Clowns for the prevention of preoperative anxiety in children: a randomized controlled trial.

OBJECTIVE: To determine if specially trained professional clowns allayed preoperative anxiety and resulted in a smooth anesthetic induction compared to the use of midazolam or no intervention. METHODS: This was a randomized, controlled, and blinded study conducted with children 3-8 years of age undergoing general anesthesia and elective outpatient surgery. Patients were assigned to one of three groups: Group 1 did not receive midazolam or clown presence; group 2 received 0.5 mg x kg(-1) oral midazolam 30 min before surgery up to a maximum of 15 mg; and group 3 had two specially trained clowns present upon arrival to the preoperative holding area and throughout operating room (OR) entrance and mask application for inhalation induction of anesthesia. The children were videotaped for later grading. RESULTS: The clown group had a statistically significant lower modified-Yale Preoperative Anxiety Scale score in the preoperative holding area compared to the control and midazolam group. The clowns' effect on anxiety reduction continued when the children entered the OR but was equal at this point to the midazolam group. Upon application of the anesthesia mask no significant differences were detected between the groups. CONCLUSIONS: This study found that the use of preoperative medically trained clowns for children undergoing surgery can significantly alleviate preoperative anxiety. However, clowns do not have any effect once the anesthesia mask is introduced.

[A Hebrew version of the FLACC scale: measurement of pain in non-verbal children].

BACKGROUND: The Israeli Ministry of Health requires that every patient have their pain routinely and systematically measured when there are treated in any of the country's medical institutions. Measurement guides treatment and enables follow-up of pain over time. Self-assessment of pain is the gold standard. Measurement is standardized by using scales representing intensity from "no pain" to "unbearable pain". Three-year-olds can assess their own pain, but younger children, or those who are non-verbal due to a medical procedure, cannot. Scales for this population rely on behavioral and physiological parameters, with assessment conducted by caretakers. Of the scales reviewed by the authors, the "FLACC" was chosen as appropriate for routine use due to its brevity and simplicity. AIMS: Translation and establishment of reliability and validity of the Hebrew version of the FLACC. METHODS: Subjects included 53 children aged 2 months to 8 years, who could not communicate verbally. Observations were conducted in the post-anesthesia care unit and the Intensive Care Unit. The FLACC was translated by the translation-back-translation technique. Inter-rater reliability was tested by two independent observers, and validity was assessed before and after provision of intravenous morphine or ketorolac. RESULTS: Inter-rater reliability was high for the total FLACC score (r = 0.94, p < 0.001), as well as for the separate items (kappa 0.5-0.85). The FLACC was considered valid, as the change in scores paralleled the known pharmacological effect of the medications. CONCLUSIONS: The Hebrew version of the FLACC was found reliable and valid for caretakers to use with children who cannot communicate verbally.

Pulse pressure and stroke volume variations during severe haemorrhage in ventilated dogs.

BACKGROUND: Similarly to systolic pressure variation (SPV), pulse pressure variation (PPV) and stroke volume variation (SVV) derived from arterial pulse contour analysis have been shown to reflect fluid responsiveness in ventilated patients. However, unlike the SPV, both PPV and SVV have not been validated during extreme hypovolaemia. The aim of the present study was to examine whether these newly introduced variables respond to gradual hypovolaemia like the SPV by increasing gradually with each step of the haemorrhage even during extreme hypovolaemia. METHODS: SPV, SVV and PPV were measured in 8 dogs following initial volume loading (10% of the estimated blood volume administered as colloid solution), 5 steps of graded haemorrhage, each consisting of 10% of the estimated blood volume, followed by retransfusion of the shed blood. RESULTS: The correlations of the SVV, SPV and PPV to the stroke volume (SV) throughout the study were -0.89, -0.91 and -0.91, respectively. Correlations of the CVP and the global end-diastolic volume (GEDV) of the heart chambers to the SV were 0.79 and 0.95, respectively. The SPV correlated significantly with both the PPV and the SVV (r=0.97 and 0.93 respectively). However, the PPV increased by more than 400% at 50% haemorrhage compared with increases of 200% and 120% for the SVV and %SPV, respectively. CONCLUSION: This study demonstrates that the present algorithm used for the calculation of the SVV and the formula used to calculate the PPV, perform well over a wide range of preload states including severe hypovolaemia. However, the PPV changes more than the SPV and SVV. This may be due to the changing relation of the SV to the pulse pressure when the filling of the aorta is greatly decreased.

Effect of a single dose of esmolol on the bispectral index scale (BIS) during propofol/fentanyl anaesthesia.

BACKGROUND: Esmolol, a short-acting beta 1-antagonist, can reduce anaesthetic requirements and decrease seizure activity during electroconvulsive therapy even after a single dose of 80 mg. We studied the effect of esmolol on the bispectral index scale (BIS), which is a processed EEG recently introduced to monitor depth of anaesthesia. METHODS: We gave esmolol 80 mg to 30 healthy male patients after induction of anaesthesia using propofol, with either fentanyl (group 1) or placebo (group 2). Patients were ventilated mechanically through a laryngeal mask airway and anaesthesia was maintained using propofol to keep the BIS value between 55 and 60. RESULTS: Esmolol did not affect the BIS index value in either group. In group 1, the areas (mean (SD)) under the BIS vs time curve 3 min before and 3 min after esmolol administration were 145 (9) and 146 (8) respectively (P = 0.116). In group 2 values were 147 (8) and 146 (7) respectively (P = 0.344). In contrast, in group 1 the area under the systolic arterial pressure (SAP) curve was 299 (31) before and 270 (29) after esmolol (P < 0.001), and 156 (17) and 141 (17) respectively for heart rate (P < 0.001). In group 2 values were 326 (36) and 302 (41) for SAP (P < 0.001) and 182 (25) and 155 (22) for heart rate (P < 0.001). CONCLUSIONS: The results suggest that a single dose of esmolol affects the SAP and heart rate but does not affect BIS values.

Pressure versus volume-controlled ventilation with a laryngeal mask airway in paediatric patients.

BACKGROUND: The utility of positive pressure ventilation with the laryngeal mask airway (LMA) in children was described previously, but the possibility of gastric insufflation, related to high peak airway pressure, continues to be a disadvantage. In this prospective study, inspiratory pressures, air leak and signs of gastric insufflation were compared between volume-controlled ventilation (VCV) and pressure-controlled ventilation (PCV) using an LMA. METHODS: Thirty-two ASA I patients, aged 4.5 +/- 4 years, who were scheduled for elective procedures under combined general anaesthesia and caudal analgesia, were enrolled. After inhalation induction and LMA insertion, each patient was randomly assigned to receive successively PCV and VCV. Peak pressures (PCV) and tidal volumes (VCV) were changed in order to achieve adequate ventilation [endtidal CO2 5-5.4 kPa (38-42 mmHg)]. RESULTS: Peak airway pressures were significantly lower with PCV than VCV (14.1 +/- 1.6 cmH2O versus 16.7 +/- 2.3 cmH2O, P < 0.001). No patient ventilated with PCV required peak pressure higher than 20 cmH2O compared with six patients ventilated with VCV (P < 0.05). Haemodynamic parameters, expiratory tidal volume and percent of leak were similar in both ventilatory modes and no signs of gastric insufflation were detected. CONCLUSIONS: During general anaesthesia in children using an LMA, PCV offers lower peak inspiratory airway pressures while maintaining equal ventilation compared with VCV. Although no signs of gastric insufflation were detected in both groups, the lower pressures might be significant in patients with reduced chest wall or lung compliance.

Malignant hyperinflation of the nondependent lung during chest surgery.

Unilateral malignant hyperinflation of the lungs during positive pressure mechanical ventilation was described during aggressive respiratory therapy of unilateral lung disease or in situations of significant difference in compliance between the two lungs. We report a case of malignant hyperinflation of the nondependent lung during chest surgery. The differential diagnosis and treatment with differential lung ventilation are described.

Propofol/remifentanil versus propofol alone for bone marrow aspiration in paediatric haemato-oncological patients.

BACKGROUND: This prospective randomized study was designed to evaluate the effects of adding remifentanil to the standard propofol-based technique in the setting of paediatric haematology-oncology outpatient clinic. METHODS: Eighty ASA III paediatric patients treated in the outpatient haematology-oncology clinic requiring bone marrow aspiration were randomly assigned either to the propofol (P) or the propofol/remifentanil (PR) group. The quality of anaesthesia and recovery were evaluated. RESULTS: The total amount of propofol required to prevent patient movement was lower in the PR group. The time interval to eye opening and to home readiness was significantly lower in the PR group. Adverse respiratory events (RR < 10.min-1 or SpO2 < 90%) occurred significantly more in the propofol/remifentanil group. CONCLUSIONS: The addition of remifentanil improved the conditions during the procedure and reduced the total amount of propofol, as well as the time to home readiness. However, the addition of remifentanil is associated with an increased risk of respiratory depression.

Work of breathing during spontaneous ventilation in anesthetized children: a comparative study among the face mask, laryngeal mask airway and endotracheal tube.

Work of breathing (WOB) increases during general anesthesia in adults, but such information has been limited in pediatric patients. We studied WOB in 24 healthy children (mean age 2+/-1.9 yrs), during elective urogenital surgery under 1 minimum alveolar anesthetic concentration halothane-nitrous oxide anesthesia with a caudal block while breathing spontaneously. WOB was measured with an esophageal balloon, miniature flowmeter, and a computerized (Bicore) system. In each patient, WOB was computed under four conditions: a mask without oral airway (-AW), a mask with oral airway (+AW), a laryngeal mask airway (LMA), and an endotracheal tube (ETT). With each apparatus WOB was studied both with continuous positive airway pressure (CPAP) (5-6 cm H(2)O) and without CPAP (or zero end-expiratory pressure [ZEEP]). Under ZEEP, WOB (g x cm/kg) among the four apparatus were (mean +/- SEM): mask (-AW) (64 +/-19.2) > mask (+AW) (44+/-17.2), LMA (42+/-15.6) > ETT (25.4+/- 12.4) (P<0.05). WOB with CPAP significantly (P<0.05) decreased from WOB with ZEEP in three groups (mask [-AW], mask [+AW], and LMA), but not in the ETT group. Tidal volume (both ZEEP and CPAP) and end-tidal PCO(2) (with CPAP only) were significantly (P<0.05) decreased only in the ETT group, whereas no significant difference was found in respiratory rate or minute volume among the four airway apparatus groups, either with or without CPAP. The reduction in WOB, when breathing through ETT was primarily attributable to decreases in tidal volume and volume work. The finding that WOB decreases with CPAP in all groups except for the ETT group suggests that the decrease is a result of improved patency of the upper airway rather than of increases in functional residual capacity and lung compliance.

Electrocardiogram-guided placement of enteral feeding tubes.

OBJECTIVE: To evaluate a new electrocardiogram guided method for placing nasoenteral feeding tubes in critically ill patients. DESIGN: Prospective case series. SETTING: Surgical intensive care unit in a tertiary center. PATIENTS: A total of 24 patients requiring enteral feeding tube placement entered the study. INTERVENTION: Standard 10-Fr flexible nasoenteral feeding tubes were inserted under direct vision by the nasal route. Before placement, two electrocardiographic reference recordings were made with the use of epigastric area skin electrodes, each 10 cm lateral to the midline 5 cm above the umbilical line. A continuous electrocardiographic tracing from the feeding tube was then monitored throughout the tube insertion process. A change in QRS axis simultaneous with electrocardiographic waveform change from reference point one to two was presumed to indicate tip passage beyond the midline and into the duodenum. Portable abdominal radiography was performed immediately after the procedure to confirm the anatomical location of the tube tip. MEASUREMENTS AND MAIN RESULTS: In four patients (17%), electrocardiographic tracings in both reference leads were identical and prevented further use of this method. In the remainder, electrocardiogram guided technique compared with portable abdominal radiography confirmed the correct position of the tube tip placed by electrocardiographic guidance. Sensitivity and specificity were 100% and 75%, respectively. CONCLUSION: This report describes a new technique of feeding tube placement. This simple and convenient bedside method allows prompt and safe initiation of enteral nutrition.

False low pulse oximetry reading associated with the concomitant use of a peripheral nerve stimulator and an evoked-potential stimulator.

One of the sources of error in pulse oximetry readings is associated with an abnormal signal-to-noise ratio. The pulse oximeter distinguishes the light absorbance of arterial blood from that of other absorbers by differentiating between a constant component and a pulsating component. The pulsating component is almost exclusively the result of arteriolar bed pulsations. Because pulse oximetry is based on the assumption that arterial blood is the only pulsatile absorber, any other fluctuating phenomenon could constitute a source of error. We report a case in which a low pulse oximetry reading was associated with concomitant use of a pulse oximeter and a peripheral nerve stimulator on the same arm. Further tests conducted using a nerve stimulator and a sensory evoked potential stimulator with different amplitudes and frequencies confirmed the association and delineated the relationship between frequency and amplitude of stimulation and the degree of artificial desaturation. A theoretical explanation for this phenomenon is presented.

Activation of monocytes via their Fc alpha R increases procoagulant activity.

There is increasing evidence in experimental models of glomerulonephritis, including IgA nephropathy, that macrophages accumulate within the affected kidneys. Increased procoagulant activity (PCA) consequent on the influx of these cells has been associated with the progression of kidney disease. We have studied the effect of activation of the monocyte Fc alpha receptor (Fc alpha R) on PCA. Immune complexes of immunoglobulin A (IgA) isotype formed in situ or the addition of aggregated IgA resulted in a dose-dependent increase of monocyte PCA. Maximal effect was achieved after 6 hours of incubation. PCA induced by Fc alpha R was consistent but was less than that observed after addition of endotoxin to monocyte monolayers or after activation via the Fc gamma R or mannose receptor. Specificity of the interaction of the ligands with Fc alpha R was shown; galactose inhibited effects mediated via the Fc alpha R but not via the Fc gamma R. Corticosteroids inhibited Fc alpha R monocyte-induced PCA. These results are likely to be relevant in the immunopathogenesis of IgA-mediated disease, particularly IgA nephropathy.

Early neonatal renal venous thrombosis: long-term outcome.

Renal venous thrombosis was diagnosed in the first week of life in 6 of 30,101 live infant births born at the Chaim Sheba Medical Center in Israel from 1984 to 1989. The thrombosis was unilateral in 5 neonates and bilateral in 1. Predisposing maternal risk factors included 2 cases of maternal diabetes and 1 case of maternal hypertension with associated intrauterine growth retardation. Perinatal risk factors included 2 cases of prematurity with severe hyaline membrane disease, 1 infant who was small for gestational age and another with asphyxia. Follow-up for 1-5 years following the acute event revealed normal growth and development in all infants. None of the patients was hypertensive and all had normal renal glomerular and tubular functions. Renal imaging and scan studies revealed loss of perfusion in 4 atrophic kidneys and diminished perfusion in the remaining 2. In conclusion, although renal venous thrombosis in neonates is associated with low mortality, long-term dysfunction in the affected kidney is common.

Predictors of outcome of stroke in infants and children based on clinical data and radiologic correlates.

Outcome predictors were analyzed in 45 infants and children with cerebrovascular disorders (CVD), based on clinical features and radiological correlates. The clinical features at presentation could be categorized into three major groups: (1) generalized: alteration of consciousness with or without seizures--24 patients (54%); (2) focal: acute hemiplegia or monoplegia with or without focal seizures--18 patients (40%); (3) cerebellar disturbances--3 patients (6%). The underlying etiology was detected in 80% of children. Thirty-seven patients (82%) survived the initial debilitating event, of whom 11 (29.7%) recovered completely and the rest had either motor or cognitive handicaps during an average follow-up period of 4.2 years (range 1.5-11 years). A head CT performed in all children revealed ischemic infarction in 29 patients (64.4%), while the others had hemorrhagic infarction. Of those with an initial generalized neurological presentation, as many as 50% had multi-focal lesions on CT. All children with focal neurological findings had a solitary localized lesion on CT, mainly in the distribution of the middle cerebral artery. Statistical analysis for outcome prediction showed that the following variables were associated with increased risk of immediate death: (1) hemorrhagic infarction demonstrated by brain CT (p = 0.031); (2) patients who presented with a generalized neurological disorder, namely alteration of consciousness, with or without seizures (p = 0.036). No other clinical or laboratory variables were predictive of imminent death, motor or cognitive handicaps. These may therefore serve as outcome predictors of stroke in the pediatric age group.

Uncommon neurologic complications of burns in infants: a parkinsonian extrapyramidal disorder and massive cerebral infarction.

We report uncommon neurologic complications of moderate to severe burns in two infants aged 13 and 19 months, respectively. The first patient suffered a 25% total body surface area burn to her lower limbs; 3 days later she became mute and irritable, with increasing rigidity of limbs and trunk. Her face was expressionless and she also had mild dysphagea. Muscle-stretch reflexes were brisk and accompanied by episodes of coarse jitteriness. A diagnosis of an extrapyramidal parkinsonian disorder was made. The infant was treated with amantadine hydrochloride, and she recovered completely over a period of 2 months. The second infant was admitted with an extensive burn to his trunk and limbs; 3 days later he became comatose and had intractable seizures, which were more prominent over his right side. Dysphasia and right-sided hemiplegia became apparent; these conditions were and remained permanent, accompanied by focal seizures and a marked cognitive delay. Although relatively uncommon, central nervous system involvement may be a hazardous complication of burns in infants, who thus represent a high-risk group.