Isoflurane in paediatric anaesthesia

The characteristics of induction with and recovery from isoflurane anaesthesia were studied in 248 children. The mean time to loss of consciousness was 1.5 min (SD 0.5). Tracheal intubation, without interruption of spontaneous ventilation, was accomplished in a mean time of 4.2 min (SD 54 seconds). Movement and excitement, of 20-30 seconds duration, occurred in 23.9% children and 22 patients coughed during induction; 15 (12.6%) during the first 124 inductions; 7 (5.6%) subsequently. The mean half-times of reduction of alveolar isoflurane concentrations in 28 children whose lungs were ventilated with isoflurane and in 13 children who breathed isoflurane spontaneously during anaesthesia were: 45 sec after exposure for one hour, 70 sec after exposure of 2-3 hours and 110 seconds following exposures of 4-8 hours. The mean recovery times of the three groups were 6.5, 9.5 and 11.5 min respectively. In two further groups of nine children the mean half times of elimination of halothane and isoflurane were 220 seconds and 54 seconds respectively; recovery from isoflurane was markedly faster. Isoflurane is well accepted by children; induction is more rapid than with halothane, and the marked flexibility in the control of its effects are due to its relative insolubility. It has wide application in paediatric anaesthesia.     

Controversies in paediatric anaesthesia

Canadian Journal of Anesthesia/Journal canadien d'anesthésie -     

Desflurane in paediatric anaesthesia

Summary
Despite the low blood-gas coefficient of desflurane, inhalational induction is delayed by airway complications in paediatric practice. A slow induction technique reduces airway complications in adults. The aim of this study was to examine the use of desflurane for paediatric anaesthesia and to reduce airway complications with a slow induction technique. Sixty children (age range, 1 month to 12 years) were anaesthetized with 3% desflurane, increased by 1% every minute until anaesthesia was adequate for tracheal intubation. Anaesthesia was maintained with oxygen, nitrous oxide, and desflurane delivered by mechanical ventilation. During induction of anaesthesia, the incidence of moderate to severe coughing was 20%, breath-holding 14%, and laryngospasm 31%. Blood pressure fell significantly ( P < 0.05) from baseline after induction of anaesthesia and remained at this level during anaesthesia. Heart rate was stable in children less than six years, but increased significantly in older children. There were no significant airway problems during recovery from anaesthesia. Recovery time was rapid: the time to awakening was 10.2 min and to discharge from the recovery room, 29.2 min. Although desflurane is not an ideal anaesthetic agent for inhalational induction in children, it maintains stable anaesthesia and provides rapid smooth recovery.     

Quality in paediatric anaesthesia

The delivery of the highest quality anaesthetic services to children depends on many factors. All staff should be adequately trained and have appropriate continuing experience. Though facilities should be as accessible as possible, they must conform to nationally recognized standards. These cover not only the skills of surgeons, anaesthetists, nursing and ancillary staff but also the provision of paediatric medical support, emergency treatment and intensive care. Standards have also been set in relation to day-care and inpatient facilities, perioperative care, acute pain management and resuscitation services. Where possible, children's surgery should be performed on dedicated operating lists, where it may be easier to create a child-orientated environment and where teaching can be effective. There should be effective links with the nearest tertiary paediatric centre and appropriate arrangements for interhospital transfer.Most children's surgery will continue to be carried out in District Hospitals, where a multidisciplinary team should agree local practice and devise protocols based on national guidelines. The concept of acceptable continuing experience should be applied flexibly, using criteria based on children's age, number of cases performed by an individual per year and case mix.In this age of risk management, professional self-regulation and clinical governance, those providing surgical services for children must be able to justify their policies.     

Propofol in paediatric anaesthesia

Propofol has been used in paediatric anaesthesia since 1985 and an increasing body of evidence has shown that it is a safe, effective induction agent which has dose-related side-effects comparable with other agents. Pain on injection can be ameliorated by the use of antecubital veins or by pre-mixing an adequate amount of lignocaine with propofol immediately prior to administration. The pharmacokinetics of propofol are different in children with their larger central compartment volume and clearance reflected in higher dose requirements for induction and maintenance of anaesthesia. This has important implications when propofol is given for sedation or anaesthesia by continuous infusion.