The patient at risk for acute renal failure. Recognition, prevention, and preoperative optimization.

Despite major advances in critical care medicine and extracorporeal renal support, the treatment of established postoperative ARF remains unsatisfactory and costly. The essential elements of perioperative renal preservation are early recognition of high-risk patients, preoperative optimization of fluid status and cardiovascular performance, intraoperative maintenance of renal perfusion, and avoidance of nephrotoxins. Pharmacologic interventions directed at preventing postoperative ARF are under intense investigation but presently are limited to renal transplant surgery.

Breath-holding-like spells in an infant: an unusual presentation of lingual thyroglossal duct cyst.

The authors report the case of an infant with a lingual thyroglossal duct cyst who presented with breath-holding-like spells, which actually represented life-threatening ball-valve obstruction of the larynx, leading to hypoxemia and transient cerebral dysfunction. When evaluating apparent breath-holding spells in young infants, physicians should include dynamic, episodic upper airway obstruction in the differential diagnosis.

Intravenous ondansetron in established postoperative emesis in children. S3A-381 Study Group.

BACKGROUND: In pediatric postsurgical patients, postoperative vomiting is a common occurrence that can delay recovery and result in unplanned hospital admissions after outpatient surgery. This randomized, double-blind, placebo-controlled, multicenter study evaluated the efficacy and safety of ondansetron in the control of established postoperative emesis in outpatients aged 2-12 yr. METHODS: Screened for the study were 2,720 ASA physical status 1-3 children undergoing outpatient surgery during general anesthesia, which included nitrous oxide. Children experiencing two emetic episodes within 2 h of discontinuation of nitrous oxide were given intravenous ondansetron (n = 192; 0.1 mg/kg for children weighing < or = 40 kg; 4 mg for children weighing > 40 kg) or placebo (n = 183). RESULTS: The proportion of children with no emetic episodes and no use of rescue medication was significantly greater (P < 0.001) in the ondansetron group compared with placebo for both 2- and 24-h periods after study drug administration (78% of the ondansetron group and 34% of the placebo group for 2 h; 53% of the ondansetron group and 17% of the placebo group for 24 h). Among patients with at least one emetic episode or with rescue medication use, the median time to onset of emesis or rescue was 127 min in the ondansetron group compared with 58 min in the placebo group (P < 0.001). The median time from study drug administration until discharge was significantly shorter (P < 0.01) in the ondansetron group (153 min, range 44-593 min) compared with the placebo group (173 min, range 82-622 min). The incidence of potentially drug-related adverse events was similar in the ondansetron (3% of patients) and the placebo (4% of patients) groups. CONCLUSION: A single dose of ondansetron (0.1 mg/kg up to 4 mg) is effective and well tolerated in the prevention of further episodes of postoperative emesis in children after outpatient surgery. Administration of ondansetron also may result in a shorter time to discharge.

Pediatric PCA: the role of concurrent opioid infusions and nurse-controlled analgesia.

OBJECTIVES: We designed a clinical study to determine: a) the safety and efficacy of patient-controlled analgesia (PCA) therapy in children and adolescents undergoing major operations, b) if the use of a concurrent opioid infusion improved the efficacy of conventional PCA therapy, and c) if nurse control of the PCA device was a useful alternative in the intensive care unit (ICU) setting. DESIGN: Subjects were randomly assigned to receive morphine sulfate for postoperative pain relief via intermittent PCA boluses on demand or PCA plus a continuous infusion (PCA + CI). Children (n = 12) who were unable to use the PCA device because of inadequate development level or upper extremity weakness were assigned to a nurse-controlled analgesia (NCA) group. SETTING: In the ICU of a university-based pediatric teaching hospital. PATIENTS: Fifty-four children and adolescents underwent elective scoliosis surgery. INTERVENTIONS: The PCA devices were connected to the patient's i.v. catheter immediately after surgery. Morphine sulfate was administered on demand by either the patient or an ICU nurse for pain relief during the first 72 h after the operation. MAIN OUTCOME MEASURES: Pain scores were recorded simultaneously by both the nurse and the patient using standardized visual analog scales. Opioid analgesic usage, side effects, and therapeutic interventions were recorded by the ICU nurse. RESULTS: There were no differences between the PCA and PCA + CI groups with regard to morphine use, pain relief, side effects, or patient satisfaction. Nurses consistently underestimated their patient's level of pain, and children in the NCA groups received less morphine per kilogram than those who self-administered their own analgesic medication. CONCLUSIONS: Both PCA and NCA were safe and efficient methods of analgesic administration in the pediatric ICU setting. However, use of a concurrent opioid infusion with PCA therapy did not provide any clinically significant advantages over intermittent bolus doses of the analgesic medication after scoliosis surgery. For patients unable to use a conventional PCA device, NCA is an acceptable alternative for the management of acute pain in the ICU setting.

Oral midazolam in children: effect of time and adjunctive therapy.

The purpose of this study was to determine the influence of timing and concomitant administration of atropine and/or meperidine on the perioperative effects of oral midazolam in children. In 154 healthy children, 1-8 yr old, we studied six oral preanesthetic medication regimens according to a randomized, double-blind protocol. Group A (placebo) received 5 mL of apple juice. The other five groups received medication with apple juice to a total volume of 5 mL, 20-60 min before induction of anesthesia. Group B received atropine (0.02 mg/kg); group C received midazolam (0.5 mg/kg); group D received midazolam (0.5 mg/kg) and atropine (0.02 mg/kg); group E received meperidine (1.5 mg/kg) and atropine (0.02 mg/kg); and group F received meperidine (1.5 mg/kg), atropine (0.02 mg/kg), and midazolam (0.5 mg/kg). The sedative effect of midazolam was maximal 30 min after oral administration. Ninety-five percent of the children who were separated from their parents within 45 min after oral midazolam administration (with or without atropine) had satisfactory separation scores (vs 66% of those separated after 45 min; P less than 0.02). Midazolam-treated patients were more cooperative with a mask induction of anesthesia compared with non-midazolam-treated children (83% vs 56%). Neither atropine nor meperidine appeared to significantly improve the effectiveness of oral midazolam. No preoperative changes in heart rate, respiratory rate, or hemoglobin oxygen saturation were noted in any of the treatment groups. Finally, oral midazolam did not prolong recovery even after outpatient procedures lasting less than 30 min. In conclusion, midazolam (0.5 mg/kg) given orally 30-45 min before induction of anesthesia is safe and effective without delaying recovery after ambulatory surgery.