Perioperative management of a paediatric patient on the ketogenic diet

The ketogenic diet has become commonplace for the treatment of paediatric patients with refractory epilepsy. I describe the perioperative management of a patient on the ketogenic diet. The basis, complications and anaesthetic implications of the diet are discussed.

Culture of bacteria from lumbar and caudal epidural catheters used for postoperative analgesia in children

BACKGROUND AND OBJECTIVES

Continuous epidural analgesia has been used with increasing frequency to provide postoperative pain relief for children. Epidural space infection is a potential complication of epidural catheter placement. This study investigated the incidence of bacterial colonization on lumbar and caudal epidural catheter tips in postoperative pediatric patients.

METHODS

In this prospective study, lumbar and caudal epidural catheters were placed in the operating room with aseptic technique. Dilute local anesthetic and/or opioid infusions were used for postoperative analgesia. On discontinuation of the epidural infusion, the skin site was decontaminated with 70% alcohol and then cultured. The distal catheter tip and hub were cultured. Semiquantitative and qualitative aerobic cultures were performed.

RESULTS

Data from 91 epidural catheters were available (45 caudal versus 46 lumbar). Of the 45 caudal catheter tips 9 (20%) were colonized, compared with 2 of the 46 (4%) lumbar catheter tips (P < .02). Staphylococcus epidermidis was the predominant skin and catheter tip organism isolated in both groups. Four of nine caudal catheter tips grew gram-negative bacteria. Statistical analyses did not show that time, skin site inflammation, or dressing condition were independent predictors of catheter tip colonization. No patient developed a clinical epidural infection during the study period.

CONCLUSIONS

The results of this study suggest that the risk of clinical epidural infection associated with caudal or lumbar postoperative catheters is low. However, the incidence of epidural catheter tip colonization is increased with the caudal route of insertion, and the bacteria differ from those cultured from the lumbar insertion site.

Comparison of patient-controlled analgesia with and without nighttime morphine infusion following lower extremity surgery in children

To evaluate the usefulness of a concurrent nighttime morphine infusion in pediatric patient-controlled analgesia (PCA), 36 school-age children undergoing elective lower extremity surgery were randomly assigned to receive morphine by PCA alone, or PCA with a nighttime infusion of morphine (PCA+BI). Postoperatively, patients breathed air and had oxygen saturation recorded continuously for the duration of PCA use. Total morphine requirements were decreased in the PCA group as compared to PCA+BI patients. PCA pump activation, VAS pain, and sedation scores were similar between the two groups at all times. Compared to the PCA group, patients assigned to the PCA+BI group spent more time with SpO2 of 90% or less, during the nighttime infusion (P < 0.05). The use of a nighttime infusion of morphine did not appear to offer any advantage over the use of PCA alone in this patient population.

Epidural analgesia improves outcome following pediatric fundoplication. A retrospective analysis

BACKGROUND AND OBJECTIVES

Nissen fundoplication is a common procedure in high-risk pediatric patients. This cohort study evaluated the influence of epidural versus intravenous opioid analgesia on the postoperative course of infants and children undergoing fundoplication.

METHODS

A retrospective review was made of the perioperative courses of 155 consecutive patients, aged 1 month to 19 years, who underwent elective open fundoplication from January 1993 to October 1994. Of these 155 patients, 72 received perioperative analgesia with epidural opioids, while 83 received parenteral opioids. Outcome variables included major morbidity factors, recovery of bowel and bladder function, and economic impact.

RESULTS

Patients in the epidural and parenteral groups did not differ with respect to age, weight, or associated preoperative medical diagnoses. The postoperative complication rate was significantly decreased in the epidural group (5.5% versus 20%) (P < .001). In the epidural group 4 patients required mechanical ventilation for longer than 24 hours, compared with 15 in the parenteral group. Patients in the epidural group were discharged earlier from the hospital and incurred approximately 20% less in hospital charges on average than their cohorts in the intravenous group.

CONCLUSIONS

These findings suggest that perioperative epidural analgesia, administered by a dedicated pain service, amy improve outcome in high-risk pediatric patients undergoing fundoplication.

Postoperative pain relief in children from the parascalene injection technique

Nineteen pediatric patients aged 6 months to 12 years scheduled for elective upper extremity surgery were randomly assigned to receive either a parascalene block or sham injection. Both groups received a potent inhalational agent for operative anesthesia. At completion of surgery, the treatment group received an injection of 0.5 ml/kg 0.25% bupivacaine with 1:200,000 epinephrine into the brachial plexus via the parascalene approach with the aid of a nerve stimulator; the control group received a subcutaneous needle puncture only. Patients in the parascalene group had superior postoperative analgesia, as evidenced by significantly less opioid requirement in the first 12 postoperative hours and by significantly lower scores on an objective pain scale. We found the parascalene approach to the brachial plexus a simple and reliable analgesic technique in anesthetized children.