Does ketamine or magnesium affect posttonsillectomy pain in children?

BACKGROUND: Many previous studies have suggested a role for the N-methyl-D-aspartate (NMDA) receptor antagonists ketamine and magnesium in decreasing postoperative pain and analgesic requirements in adults, but none has investigated these medications in children. METHODS: This randomized, double-blind, placebo-controlled study evaluated the effects of ketamine and magnesium in children undergoing tonsillectomy. Eighty patients, aged 3-12 years, were randomly assigned to four groups. Patients received either ketamine 0.15 mg.kg-1, magnesium sulphate 30 mg.kg-1, ketamine 0.15 mg.kg-1 plus magnesium sulphate 30 mg.kg-1, or placebo intravenously 5 min prior to the start of surgery. Intraoperative analgesia was standardized, and included fentanyl and dexamethasone. RESULTS: There were no differences among the groups with respect to pain assessment postoperatively. Compared with placebo, the treatment groups did not require less fentanyl in the postanaesthesia recovery room or consume less codeine in the first 24-h postoperatively. There was no evidence of synergism between ketamine and magnesium. There were no differences among the groups in the incidence of nausea, vomiting, sedation, bleeding, or dreaming postoperatively. CONCLUSION: This study did not demonstrate a decrease in pain or analgesic consumption in children undergoing tonsillectomy when pretreated with a small dose of ketamine and/or magnesium.     

Acetaminophen versus acetaminophen with codeine after pediatric tonsillectomy

OBJECTIVE: To compare the effectiveness of acetaminophen versus acetaminophen with codeine after pediatric tonsillectomy and adenoidectomy. STUDY DESIGN: Prospective, randomized, double-blind study. METHODS: Fifty-one children ages 3 to 12 years scheduled for outpatient tonsillectomy and adenoidectomy were studied. Patients were randomly assigned to receive acetaminophen or acetaminophen with codeine in unlabeled bottles for postoperative pain control. The Wong-Baker FACES pain rating scale was used to help children quantify their level of pain after surgery. The level of pain, quantity of pain medication required, presence of side effects, and the percentage of a normal diet consumed was recorded for 10 postoperative days. RESULTS: There was no difference (P > .05, all time points) in the level of postoperative pain reported by the parents and children in the two groups. The acetaminophen with codeine group tended to have increased problems with nausea, emesis, and constipation, but these differences did not reach statistical significance. Children in the acetaminophen group consumed a significantly higher percentage of a normal diet on the first 6 postoperative days (P < .05, all time points). CONCLUSION: There was no difference in the level of pain control provided by acetaminophen and acetaminophen with codeine as measured by the Wong-Baker FACES pain rating scale. Postoperative oral intake was significantly higher in children treated with acetaminophen alone.     

儿童扁桃体切除后机体免疫功能变化的探讨

用比浊法分别测定扁桃体切除术前、术后１ 周及１ 个月的免疫球蛋白（ＩｇＧ、ＩｇＡ、Ｉｇ Ｍ） 含量,了解其变化情况。结果显示,术后１ 周ＩｇＧ、ＩｇＡ、Ｉｇ Ｍ 均下降,与术前比较,差异有高度显著性（ Ｐ ＜ ０ ．０５） ;术后１ 个月,Ｉｇ 水平均有所回升,以ＩｇＡ 最明显,其含量与术前相比差异无显著性（ Ｐ ＞ ０ ．０５） ;而Ｉｇ Ｍ 、ＩｇＧ 则不明显,其均数与术前相比差异仍有高度显著性（ Ｐ ＜ ０ ．０５） 。认为扁桃体切除术后Ｉｇ 含量虽有下降,但均在正常范围内变化,故只要掌握好适应证,儿童扁桃体切除是安全可靠的。     

Clinical remission and pathological progression after tonsillectomy in a renal transplant patient with recurrent IgA nephropathy

Abstract:  We discuss a renal transplant patient with recurrent IgA nephropathy (IgAN) before and after tonsillectomy. A 36-year-old man started on hemodialysis support in 1996 due to biopsy-proven IgAN, living related renal transplantation was then performed in 1997. Six years after transplantation, the patient presented with microhematuria and proteinuria. Graft biopsy for these urinary abnormalities showed recurrent IgAN. Tonsillectomy was subsequently performed in December 2003, proteinuria remitted 6 months after the tonsillectomy and microhematuria disappeared three years later. Protocol graft biopsy was subsequently performed twice, at 2 yr after the tonsillectomy (2005) and 4 yr after (2008). Comparing the findings of the pre-tonsillectomy biopsy and the two post-tonsillectomy biopsies, an increase in mesangial cells and matrix in 2005, and an expansion of the mesangial matrix and proliferation of mesangial interposition in 2008. In addition, global sclerosis of glomeruli increased over time, the area of tubulointerstitial damage has extended as well. While the tonsillectomy led to clinical remission of recurrent IgAN, the chronicity progressed on these protocol biopsies. This is the first report of the efficacy and the limitations of tonsillectomy in a case of recurrent IgAN in a transplant patient.     

芬太尼用量对小儿扁桃体联合腺样体切除术后苏醒质量的影响

目的观察不同剂量芬太尼用于小儿插管全麻手术对术后苏醒质量的影响。方法选择60例ASA I-Ⅱ级择期行鼻内镜下扁桃体联合腺样体切除术患儿并随机分成3组。各组患者诱导用药均为：丙泊酚2.0mg／kg,维库溴铵0.1mg／kg,芬太尼2.5μg／kg,术中均以瑞芬太尼复合丙泊酚泵注维持。手术开始前,I组不追加芬太尼,Ⅱ组追加芬太尼2.0μg／kg,Ⅲ组追加芬太尼4.0μg／kg。观察指标：记录麻醉诱导前（T0）、气管插管后即刻（T1）、手术开始30分钟（T2）、手术结束时（T3）的心率（HR）、动脉收缩压（SBP）、动脉舒张压（DBP）、脉搏氧饱和度（SpO2）;记录各组患儿芬太尼、瑞芬太尼的用量和手术结束至呼吸恢复时间、至呼名睁眼时间、至拔出气管导管时间;记录各组患儿术后恶心呕吐、躁动及出手术室时自觉疼痛情况。结兽三组患儿各时间点的HR、SBP、DBP、SpO2与诱导前比较差异无显著性（P〉0.05）。麻醉持续时间三组比较无差异,麻醉药用量Ⅱ、Ⅲ组瑞芬太尼少于I组（P〈0.05）;呼吸恢复时间、呼名睁眼时间、拔出气管导管时间I组短于Ⅱ组,Ⅱ组短于Ⅲ组（P〈0.05）;苏醒后恶心呕吐发生率差异显著躁动率I组大于Ⅱ、Ⅲ组（P〈0.05）。三组均无术中知晓及其它麻醉并发症。结论小儿扁桃体联合腺样体切除手术开始前以芬太尼2.0μg／kg注入,术中以瑞芬太尼复合丙泊酚全凭静脉麻醉维持,可明显提高麻醉后苏醒质量。     

Subhypnotic propofol infusion plus dexamethasone is more effective than dexamethasone alone for the prevention of vomiting in children after tonsillectomy

Background: Postoperative vomiting (POV) is a common complication after tonsillectomy. Dexamethasone is known to decrease postsurgical vomiting. In this study, we compared the effects of dexamethasone alone to dexamethasone plus propofol on postoperative vomiting in children undergoing tonsillectomy. Methods: In a randomized double‐blinded study, we evaluated 80 healthy children, aged 4–12 years, who underwent tonsillectomy with or without adenoidectomy. After anesthesia was induced by inhalation of sevoflurane, 0.15 mg·kg^?1 dexamethasone and 2 μg·kg^?1 fentanyl was administered i.v. to all patients. The patients in the dexamethasone plus propofol group received 1 mg·kg^?1 propofol before intubation and continuously after intubation at a rate of 20 μg·kg^?1·min^?1 until the surgery was completed. Data for postoperative vomiting were grouped into the following time periods: 0–4 and 4–24 h. Data were analyzed using a Student’s t‐test and chi‐squared analysis. Results: The percentage of patients exhibiting a complete response (defined as no retching or vomiting for 24 h) increased from 37.5% in the dexamethasone‐alone group to 75% in the dexamethasone plus propofol group (P = 0.001). Twenty‐two patients (55%) in the dexamethasone‐alone and nine patients (22.5%) in the dexamethasone plus propofol groups experienced vomited during 0–4 h (P = 0.003). Eight patients in the dexamethasone‐alone group and three patients in the dexamethasone plus propofol group received ondansetron as a rescue antiemetic during the postoperative period. Conclusion: For children undergoing tonsillectomy, intraoperative subhypnotic propofol infusion combined with dexamethasone treatment provides a better prophylaxis against postoperative vomiting than does dexamethasone alone.     

内镜下动力系统辅助扁桃体囊内吸切术

目的介绍在内镜监视下应用动力系统进行儿童扁桃体吸切术的手术方法和结果。方法在内镜监视下应用Xomed动力系统对13例肥大型扁桃体炎的患儿进行了扁桃体囊内切除术，保留扁桃体被膜形成对咽缩肌的保护。结果手术进行顺利，切除干净，无并发症发生，患儿术后疼痛较小。结论该方法有术野清晰、损伤小、便于在狭小区域进行、安全高效的优点，缺点在于提高了治疗成本。     

The effect of adenoid and tonsil surgery on nasalance

The change in nasalance following adenoidectomy, tonsillectomy and adenotonsillectomy was studied in 44 children. A subjective assessment of each child's naso-pharyngeal airway was made preoperatively based on a questionnaire completed by the parents. There was no significant change in the nasalance of children following adenoidectomy, but there was a significant increase in the nasalance following tonsillectomy (P = 0.02) and after adenotonsillectomy (P = 0.001). There was no relationship between the change in nasalance and the adenoid volume removed at operation. There was good agreement between the parental subjective assessment of the naso-pharyngeal airway and the preoperative nasalance score, with the best correlation in the adenoidectomy group (r = -0.8) and the adenotonsillectomy group (r = -0.7). Nasalance is more closely related to the size of the naso-pharyngeal airway than to the actual adenoid volume, and measurements of nasalance are of no benefit in predicting adenoid volume. Tonsillectomy had a significantly greater effect on nasalance than adenoidectomy, and adenotonsillectomy had the greatest effect. Further studies are needed to relate nasalance to the size of the naso-pharyngeal airway, but it appears to relate well to the subjective assessment of the airway and may be of use in patient selection for surgery.     

Propofol reduces the incidence of vomiting after tonsillectomy in children

We compared the effect of a propofol-based anaesthetic to an isoflurane-based anaesthetic on the incidence of postoperative vomiting in children following tonsillectomy. Thirty-nine children were enrolled in the study and randomized to receive one of the proposed anaesthetics. All patients underwent a mask induction with halothane, nitrous oxide, and oxygen. Intravenous access was established and all children received fentanyl (2–4 μg·kg^-1) i.v., mivacurium (0.3 mg·kg^-1) i.v. and acetaminophen (10–15 mg·kg^-1) p.r. Following tracheal intubation, patients received either isoflurane (0.8–1.6%) or propofol (120–180 μg·kg^-1 min^-1) i.v. with nitrous oxide 70%/oxygen 30% for maintenance of anaesthesia. Vital signs were maintained within 20% of baseline. All patients were extubated in the operating room. PACU nursing staff recorded episodes of vomiting for 4–6 h prior to discharge. A telephone interview the following day was also used for data recovery. Age, sex, and duration of the procedure were not significantly different between the two study groups. Of 19 patients who received propofol, four vomited (21%); in contrast, of the 20 patients who received isoflurane, 11 vomited (55%). This difference is significant (P= 0.048 two-tailed Fisher's Exact Test). These data suggest that using propofol for anaesthesia can diminish the incidence of vomiting following tonsillectomy.