Recovery after anesthesia for short pediatric oncology procedures: propofol and remifentanil compared with propofol, nitrous oxide, and sevoflurane

Anesthesia techniques in children undergoing short painful oncology procedures should allow rapid recovery without side effects. We compared the recovery characteristics of two anesthetic techniques: propofol with sevoflurane and nitrous oxide and a total IV technique using propofol and remifentanil. Twenty-one children, undergoing two similar painful procedures within 2 wk were studied in a single-blind manner within patient comparison. The order of the techniques was randomized. Propofol and remifentanil involved bolus doses of both propofol 3-5 mg/kg and remifentanil 1-4 microg/kg. Propofol with sevoflurane and nitrous oxide involved propofol 3-5 mg/kg with 2%-8% sevoflurane and 70% nitrous oxide. The primary outcome variable was the time taken to achieve recovery discharge criteria; other recovery characteristics were also noted. The mean age of the children was 6.5 yr (range, 2.5-9.8 yr). Nineteen had lymphoblastic leukemia and two had lymphoma. All children had intrathecal chemotherapy and one had bone marrow aspiration. Most procedures lasted <4 min. The mean time to achieve recovery discharge criteria was appreciably shorter after propofol and remifentanil than propofol with sevoflurane and nitrous oxide by nearly 19 min (P = 0.001). All other time comparisons had similar trends and statistical differences. Seven parents expressed a preference for the propofol and remifentanil technique compared with one preferring propofol with sevoflurane and nitrous oxide. Children are apneic during the procedure and require respiratory support from an anesthesiologist. Discharge readiness from the recovery ward was achieved on average 19 min earlier after propofol with remifentanil compared with the combination of propofol, sevoflurane and nitrous oxide. Parents more often preferred propofol with remifentanil.     

Sevoflurane sedation in infants undergoing MRI: a preliminary report

BACKGROUND: Stillness during natural sleep after feeding may not be sufficient for successful magnetic resonance imaging (MRI) in small infants less than 5 kg. Sedation, using an oral agent, is often successful although the timing and depth of sedation is variable. In contrast anesthesia is always effective but is invasive and is associated with postanesthesia apnea and bradycardia in preterm and ex-preterm infants. We are developing an alternative technique involving insufflation of sevoflurane and present our initial experience. METHODS: Infants presenting for MRI were sedated by nasal insufflation of sevoflurane carried by 2 l.min(-1) oxygen. We recorded the sevoflurane administered, timing of sedation and scanning, conscious level, oxygen saturations, and recovery profile. RESULTS: Of the 13 infants studied (median postconceptional age: 46 weeks, range: 40-70 weeks; median weight: 4.4 kg, range: 3.3-6.5 kg), sevoflurane caused sleep and enabled successful imaging in 12. Six infants fell asleep within 10 min and the median maximum sevoflurane vaporizer setting for successful sedation was 4% (range: 4-8%). Before scanning, 10 infants remained easily roused by touch and two became unresponsive; one desaturated to 85% and required repositioning of the head to maintain a clear airway. Immediately after scanning all infants were easily roused by touch. CONCLUSIONS: Sedation by insufflation of sevoflurane in small infants is a simple and practical alternative technique for painless imaging such as MRI; further experience is necessary to determine its limitations.     

Pre-implantation apposition grafts for edentuous anterior maxillary. Retrospective study of 36 patients

INTRODUCTION: Apposition grafting is a method of choice for reconstruction of the anterior maxillary. The purpose of this work was to evaluate the success rate, the degree of bone resorption and the osteointegration of these grafts. MATERIAL AND METHODS: We reviewed retrospectively 36 cases of pre-maxillary bone apposition in patients operated from 1998 to 2002. Autografts were used for all patients. The harvesting site was parietal for 24 patients, intraoral for 8 and iliac for 4. RESULTS: There was two graft failures. The success rate was 94.5%. Partial resorption with effect on implantation was noted in 3 patients. Eighty implants were inserted successfully in 234 grafted sites with on average 2.4 implants per graft. Three implants were removed. Implant survival was 96.2%. DISCUSSION: This study demonstrated that the premaxillary apposition technique using autologous grafts provides sufficient bone volume to enable optimal implant insertion and stability.     

Regional block and DVT prophylaxis

The last few years have seen increasing concerns among anaesthetistsabout the risks of pharmacological prophylaxis for thromboembolicdisease. Increased bleeding during or after surgery is one concern,but of greater significance is the possibility of an increasedpredisposition to haematoma formation when regional block isused. Most of the recent consideration of this problem has beenin relation to vertebral canal haematoma formation after centralnerve block. Some thought must be given also to the possibilityof haematoma formation after peripheral techniques when thetarget nerve is deeply placed so that pressure cannot be usedto control bleeding after needle insertion. However, this reviewwill be focused on vertebral canal haematoma.     

Serum organochlorine levels and history of lactation in Egypt

We conducted a study in Egypt to assess the determinants of organochlorine serum levels among premenopausal women and the risk of premenopausal breast cancer for women with high organochlorine serum levels. We included 69 breast cancer patients and 53 controls consisting of visitors to the hospitals of the cancer patients. We found low levels of dichlorodiphenyldichloroethylene (DDE), total dichlorodiphenyltrichloroethane, and beta-hexacholorhexane (beta-HCH) in most subjects. Mean DDE levels were 12.7 +/- 20.3 ppb for cases and 16.6 +/- 30.1 ppb for controls (P = 0.60); beta-HCH levels were 2.1 +/- 3.8 ppb for patients and 2.1 +/- 3.9 ppb for controls (P = 0.71). Interestingly, subjects with low levels had breast fed their children for an average period of 18 months. Women with no lactation history had much higher organochlorine levels than women who breast fed (P = 0.002 for DDE). Younger age, older age at first childbirth, and shorter duration of breast feeding were significant predictors of higher levels of serum DDE levels. Younger age, older age at first childbirth, and higher body mass index were significant predictors of higher beta-HCH levels. This study suggests that organochlorine serum levels in Egyptian women are quite low, but indicates an effect of breast feeding in eliminating organochlorines, which would imply exposure to children. Organochlorine serum level was not a risk factor of breast cancer in this population.     

Prevalence of risk factors for cardiovascular disease in Canadians 55 to 74 years of age: results from the Canadian Heart Health Surveys, 1986-1992

BACKGROUND: By 2016, the proportion of Canadians older than 65 years of age will increase to 16%, and there will be an increase in the absolute number of cases of cardiovascular disease in older Canadians. The Canadian Heart Health Surveys database provides information about this population upon which health policy related to cardiovascular disease can be based. This paper presents for the first time population-based data on the risk factors for cardiovascular disease in older Canadians. METHODS: Canadians from all 10 provinces participated in surveys of cardiovascular risk factors; health insurance registries were used as sampling frames. In each province, probability samples of 2200 adults 18 to 74 years old not living in institutions, on reserves or in military camps were asked to participate in interviews and to undergo testing at clinics for major risk factors for cardiovascular disease. RESULTS: A total of 2739 men (response rate 70%) and 2617 women (response rate 66%) aged 55 to 74 years participated in the survey and also provided follow-up clinical measurements at the clinic. Overall, 52% of participants were hypertensive, 26% had isolated systolic hypertension, and 30% had a total blood cholesterol level of 6.2 mmol/L or greater. Rates of current smoking were lower in women than men (17% v. 22%). Overall, 87% of men and 78% of women who were current smokers smoked at least 10 cigarettes per day. Only slightly more than half of participants exercised at least once a week for at least 15 minutes, and almost half had a body mass index of 27 or greater. In only 4% was no major risk factor for cardiovascular disease detected. INTERPRETATION: Significant numbers of older Canadians have one or more major risk factors for cardiovascular disease. Many of these risk factors are amenable to modification.     

Precise intraoperative location of gastrointestinal bleeding with a hand-held counter. Work in progress

The nuclear medicine bleeding scan is frequently insufficient to locate sites of bleeding precisely, in spite of its great sensitivity. A small, hand-held Geiger-Müller counter, placed directly on exposed intestine in the operating room, enables precise location of the probable bleeding site. In three patients, the technique allowed a minimal amount of intestine to be resected, distinguished between large- and small-intestinal hemorrhage, and eliminated other foci as sites of bleeding.