A randomized,controlled study of fluid management in infants and toddlers during surgery: hydroxyethyl starch 6% (HES 70/0.5) vs lactated Ringer's solution

BACKGROUND: Volume replacement with hydroxyethyl starch (HES), a synthetic colloid, is widely accepted in adults, but only few data exist regarding its use in children. The aim of this study was to assess the effect of a low molecular weight HES solution (HES 70/0.5) compared with lactated Ringer's solution (LR) on haemoglobin levels as an indirect measure of plasma expansion in infants and toddlers, and its perioperative safety. METHODS: Sixty-four patients, aged 1-38 months, were allocated randomly to receive 20 ml x kg-1 body weight of either HES 70/0.5 or LR during the first hour of urological surgery lasting >2 h. Thereafter, only LR was infused to maintain haemodynamic stability. Intraoperative blood loss and administered fluid volumes were analysed. Haemoglobin levels were determined perioperatively and intraoperatively at completion of volume loading. Changes in body weight and the incidence of postoperative oedema were assessed 24 and 48 h after surgery. For the safety analysis, patients were monitored for 72 h. RESULTS: Intraoperative haemoglobin levels decreased significantly more with HES 70/0.5 (30 +/- 10 g.l-1) compared with LR (21 +/- 12 g.l-1) (P < 0.01). The overall administered fluid volumes during surgery did not differ between groups. The postoperative changes in body weight and incidence of postoperative oedema did not differ between groups. No anaphylactoid reactions, pruritus or adverse effects were observed during the study period. CONCLUSIONS: A larger decrease in haemoglobin levels in infants and toddlers after HES 70/0.5 (20 ml.kg-1) compared with LR indicates a more effective plasma expansion. HES might be considered as a volume expander in the paediatric population.     

A long-term continuous infusion via a sciatic catheter in a 3-year-old boy

We describe the case of a 3-year-old boy with a subtotal amputation of the right foot who received treatment for pain via a peripheral catheter positioned at the level of the sciatic nerve (lateral approach).We administered a continuous infusion of 0.2% ropivacaine, 0.4 mg x kg(-1) x h(-1) plus clonidine 0.12 microg x kg(-1) x h(-1) for 21 days. Pain relief was complete and the patient did not require any further rescue analgesia throughout the period even during medications and surgical treatment in our intensive care unit. We discuss the safety and efficacy of the use of a peripheral continuous infusion in children compared with other techniques of analgesia.     

Laryngeal mask insertion in children: a rational approach

BACKGROUND: Various techniques of laryngeal mask airway (LMATM) insertion have been described in adults but only limited clinical trials have been conducted in children despite a varying range in success rate by the recommended method. METHOD: The study was conducted in 62 ASA 1 and 2 children who were randomly allocated for the evaluation of LMA insertion by the midline approach with the cuff completely deflated (group MD, control group, n = 31) or laterally with the cuff partially inflated (group LP, study group, n = 31). Propofol was used as the sole induction agent in all children. Ease of insertion, position of the LMA with fibreoptic laryngoscope and incidence of stomach insufflation were assessed. RESULTS: Fewer attempts and a significant reduction in the time for insertion was noted in group LP (14.4 +/- 4.2 s) compared with group MD (23.1 +/- 2.1 s), P < 0.05. Despite a good seal around the cuff and satisfactory ventilation a significantly higher incidence of malposition of the LMA was recorded by intraluminal fibreoptic endoscopy in group MD (13% to nil), P < 0.05. Similarly gastric insufflation was significantly greater in group MD (42% compared with 10%). In children with grade 3 fibreoptic view significantly higher endtidal carbon dioxide values were recorded throughout the study period after LMA insertion until its removal. LMA was stained with blood in 13% children in group MD compared with 3% in group LP at the time of removal. CONCLUSION: A partially inflated cuff inserted by the lateral route is a better method of insertion in children and grade 3 fibreoptic views can be associated with a significant build up of carbon dioxide in children breathing spontaneously.     

Propofol and halothane versus sevoflurane in paediatric day-case surgery: induction and recovery characteristics

Background. The aim of this study was to compare the inductionand recovery characteristics associated with propofol inductionand halothane maintenance with sevoflurane anaesthesia in paediatricday surgery. Methods. In total, 322 children were assigned randomly to i.v.propofol induction and halothane/nitrous oxide maintenance orsevoflurane/nitrous oxide alone. The patients’ age, sex,and type of surgery were recorded, as were the times requiredfor anaesthetic induction, maintenance, recovery and time todischarge home. Postoperative nausea and vomiting, and the incidenceof adverse events during induction and recovery were also noted. Results. No significant differences were detected in age, sex,type of surgery performed or intraoperative opioid administration.Excitatory movement was more common during induction with sevoflurane.The mean time required for induction with propofol was 3.1 mincompared with 5 min in the sevoflurane group (P<0.001). Therecovery time was shorter in the sevoflurane group comparedwith propofol/halothane (23.2 vs 26.4 min, P<0.002). Theincidence of delirium in recovery was greater in the sevofluranegroup (P<0.001). There was no difference between groups inthe time spent on the postoperative ward before discharge home.On the postoperative ward the incidence of both nausea and vomitingwas significantly higher in the sevoflurane group (P=0.034).Five children were admitted to hospital overnight, none foranaesthetic reasons. Conclusions. The increased incidence of adverse events duringinduction, postoperative nausea and vomiting and postoperativedelirium in the sevoflurane group suggests that sevofluraneis not ideal as a sole agent for paediatric day case anaesthesia. Br J Anaesth 2003; 90: 461–6     

Nasal fractures: a study comparing local and general anaesthesia techniques

Background: The objective of the present study was to examine the outcome of nasal fracture reduction under both local anaesthesia and general anaesthesia techniques. Methods: Patient records were obtained from clinic lists of patients attending the otolaryngology (ORL) outpatient unit at ­Wellington Hospital or the plastic surgical unit at Hutt Hospital over a 24‐month period. To meet criteria for inclusion, patients had to have an isolated nasal deformity, be aged 14 years or older and be at least 6 months post reduction. Functional and aesthetic results were assessed using subjective and objective end outcome measures. A questionnaire was developed and used to assess subjective outcomes. The number of patients proceeding to open operative correction was used for the objective measure, which included septoplasty, septorhinoplasty or rhinoplasty. Results: A total of 197 patients had nasal fractures manipulated over this period. One hundred and seven were manipulated under general anaesthesia (GA) and 90 were manipulated under local anaesthesia (LA). The questionnaire completion rate was 66%. Patient demographics were statistically similar between the two groups. There was no statistical difference in patients" subjective assessment of outcome with treatment by GA or LA. More patients preferred to have their fracture manipulated under GA but this was not ­statistically significant. There was no significant difference between GA and LA groups in progression to open operative correction. Conclusions: Both LA and GA appear to be acceptable and satisfactory methods of anaesthesia in the reduction of simple displaced nasal fracture.     

Expertise in practice: an ethnographic study exploring acquisition and use of knowledge in anaesthesia

Background. Expert professional practice in any field is knownto rely on both explicit (formal) and tacit (personal) formsof knowledge. Current anaesthetic training programmes appearto favour explicit knowledge and measurable competencies. Weaimed to describe and explore the way different types of knowledgeare learned and used in anaesthetic practice. Method. Qualitative approach using non-participant observationof, and semi-structured interviews with, anaesthetic staff intwo English hospitals. Results. The development of expertise in anaesthesia rests onthe ability to reconcile and interpret many sources of knowledge—clinical,social, electronic, and experiential—and formal theoreticallearning. Experts have mastered technical skills but are alsoable to understand the dynamic and uncertain condition of theanaesthetized patient and respond to changes in it. This expertiseis acquired by working with colleagues, and, importantly, byworking independently, to develop personal routines. Routinesmark the successful incorporation of new knowledge but alsofunction as a defence against the inherent uncertainty of anaestheticpractice. The habits seen in experts’ routines are preferredways of working chosen from a larger repertoire of techniqueswhich can also be mobilized as changing circumstances demand. Conclusions. Opportunities for developing expertise are linkedto the independent development of personal routines. Evidence-basedapproaches to professional practice may obscure the role playedby the interpretation of knowledge. We suggest that the restrictionof apprenticeship-style training threatens the acquisition ofanaesthetic expertise as defined in this paper. Br J Anaesth 2003; 91: 319–28     

Anaesthetics and cardiac preconditioning. Part II. Clinical implications

There is compelling evidence that preconditioning occurs inhumans. Experimental studies with potential clinical implicationsas well as clinical studies evaluating ischaemic, pharmacologicaland anaesthetic cardiac preconditioning in the perioperativesetting are reviewed. These studies reveal promising results.However, there are conflicting reports on the efficacy of preconditioningin the diseased and aged myocardium. In addition, many anaestheticsand a significant number of perioperatively administered drugsaffect the activity of cardiac sarcolemmal and mitochondrialK_ATP channels, the end-effectors of cardiac preconditioning,and thereby markedly modulate preconditioning effects in myocardialtissue. Although these modulatory effects on K_ATP channels havebeen investigated almost exclusively in laboratory investigations,they may have potential implications in clinical medicine. Importantquestions regarding the clinical utility and applicability ofperioperative cardiac preconditioning remain unresolved andneed more experimental work and randomized controlled clinicaltrials. Br J Anaesth 2003; 91: 566–76     

Anaesthetic management of a parturient with pulmonary stenosis and aortic incompetence for Caesarean section

Anaesthetic management of Caesarean section in a parturientwith severe pulmonary stenosis and aortic regurgitation is described.The valvular sequelae resulted from previous unsuccessful surgicalcorrection (Ross procedure) of congenital aortic stenosis. Thiscase demonstrates the importance of multi-disciplinary assessmentand careful anaesthetic planning, to avoid deterioration inperioperative cardiac performance in parturients with complexvalvular disease. Br J Anaesth 2003; 90: 241–3     

Depth of insertion of the ProSeal laryngeal mask airway

Background. The depth of insertion of the ProSeal^TM laryngealmask airway (PLMA     

Disorders of the lymph circulation: their relevance to anaesthesia and intensive care

The lymphatic system is known to perform three major functionsin the body: drainage of excess interstitial fluid and proteinsback to the systemic circulation; regulation of immune responsesby both cellular and humoral mechanisms; and absorption of lipidsfrom the intestine. Lymphatic disorders are seen following malignancy,congenital malformations, thoracic and abdominal surgery, trauma,and infectious diseases. They can occasionally cause mortality,and frequently morbidity and cosmetic disfiguration. Many lymphaticdisorders are encountered in the operating theatre and criticalcare settings. Disorders of the lymphatic circulation relevantto anaesthesia and intensive care medicine are discussed inthis review. Br J Anaesth 2003; 91: 265–72