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Karanth H, Raveendra US, Shetty RB, Shetty P, Thalanjeri P. Comparative Evaluation between Sevoflurane and Propofol for Endotracheal Intubation without Muscle Relaxants in Pediatric Cleft Surgeries. Anesth Essays Res 2018; 12:434-439. [PMID: 29962612 PMCID: PMC6020561 DOI: 10.4103/aer.aer_38_18] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background and Objectives: Endotracheal intubation is the most important and crucial step during administration of general anesthesia. It is more so in pediatric patients with associated deformities of cleft lip, palate, and alveolus. Propofol, an intravenous (i.v.) induction agent, has profound depressant effect on airway reflexes with a quick and smoother induction. Similarly, sevoflurane, an inhalational agent, has relatively pleasant smell, low airway irritability, and more cardiostable properties. Hence, we sought to compare effectiveness of propofol with sevoflurane in achieving good intubation conditions without the use of muscle relaxants. Materials and Methods: In this prospective randomized study, eighty children belonging to American Society of Anesthesiologist physical status Class I and II, aged 1–10 years, scheduled for cleft surgery were included. All participants were premedicated. Patients were allotted to Group A and Group B randomly. Group A received propofol and Group B received sevoflurane as induction agents. Tracheal intubation was attempted in all patients at 150 s. Intubation conditions were assessed by using Steyn modification of Helbo–Hansen intubating conditions score. Statistical analysis was done using Student's t-test and Chi-square test with P < 0.05 regarded as significant. Results: Group B patients receiving sevoflurane had significantly more clinically acceptable intubation conditions than patients of Group A receiving i.v. propofol (P = 0.001). Conclusion: We conclude that intubation conditions using inhalational 8% sevoflurane are superior to i.v. propofol of 3 mg/kg for tracheal intubation without muscle relaxants in children undergoing cleft surgeries.
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Affiliation(s)
- Harish Karanth
- Department of Anaesthesiology, A J Institute of Medical Sciences, Mangalore, Karnataka, India
| | - U S Raveendra
- Department of Anaesthesiology, K.S. Hegde Medical Academy, Mangalore, Karnataka, India
| | - Rithesh B Shetty
- Department of Anaesthesiology, A J Institute of Medical Sciences, Mangalore, Karnataka, India
| | - Pramal Shetty
- Department of Anaesthesiology, A J Institute of Medical Sciences, Mangalore, Karnataka, India
| | - Padmini Thalanjeri
- Department of Physiology, Yenepoya University, Mangalore, Karnataka, India
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Soylu E, Kersin B, Karaaslan P, Çalım ÖF, Altın G, Tercan E. Effect of anesthesia without a neuromuscular blocking agent on intraoperative bleeding in adenotonsillectomy patients. Int J Pediatr Otorhinolaryngol 2015; 79:909-911. [PMID: 25899322 DOI: 10.1016/j.ijporl.2015.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2014] [Revised: 04/06/2015] [Accepted: 04/07/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE The purpose of this study was to examine the effect of general anesthesia, applied without a neuromuscular blocking agent, on the extent of intraoperative bleeding in children undergoing adenotonsillectomy. MATERIALS AND METHODS A total of 81 adenotonsillectomy cases were examined retrospectively. The patients' ages, genders, and tonsil and adenoid sizes, as well as anesthetic technique, operation time, extent of bleeding during operation, and period of stay in the postanesthesia care unit, were reviewed. Among the patients, 38 were administered anesthesia with a neuromuscular blocker (control group) and 43 patients were given anesthesia without a neuromuscular blocker (study group). RESULTS No statistically significant difference was found between groups in terms of age, gender, and tonsil and adenoid sizes (p > 0.05). The operation times of the study group were significantly lower than those of the control group (p = 0.036; p < 0.05). A highly statistically significant difference was found between groups in terms of extent of bleeding (p = 0.001; p < 0.01). Bleeding in the study group was significantly lower than that in the control group. No statistically significant difference was found in terms of period of stay in the post anesthesia care unit (p > 0.05). CONCLUSION In this study, we determined that, general anesthesia without a neuromuscular blocking agent significantly decreases operation time and intraoperative bleeding in adenotonsillectomy patients.
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Affiliation(s)
- Erkan Soylu
- Department of Otolaryngology, Head and Neck Surgery, Medipol University Hospital, İstanbul, Turkey.
| | - Burak Kersin
- Department of Otolaryngology, Head and Neck Surgery, Medipol University Hospital, İstanbul, Turkey
| | - Pelin Karaaslan
- Department of Anesthesiology, Medipol University Hospital, İstanbul, Turkey
| | - Ömer Faruk Çalım
- Department of Otolaryngology, Head and Neck Surgery, Medipol University Hospital, İstanbul, Turkey
| | - Gökhan Altın
- Department of Otolaryngology, Head and Neck Surgery, Medipol University Hospital, İstanbul, Turkey
| | - Elvan Tercan
- Department of Anesthesiology, Medipol University Hospital, İstanbul, Turkey
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3
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Fleming B, McCollough M, Henderson HO. Myth: Atropine should be administered before succinylcholine for neonatal and pediatric intubation. CAN J EMERG MED 2015; 7:114-7. [PMID: 17355661 DOI: 10.1017/s1481803500013075] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
ABSTRACTSuccinylcholine is often used to facilitate neonatal and pediatric rapid sequence intubation in the emergency department, and most relevant literature recommends administering atropine prior to succinylcholine to reduce the risk of bradycardia. Given the potential complications associated with combining these medications, we searched the published literature for evidence supporting this practice. Most studies recommending atropine premedication were undertaken in the operating room setting and pertained to repeated succinylcholine dosing. Furthermore, there is little published evidence to indicate that succinylcholine-related bradycardia is a clinically important side effect. Several authors have called for the practice to cease, but, to date, these calls have gone unheeded. We found no evidence supporting atropine's use in pediatric patients prior to single-dose succinylcholine. Atropine premedication for emergency department rapid sequence intubation is unnecessary and should not be viewed as a “standard of care.”
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Affiliation(s)
- Bethany Fleming
- Department of Emergency Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California 90033, USA
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Rajan S, Gotluru P, Andews S, Paul J. Evaluation of endotracheal intubating conditions without the use of muscle relaxants following induction with propofol and sevoflurane in pediatric cleft lip and palate surgeries. J Anaesthesiol Clin Pharmacol 2014; 30:360-5. [PMID: 25190944 PMCID: PMC4152676 DOI: 10.4103/0970-9185.137268] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background and Aims: Children with facial clefts are usually difficult to intubate and it is considered safer to keep them spontaneously breathing while securing the airway. This prospective comparative study was conducted to evaluate endotracheal intubating conditions in pediatric patients undergoing cleft surgeries, without the use of muscle relaxants following induction with propofol and sevoflurane. Materials and Methods: Sixty patients aged 1month to 3 years, were randomly allocated into two equal groups. Anesthesia was induced with sevoflurane 8% in oxygen in group 1 and with propofol 3 mg/kg in group 2. Laryngoscopy and intubation were attempted 150 s after induction in both groups and ease of laryngoscopy, position of vocal cords, degree of coughing, jaw relaxation, and limb movements were assessed and scored. Total score of 5 was considered excellent, 6-10 good, 11-15 poor, and 16-20 bad. Total score ≤ 10 was considered clinically acceptable, and >10 as clinically unacceptable. Chi-square and Wilcoxon Mann-Whitney tests were used to analyze data. Results: There was no significant difference between groups when ease of laryngoscopy was compared. Sevoflurane induced patients had significantly better position of vocal cords at intubation and the propofol group had significantly more episodes of coughing. Significantly less number of patients had limb movements in sevoflurane group. There was no significant difference in degree of jaw relaxation between groups. The sevoflurane group had significantly better total scores and clinically acceptable intubating conditions. Conclusion: Sevoflurane 8% in oxygen provides clinically acceptable intubating conditions without use of muscle relaxants in pediatric cleft patients.
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Affiliation(s)
- Sunil Rajan
- Department of Anaesthesiology and Critical Care, Amrita Institute of Medical Sciences and Research Centre, Kochi, Kerala, India
| | - Priyanka Gotluru
- Department of Anaesthesiology and Critical Care, Amrita Institute of Medical Sciences and Research Centre, Kochi, Kerala, India
| | - Susamma Andews
- Department of Anaesthesiology and Critical Care, Amrita Institute of Medical Sciences and Research Centre, Kochi, Kerala, India
| | - Jerry Paul
- Department of Anaesthesiology and Critical Care, Amrita Institute of Medical Sciences and Research Centre, Kochi, Kerala, India
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Abstract
PURPOSE To discuss developments in paediatric anaesthesia and explore the factors which have contributed to improved anaesthetic-related patient outcomes. METHODS Narrative review of findings in the literature retrieved from MEDLINE/Pubmed and manual search. RESULTS Adverse perioperative outcomes related to anaesthesia have been extensively debated over the past few decades, with studies implicating factors such as major human error and equipment failure. Case series and event registries have enlightened physicians on sources of error and patient risk factors such as extremes of age, comorbidity and emergent circumstances. Anaesthetic-related deaths in children fell from 6.4 per 10,000 anaesthetics in the early 1950s to as low as 0.1 per 10,000 anaesthetics by the end of the century. Advances in anaesthetic agents, techniques, monitoring technologies and training programmes in paediatric anaesthesia play a vital role in driving this downward trend. CONCLUSION Despite substantial progress, there is still much room for improvement in areas such as adverse-event reporting, anaesthetic-related risk and late neurocognitive outcomes. Systematic reviews comparing paediatric patient outcomes after neuroaxial block versus general anaesthesia are currently unavailable. The future of paediatric anaesthesia will most likely be influenced by much-needed large prospective studies, which can provide further insight into patient safety and service delivery.
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Abstract
Suxamethonium is a drug that promotes very strong views both for and against its use in the context of pediatric anesthesia. As such, the continuing debate is an excellent topic for a 'Pro-Con' debate. Despite ongoing efforts by drug companies, the popular view still remains that there is no single neuromuscular blocking drug that can match suxamethonium in terms of speed of onset of neuromuscular block and return of neuromuscular control. However, with this drug the balance of benefit vs risk and side effects are pivotal. Suxamethonium has significant adverse effects, some of which can be life threatening. This is particularly relevant for pediatric anesthesia because the spectrum of childhood diseases may expose susceptible individuals to an increased likelihood of adverse events compared with adults. Additionally, the concerns related to airway control in the infant may encourage the occasional pediatric anesthetist to use the drug in preference to slower onset/offset drugs. In the current environment of drug research, surveillance and licensing, it is debatable whether this drug would achieve the central place it still has in pediatric anesthesia. The arguments for and against its use are set out below by our two international experts, Marcin Rawicz from Poland and Barbara Brandom from USA. This will allow the reader an objective evaluation with which to make an informed choice about the use of suxamethonium in their practice.
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Affiliation(s)
- Marcin Rawicz
- Department of Paediatric Anaesthesia and Intensive Care, Medical University of Warsaw, Warsaw, Poland.
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Affiliation(s)
- Shireen M Atabaki
- Division of Emergency Medicine, Children's National Medical Center, Washington, DC, USA
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8
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Abstract
PURPOSE OF REVIEW Changes in practice and the development of new anesthetic drugs have influenced the use of muscle relaxants in children. This article reviews these developments, and defines the current role and factors affecting the choice of muscle relaxant drugs in pediatric anesthesia. RECENT FINDINGS The introduction of the laryngeal mask airway as a means of controlling the pediatric airway has reduced the need for muscle relaxants. In cases requiring tracheal intubation, however, a balanced anesthetic technique incorporating a nondepolarizing relaxant provides the best intubating conditions with the minimal potential for adverse effects. The introduction of newer less-toxic, shorter-acting anesthetic drugs has reduced the requirement for muscle relaxants during surgery. Moderate anesthesia with sevoflurane-remifentanil or propofol-remifentanil can keep patients immobile without producing hypotension and facilitate controlled ventilation once the effects of the intubating dose of a muscle relaxant have worn off. SUMMARY Recent developments in clinical practice have reduced or obviated the need for muscle relaxants in pediatric anesthesia. Muscle relaxants are still indicated for intubation and procedures requiring profound muscle relaxation, and to minimize the amounts of anesthetic drugs given to infants and sick children. Specific relaxants and doses can be chosen to suit the clinical circumstances.
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Affiliation(s)
- George H Meakin
- Department of Anaesthesia, Royal Manchester Children's Hospital, Pendlebury, Manchester, UK.
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Abstract
We have developed a modern strategy for the anesthetic management of pediatric cleft lip and cleft palate repair using anesthetic drugs such as sevoflurane, desflurane, acetaminophen, remifentanil, and pirtitramide together with new techniques. It provides best conditions for the surgeon and maximum safety for the pediatric patient. A team of pediatricians, neonatologists, pediatric surgeons, and pediatric anesthetists have tackled the problem of management of children with craniofacial abnormalities such as cleft lip and cleft palate. The best and safest anesthetic techniques are outlined and the most frequent complications are discussed, e.g. management of the difficult airway, the airway in patients with complex craniofacial abnormalities, fiberoptic endotracheal intubation through a laryngeal mask, intraoperative dislocation of the endotracheal tube, postoperative airway obstruction and perioperative bleeding.
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Affiliation(s)
- Andreas Machotta
- Klinik für Anästhesiologie und operative Intensivmedizin, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum
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Theroux MC, Rose JB, Iyengar S, Katz MS. Succinylcholine pretreatment using gallamine or mivacurium during rapid sequence induction in children: a randomized, controlled study. J Clin Anesth 2001; 13:287-92. [PMID: 11435054 DOI: 10.1016/s0952-8180(01)00267-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
STUDY OBJECTIVE To determine if pretreatment with either gallamine or mivacurium before succinylcholine in children is associated with reduction in fasciculations; postoperative myalgias; or serum levels of potassium, creatinine phosphokinase (CPK), and myoglobin. DESIGN Prospective, randomized, double-blinded study. SETTING Operating room at a children's hospital. PATIENTS 45 ASA physical status IE children, aged 3 to 15 years, scheduled for emergency surgery. INTERVENTIONS The children received either normal saline 0.5 mL, mivacurium chloride 0.03 mg. kg(-1), or gallamine triethiodide 0.04 mg. kg(-1)2 minutes prior to rapid sequence induction (RSI) using thiopental sodium 5 mg. kg(-1), fentanyl 2 microg. kg(-1), and succinylcholine 2 mg. kg(-1). MEASUREMENTS Serum potassium concentration (0, 3, 5, 7.5, and 15 min), myoglobin concentration (5 and 15 min), and CPK concentration (0 min and 24 hr). Fasciculation and myalgia were rated on a 0 to 3 score. MAIN RESULTS There was no difference between groups for fasciculation (p = 0.87) or myalgia score (p = 0.52). The mivacurium group had significantly less increase in potassium at 5 minutes (0.45 vs. 0.0, p = 0.01), myoglobin at 5 minutes (56 vs. 2, p < 0.001), myoglobin at 15 minutes (128 vs. 2.5, p < 0.001), and CPK at 24 hours (399 vs. 138, p < 0.001) following succinylcholine when compared with normal saline. Additionally, we found a significant level of association (p < 0.001) between fasciculation and myoglobin levels and fasciculation and CPK levels (p < 0.001). Gallamine was not effective in reducing the increase of potassium, myoglobin, or CPK. However, the dose of gallamine used for pretreatment was 13 times less than the dose of mivacurium. CONCLUSIONS Administration of mivacurium 0.03 mg. kg(-1) intravenously 2 minutes before administration of succinylcholine 2 mg. kg(-1) in children is effective in reducing the increase in serum potassium at 5 minutes, the increase in myoglobin at 5 minutes and 15 minutes, and the increase in CPK at 24 hours.
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Affiliation(s)
- M C Theroux
- Department of Anesthesiology and Critical Care Medicine, Alfred I. duPont Hospital for Children, Wilmington, DE 19899, USA.
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13
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Barcelona SL, Coté CJ. Pediatric resuscitation in the operating room. ANESTHESIOLOGY CLINICS OF NORTH AMERICA 2001; 19:339-65. [PMID: 11469068 DOI: 10.1016/s0889-8537(05)70232-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The resuscitation of pediatric patients undergoing anesthesia involves appropriate administration of fluid and blood products and stabilization of vital signs. Crystalloid is first-line therapy for fluid resuscitation, and should be given with awareness of its potential dilution of the child's hematocrit. Many alternatives to homologous blood transfusions now exist, however, when necessary for increasing oxygen-carrying capacity or treating coagulopathy benefits likely outweight the risks. The risks for such transfusion include infectious, hemolytic, metabolic, and immunologic effects. When fluid and blood administration does not stabilize the patient, the differential diagnosis of hypotension, arrest, or arrhythmias must include medication errors, anesthetic overdose, electrolyte disturbances, hypoxemia, ventilatory problems, and surgical insults, including medications given in the operative field. Resuscitation should include treatment of hypocalcemia and hyperkalemia, chest compressions, and the administration of epinephrine when necessary.
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Affiliation(s)
- S L Barcelona
- Department of Pediatric Anesthesiology, Children's Memorial Medical Center, Northwestern University Medical School, Chicago, Illinois, USA
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14
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Abstract
The practice of emergency medicine is a constant onslaught of decision making and challenges and the issues of airway management are no exception. Obtaining proper airway control requires thoughtful organization and planning, and necessitates a thorough working knowledge of the drugs or medications employed. Because there are so many agents available, expertise in airway pharmacology has become essential. The emergency physician who is well versed in the uses, and the physiologic effects, contraindications, and alternatives of drugs administered is both providing immediate intervention and positively affecting patient outcome, which is certainly a goal worth achieving.
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Affiliation(s)
- P S Wadbrook
- Department of Emergency Medicine, Maricopa Medical Center, Phoenix, Arizona, USA
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15
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McNeil IA, Culbert B, Russell I. Comparison of intubating conditions following propofol and succinylcholine with propofol and remifentanil 2 micrograms kg-1 or 4 micrograms kg-1. Br J Anaesth 2000; 85:623-5. [PMID: 11064625 DOI: 10.1093/bja/85.4.623] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
We evaluated the intubating conditions, haemodynamic responses and duration of apnoea in 60 healthy adult patients after propofol 2 mg kg-1 combined with either a bolus of remifentanil 2 micrograms kg-1 or 4 micrograms kg-1, or succinylcholine 1 mg kg-1. Patients intubated following remifentanil showed dose-dependent intubating conditions, similar at 4 micrograms kg-1 to the conditions produced with succinylcholine. Post-induction mean arterial pressure decreased from baseline values by 21% (P < 0.0001), 28% (P < 0.0001) and 8% (P > 0.05) in the remifentanil 2 micrograms kg-1, remifentanil 4 micrograms kg-1 and succinylcholine 1 mg kg-1 groups, respectively. The mean (SD) duration of apnoea following induction was 9.3 (2.6) min and 12.8 (2.9) min in the remifentanil 2 micrograms kg-1 and 4 micrograms kg-1 groups, and 6.0 (0.9) min in the succinylcholine group (P < 0.001 between groups).
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Affiliation(s)
- I A McNeil
- Department of Anaesthesia, Hull Royal Infirmary, UK
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16
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Abstract
Intubating conditions under halothane anaesthesia aided with alfentanil 20 micrograms.kg-1 were compared with suxamethonium 2 mg.kg-1 in 40 children presenting for day dental procedures. The condition of vocal cords, jaw relaxation and presence of movement and coughing were scored to give the overall intubating conditions. Successful intubation was achieved in 100% of the suxamethonium group and 94.7% of the alfentanil group. The cardiovascular response to intubation was attenuated in the alfentanil group. Some 43.7% of those receiving suxamethonium developed myalgia the day after surgery compared with 0% in the alfentanil group (P < 0.01).
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Affiliation(s)
- K P NG
- Department of Anaesthesiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
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17
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Abstract
A postal survey of anaesthetic techniques used for tonsillectomy surgery in children (age 3-16 years) was performed with particular reference to the use of the reinforced laryngeal mask airway and the use of suxamethonium. From 110 questionnaires despatched, replies were obtained from 88 consultant anaesthetists with commitments to otolaryngologic (ENT) anaesthesia (response rate 80%). In paediatric practice, the reinforced laryngeal mask airway was routinely used by 14 (16%) respondents from the 88 who replied. Thirteen (33%) respondents out of 39 respondents who replied saying that they had used the reinforced laryngeal mask airway at some point, reported problems with its use. Suxamethonium was used routinely by 40 consultants (45%) for tonsillectomy surgery. Severe problems with its use had been encountered by 26 (30%) respondents
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MESH Headings
- Adolescent
- Ambulatory Surgical Procedures
- Analgesics, Opioid/therapeutic use
- Anesthesia Department, Hospital
- Anesthesia, General/methods
- Anesthesiology
- Anesthetics, Inhalation/administration & dosage
- Anesthetics, Intravenous/administration & dosage
- Anti-Inflammatory Agents, Non-Steroidal/therapeutic use
- Child
- Child, Preschool
- England
- Equipment Design
- Hospitals, Teaching
- Humans
- Intubation, Intratracheal
- Laryngeal Masks/adverse effects
- Neuromuscular Depolarizing Agents/administration & dosage
- Neuromuscular Depolarizing Agents/adverse effects
- Otolaryngology
- Postal Service
- Respiration, Artificial
- State Medicine
- Succinylcholine/administration & dosage
- Succinylcholine/adverse effects
- Surveys and Questionnaires
- Tonsillectomy
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Affiliation(s)
- I S Hatcher
- Department of Anaesthesia, Sheffield Children's Hospital, Western Bank, Sheffield, UK
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18
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Abstract
Recent developments in pharmacology have offered new and broader options to the anesthesiologist caring for pediatric patients. Many new drugs do not have specific indications for use in the pediatric population, but clinical studies have examined the utility and cost-effectiveness of some of these agents. Information is presented on drugs used for premedication, induction, and maintenance of anesthesia. The clinical pharmacology of several new nondepolarizing muscle relaxants, and the recent controversy with regard to the use of succinylcholine also are presented. New drugs used in topical and regional anesthesia as well as options for anti-emetic therapy are discussed.
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Affiliation(s)
- L L Everett
- Division of Pediatric Anesthesiology, Medical College of Virginia, Virginia Commonwealth University, Richmond, USA
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