Clonidine treatment for agitation in children after sevoflurane anesthesia

Clonidine is effective in treating sevoflurane-induced postanesthesia agitation in children. We conducted a study on 169 children to quantify the risk reduction of clonidine agitation in patients admitted to our day-surgery pediatric clinic. Children were randomly allocated to receive clonidine 2 mug/kg or placebo before general anesthesia with sevoflurane that was also supplemented with a regional or central block. An observer blinded to the anesthetic technique assessed recovery variables and the presence of agitation. Pain and discomfort scores were significantly decreased in the clonidine group; the incidence of agitation was reduced by 57% (P = 0.029) and the incidence of severe agitation by 67% (P = 0.064). Relative risks for developing agitation and severe agitation were 0.43 (95% confidence interval, 0.24-0.78) and 0.32 (0.09-1.17), respectively. Clonidine produces a substantial reduction in the risk of postsevoflurane agitation in children.     

Clonidine premedication for sevoflurane anesthesia in upper abdominal surgery

The effects of clonidine as a preanesthetic medication were compared with diazepam on clinical courses of sevoflurane anesthesia in 22 patients undergoing upper abdominal surgery. The patients were divided into two groups of 11 patients each according to preanesthetic medication: atropine 0.5 mg i.m. plus clonidine 0.3 mg p.o., or atropine 0.5 mg i.m. plus diazepam 10 mg p.o. 60–90 min prior to induction of anesthesia. Anesthesia was induced with fentanyl and thiopental, and was maintained with sevoflurane, 0.5%–1.5%, nitrous oxide and oxygen, supplemented with fentanyl, 0.5 μg·kg⁻¹·hr⁻¹. While only one patient needed a vasodilator in the clonidine group for treatment of hypertension, seven patients needed it in the diazepam group. Pain score after extubation was higher in the diazepam group than in the clonidine group. The time when patients responded to verbal command after discontinuation of anesthetics was similar in both groups. Therefore, clonidine pretreatment was useful for sevoflurane anesthesia in upper abdominal surgery.     

Dose requirement for caudal anesthesia in pediatric patient

A series of 305 infants and children between 1 day to 14 years of age were operated upon using caudal anesthesia. We used 1% mepivacaine 1.2 ml.kg-1 to obtain a level of anesthesia above T10, 1.0 ml.kg-1 above L1, and 0.8 ml.kg-1 above S. Complete failure occurred in 4.3% of patients. We investigated the blood concentration of mepivacaine in 17 patients, and it ranged from 0.5 microgram.ml-1 to 5.0 micrograms.ml-1. In a two month old infant, weighing 6.7 kg, apnea and bradycardia occurred. This was managed by tracheal intubation and controlled ventilation. But there were no other severe complications. We also investigated the distance between C7 and sacral hiatus (D) in each case. The coefficients of correlation between D and height is 0.97, and high correlation existed also between D and body weight (r = 0.93). This confirms that body weight can be used as a parameter to determine the dose of local anesthetic agent. We conclude that this technique is a safe, reliable and simple way to produce surgical analgesia in infants and children.     

High intraoperative blood loss may be a risk factor for postoperative hematoma

The authors studied the incidence of postoperative intracranial hematoma to improve care after intracranial surgery. Five years (1995-1999) of surgical records were analyzed retrospectively. Patients were included if evacuation of an intracranial postoperative hematoma was reported. A control group was randomly selected. Forty-nine patients (0.8%) had postoperative hematomas requiring evacuation. The amount of intraoperative blood loss was significantly larger in the hematoma group (762 +/-735 mL [median 500 mL]) than in the control group (415 +/-403 mL; median 300 mL) (P = 0.004). Clinical deterioration occurred within the first 24 hours in 80%, within 6 hours in 51%, and within 1 hour in 12% of the patients. Those who deteriorated within 24 hours had a faster and more life-threatening deterioration than those who had a hematoma after 24 hours. A decreased level of consciousness was found in 61% and increased focal neurologic signs were found in 33% of the patients. An elevated intracranial pressure was seen significantly more often in the hematoma group (9/10 patients, 90%) than in the control group (1/8 patients, 12.5%) (P = 0.001). In this study, a large amount of intraoperative blood loss and elevated intracranial pressure were warning signs of postoperative hematoma and should alert the clinician to the increased risk. Most hematomas occurred within 24 hours after surgery, and in this time period the deterioration was more severe compared with the hematomas that occurred later.     

Awake caudal anesthesia for inguinal hernia operations

Neonates with inguinal hernia face a relatively high risk of incarcerated hernia and bowel obstruction and this therefore requires surgical treatment. Complications following general anesthesia even for minor surgery are more common in low birth weight neonates than in term neonates. Caudal epidural anesthesia without adjunct general anesthesia has been recommended for neonates to reduce the risk of postoperative complications. The successful application of awake caudal anesthesia with levobupivacaine for inguinal hernia repair in 15 low birth weight neonates is reported. Single dose caudal epidural anesthesia was administered for inguinal hernia surgery to avoid complications associated with general anesthesia. Caudal block was performed with 2.5?mg/kg body weight (BW) levobupivacaine. Caudal anesthesia can be recommended as an effective technique for avoiding postoperative anesthetic complications in low birth weight neonates.     

Administering caudal anesthesia at completion of clubfoot surgery does not affect postoperative use of narcotics

In the pediatric population, control of postoperative pain is a challenging and important issue. We conducted this retrospective study to determine whether single-dose caudal anesthesia administered after club-foot surgery helps to decrease postoperative use of narcotics. Fifty-one patients given an injection of caudal anesthesia (bupivacaine) at completion of clubfoot surgery were compared with 41 patients who did not receive a caudal block. Postoperative pain control was assessed by recording how much narcotic was used by each patient during time in the recovery room and during the first 8 hours after surgery. Results show that a single dose of caudal anesthesia administered at completion of clubfoot surgery is not associated with a statistically significant change in use of narcotics during either postoperative period.     

Sublingual morphine may be a suitable alternative for pain control in children in the postoperative period

The purpose of this pilot study was to compare the effects of sublingual morphine with intravenous morphine in the treatment of postoperative pain following adenotonsillectomy in children. Twenty-nine children scheduled for adenotonsillectomy were randomly assigned to group 1 (n=14) receiving 0.1 mg x kg(-1) sublingual morphine and group 2 (n=15) 0.1 mg x kg(-1) intravenous morphine followed by 1 mg x kg(-1) diclofenac rectally in both groups after induction of anaesthesia. Postoperatively, time to first eye opening, sedation score, pain score, time for further analgesia requests and incidence of nausea and vomiting were recorded. There was no statistical significant difference in any of these parameters between the two groups. The results suggest that sublingual morphine may be a suitable alternative to various other routes of opioid administration in children, but further investigations of the sublingual route of administration of opioids in children are required.