Epidural analgesia in children with cerebral palsy.

PURPOSE: Two modalities of epidural analgesia in children with two types of cerebral palsy (CP) were compared for differences in the incidence of common complications (inadequate analgesia, hypopnea, hypoxaemia, sedation, vomiting, pruritus, urinary retention, and seizures). METHODS: Demographic, procedural and postoperative complication data were collected on children with CP receiving epidural analgesia. Information was recorded contemporaneously with the child's care by one of the authors on 92 consecutive children with CP (age, 107 +/- 50.1 mo; weight, 26 +/- 14.2 kg) who had undergone infra-umbilical orthopaedic or Nissen fundoplication procedures between December 1994 and December 1996. The first 44 patients received intermittent bolus (IB) epidural morphine and the next 48 received continuous infusion (CI) bupivacaine and fentanyl. Two forms of CP (spastic diplegia and quadriplegia) and the two modalities of analgesia were compared. RESULTS: Excellent analgesia was obtained in 91/92 patients. Excessive sedation occurred in six patients (6.5%) but only in IB patients, (P < 0.02 vs CI). Emesis occurred in 52% of patients, and was more common in diplegic than in quadriplegic patients (68% vs 38%, P < 0.01). Pruritus was observed in 29% of patients and was more common in diplegia than quadriplegia (48% vs 12.5%, P < 0.001). The incidences of hypopnea, hypoxaemia, urinary retention and seizures were not affected by the types of CP or analgesia and no difference in sedation was observed between spastic diplegic and quadriplegic patients. CONCLUSIONS: Continuous infusion of epidural bupivacaine and fentanyl provided excellent analgesia for children with CP without serious complications. Intermittent bolus epidural morphine was associated with a high incidence of excessive sedation and should be avoided in this population.

Analgesia for venepuncture in a paediatric surgery centre.

OBJECTIVE: To establish an effective and efficient method of painless venepuncture in children 8 years and older in an ambulatory paediatric surgery centre. METHODOLOGY: Sixty patients aged 8-21 years were randomized to one of three groups: (i) nitrous oxide with EMLA cream; (ii) nitrous oxide with intradermal lidocaine; and (iii) nitrous oxide alone (n = 20 in each group). Patients in all three groups received oral midazolam for pre-operative anxiolysis. The degree of patient sedation and anxiolysis was noted by two observers before and 2 min after the administration of 50% nitrous oxide. The patient's response to venepuncture or intradermal lidocaine was rated by the two observers using an Observer Response Score. After successful venepuncture, the nitrous oxide was discontinued and the patient was asked to rate the pain of venepuncture using a Patient Response Score. RESULTS: There were no differences in the degree of sedation and anxiolysis between the three groups before or after the administration of nitrous oxide. Patients in the control group (nitrous oxide alone) had a higher incidence of withdrawal or vocalization with venepuncture. When the patients rated the pain of venepuncture, there were no differences between the three groups. CONCLUSIONS: Oral midazolam in combination with 50% nitrous oxide provides adequate analgesia and anxiolysis for venepuncture in patients 8 years and older. The addition of EMLA cream or intradermal lidocaine will decrease the likelihood of patient movement.

Physiological effects of liver packing.

Liver packing for the control of hepatic hemorrhage may compromise patients' hemodynamics and oxygenation. We present two cases where there was physiologic improvement upon removal of the liver packs.

Anaesthetic considerations for the patient with cri du chat syndrome.

Cri du chat syndrome is an inherited disease affecting multiple organ systems. Most characteristic is the anatomical abnormality of the larynx resulting in a cat-like cry. Issues important in developing an anaesthetic plan include: anatomical abnormalities of the airway, congenital heart disease, hypotonia, mental retardation, and temperature maintenance. We report the case of a 33-month-old patient with cri du chat syndrome undergoing patent ductus arteriosus (PDA) ligation and discuss the anaesthetic issues.