Decreased intraoral secretions during sedation-analgesia with propofol-ketamine and midazolam-ketamine combinations

Purpose. To investigate salivary flow over time with a balanced sedation-analgesia technique using a propofol-ketamine (PK) or a midazolam-ketamine (MK) combination in human volunteers. Methods. In the PK group, boluses of 1 mg·kg⁻¹ of propofol and 0.7 mg·kg⁻¹ of ketamine were initially administered. This was followed by an infusion, given over a 1-h period, of propofol (5 mg·kg⁻¹) admixed with ketamine (0.7 mg·kg⁻¹). In the MK group, 0.07 mg·kg⁻¹ of midazolam and 0.7 mg·kg⁻¹ of ketamine was followed by the infusion of a midazolam (0.07 mg·kg⁻¹) and ketamine (0.7 mg·kg⁻¹) admixture, also given over a period of 1 h. Salivary flow was measured prior to and at 10-min intervals during the sedation-analgesia, as well as for 30 minutes after its termination. Results. Mixed intraoral secretions were significantly reduced, by 43% and 47%, on average, in the PK and MK groups, respectively, when compared with presedation levels, and had not returned to baseline levels 30 min after discontinuation of the infusion. Conclusion. Sedation-analgesia with PK and MK combinations controls intraoral secretions by reducing salivary flow. Received: January 5, 2001 / Accepted: May 14, 2001     

The effect of adjuvant drugs on the quality of tracheal intubation without muscle relaxants in children: a systematic review of randomized trials

Intubation without prior administration of muscle relaxants is a common practice in children. However, succinylcholine may be considered as the golden standard for optimizing intubating conditions. We conducted a systematic review of the literature to identify drug combinations that included induction of anesthesia with sevoflurane or propofol. Our aim was to select drug combinations that yield excellent intubating conditions ≥80%; we identified six combinations in children aged 1–9 years. Sevoflurane with remifentanil (1 or 2 μg·kg^?1), lidocaine (2 mg·kg^?1), or propofol (2 mg·kg^?1) as the adjuvant shared the following characteristics: premedication with midazolam and/or ketamine, long sevoflurane exposure time, high inspired and endtidal sevoflurane concentration, and assisted ventilation. One combination using sevoflurane with propofol (3 mg·kg^?1) without premedication, with shorter sevoflurane exposure time, and spontaneous breathing indicated that propofol may be the adjuvant of choice for a rapid sevoflurane induction. The only adjuvant identified in propofol induction was remifentanil (4 μg·kg^?1). No serious adverse events were reported with these combinations.     

Dose of propofol required to insert the laryngeal mask airway in children

We have assessed the ease of insertion of the Brain Laryngeal Mask Airway (LMA) after induction of anaesthesia with propofol in 60 healthy unpremedicated children aged between four and nine years. Patients were randomly allocated into three groups: group A = propofol 2.5 mg·kg^?1; group B = propofol 3 mg·kg^?1 and group C = propofol 3.5 mg·kg^?1. Propofol was mixed with lignocaine 0.5 mg·kg^?1. Insertion conditions were assessed subjectively as good, acceptable, unacceptable or impossible. Insertion of the LMA was possible in all patients. Good and acceptable conditions were obtained in 35%, 70% and 95% in groups A, B, and C respectively (P < 0.0001). There was no statistically significant inter group variation in systolic and diastolic arterial pressure or in heart rate for five min after induction. All measured cardiovascular changes were considered to be clinically insignificant in healthy children. We conclude it is safe and effective to insert a LMA immediately after induction of anaesthesia with propofol 3.5 mg·kg^?1.     

Children on phenobarbital monotherapy requires more sedatives during MRI

Background: Phenobarbital induces specific hepatic cytochrome P‐450 enzyme pathways causing increased clearance of hepatically metabolized drugs. In this study, we investigated the duration and additional anesthetic requirement during Magnetic resonance imaging (MRI) in epileptic children with or without phenobarbital monotherapy. Methods: In ASA I–II, 128 children, aged 1–10 years, were included. Group I: epileptic children without anti‐epileptic therapy and Group II: children with phenobarbital monotherapy. The initial sedative drugs were 0.1 mg·kg^?1 midazolam with 2 mg·kg^?1 ketamine. An additional 1 mg·kg^?1 ketamine was administrated if required. Rescue propofol (0.5 mg·kg^?1) was provided and repeated to maintain sedation. The duration and consumption of additional sedative requirements was recorded. Results: The duration of initial and two consequent additional sedative requirements was shorter in Group II (P = 0.0001, P = 0.001 and P = 0.27, respectively). Additional ketamine doses required for adequate sedation were lower in Group I (P = 0.016). Conclusion: We suggest that the variability in response to the initial sedative agents during MRI requires titration of additive sedation with ketamine in epileptic children on phenobarbital monotherapy.     

Comparison of propofol versus propofol‐ketamine combination for sedation during spinal anesthesia in children: randomized clinical trial of efficacy and safety

Objectives: This study was designed to compare the efficacy and safety of propofol vs propofol‐ketamine combination for sedation during pediatric spinal anesthesia. Methods: Forty children, aged 3–8 undergoing spinal anesthesia for lower abdominal surgeries were included. Participants were randomly assigned into two groups. Group 1 received propofol bolus of 2 mg·kg^?1 followed by an infusion of 4 mg·kg^?1·h^?1. Group 2 received a combination of 1.6 mg·kg^?1 propofol and 0.4 mg·kg^?1 ketamine followed by an infusion of 3.2 mg·kg^?1·h^?1 and 0.8 mg·kg^?1·h^?1, respectively. The infusion rate was titrated to keep the child sedated at University of Michigan Sedation Score of 3. The heart rate, blood pressure, respiratory rate and oxygen saturation were recorded every 5 min. The episodes of spontaneous body movements and requirement of supplemental sedation were recorded. The postoperative recovery was assessed by modified Aldrette score. Results: Seventeen patients in group 1 and four patients in group 2 (P < 0.001) required extra boluses of study drug to prevent movements during lumbar puncture. Four patients experienced respiratory depression and three airway obstruction in group 1 when compared to one patient each in group 2 (P < 0.05). The recovery time was similar in both groups. None of the patient had postoperative nausea/vomiting or psychomimetic reactions. Conclusions: Propofol‐ketamine combination provided better quality of sedation with lesser complications than propofol alone and thus can be a good option for sedation during spinal anesthesia in children.     

Sublingual midazolam premedication in children: a dose response study

The purpose of this study was to evaluate various doses of sublingual midazolam premedication in children. In our prospective, double-blind, placebo-controlled trial, children (n=102, age range 12 to 129 months) scheduled for day surgery were randomized to receive either midazolam in one of three doses (0.25, 0.5, or 0.75 mg·kg^?1) or placebo. Injectable midazolam was mixed with a thick grape syrup and placed under the tongue; the patient was asked to hold it as long as possible before swallowing. Children readily accepted the mixture. Analysing all patients randomized, none of the children receiving placebo vs 28% receiving 0.25 mg·kg^?1 (P=0.02), 52% receiving 0.5 mg·kg^?1 (P<0.001), and 64% receiving 0.75 mg·kg^?1 (P<0.001) of midazolam showed satisfactory sedation (drowsy) at 15 min after administration. Children receiving the two higher doses of midazolam (0.5 and 0.75 mg·kg^?1) accepted mask induction willingly, while the group receiving 0.25 mg·kg^?1 resembled the placebo group (P<0.05).     

Intravenous sedation for children with Down's syndrome undergoing cardiac catheterization

Down's syndrome is commonly associated with cardiac malformations and sleep related upper airway obstruction. The dose response for ketamine in the presence of an infusion of fentanyl was determined in 28 consecutive children (3–51 months) with Down's syndrome and congenital heart disease during haemodynamic catheterization. The children were premedicated with flunitrazepam orally and glycopyrrolate i.v. Ventilation was continuously monitored with a capnograph. Fentanyl 1 μg·kg^?1 and 1 μg·kg^?1·h^?1 was administered in fixed doses for induction and maintenance of sedation, respectively. The mean induction and maintenance requirements of ketamine were 1.5 ± 0.5 mg·kg^?1 and 1.8 ± 0.8 mg·kg^?1·h^?1, respectively. In infants younger than 6 months, more ketamine was needed for both induction and maintenance than in older children (P < 0.005). Normoventilation without any airway manipulation could be maintained in 15 patients (54%). Respiratory difficulties were frequent: hypoventilation required temporary mask ventilation, insertion of a nasopharyngeal tube or tracheal intubation in two, seven and four children, respectively. Oral flunitrazepam premedication and intravenous sedation with low-dose fentanyl and ketamine combined with close monitoring of ventilation can be used for cardiac catheterization in children with Down's syndrome. However, the described combination of sedative drugs does not prevent the occurrence of sleep related upper airway obstruction.     

Efficacy of two oral premedicants: midazolam or a low‐dose combination of midazolam–ketamine for reducing stress during intravenous cannulation in children undergoing CT imaging

Background: Pain, anxiety and fear of needles make intravenous cannulation extremely difficult in children. We assessed the efficacy and safety of oral midazolam and a low‐dose combination of midazolam and ketamine to reduce the stress and anxiety during intravenous cannulation in children undergoing computed tomography (CT) imaging when compared to placebo. Methods: Ninety‐two ASA I or II children (1–5 years) scheduled for CT imaging under sedation were studied. Children were randomized to one of the three groups. Group M received 0.5 mg·kg^?1 midazolam in 5 ml of honey, group MK received 0.25 mg·kg^?1 midazolam mixed with 1 mg·kg^?1 ketamine in 5‐ml honey and group P received 5‐ml honey alone, orally. In 20–30 min after premedication, venipuncture was attempted at the site of eutectic mixture of local anesthetics cream. Sedation scores and venipuncture scores were recorded. Primary outcome of the study was incidence of children crying at venipuncture (venipuncture score of 4). Results: Significantly more children cried during venipuncture in placebo group compared to the other two groups (19/32 (59%) in group P vs 1 each in groups M and MK, (P < 0.001) (RR 2.37, 95% CI 1.55‐3.63). In 20–30 min after premedication, group P had more children in sedation score 1 or 2 (crying or anxious) compared to the other two groups (P < 0.05). At this time, group MK showed more children in calm and awake compared to group M (P = 0.02). At venipuncture, group P had more children in venipuncture score 3 or 4 (crying or withdrawing) compared to group M or MK (P < 0.05), while groups M and MK were comparable. Conclusion: A low‐dose combination of oral midazolam and ketamine or oral midazolam alone effectively reduces the stress during intravenous cannulation in children undergoing CT imaging without any adverse effects. However, the combination provides more children in calm and quiet state when compared to midazolam alone at venipuncture.     

A 3:1 volume admixture of 1% propofol and 2.5% thiopentone reduces pain on induction in paediatric anaesthesia

Introduction The incidence of pain on injection with 1% propofol in adult and paediatric patients ranges from 50 to 100% ( 1 ). In paediatric practice, the addition of lignocaine 1 mg·kg^?1 to propofol reduces the incidence of pain. The incidence of pain with this technique in a pilot study in our institution was 20%. Thiopentone mixed with propofol may also reduce injection pain ( 2 ). The purpose of this study was to evaluate the incidence of pain on injection during intravenous induction using a 3:1 volume admixture of 1% propofol and 2.5% thiopentone (P/T) compared to a 10:1 volume admixture of 1% propofol and 2% lignocaine (P/L). Methods After ethics committee approval and informed written parental consent, 127 children, aged 1–10 years and weighing < 40 kg were randomised into two groups; group P/L received 5 mg·kg^?1 of 1% propofol and 1 mg·kg^?1 of lignocaine, group P/T received 3 mg·kg^?1 of 1% propofol and 3 mg·kg^?1 of 2.5% thiopentone in a standardised fashion. Any subject who was not calm and cooperative immediately prior to induction after establishment of intravenous access was excluded from further study. A single, blinded observer scored pain behavior defined as any one of. a motor response of the arm, a verbal complaint of pain, cry and/or one of three standardised facial expressions of pain. Results The incidence of pain on injection was higher in the P/L group where 34% subjects experienced pain compared with 14% in the P/T group (χ² = 7.5, P = 0.006). Motor response was the most frequent pain response in the P/L group (68%). Discussion The hemodynamic effects, immediate in‐hospital or late recovery profile and incidence of postoperative nausea and vomiting of these admixtures were not evaluated in this study. Our clinical impression is that using either the P/L or P/T combination allowed rapid IV induction, and therefore rapid ventilation and LMA insertion without obvious hypotension. The P/T admixture may be less painful to inject simply because propofol is diluted. The optimum ratio of dilution of propofol with thiopentone may not be 3:1 and requires a dose‐finding study evaluating in detail the efficacy and side effects of other ratios of admixtures. Conclusion The use of a 3:1 volume admixture of 1% propofol and 2.5% thiopentone compared to a 10:1 volume admixture of 1% propofol and 2% lignocaine reduces pain on injection at induction of anaesthesia in paediatric patients from 34% to 14%, and is a practical solution for pain on injection in pediatric patients.     

Ketamine plus midazolam, a most effective paediatric oral premedicant

Healthy children, 1.5 to seven years old, were divided into three groups of 20 each. Group 1 received midazolam 0.5 mg·kg^-1, Group 2, ketamine 6 mg·kg^-1 and Group 3 a mixture of midazolam 0.4 mg·kg^-1+ ketamine 4 mg·kg^-1. Each dose was mixed with atropcne 0.02 mg·kg^-1 plus an equal volume of cherry syrup and was given orally 20 to 30 min prior to surgery. A grade of 1 (asleep, difficult to arouse), 2 (asleep, easily aroused), 3 (awake, calm), 4 (awake, anxious, occasional cry), or 5 (crying, agitated), was assigned at the time of parental separation and again when mask induction was begun. A grade of 1–3 was considered successful. For parental separation, the mixture of ketamine + midazolam was 100% successful, ketamine 90% and midazolam 75%. Successful mask induction for the mixture of ketamine + midazolam was 85%, midazolam 65% and ketamine 42%. This study indicates that a mixture of ketamine + midazolam is the most effective.     

Topical lidocaine improves conditions for laryngeal mask airway insertion

Purpose

We hypothesized that optimal laryngeal mask airway (LMA?) insertion conditions might be achieved with topical lidocaine and a smaller dose of propofol. In this study, insertion conditions after topical lidocaine 40 mg followed by propofol 2 mg·kg^?1 were compared with propofol 2 mg·kg^?1 or propofol 3 mg·kg^?1 alone.

Methods

Ninety patients were recruited for this randomized prospective double-blind study. One group received four sprays of topical lidocaine (40 mg) over the posterior pharyngeal wall followed by propofol 2 mg·kg^?1 (Group 2PL; n = 30). The other two groups received four sprays of 0.9% normal saline followed by propofol 2 mg·kg^?1 (Group 2P; n = 30) or by propofol 3 mg·kg^?1 (Group 3P; n = 30). The frequency of optimal insertion conditions (successful insertion at the first attempt without adverse responses) and side effects were recorded.

Results

The frequency of optimal insertion conditions was greater in Group 2PL (20/30, 67%) and Group 3P (22/30, 73%) than in Group 2P (11/20, 37%) (P = 0.009). In Group 3P, the mean blood pressure was lower than in the other groups prior to LMA-Classic? insertion (P = 0.003) but was similar after insertion. The incidence of apnea was greater in Group 3P patients (17/30, 57%) than in Group 2P (2/30, 7%) or Group 2PL patients (1/30, 3%) (P < 0.001).

Conclusion

Topical lidocaine 40 mg followed by propofol 2 mg·kg^?1 can provide optimal insertion conditions of the LMA-Classic comparable to those of propofol 3 mg·kg^?1, with fewer hemodynamic changes and a lower incidence of apnea.     

Midazolam does not reduce emergence delirium after sevoflurane anesthesia in children

Background: Behavioral disturbance in children following sevoflurane anesthesia is a relatively frequent event. The aim of this study was to evaluate whether a higher dose of preoperatively administered rectal midazolam compared with a lower would alleviate this phenomenon. Furthermore the impact of these two doses of midazolam on sedation at induction of anesthesia was compared. Methods: A total of 115 children presenting for minor surgery under anesthesia were included in the study. The children were randomized to receive rectally either 1 mg·kg⁻¹ midazolam (group H) or 0.5 mg·kg⁻¹ midazolam (group L). General anesthesia was induced with propofol or sevoflurane and maintained with 1.5% sevoflurane in the inspiratory limb. Prior to the start of surgery a regional block was performed to ensure adequate pain relief. Behavior on emergence was assessed using a three point scale. In case of severe agitation propofol was administered IV. Results: The children in group H were significantly better sedated preoperatively (P < 0.01). There was no significant difference in emergence behavior: 42.1% of children in group H compared with 36.2% of children in group L exhibited severe agitation requiring sedation with propofol (P = 0.37). However, regardless of the preoperative dose of midazolam more children under the age of 36 months (61.4%) were severely distressed at emergence compared with older children (16.7%) (P < 0.01). Conclusions: A higher dose of 1 mg·kg⁻¹ rectal midazolam results in much better sedated children on induction of anesthesia than 0.5 mg·kg⁻¹. This, however, does not result in a reduced incidence of emergence delirium after sevoflurane anesthesia. Regardless of the premedication negative behavioral changes occur more frequently in children younger than 3 years of age.     

Changes in carbon dioxide tension and oxygen saturation during deep sedation for paediatric cardiac catheterization

The purpose of this observational study was to determine whether hypercarbia or oxygen desaturation occurred during our current regimens of deep sedation or general anaesthesia of infants and children undergoing cardiac catheterization. Data were gathered prospectively from 50 consecutive infants and children aged 4 months to 12 years undergoing cardiac catheterization. Several anaesthetists used the following regimens, which were not randomized: 1) propofol. 1.5–2.0 mg·kg^?1 and fentanyl 1 μg·kg^?1 IV over 2 min for induction, followed by propofol infusion of 100–150 μg·kg^?1·min^?1; 2) fentanyl 2–3 μg·kg^?1 and midazolam 0.1–0.2 mg·kg^?1 IV over 10–15 min; 3) ketamine 8 mg·kg^?1 IM, or 4) same as regimens 1 or 2, plus pancuronium, intubation and controlled ventilation. Regimens 1, 2, and 3 were associated with spontaneous ventilation through the natural airway. End-tidal carbon dioxide tension (Petco₂), Spo₂, and respiratory rate were monitored for 60 min. The three regimens employing spontaneous ventilation through the natural airway were associated with both statistically and clinically significant increases in Petco₂ and decreases in Spo₂. This raises the possibility that acute exacerbation of PAP and PVR may occur in pulmonary hypertensive patients. In contrast, Petco₂ and Spo₂ did not change significantly from baseline in the controlled ventilation group.     

Procedural sedation for insertion of central venous catheters in children: comparison of midazolam/fentanyl with midazolam/ketamine

Background: There is a lack of studies evaluating procedural sedation for insertion of central venous catheters (CVC) in pediatric patients in emergency departments or pediatric intensive care units (PICU). This study was designed to evaluate whether there is a difference in the total sedation time for CVC insertion in nonintubated children receiving two sedation regimens. Methods: Patients were prospectively randomized to receive either midazolam/fentanyl (M/F) or midazolam/ketamine (M/K) i.v. The Children's Hospital of Wiscosin Sedation Scale was used to score the sedation level. Results: Fifty seven patients were studied (28 M/F and 29 M/K). Group M/F received midazolam (0.24 ± 0.11 mg·kg⁻¹) and fentanyl (1.68 ± 0.83 μg·kg⁻¹) and group M/K received midazolam (0.26 ± 0.09 mg·kg⁻¹) and ketamine (1.40 ± 0.72 mg·kg⁻¹). The groups were similar in age, weight, risk classification time and sedation level. Median total sedation times for M/F and M/K were 97 vs 105 min, respectively (P = 0.67). Minor complications occurred in 3.5% (M/F) vs 20.7% (M/K) (P = 0.03). M/F promoted a greater reduction in respiratory rate (P = 0.005). Conclusions: In this study of nonventilated children in PICU undergoing central line placement, M/F and M/K provided a clinically comparable total sedation time. However, the M/K sedation regimen was associated with a higher rate of minor complications. A longer period of study is required to assess the efficacy and safety of these sedative agents for PICU procedures in nonintubated children.     

Comparison of propofol-fentanyl with propofol-fentanyl-ketamine combination in pediatric patients undergoing interventional radiology procedures

Background: With an increase in the frequency of interventional radiology procedures in pediatrics, there has been a corresponding increase in demand for procedural sedation to facilitate them . The purpose of our study was to compare the frequency of adverse effects, sedation level, patient recovery characteristics in pediatric patients receiving intravenous propofol fentanyl combination with or without ketamine for interventional radiology procedures. Our main hypothesis was that the addition of ketamine would decrease propofol/fentanyl associated desaturation. Methods and materials: Sixty consenting American Society of Anesthesia physical status I–III pediatric patients undergoing interventional radiology procedures under sedation were studied according to a randomized, double‐blinded, institutional review board approved protocol. Group 1 received propofol 0.5 mg·kg^?1 + fentanyl 1 μg·kg^?1 + ketamine 0.5 mg·kg^?1, and group 2 received propofol 0.5 mg·kg^?1 + fentanyl 1 μg·kg^?1 + same volume of %0.9 NaCl intravenously. Results: While apnea was not observed in any of the groups, there were three cases (10%) in group 1, and nine cases (30%) in group 2 with oxygen desaturation (P = 0.052). In group 1, 12 (40%) patients and, in group 2, 21 (70%) patients required supplemental propofol during the procedure (P = 0.021). There was no evidence for difference between groups in terms of other side effects except nystagmus. Conclusions: In conclusion, addition of low dose ketamine to propofol‐fentanyl combination decreased the risk of desaturation and it also decreased the need for supplemental propofol dosage in pediatric patients at interventional radiology procedures.     

Propofol for tracheal intubation in children anesthetized with sevoflurane: a dose–response study

Background: Tracheal intubation during sevoflurane induction is frequently facilitated with i.v. propofol. We designed a dose–response study to evaluate the intubating conditions, and the incidence and duration of apnea after i.v. propofol in children. Methods/Materials: Sixty healthy children were randomly assigned to 0, 0.5, 1, 2 or 3 mg·kg^?1 i.v. propofol during sevoflurane/nitrous oxide anesthesia. Tracheal intubation was performed approximately 30 s after propofol by an anesthesiologist who was blind to the treatment. The anesthesiologist assessed the responses to laryngoscopy and intubation using a standardized scale. Incidence and duration of apnea after propofol as well as heart rate, and systolic blood pressure before and after laryngoscopy were recorded. Data were analyzed using one‐way and repeated measures anova , the Jonckheere–Terpstra test, and logistic regression, with P < 0.05 accepted. Results: The laryngoscopy score after 3 mg·kg^?1 propofol was less than that after 0 mg·kg^?1 (P < 0.01) and 0.5 mg·kg^?1 (P < 0.05). Incidence of apnea after propofol 3 mg·kg^?1, 8/10, was greater than after 0 mg·kg^?1, 3/14 (P < 0.011) and 0.5 mg·kg^?1, 3/12 (P < 0.03). Duration of apnea after 3 mg·kg^?1 was greater than after 0 and 0.5 mg·kg^?1 (P < 0.01). The risk of apnea increased 1.83 fold for each 1 mg·kg^?1 dose increase in propofol (P < 0.01). Mean heart rate and systolic pressure decreased with the main effect, time. Conclusion: During sevoflurane/nitrous oxide anesthesia, propofol 3 mg·kg^?1 provides superior intubating conditions with an increased incidence of and prolonged apnea compared with 0 and 0.5 mg·kg^?1.     

The influence of cold on pain during intravenous induction of anaesthesia with propofol in children

Pain on injection and quality of induction were compared in 74 children (5–12 years) randomly assigned to receive either 5 mg·kg^?1 of cold propofol (group A), 5 mg·kg^?1 of cold propofol mixed with lignocaine 1% (group B) or 5 mg·kg^?1 of propofol at room temperature (22–23°C) mixed with lignocaine 1% (group C). The group receiving cold propofol had to be stopped due to a very high incidence of pain (70%). The incidence of pain on injection was 3% in group B and 17% in group C (not significant). Quality of induction and side-effects were similar in the two groups.     

Posttonsillectomy vomiting. Ondansetron or metoclopramide during paediatric tonsillectomy: are two doses better than one?

This randomized, double blinded, placebo controlled, prospective study compared the antiemetic efficacy of one preoperative dose of metoclopramide 0.25 mg·kg^?1 intravenously or ondansetron 0.15 mg·kg^?1 intravenously with two doses of the same drugs (second dose administered one h postoperatively) in 200 preadolescent children undergoing tonsillectomy with either isoflurane or propofol anaesthesia. The incidence of posttonsillectomy vomiting was significantly reduced (P < 0.005) by two doses of either metoclopramide or ondansetron (18% and 8%, respectively) compared with placebo (50%). No difference in posttonsillectomy vomiting exists between the children who received isoflurane and those who received a propofol infusion. Our results suggest that two doses of metoclopramide 0.25 mg·kg^?1 intravenously, like two doses of ondansetron 0.15 mg·kg^?1, are effective in reducing vomiting after tonsillectomy in children who have received either isoflurane or propofol anaesthesia.     

Analgesia for adenotonsillectomy in children: a comparison of morphine, ketamine and tramadol

Background : Establishment of good analgesia is of major concern in the postoperative period following adenotonsillectomy. The aim of this study was to compare the effects of ketamine, morphine and tramadol on postoperative pain after adenotonsillectomy in children. Methods : Sixty children (age 5–12 years) scheduled for adenotonsillectomy were randomized into four groups to receive intravenously (i.v.) either 0.5 mg·kg^?1 ketamine hydrochloride (K), 0.1 mg·kg^?1 morphine hydrochloride (M), 1.5 mg·kg^?1 tramadol hydrochloride (T) or normal saline (S) in a volume of 4 ml during induction. After tracheal intubation 10 μg·kg^?1·min^?1 ketamine hydrochloride in group K and 0.6 ml·kg^?1·h^?1 saline i.v. in groups M, K and S were infused peroperatively. Postoperative analgesic requirements and side‐effects were recorded. Pain was assessed by the Numeric Rating Scale (NRS) and the Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) scores. Results : Heart rate increased significantly peroperatively only in group K. NRS at first and fifth minute in group M and at first minute in group T and K and CHEOPS score at first, fifth, 15th and 60th min in group M were found to be significantly lower than in the control group. The time to first analgesic requirement was significantly longer in group M compared with ketamine and the control group. Six children in group M, nine in group T, 11 in group K and 15 in group S needed additional analgesics. Conclusions : Morphine hydrochloride 0.1 mg·kg^?1 i.v. administered during induction of anaesthesia provides efficient pain relief in children undergoing adenotonsillectomy.     

Effect of different anesthetic agents on oculocardiac reflex in pediatric strabismus surgery

Purpose

The oculocardiac reflex (OCR) occurs frequently during pediatric strabismus surgery. The aim of this study was to assess the effects of various anesthetic regimens on the incidence of OCR during the surgery.

Methods

Two hundred and eighty children, 1 to 9 years old, undergoing elective strabismus surgery, were randomly assigned to eight groups; ketamine-sevoflurane (KS), ketamine-desflurane (KD), ketamine-propofol (KP), ketamine-remifentanil (KR), midazolam-sevoflurane (MS), midazolam-desflurane (MD), midazolam-propofol (MP), and midazolam-remifentanil (MR). No premedication was given. Anesthesia was induced using ketamine 1 mg·kg^?1 or midazolam 0.15 mg·kg^?1 with 66% N₂O in O₂. Laryngeal mask airways (LMAs) were placed with rocuronium 0.5 mg·kg^?1. Anesthesia was maintained with sevoflurane 2–3 vol. %, desflurane 5–6 vol. %, propofol 7–8 mg·kg^?1·h^?1, or remifentanil 0.75 µg·kg^?1 over 1 min, followed by a continuous infusion of remifentanil 0.5 µg·kg^?1·min^?1 with 66% N₂O in O₂. Heart rate (HR) was recorded during extraocular muscle (EOM) manipulation. OCR was defined as a reduction in HR of more than 20% induced by the traction of an EOM.

Results

In patients given ketamine, OCR occurred more frequently in the KP (65.7%) and KR (62.9%) groups than in the KD (29.4%) and KS (37.1%) groups (P < 0.05). In patients given midazolam, OCR occurred more frequently in the MP (54.3%) and MR (60.6%) groups than in the MD (36.4%) and MS (31.4%) groups (P < 0.05).

Conclusion

Propofol or remifentanil anesthesia was associated with a higher incidence of OCR during pediatric strabismus surgery than sevoflurane and desflurane anesthesia, when either ketamine or midazolam was used as an induction agent.