A paediatric palliative care programme in development: trends in referral and location of death.

PURPOSE: To describe the formation of a paediatric palliative care programme providing care in hospital, at home or in hospice, ensuring continuity of care where the child and family desire. STUDY DESIGN: Descriptive analysis was performed on referral source, diagnosis and reason for discharge for patients referred to the Palliative Care Team at the Children's Hospital of Eastern Ontario in Ottawa, Ontario, Canada from 1999 to 2007. RESULTS: 341 children were referred. 24% had a neurological condition, 21% had genetic disorders or congenital anomalies, 20% had cancer, 18% had metabolic or neurodegenerative conditions and 17% had another diagnosis. The major sources of referral included paediatricians, neonatologists, oncologists and intensivists. 55% of the children have died. 58% of these died in hospital, 27% at home and 15% in hospice. Of the remaining 152 children, 7% were discharged from the programme after clinical improvement, 4% were moved to another geographic location or an adult centre, 2% were not eligible, 1% declined services and 4% were lost to follow-up. The remaining 90 children continue to be followed-up. In the hospitalised patients who died, the annual referral rate increased from 20% to >50%. IMPLICATIONS: Referral to the palliative care team has increased over time in all diagnostic categories and from all sources. Most children died in hospital; however, a significant number of families chose end-of-life care at home or in a hospice.

Prevention of vomiting after strabismus surgery in children: dexamethasone alone versus dexamethasone plus low-dose ondansetron.

BACKGROUND: Postoperative vomiting is a common complication after strabismus surgery. The combination of dexamethasone and ondansetron decreases vomiting after strabismus surgery, while dexamethasone alone decreases vomiting after tonsillectomy in children. We compared the effect of dexamethasone alone to ondansetron plus dexamethasone on postoperative vomiting among children undergoing strabismus surgery. METHODS: Healthy children, aged 2-14 years, who were undergoing strabismus surgery were entered into this randomized, blocked and stratified study. Patients were administered 0.5 mg.kg(-1) midazolam p.o., 20-30 min preoperatively when indicated. The patients had an intravenous induction with 2.5-3.5 mg.kg(-1) propofol or an inhalation induction of anaesthesia with halothane and N2O. All patients were given 20 microg.kg(-1) atropine i.v. Study drugs were administered in a double-blind fashion. Both groups received 150 microg.kg(-1) dexamethasone i.v. Group D patients received placebo and group OD received 50 microg.kg(-1) of ondansetron i.v. Anaesthesia was maintained with halothane and N2O. Postoperative fluid, vomiting and pain management were standardized. Patients were followed for 24 h. We studied 193 patients with 111 patients in the OD group. Demographic data were similar. RESULTS: The overall incidence of vomiting was 23%; in group D and 5%; in group OD (P < 0.001). Each episode of vomiting increased the in-hospital length of stay by 29 min (P < 0.001). CONCLUSIONS: There was a remarkably low incidence of postoperative vomiting of 5%; with the combination of dexamethasone plus a low-dose of ondansetron which more effectively decreased vomiting after strabismus surgery in children when compared with dexamethasone alone.

The pharmacoeconomics of neuromuscular blocking drugs: a perioperative cost-minimization strategy in children.

UNLABELLED: The purpose of this investigation was to compare the costs of intermediate-acting neuromuscular blocking drugs in children during routine ambulatory surgery. We studied 200 healthy, 2-10-yr-old children undergoing elective dental restorative surgery. During Part 1 of the study, children received an inhaled anesthetic with halothane and nitrous oxide, whereas in Part 2, the anesthetic was IV propofol with nitrous oxide. The study drugs were atracurium, cisatracurium, mivacurium, rocuronium, and vecuronium. Patients were initially administered 2x the effective dose for 95% of the study drug. After recovery to 10% of baseline neuromuscular function, the neuromuscular blockade was rigidly maintained with an infusion of the study drug at about 10% of baseline function. Neuromuscular drug costs were approximated as drug usage x cost/unit. The initial drug costs were not substantially different for both Parts 1 and 2, but over time, mivacurium became the most expensive drug and cisatracurium the least expensive. In conclusion, based on current costs, cisatracurium is the least expensive intermediate-acting neuromuscular drug. IMPLICATIONS: For children undergoing minor ambulatory procedures of 1-2 h, and continuous intraoperative neuromuscular blockade is indicated, cisatracurium currently is the least expensive drug.

A randomized trial of tranexamic acid to reduce blood transfusion for scoliosis surgery.

UNLABELLED: Pediatric patients who undergo posterior spinal fusion surgery to correct scoliosis often require multiple blood transfusions. Tranexamic acid is a synthetic antifibrinolytic drug that reduces transfusion requirements in cardiac surgery and total knee arthroplasty. We evaluated the efficacy of prophylactic tranexamic acid to reduce perioperative blood transfusion requirements in a prospective, double-blinded, placebo control study. Forty patients, 9-18 yr of age, were randomized to either tranexamic acid (initial dose of 10 mg/kg and infusion of 1 mg. kg(-1). h(-1)) or placebo (isotonic saline). Perioperative management was standardized. A uniform transfusion threshold for noncell saved red blood cells was 7.0 g/dL. The total amount of blood transfused in the perioperative period was significantly reduced in the Tranexamic group (P = 0.045). No thrombotic complications were detected in either group. The administration of prophylactic tranexamic acid in patients with scoliosis undergoing posterior spinal fusion surgery has the potential to reduce perioperative blood transfusion requirements. IMPLICATIONS: The administration of prophylactic tranexamic acid in patients with scoliosis who are undergoing posterior spinal fusion surgery has the potential to reduce perioperative blood transfusion requirements.

Analysis of the efficacy of pediatric day surgery.

OBJECTIVES: To assess the efficacy and safety of a pediatric day surgery program and its benefits to the child and family. DESIGN: A review and analysis of prospectively gathered data. SETTING: The Children's Hospital of Eastern Ontario (CHEO), a university-affiliated pediatric centre with a referral base of 2.5 million people. PATIENTS: All children undergoing day surgery at CHEO during the 5 years between 1992 and 1997. INTERVENTIONS: All surgical procedures performed on a day surgery basis. MAIN OUTCOME MEASURES: Procedures performed, complications and unexpected admissions. RESULTS: An average of 4,899 children per year underwent surgical procedures in the ambulatory day surgery program. The 4 commonest procedures performed were myringotomy, tonsillectomy and adenoidectomy, dental procedures, and inguinal hernia repair. The majority of children were between 2 and 7 years of age. Complications were few, averaging 1.6% per year, with postoperative bleeding, primarily secondary to tonsillectomy and adenoidectomy, being the most common. None resulted in permanent disability and there were no deaths. CONCLUSIONS: Pediatric day surgery is a safe and cost-effective program that benefits the child, the family and the pediatric surgical program.

Effect of Trendelenburg head position during cardiac deairing on cerebral microemboli in children: a randomized controlled trial.

OBJECTIVES: We prospectively evaluated the effects of head position during cardiac deairing on the Doppler ultrasonography-detected cerebral microemboli in children and the association between the embolic counts and the clinical assessment of deairing. METHODS: Children requiring exposure of the systemic ventricle under cardiopulmonary bypass were randomized to Trendelenburg (-15 degrees ) and horizontal (0 degrees ) head positions during and after standard surgical deairing. Complexity of repair was categorized as follows: group I consisted of single simple lesions, and group II consisted of multiple complex lesions. Transcranial Doppler ultrasonography identified high-intensity transient signals in the right middle cerebral artery within the first 5 minutes after aortic declamping (release) and from this ending period until cardiopulmonary bypass termination (residual). Electrocardiographic alterations after deairing were documented. A predefined 5-point scale was used by the surgeon for blinded assessment of deairing. RESULTS: High-intensity transient signals were identified in 97% of 128 patients (aged 5 days to 17 years). The median total high-intensity transient signal count was 60 (25th-75th quartiles, 14-189). Head position or surgeon did not affect the rate of high-intensity transient signals (P >.20). During the residual interval, occurrence of HITS in group I was less than that in group II (P <.05), but there was no difference at release. The incidence of high-intensity transient signals and electrocardiographic alterations correlated with the clinical assessment of deairing (P <.01). CONCLUSIONS: Trendelenburg head position as a complement of cardiac deairing in children does not decrease the cerebral microembolic load compared with the horizontal head position. The cerebral microembolic count and the occurrence of electrocardiographic alterations usually increases when the surgeon is less confident in the efficacy of deairing.

Comparison of remifentanil versus regional anaesthesia in children anaesthetised with isoflurane/nitrous oxide. International Remifentanil Paediatric Anaesthesia Study group.

We compared the efficacy and safety of a remifentanil (0.25 microg x kg(-1) x min(-1)-based balanced anaesthetic technique with a bupivacaine-based regional anaesthetic technique in an open label, multicentre study in 271 ASA physical status 1 or 2 children aged 1-12 years. Subjects requiring major intra-abdominal, urological or orthopaedic surgery were randomly allocated to receive either intravenous remifentanil (group R; n = 185) or epidural bupivacaine (group B; n = 86) with isoflurane/nitrous oxide for their anaesthesia. The majority of children in both groups (85% in group R, 78% in group B) showed no defined response to skin incision, and although the mean increase in systolic blood pressure (+11 mm Hg) was significantly greater in group R than in group B, this change did not represent a serious haemodynamic disturbance. More children in group R (31%) required interventions to treat hypotension and/or bradycardia than those in group B (12%), but these were easily managed by administration of fluids or anticholinergic drugs. Adverse events, mainly nausea and/or vomiting, occurred in 45% of group R and 42% of group B (NS). The adverse event profile of remifentanil in this study was typical of a potent mu-opioid receptor agonist. Remifentanil was as effective as epidural or caudal block in providing analgesia and suppressing physiological responses to surgical stimuli in children aged between 1 and 12 years undergoing major abdominal, urological, or orthopaedic surgery under isoflurane/nitrous oxide anaesthesia.

Cerebral vascular effects of aortovenous cannulations for pediatric cardiopulmonary bypass.

BACKGROUND: The effects of aortovenous cannulations for pediatric cardiopulmonary bypass on cerebral blood flow velocity (CBFV) and electroencephalography (EEG) were evaluated. METHODS: CBFV and EEG were continuously recorded before (baseline), during, and after cannulations until initiation of cooling (mean +/- 95% confidence interval). Vasopressors and/or volume replacement were administered if mean arterial pressure (MAP) decreased below 35 mm Hg. Cannulation-related EEG slowing was used as a criterion for electrocortical alteration. RESULTS: We studied 124 children (3 days to 17 years of age). Aortic and venous cannulations decreased mean CBFV by 10+/-3% and 13+/-4%, respectively, from baseline (p < 0.001). MAP diminished (p < 0.01) by 8+/-3% and 12+/-4%, respectively, from precannulation values (53+/-2 mm Hg). Right atrial cannulation, which was often chosen because the patient was hemodynamically unstable, was more frequently associated with pharmacologic intervention when compared with superior vena cava (SVC) cannulation (p < 0.01). Transient EEG alterations (n = 20) were associated with persistently low MAP (< 30 mm Hg), low CBFV (< 69%), and aortic (n = 4) or SVC (n = 7) cannula malposition. Infants with right atrial cannulation and intervention had more frequent EEG alterations (p = 0.04). Patients requiring intervention were younger (p < 0.01) and had longer hospital stay (p < 0.01) than those without intervention. CONCLUSIONS: Cerebral effects of cannulations are greater in young infants. This was found to be associated with low MAP during heart manipulation or consequence of cannula malpositions.

Cerebral blood flow velocity during occlusive manipulation of patent ductus arteriosus in children.

Patent ductus arteriosus (PDA) with left-to-right shunting modifies the Doppler flow pattern of the intracranial circulation. The ability of increases in cerebral blood flow velocity (CBFV) to predict shunt resolution during PDA occlusion was evaluated. A 2 MHz transcranial Doppler (TCD) monitored diastolic and mean CBFV, plus the systolic/mean CBFV ratio in the middle cerebral artery from before (baseline) to immediately after PDA occlusion. Shunt resolution was verified by echocardiography and/or angiography. A minimum of 40% increase in diastolic-CBFV from baseline was considered successful resolution. Patients were age-stratified into group I (< 15 months; n = 23) and group II (> 15 months; n = 10). Thirty-three children were studied (age, 0.1 to 109 months) during surgical (n = 22) or coil occlusions (n = 11). Transcranial Doppler successfully identified shunt resolution in 78% of cases in group I, as compared to 0% in group II (p < 0.01). Identification rate decreased from 79% in cases of minimum ductal diameter of 3 mm (n = 19) to 21% in smaller ductuses (n = 14) (p < 0.01). Body weight and left-atrium size (p = 0.004) in group I and PDA diameter in group II (p = 0.02), were the only preoperative ductal parameters associated with diastolic-CBFV changes after ductus occlusion. Transcranial Doppler detects shunt resolution in infants with moderate to large PDAs.

Perioperative autologous blood donation in children.

Autologous blood donation in children has become a standard of care. Children have to live with the life-time complications associated with allogeneic blood including the transmission of known and unknown pathogens, and the impact of alloimmunization on future blood transfusions, organ transplants and pregnancies. Donor reaction, allogeneic exposure and utilization rates in pediatric preoperative autologous donation (PAD) programs are as good if not better than reported in adult literature. Children are very resilient when undergoing extreme isovolemic hemodilution (IHD). PAD, IHD and intraoperative blood recovery appear to be useful components of a pediatric blood conservation program. Prospective, randomized studies addressing the specific needs of children are required to properly define their perioperative role.

Prophylaxis for vomiting by children after tonsillectomy: ondansetron compared with perphenazine.

We have compared the effects of ondansetron and perphenazine on vomiting after tonsillectomy in 216 healthy children, aged 2-12 yr. The study was randomized, stratified, blocked and double blind. Anaesthesia was induced with propofol i.v. or by inhalation of halothane and nitrous oxide. Ondansetron 150 micrograms kg-1 or perphenazine 70 micrograms kg-1 was administered i.v. after induction of anaesthesia in a double-blind manner. Perioperative management of emesis, pain, fluids and patients discharge were standardized. Ondansetron and perphenazine had similar effects on postoperative vomiting (44% vs 41%; ondansetron vs perphenazine P = 0.77). By logistic regression analysis, the only significant predictor of postoperative vomiting was sex, that is males had a greater incidence of vomiting (49% vs 35%; P = 0.016). In-hospital vomiting was associated with a prolongation of stay in the day-care surgical unit of 7 min per episode of vomiting (P = 0.015). We conclude that ondansetron and perphenazine had similar effects on vomiting in children after tonsillectomy in a day-case setting.

Cerebral effects of aortic clamping during coarctation repair in children: a transcranial Doppler study.

OBJECTIVE: Haemodynamic changes as a consequence of application and release of aortic clamps for surgical repair of aortic coarctation are compensated by cerebrovascular autoregulation. Transcranial Doppler was used to study the effect of these haemodynamic changes upon brain circulation in children during aortic coarctation repair. METHOD: A 2-MHz transcranial Doppler system continuously recorded mean cerebral blood flow velocities from the left middle cerebral artery in 13 children (aged from 5 days to 14 years) during repair of their coarctation. Measurements were performed: prior to aortic clamping (baseline); during the first 5 min after clamp application; 1 min before declamping; at 1, 2, 4 and 6 min after the release of both proximal and distal aortic clamps; and at initial chest closure. A contralateral upper-limb non-invasive blood pressure cuff measured systemic blood pressures. Haemodynamic and anaesthetic parameters were monitored. Patients were stratified by age into two groups: age < 6 months (group A) and age > 6 months (group B). RESULTS: With aortic clamping, systemic blood pressures (range from: -16 to +54%) and cerebral blood flow velocities (range from -40 to +19%) changed slightly (P > 0.05) from initiation to end of aortic clamping. In group A, release of aortic clamps resulted in moderate fluctuations in systemic blood pressures (range from -34 to +15%) (P > 0.05) and a marked reduction in cerebral blood flow velocities (range from -63 to -33%) (P < 0.01). At the time of surgical closure, flow velocities had improved in all infants except one. Group B did not show major reductions in either cerebral blood flow velocity or systemic blood pressures throughout all measurements (P > 0.05). During aortic clamp release, young infants responded with lower brain blood flow velocities as compared to older children (r = 0.68; P < 0.05). CONCLUSION: Transient central nervous system hypotension results as a consequence of flow redistribution during aortic declamping in young infants. Older children usually show a faster autoregulatory compensation to these haemodynamic changes. The observed age-related physiologic differences, suggest that young infants may require higher systemic blood pressures during declamping to prevent the cerebral blood flow reduction. Transcranial Doppler appears to be a valuable monitor of these cerebral haemodynamic changes.

Low-dose ondansetron with dexamethasone more effectively decreases vomiting after strabismus surgery in children than does high-dose ondansetron.

BACKGROUND: Ondansetron and dexamethasone have been observed to decrease the incidence of vomiting by children after general anesthesia. This study compared the effect of high-dose (150 microg/kg) ondansetron with low-dose (50 microg/kg) ondansetron plus 150 microg/kg dexamethasone on the incidence of vomiting after strabismus in children. METHODS: This study had a double-blind, blocked, stratified, randomized design. With parental consent and Hospital Ethics Committee approval, healthy children aged 2-14 yr who were undergoing elective strabismus surgery were studied. Anesthesia was induced intravenously with propofol or by inhalation with halothane and nitrous oxide. Patients in the high-dose group were given placebo plus 150 microg/kg (maximum dose, 8 mg) of ondansetron intravenously, whereas patients in the low-dose group were given 150 microg/kg dexamethasone (maximum dose, 8 mg) and 50 microg/kg ondansetron intravenously in a double-blind manner. Anesthesia was maintained with halothane and nitrous oxide. All incidences of vomiting occurring as long as 24 h after anesthesia were recorded. RESULTS: Three of the 200 patients enrolled in the study were excluded from data analysis. The groups were similar with respect to demographic data and potential confounding variables. Patients vomited from 0-12 times. The low-dose ondansetron plus dexamethasone group had a lower incidence of vomiting, 9% (95% CI = 4-17%) versus 28% (95% CI = 20-38%; P < 0.001). Only 1% of the patients in the low-dose ondansetron plus dexamethasone group vomited while in the hospital. CONCLUSIONS: Low-dose ondansetron plus dexamethasone is an effective prophylactic antiemetic combination for children undergoing strabismus surgery.

Reducing pain after inguinal hernia repair in children: caudal anesthesia versus ketorolac tromethamine.

BACKGROUND: The optimal method to achieve analgesia after inguinal hernia repair in children is unknown. This study compared the analgesic efficacy, adverse events, and the costs associated with supplementation of local anesthesia (infiltration of the wound) with either intravenous ketorolac or caudal analgesia in children having inguinal hernia repair. METHODS: With parental consent and institutional review board approval, children aged 2-6 yr having elective, outpatient inguinal hernia repair were studied in this randomized, single-blinded investigation. Anesthesia was induced by inhalation with nitrous oxide and halothane or intravenously with propofol. Anesthesia was maintained with nitrous oxide and halothane. Patients were randomly assigned to receive caudal analgesia (1 ml/kg 0.20% bupivacaine with 1/200,000 epinephrine) or intravenous ketorolac (1 mg/kg) immediately after induction of anesthesia. Both groups received field blocks with 0.25% bupivacaine administered by the surgeon under direct vision during operation. Patients were assessed for 24 h. In-hospital pain was assessed using a behavior-based pain score. Parents assessed pain with a visual linear analog pain scale with anchors of 0 (no pain) and 100 (worst pain imaginable). RESULTS: The authors studied 164 children, with 84 patients in the ketorolac group. The groups had similar demographic data. In-hospital analgesic requirements and pain scores were almost identical in both groups. Pain at home was significantly less in the ketorolac group, with visual linear analog pain scale scores of 10 (0-80) compared with 20 (0-80) (median [range]) for ketorolac versus caudal (P = 0.002 by the Mann-Whitney U test). The ketorolac group also had a lower incidence of vomiting, ambulated more rapidly, and micturated earlier (P < 0.05). CONCLUSION: The use of intravenous ketorolac to supplement local anesthesia infiltrated by the surgeon during pediatric inguinal hernia repair is superior to supplementation with caudal analgesia.

Prophylaxis for vomiting by children after tonsillectomy: dexamethasone versus perphenazine.

UNLABELLED: The effects of dexamethasone and perphenazine on vomiting after tonsillectomy in children were compared in 226 healthy children aged 2-12 yr. The study was randomized, stratified, blocked, and double-blind. Anesthesia was induced intravenously (I.V.) with propofol or by inhalation with halothane and N2O. Dexamethasone 150 microg/kg or perphenazine 70 microg/kg was administered I.V. after the induction of anesthesia in a double-blind fashion. Perioperative management of emesis, pain, fluids, and patient discharge was all standardized. The groups had similar demographic characteristics. Perphenazine significantly reduced the incidence of in-hospital vomiting compared with dexamethasone (13% vs 36%, P < 0.001). The incidence of out-of-hospital vomiting was almost identical. Overall, the incidence was significantly different for perphenazine vs dexamethasone (33% vs 46%, P = 0.04) using logistic regression analysis. Of note, sex and induction technique were significant predictors of postoperative vomiting (P < 0.05) using logistic regression analysis, with male patients and those patients undergoing I.V. induction vomiting less. In conclusion, perphenazine more effectively decreases vomiting by children after tonsillectomy in an ambulatory hospital setting compared with dexamethasone. IMPLICATIONS: Postoperative vomiting can have many debilitating effects, and children undergoing tonsillectomy are at particular risk. We compared the effects of dexamethasone and perphenazine on vomiting after tonsillectomy in 266 children. We found perphenazine more effective than dexamethasone before discharge from hospital but that the two drugs have similar effects after discharge.

Vomiting after strabismus surgery in children: ondansetron vs propofol.

PURPOSE: To compare the antiemetic efficacy and costs associated with two anaesthetic regimens in children undergoing strabismus surgery. One regimen contained halothane, nitrous oxide and ondansetron, while the other contained propofol and nitrous oxide. METHODS: Three hundred children aged 2-14 yr undergoing strabismus surgery were enrolled into this single-blind, randomized, stratified, blocked study with a balanced design. Anaesthesia was induced by inhalation with halothane/N2O/O2 (Group O) or with 2.5-3.5 mg.kg-1 propofol + 0.5 mg.kg-1 lidocaine i.v. (Group P). Group O patients were administered 0.15 mg.kg-1 ondansetron (maximum dose 8 mg) i.v. and all patients received atropine 20 micrograms.kg-1 i.v. immediately after induction of anaesthesia. Anaesthesia was maintained with N2O and halothane (Group O) or N2O and propofol (Group P). Patients were followed for 24 hr after their operation primarily to assess the incidence of postoperative vomiting. For each case, the costs of the anaesthetic drugs administered and their associated intravenous administration tubing were determined. Drug costs were those prevailing at the study site at the time of the investigation. Fixed costs, such as the cost of the anaesthetic equipment were not assessed. RESULTS: Groups were similar with respect to demographic data. The incidence of vomiting in both groups was 11% while in-hospital and 23% after discharge. Each episode of in-hospital vomiting prolonged discharge by 17 +/- 4 min, P < 0.001. Mean cost per case for anaesthetic drugs was less in Group O, 18 +/- 8 vs 21 +/- 10, CDN$, mean +/- SD, P < 0.01. CONCLUSION: The two methods of antiemetic prophylaxis were equally effective. Propofol-based anaesthesia was more expensive.

Nitrous oxide does not increase vomiting after dental restorations in children.

The effect of nitrous oxide on postoperative vomiting was evaluated in 330 children who underwent outpatient dental restorations. There were two groups in this single-blind, randomized, controlled study. One group received nitrous oxide during their anesthetic, while the non-nitrous oxide group did not receive nitrous oxide at any time. Anesthesia was induced by inhalation with halothane or with propofol intravenously. The incidence of vomiting for 24 h after surgery was recorded. Overall, the incidence of vomiting was similar, with 30% of the control patients and 35% of the nitrous-treated patients vomiting after their anesthetic. However, in-hospital vomiting was less in the control group: 15% vs 24%, control versus nitrous oxide, P = 0.03. In conclusion, nitrous oxide does not alter postoperative vomiting after halothane anaesthesia for dental restorations in children.

Alfentanil mediated activation of epileptiform activity in the electrocorticogram during resection of epileptogenic foci.

PURPOSE: Alfentanil is a potent, short-acting opioid agent which has been used during balanced anaesthesia in children undergoing the surgical excision of epileptic foci. After the observation that this agent had the potential to induce epileptic seizures, we questioned the frequency of this occurrence in this group of patients. METHOD: Twelve patients (6 males, 6 females) undergoing surgical excision of an epileptic foci were prospectively followed. For each patient an electrocorticogram was recorded for 30 minutes before and after receiving alfentanil 20 micrograms/kg intravenously. The frequency of epileptiform abnormalities before and after drug administration was evaluated. When the electrocorticogram no longer showed the effects of alfentanil administration, methohexital 0.5 microgram/kg was given intravenously. RESULTS: Alfentanil induced significant activation of epileptiform discharges among 83% of these patients. Twenty-five per cent had an electrographic seizure. In comparison, methohexital induced significant activation of epileptiform discharges in 50% of these patients. None experienced electrographic seizures. CONCLUSIONS: As alfentanil can induce electrographic seizures in patients known to have epilepsy, caution is advised in its use in this group of patients.

Removal of the laryngeal mask airway in children: deep anesthesia versus awake.

STUDY OBJECTIVE: To compare the incidence of adverse airway events identified with removal of the laryngeal mask airway (LMA) from an awake child or from a child before his or her airway reflexes had returned. DESIGN: Prospective, randomized study. SETTING: University-affiliated children's hospital. PATIENTS: 333 ASA physical status I and II patients ages 1.5 to 15 years undergoing elective surgery. INTERVENTIONS: At the time of removal of the LMA at the end of surgery, patients were anesthetized or had intact airway reflexes. MEASUREMENTS AND MAIN RESULTS: Any airway problems occurring within 15 minutes of LMA removal were recorded. These problems included airway obstruction (laryngeal spasm and biting of the LMA), peripheral hemoglobin oxygen saturation less than 90%, stridor requiring manipulation of the airway, vomiting, retching, and excessive salivation. Airway problems occurred after LMA removal among 23 children who had their LMA removed prior to return of airway reflexes, and among 13 subjects who had their LMA removed after the return of airway reflexes. CONCLUSION: Removal of the LMA during anesthesia and after return of airway reflexes results in a similar incidence of airway problems in children.