RESUMO
OBJECTIVE: This study was designed to evaluate the effect of low-dose ketamine infusion on the perioperative consumption of opioids in pediatric open cardiac surgery. DESIGN: A randomized, controlled, double-blinded single-center study was conducted. SETTING: The study took place in a tertiary care children's hospital. PARTICIPANTS: Patients of both sexes aged 2-12 years who underwent cardiac surgery were included. INTERVENTIONS: Patients in the ketamine group received a bolus of 0.3 mg/kg of ketamine before skin incision followed by continuous intraoperative infusion of 0.25 mg/kg/h and postoperative infusion of 0.1 mg/kg/h for 24 h. Patients in the control groups received volumes of normal saline either bolus or continuous infusion like that of the ketamine group. MEASUREMENTS AND MAIN RESULTS: The primary outcome was the total dose of fentanyl consumed over the first 24 hours postoperatively. Secondary outcomes were intraoperative fentanyl consumption, time to extubation, modified objective pain score, and incidence of vomiting, pruritus, diplopia, or hallucinations. A total of 80 patients were recruited but the final analysis was done on 35 patients in the ketamine group and 34 in the control group. Fentanyl consumption during surgery and in the first 24 hours postoperatively was significantly lower in the ketamine than the control group. Patients in both the ketamine and control groups had similar times to extubation. Modified objective pain scores were significantly lower in the ketamine group than the control group. None of the patients in either group had diplopia or hallucinations. CONCLUSIONS: Low-dose ketamine infusion in children undergoing open cardiac surgery reduced intra- and postoperative opioid consumption and postoperative pain scores. Moreover, ketamine did not cause diplopia or hallucinations.
RESUMO
OBJECTIVE: The choice of oral or nasal endotracheal intubation in children undergoing cardiac surgery is affected by several factors. This study compared the outcomes of oral versus nasal intubation in neonates and infants who underwent open cardiac surgery. DESIGN: A randomized, controlled, open-labeled study. SETTING: At a university hospital. PARTICIPANTS: A total of 220 infants and neonates who underwent cardiac surgery. INTERVENTIONS: Patients were allocated randomly to oral or nasal intubation. MEASUREMENTS AND MAIN RESULTS: The primary outcome measure was postoperative fentanyl consumption (µg/kg/h) by intubated patients. Secondary outcome measures were the increase in heart rate (HR) from baseline during intubation, the time consumed for intubation, accidental intraoperative extubation, the occurrence of epistaxis, time to extubation, the onset of full oral feeding, intensive care unit (ICU) and hospital lengths of stay, and the incidence of postoperative complications (the need for reintubation, stridor, pneumonia, wound infection). The mean (SD) postoperative fentanyl consumption of intubated patients (the primary outcome) was significantly lower (p < 0.001) in the nasal intubation group (0.53 ± 0.48) µg/kg/h compared with the oral intubation group (0.82 ± 0.20) µg/kg/h. The median (IQR) time needed for the intubation (31.5, 27-35 v 16, 14.8-18 seconds) was significantly (p < 0.001) longer, and the mean (SD) increase in HR (beats/min) from baseline during intubation (18 ± 5 v 26 ± 7) was significantly (p < 0.001) lower in the nasal intubation group compared to the oral intubation group. The incidence of inadvertent intraoperative extubation was significantly (p = 0.029) higher in the oral (n = 6, 6.1%) than in the nasal (n = 0, 0%) intubation group. The median (IQR) time to extubation (14, 12.6-17.2 v 20.5, 16.4-25.4 hours) and the ICU length of stay (27, 26-28 v 30, 28-34 hours) were significantly (p < 0.05) shorter in the nasal group compared to the oral group. The median (IQR) time to onset of full oral feeding was significantly (p = 0.031) shorter in the nasal intubation group (3, 1-6 days) compared to the oral intubation group (4, 2-7 days). There were no significant differences between the oral and nasal groups in the duration of hospital stay and the indices for reintubation, postintubation stridor, pneumonia, and surgical wound infection. CONCLUSIONS: The nasal route for intubation is associated with less postoperative fentanyl consumption, earlier extubation, lower incidence of accidental extubation, and earlier full oral feeding than oral intubation. The nasal route is not associated with an increased risk of postoperative pneumonia or surgical wound infection.
