.

Mariner V: Plasma and Magnetic Fields Observed near Venus.

Abrupt changes in the amplitude of the magnetic fluctuations, in the field strength, and in the plasma properties, were observed with Mariner V near Venus. They provide clear evidence for the presence of a bow shock around the planet, similar to, but much smaller than, that observed at Earth. The observations appear consistent with an interaction of the solar wind with the ionosphere of Venus. No planetary field could be detected, but a steady radial field and very low plasma density were found 10,000 to 20,000 kilometers behind Venus and 8,000 to 12,000 kilometers from the Sun-Venus line. These observations may be interpreted as relating to an expansion wave tending to fill the cavity produced by Venus in the solar wind. The upper limit to the magnetic dipole moment of Venus is estimated to be within a factor of 2 of 10(-3) items that of Earth.