Postoperative comfort in paediatric outpatient surgery.

Postoperative conditions in hospital and at home were evaluated in 200 paediatric daycase patients by using questionnaires and telephone interviews. Pain was assessed by behaviour observation or a faces rating scale depending on age. Anaesthetic methods, nausea/vomiting, analgesics and parents' aspects were also recorded. Seventy per cent of the patients received regional anaesthesia. Immediate postoperative analgesia was satisfactory in 75% of the children. When the effects of intraoperatively administered analgesics wore off at home almost half the children rated higher than mild pain. The increased degree of pain at home was especially pronounced after regional anaesthesia. The total incidence of nausea/vomiting was 28% and fentanyl caused nausea and vomiting in a significantly higher proportion of cases. The study points out that immediate postoperative comfort obtained by prophylactic analgesia needs to be followed by analgesics given on a continuous basis for the first days after surgery.

Postoperative nausea and vomiting in children using patient-controlled analgesia: the effect of prophylactic intravenous dixyrazine.

BACKGROUND: Although patient-controlled analgesia (PCA) with morphine provides a high degree of satisfactory postoperative analgesia in children, it is often associated with a high incidence of postoperative nausea and vomiting (PONV). Our aim in this study was to evaluate the prophylactic effect of dixyrazine, a phenothiazine with proven anti-emetic properties. METHODS: The incidence of nausea and vomiting was studied in 60 children using PCA after major surgery. The patients were randomised to receive either dixyrazine 0.25 mg kg-1 or placebo on the induction of anaesthesia in a double-blind, placebo-controlled design. The anaesthetic technique was standardised. The PCA pump was programmed to deliver bolus doses of morphine of 20 micrograms kg-1 with a continuous background infusion of 8-10 micrograms kg-1 h-1. Nausea, vomiting, sedation and pain scores were noted every 3 h for a period of 24 h. RESULTS: The morphine consumption of morphine was the same in both groups. During the stay in the recovery room the incidence of vomiting was 3% in the dixyrazine group compared to 30% in the placebo group (P < 0.05). On the ward, 57% versus 83% of the children vomited (P < 0.05). Rescue antiemetics were significantly lower, 30%, in the dixyrazine group compared to 60% in the placebo group (P < 0.05). Higher sedation scores were recorded for the dixyrazine group in the recovery room. No other adverse effects were found. CONCLUSION: A significant number of children using PCA with morphine after major surgery experience PONV. Although prophylactic dixyrazine reduces the incidence and severity of vomiting, the incidence still remains high.

Birth asphyxia: incidence, clinical course and outcome in a Swedish population.

A total of 42,203 live infants were born in Göteborg in 1985-1991, and 292 term infants had Apgar scores < 7 at 5 min. Infants with congenital malformations, infections and opioid-induced respiratory depression were excluded and thus 227 infants were included in the birth asphyxia group, which formed the basis of this retrospective study. Clinical signs of mild, moderate or severe hypoxic-ischemic encephalopathy (HIE) were present in 65 infants, and in another 10 infants, sedated and on controlled ventilation, HIE was assumed but grading was not possible. The incidences of Apgar scores < 7 at 5 min, birth asphyxia and birth asphyxia with HIE were 6.9, 5.4 and 1.8 per 1,000 live born infants: 95% of infants resuscitated with bag and mask ventilation only, did well, compared with 1 of 11 in whom resuscitation included adrenaline. Seizures occurred in 27 of 227 infants, beginning in 18 infants within 12 h of birth. Small-for-gestational-age (SGA) infants were overrepresented in the birth asphyxia group but not in the birth asphyxia-HIE group. All infants with severe HIE died or developed neurological damage. Half of the infants with moderate, and all of the infants with mild, HIE were reported to be normal at 18 months of age. A total of 0.3 per 1,000 live born infants died and 0.2 per 1,000 developed a neurological disability related to birth asphyxia. The disabilities were dyskinetic (4), tetraplegic (2), spastic diplegic (2), cerebral palsy and mild neuromotor dysfunction (1). The relatively low incidences of birth asphyxia and HIE were probably due to effective antenatal care.

Neuron specific enolase in asphyxiated newborns: association with encephalopathy and cerebral function monitor trace.

Neuron specific enolase (NSE) in serum and cerebrospinal fluid (CSF) and glutamate in CSF were investigated in the immediate postasphyctic period in 22 term newborn infants. The cerebral function monitor (CFM) pattern was also assessed and hypoxic-ischaemic encephalopathy (HIE) was graded. NSE was significantly increased in the CSF of infants with HIE (median value 25.4 micrograms/l) compared with control infants (10.0 micrograms/l). Infants with the highest concentrations died. NSE in CSF correlated with the degree of asphyxial damage. Glutamate and NSE in CSF did not correlate, presumably due to the different time factors of the release after the insult. NSE in CSF corresponded well with the type of CFM pattern, which was also highly predictive of outcome.

Cerebral function monitoring: a method of predicting outcome in term neonates after severe perinatal asphyxia.

The cerebral function monitor (CFM), a simplified one-channel EEG monitor, was evaluated in predicting outcome after severe perinatal asphyxia in 38 term infants. Survivors were followed until 1.5-2.5 years of age. All those 17 infants who survived without major neurological handicap showed continuous activity on the CFM trace during the first and/or second day of life. Twenty of the 21 infants who either died or developed severe neurological damage had burst suppression or paroxysmal activity on the first or second day of life. Thus cerebral function monitoring can be a valuable tool in predicting prognosis for infants with severe perinatal asphyxia.

Excitatory amino acids in the cerebrospinal fluid of asphyxiated infants: relationship to hypoxic-ischemic encephalopathy.

Asphyxiated (n = 27) and control infants (n = 25) were subjected to spinal taps. Amino acids were measured with liquid chromatography and the degree of hypoxic-ischemic encephalopathy was determined in each case. In asphyxiated infants, the concentrations of aspartate and glutamate were 286% and 387% (p < or = 0.01 and p < or = 0.05) of the control values, respectively. The cerebrospinal fluid aspartate levels were significantly (p < or = 0.05) higher in the group with severe (3.4 mumol/l) compared with the group with mild hypoxic-ischemic encephalopathy (1.0 mumol/l). Glutamate was also higher in the group with severe (12.3 mumol/l) than in the groups with mild (2.7 mumol/l) or moderate (3.2 mumol/l) hypoxic-ischemic encephalopathy (p < or = 0.05). High concentrations of excitatory amino acids were present in the CSF of asphyxiated infants which may exert excitotoxic effects.

Characterization of the serum antibody response to the capsular polysaccharide of Haemophilus influenzae type b in children with invasive infections.

The serum antibody response to the capsular polysaccharide of Haemophilus influenzae type b (Hib) was studied in 30 children aged 1 day-5 years with invasive Hib infections. From each child, serum was obtained 0-2 days, 5-11 days, 1 month, and 6-12 months after onset of symptoms. Total antibodies were determined with RIA and isotypes with ELISA. Only 2 children had antibody levels above the estimated protective level (0.15 microgram/mL) in the first serum sample. The antibody response was age dependent with wide individual variations. Children > or = 2 years had increases in IgG, IgM, and IgA antibodies with predominance of IgG. The initial IgG response was IgG1 and IgG2 with predominance of IgG1. In the last serum sample, IgG1 antibodies had decreased while IgG2 antibodies remained unchanged. Only 2 of 7 children < 1 year had a detectable antibody response. The correlation coefficient for total antibodies compared with the sum of IgG, IgM, and IgA was .88 (P < .0001) and for IgG compared with the sum of IgG1 and IgG2 was .97 (P < .0001).

Normal pattern of the cerebral function monitor trace in term and preterm neonates.

Cerebral Function Monitor (CFM) recordings were performed on 10 term and 19 preterm healthy infants. Term infants were monitored once, while preterm infants were followed serially. Forty-six recordings were made on 7, 14, 16 and 9 occasions in the age groups 30-31, 32-33, 34-35 and 36-37 weeks. All infants were examined clinically at 18 months of age and found healthy. By drawing weighted lines derived from the lower and upper limits of the CFM traces, mean values of minimum and maximum cerebral activity were calculated for the different age groups. In the term infants different CFM traces were identified corresponding to quiet sleep and active sleep. In the preterm infants a similar cyclic variability of the CFM trace was noted. A gradual increase in the minimum cerebral activity was found with increasing gestational age, resulting in a gradual narrowing of the trace.