The place of ropivacaine in anesthesia

Ropivacaine has two advantages over bupivacaine. It provides more differential block when given epidurally, allowing for a better separation between sensory and motor block. This feature can be used to its advantage in obstetrics and in postoperative epidural pain relief. Ropivacaine has a lower systemic toxicity than both racemic and levobupivacaine. Especially its better cardiotoxic profile has been well documented and is an important advantage when using techniques with a potential for high plasma concentrations. Ropivacaine is less potent than bupivacaine and has a shorter duration of action. The magnitude of this potency difference however is not clearly quantified and differs with varying techniques. In some studies, the potency difference amounts up to 50% whereas in other studies the difference is negligible. The lower systemic toxicity of ropivacaine compared to bupivacaine is not offset by a lower potency, as ropivacaine in a 50% higher dose is still less cardiotoxic.     

The place of premedication in pediatric practice

Behind the multiple arguments for and against the use of premedication, sedative drugs in children is a noble principle that of minimizing psychological trauma related to anesthesia and surgery. However, several confounding factors make it very difficult to reach didactic evidence-based conclusions. One of the key confounding issues is that the nature of expectations and responses for both parent and child vary greatly in different environments around the world. Studies applicable to one culture and to one hospital system (albeit multicultural) may not apply elsewhere. Moreover, the study of hospital-related distress begins at the start of the patient's journey and ends long after hospital discharge; it cannot be focused completely on just the moment of anesthetic induction. Taking an example from actual practice experience, the trauma caused by the actual giving of a premedication to a child who absolutely does not want it and may struggle may not be recorded in a study but could form a significant component of overall effect and later psychological pathology. Clearly, attitudes by health professionals and parents to the practice of routine pediatric premedication, vary considerably, often provoking strong opinions. In this pro–con article we highlight two very different approaches to premedication. It is hoped that this helps the reader to critically re-evaluate a practice, which was universal historically and now in many centers is more selective.     

The future of pediatric anesthesia

The future of pediatric anesthesia can be thought of in terms of what will happen to the practice of anesthesia, or what will happen to the profession of pediatric anesthesia. The profession will change both under external forces, and by how pediatric anesthetists themselves decide to shape of the profession. The largest external force is likely to be cost. The profession will increasingly be expected to maintain efficiency without compromising quality. Other future issues include credentialing, training and the role of the anesthetists beyond the operating room. It’s harder to predict how the practice of pediatric anesthesia might change. New drugs may change practice, though perhaps it’s more likely that practice will change with better use of existing drugs. New technologies will have an impact in monitoring and in the gathering and dissemination of information. Practice will also change with changes in surgery. Perhaps the biggest changes will come in areas with the greatest unknowns; neonatal anesthesia is an area with many unknowns and thus great potential for change and improvement.     

The surface anesthesia in outpatient pediatric department

The combination of even parts lidocaine and prilocaine in crème substance was used for surface anesthesia in 73 children, aged 1,5-16 years. Such surgical interventions as molluscum contagiosum eradication, laser wart resection and prepuce synechia dissection were performed. The described anesthetic was highly effective in all areas, but the nasolabial triangle. Resection of warts larger then 0,5 sm required either additional infiltrative anesthesia or step-wise resection. Local allergic reaction was registered in one case, no systemic reactions were noticed. Generally, the used method of surface anesthesia proved to be highly appropriate in pediatric practice.     

琥珀胆碱和罗库溴铵对全麻诱导期氧供需平衡的影响

目的观察全麻诱导期琥珀胆碱和罗库溴铵对机体氧供需平衡的影响。方法60~70岁全麻手术患者30例,ASAⅠ~Ⅱ级,随机均分为三组:琥珀胆碱组(S组),罗库溴铵组(R组)和对照组(C组),每组10例。右颈内静脉穿刺置管至右心房,分别于麻醉前(T0)、给肌松药前(T1)、给肌松药后1 min(T2)、2 min(T3)、3 min(T4)和5 min(T5)抽右心房血,测定右心房血氧饱和度(RASVO2)、乳酸(Lac)和右心房血氧分压(RAPVO2)。结果三组患者RASVO2、Lac、RAPVO2在相应时点差异无显著意义。与T1相比,S组RASVO2在T2、T3、T4时点明显升高(P<0.05),Lac在T2、T3、T4、T5时点亦明显升高(P<0.05),R组T2时点RASVO2明显升高(P<0.05),而Lac无明显变化。结论琥珀胆碱和罗库溴铵全麻诱导期均可减少机体氧耗量,但琥珀胆碱可引起无氧代谢增加,组织氧供需失衡。     

Narcotrend在小儿手术全身麻醉中的临床应用

目的 研究Narcotrend(NT)监测在小儿患者全身麻醉中的临床效果. 方法 择期美国麻醉医师协会(ASA)分级Ⅰ～Ⅱ级、行扁桃体切除术小儿全麻患者60例,采用随机数字表法分为NT监测组(N组)和常规对照组(C组)(每组30例).以丙泊酚和瑞芬太尼维持麻醉,术中N组丙泊酚浓度根据NT值进行调整,C组丙泊酚浓度依据患者的血压、心率等生命体征进行调控.记录两组的麻醉时间、手术时间、苏醒时间、拔管时间,记录丙泊酚的用量和患者围手术期躁动、恶心呕吐、术中知晓等的发生率. 结果 两组患者的苏醒时间与拔管时间比较,N组[(6.2±1.1) min、(11.1±1.0) min]较C组[(14.1±1.8) min、(18.5±1.6) min]缩短,差异有统计学意义(P＜0.01);丙泊酚的用量比较,N组(99±8) mg较C组(148±8) mg明显减少,差异有统计学意义(P＜0.01);围手术期躁动、恶心呕吐、术中知晓等的发生率差异无统计学意义. 结论 小儿患者行扁桃体切除手术采用NT监测麻醉深度,较传统凭经验给药更安全,能减少不必要地过量使用静脉全身麻醉药物,缩短苏醒时间.     

Opiates in pediatric anesthesia

Narcotic analgesics, although frequently used in adult patients, are at present relatively minor drugs in pediatric anesthesia. This review discusses indications, clinical applications, and side effects of opiates for pre-medication, induction and maintenance of anesthesia, and postoperative pain therapy in infants and children. Opiates do not represent the agents at first choice for preoperative anxiolysis or amnesia. With the exception of certain disease states (cardiac risk, elevated intracranial pressure, malignant hyperthermia) where intravenous anesthesia including opiates is clearly indicated, inhalational anesthetics are commonly preferred to narcotics. It has been shown, however, that opiate-supplemented general anesthesia can be used for pediatric surgery in an equally effective and safe manner. Finally, there is an essential need for more narcotic analgesics in the treatment of early postoperative pain, when antipyretic-antiphlogistic analgesics alone prove ineffective. It thus seems that in pediatric anesthesia today opiates are prescribed at the wrong time and withheld when they are most urgently needed.     

Risk in pediatric anesthesia

Risk in pediatric anesthesia can be conveniently classified as minor or major. Major morbidity includes cardiac arrest, brain damage and death. Minor morbidity can be assessed by clinical audits with small patient samples. Major morbidity is rare. It is best assessed by very large clinical studies and by review of closed malpractice claims. Both minor and major morbidity occur most commonly in infants and children under three, especially those with severe co‐morbidities. Knowledge of risk profiles in pediatric anesthesia is a starting point for the reduction of risk.     

Opioids in pediatric anesthesia

Opioids are used widely in the practice of pediatric anesthesia and pediatric perioperative medicine. The benefits of opioids are well documented, and their pharmacology has been extensively studied. Nonetheless special care is important when using these agents in the pediatric population. This article addresses the developmental pharmacologic changes that occur with opioids as well as their most common clinical uses.     

Mortality in pediatric anesthesia

In last the 50 years many studies have described the causes of mortality. In newborns and infants between 5 and 6 months the risk is higher. The heart is not developed as in older/grown child and these infants need more oxygen than the older ones. Probably, the interaction or interference of positive pressure ventilation with the neonatal circulation is an important cause leading to this pathology. In many studies the authors have identified this risk in the administration of alothane. A more comprehensive literature is needed about sevoflurane in order to know if it is effective. The incidence of complications with an was twice higher than the incidence with a pediatric anesthetists. In the 50s, there have been many changes in our operational METHODS: Actually, we need more randomized and controlled studies to answer the question oh what is the cause of mortality and what we will be able to do in the future to prevent infant mortality in the operation room.     

Isoflurane in pediatric anesthesia

Seventy patients 1-10 years of age were submitted to isoflurane (I) or halothane (H) anaesthesia (O2:N2O = 1:3); H was used as a reference substance. Under I anaesthesia, haemodynamic parameters proved to be well preserved. While the pulse rate under I increased significantly, the diastolic pressure decreased as a result of peripheral vascular dilatation. Baroceptor reflexes seemed to function more properly under the effect of I. Spontaneous respiration was definitely depressed by I. Respiratory rate, minute volume, end-expiratory CO2 and pCO2 values indicated CO2 accumulation. Younger children breathing spontaneously were subject to airway problems in I more than in H anaesthesia by decreasing negative occlusion pressures. Increasing doses of vecuronium bromide (5, 10, 15 and 70 micrograms/kg body wt.) accomplished muscular relaxation of various degrees, as tested by the train-of-four (TOF) method. The use of I in two age groups resulted in faster onset, more profound muscular relaxation, and longer duration in comparison with H; these results were statistically significant.