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Park S, Kim JH, Bae JC, Lee JR, Kim MS. Tracheal intubation with or without a neuromuscular blocking agent for a short surgical procedure in children: Prospective, randomized, double-blind trial. Paediatr Anaesth 2021; 31:863-870. [PMID: 33993571 DOI: 10.1111/pan.14205] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Revised: 04/27/2021] [Accepted: 05/04/2021] [Indexed: 01/13/2023]
Abstract
BACKGROUND Although a neuromuscular blocking agent during induction of anesthesia is the standard of care in adults, some pediatric anesthesiologists remain concerned about their use for several reasons. Therefore, propofol and short-acting opioids with a moderate concentration of sevoflurane have been used as alternatives to a neuromuscular blocking agent. AIMS This study compared propofol, alfentanil, and rocuronium to determine the optimal anesthetic agent for intubation conditions as well as emergence in a short pediatric procedure. METHODS In this prospective, randomized, double-blind study, 114 pediatric patients, aged 1-9 years, were randomly assigned to one of three groups receiving either propofol 2 mg kg-1 (propofol group), alfentanil 14 mcg kg-1 (alfentanil group), or rocuronium 0.3 mg kg-1 (rocuronium group). The primary outcome was intubating conditions, which were evaluated 90 s after test drug administration. Vital signs were recorded during the intubation period. Complications during and after emergence, time to recovery, airway-related complications, and severity of emergence agitation were recorded. RESULTS Compared with the propofol group (60%), significantly more excellent intubating conditions were observed in the alfentanil group (97%, percent difference -37, 95% confidence interval (CI) -54.4--21.0, p < .001) and the rocuronium group (87%, percent difference -27, 95% CI -46.5--8.2, p = .041). Hemodynamic responses were different between the rocuronium and alfentanil groups, although the incidence of adverse events was not different among the three groups. The emergence duration was only statistically different between the rocuronium group [9.9 ± 3.2 min] and the propofol group [11.7 ± 2.2 min] (difference 95% CI 0.667-3.583, p = .001), while that of the alfentanil group [10.9 ± 2.4 min] was comparable with the other groups. CONCLUSIONS Both 0.3 mg kg-1 rocuronium and 14 µg kg-1 alfentanil are superior adjuncts for tracheal intubation in children undergoing frenulectomy in comparison with 2 mg kg-1 propofol. Hemodynamic adverse events and recovery profiles were comparable among the three groups.
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Affiliation(s)
- Sujung Park
- Anaesthesia and Pain Research Institute, Department of Anaesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, South Korea
| | - Ji-Ho Kim
- Department of Anaesthesiology and Pain Medicine, National Health Insurance Service Ilsan Hospital, Goyang City, South Korea
| | - Jae Chan Bae
- Department of Anaesthesiology and Pain Medicine, National Health Insurance Service Ilsan Hospital, Goyang City, South Korea
| | - Jeong-Rim Lee
- Anaesthesia and Pain Research Institute, Department of Anaesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, South Korea
| | - Min-Soo Kim
- Anaesthesia and Pain Research Institute, Department of Anaesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, South Korea
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Du Preez TDP, Dippenaar JD. Intubating conditions following four different doses of propofol in children. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2020. [DOI: 10.36303/sajaa.2020.26.5.2322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Abdelhalim AA, Maghraby HH, ElZoughari IA, AlZahrani TA, Moustafa MS, Alfassih KM, Ahmad AE. Using fentanyl and propofol for tracheal intubation during sevoflurane induction without muscle relaxants in children: A randomized prospective study. Saudi J Anaesth 2017; 11:312-318. [PMID: 28757833 PMCID: PMC5516495 DOI: 10.4103/1658-354x.206802] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Context: Tracheal intubation is frequently facilitated with sevoflurane induction without the use of muscle relaxants in children. Aim: The aim of this study was to compare the effects of two different doses of propofol preceded by a fixed dose of fentanyl during sevoflurane induction on quality of tracheal intubation in children. Settings and Design: This was a prospective randomized study. Subjects and Methods: Ninety American Society of Anesthesiologists I-II children aged 2–6 years were randomly assigned to one of two equal groups to receive 2 μg/kg of fentanyl with 2 mg/kg of propofol (Group I) or 2 μg/kg of fentanyl with 3 mg/kg of propofol (Group II) during sevoflurane induction. The intubating conditions and hemodynamic responses were evaluated. The time from sevoflurane induction to loss of consciousness, to intravenous line insertion, and to intubation was measured. The occurrence of any adverse effect was recorded. Statistical Analysis Used: Results were analyzed using Student's t-test, paired t-test, and Chi-square test. P < 0.05 was considered statistically significant. Results: The incidence of excellent intubating conditions was achieved more significantly in Group II (41/45 patients, 91%) than that in Group I (31/45 patients, 69%) (P = 0.008) (95% confidence interval [CI] =0.39–0.8). Whereas, there were no significant differences between the two groups in terms of the overall acceptable intubating conditions in Group I (40/45 patients, 89%) and Group II (43/45 patients, 96%) (P = 0.81) (95% CI = 0.71–1.31). No patient developed any adverse effect. Conclusion: The administration of 3 mg/kg propofol preceded by 2 μg/kg fentanyl provided a higher proportion of excellent intubating conditions compared with 2 mg/kg propofol preceded by 2 μg/kg fentanyl during sevoflurane induction in children without muscle relaxants.
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Affiliation(s)
| | | | - Ismail Ahmed ElZoughari
- Department of Anesthesia, Faculty of Medicine, Al-Azhar University, Egypt, Affiliated to King Saud University, Saudi Arabia
| | | | - Mohamed Sayed Moustafa
- Department of Anesthesia, Faculty of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Kamal Mohamed Alfassih
- Department of Anesthesia, Faculty of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Abdulaziz Ejaz Ahmad
- Department of Anesthesia, Faculty of Medicine, King Saud University, Riyadh, Saudi Arabia
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The perioperative use of nitrous oxide: renaissance of an old gas or funeral of an ancient relict? Curr Opin Anaesthesiol 2013; 26:354-60. [PMID: 23426038 DOI: 10.1097/aco.0b013e32835f8151] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Conflicting reports about adverse events following nitrous oxide (N(2)O) application have spurred a discussion whether N(2)O should be abandoned from clinical practice. Concurrently, N(2)O is increasingly used as a single anesthetic agent in medical procedures. This article reviews and discusses reports about the present use of N(2)O. RECENT FINDINGS Multiple publications demonstrate an increasing use of N(2)O as a procedural analgesic and sedative. Results from the Evaluation of Nitrous Oxide in the Gas Mixture for Anesthesia trial have been contrasted by recent studies reporting no increased risk for perioperative complications, particularly related to the cardiovascular and cerebrovascular system. Recent studies show that electroencephalogram-based anesthesia depth monitoring is not compatible with the use of N(2)O because of its distinct influence on electroencephalogram wave patterns. The clinical relevance of the proposed neurotoxicity, immunosuppression and influence on methionine metabolism remains unclear. Recently, its acute and long-term analgesic potency has been proven. Occupational exposure might pose a relevant health hazard. SUMMARY Based on the present literature, abolishment of N(2)O is controversial. When avoided in patients at risk for adverse events, N(2)O is still a valuable supplement to general anesthesia and a potent procedural analgesic drug. In the latter, its use by nonanesthesiologists should be discouraged.
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[General anaesthesia in children: a French survey of practices]. ACTA ACUST UNITED AC 2012; 31:709-23. [PMID: 22776772 DOI: 10.1016/j.annfar.2012.06.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2012] [Accepted: 06/04/2012] [Indexed: 11/22/2022]
Abstract
INTRODUCTION The practice of pediatric anesthesia requires a regular update of scientific knowledge and technical skills. To provide the most adequate Continuing Medical Education programs, it is necessary to assess the practices of pediatric anesthesiologists. Thus, the objective of this survey was to draw a picture of the current clinical practices of general anesthesia in children, in France. MATERIAL AND METHODS One thousand one hundred and fifty questionnaires were given to anesthesiologists involved in pediatric cases. These questionnaires collected information on various aspects of clinical practice relative to induction, maintenance, recovery from general anaesthesia and also classical debated points such as children with Upper Respiratory Infection (URI), emergence agitation, epileptoid signs or anaesthetic management of adenoidectomy. Differences in practices between CHG (general hospital), CHU (teaching hospital), LIBERAL (private) and PSPH (semi-private) hospitals were investigated. RESULTS There were 1025 questionnaires completed. Fifty-five percent of responders worked in public hospitals (CHG and CHU); 77% had a practice that was 25% or less of pediatric cases. In children from 3 to 10 years: 72% of respondents used always premedication and two thirds performed inhalation induction in more than 50% of cases. For induction, 53% used sevoflurane (SEVO) at 7 or 8%. Respondents from LIBERAL used higher SEVO concentrations. Tracheal intubation was performed with SEVO alone (37%), SEVO and propofol (55%) and SEVO with myorelaxant (8%), 93% of respondents used a bolus of opioid. For maintenance, the majority of respondents used SEVO associated with sufentanil; desflurane and remifentanil were more frequently used in CHU. Two thirds of respondents used N(2)O. Depth of anesthesia was commonly assessed by hemodynamic changes (52%), end tidal concentration of halogenated (38%) or automated devices based on EEG (7%). In children with URI, 98% of respondents used SEVO for anesthesia. To control the airway 42% used a tracheal tube, 30% a laryngeal mask and 20% a facial mask. Emergence agitation was an important concern for two thirds of respondents, while epileptoid signs were considered as important by only 20%. Eighty-nine percent of respondents practiced anesthesia for adenoidectomy. Anesthesia was induced by inhalation of SEVO 7-8% (41%), 6% (39%) or 4% (12%), 66% put an intravenous line (less frequently in LIBERAL). 67% of the responders managed adenoidectomy without any device to control the airway (more frequently in LIBERAL), 32% administrated a bolus of opioid (less frequently in LIBERAL). DISCUSSION This survey demonstrated that the practices regarding general anesthesia in children are relatively homogenous. Most of the differences appeared between LIBERAL and the others structures; the anaesthetic management for adenoidectomy illustrates these findings.
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Kim SH, Hong JY, Suk EH, Jeong SM, Park PH. Optimum Bolus dose of Propofol for Tracheal Intubation during Sevoflurane Induction without Neuromuscular Blockade in Children. Anaesth Intensive Care 2011; 39:899-903. [DOI: 10.1177/0310057x1103900540] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The purpose of this study was to determine the optimum bolus dose of propofol required to provide excellent conditions for tracheal intubation following inhalational induction of anaesthesia using 5% sevoflurane without neuromuscular blockade. Twenty-eight children, aged three to seven years, requiring anaesthesia for short duration surgery were recruited. Two minutes after beginning the inhalational induction with 5% sevoflurane and 60% nitrous oxide, a predetermined dose of propofol was injected over 10 seconds. Propofol dose was determined using the Dixon's up-and-down method, starting from 3 mg/kg (0.5 mg/kg as a step size). Laryngoscopy was performed 50 seconds after propofol injection. The optimum dose of propofol required for excellent intubating conditions was 1.39±0.37 mg/kg in 50% of children during inhalation induction using 5% sevoflurane and 60% nitrous oxide in the absence of neuromuscular blocking agents. From probit analysis, the 95% effective dose of propofol was 2.33 mg/kg (95% confidence interval 1.78 to 6.21 mg/kg).
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Affiliation(s)
- S.-H. Kim
- Department of Anaesthesiology and Pain Medicine, University of Ulsan, College of Medicine, Asan Medical Center, Seoul, Korea
| | - J.-Y. Hong
- Department of Anaesthesiology and Pain Medicine, University of Ulsan, College of Medicine, Asan Medical Center, Seoul, Korea
| | - E. H. Suk
- Department of Anaesthesiology and Pain Medicine, University of Ulsan, College of Medicine, Asan Medical Center, Seoul, Korea
| | - S. M. Jeong
- Department of Anaesthesiology and Pain Medicine, University of Ulsan, College of Medicine, Asan Medical Center, Seoul, Korea
| | - P. H. Park
- Department of Anaesthesiology and Pain Medicine, University of Ulsan, College of Medicine, Asan Medical Center, Seoul, Korea
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Birkholz T, Irouschek A, Saalfrank-Schardt C, Klein P, Schmidt J. Laryngeal morbidity after intubation with or without neuromuscular block in thyroid surgery using recurrent laryngeal nerve monitoring. Auris Nasus Larynx 2011; 39:288-93. [PMID: 21862269 DOI: 10.1016/j.anl.2011.07.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2011] [Revised: 07/15/2011] [Accepted: 07/19/2011] [Indexed: 10/17/2022]
Abstract
OBJECTIVE The avoidance of neuromuscular blocking agents (NMBA) for endotracheal intubation is associated with a higher incidence of laryngeal discomfort and lesions, but could impair effectiveness of intra operative recurrent laryngeal nerve monitoring (IONM). METHODS In a retrospective quality assessment study over a period of 30 months, a collective that had been intubated without NMBA was compared with a group, which had received NMBA. Endolaryngeal EMG was accomplished with a MagStim(®)-EMG-electrode. RESULTS Out of the 127 patients with 224 nerves at risk (NAR; NMBA 102 NAR, no NMBA 122 NAR), more than 90% received a total intravenous anaesthesia with propofol, and 88% had remifentanil. Laryngeal side effects and damage scores did not differ significantly. CONCLUSIONS In this special setting of IONM and thyroid surgery, avoidance of NMBA for endotracheal intubation seems not to increase the incidence of laryngeal side effects and lesions. If endotracheal intubation without NMBA is required, the authors suggest a standardized approach using induction agents as propofol and remifentanil.
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Affiliation(s)
- Torsten Birkholz
- Department of Anaesthesiology, University of Erlangen-Nuremberg, Nuremberg, Germany.
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Kim SH, Hong JY, Suk EH, Jeong SM, Park PH. Optimum Bolus Dose of Propofol for Tracheal Intubation during Sevoflurane Induction without Neuromuscular Blockade in Children. Anaesth Intensive Care 2011. [DOI: 10.1177/0310057x1103900226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The purpose of this study was to determine the optimum bolus dose of propofol required to provide excellent conditions for tracheal intubation following inhalational induction of anaesthesia using 5% sevoflurane without neuromuscular blockade. Twenty-eight children, aged three to seven years, requiring anaesthesia for short duration surgery were recruited. Two minutes after beginning the inhalational induction with 5% sevoflurane and 60% nitrous oxide, a predetermined dose of propofol was injected over 10 seconds. Propofol dose was determined using the Dixon's up-and-down method, starting from 3 mg/kg (0.5 mg/kg as a step size). Laryngoscopy was performed 50 seconds after propofol injection. The optimum dose of propofol required for excellent intubating conditions was 1.39±0.37 mg/kg in 50% of children during inhalation induction using 5% sevoflurane and 60% nitrous oxide in the absence of neuromuscular blocking agents. From probit analysis, the 95% effective dose of propofol was 2.33 mg/kg (95% confidence interval 1.78 to 6.21 mg/kg).
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Affiliation(s)
- S.-H. Kim
- Department of Anaesthesiology and Pain Medicine, University of Ulsan, College of Medicine, Asan Medical Center, Seoul, Korea
| | - J.-Y. Hong
- Department of Anaesthesiology and Pain Medicine, University of Ulsan, College of Medicine, Asan Medical Center, Seoul, Korea
| | - E. H. Suk
- Department of Anaesthesiology and Pain Medicine, University of Ulsan, College of Medicine, Asan Medical Center, Seoul, Korea
| | - S. M. Jeong
- Department of Anaesthesiology and Pain Medicine, University of Ulsan, College of Medicine, Asan Medical Center, Seoul, Korea
| | - P. H. Park
- Department of Anaesthesiology and Pain Medicine, University of Ulsan, College of Medicine, Asan Medical Center, Seoul, Korea
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Kim KS, Kwak HJ, Min SK, Lee SY, Kim KM, Kim JY. The effect of ketamine on tracheal intubating conditions without neuromuscular blockade during sevoflurane induction in children. J Anesth 2011; 25:195-9. [DOI: 10.1007/s00540-011-1092-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2010] [Accepted: 01/04/2011] [Indexed: 12/19/2022]
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Sneyd JR, O'Sullivan E. Tracheal intubation without neuromuscular blocking agents: is there any point? Br J Anaesth 2010; 104:535-7. [PMID: 20400611 DOI: 10.1093/bja/aeq060] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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