Emergence characteristics of sevoflurane compared to halothane in pediatric patients undergoing bilateral pressure equalization tube insertion.

STUDY OBJECTIVE: To compare the emergence characteristics of sevoflurane with halothane in pediatric patients having bilateral myringotomy and pressure equalization tube insertion using a highly standardized and common anesthetic technique. DESIGN: Prospective, randomized, double-blind study. SETTING: University hospital. PATIENTS: 43 ASA physical status I and II healthy pediatric outpatients scheduled for initial ear tube placement by one surgeon. INTERVENTIONS: Patients were randomized to receive either halothane or sevoflurane as their sole anesthetic drug for ear tube insertion. All patients as well as the research nurse grading emergence agitation were blinded to group assignment. No premedication was administered, and all patients received a standard dose of rectal acetaminophen for postoperative pain control. MEASUREMENT AND MAIN RESULTS: The primary outcome was the percentage of patients with emergence agitation, defined as thrashing behavior requiring physical restraint for greater than three minutes. Time to discharge from the postanesthesia care unit (PACU) and from the hospital were also compared. Sevoflurane patients had a greater incidence of emergence delirium: 57% versus 27% [95% CI (1.7%-58.1%) p = 0.047]. Time to discharge from the PACU and the hospital were longer for patients who received sevoflurane: 62 versus 50 min [95% CI (1.4-23.6) p = 0.02] and 102 versus 79 mins [95% CI (9.6-37.1) p = 0.003]. CONCLUSION: In our institution there is a trend toward greater emergence agitation in ear tube placement patients given sevoflurane versus halothane anesthesia. Further, (with our discharge criteria) patients are actually discharged from the PACU and the hospital faster when given halothane as a sole anesthetic when compared to sevoflurane.

Parental presence plus oral midazolam decreases frequency of 5% halothane inductions in children.

STUDY OBJECTIVE: To determine the frequency of 5% halothane induction and behavioral distress during inhalation induction with both oral midazolam and parental presence compared with parental presence alone. DESIGN: Randomized, controlled, double blind study. SETTING: Same day anesthesia at a university department of anesthesiology. PATIENTS: 72 ASA status I and II children, 3 to 10 years of age, scheduled for first time anesthesia. INTERVENTIONS: Children were assigned to one of two groups to receive midazolam 0.5 mg/kg orally or placebo. A parent was present during induction. Children were videotaped at baseline, after treatment, and during induction. Tapes were scored for behavioral distress using the revised Observational Scale of Behavioral Distress. MEASUREMENTS AND MAIN RESULTS: Children who received midazolam in the setting of parental presence had significantly fewer 5% halothane inductions than those who received placebo (p < 0.02). They also had less behavioral distress (p < 0.01). CONCLUSIONS: The combination of parental presence plus oral midazolam reduces the likelihood of needing a 5% rapid halothane induction when compared with parental presence without premedication.

Repatriation of 150,000 sudanese refugees from ethiopia: the manipulation of civilians in a situation of civil conflict.

This paper outlines the dramatic return to Sudan of 150,000 men, women and children from Itang Refugee Camp in Ethiopia in June 1991. These people were pawns in Sudan's civil war, manipulated by governments, military forces and the media - a state of affairs that the international community failed to deal with effectively. At the time of the return to Sudan, ICRC and the United Nations were working to assist the returnees in two different areas and each had a different access agreement and thus a different impact on the survival of the returnees. The paper focuses on the role of political awareness and negotiation in the protection of refugees and in the organisation of relief in the context of a civil war.

Meena -- her perspective on "EPI Plus".

PIP: The mean age at marriage in Bangladesh with a population of 110 million has increased from 13 to 1931 to 18 in 1992. Yet 80% of women give birth during their teens. 80% live in the countryside, only 35% complete primary school, and only 22% of women are literate (44% of men). By 1990, girls primary school attendance increased to 45% from 31% in 1970. Between 1960 and 1990 per capita calorie consumption had declined from 2300 calories/day. Maternal mortality was 600/100,000 live births. The projection of a population of 220 million people by 2025 could result in even more dire health prospects for these women. Since independence in 1971, family planning (FP) using paramedics has expanded in rural areas. Nongovernmental organizations supported urban efforts by promoting pills and condoms under the largest social marketing project. The contraceptive prevalence rate (CPR) increased to 40% by 1991, and the average number of children dropped from 7 in 1971 to 4 in 1990. The main components of child survival are breast feeding, oral rehydration therapy (ORT), and immunization. 300,000 children die annually from diarrhea, but ORT use has surged in recent years curtailing expected deaths in the wake of the 1988 and 1991 natural disasters. In 1991, immunization coverage reached 85% from under 5% in 1985. The expanded program of immunization (EPI) also integrated FP in pilot upazilas (districts) with a simultaneous increase of both CPR and EPI coverage resulting in improved child survival. There are 100,000 EPI outreaches contracting 80% of mothers with FP counseling, iron supplementation, screening risk delivery, vitamin A supplementation, oral rehydration solution distribution, and nutritional counseling. 3 phases of the classical demographic transition have taken place in Bangladesh but the population will keep increasing until stability is reached with fertility and mortality in balance that EPI and FP can help ensure.^ieng

Health implications of war in Uganda and Sudan.

Civil war disrupted agriculture and trade in Uganda and Sudan. This reduced tax revenues and drained scarce resources away from health budgets to finance increased military expenditures. Hundreds and thousands of people were driven from their homes either as internally displaced people or as refugees. Normal health service delivery systems were broken down forcing doctors, nurses and other health professionals into towns, cities or neighbouring countries in search of peace and employment. Scores of hospitals, health centres and dispensaries were abandoned, destroyed or looted, rendering even the limited physical facilities useless. Preventive public health services such as immunization and provision of potable drinking water were discontinued leaving huge populations susceptible to controllable infectious diseases and epidemics.

Health implications of war in Uganda and Sudan

Civil war disrupted agriculture and trade in Uganda and Sudan. This reduced tax revenues and drained scarce resources away from health budgets to finance increased military expenditures. Hundreds and thousands of people were driven from their homes either as internally displaced people or as refugees. Normal health service delivery systems were broken down forcing doctors; nurses and other health professionals into towns; cities or neighbouring countries in search of peace and employment. Scores of hospitals; health centres and dispensaries were abandoned; destroyed or looted; rendering even the limited physical facilities useless. Preventive public health services such as immunization and provision of potable drinking water were discontinued leaving huge populations susceptible to controllable infectious diseases and epidemics

Effect of cimetidine on biotransformation of enflurane in man.

This study was designed to test the hypothesis that administration of clinical doses of cimetidine could affect the metabolic degradation of enflurane to inorganic fluoride via inhibition of the mixed function oxidase enzyme (MFOE) system. In Part 1 of the study 38 female patients undergoing gynaecologic surgery received, double blind, either cimetidine, 300 mg PO the night prior to surgery and 300 mg IV 30 minutes prior to anaesthesia induction or a placebo. In Part 2, 24 patients received either cimetidine as in Part 1, but with continued administration for 24 hours into the postoperative period, or a placebo. Anaesthesia in all cases was with enflurane in oxygen, via a closed circuit. In both Parts 1 and 2 of the study there were no statistically significant differences between the two groups in serum fluoride levels at baseline, four hours or 24 hours postoperatively, or in the total urinary fluoride excretion during the first or second postoperative days. The authors speculate that this is due either to separate interactions of cimetidine and enflurane with the MFOE system or to the relatively low rate of enflurane metabolism.

Uganda--rehabilitation, or redefinition of health services?

Uganda had one of the best health care delivery systems in Africa. The decade of misrule by Amin saw a collapse of the country and an exodus of doctors and other professions. The 1979 liberation war and subsequent political instability and insecurity further aggravated the poor health services then available. When political stability was temporarily restored in December 1980 the cash crop export sector took priority over social services and the health budget declined to only 3.5% compared to a former level of 7.5% of government budget. Emergencies in West Nile, Karamoja and the Luwero triangle continued to plague rehabilitation efforts upto 1985. Alternate strategies for improving health are proposed including female education, increased budget allocations, food and nutrition policy and health information. Uganda's prospect for rebuilding the health services has begun with immunization, control of diarrhoeal diseases, nutrition surveillance in Karamoja and an essential drugs programme, but the success of these is dependent upon political stability and improvement in overall security.