Infectious diseases of childhood and their anesthetic implications.
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Anesthesia↗
Biomedical subjects
J H van der Walt
Publications and source records attributed to J H van der Walt.
Pulmonary volume recruitment restores pulmonary compliance and resistance in anaesthetized young children.
BACKGROUND: Oxygenation and gas exchange are impaired after induction of general anaesthesia. A timed re-expansion inspiratory manoeuvre (TRIM) improves pulmonary compliance and reverses haemoglobin oxygen desaturation rapidly in lambs. METHODS: Twenty children of less than 2 years of age were given a standardized ventilated general anaesthetic. After 15 min of anaesthesia they were randomized to receive either a TRIM or 100% oxygen for 3 min. Dynamic pulmonary compliance and airway resistance were measured. RESULTS: Pulmonary compliance fell by 12% and airway resistance rose by 12% during 15 min of ventilated general anaesthesia. 100% oxygen caused a further fall of 9% in compliance (P=0.016), whilst TRIM resulted in a 30% increase in compliance (P < 0.01). The changes in airway resistance with 100% oxygen and TRIM were not statistically significant. CONCLUSIONS: This study shows that TRIM increases pulmonary compliance during standardized ventilated general anaesthesia.
Airway Resistance↗
An audit of perioperative management of autistic children.
BACKGROUND: Autistic children are very difficult to manage in the hospital setting because they react badly to any change in routine. METHODS: We have developed a unique management program for autistic children admitted for medical and surgical procedures requiring a general anaesthetic. Details of each patient managed according to this program have been prospectively entered into an Autistic Register. RESULTS: An audit of this database shows that we have administered anaesthesia on 87 occasions for 59 autistic children over 4 years. CONCLUSIONS: There is great variation in the severity of autism and hospital needs of these children. The focus is on early communication with the patient's families, flexibility to individualize the admission process and anaesthetic plan with admission and early discharge on the day of surgery whenever possible. Oral midazolam is an effective premedication for the milder cases and oral ketamine is the most reliable for moderate and severe cases. Comparison of oral midazolam and ketamine shows no significant different postoperative recovery and hospital discharge times. Routine intravenous fluids and antiemesis prophylaxis with removal of the i.v. cannula before return to the ward are also seen as important steps to decrease stress and smooth the postoperative phase. This program has also successfully been extended to the management of problem children due to other causes.
Adolescent↗
Anaesthesia alert: an integrated, networked, register of paediatric anaesthetic problems.
The Paediatric Register of Anaesthetic Problems (PaedRAP) is a network-based anaesthesia hazard alert system. It is integrated with pre-anaesthesia consultations and patient questionnaires. All files, both electronic and on paper, are available 24 hours a day close to the operating theatres. This ensures that pertinent information is readily available when and where it is most needed. The PaedRAP is also linked to the automated theatre booking system to print warnings on the theatre lists. This minimizes the chance that important information goes unnoticed. Documentation of the progression of the various categories of patient problems and evolving management strategies has been useful both for individuals and groups.
Anesthesia↗
A timed reexpansion inspiratory manoeuvre (TRIM) for treating oxyhaemoglobin desaturation in children following a period of apnoea--studies in an animal model.
Our clinical experience has shown that the use of a constant distending airway pressure of 30 cm water for 10 s, termed a timed reexpansion inspiratory manoeuvre (TRIM), is often successful in correcting oxyhaemoglobin desaturation in anaesthetized children. The aim of this study was to assess the efficacy of TRIM in lambs. Following a standard relaxant anaesthetic, ventilation was stopped and oxyhaemoglobin saturation allowed to fall to 70% and the time taken to return to baseline was compared between three groups. The median time was 42.5 s when ventilation was restarted with 33% oxygen in nitrous oxide (33% group), 30 s when ventilation was restarted with 100% oxygen (100% group) and 22.5 s with a TRIM before restarting ventilation with 33% oxygen in nitrous oxide (TRIM group). The correction of desaturation was more rapid in the TRIM group compared with the 33% group (P < 0.004) and the 100% group (P < 0.003). Oxyhaemoglobin desaturation due to apnoea in anaesthetized lambs is more effectively treated with a TRIM than by increasing the inspired oxygen fraction.
Anesthesia, General↗
The anaesthetic management of autistic children.
Autistic children are difficult to manage and there are no anaesthesia studies to suggest management strategies. We present five case reports which describe an integrated management program taking into account the special needs of autistic children and their families. We describe a method of early warning and recognition of these patients and the establishment of a database to allow review of our program. We also present a process to minimize the stress and problems inherent in the conventional admission process. Oral ketamine (6 to 7 mg/kg) has proven to be the most reliable preoperative sedative for these patients.
Anesthesia↗
Anaesthesia and recently vaccinated children.
Most countries have active vaccination programmes for children aged two months and older. It is likely that many children presenting for medical procedures which require general anaesthesia have been vaccinated recently. Although there is no evidence suggesting increased risks associated with anaesthetizing recently vaccinated children there are many theoretical reasons why this situation needs critical assessment and review. After vaccination there is local swelling and pain at the site of the injection and the most common side effects seen are fever, malaise, headache, rash and myalgia which may last from one day to three weeks. Anaesthesia, stress and trauma are known to suppress the immune system. It is suggested that if possible, children should not be subjected to anaesthesia for elective procedures within two to three weeks after vaccination. Urgent procedures should be managed according to anaesthetic principles which will minimize the effect of anaesthesia on the physiological system affected by the immunization process at the time. Paediatric anaesthesia risk management programmes should include vaccination data to enable the risks of anaesthesia in recently vaccinated children to be analysed.
Adolescent↗
Needleless and sharp-free anaesthesia.
Accidental occupational infection of anaesthetists from patient body fluids is a very real and potentially fatal risk that will be significantly reduced with the routine use of universal precautions and the adoption of specific safe work practices. Employers are required by law to provide a safe working environment and safe systems for work which anaesthetists should implement according to recommendations in this paper. A protocol should be available to be acted upon in the event of occupational parenteral, mucous membrane and non-intact skin exposure to infected patient body fluids. Recommendations are made in six major areas of clinical practice which anaesthetists should adopt to minimize risks to themselves and other healthcare workers: loading syringes, cannulating blood vessels, administering intramuscular (IM) or local anaesthetic injections, administering intravenous (IV) drugs, use of sutures and surgical instruments by anaesthetists and the safe disposal of needles, glass ampoules and other sharp materials. Despite the known risks and the development of these safe practices there is poor compliance by anaesthetists with measures to safeguard themselves and others.
Accident Prevention↗
A national survey of atropine use by Australian anaesthetists.
All Fellows of the Faculty of Anaesthetists, Royal Australasian College of Surgeons (now Australian and New Zealand College of Anaesthetists) were surveyed by mail regarding their use of prophylactic atropine. They were asked whether their usual practice was to give atropine for the following indications: premedication, induction of anaesthesia, intubation of the trachea, one dose of suxamethonium, a second dose of suxamethonium, halothane anaesthesia, oropharyngeal surgery, bronchoscopy and eye surgery. For each indication they were asked for details regarding their practice concerning neonates, infants, children and adults. The large response rate of 86% of Fellows returning a survey form ensured that the survey was representative of Australian anaesthetic practice. Results indicate a wide variation in practice regarding the prophylactic use of atropine, with neonates, infants and children more likely to receive prophylactic atropine than adults. The majority do not give prophylactic atropine as premedication, but may give it in the younger age groups at induction, and many (67%) only give it if they are to administer suxamethonium to a child. The only indication for which a convincing majority (> 80%) of anaesthetists agreed that prophylactic atropine should be given was when a repeated dose of suxamethonium was to be given to neonates, infants or children. A large proportion of anaesthetists (> 80%) agreed that atropine is not necessary prior to halothane anaesthesia in all age groups, nor as premedication, at induction, at intubation, prior to oropharyngeal surgery or prior to eye surgery in adults. These results were compared with the practice at a major paediatric hospital where the practice is not to use routine prophylactic atropine.
Administration, Oral↗
The Australian Incident Monitoring Study. Which monitor? An analysis of 2000 incident reports.
The role of monitors in patients undergoing general anaesthesia was studied by analysing the first 2000 incidents reported to the Australian Incident Monitoring Study; 1256 (63%) were considered applicable to this study. In 52% of these a monitor detected the incident first; oximetry (27%) and capnography (24%) detected over half of the monitor detected incidents, the electrocardiograph 19%, blood pressure monitors 12%, a low pressure (circuit) alarm 8%, and the oxygen analyser 4%. Of the other monitors used, 5 first detected 1-2% of incidents, and the remaining 8 less than 0.5% each. The oximeter would have detected over 40% of the monitor detected incidents had its more informative modulated pulse tone always been relied upon instead of the "bleep" of the ECG. A theoretical analysis was then carried out to determine which of an array of 17 monitors would reliably have detected each incident had each monitor been used on its own and had the incident been allowed to evolve. To facilitate "scoring" of monitors, the incidents were categorized empirically into 60 clinical situations; 40% of applicable incidents were accounted for by only 5 clinical situations, 60% by 10 and nearly 80% by 20. 98% were accounted for by the 60 situations. A pulse oximeter, used on its own, would theoretically have detected 82% of applicable incidents (nearly 60% before any potential for organ damage). These figures for capnography are 55% and 43% and for oximetry and capnography combined are 88% and 65%, respectively. With the addition of blood pressure monitoring these become 93% and 65%, and of an oxygen analyser, 95 and 67%. Other monitors, including the ECG, each increase the yield by by less than 0.5%. The international monitoring recommendations and those of the Australian and New Zealand College of Anaesthetists are thoroughly vindicated by the patterns revealed in this study. The priority sequence of monitor acquisition for those with limited resources should be stethoscope, sphygmomanometer, oxygen analyser if nitrous oxide is to be used, pulse oximeter, capnograph, high pressure alarm, and, if patients are to be mechanically ventilated, a low pressure alarm (or spirometer with alarm); an ECG, a defibrillator, a spirometer and a thermometer should be available.
Accidents↗
Oral midazolam is an effective premedication for children having day-stay anaesthesia.
The effect of oral premedication was studied in a double-blind, randomised trial of 200 children undergoing day-stay anaesthesia. Midazolam 0.25 mg/kg, midazolam 0.5 mg/kg, diazepam 0.5 mg/kg or a placebo was given orally one hour prior to anaesthesia. Patient state was assessed at nine stages, from administration of the premedication up to and including induction of anaesthesia, using a four-point behavioural scale. Patient state was also assessed postoperatively in the recovery area and the day-stay ward. There was no difference between the four groups until induction of anaesthesia. At this stage 82% of children were either asleep or awake and calm. Patients who received midazolam 0.5 mg/kg were more likely to be asleep or awake and calm at induction rather than other groups (P = 0.05). Children receiving midazolam 0.5 mg/kg or diazepam 0.5 mg/kg slept longest in the post anaesthetic recovery room (P less than 0.005), and spent most time there (P less than .005). There was no difference between groups in the length of time spent in the day-stay ward or in the number of overnight admissions. The study shows that a high proportion of unsedated children are calm at induction of anaesthesia and that oral midazolam is an effective premedication in children for day-stay anaesthesia.
Administration, Oral↗
The perioperative effects of oral premedication in children.
The pre- and postoperative effects of oral diazepam (0.5 mg/kg), trimeprazine (4 mg/kg), pentobarbitone (3 mg/kg) and a placebo were compared in a randomized double-blind clinical trial in 149 children, aged one to ten years, undergoing adenotonsillectomy. The anaesthetic was standardised and each patient received intraoperative intramuscular papaveretum (0.3 mg/kg). Preoperative sedation was assessed in the ward before transfer onto the theatre trolley, on leaving the ward, on arrival on the theatre floor, on arrival in the induction room and on induction of anaesthesia. There was no significant difference in sedation between the four drug groups except for the placebo group which had a significantly greater unsatisfactory rating at the stage of induction of anaesthesia (P = 0.001). There were no differences in waking times between the diazepam, pentobarbitone and placebo groups, but the trimeprazine group's waking times were significantly prolonged (P less than 0.001). However, the trimeprazine group exhibited significantly less distress in the recovery unit (P = 0.02) and had half the incidence of vomiting (P less than 0.001) than did the other premedication groups.
Adenoidectomy↗
A study of preoperative fasting in infants aged less than three months.
The effects of preoperative fasting on plasma glucose and gastric emptying was studied in 62 infants aged less than three months after a feed of either breast milk or an infant milk formula. Prior to induction of anaesthesia no infant was hypoglycaemic, defined as plasma glucose less than 2.2 mmol/l. Five per cent of infants had a significant volume of residual gastric contents. The mean intraoperative plasma glucose levels rose significantly and this was not influenced by the use of intravenous Hartmann's solution or low dose opioids. Infants in this age group tolerate three- to four-hour preoperative fasts well as no infant became hypoglycaemic intraoperatively. They demonstrate a hyperglycaemic response to the stress of anaesthesia and surgery, and may not need routine intraoperative glucose supplements although plasma glucose should still be monitored.
Acid-Base Equilibrium↗
Patient-controlled analgesia in children.
The use of patient-controlled analgesia is described for forty children who had undergone major orthopaedic or general surgery. Ages ranged from 6 to 18 years (mean 11.4 years) and PCA was used for an average of 46.2 hours postoperatively. Morphine requirements overall averaged 40.5 micrograms/kg/hr (SD 22.6). Requirements for the first six hours were not significantly different to a similar period 24 hours later. There was a large individual variation for patients undergoing similar procedures. Patients undergoing scoliosis surgery required significantly more morphine than any other group of patients. Problems with patient-controlled analgesia have been of a minor nature. We conclude that patient-controlled analgesia is a suitable and safe method of pain relief for paediatric patients and that the lower age limit is that at which a child can understand the concept after suitable explanation. In this study children as young as six years were able to successfully use the method.
Adolescent↗
Use of patient-controlled analgesia (PCA) in children.
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Child↗
Patient safety in the recovery room.
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Anesthesia↗
The effect of different pre-operative feeding regimens on plasma glucose and gastric volume and pH in infancy.
The effects of four different pre-operative feeding regimens were studied in 123 children below the age of one year presenting for surgery. Plasma glucose concentrations, blood acid-base values, gastric volume and gastric pH were measured before and after induction of anaesthesia. No patient was found to be hypoglycaemic and there were no significant differences in plasma glucose concentration and acid-base values between the groups. No correlation was demonstrated between the age and weight of the patients and the duration of fasting and the plasma glucose concentration. There was a significant elevation of plasma glucose concentration in all four groups after induction of anaesthesia (P less than 0.001) compared with the pre-induction level which is a reflection of the stress of blood sampling and induction of anaesthesia. Infants less than three months of age in the milk-feed group had a significantly higher gastric volume with low pH (P less than 0.05) signifying a potentially greater risk of pulmonary acid aspiration. The practice of timing the last pre-operative feed in infancy according to the infant's normal feeding pattern does not appear to increase the risk factors for pulmonary aspiration, if milk is avoided.
Acid-Base Equilibrium↗