COMPARISON OF ORAL TRICLOFOS, DIAZEPAM AND FLUNITRAZEPAM AS PREMEDICANTS IN CHILDREN UNDERGOING OTOLARYNGOLOGICAL SURGERY

Triclofos 70 mg kg^–1, diazepam 0.25 mg kg^–1 andflunitrazepam 0.02 mg kg^–1 all in combination with atropine0.03 mg kg^–1 were compared as oral premedicants in 128children undergoing otolaryngological surgery in a double-blindstudy. All drugs provided good anxiolysis in children 5 yr andolder. In children less than 5 yr, the effects of triclofoswere superior to those of diazepam and flunitrazepam. Therewas a positive correlation between anxiolysis and the ease ofinduction of anaesthesia. In both age groups, flunitrazepamprevented the fasciculations caused by suxamethonium more effectivelythan did diazepam or triclofos. The preinduction heart rateafter triclofos was greater than after the other drugs and itsantisialagogueeffect was superior. The mean volume of gastric contents was0.4 ml kg^–1 for all the patients with no statisticallysignificant difference between the groups. The mean pH of gastriccontents was 4.5 after triclofos and 2.2 after other drugs.The serum concentration of both benzodiazepines in the olderage group was greater than in the younger age group.     

The effect of ketamine on the functional residual capacity in young children

The effect of ketamine on the functional residual capacity (FRC) was measured in nine ASA class I children prior to elective surgery. FRC was determined by the closed-circuit helium dilution method on the day prior to surgery in the awake state and also following induction of anesthesia on the day of the operation. Anesthesia consisted of ketamine by continuous intravenous infusion following preanesthetic sedation with atropine and triclofos or flunitrazepam. There were no significant differences in FRC between the measurements in the awake state and anesthetized (392 +/- 43 SEM ml, and 411 +/- 53 SEM ml, respectively), and the authors conclude that ketamine does not affect resting lung volume in young children.     

Comparison of Pharmacokinetic and Pharmacodynamic Parameters following Oral or Intramuscular Atropine in Children

Pharmacokinetic and pharmacodynamic parameters of atropine 0.03 mg/kg p.o. or 0.02 mg/kg i.m. were compared in a double-blind study in 20 children with a mean age of 5.1 years undergoing otolaryngological surgery, mostly adenotomy. Outside the study protocol, two small children accidentally received an overdose of atropine 0.3 mg/kg p.o. In addition to atropine, all children received triclofos 70 mg/kg p.o. Following p.o. administration of atropine, the mean maximum serum concentration of 6.7 nmol/l occurred at 2 h. The corresponding result after i.m. administration was 5.7 nmol/l at 0.5 h. Serum concentrations of atropine were 3.5 and 1.3 nmol/l 8 h after p.o. and i.m. administration, respectively. At 70 min the anti-sialogogue effect was clinically satisfactory after both modes of administration. The heart rate increased statistically significantly only after i.m. administration. The mean maximum rise in the rectal temperature before the start of anaesthesia occurred at 1 h and was 0.5 degrees C in the p.o. group and 0.7 degrees C in the i.m. group. The flush phenomenon, mostly on the face and sometimes also on the chest, occurred in both groups, being more intense in the i.m. group than in the p.o. group. The children who developed flush had a statistically significantly higher rise in rectal temperature than the children without flush. There was a positive but weak correlation between the serum concentration of atropine and the heart rate, whereas the correlation between the serum concentration after i.m. atropine and the rectal temperature was weakly negative. On the basis of the present study, there were no decisive differences between the effects and side-effects of the two modes of administration of atropine.(ABSTRACT TRUNCATED AT 250 WORDS)     

Awareness and memory function during paediatric anaesthesia

Background: Previous research indicates a much higher incidence of awarenessduring anaesthesia in children than in adults. The present studyis the first large-scale, intraoperative assessment of awarenessduring paediatric anaesthesia using the isolated forearm technique,and the first large-scale study of memory function during paediatricanaesthesia. Methods: One hundred and eighty-four children, 5–18 yr, underwentthe isolated forearm technique during the first 17 min of surgerywhile receiving volatile anaesthesia. The isolated forearm techniquewas modified to accommodate brief or no paralysis. Bispectralindex was monitored in a subset of 54 patients. Sixteen neutralwords were played 20 times during surgery and, on recovery,implicit memory for these words was tested with a word identificationtask. Explicit memory for the surgical period was tested witha structured interview. Behavioural changes were assessed withage-appropriate questionnaires. Results: No child had explicit recall of intraoperative events on recovery,and there was no evidence of implicit memory for words presentedduring anaesthesia. Two of 184 children made unambiguous andverified responses on the modified isolated forearm technique,an incidence of intraoperative awareness of 1.1%. One of thesechildren reported that he was uncomfortable and not completelyunconscious during surgery. Neither child had implicit memoryfor the neutral words, or adverse behaviour change. Conclusions: The incidence of awareness during surgery in children is approximatelyeight times that measured in adults by postoperative recall.In contrast to adults, there is no evidence for preserved memorypriming during anaesthesia.     

Pre-induction behaviour of children A review of placebo-controlled trials of sedatives

Placebo-controlled trials of sedative premedication in children are reviewed in an attempt to determine which drugs have been shown to reduce the frequency with which children cry or appear apprehensive. Small samples and inappropriate statistical methods limit the value of many of the studies. Most of the drugs tested will, in sufficient dose, increase the proportion of children who are asleep. Only intramuscular opioid analgesics, either alone or in combination with other drugs, have been shown repeatedly to increase the frequency of calm behaviour in those who are awake. There is some evidence, however, that intramuscular placebo controls have a lower frequency of calm behavior than oral placebo controls.     

Emergence behaviour in children: defining the incidence of excitement and agitation following anaesthesia

BACKGROUND: Children display a variety of behaviour during anaesthetic recovery. The purpose of this study was to study the frequency and duration of emergence behaviour in children following anaesthesia and the factors that alter the incidence of various emergence behaviour following anaesthesia. METHODS: A prospective study of children who required outpatient lower abdominal surgery was designed to determine an incidence and duration of emergence agitation. We developed a 5-point scoring scale to study the postanaesthetic behaviour in these children. The scale included behaviour from asleep (score=1) to disorientation and severe restlessness (score=5). Children were scored by a blinded observer every 10 min during the first hour of recovery or until discharge from same day surgery. RESULTS: We found 27 of 260 children experienced a period of severe restlessness and disorientation (score 5) during anaesthesia emergence. Thirty percent of the children (79/260) experienced a period of inconsolable crying or severe restlessness (score 4 or 5) following anaesthesia. The frequency of this behaviour was greatest on arrival in the recovery room, but many children who arrived asleep in the recovery room later experienced a period of agitation or inconsolable crying. CONCLUSIONS: Repeated assessments of behaviour following anaesthetic recovery are required to define an incidence and duration of emergence agitation. Emergence agitation occurs most frequently in the initial 10 min of recovery, but many children who arrive asleep experience agitation later during recovery.     

Assessment of risk factors for emergence distress and postoperative behavioural changes in children following general anaesthesia

BACKGROUND: Emergence distress commonly occurs in children recovering from the immediate effects of general anaesthesia. This study was performed to (1) examine whether parental presence in the operating room during emergence from anaesthesia reduces the incidence or severity of emergence distress behaviour, and (2) assess psychosocial risk factors, including child temperament and sleep behaviour, for development of emergence distress. METHODS: A randomized and controlled trial of parental presence at emergence was conducted in 100 ASA class I and II children having general anaesthesia for inguinal or penile surgery. Children in the study group had a parent present at induction and emergence of anaesthesia, while children in the control group had a parent present only at induction. Emergence and postanaesthesia care unit (PACU) behaviour was monitored using both the Operating Room Behaviour Rating Scale (ORBRS) and a 7-point Likert type cooperation scale. RESULTS: One-way anovas showed no significant differences between the control group and the study group on emergence distress behaviour. The frequency of negative postoperative behavioural changes at 1 and 4 weeks postsurgery was low in both groups. Children described as clingy/dependent (chi2 = 5.57, P < 0.06) and children with frequent temper tantrums (chi2 = 7.44, P < 0.02) were more likely to have emergence distress behaviour. CONCLUSIONS: Parental presence during emergence from anesthesia did not decrease the incidence or severity of emergence distress behaviour in children. Young children and children with a history of temper tantrums or separation anxiety may be more likely to develop such behaviour.     

The burned child — scarred for life?: A study of the psychosocial impact of a burn injury at different developmental stages

Several studies examining the psychosocial adjustment of child burn victims have resulted in contradictory conclusions, possibly because of their diverse methodology and poorly defined outcome measures. Using a standardized behaviour rating scale this study found that adolescent burn victims show a markedly poorer psychosocial adjustment when compared with younger burned children. Visible burns, emotional distress in the mother, and multiple home moves were all associated with poorer psychosocial adjustment in adolescence for burned children.     

Assessing behaviour in children emerging from anaesthesia: can we apply psychiatric diagnostic techniques?

BACKGROUND: No standardized instrument exists for the systematic analysis of emergence behaviour in children after anaesthesia. Our purpose was to evaluate children's behaviour prior to anaesthetic induction and immediately upon emergence to develop an assessment tool using psychiatric terminology and techniques. METHODS: This prospective study evaluated 25 children from 2 to 9 years of age for preanaesthetic psychosocial factors that might affect behaviour. Children's behaviour was observed from admission to the surgical unit through the induction of anaesthesia. All children received a standardized premedication and induction of anaesthesia. The maintenance anaesthetic was randomized to intravenous remifentanil or inhaled isoflurane. All children underwent repair of strabismus. We assessed the behaviour of children for 30 min upon emergence from anaesthesia for symptoms of pain, distress and delirium using an assessment tool we developed guided by the principles of psychiatry as described in Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). RESULTS: Using our assessment tool, 44% of children demonstrated altered behaviour on emergence; 20% demonstrated complex symptoms with characteristics of delirium. Children anaesthetized with isoflurane had significantly higher postanaesthesia behaviour assessment scores than those anaesthetized with remifentanil (P = 0.04). Age was a significant variable; children <62 months were more prone to altered behaviour than those >62 months (P = 0.02). Scores did not correlate with preanaesthetic risk factors including preexisting psychological or social variables or observed preanaesthetic distress. There was no delay in hospital discharge in children assessed as having altered behaviour. CONCLUSIONS: This exploratory study suggests that postanaesthetic behaviour abnormalities with characteristics of distress or delirium can be categorized using known DSM-IV terminology; in our cohort this behaviour was dependent on age and anaesthetic technique.     

Topical anaesthesia of the skin: a review

The ability to provide painless venepuncture and venous cannulation is a major advance in paediatric practice. Topical local anaesthesia of the skin can allow such procedures to be carried out with little or no discomfort in children of all ages. This has obvious psychological benefits for children, particularly those subjected to repeated procedures. The techniques for anaesthetizing the skin to be effective and safe must be based upon an understanding of the anatomy and physiology of the skin, the pharmacology of local anaesthetic agents and their behaviour when applied to the skin. Although eutectic mixture of local anaesthetics (EMLA cream) (Astra Pharmaceuticals) is the market leader, promising new preparations are being evaluated with the aim of decreasing the onset time of effective analgesia. New clinical applications for topical anaesthesia of the skin are appearing and it is likely that these will be increasingly used in the future.     

An Audit of Preoperative Behaviour and Premedication Practise at Great Ormond Street Hospital

Introduction Despite advances in anaesthesia many children are distressed at induction of anaesthesia (1). The use of paediatric premedication has declined considerably over the last ten years ( 2 ). The aim of our audit was to look at preoperative behaviour and premedication practice at our institute. Method One hundred and seventy seven patients undergoing elective procedures in the main theatre suite at the hospital were audited. This therefore excluded cardiac and neuroanaesthesia. Behaviour scores in the anaesthetic room prior to and at induction were assessed by the operating department assistants. We looked at frequency, type, dose and timing of premedication. The induction method, age and previous anaesthesia were noted. Parents routinely accompany children at induction of anaesthesia. Results Overall 75% of children had satisfactory behaviour scores in the anaesthetic room dropping to 47% at induction. The graph shows the age distribution and associated behaviour scores. Of the patients with satisfactory behaviour scores all received their premedication between 20 and 60 min prior to induction. Three patients in the unsatisfactory behaviour group received their premedication outside this optimal time. Children who had had previous anaesthetics (76%) had worse behaviour scores than those with none both in the anaesthetic room and at induction with satisfactory scores of 71% vs. 84% and 44% vs. 51 % respectively. Those having gas inductions (63%) had worse behaviour scores at induction compared with children having intravenous induction with satisfactory scores of 42% vs. 52% respectively. 12% of all children audited received a sedative premedication. 16 received Midazolam 0.5 mg/kg, 3 Temazepam 10 or 20 mg and 1 Triclofos 50 mg·kg^?1 all given orally. The premedication rate for children with previous anaesthetic experience was 14% vs. 5% in those with none. Only 5% of children received an atropine premedication 20–40 mcg·kg^?1 orally. Only 1 of the 14 children age 6 months and 2 of the 14 children age 6 months?1 year were premedicated with atropine. Discussion As a paediatric tertiary referral centre, many of the patients have previous experience of anaesthetics and have ongoing medical problems Our audit found that many of these children, especially age 1–3, are distressed at induction of anaesthesia despite methods shown to reduce peri‐operative anxiety, including play specialists. It also confirms the perceived trend for decreasing use of sedative and anticholinergic premedication. However several papers report decrease in distress at induction ( 1 ) especially in high‐risk groups ( 2 ) without undue delays in awakening and discharge using midazolain premedication. Conclusion It was decided that a more child friendly anaesthetic room with pictures, toys and other distractions would be helpful. There may also be a need to increase the use of sedative premedication in high‐risk groups especially preschool children.     

Child related background factors affecting compliance with induction of anaesthesia

BACKGROUND: Factors such as age, sex, behaviour problems, fears, earlier traumatic hospital events and reactions to vaccination were assessed together with behaviour observed before premedication in order to evaluate their importance in predicting response to the anaesthetic process. The anaesthetic process was divided into four endpoints; compliance when given premedication, sedation, compliance during needle insertion or when an anaesthetic mask was put in place and behaviour when put to sleep. METHODS: A total of 102 children who were undergoing day-stay surgery and overnight stay surgery were video-filmed during premedication and anaesthetic induction. Before premedication the children and parents answered questionnaires about behaviour [Preschool Behaviour Check List (PBCL)] and fears [Fears Survey Schedule for Children-Revised (FSSC-R)]. The films were analysed to assess behaviour before and after premedication and during induction of anaesthesia. A semistructured interview was conducted with the parents during the time the children were asleep. RESULTS: There was a significantly higher odds ratio for noncompliant behaviour during premedication if the child placed itself in the parent's lap or near the parent or had previously experienced traumatic hospital events. The odds ratio for not being sedated by premedication was higher if compliance was low when premedication was given or the child had experienced a traumatic hospital event in the past. A high odds ratio for noncompliant behaviour during venous access or placement of an anaesthetic mask was seen if the child was not sedated or the child had had a negative reaction when vaccinated. The odds ratio for falling asleep in an anxious or upset state was higher if the child had shown noncompliant behaviour during premedication, had not been sedated or had shown noncompliant behaviour during venous access or facemask placement. CONCLUSIONS: The overall most important factor that predicts noncompliant behaviour and a distressed state in the child during the anaesthetic process was the experience of earlier traumatic hospital events including negative reaction to vaccination. All elements of the process are important in determining what will happen and all steps will influence how the child reacts when put to sleep.     

Behavioural interventions for children and adults with behaviour disorders after TBI: a systematic review of the evidence

Objective: To systematically review the evidence for the effectiveness of behavioural interventions for children and adults with behaviour disorders after TBI.

Design: Using a variety of search procedures, 65 studies were identified. This literature was reviewed using a set of questions about participants, interventions, outcomes and research methods.

Participants: The 65 studies included 172 experimental participants, including children and adults.

Interventions: A number of specific intervention procedures were used, falling into three general categories: traditional contingency management, positive behaviour interventions and supports and combined.

Results: All of the studies reported improvements in behavioural functioning.

Conclusions: Behavioural intervention, not otherwise specified, can be considered a treatment guideline for children and adults with behaviour disorders after TBI. Both traditional contingency management procedures and positive behaviour support procedures can be said to be evidence-based treatment options. However, a variety of methodological concerns block stronger conclusions.     

Sexual behaviour and knowledge of AIDS among urban black mothers. Implications for AIDS intervention programmes

Questionnaires were administered to 122 urban black mothers of teenagers in order to: (i) understand aspects of their sexual behaviour and knowledge of the acquired immunodeficiency syndrome (AIDS); and (ii) assess their communication with their teenage children with regard to AIDS and sexual behaviour. The subjects comprised a 12.5% random sample of all houses in Lamontville, a black township south of Durban. The level of AIDS knowledge among mothers was high, while their sexual behaviour, characterised by a high pregnancy rate and a high proportion who have had children by more than one consort, placed them at high risk of acquiring human immunodeficiency virus (HIV) infection. No mother had experienced sexual intercourse during which her partner used a condom. Communication with their teenage children was poor; none of the mothers had spoken with them about AIDS and 89.3% had not discussed contraceptive methods with their teenage children. We found that urban black mothers were at high risk of acquiring HIV and, despite their knowledge of the modes of transmission and prevention of HIV infection, they had not begun using condoms as a risk-reducing measure, nor had they communicated the risk of unprotected sex to their teenage children. We recommend that AIDS intervention strategies should not concentrate only on passing on knowledge but also on providing women with the communication skills to negotiate the use of condoms with their partners and to convey the risk of HIV infection to their teenage children.     

Anaesthetic induction in children: the effects of maternal presence on mood and subsequent behaviour

Forty-nine children, aged from 1 to 9 years, undergoing elective surgery under general anaesthesia, were studied in two groups. In one group, each child's mother was present during induction of anaesthesia, whereas in the other group no parent was present. Children's moods and cooperation during waiting and induction periods did not differ significantly between the groups, neither was the incidence of technical difficulties with anaesthetic induction different. Induction took longer (P = 0.005) if the mother was present. Mothers, when present, were calm and supportive to their children, with one exception. No mother was critical or interfering. Each child's behaviour was assessed by questionnaire pre-operatively and 4 weeks post-operatively. There was a significant overall improvement in behaviour scores post-operatively. There were no significant differences in direction or magnitude of behaviour changes between the two groups.     

轻度智力缺陷儿童心理及行为特点分析

目的探讨轻度智力缺陷儿童的心理及行为特点,为轻度智力缺陷儿童的康复训练提供参考。方法采用韦氏儿童智力量表筛选轻度智力缺陷儿童60名作为研究组,选择正常儿童60名作为对照组,采用心理健康诊断测验量表及儿童行为量表对两组儿童心理及行为特点进行评估,比较两组间差异。结果研究组儿童学习焦虑、对人焦虑、身体症状、恐怖症状及冲动倾向等心理异常较对照组明显,研究组分裂样症状、抑郁症状、交往不良、强迫性症状、多动症状、攻击性症状及违纪症状等行为异常较对照组明显。结论轻度智力缺陷儿童存在一定程度的心理及行为异常,需要通过后天学习及训练改善。     

Social and behavioural effects of traumatic brain injury in children

Traumatic brain injury (TBI) is the leading cause of death and permanent disability in children and adolescents. Although cognitive and behavioural effects have now been reported for all degrees of TBI severity in children, other aspects of functioning which might be related (such as psychosocial adjustment), have been neglected. In the present study the social and behavioural effects of TBI were assessed by comparing 27 TBI children with 27 controls. TBI children demonstrated significantly lower levels of self esteem and adaptive behaviour, and higher levels of loneliness, maladaptive behaviour and aggressive/antisocial behaviour. These findings confirm the previously demonstrated detrimental effects of TBI on children s behavioural functioning and offer new evidence for the detrimental effects of TBI on children s social functioning.     

Effect of preoperative education on behaviour of children during induction of anaesthesia: a randomised clinical trial of efficacy

In this randomised prospective study we aimed to evaluate whether preoperative anaesthetic education delivered to children on the day of surgery reduces anxiety behaviour during induction of anaesthesia. One hundred children, six to 15 years of age, undergoing general anaesthesia for ambulatory surgery were allocated at random to a preoperative education group (n=50) or a control group (n=50). The main outcomes were behaviour score, self-reporting of satisfaction score and identification of the stage when children felt most fearful. Data from all 100 participants were analysed. There was no difference in behaviour score at induction or satisfaction score between the groups. Eighteen percent in the intervention group reported no fear preoperatively vs 10% in the control group. Intravenous induction failed in nine out of 38 children in the intervention group (23.7%) compared to five out of 40 in the control group (12.5%). When intravenous induction failed, eight out of nine (89%) of the intervention group remained co-operative during gas induction compared to two out of five (40%) of the control group. Preoperative education delivered on the day of surgery did not reduce anxiety behaviour in children during intravenous induction of anaesthesia, but did reduce anxiety during subsequent inhalational induction.     

Distress at induction of anaesthesia in children. A survey of incidence, associated factors and recovery characteristics

This study analysed the frequency of distress at induction (DAI) in 2122 paediatric patients. The data were analysed to assess predictors of DAI and to examine associations between predictors of DAI and recovery characteristics. Patient age, preoperative behaviour, premedication (oral midazolam, n =480) and venue for anaesthesia induction were associated with changes in the incidence of DAI. Distressed preoperative behaviour was a good predictor of DAI in all age groups. Premedication reduced the incidence of DAI in children aged 0.5–2 years old, and in older children who were distressed preoperatively. Induction in the Day Surgery Unit was associated with a reduction of the incidence of DAI in younger children. Children with DAI were more likely to suffer from distress at arousal ( P =0.001). Average early recovery time was prolonged 4.4 minutes and average discharge time in daypatients was delayed 36 minutes by the use of oral midazolam premedication. Premedication was not significantly associated with arousal distress. We conclude that a policy of optimizing nonpharmacological approaches for minimizing induction distress, combined with selective premedication with oral midazolam, can produce a low incidence of induction distress and adverse effects.     

Intravenous ketoprofen and epidural sufentanil analgesia in children after combined spinal-epidural anaesthesia

BACKGROUND: Epidural opioid analgesia has become more popular for postoperative pain treatment in children. Epidural opioids are associated with adverse effects such as respiratory depression, excessive sedation, protracted vomiting, urinary retention and pruritus. Following minor surgery, ketoprofen has a synergistic effect with opioids, resulting in an improved analgesia without increase in incidence of adverse effects. To see whether this is also true following major surgery, we compared the effect of i.v. ketoprofen and placebo as an adjuvant to epidural sufentanil analgesia. METHODS: A prospective, randomised, double-blind, placebo-controlled, parallel-group study design was used in 58 children, aged 1-15 years, receiving a standardised combined spinal-epidural anaesthesia. Intravenous ketoprofen or saline was provided as a bolus and a continuous infusion in addition to epidural sufentanil infusion, which was adjusted as clinically required. Epidural bupivacaine was used for rescue analgesia. The study drug infusion was discontinued when pain scores were <3 on a 0-10 scale for 6 h with an epidural sufentanil infusion rate of 0.03 microg kg(-1) h(-1). RESULTS: Children in the ketoprofen group received less rescue analgesia (none/29 vs. 8/29 children in the placebo group). In the ketoprofen group, criteria to discontinue epidural sufentanil were achieved more often (14 vs. 6 children) before the end of the 72 h study period. Less children in the ketoprofen group suffered pruritus (13 vs. 4). The incidence of nausea/retching and vomiting was similar (11 vs. 12) in both groups. CONCLUSION: In this study, ketoprofen as a background analgesic to epidural sufentanil provided improved postoperative analgesia and reduced incidence of adverse effects of the epidural opioid.