Oral midazolam and oral butorphanol premedication

Objective: To evaluate the efficacy of oral midazolam and oral butorphanol for their sedative analgesic effects in children.Methods: Sixty children, aged 2 to 10 yrs, of ASA physical status I and II, scheduled for surgical procedures of 1 to 2 hrs duration were randomized to one of the two groups. Group I : children received midazolam 0.5mg/kg orally and Group II : children received butorphanol 0.2mg/kg orally. Score of the children was assessed every 5 minutes till the induction of anesthesia. Intraoperative and postoperative analgesic requirement was recorded alongwith postoperative recovery and complications.Results: The groups were identical regarding the patient’s characteristics, hemodynamic variables, duration of surgery and awakening time. Less time was required for the onset and time of maximum sedation in the butorphanol group (p<0.05). Sedation scores were similar among the groups at all time intervals, while the scores were higher in the butorphanol group at the time of induction (p<0.05). Less number of children required intraoperative and postoperative rescue analgesia in the butorphanol group (p<0.05). Statistically significant difference was found among the groups in respect to complete amnesia (50% in group Ivs 80% I group II, p<0.05) and recollection (40% in group Ivs 10% in group II, p<0.05).Conclusion: Oral butorphhanol is comparable to oral midazolam in children but analgesia alongwith sedation is an additional advantage which makes it better than midazolam without a significant increase in side effects.     

Urinary sodium excretion: Association with hyperinsulinaemia,hypertension and sympathetic nervous system activity in obese and control children

The aim of the present study was to evaluate the association between 24 h urinary excretion of sodium and blood pressure, fasting plasma insulin, renin, aldosterone and serum norepinephrine concentrations in 45 obese and 15 control children. Urinary sodium excretion was significantly lower in obese subjects (1.3 ± 0.6 mmol/kg/24 h, P < 0.01) than in controls (2.8 ± 1.3 mmol/kg/24 h). Hyperinsulinaemia did not affect sodium excretion of obese children. Plasma renin and aldosterone levels did not correlate with sodium excretion and were significantly higher in overweight children. Serum norepinephrine levels were also significantly higher in the obese group (0.66 ± 0.89 μg/100 ml) as compared to the controls (0.11 ± 0.03 μg/100 ml, P < 0.01) and showed significant negative correlation with urinary sodium excretion (r = 0.43, P < 0.05). Conclusion Hyperinsulinaemia and the consequently increased sympathetic nervous system activity might be involved in the development of high blood pressure in obese children by decreasing urinary sodium excretion. Received: 17 January 1995 Accepted: 28 March 1996     

The success rate and complications of awake caudal epidural bupivacaine alone or in combination with intravenous midazolam and ketamine in pre-term infants

Background:

The aim of the present study is to compare the success rate and complications of caudal epidural bupivacaine alone or in combination with intravenous (IV) midazolam and ketamine in awake infants undergoing lower abdominal surgery.

Materials and Methods:

In this double-blind, clinical trial study, 90 infants (aged below 3 months and weight below 5 kg) with American Society of Anaesthesiologists I-II, were divided into three groups of each 30: Group 1 received bupivacaine 0.25%, 1 mL/kg for caudal epidural block; Groups 2 and 3 received caudal block with same dose bupivacaine along with IV pre-treatment with midazolam 0.1 mg/kg or IV midazolam 0.1 mg/kg and ketamine 0.3 mg/kg, respectively.

Results:

The success rates in Groups 2 and 3 were 93.3% and 93.1%, respectively, compared with a caudal block with bupivacaine alone 80%; P = 0.015). There was no significant difference among the three groups in terms of mean systolic and diastolic blood pressures and mean heart rate at intervals of 0, 20, 40 and 60 min (P < 0.05). There were no significant differences in the pain scores >3 on the Neonatal Infant Pain Scale at three intervals (30, 60 and 120 min) after surgery among the three groups. The complications such as apnoea or desaturation were not found in any of the studied groups.

Conclusions:

Adding IV ketamine and/or midazolam to bupivacaine caudal epidural block in the conscious infants can positively affect block success rate.Key words: Awake caudal epidural block, bupivacaine, children, ketamine, midazolam     

Could adding magnesium as adjuvant to ropivacaine in caudal anaesthesia improve postoperative pain control?

Recently, most studies reported magnesium as a N-methyl-d-aspartate receptor antagonist and its analgesic and perioperative anaesthetic effects have been discussed with central desensitization pathway. We investigated the effects of caudal ropivacaine plus magnesium and compared with ropivacaine alone on postoperative analgesia requirements. After hospital ethic committee’s consent, 60 patients (ASA I-II, 2–10 years old) who had lower abdominal or penoscrotal surgery were enrolled in the study. After general anaesthesia induction, caudal blockage was applied. Patients were randomly assigned in two groups. Ropivacaine 0.25% was administered to Group R (n = 37), ropivacaine 0.25% plus 50 mg magnesium to Group RM (n = 23) in 0.5 ml kg⁻¹ volume. Postoperative analgesia level was recorded at 15 min and 1, 2, 3, 4, 6 h by using Paediatric Objective Pain Scale (POPS) and The Children’s Hospital of Eastern Ontoria Pain Scale (CHEOPS). Postoperative motor blocks were evaluated with Modified Bromage Motor Block Scale. According to demographic characteristics, there were no significant differences between the two groups (P > 0.05). POPS, CHEOPS, Bromage Motor Scales, analgesia duration and adverse effects were similar in Group R and Group RM. It has been shown that addition of magnesium as an adjuvant agent to local anaesthetics for caudal analgesia has no effect on postoperative pain and analgesic need.     

Prospective evaluation of the pharmacodynamics of piritramide in neonates and infants

Piritramide is a synthetic opioid commonly used in Germany and Austria for the analgesia of pediatric patients. Little pharmacokinetic and pharmacodynamic data for the pediatric population is available. The aim of this investigation was to gain pharmacodynamic data on postsurgical analgesia and the side effects of piritramide. The study was approved by the Ethics Committee of the Medical Faculty. Data were collected in an open, prospective clinical trial. After obtaining the parents’ informed written consent, patients received a bolus of piritramide 50 μg/kg for postsurgical analgesia or to prevent pain resulting from invasive procedures. Titration doses of 15 μg/kg were allowed. Vital signs and pain intensity were closely monitored. Data from 39 patients could be included in the analysis. Of the patients, 95% were in the immediate postsurgical course, 5% had piritramide for invasive procedures, and 46% of the patients were ventilated. The mean piritramide dosage was 64 ± 24 μg/kg. Pharmacodynamic analysis showed adequate analgesia for at least 50% of the spontaneously breathing patients for 120 min after piritramide bolus. More than 50% of the ventilated patients showed inadequate analgesia at any point in time after piritramide bolus. Fifty-nine percent (59%) of the ventilated patients received additive analgesia versus 31% of spontaneously breathing patients. No relevant changes of vital signs could be observed. One patient received naloxone for apnea. We conclude that dosages of more than 50–70 μg/kg are needed for sufficient analgesia in ventilated postsurgical infants. In spontaneously breathing patients, 50–70 μg/kg provides a 120-min period of analgesia for more than 50% of patients. Cardiovascular stability of the patients was good and, with one exception, there was no respiratory depression     

Effect of elective antibiotic therapy on resting energy expenditure and inflammation in cystic fibrosis

Cystic fibrosis (CF) patients often present with malnutrition which may partly be due to increased resting energy expenditure (REE) secondary to inflammation. Both REE and tumour necrosis factor-alpha (TNF-α), as other markers of inflammation, are elevated during respiratory exacerbations and decrease after antibiotic treatment. However, the effect of antibiotic therapy on REE and inflammation in patients without respiratory exacerbation is not known. The aim of our study was to determine the effect of such an elective antibiotic therapy on REE, TNF-α, and other serum markers of inflammation. Twelve CF patients 5F/7M, age 15.9 ± 6.1 years, weight for height ratio 89 ± 8% without clinically obvious exacerbation and treated by intravenous antibiotics were studied. Both before (D0) and after (D14) treatment, pulmonary function tests were performed. REE was measured by indirect calorimetry and blood taken to measure inflammation parameters. Body weight increased by 1.1 kg from D0 to D14 (P < 0.001), composed of 0.3 kg fat mass and 0.8 kg fat-free mass (FFM). The forced expiratory volume at 1 s increased from 43 ± 15% of predicted at D0 to 51 ± 15% of predicted at D14 (P < 0.01). Mean REE was 41.1 ± 7.6 kcal/kg FFM per day at D0 and did not change significantly at D14 (40.6 ± 8.5 kcal/kg FFM per day). Serum markers of inflammation decreased from D0 to D14: C-reactive protein 17 ± 17 mg/l to 4 ± 7 mg/l (P < 0.05), elastase 62 ± 29 μg/l to 45 ± 18 μg/l (P < 0.02), orosomucoid acid 1.25 ± 0.11 g/l to 0.80 ± 0.15 g/l (P < 0.001), and TNF-α 37 ± 14 pg/ml to 29 ± 6 pg/ml (P = 0.05). Individual values showed a correlation between changes in REE and in TNF-α (P < 0.02). Conclusion The contribution of inflammation to energy expenditure is possible but appears to be minimal in cystic fibrosis patients treated by antibiotics on a regular basis in the absence of clinically obvious exacerbation. Received: 6 August 1998 and in revised form: 23 November 1998 / Accepted: 23 November 1998     

A comparison of intratracheal and intravenous administration of gentamicin during liquid ventilation

Pulmonary absorption of aminoglycosides is poor with intravenous administration, but may be enhanced by direct intratracheal administration of these drugs using perfluorochemical liquid ventilation (LV). To test this hypothesis, gentamicin sulfate was administered to two groups of newborn lambs during LV. Serum and lung tissue levels of gentamicin were compared after either pulmonary intratracheal (IT) or intravenous (IV) routes of administration. Serial serum levels of gentamicin were obtained every 15 min for the 1st h, every 30 min for the 2nd h, and then hourly until sacrifice (maximum 6 h). At sacrifice, representative samples of each lung lobe were homogenized and analyzed for tissue gentamicin content. At 1 h, serum gentamicin levels were similar in both groups: IT administration levels were 3.7 ± 0.55 SE μg/ml and IV levels were 3.5 ± 0.85 SE μg/ml. The peak serum gentamicin level of 4.8 ± 0.8 SE μg/ml for the pulmonary administration group occurred 1.5 h after administration. Lung tissue levels of gentamicin for IT administration (4.04 ± 0.62 SE μg/g) were significantly greater than for IV administration (1.75 ± 0.33 SE μg/g; P < 0.05). There were no significant differences in interlobar gentamicin distribution for either mode of administration. Conclusion Perfluorochemical can be used as a vehicle for intratracheal delivery of antimicrobials. This route provides equivalent serum levels at 1 h, higher lung tissue levels, and uniform interlobar distribution relative to intravenous administration of gentamicin. We speculate that pulmonary administered gentamicin during LV may provide an effective alternative treatment modality in the management of severe neonatal pneumonia. Received: 12 April 1996 and in revised form: 24 July 1996 / Accepted 28 July 1996     

Effect of central precocious puberty and gonadotropin-releasing hormone analogue treatment on peak bone mass and final height in females

To evaluate the effect of central precocious puberty (CPP) and its treatment with gonadotropin-releasing hormone (GnRH) analogues on final height and peak bone mass (PBM), we measured lumbar bone mineral density (BMD) in 23 girls at final height. Patients were distributed in two groups. Group 1: 14 patients with progressive CPP were treated with GnRH analogues; seven patients received buserelin (1600 μg/daily), subsequently switched to depot triptorelin (60 μg/kg/26–28 days); seven patients were treated with depot triptorelin (60 μg/kg/26–28 days); mean age of treatment was 6.2 years (range 2.7–7.8 years); the treatment was discontinued at the mean age of 10.1 years (range 8.7–11.3 years); final height was reached at the mean age 13.4 years (range 12.0–14.9 years). Group 2: 9 patients (mean age 6.5 years, range 4.8–7.7 years) with a slowly progressing variant of CPP were followed without treatment; final height was reached at the mean␣age␣13.6 years (range 12.5–14.8 years). Lumbar BMD (L₂-L₄ by dual energy X-ray␣absorptiometry) was measured in all patients at final height. In group 1, final height␣(158.9 ± 5.4 cm) was significantly greater than the pre-treatment predicted height (153.5 ± 7.2 cm, P < 0.001), but significantly lower than mid-parental height (163.2 ± 6.2 cm, P < 0.005). Subdividing the girls of group 1 according to the bone age at discontinuation of therapy (i.e. ≤11.5 years, n = 5, or ≥12.0 years, n = 9), the former patients had a final height significantly higher than the latter (163.7 ± 3.9 cm vs 156.5 ± 4.6 cm, P < 0.02). In group 2, final height (161.8 ± 4.6 cm) was similar to the pre-treatment predicted height (163.1 ± 6.2 cm, P = NS) and was not significantly different from mid-parental height (161.0 ± 5.9 cm). BMD values (group 1: 1.11 ± 0.14 g/cm², group 2: 1.22 ± 0.08 g/cm²) were not significantly different from those of a control group (1.18 ± 0.10 g/cm²; n = 20, age 16.3–20.5 years) and the patients' mothers (group 1: 1.16 ± 0.07 g/cm², n = 11, age 32.9–45.1 years; group 2: 1.20 ± 0.08 g/cm², n = 7, age 33.5–46.5 years). In group 1, the girls who stopped therapy at a bone age ≤11.5 years had significantly higher BMD (1.22 ± 0.10 g/cm²) compared to those who discontinued therapy at a bone age ≥12.0 years (1.04 ± 0.12 g/cm², P < 0.05). Conclusion In girls with progressive CPP, long-term treatment with GnRH analogues improves final height. A subset of patients with CPP does not require treatment because good statural outcome (slowly progressing variant). In CPP, the abnormal onset of puberty and the long-term GnRH analogue treatment do not impair the achievement of PBM. In GnRH treated patients, the discontinuation of therapy at an appropriate bone age for pubertal onset may improve both final height and PBM. Received: 5 June 1997 / Accepted in revised form 21 November 1997     

Plasma fibronectin levels in meningococcal disease

Fibronectin (a glycoprotein which modulates inflammation) may decrease mortality in systemic infection. Children with meningococcal disease (MCD) may have low fibronectin levels. We aimed to compare plasma fibronectin levels in children with MCD and controls, correlate fibronectin levels with interleukin-6 (IL-6), shock and death, and assess fibronectin as an aid to early diagnosis in MCD. Samples were taken on admission from 99 children with MCD and 49 controls. Plasma fibronectin was measured using a turbidimetric immunoassay. Plasma fibronectin was significantly lower in MCD compared to controls (57 μg/ml vs 105 μg/ml; P < 0.005). Children who died had significantly lower levels than survivors (29 μg/ml vs 62 μg/ml; P = 0.01). Fibronectin levels were negatively correlated with IL-6 levels. Fibronectin was a poor predictor of MCD. Conclusion Plasma fibronectin levels are decreased in children with MCD, especially in shock and death. This decrease is associated with high IL-6 levels. Fibronectin could be a novel therapy in severe MCD. Received: 6 June 1996 / Accepted: 16 October 1996     

Effect of antioxidant therapy on collagen synthesis in corrosive esophageal burns

To investigate the efficacy of antioxidant therapy on collagen synthesis in corrosive esophageal burns, 110 Sprague-Dawley rats were divided into five groups of 22 animals each. A standard esophageal caustic burn was produced by 1 ml of 10% sodium hydroxide solution for the rats in groups B to E; group A was instilled only with 0.9% saline after preparation of the distal esophageal segment. Group A animals (controls) were uninjured and untreated. Group B had untreated esophageal burns. Esophageal burns were treated in group C with vitamin E (10 mg/kg IM), in group D with vitamin C (10 mg/kg IP), and in group E with methylprednisolone (30 mg/kg IM) on each of 5 days. Eight rats from each group were killed 4 days after initiation of the study and the abdominal esophagus was studied for tissue malondialdehyde (MDA; μmol/g protein) levels. The other rats were killed 28 days after initiation of the study and determination of hydroxyproline (HP) (μg/g tissue) levels in esophageal tissue was performed for 8 rats in each group. Histopathologic evaluation was also performed in the other 6 rats from each group. MDA levels in esophageal tissue were significantly lower in groups C (9.24 ± 2.62, P < 0.01) and group E (6.26 ± 2.22, P < 0.001) than in group B (12.35 ± 1.80). HP levels were significantly lower in groups A (0.75 ± 0.21, P < 0.001), C (1.11 ± 0.15, P < 0.01), and E (0.96 ± 0.15, P < 0.001) than in group B (1.40 ± 0.20). Histopathologically, collagen deposition in the submucosa and tunica muscularis was lower in groups C and E than in group B (P < 0.05, and 0.01, respectively). Our results demonstrate that treatment with antioxidant drugs such as vitamin E and methylprednisolone decreased tissue HP levels, and thus inhibited new collagen synthesis and stricture formation in rats with alkali-induced caustic esophageal burns. Accepted: 16 February 2001     

Improving quality of life in asthmatic children

Objective: To assess quality of life changes in pediatric asthmatic patients switched into a single inhaler device of BudesonideJFormoterol.Methods: Thirty pediatric patients (ages 6–15 years) with moderate to severe chronic asthma previously treated with inhaled beclometasone dipropionate at a daily dose of ≥400 μg were selected to participate in an open label study. At the baselinephase (one month), pulmonary function tests (PFTs), indicators of asthma control, and a quality of life assessment (using a special questionnaire) were evaluated. Patients were initiated on a single inhaler device containing budesonide 160 μg/formoterol 4.5 μg, one inhalation twice daily instead of their previous inhaled corticosteroid and followed for two months. PFTs, indicators of asthma control, and a quality of life assessment were evaluated at each visit.Results: After switching to the new therapy, patients showed significant changes towards better quality of life in all aspects. The overall score dropped from 1.75±0.04 to 0.80 ±0.07 (mean ±SEM), p<0.001 (Score scale varies between 0: excellent to 2: very bad Health related quality of life). There was an improvement in the PFTs, where the FEV₁% improved from 62.7±2.8 to 87.4 ±4.6 (mean ±SEM), and the FVC% improved from 83.2 ±3.5 to 101.9 ±5.3 (mean ±SEM), p <0.001, and better control of asthma.Conclusion: Switching treatment from beclomethasone dipropionate to budesonideJformoterol combination appeared to improve quality of life in the patient population evaluated and in the appropriate clinical indices.     

A Prospective Evaluation of Nesiritide in the Treatment of Pediatric Heart Failure

This study sought to determine the potential of recombinant B-type natriuretic peptide (nesiritide) for the treatment of pediatric decompensated heart failure. Nesiritide is a widely used and effective treatment for decompensated heart failure (HF) in adults, but its safety and efficacy in pediatric patients is unclear. Outcomes of 55 separate nesiritide infusions of varying durations in 32 patients (13 males and 19 females; mean age, 8.01 years; range, 0.01–20.4) were evaluated prospectively. All patients received nesiritide in the intensive care unit. The starting dose (0.01 μg/kg/min) was titrated to a maximum of 0.03 μg/kg/min. All patients were monitored for clinical signs and symptoms, hemodynamics, urine output, electrolytes, oxygen requirements, and oral intake. Functional status was assessed by patients and/or their parents. All patients successfully underwent initiation and titration of nesiritide infusion. No hypotension or arrhythmias were noted during 478 cumulative days of therapy. Nesiritide was given safely with vasoactive medications. Mean urine output improved from 2.35 ± 1.71 cc/kg/hr on the day before nesiritide initiation (baseline) to 3.10 ± 1.94 cc/kg/hr on day 4 of treatment (p < 0.01). Serum creatinine decreased from 1.04 to 0.92 mg/dl (p = 0.096), mean central venous pressure from 13 to 7 mmHg (p = 0.018), and mean weight from 30.4 to 29.7 kg (p < 0.001) with therapy. Thirst, as subjectively assessed by patients old enough to respond, decreased with infusion in 31 of 42 cases (74%). Mean New York Heart Association functional class improved significantly (p < 0.001). Nesiritide infusion, alone or in combination, is a safe treatment for decompensated HF in pediatric patients. It is associated with decreased thirst and improved urine output and functional status, and it may be efficacious in the treatment of pediatric HF.     

Effect of patent ductus arteriosus and indomethacin treatment on serum cardiac troponin T levels in preterm infants with respiratory distress syndrome

Cardiac troponin T (cTnT) represents a sensitive and specific marker of ischemic myocardial damage in adult and neonatal populations. The aim of this study was to detect the potential ischemic effect of persistent patent ductus arteriosus (PDA) and indomethacin treatment on the coronary vascular bed by measuring cTnT concentrations. cTnT levels were measured in 23 preterm infants (<32 weeks of gestational age) with respiratory distress syndrome (RDS), 11 with PDA and 12 without, at 2, 4, and 7 days after birth. cTnT concentrations (mean ± SEM) significantly decreased (P < 0.05) from the 2nd (0.63 ± 0.09 μg/l) and the 4th (0.77 ± 0.13 μg/l) to the 7th postnatal day (0.28 ± 0.04 μg/l). At day 2 after birth, cTnT levels in preterm infants with RDS were significantly higher (P < 0.05) than our reference values for healthy preterm neonates (0.63 ± 0.09 μg/l vs 0.18 ± 0.04 μg/l). No differences were found between RDS infants with and without PDA at 2 (0.65 ± 0.13 vs 0.61 ± 0.14 μg/l), 4 (0.71 ± 0.21 vs 0.87 ± 0.16 μg/l), and 7 (0.26 ± 0.05 vs 0.29 ± 0.07 μg/l) days of life. In infants with PDA, cTnT levels did not differ before the first dose of indomethacin was given (0.65 ± 0.14 μg/l) or 2 h (0.65 ± 0.15 μg/l) and 48 h (0.71 ± 0.21 μg/l) afterwards. Conclusion In preterm infants with RDS the occurrence of PDA and indomethacin treatment are not associated with ischemic cardiac damage as detected by cTnT measurements. Received: 23 December 1998 and in revised form: 4 May 1999 / Accepted: 11 October 1999     

Serum D-lactate levels as a predictor of intestinal ischemia-reperfusion injury

Currently, no serum marker has proved helpful in diagnosing intestinal ischemia and reperfusion (I/R) injury. An experimental study was conducted to determine the value of serum D-lactate in detecting intestinal I/R injury. Thirty New Zealand White rabbits were divided into three groups of 10 animals each: sham-operation controls (S); I/R; and I/R plus mannitol treatment (M). Serum samples were obtained before operation (T₀), at the end of the ischemic period (T₁), after the first 30 min of reperfusion (T₂), and at the end of the reperfusion period (T₃). In Group S, mean D-lactate levels for T₀, T₁, and T₂ were 0 μg/dl, while T₃ was 5.8 ± 4.7 μg/dl. Before the operation (T₀), serum mean D-lactate levels were 0 μg/dl in all groups (S, I/R, M). Levels increased after 1 h of ischemia (T₁) in groups I/R (83.5 ± 25.6 μg/dl) and M (89.8 ± 19.9 μg/dl), but not in group S (0 μg/dl). The mean T₂ level in group I/R (231.6 ± 78.6 μg/dl) was statistically higher than in group M (140.1 ± 53.5 μg/dl) (P = 0.007). At the end of the reperfusion period, the mean T₃ level in group I/R (698.4 ± 360.4 μg/dl) was significantly higher than in group M (158.7 ± 61.4 μg/dl) (P = 0.000). In group I/R, mean D-lactate levels changed significantly at each time point (T₁ vs T₂, P = 0.001; T₂ vs T₃, P = 0.004). However, in group M the increase from T₁ to T₂ was significant (P = 0.012), but that from T₂ to T₃ was not (P = 0.293). As a result, the mean T₃ level was significantly higher than the T₂ level in group I/R (P = 0.004), but not in group M. This study confirmed a significance rise in D-lactate levels in animals with I/R injury compared to sham-operated and I/R injury plus M treatment. We suggest that serum D-lactate levels could be a useful marker of intestinal I/R injury before laparatomy. Accepted: 26 May 1998     

The effectiveness of aerosolized intraperitoneal bupivacaine in reducing postoperative pain in children undergoing robotic-assisted laparoscopic pyeloplasty

ObjectiveTo assess the effectiveness of aerosolized intraperitoneal bupivacaine in reducing postoperative pain in children. Laparoscopic surgery has decreased the severity of postoperative pain in children. However, children often experience abdominal and shoulder pain requiring significant amounts of opioids, potentially prolonging their hospitalization.MethodsForty-one consecutive patients undergoing unilateral robotic-assisted pyeloplasty between December 2005 and December 2007 were retrospectively reviewed to assess perioperative opioid requirements and length of hospitalization.ResultsIn addition to standard-of-care perioperative analgesia, five patients received intraperitoneal aerosolized bupivacaine just prior to trocar removal, 17 patients received aerosolized bupivacaine just prior to incising the perirenal fascia, and 19 patients received no intervention. There was a significant reduction in postoperative opioid utilization when bupivacaine was administered at the beginning of the surgery (0.1 mg/kg vs 0.4 mg/kg, P = 0.04), but not at the end (0.3 mg/kg, P = 0.25), as compared to controls. All patients receiving aerosolized bupivacaine had a significantly shorter time in hospital (2.4 vs 1.4 days, P = <0.01).ConclusionsThe administration of intraperitoneal aerosolized bupivacaine just prior to incising the perirenal fascia appears to be a simple, effective and low-cost method to reduce postoperative pain in children undergoing laparoscopic pyeloplasty.     

Does concomitant injection of a combined diphtheria-tetanus-acellular pertussis - hepatitis B virus - inactivated polio virus vaccine influence the reactogenicity and immunogenicity of commercial Haemophilus influenzae type b conjugate vaccines?

The immunogenic responses and local reactions to four Haemophilus influenzae type b (Hib) conjugate vaccines licensed for primary immunisation (Hiberix, ActHib, Pedvax, HibTITER) when administered concomitantly but in the opposite thigh with a candidate diphtheria-tetanus-acellular pertussis-hepatitis B-inactivated poliovirus vaccine were studied in 549 healthy infants at 3, 4.5 and 6 months of age. Local reactions were mild, but different between the four groups, a tetanus conjugate Hib vaccine showing the fewest reactions. All local reactions resolved without sequelae. There was no apparent general reaction. The immunogenic response was similar with all four vaccines, geometric mean concentrations ranging from 4.95 to 7.2 μg/ml. All but one subject had anti-polyribosylribitol phosphate polysaccharide antibody titres ≥0.15 μg/ml, and 88.0% to 96% achieved high titres (>1.0 μg/ml) generally associated with long-term protection against Hib disease. Conclusion There does not appear to be any interference with the immune response when current commercial Haemophilus influenzae type b conjugate vaccines are concomitantly administered with a candidate diphtheria-tetanus-acellular pertussis-hepatitis B-inactivated polio virus vaccine as separate injections. Received: 21 October 1997 / Accepted in revised form: 3 September 1998     

Einfluß von Surfactant auf das pulmonale Entzündungsgeschehen und die Elastasefreisetzung bei experimenteller neonataler B-Streptokokken-Pneumonie

Zusammenfassung Fragestellung: Mit Hilfe eines Tiermodells der neonatalen B-Streptokokken-Pneumonie sollte der Einflu? von Surfactant auf das pulmonale Entzündungsgeschehen und die Freisetzung von Elastase, einem proteolytischen Enzym neutrophiler Granulozyten, untersucht werden. Methode: Kaninchenfeten mit einer Tragzeit von 29,5 Tagen wurden intratracheal mit B-Streptokokken infiziert und über einen Zeitraum von 5 h beatmet. 15 min nach der Infektion wurden Surfactant (Curosurf 200 mg/kg) bzw. ein identisches Volumen (2,5 ml/kg) NaCl 0,9 % verabreicht. Im Lungenhomogenisat der linken Lunge wurden die Bakteriendichte bestimmt sowie die Aktivit?t der freien Elastase gemessen. Die rechte Lunge wurde lichtmikroskopisch im Hinblick auf entzündliche Ver?nderungen untersucht. Ergebnisse: Die mit Surfactant behandelten Tiere ( n = 11) wiesen ein signifikant niedrigeres Bakterienwachstum, geringer ausgepr?gte entzündliche Ver?nderungen bei der histologischen Beurteilung sowie eine verminderte Aktivit?t der freien Elastase (Mittelwert ± SEM: 4,22 ± 0,95 vs. 8,02 ± 1,28 μg/g Lunge; p < 0,05) im Vergleich zu infizierten Tieren auf, die NaCl erhalten hatten (n = 12). Kontrolltiere, die nur NaCl erhalten hatten (n = 11) und eine weitere Gruppe von Tieren, die unmittelbar nach Infektionsbeginn untersucht wurden (n = 8), zeigten im Vergleich eine signifikant (p < 0,05) niedrigere Aktivit?t der freien Elastase im Lungenhomogenisat (2,97 ± 0,57 bzw. 2,01 ± 0,45 μg/g Lunge). Schlu?folgerungen: Nach Surfactantbehandlung wurden bei experimenteller B-Streptokokken-Pneumonie eine verminderte Bakterienproliferation sowie eine verminderte Freisetzung von Elastase beobachtet. Surfactant scheint somit bedeutsam in die Regulation entzündlicher Vorg?nge in der Lunge einzugreifen.      

Neonatal hyperbilirubinemia and its association with thyroid hormone levels and urinary iodine excretion

Objective : To investigate, if, urinary iodine contents as a marker of iodine deficiency and hypothyroidism are associated with the incidence of neonatal hyperbilirubinemia.Methods : One hundred neonates with total serum bilirubin ≥15 mg/dl and with no known cause of jaundice were included in the study as a jaundice group. An equal number (n=100) of non-jaundiced neonates (bilirubin ≤14.9 mg/dl) with matching for age, gestation period and weight were enrolled in the study as a control group.Results : Thirteen neonates (13%) in the study group had urinary iodine levels < 100 mg/dl as against only 2 (2%) in the control group (p<0.05). Thirty-four (34/200-17%) neonates i.e. 17 each in the study and control groups had serum TSH> 5 mU/ml and hence an indirect indicator of iodine deficiency in the study population. The mean serum levels of total T3, T4 and TSH in the study neonates were 1.52 ±1.23 ng/ml, 15.8±12.0 μg/dl & 3.13 ±3.0 mU/ml respectively and did not differ significantly from the mean levels in the control group. Only one neonate in the study group had serum TSH > 20 mU/ml which was suggestive of hypothyroidism, but had normal T3 & T4. Seven neonates in the study group and 8 in the control group had low T4. There was no significant correlation between the maternal and neonatal urine iodine levels, thyroid functions and the bilirubin levels (p>0.01).Conclusion : The jaundiced babies had lower urine oidine levels than the control population. Since, there was no significant difference in the levels of the thyroid hormones, no cause and effect relationship could be inferred between iodine deficiency and jaundice.     

Perioperative anesthetic and analgesic management of newborn bladder exstrophy repair

ObjectiveReconstruction of bladder exstrophy in newborn infants requires immobilization, sedation and pain management to prevent distracting forces from compromising the repair. We present a 6-year review of our experience.Subjects and methodsWe reviewed the perioperative management of newborn infants undergoing reconstruction between November 1999 and October 2006. Data are presented as means ± SD.ResultsTwenty-three newborn infants underwent surgery under a combined epidural and general anesthetic technique. Tunneled caudal epidural catheters were inserted in all patients and intermittently injected with 0.25% bupivacaine with 1:200,000 epinephrine. Postoperatively, a continuous infusion of 0.1% lidocaine, 0.8–1 mg/kg/h was administered for 15 ± 8 (range 4–30) days. Children were sedated with diazepam for 20 ± 13 (range 2–40) days. Central venous catheters were maintained for 20 ± 9 (range 1–34) days for fluids, drug administration and blood sampling. No patient experienced bladder prolapse or wound dehiscence.ConclusionPerioperative management with tunneled epidural and central venous catheters in newborn infants with bladder exstrophy facilitates immobilization, analgesia and sedation, resulting in an excellent cosmetic repair with no case of bladder prolapse or wound dehiscence.     

Addition of sufentanil to bupivacaine in caudal block effect on stress responses in children

BACKGROUND: The aim of the present randomized study was to determine the effect of adding sufentanil to bupivacaine, compared with bupivacaine alone in caudal block, on the surgical stress response in children. METHODS: The children were premedicated with midazolam 0.5 mg/kg. All children received induction with nitrous oxide and sevoflurane. Anesthesia was maintained with the same volatile agents in the both groups. The children were randomly allocated to two groups. Group I received bupivacaine alone (n = 17) and group II received bupivacaine + sufentanil (n = 16). Caudal block was performed with 0.25% bupivacaine 2 mg/kg (group I) or 0.25% bupivacaine 2 mg/kg with sufentanil 0.5 microg/kg (group II) after induction of anesthesia. Blood samples were obtained after induction of anesthesia (T(0)) to measure baseline concentrations of cortisol, prolactin, glucose and insulin. Additional samples were obtained 30 min after the start of surgery (T(1)), and 60 min after the end of surgery (T(2)). RESULTS: All of the basal values (T(0)) were within the normal ranges of the authors' laboratory for children of this age group and there were no differences between the groups (P > 0.05). In both groups, glucose concentration increased at T(1), compared with T(0) and T(2) (P < 0.05). The glucose concentration was unchanged at T(2) compared with T(0) in both group (P > 0.05). In both groups, prolactin concentration increased at T(1), compared with T(0) and decreased at T(2), compared with T(1) (P < 0.05). Cortisol decreased at T(1) and T(2), compared with T(0) in both groups. (P < 0.05). Insulin concentration remained unchanged at T(0) and T(2), but increased slightly at T(1) in both groups (P > 0.05). There were no significant differences in plasma prolactin, cortisol, glucose and insulin levels between the two groups at T(1) and T(2) (P > 0.05). CONCLUSION: There is no advantage in adding 0.5 microg/kg sufentanil to bupivacaine over bupivacaine alone in the caudal block, with regard to the surgical stress response in children.