Cerebral arteriovenous malformations in children

The treatment of cerebral arteriovenous malformations (AVM) or vascular anomalies are challenging neurosurgical procedures for an anaesthetist. Large AVMs are uncommon in children. Only 18% of AVMs become symptomatic before the age of 15 yr. This series reviews the experience at this institution during the period of 1982 to 1992. The symptoms at the time of presentation are varied and include haemorrhage (50%), seizures and hydrocephalus (36%) or congestive cardiac failure (18%). Symptoms of congestive heart failure predominate in the new-born whilst neurological symptoms, such as stroke, seizures or hydrocephalus occur more commonly in infants and older children. Approximately one third of AVMs in childhood present acutely. Radiological investigations, e.g., CT scan, MRI and cerebral angiography are essential to identify the precise location of the lesion. Therapeutic intervention in the acute presentation may involve craniotomy for evacuation of haematoma and treatment of increased intracranial pressure (ICP). Control of seizures and congestive heart failure may take priority and allow time to plan the elective procedures of embolization and surgical excision of the AVM. Operative intervention is hazardous and peroperative complications can be expected in more than 50% of patients. The morbidity and mortality associated with cerebral AVM are high, especially in infants who present in the neonatal period with congestive cardiac failure. The overall mortality in this series was 20%. Children presenting with intracranial arteriovenous malformations require a multidisciplinary approach. The successful management of anaesthesia either for embolization or surgical resection necessitates an understanding of the disciplines of paediatric and neuroanaesthesia. Special care and specific attention to detail may contribute to reduce the high morbidity and mortality encountered in these compromised children.     

Delayed awakening from general anaesthesia in a patient with Hunter syndrome

Hunter syndrome is one of a heterogeneous group of recessively inherited mucopolysaccharide storage diseases (MPS) with similar biochemical defects manifested by impairments in muco-polysaccharide catabolism with variable but progressive clinical courses. Abnormal accumulation and deposition of mucopoly-saccharides in the tissues of several organs lead to numerous anatomical, musculoskeletal and neurological abnormalities which are known to complicate anaesthetic and airway management. Hunter syndrome has a wide variance of clinical phenotypes ranging from mild to severe. We present a patient having physical and neurological features consistent with a severe clinical presentation of Hunter syndrome (MPS, Type II). Following a seemingly uneventful intraoperative anaesthetic course including isoflurane, nitrous oxide and fentanyl (0.93 μg · kg⁻¹), resumption of spontaneous ventilation and return to consciousness were delayed until intravenous naloxone (200 μg) was administered 100 min after the opioid administration. The cause of delayed recovery from anaesthesia in this patient is unknown. La maladie de Hunter fait partie du groupe des affections hétérogènes héréditaires et récessives des mucopolysaccharidoses (MPS) avec lesquelles elle partage les mêmes anomalies biochimiques. Celles-ci se manifestent par des altérations du catabolisme des mucopolysaccharides et une évolution variable et progressive. L’accumulation anormale de mucopolysaccharides dans les tissus de plusieurs organes provoque de nombreuses lésions musculo-squelettiques et neurologiques qui compliquent la gestion de l’anesthésie et des voies aériennes. Les phénotypes cliniques de la maladie de Hunter varient de légers à graves. Cette observation porte sur un patient qui présente des manifestations cliniques graves de la maladie de Hunter (MPS type II). A la suite d’une anesthésie sans problèmes réalisée avec de l’isoflurane, du protoxyde d’azote, et du fentanyl (0,93 μg · kg⁻¹), le retour normal à la ventilation spontanée et à la conscience est retardé jusqu’à l’administration de naloxone (200 mg) iv effectuée 110 min après le morphinique. La raison de ce retard est inconnue.     

Mivacurium-induced neuromuscular blockade during sevoflurane and halothane anaesthesia in children

The neuromuscular blocking effects of mivacurium during sevoflurane or halothane anaesthesia was studied in 38 paediatric patients aged 1–12 yr. All received premedication with midazolam, 0.5 mg · kg⁻¹ po and an inhalational induction with up to 3 MAC of either agent in 70% N₂O and O₂. The ulnar nerve was stimulated at the wrist by a train-of-four stimulus every ten seconds and the force of adduction of the thumb recorded with a Myotrace force transducer. Anaesthesia was maintained with a one MAC end-tidal equivalent of either volatile agent for five minutes before patients received mivacurium (0.2 mg · kg⁻¹) iv. The onset of maximal blockade occurred in 2.4 ± 1.26 (mean ± SD) min with halothane and 1.8 ± 0.54 min with sevoflurane (NS). Four patients failed to achieve 100% block (3 halothane, 1 sevoflurane). The times from injection to 5, 75, and 95% recovery during sevoflurane (9.8 ± 2.6, 19.5 ± 4.4, and 24.2 ± 4.8 min) were greater than during halothane anaesthesia (7.2 ± 2.2, 15.0 ± 4.0, 19.2 ± 4.9 min, respectively (P < 0.005). All patients demonstrated complete spontaneous recovery of neuromuscular function (T₁ > 95%, T₄/T₁ > 75%) during the surgery which lasted 24–63 min. All patients showed clinical signs of full recovery of neuromuscular blockade (i.e., headlift, gag, or cough). Pharmacological reversal was not required. It is concluded that following a single intubating dose of mivacurium, the time to maximum relaxation was not different during halothane and sevoflurane anaesthesia; recovery times to 5, 75 and 95% twitch height were longer during sevoflurane anaesthesia and neuromuscular reversal was not necessary. L’activité neurobloquante du mivacurium pendant l’anesthésie au sévoflurane ou à l’halothane fait l’objet de cette étude réalisée chez 38 enfants de 1 à 12 ans. Tous ont été prémédiqués au midazolam 0,5 mg · kg⁻¹ et l’anesthésie est induite avec un agent volatil jusqu’à MAC 3 de l’un des agents dans du N₂O à 70%. Le nerf cubital était stimulé au poignet au train de quatre aux dix seconds et la force de l’adduction du pouce mesurée avec un transducteur de force Myotrace. L’anesthésie était entretenue avec l’équivalent MAC I d’un des deux agents volatils pendant cinq minutes avant l’administration de mivacurium (0,2 mg · kg⁻¹). Le début du bloc maximum est survenu dans 2,4 ± 1,26 (moyenne ± SD) min avec l’halothane et 1,8 ± 0,54 min avec le sévoflurane (NS). Quatre patients n’ont pas été bloqués à 100% (trois avec l’halothane, un avec le sévoflurane). L’intervalle séparant l’injection à 5; 75, et 95% de la récupération pendant l’anesthésie au sévoflurane (9,8 ± 2,6, 19,5 ± 4,4 et 24,2 ± 4,8 min) a été plus long que pendant l’anesthésie à l’halothane (7,2 ± 2,2, 15,0 ± 4,0, 19,2 ± 4,9 min, respectivement (P < 0,005). An moniteur, chez tous les patients, la fonction neuromusculaire a récupéré spontanément (T₁ > 95%, T₄/T₁ > 75%) au cours de la chirurgie qui a duré de 24–63 min. Tous les patients montraient aussi les signes cliniques d’une récupération complète (par ex., levée de la tête, réflexe pharyngé ou toux). Aucun antagoniste pharmacologique n’a été requis. Il est conclu que le délai jusqu’à la relaxation maximum après une seule dose d’intubation de mivacurium ne diffère pas entre l’anesthésie à l’halothane et l’anesthésie au sévoflurane; les délais de retour à 5, 75 et 95% de la hauteur du twitch sont plus longs pendant l’anesthésie au sévoflurane et il n’est pas nécessaire d’antagoniser le bloc neuromusculaire.

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Supported in part by a grant from Abbott Laboratories, Chicago, Illinois.     

Oral ondansetron decreases vomiting after tonsillectomy in children

Vomiting is a common, unpleasant aftermath of tonsillectomy in children. Intraoperative intravenous ondansetron (OND) reduces vomiting after this operation. Our doubleblind, placebocontrolled, randomized investigation studied the effect of the oral form of OND on vomiting after outpatient tonsillectomy in children. We studied 233 healthy children age 2–14 yr undergoing elective tonsillectomy. Subjects were given placebo (PLAC) or OND 0.1 mg · kg^?1 rounded off to the nearest 2 mg one hr before surgery. Anaesthesia was induced with either propofol or halothane/N₂O. Vecuronium 0.1 mg · kg^?1 was administered at the discretion of the anaesthetist. Anaesthesia was maintained with halothane/N₂O, 50 μg · kg^?1 midazolam iv and 1–1.5 mg · kg^?1 codeine im. At the end of surgery, residual neuromuscular blockade was reversed with neostigmine and atropine. All episodes of inhospital emesis were recorded by nursing staff. Rescue antiemetics in the hospital were 1 mg · kg^?1 dimenhydrinate ivfor vomiting × 2 and 50 μg · kg^?1 droperidol iv for vomiting × 4. Parents kept a diary of emesis after discharge. Postoperative pain was treated with morphine, codeine and/or acetaminophen. The two groups were similar with respect to demographic data, induction technique and anaesthesia time. Oral OND (n = 109) reduced postoperative emesis from 54% to 39%, P < 0.05. This effect was most dramatic inhospital, where 10% of the OND-patients and 30% of the PLAC-group vomited, P < 0.05. The OND-subjects required fewer rescue antiemetics, 7% vs 17%, P < 0.05. In conclusion, oral ondansetron decreased the incidence of vomiting after outpatient tonsillectomy in children.     

Anaesthetic management of a child with Bartter’s syndrome

We report the anaesthetic management of an eight-year-old asthmatic boy with Bartter’s syndrome who had bilateral orchidopexy with caudal epidural analgesia. Bartter’s syndrome is a rare congenital disorder characterized by hypokalaemic hypochloraemic metabolic alkalosis, hyperaldosteronism, hyperreninaemia and hyperplasia of the juxtaglomerular apparatus of the kidneys. Characteristically, although these patients are normotensive they may be hypovolaemic. They may have unstable baroreceptor responses and show marked resistance to vasopressors. Hence, fluid, acid-base and electrolyte imbalances along with haemodynamic instability pose particular problems in their anaesthetic management. Previous case reports have described the management of these patients with general anaesthesia, our patient had his orchidopexy with caudal epidural analgesia using plain bupivacaine 0.5%. The patient was haemodynamically stable throughout surgery and was comfortable with caudal analgesia as the sole anaesthetic. Hypovalaemia, acid-base status and electrolyte imbalance were treated before instituting caudal epidural analgesia. We present this case report which describes the anaesthetic considerations in the light of the pathophysiology of Bartter’s syndrome.     

Paediatric cardiac catheterization: innovations

In recent years interventional procedures have been introduced to the field of paediatric cardiac catheterization. These procedures continue to develop in complexity and increasingly are being applied to patients with reduced cardiovascular reserve, as an alternative to cardiac surgery or when cardiac surgery with cardiopulmonary bypass is contraindicated. More frequently anaesthetists are being called upon to provide support in sedating, anaesthetizing or/and resuscitating these patients. The purpose of this review is to give a comprehensive update of the interventional procedures and to review the anaesthetic management techniques as they apply to the catheterization laboratory. We will discuss possible complications and management strategies from our own experience and the experience of others. We have observed that as more complicated procedures are performed the anaesthetist plays a pivotal role in the management of the patient from arrival to departure from the cardiac catheterization laboratory, and in preventing mortality and major morbidity. Although the economic consequences of interventional cardiological techniques remain unclear, the field continues to expand and more complex procedures are continually being introduced.     

Feasibility,acceptability and effects of dance therapy in stroke patients: A systematic review

IntroductionStroke is the leading cause of non-traumatic disability in adults, with balance and gait disturbances representing the main limitations of body functions. Dance therapy (DT) has shown positive effects in older adults and in patients with neurological pathologies. This systematic review aims to examine the feasibility, acceptability and effects of DT in stroke rehabilitation, specifically on functional gains of gait and balance.MethodsA systematic search was carried out for articles published in the MEDLINE, PEDro, Web of Science, Scopus and CINHAL in February 2021 and updated in April 2021. Results: Eight studies were included (2 clinical cases, 5 case series and 1 randomized controlled trial), 7 of them in patients with chronic stroke and only 1 in subacute stroke phase. The most widely used dance modality was tango and ballet, with sessions ranging from 30 to 110 min. DT seems to show positive effects on post-stroke body functions and activities such as gait and balance. Reported dropout rates are inconsistent, no adverse effects were reported, and participant satisfaction was high.ConclusionGiven the heterogeneity and uneven quality of the included studies, strong conclusions cannot be put forward on the effectiveness of DT in post-stroke body function and activities. Nevertheless, DT seems to be safe and acceptable therapy for patients, and no adverse effects have been reported. More studies with a high level of evidence and feasibility are needed to determine the patient profile, the characteristics of the intervention, the participation rate and the role of the rehabilitation professional most likely to generate optimal benefit.     

带血管蒂皮瓣修复肢体软组织缺损及综合康复42例报告

目的：提高皮瓣转移的成功率与功能康复。方法：对４２例皮瓣转移患者采用了术前、术后的康复治疗,并进行了随访。结果：成功率达９５％,修复的缺损部位的功能恢复满意。结论：综合性康复治疗对提高皮瓣转移术的成功率及降低术后功能障碍是不可或缺的方法     

Developing rational protocols for paediatric psychopharmacological prescribing.

The number of child psychiatrists, paediatricians and general practitioners prescribing psychotropic medication for children in the UK is increasing. Medication is being used not just to treat children of normal intelligence with hyperkinetic disorder or depression, but also to modify behavioural problems in children with developmental disorders and severe learning difficulties. Literature reviews highlight the lack of robust randomized controlled drug trials on which to base clinical practice and the authors have found no appropriate existing protocols to help develop a systematized approach. Against such a background the authors have developed a comprehensive set of protocols covering prescribing details for individual drugs, and also addressing issues such as informed consent, long-term monitoring and school liaison. All children referred to the authors' clinics go through a standardized decision-making process. This article describes both the protocols themselves and the philosophies that guided their development. The authors describe how such a system benefits the children, their families, general practitioners and schools, whilst also facilitating audit and research.     

An action research investigation into the feasibility of experienced registered sick children's nurses (RSCNs) becoming children's emergency nurse practitioners (ENPs)

• ? Emergency nurse practitioners (ENPs) formally developed in accident and emergency (A & E) departments as a direct response to waiting times for the walking wounded, the need to reduce junior doctors hours and changes in nursing practice.
• ? ENPs existed informally for many years in minor injuries units and specialist ophthalmic departments.
• ? This study aimed to examine whether or not the role of ENP could be applied to the specialist service of a paediatric casualty department.
• ? The results showed that 3% of patients could be seen and treated to conclusion by a children's ENP, and some patients could have their care accelerated by a children's ENP.
• ? The introduction of children's ENPs would have an impact on waiting times, junior doctors work-load and the quality of patient care.