Tracheal extubation of deeply anesthetized pediatric patients: a comparison of isoflurane and sevoflurane

We studied the emergence characteristics of unpremedicated children tracheally extubated while deeply anesthetized ("deep extubation") with isoflurane or sevoflurane. Forty children were assigned to one of two groups, Group I or Group S. At the end of the operation, Group I patients were extubated while breathing 1.5 times the minimum alveolar anesthetic concentration (MAC) of isoflurane. Group S patients were tracheally extubated while breathing 1.5 times the MAC of sevoflurane. Recovery characteristics and complications were noted. Group S patients were arousable sooner than Group I patients (10.1 + 6.5 vs 16.3 + 9.9 min). Later arousal scores and times to discharge were the same. There were no serious complications in either group. Breath-holding was more common in Group I. We conclude that the overall incidence of airway problems and desaturation episodes was similar between groups. Emergency delirium was common in both groups (32% overall: 40% for Group I, 25% for Group S).

IMPLICATIONS

Deep extubation of children can be safely performed with either isoflurane or sevoflurane. After deep tracheal extubation, airway problems occur but are easily managed. Return to an arousable state occurred more quickly with sevoflurane, although time to meeting discharge criteria was not different between the two groups. Emergence delirium occurs frequently with either technique.

Withdrawal after narcotic therapy: a survey of neonatal and pediatric clinicians

Pharmacists at the 1995 American College of Clinical Pharmacy Pediatric Practice and Research Network meeting volunteered to act as coordinators at their sites and survey pediatric and neonatal nurses, pharmacists, and physicians regarding dependency in neonatal and pediatric patients after therapeutic administration of narcotics. Thirteen (60%) of 21 coordinators returned 244 surveys. Primary symptoms of withdrawal reported by clinicians were agitation (100%), irritability (100%), inconsolability (100%), crying (99%), tremors (98%), high heart rate (98%), fidgets (98%), high blood pressure (97%), less sleep (96%), and sweating (94%). Most clinicians considered narcotic withdrawal to be a problem (74%) that should be treated (87%). A dependency scale is being developed and will include symptoms reported by more than 75% of respondents.

Artificial surfactant for therapy in hydrocarbon-induced lung injury in sheep

OBJECTIVE

To document the effect of administering artificial surfactant into the trachea, either by instillation or aerosolization, on acute lung injury experimentally induced with kerosene in sheep.

DESIGN

Randomized, prospective, controlled study.

SETTING

Research laboratory.

SUBJECTS

Sheep (n = 24), weighing 8.5 to 25.2 kg (average 16.6).

INTERVENTIONS

In anesthetized, tracheally intubated sheep with pulmonary and femoral artery catheters inserted, lung injury was induced by instilling kerosene (0.3 mL/kg) into the trachea. After 15 mins of spontaneous breathing, mechanical ventilation was instituted with a uniform F10(2) and a tidal volume of 10 mL/kg. Sheep were then assigned randomly to one of four regimens as follows: exogenous surfactant or saline (5 mL/kg each) was administered as a bolus intratracheally or by aerosolization for 6 hrs.

MEASUREMENTS AND MAIN RESULTS

Arterial and mixed venous blood gases, pH, airway pressure, and static respiratory system compliance were measured and compared between aerosol saline and aerosol surfactant and between bolus saline and bolus surfactant. For all variables except static respiratory system compliance, the hourly rate of change from 15 mins, 1 hr, and 6 hrs after kerosene instillation was determined for each animal, and group rank sums of hourly rates of change were compared. For static respiratory system compliance, the slope of the pressure-volume curve with volumes of 100, 200, 300, 400, and 500 mL was computed for each animal at baseline and at 3 and 6 hrs after kerosene instillation. Group rank sums for static respiratory system compliance at 3 and 6 hrs were compared. Also, the 3- and 6-hr static respiratory system compliance values at each of the volumes were compared. With saline, six of eight sheep died; with surfactant, no sheep died (p = .001). When compared with saline at 15 mins, 1 hr, and 6 hrs after kerosene instillation, surfactant, regardless of whether administered by aerosol or bolus, significantly increased rate of change of arterial oxygen saturation, mixed venous oxygen saturation, and PO2.

CONCLUSIONS

In the present animal study, artificial surfactant was an effective treatment for hydrocarbon aspiration. Aerosolized surfactant achieved results similar to instilled surfactant but at a lower total dose.

Epidural morphine combined with epidural or intravenous butorphanol for postoperative analgesia in pediatric patients

We performed a prospective, randomized, double-blinded study in 60 postoperative pediatric patients aged 6 wk to 7 yr to compare the efficacy of butorphanol given epidurally or intravenously in preventing the side effects of epidural morphine. Three groups of patients received 60 micrograms/kg epidural morphine; 20 patients also received epidural butorphanol 30 micrograms/kg, and 20 patients also received 30 micrograms/kg intravenous butorphanol. All patients were evaluated for analgesia, sedation, vomiting, urinary retention, pruritus, and respiratory depression for 24 h postoperatively. Although the overall incidence of side effects was not different in the three groups, the epidural butorphanol group had a significant decrease in severity of pruritus. Sedation was seen more frequently in the groups receiving butorphanol, but was most pronounced in the epidural butorphanol group. We conclude that butorphanol has little or no effect on the side effects of epidural morphine.

Epidural fentanyl infusion with patient-controlled epidural analgesia for postoperative analgesia in children

The use of epidural fentanyl infusion with patient-controlled epidural analgesia (PCEA) is becoming popular for postoperative analgesia in adults. Its use has not been reported in the pediatric population. We report our initial experience with this technique in pediatric patients. The charts of all children who received epidural fentanyl infusions for postoperative analgesia between June 1991 and February 1992, were reviewed. Thirty-one patients, ages 6 to 17 years (mean +/- SD, 13.2 +/- 2.7) received epidural fentanyl infusion with PCEA for 36 operative procedures. Epidural catheters were either inserted in the lumbar (n = 14) or thoracic (n = 22) epidural space at a level based on the surgery. A fentanyl bolus of 1.38 +/- 0.43 micrograms/kg was delivered via epidural catheter just prior to the conclusion of surgery. A continuous infusion of fentanyl (0.56 +/- 0.18 micrograms/kg/h) with a PCEA bolus (0.53 +/- 0.17 micrograms/kg) available every 15 minutes was initiated in the recovery room and was utilized for 8 to 110 hours (59 +/- 27 hours). Pain and sedation were assessed by verbal descriptive scales, and side effects were noted. Alterations in dosing regimen were made for inadequate analgesia or side effects. Analgesia was assessed as excellent or good in 78% of the patients, 91% in the thoracic catheter group and 57% in the lumbar catheter group (P < .02). Patients with thoracic catheters were more likely to need their infusion and PCEA doses decreased, whereas those with lumbar catheters more often needed their doses increased (P < .05). No patient had respiratory depression.(ABSTRACT TRUNCATED AT 250 WORDS)