Difficult tracheal intubation in neonates and infants. NEonate and Children audiT of Anaesthesia pRactice IN Europe (NECTARINE): a prospective European multicentre observational study

BACKGROUND: Neonates and infants are susceptible to hypoxaemia in the perioperative period. The aim of this study was to analyse interventions related to anaesthesia tracheal intubations in this European cohort and identify their clinical consequences. METHODS: We performed a secondary analysis of tracheal intubations of the European multicentre observational trial (NEonate and Children audiT of Anaesthesia pRactice IN Europe [NECTARINE]) in neonates and small infants with difficult tracheal intubation. The primary endpoint was the incidence of difficult intubation and the related complications. The secondary endpoints were the risk factors for severe hypoxaemia attributed to difficult airway management, and 30 and 90 day outcomes. RESULTS: Tracheal intubation was planned in 4683 procedures. Difficult tracheal intubation, defined as two failed attempts of direct laryngoscopy, occurred in 266 children (271 procedures) with an incidence (95% confidence interval [CI]) of 5.8% (95% CI, 5.1–6.5). Bradycardia occurred in 8% of the cases with difficult intubation, whereas a significant decrease in oxygen saturation (SpO2<90% for 60 s) was reported in 40%. No associated risk factors could be identified among co-morbidities, surgical, or anaesthesia management. Using propensity scoring to adjust for confounders, difficult anaesthesia tracheal intubation did not lead to an increase in 30 and 90 day morbidity or mortality. CONCLUSIONS: The results of the present study demonstrate a high incidence of difficult tracheal intubation in children less than 60 weeks post-conceptual age commonly resulting in severe hypoxaemia. Reassuringly, the morbidity and mortality at 30 and 90 days was not increased by the occurrence of a difficult intubation event

Management of acute craniotomy pain: The analgesic effect of diclofenac sodium-tramadol or paracetamol-tramadol

BACKGROUND AND OBJECTIVE: There is currently no consensus on pain management after craniotomy in neurosurgical centers in the world. We have investigated either the addition of diclofenac sodium or paracetamol to tramadol for analgesia after craniotomy. METHODS: Fifty patients were allocated randomly to receive an intravenous tramadol with diclofenac sodium (DT) or tramadol plus paracetamol (PT), in a double-blind, randomized study. Then, all patients received bolus doses of tramadol (1.5 mg/kg) every 6 hours during the first 24 hours. Discomfort, sedation, pain scores, and side effects were recorded for up to 24 hours. RESULTS: Although there was no difference in visual analog scale scores between groups 15 and 30 minutes after extubation, and after 1 (t3), 8 (t5), 12 (t6), and 16 hours, the diclofenac-tramadol group had significantly lower scores 4 and 24 hours postoperatively (P<0.05). The number of patients requiring supplementary meperidine was significantly higher in the PT group than in the DT group. Four patients in the DT group (16%) and 10 patients in the PT group (40%) complained of pain during the first 24 hours, despite the tramadol therapy and they were treated with intravenous meperidine (25 mg). CONCLUSIONS: Addition of either diclofenac sodium or paracetamol to tramadol provided effective postoperative analgesia and patient comfort, without causing any sedation or respiratory depression after major intracranial surgery. In addition, diclofenac sodium-tramadol combination provided better postoperative pain relief and less supplementary analgesics than paracetamol-tramadol combination. © 2011 by Lippincott Williams & Wilkins

The effect of dexmedetomidine on bispectral index monitoring in children

PubMedID: 23327035The primary aim of this study was to test whether dexmedetomidine administration based on the bispectral index (BIS) monitoring caused a reduction in consumption of sevoflurane. following institutional ethic committee approval and written informed consent from all parents, fifty-four children undergoing sevoflurane anaesthesia randomly allocated to receive either dexmedetomidine (Group D) or saline (Group S). The anaesthesia was induced with 8% sevoflurane in nitrous oxide/oxygen in all children. following anaesthesia induction, group D (n=27) children received a loading dose of dexmedetomidine 1 µgkg-1 iV over ten minutes, followed by a continuous infusion at a rate of 0.5 µgkg-1 hr-1 throughout the surgery. group s (n=27) children received same volume of saline infusion due to obtained blindness. Systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate (hr), body temperature and peripheral oxygen saturation (spO2), end-tidal concentrations of oxygen, carbon dioxide (eTcO2), and sevoflurane (ETsevo) were monitorized. Bispectral index numbers and eTsevo concentrations were recorded at 2 min before incision, 2 min after incision, at the end of surgery and before the termination of anaesthesia, and finally immediately after wake-up from anaesthesia (Final BIS number). BIS number was found significantly lower in group D at before incision, after incision and at the end of surgery than in group S (p=0.000, 0.001, 0.007). End tidal sevoflurane concentrations were significantly higher in group S at before incision, after incision and at the end of surgery than in group D (p &lt;0.000 to p &lt;0.001). Final BIS number and sevoflurane concentrations were similar and there were no significant difference between the groups. it was concluded that intravenous (iV) dexmedetomidine infusion at a rate of 0.5 µgkg-1 hr-1 during sevoflurane anaesthesia significantly reduces end-tidal sevoflurane concentration and BIS number in children undergoing minor surgical interventions

Comparison of morphine and tramadol by patient-controlled analgesia for postoperative analgesia after tonsillectomy in children

PubMedID: 16238560Background: Tramadol is an alternative to other opioids for postoperative pain management. This prospective, randomized, double-blind study was designed to compare the analgesic efficacy of patient-controlled tramadol with patient-controlled morphine for postoperative pain after tonsillectomy in children. Method: Sixty patients were allocated randomly to receive a patient-controlled analgesia (PCA) with either tramadol (T) or morphine (M), in a double-blind randomized study. When surgery was completed and hemostasis achieved, a standardized loading dose (0.1 mg·kg-1 in group M, or 1 mg·kg-1 in group T) was given. Thereafter, the children helped themselves to bolus doses (morphine (0.02 mg·kg-1) or tramadol (0.2 mg·kg-1) with lockout times of 10 min without time limit via a PCA device. Scores for pain, sedation, nausea, and the bolus and total PCA doses, hemodynamic parameters and side effects were recorded at 5, 15, 30 min and 1, 2, 4, 6 and 24 h during PCA administration. Results: Pain scores decreased significantly with time in both groups (P &lt; 0.05), but were lower in group M than in group T at 1, 2 and 4 h (P &lt; 0.05). Sedation scores increased with time in both groups (P &lt; 0.05). However there were no significant differences in sedation scores between two groups at any study period, but nausea scores were higher in M group at 4, 6 and 24 h (P &lt; 0.05). Conclusion: Intravenous patient-controlled tramadol is an alternative to patient-controlled morphine for postoperative pain relief in children after tonsillectomy. Morphine gave better postoperative pain relief, but was associated with a higher incidence of nausea than tramadol. © 2005 Blackwell Publishing Ltd

Comparison of caudal vs intravenous tramadol administered either preoperatively or postoperatively for pain relief in boys

PubMedID: 15078378Background: In this study we compared caudal with intravenous (i.v.) tramadol given pre- or postoperatively for pain relief in boys having hypospadias repair. Methods: The study was approved by the Ethics Committee and informed written consent was obtained from the parents of each patient. Patients (n = 134), aged 1-3 years, American Society of Anesthesiologists (ASA) physical status I, scheduled for hypospadias surgery were recruited. The patients were randomly allocated to one of the four groups: group I (n = 33), received 2 mg·kg-1 (0.5 ml·kg-1) of caudal tramadol after the surgical procedure was completed, group II (n = 33) received 2 mg·kg-1 (0.5 ml·kg-1) of caudal tramadol before incision, group III (n = 34) received 2 mg·kg-1 tramadol intravenously, after surgery and group IV (n = 34) received 2 mg·kg-1 tramadol intravenously, after anaesthesia induction. When the patients were fully awake in the recovery area, heart rate, arterial pressure, peripheral oxygen saturation, respiratory rate, pain and sedation scores were recorded at 5, 10, 15, 30, 60 min, and 2, 3, 4, 6, 12 and 24 h postoperatively and side-effects were noted. Pain was assessed using an objective pain score (OPS). Results: The OPS were lower in caudal tramadol groups than in i.v. tramadol groups only at 3 h (P &lt; 0.05). The duration of postoperative analgesia was longer in the caudal groups than in the i.v. groups (P = 0.001). However, the duration of postoperative analgesia was unaffected by the timing of administration. Conclusions: Caudal tramadol provides better and longer lasting postoperative analgesia than i.v. tramadol. These results also suggest that preoperative caudal tramadol did not provide any clinically perceptible benefits compared with postoperative caudal tramadol

The comparison of caudal ketamine, alfentanil and ketamine plus alfentanil administration for postoperative analgesia in children

PubMedID: 12358657Background: Our aim was to compare the effect of single dose caudal ketamine, alfentanil or a mixture of both drugs in the treatment of pain after hypospadias repair surgery in children. Methods: The group comprised 109 boys, ASA I-II, aged 1-9 years, who were undergoing hypospadias repair surgery as day cases. The children were randomly divided into three groups for postoperative analgesia: group 1, only alfentanil (20 µg·kg-1) was given caudally; group 2, ketamine (0.5 mg·kg-1) alone; and group 3, alfentanil (20 µg·kg-1)-ketamine (0.5 mg·kg-1) was given caudally. The analgesic effect of caudal block was evaluated using the Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) and sedation was assessed using a five-point sedation score. The first analgesic requirement time and the number of supplementary analgesics required by each child in a 24-h period were also recorded. Results: No statistical differences were found in demographic characteristics, haemodynamic and respiratory parameters, objective pain scores, postoperative sedation scores and duration of surgery among the groups. The median time to first analgesia was significantly shorter in group 1 than in groups 2 and 3 (P = 0.009, P = 0.001). Significantly more patients in group 1 required additional postoperative analgesia (paracetamol 15 mg·kg-1) compared with groups 2 and 3 (P &lt; 0.001). Conclusions: Caudal administration of ketamine 0.5 mg·kg-1 with or without alfentanil in children produced satisfactory postoperative analgesia without respiratory depression or other side-effects

Effect of remifentanil-propofol anaesthesia on cognitive functions in patients undergoing arthroscopic surgery: A comparison of different remifentanil doses [Artroskopik cerrahi uygulanan hastalarda remifentanil-propofol anestezisinin postoperatif derlenme kriterleri üzerine etkisi: Farkli remifentanil dozlarinin karşilaştirilmasi]

The aim of this clinical investigation was to compare the recovery times and cognitive function in patients undergoing outpatient arthroscopy, after different remifentanil doses in combination with a hypnotic dose of propofol. Ninety adult ASA class I-II patients were included into the study. Prior to anesthesia, visual analog seala (VAS) patients were given baseline assessments of mental state (VAS) and cognitive function "digit symbol substitution test" (DSST). Anaesthesia was induced with propofol 2 mg kg-1 and remifentanil 1 µg kg-1. To perform endotracheal intubation cis-atraeurium 0,15 mg kg-1 was given. Anaesthesia was maintained with propofol 4-5 mg kg-1 h-1 and remifentanil infusion at three rates as 0.20 µg kg-1 min-1, 0.25 µg kg -1 min-1, and 0.3 µg kg-1 min-1 in three groups randomly. VAS and DSTT values were recorded at 1, 5, 15, 30, 45 and 60 min postoperatively. The times to be able to sit, walk, open eyes, respond to command and discharge were also recorded. Demographic variables and duration of anaesthesia were similar in groups. Significantly shorter times to be able to sit, walk, open eyes, respond to command and discharge were observed in group I when compared with the other groups. Number of patients with 100 % DSST values were higher in group I and II than group III at 5th min postoperatively (p&lt;0.05). We concluded that the lower-dose of remifentanil provided shorter and better recovery than the higher doses

Dexmedetomidine-remifentanil or propofol-remifentanil anesthesia in patients undergoing intracranial surgery

Dexmedetomidine has been shown to provide good perioperative hemodynamic stability with decreased intraoperative opioid requirements. This study was conducted to compare the effect of dexmedetomidine-remifentanil (DR) anesthesia and propofol-remifentanil (PR) anesthesia on perioperative hemodynamics and postanesthesia recovery profiles in patients undergoing intracranial surgery. After receiving Ethics Committee approval and informed patient consent, 78 American Society of Anesthesiologists physical status I or II patients between the ages of 19 and 70 years with a Glasgow Coma Scale score 14 or 15 who were scheduled for elective intracranial surgery with general anesthesia were recruited. Anesthesia induction was provided by intravenous remifentanil (0.5 µg/kg) and propofol (1.5-2 mg/kg) in both groups and maintained with infusion of DR (0.6-1.2 mg/kg/h and 0.25 µg/kg/min)-nitrous oxide/oxygen (n 2o/o2) in the DR group (n = 39) and infusion of PR (3-10 mg/kg/h and 0.25 µg/kg/min)-n2o/o2 in the PR group (n = 39). Hemodynamic variables were recorded before surgery, during the induction of anesthesia, after intubation, and during application of the headholder and skin incision; brain relaxation was also recorded. Times to extubation and awakening, eye opening, and response to commands as well as analgesic requirements were recorded after surgery. No significant difference was found in systolic blood pressure and mean arterial pressure throughout the study period except at the time of the dural incision (P &lt; 0.05). These variables were significantly lower in the DR group (P &lt; 0.05). Brain relaxation scores were similar between the 2 groups (P &gt; 0.05). Time to extubation was significantly shorter in patients receiving PR anesthesia than in patients receiving DR anesthesia (3.6 minutes vs. 5.5 minutes). Analgesic requirements were significantly higher in the PR group than in the DR group (P = 0.013). No significant side effects were reported in the 2 groups (P &gt; 0.05). In conclusion, dexmedetomidine (0.6-1.2 µg/kg-1/h-1) plus remifentanil (0.25 µg/kg-1 min-1) anesthesia offered lower analgesic requirements, a longer extubation time, and better hemodynamic stability compared with PR anesthesia for patients undergoing intracranial surgery. Copyright © 2005 by Lippincott Williams &amp; Wilkins

A Comparative Study of the Hemodynamic and Recovery Properties of Sevoflurane-Remifentanil and Isoflurane-Remifentanil in Patients Undergoing Intracranial Surgery [İntrakraniyal Cerrahide Sevofluran-Remifentanil ve İzofluran-Remifentanil infüzyonunun Hemodinamik Degiş iklikler ve Derlenme Üzerine Etkileri]

We aimed to compare the hemodynamic and recovery properties of sevoflurane-remifentanil and isoflurane-remifentanil in patients undergoing intracranial surgery. Sixty patients, aged between 15 to 65 years with ASA physical status I-III were included in this study, after approval by local ethic committee. Anaesthesia induction was provided by IV bolus remifentanil (0.5 µg kg-1) and propofol (1-1.5 mg kg-1) in both groups and maintained with 1/3 minimum alveolar concentration (MAC) sevoflurane concentration-N20/02 and remifentanil influsion (0.25 µg kg-1 min-1) in group I (n=30), 1/3 MAC isoflurane concentration-N20/02 and remifentanil(0.25 µg kg -1 min-1) infusion in group II (n=30). Systolic (SAP), diastolic (DAP), mean arterial pressures (MAP) and heart rates (HR) were recorded preoperatively, during induction, following intubation, and during the application of head holder and skin incision. Extubation and awakening time, eye opening, responsing to commands were recorded postoperatively. SAP values in following the intubation 2nd min and dura open (p=0.03), DAP values in following the induction (p=0.026) and intubation (p=0.011), before the application of haed holder (p=0.009) were higher in isoflurane than sevoflurane. MAP ve HR values were exubation time were similar in both groups. Awakening, responsing to commands and eye opening times were more rapid in sevoflurane group. We concluded that both sevoflurane-remifentanil and isoflurane-remifentanil combinations exhibited similar effects on hemodynamical variables and recovery profile more rapid in sevoflurane-remifentanil group

Comparison of ropivacaine, ropivacaine plus tramadol and ropivacaine plus morphine in patients undergoing minor hand surgery [Minör el cerrahisinde rejyonal intravenöz anestezide ropivakain, ropivakain-tramadol ve ropivakain-morfinin karşilaştirilmasi]

PubMedID: 15977096In our study we aimed to compare the effects of ropivacaine alone, ropivacaine plus tramadol HCl, and ropivacaine plus morphine HCl used as intravenous regional anesthesia (IVRA), on duration to the initiation of analgesia, total analgesia time, analgesic requirement, sedation levels and hemodynamic parameters. 53 patients undergoing minor hand surgery were included into the study. Patients were randomly divided into three groups to receive 40 ml of ropivacaine 0.2% (Group R, n=18), ropivucaine 0.2% plus 1 mg/kg tramadol HCl (Group RT, n=18), and ropivacaine 0.2% plus 0.1 mg/kg morphine HCl (Group RM, n=17) as IVRA. Following the injection, the durations for the initiation of analgesia were recorded. Levels of sedation, analgesia (VAS) and hemodynamic parameters were recorded in 5 minute intervals throughout first 35 minutes intraoperatively and at 1, 5, 10, 15, 20, 30, 45 and 60th minutes postoperatively. Patients were asked about the initiation of pain and requirements of analgesic at the first postoperative day. The duration to the initiation of analgesia was similar between the groups. Total analgesia time was found to be 304.0 ± 317.6 min in Group R, 327.0 ± 316.5 min in Group RT, and 635.9 ± 492.3 min in Group RM. The difference between Group R and RM was statistically significant (p0.05). Mild local anesthetic toxicity was observed in Group RM in two patients. We conclude that, when used as IVRA, ropivacaine alone or with tramadol or morphine produced similar analgesia and surgery conditions, and ropivacaine plus morphine had more adverse effects besides its longer duration of analgesia