Physostigmine and anaesthesia emergence delirium in preschool children: a randomized blinded trial.

BACKGROUND: A significant proportion of preschool children experiences severe emergence agitation after anaesthesia. The symptoms of disorientation, restlessness, inconsolable crying and thrashing resemble an acute psychosis similar to an agitated central anticholinergic syndrome. The primary aim of this randomized controlled study was to assess the efficiency of the cholinesterase-inhibitor physostigmine in these children and to identify adverse effects. METHODS: We anaesthetized 211 children (1-5 yr) with sevoflurane after midazolam premedication for varying operative procedures. Multimodal intraoperative and prophylactic pain therapy combined alfentanil, piritramide, diclofenac and regional/local bupivacaine. A 5-step score assessed emergence agitation. Severely agitated children were treated immediately with physostigmine (30 mug kg-1) or placebo in a randomized, double-blind fashion. The primary variable was the agitation score after 5 min. RESULTS: Severe delirium occurred in 19% of all children. Five minutes following injection, severe agitation was still present in 10 out of 20 patients treated with physostigmine and 16/20 with placebo. This difference did not reach statistical significance (P = 0.1). Rescue therapy with intravenous propofol was given after 15 min of severe agitation to four children following physostigmine and nine following placebo (non-significant). An increased rate of postoperative nausea and vomiting (45% vs. 15%, P < 0.05) was the only adverse effect observed. CONCLUSIONS: Severe emergence agitation might be related to a central anticholinergic syndrome as diagnosed empirically with a successful treatment with physostigmine. However, the results of this study do not support its routine use. The substance may augment the therapeutic options if injected slowly and after suitable prophylaxis to avoid postoperative nausea and vomiting.

Impact of the Narcotrend Index on propofol consumption and emergence times during total intravenous anaesthesia with propofol and remifentanil in children: a clinical utility study.

BACKGROUND AND OBJECTIVE: The electroencephalographic Narcotrend Index (NI) is a measure of the hypnotic component of general anaesthesia. The purpose of this study was to evaluate the impact of Narcotrend guidance on propofol consumption and emergence times in children receiving total intravenous anaesthesia with propofol and remifentanil. METHODS: Thirty children, aged 1-11 yr, scheduled for paediatric urological surgery were enrolled. Remifentanil was given to all patients at a constant infusion rate of 0.3 microg kg [-1] min[-1] throughout anaesthesia. Patients were randomly allocated to receive a continuous propofol infusion adjusted either according to a conventional clinical practice (Group C: n=15) or guided by Narcotrend monitoring (Group NI: n=15; target NI 60+/-5). All patients were connected to the Narcotrend Monitor, but in Group C the anaesthetist was blinded to the screen of the monitor. Propofol consumption (mg kg[-1]h[-1]) and emergence times (min) were the primary and secondary outcome measures. RESULTS: Propofol consumption (median [inter-quartile range]) was significantly lower in Group NI compared to Group C (NI: 7.0 [6.4--8.2] vs. C: 9.3 [8.3--11.0] mg kg[-1]h[-1]; P<0.001), whereas Log-Rank-analysis revealed no intergroup difference in emergence times (Group NI: mean [95% confidence interval (CI)] 12.8 [11.2--14.4] min; Group C: 16.4 [12.6--20.2] min; P=0.10). Haemodynamic variables remained stable within age-related limits, and there were no observations of adverse events, especially no clinical signs of intraoperative awareness in any patient. CONCLUSION: Narcotrend monitoring for guidance of propofol/remifentanil anaesthesia in children results in reduced propofol consumption compared to a conventional clinical practice.

Severe anaphylactic shock without exanthema in a case of unknown latex allergy and review of the literature.

We describe a case of severe anaphylactic shock without exanthema in an 8-year-old boy who was undergoing elective surgery for an ileostomy. The boy had a history of four anorectal operations in the newborn period, but no history of allergies. Sudden, profound bronchospasm and cardiorespiratory collapse occurred 30 min after the beginning of the operation. No signs of exanthema or urticaria were seen. The patient was resuscitated successfully and remained ventilated for 25 h. During this time, he needed epinephrine in dosages of 0.3-0.05 microg.kg-1.min-1. Radioallergosorbent (RAST) tests for the patient were positive Cap Class 3 and 4, and specific immunoglobulin E was highly positive, suggesting a natural rubber latex allergy as the cause of the anaphylactic shock. Ethylene oxide was negative. Eleven days later, a further operation was performed with a strict latex-free protocol in the presence of histamine 1 and 2 receptor antagonists. On this occasion, the intraoperative course was uneventful. Incidence of anaphylactic reactions, prevalence of latex sensitization, special risk groups and management are discussed.

[Postoperative pulmonary function after lung surgery. Total intravenous anesthesia with propofol in comparison to balanced anesthesia with isoflurane]. / Untersuchungen zur postoperativen Lungenfunktion nach lungenchirurgischen Eingriffen. Total intravenöse Anästhesie mit Propofol im Vergleich zur balanzierten Anästhesie mit Isofluran.

After lung resection, early extubation and the rapid return of the patients ability to cooperate is the predominant goal. Propofol anaesthesia is characterised by rapid awakening and recovery of cognitive and psychomotor functions and is consequently desirable for such operations. Experience so far in lung surgery, however, is limited. Besides the level of consciousness we investigated various spirometric parameters after lung resection. Total intravenous anaesthesia was performed with propofol, while balanced anaesthesia was performed with isoflurane. METHODS. A total of 93 patients evaluated electively for wedge excision or lobectomy were enrolled in an open, prospective, randomised, interindividual comparative study. Sixty-three patients could be evaluated with complete data sets. In the evening and the morning before the operation the patients were premedicated orally with clorazepate 0.5-0.7 mg/kg. Anaesthesia was induced in group 1 with propofol (1.0-2.5 mg/kg) and maintained with propofol (4-12 mg/kg) in 50% O2/air. The patients in group 2 received methohexital (1-2 mg/kg) for induction and isoflurane (0.4-2.0 vol%) in 50% O2/air for the maintenance of general anaesthesia. In both groups analgesia was achieved by using fentanyl (up to 10 micrograms/kg) and muscle relaxation by using atracurium. Psychomotor tests (minimal mental state, reaction time) were performed the day before the operation (t1), immediately prior to induction of anaesthesia (t2) and 5 min, 30 min, 60 min, 90 min, 24 h, and 7 days after extubation (t3-t8). Spirometry (forced expiratory volume in 1 s, FEV1; forced vital capacity, FVC; peak expiratory flow, PEF) was carried out at times t1, t2 and t5-t8. RESULTS. The two groups were comparable regarding preoperative status (age, sex, preoperative risk score, psychomotor tests, and spirometric values) and the operation performed (wedge excision/lobectomy, duration of anaesthesia). The extubation time was slightly shorter in the propofol group (18 +/- 8 min) than in the isoflurane group (20 +/- 6 min). Also, the results of the psychomotor tests were somewhat better in the propofol group than those in the isoflurane group. The clearest differences were found in the early postoperative period, but not all differences were significant. Statistically highly significant differences between the two groups were found for the three spirometric parameters. Based on the FEV1 value of the 7th postoperative day, FEV1 taken 60 min after extubation declined by 27.9% in the propofol group vs. 51.7% in the isoflurane group (P = 0.01). At 90 min after extubation the corresponding decline in the propofol group was 26.6%, in the isoflurane group 51.1% (P = 0.003). In addition, the decline of FVC and PEF measured 60 min and 90 min after extubation was significantly smaller in the propofol group than in the isoflurane group. CONCLUSION. The postoperative impairment of lung function after lung resection under propofol anaesthesia is statistically significantly smaller than under isoflurane anaesthesia. Total intravenous anaesthesia with propofol is particularly suitable for this kind of operation.