Generalized tonic-clonic activity after remifentanil administration.

IMPLICATIONS: This is the first report of seizure-like activity in an adult who received remifentanil. This report confirms that opioid administration can be associated with generalized tonic-clonic seizure-like activity. It is suggested that this reaction could be referred to as the "opioid-seizure syndrome."

Anesthesia and analgesia for newborn circumcision.

Newborn circumcision is likely the most common elective surgical procedure performed in children, yet a sizable portion of these procedures is performed without anesthesia or analgesia. This review discusses methods and techniques of analgesia and anesthesia for newborn circumcision. Behavioral, pharmacological, and regional block techniques are described. Ideally, the use of a combination of local anesthesia and behavioral techniques are most beneficial to newborns that undergo this painful procedure.

Paediatric anaesthesia outside the operating room.

Anaesthesiologists are regularly consulted to provide anaesthesia for children in settings other than an operating room. Current debate focuses on the appropriateness of the presence of an anaesthesiologist versus a non-anaesthesiologist. There is mounting evidence that the presence of an anaesthesiologist is safer. We will review the recent literature concerning paediatric anaesthesia outside the operating room and offer recommendations that may impact on efficacy and safety.

Anesthesia for tracheal or bronchial foreign body removal in children: an analysis of ninety-four cases.

IMPLICATIONS: This report is a description of the ventilation techniques used in 94 children undergoing general anesthesia for foreign body removal of the bronchus. No particular technique was found to be associated with a greater incidence of adverse outcomes.

Conscious sedation with remifentanil during painful medical procedures.

Remifentanil, a recently introduced ultra-short acting opioid, was used as a component of a conscious sedation technique in 30 patients for 40 painful medical procedures. In 31 of these procedures, remifentanil provided sufficient analgesia. However, 25 of those 31 patients developed apnea that required constant verbal stimulation at doses equal to or less than the dose required for analgesia. Ten of these apneic patients developed hypoxemia (oxyhemoglobin saturation less than 90%). Nine patients required abandonment of remifentanil and addition of either ketamine or propofol to achieve an analgesic state without respiratory depression. Although discharge times with remifentanil were considerably shorter, most patients, parents, and practitioners were not satisfied with the technique because of the prolonged time to reach an analgesic state, and their fear of persistent apnea. Therefore, remifentanil is generally not a useful agent as part of a conscious sedation technique during brief painful procedures. Although discharge times are rapid, it is accompanied by a high incidence of life-threatening respiratory depression at subtherapeutic levels.

Conscious sedation with remifentanil and midazolam during brief painful procedures in children.

OBJECTIVE: To test the hypothesis that remifentanil, because of its favorable pharmacokinetic properties, would be advantageous to use in combination with midazolam to provide analgesia and sedation during brief painful procedures. DESIGN: Prospective observation and data collection. SETTING: University hospital. PATIENTS: Seventeen children aged 2 to 12 years, who underwent 20 brief, painful procedures. INTERVENTIONS: Administration of intravenous midazolam hydrochloride, 0.05 mg/kg, and remifentanil hydrochloride, 1 microg/kg, followed by a remifentanil infusion at 0.1 microg x kg(-1) x min(-1). The dose was titrated at 5-minute intervals to levels of sedation and analgesia. MAIN OUTCOME MEASURES: Successful remifentanil doses, times to discharge readiness, side effects, complications, and requirement for additional medications. RESULTS: The technique was successful in 17 of 20 procedures. The mean +/- SD successful dose was 0.4 +/- 0.2 microg x kg(-1) x min(-1). Four children developed hypoxemia that abated with mild stimulation; 1 child became unresponsive and required positive-pressure ventilation. The mean +/- SD time to reach discharge criteria was 9.5 +/- 4.3 minutes. Hypoxemia was avoided in 10 of 13 patients by continuous stimulation throughout the procedure. CONCLUSION: The use of remifentanil and midazolam during brief, painful procedures results in rapid times to discharge but is complicated by a high incidence of life-threatening respiratory depression at subtherapeutic levels.

Psychogenic stridor: a cause of acute upper airway obstruction.

A 17-year-old boy was seen in the emergency department with signs and symptoms of acute upper airway obstruction, closely resembling epiglottitis. Immediate management consisted of induction of general anesthesia with spontaneous ventilation. Because no organic pathologic process was found, and in combination with subsequently known psychosocial stressors, a diagnosis of psychogenic stridor, a conversion disorder, was made. Conversion disorders may be seen by the busy family practitioner or pediatrician and are frequently underdiagnosed.

Sedation and anesthesia outside the operating room: answers to common questions.

In recent years, practitioners have recognized the importance of providing comfort to children and have increased their use of analgesics and anxiolytics during painful medical procedures. In this article, the author reviews commonly asked questions regarding administering sedation to children for painful procedures outside the operating room. Current safety guidelines are reviewed, as well as qualifications of personnel performing sedations, contraindications to sedation, fasting guidelines before sedation, and common sedation techniques.

Upper airway obstruction during midazolam/nitrous oxide sedation in children with enlarged tonsils.

PURPOSE: The purpose of this nonrandomized, case-control study was to examine the incidence and severity of upper airway obstruction (UAO) in children with enlarged tonsils during inhalation of nitrous oxide (N2O). METHODS: Following premedication with oral midazolam, 0.5 mg/kg, measurements were collected during a 3-minute control period followed by 3 minutes of breathing 50% N2O in oxygen. An unblinded anesthesiologist held a facemask over the child's mouth and nose without supporting the head or neck, or attempting to maintain airway patency. Every 20 seconds, the degree of airway obstruction was graded as none, partial, or complete. Twenty-five children presenting for tonsillectomy and 25 controls without enlarged tonsils participated. RESULTS: During 50% N2O inhalation, 14 children (56%) in the tonsillectomy group, and four children (16%) in the control group demonstrated partial UAO. One child in the tonsillectomy group with partial UAO developed hypoxemia (SpO2 72%). One child in the tonsil group developed complete UAO during inhalation of 50% N2O. CONCLUSION: Children who receive sedation with oral midazolam and 50% N2O inhalation may exhibit significant UAO, especially in the presence of enlarged tonsils. Presedation physical exams should evaluate the presence of tonsil size during examination of the mouth and airway.

Chloral hydrate sedation: the additive sedative and respiratory depressant effects of nitrous oxide.

UNLABELLED: The combination of chloral hydrate and nitrous oxide (N2O) is often used for sedation in pediatric dentistry. The purpose of this study was to determine the extent to which N2O increases the level of sedation and respiratory depression in children sedated with chloral hydrate. Thirty-two children, 1-9 yr, received chloral hydrate, 70 mg/kg (maximum 1.5 g), and then received N2O (30% and 50%). Hypoventilation (maximal PETCO2 > 45 mm Hg) occurred in 23 (77%) children during administration of chloral hydrate alone, in 29 (94%) breathing 30% N2O (P = 0.08 versus control), and in 29 (97%) breathing 50% N2O (P = 0.05 versus control). Mean PETCO2 was increased during 30% (P = 0.007) and 50% (P = 0.02) N2O administration. Using chloral hydrate alone, 8 (25%) children were not sedated, 10 (31%) were consciously sedated, and 14 (44%) were deeply sedated. Using 30% N2O, 2 children (6%) were not sedated, 0 were consciously sedated, and 29 (94%) were deeply sedated (P < 0.0001). Using 50% N2O, 1 child (3%) was not sedated, 0 were consciously sedated, 27 (94%) were deeply sedated, and 1 (3%) had no response to a painful stimulus (P < 0.0001). We conclude that the addition of 30% or 50% N2O to chloral hydrate often causes decreases in ventilation and usually results in deep, not conscious, sedation in children. IMPLICATIONS: Pediatric sedation in the dental office often consists of nitrous oxide (N2O) after chloral hydrate premedication. We found that the addition of 30% or 50% N2O to chloral hydrate often causes decreases in ventilation and usually results in deep, not conscious, sedation in children.

Breathing patterns and levels of consciousness in children during administration of nitrous oxide after oral midazolam premedication.

PURPOSE: The combination of midazolam and nitrous oxide is commonly used to achieve sedation and analgesia during pediatric oral procedures, yet there are few, if any, data that illustrate the ventilatory effects of N2O in children, especially when used in combination with additional central nervous system (CNS) depressants. It was hypothesized that the addition of N2O inhalation to oral midazolam premedication would enhance the sedative effects of the midazolam and add analgesia without causing significant respiratory depression. The purpose of this study was to test this hypothesis. MATERIALS AND METHODS: Thirty-four healthy children about to undergo restorative dental treatment under general anesthesia were premedicated with oral midazolam, 0.7 mg/kg, and were then exposed to 40% N2O for 15 minutes after a 5-minute control period. The effect of adding N2O on SpO2, respiratory rate, PETCO2, VT, and VT/TI was examined and the levels of consciousness (conscious vs deep sedation) before and during N2O inhalation were determined. RESULTS: During the course of the study, no child developed hypoxemia (SpO2 < 92%) nor clinically significant upper airway obstruction. Four children who did not develop hypoventilation (defined as PETCO2 > 45 mm Hg) during the control period did so after initiation of N2O. Overall, there were no significant differences in SpO2, PETCO2, VT, or VT/TI between the control and study periods. However, respiratory rates were significantly higher in the first 10 minutes of N2O inhalation when compared with the control period. Before starting N2O administration, 14 children were not clinically sedated, 19 children met the criteria for conscious sedation, and one child met the criteria for deep sedation. At the end of 15 minutes of N2O inhalation, 12 children were not clinically sedated, 17 children met the definition of conscious sedation, three were deeply sedated, and one child had no response to IV insertion, implying a state of general anesthesia. There were no differences in sedation scores between the control and study periods (P = .6). Overall, seven children had an increase in their sedation score while breathing N2O, four had a decrease in their sedation score, and 22 had no change. CONCLUSIONS: The addition of 40% N2O to oral midazolam, 0.7 mg/kg, did not result in clinically meaningful respiratory depression nor upper airway obstruction, but did, in some children, cause an increase in the level of sedation beyond simple conscious sedation.

Cardiac arrest after esmolol administration: a review of acute beta-blocker toxicity.

An 11-year-old, 25-kg girl with congenital myelomeningocele was scheduled for posterior spinal fusion because of progressive scoliosis. After induction of general anesthesia and administration of a standard dose of intravenous esmolol hydrochloride, her cardiac rhythm progressed to asystole. Although given ephedrine, epinephrine, and atropine sulfate, the patient's normal heart rhythm could not be restored until calcium chloride was administered. A review of the medical literature indicates that the optimal treatment for acute beta-blocker toxicity is intravenous glucagon. Calcium administration should also be considered. Acute esmolol toxicity may be self-limiting because of its extremely short half-life.

Two cases of bilateral congenital cholesteatoma--usual and unusual presentations.

Bilateral congenital cholesteatomas are rare. We present the 8th and 9th case of this entity in the literature. One of these cases is especially unusual. In that patient an ear that had been documented as normal, both radiographically and clinically, was found to have a large cholesteatoma 18 months after the contralateral ear had been treated for the same disease. The theories of the pathogenesis of this entity are also reviewed. Our cases support several of these theories. In fact, in one of the patients, it is possible that a different etiology was involved in each ear. Incidental note is made of the fact that three of the nine reported cases of bilateral congenital cholesteatoma have occurred in the same geographic locale.

Levels of consciousness and ventilatory parameters in young children during sedation with oral midazolam and nitrous oxide.

OBJECTIVE: To determine the ventilatory effects and levels of consciousness achieved during sedation with the combination of oral midazolam and inhaled nitrous oxide. DESIGN: Case series. SETTING: Surgical suite. PATIENTS: Twenty-two consecutive children, aged 1 to 3 years, were seen for elective, ambulatory surgery. INTERVENTIONS: Patients were premedicated with oral midazolam hydrochloride, 0.5 mg/kg, and then breathed 4 concentrations of nitrous oxide (N2O) in oxygen (15%, 30%, 45%, and 60%) for 4 minutes at each concentration prior to induction of general anesthesia. MAIN OUTCOME MEASURES: Levels of consciousness (conscious vs deep sedation) and ventilatory parameters: respiratory rate, end-tidal carbon dioxide tension (PETCO2), and oxyhemoglobin saturation (SPO2). Upper airway obstruction was diagnosed by clinical assessment by an experienced pediatric anesthesiologist (R.S.L.) and respiratory impedance plethysmography. RESULTS: During inhalation of N2O, 12 of the 20 children demonstrated a mild degree of ventilatory depression; PETCO2 values were equal to or greater than 45 mm Hg during at least 2 concentrations of N2O studied. There were no significant changes in SPO2 or PETCO2 with increasing concentrations of N2O (P > .05). Respiratory rates tended to be lower during inhalation of 15% N2O than at higher concentrations (P = .05). No child developed upper airway obstruction or hypoxemia (SPO2 < 92%) at any level of N2O inhalation. Sedation scores were significantly higher at 60% N2O than at all other concentrations of N2O (P < .02) At 15% N2O, 12 children were not clinically sedated, 8 children met the American Academy of Pediatrics definition of conscious sedation, and no child met the definition of deep sedation. At 30% N2O, 10 children were not clinically sedated, 9 met the definition of conscious sedation, and 1 child met the definition of deep sedation. At 45% N2O, 9 children were not clinically sedated, 9 met the definition of conscious sedation, and 2 met the definition of deep sedation. At 60% N2O, 6 children were not clinically sedated, 6 met the definition of conscious sedation, 6 met the definition of deep sedation, and 1 child progressed to a deeper level of sedation in that there was no response to a painful stimulus. One child was withdrawn from the study during inhalation of 45% N2O because of emesis. CONCLUSIONS: The combination of oral midazolam, 0.5 mg/kg, and up to 60% inhaled N2O caused mild ventilatory depression in some children and resulted in a progression from conscious to deep sedation beginning at 30% N2O. When using this particular combination of sedatives, practitioners should monitor each child's mental status continuously and adhere to the appropriate published guidelines for the monitoring and management of such patients.

Recent trends in the management of acute pain in children.

The author provides practitioners with a summary of recent trends in the management of acute pain in children. This review encompasses pharmacologic techniques as they pertain to two common acutely painful conditions in children: postoperative and procedural pain. In the area of postoperative analgesia, reviewed are the use of regional anesthesia, spinal opioids, alpha-agonists, preemptive analgesia, and patient-controlled analgesia. In the area of procedural pain, current standards for safety guidelines and several recently introduced sedative and analgesic medications are discussed. The author emphasizes that the proper and safe alleviation of acute pain in the pediatric population is not only feasible but is currently the standard of care in the United States.