Anaesthetic agents in paediatric day case surgery: do they affect outcome?

Propofol-remifentanil or sevoflurane for children undergoing magnetic resonance imaging? A randomised study

BACKGROUND

Magnetic resonance imaging (MRI) of children is generally performed under sedation or with general anaesthesia (GA), but the ideal regimen has not been found. The aim of this study was to see if propofol-remifentanil would be a suitable alternative for the maintenance of anaesthesia in this category of patients.

PATIENTS AND METHODS

Children aged 1-10 years, American Society of Anesthesiologists physical status 1-2 were included. After induction with thiopental or sevoflurane, the children were randomised to maintenance of anaesthesia with an infusion of propofol and remifentanil (group PR) (56 μg/kg/min of propofol and 0.06 μg/kg/min of remifentanil) or with sevoflurane 1.3 MAC (group S). A binasal catheter was placed in group PR and a laryngeal mask airway in group S. The children breathed spontaneously. The Paediatric Anaesthesia Emergence Delirium (PAED) score (primary end point), the number of movements during MRI, and the length of stay in the recovery room (secondary endpoints) were recorded.

RESULTS

Sixty children were included in each group. A lower level of emergence delirium (measured as a lower PAED score) was found in group PR compared with group S, and the children in group PR were discharged earlier from the recovery room than the children in group S. However, 15 children in group PR vs. 0 in group S moved during the scan (P < 0.001).

CONCLUSION

The PR infusion ensured a satisfactory stay in the recovery room, but additional boluses were necessary during the MRI. Sevoflurane was reliable during the MRI, but emergence delirium was a concern.

Reduced-dose rocuronium for day-case tonsillectomy in children where volatile anaesthetics are not used: operating room time saving

OBJECTIVES

Mivacurium, rocuronium, and vecuronium are neuromuscular blocking agents (NMB) commonly used in pediatric day-case anesthesia. Mivacurium is the most appropriate NMB for short surgical procedures where NMB drugs were required but is not available in all countries.

AIM

We evaluated the operating room time minimization after reduced-dose rocuronium (0.45 mg x kg(-1)) during elective day-case tonsillectomy in children.

METHODS/MATERIALS

One hundred and five children (6-9 years, ASA I/II status) scheduled for day-case tonsillectomy were included in prospective, double blind clinical study. Children were randomly divided in three equal groups. All children were premedicated (midazolam 0.25 mg x kg(-1) orally, EMLA). Anesthesia was induced (2.5 mg x kg(-1)) and maintained (0.1 mg x kg(-1) x min(-2)) by propofol and alfentanil (0.0015 mg x kg(-1) x min(-1)) and supplemented by inhalation mixture of 50% of O2/Air. Neuromuscular block was achieved by vecuronium (0.1 mg x kg(-1)) (V) or rocuronium in standard (0.6 mg.kg(-1)) (R) or reduced dose (0.45 mg x kg(-1)) (LD). Neuromuscular transmission was monitored by acceleromyography. Time analysis of NMB drugs action was performed.

RESULTS

Time difference from the end of tonsillectomy to T90 neuromuscular block recovery was significantly shorter in LD Group (7.3 +/- 0.41 min), (V = 15.9 +/- 1.06, R = 16.0 +/- 1.7 min) (P = 0.0011). The onset time of neuromuscular block was prolonged in LD Group (LD=3.1 +/- 0.4, R = 1.3 +/- 0.4, V = 2.2 +/- 0.2 min) (P = 0.0039) without changing the intubating conditions. The maximum operation room time saving per each tonsillectomy was 37% in LD Group (Group V 21%, Group R 17%) (P = 0.0001). Low incidence of postoperative nausea and vomiting (PONV) 3-6% (0.4577) and good visual analog scale (VAS) score (< or =2) (0.5969) were found in all study groups 12 h after surgery.

CONCLUSIONS

Reduced-dose rocuronium in addition with propofol and alfentanil in children where volatile anesthetics are not used effectively saves the operating room time during short elective surgical procedures, avoids delays in patient recovery, allows high level of acceptable intubating conditions, and improves the optimal surgical work. Low incidences of PONV as VAS score may achieved successfully.

Quality of recovery from two types of general anesthesia for ambulatory dental surgery in children: a double-blind, randomized trial

BACKGROUND

Pediatric dental procedures are increasingly performed under general anesthesia because of the inability to cooperate, situational anxiety, or other behavioral problems. Volatile anesthetics have been associated with emergence delirium in children, whereas the use of propofol for anesthetic maintenance has been shown to reduce the incidence of emergence delirium after other types of surgeries. The aim of this study is to compare a sevoflurane-based anesthetic with a propofol-based technique as it relates to the incidence of emergence delirium and the quality of recovery after pediatric dental surgery, in patients who present with risk factors for perioperative behavioral issues.

METHODS

We prospectively collected data of 179 pediatric patients scheduled for ambulatory dental surgery using a double-blind and randomized trial design. Subjects were anesthetized following standardized protocols for either a sevoflurane- or a propofol-based technique. The incidence of emergency delirium, as measured by the Pediatric Anesthesia Emergence Delirium score, was the primary outcome. Secondary outcomes included the incidence of postoperative nausea and vomiting (PONV), number of nursing interventions in the recovery room, time to discharge readiness, and parental satisfaction.

RESULTS

We found no difference in the incidence of emergence delirium after both types of anesthesia. However, use of sevoflurane significantly increased both the risk of PONV and the number of postoperative nursing interventions. Discharge criteria were met about 10 min earlier in patients anesthetized with sevoflurane. Parental satisfaction was equally high with both anesthesia regimens.

CONCLUSIONS

A propofol-based anesthetic technique did not lead to a lower incidence of emergence delirium after dental surgery in children but did result in significantly less PONV and fewer postoperative nursing interventions.

The optimal pediatric induction dose of propofol in combination with reduced-dose rocuronium and alfentanil for day-case tonsillectomy in children

OBJECTIVE

Tonsillectomy in children may be performed on a day-case basis. To achieve quality anesthesia and successful, fast recovery with minimal morbidity without the use of volatile anesthetic, the choice of drug combination has to be centered on one rapid- and short-acting hypnotic, opioid and non-depolarizing muscle relaxant. The aim of our study was to determine the optimal pediatric induction dose of propofol that by means of alfentanil and reduced-dose rocuronium allows the highest percentage of excellent intubating conditions.

METHODS

One hundred and eleven children were randomized in three equal groups and included in prospective, double blind study. Anesthesia was induced with 2.0 (Group A), 2.5 (Group B) or 3.0 mg kg(-1) (Group C) of propofol proceeded by alfentanil (0.02 mg kg(-1)). Muscle relaxation was achieved with reduced-dose rocuronium (1.5x ED(95)) (0.45 mg kg(-1)). The intubating conditions were assessed using the four-point scoring system based on the difficulty of laryngoscopy, presence of vocal cord movement and the intensity of coughing. Neuromuscular transmission was monitored by means of acceleromyography with supramaximal train-of-four stimulation of the ulnar nerve by the frequency of 1Hz.

RESULTS

Adequate intubating conditions were achieved in high percentages in all study groups (A = 94%, B = 95%, C = 98%) (P = 0.352). Significant higher differences of excellent and good intubating conditions, attributed to quality of laryngoscopy, movement of the vocal cords and intensity of coughing were observed in Group C (excellent = 94%, good = 4%) (B = excellent 80%, good = 18% and A = excellent 47%, good = 47%) (P = 0.0001). MAP decrease of 12% from the baseline occurred immediately only after 3.0 mg kg(-1) induction dose of propofol (80+/-7 mm Hg; A = 92 +/- 6, B = 88 +/- 9) (P = 0.005).

CONCLUSIONS

Induction dose of 2.5 mg kg(-1) of propofol preceded by 0.02 mg kg(-1) of alfentanil in addition to reduced-dose rocuronium (0.45 mg kg(-1)) is the optimal pediatric induction dose of propofol for improving the most excellent intubating conditions without significant hemodynamic changes.

Costing day case anesthesia: obtaining accurate patient-based costs for adults and children

OBJECTIVES

This study proposes the method requirements for a valid costing study in anesthesia to allow differences to be identified between treatments and uses these method requirements to design and conduct a robust costing study.

METHODS

A prospective, patient-based costing study was carried out in adult and pediatric day surgery in the United Kingdom. The perspective was that of the National Health Service and the patient. Data were collected for each patient until 7 days after hospital discharge.

RESULTS

Data were collected for 1063 adults and 322 children undergoing day surgery between October 1999 and January 2001. Statistically significant differences were found only between variable costs, which accounted for 11.4 percent and 9.0 percent of adult and pediatric costs, respectively. There were no differences in length of stay, fixed costs, or semi-fixed costs. Differences were not found in total costs in adults but were found in children. By day 7, postdischarge primary and secondary care costs were not different between groups in either study. No differences were found in costs to patients or parents.

CONCLUSIONS

The use of prospective, patient-based cost data enabled the detection of differences in variable costs between difference anesthetic regimens in day surgery. The stochastic nature of the data provided a measure of variability around mean cost estimates. Practice patterns in the study reflected normal practice in the United Kingdom so the costing data have direct clinical relevance. The use of different anesthetic agents only affected variable costs and had no effect on larger cost drivers such as length of stay or staff input.

Management of postoperative nausea and vomiting in children

In spite of improvements in anesthesia techniques, the 'big little problem' of postoperative nausea and vomiting (PONV) still exists. PONV can prolong recovery room stay and hospitalization, and is one of the most common causes of hospital readmission after day surgery. While there is little evidence to support prophylactic administration of antiemetics in patients at low risk of PONV, the higher risk population could benefit from the use of adequate antiemetic drugs. A wide variety of pharmacological approaches have been reported to be effective, as well as some nonpharmacological approaches. Antiemetic drugs available to treat or prevent PONV include phenothiazines, antihistamines, anticholinergics, benzamides, butyrophenones and 5-HT(3) antagonists. Since available drugs still present undesired adverse effects and are not completely able to control PONV, clinical investigations are ongoing for more effective and better tolerated agents; indeed, the ideal antiemetic drug might be cost-effective for routine use.