[Intrathecal opioid medication for perioperative analgesia in severely handicapped children undergoing spinal operations]. / Intrathekale Opioidmedikation zur perioperativen Analgesie bei schwer behinderten Kindern mit Wirbelsäulenoperationen.

PURPOSE OF THE STUDY: Intrathecal opioids have been shown to be safe and effective for postoperative analgesia in healthy children for spinal surgery. The aim of this study was to evaluate the applicability of intrathecal opioids in severely handicapped children scheduled for spinal surgery. METHODS: With hospital ethical committee approval, patients with physical states III and IV of the ASA classification requiring spinal surgery were retrospectively studied. In addition to inhalational anesthesia with sevoflurane or intravenous anesthesia using propofol, morphine 20 microg/kgBW and sufentanil 1.5 microg/kgBW were administered intrathecally before surgery. After surgery an infusion of nalbuphine was started. Need for additional intraoperative and postoperative analgesics, time of extubation, postoperative pain scores and p(a)CO2 values as well as adverse effects were recorded. RESULTS: A total of 28 patients aged from 2.8 to 18.5 years (median 11.6 years) were studied. Immediate tracheal extubation in the operating room was possible in 17 patients and for 11 patients delayed extubation was elected. All patients were extubated within 24 h except for 1 patient who received massive postoperative transfusions. In 26 out of 28 patients (93%) the combination of intrathecal opioids with postoperative nalbuphine provided adequate analgesia. Observed side effects were post-operative nausea and vomiting (PONV), pruritus and moderate hypoventilation. In two patients a change to intravenous morphine therapy was necessary. CONCLUSION: The use of intrathecal opioids for perioperative pain control from spinal fusion in severely handicapped children is feasible. Intrathecal opioids provide adequate postoperative analgesia and allow early extubation without persisting relevant respiratory compromise in most of these patients.

Shortcomings of cuffed paediatric tracheal tubes.

BACKGROUND: The goal of this investigation was to evaluate adequacy of the design of readily available paediatric cuffed tracheal tubes (CPTT). METHODS: In 15 series of cuffed (11) and uncuffed (four) paediatric tracheal tubes (ID: 2.5-7.0 mm) from four different manufacturers the following dimensions were measured: outer diameter of the tube, position and largest diameter of the tube cuff inflated at 20 cm H(2)O and position of depth markings and compared with age-related dimensions. RESULTS: Outer diameters for tubes with similar IDs varied markedly between manufacturers and between cuffed and uncuffed tracheal tubes from the same manufacturer. Cuff diameters at 20 cm H(2)O cuff pressure and cross-sectional cuff area at 20 cm H(2)O cuff pressure did not always cover maximal internal age-related tracheal diameters and cross-sectional areas. Placing the tube tip in the mid-trachea, the cuffs of cuffed tubes with ID 3.0, 4.0, or 5.0 mm would become positioned within the larynx. If the cuffs were placed 1 cm below the cricoid level, many of the tube tips would be dangerously deep within the trachea. Only five of the 11 cuffed tubes had a depth marking. In many of these tubes the distances from depth marking to tube tip were greater than the age-related minimal tracheal length. CONCLUSION: Most cuffed paediatric tracheal tubes are poorly designed, in particular the smaller sizes. A better design of cuffed tubes with a short high-volume, low-pressure cuff, cuff-free subglottic space and adequately placed depth markings are urgently needed.

Ketamine for short ambulatory procedures in children: an audit.

BACKGROUND: The purpose of this audit was the evaluation of recovery and discharge times and the identification of perioperative events related to anaesthetics with intravenous ketamine and midazolam. METHODS: In our institution, we use this method as a routine technique for short ambulatory emergency or elective procedures. Two hundred children, aged 1-16 years, were included. Ninety percent of the study patients underwent emergency procedures. RESULTS: Most perioperative events were minor and easily corrected. Intraoperatively, most events were related to respiration, including oxygen desaturation, apnoea or laryngospasm. Vomiting, vertigo, visual disturbances, nightmares and hallucinations were observed in the postoperative period. Serious complications requiring hospital admission or further interventions in the postoperative period were rare. Mean recovery time was 100 min (range 20-325) and mean discharge time 130 min (range 25-360). CONCLUSIONS: Intravenous ketamine plus midazolam is a suitable, simple and fast anaesthetic technique for short, painful ambulatory procedures. Considering the possibility of potentially serious respiratory complications, it should be performed only by qualified anaesthesia staff who are trained in advanced airway management.

Use of the intubating laryngeal mask in children: an evaluation using video-endoscopic monitoring.

BACKGROUND AND OBJECTIVE: The intubating laryngeal mask is designed to act as a ventilatory device and as an aid to blind tracheal intubation in adults. The aim of this study was to evaluate the efficacy of the intubating laryngeal mask for ventilation of the lungs and tracheal intubation in children using video-endoscopic control. METHODS: The handling and efficacy of the size 3 intubating laryngeal mask for tracheal intubation in 80 children weighing > or = 25 kg were assessed under video-endoscopic control. Ease of intubating laryngeal mask insertion, adequacy of lung ventilation through the intubating laryngeal mask and airway sealing pressures were recorded. Tracheal intubation was performed blindly by the intubator, while the supervisor observed the procedure on the video display. If blind intubation failed at the first attempt, the monitor view was used to guide the tracheal tube into the trachea. The success rate and time required for successfully placing the tracheal tube were recorded. RESULTS: Insertion of the intubating laryngeal mask was easy in all children. Lung ventilation through the intubating laryngeal mask was uniformly excellent. Blind tracheal intubation at the first attempt was successful in 53 children (66%) within 18.8 +/- 4.1 s. Twenty-four of the 27 failed blind intubation attempts were successfully intubated with video-endoscopic guidance within 28.6 +/- 9.4 s. Two children required replacing the intubating laryngeal mask, one child had to be intubated conventionally. CONCLUSIONS: The size 3 intubating laryngeal mask provides an airway that is easy to establish in children > or = 25 kg with excellent ventilation conditions and allows blind tracheal intubation at the first attempt with a high success rate. Endoscopic monitoring improves its safety and intubation success rate.

Teaching and supervising tracheal intubation in paediatric patients using videolaryngoscopy.

In 85 patients (mean age 4.6 +/- 3.1 years, range 0-10 years), a prototype of a new videolaryngoscope was used to provide a display of the intubation procedure in a paediatric anaesthesia teaching unit. The device provided important information to the teacher about the trainee's problems related to direct laryngoscopy, difficulties with tube insertion into the larynx as well as the need and extent for anterior laryngeal pressure. Because the videolaryngoscope did not impair the normal intubation procedure, it seems to be a safe and a benefical tool for teaching and supervising tracheal intubation in children. In addition, it provides a potentially useful aid during difficult laryngoscopy, since the monitor view of the vocal cords was significantly better compared with a direct laryngoscopic view (P < 0.001).

[Tropisetron for prevention of nausea and vomiting in children undergoing tonsillectomy and/or adenoidectomy]. / Tropisetron zur Prophylaxe von postoperativem Erbrechen bei Kindern. Wirksamkeit und Verträglichkeit nach Tonsillektomien und Adenotonsillektomien.

BACKGROUND: Postoperative nausea and vomiting (PONV) after tonsillectomy is a common problem in children. Tropisetron is a new 5HT3 receptor antagonist and is successfully used in paediatric patients receiving cancer therapy. The aim of the study was to assess efficacy and safety of a single intravenous dose of tropisetron for prevention of PONV in paediatric patients at risk for postoperative vomiting. METHODS: In a randomised, double-blind, placebo-controlled trial, we studied 98 children aged 2-12 years undergoing tonsillectomy or adenotonsillectomy. Patients received placebo or tropisetron 0.1 mg (= 0.1 ml)/kg body weight immediately after induction of anesthesia. A standard general anesthetic technique (Sevoflurane/N2O/O2 without neuromuscular blockers or opioids) was used. Perioperative vital signs, grade of sedation and episodes of postoperative nausea and vomiting were recorded. RESULTS: No vomiting episodes occurred in 65.3% of the tropisetron treated patients compared to 34.7% of the placebo group (p = 0.0024). Only 10.2% of the tropisetron treated patients vomited more than 3 times compared to 22.4% of the control patients (p = 0.0004). The need for antiemetic rescue medication was significantly lower in the study group (10.4%) compared to 28.6% (p = 0.025). No significant adverse effects of the study medication were shown. CONCLUSION: A single intravenous prophylactic dose of tropisetron effectively reduces the incidence of PONV during the first 24 postoperative hours after tonsillectomy and/or adenoidectomy. Because of the low incidence of adverse effects, the prophylactic use of tropisetron seems to be safe and justified in paediatric surgical patients at high risk for postoperative vomiting.

Video-intuboscopic monitoring of tracheal intubation in pediatric patients.

PURPOSE: To evaluate the efficacy of video-intuboscopic monitoring during orotracheal intubation in a pediatric anesthesia teaching unit. METHODS: In 100 pediatric patients direct laryngoscopy performed by residents or nurse anesthetists was monitored on a video display using a flexible, ultralight video-endoscopic system (O.D. 2.8 mm/length 1.8 m) within the endotracheal tube (ETT). Best direct laryngoscopic view was assessed by the intubator. The instructor observed the intubation procedure on the video display and noted number of intubation attempts, best laryngoscopic monitor view, tube passage through the larynx and final tube position. If required he gave instructions or corrections. After removal of the laryngoscope, tracheal tube position was adjusted using the monitor view. Difficulties attributed to the fibreoptic endoscope during intubation and removal from the ETT were recorded. RESULTS: The trachea was successfully intubated at the first attempt in all patients. The supervisor detected one esophageal and 12 endobronchial intubations that were immediately corrected before starting ventilation. Final visualized endotracheal tube adjustment above the carina was possible in all patients except in one with copious tracheal secretions. Compared with direct laryngoscopy the video display provided an improved view of the vocal cords during intubation. In six patients direct laryngoscopy was difficult but the tracheas were intubated using the monitor view. No difficulties with the equipment were encountered except that the black coated endoscope compromised recognition of the black ETT depth-markings in small tubes. CONCLUSIONS: Video-intuboscopic monitoring is a useful monitor of tracheal intubation. "The improved view of the cords may provide assistance during difficult laryngoscopy.

[Simple, safe postoperative parenteral nutrition with a ready-to-use all-in-one solution]. / Einfache, sichere postoperative parenterale Ernährung mit einer gebrauchsfertigen All-in-one-Lösung.

A newly developed, stable and ready-to-use industrially manufactured all-in-one solution for parenteral nutrition, containing amino acids, fat, glucose, xylitol and electrolytes, was tested in a prospective trial involving 21 patients from the 2nd to the 8th postoperative day. No side effects requiring interruption of the nutritional regimen, a positive nitrogen balance and a documented metabolic steady state proved that this solution is a safe therapeutic concept with respect to the typical postoperative metabolism. The all-in-one Vacu-Mix system is easy to handle, reduces the possibility of technical error and ensures safe and constant TPN administration.