Intravenous nalbuphine 50 microg x kg(-1) is ineffective for opioid-induced pruritus in pediatrics.

PURPOSE: This investigation evaluated the efficacy of nalbuphine in treating postoperative opioid-induced pruritus (Pr) in pediatric patients. METHODS: After Ethics Board approval, the dual site, tertiary care teaching centre study recruited 212 subjects, age > or = seven years, who received opioid analgesia postoperatively. A modified, self-report colour analogue scale (CAS) scored pruritus intensity (PrI). Subjects who reported PrI score > or = 5/10 were randomized to treatment with nalbuphine 50 microg x kg(-1) iv (max 5 mg) or saline placebo. A pruritus intensity difference (PrID) > or = 50% was considered a positive outcome. RESULTS: Of 260 subjects approached, 212 consented and 184 received opioids. Median age was 13 yr (range 7-19) and median weight was 51 kg (range 19.6-134.8 kg). Pruritus intensity > or = 5/10 occurred in 37 (20.1%) subjects. Intravenous morphine [patient-controlled analgesia (PCA)/continuous infusion] was associated with Pr in 68% of subjects over a wide dose range (9.4-63.2 mug.kg(-1).hr(-1)). Pruritus occurred in 36% of patients in the PCA group compared to continuous opioid infusion (27%) and epidural administration (27%). Pruritus intensity difference > or = 50% was achieved in 55.6% of nalbuphine and 57.9% of saline-treated subjects. CONCLUSION: This preliminary report suggests that nalbuphine 50 microg x kg(-1) iv is not effective in treating postoperative opioid-induced pruritus in pediatric patients. The modified CAS score and PrID warrant further investigation.

Intravenous nalbuphine 50 µg·kg(-1) is ineffective for opioid-induced pruritus in pediatrics.

PURPOSE: This investigation evaluated the efficacy of nalbuphine in treating postoperative opioid-induced pruritus (Pr) in pediatric patients. METHODS: After Ethics Board approval, the dual site, tertiary care teaching centre study recruited 212 subjects, age ≥ seven years, who received opioid analgesia postoperatively. A modified, self-report colour analogue scale (CAS) scored pruritus intensity (PrI). Subjects who reported PrI score ≥ 5/10 were randomized to treatment with nalbuphine 50 µg·kg(-1) iv (max 5 mg) or saline placebo. A pruritus intensity difference (PrID) ≥ 50% was considered a positive outcome. RESULTS: Of 260 subjects approached, 212 consented and 184 received opioids. Median age was 13 yr (range 7-19) and median weight was 51 kg (range 19.6-134.8 kg). Pruritus intensity ≥ 5/10 occurred in 37 (20.1%) subjects. Intravenous morphine [patient-controlled analgesia (PCA)/continuous infusion] was associated with Pr in 68% of subjects over a wide dose range (9.4-63.2 µg·kg(-1)·hr(-1)). Pruritis occurred in 36% of patients in the PCA group compared to continuous opioid infusion (27%) and epidural administration (27%). Pruritus intensity difference ≥ 50% was achieved in 55.6% of nalbuphine and 57.9% of saline-treated subjects. CONCLUSION: This preliminary report suggests that nalbuphine 50 µg·kg(-1) iv is not effective in treating postoperative opioidinduced pruritus in pediatric patients. The modified CAS score and PrID warrant further investigation. OBJECTIF: Évaluer l'efficacité de la nalbuphine contre le prurit (Pr) postopératoire induit par les opioïdes chez des patients pédiatriques. MéTHODE: Nous avons recruté 212 sujets de ≥ sept ans qui ont reçu une analgésie opioïde postopératoire. Une échelle analogique de couleur (EAC) modifiée pour l'auto-évaluation a mesuré les scores d'intensité du prurit (IPr). Répartis au hasard, les sujets dont les scores d'IPr étaient ≥ 5/10 ont reçu de la nalbuphine à 50 µg·kg(-1) iv (5 mg maximal) ou un placebo salin. Une différence d'intensité de prurit (DIPr) ≥50% était considérée positive. RéSULTATS: Des 260 sujets rencontrés, 212 ont participé à l'étude et 184 ont reçu des opioïdes. L'âge moyen a été de 13 ans (7-19) et le poids moyen de 51 kg (19,6-134,8 kg). Un prurit ≥ 5/10 a été noté chez 37 (20,1 %) des sujets. De la morphine intraveineuse [en analgésie auto-contrôlée (AAC) ou en perfusion continue] a été associée à du Pr chez 68 % des sujets pour un grand éventail de doses (9,4-63,2 µg·kg(-1)·h(-1)). Le prurit s'est manifesté chez 36 % des patients avec l'AAC comparée à la perfusion d'opioïde continue (27 %) et à l'administration péridurale (27 %). Une différence d'intensité du prurit ≥ 50 % a été atteinte chez 55,6 % des sujets qui recevaient la nalbuphine et 57,9 % de ceux qui avaient le placebo. CONCLUSION: La nalbuphine iv à 50 µg·kg(-1) n'est pas efficace pour traiter le prurit postopératoire induit par les opioïdes chez des patients pédiatriques. Le score modifié à l'EAC et la DIPr devront être étudiés plus à fond.

Bacteriostatic saline containing benzyl alcohol decreases the pain associated with the injection of propofol.

Bacteriostatic saline is a physiological saline solution containing the bacteriostatic agent benzyl alcohol as a 0.9% solution. It is used mostly for diluting and dissolving drugs for IV injection and as a flush for intravascular catheters. It also has local anesthetic properties. We studied its efficacy in decreasing the pain associated with IV administration of propofol and compared it with mixing lidocaine with propofol. One-hundred-twenty patients were randomly allocated into three groups. All patients received propofol 50 mg. The benzyl alcohol group received bacteriostatic saline as a preinjection, and the lidocaine group received propofol containing lidocaine. The placebo group did not receive bacteriostatic saline or lidocaine. Fifteen of 39 patients (38%) in the benzyl alcohol group complained of pain on injection compared to 33 of 39 (84%) in the placebo group and 22 of 42 (52%) in the lidocaine group. Differences were significant between the benzyl alcohol and placebo groups (P < 0.01) and the lidocaine and placebo groups (P < 0.01). Preinjection with bacteriostatic saline decreases the incidence of pain associated with IV administration of propofol and is comparable to that of mixing lidocaine with propofol.

Laryngo-tracheo-bronchial stenosis in a patient with primary pulmonary amyloidosis: a case report and brief review.

PURPOSE: To report a case of lower respiratory tract obstruction occurring in a patient with primary pulmonary amyloidosis and discuss anesthetic management. CLINICAL FEATURES: A 53-yr-old man was referred to our institution for microlaryngoscopy and laser treatment of the larynx. He presented with a five-year history of primary laryngo-tracheo-bronchial amyloidosis and symptoms consistent with narrowing of the conducting airways. General anesthesia was induced with iv propofol 150 mg and remifentanil 50 microg. Mivacurium 20 mg provided muscle relaxation for endotracheal intubation. Following endotracheal intubation, the airway became obstructed and patient ventilation impossible. The endotracheal tube was removed and a Dedo laryngoscope inserted. Gas exchange was maintained using supraglottic jet ventilation via a distal port of the laryngoscope. Rigid bronchoscopy showed tissue partially obstructing the lumen of the lower trachea. This was removed and the airway appeared patent. At the end of the case, a further episode of lower airway obstruction occurred requiring reinsertion of the laryngoscope and resumption of jet ventilation. Extensive debridement through the bronchoscope was required before adequate ventilation could be restored. Some days later when the patient's condition deteriorated again and he required further debridement of the trachea and insertion of a tracheostomy, guide wires were positioned in the femoral vessels in the event that cardiopulmonary bypass was required for gas exchange. CONCLUSIONS: Primary laryngo-tracheo-bronchial amyloidosis is a recurrent disease, requiring repetitive surgical procedures. Airway compromise can be a persistent problem. Awareness of this uncommon disease process and its presentation may serve to caution the anesthesiologist presented with this type of case.

Laryngotracheal topicalization with lidocaine before intubation decreases the incidence of coughing on emergence from general anesthesia.

Coughing on emergence can result in a number of undesirable side effects, including hypertension, tachycardia, tachyarrhythmias, increased intracranial pressure, and increased intraocular pressure. The efficacy of endotracheal spraying with lidocaine at the time of intubation in preventing coughing on emergence is unknown. In a double-blind placebo-controlled study, we randomized 50 ASA physical status I and II patients presenting for elective gynecological surgery <2 h duration to receive either endotracheal lidocaine 160 mg or placebo before intubation. Both groups were comparable in terms of demographics and intraoperative conditions. The incidence of coughing before tracheal extubation was less frequent in the lidocaine group (26%) than in the placebo group (66%, P < 0.01), as was the incidence after tracheal extubation (4% versus 30%, P = 0.022). This study supports the use of endotracheal lidocaine before intubation in patients undergoing general anesthesia for surgery <2 h duration where coughing on emergence is undesirable.