The development of pediatric anesthesia and intensive care in Scandinavia.

The initiation and development of pediatric anesthesia and intensive care have much in common in the Scandinavian countries. The five countries had to initiate close relations and cooperation in all medical disciplines. The pediatric anesthesia subspecialty took its first steps after the Second World War. Relations for training and exchange of experiences between Scandinavian countries with centers in Europe and the USA were a prerequisite for development. Specialized pediatric practice was not a full-time position until during the 1950s, when the first pediatric anesthesia positions were created. Scandinavian anesthesia developed slowly. In contrast, Scandinavia pioneered both adult and certainly pediatric intensive care. The pioneers were heavily involved in the teaching and training of anesthetists and nurses. This was necessary to manage the rapidly increasing work. The polio epidemics during the 1950s initiated a combination of clinical development and technical innovations. Blood gas analyses technology and interpretation in combination with improved positive pressure ventilators were developed in Scandinavia contributing to general and pediatric anesthesia and intensive care practice. Scandinavian specialist training and accreditation includes both anesthesia and intensive care. Although pediatric anesthesia/intensive care is not a separate specialty, an 'informal accreditation' for a specialist position is obtained after training. The pleasure of working in a relatively small group of devoted colleagues and staff has persisted from the pioneering years. It is still one of the most inspiring and pleasant gifts for those working in this demanding specialty.

Acetaminophen improves analgesia but does not reduce opioid requirement after major spine surgery in children and adolescents.

STUDY DESIGN: A randomized, placebo-controlled, double-blind study to evaluate the effect of intravenously (IV) administered acetaminophen on postoperative pain in children and adolescents undergoing surgery for idiopathic scoliosis or spondylolisthesis. OBJECTIVE: To evaluate effectiveness of IV-administered acetaminophen on postoperative analgesia, opioid consumption, and acetaminophen concentrations after major spine surgery in adolescents. SUMMARY OF BACKGROUND DATA: Scoliosis surgery is associated with severe postoperative pain, most commonly treated with IV-administered opioids. Nonsteroidal anti-inflammatory drugs (NSAIDs), as adjuvant to opioids, improve analgesia and reduce the need for opioids. However, by inhibiting cyclo-oxygenase enzymes peripherally, NSAIDs may inhibit bone healing. Acetaminophen, a centrally acting analgesic, does not have the adverse effects of NSAIDs and has improved analgesia in children after another orthopedic surgery. METHODS: In an institutional review board approved study, 36 American Society of Anesthesiology patient classification I to III patients of 10 to 18 years of age were analyzed. Acetaminophen 30 mg/kg, administered IV or 0.9% NaCl was administered at the end of scoliosis or spondylolisthesis surgery, and thereafter twice at 8-hour intervals. Timed blood samples for acetaminophen determination were taken between 0.25 and 20 hours after the first dose. All patients received standard propofol-remifentanil anesthesia. Pain scores (visual analogue scale [VAS], 0-10), opioid consumption, and adverse effects were recorded. RESULTS: In the surgical ward, 7 (39%) patients in the acetaminophen and 13 (72%) in the placebo group had a VAS pain score 6 or more (P < 0.05). There were fewer hours with VAS score 6 or more in the acetaminophen group compared with the placebo group (8.7% vs. 17.8% of the hours, P < 0.05). There was no difference in oxycodone consumption during the 24-hour follow-up between the 2 groups. CONCLUSION: IV-administered acetaminophen 90 mg/kg/day, adjuvant to oxycodone, did improve analgesia, but did not diminish oxycodone consumption during 24 hours after major spine surgery in children and adolescents. All acetaminophen concentrations were in nontoxic levels.

The duration of residual neuromuscular block after administration of neostigmine or sugammadex at two visible twitches during train-of-four monitoring.

BACKGROUND: Adequate recovery from neuromuscular block (NMB) is imperative for the patient to have full control of pharyngeal and respiratory muscles. The train-of-4 (TOF) ratio should return to at least 0.90 to exclude potentially clinically significant postoperative residual block. Fade cannot be detected reliably with a peripheral nerve stimulator (PNS) at a TOF ratio >0.4. The time gap between loss of visual fade by using a PNS until objective TOF ratio has returned to >0.90 can be considered "the potentially unsafe period of recovery." According to our hypothesis the duration of this period would be significantly shorter with sugammadex than with neostigmine. METHODS: Fifty patients received volatile anesthetics, opioids, and a rocuronium-induced NMB. TOF-Watch without a preload was used, but the anesthesiologist relied on visual evaluation of the TOF responses only. At end of operation, patients were randomized to receive either neostigmine 50 µg/kg or sugammadex 2 mg/kg, when 2 twitch responses were detected after the last dose of rocuronium. Timing of tracheal extubation was based on PNS and clinical data. Duration of the potentially unsafe period of recovery after reversal by either neostigmine or sugammadex was analyzed. Mann-Whitney U test and Pearson χ(2) test were used for statistical analysis. RESULTS: The times [mean ± sd (range)] from loss of visual fade to TOF ratio >0.90 were 10.3 ± 5.5 (1.3 to 26.0) minutes and 0.3 ± 0.3 (0.0 to 1.0) minutes in the neostigmine and sugammadex groups, respectively (P < 0.001). The times from reversal by neostigmine or sugammadex to TOF ratio >0.90 were 13.3 ± 5.7 (3.5 to 28.9) and 1.7 ± 0.7 (0.7 to 3.5) minutes, respectively (P < 0.001). The values of TOF ratios at the time of loss of visual fade were 0.34 ± 0.14 (0.00 to 0.56) in patients given neostigmine and 0.86 ± 0.11 (0.64 to 1.04) in patients given sugammadex (P < 0.001). CONCLUSIONS: There is a significant time gap between visual loss of fade and return of TOF ratio >0.90 after reversal of a rocuronium block by neostigmine. Sugammadex in comparison with neostigmine allows a safer reversal of a moderate NMB when relying on visual evaluation of the TOF response.

Neuromuscular block and current treatment strategies for its reversal in children.

Even though neuromuscular blocking agents are an essential part of balanced anesthesia and the risks of residual paralysis are well documented, many anesthetists seldomly monitor neuromuscular block. Classical reversal agent neostigmine is unable to antagonise a deep neuromuscular block and is rather slow to antagonise even a moderate block. These caveats may have introduced a practice to use muscle relaxants mainly for an endotracheal intubation. This review presents current views on the effects of muscle relaxants and their reversal agents in pediatric patients. This may help clinicians to reconsider the value of muscle relaxants during anesthesia in children.

Reversal of rocuronium-induced neuromuscular blockade with sugammadex in pediatric and adult surgical patients.

BACKGROUND: Sugammadex reverses neuromuscular blockade by chemical encapsulation of rocuronium. This phase IIIA study explored efficacy and safety of sugammadex in infants (28 days to 23 months), children (2-11 yr), adolescents (12-17 yr), and adults (18-65 yr). METHODS: Anesthetized patients (American Society of Anesthesiologists class 1-2) received 0.6 mg/kg rocuronium and were randomized to receive sugammadex (0.5, 1.0, 2.0, or 4.0 mg/kg) or placebo at reappearance of T2. Neuromuscular monitoring was performed using acceleromyography. Primary endpoint was time from sugammadex/placebo administration to recovery of the train-of-four ratio to 0.9. Adverse events and electrocardiograms were recorded, and blood samples were collected for safety and determination of sugammadex and rocuronium plasma concentrations. RESULTS: A dose-response relation was demonstrated in children (n = 22), adolescents (n = 28), and adults (n = 26), but not infants because of the small sample size (n = 8). After placebo, median recovery time of train-of-four to 0.9 was 21.0, 19.0, 23.4, and 28.5 min in infants, children, adolescents, and adults, respectively. After 2.0 mg/kg sugammadex train-of-four 0.9 was attained in 0.6, 1.2, 1.1, and 1.2 min, respectively. The sugammadex plasma concentrations were similar for the children, adolescent, and adult age groups across the dose range. Sugammadex was well tolerated: No reoccurrence of blockade, inadequate reversal, significant QT prolongation, or other abnormalities were observed. CONCLUSIONS: Sugammadex is a new reversal agent that rapidly, effectively, safely, and with similar recovery times reverses rocuronium-induced neuromuscular blockade in children, adolescents, adults, and the small number of infants studied.

The air-leak test is not a good predictor of postextubation adverse events in children undergoing cardiac surgery.

OBJECTIVE: The air-leak test is recommended as a method of assessing the appropriate size of an uncuffed endotracheal tube (ETT) in children. The authors' primary objective was to determine whether the air-leak test would predict adverse events and reintubations after the removal of the ETT in children who have undergone cardiac surgery. DESIGN: Prospective, observational, clinical study. SETTING: University tertiary care hospital. PATIENTS: Ninety-four children <10 years of age undergoing elective cardiac surgery requiring cardiopulmonary bypass surgery. INTERVENTIONS: The attending anesthesiologist assessed air-leak pressure after intubation in the operating room (OR). In addition, the air-leak test was performed in 42 patients before extubation in the pediatric intensive care unit (PICU). The incidence of adverse events and the number of failed extubations were recorded after removal of the ETT. MEASUREMENTS AND MAIN RESULTS: Eleven of the 94 patients were excluded from the study. Four (4.3%) of the patients died in the PICU before extubation, and 7 patients were excluded for other reasons. The median age of the 83 children was 0.9 years (range 0.01-9.6 years). The total incidences of postextubation adverse events and failed extubations were 30.1% and 8.4%, respectively. An audible air leak < or =25 cmH(2)O airway pressure during the OR phase or before removal of the ETT during the PICU recovery phase had no significant predictive value for the incidence of adverse events (p = 0.63) or reintubations (p = 1.0). The patients undergoing simple and complete operations compared with more complex and incomplete operations had significantly fewer postextubation adverse events (p = 0.03). Neonates did not have a higher risk for postextubation adverse events (p = 0.64) or reintubations (p = 0.26) than older children. CONCLUSION: The air-leak test did not predict an increased risk for postextubation adverse events and reintubations in children undergoing elective congenital heart surgery.

Tracheal intubating conditions and pharmacodynamics following cisatracurium in infants and children undergoing halothane and thiopental-fentanyl anesthesia.

BACKGROUND: The aims of the present study were to determine the tracheal intubating conditions, onset time, duration of action, and hemodynamic responses following the administration of cisatracurium 0.15 mg x kg(-1) to infants and children. METHODS: One hundred and eighty-one infants and children aged 1 month to 12 years were randomized to two groups to receive anesthesia with nitrous oxide-oxygen-halothane (group H) or nitrous oxide-oxygen-thiopental-fentanyl (group TF). Intubation conditions were assessed 120 s after cisatracurium administration using a 4-part scale. Neuromuscular transmission was monitored by recording the evoked compound electromyogram of the adductor pollicis. RESULTS: The proportion of patients with excellent or good intubating conditions was similar in both groups (88 of 90, 98% in group H; 85 of 90, 94% in group TF). However, there was a significantly greater proportion of excellent intubating conditions in group H (79 of 90, 88%) compared with group TF (65 of 90, 72%) (P = 0.01) and recovery time was significantly longer in group H compared with group TF (P < 0.001). There was also a higher proportion of excellent intubating conditions in infants compared with older subjects (P = 0.02) and a shorter onset time (P < 0.001) and longer recovery time (P < 0.001) in younger compared with older patients. Changes in heart rate and arterial pressure were negligible 1 min following the cisatracurium administration. CONCLUSIONS: Cisatracurium 0.15 mg x kg(-1) produces acceptable intubating conditions at 120 s in the great majority of infants and children. Anesthesia background and age have significant effects on intubating conditions and duration of action of cisatracurium.

Optimally fitted tracheal tubes decrease the probability of postextubation adverse events in children undergoing general anesthesia.

BACKGROUND: The air leak test is recommended for assessing the appropriate size of an uncuffed tracheal tube (TT) in children. Our objectives were to determine whether there is a certain threshold air leak value beyond which a higher risk for adverse events after removal of TT can be predicted and to define other risk factors related to extubation. METHODS: We enrolled 234 cases ranging from newborn to 9 years of age requiring tracheal intubation for elective or emergency surgery. General anesthesia was induced by a mask or intravenously. The TT size was calculated using the formula: [age (years)/4] + 4.5. After the induction of anesthesia, the patient's trachea was intubated and the correct position was confirmed. The attending anesthetist assessed the leak pressure. Incidences of adverse events (prolonged or barking cough, obstructed or prolonged inspiration or expiration, subcostal and sternal retractions, arterial desaturation, or laryngospasm) were recorded after removal of TT. RESULTS: Ten patients were excluded from the study. A total of 218 children underwent 224 operations under general anesthesia. Children who had an absent air leak at 25 cmH(2)O pressure had 2.8 times more adverse events during emergence from anesthesia than those with an audible air leak. Adverse events after the removal of TT were 3.7 times more likely to occur in children whose anesthesia was provided by a less experienced anesthesia trainee. CONCLUSIONS: Adverse events after removal of TT were more likely to occur in children with an absent air leak at 25 cmH(2)O pressure and in children whose anesthesia was provided by a less experienced anesthetist.

The analgesic efficacy of acetaminophen, ketoprofen, or their combination for pediatric surgical patients having soft tissue or orthopedic procedures.

The combined use of acetaminophen and a nonsteroidal antiinflammatory drug has been shown to provide better postoperative analgesia than either drug alone in several adult studies. However, there are no pediatric studies analyzing similar effects when the currently recommended doses of acetaminophen are used. In a double-blind, placebo-controlled design we randomized 120 children, aged 1-9 yr, undergoing orthopedic or soft tissue surgery, into 3 groups to receive either acetaminophen 60 mg/kg rectally and 40 mg/kg orally, ketoprofen 2 mg/kg IV twice, or the combination of the active drugs. The first drug doses were given at anesthetic induction and the second doses 8 h thereafter. During anesthesia all children received sevoflurane and a continuous infusion of remifentanil. Postoperative pain was evaluated by the behavioral objective pain scale (0-9) for 24 h. The rescue medication was morphine 0.05 mg/kg IV. The primary outcome variable was morphine consumption. For statistical analysis, analysis of variance, chi2 test and Kaplan-Meier survival analysis were used. Morphine requirement was less in the combination than in the acetaminophen group both in the postanesthesia care unit (2.5 +/- 1.7 versus 3.9 +/- 2.1 morphine doses) and during the 24-h postoperative follow-up (4.1 +/- 2.5 versus 5.9 +/- 2.9 morphine doses) (P < 0.05). No differences existed between the ketoprofen and the acetaminophen groups. The objective pain scale scores were lowest in the combination group both in the postanesthesia care unit and in the postoperative ward (P < 0.05). When children were divided based on their surgery, opioid requirement and pain scores were less in the combination than in the parent drug groups only after orthopedic surgery. The combination of acetaminophen 100 mg/kg and ketoprofen 4 mg/kg in a day provided better analgesia and lower pain scores after orthopedic, but not soft tissue, surgery in children.