Anaesthetic Problems Research Articles

Parkinson′s disease and anaesthesia

Parkinson's disease (PD), one of the most common disabling neurological diseases, affects about 1% of the population over 60 years of age. It is a degenerative disease of the central nervous system caused by the loss of dopaminergic fibers in basal ganglia of the brain. PD is an important cause of perioperative morbidity and with an increasingly elderly population, it is being encountered with greater frequency in surgical patients. Particular anaesthetic problems in PD include old age, antiparkinsonian drug interaction with anaesthetic drugs and various alterations in the respiratory, cardiovascular, autonomic, and neurological systems. This brief review focuses on the preoperative, intraoperative, and postoperative anesthetic management of PD and gives a brief account of intraoperative exacerbation of PDs and anesthetic management of stereotactic pallidotomy.

Paediatric Perianesthesia Questionnaire: development and data from eight hospitals across Germany

BackgroundOpinions about satisfaction with care are rarely obtained from children and few studies of this type exist in the area of paediatric anaesthesia. In this study, we developed a comprehensive self-administered questionnaire to measure the level of paediatric and, as a substitute in younger children, parental satisfaction with anaesthesia. In addition, we aimed to identify factors influencing satisfaction and compare results between hospitals. MethodsWe followed a rigorous protocol including construction of a pilot questionnaire and qualitative and quantitative analysis. The questionnaire was adapted for confounding variables. We analysed satisfied and dissatisfied groups and compared satisfaction scores between participating hospitals. ResultsA questionnaire was developed which comprised 37 questions assessed on a five-point Likert scale. With a response rate of 71%, a total of 1052 patients completed the questionnaire. In the final analysis, 760 questionnaires (72%) were included. Most questionnaires were answered by the parents [705 (92.8%)]. The mean age of children was 6.7 (4.97) yr. Multivariate analysis found a history of previous anaesthetic problems and the identity of the person answering the questionnaire as influencing factors on the sum score. The most important differences between satisfied and dissatisfied children were found for the dimensions ‘privacy and waiting’, ‘information giving’, and ‘discomfort’. Scores differed between hospitals. ConclusionsOur psychometric questionnaire provides a novel approach to paediatric patient satisfaction with anaesthesia care and covers areas deemed important by children, parents, and carers. Significant differences between satisfied and dissatisfied groups and between participating hospitals were found.

Tracheal reconstruction by re-inforced Gore-Tex in esophageal submuscular tunneling: An experimental study

BACKGROUND:Tracheal reconstructions are aimed at rearranging or replacing parts of the tracheal tissue by different techniques. Here we introduce a new technique for tracheal reconstruction.METHODS:In 10 adult dogs, after intubation with an endotracheal tube, a segment of trachea including seven tracheal rings was resected circumferentially. A submuscular tunnel was induced between mucosal and muscular layers of the adjacent esophagus lying right next to the trachea. The esophageal submuscular tunnel starts and ends exactly at the level of distal and proximal ends of tracheal resection, respectively. Inforced Gore-Tex passed through the esophageal submuscular tunnel the distal segment of trachea and end-to-end anastomosis were made between distal ends of Gore-Tex and trachea, then endotracheal tube removed and the same procedure was made for proximal ends of Gore-Tex and trachea. Afterward, the proximal and distal ends of the esophageal tunnel were approximated to proximal and distal tracheal parts over the anastomosis.RESULTS:All dogs, except one due to anesthetic problem, survived and tolerated the operation; the first two dogs experienced postoperative fever, aspiration pneumonia, and died due to tracheoesophageal fistula. All survived animals were eating and barking well. We started to scarify dogs at least 6 and 12 weeks after operation for microscopy and pathologic examination. The Gore-Texes were patent and supported externally with fibrous connective tissue in esophageal tunneling, with in growth of respiratory epithelium on inner surfaces.CONCLUSION:Air tightness, good re-epithelialization, and relatively no limitation of esophageal length and no risk of luminal collapse are advantages of tracheal reconstruction by submuscular esophageal tunneling. This new method is worthy of further investigation, as it is technically feasible and easy to implement.

Comparison of the effects of ketamine or lidocaine on fentanyl-induced cough in patients undergoing surgery: A prospective, double-blind, randomized, placebo-controlled study

Background: Fentanyl-induced cough is common but has not been viewed as a serious anesthetic problem. However, the cough may be explosive at times, may require immediate intervention, and may be associated with undesirable increases in intracranial, intraocular, and intra-abdominal pressures. Prevention of fentanylinduced cough in such situations is of paramount importance. Ketamine, at concentrations achieved with standard clinical doses, has a direct relaxant effect on airway smooth muscle. Objective: This study was designed to assess the effects of ketamine or lidocaine on fentanyl-induced cough. Methods: This double-blind, randomized, placebo-controlled study was conducted at the Erciyes University Medical School, Kayseri, Turkey. Consecutive adult patients aged 18 to 65 years and classified as American Society of Anesthesiologists physical status I or II who were undergoing elective surgery with general anesthesia were enrolled. Patients were randomly allocated equally into 3 groups to receive lidocaine 1 mg/kg, ketamine 0.5 μg/kg, or placebo intravenously 1 minute before fentanyl administration. Following intravenous fentanyl (1.5 μg/kg over 2 seconds) injection, an observer, unaware of the type of medication given to the patients, recorded the number of episodes of coughing, if any. Any episode of cough was classified as coughing and graded by investigators blinded to treatment as mild (1–2 coughs), moderate (3–4), or severe (≥5). Blood pressure, heart rate, pulse oximetry oxygen saturation (SpO 2), and adverse effects (AEs) were recorded. Results: A total of 368 patients were approached for inclusion; 300 patients met the inclusion criteria and were enrolled in the study. No patients in the ketamine group had cough. The frequency of cough was significantly lower in the lidocaine (11/100 [11%]; P = 0.024) and ketamine (0/100; P = 0.001) groups compared with the placebo group (23/100 [23%]). The intensity of cough was significantly lower in the lidocaine (mild, 7/100 [7%]; moderate, 4/100 [4%]; P = 0.037) and ketamine (0/100; P < 0.001) groups compared with the placebo group (mild, 10/100 [10%]; moderate, 12/100 [12%]; severe, 1/100 [1%]). Severe cough (≥5) was observed in 1 patient in the placebo group. Incidence and intensity of cough were significantly decreased in the ketamine group compared with the lidocaine group (incidence, P = 0.001; intensity, P = 0.003). There were no significant differences between groups with respect to systolic blood pressure, diastolic blood pressure, heart rate, SpO 2, and AEs. Conclusion: Intravenous ketamine (0.5 mg/kg) significantly reduced the reflex cough induced by fentanyl compared with lidocaine and placebo, and was well tolerated.

Comparison of Proximal Injections of Local Anesthetics with Distal Injections in Intravenous Block

Background: Perfect pain management is one of the most essential problems in anesthesia. Intravenous block isconsidered a simple anesthetic method to reduce extremity pain. This study is aimed to determine the effect ofproximal injection compared with distal injections to avoid the problems related to be in the vicinity of thesurgical field and making use of the larger proximal veins instead of the tiny distal vessels.Methods: In this randomized double blind clinical trial, the patients with traumatic injuries of upper extremitiesreferred to Rajaie Hospital from October 2003 to February 2004 were studied. The cases were divided blindly into two groups. In one group injections were performed proximally and for the second group distally.Results: This study was based on the data from 100 serial patients. The average time to achieve analgesia was4.17 + 0.57 minutes for the patients who received distal injections and for the cases that had proximal injectionthe mean time for analgesia was 5.19 + 0.55. There was no difference in the rate of haematoma formationbetween the two groups.Conclusions: In intravenous nerve block, the injection of local anesthetic agents in the proximal parts of thelimbs is a safe method and is considered as effective as distal injections.

Anaesthetic management of total craniopagus twins for magnetic resonance imaging and cerebral angiography

We describe the anaesthetic management of 4-yr-old total craniopagus twins for radiological investigations. There are some unique anaesthetic problems associated with this condition. These include cross-circulation between the twins that results in induction of both the twins after the administration of i.v. induction agent to one twin and difficulty in mask ventilating both the twins simultaneously due to the angle between the heads; different arterial pressures in the two children complicate pharmacological management and underline the importance of physiological measures to control arterial pressure. Adequate preparation and teamwork is the keystone to the management of these patients.

First International Congress of Airway Management and Anesthesia in Head and Neck Surgery, Tehran, Iran, May 20–22, 2009

First International Congress of Airway Management and Anesthesia in Head and Neck Surgery, Tehran, Iran, May 20–22, 2009

Anaesthesia for ICU-based procedures: the advantages of and options available for inhalational anaesthesia

Many patients admitted to an intensive care unit (ICU) will undergo a surgical procedure for correcting the underlying cause of their disease, to deal with the complications of their disease or the treatment of their disease, or to undergo diagnostic procedures which will direct the course of their treatment. The majority of these procedures are performed in the operating theatre, but a small number of these cases will be managed in the ICU environment, which will place the anaesthetic and surgical team in an unfamiliar environment. Many studies indicate that the outcomes of these procedures depend on the interaction of many factors, which include the extent of the procedure, the physiologic reserve of the patient, the presence of chronic pathological conditions, and the nature of the acute physiological derangements. The plan for the critically ill patient should include preoperative optimisation of the general condition, a chronological plan for the intraoperative treatment, coordination with the surgical team, provision for additional equipment, expertise and resources, and a postoperative plan. In this discussion, we shall put emphasis on the anaesthetic options, techniques and problems that we experience with the anaesthesia for procedures which will be performed in ICU.

Implicaciones anestésicas de un caso de leucodistrofia metacromática

Metachromatic leukodystrophy is a progressive, inherited and neurodegenerative disease. A patient suffering from this disease poses a lot of anaesthetic problems. We have successfully anaesthetized a female child with general anaesthesia who was suffering from metabolic leukodystrophy. La leucodistrofia metacromática es una enfermedad progresiva hereditaria y neurodegenerativa. Un paciente que sufre de esta enfermedad representa múltiples problemas anestésicos. Hemos anestesiado exitosamente una niña que sufre de leucodistrofia metacromática con anestesia general.

Obstetric Anaesthesia

Obstetric Anaesthesia Clyburn, P, Collis, R, S Harries and S Davies ( eds ) Oxford University Press : Oxford 2008 , ISBN 978-0-19-920832-6 , 682 pp., Price £42.95 The labour suite and theatres can be a daunting place for both junior and senior anaesthetists. Dealing with the numerous possible clinical scenarios, as well as the labouring mother, anxious family and possibly demanding midwife, can stretch even the most experienced clinicians. This pocket-sized book covers most aspects of obstetric anaesthesia that could be encountered by the anaesthetist. It is written with the practising anaesthetist in mind but the authors are correct in stating that this book would also appeal to a wider audience including nurse anaesthetist, midwives and obstetricians. The layout of this book will be familiar to anyone acquainted with the Oxford Handbook series. There are 22 chapters that are appropriately sub-divided, making information very easy to find. The text is arranged in bullet point form with coloured headings and tables which aids legibility of the relatively small font. The maternal physiology and pathophysiology chapters are fully comprehensive and succinct, making it a useful guide for those preparing for the FRCA examinations. The anaesthetic implications of the pathophysiological conditions are clearly summarised in coloured boxes, making it a quick initial reference for those complicated cases that can be encountered on the labour suite. There is a small section on antenatal issues. The authors state in the preface that they have included this as antenatal identification and preparation of mothers with potential for anaesthetic problems during childbirth is often a neglected area. It may have been useful if they had further expanded this chapter; however, this book is aimed at anaesthetic trainees who rarely have input during the antenatal period. The last two chapters of this book are particularly useful. The ‘controversies in obstetric analgesia’ chapter covers those grey areas that often face the trainee anaesthetist, such as feeding during labour, monitoring and mobilisation with an epidural, and fever and regional anaesthesia. This chapter concisely covers these areas well, providing the reader with the benefits, risks and appropriate management. There is also recommended further reading for those who would like to elaborate. The last chapter is a neatly presented A–Z of rare conditions that can be encountered on the labour ward, providing a quick initial information source with further key references. The conventional chapters on regional anaesthesia, caesarean section, and anaesthesia and analgesia for specific obstetric indications have a breadth of information that is easy to follow and ideal for those new to the speciality or those in need of a recap. The chapter on regional anaesthesia includes diagrams and photographs to complement the text and aid understanding and learning of what is essentially a practical skill. With the widespread availability of internet access in our hospital, one could question the need for such a book. However, having this succinct and easy-to-find volume of information at arm’s length is an essential and irreplaceable resource. We would personally recommend this book, especially for trainees who are new to obstetric anaesthesia.

Anesthesia induction, emergence, and postoperative behaviors in children with attention‐deficit/hyperactivity disorders

Given the increasing prevalence of attention-deficit and attention-deficit hyperactivity disorders (ADHD), anesthesiologists are now presented with a greater number of children who are diagnosed with these conditions. This prospective, observational study was designed to compare anesthesia induction, emergence, and postoperative behaviors in children with and without ADHD. The sample included 268 children, 4-17 years of age undergoing elective surgery with a confirmed diagnosis of ADHD. A cohort of children without ADHD, matched for age, gender, and procedure served as controls. Preoperative cooperation, induction, and emergence behaviors were measured using established scales. Postoperative maladaptive behaviors were measured using a modified Post-Hospital Behavioral Questionnaire that was administered via telephone 1 week after surgery. Children with ADHD were significantly less cooperative at induction of anesthesia compared with controls (20.9% vs 10.6% respectively, P = 0.001). Although some control children exhibited an increase in maladaptive behaviors postoperatively, these behaviors were significantly greater among children with ADHD. In particular, relative to their normal behaviors, children with ADHD had greater difficulties in concentration and decision-making; were more disobedient, impulsive, fidgety, had poor appetite; were difficult to talk to; and exhibited an increase in temper tantrums following surgery. This is the first prospective study to our knowledge that has examined the perioperative and postoperative behaviors of children with ADHD compared to those without this disorder. These results are important in alerting anesthesiologists, parents, and teachers to the potential for difficulties during induction of anesthesia and postoperative behavioral problems at home and in school, respectively.

Anestesi til barn

Paediatric anaesthesia comprises newborn, infants and children, necessitating a variety of techniques and approaches.This review is based on textbooks in paediatric anaesthesia, papers from major anaesthetic journals and many years of clinical experience.Only a few Norwegian university hospitals have full-time paediatric anaesthesiologists. Anaesthesia in infants is associated with a higher frequency of morbidity and mortality than in adults; laryngospasm and emergency delirium are more common. Calculation of the amount of intravenous fluid and medication doses must be based on weight. Techniques such as mask inhalation for induction and caudal regional anaesthesia are used more frequently in children. Disease and congenital malformations can lead to anaesthetic problems. It is therefore important for the anaesthesiologist to have all available information preoperatively.Paediatric anaesthesia presents special challenges. Safe practice requires experience and knowledge of age-related anatomy, physiology and pathology.

Drugs Errors in Anaesthesia Practice: Four Cases of Non-Fatal Morbidity

Anesthesiologists became more concerned about ensuring patient safety by a greater emphasis on outcome, quality patient care both in operation theatre and elsewhere in hospital. In the clinical practice, there is no aspect of Anesthesia that occupies a more important place in the safe management of the patients than the accurate drug administration. Medication errors represent a small part of anesthesia problems but still have potential for serious morbidity and legal consequences. The objective of this report was to describe four cases of unusual medical errors (ME) in the operation theatre, without harm to the patient, and how their analysis and identification had prevented more serious damage occurrence. Four cases of inadvertent overdose in operation theatre previous to induction anesthesia. The same syringe was used to prepare and dilute two different drugs. This error was therefore caused by the presence of the second drug. Toxicity was manifested as brief respiratory depression and sedation, and assisted ventilation was required but no adverse outcomes happened. We explain how we identified the drug involved, the point at which the error occurred in order to improve clinical practice reducing medication errors. We focus on providing more information and education to each health care professional about new drugs and their preparation process, because this is should not be an acceptable practice in 2009.

The Need for Perspective

We were disappointed that Anesthesiology chose to publish the articles by Kalkman et al. 1and Wilder et al. 2without an accompanying cautionary editorial. Kalkman et al. 1state, “children undergoing urologic surgery at age less than 24 months showed more behavioral disturbances . . . although the results were not statistically significant.” We disagree with this statement; namely, because statistical significance was not achieved, more behavioral disturbances were not observed. Furthermore, they go on to perform a sample size calculation to determine the number of patients that would be required to detect a statistically significant effect of the effect size they found. Their estimate for such a potential association between anesthesia and behavioral problems could be explained by chance alone, and using such an estimate to guide future studies is misleading. Wilder et al. 2were unable to separate out the effects of multiple anesthetics from the effects of the underlying clinical problems requiring multiple procedures. By publishing these two studies as part of a larger series including several animal models, Anesthesiology seems to send the message that two independent teams reported similar findings in humans. At a minimum, a cautionary editorial putting these studies into context was warranted. Studies such as these, reported on by the lay media, may cause an already wary public much alarm and put pediatric anesthesiologists in an impossible position. Parental concerns regarding the possible deleterious effects of anesthesia will not be assuaged by statistical explanations. Anesthesiology has an obligation beyond merely reporting interesting studies. We are sure that, like us, other readers are looking for perspective.*Tufts University School of Medicine, Baystate Medical Center, Springfield, Massachusetts. karthik.raghunathan@bhs.org

Thrombelastography-Based Monitoring for Massive Blood Loss During Elective Pediatric Surgery for Craniosynostosis Repair, a Pilot Study.

Abstract 2110Poster Board II-87The management of massive blood loss in children during trauma or major surgery is still an unsolved problem in pediatric surgery and anesthesia. Primary operative repair of craniosynostosis in infants and young children can serve as a model for excessive acute blood loss. The introduction of thromboelastography (TEG) has led to a significant decrease in transfusion of packed red blood cells (pRBC), fresh frozen plasma (FFP) and platelets in adult surgery, thereby diminishing the risks of infections and immunosuppression. Moreover a significant decrease in accompanying costs has been reported. However, no studies have evaluated the effect of TEG-guided treatment on the amount of transfused blood products in children.The primary objective of this pilot study is to obtain reference TEG-values in children during surgical repair of primary craniosynostosis. We performed a single-center pilot study on TEG-monitoring in children during craniofacial surgery. Methods:The study includes 21 children with craniosynostosis undergoing elective craniofacial repair at the Sophia Children's Hospital, Erasmus Medical Center, Rotterdam, The Netherlands. Blood samples (5 ml blood taken from an arterial line) for TEG (Haemoscope®) measurement were obtained after induction of anesthesia (T1), after the application of Ringer's lactated solution (RLS) 10 ml × kg-1 body weight (T2), after the application of hetastarch 130/0.4 6% (Venofundin®, Fresenius Kabi) (T3), after transfusion of pRBC (T4), and eventually after the application of FFP (T5). Results:21 children, less than 20 months of age, with a mean body weight of 8.5 kg underwent surgical repair of craniosynostosis. They were treated according to the local protocol on massive blood loss in children during surgery. Nine children were suffering from scaphocephalie, 4 from trigonocephalie, 3 from plagiocephalie, one from brachycephalie and 4 children had a mixed or complex form of craniosynostosis such as Crouzon disease.After the induction of anaesthesia (T1) and after the administration of RLS (T2) no changes in clot strength were seen, MA remained mean 62 mm. However, between T2 and T3 all children demonstrated a significant decline in hemoglobine from mean 6.5 to 3.8 mmol/L (p<.0005). The blood loss was mean 380 ml at T3, ranging from 200 to 700 ml, requiring mean 190 ml transfusion of pRBC (range 100-390 ml). The TEG values at T3 showed a concurrent decrease of alpha (from 66° to 57°) and MA (from 62 to 48mm) with an increasing k (from 1.7 to 3.0 min) in kaolin activated TEG measurements. Together with a decrease in MA in TEG–FF at T3 (from 18 to 5.5 mm) this demonstrates a dilutional coagulopathy. All changes were highly significant with p<.0005. Transfusion of pRBC at T4 did not change TEG parameters. No signs of fibrinolysis were seen. Discussion:The administration of hetastarch 130/0.4 6% at T3 resulted in a dilutional coagulopathy. This is due to blood loss, consumption of coagulation factors and platelets, and intravascular volume replacement. During blood loss fibrinogen synthesis will be limited. Additionally, the decreasing functional fibrinogen levels (MA-FF) point to reduced strength of the clot. Administering cryoprecipitate or concentrates of fibrinogen in an early phase might maintain clot firmness and thereby decrease blood loss and reduce the number of transfused blood products. Conclusion:In an attempt to decrease the amount of transfused blood products TEG will allow tailored interventions during pediatric surgery with specific medications like antifibrinolytic agents, concentrates of fibrinogen, or activated recombinant factor VII. Finally, TEG tailored therapy may decrease blood transfusions and transfusion related complications in children. These data strongly support the evaluation of TEG-guided interventions in children during massive blood loss. Disclosures:No relevant conflicts of interest to declare.

Expérience d’un système de recueil d’évènements indésirables en anesthésie

Objectives This article summarizes functioning and results of anaesthesia adverse effects reporting system over its first 18 months, from August 2006 to February 2008. Study design Monocentric retrospective study. Methods Reporting system is available 24/24 h, 7/7 to every employee with an individual password. A committee with anaesthesiologists, nurses and risk management engineer examines every notification by two months. We evaluated number of reports, type of reporter, type of dysfunction reported and solutions. Numerical data are compared with a Student t test or X 2 test. A p-value of less than 0.05 g being considered as statistically significant. Results One hundred and eighty-five reports were registered for the first 18 months (1% of anesthesia activity) with a slowdown with time ( p = 0.02). Eighty-six percent of the statements were made by anesthesiologists, but some physicians had never reported. Malfunctions shared between different services (identity, operating room organisation) are rarely solved (67%) compared to specific anesthesia problems (93%) ( p < 0.001). Conclusion The reporting system is simple and available but some professionals don’t declare, generating reporting bias. This network underlines major general dysfunctions (identity) but ways to solve are limited to date.

Difficult intubation during rapid sequence induction in a parturient with Ehlers-Danlos syndrome, hypermobility type

There have been several reports of resistance to local anaesthetic agents in women with Ehlers-Danlos syndrome, hypermobility type, also known as Ehlers-Danlos syndrome Type III. General anaesthesia with rapid sequence induction was performed for caesarean section due to prolonged second stage of labour, but intubation proved to be difficult. We propose that intubation difficulty probably arose from collapse of fibro-elastic tissues and adjoining C-shaped cartilages of the trachea with appropriately applied cricoid pressure. We found no other case reports of difficult intubation in patients with Ehlers-Danlos syndrome, hypermobility type. There are reports of cervical spine instability and temporomandibular joint dysfunction in patients with this syndrome suggesting a potential for difficult airway management. Additional anaesthetic problems associated with Ehlers-Danlos syndrome involve patient positioning and vascular access.

Character of distracted bone in irradiated canine mandibles and electrophysiological changes in the inferior alveolar nerve

Our aim was to explore the character of distracted bone in irradiated canine mandibles and the electrophysiological changes in the irradiated inferior alveolar nerve (IAN). Twelve Chinese dogs were studied, 10 of which were given unilateral irradiation of 60Co in the mandible with a total dose of 22.8 Gy in four 5.7 Gy fractions (biologically equivalent to 50 Gy/25 fractions) (experimental group). The other two dogs were not irradiated and served as controls. All had a bilateral corticotomy 3 months after irradiation. After a 1-week latency period distraction of the mandible was activated at a rate of 0.5 mm twice daily for 10 days, followed by a consolidation phase of 8 weeks. New bone was assessed by radiographic, histological, and single-photon electron computed tomographic (SPECT) analysis. The IAN was analysed electrophysiologically. One dog in the experimental group was excluded from the study with anaesthetic problems. After 8 weeks of consolidation there was no difference between the percentage area of new bone in the two groups. New bone was more mature and organised in the control group than in the experimental group. SPECT analysis showed that there was active osteogenic activity in dogs in the experimental group. The action potential of the IAN showed corresponding changes during the irradiation and distraction processes. We conclude that distraction osteogenesis is feasible in previously irradiated canine mandibles and IAN.

Post‐induction alfentanil reduces sevoflurane‐associated emergence agitation in children undergoing an adenotonsillectomy

Emergence agitation is a common problem in paediatric anaesthesia, especially after volatile induction and maintenance anaesthesia (VIMA) with sevoflurane. The purpose of this study was to investigate the effect of alfentanil to prevent emergence agitation without delayed recovery after VIMA with sevoflurane in children undergoing an adenotonsillectomy. One hundred and five children, aged 3-10 years, were randomly allocated to receive normal saline (control group), alfentanil 10 microg/kg (A10) or 20 microg/kg (A20) 1 min after loss of the eyelash reflex. Anaesthesia was induced and maintained with sevoflurane. Time to tracheal extubation, recovery time, Paediatric Anaesthesia Emergence Delirium (PAED) scale and emergence behaviour were assessed. The incidence of severe agitation was significantly lower in the A10 and A20 groups compared with those in the control group (11/32 and 12/34 vs. 24/34, respectively) (P=0.007, 0.006, respectively). PAED scales were significantly different between the three groups (P=0.008), and lower in the A10 and A20 groups than that in the control group (P=0.044, 0.013, respectively). However, the incidence of severe agitation and PAED scale was not different between the A10 and the A20 groups. Time to tracheal extubation and recovery time were similar in all three groups. The administration of alfentanil 10 microg/kg after induction of anaesthesia for children undergoing an adenotonsillectomy under VIMA reduced the incidence of emergence agitation without delaying the recovery time or causing significant hypotension.

Neonatal minimally invasive surgery for congenital diaphragmatic hernias: a multicenter study using thoracoscopy or laparoscopy

Minimally invasive surgery (MIS) for late-presenting congenital diaphragmatic hernia (CDH) has been described previously, but few neonatal cases of CDH have been reported. This study aimed to report the multicenter experience of these rare cases and to compare the laparoscopic and thoracoscopic approaches. Using MIS procedures, 30 patients (16 boys and 14 girls) from nine centers underwent surgery for CDH within the first month of life, 26 before day 5. Only one patient had associated malformations. There were 10 preterm patients (32-36 weeks of gestational age). Their weight at birth ranged from 1,800 to 3,800 g, with three patients weighing less than 2,600 g. Of the 30 patients, 18 were intubated at birth. The MIS procedures were performed in 18 cases by a thoracoscopic approach and in 12 cases by a laparoscopic approach. No severe complication was observed. For 20 patients, reduction of the intrathoracic contents was achieved easily with 15 thoracoscopies and 5 laparoscopies. In six cases, the reduction was difficult, proving to be impossible for the four remaining patients: one treated with thoracoscopy and three with laparoscopy. The reasons for the inability to reduce the thoracic contents were difficulty of liver mobilization (1 left CDH and 2 right CDH) and the presence of a dilated stomach in the thorax. Reductions were easier for cases of wide diaphragmatic defects using thoracoscopy. There were 10 conversions (5 laparoscopies and 5 thoracoscopies). The reported reasons for conversion were inability to reduce (n = 4), need for a patch (n = 5), lack of adequate vision (n = 4), narrow working space (n = 1), associated bowel malrotation (n = 1), and an anesthetic problem (n = 1). Five defects were too large for direct closure and had to be closed with a patch. Four required conversion, with one performed through video-assisted thoracic surgery. The recurrences were detected after two primer thoracoscopic closures, one of which was managed by successful reoperation using thoracoscopy. In the neonatal period, CDH can be safely closed using MIS procedures. The overall success rate in this study was 67%. The indication for MIS is not related to weeks of gestational age, to weight at birth (if >2,600 g), or to the extent of the immediate neonatal care. Patients with no associated anomaly who are hemodynamically stabilized can benefit from MIS procedures. Reduction of the herniated organs is easier using thoracoscopy. Right CDH, liver lobe herniation, and the need for a patch closure are the most frequent reasons for conversion.